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Bejel
259
CORRESPONDENCE. BEJEL.
To the Editor, TRANSACTIONS of the Royal Society of Tropical Medicine and SIR, Hygiene. With reference to the paper by my friend, ELLIS H. HUDSON, o n " Bejel-the endemic syphilis of the Euphrates Arab,"* may I contribute a few remarks. In Kuwait and its outlying desert, the word " bejel," so far as I have been able to determine, is unknown. Our Bedouin, however, use the word "belesh " in much the same way as the Euphrates Arabs use " bejel." They are not always sure of their own diagnosis and I am frequently asked to give my opinion as to whether a lesion or eruption is belesh or not. I had been in Kuwait some years before I made up my mind that when the Bedou spoke of belesh, he was using the desert name for syphilis. The word " belesh " is never used by the people of the city of Kuwait, who call the disease " farinji," as on the Euphrates. Among the Bedouin the initial chancre is rare. As on the Euphrates, the disease usually begins in the mouth. HUDSON states : " General adenopathy is characteristic of bejel." These adenopathies among the Bedouin attracted my attention from the very commencement of my residence in Kuwait. I was told that they were tubercular and inasmuch as tuberculosis is extremely prevalent in the city of Kuwait, I decided that tuberculosis in the desert expressed itself in adenopathy and bone disease, rather than in pulmonary manifestations, for pulmonary tuberculosis is rare in our desert. But many of these patients were not particularly ill. They came with greatly enlarged cervical glands and apparently nothing else and asked to be treated. Many of them said they had belesh. It is about 17 years since I began to use bismuth in these cases and in the treatment of belesh generally, and I have never turned back. The results are very encouraging. It would be most instructive to do some careful research work on these adenopathies so that we could positively rule out, or rule in, tuberculosis. It is quite likely that the two diseases frequently exist together in the same patient, and it is possible too that bismuth is of value in the treatment of tuberculosis. Of the efficacy of bismuth in the treatment of belesh there is no longer the least doubt. For the past 8 years we have been giving 6,000 to 8,000 injections yearly in the American Hospital at Kuwait, in the treatment of belesh and also in the ordinary course of our syphilitic work. The injections have become more than popular and the people frequently ask for them. Our preference in Kuwait is for one injection every 5 to 7 days, rather than a small injection every day, although in selected instances we do follow the latter method. It multiplies work very greatly for the staff to give daily injections. Our usual course for an *Trans. R. Soc. trop. ~ed. & Hyg. (1937), 31.
060
CORRESPCNDENCF.
adult man is four to six injections of 2 grains at each injection--the course to be repeated if necessary, and if possible with the elusive Bedou. Our people have now come to realize that our standard course is four to six injections and on the whole give us fair allegiance. It is not suggested for a moment that all patients undergo the full course--all too many drop out after one or two injections, either because of severe after-effects, for one gets an occasional troublesome stomatitis ; or because no apparent improvement resulted ; or it was too inconvenient to come so far ; o r . . . o r . . . o r . . . However, in Arabia, as elsewhere, one has to strive for an ideal. As to the best preparation of bismuth to use, I have long since decided that sobita (Howards), or sodium bismuth tartrate, is the preparation of choice for our kind of work. It is so cheap that the cost is negligible. When I first began using it in simple aqueous solution I was greatly troubled by the amount of pain which so frequently followed injection. We now give it in a solution of 50 per cent. glycerine in distilled water, sterilizing the solution in glazed porcelain casserole dishes. The use of glycerine very largely eliminates the problem of pain subsequent to the injection. The injections are always made into the gluteus muscle, unless there are special reasons for using the deltoid. The patient should always be advised to rest for 24 hours after the injection, if possible. It is a fact which we have noted again and again, that patients in the wards never have any pain worth mentioning following injection. I am, etc., Kuwait, Arabia. C . S . G . ~IYLREA. TRYPANOSOMES IN BAT AND MARMOT.
To the Editor, TRANSACTIONS of the Royal Society of Tropical ,~Iedicine and SIR, Hygiene. While visiting Berkeley, California, I had the opportunity of finding bats, Parasites were found by fresh blood examination in two out of eight bats collected in a barn at Pinole, Contra Costa County, California. The trypanosome forms are morphologically similar to those of Schizotrypanum cruzi and were scanty in the peripheral blood. The material was obtained through the courtesy of Dr. HAROLDKIRBY,Jnr., of the Department of Zoology, University of California. As far as I know, trypanosomes of bats have not yet been reported in North America. At Hamilton, Montana, while working at the Rocky Mountain Laboratory, a trypanosome resembling Trypanosoma lewisi was found in one out of four woodchucks (Marmota flaviventris nosophora) examined. I am, etc., Instituto Oswaldo Cruz, EMMANUEL DIAS.
Antrozous pallidus pacificus, infected with haemoflagellates.
Rio de Janeiro, Brazil.
