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issues which had caused public concern. For theaccused (which in effect the regional boards were) toappoint even some of the judges (which in effect thedoctor, nurse, and layman on each committee were) isnot the surest way of winning acceptance for the verdict.How much better it would have been if the Minister hadhimself formed the committees; for then these wouldhave come within the purview of the Council on Tri-bunals, which seeks to enforce a common code of prac-tice, and whose writ can be sustained by legal sanctions.(The aims and the procedure of the several committeesset up by the regional boards varied strikingly.) Thetrouble is that the reach of the Council of Tribunals doesnot extend beyond statutory or discretionary inquiries byor on behalf of a Minister, or such inquiries which aMinister might have set up but did not. Thus the

inquiries initiated by the regional boards at the requestof the Minister of Health did not fall within the Council’s

scope. Next time serious general allegations are madeagainst any branch of the Health Service, the Ministershould set up his own inquiry; and for personal com-plaints there seems to be an unmet need for a body onthe lines of the defunct Board of Control or for the" health commissioner " suggested in this week’s green-paper (see p. 210). The green-paper’s proposals holdout hope of satisfactory resolution of individual com-plaints through the health commissioner and parlia-mentary machinery. But these proposals do not cater forthe situation arising from Sans Everything, and thewords in which the proposals are expressed underlineour misgivings about the way the Minister has dealt withthe substance of the book. The green-paper says:" When appropriate, as it might well be in serious cases,they [Area Boards] would be able to investigate thecomplaint formally, as the present hospital authoritiesdo, if necessary setting up an independent [our italics]inquiry for the purpose." The report goes on:

" There

might nevertheless be cases where the member of thepublic who made a complaint to an Area Board wasdissatisfied with their reply or the action taken, andwished to seek an independent [our italics again] view.Alternative ways...." Just where does independencebegin ?The statutory responsibility of the Minister of Health

for the National Health Service is inscribed in theNational Health Service Act of 1946; and Mr. ROBINSONhas insisted that he is accountable for what regionalboards do: " ... in a service which deals with people, andpeople at their most vulnerable when they are ill, I thinkthat it is absolutely vital that any member of Parliamenton behalf of any of his constituents can get up in theHouse of Commons and ask me why that constituent wasnot treated properly at such-and-such a hospital." 2This is a sensible and humane attitude; but surely onecorollary is that, where the Minister cannot himself lookinto a complaint which threatens public confidence in theHealth Service, he should ensure that it is investigatedin a way that the man on the Clapham omnibus wouldregard as impartial.

2. ibid. 1966, ii, 957.

Leishmaniasis

THE late SAUL ADLER 1 was the father of the modem

approach to leishmaniasis, a composite disease widelydistributed in both hemispheres and in temperate as wellas tropical lands, for the infection spreads as far northas the environs of Paris. ADLER’S followers are equallywidely scattered, and one of the most devoted, RALPHLAINSON, has unravelled several important aspects of theproblem during the past decade, first in BritishHonduras and later in Brazil. The United Kingdommaintains its traditional interest in tropical medicine;LAINSON’S work in Honduras was initiated by the

Tropical Medicine Research Board of the MedicalResearch Council and in Brazil by the WellcomeTrustees with the collaboration of the BrazilianGovernment.

In Central America, LAINSON and STRANGWAYS-DIXON 2 demonstrated that the local cutaneous form of

leishmaniasis, known as " bay-sore " from Elizabethan

days, was a zoonosis, contracted by chicle (chewing-gum) collectors in the forest, and originating form atleast three types of arboreal rodents. These rats haveleishmanial sores on their tails; LAINSON inoculatedmaterial from the sores into his wife and himself, inwhom the disease subsequently appeared. LAINSONand SHAW 3 showed that a different reservoir was to befound in the Amazonian forests and that near Belem,where they are now stationed, 70% of the Orizomys areprobably infected. They 4 incriminated a forest sandfly(Phlebotomusflaviscutellatus) as the vector of the parasite- an interesting observation since this same insectcarries the infection in British Honduras 5 and inMexico. 6 The organism from these widely separatedregions behaves identically in the natural rodent hostand in laboratory animals, in which it produces character-istic histiocytomas. Probably the genetic features of thisparasite (Leishmania mexicana) are preserved when itstransmission is limited to closely related species ofPhlebotomus and rodents. In this complex, man is verymuch an accidental host and becomes infected only whenhe strays into the exotic environment of the rain forest.

