OURTH REPORT

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WE7_LCO.

TROPICAL RESEARCH LABORATORIES

A T THE

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GORDON MEMORIAL COLLEGE

KHARTOUM

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ANDREW BALFOUR, M.D.

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a

V. ^ ,

p^-f^ FOURTH REPORT

, f^SC OF THE

WELLCOME

TROPICAL RESEARCH LABORATORIES^ Kh^c4a

AT THE

GORDON MEMORIAL COLLEGE
KHARTOUM

VOLUME A.— Medical

ANDREW BALFOUR, M.D., B.Sc, F.R.C.P. Edin.. D.P.H. Camb.

DIRECTOR

Fellow of the Eoyal Institute of Public Health, the Society of Tropical

Medicine and Hygiene, and the Incorporated Society of Medical

Officers of Health ; Member of the Association of Economic

Biologists ; Corresponding Member Societe de

Pathologie Exotique and American Society

of Tropical Medicine ; Medical Officer ^^VTHSON//^^

of Health, Khartoum ; etc.

FEB B 1988

Published for

Department of Education, Sudan Government

KHARTOUM

BY

BAILLIERE, TINDALL & COX, 8, Henrietta Street, Covent Garden, LONDON

1911

[COPYKIGHT

A*

THE GORDON MEMORIAL COLLEGE
AT KHARTOUM

Patron :
H.M. THE KING

President :

Field-Marshal Tue Viscount Kitchener or Khaktoum, K.P., G.C.B.,

G.C.M.G., O.M., ETC.

Hon. Treasurer :
The Right Hon. Lord Hillingdon

Hon. Secretary :
Baldwin S. Harvey, Esq., 67, Lombard Street, London, E.G.

Committee and Trustees :

Field-Marshal The Viscount Kitchener of Khartoum, K.P., G.C.B.,
G.C.M.G., O.M., etc., His Britannic Majesty's Agent and Consul-
General in Egypt

Lieutenant-General Sir F. Reginald Wingate, K.C.B., K.C.M.G., etc.
{ex officio), Governor-General of the Sudan

Alfred Clayton Cole, Esq. {ex officio), Governor of the Bank of
England

The Right Hon. The Earl of Cromer, G.C.B., G.C.M.G., O.M., etc.

The Right Hon. Lord Rothschild, G.C.V.O., etc.

The Right Hon. Lord Hillingdon

The Right Hon. Lord Revelstoke, G.C.V.O.

The Right Hon. Sir Ernest Cassel, G.C.B., G.C.M.G., G.C.V.O., etc.

Sir Henry Craik, K.C.B., M.P.

Henry S. Wellcome, Esq.

The Right Hon. Sir William Mather

Hon. Solicitors :
Messrs. Norton, Rose, Barrington & Co.

Hon. Auditors :
Messrs. Gerard Van de Linde & Son

Director of Education in the Sudan, and Principal of the College :

James Currie, Esq.

STAFF

OF TllK

WELLCOME
TUUL'ICAL RESEARCH LABORATU HIES, 11)11

Director . .

Rcxi-nrch Chemist

l-'athologist and Assistant Bacteriologist

I'rotozoologist and Assistant Bacteriologist

Economiv Entomologist . .
Senior Assistant Chemist
Junior Assistant Chemist
Senior Laboratory Assistant
Junior Lahoratory Assistant

Clerk

Junior Clerk

Andrkw Balfouh, M.D.. etc.
William 1>k.am, F.I.C, etc.

CaITAIN K. IJ. AUCHIBALD, -M.ll., li.A.iM.C

attached E.A.

Captain W. B. Fry, M.R.C.S., L.K.C.P.,
R.A.M.C., attached E.A.

Harold H. King

J. Thompson. Ph.D., etc.

J. A. GooDSON, F.I.C.

George Buchanan

Alex. JIakshall

.1. .1. A. VlTALE, Ji.A.

Nicolas Effendi Hakim

ACKNOWLEDGMENTS

The following have kindly contributed Papers to this Report: —

W. M. Aders, Ph.D.

Captain R. G. Anderson, M.R.C.S., L.R.C.P., R.A.:^I.C., attached E.A.

Captain L. Bocsfield, M.A., M.D., R.A.M.C.

A. L. Butler, F.Z.S., JI.B.O.U., Superintendent Game Preservalion Department, Sudan

Government Service
H. Curtis, F.R.C.S.
S. C. Dunn, Government Geologist, Gordon Memorial College. Kliurtoum

E. S. Edie, M.A., B.Sc, Carnegie Research Fellow in Chemistry, 1907-9
Sir Thomas Fraser, M.D., F.R.S.

G. E. Hunt, Assoc. M. Inst. C.E., Gordon College, Khartoum
Lieutenant W. E. Marshall, M.B., Ch.B., R.A.M.C., attached E.A.
Colonel H. B. Mathias, D.S.O., M.R.C.S , R.A.M.C, P.M.O.E.A.
W. H. McLean, Assoc M. Inst. C.E., Gordon College, Khartoum
C. G. Seligmann, M.D.
A. C. Stevenson, M.B., M.R.C.S., L.R.C.P., D.P.H.

F. V. Theodali), M.A., F.E.S., Vice-Principal and Etomulogist of the S.E. Agricultural

College, Wye.
Captain D. S. B. Thomson, M.B., B.Ch., R.A.M.C, attached E.A.
Professor F. Werner, The University, Vienna

CONTENTS

VOLUME A — MEDICAL

PAGE

Lmtrodul'tion ID

Etiects of Fire — Statt' Changes — Private Workers — Title of Laboratories — Second Review
Supplement — Volume A — Pajiers Contributed — Scope of Work — Acknowledgments —
Volume B — Papers dealing with General Science — Acknowledgments — Laboratory Steamer
— Museum and Library — Acknowledgments — Scientific Staff — Future of Scientific Work
in the Sudan.

Sleeping Sickness in the Anglo-Egyptian Sudan. By Col. H. B. Mathi.\.s, D.S.O. ... 31
Investigation of Conditions in the Bahr-El-(jlhazal — Natural Barrier against Sleeping Sickness
— Quarantine Ordinance — Cases in Western Bahr-El-Ghazal — Examination of Xatives —
(;!ases in the Lado — Infected Area — Summary of Precautionary Measures — Additional Note.

Animal Teypanosomi.a.ses in the Anglo-Egyptian Sudan. By Captain W. B. Fry ... -11
Present Confusion of Classification — Necessity for Systematic Nomenclature — Review of the
Trypanosome Types — Methods of Differentiation ^Type 1, T. hrucei or jiecniidi — Morphology
— Curves of Distribution — Animal Inoculations and Reactions — Type 2, T. evansi —
Morphology — Curves <>( Distribution — Animal Inoculations and Reactions — Type 3,
T. jjecoruiii or nanwin — Morphology — Curve of Distribution — Animal Inoculations and
Reaction.s — Type 4, T. vivajr or cazalhrnd — Morphology.

Some Observations on Trypanosoma brucei (pecaudi and the Sudan Camel
Trypanosome in Cultures, with a Note on Endoglobular and Develop-
mental Forms of T. brucei (pecaudi?). By G. Buchanan o7

Technique : Culture Media, Inoculations — Appearance in Culture ; After 2i Hours, After
48 Hours, After more than 48 Hours, Stained Films, Virulence of a 22 Days' Culture on
Gerbil — Remarks : Culture of Trypanosomes.

Note on Developmental Forms of T. brucei (peamdi?) in the Internal C)r(;ans,
Axillary Glands and Bone-Maeeow of the Gerbil (Ger/iiffus jii/i/iiri/tis)—Cha,nsinti
of the Parasite — Morphology and Development in the Spleen : Intra-corpuscular, Extra-
corpu.scular — Forms Found in Lung Smears... .... ... ... ... ... ... ... 59

Notes on Human Spiroch.etosis. By Captain L. Bousfield 02

Six Cases of Relapsing Fever — Possible Vectors of the Disease — Summary of (_'linical Aspects
of Disease — Spirochsetes in Blood — Temiierature Charts.

The Spiroch.'ETE of Egyptian Relap,sing Fever. By the Director Cu

Alorphology — Staining Reactions — Animal Inoculations — Chicken Feeding and Insect Trans-
mission Experiments — Bed-bugs — Lice — Ticks — Inferences from Experiments — Tables of
Comparison — Probable Identity of Egyptian Spirochetosis with that due to >Sji. berhem.

Spirochjstosis of Sudanese Fowls. By the Director 76

Summary of Previous Paper — Brief Account of Recent Literature : jS/(. ii«u-chouxi, Sji.
neveuxi, Sj>. aiisemut — Preliminary Experiments — Dark-field Method — Differential
Staining — Experiments in Culture — Action of " GOti " — " Afterphase " Bodies— Differences
of the Disease in Chicks and Fowls — Exjieriments — Possibility of Hereditary Transmission
— Close Connectioji between Intra-corijuscular Bodies and Acute Siiirochiftosis — "Granules"
in A. jtersicus — Significance of Experiments — 0. saviijni/i — Granule Infection — Fowl Lice —
Blood Changes in Infected Chicks — Treatment — Effects of " 606 " on Sjiirochstes —
Favourable Results— Effects of "606" on Intra-corpuscular Forms — Mechanism of the
Crisis— The Infective Granule — A cycle of Schizogony — Importance of the Dark-field
Method — Summary and Conclusions — Proposed name for Sudan Fowl Spirochajte,
Sp. granulosa penetrans.

CONTENTS

PAUE

NoTK IIX A MCTIIiiII ok OllTMMNi. Ill.iMll) AsKI'TIi \|,|.^ Kcil: IIIK Crl-TIKK ul- H .KM \|l>/i ' V

IN TIIK TkhI'ICS. I>V TlIK |)ll;K<Tl>l: 107

Fallacies and 1'uzzlks in HlimU) Examination, liv tiik iJiUKcToit 109

"Adventitious" Fiilliicios— Ywust (.Vlls, I'oilfii (iriiinx, i-tc. -Spiroclia'to r'oniis— I'arasit*;-
like litxlios Ditforoncos Ix-twcuii Yt-iist Cells ami ramsites— Hlottiii)j;-|>a|H!r Fallacy —
AutdjieiU'tic Fiillacies Viicuoles " .Marii;rlianos"' — Granules — "(.'liaiii, tluinl)-l>ell, tilanieiit
and droplet" I'honomuna I'latelets Ha-mooonia — Free Flagella -Fallacies in .Staine<l
Hlooil—^//i'»K/«-/:f//eH— Alterations in Ued Cells— Curious Ai)ix!anince in Gcrbil's B1<kj<1
■■ liowell-Jolly " Bodies— Ccntrosoines in Bird's Erytlir<K-ytes— Unrecognised B<Mlies
I'eatli and Degenenition of Leucocytes -Bo<lies in tlie Extra-nuclear l'r<>lo|>la.sni
of Certain Mononuclears — Serijentfllit hominis — " lloweil and llorrocks " Bodies
I'nidentitied Parasites in Frog's Blwxl.

IJkmakks on Kai.a-azai: ix tiik Kassala anii Blue Nii.k l)isTiUfTs of the Sudan.

By Cattain L. Bouskield 127

Suiuiuary of Tour — Talile of Patients Treated -Prevalence of Bed-bugs — Duration of Di.sejuse —
Incidence of the Di.iease Xationality of Cases — Death-rates of Tr)\vns Att'ected On.set of
Di.sea.se — Physical Condition of Patients — Liver and Spleen Puncture Atypical Brxlies —
Diagnosis — Ty|)es of Parasites — Blood Films fmni .\innials— Recommendations — Ai))iendix.

/' Kala-.vzak L'ommission To IN vk.stii;atk the I'i;k\ ai.k.me and Caisk ok the Disease
IN THE Eastern Sudan.

/ (1) General Heport. By Captain D. S. B. Thomson 143

Tours of Inspection — Procedure in Villages — Native Information on Kala-azar — Native
Treatment— Infection of Riverain and Inland Villages — Comparison of Number of
Ciuses in Provinces— Method of Transmission— Sitleeii Puncture — Age, Sex, Race and
Seasonal Incidence— Is the Discii.se Curable ?— Billiarziosis — Recommendations -
Conclusion — Tables of Observations.

/

/

/

(2) Patholocical Report. By Lieutenant W. E. Mau-shall 157

Clinical Notes — Treatment — Peripheral Blood — Presence of Lei.shman-Donovan Bodies —
Relative Increase in Large Mononuclciir Leucocytes — Other Blood Changes — Relation
of Eosinoi)hilia to Kala-az;»r— Urine and Fteces in Kala-azar— Search for Lei.shman-
Donovan Bodies in Dogs and other Animals — Tables of Ob.servations — Exi)erimeiital
Kala-aziir in the Grey Monkey — Infected Cases — Non-infected Cases — Presence of
Parasites in Blood of Infected Monkeys — Tables of Oliservations — Morphology and
Culture of the Para.site- Possibility of Infection by the IVd-bug, Cimtr lictiilnriiia
— Other Protozoa met wiili (hiring the Investigation — Protozoon from jiost mortem
Splenic Puncture— Flagellated Bodies in Standing Water — Flagellated Bodies in F;ece.s
of Infected Monkey — Flagellated Bodies in Soil — Conclusions — Possible Methmls of
Infection.

Thk .\lkai,isitv ok iiiK I'.i.ooi) Seki M IS K Ai.A AZAK. Bv Cai'Iain K. (!. .\i:riiiitAi.ii I7;i
Techni(|ue — Titration of Seium against Standard .\cid Solution— Ca.se 1— Case 2— Ca.se S —
Case 4 — Conclusions.

Herpetomonas lyi:.ei. Bv Captain R. G. Arihibalu 170

.Material and Methrals Employed - Pretlagellate Stage — Post-tlagellate Stage — MetlnMJ of
Infection — Culture an<l .\ninial Experiments.

/Case ok Kala-azar tkeatek hv "C06." l!v tiik Director axi> Captain .Vrciiibali)... 185
Summary of the Case Diagnosis Continued by Spleen Puncture Injections Commenced—
Second Injection — lmi»roveinent — Effect on Parasites — Remarks.

/

/.

CONTENTS 9

PAQK

Two Cases of Non-Ulceeating " Oriental Sore," better termed Leishman Nodules.

By the Director, with Clinical Notes by Captain I). S. B. Thomson ... 191

Introduction — Case I — History — Clinical Examination — Blood Examination — Growths —
j^Iorphology of Parasites — Histo-pathologj' of Growths — Recent Literature — Case II. is
found to be a Comrade of Case I. — History — Clinical Examination— Blood Examination —
Additional Notes — Treatment — Ex]K'rimental Work.

A Case of Parasitic Granuloma in which Developmental Forms of Leishmania

tropica were Present. By Captain R. G. Archibald 207

History of Case — Study of Skin Lesions — Examination of Papules — Microscopical Examina-
tion of Stained Specimens — Differential Blood Count — Histo-patliolog>' — Summary.

Two C.\sEs OF Veldt Sore Treated by Autogenous Vaccines. By the Director ... 213

Vaccine-therapy — Case I. — Case II. — Succes.sful Treatment by Autogenous Vaccines — Use of
a Mixed Vaccine.

Ulcus Tropicum. By the Director 217

Leucoderma. By the Director 217

Fevers in the Sudan, Preliminary Note. By the Director 219 iV-'

Clas.ses of Fevers — Case of Hepatitis — Case of Malta Fever — Phlebotomus Fever or "Sand-tiy '
Fever — Dengue Fever — "Toxic Enteritis" — Miliary Tuberculosis — Prolonged Fever of
Syjihilitic Origin — Helminths as a Cause of Fever — Fever due to Old Malarial Infection —
Idiopathic Tropical Splenomegaly — Septicasmic Fever — History of Cases — Three Cases of
Pyrexia of Unknown Origin — History and Symptoms — Classificatinn of Fevers —
Temperature Charts of Cases.

Four Cases of Pyrexia due to Infection with a Bacillus of the B. Cloac.e Type,
with Notes on the Vaccine Treatment of Two of these Cases. By
Captain R. G. Archibald 231

Blood Culture for Early Diagnosis — Clinical Signs — Isolation of the Organism — Morpholog>' —
Cultural Characters — Agglutination Tests — Cultural Reactions — Presence of Organism in
Excreta — Outcrop of Boils — Success of Vaccine Treatment — Conclusions — Temperature
Charts.

Diphtheria in the Tropics. By' the Dieectoe 239

Diphtheria in the Sudan — A Coccal Form of the Diphtheria Bacillus — Seasonal Incidence —
Case in Khartoum — Bacillary Form — Involution Forms — Variation in Bacilli — Additional
Note — Associated Organism — Characters of the Organism — ilorphology — Pathogenicity.

Some Aspects of Tropical Sanitation. By the Director 240

The Sanitary Inspector in the Tropics — Effects of Sun and Humidity on Health — Native
Populations — Malaria and Mo.squitoes — Unexpected Breeding-places — Other Communicable
Diseases — Conservancy ilethods — Bacterial Treatment of Sewage — Proposed Sewage Farm
— Incinerators — Birth-rate — Milk Supply — Miscellaneous Duties — New Khartoum.

Sanitary Notes. By the Director 263

Meteorological Conditions — Mosquito Work — Statistics — ilalarial Outbreak — Irrigation Rules
— Influence of Cultivation on Diseases — The Covering of Water Utensils — Rats in
Khartoum — Infectious Diseases — Tables of Statistics — Vital Statistics — Death-rate —
Birth-rate — LiabUitv of Sudanese to Tuberculosis,

10 CONTENTS

PAOP.

TiiK Watkr-Supply ok Towns is TiiK Tropics. Hv tmk Oirwtok 2H!>

Si;;iiitii'iinoo of IS. Cnli ruiiiiiiunin in WiitiT- liiu-torial Klcua of Tropiral \Vator-.su|)|ilit'.s -
Cleiiii'.slia'.s DlisiTvatioiis— " t'oli " Staiulai'd as a|i|iliecl to ImliaC'oiii|ianitivt' Value of
Teste — B. C'/txiof— Varying Powlm-s of Resistance to >Siinliglit anionjcst ("olifonn Organisms
— Cleniesha's Conclusions — Bacterial Standards in Trojiical and TcniiK-rate I'liinates —
Shallow Well Water — Classes of Fiucal Organisms — Mine Nile Water— Collection of
Samjiles Khartoum Water-supply — GJeological Conditions — Air-lift Pump — Quantitative
Kxamination -Qualitative Examination — Danger of Crcnothrix — Pumjiing Trials— He) K>rt
of Mr. Al>el an<l Dr. Tinld— Solution of Ditticiilty — Conclusion.s — Extracts from Oovenimeiil
l!ei)ort — Tables of Tests — Ajijiendix — Notes on Distribution.

TiiK I'uKsKNcK, Type and Po.ssiblk Skjnikicanck ok Lactosk-kkrmkntini: Ba<'ii,i.i in

Sl'KKACK WaTKRS and IN THK F.KCRS OK MaN AND CkRTAIN DoMK.STir AnIMAI.S

IN THK Sudan, tocether with a Consideration ok the Effects of Sunliuht
AND Earth Hikiai, ox these Orcanisms. Pret.iminauy Note. By Caitain

R. G. Archibald :il9

Standards of Purity — OV).servations on Indian Water-su|>plies — Khartoum Watcr-sujiply —
Techniipie — Differential Sugar Jfedia — Tables of Results — Conclusions — Additional
Exiieriinents — Lactose Fermentcrs in Human Pieces — Effect of Sunlight — Effect of Earth
Huiial on the Bacterial Content — Clemesha's List of Lactose Kermenters — Tables of
liesnlt.s.

Experiments on tiik Kii.terini; Properties ok ihk /kki;. 1!v Captain 1!. fi. Archibald 335
Varieties of Zeera — Action of the Slimy Deposit — Optimum C'onditioiis for Zeer — Filtration.

Hl'.MAN BoTRYO.MYCOSIS. Jiv CaPTAIS H. G. ARCHIBALD 337

Preliminary Remarks — Clinical Signs of the Di.sease— Tendency to a Chronic Course —
Fibrotic Changes — Microscopic Appearances — Staining Reactions — Degenerative Changes —
Conclusions.

Veterinary Notes. By the Director 343

Epizootic Lymi)hangitis of Etiuines — Coccidiosis in Cattle — Piroplasmo.sia — Ana]ilasmosis —
Kilariasis : in the Horse, in the Camel, and in the Hare. Parasites.

AciD-KA.sT Bacilli in the Luni; of a Camel. 1'>v Captain R. T!. .\nciiinALD ... 352

Inter.stitial Pneumonia in a Camel's Lunc;. By Captain li. (;. .\i;riiiiiAi.i> 353

Coccidiosis of the Intestine in the Goat. By A. C. Stevenson 355

Case for Diagnosis — Post mortem — Other Case.s — Schizogony Cycle — Si»orogony Cycle —
Nficrogiimete Formation — Pathogenicity.

A Few Notes on the Protozoa Parasitic in Bufo rE(;ularis in Kiiaktuu.m. By

A. C. STEVEN.SON 35!t

Protozoa in the Blood : Tri/fmnommn rotnforinm, Hsemogregarines — Protozoa in the Intestine :
Flagellates, Ciliates.

Ml.HCELLANEOOS NoTFX.

H.«MATozoA. \'<\ THE Director ... 362

Howell-Horroiks Bodies in Human Blood. By the Director 'M-l

Description of Ca.se -Tyjies of Botlies Found — Mea.suremeiits -Atteiniits at Culture.

Mycetoma. By the Dikector 3()5

Leprosy. By the Direitor 367

Dysentery. By the Director 367

Peculiar Bodies found in the Inte.stinal Lymphoid Follicles ok an Eoyi-tian.

By .\. C. Stevenson ... 369

Routine Work. By the Direitor 370

Index 371

CONTENTS 11

VOLUME B — GENEEAL SCIENCE page

Introduction 17

Effects of Fire — Staff Changes — Private Workers — Title of Laboratories — Second Review
Supplement — Volume B — Variety of Subjects — Ornithology — Arachnida — Protozoology —
Ancient Gold Mining — Ethnology — Anthropology — Tropical Sanitary Engineering —
Entomology — Chemistry — Soil Analyses — Calotropis jirocera — Library — Distinguished
Visitors — Scientific Staff'— Future of Scientific Work in the Sudan.

PiEPOET OF THE CHEMICAL SECTION. By WiLLIAM BeaM 23

Introduction — List of Analyses and Examinations — Scope of Work.

A Test foe Ha.shi.sh — Details of Test — Variations of Method.

Khartoum Water-supply — Notes — Physical Characters — Tables of Analyses — Improve-
ment in Storage — Corrosion of Pipes — Action on Lead.

SoBAT KiVEE Water — SuitabUity for Irrigation Purj)Oses — Tables of Analyses.

ilECHANiCAL An.alysis OF Aeid Soils — Various ilethods — Tables of Analyses — Centri-
fugal Method : Size of Clay Particles — Determination of the " Silt " — Classification of
Soil Particles — Resume of the Method Used.

Soils of the Gezira — Xative Crops — Rainfall — Classes of Soil — Experimental Farm —
Effect of Baking — Chemical Composition — Tables of Mechanical Analyses — Tallies of
Chemical Analyses — Detailed Tables of Analyses.

Gypsum as a Feetiliser of Sudan Soils — Lime in Soils — Fertiliser Experiments on
Cotton Soils — Effects of Ajiplication of Gypsum to Soils — Amount to be ajiplied.

Gum Research — jNIierobial Origin — Tapping Experiments— Influence of Cold — Method —
Varieties of Iladidb Gum — Viscosity — Tapping of Talh Trees— Conclusions.

Experiments on Gum Production in Kordofan. By E. S. Edie 73

Investigations in Gum Gardens — Tables of Yields from Small Trees — Variations in Yields —

Effects of Rain — Sizes of "tears" — Tables of Yields from Large Trees — JIaxinnnn and

Minimum Temperatures — Best Time for Tapping — Viscosity and Acidity of Gum from

Small and Large Trees — Methods of Determination — Effects of Treatment of llaahiih

Trees on the Yield : Effects of Strong Antiseptics ; Table of Results — Bacterial Origin of

Gum ; Transmission of Infection ; " Iir vitro " Experiments in Gum Production — Analysis

of Resulting Bacterial Products — Laboratory Confirmation of Work in Gum Garden.
Peeliminaey Notes on the Chemistry of the Latex of Calotropis procera. By

J. Thompson 85

Native Uses of Ushar Plant — Investigations and Experiments — A Colour Reaction — Toxicity

of the Latex — Experiments with Rabbits — Toxic Portion — Detection in Cases of Suspected

Poisoning — Reactions of Foodstuffs — Reactions of Colour Reagents — General Analysis —

Extraction with Various Solvents.
Report of the Entomological Section. By Harold H. Kinc; 95

Introduction — Itinerary — Control of Locust.s — Plant Diseases Ordinance — New Blood-
sucking Flies — Collectors — Control of Moscpiitoes — Injurious Birds — Acknowledgments.

Insects Injurious to Man and Animals — Mosquitoes — The Control of Mosquitoes —
Blood-sucking Flies other than Jlosquitoes : New Tabanids, List with Localities :
Chironomidci, SinmlidiP, Psi/chodkhe, Tahanido', Mnscidti', Hijypoltoicidfr — Cimicidw
QSstridre — Ticks — Synoptic Table of Sudanese Ticks.

Animals Injurious to Farm and Garden Crops — Dura Stem-borer — Black or Greasy
Cutworm — Asal Fly — Cotton Stem-borer — Melon-Weevil — ilelon Stem-borer — Melon
Leaf Beetle— Diamond-back Moth — Cabbage Bug — Eigla Gall 'Weevil — Fig Stem-
boring Beetle — White Ants — Black Garden Ant.

Plant Diseases Ordinance — Explanatory Note — Contents — Di'finitions — Articles
Exempted — Detailed Explanations of Contents.
A New Genus and Two New Species of Culicid.e from the Sudan. By

F. V. Theobald 151

Genus, Dicevomj/in : Dicernmi/ia nfriraii/t, n. .sp. — Cider siid'Hinisix. ii. s]i.

12 CONTENTS

PAGE
TlIK I'|N(IIK> AM> WkaVKII I5lltl>s OF TIIK Sl'IIAN, HKINd NiiTF-s iiN niK (iltiilip coNTAISINi:

riiK Hiiiiis Injurious to (iKain Chops. 15y A. L. liuTi.Kit I.')7

Iiilrotliu-tioii I'tility of Hiids ha Ihsim-i KilU-rs.

1'aht I., TiiK Famii.ii->, Sub Fa.mii.ii-> anh (!knkha -Kiiiiiily I., /■'rim/it/iilii' : .Sul»-
fitiiiilii's, Jim/ieriziiiff ; Friiujilliuw Family II.. I'litreida- : SuW-fainilics I'it/iiiiDi' :
K»lritilin)f ; I'loceinu-.

I'aut II., Notes on thk Spei-iks- Family, J-'rimjilliiltf — Siil)-family, Einlierizinn- : (ifiiCTH,
Kiiiherlzit : Friwiilliiriii SuW-faiiiily, FriinjilliiKt : (ii-iicra, Fn/l/iron/iizn : Scriiiiiii :
l'nll<>»jiiiii ; I'lixiser : Fetruitin — F'aiiiily, /^/oreiVAf- Suli-faiiiily, Viduimt : Gl■nt•|•l^
//jZ/iiM'/ifiii ; VUhut ; Colin»iut»»er : Urohrachiin : I'yirmiflitHii ; (jiielea — Sul)-faraily,
Hftnliliiiip : fii'iiera, Amnrliiin : I'/ii/rfiitnin : Urtihmrliii : Orti/ijoitiiiia : >Spermeiiteii ;
I'mii/iiil/iii.* ; Exlrililit : Ldi/oiionlirld .- J'l/fe/ia—Snyi-fixmtiy, I'hteeimf : Genera,
SjiermoKj>i:ii : S/mrojii/ien : Aiiif)/;/oi>jiiza : DlnemdlUt ; Textor ; Plocei/Mixser ; Annjilecfei ;
.Wii/i/ii/'im : /fi//i/iiinliir<iii» : SiliKjrn : J/i/ji/iniitoniiK ; A''iii//io/i/n7ni>.

AniHTIoNAI. Note on a Sl'Eclt>< ok LaKK, Mihinororiijilin liiiiiiiriiliil<t.

8uoRpioNs ANii Allied Annulated Spiders ok the Anulo-Ecvptian Sudan. I'.v

1'kokkssou F. Wekneu 179

Chaiiieteristics of Scorpions — Habit-- — Poison — Distribution — Scorpions Found in Deiiosits
of tlie Silurian Period — Virulence of Poison — Symptoms of Poisoning — Two Main Divisions
of Sudanese Scorpions — Descriptions of Genera — Butlius : I{. nmoritij-i : H. iiuinqnencarlnnlu* :
li. nerititHVS : li. iejitoche/i/x : H. iiriiterariiiiitu* : li. miniij- — Parabutlius : /'. fiiniteri —
Xamiliuthus : X. nii'lersoni — Pandiiius : J'. /m/h<liix : ]'. erilialis : P. imjiernlar.
List of Sudanese Scoriiions.
Characteristics of Pediiialjii — t'oniiiari.-ion with Scorjiion.s — Descriiitions of Genus Damon :

D. iiinr(/<itii.i.
Characteristics of Solifuj<a' — Distribution — Habits— Main I )i visions of S])ecies — Descripl ions
of Genera — (Jaleodes: G. arafm — Parajoileodes : /'. .tm/uns — Othoes : 0. flweeri —
Hliajjodes : Rh. nu'fiinori'/ihn/iii> — Solpuga : S. deiitntidfitf:, S. nrhweinfitrthi — Dwsia :
I), i/inn/ierr/i — Gluvioi)sis : G. ni/escens.
NoTt^s ON Two Specimens ok Spittinc-Snakes kko.m Southern Hiiodksia. Hy Henry

Curtis 195

Effect of Ejected Fluid — Sjiitting Cobra — A'aia iii'irirt^h's — Venom — Reproductions of and
Extracts from .some Hecent Literature.

A Note on the Sudan Spittinc-Snake. Hy Sir T. It. Fkaser 2oi

Herpetomonas Asi-on<;opi. Hy \V. M. Atikrs 202

Hyper-parasitisin — Melon Bug — Alimentary Tract — Method of Examination — Structure and
Life-cycle of the Parasite— Resting Stage — Pnx-ess of Divi.sion — Concluding Remarks.

Ancient (Jold Mininc; in the Sudan. By S. C. Dunn 207

In Earliest Times — The Pluenicians — The Egyptians — Turin Pajiyrus — Wealth of Ancient
Egypt— Foreign Domination in Egyi>t — Cufic In.scriptionsMethod of Mining— Slave
Workers — The Gold Ore— Hewing — Pounding — Milling — Wa.sliing — Melting — Grades of
Gold — Old Workings — Means of IllumiMation — Quartz — Preliminary Breaking — Circular
Griniling Mills — Wa.shing Tables — Melting Pots Slag — Camps — Wells — Burying Places-
Potsherds.
'^ Cult ok Nyakani; and the Divine Kincs ok the Shii.i.ik. 1^ C. f!. Selicmann ... 21(1
Preliminary Remarks — Sliilluk C 'ountry — Population—
Shilink Kings-
Killing of the King and Transmi.ssion of the Divine Spirit -
(!ult of Nyakang at his C'enotai)h Shrines-
Cult of the Sliilluk Kings at their Grave Shrines-
Reverence for Trees —

Api)eairance of Shilluk Kings in Animal Form -
Concluding Remarks—

CONTENTS

13

PAGE

SoMp; Tribal Customs in their Relation to the Medicine and ^Morals ok the
Nyam-nyam and Gour Peoples inhabiting the Baur-El-Ghazal. By Cai-tain
R. G. Anderson 23!)

Introduction — Tribal Distribution — Nyam-nyam People — Gour People — Character and Type —
Civilisation and Mohammedanism — Morality — Punishment — Mutilation — Execution : By
Throttling, By the Knife, By the Spear, By Poison, By Fire — Ordeals — Flogging — Theory
of Disease — Doctors and their Cures : Salt Cure, Sucking Cure, Extraction of Foreign
Bodies, Tying Cure, Scarring, Cupping, Heat Cure, Spitting, Whistling Cure — Oracular
Rites : Benga Rite, Devil-dancing, Divination, Divining Board, Other Means of Divination
— Evil Spirits : Sahar or Zarr, Blood-brotherhood, Casting out Devils, Sacrifices — Charms :
]Medico-Magical Charms, Attractive Charms, Whistle Charms, "Gun iledicine," ]SIourning
Charms, Lightning Charms — ^laladies : Fever, Chest Complaints, Eye Diseases, Chigger,
Guinea-Worm, Snake Bites and Scorpion Stings, Stomach Complaints, Venereal Disease,
Headache, Sun-stroke, Mental Disease, Skin Disease, Leprosy, Deformities, Elephantiasis —
Drugs — Arrow Poisons — Surgery : Circumcision, Tribal Cosmetic Operations — Extraction
and Mutilation of Teeth — Tribal Markings (Scar Tattooing) : Spurious Face Markings,
Lip Perforation, Nose and Ear Perforation — Minor Surgery : Wounds and Ulcers, Fractures,
Foreign Bodies, Surgical Instruments and Appliances — Personal Hygiene — Cannibalism —
Birth — Death — Conclusion.
Some Municipal Engineering Problems in the Tropics. By W. H. ^[cLean and

G. E. Hunt 279

Introduction — Meteorological Conditions.

Town Planning — Old Khartoum — New Khartoum — Future Development.

Streets and Open Spaces — Streets — Rain Water Drainage — Tramways — C)pen Spaces — Trees.

Buildings — Tj^pes of Houses.

Water-supply — Distribution — Wells — Irrigation.

Sanitation — Waste Water Disposal : Irrigation, Percolation Pits, Waste Water Pits — Latrines
and LTrinals — Conservancy.

Town Building Regulations — Contents — Preliminary : Title, Scope, Interpretation, Classifica-
tion of Land — General Regulations — Si)ecial Regulations — Building Petition — Drawings
Lodged with Municipal Authority — Contravention of Regulations — IHlapidated or
Neglected Buildings.
Index 313

CONTENTS OF THE SECOND EEVIEW

OF RECENT ADVANCES IN TROPICAL MEDICINE, ETC.

VOLUME SUPPLEMENTARY TO FOURTH REPORT

Air — Ankylostomiasis — Anthrax — Bacteriology — Beri-beri — Beverages — Blackwater Fever —
Blood — Bubo — Calabar Swellings — Cancer — Cerebro-Spinal Fever — Chicken-pox — Chigger —
Cholera — Climate — C!r>thing — Dengue — Diarrhcea — Diphtheria — Disinfection — Dropsy —
Dust — Dysentery — Elephantiasis — Enteric Fever — Faeces — Fevers — FOariasis — FOters —
Flies — Food — Food Poisoning — Goundou — Guinea- Worm — Htematozoa — Heat Stroke —
Hydatid — Hydroi)hobia — Influenza — Insects — Leishmaniosis — Leprosy — Liver Abscess —
Malaria — Malta Fever — Measles — MUk — Mosquitoes — Jlycetoma — Myiasis — Ophthalmia —
Oriental Sore — Parasites — Paratyphoid Fever — Pellagra — Phlebotomus Fever — Piroplasmosis
— Plague — Pneumonia — Preservatives — Protozoa — Refuse Disposal — Schistosomiasis —
Scorpion Sting — Scurvy — Sewage — Skin Diseases — Sleeping Sickness — Small-pox — Snake-
bite — Spirochajtosis — Sprue — Staining — Syphilis — Technique — Tetanus — Ticks — Tropical
ilediciue — Trypanosomiasis — Tsetse Flies — Tuberculosis — Typhus Fever — Vaccination —
Vermin — Verruga — Veterinary Diseases — Water — Whooping Cough — Yaws — Yellow Fever.

14

LIST OF I I. I. I'S'I'IJATIONS

V O L U M I-; A

PAGE

Fift. 1.— lU'licf Map of Kliartoiiiii 2

Fix. 2.— Biu-U'riolii^'ual Lalicuatm-.v 18

Figs. 3-4. — Patlioloffical .Miisfuiii 27

Fig. 6. — Maji of Angl<)-Egj'])tiaii Sudan ... 30
Fig. 6.— Maj) of Northern Hahr-Kl-Oliazal... 33
Fig. 7.— Map of Southern I5ahr-El-Ghaziil ... 35

Fig. 8.— Map of Liuh) 37

Fig. 9.— Typical Haunt of f,'. /I'lZ/Mi/is on

the Yei River 39

Fig. 10.— Clearing Operations on Yei River 39
Fig. 11. — Sleeiiiiij,' Sicknes.s Camp, Yei ... 40
Plate I. — Animal Tryimno.somes of the

Anglo- l<;frji)tian Sudan ... Fnriiui 41
Fig. 12. — Curve di.stribution, 'i'.vpc 1 (Bruce) 47
Fig. 13. — Curve distribution, Tyjie 1 (Khar-
toum) 47

Fig. 14. — Curve di.stribution, Type 2 (I'.ruce) 51
Fig. 16. — Curve distribution. Ty)]e 2 (Khar-
toum) 61

Fig. 16. — Curve distril)uti(m, Tyi>e 3 (Royal

Society) ... ... ... ... 55

l'i,.\rK II.— Cultivation Form.s of T. hmrei.

Develo|imental Cycle of T. hmrei

in Ger/iiffiix pi/r/nn/iis ... F(iciH<i 57

Fig. 17. — Apjiareut formation of nou-flagel-

late body from trypanosome in

lung. And vice veisa 01

Figs. 18-24. — Temperature Charts, Human

Spirochietosis, Ca.ses 2-8 ... G5-GG

Fig. 25. — Spirocha-tes showing innrphological

features ... ... ... ... 07

Fig. 20. — Temperature Chart. Egyptian

Relapsing Fever, .Monkey ... 69

Pt.ATE III.— Smears from .Malpighian tube of
Ar<ia.i peraiciix fed on chick with
Acute Spirochfetosis. S/iirochfetn
r/ranuloKa )>enetrans, n. sp. Farintj 82
I'r.ATE IV. Spirochietosis of Sudanese fowls 103
Fig. 27.— .\pparatus u.sed for obtaining
blood aseptically for the culture
of luematozoa in the Tropics ... lOS
I'l.ATK \'. — Fallacies and Puzzles in living
blood together with .some blowl
parasites by way of conti-ast Furiini 109
Fig. 28. — Spirocluetullike InKlies found in the

blood of a Jackson hartelweste ... Ill
Fig. 29. — S/iirtn'luHti hovi> raflrii>,\\. i<\t. ... HI

PAGE

Plate VI. — Fallacies and I'uzzles in .stained

blood ... ... ... Fni-itui 112

Fig. 30. — Altered red cells showing various
phenomena as .seen liy the dark-
field metluxl 116

Plate A'II. — Fallacies and Puzzles in stained

i>lood ... ... ... Ftiriuij 120

Fig. 31. — .Ma)) .showing distribution of Kala-
azar in Ka.s.s)ila and Blue Nile
Districts 120

Figs. 32-35.— Kala-azar, Ca.ses 1-4 135

Plate VIII. — Kala-azar jMirasites 137

Platk IX.— Doubtful "bodies" from a dog.
I'nrecogni.sed bodies in Kala-azjir
sjileen-films 139

Fig. 30. — Map of Eastern Sudan, showing
Area, known at present to be
infected with Kala-azar 142

Pl.\tk X. — Protozoa other than Kala-azar ... l.'iO

Plate XI. — JJerpetomonas h/i/o'i. (1) Flagel-
late form. (2) Cyst formation in
liinil gut of Li/i/cfiis militiirin ... 178

Platk Ml. Kala-azar. J'ara.sites before and

after treatment with " GOO " Farimj 185

Fig. 37. — Temperature Chart, Case of Kala-
azar treated by " 606 " 1 88

Figs. 38-39.— Oriental Sore. Neck growth 193

Fig. 40. — Oriental Sore. Growths on face,

neck and left arm 193

Fig. 41. — Oriental Sore. Growths on shimlder

and arm ... ... ... ... 193

Fig. 42. — Oriental Sore. Parasites free and

grouped together 195

Fig. 43. — Oriental Sore. Section of small

growth first removed 197

Fig. 44. — Oriental Sore. Cell nest, .showing

|)igment in central inclusion ... 197

Fig. 45. — Oriental Sore. Section of growth

exci.sed, showing downgi-owths ... 197

Fig. 40. — Oriental Sore. Section of small

growths first removed ... ... 197

Figs. t7-4H.— Oriental Sore. Curious cockle-
shaped bodies ... ... ... 205

Plate XIII. — Lrishmanla ti-o/>irn. Parasites
from ulcer on forearuL Film from
f'lriiK /ro/iiriini showing spiro-
clnetes and fusiform bacilli Fitcimj 207

LIST OF ILFjUSTRATIONS

15

I'AGE

Fig. 4'J.— Papules on Chest 'MH

Fig. 50. — Papules on Abdomen '2Uii

Fig. 51. — Skin lesions on forearm 208

Fig. 52. — Section of papule from case in

wliich developmental forms of

Leishman hodies were found ... 210
Fig. 58. — Veldt Sore. Skin le.sions on lower

jaw (Egyptian otKcer) 212

Fig. 54. — Veldt Sore. Skin lesions on wrist

(Egyptian officer) 212

Fig. 55. — Veldt Sore. Skin lesions on neck

(Egyptian .soldier)... ... ... 212

Fig. 50. — Veldt Sore. Skin lesions on wrist

(Egyptian soldier) 212

Fig. 57. — Veldt Sore. Case II. — Film from

ulcer showing diplococci 215

Fig. 58. — Veldt Sore. Case II. — Film from

ulcer showing diphtheroid l>acilli 215

Figs. 59-61. — Leucoderma 216

Fig. 62.— Temperature Chart, No. 1, Hepatitis 21 8
Fig. 63.— Temperature Chart, No. 2, .Malta

Fever 218

Fig. G-t.— Temperature Chart, No. 3, Toxic

Enteritis (?) 221

Fig. 65. — Temperature Chart, No. i, Tuber-
culosis 221

Fig. GO. — Temperature Chart, No. 5, BOhar-

zio.sis of rectum ... ... ... 221

Fig. 67. — Temperature Chart, No. 6, Si)leno-

megaly 225

Fig. 68.— Temperature Chart, No. 7, Acute

Splenomegaly ... ... ... 225

Fig. 69,— Temperature Chart, No. 8, Pyelo-
nephritis (?) ... ... ... 225

Fig. 7(». — Temperature Chart, No. 9, Fever

of Uncertain C)rigin ... ... 227

Figs. 71-73. — Temperature Charts, Nos. 10-1 2,

Fevers of Uncertain Origin . . . 229
Figs. 74-75. — Temperature Charts, Cases I.

and II 230

Fig. 76. — Bacillus of the CVofic'p group ... 232
Figs. 77-78. — Temiierature Charts, Cases III.

and IV 233

Plate XIV.— Diphtheria 241

Figs. 79-80. — Diphtheria. Organisms from

ease of British officer 247

Fig. 81. — Small Incinerator at Daim ... 259

Fig. 82. — Refuse Incinerator and Trolley at

Sewage Farm 259

Fig. 83. — Bucket cleaning at Sewage Farm... 259

Fig. 84.— Bucket Repairing 259

Fig. 85.— Exterior View of Portion of Meat

Market, Khartoum 261

Fig. 86. — General View of Dockyard,

Khartoum North 261

Fig. 87. — Plan of Khartoum showing position

of Sudan Development and Ex-
ploration Company's Farm ... 267
Fig. 88. — Plan of Sudan Development and

Exploration Company's Farm ... 269

Figs. 89-90.— Irrigation Canals 271

Fig. 91. — Lines of Zeers on stands in Town

Quarter, Khartoum North ... 273

Fig. 92. — Zeer with cover 273

Fig. 93. — Village street showing burnias on

stands 273

Fig. 94.— Site, Plan and Elevation of Buvi

Water Works, Khartoum ... 288

Fig. 95. — Apparatus for collecting water for

bacteriological analysis ... ... 300

Fig. 96. — ilap of Khartoum showing probable

line of percolation of Blue Nile ... 307
Fig. 97.— Section of Well No. 6, Ruri Water

Works, Khartoum 309

Fig. 98.— Water Tower 309

Fig. 99.— Well Head, showing pipe of air-lift 309

Fig. 100. — Large Covered Reservoir 311

Fig. 101.— Bornes Fontaines 311

Fig. 102.— Section of a Zeer 335

Plate XV. — Human Botryomycosis F<icin<i 337
Plate XVI. — Human Botryomycosis ... 339

Fig. 103. — Botryomycosis of the upper jaw... 341
Fig. 104. — Botryomycosis of portion of hand 341
Fig. 105. — Botryomycosis of the groin ... 341
Plate XVII. — !Micro-filaria;. Anaplasmosis.

Epizootic Lymphangitis ... Facinrf 346
Plate XVIII. — Interstitial pneumonia.

Aspergillary pneumokon iosis

Facim/ 353
Fig. 106. — Fibroid pueunionia in a Camel's

lung 354

Plate XIX. — Coccidiosis of the intestine in

the goat ... ... ... FiiciiKi 355

Plate XX. — Coccidiosis of intestine in goat 357
Plate XXI. — Protozoa in the lilood of Bufn

ret/ulitrix ... ... ... Fncin;/ 360

Fig. 107. — Flagellates in intestine of toad ... 361
Fig. 108. — Unnamed organism in toad ... 361
Plate XXII. — X bodies in human lilood.

Peculiar bodies in Intestinal

Lymphoid Follicles ... Facing 362

Pl.\te XXIIL— Mycetoma 364

Figs. 109-111.— Mycetoma of the hand ... 366
Figs. 112-113. — Typical Tuberculous Leprosy 367
Figs. 114-117.— Mycetoma of the feet ... 368

Fig. 118. — Floating Laboratory and Steamer 370

16

LIST OF ILLUSTRATIONS

V L U M ]•; B

PAQE

Fig. 1.— >[a|i C.I" Anglo-Eiary|itiiin Sudan,

slidwiiif; IVdviiu'i's ... ... 2

Fig. 2.— Floating Lalioratory and Steamer

Cidex 16

Fig. 3.— Mi'dmnical Sliakcr for Soil tube.s ... 35

Fig. 4. — CViitrifiigi' fur Soil analysis 39

Fig. 5. — Aiijiaratus for tlu' detOTinination of

"Silt- 41

Fig. 6. — .Map showing mean rainfall in Ilic

Anglo-Egyiitian Sudan, 1905-9 ...46-47
Fig. 7. — Map showing proposed flczira Irri-

gixtion Scheme 49

Fig. 8. — Map of the Oezira, showing points

at which samples of Soil were

collected for Analysis 51

Fig. 9. — Cii/otro)iis procern, showng leaf,

Hower and seed-jxxl 87

Fig. 10. — Calotropis procera, showing entire

plant 87

Fig. 11.— Mapof Anglo-Egj'ptian Sudan ... 94
I'l.ATi: I. — Chrysops fuscipennh. Ucema-

to/jota alji/xxinica. llwmatopota

hruimescens. TabanHS sufis

Facinri 112
I'lvii 11. — Tahanus cnmelnrius. Tahanw'

(Ustinctiig. Talianns kitif/i.

Tahaiuiif mordax Facinri 114

Platk III. — Tfihitnns Iwiiioln. Tfihnnus

}Mr FnciiKj IIG

I'r.ATK IV. -7V//«(7t»s (litd'niatu.f. (r'tsfro-

p/iiliis asiniis. (Estrus variolosus

Faciiui 118
Fig. 12.— Heads of Tnhanit.o l-imii and

Tahaniis tieniola ... ... ... 120

Fig. 13.— View of Khor Arbat 121

Fig. 14. — A rock at Khor Arbat showing

sites selected by T. kin;ii for

ovipo.siting 1 22

Pl.\tk V. — Tabarius diUenitUus. I'abannii

Mwji 123

I'r.ATK VI. — Lypero^m crhjun. Lifperoua

minitta. Lyperoitia fliiron.ri.

Lynchia iiuiurn. Fc/ie.'<li//iii.^

nepiaceus. Nycterihofca (ifricann.

Simulium tjriseicoUin. Siiiudium

damnosum. Culicoides,sp. Facing 126
Fig. 15.— Larva of (Estrim variolosug ... 127

V\g. 16.— Pu\>i\ of (Futi-us variolosus 127

Platk VII. — Cotton fitcm-horer,Sp/ieiioptera

nerjlecta 185

I 'r. \\v. \ 1 1 1. — .Melon Weevil, liarin trfff/ardJii.

Melon St<'ni-borer, A/twiieri/iia

ttiiiuliila ... ... ... Farinij 137

Platk IX. — ,Sino.n//on mtdnnioiin. Jiaris

/oratii. A/i/i'moi/tiKter harhara.

A idacfn>horix fore i col I in. /lai/rada

picta ... ... ... Facinij 140

Fig. 17. — Diceroinyia iij'rirniia ... ... 152

Plate X. — Diceromyia a/rim iia,i\.s\>. ... 153

Fig. 18. — Diceromyia africana , ^ chiaycr ... 154

Plate XI. — C iilej: sud/ineriKin, n.i<\i.... ... 155

Fig. 19. — Cu/ej- SudaveiisiH, $ c\ii!i\n'v ... 150
Platk Xll.—Qne/ea a'l/iioj>ica ... F'tciiif/ 1C7
Plate XIII. — ITyphanlornis tO'ttiojitents

Faciiui 175

Plate XIV.— Rnthidie 178

Fig. 20. — hiithits occitanus, ivoxu ahove ... 179
Fig. 21. — Bnthn« occitanns, abdomen from

below 179

Fig. 22. — La.st two segiuents of caiula of

Biit/iHs amoreuM 186

Fig. 23. — Last two segments ol caudu of

llnlltiis (jiiinquf.i/riatns ... ... 186

Fig. 24.— End of foot of a 7i(t//t7« 186

Fig. 25.— Cephalothorax of /?«//(?(.« i»ina.>:.. ISO
Fig. 26. — Movable finger of in.ixillary palji

oi a, Fai-a//utfinx isO

Fig. 27. — Sternum of Fandiniis 1 86

Plate XV. — Pandinun imperator. Pan-

dinns pallidus. Jiuthus ncufe-

carinatu.^. Damon variegatns ... 189

Fig. 28. — Ma.xillary jjalii of Damon vni-ietiatun 190

Fig. 29.— Mandible of a r,V«>,^x 192

Fig. 30.— Mandible of a y^V/w/f*- 192

Fig. 31. — Upper mandibular finger of Sdjmtia

sr/iwein/iirf/ii ... ... ... 192

Fig. 32. — Mandilile of Gfumojiniii ni/esreiiit 192

Fig. 33. — Mandible of i)(psm e/«ren4e)v/i' ... 192
Fig. 34. — Upper mandibular finger of Salptuia

dentatidenn ... ... ... ... 192

Yig. ib.—Galeodes arabs 192

Plate XVI. — A'aia niririco/lis 197

Fig. 36. — .Mimentary tract of adult melon

]nig, Axjujngojius vidiiatiis ... 202
Fig. 37. — Structure and life-cycle of J/er/ie-

tomonas aspongopi ... ... 203

Fig. 38.— Over-seer's store hut, dugout ... 206

Fig. 39. — Overseer's hut near old furnaces 206

Fig. 40.— A dam acro.ss a Khor 206

Fig. 41. — Overseer's hut, )>lan from back ... 206

LIST OF ILLUSTKATIONS

17

Fig. 42. — Milling stones

Fig. 43. — Milling stones showing inner luces

Figs. 44-45. — Washing tables

Fig. 46. — Diagram showing construction of

a washing table

Fig. 47. — Diagram ilhtstrating construction

of washing table ...
Fig. 48. — Sectional elevation of ancient

furnace
Fig. 49. — Dwelling of Shilluk King, Fashoda
Fig. 50. — Shilluk village near Fashoda
Fig. 51. — Tomb shrine of Shilluk King, near

Fashoda
Fig. 62. — Tomb shrine of Shilluk King in

village near Fa.shoda

Fig. 53. — Shrine of Nyakaug at Akurwa
Fig. 54. — Shrine of Nyakang at Fenikang ...
Figs. 55-6. — Paintings on tuld of Nyakang at

Fenikang ...
Fig. 57. — TuM of Nyakang at Fenikang,

showing elejihant tusks before

the door

Fig. 58. — Part of Shrine of Nyakang at Feni-
kang

Fig. 59. — Tree of Nyadwai and his grave at

Kodok

Fig. 60. — Grave Shrine of Yur Adodit, new

<«W being built
Fig. 61. — Nyam-nyam Musical Instrument...

Fig. 62. — Nyam-nyam Pillow

Fig. 68.— MutLlation

Fig. 64. — Mutilation. Two men nuitilated

by the Nyam-nyam
Fig. 65. — Mutilation. Zandeh who has lost

upper lip and upper portion of ear
Fig. 60. — MutDation. Sultan Yango and

some of his younger sons
pL.iTE XVII. — Nyam-nyam and Gour

Charms, etc.

Fig. 67. — The Doctor. A Nyam-uyam doctor

armed with his stock-in-trade . . .
Fig. 68. — The tying cure. A tight cord tied

round the chest of a man suffering

from pleurisy
Fig. 69. — The tying cure. Gour men wearing

" ties ■' for the cure of headache
Fig. 70. — Cuppmg. The native doctor

cupping a patient

PL.A.TE XVIII. — Nyam-nyam and Gcmr

Charms, etc.
Fig. 71. — Divination. A Nyam-nyam devil-
dancer and his assLstants

PAGE

211

Fig. 72.-

211

211

Fig. 73.-

213

Pl.\te

214

214

Plate

233

233

Fig. 74

234

Fig. 75.-

234

Fig. 76.-

235

235

Fig. 77.

236

Fig. 78.

237

237

Fig. 79.

Fig. 80.-

238

Fig. 81.-

Fig. 82.-

238

Fig. 83.

240

240

Fig. 84

244

245

Fig. 85.-

Fig. 86.-

245

Fig. 87.-

Fig. 88.-

245

Fig. 89.-

Fig. 90.-

249

Fig. 91.-

251

Fig. 92.-

Fig. 93.

251

Fig. 94.-

Fig. 95.-

251

Fig. 96.-

Fig. 97.

2il

Fig. 98.-

255

Fig. 99.-

Fig. 100.

263

Fig. 101.

—Food. Two Nyam-nyam dogs in-
digenous to the country

—Native Smoking. A Gour mother

smoking the long-stemmed gourd

htibble- bubble

XIX. — Doctors Fee. Native Pipe.

Nyam-nyam knives. Poisoned

Arrows
X.X. — Extraction and Mutilation

of Teeth

. — Teeth. A Zandeh girl with

.sharpened teeth ...
— Lip perforation. A Gour woman

wdth lip discs and .showing dress
-A group of Nyam-nyam showing

then- sharpened teeth

—Lip perforation. Gour women

with lij) discs, ear-rings, heavy

bracelets, leaf skirts and

charms

-Cosmetic scarring. A Nyam-nyam

woman extensively scarred over

the body
Divining board, Euwa rite...
-Public Gardens and Gordon Statue

-Tramway

-View of part of Khai'toum...
-Embankment Koadw-ay, showing

shade trees
—Provisional plan of Khartoum

City showing proposed lines of

development
-Type Sections of Streets, etc.
■Eain-water drainage system
■Bungalow

Native House

Distribution Station (street fountain) 291

■Water-cart stand post 291

Plan and Elevation, Bimgalow at

Gordon College

Percolation Pit

-Percolation Pit, new type, with

mosquito trap
Type Waste-Water disposal system

Type Waste- Water Pit

Type Well-head

-Latrines for Khartoum Primary

School 299

Public Urinal with wash pit ... 301

Type European Latrine 301

-Type Native Latrine 301

-Refuse De.structor 302

263

263

265

267

269

269

269

271

271
277
278
278

278

278

283
287
289
291
291

293
295

295
297
297
297

IXTRODUCTION

\ LONGER time thau usual lius, on this occasion, elapsed between the appearance of
Reports. This is due in part to the fact that there have been additions to the Staff,
and it was felt desirable that the work of new members should be included, and in part to
the increasing difficulty of finding leisure to compile and issue records of this magnitude.
Indeed, on the present occasion, it was found necessary to split the Report into two volumes.
For a time also we were sorely hampered by the effects of the disastrous fire to which
allusion was made in our Third Report, and had to start building up once more, without
thoughts of output or future publications. Our difficulties were, however, greatly
minimised by Mr. Wellcome's speedy and ample aid, and by the help afforded us by
the Director of Education and his Staff.

Sad to say, no sooner was some progress again being made than we lost by death
our very capable and energetic laboratory assistant, Mr. E. 0. Inglis. He had only been
six months in Khartoum, but had already proved himself a man of the right stamp, and
his loss was greatly deplored. His place was difficult to fill, but eventually we were
fortunate enough to secure Mr. George Buchanan, who, having been trained imder
Mr. Richard Muir in the pathological laboratory of Edinburgh University, had gained
much insight into laboratory methods, and, being an artist of no little skill and a Xew .Assistants
good photographer, has been able to render admirable service. Shortly afterwards a
second assistant, in the shape of Mr. A. Marshall, was appointed, as it was impossible
for one man to cope with the ever-increasing routine work, museum work, oversight of
experimental animals ami equipment, and all the manifold duties which fall to the lot
of a laboratory assistant, and which are much more onerous in the Tropics than in a
temperate climate.

It was, however, evident that additions to the Scientific Staff were absolutely
essential, and as a result of an earnest appeal, strongly backed by the Director of
Education, two new appointments were made.

