'JS^'

' . REV] EW

njiVANGES )K' TROPICAL
inc., ETC.

v^U)')^) I'MF-NT TO THIRD REPORT
WEIJ.COME RESEARCH LABORATORIES

KHARTOUM

ANDREW

OUR, M D.

C. Whltebread

Map of Anclo-Eoyptian Sudan

VJ\ i REVIEW

'*Vr ' °^ SOME OF THE

RECENT ADVANCES IN TROPICAL MEDICINE

HYGIENE AND TROPICAL VETEBINARY SCIENCE, WITH SPECIAL REFERENCE

TO THEIR POSSIBLE BEARING ON MEDICAL, SANITARY AND

VETEBINARY WORK IN THE ANGLO-EGYPTIAN SUDAN

BEING A SUPPLEMENT TO THE

Third Report of the
WELLCOME RESEARCH LABORATORIES

AT THE

GORDON MEMORIAL COLLEGE
KHARTOUM

BY

ANDREW BALFOUR, M.D., B.Sc, F.R.C.P. Edin., D.P.H. Camb.

DIKECTOR

Fellow of the Royal Institute of Public Health, the Society of Tropical Jledicine and Hygiene, and

the Society for the Destruction of Vermin; Member of the Incorporated Society of

Medical Officers of Health, and the Association of Economic Biologists;

Corresponding Member Society de Pathologie Exotique ;

Medical Officer of Health, Khartoum ; etc., etc.

AND

R. G. ARCHIBALD, M.B., R.A.M.C, attached E. A., Pathologist and

Assistant Bacteriologist

Fellow of the Society of Tropical Medicine and Hygiene

Published foe

Department of Education, Sudan Government

Khartoum

BY

BAILLIEEE, TINDALL & COX, 8, Heneietta Steeet, Covent Gaeden

LONDON

1908

CONTENTS

Prefatory Note .

Ainhum

Air . .

Akatama

Animals

Ankylostomiasis

Anthrax

Bacteriology

Beri-beri

Beverages

Bilharziosis

Blackwater Fever . .

Blood

Bubo

Calabar Swellings . .

Cancer

Cerebro-Spinal Fever

Chicken-pox

Chigger

Cholera

Climate

Clothing

Dengue
Dhobie Itch
Diarrhoea
Diphtheria
Disinfection
Dropsy
Dust

Dysentery
Elephantiasis
Enteric Fever
Faeces
Fevers
Filariasis
Filters
Flies
Food

Food Poisoning
Guinea Worm
Haematozoa . .
Heat Stroke
Hydrophobia
Ice . .

Infectious Diseases
Influenza
Index

PAGE

■ .

.. .. .. 6

:ent

N . .

Advances in Tropical

Medicine, etc.,

7

PAGE

• • • • < * 1

PAGE

7

Insects

. . 92

7

Leishmaniosis

. . 95

8

Leprosy

. . 99

8

Liver Abscess

. . 107

9

Malaria

. . 109

11

Malta Fever

. . 118

11

Measles

. . 122

14

Milk

. . 125

16

Mosquitoes . .

. . 132

17

Mycetoma . .

. . 135

19

Myiasis

. . 137

21

Onyalai

..139

24

Oriental Sore

. . 140

25

Parasites

. . 142

25

Paratyphoid Fever

. . 147

27

Piroplasmosis

. . 148

29

Bovine . .

. . 151

30

Canine . .

. . 153

30

Plague

. . 155

33

Scorpion Sting-

..165

35

Scurvy

. . 167

36

Sewage

. . 168

38

Skin Diseases

. . 170

38

Sleeping Sickness

. . 173

41

Small-pox . .

. . 180

44

Snake Bite . .

. . 184

47

Spider Bite . .

. . 185

48

Spirochaetes and

48

Spiroehaetosis 185

54

Sprue

. . 194

54

Staining

..196

62

Syphilis

. . 198

66

Ticks

..199

70

Tropical Medicine

. . 202

74

Trypanosomiasis

. . 204

75

Tsetse Flies . .

. . 209

79

Tuberculosis

.. 210

82

Typhus Fever

. . 215

83

Vaccination . .

. . 216

86

Veterinary Diseases

.. 217

87

Water

. . 225

88

Weil's Disease

. . 231

91

Whooping Cough .

. . 233

91

Yaws

. . 234

92

Yellow Fever

. . 236

• • • • • .

239

PREFATORY NOTE

TT is a difficult matter for medical and veterinary officers stationed in the Sudan,
-*- especially those who happen to be in out-stations or who have to travel frequently,
to keep in touch with current literature. This Review is intended to help them in some
measure, to serve as a guide to new books and papers, and to present in a small compass
the most important recent discoveries on the subjects indicated. It is also intended to
indicate in what directions our Imowledge as regards tropical and veterinary medicine,
bacteriology and hygiene is deficient in the Sudan, and it is hoped that it will thus
stimulate research and lead to the acquisition of useful information. References are given
so that those who wish to go more fully into any special subject may be able to obtain
the original book or paper. Every care has been taken to render these as correctly as
possible. No attempt has been made to produce a text-book, and for the most part the
references have been confined to sound practical papers likely to be helpful, but the
scientific aspect of certain questions has been considered for the reasons stated above.

While in the main intended for medical and veterinary officers in the Sudan, many
of whom have rendered the laboratories valuable assistance, it is hoped that workers in
other tropical countries, where the conditions are similar to those obtaining in the
Sudan, may find this Review of service. It is possible that it may also appeal to
the students of Tropical Medicine in temperate climates, especially such as may
be preparing for special examinations.

At the same time, it is to be regarded as supplementary to the Third Report of
the Wellcome Research Laboratories, and hence the range of subjects dealt with
is, of necessity, limited.

REVIEW

Of some of the moke Ebcent Advances in Tbopical Medicine, Hygiene
AND Tropical Veteeinary Science, with special reference to their

POSSIBLE BEARING ON MeDICAL, SaNITARY AND VETERINARY WORK IN THE

Anglo-Egyptian Sudan.*

Ainhum. Ashley-Emile,^ in an interesting paper on ainhum, is inclined to
trace a connection between ainhum and leprosy, regarding the former as a modified
expression of the latter in persons of a "leprous diathesis." His argument is rather
laboured, but there may be something in the anatomical reasons he advances for
the seat of election of the disease. He believes the flexor tendon of the small toe to
be specially subject to strain during the act of carrying heavy burdens, and that this,
combined with an enfeebled nerve supply, leads to fibroid degeneration round the joint with
resulting occlusion of arteries and strangulation of the toe, which enlarges owing to venous
dilatation.

Wellman,^ on the other hand, adduces evidence to show that ainhum and leprosy are
not related, and in a later paper suggests that the chigger may play an important part in the
development of the complaint. He points out that this theory accounts in large measure
for the geographical distribution of the disease. Apart from these theories, ainhum has been
stated to be due to injury, to be a trophoneurosis, a circumscribed scleroderma, a con-
genital, spontaneous amputation, and the result of self-mutilation by ligatures, wearing of
toe-rings, etc.

Manson^ favours the traumatic theory, and cites a similar condition affecting the tail
of a pet monkey. There is nothing new to record regarding treatment. Ainhum occurs in
the Sudan, and I have seen an imported case in Khartoum.

So far as is at present known, the chigger is confined to the Bahr-El-Ghazal Province,
while Dr. Wenyon reports ainhum to be common at Bor on the White Nile. The natives
attribute the condition to injury caused by the coarse grass. It would be interesting to
determine accurately if the distribution of the disease and of the chigger coincide in the
Southern Sudan.

Air. The remarkable influence of rain as a purifier of the atmosphere was well shown
by an investigation^ carried out in London in the summer of 1903. A rainfall of about
3-8 inches in five days actually was responsible for the removal of 3738 tons of solid
impurities. Of these no less than 2000 tons consisted of soot and suspended matter,
common salt and sulphate of ammonia constituting the remainder.

This does not take into account the great bacterial purification also effected.

Much of the Northern Sudan is practically rainless, and there can be no doubt we suffer
from the lack of the freshening effect of rain upon the atmosphere. This, as has been
pointed out, is due possibly to an oxidising action and perhaps to the formation of peroxide
of hydrogen. No one who has lived long in Khartoum but knows there are times when the
air seems lifeless and heavy. Indeed, this is frequently the case in the late afternoons in the
winter. Doubtless the feeling is in part due to the dying down of the breeze, but though
the air is free from gross impurities it is charged with organisms, especially with moulds.

In this connection allusion may he made to Gordon's^! work on the presence of
streptococcus brevis in the saliva, and its use as an indicator of air pollution. By this
means he has shown the presence of particles of saliva in the air at a distance of 40 feet
in front of a speaker. It would be interesting to know if conditions differ greatly in a hot,

• With the exception of the article on Typhus Fever, the notes referring to the Sudan and a few other
paragraphs, the portion of the Review from " Tuberculosis " onwards is the work of Mr. R. Q. Archibald.

The Review only extends to papers, etc., appearing in journals not later than about the middle of July, 1908.

' Ashley-Emile, L. E. (February 1st, 1905), "On the Etiology of Ainhum." Journal of Tropical
Mediciru:, p. 33.

' Wellman, F. C. (October 2nd, 1905), "Ainhum and Leprosy, a Critical Note." Journnl of Tropical
Medicine, p. 285.

" Manson, Sir Patrick, London, "Tropical Diseases." 4th Edition. 1907.

* "Some Interesting Pacts Regarding the Purifying Effect on the Air of the Recent Rain." Lancet,
p. 1759, Vol. I. June 20th, 1903.

" Gordon, M. H., Report of Medical Officer Local Government Board, 1902-1903.

t Article not consulted in the original.

O REVIEW — TKOPICAL MEDICINE, ETC.

Air— dry country, and to ascertain the effects of the powerful sun's rays on aerial micro-

cotiUmud organisms. In case anyone feels disposed to take up this matter, mention may be made of
work by Soper,' who compared the plate and filter methods of bacteriological analysis of air,
and found that the slightly increased accuracy of the latter did not compensate for its
greater difficulties of technique. The action of sunlight upon bacteria generally, and
especially on B. tabercnlosis, has been re-investigated by Weinzirl,- who notes that some of
the saprophytic micrococci of air are much more resistant than the easily-killed, non-spore-
bearing, pathogenetic forms.

Akatama. This is a curious disease described by Wellman'' as affecting the Bantu
races in West Central Africa. He considers it to be possibly of the nature of an endemic
peripheral neuritis, and states that it is characterised by numbness and intense prickling and
burning sensations in the presence of cold or damp. Erythema and sometimes swelling is
present and the gait may be affected. It is of economic importance owing to its crippling
action on porters and servants. It is commoner in men than in women and specially attacks
the young and middle-aged. No specific cause has been found. Exposure to changes of tem-
perature seem to be operative, and though it has been suggested that akatama may resemble
beri-beri, Wellman is inclined to believe in a local cause, as the trouble may be confined
to a small part of the body. This seems probable, as the symptoms usually occur first in the
arms and legs, i.e. exposed portions. It is in no sense a "place disease." The prognosis
is good as regards life and general health, but the disease may remain unrelieved. No
special treatment is recommended. As mentioned in the First Report, there is stated to be
a disease (Abu-Agele, literally " the father of the tying-up") amongst the Arabs in Kordofan
which causes the so-called "haltered camel's gait," i.e. a kind of hobbling movement.
Major Bray was my informant as to this condition, concerning which I have been unable
to obtain any further particulars. The climatic conditions in some parts of Kordofan
somewhat resemble those prevalent in the Bantu country which Wellman describes, and
it is possible the two conditions may be allied. The subject at least seems worthy
of investigation.

Amceba. See Dysentery (jiage 48).

Animals. Under this heading one may note a paper by Eaton Jones'* on the
keeping of horses and cattle in towns. He cites the following diseases as communicable
from these animals to man : —

Anthrax, foot and mouth disease, glanders, rabies, actinomycosis, malignant cedema, tetanus, tuberculosis,
vaccinia, diphtheria, scarlatina, mange, ringworm and influenza.

He states that infection may occur directly or indirectly, by transmission through the
atmosphere and gaining an entrance to the system through the numerous membranes or
abraded skin surface, by means of the alimentary canal and entering with the food, by
inoculation from contaminated soil, or from clothing, fodder, or other articles that have been
in contact with the specific poison. He pleads for hygienic stables and cowsheds, and for
the removal of animal habitations from the close proximity of dwelling-houses.

This is a matter worthy of consideration in the Sudan, and so far as Khartoum is
concerned will be found discussed under " Sanitary Notes " (Third Eeport). Possibly obscure
outbreaks of diphtheria may have their origin in an animal source, while in a hot country
the question of breeding-places for house and other flies is of great importance. As a matter of
fact, however, the native lives surrounded by donkeys, pariah dogs, sheep, goats and fowls,
and as a rule does not seem to suffer in any way. I believe that in a hot, dry country much
can be done with impunity, which, if practised under temperate and humid conditions, would
bring about its own punishment. Still a case of echinococcus cyst of bone was recorded in
the Second Laboratory Eeport, and quite recently attention has been drawn to a curious
Endemic Paralytic Vertigo'^ occurring in Switzerland and Japan, and which is apparently

' Soper, Q. A. (May, 1907), " Comparison between Bacteriological Analysis of Air by the Plate Method and
by Filters." Journal of Infectious Diseases, Suppl. No. 3, p. 82.

» Weinzirl, .J. (May, 1907), " The Action of Sunlight upon Bacteria, with Special Reference to B. Tuberculosis."
Journal of Infectious Diseases, Suppl. No. 3, p. 128.

' Wellman, F. C. (September 1st, 1903), " Observations on Akatama, a West African Disease." Journal
of Tropical Medicine, p. 269.

•* Eaton Jones, T. (March, 1904), " The Influence upon Public Health of the Present Method of Keeping of
Horses and Cattle in Towns." Journal of State Medicine, p. 153, Vol. XII.

° Miura, K. (October, 1907), " Some Remarks concerning Kubisagari or Vertige Paralysant." Philippine
Journal of Science, p. 409, Vol. II.

EEVIEW — TKOnCAIi MEDICINE, ETC. 9

aasociatefl with the close proximity of stables aud cowsheds to human habitations. This, Animals—
if confirmed, is fresh evidence of the numerous links uniting human and veterinary pathology continued

and the necessity for a combined study of both sciences.

Ankylostomiasis. This is a subject of very considerable importance in the
Sudan, owing to the latter's close relations with Egypt and to the large number of
Egyptians, military and civil, in Government and other employ. Of late years a good many
new facts have been elicited about this disease. Of these, none is more suggestive than that
referred to by Ferguson,' of Cairo, namely, the influence of intestinal sepsis in the
production of the advanced anajmia. The sites of attachment of the worms, he states,
become, sooner or later, minute septic foci, and the influence upon the blood of the
absorption of the septic matter from these foci is well marked. He also refers to
the active myeloid transformation occurring in the femur, and draws attention to the
similarity of the blood condition in some cases of ankylostomiasis to what is found in
progressive idiopathic anaBuiia. Boycott," on the other hand, contrasts these two
conditions and maintains that in ankylostomiasis the apparent anemia is due almost
entirely to the diluted condition of the blood. He points out that the production of the
mechanism of this hydraemic plethora in ankylostomiasis is as obscure as it is in chlorosis.
He shows by an estimation of the total oxygen capacity of the blood that it can scarcely be
due to the multiple small hfemorrhages such as might be caused by the parasites, which,
though they are said to feed on the intestinal mucous membrane, do at times contain blood.
Indeed, it is stated^ that at post mortems on cases of ankylostomiasis the greater majority
of parasites are swelled out like leeches, that the contents of their intestines consist of
blood, and that so firm is their hold upon the mucous membrane that it is not easy to
understand how any food other than the blood from the bite can gain access to their buccal
cavities. Moreover, it is to be remembered that Loeb and Smith have described certain
organs producing a powerful anti-coagulant substance. If, therefore, Looss's theory that the
intestinal mucous membrane forms the worm's food be correct, what can be the use of this
curious secretion?

Macdonald* has directed attention to the presence of ankylostomiasis in Australia, and
the tendency to moral degeneration associated with the disease. This occurs in children as
well as in adults, and is probably due to a weakened physiology of the victim and an
existing nerve toxin. Happily thymol in curing the disease abolishes the tendency towards
immorality. Manson confirms Macdonald's observations as regards children.

Schtiffner^ has an interesting paper dealing with the skin irritation produced by the
passage of the larvae into the tissues, and has observed, in Sumatra, that other parasites
present in the stools, notably Strongylus stercoralis and the larvae of a fly, were apt to
crowd out the young ankylostomes, so that it was difiicult to obtain cultures of the larvae.
This is an important observation, but requires confirmation. While on this subject one may
refer to a paper by Branch'' on the culture of ankylostome lai-vae. He has found both
varieties of the worm, namely, A. duodenale and N. americanus, in the West Indies, and has
succeeded in obtaining the larvae by the following procedure : —

a portion, the size of a hazel nut, of ffecea, containing abundant ova, is laid on a piece of lint in a Petri
dish, and enough sterile water is added to gatixrate the lint and wet the bottom of the dish. The dish is
left at room temperature exposed to light near a window and the supply of water is maintained as required.
The larvae hatch in about three days, and after two or three days more they begin to find their way into
the water at the bottom of the dish, which must be kept wet enough. Soon after they are hatched one may
see larvae swarm on the surface of the ffeces by breathing on it. They protrude their bodies and wave
excitedly. They climb on each other so as to form actual tufts which can be picked off with the poiat of a
needle.

For mounting he recommends embedding in a smear of glycerin and egg-white, treating
with absolute alcohol, washing to dissolve out the glycerin, and staining with hsematin
and eosin.

' Ferguson, A. B. (November 9th, 1907), " Anaemia in Ankylostomiasis." British Medical Journal, p. 1320.

- Boycott, Arthur E. (September 9th, 1907), " Anaemia in Ankylostomiasis." British Medical Journal, p. 1318.

' " Ankylostomiasis Infection vid the Skin " (November 1st, 1906). Journal of Tropical Medicine, p. 340.

•• Macdonald, T. F. (January 11th, 1908), " Experience of Ankylostomiasis in Australia." Lancet, p. 102, and
Journal of Tropical Medicine and Hygiene, .January loth, 1908, p. 25.

" Schiiffner, W., " Ueber den neuen Infectionsweg der Ankylostomalarvae durch die Haut." Cent.filr Bakt.,
Originale I., Vol. XL., p. 683.

" Branch, C. W. (November 1st, 1907), " Notes ou XJncinaria." Journal cf Tropical Medicine and Hygiene,
p. 352.

10 REVIEW — TROl'ICAL MEDICINK, ETC.

Ankylosto- As regards the larvte of Necator lunericanus (Uncinaria americana), Smith'* has shown

miasis— that they produce a substauce which is very irritating to the skin and leads to severe itching

coniiniial with a tendency to vesiculation. This irritation leads to scratching, and the latter may
actually facilitate the passage of the larviE through the skin.

Leiper," who employs the term Agchylostumiasis, has shown that the so-called
" American " Hook-worm is widely distributed in Africa. It occurs on the West Coast, in
Uganda and in North-West Rhodesia, but apparently not in Egypt. It has also been
found in Ceylon, Assam and Burma, and probably is world-wide.

I cannot speak to its presence in the Sudan. The eggs of what is apparently
A. duodenale are frequently found in the stools of Egyptian soldiers in Khartoum, but one
has not had time to work at this subject. The disease is certainly not so much in evidence
as in Egypt, but there seems no reason why it should not occur and spread in the Sudan,
though probably Egyptians are more liable to infection than Arabs or Sudanese.

Saudwith^ indeed notes its prevalence in Upper Egypt and suggests that it will increase
as irrigation increases. I think this is very likely, and that measures should be taken to
guard the Sudan, as far as possible, from its invasion. This is admittedly a very difficult
matter at the present time, but seems worthy of consideration. The careful medical
inspection of recruits in Egypt no doubt weeds out a considerable number of advanced cases,
while up to the present there has been very little, if any, immigration of the Egyptian fellaheen
into the Sudan for purposes of agricultural work. Possibly this may change in the future
and then it would certainly be advisable to have some system of medical examination and to
either reject infected individuals or submit them to suitable treatment before admission to
the Sudan. In this connection one may** note the remarkable results obtained in the
campaign against ankylostomiasis in Porto Eico. The overwhelming importance of the
disease as a factor in the industrial efBeiency of that island having been fully established,
steps were taken to treat the infected with thymol, partly in hospital but mostly as
dispensary out-patients. Beta-naphthol, which is much cheaper, was also tried, but was not
nearly as good in the case of out-patients. Nearly 20,000 persons were treated within a
period of sis months and with most gratifying results. It was found that, as a rule, five doses
of thymol were sufficient to practically cure a patient, i.e. to render him healthy and to
reduce his power, by nineteen-twentieths, of infecting the soil afresh. The report is well
worth perusal, and the cost of the operations was remarkably low. It is evident that a great
deal can be done by energy and persistence, even in a country sorely stricken by this most
debilitating and frequently fatal disease.

Hermann's method of treatment by means of eucalyptus oil, chloroform and castor oil
was described by Philipps,^ who recorded good results obtained with it in Cairo. It seems
to be efficient and practically free from danger.

For the ankylostomiasis of mines, sodium chloride has been shown to be a prophylactic''
and can be used in a 2 per cent, solution as a spray, but, as Looss points out in a paper'*
dealing with many particulars of the life-history of the larvas, the only efficient preventive
measure is an efficient system of conservancy. Hence the necessity of arranging for such,
especially in cultivated portions of the Northern Sudan where moist conditions of the soil
prevail and where, if this sanitary measure be neglected, the disease may establish itself
and in the future produce much invaliding and incapacity for work. It is worth noting,
however, that some hold the view, a view not shared by Looss, that the larvae show
remarkable powers of resisting dryness, so that even under ordinary conditions in the Sudan
there may be danger from the employment of imperfect conservancy methods which permit
systematic fouling of the surface soil of towns and villages.

' Smith, C. A. (November 24th, 1906). Journal of American Medical Association.

* Leiper, R. T. (March 23rd, 1907), "Distribution of American Hookworm." British Medical Jmtrnal,
p. 683, Vol. I.

= Sandwith, F. M., " Medical Diseases of Egypt," Part I., 1905.

* Prelim. Beport of the Comm. for the Suppression of Ankylostomiasis in Porto Eico, San Juan,
December 31st, 1905.

' Philipps, L. P. (December 1st, 1905), "On Eucalyptus Oil as a vermifuge in Ankylostomiasis." Journal of
Tropical Medicine, p. 341, Vol. VIII.

" Manouvriz, A. (November 25th, 1905), " The Prophylaxis of Ankylostomiasis.'' British Medical
Journal, p. 1418, Vol. I.

■• Zeitschrift.fiir Klin. Med., t. LVIII., p. 43.

• Article not consulted in the original.

REVIEW — TROPICAL MEDICINE, ETC. 11

Anthrax. This disease is said to have occurred in Kordofan, but it has never come
under my notice in the Sudan. Stockman,' however, has suggested the possibihty of the
introduction of the disease through oil cake for cattle, a point proved beyond doubt,- though
nothing definite regarding its importance has been ascertained. Kessler^ has investigated
the influence of the tanning process upon anthrax spores and has found that chemicals and
processes in common use cannot be said to destroy all of the anthrax spores upon infected
skin. These can even resist exposure to solutions of caustic lime for from 12 to 17 days.
A 1 per cent, solution of formalin, however, if allowed to operate for a period of 48 hours
easily destroys the spores. Experiments by Sirena''* showed that the spores maintained
both their vitality and virulence for periods of years in the soil, in sea-water and in
distilled or sterilised water. These points seem worth considering, as in the future the trade
in Sudan hides is likely to increase. Veterinary officers may note the most recent method
of transmitting anthrax material to the laboratory for purposes of culture and animal
inoculation. This is the plaster of Paris rod method introduced by Forster, of Strasburg.
It has been tested and found satisfactory. A reference to it will be found in the Journal of
Tropical Veterinary Science for July, 1907, while Forster describes his method in Cent. f.
Bakt., Abt. I. Orig., Vol. XL., 1906, p. 751.

Mazzini^ has worked at the diagnosis of anthrax, and concludes : —

1. The material should be collected from the animal before advanced putrefaction occurs, preferably not
later than 24 hours after death in the summer.

2. The method of Heim, with threads, or that of Pischoeder, with 2 to 3 millimetres of blood, is the best,
because putrefaction is thus arrested or impeded.

3. The cultural test is made by sewing a piece of thread saturated with spleen juice on Agar.

4. The biological proof on the guinea pig is less reliable on account of the presence of extraneous organisms.

5. The failure of both these above tests does not exclude anthrax. Heating of the material to 60° C. must
be had recourse to.

Bacteriolog;y. Under this heading only questions of general bacteriological interest
will be mentioned.

Bond'' has drawn attention to the urinary mucous tract, and not the blood stream, as the
route of invasion by pathogenetic organisms under certain conditions. This occurs in some
cases clinically like pyelitis, but in which no adequate cause for the illness can be found.
Females are chiefly affected, and there is a distinct connection with the pregnant state. He
has shown that wliere there is a temporary arrest, partial or complete, in the normal out-
going flow of urine from the kidney a regurgitant mucous stream may occur in the genito-urinary
tract, and micro-organisms may thus be carried from the urethra or bladder to the ureter and
kidney. Those principally concerned appear to be the gonococcus, streptococci, Staphylo-
coccus albus and the Colon bacillus. He is inclined to think that the Tubercle bacillus may
reach the kidneys in this way. The question is one of considerable interest in a dry and very
hot country like the Sudan. In the First Eeport of these Laboratories I made mention of a
condition resembling a mild pyelitis which is apt to occur in new-comers, and which is
believed to be due to the irritation produced by concentrated urine. In the light of Bond's
observations it is possibly micro-organismal in nature and due to some such condition as he
describes, although the disturbance is usually of so mild a nature that it would scarcely seem
to be infective.

Arnold' has tested the effect of the exposure to tobacco smoke on the growth of patho-
genetic micro-organisms, and concludes that it is very probably detrimental to the growth of
some of these, especially perhaps the diphtheria bacillus. He points out, however, that its
effect is certainly not greater, and is probably less, than that of smoke derived from other

' Stockman, S. (May, 1905). Public Health, Vol. XVII., p. 491.

' Stockman, S. (October, 1906), "The Causes of Anthrax in Great Britain." Journal of Tropical Veterinary
Science, p. 432, Vol. X.

' Kessler, H. (February, 1905), " The Influence of the Tanning Process upon Anthrax Spores." Public Health,
p. 273, Vol. XVII.

• Sirena, S. Arch, de la Sc. Mid., t. XXX., No. 8, 1906.

" Mazzini, Q. (1908), "Experiments Regarding the Diagnosis of Anthrax." Article translated in yow/m?
uf Tropical Veterinary Science, May, 1908, Vol. Ill, No. 2.

« Bond, C. J. (.July 12th, 1907), " On the Urinary Mucous Tract." British Medical Journal, p. 1639.

■> Arnold, M. B. (May 4th, 1907). lancet, p. 1220, Vol. I.

* Article not consulted in the original.

12 . REVIEW — TROPICAL MEDICINE, ETC.

Bacteriology sources. Tiillat, quoted by Arnold, regards the action as duu to the presence of formaldehyde
—continued j^ tobacco sinoke. The kind of tobacco employed seemed to exert no influence on the results.

Castellani' has isolated from the blood of three patients suffering from fever, in Ceylon, an
organism which he has called Bacillus ceijhmensis. Further particulars will be found under
the heading of " Fever " {paye 69), but it may be stated here that the bacillus was non-motile,
produced a pellicle in broth, acidified and coagulated milk slowly, produced acid but no gas
in glucose, and produced neither acid nor gas in saccharose, manuite, dulcite or lactose.
There was no indol formation. From a fourth case, in which the clinical symptoms were
slightly different, a somewhat similar organism was isolated, but it acidified and clotted milk
quickly and formed indol. In every instance the organisms were agglutinated by the blood of
the patients from whom they were recovered.

When examining a well-water in Khartoum, I came across an organism which morpho-
logically and culturally resembled this B. ceylanensis, but the only sugar media in which it
was tested were lactose and glucose and its pathogenicity was not determined. Intra-
peritoneal injections of broth cultures of B. ceylanensis killed guinea pigs in 24 to 36 hours.

Buckley,^ in a very important paper, records the results of his careful and elaborate
experiments on the resistance of some pathogenetic micro-organisms to drying. Those
used were Staphylococcus pyogenes aureus. Bacillus coli communis, Bacillus typhosus, Bacillus
diphtherias, Bacillus pestis and Spirillum choleras. Of these, Staphylococcus pyogenes aureus
was found to be the most, and Spirillum choleras the least, resistant.

The latter cannot live in a condition of complete dryness. Of the other four, B. coli
commimis and B. typhosus proved more resistant than the B. diphtheriee and B. pestis. The
remaining conclusions I quote verbatim : —

Some organisms live longer in a moist and others in a dry atmosphere. In the first class are the
Spirillum, chnh'rw and the Bacillus coli communis, which live very much longer, and the Bacillus typhosus
and the Bacillus pestis, which live only slightly longer, in a moist atmosphere than in a dry one. In the
second class are the Staphylococcus pyogenes aureus and the Bacillus diphtheriee.

Speaking generally, the absolutely dry atmosphere of the desiccator is less harmful to the bacteria used
in these experiments than the partially dry atmosphere of the room. This is possibly due, as suggested by
some observers, to the quick drying of the outer portions of the individual bacilli, which would result in the
formation of a complete protective coat for each organism. The cholera spirillum is an exception to this rule.

The material infected exerts a considerable influence on the powers of resistance to drying possessed by
the different organisms ; but this influence is not of the same kind on all bacteria nor under all conditions of
dryness or moisture. On examining the Tables it will be found that the longest life was reached usually on
plaster and Ume wood. The single exception is in the case of the Bacillus pestis, which was very short-
lived on lime wood, and this was the case in each of ten series of experiments. All the organisms were
short-lived on paper. As would be expected from the fact that the emulsion is unable to sink into glass, and
would consequently dry rapidly, the organisms did not live very long on that material.

The effect of pine wood was variable, and especially so in the moist chamber, pointing to the fact that
some constituent or constituents of the wood were capable of acting injuriously upon the organisms in the
presence of moisture. In all cases this variety of wood exercised an adverse influence on the organisms, and
this suggests the advisability, from a sanitary standpoint, of the use of pine wood, as far as possible, in such
buildings as hospitals — and especially hospitals for infectious diseases.

Infection can persist in dry buildings, cloths, etc., for at least the following periods: —

Staphylococcus pyogenes aureus ...
Bacillus diphtheria: ...
Bacillus coli communis
Bacillus typhosus

Bacillus pestis ...

Spirillum cholcrm ... ...

(These figures represent in each case the longest period during which the organism was found living on
any material in the desiccator, or in the air of the room).

In the case of certain organisms, infection may persist for even longer periods if the buildings, etc.,
are damp : —

Bacillus coli communis for 168 days.

Bacillus typhosus ... ... ... ... ... ... ... ,, 119 ,,

Bacillus pestis ... ... ... ... ... ... ... „ 45 ,,

Spirillum cholerce ... „ 21 „

' Castellani, A. (January, 1907) , " Notes on cases of Fever frequently confounded with Typhoid and Malaria
in the Tropics." Journal of Hygiene, p. 1, Vol. VII.

^ Buckley, Q. Q. (February, 1907), " The Resistance of some Pathogenic Micro-organisms to Drying." Public
Health, p. 290.

for 140

days.

114

,,

92

n

91

M

34

12 hours

REVIEW — TROPICAL MEDICINE, ETC. 13

Of very great interest to us in the Sudan are the epidemiological instances cited in Bacteriology
connection vpith Enteric Fever. These are as follows: — —,-niiiiviirii.

Henrot (quoted in the Lancet, 1896, 1901, 1903, 1907) gives particulars of an epidemic
of typhoid fever which occurred in two regiments of cavalry quartered at Eheims.
During some mancEuvres the men rode over ground which had been manured with night-soil.
The weather was dry, and much dust was produced, which was inspired and swallowed by
the troops. A bad smell was noticed at the time. Shortly afterwards the epidemic broke
out amongst these men. The water supply was not to blame, as other people drinking
from the same source were not affected.

In the British Medical Journal of November 10th, 1900, is an article on the outbreak of
typhoid fever at Quetta, India. At this place the water supply is derived from the hills and
was above suspicion. There was, as usual, freedom from typhoid fever up to May, but from
May 2nd to 13th there were dust storms. Sore throats and tonsillitis resulted, followed by
an outbreak of typhoid fever, some of the cases commencing with sore throat. The night-
soil was placed in pits to the north-west, from which quarter the prevailing winds blew, and
in the dry air the deposited matters were dried and blown about as dust. Those companies
suffered most who were nearest to the filth pits. The air coming from the direction of the
pits contained " large numbers of germs that are invariably present in fscal matter, and not
in pure air, although the enteric bacillus itself was not isolated." It appears, from a subse-
quent article in the issue of September 14th, 1901, that the outbreak ceased on the removal
of this source of infection.

The foregoing examples, which could easily be multiplied, will suffice to indicate the
probable influence of desiccated products on the dissemination of disease.

It is a pity that no reference is made to experiments with the bacillus of dysentery,
though this subject will be discussed in its proper place. It would be useful also to have
reliable data dealing with the combined influence of drying and high soil and atmospheric
temperature.

The bacteriology of the common cold has been the subject of considerable work and
discussion. Miller^ confirmed work of earlier observers by showing that the organisms found
in catarrh are those normally present in the nasal mucous membrane. These were chiefly
Staphylococcus pyogenes albus, Streptococcus pyogenes and an undetermined diplococcus.
Staphylococcus pyogenes aureus, Hoffmann's bacillus and Bacillus subtilis were also found.
He points out the mechanism of infection, i.e. the chill, resulting lowered vitality of the
mucous membrane, disturbed balance between the tissues and the^erms, bacterial action
and the reaction of the tissues leading to the presence of leucocytes and antitropic bodies.
Treatment can only be successful in the incubation period, usually of 24 hours' duration, and
is to be sought in the inhalation of a volatile antiseptic such as eucalyptus oil.

Benham," as the result of a specially careful investigation, found in a series of 27 cases
both Diphtheroid bacilli and the Micrococcus catarrhalis which was isolated by Hajek. He
thinks the former may be responsible rather for painful sore throat with headache, malaise
and muscular pains, irritable cough and scanty, viscid expectoration, than for the true coryza
symptoms. He suggests it be called Bacillus septus, or "Cautley's" bacillus, after its
discoverer, who named it B. coryza} seginentosus. Pfeiffer's bacillus was scarcely in evidence
at all, a point of considerable interest.

Allen, ^ while pointing out that several organisms are operative, presses the claims of
Friedlander's bacillus and adduces evidence in its favour as being of etiological importance,
at least in the type of cold characterised by shivering, general depression and malaise, with
acute running from the nose and eyes. He admits that Diphtheroid bacilli may play a part in
cases with sore throat, cough and scanty, viscid expectoration.

Gordon'' suggests that animal experiments might help to settle the question. In a
review'^ of the whole subject we find that, in 50 out of 56 cases examined, the B. coryzae

' Miller, J. (May, 1906), " The Etiology of Coryza." Birmingham Medical Review.

' Benham, Chas. H. (May 6th, 1906), " The Bacteriology of a Common Cold." British Medical Journal,
p. 1023, Vol. I.

' AUen, R. W. (May 12th, 1906), " The Bacteriology of a Common Cold." British Medical Journal,
p. 1131, Vol. I.

* Gordon, M. H. (June 2nd, 1906), " The Bacteriology of a Common Cold." British Medical Journal, p. 1193,
Vol. I. - i- •

^ Gordon, M. H. (September 22nd, 1906), "The Bacteriology of a Common Cold." British Medical Journal,
p. 1318, Vol. I.

14 KEVIKW — TROPICAL MEDICINE, ETC.

Bacteriology seginentosns was preseat but its precise etiological significance in relation to the common
— ^-Dntintu-if cold has yet to be determined. The Micrococcus catarrhalis has more recently been the
subject of work by Arkwright,' whose conclusions arc as follows: —

1. Qr.im-uegative cociii derived from the nose can be divided into several different races, which require
careful culture for their ideutilication.

2. 3f. catarrhaUs is present very frequently in the normal nose, especially in the young and more
especially in infants.

3. Its frequency does not appear to be greater in ordinary catarrhal states than in non-catarrhal. In
this respect it differs from the pncumococeus and Hoffmann's bacillus.

It would, I think, be interesting if some work on this subject were carried out in
tropical countries. In the Sudan, at certain seasons of the year, the influenzal type of cold
is very common, the exciting causes being chill, and, to a lesser extent, the irritation
produced by dust. It is possible that diphtheroid organisms are not so prevalent as amongst
urban populations in temperate countries, and it might be possible to settle which is the
true organism of coryza more easily than in a place where micro-organisms abound and
conditions are more complicated.

It is worth noting that spraying the floors of schoolrooms with weak formalin
solution has been found to inhibit the spread of infectious colds.

Gwyn and Harris- have worked out a comparison between the results of blood cultures
taken during life and after death, a subject of very considerable importance. Their chief
conclusions are as follows : —

1. That within certain limits post mortem bacteriological methods afford trustworthy means of
determining or confirming the presence of any of the well-known infectious processes.

2. That the more often a marked ante mortem infection is present, the greater probability there is of
finding an uncomplicated post mortem bacteriological result, provided the investigation is carried on within a
reasonable time after death, say 12 hours.

3. That a bacteroemia due to the common organisms of the intestinal tract and the so-called "agonal
invasions" of the blood streams do occur, yet they should not be assumed to be present with any great
degree of frequency.

With regard to 2, one can say from the result of animal post mortems that the period
mentioned has to be greatly shortened for the Sudan. In the summer a period of four hours,
as a rule and under ordinary conditions, suffices for the occurrence of a general bacteriological
infection which is especially fatal to examinations having for their object the recovery of
hsematozoa from the blood and organs.

But little is said in text-books regarding the important ultra-visible viruses which are
of special interest from the veterinary standpoint. A paper on this subject by Macfadyean'
is, therefore, likely to prove of great value. In the first instalment he deals with the
viruses of the mosaic or spotted disease of the tobacco plant, of foot and mouth disease,
and of African horse-sickness and also discusses the technique employed for the isolation
of the ultra-visible viruses.

Beri-beri. The vexed question of the precise etiological factor determining this
disease still remains unsettled, and this despite a great deal of work by able observers. It
is impossible to detail at all fully the various researches and their results, but mention may
be made of the essay by Gerrard,^ which gives a very graphic description of the symptoms.

He appends a table of types as follows : —

W(

et Dry Fulminating Mixed

Spasmodic Eudimentary

A useful list of the diseases from which beri-beri has to be distinguished is included.
These are alcoholic neuritis, arsenical neuritis, lead-poisoning, malarial cachexia, Landry's

' Arkwright, J. A. (January, 1907), "On the occurrence of the Micrococcus catarrhaUs in normal and catarrhal
noses, and its differentiation from other Gram-negative cocci." Journal of Hygiene, p. 145, Vol. VII.

= Gwyn, N. B., and Harris, N. MacL. (June, 190.5), " A Comp.^rison between the results of blood cultures
taken during life and after death." Journal of Infectious Diseases, p. 514.

" Macfadyean, J. (March, 1908). "The Ultra-visible Viruses." Journal of Comparative Pathology and
Therapeutics, Vol. XXI., Part I.

* Qerrard, P. N., " Beri-beri, its Symptoms and Symptomatic Treatment." London, Churchill.

REVIEW TKOPICAL MEDICINE, ETC. 15

ascending spinal paralysis, locomotor ataxy, ataxic paraplegia, spastic paraplegia, myelitis Beri-beri—
affecting the lumbar region, epidemic dropsy, pernicious anfemia, heart-disease, Bright's continual

disease, ankylostomiasis, trichinosis, pellagra, ergotism and lathyrism. It is curious that in
this long list scurvy is not included, for the resemblance of certain cases of scurvy to certain
types of beri-beri is well known.

Thus, Barnardo,' in a paper on scurvy affecting troops in Somaliland, draws attention to
toxjEmic cases characterised by a neuritis sometimes peripheral, sometimes cardiac, and
suggests that both scurvy and beri-beri may be due to toxin production in the alimentary
tract, as suggested for the latter by Hamilton Wright, an hypothesis first put forward by
Chevers. Hoist and Frolich^ term ship beri-beri " the younger brother of scurvy," but point
out that it is possibly a different disease from tropical beri-beri. However that may be,
beri-beri has been mistaken for scurvy more than once, and their resemblance has to be kept
in mind, especially when one is dealing with advanced, untreated scurvy. This fact was
forcibly brought to my notice by an epidemic of the latter which occurred in the
Civil Prison, Khartoum, during the winter of 1906. Several of the patients developed
symptoms strongly recalling dropsical beri-beri. Hyperaesthesia, oedema, peculiar gait,
cardiac dilatation and other classical signs were present, though most of them presented, in
addition, spongy and bleeding gums. Epidemic dropsy was the other disease which had to
be differentiated, and it was only when energetic treatment, principally of a dietetic nature,
was established that the question of diagnosis was settled.

The disease is known to occur in the French Sudan, while Bagshawe^ suggests on very
strong evidence that the condition " Bihimbo," in Uganda, is really beri-beri. Hodges*
comments on this and records his opinion that the disease is, in all probability, beri-beri.
Captain Ensor states that he has seen two typical cases in the Sudan, and I have met with a
case of peripheral neuritis not unlike beri-beri. As, therefore, the disease may come more
into prominence in the future, a few notes on recent work upon it may prove useful. As
regards its etiology, facts favouring the mouldy rice theory are quoted by Gimlette^ in a
paper on a localised outbreak in the Malay Peninsula, while, under " Current Topics," the
Indian Medical Gazette'' deals with the same question and cites, as does Gimlette, the
suggestive work of Hose and Lucy of Penang. The theory that beri-beri is due to an
intoxication by a poison conveyed in " uncured " rice originated with Braddon, who has
recently published a large work' on the subject and brought forward such evidence that, to
quote a review, "one is inclined to come to the conclusion that rice does play a part in the
production of the disease, or, at least, that further experiments should be carried out to
prove or disprove its action as a cause." Fletcher* supports Braddon's view as a result of
his experience and experiments in connection with an outbreak at Kuala Lumpur Lunatic
Asylum. He concludes that : —

Uncured rice is, either directly or indirectly, a cause of beri-beri, the actual cause being either (1) a poison
contained in the rice ; (2) deficiency of proteid matter, the disease being due to nitrogen starvation ; or (3) uncured
rice does not form a sufficiently nutritive diet and renders the patient's system specially liable to invasion by a
.specific organism which is the cause of beri-beri.

This leads us to speak of the organismal theories and to quote Herzog," whose
investigations are recorded in a very complete and interesting paper. His experiments
led him to believe that none of the claims brought forward for the discovery of a specific
micro-organism for the disease can be looked upon as substantiated. This includes

• Bamardo, J. P. (July, 1904) "Scurvy in Somaliland: Notes on the Condition of Blood Serum." Indian,
Medical Gazette, p. 241, Vol. XXXIX.

' Hoist, A., and Frolich, T. (October, 1907), "Experimental Studies Relating to Ship Beri-beri and Scurvy."
■Journal of Hygiene, Vol. VII., No. 5.

' Bagshawe, A. Q. (January 15th, 1907), " ' Bihimbo ' Disease r The Nature of the Disease termed ' Bihimbo '
met with in the Chaka District of the Uganda Protectorate." Journal of Tropical Medicine and Hygiene,
p. 18, Vol. X.

•* Hodges, A. D. P. (October 31st, 1906), "Report to P. M. O. Uganda and East Africa on Sleeping Sickness."

^ Gimlette, J. D. (September 1st, 1906), " Beri-beri, Mouldy Rice : The Occurrence of Beri-beri in the Sokor
District."

" "Beri-beri and Diet." (May, 1906). Indian Medical Gazette, p. 183, Vol. XLI.

' "The Cause and Prevention of Beri-beri." London, Rebman, Ltd., 1907.

' Fletcher, W. (June 29th, 1907), " Rice and Beri-beri." Lancet, p. 1776, Vol. I.

'' Herzog, M. (September, 1906), " Studies in Beri-beri." Philippine Journal of Science, p. 709, Vol. I.

16 REVIEW — TEOPIOAL MEDICINE, ETC.

Beri-beri— Hamilton Wright's' bacillus found in the gastro-duodenal lesions described by him, and
rnnthined various other bacilli and cocci which have been claimed as etiological factors, together
with Glogner's amoeba and the haamatozoon put forward by Fajardo. Herzog expresses
his belief that " the disease is due to an organism which gains entrance into the human
body either directly or through food, and there produces a toxin which in character and
effect is similar to the diphtheria or tetanus toxin, and which, by an accumulative action,
gives rise to the well-characterised anatomical and histological lesions of beri-beri."

This is more or less in accord with Daniels'- conclusions, who regards beri-beri as an
infectious disease, and points out that there is no evidence that an intermediate host is
required, but that if such is required it must be a bed-bug or a flea. Indeed, he tends to
think that a protozoon may yet be found.

In this connection mention must be made of the recent observations by Hewlett and
de Kort^' on a disease in monkeys closely resembling beri-beri. In the urine of these
monkeys, and also in that of beri-berics, they found peculiar highly refractile bodies which
they think may be protozoa. They also describe certain inflammatory changes common to
the monkey's kidneys and the kidneys of a number of cases of acute beri-beri sent them from
Singapore. In reply to a paper by Wright, they point out^ that it is the intra-tubular
haemorrhages to which they specially refer. A recent review of the whole subject is that by
Nocht,'^* while experimental work has been performed by Hunter and Koch" in Hong Kong,
who employed monkeys, and believe it is impossible to transmit beri-beri from man to
animals, and that, in the strictest sense of the term, beri-beri is not an infectious disease.
Other recent work is that of Tsuzuki,'* who has found what he calls the " kakke coccus " in
the urine, stools and intestines of beri-berics, an organism which is agglutinated by the
blood-serum of beri-berics and produces in animals a disease which closely resembles human
beri-beri. As regards prophylaxis and therapeusis, there is little new to note. Herzog
mentions that women sick with beri-beri should not nurse children, describes a method
of treatment in vogue in Japan, and states that " rice should, in private practice at least, be
entirely withdrawn from the daily diet of the patient."

Beverages. Under this heading attention may be drawn to the review of
Dr. Hamer's^ report on aerated waters. This shows how often waters, in themselves
good, become contaminated in process of conversion to aerated waters by the use of unclean
charcoal filters, by faulty storage, by faulty bottle cleaning, and especially by neglect in
purifying stoppers. It also points out that the evidence regarding the ability of carbonic
acid gas to destroy pathogenetic organisms, such as the Bacillns typhosus, is inconclusive
and quite insufficient to warrant neglect of precautions.

This subject, which is one of much importance in the Sudan, will be further discussed
under " Sanitary Notes" (Third Eeport). It is said the Spirillum choleras speedily perishes
in well-aerated waters, and in India" it is recommended that such waters be drunk when
cholera is prevalent, provided no bicarbonate of soda has been added.

Attention having been drawn to the presence of antimony in bottled beverages, the
poison having been derived from the rubber rings used to make the stoppers fit tightly,
Thresh^** investigated the subject. He concluded that the solubility of the antimony sulphide
contained in the rubber is so slight that the only danger to be apprehended is from detached
particles, and especially if old rings are used. At the same time, he notes that antimony

• Wright, Hamilton (May, 1902), "On the Classification of Beri-beri." ShuHes from Institute for Medical
Research, Federated Malay States, Vol. II.

'' Daniels, C. W. (1906), " Observations in the Federated Malay States on Beri-beri," Vol. IV.

= Hewlett, B. T., and de Kort^, W. E. (July 27th, 1907), " On the Etiology and Pathological Histology of
Beri-beri." British Medical Jmirnal, p. 201.

• Hewlett, E. T., and de Korte, W. E. (November 2nd, 1907), " The Pathological Histology of Beri-beri."
British Medical Journal, p. 1281.

"> Nocht, B., " Eeal Encycl. d. gesamt. Heilkunde." 4th Edition. Berlin and Vienna.

" Hunter, W.,and Koch, W. V. M. (November 1st, 1907), "Experimental Beri-beri in Monkeys." Journal of
Tropical Medicine and Hygiene, p. 346. Vol. X.

' Tsuzuki. Archiv/iir Schiffs-and Trap. Hyg., Bd. X., Heft 13.

« Hamer, W. H. (July 4th, 1903), "The Purity of Aerated Water." Lancet, p. 40.

• Duke, I., Calcutta, 1904, " The Prevention of Cholera, and its Treatment."

JO Thresh, J. C. (November, 190.5), "The Presence of Antimony in Bottled Beverages." Public Health, p. 95,
Vol. XVIII.

• Article not consulted in the original.

REVIEW TROPICAL MEDICINE, ETC. 17

sulphide is a cumulative poison and that, as the quantity in the rings is considerable, a Beverages —
rubber free from such poisonous ingredient should be used. coaiUued

A serious indictment of both tea and coffee is put forward by Fernet'* who calls them
" satellites of alcoholism," and describes caffeism and theism in acute and chronic forms.
Coffee is especially libelled, because its abuse has recently increased in France. It is said
to depress the mental power, and chronic coffee intoxication leads, it is asserted, to impotence
and sterility, while the children of coffee drinkers are ill-formed, ill-nourished, abnormally
excitable and often suffer from arrests of development. The quantity sufficient to produce
such dire results is uncertain, but three or four small cups daily may be enough to cause
chronic intoxication.

These remarkable statements certainly do not find confirmation in the Sudan, where
coffee is largely drunk both by Europeans and natives, though be it noted, it is very excellent
coffee, prepared directly and carefully from the bean. Indeed, as the British Medical
Journal- remarks: "There can be little doubt that Dr. Fernet's article is somewhat tinged
by exaggeration, though it is well to bear in mind that some of these ill effects may be
encountered in practice from personal idiosyncrasy or excessive use of tea and coffee."

Bilharziosis. The most recent work on this subject will be found incorporated in
Madden's^ monograph which, dealing as it does with the disease from an Egyptian
standpoint, is of special interest to us in the Sudan. The author supports Looss's theory as
to the direct entry of the miracidium by way of the skin, and he rejects Sambon's supposition
that there are two species of Schistosomum, one characterised by terminal-spined, the other
by lateral-spiued, ova. He also mentions an interstitial nephritis due to the disease, and
deals with its effects on the female generative organs.

Looss'' in a recent paper severely criticises Sambon's views, and regards the evidence
adduced by the latter as wholly inadequate to prove the existence of Schistosomum mansoni.
He points out that no distinctive anatomical character of (S. mansoni has been
demonstrated, and, as regards the egg, states that proof of its belonging to a definite
species must consist in showing that one form of egg is constantly connected with a certain
anatomical structure, and the other form as constantly connected with another anatomical
structure of the adults. " Until this is done," he says, " I am afraid that S. mansoni will
find little approval with zoologists in spite of Dr. Sambon's contention that to zoologists the
character of the ovum should sufBce for the determination of a new species."

Looss goes on to say that the position of the spine depends on the relative position of
the egg during the process of its formation in the ootypes, and points out that long ago
Bilharz found that in Egypt the eggs of S. haimatohium and ti. mansoni may occur in
one and the same individual female. Moreover, he would lay no stress on the point if a
lateral-spined egg happened to be found in the urine. To him it would appear as an
accidental exception, due to accidental reasons, to the rule that the urine contains terminal-
spined eggs only. One important statement made is, that the lateral-spined eggs do not
come from the rectal lesions. They are probably abnormal eggs, for Looss has found that
very generally Trematodes, as they approach sexual maturity, form such ova. At the same
time, he does not pretend that immaturity is the sole cause of the lateral spine. Indeed, an
immature female may quite possibly produce a terminal-spined egg.

Taking up the question of geographical distribution, Looss apparently shows that
Sambon's position is untenable, and mentions that in LetuUe's case, where the bladder was
entirely free from infection, both forms of egg were found.

One cannot follow Looss throughout his whole argument, but one statement must be
noted. His experiments to find an intermediate host in various species of mollusc have
invariably failed, and he has been forced to the conviction that "Ifaw himself acts as
intermediary host." If this be true, then the spread of iS'. heematobium is not limited by
the natural geographical distribution of a special intermediary host. He now believes, and
he adduces some proof in favour of the idea, that the miracidia enter through the skin and
that a few of them reach the liver and there form sporocysts. He proceeds to discuss this

' Fernet, Scmaine Midicale, No. 31, 1906.

^ British Medical Journal, p. 652, Vol. II. (September 15th, 1906), " Our Breakfast Beverages."

' Madden, P. C, " Bilharziosis," Cassell & Co., 1907.

^ Looss, A. (July 1st, 1908), "What is Schistosomum Mansoni?" Annals of Tropical Medicine and
Parasitoluijij, Series T.M., Vol. II., No. 3.

• Article not consulted in the original.

18 REVIEW— TROPICAL MEDICINE, ETC.

Bilharziosis view at length, and states that a first infection with a female sporocyst would give a picture
—contiimcd typical of " Hansen's Bilharziosis," i.e. an untouched bladder, but lateral-spined eggs
appearing for years in tlie faeces.

Whatever may bo the truth regarding )S'. mamoni, and I confess that, considering
Looss's vast experience and great repute as an helminthologist, his opinion carries most
weight, there can be no doubt as to the importance and interest of his paper, which should
be carefully studied by all interested in Bilharziosis.

A useful and well-illustrated paper is that of Sandwith,' who mentions Dight's
suggestion to inject large quantities of sulphuretted hydrogen and carbon dioxide gas into
the rectum or bladder for the purpose of killing the worms in situ.

Symmers,- in a paper describing a remarkable case, mentions that he has twice found
living worms in the pulmonary blood, and describes a peculiar condition of polypoid
outgrowths on the serous coat of the ileum, caecum and colon, extreme polyposis of the large
bowel, a fibrosis of the appendix vermiformis, the presence of eggs in the pancreas and
lymphatic glands, and the typical liver cirrhosis, although there was only incipient
bilharziosis of the urinary bladder.

Williamson," in a paper on the disease in Cyprus, shows how it was connected with
bathing in a certain river, while a suggestive article on Endemic Haematuria in South Africa,
by Stock,'' draws attention to the presence of fat in the urine and mentions the "toxin"
treatment advocated by Birt. He cites two cases which contracted enteric fever and, as a
result, were apparently cured of their bilharziosis, and a case of fatal dysentery in a native
where, within two hours of the patient's death, the worms, on being dissected out, were found
to be dead. He suggests repeated small doses of Wright's anti-typhoid serum, and mentions
two cases under this treatment, of which, however, I can find no further record.

Letulle' has a paper on intestinal bilharziosis, and mentions the occurrence of the
disease due to S. mansoni in the lesser Antilles, particularly in Martinique. He specially
points out that it is solely confined to the lower end of the intestinal tract.

The paper is well illustrated and discusses the morbid histology of the lesions very fully.

Manson" adopts Sambon's classification, already mentioned, and regards S. mansojii,
which has lateral-spined ova, as being probably a West African species which has been
introduced into the western hemisphere by the African negro. It was first found by him in
a West Indian patient whose urine was free and who had never suffered from haematuria.
Sambon^ has recently again dealt with this subject, and points out that he based his
differentiation of the two species on diiiferences in the structure of the female genital tract
and on the ova, which are distinguished not only by the position of the spine but by its size
and shape and by their own anatomical differences. He also considers the peculiar
geographical distribution and anatomical habitat of 8. mansoni as proof of its being a new
parasite. A concise account is given by Manson of S. japonictim, the trematode found by
Katsurada in human stools and in the portal system of cats in Japan, and discovered
independently by Catto in a Chinaman's meso-colon in Singapore. Hanson's book is,
however, in every practitioner's hands and need not be quoted here. The occurrence of this
parasite in the Philippine islands has been noted by WooUey.** He found lesions in the
lung, liver and bowel of a Filipino and noted fibrosis of the liver.