Further south in Brazil, the disease takes a more

virulent form (" espundia ") in which the nose andmouth may be destroyed; here the disease is much lessof a zoonosis and other vectors are concerned. 7 In

Venezuela, Ethiopa,9 and elsewhere, an extraordinaryvariety of the disease (" leishmaniasis diffusa ") has beenreported in which the parasite spreads throughout theskin, giving rise to an almost incurable condition

resembling lepromatous leprosy. At first it was

assumed that a different species of organism (Leish-mania pifanai) was responsible, but today the condition1. Adler, S. in Advances in Parasitology. New York, 1964.2. Lainson, R., Strangways-Dixon, J. Trans. R. Soc. trap. Med. Hyg.

1964, 58, 136.3. Lainson, R., Shaw, J. J. ibid. 1968, 62, 385.4. Shaw, J. J., Lainson, R. ibid. 1968, 62, 396.5. Disney, R. H. L. Bull. ent. Res. 1966, 56, 445.6. Biagi, F. F., Biagi, M. A., Beltran, H. F. Prensa méd. mex. 1965, 30, 267.7. Coelho, M. de V. Desenvolvimento de especies de genero Lutzomyia

Franca, 1924. Instituto Nacional de Endemias Rurais, Brazil, 1966.8. Pifano, F., Scorza, J. V. Archos. venez. Patol. trap. Parasit. méd., 1960,

3, 15.9. Bryceson, A., Leithead, C. S. Ethiop. med. J. 1966, 5, 31.

204

is believed to be the result of an abnormal response bythe host-possibly the failure of cell-mediated immunity.

In the Old Word, cutaneous leishmaniasis presents amore uniform appearance and, although it goes by manypopular names (oriental sore, Biskra button, Gafsasore, Baghdad boil, Delhi boil, Jericho boil, &c.), the

epidemiological pattern follows a definite course. Theinfection begins as a zoonosis affecting the semi-desertrodents such as gerbils (or, possibly, originally lizards 10)and burrow-inhabiting sandflies; man is infected byaccident when he strays into the steppes; the disease isthen introduced into human settlements where dogs alsoharbour the parasite, and eventually rodents and dogsentirely disappear from the scene and inter-humantransmission by domestic sandflies, as in India, is thefinal result. In the pristine forests of Central and SouthAmerica, man is only exceptionally attacked, but if thecountry is disturbed either by deforestation or byrevolutions when the inhabitants take to the woods, thedisease becomes epidemic. A similar situation arose

recently in the Middle East war 11 when many cases oforiental sore appeared among the troops, and, inci-

dentally, a new reservoir (a merion) of the infection wasdiscovered.The visceral type of leishmaniasis (kala-azar) has a

similar composite picture in Latin America, Kenya andthe Sudan, Europe (even the French Riviera), the MiddleEast and the southern republics of the U.S.S.R., theIndian subcontinent, and China. There are manyzoogeographical peculiarities in the distribution of kala-azar and in its reservoirs and its vectors. Kala-azar is

usually easy to diagnose by the isolation of the organism,but if it arises in unusual circumstances it may not be

recognised immediately. For instance, cases associatedwith blood-transfusion have been reported in northernlatitudes like Sweden 12 and England, and even venerealinfection has occurred.13 The identification of theindividual species of Leishmania is much more difficult,for morphological differences do not exist and the

investigator is dependent upon complicated tests such asthat of ADLER 1 or the new haemagglutination reactionof BRAY and LAINSON.14 With the exception of espundia,leishmaniasis is usually readily cured with antimonialdrugs, but its prevention presents many problems. Onthe one hand, the synthetic insecticides like dicophane(D.D.T.) quickly destroy the domestic sandflies, as

happened fortuitously in India during the malaria-eradication campaigns; on the other hand, when thevectors are exophilic and when sylvatic reservoirs arepresent, eradication of the disease or even its controlbecomes much more difficult. The Russians 15 suc-ceeded by the large-scale poisoning of the gerbils, and theChinese by the destruction or cure of infected dogs, butin Africa and Latin America no solution has yet beenfound. MANSON-BAHR 16 attempted to immunise the10. Hoare, C. A. Proc. Int. Congr. trop. Med. Malar. 1948, 2, 1110.11. Gunders, A. E. Nature, Lond. 1968, 219, 8512. Barr, M. E. Bengtsson, Garnham, P. C. C., Huldt, G., Kostmann, R.

