381

MEDICINE IN KHARTOUM

IN February, 1924, the Kitchener School ofMedicine at Khartoum was opened. On his lastvisit to the Sudan Lord KITCHENER expressed astrong wish that medical training should beavailable for Sudanese students. The proposalappealed strongly to the Sudanese and no less than11,000 was subscribed by them towards the

original scheme. It soon became obvious that thestudents were not only extremely intelligent butalso made efficient and reliable doctors. The

original object of the school was to turn out asmall group of young men who could carry on the

practice of medicine in the extremely tryingclimate of the Sudan. The principle of the smallgroup has been adhered to and as a result it maybe doubted whether any medical students elsewherein the world receive more individual tuition. The

report by Sir ALFRED WEBB-JOHNSON to the com-mittee of management of the English ConjointBoard, mentioned elsewhere in this issue, gives anencouraging picture of the Kitchener school. In

its early days the school was fortunate in that SirHENRY WELLCOME established in the GordonCollege a group of laboratories for tropical agri-cultural and medical research. It has now been

wisely decided to separate these two branches.The medical work is being carried on in the Stacklaboratories close to the hospital and medicalschool, while the agricultural branch is at Medaniin the Gezira where it is in immediate touch withthe problems and difficulties which confront agri-culturists in the Sudan. Sir Alfred looks forwardto the establishment of a university college inKhartoum embodying departments of arts, science,agriculture, engineering, veterinary science andmedicine. There can be little doubt that a move-ment will speedily develop for a university inKhartoum, and this deserves every encouragement.With the decline of western academic influence inEgypt the importance of the Sudan as a culturalelement in Africa may be expected to increase. Ittherefore becomes doubly important that the

development of a university at Khartoum shouldin no way be impeded.

ANNOTATIONS

MORTALITY TREND IN DIPHTHERIA

DIPHTHERIA, like other diseases spread by dropletinfection, is probably quite as prevalent in this

country today as it was forty years ago when com-pulsory notification was introduced. During thisperiod, however, certain other changes have takenplace which have perhaps not received all the attentionthey deserve. It appears that the spearhead of

diphtheria’s attack on child life has been movinggradually from the child of pre-school age to thechild of school age. Picken,l two years ago, after

pointing out that the earliest indication of this

change was noted by Murphy 2 as long ago as 1907,showed that the shift of fatality to older childrenhad continued-being particularly striking in Londonduring 1932-35. He noted a similar change inManchester and in Glasgow.Knowledge of this subject, has now been put on a

wider basis by Wright,3 who has completed a valuableand comprehensive study of the clinical severity ofdiphtheria in seven cities (Liverpool, Birmingham,Manchester, Glasgow, Leeds, Hull and Edinburgh)over the period 1911-35. * He finds that, though theincidence of diphtheria in the cities concerned showsfluctuation, there was a uniform and considerabledecline in clinical severity as far as could be judgedby case-fatality rates. During the final quinquennium(1931-35) of the study, however, the decline ceased,and in some places there was an increase in clinicalseverity which was independent of epidemics. Thisgeneral picture can be traced also within the variousage-groups of 0-4 years, 5-9 years and 10-14 years,but the decline in case-fatality rates was propor-tionally less for the age-group 5-9 than the age-group0-4 in all cities studied except Glasgow. Theshift of mortality to older children Picken was inclinedto attribute to the more recently recognised typechanges in the diphtheria bacillus itself. Cheeseman,Martin and Russell 4 on the other hand have adduced

1. Picken, R. M. F., Lancet, 1937, 1, 1445.2. Murphy, S., Trans. epidem. Soc., Lond. 1907, 26, 99.3. Wright, H. D., J. Path. Bact. July, 1939, p. 135.4. Cheeseman, E. A., Martin, W. J., and Russell, W. T.,

J. Hyg., Camb. 1939, 39, 181.

evidence that reduction in the size of families, wherebychildren fail to encounter infection until school years,is primarily responsible ; and improvement in theenvironment of young children also plays a part.

