GANT on RECTUM ANUS, and COLON - Yale...

Beg;sterni at the Cbi&eae Post Office as a Newspaper,

Voi. XXXV II, No. 10, 0 0 TOBEK, 1923

Published M onthly by the

MEDICAL MISSIONARY ASSOCIATION OF CHINA.

TABLE » OF C O N TEN TS.

Page.

iala-Azar in China. C. W Young, a.D. 797

Biooc Pressura of Cantonise Students.W W Caùtiarv, M.n. 82:'

Deficiency of Breasi-Milk in Nursing Mothers; treatment Smyly.

....................... 834

Valuable Aids in Oscular Therapeutics.B Peterson, M.xi. ... ... b42

Treatment oi Schistosomiasis Japonica.E. C. t’aost, M.». ... ... ... 847

Simple Form of Carrel-Dakin Electrolytic Ceil. 1.1, It. Bteplitnsou, M..V. ... 850

Editoria): Medica! Education in China ... 853

League of Nations Health Committee ... esc

Page.

League of Kations Opium Advisory Committee ............... ... ... 857

Hospital Reports..........................

Administration of Mission HospitalsChina. J . H. Snoke, M.D.

Current Medical Literature

Irregular Practitioners in Canton

Tuberculosis in Hongkong

Book Reviews

Report of Kuling Branch of C.M.M.ft.

With the Executive Secretary ,.

Correspondence ...........................

Hews and Comments

in

859

860 807 878

877878 881 88*2

äSä 884

JustIssu.d GANT on RECTUM ANUS, and COLON Élusiration' ¡us is a complete treatise designed for specialist, practitioner, surgeon, and student. J$.

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Q l x i m p d i a l J m t r n a L

VOL. XXXVII. OCTOBER, 1923. No. 10

KALA-AZAR IN CHINA*

C h a r l e s W. Y o u n g , m\ d ., Peking.

It will be remembered that the parasite of kala-azar was discovered in England by Leishman1 (1903) in a British soldier who had contracted the disease near Calcutta. It is interesting to note that the first case from China in which the organism was found was that of a German soldier who took part in the relief of the legations in Peking in 1900. He was sent home from Tsingtao and died of tuberculosis in the St. Joseph Hospital, Leipzig, May S, 1902. Microscopical preparations of the spleen, liver and bone marrow from this patient were exhibited at the meeting of the Medical Society of Leipzig on February 3, 19032 and discussed as probably being evidence of Banti’ s disease. The case was also presented by Professor Marchand", of the University of Leipzig, at the meeting of the German Pathological Society at Cassel in September 1903. Neither he nor others at these meetings could explain the small round bodies found in the phagocytic ceils in the spleen, liver and bone marrow. When Leishman’s paper came to the notice of Marchand and Ledingham they published papers identifying Marchand’s “ cell-inclusions ” as the Leishman- Donovan bodies4.

A s with Indian kala-azar, the second case recorded was from spleen puncture in a living patient in the country concerned. Aird found the Leishman-Donovan bodies in a Hankow patient in 1905. Dr. S. T . Kerr reported the case in the Journal of Tropical Medicine5. Probably the patient was a Chinese though this was not mentioned in the very brief note. The diagnosis from the stained smear was confirmed by Sir Patrick Manson.

»Read at the C.M.M.A., Biennial Conference, Shanghai, February, 1923. Section on General Medicine.

79§ The China Medical Journal.

The third and fourth cases were reported by M artini6 from Tsingtao, Shantung, , in 1907. Both patients were Shantung Chinese.

The fifth was a British sailor who had visited Hongkong, Shanghai, Weihaiwei, Tientsin and Hankow in 1904 to 1906. The case was reported by Bassett-Smith7 (190S) then Fleet Surgeon in the British Navy.

The sixth was a Chinese living near Kiukiang. He had come from Shantung two years previously and had suffered from fever and enlarged abdomen before leaving his native province8’9 (1909,1910).

Later, Dr. W. H. G. Aspland reported a patient of Dr. Lillie Saville, from Tientsin30 (1910) and one from his own clinic'1 ( 19 11) .

The stud}- by S. Cochran 12,13 ( 19 1 1- 19 13 ) of the distribution of the disease in China and Korea, the age and sex incidence together with other clinical and epidemiological data, was the first thorough contribution on the subject from China and is still the best. From previous reports in the literature and from answers to a questionnaire sent to medical missionaries throughout China, he was able to locate the disease, microscopically diagnosed, in twelve centers from Peking to the AVu Han cities and Kiukiang, and from Tsao Shih, Hupeh, to Tsingtao, Shantung. Observers in ten cities south of the Yangtse River, in five provinces and in Formosa, reported negative microscopic findings. Cases clinically resembling kala-azar were reported from many places both within and without the endemic area. However, there are diseases which sometimes resemble kala-azar so closely clinically that only the finding of the etiological agent constitutes proof of the disease.

Since Cochran’ s paper, Reed14 (1914) reported from Changsha, Hunan, one patient, a boatman whose home was near Ichang. He had lived in Changsha one year but had had s3anpt0ins of the disease for five years. Two Leishman-Donovan bodies were found in a leucocyte from the peripheral blood. In view of the man’s occupation it is difficult to say where his infection was contracted. tW hile I know of a few other cases reported south of the Yangtse .during this period none so far as I am aware have been published in the literature and there was no evidence of their local origin.

Kala-azar in China. 799

T a b l e I .— E a r l y C a s e s o f K a l a - A z a r ix C h in a .

CaseNo. Where Contracted By Whom Reported How Diagnosed Where Reported

I Chihli or Shantung

Marehand and Ledingham

Autopsy. Stained tissue sections

Lancet, 1904, i, 149. Centralbl.f. Bak. u. Parasitenk. Orig. 1904, 35, 594-

2 Hankow .......... Dr. T. S. Kerr for Dr. Aird

Spleen puncture Jour. Trop. Med., 1905 8, 220.

3 E. Shantung ... M artini.......... Spleen puncture Berliner Klin. Wc- hnschr., 1907, 44, 1042.

4 Iviaoehow.......... M artini.......... .Spleen puncture Berliner Klin. Wc- hnschr., 1907, 44, 1042.

5 Had visited Weihaiwei, Tientsin, Shanghai, Hankow, Hongkong.

Bassett-Smitli Liver puncture Brit. Med. Jour., 1908, 1, 1043.

6 »Shantung. Reported from Kiu- kiang

Bassett-Smith Liver puncture Brit. Med. Jour., 1909, 2, 1614 ; 1910, 1, 750.

7 Tientsin .......... Aspland (Dr. Saville’sease)

Peripheral blood Brit. Med. Jour., 1910, 1, 139.

8 Peking .......... Aspland Spleen puncture China Medical Jour. 1911, 25, 212.

9 Hwaiyuan, A nhui

Cochran.......... Spleen punctures and l3'mph gland smears

China Medical Jour. 19 11, 25, 273.

10 Hwaiyuan, Anhui

Cochran.......... Spleen punctures and lymph gland smears

Jour. Lond. Sch. Trop. Med., 1912-13, 2, 179.

T h e E n d e m ic A r e a .

It is ten years since Cochran13 outlined the endemic area on the basis of replies to a questionnaire sent out to members of this Association. In December, 1922, another questionnaire was sent out by the present author and a map has been compiled as a result of the answers received (Map No. 1) . During the period between the two surve}^ hospitals have increased in numbers and equipment,

Sop The- China Medical Journal.

so that instead of the twelve centers which Cochran was able to report as having kala-azar, twenty-five are represented in the present investigation. The infection is much more intense in the area previously marked as endemic. In addition, cases are reported from Hsianfu, Shensi and Lanchowfu, Kansu, as well as New- chwang and Liaoyang in Manchuria. The Manchurian cases wrere diagnosed by spleen puncture, the Sianfu from peripheral blood ; but those from Kansu only clinically. Confirmation of these observations is awaited with interest. The new centers to the north-west suggest an interesting lypothesis regarding the route by which kala-azar entered China, but speculation with the present meager data is hardly worth w7hile.

O b s e r v a t io n s in an 'In f e c t e d V i l l a g e .

In March, 1922, Dr. W ylie and the author visited a village in Tinghsien (/E $£), Chihli Province, from which nine kala-azar patients had been received at the Taylor Memorial and Hodge Memorial Hospitals, Paotingfu. Our objects were to study the condition of treated patients, to ascertain so far as possible the presence or absence of the disease in the neighboring villages, and

in so far as opportunity afforded, make observations touching the problems of vertebrate reservoirs, insect vectors or hosts, and on the transmission of the disease. In the short time at our disposal, it was possible to carry out onty a small part of what we desired.

The village of Sha L iu T s ’un ifci") lies in the southernpart of Tinghsien (;$£“ ,1&) on a sandy plain 60 li (20 miles) south of the hsien city. In travelling to our destination we passed through K ’ung T s ’un, the home of two (?) former kala-azar patients of the Taylor Memorial Hospital. Besides examining them, we found six new cases in their village in an hour’s time.

Sha L iu T s ’un is a prosperous village of farmers. Many of the houses are of brick. On account of the absence of poverty there is little infestation with lice. F ig . 1 shows a map of the village with locations of the homes of the kala-azar cases. They seem fairly evenly distributed. Observations were made on the two discharged patients from K ’ung T s ’.un and five from Sha Liu T s ’un. Their condition as indicated by the size of spleen and liver and by the globulin precipitation test was noted. This is shown in the following Table.

Kala-asar in China. So i

T a b le I I ,— T r e a t e d .C a s e s ( l i v i n g : d is c h a r g e d ). R e la t io n

o f S iz e o f S p le e n and L i v e r t o G lo b u lin T e s t .

No. HospitalNo. Name Age Spleen Liver Globulin

Test

5ó

1221

30

ÓI

86

5 2 1/2 1 305/19 259/19

/ 2 1( 439,/iS \ 289/19 ( 89/20 ( 693/181 145/20

/21 ?

Shih Tsao Ling. Hao Tzu Hsi ... L iK e T e Chang P ’ieh Er.

Fang Shu Ching

Liu Chi vSo

Liu Yen Cli’ou...

918

13

18"

207

n.p.n.p.n.p.

2 cm. below c.m.

Splenectomy

j-P-n.p.

n.p.

j.p.

n.p.

j-P-n.p.

±+

±

+

n.p.=not palpable j.p .= ju st palpable

T a b l e I I I . — N e w C a s e s o f K a l a -a z a r : R e l a t io n o f S iz e o f

S p l e e n a n d L i v e r to G l o b u l in T e s t .

No.Duration

ofDisease

Name Age Spleen Liver GlobulinTest

1 2 years Wang So Lan 7 to umb. + + +2 1 year Wang Ch’o Er 6 j-P- + +3 6 months Wang Te Yin 3 1 f.b. (Healed +

below c.m. Cancrumoris;

1 severalteeth out)

4 1 yi years Shih Ling Yin 5 to umh. + + + +7 Hao W n E r .......... 15 ¡ to umb. + + + + +8 Hao Hsiang Ch’en 6 n.p. +

18 Liu Chan Chiang... 16 6 c.m. 3 f-b. + + + +26 Liu Hsia Hun 7 palpable palpable + + +4i Y ing Yin Cli’uan ... 9 1 f.b. 2 f.b. +45 Liu I K u .................. 5 to umb. 3 f-b. + + + +46 Liu Wen Ch’ing ... 3 ? (crying) + + + +47 Liu Chia Chieh ... 7 to umb. 3 f-b- + + + +77 Liu. Lao Cheng 6 to umb. 2 f.b. + + + +83 Liu Lu Teh .......... 4 to umb. 2 f.b. + + +84 Meng Huai Tan ... 3 j-P- V + +85 Liu Shu Ling 13 to umb. 8 c.m. + + + + +94 Y'ao Tsao T ’ang ... 17 to umb. 2 f.b. + + + +95 Ch’en Hsiao T ’ang 6 8 c.m. 2 f.b. + + + +97 Ch’en Chiu Te 17 j-P- n.p. + + + +98 Ch*en Hsiao Ling... 10 3 f-b- 2 f.b. + 4-+ +

umb.=umbilicus f.b. = fingers breadthsbelow c.m .=below j.p = ju st palpable

costal margin n.p.=not palpable

802 The China Medical Journal.

[Table II on preceding page was compiled in March, 1922. The year when each case was treated is indicated by the last two numerals of the history number. With these cases may be contrasted the other cases (Table III) seen since.]

Table IV is a summary of the records of patients writh negative or doubtful globulin test and with palpable spleen; the number of those clinically well with negative globulin tests is also given.

T a b le IV . R e la t io n o f S ize o f S p le e n and L i v e r to

G lo b u lin T e s t (N e g a tiv e o r D o u b t f u l) .

No. Name Age Spleen Liver G lobulin T est Remarks

1 0 0 T ’ien Kuang Wen 1 5 2 f.b. j-P- + Severe a n e m i a ; about 20% hb. no K .-A .' known in village.

1 0 1 Hu Chi Shan 2 2 j-P- li.p. — High hemogloblin.

The number of patients with negative globulin test, clinically well, was 68.

Two cases (Table V.) of apparent spontaneous cure after cancrum oris were found.

T a b l e V . A p p a r e n t S p o n t a n e o u s C u r e .

No. Name ,A.ge j Spleen Liver G lobulin Test Remarks

3 Wen Te Yin 3 i f.b. ± “ Healed cancrum oris” . Several teeth fell out.

43 Liu Huan Te 26 A t about ten years of age,had enlarged spleen with cancrum oris on left side followed by scar tissue which prevents him from opening his mouth.

f.b.=fingers’ breadths

Kala-azar in China.

The homes of all discharged patients were visited, a globulin test made on all members of the family present, and in the case of children au abdominal palpation for the size of the spleen and liver. Following are protocols (Table VI) of two families as examples of the method and results.

1

T a b le V I.— Specim en F a m ily P r o t o c o l s .

Village Location of Village No. of FamiliesSha Liu Ts'un 35 li S.E. of Hsiu Lo Hsieu 240

60 li S. of Tiugcliow

No. Name AgeDuration

ofsymptoms

Spleen Liver GlobulinTest Remarks

12 Li Ke Te

Father

An.p.

n.t.

T. M. Hosp. No. 259-19

(not at home) “ well ”

13 Youngerbrother

... n.p.

14 Mother ... —

15 Son n.p. —

16 Wife —

*17 Dog —

B

18 Liu Chan Chiang

16 3. cm. from umb.

3 f.b. below c.m.

+ + + + Treated for malaria

T. M. Hosp. No. 20

19 Mother ' — ...

20 Olderbrother

—

*2oa Dog ... — ...

n.p.— not palpable; mnb.— umbilicus ; below em.=below costal margin ; n.t.—not tested; f.b.—-fingers’ breadths. ,

8 o 4 The China Medical Journal.

In all, 97 persons from 40 families were examined. In the journey of 70 li (23 miles) from Hsin Lo Hsien to Sha L iu T s ’un and return, inquiry was made in all villages as to the presence of the disease. The inhabitants know it well and usually answered frankly. It is possible that in Tung Wang T s ’un and Hsi Wang T s ’un the negative answer was dictated by fear. There was no ready means of confirming or disproving the statements. Table V II shows the presence or absence of kala-azar in these villages. In all villages where the disease is indicated as “ present” , patients were examined and enlarged spleen with positive globulin precipitation test in the blood was found. From four of the six “ positive” villages, patients had entered the Taylor Memorial Hospital and the diagnosis had been confirmed, in most cases, by spleen puncture. In Sha L iu T s ’un, the only village carefully studied, one family in every twelve had had a case in the last four years. This means that about 1 2 / 3 per cent of the population had suffered from kaia- azar in that time.

T a b le V II .— K a la -a z a r in C hine.se V i l l a g e s .

Name of Village Location No. of Families

Presence or absence of kala-azar

Hsin Ló Hsien

. T s ’aö T s ’un 15 li S.E. of Hsin Lo Hsien

No investigation none

K ’ung' T s ’un 20 li S.E. of Hsiii'Lo Hsien 350-360 Present

Sha Liu T s ’un 35 li S.E. of Hsin Lo Hsien 60 li S. of Ting Chow

240 Present

Lien T ’ai T s ’un 3 li E. of Sha Liu T s ’un ’ Present

Pai Tien 3 li S. of Sha Liu T s ’un ... Present

Tung W ’ang T s’un 30 li S.E. of Hsin Lo Hsien none

Hsi W ’ang T s ’un 29 li S.E. of Hsin Lo Hsien none

Nan Chang T s ’un 20 li S.E. of Hsin Lo Hsien 100 Present

Yü Ti 10 li S.E. of Hsiii'Lo Hsien* 800 Present

It is noteworthy in considering the question of insect transmission, that the twenty cases in Sha lyiu T s ’un occurred in

The China Medical Journal.

HOW CAN MISSIONARIES BE OF MOST USE TO CHINA DURING THE NEXT DECADE.*

W o n g M a n , M . R . C . S., (E n g .), H a ck et t M e d ic a l C o l l e g e , C a n t o n .

When I was asked Lo lead the discussion to-day on our service as medical missionaries to the Chinese I made several excuses, one of which was that as I have been in England for several years and have but recently returned, I may not be fully able to express present Chinese opinion on this subject. However, I consented to state my own personal views, but as it was only yesterday that I was asked to take part and as I have been very busy since with little time for preparation, I am afraid that what I say may seem very loose and disconnected.

Our subject is, “ How can missionaries be of most use to China during the next decade?” Let us first define our terms. “ Most use to China” means what it says:' “ to China” , and to China alone. A s missionaries we must forget from what country we have come and think only of serving China, not England, or the United States, or any other country. It is very easy to err in this respect and for the most part quite unintentionally or unconsciously. Especially is this true in face of a sudden crisis or decision; it is then that we are apt to think and act as patriots instead of as missionaries. “ Of most u se” means serving China’ s greatest needs. There are different opinions as to what are China’ s greatest needs; it is here that we have to exercise careful judgment. No : I must not put it in this way. Better to say that we have to lipten carefully to the voice of God and find out the most essential needs of China according to the will of God.

Are China’ s essential needs material? One would think so, to judge by present circumstances and general opinion. W hy then are they not met ? Has China no one capable enough to meet them ? Apparently not. We have to-day in treaty ports and in the political centres thousands of returned students— engineers, doctors, lawyers, miners, economists and others. Are they doing their part in meeting China’ s material needs ? No. Many are idle and many have

*Read at a meeting óf the South China Branch of the C. M. M. A., July, 1923.


changed their profession, doing something different from that for which they were trained by years of labour and study abroad. China’s material needs are not being met, not because she lacks the men with knowledge, but because she lacks men who will do their duty-

So we come to the heart of the problem. China’ s needs to-day are not so much material as spiritual. She wants men of character who know the meaning of service, of duty, of patriotism, but chiefly of Christianity. In helping to train such men missionaries are given a great privilege and opportunity to serve the Chinese, and I do not hesitate to say that all the good there is in modern China is largely owing to what has been taught and accomplished by missionaries. Yet our work is by no means perfect.

Let us examine what has been done. I have been asked to criticise, and I do so in a spirit of humility and with no desire to give offence. Most of our missionary work has been educational. It seems to me there has not been the clear thinking to distinguish between Western civilisation and Christianity; that we have met with more success in spreading this civilisation than in propagating Christianity, and that we have been turning out too many half- Christians. To have a bath once a day, to wear a wrist watch and to play games may be a part of Western civilisation, but not an essential part of Christianity. The object of our schools should be to influence those under our charge to gain the missionary spirit. Let us not be satisfied until we have done this with every one of our pupils. Thus the ideal for our medical schools should be, “ every graduate a m issionary;” for our hospital wards, “ every patient a convert.” Then, and only then, shall we be able to face God with the consciousness of having done our duty. Further, the future of our pupils should cause us deep concern. We tend to praise those we call Christian military leaders, politicians, and rich men. Let us be careful, for in the present state of the country it is exceedingly difficult for any one to attain to high position or great wealth without giving up some of his Christianity or resorting to practices which are not Christian in principle. The teaching concerning the rich with the saying how hard it is for a camel to go through the eye of a needle still holds true to-day. Let us rather hold up as our ideal the humble and poor Christian worker.


The lack of steady zeal and consecration may be observed occasionally. Some missionaries seem to have spent all their spiritual energy in making the decision, the sacrifice, to come to China, so that when they arrive here, in no long time they seem exhausted and lose the fervor which once they must have possessed. To follow up this thought I may take my own case. Very often I get so tired in going a considerable distance to see a patient and in making the necessary examination that my work becomes nothing more than purely professional, indistinguishable from that of an}T secular physician. I quite fail to add that little extra touch of love and kindness which should emphasize the service of the Christian doctor, just that little more which makes all the difference in the world but which requires such strength as only God can give and only constant nearness to Him can bring.

There is another point. When the first disciples went forth to preach, at Rome for instance, they were going from a lower civilization to a higher; they had nothing to give but the Gospel and they did good work. Now the situation is reversed. Missionaries come from a higher material civilisation and they have to contend with a two-fold danger; on their own part, lest they let their civilisation obscure their m essage; and on the part of the Chinese lest they are attracted by the glamour of material advantages instead of by the living gospel.

Lastly , the attitude of missionaries towards Chinese Christians. It exhibits too much autocracy instead of paternal love towards the Chinese.. If missionaries find they have yet to rule, let them rule like a loving father who withholds certain privileges only because the son is not yet ready for them. There is a mighty difference between autocratic and paternal rule. I need not dwell on the importance of bridging the gap between missionaries and the Chinese; let us not by our own hands create more separation than is unavoidable, either by our attitude or by our manner of life.

I have said enough on the theoretical side. In practice we should continue mainly our educational work and concentrate on imparting Christianity to the students. I suggest we should rewrite all our school-books in the spirit ot the Sermon on the Mount, especially our history books in wrhich selfish patriotism is exalted to the highest degree. How can we hope to bring up our


pupils to be Christians if we feed their minds on the . current morality of the world. And what is the difference between a mission and a secular school unless we strive with all our endeavor to teach our pupils Christian thoughts and ways of life ? I feel that we are letting our chances go if from fear or cowardice we do not give our pupils pure Christianity. I would rather see China with dirty streets and no electric lights, but with the living message of God in the hearts of the people, than to see her a godless, powerful, and rich nation, a force to be reckoned with and feared in the world.

L et us preach Christianity and not Western civilisation; where the Chinese are concerned let us forget our own countries and our own churches or societies, and then we shall be of most use to China in the next decade. In conclusion, I repeat that what I have said has been spoken in a spirit of humility and with no desire to give any offence.

CHM PRCMNCe

D IS T R IB U T IO N by I I S E N & ä o f S 3 C A 3 C 5 o f K A L A -A Z A R î m o n T T 1E C L IN IC S o f T M C

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Kala-azar in China.

twenty different families. While this does not constitute proof, it is distinct evidence against transmission by the bed-bug. No bedbugs were collected for the reason that none were to be found at the season at which the visit was made.

T a b le V III .— K a la -a z a r : G lo b u lin T e s t o f A n im a ls in

H om es o f P a t ie n ts .

Patient’s Animal’sNo. Animal Whose house Globulin

Test *Globulin

Test tRemarks

!7 dog Li Ke Te — — T. M. Hosp. Xo. 259/ 19

20a dog Liu Chan Chiang + + + + ■— Trtd for malaria in T. M. Hosp.

34 cat Fang Shu Cliing — — T. M. Hosp. Xo. 439/iS, 289/19, 89/20.

40 cat Liu Chen Pang — — Host.62 hen Liu Chi So — ( + + + ) T. M. Hosp. Xo. 639 /

iS ik 145/2063 Pig Liu Chi So See above Xo. 6264 pig Liu Chi So „ Xo. 6270 hen Xing Hsi Ch’un dead (+ + ) T. M. Hosp. Xo. 313 /

1971 dog Xing Hsi Ch’un dead —72 cow ? — On Street. “ Xo. K.

A. in owner's family. ”

74 hen Liu Ch’eng Pao dead + + + (Died of small pox athome, 1920)

80 cow Liu Ch’eng Pao dead —Si Shui Chi (+ + + ) Wild bird, (Smears

neg, for L.-D.)

