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Agglutination Reactions of Vibrio kegallensis.-Rabbits were inoculated with the three strains, and the serological reactions compared with each other and with trus cholera. The results are seen in the following table:--
Bera.
Kegallensis, Strain I., serum
Kegallensis, Strain II., serum ... Kegallensis, Strain III., serum True cholera serum (Berne)
Agglutination Limits with
Strain 1.
Strain II.
Strain IIL
Trae Obolers Vibrio.
2,000
2,000
1,800
0
2,000
2,000
2,000
0
2,000 10
2,000
1,800
10
90
20
4,000
Absorption Tests.-Absorption tests give results confirming those obtained by agglutination reactions, the conclusion being that the three strains are identical and represent one single species, and that they differ from true cholera.
Pathogenicity. Was the vibrio the real cause of the two cases of cholera-like disease? The fact that it was present in large numbers and was the only vibrio present is rather in favour of it, though I have been unable to reproduce a cholera- like disease in the lower animals (monkeys and rabbits) by feeding experiments.
Conclusions.
1. From two cases of clinically cholera-like disease, and from the water of a well near which several similar cases had occurred, a vibrio was isolated which is In a preliminary note, biologically different from the true V. cholera, Koch. published some time ago, referring to the first case, I named it V. kegallensis, Cast, 1913.
2. Though its pathogenicity has not been completely proved, the probabilities are that it is the cause of certain cases of cholera-like disease, or "Paracholera."
THE INTERNAL TREATMENT OF YAWB.
Ehrlich's salvarsan-first introduced for the treatment of yaws by Nicol, Strong, and myself—is without any doubt a specific which acts in a manner little less than marvellous on the disease. "It would seem, therefore, superfluous at the present time to experiment with any other treatment. It must be noted, however, that while the salvarsan treatment can be easily carried out in large cities like Colombo, where well-equipped hospitals are available, and in other localities of the island where qualified medical men are present, it can only be used with great difficulty, how- ever, in districts of the interior, where hospitals are few, and properly qualified On the estates also there is generally only an apothecary, who can hardly be entrusted with the performing of intravenous injections; moreover, some fow natives absolutely refuse any kind of injection treatment, either intravenous or muscular. At the present time another reason for experimenting with other forms of treatment, even if less efficacious, is the war, which has already caused a shortage of salvarsan.
men scarce.
For the above reasons I have, since several months, again made some researches. on the internal treatment of the disease. I will say at once that the mixture I am using contains no new substance, but a combination of easily obtainable drugs which have been found in the past to be beneficial in the disease by myself and others. If there is anything new, it is in the combination of the drugs, and in the measure of the doses given.
The mixture contains:-tartar emetic, gr. 1; sodii salicyl., gr. 10; potassium This dose iodide, 1 drachm; and bicarbonate of soda, gr. 15, to 1 oz. of water.
is given, diluted in 4 ozs. of water, thrice daily in adults and youngsters above 14 years; half doses are given in children 8 to 14 years of age, and one-third or less in younger children.
Tartar Emetic-Antimonial preparations were first introduced in the treat- ment of yaws by Brault in 1911; he gave them by intravenous injections, as in sleep- ing sickness. In my experience such preparations have a beneficial effect, but the action is very slow, and very much less evident than potassium iodide.
Sodi Salicylate-In the experiments I carried out in the clinic some years ago. I found out that this drug has a very slight beneficial effect in yaws: it has little or no direct effect on the yaws lesions, but hastens the disappearance of The thick yellow crusta due to secondary pyogenic infections.
07
Potassium Iodide.-Some years ago, long before salvarsan was introduced, I made some experiments in the Colombo Clinic for Tropical Diseases with various drugs, pot. iod., mercury, etc., and came to the conclusion that, while mercury was generally inefficacious, potassium iodide gave fairly good results in a certain number of cases; the great drawback was that good effects were obtained only by using very large doses, and these very often gave rise to such severe symptoms of iodism that the patients refused further treatment.
Sodii Bicarbonate.-The addition of bicarbonate to the mixture was made with the object of avoiding, as far as possible, iodism: thereby enabling one to give The presence massive doses of potassium iodide, which only are really effective.
of large doses of bicarbonate seems also to diminish the emetic action of antimonium preparations.
Appearance of the Mixture. The mixture is, pharmacologically, a very inele gant one; it is cloudy, and has a sediment, owing to the presence of a large amount of bicarbonate of soda. At the time of administering it, however, a dose is diluted with four times the amount of water, and then becomes clear.
