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BILHARZIASIS: ITS INCIDENCE AND ERADICATION.
196 Salonika command that a given quantity of quinine is more effective and speedy in its action when introduced intramuscularly than when given by the mouth. In the light of this definitely formed opinion it is interesting to note the experience of Captain K. McLay and Captain T. S. Hele, of the Malaria Enquiry Laboratory, who found that parasites disappeared from the peripheral circulation, and that in the healthy subject quinine was excreted more speedily after oral than after intramuscular administration. There is, however, no doubt as to the great value of the intramuscular method in cases of vomiting and other conditions in which intestinal absorption is impaired; when it is desired to introduce a larger amount of quinine into the system than can conveniently be given by mouth; or in cases of cerebral malaria as a supplementary measure to intravenous injections. Considering the enormous number of intramuscular injections that were given, it is remarkable how few and trivial the local ill-results have been ; the risk of these is negligible if obvious precautions are taken to avoid sepsis and injury to nerve trunks. A certain limited degree of tissue-necrosis is probably an almost constant result, but it is exceptional for this to occasion any symptoms or signs beyond transient discomfort and a localised induration which speedily disappears and leaves no permanent disability. It was found, however, that a more serious degree of necrosis, amounting to extensive destruction of muscle tissue, may occur if repeated intramuscular injections are given to patients with seriously lowered vitality, such as those suffering from the effects of chronic dysentery ; in such cases all the circumstances should receive careful con-’ sideration before the use of intramuscular quinine is decided on. Rectcib and subcutaneous quinine.-As an exceptional measure quinine was administered per rectum in doses of 5 to 10 gr., dissolved in5 to 10 ounces of saline. This method proved of value* when it was desired temporarily to supplement the amount of quinine introduced by other channels. The subcutaneous method was also employed in a small series of cases by Major E. B. Gunson, R.A.M.C., but did not appear to possess any advantage over the intramuscular method. On the other hand, the technique is less convenient and the risk of local complications is greater. was a marked divergence of opinion
prophylaxis.
Many
of these have been
published,
and I wish here
only to allude to the results obtained by Major A. G. Anderson, R.A.M.C., in the special malaria wards set apart for observation purposes at a base general hospital. In these wards the best results in the prevention of relapses were obtained by the so-called week-end system, in which 30 gr. of quinine were given on each of two consecutive days in each week. By this method the percentage of non-relapse cases was increased to 78 per cent., as compared with 32 per cent. in the control series, in which no quinine was given No inafter the initial pyrexia had subsided. convenient symptoms arose from the larger weekend doses in the case of patients treated in hospital, but equally good results may be obtained by the same weekly quantity of quinine distributed in daily doses of 10 gr. for six days a week, a plan of treatment which has undoubted advantages in the case of individuals who are occupied in their daily work, as has been pointed out by Sir Ronald Ross in a recent communication to THE LANCET
(Jan. 3rd).
______________
BILHARZIASIS: ITS INCIDENCE AND ERADICATION. BY FRANK
MILTON, M.R.C.S. ENG., L.R.C.P. LOND.,
LATE PROFESSOR OF CLINICAL SURGERY, GOVERNMENT SCHOOL OF
MEDICINE, CAIRO,
IN THE LANCET of Oct. llth, 1919, a paper under the above heading appeared, written by (Mrs.) B. Sheldon Elgood and Major Thomas Cherry, the main points of the paper being : 1. The absence of schistosomiasis from Crete and its presence in Cyprus is due to the free flow of the mountain streams during the summer in the former and the presence of marshes and streams nearly dry in the summer in the latter, 2. The festival of Shem-enNesim is the occasion and cause of the infection of the population of Cairo with schistosomiasis, and accounts for the recognised age-incidence of the disease, it being known to occur with greatest frequency among children above the age of infancy and in young adults. 