MAURITIUS.

1381 MAURITIUS.

Annotations. "Ne quid nimis."

THE

STUDY OF DEEP X RAY THERAPY. MORE than a year ago Dr. Reginald Morton related1 to the Section of Electro-Therapeutics of the Royal Society of Medicine his impressions of deep X ray therapy gained during a visit to the Frauenklinik at Erlangen. After a week’s study of the methods there employed he came away with the conviction that the apparatus and technique constituted a real advance in radiology. Admittedly no new principle was involved, but a greater degree of penetration and intensity was attained at Erlangen than elsewhere, and the results already shown in of uterine carcinoma, apart from surgical cases intervention, were, to say the least, very encouraging. A latent period of scepticism was followed by an increasing rush to the scene of action, with the amusing result that the admission thereto has been strictly rationed. The British Medical Journal of Dec. 3rd recounted the difficulties of Dr. Nordentoft, of Copenhagen, in getting to Erlangen. The fact is, and we have it from Prof. Wintz himself, that the work of the radio-therapeutic department has been seriously embarrassed by the attention given to it. Prof. Wintz is desirous of restricting the visitation to a post-graduate course to be held in the early part of next year. Those who intend to take part in it should not only possess a competent knowledge of the German language, but they would be wise to master a book2 written by Dr. F. Voltz when he was head of the experimental laboratory attached to the radiotherapeutic department at Erlangen. It is a complete exposition of our knowledge of the character of X rays, their chemical and physical properties, and of methods for measuring their wave-length, their penetrating power through various substances, and their quantity in arbitrary units. Not only are these matters described in great detail, with a wealth of numerical tables and diagrams, but the secondary phenomena attending the passage of a beam of X rays through matter are also fully dealt with. The scattering of the primary beam, the excitation of secondary radiation, and the selective absorption have each to be taken into account in an attempt at estimating what the intensity of radiation at any particular point may be. Dr. Voltz states that the main object of his book is to provide data from which the radiologist may estimate dosage. The treatment adopted is rigidly physical; mathematical formulae are freely distributed throughout its pages and make its study exhilarating if difficult. The experimental plan of the work actually forms the basis from which the quantitative methods of measurement used in the Erlangen clinic have sprung. It has been felt for many years by radiologists that the means at their disposal for the accurate measurement of doses were scanty. The electrical method described here, which is based upon the principle of the first inoto-quantimeter of Szillard, has been much developed by German physicists in the last few years, and it seems likely enough that this instrument, or some variation of it, will become extensively employed by radiologists. Its use alone will not give them all the information they want, but the fundamental principles upon which it is based will necessarily become better known, and medical men will become more familiar with physical quantities and expressions of which at present they are rather shy. 1 THE LANCET, 1921, i., 24, 37. 2 Die Physikalischen und Technischen Grundlagen der Messung und Dosierung der Röntgenstrahlen. By Dr. Friedrich Voltz, Physikalischer Assistent der Strahlenabteilung der Universitätsfrauenklinik Munchen. Berlin : Urban und Schwarzenberg. 1921. Pp. 300. M.96.

MAURITIUS defaults

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sanitary reformer, despite the fact that the island has been a Crown colony for over 100 years. Such was the inevitable conclusion to be drawn from the graphic account given by Dr. Andrew Balfour to the Royal Society of Tropical Medicine and Hygiene of a recent visit to the island, undertaken at the instance of the Colonial Office and with the object of reporting on the sanitary conditions which had been seriously complained of by the Governor, Sir Hesketh Bell. Up to the middle of last century Mauritius appears to have been a peculiarly pleasant place to live in. Its scenery affords as much variety as can be hoped for in an island rather smaller than the county of Surrey ; its climate is mild and equable, even delightful between May and December, and though periodically prolonged heavy rains and destructive hurricanes occur, the porous volcanic soil dries rapidly. But since 1854, when a visitation of cholera swept away 17,000 of the inhabitants, Mauritius has been under the scourge of disease. In 1865 the chance call of a ship at Port Louis from the malarious African coast introduced the Anopheles costalis, and the deforestation then in progress, to make room for the sugar cane, had undoubtedly prepared a way for the outbreak of malaria which decimated the island in 1867 and 1868; 31,800 of the population succumbed to this epidemic. Endemic malaria still claims 3000 to 4000 victims every year. Antimalarial measures on a large scale have been attempted, and in many parts of the island canalisation of streams has been carried out or begun as the result of Major Ronald Ross’s survey and classic report in 1908. Unfortunately, however, his recommendations were only