Mammals :— 3 dogs, 2 cats, 2 cows, 2 pigs, all negative Birds :— 3 hens, 1 sliui chi (water-fowl), all falsely positive

Total :— 13 animals examined

* See Tables II and III.

tThe tests showing ( + +) or (+ + + ) indicate false positive reactions. These are due to the cloudiness caused by the nuclei of the red cells in birds. This can be proven by addition of a drop of dilute hydrochloric acid. Globulin is dissolved immediately ; the nuclei are not. The nuclei can be demonstrated by staining a smear from the cloudy fluid in the bird blood tubes.

8o6 The China Medical Journal.

Globulin tests were also made in several instances, on the domestic animals in the homes of patients to discover, if possible, a vertebrate reservoir. It must be admitted that we have as yet no proof that the blood of animals with leishmaniasis shows a positive globulin test, but it seems likely that such is the case and we hope to be able to obtain the proof from experimentally infected animals. In countries where canine kala-azar exists this may offer a simple method of study which, so far as I am aware, has not yet been utilized. The number of animals whose blood was submitted to the globulin test (Table V III) was not large but they are worth recording.

This brief visit to an endemic area did not yield results of great importance but it did indicate an intensity of infection not previously appreciated. Since the study just outlined, Dr. Wylie has made available the data on the distribution by hsiens, of 84 kala-azar cases seen in his clinic from 19 18 to 1922. These are given in Map No. 2. It is to be noted that the area from which they come lies almost entirely-to the south of Paotingfu. A spot map for kala-azar patients in the clinics of the Peking Union Medical College Hospital is shown in Map No. 3. Only those cases are indicated in which it couid be determined with reasonable certainty that the infection was contracted in Chihli Province. It will be noted that, aside from those patients living in or around Peking, the cases came from along the railways. This probably means that the reputation of the hospital has spread along the lines of easy communication and indicates nothing as to relative intensity of infection. A stud5' of Dr. W ylie’ s cases aroused a desire to find out the distribution around other hospitals in endemic areas which have paid especial attention to the treatment of the disease. Three such hospitals stand out conspicuously; namely, the hospital of the Department of Medicine of the Shantung Christian University at Tsinanfu, Shantung (Map No. 4); the Southern Presbyterian Missions Hospitals at Hsiichowfu, Kiangsu (Map No. 5 ); and those of the Northern Presbyterian Mission, at Hwaiyiian, Anhui (Map •No. 6). Through the courtesy of the physicians in charge I am able to present maps showing the distribution of the kala-azar cases jn their clinics during the periods indicated. Especially striking is the situation in and around Hsiichowfu where the disease deserves the name of a scourge. In a clinic at Pien T ’ang, 1.00 li

Kala-azar in China.

east of Hsiichowfu, Dr. MacFadyen saw 25 cases which he diagnosed as kala-azar among 125 patients. At Ting Chwang, 18 li southeast of Hsiichowfu on the edge of the old Yellow River bed, it is reported by the inhabitants that every second child in the village has kala-azar. At Hwang Mo Kang, three li south of Hsiichowfu, a village of about 100 families, there are twenty cases. On the other hand, there is a district around Yuan Chia \Ya, 60 li south of Hsiichowfu, from which no cases of kala-azar have been received although the mission has preaching centers there and patients come with other diseases.

In Map No. 7 the data from five of these hospitals are combined with those from others in the area, from Dr. Cochran’s survey together with Martini’ s Chiao Chow (Kiao Chow) case. Each hsien from which kala-azar has been reported is shown in black. The returns are incomplete. Those from hospitals where the disease has been recognized and treated for many years, such as those at HwTai Yuan in Anhui, indicate infection in every hsien in a rather sharply defined field. From the data in hand it is safe to say that kala-azar is endemic over most of Chihli, Shantung, north-western Kiangsu, northern Anhui and northern Honan. Furthermore, there are areas not indicated on this map in Hupeh and lower Kiangsu, but the limits of these have not been defined.

A g e I n c id e n c e

Nicolle1 ’ gave the name Leishmania infantum to the parasite found in North Africa on the basis of his observations in eleven cases varying in age from 5 months to 6 years, with an average of 2 years. In 19 2 1 , he16 reviewed his observations up to that date. 0 f 59 cases confirmed by positive findings at spleen puncture, 34 were under two years of age and all were under ten. The average was slightly over two years. Jemma17, in Palermo, found 58 cases from one to four years old, and onty five from four to six years. On the other hand, Wenyon18 has collected reports of adult cases in this area by eleven different workers and summarizes thus : “ It isthus evident that the Mediterranean disease attacks adults, and the Indian disease, children as in other endemic areas, and it can no longer be maintained that infantile kala-azar is distinct from that of India. This conclusion is borne out -by all the clinical features of the disease and the characters of the organism producing it .” Nicolle, indeed, came to practically the same conclusion in h islast

8o8 The China Medical Journal.

paper referred to16, where he says : “ The lack of authentication of the disease in individuals older than ten j-ears (in Tunisia) justifies the name kala-azar of children (‘ kala-azar des enfants’) under which we designated it at the beginning of our researches. We do not think that the term implies a difference from the kala-azar of India. Several cases ot the disease have been observed in adults in the Mediterranean basin (Tripoli, Sicily, Crete, Egypt) where kala-azar,"as in India, is a disease which shows a preference for young subjects.”

For India the age incidence found by different investigators is shown in Table IX .

T a b l e I X . — A g e I n c id e n c e o f K a l a -a z a r in I n d ia .

Age Mackie, 1 Assam. 1913

Muir, 2 -r, .. A ’ : Rogers, 3 Assam. 1 * ’„ , Assam Burdwani

Rogers, 3 Sylhet

Rogers, 3 Calcutta

Rogers, 3 Europeans

No. % No. % No. % No. % No. % No. %

1-56-10

11-15.16-2021-2526-3031-3536-40

9100491712

Sa

55-9%

33-8

6.2

4.1

Av. age

21.41 years

2—40

years

25.6

24.4

50.0

39

30

31

8

40

32

16

4b

20

2216

22

20

195 100.0 roo.o 100.0 J 100.0 100.0

a .“ over 30 years.” b “ over 40 years.”

R e fe r e n c e s

1 Tropical Diseases Bulletin, 1914, V., p. 262.2 Tropical Diseases Bulletin, 1917, X I, p. 151.3 Rogers, Sir Leonard, “ Fevers in the Tropics.” 3rd edition, p. 21.

So far as I am aware only two series of figures have beenpublished on this subject for China : those of Dr. Cochran13 and Dr. W ylie.19 These figures are omitted from the tabulation presented because a larger series has been obtained from both Hwaiyuan and Paotingfu. The following Table shows the age incidence, in 762 cases from the sources indicated as well as a curve based on these figures*

K ala-azar in China. 809

T a b le X .— A g e In cid e n ce o f K a la -a z a r in C h in a .

Age

Paotingfu Wylie 1918-22 4 yrs.

Tsinanfu Struthers 1920-22

29 months

Hsiichowfu MacFadyen

1921-22 21 months

Hwaiyuan Cochran,

Kerr, Murdock 1902-22 21 yrs.

Peking Union Medical College 1916-22 7 yrs.

Kala-azarSurvey Summary

No. % No. % No. °/o No. % No. % No. % No. %

1-10 23 25.3 54 38.9 43 33.6 36 20.2 35 29.0 49 46.7 240 31.5

11-20 42 46.1 44 31.7 48 37.5 81 45.5 58 48.0 33 31.4 306 40.1

21-30 19 20.9 25 18.0 25 19.5 44 24.7 16 13.2 11 10.5 140 18.4

31-40 6 6.6 13 9.3 11 8.6 11 6.2 11 9.2 8 7.6 60 7.9

41-50 1 1.1 2 1.4 1 0.8 5 2.8 1 0.8 4 3.8 14 1.8

51-60 1 0.7 1 0.6 2 0.3

91 100.0 139 100.0 128 100.0 178 100.0 121 100.0 105 100.0 762 100.0

C u r v e S h o w in g A g e In cid en ce o f K a la -a z a r in C h in a

per cent

S e x I n c id e n c e

Mackie20 found in Assam, India, that the mortality figures of the two sexes from kala-azar were very nearly the same. There are

8io The China Medical Journal.

no comparable figures for China. Social conditions in China make hospital statistics undependable for ascertaining the facts. These can only be discovered by a thorough study of infected villages where all the homes are accessible. No such survey has been made.

T h e D i f f e r e n t i a l D ia g n o s is o f K a l a -a z a r

Notwithstanding all that has been written about the diagnosis of kala-azar it is evident that this is not always eas} . It should be emphasized that while a probable diagnosis can be made on physical examination only, the proof lies only in the discovery of the etiological agent. Although the Leishman-Donovan body has a very characteristic structure which renders it unmistakable to a trained worker, frequent mistakes are made b}r those unfamiliar with microscopical examination of the protozoa. It therefore seems desirable to discuss briefly the diagnosis of the disease.

T h e T e m p e r a t u r e C u r v e

Sir Leonard Rogers21 was the first to call attention to the peculiar “ double remittent ” 'fever found in many cases of kala- azar, especially in the acute stage. The temperature must be taken at intervals of not more than four hours to showT this feature. Tvala-azar does not always show this “ double spike ” every twenty- four hours. In early acute cases, the disease is frequently mistaken for typhoid fever and the temperature curve may show nothing to distinguish it from that disease. Kala-azar may be mistaken for estivo-autumnal malarial fever. The temperature curve, therefore, while characteristic in some cases cannot be relied upon in all, for diagnosis.

E n l a r g e m e n t of t h e S p l e e n a n d L i v e r

Kala-azar is characterized by an enlargement of the spleen and usually of the liver. However, in early cases the enlargement is not marked. Sometimes a kala-azar case with a just palpable spleen combined with a rather high remittent temperature very closely simulates typhoid fever. One such case, an American child, was referred to us after treatment for six weeks as typhoid fever. Spleen and blood cultures, as well as spleen smears, were positive for kala-azar. Enlarged spleen is common in many parts of China.

Kala-azar in China. 8 1 1

In North China in the area endemic for kala-azar there are many cases of splenomegaly, some with and some without leukopenia which are not kala-azar. This is in a region where estivo-autumnal malaria is not endemic. The nature of these is unknown. Some are doubtless Banti’ s disease. Other diseases with splenic enlargement from which kala-azar must be differentiated are miliary tuberculosis, syphilis, malaria and schistosomiasis.

The enlargement of the liver in kala-azar is not so marked as that of the spleen and may be absent even when the latter organ has reached the level of the umbilicus.

T h e B eood in K a l a - A z a r

Kala-azar is characterized b\r an anemia M'hich majT be extreme. Rogers22 and Knowles"3 have discussed the changes in the number of red cells and amount of hemogloblin. We can confirm Knowles’ observation of the frequent occurrence of nucleated red cells, especially in the blood of children.

Rogers was the first to describe the characteristic feature of the leukopenia in kala-azar, that is, the fact that the white cells are more marked!}- reduced than the red, so that the ratio may be even less than one leucocyte to 4,000 erythrocytes. He considers a ratio of less than one white to 1,500 red as “ almost absolutely diagnostic” . Again, attention must be called to the fact that leukopenia alone does not serve to distinguish kala-azar from the diseases with which it is most likely to be confused, viz., typhoid fever, malaria and Banti’ s disease. Further, it should be noted that not rarely in patients with secondary infections such as broncho-pneumonia, cancrum oris, and various pj'ogenic infections, there may be a leucocytosis.

When the characteristic leucopenia is present it is marked by a decrease in the granular cells, i.e ., those of undoubted bone-marrow origin. The polymorphonuclears are reduced while the eosinophiles and basophiles usually disappear altogether. On the question of the increase or decrease in eosinophiles there is a singular difference of opinion. Rogers24 states that “ the eosinophiles are decreased, in the absence of intestinal parasites, so that in a count of 250 to 500 leucocytes, as a rule, no eosinophiles are met with. This change

S i 2 The. China Medical Journal.

is apparent^ similar in nature to the loss of the polynuelears, but is less significant owing to the small numbers of these corpuscles normally present in the blood.” Knowles25 on the other hand sa y s : “ There is a marked increase in the coarsely granulareosinophile cells. A s will be shown later there are reasons for regarding this increase as due not simply to ankylostome and other helminthic infections, but as part and parcel of the reaction of the patient to the disease (kala-azar).” Rogers gives no detailed •differential leucocyte counts. Regarding the change in the proportions of the different kinds of white cells, he merely states that “ this consists in a considerable and not rarely an extreme reduction in the percentage of the polymorphonuclear neutrophiles and eosinophiles accompanied by a relative increase in the proportion of the large mononudears and lymphocytes although owning to the great total reduction these also are commonly below the normal number per cubic millimeter of the blood.” “ The lymphocytes are increased together with the large mononuclears in proportion to the reduction in the percentage of the polynuelears and eosinophiles.” Knowles2'* gives the data upon which he bases his statement regarding the increase of eosinophiles.. These have been tabulated together (Table X I) with similar findings from our own clinic.

T a b le X I .— K a la -a z a r : D i f f e r e n t i a l L e u c o c y t e C o u n ts in

C a s e s T r e a t e d and U n tr e a te d .

Knowles P e k in g U n io n M ed ic a l C ollege

47 cases of un

treated kala azar

31 cases of

cured kala azar

f‘ Health

y person

”

27 cases of untreated

kala azar

8 cases of

treated kala azar

“ H e a l t h yperson”

Ploymorphonuclearneutrophiles 48.00 45-74 71-75 46.37 49-25 67.5

P.M. eosinophiles 5-92 14.58 2.00 1.62 1.62 •5P.M. basophiles 0.24 0 .3 9 0.25 .22 .12 .0Large mononuclears ... 19.40 16.19 3 .0 0 17 .11 17-37 4.0Lymphocytes ... 26.44 23.10 23.00 38.66 25.62 37-0Total leucocyte count

per cmm.33 cases

5,145

30 cases8,874 7,000 4,307 5,6i 3 8,200

Red blood cells per cmm__ 2 ,457,270 4,039,070 3,141,815 3,505-877 4,800.000

H em ogloblin.............. 39% 58% 53 -8% 70.6% 100%

SliANTUNG- PROVINCESHANTUNG C A S ES

HsicnNo. H *ien ■No. of

C ilM 'S

1 L i n g .................................... 12 Yu Cheng ........................ 23 Chi T u n g ........................ 14 C hi Y a n g ........................ 15 C h 'ang Chiu 16 Chou Ping . • 17 Po Hsing 48 Kuang Y a o ........................ 19 C hang 1 ........................ 3

10 Po Ping 21 1 Chi Ho ........................ 212 Li Cheng (T s in an fu 3013 1 Tu < Ching Chou Fu> 714 Ch ang L o ........................ 21 5 Wei • ■ ........................ 216 L iao Ch'eng

l,Tung C h ’ang Fu)1

17 C h ’ao Ch 'eng 118 Yang Ku »

819 C h ’ang C h 'ing20 T a i An 1221 Lin Chu 122 An Ch iu 223 Kao Mi .......................... 124 F a n ...................................... 225 Shou C hang 126 Ning Yang 127 Hsin T a i 128 Men Yin .......................... 329 1 S h u i.................................... 130 Lu (Lu Chou) 131 Pu (Pu Chou» 332 Szu Shui 533 Chou 234 Yu T a i .......................... 135 T e n g .................................... 436 1 ..........................................................

T o t a l .

1

113

CHIHLI C A S E S

37 T a M ing (T a M ing Fu) • 138 C h 'in g H o .......................... 139 Ning C h ’ing 1

T o ta l . ■ 3

DlSTCiBUTIOM BY M2IEKJ5 OF 116 C A S E S OF K ALA-A Z A B FGOM ThfE MOSPtTAL o r T H E SMAInTTUNG CHEISTIAN UNMFSZ5CTY TSIN AN . T V O V C A C S .

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2>k M O N T H S 4 4 C A S E S

^fcOV/NCE; M 5 IEKI N°0 CASE'S TOTAL ( ’ KIAWC.SU ’ TAMQ S H A N 1-4- __

1 : _ P & l i o"1— M SI A O

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PEI * j 2»' S U I N IN G 5 £ 9 5

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U N O P 'l 6

TO TA L-

Kala-azar in China.

T h e leucocytes are classified by Knowles as polymorphonuclears, coarsely granular eosinophiles, m ast cells, large hyalines and transitionals, lym phocytes and small mononuclears.

W hile the attempt has been made in our series to select only cases in which the fecal examination showed no intestinal parasites present, it is possible that the high eosinopliile count in some of the specimens was due to unrecognized helminth infection..

Of our 27 untreated cases 16 showed no eosinophiles and 22 no basophiles whatever, while the average of all the untreated cases gave only 1 .0 7 ^ of eosinophiles and 0 .22% of basophiles.

T h e G e o b u e in P r e c ip it a t io n T e s t

T h e final diagnosis of kala-azar depends on the discover}’ of the etiological agent. Recently, however, B ra m a ch a rr5’-6 R a y 27, and S ia 2S, have described tests for kala-azar using either serum or whole blood diluted with distilled w ater.* S ia and W u1'9 have shown that the precipitate is composed of the serum globulin which is insoluble in the distilled water. The test must of course be considered to give presum ptive evidence onl}r. W hile there are no grounds beyond experience on wThich to base the statement that the test is specific for kala-azar, such has been the estimate by most who have used it.

Am ong those who kindly answered the questionnaire sent out, two have questioned the specificity of the test. The first sa\'s that it is also given by leukemia. T h is criticism is not well founded, for it can be shown that in leukemia the cloudy appearance is due to the undissolved nuclei of the leucocytes, not to a precipitation of globulin. T h e use of serum alone in leukemia gives a negative test. W heu the whole blood is used, the addition of a drop of dilute acid to the tube does not cause disappearance of the precipitate as is the case in the genuine globulin precipitation test. The second criticism is the statement that a sim ilar test is given in schistosomiasis. The observation has been made by two different workers in different provinces in the schistosome endemic area.

♦Twenty emm. of blood are drawn from an ear or finger puncture into the pipet of a Salili hemoglobinometer and expelled into a small test tube ■ontaining 0.6 e.c. distilled water. Mix. Read after five minutes. A positive

test is indicated by turbidity with a precipitate on standing.

8 i 4 i The China Medical Journal.

Except as noted below we have been unable to obtain serum from Schistosoma cases. It is not impossible that this disease does give the test. Our grounds for reserving judgment in the matter are based on the following observations. A patient suffering from proven schistosomiasis who was under observation for thirty-seven days in the Peking Union Medical College Hospital, failed to show any flocculation resembling the globulin precipitation test found in kala-azar. Eleven specimens of sera obtained from four experimentally infected dogs have been examined. No positive test was found. There certainly are no a priori reasons why kala-azar should be the only disease to increase the serum globulins to a point where they are precipitable when the blood or serum is diluted with distilled water, so that further study of the question with quantitative estimation of the serum albumin and globulin is awaited with interest.*

After many tests on proven cases of kala-azar the following seems to be a safe statement regarding our experience with the test. The globulin precipitation test has been present in all cases of well-developed kala-azar, that is, when the spleen has reached the level of the umbilicus. It was absent or very doubtful in an American child who had been sick six weeks and in whom the spleen was just palpable. Cultures from the spleen and peripheral blood were positive as were smears from the splenic puncture. The test increases in intensity approximately with the increase in size of the spleen, and decreases under treatment with the decrease in the size of the spleen. In making these statements there is no intention to imply a causative connection between the size of the spleen and the amount of globulin in the blood. When the treated patient is free from signs and symptoms of the disease and the spleen is no longer palpable the test becomes negative. This is shown in Tables II. and I II . taken from the Sha L iu T s'un series and three Tables from the clinics of the Peking Union Medical College Hospital (Tables X II , X I I I and X I V . )

♦Since the preparation of this paper, a clinical study of schistosomiasis cases in Kasliing, Chekiang, by Dr. H. E. Meleney, of the Peking Union Medical College, lias shown that the globulin precipitation test is Constant in well-developed cases of schistosomiasis and that it tends to disappear under treatment with antimony. The formol-gel test is also positive. Analysis of the sera show that, as in kala-azar, the flocculation is due to '■ great increase in the serum globulin.

Kala-azar in China. 815

T a b le X I I .— G lo b u lin P r e c ip it a t io n T e s t in C a s e s ok

U n t r e a t e d K a la -a z a r .

Historynumber Culture Smear Size of Spleen Globulin

Test

691

744

786

819

S32

O. P. D. 7336

1283

13 1 1

1390

1671

1699

1757

O. P. D. 12149

1881

O. I». D. 140S1

1995

2137

2195

O. P.D . 15805

0 . P. D. 16059

2312

2323

0 . P. D. 16155

O . P . D . 16335

S +

s +

S +

S +

s +

B +

I *! ♦B +

S +

B

I *B +

BS + B +

BS +

BS + B +

B +

B +

B +

b ‘+

S +

S —

S +

S +

s +

s +

s +

s +

s +

s +

17 c. m. b. n.

21 c. m. b. c. m.

25 c. m. b. c. m.

16 c. m. b. n.3.5 c. m. r. m. 1.29 c. m. b. n.

5 c. m. r. m. 1.5 c. 111. b. u.

30 c. m. b. n.

30 c. m. b. n.

21.5 e. m. b. 11. 1.5 e. m. 1. 111. 1.

19 c. m. b. n.

24 c. m. b. c. m.

26 c. m. b. n.9 c. m. 1.111. 1.

18.5 e. 111. b. n.

s + 3 c. m. b. c. m.

6 c. m. b. c. m.

s + 25 c. 111. b. c. m.5 c. m. r. 111. 1.

s + 17 c. m. b. c. 111.

s + 20 c. 111. b. 11.

9 c. 111. b. c. ni.

23 c. 111. b. c. m.

29 e. 111. b. n.4 c. m. r. m. 1.

20 c. 111. b. e. 111.

... 30 e. m. b. n.

to a. s. s.

pos.

pos.

pos.

pos.

pos.

+ + +

+ + +

+ +

pos.

pos.

±pos.

+ +

+ + +

T a b le X I I .— G lo b u lin P r e c ip ita t io n T e s t — (Continued.)

S i 6 T h e China Medical Journal.

Historynumber Culture Smear Size of Spleen Globulin

Test

2467

O. P. D. 17S13 2751

O. P. D. 1S404 3277 3537

2669

BS + BS + B + B — S + B + B + B +

B +

S +

S +

s " +

B + B +

1 1.5 c. m. b. c. in.

30 c. 111. b. 11.

23 e. m. b. n.13 c. 111. b. e. m.

15 e. m. b. c. m.10 c. m. b. c. m.6.5 c.iii. b. u.3 c. 111. r. m. 1.

18.5 c. m. b. n.

+ + + +

+ +

4- + + + + + + +

+ + + + + + + + + -M +

+ +

B = blood l.m.l.S — spleen b.u.b.11. — below left nipple pos.b.e.111. below costal margin a.s.s.r.m.l. = to right of midline

to left of midline below level of umbilicus positive (degree not recorded) to level of anterior superior

spine.

T a b le X I I I . — G l o b u l i n P r e c ip ita t io n T e s t .

Total treatment 12 mg. of antimony or less per kilogram weightof patient.

Specimennumber

Historynumber

Culture Smear Size of Spleen

Mg. of anti- 111011 y per k.

wt. of pt.

Globulin at time of cult.

124 ’ 3333 B — B + 23 c.111. b.c.m. •32 + + + +

1 1 8 ’ O.P.D.20503

B — B + 9.5 c.m. b.c.m. •49 + + + +

n o ’ 2882 B — 0 to a. s. s. 1 .200) + + + +

1 J 9 ’ 29S4 B — 0 10 c.m. b.c.m. 11-43 + + +

40’ 1390 B + 0 4.5. l.m.l. 5-77 + + +

147’ 3333 s + S + 21 c.m. b.c.m. 9-1/ + + +

39’ 118 B + S + b.u. 10.97 + + + +

100’ 2467 B + 0 23 c.m. b.11. 11,96 + + +

BSb.11.b.c.m.r.m.l.l.m.l.b.u.