Logan" describes three cases in China and gives rough drawings of the eggs and free
embryos as they appear in the faeces. He thinks the fact that the egg is only a little larger

' Sandwith, Practitioner, October, 1904.

- Symmers, W. St. C, " Studies in Pathology." Aberdeen, 1906.

' Williamson, Q. A. (November 9tli, 1907), " A Further Note on Bilharzia (Schistosomum) Disease in Cyprus."
Journal of Tropical Medicine, p. 133.3.

■* Stock, P. G. (Sept. 29th, 1906), " Endemic Hsematuria." Lancet, p. 857, Vol. II.

= LetuUe, M. (April 15th, 1905), " Intestinal Bilharziosis." Archives dc Parasit6logie, p. 329, Vol. IX.

« Manson, Six Patrick, " Tropical Diseases." 4th Edition, 1907.

' Sambon, L. W. (.January 11th, 1908), "The part played by Metazoan Parasites in Tropical Pathology."
Lancet, p. 102 ; and (January loth, 1908). Journal of Tropical Medicine and Hijtjiene, p. 27, Vol. XI.

" Woolley, P. G. (January, 190G), "The Occurrence of Schistosomum Japonicum vel Cattoi in the Philippine
Islands." Philippine Journal of Science, p. 83.

° Logan, O. T. (February 16th, 1906). " Three cases of infection with Schistosomum Japonicum in Chinese
subjects." Journal of Tropical Medicine and Uytjicne, p. 294.

REVIEW TEOPICAL MEDICINE, ETC. 19

than that of Ascaris lurtibricoides is very important for the novice in faecal examinations Bilharziosis
to note. — continued

Dr. Low's^ note on making permanent preparations of bilharzia eggs may be quoted.
The little shreds of mucus passed with the urine are mounted in glycerin jelly and the
cover slips ringed with Canada balsam or asphalt.

It is perhaps worth mentioning here that there is a Schistosomum bovis of cattle and
sheep, first described by Sonsino in Egypt, while Montgomery- describes a new species
S. indicum, affecting horses and donkeys in India, and has also found two new species,
8. bomfordi and iS'. spindalis, in Indian cattle. He also records the fact that a very large
number of human cases were introduced into India from South Africa, and that the former
country is evidently well-suited to the propagation of the Bilharzia parasite.

That bilharziosis occurs and is endemic in the Sudan has been shown in the First and
Second Eeports of these Laboratories. Only S. luematohium has, so far, been found. That
it is also frequently being introduced from Egypt there can be no doubt, and as irrigation
schemes increase, so will, in all probability, the amount of bilharziosis. At present the
infection is probably limited, as regards its source, to the Nile, though, if the view be correct
that the embryo reaches its human host in the body of some crustacean, then well-water may
also be implicated. Time has not permitted further experiments with the species of
Ostracode mentioned in the Second Report, but certainly the results obtained were suggestive.
It is difiScult to know if anything could be done to check the probable increase of this
disease. At present it is not much in evidence, save amongst those who have lived in Egj'pt,
and, strictly speaking, it would be well to guard the Sudan against it in somewhat the same
manner as has been suggested for ankylostomiasis. Practically, however, any such scheme
would, under existing conditions, almost seem impossible of realisation, though, if it could be
properly carried out, the urine of immigrants likely to be bilharzia-carriers systematically
examined, and those found infected refused admittance to the country or, at least, placed
under medical control, I believe a possible danger might be averted. Bilharziosis is a serious
menace to health in South Africa and fills the hospitals in Egypt. Hence it would be well to
limit it as much as possible in the Sudan, and a sanitary policy directed to this end, though
it may be regarded as Utopian, has much to commend it, while if it is to be introduced at all,
the present is the time for action.

Blackwater Fever. The precise nature of this dreaded complaint, and one which
has taken toll of several valuable lives in the Sudan, still remains unsolved. The chief
views regarding it are : —

1. It is due to quinine acting under certain conditions and usually on a person the
subject of malaria. This view is quite untenable, as is clearly shown by Manson.'' At the
same time, quinine can and does produce haemoglobinuria. This is one of the rarer toxic
effects of the drug.

2. It is a manifestation of malaria, either a severe form of the disease or a symptom
of the concurrence of a kidney lesion with malaria, a view strongly urged by Plehn.
Buchanan'' has pointed out that three factors may be operative — malaria, quinine and the
kidney lesion.

3. That it is a specific disease due to a special blood j)arasite, in all probability one of
the piroplasmata, which may be conveyed from the sick to the sound by means of ticks.

Having seen very little blackwater fever, one has no opinion to offer, but an obseiwation
by a layman who has had great experience of the disease, and has lost many friends and
companions by reason of it, may not be without interest. He informs me that at least half
the cases which came under his notice had recently suffered from acute gonorrhea. This
may have resulted merely in a lowering of general vitality, rendering the patients more liable
to serious disease ; and, of course, it is certainly not operative in many cases of blackwater
fever, but it may possess some interest in view of the theory which regards a kidney lesion

' Low, Q. C. (February 16th, 1907). " Method of mounting specimens of Bilharzia eggs, embryos, etc."
Jauriial of Tropical Medicine, p. 67, Vol. V.

° Montgomery, R. E. (January and February, 1906), " Observations on Bilharziosis among Animals in
India." Journal of Tropical Veterinary Science, p. 15, Vol. I.

" Manson, Sir P.ttrick (1907), " Tropical Diseases." 4th Edition.

* Buchanan, W. J. (April 27th, 1907), " The Third Factor in the Etiology of Blackwater Fever." British
Medical Journal, p. 990, Vol. I.

continued

20 BEVIEW — TEOPICAL MEDICINE, ETC.

Blackwater as one of the essential factors. I merely mention it here as I can find no reference to its
Fever— having been noted in connection with blackwater fever.

Christophers and Bentley' observed a phagocytosis of rod blood corpuscles in the spleen
of a case of blackwater fever. They specially note that the engulphed erythrocytes con-
tained no parasites, so that the condition is different from what is seen in canine
piroplasmosis where the phagocytosed red colls always contain piroplasmata. They strongly
incline to the view that blackwater fever is the result of malarial infection. As regards the
significance of the condition they describe, they think that if the phagocytosis of apparently
normal red cells be taken in conjunction with the generally recognised fact that exposure
for a certain time to malarious conditions is necessary before blackwater fever can be con-
tracted, then it must be admitted that under certain conditions at some stage in the process
of malarial immunisation, a process which is known in some degree to occur, there results
a liberation of specific poison from the red cells, causing the extensive destruction of these
elements which is the essential feature of the disease.

To medical officers in the Sudan, notes on new or recent methods of treatment are likely
to be more serviceable than a recounting of various etiological theories.

Vedy,-* a French doctor with much experience, believes the disease to be due to a toxin
probably elaborated by a special micro-organism. His routine treatment consists of free
purgation followed by frequent enemata, and in serious cases saline infusion. These measures
are for the elimination of the supposed toxin, and are supplemented by the administration of
warm water and weak tea by the mouth. Symptoms are treated as they arise ; tendencj'
to heart-failure, by caffeine and champagne ; vomiting after the first day, by morphine and
counter-irritation. The use of antipyretics and digitalis is contra-indicated, while pilocarpine
is stated to be dangerous in this disease. This author also gives useful rules as regards the
giving or withholding of quinine.

1. If, twenty- four hours after the onset, malaria parasites are present in the blood, give
a small dose (12 grains) of quinine.

2. Never give quinine if malaria parasites are not present in the blood.

3. If in doubt (if an examination of the blood is not practicable), do not give quinine.

Hearsey's method, which is a modification of that of Sternberg for yellow fever, consists
in the administration of 10 grains of sodium bicarbonate and 30 minims of the liquor
hydrargyri perchloridi. The mixture is given every two hours for the first twenty-four hours
and thereafter every three hours until the urine is free from hemoglobin. Hearsey" recorded
18 consecutive cases treated in this way without a single death. The accompanying treat-
ment consisted of milk and barley water given frequently and in small quantities. Cham-
pagne and acid drinks are eschewed, brandy being the stimulant employed when required.
Benger's food is stated to be of great value. During convalescence the scaly preparations
of iron were found most suitable as blood tonics.

Boxer'' lays great stress on proper nursing and rectal feeding. He condemns the
exhibition of quinine and thinks all drugs are better avoided, except perhaps calomel given
as a purgative.

Owing to its anti-hoemolytic action, Vincent' recommended the administration of
chloride of calcium in doses of 4 to 6 grammes by the mouth, or 1 to 2 grammes
subcutaneously dissolved in physiological salt solution.

Hartigan" suggests, but it is merely a suggestion, the use of euquinine, the ethyl-
carbonate, owing to its being a non-irritant, while Cook, quoted by Harford," describes the
practice in vogue in the German colonies, where cases are not invalided home, but if they

' Christophers, S. R., and Bentley, C. A. (March, 1908), "Note on the Phagocyto.sis of Red Blood Corpuscles
in the Spleen of a Case of Blackwater Fever. Itulian Medical Gazette, Vol. XLIII., No. 3.

^ Vedy, L., " La fievre bilieuse ha>moglobinurique dans le basin du Congo." Paris, A. Maloine, 1907.

' Hearsey, H. (March 5th, 1904), "The Treatment of Haemoglobinurio Fever." British Medical Journal,
p. 544, Vol. I.

■• Boxer, E. A. (May 7th, 1904), " Haemoglobinuric Fever." British Medical Journal, p. 1078, Vol. I.

' Vincent, H., C. K. Soc. Biol., t. LIX., 1905, pp. 633, 635.

" Hartigan, W. (January 15th, 1907), " Euquinine — Its Suggested Use in Blackwater Fever." Journal of
Tropical Medicine and Uygiene, p. 17, Vol. X.

■» Arch. f. Schiffs. n. Trop. Jlijg., January, 1906.

* Article not consulted in the original.

REVIEW — TEOPICAL MEDICINE, ETC.

21

have survived a first attack are put on gradually increasing doses of quinine each day, the Blackwater
urine being examined for the presence of hiEmoglobin. If this does not occur in it, and if Fever-
there be no rise in temperature, jaundice, or liver pain, the dose is run up to 15 grains, and this continued
is then given every 8th or 9th day, with, it is said, the result that neither malaria nor black-
water fever occur. Cook himself employs Hearsey's treatment with apparently good results.

Mayer' described an interesting case which was treated by four-hourly saline enemata
day and night — one pint being given at a time, during the height of the fever. Quinine was
added to some of the latter enemata. The patient made a good recovery and the author
notes that he was remarkably comfortable, that there was no vomiting during the whole
course of the illness, that there was a regular rise of temperature every evening probably due
to his being supplied with fluid, and that this rise yielded to treatment with small doses of
quinine freely diluted. It should be noted, however, that the nursing was apparently ample
and good.

Skelton- (Sierra Leone) distinguishes between hsemoglobinuric paludism (true black-
water) and quinine intoxication. He gives quinine by rectal injection, lirst of all
administering a soap and water enema. The medicinal enema consists of quinine sulphate
5 grains, dilute hydrochloric acid q.s. to dissolve the quinine, and warm water 3 ounces.
He gives opium for vomiting, 1/3 grain morphia repeated, if necessary, in 6 hours. As soon
as the stomach will retain it he gives quinine by the mouth.

Dammermann''* reports favourably on the use of the decoction of the leaves of an African
plant, Combretits raimbaHthins, together with milk and potassium acetate. He gives his
decoction in a strength of 24 parts to 1500 of water as a prophylactic to persons in whom
quinine is apt to induce blackwater.

A practical point is mentioned by Mense,"** who finds that the kidneys are well flushed
by large quantities of warm tea, best sucked through a tube, as this method tends to prevent
vomiting. For this symptom Gush'' recommends an effervescing mixture of carbonate of
ammonia, sodium bicarbonate and citric acid. I have examined several blood films from
blackwater cases occurring in the Bahr-El-Ghazal and have never found parasites of any
kind present. In one case, which terminated fatally in Khartoum and has been recorded by
Crispin,'' I found the urine, which was at the time free from hasmoglobin, loaded with uric
acid. This case was from the Blue Nile, but the patient had previously suifered from the
disease in Central Africa. Eecently, a primary case has occurred at Eoseires on the Blue
Nile, a place with an evil reputation for malaria. One cannot, however, be quite certain if
this was a true blackwater case or a severe case of malaria in which haemoglobinuria
occurred.

Blood. Under this heading no allusion will be made to blood parasites. It is
intended to deal very briefly with questions of morphology, clinical technique and medico-
legal examinations which may furnish useful information to workers in the Sudan and other
tropical countries.

Ilankiu^ describes methods for the recognition of blood and seminal stains, especially
in tropical climates. He points out that the high temperature of tropical climates
has a two-fold action on blood and seminal stains. If the latter are kept damp
they are apt to putrefy, if dry they become so insoluble as to be acted on with
difficulty by ordinary reagents. In a blood stain so altered he finds that the absorption
bands of haemochromogen can be obtained, even when the blood-colouring matter is in an
apparently undissolved and insoluble condition, by the following method : —

If on clothing, cut the stain out and plunge into boiling water for a few moments. Then
place on a glass slide and wet with ammonium sulphide. Examine under the microscope

1 Mayer, T. F. Q. (December 2ucl, 1907), "A Case of Blackwater Fever, Treated by Saline Enemata."
Journal of Tropical Medicine, p. 378, Vol. X.

' Skeltou, D. S. (June, 1908), " Some Observations on Blackwater Fever." Journal of the Rnijal Army
Medical Corps.

" Dammermann, Deutsche Mai. IFochen, 1906, No. 23.

■* Mense, Arch. f. Schijfs. u. Trop. Uijy., January, 1906.

^ Gush, H. W. (December 16th, 1907), "Prophylactic and Remedial Treatment of Blackwater Fever."
Journal of Tropical Medicine and Hijijicnc, p. 401, 'Vol. X.

« Crispin, E. S. (August 5th, 1905), "A Case of Blackwater Fever." Lancet, p. 357, 'Vol. II.
' Hankin, E. H. (November 10th, 1906), " Methods for the Recognition of Blood and Seminal Stains
Especially in Tropical Climates." British Medical Journal, pp. 1261, 1843, '7ol. II.

* Article not consulted in the original.

22 REVIEW — TROPICAL MEDICINE, ETC.

Blood— and move the specimen until the whole field of view is occupied by a portion of the coloured

continue/ material. If necessary an oil immersion must be used. Eeniove the eye-pieco and replace
by a micro-spectroscope. If the stain is of blood the two absorption bands of
hiCmochromogen will be seen. If invisible, as a result probably of commencing putrefaction,
a drop of a 10 per cent, solution of potassium cyanide should be allowed to fall on the stain,
and the bands will appear somewhat nearer the red end of the spectrum than usual. The
boiling is to prevent the colouring matter going into solution and being so diluted that the
bands could not be seen. Stains on weapons or jewellery should first be wetted with
ammonium sulphide. A small portion may then be scraped off with a knife and treated
as above.

A new method of employing the guaiac test had been introduced by Holland'* owing to
the difficulty of getting really old turpentine or good peroxide of hydrogen. He employs as
an oxidising agent, sodium perborate, made from sodium dioxide and boric acid. Freshly
broken pieces of guaiac resin are dissolved by boiling with alcohol in a test-tube for a few
minutes till the tincture is yellow. The suspected material is then cautiously mixed with a
drop or two of the guaiac solution to make a milky mixture. This is brought in contact with
a fragment of sodium perborate on a white plate.

If the proportion of blood bo large, the white perborate turns blue in a few minutes and
remains blue until the drying of the guaiac leaves a yellow residue which changes the blue to
green. If small, the white perborate turns a pale blue which becomes green as the guaiac
dries. The test is simple and delicate, but is, of course, liable to the fallacies belonging to
the ordinary guaiac reaction.

Turning to clinical methods, we find that Leishman^ describes a simple method of
enumerating leucocytes.

Two pipettes are employed — one, an ordinary one-cubic centimetre pipette graduated in 1/lOOths of a
cubic centimetre ; the other, a capillary pipette to deliver five cubic centimetres. This quantity of
the blood to be tested is taken up in the capillary pipette and at once diluted 200 times by being blo^vn
out into a watch-glass containing 995 cubic millimetres of water. Hjemolysis occurs but the leucocytes
remain unaltered. Stir, shake and, after the capillary pipette has been washed and dried in the flame, take
up with it two successive volumes of five cubic millimetres each and discharge them side by side as small
drops on a clean slide. Allow these to dry and stain with Leishman's stain.

Count all the leucocytes in each drop with the help of a ruled cover-glass, prepared by allowing a drop
of Leishman's stain to evaporate on the well-polished surface of the glass and ruling on the thin lilm which
is left a series of parallel lines with the point of a sharp needle, A drop of cedar oil is placed on the stained
drop film and the cover glass dropped on it, ruled surface downwards. Count, with a 2/3rd inch lens, the
leucocytes in all the drops, representing the 10 cubic millimetres of the diluted blood. Multiply by 20 and
you get the number per cubic millimetre of undiluted blood. The error, compared with a Qower's
haemocytometer count, seems to be about minus 5 per cent., %vhich may be allowed for or neglected.

General clinical methods of enumerating leucocytes, including new and simplified
procedures, are described by Turton," but lack of space forbids a review of his paper.

Of more interest to the ordinary blood examiner are certain papers on Htemiconia, what
used to be called blood dust. Love* draws attention to the special prevalence of htemiconia
in typhus fever and describes four forms of bodies. 1. Protoplasmic bodies with bright
retractile spots whose origin presents no difficulty, as staining shows them to be derived from
fragmented neutrophile cells. 2. Small, round, highly refractile bodies from 0-5 to 1/j in
diameter, and appai-ently motile. 3. Eod-like bodies, also apparently motile, from 0-5 to 2/x
in length. 4. Dumb-bell forms, from 2 to ijx in length, and apparently motile. He
regards the last three as of the same class and mentions their incessant dancing movements
and the fact that they cannot be stained. From this, and from their disappearance during
the fixing process, he concludes that they cannot be derived from the disintegration or
fragmentation of leucocytes or red blood corpuscles.

Porter' describes five forms, a. Greyish-blue, flagellated bodies of indefinite shape and
possessing a twisting or rotatory movement. 6. Bodies like a large diplococcus with rapid

' Holland, J. W. (June 8th, 1907). Journal of American Medical Association. Chicago.

* Leishman, W. B. (March 31st, 1906), "A Simple Method of enumerating Leucocytes." Lancet,-^. 905.

' Turtou, E. (February 25th, 1905), "CUnical Methods of Enumerating Leucocytes." British Medical
Journal, p. 410.

♦ Love, A. (December 29th, 1904), " Hoemioonia." Lancet, p. 1781.

' Porter, P. (December 21st, 1907), " Observations on Blood Films, with Special Reference to the Presence of
Hsemiconia." British Medical Journal, p. 1773.

• Article not consulted in the original.

REVIEW — TROPICAL MEDICINE, ETC. 23

movement, c. Bodies of indefinite shape, dumb-bells, rods, knobbed at one end, like a Blood-
tadpole, etc., with slow movements, d. Small, round, vesicular, highly refractile bodies with continued
a central ruby-coloured spot. These are usually quiescent, but may move slowly, e. Small,
very rapidly moving, highly refractile micrococcal forms. Attempts at staining and
cultivation failed. Porter believes that some are escaped nuclei of leucocytes, some escaped
granules of leucocytes, others portions of disintegrated red cells, and that all are produced by
some change in the blood constituents.

Nuttall and Graham-Smith' describe very similar forms, and state that they are liable
to be mistaken for free forms of piroplasmata. In a later paper^ they describe and figure
the curious changes red corpuscles undergo in blood films, bodies being produced which
might deceive the very elect. No one who has done much blood work but has encountered
and probably been puzzled and deceived by some of these bodies. In my own experience
the small, colourless, spherical forms have proved most troublesome, especially when working
with fowl's blood. They are probably the free granules of leucocytes, but it is curious that
they cannot be stained : —

One of the most useful and practical papers which has recently appeared is that by
Sutherland on " The Differential Diagnosis of Tropical Fevers." It occurs as an appendix
to Chapter III. of Eoberts'^ admirable work on Enteric Fever in India. Here we need only
note some of the remarks on leucocytes : —

" A leucocytosis or relative increase of the lymphocytes or of the polymorphonuclears in the circulation,
with absence of parasites in the peripheral blood, spleen or lymph, is always suggestive. A lymphocytosis
points to tuberculosis or to a bowel infection by one of the typhoid or allied groups, and a polymorphonuclear
cytosis to a local septic infection. A lymphocyte increase is of less value in diagnosing local infections than
an increase of the polymorphonuclears, and calls for the diazo reaction, the agglutination and sedimentation
tests and the search for tubercles in the choroid with the ophthalmoscope to clear up the issues. Increase of
the polymorphonuclears, on the other hand, is distinctive, for it means local septic infection somewhere."

A long list of what has to be looked for follows, in which one specially notes oral sepsis, sore
throat, appendicitis and liver abscess.

One may add to these notes as the result of the work of Stitt, Vedder, Ashburn and
Craig, and to a less extent from personal observation, that a decrease in the
polymorphonuclears and a marked increase in the small lymphocytes points to dengue fever,
especially if there is an accompanying leucopenia. This will be considered later. A useful
paper on the conditions producing eosinopliilia is that by Fearnsides,'' who in a summary
states that the condition is usually associated with the presence of Hchistosomum Tiiematohium,
Trichmella spiralis, Ankylostoma diiodenale, the various species of Filarial and Echinococcus
cysts. It may also occur associated with the presence of any one of the Helminthidx, but is
rare in cases infected with Dihothriocephalus latus, and not common in infections with
Trichocephalus trichiurus. He further points out that the changes in the leucocytes are to be
regarded as due to toxic agents produced by the worms, and in the nature of a reaction for
the good of the host.

Emery,* in his useful clinical work, gives an easy method of recording the differential
leucocyte count, which does not seem to be very generally known and certainly saves much
time. " The simplest way of noting down the leucocytes," he says, " is to assign letters to
each variety, P for polynuclear, E for eosinophile, etc., and to put these down in blocks of
five each, thus : —

P P P L E

P P L L H

L P P P P

P L L P L

P P P L P"

In this way you can tell at any time how many leucocytes you have counted. I should
think that anyone who has made differential counts in the heat of the Sudan by the ordinary
method of headings and columns will appreciate this simplified and rational procedure.

' Nuttall, Q. H. P., and Qraham-Smith, Q. S. (October, 1906), " Canine Piroplasmosis." Journal of Hygiene,
p. 586.

'^ Nuttall, G. H. F., and Qraham-Smith, Q. S. (April, 1907), " Canine Piroplasmosis." Journal of Hygiene, p. 586.

■' Roberts, E., " Enteric Fever in India, etc., etc." Loudon, 1906.

•• Fearnsides, E. G. (March, 1906), " The Effects of Metazoan Parasites on their Hosts." Journal of
Economic Biology, p. 41, Vol. I.

^ Emery, W., " Clinical Bacteriology and Hematology." 2nd Ed. London, 1906.

24 REVIEW — TROPICAL MEDICINE, ETC.

Blood— Eogers' states that the count can be much shortened and simplified by enumerating only

continued 250 leucocytes. This is done by counting backwards and forwards from edge to edge of the
best part of the blood film, avoiding the thick end and the "tag" end. He only counts
polynuclears, large mononuclears including transitional forms, lymphocytes and eosiuophiles.
He uses a 1/8-inch or Zeiss D objective and considers as large mononuclears only such
mononuclear cells as are as large as, or larger than, an average polynuclear, the smaller ones
being classed as lymphocytes. By this method he obtains reliable results. While for rough
and ready work for clinical purposes this is no doubt a very useful and rapid method, I'' have
pointed out that in accurate estimations the leucocyte classification adopted by Button and
Todd seems to be the best, and that it is necessary to have some generally employed
classification for comparative purposes.

The error of a haemocytometer count and the method of correcting the same is
discussed by Student''* and noted in the epitome of the British Medical Journal.^ It need
not be discussed here but the reference may be found useful.

Horrocks and HowelP describe and illustrate some curious X-bodies which they found
in Spain in the blood of patients suffering from an ill-defined form of fever and in cattle
which were not healthy.

As in the blood of a sick dog in Khartoum, examined by Mr. Archibald, I have seen
bodies exactly like some of these described, and, as the condition may yet prove to be an
important one, I quote their description of the bodies stained by Leishman's method : —

The bodies, when stained, were characterised by a faint capsule with a circular centre staining deep blue ;
they varied in size, some being as large as a red corpuscle, others only about one-eighth the size of a red corpuscle.
In addition to these forms, which were the most common, the following were also seen :

(a) A small, blue circular centre surrounded by four or more faiut capsules concentrically arranged ; (i) two
circular bodies, each having a dark blue central point surrounded by a light blue ring, enveloped in one capsule
which appeared indented as if two capsules were in process of formation; (c) similar to (b), but the part
surrounding the deep blue centre stained a deeper blue, and two indented capsules were seen ; (ri) a dark blue
central part, shaped like a crescent, containing a small circular body, with a deep blue central point within the
arms of the orescent. None of the bodies on the slide showed any signs of chromatin.

Intravenous inoculation of a rabbit gave positive results.

The authors were unable to pronounce on the precise nature of these bodies, which,
however, proved not to be acid fats. In fresh blood the bodies showed no amusboid
movement.

Bubo. A case of climatic bubo in Uganda is described by Castellani." Blood and
bacteriological examinations were negative. He mentions that the disease occurs chiefly on
the east coast of Africa, the West Indies and Straits of Malacca and China. It has not
been recorded from Central Africa.

Cantlie and Hewlett' discuss the relation of climatic bubo to plague. Cantlie named
it pestis minor, although pus from the affected glands proved sterile. Cantlie and Hewlett
record a case where three bacteria were grown from the excised gland, i.e. Staphylococcus
pyogenes albus, litaphylococcus cereiis albiis, and a minute bacillus staining by Gram's method and
curdling milk. The last-named was non-pathogenic to guinea pigs and mice, and corresponded
to a micro-organism isolated by Kitasato from a case of plague. Simpson stated that
climatic bubo seemed to bridge over the true plague epidemics. Wright looked upon the
disease as distinct from plague, while Emery regarded the organism in question as possibly
the acne bacillus of Sahouraud, which might have reached the glands from the skin.
Clayton* reports four cases in which he performed blood examinations, finding in two of

' Rogers, L., "Fevers in the Tropics." London, 1908.

^ Balfour, A. (April 1st, 1907), " Notes on the Differential Leucocyte Count, with Special Reference to
Dengue Fever." Journal of Tropical Medicine, p. 113.

3 Student, " Biomelrika," Vol. V., part III., pp. 351-360.

■♦ British Medical Journal, p. 154, Vol. II., January 18th, 1908, " The Error of a Hsemocytometer."

' Horrocks, W. H., and Howell, H. A. L. (April, 1908), "X-bodies found in the Blood of Human Beings and
Animals." Journal of the Royal Army Medical Corps, Vol. X., No. 4.

" Caatellani, A. (December 15th, 1903), " Climatic Bubo in Uganda." Journal of Trojiical Medicine, p. 379.

' Cantlie, I., and Hewlett, R. P. (April 4th, 1904), "Bacteriology of Climatic Bubo." British Medical
Journal, p. 593, Vol. I.

« Clavton, T. H. A. (.January 2nd, 1905), "Notes on Climatic Bubo." Journal of Tropical Medicine,
p. 1, Vol. VIII.

• Article not consulted in the original.

REVIEW — TROPICAL MEDICINE, ETC. 25

them marked eosinophilia, which he suggests as due to toxin action. He comes to no definite Bubo-
conclusion regarding the cause of the disease but quotes several arguments against the continued
pestis minor theory.

I do not know if climatic bubo has been observed in the Sudan. It is possible that it
occurs in the southern districts contiguous to Uganda, but I have never heard of its being
reported. .

Cachexial Fever. See Leishmaniosis (page 95) .

Calabar Swellings. The relation of this condition to Filaria low and diurna is
dealt with in the Journal of Tropical Medicine, 1/7/04. Amongst other places these are found
on the Upper Congo, so that it is quite possible they may occur in the Bahr-El-Ghazal
Province. Manson thinks it practically certain that they are somehow produced by F. loa,
though the mechanism of their production is unknown. Their sudden appearance, gradual
disappearance, painlessness, and the fact that they never suppurate, sufficiently distinguish
them. The only human filaria I have found in the Sudan is F. perstans, and it occurred in
a Ugaudese.

Cancer. The literature on cancer during the past few years has become enormous,
and one can only direct attention to a few points, such as the possible parasitic origin of the
disease, supposed preventive methods, and its occurrence in the coloured races and in
tropical countries.

Ford Eobertson and Wade' described bodies like the Plasmodiophora brassica which is
known to cause tumours in cruciferous plants. These are only demonstrable by special
metallic processes. In a later paper" they describe the technique and also methods of
culture which they maintain were successful, and discuss the probable etiological relationship
of these parasites to carcinoma. The tendency of other observers was to regard these bodies
as cell inclusions. Ford Eobertson and Young,' however, in a still more recent article, deal
with cyanide-fast bodies in tumour cells and describe improvements in the technique of
preparing and staining tissues by their special processes. They also note a great activity
of polymorphonuclear leucocytes which they believe to be directed against a specific parasite.
Still more recently the senior author'' describes rod-shaped bodies, something like tubercle
bacilli but evidently not bacteria, in certain carcinomata. He believes these to be a stage in
the life-history of the protozoon found by himself and Wade, and that several allied species
are concerned in tumour production.

Interest for a time centred round the Micrococcus neoformans of Doyen, but the most
recent work, including that of Dudgeon and Dunkley,^ discredit it as a cause of cancer.
These authors have shown that it is an organism of very low pathogenicity, and that the
serum of patients suffering from malignant disease does not develop any very marked
agglutinative property for M. neoformans. In fact, it is less than that which is found for the
Staphylococcus albus.

Mention should bo made of the work of Gaylord and Calkins' who found a special
spirochaete, S. microgyrafa (Lowenthal), in primary and transplanted carcinoma of the breast
of mice. It does not stain by Giemsa.

Two papers which have at least the merit of being interesting and practical are those of
Keetley'^ and of Brand.' The former is strongly in favour of the parasitic theory, and
lays down very stringent prophylactic rules which at the present day would be difficult to
enforce in their entirety amongst all classes, however desirable they may be. He says :

1. Sterilise the food, and points out that it is where food tends to tarry that cancer of the alimentary tract
is apt to develop. 2. Ensure a sufficient and regular toilet and protection of the nipples and genitalia.

1 Robertson, F., and Wade, H. (August 13th, 1904), " Cancer and Plasmodiophora;." Lancet, p. 469, Vol. II.

^ Robertson, P., and Wade, H. (January 28th, 1905), "Researches into the Etiology of Carcinoma, etc."
Lancet, p. 215, Vol. I.

' Robertson, P., and Young, C. W. (August 10th, 1907), " Researches into the Etiology of Carcinoma ; Notes
upon the Peatures of Carcinomatous Tumours revealed by an Improved Ammonia-silver process." Lancet, p. 359.

* Dudgeon, L. S., and Dunklcv, E. V. (.J.anuary, 1907), "The Micrococcus Neoformans." Journal of Hygiene,
p. 13, Vol. VIII.

■'■ Gaylord, H. R., and Calkins, Q. N. (April 10th, 1907), "A SpirochaBte in Primary and Transplanted Carcinoma
of the Breast in Mice." Journal of Infections Diseases, p. 155, Vol. IV.

« Keetley, C. B. (October 13th, 1906), "The Prevention of Cancer regarded as a Practical Question Ripe for
Solution." Lancet, p. 993, Vol. II.

■> Brand, A. T. (January 11th, 1908), " Some Remarks on the Infectivity of Cancer." Lancet, p. 80.

26 KEVIEW — TROPICAL MEDICINE, ETC.

Cancer — 3. Taku care of mouth and teeth. 4. Destroy dressings from discharging, malignant uleerations. 5. Attend to

continued non-malignant sores and tnmours. Excise cancerous and douljtful tumours early. 7. Practise abstinence from

alcohol, tobacco, excessive meat eating, and foods which leave waste ijroducts. 8. Avoid all unnecessary

familiarity, especially with strangers. 9. Attend carefully to kitchen hygiene and the hygiene of food generally.

Brand advances many very suggestive points, especially on the infectiousness and
auto-inoculability of cancer, and points out that it is impossible for the "carcinoma cell" to
bo the true parasite as suggested by Butlin. He recommends the examination of fresh,
living carcinoma cells on the warm stage of the microscope, and suggests that the new device
of Gordon which enables a good magnification of 7000 diameters to be obtained, and the
system of dark-field illumination introduced by Siedentopf may greatly facilitate cancer
research. He strongly advocates cleanliness in its widest sense, showing how very readily
food, especially vegetables and fruit, can become contaminated, and denounces earth burial,
advocating cremation.

As regards distribution, Sutherland' presents statistics for the Punjab, which, as he says,
tend to show that cancer is not a common disease there, but that such cases as occur
apparently affect all classes. He also notes that the nature of the diet does not seem to
affect the incidence of cancer in the Punjab. The same, he says, is true of alcohol, syphilis
and malaria. From India^* during 1904, 146 cases of malignant new growth were reported
to the Imperial Cancer Research Fund amongst vegetarian natives, 137 amongst natives living
mainly on flesh diet, and 222 amongst natives living on a mixed diet. " Cancer in the British
Colonies " is the title of a paper in the Journal of Tropical Medicine of March 1st, 1905,"* and
a point of interest to us in the Sudan is the statement that the disease has not been seen
amongst natives of the Gambia, Ashanti and Natal, and that it is said to be rare in
British Central Africa, the Eastern African Protectorate, Southern Nigeria and on the
Gold Coast.

Thus Hearsey says that amongst the natives of British Central Africa, though cancer
occurs, it is of the utmost rarity, while non-malignant growths are relatively common.

Amongst the Chinese, cancer is rare (Clark), and the same is true of the Malay States,
Jamaica and Ceylon, while in British New Guinea, where be it noted the Papuans cook all
their food and live chiefly on vegetables and fish, the disease seems to be absent (Craigen).

As regards the Sudan, I have records of only ten cases of malignant tumour examined in
these laboratories during the past five years. Of these, half were carcinomatous and half
sarcomatous. I think it may be taken that malignant disease is not common amongst natives
of the Sudan even though in the northern parts the native, in many places, has come into
association with Europeans. I cannot say much about the matter from a clinical
standpoint, but I understand that most cases of new growth dealt with surgically at the
Military and Civil hospitals in Khartoum are sent to the laboratories for diagnosis and, if
this be the case, neoplasms play no great part in the pathological field.

Dr. Watcrfield of the Sudan Medical Department confirms this statement, and his
experience goes to show that tumours of all kinds are rare in the Sudan.

At my request. Colonel Hunter, P.M.O., kindly sent out a letter of enquiry to his
Medical OflScers, asking for their opinions regarding the prevalence of cancer in their
districts.

Captain Thompson, writing from Wad Medani in the Blue Nile Province, reports : —

" So far as I have been through this Province up to date, I have seen no cases of malignant disease." He
adds : " I may say that I saw a case of scirrhus of the breast in a woman at Kassala in 1906, and a suspicious case
in a, boy in this Province, who, however, did not come here for treatment as directed."

Curiously enough, shortly after this was written Captain Thompson sent in for
examination the tissues from a well-marked case of epithelioma of the foot.

Captain Brakenridge, S.M.O., Bahr-El-Ghazal, answered: —

" I have never seen a single ease of malignant disease in this Province in about twenty-one months I have
served here. In fact, in my eight years' service in the Egyptian Army I only remember to have seen one
epithelioma of the tongue in a Sudanese, and one sarcoma of the neck in an Egyptian."

Captain Anderson replied from El Obeid, Kordofan : —

" During a year spent in the Province, in which time I have inspected widely in all directions and seen
many hundred sick, I have never come across a single case of malignant disease amongst the Arab, Nuba and

• Sutherland, D. W. (November, 1904), " Cancer in the Punjab." Indian Medical Gazette, p. 425, Vol. XXXIX.
» " Scientific Reports of the Imperial Cancer Research Fund," No. 2, Part I, 1905.
° Quoting " Blue Book on Cancer in the Colonies, 190G."

• Article not consulted in the original.

REVIEW — TROPICAL MEDICINE, ETC. 27

Misad tribes. This is iilmost as remarkable as the virtual uon-existeuce of tubercular disease in Kordofan. Cancer —
Microbic diseases (thaaks, I imagine, to the wide air space and strong sun) are universally rare, while parasitic continued

comi^laints — malaria, guinea worm, taenia and other intestinal worms— are of common occurrence."

Captain Bousfield, of Kassala, stated that : —

" During my year's stay in this Province I have not seen a single case that I could definitely diagnose as
malignant disease, either amongst the civil or the military. In the Military Hospital, Kassala, there have been
no cases of malignant disease during the years 1904-1907 inclusive. At Qodaref there has been a case, scirrhus
of the breast in a woman aged about 4.5, and a doubtful case of sarcoma of the leg (possibly a mycetoma) in a man
aged about 40. There have been no eases that could certainly be diagnosed as malignant disease in the Kassala
Civil Hospital. My own opinion is that epithelioma, carcinoma and sarcoma are extremely rare in this
Province."

It is worthy of note that all these regions are somewhat remote, and the natives
inhabiting them do not come much into touch with Europeans. With the exception of
the Bahr-El-Ghazal, which is a negroid district, the prevailing type of inhabitants is the
Arab, who, however, very frequently has much negro or other blood in his veins.

Cerebro-Spinal Fever. If the subject of cancer has no very intimate relation-
ship with the Sudan, the reverse is true of cerebro-spinal fever, which, in former years, was
much in evidence so far as can be ascertained, and accounted for many deaths, while every
now and again sporadic cases or small epidemics occur under existing conditions. It was
Buchanan who drew special attention to its appearance during the dusty months of the year
in India, and doubtless the inhalation of dust plays a part in its propagation.

Goodwin'* in a large number of cases found the ineningococcus present in the nasal
cavity, while Vansteeuberghe and Grysez- discovered it in the noses of healthy men, cultivated
it, and proved that the cultures, when injected under the meninges of rabbits or guinea pigs,
produced the typical lesions of cerebro-spinal meningitis. The necessity of dealing with
infected nasal discharges is therefore apparent and disinfection of the nasal cavities of the
patient and all contacts is clearly indicated.

The same points are also brought forward by Fraser and Comrie," who record that hot,
dusty, ill-ventilated atmospheres, which provide conditions favourable to the growth of
the ineningococcus and to the occurrence of naso-pharyngeal catarrh, are often associated
with the dissemination of epidemic cerebro-spinal meningitis. Tliey also state that " the
high comparative percentage of fathers whose naso-pharynx was found by us to contain the
meningococcus, points to the fact that they probably are the carriers of the disease to their
children."

Speer'* describes an early pressure symptom which he has found regularly present
together with Keruig's sign. It consists of a turning in of one or both feet until, if not
disturbed, one lies across the other. The legs later become flexed and tend to cross each
other. The symptoms, he states, are due to a combination of toxin poisoning, nerve
irritation and pressure. The Indian Medical Gazette for September, 1905, publishes the
leaflet issued by the German Health Department. The only points requiring notice are that
children attending school, although in good health, must be kept from school if they live in
the same house as the patient, until the medical authorities permit their re-admission to
school, and the recommendation of a weak solution of menthol for the disinfection of the
throat and hands. Under the heading " Nursing" one notes that the gargling water of the
patient should be disinfected. As regards the rash, Chalmers' describes a case in a child
where the features of a typhus rash were exactly reproduced, while Wright" gives an account
of the rashes met with in the Glasgow epidemic. These were usually haemorrhagic and of a
purpuric nature, varying in size from a mere point to something smaller than a lentil,
and often being grouped in clusters. Occasionally these spots came out in crops. In one
case he describes purple and maroon spots together with larger, pale-blue blotches on
the trunk and limbs.

' Goodwin (November 11th, 1905). Medical Record,

'' Vansteenberghe, P., and Grysez (January, 1905), "Contribution a I'Etude du Meningocoque." Annals de
VInstitiU Pasteur, p. 69, t. XX.

' Fraser, J. S., and Comrie, J. D. (July, 1907). Scottish Medical and Surgical Journal.
* Speer, G. G. (May 15th, 1905). Medical Record.

' Chalmers, A. K. (July 7th, 190G), "The Rash of Cerebro-Spinal Fever." British Medical Journal, p. 23.
" Wright, W. (September loth, 1906), " The Rash in Cerebro-Spinal Meningitis." Lancet, p. 717, Vol. II.

• Article not consulted in the original.

28 KBVIEW — TUOPICAL MEDICINE, ETC.

Cerebro- Steven,' in an interesting lectm-e, deals with the differential diagnosis, mentions a

Spinal Fever case where faecal poisoning was mistaken for a case of cerebro-spinal meningitis, and refers
—continued to an Egyptian case of vei'minous infection closely simulating the fever.

Nedwiir- records two epidemics in the Sudan occurring in the summer of 1005 and 1906,
during the months, be it noted, when the dust storms occur. From a study of 22 cases he
concludes that non-recovery of the knee jerks within a week of the onset of the disease is an
unfavourable sign. The mortality was roughly 59 per cent.

Cases of remarkable cure after the use of collargol are reported." It is employed as an
injection into the spinal canal, doses mentioned being 0-05 gramme and 5 c.c. of a 1 percent,
solution.

The claims of Weichselbauni's meningococcus to be the cause of the disease have been
amply confirmed by recent work to which there is no need to allude, but mention may be
made of the bacillary form which this organism may assume when cultivated. A note on
this will be found in a paper by Darling and Wilson'' who from their work conclude that the
Meningeal diplococcus belongs to the Streptococcus fsecalis group, and is identical with the
Micrococcus rheunialicus.

The latter author' in a later paper states that all the Gram-negative cocci met with by
him and his co-workers iu cases of cerebro-spinal meningitis failed to grow on the
Drigalski-Conradi medium. To this rule he found three exceptions, and the diplococci from
these cases not only grew well on this medium, but, instead of tending to take on a
bacillary form as is usual, retained their diplococcal characters on the Drigalski-Conradi
medium, although they tended to assume the bacterial form on agar. " We conclude then,"
he says, " that in the lumbar puncture fluid of certain cases of cerebro-spinal meningitis
Gram-negative diplococci may be found which differ from Weichselbaum's and Still's cocci
in respect of their morphology and capacity for growth on the Drigalski-Conradi medium.
It may be that certain abnormal appearances presented by meningococci, such as growth in
short chains which competent observers claim to have seen, may have been due to the
presence of this coccus in the cultures."

The opsonic power of the serum has been the subject of research by various workers,
and Houston and Eankine'' tabulate the results of their examinations, finding that the
opsonic index seems to be a more delicate test of infection than the agglutination reaction,
and that the two tests combined will prove of great value in diagnosis. Levy'* records a
remarkable series of cures by means of Kolle-Wassermann's serum injected intra-spinally.
The dose for children over one year was 20 c.c, for adults 30 to 40 c.c. Of 23 cases treated
with the serum, only 5 died, and of these 3 had too small a dose or received the dose
subcutaneously. Of 17 cases properly treated, only 2 died. A preliminary injection of
morphine is given, then the serum, and the patients are kept for eight to twelve hours with
their pelves raised. Robb** speaks favourably of Flexner and Jobling's serum, but does not
commit himself to a definite opinion as to its merits. Trautmanu and Fromme''* record the
results of work done in the Hygienic Institute in Hamburg during 1907. Thirty-two
specimens were examined from patients and 312 from contacts. In only 9-2 per cent, of
the latter was Weichselbaum's meningococcus isolated. One "germ-carrier" case remained
infective for 66 days. In subcultures on Loeffler's serum a typical growth was common,

' Steven, J. L. (September 8th, 1906), "Epidemic Cerebro-Spin.il Fever, with Illustrative Cases." Lancet,
p. 638, Vol. II.

2 Nedwill, C. L. (December 1st, 1906), " Cerebro-Spinal Meningitis in the Sudan." Lnncet, p. 1502, Vol. II.

' January 12th, 1907, " Recovery from Cerebro-Spinal Meningitis under Injections of Collargol in the Spinal
Canal." Lancet, p. 106, Vol. I.

" Darling, J. S., and Wilson, W. J. (February 23rd, 1907), "A Case of Cerebro-Spinal Meningitis." Dritish
Medical Journal, p. 433, Vol. I.

^ Wilson, W. J. (June 20th, 1908), " DifEercntiation of certain Gram-negative Cocci occurring in Cases of
Cerebro-Spinal Meningitis by their Morphology and Power of Growth on the Drigalski-Conr.adi Medium."
Lancet, Vol. I.

'^ Houston, T., and Rankine, J. C. (May 4th, 1907), "A Note on the Opsonic Power of the Serum, with
Reference to the Meningococcus of Cerebro-Spinal Fever occurring in the Belfast Epidemic." Lancet, p. 1213, Vol. I.

' Levy, Q. Deutsche Med. Wochen., 1908, No. 4, p. 139.

' Robb, A. G. (February 15th, 1908), "The Treatment of Epidemic Cerebro-Spin.al Fever by Intra-spinal
Injections of Flexner and Jobling's Anti-meningitis Serum." British Medical Journal, p. 382.

» Trautmaun, H., and Fromme, W. (1908). Munch. Med. IVochcnschr., No. 15.

• Article not consulted in the original.

REVIEW — TEOPICAL MEDICINE, ETC. 29

in primary cultures involution forms often occurred. The organism was found to ferment Cerebro-
gluoose and maltose, but not levulose. The diagnostic value of the agglutination test is Spinal Fever
slight. The Diplococois crassits which occurs along with the meningococcus is agglutinated — continual
by meningococcus serum. A valuable and very practical paper is that by Eobertson' of
Leith, who deals specially with administrative control, and advocates the douching of the
nasal cavities of all " intermediaries " with chlorine water. His method was to douche at
intervals of two days, and three times in all. He also draws attention to the value of
formamint lozenges, especially for children. He also recommends the isolation of all
those living in infected houses. Thorough spraying of infected premises with formaldehyde
was deemed useful, and, a point which might be missed, the confiscation and destruction
of all foodstuffs found in lower class houses is stated to be a valuable preventive measure.

As regards diagnosis, Birnie and Smith-* successfully isolated and cultivated the specific
organism from the blood by the simple procedure of puncturing a vein and distributing
4 cubic centimetres of blood equally between two flasks containing 75 cubic centimetres of
sterile bouillon. Kutscher' finds an agar, made with human placental juice, an excellent
medium for the growth of the first generation of the meningococcus.

In the only case I have seen in the Sudan I was able to isolate and cultivate a
Jiplococcus from the meninges, which answered in every respect to that of Weichselbaum.

Chlorine water would probably be of little use as a nasal douche in this country, but the
menthol wash recommended by the Germans might be tried. It would, I think, be
comparatively easy, in the light of recent knowledge, to control an outbreak in Khartoum,
where the people are amenable to sanitary control, and very thorough disinfection methods
followed by compensation can often be adopted owing to the small value of native dwellings
and belongings. [Note. — A recent outbreak has enabled one to prove the truth of this
assertion.]

Chicken-pox. In the Sudan, where one deals chiefly with black skins, the diagnosis
of chicken-pox from small-pox is sometimes very difficult. The following points, which have
served one as fairly trustworthy guides, and have been gathered from various sources, may
be helpful. Rogers* suggests that the blood changes in the two conditions might well
repay study : —

1. Prodromata. Often no prodromal period in chicken-pox. Usually present in small-pox.

2. Feeling of illness when rash appears in chicken-pox. The opposite is true in mild or moditied small-pox.

3. Facial appearance. Nothing special in chicken-pox ; heavy, anxious or stuporose in small-pox.
Amongst the natives these three are of less value than the following : —

4. Frequently a rise in temperature accompanies appearance of rash in chicken-pox. In small-pox the
temperature falls at this time.

5. Eash appears first on the trunk in chicken-pox, on the face in small-pox.

6. Distribution of rash. Trunk and proximal portions of extremities in chicken-pox. Face and distal
portions in small-pox, together with back of trunk. {Six, however, note under " Small-pox," page 183).

7. If a so-ca,lled " skin window " be marked off, the irregularity of the rash is well seen in chicken-pox.
i.e. vesicles and pustules together in the area. Not so in small-pox.

8. Rapid change from papule to vesicle in chicken-pox, frequently in a few hours and within 24 hours.
At least 24 hours in small-pox, often 72 hours.

9. Centre of vesicle its highest point in chicken-pox ; depressed in small-pox.

10. Papules of chicken-pox not so firm and shotty as those of small-pox.

11. Depth of skin involved. Less in chicken-pox than in small-pox. Hence "seeds" in palms and soles
usually found only in the Utter.

12. The character of the scales, thin in chicken-pox, thick in small-pox, is said to aid one, but I have
not noticed this in native cases. Early cupped scabs in chicken-pox are, however, very characteristic.

13. The scars of chicken-pox are smooth and have irregular edges, while those of small-pox are pitted
and as if punched out. The former are often wider as the vesicles tend to spread laterally.

^ Robertson, W. (July 27th, 1907), "Remarks on the Outbreak of Epidemic Cerebro-Spinal Meningitis."
British Malical Journal, p. 185.

- Birnie, J. M., and Smith, M. T. (October, 1907). American Journal of Medical .Science.

'■' Kutscher, K. (November 9th, 1907), " Ein Beitrag zur Ztichtung des Meningococcus." C'c7U. filr Bakt.
Abt., 1907, Vol. XLV., No. 3, p. 286.

•* Rogers, L., " Fevers in the Tropics," London, 1908.

* Article not consulted in the original.

30 REVIEW — TROPICAL MEDICINE, ETC.

Chicken-pox Neech,' Eolleston"* and Porter' have recorded cases in which the eruption became

—continued confluent, in this and other respects closely resembling that of small-pox. Mackenzie' thinks
that varicella, " with its polymorphic eruptions, mature and immature developments and
retrogressions, recurrent invasions, uneven temperature and irregular periods of incubation,"
must be regarded as a mixed infection, and that it is possibly " a non-specific, non-variolous
varicella and a very slight but genuine variola infantum of childhood." RoUeston'^ has a
paper on the accidental rashes of varicella, which in order of frequency are classed as
scarlatiniform, purpuric, morbilliform and mixed. He mentions that there may possibly
be a chicken-pox without vesiculation, and discusses the nature of the accidental rashes
which are pi'obably septic or toxic.

Bray" describes a condition amongst the Sudanese. It is called by them Boorglum, and
is apt to be mistaken for chicken-pox. It is said to be most common at flood Nile, and takes
the form of a superficial rash, papular, vesicular and pustular, affecting the back of the
hands and forearms, the dorsum of the feet and the front of the leg. It is probably
parasitic, is commonest in those who work with mud bricks, and is best treated by the
application of iodine.

I have seen Boorglum in a Greek bricklayer, and the rash is certainly like that of
chicken-pox. There is, however, no constitutional disturbance and the distribution of the
eruption is different.

Chigger. As Sarcopstjlla penetrans is well known in the Bahr-El-Ghazal, and has
caused much invaliding amongst men in the Sudanese battalions, the following points in its
life-history elicited by Wellman' are likely to prove useful: —

1. The eggs are .always laid while the chigger is yet embedded in the flesh of her host. Her different
behaviour after artificial removal does not form a real exception to these statements. In such an event she
extrudes all her eggs at once and dies, but such eggs do not hatch into larvse. Even if the chigger has
completed her gestation and has begun to lay her eggs before her removal, only the most mature eggs
in the posterior part of the abdomen will develop.

2. They never (.at least in this climate, Angola) hatch into larvaa in the body of the parent.

3. They are not laid at one time in masses, but discreetly, and sometimes at considerable intervals,
depending on circumstances. If the chiggers are in the sole of the foot, and the infected person walk about,
the eggs may be seen dropping from his feet as he goes, or by pressing gently on the skin near a ripe chigger
two or three eggs may be seen to escape one after another. Such eggs readily hatch out. So while it is
doubtless a good rule to burn all chiggers removed, yet this has no effect on the usual mode of propagation, and so
long as natives go about with infected feet the cycle will go on.

4. The shell of the parent when dead, and empty of eggs, usually dries up in sittt and causes no further
trouble. Occasionally it may cause irritation, swellings and ulcers, but most of the abscesses, sores, etc., from
chiggers come from removing the insects with septic instruments.

5. The mature ova, if placed in a glass-covered dish containing some dust from the floor, go through the
developmental stages common to all fleas, which have often been described. In natural conditions they develop
in the dirt and cracks in the floor, and in chigger countries it is therefore important to compel one's native
servants to keep their feet clear of chiggers, and to allow no other natives (especially children, who are always
infested) in one's quarters.

Cholera. The Sudan has always been liable to invasion by cholera from Egypt
and from the great pilgrimage centres on the eastern coast of the Eed Sea. Given invasion,
the disease is now more likely to be disseminated owing to improved methods of communica-
tion and especially to the establishment of the Atbara-Port Sudan Eailway. Hence any
acts relating to cholera must ever be of interest to the Medical OfEcer, and more especially
when these deal with preventive measures. The useful Indian pamphlet by Duke'" sei-ved
as a basis for the cholera notices drawn up this year for Khartoum City and Khartoum
North, and to be issued if the disease became epidemic in any part of the country. As these
are possibly of some general interest they are here introduced although, happily, their utility
or otherwise has not so far had to be tested.

' Neech, .J. T. (February 24th, 1906), "A Note on a Case of Confluent Varicella." Lancet, p. 515.

^ Rolleston, J. D. (January, 1906). British Journal of Children's Diseases.

' Porter, C. R. (May 18th, 1907), " A Case of Confluent Hsemorrh.agic Eruption in Varicella." Lancet, p. 1352.

■• Mackenzie, J. (January, 1907), " A Study in Varicella." Journal of Royal Institute of Public Health, p. 17.

' Rolleston, J. D. (M.ay 4th, 1907), " Accidental Rash of Varicella." British Medical Journal, p. 1051.

° Bray, H. A. (October, 1904). Journal of the Royal Army Medical Corps. London.

' Wellman, P. C. (December 1st, 1905), "A Point in the Life-History of Sarcopsylla Penetrans." Journal of
Tropical Medicine, p. 394.

" Duke, J., " The Prevention of Cholera, and its Treatment." 3rd Edition. Calcutta, 1905.

* .iVrticle not consulted in the original.

REVIEW — TEOPICAL MEDICINE, ETC. 31

Cholera is in the majority of cases a water-horne disease, due to water having become Cholera-
contaminated with the cholera organism derived from some person suffering from the disease. cmitinued

It is, therefore, usually conveyed by the drinking of water which has become polluted
by the excreta or discharges of an infected person, as such water may occur in the form
of ice, or may be found added to milk, or used for the washing of vegetables, etc. ; ice, raw
milk and uncooked vegetables, salads and fruit may also transmit infection. Flies also and
other insects, especially ants, may be to blame by carrying the infection from polluted
matter to food and drink, while these may be contaminated by the infected and dirty hands
of those engaged in their preparation. The organism is easily killed by boiling and drying,
hence the value of the following : —

Pbeventive Mbasubes

(i.) All water intended for personal use, viz., drinking, cooking, washing, and, wherever possible, bathing,
must be boiled. Drinking water is best boiled in a can provided with a cover and a tap. The boiled and
cooled water can then be drawn directly into the cup or tumbler. Care must be taken that an infected
drinking vessel is not used, as, after the boiled water has cooled, it can be re-infected. Water from zed's and
goulahs should be looked upon with suspicion unless these are carefully watched and cleaned.

(ii.) All raw milk must be boiled.

(ui.) Uncooked vegetables, raw salads and fresh fruits, especially melons, should be avoided.

(iv.) Food stuffs should be carefully protected from flies, ants and other insects, and not stored anywhere
in the proximity of latrines or any collection of refuse. As far as possible all food should be cooked. Jellies
are liable to become contaminated and should be avoided.