CORRESPONDENCE. BEJEL.
To the Editor, TRANSACTIONS of the Royal Society of Tropical Medicine and SIR, Hygiene. With reference to the paper by my friend, ELLIS H. HUDSON, o n " Bejel-the endemic syphilis of the Euphrates Arab,"* may I contribute a few remarks. In Kuwait and its outlying desert, the word " bejel," so far as I have been able to determine, is unknown. Our Bedouin, however, use the word "belesh " in much the same way as the Euphrates Arabs use " bejel." They are not always sure of their own diagnosis and I am frequently asked to give my opinion as to whether a lesion or eruption is belesh or not. I had been in Kuwait some years before I made up my mind that when the Bedou spoke of belesh, he was using the desert name for syphilis. The word " belesh " is never used by the people of the city of Kuwait, who call the disease " farinji," as on the Euphrates. Among the Bedouin the initial chancre is rare. As on the Euphrates, the disease usually begins in the mouth. HUDSON states : " General adenopathy is characteristic of bejel." These adenopathies among the Bedouin attracted my attention from the very commencement of my residence in Kuwait. I was told that they were tubercular and inasmuch as tuberculosis is extremely prevalent in the city of Kuwait, I decided that tuberculosis in the desert expressed itself in adenopathy and bone disease, rather than in pulmonary manifestations, for pulmonary tuberculosis is rare in our desert. But many of these patients were not particularly ill. They came with greatly enlarged cervical glands and apparently nothing else and asked to be treated. Many of them said they had belesh. It is about 17 years since I began to use bismuth in these cases and in the treatment of belesh generally, and I have never turned back. The results are very encouraging. It would be most instructive to do some careful research work on these adenopathies so that we could positively rule out, or rule in, tuberculosis. It is quite likely that the two diseases frequently exist together in the same patient, and it is possible too that bismuth is of value in the treatment of tuberculosis. Of the efficacy of bismuth in the treatment of belesh there is no longer the least doubt. For the past 8 years we have been giving 6,000 to 8,000 injections yearly in the American Hospital at Kuwait, in the treatment of belesh and also in the ordinary course of our syphilitic work. The injections have become more than popular and the people frequently ask for them. Our preference in Kuwait is for one injection every 5 to 7 days, rather than a small injection every day, although in selected instances we do follow the latter method. It multiplies work very greatly for the staff to give daily injections. Our usual course for an *Trans. R. Soc. trop. ~ed. & Hyg. (1937), 31.
060
CORRESPCNDENCF.
adult man is four to six injections of 2 grains at each injection--the course to be repeated if necessary, and if possible with the elusive Bedou. Our people have now come to realize that our standard course is four to six injections and on the whole give us fair allegiance. It is not suggested for a moment that all patients undergo the full course--all too many drop out after one or two injections, either because of severe after-effects, for one gets an occasional troublesome stomatitis ; or because no apparent improvement resulted ; or it was too inconvenient to come so far ; o r . . . o r . . . o r . . . However, in Arabia, as elsewhere, one has to strive for an ideal. As to the best preparation of bismuth to use, I have long since decided that sobita (Howards), or sodium bismuth tartrate, is the preparation of choice for our kind of work. It is so cheap that the cost is negligible. When I first began using it in simple aqueous solution I was greatly troubled by the amount of pain which so frequently followed injection. We now give it in a solution of 50 per cent. glycerine in distilled water, sterilizing the solution in glazed porcelain casserole dishes. The use of glycerine very largely eliminates the problem of pain subsequent to the injection. The injections are always made into the gluteus muscle, unless there are special reasons for using the deltoid. The patient should always be advised to rest for 24 hours after the injection, if possible. It is a fact which we have noted again and again, that patients in the wards never have any pain worth mentioning following injection. I am, etc., Kuwait, Arabia. C . S . G . ~IYLREA. TRYPANOSOMES IN BAT AND MARMOT.
To the Editor, TRANSACTIONS of the Royal Society of Tropical ,~Iedicine and SIR, Hygiene. While visiting Berkeley, California, I had the opportunity of finding bats, Parasites were found by fresh blood examination in two out of eight bats collected in a barn at Pinole, Contra Costa County, California. The trypanosome forms are morphologically similar to those of Schizotrypanum cruzi and were scanty in the peripheral blood. The material was obtained through the courtesy of Dr. HAROLDKIRBY,Jnr., of the Department of Zoology, University of California. As far as I know, trypanosomes of bats have not yet been reported in North America. At Hamilton, Montana, while working at the Rocky Mountain Laboratory, a trypanosome resembling Trypanosoma lewisi was found in one out of four woodchucks (Marmota flaviventris nosophora) examined. I am, etc., Instituto Oswaldo Cruz, EMMANUEL DIAS.
Antrozous pallidus pacificus, infected with haemoflagellates.
Rio de Janeiro, Brazil.