Dr. James Thompson, late research student at the Lister Institute, arrived early in
1910, to take up the duties of senior assistant chemist. In addition to routine work it
was specially desired that Dr. Thompson should conduct pharmacological research work
on the obscure drugs and poisons employed by the natives and on such allied subjects
as seemed worthy of special consideration.

At a later period, through the kind offices of Sir William Leishmau, F.R.S., the
services of Captain W. B. Fry, R.A.M.C., were enlisted as Assistant Bacteriologist and
Protozoologist. Unfortunately, Captain Fry had not been long with us, before, as a
result of laboratory infection, he contracted Malta Fever and had eventually to return
to England on sick leave. This has upset his research work on animal trypanosomiasis,
which consequently does not figure so largely in this Report as would otherwise have
been the case. Captain Fry's knowledge of some of the newer methods and up-to-date
procedures has, however, been of great service.

The routine work continues to increase both in variety and magnitude. Since the increase in the
date of the last Report nearly 1,800 examinations have been conducted in the bacterio-
logical laboratory alone, comprising Wassermann te.sts, the preparation of bacterial
vaccines, reporting on veterinary material, and on all the usual class of specimens
which are sent in from hospitals and by practitioners. Certainly more use i.s now

work of the
Laboratories

20

INTRODUCTION

Private
Workers

made of such facilities as the laboratories afford, not only in tiie directions mentioned,
Water-supply but iu liygieiiio work, more especially of course for Khartoum. Thus, a prolonged
investigation ou the proposed water-supply for this city taxed severely the resources
both of the chemical and the bacteriological departments and left but little spare time
for research. As will be seen, however, this water enquiry, which turned out to be one
of great interest and complexity, soon assumed the nature oi a research which led,
I believe, to the satisfactory solution of an important and ditlicult problem.

These are but a few examples of the purposes which the laboratories iwv/ serve.
The scope of the work and details regarding it will be considered immediately, but here
one would chronicle a new development, namely the advent of private workers who, at
their own charges, have spent a considerable time in Khartoum carrying out research
work in the laboratories and, for the sake of gaining experience in tropical work, kindly
assisting the 8tafif iu routine and other work. Thus, during the winter 1908-9,
Dr. A. C. Stevenson of the University College Hospital, London, was one of these
volunteers and he rendered good service by discovering coccidiosis in Sudanese goats,
an observation which enabled the veterinary officers to take measures for stamping out
the disease amongst infected herds. Dr. Stevenson also investigated the hiematozoa and
intestinal protozoa of the common toad in Khartoum, and he contributes papers on both
these subjects to this Keport. He has also kindly supplied the drawings illustrating
them. Dr. W. M. Aders, our other free-lance, was here at the same time as
Dr. Stevenson. In addition to helping us with his zoological knowledge he studied the
subject of hyper-parasitism, and contributes a paper on his researches into the
Herpetomonas parasite which he found in AsjMnr/ojnis vidiiatus, the melon bug of
the Sudan.

Since these gentlemen left, applications have been received from an Italian Scientist,
an American Professor and a medical missionary resident in Persia, Ibr permission to
study tropical medicine in the laboratories. Unfortunately, we have little spare room at
our disposal, but in one of these cases arrangements have been made to grant the
request, and Professor E. F. McCampbell of the Ohio State University, Columbus, will,
I hope, be our guest and fellow-worker during the winter of 1911—2, both in the main
laboratories and in the floating laboratory. The latter has been most usefully employed
in the service of the Kala-azar Commission on the Blue Nile, and reports of the work
done will be found included. The subject of transmission ia this disease is a very
difficult one, but Lieut. W. E. Marshall's careful observations go some way towards
solving the problem.

Before proceeding briefly to outline the work ucuuinplinhcil in the different sections,
one has to record the fact that, at ^Ir. Wellcome's request, the distinguishing word
" Tropical " has been added to the title of the laboratories, and they will hereafter be known
as the Wellcome Tropical Kesearch Laboratories. As mentioned, the laboratory work has
Laboratories SO greatly increased, and the number of our outside contributors is on this occasion so
numerous, that it has been found advisable to split the Fourth Keport into two volumes,
the first dealmg with medical, the latter wth general science. At the time of writing,
it is also hoped to bring out a Second Review Supplement more or less on the same lines
as that issued as an appendix to our Third Report. We have received a good many letters
testifying to the utility of that publication and expressing a hope that another volume
would be forthcoming. Hence, both for our own sakes and for workers in the Sudan and

INTEODUCTION 21

in other tropical countries, it seems advisable to make an effort to produce another
compilation of this kind. Indeed, it is intended to extend its scope to the whole subject
of tropical medicine so that it may be more generally useful. The difficulty, however,
will be to keep it within reasonable limits as regards size. We will now consider the
contents of Volumes A and B with such comments as may seem desirable.

Vohunc A represents the research and routine work done in the bacteriological
section, but also, I am glad to say, includes a paper by Lieut.-Colonel H. B. Mathias,
D.S.O., E.A.M.C, President of the Sleeping Sickness Commission, on the question of
this disease in the Sudan. It is illustrated by maps showing fly areas and the
distribution of the endemy in the Lado District, and represents the great amount of
careful investigation carried out l)y the officers of the Egyptian Medical Corps who have
been detailed for special service in the Southern Sudan. The laboratories are very much
indebted to Lieut.-Colonel H. B. Mathias, not only for his valuable paper, but for his
constant aid and support in his joint capacities of Principal Medical Officer of the Egyptian Contributors
Army ;iud Director-General of the Sudan Medical Department. I note that in his '° °"""=-
Annual Eeport for 1909 he writes as follows: "I would like to point out here what a
valuable asset such a well-equipped Laboratory, with well-trained observers, is in Khartoum.

" Had such facilities not existed for research work, a large expenditure must
necessarily have been incurred by the Government this autumn, in carrying out
precautionary measures when a case that was clinically one of Asiatic cholera occurred,
but which was proved not to be so by bacteriological examination.

" Moreover, by enabling a rapid and correct diagnosis to be arrived at in cases of
certain diseases, such as kala-azar, malaria, diphtheria and enteric fever, etc., individuals
derive the greatest benefit, as well as the community at large."

Naturally, such an expression of opinion from one so well qualified to judge is very
gratifying to those responsible for the laboratory work. I quote it here as a powerful
argument in favour of a statement which I propose to make later in this introduction
{vide fage 29).

Other valued contributions to Volume A are those by Captain L. Bousfield, E.A.M.C,
who, though unfortunately no longer in the Sudan, has kindly given us an account of
his experience in kala-azar and relapsing fever eases, and to whom the laboratories owe
much for his kindness in presenting museum specimens and furnishing notes and
information. The papers, by Captain Douglas Thomson, E.A.M.C, and Lieutenant
W. E. Marshall, E.A.M.C, who formed the research members of the Kala-azar,
Commission, have already been mentioned.

In the spring of 1909, the laboratories were visited by Colonel Sir David and Ladv
Bruce, who were on their way to England from Uganda. Sir David Bruce kindly
discussed with me the whole question of animal trypanosomiasis in the Sudan, and he Animal try-
and Lady Bruce were good enough to examine my preparations. Sir David laid stress P^""^"""^'^
on the confused nomenclature which existed, and outlined a scheme which he intended to
follow out and which gave every promise of simplifying what is undoubtedly a difficult
problem. At a later period our conference was resumed in England, and it was agreed
to adopt Bruce's method when dealing with the trypanosome diseases of the Sudan.

In the meantime. Captain Fry had joined our Staff', and so it was arranged that
he should be entrusted with the work. Lady Bruce most kindly undertook an extensive
series of special measurements of our trypauosomes and prepared careful drawings of

22 INTKOnilCTION

tliciii. SiiiiK' of these have been incorporated in I'latr I. wliidi is most useful, as
it had heen found that the tryi)anosoiue platu in mir Tliird Keport had, through soiue
misunderstanding, not been drawn correctly to scalu, and lience gave a wrong impression
of the size of the different parasites. As has been explained, Captain Fry's illness
prevented him doing as much as could have been desired, but his preliminary work
will be found detailed, and fresh light has been thrown on the subject by some
observations of Mr. Buclianan, who, in our most common species of trypanosome, has
discovered an endoglobular stage in the life history resembling that described by Ghagas
for Endotri/panum ci-uzi.^ To liim also are due tlu; few details forthcoming as regards
cultivation. The work has been hampered by the lack of strains. It is not difficult
to get the camel and the common horse trypanosome, but it is not easy to secure
strains of the cattle parasite {T. nanuvi) or of T. rirn.r (raznlhoui) and other forms
which may exist. As, however. Captain Archibald is proceeding tu tlic Lado District
witli the floating laboratory in connection witli sleejiing sickness work, it is hoped
to secure some of the less well-known strains which urgently I'equiru working out.
Work of the A glaucc at the contents of Volume A will show that Captain Archibald certainly cannot
and his Staff ^^ accused of lack of diligence, ami when it is reiiieniliereil that the chief burden of
the routine work has fallen on his capable shoulders, it will be apparent that his time
has been fully occupied. Usefully so, also, one may say. He has discovered the
existence of human botryomycosis in the Sudan, the presence of a special fever due to
a specific microbe, the occurrence of acid-fast bacilli like 1>. tuberculosis in tlie lungs of
camels, a form of cutaneous leishmaniosis not hitherto found in the Sudan, and, in
addition, has undertaken a laborious piece of work on the bacteriological examination
of water with a view to comparing conditions in the Sudan with those at which
Clemesha and his assistants have worked so assiduously in India. Nor is this all, for
during my absence on leave he had charge both of the laboratories and of the public
health work for the town, and from the sanitary standpoint has tested the value of
the Egyptian zeer as a water filter.

My own work has been very varied, and I could have wished that it had been
more thorough, but one's time is so taken up with administrative and clerical work that
it is hard to obtain what may be called consecutive leisure. Still, the increase in the
Staff has relieved one from a good deal of the routine examinations and has made
Work on fowl some research possible. The work on fowl spirochsetosis, a puzzling problem, has been
spiroc aetosis (.yujijjumj ^yitjj some success iu certain directions, more especially as regards the
changes undergone by spirocha;tes ingested by the ticks which serve as vectors. The
results confirm those obtained by Leishniau in human tick fever, and indicate how
important is the study of comparative pathology in the Tropics. Moreover, recent
observations by special methods have, I believe, settled the question of the life-cycle
of the parasites, both in the fowl and in the tick, and at the same time have
demonstrated the important role played by the "infective granule" in this spiroch;etosis.
These results may yet be found to have an important bearing on African Tick Fever
and on other spirochtetal infections of man.

An incomplete research on the spirochtete of Egyptian relapsing fever went some way
to show that we were dealing with the newly-found .S/>. hn-bira of Algeria and to indicate

' Chagns, C. (August, 1909), " Uber eiae uoue Trypanosomiasis dcs Menscheii." .lA-«i. Inalil. Oximjilo
Vraz. T. 1. £. 2.

Additional
contributions

INTRODUCTION 23

that the human spirochtctosis of North Africa is due to this prutozuou wliich, in all
probability, is a specific entity.

It has seemed worth while to compile a paper on the fallacies and jnizzles met with
ill bluod examinations in the Tropics and elsewhere, and also again to deal with the
broader aspects of sanitary work. A popular, rather than a scientific, paper gives some
idea of the life of the sanitary inspector in Khartoum, and was originally written as an
address to sanitary inspectors in England. Under Sanitary Notes the whole question of
the water-supply of Khartoum forms an interesting and I hope instructive paper, and
shows how necessary it is for all departments to work harmoniously together for the
welfare of the public health. Of the papers on Sudan skin lesions, the first is the most
important, for the peculiar non-ulcerating form of so-called " Oriental Sore " had hitherto
escaped attention and formed a good subject of study, though here again the work was
curtailed for lack of time and material. As an introduction to Captain Archibald's paper,
one has inserted some notes on fevers in the Sudan, more for the purpose of drawing
attention to how little we know about them than giving any full description of them,
which, indeed, with our present knowledge is impossible. Diphtheria, however, receives
a special article to itself, as I believe a curious coccal form of the diphtheria bacillus has
been met with in the Sudan. I have ventured to present a paper entitled Veterinary
Notes, for a great deal of our work here is concerned with diseases of animals, and, in the
absence of any expert on veterinary laboratory work, these few lines may help the Sudan
veterinary officers and, along with the Review Supplement, be some return for the many
kindnesses they have shown the laboratories. More especially would one mention in
this connection Captain F. U. Carr, the Director of the Veterinary Department, and
Captain G. P. Knott, A.V.C. The latter takes a very keen interest in the work ami
rarely returns from tours of inspection without submitting material for examination
and presenting specimens for exhibition. One may record the fact that Theiler's
Anaplasmosis of South African cattle has been found in donkeys in the Sudan, and is
here described.

The other papers scarcely call for notice except, perhaps, that on the discovery of
X bodies in human blood. For several reasons the work on this curious and rare condition
could not be carried to a finish, and indeed this is one of the chief difficulties of
research in a country like the Sudan. We need days double their present length, we
require more facilities for seeing cases, though, so far as the Military Hospital in Need for help
Khartoum goes, these are most generously aiforded, we want more help and more money Material
and more opportunities for instructing native medical officers so that they can send in
material for examination in a proper manner and thus, in certain blood collections,
minimise the risks of bacterial impurity. Still, things are improving, and the recent
issue of regulations by the Sudan Medical Department, with full instructions as to the
preparation and forwarding of material for laboratory examination, marks an important
step in advance.

Lastly, as regards Volume A, one must mention Dr. E. V. Crispin, Major
S. O'Grady, R.A.M.C, and Captain Douglas Thomson, RA.M.C, as kind contributors of
clinical notes ; while Major F. F. Carroll, Major H. Ensor, D.S.O., and Captains
W. Byam, A. G. Cummins, C. M. Drew, E. J. C. Thompson and W. H. S. Burney,
R.A.M.C. (attached to the Egyptian Army), together with Mulazim Awal Iskander
Eft'. Sarkis, E.M.C., have been at pains to furnish us with records of cases. So also.

24

INTRODUCTION

ou tliu Civil side, Imvu Drs. V. S. Hudson, H. C. Snuin-s, 0. Atkey, G. R. Footner,
S. Siiigli and N. Mfilouf of the Sudan Medit-al J )oi)artment. To Dr. Watcrtidd wo are
again indebted for museum speuinieus. Major W. Erskine, K. A. 51.0., while in Kiiartouiii
in eharge of liritish troops was most diligent iu liis attendance at the laboratories,
where he did much work on Widal reactions, testing the permanency of the effect of
anti-typhoid inoculation ou the men of the Coldstream Guards. Major J. C. Jameson,
Captain Harvey and Captain O'Farrell have since that time also spent much of their
leisure at the benches. The last named has, moreover, very kindly aided iu the
compilation of the Review Supplement.

Volume />'. Turning now to the second volume, it will be found that its contents
range over a considerable variety of subjects. Chemistry, Entomology, Ornithology,
Helminthology, certain Arachnida of the Sudan, Protozoology, Geology, Anthropology,
Sociology and Sanitary Engineering all ehiiming attention.

Again we are indebted to extra-mural workers. Mr. A. L. IWitler, at my request,
kindly furnished a useful practical paper on the grain-eating birds of the Sudan, wliich,
fortunately, thanks to Jlr. Wellcome, it has been possible to have illustrated in a manner
worthy of the text. Dr. Leiper,' for the second time, favours us with an account of
Sudanese parasitic worms, and Professor Werner, of Vienna, witli a most interesting paper
on scorpions and annulated spiders which, with its fine illustrations, cannot fail to
be of value. Sir Thomas R. Fraser, of Edinburgh, has very kindly given us a paper
on the venom of the Sudan " Spitting-Snake," and Mr. Henry Curtis has written an
account of the " Spitting-Snakes " of South Africa, which is illustrated by drawings made
by Lady Dorothy Stanley. Mr. Duuu contributes an interesting account of ancient
gold mining in the Sudan and Mr. F. V. Theobald notes on two new mosquitoes.

Dr. Aders' paper has been mentioned, and Captain Anderson, whose monograph on medical
customs in Kordofan was one of the features of our last Report, has again put pen to paper
on our behalf, and contributes a most interesting paper ou the Nyani-nyam and Gour people
inhabiting tlie Eastern Bahr-El-Ghazal. The chief anthropological interest is this year
supplied by Dr. C. G. Seligmann's paper. He and Mrs. Seligmann, iu 1908-9, were given
the laboratory steamer for their journey south, and in return Dr. Seligmann has kindly
become a contributor, dealing with subjects on which he is a well-known expert.

Finally, Messrs. W. H. McLean and G. E. Hunt, of the Gordon College, who have
aided me so greatly in the public health work of the city, have compiled a practical
paper on such aspects of tropical sanitary engineering as are likely to appeal to those
who have to cater for the sanitary ueeds of towns in tropical countries, and which
should be most useful to Medical Officers of Health, Sanitary Inspectors, Municipal
Engineers, Boards of Health and other local Sanitary authorities, at least such as have
to work iu hot, dry and dusty countries like the Sudan.

Turning now to the work of non-medical members of the Staff, one linds that
Mr. King has been most assiduous in his undertakings. As, at the beginning of his
report, he gives an outline of what he has accomplished, wdiere he has been and what
he intends to do, I need not enter into details, but content myself with sajTug that
Mr. King is a very valuable asset to the Sudan, and that every facility should be given
him to make the most of his keen interest in, and sound knowledge of, his sui)ject.

I need merely refer to his researches on the bionomics of Tabanida;, which are now
' Unfortunately the paper by Dr. Iicipcr was not received in time for publication.

INTRODUCTION 25

quoted in all works on this subject, to the Sudan Plant Diseases Ordinance, which owes
its existence to his efforts, and to his notes on mosquitoes and mosquito-devouring fish,
to indicate what an essential factor this economic entomological worlc is in the well-beino'
and for the future of the Sudan. A most gratifying feature is the help rendered
Mr. King by well-nigh everyone, from Governors of Provinces downwards.

One leaves the most important items to the end as a rule, working, as it were,
towards a climax, and hence it is only fitting that this place of honour, so far as
Volume B is concerned, should be devoted to a brief consideration of the work of the
chemical laboratory. Although Dr. Beam has certainly not received that outside aid
which should have been fully and cordially extended to him, yet, I think, there are now
few in the country who will deny how great a bearing his laborious and painstaking
investigations into Sudan products and soils have on the development of the country.
He has undoubtedly been hampered and hindered in his work by those who, without Work of
proper scientific training, could not appreciate the necessity for scientific methods of Laborato"^*^'
collection and procedure, and, I fear, resented advice on these essential points. I believe,
however, that the worst is past and that those responsible for the development of
commercial products are now likely to co-operate and to recognise how absolutely
essential it is to abandon slipshod measures and to proceed on sound scientific lines.
This is specially necessary in the case of soil investigations which now bulk so largely.
The locality which is being chiefly studied is the Gezu-a, that vast area lying between
the Blue and White Niles, which, if properly handled, may yet bear great crops of
wheat and of cotton. There is a scheme afoot to place it under perennial irrigation,
and, as the cost of the irrigation work will be very great, it is essential that a sound
knowledge of the character of the prevailing types of soil be secured before any reliable
opinion can be expressed as to the success or otherwise of such an undertaking. As
Dr. Beam says, " attention has been called to the paramount importance of a study oi'
the subsoil as well as of surface conditions, since the question of drainage, resistance to
drought and root penetration will depend essentially upon the nature of the substrata.
Mechanical analyses of these soils and their subsoils {i.e. the determinations of the
proportions of gravel, sand, silt and clay) are therefore being made in all cases, and
determinations of the proportion of the essential plant constituents, potash, phosphoric Analyses
acid and nitrogen as well. These results, taken in conjunction with the observations made subsoils^"
in the field, should yield sufficient evidence to enable one to form at least a reasonably
accurate judgment as to the results which may be expected from irrigation if the
cultivation is carried out on suitable lines."

Soil samples are also being obtained from Dongola and other districts, so that a good
general idea may be obtained of the classes of soils met with in areas which are, or are
likely to be, cultivated; while the prospect of increasing the yield of certain crops by
scientific treatment is shown in a most interesting paper on " Gypsum as a Fertiliser
for Sudan Soils." Moreover, after a prolonged and careful study of the question
of soil examination. Dr. Beam has devised new, rapid and special methods, which not
only greatly facilitate his own work, but appear to place the physical examination of
arid soils on a sounder basis than it has hitherto occupied. These are fully described.
The gum work, which for reasons explained by Dr. Beam, had perforce been abandoned,
is shortly to be resumed \vith, it is thought, better chance of successful results.
Mr. Edie again contributes a paper on the subject, having kindly continued and

26

INTKOni'CTION

The Poisonous
Ushar plant

'Cti/t'x'

t'xtenik'il liis obsurviitioiis in Eiii^liin<l. Of spuciiil interest are his couclusious, based
oil Dr. Huam's suggestions, as regards the role of uuts in gum production, au interesting
analogy, possibly, between the transmission of diseases aflfecting animal and vegetable life
respectively.

Dr. Thompson, besides assisting in the work on soils, water, poisons, commercial
products and the various analyses which are always being conducted, took up as a Una
of research the pharmacology of Cti/utropix procfru, the Ushar plant, with a view to
isolating the toxic principle or principles which, as previously explained, may occasion
poisoning by merissa, the national Sudanese drink, a kind of beer brewed from dura —
(millet). His results are detailed in his paper. In this connection one would gratefully
acknowledge the kind help received from Dr. Power and Mr. C. .T. S. Thompson of
th(^ Wellcome Chemical Research Laboratories in Luiulon, wlio furnished records
of the literature on the subject to which we could not otherwise have easily gained
access.

Dr. Beam, himself, has succeeded in finding a colour test for the detection of
hashish, a most useful discovery the valuf of wiiicli has lieen confirmed by Professor Schmidt
and Mr. Lucas in Cairo, and has been concerned in all kinds of analytical and ailvisory
work, the outcome of questions brought before the Central Economic Board.

Mr. Goodson, who has been elected a Fellow of the Institute of Chemistry, has
rendered valuable assistance and has also had charge of the meteorological work for
Khartoum, a duty which I am informed he discharges in a most satisfactory manner,
but which naturally trespasses somewhat on time whicli might well be devoted to
chemical investigations when there is so much to be done.

The laboratory steamer has been mentioned. It was named the " Culu;" and has
been well-nigh as ubiquitous as its namesake. After conveying the Floating Laboratory
up the Blue Nile, it took Dr. and Mrs. Seligniann up and down the White Nile. Then
Colonel Mathias and I travelled by it to the Bahr-El-Ghazal where a trypanosome strain
was secured and where experiments were made with a Dinka tsetsefuge in the shape of
Vitis produetn. So far the outlook in this direction is nut promising, but Mr. King,
who is now working for the Sleeping Sickness Commission, is to repeat and amplify the
observations. Cattle diseases were also studied and posts on the Nile visited and
reported upon at the instance of the Central Sanitary Board. The S. IV. " Cide.i;" then,
is a most useful auxiliary, and greatly enhances the value of tiie laboratory barge,
making the latter independent of the ordinary Nile steamers.

The laboratories' museum has been hou.sed in a new and larger rouui kindly granted
for the purpose by Mr. Currie and, under the fostering care of Mr. Buchanan, has
considerably developed, though one still regrets the serious losses caused by fire. It is,
however, in a better state generally than has ever been the case before. Dr. Waterfield
has kindly sent some very interesting material from Port Sudan, anil a circular which
was sent out has produced good results on the whole.

The library increases slowly, for our funds are limited, but our exchange list
has attained formiilable dimensions and the work of checking, acknowledging and
cataloguing reprints and other publications is no light matter considering we do not
possess a .secretary or librarian.

One again takes this opportunity of thanking all those, and tlicy are now to be
found in most parts of the world, wlm liave been good enough to .sen<l us reprints of

Fig. 3. — Sectional View of the Pathological Museum

G B D c a AN A

Fig. 4. — S ectional View of the Pathological Museum

28

INTBODUCTION

Distinguished
Visitors

their work. Thanks are also due to the Editors of the British Medical Journal, Lancet,
Journal of Tropical Medicine and Ilyfjicnc, Journal of Hygiene, Journal of the Hoiial
Army Medical Corps and Journal of Comparative Pathology and Therapeutics for Iciud
permissiuu to reproduce papers in this Report.

So many Sudan officials have given us kindly aid that I cannot attempt to mention
all of them here. I have already referred to the medical ollicors who have helped us,
and Dr. Beam and Mr. King make their own aclcuowleilgments. I would, however,
specially like to thank Captain A. L. Hadow, because, though not a medical man, he
has taken a great deal of trouble to secure specimens of poisonous snakes, of venom and
other objects of interest, while the note on venom by Sir Thomas R. Fraser, and an
account of " Spitting-Snakes " by Mr. Henry Curtis have already been mentioned.
My thanks are also due to El Kairaakam C. V. N. Percival Bey. I may state
here that JIajor Lyle Cummins, R.A.M.C., late of the Egyptian Medical Service,
has kindly acted as the Editor in England of this Report, an arrangement made by
Mr. Wellcome, and one which has helped me very greatly. Many of the illustrations
have again been entrusted to Mr. Richard Muir wliose skill requires no encomiums
from me.

The laboratories have been visited by a number of persons interested in their work.
I have mentioned Sir David and Lady Bruce. Captain F. P. Maclde, I.M.S., followed
them, also on his way from Uganda. Monsieur A. Solvay, of Brussels, came and saw
and, as on a previous occasion, most kindly gave us a generous donation which enabled
us to purchase a special microscope for the chemical department and to secure some
books of which we had need. I only wish more visitors to Khartoum would follow
M. Solvay's example. Perhaps they would if they imderstood the laboratories stand,
in some degree, for health, and health means comfort and prosperity and a good many
other things which make life worth living. It is Emerson who says, " The first Wealth
is Health," a motto which might suitably be inscribed upon our walls and exhibited at
intervals to those who control our finances ! Lord Kitchener also inspected us and, with
his Indian experience, showed himself a keen, though happily a friendly, critic. One has
also to record Mr. Wellcome's return to the Sudan. Needless to say we were pleased to
see him, and he went fully into all matters pertaining to the laboratories, and, as ever,
showed much interest in their development. He had recently been in Panama, studying
the Sanitary Department work, and it is remarkable how many of the problems in the
Sudan resemble those in the Canal Zone though, of course, on an infinitely smaller scale.
There are, however, the same difficulties and disappointments in both places, and one
derives a kind of vicarious comfort from such a reflection. At tlie same time we still
retain the support of H.E. the Governor-General, while to Mr. Currie, to whose far-seeing
grasp of affairs the establishment of the laboratories was primarily due, we are more
than indebted. Under a less sympathetic, a less inlluential, or, I may add, less determined
chief I am quite certain that the development of the laboratories would more than
once have received a serious . check, not fi-om any hostility towards them but from a
lack of knowledge of their needs and a lack of appreciation of all they represent and
of Emerson's sound dictum. In the past, one has always concluded an Introduction by
considering the future, and, after eight years of experience, one has now a good idea
of what is and will be actually required to keep these laboratories abreast of the times.

Requirements In our Third Report I spoke of the necessity of a new huildi

this I will (leal

INTKODUCTION 29

with the Scientific Staif as it should be. liere is what we want, what we have in
part obtained, and what I trust will yet be forthcoming : —

Scientific Staff:
Director

Bicreati. of Microbioky// :
Bacteriologist
Pathologist

Veterinary Pathologist
Prutozoologist
Helminthologist

Division, of Entomology :
Two Economic Entomologists, one especially concerned with medical entomology

Uioision of Botany :
Botanist
Mycologist

Bureau of Chemistry :

Research Chemist in Charge
Economic Chemist
Agricultural Chemist
Pharmacological Chemist, whose work would include toxicology

In time, no doubt, it would also be well to have an Assistant Director, a
Hsematologist to carry out serum tests such as Wassermann's reaction, other complement
fixation and precipitant tests for blood, and such new developments in this important
diagnostic branch of medicine and surgery as may arise. An Anthropologist would also
pay his way, especially if his main work was in the direction of sociology.

These then, with the necessary assistants including an artist, witli an adequate
clerical staff, and more especially with a secretary who could also look after the library,
would supply a force which might wage a most successful war with disease in man and
animals and plants, which might make the most of such products as the Sudan yields
and indicate how they might be improved, which might point out along what lines
agriculture should develop, and aid those who will irrigate and till what is now a virgin
soil. They will cost money but they will save money, and indirectly they will make
money. Money, however, is after all not everything. " The first Wealth is Health," ^ 7th'^'
and given health all other things may be added unto us, even in a country like the 's Health "
Sudan with its manifold drawbacks and disadvantages. When I asked Sir David Bruce
what he thought should be our annual contingent he straightway replied "ten thousand
pounds." We are a very long way off ten thousand pounds, but one is not without hope
for the future when one sees how everywhere Science leads the way. We have already
grown from small beginnings to a respectable stature, are, I think, secure against
extinction, and, so long as we proceed on practical lines which have a bearing on the
development and progress of the country, should not fail to receive that support and
consideration which the magnitude, scope and importance of the work that now falls to
our share amply justifies.

Fio. 5.- Map or Anglo-Egyptian Sudan

Sleei'inu Sickness in the ANtiLO-EaYi'Ti.vN Sudan

being a

NOTE ON THE A UMINISTBATI VE HEASUUES THAT HAVE BEEN TAKEN IN THE SOUTHEUN SUDAN
TO DEAL WITH THE ADVANCE OP SLEEPING SICKNESS NORTHWARDS PROM UGANDA, THE LADO,

BELGIAN COKGO AND PBENCH CONGO

BY

Colonel H. B. BIathias, D.S.O., R.A.M.G., P.M.O.E.A,.

President, Smlan Sleeping Sickness Commission

Dr. Andrew Balfour has asked me to write a short note on the above subject for
the Fourth Eeport of the Wellcome Tropical Eesearch Laboratories and I gladly do so.

In the Third Eeport (1908), extracts from Captain Howard Ensor's report to the
Sudan Sleeping Sickness Commission appeared, and in these extracts all that was then
known of the distribution of tsetse flies, both G. palpalis and G. morsitans, in the
Bahr-El-Ghazal was set forth, and the question as to whether sleeping sickness existed
at that time in the Province discussed, without its being possible to give a definite
answer one way or another. Certain recommendations were, however, made by this
Officer, and, acting on these, and from the general information contained in his report,
it was decided by the Sudan Government to despatch a British Medical Officer in the British
autumn of 190S to the Bahr-El-Ghazal, and Captain E. G. Anderson, E.A.M.C, attached ^^^'^'"^^ .

■^ Officer detailed

to the Egyptian Army, was selected. for "Sleeping

He was ordered to travel over, and investigate the conditions existing in, the S"=''"*=^^
southern portions of the Bahr-El-Ghazal (its southern frontier and immediately
adjacent states) which have a more direct bearing on the gradual invasion of sleeping
sickness from the south.

Leaving Khartoum in November, 1908, he proceeded to Shambe on the White
Nile, thence south by way of M'volo and Meridi to the Eiver Sueh, carrying out the
routine examination of the inhabitants by the way and afterwards returning and
traversing the northern frontier of the Lado. He paid special attention to the
upper portion of the Eiver Yei, and the villages Amadi, Dego and Dai, which were
suspected centres of sleeping sickness, and then crossed to the southern limits of
Mongalla Province on the Nile. With regard to the information obtained by him, it
will be sufficient to mention here that not a single case of sleeping sickness could be
found, and that after five months of arduous travel, as the rains were starting, making
further progress in the southern Bahr-El-Ghazal almost impossible, he was ordered to
return to Headquarters and write his report.

Captain Anderson brought to notice among other things the important fact that a Natural
barrier exists to the east of the Bahr-El-Ghazal against the inroad of sleeping sickness. ^"'"^

'-' X o ) against

consisting of a large area devoid of permanent open water of any sort, which stretches Sleeping
from the Eiver Yei to the Nile. Also in Mongalla Province, between Mongalla station ^"^l^"^^^
and Gebel Lafone (some 60 or 70 miles) there is an extensive plain, very thinly
populated, devoid of permanent open water and free from tsetse flies, and farther
eastward still, towards Abyssinia, the country is reported to be desolate and uninhabited.
On reference to Map (Fig. 7) it will be observed, as pointed out by Captain Anderson, that

:{2

SLEEl'INO SICKNKSS IN TlIK ANGIiO-KOYl' TIAN SIDAN

C;ises

rffKirtccl from
tliu Western
l!:ihr-i;i-
Ghazal

Qiiaraminc
Ordinance

Clearing of
river banks

tho Yei llivur route to llie Bahr-El-Ghazal from the Lado, and the Nile route from
Uganda, can bo controlled by Inspection Posts at M'volo and Mongalla respectively, and
measures were at once taken to have Medical Ofiicers stationed at each of these places
for that purpose.

Beyond rumours (alluded to in Captain Anderson's report) of sleeping sickness in the
Liido, and information obtained through the courtesy of Dr. Errara, of the Belgian
(iovurnment Service, nothing further was heard of sleeping sickness in the southern Sudan
until October, I'JO'J, when the Senior Medical Officer, Bahr-El-Ghazal, wired, saying that
the Medical Ollicer at Ragaa had reported that there were some suspected cases at that
station, which is near the western boundary of the above-named Province. He asked
permission to proceed and investigate, and for the services of the British Medical Officer
engaged on sleeping sickness work. Captain C. M. Drew, R.A.M.C., attached to the
Egyptain Army, was despatched to the western Bahr-El-Ghazal in December, 1909, and
Captain (now Major) Ensor, D.S.O., R.A.M.C., who was going to the Bahr-El-Ghazal
as S.M.O. in i-elief of Major Carroll, accompanied liim.

Both Officers were appointed members of the Sudan Sleeping Sickness Commission.
Captain Drew was ordered to visit as much as possible of the western Bahr-El-Ghazal and
to enquire into the prevalence of sleeping sickness, to map out fly areas, and to devise
measures for the prevention of a possible invasion of the disease from the infected districts
of the French Congo.

Major Carroll and Captain Ensor met at W'au and, in consultation, sent in
reconnnendations as to the precautions that were necessary with regard to traders, porters,
and other persons crossing the frontier, which were embodied in an Ordinance whereby
all porters are stopped at the frontier posts and turned back, animal transport being used
to convey the goods subsequently.

By reference to Figs. 6 and 7 it will be observed that Isolation Camps have been
established at Ragaa and Dem Zubeir, and Inspection Posts on the main trade routes from
the French Congo to the Sudan, viz., at Dem Zubeir, Sabun and Said Buldas respectively.

This scheme of quarantine has been found to deal adequately with the supervision
of all classes except refugees. All the merchants and the majority of the natives use the
roads, but the refugees make their way through the forests and avoid the posts. The only
way of detecting and dealing with them is to insist on the Sheikhs and Sultans bringing all
new-comers to their villages to the Government Posts for medical examination, after having
been thoroughly warned of the danger of harbouring such people. This arrangement has
been carried out and has been the means of detecting one case of sleeping sickness.

In addition to the above methods, clearing the fords of palj)alis-ha,unted khors on
the main road from Wau to Katia Kiugi (roughly 400 miles) was carried out, and extensive
clearing done at the Quarantine Camps at Ragaa and Dem Zubeir, and the Inspection
Posts at Biri and Said Buldas. The banks of the river at Ragaa were cleared for about
three miles, and, 300 yards back, similar extensive clearing was carried out at Said Buldas
— these clearing operations will be carried out twice a year, in future, by local arrangement.

DiscovKKY OF Sleepinu Sicic.VESs Cases in the Wksteun Bahu-El-Ghazal

Only two cases of sleeping sickness were found by Captain Drew at Ragaa, although
it is thought likely that a few cases had already terminated fatally before he got there.
They wore all in natives who had come from the French Congo, the two positive cases
being found among natives wiio had been detained in the Quarantine Camp by order of
Major Carroll.

-■V

- ■^^v,.

''fi'^'Wm^

■'■' ' \M '■■■-..Si \S

. ),

34

SLEEPING SICKNESS IN THE ANOLO-EGYl'TIAN SUDAN

l^xaniiimtion
if Natives

Sleeping
Sickness in
the I. ado

Search for
western and
northern
limit of the
disease

Of Natircs living enfirehj in the Eahr-El-Ghazal , Captain Drew cxaiiiiiiiid 1400; of
this iiuinbor, 271 had onlarf^ed cervical j^lands attributable to one cause or anotlier.

The routine method of examination consisted of gland palpation, examination of
fresh and stained blood films, and gland puncture.

WluMi no obvious cause of gland enlargement was observed, an examination of the
fresh l)loi)d was made, altogether 130 blood examinations being carried out; in no case
were trypanosomes found or auto-agglutination noted.

Seventy-three persons coming to the Bahr-El-Ghazal from the French Congo and
detained in the Quarantine Camps were also examined. Fifty were merchants and their
servants, and twenty-three were natives desiring to settle in the Bahr-El-Ghazal.

Blood examinations were made in each case and all found negative, except two of
the latter in which auto-agglutination was noted^one, an Arab, was obviously in the
last stage of sleeping sickness, the other an apparently healthy man with the exception
of some enlargement of the glands, and mental dulness. Trypanosomes were, however,
found in the gland juice.

By the terms of an agreement with the Belgian Government, the Lado was
taken over by the Sudan Government in Juno, 1910, and a Commission, of which Captain
Colin Mackenzie, D.S.O., E.A.M.C, attached to the Egyptian Army, was a member, left
Khartoum on April 14 for this purpose.

It was known that sleeping sickness existed in the Lado, and Captain Mackenzie
was ordered, as far as time and circumstances permitted, to ascertain to what extent
the disease was pi-evalent in the Yei Valley and other parts of the country. He was
met on arrival by El Yousbashi Yusef Effendi Dervish, Medical Corps, E.A., who
liad been stationed at Mongalla for some time previously, and who had sent
valuable information to Headquarters, which ho had collected from various sources,
of the amount of the disease in the Lado. This Medical Officer was sent ahead by
Captain Mackenzie to Yei on May 16 to meet Dr. Errara, the Belgian Medical Officer
of the Lado, and ascertain from him particulars of the various cases already known
at and around the post. These cases were then to be brought before Captain Mackenzie
on the arrival of the Commission at Yei in order that he might satisfy himself as to the
diagnosis, before the occupation of Yei and Kagelu Posts camo up for decision.

Captain Mackenzie met Dr. Errara personally, later, and was informed by him that
sleeping sickness had existed in the Lado for over two years and that he had reported
the matter to his Government.

On June 8, at Yei, Captain Mackenzie found Dervish Effendi had collected fifteen
cases of sleeping sickness, in eight of which he found trypanosomes, the remainder had
been treated with atoxyl. Most of these people came from Wata and Lajuba, and eight
of them were women or children. The women do most of the water-carrying, and
probably were infected when drawing water from the river: "All seemed to take the
greatest delight in having their cervical glands punctured, even the children siiowing no
signs of fear ! "

Dr. Errara also stated that, according to native reports, sleeping sickness exists far
north in the Yei Valley, and, with a view of ascertaining the western and northern limits
of the disease and of G. palpalis, Captain Mackenzie, after leaving Yei, proceeded to
Libogo on the frontier, thence along the Congo watershed until the head waters of
the River Tor were reached. He followed down the course of tliis river to Fudl-il-Mula,
near Kapei on the River Yei, and next proceeded northwards to Waringua, Beringis
village near Wandi, which was found infected. From Waringua, he next marched east,

36

SLEEriNG SICKNESS IN THE ANGLO-EGYPTIAN SUDAN

The infected
area

Summary of
precautionary

crossing the Yei at Luri Rapids and thence north down tlie east bank to Lorella, and from
Lorella, again east to Buiidukia. This was one of the places where the natives reported
sleeping sickness existed, but none could be discovered, neither was any found in the
villages between here and Lado. G. morsitans was very numerous in places, but no
i.f. palpalis was found farther north than Wandi.

As a result of his investigations Captain Mackenzie concludes:- -

1. That a line drawn from Loka to Bangali and thence to Libogo, from there along
the watershed to the source of the Tor, then down the Tor to just north of Beringi
and thence to Loka, would enclose the area which is at present infected with sleeping
sickness (Fig. 8).

2. That there are probably a few isolated cases outside this area occurring in men
who have been working and become infected in Yei.

3. That G. palpali.i is to be found near water in most of tlie area above mentioned.

4. That G. palpalin also extends all along the River Tor and its tributaries, and
also northwards along the River Yei. (Fig. 9).

In the meantime, another British Medical Officer was engaged to carry on sleeping
sickness work, and, on the return of Captain Mackenzie, this Officer, Captain
R. J. C. Thompson, R.A.M.C., went to the Lado as S.M.O., and was accompanied by
two Egyptian Medical Officers to assist hiui. Owing to it being the rainy season, he
has found that clearing is difficult, but a great deal has already been accomplished
around Yei on both banks of the river, and G. palpalis is now reported as
rarely seen.

The sleeping sickness cases are being marked dow'n, and will shortly be collected
in a camp in a fly-free area.

Regulations have been drawn up with regard to the importation of porters, and
communication with the Bahr-El-Ghazal prohibited, and it is hoped, in a relatively short
period, to have final arrangements for dealing with the disease in the Lado, complete.

In conclusion, I recapitulate the measures that have been taken as a result of
recommendations advanced, and the information obtained by the Medical Officers of the
Egyptian Army on behalf of the Sudan Sleeping Sickness Commission.

1. An Inspection Post has been established on the Nile at Mongalla.

2. Lado.

{a) Mapping of the country showing fly areas, and areas proved to be infected with
sleeping sickness.

(6) Notifying all cases, in order that tlu'v may be moved to a sleeping sickness camp as
soon as possible.

(c) Clearing fly areas round Yei and Kagelu posts.

(rf) Enforcing of regulations regarding traders, porters, etc.

3. Bahr-El-Ghazal. Eastern Boundary.

(n) Establishing an Inspection Post at M'volo, which latter station has been moved to
a more healthy site in a fly-free area.

(h) Medical Officers at Meridi and Yambio warned to examine all natives arriving from
the Lado, or Congo Free State.

4. Bahr-El-Ghazal. Wi'sfern Bnimdari/.

(a) Quarantine Stations and Inspection Posts established on the main trade routes,
(fc) A vast amount of clearing carried out.

(c) Special regulations issued dealing with traders, porters and refugees from
the French Congo.

C O jv

Map of LADO

Sleeping Sicftness

Gfossina pa/palis

G/osslna morsitans

Probable Limit of

Sleeping Sichness Area

NB. Medical Officers are now stationed
at iei, Loka and Lado.

Fig. 8. — Map of Lado showing Tsetse Fly Areas and Probable Limit of Sleeping Sickness

From a map conipiltd at the
SmT'ty Office, Khai-touin

38

SLKHriNO SICKNESS IN TIIF, ANOLO-EOYl'TIAN SLM).\N

Uifticullies
on the
souihprn
fronlior

In the soiitli tlioic is a long line of fiontiur where the Bahr-El-Ghazal adjoins tlie
Congo Free Stiito, tlie houndary line heing the Nile and Congo Kiver watersheds, where,
owing to the physical conditions obtaining, any methods of prevention would appear next
to impossible. The country is densely wooded, there are no main trade routes, merely
small native paths through the jungle ; the rains last for nine months of the year (March to
November) and are the chief hindrance to inter-cominunication. Owing to the flooding
of swamps and roads and the rapid growth of tropical vegetation which they cause,
any inter-tribal communication taking place daring tlie dry season is prevented. This
district, moreover, is reported to be now thinly populated, so that short of an emigration
northwards of a whole tribe en niamso to escape from sleeping sickness in the Congo
Free State (as suggested by Captain Ensor, in his 1907-8 report) the danger on this
boundary does not appear to be an imminent one. It is hoped, however, sliould the
services of Captain Drew be available later, to send liirn along tliis boundary in order
to collect more definite information as to the present condition of affairs.

Clearing
nieasuri'S
adopted

Numl»cr of
cases under
sur\cillance

Additional Note

Since writing the above I have made a tour of inspection in tlie Lado accompanied
by Captain R. G. Archibald, E.A.M.C., of the Wellcome Tropical Research Laboratories,
Khartoum, and visited the Sleeping Sickness area.

I found an immense amount of work had been accomplished by Captain R. J. C.
Thomp.son, R.A.M.C., and the two Egyptian Medical Officers, Mulazimin Awal Nesib Eff
Haddad and Nesib Eff Bas, who are assisting him.

The majority of the kliors between Loka and Yei, where they cross the Automobile
Road, have been rendered fly-free.

The banks of the River Yei, for a distance of over three miles in the vicinity of Yei
itself, have been thoroughly cleared of all vegetation. (Fig. 10.) During my stay of
five days in Yei not a single flj' could be found, unless an excursion was made on to
the uncleared river bank, where there were plenty of palpalis in evidence. In addition to
tiiis, much clearing of vegetation, and drainage, have been carried out in and around Yei itself.

Kagelu Government Farm, some six miles west of Yei on the Automobile Road, has
also been rendered fiy-free.

Many of the villages in the sleeping sickness area have been dealt with, tools have been
lent to the various Sultans and Sheikhs, and they have been encouraged to clear all trees
and undergrowth from the neighbourhood of watering places.

At Yei, Captain Thompson has built an Isolation Camp and a good hospital for
sleeping sickness cases (Fig. llj. There were 40 of these in camp undergoing treatment
at the time of my visit.

Treatment. — This has consisted in intravenous injections of a special preparation of
metallic antimony, which was kindly given us for experimental work by Mr. H. G. Plimnier,
F.R.S. In addition, a certain number of cases were being treated with atoxyl, and others
with "606."

Captain Thompson is of opinion that he has got nearly half of the total number of cases
in the sleeping sickness area of the Yei Valley now in camp. I am, however, doubtful on
this point, and anticipate it will be found that the number of cases in this area will prove
eventually to be nearly double this number. From the evidence of the natives themselves
many of the smaller villages have already been decimated by the disease, with which the
people ai'e well acquainted, and which they appear to be able to recognise in the
earlv stages.

K. G AR'HI hat [)

Fig. 9.— Typical Haunt of i,i,:ss,na paipatis on the Yei River
There is a patch of sand at the water's edge

Fig. 10.— Clearing Operations on the Yei River

I -1 » 'WT

40

SLKEPINO SICKNESS IN THE ANGLO-EGYPTIAN SUDAN

nislribution
of Fly

Conclusion

It seems to me to be reasonably possible for the disease to be kept under control in this
part of the Lado, provided that fresh infection is not introduced by means of porters
coming; from Uganda and the Congo. They are now being carefully examined at Yei, and
the Sudan Government is being advised as to the framing of regulations for dealing with
this danger.

Witli regard to the distribution of tsetse fly in the fjado, T met Captain Drew,
K.A.M.C., and Mr. King, Government Entomologist, in Yei. They had followed down the
course of the River Yei from M'volo, in the Bahr-El-Ghazal {vide Map, Fig. 7), and
reported that palpalis was present, both on the river and adjacent khors, throughout the
entire route.

El Bimbashi Stigand, tlie Inspector at Rejaf, reported he had found momitans and
-palpalU in khors north of the Automobile Road between Ganzi and Wande, and also showed
US flies of both species collected from around Kajo-Kaji south of Rejaf. Tliis fly area
apparently extends into the hills in the neighbourliood and was formerly believed to be
fly-free. Further reports having also been received of the spread of Sleeping Sickness
northwards on the right bank of the Nile in Uganda territory, Mr. King has now gone
to Kajo-Kaji to investigate into the northerly limit of palpalis on the Nile bank in
the Lado.

Personal!}' I am of the opinion that where suitable conditions of water and shade
exist, there palpaUf, morsitans, or both, will be found, and that the tsetse fly lias a much
wider area of distribution in the Lado tlian was at first suspected.

*A.-v_^ :d?->k..Y> > -^v-*t>.*:

Fig. 11 .— Sle ecino oiv-KNt^.s Cam *-. Y i

I '

o

.jNte/:

C>.

PLATE 1

\

1

••.*'-A .#*

-•fa.

■~^

r^»

v^^-

r^'

^,~^>'"

^..

_/

^cji^'ir

x

J'

\/ . -^

r^

^

&

^

•

I.ehhi:

I

Trypanosoinc

Trypanosomc

the biles

3.
4.

Trypanosomc
Trypanohoinc

7.
Stain

Trypanosomc
Trypanosomc
Trypaiiosomc

Animal Trypanosomes of the Anglo-Egyptian Sudan
of cquincs on the Sobat and White Nile in ihe Uahr-El-Chaial. '/'. l-rucri
of horse. 7". brucci. This horse was never in a ls«>e lly area, but was exposed to
of T, ttrniola

of camels from Kordofan and Erkowit. /'. fvoHsi. a. very rare " short " form
of cattle in Kassala I'rovince and of goats in the Bahr-EI-Ghaial. /'. vitajc
of cattle on the While Nile, /'. naimm

of goats in the Bahr-Kl-Chaial anil of a horse from Uganda. 7'. t.«'rum or T. nn„u,
of sheep in the Bahr-EI-*ihazal

X 2000 iHnm.

Animal Trypanosomiases in the Anglo-Egyptian Sudan

BT

Captain W. B. Fry, M.R.C.S., L.K.C.P., R.A.M.C, attached E.A.

Prutozoulogist and Assistant Bacteriologist
Wellcome Tropical Kesearcli Laboratories, Khartoum

Intkoduction

The question of animal trypanosomiasis in the Sudan, though perhaps of not so urgent
a nature as in some tropical countries, is yet of sufficient interest and potential economical
importance to justify thorough investigation ; moreover, it behoves us in practical tropical
economy to remember that the question as to whether existing conditions are compatible
with, or favourable to, the spread and prevalence of a disease, is of almost as much
importance as the knowledge of the existence of the disease itself.

Was not the enormous loss of life from sleeping sickness on the lake shores in
Uganda caused by the introduction of an infected agent into an area fulfilling in every
way the environments required for the rapid spread of this disease ? A knowledge of the
bionomics of the Trypanosoma (jamhiense might well have rendered this disaster preventable.
The prevalence of biting flies and other general conditions occurring in the southern Sudan,
which is largely a country of swamp and jungle, present a state of things which is, in
general, as favourable a condition as it is possible to conceive for the spread of the various
trypanosomiases.

Having accepted these facts, we must go on to consider what is at present known
as to the existence of the trypanosomiases, and we are at the outset faced by the
difficulties which have been occasioned by the want of uniformity of opinion which at
present exists as to the identity and characteristics of some of the less known
trypanosomes.

In probably no other subject of scientific research at the present time does such Present
confusion prevail as in the study of these diseases, a condition of affairs largely due to the
diverse temperaments and knowledge of numerous observers varying in nationality, many
of whom are not disinclined to add their personal opinions to the literature of this
comparatively new field.

Agreement on the question of nomenclature is by no means unanimous with regard to
some quite well-known species, so that the identification of a possible new species or
variety of species is fraught with the greatest difficulty.

For the sake of clearness in this introduction and subsequent paper, we shall therefore
allude to the trypanosomes of this country under the heading of " Types," and having
briefly mentioned, under four classes, the trypanosomes which have already been discussed
at some length in the Second and Third Eeports of these Laboratories, we shall then go
on to enumerate the principles governing some proposed methods of classification.

We have classified the known trypanosomes into the four following main types : —
1st Type — T. hrucei or T. pecaudi.
2nd Type — T. evatisi.
3rd Type — T. na-Hum or pecorum.
•ith Type — T. viuax or cazalboui.

confusion of
classification

12

ruvrVNOSOMlAHKH IN THE ANCi I.O-IUi VTTI AX STDAN

Necessity for
a systematic
nomenclature

Tliosu lyi>us possrss rcailily recoj;nisable morphological characteristics wliicii, at any
rate, enable one to differentiate positively between the four.

It will be very apparent how desirable a system of general distinction is, when the
extent of tiie Anglo-Egyptian Sudan is considered, and when it is rcnioinbered tliat, owing
to natural conditions and geographical necessities, both animal and liuiuan life lias a
tendency to clump into diffuse and somewhat widely separated colonies or tribes. This
occasions not only the discovery of apparently isolated types of the disease, but undoubtedly
alters and influences the virulence and characteristics of trypanosomes whicli are of the
same stock. Unless some system be carried out, terms such as the " Trypanosomiasis of
Mules," "Trypanosomiasis of the ShiUuk Cattle" and "The Disease of the Camels of
Erkowit," come into existence, and, as they give no clue as to wliat the pathogenic agent
is, endless confusion is caused thereby.

While it is admitted that morphological distinctions alone are not ideal or completely
adequate, yet they are of great practical utility in advancing towards intelligent
classification, rendering further separation an easy matter, thereby saving us from the
fallacies of identifying trypanosomes by their local hosts. The advance of the study of
these diseases has been to siiow that the connnunicability of the infection is less limited
than was at one time supposed, and that the restriction of a certain type of trypanosome to
one class of animal is due as largely to the existence of a suitable transmitting agent
as to the inherent refractory nature of the other animals.

We may at this point take a concise review of our four types.

Ti/pe 1. T. brucei or pecmuli, found on the Sobat and White Nile and in the

Balir-El-Ghazal ; this trypanosome has been carefully investigated and reported on by

Dr. Balfour in the Second and Third Reports, and the conclusion arrived at was

that it most closely resembled what has been called the T. pecatidi of Senegal.

Colonel Sir David Bruce, F.R.S., has, however, shown that, morphologically, it almost

exactly resembles what he describes as T. brucei, a point more definitely considered in the

second portion of this paper. Moreover, a comparison of the animal reactions shows few

discrepancies. It is not intended here to discuss the position of T. pecaudi as to its

specificity or otherwise, but it is obvious that it were better to include a doubtful

Review of ihe trypanosome under the iieading of a large and well-recognised class than to place it with

irypanosome smaller and less old established genus, should the reasons for placing it witli one or

types "^

the other be in any way of equal weight.

It has been suggested that a reason for regarding Type 1 as T. pecaudi is, that wliilu
horses, mules and donkeys are particularly affected on the White Nile and in the
Bahr-El-Ghazal, we have in these same districts herds of cattle belonging to the natives
which are, at any rate, so far unaffected that the natives can maintain them and breed
them in these regions, circumstances in some ways analogous with tlie occurrence of
" La Baleri," whose pathogenic agent has been called T. pecaudi.

A brief consideration of a few points will show how fallacious a liasty suggestion
of this kind may be ; firstly, T. brucei produces a more chronic disease in bovidtc than
in equidic ; secondly, cattle are not entirely refractory to T. pecaudi ; thirdly, horses,
mules, etc., are animals of transport and travel in these countries, and of necessity must be
more liable to infection than the cattle wliicli the natives know how to keep in districts,
or parts of districts, where they are most likely to survive. Moreover, it is not impossible
to imagine that the cattle in these regions may have developed, in common with the wild
animals, a relative immunity or refractoriness to T. brucei. It is hardly necessary to enter
into any further considerations of this nature.

ANIMAL TKYl'ANOSOMIASES IN THE ANGLO-EGYl'TIAN SUDAN 43

Tijpe 2. T. evansi, affecting camels from Kordofan and Erkowit. In classing some of
our known strains under this heading we are on less debatable ground than is certainly
the case with two of the other types. Its general host here is most undoubtedly the camel,
it is rarely dimorphic, and its morphology, as will be shown in detail, approximates to
the evansi type ; moreover, its animal reactions resemble those of the Indian Surra.

Type 3. T. nanum or pecorum. This form has been found by Balfour to occur in
epidemic form in the Shilluk cattle, and Drew came upon a similar type in goats near Eagaa
in the Bahr-El-Ghazal. A specimen from the first of these sources was named T. nanum
by Laverau, from films sent him by Balfour, in 1905. Wenyon, in the Third Eeport, speaks a possible
of T. nanmii as occurring among mules and donkevs in the Bahr-El-Ghazal, and describes error in

• -1 ■ *T p Tpi- -ii classification

under this heading two main types with an intermediate form. A study of his article has
led us to the conclusion that he was dealing with some other kind of trypanosome, because,
for one thing, uniformity of morphology is considered by us to be an outstanding
characteristic of this species. The reason that T. pecorum has been included in the
nomenclature of this type is the strong morphological similarity between some specimens
obtained from the cattle and goat infections, and the T. pecorum described by Bruce
and others in the communication to the Royal Society, of June, 1910.

Tt/pe 4. T. vivax or cazalboui, from cattle in Kassala Province. This trypanosome,
considerably shorter than T. evansi, is so typical on account of its extraordinary motility
and its animal reactions, that, for this type, differentiation is simple. The question of the
distinction, if any, between T. vivax and cazalboui will not be entered into here.

We shall now briefly discuss in general the means which are at present at our Methods of

, . . , , , iTip differentiation

disposal for differentiating trypanosomes, and it is here urged that some settled plan of
procedure on the part of all observers would go far to prevent the inundation of scientific
literature with the profitless discussions which arise round the nomenclature of similar
type trypanosomes occurring in various parts of the globe. We have, at present, five
possible headings, of varying importance and usefulness, under which classification may
be attempted.

These are : —

1 , . . ... ... ... Morphology

'2 ... ... ... ... Auimal inomilations and reactions

3 ... ... ... ... Culture

•i ... . . ... ... The question of the carrier

5 ... ... ... . . Reaction to drugs

These headings w-ill now be gone into, a few words also being said about what is
known as cross-iiioculatiou, and it will be seen that by an application of some or all
of these means a trypanosome can be classified with a reasonable amount of certainty,
but it must at the outset be made plain that a certain degree of simplicity and definiteness
is essential for satisfying the clauses under these headings, for as surely as the methods
of identification are made numerous and complicated, so surely will the risk of unnecessary
division of types increase. Not only are the relative values of the above headings of
themselves far from being equal, but they also vary in value as a means of distinction
for the different trypanosomes.