(v.) Personal cleanliness on the part of those engaged in preparing food and drink is most essential.
Care should be taken to see that cooks and other servants are cleanly in their habits and clothing, and are
careful to vi-ash their hands before handling food or dishes or vessels used for food or drink.

(vi.) General cleanliness, especially in latrines and in kitchens and cook-houses is most necessary. All
dishes should be carefully cleaned with boiling water, and kitchen cloths should be well washed and dried in
the sun. Any cloths used for straining soups, sauces and the like should be washed in permanganate
solution (ride infra.). Brooms, brushes, or cloths used for cleaning out latrines must on no account be used in
kitchens or cook-houses.

(vii.) In any case of cholera or disease like cholera, with diarrhoea, colic, vomiting or cramps in the arms,
legs or stomach, the vomit or stool should be kept covered up until seen by a Medical Oflicer. The latter
should at once be informed of the illness, and only those in actual attendance on the patient should be
permitted to stay in the room with him.

Great care must be taken thoroughly to wash and disinfect the hands immediately after touching the
patient or the bed-clothes or any vessel containing his vomit or dejecta.

The same care is necessary on the part of those dressing or burying the corpse of anyone dead of the disease.

(viii.) Any symptoms like those occurring early in cholera, especially colic and diaiThoea, should at once be
treated. In order to enforce these precautions, and for the general information of the public, it is hereby notified :

1. That no water will be allowed to be taken from the river bank. Anyone attempting to do so will be
liable to imprisonment or punishment.

2. That no bathing or washing will be permitted from the river bank, nor will anyone be permitted to
foul the bank, or the river from the bank, in any way whatever under pain of punishment.

3. Pure water may be obtained from such wells in the town as have been disinfected, and inhabitants are
warned again.st using water from any untreated well. Bathing and washing in the immediate vicinity of wells
is prohibited.

It is hoped that a general supply of pure water will be distributed both in Khartoum and Khartoum North.

4. The general public milk supply will be placed under sanitary control, and inhabitants are hereby
warned to obtain their milk only from one or other of the Municiiial MUk Depots. The site and arrangements
of these will be duly notified later.

5. AU aerated water factories will be placed under sanitary control, and only such aerated waters as can
be drunk with safety will be issued.

6. The ice factory will be placed under sanitary control, and only such ice as can be used with safety will
be issued.

7. Disinfectants will be issued at cost price from the office of the Sanitary Inspector in the Mudiria.
Purchasers must bring their own bottles. Instructions for the disinfection of weUs, latrines and kitchen floors
will be issued separately.

8. The use of weak tea and lemon drinks made with boiling water is hereby recommended, as is an
early application for preventive medicines in all cases of colic or diarrhoea.

9. The inhabitants are informed th.at cholera is a complaint which is very easUy prevented and controlled
provided the necessary measures are taken, and they are invited to co-operate with the authorities and to assist
them to cope with the disease.

Ants as carriers of infection were specially included, because in Khartoum they are more
in evidence than flies, and I am certain that from their crawling habits and scavenger
propensities they can play a considerable role in the infection of food and drinks.

32 EEVIEW — TROPICAL MEDICINE, ETC.

Cholera— From a paper by O'Gorman' one picks out the following practical points as likely to be of

continued service. Noto the stage when called to a case, as the treatment varies with the stages of the
illness. Look for a blood-shot condition in the eyes, sometimes the only outward
indication of reaction. Take the temperature in the axilla in preference to the mouth or
rectum (dangerous and unnecessary). Eemember the differential diagnosis from arsenical
poisoning. The author recommends as a routine practice in every case and at any stage the
exhibition of calomel and sodium bicarbonate in doses of 3 to 6 grains and G to 12 grains
respectively, repeated if rejected, until retained. The calomel increases the flow of bile,
acts as an intestinal antiseptic, is sedative to vomiting, especially in frequently repeated
fractional doses, gr. 1/10 to gr. 1/20, every quarter or half-hour, is diuretic, antiphlogistic,
and, taken continuously in doses short of toxic, stimulates the faculties, physical and mental.
Soda aids its action, prevents salivation and supplies a vital element to the blood.

In the first stage he also recommends the administration of intestinal antiseptics such as
sulpho-carbolate of zinc, copper arsenite, acetozone, medical izal or medical cyllin.

For the rest, stop food, give fluids and try to prevent collapse. Carminatives, sedatives
and astringents are useful and should be given. He mentions chlorodyne, camphor and
opium amongst the drugs, and states that nuclein may prove very valuable owing to the
increase of polynuclears it produces and its stimulation of cell growth.

In the stage of collapse he utters a warning against alcohol, and states that there are
only two great remedies, namely, atropine and strychnine. He regards these as sheet
anchors in cholera.

In the case of both drugs small doses frequently repeated are best, and the strychnine
should be pushed and any ill effects neutralised by chloral. The value of heat, sinapisms
and warm rectal injections is mentioned. In the stage of reaction, he points out that the
occurrence of urination is a favourable sign and where there is danger of urtemia,
pilocarpine may be tried. It is, however, risky, and diaphoretics and hot cofl'ee are safer
and often efficient.

The article concludes with advice as to diet, sanatogen, somatose and plasmon being
mentioned. This treatment certainly does not err in the way of doing too little, and
possibly the writer is over-fond of medicaments and expects too much from them, but he has
evidently had large experience of cholera and gives definite and apparently sensible reasons
for his recommendations.

It is curious he does not mention the red iodide of mercury treatment in extreme
collapse, so strongly advocated by Duke (with whom he is otherwise more or less in
agreement), who gives dilute sulphuric acid in the early stage together with cannabis indica,
and for suppression of urine recommends subnitrate of bismuth and turpentine with cupping
to the loins, and, if required, pilocarpine controlled by strychnine.

Both mention the necessity of an early aperient dose in some cases, the one
recommending sulphate of magnesia, the other castor oil with tincture of belladonna.

Choksy- has a paper advocating cyanide of mercury in doses of 1/lOth of a grain every
two or three hours as a germicidal agent. He reports favourably on its use, the only
drawback being a tendency to stomatitis during convalescence. In other directions his
treatment is like that of O'Gorman. In acute delirium during the reaction stage bromide
and hyoscyamus are indicated.

McCombie' reports very favourable results from employing subcutaneous injections of
salt solution (60 grains to a pint of boiled water) at a temperature of from 115° F. to 110° F.,
repeated whenever the pulse tended to fail. The addition of adrenalin chloride (1 in 1000)
to the pint of salt solution also seemed beneficial.

Eogers and Mackelvie' speak highly of the value of large quantities of hypertonic salt
solutions in transfusion for cholera. The strength they employ is just about two drachms
to the pint, and they inject, as a rule, four pints at a time, intravenously. Subcutaneous
injections are only of benefit in mild cases. By this new procedure they believe the

» O'Gorman, P. W. (November, 1905), " How to Cure Cholera." Iiidian Medical Gazette, p. 414, Vol. XL.

' Choksy, Khan Bahadur, N. H. (April 20th, 1907), " Some ladications for the Treatment of Cholera." Lancet,
p. 1077.

" McCombie, P. C. (May 26th, 1906), "A Note on the Treatment of Cholera by Saline Injections."
Lancet, p. 1468.

■• Rogers, L., and Mackelvie, M. (May, 1908), "Note on the Value of Large Quantities of Hypertonic Salt
Solutions in Transfusion for Cholera." Indian Medical Oazctlc.

KEVIEW — TROPICAL MEDICINE, ETC. 33

mortality has been halved. They have also found repeated dry cupping over the loins of Cholera-
great service in ursemic cases. continued

Waters^ praises izal. He made stock solutions, of which each fluid drachm contained
fifteen minims of izal made up with tragacanth mucilage. Each drachm was diluted with
seven of water, and this dose of 1 oz. was given every hour or two hours as long as necessary.
He had no less than 41 recoveries out of 56 cases.

Banerji^ testifies to the value of the eucalyptus treatment introduced by Major Harold
Browne. The oil was given in 5 minim doses, together with mucilage and syrup of lemons.
Thirty-three cases, most of them in the stage of collapse, were treated and the percentage
of recovery was sixty-three. The oil is said to act both as an antiseptic and stimulant.

Other points of interest are the " latent " cholera carriers found by Gotschlich'^ at Tor,
who, though they harboured true cholera vibrios, did not give rise to an epidemic and did not
die of cholera, but from dysentery and gangrene of the bowel ; and the quick agglutination
method of diagnosis introduced by Duubar** and said to be reliable. It is as follows : —

Mix a particle of faecal mucus with 1 drop of peptone water and 1 drop of a 1 in 500
dilution of cholera serum (mixture a). Mix a similar particle with 1 drop of peptone water
and 1 drop of a 1 in 50 dilution of normal rabbit's serum (mixture b). Place each mixture
on a cover glass and examine as a hanging drop preparation. Observe agglutination in a,
none in b. Maximum result after about 3 hours. In this connection one must cite the work
of Ruffer,-' which leads him to state that "it is not advisable to trust to the agglutination
test only in bacteriological diagnosis of cholera. The test is useful but not specific." It
would seem then that the haemolysis test must always be applied, for Euffer noted no
vibrio hsemolyses, when the agglutination test, Pfeiffer's reaction and the fixation test are
positive, while he states distinctly that " the agglutination, saturation and Pfeiffer's tests are
not in themselves of absolute diagnostic value for cholera vibrios.''

Some of Euffer's results have been called in question, and it is very desirable that his
conclusions should be definitely confirmed or confuted, as they upset prevailing ideas on the
bacteriological diagnosis of cholera.

Eecent work on anti-cholera serum. Strong's new prophylactic, etc., though important
and suggestive, scarcely comes within the scope of this resume.

Climate. Sandwith*^ has a paper on hill stations and other health resorts in the
British Tropics. He deals with Egypt and then goes on to speak of the Sudan, which he says: —

Is less destitute of mountains, and the Government has now established a sanatorium at Erkowit (3500 feet) ,
30 miles due west of Suakin and 22 miles due east of Summit Station on the Nile Red Sea Railway, from
which there is a motor road. The best season is from May to September, when the headquarters of the Suakin
province move there. It is now utilised for change of air by officials from Suakin, Port Sudan and Khartoum,
and has the f;reat advantage of being uninhabited by natives. Visitors now live in tents, but temporary rest
houses are being built.

Unlike the neighbouring hills, which consist of bare ironstone and diorite, there is here wonderful
vegetation, grass, maiden-hair fern, many shady trees and fine open spaces large enough for playing polo and
goU. There are easy walks to neighbouring hill crests, from which magnificent views of the Red Sea coast
can be obtained. The climate is relatively cold, very fresh and invigorating for all convalescents. Vegetable
gardens have been planted and some Southdown sheep have been imported by the Governor of the province but
most food has to be conveyed from Suakin. There is a good supply of water from a spring in the hills, and
soundings are now being taken to find other sources. In order to keep the ground as clean as possible native
tribes with their camels, cattle and goats, are forbidden to enter the station.

He has a few notes on Sinkat, also, and concludes thus : " There is no special sanatorium
for the Blue and White Nile or for the Bahr-Bl-Ghazal, which is the most tropical
part of the Anglo-Egyptian Sudan." It is found by experience better to allow convalescents
to spend a fortnight in Khartoum before they proceed to Cairo and Europe.

> Waters, E. E. (December 1905), "The Treatment of Cholera with Izal." Iiidian Medical Gazette, p. 451.

^ Banerji, H. C. (January, 1905), "Oil of Eucalyptus in Cholera." Indian Medical Gazette.

' Gotschlich, P. (1906), "Uber Cholera uud Choleraiihnliche Vibrionen unter den aus Mekka Zuri'ickkehrcnden
Pilgern." Zeil.filr Hyg. u. Inf. Krank., p. 281.

* Dunbar. Berliner Klin. JFochcn., 1905, No. 39, p. 1237.

^ Rufler, M. A. (March 30th, 1907), " The Bacteriological Diagnosis of Cholera." British Medical Journal,
p. 735.

" Sandwith, P. M. (November 15th, 1907), " Hill Stations and other Health Resorts in the British Tropics."
Journal of Tropical Medicine and Hygiene, p. 361, Vol. X.

• Article not consulted in the original.

34 REVIEW — TROPICAL MEDICINE, ETC.

Climate— It is not quite the case that no natives inhabit Erkowit. They are accustomed to graze

continued their animals at these altitudes which they visit periodically, and indeed there is a native

cemetury on the ground. At certain seasons Erkowit is wrapped in damp mists, but on the

whole the description given is correct, and, though not ideal, the station is likely to prove

valuable.

In summing up, Sandwith points out the absurdity of sending a patient suffering from
the dire effects of malaria to a health resort where he can become re-infected, and speaks of
the necessity for maps showing the distribution of malaria-bearing mosquitoes. In their
absence, he says, we must be content to judge by altitude, and, in a country where malaria is
endemic, regard any height under 5000 feet as unsatisfactory.

In 1906 the larvae of Pyretophorns costalis were brought me from a water-course at the
base of the Erkowit plateau. I reported the matter and mentioned its importance, but so
far as I know further action was not taken until I sent Mr. King specially to Erkowit for the
purpose of determining precisely the species of mosquito present and their distribution.
He did not find Anophelines at or near Erkowit, but discovered a new species of sand-fly
and certain mosquitoes which are described in his report.

Sandwith points out that malarial patients are apt to get fever attacks when exposed to
cold altitudes, sea breezes, or even the damp cold of countries such as England. He believes
this to be largely due to an insufficient quinine treatment. Cantlie,' on the other hand, from
personal experience, records his belief that "it is not the cold but the hot weather in
Britain, especially in the south of England, that has to be dreaded by the old tropical
resident who is the subject of chronic malaria. As far as the British Isles go, he recommends
the climate of Morayshire and Nairn in the North of Scotland, while in the winter he
believes in the Swiss mountains at an altitude of not less than 4000 feet.

Sandwith regards change to a temperate climate as essential in bad cases of sprue and
beri-beri, while for cases of dysentery and enteric the sea coast is recommended, but here
also insufficient or improper treatment previously may be the chief cause of a relapse. Such
cases sent to the hills in India are apt to contract hill-diarrhoea.

Much interesting information regarding climate will be found in "Woodruff's book," which,
however, has to be read as a whole and cannot well be quoted here. A good deal that he brings
forward is not applicable to the Northern Sudan, for he deals chiefly with typical tropical
conditions where heat and moisture are combined to the greater detriment of those exposed
to them.

Wolfe'^* has investigated the effects of climates on American soldiers stationed in the
Philippines. His paper is of a preliminary nature, but he notes that the kind of life led by
the individual has much to do with the change produced. A more or less active life
is necessary. The more indolent the life the sooner the stagnation and retrogression. Men,
however, break down under excessive marching in the Tropics quicker than in temperate
climates. The points observed were : (1) The pulse rate taken during sitting, standing and
exercise ; the maximum and minimum rates of the pulse ; (2) the respiration ; (3) the
haemoglobin ; (4) erythrocytes ; (5) leucocytes ; (6) differential leucocyte count.

A remarkable paper is that by MacDonald,* who, dealing chiefly with tropical
Queensland, advocates an active out-door life, his motto apparently being " the more
sun the better," and this for man, woman and child. He advances proof to show that
under such conditions the white race thrives ; this even in a country where the rainfall
is heavy. His arguments certainly tend to upset all prevailing ideas on the subject, and
do not seem to have been taken very seriously by those who discussed a paper which,
whatever its value, is certainly interesting and perhaps suggestive.

Haldane^' has discussed the influence of high air temperature and has conducted
experimental work on the subject. He quotes the old experiments carried out by Blagden,

' Cantlie, .T. (June loth, 1907), " Clinical Observations on Tropical Ailments as they are met with in Britain."
British Medical Journaf, p. 1455.

^ Woodruff, C. E., " The Effects of Tropical Light on White Men." Rebman, London, 1905.

» Wolfe, E. P. (August 31st, 1907), "A Preliminary Report of Research Work on the Effects of Tropical
Climate on the White Race." Medical Record.

* MacDonald, T. F. (May 1st and 15th, 1908), "Tropical Lands and White Races." Journal of Tropical
Medicine and Hygiene, Vol. XI., No. 10.

' Haldane, J. 0. (October, 1905), "The Influence of High Air Temperature." Journal of Hygiene,
p. 494, Vol. V.

• Article not consulted in the original.

REVIEW — TROPICAL MEDICINE, ETC. 35

Forsyth and Dobden, in 1775, who found that they could remain for a few minutes in a room Climate—
at about 250"^ F. (121° C.) without serious inconvenience or marked rise of body temperature eoniimied

althougli beef-steaks exposed in the room at the same time and place could be cooked within
13 minutes. Needless to relate the air was dry. A few of his conclusions may be cited,
(a) The rectal temperature did not show any abnormal increase during rest in still air until
the temperature by the wet-bulb thermometer reached about 88° F. (31° C.) provided the
subjects were stripped to the waist or clad in light flannel, {li) In moving air (with the wet-
bulb still below the body temperature) a higher wet-bulb temperature could be borne without
abnormal rise of rectal temperature, (c) The symptoms observed to accompany the rise of
body temperature were — (1) a marked increase in the pulse-rate, accompanied by throbbing
in the head; (2) dyspnoea, particularly on any exertion; and (3) a general feeling of exhaustion
and discomfort. These he points out depend to some extent on other causes than the rise
of body temperature as indicated by the rectal thermometer.

Tyler' has introduced a new scheme for correlating personal sensations as regards
climatic conditions with the ordinary measurement recorded by meteorological instruments.
His paper is very erudite, and we may merely note that he finds that, except for any dry
conditions of the atmosphere, the readings of the wet-bulb thermometer indicate very closely
the degree of discomfort experienced due to temperature and humidity, and that these
readings, or what he calls his " hyther "^ degrees, form the best available means for comparing
cliraEites. It is not possible here to discuss the question of the climate of the Sudan, for at
least three distinct varieties exist ; that of the Eed Sea littoral, that of the dry, sandy
northern regions, and that of the humid and rainy south. Doubtless also the desert climate
is modified by proximity to rivers, by elevation as in Kordofan, by the presence of vegetation
as in some parts of the Kassala province. Some allusion to the climate of Khartoum will
be found under " Sanitary Notes," this being the only part of the country about which one
can speak as a result of any prolonged experience, and even then five years is no great
length of time considering how climatic conditions often run in cycles.

Clothing. This question as regards the Tropics is briefly discussed in Woodruff's
book," but with special reference to the Philippines. It is pointed out that the outer day
clothing should be white, grey, or yellow, the colours which absorb heat least ; but, as White
clothing freely transmits the actinic rays which are dangerous to the nervous system of
white men, and the light rays said to produce skin disease in blondes, the underclothing
should be opaque and black or yellow in colour.

Sambon's paper* advocating the use of " Solaro " fabrics may be read with advantage,
this cloth being a successful attempt to obtain the ideal fabric for the white man
in the Tropics, i.e. one which will at the same time exclude the harmful, short or actinic
rays and reflect the heat rays, thus avoiding complexity of garments and much unnecessary
weight.

Duke, in his pamphlet on cholera, strongly condemns the persistent use of a thick belt or
kummerbund. It acts like a poultice, weakens the abdominal organs and actually tends
to increase the action of the bowels. This, of course, does not apply to its use at night,
especially when sleeping out of doors where there is a risk of chill.

A very practical and up-to-date paper, which takes care to consider tropical conditions,
is that by Chesney.'' The proper clothing for women receives due notice. Absorbent
materials for underwear are condemned, and light non-absorbent clothing, which of necessity
has to be frequently washed, is recommended. The author notes that in the Tropics the
wearing of a cholera belt is not now an article of faith, and acquiesces in the more modern
ideas regarding its usefulness.

' Tyler, W. P. (.A-pril 1.5th, 1907), " The Psycho-Physical aspect of Climate, with .1 Theory concerning
Intensities of Sensation." Journal of Tropical Medicine, p. 1-30.

^ " Hyther" — the joint effect of temperature and humidity on human sensation.

" Woodruff, "The Effects of Tropic.il Light on White Men." London, 190,5.

■* Sambon, L. W. (February 15th, 1907), " Tropical Clothing." Journal of Tropical Medicine ami Hygiene"
p. 67, Vol. X.

= Chesney, L. M. (July, 1908), '■ Hygienic Clothing and Disease." Journal of the Royal Institute of Public
Health, Vol. XVI., No. 3.

36 REVIEW — TKOnCAL MEDICINE, ETC.

Dengue. Cai-pontcr and Sutton'* investigated the patliology of dengue fever in 1904.
They failed to find any organisms in the blood of dengue cases, nor were they able to
implicate any of the mosquitoes with which they worked. C'nlrx faUgaiis, however, was not
one of these. In throat swabs a small diplococcus was found, either free or in the epithelial
cells. A leucopainia was found present from the first, and it is suggested that a diplococcus
or delicate, bipolar staining bacillus like Pfeiffer's bacillus of influenza may be the cause,
infection taking place by way of the respiratory tract.

A full report of an epidemic in Brisbane in 1905 will be found in the Journal of Tropical
Medicine for December 15th, 1905. In some instances the incubation period seemed as short
as 24 hours. The characteristic " breakbone " pains were not much in evidence. Avery
minute account of the symptoms is given. As rare complications, pneumonia, pleurisy,
parotitis and orchitis are mentioned. Ulceration of the oral mucous membrane and the
fauces, and gingivitis were noticed. Diarrhoea with mucous evacuations was not uncommon
and dysuria occurred. As sequelae, boils and carbuncles, an itchy vesicular eruption of the
hands, muscular rheumatism, neuralgias, giddiness, nervous depression and loss of memory
are recorded. Eye lesions were fortunately rare. It is pointed out that the initial symptoms
of dengue closely resemble those of yellow fever. In the differential diagnosis from influenza,
stress is laid on the rash, not, however, a constant symptom, and still more on the almost
invariable absence of catarrhal symptoms of the respiratory tract and the extreme rarity of
pulmonary complications. The few differential leucocyte counts made did not show the
apparently characteristic changes to be detailed immediately. No evidence is adduced as
to etiology.

Stitt- has a paper on the blood changes, and details what he considers the most
characteristic blood findings as follows : —

1. Absence of a demonstrable protozoon.

2. Leucopaenia.

3. Diminution of polymorphonuclears.

4. A striking variation in the percentage of other leucocytes at varying periods of the disease. At first
a large increase in the small lymphocytes is observed, then the appearance of a greater proportion of large
lymphocytes, and in the final stages (at the time of the terminal rash and during convalescence) a most striking
increase in the mononuclears.

Stitt failed to find the so-called protozoon described by Graham, ^ of Beirut, but certain
observations led him to believe that some species of culex is very probably the transmitter of
the disease.

The following are the important conclusions of Ashburn and Craig* as a result of their
■work on a dengue epidemic occurring near Manila in the Philippines : —

1. No organism, either bacterium or protozoon, can be demonstrated in either fresh or stained specimens
of blood with the microscope.

2. The red-blood count in dengue is normal.

3. There occur no characteristic morphological changes in the red or white corpuscles in this disease.

4. Dengue is characterised by a well marked leucopenia, the polymorphonuclears being decreased, as a
rule, while there is a marked increase in the small lymphocytes.

5. No organism of etiological significance occurred in broth or citrated blood cultures.

6. The intravenous incubation of unfiltered dengue blood into healthy men is followed by a typical
attack of dengue.

7. The intravenous inoculations of filtered dengue blood into healthy men is followed by a typical attack
of the disease.

8. The cause of the disease is, therefore, probably ultra-microscopic iu size.

» Carpenter, D. N., and Sutton, R. S. (January 21st, 1905). Journal of Amcricda Medical Association.

■' Stitt, E. R. (June, 1906), "A Study of the Blood in Dengue Fever, with Particular Reference to the
DiSerential Count of the Leucocytes in the Diagnosis of the Disease." Philippine Journal of Science, p. 511, Vol. I.

=> Graham, H. (July 1st, 1903), " ' The Dengue,' a Study of its Pathology and Mode of Propagation." Journal
of Tropical Medicine, p. 209, Vol. V.

•* Ashburn, P. M., and Craig, C. P. (June 15th, 1907), "Experimental Investigations Regarding the Etiology
of Dengue Fever." Journal of Infectious Diseases, p. 440, Vol. IV.

* Article not consulted in the original.

REVIEW — TEOPICAL MEDICINE, ETC. 37

9. Dengue can be transmitted by the mosquito, Culex fatigans, and this is probably the most common Dengue —
method of its transmission. continual

10. The period of incubation in experimental dengue averages three days and fourteen hours.

11. Certain individuals are absolutely immune to dengue, as proved by our experiments.

12. Dengue is not a contagious disease, but is infectious in the same manner as is yellow fever and the
malarial fevers.

In another paper^ they deal with diagnosis. In differentiating from yellow fever the
slower pulse, jaundice and hgematemesis occurring in that disease are helpful. The same
would hold good in the Egyptian disease most resembling yellow fever, namely, infectious
jaundice. As regards influenza, they point out the association of dengue with the presence
of mosquitoes, while influenza occurs where they are absent and often in cold weather.
They mention the catarrhal symptoms in the latter and lay stress on the leucopaenia and
lymphocytosis found co-existing in dengue. Early small-pox has to be difierentiated, and
sometimes an acute follicular tonsillitis simulates dengue. The prophylaxis resolves itself
into protection against mosquitoes. In this paper are recorded the differential blood counts
by Vedder who assisted in the work. The variation in the relative proportion of the large
and small lymphocytes found by Stitt was not confirmed, but, as already stated, his other
results were substantiated.

Eoss" has recently advanced strong confirmatory evidence to show that the immunity
of Port Said from dengue fever since 1906, while epidemics raged elsewhere in Egypt, was
due to the abolition of Gulex fatigans in that town. The same is true of Ismailia, which
escaped during the epidemic of 1907.

One^ has been able to make some personal observations regarding dengue in the Sudan,
but only on a small scale. As the disease was very prevalent in Egypt and parts of the
Sudan during the summer and autumn of 1906, one was in hopes of being able to carry out
a study of the blood in dengue. Fortunately in one sense, unfortunately in another, though
Port Sudan and Haifa were visited by epidemics, Khartoum, so far as can be told, wholly
escaped. Not a single case of dengue fever was notified, and this, although it is more than
likely that several persons suffering from dengue must have reached Khartoum by railway
from the north, while I saw one case which arrived in Khartoum before convalescence was
fully established, and while he was probably still in an infectious state.

Is it not possible, then, that the immunity which Khartoum has enjoyed is due to the
comparative freedom of the town from mosquitoes, and especially from Cidex fatigans ? No
species of mosquito was at all common in Khartoum during the months when dengue was
prevalent in other parts of the Sudan and in Egypt. Thus, during June, 1906, there were in
Khartoum 689 water collections which might have served as mosquito breeding places. Of
these 17 were infected with larvae or pupae, being 2-47 per cent. The corresponding figures
for Khartoum North were 125 ; 4 ; 3-2 per cent. During July the percentage infected in
Khartoum was 4-35, in Khartoum North 3-2 ; August, Khartoum 7-22, Khartoum North 3-20 ;
September, Khartoum 9-94, Khartoum North, 3-20 ; October, Khartoum 8-32, Khartoum
North 4-76. The slight rise in August, September and October was due to heavy rainfall,
but adult mosquitoes were not numerous.

The figures are only approximately correct, but they give a good idea of the state of the
town. One does not wish to press the point too much, but the observation is interesting and
suggestive so far as it goes.

I append a table of differential leucocyte counts made on blood films from cases of dengue
and supposed dengue sent me by Dr. Crispin from Port Sudan. It is necessary to note
that one has classed as lymphocytes, both true lymphocytes and lymphocytes with irregular
nuclei, while under the term mononuclears, are included both large lymphocytes and large
mononuclears in accordance with the very useful classification of Dutton and Todd.*
Transitionals, however, have been placed separately.

My cases were few in number, and most of the bloods were taken only in the early stages
of the fever. Moreover, in one or two cases, I do not know what the eventual diagnosis was.

' Ashburn, P. M., and Craig, C. P. (May, 1907), " Experimental Investigations regarding the Etiology of
Dengue Fever." Philippine Journal of Science, p. 71, Vol. II.

" Ross, E. H. (July 1st, 1908), "The Prevention of Dengue Fever." Annals of Tropical Medicine and
Parasitology, Series T. M., Vol. II., No. 3.

' Balfour, A. (April 1st, 1907), " Notes on the Differential Leucocyte Count, with Special Reference to Dengue
Fever." Journal of Tropical Medicine awl Hygiene, p. 113, Vol. X.

■• Dutton, J. E., and Todd, J. L. (1903). The Thompson, Yates ami Johnson Laboratories' Report, Vol. V., New
Series, Part 2, Liverpool.

38

REVIEW — TKOriCAL MEDICINE, ETC.

Dengue —

coniituud

DENGUE FEVER

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Case 7

Case 8

Case 9»

» Day of
Fever

Second Day
of Fever

Second Day
of Fever

Third Day
of Fever

Third Day
of Fever

First Day
of Fever

» Day of
Fever

? Day of
Fever

Ninth Day
of Fever

Eosinophiles

1-75

1-25

2-5

1-5

■75

1^75

125

2

6^25

Polymorphonuclears

S7-S5

60

SJ-5

07-^0

35 -"^5

SI,--25

SI -70

4.3

U-2S

Mononuclears

27

12

14-5

7-5

1025

8

5

12^76

26

Lymphocytes

Ki-J

25

m-5

33

5S-35

5^2d

52-25

38^5

22-25

Transitionals

1-25

1-75

1

1-75

•25

■5

•75

3-75

125

Basophiles

•25

•25

■25

•25

•5

Myelocytes

125

* Terminal rash fading

temperature normal. — Case 9 was a European. I believe all the other bloods were those of
natives ; Egyptians, Arabs or Sudanese.

In every instance 400 cells were counted. Still, in the apparently undoubted dengue cases
(Nos. 4, 5 and 7), the results ajspear to confirm those of Stitt, though, as mentioned in my
original paper, it is very necessary that some kind of standard classification of leucocytes be
adopted whereby differential counts by various observers in all parts of the world may be
made strictly comparable.

A paper by Saigh,i on dengue in Port Sudan, states that the cases there occurred chiefly
in houses infested by mosquitoes (species not stated), and that the fever reappeared when
there was an increase of mosquitoes in the town. Further, all persons living in the hospital
escaped infection, and the hospital was the only place free from mosquitoes.

Phillips- in his Egyptian cases used aspirin for relieving pain, and found calcium chloride
useful in heemorrhagic and urticarial cases.

Dhobie Itch. This does not appear to be very common, at least in the Northern
Sudan. The climate is probably too dry to favour the growth and proliferation of the germs.
In one case I found what I believed to be Microsporon miuntissimnm. Chrysophauic acid
ointment proved efficient. Glacial acetic acid has been recommended, and for natives strong
liniment of iodine is most serviceable.

Diarrhoea. This is always an important question in the tropics owing to its relation
with dysentery and sprue, but the infantile form also merits attention. Eecently there has
been much work done on infantile diarrhoea.

Hewletf states that the Bacillus dysenteriie is probably the etiological factor in various
forms of infantile and epidemic diarrhoja. He mentions that Miss Wollstein isolated this
organism in all (39 out of 114) cases of infantile diarrhcea where blood and mucous were
present.

An article in the Lancet for September 17th, 1904, in dealing with errors of diet as a cause
of infantile diarrhoea, mentions the septic variety which may attack strong as well as weakly
subjects, and in whicli nervous collapse may continue after the diarrhoea ceases to be a cause
for anxiety. Nash,' while admitting that there may be some connection between sub-soil
temperature and the advent of epidemic diarrhcea, regards contamination of food by infected
dust, and especially infection-conveying flies, as the main cause of the disease. "The
essentials," he says, "for putting a stop to the great waste of infant life every summer are

' Saigh, S. (November 1,5th, 1906), " Dengue in Port Sudan, Rod Sea Province." Journal of Tropical Medicine
and Hijgicm, p. 348, Vol. IX.

^ Phillips, L. (December loth, 1906), " Dengue in Egypt." Juarnal of Tropical Medicine and Hygiene,
p. 373, Vol. IX.

' Hewlett, R. T. (April, 1904), "Dysentery and Infantile Diarrhoea, the Etiology of." Journal of State
Medicine, p. 229, Vol. XII.

* Nash, J. T. C. (September 24th, 1904), "Some Points in the Prevention of Epidemic Diarrhcea." Lancet,
p. 892.

REVIEW — TROPICAL . MEDICINE, ETC. 39

(1) Clean milk supplies ; (2) Clean towns with well-organised system of sewage removal, dust Diarrhoea-
collection and disposal, and street watering ; (3) Clean homes where sufficient domestic continued
hygiene prevails to permit an understanding of the importance of clean utensils for food, the
covering over of food to protect from dust and flies, and personal habits of cleanliness ;
(4) Inhibition of fly life."

In a later paper'* he states that there is no one specific micro-organism of diarrhoea and
that he is not convinced that breast-fed infants are really liable to epidemic diarrhoea.
Thus, amongst 138 deaths of infants under one year of age, there were 68 deaths from
diarrhoea in hand-fed infants and not a single death from diarrhoea amongst the 28 who had
been entirely breast-fed.

Hewlett- agrees on most points with Nash, admits with him that there is no specific
micro-organism, but again states that the B. dysenteriie is the causative organism in a large
proportion of the cases, other organisms, such as B. coli, Proteous vulqaris, Streptococci,
B. pyocyaueus, and perhaps others, being operative in the remainder. He thinks that
infection of the food takes place mainly in the homes.

GrifiQth'''* notes that bacteria of the lactic acid-producing group clearly exert an
inhibitive influence upon some of the milk bacilli which are specially dangerous to infants,
and concludes that this explains the value of milk purposely soured by adding the lactic acid
bacillus — for instance, buttermilk, which is useful in diarrhoea. He thinks that heat also
plays a part in infantile diarrhoea by its depressant action on the nervous and vaso-motor
systems and by its interference with the digestive processes.

Sandilands'' considered epidemic diarrhoea in its relation to the bacterial content of food
and dealt with cow's milk and food other than natural cow's milk, especially Nestle's milk.
He quotes Hope, Eustace Smith and Cautley to the effect that living bacteria are found in
condensed milk, that such milk rapidly breeds bacteria even when still apparently fresh, and
becomes unfit for the child's consumption, and that tins of condensed milk once opened are
liable to decompose rapidly, especially in hot weather. His general conclusions are as
follows : —

1. lu proportion to the number of consumers, Nestle's milk containing comparatively tew bacteria is
more frequently associated with diarrhoea than cow's milk in which the number of bacteria is phenomenally high.

2. In certain seasons cow's milk may be exposed to temperatures which favour a high bacterial count
and yet not become a fi-equent source of diarrhcea.

3. The numbers of bacteria in preserved and natural cow's milk have no direct influence on the
incidence of diarrhcea.

4. The groat majority of cases of diarrhoea arc due to the consumption of food which has been infected
iu the district in which the cases have occurred.

5. The infective matter thug conveyed to food is generally the excrement of some person suffering from
diarrhcea.

6. The life history of house-flies and the facility with which they can convey the fsecal excrement of
infected infants to food of the healthy suggest that the seasonal incidence of diarrhoea coincides with and
results from the seasonal prevalence of flies.

Newsholme's views'' coincide in large measure with those already detailed. He states
that breast-fed infants have only one-tenth of the average proclivity of infants to fatal
diarrhoea, and suggests that possibly toxic products of bacterial action may be operative both
in fresh and condensed milk infection, and that the latter may be derived from the farm and
not the domestic in all cases. Most of the evidence, however, is against this supposition.
The whole question of the causation of infantile diarrhoea is yearly becoming of greater
importance in Khartoum and other towns in the Northern Sudan, for while the native
breast-fed child is not likely to be a sufferer, the infants of the lower class Europeans of
various nationalities may and do fall victims to the disease. In the summer of 1907 there
were a considerable number of cases of infantile diarrhoea in Khartoum. While these cases
were doubtless due largely to contamination of milk, I have no doubt that improper feeding

1 Nash, J. T. C. (May, 1906), Practitioner.

- Hewlett, R. T. (August, 1905), " The Etiology of Epidemic Diarrhoea." Journal of Preventive Medicine,
p. 496, Vol. XIII.

» Griffith, J. P. C. (July 15th, 1906). Therapeutic Gazette.

* Sandilands, J. E. (January, 1906), "Epidemic Diarrhcea and the Bacterial Content of Pood." Journal of
Hygiene, p. 77, Vol. VI.

" Newsholme, A. (April, 1906), "Domestic Infection inEelation to Epidemic Diarrhcea." Journal of Hygiene,
p. 139, Vol. VI.

• Article not consulted in the original.

40 KEVIEW — TROPICAL MEDICINE, ETC.

Diarrhcea— played a part, and in any case I question if flies were operative to any large extent as carriers
cmiiiiiicd of infection. The house-fly is at no time a great nuisance iu Khartoum and is usually killed
off in large numbers by the hot weather which begins in April as a rule. I am inclined to
think that infected dust played a part, even though the conditions for sewage removal had
been improved and there was little dysentery amongst the civil population. The chief cause,
however, I believe to be the filthy conditions associated with the transport and distribution
of the milk, which persist, despite efl'orts made to suppress them, and will persist until the
measures which have been repeatedly recommended are put in force. This matter is dealt
with under " Sanitary Notes," and so need not be discussed here at length : —

Turning now to symptoms and treatment : —
Batten'* classifies infantile diarrhoea as follows : —

1. Irritative, due to improper or undigested food. Stools bulky, green, sour and
with curds.

2. Catarrhal, due to prolonged indigestion. Stools brownish-green with mucus and
foul smell.

3. Ulcerative colitis. Bare. Blood and mucus stool.

4. Acute infective. Stools watery, often greenish, offensive. Choleraic symptoms.

The last is the " summer diarrhoea " type, and it is in this form that cerebral symptoms
occur, due probably to toxic action.

As regards treatment in the very severe cases, liquor strychninas hypodermically is said
to be the best preventive of collapse, while ether and brandy hypodermically are contra-
indicated. Transfusion with normal saline, followed by a hot bath and, when the rally has
taken place, by stomach-washing are recommended as an effectual line of treatment. Sodium
bicarbonate 2 grains to the ounce is used for the lavage. Eectal irrigation is useful, and
Younge" speaks very highly of quassia infusion for this purpose, in doses of ^ to 1 dr. repeated
every 3 or 4 hours as required. It is best given after a dose of castor oil to clear the bowel".

For feeding, albumen water, barley water, rice water, etc., all have their advocates,
while in a case recorded by Myers^* nothing succeeded till a solution of gmii arable, 1 ounce
to the pint, was given. This, at least, is a remedy easily obtainable in the Sudan.

As regards other forms of diarrhoea, Thresh'' has recorded a widespread and serious
epidemic due to a water supply having become polluted by washings from garden soil
manured with road sweepings and the like. Such a condition is rare, but shows how
carefully a public water supply should be guarded. In the Civil Prison at Khartoum cases
of severe diarrhoea have occurred, due possibly to soakage of foul matters into a well. The
area of cement round the mouth of the well had become cracked and broken, and it was the
custom to wash vessels which had contained food on this spot. When the practice
was discontinued the cases of diarrhoea no longer occurred. In some of them B. pyocyaneus
may have been the exciting cause, as it was found post mortem in a case terminating fatally.

Castellani,* in Ceylon, found flagellates in the excreta of cases of diarrhoea. He describes
three types and suggests that they were etiological factors in the production of the condition.

The role of Balantidium coli in diarrhoea is mentioned by Strong,'"' who thinks that man
may sometimes derive this parasite from the hog. The encysted forms become dried and get
blown about so that water or food may become contaminated. The diarrhcea is often
associated with colic and persists until treatment is directed against the parasite.

The view that the hill diarrhcea of India is due to the presence of mica in water is
criticised adversely by Maynard.' He regards it as due to liver congestion, the result of chill.

' Batten, F. E. (January 3rd, 1906), Clinical Journal.

" Younge, S. H. (September 8th, 1906), " Treatment of Infantile Diarrhoea." British Medical Journal,
p. 573, Vol. II.

=" Myers, G. T. (June, 1906) Medical Record.

* Thresh, J. C. (November 28th, 1903), " Diarrhcea and Polluted Water." Lancet, p. 1519, Vol. II.

' Castellani, A. (November 11th, 1905), " Diarrhcea from Flagellates." British Medical Journal, p. 1285, Vol. II.

" Strong, R. P. (December, 1905), " The Pathological Significance of Balantidium coli." Indian Medical
Gazelle, p. 470, Vol. XL.

■" Maynard, A. E. (January 20th, 1906), " Hill Diarrhcea." British Medical Journal, p. 141, Vol. I.

• Article not consulted in the original.

EEVIEW — TEOPICAL MEDICINE, ETC.

Proiit' has described an outbreak of dysenteric diarrhoea at Bathurst due to the foulinR Diairhflea —
of drinking water by the excreta of locusts. These latter consisted of spindle-shaped bodies coaiii^ -^

which were composed of the fibrous indigestible parts of the grass matted together, and
also of the siliceous spicules found in many grasses. The result of their ingestion was a
mechanical irritation like that induced by ground-glass poisoning.

Diphtheria. Most of the recent papers on this subject seem to deal with treatment,
the preventive use of antitoxin, and the bacteriological aspect of the disease.

Sambon,^ in an ingenious paper, seeks to prove a relationship between diphtheritic
affections of man and those of the lower animals. He deals specially with avian diphtheria
and states that if the diphtheria of fowls is transmissible to man, then the eggs of these
birds must play an important part in its transmission, because diphtheritic patches have
been found in the oviducts. The paper is interesting and suggestive, but is severely
handled from the veterinarian standpoint by Mettam,^ who states that the historical
references and most of Dr. Sambon's quotations will not bear inspection for a moment. He
agrees with the opinion of Friedberger and Frohner relating to the transmission of animal
diphtheria to man — it is a mere assumption due to ignorance of veterinary pathology.

In a discussion on "What is notifiable diphtheria?'' Williams* divided the clinically
mild and doubtful cases into three groups : —

1. Patients without ordinary clinical signs of diphtheria, not definitely ill and yet
anaemic, with quickened pulses, nasal catarrh, and other local symptoms which bacteriologi-
cally prove to be diphtheria.

2. Cases with any of these lesions but with no general symptoms of ill-health.

3. Persons who are quite well and have no local lesions but by cultural tests are
found to harbour diphtheria bacilli.

He is inclined to regard cases coming under groups 1 and 2 as requiring isolation and
treatment, but as regards 3 he points out that there is no evidence that infected contacts can
spread diphtheria until they have developed local symptoms.

Higley' describes a rapid method (fifteen minutes) of certain diagnosis by examination of
stained smears from deposits or false membranes. The material for the smear is obtained
by passing a looped needle flattened at the curve lightly over the false membrane. The
stains used are : 1. Five drops Kuhne's carbolic methylene blue in 7 c.c. of tap-water.
2. Ten drops carbol fuchsine in 7 c.c. of tap-water. Method — -Fix in usual way. Apply
No. 1 for 5 seconds. Wash with tap-water and dry between filter paper. Apply No. 2 for
one minute, wash, dry, and mount in balsam. Loeffler's bacilli then appear as dark red or
violet rods, irregularly stained and often containing polar dots. The colour means nothing,
the other points are characteristic.

Pennington'' has a paper on the virulence of diphtheria organisms in the throats of
healthy school children and diphtheria convalescents. He found that 10 per cent, of the
former harbour in their throats bacilli morphologically indistinguishable from diphtheria
bacilli. One half of these did not affect guinea pigs. About 30 per cent, of them were
clearly attenuated, 14 per cent, moderately virulent. In the convalescent cases the great
majority of the bacilli were highly virulent. His conclusions seem to be that, in healthy
persons unexposed to infection, if diphtheria bacilli are present, they are usually non-virulent,
that in healthy exposed people the organisms are markedly virulent and such persons are a
fruitful source of infection, and that convalescents from diphtheria carry and disseminate
virulent organisms as long as any remain in their throats, a period which may far exceed
the duration of the clinical evidence of the disease. He submits that preventive measures
should be based on these findings, but admits the practical difficulties of carrying such into
effect. It is, therefore, evident that his views differ considerably from those of Williams.

' Prout, W. T. (April 2oth, 1908), " Unusual Cause of Dysenteric Diirrhoea in the Tropics." Lancet, Vol. I.

2 Sambon, L. W. (April 18th, 1908), "The Epidemiology of Diphtheria, etc." Lancet, Vol. I.

= Mettam, A. E. (May 2nd, 1908). Ibid.

* Williams, P. W. (September 16th, 1905), "Wh.it is Notifiable Diphtheria?" British Malical Journal,
p. 647, Vol. II.

« Higley, H. A. (May 20th, 1905), "Rapid Bacteriological Diagnosis of Diphtheria." Epit. of British Medical
Journal, p. 80, Vol. I.

>> Pennington, M. E. (.Januuary 1st, 1907), "The Virulence of Diphtheria, etc." Journal of Infectious Diseases,
p. 36, Vol. IV.

4ii REVIEW — TROPICAL MEDICINE, ETC.

Diphtheria— MaoCombie' deals with the grave clinical significance of skin haEmorrhages in diphtheria.

cantiiiwd In pre-antitoxin days patients hardly ever survived more than two days after their
appearance, and while they are now, thanks to antitoxin, rare, they almost invariably herald
death within 4 or 5 days, though sometimes life is prolonged for a week or a fortnight. The
fatal issue is due to toxaemia and cardiac failure, and persistent vomiting is often a marked
symptom.

Ashby,- in a very well-illustrated paper, records an outbreak of milk-borne diphtheria
associated with an ulcerated condition of the udders of cows. Like all such epidemics it
was less severe and less fatal than the usual form.

Davies'' has a very useful and practical paper with diagrams of highly magnified bacilli
classified according to the types described by Westbrook, i.e. the granular, the barred and
the solid types, each of which are sub-divided into varieties. He points out that school
examination of contacts in infected classes is a much more rational procedure in urban
communities than mere school exclusion without such examination, provided the possibility
of home contacts is not forgotten. As regards " Carrier Cases," he quotes the conclusions of
the Committee of Massachusetts Association of Boards of Health, which are as follows : —

1. It is impracticable to isolate well persons infected with diphtheria bacilli, if such persons have not,
so far as known, been recently exposed to the disease.

2. It is not advisable, as a matter of routine, to isolate from the public all the well persons in infected
families, schools and institutions.

The exceptions have to be made as a matter of expediency, in regard to wage-earners, business and
professional men.

It is, however, advisable to keep the children in infected families away from day school, Sunday school
and all public places.

Wage-earners may usually be allowed to continue their work, but teachers, nurses and others who are
brought into close contact with children, and also milkmen, should not be allowed to do so.

In schools and institutions all infected persons, sick or well, should, if the infection is not too wide-spread,
be separated from the others.

When diphtheria appears in a community which has for some time been free from it, it is advisable to
isolate all persons who have been brought into contact with the patient until it shall have been shown that
they are free from diphtheria bacilli.

Davies also suggests that the modified phenomena of the late stages of epidemic
invasion may be due to an acquired immunity resulting from the prevalence of atypical
forms of the diphtheria organism, especially Hoffmann's bacillus.

Eothe^ describes a cultural method of distinguishing between true and pseudo-diphtheria
bacilli. He uses a medium composed of a mixture of one part of neutral broth free from
sugar and four parts beef serum. To this he adds ten parts of litmus, and dextrose or
laevulose in a proportion of 10 per cent, of the whole. He finds that true diphtheria bacilli
always attack the dextrose or lasvulose and colour the litmus red, while, so far as is known,
no pseudo-diphtheria bacillus has this combined action.

Graham-Smith"' has a paper somewhat on the same lines. He found that most
diphtheria-like organisms tested produce less acid than the diphtheria bacillus. Hoffmann's
bacillus and diphtheria-like bacilli from the normal ear can be easily differentiated, since
they form no acid. Any bacillus which acts on mannite or saccharose could also be easily
differentiated.

Lewis" has a very useful paper on the bacteriological diagnosis of diphtheria. He
notes that fallacies may arise, owing to fault on the part of (1) the clinician, or (2) the
bacteriologist. As regards (1), the throat may have been treated with antiseptics prior to
the application of the swab ; the swab used may have been of wool impregnated with an
antiseptic ; the wrong locality of the throat may have been swabbed, this being a frequent

' MacCombie, J. (December 22nd, 1906), "Exanthem of Scarlet Fever and some of its Counterfeits, and the
Chemical Significance of Skin Hemorrhages in Diphtheria." British Medical Journal, p. 1757, Vol. II.

^ Ashby, A. (December, 1906), " A Milk Epidemic of Diphtheria associated with an Udder Disease of Cows."
Public Ucaltli, p. 145, Vol. XIX.

3 Davies, D. S. (March, 1907), " Diphtheria and Small- Pox : An Epidemiological Contrast." Public Health.

* Rothe (August 31st, 1907), " Beitrag fiir DifEerenzierung der Diphtheriebacillen." Cent. f. Bakt. I., Oria.,
t. XLIV.

= Graham-Smith, G. S. (July, 1906), "The Action of Diphtheria and Diphtheria-like Bacilli on various
Sugars and Carbohydrates." Journal of Htjijicnc, p. 286, Vol. VI.

» Lewis, C. J. (August, 1907), "The Bacteriological Diagnosis of Diphtheria." Birmingham Medical Mevieia.

HEVIEVV — TROriCAL MEDICINE, ETC. 43

source of error. As regards (2), there may have been a perfunctory application of the swab Dipun,eria—
to the serum ; tlie temperature of incubation may have been wrong and not between 33" C. coiUinu,^

and 37" C, as is essential if the bacillus is to grow more rapidly than the accompanying
cocci ; the number of colonies examined may be too small , the slide may be greasy : the
stain may be old or unfiltered ; the staining may be careless ; the examination may be too
limited, i.e. sufficient fields may not be examined.

After dealing with the characters of diphtheria bacilli and their classificatiou, he
concludes by stating that : —

The greater his knowledge of the circumstances o£ each individual case, the more valuable is the report of
the bacteriologist. From a bacteriological standpoint alone a diagnosis of diphtheria, though generally reliable,
is beset with difficulties. The bacteriological report must be a factor, and an important factor, in the decision,
but the final judgment can only be made by the practitioner in conjunction with the medical officer of health.

Slater' reports a most interesting case of skin diphtheria of 3 years' standing. The
original seat of the disease was the eyes, then the vulva became affected, the bacilli entered
the superficial lymphatic circulation and produced a condition like herpes, possibly as the
result of a toxic peripheral neuritis. Typical Klebs-Loeffler bacilli were isolated and no
treatment had any effect until antitoxin was given, when the result was remarkable. The
author does not say if this curious carrier case infected other people. Four other cases of
skin diphtheria in the form of ulcers of the toe are narrated by Heelis and Jacob.- The
condition at first resembled chilblains, but later a contact developed faucial diphtheria. Skin
diphtheria, then, may in some measure explain the origin of certain obscure cases or even
epidemics.

The question of treatment hardly falls to be considered here, but as it is sometimes
difficult to obtain or store antitoxin in the Sudan, Leonard Williams'" strong advocacy of
biniodide of mercury, given as a mixture containing the perchloride of mercury and iodide
of potassium, may be cited. So may the use of 4 per cent, solution of formalin as a throat
swab or gargle (Brunton-*)* and of formolyptol both as a spray and as an internal remedy in
2 minim doses (Eendle'"').

Crookshank'"' advocates the hypodermic administration of adrenalin chloride and
strychnine in severe cases of diphtheria marked by vomiting and cardiac depression. He
employs tabloids, each containing ov,uth of a grain of adrenalin chlorine and y'riith of a
grain of sulphate of strychnine. One or two of these may be given every two, three or
four hours. Even in desperate cases it may be of service, all food, other medicine and
throat treatment being stopped when vomiting occurs.

The preventive use of antitoxin, however, calls for some brief notice, as, in such a
country as this, provided the serum was available, it would constitute an important method
of checking and controlling an epidemic.

Shackleton^ records a school outbreak where antitoxin proved efficient as a prophylactic.
The dose given was 2000 units of Burroughs Wellcome & Co.'s serum, or 1000 units of the
Lister Institute serum. Norton'* describes a somewhat similar experience, in which the results
vyere most gratifying and there were practically no ill-effects.

Sittler'-'* has come to certain conclusions as to the length of immunity after injection of
diphtheria antitoxin.

1. The immuuity given by the prophylactic injections lasts from three to five weeks, if the childi'en arc
not too often exposed to diphtheria in the interval.

'■ Slater, A. B. (January 4th, 1908), "A Case of Diphtheria of the Skin of three years' duration treated by
Antitoxin." Lancet, p. 15, Vol. I.

- Heelis, R., and .Jacob, P. H. (March 10th, 1906), "A Series of Four Cases of Cutaneous Diphtheria."
British Medical Journal, p. 556, Vol. I.

" Williams, Leonard (1907), " Minor Maladies." London.

■* Brunton, T. L. (February 15th, 1906), Clinical Journal.

" Bendle, C. E.R. (February 18th, 1905), "Formolyptol in Diphtheria." Lancet, p. 460, Vol. I.

« Crookshank, P. G. (April 25th, 1908), " A Note on the Treatment of Diphtheria." Lancet, Vol. I.

' Shackleton, W. W. (Sept. 15th, 1906), "The Prophylactic use of Anti-Diphtheritic Serum." Lancet,
p. 722, Vol. II.

" Norton, E. E. (July 13th, 1907), "The Prophylactic use of Antitoxin in Epidemic Diphtheria." Lancet,
p. 85, Vol. II.

» Sittler, P. (September, 1906). Jahrbuch f. Kinderhcilk.

• Article not consulted in the original.

44 REVIEW — TKOPICAIi MEDICINE, ETC.

DiDhth«>-ia '-• Uninimunised childrou are much more suscei^tiblc to diphtheria than the childi-en who have been

" immunised.

3. Catarrhal affections of all kinds, and wounds of the mucous membranes, predispose to diphtheria
and tend to shorten the period of immunity.

4. The length of the period of immunisation is not increased by using doses larger than 500 units.

5. Certain children show a greater predisposition to diphtheria than others. It is advisable to isolate
these children as thoroughly as may be, so as to avoid the necessity for too frequent injection of antito.xin.

In my experience cases of diphtheria, so far as Khartoum is concerned, are apt to crop
up in October, when the summer has been dry. I have never seen an extensive epidemic
nor have I ever been able to trace the disease to its source. Apparently it has been
introduced from outside, and it is usually of a severe form associated with streptococcal
infection. The type of diphtheria bacillus present has, as a rule, been what Westbrook
would term Granular C. The disease is undoubtedly rare in the Sudan.

Disinfection. This is such a wide subject that it is difficult to pick out the papers
most likely to be useful. Those selected will be found practical and to possess a bearing on
sanitary work in the Sudan.

As regards the disinfection of ships, the Clayton process may be briefly described as one
in which sulphur dioxide gas, produced by combustion of sulphur in a special apparatus, is
driven into the lower parts of the holds which have been previously rendered air-tight.
The air is extracted from the upper parts of the hold until all the air space is permeated
with the gas to the extent of 10 per cent., the extracted air being passed over the heated
sulphur in the furnace. One pound of sulphur is required for every 400 cubic feet of space.
Three per cent, gas in the air is fatal to rats. There is no risk of fire, and the cost is £1
for every 100 tons gross register.

A Local Government Board report on the value of sulphur dioxide as a disinfectant and
destroyer of rats is quoted in the Lancet for December 17th, 1904. It points out that the
results achieved depend on whether the cargo is left in the hold or not. While, in the latter
case, these are eminently satisfactory, rats, cockroaches and fleas being killed by a uniform
diffusion of as little as -5 per cent, of the gas, matters are quite different with the cargo
in situ, owing to the slow penetrating power of sulphur dioxide. A suggestion is made that a
small proportion of carbon monoxide (say 10 per cent, of "producer gas") should be added
to the gas in the holds for the purpose of killing the rats. A later and similar report
states that while carbon monoxide kills rats it fails to destroy mosquitoes and bacteria.
Formaldehyde vapour, while destroying bacteria, spares rats and mosquitoes, has practically
no penetrative power, and for its subsequent complete removal the disinfected material must
be chemically treated.

