628 Sir FRANK CONNOR described his cases in Bagdad and in India of familial and of multiple oriental sore. His clinical observations of these and other cases, their personal habits and circumstances, favoured the theory of the frequent occurrence of direct contact transmission of oriental sore. Dr. CHRISTOPHERSON pointed out the profound biological difference between the morphologically indistinguishable parasites of trivial oriental sore and fatal kala-azar. Parasites of oriental sore experimentally inoculated into human beings always produced only oriental sore. Clinical evidence suggested that oriental sore was the result of skin infection with insect flagellate, and kala-azar resulted after the flagellate had been further pathogenically modified by additional developmental cycle in another host. His own experience of naso-oral and dermal leishmaniasis in Sudan showed that lesions could be the result of inoculation by insect, and also by direct contact infection. Dr. MANSON-BAHR said he had observed oriental sore appearing in one parent in India, and six months after the family of four had returned to England the sore appearing in the other parent and the two children before the lesion in the first parent had healed. This suggested direct contact infection. He pointed out that to Dr. Wenyon we owed valuable and indispensable pioneer work on the transmission of oriental sore.
ingesting flea faeces containing infective trypanosomes. If the sand fly were the vector there were several possible modes of infection of man. Flagellates might be occasionally ejected from the fly’s rectum on to the skin, but dose deposited would be even smaller than that injected from probocis. Crushing of sand fly gave larger dose which might be inoculable by scratching or by conveyance on fingers to mouth or conjunctiva.
In India the distribution of kala-azar corresponded with that of the sand fly Phlebotomus argentipes. In China the disease was found only north of the Yangtse. There was no information regarding existence of sand flies south of it. In India argentipes was most suspected, though development occurred also in papatasii. In North China P. major var. chinensis and P. sergenti var. became infected, but former was the better host. With oriental sore, P. papatasii in Palestine and Biskra had been infected, and in In Palestine and Biskra Bagdad P. sergenti. P. papatasii had been found infected in natives. In India a single infected P. argentipes had been captured in a kala-azar house. With South American cutaneous leishmaniasis a single experiment suggested that P. intermedias might be the vector. There were infections of animals-e.g., gecko and chameleonand plants, with leptomonas, but nothing was known as to the relations these might have to the human diseases. At present, therefore, transmission problem of kala-azar and oriental sore centred around sand flies. The extraordinary flagellate development of leishmania parasites in them was convincing evidence that they were the vectors.
Discussion. Prof. HINDLE gave an account of recent work supporting the view that sand flies were mainly responsible for the transmission of leishmania. He pointed out : (1) The specific nature of the development in the sand fly. The sand fly stomach did not serve merely as a favourable culture tube, for, if so, different strains of leishi-itania should develop equally well in any one species of phlebotomus. Yet, though four different strains of leishmania all developed into flagellate stage in the Chinese sand fly P. major var. chinensis, only the local strain of leishmania showed attachment of flagellates to stomach wall, and subsequent incursion of pharynx and buccal cavity. This presence of flagellates in anterior gut occurred ,only in the species of sand fly and with the particular :strain of leishmania that seemed to be transmitted by it. (2) The virulence of the flagellates in the sand fly, proved by inoculation of contents of infected flies into susceptible hosts. As corollary, since these flagellates were present in the infected fly’s proboscis and must therefore be inoculated into skin when that fly fed, that fly’s bites would sooner or later produce infection. (3) The geographical evidence. In both India and China there was close agreement between distribution of kala-azar and that of sand fly presumably responsible for transmission of the disease. He criticised the transmission experiments up to date, and showed that with kala-azar they were inadequate in number to In prove or disprove infectivity of the sand fly. China kala-azar occurred in infants who, by reason of age, could not have been exposed to sand fly bites. Low and Cooke’s case of kala-azar in an infant born in England, whose mother had contracted kala-azar in India, demonstrated that the disease might be congenitally acquired. The infant cases in China were doubtless of that kind. Referring to possibility of a second insect host in the cases of leishmania and trypanosoma in which flagellate stage occurred only in anterior gut of insect vector, here the parasite had merely lost hind gut flagellate stage in becoming closer adapted for life in the vertebrate host. Suppression of development in insect host reached its limit in the disease " dourine," where the trypanosome had become a parasite of the vertebrate host only, and transmission was only by direct contact in coitus. Colonel A. G. MCKENDRICK quoted results of his statistical inquiry in support of the theory of sand fly transmission of kala-azar.