In the first place we have morphology, and this, under some circumstances, is Morphology
absolutely straightforward ; for instance, no one seeing a slide of T. nanum, from general
morphological considerations, would confuse it with T. evansi ; but in most cases, and for
trypanosomes of a somewhat similar structure, something more definite is required, and

44

ANIMAI. THYPANOSOMIASES IN TUE ANGLO-EGYrTIAN SUDAN

Uruces system

of

measureniiiit

Animal
inoculations
and reactions

(_'ultural
methods

keaclinn
to drugs

this we liave in Bnice's system. Under this system the trypaiiosomes are drawn at a
{^iven magnilicatioii (2000 diameters) and they are measured in a uniform way (i.e. with
calipers down the body keeping the points of the instrument rigidly in the middle) from
films, if possible, fixed and prepared in a uniform fashion — osmic fixation, Giemsa staining.

From numbers thus drawn and measured the average size is obtained, and a maximum
and minimum length is stated also, charts giving curves of the distribution, by percentages
in respect to length, are prepared and the type thus graphically illustrated.

Wo have here, then, a definite and simple method of morphological classification
which, following Bruce's system, is being carried out in these laboratories, and from
which clear statements of results can be obtained.

It must be remembered that in this method there are some pitfalls and some
fallacies, but they can readily be avoided or taken into account, as, for instance, in the
comparison of trypanosomes from different animal sources. A comparison of tables from
the measurements of trypanosomes from a coimuon laboratory stock animal, such as
the rat, is preferable to the indiscriminate study of the relation of trypanosomes in
different classes of animals.

It is well known that the inoculation of the same strain of trypanosome into various
animals is productive of certain differences in measurement, hence it is unwise to compare
new species without taking this into account. In these laboratories the most convenient
animal is the gerbil, but in general, any of the small rodents is, as a rule, a suitable
animal. So nmcii for morphological methods, on the whole simple and workable.

In animal inoculations and reactions we have another exceedingly useful method
of distinguishing trypanosomes, but one that must be used with a somewhat open mind,
for we know from laboratory experiments that, by certain methods of transmission, we
can infect animals which have proved refractory to the original strain, and wc can do
this in a simple manner. Also, one sees how readily a strain, owing to laboratory
transmissions, sometimes varies in character and virulence. We are thus led to keeping
our distinctions, as far as animal reactions go, on broad general grounds, and to avoiding
the error of allowing overmuch importance to the i-efractory power or susceptibility of
occasional animals. Pathological changes in animals should also be viewed in the same
manner ; for instance, opacity of the cornea is not seen in every case of Surra in dogs.

Cultural methods. These have not proved of very great value, for beyond the point
that various observers have been able to say that a certain trypanosome can be " grown
readily" or "cannot be grown" we can arrive at few more subtle distinctions; however,
so far, these methods do help us. But here again, the possibility of a trypanosome being
easily growable, or the reverse, according to its more immediate host environment, must
not be forgotten. Also, the preparation of media is dependent on individuals and different
supplies of blood serum — points well illustrated by the fact that some observers have been
able to grow known strains while others have failed.

These conclusions will make us chary of jumping to definite conclusions under
this heading.

The question of carrier is one probably of more importance in practical bionomics
than in differentiating trypanosomes, still it is also useful in this connection ; but an
acquirable suitability of carrier is as understandable as an acquirable susceptibility of host.

Reaction to drugs, is a method at present of the most questionable importance
and of which little can be said except that it is unsatisfactory. Two drugs are being
used here in this connection, metallic antimony and Ehrlich's "GOG," but from experience
with various antimony and arsenic compounds, little can be hoped as yet from this method.

ANTMAI. Tr.VPAXOSOMIASKS I\ THE AXOT,0-EOYrT[AN SUDAN 45

Tliis will readily he understood if ability to produce antimony-fast and arsenic-fast strains
be acknowledged, and the great want of uniformity of result between the action of a similar
dose of a drug on similar animals, which have been infected at the same time, be known.
Finally, as to Laveran's cruss-jnoctdafimi method, which depends on the fact that doss-
animals naturally recovered from a trypanosomiasis cannot again be infected with the
same disease though still susceptible to other strains, its application is necessarily limited ;
for unless a large number of " immunes " be kept up, a considerable time is required to
prepare an immune animal. This difficulty is increased bj- the fact that animals in which
trypanosomiasis is an acute disease die when inoculated, while those in which it is
chronic, live on, presenting us with the difficult problem of accurately fixing the time
of recovery. Also, unless the experimental animal is to some extent resistant to the
trypanosome under investigation, it is lost to the laboratory.

The method must be looked upon as cumbersome and not easy to carry out.

In the writer's experience with T. evan$i, animals cured by drugs are as susceptible to
a secondary inoculation of the original trypanosome as they were to the primary, a point
giving rise to more theoretical fallacies. On the whole, therefore, the method does not
appear suited to general tropical laboratory work.

The introduction to this short study of the trypanosomes of the Anglo-Egyptian
Sudan was written with a view to make clear to the reader the general extent of our
present knowledge on the subject, and also to convey, in general, an impression of the
main principles which have been observed in making this study.

If the second object has been attained, the importance attached to the vai'ious
phenomena recorded in connection with our four types will be readily undeistood,
certainly at least as far as the work of classification goes.

A confession of faith on the part of a writer of a scientific article would go far
sometimes to rendering his writings intelligible. An ignorance of the axioms and postulates
governing his observations renders them often needlessly obscure.

The general acceptation of Koch's postulates must have prevented endless discussions
on the pathogenic bacteria, for they make clear an observer's view-point.

As no such general postulates are forthcoming on the subject of protozoal infections,
it is pleaded that there is justification for indicating a point of view before entering
into the treatment of a subject like trypanosomiasis, of which the manifestations are as
varied as the manifestations of grace.

The four types have been described roughly in the order of what is at present
considered to be their relative economical importance ; and the amount of work done
on them follows closely in the same sequence.

Type 1
7'. hnicei or ppcaiidi (Plate I., figs. 1-2)

The distribution of this trypanosome is certainly of a very extensive nature and
probably affects numerous species of animals. Its occurrence as affecting more particularly
horses, mules and donkeys in the Bahr-El-Ghazal and on the White Nile, which has
already been mentioned, is far from leading one to suppose that it is limited to these
regions or to these animals. The outstanding characteristics of the type, as observed
here, are its well-marked and persistent dimorphic character and its virulence towards
dogs and the smaller animals. We have, as a point of interest, recently received
additional evidence that it occurs in the former as a natural infection.

(a) Living and unstaiiu'd. An actively motile trypanosome occurring in two easily Morphology
recognisable forms, the long slender forms with a free flagellum and short stouter forms

•tfi

WIMM. TUYrWOSnMI ASF.S IN THK Wr.r.O-r.r. YI'TI AN SI'PAN

with no frou lliincllnin. TIrtu arc, of coiiisu, i,'rtulat,i(iMs lictwccti tlio two, ami lliis
(listiiictioii, tlioiit^li voiy coiivoiiicnt, is not intentltifl to hv aii)itiary. An interesting point,
liowt'ver, has been noticed here during observations made on llic disease in j^erbils. It has
i)cen foiin<l tliat, in a eonnnencinji infection, the lonf^ slen(hT forms are the first to appear
and tlie stout forms are not found till tiie infection is well advanced ; further, these forms
are very much in evidence in the closing phases of the disease.

[b) Fixed and utained. In general, the films were stained here simply by the ordinary
Leishman method. Osmic acid fixation with (iiemsa stain was also used. Studied in this
way, the two forms mentioned above are very apparent but, as stated, there is no distinct
line of demarcation between the two, intermediate forms being easily recognised.

heiKjth. — The measurements are made, as explained in the introduction, after Bruce's
principle, many of the tables below being compiled directly from measurements so kindly
undertaken and ri'sults olitained Ijy Colonel Sir David ]5ruce in his Londim Laboratories,
and to whose courtesy and help we are so mucli indi'btcd in ))n'])aring tliis ))a))er.

Table 1. Measurements of Trypanosomes of Tyjie 1 ('/'. Unirei).

Dim-

.ranunry 27, 1906
February 2, 1908
February 11, 1908
November 20, 190s
December 12, 1910
December 21, 1910
.T.immrv 1, 1911

. . , Method of fixing

•^"""•'' and s.aininK

Kilt

Gcrbil ...

Qerbil ...
IMonkoy 2

(ierl)il ...

Ocrbil ...

Ocrbil ...

In microns

Average
Length

Ijeishuiaa
Tjoishman
rjoisliman

22-9
211-7
21-2
lG-8
22-9
21-4
2G-4

Maximum
Length

Minimum
Length

.'U-O
28-0
33-0

2.')-li
.■i7-ii
27-0
:U-0

14-0
l(l-0
16-1)
14-11
IG-ii
I.-.-ii
l,S-()

Measurements
' by Colonel
I Sir David
Bruro, 1910

MiNisiiromi'iits

KliartoHiii,

l)eccmborl910-

.lanuarv 1911

Gross average

oo.o

30-7

15-6

In comparing this table with Bruce's own measurements of 7'. briicei of the original
Zululand strain discovered by him in 1894, we are at once struck by the resendjlance.

.\v«;raK<-

M.ivinnini

1 ,„cil,

1

Minimum
l.innlli

Trypanosome Type 1, Kh.artouni

.j.j.o

:!n-7

1.". 1.

r. frri/cej, Zululand, 1894 .. .

22-8

■^-,■^\

l.MI

7". ftniCTt, Uganda, 1909

23-6

34-0

l.-.-o

1

In the above table, twenty trypanosomes Avere measured in each case, and from
these the average length was obtained, the length of the longest and shortest form
being also given.

It must again be emphasised that these tables have their value rather as a synthetic
whole than for detailed analysis, and that discrepancies in detail nmst not be allowed
an undue importance. For instance, the table shows a variation in maximum lengths
between 27 and 34 microns in the last two cases. We liave mentioned above the varying

ANIHr.VL TKYPANOSOMIASES IN THE ANCr.O-F.ri YTTIAN SUDAN

47

previilunco of tho sIuiiiUt ami the stout foniis, and tliis alone, taken witli tlie fact that the
ti-ypanosomes are measured just as they come on tho slide, will save one from the pitfalls
of detailed critical analysis. Following still in Bruce's footsteps wc give charts showing
the curves of the distribution by percentages in respect to length. Chart 1 is a
reproduction of a cliart prepared by Colonel Sir David Bruce in London in 1910.
Chart 2 was compiled in Khartoum, and on this chart is show-n the striking resemblance
between the curve obtained here and tlie curve distribution of the strain of T. hrncei from
Uganda, 1909, as depicted in the Proceediwj.-.- of the Eoi/al Society, B., Vol. 83, 1910
(Colonel Sir David Bruce and others).

Chabt 1

Type 1. — Chart compiled by Colonel Sir David Bruce, 1910

/' 1'- ri 14 15 16 17 IS 111 -id 21 22 2.3 24 25 26 27 28 29 aO 31 32 33 .34 36 .36 37 3S 3a

"11

18

l<i

14

I'l

^

111

'\

/

V

\

6

/

\

\

/^

s

/

r<

^

^\

\

4

/

V

s

Sr-

y

\

\

A

»^

V

\

\

^^

^

Fii 12, — Carre 'listrihution by length -^f Typ^ 1

Chaet 2
Type 1. — Chart compiled in Khartoum, 1911

/' 12 13 14 15 16 17 18 19 20 21 22 23 24 26 26 27 28 29 30 31 32 33 34 36 36 37 38 39

20
IH
16
14

A

c 10

i '

<

1 8
6
4

I

V

r

^

J

\

\

"""'

/

\

A

r-^.

A

i

1

/

\

\^

A

\t

f\

\t

^\

I

,.'^'

V

..J

V

\\

,/

r

^

-

<f

o*

v'

y

Fi^, 13 — r'nrvp rli.ttrihntinn by length of Type 1. Dotted Line — 7". hntcei, Klirirt.outn :^.ili.l Tin-^— T'. h-ttct'i, ^^■iti'l.i
N,B. — Tbri Kliartotim Cur\-e was compiled from 150 nieasuiemeuts.

Added interest is given to these curves if they are compared with the two charts given
of Khartoum Type 2 — T. eransi (page 51).

Breadth. The long slender forms average from 1 to 2 microns ; tlie short stout forms
from 2 to 3 microns.

4>!

\\I\I\I, rUVIVWdSOMIASKS IN- Till'. \N(; r.O-Kf, VI'TI AN SfPAX

I'l/tii/iUi.-'iii. Tlic cell contents at tinu's slmw wcU-niavked f^ranules but, as a rule, stain
a cU-ar i)alo 1)Uh'.

Xiirlriis. Is situated aliout the middle of tlie trypaiiosonie and is oval or kidney
shaped in the lonj^ forms and round or oval in the stout forms.

MicriiiiHclpiis. Small and round ; situated from 1 to 2 mici'oiis from the posterior
Gxtrenuty.

I'liihtliitori/ meiiihrane. Shows well-marked folds and utididations.

FlmjeUiim. Free in the lonj,' forms and measures on an average (i to 7 microns.

Ani.mal Inoi'vlations and Reactions

The foUowiii-,' tables show the laboratory animals susceptible to this strain. Tliey have
been compiled from the records in the Laboratories of the Gordon College. It will be
observed that the trypanosome is fairly virulent to most of our stock animals.

DOGS

Kxperiment Number

Duration of the disease

Remarks

X n

X 7

X 11

X 14

X 18

A 1

23 days
28 days

13 days
25 days

14 days
34 days

('orneal opacity, pericardial effusion, enlarged spleen

., liver and spleen enlarged

•1 ■• »♦ " ?» ', If

Perii^ardial offusiou, liver and spleoii enlarged
»i »» »» »j »i

Average duration of the disease in dogs = 23 days
MONKEYS

X S
X 1.!
X 15
X 22
X 26
X 30
X 35
X 37
X 411
X 41
X 48
X 4'.»
X 50
X 51
X 5-2

Experiment Number

Duration of the discise

16 days

21 days

... 1 11 days

36 days

37 days

20 day-

26 day-

32 days

31 days

15 days

17 days

44 days

18 days

24 days

16 days

Remarlcs

Spleen and liver enlarged

»» j» »»

, ' " •»

Spleen moderately enlarged

Spleen enlarged, nicer in caecum

Spleen little enlarged, corneal opacity

Ulcerated stomach

Spleen and livor nilnrged

Average duration of the disease in monkeys = 24 days

ANIMAL TRYPANOSOMIASES IX THE ANGLO-EGYPTIAN SUDAN

GERBILS

49

Kxperiment Number

Duration of the disease

Remarks

X

19

X

•21

X

23

X

25

X

27

X

31

X

32

X

33

X

34

X

39

X

■42

X

43

X

44

X

45

X

4ti

X

47

A

3

A

4

A

5

A

7

A

8

A

10

li

11

G

12

21 days

16 days

8 days
15 days
lU days

6 days
IG days

9 days
12 days
34 days

G days

21 days
20 days
24 days
lU daj's

22 days

7 days

17 days

8 days
20 days
32 days
10 days

23 days
S day>

Enlarged spleeu

Average duration of the disease iu gerbils = 15 days

111 rabhitf experiment X 17 gives 39 days as the duration of the disease, baldness
and blepharitis being a feature of the malady. The conclusion arrived at here is that
in rabbits the disease is of a somewhat chronic type.

In jerboas the disease is acute, killing the animals in about 7 days.

Guinea-pig:' and rats are also susceptible to this type of trypanosome.

3. Culture. This trypanosome has been cultivated repeatedly in these laboratories
by Mr. George Buchanan, whose notes on this subject will be found at the end of this
paper. In general it may be stated that it grows readily and is comparatively easy to
cultivate.

4. Carrier. No laboratory experiments have been carried out liere. Gios.nua
inorsitans and a great variety of biting flies abound in the districts where it appears to
be endemic. At present we may perhaps regard G. mnrsifans as its carrier.

50

ANIMAL I'ltYrANOSOMlASI^S IN Till': AN(i I.O-KC Yl'Tl AN SCDAN

I )rii|;-ri,'actiDns
ill gerbils

Morphology

•j. Hraclii',1 In drKijs. Sumo uxpuiiiiioiits have been caiiiu<l out with disuaso
l)roiliicod in gerbils by this tiypanosoine. This animal has been selected as the course
of the disease is an acute one, the tiypanosoine being constantly in tlic blood till death,
and the fallacies due to dealing with a chronic disease in which the tiypaiiosomes appear
and disappear of their own accord, are avoided. One dose of metallic antimony in
sterile olive oil (3 to 5 minims) causes complete clearance from the blood of all
trypanosomes in from 2-3 hours. Kocurrcncc takes place after several days Init tlie
iuitimony acts with great trypanocidal vigour.

One dose of Ehrlich's "(iOG" given in the same way causes a dimiiiutiun in the
number of trypanosoines in 24 and 48 hours and probably does not postpone the end
for more than 2 or 3 days— it is relatively weakly trypanocidal. The exact amount
of antimony and " C06 " in the dose is not here specified as it has been found by the
writer from experiments performed both hero and in London that probably (jidy a small
l)roportion of the drugs thus injected is actually absorbed Ijy the body and thus rendered
available for trypanocidal effects.

I do not propose to outer into a discussion as to whether Mr. Buchanan's work on
tlie developmental and intra-corpuscular forms as found by liim will necessitate a change
of nomenclature in this type or not. His work on this point is very interesting and will
be found in an article by itself following this paper. At present, however, I may say
tliat I do not thiidv we have sufficient grounds for eml«uking on fresh nomenclatures.

Type 2
2'. evansi (Plate I., fig. 3)

The laboratory strains here of tliis tiyi)aiu>sonio have been obtained fiom camels
but there are some grounds for believing that mules and horses are at times alToetod.
The disease is, as far as can be ascertained, probably widely distributed in the Sudan
desert country w-here the camel is used. Its recognition by us as affecting camels in
such widely separated districts as Kordofan and the Red Sea Province gives colour
to this supposition.

(n) Living and unstained. \n actively motile ti-ypanosomo of a strikingly inononiorphic
type, no markedly noticeable variations in length occurring in the unstained parasite,
an observation which is continued by measurements and study of the stained specimens.

(6) Fixed and stained. It is characteristically a long slender trypanosome with a

well-developed tlagellum, and tiie posterior end is definitely seen to be what is called

" pike-hoaded." It certainly closely resembles the classical picture of tiie Trypanosome

of fiidiiin Surra.

MKASUBEMENTS OP TYPE 2 (T. evami)

Mt;iho(l of lixiiiK
and staining

In microns

n.alc

.\hii)i.il

.Vvcraijc
Length

Maxintuni
Length

Minimum
Length

kiniarks

January 6, lUns

Du^' ...

_ 1

24-4

29-0

2(111

,

.January 16, l'.)08 ...

Ital.l-it ...

—

22-(i

•Jii-o

19-(i

Muiitiurcmuiits
liy Colonel

Dt'cciiiber 1.3, 19UH . . .

(';iiiR-l

•J3-J

•ji;-ii

2()-(i

Sir David
Bruce, 19111

.laiinary 25, 19(19

Dog

—

2:)-2

2G-(i

22-(l

;

Doirnnilicr 20, run ..

llcrbil ...

l-.eisliin:iti

2.3-0

•.'7-u

IT-i-i

1 itcasui'oineiit--
' Kliai-toinii,

.huiiiarv 2. I'M 1

(lerl)il ...

»i

24-.'i

2'.)-ii

■-•■•■'

1 nefeinljerl910
1 .laiinarv 1911

( OU-

ANIMAL TBYl'ANOSOMIASES IN THE ANGLO-EGYPTIAN SUDAN

51

This table is prepared in the same way as the preceding tables, and in it the close
resemblance of the six series of measurements quoted here is very striking, when it is
remembered that the strains which they represent have been obtained from different
sources.

Two charts are here given showing the distribution by percentages in respect to
length of this trypanosome ; one was prepared by Colonel Sir David Bruce in London, and
the second prepared in Khartoum.

Chart 3

Tijpe 2 — Chart compiled by Colonel Sir David Bruce, 1910

/^' 12 13 14 15 16 i; 18 19 20 21 22 23 24 J25 26 27 28 29 SO 31 32 33 34 36 36 37 38 39

20
18
16
14

^ ...

im12

§10

Ply. U — Curve diatribution b7 len^tb of Type 2 (T, evansi)

Chart 4
Type 2 — Chart compiled in Khartoum, 1911

I' 12 1-! 14 l.T 115 17 18 19 20 21 22 23 24 '^o 26 27 28 29 30 31 32 33 34 36 36 37 38 39

■'■0

A

s

\

\

1

\

\

i

\

p

/

y

A

s/

/

\

o

/

/\

7

s

Fig. 15. — Cur/e disti-ibution by length of Type 2 (T. i;vansi}

These two charts are very similar, and, as mentioned above, make a striking contrast
with the charts showing the curves of Type 1 and the T. brucei of Uganda.

Bri-iiiltJi. Til is trypanosome varies from about 1'5 to 2-5 microns in breadth.

Oy topi (1.1 III. The cell contents do not show the granules as well marked as seen at
times in Type 1.

Oli

VNl.MAI, lUVI-ANDSOMlASKS IN I'HK ANUljO-liUYPTlAN HIDAN

Xucli II.-. l> situatL'fl in the iijiilcUu of tlic ti v[)iinos()iiio and is oval or louiMt in
structure.

I'lidiiliiliiri/ iiifiiiliniiii . Well developed and shows well-pionounced folds and
undulations.

Fliiiirlhnii. Free in ull lornis found, and as sucli, measures fi'oin 5 to 7 niicions.

Animal Inocui.a tions and J{ inactions

Experiment Number

Uiiratioii of ihe Disease

Remarks

11 1

li; days

li •-'

uvcr ih clays

(i 3

ovor Vl days

(.1 4

111 (lays

(1 5

U (lays

a 8

•n (lays

Liver and spleen enlarged

(i 9

(■vor UU (lays

(i lu

over 35 days

It will bu seen from these results that, though this trypanosomiasis sometimes runs
an acute course in gerbils, it also at times occurs as a chronic type, the trypanosomes
disappearinj; from the lilood for several days at a time, to reappear and swarm again
with another subsequent disappearance.

In rabbits the disease is chronic, blepharitis and baldness being symptoms, and the
disease resembles in every way in this animal the effects produced by Surra.

In guinea-pigs the disease is chronic and shows no marked characteristics. Dogs
are susceptible and die witli niark('d splenic (enlargement, the symptoms ajjpearing to he
indistinguishable from Surra.

3. I'liltnrc. All experimental efforts, so far as culture goes, in these laboratories
have been failures. The cultivation evidently presents more dilliculties than that of
Type 1, certainly as far as our present methods go.

4. ('arrier. In both the Red Sea Province and Kordofan the natives attribute the
disease to the agency of the seroot fly. As far as one can definitely say anything on
this heading in the first-named of these regions, Tahuuns nujix is the causal agent of
transmission ; in the latter Tdbuiiiis fn'in'ula. In both jdaces several species of Tn7«iM«.<
exist, and species of Hippoboyca are also found.

5. Ueactiun tu dnif)s'. The disease in the laboratoiy animals available at jiresent
being of a chronic nature, it has been deemed unsatisfactory to quote any experiments
with this trypanosome as the chronicity of tlie disease tends to make the results
misleading.

It is interesting here as a footnote to this section to state tliat Sir John McFadyean
is not quite in agreement with the writer of this paper on the close resemblance of our
Type 2 trypanosome to that of Indian Surra. He states in a letter to the Director of
these laboratories " I liave still tin? camel trypanosome running. I do not think that it
corresponds with the Indian T. cnnisi, but it is a very hard nuitter to distinguish between
some of the trypanosomes from morpliological characters."

animal tkypanoaoimiases in the anglo-kgyptian sudan 53

Type 3
T. jjecoriuii or iiaiiinit (Plate I., figs. 5, 6, and possibly 7)

Unfortunately, no strain of this trypanosoine has been available in these laboratories
in the last year, so the consideration of this type must be a short summary of
investigations performed some time ago and a record from work on stained sjjecinieus.
This type has been carefully described by Balfour in the Second Report, in discussing
trypanosomiasis among the Shilluk cattle.

Up till recently T. naii.uni has been considered a distinct entity, i.e. a small
trypanosoine affecting cattle and possibly mules ; cattle may either die or recover and
so far as is known the parasite is conveyed by G. morsitau!'. More extended
investigations go to show that 2'. iinmcm affects other animals in the Sudan, or at least
that there are types very closely allied to it wliich aii'ect horses, goats and sheep.

A great deal more work is required to elucidate these types, especially with regard
to the susceptibility of laboratory animals. This will be referred to under "animal
inoculations and reactions " where the main difficulties of arriving at a conclusion are
further entered into. We shall now follow the same system of description as with our first
two types, but it must be remembered that we are fully alive to the fact that we may be
dealing with the characteristics of possibly more than one variety of trypanosome.

(((.) [livlruj and unstained. This trypanosome has never been observed in fresh blood Morphologv
by the writer but an extract from Balfour's description is here given verbatim. " The
trypanosome is a small one. It is not very active in fresh films and I have never seen
one traverse the whole field of the microscope. The motion is undulating combined with a
vigorous lashing to and fro of the anterior part of the body which tapers to a very tiny
fiagellum. Eippling and what may be termed spreading movements have been observed.
The parasite advances usually with the narrow end in front but this motion is often Descript
reversed. A fact that is very noticeable is that the trypanosome tends to adhere to the ^.^

•^ -^ ^ and Bruce

red blood corpuscles. Even in a thin field this is seen, the parasite seeming to take a compared
delight in butting and boring at the erythrocytes. Frequently it gets beneath them and
is lost to view, the agitation it jjroduces being the only clue to its presence." This
graphic description is exceedingly interesting when compared with Bruce's description of
the T. peconiin of Uganda which is also given verbatim. "This trypanosome, when
observed in a preparation of fresh blood, is seen to remain at or near the same spot in
the field, that is to say it is non-translatory. It is, however, active and restless, the
body quivering rapidly, and the undulating membrane and fiagellum keeping up a
constant vibratory motion. As a rule it moves with the fiagellum end in front. The
contents of the cell are homogeneous, except for a vacuole at the posterior extremity.

"A marked characteristic of this species is that it exhibits alternating periods of
quiescence and activity. When quiescent it is usually invisible as it has a habit of
burying itself under small collections of red blood corpuscles."

One cannot but be struck by the resemblance of these two descriptions, the one of
the trypanosoine of the Shilluk cattle and the second that of T. pecomm in the domestic
animals of Uganda.

(b) Fixed and stained

Lenijtli. Tlie tables of lengths here given are all prepared by Col. Sir David Bruce
from slides given him by Dr. Balfour, but do not include the original type strain
found in cattle. As there is doubt as to what strain of trypanosome we are dealing
with, the provisional nomenclatures, as supplied by Col. Sir David Bruce, are here
given above the dift'erent slide measurements.

ions

54

ANUrAI. TUVI'ANOSOMIASKS IN THK AN(1I,0-H(; VrTl AN SlUAN

Tiii/i:tiias,i,i,,i /Hi-iini III or iiiiiiiiiii (and ii'mo' ?' -HALFOL'U'S
I'KYPANOSOMH OF (K)ATS^

Aniriuil
<u..lt

Method of lixinK
iind staining

In microtis

Date

Average Maximum Minimum
Ic-n^th leiigtii length

Kemurks

\pril H'

IjL'ishmaii

1
i:jr» l(i-(» 1-JM(

DuuIjIc infection

rrnpiiiwsomii /...,."." BALFUUU'S Tlii'i'ANOSOMK OF LANJXiN'S I'oNNI

Kul.ruary 3. I'Jlll ...I Huisi; . Leisliiiiaii 12-fi 15-0 mo

i

MoilSlll'l'llR'llts

Tnniiiiwsomi' ? BALFOUIt'S TKVI'A^"l)S^)^rl•: OF WENYON'S DOli by Colonel

■ ' Sir David

Bruce, 1910

April 1. I'.HKi .

Hoc

Loisliinaii

ii;-j

18 -U

ia-0

Tniiiammmii ? BALFOUR'S TRYFANOSOME OF SHEEP (BAUR-EL-(iUA/AI,)

— Sheep ... Hieishman Irfl 18'0 13U

i III

Witli lefui'oncu to these slides, in the first case where vivax is mentioned an occasional
trypaiiosome was found that varied from the general type of the infection, and this led
Colonel Sir David Bruce to conclude that there was the possibility of a mixed infection.
This type was not included in the drawing from which the measurements were made.

With regard to the second slide, this pony came from Uganda where it was possibly
infected.

W'itli regard to the dog and sherp slides Colonel Sir David J3ruco suj)plies tlic
following footnote : —

" These tiypanosonies look very alike. They are most closely related to Tii/jiiiiiononia
pfciirum, but are larger. It may be a new species but would require to be studied further
in different animals before an opinion could be given."

It may be stated that the Wenyon dog strain was originally derived from a heifer
on the Sobat, and it ap})ears probable that this nionomorphic strain is quite distinct from
the so-called diiiioi phic T. minutn. w'hich the same observer found in iiiulfs in tlic
Bahr-Kl-Ghazal.

With regard to the other dimensions the descriptions given below apply in general
to all the above specimens.

Breadth. The average breadth is from 1 to 2 microns.

Cytoplasm. Generally clear and staining a light blue in some specimens ; well-marked
granules are apparent.

Xiiclens. Oval in shape and is situated somewhere about tln^ centre of the body.

MirriiiinclpiiK. Small and round and situated near and oftcMi apparently at the
posterior extremity.

Undulatorij membrane. Fairly well developed.

F'tnoellnm. An mentiomil on tlic ])rc'vi()iis ])age there is no free flagelhmi. or if there
is, it is (!Xtromely short.

As a matter of comjini is<iii one mijibt refer the leader to the original 7'. iuihiiih
measurements by Laveran and Balfour, as stated in the Second Report of these

ANIMAIj trypanosomiases in the ANQLO-EGYrTIAN SUDAN

55

Liiljoi'atories {jnujus 119, 120). Wliile these were not done according to Brace's method they
are suflSciently accurate for all practical ijurposes. The fading of the old films has
rendered satisfactory re-measurement impossible. We have, however, made use of the
chart showing curves of distribution in respect to length of T. nanum, Uganda, 1909,
and Balfour's T. nanum, Sudan, 1904, as represented in the Proceedings of the Royal
Socieh/, B., Vol. 83, 1911. (Col. Sir David Bruce and others.) The second curve
mentioned was prepared from slides supplied by Dr. Balfour in the summer of 1910.

Type 3. Chart copied from the Proceedings of the Boyal Society, B., Vol. 83, 1911.

/^' 10 II 12 13 14 16 16 17 18 19 20 21 22 23

.iO
45
40
35

|30

1

!

,/^

^.

o

£20

!

/

\,

1/

\

10

,

'''^

/

\

\

/

/

.,

/

/

«

^' ISolia line — /'. nanum, Li^anda. 1909

Animal Inoculations and Eeactions

The following experiments were performed by Dr. Balfour, and are detailed by him in
the Second Eeport of the Laboratories {pages 120, 121) : —

Experiment

Number

.\niiiial

Result

X 1

..

Moukoy

Negative

X 2

Rabbit

,,

X 3

Kabbit

X 4

Jloukcv

X 5

Dog

a

These inoculations were carried out with the trypanosome from the same cattle strain
of which the slides were sent to Laveran, who gave this trypanosome its title of " nanmn."

These experiments are, as Dr. Balfour himself confesses, quite inadequate to furnish
any exact idea of the pathogenicity of this trypanosome to laboratory animals.

Attention is drawn strongly to this point because monkeys, dogs, rats and mice
have all been shown to be susceptible to T. pecorum of Uganda ; and if, as it would apj)ear
above, these animals prove insusceptible to T. nanum on further experiment, we shall
be forced to create new types or at least make one sub-division. However, until we can
carry out more detailed and extended experiments on these points we shall class these
possibly various strains of trypaiiowomes under the heading T. nanum, or pecorum,
regarding the niorphnlogical reseiiililaiices as sufficient justification for so doing.

3. Cidlure. No experinieiits have as vot been undertaken in this country to attempt
to cultivate any strain of this type.

oU

AXl.MAI. THYl'ANOSOMIASKS IN I'HK A.Nli LO- i:<i Yril AN SUDAN

4. Carrier. Thu carrier of this tiypaiiosoiiiu is iioi duliiiitfly known, biting tiius ami
ticks have been suspected; they both abound in those regions where tliis disease is prevalent.
T). Reaction to tlnnjs. No experiments iiave Itecn performed.

.\1iir|ihoU)gy

liioculaliun^

Tvi'K I
T. rtvax or cazalbuui (I'hile 1., lig. 4)

No living strain has as yet been available for investigation in these laboratories.
Dr. Halfoiir lias described tlie occurrence of this tyi)r nnder the heading of " Cattle
Trypanosomiasis of Kassala " in the Tliiid Kcpoit. From a consideration of its
morpliology in the stained specimens which have been available, we have decided to class
this type as above. As so little is known wu shall give its characteristics in all brevity.

\\\ general, resembles very closely the type specimens of 7'. n'rax as depicted by vaiious
observers, showing the well-known characteristic shape.

Liiiijth. Variations in length are apparently not marked.

TYl'E i. T. ciciix ur Cdzulhoai

l).ilc

Animal

Method of fixing .\verajje
and ^tainiiiK length in u

Maximum
length in fl

Minimum u . _i
k-nslh in fi K«-"i^>rk^

Jauiiiiry, 1"J07

Cattle ..

19-1

21

IR 1 Measurenieiits
liy Colonel
Sir David
1 Bruce, 1910

HreaJlh. — From 2 to 2-5 microns. lUjtoplcufiH. Clear staining cell contents, rarely
granular. Nucleus. — Long and oval, situated towards the anterior extremity.
MicroHuc.leui'.' -Large, round, and terminal or sub-terminal. Fiidulaionj uuniihraiie. —
Unfolded and well developed. i'7(;;/c///(;;/.- -Free, from about ',\ to o mici'ons.

Animal inoculations are known to affect cattle and supposed to be very virulent to
sheep and goats in .\byssinia. Tlie insusceptibility of smaller animals to this tyjjc lias
been the cause of our ditticulty in obtaining a living strain.

3. Culturi'. This species is said to grow readily so tluit we are in hopes of soon being
successful in this direction.

4. (Jarricr. Supposed to be a Tabanin' or llippohtiscu.
i). Jicaclioii (u (/(•«;/.•>•. Nothing is known.

We liave now com))leted our present classitication into four tyjies, but, doubtless, we
shall shortly find need for amplification and modification in the classes as worked out here.

Captain .\i fliil)alcl is, at the time of writing this ])a))(T. proceeding to the Lado with
the object of obtaining and working on the strains of that district, and, as he is taking
up the floating laboratory and is well provided with experimental animals, we have good
reason to hope for the most fruitful results.

In conclusion, I have to thank most sincerely Colonel Sir 1 )avid Bruce,C.B.,F.R.S.,A.M.S.,
for his extremely kind help and advice as to the treatment of the animal trypanosomiasis
of the .\nglo-Egyptian Sudan and for the use of liis charts and measurements of which
this paper is so largely made up, and l^ady Bruce for the excellent Trypanosonie Plate.

I am indebted to ^lajor StaTidisli (J'Crady and Captain W. R. O'Farrell, H..\.M.C.,
for great assistance in making drawings from microscopic specimens and in other
directions. Mr. George Buchanan's work in these laboratories speaks for itself in
this Report.

PLATt II

A^

^%^

< .

\

y"

H

'I '

^ '

m.-^

^:y

■3

. f)

\

-IJ

^

* 23

1 — 2. LrishtHttH St»tin
3. tiicmsa Stain

1 — 3. CuLTivATtoN Forms of 7'. brucei (pecaudi)

1. Aggloiiieratioti of irypanobOincs in 24 hour>' culture

2. Young forms from a bubculturc of 15 days

3. FlaRcIlatc herpctoinunad forms from 15 day>' bubculture

4 — 25. DeveLOPM BNTAL CVCLE OF '/'. hrucei ipecautii I in ilfrhitius />yf:argus

4*~12. Endoglobular forms in the spleen

13 — 17. Kncysted forms in splenic pulp

18 — 23. Forms found in luny smear on sixth day alter ino<:uIation. 1-ig. 23 >h<»ws basal

24—26. Forms found in smear from axillary gland on seventh day after inoculation

X 2000 <//*! /// .

.granule

X 2000 iHiim.

Some Obseuvations on Trypanosoma Brucei? (Pecaudl?) anh the

Sudan Camel Tkypanosome in Cultures

WITH A note on

Endoglobular and Developmental Forms of T. Brucei? (Pecaudi?)

BY

George Buchanan

Senior Laboratory Assistant

Wellcome Tropical Kesearch Laboratories, Khartoum

The cultivation of these trypanosomes was carried out mainly with a view to determine
if their cultural features corresponded to those of T. brucei and T. evansi respectively,
to which in many other respects they appear to be closely allied.

Techniqiie

The culture media used were Novy and MacNeal's blood agar and Nicolle's
modification of the same. The inoculations were made from the heart's blood of infected
gerbils. Not more than two drops of blood from a capillary pipette were usually introduced
into the small amount of condensation fluid, the tubes then being incubated at 22' to 25° C.

T. liEUCEi (pecaudi)

The inoculations were made at a time when the trypanosomes were not too numerous
and before the appearance of the swollen involution forms in the peripheral blood.
It was found that cultures inoculated with blood showing a heavy infection, or after Techni<|u«
the animal had succumbed to the disease, were invariably failures, as in such cases
there was a preponderance of degenerated trypanosomes which only further rapidly
degenerated in the fluid.

Nicolle's medium unfailingly showed motile trypanosomes up to sixteen days, while in
Novy and MacNeal's blood agar no recognisable forms were seen after five days as a rule,
with the exception of one culture which showed feebly motile trypanosomes up to the
thirtieth day, and from which sub-inoculation was successful.

Appearance in Gidtnre

The 24-hours' cultures showed numerous individual trypanosomes actively motile,
while clumping in the form of rosettes was also much in evidence (Plate II., fig. 1). The
tendency to agglomerate at this stage was very marked in all cultures, and such formation
rapidly progressed on the union of two trypanosomes being established, others then
appearing and uniting by their anterior ends. Tlie numbers forming clumps averaged eight, cuUmes
although, in one instance, as many as eighteen were seen. Several were also observed
dividing longitudinally at this stage.

The stained films showed trypanosomes in varying stages of degeneration. The
flagella had disappeared in the presumably young forms, while others, corresponding to
the swollen trypanosomes in the peripheral blood, were in an advanced stage of
disintegration, assuming very eccentric forms with elongated and thickened flagella.

In the 48-hours' cultures, the number of trypanosomes was well maintained, but the
clumps were not so numerous, and those seen presented a whorl-like formation. The
trypanosomes in the stained films contained vacuoles and were rather granular in
appearance.

oS

SOMK OHSKRVATIONS ON Tl! Yl'ANOSO^r A ItlUCKI ? (rKCAmi'

SiilxiiUiiri'
successful

Appearance
of a

herpetomonad
type in culture

DifBculty in
culture
altempLs «iili
T. tviini

From 72 linurs oiiwiiiils lliLrc wiis a proj^ressivo decioasc In tlio luiiiiljcf of
ti-vj)aiu)somes, their niovi'iiii'iits l)cinj{ more rotatory in nature and very slugyish. The
clumps disappeared entirely and tliose trypanosonies present on the eighth and sixteenth
days, in hoth media, reacted very feebly to ]jeishman's mixture, staininj; a diffuse pale
blue colour with no evidence of nucleus or flagclluni.

As mentioned on the |)re.vious pat^e, subculture into Novy and MacNeal's blood agar
was successful from a thirty-days' gi'owth in the same medium. No forms were recognised
in tlie subculture until about the fifteenth day, wlien young trypanosomes, long, thin, and
of uniform thickness were seen, some possessing a terminal flagelluin in active motion but
not communicating the characteristic undulatory waves to the body, which never altered its
regular outline. Typical rosette forms were also very numerous, the numbers composing
wiiich ranged from seven up to sixty. Some clumps consisted of dividing spherical and
irregular fornis (Plate Jf., fig. '2), while the larger masses comprised forms from small
round types in the centre to almost fully-developed trypanosomes radially disposed at the
periphery.

The blepharoplast and nucleus sliowed uj) ))ionouncedly in the stained films, and the
protoplasm appeared vacuolated and granular in the young spherical forms, some of which
were fused together with dividing blepharoplast and nucleus indiscriminately placed. In
the more fully developed trypanosomes, short innnature flagella were seen attached to their
anterior ends, the blepharoplast in many cases being likewise situated anteriorly, thus
presenting figures identical to the herpetomonad type of ))arasite (Plate TI., fig. 3).

This strain of T. hnicei (pecandi) is being still further successfully subcultured without
difficulty, tlie forms most numerous in each succeeding subculture being those elongated
trypanosomes with the terminal flagella which have been most in evidence since the second
subculture.

The virulence of a twenty-two days' culture was tested on a gerbil. but the animal
never became infected.

7iV(rt.a.yfcj. --Although the behaviour of this sti-ain in culture is much like tluit of T. hnicei
in some respects, yet, from the numerous cultures made, one cannot say that it
only grows exceptional I y on culture media, upon which fact Novy and MacNeal lay
stress. Primary cultivation proved comparatively easy in the sense that the trypanosomes
maintained their motility and numbers moderately well in the original cultures, and this
perhaps more so in Nicolle's medium provided no bacillary contamination ensued after
repeated examination. It is true, however, that they did not nniltiply. Like 7'. bnirei
it certainly does grow very readily after tlie first subculture has been establislii'd and. in
subsequent cultures, the trypanosomes multiply on an extensive scale.

T. KVANsi (Camkl Rtuainj

Kejieated attempts were nuide to cultivate this trypauosome from gerbil's blood in the
above-n)entioned media but with no success save in so far as the parasites were evident
and remained motile up to about eight days, after wliicli no forms could be recognised
either in hanging drop or stained films. A few sub-inoculations were made, but none of
them revealed trypanosdiius at anv period, tlie media remaining (piite sterile for many
weeks afterwards.

Even after 24 hours' incubation the cultures invariably showed a decided decrease
III the number of trypanosomes, although those surviving were very actively motile.
The formation of clumps was not marked at any period. In the stained preparations
all the trypanosomes present appeared much thinner and decidedly degenerated, with

SOJIF. Or.SERVATTOXS ON TUYrAXOSOMA I5KUCET ? (PECAITni ?) 59

110 rtagcllii. Their motility buciiiiie less active each succeeding day and, after the third i"-xpi-iiTiic_-ius
day, no typical trypaiiosome forras could be seen, all having assumed small spherical ^ „ ^^.•
or pear-shaped forms with long flagella attached. Some clumps of these forms were
seen on the sixth day slowly performing rotatory motions but no flagella were visible,
they having gradually shortened and finally disappeared.

Subcultures were usually inoculated on the fifth day when the round forms were
present, but examination up to three weeks showed no recognisable trypanosomes.

The culture work with this trypanosome is very incomplete as variations in the
proportions of blood and agar, advocated for other species, have not yet been tried, so
that nothing definite can be said, meantime, regarding the success or failure in cultivating
this strain. But the attempts made, their failure, and the forms met with up to a
limited period, correspond very closely to the cultural behaviour of T. ovand described
by Laveran and Mesnil.

Note on Developmental Forms of T. brucei (pec.\udi) in the
Inteen.vl Organs, Axillary Glands and Bone-marrow of the Gerbil

(Gerbillus rygargus)

The transmission and maintenance of the trypanosome strains being under my care,
ample opportunities were afforded of noting the progress of the disease induced by them
in experimental animals and the structural changes in the trypanosomes themselves at
varying periods. It was, however, mainly the cultural work associated with this
trypanosome that led to further investigation of these developmental forms and thereby
established the observations forming the subject of this note.

On beginning the culture work, inabilitj' to recognise if certain forms met with in
cultures were either developmental or degenerative phases, suggested a study of the
changes which the parasite undergoes, both in the body of the gerbil after death and in
citrated blood, and the comparison of these changes with the forms found in Novy and
MacNeal and Nicolle's media. With this in view, a gerbil was inoculated with infected
blood and chloroformed on the fifth day after injection. Cultures from the heart's blood
and smears from the various organs were made, all being examined at regular intervals
for comparison. Light was thereby thrown on the point in question, but, in addition to Xrypanosome-
this, attention was drawn to what undoubtedly looked like trypanosome forms in the 1''^'^ inclusions

in the red cells

red blood corpuscles in the spleen. Some of these were identical with those figured by of spleen
Chagas in his paper on Schizotrj/paniiiii cruzi, which appeared at the time this work was
being conducted.

In order to coiifirm the observations made, a series of inoculations was carried out
in gerbils.

In the first of the series, five gerbils were employed, these receiving subcutaneous
inoculation in the flanks. In each of the two later series, however, it was found
necessary to use eight gerbils at least, the injection being given intraperitoneally as
recommended by Chagas. The amount of infected blood in citrate inoculated into each
animal was 10 minims, all the eight forming one series receiving the injection at the
same time. A gerbil of the series was then chloroformed on each succeeding day,
beginning on the first day after injection. Films from the peripheral and heart's blood
were taken, and smears from the lung, liver, spleen, bone-marrow and axillary glands
were made, these being fixed and stained by various methods.

fiO N'OTF. ON m.;vi:i.nrMi'.NT.\r, 1'(1ums of TUvrANOsoMA uuicki (i-KfAfPi)

Ihc iniia- As liotli the iiitni-corpuscular forms ami those wliiili possibly represent encysted

corpiiscuhir sttttjos aiineareil in the si)leen on the fifth <hi\ in tlio first noi'bil, a careful examination

forms apix-ar h 1 1 l ■ , ,

frum sixth to <'f tile films in the first series up to that tnne was mane, but none of the forms seen in

ciRhth ilay (|,y oi-jj/injil slide were recoonised. In the other series, however, examination of spleen

smears from f^erbils chloroformed on the sixth and seventh day respectively revealed

both of the forms mentioned. These were also usually nbtaiiied in suljscipicnt ind(')icndpnt

ruses (in the seventh and cif^hth day.

^^01!IM^OI,Of; V AND ])KVF.I,OI'Mr.XT IN T H I'. Sl'LKKS

(a) liitra-riirpHfciiliir. No definite merozoite forms as described by Chayas were
ever seen enteriufj; the red cells, and the small inclusion shown in Plate II., fig. 4, was

KiiiR forms the only appearance observed whicli suggested a merozoite. Speaking generally, the
smallest intra-corpuscular forms met with took the shape of very small rings with two
chromatin masses, and were about one-third the size of the red blood cell. Nearly all
stages from this to a fairly mature trypanosome, contained within the limiting envelope
of the red cell, could be traced, the intermediate stages in many cases being similar to
those of Schi:otr\jpanum cnizi (Plate II., figs. 4-12). This fairly mature trypanosome,
however, possessed neither undulating membrane nor flagellum. Some of the more mature
forms were coiled uj) or S-shaped. every part of them being wholly witiiiii the corpuscle.
These varieties were not so numerous as the complete ring forms. The blepharoplast
was not recognisable in all cases, but, when present, w-as usually situated at the thinnest
part of the ring.

(b) Extra-corpmcidar . Ring forms were also met with free in the plasma, and these
impressed one as being possibly encysted and likewise showed a development similar to
that seen in the red cell. Numerous small solid, encysted (?) forms appeared in the spleen
on the fourth day in one gerbil (Plate II., figs. 13 17), and these, as a rule, were also
present in other animals in the bone-marrow and axillary glands on and after the sixth

-Spherical day. The very small types appeared as spherical masses of densely-stained blue

protoplasm, the nucleus in some being indicated by a small undefined violet mass, while
the blepharoplast was detached.

Round the spherical body here described there existed, as a ride, at least when
development was somewhat advanced, a clear area which gave the impression that the
protoplasmic mass was lying in some form of vacuoloid space which was possibly
surrounded by a limiting membrane. It was in connection with tliis mend)rane (?) that
the blepharoplast was found, hence the use of the term "detached" (Plate II., fig. lo). It
was found that, as the protoplasmic mass became larger, a clear area developed within
it. This increased in size, the nucleus of the mass became more distinct, and finally
the blepharoplast appeared gradually to approach the mass until it became part of it.
Such a movement on the part of the blepharoplast is well-nigh inconceivable unless there
was originally some connection between it and the main mass of protoplasm. Such,
however, I have never been able to demonstrate.

Eventually the spherical mass<^s became ring-shaped, resembling in every respect
those met with in the red cells.

These stages were always observed within the vacuoloid space wliich eidarged to
accomuiodate the requirements of the developing trypanosonie. As in the red cells, forms
almost mature were eventually found. These, wliich possessed free extremities, often
assumed S shapes within a faintly defined capsule, the nucleus and blepharoplast
being situated as in an ordinary trypanosome. Later observations showed that these

bodies

NOTE ON DEVELOPMENTAL FORMS OF TRYPANOSOMA BRUCEI (PECAUDi)

61

forms were invariably found free in the plasma of the spleen, bone-marrow and axillary
gland several days previous to the appearance of the intra-corpusculai' forms.

Forms found

Lung Smears

The probability of schizogony occurring in the lung as in the case of Schizotrypanmn
cnizi was borne in mind, but no definite schizonts were seen in any of the smears. Yet the
forms figured by Chagas,' and described by him as parasites in the lung of vertebrates
preparing for schizogony were exceptionally numerous in the lung of a gerbil on the
sixth day. In fact they were the only forms present in smears from the lung at that time,
but no suggestion of merozoite formation was ever observed. Some forms seen resembled
the so-called latent bodies of T. gambiense described by Moore and Breinl,- and more recently
by Fantham,^ as occurring both in T. rjamhiense and T. rJwdesiense infections. Their method
of formation, however, seems to be somewhat different to that described by these authors.
It is, jjerhaps, sufficiently indicated by the cycle of events shown in Fig. 17. In
addition there was markedly evident the presence of individual spherical forms dividing Presence of
into two, and occasionally three, separate bodies, each of which eventually assumes a "'^"^ ^^^'

' ■ '^ " young

trypanosome shape. As a result, large numbers of what were undoubtedly very young trypanosomes
trypanosomes, each with a well-defined nucleus but without undulating membranes and '" '""g-fiims
flagella, were present in the lung smears.

r

y^.

f

O. BUCHiKiU

X apprax. 2000 diatii.

Apparent fonnatioo of non-fla^ellate body from trypaaosome in lung
apparent metamorphoKis of non- flagellate body into trypanoaoine in King

No definite intra-corpuscular or free encysted forms were ever seen in the lung or
peripheral blood. The former appeared exclusively in the spleen while the latter were
found without fail in the spleen, bone-marrow and axillary glands.

The axillary glands showed an unending variety of young trypanosomes corresponding
in the main to those described above in the lung, while the encysted stages were also very
numerous.

A marked feature, perhaps worthy of note, was the constant presence of free chromatin Free
granules in nearly all the smears from the second dav onwards. These were apparently i^hromatin

T ■ 1 /• 1 " 1 ■ p T ■ ■ " ' "granules"

derived from the nuclei of disintegrating trypanosomes and possibly represented a first
stage in development.

* Chagas, C. (August, 1908), " Uber eine neuc Trypanosomiasis des Menschen." Memorias de Instituto
Oswaldo Cruz, Vol. 1, No. 2.

= Moore, J. E. S. and Breinl. Anton (.July, 1907), " The Cytology of the Trypanosomes." Annals, of Tropienl
Medicine and Parasitohir/;/, Vol. 1.

' Fantham, H. B, (1910), "The Life-history of Trt/pnnosomn yimihienise and Ti-iipnnosuma rluidesiense as seen in
rats and guinea-pigs." Proceeding!: of lioyal Society, B. Vol. 83.

Notes on Human Spiroch.ktosis

BY

Cait.vin L. Housfibi-I). M.A., ^f.D. (O.vntab.), M.R.C.S.. L.R.r.P., H.A.M.C.

late attachcil Egyptian Army

The following article is founded on observations derived from six cases of relapsing
fever, which occurred amongst the troops at Khartoum in January, 1910, and from
two cases seen in Cairo in March of the same year.

I believe relapsing fever had never been diagnosed in the Sudan before
Captain A. G. Cummins, R.A.M.C., reported it in two cases at El Obeid, both i)eing
Egyptian soldiers who had just returned of!' furlough from Egypt.

Late in 1909 a case was found at the Civil Hospital at Khartoum, aiul this case
apparently came from Egypt, as did iive of the six cases treated at the Military Hospital,
Khartoum.

Human spirochaBtosis probably is not endemic in the Northern Sudan, for it seems
scarcely possible that it could have missed recognition, and everything tends to uphold
the view tliat all the above-mentioned cases were imported from Egypt, where the
disease is well known and causes considerable epidemics.

The important question arises whether the Egyptian may not be able to introduce
this disease into the Sudan and so permanently infect a district at present apparently
free, a question which has also to be faced with regard to bilharziosis, at least in certain
localities.

Of the six Kliartouiu military cases the first was taken ill in Cairo twelve days
after joining from his village, Ashmun Gurice, Moudiriah Manoufia, where it seems
probable that he contracted it, for Captain R. G. Anderson, R.A.M.C., kindlv made
enquiries and found that there was an epidemic of this fever in a neighbouring village,
Kafr-El-Gazzar.
History of the The other recruits with whom he mixed were apparently healthy.

He was admitted to hospital in Cairo for six days with fever; probably this was
his first attack as he asserted he had no fever in his village.

Very shortly after discharge he started for Kliartoum and gave the history of being
ill with fever most of the journey up country.

Arriving at Khartoum on January 1, he was admitted on the '2nd with fever,
temperature 102' F., and suffered from a marked rigor shortly after admission.

Only a few spirochtetes were found after a prolonged search.

_The other patients were taken ill on January 3, 7, 9, (two) and 14 respectively,
but were not admitted to hospital till January 5, 10 (two), 12 and 15.

The first five cases all occupied the same l)arrack-room at Cairo, all stated they
were bitten by bugs while there, but only No. 1 was taken ill.

All occupied the same railway carriage on the way up to Khartoum and durin<; this
time must have been in intimate contact with each other.

On arrival at Khartoum the four yet unaffected went to separate barrack rooms, all
of which probably harboured bed-bugs.

The main point of interest centres round the sixth and last case, the only one to
contract the disease in Khartoum, for he had been resident in the Sudan for over a year.

first case

NOTES ON HUMAN SPIEOCH-ETOSIS 63

This man did not occupy the barrack-rooms, but was the pack store-keeper, who
issued clean clothes to the troops, taking the dirty ones and placing them in cloth bags
ready for the wash.

It was found that he not only lived, but also slept, in the same room w'ith these
bags of dirty linen, prior to their being sent to the wash.

Every additional item of evidence on the transmission of this disease is of importance,
and this last case seems to help to corroborate the view held by Dreyer, Kirton and
Graham W. Smith in Egypt, and by Mackie in India, that lice, Pedicnli vestimentoruin,
are the usual carriers of the disease from man to man.

No definite evidence can be adduced from these cases, for, unfortunately, no Pedicnli. Evidence as to
capifit:, vestimentorum or Phthirius pubis were found in the infected cases, since, by P™ ^ ^,

z ' ± J ^ J i< vector

the time the diagnosis had been made, their clothes had been sterilised and washed,
following the general rule on admission to hospital.

Further, Dr. Andrew Balfour's experiments with I'ediculi vestimentorum taken from
other recruits coming up with these cases, failed, owing to the difficulty of keeping the
lice alive.

Nuttall has proved that Giinex lectularius can convey the disease from mouse to
mouse, and Schaudinn found spirochaetes persisting in bugs up to 30 days, but it seems
probable that the latter are not the usual transmitters of the disease.

The six Khartoum military cases were undoubtedl}' bitten by bugs in Cairo and in
Khartoum, but no other cases occurred amongst the soldiers in Khartoum, though each
case went to a separate barrack-room where bugs existed.

Dr. Balfour failed to find spirochaetes in bed-bugs taken from the crevices in the
wall near the bed of one of the cases.

The flea is considered not to convey the disease, though it is certainly food for
thought that the disease is common in Egypt wdiere fleas abound, while unknown in
the Sudan, where this pest is, as far as my knowdedge goes, practically never seen,
though Cimex lectularius and Pediculus vestimentorum are common to both countries.

The case of the pack store-keeper seems to implicate Pediculus vestimentorum rather
than the flea or the bed-bug.

A brief summary of the clinical aspect of the disease is given. Clinical picture

The duration of the first attack varied from 2-8 days, while the relapses varied from
4-6 days.

One case probably had three relapses, one had two relapses, five had one relapse
and one had only one attack of fever.

The fever usually reached its maximum or thereabouts during the first 24 hours
wnth subsequent morning remissions.

The termination of all, except one, was by crisis with marked diaphoresis.

Between attacks, and subsequent to the last attack, the temperature was subnormal
for some days.

The case having no relapse showed the highest temperature, 107-4" F., and the
pyrexia only lasted two days.

The spleen was palpable in six cases, enlarged to percussion in one and apparently not
enlarged in another.

Increase in size of the spleen was noted on several occasions during a relapse.

Seven complained of pain in the splenic region and two had spleens tender to
palpation.

The liver was not enlarged in any case, but was tender and painful in two.

04

NOTES ON HUMAN SPIBOCH.T'.TOSIS

Prostralion
ami weakness

Spiroch^etes
found in films

Morphology
■f the par.isiies

AniBinia was present in five cases, in two to a marked degree.

Epistaxis was noted in two cases, a definite rigor in one, herpes labialis in one and
vomiting in two.