A short account of the "producer gas" employed by Nocht and Giemsa in Hamburg is
given in Public Health for September, 1905. The gas is generated by a current of air blown
into a producer where coke is burned. The plant both introduces and removes the gas from
the holds. It gives excellent results in the case of rats, while an apparatus enabling the
generator gas to be mixed with formaldehyde vapour, so as to obtain simultaneously a
disinfecting action, has likewise been provided. The cost is moderate. The prime cost of a
large floating plant is about £2500, and if 100 vessels be treated a year the cost per vessel
works out at about £3 or £4.

Sandwith^ recently saw the apparatus at work. The gas took 12 hours to disinfect a
large passenger steamer, but it is believed that all rats on a ship are killed after about
ten minutes' exposure. The gas itself consists of about 8 per cent, carbon monoxide with a
little carbonic acid and some 70 per cent, of nitrogen. The cost for disinfecting a moderate-
sized steamer was £7. 10s. He does not mention the accompanying use of formaldehyde, but
states that no harm results to the cargo.

Chloride of lime, if properly used, is so useful a disinfectant that a few papers on it may
be quoted.

Hankin^ worked on the subject in India and found that " specimens having the form of
a coarsely granular powder keep longer than other specimens in which the material takes the
form of adherent masses." His other conclusions are tabulated : —

1. Chloride of lime, when fit for use, has a strong smell of chlorine. If it has been kept in a hot climate for
three months, the amount of available chlorine present will usually be about one-third of what it was originally.

1 Sandwith, P. M. (November 30th, 1907). Lancet, p. 1535, Vol. II.

- Hankin, E. H. (September, 1904), "Chloride of Lime as a Disinfectant." Ittdian Medical Gazette, p. 351,
Vol. XXXIX.

REVIEW — TBOPIOAL MEDICINE, ETC. 45

After the lapse of the above period, the amount of available chlorine may be less and the substance will Disinfectioa
then be unfit for use. contiitncd

2. Chloride of lime is readily attacked by various kinds of organic matter. Therefore, it is unsuitable for
dealing with sewage or other large masses of putrefying material. On the other hand, it may be used with
advantage in places where the infective material can only be embedded in small amounts of organic matter.

3. Owing to its deodorant properties and penetrative power, chloride of lime may be used in the interior
of infected houses, both on the walls, on furniture, or on cement or stone floors.

4. Whitewash made in the usual way with quicklime is rendered far more active if half a pound of chloride
of lime is added to every 7 gallons of the liquid.

5. Owing to the bactericidal power of chloride of lime under circumstances in which its action is not masked
by the presence of an excess of organic matter, it is likely that it could be useful in the cleaning and disinfection
of wells, either in place of, or mixed with, permanganate.

Owing to its unpalatable taste, it would, however, be necessary to pump out the well, preferably on the
following day, before bringing the water of the well into use.

I have found that chloride of lime even when stored in a comparatively cool place in
closed metal drums, rapidly deteriorates in the Sudan. A six months' old sample analysed
by Dr. Beam was found to have only about 1 per cent, of available chlorine instead of the
30 per cent, which should have been present.

Klein^ has a paper on the bactericidal efficiency of hypochlorites in the presence of
organic matter. He experimented by adding chloros to urine, letting the mixture stand for
an hour and then adding the typhoid bacillus. Owing to the previous action of the organic
fluid on the disinfectant the co-efficient of the latter fell to 0-8. On the other hand, if chloros
be added direct to typhoid infected urine, the co-efficient for chloros in a icatery distribution
of B. typhosus works out at 21-0.

It is worth noting that chloros, a valuable disinfecting agent at home, is not suitable
for export.

A somewhat similar, but more elaborate, paper is that by Harris and Prausnitz^ on
faeces-urine emulsions used for testing disinfectants.

The disinfection of books is a practical question which often crops up. Formaldehyde
is usually recommended, but Badia and Greco'* conclude that for a complete and proper
disinfection of books the use of the autoclave is essential despite its drawbacks. On the
other hand, Kister and Trautman''* find that if books of any kind are placed on a suitable
stand with their leaves opened out so as to prevent more than six or eight pages sticking
together and are then subjected to their process of formalin disinfection at an increased
tempei'ature in a vacuum, satisfactory results are obtained. No damage results, the only
bad effect being a tendency for the leaves to curl. This is overcome by pressure.

In a country like the Sudan, where white residents are largely at the mercy of native
servants, it is worth \vhile knowing how readily and efficiently to disinfect ordinary table
utensils. When one considers that such servants not infrequently suffer from venereal
disease and other communicable disorders, the importance of such knowledge is apparent,
though in actual life the necessity for its application would appear rarely to arise.

Beck' has studied the question, hitherto rather neglected, and finds that in most
instances immersion in a 20 per cent, solution of carbonate of soda at a temperature of 50" C.
suffices, but it will not serve in cases of infection by the Tubercle baciUus, and it is not easy to
be sure of the temperature. Below 50° C. the action is ineffective, while a higher
temperature damages table-knives, mounted forks, etc. Therefore immersion in alcohol at
60° G. for half an hour is recommended as an easy and reliable method. It is sometimes
necessary to disinfect railway carriages. The formalin-permanganate method, in which
formalin is poured upon crystals of permanganate of potash, is stated'' to be the best. The
proper proportions for use are one cubic centimetre of formalin to 0-5 gramme of the

1 Klein, E. (October, 1906), "The Bacteriological Efficiency of Hypochlorites in the presence of Organic
Matter." Public Health, p. 27, Vol. XIX.

- Harris, C. E., and Prausnitz, C. (March, 1907), "The Determination of the Efficiency of Disinfectants."
Journal of the Royal Instilutc of Public Health, p. 147, Vol. XV., No. -3.

^ Badia and Greco, N. V. (August 7th, 1906). Anal, del circ. Med. ArgcntiRo.

•* Kister and Trautmann, H. Zcit.f. TnberkiUbsc, 1907, No. 6, p. 497.

' Beck, M. (August 7th, 1906), " Zur Frage der Disinfektion von Ess- und Trinkgeschirren." Cent. f. Bakl.
I. Orifi., Bd. XLI., p. 853.

' Lancet (December 15th, 1906), p. 1675. "The Disinfection of Railway Carriages with Formaldehyde."

* Article not consulted in the original.

46 REVIEW — TROPICAL MEDICINE, ETC.

Disinfe»;tion pormauganate, and from 200 c.c. to 500 c.c. of formaldehyde are required per 1000 cubic feet
—L-ontitKu.i of air space. The presence of added water is unnecessary. The chief point about this method
is the sliort exposure and the large quantity of gas evolved. It is also easily carried into
execution and does not require elaborate apparatus.

Firth' draws attention to this method. The gas evolved consists of formaldehyde,
water-vapour, carbon dioxide, and traces of formic acid, and the reaction is apparently
expressed by the formula

4 K Mn 0, + 3 H., CO + H, = 4 Mn (OH), + 2 K, CO^ + CO..

The proportion of the two substances which gives the best results and the driest residue, is
two parts of formalin to one part of permanganate. The method is effective, simple, rapid,
and, by virtue of the inexpensive apparatus required, preferable to the older and more
cumbersome methods. For a space of 2000 cubic feet, 285 grammes, or 10 oz., of the
permanganate and 570 cubic centimetres, or one pint, of formalin are required, the
reagents being mixed or added the one to the other in an ordinary galvanized-iron pail.
The crystals, which are better crushed, are put in first, and then the formalin is poured on
them. There is time for the operator to withdraw, and the period of disinfection should be
six hours. Heat and moisture are essential for efficient disinfection. From 60" F. to 70" F. is
a proper temperature, while it is well to render the air of the room moist in a dry country.
One has employed this method on several occasions in Khartoum, and it appears to be
efficient. The walls of the room to be disinfected are damped and the air sprayed with
water before the gas is evolved. Firth's paper, which deals generally with disinfection by
formaldehyde, contains much of interest, and he is inclined to urge the abandonment of
so-called room disinfection altogether and confine attention to the infected person, his
clothing and his bedding. The above method can be utilised for sterilising clothing in a
very simple manner.

Eecent work on plague has drawn attention to disinfectants capable of killing fleas.

SaigoP experimented with numerous chemicals. He found that petrol or benzine with
cyllin or phenyle (in equal quantities) made up to 1 in 300, i.e. 1 in 1600 of both, were
satisfactory. Actual contact with the fluid is necessary to kill the insects, though free use of
the emulsion will drive out of a house those that escape actual contact. Female fleas are
more resistant than the males. Both cyllin and phenyle emulsify petrol, but the former is
preferable owing to its greater germicidal powers. The emulsion, for the making of which
he gives directions, must be fresh.

Somerville" found that cyllin 1 in 400 and phenyle 1 in 250, and Jeyes' fluid 1 in 250,
were efficient in five minutes, while a jelly of 80 per cent, petroleum with 20 per cent,
whale oil soap used in a 3 per cent, solution is said' to be the best contact insecticide known.
A 10 per cent, solution is absolutely certainly lethal for fleas. Hossack has done much
work on this subject. He confirms Saigol's work with petrol and phenyle, but not as
regards petrol and cyllin. This discrepancy was probably due to the difference in the
samples used. He concludes that " the ideal for plague purposes would be a cyllin with the
pulicidal power of the most potent samples of phenyle or phenyle with the germicidal
power of a cyllin."

One may add a brief note on the disinfection of stools, and also of drain and water
pipes, as it is sometimes difficult to obtain reliable information on these latter points.
A good way of disinfecting cholera stools is to add together equal parts of fresh quicklime
and water. Then dilute the slake lime so formed with three times as much water as has
been previously used. Equal quantities of this mixture and cholera dejecta are thoroughly
stirred together and allowed to stand for an hour, when all the vibrios are killed.

Fresh and good chlorinated lime in powder form, and in the proportion of two table-
spoonfuls to a pint of cholera dejecta, is effective in twenty minutes. Strong izal, 5 per cent.,
or carbolic acid 1 in 10, with contact for two or three hours and thorough mixing, and a
sufficiency of the disinfectant (rough guide = complete covering of the stool), are measures
useful for enteric and dysenteric excreta. In typhoid bacilluria the urine may be diluted
with half its volume of 1 per cent, formalin.

' Firth, R. H. (April, 1908), " Disinfection by Formaldehyde." Journal o} the Royal Army Medical Corps,
Vol. X., No. 4.

"^ Saigol, R. D. (-July, 1907), "The Plea-killing Power of various Chemicals." Iiulian Medical Oazette,
p. 256, Vol. XLII.

" Somerville, D. (August, 1907), " Disinfectants against Fleas." Indian Medical Gazette, p. 316, Vol. XLII.,
No. 8.

BEVrEV — TROPICAL MEDICINE, ETC. 47

For drain pipes a solution of i tto'is sulphate 1 lb. to the goilon \n recommended, while Disinfection
water pipes are disinfected by .♦JUini; v.hem with a 2 per cen', . -^elation of carbolic acid for — continued
24 hours and then flushing them out \' i -lure water.

Dropsy (Epidemic) . Our knowleu, th^, sease does no to have increased.

Eogers' describes it as met with in India. The rash ■ to be ran vhile it would

seem that the presence of the jerks and the absence of anaes^ ''ish it from
beri-beri. I have never heard of its being founu in t' Sudan.

Since the above was written, an important paper by '^QJp ( He was

appointed to investigate the causation of beii-beri in Indian jtii. 'there was

no true beri-beri in Eastern Bengal and Assam — the uljease present oic dropsy.

He believes this latter to be a specific infectious or bacterial disei s conveyed

from person to person by bed-bugs. His reasons for looking upon •' rial disease

are : (1) Its epidemic character ; (2) the initial fever; (3) the rash o. ) the local

or house infectiousness ; (5) the sudden disappearance of the disease wn.. ted houses

are vacated. The bed-bug theory is supported by (1) the well-known manner in ivliich the
disease ailects households ; (2) its close association with the sleeping places of affected
persons ; (3) the presence of bug-infested bamboo stools (morahs) in an infected district ;
(4) the benefits resulting from evacuation of infected jails and houses. He recommends
the latter method combined with bug prevention and bug destruction as likely to prevent
and eradicate the disease.

Pearse,^ the Health Officer of Calcutta, is inclined to believe that beri-beri and
epidemic dropsy are one and the same disease due to a specific organism, but Delany, in
the paper just quoted, enters very fully into this question and tabulates the particulars in
which the diseases resemble and differ from each other.

The diseases resemble one another in the following manner : —

{(t) Both occur mostly in epidemics.

(6) The knee jerks are altered in each.

(c) Dropsy of various degrees occur in both.

{d) There is considerable cardiac disturbance in each, dilatation and heart murmurs being present, or
palpitation and dyspnoea only.

(f) In each disease the pericardium, pleura and peritoneum may contain fluid.

(/) In each disease there is frequently oedema of the lungs.

{g) Cutaneous sensation is disturbed in both diseases.

(A) Hyperaesthesia occurs in both.

(i) In each disease motion is frequently disturbed or interfered with.

{}) And in each disease death occurs with distressing dyspnoea and orthopncea.

But the diseases differ as follows : —

(a) Knee jerks in beri-beri are at first and for a brief period (rarely over 48 hours) increased and painful,
and then lost in probably more than 95 per cent, of cases.

In epidemic dropsy knee jerks are diminished or lost in no more than 3 per cent, of cases.

(b) Anaesthesia is a marked feature of beri-beri and will be found in practically every case either in small
patches or over extensive areas. In epidemic dropsy cutaneous sensation is lessened over the dropsical areas and
not in patches otherwise than over dropsical areas ; but in this disease, though cutaneous sensation is diminished,
it is not lost, and probably is only so diminished from mechanical interferences with nerve termini by the
effused fluid.

(c) In bei'i-beri true paralyses occur, with toe drop, wrist drop, paraplegia or paralysis of all four limbs. In
epidemic dropsy various forms of paresis are simulated by mechaniciil obstruction around, joined by the effused
fluids ; the very weight of a swollen limb may cause a difficulty in using it. An ataxic gait is simulated owing
to the swollen legs, and this may be more apparent when the external genital organs are swollen.

But in beri-beri a characteristic symptom is the presence of varying degrees of paralysis in cases that have
no dropsy whatever (dry beri-beri), and this occurs, according to Hunter and Koch of Hong Kong, in quite
50 per cent, of the cases, these cases having besides the characteristic patchy anaesthesia.

(d) The hypei-testhesia differs in the two diseases, being present in the dropsical skin and subcutaneous
tissue when gently pinched in epidemic dropsy ; but in beri-beri, the muscles are painful on moderate deep
pressure in cedematous and non-oedematous parts alike.

(c) Some few cases of epidemic dropsy are found to undergo a general emaciation and so simulate the
atrophic stage of beri-beri in which the muscles atrophy to such a degree that the patients look like living

' Rogers, Leonard, " Fever in the Tropics." London, 1908.

'' Delany, T. H. (May, 1908), " Epidemic Dropsy or Beri-beri in Eastern Bengal." Indian Medical Gazette.

» Pearse, P. (March 2nd, 1908), " On the Identity of Beri-beri and Epidemic Dropsy." Journal of Tropical
Medicine and Hiji/iene.

48 REVIEW — TEOPICAL MEDICIN 6 ETC.

Dropsy — skeletons. But these case?- of emaciation .ire able to move their li .i- 1 about in bed, thougti they are feeble. In
continued '^'^7 '"■'Se outbreak of beri-beri those cases of atrophy with ex^-^nsive and severe paralysis are present in quite
largo numbers and are often b'^iti :jii(.n for many mouths.

(/) A marked featur i heri-l)eri is the sudden dci»' .;hat occur in addition to the distressing deaths
vrith dyspnoea and ortho ich .as al > ."'cur ."^ "l'?"'' ^ropsy. These sudden deaths occur not alone in

cases with paralysis •■- but in per^ Hii ' ontly vs. , or who have but the mildest .symptoms.

(g) There ■' ' isis and aiue.. -« (diminution, of Jjsemaglobin) in epidemic dropsy, but in beri-beri

ansemia is not ' - ■ ■ '

(A) Of n '.ho ii''P'' ' olrasii'.- j%:iix!uticular mottling and staining along the course of

superficial vJ »li.^ .csquaiW't n iod initial fever in epidemic dropsy.

(i) Lasi ./i-beri are cs.=- i\ illy those of peripheral neuritis, and the central nervous

system is unal c.»se. (Hunter and ' ..'L, Manson, Braddon, Wright).

Eeane-i "jguments against Delany's view that bed-bugs may be the carriers.

Dust./ ->'S arc of more importance than this in the Northern Sudan, and

hence a pa 1 .ist Problems^ merits attention. "A road to be dust proof," it says,

" should have a, .^-nooth, impermeable, enduring surface, and a hard foundation which will not
work out through the top ; such a road can be built by using slag taken hot from the furnace
and dipped in tar until soaked from surface to centre, after a method invented by Mr. Hooley,
of Nottingham, under the name of ' tarmac' " While this is good for new roads it would
not pay to lift and relay those already existing, and in Khartoum no slag is available.
Palliatives, known as " Westrumite " and " Akonia " are said to be inexpensive, and their
effect on dust much more enduring than mere watering. They were considered for the
Khartoum streets, but the cost was found to be prohibitive.

Dysentery. A vast deal of literature has accumulated on this important subject
and it is no easy matter to pick out the papers most profitable for review. No doubt many
have been missed, but it is hoped those selected will prove useful.

Waters^ brings out very strongly the influence of soil contamination as a factor in the
spread of dysentery, and especially in camps, jails and institutions. He cites South African
experience, the role j)layed by flies and the filthy habits of native prisoners. He also points
out that men who have suffered much from malaria are very prone to dysentery, and that
previous dysenteric attacks also predispose to the disease. He found that hard, out-door
labour, necessitating exposure, favoured dysentery,. and he mentions the substances used by
malingerers to produce a condition like the disease. As regards the blood state, a general
increase in the small lymphocytes was noted.

Hewlett* reviews the findings of Schaudinn as regards the differences between
Enfamceba histolytica and Entauuela coli [vide infra), and alludes to Musgrave's and Clegg's
work on Amoebiasis and the cultivation of amcebse. The most important point to which he
refers is the apparent necessity for symbiosis with bacteria for the growth of the
amoebae. In this connection he cites Lesage, who found, along with Entamoeba histolytica,
a bacillus which he termed the Paracolon hacillus.

McWeeney' mentions briefly the vegetative and sexual cycles of both forms of amcebse
and refers to Schaudinn's classical and careful experiment of feeding a young and healthy
cat with meat and milk infected solely with the small, brown spores of Entamoeba
histolytica. The cat died of dysentery and showed characteristic ulceration of the large
intestine, while crowds of amoebae were found in the ulcers and penetrating the wall
of the gut.

The amoeboid stage of the parasite was found incapable of transmitting the disease.
It would seem that the disease is not propagated by amoebae introduced per os. The older
experimenters had often succeeded in producing infection by the introduction of amoebae per
rectum, but, as this can hardly be realised under natural conditions, it is to the dried-up
spore-containing faeces present in dust and water that we must look for the propagation of
dysentery. These spores can be conveyed by flies and can be blown about by the wind.

» Reaney, M. P. (July, 1908), "Epidemic Dropsy." Indian Medical Gazette.

- " Dust Problems." British Medical Journal, p. 1763, December 31st, 1904.

^ Waters, E. E. (December 1st, 1903), " Dysentery." Journal of Tropical Medicine, p. 363, Vol. V.

■* Hewlett, R. T. (April, 1905), " Pathogenic Amoebae and their Cultivation." Journal of Preventive Medicine,
p. 237, Vol. XIII.

' McWeeney, E. J. (March 2.ith, 1905), "On the Relation of Parasitic Protozoa to each other and to Human
Disease." Lancet, p. 783, Vol. I.

r.EVIEW — TEOPICAL MEDICINE, ETC. 49

Fearnside^ has a paper ou jail dysentery, and one may note two of his conclusions. Dysentery—
(1) Mud banks (sleeping places) should be abolished and plank beds substituted, as the continued
former are insanitary and apt to become septic. (2) Association wards should be done away
with and the cellular system introduced, as the segregation thereby obtained tends to check
the spread of infectious disease.

O'Kinealy- points out the frequent association of oral sepsis, evidenced by bleeding and
unhealthy gums and jail dysentery and diarrhoea. He believes that careful attention to
prisoners' teeth and gums is very necessary.

Matthews'" mentions an outbreak at Aden due to the inhalation of contaminated dust.

NewelP classifies dysenteries as : (1) Catarrhal. (2) Acute, specific or bacillary.
(3) Amoebic. (4) Spirillary. (5) Mixed. (6) Chronic. This is useful, but takes no account of
fluxes due to the malarial parasites, Balantidium coli and Trichomonas.- "We know also that
there is a dysentery associated with kala-azar, and verminous dysentery forms a class by
itself. Newell also lays stress on the influence of wind-blown infected dust.

Spirillary dysentery has been mentioned. Dantec''* made a clinical study of this form,
which is easily distinguished from the bacillary type by the absence of any temperature rise.
The liver is not affected, and the proper treatment, rapidly effectual, is by antiseptic enemata.

I have seen one case of animal spirillary dysentery in the Sudan. It was found by
Captain Olver in a native dog belonging to myself. There was no rise of temperature, but
the stools were full of blood and mucus and the animal rapidly emaciated.

Dopter" insists on the unity of bacillary dysentery. Under this term he would include
the so-called pseudo-dysenteries and dysenteries of infants and aliens.

Gauducheau' reports that when trying to reproduce abscess of the liver in a dog by a
portal injection of pus from a human hepatic abscess he brought about a fatal amoeboid
dysentery. This is a matter of considerable interest. Indeed, from the post mortem
appearances in a case of multiple liver abscess which came under my notice, I suggested**
that, in some instances, hepatic abscess may precede a dysenteric affection of the large bowel.

Vedder'* classifies the characteristics of the dysenteric and normal amoebae as follows : —

Entamccba histolytica ( Dysenterice ) Entaimvha coli

Size
25-30 microns (not a distinguishing feature) 10-20 microns

Shape
Usually some other shape. Spherical when resting.

Colour
Greenish. Opaque greyish.

Protoplasm
Ectoplasm and entoplasm easily distinguished Ectoplasm and entoplasm distinguished

with diificulty.
Ectoplasm very refractive. Ectoplasm not refractive.

Ectoplasm finely granular. Ectoplasm homogeneous.

Entoplasm coarsely granular. Entoplasm finely granular.

» Peamside, C. P. (July, 1905), " Dysentery in the Prisons of Madras Presidency." Iiulian Medical Gazette.
p. 241, Vol. XL.

^ O'Kinealy, P. (July, 1905), "The Relation of Oral Sepsis to Dysentery." Indian Medical Gazette, p. 250,
Vol. XL. i- J J ^f,

' Matthews, E. A. (July, 1905), "The Etiology of Dysentery, with Notes on Treatment." Indian Medical
Gazette, p. 253, Vol. XL.

" NeweU, A. Q. (July, 1905), "Dysentery: Its Varieties and Causes, Summarised and Criticised, with a
Note on Treatment and Prevention." Indian Medical Gazette, p. 257.
' Dantec, "La Caducie." December 17th, 1904.

" Dopter, C. (January 15th, 1906), "La Dysenteric BaciUaire, Discussion sur I'Unitd Specific." Bulletin
dc rinsliliU Pasteur, p. 49.

' Gauducheau, A. (January 15th, 1906), "On Experimental Reproduction of .A.mcEbic Dysentery by
Intravenous Inoculation of Pus from a Hepatic Abscess." Journal of Tropical Medicine, p. 52, Vol. IX.
' Balfour, A. (November 21st, 1903), " A Case of Multiple Liver Abscess." Lancet, p. 1425, Vol. II.
' Vedder, E. B. (March 24th, 1906). Journal American Medical Association.

• Article not consulted in the original.

50 REVIEW — TEOPICAL MEDICINE, ETC.

Dysentery — Pseudopodia

continued Large and easily distinguished. Hard to distinguish.

Certain ectoplasm and entoplasm. Entirely ectoplasm.

Vacuoles
Many. Often absent.

Never more than one.

Nucleus

Often absent. When present its structure Almost invariable, with well-defined

hidden except in stained specimens. Nuclear nuclear membrane and other

membrane not well defined. Changes posi- structure.

tion markedly. In moving, organism retains relative

position.

Bed Corpuscles ingested
Many. None observed.

Motility

Great progressive motility. Often absent, or, when present, of

limited extent and short duration.

Losch, quoted by Manson, gives very similar characteristics, and in addition mentions —

Multiplication

In the intestine by fission and budding. On In the intestine by binary fission

hard fseces or outside the body resistant and also by multiple fission into

spores formed without encystment. 8 amcebulae. On hard fseces and

outside the body encystment and
formation of 8 amoebuke.
(These develop when swallowed). (These are set free when swallowed).

Musgrave and Clegg,^ in a long paper on the cultivation and pathogenesis of amoebae,
oppose Schaudinn's views, and believe that the name Amoeba coli (Losch) should still be
retained to represent those amcebae which are found in human intestines. They do not
believe in differentiating between E. coli and E. histolytica for the following reasons : —

Amoebae found in the stools of so-called healthy people do not always conform to the requirements for
E. histolytica. Cultures of amcebae answering more nearly the description given for E. coli, can Ijy methods
described in this paper (M. & C.) be made to produce ulcerative colitis in man and monkeys and abscesses of the
liver, omentum, spleen and lungs in monkeys. In cultures, single species of amoebae are often found
which are characterised by possessing a combination of some of the features which have been described
as distinctive for different species. Amcebae from many extraneous sources, and presumably saprophytic, may be
cultivated on artificial media, and with such cultures ulcerative amoebic colitis may be produced in man and
animals, and abscesses brought about in the liver, lung, omentum, spleen and muscular tissues of animals.

These conclusions are, however, challenged by Vedder,^ who points out that many of
them are based on fallacies and faulty working methods, and concludes that the criticisms
are not well founded.

Ashburn and Craig^* have worked at the presence of amcebae in healthy persons,
American soldiers in the Philippines. They examined 100 cases. In 72, E. coli
was present ; in 2, E. dysenteriie. None of the 72 had dysentery or diarrhoea at the time of
examination, nor had they ever been on the sick list owing to these diseases. The two men
with E. dyseyiteriie appeared well, but were found to have dysenteric symptoms and were
eventually invalided for chronic amoebic dysentery. Their interesting conclusions are as
follows : —

In the Philippine Islands a very large proportion of white men are infected with E. coli, and such
infection does not result in symptoms of diarrhoea or dysentery ; in many of the cases the amoebse disappear
but in the large proportion E. coli may be fouml even after the lapse of nine mouths, during which time
the infected individuals have remained in perfect health as regards dysentery or diarrhoea.

We also conclude that E. coli differs very markedly from E. dysenteria; as regards morphology, and that it is
possible to distinguish these two species of amoebae by their morphological characteristics as observed in fresh
specimens of faeces. We do not believe that the very large proportions of infections with E. coli which we have

' Musgrave, W. E., and Clegg, M. T. (November, 1906), "The Cultivation and Pathogenesis of Amoebae."
Philippine Journal of Science, p. 909, Vol. I.

- Vedder, E. B. (June Ist, 1907), " Is the Distinction between Entamoeba Coli and Entamoeba Dysenteriae
Valid?" Journal of Tropical Medicine and Hygiene, p. 190.

' Ashbnrn, P. M., and Craig, C. F. (September, 1907). The Military Surgeon, p. 222, quoted in Indian
Medical Oasette, December, 1907.

• Article not consulted in the original.

REVIEW — TROPICAL MEDICINE, ETC. 51

demonstrated can be explained logically by the theory of " latent infectious," but only, as we have stated in a Dysentery —
previous report, "by the fact that the non-pathogenic E. coli is the organism present in these cases instead of the contimied

pathogenic E. dijsenterke."

Dr. Wenyon, working in Khartoum at cases of all kinds in the Military Hospital, found
that in the great majority E. coli or its cysts were present. These cysts were found in
recently passed fseces, and he has shown' that in mice and monkeys the formation of similar
cysts commences in the cscum. In cases of dysentery these cysts of E. coli were also present,
while the small cysts of E. histolytica were not seen. Further reference to this work will
be found in Dr. Wenyon's report.

Birt^ has worked at South African dysentery. He isolated Shiga's bacillus in 26 out of 55
cases examined. Amoebae were only found once. The method of examination adopted may be
detailed. Wash a fragment of blood-stained mucus in sterile salt solution. Transfer to a
second lot and shake vigorously. Place on Drigalski-Conradi medium, taurocholate neutral
red, crystal violet, lactose agar, lactose litmus agar or ordinary agar (+ 25 Eyre's scale).
Next day transfer more delicate colonies to Doer's modifications of Barsikow's medium
consisting of nutrose, mannite, litmus and water. Shiga's bacillus leaves this unchanged.
The colon bacillus curdles it and turns it pink. Sub-cultivate on agar and, if Gram-negative
rods obtained, put up in sedimentation tubes with the patient's serum, normal human serum
and the serum of an animal immunised with Shiga's serum.

Highest dilution noted for clumping was 1 in 600, the usual 1 in 20-50. The
agglutinating power was not of long duration.

Blackham' has written a very excellent paper on tropical dysentery, chiefly from the
bacteriological standpoint, at the close of which he states that the various strains of
B. dysenterim isolated by Shiga, Plexner, Vaillard, Harris, Firth, etc., are simply varieties
of the same organism. There are also non-pathogenic pseudo-dysentery bacilli which act
on carbohydrates unaffected by Shiga's and the other pathogenic bacilli, and fail to produce
enteritis in animals. The dysentery organisms will live on clothing for at least three weeks
and are said to maintain their virulence in damp soil for months. Spread on bread crumbs
or similar articles of food, they survive for about a week. They are not very readily
destroyed by heat or by weak solutions of perchloride of mercury or the higher phenols.
The Widal reaction is often poorly marked, but is of some value, and can usually be
obtained within two weeks of the onset of symptoms.

The character of the stools alone is not to be considered as a test of the presence or
absence of dysentery. A group of maladies of varying severity come under the term
dysentery, ranging from the acute dysentery of armies to the simple infective diarrhoea of
infants and adults.

Blackham believes that "in the tropics all cases of diarrhoea should be treated with
the same precautions as if they were manifest cases of dysentery, and in hospital should
invariably be isolated and their stools sterilised in some simple form of steriliser or
by means of disinfectants."

Duncan,'* in a useful paper, describes the different types of stool met with in cases of
dysentery, and concludes by considering the indications obtainable from the different
appearances of the stools in dysentery as regard prognosis.

1. A good result can be foreshadowed in those cases in which are passed mucus with
minute faecal lumps, stained or not with blood, and in which the blood and mucus
disappear ; the ordinary faecal characters will soon manifest themselves.

2. The prognosis is of evil omen : (a) according to Sir Joseph Fayrer, in the cases in
which pulpy stools without blood or mucus are passed ; (6) where fluid faecal matter is from
time to time passed throughout the illness, the prognosis is unfavourable, inasmuch as these
characters of the stools show the disease to be extensive, and affecting chiefly the upper
part of the large, as well as in some cases part of the small, intestine ; (c) where the stools,
in conjunction with the symptoms that are laid down as characterising the true amcebic
dysentery, are present, the prognosis is again unfavourable on account of the high mortality
that is said to attend this form of the disease ; (d) the prognosis is of the worst possible

' Archiv. fill- Protistenkuiide, Suppl. I., 1907.

^ Birt, C. (March 31st, 1906), " Dysentery in South Africa." Lancet, p. 904, Vol. I.

■■■ Blackham, R. .T. (December Ist, 190G), "Tropical Dysentery." Lancet, p. 1493, Vol. II.

* Duncan, A. (May 2nd, 1904), " The Stools of Dysentery and the Prognostic Indications derivable from
them." Journal of Tropical Medicine, Vol. VII.

52 REVIEW — TROPICAL MEDICINE, ETC.

Dysentery— character where the stools consist of blackish-red or blackish fluid, with a horribly
continued putrescent odour, and of bits of gangrenous tissue.

Dopter* records three cases of amoebic dysentery, in which all ordinary methods of
treatment failed, but which were speedily cured by lavage with a 1 in 100 creosote wash.
He suggests that the creosote does not merely act locally, but, being absorbed, reaches and
acts upon the Amceha dysenferica in the tissues and in localities where it cannot be affected
by other medicaments.

Vincent-* believes that in water-borne epidemics the amoeba is more frequently the
cause than the bacillus. He investigated the length of life of B. (hjsenteriie in various
waters and the action of antagonistic saprophytes, and concludes that water is not a
suitable medium for the bacillus. At the same time, it lives a long time in frozen water
with light excluded, which perhaps explains the outbreaks and frequency of epidemics in
cold countries.

Billet^* has described a special form of Trichomonas which he terms T. dysenterix as
distinct from T. intestinalis, and which he believes plays a jjart in the production of
tropical dysentery.

So far as Khartoum is concerned there can be little doubt that polluted surface soil
played an important part in the only dysentery epidemic — a slight one — which has visited the
town. Eeference to this and other points with relation to dysentery in the Sudan will be
found under " Sanitary Notes" (Third Report).

As regards the treatment of dysentery, one must distinguish between measures suitable
for bacterial dysenteries and those useful in amoebic cases. The treatment for the former
class has been revolutionised by the introduction of appropriate sera, and considerable
literature has accumulated on this most important subject.

Blackham'' in the first place gives a table for the differential diagnosis of Amoebic and
Bacillary Dysentery : —

Amccbic Bacillary

1. Always chronic in its course. 1. Acute in onset and running a rapid

course in nearly all cases.

2. Pyrexia rare. 2. Pyrexia common.

3. Toxic symptoms not present except where 3. Toxic symptoms usually present.

there is liver abscess.

4. Liver abscess occurs in about 16 per cent. 4. Liver abscess never occurs.

of cases (Curry).

5. Small intestine frequently attacked. 5. Disease confined to large intestine.

6. According to Krause and Kartulis, under- 6. Ulcers usually found on surface folds

mined ulcers present. of intestine.

Personally I very much doubt if bacillary dysentery is always confined to the large
intestine. In the Second Eeport of these Laboratories I recorded a rapidly fatal case of a
disease exactly like dysentery where, post mortem, all that was found was a comparatively
small area of the small intestine acutely inflamed and presenting an appearance like a
measles rash. I had no opportunity of examining this case baoteriologically, but it was
either bacillary dysentery or some hitherto unrecognised, infective, inflammatory process.

The main points brought out by Blackham as regards treatment are : (1) Value of opium
in doses of gr. ^ to gr. J of morphine hypodermically. (2) Clear soups are better than milk ;
and weak chicken broth, whey and egg albumen may be given till the tongue cleans.
(3) Stimulants rarely necessary ; when required try a teaspoonful of brandy in a tablespoonful
of coffee. (4) Value of preliminary dose of castor oil with or without 15 or 20 minims of
Liquor Opii Sedativus. (5) Medicinal treatment lies between use of sodium sulphate or of
calomel The latter is given in gr. | doses every hour for twelve hours during the day,
stopped at night, and repeated in the same way during the second and third days. Bismuth
should be given after the calomel for 3 or 4 weeks. (6) The specific serum treatment is
valuable and should be tried. (7) In sub-acute and chronic cases in the tropics, where good

" Dopter, C. (February 12th, 1908), "Traitement de la Dysenteric Amibienne par la Creosote." £ull. dc la
Soc. Path. Exot.

« Vincent, H. (June, 190G). ricnic d'Hygiine, t. XXVIII, No. 7.

= Billet, A. La Gaducie, August 17th, 1907.

■• Blackham, R. J. (Pebruarv, 1908), "The Treatment of Dvsentery." Journal of the Royal Institute of
Public Health, p. 77, Vol. XXIV."

• Article not consulted in the original.

KEVIEW — ^TROl'ICAL MEDICINE, ETC. 53

nursing is available, lavage is valuable. (8) Any morbid condition of the blood must be Dysentery-
attacked, i.e. malarial infection by quinine and diminished alkalinity by lactate of sodium. cunUmud

For amcebic dysentery, ipecacuanha is stated to be the sovereign remedy. Thirty to
forty grains, presumably with the usual precautions, are administered at first and the dosage
diminished every night. Then castor oil with or without opium is exhibited, very small
doses being given. Finally, simaruba with aromatics and an intestinal antiseptic, such as
salol or salicylate of bismuth, conclude the cure.

Vaillard and Dopter^ report most excellent results with the anti-dysenteric serum
prepared in the Pasteur Institute, Paris. It was found to greatly lessen mortality, to
diminish the severity of the symptoms, and to hasten recovery. They insist on early
administration, the giving of sufficient dosage, regulated by the gravity of the case, judged
by the numbers of stools in the 24 hours and general symptoms of intoxication. In cases of
moderate severity, 20 c.c. suffice. In very severe cases, up to 100 c.c. may be given
repeatedly each day till improvement results.

Sandwith,- in a review of the whole subject, mentions chronic " dysentery carriers," and
the rare occurrence of mixed bacillary and amcebic cases. He details the serum rules
(Shiga) in Japan. These are (1) in mild cases the serum is injected in one dose of 10 c.c;

(2) in cases of average severity, a second time after an interval of from six to ten hours ; and

(3) in severe cases repeated twice daily for two or three days. The serum is derived from
horses repeatedly inoculated subcutaneously with an emulsion of Shiga's bacillus in a normal
saline solution which has been heated to 60° C.

By medical treatment alone, patients recover in 40 days or die on the eleventh
day ; by the serum treatment, they recover in 25 days or death is postponed till the
sixteenth day.

A polyvalent serum is likely to prove the best, there being so many different strains of
dysentery bacilli. Ipecacuanha for amcsbic dysentery was found disappointing in Egypt,
and calomel is not recommended, but the fractional method of dosage is not considered.
The sulphate of magnesium or sodium treatment gave good results in Egypt. Eules for
lavage are mentioned, one pint of fluid increased rapidly to two pints being the quantities
usually employed, and the value of this treatment in certain instances before cases have
become chronic is emphasised.

Castellani^* has tried the opsonic treatment in a case of chronic dysentery with
marked success. The Kruse-Shiga bacillus isolated from the stools was used in the
preparation of the vaccine.

Drake, ^ writing from Assam, reports very favourable results from the administration of
gr. 5 yellow santonin with dr. 2 of olive oil. Unfortunately he does not say what type
of dysentery was present. It is quite possible that it may have been the verminous variety,
which would explain the beneficial action of an anthelmintic drug.

Forster^ has a paper on the vaccine-therapy of dysentery. The vaccine employed
consists of a dead emulsion of B. Shiga in normal salt solution to which 0-5 per cent, of
carbolic acid has been added. The emulsion is prepared from 24-hour agar slope cultures
and is killed by heating to 60°-63° C. in a water bath for twenty minutes.

Stephen" records a case of old-standing dysentery in a British Officer treated with this
vaccine. Perfect cure apparently resulted after three inoculations, although the patient had
previously been practically incapacitated for work during a period of five years.

1 Vaillard and Dopter, C. (April 26th, 1907), " La Serotherapie dans le Traitement de la Dysenterie BaciUaire."
Aim. de I'Inst. Pastcvr, t. XXI.

- Sandwith, P. M. (December 7th, 1907), " Hunterian Lectiu-e on the Treatment of Dysentery." Laiicci,
p. 1589, Vol. II.

3 Castellaui, A. (1907). Arc!ai\ fur Si-Mjls uiul Trap. Hyg., Bd. XL, Heft. 3.

■• Drake, D. J. (November 1st, 1907), "The Treatment of Dysentery by Yellow Santonin." Journal of
Tropical Medicine, p. -3.51, Vol. II.

5 Forster, W. H. C. (June, 1907), " A Preliminary Note on the Application of Vaccine-Therapy to Dysentery."
Indian Medical Gazette, p. 201, Vol. XLII.

« Stephen, L. P. (October, 1907), " Case of Old-Standing Dysentery treated by Vaccine-Ther.ipy." Indian
Medical Gazette, p. 375, Vol. XLII.

* Article not consulted in the original.

64 REVIEW — TROPICAL MEDICINE, ETC.

Dysentery— Gillit^ also describes cases successfully treated at Midnapore Central Jail. The

contimiM mortality before this line of treatment was adopted was 5-9 per cent., since its introduction
only 0-9 per cent. The number of cases recorded is not very large — 140 all told — but there
seems no doubt as to the efficacy of the treatment.

Elephantiasis. Castellani- has used thiosinamin in the form of Merk Fibrolysin
(a water soluble combination of thiosinamin with sodium salicylate) in the palliative
treatment of elephantiasis. After bandaging and massaging of the infected parts the drug is
injected in doses of 2 c.c. every day or every other day for about a month. Then the
fibrolysin is stopped and rubber bandaging or ordinary bandaging again resumed for a week
or ten days. Thereafter another course of thirty or more injections is given, and so on as
required. In suitable cases he believes this treatment may prove useful.

Christophers,^ in a paper entitled " What is really known of the cause of elephantiasis ? "
points out the grounds on which the assumption that it is due to the presence of Filaria
nocturna in the lymphatics is based. He shows that deductions drawn from geographical
relationship and race incidence may be faulty. He also states that we can only say that
presKinably elephantiasis is due to blockage of the lymph channels. One perhaps is on
firmer ground when noting the association of elephantiasis with other diseased conditions,
some of which are undoubtedly due to filaria, such as varicose lymph glands, lymph
scrotum, etc. Doubtless the active inflammation, and even liaBmorrhage produced by the
worms, have more to do with the pathological conditions than the mere presence of
the worms themselves. He lays stress on the difficulty of " explaining how with so complex
a collateral circulation the blocking can ever be so complete as to lead to the terrible
conditions one so frequently sees, and the need for actual and accurate observation on the
disease, especially as regards the blocking of glands by undeveloped embryos and a
consideration of the localisation of the blocking."

Prout* has a long paper on the role of filariae in disease production, dealing, however,
solely with F. loa and F. nocturna. As regards the latter and its relations to elephantiasis,
Prout announces himself a sceptic with reference to Manson's theory, and, especially as
regards localised elephantiasis, is on the look-out for a specific micro-organism, gradually
spreading by the lymphatics from the periphery.

In the discussion'' on this paper its author's views were rather severely criticised.
Low contended that filaria was at least one of the causes of elephantiasis. Carnegie Brown
held that though elephantoid disease was certainly due to filaria, the relation of the latter
to elephantiasis had not been proved. Basset Smith, however, mentioned a case of
apparently recent elephantoid disease in which no filaria were found. Manson discrimi-
nated between tropical and non-tropical forms of elephantiasis and elephantoid disease, and
stated that the filarial doctrine of elephantiasis, which was too readily accepted, was now
threatened with too hasty a rejection. The journal must be consulted for full details.

As regards the Sudan the question of elephantiasis is briefly considered under the
heading " Filariasis " {fage 70).

Enteric Fever. Probably the most valuable recent contribution to our knowledge
of Enteric Fever, from the tropical standpoint, is the work by Eoberts.'" One cannot refer to
it here at any great length, but of special importance to those working in the Sudan are the
conclusions regarding the liability of the native Indian to the disease. Eoberts believes
that the Indian possesses a natural immunity of a two-fold nature. It is in part racial, due
to anatomical differences in the intestine, for, as he points out, both the large and small
intestines in natives are in many instances considerably longer than in Europeans. He cites
a case of a Mohammedan in whom both guts combined totalled 50 feet. Further, the
intestinal walls in natives are thicker and more muscular, and Peyer's patches are not so

' Qillit, W. (January, 1908), "Notes on Porster's Vaccine Treatment of Dysentery." Indian Medical Gazette,
p. 12, Vol. XLHI.

" Castellani, A. (August 1st, 1907), " Note on a Palliative Treatment of Elephantiasis." Journal of Tropical
Medicine and Hygiene, p. 'IM, Vol. X.

^ Christophers, S. R. (November, 1907), "What is really known of the Cause of Elephantiasis?" Indian
Medical Gazette, p. 404.

* Prout, W. T. (April 1st, 1908), " On the R61e of Filaria in the Production of Disease." Journal of Tropical
Medicine and Hygiene, p. 109.

' Discussion on above paper in Journal of Tropical Medicine and Hygiene of June 1st, 1908.

" Roberts, E., " Enteric Fever in India and in other Tropical and Sub-Tropical Regions." Thacker Spink & Co.,
Calcutta, 1906.

REVIEW — TEOPICAL MEDICINE, ETC.

65

much in evidence. The other factors operative are diet, habits, general surroundings and
adaptation of the human organism to the disease causes which are most prevalent.

As regards habit and dietary, he gives an interesting comparative table which in large
measure applies as much to the Sudan as to India, though in towns like Khartoum there is
no doubt that the habits and dietary of certain classes of the natives, and especially the
servant classes, has altered considerably within the past few years, and will continue to do
so as a direct result of increased prosperity, a higher standard of comfort and association
with, and imitation of, Europeans : —

Enteric
Fever —

eonlinued

The Native
Cold and dry.

Bulky and coarse. Much waste.
Vegetable grains. Cereals and pulses ; large

cellulose content. Low proteid and fat content.
Very partially cooked, plain and monotonous

from day to day.
Meals infrequent, twice daUy with long fasts.
Mastication generally good.
The majority eat to live.
Life and work in open air.
Fffical evacuations twice daily, large 10-12 oz. ;

completer by squatting.
Strain on stomach and large bowel.

The European
Hot and fluid.
Concentrated and soluble.
Animal food with high proteid and fat.

Thoroughly cooked and sophisticated.
Very mixed and varied.

Meals frequent, 4 or 5 times a day.

Faulty in extreme.

More often live to eat.

Sedentary, indoor.

Small 5-6 oz. ; constipation rife. Purg-
atives.

Strain on stomach and small intestine.

The influence of these dietaries and habits on toxic putrefactive processes in the
intestine is discussed in a very interesting manner.

As regards the diseases prevalent, the author lays great stress on the liability of the
Indian to dysentery and other bowel complaints apart from enteric fever, and thinks that
the reaction of the tissues against B. dysenterise in its various forms may confer local
immunity against the closely allied B. typhosus. Indeed, when he considers the question
from the bacteriological point of view, he is inclined to favour the theory that B. coli under
favourable conditions may develop in the intestinal canal into the true B. ti/pJwsiis. It
must be admitted that this is a very engaging theory and that one sees cases of what are
probably B. coli infections which very closely resemble early enterics. Indeed, one has felt
that if such cases had not been promptly treated with calomel and appropriate dieting, they
would, in all probability have passed into a condition almost indistinguishable from typhoid
fever. On the other hand, there is no definite proof that this ever occurs, while Eoberts'
views on the rarity of enteric fever in the native Indian are opposed by Eogers,i who finds
that the disease is widely prevalent save in Eastern Bengal and Assam, where there is a
heavy and continued rainfall. Further, he states that the clinical picture in natives is
precisely the same as that in Europeans. Thus, while Eoberts believes that European
troops chiefly obtain infection in the cantonments themselves, owing mainly to faulty
conservancy methods, Eogers maintains that the native bazaars also present foci of infection.
His conclusions are chiefly based on the evidence obtained by the application of the Widal
test, but Roberts' book is so carefully compiled, his reasoning seems so accurate, and his
conclusions are so well supported by statistics from other tropical countries, that there is
much to be said for his attitude on the subject. It is, of course, possible that the native
sufi^ers from a mild and unrecognised form, but, so far as Khartoum goes, I do not think this
is the case, for, if the disease were at all common, the conditions governing our water supply
would assuredly have led to epidemic prevalence amongst the susceptible European
population. This matter, however, will be further discussed under "Sanitary Notes"
(Third Eeport). Eogers- explains the difficulty by pointing out the low incidence of typhoid
amongst persons over the age of 25 years in India. He believes this explains the com-
parative rarity of the disease in the native army and in jails, which, he says, led Eoberts to
conclude that natives of India were relatively immune because the majority of those in the
native army and in jails are over this age. He finds the disease not uncommon in native
children and in the poor Europeans of Calcutta reared under the same conditions as the native.

However, there seems little doubt that the disease, in epidemic form, is rare amongst
natives in India, while in the Sudan I believe it is, so far, rare in any form.

Stock^* believes that enteric fever is a common disease of tropical regions and mentions

' Rogers, L., "Fevers in the Tropics," 1908.

' Rogers, L. (August, 1907), "The Incidence of Typhoid Fever on Civilian Europeans and on Natives in
Calcutta." Indian Medical Gazette, p. 291, Vol. XLII.

^ Stock, P. Q. (January, 1908), "The Etiology of Enteric Fever." Tramvaal Medical Journal.

* Article not consulted in the original.

56

UEVIEW — TKOriCAL MEDICINE, ETC.

Enteric
Fever —

continued

that in South Africa tlio KafBrs suffer from it much more frequently than is supposed and
tend to scatter infection broadcast.

Considerable importance now attaches to the question of typhoid carriers, i.e. persons
who have recovered from the disease but harbour the specific germ in their bodies and are
in a condition to infect those with whom they or their excreta come in contact.

Levy and Kayser''' record the results of the bacteriological examination of the body of
a person who was known to have been a typhoid fever " carrier" during life. The patient,
who was in an asylum, must have harboured bacilli for several years and had re-infected
herself from the gall bladder or bile ducts. She died of typhoid sepsis, but during life the
bacilli were present in her stools and she had undoubtedly been the cause of several small
epidemics.

Kayser had previously recorded two cases in 1906, one in the person of a female baker
who infected every new employee at the bakery which she owned, and the other in a female
engaged in the milk trade, who was apparently responsible for the outbreak of an epidemic
due to infected milk in which 17 cases were involved with two fatalities.

These and other instances are referred to by A. Ledingham and T. C. S. Ledingham- in
a paper dealing with cases of enteric fever which kept cropping up in a Scottish lunatic
asylum and which were traced to the pi-esence of three typical typhoid carriers. They state
that the bacilli probably vegetate in the gall bladder, from which they are intermittently-
ejected into the intestine, and make it clear that anyone found to be a typhoid carrier
should be kept constantly under bacteriological supervision. They also suggest that
possibly many typhoid epidemics would be avoided if the excreta of recovered typhoid cases
(especially female cases) were examined systematically (say once a month) up to six months
after recovery. A point they mention which is worth noting is that typhoid stools
submitted for bacteriological examination should on no account be mixed with urine, as the
latter markedly inhibits the growth of intestinal organisms on the plate. They also give a
useful bibliographical table.

In the Lancet for January 23rd, 1908, allusion is made to an outbreak in a Home for
Inebriates, which was also traced to a typhoid carrier, and mention is made of Dudgeon and
Gray's work, which resulted in the finding of typhoid bacilli in bone lesions 3J years after
an outbreak of enteric fever.

Dean^ has drawn attention to the case of a typhoid carrier of twenty-nine years'
standing, and details the bacteriolgical method he employed in recovering B. typhosus from
the stools. A general review of the subject will be found in the copy of the journal in
which Dean's paper occurs.

Forster,''* impressed by these discoveries, has put forward a new theory as regards the
pathogenesis of typhoid. Because the bacillus is regularly found in the gall bladder during,
and often for a long time after, the disease, because it is usually not found in the faeces in
the early stages, while Conradi has found it in the blood during the incubation period, and
because if one injects typhoid bacilli into the circulation of animals they are excreted into
the bile, Forster concludes that the bacilli taken into the stomach and intestines with food
and drink do not multiply there but pass into the circulation from which they are excreted
into the liver and bile. He believes the bacilli which appear in the stools after the end of
the first week of the fever are derived from this source and from the intestinal ulcers.

The same is more or less true of paratyphoid infections. The occurrence of " carriers "
is explained by the fact that bile plus proteid matter (say inflammatory products) constitutes
a good medium for the B. tijphosns. Most enteric patients cease to be carriers after two to
six weeks, but about 2 per cent, go on excreting bacilli for several or even many (20 or
more) years. The majority of these are women, females being more liable to diseases of
the gall bladder than men.

As showing the great hygienic importance of these carriers, Forster presents some very
interesting statistics. Of 386 cases investigated, 77 (20 per cent.) were due to infection

1 Levy, E., and Kayser, H. (December 11th, 1906). Miiiich Med. Ifoch.

» Ledingham, A., and Ledingham, T. C. S. (January 4th, 1908), " Typhoid Carriers." Brituih Medical
Journal, p. 15.

= Dean, Q. (March 7th, 1908), " A Typhoid Carrier of Twenty-nine Years' Standing." Lancd, Vol. 1.

* Forster, J. MUnch. Med. Woch., 1908, No. 1, p. 1.

• Article not consulted in the original.

REVIEW — TROPICAL MEDICINE, ETC. 57

from " carriers," 117 (30 per cent.) to contact infection, 45 (12 per cent.) were indefinite, Enteric

and the remainder due to food or water infection. Gall bladder symptoms should be Fever-
looked for in persons who have recovered from enteric fever, and if the stools are to be continued
examined it is well to previously administer a laxative or cholagogue.

Preventive measures are very difficult. Strict cleanliness and the regular employment
of disinfectants are indicated. Cholagogues, intestinal antiseptics, the introduction of lactic
acid bacilli and anti-typhoid immunisation have all been used in order to try and dislodge
the bacilli, but in vain. Some obstinate cases have apparently been cured by cholecystotomy
or cholecystectomy. (Dehler).

For much interesting information regarding carrier cases and the etiology of the
disease, the reader may be referred to the papers^ read at a recent discussion on typhoid
fever. One of these, by Hamer, puts forward his bold and heterodox views regarding the
etiological role of i?. typhosus. He does not think this organism necessary for the production
of typhoid fever, but his ingenious arguments do not appear to have convinced many of his
hearers.

One may next pass in review the several recently devised methods for facilitating the
diagnosis of enteric fever.

These may be classed as : (a) clinical, (b) bacteriological. The former may be
divided into the ophthalmo-reaction test and the observance of certain special symptoms,
the latter into the agglutination test, the blood culture test and the recovery by new, special
methods of the specific organism from the stools or urine.

After the introduction of the ophthalmo-diagnostic method for the diagnosis of
tuberculosis, it occurred to Chantemesse-* to try a like reaction in the case of enteric fever.
He killed cultures of B. fi/phosus by heating them ; dried, powdered, and emulsified them
in water. This emulsion was sedimented and eentrifugalised till it was only slightly
opalescent, and an active principle (a soluble toxin) was then obtained by precipitation with
absolute alcohol. This precipitate is dried and keeps well. 1/oOth of a milligramme of
this powder is the dose, and it is used in solution, being instilled into the conjunctival sac of
the patient. If the latter has enteric fever and gives the Widal test, an inflammatory reaction
occurs which lasts for several days. Positive results were obtained in 63 cases of enteric
fever and negative results in 50 patients who were not suffering from typhoid and did not
give the Widal test. If rabbits be inoculated subcutaneously with typhoid bacilli and then
after 48 hours tested in this way, they are found to give the reaction while healthy rabbits
yield negative results.

Philipowicz's sign is regarded by Eegis'* as pathognomonic. It consists of a more or
less definite yellow coloration of the palms and soles. It is said to be most common in
children, less so in women and least of all in men. It commonly appears during the first
week, vanishes when convalescence is established, but reappears if a relapse occurs. The
same author mentions Bernard's sign, which consists in the presence of two or three small
swellings, varying in size from a filbert to an almond, and to be made out by careful
palpation in the right iliac fossa. They are believed to be due to swollen Peyer's patches
in the lowest part of the ileum, lie parallel to the long axis of the colon, and are from a half
to one inch distant from each other.

EoUeston^* has drawn attention to the value of the condition of the abdominal reflex
as a diagnostic and also as a prognostic sign. He says : —

1. The .ibdominal reflex is affected in a very large number of cases of enteric fever, the percentage of
cases in which it is entirely lost exceeding those in which its normal activity is only diminished.

2. From its absence under the age of fifty being confined to certain nervous disease and acute abdominal
conditions, notably appendicitis and enteric fever, the absence of the abdominal reflex in a given case of coutinued
pyrexia in any patient below fifty is of considerable value.

