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Six consecutive stool examinations were negative forEntamœba histolytica and sigmoidoscopy showed normal

appearances. The white blood-cells numbered 8000 perc.mm.

He was put to bed and daily intramuscular injections ofemetine hydrochloride gr. 1 were begun on Jan. 5. Afterthe third injection the lower chest pain disappeared and thepulse-rate increased to 80 ; it was then quite regular, butnext day extrasystoles appeared at every second to fourthbeat.. The course of emetine (gr. 11) was completed onJan. 17 and on Jan. 23 a cardiogram (fig. 4) showed restorationof normal rhythm : rate 40 with P—R interval 0-2 sec. Radio-

graphy now showed free movement of the diaphragm ; the

right dome had returned to its normal level and was of

Fig. 3-Postero-anterior radiogram of chest(Jan. 23, 1948) showing right dome ofdiaphragm now normal in position andregular in outline ; size and contour ofheart normal ; and pulmonary arc stilla little prominent.

regular outline (fig.3). The heart wasmore vertical and itssize and contournormal.At this time the

patient complainedof pains in the jaws,shoulders, andbuttocks. The

erythrocy t e - s e d i -mentation rate was4 mm. in the firsthour r (Westergren).The pains graduallysubsided during thenext four weeks.A cardiogram on

Feb. 2 again showedsinus bradycardia :rate 45. The P—R

interval hadlengthened to 0-24sec. but r, R, and Tin all the limb leadswere of higher volt-age. Lead in showedtwo sino-auricularnodal extrasystolesfollowed by ventri-

cular escape. By Feb. 23 the pulse had accelerated and acardiogram (fig. 5) showed normal rhythm, rate 70, with P-Rinterval 0-2 sec., and no extrasystoles. ’Diodoquin’ (di-iodohydroxyquinoline) gr. 3¼ thrice daily was then given fora month. He was apyrexial throughout the illness.

COMMENT

Though final proof of the amoebic origin of the hepatitiswas not obtained, the history of recurrent diarrhoea

since serving in North Africa, and the rapid responseto emetine, left little doubt. The heart-block also

disappeared after emetine gr. 3 and the Stokes-Adamsattacks ceased shortly after the start of therapy. Thedecrease in the size of the cardiac shadow during treat-ment could be attributed to descent of the diaphragmand the restoration of normal cardiac rhythm andrate.

There was no evidence of valvular disease of theheart, but a rheumatic lesion involving the conductingtissues had to be considered in view of the jaw andlimb pains which developed during treatment. Atthat stage, however, the erythrocyte-sedimentation ratewas normal, and it seemed more probable that the painswere due to emetine intoxication ; the pains disappeareda few weeks later. As to the relation of the amoebic

hepatitis to the heart-block one could only speculateas to whether the cardiac lesion was an indirect toxiceffect or due to blood-borne amoebic metastases ; thelatter seemed more likely in view of the rapid responseto specific therapy. As the patient had had no diarrhoeafor nine months and his nutrition was good, the effectsof dehydration and malnutrition could be excluded.

Considering the proximity of the left lobe of the liverto the pericardium, it is strange how rarely the heartis affected in amcebiasis. Possibly cardiographic studieswill reveal more such cases in the future.

Fig. 4-Electrocardiogram (Jan. 23, 1948), lead 1, showing normalrhythm re-established during emetine therapy ; sinus bradycardia40 per min. ; and P-R interval 0’2 sec.

Fig. 5-Electrocardiogram (Feb. 23, 1948), lead 11, showing bradycardia,

superseded by sinus rate of 70 per min.

Extension upwards of an abscess of the left lobe ofthe liver may cause inflammatory adhesion of the twolayers of the pericardium, or rarely the abscess mayrupture into the pericardium with rapidly fatal result(Connor 1929).

