HUMAN TRYPANOSOMIASIS TREATED WITH TRYPARSAMIDE.

589 tonsillar sepsis, when tonsillectomy is contra-indicated of cases, especially where children who have been in by the general condition of health, Dr. McKenzie contact with tuberculosis. Up to the present time prefers piecemeal diathermy to other methods, such 160 sessions have been held in 75 centres, upwards of 8000 cases having been examined. It is the intention as the galvano-cautery or London paste ; he coagulates one or more areas of about 1 cm. in diameter of the department to establish some 20 centres in the at intervals of once a week or longer, and the duration Province in which clinics will be conducted once or of treatment is from two to four months. It is twice a year as may be required. acknowledged that there is some soreness, the procedure is a very tedious one, and it is at least difficult to ensure the removal of the whole tonsil and nothing HUMAN TRYPANOSOMIASIS TREATED WITH but the tonsil. The only really satisfactory method of TRYPARSAMIDE. treating diseased tonsils still seems to be complete IT is now eight years since the tryparsamide treatsurgical removal, and this operation is rarely contra- ment of human trypanosomiasis was instituted in indicated by the patient’s general condition if careful the Belgian Congo, and a critical analysis of available attention be paid to the method of anaesthesia. It is records has now been made by Dr. Louise Pearce case in the treatment of cancer that diathermy in these and published as Monograph 23 of The Rockefeller regions finds its most useful application, and Dr. Institute for Medical Research. The total number of McKenzie gives a very valuable description of its cases Most of them were is 1848. considered both to to and ineradicable operable application with infected Trypanosoma gambiense and were in In connexion-with medical diathermy the cancers. an advanced stage of the disease ; a small number enthusiastic French exponent of the method, Dr. with T. rhodesiense. Dr. Pearce has were infected is Robert Leroux, quoted freely. The author’s most a judicious and conservative attitude maintained with the treatdeals important personal ment of deafness and tinnitus. Of 47 cases under towards the effect of treatment, based, as it should be, his care 5 were cured, but 4 of these had only on the conception that a drug adapted to general use in African sleeping sickness must have a biological lasted for a few weeks, 5 showed great action likely to benefit patients in advanced as well as 13 but to in 2 tended the ment, improved relapse, tinnitus increased, and in the remaining 22 there was in early stages of infection. Tryparsamide is the Of 11 cases of less than one year’s dura- sodium salt of N-phenyl-glycineamine-p-arsonic acid ; no change. tion, 3 were cured, 4 improved, and 4 unchanged. the compound was developed at the Rockefeller On these findings it is recommended that practi- Institute for Medical Research and was synthesised tioners should advise diathermy for patients suffering by Jacobs and Heidelberger, its biological action from deafness and tinnitus after colds and influenza, having been studied by Brown and Pearce. Though and after acute otitis. Conservative family doctors the arsenic content of the drug is high (25’32 per cent.) the dose that can be administered to laboratory may claim that older methods of treatment give animals by any route is very large ; but there is a comIn recent affections. just as good results in these narrow margin between the lethal dose and any case there is no doubt that surgical diathermy paratively that the dose produces no apparent organic impairment. has proved its value in laryngology, especially in the tests on mice and rats may give a. While therapeutic treatment of malignant disease, and this lucid expoindication of potential trypanocidal accurate fairly sition of the technique and results of its application action they convey little idea of the actual curative will be appreciated. value. The infected rabbit is the animal of choice, since it shows many of the conditions, including A TRAVELLING CLINIC. involvement of the central nervous system, which are SiNCE 1924 the provincial department of health of found in man. In this animal tryparsamide has. Ontario has maintained a travelling clinic for the proved highly effective especially in T. gambiense diagnosis of diseases of the lungs. Clinics are and T. brucei infections. A drug which will cure a organised only with the consent of the county or well-developed infection in the rabbit in the same local medical society or, where no such society exists, unit dose as-will destroy parasites in the circulating of the practising physicians. Only one centre has blood must have great penetrating power, and it is been visited where this consent was refused. The to this power the therapeutic activity of tryparsamide staff of the clinic consists of from one to three is ascribed. In experimental animals the trypanocidal physicians and a nurse. The equipment includes a action of the drug has been found less potent against portable radiological unit and X ray films are taken T. rhodesiense than against T. garabiense, and experiof every case. Tuberculin intracutaneous tests are: ence with human infections confirms this variation. done on all children under 16 years of age. No case! The first investigation on the action of tryparsais admitted to the clinic unless referred by the family mide in African sleeping sickness was carried out by physician, and no information is given to the patient Dr. Pearce herself in 1920. At its conclusion supplies at the time of examination. When the clinic returns! of the drug were given to physicians in charge of the to Toronto and the radiograms are interpreted and hospital at Leopoldville as well as to others in the the data are correlated, a typewritten report is sent Belgian Congo, and to those in charge of the Pasteur to the physician who has referred the case. This! Institute in Brazzaville, in French Equatorial Africa. report includes history, physical findings, X ray Further studies were afterwards made in the interpretation, a diagnosis if possible, and any Cameroons, Angola, Nigeria, the Sudan, Uganda, recommendations that might be helpful. In this and Tanganyika Territory. For the most part these way the clinic is intended to work directly with the reports are concerned primarily with the treatment of medical profession in the public service-a serviceB native patients in hospital " concentration camps." which is supplied by the department without cost to) The greater part of this monograph concerns itself physician or patient. The clinic will deal with anyr with an analysis of these extensive data, the number of chest case referred to it, including non-tuberculous European and American patients treated with cases, definite cases of tuberculosis, suspicious cases, tryparsamide being small. The work is carefully and contacts. Especial importance is, however, annotated and elaborate appendices are included. attached to the examination of the two latter typesiIts study will show that the drug has now an "

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590 established value. The Report of the League of Nations on the Second International Congress on Sleeping Sickness states that all medical officers agree that the former methods of treatment should be replaced by tryparsamide. The examination of the cerebro-spinal fluid and the institutional treatment of all cases presenting modifications of this fluid is advised. The course recommended is one of 12 injections, the maximum dose being 2 g. In the Memorandum submitted by the British Colonial Office to the League of Nations Conference, the

Uganda report refers to the prophylactic value of injections of tryparsamide for members of any hunting party. Sterilisation of the blood was found to persist for a considerable period after such injection ’ that mechanical transmission from one individual cyclical infection of the fly should be prevented by.this means. so

to another and also the

OCCLUSION OF THE CORONARY VESSELS.