3. Schistosomiasis might be eradicated from Egypt were flocks of ducks kept in the infected districts and directed by the children to the portions of the canal known to harbour infected molluscs. some parasite-destroying properties, especially in subThe first proposition is interesting, but it must it tertian malaria, and may prove to be of value in the be remembered that both the molluscar hosts and treatment of cerebral cases in which quinine has been the cercaria of the schistosomidaa have great of to tolerance and still of the symptoms pushed verge a heavy parasite infection remain. Apart from the capabilities of adaptation, being even able to thrive question of its specific value, galyl has a definite use in in the hot springs at Gabes in Tunis, where the stimulating the activity of the blood-forming organs, and temperature of the water is over 40° C., and it is was used with benefit in the severer grades of anaemia quite possible that it is not the disease that is with cachexia and marked splenic enlargement following wanting in Crete but its recognition. The second malaria and in convalescence from blackwater fever.’: contention is of greater interest, and opens up a The Preventioit of Relapses. much more important question. It may very well A very short experience in Macedonia was be that many Cairene children are infected at sufficient to bring home to all those concerned Shem-en-Nesim, although opportunities for them with the management of malarial cases the to become infected at garden pools, fountains, and limitations of quinine treatment. Side by side the Khalig are plentiful throughout the year; but with its remarkable power in controlling the one may well question whether the age-incidence acuter manifestations of the disease and its is due to so simple a cause. Shem-en-Nesim is special importance in such conditions as cerebral essentially an Egyptian festival, but inquiry will malaria, when the life of the patient may depend show that the age-incidence of schistosomiasis is world-wide. Wherever the disease is endemic in a on its proper use, there was accumulating evidence of its inadequacy in preventing the recurrence of high degree-i.e., wherever the chance of infection relapses. Innumerable observations were made is constantly present at all periods of life-the both at the base and in corps areas with the greater number of cases of schistosomiasis will be object of testing the value of quinine in relapsefound to occur in advancing childhood and early
197
youth, whilst
mature adults are comparatively free ; time, the cases among the young population are mild in degree and present but simple symptoms, whilst the majority, if not all, the cases among adults are by comparison severe and show a complication of symptoms. at the
mind back over the many hundreds of cases seen in hospital and private practice in Egypt, one finds it hard to recall any but cases of simple haamaturia in the young or any but severe cases of cystitis, proctitis, fistula, and so on, in mature adults. I am speaking now, of course, of native Egyptians who have passed their lives in the midst of potential infection. That the age-incidence is the same in all parts of 1 the world is shown by the records of Thomson in the Eastern Soudan; by Conorand Conor and In
of deposited eggs. The general systemic disturbance, the fever, and the urticaria exhibited during the early weeks after infection by any of
vicinity
same
running
one’s
the three species of schistosomes point to the general action of a toxin produced by the parasite. The great increase of the eosinophile elements of the blood during the early months of infection probably indicate the effort of the organism to resist the action of this toxin and to produce immunity to its harmful effects. In 1916 Fujinami 12 showed that a horse which had recovered from schistosomiasis failed to acquire the disease a second time when experimentally exposed to infection, whilst two other horses, which had never had the disease and were exposed to infection under identical conditions, both became heavily infected. Sueyasu,13 working on the blood of this first " immune horse, obtained a positive complementfixation, with both an aqueous and an alcoholic
I
Benazet,3 amongst others, in Tunis; by Clapier6on the West Coast of Africa ; by Allen5 and Petrie in Natal; by Turnerat the Cape and in the Trans-9 vaal ; by Leger 8 in the West Indies ; by Ris-quez antigen. in Venezuela; by Gonzales 10 in Porto Rico; by Last year Hamilton Fairley,14 in his own words, Edgar’1 in China; and by Fujinami 12 in Japan. adduced definite evidence of an immune body Spring-time festivals, such as Shem-en-Nesim, are in the sera of patients affected with either the universal, but it must need some much more Sch. haematobium or the Sch. mansoni type of profoundly acting influence than annual excursions Egyptian bilharzia." of the townspeople into the country to bring about If immunity be acquired by an attack of schistoa condition characteristic of a particular disease somiasis the disease, in a country where the throughout the world, and I think that this disease is endemic and where the mass of the influence in the case of schistosomiasis is that of population is constantly exposed to the risk of acquired immunity. infection, would naturally tend to become a disease Evidence of Acquired Immacnity in Schistosomiasis. of early life exactly as the ordinary zymotic diseases The only direct experiment to prove the acquisi- are in England, and as few of us escape in our tion of immunity in schistosomiasis that I am early years, so do few Egyptians escape schistosomiasis during their youth. aware of was that of