Prostration and weakness were marked in all, but, with the subsidence of the fever,
rapid recovery ensued in all but one debilitated case.

Headache, backache and a moist white furred tongue were seen in all, and three
complained of pain and tenderness over the tibiir.

Jaundice, eye affections, albuminuria and diarrhoea were never encountered.

The heart and the lungs were normal, though one case showed some congestion of
the right base.

The two cases which were admitted in March, 1910, to the ]*jgyptian Army General
Hospital, Abbassia, pi-esented symptoms not encountered in the Khartoum series.

One was admitted with a temperature of 10.3 P., in a lethargic condition, quite
conscious, but with motor apiiasia.

The pulse was 116, respirations 28, and some rilles and diminutiuii of In-eath sounds
were noted at the right base.

The spleen and liver were not enlarged.

Next day his knee jerks, cremasteric and abdominal reflexes could not be elicited,
and there was some cervical rigidity and tenderness over the spine, but Kernig's sign
was absent.

He was thereupon isolated, as cases of epidemic cerebro-spinal meningitis were
occurring at that time.

.\ fair number of spirochffites were found in his blood, and on the third day his
temperature rose to 104 F., fell by crisis with profuse sweating, and his speech and reflexes
were restored within three days.

He had no further pyrexia, but gave a history of two attacks of fever lasting
6-7 days during the previous month, so that this was probably his second relapse.

The second case was admitted with a temperature of 102 F., slightly enlarged spleen,
and considerable pain in both knee-joints.

Blood examination showed nothing abnormal, and, under salicylates, his temperature
fell to normal, and he was thought to be suffering from a mild attack of rheumatic fever.

Eight days later his temperature rose to 101 F., and the next day a few
spirochaetes were found in his blood ; the following day very many were found in
the films.

On the fifth day his temperature fell by crisis from 103 F. to normal, accompanied by
profuse diaphoresis. There were no complications during this attack of fever, but, three
days later, his right knee-joint became swollen, hot, very tender, and distended with fluid ;
there were no constitutional symptoms and no rise of temperature occurred. The condition
cleared up in four days without salicylates, and there were no further relapses.

I think the joint condition must have been due to his spirochietal fever, and was not
of rheumatic origin ; at no time did he have a sore throat.

Dr. .\ndrew Balfour has studied the morphology of the spirochaetes found in the
Khartoum cases {pa'je 67), and only a few remarks need be made here.

In some cases the spirochaetes were very numerous, in others they could only be found
after prolonged search.

They were only found during the periods of fever, and though careful search for
possible intra-corpuscular forms during the apyrexial periods was made, yet none were
noted.

NOTES ON HITMAN SPIBOCH^TOSIS

65

The long spiral form was by far the comrnonest, but figures of 8 and coils were
frequently seen, though my impression from the dry films was that these latter were far
more frequent in the thicker parts of the films, i.e. when the spirochiEtes had more
opportunity for movement prior to drying on the slide.

The very excellent arrangement in the Egyptian Military Hospitals of sterilising at
once all the clothes of admission cases and then having them washed before being placed
in the pack store unfortunately prevented one following up the cases with a view to finding
Pedicidi vestimentoruin.

These notes deal with the clinical sides of the cases which supplied Dr. Balfour with
the spirochaetes for his experimental work.

I wish to thank Dr. Balfour for taking such interest in the cases, and also Mulazim
Awal Basili Effendi Suda, Medical Corps, for his help in the clinical and microscopic
work.

Tempek.^ture Ch.4RTS

lo;

106*
106'
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103
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98°
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107

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Fig. 20. Case 4

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Fig. 24 .— Cas t

The Sfikoch-ete of Egyptian Kelapsing Fever
Is IT A Specific Extity?

BY

The Directoe

Captain Bousfield has asked me to add some notes on the experimental work
carried out in connection with the cases of Egyptian spirochaitosis he has recorded.
I do so with pleasure, but fear they are far from complete. At the time, I was working
practically single-handed in the laboratory, being busy with administrative routine and
research work, and in addition had my usual duties as Medical Officer of Health for
Khartoum to perform. Hence it was impossible to carry out research work on this
spirocha;tal fever in any great detail. The unfortunate loss of the strain, combined
with the recovery of all the patients, brought the work to an untimely end, but it has
been possible to come to certain fairly definite conclusions which are here stated.

-', — T'' sho\r inoi7"'holoi;ii

In the first place a word as to the morphology of the spirochsetes concerned. One
would like to have studied these by the dark-field illumination method, but at that time
I did not possess the necessary apparatus. I only examined stained preparations of human
blood, though I observed the parasites in fresh films from the blood of successfullv
inoculated animals, monkeys and gerbils.

Morpliology

6H

THK SPIKOCH.«TE OF EGYl'TIAN HEI.Al'SINCi FKVEU

.Staining
reactions

111 IJliiis stained \)\ [ji-isliiiiaii's niulliod the spirochiutes are found to vary in lengtli
from 13-5 /« to 22-5/1, wliile tlieir breadth is about 0'25 f. The number of spirals varies
from two to six, and the most characteristic feature of the parasites is the great irregularity
of these spirals and the marked tendency to the formation of loops, circles and {igure-of-8
forms (Fig. 25, a, h, c). A small and narrow spiral is frequently succeeded by a large and
wide one, so that there is nothing to be gained by measuring the individual spirals. So far
as this feature went there is a distinct resemlilance to i^pirochwla duttoni, and it is noticeable
in human, monkey and gerbil blood. For the most part the spirochictes stained uniformly.
Where breaks appeared in the ribbon they could usually be explained as divisions between
dividing forms. Parasites in gerbil's blood, however, tended to show unstained points
in the chromatin core (Fig. 25, c). This is also true to a lesser extent of those in monkeys
blood (Fig. 25, l>). In the light of the animal inoculations (ride infra), is it to be regarded
as an expression of the unsuitability of tlie medium to the spirochaete ? No evidence
of longitudinal division has been seen, and never more than two spirochsetes have been
found united end to end. Their ends are, as a rule, finely pointed.

.\.\i>i.\L Inoculations

I. Gekbils

Loss of the
strain in
gerbils

On January 12, 1910, a gerbil or desert mouse (GerbiUus pygargus), No. 1, was
inoculated subcutaneously with the blood of a patient which showed spirochsetes. On
January 14, this animal for the first time exhibited parasites in its peripheral blood, an
incubation period of two days. The spirochictes were fairly numerous but the animal
showed no sign of illness. A few drops of its blood were taken, citrated and inoculated
into gerbil 2.

On January 15, spirochictes were still present in the blood of gerbil 1, but they were
absent on the 16th, and, despite daily examinations up to the 24th, and occasional
observations thereafter, they w-ere never again found. The gerbil at no time appeared ill.

Gerbil 2. — Inoculated from gerbil 1, as stated, on January 14. Showed spirochtetes for
the first and only time on January 18. Never ill.

Gerbil 3. — Inoculated from gerbil 2, on January 18. Showed spirochetes on January 20,
for the first and last time, but it was chloroformed on January 22, as it was looking ill and
its coat was rough. Some of its heart's blood was used for the inoculation of a monkey
(vide page 69) .

Gerbil 4. — Inoculated from gerbil 3, on January 20, in order to preserve the strain.
A bacterial infection resulted, from which the animal speedily recovered, but, possibly as a
result of this accident, it at no time exhibited spirochictes. On January 24 it was
chloroformed and a few drops of its heart's blood were inocidated into gerbil 5. No
spirochaetes could be demonstrated in this heart's blood. Its liver and spleen examined by
the Levaditi method also failed to show spirochiEtes.

Gerbil 5. — Inoculated, as just stated, with apparently sterile heart's blood from gerbil 4.
on January 24. It remained perfectly well and at no time exhibited a spirochaetal infection.

Gei-bil 6. — Inoculated on January 18 with a few drops of citrated finger blood from a
patient in the non-febrile ulaije. It never showed spirochictes.

From the above it will be seen that the strain in gerbils was unfortunately lost.

THE SPIROCH.ETE OF EGYFTIAX RELAPSING FEVEE

69

II. Monkeys (Cercopithecus sahaeus)

Monkey No. 1, as already noted, was inoculated with some of the lieart's blood of gerbil 3,
at a time, however, when the latter animal exhibited no spirochsetes in its circulation.

This inoculation proved negative, and, as an opportunity was afforded on January 25 of Successful
inoculating this same monkey (the only one which, on that date, could be obtained) with ^"^°'="^'°"
blood from one of the cases in hospital, this was done and the monkey received
subcutaneously three drops of finger blood from an Egyptian soldier who had relapsed
and was showing spirochsetes in his blood. The monkey was found to be infected on
January 29, there being a good many spirochsetes present in the peripheral circulation.
The incubation period was, therefore, apparently four days. This infection increased, and
by .January 31 might be described as heavy. On this day the animal looked somewhat

lil'j S t.h ^ No 1
Cercopit/ucits iabaciis, i Disease: Relapsini; Fever (Egyptian)

UAY 1 -1 3 4 5 6 7 8 9 10 11 12 13 14 16 16 17 18 19 20 21 22 23 24 2o 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

*i^ i

/ T /

Z- / / ^^ Aa /- i / ^. A/^^s K \

; / J \/^\\'\\\' ^^^ UaA^^ M^ "^^

vyi T^^u^ V y V V

98' __ . 1

D.^TE 25 26 27 28 29 30 31 1 2 3 4 6 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 2 3 4 5 6 7

Fig. -(S. — + s;c;a=:6iiirt;chaetcs m lienjilienii cuvtiiatiou

ill. No coryza was noticed. Its temperature was taken daily, and the chart (Fig. 26)
shows the course followed. On February 1, though the animal still appeared ill, no
spirochsetes could be found. On February 2 the monkey looked better and the search
was again negative.

With the fear that one had delayed over long, a small quantity of finger blood was
taken, citrated and inoculated into monkey 2.

Monkey 1 remained well and did not relapse. Although on February 13 its temperature
rose suddenly, no spirochsetes were found in its blood.

At the time they were present, lice and ticks were fed on the monkey in connection Feedini,'
with experimental work on the possible carrier of the virus {cide page 71). e.\penmeinh

Motikey No. 2 {Gercopithecus sahaeus). — Inoculated subcutaneously on February 2, from
monkey 1, at a time when the latter's temperature was still elevated, although spirochsetes
had apparently disappeared from its peripheral blood. It is unfortunate that a monkey was
not obtainable at an earlier period for inoculation with blood rich in spirochsetes, as no
infection occurred, but, as will be considered later, this negative result is of some interest
and importance. One cannot but regret that great press of work prevented these
inoculation experiments being carried out in a more extensive and thorough manner,
although it is true that the peculiar behaviour of the strain was one cause of the
limiting of the observations. It was only the importance of trying to come to a

70

THK Sl'IltOCH.KTK OK KGYl'TlAX KELAPSING I'EVEK

coiicliisiuu iet,'ar(liiif,' the piccisu naturu of this spirochastosis wliich iiicUiced one to
uudertake the investigation at a time when one was overburdened with other work
wliicli had to be completed. Human spirochuitosis luin;,' ijractically unknown in the
Sudan, so far as one can tell, it was felt that the (i))|)ortunity should not l)e missed.

I I

■ I E«HO.\

Uii .liuuiarv liU, a jerboa [Jacuhii: ijorduit!) was inoculated willi hnger blood from a
relapse case. No infection oi- illness resulted. This jerlma iiail a heavy hu'mogregarine
infection.

1 \' . C H 1 c K E .\

On January 2ti, a >iiun^' cliick was inoculated with linger blood Iroiii the ■^iiiin-
relapse case. No infection or illness resulted.

Kxperinicnl.il
wurk

V. l''i;i;i)iN(; and Inskct TK.\xsiiiissiON IIxi'eimmhnts

(1) Bed-Biujs. — -As stated by Captain Bousfield, a certain number of bed-bugs was
secured from crevices in the barrack walls close to where the infected men slept.
These were gorged with blood, but dissection of some of them failed to reveal any
spirochaetes either in their stomach contents or in their tissues. A few were fed on a
gerbil and the tissues of several were made into an emulsion and inoculated into another
gerbil, but in both instances the result was entirely negative.

(2) Lice (a). — On Januaiy 17, five lice {Pediculits vestimenti) were obtained from the
clothes of a recruit who had been in contact with the j)atients. One of these lice was
immediately dissected, but no spirochetes were found. The remaining four were placed
on a gerbil which was kept in a jar, the base of which stood in a vessel containing
water. On January 18, another batch of live lice was secured, on this occasion from
the clothes of a patient admitted to hospital three days previously. Two of these lice
were dissected and examined, one on January 18, the other on the 19th. In neither case
were spirochastes found. The remaining three were placed on the gerbil. The latter,
though frequently examined, never showed sj)irocha3tes and never appeared ill.

(6) An attempt was made to infect lice obtained from the clothes of men at the
sewage farm by feeding them on gerbil 2, at the time when its blood contained
spirochaites. The experiment failed, all the lice being devoured by tiie mouse, wliieh
was exceedingly active.

(o) On January 25, three lice were fed on one of the patients, during a relapse, and
at a time when spirochaetes were present in his blood. All three became well gorged.
Kxaininaiioii On January 26, two were dissected, one twenty-four hours after feeding, the other thirty
■ ifiite negative hours after feeding. In the first case the whole louse was crushed and examined in the
fresh state, then smeared into a film which was stained. In the second case the louse was
carefully dissected and the tissues examined in the fresh state only. By an oversight the
stained films of the tissues were not investigated.

On Jauuary 27, the third louse was dissected and examined piecemeal, both fresii and
stained preparations being made.

In none of these lice were any spirochsetes observed, despite very prolonged and
careful search, nor were any granules observed like those found by Leishinan' in
Oriiitkodorns iiiouliala fed on blood containing Spirochieta diittoni, or bj' myself- in
Aryas persicuii fed on the spirochaetal blood of fowls in the Sudan.

THE SPIKOCH.'ETE OP EGYPTIAN BELAPSING FEVER 71

(d) Ou Jaiuuiry '21, aiiuthei- batch of nine lice was fed in the morning on a patient
showing a fair number of spirochtetes in his blood. One of these, a well-gorged insect, was
dissected and examined piecemeal with negative results. The remaining eight were fed on
monkey 3 {vide infra). They were removed from the animal after feeding, and next morning
w'ure all found dead, probably owing to the coldness of the night.

(e) On January 30, another batch of lice w'as fed ou monkey 1, in the morning, when the
animal's temperature was 104-4 ¥., and spirochtetes were present in its blood. Several fed
well. A solitary louse was fed in the evening and kept separate from the others, all,
however, being maintained at a moist temperature of 37 C. Unfortunately, on January 31,
all were found dead.

Indeed, the great difficulty was to keep the lice alive. Three days was the longest
period they ever survived, and then only when kept at 37' C. in glass jars containing pieces
of paper which had been soaked in human blood. If they died during the night they were
usually too dried up in the morning to be of any use for dissection.

(/) Monkey No. 3 {Gercopithecus richer). — ^As already noted under d, eight lice which had Experiment
feasted on a patient were fed on this monkey on January 29. No infection resulted. °" * ""^"key

Uniform failure, then, marked these lice experiments, and in part this may be due to the
small number of insects employed at any one time. They were only intended as
preliminary investigations, but, owing to the loss of the strain and the difiliculty experienced
in keeping the lice alive, are all that one has to present.

(3) Ticks. — A few feeding experiments, with subsequent dissection, and, in one instance,
the inoculation of emulsified tissues into a monkey, were conducted with Ornithodoros
savignyi, both nymphs and adults, obtained from Kordofau through the kindness of
Captain Cummins.

As the results were entirely negative, they need scarcely be described in detail.

These, then, are the experimental data accumulated, and it will be seen that there is
little enough to go on in coming to any conclusion. For all that, there are certain
signiiicant findings which may be considered.

One may say at once that, as a result of observing the disease in gerbils and a monkey, inferences
and noting the effects of sub-inoculations, one was inclined to regard this fever as possibly '°'" .

o X- J experiments

due to a specific and hitherto undescribed spirochaete. Captain Bousfield, from his clinical
studies, wrote as though it was due to Spirochaita recur rentis, but I informed him that I was
unable to agree with this view of the case. Shortly afterwards I had an opportunity of
showing specimens of spirochsetes and giving details of the work to Captain Mackie, I. M.S.,
who haj)peued to be passing through Khartoum on his way from Uganda. He was inclined
to agree with me, but, of course, it was difficult to say anything definite as a result of such
meagre and incomplete observations.

It is worthy of note that Dreyer of Cairo,'' about the time this work was proceeding,
published a paper in which he suggested that the spirochaste of Egyptian relapsing fever
might be a distinct entity. He was unable, however, to advance any proof in favour
of this hypothesis.

.While I was writing this paper, a most interesting account of a form of relapsing fever
in South Oran appeared under the joint authorship of Sergent and Foley. ^ They give spirMhutu
an excellent account of the symptomatology, etiology and epidemiology of this human ^"''''"'''"
spirochaetosis, and conclude, on what seem to be good grounds, that this Algerian
spirochaetal fever is distinct from any form hitherto described, and is caused by a special
spirochaete which they propose to name Spirochseta berbera, now sp.

One would refer the reader to their paper for full details, but it is worthy of note that

ri

I'HK

bl'lKOCH.ETK

OK KUVl'Tl.VN

HKLAl'SINU

KEVKH

KKyptian

•V. 0) possibly

K-rtvrn

1 .Mgeri.Lii Kuropeail
Sfi. l>ert*tra Sp, otrrrineifH

African .Xincrtcan Asiatic

nov. sp. 1 irt^tiirr^»/ij!)

Sp. tiuttoni sp, tiffvyi Sp, rartcri

Minimal length

13-5jii, but pos-
sibly some
coiled forms
only I'in

l-i,l

12/^

13/«

7— 9/i

12 /<

Shape

Irregular open
Hexures

Irregular open
Hexures

Sj>iral

0))cu flexures

R e g u 1 a r 1 y
spiral

Open flexures.

Fla;_'.01;.

'>

•>

Peritrichous ...

Peritrichous ?

T c r m i n a 1

(Novy) ;
Peritrichous
(Fnenkel)
Small rodents

1

AnimaUsuscep-

(ierbils, but

Rats and

Small rodents

Small rodents

Small rodents

tilile

only slightly ;

mice with

only after

and many

very susce])-

infected with

monkeys ('.Vr-

cl i th c u 1 1 y ;

passage

animals very

tible

difficulty.

cupitlucun)

m o n k e y s
(Mac It c «,< ;
Ci/iioccpluilus)

through mon-
keys

susceptil>le

Course in

Very niilil

As a rule, mild

Mild

Very severe . . .

1 Severe

Very milil.

animals

1

Sub- iuocula-

( ierbil to gerbil

Rat to rat or

M o u k e y t o

Monkey to

Monkey to

Monkey to

t i o n s in

positive; mon-

mouse to

monkey and

monkey posi-

monkey and

monkey and

auimaU

key to mon-

mouse with

mouse to

tive ; same for

mouse to

mouse to

key probably

difficulty;

mouse posi-

most animals

mouse posi-

mouse posi-

negative

monkey to
monkey nega-
tive

tive (Fiille-
boru and
Meyer)

(Breiul King-
horn and
Garrett)

tive

tive (Mackie).

Course in man

Fairly severe...

Fairly severe

One, sometimes
two, relapses

Severe, four or
five relapses

?

Severe, one or
two relapses.

Parasites in

Variable

Variable

Heavy infec-

Very sparse . . .

9

Variable.

hnman blood

tion

Natural trans-

By lice?

By lice ?

?

By ticks

y

By lice ?

mission

Scrum-reaction

9

Immune scrum

Immune serum

Immune serum

Immune serum

Immune serum

possibly with-

without any

withouteflfect

withouteffect

withouteffect

out effect on

effect n

on novtji or

on obcrnicicri,

on iwi'ifi

Sprccurreiitis

novyi and

oberiueicri

dultoni or

(Russian

dattoni

carlcri

strain)

Egyptian
Sp. ft) possibly

AlKerian European African
a/. iH'rbera,

American

Asiatic

nov. sp. ^P' recurrcntis Sp, duttoHt

\

Sp. Hovyi

Sp, carter!

Incubation

Doubtful; pos-

Not stated ...

5—7 days

7—10 days.

5 — 7 days ...

7 days

period in man

sibly more
than 12 days

Duration of

•2— 8 days "...

— 7 days

5—6 „

Average 3 days

5-6

5 — 7 days

first attack

(rarely 4—5).

Duration of

•2—9 days: 6

G— IG days :

7—10 ., ... 1 — 8 daysl

7— in

5 — 13 days;

apyrexia apparently!

usuallv 7—8 1 (oceasiouallv

occasionally

the most days |

10—18).

up to 19 days

i;ouimou

Number of

One or two,

One or two [ 1 — "2

3 — o (some-

One (rarely

1 relapse in 40

relai)ses

possibly three

certainly, pos-

times up to

2—5)

per cent., 2 in

sibly others,

11).

7 per cent.

but V c r v

and 3 more in

sUght

3 per cent.

Kclapscs absent

In one case ...

?

Nutnncouimon

In 60 per cent.

Uigors and'

Present; rigors

Rigors not [Present ...|

Rigors in 50

Present

Very fre<iuent

sweating

only in one
case

mentioned ;
sweating
marked

})er cent, only,
s w c a t i n"g
present.

Paias in limbs,

Present

Frequent

„

Frequent

,. ,,

muscles, etc.

Tox le m ia ^

Possibly in one

Absent ... Mentioned ...

?

Mentioned ...1

Present in 10 —

(b i 1 i '" u * ■
Jy-i.

case

1

20 per cent.

THE SriBOCH^TE OF EGYPTIAN BELAPSING FEVEB

73

Egyptian

Algerian

European

.\frican

.\merican

.^ sialic

S/>. m possibly

Sp. h-rh-ra.

beroti-a

uov. sp.

Sj>. recTit-rentis

sp. dttttotli

Sp. iio7yi

Sp. cartn-i

Low pulse-rate

Apparently not

No mention ...

Present

9

Present

Almost invari-

after crisis

noted

ably present

The tongue ...1 White and Moist, white

Large andj ?

Large and

Large, flabby

furred

and furred

moist, except

moi.st, except

and moist, ex-

in centre

in grave in-
fection

in grave in-
fection

cept in grave
infection

Appetite

Not mentioned:

Not mentioned:

Poor, some-

9

Poor

Poor, rarely

probably

probably

times vora-

voracious

therefore

therefore

cious

never vora-

never vora-

cious

cious

.laundifo

Absent

Exceptional

Mild, except in

Infrequent in

Mild, except

Present in 70 —

and slight

grave infec-
tion

Uganda.

in grave in-
fection

80 per cent. ;
grave in tox-
aemia

Vomiting of

Not mentioned:

Not mentioned;

Not uncommon

Nut nsnal

Not uncommon

Present in 70 —

bile

vomiting
present

vomiting
present

80 per cent.

Diarrhoea

Absent

Bare

Of brief dura-
tion

Always in tha
Congo ; infre-
quent else-
where.

Moderate

Present in 1'2
per cent.

Tympanites ...

Not mentioned

Common

Grave in
toxaemia

?

Grave in
tossemia

Invariably as-
sociated with
toxaamia

Hiccough

„

Not mentioned

Present

Mentioned . . .

Present

Often present

Haemorrhage

;i J!

Not frequent...

?

Not frequent

More frequent

from stomach

than in the

and intestines

other vari-
eties

The liver

Tender, but not i Enlarged and
markedly en- tender

Enlarged

Enlarged

Enlarged

Enlarged and
tender

larged

The spleen ...

Enlarged and

,.

,•

,, ,,

tender

Parotitis

9

?

Mentioned ... ' ?

■?

Present in

about 10 per

1

cent.

The urine ... I No alljumi- 1 Dark ; excess

High-coloured, 1 ?

High-coloured

High, bilious,

nuria

of urobilin :
slight albu-
minuria

scanty

scanty

Huematuria . . .

Absent

Absent

?

?

Present

? more frequent

1

than other

'.

haemorrhages

Epista.xis

Mentioned ... Mentioned ... i Mentioned ...

Mentioned ...

More frequent

Present in 10

than other

— 15 per cent.

hasmorrhages

Pulmonary

„

„ ... „

.,

Present ^

Present ; more

symptoms

so in toxaemia

Delirium (vio-

Absent

-Absent

,]

Infrequent . . .

Not uncom-

lent)

mon; also
maniacal

Facial paralysis

,,

„

•>

Mentioned . . .

9

Not observed...

Eye aflfections

„

Slight conjunc-
tival injection

Mentioned . . .

Frequent (Mot-
fat, Harrord,
and Cook).

Mentioned ...

Present in
about 1 per
cent.

Herpes labialis

May occur . . .

May occur . . .

Not uncommon

?

?

Not uncommon

Mortality rate

Nil (8 cases)...

Xa (42 cases)

Very low, under

1.3-6 per cent.

"2 to 4 per cent. :

30 to 40 per

5 per cent, ex-

(?) ; about

rarely 10 per

cent, in all

cept in grave

50 per cent.

cent, higher

cases; if toxse-

infection

on the Zam-
besi (?), pro-

in toxiemia

mic cases are
excluded 15

bably lower.

— 20 per cent.

74

THE SPIBOCH.ETE OF EGYPTIAN RELAPSING FEVEB

Comparison of
the Egyptian
Spiro<h:etosis
with other
varieties

Probable
identity of
Egyptian
Spirochaetosis
with that due
to S/i. tirrhrra

while the spirochsete was inoculable from m;in to tlio monkey (Macacus siveimi,
M. ri/)iomologus, M. inuiif, Gynocephahts sjihiti.v), it could not he transferred from
monkey to monkey.

Now this appears also to be true of the Egyptian spirochaBte, nlthoiif^h my single
inoculation from monkey to monkey (Oercopithecus sahaeus), was, most unfortunately, not
made at the time most favourable to ensure success.

Sergent and Foley found that rats and mice could be inoculated, but ran a very mild
course and recovered. This I found true of gerbils. They also observed that it was
well-nigh impossible to obtain successive passages in rats and mice. These sub-inoculations
only succeeded in the case of some newly-born mice. I have no parallel observation to
record, and had no ordinary laboratory white rats or mice available. I obtained some
white rats with all speed from Cairo, but they arrived too late.

Considering the paucity of my experiments and observations, it is jjerhaps scarcely
worth while to enter at great length into a full comparison between this Egyptian
spirochmtosis, the well-known American, European, African and Indian varieties, and the
new Algerian type, but, taking a leaf out of Mackie's' and Clioksy's" books, J have followed
the excellent plan of comparative tables adopted by them, and, so far as is possible, have
compared all the different species of spirochetes and the fevers they cause. I have added
somewhat to Choksy's lists and altered them as seemed desirable, with the results shown in
the tables. The entries regarding the symptomatology of the Egyptian fever are, of course,
derived from Captain Bousfield's paper, and from such recollection of the cases as I possess.

It is scarcely necessary to point out that such tables as those given must be accepted
with some reservation. A great deal, naturally, depends on the personal equation, both as
regards the observer and the patient, while environment may play a part. Again, it is
scarcely scientific or correct to compare an epidemic of eight cases with one of forty-two, or
to compare the symptoms seen in both with those observed in a very large number of cases
of the other forms of spirochiEtosis. Still, bearing these sources of fallacy in mind, the
comparisons may be of some service.

This Egyptian spirochaetosis is certainly not tlic true African form due to Sp. duttimi ;
the American variety, for several reasons, can be excluded, and the animal reactions would
appear to put the European form out of court. Of the well-known varieties there remains
the Indian type, due to Sp. carferi. It is strange that Sergent and Foley do not compare
their spirochete with the Indian species, or the Algerian illness with that prevalent in
India. This is the more remarkable as there is evidence in both diseases to show that lice
act as carriers of the virus, a fact mentioned by the French observers. Perhaps, however,
they did not trouble to do so owing to the fact that the results of animal inoculations differ
in the two cases. Sp. carteri can be transmitted from monkey to monkey and from mouse
to mouse. Moreover, the blood of a monkey in the apyrexial stage remains infective,
so that Mackie' concludes that the spirillum remains in the circulating blood in an
unrecognised and ultra-microscopic form.

Taking everything into consideration, I believe that Sergent and Foley are justified in
regarding the fever in South Oran as a sijecial form due to a specific spirochaste, and, from
such facts as one has been able to gather or establish regarding the Egyptian illness,
I am inclined to think it is the same disease, due, therefore, to Sp. berhera, and conveyed
by lice. This, also, despite Strong's" note to the effect that he has seen in Egypt
infectious due both to Sp. ri-curreiitis and Sp. duftoni.* The view advanced is in favour of
Dreyer's supposition, but it is evident that much more work will have to be accomplished
before we can be absolutely certain that there is a distinct North African spirochetosis of

THE SPIROCHETE OP EGYPTIAN EELAPSING FEVER 75

man. It is, perhaps, a little surprising that more has not been done in Egypt to clear
np this important question. For those desirous of entering more fully into the matter,
I append to the attached references a list of recent papers likely to be of use. Some
of these are mentioned by Captain Bousfield. Mr. George Buchanan has executed the
drawings and prepared the chart with his usual care and skill.

*I wrote Dr. Strong about his cases and he has very kindly replied to the effect that " the case infected
apparently by Up. dultnniwas observed in a man whom I believe had previously been a sailor on one of the steamers
which landed at Port Said. I inoculated white mice with his blood which later showed the parasites. It seem^
quite pnsxihlr that the ease wight hare lieen an impm-ted one." The italics are mine. Dr. Strong does not
furnish inform.ition regarding the .S'/'. recurrent lis cases. — A.B.

Eeferences

. r,..' ,^'^ir'""''"' ^\- ^ (February, 1909.) " Preliminary Note on Experiments in connection with the Transmission
ut lick- J? ever. Joiirnr,/ uf the Iio)/al Jrnu, Medicul Corps, vol. xii., No. 2, p. 123; and (.January 1910)
Observations on the Mechanism of Infection in Tick Fever and on the Hereditary Transmission of Spirnrhn'ta
diittiini in the Tick." Tnntstie/ ionx Soeiefjf Trrqiienl Merlu-iiie awl Hiigienc, vol. iii., No. 3, p. 37.

- Balfour. A. ^October 1, 1909.) "Further Observations on Fowl SpirochfPtosis," Juarnal Tronieal
Meilieinc and Hite/iene, vol. xii., No. 19, p. 28.i.

'■ Dreyer, W. (.lanuary, 1910.) " Uber dur.^h Protozoen in Blut hervorgevufene Erkrankuncen bci Mcns(-hcn
und lieren in Agypten." Archiv.fur Schiffs uml Tropen. Hiig., vol. xiv., No. 2, p. 37.

■> Sergent, Edm., and Foley, H. (May 25, 1910.) " Recherches sur la lievrc recurrentc." Ann. de rinsi
1 axt., vol. XXIV., No. ,i, p. 337.

■■ Mackie, F. P. (1907-S.l "A Review of Recent Work on Spirillar Fevers." Trans. Am.. Soc Trvn
Med., vol. in. '

" Choksy, N. N. (1909.) " Bombay Relapsing Fever." Traiwactioas BoMba/t Medieal aiiujrcts, Bombay.
■ Mackie, F. P. ;September, 1907.J " A Preliminary Note on Bombay Spirillar Fever." ifrHcc^, vol. ii., jx 832.
» Strong, R. P. (June, 1909.) " Relation of the Indian Form of Rclaiising Fever to African Tick Fever "
rhil. Jonrn. Se., vol. iv.. No. 8, p. 137.

Additional Eeferences

Brumpt, E. (1908.) " Existence de la ' Fievre des Tiques ' en Abyssinie." /.'«//. .S'»r. P„l/i. E.mt vol i
No. 7, p. 432. " ' '

Brumpt, E. (1908.) " Transmissions du Spirochaeta duttoni et du Spirochacla yaUiaaru,,, par rUrnilhodorus
iiwubata, non-transmission des Spirochetes dc la fievre recurrente americaiue ct algerienne par ce mSmc narasite "
BuJl. Soc. Path. Exot., vol. i.. No. 9. a l i ■

Cummins, A. G. (February, 1910.) "Notes fi-om Kordofan on Two Cases of Fever associated with
Spirochaetes in the Blood." Journal of thi Roijal Armi/ Medical Cordis, vol. xiv.. No. 2, p. 199.

Darling, S. T. (August, 1909.) "The Relapsing Fever of Panama." Arel'i. Internal. Med. vol iv
pp. 1.00-18.5.

(tin, H. A. (1909.) " Zur Technik und Vcrwendbarkeit des Burrischen Tuscheverfahrcns." Cent f Bakt
I. Abt. Orig., vol. Iii., p. 620.

Kladnitzky, N. N. (1908.) " Ueber die Vermchrung der Riickfallspirochiiten in K6rper der Wauzen
Vorliiufige Mitteilung." Vent.f. Bakt., Abt. I. Orig., vol. xiv., p. 126.

Mackie, F. P. (December 14, 1907.) "The Part Plaved by Pedieuhns eorporis in the Transmission of
Relapsing Fever." British Medical Journal, p. 1706.

Manteufel, B. (1908.) " Experimentelle Untersuchungen zur Epidemiologic des europiiischen Riickfall-
fiebers." ecn^/. ^aX-^, Abt. I. Orig., vol. xlii., p. 116.

Mathis, C, and Leger, M. (January, 1910.) "Recherches sur le spirochete dc la fievre dn Tonkin."
Bull Soc. Med.-t'hirnrgicale dc I'lndo-Chinc.

Mathis, C. and Leger, M. (February, 1910.) " Sensibilite de la souris blanche an spirochete de la fie^-re
recurrente au Tonkin." Bull. Soc. Path. Eo-ot., vol. iii.. No. 2, p. 75.

Nattan-Larrier, L. (May 12, 1909.) " Penetration du Spirille de la fievre recurrente a travers les teguments
ct les mutpieuses intacts." Ball. Soc. Path. E.vot., vol. ii., No. 5, p. 239.

Neumann, R. 0. (1909.) " Ueber das Verhalten der Spirochiiten des Riickfallfiebers im Tierkiirper und die
experimentelle Uebertragung der Parasitcu durch Zecken und Liinse." Munch, mediz. ll'oeherischr., No. 9.

Robledo, E. (March 10, 1909.! "Fievre recurrente de Colombie." Bull. Soc. Path. E.eot vol ii
No. 3, p. 117. ' ■'

Sergent, Edm., and Foley, H. (March, 1908.) " Fievre recurrente de Sud-Oranais et Pediculus ve.it iuicnti "
Bull. Soc. Path. E.cot., vol. i., No. 3, p. 174.

Smithy C4rahani U. (1909.: On some Cases of Relapsing Fever in Egijpt and the Question of Cnrriage hit
Domestic J'crmin. London. ' ' "

Soulie, H., and Gardon, J. (1905.) "Fievre recurrente et paludisme observes chez un Europ^en a I'HoDital
Civil d'Alger." Ball. Mid. Algiric.

Souhe, H. (September, 1907.) " Su r un nouveau cas de spirillose humaine observe a Alger." Province Medicate.

SriKoi'ii.irrdsis ok Sudanksk Fowls

BY

The DiRECTon

Tlie principal points brought out in the preceding paper on tliis subject were as
follows :^

((/) The r61e of An/as jjcj-s/chu as a carrier of the disease.

{b} Tlie occurrence of an "after phase," or sub-acute and chronic stage, characterised
l)y tlio presence of curious intra-corpuscular bodies, wliich were shown to be due, in all
probal)ility, to the invasion of the erythrocytes by spirocha?tes.

(c) Tlie breaking up of these bodies, both in vivn and in, vitro, into tiny granules
("spore" forms), which, it was suggested, might play a part in the life-cycle of tlie
parasites.

It seems advisable to give a brief account of the literature on Fowl SpirochsEtosis
which has accumulated since the paper in tlie Third Report was written.

1. Gareitschnoff' in 1907 described a case of fowl spirillosis in Bulgaria, a new locality
for the disease which is much more widespread than was originally thought to be
the case.

2. (lalli-Yalerio,- in a preliminary note, signalised the production of spirochastosis in
fowls at Lausanne by means of ticks {Art/as pemicus) which had been fed on infected
fowls in Tunis.

Later^ he returned to the subject, having carried out numerous experiments. As a
result, he came to the conclusion that there is a single form of avian spirochaetosis and that
therefore the spirochsBte with which he worked is Sp. marchouxi (jjallinarum).

Of special interest hei-e is the fact that in a fowl bitten by A. persicus, and which
succumbed nearly a month afterwards without showing spirochajtes, the red cells were
found to harbour pyriform bodies whicli Galli-Valerio thinks resemble the after phase
bodies. Spirochaetes were not found in sections of the organs stained by the Levaditi-
Volpino method. Other forms, even more similar, were discovered in the erythrocytes of
a rat inoculated from an infected fowl and which also died. The author is doubtful as to
what interpretation to put upon them, but thinks they may be evidence of a feeble infection
passing into a chronic state.

3. Comte and Bouquet* observed a spirochsetal disease of fowls in the oasis of Degache
and in the neighbourhood of Tunis, and found that it was transmitted by -4. persicus.
Bats were not susceptible, but geese and ducks could be infected. Brumpt has named
the infecting agent Sp. nicoUei n.sp., as, from its peculiar immunity reaction, he believes
it to be a distinct species. It does not protect against itself.

> QareitschDoff, Q. (July, 1907), "Ein Fall voa Hiihnerspirillose in Bulsarien." fclerinaria Sbirka.

' Qalli-Valcrio, B. (1908), " Spiroch^tiase des ponies determinee a Lausanne avec Argus persiciiji, Fischer,
Tiinisie." I'enl. f. Bakl., Ori'j. Abt. /., Bd. 46, H. 4.

" Oalli-Valerio, B. (1909), " Recherchcs sur la Spi rochet iase des ponies de Tunisie et snr son atrent de
transmission: A njas persicus, FistOier.'" Cenl. /. Jinkl.,-Ori<j. Abt. I., Bd. 50, //. 2.

' Comtc, C, and Bomiiiet, H. (1909), " Becherches expcritinMitnl.-^ -nr la apirillose (ins ]kiii1cs m '!'iiiii-;ic."
Arch. <U rinsl. Bct.il. ilc JViniJ*., p. 163.

SPIEOCH.ETOSIS OF SUDANESE FOWLS 77

4. Simond, Aubert and Noc' described a fowl spirillosis at Martinique which they
believed to be identical with that originally found in Brazil. They say it probably
exists in Guadeloupe and French Guiana.

5. Mezincescu and Calinescu- met with the condition in Roumania where .-1. persicus
was common. Ducks and geese were also affected.

6. Brumpt and Foley-' in 1908 gave a short account of .S'^. ijaUinaruiti in fowls in South
Oran.

7. The former author at a later date' produced a very interesting paper on a fowl
spirochetosis in Senegal. He has named the parasite Sp. neveuxi as he found
that it could infect fowls which had acquired innnunity to Sp. gallinarum infection
and, conversely, fowls inunune to Sp. nereu.vi contracted the Brazilian septicaemia.

A point of special importance, and one which from personal experience I believe to Immunity of
be true, is cited by Brumpt. He finds that while chicks are easily inoculated with ^'^"" ^"'^^
different species of spirochaetes, certain adult birds exhibit a natural innnunity conferred
apparently by age. Thus he found one very old fowl (five years) which could neither
be inoculated by the bites of Argns ticks nor by inoculation with Sp. nereu.ri. He believes
this peculiarity to be shared alike by rats as regards the spirochete of African tick
fever (Abyssinian strain). The duck, goose, Java sparrow, sparrow and chaffinch are
susceptible to Sp. nereu.vt. He did not experiment with the pigeon. The infection seemed
somewhat less virulent than that produced by Sp. marcluiti.vi, but, like the latter, is
convej'ed by Argas persicus.

8. Still later, the same author'' found that the Somaliland infection was due to
Sp. mnrchou.vi, or as he calls it Sp. gallt'naruni, and was conveved, like the other,
by Argas persicus.

9. Bouef' encountered a fowl spirillosis in the French Sudan. By inoculation
experiments he apparently proved the identity of this Sudanese spirochete with
Sp. marchou.v.i, and further found it the same as the Senegal virus wdiieh Brumpt
named iS'^. neveu.vi.

This then would tend to support Galli-Valerio's view. Bouet found my " after phase " " After phase '
bodies in the red cells but would not commit himself to an opinion regarding their nature. [jociies found

t^ o r, ^^y Bouet

10. Mohn' found the disease in the German Cameroons, but of more importance is the
work of Blaizot.

11. In 1909, he presented two papers'* * ° dealing with the effects of the Somali
virus [Sp. gallinarum) on chicks of from five days to three months old, comparing the

^ Simond, Aubert and Noc, F. (April 20, 1909), "Sur I'existence de la spirillose des ponies k la
Martinitiue." C. 11. Soc. Biol., Vol. 66, p. 714.

- Mezincescu, D., and Calinescu, J. (1909), "Spirillose des poules et Ariins pirsicus en Rounmnio."'
Bull, de la Soc. dc Path. Ej-ot., Vol. 2, p. 292.

■' Brumpt, E. and Foley (July 18, 1908), "Existence d'une Spirochetose des poules jV Spiroi-liwla (faliinariiiii,
R. BL, dans le Sud Oranais. Transmission de (^ette maladie par Arqas persicus." Cnmpf. Henri, dc: Sfanres de,
la Soc. de. Biol. Vol. 65, p. 132.

■* Brumpt, E. (.June 9, 1909), " Sur une nouTelle spirochetose des poules du Senegal produitc par Spirocliaia
iieveaxi n. sp." /lull, dc la Soc. de Path. E.eot. Vol. 2, p. 28.5.

■'• Brumpt, E. (July 17, 1909), " Existence d'une Spirochetose des Poules Spirocholn •i<illiiiiinii,i dans Ics
pays Somali." Comfit. Rend, des Stances de la Soc. de Biol. Vol. 67, \r. 174.

•■■ Bouet, G. (June 9, 1909), "Spirillose des Poules au Soudan Framais."' Bull, de la ,S'oc. dc Path. Ejnt.
Vol. 2, p. 288.

■■ Mohn (1909), " Uber Hiihnerspiroohatoso in Ivamernn." Quoted in Xotizcii aus der Trnp. mui Brief l: des
Ins. f. Sch. u. Trop. zu Hanih. Xo. 5.

" Blaizot, L. (October 23, 1909), " Etudes sur la Spirochetose des Poules produite par Sp. gallinnram (Virus
Somali). La maladie chez les poussins 1. Modifications de la virulence du parasite par passages directs."
Compt. Rend, des Seances de la Soc. dc Biol. Vol. 67, p. 421.

■■■ Blaizot, L. (October 30, 1909), loc. cit. Vol. 67, p. 447.

78

SPIROCHiETOSIS OF SUDANESE FOWLS

The lime ol
obtaining the
virus is
important

Vectors of
S. gatlinaruni

13

disease in them as ]iiorluccd by tick liitc and by inoculation, and contrasting,' tlu^
condition eansod by spiiocba^tes takrn fioii} birds early in a series of inoculations
and those taken late.

In the case of tick bite tlie disease was found to i)0 of },'reat severity, the chicks often
dyinj? before spirocliaates had time to appear in their blood. In the case of inoculation
everything depended on the time when the virus was obtained. If early, in the successive
passages from chick to chick, a lengtliy illness resulted and tiiere was a marked reaction
of tlio organism against tiie virus; if late, the disease was shorter and tiieie was no reaction.
Ill a later paper Blaizot,' working witli tiie same strain, j)ointed out tiie curious fact
tliat while successive passage of the virus through chicks greatly increased its virulence
for chicks, it at .the same time lessened its virulence for adult fowls.

12. Balfour- at an earlier period comnumicated a paper on further work witli the
spirochuete of fowls in the .\nglo-Egyptian Sudan. .\s tiie jiiesent article includes
and extends tiiese oliservations they need not be considered here.
I'rowazek,-' working at Rio de Janeiro with t^p. ijaUinnrnni, discovered that tliis
parasite passes through a regular cycle of development in tiic cceleniic llui<l and
finally in the salivary glands of Aryas ininiatKK.

He figured dividing and resting forms and conchuled that the tick is a true host for
the spii-ochijete. His paper is important and requires early confirmation.
Dschunkowsky and Luhs^ at tlie Veterinary Congress at the Hague, dealt witli the
spirillosis of geese due to Sp. anserina. They managed to cultivate the parasite in
a special manner and found atoxyl to be a specific against tlie disease. Further,
they succeeded in preparing a preventive and cuiativc serum from the l)lood of
treated geese.
15. Tlie same authors' mention the occurrence of what tliey consider to be my intra-
corpuscular bodies in altered red cells of sick and healthy fowls examined at
Elizabethjiol and at Surnabad in Transcaucasia. In geese they found two forms,
one recalling the bodies, the otiier in geese suffering from spirillosis and formed
of paranuclear bodies included in unchanged red cells.

They ask if tlie occurrence of these forms in healthy birds does not throw douijt on
their parasitic nature, and suggest they may merely be endogenous deformities like Kurloff's
bodies or Ferrata's plasmosomes {vide paye 123 and Plate VI., figs. 15 and 3).

One would like to see their specimens before expressing an opinion on the nature
of their findings.

IG. Schellack" has continued the researches mentioned in our Tliird lieport. He finds
that Ar(jas iniiiialiis, A. reflcxiis and .1. pe.rsicus are all efficient as vectors, while
Ornithodoros mouhata can also transmit Sp. (jalliiKintui. f>cr)iia)ii/.t.<:it.i avium is not
a carrier. The role of other ecto-parasites of the fowl as carriers has not been

14

' Blaizot, L. (June 15, 1910), " Etudes sur la Spiroch«5to.'!e dcs Poules produite par Sd. yallinanim (Virus

Somali)^UDe proprii'-te de la r.ice cultiv^e sur poussins." t'ompl. Jlnid ili\i Simicci tie la Soc. lU Biol.
Vol. 68, ].. 2rt.

'-Balfour, A. (Oirtoljcr 1, 1909), "Further observations on Fowl Spiroclitetosis." Journal of Tropical

Malieine and IlijyirM, Vol. 12, p. 285.

' Prowazek, S. (August, 1909), " Contribuii^ao para o estiido do dezeiivolviniciito de ' SpiriKlurla yallinnrain .' "
Mr,,,. ,l„ fn.ll. (isirnhln Cm:, Vol. I., No. 2.

* Dschunkowsky, E., and Luhs, J. (1909), " Prophylaxis and Pathology of Protozoan Discises." (Quoted
in the Journal of Tropical Afnliciue anil Ifi/gieni', Vol. XII., p. 292.

' Dsohunkowsky, E., and Luhs, J. (1910), " Sur I'Etude des Maladies Protozoires des oiseaiix domcstiques
en Transcauoasie." Jtee. yin. de Mid. I'M., Vol. XIV., Nos. 163-4.

° Schell.Hrk, A. (1909), "Versuche zur Ubertragung von Spiro'li„i,i „„li:,i„,-,i,., nnd Spirucluilo <il„i-„iri,-rl."
Arh. aits il. Kai.irrl. GeguttdhtHsamte Bd. 30 H. 2 s. 352.

SPIROCHETOSIS OF SUDANESE FOWLS 79

demonstrated. If the hen-house is infected, he says that infection per as can
take place.

17. Tedeschi^ by the use of abrin killed Sp. (laUinai-niu, and thus produced a vaccine -V pioteciive
whicli protected canary birds. It is worth noting that he found that iS'^. duttoni

in experimental animals during fever-free periods, remained in the blood as endo-
globular forms, both in the erj-throcytes and the leucocytes.

18. Dodd- has a paper on fowl spirochaetosis in Queensland. He describes the symptoms
well, but there is not much that is new in his account. He did not find the
"after phase" bodies despite careful search.

19. Blaizot'^ contributed a paper on relapses in the fowl spirochaetosis of Tunisia
(virus de Degache). He cites the work of Conite and Bouquet, already mentioned,
and also the facts as regards recurrence discovered by Bouet and myself. The object
of his research was to discover if relapses, characterised by the presence of spirocho'tes
in the blood, occurred in the Tunisian spirochetosis.

This he found to be the case and he points out that so far as we know at
present only a heavy, acute infection is capable of conferring a permanent immunity.
He points out the close relationship existing in this direction between African fowl
spirochaetosis and the spirochetal fevers of mammals. He puts forward the ingenious
suggestion that both relapses and absence of immunity may be due to a premature
crisis occurring before there has been time for saturation with auti-bodies and thereby
preventing the first infection being sutificiently severe to ensure a complete immunity.
From the study of this question of inmiunity Blaizot believes that it may yet be
possible to affirm that Africa is the original country whence avian spiroeh»tosis spread.
His paper is interesting, suggestive and will repay careful perusal.

20. Quite recently, Jowett^ has discovered fowl spirochaetosis in the vicinity of
Cape Town. Moreover, along with the disease, he has found intra-corpuscular
bodies exactly like those in Sudan fowls. A. pcrsicus is the vector, and, judging
from the preliminary paper, this spirochaetosis of South Africa is identical with our
Khartoum form.

21. Gilruth'J describes the disease from Victoria, in Australia, but did uot find
endoglobular forms.

22. Dschunkowsky" has recently treated the spirillosis of geese successfully with "606," Successful use
which he finds to be much more active than atoxyl.

23. Blaizot" in yet another paper returns to the subject and deals with the subsequent
cachexia, the question of intracerebral inoculation and the susceptibility of fowls to
second infections.

• Tedeschi, A. (1910), " E.xpenraenteUer Beitrag zur Recurrensfiebers (Spirochcele Duttoni)." Cent. f. Bakl.
Oriij., Abt. I. Bd. 54, H. 1, p. 12.

-Dodd, S. (March 31, 1910), "Spirochaetosis in Fowls in Queensland." Journal of Comparatire
I'litholuyi/ anil Therupeulics, Vol. XXIII., part 1.

■' Blaizot, L. (1910), "Note sur la recurrence dans la Spirochsetose des Poulcs en Tunisie (virus de
Degache)." Arch, de VInst. Past, de Tunis, part 2, p. 53.

* Jowett, W. (December, 1910), "Fowl Spirochsetosis, Note on the Occurrence of, at the Cape." —
T/ic Atji-ie.uUnnd Juarnal of the Cape nf Good Hope, Vol. XXXVII., No. 6.

■'■ Gilruth, J. A. (1910), "Note on the existence of Spirochaetosis affecting Fowls in Victoria." Proceedimjs
lioj/al Sociclii, I^ietoria, Vol. XXIII.

» Dschunkowsky, E. (.January 5, 1911), " Heilversuche rait Ehrlich-Hata " 606 " bei der Qansespirillose, etc."
£cr!. ticrarzlh Il'och.

■ Blaizot, L. (1910), "Nouvelles Recherches sur la Spirochetose des Ponies." Arc/i. de rin.tt. Past., Tunis,
part IV.

so

SriROCH.F.TORIS OF SUPAXESE KOWT.S

I'l.ss,!,!,.
relationship
of the intra-
corpiiscular
bodies lo
spirochaetcs

The great
value of the
dark-fieM
inethrxl

24. Gozony,' in a hif^hly interesting paper, sliows that spirochaftal infection can take
jilace through the unbroken mucous membranes, and believes that the leucocytes
play a great part in the production of natural imnnmity, not, however, by ))hagocytic
action, but by the production of substances injurious to the parasites.
'l-'t. Xattan-Larrier- deals with hereditary transmission and congenital immunity in
spirillosis in several papers wortliy of study.

Although the previous work in the laboratories had. as it were, cleared the ground
to a considerable extent, certain points still required elucidation, and during the winter
of 1908-9, and the spring following, the work was continued as opportunity offered and
was also resumed in the succeeding winter with the object of ascertaining :-

1. If further proof could be obtained as to the relationship of the intra-eorpuscular
bodies and the spirochsetes.

This necessitated a further study of their morpholog^i-, both by the methods previously
employed and by such other methods as suggested themselves, notably the employment
of dark-field illumination, special staining processes and therapeutic measures, and by a
consideration of any analogies which it might be possible to trace in similar or allied
ha?matozoa.

2. The course and nature ot the disease in cliieks. It was found that these were
much more convenient for the experimental work than adult liirds, but it was soon
apparent that conditions in chicks were not analogous to those in fowls. This is interesting
as the fact was also noted at a later period by Brumpt and Blaizot in the papers
already cited.

3. The fate of spirochtetes ingested by Arijan pergicns and tiie true role of this tick
as a carrier.

4. If Oniifhodoros siin'fjiiiii, the human tick of the Sudan, a species closely allied
to ". inotthata, served also as a vector. Experiments in this direction led me independently
to the discovery of the curious bacterial or mycelial-like forms in the tissues of this tick,
which Leishman also found, as a matter of fact, in ticks which reached him through
Dr. Graham-Smith but which I sent to the latter. They were obtained at a small oasis
in the desert near Khartoum. Some time has been spent in trying to determine the
nature of these forms.

5. If the fowl lice, so commonly found on the birds, could transmit the disease and,
if so, whether or not they were true hosts or merely mechanical vectors.

6. If pigeons and other birds are susceptible to the Khartoum virus.

7. If any other blood changes, besides those already mentioned, required notice.

8. If the pjhrlich-Hata preparation, "606," was effective as a therapeutic agent
in this form of spirochaetosis.

(1) Taking these subjects in the order stated, one found the dark-field method of great
service. It confirmed certain observations previously recorded, i.e. the entry of spirochsetes
into red cells and the longitudinal division of the parasites, and enabled these two
phenomena to be witnessed with comparative ease and frequency, and latterly it has
indicated what is, in all probability, the method by which the bodies are formed. Although
spirochsetes could be seen entering the red cells and also leaving them, and specimens
removed and stained at the proper time showed spirochaetes actually in the cytoplasm
of the erythroblasts, no formation of bodies directly from spirochsetes could be observed.

'Gozony, L. (Felminrv 1-3, 1911). "Die Infektionswcge nnd natiirliclic Imiiiunitat l»ei Spironhatosen."
frill./. Bali, ftriii., Vol. LVII.. [art G.

' Nattnn-Ijirrier, I.. (Man-h 10, 1911). "Spirillose horfditain- et iniiminiti- con^'-nitale, </ .«■(/." I'mnpl.
Henit. Sue. Binl.

SPIEOCHa:TOSIS OF SUDANESE FOWLS 81

It was found that by this method living and fairly active spirochaetes could
sometimes be demonstrated thirty hours* after the putting up of the cover-glass
preparation, but in no instance, even when they entered corpuscles, did they coil up
or break down to form anything approaching the inclusions. These latter are clearly
visible by the dark-field method, appearing as silver rings or presenting appearances not
unlike tiny cartwheels, owing to their granular contents reflecting the light brilliantly,
while their vacuoloid areas remain dark. A "tucking in" of the corpuscular envelope at
the point where the body, if peripherally placed, was situated, was often apparent,
as, indeed, is the case in stained specimens. The method, however, indicated that the Breaking up
spirochaetes eventually break up into granules, and suggested the possibility that it is spirochetes
these granules which really invade the red cells. True, this has never been seen to into
happen in films of peripheral blood, but blood between a slide and cover-glass is not the S''*""^
same as blood in blood-vessels, and, moreover, granting that these bodies really represent
a stage in the spirochaete life-cycle, it is quite likely that they enter the red cells in the
internal organs. At first this was merely a supposition. I killed chicks showing good
body infections and submitted emulsions of liver, spleen and lung and also the expressed
juice from these tissues to dark-field examination, finding a large number of free granules,
but it was not until I performed liver puncture and examined the blood thus obtained by the
dark-field method {vide page 104) that I obtained any definite evidence as to what really
seems to happen. Latterly, also, when employing "606" as a therapeutic agent, I have
obtained some very suggestive appearances in tissue stained by the Levaditi method {i-ide
pages 100 and 101).

Acting on Dr. Stevenson's suggestion, I stained films of peripheral blood by the
Heidenhain method and counter-stained deeply with saffranin. The result went a long
way to show that the bodies have nothing to do with corpuscular or nuclear substance,
for, while the red cells stained a dull brownish-grey, their nuclei of course being of a darker
hue, the bodies stood out as brilliant pink dots (Plate III., fig. 8), taking on the saffranin
stain intensely, but unfortunately diifusely, so that no granular structure could be seen.

It is true that the nuclei of the red cells, possibly because they contain chromatin,
exhibited, in some instances, pinkish granules, more especially when the corpuscles stained
faintly and were therefore probably degenerated, but these were unlike the bodies, being,
as a rule, darker and having irregular outlines. Thej' suggested nodes in the nuclear
network. Much the same aspect is presented by films stained by the Heidenhain method
and counter-stained with eosin. " Spore " forms of the bodies show black granules when
stained by the Levaditi-Yamamato method.

When films were first of aU deheemoglobinised and then stained by either of these
two methods the bodies were found to retain the counter-stain for which they possessed an
afiBnity. No further light was, however, thrown on the problem.

Other staining processes did not help one. The silver nitrate method of Khitrovo' Differential
for Sp. pallida was tried as was the Burri Indian ink method, but without any addition ''

to our knowlege being gained. Wet fixation was adopted, but in vain so far as the
discovery of anything new as regards the morphology of the bodies was concerned.
In this respect one is not further advanced than at the time the Third Eeport was
written, though better specimens of the "spore" forms have been obtained which show
the inclusions forming or breaking up into granules and the discharge of the latter

* In one instance I found a still-living spirochaete after 72 hours
' Khitrovo (November, 1909), Archives Med. Beiges, quoted in Journal Royal Army Medical Corps, May, 1910.