- blood- spleen- below left nipple- below costal margin = to right of midline = to left of midline

=-■ below level of umbilicus o — 110 record

pos. = positive (degree not recorded 1a.s.s. = to level of anterior superior

spinep. := palpableb.p. = . barely palpable11.p. —• not palpable

ANIiUI PROVINCEDISTRIBUTION ,bv MSIENs op 171 CASES or KALA -A ZA P in TME CLINICS op TM E MINI WANG a n d MIN KANG HOSPITALS H V A tyU A N , 1902-1922 (9 IV E A B S )

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Kala-azar in China. S i 7

T a b le X I V .— G lo b u lin P r e c ip ita t io n T e s t .

Total treatment above 12 mg. of antimony per kilogram weightof patient.

Specimen

number

Historynumber

Culture Smear vSize of Spleen

Trt. mg. per kg. patient

Glob, at time of culture

82’ 691 B — 0 6 c.111. b.c.m. 20.66 —

94’ 1S81 B — 0 P- 22.72 +

12 5 ’ 1881 B — 0 b.p. 22.79 i cult. Sept. 12. glob. Ja n .li, vSpl. j.p.

132 ' 3503 B — 0 xo c.m. b.c.m. 23-36 + +

58’ 786 B — 0 n.p. 26.44 ±

89’ 390 B — 0 4 c.m. b.c.m. 26.79 —

74’ 691 B — 0 4 c.111. b.c.m. 27.62 —

I 34’ 786 B — 0 n.p. 34-22 + +

1 1 7 ’ 1671 B — 0 P- 35-69 + + +

126 ’ O.P.D.16059

B — 0 6.5 c.m. b.c.m. 40.75 +

12 3 ’ 2137 B — 0 15 c.m. b.c.m. c.m. b.u.

42.90 + +

129’ 2137 B — 0 15 c.111. b.c.m. 5 c.m. l.m.l.

46.77 +

153’ 2137 B — 0 9 c.m. b.c.m. 11.5 c.m. l.m.l.

57.68 +

16 3’ 2195 B — 0 5 c.m. b.c.m. 61.62 ±

n 6 ’ O.P.P.14081

B — 0 b.p. 67.08 —

156 ’ 2669 B — 0 3 c.111. b.c.m. 3¿ c.111. l.m.l.

77.64 + +

B — bloodS — spleenb.n. =3 below left nippleb.e.m. below costal marginr.m.l. = to right of midlinel.m.l. = to left of midlineb .u. ' = below level of umbilicus

pos. =- positive (degree not recorded)a.s.s. = to level of anterior superior

spinep. — palpableb.p. == barely palpable n.p. = not palpableo — 110 record

8i8 T h e China Medical Journal.

T h e F o r m o l- g e l o r A l d e h y d e T e s t .

Since the publication of the globulin precipitation test, another called the formol-gel or aldehyde test has been devised30'33 for kala- azar. It was used originally for the diagnosis of syphilis, but the results obtained are sufficient to differentiate the two diseases. Turkhud and A vari34 state that the test was positive in each of 1 16 cases of leprosy tested. Evidently the statement refers to the original test; not the modified one as used for kala-azar. The test, in brief, is one drop of commercial formalin added to i .o c.c. of serum from the suspected case. The serum becomes solid and opaque in 3 to 20 minutes in positive cases, while it may show opacity in several hours in syphilis, phthisis, leprosy, malaria, and in some other diseases. As I have had little experience with the test and others will report on it during this conference, I shall not speak further about it.

D ia g n o s is b y V is c e r a l P u n c t u r e

Donovan 33 ,36 employed spleen puncture and staining of smears made with the spleen juire obtained. While this method offers the best chance of finding the organism, it has the disadvantage of being dangerous to the patient. Donovan had a fatalit}*- in his first series and many have been reported since. Almost every writer of experience has warned against spleen puncture and has given precautions to be observed. The reason is not that the procedure is dangerous in itself, but that the disease causes a prolongation of the bleeding time37, and usually of the coagulation time. The first is simpler to determine but is not so well known. A small cut is made in the finger, or preferably in the lobe of the ear, with a small lancet after cleaning the part with an alcohol pledget and allowing it to dry. The incision should be deep enough to cause a drop of blood to appear without any manipulation of the part. With a piece of filter paper the drops of blood are blotted up each half minute so long as the oozing continues, a fresh place on the paper being used each time. The number of spots divided by two gives the “ bleeding tim e” in minutes. The normal is one to three minutes. In kala-azar, if the bleeding time exceeds seven minutes, spleen puncture should not be done without a preliminary transfusion of blood. In one of our hospital patients, (No. 1390) the time was reduced from 2 1 J/4 minutes to 4 minutes in eight days, apparently as a result of

Rala-azar in China.

specific therapy (intravenous antimony salts). On two occasions, at least, surgeons in China have made spleen punctures just before splenectomies and have found free blood in the peritoneal cavity. On account of the danger to the patient, liver puncture has been advocated as a substitute. While it is safer, it offers less likelihood of finding the organism.

C u l t u r e s fr o m S p l e e n J u ic e a n d P e r ip h e r a l B lo o d .

Rogers88 was able to cultivate Leishm ania donovani by simply adding saline containing 10% sodium citrate to the spleen juice obtained by puncture, but he was unable to continue the growth in subcultures. Nicolle”9 modified a medium previously used and this, “ N .N .N .” * is now the one commonly used. The spleen juice is distributed among several tubes and they are incubated at 22°C-25°C. We have modified the procedure slightly by drawing the spleen juice into 2 c.c. of 1% citrated Locke’s solution. This is diluted in 50 c.c. of the same fluid centrifuged at high speed, and the sediment suspended in about one c.c. of the saline solution and planted as before. The undiluted spleen juice in the needle is used for making smears for staining. Mayer and Werner10 cultivated the parasite from peripheral blood obtained by puncture of the finger tip. Others used the same method. Row23 diluted o .5-2.0 c.c. of blood in 20 c.c. of saline, and planted the sediment obtained after the tube had been allowed to stand over night. Neither method gave constant results. The author41 has used the following method : 10 c.c. of blood are drawn into 2 c.c. of 1 per cent, citrated Locke’s solution and immediately expelled into a flask containing 50-70 c.c. of the same fluid. This diluted blood is divided between two 50 c.c. centrifuge tubes with pointed bottoms and spun slowly (about 750 r.p.in.) for about five minutes. The time depends upon the interval necessary to throw down the red cells while the platelets are left suspended and give a slight cloudiness to the supernatant fluid. This latter is pipetted into clean 50 c.c. centrifuge tubes and spun rapidly (about 1400 r.p.m.) for five minutes. The clear supernatant

* The formula for “ N.N.N.” is :Agar ... ... 16.0 gramsSalt ................. 6.0 gramsWater ... ... 900.0 e.e.

Sterilize. To three parts of this medium in a test tube cooled to 45°C. is added one part of defibrinated rabbit’s blood.

I The China Medicai Journal.

.fluid is discarded, the sediment suspended in about i -c.c. of fluid and planted in a series of tubes of N .N .N . medium. Such a culture develops from the extracellular parasites present. It has been shown that intracellular parasites are to be found in the bottommost part of the red cell fraction obtained at the first centrifugalization. A small portion of this may be removed with a pipet and added to the platelet fraction before the second centrifuging and the combined sediment planted. This bottommost portion of the red cell fraction is that used for peripheral blood smears and will be referred to later.

D ia g n o s is f r o m E x a m in a t io n o f P e r ip h e r a l B l o o d .

Donovan found the parasite in blood smears from the finger tip. Numerous other workers, notably Patton 42 and Knowles ' 3 have tried to use the method as a routine procedure. The latter considered that he had increased the likelihood of finding the Leishman-Donovan body if he injected one c.c. of i :iooo adrenalin, one-half hour before taking the material for the smears. However, he only succeeded in finding organisms in 5 per cent of the smears, and in 9 per cent of the cases, in* 263 smears from 1 1 5 cases. In studies during the past year the author has devised and published elsewhere41 a method which appears to increase considerably the ease of finding the parasite in the peripheral blood. In 27 slides from 9 specimens from untreated patients in which the method was tried, all the specimens (Table X V ) showed parasites in one or more of the slides examined.

T a b le X V .— K a la - a z a r : Su m m ary o f B lo o d S m e a rs, b o tto m m o st B lo o d .

Specimensfrom

Number of specimens examined

Number of slides

examined

Number of slides

positive

Percentage of speci

mens positive

Percentage of slides positive

Untreated cases 9 27 21 100 77.8

^T rea ted with less than 12 mg. Sb.

7 26 15 71.4 57-7

T r e a te d with over 12 mg. Sb.

7 14 0 0.0 0.0

*In this small series no parasites were found in smears f rom patients who had received more than 4.34 mg. of antimony per kilogram of their weights.

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K ala-azar in China. 821

Some of the slides showed infected leucocytes in almost every field, but this is unusual. To make the smears the blood specimen was treated exactly as for blood culture until after the first centrifuging. The supernatant fluid and about half of the red cells were pipetted off. With a pipet having a rubber bulb and bearing a capillary tip about 5 cm. long, blood from the bottommost part of the tube is now drawn up to a height of one to two centimeters and smears were made on glass slides in the usual manner, care being- taken to use the whole of each drop of blood in making the smears. They were stained by W right’ s, Irishm an 's, or Giemsa’ s stain. The organisms are usually found in the polymorphonuclear or large mononuclear leucocytes which are most numerous along the edges and in the “ tail ” of the smear. In a comparison of the infected leucocytes in the butty coat, and in the bottommost blood, it was found that in the series of slides studied, there were 4.6 times as many in the latter as in the former. By the use of the large amount of blood and the centrifuging method, it seems possible to diagnose the disease from the peripheral blood in many cases. The method can be further simplified by substituting sedimentation for centrifugation. The diluted blood is placed in a conical vessel such as a urine glass or large centrifuge tube with pointed bottom, and allowed to stand over-niglit. It will be found that the blood constituents divided themselves in a manner very similar to that obtained by centrifugation. The upper cloud\T fluid and red cells are discarded as before and a small amount of the bottommost part taken up in a capillary pipet. Smears are made and stained as before. The number of infected leucocytes varies greatly in different cases- The careful examination of say two slides will usually disclose parasites, and frequently they are found in the first preparation after only a few minutes’ search.

B ib l io g r a p h y .

1 . Leishman, W. B. : Brit. Med. Jour., 1903, 1 : 1252.2. Marchand, F. : Munch. Med. Wchnschr., 1903, No. xi. March 17.3. Marchand, F. : Verhandlungen der Deutsch. Path. Gesel. 1904

vSechtc Tagung, p. 251.4. Marchand, F. & Ledingham, J. C. G. : Centralbl. f. Bakt. u.

Parasitenk., 1904, 35» 594 ! Lancet, 1904, 1 : 149.5. Kerr, T. S. : Journal of Trop. Med., 1905, v m : 220.6. Martini. : Berl. klin. Wchnschr., 1907, xi.iv : 1042.7. Bassett-Sinith, P. \Y. : Brit. Med. Jour., 1908,1 : 1043.

(Tjie China Medical Journal.

S. Bassett-Smith, P. W. : Brit. Med. Jour., 1909, 11 : 1614.9. Lambert, A. C. : Brit. Med. Jour., 19 10 ,1 : 139.

10. Aspland, W. H. G. : Brit. Med. Jour., 1910, 1 : 750.11. Aspland, W. H. G. : China Med. Jour., I9I 1 . x x v : 212.12. Cochran, S. : China Med. Jour., 19 11, x x v : 273.13. Cochran, S. : Jour. Lond. Sch. Trop. Med., 1912-13, 11 : 179.14. Reed, A. C. : Jour. Amer. Med. Assn.. 1914, t x m : 1572.15. Nicolle, C. : Annales de l ’Inst. Pasteur, 1909, x x m : 361.16. Nicolle, C. : Arch. Inst. Past, de l ’Afrique de Nord, 1921, 1 : 33.17. Quoted by Rogers, Sir Leonard ; Fevers in the Tropics, 3rd ed. p. 21,18. Wenyon, C. M. : Trop. Dis. Bui., 1922, x ix : 1.19. Wylie, J. H. : China Med. Jour., 1920, x x x iv : 593.20. Machie, F. P. : Ind. Jour. Med. Res., 1913-14, 1 : 626.21. Bogers, Sir Leonard : Fevers in the Tropics 3rd ed., p. 30.,22. Rogers, Sir Leonard : ib id ., p. 37.23. Knowles, R. : Ind. Jour. Med. Res. 1920-21, v m : 141.24. Rogers, Sir Leonard : loc. cit., p. 43.25. Bramachari, U. N. : Ind. Med. Gaz., 1917, u i : 319, 429.26. Bramachari, V. N. : Kala-Azar. Butterworth, Calcutta, 2nd Ed-

1920, p. 87.27. Ray, C. : Ind. Med. Gaz., 921, i.vi : 9.28. Sia, R. H. P. : China Med. Jour., 1921, x x x v : 397.29. Sia, R. H. P. : and Wu, H., China Med. Jour., 1921, x x x v : 527.30. Gate’ and Papacostas : Comptos Rend. Soc. Biol., 1920, p. 1432.31. Fox and Mackie : Ind. Med. Gaz., 1921.32. Napier, L. E. : Ind. Jour. Med. Res., 1921-22, i.ix : 830.33. Mills, P. S. : Ind. Jour. Med. Res., 1921-22, ix : S47.34. Turkhud & Avari. : Ind. Jour. Med. Res., 1921-22, ix : S50.35. Donovan, C. : Brit. Med. Jour., 1903, 11 : 79.36. Donovan, C. : Brit. Med. Jour., 1904, 11 : 651.37. Duke, W. W. : Jour. Am. Med. Assoc., 1910, i.v. : 11S5.38. Rogers, Sir Leonard : Lancet, 1904, 11 : 215.39. Nicolle, C. : Compt. Rend. Acad. Sci., 1908, c x l : 842.40. Mayer & Werner : Deutsch. Med. Wchnschr., 1914, xi. : 67.41. Young, C. W. and Van Sant, H. M. : In press.42. Patton, W. S. : Ind. Jour. Med. Res., 1914, n : 492

K ala- a za k in I n d i a .— The Indian Medical Gazette of July, 1923, a “ special kala-azar number,” contains a valuable collection of papers 011 the subject of kala-azar in India written by workers who have made a special study of the disease. An editorial gives an admirable review of our present knowledge with reference to the disease and its problems, and there is also a full article by Knowles, Napier and Das Gupta on what is said to be the most important unsolved problem in tropical medicine— the transmission of kala-azar from man to man. The Indian M edical Record has also issued recently (September, 1923) a special kala-azar number, further evidence of the great attention which is now being paid to the disease throughout Eastern India.

Blood Pressure of Cantonese Students. 823

BLOOD PRESSURE OF NORMAL CANTONESE STUDENTS

W. W. C a d b u r y , m .d ., Canton Christian College, Canton.

(Continued from p. 726)B lo o d P r e s s u r e : R a c ia l V a r ia t io n s .

The question of racial variations will be now considered. But little mention has been found of racial variations in the textbooks on Blood Pressure, and we have been able to find only a few references in general medical literature.

McCay 29 studied the blood pressure of over 500 adult male Hindus from Lower Bengal, aged 20 to 25 years. The Riva-Rocci instrument was used with a broad armlet. The systolic pressure only was determined by palpation with the patient sitting. The average pressure was found according to one report to be S3 mm. to 1 18 mm. Hg. In a later report, however McCay 30 states it was from 90 mm. to 105 mm. or generally just under 100 mm. To explain this low pressure, he considers climatic conditions are not the chief cause; Europeans living in Calcutta did not show this low pressure, their average ranging from 1 1 5 mm. to 130111m . Hg. As the capacity for voluntary muscular work in Europeans is greater than in Hindus we may assume that the muscular power, of involuntary as well as of voluntary muscles, is also greater.

The Filipino has been more carefully studied than individuals of other Oriental races, with regard to his blood pressure. The first work was done by Musgrave and Sison 31. A study was made of 97 Americans and Europeans, and 40 Filipinos who were mostly students. The ages varied from 25 to 40 years. These observers concluded that the systolic pressure of persons living in the tropics is lower than the general averages given. The heart and biood vessels are not to blame. Variation in the volume and viscosit}^ of the blood may be a factor. Anemia is not a cause. The most probable cause is the lowered peripheral resistance that occurs in the tropics28. If this be true, then the lowered blood pressure may be explained in two ways : the secretory function of the skin is increased, and probably the normal surface resistance and vasomotor tension necessary to produce the required surface heat of temperate climates is greatly diminished in the tropics the year round.

824 T h e China Medical Journal.

There are also to be considered the splanchnic influences which control vasomotor tone.

F o r foreigners, the following pressure readings were obtained :

Of the Filipinos, 30 males gave an average sj^stolic pressure of 10S mm. and 19 females of 1 1 3 mm.

A very extensive study was carried out by Chamberlain"7. He recorded the systolic pressure of 1,042 healthy, white, American soldiers, the age of the majority ranging from 20 to 40 y e a rs ; and of 386 Filipinos representing various tribes and including soldiers, laborers, servants and convicts. Most of them were under 42 years of age. Chamberlain assumes a normal of 1 1 5 mm. to 150 mm. Hg. for men of 15 to 30 3'ears of age living in the temperate zone. In the Philippines, he finds the average pressure of white men at this age to be 1 1 5 mm. and those from 30 to 40 years of age, to be 1 18 mm. Seasonal changes and the complexion, whether blond or brunette, did not affect the systolic pressure. He suggests that there is a vaso-constriction of superficial blood vessels. The average systolic pressure of Filipinos between 15 and 40 years of age Chamberlain found to be 1 1 5 to 1 16 . mm. He concludes there is no essential difference between the blood pressure of white men and that of Filipinos (Table I).

A later study of Filipinos has been made by Concepcion and Bulatao 32, using an Erlanger sphygmomanometer. Readings were obtained from 697 males and 218 females varying in age from 15 to 87 years. The males were chiefly convicts and medical students. The females were also convicts and students. The results may be found in Tables I ., II. and III . For males of the average age of 29.5 years, and of females of the average age of 25 .1 years, the average readings were as follows :

Duration of Residence in Tropics. Systolic Pressure.

1 month to 1 year 1 year to 5 years

124 mm.1 1 5 mm.116 mm. 1 1 3 mm.

5 years to 10 years Over 10 years ...

'Systolic pressure... Diastolic pressure Pulse pressui'e ...

M a le s

1 15.6 mm.F e m a le s

1 16 mm.s 3-432.-6

79.1

36-4

Blood Pressure of Cantonese Students. S25

There is to be noted a general tendency for the systolic, diastolic and pulse pressures to ascend with age. Concepcion and Bulatao conclude that the systolic pressures of Filipinos are very much lower than those ol Americans living in temperate climates (Woley), but the same as those of Americans living in the tropics (Chamberlain).

In 65 cases of opium addicts the blood pressure was much below the average of other persons.

Investigation of the blood pressure of American Indians has been made by Harley Stamp'’*3, tribes living in the Arctic and those 111 the temperate zone being included. He concludes that “ the normal age charts of blood pressure records of the American Indian differ but slightly from those of the white man, except that there seems to be a uniform tendency to reduced blood pressuie at or about the age of 45 years.”

The blood pressure in the Japanese has been studied by Tanemura31 who examined 2,842 health}- male Japanese and 1,10 0 female Japanese. The ages varied from 4 to 25 years. He used a von Recklinghausen tonometer, reading by Korotkoff’ s auscultatonr method. The results were recorded in centimeters of water. The average height for boys of 4 years of age was 93 cm., for boys of 19 years, 160.3 cm- The body weight was 13 .6 kg. for boys of 4 years of age, and 54 .1. kg. for men of 21 years. The annual increase in the blood pressure was particularly marked in boys from the 13th to 17th years. In general, the curve of rising blood pressure ran parallel with the curves of body height and weight.

The normal blood pressure of boys at 4 years of, age was : systolic, 72 111111., diastolic, 49 mm. Hg. (98 cm. and 67 cm. water). A s the age increased it rose gradually to systolic, 122 mm., diastolic, 83 111m. Hg. (.165 cm. and 1 1 2 cm. water) in men of 19 years. The pulse pressure rose from 23 mm. Hg. (31 cm. water) at 4 years to 40 mm. Hg. (54.5 cm. water) in men of 19 years.

B lood P r e s s u r e of C h i n e s e .

A preliminary report of the Research Committee of the China Medical Missionary Association on the pulse and blood pressure °f normal individuals was published in 19 2 1 33. This forms the basis of the present study.

826 T h e China M edical Journal.

F irst of all a questionnaire on the subject was sent out to missionary physicians throughout China. Answers giving records of normal persons were received from only three : Doctors C .G . Trimble, G. Duncan Whyte and H .W . Boyd. Doctor Trimble sent in records of 32 normal male Chinese : 24 from the province of Fukien, which lies between 230 and 290 N. latitude, and 8 from other provinces of China. The respective occupations of these Fukienese were student, merchant, druggist, coolie, soldier, barber, shoemaker, baker, boatman, preachcr and farmer. The Pilling special sphj’gmomanometer was used with the auscultatory method. The ages varied from 18 to 43 years and the average pressure obtained was as follows : systolic, 100 mm. ; diastolic, 6 1 mm.; pulse pressure, 38 mm. (Tables I ., I I., and III .) . The eight remaining records from other provinces of China were of persons whose ages ranged from 19 to 28 years, and wrho lived in central or North China. Four were from the province of Chihli, two from Shantung, one from Kiangsu and one from liunan. The average pressures were as follows: systolic, ro6 m m .; diastolic, 66mm.; pulse pressure 40 mm.

The examinations made by Dr. G. Duncan Whyte were of healthy students in Swatow, a city in the northern part of Kwangtung province. He employed the Faught instrument and the auscultatory method. There were 85 males examined varying in weight from 25.8 kg. to 64.4 kg. (57-142 lbs.) and in height from 137 cm. to 176 cm. (54-69 1 / 2 inches). The ages varied from 15 to 25 years. Only two of the students were over 22 years of age. Eighty-three men furnished the following averages : systolic, 109 m m .; diastolic, 71 m m .; pulse pressure 38 mm. (For the pressures recorded for each age, see Tables I ., II. and III.) Dr. H. • Boyd, of Canton, studied the blood pressure of 15 men and 10 women from the provinces of Kwangtung and Kwangsi. Their ages ranged from 18 to 54 years, averaging 28 years. Their occupations were those of farmer, mechanic, merchant, student, housewife, prostitute, nurse, druggist, soldier, physician and laboratory assistant. Their weights varied from 26.3 kg. to 66.2 kg. (58 to 146 lbs.) and their heights from 139 .7 cm- *° 182.8 cm- Boyd used a Tycos instrument with the auscultatory method. He obtained the following averages : systolic pressure, 107 mm.; diastolic pressure, 67 m m .; pulse pressure, 40 m m .; average pulse rate, 81.

Blood Pressure of Cantonese Students.

B lood P r e s s u r e of C an to n ese S t u d e n t s (Cadbury).

The author’s investigation of the blood pressure of healthy Cantonese was conducted as part of a general plan to determine the normal blood pressure of the Chinese race.

The records obtained were ail of healthy Chinese students of the two southern provinces of China known as Kwangtung and Kwangsi. The latitude of Canton, the capital of Kwangtung, is 230 06.’ i North. The two provinces lie between 20° and 26° N. latitude.

It is well known that the Cantonese differ in many ways from the people of other parts of China. They are shorter, lighter and with smaller features. Unlike most: people living in the tropics they are noted for their energy and progressiveness.

A ll of the author’s records were taken in the routine physical examination of 774 students of the Canton Christian College. These young men live in much better hygienic conditions than the average Chinese. They take part in athletic sports and eat a better quality of food. Their life is very similar to that of American boys.

All students in whom there were cardiac murmurs or other evidence of cardiac or pulmonary disease were excluded. The records are based therefore on the examinations of none but healthy young men.