Studies of this kind, apart from their value to thepublic-health departments concerned, have generalimplications that should not be ignored. If, as is sug-gested, the decline in clinical severity of diphtheriahas now either ceased or been replaced by a rise, thena sharp stimulus towards active immunisation is

required. The well-attested shift of mortality toolder children also has a bearing on immunisation,indicating the desirability of immunising the childpopulation as a whole, instead of concentrating on thevery young.

RADIOGRAPHY OF THE COLON

EXAMINATION of the several parts of the alimentarytract taxes the ingenuity of the radiologist. Thestomach and duodenum can be made empty byfasting, and their peristaltic movements are frequentenough for a series of pictures to be taken at shortintervals after the barium meal, when the changingcontour of the opaque contents admits of diagnosticinferences. When the rate of passage is quick, as

it is through the small intestine, strial pictures maybe obtained by using a thin barium-impregnatedpaste. For the colon the barium meal is supple-mented by an opaque enema. Both have theirdisadvantages. By the time the barium meal reachesthe colon it is mixed with residues of other meals,so that beyond the caecum and ascending colondetails of filling may be confused, and even for thispart of the colon a supplementary opaque enema isneeded. The barium enema has the disadvantage ofbeing given against the normal course of peristalsis;it may need a previous lavage of the colon to clearout food residues ; moreover the ordinary movementsof the colon are infrequent and spasm may confusethe picture. In a recent study Rachet and Arnous 1point out that even two or three pictures taken atshort intervals may not be really satisfactory for

1. Rachet, J., and Arnous, J., Pr. méd. July 8, 1939, P. 1093.

382

diagnosis, nor do the methods of partial evacuationand air-insufflation preclude leaving a small lesionunnoticed. It is not often possible to have a furtherpicture made within a few days or weeks ; were

this done opaque residues of a former barium mealwould often be found in colonic diverticula. Theauthors therefore advocate taking a series of pictureswhile administering a drug which stimulates peris-talsis. The technique they use requires lavage ofthe bowel with weak saline (15 per 1000) the previousnight and early in the morning, a third wash ofwarm water being given if the second is not returnedclear. The opaque enema, which must be quitehomogeneous and of body temperature, is then givenslowly under low pressure, air-inflation being usedto distend the bowel. Twenty minutes earlierprostigmine has been injected subcutem to stimulateperistalsis. The patient lies in the same positionfor an hour during which exposures are made atintervals of ten minutes. By this method usefulresults have been obtained in the hands of theauthors, who emphasise its help in precise diagnosisof the extent and operability, and even of the nature,of the lesion. It seems, however, that equally goodresults are obtained, with less strain on the patientand in shorter time, by proper orientation of X-raytube, patient and plate, controlled by preliminaryradioscopy and manipulation.

CONVULSION THERAPY AND ITS EFFECTS

MANY observations have now been made of thechanges produced by Cardiazol in the brains of suchanimals as the guineapig, the rabbit, the cat and thedog, but the findings are less safely applicable tohuman beings than would be the results of similarstudies in primates. Strecker, Alpers, Flaherty andHughes have now examined the brains of seven

monkeys who had received intra-arterial injectionsof cardiazol in the doses and frequency usuallyemployed in clinical work on schizophrenics. The

experiment was intended to parallel closely cardiazoltherapy, but there were divergencies, in that three ofthe animals died because of protracted convulsions,and in others seizures were of more than five minutes’duration, necessitating the injection of sodiumAmytal to bring them to an end. In three animalsno structural changes were found in the brain, inanother there was swelling of the cytoplasm in theexternal granular layer of the frontal and parietalcortex, and in the remaining three subarachnoidhaemorrhage was observed over the cortex and at thebase of the brain. Cells in the supra-optic nucleusof the hypothalamus showed in some of the animalsloss of Nissl substance and vacuolation of nuclei.The investigators emphasise that those animals thathad pathological changes in the brain had had,altogether, more minutes of active convulsion duringthe experimental period than the others, and that ithad not been possible to demonstrate any sub-arachnoid haemorrhage (by examination of the