82

SPIROCHETOSIS OF SUDANESE FOWLS

Kxperiments
in culture

Observations
M night

from the red cells. (Plate III., fig. 3). In all probability, beyond this " schizogony-like "
stage there is nothing more which can be made out.

One thought that possibly the use of culture media might help in solving the problem,
and, accordingly, blood containing spirochaetes or bodies was added to tubes of Novy,
MacNoal and Nicolle's media. The spirochaetes remained alive and active for 12 days,
thereafter becoming sluggish. By the fourteenth day the majority were dead and had lost
their staining affinities. In one instance a parasite was found to have entered a red cell.
No multiplication was observed.

The intra-corpuscular bodies remained wholly unchanged even when their host
cells degenerated.

Little of fresh interest has been made out in preparations stained, as formerly, by the
Leishman and Giemsa methods, but Plate III., fig. 7, shows apparently a certain
intimate relationship between the inclusions and the spirochaetes. This is specially true of
the top part in fig. 7 and one of the corpuscles shown under fig. 6. In the former the
suggestion afforded is that the spirochaetes are entering and coiling up in the red cells.
In the latter, the appearance suggests an included spirochaete with a portion of one end
still free. I now think these ai-e accidental appearances, but they serve to perplex one,
and confuse the issue. Although I have found it impossible to demonstrate the entry of
the spirochetes, as such, into the red cells and the subsequent formation of encysted
forms exactly like the bodies, I have, as mentioned in the last Eeport and in this
paper, seen spirochajtes enter the erythroblasts, a fact which also tended to conceal
what I now believe to be the true course of the cycle.

Thinking that the red cell invasion might have something to do with the habits of
the tick vectors and therefore might only take place at night I repeated observations
previously made at night, but employed, in addition, the dark-field method. Captain
Archibald kindly assisted me, but though we worked at midnight and at other hours, no
fresh light was thrown on the problem.

Additional evidence that the corpuscular inclusions were in reality stages in the
spirochaetal life-cycle was, however, obtained by the discovery, on several occasions, that,
when the peripheral blood exhibited only bodies, sections of the liver, and sometimes
also of the spleen, showed abundant spirochaetes. In this connection the following cases
may be cited.

1. Fowl. White hen. Brought iu from market in extremis and the peripheral blood on examination found
to have a huge intra-corpuscular infection. No spirochaites could bo found in the peripheral blood nor were any
jiresent in smears made from the lung and bone-marrow in which bodies were numerous. Unfortunately, lilms
were not made from the liver, spleen or kidney, but these organs were stained by the Levaditi-JIanouelian
method and spirochietes were found in the liver "and kidney though not iu the spleen and lung. In the kidney
sections the red cell infection was apparently also visible. A point of much interest, the significance of which
was not recognised at the time, was that many of the spirochietes were fragmented or breaking up into black
granules

2. Chick iV. On March 6, 1909, this small, clean, healthy bird was inoculated, subcutaneously, with a few
drops of peripheral blood from another chick which showed a very heavy endoglobular infection but no
spirochietes.

March 9. A few bodies found for the first time.

March 10. None found to-day, but gaps in the corpuscles noted. These suggested spaces previously occupied
by the inclusions.

March 11. A few small bodies again present and some gaps still visible.

March 17. A great increase in the number of bodies had taken place. " Spore "' forms present. Multiple
infection of red colls. Bodies of varying size and shape.

March 18. Literally, a huge infection which presumably caused the death of the bird, though post mortem
a greatly distended gall bladder was present.

The red corpuscles of the heart's blood frequently showed many bodies close to their peripheries, there being
an apparent gap in the corpuscular envelope where the body impinged against it. This lack of continuity in the
corpuscular envelope must not be confounded with the gaps or spaces in the corpuscular substance mentioned
al)0vc. The liver, examined by the Levaditi-Manouelian method showed undoubted spirochaetes lying both in
and on the hepatic cells.

PLATE III
/

u

/

V-

f^ # ^^

•^

5'.\

'^r

I

^

•^ %^

;Vi".

?

d'^

/>

<.

P.. D. ilciK

1. Semi-diagrammatic and composite drawing from smears of portions of one Malpighian tube of a tick (Ar^as />frsittts 9^
incubated for 23 days at 37° C. after feeding on a chick with acute spirocha;tosis. Small clumps of Leishman's spirochsete granules
and transition of granules into spirochaetal forms. The two large nucleated granular cells in the middle are normal tissue cells
and are introduced by way of contrast.

Lcishiuan Stain

"i <

A

X 1000 i/iam.

■,^^

•

r^'

<•

# ^

2. Heavy gr;inule infection at different stages

3. Inclusions showing "spore" forms discharging "spores"

4. Clump of spirocha;tes with central node (peripheral blood)

5. Spirochaetes from coclemic fluid of infected Ar^as ptrsicus
2-7. Lcishman Stain

8. Iron Hiematoxytin and SaJ/ranin Stain

Spii-ochfCta granniosa penetrans, ii.sp.
2 — 8. Cycle of Schizogony

Gaps in red cells after discharge of "spores" and

inclusion with attached rods
Inclusions and free spirocha;tes in apposition
Multiple infection of red cell-especial staining

X 1000 iiiant.

SPIEOCH^TOSIS OF SUDANESE FOWLS 83

One need not here take up the question of the use of therapeutic agents as a means of Action of
settling the above question. The matter will be found discussed under the eighth heading,
and it need be merely said that the use of " 606 " by subcutaneous injection in appropriate
doses rapidly drove all spirochsetes out of the peripheral blood and appeared also to
induce changes in the bodies which led to their eventual disappearance, while, as already
mentioned, some highly suggestive results were obtained {vide jMijes 101 and 102).

If we search for analogies which may throw light on the subject we find the
observations of Galli-Valerio and of Bouet, already quoted, to be at least significant,
although neither of these authors is so far prepared to subscribe unreservedly to Sambon's
hypothesis or apparently to accept such arguments as one has hitherto adduced. The
same may be said of the findings and conclusions of Dschunkowsky and Luhs, though here
we are not on such certain ground. For one thing I have only seen extracts of their
papers. For another, they seem to be describing several curious appearances in the blood,
possibly no one of which is identical with what I have called, possibly erroneously, as will
be seen, the " after phase."

It must be remembered also that neither Blaizot nor Dodd were able to find the
inclusions, although it is true that they may have been working with a different strain of
spirochiEte. This is very probably the case so far as the Australian observations go, but
the Tunisian strain certainly resembles that with which one has been working in several
important particulars. Jowett's recent discoveries in South Africa are naturally of special
interest, and his future work may serve to throw confirmatory light on tlie problem. (See
also references to recent papers by Bosanquet and Dobell, jjaye 107.)

Another point of interest was kindly brought to my notice by Colonel Sir \V. B. Leishman,
F.R.S. He told me that he attended a meeting of the Pathological Society of Great Britain
and Ireland, where a paper was read by Dr. Henry, on the heemoprotozoa of British sea-fish.
A spirochietosis was described, and at the accompanying lantern demonstration Sir W. B.
Leishman noticed inclusions in the red cells of the tish which showed the spirochujtes in
its blood. He told me these forms closely resembled the bodies of fowl spirochsetosis.
A portion of Henry's^ paper has since appeared, but it is only a preliminary note, and
though a Sp. yadi pollachii has been described as a new species no mention is made of red
cell inclusions. A more detailed paper is promised shortly.

One also finds an account by Tidswell- of " rounded bodies," possibly protozoal, in the Possible
blood corpuscles of a leather-jacket fish {Monacaiithuf sp.). The description given certainly ^/"M^f*^^ '" _..
suggests my " after phase " bodies, but in no instance were more than two found in one
red cell. The nature of these bodies is regarded as uncertain. They do not suggest the
product of degenerative processes, and the final conclusion reached is that " if they are not
protozoal they are more or less normal products of the cell, either when in its younger
condition or adult form." They ask if they may be ceutrosomes like those described by
Ross, Moore and Walker in the erythrocyte of the axolotl, the crocodile, man, etc., but find
that they are quite unlike these. No statement is made as to whether spirochaetes were
found in the tish. I should not be surj)rised to find that tish of this Australian species
suffer from spirochtetosis.

I mentioned the so-called cytamoebae of frogs and other reptiles, in the paper on fowl
spirochtetosis in our Third Report. It is possible that Carini's^ work on trypanosomes

> Heury, Herbert (1910), "On the Haemoprotozoa of British Sea-Fish (A Prelimiuary Note)." Journal of
Pallwlogij and, Bactcrioluijy, Vol. XIV., p. 463.

- Tidswell, P. (1909), l!rp,„-U of tlw Goixniinciit Biii-om of Mkrohioloyij. New South Wales, p. 45.

' Cariiii, A. (February 25, 1910), "Stades Endoglobulaires des Trypanosomes." Ann. dc I'Inst. Past.

84 SPIROCHilTOSIS OF SUDANESE FOWLS

of frogs throws light ou these inclusions and also incidentally on the "after phase."
Certainly the spherical chromatin-staining bodies, which he describes and figures as the
first stage in the intra-corpuscular life of a trypanosome, closely resemble one form of
cytanioeba and recall very forcibly the bodies in fowl spirochjetosis.

Some analogy may also be traced in the results obtained from the examination of
infected ticks (A. persicnt) presently to be described. As previously noted, the bodies
appear to break up into granules which are discharged from the host cells, and certainly
these granules recall those found in such abundance in ticks fed un spirochsetal blood and
first described by Leishiuau in Oniithodoros mouhata.

Other somewhat similar conditions may perhaps be found in the changes undergone
by the nuclei of trypanosomes in the spleen and possibly in other of the internal
organs. The parasites break down and their nuclei disiiitegi-ate into small chromatin
granules. It is probably from these that the small forms (merozoites ?) which invade
the red cells in the case of >>cliizotrypau<iiii cruzl and T. hrucei {f/ecaudi'i) of the Sudan
(Buchanan) are derived (ride pa'je 60).

Again, a recent paper by Gonder' on the life-cycle of Theileria pari-a shows, so far
as I can follow him, the important part played by the nuclei of the gamonts. These
nuclei, however, jjossess distinct karyosomes, while some are even credited with
jjossessing second nuclei of the nature of blepharoplasts, so that they appear to be more
organised than the spirochx-tal granules. I believe, however, as I stated at the
Meeting of the British Medical Association in 1910, that in many protozoal infections
the infective " granule "' will be found to play an important role and to explain
conditions which are at present puzzling or obscure. Meyer- has reached conclusions
very similar to those of Gonder.

SuflScient has been said, both in this paper and in that on Blood Examination (/"i;/'- IH),
to show that the whole question of red cell inclusions is, with our present knowledge,
one of exceptional difficulty. In studying the morphology of these " after phase " bodies
I have frequently been puzzled, especially when examining the fresh blood, to account
for some of the curious conditions encountered. In the paper to the Journal of Tropical
Medicine attd Uygieue to which reference has already been made (jpaye 7H), I described
certain features which I believed were presented by these bodies in the fresh blood of
chicks, and which, though I am now doubtful if the forms on which the observations
Tbe-a/ter were mad$; were in reality the bodies of the "after phase," 1 find it hard to explain
phase bodies -^^ ^^^. satisfactory manner. These features were motility and a definite appearance
which suggested either a granular structure of the bodies or was evidence that they were
jjossibly coiled-up spirochetes.

I may very briefly quote from the former pa|)er as regards these two conditions
without giving the illustrative details there recorded.

" The spherical, intra-corpuscular bodies in afi'ected chicks are frequently actively
motile, circling in one or other direction round the nucleus of the red blood corpuscle.
If the corpuscular infection is multiple the bodies may pass each other, may unite or
at least lie in close apposition to one another, and, in some cases, may apparently fuse,
though it is difiBcuh to speak with certainty as regards this last point.

"The spherical, intra-corpuscular bodies in affected chicks may, whether themselves
actively motile or not, exhibit each at its centre what looks like a tiny motile filament

' Gonder. R .rva: the Cause of East Coast Fever in

Cattle in Sonth .\ (i». Vol. XXIII. Pan -1.

' " I'-'ll;. ii--\xi\x^'- ^ur Uuau^c uua Bedentoue der Kt-chscheu Plasmakn^lii

in der : i^n KOstcsofiebers." Vent, fir Bnkt. Orig. Vol. LVII. Part 5.

SPIROCHJiTOSIS OF SUDANESE FOWLS 85

which waves to aud fro. The appearance may be roughly imitated by making a
ring of the thumb and index of one hand. Then pass the two terminal phalanges of
the index finger of the other hand through the centre of the space thus enclosed, and
move them so that the tip of the linger waggles briskly to and fi-o. I have said
the appearance is that of a tiny filament, yet this may be an optical illusion, and the
curious phenomenon may depend on the active movement of granules into which the
body is breaking up. After many observations, however, I am inclined to believe in
the presence of an actual filament which may or may not be a portion of a partially
encysted spirocheete."

I am now inclined to think that in the blood of these Sudanese fowls two or more The true
"inclusion forms" are to be met with in the red cells which, under certain conditions, "after phase

body is pro-
may very closely resemble each other. Thus, in the fresh blood, I doubt if the motue tablynot

bodies described were examples of the true " after phase " forms. These latter were motfle

certainly present in the blood, but I am now driven to believe that they are invariably

motionless save for the slight oscillations mentioned in the paper in our Third Eeport.

On page 19 of that Eeport it will be seen that one records movement in what appeared to

be an " undoubted " body. It did not then occur to me that the blood was being examined

under abnormal conditions and that the fact that it was heated probably explaiaed this

phenomenon even if the body seen did represent a true "after phase" form, which may

not have been the case. Both this body and other motile forms I am now inclined to

consider as the vesicles described by Crawley {page 118j, though it seems to me impossible

to distinguish them from the true inclusions which stain well and which I am endeavoiu-ing,

by advancing further arguments, to prove to be endoglobular stages of the fowl spirochete

in the Anglo-Egyptian Sudan.

-Is regards the second observation, that of the filament phenomenon, I am still in
doubt, not as regards its occurrence, for that has been confirmed by several observers here,
but as to its precise significance.

The fact that I have never observed it in the blood of normal gerbils and yet noted it
in the blood of several gerbils which had been inoculated, either with human spirochaetal
blood or the blood of animals successfully inoculated with the spirochetes of Eg\-ptian
relapsing fever, would tend to show that it bears some relation to spirochetosis. Some
of these gerbils showed spirochetes, for brief periods, in the blood, others did not.
In one of the latter, examination of the spleen and liver by the Levaditi method was
negative as regards the presence of spirochetes. This, however, in view of the variable
results obtained in chicks {page 86), means little. That these filament bodies, however,
are not the true " after phase" bodies, though exceedingly like them in fresh blood, would
seem to be proved by a control case in which a chick with, so far as could be told from
examination, perfectly healthy blood, was iaoculated with two drops of citrated finger-blood
from a case of human spirochetosis (Sp. berbera .^). In fresh films on the day following,
bodies showing the fUament phenomenon were present in or on the red cells, and yet
nothing was visible in stained preparations. It is true that careful focussing made me
regard these bodies, which were not again found, as epi-corpuscular, but they showed the
waving filaments.

Is it then possible that, apart altogether from the question of spirochete invasion Is the con-
of the red cells, there is present in the spirochetal blood some toxic substance which bvatoiiii?
affects the cytoplasm of the erythrocytes producing a peculiar vesicular condition apparent
only in the fresh blood and, possibly, in addition, certain degenerative changes which in
stained films either resemble or are themselves the true "after phase" bodies? In order

86 Sl'lKOCUJGTOSIS OK SUDANESE FOWLS

to obtain, if possible, some information on this ))oint the following; expoiinieiit was
carried out : —

Jiinnnrii "24, X911. 5 v.M. of liluud drawn with aseptic precautions liy a syriu^e from tlie winjj vein of a
fowl showing many si>irocha!tes in its bluod. Citrate solution added and the mixture filtered through a
small Histeur-Chamberlain filter F.

Itesulting filtrate found clear of parasites and 10 minims of it inoculated subeutaucously into a clean,
healthy chick. The result was entirely negative. It is worth noting here that, at a later date, this chick
was sucivssfiilly inoculated with sjiirochiotosis.

Other points rehiting to the bodies and tlieir eoiuieetion with the spirochiete infection

are so intimately mixed up with the second of our statements that we may at once proceed

to its consideration. As space is limited and as records of cases form uninteresting reading

it is not proposed to give details of all the experiments carried out (some 70 in number on

chicks alone and many more on fowls, obtained both in the open market and from our own

specially bred stock), but merely to supply good illustrations as proofs of conclusions stated.

DifTeienccs of (2) lieference has already been made {page 11) to the fact that there were marked

ihedisi-aicm differences between the disease in chicks and that in fowls. The most imiwrtant are here

chicks and ^

fowls given in detail, but it must be remembered that to draw definite conclusions from

experimental work of this kind requires great care, for, as Levaditi and others have shown,
it may be impossible, by ordinary methods, to demonstrate the presence of free spirochastes
in the blood of a bird, even though, as shown by inoculation, they actually do exist.
At the time most of these experiments were conducted, the use of ricin for facilitating
the search, as afterwards advocated by Levaditi and Stanesco,' had not been demonstrated
and one had to rely on tlic prolonged search of films which, though imiuirtant, was very
tiring and occupied a great deal of time. For example, if one inoculated a chick with
spirocha;tal blood, and bodies only appeared, and then one inoculated this chick's blood into
another bird with the result that spirochtctes occurred in the latter, one could never be
absolutely certain that there had not been a few spirochiEtes lurking in the peripheral blood
of the first chick, for it would be impossible to examine as a routine the number of films
which would represent even the few drops of blood used for an inoculation. Again, it is
sometimes very dilficidt to say whether a bird is absolutely clean or harbours a few bodies.

Bearing these difficulties in mind, tlio following is the list of the differences to which
allusion has been made: -

[a) In chicks, not infrequently, the inoculation of blood containing, so far as could be
told, free spirochuBtcs only (and these in large numbers) into a clean chick has resulted,
not in the appearance of free spirochtetes, but of what one regards as the intra-corpuscidar
stage in that chick's peripheral blood. At a later date, free spirochtetes may also appear.
The same phenomena may also follow tick-bite or tlie inoculation of enuilsions of the
tissues of infected ticks. Hence it would seem that the term " after phase " may, in
some respects, be a misnomer. On the other hand, the inoculation of blood, containing
apparently only the intra-corpuscular bodies, has now and again resulted in the
appearance of free spirochiEtes at first, and of bodies later. Granting that no spirochajtes
had been present in the blood used for inoculation, are we to conclude that the spirochajtos
have been derived from the bodies direct or from infective granules (spores or merozoites)
into which the bodies have luokin up? Again, supposing that a few spirochiEtes were
present but had boon missed, are we to assmne that the blood of the inoculated chick was in
a condition favouring cell parasitism which consequently occurred, the spirochiEtes, as
granules, at once invading the red cells and appearing as the familiar inclusions'?

' Levaditi, C, and Stanest;o, V. (lilln). "Sur nn |)rocedc facililant la recherche des tryjutDosomes
ct des lilaires dans le sang." C'oinpl. rend dc la &te. dc Biol,, T. Ixvii, pp. 594-596.

SPIKOCHalTOSIS OF SUDANESE FOWLS 87

I fear I cauuot answer these questions, but proceed to give illustrations. Unless
otherwise stated, all inoculations were made subcutaneously.

Examples : Experiments

Chicks c and d, clean birds, were inoculated on Pubruary 18, 1909, from a case of acute, hut not very
severe, naturally acquired spirochsetosis in a fowl. On February 20, chick c showed bodies only, and, on the
following day, chick d followed suit. The bodies increased in nuuiljer but at no time was the infection in
either bird severe. Chick c, which showed the most Ijodies, was chloroformed on March 8 and its liver
examined by the Lcvaditi-Manouelian method but no spirochfetes were found. Chick '/ continued to show
bodies for a time but they gradually lessened, and, by March 20, had entirely disappeared from the blood.
In neither case was there any marked illness.

I'hiel:, clean bird. Inoculated ou May 2.0 with infected tick tissue (vide infra). On the following day
bodies only found in very considerable numbers (there had been no sign of them in the preliminary
examination). On May 29, spirocha;tes also were found in the blood. An increase had taken place in the
numl>er of bodies.

Mai; 30. Increase in the number of spirochaetes. Bodies apparently not so numerous as j'csterday.

Jfiij/ 31. No bodies found even after prolonged search. Spirochtetes fairly numerous. Tangles forming,
indicating the crisis.

June 1. No spirochaetes. A few bodies.

June 3. As above.

June 5. A few spii'ochaites and a few bodies found.

June 0. Large numljers of spirochaetes. Tangles again forming. No bodies seen.

June 7. As above.

June 8. No spirocheetes. Bodies present and showing so-called " spore " forms.

June y til 13. As above.

June 14. Bird died. Nothing special found post mortem. Section of the liver, spleen and lung were
examined by the Levaditi-Volpino method, but no spirochaetes were found. Unfortunately the presence or
absence of granules was not noted.

This w-as a most interesting case, and, I am bound to say, suggests a close relationshijs
between the spirochtetes and the inclusions. The alternating presence and absence of the
latter is, I think, also suggestive in this direction, as is their increase and decrease shown
both in this and other cases [vide infra).

(ft) In chicks, relapses are common, and the disease therefore approaches mammalian
spirochaetosis in type. Spirochtetes vanish from the perii^heral blood, which niay then be
quite free or may show bodies. Then, the intra-corpuscular bodies, if present, still
persisting, the spirochaetes recur. This may happen on several occasions.
Examples :

Chick X. Clean bird. Mai/ 12, 1909. Inoculated with spirochastal blood from another chick. No bodies
present in blood used for inoculation.

May 14. Infected. Spirochaetes only.

May 15. Slight increase in number of spirochaetes.

May 16. Spirochetes apparently comj^letely absent and remained so till

May 18, when they recurred.

May 20. Spirochtetes fairly numerous. Chick ill.

May 21. Found dead. Spirochaetes present in hearfs blood. Liver shows a few greenish-yellow spots.
Microscopically, there was cloudy swelling and the spots were found to be necrotic areas.

Chick V. Bird showing some bodies in the blood prior to inoculation (vide r and d). Were these true
bodies of the " after phase " '? Apparently so.

May 8, 1909. Inoculated with blood from chick showing both spirochaetes and bodies.

May 9. Both spirochetes and bodies present. JIany of the latter very small.

May 10. Enormous number of spirochfetes present. Bodies as above. Bird not very ill.

May 11. As above, but tangles numerous to-day. Some of the leucocytes show large, more or less
spherical, rose-pink (with Leishmau stain) masses in their extra-nuclear portions, the significance of which
I am at a loss to understand. Granular white cells, suggesting myelocytes in all but size are present.

May 12. As above.

May 13. Entire absence of spirochaetes. Bodies about the same.

May 14. As above.

May 15. Kecurrence of spirochaetes. Considerable number and tangles. Bodies also increased in number.
Multiple infection common. The suggestion is that the spirochetes are now entering the corpuscles, but this
was not actually observed. In the fresh blood, motility of what, at the time, were thought to be genuine
bodies was observed. In stained tilms, " spore " forms found. One corpuscle seen with a gap in it and, hard
by, 15 small chromatin granules observed which may well be sjjores. (Plate III., fig. 3.)

A few, though each is distinct, are united, the majority are free. Possibly, some of the very tiny bodies
in the corpuscles are spores which had re-entered the red cells. This would account for change's in the size
of the bodies which may undergo schizogonic development from the merozoite stage.

88 SIIHOIM.KTUSIS OK SUDANESK K0WL8

Miiij 10. Uiril fuuiul (Icail. Kautciial invasion. N<i spiruehmtus I'oiiml in iuli.riial urgaus by tlic
]-cvaditi-VolpiiK) iiictliod.

('hick S. This example may :\\m l>e iii\tii\ as. like V, the bird was iiioeiilated with blood coutaiuiujr
both spirorhivtos and bodies, but eventually recovered.

.!/<((/ 4. Clean bird. Inoculated from another chiek.

Miiij C. Bodies nlone found in the blood. It is unfortunate that uu examination was made on Mmj .">.

Miiii 8. Spiroehii'tes present in lar^je numbers and exist alontf with the bodies.

.1/(11/ 'J. No si)iroehiBtes and very few bodies found.

Miijl 10. Only n few small bodies seen.

Miiij 13. As above. Bird very well. Examination discontinued.

Is iinmuniiy (p) III cliicks, the presence of iiitra-corpviscular hodies does not signify tliat tlie biid is

Lpcntui iiiiniune to spirocliictal infection, as has been found, at least so far, to be the case in adult

on age ? ' ' ' '

fowls. Chicks showing bodies have often been successfully inoculated either by tick-bite
or tlie needle, with spirochastal material. Is, tlierefore, the inununity of the adult bird,
as suggested by Brunipt ipaijc 77) dependent on age alone? Examples have already been
given, but several cases may here be quoted with advantage, not only where spirocha.'tosis
developed after inoculation but where iuoeulatiou was followed solely, so far as could l;e
told, liy a great increase in tin- number (if bodies.

Ediimpleis :

Chick Ml. Shows bodies in blood.

Miiirh i), 1910. Inoculated from fowl with acute spirochaitosis.

Miiich 10. Bodies only present. No ehaujjc.

Mnirh 11. Distinct increase in the uuniber of bodies. No spiroch;utcs.

Miirch 12. Heavy spirocha;tal infection which persisted aloni; with the liodics till Mnrch H, when crisis
occurred.

Chick iM. Bird with slijjht body infection.

June G, 1910. I'laced in cage with batches of ticks (./. jnrsiciis), some of which, on dissection, sliowed the
infective jfniuules to which reference has Ijeen and will be made.

June 7. No chiintre.

June 8. Heavy body infection. Duiible and multiple infectiun of red cells not unconinion. This gri"l""".V
diniiuislied and the liird, which was never really ill, recovered.

I 'hick f Its blood contained bodies, it was inoculated with an emulsion of infective tick tissues and developed
aoute spirochaitosis. Details need not be ijiveu. The course of the c;isc was similar to that in chick bb.

Chick I. Shows bodies in blood.

Mnrch o, 19119. Inoculated from chick, which the day before its blood was taken for this jjurjio.sc, had shown
spirochiutes, but to-day {Miicch 5), shows only a few bodies. T'here were, however, in all probability a few free
spirochittes still lurkiufj in its blood. tho\i^'h detinitc immf of this (cannot be advanced.

Mnrch G and 7. No change.

Mnrch 10. Very considerable increase in the number of bodies. Multij)le infection of red cells. Bird
chloroformed. I,ung smears showed bodies only. Nothing special noted. Levaditi sections negative so far as
presence of spiroc-ha;tes is concerned.

((/) Whatever may be the significance of the bodies it would ap[)ear that tlie

spirochiete infection //<■/■ sn does not protect against itself. If tiiis is tine and if Biuinjit is

correct, then our spirochtete is like N/'. uirullei in this particular. It must be renienibered,

however, that to arrive at correct conclusions as regards this matter, several points, as

Blaizot' has quite recently pointed out, require consideration. These are the methods of

inoculation, the natuie or rather age of the virus as regards passage and the duration of the

Hrst attack. One has not had time to work out the (juestion on proper lines, but certain

osperiinents tend to prove the above statement.

J'JuMiupIcK :

Chick r. Mnii 1, 1909. Inoculated with spirochiotal blood from another chi<^k.

Mill/ 3. Found heavily iiife<-tcd with spiroclnetcs. Ticks (./. jnrsiciis) fed on it.

Mill/ 4. Both spirochietes and liodies present.

Mill/ 5. No spirochietes found to-day. Inerca-se in number of liodies.

.1/(1// H. A great further increase in uuuibcr of bodies. Multiple infeetiou of red cells not unctimmoii
Bird seedy l)Ut not very ill.

.l/((.i/ 9. As aliovc, but in addition "s))ore" forms showing to-day when the bird was again inoculated with
chick Ijlood showing both bodies and spirochietes.

' Blaizot, L. (1910), " NoHvcUus Rocherchcs Bur la spiroohOtosc dcs I'oules." Arch. Instil. I 'nM. 'I'lini.i. I't. IV.

sriEOCHJ-.TOSIS OF SUDANESE FOWLS 89

May 10. Bodies as before but a few spirochaites arc now present, as well. Were these the result of the
second inoculation or is it a relapse? It is impossible to say definitely, l>ut in all probability this is a .i<ood
exami^le of statement (/.

.\[n>i 11. Found dead, a fact which rather encourages the view just stated. In Ijcvaditi sections spirochsetes
were found in the hepatic sinuses.

A chick which had developed spirochajtosis from having infected lice placed upon it, which had
recovered after a heavy infection and which had shown no spirochsetes in its peripheral lilood for eight
consecutive days received, on .lanuary 2.1. 1911, an injection of fowl's blood containing numerous parasites.
It showed no spirochsetes up to .lanuary 2ft. on the morning of which day it was found dead. No spirochsetes
were found in its heart's blood or oi-gans.

A very sudden fall in the temperature of the laboratory during the night may have accnuntcd for death.
The case of the chick (cldc paijr 8G) which received an injection of filtrate from spirochaetal blood and yet
was subsequently successfully inoculated with spirochietosis, may be taken as another example of (/, but a
better instance is found in the case

(e) Very young chicks obtained from the village or market may exhiliit a few intra- possibilitv of
corpuscular bodies. It is, of course, possible that they tnay have been infected in the ,raiismiSnn
usual way through the agency of ticks, and have passed, either directly or secondarily,
into the " after phase," but as there is often no sign of tick infestation upon them, as
thev usually appear in good health and fair condition, and as the infectiofi is, as a rule,
scanty, one is constrained to ask if they may not be examples of hereditary transmissions.
It has been shown that iS'p. iHarehou,n ((/allrnariim) can pass into the immature
ovum of the fowl, so that it is quite possible that chicks, even live chicks, may be hatched
exhibiting a spirochsetal infection of this form. It is worth noting that such chicks are
not immune, for, if bitten by infected ticks (A. pemicKt!) or inoculated with spirocheetal
blood, free spirochaetes appear in their peripheral blood or, as already fioted, after a
certain itioculation period, the niniiber of intra-corpuscular Ijodies in their blood undergoes
a fiiore or less marked increase. Examples of these statements have been given, but
I confess this question of bodies in very young chicks presents difficulties. Are the
appearances really the true inclusions, frotti which they seem to me to be indistinguishable,
or do they represent changes in the red cells of the chick or persistence of etnbryonal
conditions'? I endeavoured to solve the problem by breeding out chicks frotn what was,
presumably, a healthy stock of fowls, i.e. a stock bred on the pretnises atid never
infected. In the chicks of a cock and hen of this kind, however, I found corpuscular
inclusions, one of these birds beitig chick ihi whose case is recorded on page 88. It is
very difficult, with native attendants who are practically all either thieves or liars, or
both, to be sure things are carried out as desired, and with the pressure of work utider
which one usually labours, it is impossible to keep a close eye on matters of this kind,
so that I cannot lay too much stress on these observations which shoirld be repeated.
In this country it is hard to obtain fowls which one knows have never had spirochsetosis,
and I have not latterly been able to obtain foreign breeds which, moreover, are very
apt to die.

It may be a mere coiticidetice but it seems to me worth recording that the above-
fuentioned healthy cock atid hen of our owti stock, wheti inoculated with infective tick
tissues, both showed spirochajtes in due course but tiever showed bodies, though
examined at intervals for a month and tnore. Both birds recovered completely after
passing throligh a transitory leuksemic condition.

(/) The injection of blood containing, so far as is known, intra-corpuscular bodies
only into chicks may result in an infection of the peripheral blood with bodies only.
Such infection, after a titne, usually undergoes a great increase, resulting not uncotntnonly
in death, and post mortem spirochetes may be found in the organs.

K.i-mnph. An excellent exatnple has already been given in the case of chick N {pacje 82)
and, curiously enough, a certain chick 0, inoculated with a liver emulsion from the bird

90

8PIBOCH-ETOSI8 OF SUDANESE FOWLS

Probable
incroiise of
virulence in
passage from
chick to chick

used in the inoculation of N (sucli eimilsiun containing, so far as could Ix' told, only
bodies), ran a course almost pi-ecisely similar to N.

(;/) Although I have not performed a sufficient number of consecutive transmission
experiments on chicks to be quite certain, I believe that the disease increases in virulence
when passed from chick to chick. This is what Blaizot found with his virus. I have
not observed the effect of such heightened chick virus on fowls.

Section (2) may be suitably concluded by an account of the remarkable history of
a certain chick which demonstrated several of the points mentioned, both in this and the
preceding section. This account also gives details as to motility and the filament
phenomenon previously mentioned (jpage 85).

chick I, a small, clean I'hick, was imieiilated sulieutancoiisly on .)/<irc/i 1, 1909, with the heart's blood of a
chirk which had passed, apparently completely, into the "after phase." The absence of free R]iiroi'hii'tes from
this latter i-hick was continned by the examination of its liver and spleen, sections of which had been stoined by
the IjevaditiJIanouelian method. No free spirochietes could be seen, but bodies were readily demonstrated in
the red l)lnoil corpuscles of the blood sinuses.

Miin-/i 3. Chick exhibited free spirochietes in its peripheral blood in fair n imbers. It would appear,
therefore, that these must have been derived in some way from their intra-corpus('ular bodies in its blood. It is
scarcely necessary to add that the chick was protected from tick-bite. (Later knowledge would point to free
granules being the source of the spirochiptes.)

March 4. No spirochiPtes found, but bodies had .ippean^d in considerable n\imbers.

March 6. Uodies more numertius. No fpiroehiptes.

March 7. Bodies still increasins; in number. Some large forms noted.

March 8. Condition much the same. Jlultiple infection of corpuscles common. Hird shows no marked
signs of illness, but appears slightly emaciated.

March 9. An apparent decrease in the number of bodies which arc, for the most part, of small size. The
same note is applicable to the appearance presented on March 10.

March 11. A further diminution in the number of bodies was noted. No furthi:r examination could be
conducted until —

March 17, when it was found that the free spirnchaics hati rcciirrri/ in the liluoil. There was a heavy infection,
and bodies in small n\inibers were found to be still present. In one instance a spirochiete was found attached by
one end to one of the spherical intra-corpuscular forms. Free spirochietes were also oliserved, arranged as though
radiating from a common centre, a tiny uuiss or ball of chromatin, and so-called protoplasmif^ balls, which may lie
likened to the root nodes of certain plants, were observed on several of the parasites. The bird was carefully
examined for lice and ticks, liut none were found on it. The blood was pale, watery, and coagulated with
great rajjidity.

K.r(iiiiiiialiiin (if Frish FiliK.i — Many a<'tive spirochietes. The number of bodies distinctly decreased from
that noted in former preparations of fresh blood.

A red corpuscle observed with two spherical bodies in it, one slightly larger than the other. Both bodies
were motile, and moved round the corpuscle between its nui'leus and its periphery, the movement being, as a rule,
from left to right. The waving filament, already mentioned, was seen projecting from the ciuitre of the larger
iKxiy and lashing to and fro. My assistant, Captain Archibald, and other workers in the lalniratories contirmed
this observation. The bodies were seen to pass each other, and om^ apparently disappeared for a time below the
other. The <'orpuscle at this stage underwent change in shape owing to pressure exerted by a neighbouring
eosinophile leucocyte, but the bodies remained unaffected for a period of two hours, during which time they were
the obje<:ts of continned ob.serv.atiou. This was then intermitted, and. when last .seen, the bodies were motionless,
lying side by side, their adjacent 'rims" llattened as though they were pressing or being jircssed against each
other. On the examination of their host corpuscle being renewed two hours later, the bodies could not be
recognised, all that was visible being a roughened, granular appearance of the spougiti))lasm of the corpuscle at
the point where the bodies had last been seen. In stained preparations the free spirocluetes tended to form loops
and rings.

March 18. The condition of motile bodies observed in several corpuscles. One large body showed the
waving " lilament" at its centre remarkably well. In one corpuscle two motile bodies were seen to undergo what
looked exceedingly like a process of fusion. At my request Captain Archibald watched one of the large motile
bodies continuously for a period of three hours. He noticed a granule or grannies apiiarently attached to the
waving filament which the body presented. The liody itself was very actively motile, and. besides movement of
translation, kept dancing about between the cell envelope and nucleus. It gradually U^'ame indistinct, and the
red corjmscle became jiale in colour. Finally the body could no longer be detected, but a distinct gap was seen in
the corpuscular envelope at the spot opposite which the l>ody had been situated. I looked at the i)re|)aration
from time to time and c-onfirmed these findings. The fate of the grannie and filament remained unknown;
they disap|)eared along with the body. No definite extrusion of the body or of any granules from the corpuscle
could l)e oljserved.

A stained film led one to think that the nnmlier of bodies generally had certainly decreased. The chii-k
remained in very fair health, though somewhat thin ; it took food readily.

March 19 and 20. The aliove notes a])ply, though, on the latter date, no marki'd motility w.as observed in
any of the biKlies. The blood coagulated with ast^onishing rapidity, but there was no sign of ai-iite illness.
Temj>crature at mid-day lO."! P,

March 21. Some interesting ap))oar8nces in the fresh IiUhhI. Spirocluptes fewer. Bodies ap)M»rently
increased in number. Some corpuscles showed four or even five bodies of different sizes. A <'ori)U8cle was

SPIROCHETOSIS OP SUDANESE FOWLS 91

observed exhibiting a large body with four small ones in close attendance, and, in addition, another small body
situated by itself. The large l.iody, to which the four small ones had by this time formed a kind of tail, impinged
against the small separate body, and was arrested by it. As a result, the " tail " moved on and passed in front of
the large body, which itself eventually slipped past the smaller one. In one instance a spirochaete was seen
apparently attached, by one end, to a body which formed one of four in a corpuscle; the smallest of the four, the
only one not quite spherical in shape, and the only one of the four exhibiting motility. Some spirochfetes were
still living and motile eight hours after the preparation of this film, which had been kept throughout at room
temperature, i.e. about 35° C.

March 22. A great reduction in the number of spirochsetes both in fresh and in stained tilms noted.
A motile body presenting a filament was watched for one hour. After an interval of two and three-quarter
hours the film was again examined, and the body was found to have almost vanished, a localised granular
appearance in the spongioplasm of the corpuscle alone remaining. Another body was seen which appeared to lie
discharging actively motile granules into the liquor xavc/iiinif!, but I was unable to satisfy myself on this point.

The chick at this date was ill, with ruffled feathers and drooping head, but took food readily.

March 23. Temperature of chick, 105'5° F. No free spirochaetes in either fresh or stained films. No
increase in the number of intra-corpuscular bodies. Motile forms of these latter again visilile, one exhibiting a
filament watched both by Captain Archibald and myself. The following is a brief record of the observations: —

5.45 p.m. : Body active and central filament very active, lashing to and fro. 6 p.m. : Only change noted was
an appearance as though the body was throwing out a pseudopodium towards the periphery of the red blood
corpuscle. 6.15 p.m.: Central filament still active. No further change. 7.20 p.m.: As above.

Observation discontinued, but resumed at 9 p.m. when the body was found to have disappeared, the granular
condition of the spongioplasm remaining as in other cases. In addition there was seen a distinct, though slight,
jirotrusion of the corpuscular envelope, opposite the spot where the body had last been seen.

Stained films showed nothing special save that one body exhiliited a tiny chromatin rod projecting from it, an
appearance previously figured in one of the coloured plates of the Third Report of these laboratories. (Plate VI.)

March 24. No spirochsetes, but an undoubted increase in the number of liodies. This was true both of fresh
and stained films, but was better marked in the case of the latter. A motile body with filament was observed to
contract and change shape prior to becoming practically invisible. Motility was not so marked in the bodies
generally, and those showing filaments were distinctly in the minority. In stained films, gaps were seen in some
of the corpuscles, and the large size of many of the bodies was noted. Multiple infection was common. The bird
was worse and very somnolent, but would wake up to take food, and at times was finite lively.

March 25. No motile bodies and none with filaments seen. Otherwise as above.

March 26. Spirochfetes were once more present, though not in large numbers. Several were, to all
appearance, attached to the bodies.

March 27. An extraordinary film. The spirochaetes were present in enormous numbers, occurring free and in
tangles, while the bodies had also undergone a great increase in number. In fresh films they did not exhibit
motility or filaments ; in stained preparations " spore " forms were visible. The tendency for the free spirochetes
to form coils and loops was again noted. By night the chick was very ill and weak, so it was chloroformed and a
post mortem performed. There was a condition of general anemia of the tissues and organs. The heart muscle
was exceedingly pale. There were marked green patches on the surface and in the interior of the liver, which
proved, on section and staining by Mayer's hfemalum, to lie areas of necrosis, the condition being like that
sometimes seen in syphilitic livers. The green colour suggested chloroma.

Smears were made from the heart's blood, liver, spleen, lung, and bone-marrow. Those of the lung were most
interesting, owing to the vast number of spirochaetes present, but otherwise nothing special was noted. The liver,
spleen and lung were prepared by the Levaditi-Manouelian method, but no spirochfetes could be found in these
tissues. Qalli-Valerio,' using the Volpino-Levaditi method, never found spirochfetes in liver sections even when
the free parasites were present in the circulation. As will have been noticed, I sometimes succeeded, sometimes
failed, but would observe that sometimes a high ocular, Zeiss No. 12, was necessary along with the l/12th oil
immersion in order to make absolutely certain of their presence. Unfortunately the presence or absence of
granules was not noted.

In conclusion, I do not know that these earliei' researches threw much fresh light on
the chief problem — the nature of the bodies. Certain powerful evidence was no doubt
forthcoming to show that they are, as previously stated, spirochsetal inclusions, but at the
same time certain apparently puzzling facts were demonstrated which tended to confuse
the issue.

One has not been able to observe their actual formation in the red cells by any of
the methods employed and, without this demonstration, any array of proofs is of necessity
somewhat incomplete. Still, despite certain difiBculties, I adhere, especially in the light
of observations yet to be recorded, to my former opinion and, as stated, am forced to
believe that these inclusions are not the direct result of spirochaetes invading the
erythroblasts and breaking down therein, but are due to an entry of small granules
derived from the chromatin cores of spirochaetes which have already disintegrated. If
this be so I am well-nigh persuaded the action takes place in the internal organs,
more especially the liver and possibly also in the spleen and lungs. Did it occur

' Qalli-Valerio loc. cit.

92

SI'inOCH.TvTOSIS OK srPANF.SK I'owr.s

Closr
connection
between the
intra-

corpii scalar
tKxlies and
acute spirn-
chtPtosis

Influence of
tcmp<*rature

ill tlie peripheral blood 1 think one would have witnessed it hy the aid of dark-field
illuniiuation, althou-jh, of course, the blood is in an abnormal condition and below the
temperature found in liic sick fowl. (See account of liver puncture case, /"((/-■ 102.)

Certain it is that there is an intimate connection l)etween acute spirocluetosis of
fowls and these inclusions, and also in all prol)al)ility between the latter and the " infective
granules" found in the ticks which serve as vectors in the former.'

(3) We now pass to consider the fate of spirochietes inj^ested by Arf/dn pcmriis, and
the true role of the tick as a carrier. In some ways this part of the research is the most
interesting and important because of the analogies found to exist in this connection
between human and comparative pathology. In the first place, however, we may consider
a few experiments carried out to see if Prowazek's observations on N/>. iitillitinniin in
Brazil (pa<j>' VH> could be confirmed in the case of this spirochaetosis.

E.rperimeiil :

Defeniher i>, 19111. A largo Imtch of J. prraicius, most of them, imfortunately, ininintiiro tii-ks (ii.vmplis),
fed on a fowl with a heavy spiroc^hset.al infection. No bodies in fowl's blood.

Dccfmliri- fi. ."ird day after inoculation. Rx.amination of coelemic fluid, obtained in the nsiial way,
commenced. A few unaltered spirochaetes found. Thereafter a fresh tick was taken on each occasion on
which an examination w.as conducted.

Drcfiiihn- 9. 4th day. A doubtful dividing form seen.

December 11. 6th day. A fciir number of spiroohietcs found. This suggests some multiplication.
Forms suggesting longitudinal division observed.

Dee^mbrr 12. Spirochaetes present liut very few in number. No evidence of division or miiltiplicjition.
Thereafter examiu.itious on the 14fh, 16th and 18tU days. All negative.

Ijccembir 19. 14th day. Two immature ticks examined, one a female. No s))irocha>tes in coelemic
fluid. Following Prowazek's method thj sjilivary glands were disse<'ted out, smeared and examined, also
with negative results. There were infective granules (ride infrn), in the Malpighian tubes.

Examinations were discontinued on the 16th day after inoculation, nothing further having been found.

In this instance these spirochiefes were not found in the ticks after the 7th day. Care was taken to
examine ticks which ajiparently had fed well on the fowl, but it is evident that, unless the observations are
very numerous and extended, fallacies niay occur.

More work has recently been accomplished in this iliiection and the above result
has to some extent been confirmed. The longest period I have, so far, by ordinary
staining methods, found the parasites to persist in the tick is nine days. This occurred
in the case of ticks brought me from .Tebelin on the White Nile, some 122 miles south
of Khartoum where the fowls were ill. These ticks had last fed nine days before
examination, and in the Malpighian tube of one of them I found a solitary spirocha-te.
Examination of the coelemic fluid proved negative. It would appear, therefore, that
there is no such development as Prowazek described for Fip. (jaUinaruiii in Jn/r(.v
mlniatus in Brazil. It is interesting to note that the earlier work of Borrel and
Marchoux- with the same strain and the same tick, but carried out under different
conditions, did not yield quite the same results as those obtained by Prowazek. They
found that if infected ticks, Argas miniatus, were kept at 15-20 C. the spirochiBtes
rapidly disappeared, so that after three to four days none could be found. If,
moreover, one then kept the ticks at a temperature of 35' C, even three months
later, the parasites speedily reappeared multiplied, and were found especially in the
salivary glands. It is possible that this observation derives special interest from the
account of a special life-cycle which we now propose to discuss.-'

' This and the preceding portion of the paper, suffers from the fact that when they were written, one
was working partly in the dark. Still, owing to this very fact, the records of raises pos.sess a certain value
and should \>c considered in the light of results hereafter detailed. There has not l>een time to re-write
the whole article. — A.B.

■- Borrel, A., and Marchoux. K. (Kclmiary 2:'), 19a'i), "Argas et Spirilles." ''. /,'. Sue. ItwI. T. ."18.

" I have since foimd, by the dark-field method, clumps of motionless sheaths in the contents of the
alimentary diverticula of a tick 19 days after it had fed on si)irochietal blood. There were no living parasites
present. The periplasts stained very faintly with Honianowsky but could be detected in a stained tilni. There
had been no multiplication of spirochiptcs. The tick had been kept at a temperature of 3" C.

SPIROCHa;TOSIS OP SUDANESE FOWLS 93

In tho second place, therefore, attention is directed to the series of observations
conducted on the lines of Leishman's' suggestive work on the peculiar chromatin granules
which he described as occurring in the tissues of 0. moubata fed on blood containing
Sp. duttoni. This work appeared after I had proved that A. persicus was a carrier of
the Sudan spirochsetosis of fowls, and it led me to investigate the matter with a view to
finding if the Sudan spirochsete underwent similar changes. Such I speedily found to be
the case, and, so far as time permitted, I have endeavoured to follow out Leishman's methods
of investigation. It has not, however, been possible to obtain as much leisure as I could
have wished. Still the following results have been obtained.

(i) Ticks (A. peisicus), either as larvae, nymphs, or adults, fed on chicks with acute
spirochastosis, exhibit peculiar chromatin granules.

I have found these in the ovaries, eggs, oviducts, alimentary diverticula and salivary ■■ Granules" in
glands of the ticks, but more especially and in greatest number in the Malpighian tubes. -"'•/"•"Vw
Sir W. B. Leishman kindly examined my earlier preparations and assured me that the
granules, save in some minor particulars, are identical with those found by him.

In carrying out experiments to illustrate this point my difficulty has been to find ticks
free of these granules. Spirochsetosis is so common and widespread in Khartoum that
ticks without these granules in some portion of their tissues are the exception. Again, as
Leishman points out both in his first- and second^ papers, " conservative surgery in the
case of a tick is unfortunately impossible," and hence "whatever conclusion one arrives at
as to the condition of a given batch or brood of ticks, must be founded on the examination
of a sample of such batch. However large the sample, and there are obvious limits to this
where it is desired to follow up the course of subsequent events in such a batch, any
conclusion is open to the objection that a diiferent condition existed in a member of
the group which was allowed to survive." It is, however, possible, without killing a
tick, to obtain coelemic fluid by amputating a leg, while the contents of the alimentary
diverticula can be obtained by snicking the edge of the body. The tiny wound, as
a rule, heals rapidly. I fear I was unable, through sheer lack of time, to make my samples
as large as Leishman's, but I did my best, and in this and other work of a like nature
I think my controls have been sufficient, for, like Leishman, I have examined a great
many ticks in all stages of their development. For the reason above stated it is not
easy to say how long a time elapses between the ingestion of spirochsetal blood and the
appearance of the granules in the place where they are most easily and constantly
demonstrated, the Malpighian tubes (Plate IV., fig. 1). We have seen (page 92) that
the spirochsetes themselves do not appear to persist in the tick for a longer period
than nine days under ordinary laboratory conditions.

I have found granules within two days of the date of feeding, but cannot be sure that
they had not been present before. Until one obtains, by breeding or otherwise, a plentiful
supply of granule-free ticks this question cannot be settled.

As regards the granules themselves, the best idea of their structure and arrangement Tendency of
will be obtained from the coloured drawing (Plate III., fig. 1), where they are shown both 'he grannies

to form

in the tissues and lying free. In both situations the tendency to form clumps is very ■■clumps"
marked. The individual granules are small, usuallj- coecal-shaped, though frequently
irregular in outline and, not rai-ely, appearing like small bacilli. They are so minute that

' Leishman, W. B. (February, 1909), " Prelimiuary Note on Experiments in Connection with the
Transmission of Tick Fevers." Journal uf tin- Rmjal Army Medical Corps, Vol. 12, No. 2.

- Loc. cit.

■' Leishman, W. B. (.lanuarv, 1910), " Observations on the Slechanism of Infection in Tick Fever and
on the Hereditary Transmission of Hpirochieta Duttoni in the Tick." Transactions of the Society of Tropical
Medicine and Hu'jiene, Vol. 3, No. .3.

9i SPIROCH.ETOSIS OF SUDANESE FOWLS

it is impossible to make out any dofinito structure, hut it is concoivaljlo that uauli contains
what answers to a nucleus and possibly also some tiny granule corresponding to a
blepharoplast. Examination with the highest powers (oil immersion l/12th, comp. oc. 18,
with appropriate tul)o length) has only enabled one to note that some show points which
stain more deeply than their general substance. They take on tlie chromatin colour
strongly and exist in enormous numbers when the infection is at all severe. Tiiis is
especially true in the Malpighian tubes, in the tissues of which they lie in densely-packed
clumps, though the irregular distribution mentioned by Leishman is strongly in evidence.
Wlien the tubes are ruptured on the slide the clumps adhere in masses or break up into
single agglomerations or into the individual t^'nuiuh^s of wiiich tiiey ai'e com]ioscd. It
is then seen that these latter vary greatly in size as well as in shape. In some of the
free clumps every individual granule can be clearly seen, others arc (juite dense and
dark, and suggest tlie presence of a stained matrix Imlding tlic granules together. The
appearance, however, may merely be due to a somewhat diffuse staining. Like the
granules themselves the free clumps vary greatly in size and shape. The smaller ones
are often the denser looking. Some are very large and groups of these may occur
})aeked close together, but with the outline of cacli absolutely distinct, altlmu'.'h tliere
is no evidence of any retaining membrane or capsule. The chromatin colour is niucli
better marked in the liberated clumps and granules than in those lying in or on the
tissues, for in the latter case the blue background (Leishman or Giemsa) tends to
obscure them. It is well, therefore, in every case to lacerate the tissues on the slide
before fixing and staining. The granules show up well by the dark-field method, present
an active, dancing movement and closely resemble the red cell inclusions of fowls in the
earlier stages of the latter.
Thp granules (ii) If ticks containing granules are kept in the incubator, at 37° C, in the manner

assume a devised by Leishman, the granules mav be seen to undergo a change and to assume a

spirochaetil "^ " i . i. . i t ■ ■

form in ticks spirochsBtal iovm. This is confirmatory of Leishman s observations on iS/j. ihilli'iu in
kept at 37' C. q jfioubata, though I am not certain that the change is precisely similar or takes place in

the same position. Moreover, I have some evidence to show that, at the high summer

temperatures prevailing in the Sudan, this change may occur, at least to some extent,

without the use of the incubator.

Example :

March 16, 1910. Batch of ticks (-•/. persicus) oljtained from a fowl-nm and lieu-house iu Khartoum.
Samples examined were; found to be heavily infected with granules. These were specially evident in the
Malpighian tubes, and it was also found that in this situation the granules had apparently undergone some
development, the weather, at the time, being very hot. In addition to granules, short rods, comma forms,
and what suggested minute though stout spirochietes. were present.

iMnrch 21. Ticks placed in the incubator, at 37° C, along with a dish of water to keep the atmosphere
moist.

Mnreh 29. One adult 9 removed from incubator and examined. Tn the llalijighian tubes there was
certainly an appearance which might be construed into a development of young spirochsptes from the
granules. A few half-develo])ed eggs were removed from the ovary, smeared sejjarately on slides, and
stained. Some showed an excellent granule infection but there were no yoinig spiroclurtc forms.

The alimentary diverticula and contents exhibited no granules or spirocha-tes. rerhajjs this was duo to
tlie fact that 13 days, at least, had elapsed since feeding.

Small but numerous granule clumps were seen in a smear of the ovary and two small clumps were
observed in that of the salivary glands.

April 4. Adult <J e.xamined. Malpighian tubes alone searched. Heavy granule infection and undoubted
evidence of development and change into young spirochirte forms.

April 13. Adult 9 examined. Malpighian tubes showed tlie above change still more marked.
Undoubted spirochicte forms present. The same change, though not so mui^h in evidence, was found in
certain parts of the ovary smear.

The oviduct, which contained spermatozoa, and the salivary glands showed no granules.

April 14. Two ticks taken and an emulsion made from their salivary glands. This was inoculated
into a healthy cock of our own breeding. Up till April 18 the result was negative. The next examination
was made on the •23rd, when the cock was found to lie suffering from spirochietosis (iiVc pnije 9,'i). On the

HPIROCH.KTOSIS OF SUDANESE FOWLS 95

same clay, n hualthy hcii uf our own breeding was inoculated with au omulsiou of the ovary and eggs of
cue of the ticks. The bird developed spirochsetosis on the 20th, and rau a mild course. The second
tick was a male. No granules were found in its testicles or spermatozoa.

Jimc 11. Adult 6 dissected, and Malpighiau tubes and testicles carefully examined, with entirely
negative results.

June 28. Three young males dissected, an emulsion made of their Malpighian tubes, alimentary
diverticula and testicles aud inoculated into a chick which showed a few intra-corpuscular bodies. Previous
examination of the Malpighian tulies had shown the presence of granules.

On July 2 this chick, which was carefully protected ft-om any other source of infection, exhibited
spirochsetes in its blood {ride tiifrii).

The young spirochsetes were like those described by Leishraan for ,S'p. ilidtoni in (I. iiumbatn ; shorter,
more homogeneoiis aud less regularly curved. I noticed that they took on more of a red than a violet or
purple hue when stained by Komanowsky. Indeed, their staining corresponded to that of the granules from
which they appeared to develoj].

Leishmau found his forms apparently actually in the cytoplasm of the cells lining the tubules and the
intestinal diverticula. I have not seen any in these situations, but they may have been freed from the cells
in the process of making the smears.

(iii) Chicks inoculated with an emulsion of crashed larvae, showing these granules
hut no spirochaetes, develop acute spirochaetosis. The same is true of birds, both chicks
and fowls, inoculated with emulsions of washed tissues or eggs from ticks containing
these granules. In some instances, in the ease of chicks at least, free spiroehtetes are
the first to appear in the blood, followed by bodies later ; in otlier cases the bodies
have first of all developed and either persisted unaccompanied or been followed by free
spirochaetes. It is of sjiecial interest to note that whereas a first inoculation of this
kind may prove negative, a second inoculation carried out after the material has been
kept for several days at 37 C. may prove successful.
Kmmph.s. Chick. Very young, clean bird.

.)/(!(/ 24, 1909. Inoculated with an emulsion i^repared from a batcli of 40 young tick larvo?, a few days
old. Samples of same batch of larvae showed granules but no spirochetes.

Mai/ 28. Spirochifites found for the first time. (The bird had lieen kept in a siiecial sterilised cage
protected from tick or other insect bite.)

May 29. As above. No increase. No bodies seen.

Increase of spirochsetes. Tangles forming. No bodies observed.
The crisis has occurred and the blood appears to be wholly free.
No spiroehffites. A few bodies present.
As above.
As above.

Recurrence of spirochsetes. Present in large numbers aud forming tangles. No bodies seen.
Spirochsetes appear to have again quitted the peripheral blood. Two large films carefully
Only a few bodies present.
This blood condition continued till .lune 14, when the chick was found dead.

Two other good examples (cock and hen, page 94) have just been mentioned. In both, the ticks had not
fed at all for at least 28 days. Both birds recovered after passing through a transitory leukfemic state.
Another and even better example is that of the chick [pitge 951 inoculated successfully with the tissues of
three male ticks, for these ticks had not ted at all for no less than 103 days and yet were in an infective
condition, the incubation period being five days.