A Nicholson sphygmomanometer was used, employing the auscultatory method. A 14 cm. wide cuff was used on the right arm with the subject sitting and resting his arm on a table.

The systolic reading was made at the first detection of sound, and the diastolic at the fourth phase, but m the younger bo3',s the diastolic reading was often very indefinite. Taking the averages of certain age periods, we find as follows :

Age period : 7 to 14 years. Systolic, 83 m m .; diastolic, 5 1 mm.; pulse pressure, 3 1 mm.

Age period : 15 to 20 years. Systolic, 10 1 mm. ; diastolic, 62 m m .; pulse pressure, 39 mm.

Age period : 21 to 30 years. Systolic, 10 1 m m .; diastolic, 68 mm.; pulse pressure, 36 mm.

(In Tables I. I I . , I II . and V I., figures are given more in detail.)

•The China Medical journal'.

There is very probably a slight error in the age factor in a few of the records since Chinese generally estimate their age as one year older than they really are because the} reckon the}’ are one year old at birth. However, even by the most casual glance at the figures in Table I. it is clearly evident that a Cantonese youth has normally a systolic pressure considerably lower than that found in Europeans and Americans. It follows closely Musgrave’s figures for Filipinos, but is lower than that reported by Chamberlain, and by Concepcion and Bulatao for the same people. It is also lower than the Japanese records but compares more closely with the pressure found among Bengali. The diastolic pressure is also lower than what has been recorded by other observers, bat the pulse pressure is slightly higher than that found in one of the studies of Filipinos.

Objection is taken sometimes to the misleading character of averages. We have therefore taken the systolic readings of youths between the ages of 15 and 20 years, and grouped them in their order of frequency. The average readings were 97 mm. and 103 111m'. respectively. The.percentages according to different readings were as follows :

Age, 15 years Age, 20 years71 to 80 mm. Hg 1 2 ^ 4 °/o

81 to 90 mm. Hg 2>l % 12%81 to 100 mm. H g 19 % 38%

10 1 to 1 10 mm. H g Zl0/° 22%h i to 120 111m. H g 6% 16%12 1 to 132 mm. Hg 1 °/o 7 c/0

Thus 8 i°/o of the readings for the fifteenth year of age were between 81 mm. and 1 10 mm. For the twentieth year 60% of the readings were between 91 mm. and 1 10 mm.

Following Wolfensohn-Kriss and Michael, we have estimated the blood pressure in accordance with weight. (See Tables V. and V II .) . Here the age factor was not involved, except that all measurements were those of boys and young men of from 7 to 36 years of age.

The systolic pressure shows an increase from 81 mm. in boys weighing from 16 kg. to 20 kg. to 106 mm. in young men of 61 kg. to 65 kg. weight, an increase of 25 mm. The diastolic pressure shows an increase of 15 mm. and the pulse pressure a much Uss marked increase.

Table V I .—Blood Pressure of Healthy Male Chinese Students of the Canton Christian College.

AgeNum

ber examined

| Av. Systolic Pressure

Av.DiastolicPressure

Av.Pulse

Pressure

Max.vSystoliePressure

Min.vSystoliePressure

Max.DiastolicPressure

Min.DiastolicPressure

Max.Pulse

Pressure

Min.Pulse

Pressure

Average Rate of

Pulse

7 2 6.5 35 30 70 60 40 30 30 30 788 11 80 50 28 95 60 60 35 40 20 899 18 84 53 3i 100 60 75 35 50 15 92

10 28 80 5i 29 n o 60 70 35 50 15 90ii 3i 83 50 33 100 65 75 3<J 45 10 s512 48 88 55 33 65 75 20 60 15 8413 47 89 56 33 105 75 70 40 50 J5 85M 63 97 59 35 125 75 85 30 65 . 15 8415 90 97 60 36 130 75 So 35 70 15 8216 101 100 60 4i 130 70 85 35 70 10 8317 97 100 63 37 130 75 95 40 70 10 8318 81 102 64 39 130 75 85 45 70 10 8219 65 105 65 40 130 70 80 45 65 10 Si20 46 103 62 4i 125 S5 80 50 65 20 7«21 18 102 b3 40 125 85 80 50 65 20 8022 15 108 59 42 155 85 80 45 65 20 Si23 5 93 59 34 110 80 65 53 57 15 7824 2 103 57 40 105 100 60 55 40 40 6025 2 100 73 27 100 100 80 65 35 20 7726 I 95 • 7o 25 7227 I n o 85 25 6429 I 95 70 25 8830 I 105 75 30 723r I 130 80 50 8136 I go 50 40 72

to

Blood Pressure

of C

antonese Stu

dents.


Table VII. Average Blood Pressure of Cantonese Males According to Weight

Weight in kilograms

Numberexamined

Averagesystolicpressure

Averagediastolicpressure

Average pulse pressure

11-15 i 60 1111-11. 30 mm. 30 111m.16-20 30 81 5 1 2921-25 66 83 5 1 3226-30 85 S7 55 323 1 - 3 5 70 94 60 3436-40 6 7 96 59 3741 -4 5 141 100 60 4046-50 160 IOI 6 3 3 25 x-55 107 104 64 4056-60 35 106 65 41 .61-65 9 106 66 41

Wolfensohn-Kriss’ s figures closely parallel our own up to the 40 kg. to 45 kg. limit. After that, lier records are higher. Michael, on the other hand, gives a considerably higher reading throughout the series.

I f height is taken as .the standard for estimating the pressure, there is also found to be a progressive increase as the subject grows. (Tables IY . and V III.).

Table VIII. Average Blood Pressure of Cantonese Males According to Height

Height in centimeters

Numberexamined

Averagesystolicpressure

A verage diastolic pressure

Average pulse pressure

g o -i00 I 70 mm. 40 mm. 30 min.lOI-IIO 3 65 41 23in -12 0 O - 82 50 31121-130 68 84 52 32131-140 89 87 55 32141-150 93 96 59 37151-160 200 100 61 39161-170 256 102 63 391 7 1 - 1 8 0 32 66 301 8 1 - 1 9 0 i *05 70 35

Thus between the. io i cm. to n o cm. group and the 17 1 cn . to 180 cm. group, the systolic pressure rises 40 mm. the diastolic, 25 mm. and the pulse pressure 16 mm.

Comparing our readings with those of other observers, the Cantonese student shows a marked inferiority in blood pressure taken with reference to his height.

Since preparing this paper an article has appeared b}- C. L . Kao -!6 011 the blood pressure of 261 normal Chinese, mostly males, of Changsha, Hunan. The majority were students and their ages varied from 13 to 42 3 ears of age. He gives the following summary of his findings.

Blood Pressure of Cantonese Students. 83 1

Age Numberexamined

Sys.pressure.

Dias.pressure.

Pulsepressure. Pulse Rate.

13 -14 6 102 60 mm. 42 mm. 8115-20 1S2 114 68 46 7821-25 63 116 44 7926-42 10 1 1 3 71 42 75

For the whole number of 261 Chinese the averages were as follows: systolic pressure, 1 14 .5 mm- (one estimate, 12 3 .5 mm- which is given is evidently an error.) ; diastolic pressure, 69 mm. ; pulse pressure, 45.5 mm.

It will be noted that these fignres are slightly higher than those which we obtained for Cantonese, which may be accounted for by the province of Hunan being considerably further north than Canton.

D i s c u s s io n ..

It thus appears that the systolic blood pressure of Cantonese and other Chinese young men belonging to the south of China averages from 20 mm. to 30 111111. Hg less than the normal for people of Europe and North America. Corresponding^ low systolic pressure has been observed among Bengali and Filipinos.

The diastolic pressure of the Chinese is also lower than the generally accepted normal, but by only 10 111111. to 20 mm. The Filipinos’ diastolic pressure seems to be higher.

The average pulse pressure shows little variation from the generally accepted normal, and is therefore relatively high.

In our studies there is a regular arithmetical increase of systolic and diastolic pressure values from 7 to 22 years of age. A less regular increase is observed in the pulse pressure.


In this connection it is a remarkable fact that hypertension as a pathological condition in Chinese is very unusual. In an extensive medical practice of more than twelve years in Canton, we have rarely met with hypertension, either with or without signs of nephritis, although chronic Bright’ s disease is very common. When met with, marked hypertension has generally been associated with aortic valvular disease of the heart. Other observers in Canton have confirmed these findings.

In looking for a possible explanation of this rarity of hypertension the following suggestions have been made to us :

1. The use of opium.2. Decreased capacit}7 for muscular effort, causing a decrease

in muscle tone.3. Small stature and lighter weight.4. Deficient adrenal or other hormones in the bod}’ , causing

a lack of dynamic force.5. The largely vegetable diet. The Chinese subsist chiefly

on rice, with onhr a small amount of meat.6. Simplicity of life, and absence of nervous strain.7. Effects of the tropical climate, S7' 30’ 31' causing : (a)

constant dilatation of the peripheral blood vessels; (b) an increase of the secretory function of the skin, and probably the normal surface resistance and vasomotor tension necessary to produce the required surface heat of temperate climates is greatlj* diminished in the tropics the year round ; (c) splanchnic influences, the vasomotor tone of the splanchnic system having a marked effect on motor tone; (d) a vaso-constriction of the superficial blood vessels; (e) variations in the volume and viscosity of the blood.

In view of our studies of the blood pressure of Cantonese youths, we can exclude the first and second of the foregoing as possible factors. The third is more cogent as our studies prove that the Cantonese is shorter in stature and of lighter weight than American and European 37ouths. The fourth is at present based 011 theory7; we have seen 110 lack of vigor or dynamic force in our students. We may infer that diet and the various factors listed under climate have a bearing on blood pressure.

C o n c l u s io n .

A study of the blood pressure of 774 healthy, male Cantonese youths shows that their average systolic and diastolic pressures;

Blood Pressure of Cantonese Students. 833

and, to a less degree, the pulse pressures, are lower than the standards for European and American youths of corresponding age, weight, and height.

R e f e r e n c e s .

1. Korotkoff. 1905. Tr. Imp. Acad. Med., St. Petersburg, X V : 365.2. Barach J. H. and Marks, W. L. 1914. Arch. Int. Med., X III : 648.,3. Judson, C. F. and Nicholson, P. 1914. Arner. Jour, of Dis. of Child.,

V III : 257-4. Murray, J. R. 1914. Brit. Med. Jour., I : 697.5. Warfield, L- M. 1917. Amer. Jour. Med. Seien., X X X I I : 154, 414.6. WTeysse, A. WT. and Lutz, B. R. 19 j 3, Amer. Jour, of Physiol., 32.

427.7. Mackenzie, L. F. 1920. Medical Record, X C V II : 1029.8. Editorial, 1920. Jour. Am. Med. Assn., L X X V : 1650.9. Woley, H. P. 1910. Jour. Am. Med. Assn., L V : 121.

10. McCrae, T. 1920. Med. Clin, of North Am., March, p. 1177.11. Fraser, J. and Cowell, E. H. 1918. Jour. Am. Med. Assn., 70,

L X X : 520.12. Lee, R. L. 1915. Bost. Med. and Surg. Jour., C L X X III : 541.13. MacWilliam, J. A. and Melvin, G. S. 1914. Brit. Med. Jour., 1 : 693.14. Wolfensohn-Kriss, P. 1910. Arch. f. Kinderheilk., L I 1I : 332.15. Fisher, J. W. 1912. Proc. Assn. Life Ins. Med. Directors of N. A.,

P- 393-16. Katzenberger, A. 1913. Zeitsch. f. Kinderheilkunde, IX : 167.17. Bing, H. I. 1915. Ugeskrift f. Laeger, Copenhagen, L X X V II . No.

23, 923. Abstr. Jour. Am. Med. Assn., L X V : 468.18. Faught, F. A. 1916. Blood Pressure from the Clinical Standpoint,

2nd. Ed., W. B. Saunders, Philadelphia.19. Alvarez, W. C. 1920. Arch. Int. Med. X X V I : 381.20. Hunter, A. and Rogers, O. H. 1919-1920. Proc. of Assn. of Life Ins

Med. Directors of N. A., V I : 92.21. Hunter, A. 1920-1921. Proc. Assn. of Life Ins. Med. Directors of

N. A , V II : 153.22. Faber, H. K. and James, C. A. 1921. Am. Jour. Dis. of Children,.

X X I I : 7.23. Goodman, G. H. 1914. Blood Pressure in Medicine and Surgery, p.

64. Lea and Febiger, Philadelphia.24. Moulton, R. H. 1921. The Forecast, (September) p. 171.25. Norris, G. W. 1917. Blood Pressure, p. 378, Lea and Febiger.26. Michael, May, 19 11. Am. Jour. Dis. of Children, I : 272.27. Chamberlain, W. P. 19 11. Philip. Jour, of Science, V I : 467.28. Castellani and Chalmers, 1919. Manual of Tropical Medicine, p.

75. Bailliere, Tindall and Cox, London.29. McCay, D. 1907. The Lancet, I : 1483 ;30. McCay, D. 190S. Scientific Memoirs, Goverment of India, X X X I V :

23, 1908.31. Musgrave, W7. E. and Sison, A. G. 1910. Phil. Jour, of Science. V :

325-32. Concepcion, and Bulatao, E. 1916. Philip. Jour, of Science, X I :

135-33. Harley, Stamp, quoted by Faught, F. A. op. cit., p. 161.34. Tanemura, I. 191S. Kyoto Igaku Zeshi (Kyoto Journ. of Med.

Science) X V : 84. Abstr.. China Med. Jour., X X X I V : 542.35. Cadbury, W. W. 1921. China Med. Jour. X X X V : 242.36. Kao, C. L. 1922. Nat. Med. Jour, of China. V L II : 101.

8 3 4 The China Medical Journal.

DEFICIENCY OF BREAST-MILK IN NURSING M OTHERS: TREATMENT*,

D r . E i l e e n S m y l y , P e k in g .

Recognizing the importance of breast-feeding in China, especialh* amongst the poorer classes where satisfactory alternatives to mother’ s milk are so few, I venture to present to you a case which I treated with marked success on the lines laid down by Dr. Truby’ K ing, of New Zealand, the Director of the British Babies of the Empire Association.

While acting as Medical Officer of an asylum in New Zealand, Dr. Trub}^ King took up in his leisure hours the breeding of calves and the stud\T of the conditions affecting their growth and development. In the course of his experiments, he found very marked differences in the development of the tissues and distribution of the muscle and fat between the bucket-fed and milk-fed calves, and discovered that it was possible to tell quite clearly what veal had been bucket-fed and what milk-fed. He also found that healthier, stronger calves were born and raised when the mother was allowed open-air freedom and exercise, during pregnancy and lactation.

At the time when Dr. Truby King carried on his experiments, the death rate amongst babies in New Zealand was very high and breast-feeding to a large extent abandoned. He therefore began to apply to human mothers the same principles that he had used in the treatment of cows, and with the help of Lady Plunkett, founded the Karitane-Harris Hospital and organized the service of Plunkett nurses, trained in the Hospital to act as inspectors and help nursing mothers in their homes.

Out of his long experience of tweiityr-five years of careful and thorough investigation and research, and many years of experience of treatments at the New Zealand hospitals and later at the London hospitals, he puts forward as an axiom the statement that “ every mother can nourish her offspring in the natural way. The exceptions are so rare and so striking as merely to prove the rule that, practically speaking, the breast-feeding of babies should be and could be universal.” The common exception which he recognizes is tuberculosis, where the doctor is satisfied that suckling

*Read at th-e C.M.M.A., Conference, Shanghai, February, 1923.

would involve risk of infection to the child. During temporan’ acute disease, such as measles or scarlatina, the milk should if possible be kept going by liand-massage and hand-milking, and suckling resumed upon recovery.

Dr. Truby King also says : “ It needs to be deeph7 impressedon mothers, that failure in nursing, is almost always due, not to failure of nature, but to failure to live in accord with natural laws and requirements, and failure in management.” Perhaps this statement needs to be deeply impressed on not a few doctors also.

This, then, is the keynote of his treatment, simple living in accordance with natural laws of health. The patients admitted to his hospitals were mothers who for some reason or other had given up nursing their babies, or had been considered unfitted for it. After a surprisingly short residence in hospital, in some cases not longer than a week, the breast supply returned and patients were sent out entirely supporting their babies.

One most striking case was that of a woman admitted to hospital with the history of having ceased nursing her baby eight weeks before admission. Under treatment she w as again able to take up the feeding of her child in entirety.

The appended chart (Fig. 1) is that of a case which shows very strikingly the results of simple hygienic measures and sensible health}’ living. The baby was one month old; the mother had been weaning him for a fortnight and had completely given up breast-feeding for one week before admission. The treatment as given in the records is as follows : To increase the all-roundhealth, tone and fitness of mother and child, both were placed under the best ln-gienic conditions. They lived in pure, cool air, day and night, were kept out of doors, and led simple w7ell-regulated lives, with adequate exercise, rest and sleep. The mother took graduated cold baths, had a good rub down, and then active walking exercise before breakfast. Strict attention was paid to the regulation of the bowels. The breasts were stimulated morning- and evening by massage and alternate sponging with hot and cold water. In the course of a week under this simple treatment the breast supply was increased twenty times, i.e., from 1 - 1 / 8 ounces to 21 ounces (see Chart), and the mother on leaving hospital, was entirely supporting her child.

Deficiency of Breast-millz: Treatment. 8*5

S36 The China Medical journal.

O u n c e s

25—

20-

15-

10-

ED ay 1

R■ K '

¡2 3

-MOTHER’S MILK.

I ■4 , 5 6

-HUMANISED MILK,

-WATER.Fig. 1.—Chart showing development of baby one month o ld :

full diet, 25 ounces (Smyly).

Deficiency of Breast-m ilk: Treatment. S37

As can be seen from this case, the methods of treatment are so simple that the poorest mother can carry them out in the poorest home. The treatment falls under the two main headings of general and local.

G en e r a l and L ocal M eth o ds of T r e a t m e n t .

General treatment.— This consists in the toning up and better care of the general health of both mother and baby by living a simple, healthy, well-regulated life, in fresh air, and hygienic surroundings, and on an ordinary simple diet.

Exercise without fatigue.— Both mother and child should be much in the open air and sunlight. Graduated cold baths and a good rub-down followed by a brisk walk are recommended for the mother.

I find that morning exercises on rising and just before the bath take the place of an early morning walk very effectively, and give the patient a sense of well-being to begin the da}7. They should be done with open window's and deep breathing, exercising all the muscles in turn and particularly the abdominal muscles.

For the baby, sunlight and a set period of the da}', when in a warm room all bulky clothing may be removed and the baby allowed free use of its limbs. By aiding the baby’s digestion and increasing appetite this reacts on the secretion of milk.

R est.— Bxercise must not be carried to the point of fatigue, which is one of the chief inhibitors of a good milk supply. Mental fatigue should be avoided. A nap in the afternoon is to be recommended, expeciaily for foreign patients. If the mother has unavoidably become fatigued, and the breast supply is in danger, a day in bed very often is sufficient to restore the balance.

Regulation of the Bowels.— A t least one free motion should be obtained daily7, either by laxatives, of which Liquid Paraffin is one of the best and easiest to take regularly, or better still, simply by changing or regulating the diet.

D iet.— It is not necessary for the patient to over-eat when nursing; prescribe a plain wholesome diet, preferably whatever the patient has been accustomed to, rich in fruits or vegetables, if possible, and avoiding many sweets.


F lu id s .— Administration of fluids is an important point in the treatment. Dr. Truby King has found from experience that water is a better lactagogue than milk. Milk, not-exceeding'i -2 -pints daily is good for those who care for it. It ma}' be taken wdth cocoa or in coffee made with milk. A larger quantity is apt to be constipating. I have found that one of the worst ways of trying to retain or increase breastmilk is for the patient to lie in bed (except in case of fatigue or weakness) and drink quantities of cocoa. Five pints of fluid daily, mainly water, is Dr. Truby K ing’s recommendation, and working on that, I have found that after the first struggle to drink 8-10 tumblers of water daily, patients very soon get to want it, and take it without trouble. It may be taken as weak tea, expecially in the case of Chinese patients.

For poorer class Chinese, bean-curd milk from the soya bean, called “ to fu chiang ” (j¡f )§£ üj|) in North China, has .the same chemical composition and is an admirable substitute for milk, while it has the advantage of being very cheap, two coppers a quart.

'Massage and sponging of breasts.— Massage and alternate hot and cold sponging of the breasts morning and evening should be performed. The hand should be lubricated with a little oil and the massage carried out from the periphery, stroking toward the nipple, massaging the w7liole cirumference of breast in this w'ay. This is followed by sponging. The patient should have two basins, one of very hot and the other of quite cold water and two sponges- First sponge each breast with hot water two or three times, then with cold. When the hot w-ater cools renew it, and repeat for about five minutes, ending with a brisk rubbing with a rough towel. It is well to do the massage and sponging midway between nursing hours, in order to leave the breast a little while to rest after nursing.

Regularity in nursing.— This is very essential, not only for the baby’ s but also for the mother’ s sake- Feeding oftener than 3-hourly should not be allowed, and the mother should if possible have undisturbed nights. I f the baby wakens at night it should be given water. Night feedings and irregular or 2-hourJy daily feedings -are exhausting for the mother, and inhibit a good milk- supply. -- ............ .............

The 4-hourly feeding schedule is the ideal-, and can in most cases be undertaken from birth with very satisfactory results, but if at first the mother’ s milk is scant}’ , the baby may be fed 3-houri}’- for a week or two until the supply increases.

Sometimes if one is not careful, as the milk increases the baby may over-feed and get a green diarrhoea as the result. It is then advisable to take it off the breast entire!}' for twenty-four hours and give water only. This is usually sufficient to clear up the diarrhoea at once. In this interval the milk should be drawn off by hand- massage and hand-milking at each feeding time, otherwise the secretion stops. I do not advise the use of the breast-punip, as it does not supply the stimulus to further secretion which is given by hand manipulation.

It is of course necessary to weigh the baby before and after each breast feed, to ascertain how much it is getting and how much, if any, artificial food needs to be added.

In closing I wish to present to your attention a case which Dr. J . Preston Maxwell t very kindly handed over to me for treatment. Mrs. Chung, aet., 33. When seen by me during pregnancy, the patient was flabby, anaemic, with breasts poorly developed. It was difficult to believe that there was any active breast tissue present. Hospital notes are as follows :

Chung Cli’uan Shih, aet., 33. Nos. 3362, 3363. Admitted to hospital October, 1922, in labour at full term. Previous obstetrical history : one child in 1920, died one month after birth; one child in 1921, died 9 days after birth. Both deaths were apparent]}- due to lack of milk and neglect.

Blood Wassermauu, negative. Woman of low mentality. Never had much milk and had to start supplementary feeding of infant a week after birth.

Baby, female, w7eight 2287 grammes (5 lbs.) at birth; 011 the 10th day 1969 grammes (4 lbs. 5 ozs.) ; and at discharge on the 2oth day, 2287 grammes (5 lbs.)

Fu rther history after discharge Jrom H ospital.— While under treatment with me, the patient lived in a small Chinese room, which was kept as airy as possible by keeping the door open during the day. She received only the ordinary diet to which she had been accustomed before entering hospital, supplemented by an extra bowl of rice daily. In addition she drank i-i£ pints of “ to fu chiaug ” [ S H -and 3^-4 pints of water or Chinese tea daily. A large quantity of “ to fu chiang ” given at first was found to cause constipation in both mother and child.

Deficiency of Breast-milUr Treatment. S39

i The China Medical Journal.

After the first day the patient was herself able to conduct the massaging and. sponging of the breasts night and morning very satisfactorily. With her it was not necessary to emphasize the need of rest. On the other hand it was difficult to insure that she got sufficient open-air exercise, until I hit upon the plan of sending her on small shopping expeditions.

