CO885-(18-19) — Page 551

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༄།།་།་། ་། །། mmimmimi C.O.885

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These facts seem to show that atoxyl has a temporary good effect on sleeping sickness patients, but that this effect in the great majority of cases is only a tempor- ary one, as nearly half the cases admitted in December, 1906, and January, 1907, are now dead.

It will be seen from the above table also, that in 231 cases atoxyl was remitted. These cases were selected because they presented the following features:—

There was an absence of trypanosomes from the glands, and the patients appeared well and fairly strong. A few of them presented tremor of the tongue and itchiness of the skin, but they had all been under atoxyl treatment for at least four months, the majority for six months. Sixty-four of these cases have relapsed up to the present. (Note: that there generally was an interval of some three or four months, during which time the patients were having no atoxyl, before the relapse became evident.) Twenty-eight of these people in whom atoxyl was remitted as above have died up to the present (November 30th, 1907).

Dr. van Someren, reporting on the value of atoxyl treatment, in August says:- Up to the present I have never seen any untoward symptoms follow the injec tion of one gramme atoxyl. Injections are sometimes followed by a slight rise of temperature, and by some pain in the chest, which, however, soon disappears. There have been 95 deaths up to the present time in the camp; of these five died from extraneous causes; 27 died fairly soon after admission, having had only a few injections of atoxyl; the remaining 63 showed a marked initial improvement, but subsequently died after a shorter or longer interval. This may seem a large number, but it must be borne in mind that many of the patients were brought in in a very late stage of the disease. Epileptiform seizures towards the end were very common. In some cases these seizures recurred rapidly, and were prolonged in duration. A sudden access of mania, terminating fatally in a few days, occurred in one case that had been under treatment for eight months.

Various paralyses, both hemiplegic and paraplegic in type, were present. a glosso-pharangeal type being common, the patient, though appearing from his expression to be mentally bright, being unable to speak or swallow. Bed-sores in the paralytic cases were, as was to be expected, distressingly common, and often reached great dimensions.

It is evident from these that in certain cases the drug proves quite ineffectual in arresting the disease. This leads one to suspect that though temporarily checked, the trypanosome sul sequently acquires an immunity to this drug. Initial large doses, given consecutively, might, therefore, be of value.

In no case have trypanosomes been found after the treatment with atoxyl in the superficial lymphatic glands, the earliest disappearance of the parasite being in our experience about 12 hours after the first dose with the non-appearance at any subsequent period as far as can be made out. A certain number of cases, however, while appearing outwardly healthy, and even the patient himself may declare that he feels well, yet, on examination, one finds that they have a continuous irregular temperature, rising possibly to 103° F. or more every evening with remissions to normal or subnormal at intervals, but in the main fluctuating between normal and 100° F. By special request of His Excellency the Governor, no lumbar punctures or post-mortem examinations are performed at our camps for fear of rendering them unpopular, so that it is impossible to say more than that after atoxyl the trypano- somes cannot be found in the blood or gland juice. It may be that trypanosomes could be found in the cerebro-spinal fluid; in fact, this was actually found to be the case by Dr. Collyns in a patient who had undergone a course of atoxyl, and in whom a continuous temperature persisted, though trypanosomes could not be found in the glands or blood.

Trypanosomes have not reappeared in the blood or lymphatic glands of any of these cases up to the present. In most cases the formerly enlarged lymphatic glands have decreased in size to a remarkable degree, and in many no gland enlarge- ment can now be recognised.

Loss of sexual power is a very common and early symptom of sleeping sickness; the sexual history of 75 people is as follows:-

29 of them have regained their sexual functions after a cessation of from

four months to two years in some cases.

15 patients, though feeling otherwise sound, are still either impotent or

amenorrhoeic.

31 cases, including children, have been sexually normal throughout the course

of the disease.

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These facts seem to show that in some cases this drug is of very real benefit. Up to September, 1907, Dr. van Someren says concerning atoxyl " In no case as yet has any untoward symptom occurred which could be attributed to any toxic effects from the drug. I have had several cases of intense vertigo, which I thought at first might be due to an excessive dose or to an accumulative effect of the drug, but vertigo I found to be a fairly common symptom in fresh cases, and further, there appeared to be no difference in the duration of the attack, whether the drug was intermitted or not. The administration of 5 c.c. (one gramme) of atoxyl to an adult is followed by absolutely no reaction beyond, in some cases, a slight rise of tempera- ture subsequently, such as is often met with."

Father Vurangot, of the "White Fathers," reporting at the middle of August on his experience with atoxyl and on its value says: "I have been giving atoxyl in doses of 5 c.c. of a 20 per cent. solution (one gramme) repeated every nineteenth or twentieth day. I have treated four cases in this way for as long as nine months. have never seen a dose I think three of these four are now cured of the disease.*

of atoxyl followed by urgent symptoms, but some of the patients to whom I have given injections have had high fever for one or two days afterwards, which has abated without the use of quinine. Equally the majority of those who have had atoxyl have complained of pain in the chest afterwards, but this symptom only lasts for two or three days. I have never seen an abscess follow on an injection of atoxyl."

I take it that this must also be the opinion of the German Commission under Professor R. Koch, who left Sesse at the beginning of October of the present year, for Professor Klein, before he left Uganda, advocated the giving of atoxyl in doses of one gramme on two consecutive days, and repeating the same in a fortnight's time. Dr. van Someren, reporting again on atoxyl on October 29th, said that he had had a succession of patients with symptoms which he thought were undoubtedly due to the toxic effects of arsenic. That he had been giving atoxyl in exactly the same doses as usual, and that further, the toxic symptoms had manifested themselves after comparatively small doses in cases who had not been treated before. Dr. van Someren then gives details of 19 cases, all of whom developed more or less urgent symptoms within 48 hours of their injections, such as intense colic, vomiting, vertigo. He goes on to say that and intense headache. Fire patients develored amaurosis. luckily he had no fatal cases in which blame could be laid on the drug, and that he had been able to allay the distress fairly quickly in most of the sufferers.

Dr. van Someren adds that this uncertainty in the action of our present supply of atovyl renders the estimation of the doses for any particular patient much more difficult than formerly.

On receint of this communication from Dr. van Someren I immediately sent word to Drs. Baker and Collyns, who are in charge of our camps in Usoga and Busiro, to report on their experience with this atoxyl. Both these doctors reported that they had noticed differences in the atoxyl that had recently been supplied to them.

(1) It was much more soluble than former samples.

(2) The solution of the drug changed colour much sooner than formerly

(more unstable).

(3) That its administration did not scem to be followed by the same improve- ment in their patients which had been previously noted with former samples of the drug.

(4) That. however, they had not found that urgent symptoms followed its

administration.

Amaurosis has been noted 14 times at Busiro-always in people who have been on atoxyl a long while, and Dr. van Someren reports five more cases, which he puts down to the new supply of atoxyl. As these cases all seemed to come together, it is certainly very suspicious. Up to the time of Dr. van Someren's report, the medical officer in charge at Busiro had not connected the cases of amaurosis that had occurred there as due to the atoxyl. I am not aware that amaurosis has ever been mentioned as a symptom of sleeping sickness by any observer before, whereas I believe it has been reported before, after injections of atoxyl, and may be due to the aniline which it contains.

To get the greatest value from atoxyl treatment, it seems that the initial doses of the drug should be as large as possible. Recent work on the subject seems to

I have personally examined these cases. Trypanosomes cannot be found in their glands or blood and they seem at present normal individuala.