Correspondence. "Audi alteram partem."
ACUTE DISSEMINATED ENCEPHALOMYELITIS. To the Editor
SIR,—Attention should be directed to the frequency of acute disseminated encephaloin certain parts of London. A number of cases more or less similar have been met with during the last few years in association with vaccination or with measles, but otherwise, until recently, they have been rare. In June last, however, Drs. Hunter and Brain1 were able to report that they had seen six cases within a period of two months. In Germany and Austria such cases have been recorded in moderate numbers during the last two years, and there they seem to have occurred in circumscribed epidemics. Redlich2 in March, 1927, reported that he had seen numerous cases in Austria ; Pette3 saw 25 at Hamburg in 1926, and the early part of 1927, Muntzka4 in a paper just published records five cases at Dolling. Now that these cases are occurring more commonly in London it is desirable that their clinical features should be made widely known in order that as many as possible of the cases may be recognised. The more severe of the cases which I have seen are characterised clinically by the facts that the symptoms are referable to widely separated, or, at any rate, discrete parts of the central nervous system, and, secondly, that they come on in a series of attacks, different parts of the cerebro-spinal axis becoming involved suddenly at different times. with which
The first case I saw was that of a man of 70 who was under the care of Dr. C. E. Sundell at the Seamen’s Hospital in January of this year. His illness began with pains in both legs, and within a day or two the legs became weak and numb ; subsequent examination showed that this paralysis was of the flaccid type. During the next week there was considerable recovery and then paralysis of the 1 Hunter, D., and Brain, W. B. : THE LANCET, 1928, i., 1250. 2 Redlich, E.: Wien. klin. Wochschr., 1927, xl., 344. 3 Pette, H. : Münch. med. Woohshr., 1927, lxxiv., 1409. 4 Muntzka, K.: Zeitschr. f. d. g. Neur. u. Psych., 1928, cxvi., 161.
629 hands came on abruptly in the course of a few hours ; the extensor muscles in the forearms were as a whole more affected than the flexor, and in the right arm partial paralysis extended as high as the deltoid. Accompanying this paralysis was a sensory loss corresponding to the fifth and sixth cervical segments of the cord. These symptoms remained almost stationary for 14 days, and then acute bulbar symptoms came on and the patient died within a few hours from respiratory failure. In this case there was evidence of invasion at different times of three portions of the nervous system-lumbar enlargement, cervical enlargement, and medulla. In the next case-a man of 32, admitted under the care of Dr. S. Wyard at the Bolingbroke Hospital on the last day of June-the patient had felt indefinitely ill for a few days and had severe headache ; then he gradually lost the power of his legs in the course of four or five days, and the paralysis was accompanied by a feeling of numbness both in the legs and in the arms. During the next five or six days he was semi-conscious all the time. A fortnight after the beginning of the illness the left side of the face became paralysed, but it recovered rapidly after four days. In the limbs, at this stage, the tendon-jerks were all weak, the knee-jerks being unobtainable ; the plantar reflexes The abdominal reflexes were were indefinitely extensor. absent. The patient complained for many days of severe pains in the arms. The cerebro-spinal fluid contained an excess of protein (0-10 per cent.) but no excess of cells. In the course of five or six weeks this patient made a complete recovery. A third
case was that of a man of 55, admitted under my at the Bolingbroke Hospital on August 27th, 1928. He had not felt well for some months, and four daysbefore admission on awakening in the morning he found that both his arms were weak and shaky. Within the next four days the hands became almost useless, and then recovered considerably. Two days after admission both hands had fair power, but they were still tremulous. By that time both sides of the face had become completely paralysed. The tendon-jerks were all brisk, and the plantar reflexes indefinite. There was no sensory loss. The patient was slightly delirious, but could be recalled to consciousness. He answered questions, but was very irritable. The cerebrospinal fluid showed an excess of protein (0-085 per cent.). but no increase of cells. During the next 13 days his condition was almost stationary, but towards the end of that time his face showed great recovery. Then on Sept. gth his temperature, which had hitherto been normal, rose to 100° F., and at the same time the patient began to have difficulty in swallowing and in talking. During the next 48 hours the temperature rose steadily to 102.4’ F., and the paralysis of larynx and pharynx and tongue became absolute. The patient died from respiratory failure on Sept. 14th. A fourth case was that of a little girl of 8 whom I saw at the National Hospital, Queen-square, on August 23rd. After a period of indefinite malaise she had suffered from pains in the lower limbs ;then her legs became weak and she had difficulty in micturition, amounting almost to retention of urine. At that time she was considered to be suffering from poliomyelitis, but she had a high temperature. After three weeks the power of the legs had in great measure returned, but then the patient began to have difficulty in talking. (The precise nature of this difficulty cannot be determined.) She became very drowsy, and lay constantly with her head and eyes turned to the right. About the time of this aggravation her sight became dim. When admitted to the hospital she had extensor plantar responses on both sides, absent tendon-jerks in the right leg and arm. intention tremor in both hands, conjugate deviation of the eyes to the right, without any single ocular palsy, and partial atrophy of both optic discs. She is now recovering well, butitis too early to say how far recovery will go.