Progress under treatm ent.— When patient came under my care the baby was being fed 4-liourly. One ounce of breast milk was supplemented by one ounce of a cow’s milk mixture at each feed. This was continued for three or four days. Under treatment the milk gradually increased. Unfortunately, owing to the fact that I was unable for several days to superintend the 4-hourly weighings, the cow's milk was not decreased as the breast milk increased, and the baby became overfed and began to have a green diarrhoea. We took it off all milk at once and put it on water for 24 hours, at the end of which time the diarrhoea had ceased and a small soap and water enema gave an almost normal motion. During this time the breast milk was drawn off by hand massage and milking at 4-hourly intervals. Breast feeding was slowly restored, at first giving 2/3 water to 1 / 3 milk and gradually increasing the breast milk and decreasing the water. A t this juncture it was thought advisable to stop cow’s milk altogether, and give 3-hourly breast feedings, that is, giving seven feedings of breast milk in the da}', instead of six. In addition, if the baby was thirsty we gave water in the afternoon and at night.

The breast milk continued to increase and after a week we were again able to resume 4-hourly feedings. ,The progress of the baby remained satisfactory. The weight chart appended (Fig. 2) shows the fairly steady weeki}' gain. On December 2nd, after a month under supervision, the patient returned home and is at present carrying on the treatment herself in a very small and overcrowded home. Her own physical condition is greatly improved. She is brighter and more active and has a good colour.

When we consider the low mentality and poor physique of this patient and the by no means ideal conditions under which she was treated, the results, though not so dramatic as those of Dr. Truby King, are at all events sufficient to encourage us in the use of the treatment in similar cases of deficiency.

R e f e r e n c e

King, F . T . Natural Feeding of Infants; Feeding and Care of the Baby.

Deficiency of Breast-milH: Treatment. 841

842 IThe China Medical Journal.

SOME VALUABLE AIDS IN OCULAR THERAPEUTICS.*

R. A. P e t e r s o n , m .d., Nanking.

The treatment of ocular diseases has been facilitated by the accessibility of the ej^e. In no other place in the body can pathological processes be followed as they can be there. Objectively and subjectively, the ophthalmologist is in closer touch wdth hisfield than either the internist or the surgeon. The cause of themorbid process can be followed from day to day and the effect;pf the various therapeutic measures used can be closely observed. Naturally this has led to marked progress in the field ofocular therapeutics. It is the purpose of this paper to call attentionto certain procedures, some of long standing, others of more recent development, which have proved to be of value in this field.

Applications of heat or cold have always played an important part in the treatment of ophthalmic disease or injury. Where it is desired to relieve pain, to promote lymphatic circulation, and to facilitate resolution by aiding nature to delimit infection, hot fomentations have a wide use. In treatment of infected corneal ulcers with rapidly spreading margins, the use of high degrees of heat by aid of the pasteurizers or thermaphores now in use, or even by the actual cautery, tends to destroy the organisms present and prevent the spread of the lesion. Cold has a more limited field, but where it is desired to attenuate the virulence of very active organisms, as in gonorrheal conjunctivitis, it has its indications. Cold packs used after severe treatment of the conjunctiva are, at times, more grateful to the patient than the application of heat.

Subconjunctival injections deserve an important piace among the measures employed in eye treatments- Used in conjunction with the routine measures employed in stubborn cases of uveitis, they seem to furnish the stimulating element needed to attain early resolution. In cases of parenchymatous and ulcerative keratitis, they have distinct merit in promoting lymphatic circulation. Used in conjunction with dionin in the non-surgical treatment of detached

*Read before the Section 011 Ophthalmology at the Biennial C on feren ce of the China Medical Missionary Association held in Shanghai, Chin«, February 1923.

retina, they appear to be of value. Various solutions are advised, the favorite being normal salt solution of which one or two cubic centimeters can be given subconjunctivally every second day, if desired. One or two applications of cocaine or holocain are usually sufficient to anaesthetize the conjunctiva. In specific iritis or corneal ulcer with hypopyon, many advocate the use of ten to twenty minims of one to four thousand (1 14000) solution of cyanide of mercury in a one per cent solution of novocain. In spite of the novocain, the after-pain is frequently7 severe and, due to this fact, salt injections are much more popular both with the patients and the profession and, in fact, frequently give as good results. Guiacol cacodylate, subconjunctival!}-, has been advocated by D arier1 in tuberculous affections of the eye, and M azzei" has used subconjunctival injections of boiled milk very successful!}' in the treatment of phlyctenular conjunctivitis.

The marked value of large doses of the salicylates in ocular therapeutics was first recognized by 11. Gifford* and his original rule of one grain daily per pound of body weight is still pertinent in determining the safe possibility of dosage. Sodium salicylate because of its toleration, its inexpensiveness, and its ease of administration is the form most frequently used. Dispensed with elixir of pepsin as a vehicle, it is not unpleasant to the patient and a daily dosage of sixty to eighty grains in this form will prove as effective as larger doses of the dry powder or tablets. In cases where the salicylates are not tolerated or apparently have no effect, cincophen, or atophan as it is more popularly known, gives practically the same results. The pharmacological action of this group of drugs has not been fully worked out but their marked antiphlogistic action on local inflammations renders them a valuable adjunct in the treatment cf eye conditions. These drugs are especially indicated in the so-called rheumatic affections, such as rheumatic iritis, iridocyclitis and episcleritis, in acute and fulminant glaucoma, and in postoperative infections. A fter the development of sympathetic ophthalmia, the salicylates seem to aid in the conserving of visual function by lessening the virulence of the infection. In obstinate cases of uveitis, they can, as S. R . Gifford1 has pointed out, be used over a period of months without toxic effect other than occasional occurrence of tinnitus or slight nausea. Anim al experimentation has indicated that the renal function

Some Valuable Aids in Ocular Therapeutics. 843'


should be watched during their use but clinical experience, seems to show that the sodium salt, at least, causes no appreciable renal damage when used within proper limits. Naturally- the causative factor must be eliminated by proper treatment but, while this is being done, the salicylates will tend to control the inflammation and keep permanent structural damage at a minimum.

The course of treatment of acute and chronic inflammations of the eye involving the uveal tract, primarily or secondarily, is known tomam- ophthalmologists as the “ active” course of treatment. This can be outlined briefly as consisting of the use of atropine or eserine as indicated, the uss of salicylates, pilocarpine sweats, thorough elimination, mercury by inunction or hypodermic injection, with rest m bed, proper diet and, of course, treatment of the causative factor. In some cases ail of these measures are not necessary, but in severe cases of iridocyclitis of specific, postoperative, or of so-called rheumatic origin, each measure plays a distinct part in bringing the process under control with a minimum of damage to the eye.

In the past three years the use of milk in ocular therapy has attracted much attention. According to Mazzei", it was first used by Muller and Thanner at Vienna during the Great War. Daner later began its use and advanced the belief that its good effects are due to the stimulation of leucocytosis and phagocytosis. From the many favorable reports that have subsequently appeared, it would appear that it is worthy of trial in certain types of eye inflammations. Intramuscular injection in gonorrheal ophthalmia rapidly reduces the swelling of the lids, relieves the pain, gives an early decrease in the bacterial contents of the discharge and paves the way for treatment with silver nitrate. In the treatment of phlyctenular conjunctivitis and keratitis, in serpigenous ulcer, and in the prevention of postoperative inlection, many encouraging results have been reported. The value of milk injections in nonpyogenic cases is considered problematical. It must be borne in mind that milk injections are only; to be considered as adjuvants to the recognized forms of treatment and that no immunity against future infections is established. The milk should be free from all bacterial contamination, sterilized by boiling, and three to five cubic centimeters injected intramuscularly, or one fifth of this amount subconjunctivally, every second day until a marked reaction with

elevated temperature and leucocj'tosis is noted. Smith5 reports that, in the Vienna eye clinics, the intramuscular injection of 10 c.c. of sterilized milk daily for four days is the routine treatment for cases in which milk therap}^ is deemed’ advisable. The Vienna school considers that the indifferent results reported by some ophthalmologists are due to the inadequate doses given.

The preparation, mercurochrom-220, was introduced to the medical profession by Young, White, and Schwartz of Baltimore. Its use in the treatment of conjunctival infections was first described by Greenwood in 1920. It is of value in the treatment of any acute pyogenic infection of the conjunctival sac. A number of operators use it preceding and following operations about the eye as a safeguard against infection. Apparently it has very little effect on the Morax-Axenfeld infections. The drug, up to a three per cent solution, is used in connection with boric acid irrigation and other routine measures. Its intense red staining of the skin renders it objectionable to some patients, but reasonable care in its administration usually suffices to keep the mercurochrom from getting into contact with the skin. Corneal erosions and ulcerations are made conspicuous by it as it stains the interstitial tissue of the cornea a very vivid red, even going beyond the margins of epithelial loss.

Optochin, or ethyl hydrocuprein, has had a rather checkered career. It is advocated as a specific in pneumococcus infections of the conjunctival sac and, as such, has a number of warm advocates. Many, however, report disappointing results, especially in cases of pneumococcus ulcer. The main difficulty in its use lies in the fact that pneumococcus infections of the conjunctival sac and cornea are frequently associated with other organisms on which this drug has no action. In these cases, ethyl hydrocuprein alone does not suffice and other treatment is indicated.

Blepharatis marginaiis does not seem to be met with as frequently in China as in the United States. The more stubborn cases of this condition can be controlled with one or two applications of citrine ointment prepared with a cod-liver oil base. The ordinary citrine ointment is of a stiff consistency, hard to apply, and seems rather inactive. When cod-liver oil is used as a base, it becomes a stickjr, adhesive ointment which, when warmed, is very easily applied to the lid margin after the crusts have been removed. Following the application of the ointment, hot packs are applied to

Some Valuable Aids in Ocular Therapeutics. 845

846 The China Medical Journal,

the lids for five minutes and the then excess is removed witli vaseline. Naturally the u n d erlin g condition, be it refractive or what not, must be relieved,

Fluorescin is of value in determining the extent of epithelial loss in corneal ulcers or erosions. It stains the interstitial tissue of the cornea a bright green. It is more trustworthy than mercuroehrom for this purpose as it does not penetrate beyond the limits of epithelial loss as is done by mercuroclirom. It is used in a two per cent slightly alkaline solution. I f the solution is net alkaline, the color will be much less intense. One or two minims are instilled in the conjunctival sac, the lids kept closed for one minute, and then the excess is removed by a boric acid irrigation.

Holocain is one of those drugs of which the usefulness is not restricted to one sphere of action. It is known chiefly for its anaesthetic value in cases of suspected hypertension where its use will not increase the intraocular pressure. It is also valuable as an aid in caring for those corneal infections where photophobia is marked by enabling the patient to overcome the blepharospasm and allowing light and other therapeutic measures free access. Holocain is also a good lymphagogue and it is often combined w7ith dionin in treatment of ulcers of the cornea to secure the maximum stimulation possible of the lymph circulation.

The value of various agents in disinfecting and cauterizing corneal ulcers that respond sluggishly to treatment has long been recognized. Chief among these is iodine, especially a thirty per cent solution made as a thick syrup so as to avoid spreading and applied with a cotton point to the ulcer. Trichloracetic acid can be used in a similar manner but care must be taken that the eye is flushed with salt solution immediately following the application to wash away any excess present. Extreme caution must be used in applying it to ulcers w7ith thin floors, otherwise a bad perforation may result. Silver nitrate is occasionally used in a similar manner, but tends to leave a more marked corneal opacity.

Of the systemic conditions giving rise to eye complications, syphilis is very frequent in its occurrence and its gratifying treatment wTith mercury, the iodids, and salvarsan or one of the other arsenical compounds for intravenous medication, is'noted by both the internist and the ophthalmologist.: One of the newer therapeutic measures, according to Professor E . Fuchs, is the arrest

Treatment of Schistosomiasis Japónica. S47

of optic, atrophy in tabes by inoculating the patient with the malaria organism and allowing him to run an active course of the disease. In diabetic cases requiring ophthalmic operations, Professor Fuclis also emphasizes the fact that, during the postoperative course, it is unwise to stop giving carbohydrates as the restriction may induce acidosis or delayed healing. Tuberculin benefits many tuberculous conditions of the eye to a marked degree when given therapeutically and is also a valuable diagnostic agent.

B ib lio g r a p h y .

1 . Darier. Ophthalmic Therapeutics.2. Mazzei. Milk in ocular therapeutics. Abstr. Am. Jour.'

Opth., Vol. 5, p. 845.3. Gifford, H. Trans. Opth. Sec. A. M. A ., 1899, p. 322.4. Gifford, S. R . Am. Jour. Opth., Vol. 5, No. 12 , p. 948.5. Smith, D. V ., Peking. Personal Communication.

TREATMENT CF SCHISTOSOMIASIS JAPONICA.*

E r n e s t C a r r o l l F a u s t , m .d ., P e k in g .

With the introduction of tartar emetic as a therapeutic in the treatment of Egyptian bilharziasis b\T Christopherson in Ma\' 19 17 , the use of this drug has been found universally successful in the treatment of that infection. In Egypt and the Sudan nearlj’ thirty thousand cases of the infection are treated each year in the five Government hospitals, and of this number 50 per cent are cured, while the other 50 per cent are usualh7 benefited but break off treatment before a cure has been effected. The drug is considered to be an absolute specific for Eg}*ptian bilharziasis.

While it is unlikely that as high a proportion of the population of the Yangtze Valley is infected with schistosomiasis japónica as is the case in E g j ’pt with the bilharzia infection, where 6 million out of the 30 million population are infected, it seems probable that 10 million Chinese people harbor the infection. The need for giving various drugs a thorough trial, and of finding one, if possible, satisfactory for general application to the disease and using it on

^Contribution from the Parasitology Laboratory, Department of Pathology, Peking Union Medical College.


a large scale deserves serious consideration. The object is twofold : (1) to cure or improve the condition of the patient, (2) to prevent him from being a “ schistosomiasis carrier,” thus endangering the community.

T h e A n tim o n y C ompounds A v a il a b le F or U s e .

1 . Potassium antimony tartrate. This is not generally used, because of its toxic effects.

2. Sodium antimony tartrate, {abbrev., s. A. T. ) . In general use for Egyptian bilharziasis, dermal leishmaniasis and kala azar.

3. Potassium ammonium antimony tartrate (antiluetin) and antimony hydrargyrum (neo-antiluetin), Japanese preparations, recommended for schistosomiasis japonica by Dr. F . Katsurada.

4. Emetine. This is too well understood as a specific in amoebiasis to be described. It has more recently been used in treating schistosome infections.

5. Colloidal antimony. There are several preparations. One going under the name of Oppenheimer’ s colloidal antimony is in use in South Africa in the eradication of

fascioliasis (sheep liver-rot); another known as collosalantimony (Crooke’s) has been used in bilharziasis; still another is in use in the kala-azar clinics in the Peking Union Medical College (prepared by Dr. J . H. Korns).

t Dosage Em ployed .— The Christopherson method emplo3'ed in the Egyptian infections (both vesical and rectal) consists of the equivalent of about 1.5 to 1.8 gm. of sodium antimony tartrate distributed over a period of 28 days, beginning with grain ( i J/2 mils of a 2 per cent solution) and working up to a maximum of 2 Vz grains (7^2 mils of a 2 per cent solution). Dr. Cawston of Durban, Natal, emplo3'ed this method on a European infected with schistosomiasis japonica (contracted in Hunan, China), and cured the patient after 1.26 gm. of the drug had been us^d.

The Method of Treatment.— It is common knowledge that antimony compounds must be administered intravenously in order to be effective without being locally irritating. The drug should not be injected within a period of two-and-a-half ho&fts before or after meals. The patient should recline during the

Indications and Contra-indications.— The drug is indicated on finding the eggs of a schistosome in the feces, or in the absence of that evidence when the clinical picture is typical, or when biological tests such as the complement-fixation reaction (Fairley, 19 19 ) is positive. Cawston (1922) recommends emetine for small children.

The drug is contra-indicated in cardiac trouble and emaciation. Biological Tests of the Effect of the Drug on the E ggs and the

Worms.— A reduction in the eosinophilia is no criterion of the effect of antimon}T salts on the schistosomes, since accompanying helminths, such as ancylostomes and ascarides, are more likely to be responsible for the eosinophilia than the blood-fluke. The relief of the symptoms of the disease is not sufficient. Cawston (loc. cit.,) cautions against this, since the patient becomes a “ carrier” , unmindful of his danger to the community until a recrudescence of the symptoms occurs. It seems probable that the most practical method at present available for diagnosing the disease in China is the search for the eggs, covering a period of five or more days after a full treatment has been given. Kven here care must be excrcised, since the schistosome eggs, affected by secretion of the drug in the feces, ma} be found degenerate, while the worms in the portal system are still alive. In such a case Christopherson recommends complement fixation to determine if the worms are still alíve.

Dispensary Treatment.—While the first experimental treatment of schistosomiasis japonica should be carried out on inpatients, to determine the exact procedure to be followed in China sooner or later dispensary treatment will have to be inaugurated, and, perhaps in case of heavily infected villages some distance from the hospital, travelling dispensaries should be advocated.

REFERENCES.

Cawston, F. G., 1922. The Antimony Treatment in Some Tropical Diseases.South Afr. Med. Jour., July 8th, 1922, 11 pp.

Christopherson, J. B., 1921. Demonstration of the Technique of the Intravenous Injection of Antimony Tartrate in Bilharzia Disease. Proe. R. Soe. Med., 14 : 18-21.

1921. The Intravenous Injection of Antimony Tartrate in Japanese Bilharzia Disease. Brit. Med. Jour., Oct. 8, 1921, 2 pp.

Fairle}7, N. H., 1919. The Discovery of a Specific Complement Fixation Test for Bilharziasis and its Practical Application in Clinical Medicine. Jour. Ro}ral Army Med. Corps, X X X I I : 449-460.

LeBas, Geraldine Z. L-, 1922. Of the Nature of the Antigen in the Complement-fixation Test for Bilharziasis. Jour. Trop. Med. Hyg., X X V : 49-61.

Tyau, E. S., 1922. The Treatment of Asiatic Schistosomiasis. National Med. Jour. China, V III : 38-85.

Treatment of Schistosomiasis Japonica. S49

850 T he China Medical Journal.

SIMPLE FORM OF CARREL-DAKIN ELECTROLYTIC CELL.

B . R . S t e p h e n s o n , m .a ., Peking Union Medical College, Peking.

In the two articles by Cameron on the preparation of Carrel- Dakin solution which have appeared in the China Medical Journal (xxxvii : 44-49, 403-411), he has fully discussed the theory and the various methods of preparing this solution. The method which be has found to give the best results is the electrolytic, but the cost of the cell makes it impossible for most mission hospitals to use this method. A t the suggestion of Mr. Cameron and interested physicians, I undertook, about a year ago, the development of a cell that could be secured locally and would be much cheaper than the commercial cells available. A cell has now been developed which gives all the results that the larger cell gave and at a cost which is trifling compared with that of the cell in the Peking Union Medical College pharmacy.

After trying out all the different kinds of electrodes available, varying their size and using several different kinds of containers, a cell was finally chosen which is of cement with a capacity of about 2.5 liters, and inside dimensions 6 x 1 1 x 54 centimeters. This cell is adapted for 1 10 volts direct current. It has two graphite electrodes which project up out of the cell and 15 small graphite plates 6 x 10 x y2 centimeters, set in equally spaced grooves in the sides of the tank, similar to those shown in the drawings on page 5 of Mr. Cameron’s second article. The solution fills the cell to the top of the plates. A spout, through which the liquid may be drawn off, is provided in the side of the tank. The current is from 5 to 7.5 amperes, depending upon the temperature of the solution. The time is ten minutes. The cost of power is about one cent Mex. per liter of solution. This tank can be ver}?- easily made by an}- machinist or carpenter who can construct a mold. The electrodes can be purchased from the Acheson Graphite Company of Niagara Falls, New York, and sent out by parcels post. The total cost of the cell should not be over Mex. $ 10 .0 0 including an extra set of plates. We have the forms an the dgraphite in the Physics Department of the Premedical

Sim ple form of Carrell-Dakin Electrolytic cell. 851

School of the Peking Union Medical College, and will undertake to supply any hospital with such a cell and an extra set of plates at the sum stated.

Alternating current may be used to operate the cell if an additional cell, called an electrolytic rectifier, is used in series with the Carrel-Dakin cell. Such a rectifier would make the initial cost more and would cost more to operate, due to losses in the rectifier. The Carrel-Dakin cell described above could not, in general, be used with a rectifier, because the voltage drop, through the rectifier, would make it necessary to shorten the cell. I have not yet worked out the particular type of cell that will be best adapted for use with the rectifier, but I have produced the solution using a rectifier, and thus know that it is simply a matter of taking time to ascertain the best working conditions.

The electrol3'tic rectifier, mentioned above, can be made by using a large plate of lead and either one or two plates of aluminum, in a 20 per cent solution of ammonium phosphate. If two plates of aluminum are used, both halves of the cycle are rectified and the power loss is decreased and also the heating of the electrolytic cell. But in order to use two plates, an inductance coil must be placed in parallel with the aluminum plates and the alternating current connected at the ends of the inductance coil. The Carrel-Dakin cell is. connected between the lead plate and the middle of the inductance coil. If one had a transformer, it might be connected up so as to act as the inductance coil. The Carrel-Dakin cell and the rectifier could be made in the same box if there were a water-tight partition between. It would be advisable, in order to reduce resistance, to have the lead and aluminr.m plates as large as possible, so that they should be lengthwise of the tank. Such a rectifier is rather inefficient and can be used for only a short time due to the heating, but it is perfectly satisfactory for the Carrel-Dakin cell where the total flow is but a few minutes.

S u m m a r y of R e s u l t s .

1 .— Graphite, not carbon, must be used for the electrodes.

2 .— Any kind of non-conducting container such as glass, glazed earthenware, stone or cement, may be used, providing it can. be obtained in a rectangular form.

852 •The China Medical -Journal.

3 .— The amount of hypochlorite solution produced - depends upon the time, the current density, the number of plates and the temperature of the solution.

4.— The temperature must not be allowed to become too high, preferably not above 40° C. and certainly not above 50° C. The solution should be cooled as soon as possible and kept in a cool place.

5 .— The current density depends upon the size of the plates, upon whether or not the current is confined to the plates, and upon the length of the cell.

6.— The optimum current density seems to be about o. 1 ampere per square centimeter of plate area.

7.— Smaller amounts than the full capacity of the cell may be made, the time being proportional)y changed.

8 .— Only direct current is usable through the cell.

P r e v e n t i v e M e d i c i n e .— The .student should habituate himself to think widely and resourcefully of the means of prevention in their whole range. Poverty, industry, personal habits, social conditions, channels of infection, must be considered as well as the grand category of the therapeutics which prevent— drugs, vaccines, serums, organic substances, sunlight, electricity, radium, massage, psychology— and the still wider factors of environment. He is to learn by ingenuity to apply and adapt all knowledge to the harnessing of disease as a whole. The patient is to be cured; yes, but -out of the patient is to be wrought an understanding of, and an attack upon, and the prevention of, the particular disease from ‘ which he suffers. It way well be that the student cannot practise prevention as he learns to practise the cure, for the issues raised are beyond his immediate control. But when he enters upon his life’s work as a medical practitioner he will find that it is required of him that he shall take an essential part in the vast national and international machinery now in being for the conquest of disease. There are not less than a score of Acts of Parliameut which impose public preventive duties upon him as a medical practitioner. He must know how to comport himself in relation to those laws. But more than that, his private patient is concerned not only with the alleviation of his malady, he is anxious about the future and his capacity to work, and he asks, “ What can I do to prevent this ?” Surely, that i§ a very cogent and penetrating question for the medical practitioner to answer. His answer, and its wide promulgation and proper interpretation, is the fulfilment of his splendid part as the missionary of Preventive Medicine. For his comfort he may remember that to prolong human life and to make it fuller, better, and more effective, is the “ master task of mankind.” — Sir George Newman, B rit. M ed Jour., September., 1923.

‘She China Jttebicnl Journal.V o l. XXXVII. OCTOBER, 1923 . No. 10

MEDICAL EDUCATION IN CHINA.

For many years medical missionaries in China were sharply divided in opinion as to the standard of medical education most suitable in the present state of the country. On the one side it was contended there should be the same high, standard as in the W est; that in medicine, as in everything else, the Chinese should receive the very best service within our power to render; that to start with a lower standard, or to have two standards one inferior to the other, would not be giving our best to the sick and injured and the policy would cause much confusion, especially when the time came, as it inevitably would, when there must be but one standard and that the highest.