SUMMARY

A well-nourished man with amoebic hepatitis butwith no recent dysentery had complete heart-block,which appeared to respond to emetine. In three previouslyreported cases of amoebiasis with auriculoventriculardissociation the patients had diarrhoea, thus introducingother possible factors affecting the conducting tissues.Our thanks are due to Dr. T. Fane Tierney for the X-ray

photographs. ‘

REFERENCES

Connor, F. P. (1929) Surgery in the Tropics. London; pp. 103and 128.

Gerbasi, M. (1931) Pediatria. 39, 513.Heilig, R., Visveswar, S. K. (1943) Indian med. Gaz. 78, 419.Petzetakis, M. (1925) Arch. Mal. Cœur, 18, 70.

Medical Societies

ROYAL SOCIETY OF MEDICINE

Developments in India

AT a meeting of the section of epidemiology and Statemedicine on July 6, Sir ALLEN DALEY, the president,welcomed Dr. K. C. K. E. RAJA, director-general ofhealth services, government of India. -

Dr. Raja surveyed recent developments in the field ofhealth in India. He took as his starting-point the publica-tion of the Bhore report in 1945. At the end of thewar India was in a satisfactory financial position, andthere were hopes that a quick start might be made withthe extensive public-health programme outlined in thereport. The partition of the subcontinent, however,brought with it pressing problems which soon absorbedthe government’s attention. A vast exchange of popula-tion with Pakistan was accompanied by much bloodshed ;camps had to be opened for the refugees -and displacedpersons, and food, clothing, housing, and medical careprovided. At one time the largest camp held no lessthan 300,000 inmates. All the available resources ofpublic health were mobilised to meet these needs, andthe medical services were heavily strained. The absenceof epidemics during those tense months reflected thestupendous efforts that were made.

It was important, he continued, to understand theexisting conditions before judging how effective thepublic-health programme of the new government waslikely to be. In 1944 the death-rate in British Indiawas 24-1 per 1000, and the infant-mortality rate 169,compared with 11-9 and 46 respectively in England andWales. It was estimated that there were 100 millioncases of malaria each year, and 21/2 million cases of opentuberculosis with an annual mortality from this causeof half a million. There were about 1 million cases ofleprosy, a quarter of which were infectious, and about37 cases of venereal disease per 1000 of the population.

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By contrast, the traditional endemic infections of India,- cholera, smallpox, and plague-together accountedfor only some 5 % of the total deaths. The diet of thepeople was insufficient and unbalanced, being largelycereal. There was also a great shortage of medicalpersonnel, as shown by the figures of 1-6 doctors and2-4 hospital beds per 10,000 of the population, and5000 midwives for the whole country instead of the100,000 who were needed.The Bhore Committee recognised that the prime needs

were for vast expansion of the health services, and fora general rise in the nutritional standards of the people.They drew up a short-term and a long-term programme.The former, to be spread over ten years, provided for theestablishment of a primary health-centre unit for each40,000 of the population ; each primary centre was toinclude a 30-bed hospital, and to afford a service of home-visiting by doctors and nurses. Twenty-five of these unitswould be grouped under a secondary health-centre unit,in which there would be a hospital of 200 or 500 bedswith special departments. The large unit of public-healthadministration would be the district health organisation,catering for some 3 million of the population. The long-term programme outlined a more detailed and elaborateframework which could be built on the short-termdevelopments. In 1946 all the provincial governmentsaccepted in principle the Bhore Committee’s public-health proposals, which were now beginning to be putinto effect.Meanwhile various government measures had an

important bearing on public health. The Employees’State Insurance Act provided cash and medical benefitsfor sickness and injury. At its inception it covered2,500,000 people, but it would in time be extended tocover 85 % of the population. The Factories Act hadbeen newly amended to promote the health, safety, andwelfare of factory workers, and provide for medicalattention inside the factories. The age at which childrenmight be employed was raised by law from 12 to 131/2years, and adolescents were prevented from enteringhazardous occupations. In addition, steps were beingtaken to control the drug industry. The anti-tuberculosiscampaign was advancing steadily, and an extensiveprogramme of B.C.G. vaccination had been started. Theprovision of rural tuberculosis centres was beingconsidered.

