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MEDICINE IN KHARTOUM
381
MEDICINE IN KHARTOUM IN February, 1924, the Kitchener School of Medicine at Khartoum was opened. On his last visit to the Sudan Lord KITCHENER expressed a strong wish that medical training should be available for Sudanese students. The proposal appealed strongly to the Sudanese and no less than 11,000 was subscribed by them towards the original scheme. It soon became obvious that the students were not only extremely intelligent but also made efficient and reliable doctors. The original object of the school was to turn out a small group of young men who could carry on the practice of medicine in the extremely trying climate of the Sudan. The principle of the small group has been adhered to and as a result it may be doubted whether any medical students elsewhere in the world receive more individual tuition. The report by Sir ALFRED WEBB-JOHNSON to the committee of management of the English Conjoint Board, mentioned elsewhere in this issue, gives an encouraging picture of the Kitchener school. In
its early days the school was fortunate in that Sir HENRY WELLCOME established in the Gordon College a group of laboratories for tropical agricultural and medical research. It has now been wisely decided to separate these two branches. The medical work is being carried on in the Stack laboratories close to the hospital and medical school, while the agricultural branch is at Medani in the Gezira where it is in immediate touch with the problems and difficulties which confront agriculturists in the Sudan. Sir Alfred looks forward to the establishment of a university college in
Khartoum
embodying departments of arts, science, agriculture, engineering, veterinary science and medicine. There can be little doubt that a movement will speedily develop for a university in Khartoum, and this deserves every encouragement. With the decline of western academic influence in Egypt the importance of the Sudan as a cultural element in Africa may be expected to increase. It therefore becomes doubly important that the development of a university at Khartoum should in no way be impeded.
ANNOTATIONS MORTALITY TREND IN DIPHTHERIA
DIPHTHERIA, like other diseases spread by droplet infection, is probably quite as prevalent in this country today as it was forty years ago when com-
pulsory notification was introduced. During this period, however, certain other changes have taken place which have perhaps not received all the attention they deserve. It appears that the spearhead of diphtheria’s attack on child life has been moving gradually from the child of pre-school age to the child of school age. Picken,l two years ago, after pointing out that the earliest indication of this change was noted by Murphy2 as long ago as 1907, showed that the shift of fatality to older children had continued-being particularly striking in London during 1932-35. He noted a similar change in Manchester and in Glasgow. Knowledge of this subject, has now been put on a wider basis by Wright,3 who has completed a valuable and comprehensive study of the clinical severity of diphtheria in seven cities (Liverpool, Birmingham, Manchester, Glasgow, Leeds, Hull and Edinburgh) over the period 1911-35. He finds that, though the incidence of diphtheria in the cities concerned shows fluctuation, there was a uniform and considerable decline in clinical severity as far as could be judged by case-fatality rates. During the final quinquennium (1931-35) of the study, however, the decline ceased, and in some places there was an increase in clinical severity which was independent of epidemics. This general picture can be traced also within the various *
age-groups of 0-4 years, 5-9 years and 10-14 years, but the decline in case-fatality rates was proportionally less for the age-group 5-9 than the age-group 0-4 in all cities studied except Glasgow. The shift of mortality to older children Picken was inclined to attribute to the more recently recognised type changes in the diphtheria bacillus itself. Cheeseman, Martin and Russell4 on the other hand have adduced 1. Picken, R. M. F., Lancet, 1937, 1, 1445. 2. Murphy, S., Trans. epidem. Soc., Lond. 1907, 26, 99. 3. Wright, H. D., J. Path. Bact. July, 1939, p. 135. 4. Cheeseman, E. A., Martin, W. J., and Russell, W. T., J. Hyg., Camb. 1939, 39, 181.
evidence that reduction in the size of families, whereby children fail to encounter infection until school years, is primarily responsible ; and improvement in the environment of young children also plays a part. Studies of this kind, apart from their value to the public-health departments concerned, have general implications that should not be ignored. If, as is suggested, the decline in clinical severity of diphtheria has now either ceased or been replaced by a rise, then a sharp stimulus towards active immunisation is required. The well-attested shift of mortality to older children also has a bearing on immunisation, indicating the desirability of immunising the child population as a whole, instead of concentrating on the very young. RADIOGRAPHY OF THE COLON
EXAMINATION of the several parts of the alimentary ingenuity of the radiologist. The stomach and duodenum can be made empty by fasting, and their peristaltic movements are frequent enough for a series of pictures to be taken at short intervals after the barium meal, when the changing contour of the opaque contents admits of diagnostic inferences. When the rate of passage is quick, as it is through the small intestine, strial pictures may be obtained by using a thin barium-impregnated paste. For the colon the barium meal is supplemented by an opaque enema. Both have their disadvantages. By the time the barium meal reaches the colon it is mixed with residues of other meals, so that beyond the caecum and ascending colon details of filling may be confused, and even for this part of the colon a supplementary opaque enema is needed. The barium enema has the disadvantage of being given against the normal course of peristalsis; it may need a previous lavage of the colon to clear out food residues ; moreover the ordinary movements of the colon are infrequent and spasm may confuse the picture. In a recent study Rachet and Arnous1 point out that even two or three pictures taken at tract taxes the
short intervals may not be 1.
really satisfactory
for
Rachet, J., and Arnous, J., Pr. méd. July 8, 1939, P. 1093.