On the other hand, it was pointed out that among the hundreds of millions of Chinese all but a very small proportion of the sick and injured are wholly dependent upon ignorant native doctors; that it will be many years before the number of graduates of high grade medical schools will be sufficiently large to meet the medical needs of the Chinese; that the ignorance, superstitions and prejudices of the people form so great a barrier between them and highly trained physicians as to prevent helpful contact; that the large staff of teachers required for a first-class medical school, some of whom must give their whole time to teaching, and the very expensive laboratories which are necessary, will not permit missionary enter

prise, unless aided from without, to maintain more than a very few schools of this kind. Consequent^7, until the Chinese government establishes an efficient system of education, including the study of medicine, more help would be given to the Chinese, if, as in India, medical schools of a secondary grade were opened, in which a sound knowledge of medicine and surgery could be obtained in less time and at less expense than in the high grade institutions. More students would then be drawn to medicine and their education would not separate them too much from the common people.

It should be understood that the arguments presented by each side were more comprehensive and persuasive than can be indicated

here. Eventually it was decided by our Association to ~have:one uniform standard of medical education of the same high grade-as in the West. Under this arrangement good work is being done.

The foundations, therefore, of medical education have been well and truly laid, but the superstructure is rising very slowly. In other words, the number of students in the medical schools, missionary and non-missionary, is so small that when we consider the vast regions in China where scientific medicine is almost unknown, it is evident that there are still educational difficulties to be overcome. For Chinese students do not seem to be drawn to the practice of medicine. So far, comparatively few have come from missionary colleges and universities. In the government schools, where the course is probably much easier and the annual tuition fee is the very small sum of Mex. $24— $30, there is the same dearth. The total number of students in government universities and professional schools in 1923, is 24,366. Of these, 1037 (4.2 per cent) are medical students : 1 1 being in the universities; 742 in the central and provincial government medical schools (Peking, 222; Kiangsu, 96; Chekiang, 205; Kwangtung, 10 6 ; Chihli, 113), and the remaining 284 m private medical schools formally recognized by the Chinese Government, namely, the Union Medical College in Peking, the Japanese Medical School in Moukaen, the Yale Medical College in Ch’angsha, and the Kungyi Medical School in Canton. Taking the professional schools only, the students in 1 9 2 3 'number 1 5 , 1 9 1 ; of these 1,026 are medical students (6.7 per cent). In 19 16 , the students in professional schools numbered 13 ,7 8 6 ; of these 950 (about 6.9 percent) were studying medicine. Numerically, there has been a v e ^ slight gain during the seven years; but proportionately, there has been a slight decline. In the United States, with a population of nearly 106 millions there are 17 ,700 medical students; roughly, about one to 6,000 people. A t this rate, with a population of 400,000,000 th e r e should be in China over sixty thousand students... In England the number of practitioners now on the register is 46,477 in a population of nearly 43,000,000; in the same proportion China requires more than 400,000 physicians. Perhaps one physician to

e v e r y two thousand of the population would be quite sufficient; even so, 200,000 physicians would be required. At the present time it is

doubtful if in the whole of China there are more than 1200 students

854 (The China M edical Journal.

Medical Education in China. 855

in the medical schools. Unless there is a rapid increase, the number of graduates each year will be very small, certainly not more than 250. Those from government schools will probabh* enter the government, service, either civil or military, or engage in private practice in the large cities. Very few will risk starting in small towns or rural districts, and ver} few will serve in mission hospitals. How is scientific medicine to spread unless, we have the physicians to create and meet the demand for it ? How can missions comply with the requirement that every hospital should be adequately staffed, if well-trained Chinese physicians cannot be obtained ? In response to the expressed desire of our Association and in accord with their own sense of what is fitting, medical missionaries abandoned the attempt to support other than first-class medical schools, also the training in local hospitals of students to practise as doctors. It was expected, however, that high grade schools would at least graduate physicians in sufficient number to meet all missionary needs now and in the future. If these schools are unable to do this, through no fault of their own, be it said, medical progress in China will be very slow. (It has not been possible to give the statistics of missionary medical schools as recent reports have not been received; the omission does not greatly matter as the number of students in these schools is not sufficiently large to affect our argument.)

What is to be done? The main difficulty seems to be that the practice of medicine, except perhaps in a few large cities, is not sufficiently lucrative. The great mass of the people are either ignorant of scientific medicine, or do not yet believe in its superiority over the empirical methods of the native doctors. All practitioners are regarded as being on one level, a change being quickly made from one to another if the patient does not immediately improve, even in diseases such as typhoid fever. There is little or no scope for the knowledge and skill of the scientifically trained physician. W ithal, the remuneration is poor and uncertain. It should not be suprising, therefore, that so few wish to enter the medical profession.

From another point of view this dearth of medical students is a matter which ought to.receive immediate and serious consideration. To supply men and means for the medical work that is being done by m issionary societies in China is a burden w illingly borne by

856 T h e China Medical Journal.

the home churches, but their present resources are not such as to allow further expansion and few expect even the present work to be carried on indefinitely. The Chinese must be induced to undertake the medical care of their own people. How to do this is the problem we must now try to solve. It will be most helpful if our readers who are interested in medical education will write to the Journal offering suggestions as to how we m ay promote the growth and prosperity of medical schools.

LEAGUE OF NATIONS HEALTH COMMITTEE.

The sixth session of the League of Nations Health Committee began in Paris on Maj* 26th, 1923, and the discussions which have taken place there show that co-operation in public health matters among the various Governments has greatly developed in the two years since the League Health Organization was founded. In the field of epidemiological intelligence and public health statistics considerable progress has been made in organizing a regular and rapid collection and distribution of information, and it is hoped by the League Health Organization that in time it will become a central clearing house for all such matters. Reports on the progress of the three committees of inquiry working under the auspices of the Health Organization were discussed. The first is a small committee of experts set up to investigate the prevalence of sleeping sickness and tuberculosis in tropical Africa since the war. The second is the joint sub-committee of the League of Nations Opium and Health Committees which deals with the present position of the subject as set out above. The third is a joint subcommittee of the Health and Transit Committees, which is

V *collecting information to serve as the technical basis for a conference between the various European States which have navigable inland waterways, for the purpose of co-ordinating and tightening up sanitary control and anti-epidemic measures without interfering with the normal working of these arteries of trade.

Further reports which were discussed concerned the progress of the applied research work, which aims at international agreement as to the methods of establishing serological tests in order to

facilitate international co-operation in improving the whole technique of immunization by serum injections. It is proposed by the Health Organization that a similar programme of research work, conducted in many countries on a common plan, should be instituted in regard to certain biological products used as drugs, such as digitalis, pituitary extract, and insulin. The question of further perfecting and developing the system of visits of international groups of public health officers to study the sanitary systems of one or two countries was also considered. The first of these study visits, so-called “ interchanges,” took place in Belgium and Italy, the second in Great Britain and A u stria ; a third (for specialists in the campaign against malaria) is at present taking place in Italy, and another visit is being arranged to the United States.

League of Nations Opium Advisory Committee. 857

THE LEAGUE OF NATIONS OPIUM ADVISORY COMMITTEE.

The fifth session of the League Advisory Committee on the Traffic in Opium and other dangerous Drugs was held in Geneva, June 1923. The session was particularly important and showed a great increase in the Committee’ s activities. The United States presented two proposals as follows : —

1. If the purpose of the Hague Opium Convention is to be achieved according to its spirit and true intent, it must be recognised that the use of opium products for other than medicinal and scientific purposes is an abuse and not legitimate.

2. In order to prevent the abuse of these products it is necessary to exercise the control of the production of raw opium in such a manner that there will be no surplus available for non-medicinal purposes.

The Committee approved and unanimously adopted four resolutions which embodied these and other proposals. The first resolution accepts and recommends the U. S ., proposals as embodying the general principles by which governments should be guided in dealing with the traffic in dangerous drugs; the second is an appreciation of the value of the co-operation of the U. S ., and expresses the belief that all the Governments concerned will give

858 T he China Medical Journal'.

the fullest possible effect to the work of the Convention ; the third describes the activities of the Committee during the last two years. The fourth resolution is as follows :— - '

That, as a means of giving effect to the' principlès submitted bjr the representatives of the United States and the policy which the League, on the recommendation of the Committee has adopted* and having regard to the information now available, the Committee recommends to the Council the advisability of inviting : ;

(a) The Governments of the States in which morphine, heroin, or cocaine, and their respective salts are manufactured and the Governments of the States in which raw opium or coca leaf are produced for export for the purpose of such manufacture ;

(b) The Governments having territories in which the use of prepared opium is temporarily continued under the provisions of Chapter n of the Convention and the Government of the Republic of China, to enter into immediate negotiations (by nominating representatives to form a committee or committees or otherwise) to consider whether, 'with a view to giving the fullest possible effect to the Convention of 1912, agreements could not now be reached between them ;

(c) As to a limitation of the amounts of morphine, heroin, or cocaine and their respective salts, to be manufactured ; as to a limitation of the amounts of raw opium and the coca leaf to be imported for that purpose and for other medicinal and scientific purposes ; and as to a limitation of the production of raw opium and the coca leaf for export to the amount required for such medicinal and scientific purposes. The latter limitation is not to be deemed to apply to the production and export of raw opium for the purpose of smoking in those territories where that practice is temporarily continued under the provisions of Chapter 11 of the Convention.

(d) As to a reduction of the amount of raw opium to be imported for the purpose of smoking in those territories where it is temporarily continued, and as to the measures which should be taken by the Government of the Republic of China to bring about a suppression of the illegal production and use of opium in China.

A t Geneva, on September 27th, 1923, the Assembly of the League of Nations adopted the resolutions submitted b} the Opium Committee, including the resolution urging th i countries which have not yet ratified the Opium Convention of 19 12 to do so soon and to apply its provisions.

'Hospital Reports. 859

1bo$pital IReports*

H AN G C H O W H O SPITAL A N D M ED ICAL TR AIN IN G COLLEGE.

In connection with the Church Missionary Society. Annual Report for 1922.

F o r e ig n M e d ic a l S t a f f : Drs. D. Duncan Main, C.Frederick Strange, Dansey Smith, Sidney L . Lasell, Stephen D. Sturton.

The reports of the Hangchow Hospital with its many Departments are always instructive and interesting and the latest report is no exception. Having been away on furlough, Dr. Main writes the introduction only. Dr. Strange describes the work generally. Among other new enterprises, funds are being raised to erect a home for women lepers which is very much needed, as the number of these most unfortunate women coming to the hospital is steadily increasing. Passing to his own surgical work, w'liich has been much larger than in previous }^ears, Dr. Strange records the gratifying fact that in 98 per cent, of his cases the wounds healed by first intention. Dr. Danse}' Smith, in charge of various departments and sanatoria, has had all the work he could possibly do and reports some very interesting cases. Dr. Sturton writes on the work of the Out-patient Department and Pathological Laboratory, the X -ray and the Electro-therapeutic Departments. There are algo other short reports. Two of the Chinese physicians on the staff give very interesting autobiographical sketches. The total number, of in-patients was 2,796; Out-patients, 35,344. Major operations, 77 1.

CHURCH G E N E R A L H OSPITAL, A M E R IC A N CHURCH M ISSION, W U C H A N G .

Annual Report for the year 1922.

Foreign Staff : Men’s Department, D rs. Theodore B liss and C. M cA. W assell. Women’ s D epartm ent: Dr. M ary L . Jam es,

The number of in-patients admitted during the year in the Men’s Department was 1,430 . A little epidemic of cholera is Recorded in which the death rate was 35.29 per cent. Dr. Wassell


notes that the diseases causing the greatest number of deaths are tuberculosis, cholera, estivo-autumnal malaria and amoebic dysentery, in the order given. A start has been made in the training of hospital technicians.

Dr. James gives a well-written report of the work in the Women’s Department. In-patients numbered 605. Much attention is given to the training of nurses and orderlies. The experiment is being tried of giving a pre-nursing course to a class of ten. The girls study in the morning and help in the hospital work for about two hours in the afternoon. The plan has been used wTith much success in the United States. The Religious and Social Service Department has leased a house to which old patients who are disabled, homeless, and who no longer need hospital care, are transferred. Instructions in various forms of handwork is given to former patients to help them to earn their own livelihood. In viewT of all that is being done for the souls as well as the bodies of the patients, the report closes very fittingly with a few earnest words from the chaplain of the hospital.

ADMINISTRATION OF MISSION HOSPITALS IN CHINA.*

J. H. S n o k e , m .d „ f .a . c .S. Superintendent, St. Luke’s Hospital, Shanghai.

Success and failure in hospital administration are alike often determined by the same incidents or conditions, the difference in results being only a matter of arrangement. The same rules, methods, personnel, phj’-sical plant, and location will mean, under some arrangements, success ; under others, disorder and failure. The many patterns and colors in a kaleidoscope are made possible simply by re-arranging the same pieces of colored glass. The successful hospital is one which is well arranged, well organized, and well administered. A well administered hospital is one in which there is conscientious, thorough, courteous, sympathetic- work done by every one connected with it ; where there is prompt, skilful medicai and surgical attention ; careful, kindly nursing ; a thorough study of disease and its wise treatment; systematic notes and complete records ; careful attention to business details ;

*R ead at the C.M.M.A,. Conference.held in Shanghai, February, 1923..

economy, but no stinting, of time, eftort or m aterials; an atmosphere of helpfulness, harmony and co-operation.

H o s p it a l O r g a n iz a t io n : T h e B o a r d o f T r u s t e e s .

Proper organization is one of the most important factors. The following are, I think, basic principles in sound hospital organization. There should be, first of all, a Board of Trustees. This Board should be chosen with great care, bearing in mind the statement of Colonel Gorgas that “ all boards are long, narrow, and wooden.” Each member should be vitally interested not only in his particular institution but should have also a vision of community needs. None should be chosen because of wealth, political standing, or seniority of service. Put before this Board •only matters of policy. Never allow it to discuss details if you can help it, or onlj’ such details as are referred to it by the Hospital Administrator or Superintendent. There should not be too inanj' committees. Some one has said, “ A committee is an American invention for evading responsibilitjr and postponing action.” This Board should have final authority in all matters and should provide, supervise, and audit the finances. No member •of the hospital staff should be eligible to membership.

T h e H o s p it a l A d m in is t r a t o r or S u p e r in t e n d e n t .

Next to the Board of Trustees should be the administrator. It is just as important that he should be as carefully selected as the members of the Board. He should be the executive officer of the Board of Trustees and the only medium of communication between it and all other departments. He must have authority commensurate with his responsibilities. He must be a coordinator, a harmonizer, but never a dictator. He must be more than a good steward. He must have vision to see beyond the four walls of his office. It is a sound business principle that any large organization must have a single executive head. He should be that head. He should be an advisor to the Board and should take part in all its discussions, for he should be the best informed on all matters relating to the hospital.

M e d ic a l a n d S u r g ic a l S t a f f .

The hospital staff has its duties which are or should be wholly concerned with the care of patients. Some have greater responsi*

Administration of Mission Hospitals in China. 861

bilities than others,-but-all contribute to this one great end/-- The whole organization,- in fact, exists for and should focus on-the patient. There should be the greatest harmony and willing teamwork. ’The staff member, be h'e'sUrgeon, assistant, interne, nurse, or hotise-keeper, who fails to co-operate, who wishes onty for - selfadvancement and' personal glory, who labors for what he will get and not for what he can give, is worse than dead weight, and should' be .set right or replaced no matter what his ability or connection may be. There should be harmony also between staff and superintendent. I)r. Smith, the superintendent of Johns Hopkins Hospital, Baltimore, says : “ The Staff members should understand that he (the superintendent) is not trying to hamper them individually or collective^’ , but that because of his impartial position, and because of his broader knowledge of affairs in all departments, and of the resources available, he is trying to co-ordinate individual efforts to form a harmonious and efficient machine. If this were understood and practised more generally by both superintendent and staff, the efficiency of our hospitals would be remarkably increased.”

Let us now examine more particularly the three classes of mission hospitals in China to see whether these general principles can be applied. These are :

1 . — The so-called “ One-man ” hospitals, with only one foreign doctor and his or her Chinese helpers. About 69 per cent of all our mission^hospitals in China belong to this class.

2.— Hospitals in which there are two foreign doctors and a foreign nurse, about 18 per cent of the total.

3 .— In the third class are hospitals which have more than two foreign doctors, about S per cent.

About five per cent’ of the mission hospitals in China have no foreign doctors.

T h e ‘ ^O n e -m a n ” H o s p it a l .

The “ One-man” hospital seems to present the fewest difficulties in. an administrative way. There is, or should be, no doubt as to the one physician’ s responsibility and authority. But in some missions the town meeting method of administration still exists. A ll missionary^activities, no matter now specialized, are discussed and decided by the members of the mission as a whole, although the majority of them know almost nothing about the

86a: j The China Medical Journal.

Administration öf Mission Hospitals in China. $63

conduct of: any kind of hospital. Yet they insist upon legislating for the doctor, who probably is the only person there who has had any administrative, experience in hospitals. Should there be any failure of the medical work, complete or partial, it is usuallv charged to the doctor even when plans proposed by him have been, vetoed.

Another difficulty in the management of the “ One-man” hospital is that, in many instances at least, the doctor.tries personally to attend to all the details of the in-patient and out-patient departments, the kitchen, laboratory, and the house-keeping. Some of these duties must be handed over to others; if not, the doctor bccomes a wreck (and the break-down is usually blamed on the climate).

What is the solution of these difficulties ? The following suggestions are offered :

1 . Have the Home Board appoint two members of the mission to act with the doctor in charge; these to co-opt two others 011 the field, one a business man interested in hospital work, and the other a leading, interested Chinese. These five should constitute the Committee of Control. They should keep full minutes of all their meetings and these minutes should be presented as information to the mission as a whole. Any policy or action of the Committee of Control which the mission considers unwise may be referred to the Home Board for final decision by a three-fourths vote of the whole body. Both the Committee and the mission should furnish each other with copies of all correspondence. This Committee should elect a chairman, a treasurer and a secretary (the doctor in charge should be secretary), and it should meet regular^’ . Special meetings may be called by the Chairman of the Committee and one other member. As a general principle, no staff member should be on such a committee; but where there is only one foreign doctor on the staff I think an exception to this rule should be made, but tinder no other condition.

This committee should concern itself with general policies and such details as are referred to. it by the doctor in charge, and it should have, the right to a full explanation of any action taken by him. It should deal directly with the Home Board, not through the mission.


2. Employ a Chinese to act as accountant and assistant manager. Turn details over to him such as running of the kitchen and laundry, attending to the coolie staff, admission of patients, and collection of bills. The doctor in charge should give him a definite time each day to report and to get further instructions.

The subjects of nursing, laboratory work, and clinical assistants are to be considered in another paper, so will not be mentioned here.

T h e H o s p it a l w it h t w o P h y s i c i a n s .

The second class, or the “ Two-man5' hospital, seems to me to present the greatest difficulty. When medical men cross the ocean and arrive in China some subtle change seems to have taken place which makes them unwilling to work under anyone else. That we should begin w^ork in a subordinate capacity is taken for granted at home; but as soon as we land here, we consider ourselves much better fitted to manage things than those who were here before us in spite of the great difference of conditions at home and in China. Wre immediately begin to choose and pick the things wThich we are willing to do, and those we are willing the other fellow should continue to do. We are quite ready to be the chief surgeon or the chief clinician, but we do not wish to be bothered with petty details. Or, on the other hand, the doctor who has been on the field before his co-w7orker arrives, is so domineering and set in his ways that he is entirely unwilling to listen to any suggestion of changes in the monotonous routine he has gotten into. He is unwilling to permit the new arrival to carry on his work according to the standards of the well-regulated hospitals he has just left in the home land, or he assigns to the newcomer such duties and details as are unpleasant to himself and refuses him any individual choice. Both attitudes are wroug, and they may be the beginnings of the end of the usefulness of both men. The foreign nurse— for no hospital should ever have two doctors before it has a foreign nurse— is seldom a help in a difficulty of this kind. Either she swears b}?-, or at, the doctor already on the field. I f she sides with him, the new arrival will have both of them to contend with. I f against him, she will side with the new arrival in almost anything he may propose.

Again, what is the solution ?

1 . I suggest the formation of a Hospital Committee of five, three of whom should be appointed by the Home Board from the mission body. These three should choose two others who are not members of the mission. The latter ma}r be both Chinese; or one may be Chinese and the other a foreign business m an; or one may be Chinese and the other a doctor of another mission. No member of the hospital staff should be a member of this committee. The control of the hospital and its staff should be in the hands of this Committee, and its relation to the mission and Home Board should be as stated under the first group. The duties of each member of the staff should be carefully and definitely indicated, and the Committee should see to it that each adheres strictly to such a division. On this division, and its maintenance depends the success or failure of the scheme. Some one on the staff should be designated as being in charge, so that minor questions not otherwise covered can be referred to him. In all circumstances there must be a head or chief authority.

2 . A s in the “ One-man” hospital, there should be a Chinese accountant and assistant manager, whose duties should be the same as mentioned above. He should report daily at a definite time to the person in charge and receive instructions.

T h e H o s p it a l w it h m o r e t h a n t w o P h y s i c i a n s .

The third class seems to me to lend itself very well to an unmodified application of the principles found most acceptable at home, provided we are willing to accept them. Here again comes the bogey of one man being elevated above another, or of being subject to the authority of another. That some individual must have authority is, I think, inevitable in any sound organization, be it ever so democratic; and authority given means that others are subject to it. This authority may be derived from the very persons over whom it is exercised, nevertheless it exists and must be respected. I f modification of home methods is desired or thought necessary, may I suggest for this group an outline of the scheme now in use at St. Luke’ s Hospital, Shanghai? Our Bishop is the linal authority on the field. He appoints annuall}’ four members

the hospital staff, one of whom is designated as Chairman, ihese four, together with the superintendent who is secretary with equal power, constitute the Hospital Council. The duties of this Council are :

Administration of Mission Hospitals in China. 865

866 The China M edical Journal.

1 . — Control of the internal management of the hospital.'

2 .—Nomination of all permanent staff members and chiefs of service for approval of the Bishop.

3.— It recommends to the Bishop any change in policy or any plans for the disposal or purchase of property.

4 .— It fixes Lhe duties and powers of the superintendent and other officers.

The activities of the hospital are divided into administrative, religious and social service, and the clinical care of patients. Administrative activities, of course, are under the direction of the superintendent and include laundiy, stores, house-keeping, accounts, mechanical department, kitchen repairs, etc. The social and religious activities are under the direction of a committee appointed by the Council, the Chairman of which is the hospital chaplain. The clinical activities of the hospital are under the direction of a clinical committee which is composed of the Chiefs of the following services : surgical, medical, laboratory, and nursing. The superintendent is a member ex officio and acts as secretary^.

It seems to me that the questions to be answered regarding the administration of mission hospitals are as follows :

1 . — Do mission hospitals need a definite form of organization?

2 .— Do they realh' want any organization based on home standards ?

3.— In matters of hospital administration, are members of the hospital staff willing to give up their much cherished and jealously guarded prerogatives of equality? For sound organiz'afion surely meaus that.

4.— How should hospitals be classified with regard to organization ?

5 .— Is there any standardised scheme or organization which could be made practicable for each class.?'

Current 'Medicài Literat tire'. S.67

Current ADeMcaf literatu re .

V A C C IN E T R E A T M E N T OF TU BER CU LO SIS B Y A N E W M ETH OD.

E d i t o r i a l , B rit. M ed. Jotir., June 23, 1923,

As to the efficacy of vaccines in the treatment of bacterial infections there have been many opinions, but there must be few who hâve not felt some degree of disappointment a t ‘the slow and limited progress which has followed the classical researches of Pasteur and of Koch. The methods described by Professor Dreyer (Brit. Med. Jour., June 23, 19 2 3 J aim at the removal of one difficulty, and probably an important difficulty, in the production of active immunity.