Proc. Int. Congr. trop. Med. Malar. 1963, 7, 315.13. Symmers, W. St. C. Lancet, 1960, i, 127.14. Bray, R. S., Lainson, R. Trans. R. Soc. trop. Med. Hyg. 1967, 61, 490.15. Latyshev, N. L, Kryukova, A. P. Trudy Voenno-med. Akad. RKKA

1941, 25, 59.16. Manson-Bahr, P. E. C. Trans. Roy. Soc. trop. Med. Hyg. 1961, 55, 550,

population in an endemic area in Kenya by vaccinationwith an avirulent strain of Leishmania donovmsi 17

derived from ground squirrels; although the method hadsucceeded in volunteers, it failed in the field, perhapsbecause the viability of the vaccine had become lost inthe course of the campaign. Nevertheless, the use ofvaccines, after further development, may well prove thebest method of prophylaxis of the visceral disease, andthis method has been successfully applied for centuriesin the Middle East for the prevention of cutaneousleishmaniasis.

Clearly leishmaniasis has immense practical import-ance and offers a challenge to the epidemiologist,immunologist, and parasitologist. It is not surprising,therefore, that the World Health Organisation 18 held alarge international symposium last year in Moscow todiscuss the subject, and that many Governments andFoundations (including British) are deeply involved inresearch.

Annotations

ANTILYMPHOCYTE SERUM

MANY preparations of antilymphocyte serum have nowbeen tested in animals and in man. Some have beenraised by immunising rabbits with mouse thymocytes.Others have been raised in horses by injecting whateverhuman lymphoid material was available, includinguntreated cadaver spleen. Sometimes the unmodifiedserum has been used, sometimes the separated globulin,after absorption with red blood-cells.

Starzl’s group in Denver have given antilymphocyteglobulin, in combination with azathioprine and predniso-lone, to 53 patients who received renal homografts.19 Allthe patients had fever, and also pain, tenderness, erythema,and swelling at the injection sites. 11 had anaphylacticreactions, which led to the treatment being stopped in 8.Skin reactions and joint pain were common. In 9 patientsa thrombocytopenia of less than 50,000 per c.mm.

developed at some time during treatment. In spite of allthese drawbacks, the one-year survival of patientsreceiving homografts rose to 95%, and no deaths weredirectly associated with antilymphocyte-globulin treat-ment. Renal biopsy in the first 8 of these patients showedno evidence of serum-induced nephritis at the end offour months.20

Other clinical studies in a few patients have beenreported. The lymphocytes which Carraz et al 21 usedto raise an antiserum were obtained from thoracic-ductfistulas induced in patiems awaiting a kidney graft. Side-effects, similar to those described by Starzl, were seenin 15 treated patients, but treatment had to be stoppedin only 1 case of serum sickness. No toxic effects onthe kidney were recorded.

Yet another approach has been pursued by Tsirimbas17. Heisch, R. B. E. Afr. med. J. 1957, 34, 183.18. W.H.O. Inter-regional travelling seminar on Leishmaniasis, U.S.S.R.,

May 22-June 10, 1967.19. Kashiwagi, N., Brantigan, C. O., Brettschneider, L., Groth, C G.,

Starzl, T. E. Ann. intern. Med. 1968, 68, 275.20. Starzl, T. E., Porter, K. A., Iwasaki, Y., Marchioro, T. L., Kashiwagi,

N. in Antilymphocytic Serum (edited by G. E. W. Wolstenholmeand M. O’Connor); p. 4. London, 1967.

Brochier, J.,21. Carraz, M., Traeger, J., Fries, D., Perrin, J., Saubier, E., Brochier, J.,21. Veysseyre, C., Prevot, J., Bryon, P., Jouvenceaux, A., Archimbaud,J. P., Bonnet, P., Manuel, Y., Bernhardt, J. P., Traeger Fouillet, Y.Rev. Inst. Pasteur Lyons, 1967-68, 1, 17.