In the cock and hen, intra-corpuscular bodies did not ajjpear, nor were they found in the chick
inoculated with au emulsion of larval tissues. They occurred, however, in small numbers in the blood of a
clean chick inoculated with an emulsion of tick eggs showing granules, and the two following cases
demonstrate their appearance in the blood, in one instance before the spirochfetes. in the other, synchronously
with them.

('/lid:. Clean bird.

M((i/ 25, 1909. Inoculated with an emulsion of washed llalpighian tube tissue which showed granules
liut no spirochaetes.

Jf)fil 26. Bodies present in considerable numliers. It seems scarcely possible that they had been missed
in the pi-eliminary examination, and yet their rapid appearance is remarkable. They continued present till

JAr// 29, when spirochaetes were found for the first time. Some were short, otliers coiled and in loops.
A well-marked increase in the number of bodies was noted.

.)fii!l 30. Spirochaetes more numerous to-day, while the bodies appear to have diminished in number.
Mdi/ 31. No bodies found even after prolonged search. Spirochaetes fairly numerous.
No spirochaetes. a few bodies.
As above.
As above.

Recurrence of sjiirochaetes in large numbers. Tangles present.
As above.
Crisis. No spirochaetes. Bodies present and many ■• spore " forms.

May

30.

May

31.

June

1.

June

3.

June

5.

June

e.

June

7.

searched.

June

1.

J tine

3.

June

5.

June

G.

June

/ .

June

8.

96

SriHOCH.ETOSIS OK SfHANESE FOWLS

Significance
of the experi-
ments

Ornithodoros
savignyi

I jrainiln
infection, Imt
not spiro-
chiEtosis,
apparently
transmitted liy
O, iavignyi

June 9 to 13. As above. Bodies persisted.

June H. Died. Nothing to note post mortem.

Chick. Clean bird.

AWni/ 25. Inoculated with emulsion of washed and crushed oviduct tissue which showed ffranulcs only.

Mill/ 29. Spirochirtes found for the tirst time. After a loiii; searcli a few very small bodies discovered.

.1/(11/ 30. Marked increase Injth in spirochii'tes and IkkUcs, and ap|)earances certainly suK^estive t>f
invasion of the red cells by the former (Plate III., tig. 7). Some of the liodics are i|uitc lar^fc and
appro.xiinate to '"spore" forms.

Miiy 31. Both present but not ipiite so numerous.

Jiive 1. A few spiroeha>tes but a large number of bodies. Multiple infection of red cells observed.

June 3. No spirochoetes. Bodies more numerous and an increase in multiple infection.

June 5. A very heavy infection with bodies. No si)irochietes.

June 6. Infection not so great. No spirochetes.

June 7 to 10. As above.

June 11. Died.

These cases are highly interesting, not only from the point of view of the infectiveness
of tick tissues containing granules, hut because tliey appear to demonstrate, beyond all
doubt, a definite relationship between the spirochaetes and the erythrocyte inclusions.
One has several other records which need not be detailed.

(iv) If batches of ticks, samples of wliich are found only to show granules in their
tissues, be fed on clean chicks, such chicks, after from two to four days, may exhibit, not
spirochaetes, but the corpuscular inclusions. It is scarcely necessary to give examples,
and in any case the observation requires confirmation, as only a few observations were
made in this direction. Its possible significance has already been discussed.

The following furtlier points appear to me worthy of consideration and experimental
work, l)ut so far I have not been able to pay attention to them. It will be seen that,
in part, they are suggested by Leishman's able research.

L The tracing of the development of the granules in eggs, larva? and nymphs.

2. An investigation of the excretory fluid of .1. peisicns and inoculation experiments
with it. This tick, however, feeds best at niglit and does not excrete a copious discharge
like Ornithodoros.

3. The feeding of uninfected ticks on chicks showing bodies only in their peripheral
blood. As noted it is not easy to obtain ticks wholly devoid of granule infection.

(4) This brings us to the work with O. sariijinji, the human tick of the Sudan.
I do not intend here to enter into the question of the curious rod-shaped liodies
which I found in the organs of these ticks, and to which allusion has already l)een
made (ride pa(je 80). Captain Mackie, I. M.S., to whom I had the pleasure of showing
them, told me he had seen similar appearances in tsetse flies.

One will only consider the relationship of (I. savignyi to onr fowl spirochictosis.
I have carried out work with this tick moie or less on the same lines as with A. prrfirua
and have decided tliat it is not a true host of the fowl spirocha'te. The parasites may
be found, either granular or tmaltered, for 4 or o days in their alimentary diverticula'',
hut the special granule infection does not occur as in the fowl tick, at least on a large
scale, nor have I found spirochaetes elsewhere in the ticks. Moreover, I have never
been able to give a chick spirochetosis by allowing O. snrignyi, which had jireviously
ingested blood from an infected bird, to feed on it, even when the ticks had. in the
interval, been kept at 37" C. I have, however, fed O. mriijnyi on chicks showing good
"after phase" infections, and by means of them apparently induced a i)ody infection
only in a clean chick, or a great increase in llic innnber of bodies in a chick which
was not clean hut harboui'c^l a few of the inclusions. Nothing was found in samples of
the tick batches examined, and, unless I mistook some other' corpuscular condition for
the supposed spirochaete inclusions, it seems difficult to explain these results, unless.

SPIEOCH^TOSIS OF SUDANESE FOWLS 97

indeed, one adopts the viow that the few bodies ingested broke UX3 into granules which,
thougli they did not nmltiply, were yet infective in that they were capable of invading
the red cells of any chick into which they were injected, and then undergoing their cycle DifiicuUy in
of schizogon\'. Perhaps sufficient tests have not been made and a certain proportion °'''^'"'"g

^ ^ O. savigfiyt

of O. savignyi may yet be found effective as regards spirochsete transmission. These ticks
have to be brought in by camel from an oasis some hours from Khartoum or sent by
post from Kordofan so it is not always easy for me to have a good stock in hand.
(The above supposition is probably correct as more recent work shows that the spirochaBtes
undergo the same preliminary changes in this tick as they do in A. persicus — they
shed granules.)

(5) Can fowl lice (Menopon sp. ?) act as vectors'? If one could prove these ecto-parasites
to be carriers, yet another link would be established in the chain of analogy between
this variety of fowl spirochsetosis and certain forms of human relapsing fever (Indian and
North African). This has now been done. My earlier experiments were either negative or,
like the observations recorded in the Journal of Tropical Medicine and Hygiene of October 1,
1909, gave only indirect proofs. In this case lice were fed on a chick heavily infected
with spirochtetes and transferred on March 1, 1909, to a healthy, clean bird, which
was carefully protected from tick infestation. Owdng to press of other work this chick's
blood was not examined till March 5, when its red cells were found to harbour
bodies, no spirochaetes being found. It was chloroformed and an emulsion of its
liver inoculated into a third chick, which, unfortunately, w'as not a clean bird in that
it showed some bodies, but it happened to be the only chick available at the moment.
Examination of the liver of the second chick by the Levaditi-Manouelian method proved
negative as regards the presence of spirochfetes. What happened in the third chick is
interesting. On the day (March 6) following the inoculation of liver emulsion a huge
increase in the number of bodies took place. On the same date some drops of its
peripheral blood were inoculated into a fourth chick ; it was chloroformed and an
emulsion of its liver injected into a fifth chick. This fourth chick, which is the chick
mentioned on page 82, developed bodies eventually, died, and its liver was found to
contain spirochaetes. It may be said that the fifth chick also developed bodies and
died, but no spirochaetes were found in its liver. The weak link in this chain of
events is, of course, the fact that the third chick was not a clean bird. Still, the
results were suggestive, and made one think that lice might act as vectors.

Eecently, Captain Archibald has carried out some experiments which, I think, Fowl lice are

definitely confirm this view. Here is one of them : — vectors

Junaitrn 10, 1911. Lice removed from a healthy fowl aud jilaeed ou a chick showing a heavy
spiroehiete iufection. No bodies present.

Jaiiu'inj 12. Lice removed from the infected chick aud placed ou a healthy clean chick. Every
subscciucut day this operation was repeated up to Jctiiimnj 14. Some tweuty lice in all were used. Blood
e.Kamiuations negative till

Jniitftrji 16, when a few spiroehietes were found in the blood of the chick on which the successive
batches of lice had been placed.

Jaiiadnj 17. Heavy spirochaetal iufection.

This bird eventually recovered without at auy time showing intra-corpuscular forms in its peripheral
blood

An experiment of this kind does not of course determine the incubatiou period after louse-bite, but a
subsequent case supplied this information.

Jammry 17, 1911. Two dozen lice from a chick suffering from acute spirochastosis placed on a healthy,
clean chick, which was protected from tick bite. Daily blood examinations proved negative until
Januarii 22, when the bird was found dead with spirochsetes in its heart's blood. The incubation period
would, therefore, seem to be about four days.

Examination of the lice from this chick proved entirely negative both as regards the presence of
spirochaetes aud of granules, and in this respect resembled all previous examinations of lice. Hence

98 SFIKOCHJETOSIS OK srUANESE FOWLS

I am pLTsimdi'il the lii'i- act mtTcly a» iiR'rhaiiical traiiMiiittLT.-, ami 1 du not think thuv play any great part
iu till' spread nf tlio disease. It is true, however, that more dis,sectious are reniiired, for one should not
geiienilise on a eoin])iinitively small numl>er o£ oliservations.

Pigeons not (6) Pigeons do not seem to be susceptible to this form of spirochsetosis, as proved

susccpii ic jjy several inoculation experiments. Intra-corpuscuhir bodies have never been found in
the blood of these birds, nor have they ever been found sutt'ering naturally from
spirochtetosis, although kept in close proximity to infected fowls, and, no doubt, frequently
bitten by infective fowl ticks. This tends to show that the Sudan spirochtEte is a specific
entity or at least that it is not Sp. iiiarchou.ri. I have not been able to carry out the cross-
inoculations advocated by Laveran for the determination of specificity in trypanosomiasis
and in any case I doubt the value of this method in spirochastosis. Possibly Levaditi's'
new "attachment method" may find a use in the latter form of infection.

As mentioned in our Third Keport, geose are susceptible to the disease. They suli'er
from it naturally, and of special interest is the fact that in them the corpuscular inclusions
are associated with the spirochaites just as in fowls. Indeed, it was the presence of the
former in geese that led me to look for and find the latter, and so prove the condition
to be a spirochastal septicaemia.

Dr. Wenyon also found guinea-fowls on the White Nile suS'ering from spirochaitosis,
but did not observe any inclusions in their red cells.

I was not able to procure any ducks, and it scarcely seemed necessary to inoculate
wild birds on a large scale, as it would have served no useful purpose.

However, a water-wagtail, Motatilla alha, was obtained, and received an injection of
spirochaJtal blood on January 25, 1911. Nothing was found iu the blood up to January 28,
on the morning of which day the bird was found dead. No spirochtetal infection found.
A small bird, I'asser rufidorsalis, the local species of house sparrow, also gave a negative
result. Here, perhaps, one may mention that further oljservations on gerbils prove them
to be immune to infection.
Blood changes (7) Blood changes ill infected chicks. Some of these were mentioned in our Third

Eeport, and I do not think there is umeh else to record. In the accompanying severe
amemia the red cells may be greatly changed and, in smears, may be found spindle-shaped
and niiims their nuclei. As mentioned in the paper on Blood Fallacies (pnyi- 115j, the
leucocytes may, as a result of degeneration, show most curious changes. Kurloff's bodies
and plasmosomes are sometimes found in them and myelocytes nmy be present in the
blood. Fleeting leukccmic conditions are not uncommon as are increases in the number of
the thrombocytes, which are sometimes found in huge masses. These interesting cells may
also contain inclusions. The latter may be the " deeply staining (deep purple with Wright's
stain) bodies about the size of, or somewhat larger than, a mast cell granule " mentioned
by Burnett, and which he believes to be a sign of degeneration. I do not know what they
are and have but rarely seen them. The same is true of the large rose-pink bodies found
in the leucocytes of chick V. (pui/e 87^.

(8) Tlierapeulic measures. — In the Sudan, at present, these can only, I fear, iui\e
a scientific interest, for the native, who alone keeps and breeds fowls on a large scale, is
so careless and apathetic that he would never trouble his head about prevention or
treatment. If his fowls die, it is the will of God, if they are ill and recover, to Allah be
Treatment the praise, and this fatalism is hard to overcome. As an example one may mention what
occurred when, in order to try and get the fowl vendors in the Khartoum market to mend
their ways and to look after their birds, one ofifered some substantial (from the native

■ IiCvaditi, C, and Mutermilch, S. (1910), " Diagnostic dcsTrypauosomiatiCS par Ic Phcuoni^ue de rattacbineut."
Ctmpt. Jlend. Soc. Biol., Vol. LXIX, No. 3S.

in infected
chicks

with ■■ l!OG'

sriKOC'H.ETOHIS OF SUDANESE FOWLS 99

point of view) niouej- prizes for the best kept and finest fowls. I was, myself, asked to
be the judge, and found, amongst the avian candidates, one hen dying apparently from
acute spirochietosis, one cock without a leg, several other deformed birds, not a few
infested with vermin, and none that in any civilised country would have been considered
for a moment. The only wonder is, that cases of acute enteritis and fowl diphtheria
were not likewise present !

I fear, therefore, it will be a long time before the ordinary native takes any real
interest in veterinary medicine, and there is, at present, a lack of machinery for educating
him in its principles and for pointing out how he might benefit by taking an intelligent
and enlightened view of western advance in such matters.

So far then one has been unable to carry out any scheme whereby the serum of
infected birds freed from spirochaetes, or that of recovered birds, might be tried (possibly in
vain) for preventive inoculation or where atoxyl might be employed as a curative remedy.
The work with orsudan, mentioned in our Third Report, was brought to an untimely end
by the fire in the laboratories and has not been resumed. As I was thinking of testing
the effects of atoxyl, which, both as atoxyl itself and as atoxylate of mercury, has been
found to be specific for the Brazilian septicaiuiia of fowls, "606" appeared upon the Experiments
scientific horizon, and, on reading about its great efficiency in avian spirochaetosis,
I determined to test it on the Sudan disease and also to see if it woidd help in clearing
up the question of the true nature of the intra-corpuscular bodies.

Professor Ehrlich, to whom I wrote, most kindly and generously sent me a good supply
of the drug, and though there has not been time for any extensive series of observations,
the following results may be recorded : —

1. Effects on SpiRocHiiTES

JitiiiKirii H, mil. Young fciwl weighing 4'20 grammes sent from the market and found to l)e suffering
from spirochietosis. It was evidently at the Ijegiiiuing of an attack and was not very ill, but showed
about one sjjirochBetc in everj' half-dozen microscopic fields examined (Of. 1.. oil imm. i/l'2th Leitz).
The bird's skin was hot and it was evidently fevered.

Janunrij 25. Infection found to have considerably increased over-night. Spirochaetes numerous and
forming small tangles. Given ■001 gramme ''600" rubbed up with sterile olive oil and injected into the
muscles of the thigh.

JiiiiUJirii 26. Blood found to be quite free from spirochastes. Bird apparently well and fairly lively.
Spirochsetes never reappeared, but on JintKari/ 30, bodies were found for the first time. The infection
was slight. Some were merely tiny granules, others snggested diplococci and others again, though small,
were of the usual ring form.

Ffbruriri/ 1. Increase in number of bodies. Ring forms increasing both in numbers and in size.

Fehriuiry 4. Increase still continuing. Multiple infection of red cells observed.

FebniJirii o. Infection now very heavy. Multiple infection common. All stages from the tiny
granule to the large "spore" form seen. Small and large forms together in the same corpuscle.

The course of this case suggested that, in addition to freeing the peripheral blood of spirochsetes,
the drug had broken up these latter in the internal organs into infective granules. These had then,
invaded the red cells and proceeded to develop in them, finallj' undergoing a true schizogony with the
formation of merozoites.

It would perhaps have been lietter not to interfere further with the ]jrocess but merely follow up the
case. For better or worse, however, one decided to administer more "&)(}" and on this date about
"002 gramme was given.

Februiinj 6. The red cells stain badly but the bodies are very distinct. Though not less numerous
they appear shrunken. A few " spore " forms visible.

Fibruiirii 7. Distinct diminution in number of bodies. Some of the red cells have spherical holes
in them as if the bodies had fallen out of them. Slultiple infection still present.

FibriKiri/ a. No change, so another 002 gramme "606" given. Weight = 372 grammes.

Fibrttary 9. A very marked decrease in the number of bodies. No multiple infection seen. The
few bodies persisting are small. No gaps or holes seen in red cells.

Ffbrwinj 10. Blood very watery and anaemic but bird well. Still further diminution in the number
of l;odies but a fair number persist.

February 11. No change.

February 12. Possiblj' a slight increase in the bodies. Weight — 403 grammes.

ICK) SllKOCH.ETOSIS OF SlUASKSE FOWLS

Fthniarij 15. As l>y tiiw ((ate no marked chauge had oiviirrfd tliu f<iwl was fhlortpfornied. Weight -4ii4
gmmiucs. Post morteiu iiuthiiig siK-oial was found. Kiliiis of liver, spleen and lung juice examined i>y the
dark-Keld method but no spirochii'tes found. None found in stained smears.

Levaditi sections showed some granules iu the liver, (xfurring chielly in groups and in the cjipillaries
hut they were luit a marked feature. The lung and s])lcen exhibited a somewhat similar ap|)eaniiiee.
In the latter black grannies were numerous though I do not think they were derived from lirokcn down
spinK-hietes. It is not easy to differentiate granular conditions met with in sections stained by the
unmtiditied Levaditi method. No spirocha^tcs were found.

Jiiniiiirii "io, I'Jll. Small ehick. wcighiug 80 grammes only, showed on this date the first signs of a
spinx:hictal iuteetiou following a lalionitory iuo<Milatiou. A very few spiroehtetcs present iu each film of
Iioriphcnil blood. Given alraut •OWJ.i gramme "606" a.s in former case.

Jnniuirii 26. Blood free from spirochajtcs. Those iu the blood had lieeri driven out of it while increase
of the infection h.id been checked. The bird, however, did not look very well, its feittbers being ruffled
and its wings drooping.

.liiHimrij 27. Found dying. No spiroehaetes were found iu blood from tlie heart and lungs. Desith
may have beeu due to their sudden destructiou or the lethal action of the drug on the chick itself or to
the effects of a sudden drop in the temperature of the laliiPRitory.

Liver, spleen and lungs examined by the Levaditi methotl.

In all the sections, l)ut more es]x;cially in the liver, there was found a remarkable apixjanmce of
gmnulcs closely resembling those fouud iu ticks though, of course, they had not a chromatin colour. They
occurred scattered all through the ti.ssues and were evidently not stain dejxjsit.

In order to compare these granules with those found iu ticks I stained a jwrtion of the ^lalpighiau
tulxjs of a female .Injus jirrxinis, heavily infected, by the Levaditi method and fouud the appearance
presented precisely similar to that shown by the chick's liver sections. There can therefore, I think, be little doubt
as regards the spirochx'tal origin of the granules in the latter, and any considenition of their l)cing due to
stain deposit or to the jwculiar granular condition sometimes found in a))]>!ireutly nornuil tissues can, I think,
l)e excluded. (Further work in many other cases has amply confirmed this view. The granules fouud are
Hudoul)tedly derived from spirochietes.)

Fcbruitrii 20. Fowl. Weight = 741 grammes.

Fair spirochtete infection. Small tangles in the blood. Given 0025 gramme '" 606 " iu oil subeutAucously.
.\ blood film taken 5J hours afterwards showed a great diminution in the numljer of spirochietes. Only a
few were found after a long search.

FrhriKini 21. Bird fouud dying about 7 a.m. No spirocha;tes in the jieriphcral blood. Died at 8 a.m.
Smear from liver, spleen and lung showed neither spirwhajtes nor granules, liut some suggestive looking
granules were seeu in liver and spleen juice examined by the dark-field method. It is, however, impossible
to distinguish the numerous particles which are seen iu such preparations.

Liver sei:tions prepared by the Levaditi method showed granules like those in the small chick which
died .January 27. In the spleen there were degenerated or necrotic areas which also showed granules though
these may uot have been of the sjime nature as those iu the liver. Lung sections showed nothing definite.
There were no spiroehaetes.

Februtiri/ 'i'3. Chick. Weight = 62 grammes. Fair spirochEete infection. Given 0002 gramme " 606." The
infection had a severe effect, the bird rapidly becoming ill with <|uickened respirations, drooping head, closed
eyes and ruffled feathers. Was this due to sudden lil)cr!ttiou of toxines ? Si.x hours after the injection a
few spirochetes were still present in a blood film made from a wing vein.

Fibniiiiii 24. Found dead, liut not yet stiff, in the morning. No spirochajtes in heart's blood nor iu
liver, luug and spleeu smears. No granules or corpuscular inclusions seen. Levaditi-Yamamato sections of
the internal organs, however, showed the usual general granular condition. In the lung sections there also
appeared to be fragments of spiroch;etes or of periplastic sheaths.'

The next case is of considerable interest.

Fflni'irii 23. A fowl which had been brought in from the market exhibiting only Ixidies was fouud on
this date to he harlxjuring spirocha-tes as well iu its blood. It weighed 6.'W grammes and was given 002 gramme
of " 606 " subcutaneously.

Fr.hninty 24. No 6piro<.'haetes found in peripheral blood. A distinct diminution in the number of bodies
but little, if any, change in those present.

Frhrwxni 25. No spiro<.-haBtes. Bodies much the same (iiveu 00.3 grammes "'606."

Ftbnutnj 26. No spiroehtetes. Increase in the number of bodies and increase in the size of some of
them. Bird fairly well, but weak in the legs.

Fcbrunnt 27. As above.

Frhnuinj 28. "Spore" forms present to-day. Al-so multiple infection. Some early granule forms also seen.

.\fnrch 1. More early granule forms to-day. Not many "spore" forms. Multiple infection still jwrsists.

ilitrch 2. Increase in numlx;r of )x>dics. It would seem as though the snuill granule forms have taken on
the ring shape and that the previous ring forms have increased in size and arc approaching the schizogony
stage.

March 3. More large " spore " forms to-day. Some with " exit gaps." Small ring forms also present.

March 4. No change noted from yesterday.

Mnrch 5. Found dead. Heart's blood as above. No spirochcctes found iu liver juice by the dark-field
method.

An examination of sections of liver, spleen and lung stained by the Levaditi method shows throughout a
fine granulation which suggests a spirochaital origin. No spiroehtetes found.

' In a later very interesting c.ise, not only w.is a typicsil granule infection present, but in liver sections
spirocluetcs, or rather spirochaetal sheaths, could be seen with similar black granules in them.

SPIKOCHiETOSIS OF SUDANESE FOWLS 101

There is, I think, no need to multiply the records of cases; "606" in sufficient Results are
doses can certainly banish spirochictes from the peripheral blood and in certain instances f*™"'^*'"'^
absolutely cure the bird. In other cases the granule phase supervenes on which the
drug has apparently only a limited effect and sometimes, possibly, none at all. This
question will be discussed immediately, and the nature and significance of the action of
"606" will be found dealt with in that part of the paper termed "The ilechanism of
the Crisis " (ride paye 102 j.

It only remains to be said that chicks are very susceptible to the toxic effects of
the drug, and that it is much more easy to cure adult fowls with it than the delicate
and immature bird which usually perishes from the combined effects of the infection and
the medication.

2. Effects on Ixtka-cohpusltlak Fokjis

In one of the earlier experiments, a chick with a heavy "body" infection was given
too large a dose of "606" and died a few hours afterwards. Apparently as a result
of the administration of the drug, while there was no diminution in the number of
bodies found in the heart's blood, they had undergone considerable change, breaking
up into " spore " forms, several of which were discharging granules from the red cells.

These granules were found lying free in clusters (Plate IV., tig. 3)T

It is perhaps scarcely necessary to give in detail the dozen experiments carried out
to discover how "606" affects the inclusions. It may be said at once, that, as was to
be expected, there is no rapid action on them as upon the spirochetes. In the majority
of cases, however, the drug seems to hasten the disappearance of the bodies. It is, of
course, difficult to say in any individual case that the disappearance is due either wholly
or in part to the "606" as the condition tends towards cure in many cases.

Still, when one finds a fowl with a heavy infection treated by the drug and its blood
freed permanently from the intra-corpuscular forms in the short space of eight days,
the result is suggestive. In some instances, as in the case recorded above, "606"
appears to hasten the breaking \i]i of the bodies into "spores" and the discharge of
the latter from the red cells. In such cases I have seen the infection increase, possibly
because some of the free granules escaped destruction and re-invaded the erythroblasts.
There is no doubt that they are much more resistant than the free spirochietes and The granules
this fact may yet throw- some light on the persistence of spirochaetal infectious in man. ^"^ "'°''<=

•' -^ ox- r resistant than

Death frequently i-esults in the case of fowls in the "after phase," or as one may now free spiro-
perhaps call it the " granule phase," when they are treated by the Ehrlich-Hata "^''*'^''
preparation.

It will be necessary to carry out many more experiments before the precise action
of the drug on the inclusions and the infected birds can be ascertained.

In some of the fatal cases the organs examined by the Levaditi method, and more
especially the liver and lung, showed rather suggestive clumps of little black granules
which may have resulted from the blood infection, but I am not prepared to be dogmatic
as to their origin. On no occasion was any appearance met with resembling the great
granule infection presented by the organs of the chick treated for acute spirochaetosis
by " 606."

The Mech.\xism of the Crisis

As Eevealed by the Dark-Field Method

I uow pass to some most interesting and suggestive work recently carried out and
still uncompleted, which, as already indicated in several places throughout this paper,

• For Plate IV., fig. 3 read Plate III., fig. 3

102 SI'IHOCII/TITOSIS OF MllANKSK FOWLS

lias, I lnlic\f, I'lfiiii'd u|) llic prolih'iii of this fowl spiroclia'tosis in a satisfactoi'v
manner. It will ho aijpari'iit that " 60(j " producus what may l)i' called an artilicial
crisis, and this jjave one an opportunity of discovering, more readily than one can
do under natural conditions, what happens to the spirochietes after the pei'ijiheral blood
Anificiiil has heen freed or nearly freed of them. For this purpose liver puncture was employed,

'•'"'''* anil at a later date well-infected chicks which had i)een -^iven a dose of "60(5" and

whose peripheial hlood no loii^'er harboured parasites or showed oidy very few of
them were chloroformed, and blood was ipiickly taken by means of asj)iration from
tin: liver, s])leeii and luu^'. If then a drop of liver juice be examined by the dark-
tit'ld method it will be found swarming' with spirochaites ami with highly refractile
granules. The source of tlic latter is soon apparent, for attention will be directed to
s])irochu?tes which are not moving in the usual way but are in a state of violent
cuntortioii or are, so t(.i speak, shaking themselves to and fro. Indeed 1 cannot give
a more apt comparison than by likening their movements to those ui dogs which have been
in water and are shaking themselves vigorously to dry their coats. The object of the
spirocha'tes, however, is to rid themselves of the ijright, spherical granules which can be
seen within tluiii and wliich may or niay not be aggregations of the so-called chromatin
core (Plate I\'., lig. 2j. These are forced along the periplastic sheath or cell membrane and
suddenlv discharged from one or other end of the parasite, so that they become free in the
medimii and dance hither and thither as tiny, solid, spherical, brilliantly white particles.
Granules In prt)cess of time the spirocluete loses its activity, becomes dillicult to see and eventually

shed from the jj j .^ ^^ ^^ ^^j j^. j^ ^j^^ y^ ^^^^ lifeless sheath drifting aindessly in the fluid and liable

to be caught up and swept away by some still vigorous parasite. Such a sheath may
still retain one or two of the granules which it lias been unable to discharge. As may
be imagined the process is most fascinating to watch and my observations have been
conlirmed bv Ca])tain Fry and Mr. Buchanan of these laboratories and by Major Knsor
and Captain ()l''airel, H..\..M.C'. I may also say that the lirst named had previously
seen a shedding-off of granules by trypanosomes in the periplieral blood of experimental
animals, a phenomenon which he is now studying

Tlic> same phenomenon is to be witnessed in films from the spleen and lung and

may yot be found to occur, under certain conditions, in the periplieral blood.' All

the spirochietes seen do not exhibit this granule shedding. Some will be found dead

and motionless, killed outright by the drug. Some look and move like ordinary

parasites but it is probable that in the long run these start the convulsive movements

and discharge granules, as if a him be examined after 24 hours it is customary to

tiiid no living spiroeluetes, only a few "shadow" sheaths with or without a few bright

granules in them. The spirochiEtes which exhibit these remarkable changes are easily

distinguished by their peculiar movements. These are not continuous. Between the

convulsive shakes the spirochajtes straighten themselves and lie motionless as if exhausted,

then all of a sudden they are again thrown into violent contortions during which very

often the granules can be seen shifting to and fro within the sheath. .\s a rule,

Changes in the however, they are driven towards one end and then by means of a final flicker set free.

spirot .xtei ^^ ^ rule, after expulsion of a granule, quiescence occurs, but this is not always the

shedding of case. Observation has to be both close and unremitting, as even in a very thin and small

granules ^[1^1 numerous free granules are usually already present and if these are in the

'Is it jxissiblu that the i;oecoid bodies described iu the blood of rclnpsiuK fever f«scs arc, iti reality, these
spirochetal xrouules ? I have now foiiud that the granule shcddiug does occur in the peripheral blood uuder
certain conditions.

PLATE IV

•

w

^iii *

/

#V

\.

i '"^M^

SpiROCHiexosis OF Sudanese Fowls

1. Malpighian tube of Af^as ^ersrcus showing granule iiiteciion

2. Chick's blood showing granules in spirochsctes
y. Chick's blood showing free granules

X 1000 ^//uf//.

104 SPIROCHETOSIS OK StnANFSF; FOWLS

noif^hbourhooil of the dischaitjiiig spirochieti- ii i> uliin \ii\ diflicult to sun il a yruiiiilf,
suddenly appeiii-ing, has actually just been ejected from tlie parasite, the more so as
the latter tends to lash and shake itself out of focus.

After the process lias yone on for some time the wiiole spirochitte appears shorter and

broader, more rihbon-like in fact, and this would appear to be due to a process of flattening

owing to loss of its central substance. It should be noted that under the conditions

' hans" i" mentioned the red cells are fragile and will often be found undergoing curious changes

the red cclli . , ^, ^, ,-t, tiih -i.i

givmg rise to what 1 have termed the chain, droplet, dumb-bell and filament phenomenon
(iKiijc 115 and Fig. 30) first described by Nuttall and Graham-Smith. The curious slender
motile tilanients might easily bo mistaken by the inexperienced for altered spirochistes
though the droplets or rings into which they disintegrate, owing to their low refractilc
indices, could scarcely be taken for the infective granules. It is highly probable that these
granules are derived from the chromatic core as, after their discharge, nothing but a sheath
which stains but faintly with Romanowsky remains unless, indeed, the shedding has not
been quite complete when granules are still to be seen inside the sheath (Plate IV., tig. 3).
At the same time it is a remarkable fact that the free granules themselves do not appear
to take on this stain. Only on one occasion have I found them faintly indicated. They
might easily have been missed. They are, however, readily coloured by the Levaditi-
Yamamato method and then appear as black, homogeneous, spherical dots scattered in
great profusion throughout the smear. It is possible that these granules possess an
aflinity to those recently described by Dobell' in Cristispira veneris. As noted, the
granules on being set free are very active. They dance hither and thither and
sometimes appear to increase in size. Beyond this change I have been unable to
discover what happens to them. I have never seen them enter red cells in prepara-
tions of the kind mentioned and they appear eventually to die in these cover-glass
tiluis. At the same time they require further watching in cases where the crisis
occurs naUirally and in ichicli, be it noted, precisely the same phenomenon occurs although no
drug /(«»• been administered.

So far I have not seen it in the peripheral blood, even in cases treated by "606,"
but my observations have been limited and unsatisfactory.'' In the case of a chick which
had passed the crisis nalurally on the previous day and whose blood was free of spirochaetes
Do the but was beginning to exhibit bodies, I witnessed what appeared to be the entry of a

fhe red cells? ^''^*'' g^'a^ule into a red cell. This was in a thin liver juice film examined by the dark-
field method and in which were many free granules and a few red cells containing
bodies. Certainly a bright granule invagiuated the cell envelope and apparently made its
way into the cytoplasm. It then became partly surrounded either by a portion of the
invaginated cell envelope or by a capsule of its own formation. As one was watching the
process with deep interest a sudden current in the film carried the corpuscle away nor could
it again be found. Major Ensor and Captain Fry, who were interested spectators of this
process, were both inclined to regard it as an entry of one of the granules into a red cell.
Certainly there can be no doubt as to the invagination, but it is evident that more
observations are required. (These have now been made on peripheral blood, liver, spleen
and lung juice and bone-marrow preparations, but as yet in vain.)

'Dobell, C.C. (A])ril, 1911), "Ou i.'riMUpira veneris nov. sp., and theatfiniticsandClassilicatiouofSpirochuites."
Quarterly Journal Microscopical Science.

• Since writing the aliove I have witnessed spirocbirtes shedding granules ejtaetl.r as described in a film of
blood from the heart of a very j'oung chick which had l)cen inoculated 3.3 hours previousl.v with blood from a
small chick just Ixifore the crisis, and which developed lx)th spirochsetes and bodies almost simultaneously after a
very short inculjation period Jless than 20 hours).

SI'IEOCH.ETOSIS OF SUDANESE FOWLS 105

There can, I think, be little doubt that it is indeed these granules derived from
spirochastes which enter the erythroblasts of the fowl in which, possibly because of some
capsule they secrete, they can be stained by the Eomanowsky method. They appear at first
as tiny specks and rapidly become the ring or large solid or irregular forms which have been
described and which pass on to the "spore " bodies, thus completing a cycle of schizogony
or a special cycle, which ends by the discharge of tiny granules (merozoites) into the
liquor sanguinis. As a result of these later observations I have abandoned the erroneous schizogony
idea, which I quite failed to prove, that the bodies are directly formed from the spirochaetes
and that the larger forms are the early forms due to the parasites coiling up and
contracting in the red cells. The supposition was perhaps pardonable as spirochetes can
and do enter and leave the red cells and the invasion of the red cells by the granules does
not appear to take place in any regular manner. There do not seem to be any
"generations" of bodies, all completing their cycle of development at or about the same
time. The entry and the maturation are apparently irregular as regards time and hence
a confusing picture is presented, J'oung forms, ring forms, and spore forms all occasionally
being present in one film. A study of some of the case records, however, would seem
to give some idea of the usual duration of the cycle. Perhaps renewed study of the
infection in the light of these discoveries will yield further information as to this non-sexual
cycle. What is its object ? This is not altogether easy to answer for one has not yet seen
spirochetes develop from the tiny granules set free by the rupture of the schizogony forms
in the red cells. True there are indications that this occurs but the mechanism of develop-
ment as yet remains unknown. Again only a certain proportion of the granules discharged
by the spirochaetes pi-obably enter red cells. What happens to the rest? From the study Bearing of the
of Levaditi sections they appear to be stored up in the internal organs. Is it from these observations
that fresh spirochaetes develop and does this in some measure explain the mechanism of ^ i,ocha:tai
relapse not only in this fowl spirochsetosis but in human tick fever ? Does it also perhaps infections
throw light on the chronicity of such disorders as syphilis and j'aws? The granules
discharged by spirochaetes are resistant, much more so, I think, than the parasites from
which they come. One can cure a fowl entirely by "606," presumably by killing all the
spirochaetes in it outright. If, however, too small a dose be given, granule discharge begins
and unless the amount of "606" present is sufficient to kill these infective granules, the
cycle of schizogony starts, just as it starts under natural conditions if the leucocytes or the
protective fluids or anti-bodies of the bird have not proved powerful enough to destroy
all the spirochtetes.

It would seem to be a protective process on the part of the parasites and may
also be connected in some manner with the cycle in the tick, but it is little use theorising,
and the various questions to be settled will have to obtain their answers by the
application of these newer methods and bv prolonged and careful observations.

■ ^ " Importance of

It would seem probable that these infective granules have not previously been noted, the dari<-ficki
partly because they can only be well seen by the dark-field method and partly because '"''"'°''
when free they do not appear to stain, at least with any certaioty, by Eomanowsky.
This is a very curious thing, but it would seem to be undoubtedly the case.

The fact that one is apt to get stain deposit by the Levaditi process and even by
its modifications adds to the difficulties of the work, which in any case has shown that
it is by the study of the lii-imj parasite that progress is chiefly made. At the same
time the Yamamato modification, slightly altered, has been of signal service.

As this paper has to go to press, it is only possible to indicate along what lines further
work is proceeding.

IOC

Sl'IKOCHJITOSlS OF SdnANESK KOWLS

The Sudan
spirochete a
specific entity

(1) A mini' cxtoniled study of liver, spleen aiul hiii^' blood by the diirk-lield method in

cases at and foUowinf^ the crisis, to sec if tlic entry of grannies into red cells can

be confirmed.'
(ii) An cft'ort is beinj; made, by using tlie dark-lield method, to discover wliat becomes

of the tiny nierozoites set free from the red cells,
(iii) In the same way observations will be conducted on spirochiutes ingested by ticks

to see if they participate in granule discharge.- Tlie development of the Leishman

granules in ticks is being studied by the dark-field method. So far it would seem

tiiat a meal of blood hastens the change into spirocluetal forms,
(iv) The changes, if any, undergone by iiitra-cor])nscnliir liodies ingested by ticks will be

studied in a similar manner. '
(v) The infectivity of the peripheral Ijlood, and jiossibly also thiit of I In- lilooil of the

internal organs of birds treated by " 606." will be determintHl.
fvi) [t may \h; worth while to obtain blister serum from infected fowls efliciently treated

by "606" and test its value as a curative or protective agent in the same way as

has been done in yaws,
(vii) The protective action of " 606 " will be tested by injecting it simultaneously with the

virus.

SuMM.\Rv .\ND Conclusions

Further work on the spirochsetosis of fowls in the Anglo-Egyptian Sudan, while
confirming certain earlier observations and conclusions, has led to a modification of some
of the previous views. The new features ascertained and conclusions reached may be
tabulated as follows : —

1. In all probability the avian spirochirtosis of the Sudan is due to a special
spirochete distinct from Sp. marchouxi and most, if not all, other species hitherto described
with the exception of that recently discovered by Jowett in South Africa. The chief
points wliicli liave led nie, somewhat against my own inclination, for the multiplication of
species is to be deprecated, to adopt this view are : —

(a) Its peculiar tendency to breakup into "infective granules" in the internal organs.
These granules, which are discharged by the still living spirochsetes from one or
other end of its periplastic sheath or cell membrane, would appear to constitute
a stage in the non-sexual life-cycle of the parasite, for they seemingly enter the red
cells, develop in them, undergo a process akin to schizogony and regain the /iV/«(-r
yiDiiinhiia as tiny nierozoites which vary in number and slightly also in size.
(/.} The course of the disease in fowls and in chicks. This, it is true, somewhat resembles
the spirochirtosis of fowls in Senegal, due to Sp. iifvoiixi (Brumpt) and which Bouet
found in the French Sudan. If it is the same disease, and there are points of diflference,
the spirocha»te of the Anglo-Egyptian Sudan was first discovered and has priority in
nomenclature. Our fowl spirocha-tosis would appear to differ in some respects,
notai)ly as regards the "granule phase" from the Tunisian and Somaliland strains,
(p) The peculiar sexual (?) life-cycle, partly worked out in the tick, Anjan pevairm (Fischer)
and which seems in most respects comparable to that descrii)od by Leishman for
Sp. iliilliiiii in (h'liithciilnniK monbnia.

' So far, efforts have l»ecti misiincessfnl in this direetion.

'-■ Tlicy do, lioth in the case of Antnx itrrxii-iis .ind Oriiillioriloriis siivl;iiiii>, the ijrwes^ lieing e.x.ictly .siniilar
to that oeeiirriuK in chieks.

" A disch.irpe of frraiinks from the red i-i-lls has Ihvmi simv imti'd. The frranules remained ehiniiied and did
not disperse.

SPIROCH.ETOSIS OF SUDANESE FOWLS 107

(rf) The absence of any cycle in the tick corresponding to that described by Pro\vaz;ek
for Sp. gallinarum {iiiarchouxi) in Ar(ias miniatnt-.

(e) The fact that lice (Alenopon sp. ?) have been shown capable of transmitting the disease

may be another distinguishing factor.

(f) The insusceptibility of pigeons to the disease. The fact that gerbils cannot be

inoculated with it may also serve to separate it from other forms of avian

spirochsetosis.

These then, with other minor points, seem to me to justify one in finally regarding
this Sudan spirochaete as a specific entity. I propose to name it Spirochieta f/rawilofa Proposed
penetrans *(nov. sp.), which, if a somewhat lengthy name, would seem to direct attention "^'"'^'
to its outstanding and peculiar features. I admit that the last word has not been said pcneirans
on what is a difficult subject and await with interest the researches being carried out in
South Africa on a spirochaete strain, which would appear to be the same as that with which
this paper deals. Meanwhile, recent papers by Bosanquet' and Dobell- on certain non-
pathogenic spirochaetes are, to saj- the least, very suggestive.

I cannot conclude without expressing my thanks to Professor Ehrlich, who most
kindly and generously supplied me with a considerable quantity of his new drug for
purposes of experimental research. I am also greatly indebted to Captain E. G. Archibald,
E.A.M.C., for his assistance at various stages of the work, and to Captain W. B. Fry,
E.A.M.C., for special help in connection with the dark-field work. To Messrs. Buchanan
and Marshall, our laboratory assistants, my thanks are also due, and more especially to
the former for his admirable drawings illustrating certain of the conditions mentioned ;
while Mr. F. C. Murray-, Chief Sanitary Inspector, Khartoum, has been at pains to
procure material for the research in the shape of sick fowls and infected ticks.

Additional Note

Subsequent experiments have proved that if a chick be fed on recently-infected
ticks, other means of infection being prevented, it develops spirochaetosis. The
incubation period is five days. According to the rules of scientific nomenclature the name

of the spirochaete would need to be Sp. granulosa, and the term penetrans reserved as a

sub-species title if such were found necessary.

XOTE ON A ^IeTHOIi OF (^BTAIXIXG BlOOD AsEPTIf ALI, Y FOR THE
CULTUr.E OF H.EMATOZOA IN THE TroI'ICS

BY

The Directoi;

Until one hit upon the idea of the simple apparatus herewith described (Fig. 27)
one had found it well-nigh impossible to prepare blood-agar tubes for trypanosome culture
which did not speedily become contaminated, usually with cocci and moulds. Since it
has been in use the difficulty has disappeared, and we have been able in these laboratories
to cultivate trypanosomes and Leishmania with comparative ease.

' Bosanquet, W. C. (February, 1911), " Brief notes on the Structure and Development of Spirochcrta nnnrlontn;
Keysselitz." Quarterly Journal Microscopical Science.
- Loc. cit.

108

NOTU ON A METHOD OK OHTAINING IlLOOD AHEl'TICALLY

The apparatus consists of a stout bottle of 500 c.c. capacity, fitted with a rubber
cork which is well fastened down and luted with parailiri wax where it is in contact
with the mouth of the bottle.

Through this cork, pass two glass tubes, one reaching aliout lialf-way down tlie
bottle, tlie other almost flush with the base of the cork.

The former is connected by means of rubber pressure tubing witli a large hollow
needle of tlie kind employed for lumbar puncture. The pressure tubing is controlled by
a clamp. The latter is similarly connected with a short length of glass tubing tlirough
which the blood is eventually added to the culture tubes. The bottle contains glass
beads for dcfibrinating the blood, and in its neck there is fixed a metal perforated
diaphragm to keep back clot.

Method nf use. A vacuum is produced in the bottle by means of a Geryk air-pump.
Then a couple of test-tubes are
fastened over the needle and the glass
tubing respectively, as shown in the
drawing, and the whole apparatus is
sterilised in the autoclave under
pressure.

A rabbit is now etherised, fastened
to a board, its chest shaved, and a
point selected in the sixth or seventh
left interspace counting upwards from
the costal margin. This point is about
liiilf-aii-ineii fiom the mid-sternal line.
The skin over this area is seared with
a hot iron. Removing the first test-tube
and placing his sterilised thumb against
the needle and about half-an-inch from
its point, the operator directs the latter
downwai-ds and to the left when it will
enter the base of the heart just about
the root of the great vessels. The - ---n-

thumb-point pi-events the needle going

too far. The first clamp is then loo.sened and blood readily enters the bottle which
is kept warm by means of a hot cloth wrapped round it. .\s tlie blood flows the bottle
is shaken to facilitate defibrination. When no more blood can he obtained, the rubber
connection is clamped and the needle withdrawn, the rabbit being usually dead by this
time. After further shaking, the test-tube is removed from the glass tubing, the bottle
is inverted and tubes of melted agar or salt agar have the blood rapidly added to them,
the addition being controlled by the clamp or by the thumb and forefinger. In this
way, even from our small Sudanese rabbits, some 14 to 18 tubes of Novy-MacNeal or
Nicolle's medium can be obtained, and of these one does not expect to have more than
two to four go bad through aerial contamination.

I am indebted to 'Sir. G. Buchanan for the drawing and for some useful suggestions
as regards the technique emijloyed.

PLATE V

*

^ *

0«» P

(1

,c-.

^

r-"ir ^«

(i

-^

.» vj^

.■TH^

(^

Fallacies and Puzzles in Living Blood together with some Blood Parasites

BY WAY of contrast

1. Red blood corpuscles and platelets

•2. Red blood corpuscles, crenated

^. Red blood corpuscles showiag vacuoles

4. Red blood corpuscles showing spherical and uval ^aps or

so-called Maraglianos

A. Red bliKwl corpuscles shoeing eye spots, a special form of fig. 4

6. Red blood curpuscles showing chains, a special form of fig. 4

7. Small globules on red blood corpuscles

5. Granular masses on red blood corpuscles

9. Platelets vn red blood corpuscles

10. Piroplasnia

11. Voung schizont — malaria (pigment)
1'2. I.arge schizont — malaria (pigment)

13. Poikilocytes — normoblasts and red blood corpuscles in

profile, also one dropsical erythrocyte

14. (Jametes — malaria (crescents)

Ifl. Gratmles from eosinophile leucocytes on red blood
corpuscles

X 1000 diatn.

Fallacies and Puzzles in Blood Examination

Being au account of the more common deceptive appearances met with in such work,

especially in tropical countries

BY

The Dikeotou

It has occurred to me that, for those at least who are novices in the art of blood
examination, and more especially for such resident in tropical countries, a short paper
on some of the more common sources of error encountered in this work may be useful.
It is true that some of them are mentioned in the text-books, more especially in volumes
devoted to malaria, but, even in these, I find there are many omissions, and one has to
search through papers on various subjects before one gets an idea of all the pitfalls
into which the hasmatologist may be plunged.

Moreover, it would seem that there is an urgent need, in English at least, for some
such article. From time to time one finds descriptions of so-called blood parasites. Objects
either in man or animals, which it does not require a Solon to diagnose as being in ^™"gy'-* ^

' ^ o o blood parasites

reality one or other of the conditions we propose to describe, and not haematozoa at all.

For example, to take two recent instances, I would cite the papers on blackwater
fever by Dr. Foran of Nigeria, and Dr. Breeze of Tangiers, respectively.

Dr. Foran describes what he believes to be piroplasmata in stained films and what
he regards as free forms in fresh blood. He is, however, well read, cautious and candid,
and admits that he may be entirely mistaken. It is only too probable that this is the
case and that he has confused several blood conditions, one doubtless pathological, the
others histological. There is no need to quote from the paper at any length, but had
Dr. Foran been able to read a good account of blood fallacies and blood puzzles, I do
not think his paper, which he is frank enough to confess is by au amateur, would ever
have been penned. The pity is that he suggests this " piroplasm " is the cause of
blackwater fever.

Observe the result. Dr. Gabrielle Breeze, of Tangiers, stimulated by Dr. Foran's
article, likewise plunges into print and describes bodies encountered by her in the blood
of blackwater fever patients both in fresh and stained preparations. Here again there is
little doubt but that these "spore-like" forms were derivatives of the blood itself, though
Dr. Breeze is possibly on surer ground when mentioning the curious X-bodies of Howell
and Horrocks. She, however, like Dr. Foran, is a careful worker, and concludes by
saying: "Of course I may be mistaken in my observations and supposition as to the Examples in
meaning of the bodies I saw, but unless we record what we see and are ready to prove '^'^™'-

, , . . literature

(.■<ic) ourselves mistaken, if we are so, much knowledge may die with us and our
labours in tropical lands fall short of their possibilities." It is a pity, however, if time
be wasted and other workers possibly misled.

One cannot hope to deal with every source of fallacy which may occur any more
than one can hope to describe every type of puzzling and peculiar condition, but by
grouping together and illustrating in one paper the more frequent sources of error and
difficulty it may be possible to help those who are unfavourably situated for the obtaining
of advice either from books or from more experienced observers.

10

FALLACIES AND I'TZZLKS IN" HL0O1) EXAMINATION

\ilventi(ious

l.iUacics

N'casl cells,
pollen grains,
and debris

l\>ssibilily of
inteslinal
parasites In
lilood films

For convenitMicc one may divide tliose conditions into two classes according to
their origin : —

1. External, Adventitious or Heterogeuetic.

2. Internal or Autogenetic.

In the first class we consider cases in which the souree of fallacy oi- the j)ii/,/liiig
condition is derived from outside the blood itself as, to take a classical example, the
inclusion of insect hairs in a film simulating filariie. This is the view taken by Low and
Stiles of the Filaria ijiijas described by Piout. It is perhaps scarcely necessary to mention
another case in which cotton fibres, gaining access to blood films, led to a wholesale
diagnosis of filaria cases. This is the type of fallacy which care and cleanliness, the
watchwords of a hiematologist, should avert.

For several reasons Class I. is moie likely to be found in stained blood and it is
sometimes far from easy to come to a definite conclusion, especially when one is examining
films prepared by another person and perhaps sent from a distance. It may then be
impossible to make that examination of the fresh blood film which so often clears up a
difficulty. In this connection one would cite the frequent presence of yeast cells in
films made in the Tropics. Of this nature are the curious bodies described by Neave,
illustrated in the Second Report of these Laboratories and here again reproduced
(Plate VI., figs. 1 and 2). The occurrence of chromatin-like granules in such cells is apt
to be confusing as is the definite arrangement of a capsule or enclosing membrane and the
frequent presence of definite segments. Such bodies are not likely to find their way
into fresh blood preparations which have perforce to be quickly made, but they are very
likely to be blown by the wind on to films whicli, though drying, are still wet, and in such
a case they may, to all appearance, be on the same level as the corpuscles.

Possibly also yeast spores may develop to some extent in blood films and produce
confusing pictures.

In the same category come pollen grains and animal and vegetable debris found in
dust, but in my experience these are not so common nor so puzzling as the yeast cells.
These latter may gain access to blood films in another way, and in this connection I quote
a paper which I had occasion to write in connection witii the finding by Professor Nuttall,
of Cami)ridge, of a new spirocluete in the African buffalo. I'rofessor Nuttall's original
paper, which drew forth my comments, should be consulted, and his drawings — republished
here by his kind permission — -may with advantage be compared with those I here submit
and which represent the similar bodies in tin: films from the hartebeeste.' (IVi/c
Figs. 2K and 29.)

I also present Professor Nuttall's interesting rej)ly and, while tiie (juestion still
remains open, would insist on the recognition of this source of error.

" I have been much interested in Professor Nuttall's paper in the April munber of
Pariisitiiltiiiy (Vol. III., p. 113) and especially in his description of a parasite found
by liim in blood smears from a buffalo sent to Englan<l from Jlritish Ivist Africa. He has
named this organism Spirochn'ta borin cuffn'y though he is evidently somewhat doubtful as to
its nature. I write to say that early in 1909 I received from Captain Iladow one blood
smear from a Jackson hartebeeste which he had shot in the Bahr-El-Ghazal and on
the body of which he found '/. iiKin-ilmis in the act of feeding. In this smear I found
organisms which answered very closely to those described and figured by Professor Nuttall

' Tlirouijli the kindness of Professor f). II. F. Nuttnll, F.H.S., it 1ms Keen pos.sil)le to roproduee his
illustration (Fij;. 20) of the Spiroclmln bm-is ai[fris described by him in /'iii-a.iili>liyii. Vol. Ill, No. 1,
April 30, 1910, /</<. 113 and 114.

FALLACIES AND I'CZZLES IN BLOOD EXAMINATION

111

(Fig. 28). They were somewhat smaller, having an average length of 16'5/:i and a breadth of
0-7^( but presented the same appearance, stained in the same way, and in some instances
showed the achromatic transverse bands which he mentions. From its shape 1 mentally
termed one variety the buffalo-horn type and I made drawings of the different forms
encountered. On April 18, 1909, I sent the slide to Dr. Wenyon, at the London School of
Tropical Medicine, with a note directing his attention to these curious parasites and stating
that, to me, they looked more like spirochaetes than anything else, but that I was unable to
classify them. Unfortunately, though my letter was safely delivered, the box containing
the slide was never seen again. Dr. Wenyon, however, wrote and told me that he had
come across similar forms in the blood of big game which had been shot, and recorded his
opinion that the forms in question were not blood parasites at all but were derived from
the intestine and had been carried into the exit wound by the bullet or by discharges
finding their way along the bullet track. One recognised the possibility of such an

V

X 2000 </in/n.

Fjft. C';) — Spirochieta bovis caj/'ris, a. sp.. Nutt.-ill
a-ti S.iii-ocliietes showio§ v.iriiition in si/e bub unifoiixiicy ia (>b»pe
Whereas in (aj tlie paiafrittf shows no internal structure, in fdj and (c)
the chromatin occurs as flne dust tbroii^bout the faintly violet-blue
staining protoplasm. In (ti) there are achromatic transverse bands

* X 'lOQQ ilium. ia/>J>ro.i-.t

i'<e. 26. — tii>)rochaet« like bodies lound in the blood of a Jackson
hartebeeste.

occurrence and the fallacies to which it might give rise, and, on meeting Captain Hadow,
I asked him if he remembered where the animal had been wounded. To the best of his
recollection, the bullet had passed through the neck, severing the gullet, and it is quite
possible that in the last throes stomach contents might have regurgitated through the
wound of exit. The presence of very thin thread-like spirochsete forms in the film and of
some bodies which suggested yeasts, made me refrain from publishing any account of the
case until I had more evidence regarding Dr. Wenyon's hypothesis.

" Quite recently I received from Captain Cummins, S.M.O. Kordofan, a blood smear from
a goat which had died from infectious pleuro-pneumonia. He wrote to say that he had found
spirochgete-like bodies in the film and solicited my opinion about them. To my surprise,
on examining the specimen, I found my hartebeeste parasites or forms very closely
resembling them. I wrote to CajDtain Cummins mentioning the case of the hartebeeste and
the view of Dr. Wenyon, and asking him if the blood sent could have been contaminated

ll'J KALI.AfllOS ANM) rrZZLES IN' HI,OOI) KXA.MINATION

from the stomach or intestines. He replied that there was every possibility that this had
occurred as, prior to niakinj; the filni, he had been examining the goat's intestines. Indeed,
he thought it very likely tliat such an accident had taken place and agreed witii me
in thinking that these parasites were of intestinal origin.

" I think with these facts before us we would do well to hesitate to accept S^i. bmix

oii.-stion of ciiffrii as a true parasite of the buffalo. Perhaps Professor Nuttall would kindly state if

s.hnhoiffris there were any other peculiar forms, such as yeast cells, in his preparations or anything

pointing to infection from internal organs, while it might be well to ascertain if there was

any chance of the blood becoming contaminated before or at the time the blood was taken.

" I do not write in any critical spirit but because I know by sad experience that there
are many pitfalls in blood work in the open in tropical countries, and it would be well
to make certain if Professor Nuttall's interesting parasites are really, as he thinks,
hwmatozoa, in which case it would appear that the Jackson hartebeeste, of the Southern
Sudan, harbours a similar organism. I am inclined, however, to agree with Dr. Wenyon,
especially in the light of what was found in the case of the goat, and to consider these
curious bodies representatives of the flora of the intestinal tract.

"Perhaps if this letter catches Dr. Wenyon's eye he will give us the benefit of his
experience and aid us at arriving at the truth."

Jiephj. — " Dr. Balfour's note raises the question whether SpirocltR'ta bovis caffriif is
a blood parasite or an organism derived from the alimentary canal owing to the entry
of intestinal contents into the blood or blood stream consequent upon the effects of gunshot
wounds. I must confess that this source of error did not occur to me in this case.

" On again looking very carefully through the blood-films, I have succeeded in detecting
a few small bacilli which indicate that the blood may well have become contaminated either
whilst in the circulation or after the films were prepared. Mr. W. F. Cooper obtained the
blood as it welled from a stab in the heart of a buffalo (No. 1) which he had shot, the
bullet having passed a little in front of the heart and broken the animal's leg. He felt
' sure that there was practically no chance whatever of organisms from the intestines
getting into the blood circulation.' On the other hand, it must be noted that the films
may have become contaminated after they were taken owing to accelerated manipulations
consequent upon another buffalo (No. 2) showing a desire to charge Mr. Cooper whilst
he was engaged in preparing the films. I may add that the blood of buffalo No. 2
contained no spirochaetes.

" Whether the organism is or is not a haematozoon can only be decided by further

observations. I am not aware that such forms have been described as occurring in the

intestines of animals ; they certainly differ very considerably from the typical spirocha^tes

which various observers have found in the intestine."