If antibodies are to be produced it is essential that the antigen should come into intimate contact with the cells of the body of the patient. Dre^^er assumes that the absorption of bacterial antigens is hindered bj' the fatt\r envelope.by which the bod\'of certain classes of micro-organism is surrounded. This fatty envelope is intimateh7 associated with the staining properties of those bacteria which we designate “ acid-fast” or “ Gram-positive'*. It is for this reason that antibod3' formation has been more readily evoked by the injection of Gram-negative bacteria, and that comparatively little success has been obtained by the inoculation of emulsions of acid-fast or Gram-positive varieties.

The essential feature of the investigation lies in the separation of the more soluble constituents of the bodies of bacteria from the relatively insoluble fatty and lipoid substances which form the bacterial envelope. The greater part of the experimental data is concerned with the tubercle bacillus, and the methods employed in the case of this micro-organism are described in detail. Tubercle bacilli obtained from a glycerin broth culture are treated in the way outlined, and eventualh* a product is obtained which is entirely non-acid-fast and is described as a “ defatted antigen” . In the case of Gram-positive bacteria, such as staphylococci and the anthrax bacillus, the object of the method is to obtain a production which has lost the property of retaining t.he stain b}- Gram ’ s method.

The defatted antigens are either suspended in saline and used for the production of active immunity by injection, or digested with tn^psin for the preparation of a reagent suitable for use in precipitation or .complement fixation experiments. Rabbits injected with the defatted. products of the tubercle , bacilli developed antibodies which could be demonstrated, by .precipitation, complement; fixation,

80S The China Medical Journal.

and agglutination experiments. Thé published experiments show that animals injected with defatted antigen produce a serum which reacts not only with the defatted antigen but also with a recognized antigen of the usual type prepared from tubercle bacilli. For this purpose Boquet’ s and Nègre’ s antigen was chosen. On the other hand, the defatted antigen reacted in vitro not only with the serum of animals which had been injected with this defatted antigen, but also with serum of animals which had been injected with an ordinary emulsion of living tubercle bacilli. Suitable control experiments, in which normal serum and immune serums other than antituberculous serum were employed, were of course made. These experiments showed that the defatted antigen was specific, and could be used with success for the production in experimental animals of antibodies to the tubercle bacilli. Moreover, the antigen after treatment with trypsin proved to be a verj- useful reagent for the detection of antibodies in the blood of tuberculous animals. Apart from the all-important therapeutic possibilities of this new preparation, it seems probable that a significant step has been made towards obtaining a trustworthy serum test for tuberculous disease. It is worthy of note that, while well-marked serum reactions took place in mixtures of the antigen, both with the serum of animals injected with this antigen and with the serum of animals injected with living tubercle bacilli, the most pronounced reactions were obtained with the serum of animals which had been injected with living tubercle bacilli and were subsequently given doses of the defatted antigen.

The most interesting and at the same time most important of the experiments are those which related to the treatment of tuberculous guinea-pigs with defatted antigen. Fu ll details are given of experiments on four guinea-pigs. These animals were infected with a strain of living tubercle bacilli. The culture which was used is, on the whole, of slight virulence, and has usually produced death in four to ten months after infection. In the first experiment described, treatment was commenced twenty eight weeks after infection. The animal then weighed 630 grams, some 200 grams less than the average weight for its age. The spleen was large, and could easily be felt, and there were three or four enlarged glands in the inguinal region. Treatment consisted in the injections of defatted antigen at intervals varying irom three to thirteen days. The w-hole treatment occupied eighteen weeks. Two weeks after the cessation of treatment the animal looked perfectly healthy, and was of normal weight for its age (906 grams). A s a result of treatment the animal gained 300 grams in twenty weeks. The spleeji and glands seemed smaller. In two- other animals satistactory results were obtained. In the fourt‘1 animal considerable improvement was observed as the result or treatment, but the animal died shortly after the birth of young.

Current Medical Literature. 869

The histological appearances of the organs of this animal presented an appearance of anaemic necrosis with fibrosis.

Encouraging results were also obtained by the treatment of tuberculous rabbits with the defatted antigen. Professor Dreyer is careful to point out that only time can show whether this beneficial effect is permanent, and that to attain certainty it will be necessary to watch the animals for a long period without further treatment, and then kill them and make a search for tuberculous lesions in their organs. Nevertheless, the results obtained are very striking. The susceptibility of the guinea-pig to the tubercle bacillus is well known, and the results already obtained are sufficient to justify considerable confidence in the value of the method.

As regards the treatment of human disease, a beginning has been made. A few cases have been treated at the Brompton Hospital, and 60 cases are under treatment at the London Hospital; the interim report on these cases by Drs. Fildes and Western is quoted in full by Professer Dreyer in his article. Thej7 have observed in nearly all cases improvement which, in their opinion, is of an order which exceeds obviously that obtainable by any other form of treatment applicable Lo these conditions. It is, of course, too soon to attempt to express any judgment on the results obtained on human cases of tuberculosis, but the experiments carried out on animals justify us in entertaining great hope of the efficacy of this method, and we shall look forward with the greatest possible interest to the full report of the first batch of cases treated.

The possibility of a cure for tuberculosis which is contained in Dreyer’ s work is of such outstanding importance that we have given little space to the consideration of the results obtained with other bacteria. But from a theoretical, and eventually perhaps from a practical standpoint also, the most interesting observations are those concerned with the anthrax bacillus. Pasteur had succeeded in attenuating the virulence of this micro-organism by growing cultures at 420 C. Dreyer has shown that when grown at this high temperature the anthrax bacillus loses its capacity to retain the stain by Gram’ s method. Moreover, by suitable experiments Dreyer has demonstrated that bacteria from cultures grown at 420 C. are more readily killed by both normal and anti-anthrax serum than bacteria from cultures grown at 370 C. The attenuation of virulence produced by growth at the higher temperature is thus associated with, and presumably directly caused, by the loss of the fatty envelope. In this experiment may lie an explanation of such success as has been hitherto achieved by the vaccine treatment of bacterial infections. To many people it has seemed remarkable that a patient grievously ill from the presence of millions of microorganisms in his tissues should be expected to benefit from the subcutaneous injection of a few millions of the same micro-organism


grown on an agar slope.; Dreyer has shown that the Staphylococcus aureus and the anthrax bacillus grown on. artificial media have more resistance and a thicker envelope of fat when grown at 370 C. than at 420 C. It is possible that micro-organisms, when, actively pathogenic in the human tissues, ma}' have envelopes thicker still, and so possess still greater powers of resisting anti-bacterial substances than micro-organisms growing on artificial . culture media even under the most favorable, conditions which we can contrive. The favorable effect of the injection, of a vaccine seems to be due to its providing the tissues of the patient with microorganisms which are more easily soluble, and hence of higher antigenic value, than those already present in his tissues.

It is difficult to summarize the result of Professor Dre3-er’s experiments, and it is impossible to forecast the effect they may have on the further development of methods for the diagnosis and treatment of infectious disease. But putting the matter at the lowest, he has. made an important contribution to our knowledge of bacterial immunity, and has, devised methods by which it may be obtained where hitherto .it has been unobtainable. It is the orginality of the methods employed and the nature of the results he has obtained which invest his communication with such great interest. It must be regarded, as we feel sure he would wish to have it regarded, as a preliminary communication. The experiments on animals are few, and the time during which these animals have been observed, having regard to the importance of the issue, is short. From the ftill details published it is clear that every effort has been made to avoid experimental error and the mistake of drawing premature conclusions which the facts so fa4> established do not warrant.

It is onh7 a tribute to the value and importance of Professor Dreyer’ s experiments and observations to say that we shall await their confirmation and extension with the liveliest interest. The results already obtained are few, but they are in themselves of .the greatest importance and sufficient to justify the fullest possible investigation of .methods w'hich have been emplo37ed with such striking success. It is evident that the investigation now reported is a milestone on the path of progress towards the cure of bacterial disease.

The Medical Research Council has issued the fo llow ing statement as to the value of the foregoing method of .treatment : ‘ ‘ Whenit had been shown by experiment that sma.ll animals, highly susceptible to tuberculosis, when infected with, tubercle bacilli w ere improved, or lost the signs of active disease after ihe ;use of Pro-: jfessor D reyer’ s new antigen or vàccinej arrangement^-; ere .made

Current Medical L iterature.

for trials of this treatment under suitable control at three hospitals in London. The results which have been obtained hitherto have been favorable almost-without exception. Upon the results, highly promising as they now seem to be, which have been obtained in cases of tuberculosis of the lungs or of other internal organs, no final opinion can be passed until a longer period has-elapsed-.- In cases of tuberculous disease -of the glands and of the skin it can be said already that the results of this treatment have surpassed any known to -have been attained regularh7 by other methods.- E n couraging results have also :been gained in the treatment of infections like those in puerperal fever and other septic conditions. There is good ground therefore for hope that a very important advance in the curative treatment of tuberculosis and of some other diseases has been made.”

T R E A T M E N T OF CHRONIC M A L A R IA

D i x s o n , Brit. M ed. J o . u r June 30th, 1923.

For man}- years Dixson has treated malaria on the principle that there should be, with the quinine, a more or less continuous coincident administration of an aperient, preferably calomel-. In detail his method is as follows :

1 . Give a small dose of calomel at once, one grain, perhaps repeated in an hour or so; this single dose is to be administered each night at bedtime. The pill form is to be preferred as less liable than that of a powder to cause mercurialism in the mouth. This should be followed early next morning by a saline aperient. T his will help release of bile into the duodenum and by itsantiseptic and aperient action without irritation cleanse thebowels. The continual administration of calomel, in doses insufficient to risk distinct mercurialization, is to his mind extremely important; indeed he thinks it is essential, though in certain circumstances a stronger dosage for the purpose of thinning the thickened bile might be desirable. The rapidity, however, withwhich the calomel aids quinine indicates a local gastro-intestinalaction rather than one due to absorption.

2. Give the quinine in 3 or 4 grain doses according to the size and strength of the (adult) patient, as a p ill; the small dose and form avoid irritation of the. stomach.

3 . ’ Give the hydrochloride; this is in order to secure rapid absorption with minimum of gastric irritation.

: 4.. Give the doses an hour or more before meals, and atbedtime; this is in order to secure rapid absorption-


5. Give with each dose 3 or 4 ounces of water; the amount of fluid by diluting the quinine freely, prevents disturbance of the stomach and encourages rapid removal from it.

6. Continue the treatment for two months.

CARBON T E T R A C H L O R ID E W IT H OIL OP CHENOPODIUJVT IN H E L M IN T H IA S IS .

Reed, Brit. M ed. Journ., June 23, 1923.

In the General Hospital, Kuching, Borneo, after trying various combinations the following standard treatment was given to adults : one ounce of castor oil is given at night, and the next morning a mixture containing 1 drachm of carbon tetrachloride, 1 c. cm. of oil of chenopodium, and half oz. of liquid paraffin. As a rule the faeces are examined again a week to ten days after treatment and if necessary the treatment is repeated. The immediate effect on the patient does not seem to be any more marked when the mixture is used than when the carbon tetrachloride is given alone. Almost all the patients complain of feeling drunk for a time varying from a few minutes to a day. As a rule, three or four motions are produced in the twent37-four hours following the treatment, and these often contain numerous wrorms (ascaris). Occasionally slight vomiting, headache, or pain in the abdomen occurs.

The treatment has been given to Chinese, D yaks, Tam ils, and one Japanese, and the series of 84 cases contains one European and one Chinese schoolboy who were not in the General Hospital. A lmost all the Ltyaks examined have been found to harbour ascarides, and a large percentage hookworms also. In spite of this fact, almost all the very heavily infected cases, exhibiting extreme anaemia, oedema, and debility, occur in Chinese, and no death from ankylostomiasis can be recollected among the D yaks at the General Hospital. The Chinese also appear to be somewhat more resistant to treatment. The results as regards actual clinical improvement among the heavily infected Chinese have been somewhat disappointing. In several the stools have been reported free from ova after treatment, and the patient has left the hospital without oedema and feeling much stronger, though probably with still a high degree of anaemia; onhT to return shortly afterwards with oedema again, the faeces still showing no ova. In many cases a weekly haemoglobin test by the Tallqvist method was made, but few showed a rapid or extensive rise. Many cases of this nature were heavy opium smokers.

Current Medical Literature. 873

All cases were given Mistura ferri arsenicali«, and many showed an immediate, rapid, and apparently permanent improvement, in contrast to the type of case mentioned above.

ORAL A D M IN ISTR AT IO N OF V A C C IN E S IN E N TER IC A N D O TH E R IN T E S T IN A L IN FECTIO N S.

P i r i e a n d O r e n s t e i n , Med. Jotir. South Africa, April, 1923.

The authors discuss the subject of the administration of vaccine by the mouth in affections of, or diseases acquired through the alimentary tract. They regard it as reasonably certain that protection against such diseases can be successfully obtained bv this route. In support of this contention Besredka is quoted as holding the view that in typhoid fever and dysentery immunity is the peculiar property of the cells of the intestinal mucosa, and that any immune bodies found in the blood are accidental, not essential, and merely evidence that infection has occurred. Besredka also maintains that the value of subcutaneous protective inoculation is solely due to its action on the intestinal mucosa. Further, Nicolle and Conseil, working on volunteer subjects, are cited as having demonstrated the success of the oral administration of vaccine in experimentally produced bacillary dysentery and Malta fever. It is contended that like results could be obtained in tj^phoid, paratyphoid, and cholera. Attention is drawn to the absence of any appreciable agglutinin formation in the cases of these observers, who also found it impossible to infect native Tunisians with dysentery, probably owing to immunity acquired through the frequent drinking of infected water, and the authors advise imitating nature in this respect by administering frequent small doses of vaccine. A s evidence of the value of oral vaccination the authors publish an account of an epidemic of enteric fever occurring among natives in a gold mine in which the method was tested. Seven strains of B . typhosus wTere employed in the preparation of the vaccine, which was administered in liquid form on three successive days in doses of 40 million in conjunction with 3 grain keratin- coated oxbile pills. Although the treatment was commenced a little later than half-way through the epidemic, which might possibly have already commenced to decline, nevertheless the course of events subsequent to its inception was such that the authors feel justified in presuming its efficiency. Twenty cases were admitted to hospital after vaccination had been initiated; of these sixteen had been vaccinated and four not. Among the sixteen vaccinated the mortality was five ; among the unvaccinated it was three. It is thought probable that the former were in the stage of incubation when vaccinated, as the fatal cases among them died on the second, fourth, sixth, twelfth, and eighteenth days after admission. It should also be noted that of 3,600 natives in the camp 1,500 received two doses only of vaccine.

8.74 The China. Medical Journal.

P R O P H Y L A X IS OF TU BER CU LO SIS IN T H E N E W B O R N .Debre, G yn. et Obstet., 1923, V II : 199

The author remarks that the child of a tuberculous mother is usually healthy-at birth, and that the hereditary dystrophy which has been described in. such infants is almost invariably due to an early overlooked post-natal infection. The occasional presence of tubercle bacilli in the milk of tuberculous mothers is of little importance, but the possibility of the infant inhaling or ingesting particles containing virulent bacilli coughed or spat up by the mother is fraught with much danger. Five cases are related in which an infant, succumbed to tuberculosis from one to five months after birth in spite of having been totally separated from the mother after her discharge from the lying-m-home. Debre advocates absolute separation of the tuberculous mother from her infant; in conjunction with L . Bernard and Couvelarie arrangements have been made in certain Paris prenatal clinics for the preparation of tuberculous pregnant women for this drastic step, and some infants are ultimately “ boarded out ” in families other than their own.

CAN CER OF T H E B R E A ST.T i x i e r , L y o n Chtrurgical, November-December, 1922.

T ixier has investigated the results of the surgical treatment of cancer of the breast from the years 1902 to 19 14 . He operated upon 2 1 1 cases in this period; of these, 57 cases were living six vears after operation; 68 died within two years. Three factors are of importance in considering the prognosis of cancer of the breast : (1) Age of' the patient. Under 50 years of age only 30 per cent of cases lived more than six years ; between 50 and 55 years of age 43 per cent of cases survived more than six years. (2) The presence of ulceration at the time of operation. This is a feature of great gravity ; out of 14 patients where the growth had ulcerated through the skin 1 1 died during the first two years. (3) The date of operation after the appearance of the tumour; this is, of course, open to mistakes on the part of the patient. Where the growth had been discovered for less than a year 23 cases out of 70 were alive after six years. The author points out that patients who come to the surgeon within the first year are often affected with a rapidly growing cancer, and the presence of pain draw's their attention to it. These are operated upon relatively early owing to the malignancy of the tumour; in view of this the percentage of recoveries may be low. At the operation he removes a large area of skin, and the pectoral muscles and overlying fascia. A careful dissection is made of the fatty tissue in the apex of the axilla, and stress is laid on the removal of a gland lying under the clavicle on the axillary vein. H e has used radium in a number of cases both

Current Medical. Literature, «75

before and,-after -operation. In cases of recurrence lie. lias seen no cures following radium. It is, lie says, impossible to make a prognosis from microscopic., examination of the tumour after removal.

O P E R A Í1 Y E T R E A T M E N T OF C ER TA IN FR AC TU R ES OF LONG BONES.

M o o r h e a d , Jour. Am cr. Med. Assoc., April, 1 9 2 3 .

The principie of “ notching” has been employed in a series.of cases of fractures, and success by this procedure lias been very gratifying. The time to operate, says the author, is within the first thirty-six hours; if possible, the earlier the better, if there are none of the usual operative contraindictions. The fragments a-re notched by a rongeur, chisel, saw, or “ bone notclier” . The advantages claimed for this method are (a) More accurate coaptation means firmer, earlier union in more exact alignment, (b) With the assurance that definite. coaptation has been obtained, there is less danger of the interposition of soft or hard parts which would prevent or impede union, (c) Primar}- neural or vascular damage is more readily discovered and corrected ; secondary neural or vascular damage from pressure or callus inclusion is very unlikeh’ . The disadvantages given are : (a) Fractures are put into the operative class, with the. attendant risks, (b) The method is needlessly severe and dangerous, since good results have heretofore been obtained by simpler methods, (c) It is inapplicable for general use. (d) It produces shortening; this, however, is usually slight and of no importance. The method is stated to be particularly adapted to recently displaced or old malunited fractures of the shaft of the radius, ulna, tibia, and humerus, in the order named.

R A R IT Y OF APPE N D ICITIS AMONG T H E C H IN E SE.W eisc h e r , Zcntralbl. /; Chir., June 2, 1923.

Weischer quotes the words of Professor Perthes : “ The factthat the question of appendicitis does not arise in China arouses the suspicion that it is connected with diet,” and reports his own experience in confirmation of this. The author was attached to the polyclinic for Chinese at the Catholic Mission Hospital at Tsingtau from 19.15 till 1923, during which time there were 86,000 admissions, almost entirely .from the poorest classes. Only two cases of appendicitis occurred, and these chronic. In one of these, a man of 28, the lumen of the diseased appendix contained Trichocephalus dispar. The other case was that of a Chinese woman of 29, who, as sister of an order, had lived for many years on a European diet. In this case there were two faecal concretions in the appendix, and numerous adhesions about the caecum.,


IRREGULAR PRACTITIONERS IN CANTON.

The Canton D aily News-with laudable public spirit is opposing the irregular practitioners of medicine in Canton. “ There is a requirement at present under the regulations of the Municipal Health and Sanitation Department which calls for the registration of all doctors practising medicine in Canton. This measure is a verj salutary and wise one in view of the many quacks and irresponsible deceivers who carry on the business to the jeopardy of the lives of so many people.

“ Naturally a wave of opposition arose, but this soon subsided in the face of public opinion. Other methods have since then been employed to evade the requirement. False certificates, borrowed diplomas, and the like are brought in as evidence of qualification to practise. In the case of the foreign doctors unwilling to register, £a certain amount of defiance has been inevitably exhibited]

because they can always fall back on the “ treaty” idea to cover a multitude of sins. We understand this latter question is still under discussion. As far as we know there is nothing under the treaty that can be construed to preclude our Municipality from having jurisdiction over persons among our people. We can least afford to wink at foreign quacks practising freely in our midst and among our people while we hound down all Chinese quacks mercilessly.

‘ f In this connexion we are glad to note many quacks taking down their signboards and closing up their business. And it is an encouraging sign to note that the private citizens are lending their assistance heartily to the authorities by supplying them with the necessary information.

‘ ‘ W ith the suppression of so many quacks a new responsibilit}' arises, namely, to provide adequate medical facilities to meet the demands for treatment. To this end, there should be established immediately Government out-door dispensaries where, for a nominal fee, medical attendance and medicine may be supplied to the people. The service can be made to pay for itself almost from the start. We look forward to this step with deep interest.” -

Tuberculosis in Hongkong. S 77

TUBERCULOSIS IN HONGKONG.

In the annual report issued by the Alice Memorial Hospital in Hongkong some interesting notes occur. It points out that in Hongkong the number of Chinese availing themselves of Western methods of treatment has greatly increased in recent years and the time has now come to initiate a scheme for the efficient treatment of tuberculosis, m the interest of the patient, his relatives, and the community.

A Sanitorium in the country within convenient distance of railway or motor-bus for the treatment of early cases and also a home for advanced cases are urgent needs. There are other aspects of the problem which might be dwelt on, but meantime if something can be done on the lines suggested a step forward will have been taken.

It may be argued that patients would not use a special institution, but experience has proved that when the Chinese have had the benefits of Western methods demonstrated to them they realize that their prejudices were ill-founded and they become advocates of treatment which they at first opposed through ignorance. As an illustration it may be mentioned that when the Alice Maternity Hospital was opened a prominent Chinese gentleman stated that he thought the building was too large, but in a few years all the accommodation was required and recently similar institutions have been opened in W'anchai and Saiyingpun Districts b}r the Chinese Public Dispensaries.

PEKING UNION MEDICAL COLLEGE: DEPARTMENT OF OPHTHALMOLOGY.

The Department of Ophthalmology of the Peking Union Medicai College will be glad to receive any pathological specimen of the eye or its appendages for pathological diagnosis.

A pathological report, and upon request, a stained section of the material, will be returned to the sender on completion of the examination. A brief history of the case, with name and age of the patient, should accompany each specimen. The specimens should be fixed in Muller’s fluid as soon as excised, and mailed to the Department in a wride-mouthed container, immersed in the Muller’ s fluid and tightly corked.


Book IRevnews.

A System o f Surgery:— Edited by C. C Choyce. Second edition. Three Volumes with 50 Illustrations in colour, 98 half-tone plates, and gin figures in the text. Price £6 net. Publishers : Cassell & Co., London.The second edition of this invaluable work was arranged for in 1914

but has been delayed by the years of war and of subsequent disturbance. The many advances in surgery have necessitated an expansion to the extent of about 300 pages. Several of the sections have been entirely rewritten and all the rest have been so thoroughly reviewed that it is practically a new work.

As many readers of the China Medical Journal already know, the editor, Mr. Choyce, is the Director of the Surgical Unit at University College Hospital Medical School. A number of the contributors are also on the staff of this School while others represent most of the great teaching centres of Great Britain and (in one case) France. The value of the articles is at once evident on mention of such names as Leon Calmette, Georges Dreyer, Hey Groves, Sampson Handley, Alexander Miles and Wilfred Trotter among many others.

This work, as it stands, may be looked upon as the most up-to-date presentation of the British surgery of to-day. Too full, perhaps, for those engaged chiefly in general practice, it is indispensable to anyone who is seriously occupied with the teaching or the practice of Surgery. C. C. E.