It is to be same
that in less
disease, the malady would not get beyond the of
one more or less localised cases have been of this
of the German
lesion, and most type. Many of
them presented the picture of a transverse myelitis of sudden onset and rapid recovery. Others at certain stages closely resembled poliomyelitis. In the last few weeks I have seen one case, similar to the foregoing as regards onset, but in which only spinal symptoms have appeared, and another case in which the diagnosis remains in doubt between this disease and poliomyelitis. The prognosis generally seems to be more favourable than the record of these few cases implies. In Redlich’s cases complete recovery was the rule and fatalities were few. In Pette’s series of 25 cases most of the patients made good recoveries and there
Hunter and Brain reported were only two deaths. four complete recoveries and one death among their six cases. Recovery may be incomplete and permanent defect remain, but no " after-effects " in the sense of disabilities developing after apparent recovery have, to my knowledge, been described. I am, Sir, yours faithfully, J. PURDON MARTIN.
LATER RESULTS OF PARTIAL GASTRECTOMY FOR GASTRIC AND DUODENAL ULCER.
l’o the Editor
SiR,-Dr. Arthur Hurst’s letter in THE LANCET of 1st cannot be allowed to pass without comment. " Our experience shows that gastroenterostomy is the commonest gastric disorder to-day, and undoing gastro-enterostomies is the operation we now most frequently recommend." This emphatic opinion from so eminent an authority might cause considerable confusion in the mind of the profession, if he had not spoilt the first part of this terse paragraph by figures cited immediately before it-viz., since 1921 there had been at the New Lodge Clinic 37 patients suffering from gastric ulcer, 165 from duodenal ulcer, and 67 from the ill-results of gastro-enterostomy or partial gastrectomy. So on his own showing gastro-enterostomy is not the commonest gastric disorder of to-day. Moreover, he does not indicate a very obvious point, which is that his clinic naturally collects failures. Against Dr. Hurst’s statement that the undoing of gastro-enterostomy is the operation he now most frequently recommends I put this one-of the hundreds of gastro-enterostomies I have done myself for duodenal ulcer and of the thousands I know which have been done by my colleagues, I cannot recall a single case in which the gastro-enterostomy has been subsequently undone, except where a jejunal ulcer has developed, and then, of course, it is the jejunal ulcer which is the disorder and not the gastroenterostomy. But I suppose all of us have undone gastro-enterostomies performed where there was no sign of ulcer, past or present, and possibly Dr. Hurst has this class of case in mind when he makes the sweeping statement quoted above. In Leeds we hav& put this kind of surgery behind us long ago. I am, Sir, yours faithfully, E. R. FLINT.
To the Editor
of THE LANCET.
SiR,—I find it a little difficult to reply, at one and the same time, to Dr. Hurst and Mr. Flint, for while the one ironically suggests that all operative procedures on the stomach are doomed to ultimate failure and that the commonest gastric operation of to-day is the undoing of gastro-enterostomies, the other tells us that the unsatisfactory results of gastroenterostomy, far from reaching the 36 per cent. suggested in my article, are not more than 10 per cent., and that in many of these the symptoms are so slight that the cases could be considered satisfactory. Were I not very deeply impressed by the fact that in the present state of our knowledge of gastric and duodenal ulceration it is impossible to be categorical (even that. surgical treatment is useless) I should find it impossible to reconcile these two opinions. Without reopening the whole question, however, there are certain explanatory points to which I should like to refer. Both Dr. Hurst and Mr. Flint appear to be unfavourably impressed by the fact that I use the ability to take all kinds of food without restriction as one of my criteria of cure. But could any test be more appropriate, especially from the patient’s point of view ? If he has to continue upon a special restricted