MEDICINE IN KHARTOUM IN February, 1924, the Kitchener School of Medicine at Khartoum was opened. On his last visit to the Sudan Lord KITCHENER expressed a strong wish that medical training should be available for Sudanese students. The proposal appealed strongly to the Sudanese and no less than 11,000 was subscribed by them towards the original scheme. It soon became obvious that the students were not only extremely intelligent but also made efficient and reliable doctors. The original object of the school was to turn out a small group of young men who could carry on the practice of medicine in the extremely trying climate of the Sudan. The principle of the small group has been adhered to and as a result it may be doubted whether any medical students elsewhere in the world receive more individual tuition. The report by Sir ALFRED WEBB-JOHNSON to the committee of management of the English Conjoint Board, mentioned elsewhere in this issue, gives an encouraging picture of the Kitchener school. In
its early days the school was fortunate in that Sir HENRY WELLCOME established in the Gordon College a group of laboratories for tropical agricultural and medical research. It has now been wisely decided to separate these two branches. The medical work is being carried on in the Stack laboratories close to the hospital and medical school, while the agricultural branch is at Medani in the Gezira where it is in immediate touch with the problems and difficulties which confront agriculturists in the Sudan. Sir Alfred looks forward to the establishment of a university college in
Khartoum
embodying departments of arts, science, agriculture, engineering, veterinary science and medicine. There can be little doubt that a movement will speedily develop for a university in Khartoum, and this deserves every encouragement. With the decline of western academic influence in Egypt the importance of the Sudan as a cultural element in Africa may be expected to increase. It therefore becomes doubly important that the development of a university at Khartoum should in no way be impeded.
ANNOTATIONS MORTALITY TREND IN DIPHTHERIA
DIPHTHERIA, like other diseases spread by droplet infection, is probably quite as prevalent in this country today as it was forty years ago when com-
pulsory notification was introduced. During this period, however, certain other changes have taken place which have perhaps not received all the attention they deserve. It appears that the spearhead of diphtheria’s attack on child life has been moving gradually from the child of pre-school age to the child of school age. Picken,l two years ago, after pointing out that the earliest indication of this change was noted by Murphy2 as long ago as 1907, showed that the shift of fatality to older children had continued-being particularly striking in London during 1932-35. He noted a similar change in Manchester and in Glasgow. Knowledge of this subject, has now been put on a wider basis by Wright,3 who has completed a valuable and comprehensive study of the clinical severity of diphtheria in seven cities (Liverpool, Birmingham, Manchester, Glasgow, Leeds, Hull and Edinburgh) over the period 1911-35. He finds that, though the incidence of diphtheria in the cities concerned shows fluctuation, there was a uniform and considerable decline in clinical severity as far as could be judged by case-fatality rates. During the final quinquennium (1931-35) of the study, however, the decline ceased, and in some places there was an increase in clinical severity which was independent of epidemics. This general picture can be traced also within the various *
age-groups of 0-4 years, 5-9 years and 10-14 years, but the decline in case-fatality rates was proportionally less for the age-group 5-9 than the age-group 0-4 in all cities studied except Glasgow. The shift of mortality to older children Picken was inclined to attribute to the more recently recognised type changes in the diphtheria bacillus itself. Cheeseman, Martin and Russell4 on the other hand have adduced 1. Picken, R. M. F., Lancet, 1937, 1, 1445. 2. Murphy, S., Trans. epidem. Soc., Lond. 1907, 26, 99. 3. Wright, H. D., J. Path. Bact. July, 1939, p. 135. 4. Cheeseman, E. A., Martin, W. J., and Russell, W. T., J. Hyg., Camb. 1939, 39, 181.
evidence that reduction in the size of families, whereby children fail to encounter infection until school years, is primarily responsible ; and improvement in the environment of young children also plays a part. Studies of this kind, apart from their value to the public-health departments concerned, have general implications that should not be ignored. If, as is suggested, the decline in clinical severity of diphtheria has now either ceased or been replaced by a rise, then a sharp stimulus towards active immunisation is required. The well-attested shift of mortality to older children also has a bearing on immunisation, indicating the desirability of immunising the child population as a whole, instead of concentrating on the very young. RADIOGRAPHY OF THE COLON
EXAMINATION of the several parts of the alimentary ingenuity of the radiologist. The stomach and duodenum can be made empty by fasting, and their peristaltic movements are frequent enough for a series of pictures to be taken at short intervals after the barium meal, when the changing contour of the opaque contents admits of diagnostic inferences. When the rate of passage is quick, as it is through the small intestine, strial pictures may be obtained by using a thin barium-impregnated paste. For the colon the barium meal is supplemented by an opaque enema. Both have their disadvantages. By the time the barium meal reaches the colon it is mixed with residues of other meals, so that beyond the caecum and ascending colon details of filling may be confused, and even for this part of the colon a supplementary opaque enema is needed. The barium enema has the disadvantage of being given against the normal course of peristalsis; it may need a previous lavage of the colon to clear out food residues ; moreover the ordinary movements of the colon are infrequent and spasm may confuse the picture. In a recent study Rachet and Arnous1 point out that even two or three pictures taken at tract taxes the
short intervals may not be 1.
really satisfactory
for
Rachet, J., and Arnous, J., Pr. méd. July 8, 1939, P. 1093.