Effects of the Mixture.-I have tried the mixture in eleven cases, given in the doses mentioned, for ten to fifteen days; then five or ten days rest; then in some cases another course for another five or ten or fifteen days. The results were very, satisfactory in recent and fairly recent cases, in which the disease had started three to twelve months previously: this can be seen from the annexed photos. In very old cases the results were much less satisfactory, and could not in any way be Very mild compared with those obtained with salvarsan and neo-salvarsan. symptoms of iodism were noticed in three cases, but were not sufficiently severe to stop the treatment or decrease the doses: it was, in fact, remarkable how well borne were in most cases the huge doses of potassium iodide given. In four cases in which I increased the tartar emetic to gr. 2 nausea and vomiting occurred, No symptoms and the tartar emetic had to be decreased again to gr. 1 per dose. pointing to any depressing action on the heart were noted.
Resumé and Conclusions.
1. Ehrlich's salvarsan and neo-salvarsan are, without any doubt, the specific drugs for yaws. Their efficacy in the disease is, in fact, almost marvellous, and more striking by far than in syphilis. When, however, for any reason, such as shortage of the above drugs, the absence of properly qualified medical men in the infected districts, refusal of patients to be injected, etc., an internal treatment by easily obtainable drugs is desirable, the mixture I have suggested and used may be recommended, especially in recent cases.
2 The mixture contains tartar emetic, gr. 1; sodii salic., gr. 10; potass. iodod. 1 drachm; sodii bicarbonate, gr. 15; to loz. of water. Three doses are given diluted in four times as much water to adults, half doses to children 8 to 14 years of age, and one-third or less to younger children. The active drugs in the mixture are the potassium iodide, and, in a very much less degree, the tartar emetic, while the sodium salicylate seems to hasten the disappearance of the crusts. The presence of a large amount of bicarbonate of soda-though making the mixture a very inelegant one-apparently prevents to a great extent the symptoms of iodism and decreases the emetic properties of the mixture, in this way rendering possible the administration of massive doses of potassium iodide and large doses of tartar emetic. As regards other drugs tried, such as mercury and liq. arsenicalis, their action, in my experience, is practically nil, though occasionally such drugs may be incorporated in the mixture.†
A CASE OF TRIPLE INFECTION: TYPHOID, Paratyphoid A, and Paratyphoid B.
Cases of contemporaneous double infection, typhoid and paratyphoid A or paratyphoid B, have been placed on record by several observers, and I have seen several such cases in Ceylon, but to my knowledge no cases of triple infection-typhoid, paratyphoid A, paratyphoid B-have been published. The following case, there- fore, may be of some interest:-
* Not reproduced.
It may be of interest to put on record that I have used a somewhat similar treatment in a This patient had my yaws case of kalazar, a coolie who had contracted this disease in India. mixture for several months, and also intravenous injections of tartar emetic and liq. Fowleri, with satisfactory results.
G 2Page 331
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68
Mr. E., American, 50 years of age, was on a pleasure trip round the world in 1918-1914. In January, 1914, while in India, he began feeling unwell, tired, and feverish. He took large doses of quinine, which did not influence the fever. He arrived in Colombo on the 31st January, and, feeling very unwell, consulted me the same day: temperature 102°, pulse 90, tongue coated, slight abdominal dis- tension, spleen just palpable, no roseola. I took him to a nursing home and treated him for enteric on the usual lines. He had several extremely severe hemorrhages a few days after entering the home, and his condition became very serious: the course was very prolonged, two relapses taking place, the last with signs of severe cystitis. He finally recovered completely, and left Ceylon in April, 1914.
Bacteriological Examinations carried out.-The blood was tested for aero- logical reactions six times during the whole course of the malady: twice during The stools were bacteriologically examined three the first week in the home. times: once before the hemorrhages took place. The urine was bacteriologically examined twice during the last relapse, when the patient began complaining of urinary symptoms.
Blood. Serum reactions: tested six times against B. typhosus, B. paratyphosus A and B, during the whole course of the disease and convalescence agglutinated completely all of them, the average agglutination limits being represented by dilu- tions of 1 in 80 for B. typhosus, 1 in 60 for B. paratyphosus A, 1 in 80 for B. para- typhosus B. Owing to to objections on the part of the patient's relations, no hæmocultures were carried out.
Absorption Tests.-Serum reactions are not sufficient to make a diagnosis of mixed infection, because multiple agglutination does not always mean multiple infection. Absorption tests carried out twice showed the typhoid, paratyphoid ́A, and paratyphoid B agglutinins to be specific.
Stools.-The stools were bacteriologically examined four times on the first occasion, before the hemorrhages took place, B. typhosus, B. paratyphosus A, and B. paratyphosus B were isolated. On the second and third occasions only B. typhosus and B. paratyphosus A were grown.