Endocrine Diseases: i n c l u d i n g t h e i r D i a g n o s i s a n d T r e a t m e n t . By Professor Wilhelm Falta, Vienna. Translated and edited by Milton K. Meyers, M.D., Philadelphia, U.S.A. With a foreword by Sir Archibald E. Garrod, K. C. M. G., M.D., (Oxon), F. R. C. P. (London),F. R. S. Third Edition with supplementary notes by the Editor. 104 Illustrations in the Text. Price G. $8.50. Publishers : P. Blakislon’sSon & Co., 1012 Walnut Street, Philadelphia.A volume of which the author is an Austrian, the translator and editor

an American, and the writer of the foreword an Englishman, may almost be regarded as an international production and therefore more than ordinarily authoritative. Pronouncements of this kind are needed for within the last few years there has been much speculative writing concerning the functions of the ductless glands. In this volume, which confines itself to the clinical aspects of the diseases of these glands, though we are on former ground there is still much that is plainly said to be uncertain. For instance, Professor Falta is a staunch upholder of the view that all the morbid symptoms which result from diseasestof the glands of internal secretion, so far as they can be ascribed to their secretory functions, are attributable either to depression or exaltation of the function of the gland concerned. Others are unable to accept this interpretation, and hold that the maladies so often ascribed to excessive functional activity are rather due to perversion of function and the production by the gland of an abnormal secretion. Further, there are problems connected with the interaction of the various secretions, and the inter-relation of the endocrine glands and the nervous system, which are still unsolved. Nevertheless, much progress has been made. In this work the maladies of the hormonopoietic system are for ttut first time discussed in a single volume and from the clinical standpoint.

After an illuminating introduction the diseases of the thyroid are considered. As to the etiology of Basedow’s disease it is said we do not know anything definite and there is no specific method of treatment. Surgical treatment in general surpasses the medical, and in an addendum the editor discusses the whole subject very instructively. In the chapter 01;

Book Reviews. S79

the parathyroids it is held that tetany depends 011 the insufficient functioning of these glands ; but in regard to treatment it is said that 110 decisive results are obtained by the administration or subcutaneous employment of dried parathyroid gland or of extracts of parathyroids. “ Neither stomachal, nor subcutaneous, nor intraperitoneal administration of parathyroid extract in large doses served to influence in any way parathyroprivic tetany.” “Again, the feeding of very large amount of the extracts of the parathyroids of horses remained without results in human beings.” Against this is recent experience of the unquestionable benefit derived in cases of sprue from the administration of parathyroid extract combined with calcium lactate. Passing over valuable chapters on the diseases of various glands to diseases of the sexual glands, the author states that the drug therapy of glandular insufficiency has as yet had in man no decisive results ; but he thinks that the experiments on transplantation of the sexual glands are very promising. Reference is made to the case reported by Halliday-Crom, in which amenorrhoea had set in after labor and symptoms of the absence developed. The small cystic ovaries were removed and a foreign ovary implanted. The woman again menstruated four months after the operation, and four years after the operation she again conceived and bore a normal child. “ There is indeed in this case no doubt that, if there has been no error of observation, this woman bore the child of another woman. Serious objections might be raised against such procedures on ethical and forensic grounds.”

The whole work is extremely interesting and, as Sir Archibald E. Garrod says in his foreword, it is all the more valuable because it is the work of a physician who combines bedside observation with experimental research in the laboratory. The illustrations are numerous and good.

Diagnostic M ethods:— Chemical, Bacteriological, and Microscopical. AText-book for Students and Practitioners. By Ralph W. Webster, M.D.,Ph. D. Seventh Edition, Revised and Enlarged. With 37 Colored platesand 172 other illustrations. Price G. $8.00. Publishers : P. Blakiston’sSon & Co. 1012 Walnut Street, Philadelphia.In the present work the author has brought together for the use of

students and practitioners, the generally accepted facts regarding the various phases of clinical medicine which may be studied by the use of laboratory methods though it is strongly advised this should always be done in conjunction with direct clinical examination. In this edition—the seventh— much new material has been added. By far the strongest chapters in the book are those on the urine (224 pages) incorporating the latest methods of Folin and his collaborators; on the blood (360 pages), transudates and exudates, including such procedures as Van Slyk e’s method of determining oxygen capacity and hemoglobin content of blood ; Stadie’s method for methemoglobin in blood ; Van Slyke and Silverson’s method for carbon monoxid in blood ; Benedict’s new method for uric acid in blood ; Tisdall’s method for inorganic phosphates in blood; Kramer and Tisdall’s method for calcium in blood; Whitehorn’s method for chlorids in blood; Kohner’s Standardized Quantitative Wassermann Test ; Warthin and Starry’s method for spironemata in tissue; Noguchi’s new method for proteins in cerebrospinal fluid; Colloidal Benzoin Test of Guillain, Laroche and Lechelle.

The chapter on the intestinal parasites so far as it relates to those which are common in tropical and sub-tropical countries, needs to be added to here and there. Apart from this, the work is thoroughly up-to-date and the numerous bibliographic references on almost every page will greatly help the research worker. The 37 colored plates and other illustrations are very useful. The volume is excellent for its purpose.

S8o The China Medical Journal.

Diseases o f the Rectum and Colon and their Surgical Treatment.—By P. Lockhart-Mummery, F.R.C.S., (Eng), M .A., M.B., B.C., (Cantab).Senior Surgeon to St. Mark’s Hospital, London. Price 25/- net.Publishers : Bailliere, Tindall and Cox. 8 Henrietta Street, CoventGarden, London, 1923.During the last twenty years, as the author states in the preface, great

changes have taken place in surgery generally, and more particularly in that special branch of surgery dealing with diseases of the rectum and colon. Before this period operations upon the large bowel were considered necessarily dirty, and aseptic healing was not even expected. To-day all that is changed, and the modern rectal surgeon expects to operate on clean tissues and to obtain aseptic healing. It is well this progress has been made for diseases of the large bowel are assuming increased importance, due largely to the fact that they are becoming more common. “ This is probably to be attributed more to modern methods of dietary than to any other factor. Among uncivilized races of mankind the alimentary system has to digest and deal with food in which digestible and indigestible materials are about equally mixed. But under our present high state of civilization, foods, both animal and vegetable, are specially grown. The animals which supply our meat are specially bred and cared for to render the meat free from gristle, and the vegetables are cultivated to contain but little cellulose, and are further prepared, especially in the case of bread, to reduce this ingredient to the very minimum. Under these conditions, to which must often be added a sedentary occupation, the normal stimuli to peristalsis and digestion are to a large extent absent.” In this connection a comparison of the diseases of the Chinese which can be fairly ascribed to dietary faults and deficiencies with diseases of similar origin in other countries, would be very interesting.

In the description of the diseases included in the volume, and the advice which is given for their treatment, both medical and surgical, there is constant evidence of the author’s great experience. The chapters on the common complaint of hemorrhoids, for instance, is very good. As to internal hemorrhoids he states that with but few exceptions no treatment other than operative will cure. “ Non-operative treatment will often relieve the symptoms, and, if persisted in, will sometimes keep the patient free from discomfort for a considerable tim e; but a cure of the condition by anything short of operation is only possible in a few exceptional cases.” Moreover, “ the operation for piles is one of the safest in surgery, and enables the patient to be cured in the space of ten days or a fortnight, s" there is no advantage in palliative treatment.” The various operations are fully and clearly described— divulsion of the sphincters, injection with carbolic acid, liigh-frequency electric currents, excision, the ligature operation, clamp and cautery, and Whitehead’s operation. All have given good results in certain cases. But the author’s own preference is for the ligature operation, and “ in cases where the after-treatment of the patient must be entrusted to those unaccustomed to rectal surgery, I should always prefer the ligature operation.” As to the severe after-pain which follows operation, the author says this can be prevented by applying the sairu- prineiples that have enabled surgeons to avoid pain resulting from operation wounds in other parts of the body. “ We have found that if a wound is made with no bruising or tearing of the tissues, under aseptic conditions through clean tissues, and is kept aseptic and at rest, pain, except of a very slight and transient character, does not result. The anal region is no exception to this rule, and, given the same conditions, after-pain will be equally absent from operations in this region.”

The other surgical diseases of this part of the body are dealt with in the same thorough, helpful manner. The work is written with admirable

Report of K uling Branch of C .M .M .A . SSi

lucidity. The illustrations are numerous and good; some of the plates are colored. We take pleasure in recommending the volume to all who are interested in rectal surgery.

British Jounal o f Anaesthesia.—This is a new quarterly medical periodical, the first number of which appeared last July. It is conducted by an editoral board of twelve anesthetists in various centers in Great Britain, and is edited by Dr. H. M. Cohen, anesthetist, vSt. Marys’s Hospital, Manchester. The annual subscription is £2. ($9.50). In the first issue, containing fifty-four pages, is an article by Drs. J. T. Gwathmey and E. P. Donovan of New York, dealing with painless childbirth by synergistic methods.

REPORT OF KULING BRANCH OF C.M.M.A.

This Association has just closed a very successful season of meetings during Ju ly and August, and numerous opportunities have been afforded to promote the constitutional aims of the Association, namely, “ the cultivation of Medical Mission work in all its aspects and the establishment of a brotherly bond of union between its members

The 1923 season was marked by three outside speakers who added fresh interest to discussions and who brought word of new developments in other places. These were Dr. Wang, Professor of Pathology at Hongkong University, Dr. W . R . Houston, Professor of Medicine at the Universit}" of Georgia, U .S .A ., and Dr. Reid Hunt, Professor of Pharmacology at the Harvard Medical School. Visitors of this type have much to give us at a place like Kuling because of their rich backgrounds and keen viewpoints on current problems.

Other speakers included Drs. Louise W Farnam, Changsha; Dr. R . M. Atwater, Changsha; Dr. C. T. Maitland, Tsm anfu; Dr. Henry Fowler, Shanghai; Dr. Mary James, Wuchang, and Dr. Andrew Graham of Ichang.

It is planned that for another season the Medical Hall will be put into better shape for the library and social uses of the members on the hill. It is hoped that any who have duplicate medical books of recent date will bring one copy to the L ibrary and an}- who will iend current journals for the use of the members will confer a great help on those who otherwise do not have access to these publications.


Officers for 1924 are as follows :President : Dr. Henry Fowler, Shanghai (re-elected).Vice-President : Dr. Agnes Murdock, Hwaiyuen, An.Treasurer : Dr. Owen Chapman, Hankow.Secretary : Dr. Reginald Atwater, Changsha.Trustees : Dr. W. B. Russell, Changchowkou.

Dr. C. K. Buswell, Ruling.Dr. W. B. Berst, Ruling.

W ITH THE EXECUTIVE SECRETARY

W ill members of the Association please make a note of the following : —

The Secretary’ s private address is 138 Dixwell Road, Shanghai, and his telephone number, North 4120 .

When not at the office —4 Quinsan Gardens— he can generally be found as above. The Secretary sincerely hopes that members will get in touch with him when passing through Shanghai. It may be noted that of the many puzzling roads in Shanghai, Dixwell Road is perhaps the worst. To reach 138 Dixwell Road take a Hongkew Park tram, alight at Dixwell Road on the right, follow this part of Dixwell Road and the first turn on the left leads to the Secretary’ s house.

Owing to faulty postal arrangements letters and papers are being delayed or lost in transit. A Post Office box has, therefore, been arranged for. Kindty address all papers or official communications to the Editor or Secretary :

P. O. Box, No. 1 1 2 1 ,Shanghai.

The Association has now a telegraphic address of its own. Address all telegrams :

Medmissan,Shanghai.

The Secretar}- would be grateful for copies of ail reports, papers and photographs relating to the Hospitals in China. He is very anxious to have details to hand for reference of all the Medical Mission work carried on in China.

Correspondence.

Corresponbence.

883

Correspondents are requested to write on one side of the paper only, and always to send their real names and addresses. The J o u r n a l does not hold itself responsible for the opinions or assertions of correspondents.

Ankylosis of the Elbow Joint.

To The Editor,

D e a r S i r :— With reference to D r. Tootell’s interesting article on the above subject in the August number of the Journal it may be worth while to record experiences during the great War with these cases.

The writer had occasion to perform a good many excisions of elbow joint during the War and used, where it was possible, the same operation described by Dr. Tootell. In almost every case, however, the operation was performed for the result of gunshot wounds which had all been more or less septic before operation, and in some cases the operation consisted in taking out splintered fragments of bone from the still septic joint. It may be said right away that, though of course we aimed at asepsis, we did not find that the end result of these septic cases was any worse than the clean ones ; in fact, the longer period under treatment was, in some cases, useful in ensuring that the patient kept up exercises— which were otherwise apt to be neglected as soon as comparatively slight movements were found possible.

Exact figures of the numbers of cases done and the results are, unfortunately, not available; but, amongst them all, the writer can only remember one patient who did not get at least sufficient movement of the new joint to enable him to feed himself and perform various kinds of work with more or less ease. In most cases there was very free movement. In the one case referred to the poor result can be fairly attributed to the patient’s absolute refusal to move his arm or have it moved so that the only course was to procure ankylosis in the best position.

The method of treatment was the same, so far as operation was concerned, as Dr. Tootell’s, but the after treatment varied in that the arm was moved freely from the first day after operation, every day or every time it was dressed until he could move it for himself, a feat which he was of course encouraged to perform at the earliest possible date. To facilitate this we used a splint which was found extremely satisfactory, easy to make, and easy to apply. It consisted of two cuffs of poroplastic which could be bandaged to the arm above and below the joint, the two being connected by an iron bar jointed at the elbow and held in any desired position as to flexion or extension by a butterfly nut which had to be placed exactly opposite the desired new joint in applying the splint. This bar was made with a shoulder at right angles with the poroplastic so that the main part of it was well out of the way of dressings and the splint did not have to be moved for changing them.

Description of one case will suffice to shew method used. A young sergeant arrived in hospital with his right arm perfectly straight, i.e., in full extension, with firm bony ankylosis in that positiou. Even the inter-phalangeal joints were stiff with fibrous ankylosis ! Just why the arm had been put into that position for a gunshot wound of the elbow and left there for so long was not stated. It was then some months from date of injury. E xcision of the joint was done and the arm put up on one of the splints described in less than right-angled flexion. The original wound was only lightly healed at the time of the operation and required daily dressings. From the first at each of these dressings the arm was flexed and extended freely, the metal joint rendering this almost entirely

S84 The China Medical Journal.

painless by steadying' the bones and preventing them from grating together (no attempt was made to cover the ends of the bones). After each dressing the arm was again fixed in the most useful position so that he could feed himself, which he did after the first few days. After a fortnight he could easily flex and extend the arm himself when the arm was placed horizontally, and in a month's time he was able to dispense with the splint having very fair movements which were increasing steadily when the writer last saw him.

During the last three years in Tainan, Formosa, we have done six ;

excisions of elbow, three of them being in hospital at the same time, and all of them for faulty union after fracture with resultant ankylosis. The splint was not used in these cases but movements were begun at once and in each case the result was satisfactory In three of them it was practically perfect.

The great difficulty seems to be to make the patients understand that success of the operation largely depends on their willingness to exercise after it.

Yours truly,P e r c y C h e a l .

Taiwan, Formosa. September, 1923.

NEWS AND COMMENT

B i r t h .

D a l e .— On July 18th, 1923, atThai-yong, near Wukingfu, to Dr. and Mrs. W. Chalmers Dale, of the English Presbyterian Mission, Shanghaug, a son (Henry Donald).

B r i t i s h M e d i c a l A s s o c i a t i o n a n d t h e C. M. M . A .— On July 25th, 1923, the Medical Prayer Union held what is hoped to be the first of a series of medical missionary breakfasts in cotmectkm with the Annual Meeting of the British Medical Association. A large number of guests were present. Greetings from the China Medical Missionary Association were conveyed by Dr.G. Duncan Whyte, who emphasized the satisfaction of medical work abroad, and ascribed it to the absence of any fear of competition, the ability to treat poor patients freely, and the opportunity of taking up any specialty with certainty of abundant material for investigation.

A t the Comitia of the Royal College of Physicians of London held on July 26th, 1923, among the candidates admitted to membership, was George Duncan Whyte, M. B. (Edin.), of Swatow.

I n t e r n a t i o n a l C o n g r e s s o f O p h t h a l m o l o g y (1925).— The Committee of British Ophthalmologists appointed to organize an International Congress in 1925 finds, with regret, that it is unable to do so in accordance with the conditions under which the British invitation was accepted b3r the Washington Oph- thalmological Congress in 1922. It will be remembered that at Washington it was decided that the next Congress should be strictly International and that German should be one of the official languages. The Committee has since been informed that the Société Française d’Ophtalmologie, the Société d’Ophtalmologie de Paris and the Société Belge d’Ophtalmologie have passed resolutions to the effect that they feel themselves unable to participate in a Congress if Germans are invited. The Committee is of opinion that to proceed with the Congress in these circumstances would tend to perpetuate a schism in the ranks of Ophthalmology and militate permanently against the progress of the Science which all desire to promote. The Committee has, therefore, reluctantly decided to postpone the Congress.

News and Comment. SS5

D u r a t i o n o f L i f e o f J a p a n e s e .— That the average life of a Japanese is as low as 30 years, while that of the European is nearly 50 years is a startling fact, according to a publication just issued by the Japanese Department of Home Affairs. The pamphlet has been compiled by the foremost professors of Japan by- order of the Government for the purpose of improving the sanitary conditions and the daily life generally of the Japanese. The work, which bears the title “ Primary Lessons in Hygienics ” , contains a lot of statistics and much useful information.

H o s p i t a l A c c o u n t a n c y .— There is no better check 011 extravagant administration in public institutions than comparison with those of a similar character. This is only possible, however, if there is a standard system of accountancy so that the figures are really made comparable. With a view to securing such a standard method of bookkeeping in tuberculosis institutions the Ministry of Health has issued a skeleton form of accounts (Form T. 90) the adoption of which will make it possible to ascertain the average weekly- cost of a patient not only to the whole of the services rendered but also under various subheads such as salaries, provisions, drugs, lighting, and fuel, laundry^ etc., Brit. M ed. Jour., July- 2, 1923.

T h e M i s s i o n a r y - h a u n t e d C h i n e s e G o v e r n o r . — Sir John Jordan, speaking at Wimbledon, in February, 1923, of tlie Opium trade and the steps taken to reduce that trade in the early years of this century, said: “ In 19 11, Great Britain was given the right to examine all tlie provinces of China to see if the terms of the Treaty (of 1906, reducing the opium trade by one-tentli each year) were being carried out. In this the missionary7 gave immense assistance. I can never pay enough tribute to the help these men gave us in China. But for the missionaries this work could never have

been carried out. I remember asking one of the governors over one of these provinces, ‘ How did you clear the province of opium ? How did you do it ? ’ His reply was ‘ What else could I do ? Whenever a blade of opium appeared in a field the missionary came and told me about it : I had to do it ! ’ ”

E y e d i s e a s e s in I n d o - C h in a .— In the French Ophthalmic Hospital, Hanoi, Tonkin, a centre of ophthalmic teaching in I n d o - C h in a , the most striking feature of the years 1917-20 is the very- high proportion of trachoma to other diseases treated. During this period 16,625 operations were performed, and, of these, 110 fewer than 13,576 were for trachoma and its complications, 5,922 being for entropion. I t is noticeable that, in spite of the prevalence of trachoma, only 7 cases of acute dacryocystitis were admitted during this period. 509 cases of senile cataract were admitted and 145 cases of glaucoma. Combined extraction was performed in the vast majority of cases of cataract.

C e r e b r o s p i n a l M e n i n g i t i s in F o r m o s a .— From March 21 to 31, T923, seventy-four cases of cerebrospinal meningitis, w-ith sixty^-three deaths, were reported in the island of Taiwan (Formosa), Japan. Thè total number of cases reported from January 1 to March 31, 1923, was 53S, with 269 deaths, in a population

3»835»8i 1.

T r a c h o m a i n A n n a m .— Trachoma furnishes 36 per cent, of the outpatients, 50 per cent, of the inpatients and 68 per cent, of the operations. It is in the schools that this disease can best be combated by (1) the inspection of the scholars ;(2) the grouping of the infected, and(3) the application of suitable treatment. The co-operation of the scholars, and especially of the monitors, is cultivated. Trachoma ranks very7 easily first in Annam as a cause of

I blindness.


TTbe Cbina flfoefctcal journalP u b lish e d by

The China Medical Missionary Association.E D IT O R — Edward M. Merrins, M.D.,

St. John’s University. Office address, 4 Quinsan Gardens, Shanghai. Medical papers and other literary communications for the Journal, books for review, and exchange medical journals, should be sent to the Editor.

E D IT O R IA L BO A RD .— Drs. R. C- Beebe, Shanghai; W. W. Cadbury, Canton; E. D. Congdon, Peking ; C. L . Davenport; Shanghai; H. E . Earle, H ongkong; H. J- Howard, Peking; J . L. Maxwell, Shanghai; A . W. Tucker, Shanghai; W ay Sung New, Shanghai.

T R E A S U R E R .— The Executive Secretary, Dr. Jam es L. Maxwell, is also Treasurer of the Association. Office address, 4 Quinsan Gardens, Shanghai. A ll payments, whether subscriptions to the Journal, payments for advertisements, or Association dues, should be sent to him. Checks should be made payable to the China Medical Missionary Association and the amount stated in dollars, Shanghai currency.

R E C O R D IN G S E C R E T A R Y .— H. H. Morris, M.D., 24 Minghong Koad, Shanghai. Members of the Association should inform him of change of address and state whether change is temporary or permanent.

M E M BE R S A N D S U B S C R IB E R S .— Active members of the C.M.M.A., who have paid their dues to the Association for the current year are entitled to the Journal for the year without further payment (Bylaws, 16-18). To all others the subscription is $ 10 .0 0 per annum, Shanghai currency.

M A N U SC R IP T S .—Authors should put name and address on MS., which should be typewritten, doub'ed-spaced, and sent to editor by registered mail. Number the leaves of MS., consecutively, beginning with title page. Translate Chinese characters, and when romanised Chinese terms or phrases are used give also the Chinese characters. I f time permits, every author is sent a first proof of his article for revision, which shôuld be returned promptly. Medical papers are solicited from all physicians and surgeons in the Far East.

I L L U S T R A T I O N S .-Illu strations should be clear. I f photographs are used send a good print rather than a negative. Write title or short explanation on back of each picture or table. See that text references and “ figures” correspond. It is strongly recommended by our printers that all drawings, charts, sketches and photo

graphs should be simply in black and white. This w ill ensure the best effect in reproducing them as illustrations. No drawings or photographs should be marked with colored pencils or colored inks, as when the copy to be reproduced is so marked, satisfact' ry results cannot be produced. The lines of all blocks should 1 e uniform in color. A ll words and figures inserted in drawings should be distinct, and sufficiently large so that if it is necessary to reduce the drawing in size the wording and figures will still be decipherable. WJ en drawings cannot be reduced it is better to insert the words and figures separately and indicate by lines their proper pjsition.

B IB L IO G R A P H IC R E F E R E N C E S .— As the Journal is printed by Chinese whatever method is adopted should be as simple as possible consistent with clearness. The

i Harvard system, in which nil references are arranged ; t the end of the p;iper according to the alphabetic order of authors’ surnames, and reference numbers are not required, is therefore to be preferred. But any good system of references may be used.

R E P R IN T S —Contributors of original articles are supplied with sixteen reprints, free of charge. Additional reprints may be obtained on written request which should be attached to the MS. sent in. The price of additional reprints is as fo llow s:—

$ c.50 copies of Journal pages . . . . 1.00

100 ,, „ 1.50200 ,, ,, 2.0050 copies beyond four up to eight pages 2.otj

100 ,, „ ,, 2.50200 ,, ,, „ 3.00

Postage extra, according to weight.If a printed cover is desired the extra cost

■will be, for 50 copies, $1.25; 100 copies, §1.75; 200 copies, $2.50.

A D V E R T IS E M E N T S .— A ll communications relating to advertisements should be sent to the Advertising Department, C H IN A M E D IC A L JO U R N A L , c/o The Shanghai Mercury, L td , 5, Hongkong Road, Shanghai, China.

Œbe <$luartecl£ Journal tor ChineseIRUtôCô. In English and Easy Wenli- Published by the Nurses’ Association of China Editor : Miss Margaret Deiter,R .N ., Luchowfu, via Wuhu, Anhwei.

Annual subscription to Journal $1.00. Subscriptions and other business communications should be sent to Miss Cora E. Simpson, R.N ., General Secretary, Nurses’ Association of China, 10 Quinsan Gardens, Shanghai.

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