3. The comparatively transient nature of the affection of the abdominal reflex in enteric fever is a striking
contrast to the more chronic affection of the knee and ankle-joints in diseases associated with peripheral neuritis,
e.g. diphtheria.

4. Return of a lost reflex, and, a fortiori, resumption of its normal activity, are a valuable indication of
commencing convalescence, and often correspond with lysis and characteristic changes in the fseces and urine.

' Procecdimjs of Royal Society of Medicine (April, 1908), Epid. Section, Vol. I., No. 6, p. 169.
= Chantemesse. Deutsche Med. JVoch., No. 39, and Bull Acad. Midecine, July 23rd, 1907.
' Regis, L. (July 4th, 1906). Medical Press.
* Rolleston, J. D. Brain, 1906, p. 99.

* Article not consulted in the original.

58 REVIEW — TROPICAL MEDICINE, ETC.

Enteric 5. The objective sign of return of the reflex is often associated with the return of the subjective feeling of

Pever ticklishness normal to the individual.

continual *^- -^'^ reappearance of pyrexia in convalescence, the condition of the abdominal reflex is a valuable index

of the nature of the pyrexia. (That is to say, its disiippearauce or its becoming sluggish would point to a relapse.)

7. No constant relation exists between the condition of the abdominal reflex and that of the tendon
reflexes.

8. The frequency, degree and duration of impairment of the abdominal reflex are, aa a rule, in direct
proportion to the age of the patient.

Another clinical aid is the recognition of leucopaenia. Horderi records a case in which
the bacilli were demonstrated in the blood in the absence of the Widal test and where there
was a marked leucopaenia, the white cells numbering 1400 only. Here the leucopajnia
suggested enteric fever and the further examination which led to the diagnosis being
established. Gennari'-* has specially investigated this subject. He concludes that in the
early stage of typhoid, leucopaenia, if present, is a valuable aid to diagnosis, and all the more
so because at the beginning the Widal reaction is often negative. Leucop<Bnia may be met
witli in miliary tuberculosis, but it is rarer in these cases. If any complications occur in
the course of the typhoid a comparative leucocytosis may ensue, but apart from this,
leucopaenia or a normal leucocyte count is the rule. Leucopaenia seems more often present
in bad cases. In 55 of Gennari's 106 cases the differential leucocyte count showed no
departure from the normal in 19, while in 36 there was diminution of the polynucleated
cells, increase of the lymphocytes, absence of eosinophils cells and increase in the
mononuclears.

Passing now to bacteriological methods, we find the value of Ficker's modification of
Widal's test mentioned^ in an article taken from a Berlin medical paper. While it is quite
reliable and very convenient, it has the disadvantage that the reaction is useless in the early
stages of the fever and is not obtained much before the end of the second week of the disease.

Numerous papers testify to the value and usefulness of the Widal test, although the
discovery of the paratyphoid fevers has, to some extent, interfered with it. Eogers'' devotes
a page to this subject. He regards complete reactions up to 1 in 100 by the microscopical
method, with a time limit of one hour as almost absolute evidence of an actual attack of
typhoid or immediate convalescence from one. Such reactions are exceptional in the first
week of the disease, and only found by a single examination at later dates in three-fifths to
two-thirds of the cases. Reactions in lower dilutions are highly suggestive and should lead
to further testing after a few days have elapsed, while any case at all resembling typhoid in
which a negative reaction is got should also be re-tested in five to seven days' time. It
must also be borne in mind that repeated negative reactions throughout may he obtained iii
luidouhted and often very severe typhoid, so that when clinically there are any good reasons for
looking on a case as one of typhoid, a negative Widal should be allowed little or no weight
against the clinical diagnosis. Where it is most valuable is in enabling very mild and
abortive cases to be recognised and properly treated, and preventive measures against the
spread of the disease being taken, but it still remains only an additional aid in forming a
diagnosis, which in the majority of cases can be usually made from a study of the
temj)erature curve, pulse rate and other clinical characters before a reliable Widal reaction
can be obtained. This is an excellent precis of the case, and in the Sudan one has met
with the exceptional cases mentioned. Eogers' technique for the Widal test can also be
recommended, and one has adopted it in preference to Eostoski's method previously
employed. The latter author'' discusses the conditions other than enteric which are apt to
give the Widal reaction. Chief amongst these is jaundice, and hence it may be found
present in Weil's disease. A case of puerperal fever has also been known to give a
positive Widal, while proteus and staphylococci can give rise to an agglutinin acting on
typhoid bacilli. Direct culture from the blood has come to the fore of late.

Castellani" describes his so-called " dilution method," which consists in adding small
quantities (a few c.c.) of blood to comparatively large quantities (300 c.c.) of faintly

» Horder, T. J. (January 19th, 1907), "A Case of Typhoid Fever Diagnosed by Blood Culture in the
Absence of the Agglutination Reaction." Lancet, p. 168, Vol. I.

« Gennari, C, Ref. Med. (March 16th, 1907). Quoted in Epit., British Medical Journal of June 15th, 1907.
= November, 1906, "The Diagnosis of Typhoid by Ficker's Test." British Medical Journal, p. 451, Vol. II.
■• Rogers, L., "Fevers in the Tropics." London, 1908.
' Rostoski, " Manual of Serum Diagnosis," Translated by Bolduan, 1904.

" Castellani, A. (May 5th, 1906), " Early Diagnosis of Typhoid Fever." British Medical Journal, p. 1071,
Vol. I.

* Article not consulted in the original.

REVIEW — TROPICAL MEDICINE, ETC. 59

alkaline beef broth or peptone water, incubating at 37° C. and sub-cultivating the organisms Enteric
which develop. The novelty of the method lies in the great dilution of the blood. Fever—

Conradi'* introduced the bile method, now generally employed. He took the blood continual

from the ear in a capillary pipette containing a little fluid. The liquid is then transferred
into a small glass tube containing 2 c.c. to 3 c.c. of a peptone glycerin mixture (10 per ceut.
peptone and 10 per cent, glycerin with ox bile), and this process of transference is continued
till the ear ceases to bleed. Proportion of blood to the bile mixture is 1 to 3. The tube
containing the blood and bile mixture is then incubated at 37° C. for ten to sixteen hours,
and cultures finally made on Drigalski-Conradi agar plates. The diagnosis is usually
established in from 26 to 32 hours.

Meyerstein-* uses the active bile constituents, the biliary acids, as his medium for
increasing the number of bacilli present in the blood. The substance can be prepared by
a simple method, and the results are said to be more quickly obtained and to be more reliable
than those given by the Widal test.

It has also been found that typhoid bacilli can be cultivated from the blood-clot of
specimens sent for a Widal reaction (Muller and Graff'*), and this has been confirmed,
good results being got by spreading the clot on an Endo or Drigalski plate. It would seem
that the colonies cannot be obtained from the serum.

A better and simpler way is to put the clot into a tube containing 5 c.c. of fresh ox bile
which has been sterilised in a steam oven or by boiling in water; the tube, after cooling,
being plugged with wool as usual. Incubate clot and bile for a night at 37° C. and plate
out as mentioned. The bile is said to dissolve the blood and set free the organisms. This
method is likely to be useful in the Sudan where blood is often sent from a distance and
sometimes arrives in such a condition that it is difficult to obtain sufficient serum for the
ordinary Widal test.

Zeidler^ records his results with the bile method, using 30 drops of blood to 5 c.c. of
sterilised ox bile, incubating at 37° C. and plating out on agar or the malachite agar
of Loeftler. He concludes that from the fourth day of the fever onwards, both in mild and
severe cases, the presence of the specific bacillus in the blood can be demonstrated, and that
this method is superior to all others, being the most certain, the most speedy and, when
positive, absolutely reliable, while it is at least as simple as the Widal test.

Coleman and Bunton'* employ a mixture of ox bile 90 c.c, glycerin 10 c.c, and
peptone 2 grammes. This is distributed into small flasks, 20 c.c. in each, and sterilised.
Three flasks are used for each examination, about 3 c.c. of blood being run into each.
The flasks are incubated, and next morning streaks from each are made over the surface of
a litmus-lactose-agar plate. The authors believe that B. typhosus is present in the blood in
every case of typhoid fever, and that failure to recover it is due to error in technique.
The bacilli seem to disappear about the time the temperature falls. They are found equally
in the blood, but not with the same persistence in the mild as in the severe cases. To
produce typhoid fever it seems necessary that the bacillus must not only be present in the
body and growing, but that it should be in a situation whence it has free access to the
blood. The bacillaemia does not constitute a true septicaemia, but represents an overflow
of bacilli from the lymphopoietic organs.

Although I have not seen it advocated, save by its author, and have had no personal

experience of it, mention may be made of Poeppelmann's^* method. After cleaning the
finger and pricking it with a sterilised needle, a large drop of blood is squeezed out on a
clean slide. Portions of this are transferred to, and spread out on, other slides previously
cleaned with alcohol and ether and sterilised. After the films have dried, the slides are
placed in E. May-Griinwald solution.

This fixes and stains at the same time and within 2 to 6 minutes. Wash in distilled
water for about one minute and dry rapidly before a fire or between blotting paper. The

» Conradi, H. (January 11th, 1906). Deut. Med. Woch.

2 Meyerstein, W. Miinch. Med. Woch., 1908.

= Muller and Graff, H. Munch. Med. Woch., 1906, No. 2.

* Zeidler, Q. (August 20th, 1907), " Zur Prage der Typhusanreicherung mittels der Qallenkultur."
Cent. f. Bakt. I. Oriij., Bd. XLIV.

° Coleman, H., and Bunton (June, 1907). American Journal of Medical Science. Quoted in Epit. British
Medical Journal, April 25th, 1908, p. 68.

° Poeppelmann, P. W. Deut. Med. Woch., 14th June, 1906, quoted in Epit. British Medical Journal,
December 1st, 1906.

• Article not consulted in the original.

60 REVIEW — TKOPICAL MEDICINE, ETC.

Enteric examination is made under liigli powers (1000 diams.). The bacilli are coloured blue, but in

Fever— their case the stain varies in intensity. Failure to stain may be due to disintegration.

continued Very large numbers may be found. The sources of error are discussed and are to be avoided

by scrupulous cleanliness, filtering the stain, taking care not to decolorise for more than

one minute in water and to dry rapidly.

Still dealing with the bacteriological diagnosis, we come to the methods in vogue for
isolating B. typhomtt: from the urine and faeces. These are very numerous and in many cases
complicated, so that brief reference to some of the more recent must suffice.

Lceffler'* now recommends a special medium containing nutrose 1 per cent., peptone
2 per cent., glucose 1 per cent., chemically pure malachite green 1 per cent, of a 2 per cent,
solution, and normal salt 1-5 per cent. In this mixture B. tijpho>ius produces a true
coagulation, the whole mass becoming solid save for a clear green liquid comparable to the
whey of clotted milk. The appearance with B. coli is quite different, owing to the
fermentation of the sugar and production of gas. The presence of malachite green is not
essential. It merely hastens the reaction.

It was Lceffler who discovered that malachite green added to nutrient gelatin or agar
inhibited the growth of B. coli but not that of B. typhosus. On such plates, however, only
colonies in proportion to the bacilli actually present in the material examined can develop.
The number of such, as in shell-fish, water, milk, etc., may be very limited, hence
Klein- has devised a true "enrichment" process. He used for this purpose fluid media
to which bile salt was added, making indeed a malachite green bile salt broth. He
records good results with this medium, and the method of preparation will be found
detailed in his paper.

The method of Lentz and Tietz may be described. They crush up the stool in an equal
quantity of 0-8 per cent. NaCl solution and filate out on the surface of a malachite green
plate (malachite green No. 1, Hochst, 1 to 6000 of agar). Incubate for 24 hours at 37° C.
If no colonies of B. typhosus be found, suspend the surface growth of the plate in about
8 c.c. to 10 c.c. of broth, and inoculate from the uppermost layer of this broth, which has
been allowed to stand for some time in the plate which is sloped.

Eivas^* believes that the frequent failure in detecting B. typhosus in infected water
supplies is largely due to faulty laboratory technique. He shows that litmus, Parietti's
solution, Drigalski-Conradi medium, the Endo medium and others, have actually a germicidal
effect upon the bacillus whatever their value may be as means of differentiation.

The viability of B. typhosus in sterilised and unsterilised soils has recently been
investigated by Mair,'* who finds that : —

1. The typhoid bacillus can survive in natural soil in large numbers for about 20 days and is still present in
a living condition after 70 to 80 days.

2. There is no evidence that the typhoid bacillus is capable of multiplying and leading a saprophytic
existence in ordinary soil.

3. In some samples of soil, but not in all, the typhoid bacillus dies out much more rapidly (in 11 days) if the
soil has previously been subjected to sterilisation Ijy steam under pressure. This is apparently due to the
production of bactericidal substances during sterilisation.

Enteric fever has of late received special consideration from a military standpoint.

Harrison"' has dealt with the preponderating importance of dust, flies, and personal
infection in hot countries, the difficulties of enforcing suitable conservancy methods and, as
a result, the necessity for the exclusion of typhoid carriers from a force when it takes the
field and the necessity for general anti-typhoid inoculation. He also advocates special
depots for typhoid convalescents.

Davies" has an important paper on direct contagion, that is to say, personal infection.
He admits that it may play an important part in the spread of the disease, and tabulates a

' Lceffler, F., " Zum Nachweise und Zur Differenzial-diagnose der Typhusbacillen mittels der
Malachitgrun nahrboden." Deal. Med. Wocli., No. 39, 1907.

■- Klein, E. (November 30th, 1907), " A Contribution to the Bacteriological Analysis of Materials Polluted
with the Bacillus Typhosus." Lancet, p. 1519.

= Rivas, D. (1908). Quoted in Lancet, June 27th, 1908.

* Mail, W. (January, 1908), "Experiments on the Survival of B. 'I'liphosm in Sterilised and Unsterilised
Soil." Journal of Hygiene, p. 37, Vol. VIII.

» Harrison, W. S. (November 23rd, 1907), " Enteric Fever in War." Lancet, p. 1463, Vol. II.

« Davies, A. M. (August 31st, 1907), " Enteric Fever, its Spread by Personal Infection, .ind Preventive
Measures on Active Service." British Medical Journal, p. 505.

• Article not consulted in the original.

BBVIEW — TROPICAL MEDICINE, ETC. 61

lengthy list of thorough preventive or protective measures. Most of these are the same as Enteric

those laid down for any dangerous, infectious disease. We specially note that all remains Fever—

of food supplied to patients, and not consumed, should be destroyed, that everything which continued

enters an enteric ward, books, journals, even empty soda-water bottles, should be regarded

as infective and treated accordingly, that all utensils and apparatus for use in enteric cases

should be kept separate and apart and specially marked, and that nursing attendants should

be specially detailed, fed and housed apart, and, while not absolutely isolated, should wash

and change their clothing before associating with the rest of the staff.

Eules are given for the procedure to be followed on admission of a case to hospital
(disinfection of kit, bedding, etc.), when convalescence is established (use of urotropine,
examination of the stools, etc.), also in slight cases apt to be unrecognised (provision of
quarantine or segregation camps, etc.). The piaper then goes on to deal with enteric under
active service conditions, and, while space forbids further quotations, it may safely be said that
it is well worth the perusal of all in medical charge of troops and those responsible for the
health of men in camps, as for example the camps of the Survey Department in the Sudan.

Another useful paper on the same lines is that of Caldwell. ^ He recommends shallow
and narrow latrine trenches 1 foot in depth and 1 foot in breadth, and the direction that
men should straddle across these to prevent fouling of their edges. Straton, whom he
quotes, advocates the use of a 2 per cent, solution of crude carbolic acid in latrine buckets
to keep away the flies.

Statham,-* dealing with etiology, mentions that there are a number of allied but distinct
species of bacteria, which may produce disease indistinguishable from typhoid fever, and
tliat most of the varieties of bacteria composing the typhoid colon group, are found in
apparently healthy animals, while many diseases amongst domestic and other animals are
caused by bacteria which may produce typhoid in man. He also refers to the fact that
typhoid has been induced in human beings by eating the improperly cooked flesh of such
diseased animals.

As regards anti-typhoid inoculation, Leishman^ describes the preparation of the new
modified vaccine. The bacilli are only subjected to 53° C, the minimum temperature which
ensures their death within one hour. The results with this vaccine have been most encouraging.
In one regiment out of a strength of 509, 147 were inoculated. Sixty-two cases of enteric
with eleven deaths occurred, all amongst the uninoculated with the exception of two, both
being men who had refused the second inoculation ; both of these men recovered.

This author^ also records the utterances of Chantemesse as regards the remarkable
results obtained by the use of his curative serum. Chantemesse stated that he had never
lost a patient in whom the treatment was commenced during the first seven days of the
disease. Especially noticeable is the fact that the spleen appreciably enlarges after the
serum injections — Chantemesse attributes to this an important part in the origination of
the beneficial changes which are found in the blood itself (leucocytosis, increase of
mononuclears, rapid reappearance of eosinophiles).

With reference to treatment, perhaps the most suggestive of recent papers is that by
Young-' on the dietetic management of cases. After prolonged trial he has entirely
disregarded the " antiseptic " method of treatment in all its forms, being convinced that
when diarrhoja (or tympanites) occurs the only true remedy is a careful revision of the dietary.
In a properly dieted case these troublesome symptoms should not arise, for the diet should
fulfil the following requirements : —

1. It must be such that no solid residue, and certainly none of the least irritating character, enters that part
of the tcstiual tract where the local lesions are situ.ated.

2. It must be such that fermentation of such a kind as to generate flatus does not take place.

3. Inasmuch as the whole of the digestive functions are below par, it must be one which is readily digested
and assimilated.

4. It must be such that the various tissues are provided with proper material for the renewal of that waste
of substance and vitality common to all prolonged fevers, and especially such pyrexial conditions as are
accompanied by the circulation of toxins.

' Caldwell, R. (August 31st, 1907), " On Enteric Fever during Active Service." British MedicalJournal, p. 513.

= Statham, J. C. B. (January, 1908), "The Complex Nature of Typhoid Etiology, etc." Transvaal Medical
Joitrnal.

' Leishman, W .B. (March, 1908), " The International Congress of Hygiene, Berlin." Journal of the Royal
Army Medical Corps, Vol. X., No. 3, p. 247.

" Leishman, W. B. (March 23rd, 1907), "Anti-typhoid Inocul.ation in the Army." Lancet, p. 806.

^ Young, M. (September, 1906), "The Dietetic Treatment of Enteric Fever." Public Health, p. G8G.

• Article not consulted in the original.

62 REVIEW — TKOPICAL MEDICINE, ETC.

Enteric In a properly dieted case constipation takes the place of diarrhosa, but this tendency

Fever— can be corrected by the use of sanatogen. Young mentions a list of foods devised to satisfy

coidimud the cravings of the enteric patients for an ampler dietary : —

1. Benger's and Mellin's foods, made with or without milk and fortified with cream, are of temporary value.
So are Jellies, bread crumbs, isinglass or rusks in beef-tea, and light puddings.

2. Bread jelly made by thoroughly soaking stale bread, pressing out the water and allowing the pulp to
simmer gently for one or two hours. Strain through muslin and allow filtrate to set. Two tablespoonfuls of the
jelly suffice for one feed.

3. Baw meat pulp carefully prepared and given in the form of little balls to be eaten with a rusk.

4. Junket made in the usual way and given if desired with cream or brandy.

5. Suet puddings, given after the temperature has been normal for a few days. The suet must be shredded
in thin slices and all the fibre removed. Wheat flour with an equal quantity of maize should be used. The
latter contains little gluten. Cook well and serve with sweet sauce or gravy.

6. Fish, best in the form of whiting.

7. Modified milk diets. Swithinbank and Newman's rules for boiling milk to prevent alteration in flavour
and formation of scum are given.

(i.) Use an ordinary double milk pan, or a smaller covered saucepan containing the milk placed inside a
larger one containing the water.

(ii.) Let the water in the outer pan be cold when placed on the fire.

(iii.) Bring the water iip to the boiling point, and maintain it at this for 3 or 4 minutes without removing
the lid of the inner milk pan.

(iv.) Cool the milk down quickly by placing the inner pan in one or two changes of cold water without
removing the lid.

(v.) When cooled down, aerate the milk by stirring well with a spoon.

Young now uses boiled milk with sanatogen added to it (2 grammes, i.e. 31 grains to
the pint). He also permits the addition of cocoa, coffee and tea to the milk. Other points
he notes are that cream added to soup or beef-tea improves the flavour and adds to the
food value, that sound oysters are useful, that glucose added to beef tea (one teaspoonful
to about 10 oz.) is valuable, and, quoting Harbin, that gelatin adds relish, lessens the
nitrogenous waste and prevents haemorrhage. Its food value, however, is nil.

Young also deals with the question of drinks, and describes the preparation of a very
cooling beverage made from apples. He notes that ulti-amarine is found in sugar, and mica
in barley, and therefore thinks that in preparing food and drinks it is wise to make a
solution of the sugar first, allow this to settle for 6 hours and decant all except the bottom
portion. The latter contains the ultramarine, which chiefly consists of silica, alumina and
soda. In making barley water the barley must be well and frequently washed beforehand.

For the treatment of marasmus he speaks very highly of sanatogen, which is said to be a
combination of pure casein and glycerophosphate of sodium. The large quantity of organic
phosphorus is said to make it of value as a metabolic stimulant.

I have known a case in the Sudan in which milk was not well tolerated and sanatogen
was used with success, but otherwise I do not know that typhoid cases require any special
treatment, dietetic or otherwise, in a hot country, beyond such as may lessen the tendency
to hyperpyrexia. Rogers believes this is best done by the cold pack treatment.

Ewart,' quoted by Young, advocates the Empty Bowel Treatment, or " plenty of food
and no faeces." He gives peptonised milk, white of egg diffused in whey before peptonising,
yellow of one egg a day, saccharin, lactose or a non-fermentable form of glucose, clarified
honey, maltine, oil or cream, one ounce a day, common salt 10 to 15 grains to every half-pint
of whey, watery extracts of vegetables, the juice of various fruits.

Young has modified this, giving the whey with cream and sanatogen. Of this
prepared whey he administers 2^ to 4 pints in the 24 hours. It is easily prepared, easily
digested, easily assimilated, and is declared to be a simple and perfect diet for the early
stages of enteric fever.

Faeces. Nothing is more important in the diagnosis of disease in tropical countries
than the examination of the faeces. This is specially true of the Sudan, a country in close
proximity to and having much intercourse with Egypt, where, as is well known, metazoan
parasites play no small part in the pathological field. There can be little doubt that in the

Ewart, W. (December 19th, 1905), "The Treatment of Typhoid Fever." British Medical Journal, p. 1720,
Vol. II.

BEVIEW — TBOPICAL MEDICINE, ETC. 63

majority of cases an examination of the faeces should be a matter of routine procedure. Faeces-
Judging from the small amount of this class of work which falls to the share of the continued
laboratories, these examinations are not frequently made in medical practice in Khartoum.
Such work is disagreeable, especially in a hot country, and it has to be quickly conducted to
be of value. Still I am very certain that a systematic examination of stools would well
repay the time spent upon it, both as an aid to diagnosis and to amplify our knowledge of
intestinal parasites and various bowel affections.

Anyhow, some notes on the examination of faeces, a subject which has shared in the
recent and general advance of medical knowledge, cannot fail to be useful.

Baumstark^ points out that in order to properly test the capabilities of the intestine
a special diet must be adhered to and it must fulfil certain requirements. These need
not be tabulated here, for it is more to the point to quote from the notes dealing with
the macroscopic, microscopic and chemical methods : —

The Macroscopic is the most important and determines the consistency, colour and smell of the faeces.
The motion is thoroughly stirred with a wooden spatula and a quantity of the size of a walnut is put in
a grater and ground down with a glass pestle, with a gradual addition of distilled water, to an absolutely fluid
mass. When no more solid parts exist pour it on a large black plate. With normal intestinal action nothing
but macroscopically recognisable remnants of cellular particles (rusk, gruel, cocoa) of the test diet should be
found in the faeces. The following are of importance as pathological food remnants.

1. The remnants of the connective tissue and tendons from the minced meat which has been consumed ; and
these, owing to their light yellow colour, their fibrous form, and their firm consistency, can be recognised and
most easily distinguished from mucus. Where any doubt exists, a small filament can be treated with a drop of
acetic acid ; in the case of connective tissue the filamentous structure vanishes ; in the case of mucus it only then
becomes visible. Quite isolated, small, sinewy filaments are to be found sometimes with quite normal digestions,
but when in a great quantity they are always pathological.

2. Remnants of muscle which look like very small, brown-coloured splinters of wood. They are soft,
become smaller when pressed, and disclose under the microscope muscle structure. In many cases connective
tissue and remnants of muscle are to be met with in the same stool.

3. Remnants of potato, sago and similar transparent grain, which are frequently mistaken for mucus but which
can be distinguished by their globular form and their hard consistency ; they stand out above the level of the
thin, spread out layer of the fieces. Under the microscope the potato cells appear to be either empty or filled
with bluish (stained with iodine) coloured grains of starch.

The Microscopic Examination. — This is chiefly useful for the verification of the results obtained by the
macroscopic examination ; for example, in the differential diagnosis of connective tissue and mucus shreds. Three
microscopic preparations are made, distilled water being added when the ground-np faeces are too hard. The first
is simply a small particle placed on a slide and pressed by the cover glass into a thin layer. The second is rubbed
up with a little drop of 30 per cent, acetic acid solution and held over a flame until it begins to boil ; the third is
rubbed up with a little drop of a strong solution of iodine in iodide of potassium (iodide 1, iodide of potassium 2,
distilled water 50), and covered.

Under normal intestinal conditions the following should be observed in the preparations. 1. Preparation
without addition — muscular fibres (flake-like formations coloured yellow and rounded at the edges with indications
here and there of transverse striae), some scattered small and larger yellow lime salts, light and dark yellow flakes
consisting of sebates of lime, uncoloured (unstained) soaps, single potato cells empty, sparse remnants of chaff
from gruel, and remnants of cocoa where cocoa was given instead of milk. 2. In the second preparation, when it
is placed under the niicroscope whilst still hot, the larger lime salts and soap flakes are melted to neutral fat drops
which, after they are cold, become solidified into small sebacic acid flakes. 3. In the third preparation, which is
brown-coloured from the iodine, the potato cells now violet (but not blue) and sometimes violet-coloured sporules
(Clostridium hutyricum) are met with.

Pathologically the following may be observed in the three preparations. In No. 1 broken pieces of muscle
tissue in larger number with more clearly defined transverse striae and sharp edges, neutral fat drops, sebacic acid,
and soap needles in such quantity that they form the largest part of the preparation, and an abundant quantity of
potato cells with more or less well-preserved grains of starch. In cold acetic acid preparations there are
pathologically such a number of sebacic acid flocculi that all of the other component parts are in the minority.
In the iodine preparation are bluish-coloured potato cells, as also scattered remnants of grains of starch, blue or
violet sporules or bacterial flora, and oat colls which are yellow-coloured from the iodine.

One need not here detail the rather complicated chemical examination, but proceed to
the author's consideration of the presence of mucus in the faeces : —

In many cases of sluggish motion without there being any symptoms of inflammation, a thin mucous coating
of the faeces will be observed which causes the hard scybala to appear as if varnished. Many authorities do not
regard this as arising from inflammation, but look upon it as ejected secretion. But where mucous shreds are seen
constantly deposited externally on the scybala and also mixed with them during a lengthy period of observation,
the existence of an inflammatory alteration of the mucous membrane may be inferred. The smaller the mucous
particles are and the more they are mixed with the faeces so much higher is the part of the intestine from which
they proceed. Their descent from the small intestine can only be assumed if the faeces are liquid and if the
mucous flocculi are quite small and contain half-digested cells — that is to say, kernels of cells in their characteristic

' Baumstark, E. (June IGth, 1906), "Examination of the Faeces." Lajiccl, p. 1683, Vol. I.

64 KEVIEW — TROPICAL MEDICINE, ETC.

Paeces — arrangement. The larger the number of Riioh cells the higher the degree of inflammation. The Inlirubin colouring

contiiiuc<l '"fitter in the sublimate test and the presence of l)ilirul)in crystals in the microscopical examination strengthen
the assumption of the mucus originating from the small intestine.

The diagnostic conclusions to be drawn from the foregoing observations are as follows. The presence of
connective-tissue remnants in the test-diet stools points with certainty to a disorder of the digestion, as only the
gastric juice is able to dissolve raw connective tissue — i.e. from the centre and not from the well-cooked part of
the meat. Achylia or hypochylia would usually be accountable for such a condition. Excessive peristalsis
perhaps also plays an important part in some of these cases. Again, in excessive acidity associated with insuilicient
pepsine secretion (cases which not infrequently occur) the raw tissue meets with unfavourable conditions and
appears again in the stools. A very minute examination of the stomach should be carried out in these circum-
stances. If muscle remnants are found macroscopically, or even in considerable amount microscopically,
disturbance of the digestion in the small intestine may be inferred, for the stomach plays only an unimportant
part in the dissolving of meat fibre and the digestion of meat does not take place in the colon. With both
connective-tissue and muscle remnants in the stools it may be concluded that both stomach and small intestine
arc deranged.

With regard to the digestion of fat, it is to be observed that slighter variations in the fatty contents of the
normal stool have no diagnostic meaning, for every stool contains fat in the normal faeces to the extent of 23 per
cent, of the dry substance. A morbid increase of the fatty contents is proved at the macroscopic examination by
the clayey quality of the light-coloured, nearly white faeces, by the very sour reaction, by the copious quantity of
the faeces, and by their filmy appearance when rubbed up. Microscopical increase of the sebacic acid flocculi in
the cold acetic acid preparation and neutral fat drops and salts of lime and soap crystals in a native preparation
confirm the diagnosis. If the sublimate test show a complete absence of bile in the stools together with an
increase of the fatty contents (in which case icterus also occurs), the cause of the disease is to be sought for in the
biliary duct system. If, however, in conjunction with the increase of the fat contents (especially in the form of
neutral fat drops in the native preparation) , there are signs of muscle tissue simultaneously with the presence of
hydrobilirubin and absence of mucus, then the pancreas is the seat of the disease.

In rare cases, where biliary deficiencies and pancreatic diseases are excluded, severe forms of intestinal
disease, such as tuberculosis, amyloid disease, or tabes mesenterica, may be the cause of the derangement of fat
absorption. The digestion of albumin is then likewise disturbed, and, as a rule, prior to the impairment of fat
absorption. Moreover, purely functional disturbances of absorption limited to fats are sometimes observed. The
simultaneous appearance, however, of mucus and processes of decomposition are decisive as regards an organic
disease of the intestinal wall itself.

A complete absence of red or green colouring in the sublimate test shows absence of bile in the intestine (and
icterus exists). If icterus be non-existent, then it a question of a temporary suspension of the secretion of bile.
In the case of brown, fresh stools, absence of red colouring or a muddy colour would point to intestinal
decomposition. When green colouring (bilirubin) is macroscopically demonstrated or if green colouring of
separate particles — for example, of muscle tissue — is seen microscopically, it shows too rapid a passage through
the colon ; if the entire stool be coloured green, then most probably the small intestine is also involved. If there
be a simultaneous appearance of small mucous flocculi described above, the cause is an inflammation of the mucous
membrane of the small Intestine.

Strasburger'* has a paper on much the same lines. He says that : —

Mucus can be recognised under the microscope, especially if one adds acetic acid. Mucus when recognised
in the motion points to a catarrh in some portion of the intestine, and roughly the catarrh is in the large gut
when the mucus is recognised macroscopically and in the small intestine when it is only detected microscopi-
cally. One learns more by noticing whether the mucus is intimately mixed with the faecal material, and whether
there are many cells associated with it. Blood and pus must be carefully looked for, and one must bear in mind
that the red corpuscles may not be sufliciently preserved to be recognised under the microscope when the source
is high up in the small intestine.

Bacteria and animal parasites are considered : —

Comparatively mild affections due to staphylococci can be readily distinguished by means of the micro-
scope from the more dangerous infections due to streptococci. Typhoid, cholera, and dysentery bacilli can
only be detected by culture, but tubercle bacilli may be demonstrated with compai-ative ease on cover-glass
preparations. The amoebae of dysentery, or certain forms of enteritis, can be seen under the microscope in
fresh stools, but one must be careful not to press the cover-glass firmly on to the slide and also to keep the
sUde warm if one wishes to recognise their movements.

The latter injunction is unnecessary during the hot weather in the Sudan. At other
times a warm stage or, what is far better, a Nuttall's microscope thermostat will be found
necessary.

Daniels gives- a good account of the examination of faeces. The following may be
quoted : —

Macroscopic examination. The points to observe are —

1. The presence or absence of blood, mucus, muco-pus or pus, and the arrangement relative to the stool of
such a discharge.

' Strasburger, J. (April, 1904), Berl. Klin. Quoted in Medical Annual, 1906.
' Daniels, C. W., " Laboratory Studies in Tropical Medicine." 2nd Edition, 1907.

• Article not consulted in the original.

EEVIEW — TBOPICAL MEDICINE, ETC. 65

2. The colour of the stool and its consistence. Faeces —

3. The presence or absence of evidence of gaseous fermentation. continued

4. The odour.

5. The reaction, determined as soon as possible after the stool is passed.

6. The bulk of the stools.

7. Any visible signs of animal parasites, such as the worms themselves or the proglottides or segments of
tape-worms.

8. Mucus alone, or streaked or mixed with the blood, usually indicates inflammatory action in the lower
bowel, not necessarily dysenteric. It may be caused by anything that sets up such inflammation, such as bilharzia,
ulcerated haemorrhoids, or chronic ulcerations of various kinds of the rectum. These latter include malignant
growths, granulomatous growths, and the ulceration left as a sequela of dysentery. Rarely, mucus derived from
the small intestines is passed with the faeces. Such mucus is recognised easily as it is stained with bile.

Clear mucus, whether streaked with bright blood or not, without any admixture of faecal matter, is met with
in early or acute dysenteric attacks. Turbid or purulent mucus, sometimes in large quantities and passed either
without any stool or with solid-formed motions, is more indicative of a chronic ulceration of the rectum, from
whatever cause.

Sometimes the mucus is passed in large masses and condensed, and may include much debris and numerous
epithelial cells. In the condition known as membranous colitis, complete casts, several inches in length, of the
rectum may be passed. These are usually twisted up when passed, and may be mistaken for worms. They can
sometimes be floated out in water, and in any case the microscopic structure should render any mistake impossible.

With ulceration limited to the rectum, stools are often coated with mucus. The more intimately the mucus
and blood are mixed with the faeces the higher up are the lesions from which the mucus or blood is derived. In
some lesions the mucus is so intimately mixed with the fluid faeces that it is difficult to discern, but tilting the
vessel from side to side will often indicate its presence by the manner in which the stool flows. In some cases it
is better shown by adding water to the faeces, when the flakes or masses of mucus can be more readily seen,
especially if the diluted faeces are poured from one vessel to another. Amoebae are killed or have their motility
destroyed by this addition of water, and therefore this method should only be adopted when the masses cannot
be seen on inspection.

Blood may be passed, bright red or in clots, in large quantities. This is no proof that it is passed from the
rectum, as if in sufficient quantity and not mixed with the faecal contents of the intestine it need undergo very
little change in passing thi-ough the large intestine. Such blood is occasionally passed in ankylostomiasis. If
intimately mixed with the faeces it may have lost completely the red colour and appear black and tarry — melaena.

The consistence of the stool is of great importance, and it will be found that " looseness " of stools is of more
importance in tropical practice than in England. In ulceration of the caecum and upper part of the colon, even
when this is acute and extensive, there need be neither visible mucus nor blood, nor even tenesmus. " Tropical
diarrhoea, " is fi-eqnently shown at post-mortem examinations to be dysenteric. It is very fatal. On the other
hand, mucus and blood may be passed with formed or even hard stools when there are a few chronic ulcers high up
in the large intestine.

In some forms of tropical diarrhoea, particularly that form known in the East as sprue, the stools passed are
full of air bubbles and are undergoing active gaseous fermentation.

The odour varies so greatly with the diet that it is of minor importance. In the races subsisting mainly on a
scanty vegetable diet the odour is singularly slight. The smell is mainly due to indol and skatol. In cases of
dysentery associated with formation of sloughs the ordinary fscal odour is replaced by the peculiar penetrating
smell associated with that condition. Excessive decomposition of the stools may cause an increase in the intensity
of the normal smell, or if the diet is mainly of carbohj'drate food-stuff, no increase, but even a diminution.

Variations in the odour indicate changes in the decomposition of the contents of the intestine, often from
variations in the food, but sometimes from variations in the "flora" of the intestinal contents, rarely from
structural lesions of the intestinal wall.

The result of the administration of intestinal antiseptics is more often a diminution in the putrefactive
changes in the contents of the bowel than any real improvement in the diseased condition of the intestinal wall.

The normal reaction of the faeces as determined by litmus is nearly neutral ; when fasting it is acid, with a
milk diet faintly alkaline. It is usually acid to phenolphthalein. In many cases of diarrhcea and dysentery this
is replaced by a decidedly alkaline reaction. To determine the reaction the faeces must be examined as soon as
they are passed, as a change rapidly occurs in most faeces, particularly when fluid, rendering them alkaline. Solid
motions must be rubbed up with water in a mortar.

Indeed, the whole of this section is worth careful perusal. As regards parasites, the
method of straining through muslin or fine wire gauze is described, while a point of practical
importance in examining for ova in a watery stool is to remember that the eggs are heavier
than the fluid and sink to the bottom of the vessel, from which they can be obtained by a
pipette.

Sandwith,> under "Ankylostomiasis" (page d) , notes that free moving larvae in fresh
faeces are never ankylostoma but are probably Strongylus stercoralis.

1 Sandwith, P. M., " The Medical Diseases of Egypt," Part I., 1905.

66 REVIEW TROl'ICAIi MEDICINE, ETC.

Fevers. Under this heading one considers those obscure and indefinite febrile
processes in the tropics to wliich so much attention has been recently directed, and on
which, no doubt, a great deal of work still remains to be done.

In the first place, however, one may quote Sutherland's valuable paper' on the method
of approaching a case of fever for the purpose of forming a diagnosis : —

The cause (he says) must bo infective or non-iufectivo. If iafective, look fiir a p.irasite which must be either
(a) Animal (rimoelia, piroplasma, Leishman-Donovan l)o<ly, trypanosouie, worm enil)ryo or worm), or (h) Vegetable
(coccus, bacillus, spirillum or fungus).

The infection must be cither (a) of the general circulation, (b) of the spleen or lymph circulation, (c) a local
infection of some mucous surface of entrance iulo, or exit from, the body, (d) an intoxication from without.
Methods of procedure : —

1. Is it a general infection? i.e. of the circulating blood. If so, the parasite must be found in the
circulation, or evidence must be obtained of its having been there.

Examine fresh blood at room temperature and on warm stage.

Examine blood films stained and with or without decoloration of the red cells.

A negative finding is inconclusive, for (1) the parasite m.ay not be in the circulation at the time, e.g. the filaria
embryo, or (2) the parasites may be few in number ; and in any case one can hardly expect that a single drop of
blood will always contain a parasite. Remember the value of drawing off a large quantity of blood, citrating it
and incubating it at body temperature for some days. Sometimes parasites can only be found by making cultures
from the blood or by making inoculations into susceptible animals.

If parasite not present, evidence of its previous presence shown, as in malaria, by broken up red cells and free
pigment taken up by the leucocytes. The spirochsete of relapsing fever also leaves behind it iu the blood, in the
apyrexial periods, small coccus-like bodies.

(It is possible that in human spirochaetal infections endoglobular bodies will yet be
discovered similar to those found in the blood of fowls and geese. — A. B.)

Changes in the number of leucocytes, or in the differential count, are not distinctive. Taken with other signs,
however, an increase of the small lymphocytes at the expense of the polymorphonuclears would point to Dengue
fever. This point is not mentioned by Sutherland, but vide notes under " Blood " and " Dengue."

When the above methods fail to reveal a parasite or signs of its presence in the circulating blood, we are
justified in assuming that the infection is not a septicaemia.

2. Is it a spleen or lymph infection ?

Remember the circulating blood is inimical to microbes which take refuge iu the lymph stream, and that the
spleen, lymphoid tissues and lymph glands are the filtering media of the blood. If the parasite be in the spleen
or in the lymph circulation its toxins must pass into the blood. Evidence of this is seen in leucocytosis or
lymphocytosis. The latter is specially distinctive of spleen and lymjjh infections, particularly when the
lymphocyte increase is of the large mononuclear variety.

In marked relative increase of large mononuclears, suspect malaria or kala-azar, but less marked increase
occurs in enteric, tuberculosis and possibly syphilis.

When parasite is in spleen, look for spenomegaly.

Splenic puncture may be required, and reveals Leishman-Donovan bodies, malaria parasites, bacilli of anthrax,
typhoid or micrococcus of Malta fever.

Presence of macrophages evidences splenic irritation. Absence of parasites and macrophages implies that
there is no infection of the spleen.

As regards a parasite in the lymph circulation, consider the tonsil, vermiform appendix and superficial lymph
glands. Look out for enlargement ; or, in the case of the lymph sacs, effusion. Puncture of the tonsil or enlarged
gland may reveal the parasite. Some infections, i.e. of Peyer's patches, deep lymph glands, etc., do not betray
their presence, and are considered under local infection.

The parasite m.ay be found in lymph sac effusions or, if these are sterile, the agglutination test may reveal the
presence of tubercle, or a guinea pig may be inoculated.

[Here one may add that the ophthalmo-reaction would now be tried both for tubercle
(Calmette) and typhoid (Chantemesse). — A. B.]

In all doubtful cases where the blood examination shows leucocytosis or lymphocytosis, where there are no
physical signs and whore spleen puncture is negative, lumbar puncture should be made to see if there be effusion
into the meningeal lymph sac. Signs of exudation (as distinct from transudation) are positive, and the discovery
of the parasite completes the diagnosis. When the exudate is sterile the case is likely to be one of tuberculosis, and
confirmation is to be sought by the agglutination test and by inoculation into guinea pigs.

It is here that one may insert a note on the diagnosis of a condition not mentioned by
Sutherland, and indeed only very recently brought to notice in India by Eoberts and
Bhaudarkar, namely Acute Tuberculous Fever. This will be mentioned later on. Here we

' Sutherland, O., in " Enteric Fever in India, etc." Roberts, E., Calcutta.

EEVIEW TROPICAL MEDICINE, ETC. 67

need only indicate that at this stage, suspecting this condition, attention would be directed to Fevers—
the urine and search made for the tubercle bacillus in the manner to be presently described. coniiimed

Eeturning again to Sutherland's deductions, we find that

absence of signs of enlargement of lymijhoid structures, of effusion into serous sacs, and negative results from
lumbar puncture, imply that there is not a lymph infection, with the possible exception of infection of the visceral
lymphoid tissues or of the deep lymph glands. The three infections most likely to occur in these situations are
enteric fever, Malta fever and acute general tuberculosis, and further evidence can be gained as to these by the
agglutination and sedimentation tests and by the diazo-reactions,

(Also possibly by the ophthalmo-reactions. — A. B.)

A positive diazo-reaetion might imply either enteric fever or acute general tuberculosis, but positive
agglutination and sedimentation reactions for enteric and Malta fevers distinctive, under proper conditions, of
the technique employed.

3. Is it a local infection ?

As a rule there are well-marked symptoms, but in deep-seated afiections the physical signs may be overlooked.
These secret local infections are generally associated with the micro-organisms of suppuration, with bacilli of the
typhoid, colon or para-colon groups, or with the tubercle bacillus ; and unless borne in mind they will often pass
unrecognised. Septic throat infections are liable to be overlooked, and the resulting fever is often attributed to
" malaria," simply because the throat was never examined.

The blood examination usually gives evidence of these infectious, and a leucocytosis or relative increase of the
lymphocytes or of the polymorphonuclears in the circulation, with absence of parasites in the peripheral blood,
spleen or bowel, is always suggestive. A lymphocytosis points to tuberculosis or to a bowel infection by one of the
typhoid or allied groups, and a polymorphonuclearcytosis to a local septic infection. The diazo-reactiou may give
evidence about the first two, the agglutination and sedimentation tests about the second, while the finding of
peptone or albumose in the urine may indicate the third. A lymphocyte increase is of less value in diagnosing
local infections than an increase of the polymorphonuclears, and calls for the diazo-reaetion, the agglutination and
sedimentation tests, and the search for tubercles in the chloride with the ojihthalmoscope to clear up the issues.
Increase of the polymorphonuclears, on the other hand, is distinctive, for it means local septic infection somewhere,
and should send the observer back fi-om the microscope to the patient to look more carefully for it. The
conditions which should be examined for, one by one, are : — Oral sepsis, sore throat, appendicitis, abscess of the
liver, subphrenic abscess, infective cholangitis, infective endocarditis, phlebitis, empyema, deep-seated pneumonia,
abscess of lung, suppurative osteo-myelitis, suppurative periostitis, pyelitis, salpingitis, otitis media, mastoiditis,
thrombosis of the lateral sinus, abscess of brain, cerebro-spinal meningitis, etc. With a polymorphonuclear
increase in the blood, more thorough clinical examination will generally reveal the local mischief and settle the
diagnosis, although the particular infecting microbe may not be determined until the necessary operation is
performed.

If the diazo-reaetion, the serum agglutination and sedimentation tests have given positive reactions and have
indicated the nature of the infecting microbe, the diagnosis should be confirmed by microscopic examination of the
sputum, fteces and urine, as the case may be, and cultures should be made and animals inoculated if necessary.
The infecting micro-organism can generally be distinguished from others by making the agglutination and
sedimentation reactions with the patient's blood, due regard being paid to the probability of a mixed infection
(symbiosis).

Having isolated the infecting agent in the above ways, it should be cultivated, or kept in sealed tubes if the
former be impossible, and subsequently used for prognostic purposes by testing, from time to time during the
illness, the agglutinating power of the patient's blood and its bactericidal and phagocytic powers.

Apart from the side-room (laboratory) research, valuable information will be obtained from day to day at the
bedside by watching the course of the disease, and the effects of treatment. The daily physical examination may
reveal some local lesion which at first was not apparent ; the time test may bring out distinctive rashes and show
the affection to be one of the eruptive fevers, or may reveal characteristic features which identity the condition ;
the fever chart may become typical or the therapeutic quinine test abolish the fever. A consistently slow pulse
will point to typhoid, the tdchc ciribrale to typhoid or acute general tuberculosis, and so on through all the
established diagnostic criteria.

If such a method of procedure be followed as a routine in doubtful eases, few will remain over to be returned
as Simple Continued Fever, Remittent Fever, etc., terms which now fill the Returns. On the other hand, many
slight cases of fever will occur where little or no information is got fi'om the side-room examinations, and where
recovery takes place before a scientific diagnosis has been made. In these eases it is hard to .s.ay what the fever
should be called, and as they are generally associated with a little gastric, intestinal, bronchial, or uterine catarrh,
it is best to return them under those heads. It would be well to regard every case of fever as having its origin
and being in some infection or toxic process, i.e. in the reaction of the tissue cells thereto, and it is safer to
conclude that heat and " chill " act only as predisposing factors.

In the above sketch, little has been said about toxic causes of fever as apart fi'om infective causes, but doubtless
toxic substances produi.'ed by intestinal and other parasites are capable of causing fever, and in most cases in India
a search tor ova in the stools, urine and sputum should be made. There is also the condition called " Fermentation
fever," a subject to which Burdon-Sanderson was the first to direct attention, and which arises from the absorption
of digestive ferments, fibrin ferment, extracts of fi-esh tissues, etc., and which is seen with gastro-intcstinal
disturbance, particularly in children, and after bruises, hfemorrhages, operations and the passage of a sound or
catheter. It may also be noted that, as in the case of tuberculin. Professor Krehl has obtained a pyrogenetic
albumose from cuhivalions of U. coll comniuiie.

68 REVIEW — TKOPICAL MEDICINE, ETC.

Fevers- Mention has been made of the Acute Tuberculous Fever described by Roberts and

cnniinucd Bhandarkar.' This is described as

a continued fever of a remittent or intermittent type, lasting from a week to four weeks or more, and
due to an acute invasion of the tubercle bacillus which during the febrile period and for a long time afterwards is
found to l)e excreted in the urine. The main symptoms seem to be furred, but not " typhoid," tongue, skin dry
aud hot. no sweats, urine highly-coloured without albumen, and, specially characteristic, pain and tenderness
in the epigastrium. The mind is clear, forming a marked contrast to the typhoid mental state. The liver
is often enlarged, the spleen not so, aud the bowels are usually constipated.

Recovery may take place or the patient may drift into a tuberculous career, commencing with an indefinite
kind of illness characterised by dyspepsia, fever relapses, depression and malaise. Some cases dcvelo]! obvious
tuberculosis. The diagnosis from liver abscess is very difficult, but is accomplished by finding tubercle bacilli in
the urine by the following technique : —

Centrifuge, wash the deposit once or twice in distilled water before fixation and use egg aDiumen in the
fixing process! Stain by the Ziehl-carbol-fuchsine process with a final metliylene blue (lightly done) as a counter
stain. Other acid-fast bacilli have to be eliminated by the procedure recommended by Coles.

Tests on guinea pigs which have been made were not completed at the time of publication.

These observations, which are very interesting, require confirmation, but, if this bo
forthcoming, a most valuable addition will have been made to our knowledge of obscure
fevers, at least in India. Tuberculosis is far from being uncommon in the Sudan, and it
will be well to keep on the look-out for cases answering to this description.

Rogers' book, already frequently quoted, is at the present time the standard work on
tropical fevers, at least so far as India is concerned. The two chapters therein which bear
especially on the subject under discussion are those respectively entitled " Unclassified Long
Fevers " and " Unclassified Short Fevers." As regards the former, the author mentions
Crombie's old classification and shows that his " remittent fever" is really typhoid, which
was supposed to be uncommon amongst natives, while kala-azar accounts for another type.
He then discusses certain doubtful, irregular, long fevers, dwelling principally on their
incidence, and concludes that though they " may possibly belong to some one or more still
undifferentiated tropical diseases, yet they present no features incompatible with their being
either paratyphnids, including the class recently described by Castellani, or early cases of
sporadic kala-azar, but they require further study and following up for long periods before
their exact nature can be finally decided. Special reference is made to a Low Fever of
European immigrants occurring in the damp, hot provinces of India, benefited markedly
by change of climate or removal to a place with a dry soil, and due in all probability either
to an enfeeblement of the heat-regulating mechanism or possibly to some undiscovered
protozoal parasite. In the latter connection, he considers a leucocytozoon, but no parasites
of this kind have been found in these cases. He also notes that a fever resembling kala-
azar, but without the Leishman-Donovan bodies, has been described in the Philippines.

Mention is also made of undetermined fevers in China, such as the Double Continued
Fever described by Manson and a similar form found by Rousseau amongst sailors at
Hankow.

As regards the " Unclassified Short Fevers," we are now, thanks to Rogers' own work,
on surer ground. He has described as a distinct entity, what he calls Seven Days' Fever, a
condition which Sandwith believes exists in Egypt and which very probably occurs also in
the Sudan : —

The onset is sudden, in many oases rigor or chillness being present. Repeated rigors may occur resembling
those of malaria. Rarely the onset is gradual.

There is a flushed face, reddened conjunctivae, often a listless, typhoid-like expression, while abdominal
symptoms and even a few rose spots may suggest enteric fever.

Pain in the back and limbs is common, but the joints arc rarely affected, thus distinguishing the attack from
dengue. Headache is common, severe and often frontal in site. The tongue is furred on the dorsum and has raw,
red edges. It is like the tongue seen in influenza or dengue.

Sickness may occur, but the bowels are usually regular. Abdominal pain and distention are not infi-equent.
Slight enlargement of the liver was found in 5 per cent, of cases, and of the spleen in only 7 per cent. Respiratory
symptoms are absent. The pulse is like that in typhoid and p;iratyphoid, and is therefore somewhat characteristic.

Rashes may occur but are not common. The typical temperature curve is of a saddle-back shape, the remission
being slight, moderate or deep. Sometimes there is complete remission to normal before the terminal rise. There
is also a type of case showing a continued typhoid-like curve and, as there is usually a terminal rise, cases coming
late under observation are apt to be confusing.

' Roberts, J. R., and Bhandarkar, R. S. P. R. (February 15th, 1908), " Preliminary Note on the Existeuco
of an Acute Tuberculous Fever in India which has been coirfuscd with Continuous and Remittent Fevers."
British Medical Journal, p. 377.

REVIEW — TROPICAL MEDICINE, ETC. 69

The name indicates the usual duration. From 4 to 8 days seems to be the limit. The convalescence is rapid Fevers —
and relapses do not seem to occur. m.Uinued

The differential leucocyte count shows a considerable reduction in the percentage of the polynuclears with a
corresponding increase in tho.se of: the lymphocytes and large mononuclears. The cause seems to be a bacillus
which has been cultivated fi-om the blood and resembles those of the coli group of organism.s. It differs, however,
from B. typhosus and J'nrntyphosiis. The agglutination test was positive up to 1 in 40, but the reaction was not
sufficiently constant to furnish a reliable diagnostic method.

Salicylate of soda and belladonna seemed to be the most u.seful drugs. Quinine only made the headache
worse. No fatal case is reported.

The fever is much commoner in adult males than in females or children, and is much rarer in natives than in
Europeans. The differential diagnosis is given, dengue being the great difficulty.

As regards distribution, it seems to occur principally on or near the sea-coast.

Clayton^ studied an outbreak of Seven Days' Fevei- among the men of a cruiser
temporarily quartered ashore in Bombay. The clinical symptoms are carefully described
and suggestive facts brought forward to show that possibly the disease was transferred from
sick to healthy through the medium of a suctorial insect. No organism was found in the
blood, and experimental work was not conducted.

Another fever described is the Three Days' Fever of the hot season of Upper India, the
cause of which is unknown but in which there is a large mononuclear increase. The
temperature rises sharply and has a steady step-like decline, while headache and inliuenza-
like pains seem to be the principal features. It is identical with the Chitral Fever described
by McCarrison.-

I have myself suffered in Khartoum from what was either an attack of Seven Days'
Fever or of Influenza. That it is was probably the latter is indicated by the marked benefit
derived from a full and early dose of opium in the form of Batley's solution, but I am bound
to say the rapid and complete convalescence after what was a short but severe and
prostrating attack of pyrexia rather suggested this Seven Days' Fever, which, however, at
that time had not been definitely distinguished.

There occurs also in Khartoum, more especially during the hot weather, a febrile
condition of a few days' duration with indefinite symptoms of headache and malaise. In
such cases I have been struck by the increase in the number of blood-plates which one finds
when stained films are examined. Masses of platelets are visible usually along the edge or
towards the ragged end of the film, though they also occur scattered through it. I am
inclined to think there is some definite relation between this increase and the fever, but
further observations are required, especially as regards the differential leucocyte count.

Castellani' has described cases of unclassed fever in Ceylon which, on superficial
examination, may be taken for atypical forms of typhoid, paratyphoid, or malaria. The
temperature is generally irregular ; pulse frequently very slow ; spleen not sensibly enlarged ;
no roseola ; slight intestinal symptoms occasionally present ; Widal test constantly negative ;
malarial parasites absent. The interesting bacteriological findings in these cases have
already been discussed under "Bacteriology " (page 12).

Cropper'' has described in Palestine a so-called Syrian Fever, which is generally
quotidian or remittent in character, is accompanied by slight chills and more marked
sweats, and is seen most severely in young infants who may have moderate enlargement of
the spleen. In the red blood corpuscles the pale rods and melon-seed-shaped forms, known
as Cropper's bodies, are found (see pages 111-112). In this fever, quinine is distinctly of use,
but prolonged treatment is necessary.

Wellman^* has observed, in tropical Africa, a fever common in the dry season, of gradual
evolution, long duration and characterised especially by persistent hyperpyrexia and a
heavy mortality. In one case he found a great number of short bacilli in the blood.