Fujinami,12 when he used All helminthic infections appear to give rise to he and when obtained -the horse, results which some general disturbance of the system of the host, after were more than suggestive. But, all, experiment is hardly necessary when we clearly see the and it is highly probable or, as I venture to think, certain that each helminth produces its own toxin, process going on in nature before our eyes. Take the case of the Egyptian peasant, the greater which is absorbed by its host and sets in train part of whose life is passed in direct contact with changes which lead to immunity not only against cercaria-bearing water. He acquires the disease further harmful effects of the toxin, but render the early in life, passes blood in his urine for so many tissues of his body inimical to the parasite itself. months*, or it may be for a few years, and then this These changes not only lead to the death of the ceases and he is spontaneously cured, and not only is original parasites, but prevent the development and he cured of this attack but his history will show that growth of any other parasite of the same specie, the although he continues to expose himself to reinfec- immature forms of which may have gained entrance tion throughout the remainder of his life he never to his body. Were this not so, the fellaheen of again suffers from hsematuria or reacquires the Egypt, who are constantly in contact with water disease. This is the history of the vast majority containing Schistosoma cercaria, would be accumuof the natives of Egypt, but, as we know only too lating new schistosomes throughout their lives, and well, there are cases, in great numbers, in which they would of necessity suffer from the effect of the the disease, instead of undergoing spontaneous infection in an increasing degree as their age instead of the disease being, as we know cure, progresses and shows signs, as it were, of increased it one of early life. is, essentially malignancy, lasting for the remainder of the victim’s The idea of introducing flocks of ducks to life, and eventually, it may be, killing him. Between these two extremes, the simple uncom- eradicate bilharziasis from Egypt is ingenious, plicated case of hsematuria going on to spontaneous but it must be remembered that ducks themselves are liable to attack by BilharzieUa polonica, cure and the progressive case going on to death, there is every grade of duration and severity. and one wonders what would be the result These cases show that complete immunity is not if the village children, either through defective acquired in every case and that there are individuals instruction or mere devilment, instead of leading whose resistance is strong and rapidly developed their charges to the beds of Bullinus contortus Planorbi8 and others less capable of resistance and who do hurried them to the haunts of not react defensively to the toxins elaborated by mareoticus !/ "
,
the parasites.
Pathologically the agglomeration of multinuclear cells, stellate cells, and eosinophiles in the bilharzial tubercles
found in the liver and elsewhere wherever eggs are lodged, and the excessive formation of bilharzial granulation tissue occurring in connexion with old-standing bilharzial lesions, point to the local action of a toxin generated in the
References.—1. Report of the Kala-azar Commission in Eastern Soudan, 1911. 2. Arch. d. Inst. Pasteur d. Tunis, 1910; also Tunisii Médicale, June 15th, 1911. 3. Ann. d. Inst. Pasteur de Tunis, 1912, No. 3, p. 118. 4. Bull. Soc. Path. Exot., vol. ix., No. 9, p. 739. 5. THE LANCET, July 15th, 1882. 6. B.M.J., Jan. 18th, 1903. 7. Jl. Trop. Med, and Hyg., February, 1910. 8. Bull. Soc. Path. Exot., vol. vii., No. 1, p. 75, 9. Gaceta Med. d. Caracas, vol. xxiii., No. 17, p. 135. 10. New Orleans Med. and Surg. Jl., November, 1916, p. 352. 11. Jl. State Med., September, 1913, p. 542. 12. Kyoto Igaku Zassi, July 20th, 1916, 13. Idem. 14. Jl. R.A.M.C., vol. xxxii., No. 4, p. 245. Coonoor,’S. India.
prophylaxis.
Many
of these have been
published,
and I wish here
only to allude to the results obtained by Major A. G. Anderson, R.A.M.C., in the special malaria wards set apart for observation purposes at a base general hospital. In these wards the best results in the prevention of relapses were obtained by the so-called week-end system, in which 30 gr. of quinine were given on each of two consecutive days in each week. By this method the percentage of non-relapse cases was increased to 78 per cent., as compared with 32 per cent. in the control series, in which no quinine was given No inafter the initial pyrexia had subsided. convenient symptoms arose from the larger weekend doses in the case of patients treated in hospital, but equally good results may be obtained by the same weekly quantity of quinine distributed in daily doses of 10 gr. for six days a week, a plan of treatment which has undoubted advantages in the case of individuals who are occupied in their daily work, as has been pointed out by Sir Ronald Ross in a recent communication to THE LANCET
(Jan. 3rd).