imperfectly put into effect, despite subsequent efforts by local health officers. Dr. Balfour found pools in the streets arising from defects in the water pipes, from overflow wastage or drainage from pools in the vegetable gardens ; he found stagnant water collecting in waste tins, graveyard urns. and hollow shells of the large edible snail. From all these sources larvæ of A. costalis were obtained. The irrigation of extensive sugar plantations, the overflows from unchannelled streams, the reed-grown banks of streams and rivers, and the marine swamps also afforded sufficient evidence of mosquito-breeding haunts to account for the general prevalence of endemic malaria. On the other hand, certain areas are free from the pest, as the result of proper canalisation and clearing of growth of river margins, and here streams are so shaded that the spread of a water weed inimical to mosquito larvæ is allowed full scope. Apart from malaria, the other principal causes of death in Mauritius are pulmonary tuberculosis, dysentery, bronchitis, and pneumonia. The death-rate of children under the age of 5 years For the in 1918 was over 300 per 1000 births. spread of dysentery and enteric fever the shallow wells, with every chance of contamination from the surface which form the water-supply in many parts of the island, are mainly responsible. Moreover, the insanitary conditions of the towns and the primitive methods used for the carriage and disposal of excreta, call for the most active measures of reform throughout the island. In the market places flies reign supreme ; dogs have free run of the garbage and refuse heaps, the most elementary precautions being neglected. In the outskirts, pigs in large numbers roam at will, even wallowing in the open sewage pits through the brokendown barriers. It is not surprising, therefore, that among other intestinal disorders helminthic disease, especially ankylostomiasis, is common. Although the health report for 1918 states that a new leper colony was being erected a few miles out of Port Louis, the old leper hospital, condemned as long ago as 1878, was still in use on the outskirts of the town at the time of Dr. Balfour’s recent visit. The sale and distribution of hand brooms made by the lepers is doubtless responsible for the spread of the disease, which, in Dr. Balfour’s opinion, is more prevalent than is

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The want of proper supervision of vessels moored to the quayside of Port Louis readily admits of the transmission and spread of plague by infected rats which are able to land without restraint. It is evident from Dr. Balfour’s disclosures that drastic action is imperative. To meet the situation, a levy on the sugar industry, the staple trade of the island, to the amount of £1,000,000 has been proposed. But more than this is called for. Inadequate medical and sanitary staff with insufficient authority and power of administration would seem to account for much of the delay in carrying out the greatly needed preventive and sanitary measures of reform. Much good work has been and is being done by the Mauritian doctors in the hospitals, bacteriological and public health .departments, but their powers are limited and their range of duties overwhelming in the face of such heavy odds. Valuable aid has been rendered by voluntary bodies and by the Rockefeller Foundation. Dr. Balfour is hopeful that the unenviable reputation -of the island may yet be removed by the application of modern knowledge on vigorous and sound lines. But the efforts will have to be persistent and strenuous, and, moreover, inevitably expensive. The picture of the insanitary conditions of the island drawn by so impartial an observer as Dr. Balfour does not appear to fix the responsibility therefor on any one race, but would imply that the community as a whole pays but little attention to the counsel of its medical advisers. Dr. C. L. D’Avoine, whose letter we publish in this ,issue, appears to blame the slackness of the supervision exercised over the coolie class which, in view of Dr. Balfour’s exposure of the general attitude, is