' Clayton, F. H. A. (.June 15th, 1908), "A Contribution to the Study of Seven-d.ay Fevers of the Indi.iu
Ports." Journal of Tropical Medicine and Hyijiene.

- McCarrison, R. (January, 1906), "The Three Days' Fever of Chitral." Indian Medical Gazette, p. 7,
Vol. XLI.

■' Castellani, A. (January, 1907), "Notes on Cases of Fever frequently confounded with Tyjohoid and
Malaria in the Tropics." Journal of Hygiene, p. 1, Vol. VII.

* Cropper, J. (February, 1907), " The Malarial Fevers of Palestine, and their Prevention." Journal of the
Royal Institute of Public H.alth, Vol. XV., No. 2.

'■ Wellman, F. C. (1906), Arch, filr Schiffs. und Trop. ffyg., t. X.

^ .\rtii'le not consulted in the original.

70 BBVIEW — TROPICAL MEDICINE, ETC.

Fevers — An interesting account of Miliary Fever, or " Sweating Sickness," is given in the

conlinued Lancet of November 17th, 1906, while Scholz>* has recently reported an epidemic of this

curious disease, the infection of which Chantemesse suggests may be carried by the fleas of

field mice. He noticed that the districts concerned had been overrun by these rodents and

that many of the patients exhibited flea bites.

McCowen- has described very fully a Bilious Typhus Eelapsing Fever, but as this really
seems to bo a special and definite form of true relapsing fever it will be considered under
that heading.

Eow^ has a paper on serum reactions in obscure, irregular, continued fevers in India
which led him to believe that both the Bacillus enterHidis of Gaertner and the Bacillus culi
communis, especially the latter, stand in causal relationship to some of these forms of illness.
Indeed, in some measure he anticipates the more recent work of Rogers and Castellani.

The same point was urged as regards Simple Continued Fever even earlier by
Caldwell,* who quotes the still earlier work of Busch.^* At the same time, it must
be remembered that in 1902 the agglutination reaction in all its phases was not so fully
worked out as is now the case, and it seems desirable that definite evidence should be
obtained as to the role of B. coli in these obscure but common cases.

Brief reference may be made to De Korte's paper'* on Amaas or Kaffir Milk-pox, which
seems to be small-pox mitigated by some undetermined factor or factors. It is not varioloid
varicella, and is to be distinguished from what is known as Infectious Disease in Lascars.
It is quite possible that amongst coloured races true modified small-pox occurs, and
Colonel Hunter has told me that he has frequently wondered how often some of the
outbreaks of so-called varicella in the Sudan are really mild and modified variola.

The point is one worthy of attention, albeit variola is steadily diminishing owing to
general and efficient vaccination.

Filariasis. Low" has dealt with the unequal distribution of filariasis in the
tropics. His researches were carried out in the West Indies, the distribution of F. nocturna,
F. demarquaii and F. perstans being noted. He found that

where there was much clinical filarial disease, elephantiasis, etc., then the percentage of ordinary healthy
people with embryos in their blood was high ; where there was little disease, then the percentage was low.
As regards F. nocturnu, he found that its distribution in the various islands was very peculiar and interesting,
and records his belief that there was something over and above the mere presence or absence of C. fntigans to
account for the peculiarities he encountered. Much the same as regards distribution was true of F. demarquaii
and F. 2>''rstins, even though, as he points out with regard to these parasites, we are not on such certain ground, as
their proper intermediate hosts are unknown, unless the tick, Ornithodoros moiibata, as Wellman believes, acts for
the latter. Hence their irregular distribution may depend on the presence or absence of the intermediary. In a
discussion on this paper, Sambon stated that he believed that several worms had been confounded under the name
Filaria banerofli. He suggested that hypcr-parasitism might explain the absence of filarite from certain regions.
Lciper confirmed Low's statement as to the prevalence of F.pcrstans (i.e. the blunt-tailed embrj'os) in the blood
of African natives in Uganda and E. Africa, and to the absence of the sharp-tailed embryos {F. diurna and
F. nocturna). He pointed out, however, that though sharp-tailed embryos did not occur in Africa in man they were
present in monkeys, and in these resembled very closely the embryos of F. noclurna found in the W. Indies. He
also mentioned that distribution could not be determined on larval forms alone.

Sandwith stated that filariasis was not an extremely common disease in Lower Egypt, and that neither he nor
anyone else in a.ll probability could speak as to its incidence amongst Nubians. He also referred to Hayward's
observations, who examined 400 patients in the hospital at Port Said and found that 15 per cent, of them were
infected. Manson "asked why it should be that in countries where C. fatiijitns was eiiually prevalent the disease
it produced was very common in one, and in another it was very rare ? He believed that if a satisfai'tory answer
could be found, the means to counteract the pathogenic influence of the filaria would be also forthcoming. He further
discussed the question of repeated re-infections and the remarkable fact that the propagation of the filaria was
restricted in some way or other. He had obtained no evidence of hyper-parasitism and thought there must be
some other explanation. He also discussed the relation of filariasis to elephantiasis and the fact mentioned by

' Soholz. Zeit. f. Klin. Med. Vol. LIX., Nob. 5, 6.

2 McCowen, W. T. (October, 1906), " Bilious Relapsing Fever." Indian Medical Gazelle, p. 387, Vol. XLI.

'■^ Bow, R. (August, 1905), "Obscure, Irregular, Continued Fevers of the Typhoid Group, .and their Probable
Relation with different species of Bacilli of the Typliu-Coli Race." Indian Medical Onzclte, p. 292, Vol. XL.

■• Caldwell, R. (February, 1904), " Simple Continued Fever : Its Cause and Prevention." Jnuriial of Slate
Medicine, p. 103, Vol. XII.

^ Busch, P. C. (May 31st, 1902). New York Medical .Tnurnal.

De Korte, W. E. (May 7th, 1904), " Amaas or Kaffir Milk-pox." Lancet, p. 1273, Vol. I.

■" Low, Q. C. (February 15th, 1908), " The Unequal Distribution of Filariasis in the Tropics." Journal of
Tropical Medicine and Hygiene, p. 59, Vol. XI.

• Article not consulted in the original.

EBVIEW — TROPICAL MEDICINE, ETC. 71

Low that in a country where filariasis was prevalent patients who were the subject of elephantiasis were rarely Filariasis —
affected, or at all events seldom showed eiiiljryos of the parasite in their blood. This, he thought a strong proof continued

that the parasite was the cause of the disease, something having happened to the subjects of elephantiasis
previously, when they wore actively infected with filariae, which set up the elephantiasis and caused the death of
the parasite.

In his reply. Low stated that though all elephantiasis w.as not filarial in origin the vast majority of tropica!
cases were due to this cause. He thought the death of the parent worm plus streptococcus might be the real
factor. He had traced the development of elejihantiasis in Barl^ados, where there was no malaria, from the initial
fever and so-called ague, through recurrent attacks of lymphangitis to the true elephantiasis state. Embryos,
however, were not found in the blood of those subject to the lymphangitis attacks, a curious fact which, however,
did not vitiate his conclusions.

Wellman's suggestion, anticipated, however, in some measure by Feldman, has been
mentioned. He' records work on OriiifJwdoros moubata, in which tick lie found what he
believed to be developmental forms of F. perstans. He thinks that the cycle is probably
direct, from man to tick and from tick back to man. His experiments were carefully
conducted and his results appear more reliable than those of Feldman,- who claimed that
ticks (species not stated) take up F. peisfaus when sucking infected blood, that the worms
undergo a certain development in the ticks and pass out with the eggs, being deposited in
ripe bananas. These arc ingested and the filaria bore their way into the tissues of the
abdominal cavity and assume the adult form. Wellman was unable to confirm these
observations and points out certain fallacies in them, one being that microscopic nematodes
occur naturally in bananas.

Several recent papers deal with the development of filarias in mosquitoes. Thus
Lebredo^ worked at the metamorphosis of filaria in the body of Culex pipiens. The paper
goes minutely into details, and only portions need be quoted. Having traced the embryo
from the blood to the stomach and then to the thorax of the mosquito, he finds that the
embryo rests in the thorax and goes through the following transformations : —

(a) Narrowing and invagination of the tail.

(b) Invagination continues and the embryo grows shorter and wider.

(c) Widening and shortening continue and the invaginated portion forms a hyaline appendix.

(il) Period of growth and formation of the three lobes (at caudal cud). He further states : " It happens
sometimes, though rarely, that when the filaria reaches its maximum size, and starts on its way to the head, it may
mistake the route, and wander towards the caudal extremity. The worm, however, will always keep in the fatty
tissue, and close to the chitiuous covering. These stray worms all proceed from the thorax. I have never met
with a single embryo undergoing the process of metamorphosis in any other structure than the thoracic muscles."

The characters which lead one to the conclusion that the filaria has completed its cycle
of development in the mosquito are stated to be : —

1. The arrival in the labium.

2. Complete development of the three caudal lobes.

3. Active motility.

Several other points are emphasised : —

(I.) When a mosquito falls into the water, if its cuticle be preserved, the filariae it may contain arc unable
to escape, and perish by imbibition of water within a period of 24 hours. (lI.) The filaria docs not pass fi-om the
living mos<iuito in the act of suction of water or sugar. This rather tends to show that it is not likely to p.ass
into bananas. Interesting experiments on the exit of the filaria from the proboscis arc recorded. They lead to
the conclusion that the heat in human blood is a factor in determining the exit of the filaria at the moment of
the mosquito biting.

The author also concludes that only a series of accidents could bring the filaria to the
human stomach as in the suggested imbibition of water.

The page on Histological Technique is certain to be found useful, and I transcribe
it in toto : —

For studying the distribution of the filariaj in the body of the mosquito, sections are best used.

On the other hand, if we wish to follow the cycle of development of the parasite, of its dimensions and
structure, we must dissect the infected mosquitoes.

Technique for the prcjMration of sections —

1. The live mosquito is placed iu absolute alcohol. In this manner the pouetratiou necessary for fixation and
dehydration is obtained. Duration 24 hours.

1 Wellman, P. C. (July 20th, 1907), "Preliminary Note on Some Bodies Pound in Ticks— Ornithodoros
moubata — Ped on Blood containing Embryos of Pilaria." British Medical Journal, p. 142.

= Feldman (April 15th, 1905), " On Filaria Perstans in the Bukota District." Journal of Tropical Medicine,
p. 125, Vol. VIII.

^ Lebrcdo, M. Q. (May, 1905), " Metamorphosis of Filaria in the Body of the Mosquito CCulcx Pipiens)."
Journal of Infectiuus Diseases, Suppl., No. 1, p. 332.

72 REVIEW — TROPICAL MEDICINE, ETC.

Filariasis — 2. Removal of wings and legs in the same liquid, in a watch-glass.

coiUinmd 3. Equal parts of absolute alcohol and ether, 24 hours.

4. Weak solution of celloidin, 24 hours.

6. Thick celloidin, 24 hours.

6. Mounting on block.

7. Chloroform, 20 minutes.

8. Eighty per cent, alcohol until ready to cut.

The sections were always stained in Bohmer's haematoxylin, followed in some cases by eosin and in others by
van Qieson's solution.

Dissection —

The living insect is placed in a test-tube with a small amount of water, and is shaken until the wings become
wet, and the insect floats on the water. The liquid is poured into a watch-glass, where the legs and wings are
pulled oflt by means of forceps.

The further dissection should be made in the following order ; —

Dissection of the abdomen upon a slide, constantly irrigating the mosquito with distilled water or weak salt
.'ioUition. After dissection place under microscope and determine by medium power whether there are any filariae.
The head and thorax are transferred to another slide. Here the chitiu is broken near the neck, and the head is
transferred to another slide. Each part is thus dissected separately, and we are able to determine the localisation
uf the parasites. If the latter be well advanced in their development, they push their way out through the
openings made in the chitinous covering at the time of dissection.

If we wish to preserve the specimens, the filariae, if they are large enough, are transferred from place to place
upon the slide, and repeatedly washed, while we clean and remove all detritus of the body of the mosquito from
the slide. We finally add a drop of mixture of water, glycerin and formalin, and the preparation is covered and
cemented. Such preparations may be studied with the immersion lens.

When the filariae are too small to be isolated, it is best to leave them in the midst of the detritus, and to stain
them as follows : —

1. Allow them to dry on the slide.

2. Fix with 95 per cent, alcohol, 1 to 2 minutes.

3. Place in water a few minutes.

4. Bohmer's haematoxylin, 1, 2 or 3 minutes, according to the intensity of the stain desired.

5. Wash in running water, 3 to 5 minutes.

6. Watery -01 per cent, solution of eosin, J to 1 minute.

7. Wash in 95 per cent, alcohol.

8. Dry with paper.

9. Oil of cloves, 2 to 3 minutes.

10. Xylol.

11. Balsam.

The above technique may appear complicated, but it may be carried through in 8 to 10 minutes. Without
staining, the filariae, when they are too small or too few, may escape observation.

The dissection above described is not a careful dissection of the insect, but should be considered rather as a
coarse fragmentation into sections as follows : — The stomach, intestine and ovaries in one piece ; the thoracic
muscle in four or more bundles ; and the head and mouth parts. Care should be exercised not to lose a single
fragment.

A somewhat similar paper is that by Ashburn and Craigi on the development of a
human blood filaria F. philippinensis in G. fatigans. They summarise the changes as follovvs : —

In from 14 to 15 days the development is complete and the filaria has passed into the labium of the
mosquito ; the sheath of the embryo is lost in the stomach and the worm penetrates the stomach wall and reaches
the muscles of the thorax where most of the developmental changes occur ; during this period of time the filaria
has increased in length from 0-32 millimeter to as much as 2-20 millimeters, and in breadth from 0-0065 to
0-02 millimeter ; it has developed a well-marked intestinal canal, divided into oesophagus and intestine, a well-
defined anus and three papillas which are situated at the end of the tail ; the mouth appears to be simply a
circular cavity having no distinct lips. Development, so far as the morphology of the worm indicates, appears to
be complete at about the eleventh day, the only changes occurring after that being a lengthening and narrowing
of the filaria, which enables it to enter the labium of the mosquito. F. philippinensis does not seem to be
pathogenic.

Fulleborn'2 has conducted an able research on the transmission of Filaria immitis of the
dog by certain mosquitoes, notably Anopheles viaculipcnnis and Stegomijia calopus. He has
shown the important influence of humidity and temperature on the act of transference of

' Ashburn, P. M., and Craig, C. F. (March, 1907), "Observations upon Filaria philippinensis Development
in the Mosquito." Philippine Journal of Science, p. 1, Vol. II.

■■' Piilleborn (1907), " Uebertragung von Filarienkrankheiten durch Mucken." Arch. f. Sch. u., Trnp. Hyg.,
t. XI., No. 20.

REVIEW — TROPICAL MEDICINE, ETC. 73

the filaria from the mosquito to the dog, and has devised ingenious experiments for his Filariasis—
preliminary investigations. continued

Smith^ has recorded from Sierra Leone the presence of two motile worms, apparently
nematoids, and resembling developing filaria embryos, in the thorax of a mosquito, which
appeared to be a non-blood sucker. This latter fact, however, required confirmation, and I
can find no further reference to the subject.

Observations by Billet'-* appear to show a more or less close genetic relationship
between F. loa and F. dinnia, while an interesting case of F. loa infection is described by
Livon and Penaud,^* of Marseilles, wherein the microfilaria were found in the blood, urine
and saliva, and where there was a marked eosinophilia (55 to 70 per cent.).

Ward has studied F. loa in North America. He mentions all the cases on record and
gives a very full and complete bibliography.

The geographical distribution of F. loa is given and the statement made that the West
Coast of Africa is the proper home of the parasite. Strong recent evidence of the relation
of the parasite to Calabar swellings is cited. Ziemann is quoted as finding the embryos
in the swellings, but he believes that the latter are due to F. perstans, which he regards
as the embryonic F. loa, while F. din ma (he says) does not differ from F. lancrofti.

Ward suggests that the swellings may be due to the discharge of waste materials of a
toxic nature.

Several new facts have accumulated regarding filariasis in animals. These will be
found detailed under the heading "Veterinary Diseases" (page 217^.

Nuttall* has publishel notes for the preservation of filaria intended to be sent for
identification or study. These are as follows :—

Embkyos in the Blood

1. Drop blood in a solution of 1 in 4000 perchloride of mercury in 8 per cent, saline. Mis by shaking, cork
and send without more ado.

2. Drop blood into solution of iodine added to 8 per cent, saline, in quantity sufficient to give the saline a
pale sherry colour. Mix, cork and send.

3. Drop blood into 10 per cent, boiling formalin solution, allow sedimentation to take place, then decant and
preserve in 5 per cent, formalin.

4. Make blood smears on cover glasses, dry, pack them back to back, surround with thin paper (paraffined
better), put into smaU box into which paraffin, melting at not too high a temperature, say 50' to 60° C, has been
poured. Now pour in fresh melted paraffin so that the cover glasses lie in a block of paraffin.

Note. — I have devised this method in the hope that it will work with films collected in the tropics, excluding
their growing mouldy and altering with regard to stains.

Adult Pilable

1. Place worms in saturated perchloride of mercury for 24 hours, then rinse with water for 30 minutes and
place in 70 per cent, spirit to which a little iodine has been added, so as to give it a sherry colour. Cork and
send.

2. Place worms in dish, pour on boiling s.atuiated perchloride, rinse as before and store in iodinised 70 per
cent, alcohol.

3. Drop worms direct into 4 per cent, formalin in 8 per cent, saline ; cork and send.
The different methods can be used according to the convenience of the worker.

Low' gives the following method for making permanent preparations of filarial embryos.
Spread a large drop of blood as a film on a slide and allow to dry. Place in water till all
the red colour of the blood disappears and then apply a few drops of fuchsin, methylene blue
or hsematoxylin for a few minutes. Wash again in water, dry and mount in Canada balsam.

O'Brien^ mentions two cases in which atoxyl, given intravenously, caused the embryos
of F. nocturna to disappear from the blood. He administered from 5 to 40 minims of a
5 per cent, solution, continuing the treatment in one instance for about two months.

' Smith, F. (May 1st, 1905), " The Development of Filarise in the Mosquito." Journal of Tropical Medicine,
p. 140, Vol. VIII.

" Billet, A., C. K. Soc. Biol, t. LXI., p. 507.

" Livon, J., and PSnaud, December 1st, 1906, C. R. Soc. Biol.

* Nuttall, Q. H. F. (October, 1904), "Directions for Preserving Filariae." Indian Medical Oazette, y. 391,
Vol. XXXIX.

" Low, Q. C. (February 16th, 1903), " Method of Mounting Specimens of Bilharzia Eggs, Filarial Embryos,
and Small Worms of Any Kind." Journal of Tropical Medicine, p. 67, Vol. V.

' O'Brien, R. A. (May 15th, 1908), " The Administration of Atoxyl Endovenously in Filariasis." Journal of
Tropical Medicine and Hygiene.

• Article not consulted in the original.

74 REVIEW — TROPICAL MEDICINE, ETC.

Filariasis— Personally I cannot say much about filariasis in the Sudan. The only filaria I have

continued found in human blood in this country was F. jierstans, and that in a Ugandese at Tautikia.
In the only case of elephantiasis whose blood I examined at night I failed to find embryos.
Neither have I found them in the blood of monkeys (Cercopithfcuf:) . Elephantiasis does
occur, but is apparently not a common disease. Singer' records that in South-Western
Abyssinia elephantiasis occurs, but is rare. Ensor has recently reported filariasis to be
common in the southern Bahr-El-Ghazal Province of the Sudan.

Giilex fatiijans is common all over the Northern Sudan and occurs also in large numbers
on the Upper White Nile, but in these southern territories Mansouia uniformis is more likely
to play tlie part of a filaria vector. A great deal of useful information could be obtained
by the systematic examination of bloods at night in the various hospitals. So far as I know
nothing has been done in this direction. It would entail hard work in such a trying
climate, but during the winter months the examinations could be made without very much
discomfort or fatigue. It would seem advisable, in the case of elephantiasis patients
brought in for operation, to enforce the use of a mosquito net at night, as where G. fatujans
or M. uniformis are present the disease might be transferred from the sick to the healthy.

The question of infection with Filaria medinensis is considered under the heading
"Guinea Worm" (page 83^.

Filters. An important practical paper of recent date is that by Bulloch, Craw and
Atkin- on the relative efficacy of the Doulton, Berkefeld and Browiilow filters. An
investigation such as they conducted was urgently required, for doubt had been thrown on
the efficacy of the Berkefeld filter, despite the statements of Woodhead and Cartwright
Wood. The later investigators conclude that —

Of all the filters tested, the Doulton filters alone uniformly prevented the direct transmission of micro-
organisms ; the Berkefeld filters all permitted direct transmission, with one exception, and all the Slack and
Brownlow filters gave contaminated filtrates immediately. In the case of the Berkefeld filters and the Slack and
Brownlow filters the germs passed through within 15 minutes from the commencement of filtration, v/hereas seven
out of ten Doulton filters withheld the organisms and gave sterile filtrates for four days and in three cases for
longer periods. As these tests were made with a water pressure varying from zero to 32'5 lb. per square inch,
often in a few seconds, the above examination appears to us to be not only severe but also conclusive.

Craw has a supplementary paper on the grain of filters and the growth of bacteria
through them, and brings out some interesting points. He finds that the size of pore is very
small in the Doulton filter, relatively greater in the Pasteur-Chamberland, very much
greater in the Berkefeld, and in the case of the Slack and Brownlow filter the pores are of
striking magnitude. These points are very well brought out in a series of photographs.

He concludes that the grain of a filter is a very important, if not the most important,
factor in governing the growth of bacteria through the filter mass, and that in the filtration
of fluids containing colloidal substances, suspended matter or micro-organisms, the chemical
nature of the filter mass will be eliminated very rapidly as a factor in the efficiency of the
filter owing to the formation of a coating of foreign material, derived from the Huid, over the
chemically active surface.

As regards water filtration on a large scale, much valuable information will be found in
Hazeu's work, 2 which is far too little known on the eastern side of the Atlantic. A short
resume of the subject, comparing the English sand filter with the American mechanical filter,
is given by Eobiuson.' As he points out, the latter, where a chemical precipitant is
employed, are specially applicable to very turbid and muddy waters. The efficiency of the
mechanical filters depends entirely on the use of coagulants, hence the value of a paper by
Whipple and Lougley' on the necessity of using basic and not neutral alum in mechanical
filtration. With neutral alum the bacterial efficiency was only 95-5 per cent., while with
basic alum 98-4 per cent, was obtained. As a result they contend that specifications for
filter alum should always require that there shall be a substantial excess of alumina, that is,

' Singer, C. (January 16th, 1905), "Notes on Cases met with in South-Western Abyssinia in March, 1904."
Journal of Tropical Medicine, p. 17, Vol. VIII.

"- Bulloch, W., Craw, J. A., and Atkin, E. G. (.January, 1908), "On the Relative Efficacy of the Doulton,
Berkefeld and Brownlow Filters." Journal of Hygiene, p. 63, Vol. VIII.

= Hazen, Allen, " The Filtration of Public Water Supplies." New York, 1903.

* Robinson, W. J. (September 15th, 1906), " Artificial Purification of Water Supplies." Brilish Medical
Journal, p. 623, Vol. II.

* Whipple, G. C, and Longley, P. F. (February, 1906), " Experience with the Use of a Non-basic Alum in
Connection with Mechiioical Filtration." Journal of Infectious Diseases, Suppl., p. 166, Vol. III.

REVIEW — TKOPICAIj MEniCINE, ETC. 75

that the alum shall be distinctly basic. This is usually so in any case when the available Filters —
alumina exceeds 17-5 per cent. The following is the type of specification recommended : — continued

The basic sulphate of alumiuri shall be guaranteed to coutain 17 per cent, of alumina (Al., O3), soluble in
water, and of this amount at least .5 per cent, shall be in excess of the amount theoretically necessary to combine
with the sulphuric acid present. It shall not contain more than 0-1 per cent, of matter insoluljle in water, and it
shall be practically free of chips and debris of all kinds. It shall not contain more than 0'5 per cent, of iron
(Fe„ O3), and the iron shall be preferably in the ferrous state. The alum shall be crushed to pieces of such a size
that they will pass through a ring three inches in diameter.

If bidders so desire, they may bid on a, product containing a large amount of soluble alumina, stating, however,
the amount which they guarantee. The additional strength will be taken into account in deciding where to place
the order.

Mention may be made of closed Candy filters, specially adapted for waters containing
iron ; and the Bell filters, which seem to be an adaptation of the American mechanical filter,
are closed, appear to be efficient bacteriologically, are easily cleaned, and are likely to have
a future before them as they are not very expensive.

Smith' deals with modern methods of water filtration, considering first the sand
filter used both in the old manner and along with the " Howard" process, which consists
in running on to the surface of the filter a strong solution of aluminium sulphate at the
beginning of every filtering period, thus inducing a rapid formation of the so-called vital
layer. He also notes the spreading of the raw water over the filter bed by means of a
revolving sprinkler — a recent innovation. Secondly, he describes mechanical filters,
distinguishing four chief types — the Jewell, the Bell, the patent open and pressure filters
of Eeeves, containing quartz crystals, and the Candy filter. A warning is issued against the
use of any of these types without due precautions as to skilled oversight, etc. It is advisable
that such filters should be tested with the water which it is proposed to purify.

As regards the question of domestic and public filters in Khartoum, see " Sanitary
Notes" (Third Eeport).

Flies. Under this heading a few papers will be noticed dealing not only with biting
flies but with those flies which from their filthy feeding habits may carry disease germs.

Austen- deals with the house-fly and certain allied species as disseminators of enteric
fever among troops in the field. He quotes Major Smith, who says : —

an old idea of some Anglo-Indian sm-geons was that dysentery could be caught by using the same latrine as a
dysentery patient. There may be something in this. Experiments on animals have shown that the disease can be
inoculated per rectum. The ubiquitous fly may, therefore, be a dysentery incubator in open camp latrines.

Enteric fever may possibly be conveyed in a similar manner, and Austen observes that
many cases of intestinal myiasis due to the larvifi of flies belonging to the genus Homalomyia
(H. canicidaris, Linn., and Soalaris, Fabr.), are probably to be traced to the parent flies
having oviposited on the anus when the patient has been using some country privy where
these flies are common. He then proceeds to describe the characteristics, life-history and
general bionomics of the commonest latrine-haunting flies, especially as regards South Africa.
He notes that Homahnnyia canicidaris is very often mistaken for Musca domestica, the true
house-fly, but it is smaller, narrower, and the fourth vein runs straight to the tip of the
wing instead of being bent up at an angle as in Musca. It is often called a " young house-
fly " by those who do not know that the larval stage is the period of growth in insects and
that no insect grows, in the true sense of the word, after attaining the perfect state.

After dealing in detail with the house-fly, Austen mentions two other filth carriers,
the plum-coloured or metallic-green or bluish-green Pycnosoma flies, P. ■mai-yinale and
P. chlurupliijga, which also breed in decaying animal and excrementitious matter and
accordingly haunt latrines.

Methods of preventing the access of flies to latrine trenches are given and a suggestion
made, that light metal covers, provided at regular intervals with apertures, closed by spring
flaps which could be actuated by the feet of the users, might prove useful, especially if
combined with the discharge into the trench of some such fluid as kerosine or crude creolin
in solution.

1 Smith, W. R. (May, 190S), " Modern Methods of Water Filtration." Journal of tlie Koyal Institute of
Public Health, Vol. XVI., No. 5.

= Austen, E. E. (June, 1904), "The House-Fly and Certain Allied Species as Disseminators of Enteric Fever
among Troops in the Field." Journal of the Royal Army Medical Corps, p. 651.

76 REVIEW — TnOPIOAL MEDICINE, ETC.

Flies— A very excellent paper on House-Flies is that by Howard.' He deals with all the flies

conlinufd which invado houses in the United States, mentioning Mnsca domestica, Stomoxys calcitrans,

Pollenia rudis (the cluster fly), Muscina stahnlans, a stable fly exactly like the common

house-fly, and throe species of so-called blue-bottle fly, namely, GalUplwra erythrocephala,

the blow-fly, the small blue-bottlo fly, Phormia temenovie, and the green Lncilia ciesar.

Hoinalomyia canicidaris and Homalomi/ia brevis also receive attention, as does the small,
jet-black window fly, Scenopinus fenestralis, which breeds in the dust under carpets. The
small and slender Sepsis violacea, often seen on window-panes, is also mentioned and figured.
The chief natural enemies of the house-fly are detailed. These are the house centipede,
a small reddish mite and, in its larval stage, hymenopterous parasites and predatory beetles.
EmpHsiiia mnscxi, however, a form of fungus, is its principal destroyer, but its action is more
than counterbalanced by the rapidity of development of the fly.

Eemedial and preventive measures as regards the breeding of house-flies are considered.
Stable manure is their special breeding-place, and experiments were tried with various
substances. It was found that by spraying eight quarts of fresh horse manure with one
pint of kerosene and afterwards washing down with one quart of water the manure was
thoroughly rid of living maggots. While good results were obtained on a small scale, this
method employed on an economical basis proved inadequate wlien applied to large quantities
of manure. Chloride of lime also failed on a large scale and the best results were obtained
by the preparation of a special receptacle for manure. A chamber 6 feet by 8 feet was
constructed with a door opening into the stable, and a window with a wire screen. In the
outside wall of this building another door was placed. All manure was thrown into this
chamber and each morning a shovelful of chloride of lime was scattered over the fresh layer.
After ten days or two weeks the manure was removed via the outside door.

House-flies also breed in human excrement and, as recently discovered, in cow-dung.
Howard mentions a French method for keeping them away from privies and cesspools.
Residuum oil is used, two litres per superficial metre of the pit. This is mixed with water,
stirred with a stick, and thrown into the receptacle. Not only does this kill larvte and
prevent the entrance of flies, but it practically turns the cesspool into an anaerobic tank.

Finally, Howard quotes certain U. S. regulations which might well be adopted with

appropriate modifications in all towns : —

All stalls in which animals are kept shall have the surface of the ground covered with a water-tight
floor. Every person occupying a building where domestic animals are kept shall maintain, in connection
therewith, a bin or pit for the reception of manure, and, pending the removal from the premises of the manure
from the animal or animals, shall place such manure in said bin or pit. This bin shall be so constructed as to
exclude rain-water, and shall in other respects be water-tight, except as it may be connected with the public sewer.
It shall be provided with a suitable cover and constructed so as to prevent the ingress and egress of flies. No
person owning a stable shall keep any manure or permit any manure to be kept in or upon any portion of the
premises other than the bin or pit described, nor shall he allow any such bin or pit to be over-filled or needlessly
uncovered. Horse manure may be kept tightly rammed into well-covered barrels for the purpose of removal in
such barrels. Every person keeping manure in any of the more densely populated parts of the district shall cause
all such manure to be removed from the premises at least twice every week between June 1st and October Slst
and at least once every week between November 1st and May 31st of the following year. No person shall remove
or transport any manure over any public highway in any of the more densely populated parts of the district
except in a tight vehicle which, if not enclosed, must be effectually covered with canvas, so as to prevent the
manure from being dropped. No person shall deposit manure removed from the bins or pits within any of the
more densely populated parts of the district without a permit from the health officer. Any person violating any
of the provisions shall, upon conviction thereof, be punished by a fine of not more than 40 dollars for each offence.

Fresh proof of flies as carriers of infection is furnished by the work of Buchanan^ with
M. domestica and the blue-bottle fly M. vumitoria. He describes the form and structure of
the fly's tarsus and shows how well adapted it is for carrying a large amount of infective
material. He had positive results as regards transference of specific germs and growth on
media, with swine fever, staphylococcal abscess, pulmonary tuberculosis and aiithrax. It
was less easy to prove conveyance of infection in the case of enteric fever, but this also was
successfully accomplished, the culture medium employed being that of MacConkey as
modified by Griinbaum and Hume.

Another useful paper is that by Hewitt. ' He believes that Homalomyia canicularis is
quite as guilty as M. domestica in the dissemination of infectious disease. He notes that in

' Howard, L. O. (September 21st, 1906), United States Dept. of Agriculture, Bureau of Entomology Cir.,
No. 71. Kevised Edition.

^ Buchanan, R. M. (.July 27th, 1907), "The Carriage of Infection by Flies." Lancet, p. 216, Vol. II.

" Hewitt, C. Q. (December 11th, 1907), " On the Bionomics of certain Calyptrate Muscidse and their Economic
Significance, with Especial Reference to Plies Inhabiting Houses." Journal of Economic Biology, p. 79, Vol. II.

EEVIEW — TEOPICAL MEDICINE, ETC. 77

England the method to bring about its decrease would be the universal adoption of the Flies-
water-closet system and also the proper disposal of kitchen refuse. coviinwd

Newstead^ has studied very fully the habits, life-cycle and breeding-places of the
common house-fly in Liverpool. The paper must be consulted for details but the conclusions
regarding breeding-places and the preventive measures recommended maybe tabulated here.

i. The chief breeding-pl.aces of the house-fly are : —

(a) Stable middens containing fermenting manure or a mixture of this and cow-dung ;
(h) Middens containing fermenting, spent hops ; and

(c) Ashpits containing fermenting vegetable matter, or about 25 per cent, of the total number of pits
examined,
ii. That covered ashpits and middens were as badly infested as those which were open,
iii. That house-flies breed in all temporary collections of fermenting matter.

iv. That house-flies breed in relatively small numbers in ashpits where no fermentation takes place.
V. That they do not breed in ashpits which are emptied at short intervals, or in the patent bins,
vi. That the use of disinfectants in ashpits does not prevent the flies breeding in such receptacles,
vii. That very dry or excessively wet ashes or moist cow-dung does not harbour them.

viii. That the i^resence of fowls (not ducks or geese), which had free access to the stable middens, reduced
the number of larvas and pupae to a very marked extent.

ix. That the life-cycle of the fly, in all kinds of fermenting materials, is reduced to the minimum period of
ten to 14 days ; and that in the absence of such artificial heat the cycle may occupy a period of from three to five
weeks or more, according to the temperature of the outside air.

X. That the house-flies do not depend entirely upon excessively warm weather for breeding purposes,
though in hot seasons they would breed much more rapidly in non-fermenting materials, and their numbers, under
such conditions, would be greatly increased.

If house-flies are to be reduced to a minimum, I would submit the following suggestions

1. That stable manure and spent hops should not be allowed to accumulate in the middeosteads during the
mouths of May to October inclusive, for a period of more than seven days.

2. All middensteads should be thoroughly emptied and carefully swept at the period stated in 1.

The present system of partly emptying such receptacles should in all cases be discontinued.

The walls of middensteads should also be cemented over, or, failing this, the brickwork should be sound and
well pointed.

3. That all ashpits should be emptied, during the summer months, at intervals of not more than ten days.

4. That the most strenuous efforts should be made to prevent children deffecating in the courts and
passages ; or that the parents should be compelled to remove such matter immediately ; and defecation in stable
middens should be strictly forbidden. The danger lies in the overwhelming .attraction which such fajcal matter
has for house-flies, which'latter may afterwards come into direct contact with man or his foodstuffs. They may, as

Vedeer puts it, " in a very few minutes load themselves with dejections from a typhoid or dysenteric

patient not as yet sick enough to be in hospital or under observation, and carry the poison so taken up into the
very midst of the food and water for use at the next meal. There is no long, roundabout process involved."

5. Ashpit refuse, which in any way tends to fermentation, such as bedding, straw, old rags, paper, waste
vegetables, dirty bedding from the" hutches '" of pet animals, etc., should, if possible, be disposed of by tenants,
preferably by incineration, or be placed in a separate receptacle so that no fermentation could take place. If such
precautions were adopted by householders, relatively few house-flies would breed in the ashpits, and the present
system of emptying such places at longer intervals than, say, four to six weeks, might be continued.

6. The application of Paris Green (poison) at the rate of 2 oz. to one gallon of water to either stable
manure or ashpit refuse will destroy 99 per cent, of the larvae. Possibly a smaller percentage of Paris Green might
be employed with equally good results.

One per cent, of crude atosyl in water kills 100 per cent, of fly larvae.

The application of either of these substances might, however, lead to serious complications, and it is very
doubtful whether they could be employed with safety. Paris Green, at a rate of 1 to 2 oz. to 20 gallons of water,
is used largely as an insecticide for fruit pests. It does no harm to vegetation when applied in small quantities ;
but cattle might be tempted to eat the dirty straw in manure which had been treated with this substance, and the
results might prove fatal if large quantities were eaten.

7. The use of sun-blinds in all shops containing food which attracts flies would, in my^ opinion, largely
reduce the number of flies in such places during hot weather. Small fruiterers' and confectioners' shops, as a rule,
are not shaded by sun-blinds, and in their absence flies literally swarm on the articles exposed for sale.

8. The screening of middensteads with fine wire gauze would, undoubtedly, prevent flies from gaining
access to manure, etc., but it is very doubtful if this method would meet with any marked success. The gauze
would rapidly oxidize, the framework supporting it would probably warp, and numbers of flies would be admitted
whenever the receptacle was opened. Moreover, the erectio'n of such a structure would prove a great
inconvenience and a hindrance to the removal of the refuse. This, however, does not prejudice the possibility of
erecting a good fly-proof screen in the future.

' Mewstead, R. (February 29th, 1908), "On the Habits, Life- Cycle and Breeding- Places of the Common
HoHse-Fly (Mmea domcstica, Linn./" Animls of Tropical Medicine and Parasiloloijy, p. 507. Vol. I., No. 4.

78 REVIEW — TROPICAL MEDICINE, ETC.

Flies— Notes are added on Calliphora erythrocephala, the " Blow-fly." It feeds on the faeces of

cmitiiiued man to a greater extent than the house-fly, and is very partial to fruits of various kinds,
hence it is very likely to be a vector of disease.

Franklin' writes with Indian experience. He thinks that there the house-fly breeds in
great numbers in night-soil and not in the vicinity of cook-houses, which apparently only
constitute its feeding grounds. He has made observations on these terrible pests, owl
midges, which, if confirmed, are likely to be helpful, for he finds that these so-called " moth-
flies " (in Khartoum they are always, though erroneously, termed sand-flies), breed out in
material taken from the neighbourhood of cook-houses, for example, what is found in the
drain at the back of cook-houses. He describes the larviE and pupae, and imagines from
some experiments, it would seem, that these tiny diptera can, like the house-fly, carry about
excrementitious material.

Another Indian paper is that by Major F. Smith, who draws attention to a very
important matter as regards the tropics, namely, the breeding out of M. entxniata and
Anthomijia tonitrui in scattered deposits of human fteces, and the occurrence of maggots of
these flies in the soil under the fcecal masses. As the faeces dry and crumble, the maggots bury
themselves in the earth, finding a passage by way of cracks or the holes made by worms or
dung-beetles. They were found to take about 14 days to hatch out.

Dog excrement was also found to serve as a breeding-place for M. entseniata, which, be it
noted, haunts houses and hospital wards. Cow-dung and earth under it harboured maggots
of M. dumesiica and M. enteeniata, while horse and donkey dung yielded larvte of M. domestica,
but did not seem to be a very favourite breeding-ground, at least in dry weather.

Experiments seemed to show that house-flies did not breed in ordinary ground as
distinguished from organic deposits.

The question of flies and their breeding-places, as regards Khartoum, will be discussed
under " Sanitary Notes." One need only note here that Major Smith's observations apply
to the Sudan as well as to India. They have been amply confirmed by Mr. King.

Passing now to biting-flies, we find a reference to the work of Legaillon- on the life-
history of Tahanus quatuornotatns. This is of Special interest in view of King's work on
T. bignttatiis in tlie Sudan.

The eggs are laid in bunches in places that may be either dry or moist, for instance, on
the leaves of plants, and are at first white, but soon darken. As is already known, some
larvae may be aquatic and others terrestrial, while their habits are carnivorous. The eggs of
the species under consideration hatched out in 14 days (in June), and are white and
transparent. They feed on dead prey and on organic detritus, and perhaps even on sluggish,
living animals. They can live under varied conditions of moisture and even in water.

One can only give some references to other papers or works on biting diptera. Thus
there is Austen's beautifully illustrated work on the British Blood-sucking Flies, while
Bouvier has a good paper in the Annales de Vlnstitut Pasteur of 25th July, 1906. Dudgeon
deals with the biting-flies of the West Coast and the Niger in the Journal of Tropical
Medicine for 1st November, 1906, and 15th November, 1906, and Newstead with those of
the Congo Free State in the Annals of Tropical Medicine and Parasitology of 1st February,
1907. (Series T.M., Vol. I., No. 1).

A German work by Griinberg is entitled " Die Blutsaugenden Diptera," while a
French paper by Surcouf, with coloured plates, occurs in the Archives de Parasitologie for
1st August, 1907. (Tome XI., No. 3)

Picard"* gives the distribution of the following species of Stomoxys which are found in
Tropical Africa : S. calcttrans, L. ; iS'. Korogwensis, Griinberg ; S. honffardi, Picard ;
S. inornata, Griinberg ; S. glaiica, Griinberg.

[Those interested in the distribution of Tabanid:e will find a list of those which occur in Angola given by
Wellman in the Journal of Tropical. Molicine and Hygiene for April 15th, 1908, p. 117, while Austen deals with new
African Tabanidie in the Annals and Magazine of Natural History, for March, 1908. In the same journal
Miss Ricardo commences a descriptive paper on 30 new species from Africa and Madagascar, which is continued
and completed in the April number.]

' Franklin, G. D. (September, 1906), " Some Observations on the Breeding-Ground of the Common
House-Fly, and a Description of a Species of Moth-Fly." Indian Medical Oazctlr, p. 349, Vol. XLI.

^ Legaillon, A. (February loth, 1906), "Egg Deposition and tlie Darval Life of the Tabanidte." Juarnul of
Tropical Medicine, p. 58, Vol. IX.

"• Picard, F. (1907), " Sur quelques Stomoxys de rAfrinue occidentale," Sail. Soc. Entomol. de France,
No. 18, p. 312.

• Article not consulted in the original.

EEVIEW — TROPICAL MEDICINE, ETC. 79

Food. It is quite impossible to deal in any detail with the mass of recent papers
on this subject. We propose only to mention a few which refer to food in the Tropics
or to tinned foods or to foods suitable for travel, as being most likely to be useful from
a Sudanese standpoint.

Simpson! points out that the defect likely to be in the diet of a European in the Tropics
is that it is too nitrogenous and fatty. This is due to the tendency to continue a diet
suitable for a temperate climate. The result is that too much meat is taken, which places a
strain on the excretory organs and causes disorder of the digestive functions. The condition
which ensues predisposes to sunstroke. Animal food should be diminished and a more
liberal allowance of vegetable food taken. The latter supplies the necessary constituents in
a less stimulating form and one more suited to a climate in which congestion of the abdominal
viscera is specially apt to occur. lu the Tropics, where the temperature is nearly as high
and sometimes higher than that of the body temperature, there is not the same necessity for
fatty food as in colder climates, and the substitution of fruits and farinaceous substances
for oleaginous articles will not only be more grateful to the taste but will prevent intestinal
disorders which, under the circumstances, are likely to be produced by a diet which is too
fatty. It would be a mistake, however, to exclude meat altogether from the diet, and, in the
case of special hard work out-doors, meat may be increased in the diet with advantage.
Carbohydrates furnish energy with a moderate production of internal heat, hence they are
very valuable in the Tropics, especially indigenous cereals such as maize, rice and the native
lentils, as they contain less nitrogen. Sugar is excellent when energy is to be liberated
rapidly with the least tax upon the digestive system. Simpson cites the case of the debilitated
cavalry horses in the Philippines which recovered health and energy when their coarse grass
or hay was sprinkled with molasses or sweetened water. He also refers to the deficient
nitrogen in the diet of the Hindoo, rice itself, though agreeable and digestible being deficient
in nourishment. In grain-eating populations starchy constituents bulk too largely and
require to be supplemented by a little animal food rich in oil, or seeds rich in albuminates
or oil, such as ground-nuts, or by adding other pulses less rich in oil and supplying the
requisite amount of oil separately.

Some useful notes are given on the decomposition of flesh and fish foods in the Tropics
and the danger of such decomposed food giving rise to choleraic diarrhcsa, while diseased
meat and adulterations of various kinds are also considered.

A good little book is that by MacKnight,^ which gives lists of foods found in and suitable
for the Tropics. It is a careful compilation and useful for reference.

El gofio is a food which has been praised for use in warm climates.^ It is manufactured
from different flours, including those obtained from wheat, maize, barley, white lupine, rye,
chick-peas and beans. It is said, along with milk and eggs, to be amply sufficient for
nourishment in the Tropics and is recommended as a ration for soldiers.

Wiley* mentions the value of a fruit diet and draws attention to the fact that the
prevailing characteristics of the natural food of the Tropics is found in the excessive
quantity of sugar which they contain, or, as in the case of cassava, of starch. The amount
of protein is very small, and the amount of oil is, with the exception of the cocoanut, not
marked. On the whole it appears that the natural tropical food is one composed of a large
excess of carbohydrates, in which sugar predominates. A gradual change in dietary is
indicated when one takes up residence in a tropical climate.

An excellent paper is that by Cantlie.^ He derides the erroneous belief that the natives
of the Tropics and sub-Tropics live on rice, and points out that vegetable eaters, quite apart
from the vegetarian faddists, are by no means confined to hot countries. He then considers
the various kinds of food available in the Tropics, some of his remarks applying with
particular force to the Sudan. He points out why beef is difficult to obtain and why, when
obtained, it is often tough and unsavoury. He mentions that most Europeans eat more meat
(when they can get it) in the Tropics than at home. Some say this is because the climate
is exhausting, and more strengthening food is required ; but the real reason, no doubt, is that

' Simpson, W. J. (July 15th, 1903), " Tropical Hygiene." Journal of Tropical Medicine, p. 224, Vol. V.

- MacKnight, T. M., " Pood for the Tropics," London, 1904.

= Reyes, S. (March 12th, 1904), " Pood in Warm Climates." Liaicd, p. 739, Vol. I.

♦ Wiley, H. W. (December 3rd, 1904), " Diet for the Tropics." Quoted in Epit. British Medical Journal, p. 83.

" Cantlie, J. (October 15th, 1906), " Pood and Digestion in the Tropics." Journal of Tropical Medicine,
p. 312, Vol. IX.

80 EEVIEW — TKOPICAL MEDICINE, ETC.

Food— the nutritive quality of the beef and mutton is inferior, and that more has to be taken to

continued supply the bodily wants, thereby taxing the digestive organs, which in hot climates are
usually feeble, and bringing a train of gastric, hepatic and intestinal troubles. As regards
fowls, it is stated that their nutritive value is relatively small and chicken is frequently
difficult to digest. Moreover, the monotony of eating fowl day after day, and month after
month, let the fowl be cooked in ever so many ways, palls upon the appetite after a time,
and digestion and nutrition suffer. One may add here that this is still more true of pigeons,
which form such a staple dish in Egypt and the Sudan. " Curry," says Cantlie, " if properly
made, is a hygienic dish and the condiments should be added by the consumer himself, or
herself, at the table and not by the cook." The word " curry " really means sauce, and the
therapeutic use of pepper seems to be not so much as a stomachic tonic as an intestinal
stimulant and chiefly as a stimulant to the large intestine. It is the large intestine that
first flags in its duty in the case of natives of tropical countries, who are very subject to
constipation owing to the atonic condition of the colon, a state of things often remedied by
the use of black pepper.

Alcohol. The natives of warm climates, both by their religion and their habits, shun
alcohol. It is in no sense a food, and Europeans in tropical countries would do well to
avoid its use altogether.

Spirits and beer in hot, moist climates are positively detrimental to health ; light wines,
white or red, do least harm. Champagne, taken after excessive fatigue, about sunset, is
perhaps the safest form of alcoholic beverage. It should not be taken with meals, but only
on reaching home after a fatiguing march, or long exposure to wet.

It is possible that in such a dry country as the Northern Sudan alcohol is not so
detrimental as in moist regions if taken only after sunset, and many feel the better for an
evening " nip." At the same time, the evil effects of alcohol may be insidious and may not
show themselves for years. On the whole, I am inclined to think that the total abstainer is
the more energetic and more healthy man here as elsewhere in tropical countries, but it is
well not to be too dogmatic and to remember " what is one man's food is another's poison."

Tea. " As a stomachic tonic," says Cantlie, " and as a safe way of introducing fluid to
the system, tea would seem beneficent and hygienic." It was evidently introdi;ced by the
Chinese, owing to the calamities arising from drinking unboiled water. Deep well-water is
almost unknown in China, and the shallow wells and streams are so apt to become polluted,
owing to the habits of the Chinese, that experience dictated the necessity of boiling the
water. But boiled water being insipid, and the object of its being boiled not being evident
to ignorant and thoughtless people, the water was " flavoured " by the leaves of the tea plant,
a custom which has become widespread. It was, no doubt, for hygienic purposes tea was
introduced, but the abuse of tea-drinking has brought many evils in its train. The Chinese
drink tea after finishing their principal meal, and in fact as a drink at any time. They do
not drink tea during their meal, but after the meal is finished. The pernicious system of
drinking tea during a meal is one peculiar to British folk, and the habit is fraught with
many dyspeptic troubles. The best China tea, i)repared by pouring boiling water over the
leaves and immediately pouring the water oii' the leaves, is a wholesome fluid, calculated to
aid digestion, especially when taken after the meal is finished. Tea taken with animal
food, be it eggs, fish, flesh or fowl, is a certain means of producing dyspepsia, for when the
tea is " drawn " for a long time, and when the tea used is of an inferior quality — the
method and material usual in Britain and Australia — the tannic acid of the decoction,
uniting with the albumen of the animal tissues, produces a leathery compound which no
gastric juice, however potent, can penetrate and digest. Tea, used as the Chinese use it, is
a hygienic drink ; as it is usually used in Britain and by the British folk throughout the
Empire it is detrimental to the public health.

Coffee. Two or three mouthfuls of good coffee after a meal are an aid to digestion ;
taken in quantity — brcakfast-cupfuls — it is an impediment to digestion, and, diluted with
half milk and taken with a meal of eggs, fish, fowl, or flesh, is still more so.

Tobacco. Tn moderation, and smoked soon after a meal, the deleterious effects of tobacco
arc infinitesiujal. When indulged in to excess, say six to eight cigars, or fifteen to twenty
cigarettes, or 1 oz. of pipe tobacco, it is an injurious cardiac depressant.

An interesting letter is that by Payn,' whose conclusions we quote, although he refers
more to conditions suitable to cold than hot countries. Still, even in hot countries sugar is

> Payn, F. W. (September 21st, 1907), " Athletics and Food Values." Lancet, p. 859, Vol. II.

REVIEW — TROPICAL MEDICINE, ETC. 81

of decided value as a producer of energy, and I have myself felt benefited from taking a Food —
liberal allowance of sugar during the trying summer months. I am inclined to think that conlinued

the good etfects of the cup of strong cotfee so frequently taken in the forenoon during office
hours are due in some measure to the contained sugar. Payn mentions : —

1. The incalculable restorative effects of liquid at a high temperature aft.er over six hours of continuous
marching. So great is the effect of boiling water on the efficiency of a man undergoing a forced march of 10 to 14
hours tliat I feel certain, from my experiments, that it is more important to provide the soldier on a long march
with a small apparatus for heating liquid than with food. The extent to which boiling water can take tlio place
of food was never fully realised by me until I marched 14 hours on three sandwiches and plenty of hot water.
Nothing but the possession of a spirit-lamp saved nio fi-om serious illness from fatigue and exposure during
some of these marches, and I have no doulit many travellers could corroborate this.

2. The imperious craving for sugar in some form which these long marches produce and the enormous
importance of an adequate supply of sugar in the diet of soldiers performing much liodily exertion. I have no
hesitation in saying, firstly, that the importance of sugar (owing to the consumption of the sugar in the Ijlood by
bodily exercise) is most inadequately recognised in English military diet ; and, secondly, that the private soldier
is too often driven to satisfy the natural craving for sugar after violent exercise by drinking alcohol. Hence he
believes that alcohol is natural and does him good. I further believe that it could be shown Ijy experiment that
men who were allowed a glass of milk with four lumps of sugar in it could undergo greater fatigue on that drink
than on almost any other.

.3. The vast superiority of hot oatmeal porridge at breakfast and supper over almost every other article of
food in maintaining efficiency and health during prolonged marches. Abnormal exertions, such as 15 hours of
climbing, throw the real value of foods into a far stronger relief than usual. The presence or the lack of that food,
during an ordeal of this sort, at breakfast or supper has so vast an effect on one's condition that I can scarcely
imagine any General who is aware of its value overlooking it as an almost complete and most portable food for a
forced march of 14 hours. It is far richer in mineral salts than meat.

4. The utility of dried figs. Given a meal of hot porridge for breakfast and supper a soldier could mai-ch
without discomfort or harm for a whole day or night on a handful of ligs and some hot liquid, owing to the fact
that they are so full of sugar and mineral salts, which are what the marching man chiefly needs, .\nyone who
overlooks the value of the fig in catering for the food of an army corps on campaign commits a great blunder. In
a rapid campaign the great requisite in food is the irreducible minimum for health and strength, which is not the
case in time of peace. I believe that a scientific medical investigation of the effects of the ordinary soldiers' diet
and of such a diet as the one indicated above in the case of men undergoing long tests of endurance, would be
exceedingly valuable from a military point of view as well as of great scientific interest, and I also believe that a
medical investigation of the dietetic tastes of persons who are known to perform so much bodily exertion as the
leading lawn-tennis players could scarcely fail to disclose new and valuable facts on the relation of athletics to
food values.

As regards tinned foods, Cathcart' deals with the bacterial flora found in "blown"
tins, chiefly in those containing sardines. The tins were bulged and, on being opened, a
foetid gas escaped, but the flesh of the sardines appeared quite normal and healthy. It was
found that organisms of an intestinal type were present, which on re-inoculation into sound
tins gave rise to a gaseous decomposition. No toxic symptoms were produced on feeding
guinea pigs with the contents of the " blovsrn " tins.

Beans form a favourite article of consumption in the Sudan, hence attention may be
directed to an epidemic of poisoning due to their use when tinned, and recorded by Eolly.'-*
Bacillus paratyphi, B., and Bacterinin coli commune were found present, but, owing to the fact
that the beans had been heated almost to the boiling-point, the illness was of a very benign
character. Two hundred and fifty people, were, however, affected. The bacteria appear to
have been killed and only their toxins consumed.

A question sometimes asked in the Tropics is — " How long may tinned foods be expected
to remain in good condition?" Harrington^ answers this by stating that properly canned
foods, according to the evidence at hand, should remain in good condition indefinitely. He
cites a case where tins were known to remain in good condition for 63 years. At the same time,
there do not seem to be any statistics on this point so far as hot countries are concerned.

Beveridge,'' has an instructive paper on South African experiences. He found

that no tinned meat stocked in the open, exposed to changes of temperature, heat of the sun and effects of rain in
warm climates, shoald ever be kept for more than one year. When under suitable cover, perhaps for two years, but
never more, and in all cases should be inspected at intervals. He explains that the paint of the tins gets cracked
or knocked off, damp and heat induce rust which specially affects dirt or cracks, and a hole, which may be very
minute, speedily forms. He also notes that, on long keeping, a change, of the nature of adipocere, not understood,
sometimes takes place in the meat itself, and this is another argument against long keeping. Paper labels are
condemned, while only painted tins should be accepted.

» Cathcart, E. P. (August, 190G), "The Bacterial Flora of 'Blown' Tins of Preserved Food." Journal of
Hygiene, p. 248.

1 Eolly, M&nch Med. IFoch., 1906, No. 37, p. 1798.

" Harrington, C. H., " Practical Hygiene." 3rd Edition.

•* Beveridge, W. W. 0. (August, 1906). Journal uf the Roijal Army Medical Corps.

' Article not consulted in the original.

82 REVIEW — TROPICAL MEDICINE, ETC.

Food — The most dangerous tinned foods are those eontiiiniiig much moisture, i.e. milk, salmon, lolistor and mixtures

continued °^ meat and vegetables.