I Ii

has been shown to be the case experimentally in animals, where the lower the blood pressure the larger the infarcted area produced. Each observer who has investigated by these methods has been able to add something to our knowledge of the coronary artery circulation, and how it is affected by disease. More particularly we are learning something of the cause for the varied individual reactions to blockage of the same vessel W. Spalteholz, or the same branch of a vessel. in 1907, by means of his injection and clearing technique, claimed to have demonstrated that no end-arteries existed in the heart, and that there was a rich anastomosis in all its muscular and endothelial layers. Gross established the fact with his radioopaque bismuth injection technique. " The heart," he said, is perhaps the richest organ in the body as regards capillary and precapillary anastomoses between branches of the same main vessel and between branches from the two sides." Gross also showed that the accumulation of epicardial fat added to the heart a vascular sheath which slowly thickened with age and made anastomotic communications with the ’’

IT is now 25 years since A. G. Fryett showed that the coronary arteries could be injected post mortem with a underlying muscle, thereby putting a new complexion substance opaque to X rays, making it possible to study ’, on the behaviour of epicardial fat which up till then these vessels and their branches in detail and note thei had often been suspect of causing sudden death

changes in disease.

Since then several observers have where no other cause could be demonstrated. Finally. these lines with variations in technique and Hadfield confirmed2 Gross’s statement and Geoffrey apparatus. In the September number of the was able to show that the anastomoses in the epicardial Practitioner appears an important radiographic study fat of the senile heart helped it to compensate to a of these arteries with special reference to coronary considerable for a diminished flow through degree thrombosis by Dr. E. Wyn Jones, from the heart its atherosclerotic vessels, provided there was no department of the Liverpool Royal Infirmary. It serious drop in blood pressure. Using the celloidin differs from previous work in combining clinical technique of Morison followed by erosion in strong observation of individual cases with subsequent acid, Hadfield confirmed the presence of innumerable pathological investigation-a method that should anastomoses, which explained recovery following be fruitful of results. Dr. Wyn Jones-whose extensive coronary occlusion- In the future it may article was adjudged to be the best submitted in a prove possible to inject some substance opaque to competition open to practitioners of not more than X rays into the veins of the living subject, permitting two years’ standing-devised his own method of a detailed examination of the coronary circulation injection, on the lines of the standard technique during life. introduced by Louis Guss in 1921 but simpler and easier of manipulation. His findings agree in the THE ORAL INJECTION OF LIPIODOL. main with those of previous investigators, but he is able to add two new facts to our knowledge : one, FOR introducing lipiodol into the lungs oral injection that in 5 per cent. of hearts the left coronary artery seems to be the method of choice in America, and is is the sole supply of the neuromuscular tissue, the increasingly employed in this country. The ease other that Iper cent. of all hearts possess three with which it can be done is often almost incredible. coronaries, the accessory vessel being found more With no previous a,nsesthetisa,tion, with the patient commonly on the right in the proportion of 8 : 1. sitting on a chair and holding out his own tongue, Possibly the latter is the accessory vessel demonstrated and with apparatus no more elaborate than an by J. S. Campbell in 1927 at a meeting of the Associa- ordinary 20 c.cm. syringe and a straight cannula tion of Physicians of Great Britain and Ireland, and the oil can be steadily dropped over the back of the judged by him to be a branch arising from the right tongue into the trachea, and the whole affair may be coronary artery near its origin; this vessel was over in three or four minutes. Many patients will present in 20 per cent. of his series.1 Dr. Wyn declare themselves unaware that anything is happenJones notes that the coronary anastomosis becomes ing, but others, of course, are intolerant. Others, much more extensive with increasing age, a fact again, while appearing to allow the oil to descend confirmed by others, and it is of interest to realise that the trachea, will hold the oil above the glottis and previous coronary disease is an advantage to the then expel it all by a sudden cough. In such a case patient whose artery is occluded; the gradual it is an advantage to be able to see exactly where the diminution of the lumen of the vessel by athero- oil is going, and Arnold Josefson, of Stockholm, sclerosis allows an efficient compensatory anastomosis has described3 an instrument for this purpose. to develop, so that when the final block occurs the new It consists of a curved spatula along the upper surface anastomotic channels are ready to take on the of which is affixed a cannula projecting beyond the necessary work. Again a condition ofhigh blood end of the spatula ; above this is a lamp and a pressure is also an advantage to the patient, for the laryngeal mirror. Such a device may be of value in fall of pressure consequent on the shock of the sudden difficult cases, but with gentle persistence it will be thrombosis is not so great as it would be in a patient found that even the intolerant are often able to allow if the pressure were normal, and there is no delay in the oil to flow down the trachea. Lipiodol injections the opening up of new anastomotic channels. This worked

on

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1 THE LANCET, 1926, ii., 168.

2 Brit. Med. Chi. Jour., 1927, xliv., 257. 3 Acta Med. Scand., 1930, lxxiii.,

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