______________
BILHARZIASIS: ITS INCIDENCE AND ERADICATION. BY FRANK
MILTON, M.R.C.S. ENG., L.R.C.P. LOND.,
LATE PROFESSOR OF CLINICAL SURGERY, GOVERNMENT SCHOOL OF
MEDICINE, CAIRO,
IN THE LANCET of Oct. llth, 1919, a paper under the above heading appeared, written by (Mrs.) B. Sheldon Elgood and Major Thomas Cherry, the main points of the paper being : 1. The absence of schistosomiasis from Crete and its presence in Cyprus is due to the free flow of the mountain streams during the summer in the former and the presence of marshes and streams nearly dry in the summer in the latter, 2. The festival of Shem-enNesim is the occasion and cause of the infection of the population of Cairo with schistosomiasis, and accounts for the recognised age-incidence of the disease, it being known to occur with greatest frequency among children above the age of infancy and in young adults. 3. Schistosomiasis might be eradicated from Egypt were flocks of ducks kept in the infected districts and directed by the children to the portions of the canal known to harbour infected molluscs. some parasite-destroying properties, especially in subThe first proposition is interesting, but it must it tertian malaria, and may prove to be of value in the be remembered that both the molluscar hosts and treatment of cerebral cases in which quinine has been the cercaria of the schistosomidaa have great of to tolerance and still of the symptoms pushed verge a heavy parasite infection remain. Apart from the capabilities of adaptation, being even able to thrive question of its specific value, galyl has a definite use in in the hot springs at Gabes in Tunis, where the stimulating the activity of the blood-forming organs, and temperature of the water is over 40° C., and it is was used with benefit in the severer grades of anaemia quite possible that it is not the disease that is with cachexia and marked splenic enlargement following wanting in Crete but its recognition. The second malaria and in convalescence from blackwater fever.’: contention is of greater interest, and opens up a The Preventioit of Relapses. much more important question. It may very well A very short experience in Macedonia was be that many Cairene children are infected at sufficient to bring home to all those concerned Shem-en-Nesim, although opportunities for them with the management of malarial cases the to become infected at garden pools, fountains, and limitations of quinine treatment. Side by side the Khalig are plentiful throughout the year; but with its remarkable power in controlling the one may well question whether the age-incidence acuter manifestations of the disease and its is due to so simple a cause. Shem-en-Nesim is special importance in such conditions as cerebral essentially an Egyptian festival, but inquiry will malaria, when the life of the patient may depend show that the age-incidence of schistosomiasis is world-wide. Wherever the disease is endemic in a on its proper use, there was accumulating evidence of its inadequacy in preventing the recurrence of high degree-i.e., wherever the chance of infection relapses. Innumerable observations were made is constantly present at all periods of life-the both at the base and in corps areas with the greater number of cases of schistosomiasis will be object of testing the value of quinine in relapsefound to occur in advancing childhood and early
197
youth, whilst
mature adults are comparatively free ; time, the cases among the young population are mild in degree and present but simple symptoms, whilst the majority, if not all, the cases among adults are by comparison severe and show a complication of symptoms. at the
mind back over the many hundreds of cases seen in hospital and private practice in Egypt, one finds it hard to recall any but cases of simple haamaturia in the young or any but severe cases of cystitis, proctitis, fistula, and so on, in mature adults. I am speaking now, of course, of native Egyptians who have passed their lives in the midst of potential infection. That the age-incidence is the same in all parts of 1 the world is shown by the records of Thomson in the Eastern Soudan; by Conorand Conor and In
of deposited eggs. The general systemic disturbance, the fever, and the urticaria exhibited during the early weeks after infection by any of
vicinity
same
running
one’s
the three species of schistosomes point to the general action of a toxin produced by the parasite. The great increase of the eosinophile elements of the blood during the early months of infection probably indicate the effort of the organism to resist the action of this toxin and to produce immunity to its harmful effects. In 1916 Fujinami 12 showed that a horse which had recovered from schistosomiasis failed to acquire the disease a second time when experimentally exposed to infection, whilst two other horses, which had never had the disease and were exposed to infection under identical conditions, both became heavily infected. Sueyasu,13 working on the blood of this first " immune horse, obtained a positive complementfixation, with both an aqueous and an alcoholic
I