The more acid foods, sueU as fruit, jams and vegetables, are more liable to take up metals from the tins.
The simpler tlic preparation, the bettor it stands the effects of climate and heat. Useful notes on inspection are
given. Apparent l>iilging may Ijc due to the tins being dented. A good tin of meat has usually sliglitly concave
ends owing to a partial vacuum forming during the process of sterilisation.

Ee-solderiug should be looked for. As a rule, two holes are made in one end of the tin to permit steam to
escape. Re-soldering, or the presence of a third or more soldered holes points to puncture to allow gas to escape.

Dented tins, if otherwise fit, should be issued early, as they are apt to rust and perforate on keeping.

On opening certain tins, i.e. of marmalade, rhubarb, tomato soup, etc., a blackened appearance may be
noticed. This is due to the action of the vegetaljle acids on the tin-plating, and if slight, and there is no evidence
of fermentation as evidenced by minute gas buljbles, may Ije neglected.

Decomposition may result from incomplete sterilisation, or incomplete sealing of the tin. Bulged tins, may be
tested liy puncturing them under water to test for the escape of gas. In some cases, a little gas will escape from
tins euutaiuing perfectly sound meat, owing to incomplete exhaustion during the process of sterilisation, Init
which, being sterile, is of no real consequence and amounts to, as a rule, only about 1 c.c. or so. One test
described is as follows : — When the swelling is not apparent, the tins are boiled for one hour, which causes, by
expansion, the ends of all to swell ; they are then cooled and set aside for eight hours, when the sound ones
will return to their former condition. The unsound ones will remain liulged as the convexity is due to the
pressure of gases. Viry states that putrefaction may take place in tinned meats without tlie formation of gas,
but Beveridge has not been able to confirm this. The presence of moulds at once condemns, the sterilisation
not having been efficient. Moulds impart an unpleasant taste to the food and are apt to cause diarrhoea.

Eber's test for the decomposition of meat is said to be useful but not absolutely reliable, owing to the
presence of trimethylamine, in, for instance, mutton and pickled foods. A small quantity of the reagent, which
consists of one part sulphuric ether, one part pure liCl. and three parts cthylic alcohol, is placed in a test-tube or
other suitable vessel. The material to be examined is smeared on the end of a glass rod, which is dipped below
the sm-faee of the reagent but is not allowed to touch the side. If ammonia be present, a cloudiness appears or
fumes may be given off.

Food Poisoning. This is a subject of very considerable importance in all hot
countries, and one has seen several examples of it in the Sudan. It may result from : —

1. Faulty preparation of food, as from dirty kitchen utensils, the dirty hands of cooks
and their assistants, imperfect or defective cooking, or the addition of deleterious substances,
either designedly or accidentally.

2. Decomposition vyhich is very apt to occur, especially in foods kept over-night.

3. Contamination, apart from preparation, i.e. from faulty storage or from the filthy
feet of flies or other insects.

4. Injurious food-stuffs, such as bad tinned foods or imperfectly cured or preserved
foods.

I recall an epidemic occurring at the Grand Hotel, Khartoum, and in this connection
Walker's paper' on the so-called "Canary Fever" of Las Palmas is specially interesting.
He has shown that this condition is in all probability due to bacterial infection of food. It
is peculiar by occurring in hotels, coming on suddenly, and attacking a number of hotel
residents at the same time. It is characterised by vomiting or nausea, followed by diarrhoea,
and the stools may contain mucus and even blood. The temperature may rise, but not as a
rule to any considerable extent. The length of attack varies from two days to three weeks.
The causes are discussed, and I quote here in full the preventive measures recommended,
because I think they are specially applicable to the hotels and numerous restaurants in
Khartoum, and because it has been found necessary in certain cases to enforce the adoption
of somewhat similar precautions : —

Meat and fish, particularly, should be protected from flies in as effective a manner as possible before it is
brought into the hotels.

When in the hotels all food should be protected from flies; the larder should be entirely fly-proof; the
entrance should be protected by two doors, between which there is room for a man to stand ; both these doors
should close automatically with springs, and it would be well to have some simple automatic arrangement which
would prevent one being opened until the other was closed. It should be easy to catch the few flies that might
possibly get into the larder, in spite of these precautions, by means of fly tr.aps.

Of (rourse the best plan would bo to keep the food in a chamber which was constantly below fi'cezing-point.
When the food was removed, once or perhaps twice during the day, it should be kept in fly-proof receptacles.

Meat should be kept hanging up, and not laid upon shelves.

Shelves and tables in the larder, serving rooms and kitchens, should be made of some non-absorptive material,
such as marble or slate. Most of the shelves and tables upon which the food was placed during the process of
cooking and serving, which I saw in the islands, were made of soft wood. No matter how much this wood be

• Walker, C. E. (February 29th, 1908), " Observations on the so-called ' Canary Fever.' " Annals of Tropical
Medicine mid Parasitology, p. 483, Series T.M., Vol. I., No. 4, Liverpool.

REVIEW — TEOPICAL MEDICINE, ETC. 83

scrubbed, there must always be a certain amount of organic material in a more or less advanced stage of Food

decomposition in the cracks. In the serving rooms, kitchens, etc., and wherever food is exposed for any length of Poisoning'

time to contagion by flies, the food should be covered up as soon as it is put down. The ordinary wire gauze dish cnutinved

covers are cheap, and admirably suited to this purpose.

Cooking utensils, plates, dishes, forks, spoons, etc., should be sterilised shortly before use. This would not
involve any very coasiderable extra labour, and convenient apparatus would not lie very costly. No pressure of
steam would be necessary, only tlie utensils should be brought to the temper.ature of steam. Cleaning with a jet
of live .steam, such as is done on ships, would be very effective.

Copper cooking utensils have the disadvantage that they require re-tinning at intervals. There is no means
of getting this done in a first-class manner in the islands. The tinning is often irregular, and it is impracticable
to get such a surface really clean and free from small collections of organic material. Something other than
copper would, therefore, be an advantage.

Soup must be made fresh every day, and the stock-pot abolished.

With regard to rechauffes, even if protection from flies is guaranteed between the first and second cooking, it
would be well if the material were always brought to boiling-point and kept so for some minutes.

Cold cooked provisions must be kept free from flies.

There should be b>it little difficulty in keeping the kitchen, and even the whole house, comparatively fi'cc
from Hies by means of wire gauze frames to tlie windows and doulile doors; the outside door to consist of a frame
with wire gauze stretched upon it. Such a plan would allow plenty of air to come into the rooms, and would
exclude the majority of the flies. This is done very extensively in America, and even by some people in England.

No suggestion is intended that the kitchens of the hotels are not clean in the ordinary acceptance of the word.
For instance, the kitchens of those I visited would compare very favourably with any kitchen I have seen in Europe.

What the observations really imply is that precautions which are sufficient in England to prevent a degree of
infection by bacteria enough to produce symptoms, are wholly inadequate under the conditions of temperature,
etc., in the lower and hotter parts of the islands.

It is quite possible that there may be one or more specific bacteria which are specially responsilile for the
aeuteness of the symptoms. Even if this be the case, however, there seems but little doubt that the flies are to
a large extent responsible for the original infection of the food. The rapid multiplication of the bacteria aud the
consequent production of toxins depends upon the local conditions. It would seem that the suggested precautious
are necessary whether there be a specific micro-organism or not. It is probable that food is more frequently
infected, even in the best conducted private kitchens in the towns in the islands, than is the case in Europe, and
that consequently the residents may have acquired a limited degree of immunity. I met several residents,
however, who told me that they had suffered from attacks after dining at hotels, but not at any other time.

An important paper, dealing with the bacteriological aspects of an epidemic of food
poisoning due to brawn containing the Bac!U}i!< enfprifidix of Gsertner, is that by Buchan.'
It is likely to be useful to any bacteriologist having to carry out an investigation of an
outbreak of this type.

Titze- sums up our present knowledge regarding meat poisoning as follows : —

1. By far the majority of cases of meat poisoning hitherto investigated have been shown to Ije due to bacteria
belonging to Gfertner's group or to the paratyphoid B. group.

2. These bacteria usually obtain entrance to the tissues of animals intended for slaughter as a result of septic
disease. The.y may not be the primary cause of septic processes, but possibly constitute an accompaniment of the
general disease condition produced by ordinary sepsis-producing organisms.

.3. The paratyphoid bacillus may also be conveyed to the flesh of perfectly healthy animals through various
accidental circumstances (poisoning by sausage meat).

4. We know nothing regarding the occurrence and spread of meat poisoning bacilli in and by healthy men
and animals, or their mode of existence outside the animal body ; we are equally ignorant regarding the reasons
for the variation in their powers of producing toxin, and in regard to the essential factors in toxin production.

■5. No sufficient investigations have been conducted regarding the injurious qualities of meat which has
undergone albuminous decomposition in consequence of the action of saprophytes (ptomaines and sepsins).

6. Botulismus is produced by an anaerobic saprophyte, the BacUlus botulinus.

Guinea Worm (Dracontiasis). The most important recent work on this subject is
that by Leiper.'* He first of all classifies the hypotheses of infection that have been
advocated, as follows : —

i. Those in which the development of the embryo is supposed to occur without the intervention of any
intermediate host, human infection being caused by —

(a) The embryo, as discharged from the parent worm ; or

(h) The mature larva, evolved from the embryo in water or marshy soil ; or

(c) The young adult, the product of the continued grovrth of the larva in water.

' Buchan, P. (December 7th, 1907), " kn Outbreak of Food Poisoning due to Eating Brawn." Lancet,
p. 1604, Vol. II.

- Titze, C. (March, 1908),"Zeits ftir Fleisch und Milchhyg." Quoted in Jounial of Cmnparalive Patliology
inul Therapeutics, March, 1908, p. 87.

" Leiper, R. T. (.lanuary 19th, 1907), "Etiology and Prophylaxis of Dracontiasis." Biiiish Medical Journal,
p. 129, Vol. I.

84 BEVIEW — TROPICAL MEDICINE, ETC.

Guinea He points out tliat these theories have become discredited, and gives further

Worm — experimental and literary evidence in favour of their being discarded. The embryos cannot

ointiiiuol infect man by the skin or mouth or undergo further development in water. His own
observations on the vitality of the embryos in water show that the usual period of survival
was three days, though some survived till the sixth day. In mud they lived a day or two
longer, probably because in this medium they move more slowly and are consequently
exhausted. Although provided with a mouth and digestive tract they are still unable to
obtain food for themselves.

ii. Those in which an intermediate host is considered essential fur the development of tlu^ larv.-i in order
that it may become iitted to re-infect mnu.

(d) The only, and in itself suiBcient, host being Cyclops.

(c) A second, and at present unknown, intermediate host being necessary to continue and complete
the changes begun in cyclops.

Leiper, in his experiments in Nigeria, found that, of all the organisms in the ponds,
Cyclops alone was capable of infection, and he believes that the mode of entry of the
embryo is not through the integument of the cyclops, as usually taught, but by way of the
intestine. As regards the completion of metamorpliosis, ho found tliat the striated cuticle
of the embryo was cast generally on the eighth day. The larva which emerged lost, two
days later, a very delicate enveloping pellicle, and from that time onwards underwent no
further ecdysis. The subsequent changes were confined to the differentiation of internal
structures, the larva apparently becoming mature in the fifth week. These observations
differ from those hitherto accepted.

Leiper also noted that the larvae showed no disposition to leave the cyclops and become
free-swimming, evidence that infection of man does not occur by the skin. As time went
on the larvae became more quiescent, and when the cyclops died the larvae were found dead
in its interior.

As regards the way in which they leave their host, Leiper^ refers to his pi'evious work,
in which he demonstrated the action of a 0-2 per cent, solution of hydrochloric acid in
killing the cyclops and rousing the larvae to such activity that they speedily escaped by the
mouth, anus, genital opening, or a breach in the cuticle of the cyclops, and swam about
freely in the fluid.

The later work has consisted in feeding a monkey on bananas containing cyclops
which had been infected for five weeks, and which had in them apparently mature larvae.
Six months later a careful post-mortem examination of the monkey revealed the presence in
the connective tissues of five filarite, which possessed the anatomical characteristics of
Filaria inedinejisis. There were three unimpregnated and obviously immature females about
30 mm. long, and two remarkably small males (22 mm.), which were obtained one from the
psoas muscle and the other from the connective tissue behind the oesophagus. These
results (says Leiper) point strongly to the truth of the theory that infection of man takes
place from the drinking of water containing infected cyclops. The suggestion that a second
intermediary host is necessary for the complete development of the guinea worm larva is
disposed of by the fact that this is actually attained in cyclops.

He comments upon the importance of the discovery of the male and immature female
forms in the connective tissue, showing that the guinea worm thus comes into line with
what we know of the after-development of other filariaj.

He thinks that Geotropism (tendency to grow downwards towards the earth) affords a
rational explanation of the remarkable distribution of the parasite in man.

An important fact to which attention is drawn is that the embryos are immediately
killed if dried by natural evaporation, and they cannot be revived by the re-addition of water.

A review is given of the conditions essential for the completion of the life-cycle of the
parasite, as follows : —

The young must be discharged directly into fresh water soon after the parent worm h.as succeeded in creating
a break in the overlying ^kiu and before the wound has become markedly septic. The embryos must find a cyclops
within a few days. They must, moreover, succeed in entering its body cavity. Five weeks later they will have
developed into mature larvse. These must, thereafter, be taken into the human stomach, and having been set free

• Leiper, R. T. (January 6th, 1906), "The Influence of Acid on Guinea Worm Larva encysted in Cyclops."
British Medical Journal, p. 19, Vol. \.

RBVlteW — TROPICAL MEDICINE, ETC.

85

flora their host by the gastric Juice, reach the cormective tissues l)y penetrating the gut wall,
parasite will necessarily be broken : —

The life-cycle of the

(1) By the death of the embryos, either from sepsis while still within the parent worm, or, if after their
discharge, by saltish water or drying. (2) If Cyclops arc not present in the water or, if the infected cyclops
die or are not taken into the human stomach. (3) If the larvae, ingested by the final host, are immature or fail to
escape fi-om the chitiuous sheath of the cyclops. Though they do lind their final habitat, the cycle will still be
incomplete if (4) there are not both males and females among the matured adults and if in their wandering the
females are not impregnated.

It will at once be seen from the above summary that the isolation of infective man
from healthy cyclops and of infected cyclops from man must be the object of any organised
eli'ort to stamp out dracontiasis.

Leiper then proceeds to detail preventive methods, so far as the West Coast of Africa is
concerned. These really resolve themselves into prevention of the fouling of water and the
provision of pure water. They have more or less a local bearing, but ho mentions that he
found another nematode larva in cyclops which might be a source of error in the course
of investigations. Finally, in a suggestive paragraph, he indicates lines of future work. We
tabulate the various points : —

1. Accurate observations as regards the conditions under which the intermediate host lives and multiplies in
tropical countries.

2. Determination of its natural enemies.

3. Determination of its food supply.

4. Oljservatious as to whether it can survive the drought of the summer, buried beneath the sun-caked mud,
or if, when once a pool has dried, it must be re-stocked from another source.

5. E.xperiments to see if, by the addition of chemicals, we can destroy the cyclops in suspected waters
without rendering these useless or dangerous to man.

As if in answer to these suggestions by Leiper, we find papers by Graham and Brady' on
the Cyclopidse of the African Gold Coast. The former points out that the inference that all
species of Copepoda cannot act as efficient hosts to guinea worm is strengthened by the
following considerations : —

1. There is a large number of species.

2. The habits of the different species vary greatly. Some are surface feeders, some are found at the bottom.
Some inhabit foul, some clean water. Some leave the water to climb on stalks of water-weed enveloped in a drop
of water carried with them, some do not leave the water ; some are found in streams, some are not.

3. The different species are infested by different parasites, some only by eoto, others by ento-parasites
(worms).

4. The different species differ in the date of their appearance in the pools. Some are found early in May ;
some appear, or, nt least, only become numerous, in July.

The significance of the date of appearance is dealt with in a previous paper,- where it is
shown that, in the Gold Coast, June is the month during which the signs and symptoms
of guinea worm infection attain their maximum. Presumably the month of maximum
manifestation in man is the month of maximum infection of cyclops. It is pointed out that
in the locality examined, when the streams were full of water, cyclops were found in the
streams and not in the wells, but when the channels were dry the cyclops occurred in the
wells and bred there. The natives stand in the wells during the dry season whilst drawing
water ; the embryos in their legs can then escape and infect the cyclops. The prophylactic
measures recommended are (1) careful filtration of the drinking water ; a fine handkerchief
will serve the purpose, as by this means cyclops can be readily removed ; (2) prevention of
infection of cyclops by providing troughs for the natives to draw water from, so that the
cyclops is excluded.

In a discussion on the above remarks, Sandwith stated that in the Sudan human beings
suffered from Filaria viedineiisia during two or three months of the year only, there being a
distinct periodicity. Chalmers stated his belief that the great amount of physical infirmity
due to guinea worm was not fully appreciated.

The life-span of the female worm, as noted by Manson and others, extends to about one
year (Graham says roughly ten months), and evidently depends on the habits of the species
of cyclops which serves as its intermediate host.

Guinea
Worm —

continued

1 Brady, Q. S. (November 9th, 1907), "Notes on Dr. Graham's Collection of Cyclopids fi'om the African Gold
Coast." Annah of Tropical MnUcinr mid raraaitoloyu, Series T.M., Vol. I., No. 3, p. 423.

^ Graham, W. M. (August loth, 1905), "Guinea Worm and its Hosts." Journal of Tropical Medicine
p. 248, Vol. V.

86 HEVIKW — TKOl'ICAL MEDICINE, ETC.

Guinea So far as the Sudan is concernefl, ]5ray' has shown that it is doubtful if dracontiasis

Worm— exists in Kassahi, but it occurs in Gedarcf and is very common in Gallabat on the Abyssinian

coitUimal frontier. It occurs but with no great frequency on the blue Nile, but is common on the

Upper White Nile, and is very prevalent in the Bahr-El-Ghazal Province and in Kordofan.

It is found chiefly in villages using surface water or shallow wells or employing hollow

Tobeldi trees (Adansonia digitata) as water reservoirs.

He notes that the life-span of the female worm is from nine months to one year.
Captain Cunnnins recommended that each native soldier bo provided with a strainer like
that mentioned by Graham. That the Nubas of Kordofan believe that infection takes place
by way of the skin is shown by the fact that they wear wooden pattens when crossing wet
or marshy places, whence, as experience has taught them, infection may be derived, (/b'ee
Captain Anderson's paper. Third Eeport.)

Hffimatozoa. This is a big subject and the literature upon it is very scattered, but a
good ret-Hmi'hy Sambon will be found in the 4th Edition of Hanson's 'Tropical Diseases.
His new classification is also given, but whether it will stand the tests imposed by time and
increased knowledge remains to be seen. The statement that the ookinete of the
HiEmogregarinidae encysts and produces sporozoites in secondary cysts or spore bags was, I
believe, founded on Christophers' work- with Ilfemoyrcgariiia (jcrhiUi and lice. The latter,
however, has had reason to doubt the correctness of his observations regarding the stage in
the louse, and believes that the appearances he described were due to a coccidial infection
of the louse itself.

Dutton, Todd and Tobey^ describe certain parasitic protozoa observed by them in the
Gambia and Congo Free State, amongst which we note the following blood parasites : —
Tnjpaiwsnui theileri, in all probability occurring in antelopes as far north as Kasongo, several
other forms of trypanosoma, including a large one in the monkey (Cercdpithecns i<chmidti),
malarial parasites in monkeys, malarial parasites and possibly spirochetes in bats. They
also found free gregarine forms in the blood of healthy dogs, probably the vermicule stage of
a htBmogregarine similar to that found in dogs in India, and also in dogs in Khartoum, by
Captain Giver, P.V.O., but so far undescribed.

In birds Proteosonia was never seen, but Halteridium was very common. This is
interesting in the light of Dr. Wenyon's investigations in the Southern Sudan.

So-called Leucocytozoa of birds are described, and this subject will be found considered
by Dr. Wenyon, whose observations are at variance, as regards the morphology of these
parasites, with those of the Liverpool observers.

Various parasites in reptiles and amphibians are described and figured. What is called
a Cytamceba of the frog appears to me to resemble very closely the endoglobular forms of
spirochiete I have found in fowls and geese in Khartoum. One cannot enter into any details
regarding these numerous hsematozoa, but some of the more important, such as trypanosomes
and spirochtBtes will be considered under their appropriate headings.

The most interesting of recent discoveries is that of the Sergents in Africa, who in a
patient suffering from night-sweats and nausea found on two different occasions a peculiar
ectoglobular parasite. It is vermiform in shape and measures about 40 n in length by 1 to
1-5 /I in size and is sharply pointed at either end. What seems to be a nucleus occupies
the whole of the middle third of the body. It was noticed that the parasite used to
disappear from the blood about 6 p.m. It therefore possessed a periodicity like tilaria
embryos. A sketch of this parasite is given in the latest (3rd Edition) of Christophers' and
Stephens' work.^ In this volume will be found notes on practically all the haematozoa found
up to date, and it is perhaps scarcely necessary to mention more of them, with the exception
of the hajmogregarine of cattle, H. h(,vi>', found in Erythrea by Martoglio and Carpano.-^*

' Bray, W. (October, 1904), "The Southern Sudan: Its Climate and Diseases." Journal of the Royal Army
Medical Corps.

^ Christophers, S. R., " Hsemogregarina Qerbilli." Sclaitijic Memoirs of the Govcniincnt of ItifUn, No. 18.
Calcutta, 1905.

■' Dutton, J. E., Todd, .J. L., ■•ind Tobcy, E. M. (November 9th, 190"), " Coucernino; certain Parasitic Protozoa
observed in Africa." Mem. XXI, Liverpool School of Tropical Medicine, and Jnnalsof Tropical Mcdiciiu- and
Parasitoloyn, Vol. I, No. 3, p. 28.5.

* Stephens, J. W. W., and Christophers, S. R., " Practical Study of Malaria," p. 261. 3rd Edition.

' Martoglio, P., and Carpano, M., Ann d'Ig. Sperim., t. XVI., 1906.

• iVrticle not consulted in the original.

KEVIEW — TROI'ICAL MEDICINE, ETC. 87

This was a single observation, and it seems a little doubtful if the interpretation was correct. Hsmatozoa
The parasites were 7 /it to 10 |tt in length and from 1 /it 6 to 2 /u in breadth, and had rounded —omUnuo/
ends. Inoculation experiments failed. Mention may also be made of the Spirochieta
thdhri found in cattle in the Transvaal and the Cameroons, the Sp. ovis of sheep in
Erythrca, which is possibly identical with the Sp. tlmileri and the Sp. eqiti which occurs
in mammals in the French Sudan.

Sambon' has drawn attention to certain appearances in the haemogregarines of snakes,
namely, delicate oblique lines passing transversely across the long axis of the parasite at
from 1 /I to 2 ^t from one or both of its extremities. He regards these as possibly representing
lines of future cleavage of the capsule of the sporont, sporont being the term applied to the
new forms developed from the merozoites and destined to pass into the body of the definitive
host and so carry on the further life of the parasite. He also describes a beak-like
projection at the anterior extremity of the sporont, and in one species noted a definite
dimorphism which may represent sexual differentiation.

Two other discoveries may be quoted, as their confirmation might well be worked out in
the Sudan. These are {1) the observations by the Sergents-* that Hfeinoproteus (Haltcridium)
columhn? passes through its stage of sporogony in one of the Hi.ppohoscidce, Lynchia maura.
The incubation period in the pigeon is from 34 to 38 days, and the earliest forms in the
bird's blood are very minute, i.e. 1 ^t to 2 /» in diameter. (5) The confirmation of this
observation as regards Hip>pobvscida3 by Aragao,^* and his statement that part of the cycle
of evolution is passed in the lung of the pigeon, cysts containing the merozoites being
found in the large mononuclear leucocytes of the pulmonary capillaries.

Heat Stroke. Duncan^ describes the clinical varieties as follows : —

A. Heat collapse. K. Heat stroke. («) Direct heat stroke or sunstroke proper ; {b) Indii'ect heat stroke.

.\. Heat collapse. The patient suddenly turns giddy and falls. Skin moist and cool. Breathing hurried
but never stertorous, pulse small and soft, pui^ils dilated, temperature at or below the normal. No loss of
consciousness, and recovery the rule.

B. Heat stroke («). Direct heat stroke or sun stroke. There are several forms. 1. Occurs in persons
unaccustomed to marching and attacks them specially when the air is moist. There is violent headache and
oppression followed by convulsions, loss of consciousness, difficult respiration, small and irregular pulse and often
incontinence of urine.

2. Is characterised by excessive sweating, pallor, cyanosis, shallow breathing, injected eyes, swollen veins and
partial collapse without complete unconsciousness. Revival occurs under proper treatment.

3. No fatigue is complained of, but the patient is thirsty and suddenly falls forward comatose. The coma
may last 24 to 36 hours and end in death.

4. After exertion and exposure to the sun a racking headache sets in. This becomes intense and finally
agonising. Great intolerance of light ensues, followed perhaps in 48 hours by unconsciousness. If death does not
occur, the intense pain in the head may last from six to eight weeks unrelieved by any drug, but there may be
slight evening remissions. It then gradually abates. (6) Indirect heat stroke. This is the syncopal form, occurring
not in the open but in the hot house or bungalow. Duncan finds it the most frequent tj'pe. At the onset the skin
becomes pale; there is nausea, colic and incontinence of urine. Convulsions now follow, to be succeeded by cyanosis,
dyspncea and insensibility. The breathing is stertorous, the pupils contracted and the body temperature may
reach 108' F. to 110° F., remaining high post mortem.

I have seen such a case, terminating fatally, in a young British soldier in Khartoum.

The diagnosis at first was very difficult, renal colic being the condition which suggested
itself. The post mortem appearances, especially a peculiar bluish and milky opacity of the
brain membranes, recalled another case which was not diagnosed during life and which was
complicated by a form of irritant poisoning. I have known type No. 3 occur in Khartoum,
but I am inclined to think, from what I can gather, that heat stroke is rare in the Sudan,
doubtless in part because of the excessive dryness of the atmosphere throughout the greater
part of the summer. Dr. Crispin notes that it is commoner on the moist Eed Sea Coast.

Duncan deals with the indirect causes and considers treatment under Preventive and
Curative Measures. As regards the former, he mentions the custom, common to old
European residents in Egypt, of wearing under the helmet, a tight jean skull cap similar to
that worn by the Arabs under the turban or tarboosh. I have never heard of this custom

> Sambon, L. W. (June loth, 1907), " Haemogregarines of Snakes." Lmicet, p. 1650, Vol. I.
- Sergent, Ed. & Et. (November 24th, 1906). C. E. Hoc. Biol., t. LXI.

' Aragao, de B., Brazil Medico, t. XXI., No. 31, August lath, 1907. Quoted in Ball, dc I'lustil. Pasteur,
November 15th, 1907.

* Duncan, A. (April 1st, 1903), " On Heat Stroke." Journal of Tropical Medicine, p. 101, Vol. V.

* Article not consulted in the original.

88 REVIEW — TKOriGAL MEDICINE, ETC.

Heat Stroke being in vogue in tlie Sudan. Proper forms of helmet, tinted glasses, loose clothing of a
— continued proper colour, and the spinal pad are all considered.

As regards treatment, douching the head and neck with cold water, the application of
annnonia to the nostrils, turpentine cneniata and mustard poultices to tlic chest are
mentioned. The use of ice to the head is contra-indicated where the skin is cold and the
pulse feeble. Convulsions indicate a few whifl's of chloroform. In cases of direct heat
stroke in Italy, trinitrin has been found useful, a solution of 1 in 1000 being given in doses
of 20 minims to 4500 minims of water every quarter of an hour. Venesection is dangerous.

Manson quotes Chandler's treatment for hyperpyrexial cases. It consists principally
in the use of ice and iced water externally, with the patient on a stretcher, digitalis being
given to ward off heart-failure. Strychnine is contra-indicated. Artificial respiration has
saved cases iu desperate straits.

Gardini,' describing cases in Florence in 1905, notes that the attacks frequently came on
after a full meal when the production of CO., was increased, and that the coma of sunstroke
resembles that of urismia, but, unlike the latter, is usually associated with hyperpyrexia.
The types he gives in order of frequency are : 1. Mixed forms, 2. Asphyxial, 3. Syncopal,
4. Cerebro-spinal. In every case, he states, the prognosis should be reserved, as cases
beginning very slightly may rapidly get worse.

Rogers believes that under the terms Heat Exhaustion, Sunstroke and Heat Stroke or
Siriasis, two broadly different conditions are included. First, — syncopal attacks due to
exposure to the direct rays of the sun or to hard labour during great heat {i.e. in stokeholds
of Red Sea and Persian Gulf steamers). In these cases there may be no marked elevation
of body temperature, and, if properly treated, recovery is the rule, with or without some
permanent mental injury.

Second, — true heat stroke with hyperpyrexia and acute pulmonary congestion, coming
on very suddenly, usually without any actual exposure to the sun's rays. Such cases only
occur under very trying atmospheric conditions, either excessive dry heat or lesser
degrees of moist heat. This is true heat stroke.

In the first class, it is faintness due to heart-failure under special stress which takes
place. In the second, it is essentially loss of consciousness due to hyperpyrexia, the cause
of which is attributed either to exposure, to excessive heat, producing in some way not yet
fully understood, failure of the heat-regulating mechanism of the body, or to the toxins
produced by a hypothetical microbe. It may be said at once that Rogers has no faith
whatever in Sambon's microbic theory, and adduces arguments against it. He dwells upon
the important part the presence of atmospheric moisture plays by checking surface
evaporation. Alcohol seems both to predispose markedly to heat stroke and to greatly
increase the gravity of the cases. Rogers also contradicts the statement that the disease is
never found at an altitude above 600 feet, and shows that 71 per cent, of 424 Indian cases
occurred at over this elevation above sea level.

As regards premonitory symptoms, the desire to micturate freely receives special mention.
It appears to be a valuable warning sign. The author thinks that quinine, guarded by
cardiac tonics, should always be used, as, apart from the question of malaria, it is likely to
help in restoring the control of the heat-regulating mechanism. He suggests careful
intravenous administration, and the rubbing of 10 to 15 minims of creosote into the axilla, as
a method of producing diaphoresis. The occurrence of mild forms of fever due to heat stroke
is considered, and it is stated that they quite possibly exist but are not common, in Calcutta
at least.

Hydrophobia. This disease is happily not common in the Sudan, but a case did
occur in Khartoum, and, as in most tropical countries, it may assume importance, some of the
recent work upon it — mostly foreign — may be cited.

Williams and Lowden- carried out original work with two ends in view.

1. To determine the value of the " Negri bodies" in diagnosis and methods for their
rapid identification.

2. To determine their precise nature.

' Qardinj, O., Clin. Modern, No. 22-24, au XII. Quoted in Epit., British Medical Journal, October 6th, 1906.

" Williams, A. W., and Lowden, M. M. (May 18th, 1906), "The Etiology and Diagnosis of Hydrophobia.''
Journal of Infectious Diseases, p. 4o"i.

KEVIEW — TKOPICAL MEDICINE, ETC.

89

They detail the techniquo both for smears and sections. That for smears may bo
quoted here as likely to prove useful : —

1. Glass slides and cover-glasses are washed thoroughly with soap and water, then heated in the flame to get
rid of oily substances.

2. A .small bit of the gray substance of Ijrain chosen for examination is cut out with a small, sharp pair of
.scissors and placed about one inch from the end of the slide, so as to leave enough room for a label. The cut in
the brain should be made at right angles to its surface and a thin slice taken, avoiding the white matter as much
as possible.

3. A cover-slip placed over the piece of tissue is pressed upon it until it is spread out in a moderately thiu
layer, then the cover-slip is moved slowly and evenly over the slide to the end opposite the label. Only slight
pressure should be used in making the smear, but slightly more should be exerted on the cover-glass toward the
label side of the slide, thus allowing more of the nerve tissue to be carried farther down the smear and producing
more well-spread nerve cells. If any thick places arc left at the edge of the smear, one or two of them may be
spread out toward the side of the slide with the edge of the cover-glass. If the first smear does not seem to be
well spread out others should be made until a satisfactory one is obtained.

4. For diagnosis work such a smear should be made from at least three different parts of gray matter of the
central nervous system : first, from the cortex in the region of the fissure of Rolando or in the region corresponding
to it (in the dog, the convolution arouud the crucial sulcus) ; second, from Amnion's horn ; third, from the
cerebellum. In many of the animals reported here smears were made from the gray matter of the cerebral cortex,
around the fissures of Rolando and Sylvius, from the olfactory bulb, Ammon's horn, cerebellum, medulla in the
region of the roots of the cranial nerves, spinal cord in the dorsal and lumbar regions, spinal and Gasseriau
ganglia, salivary glands, suprarenals, and some of the peripheral nerves. From the last four-named structures the
smears were not very successful, so only a few vrere made.

5. The smears were dried in air, and subjected to one of the two following staining methods : —

(a) Qiemsa's Solution. The smears are fixed in methyl alcohol (commercial is just as good as pure) for
about 5 minutes. The staining solution recommended last by Giemsa (1 drop of the .stain to every c.c. of distilled
water made alkaline by the previous addition of one drop of a one per cent, solution of potassium carbonate to
10 c.c. of the water) is poured over the slide and allowed to stand for one-half to three hours. The longer time
brings out the structure better, and in 24 hours well-made smears are not overstained. After the stain is poured
off, the smear is washed in running tap-water for one to three minutes, and dried with filter paper. If the smear
is thick, the " bodies " may come out a little more clearly by dipping in 50 per cent, methyl alcohol before washing
in water, then the washing need not be as thorough. By this method of staining, the cytoplasm of the " bodies "
stains blue and the central bodies and chromatoid granules stain a blue-red or azur. Generally the larger
" bodies " are a darker blue than the smaller, the smallest of all may be very light. The stain varies somewhat
according to the thickness of the smear. Some have a robin's egg blue tint, but this is after a longer fixation in
the methyl alcohol. In this case the red blood cells may have a greenish tint. The cytoplasm of the nerve cells
.stains blue also, but with a successfully made smear the cytoplasm is so spread out that the outline and structure
of most of the " bodies " are seen distinctly within it. The nuclei of the nerve cells are stained red with the azur,
the imcleoli a dull blue, the red blood cells a pink-yellow, more pink if the decolorisation be used. The " bodies "
have an appearance of depth, due to their slightly refractive qualities.

For diagnostic purposes this method of staining may be shortened as follows : Methyl alcohol, five minutes,
equal parts of the Giemsa solution and distilled water, 10 minutes. In this way " bodies " are generally brought
out well enough for di.aguosis, and sometimes the structure shows distinctly. It is always well, however, to make
smears enough for the longer method of staining, in case the shorter one should prove unsatisfactory.

(b) The eosin-methylene blue method recommended by Mallory. The smears are fixed in Zenker's solution
for one-half hour, after being rinsed in tap-water they are placed successively in 95 per cent, alcohol iodine one-
quarter hour, 95 per cent, alcohol one-half hour, absolute alcohol one-half hour, cosiu solution 20 minutes, rinsed in
tap-water, methylene-blue solution 15 minutes, and dried with filter paper. With this method of staining the
cytoplasm of the " bodies " is a magenta, light in the small bodies, darker in the larger; the central bodies and
chromatoid granules are a very dark blue, the nerve cell cytoplasm, a light blue, the nucleus a darker blue, and
the red blood cells a brilliant eosin pink. With more decolorisation in the alcohol the " bodies" are not such a
deep magenta and the difference in colour between them and the red blood cells is not so marked.

The " bodies " and the structure are often more clearly defined with this method, and perhaps, on the whole,
it is better to use it for making diagnosis ; but when there are only tiny "bodies" present, or when the brain
tissue is old and soft, the Giemsa stain seems to be the more successful ; above all, when one wishes to study the
nature of the central structures and granules the Giemsa stain must be used. We therefore recommend strongly
the use of both methods. Even if both are used, and one has to wait for the longer method, the technique is far
simpler than any so far published.

Van Dieson, working in our laboratory, suggests a staining method which differentiates the " Negri bodies "
more quickly than either of the two methods described above. So far, the best proportion of the stains used have
not been determined, but satisfactory results have been obtained from the following mixture : To 10 drops of
distilled water three drops of a sat. ale. sol. of rose-anilin-violet and six drolls of LcefiSer's solution of methylene
blue are added. The smears are fixed, while moist, in methyl alcohol for one minute. The stain is then poured
on, warmed until it steams, poured off, and the smear is rinsed in water and allowed to dry.

The cytoplasm of the " bodies " is a deep and distinctive red, their inner structures are a dark blue, the nerve
cells are a light blue, and the blood cells a pale salmon-red.

The staining mixture remains good for about an hour.

Their summary and conclusions are as follows : —

1. The smear method of examining the " Negri bodies " is superior to any other method so far published, for
the following reasons : (n) It is simpler, shorter and less expensive ; (b) the " Negri bodies " appear much more
distinct and characteristic. For this reason, and the preceding one, its value in diagnostic work is great ; (c) the
minute structure of the " Negri bodies " can be demonstrated more clearly ; (li) characteristic staining reactions
are brought out.

Hydrophobia

— continued

90 REVIEW — TKOPICAL MEDICINE, ETC.

Hydrophobia 2. The " Negri bodies," as shown by the smears as well as by the sections, are specific to hydrophobia.

— cuiili/iiied 3. Numerous " bodies " are found in fixed virus.

4. " Bodies" are found before the Ijeginuing of visible symptoms, i.e. on the fourth day in fixed virus, on the
seventh day in street virus, and evidence is given that they may be found early enough to account for the
appearance of iafectivity in the host tissues.

5. Forms similar in structure and staining (lualities to the others, but just within the limits of visible
structure at (1500 diam. magnification) have been seen. Such tiny forms, considering the evidence they give of
plasticity, might be able to pass the coarser Berkefeld filters.

6. The "Negri bodies" are organisms belonging to the class Protozoa. The reasons for this conclusion are :
(a) They have a definite, characteristic morphology ; (i) this morphology is constantly cyclic, i.e. certain forms
always predominate in certain stages of the disease, and a definite series of forms indicating growth and multipli-
cation can be demonstrated; (c) the structure and staining qualities as shown, especially by the smear method of
examination, resemble that of certain known Protozoa, notably of those belonging to the sub-order Microsporidia.

7. The proof that the "Negri bodies" .are living organisms is sufficient proof that they are the cause of
hydrophobia ; a single variety of living organisms found in such large numbers in every case of a disease, and
only in that disease, appearing at the time the host tissue becomes infective in regions that are infective, and
increasing in these infective areas with the course of the disease can be no other, according to our present views,
than the cause of that disease.

A somewhat similar rapid method of diagnosis is that given by Frothingham.^*

Cornwall' has a paper on recent advances of knowledge in connection with rabies, in
which he points out that "Negri bodies" can be demonstrated in brains which have been
ill-preserved and are even in a state of putridity. A microscopical diagnosis can now be
made in a day or so. If " Negri bodies " are found, rabies can be safely diagnosed. If not
fovmd, and the specimen is fit for inoculation into a rabbit, the biological test can still be
made, and in a few cases it succeeds where the " Negri bodies " have been missed by the
microscope. It is evident that early diagnosis is important in the case of patients unwilling
to go for treatment until the diagnosis is certain, while it is satisfactory for patients under
treatment to know that the latter is absolutely necessary. While "Negri bodies" are easily
found in the brains of animals dead from street virus, they are with difficulty found in fixed
virus-^ brains, and then only in very minute forms. All observers agree that rabic virus
filtered through a Berkefeld candle retains its virulence. The large " Negri bodies " cannot
pass this filter, so if, as Negri holds, the brain is thickly studded with minute forms or
spores, which are unstainable or ultra-microscopical, and, therefore, invisible, the filtrability
of the virus is an argument in favour of the parasitic nature of those bodies.

Nitsch, while giving some very gratifying statistics as regards the Pasteur treatment
in his hands, indicates further improvements in the method by combining injections of
antirabic serum with injections of fixed virus, as Pasteur's method of immunisation can
only succeed in those cases which have a sufiiciently long incubation period to allow of
immunisation before the outbreak of the disease.

Stefanescu^* has signalised the discovery of the " Negri bodies " in the salivary glands
of mad dogs, while Babes"* believes : (1) That certain very fine spherical, black or blue
bodies (Cajal-Gicmsa stain) found in degenerated nerve cells represent the parasites of
rabies in full activity; and (2) that the large "Negri bodies'' are encapsuled forms in process
of involution and transformation owing to the local reaction induced in the invaded cell.

Lentz'' has recently described two new staining methods for the " Negri bodies," and
illustrates the results by two coloured drawings which give a very clear idea of the form of
the corpuscles.

Negri,'* continuing his previous work, indicates a cycle of development for the bodies
bearing his name, which, though incomplete, is suggestive and strengthens the idea of their
being protozoa. There are two phases : (</) large chromatin masses breaking up into

' Frothingham, L. (April, 1906). Journal of Medical Kcscarch, Vol. XIV.

- Cornwall, J. W. (April, 1906), "Recent Advances of Knowledge in Connection with Babies." Indian Medical
Gazette, p. 121, Vol. XLII.

" "Fixed virus" results from the serial passage of "street rabies" through rabbits. It is exalted in
virulence. — A. B.

* Stefanescu, E. S. (May 18th, 1907). C. R. Soc. Biol, t. LXII.

° Babes, V. B., Press Medical (October 20th, 1906), Zcil.j. Uyy., t. LVI., f. 3, May 24th, 1907.

« Lentz, 0. (July 27th, 1907), " Ein Beitrag zur Fiirbung der Negrischen Korperchen." Ccnt.fui- liakt. I. Oria.
Bd. XLIV., p. 374.

■" Negri, A. N. (May 5th, 1907). Rendie d. R. Ace. dci. Lincci, t. XVI.

• Article not consulted in the original.

REVIEW — TKOPICAL MEDICINE, ETC. 91

(?)) grains which are surrounded by a ring of protoplasm, and which are so small as only to be Hydrophobia
visible eii, masse. — continued

Eemlinger,' in an important paper, states that spontaneous recovery of experimental
rabies can take place in the dog and that the rabic virus can persist in the saliva
of recovered animals. The points he raises require confirmation, and are under the
consideration of a special Committee.

Ice. A paper on the Pollution and Self-Purification of Ice, in the Monthly Bulletin,
New York State Department of Health, of March, 1907, will amply repay perusal to all
those responsible for the public health, and more especially in hot climates.

It is pointed out that there are very few cases on record where intestinal diseases have been traced to ice as
the vehicle of infection and that, of these, one must clearly distinguish between intestinal disturbances caused by
decomposing organic matter, and diseases, such as typhoid fever or cholera, caused by the specific germs. Some
half-dozen supposed ice-borne epidemics, chiefly of enteric fever, are cited, and the conclusion come to is that the
evidence is by no means reliable.

Ice may be infected because derived from polluted water, natural ice may be contaminated in situ, and either
natural or " artiticial " ice m.ay be rendered impure during manufacture, handling or distribution. The last-
mentioned is by far the most serious mode of infection, for it leaves the time interval, between infection and
transmission, too short for any counteracting influence of cold to be exerted. The influences effecting self-
purification of ice are : —

1. The phenomenon of subsidence and oxidation upon suspended matters, including bacteria in bodies of
quiescent or slowly flowing water. This, of course, applies chiefly to ice from lakes and ponds. In rivers,
however, it is found that in a run of from 10 to 15 miles, from 50 per cent, to 75 per cent, of the bacteria are
removed by this means.

2. The removal of suspended and dissolved matters brought about during the freezing process, the so-called
" filtration process of freezing." This in general effects a reduction of about 90 per cent, of the suspended
particles and bacteria and also eliminates to a certain degree chemical compounds in solution.

3. And, most important, the effect of low temperature. The special point to note is that the period of
exposure is of greater importance than the degree of cold. It is said that bacteria are reduced in number about
50 per cent, after exposure to freezing temperatures for one hour ; 90 per cent, after 24 hours ; and practically
100 per cent, after two to three weeks. The few killed after a month are so attenuated as to be unable to produce
disease.

4. The general tendency to the destruction of pathogenic bacteria when exposed or disseminated through a
body of water. This is no doubt due in part to unfavourable environment and in part to the hostile action of the
common water bacteria. It is thus evident that in most instances it is the storage, handling and distribution of
ice which require special attention from the standpoint of a health officer.

As regards Khartoum, a few remarks on this subject will be found under " Sanitary
Notes" (Third Eeport).

Infectious Diseases. Under this somewhat comprehensive title we propose to
consider only one point, namely, the early diagnosis of infectious diseases by recognition
of the involvement of lymph glands.

Vipond- has a very interesting paper on the former subject, and his conclusions may
bo quoted with advantage. He says : —

1. The nodes are enlarged in infectious diseases.

2. They are enlarged some days before the development of the disease. I have found them to be enlarged
and tender seven days before the rash of measles appeared.

3. The enlargement is most marked between the ages of from three to 18 years.

4. The enlargement is not produced by the irritation of the rash, but is due to the absorption of the poison
or toxin.

5. As a rule nursing infants do not contract infectious diseases readily, as the tonsils are small and inactive.

6. The tendency to contract infectious disease would be much lessened if the mouth and tonsils were in a
healthy condition.

7. The enlargement of the nodes is more marked in certain infectious diseases than in others. For instance,
they are larger in erysipelas, measles and rubella than in scarlet fever and whooping-cough.

8. They resolve more quickly in diphtheria under the influence of antitoxin than they do in measles and
erysipelas.

9. In all infectious diseases (except those of local incubation) the poison most likely enters the system
through the tonsils.

10. Suppuration does not take place in the nodes unless we are dealing with a mixed infection.

^ Remlinger, P. (November, 1907), "Spontaneous Recovery of Experimental Babies in the Dog and the
Persistence of the Rabic Virus in the Saliva of Recovered Animals." Journal of Tropical Vdcrinarij Science, p. 393

- Vipond, A. E. (December loth, 1906), "The Early Diagnosis of Infections Diseases by the Recognition of
the General Involvement of the Lymphatic Q-landular System." British Medical Journal, p. 1710, Vol. II.

92

REVIEW — TROPICAL MEDICINE, ETC.

Infectious Piu.-illy, when called t.o see a child suffering from an infectious disease, it is one's duty to examine the other

Diseases — children in the family who liave been exposed, and, it the nodes are found to be enlarged, they too should be

continued ^'''^^'•^^^^ immediately, and thus do away with the dangerous custom of billeting children upon friends and relatives,

with the iuevitalile result of spreading the disease broadcast. I am satisfied that in the future the practice of

isolating children already suffering from infected nodes will largely do away with epidemics in public schools.

A glance at the mortality tallies of all our large cities will show a high death-rate from infectious diseases, and
the early recognition of infectious diseases by means of the node involvement would result in these precautious,
which would prevent the spread of the disease, thus materially reducing the death-rate resulting from infectious
diseaseii.

Influenza. Influenza, or what is said to be influenza, although I do not know that
any cases have been diagnosed bacteriologically, has occurred more than once in Khartoum,
and doubtless true influenza is not unconuiion in the Sudan, for the disease is by no means
confined to countries with cold or temperate climates. Hence some very interesting and
apparently none too well known facts brought out by Allbutt' may be mentioned with
advantage. 1 have tabulated them just as they occur in the course of his lecture : —

1. Gases in which the respiratory tract is unaffected are not infectious, the disease being propagated in the
sputum and spr.-iy from the respiratory tract and apparently in no other manner save, perhaps, at the very
beginning ol epidemics, for between epidemics the bacillus must be latent somewhere, unless, indeed, it is normally
present in human beings, i.e. in the oral cavity, and for some reason or other takes on pathogenic properties.

2. The origin and habits of the parasite are still unknown.

3. Five to six months immunisation after attack is generally conferred even on very susceptible people.
Twelve months is the more usual respite.

4. The inllammation appears to be of an erysipelatous type. There is a tendency to small cell and nuclear
infiltration, there being far more intestinal infiltration than in croupous pneumonia.

5. The disease is very seldom confined to one lung.
G. Influenza, like phthisis, may excavate the lung.

7. In convalescence the malaise very often departs as suddenly as it came on, that is to say, a brusque
recovery occurs in the course of a protracted convalescence.

8. Allbutt adds a fourth to those usually recognised, namely the continuous form. There is a persistent
febrile state, though the temperatures are not high nor the .symptoins severe.

9. In making the diagnosis, it is important to note that, unlike what is found in other febrile conditions, the
urine in infiueuza is not high coloured and is not lateritious as in " chill." This would appear to bo a practical
point of very considerable importance.

10. Paraplegic attacks and peripheral neuritis may occur as sequelae.

11. Angina pectoris may also be a sequel.

12. ^ It is not safe to give a patient chloroform for some time after an influenzal attack, owing to the cardiac
disability which ensues upon it.

Eogers- mentions that in India the type of the disease does not differ from that met with
in Europe. The great frequency of respiratory and throat complications help to distinguish
it from malaria and seven days' fever. Its diagnosis from dengue has been considered.

Williams,-' following Corvisart and Wilks, speaks of the great value of an initial dose of
opium in influenza. A full dose of 20 to 30 minims of liq. opii. sedativ. is given, and as a
rule abolishes the distressing pains in a short space of time and ensures refreshing sleep.
Indeed the action is so marked that it is probable the drug exercises a specific action on
the Pfeiffer bacillus.

Nash^ states that in every case of influenza there is a swelling and cedema of the uvula,
which, as a result, has a pale, waxy, cedematous appearance. It is found at the commence-
ment of the attack and usually lasts for several days. He regards it as a certain sign of
the disease.

Insects. A good general article on the relation of insects to human diseases, albeit
now a little out of date, will be found in " Harrington's Hygiene."''' From this and other
sources one has compiled a list of injurious insects and the human diseases they are known,
or supposed, to transfer.

1. Ants. Cholera? dysentery? enteric fever? and indeed all those diseases due to
contamination of food (.sep " Flies," page lb). There is no definite proof that ants act as
vectors, but considering their habits in tropical countries, it is far from unlikely.

' Allbutt, T. C. (May 6th, 1905), " Discussion on Influenza." Brilish Medical Journal, p. 977, Vol. I.

• Rogers, L., " Fevers in the Tropics," 1908.

= Williams, W. L., " Minor Maladies."

" Nash, W. G. (April 4th, 1908). Lmicct, p. 1032, Vol. I.

' Harrington, C, " Practical Hygiene." London, 1905.

REVIEW — TROPICAL MEDICINE, ETC. 93

2. Bed-bngs. Anthrax ? cerebro-spinal meningitis ? endemic gastric catarrh of Austria- Insects-
Hungary ? epidemic dropsy ? intermittent fever ? (Russia), leprosy ? Leishmaniosis? mouse continued
septiciemia? plague? skin diseases ? spirochustosis? tuberculosis (Dewcvre's case), typhus

fever, yaws '?

3. Cnckroache.i. Plague?

4. Fleas. Miliary fever ? plague, taenia cucumerina, typhus fever ?

5. Flies (non-biting). Anthrax, conjunctival diseases, cholera, diarrhcEa, dysentery,
enteric fever, myiasis of various kinds, metazoan parasites (by transporting their eggs and
depositing them on food) ; leprosy ? ophthalmia, skin diseases, staphylococcic infections,
trypanosomiasis? tuberculosis, yaws? (Castellani).

6. Fill's (biting, apart from mosquitoes). Anthrax (as in Cyprus). Septic and
septicaemic infections, trypanosomiasis.

7. Itch Insect. Leprosy? skin diseases.

8. Lice. Skin diseases. Spirochaetosis.

9. Mosqidtocs. Dengue ? distomiasis ? filariasis, leprosy ? malaria, Malta fever ? seven
days' fever? Weil's disease ? yellow fever.

10. Ticks. Black-water fever? filariasis (F. persfans) '? plague? (Skinner). Japanese
Eiver Fever ? skin diseases, spirochaetosis, spotted fever of Rocky mountains ? trypanoso-
miasis? (Manson's suggestion). Typhus fever? yaws?

One may also mention as of less importance certain Coleopterous and Lepidopterous
larvae which produce cutaneous irritation and inliammation, while spiders, scorpions and
centipedes must also be kept in mind.

As regards the Bed-bug, the following is quoted from the Indian Medical Gazette of
June, 1906:—

There is .a definite tradition in Russi.i, fi'equently repeated by Professor MetehuikofF, in his lectures .at the
Pasteur Institute, that the bed-bug forms an intermediate host or is at least an agent for conveying intermittent
fever, so common in certain districts of that country. Its possibilities in the rule of intermediary in cerebro-spinal
meningitis arc still the subject of investigation.

In these circumstances, all possible information with regard to the pest is interesting, and consequently a
leaflet issued by the Department of Agriculture should attract attention. This pamphlet is written by Dr. Qirault,
who has carefully followed the life-history of eimex or clinocoris, as the insect is variously called in scientitic
nomenclature, and has found important new material with regard to its feeding habits. The adult insect feeds
about once in from thirty-sLx to forty-eight hours, taking nearly fifteen minutes to get its till of blood. At earlier
ages, the feeding period is much shorter. Except in susceptible human beings who have a decided idiosyncrasy,
no local effect at all is produced by the feeding process. Some individuals, however, suffer from almost intolerable
itching and have a series of urticaria-like lesions. The parasite is so jirevaleut in certain parts of the country,
however, that it is evident that those with an idiosyncrasy are comparatively rare. The insect may live from five
to ten weeks or even longer without any food. This is especially true during the winter, when, if they have no
food, they go into a short comatose condition. While each insect seems to live not longer than about 100 days at
the outside, some have been known to exist as long as eight months ; and it is these that enable the species to
continue its existence even under unfavourable circumstances, so that they live from season to season in lumber
eamps, summer residences, empty apartments and the like.

Another interesting phase of investigation with regard to the bed-bug and its connection with disease was
carried out by Drs. Qirault and Strauss, as to whether or not the insect had other host relations besides those with
the human race. As is easily understood, the host relations of this insect are greatly increased in importance
because of their scope in the potential transmission of disease if they attack other animals than man. It has
been found experimentally that at least mice, both living and dead, are attacked by bed-bugs and that young mice
particularly seem to provide an excellent supply of food for them. This observation has been confirmed by
observations made by Drs. Qirault and Strauss, and, as it seems not unlikely that other small animals, including
even rats, may also be hosts, the spread of such affections as pest, mouse septicaemia and the like by means of this
parasite must be taken into account. In a word, a new departure of disease etiology seems to be opened up by
these observations.

Cimcx lectularius measures 4-5 mm. in length, 3 mm. in breadth, and has eight abdominal segments. The
females deposit fifty whitish eggs at a time, three or four times a year, and eimex becomes mature in about
eleven months. Bed-bugs live in cracks and fissures, under carpets, behind pictures, in furniture, bedsteads, etc.
Hidden by day, at night they attack persons to suck their blood. An alkaline secretion of their salivary glands
forms the so-called " wheal." Bed-bugs can migrate from house to house and may leave a house if it becomes
uninhabited. The characteristic nasty odour of bugs is due to a clear, oily, volatile liquid secreted."

Patton deals with the distribution of the bed-bug, of which the two common species are
Gimex lectularius, Linn., and 0. rotnndatns, Sign., as Patton has named C. macrocephalns. In a
private conmiunication, Patton informs me that the bed-bug from Angola is C. rotundatns, and
suggests that it is probably the carrier of Leishmaniosis in the Sudan. The Khartoum bug
is C. lectularius. Patton also points out that the bug lives on blood alone, not on moist

94 KEVIEW — TROPICAL MEniCINE, ETC.

Insects— wood, dust and dirt, as has been stated. His latest description' of bed-bugs may be quoted
continued with advantage : —

The fiict that tlie Leishman-Donovan body undergoes its c.xtra-corporcal development in the bed-bug,
Cimer rotnwi(ttus, makes it necessary to describe l)rieHy the two species of this insect associated with man.