Urine. On the two occasions when the urine was bacteriologically examined, B. typhosus and B. paratyphosus A were isolated.
Remarks and Conclusion.
It would seem to me that the patient was suffering from a contemporaneous triple infection, viz., typhoid, paratyphoid A, and paratyphoid B, as the three germs were isolated contemporarily from the stools on one occasion, the blood agglutinated the three micro-organisms during the whole course of the disease, and absorption tests showed the agglutinins for each germ to be specific.
Such cases of multiple triple infection must be rare, but those of mixed double infection: typhoid+paratyphoid A or B, are not so rare in Ceylon, where I have seen also mixed paratyphoid A and paratyphoid B infections. They all serve to emphasize, in my opinion, the advisability of using, for prophylactic purposes, the combined typhoid + paratyphoid A+paratyphoid B vaccine, as introduced by me and used since 1905, instead of the simple typhoid vaccine as generally done.
A CASE OF Vaginitis of HYPHOMYECETIC ORIGIN.
Was admitted to the Lying-in She was Cingalese woman-a vagrant-age about. 35. Home in October, 1914, being in a condition of advanced pregnancy. almost a dwarf, and greatly deformed, owing, probably, to rickets in childhood. The surgeon in charge of the home, Dr. Sinnetamby, decided to perform a Cæsarean so by the discovery of a thick vaginal operation, but was stopped from doing discharge, which, from its macroscopical appearance, was suspected to be of gonorrhoeal origin. The discharge, collected by means of sterile swabs, and also by a large sterile pipette, with all precautions, was examined by me at the Bacterio- logical Institute. The discharge was thick, of a yellowish colour, and some mem- No gonococci or cocci of any kind were present; brane-like formations were seen. instead, an enormous number of yeast-like cells, long mycelial filaments, and a few bacilli. The membrane-like bodies apparently consisted of enormous masses of the fungus. Several maltose and glucose agar tubes were inoculated, and white, creamy, roundish colonies, characteristic of a monilia, developed within twenty-four hours and soon coalesced together. The fungus, for purposes of identification, was inocu- The results are collected lated in litmus milk, gelatine, and various sugar broths
in the following table:-
Monilia pinoyi, Cast.
Monilia pinoyi, Cast.
Litmus Milk.
O
•
Arabinose,
69
MONILIA PINOyi, Cast.
AG
AG
AG
0
0 0
ల
O
Peptone Water
C
о
Indol.
O
Gram.
Dulcite.
O
Gelatine.
O
Dextrine.
පු
Berum.
O
Rain.ose.
O
Neutral Bed.
O
Abbreviations used in the table:-A, acid; G, gas; C, clot (milk), clear (broth and peptone water); O, negative result: viz., neither acid nor clot in milk, neither acid nor gas in sugar medis, non-productive of indol, non-liquefaction of gelatine or serum, as the case may be; +, positive result: liquefaction of medium.
From the table it will be seen that the fungus does not coagulate milk, does not liquefy gelatine, and produces gas only in the following three sugars glucose, levulose, maltose. The fungus is, therefore, probably identical to Monilia pinoyi,
Cast., 1911, which I described some years ago.
COMBINED PRophylactic VACCINATIONS.
During the last six months I have continued the use of mixed prophylactic vaccines with satisfactory results. The mixed vaccines which I have found most useful from a practical point of view are the following:-
1. Typhoid-paratyphoid A-paratyphoid B.
2. Typhoid-paratyphoid A-paratyphoid B-cholera.
3. Typhoid-paratyphoid A-paratyphoid B-Malta fever. 4. Plague-cholera.
I have described in previous reports the preparation of the above vaccines and other mixed vaccines. I based their preparation on some experiments I carried out in 1901-1902, when I was able to demonstrate that an animal inoculated with two species of bacteria produced agglutinins and immune bodies for each species, the amount of such agglutinins and immune bodies not being much less than in control animals inoculated with one species only.
Moreover, I demonstrated that even inoculating an animal (rabbit) with three different germs (B. typhosus, B. pseudodysentericus, No. 1 (Kruse), strain of B. coli communis), the amount of agglutinins and immune bodies elaborated for each germ was nearly the same as in animals respectively inoculated with one germ only. In rabbits I found that by inoculating more than three species of micro-organisms no good results were obtained. In man it appears that vaccines consisting of four species, and occasionally even vaccines composed of five species, can be inoculated with satisfactory results.
ALDO CASTELLANI.
Colombo, 31st December, 1914.