Parasite-like Parasite-like bodies may not, however, gain access to blood films only from the

"f. ™'" alimentary tract. The skin, and more especially the hairy hides in animals, and the

andbairof feathers in birds often yield their quota, and some very curious looking organisms may

animals may ^^^^^ ^^ added to a blood smear. It is unfortunate that some which I possessed perished

appear in films "^ '■

in a fire and so cannot be illustrated, but I direct attention to Plate VI., tig. 19, which
shows a flagellated form found in a blood film made from a guinea-fowl. I fear I cannot
say exactly what it is, but I have a shrewd suspicion it was derived from the feathers.
See also the peritrichous ciliate, probably a cyclochaeta (Ashworth) from the gills, found by
Neave in the blood of a fish (Plate XXI.. fig. a, Second Report, 1906), and the curious
pigmented bodies found by Major Howard Ensor in human blood films taken at Wau.
They appear to be artifacts and possibly have an animal origin (Plate VI., fig. 17). In a

i

I

I

I

I

r

PLATE VI

I

V

«i3

<f

U,

•

I

'tti^

>

•Mi

v--n^

« 1^

1, 2. 19- R- D. MoiR

3 — 18— g. boohan4n

Fallacies and Puzzles

1, 2. Unknown and peculiar bodies in the guinea-fowl
f Xuuttda ptilo7-hyticha) probably of the nature of
yeasts.

3. Plasmosomes of Ferrata— fowl's blood.

4. "Corps en pessaire" — after Brumpt.

5. Filaments in red cells — after Brumpt.

6. Enucleated and distorted red cells in fowl's blood.

7. Greatly altered red cell in fowl's blood.

8. Ring forms (Corps en anneau) in red cells— Webster

after Schleip.

9. Curious cells in fowl's blood, probably altered leucocytes.
10. Degenerated leucocyte in fowl's blood.

Leh/tmaTi Stni't

I N Stai NED Blood

11. Basophilic red cell with nuclear remnant— .T,fter Cabot.

12. Anaplasfiia ma?-ginale.

13. Half-moon red cells from case of malarial cachexia.

14. Peculiar bodies in fowl's blood— fragments of throm-

bocytes.

15. Kurloff's bodies— after Ferrata and Kippenheini.

16. " Jolly " body.

17. Major Ensor's pigmented bodies from Wau,

possibly artifacts.

18. Piroplasmosis and Anaplasmosis of the donkey.

19. Pyriform flagellate in blood of guinea-fowl (Nnmida

ptilorhynch a) .

3—19. X 1000 tfinm.
1—2. X IfiOO diam.

FALLACIES AND PUZZLES IN BLOOD EXAMINATION 113

case like this a careful search of the film helps one to a decision, if not to a diagnosis, for
it should always be remembered that a i^arasitic blood infection is usually multiple, that
is to say, that it is rare to find only one example of a true blood parasite in any given
film. This may occur, especially as regards malarial crescents and filariae, but if we think
we have found a new and peculiar hsematozoon, and yet can only discover a solitary
example of it in, say, two good-sized and well-made blood films, it is well to pass into a
mood of combined reflection and doubt. Wherever possible, also, it is advisable, as Daniels
says, to examine some part of a slide where the stain has extended beyond the blood
film and see if the same appeai'ances are there. Another point worth noting is that
in Australia the spermatozoa of birds (honey-eaters) were at first mistaken for spirochetes
in the blood, as the long and narrow types show regular spiral curves. The shot wound
had apparently injured the spermatic duct and permitted spermatozoa to pass into the
blood clot.

Eeturning to our yeast cells we find they present very varying forms. A glance at
Plate XIV., fig. fj, in our Second Report will show a torula from the stomach of a jerboa
which, under certain conditions, might quite possibly deceive the very elect, while
reference to paije 205 in this Eeport will show what I believe to be another form of
yeast cell which was associated with a cutaneous Leishmaniosis, and led more than
one person who saw it, astray.

How easy it is to fall into what we may perhaps call the yeast trap is shown by the
amount of literature which has accumulated on the pai-asite of epizootic lymphangitis.
This has been definitely shown to be a yeast, and has been cultivated as a fungus growth
on artificial media, and yet many able observers have considered it to be a protozoon
allied to the Leishmania or Leucocj"tozoa.

What then will guide us in distinguishing a stained yeast cell from a blood parasite ? How to dis-
Apart from the historv of the film and the general shape and appearance of the veasts, one ""S"'^^ y^^'
notices that those portions of their cytoplasm which take on the chromatin hue, stain a parasites
very intense ruby-red, and that they are also, as a rule, more compact and " solid '' looking
than the nucleus or blepharoplast of a liEematozoon. The appearance of the capsule
may help, as witness the well-known double contour of the Saccharomyces farciminosus,
to adopt Eivolta's name for the parasite of epizootic Ijinphangitis. In some cases, however,
the only thing to be done is to make a careful drawing and record the find with such
particulars as may help, especially making mention of any other forms — bacilli, cocci,
etc., which may indicate contamination (i-ide Plate VII., fig. 10).

After all, a little experience and careful reasoning will usually prevent mistakes in the
case of Class I., but mention must be made of another and most important fallacj\ It
is, or has been, until recently, a common custom to dry a stained blood film, after washing,
by means of blotting paper. What is often done, is to have a bunch of pieces, of paper,
to lift some of them up exposing the surface of one, place the slide on this and blot the
film with those held in the hand. Now, unless care be taken to see that the piece of
filter paper, whose under-surface is pressed down upon the film, is of virgin purity,
disaster may ensue. I remember telling my laboratory attendant to prepare for trans-
mission to India a number of films of mammalian blood showing hiEmogregarine
infection. Happily, I bethought me to look them over before despatch. I speedily
found they contained oval and nucleated red cells w-hich must have come from a bird
or a reptile. Despite denials, I came to the conclusion that either the slides, the
pipettes or the spreading needle used had been dirty. It was not until a somewhat
similar episode occurred in the course of my own work that I realised what had

114

FALLACIES AXD PrzZLES IN IlLOOD EXAMINATION

■ Blouing
paper " fallacy

Autogcnetic
fallacies

Vacuoles

happeneil, luiiiicly, that the same piece of blotting paper used to dry a stained film of
fowl's blood had been used to blot the other film and the corpuscles had been transferred
from the paper to the slide. I have known of cases in which parasites were transferred
in a similar way, so the need of care is obvious. Fragments of stained epithelium and
stain deposits often spread beyond the marf^in of any red cell on which they may lie,
and may be troublesome, though focussing helps to decide.

On the whole, however, care and a little experience will soon do away with the
fallacies and puzzles belonging to Class I., and with a caution as to avoiding calling
dirt or skin pigment, melanin, which latter never occurs free, remembering that cocci
and bacteria get into blood and that there are sometimes strange flaws and cracks in
glass which may retain a stain, we may pass to the consideration of the second group.

This it is best to consider under two headings : — •

1. Those found in fresh blood.

2. Those present in stained preparations.

The former, so far as fallacies are concerned, are tlie more difficult, the latter,
I think, contain most of the puzzles.

1. Ordinary crenations of the red cells do not as a rule cause any diflBculty (Plate V.,
fig. 2), but sometimes they present a hyaline appearance and look as if situated in the
erythrocytes. Careful focussing soon makes their real nature apparent, for they have no
defined outline and change from dark to light or reversely as one alters the focus. In
this way they can be readily distinguished from a malaria ring-form, a piroplasm
or a spirochaBtal granule or body, the three things which they are most apt to resemble.

Distorted red cells have been mistaken for malarial crescents, but the absence of
pigment should make things clear. I believe a red cell containing a half-grown benign
tertian parasite can rupture, or be ruptured, prematurely, and the amoeboid processes
of the parasite be severed and roll up into little protoplasmic masses in the blood.
These are at first puzzling, but the presence of dancing particles of pigment is a sure
guide to their origin, and fragments of the broken host-cell can sometimes be seen in
their vicinity. Vacuoles are always mentioned as specially diflBcult, and sometimes they,
and also a retraction of the haemoglobin from the edge of an erythrocyte, cause trouble,
more especially in malaria examination.

In distinguishing a vacuole from a young malarial parasite, a piroplasm or a spirochaetal
inclusion and of the three the last is the most difficult to differentiate, the following
points should be considered : —

(i) Vacuoles usually have well-defined, clear-cut margins, while the periphery of a
parasite melts, as it were, into the haemoglobin of the host-cell (Plate V., fig. 3).

(ii) Although a vacuole may change in shape it never shows true amccboid
movement. The slight alterations of shape which may occur in its contour, however,
must not be overlooked.

(iii) A vacuole never shows pigment or any appearance suggestive of granules m its
interior or projections from the vacuoloid area.

(iv) A vacuole is clear, with no "ground glass" aspect. It is highly refractive and,
on focussing up and down, seems to spread and contract in a characteristic fashion.

(v) Vacuoles never stain as a whole, though there may be deposits of colour rouml
their margins.

Splits or cracks in red cells are easily recognised and only require mention, but
one of the most difficult of all blood appearances is furnished by areas devoid of
haemoglobin, also called "eye spots," "spherical gaps," "hyaline bodies," "nuclear

FALLACIES AND PUZZLES IN BLOOD EXAMINATION 115

fragments," " pseudonucleation," "globular decolorisation," " Maragliano's endoglobular

degeneration " or more shortly " Maraglianos" (Plate Y., figs. 4, 5 and 6). These, though

they are found in normal blood, especially, it seems to me, in that of gerbils and small rats,

appear to be more abundant in certain pathological conditions and so are very apt to

be mistaken for haematozoa. I have little doubt they are responsible for some of the "Maraglianos"

descriptions given by Drs. Foran and Breeze, as they tend to occur in acute infectious

conditions, and, as they are found in any part of the red cells, vary in shape and sometimes

appear to possess some kind of structure, they may be most confusing. They are not clear

like vacuoles, and I have sometimes observed what looked like a tiny waving filament

projecting from their centre. This is especially well seen when dark-field illumination is

employed. Moreover, though they have no amceboid movement, they seem capable of

changing their position in the red cells and this without any pressure upon the cover-slip

or disturbance of the blood film. The movement appears to be due to progressing

coagulation and consequent constriction of the protoplasm (Webster). They may be

multiple and are round, oval and spindle-shaped. The more elongated forms are those

which often have a little dark spot in the middle, which may be so distinct as to look

like pigment (Plate V., fig. 5). They usually change a little in size on focussing and

this helps to distinguish them in some measure.

It would seem that the bodies described by Cabot as occurring in pernicious anaemia,
leukaemia and lead poisoning, and believed by him to be nuclear remnants, fall into
this class, and I expect that further observation on Cropper's bodies met with in cases
of fever will show that they are of a similar nature. A glance at Plates i and iii, in
Buchanan's book. The Blood in Health and Disease (1909), will be found helpful
by those to whom abnormal red cells present difficulties. Indeed, this book is very
useful to anyone studying blood morphology and more especially cellular degenerations.
Half the battle is often to know where to look for information, and British doctors in
the Tropics are not likely to turn to Pappenheim or to be regular subscribers to the
invaluable but almost too voluminous Folia Saematologica, edited by that indefatigable
German hsematologist.

Still considering the unstained blood, we must not lose sight of granules from broken- Granules
down leucocytes which may overlie red cells and cause trouble (Plate V., fig. 7).
They have no amceboid movement, do not present the "ground glass" appearance,
and are easily differentiated by focussing, while, of course, they vary greatly in size. It
is a good plan, if a doubtful bodj^ is seen apparently lying in a red cell, to search the
plasma and see if its exact counterpart is not to be found lying free.

While we are on the subject of red cells, it will be well to make mention of the
curious degeneration they may undergo, especially when the temperature is raised. The
changes which occur have been described and illustrated by Nuttall and Graham-Smith
and I have frequently observed them, especially when working with fowl's blood in a
thermostat and employing dark-field illumination.

One is inclined to call these alterations in shape "the chain, dumb-bell, droplet, and "Chain. dumb-
filament phenomena," a term which, though clumsv, is fairly comprehensive and, I think '^"^ '^'^°P'"-
descriptive. A glance at Fig. 30 will take the place of a page of print, and it is phenomena"
unnecessary to say more, as, even in the height of a Sudan summer, I have never
encountered these changes in blood films examined at room temperature, at least when
using transmitted light, so it is very unlikely that they will trouble the ordinary observer,
though they are at first very puzzling to anyone working with heated blood. As NuttaU
and Graham-Smith point out, however, these alterations in red cells may be produced

116

FALLACIES AND PUZZLES IN HLOOD EXAMINATION

if one employs a platinum loop to transfer a drop of blood to a slide and does not take care
to see that it has cooled sufficiently after sterilisation in the Hame. The glow may
have faded from it but it still may be too hot. The same thing may occur if a finely drawn
glass pipette is used immediately after it lias been made, so it is well to be careful
in these directions.

? ;^ Ti ' — A t I y R V :■ H I 1 '' r ■ ; .1
Tbfi ctaalo, tlutnb-b«ll. droplet, nod fllameDt phenomena in fowl's blood and butnan blood un necn by Uie dark-fleld method

In part after N'uttall and Gniham-Sroith
Not drawn tfl scale

In the fresh blood of man the platelet is not very likely to be a source of fallacy, but it
is said that a platelet lying on a red corpuscle may simulate a malarial plasmodium and is
to be distinguished by the fact that it is less opaque, has a granular look and is less
refractive. Moreover it often presses the haemoglobin of the red cell away from under it
and so looks as though surrounded by a pale area (Plate V., fig. 9). It may here be
pointed out that in the case of any doubtful body lying on, or apparently in, a red cell,
help will be obtained by altering the illumination of the field. A dull light is responsible
for many errors and brighter illumination may even change the colour of a dark object
from black to a bright crimson. By touching the edge of a cover-glass with a needle

FALLACIES AND PUZZLES IN BLOOD EXAMINATION 117

and seeing if the body moves with, or independently of, the red cell, error may sometimes
be avoided.

In the blood of cattle especially, platelets may assume strange shapes suggestive
of flagellates, but the fact that these thrombocytes always tend to unite in clusters
helps one to distinguish them. Botli in human and animal blood there is likely to be
more trouble with platelets in stained preparations {vide infra and Plate VII., fig. 2).

At the same time a mass of platelets in human blood, surrounding a little dirt
which simulates pigment, may look very like a sporulating malarial parasite, but blood
platelets have ragged edges and one can nearly always have recourse to staining in a case of
this kind, while one should never dissociate the blood examination from the clinical
conditions. It is perhaps worth noting here that the latest work on the histogenesis
of blood platelets goes to show they are detached portions of the cytoplasm of
megakaryocytes, i.e. the giant cells of blood-forming organs (Wright). Swingle has
shown that blood platelets in blood ingested by an insect host may very closely resemble
herpetomonadiue flagellates and, from what I have seen, I believe errors can arise in fresh
blood if this fallacy is not borne in mind. It is, however, rather beyond the scope of
this paper to consider difficulties in connection with ingested blood. No one should take
up this study until he is in a position to grapple with the numerous problems which
assuredly await him. The same is true of the examination of blood from culture media.

For those who seek to diagnose malaria from the presence of free spores in fresh blood,
a proceeding which Deaderiok emphatically condemns, the little dancing particles of blood-
dust or heemoconia may serve as a stumbling block. Personally, I do not think blood-dust
ever simulates parasites though it may be confused with granular debris from leucocytes, Hremoconi;
a matter of no moment, or with micrococci or fat droplets. The latter would appear not to
be an error, for, though Buchanan says they consist of fibrin, recent work with the
ultra-microscope by Neumann and others goes to show that they are really fat particles
possessing Brownian movement. They are more numerous after a meal and disappear
if the person or animal is starved. If neoessai-y, in the case of animals, this would furnish
a means of distinction. They may be absent in persons suffering from disorders of the
alimentary tract. Some of the appearances last described, and more especially blood-dust
and droplet degeneration of red cells, are much better seen with dark-field illumination, and
as the day will come when this method will be employed as a routine procedure, and also, in
all probability, as a method of differential diagnosis, some words on the appearance
of microscopic fields observed under this condition may not be out of place. The first thing
that strikes one is the enormous number of minute dancing particles. These vary in size
from about '2ft in diameter to the very tiniest specks which, being brilliantly illuminated,
look like infinitely minute sparkles. Crawley states that even with a magnification of 2,160
diameters some look only like tiny points of light. The larger particles vary in shape being
round, oval, rod, or dumb-bell shaped, and, while the smaller are solid, the larger may
appear vesicular. In these, which are highly refractile, one can sometimes see a central spot
of a ruby colour. This is mentioned by Porter. Crawley describes particles exactly like
blood-dust, which certain focussing tests and observations on their limited movements
apparently proved to be intra-corpuscular. I have never noticed these. He thinks some of
the blood-dust must therefore consist of broken-up erythrocytes or fragments derived from
them, but, personally, I do not see why fat particles by a process of osmosis might not
find their way into red cells. Indeed, in ordinary fresh blood films, viewed by transmitted
light, I have seen spherical bodies in red cells which certainly suggested oil globules. It is
worth noting that according to Love, ha>moconia are specially numerous in the blood

118 FArj.AC'IES AND PUZZLKS IN BLOOn EXAMINATION

of typhus fever jmtieuts. One has meiitioned the chain, fliinib-bell, droplet and hlaiuont
phenomena exliibited by red cells brought under the influence of heat (Fig. 30).
Crawley has recently described similar changes seen in blood %vith dark-tield illumination
and has termed tliem beaded threads. I have also observed these and I was at
first inclined to think that the proximity of a liot lamp, the source of light, had
sometiiing to do witli their presence, but recent work witii a better api)aratus has
negatived this view, and it is evident that they can l)e seen by the dark-field method
wiien there is no possibility of the blood temperature having been raised, at least to
Free flaRi-iia any appreciable extent. Crawley also noted free flagella in the blood. These are
probably of the same nature as the beaded thi'eads, and are, I expect, what I have
termed filaments, but one must not forget that under artificial conditions lymphocytes
(Ross and Maealister) and myelocytes (Buchanan) may flagellate. Such a phenomenon may
be induced by certain excitants, atropine and methylene blue, as well as by a cancerous
plasma. This being so, it is possible that certain pathological conditions of the blood may
Ijring about tiie flagellation in white cells and that free flagella may account for some errors
of diagnosis. Indeed, Crawley, I find, mentions their occurrence. Bodies showing
pseudopodia have also been seen in normal blood under dark-field illumination, and thereby
a fallacy was cleared up, for at one time they were supposed, by Koch and Kleine,
to be associated with piroplasmosis in dogs and cattle. They are only greatly altered
blood cells, and Crawley believes them to be more probably derived from erythrocytes than
from leucocytes. Crawley has also some interesting notes as regards the behaviour of both
red cells and white cells under this form of examination, and I see he notes the stimulating
effect of the heat of the dark-tield method upon the leucocytes. The vesicles which he
describes as occurring in red cells are, I think, analogous to the bodies I found in the fresh
blood of fowls and which I fear I mistook for a special form of intra-corpuscular spirochajtal
inclusion [Journal of Tropical Medicine and Hygiene, October 1, 1909). I have certainly seen
sucli bodies grow smaller and become the nebulous clouds of which he speaks. He can give
no explanation of this phenomenon, and neither can I, but I was able to recognise I had
made an error by finding similar bodies in the blood of gerbils, which, though inoculated
with spirochaatal blood or blood supposed to contain spirochictes, never showed any sign of
iUness. The trouble is that the true intra-corpuscular forms look exactly like the pseudo
forms. I believe the fact that the latter are motile, a point mentioned by Crawley, may
serve to distinguish them. Reference to this matter will also be found in the paper entitled
" Spirocha-tosis of Sudanese Fowls," page 84. Blood plates are better studied by
transmitted light, but it is said that the dark-field method has shown tliat mononuclear
leucocytes break up into bodies like hamatoblasts, an observation which, if confirmed,
while not of much importance in the examination of fresh blood specimens, may well
explain some puzzling features met with in stained films of animals' and birds' blood.

A suggestive paper is that on leucocyte degenerations in the cerebrospinal fluid by
Kve. The illustrations he gives show that if similar changes can occur in the blood, and
under certain conditions nothing is more likely, then there is every probability of the
resulting motile, globular, hyaline and flagellated bodies which are produced, being
mistaken, as they were at first by him, for extraneous protozoal contaminations.
haii.ici.-> in 2. We pass now to the examination of fallacies and puzzles in the stained blood, and

stained blood ^^ ^^^ ^^g jjg^e only considering those of an autogenetic nature, it will be as well to take
up in turn each of the main groups of blood elements and see how it may deceive or
trouble the observer. Pride of place may be given to the little blood platelets, for
I lielieve thcv are a more common source of error than anything else in the blood.

FALLACIES AND PUZZLES IN BLOOD EXAMINATION 119

A blood plate resting on a red cell may, as in fresh blood, cause the inexpert to diagnose
malaria, but the fact that it has no blue-staining protoplasm, that its chromatin is
deep red, irregular and granular, that its outline as a rule is somewhat indefinite,
and that generally it has pushed the haemoglobin away from below it and consequently
produced a ring-shaped, non-staining area around it should prevent the error (Plate VII.,
fig. 2). A mass of platelets has before now been mistaken for a crescent or a clump of
spores, but the staining reactions and the lack of pigment should leave no room for doubt.
I have seen platelets which required a little careful observation to be sure they were
not Leishman-Donovan bodies, for they sometimes show dark chromatin rods very like
blepharoplasts, but one is guided correctly by much the same considerations which
weigh with one in distinguishing them from malarial plasmodia. Their reticular structure
is, I think, on the whole, the surest guide to their identity. Osmic acid fixation
probably preserves their form better than any other method.

In animal blood the platelets may assume confusing forms as may be seen by reference Platelets
to Plate XV. of our Second Report where flagellated and blue-staining forms are seen.
A little experience soon sets one right. The same thing applies in a lesser degree to
the platelets in equines. It is not, I think, necessary here to enter into the question of
true and false platelets and the so-called Arnold's bodies, but as a red cell is often seen
apparently extruding platelets — an appearance which may confuse a beginner — it is worth
noting that Hugh Eoss states that this phenomenon is never apparent when blood is
examined by in vitro methods. He has also drawn attention to the presence of diffusion
vacuoles in platelets which appear as red spots when stained. In fowls, the so-called
thrombocytes take the place of platelets, and as they are quite large cells and may stain
quite deeply by the Eomanowsky method, I have known them mistaken for haemogregarines
[Third Report, Plate V., fig. 2). I cannot do better than quote the description given bj'
Burnett of these spindelzellen, as von Eecklinghausen named them, especially as I find very spindehelUn
few people, even those accustomed to blood work, seem to recognise them as a distinct
entity. They are most likely to be mistaken for distorted lymphocytes.

Burnett describes them as "elliptical, oblong or spindle-shaped cells with an elliptical
to broadly oval nucleus. In size the cell has nearly the length and about one-half the
width of the average red cell. The nucleus occupies about one-half the length and nearly
the entire width of the thrombocyte and is usually situated in the central part of the cell.
The cell body is pale and often contains one or more clear vacuoles and occasionally one or
more compact, rounded, deeply staining (deep purple with Wright's stain) bodies about the
size of, or somewhat larger than, a mast cell granule. These bodies are probably a result
of degeneration. The thrombocytes show a marked tendency to collect in clumps. In
fresh blood and in the less thinly spread parts of films, they collect in masses in which it is
difficult to distinguish the outline of individual cells. This indistinctness of cell outline and
structure shows another property of these cells, that is their vulnerability. They change
quickly when taken from the blood vessels, passing through a characteristic series of
changes. Both cell body and nucleus become less distinct, the cell body losing its structure
first. Finally, both become structureless, appearing in stained preparations merely as a
diffusely stained mass, the nucleus being distinguishable by having a slightly deeper stain."

Turning now to the red cells, alterations in shape and size need not long detain us, Alterations in
for all the ordinary changes are fully dealt with in the standard works on the blood and
are, or should be, known to every medical student. When, however, an observer for
the first time encounters in the blood of a fowl forms like Plate YI., figs. 6 and 7, he is
apt to be puzzled although they are merely distorted and enucleated erythrocytes which

120 FALLACIES AND PUZZLES IN HLOOll EXAMINATION

liave probably assuniefl these shapes as the result of the spreading of the film. Plate VI.,
tig. 7a, shows another curious appearance due to this cause and which the inexperienced
might mistake for a parasite. So-called haamoglobin drops are also met with in birds'
Corps en blood. They look like human red cells. Again the corps en pessaire and corps en annean

ptssaiie ^j ^j^g French authors, Plate VI., figs. 4 and 8, are not always correctly diagnosed by the

student of the blood of malarial cachectics though their colour should prove their source.
Fragile red cells assuming half-moon and other peculiar shapes are apt to be confusing.
I have seen them in chronic malaria (Plate VI., fig. 13).

When one encounters endoglobular and aua;mic degeneration of red cells with a deposit
of blue stain at their centres one may go wrong and think of malaria or a new hsematozoon,
but the absence of chromatin and the general distribution of the stain are distinctive.
There is more reason for granular or bacillary-like basophilia (Plate VII., fig. 5), especially
when associated with polychromasia, leading one astray. Basophilia is very common
in the blood of all kinds of rats, and, indeed, some persons think that certain
so-called basophilias are not histological changes at all but are due to parasitic
invasion. For instance, Graham-Smith, in 1905, described bacillary-like bodies with
protozoal staining reactions in the red cells of the mole. These are not at all unlike the rod
forms I found in the jerboa and which Laveran assured me merely represented basophilia.
The latter, however, do not usually stain blue with Eomanowsky, and in cases of this
kind the tinctorial reactions are of the greatest service in arriving at a diagnosis. They
may, however, do so. There are also different kinds of granules. Naegeli's azurephil
granules, which are probably due to degenerative changes in old erythrocytes, are quite
distinct from what Ferrata calls the true blue basophilic punctations which have a
regenerative significance and consist of what Pappenheim calls parachromatin, a
substance allied to the chromatin of which the Jolly bodies (vide page 121) are composed.
Mention may also be made of Cabot's ring bodies which are rare and occur in
acute, large lymphocyte leukaemia and pernicious anaemia. They stain red both with
Romanowsky and with methyl-green-pyronin. Sometimes true basophile granules may
be very large like those met with in embryonal blood. Eecent work on staining
the living blood has led to the discovery of the granular-filamentous substance of
Cesaris-Demel and his metachromatic-granular material, but in ordinary blood work
consideration of these can, I think, be discarded so far as our present point of view is
concerned. It is worth noting that the Maurer and Schuffner dot phenomena of malaria
are placed in a special class by Pappenheim.
Curious Plate VII., fig. 7, shows an appearance noted in a polychromatophilic red cell from

appearance in ^ irerbil which had been inoculated with finger blood from a relapse case of human

gerbil's blood " , t • , t ■,> , .

spirochaitosis but which never showed infection. It will be seen there was a curious
chromatin streak which ends in a kind of short fiagellum, running down the centre of
the corpuscle. What is this? I confess I do not know, but think it must be a stain
deposit in a corpuscular split or crack. It w-as the only thing of the kind in the film.
It is probably allied to the ring and figure-of-eight bodies {corps en anneau) mentioned
by Schleif, Webster, Brumpt and others, or to the intra-corpuscular polychromatophilic
filaments known to occur in red cells (Plate VI., fig. 5).

Very frequently in the blood of rodents, especially rats and guinea-pigs, stained by the
Leishman or Giemsa methods, one encounters little spherical chromatin dots in the
red cells, recalling in all but position the marginal dots [Anaplasma marginale), Plate VI.,
fig. 12, of Theiler, now said to be the parasite of gall-sickness in cattle in South Africa.
To the best of my knowledge, one may search in vain through English books for any

PLATE VII

#

) V-

*

/t

• •

Vw

H'

%

R. D. MniB

Fallacies and Puzzles

1. Blood of*'donkey showing anaplasmosis of red cells and a

curious spherical body of unknown nature, possibly
associated with an accompanying piroplasmosis.

2. Blood platelet lying on red blood corpuscles.

3. Stain precipitate on and around red blood corpuscles.

4. " Chinks " or cracks in red blood corpuscles.

5. Basophilic rods, free and endoglobular, Polychromasia of

red cells.

Lcishman Stain

Stained Blood

Blood film from gerbil which had been inoculated with blood
from goat unsuccessfully inoculated with camel trypano-
some blood. Curious bodies with spherical granules.

Blood film from gerbil showing chromatin streak in red cell.

Blood film from gerbil which had been inoculated with human
spirochaetal blood. Unknown ring body.

Macrophage, or leucocyte undergoing chromolysis.

Blood film from red or Uganda cob showing contamination
from yeast cells and other curious bodies simulating
parasites,

X 1000 tiiinn.

FALLACIES AND PUZZLES IN BLOOD EXAMINATION 121

account of these, and I am quite sure they have perplexed many a student in the Tropics.

These little red bodies were first described, so far as I know, by Jolly, and bear his name

alone or are called Howell-Jolly bodies, Plate VI., fig. 16. Ferrata has made them the "Howeii-

object of study. They are most commonly single, but two may occur, one often being J°"y " bodies

larger than the other, and they may be combined with punctate basophilia. It is

important to note that they have been seen in human blood in cases of leukanaemia.

A study of the normal bone-marrow apparently showed them to be chromatin residues

from nucleated erythrocytes, but Jolly has recently put forward the view that they are

probably due to hydration of the stroma or corpuscular membrane, and believes that

polychromatophilia, granular red cells (seen in unfixed films) and basophilic granulations

are only different degrees of the same change. One need not go further into this question

here beyond pointing out that a study of embryonal blood clears up many obscure points in

blood cell morphology. These nuclear remains, if such they be, stain red with Leishman

and Giemsa, and green with methyl-green and pyronin combined. A very puzzling

conjunction, and one frequently overlooked, is a nuclear fragment situated in a basophilic

red cell which stains blue like a leucocyte fragment (Plate VI., fig. 11).

Until quite recently the marginal dots of Theiler, found in cases of piroplasmosis
in cattle, were doubtless thought by most to bo of this nature, though Theiler himself
could offer no explanation regarding them. Now, however, he and Spreull believe them
to be of a parasitic nature, and he has named this new protozoon Anaplaama
marginale, and apparently definitely proved it to be the cause of gall-sickness (Plate VI.,
fig. 12). According to Spreull they may occur free in the plasma. Whether or not this work
is confirmed, it behoves all workers in the Tropics not lightly to dismiss chromatin-staining
bodies in red cells as nuclear remnants, but to find out if they may have any clinical and
pathological significance, to look for them in the fresh blood, to test the effects of
different staining methods upon them and to carry out suitable inoculation experiments.
More especially is this true if they appear to have a selective affinity for any special
portion, i.e. the margin, of the host cell. {See also page 345 of this Eeport.)

Megaloblasts showing polychromatophilia, and especially if their nuclei are under-
going degeneration, may be a source of trouble, but the presence of ordinary
megaloblasts in the film should clear things up just as the free nuclei of normoblasts
are explained by the presence of nucleated reds. In the red cells of birds and reptiles
one may encounter the extra-nuclear centrosomes of Eoss, Moore and Walker. They centrosomes
have also described them in human corpuscles. They stain bright red with polychrome '" ^'"^'i'^

crvthrocvtcs

methylene blue and occur as single granules, or as little groups of granules often
connected by filaments. The result is a kind of star rosette. They occur along with the
chromo-linin granulations of these authors and are shown by their methods of vital
staining. Ferrata and Boselli have recently described the chromo-linin granulations
under the name of the granular thread-forming (fadenformige) substance.

It is now time to turn to the white cells and see what they can yield in the way
of fallacies and puzzles in stained blood preparations. I do not here intend to say
anything about the leucocytes of pathological significance, such as myelocytes, which
may be present in the peripheral blood, or to describe different kinds of basophiles,
mast cells, etc. It seems to me that these are rather outside the scope of this kind of
paper, and in any case they can usually be recognised without much difficulty. One
wishes rather to deal with fragments from white cells, inclusions in them, curious
nuclear changes and conditions which may suggest blood parasites either in leucocytes
or free in the plasma and yet derived from them.

12-2

KALLACIES AND PUZZLES IN BLOOD EXAMINATION

Unrecognised
bodies from
the blood of a
donkey and a
gerbil

Death and
degeneration
of leucocytes

For instance, the spherical, homogeneous, blue-staining bodies, so often met with in
spleen smears in kala-azar, may be found in the peripheral blood, and to those not
accustomed to them prove a difficulty. They are, however, quite distinctive, especially
if one remembers that in all probability they are fragments of host cells (macrophages)
which, having been broken off, assume the spherical shape in the circulating blood. This,
however, is by no means proved, and what is one to make of the body shown iu Plate VII.,
fig. 1, or that portrayed under fig. 6?

The first is from the blood of a donkey which was possibly a recovered case of
piroplasmosis, the latter was from the blood of a gerbil which had been inoculated,
with negative results, from a goat, which in its turn had been inoculated with the
camel trypanosome of the Sudan.

I confess I do not know what these bodies are, and I would be glad of suggestions.
The first is, possibly, not unlike the bodies into which mononuclear leucocytes may break
up (vide page US), and it is worth remembering that in severe and advanced cases of
piroplasmosis, whether bovine, equine or canine, the blood may show marked
degenerative changes and present curious pictures of cellular vagaries. From the same
donkey's blood comes Plate VII., fig. 9, and it is almost certainly merely a degenerated
leucocyte where the nucleus has undergone chromolysis. In the same category come,
no doubt, the strange cells, Plate VI., figs. 9 and 10, from the blood of a fowl which
was dying in what I have called the spirochajtal "after phase," or better, "granule
phase." There were myelocytes present in its blood and every evidence of great blood
destruction.

The work of Ross on achromasia of the leucocytes and on the changes which occur
when they die, helps us to understand some of these appearances. After their death
polymorphonuclears and eosinophiles often appear mononucleated. This is possibly due
to liquefaction of the nucleus, its lobes running together. Liquefaction of the cytoplasm
is said to begin at the periphery of the cell, and progress towards the nucleus, while
in achromasia the granules of leucocytes turn red. It is well to keep in mind the
fact that in blood films we may possibly encounter white cells which had been
circulating as dead matter, and, therefore, exhibit changes which are never seen in
living cells.

Apart from actual death, degeneration and vacuolisation may make leucocytes almost
unrecognisable, especially if there is much karyolysis of their nuclei. The clinical condition,
the history of the ease, other blood findings and the evidence of grave ansemia will
usually lead one to a diagnosis of such abnormal cells. Anyhow, they cannot well be
mistaken for anything else, and their outlines are too irregular and broken for them
to suggest protozoa. Plate VII., fig. 8, however, represents a parasite-like body, about
which I cannot give an opinion, though I expect it is derived from a white cell. It
was found in the blood of a gerbil which had been inoculated, without result, with
human spirocha9tal blood. The chromatin is well marked in it, and, as will be seen, it
is ring-like.

Although not like these, this leads one to speak of oval or round rings which may
occur in the cytoplasm of lymphocytes. Certain forms, which Ross suggests may be
centrosomes, occur when blood is kept on a jelly and stained with an alkaline stain.
They are situated above or below the nucleus, not in it. Is it possible that such rings
may show, under certain conditions, in the peripheral blood ? I have seen in the
extra-nuclear portion of a camel's mononuclears, tiny chromatin-like and very perfect
rings, the significance of which is quite unknown to me. They were not numerous, and

falla(jip:s and puzzles in blood examination 123

I do not think they had anything to do with the trypanosomiasis from whicli the

animal was suffering.

If " ruby" granules are found lying free in a blood film stained by Leishinan's method

one niay be pretty certain they are derived from a lymphocyte, at least if the blood bo

human, but I do not think anyone would make a mistake about them, and they are

not common, for the lymphocyte is not a very friable cell. They stain quite differently

from free eosinophile granules which only a tyro would fail to recognise at a glance. It

must not be forgotten that recent blood investigations have shown the frequent presence

of special granules or bodies in the extra-nuclear cytoplasm of certain of the mononuclear Bodies in

elements. The most important of these are those known as Ferrata's plasmosomes, ''"^ extra-
nuclear proto-
Plate VI., fig. 3, and Kurloff's bodies, Plate VI., fig. 15. The former are small, are found piasmofcertain

in all types of lymphoid mononuclears, possess what is called a metachromatic staining mononuclears

reaction, and by Ferrata are thought to be evidence of a regressive metamorphosis. The

latter, which are larger, and which have been the subject of a special paper by Schilling,

have been supposed to be secretion vacuoles or — and from the point of view of the

present paper this is important — parasites. Indeed, I have seen it suggested that the

intra-corpuscular stage of fowl spirochietes, which I described in red cells, was in reality

of the nature of plasmosomes or Kurloff's bodies, hence the importance of bearing them

in mind.

Schilling's work goes to show that they are merely phagocyted structures (the action
having taken place during blood formation), which undergo only regressive change after
absorption by the mononuclear cell. His observations were made on the blood-forming
organs and tissues of the guinea-pig. An illustration of these bodies is shown, Plate VI.,
fig. 15, which I trust may be helpful. I have encountered them in the mononuclears
of fowls and rats, and for a long time did not know what they were.

One has mentioned fowls' blood, and some reference is necessary to the interesting
work of Kasarinoff on the blood of pigeons. (Folia lliem.atoloyica, Bd. X. H. 2. Part 1.
Archiv. November, 1910). His tine plates of normal and abnormal cells, and curious
blood findings are well worthy of close attention. Of special interest are the polar bodies
he describes in thrombocytes after treatment of the blood with saponin. They appear as
small, single dots, or as spherical solid bodies, or as rings with solid inclusions, or
as signet shapes, or as little spore-like clumps. Indeed, save for their colour reaction
(" azurephil ") and the fact tliat they occur in thrombocytes they closely resemble some
of the bodies in fowl's red cells which I believe to be spirochsetal inclusions. As
I state elsewhere {page 85) it may be that one has confused two conditions, and that
some of the red cell forms are of the nature of these peculiar polar bodies. So far as
I know the nature of these has not been settled.

Kasarinoff also draws attention to the spherical plasmocytes of birds' blood which Spherical
are like human blood plates and are portions torn off the plasma of thrombocytes plasmocytes in
(plasmorrhexis). Their likeness to blood plates is intensified by the fact that they may
contaiir remnants of the polar bodies at their centres. I have seen these in films
showing fowl spirochsetosis and they are shown in Plate VI., fig. 14.

A paper in English which gives some account of the red and white blood cells of
certain animals is that by Goodall {Journal of Pathology and Bacteriology, Vol. XIY.,
p. 195, 1910) which may be found useful by laboratory workers in the Tropics, though it
must be remembered that the state of the blood in hot countries may differ very
considerably from that in temperate climates. Unfortunately, we have no tropical
standards to guide us, at least as regards the lower animals.

121

1 \I.I,AIIK!S AM) I'l-ZZLKS IN HI.OUl) EXAMINATION

Uses of the

Folia

H,tmatotiiigi(a

" Howell and

Horrocks"

bodies

There are iiiaii\ oilier points with which one might deal, including conditions met
with in smears from such organs as the spleen and liver, but I feel that a paper of
this kind should not be too cumbersome and, after all, the ordinary clinical and laboratory
worker does not find it necessary as a rule to i)lungc very deeply into the abstruse
aspects of hajmatology. In any case he will find the Folia Jhvmatoloyica a mine of
wealth, and realise how very far we are behind the Germans in a full knowledge and right
understanding of well-nigh everything connected with the blood. Our text-books, though
practical, avoid altogether those doubtful subjects which are often those on which light
is required, and I trust that some one witii time, leisure, and tlie necessary knowledge,
will produce an English work which may aid tiiose of us who have little time to read
lengthy German papers, who have to work l)oth at human and animal blood, and who
are constantly meeting with appearances wbicli we either cannot explain or class vaguely
as degenerations.

It may, however, be as well to make mention of a few recent and little known
discoveries of true haematozoa, either in human or animal blood so that the worker in
the Tropics may be on the look-out for these or similar parasites.

Taking the human blood first, there is the ectoglobular, vermiform parasite found
by the brothers Sergent in Algeria and now named by Brumpt Serfjetitclla homiiiis. It
is something like the leucocytozoon of a bird in shape, being pointed at the ends and
containing a large oblong nucleus at its centre. These parasites exhibited periodicity,
disappearing from the blood in the evening, and may have been the cause of the nausea
and night sweats from which their human host suffered. In some illustrations it looks
not unlike Nuttall's buflfalo spirochtete and my hartebeeste forms. Somewhat crescentic
and vacuolated bodies found by Castellani and Willey in human febrile cases and by
Castellani and Sturgess in Bos tiidiruii also merit consideration.

Then there is the unknown protozoon found by Hoefer in a case of anasmia at
Leipzig, in a woman who had never been away from the neighbourhood of that city. It
stains like a malarial parasite, shows chromatin, occurs in the red cells as rings or as
curved pyriform bodies, and also apparently as a large blue staining mass, dotted with
tine chromatin granules and rather like a benign tertian pai-asite, but devoid of pigment.
In the jjlasma, double, possibly dividing, free forms occur which may show two nuclei
each, and are either pear or somewhat spindle-shaped. There is also another free form
something like a stout vermicule.

It would be well to bear in mind the possible occurrence of hiemogregarines in
human blood of the type found in certain manmials.

One does not know what the X bodies of Howell and Horrocks me, l)ut, un ihey
seem to be associated with febrile conditions, they may be of a parasitic nature, though, if
so, they are something entirely novel. I have seen them once in the blood of a sick dog,
and the following is the description given of them when stained with Leishman's stain : —

The bodies, when stained, were characterised by a faint capsule with a circular
centre, staining deep blue ; they varied in size, some being as large as a red corpuscle,
others only about one-eighth the size of a red corpuscle. In addition to these forms,
which were the most common, the following were also seen : -

(n) A small, blue circular centre surrounded by four or more faint capsules
concentrically arranged ; (h) two circular bodies, each having a dark blue central
point surrounded by a light blue ring enveloped in one capsule which appeared indented
as if two capsules were in process of formation ; (c) similar to {b), but the part
surrounding the deep blue centre stained a deeper blue, and two indented capsules were

FALLACIES AND PUZZLES IN BLOOn EXAMINATION 125

seen ; (d) a dark blue central part, shaped like a crescent, containing a small circular
body, with a deep blue central point within the arms of the crescent. None of the bodies
on the slide showed any signs of chromatin. Since the above was written I have found
them in human blood in a case of urticaria without any fever [vide page 362). Major
Howard Ensor has also come across them in a case of fever and in a splenic puncture
film from a case of supposed kala-azar.

As regards parasites in animal blood, certain unidentified forms in frogs' blood claim Unidentified
attention. Thus there is one form found in this amphibian's red cells and described P*''^"^^ '"

^ frogs blood

by Button, Tod and Tobey. The appearance is that of more or less spherical chromatin
staining bodies, and recently Carini, who has been working with frogs' blood in Brazil,
has suggested that it represents an endoglobular stage in the life history of a trypanosome,
for he has found and figured such a condition. Certainly at an early stage the small
inclusions he illustrates resemble the bodies described by the Liverpool observers. I think,
however, that the so-called cytamoebae, at least in certain of their forms, which these latter
also discovered in frogs' blood in West Africa, are even more like Carini's early trj^anosome
stages, and also closely resemble, as I have mentioned elsewhere, some of the " after phase "
bodies in the blood of spirochaetal infected fowls. Other cytamoebae in the frog, however,
approximate to the " bacilloid " and bacillary bodies which Carini also found in
Leptodactylus ocellatiis. The first are little oval, blue-staining masses with a single
central chromatin dot, spherical or star-shaped, or two granules, one at either end, or
a splash of chromatin along their sides. They may be single and multiple, the latter being
apparently division forms.

The bacillary forms are perhaps of greater interest. Kruse was the first to find them
in frogs caught in the neighbourhood of Paris, and their frequent presence in the red cells
of European frogs has been signalised by Labb6, Laveran, Ziemann and others. They look
for the most part like little bunches of bacilli irregularly arranged at one end of the
erythrocyte and having no connection with the nucleus. They may have a beaded
look or may appear almost like a tangled skein in a vacuoloid space. They may also look
like rods sticking out of a central dark-staining mass. Those found bj- Cai'ini are shorter
and thinner than those called Bacillus krusei and are believed to be specifically distinct but,
so far, I do not think anyone has come to a definite conclusion regarding any of these
bodies though they are apparently undoubtedly parasitic. The same is probably true of the
small spherical pink-staining (with Giemsa) bodies found in the red cells of the leather-
jacket fish of the Australian seas. Multiple infection of the red cells was, however, never
present, a point rather against their being protozoa.

Another point to be borne in mind is that Probat of Muansa and Francis of Texas Free spores of
have found what seem to be the free spores of Sarcosporidia in the blood of animals. sanosponoia

^ ^ in the blood

These few notes on the less known human and animal blood parasites conclude
this paper. No one is better aware than I am how imperfect and incomplete it is ; but, for
the most part, it has been written as the outcome of practical experience, and if, with
the aid of the illustrations, it saves some from certain pitfalls into which the writer
has fallen, and helps others over the haematological stiles which bar the way to progress, it
will have served its purpose and not have been penned in vain.

It has not been thought necessary, in a paper of this kind, to give references in detail,
as the article itself is intended, in some measure, to obviate the necessity of frequent
recourse to books and periodicals.

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Fio. 31.— Rough Map. showiho distribution or Kala-azar in Kassala and Blue Nile Districts

UP TO May. 1909
The Sudan area 1 dolled linil may be considered to be practically free, except from imported cases
P = Definitely proved cases .s" = Suspected cases

To these cases must be added —

(11 From While Nile (onel (2i Late Dr. Pirrie (3> From KelU (one) (4) From Singa (one)

Remarks on

KaLA-AZAR IX THE KaSSALA AND BlUE NiLE DISTRICTS

OF THE Sudan

BY

Captain L. Bousfield, M.A., M.D. (Cantab.), M.R.C.S., L.R.C.P.. R.A.M.C.

Late attached Egyptian Army

The Sudan Government caused an investigation to be made with the object of
finding out if kala-azar existed or was prevalent in the above-named districts in 1909.
A report was submitted to the Government in May of that year, and this article, at
Dr. Andrew Balfour's request, deals with the main points in that report.

The tour lasted from the middle of January to the middle of May, 1909, and, during Extent of tour
that period, some 1,300 miles had to be covered, 900 of which were by camel, and, since
more than half of the available working time had to be spent on general medical work,
the actual time at my disposal for this investigation was quite inadequate for anything
further than a rough estimation of the amount of the disease present in the various
communities visited.

Those who may wish to see a fuller account are referred to the August and
September numbers of the Journal of the Royal Army Medical Corps, 1910.

The accompanying table shows the towns and villages visited and the number of
cases, divided into three classes :

(1) Proved microscopically.

(2) Clinically certain.

(3) Highly suspicious.

Only those in whom definite parasites were found are included in Class 1.

The table shows that 57 proved and suspected cases were seen and points to
the Blue Nile being seriously infected, for only three places were visited, viz., Sennar,
Abdin and Singa, and yet ten cases were found in them.

When the report was written, 42 cases of proved kala-azar had been found in the
Sudan, and of these, 15 at least had contracted the disease on the Blue Nile.

Of these 42 cases, 41 have been diagnosed since May, 1907, and have contracted
the disease either on the Blue Nile or in the Kassala District.

The fact that the disease has been found mainly amongst government oflBcials and
employees calls for attention, when one remembers that they are far more under the
medical eye than are the natives.

The map shows the distribution of the cases proved and suspected, and an attempt Distribution
has been made to piece together all available information, so that the map is a ^°"g"^<='"
composite one showing all known cases in these stations and does not represent the
numbers seen on this tour ; since its compilation, fresh cases have come to light.

There is fair evidence to support the belief that all the cases shown in the Sudan
area (dotted tint) wei-e imported.

Thus it seems probable that, as in India, the disease tends to cling to river banks, but
it is to be noted that in none of these places off the rivers was I able to stay longer

128

UKMAISKS OS KAl.A-AZAH

than two days, a time totally insufficient to gain a very reliable knowledge as to the
existence of cases. However, it can be definitely stated that the disease exists to no large
extent in these towns and villages at present. Visits extending to a week or more were
made only at Gallabat, Mafaza, Singa, and Sennar.

Number of
patient> trcited

KaLA-A/ ^ K

Total,

proved

and

suiipcctcd

Province Place

Proved

Clinically

ccrt.-iin

Highly

auspicious

Katisala

. 1

Hospital

1

'2

3

(J

i Tomat

1-2

1

—

—

1

1

' So6

12

—

2

1

3

Wad Heleiwa

7

—

1

—

1

1 Qedaref

Hospital

:i

—

2

5

Shesbeioa

1!)

—

—

Abu Halud

21

1

1

2

Seraf Sayeid

12

-

—

1

1

Gallabat

ICl

:3

4

3

1(1

Tukelein

4

—

—

1

1

1 Doka

.5

—

1

—

1

1 Koui Shetta

14

—

—

—

II

Matna

9

—

—

—

Qalel-el-Nahl

7

1

—

—

1

Wad Shusha

None could be

induced

to attend

for treat

ment

Mafaza

1.52

1

2

2

5

Keili-

—

1

—

1

Lneisa

9

1

-'

1

' Singa

Hospital

5

3

2

10

Blul- Nile

< Abdin

2.5

2

1

-

3

, ScDnar

152

3

2

.5

White Nile

.. Costi

6

627

23

17

17

Total ...

57

In no place was the disease in any way evident, and cases had to be found by careful
enquiry and examination. The following facts are cited to show that in some cases
the disease is epidemic to a limited degree even at the present time, though in the vast
majority of cases I could only find single individuals attacked, the other members of
the family or community showing no signs of the disease.

(1) At Sennar two servants of an official were found very ill with the disease, one
died while I was there and the other was apparently dying. Further enquiries elicited
the report that two other servants had died in Khartoum after a good deal of fever in 190H,
' Case found on return in Khartoum Military Hospital.

KEMAKKS OX KALA-AZAE 129

both having greatly enlarged spleens ; proof of their deaths in Khartoum I was not able to
obtain. The marmiton (cook's boy) also died of fever in the same year. All apparently
occupied the same quarters.

(2) At Mafaza, between August, 1907, and April, 1909, amongst those occupying the
police lines, eight died of this disease, while another policeman, the sub-mamour and his

two servants almost certainly died from this cause. Associated

(3) At Abdin, two brothers were found, one with definite kala-azar, while the other '^^^^
had been ill for two years with fever and had a spleen reaching to the umbilicus.

There was practically no time to study the important question as to how the disease is
transmitted, but the following facts were forcibly impressed upon one.

(a) Bed-bugs are extremely common : qi;ite 75 per cent, of the native angareebs
harbour them ;

(ft) Angareebs in places away from the river banks seem to harbour bugs just as
frequently as those in places situated on the rivers.

The following facts, with reference to the presence or absence of bugs in angareebs,
were ascertained in 20 cases of kala-azar : —

(1) Live bed-bugs found in eight instances ;

(2) Eecently deposited eggs, but no live bed-bugs found in four instances ;

(3) No signs of bugs or their eggs in four instances ;

(4) In the case of those who did not use angareebs, or had not used them in the
place where seen, bed-bugs were found in four instances.

All the bugs examined were believed to be Cimex lectularius, owing to their presenting
distinctly flattened or concave edges on the dorsal aspect of the pro-thorax.

Oimex roiundatus has, I believe, at present never been identiiied in the Sudan.' The
disease in the Sudan certainly seems to spread, in some cases, through the members of a Bed-bugs
household or community, and this suggests that it may be conveyed by the bed-bug.
Against this view, however, is the striking fact that in the Sudan, as in India, the
disease appears to cling to river banks, and yet bed-bugs are equally common in places on
and away from the river and infected persons must frequently be visiting these places off
the river.

The popular belief, which I have often heard expressed, that angareebs strung with
strips of hide do not harbour bugs is quite fallacious, as many such angareebs w-ere seen
teeming with these pests. In view of the possibility of the disease being carried from
domestic animals to human beings, the animals kept in the tuMs or hooshei^ of those
suffering from kala-azar were noted, but in no instance were animals, evidently ill,
discovered. The domestic animals seen were donkeys, sheep, goats, dogs and chickens.

Trade, habits, and food seemed in no way connected with the transmission of the
disease, but it still has to be determined whether river water, or the eating of fish, may
not be a means of conveying the disease in the Sudan, a possibility in view of the tendency
of the disease to cling to river-side villages and the frequent initial intestinal disturbance.

The disease runs in many cases a very severe and rapid course, and of those diagnosed •^'""'■■al lype

often severe

on this tour, eight were known to be already dead in June, 1909. The average duration g^^d rapid
of the illness, according to the statements of the various patients, who, how-ever, are not
by any means entirely to be relied upon, was twenty-one-and-a-half weeks, while five
terminated fatally in thirteen weeks. Nine cases gave a history of illness of less than
three mouths, while five more stated the disease had lasted five months or less. The
most rapid case was that of a woman aged about 18, at Kassala ; she and her husband were
' It has uow beeu found iu the Red Sea Proviace and the Lado district. — A.B.

130

REMARKS ON KALA-AZAH

Is the disease
a recent iniro-
duction into
the Sudan ?

Incidence by
months

most dutiiiite in thoir assertions that shu had Ijuoa ill only twenty days before admission
to hospital where she died six days later.

Another case, a boy at Abdin, declared most definitely he had only been ill 15 days,
and had not previously had fever. He was evidently very ill indeed, but probably the
history was faulty as his spleen nearlj' readied the umbilicus ; his peripheral blood
showed Leishman parasites.

Chronic cases were seldom seen; three, however, gave histories of five years (Lueisa),
three years (Abdin), and two years (Abu Galud) respectively.

The following points make one inclined to the view that the disease may be a new
arrival amongst a previously uninfected people : (1) The virulent character ; (2) the
comparatively few chronic cases observed (this, in my opinion, is a very suggestive fact) ;
(3) the epidemic character the disease has assumed at Mafaza and Sennar; (4) the
absence of history of a past epidemic, though this is naturally extremely difficult to
determine owing to the ever-present malaria after the rainy season both near and away
from the rivers ; (5) the failure of medical recognition, though it nmst be kept in mind
that the disease has been but comparatively recently separated from malaria and many
medical men are still ignorant about this malady.

No information was obtained as to the incubation period of the disease, though much
attention was paid to this point.

The only case that in any way threw light on this point suggested 16-18 days as
the incubation period.

The incidence of the disease appears to favour the months of July, December, and
January, which correspond to the commencement of the cool and rainy season and the
few months following the end of that season. It is often quite impossible to obtain definite
information from a native about the date of onset, but the following table gives the
approximate months of onset of all the cases, proved or suspected, that I have been
able to follow : —

KAT.A-A/.AU CASKS

vcd

Jaauary
February
March
April

June

July

August

September . . .

October

November ...

December

Su&pec

ted 1

Total

3

8

.3

5

2

3

2

3

1

1

—

G

o

5

A point to be carefully remembered in the Sudan is that it is quite common for a
kala-azar patient to have had malaria and to give a history of fever every alternate

EEMAEKS ON KALA-AZAE

131

(lay, probably recognising the malarial paroxysms while failing to recognise the fever on
the intermediate days.

The average age of those aifected was about 18 years, the eldest being about 40 and Age, sex and
the youngest about 6. These figures are only approximate, as the ages had of course to '^^'^'^
be judged on appearance and medical examination.

Nineteen out of the twenty-two were males, the three females being extremely ill,
and, in fact, manifestly moribund, when seen.

This great preponderance of males over females only illustrates the difficulty a doctor
exjjeriences in seeing the female population of a Mohammedan connnunity ; in all
probability the two sexes are attacked equally.

The attached table gives the nationality : —

Nationality

Suspected
Kala-azar

Arab

13

20

33

Sudani

5

1

6

Mixed origin

2

8

10

Egyptian

2

1

3

Abyssinian

—

3

3

Turk

—

2

2

It is also worthy of note that four Englishmen have been reported as contracting
the disease in the Sudan.

The preponderance of Arabs is but natural, considering that they greatly exceed the
other types in number in the districts visited.

From a study of the death-rate statistics in the main stations visited it would appear
that the death-rate is rising considerably in Singa, Gallabat and Mafaza, especially in
the first-named town. The fallacies are that the populations of these towns vary greatly,
often year by year, and, further, every year probabh' sees an improvement in registration.

The actual figures for Singa are for 1907, 221 ; for 1908, 361 ; and till the end of March
1909 (i.e. 3 months), 109.

I believe the death-rate at Singa is increasing in a greater ratio than is the
population ; it is to be noted that 109 deaths were registered up to the end of March,
and if this be kept up for the three remaining quarters, then the total for 1909 will be
436. The death-rate is usually greater in the latter half — i.e. during the rains and Deaili-rate
subsequent fever period — than in the first half of the year, so that probably this total
will be exceeded and the death-rate will have more than doubled in three years.

The onset was either by short attacks of fever, frequently repeated, or by a serious
continuous attack.

Personal observations on the type of fever were of too short duration to be of any
value, but it was noted that the chronic cases seldom had any fever or only a rise to
99' F. at night ; most of the cases seen within a few days of death had a normal or
subnormal temperature.

Wasting was marked, especially in the chronic and very acute cases {vide Figs. 32, 33a,
and 34). Many of the subacute type showed but slight signs of emaciation, and this
renders the diagnosis more difficult, since it is not easy to determine whether some Arabs,

132

UEMAKKb ON KALA-A>C.\1{

who lire naturally thin, are wasted, especially as many are jjoor aiul tliereloie badly led.
Emaciation was marked in eleven cases, slight in eight, and not evident iu three.

Wi'dkiifug was noticeable in all cases, but especially in the very acute, while in the
subacute it was not very striking.

I'rotttlwrance nf the Ahdainen. In thirteen out of the twenty-two cases the abdomen was
not prominent, while in several cases it was actually the reverse. Those who had large
abdomens were the chronic cases, and the average duration of these cases, when seen,
worked out to nineteen mouths.