cerebrospinal fluid) in schizophrenic patients treatedwith cardiazol, probably because the duration ofconvulsions was so much less in them than it was inthe monkeys. It seems likely, however, that it wasnot so much the total duration of the convulsions overthe whole period of the experiment as the durationand severity of the individual convulsions that proveddecisive in bringing on the rather gross changesfound, in which case Strecker and his colleagues,instead of advising that the total number of treat-

1. Strecker, E. A., Alpers, B. S., Flaherty, J. A., and Hughes, J.,Arch. Neurol. Psychiat. Chicago, May, 1939, p. 996.

ments in a single case of schizophrenia should belimited to ten convulsions, might have taken it asthe moral of their story that the dose of cardiazolgiven should never be such as to bring on a prolongedconvulsion or, of course, repeated convulsions.Any objection to cardiazol treatment based on the

above findings and conclusions would presumably beraised still more strongly against picrotoxin, anotherconvulsant drug recently introduced into the treat-ment of schizophrenia. A. A. Low 2 and his col-laborators have tried this drug because they wishedto avoid the terror of which patients complain afterthey have had cardiazol. Although picrotoxin canbe used apparently without danger to life-theyhave given it to 38 patients intravenously, with noworse complications than subluxation of the jaw,dislocation of the shoulder, and fracture of thescapula-it is prone to cause repeated convulsionsafter a single injection. All but 2 of the 38 patientshad at one time or another multiple paroxysms, andthe patients who recovered were those who hadfewer of these. From this it is concluded that thetendency to recover is in inverse proportion to a lowconvulsive threshold for the drug : no mention ismade of the possibility that rapidly repeated con-vulsions may do cerebral damage of a kind unfavour-able to recovery. Biochemical observations on thepatients showed that the pH andC02 content of theblood, when two or more convulsions succeeded eachother, tended to fall progressively with each paroxysm.Because of this the investigators decided to inject abarbiturate regularly after the second repeated con-vulsion to prevent further ones. It had also beenobserved that in the patients who had four immedi-ately successive convulsions the sugar in the bloodfinally reached 210’4 mg. per 100 c.cm., and thewhite-cell count 34,300; the fasting level had notbeen restored an hour after the last seizure. In otherrespects the drug acted pretty much as cardiazoldoes, except that the patients found it less disagree-able, and there was an interval, longer even than thatwith triazol, between the injection and the first fit. Onthe whole, cardiazol seems preferable to picrotoxin.

BEST TEST FOR CLEAN MILK

SiNCE 1929 a serious attempt has been made bythe sanitary authorities in Italy to improve thecleanliness and safety’ of the milk-supply. Themain test used in the control of bacterial cleanlinessis the plate count. Increasing dissatisfaction, how-ever, is being expressed with this method, and asearch is being made for some more reliable substitute,among those receiving attention being the modifiedmethylene-blue reduction test described by Wilsonand his colleagues, now adopted officially for the

grading of raw milk in England and Wales.Asdrubali 3 describes a careful examination of 120samples of raw milk by means of the plate count,the Breed smear count, the modified reduction test,the keeping-quality test and the titratable-aciditytest. The relation between the reduction test andthe bacterial cleanliness of the milk as judged onthe basis of the other four tests was then worked out.In 90 of the samples the plate count and the reductiontests were in good agreement. In the remaining30 samples the results of the two tests were discordant ;in 27 of these the reduction test gave the right andthe plate count the wrong answer. Very strikingwere the results of the reduction and the keeping-

2. Low, A. A., Blanrock, M. F., Sachs, M., Wade, C., andRoss, E., Ibid, April, 1939, p. 747.

3. Asdrubali, M., Ann. Igiene (sper.) 1939. 49, 218.