hardly surprising. THE GENESIS OF TUBERCULOUS DISEASE. ONF. of the most remarkable tendencies in modern -medicine is to refer the genesis of disease in adult life and old age to childhood and even to infancy. Mental disease in the adult is now often traced to psychic trauma in childhood, and the monarticular arthritis of middle and old age to almost forgotten and apparently transient injuries to the same joint several decades earlier. Many similar examples could be given. In the past we have been rather like the child who, - seeing a picture of an iceberg, thinks that it is floating ,on the surface of the water, and does not appreciate the size of the mass of which only a small fraction is visible. The discovery of the tubercle bacillus gave us for many years a myopic view of the duration ,of that disease. Inoculation of animals with the tubercle bacillus being followed in a few weeks or months by fatal tuberculosis, what was more natural than to assume that some similarly expeditious process was that which usually occurred in man ? There was, indeed, much reliable evidence to prove that a rapid sequence of infection, disease, and death is fairly common. For many years Behring’s dictum that pulmonary tuberculosis in the adult is the end ,of the song sung to the baby in his cradle was regarded ,as more poetic than true. In 1895 Dr. K. F. Andvord, of Christiania, put speculative hypothesis on a much surer footing, and a perusal of his statistical and critically analytical paper1 leaves even the modern reader impressed by his insight. Many of the criteria by which the hypothesis can now be tested were then lacking ; the Pirquet test, for example, had not been devised. Yet Dr. Andvord found enough evidence on which to make out a plausible case, and the mass of papers which have appeared on this subject since 1895 are a bulky testimonial to Dr. Andvord’s pioneer work. In the current number of Tubercle Dr. Andvord discusses the relation of tuberculosis in the adult to infection in childhood, and shows how the evidence of post-mortem examinations, of mass clinical examinations in certain areas, of vital statistics, and of many other lines of investigation can be made to converge on this one point. One of the tests to which 1 Norsk

Magazin for Lægevidenskaben, 1895, No. 12.

he puts his theory is the consideration of the influence of a vigorous anti-tuberculosis campaign on a population classed in so many age-groups. If his theory is correct, this campaign should first reduce the incidence of tuberculosis in the youngest age-class, and should for many years have little or no influence on the older classes. For persons over 30, for example, would have received their fatal infection much earlier. The experience of the Finnish National Association for Combating Tuberculosis throws instructive light In 1909 a certain district in Finland on this point. was selected for a large-scale experiment in antituberculosis warfare. A mass clinical examination of practically all its inhabitants was made, and then for 10 years a hustling anti-tuberculosis campaign was conducted, with a network of dispensaries, propaganda centres, and many other weapons. At the end of this period another mass clinical examination was conducted in the same district, and it was found that the cases of pulmonary tuberculosis had dwindled to a third of their total number 10 years ago. But while, in the first decade of life, this morbidity was less than a quarter of what it was, the reduction in the second decade of life was only to a little less than a third, and in the third decade only to a half. Between the ages of 30 and 50 there was little or no change in the morbidity from pulmonary tuberculosis. Another conclusion to which Dr. Andvord comes is that not only is the fatal pulmonary tuberculosis of adult life the result of severe infection in childhood, but that in a large proportion of cases the disease is clinically demonstrable from childhood onwards. Even in childhood it is possible to distinguish between the case showing a mild, benign infection, and that already more or less doomed to develop fatal tuberculosis later in life. Dr. Andvord, indeed, goes so far as to say that the gulf between the two is wide. He admits the possibility of a narrow belt of intermediate cases running between these two extremes, but maintains that it is very narrow. If, as he argues, 80 to 90 per cent. of fatal cases of pulmonary tuberculosis begin within the first three or four years of life, and if by deferring the first infection till after the fourth year we can force it to assume a permanently benign instead of a slowly virulent character, the task of suppressing tuberculosis is greatly simplified-on paper at any rate. We may, perhaps, come to focus attention on these first four fateful years instead of frittering away our energies and resources in rescuing from exposure to infection adults who are either already more or less immune on account of a benign, accidental inoculation, or whose real danger lies in a series of reauto-infections. This class requires rescuing on quite other principles than the prevention of exogenous infection. The time may not be far distant when almost every potential consumptive will be identified as such in early childhood, and will enjoy systematic supervision and treatment to the end of his days so that he may not end them in the misery of fatal pulmonary tuberculosis. The comprehensiveness and simplicity of Dr. Andvord’s conception of tuberculosis are

certainly alluringly plausible.

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THE THREAD OF BIOCHEMISTRY. WHETHER the medical student should be taught chemistry, physics, and biology as independent sciences, or go through a specially selected course in consideration of his future needs, is still a moot question. Presumably within a few years a preliminary survey of these subjects will have been made by every student during school years, specialised courses being reserved for the medical curriculum. In any case a considerable extension of biochemical teaching may be forecasted, for the proper interpretation of many of the newer clinical methods of investigation-for example, gastric analysis, determination of basal metabolism, calculation of diabetic diets, and renal function-depends on a knowledge of biological chemistry greater than that now exacted