Accordin.i^ to Mr. Distant, tlie family C'iinkiihr, which contains four genera, ('imej', Occidcas, Oucodmnn and
Hemaloaijihon, belongs to the lletcroplcra, a sub-order of the h'hijiic/wla, and is placed in the series Gi/nuioccrtn.
between the families Phi/mafidic and (Jcrtocombida:. Mr. Distant informs rac tlie genus Cimcx at present eoutains
four species, ' 'inifj- Ici-lulanas, Linn., Cimcr rotimdalun, Sign., Cimc.r pipislrclli, Jenyns, and Cirnej- columbariiis, all
of which have the following characters : The head is short and broad with two prominent eyes, but no ocelli.
The antenmu arc four-jointed, the apical joints being slender; the elytra are rudimentary and lie over the
metathora.x. The jjrothorax is semilunar in shape with its anterior angles considerably extended. The abdomen,
which is uncovered, consists of seven segments and an eighth anal appendage ; the legs are slender, the anterior
tibiae more tlian twice as long, and the posterior three times as long, as the tarsi, which are three-jointed. The
proboscis is fle.Kod in a groove beneath the head and prothorax.

Tjipe. species, i.'imej- leclularius, Linn. The adult insect of this species is reddish-brown in colour and is
covered with fine hairs ; it varies in length from 4-5 mm. to JJ mm., the male usually being a little smaller than
the female. The head is short and broad and is inserted into a notch in the protliorax ; it contains two lateral
prominent eyes in front of which arc the two antennae and in the median line the thick first segment of the
labrum which is continuous with the dorsal integument of the head. The antennae consist of four segments, tlie
first two being the thi<;ker, while the third and fourth are slender and covered with long hairs.

The prothorax is semilunar in shape with two rounded horns extending close up to the eyes ; its upper surface
is raised in the centre and towards the sides, ending abruptly at a line a little beyond the level of the eyes; the
remainder of the surface, including the two horns, is flattened from aljove downwards. The ventral surface of the
prothora.x is concave and hollowed out on each side of the mid-line where the first pair of legs are inserted. The
mesothorax, as seen fi'om the dorsal surface, is triangular in shape with its apex projecting over the mesothorax and
between the elytra. The mesothorax, next in size to the prothorax, is almost entirely covered on its dorsal side by
the elytra, and on the ventral surface is .seen as a small cleft on the inner side of the middle coxa. The elytra,
which are inserted into the mesothorax just below the lateral angles, are two rudimentary scallop-shaped pieces
of chitin lying over the metathorax and sides of the first abdominal segment. Their dorsal surfaces are convex
and covered with bristles, while their ventral surfaces are concave. The abdomen is rounded and consists of seven
segments with an eighth and appendage. It is broadest at the third segment and gradually becomes narrower
towards the end where it is covered with long hairs. In the male, the penis is seen flexed in a notch between the
seventh and eighth segments.

This bug is distributed through Europe and North America, and is also found in Suez, Egypt, the Sudan, the
North-West Frontier Province of India, China, South Africa and Australia.

Cimcx rotimdatus. Sign., or the Indian bed-bug, is darker than the above species, being of deep mahogany
colour ; its head is not as long or as broad as that of tediilarius. Its prothorax is also narrower and shorter, is
more rounded and not flattened at the sides as is the prothorax of tlie type species. Its abdomen is orbicular,
being broadest at the second segment, and tapers more abruptly towards the end ; in all other respects it is similar
to Cimcx leclularius.

Cimcx rotundaiiis is distributed throughout India, Burma, Assam, IMalay, and is also found in Aden, Sierra
Leone, the Islands of Mauritius, Reunion, St. Vincent and Porto Rico.

Cimcx pipistrellli, Jenyns, is similar in colour to rotundalus, its prothorax is also less marginal, and in all
respects it is more closely allied to the Indian bed-bug.

Cimcx colmnbarius, Jenyns, has a similar prothorax to leclularius and is also of the same colour.

Dissection of Ihe bed-bug. The following method of dissecting the bed-bug has been found satisfactory. After
having killed the insect by placing it in a tube with a plug of cotton wool containing a few drops of chloroform, it
is taken up with a pair of forceps and the legs are pulled off. In removing the fore legs it is necessary to be
careful not to injure the prothorax, as they are firmly fixed in concavities on its under surface. The elytra are
next removed by raising them with a fine pair of forceps and gently twisting them off from their joints at the
angles of the mesothorax. The bug is now placed in a drop of normal saline solution with its head directed
towards the dissector. A fine needle is inserted with the left hand into the right side of the prothorax, while with
another fine needle in the right hand the joint between the prothorax and mesothorax is separated. By gently
drawing the needle in the left, hand and by exerting pressure on the dorsal surface of the abdomen with the other
needle, the cesophagus, midgut and the remaining part of the intestinal tract arc drawn out, and any portion can
then be isolated and examined. The salivary glands lying on each side of the oesophagus are also exposed by this
method. The ducts of the salivary glands and the oesophagus can be followed into the crop situated in the head
by carefully removing the prothorax.

As the barracks in Khartoum used to swarm with bugs, and as they are troublesome in
the quarters of the Public Works Department, these notes may be of some interest, though
one has never heard of any similar condition prevailing locally.

The endemic gastric catarrh mentioned under " Bed-bugs " is described by Kirchenberger
and Vala.-* It occurs during the summer months in the southern provinces of Austria-
Hungary, and specially attacks soldiers in barracks. The incubation period is three to five
days, followed by a prodromal stage of a few hours characterised by malaise, headache and

' Patton, W. S. (1907), "The Development of the Leishman-Donovan Parasite in Cimex Rotundatus."
Scientific Memoirs of the Government of India, No. 31.

= Kirchenberger and Vala (September 3rd, 1907). Allgem. Wien. Med. Zeilung.

' Article not consulted in the original.

BEVIEW — TKOPICAL MEDICINE, ETC. 95

constipation. There is then a rise of temperature, the globes of the eyes become tender Insects—
and there is a characteristic injection of the conjunctiva, hence the name "Dog disease" conHimed

applied to the condition from the fancied resemblance of the affected eye to that of a dog.
Mild bronchitis, gastric tenderness, cramps and epistaxis are the chief symptoms, together
with a rash like urticaria or erythema multiforme. The disease lasts two to four days and
terminates by crisis, but convalescence is slow and there may be considerable anaemia.
A lasting immunity to further attacks seems to be conferred by the disease. It has
been attributed to the bites of certain gnats but there seems more reason to believe that
bed-bugs may be the vectors.

King' has described a very tiny blood-sucking Hemipfernn, which he found in Khartoum.
It attacks without provocation, but only causes slight local irritation.

As hornets are common in the Sudan, though apparently for the most part quite
inoffensive, attention may be directed to a note wherein MacWatters- details three cases in
which serious symptoms of collapse followed the sting of a hornet {Vesjja urieNlalis).

Wellman"' draws attention to the noxious larvae of Coleoptera and Lepidoptera above
mentioned, some of which may cause severe pain and skin eruption, while nervous symptoms
may follow contact with stinging caterpillars. He has also a note on two species of
Myriapods, and states that their poisonous secretion is probably from the foramina
repugnatoria which are at the sides of the segments and look like trachael stigmata. One
has had Myriapods sent from the Southern Sudan, some of which are said to be much
dreaded by the natives. They are being determined by Professor Werner of Vienna.

Jaundice (Infectious). See Weil's Disease, page 231.

Kala-azar. See Leishmaniosis (below).

Leishmaniosis. Various reports have shown that this deadly disease is of much
wider distribution than was at first tliought to be the case. Assam, Bengal, Southern India,
Ceylon, Burma, China, Arabia, Egypt, Sudan, Tunis, Algeria, South Africa and Crete are
the places where it has been known to occur.

Most of the facts presented in various papers, together with original matter, are to be
found in Rogers' work.* We can only quote some of the more important points to which
he refers and supplement them from more recent papers.

In speaking of a certain epidemic, he explains the peculiarity of its course by the fact
that the disease travelled through the virgin soils of a certain northern valley in Assam,
previously unaffected by the sporadic form of the disease, and there found a population fully
susceptible to its deadly influence. Hence it was able to work terrible havoc. This, if
confirmed, is interesting in the light of a similar state of things probably existing in Central
Africa as regards Sleeping Sickness, which invaded Uganda from the west with such dire
results.

The early stages are very hard to diagnose, the differentiation from typhoid and para-
typhoid being especially difficult. Eogers says the high continued type of fever, especially
with a slow pulse, is almost conclusive evidence of typhoid as against early kala-azar,
while the high remittent type is almost equally rare in the latter disease. Some typhoids,
however, show the slow remittent type which is common in kala-azar, and if a negative
serum test has also been obtained, the blood changes must be turned to for help.

Three of the most important early signs are : —

1. Double remittent type of pyrexi.a.

2. Persistent remittent fever with absence of severe coastitutional disturbance and of abdominal or
respiratory symptoms.

3. Enlargement of spleen down to the navel.

Rogers has shown that a marked relative leucopaenia, say less than 1 white to about
1000 red corpuscles, is practically diagnostic of the disease and is of bad prognostic
significance. There is nothing special to note as regards general symptoms, except possibly

' King, H. H. (December l.ith, 1906), "Blood-Sucking Hemipteron." Journal of Tropica! Medicine, p. 373,
Vol. IX.

^ MacWatters, R. C. (June, 1908), "Some Effects from Stinging by a Hornet {Vespn Oricntalis):' Indian
Medical GcateUe.

' Wellman, P. C. (June 1st, 1907), " Notes on some Noxious Larvse from .\ngola." .Tournal of Tropical
Medicine and Hi/i/ieiic, p. 185, Vol. X.

■* Rogers, L., " Fever in the Tropics." (Loc. cit.).

96 REVIEW — ^TROPICAL MEDICINE, ETC.

Leish- that the majority of cases begin with rigoi's, but a good account is given of the changes in

maniosis— the spleen and liver. The former is usually liard and, in very chronic cases, its firm edge may
cniitiiiued project so as to be evident to sight through the abdominal wall. The rapid increase, and the
still more striking rapid decrease, which may occur in the size of the spleen are described.
In very chronic cases an actual cirrhosis of the liver may occur. The surface of the organ
is smooth, and microscopically tliere is a very diffuse intra-cellular cirrhosis in the fibro-
cellular tissue of which shrunken parasites of kala-azar may still bo visible with a high
power. Advanced cases are accompanied by ascites.

The cliief blood change is a great rehitive reduction of the leucocytes which may be e-xtreiue even at a very
early stage. There is usually also a marked increase iu the percentage of the large mononuclears. This, be it
noted, rarely occurs early in typhoid, and hence is a useful diagnostic aid.

Possibly improved technique will be able to demonstrate parasites in the peripheral blood even early in the
disease. As regards the general course of the fever, many charts are given showing the different types of fever.
A double remittent passing into a low fever is common, while the low continued type also occurs. Both high
continued and the high remittent forms are much more rare.

Ijhiod chcuuft's.

1. Marked antemia is only characteristic of the later stages.

2. Relative leucopa?nia is very marked and may be pathognomonic. It is less marked during high fever than
during remissions or low intermittent pyrexia. It is important to note that a great degree of leucopteuia may be
absent in kala-azar, (a) during any inflammatory complications such as pneumonia, dysentery, caucrumoris,
meningitis, phthisis, etc. ; (i) during high remittent pyrexia occasionally ; {<•) during the very earliest stages of the
disease such as the first month of fever, or in recovering patients who have iteen free from fever for some time.

3. Increase iu the large mononuclears. Note that kala-azar differs from malaria in that this increase seems
to occur more frequently when there is high remittent fever than when it is intermittent or absent or when the
temperature is normal. In malaria it is less marked or even absent during pyrexia. An increase of the large
mononuclears in typhoid during fever is very rare, hence this sign is valuable iu early kala-azar with high
remittent fever which closely simulates that of enteric.

4. Decrease in the polynuclears. This, which is marked, is of significance in two directions, (a) As a
prognostic sign, tlie prognosis becoming progressively worse as the polynuclears become fewer and fewer.
(A) As a factor predisposing to the secondary inflammatory complications, often coccal or bacterial in origin,
which so often prove fatal. This is easily understood when it is remembered that tliere may be a loss of
nine-tenths of the phagocytic polynuclear leucocytes.

5. There is increase of the lymphocytes and decrease of the eosinophilcs, but these changes are of no special
import.

As regards treatment, Rogers upholds the utility of quinine given in large doses and for months together if
necessary. He has repeatedly seen a high remittent fever reduced to a comparatively harmless low intermittent
one by increasing the quantity of quinine given, say, up to 60 grains or even 90 grains a day. He also points out
that a considerable number of cases wholly recover.

The parasite is then fully considered. It may be found in practically every organ of the body, but is most
n\iraerou6 in the spleen, bone-marrow and liver. Christophers' work is mentioned. It showed that the parasites
multiplied mainly in the large endothelial or macrophagic cells of the spleen and bone-marrow, especially until
the invaded cells bulge into the lumen of the vessels. Hence, when .splenic puncture is performed, the larger
capsulated forms are obtained.

It has been found that the parasite is absent from the body in diseases other than kala-azar.

The flagellated stage of the parasite is then discussed and its resemblance to
Ilerpetomonas noted. These discoveries and observations are so well known that there is
no need to refer to them here at any length. One important point, however, is the optimum
temperature for the cultivation and development of the parasite. This is between 20" C.
and 22" C. Hence, in working with bed-bugs, it is well to carry out the feeding experiments
during the cold season. It was Eogers who determined that the reaction of the tluid in the
stomach of the bed-bugs, after they had sucked human blood, was distinctly acid, and this
led him to employ an acid medium (citrated human spleen blood plus sterile citric acid) for
observing the development of the parasite. Prophylaxis on plantations and in villages in
India is fully considered. Segregation of the sick, building of new lines and the destruction
of old houses and purification of old sites by fire are advocated, as is the destruction of
bed-bugs by sulphur fumigation, washing beds with strong boiling carbolic lotion, boiling
clothes in the same or destroying them altogether and burning blankets.

Rogers,' in a recent paper, enters more fully into the question of the cirrhosis of the
liver present in cases of kala-azar, and concludes that : —

1. The most chronic cases of kala-azar not infrequently terminate theii' course with ascites due to cirrhosis
of the liver.

2. The cirrhosis is of a peculiar intralobular type of uniform distribution, and with a smooth surface to
the organ.

' Rogers, L. (July Ist, 1908), " A Peculiar Intralobular Cirrhosis of the Liver produced by the Protozoal
Parasite of Kala-azar." Annals of Ti-opkul Medicine and Parasituluyy, Scries T.M., Vol. II, No." 3.

EEVIEW — TROPICAL MEDICINE, ETC. 97

3. It is due to the protozoal parasite of kala-azar, which may be found in the liver and other organs after Leish-
^^^^■^- raaniosis—

4. This form of cirrhosis of the liver is much commoner in Lower Bengal than a true malarial cirrhosis, conlimied
with which it has probably hitherto been confused. It is, however, much less common than atrophic cirrhosis

due to unknown causes.

Patton,! who has done the work on the development of the parasite in the bed-bug,
records his latest work from which we cull a few notes and his conclusions. The large
endothelial cells mentioned above, which contain the parasites in large numbers and are
found in the liver, spleen, bone-marrow and lymphatic glands, occur in the peripheral blood
of patients some days before death. "It seems most probable," says Patton, " that the
rupture of these cells and the liberation of the parasites they contain, explains the
occurrence of the large numbers of parasites in the peripheral blood of patients suffering
from ulceration of the large intestine. Once the parasites are set free in the plasma they
are immediately taken up by mononuclear, eosinophyl or polymorphonuclear cells."

It is suggested that the brawny swellings met with in the course of the disease, and
caucrum oris, which is so common, both owe their origin to hiEmorrhage caused by the
blocking of a small vessel by one or more of these large cells.

Attention is drawn to large, non-nucleated, parasite-containing, blue-staining (with
Giemsa) bodies, also found in the peripheral blood. Some believe them to be altered red
blood corpuscles, others, detached buds of macrophages or mononuclear cells.

The general evidence seems to be against the occurrence of parasites in the red cells.

In continuation of his last report,- Patton gives more confirmation regarding the
development of the parasites in G. rotundatas. After the early stages of development, t.e.
increase in volume of protoplasm and in size of micronuclei which show signs of commencing
division, one or other of two things takes place : (1) the parasite may rapidly pass on to
flagellation ; or (2), what is more important, they further enlarge and by consecutive
division of the macro- and micronuclei produce a rosette of from four to eight parasites.
"The single flagellates enlarge and begin to divide longitudinally to result in oval or
spindle-shaped cells, while the rosettes, after flagellation, begin to divide up into separate,
elongated flagellates. The oval or spindle-shaped parasites divide repeatedly ....
and result in smaller and more irregular forms. All these changes may be seen in the bug
during the first three days. Still later, longitudinally division of the oval and irregular
flagellates progresses rapidly, so that by the fifth day the majority have become small or
spirilla-like flagellates."

Patton also deals with temperature requirements and concludes that the disease
usually begins in the cold weather, but this is not to say that infection can only take place
during this season.

The final stages of development and the method of re-entry into the human body have not
yet been determined, but the conclusions on this very valuable work so far are as follow : —

1. Though kala-azar is a chronic disease lasting many months and often years, it occasionally runs an acute
course terminating in from four to five months, as illustrated by the case described above. In these acute cases, as
well as in the chronic ones terminating with ulceration of the large intestine, the parasites are found a few days
before death in large numbers in the peripheral blood in the leucocytes and endothelial cells, and the latter are
probably the source of all the parasites seen in the circulating blood.

2. Though the parasites are most abundant in the peripheral blood towards the end of the disease, they are
also found in the early stages, as a case recently seen clearly illustrated.

3. In the female as well as in the male bed-bug (Cimex roUmdatus) the parasites have by the third day
passed through all the intermediate stages of development described above up to the formation of the mature
flagellates. Rapid multiplication by rosette formation is a " characteristic feature of the development of the
parasite in the bed-bug." As the male bug sucks blood, it probably plays as important a role in the transmission of
the disease as the female bug.

4. The infection acquired by the bug varies considerably, some ingesting large numbers of parasites, others
only a few ; and there is no evidence at present to show that the development in the bug depends on variations in
the temperature.

5. The tendency that the disease has to linger in a house for a long time is probably explained by the fact
that the parasite may remain in the midgut of the bug for several days before beginning to develop, and, as the
nymphs, which take from seven to ten weeks to arrive at maturity, may ingest the parasites shortly after hatching,
and as a rule feed only once between each moult, the infection may remain for a considerable time in a house ;
there is no evidence at present to support the view that the infection is inherited by the bug.

• Patton, W. S. (1907), " The Development of the Leishman-Donovan Parasite in Cimex Rotundatus."
Scientific Memoirs of the Government of India, No. 31.

' Patton, W. S. (1907), " Preliminary Report on the Development of the Leishman-Donovan Body in the
Bed-Bug." Scientific Menwirs of the Government of India, No. 27.

98 REVIEW — TROPICAL MEDICINE, ETC.

Leish- Leishmaniosis was recently discussed' in London. Bassett-Smith referred to the

maniosis— occasional similarity of the temperature chart to that of Malta fever, the occurrence of

cuntimifd hcemorrhages (epistaxis), the benefit resulting from atoxyl treatment, the drug being pushed

to 12 grains a day, and the danger of splenic puncture. Liver puncture, he thought, was

safe.

Precautions for puncture are : (1) Warn patient to avoid movement. (2) Thoroughly
sterilise the skin. (3) Use a small needle and withdraw the blood quickly. (4) Apply a
firm binder and make patient lie quite still in bed for several hours afterwards.

Manson described a case in a European which seemed to be about to terminate fatally
and then markedly improved. This may or may not have been due to the atoxyl used in
treatment.

Others spoke to the value of change of air and a sea voyage. The general impression
was that when cure resulted, nature had been the successful physician.

Low mentioned a case clinically indistinguishable from kala-azar in which no parasites
were found on spleen and liver puncture and in which, post mortem, double tumours of the
adrenals were found, although there was no bronzing of the skin. He also mentioned other
conditions, such as splenic ana3mia, closely resembling kala-azar, and pointed out that for a
certain diagnosis the parasite must be demonstrated.

Leishman mentioned Cummins' suggestion to produce artificial pustulation and thereby
obtain polynuclears without having to resort to splenic or hepatic puncture.

Woolley- has described cases in the Philippines with symptoms of splenomegaly,
rheumatic pains, ccdema, diarrhoja, with or without hepatic enlargement, and remittent
fever, but in which no Leishman-Donovan bodies could be found. He believes they may be
associated with a chronic infection or intoxication originating in the intestinal tract and
that, while a certain number of cases of tropical splenomegaly may be due to infection
with the Leishman body, it will be found that various organisms are associated with the
clinical picture and that the symptoms will depend chiefly on intestinal conditions and
pathological changes in the intestinal walls.

NicoUe and Cassuto^ have an interesting paper on three cases of splenomegaly in
children at Tunis, in which cases the Leishman bodies were observed. There is a good
coloured plate showing amongst other things a capillary of the liver with parasites in the
endothelial cells and the forms met with in culture. The authors conclude : —

1. That there exists in Tunis an illness of infants with symptoms similar to those of kala-azar and
apparently identical with certain cases of infantile splenic ansemia, described more especially in the south of Italy.
It usually seems to terminate in death, but treatment by atoxyl may possibly prove beneficial. The etiology "is
unknown and the diagnosis can only be made with certainty by splenic puncture.

2. The pathogenic agent is a protozoan indistinguishable from the Leishman body. Its habitual site
appears to be the endothelium of the vessels, and it is found iu the blood and liver and more rarely in the
lymphatic glands and in the blood.

.3. This parasite is easily cultivated at 22° C. in the condensation water of blood-agar (Novy and McNeal's
medium). The culture forms are identical with those of the Leishman parasite in citrated blood.

4. Until the identity of this parasite either with the Leishman body or the organism of oriental sore
described by Wright, is established, it is proposed to group the following under the generic name Leishmania.

Leishmania wrighti, the cause of oriental sore.

Leishmania doiwvani, the cause of kala-azar.

Leishmania infantum, the cause of an infantile splenic infection closely resembling kala-azar, observed iu
Italy and in Tunis.

One's impression is, however, that the three cases recorded were merely examples of
kala-azar affecting infants, and that there is no need to accord them special distinction.

In a later paper, Nicolle and Comte'' mention the very interesting fact that they have
found the parasite in a dog in Tunis. They also state that the children whom they found

» "Kala-azar" (March 16th, 1908). Journal of Tropical Medicine, p. 85, Vol. XI.

' Woolley, P. Q. (June, 1906), " Tropical Febrile Splenomegaly." Philippine Journal of Science, p. 533,
Vol. I.

= Nicolle, C, and Cassuto, E. (February 1st, 1908), " Sur Trois Cas dlufection Splenique Infantile a Corps
de Leishman observes en Tunisie." Archive de I'lnMitiU Pas/cur de Tunis, p. 3.

* Nicolle, C, and Comte, C. (April 11th, 1908), " Origine Canine du Kala-azar." Archive de I'Inslitui
Pasteur de Tunis, p. 59.

EEVIEW — TROPICAL MEDICINE, ETC.

99

infected had been in habitual contact with dogs. They are inclined to think that infection Leish-
may be derived from the dog, and that in this animal the disease runs a benign course, maniosis—
Their work, which is of a preliminary nature, requires confirmation, but is at least continued

The presence of Leishmaniosis in the Sudan was first determined by Neave, who
reported a case in a child from Meshra-El-Kek. For a considerable period thereafter no
further cases were recorded, but recently, thanks to the work of Captains Cummins and
Bousfield, of the Egyptian Medical Service, a considerable number of instances of the
disease have been brought to light. In addition, as already mentioned. Dr. McTier Pirrie
fell a victim to it, and I have found the parasites in the splenic smears of several cases sent
me for diagnosis from Wad Medani. A second fatal case in a European has recently occurred.

As Captain Cummins furnishes a special paper on this important subject there is no
need to enlarge upon it here.

Its distribution has yet to be fully woi-ked out, but it seems commonest in the Kassala
and Sennar Provinces, at least at the present time. So far G. lectularius is the only
species of bug found in the Sudan, but it is possible that G. rotundatus vyill be discovered in
the regions where kala-azar is endemic.

I have little doubt but that the disease is much more common than is generally supposed
and that hitherto it has been overlooked or not recognised. Every effort will have to be
made to arrest its spread should it show signs of extending beyond its present known limits.

Leprosy. In looking over the recent literature relating to leprosy, one notes the
tendency to attribute the disease in the first instance to the bites of insects.

Thus Mugliston' of Penang suggests that Acarus scablei may be the carrier of infection.
He found that of 77 lepers, 44 had itch on admission, 11 of the others remembered having
itch, and from the remaining 22 no history was obtainable. He thinks it possible that the
bacillus of leprosy may be conveyed either m or on the insect.

Bassewitz-* also cites a case where in all probability leprosy was conveyed by the
parasite of scabies from a leper to his attendant. The incubation period was two and a half
years.

Goodhue^ of the Leper Settlement at Molokai, Hawaii, reported the finding of the
bacillus of leprosy both in the female mosquito, Gtdex pungens, and in the bed-bug, Gimex
lectularius. He is inclined to think that the bug is a greater factor than the gnat in the
spread of leprosy.

Smyth' of Lebombo states that in his diocese there are tribes which till quite recently
have been free from European influence. The cases of leprosy amongst them are sporadic.
These natives eat and drink out of the same pots ; if there be food, no matter of what kind,
they all share alike. They practically live altogether, with one exception — no healthy
person ever sleeps with a leper, or one suspected of leprosy. In the case of married people,
they have intercourse, but it is always in the daytime if one is a leper. The children of such
parents appear to be normal. The sick are isolated in a hut or huts quite close to the
village, but no healthy man or woman sleeps there. Smyth argues with some force that if
the intermediate host were winged, it would fly from hut to hut, and therefore leprosy would
spread in the villages in a way that it does not seem to do ; if it were infectious, like some
other diseases, people would catch it from the common spoons and cups ; if it were due to
food, all who eat that food would be liable to get it. Therefore we are driven to the
conclusion that the Cimex lectularius, or some similar wingless parasite that feeds at night, is
the means of conveying it from man to man.

Hutchinson^ adduces the following arguments against the insect theory : —

1. If such conveyance were possible, how account for the disappearance of the disease in the fifteenth and
sixteenth centuries from England and from Europe ?

» Mugliston, T. C. (July loth, 1905), "On a Possible Mode of Communication of Leprosy." Journal of Tropical
Medicine, p. 209, Vol. VIII.

- Bas.scwitz, E., Miinch. Med. Wocli., 1905, No. 41.

■• Goodhue, B. S. (August, 1906), "The BacUlus Leprae in the Gnat and Bed-Bug." Indian Medical Gazette,
p. 342, Vol. XLI.

* Smyth, W. R. (December 8th, 190G), " Leprosy." British Medical Journal, p. 1670, Vol. II.

' Hutchinson, .1. (December 22nd, 1906), " Mosquitoes and Leprosy." British Medical Journal, p. 1841, Vol, II.

• Article not consulted in the original.

100 REVIEW — TROPICAL MEDICINE, ETC.

Leprosy — 2. Leprosy now prevails extensively in Southern Chin.a and is unknown, for the most part, in the North.

coiUititied 3. Husband and wife scarcely ever suffer together.

4. The medical officers and nurses of leper asylums never contract the disease.

a. In all leper asylums there are a certain number of inmates who have been admitted under erroneous
diagnosis. These often remain there for years, yet they never acquire leprosy.

6. The lepers who are brought from abroad into England and Northern Europe never become sources of
infection to others. Further, it docs not seem probable that the prick of an insect should convey a disease
respecting which carefully-conducted experimental inoculation always fails. Moreover, leprosy never shows any
primary sore.

Turning to other aspects of the question, an analysis of 220 cases of Sudanese leprosy
by Tonkin' is of special interest to us here. The Central Sudan, i.e. the region about
Sokoto, Kano and Kuka is that concerned. In many ways the habits aud customs of the
races inhabiting this part of Africa appear to be identical with those of the people of the
Anglo-Egyptian Sudan, and to anyone anxious to work out the leprosy problem in the latter
country, a perusal of Tonkin's paper is indispensable. In a summary he shows that the age
of onset seems to work out earlier for the Sudan than in some other exploited areas, but he
notes that this may be due to some special local conditions which have escaped attention.
He says little about recovery from the disease, but indicates that in the Central Sudan as
elsewhere there is evidence to show that it occurs and that this question is one meriting
more attention that it has yet deserved.

The history of his cases does not support the factor of heredity as being instrumental
in the production of the disease and he brings forward arguments against it, for example :
leprosy is a disease which reacts prejudicially on propagation, hence it is not likely to derive
support from a factor that is hereditary. As regards predisposition, he shows that leprosy
has occurred in many people who have had no leprous ancestors. He believes deficiencies
of diet have a great deal to do with it, coupled with faulty hygienic principles as regards
clothes and bedding. He says that wherever leprosy occurs we have habits with regard to
clothes and bedding which are open to criticism and stereotyped national diets which leave
much to be desired. He remarks that in the Central Sudan the communistic way in which
unwashed clothes are handed about must have a direct influence on the spread of leprosy,
and that a diet in which the carbohydrate elements are represented to an extent which
disturbs the proper proportion of the nitrogenous would appear to handicap races reared on
it in their fight against the disease. He does not, however, believe that an ill-assorted diet
will cause leprosy or that the disease cannot be contracted without the intervention of such
a diet. Still he does maintain that in the Central Sudan the most frequently operating
factor, not in causing the disease but in assisting to determine its incidence, is that of a
badly balanced and, therefore, ineflBcient diet.

It is worth noting that fish is recorded to be dear and, therefore, consumed by the
masses of the country even to a less extent than meat, which is by no means a staple form
of food. Salt throughout the whole country is scarce and dear.

These latter paragraphs lead us into the realms of controvei'sy, and though it is, of
course, impossible to quote fully from the literature which has accumulated regarding the fish
theory of leprosy so ably and ingeniously put forward and tenaciously supported by
Jonathan Hutchinson, reference must be made to several of the more interesting recent
papers available.

The whole subject is considered in a review- of Hutchinson's work " On Leprosy and
Fish Eating : A Statement of Facts and Explanations." Hutchinson's theory is that the
fundamental cause of true leprosy is the eating of fish in a state of commencing
decomposition. The cause of the disease is, in his opinion, some ingredient or parasite
generated by, or introduced into, fish which has been either not cured at all or cured badly.
As a result, it is maintained that segregation of lepers will not stay the disease.

So long as the food is not taken from the hands of lepers it is asserted that there is no
danger from consorting with them.

The various arguments brought forwai-d to prove the fish theory are detailed at some
length, such as the irregularity of the distribution of leprosy and the fact that a very large
number of lepers are found in all countries who have neither inherited the taint nor been in
any way exposed to contagion.

• Tonkin, T. J. (April 18th, 1903), " An Analysis of 220 Cases of Sudanese Leprosy." Lmicct, p. 1077, Vol. I.

^ Hutchinson, J. (June 16th, 1906), " On Leprosy and Pish Eating : A Statement of Facts and Explanations,"
Review in Lancet, p. 1095, Vol. 1.

EEVIEW — TROPICAL MEDICINE, ETC. 101

The conditions under which the disease has declined in certain countries and has held Leprosy-
its ground in other countries are cited, New Zealand, Spain and Crete being examples of continited
the latter state of things. In Norway, leprosy is limited to fishermen, boatmen and
peasants, whose staple food consists of milk and the products of the sea. Peasants inland,
who suffer, have free access to fish food during its conveyance from the sea.

As the majority of observers do not accept Hutchinson's deductions, the arguments
against them in this review may be given in full : —

It must be confessed that this interesting theory does not meet with the approval of a large number of
physicians who have had personal knowledge of the disease. Let us note some of the objections to it. And first
as to bad fish being the essential factor. Should any cases be shown to exist where bad fish has not been the
essential factor, it must follow that the theory falls to the ground. Are there such cases ? We have seen that the
author explains the decline of leprosy amongst the Maoris to the fact that they have changed their diet to one of
meat, potatoes and bread. Now Dr. Francis Day, whilst travelling in Burmah, never saw a case of leprosy
amongst the indigenous population, although the Burmese like fish, and especially the odoriferous " nga " fish.
Dr. Vincent Richards, a man of acknowledged authority on tropical subjects, shows by statistics not only that the
consumption of fish has nothing to do with leprosy as regards its causation, but he also states that it would be
quite as logical to state that this factor is a prophylactic, the disease being less met with in those districts where
there is the greater consumption of fish ; and lastly. Dr. Crane, the Government physician in Hawaii, has written
that from time immemorial fish, especially raw fish, had been the staple food there until the year 1860. Until
that year there were no lepers in Hawaii nor was there any history of the disease. At this date it appeared, and
in a few years after its introduction it had decimated the community, yet at this time canned foods, fresh meat,
and vegetables had been very largely substituted for fish in the diet, and the use of fish, especially raw fish, had
enormously decreased. The history of Hawaii, in fact, demonstrates this fact, " all fish, no leprosy," " little fish,
no leprosy," and the argument is as valid as that used by the author in the contrary sense, concerning the Maoris.
Again, experience in India demonstrates the fact to the physicians in that country that many lepers declare, not
only that they have never eaten fish, but that they actually do not know what it is. Caste ordinances, again,
militate against the use of fish in many who have become lepers.

Let us consider, also, the question of contagion. How can the fish theory explain the cases shown by
Dr. Benson at the Dublin Medical Society in 1872 and 1877 ? In 1872, a leper was shown by him who had
acquired the disease in the West Indies. In 1877, Dr. Benson showed a second case in the person of the brother
of the first, who had never been out of the United Kingdom. This man had slept in the same bed with his
brother and occasionally worn his clothes. Consider, again, the case mentioned by Professor W. Osier. Here
seven people were in turn affected by what to most minds must seem to have been contagion. And in connection
with the question of contagion, the remarks of Von Duhring are peculiarly apposite — namely, that all negative
evidence brought forward as to its non-communicability is valueless in the face of one positive fact. Lastly, as
regards the alleged failure of segregation to prevent the disease, few of those who have had personal experience
will agree with the author. To mention one instance only, in Madagascar the former limited amount of leprosy
has rapidly increased since segregation was abandoned. It is thus seen that there are many objections to
Mr. Hutchinson's theory which must be overcome before it can be finally accepted as the true explanation of the
disease.

Indian experience is also adverse, as evidenced by another review' which we quote at
some length, partly because the arguments used appear to be very sound, and partly
because one has been specially asked to furnish information on this subject as regards the
prevalence of leprosy in certain parts of Kordofan where there are lakes containing fish.

After pointing out that the important question of personal immunity is wholly ignored
in Hutchinson's work, the reviewer says : —

Passing now to the consideration of the fish hypothesis itself, we find that the chief reasons for which fish is
considered to be the article of food responsible for the propagation of leprosy are these. Granting that it is due
to an article of food, it must be one which is of universal use and which has the same quality in all lands. There
is no vegetable met with in all the districts affected by leprosy ; the vehicle is not milk, for some races, the
Tartars for instance, almost live on milk and yet have no leprosy, and there are many leprous centres where milk
is almost or wholly unknown ; while of flesh foods there is no reason to suspect that of animals and birds. We
may note that the author has not taken into account the most widespread article of food, namely, salt. All places
where leprosy now prevails (he continues) are either on the sea-coast or near to rivers or lakes, except in the case of
India, and this exception he considers as probably not so great as it at first sight appears. The disease is of such
special and emphatic individuality that it can have but one and the same cause. That cause is in nineteen-
twentieths of its instances fish, and respecting the twentieth he considers that despite defects in evidence the
inference is justified that it is fish. But, we point out, the cause is, in all cases, the bacillus, irrespective of its
vehicle or point of introduction, and the same bacillus will produce the same reaction in the human being in
whatever way it may gain entrance to the tissues. As regards the kind of fish which is considered to cause the
disease, one finds from scattered references up and down the book that although salt fish is constantly spoken of as
a cause of leprosy, this is not what is really meant. Properly salted fish is looked upon as perfectly safe. The
article which is considered to be the cause of leprosy is fish in an early stage of decomposition, either from not
having been preserved at all, or from having been merely dried or improperly salted and subsequently eaten
uncooked. We believe that in one place only in the book (page 49) is it stated that it is uncooked fish of the
character just stated which is considered responsible for the transmission of leprosy, and although much space is
devoted to the attempt to prove that leprosy is associated with the ingestion of decomposing fish, no attempt at
all is made to show that the fish is uncooked or imperfectly cooked. Having followed the argument so far, the
conviction occurs that here, at all events, is something which is capable of proof or disproof, seeing that all

' Hutchinson, J. (August, 1906), "On Leprosy and Fish Eating." Review in Indian Medical (Jazettc, p. 327,
Vol. XLI.

102 EBVIEW — TROPICAL MEDICINE, ETC.

Leprosy — t'liiit is necessary to test the matter is to ascertain whether the iiicidonce o£ leprosy is co-extensive with
continued tl'c use as ;x food of decomposing fish. Such an expectation is doomed to disappointment. We read: "The
fish hypothesis assumes that it is probable that even in fish in a state of decomposition the presence o£
the dangerous ingredient is exceedingly rare, but that a very .small quantity of fish contaiuiug it may
be efficient in the production of the disease. Thus the large or small consumption of fish has little to do
with the matter." In other words, Mr. Hutchinson has hedged, and the hypothesis as now enunciated by him is
incapable of proof or disproof, and his challenge of refutation he can make with perfect safety. The whole tenor
of the book shows that the author occupies towards his offspring the position of an interested advocate, and never
that of an impartial judge. The fish hypothesis is supported thus : As a general statement it is true that all
places where leprosy is now prevalent are either on the sea-coast or near to rivers or lakes ; all over the world it is
a disease of tribes which fish and not of those which hunt. It was very prevalent in Europe in the middle ages
and began to decline before the reformation, the conclusion reached being that its prevalence was due to the
eating of improperly dried fish on fast days, and its disappearance to the religious laxity which he assumes to have
preceded the reformation. He shows quite clearly that at that time isolation of lepers was not attempted.
Leprosy has not been prevalent in Russia because the Greek Church does not allow of the eating of fish on fast
days. It occurs more in men than in women, partly because men no doubt get an unfairly large share of the
decomposing fish food where it is an expensive luxury, and partly because men are dirtier feeders. Among the
Hawaians the appearance of leprosy, forty years after white men came among them, was coincident with the
establishment of a factory for curing fish. From Cape Town dried fish is distributed largely to the Malmesbury
district, a noted centre for lepra. Leprosy in Norway only occurs on a strip of the western coast where there is
little laud for cultivation, and fish is the principal article of food and is preferred tainted. There is a large export
of dried fish from Norway to Spain and from Newfoundland to Portugal, and there is much leprosy in Spain
chiefly along the north and south coasts. We should imagine that were there any value in this argument, the
incidence of leprosy in Spain and Portugal would follow the trade routes, and not be chiefly incident on the more
inaccessible north and south coasts.

The large proportion of lepers in India who are Christians, he considers a proof of his hypothesis. We have
ascertained from the manager of a leper asylum with 200 inmates that nearly all the Christian lepers there have
become Christian since their admission into the asylum as lepers. There is one part of Mr. Hutchinson's argument,
which we do consider to be built on a basis solid and capable of being upheld, though we entirely dissent from the
conclusion drawn from the facts ; we refer to the inverse ratio between the abundance of salt and the incidence of
leprosy. The author gives the amount of salt required daily by an adult as from 300 to 400 grains, including that
present in the food ; he states that the development of the salt trade and the introduction of bettor kinds of salt
have often been coincident with the decline of leprosy in a very marked manner, that for example one great
difference between Northern and Southern China is that in the one salt is abundantly produced, and is an article
of export, while in the other it is imported and subject to tax, that iu the latter leprosy is abundant and in the
former unknown. He brings forward other statements of a like nature. Almost the whole of the salt used for
fish-curing iu Norway is imported, and we presume therefore dear, and that it is unlikely that the poor will get it
in sufficient quantities. It is worthy of note that it is precisely those parts of Europe which are the most
remote from the beaten tracks of commerce, and to which the importation of salt in common with other
commodities would be unsatisfactory, that leprosy has lingered longest. Doubtless no one predisposing cause
accounts for all the facts. In some places, probably the Sandwich Islands group is one of them, leprosy has
appeared recently because it has been recently introduced, and just as measles, having within comparatively recent
years been introduced into Iceland, the Faroe Islands and the Fiji Archipelago, has raged virulently among
hereditary unprotected races, so has leprosy in the Sandwich Islands increased by leaps and bounds, till 40 years
after its introduction, every fiftieth individual was a leper. Some, too, of the world-wide decline of leprosy may
probably be fairly put down to the natural decline of an epidemic disease in the course of years, one of the most
familiar examples of which is plague."

Jennings^* notes that in Abyssinia there are some 8000 lepers, who can rarely, if ever,
have eaten fish, owing to the scarcity of the article in a country where, " during the greater
part of the year, many of the wells do not contain water, much less fish."

An interesting paper on leprosy in Cape Colony is that by Black. ^ He also argues
against the fish theory as regards the Cape, and draws special attention to his observation
that the disease begins (how long after the implantation of the bacilli cannot at present
with certainty be known) as a small collection of round cells under the mucosa of some
part of the nasal cavity. Some of these contain bacilli which pursue some part, at any
rate, of their life-history in their interior. Their dissemination to distant organs appears
to be mainly by the blood stream, and these cells come to rest in situations where there
is a tendency to intermittent stasis or slowing in the fine capillary circulation. Hence the
lungs, brain and spinal cord, being furnished with a rapid, free and continuous current of
blood are practically exempt from the occurrence in them of leprotic granulomas. On the
other hand, just as we have in leucocythiemic conditions an infiltration and enlargement of
the liver and spleen, so we have such in leprosy by bacilli-containing leucocytes.

In connection with the nasal-infection it is noted that one of the earliest signs of
nodular leprosy is a slight erythema of the skin about the root of the nose and eyebrows,
sometimes extending to the malar regions, and that with these slight signs extensive

' Jennings, J. W., " With the Abyssinians in Somaliland." Quoted in Journal of Trorikal Medicine,
February 15th, 1908, p. 62.

■^ Black, R. S. (April 28th, 1906), " Remarks on Leprosy in Cape Colony." Lane.t, p. 1167, Vol. I.

• Article not consulted iu the original.

REVIEW — TEOPICAL MEDICINE, ETC. 103

ulceration of the nasal mucous membrane may be found with abundant bacilli practically in Leprosy—
almost pure culture. coniinued

Nasal obstruction is often the earliest symptom, though naturally its significance is
frequently unrecognised. Black admits that great difficulties surround the actual
circumstances of the communication of the disease from individuals, and, from the fact that
it seems almost impossible to reproduce the disease in animals, concludes that there is some
very special relation between seed and soil. He thinks that the agency of an intermediate
host, be it flea, bug, or acarus has not been proved, and mentions that if the nasal mucous
membrane is the primary seat of infection then the intermediate host theory, however
enticing, must go by the board.

In a later paper, Black^ again deals with the question and advances a theory to account
for the marked clinical difference between maculo-anaBsthetic leprosy and nodular leprosy.
He believes that nodular and mixed leprosy are simply maculo-anaesthetie leprosy plus the
infiltration and cBdema of the subcutaneous tissue in various parts of the body, caused by
the active invasion of the Bacillus leprse. Continuing, he says : —

In practically all cases of nodular leprosy anaesthetic and leucodermic patches can be found just as in maculo-
ani'esthetic leprosy. I also noticed that when a nose had fallen in, in some cases of nodular or mixed leprosy the type
of the disease in the individual seemed to change and he became practically, in course of time, a maculo-anaesthetie
case, the infiltrations being gradually absorbed. I further noticed that some cases of undoubted maculo-anfesthetic
leprosy were of an extremely mild character. A patient would have a few anaesthetic patches on his body with,
perhaps, a contraction of the small and ring fingers of one of his hands and would otherwise be in perfect health —
in which condition he would remain for years. I also found that practically all the active cases of mixed and
nodular leprosy suffered from rhinitis and were discharging bacilli with the nasal secretion in great numbers,
whereas, except in a few of the early cases, I found that the maculo-antesthetic patients had no bacilli in their
nasal secretion. The above considerations afforded me what I consider to be a solution of the problem. I think
that there can be hardly any doubt that leprosy in its early stages begins as a small ulcer on some part of the
extensive nasal mucous membrane. We know quite well, from our clinical experience of the disease, that leprous
ulcers in favourable circumstances tend to heal. There can, therefore, be little doubt that a person can suffer from
a leprous ulcer in the nose that may heal and pass entirely away. This is the explanation of the maculo-
antesthetic cases. They have had nasal ulceration which has passed away, in some cases leaving perhaps a
cicatricial shrinking of the nasal septum, but during the time the ulcer existed leucocytes or white connective
tissue corpuscles got detached from the ulcerating spot and, along with the bacilli which they were attempting to
devour, were carried by the blood stream and lodged in various situations in the peripheral nerves, where they got
entangled, and the bacilli then proceeded to grow, causing pressure on the fine nerve fibrils and consequently
setting up nutritive changes in the skin which these axis-cylinders supplied, thus causing the patches of
discoloration and anaesthesia.

In the nodular and mixed cases the progress of the disease is quite different. Instead of the nasal ulcer
healing up it proceeds to grow apace, producing extensive destruction of the nasal mucous membrane, causing it
to swell up and iiltimatcly attacking the nasal bones themselves. We have something to guide us from what we
know of other diseases affecting the nose, such as fleshy growths from the nasal mucous membrane, and how, if
not treated, the nose becomes distended and the aspect of the patient altered. Also in the disease called post-
nasal adenoids in children, how from their intra-nasal pressure they cause the face to assume a heavy, puffy and
stupefied appearance. A similar condition takes place in nodular leprosy. The accumulating swelling of the
mucous membrane extending into the numerous interstices of the naso-pharyngeal cavity causes the face to
assume its characteristic appearance of this clinical variety of the disease, assisted of course by the leprotic
infiltration from the festering nasal ulcer. But the festering sore has other consequences. The enormous number
of leucocytes which are on the scene trying to overcome the invading bacilli get many of them translated to
other parts of the body. They carry with them bacilli which in leprosy seem to have the property, at any rate at
some part of their life-history, of growing within the white blood corpuscles and thus propagating the disease
through all the parts of the body. As in maculo-anaesthctic leprosy, they get entangled in the peripheral nerves
and cause anfesthesias and the discolorations of the skin and they also in nodular leprosy form large accumulations
in the liver, the spleen, and in certain situations in the subcutaneous tissues throughout the body, and the patient
becomes at last, if not properly treated, a mass of ulcerating sores.

The course of the disease is, as is well-known, extremely protracted, and the cases which we see in our asylums
are in nearly every instance in a very late stage of the disease, even on admission. The very early stage of the
nasal ulceration, naturally not being recognised, is completely overlooked, even by the patients themselves. They
think that they arc perhaps merely suffering from a protracted nasal catarrh, to which they pay no attention and
which they forget all about when the graver symptoms of the disease make their appearance. But at these
extremely early stages of the disease, these people are sources of infection, and this fact affords a very clear and
simple explanation of those mystifying and apparently hopelessly inexplicable cases of leprosy which from time to
time occur. You ask one of these patients : " Has he ever been in contact with a person suffering fi'om leprosy ?"
And he vehemently and perfectly truthfully affirms that he has never been in such contact. But though he did
not know it, and though the communicator of the disease did not know it, he has been in contact with a person
suffering from the primary early rhinitis of leprosy.

This view, as the author remarks, brings leprosy, as far as pathology and treatment
are concerned, into line with tuberculosis and diphtheria, and he makes the suggestion that
possibly the opsonic treatment of Wright might be applied with advantage.

1 Black, R. S. (October 20th, 1906), " A New Aspect of the Pathology and Treatment of Leprosy." Lancet,
p. 1064, Vol. II.

104 REVIEW — TROPICAL MEDICINE, ETC.

Leprosy— Hillis' refers to Black's work on the nasal conditions which he, to some extent,

eontiiuied anticipated, but mentions non-tuberculated or aniBsthetic cases of leprosy with reliable
histories in which from beginning to end there was no nasal affection whatever.

Clift^ suggests that leprosy, like tuberculosis, may have an intestinal origin. Thus flies
may infect fish and other food-stuffs which under certain conditions would form a good
nidus for the bacillus. The benefit resulting from taking salt may, he thinks, be explained
by the resulting increase of hydrochloric acid helping the digestive juices to destroy the
germs.

The blood in leprosy has recently been the subject of study by Bourret.^ He examined
ninety cases in French Guinea and found changes which, though marked, cannot be
considered as characteristic. The haemoglobin value is lowered, the number of red
corpuscles diminished and the erythrocytes frequently present morphological lesions
(anisocytosis, vacuoles, poikilooytosis, polychromatophilia, granular basophilia), while
normoblasts also occur. The absolute number of leucocytes is generally diminished, never
increased. In all the forms of the malady, whether or not attributable to it, there
frequently exists an oosinophilia which may be considerable. The relative proportion of the
lymphocytes is often augmented, while the large mononuclears remain almost constantly
below the normal. Often enough there is an eosinophile and neutrophile myelocythemia,
but slight in extent.

Passing now to the question of treatment, the Lancet* notes that for many years
preparations of mangrove, lihizophora mangle, have enjoyed a great reputation as a cure for
leprosy amongst the jDeople of Cuba, and goes on to record the results obtained by Duque
and Moreno, which were certainly very remarkable.

A fuller account, dealing also with other work by Padilla in Central America, is quoted
by Nicholson'' as follows : —

The effects of mangrove on leprosy are as follows. At first, if administered in large doses to commence with,
it produces nausea, lassitude, vomiting and purging, which, however, disappear with the suspension of the
treatment. For this reason it is always advisable to commence with small doses, in order to gradually accustom
the patient to the drug.

The first thing the patient experiences after 15 to 20 days' treatment is an unaccountable feeling of
cheerfulness, ajjparently without cause for same, and without doubt he has a better appetite, and the lepralgic
pains are not so severe ; he feels active and disposed to carry on his usual occupation. The following month the
patient is another man; he has put on flesh, eats well, digests well, sleeps well and works without feeling weary;
the spots have become somewhat rose-coloured, more so in the periphery than in the centre, and those which are
confluent tend to separate, leaving large intervals of healthy skin between each other ; if there are any ulcerations
suppuration is diminished in them, they lose their dark colour and take on a bright red hue, and the inflammatory
areola disappears, the Icpromata undergo a transformation, the fresh nodules are not so extensive, and the fever
usually present on these occasions almost entirely disappears. Following up the treatment, the improvement
becomes more marked, the periodic crops of le^jromata disappear definitely from the fifth to the seventh month of
treatment, and the lepro-tuberculomata disappear in two ways, either by becoming inflamed, painful and
suppurating, or else they undergo fatty degeneration and become absorbed, leaving behind them in each case a
white scar with a faint, rose-coloured tint. Sometimes they become encysted and calcified, necessitating their
removed by incision ; the ulcers about the eighth month of treatment have healed up. The anesthesia has
completely disappeared. At the ninth month, according to Drs. Duque and Moreno, the alopecia ceases, and the
eyelashes and eyebrows grow again. What is most noticeable in these patients is the return of the face to its
normal condition, for it would at first seem impossible that faces with a skin like parchment, which give this
characteristic and repulsive aspect, could return in a relatively short time to their normal condition with a fine
skin. In a year, according to these same Cuban physicians, the patient is generally cured.

Dr. Padilla now gives an account of three cases which came under his own personal observation. The first
of these patients was under treatment for ten months, the second one for seven months, and the third for barely
six months, and he states that tlie first and third cases gave the best possible results ; but in the case of the second
patient it was noticed that scarcely any hairy down reappeared on his body, nor did his eyelashes and eyebrows
make much progress as regards growth. The first case occurred in a man aged 32 years, a widower, and a field
labourer, with no family history whatever of the infirmity from which he suiiered, which he believed he contracted
from a female servant who lived in his house. His two sons, one aged 11 years and the other 9 years, are both
healthy.

He stated that the first manifestations that he noticed occurred about six years ago, commencing in the left
cheek, and about two months later in the right cheek, and these were like thick ridges which increased until they
covered the whole of his face, and were accompanied with painful pustule^ which afterwards disappeared. A year

' Hillis, J. D. (December 1st, 1906), " A New Aspect of the Pathology and Treatment of Leprosy." Lancet,
p. 1544, Vol. IL

« Clift, H. L. (April 24th, 1907), " Intestinal Origin of Leprosy." British Medical Journal, p. 931.

' Bourret, B. Q. (.January 22nd, 1908). Bull, de la Soc. de Pathologic Exotique, t. I, No. 1.

* Lancet (October 2lBt, 1905), " Mangrove Bark in Leprosy," p. 1201.

" Nicholson, J. E. (October 2nd, 1905), "Treatment of Leprosy by Mangrove." Journal of Tropical Medicine,
p. 293, Vol. vm. I y y a

REVIEW — TROPICAL MEDICINE, ETC. 105

afterwards he had more spots, which spread to the nose and oars, taking on a blackish tint with scales which had Leprosy —

disfigured his nose, and some ulcerated nodules on his ears, and also scattered over many parts of his body, continued

including his nails, and certain affected parts were also attacked by local inflammation. Dr. Padilla diagnosed

the case as one of tubercular leprosy in its third stage, and he commenced treatment by 30 grammes of mangrove

boiled in 120 of water, to be taken daily; this was done for twelve days. For another similar period the dose

was increased to 45 grammes daily, and then for another ten days to GO grammes a day. After this the fluid

extract was used, commencing with 20 grammes daily, the dose being gradually increased up to 45 grammes in a

month's time ; a great improvement was now observed, including the reaijpearanee of downy hair, the swelling of

the feet disappeared, the patient enjoyed a good appetite and slept well, was very cheerful, and was now able to

attend to his usual occujDations. The fluid extract was now changed for the dry in doses of 2 grammes daily,

which wore gradually increased up to 7 grammes in the next two and a half months. Eleven months after the

commencement of the treatment the patient was the first to ask for its suspension, since he felt and appeared to

be thoroughly restored to health.

The treatment has also been tried in the Havana leper hospital during more than two years, on 17 cases, the
drug being given internally and applied locally, and though the results obtained were not equal to those recorded
by Duque and Moreuo, considerable improvement occurred in every case, one being completely cured with
disappearance of Hansen's bacilli.

Diesing^* reports cures by means of subcutaneous injections of iodoform. He
employs a 30 per cent, emulsion of iodoform in olive oil and injects from 2 c.c. to 8 c.c. of this
daily under the skin, at first in the neighbourhood of the infected areas, and later, when the
lesions are healing, in some suitable situation. The dose is increased fairly rapidly to
8 c.c. and the desired result is obtained in about six weeks. Tincture of iodine may also,
with advantage, be painted on externally. It is suggested that either the amount of iodine
liberated is sufficient to disinfect the whole body, or that the bacilli, having been killed by
the iodine, produce or set free antibodies, which eventually attack and destroy all the
organisms present in the body.

Thompson- reports a case in Australia which failed to benefit by the administration
of gurjun oil, but was greatly improved, indeed was very nearly cured by chaulmoogra oil
(Oleum (jynocardmm) and frequent hot baths. The dose of oil at first was 45 minims a day
given in three doses. This was finally increased to 270 minims and for a time was combined
with strychnine. A good deal of benefit, however, may have been due to causes inherent in
the patient. In the account of the ease, Thompson mentions two special methods of
examination which can be employed to test whether leprosy is or is not present. These we
quote as likely to be useful, and they are said not to be generally employed : —

(a) The way is systematic examination of the peripheral nerve trunks as a matter of routine. In the
accounts referred to these are most often omitted from mention ; and if their condition be noted, then it is done
only by way of adding one additional item to the complex of signs and symptoms fi'om which the diagnosis must
be deduced. But I now submit that such alterations as have been mentioned above, however (hardness,
inseusitiveness, increas