The fact that 59 per cent, showed no protuberance is, to my mind, highly suggestive of
a new disease, likely to take on an epidemic character. No chronic case was seen without
some protuberance of the abdomen, a condition probably essential, and due to nature
making accommodation for the greatly enlarged spleen and the enlarged liver.

Enlargement of the Spleen. In nineteen cases out of the twenty-two the spleen was
enlarged to within an incli of the umbilicus or to a greater extent. In the remaining three
the spleen was palpable or extended one inch below the costal margin. In all cases the
enlargement was regular, the edge definite ; tenderness on palpation was complained of in
three cases.

Very large spleens were always and only found in chronic cases ; the very acute having
but comparatively slight enlargement of this organ and no prominent abdomen.

Enlargement of the Liver. In seventeen out of the twenty-two cases the liver was
distinctly enlarged though in most cases to no great degi'ee. The largest extended down-
wards to the level of the umbilicus and the liver duluess was increased upwards one costal
space. In no case was it noticed to be smaller than normal.

Jaundice was found in tw^o cases, but in neither to a marked degree.

The conjuncticie were distinctly of a yellowish tinge in seven of the twenty-two cases.

Pigmentation was only once seen, and then it was doubtful if it was due to kala-
azar, and was confined to a curious bronzing of the face. There were no special changes
noted in the skin, hair, or nails, and the nervous system appeared normal in most cases.

Mental depression was very marked in four cases, but all were acutely ill ; one case
was extremely deaf (no quinine had been taken), the power of speech was greatly
impaired, and there w'as marked mental dulness for tliree weeks before death. No
malignant tertian parasites were found in this case.

Diarrhoea was a very marked and serious complication in twelve out of the twenty-
two cases. It was often, according to accounts, accompanied by the passage of blood
and slime in the stools.

Undoubtedly several cases started their disease witli attacks of diarrhoea, and my
belief is that the majority had this complication early in the course of the disease.

The frequency of diarrhoea, accompanied by the passage of blood and slime in the
stools, naturally suggests the possibility of infection through the alimentary tract, and is
a point that should be carefully investigated in the Sudan.

(Edema of the legs was noted five times, one patient presenting oedema of legs, face
and a slight effusion into the peritoneal cavity, while another showed oedema of legs and
face. In the few cases where the urine was examined !io trace of albumin or liilc could
be found.

Suppurative processes were practically absent. Only one proved case showed some
boils scattered over his legs, and one suspicious case had a suppurative condition of the
scalp ; this is no greater percentage than would be found amongst the genei-al
population.

)ienic
puncture

REMARKS ON KALA-AZAE 133

L'aiii was never a marked symptom, though several complained of attacks of pain
over the splenic region, these attacks apx^areutly lasting several days and due, possibly,
to sudden enlargement of the organ or to adhesions.

Headache, pains in the lumbar region and in the shins were sometimes encountered,
but invariably accompanied by fairly high fever.

Epista.cis was troublesome in one case, and bleeding gums were encountered on
several occasions.

Ksemoptysis was complained of by one patient, who showed no physical signs of impossibility

.... T ,, -1 11 ,. ■ ,. 1 .1 ,. , of performing

phthisis, and there was no avaiiable sputum tor examination when the patient was seen. ^ mortems
It is much to be regretted that no post mortem examinations were made, but this was

next to impossible owing to there being no available place, the fnhl being usually in a

compound occupied by many other people, and the prejudice against such a procedure

very strong.

Figs. 32-35 {puije 135) illustrate various types of the disease as met with in the

Sudan : —

1. A subacute case.

2. Comparison between chronic malarial and kala-azar patients.

3. Extremely acute case of kala-azar.

4. A doubtful chronic case of " kala-azar."

Owing to the very short time allotted, it was considered advisable to make a definite
diagnosis by splenic puncture. The writer is well aware this procedure is open to ^P'^
criticism, but circumstances must be taken into consideration, and as patients were
usually seen but once, even if blood-counts, etc., had been made, the diagnosis would still
have been in doubt, and the slight risk to the patient had to be faced rather tlian leave
a case at large to infect the general community. Altogether I have now performed
over 120 splenic punctures without any dangerous symptoms or bad results. Calcium
chloride was never administered and many cases walked away 15 to 30 minutes after
puncture.

My experience of liver puncture, a procedure held to be safer, is small, and in the
few cases in which I have employed it, I have been unable to find parasites. The
cases had but slight splenic enlargement and therefore liver puncture was undertaken,
but they may not have been examples of kala-azar.

When patients are under observation, probably liver puncture should be first employed,
and, if negative, splenic puncture undertaken. I have met several instances where
doctors have used a small exploring needle and syringe for splenic puncture, and to my
mind this is but courting disaster, and quite unnecessary.

Eecently in Egypt, a doctor told me of two fatal cases, one from splenic and the Dangers of
other from liver puncture, but in these two cases such a svringe and needle had been '^^" 'y*"^

^ . o nique

employed. Only three of my cases showed any symptoms after puncture and these
were trivial : —

1. One case vomited and fainted ten minutes after puncture, but rapidly recovered
and had no further unfavourable symptoms.

2. A case, whose maximum temperature had been 100 F., had a rise the evening
after the puncture to 105' F., but then reverted to his former type of fever.

3. One case had pain for twenty-four hours over the site of puncture, but no
accompanying signs.

I have never seen any signs or symptoms pointing to blood effusion into the
peritoneal cavity.

134

REMAUKS ON KALA-AZAK

The nielhod
recommcndetl
for punciiire

Appearance
of the blood
Nv itbdrawn

The method umployed for splenic punctui'u was careful cleansing of skin, luiiuls,
and sterilisation of an all-glass hypodermic syringe, with a hypodermic needle about
1^ inches long.

The site of puncture was carefully located before the little operation. The patient
was told to take a deep breath and hold it ; several ])reliminary exercises were carried
out, so that he fully understood what was required and that lie was not to let go his
breath till the needle was withdrawn. The needle was then inserted rapidly and at
right angles to the spleen, and several drops of blood were at once drawn off. The
proceeding did not cause pain to any degree, :ind the whole performance was finished in
about five seconds or less.

In some cases the lax and thin abdominal wall allows of the spleen being more or
less fixed against the lower ribs by inserting the hand under its edge and pressing firmly
upwards and outwards, and in these cases inspiration need not be employed. The cases
where danger may occur are those who are very nervous or very young ; my small
experience does not seem to point to advanced antemia being a cause of danger ; many
patients punctured were extremely anaemic. In such cases, should sudden expiration
take place, it is of the utmost importance, I believe, to hold the syringe very loosely,
so that the movement of the syringe in the direction of the long axis of the spleen is
in no way hindered, and thus the needle with the spleen is not fixed ; if held firmly
and fixed, the needle might be very liable to cause a rupture of the splenic capsule.

It was found that if the syringe rapidly filled with blood, the chances of finding
parasites were small, and the blood usually had more or less the characteristics of
peripheral blood ; probably in these cases the blood came directly from a splenic sinus.

In a few cases it was found almost impossible to draw off any blood, in one case
even after three punctures ; usually, however, enough was obtained, though not sufficient
to make a good film. In these cases it was noticed that the spleens were not easy to
puncture, and tlie difficulty was probably due to a thickened capsule. By giving a few
slight lateral movements to the needle the splenic pulp is slightly damaged, and blood
can, in some cases, be drawn off, as in puncture of a lymphatic gland, though such a
procedure should be avoided unless absolutely necessary.

A positive spleen puncture settles the diagnosis, but a negative result still leaves
one in doubt.

In three definite cases, and in several that were clinically kala-azar, the blood
withdrawn had, to tiie naked eye, the appearance of slightly clouded serum, though
undoubtedly coming from within the spleen itself ; this was noted especially in severe
and rapid cases of kala-azar.

The method employed for splenic puncture has been given in some detail, but it
must be kept in mind that this method was used with natives, who are not highly strung,
and either do not show or do not feel pain as the civilised white races do. Hence tlie
method of taking a deep breath and holding it, by means of which the spleen is depressed
and held downwards towards the pubis, might quite well with a hyper-sensitive white
person be most dangerous, as the natural inclination of a person who has not full
control of himself would be to let go his breath on puncture, and thus a more serious
tear occur in the splenic capsule than if no previous deep inspiration was taken.

In dealing with an individual of a white race, especially if of a nervous temperament,
I would suggest that it would be better to produce a reflex cessation of respiration by
telling him to take a series of deep breaths and so produce a condition of apnoea for
the puncture.

L. Borj9FiFr-D

Fig. 32.— Case 1
Boy, aged about 9, at Gallabat. Ill probably six months.
Limits of spleen and liver delineated in white paint.
Emaciation marked. Died March 27. 1909.

"A ■' Fig. 3 3.— Case 2 " B "

Two cases at Singa. "'A"— Boy with kala-azar. Ill
eleven months. Died May 28. 1909. " B " -Girl from
same house, but suffering from profound malarial infection.
This photograph shows plainly the difference in wasting
and in the prominence of the abdomen.

Fi:. 34. -Ca.;. .
A very severe and acute case at Gallabat. Duration three
months. Died March 23. 1909. Diagnosed at first as
dysentery. Marked wasting, and weakness very pronounced.
Enormous number of parasites in spleen blood. Peripheral
blood like serum. No malarial parasites found. Spleen not
very greatly enlarged.

Fig. 35 . — Cao e 4
Case at Gallabat. An Abyssinian, ill two years. Typical
parasites could not be found in spleen blood. No malarial
parasites in peripheral blood. Liver and spleen enlarged.
Wife ill with fever for five months. Fever in both cases
unaffected by quinine.

i;^(;

JIEMAUKS ON KAIiA-AZAU

Kelalitin uf
nunilx^r of
parasites to
severity of
inffclion

Other aids to
diagnosis

Absence of
malaiial
parasites in
kala-azar cases

Nil ciists tliiii pii^si'iited only atypical bodies were included in tlic list of those
deliiiituly diat^noscd, though it is a striking fact that these bodies were milij found in
those with typical parasites, or in cases that were clinically kala-a/ar. These atypical
bodies are illustrated in Plate VIII., tigs. 7, 8, 9, lo and 111, while othi-rs were frequently
seen having no signs of a blepharoplast.

In ten cases the parasites were readily found, and the diagnosis settled by a few
minutes microscopic work, but the remaining twelve needed much laborious work before
they could be demonstrated.

Major Cunnnins, R.A.M.C., stated that the number of parasites found had no relation
to the severity of the infection. My experience certainly does not coincide with his, for
my cases, which were acutely ill with the disease, practically invariably presented a large
number of parasites in the splenic films, and only required a few minutes for microscopic
diagnosis, provided tliat true splenic blood was withdrawn. In contrast to this, the
chronic cases presenting wasting, prominent abdomens, large livers and spleens, and a low
fever, and whicii could easily be diagnosed on clinical grounds alone, presented very
few parasites, and often it was extremely tedious to demonstrate them, while in
several such cases there was an absolute failure. I do not think any of these were
chronic malarial cases.

Fifty-six splenic punctures were performed during this tour, and iweuty-two positive
results were obtained. In thirty-nine cases, which were undoubtedly kala-azar from
a clinical standpoint, nineteen showed parasites in tlieir splenic blood — i.r. in about
48-5 per cent, of the clinical cases the parasite was demonstrated.

Other aids to diagnosis, such as the type of fever, the effect of quinine, leucopenia and
differential counts, could seldom be employed, owing to the impossibility of following
up the cases and to lack of time.

Though a differential count is most useful when one has a patient under constant
observation, yet for such a rapid tour of investigation the method was found by me of little
value, the percentages varying considerably. Without finding the parasite I felt that
a diagnosis, founded on not very definite clinical grounds, together with a differential
count supposed to indicate the presence of the disease, was scarcely sufficient to justify
isolation and destruction of property.

In the definite kala-azar cases the finely granular polymorphonuclear leucocytes were
usually present in numbers varying from 30 45 per cent., while tlie large mononuclears
varied from 16-32 per cent.

Malarial parasites were not found in a single case of kala-azar, either in the
peripheral or splenic blood, and in the suspected cases only in four instances.
Considering how extremely common malaria is, this is very remarkable, and 1 can
only suggest that it is a case of the survival of the fittest. The weaklings dying off
from malaria in early childhood, those with stronger constitutions surviving and growing
up, gain an inmiunity, so that, although suffering from malaria during the rainy season,
yet they are capable of ridding their general circulation of the parasites when once the
malarial season is over, in spite of their not taking quinine. This tour was made
during the non-malarial season.

In several cases the peripheral blood was watery and spread on the slides extremely
badly. In three virulent cases it resembled cloudy serum.

The type of parasite usually encountered was the typical one now so well known as
to need no description, Plate VIII., tig. 1. Most of the forms were free and well developed.

PLATE VIII

M

^^0 ^L^

#

L. BonsFiKf,i>

■ ^ c

KaLA- AZAR

1—6. Parasites found in chronic case (3 years' duration) : 1. Typical parasite ; 2. Slightly degenerate enlarged
parasite ; 3 — 6 are believed to be further stages in the degeneration of the parasites within the body.

7 — 9. Forms only seen in chronic cases — apparently parasites in which the hlepharoplast resembles in size and
staining the macronucleus, unless it be a divided macronucleus.

10-11. Degenerate forms found in very chronic case (5 years' duration).

12—14. Degenerate forms found in case (? 6 months' duration).

These forms were found frequently in long-standing apyrexial cases, which presented typical symptoms and signs
of kala-azar, and are believed to represent degenerative processes occurring in the parasites within the body.

15 — 16. Parasites similar to those depicted in figs. 1—14.

17. Parasites showing curious division of hlepharoplast.

18. Parasites found in leucocyte in the peripheral blood.

19 — 22. Leishman parasites, after one injection of orsud.an, showing marked vacuolation.

j'^ objective. No. 8 ocxttar

138

REMARKS ON KALA-AZAR

Types of
parasites
encountered

Examination
of dogs

In chronic cases it was frequently extremely difficult to demonstrate the parasite,
though on several occasions structures were seen which I boliove to be degenerated
parasites. These are illustrated in Plate VIII., figs. 10 luid 11. The cytoplasm in these
bodies was often degenerated, staining badly, often taking a reddish tinge and showing
granulation and excessive vacuolation ; the macronucleus was often ill-defined and
faintly stained, the blepharoplast (?) diffuse and staining like the macronucleus.

These, however, appeared to be parasites owing to their definite borders, the
protoplasm staining blue and containing a chromatin mass, and what appeared to be an
altered and degenerate blepharoplast. These changes were never noted in the smaller
and younger parasites, nor in those of virulent cases. Excessive vacuolation was seen
in parasites after a single injection with orsudan (vide Plate VIII., figs. 19-22).

Further, in chronic cases, parasites (?) were found which showed no signs of a
blepharoplast as usually seen, but two more or less equal chromatin masses usually
equally deeply stained — sometimes one, usually the smaller, somewhat more deeply
coloured (vide Plate VIII., figs. 7, 8, 9, 15 and 16). Such structures were only seen
in kala-azar cases, or those clinically like this disease. These forms did not appear
degenerate like the others already described.

Occasionally parasites were observed of about the diameter of a normal red corpuscle,
sometimes quite circular in outline, but typical in the possession of nucleus and
blepharoplast. The cytoplasm, however, was more granular and vacuolated than in the
younger oval forms. One parasite seemed to be within a red cell and appeared to be
exactly in focus with the edge of the corpuscle, but since this was the only one seen in a
very large number of films, it is probable that it was superimposed. Parasites within
cells were not seen with any great frequency, possibly due to the fine type of needle used.

In only two cases (both acute) were parasites found in the peripheral blood, in one
case free, and in the other free and in phagocytes ; no attempt was made to find parasites
in centrifugalised blood.

Occasionally a parasite with a bi-partite blepharoplast was observed ; in one case
the adjacent ends of this divided inicronucleus were distinctly enlarged (vide
Plate VIII., fig. 17).

Smears from the blood and various organs of the " Urmoot " fish were examined with
negative result ; this fish is largely eaten at Mafaza. Bed-bugs {Cimex lectularius) were
dissected on several occasions and smears made from various parts but with no definite
results — considerable previous practice and experience is required for this work, and
without such knowledge and experience the observations are not trustworthy.

I can only say that two structures, very like kala-azar parasites, were observed in
a smear from the mid-gut of a bed-bug, gorged with blood, which I had caught on the
angareeb (bed) of a very virulent case of kala-azar.

Tw'o dogs were killed and smears made immediately from the spleen, liver, kidneys,
mesenteric glands, and heart's blood —

1. A dog, male, about 4 years' old, belonging to an extremely acute case of kala-azar
and living in the same tukl with the patient, was killed and examined at Gallabat. It was
very w-ell nourished and exceptionally clean for a native dog. No ecto-parasites were found.

Nothing abnormal was noted in the organs except that the mesenteric glands in
connection with the small intestines were greatly enlarged and of a deep maroon colour,
while the two largest appeared lighter in colour, and as though they were about to break
down and suppurate. The intestines connected with the glands showed no macroscopic
disease.

PLATE IX

o

.'jH

L. BODSFIELD

I

o

'■ 1

/ ^

Doubtful "Bodies" from a Dog

4w

Structures, possibly kala-arar parasites, found in an apparently perfectly healthy dog which lived in a compound
containing a very virulent kala-azar case, a woman aged about 22, at Gallabat.

1 — 8. Structures found in smears from spleen.

9 — 11. From liver smears.

12 — 16. From mesenteric glands, which were much enlarged.

17. Only structure in any way resembling a Leish man- Donovan body found in the kidney smears.

/^f

^^

22

T. BonsFiF:r,T> '24

Unrecognised bodies in Kala-azar spleen films

Structures found in spleen blood from case at Tukelein, man aged about 35.

18. Normal red cell.

19 — 25. ? Parasites. No intra-corpuscular forms found. Distributed about the slides, but usually more or less
aggregated together.

24—25. Found lying together as drawn. Short detailed account of case given.

140 KKMAnKS ON KALA-AZAR

Smears were made from tlie spleen, liver, kidneys, and mesenteric glands, and a few
structures were found which were extremely like Leishman-Donovan bodies {vide Plate IX.,
figs. 1-17).

It is impossible to say definitely what tliesc an-, u^ lilm^ only were made, and it
was quite impossible to attemjit any cultures.

Very few bodies, scattered here and there, could be found in the films, and iu the
kidney films only one was found after prolonged search.

All that can be said is that these structures have a striking resenil)laiice to knla-azar
parasites, and work should be carried out on dogs in the Sudan.

2. The second dog, though very wasted, showed no structures similar to the
Leishman bodies, but many lilariaj were found in the liver and spleen smears ; tiiis dog
was a vagrant.

I wish to thank all who most kindly assisted me in my investigations, and to record
that every help and courtesy was afl'orded me by the English and Egyptian officials and
the medical oflBcers, amongst whom I would specially thank El Sagh, Mohammed Etf,
.\li Niklawi, Sudan Medical Department, who gave me much assistance and information
and kindly sent me several detailed reports on the cases at Singa.
'*'*=°"'" The following is a brief summarv of the recommendations suggested to condiat the

raendations for

pr.-vemion disease :•

1. Burning of infected huts, angareebs, etc.

'2. Isolation of acute cases, and compulsory isolation villages for chronic cases.

3. Special quarters to be allotted to Abyssinians in towns and villages.

4. Careful medical examination of Abyssinians before enlistment into the army or
police, or before employment as servants to officials.

5. That all officials in the infected districts who have to visit villages be supplied
with tents, and that all possess small camp-chairs.

6. Avoidance of native angareebs by officials, their servants and police.

7. A course of instruction to officers of the Military and Civil Medical Departments
on this disease, especially with regard to its pathology and microscopical diagnosis.

8. Until our knowledge of the ti-ansmission of the disease is more definite, it
■would be wise for officials not to keep dogs.

9. That all the angareebs used by the soldiers and police be placed, uncovered,
exposed to the sun from early morn to sundown. My belief is that one day's exposure
to the tropical sun of summer would destroy all the bugs, even those within the crevices.

This requires a series of experiments ; in the one instance in which I tried it
I could find no live bugs after one day's exposure, though there were many to be found
previously.

10. The invaliding from the army and police of tliose who are weak and wasted
and have enlarged livers and spleens, with subsequent supervision.

13. The most effective way of getting rid of bugs from woodwork and crevices in
walls, etc., is to play the flame from a painter's lamp direct, and subsequently apply a thick
wash of lime. *'

14. Further investigation of the disease, especially up the Blue Nile.

This has already been done by the Second Commission sent by the Sudan Government
in 1909, and its report will no doubt add very greatly to our knowledge of the extent,
distribution, pathology, etc., of this disease in the Sudan.

That the acute epidemic type as well as the sporadic type exists in the Sudan is now
well established, and several of the most acute virulent cases did not raise in mv mind tlie

KEMAKKS ON KALA-AZAK 141

diagnosis of kala-azar but that of an acute fever ; several times that of dysentery.
It was a great surprise, therefore, to find the enormous numbers of parasites procured from
the puncture of the but slightly enlarged spleen.

These acute cases are extremely important, and medical men must keep the possibility
of kala-azar in mind in the case of acute fevers in the Sudan — as for chronic cases they
are walking advertisements of their disease.

Appendix

Unidentified bodies were found in the splenic blood of a case suspected to be
suffering from kala-azar.

The history of the case was as follows : —

An Arab, aged about 35, had lived all his life at Tukelein, near the Atbara, near
Gallabat. He had been ill two or three months with cough and stated he had at
times expectorated blood. He was very thin and wasted. There was no other history
of illness and he stated he had never had fever, but when seen at 10 a.m. his
temperature was 100'2' F.

Famili/ hisiorij. — His wife had died three months jireviously after three months
continuous fever. She had no dysentery, cough or expectoration of blood. His boy,
aged about 5, was said to be quite well, but on examination both the liver and spleen
were found to be considerably enlarged and his temperature was 100' 1 F. The father
and the child liiniself said he had not been ill with fever. Tlie lungs and heart
appeared normal.

Plti/xi'aiJ I'.rii.iniiKiliiiii. — Marked wasting and general weakness. Patient evidently Unidentified
seriouslv ill. Bliulitlv anaemic. Coniunctiva* not yellow. No cedema. No physical signs .° '^^ °"".

. o . J J 1 . o ,n spleen oi

of lung or heart disease. Spleen enlarged one inch below the costal margin. Liver not "suspected"
enlarged. A splenic puncture was performed, but very little blood could be withdrawn '^^^^
and the films were made with difficulty. Microscopical examination revealed neither
kala-azar nor malarial parasites, but some curious bodies were discovered which are
drawn in Plate IX., figs. 19-25. The films were bad, many red cells were distorted, but
in those which were intact no intra-corpuscular bodies could be found. It is greatly to be
regretted the case was only seen once and no peripheral blood taken. Further, the
films were not examined till the next day, as my microscopical apparatus had to be
left behind owing to the difficult and stony track from Gallabat to Tukelein.

Possibly these structures are haemogregarines. The average length was Sfi to 5^i,
breadth about 0-5p. The central portion was nearly always narrower than the
extremities, which were rounded. The outline was definite, the protoplasm stained blue
and contained a nucleus which usually extended completely across the structure. No
chromatin dots were noted scattered about in the ijrotoplasm and there was no pigment.
No trace of an enclosing red cell could be seen.

Possibly Plate IX., figs. 24 and 25 represent vermicules fixed during motion.

Fig. 20 shows a double nucleus, situated in the centre, the smaller lying against the
convex border of the parasite in its long axis.

Fig. 23 shows forms very similar in shape to the diplococcus of pneumonia, having
blue bodies with definite chromatin transverse bars.

It seems worth reporting this case and drawing the structures, and though it is
scarcely possible to say definitely what they are, yet they appear from their definite
borders, staining properties, etc., to be parasites. They are scattered here and there
throughout the two films taken.

Fig. 36. -Map op Eastern

.Virjr, A I' FA KNJWN AT P R E <; E N T T .1 B f i N K F L* T E D WITH KaLA-AZAR

Kai,a-azai: Co:MMrssiON

TO ixvf,st[(;ate the 1*i;evat,e\ck Axn Cause of

THE Disease i\ the Eastern Sudan

( 1 ) a E N E i; A r, R E r i > n t

1!Y

Cat'Tain D. S. B. Thomson, M.I^, B.Ch., B.A.O., D.P.H, R.A.M.C.

Attaclied Egyptian Army

The ronimissioii, wliicli was appointed by the Sudan Government, left Khartoum
on November 3, 1909, on board the steamer Ciile.r, with which was the Wellcome Tropical
Eesearch Floating Laboratory. Both of these were kindly placed at our disposal by the
Director of the Wellcome Tropical Research Laboratories, Khartoum.

It was decided that one of us, the pathologist, should remain in Singa with the
Ijaboratory, the other travelling through the country to determine the area of prevalence
of the disease, and if possible its cause.

On arrival at Singa, it was decided to make a series of tours of inspection, eacli Tours of
taking about two months. inspection

The first, from Singa to Roseires. going south by the west bank and returning north
by the east bank.

The second, from Singa to Gedaref, thence to Gallabat, visiting the surrounding
villages and returning to Gedaref and Singa by different roads where possible.

The third tour, south to Karkoj, thence east to Khor Agaliin and thence south along
the west bank of River Binder as far as the Khor Galegu, returning north by the east
bank visiting all the villages as far north as Bardana, and returning to Singa.

The fourth toui', north to Sennar by the west bank, returning to Singa by the east
bank.

The fifth tour, south-west from Singa to Dar Agil, thence north along Khor Um Esh to
Teigo and thence north-east still along the Khor to Hillet Howeires and back to Singa.

These five tours took eight months of actual travelling, the last one extending into
the month of July, after which, owing to the rains having started and the presence of
"fly," camels could no longer be employed.

In all 219 villages were visited and 2,100 miles covered by camel and river.

The time spent in each village varied according to its size. In the larger villages
three days were necessary, whereas in the smaller, one day was sufficient to see all the
inhabitants and sick. As far as possible a stop of at least one day was made in each
place.

Naturally, general medical work was predominant and no difficulty was found in
getting the natives to come for treatment. No accurate record was kept of the number
of cases treated, but at the lowest computation at least 3000 men, women and children
were treated or given advice.

On arriving in a village the procedure was as follows : — Procedure in

The Sheikh was told to warn the people of the English doctor's presence, his willingness ^'"ages
to see all sick, and visit in their houses those unable to come to him, and that all medicine, etc..

Tlu> said

Cause of

ri.c .

Disease

Tl.

ici'^rTiling t:>

144 KALA-AZAE COilMISSION

was fiee of charge. Oue is in most cases met immediately with the reph' " Qulliiia
shudad, bi Amanillah" (We are all well, God be praised), but a walk through the village and
conversation with the people soon overcomes their fear of the Tourk. One finds that all the
maimed, the halt, and the blind, are first .sent to see what effect the " Dawa el tourkowi "
will have. If one succeeds in a simple case in giving immediate relief, the whole village,
who previously were "shudad." will come clamouring for medicines. Quinine is known
practically everywhere as a cure for fever and is asked for freely. Purgatives, the stronger
the better, are also in great request, no medicine being considered thoroughly efficient
unless accompanied by thorough purgation.

Nearly all ills are attributed to " Wisaka fi butn " (dirt in the bellyj and they
consider it can only be removed by this means.

Many cases of both surgical and medical interest were seen, but the rooted objection
to coming to hospital for operation or prolonged treatment is so great, io addition to
the difficulties of transporting the patient, that one rarely got cases to come to Singa.

The first point to be settled was whether the disease was one recognised by the
natives ov not. By questioning the oldei- inhabitants of \Tllages it appeared that kala-azar
had been well known for some consideraUe tinje by tihe names of " Sjnieib/' "Dobaal"
or " ICarad-el-Seyid," and by western Arabs as "Abu Safar." This was confirmed in the
various villages eithei- ' ^ '-^-Mig souie oif the iuhabitants to describe the syiuptoms of
tJie disease known as ' or else by describing the syinptojiis and asking vrhat

the disease was calied

The symptoms as desc: j aje as foUows. The disease appeared generally

duiiii^' the "(luuiJ.' '■ . . after iiie rains, about October. The fever is

f?| - 1, the patieiit g»-a4ual|[y v,»stes away, tliough his abdomen

»e^jai^s pi TP«y liiescrihe the anaemia by saying " El damm asfar " (the blood

be. ..1. ■ < .1 J ' i of the feet and face appear. They notice

<J» . . _ is, cancruin oris, sudden swellings, cough

with 4yspn«* »»4 bloo4-sit*»nje4 spuitnnj, but these latter, more rarely. The disease lasts
as a rnle from three to six it is practically always fatal and appears to attack

all age<^ j! , ...ii , n,; , . dy cijii4ren and young adults.

T' (i and chronic, the acute form being almost entirely

confined to the yownger cases an4 the few chronic ones to the older adults.

Ti ~ i u a one for the disease, whereas " Dobaal"

is Tl 1. 1 I . . _;._ Southern districts of the Blue Nile and

K |Cara4-el-Seyid " is a general t«rm applied to the disease ; " Abu Safar" being

the »»»«e given to this disease by the Western Arabs.

The disease was br : .! • • - • - :h P ._.a,.i m ilit- time of the ^ilahdi. and,

since then, it has alw.. , ^^ ., , i i.ily never in an epidemic form,

as never more than two or three cases were in the same village.

It is now less common and some of the older natives say that though they have heard
of the disease and know its symptoms, yet they have never seen a case. Others have
seen one a long time ago, or heard of a case in another village.

1 questioned many old Taaishi men as to what they knew of the disease in the west.

■ ^'i it was never common.

ports, but vaguely known.
.ig supposed etiological factors may be of interest, and possibly have some
.; may ul; prove to be the real cause of the disease.

M.j; is appall. ,M, .tn essential factor in producing it, di-inknij; water irom

KALA-A2AH COJrMISSION 145

wulls which have buuii Hootk'il iliiiin^ tht^ i.iiiis, using IIV//fc</< with fund, liatiiig Munihtki,
sloepiiif,' on the },'muntl at tho bugiiuiing of tlie rains and so inhaUng tin; vaiiours whic.ii
arist) from tho warm moist earth, all these have been given as causes of kala-azar.
Some consider the disease higldy infectious and won't oat or driidi frojn tin; same vessels as
the patient or sleep in the same house.
Wei/kiih is made as follows : —

Dura stalks are heaped on the ground and burnt, the ashes collected and put into a
iliiiiii, in which there is a small hole at the bottom. Water is poured on to this and (liters
through into a second vessel. The filtrate is light yellow in colour and slightly saline
in taste and is used with food instead of salt, when salt is unobtainable or the people
too poor to buy it.

ManiUki is a strong-smelling preparation of raw pounded fish, bones included, made
into balls and hung up in the Inkl, pieces being broken oft' as reijuired. These fish balls
are made either from a mud fish called itannnut, or else from Hear which they say is
a young form of the fish known as Haps. Both Wiijkab and Mandaki are only used by the
very poorest people, and, under exceptional circumstances, by others.

All these alleged causes would seem to point to an intestinal infection caused by food
or water getting contaminated by soil.

Some years ago in the Dahari of the Ge/iia west of Wad Medaiii, I saw several cases
of night blindness which were attributed to the excessive use of Wi'ijkah.

I wish to thank the Inspector-General, Sir Rudolph Jiaron von Slatin Pasha, lor Native
the following interesting information as regards native treatment which he kindly sent me.' ■'''^'^""'^"'

"The disease which the natives of the Northern Districts in the Sudan call ' Kl
Semeih,' is called by tiie Taaisha Tribes of the West ' Abu Safar,' which means ' father
of yellow.'

"It commences with strong fevei-, the body loses all its fiesh and the colour of
the skin becomes extremely pale ; the abdoiiaeu increases considerably in size and the
tongue turns white.

" The process of natives in the treatment of this disease is as follows : -
" They take the root of a climbing shrub, called El. Lawia, whose leaves are of this
shape («:c^^) and that of another shrub called El Deheujhi, and mix theru with 'Iron
scale' {Khanj-EI-JIaJid), and a handful of red ^jepper (Sluitla). All this is pounded
into powder. A young he-goat is then slain and skinned ; and the head, feet and inside
being discarded, the remainder is cut into small pieces and put into a large pot filled witlj
plenty of water. This is mixed with the powder thus prepared, the pot is placed on
the lire in the evening and caused to boil for some six hours.

"At daybreak, the patient is first given about ^ a rotl of Setun (butter J and then about
the same quantity of the prepared broth and a few slices of the boiled bitter goat-meat.

"The effect is that of a very strong purgative, and the same treatment should be
repeated for three times in succession (it is advisable to take the broth of this jjurge a
li|^le warm J, while at the end of the three days the patient should consume l:>eiim in large
quantities for another three days, and the diet should consist of meat, bread, milk, but no
vegetable such as Weika, or what the Sudanese call El JJurrahu."

These shrubs exist in districts south of Sennar, but the natives do not use them.
I questioned some of the older Taaishi on the Blue Nile and they confirmed this, and
say that the plant is known here also as El Lawia, though the natives of the district were
ignorant of its u se. So far as I could find out, there is no recognised treatment for the
' Statement made in Arabic by " Western Arabs."— E. Slatiu

146

KALA-AZAU lOMMISSlON

Infection of
Kiverain and
Inland
Villages

Comparison
of number
of Cases in
Provinces

(Jueslion of
Introduction
from
Abvsbinia

most ht'avily infected are the
l^aiankwii was tlie only place

disease on the Blue Nile beyond the regulation native procedure of jjurf^atives, drinks of
tannin, etc., cupping, both wet and dry, over the spleen, and l)listeiing or tiring, all
of which are used in cases of enlarged spleen, and fever.

During the various tours, both riverain and inland villages were visited. Judging from
the nuinljer of cases found and reported tlic disease is unquestionably more coiiinion in
riverain villages.

Of the various districts visited, beyond douhi the
Merakiz of Singa and Abu Naama.

Practically all the cases found came from this area,
iu which more than one case was found.

The villages of Tama and Beheiga nuiy be mentioned as of especial interest.

These villages are situated about 200 yards back from the river on .\zaza soil, /.'■. a
light kind of soil, and about .500 yards apart. The ground has a natural slope on all sides
and trees are cleared away from the villages for a very considerable distance. In fact,
the sites would appear to be ideal ones, yet during the past six years the people have lost
so many of their relatives and children, from, they say, " Sinieih," that the greater number
of them have left the villages, and the remainder wish to go. This has been arranged for.
They state that the first year they came there they were healthy and well, but that then
the disease began and killed them ofl', as many as five in the year dying of it.

On the occasion of my first visit I examined all the remaining people of the two
villages but could find no trace of the disease in any of them. Nor was I able to get any
information about the origin of the disease there, as to whether the first case had been
elsewhere, or in contact with an infected patient, or come from a village in which the
disease was present.

In the village of Tama the Sheikh reports a case of mother and child being infected
and both dying, the mother showing signs of the disease one month after her son's death.
This is the only case in which there has been any record of more than one member of a
family being infected.

The comparative figures of cases in various provinces are interesting.

Captain Boustield, in his report last year, states that of 42 cases reported up to
May, 1909, 15 were from the Blue Nile. Of the 41 new cases reported by us during
1909-10, 36 have been seen or reported in Sennar Province.

These figures are very striking, though the fact that the greater part of the time of
the Commission was spent in this province, may account for so few cases being noted
in Kassala Province, where only six weeks were spent, the reason for this being that
it was deemed better to devote the greater part of our time to, as yet, unvisited districts.

The suggestion has been made that the disease is introduced into the Sudan from
Abyssinia. The arguments in favour of this as regards Kassala Province are justifiable,
though there is no evidence to show that the disease itself exists in Abyssinia. It also
might be ar-^ued that the habits of the Abyssinians would make them jjartieularly prone
to infection in a country in which the disease already exists.

.\s regards Sennar Province I do not think that tiie disease can be attributed to
.\byssinian sources. The number of Abyssinians coming as far north as, say, Singa is
small, and certainly in no town on the Blue Nile is there anything like the colony of
these people that one finds in Kassala, Gedaref and Gallabat.

The total number of Abyssinians in Singa is 14. which is a very small percentage
of the total populatitm of the chief town of Sennar Province. I think that a great deal
more evidence will be required in support of this theory before it can be accepted.

KALA-AZAE COMMISSION 147

The question of the disease being endemic or epidemic is most important. Epidemic

From all the information obtainable, undoubtedly the weight of evidence is in favour "''Endemic?
of the disease having been present in the country for many years.

Also it apparently used to be much more prevalent in certain districts than at
present, though in no case could I get any information of its occurrence in true
epidemic form.

Certainly, in some instances, there would appear to have been small epidemic
outbreaks of the disease, f.</. the village of Tama. It is difficult to say whether these
outbreaks are premonitory of a severe epidemic or merely the last epidemic flicker of
a disease which is becoming endemic. In other words, that the epidemic has left
behind a sporadic affection.

The latter seems to be tlie more likely solution under the circumstances.

As regards transmission, the accepted theory, at present, is that the vector is t'iinex Mi-thod of
rdtiuidafii!-, yet this bug has never been found in any of the infected areas of the Sudan. ransmission

The native information on the subject would favour an intestinal infection and the
possibility of this mode of infection should not be lost sight of. This subject will be
fully dealt with in the pathological report {vide payes 157-172).

The possibility of infection from animals must also be considered. The tiikh of
natives generally hold at night, all or nearly all the following animals : goats, sheep, hens,
pigeons and perhaps a litter of puppies, in addition to three or four human beings. No
animals suffering from disease were noticed in the houses of any of the patients.

In several villages I heard of and saw outbreaks of spirochsetosis amongst the fowls of
the natives. Also outbreaks of Ahniiil had killed off nearly all the goats of some villages.

This is a disease apparently affecting the lungs and is very rajjidly fatal. I myself
saw no animals actually suffering from this condition.'

The procedure on finding a case of kala-azar was as follows : — I'locedurc

The parents of the patient were told that he was suffering from " Simeih," and the '^" ""^'"S
advantage of transferring the case to Singa for treatment was pointed out, especially Kala-azar
as, according to their views, the patient was bound to die, whereas if sent to Singa
there was the possibility of prolonging life. They were told that the tnkl, together
with the angareeh, hinsJi, etc., occupied by the patient, would be burnt and ample
compensation given for what was destroyed. In no case was there the least difficulty
in carrying out this procedure, the parents being only too glad to grasp the possibility
of saving their child's life.

When the patient had been removed to hospital, the tukl, etc., was burnt under
personal supervision and a certificate given to the owner for the compensation, which
he drew at the nearest Markaz.

Spleen puncture was performed in every case which was at all suspicious and in Spleen
many otliers in which splenomegaly was the only symptom. punctuie

No difficulty was met with in making sjjleen punctures. The skin, having been
washed with soap and water, was then thoroughly rubbed with methylated spirits and
painted with tincture of iodine. After the needle was withdrawn, a piece of cotton wool
soaked in collodiuin was placed over the puncture.

A 2 c.c. all-glass syringe, with a fine needle, was used in every case. The needle
was introduced just below the costal margin in every case but one, in which, owing to
the small size of the spleen, the needle was inserted in the intercostal space.

' This is iufuctioiis pleuro-pncnmouia. — A.B.

14.S

KALA-AZAH COMMISSION

Age
incidence

Sex
incidence

Race
incidence

In some cases, blood did not How freely until the needle had been withdrawn slightly.
The needle was wholly withdrawn as soon as blood appeared beyond its butt, the blood
thus obtained being suflleient for many slides.

Ill all, 53 spleen punctures were done on tour anil in no case were any unfavouraVjlu
results noted. Every case was kept lying down for two hours after spleen puncture,
and then carried to his house, and told not to walk about till next day. This order was
often not obeyed, and I have met many cases, three hours after being punctured, walking
about unconcernedly.

Of the 37 cases seen and reported on the J-ilue Nile, 24 were in boys and girls from
7 to 18, whereas of the 5 cases noted in Kassala Province, 4 were in men of from 20 to 30
and only 1 in a child.

It would therefore appear as if the type of disease found in the Sudan is very similar
to that of India. In India, 50 per cent, of the cases quoted by Kogers were in children
and young adults up to 20 years of age. In the report of sporadic cases at Sylhet an
even higher percentage, namely 69 per cent., of cases under 20 years, is reported.

This latter percentage more nearly agrees with our observations on the subject.

.•\s regards sex incidence, of 42 cases, 8 only were females. I do not think that this
preponderance of male cases is in any way due to the objection of the natives to bring their
women folk for treatment, as seclusion of the female sex is not carried to such an extent in
these districts as in Egypt. Many women who were unable to come for treatment or whose
husbands were unwilling for them to leave their houses were visited in their houses.

As far as can be seen no special race shows a predisposition for the disease, all seem to
be equally prone to infection.

The following table shows the race incidence : —

Positive
Kala-azar

Microscopically

negative, clinically

po:>itive

Possible cases by
native report

Akab

'J

4

8

SUDANKSK

7

3

6

EoyPTIAN

2

Nil

Nil

Abvssinian

1

1

Nil

Berbekeen

1

Nil

Nil

ToTAt.

14

.Seasonal
incidence

As cases have been seen at various seasons of the year, it is dillicult to determine
the actual time of infection. From information gathered from native sources the disease
would seem to show itself at the end of the rains; this would seem to favour infection
taking place during the rains, the cool season.

It must be remembered that during December and January the temperature is
generally low, and, assuming that a low temperature is a necessary factor in infection,
it is quite possible that the disease may be contracted during these months and, lying
dormant through the hot weather, only asserts itself during the following rains.

This would point to a prolonged quiescent period, though, experimentally, it has been
found possible to demonstrate Leishman-Donovan bodies by spleen puncture within fifty
days of infection.

KALA-AZAK COJIJIISSION lid

As regards faiiiily distribution thu disease would appear to differ from that seen
in India.

Ill only one case was there any history of infection of the second member of a family.

The question as to whether the disease is curable is of the utmost importance and, '* Kala-azar

. ., , . curable?

wliether a permanent cure is possible or not, is a moot point.

The following four cases which we have seen, are of interest, as they were reported
as positive last year by Captain Bousfield.

Saleh Mohammed has been seen three times since last November, and on each occasion
has been fit and well. On the first occasion on which he was seen both spleen and
liver puncture proved negative.

The patient suggested to us that he should come again next day for further punctures
as he said that since he had been first punctured, six months before, he had had no sign of
fever, and this he attributed to the puncture.

Shawish Tisama was seen in February, 1910, about ten months since he was diagnosed
kala-azar. He was fit and well. Spleen puncture was negative for Leishman-Donovan
bodies.

Eamadan Someet, a boy about ten, seen at Gallabat a year after original diagnosis
was made. He was tit and well with no fever, and sjaleen barely palpable.

Ali Abdel Kader. This case was diagnosed as suspicious by Captain Bousfield.
When seen by us he had fever, enlarged spleen, and leucopenia. Leishman-Donovan
bodies were present in the peripheral blood. He was treated with tincture of senega and,
after three months' treatment, fever had ceased and parasites had disappeared from the
peripheral blood. After six months' treatment the spleen was not palpable.

The treatment Avhich these cases had was as follows: —

The first had a short course of quinine, apparently about 25 grains a day, for five days.

The second was treated first with regular doses of quinine and since November
has been taking tincture of senega regularly.

The third was treated with quinine for a period of some months.

The fourth was treated entirely with tincture of senega for 5 months. None of these
cases, as far as I could find out, had had any suppurative focus, or anything wrong with
them which would tend to create a leucocytosis, since they were diagnosed kala-azar.

Are these four cases of spontaneous cure of the disease ; is the disease simply dormant
in their systems in some form of which we know nothing, or is spleen puncture of therapeutic
value in some instances?

I have frequently heard natives say that spleen puncture, even in cases of malarial
splenomegaly, has improved their condition and reduced the siie of the spleen.

A point of considerable interest, which was noted during the tour west of Singa, -^ focus of
was the enormous number of cases of bilharziosis.

All the villages lying on Khor Um Esh would appear to be more or less infected.

This khor, which has a shallow, ill-defined bed, runs in a north-easterly direction
for about 20 miles and joins the Blue Nile at Abu Shoka. During the rains it is
always full and is fed by many subsidiary khors, of a similar nature to the main khor,
which drain a large area. During the dry season the people dig wells in the bed of the
khor, getting water about 30 feet from the surface.

In the greater percentage of cases seen, children, chiefly boys, from 5 to 15 years
of age, were infected, though both men and women also suffer from the disease.

Patients complain of " Bouul Har " or scalding urine. Microscopic examination of
the urine showed numbers of bilharzia ova.

bilharziosis

150 KALA-AZAK COMMISSION

The children all complained of frequent micturition and irritation of the bladder;
some cases I saw jiass(>d larfjf clots of pui'c i)lood and a very small quantity of uiine with
them.

Others undnuhtedly, from their symi)toiiis, had infection of the rectum as well, and
were passinj,' hlood and nmcus.

Several women whom 1 saw suffering; Imiii this disease also complumcd of renal
and ovarian pains, which may have meant an infection of these organs also.

'I'lic heavy infection of this definite area with hilharzia is of exceeding interest as,
up to the present, only isolated cases of hilharziosis in Sudanese and Arabs have been
recorded, and so far as I know no definite infected area has been reported. Samples
of watei' were taken froMj the wells of IJillet Howeires, in wiiich at least two-thirds
of the boys appear to be infected.

The examination of the water sliowed eonsideralile deposit, cliietiy earth and sand,
with some vegetable debris. Flagellated and ciliated bodies were present in considerable
numbers.*

R K (.■ O M M K. M) A T 1 O N S

Kecommenda- 1 That a special-service 15ritish Medical Officer witii a knowledge of kala-azar

be appointed to Sennar Province for the further investigation of this disease. That he
be given full power of isolating cases and contacts as he may think fit.

2. That he make further experiments to determine, if possible, the mode of infection.
We think that, owing to the wide-spread distribution of tiie cases and the absence of
epidemics, animal experiments, which we have found to be easy and piaeticable, promise
the best results.

3. All Medical OHicers serving in infected districts should be thoroughly cognisant
of the clinical features of the disease and instructed in making proper peripheral blood
films, which they should send to some competent authority for examination.

4. In infected areas all sanitary barbers who have iu)t been as yet instructed in
the symptoms of the disease, should lie instructed therein without delay.

.'j. They should be ordered to leport all suspicious cases to the Medical Otficei- of
their district, and, as an incentive to the discovery of all cases, they should be given a
reward of I'.T. '25 for every positive case reported.

(J. Ollicials and employees of the Government suffering from fever should not neglect
such attacks, especially if persistent, but consult a Medical Ollicer. It is possible that
kala-azar in its early stages is a curable disease.

7. -Ml ollicers, employees, etc., sliimld taki' jiio[)li\ lactic <loses of (iiiiniiiu during
the Kliiirif.

H. Owing to the, as yet, uncertain method of transmission of the disease, preventive
measures of a general sanitary natine should lie generally carried out.

(o) Personal cleanliness and house cleanliness are of importance. Should tlie

disease be carried from person to person neglect of this fact is dangerous.

(/() Especial attention should be given to absolute cleanliness of kitchens,

cooking and table utensils and food. Water should be filtered or boiled.

(/•) Cleanliness of villages is essential, and we would suggest that Sheikhs be held

responsible for this, .\ dirty and insanitary village might be the starting point of an

epidemic.

• KiKniiry sluiwwl that iiifuctiiui in all i>rol>al)ility was a<N|uircd through the skiu (.nviiij; to the haliit of
inddliiiir nliout in the- infu'-tcd |>ool» formed rouud the welU. — .V.B.

KALA-AZAE COMMISSION 151

(d) The present system of putting animals at night in zerebas adjoining the
owner's tnkl, and in some cases in their fi(kl, is to be condemned.

(e) Tliat fiikh of infected cases and all such belongings as cannot be thoroughly
disinfected be burnt.

(J) Should an extensive outbreak of kala-azar occur in any village, the whole
village should be burnt and a new village built on a fresh site, after the patients
and contacts have been isolated.

9. A careful record of all cases of kala-azar should be sent half-yearly by Senior
Medical Officers of Provinces to the Principal Medical OflScer.

Conclusion

In conclusion, we wish to express our best thanks to the Principal of the Gordon
College and the Director, Wellcome Tropical Research Laboratories, for so kindly placing
their steamer and floating laboratory at our disposal.

To the Governor and Officials, both English and Egyptian, of Sennar Province for
the great assistance they have given us in carrying out our investigations. To Captain
Bousfield, E.A.M.C., whose report on kala-azar was most useful to us in our researches,
and to El Yousbashi Nesib Eff. Barudi, S.M.D. for his invaluable help both in our
clinical and pathological work in Singa.

152

Name

KALA-A/>AU I'OMMISKION
UASES OP KALA-AZAK FOUND BY COMMISSION

Villaee

Aye

Nutiaii-

aiity

., , It, - „. IVriphcral Splccii

Muku ] Province b,"^ Pu,K:turc

Ali Wad T..ti. M.

(i:iMii Kl Soc.l Wad Hay iHmlj ... | M.

Fntiiia Uint Izz

AMI Sadik Wad Omar . M.

311-27 Nafar Mohcl., Alidcl Haliiiii,

Wks. Dcpt M.

I'Jii Nafar Omikui Bcriraz, A. I5ii. M.

All Eff. Gadeiii Katili M.

Alxlnlla Wad BariHid , ... M.

Sabah El Khtir Wad Tiali ... M.

Zuiimlj Biut Uakbat F.

Aliiiifd Adam Adam ... ... M.

Ibrahim Wad Besliir M.

Egyptian ... ... M.

Gasmallnli Molid M.

Kassaln Aim G.iada... M.

Mohd. Ewad El Seed M.

Yiibuf El Tigaiii .. M.

Vadisi Katiil>a M.

Al)lin.s Ahdol Beveii M.

10

10

13

1-1

•23

25

25

10

12

11

33

11

34

19

25

12

I'J

10

Sudan. Wad El AiuK Siu(;ii Senuar

Aral) AI)U Hogar Siiiga Scuuar

Arab

Arab

Egyp.

Arab

Sudan.

Sudan.

Sudan.

Arab

Arab

Arab

Egyp.

Arab

Sudan.

Arab

Arab

Abys.

Arab

Barankwa

Barankwa

Gednrcf Gcdaref

Abu
Nnauia

Abu
Naauia

Senuar

Sennar

Kas.sala

Gedaref , Godaref Kassala

Gallabat

Taulikia Siuga

Gallabat

Jlausoura

Hariri

Karkuj

Launi

Singa

Siuga

Abu
Naama

Abu
Naama

Ka.s.sala

Seunar

Sennar

Scuuar

Senuar

Scuuar

Abu Naama Abu , Sennar

Naama:

Mafaza

Uoscircs

Sbcltal

Taugaru

Siuga

Mafaza

Koseires

Singa

Abu
Naama

Siuga

K.iKsala

Scuuar

Scunar

Scuuar

Scunar

Singa I Singa | Senuar

KALA-AZAK COMMISSION
CASES OP KALA-AZAK POUND BY COMMISSION— i-..«/«(«,y(!

153

Date seen

Duration
of Illness

Result

Complications

Remarks

Nov. 25, 1909

1 month

Died, Jlav Ifi, 1910

Do<\ 11, 1909 1 iiioiitli Died, Jan. 5, 1910

Nov. 19, 1909 .■) montli-^ Died, .Jan. 9, 1910

Nov. 19, 1909

14 days

Feb. 19, 1910 6 weeks

.Tan. 13, 1910

.Tan. 20, 1910

Dec. 9, 1909

Nov. 20, 1909

Dee. 6, 1909

Doe. 17, 1909

Dee. 12, 1909

1909 3 months

1 month

6 weeks

6 weeks

3 months

3 months

1.') days

2 months

Peb. !.■), 1910

May 27, 1910

.Inly 2fi, 1910

1 month

2 months

5 months

4 montlis

.July 20, 1910 2 months

i

April 19, 1910

9 months

Died, Jan. 20, 1910

Died, April 1910
Died, .Fan. 2«, 1910
Died, April 2, 1910
Died, Dee. 17, 1909
Died, Dee. 10, 1909
Died, Dee. 19, 1909
Died, Dee. 3, 1909
Died, Dee. 14, 1909
Died, 1909
Died, M.ir. 20, 1910
Died, Oet. 11, 1909
Died, .Inne 23, 1910
Died, .July 20, 1910
Died, .Tnly 31, 1910
Died, .Tnne 20, 1910

Wasting. Slig^ht redenia of feet
and face

("Edema of feet and faee.
Wastintr slis^ht

(T.denia of feet and faee.
Wasting marked. Diarrhcea

Cancrum Oris. ( Edema of feet
and faee. Wasting

Cancrum Oris. Diarrhoea.
( Edema of feet and faee

ffidema of feet and face.
Wasting

Pigmentations marked

Had intermittent attacks of
Fever for 2 months

Qidema of feet and face.
Wasting. Apatlietii:

Diarrhcea. ffidema of feet and
face

ffidema of feet and face.
Wasting

Cough with bloody expec-
toration

Case too ill for spleen punc-
ture, spleen was barely
palpable

Transferred to Cairo

This case was treated in
Boseires and diagnosed on
a post mortem spleen smear

Practically in r.r/ivnii.i when
seen

Perforating ulcer, large Sudden perforation of an
intestine nicer at splenic flexure

l.jl

K ALA- AX. AH COMMISSION

CASES OF KALA-AZAH OLINIl'ALLY POSITIVE

.Name

Sexi

A i Nation-

'^*' ality

Vill:.|ie

M.irka/

IVitviiice

KcMill

Kciiiurk*.

Mtim BintSeyid

P.

7

Sudan.

Bcrta

Abii Nanmn

Scnnar

Died

Patient too ill to
remove or U>
have .spleen
puncture jier-
I'urmed. Peri-
pheral IiUkkI
noKative

Mdhanunud Wad Omar

M.

;">

Aral.

.Vdam Hourain

Singa

Sennar

Died

Ditto

Ali Wad Omar

M.

7

Arab

Lannl

At)U Naama

Sennar

Unknown

Clinically typi-
cal. Peripheral
blood nega.
tive. Improved
under tiuinine

Abdelnalii fleliara

M.

9

Arab

TiUeisa

.\bn Itii-liiin

Sciniar

L'nknown

Clinically typi-
cal. Peripheral
blood neuativc.
Too ill to move
or to have

spleen puni-ture

1

performed

Abdcl Fattah Said

M.

26

Sudan.

Roseircs

Roscires Scnnar

Diefl

A ))ost mortem

spleen smear

was made bv

M.O.. lioseires,

but lost. Case

stated to be

identical with

other case

which died in

hospital and

was positive

Khadmallrili Hint Reliai

F.

10

Sudan.

—

—

Sennar

Died

Reported by
SI.O., Roseires

Al)del Haniid El Walied

xr.

r.o

.\rab

Kcnciza

.Mm Naama

Sennar

Died

Enormous as-
cites with pres-
sure oedema.
Tapped twice.
Improved
greatly. Died
about a month

i

afterwards

CASES REPORTED AS KALA-AZAR BY NATIVES

Sex .Akc

Nationality

Fatinia Bint Scyed
Tindel Wad Dafter
Ahmed Mohd. Ali Alalia
.Suleiman Xlnlid. .

Haklaf Ali

Hagciza Bint K.tniia

-Vtaniinnu ...

Abdcl Rahim Wad Farag

.Amina Mamallah ...
— Bint Hamniam
Mohd. El Teyeb

P.

13

M.

11

M.

.10

jr.

40

M.

.3-.

p.

30

p.

30

M.

1

M.

28

P.

8

M.

60

Sudan.
Sudan.
Arab

Tama Aral)
Tama .\rab
Sudan.
Sudan.
Sudan.

Sudan.

Arab

Arab

Village

.\ttib

Wad Daftar

Kakoum

Tama

Tama

Tama

Tama

Tama

Bados

r.nci^a

Marlcaz

Abu Naama
riedaref .
.Mm H.'\sliin
Aliu Naama
Abu Naama
Abu Naama
Abu Naama
Abu Naama

Abu Hashim
Roseires
.Abu Hashim

Provini-f

1 >iir:>

Died,

ion ol' llliH".^ aii<l
Kt^iill

Sennar

5 months

Kas.sala

Died.

3 months

Scnnar

Died,

2 years

Sennar

Died,

3 months

Sennar

Died,

3 months

Senuar

Died,

2A months

Scnnar

Died.

2 months

Sennar

Died,

1 month son of

previous i-ase!

Senimr

Died.

3 months

Sennar

Died,

li months

Scnnar

Did

.'t month**

At.so: — Two Cases, names not obtainable, from Basiak .\r:ib<.
One Case, name not obtainable, from Sudanese.

KALA-AZAl! COMMISSION

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1—4, XlOOO^;Viw.; 5-6. xSOO tf/nm.; 7. x ISOO ///Viw. : !*-12, x2000f//rt'/
Protozoa other than Kala-azar met with bv the Commission

1—2. C>'Si-til(e bodies from frcces, case of k.il.i-nz.ir. Probahlv one stage in fig**. 3 :in<l 4.

3 — 4. TrifhomaMix bodies from ?*ame case.

ft— 6. Ralaniidiiim found in (wo cuse*^, from -^plfen puncture and from the mticovis membrane nf ihc )ar>;e ince^iine. Adult
para*iiic.

7. YoiniR form^ of !* and fi.

8—9. Flancllatcd bodies in distillcii water.

10—12. Flagellated bodle<* from fsecei* of monkey infericj with kala-aiar.

IvALA-AZAi: Commission

TO INVESTIfJATE THE PREVALENCE AND CaUSE OF

THE Disease in the