Turning to the problems of medical education andresearch, Dr. Raja said that the Bhore Committee’sthree main proposals in this field had all been acceptedin principle. The first of these was the establishment ofan All-India Medical Institute ; cost, and shortages ofbuilding materials and teachers were causing delay,but these difficulties would be overcome. The second wasthe improvement of selected departments of existingmedical colleges. The third was the establishment ofspecial teaching and research centres for the study ofvarious diseases ; and malaria and leprosy had beensingled out as the first subjects for study at such insti-tutes. In addition, a Council for Postgraduate Educationwould supervise the training of specialists.The work of implementing various parts of the health

programme had been divided between a number ofspecial committees, some of which had already presentedtheir reports. The upgrading committee was examininghospitals with a view to making them suitable for post-graduate teaching. The vital-statistics committee hadproposed the appointment of a registrar-general forIndia, to be aided by provincial registrars. The firstregistrar-general had in fact already begun work, and itwas hoped that big changes would soon be made in thesystem of registration in the villages. The leprosycommittee had proposed the establishment of a centreat Madras for the study of this disease. The rural healthcommittee had not yet reported. In this field Dr. Rajaattached importance to the early establishment of primaryhealth centres, which could show quick results ; in someprovinces these might be built around the existingdispensaries. Furthermore, an effective anti-malariacampaign could greatly improve the general standard ofliving in the locality, as had been convincingly shown inCeylon. Another committee was concerned with theproblem of the indigenous systems of medicine ; thegovernment of India took its stand firmly in support

of scientific medicine, but felt that research into thetraditional systems should be stimulated.

Finally, Dr. Raja emphasised that India was partici-pating actively in the work of W.H.O., on whose agenciesit had many members. Both W.H.O. and F.A.O. werehelping India a great deal, especially in the fields ofmalaria, tuberculosis, and children’s diseases.

Sir BENNETT HANCE paid a tribute to Dr. Raja’s workas secretary of the Bhore Committee. He welcomed theproposal to establish an All-India Medical Institute,which he felt could do for Indian medicine what theJohns Hopkins Institute had done for Americanmedicine.

Sir GEORGE MCRoBERT hoped that Indian postgradu-ates working here would not spend their time studyingfor higher British qualifications, but would instead gainpractical experience in such specialties as thoracic andplastic surgery ; the higher degrees of Indian universitieswere quite as good as ours. He asked what the govern-ment was doing about population control, which seemedto be the most urgent problem of all.

Dr. Raja agreed that fertility was continuing tooutstrip mortality. At present a contraceptive programmewas out of the question ; there were not enough peoplequalified to give contraceptive advice and training,there were religious objections, and the consequencesof widely diffusing such advice might be undesirable.In any event, the result would not show itself for twogenerations. The problem was basically that of food-supply. There were 200,000 square miles of cultivableland which could be used for food production whenmalaria was controlled. The productivity of the soil waslow, but could possibly be increased threefold over thewhole country. These measures would more than closethe gap in the food-supply. There were also greatpossibilities of hydro-electric development. The solutionlay in improving the resources of the country, and ineducating the individual in a sense of responsibility.

New Inventions

APPARATUS FOR INTERMITTENT VENOUS

OCCLUSION

OVER ten years have elapsed since Collens andWilensky 1 first reported the results of intermittentvenous occlusion in peripheral vascular disease. Theybased their theoretical considerations of the practicalvalue of the method on the observations of Lewis andGrant,2 who found that raising the venous pressure ina limb with a tourniquet, followed by release of thepressure, produced vasodilation of the arteries lastingfrom half to three-quarters of an hour. In 124 cases ofperipheral vascular disease Collens and Wilensky showedthat treatment by intermittent venous occlusion couldrelieve pain, heal ulcers, and increase walking capacity.The benefit was apparent in arteriosclerosis, includingdiabetic peripheral vascular disease and thrombo-angiitis obliterans. These results were confirmed in thiscountry by Brown and Arnott.3

Fig. I—Principle of apparatus.