Benazet,3 amongst others, in Tunis; by Clapier6on the West Coast of Africa ; by Allen5 and Petrie in Natal; by Turnerat the Cape and in the Trans-9 vaal ; by Leger 8 in the West Indies ; by Ris-quez antigen. in Venezuela; by Gonzales 10 in Porto Rico; by Last year Hamilton Fairley,14 in his own words, Edgar’1 in China; and by Fujinami 12 in Japan. adduced definite evidence of an immune body Spring-time festivals, such as Shem-en-Nesim, are in the sera of patients affected with either the universal, but it must need some much more Sch. haematobium or the Sch. mansoni type of profoundly acting influence than annual excursions Egyptian bilharzia." of the townspeople into the country to bring about If immunity be acquired by an attack of schistoa condition characteristic of a particular disease somiasis the disease, in a country where the throughout the world, and I think that this disease is endemic and where the mass of the influence in the case of schistosomiasis is that of population is constantly exposed to the risk of acquired immunity. infection, would naturally tend to become a disease Evidence of Acquired Immacnity in Schistosomiasis. of early life exactly as the ordinary zymotic diseases The only direct experiment to prove the acquisi- are in England, and as few of us escape in our tion of immunity in schistosomiasis that I am early years, so do few Egyptians escape schistosomiasis during their youth. aware of was that of Fujinami,12 when he used All helminthic infections appear to give rise to he and when obtained -the horse, results which some general disturbance of the system of the host, after were more than suggestive. But, all, experiment is hardly necessary when we clearly see the and it is highly probable or, as I venture to think, certain that each helminth produces its own toxin, process going on in nature before our eyes. Take the case of the Egyptian peasant, the greater which is absorbed by its host and sets in train part of whose life is passed in direct contact with changes which lead to immunity not only against cercaria-bearing water. He acquires the disease further harmful effects of the toxin, but render the early in life, passes blood in his urine for so many tissues of his body inimical to the parasite itself. months*, or it may be for a few years, and then this These changes not only lead to the death of the ceases and he is spontaneously cured, and not only is original parasites, but prevent the development and he cured of this attack but his history will show that growth of any other parasite of the same specie, the although he continues to expose himself to reinfec- immature forms of which may have gained entrance tion throughout the remainder of his life he never to his body. Were this not so, the fellaheen of again suffers from hsematuria or reacquires the Egypt, who are constantly in contact with water disease. This is the history of the vast majority containing Schistosoma cercaria, would be accumuof the natives of Egypt, but, as we know only too lating new schistosomes throughout their lives, and well, there are cases, in great numbers, in which they would of necessity suffer from the effect of the the disease, instead of undergoing spontaneous infection in an increasing degree as their age instead of the disease being, as we know cure, progresses and shows signs, as it were, of increased it one of early life. is, essentially malignancy, lasting for the remainder of the victim’s The idea of introducing flocks of ducks to life, and eventually, it may be, killing him. Between these two extremes, the simple uncom- eradicate bilharziasis from Egypt is ingenious, plicated case of hsematuria going on to spontaneous but it must be remembered that ducks themselves are liable to attack by BilharzieUa polonica, cure and the progressive case going on to death, there is every grade of duration and severity. and one wonders what would be the result These cases show that complete immunity is not if the village children, either through defective acquired in every case and that there are individuals instruction or mere devilment, instead of leading whose resistance is strong and rapidly developed their charges to the beds of Bullinus contortus Planorbi8 and others less capable of resistance and who do hurried them to the haunts of not react defensively to the toxins elaborated by mareoticus !/ "
,
the parasites.
Pathologically the agglomeration of multinuclear cells, stellate cells, and eosinophiles in the bilharzial tubercles
found in the liver and elsewhere wherever eggs are lodged, and the excessive formation of bilharzial granulation tissue occurring in connexion with old-standing bilharzial lesions, point to the local action of a toxin generated in the
References.—1. Report of the Kala-azar Commission in Eastern Soudan, 1911. 2. Arch. d. Inst. Pasteur d. Tunis, 1910; also Tunisii Médicale, June 15th, 1911. 3. Ann. d. Inst. Pasteur de Tunis, 1912, No. 3, p. 118. 4. Bull. Soc. Path. Exot., vol. ix., No. 9, p. 739. 5. THE LANCET, July 15th, 1882. 6. B.M.J., Jan. 18th, 1903. 7. Jl. Trop. Med, and Hyg., February, 1910. 8. Bull. Soc. Path. Exot., vol. vii., No. 1, p. 75, 9. Gaceta Med. d. Caracas, vol. xxiii., No. 17, p. 135. 10. New Orleans Med. and Surg. Jl., November, 1916, p. 352. 11. Jl. State Med., September, 1913, p. 542. 12. Kyoto Igaku Zassi, July 20th, 1916, 13. Idem. 14. Jl. R.A.M.C., vol. xxxii., No. 4, p. 245. Coonoor,’S. India.