565

Filariasis, another mosquito-borne disease, is stillrampant in many of the islands, although in generalits importance seems to be steadily declining." Barbados leg," as elephantiasis once was called,is now comparatively rare in that island, and evenin St. Kitts and Antigua, which once were strongholdsof the disease, there has been a very considerabledecrease in its incidence during the past 20 years.The majority of the important diseases, however,are faeces-borne ; enteric and dysentery, diarrhoeaboth in infants and children, and helminthiasis arethe commonest of these. Enteric and dysentery arenot so universal as they used to be, but helminthicparasites are still very common. Hookworms are

found in all the islands but are especially common.

in the southern groups. In Barbados, with twokinds of soil-clay and chalk-they are widespreadon the first and rare on the second ; in Antigua wherechalk, clay, and volcanic soils are found, there is a lightinfection on the chalk, medium on the clay, and heavyon the volcanic portions. In all districts soil pollutionis universal and heavy, and light infestations are dueto natural causes, not to man’s activities. Theround worm, Ascaris lumbricoides, is even more

common and about 60 per cent. of the inhabitantsare infected. These two parasites cause a greatamount of debility and are very important economicfactors in the prosperity of the islands.

Schistosomiasis has not the same general spread asthe truly intestinal parasites, and is confined to St.Kitts, Antigua, and St. Lucia among the Britishislands. The parasite found in these islands andthroughout the tropical parts of the New World isS’chistosonaa mansoni. It was first reported by SirPatrick Manson from Antigua in 1902, but there isreason to suppose that the patient acquired hisinfection in St. Kitts. The parasite, like all theothers, originally came from Africa, probably withthe negro. In St. Kitts, however, for over a hundredyears African monkeys have roamed the forestsand plagued the planters ; Dr. Cameron found thatin addition to being an economic nuisance, they werealso harbouring Schistosoma maitsoni and wereconsequently likely to prove a serious factor in anyschemes for the eradication of the disease. Thera-peutic measures, which have been successfully used

. against this parasite in man, could in theory eradicateit if all human carriers were treated and cured and ifno reservoir existed to reinfect the snails. But a

wild monkey cannot be treated and so eradicationmust necessarily, in St. Kitts at least, lie in attackson the immediate hosts which live in considerablenumbers in the few streams in the island. Amongthe minor horrors of the West Indies are insectpests of all sorts ; the domestic flies, particularlyevident on Sundays when the shops are closed ;mosquitoes, which bite in relays throughout the24 hours ; chigger fleas, which burrow into the skinof the toes ; Jack Spaniards, large wasps which cansting most ferociously ; betes rouges, harvest miteswhich climb up the grass on to the limbs and wherethe clothing fits tightly, enter the skin-these andmany others plague the life of the stranger. In afew islands poisonous snakes still exist, while inTrinidad there lives a species of blood-sucking batwhich, while it does little permanent damage, is aconsiderable source of annoyance to man and beastalike. The major problems of these islands, however,can be solved only by drainage and fxces disposal

Ischemes-and above all by education. The negrohas still to acquire the latrine habit; when he has donethis the high degree of parasitism will be enormously 1reduced. Venereal disease, another major scourge, ican only be eliminated by an enlightened and edu- icated public opinion. Malaria and filariasis depend 1on mosquito eradication in which drainage plays an 1important part. But all these hygienic measures 1depend on material prosperity and a new outlook ion the part of the peasant. The material prospects (of many of the islands are not too good, but a tradein tropical products and a multitude of visitors towhat might easily be ideal health resorts would help

to counteract the adverse effects of beet and artificialsilk on the cane-sugar and cotton industries. Theoutlook of the negro is another matter, however,which will only be altered after much constantendeavour. Nevertheless, as Dr. Andrew Balfourpointed out in the discussion, considerable advanceshave been made within the last 30 years and morethan would seem possible at the moment may yet beaccomplished. These islands are among the beautyspots of the earth. Their soil is fertile and theirclimate, though tropical, is tempered by the tradewinds from the Atlantic. Any effort to make themagreeable health resorts would probably be wellrepaid. ____

SURGERY IN THE DIABETIC.

I ,

IN prolonging the lives of diabetics insulin hasincreased the number of those who develop surgicalcomplications or coexistent diseases needing surgicaltreatment. J. A. Reed finds that the surgical mor-tality-rate has been reduced to one-third of whatit was before the use of insulin, but, of course,these patients still run a greater operative risk thannormal people. For successful treatment the firstessential is close cooperation between the physicianand surgeon, both before and after operation. Theaim of treatment is to maintain the blood-sugar atits normal level, to promote storage of glycogen bythe liver, to overcome ketosis, and to give a sufficientamount of fluid. To accomplish this Reed is accus-tomed to give a diet containing 100 g. of carbohydrate,the same amount of fat, and 1 g. of protein per kg.of body-weight, with enough insulin to abolish ketosisand bring the blood-sugar to normal level. When thishas been done the operation is performed, preferablytwo hours after the usual breakfast, given in fluidform. In his opinion the anaesthetic of choice isethylene and nitrous oxide, with ether in cases wheregreater relaxation is required. After operation thepatient should return as soon as possible to his previousdiet, while starvation is to be avoided at all costs. Inthe treatment of diabetic gangrene, Reed againemphasises the importance of early consultation withthe surgeon, and points out that to-day infection andgangrene are greater enemies to the surgical diabeticthan acidosis and coma. Focal sepsis and arterio-sclerosis are the two most important predisposingcauses of gangrene, and uncleanliness of the feet isa factor which should not be forgotten. In a paper ondiabetic gangrene, B. C. McMahon, Rudolph Scharf,and W. M. Bartlett2 say that although cases of drygangrene often recover entirely with adequate medicaltreatment, gangrene which is tending to spread, or isassociated with severe toxaemia or septicaemia, or

occurs in a patient whose diabetes cannot be controlledwith insulin and diet, should be treated as a surgicalemergency. In their series of 19 cases, ten healedby primary and six by secondary union, while onefailed to heal in six months. In one of the fatal casesdeath followed reamputation for secondary gangrene,and in the other it was due to septicemia. Thesewriters emphasise the importance of radical surgicaltreatment, bearing in mind the risk of possiblereamputation, and for gangrene below the knee theyprefer the Stokes-Gritti amputation, both as regardshealing capabilities and the giving of a good weight-bearing stump.

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NEW VIEWS ON RHEUMATISM IN CHILDHOOD.

ONE result of the renewed interest in rheumatism isthat work in other parts of the world is being studiedwith more care in this country. As far as rheumatismin the child is concerned many observers think thatthe disease is much more prevalent here than elsewhere,but it would be rash to conclude from this that know-ledge of the disease is confined to these islands. Workin America has attracted attention to the possibilityof rheumatism being in the nature of an allergic

1 Surg., Gyn., and Obst., Jan. 1929, p. 44.2 Ibid., p. 125.