514 TYPES OF STREPTOCOCCI IN SCARLET FEVER.

list, probably because they are comparatively welloff, and have plenty of time for rest and social inter-course between fares. In 81 cases the habit wasacquired below the age of 35, and, once started, ittended to continue for many years. Sixty-five ofthe addicts declared that opium-eating did themharm ; they wished to give it up but were afraid todo so because of the symptoms which develop onwithdrawal of the drug. Heredity did not appear tobe an important predisposing cause. In this seriesof 100 addicts, 34 took from 10 to 20 gr. of opiuma day, 25 per cent. took more than 20 gr. a day, anda number of the latter took over 50 gr. The largerdoses were taken by the younger men. Individualstudy showed that the habit decreases workingcapacity, whilst the rapid onset of withdrawalsymptoms quickly causes slavery to the drug. Itis worth noting that all the addicts examined wereat work. This probably means that the later andmore disastrous consequences of the habit are masked,for these would be found among men who were nolonger fit for employment.

THE ANOPHELINE MOSQUITO.IT is now nearly 30 years since Ross in India first

demonstrated the presence of the parasites of humanmalaria in the gut of " dapple-winged " mosquitoes.Since then a large amount of research has been carriedout in various parts of the world regarding the partplayed by anophelines in the dissemination of thedisease. At first it was thought that all anophelinemosquitoes were equally concerned in the transmis-sion of malaria, but research by Stephens, Christophers,James, and others effectually demonstrated thatcertain species were far more efficient malaria-carriersthan others. In considering the part played bydifferent species, it has to be remembered that manyfactors may affect the results of observation. Amongstthese may be mentioned the time of the year at whichthe investigation is carried out, and whether or not imalaria is rife at the time. As is pointed out bySwellengrebel, Schuffner, and de Graaf,several questionsmust be answered in assessing the capabilities of anyparticular species. Does the species occur in greatnumbers ? Is it capable of allowing the parasites ofmalaria to complete their development ? Does it

habitually feed on human blood, not only in captivity,but also in nature ? Does it feed in the jungle, ordoes it regularly visit man in or near his dwelling-places ? In an Indian medical research memoir 1 of117 pages Major G. Covell, of the Central MalariaResearch Bureau, Kasauli, has now summarised allthe available information on these subjects, arrangingthe known species of anopheles in alphabetical order.He has considered the distribution, breeding-places,habits, relation to malaria, and experimental infectionsof anophelines, and in so doing has conferred a veryconsiderable boon on his fellow-workers not only inIndia but throughout the tropical world. The reportincludes a very complete bibliography as well as anindex.

____

TYPES OF STREPTOCOCCI IN SCARLETFEVER.

Dr. F. Griffith, of the Ministry of Health, has foundthat haemolytic streptococci isolated from cases ofscarlet fever fall into three main serological groups(Types 1, 2, 3), while a large heterogeneous group oforganisms-roughly 50 per cent. of the whole-whichseem to possess individual antigenic properties

’ are designated Type 4. Of these groups Type 2 isthe most sharply defined, and is found only in associa-tion with scarlet fever, while Types 1 and 3 show

1 Memoir No. 7 (Supplementary Series to the Indian Journalof Medical Research). A critical review of the data recordedregarding the transmission of malaria by the different species ofanopheles ; with notes on distribution, habits, and breeding-places. By Major G. Covell, M.D., I.M.S. Published for theIndian Research Fund Association by Thacker, Spink, and Co.,Calcutta.

relationship with heemolytic streptococci from non-scarlatinal sources, such as puerperal fever and sore-throat. Similar results have also been obtained byG. R. James and J. Smith, and an attempt hasnow been made by Dr. William Gunn 1 to correlatethe type of streptococcus found in scarlet fever withthe clinical findings. One hundred patients withscarlet fever were investigated, and streptococci wereisolated from 93 of them. In two cases the organismswere of Type 1, in 34 cases of Type 2, and in 17 casesof Type 3, whilst in the remaining 40 they were either ofType 4 or unclassified. ’The proportion of types was notdependent on any age-groups. No definite conclusionscould be drawn about streptococci of Type 1 as onlytwo cases occurred in the series ; Type 2 was associatedwith the most typical and severe forms of the disease ;Type 3 with those which were less severe ; and Type 4appeared to cause only a mild attack. The complica-tions were most severe when Type 2 organisms werefound, and were less numerous and severe in Types 3and 4. Infection by the unclassified strains clinicallyresembled infection by Type 3. There were fourinstances of scarlet fever occurring in two members ofthe same family, and in each case the type of strepto-coccus isolated from different members of the familywas the same (Type 2 three times and Type 3 once).The differences in type of the scarlatinal streptococcimay explain the different results obtained with thesame batch of scarlatinal antiserum in cases apparentlysimilar from a clinical standpoint, and may also,explain why some cases give anomalous results to theDick and Schultz-Charlton tests. It will be necessaryto consider the risk that a patient with mild Type 4infection may be attacked whilst in hospital by avirulent Type 2 streptococcus ; it has often beenobserved that when hospital beds are close togetherthe proportion of cases developing scarlatinal com-plications may become larger. Though the importanceof recognising the various types of scarlatinal strepto-cocci has not been fully determined, it is obvious thataetiology of scarlet fever is not quite

a simple as was

thought at first. ____ BWE offer our congratulatioys to Mr. Priestley

Smith on receiving the Lucikii Howe medal of theAmerican Ophthalmological Society. This medalhas been awarded only three times previously, therecipients being Dr. Kohle, of Vienna, who first usedcocaine in ophthalmic surgery; Prof. Fuchs, ofVienna ; and Dr. Edward Tackson, editor of theAmerican Journal of Ophthalmology. Mr. PriestleySmith was personally visited, on behalf of the Society,by Dr. W. H. Wilder, who took the opportunity ofseeing the apparatus which Mr. Smith is using inhis investigation of the circulation of the eye.

WE are asked to remind readers that the nextsession of the Journees M édicales, organised by acommittee of the Revue Pratique des Maladies des-Pays Chauds, will take place from Dec. 15th to 24th,1927, in Cairo. All communications should beaddressed to M. Zeitoun, Secretaire-General, 32, RueGay-Lussac, Paris (V.). The organisation has receivedthe support of numerous influential Egyptians bothas patrons and as active collaborators. The Com-mittee have under consideration the propositionrecently made by the Egyptian Government to makea session of the Joitrnges Medicales coincide withthe centenary of the Kasr-el-Aini Hospital inDecember, 1928, and we learn that there is everyintention to establish a close relationship betweenthe two movements.

1 Metropolitan Asylums Board Annual Report, 1926-27.

LEGACY TO THE PASTEUR INSTITUTE.-The deathhas occurred at his villa at San Remo of Dr. Rene MariusAppert, of Paris, aged 65, who has bequeathed the residueof his estate to the Pasteur Institute, Paris. The value ofthe legacy is expected to approximate to .8160,000.

515GENERAL PARALYSIS OF THE INSANE.

Modern Terbnique in Treatment.A Series of Special Articles, contributed by invitation,on the Treatment of Medical and Surgical Conditions.

CCXXXIX.

THE TREATMENT OF G.P.I. (PARESIS ;DEMENTIA PARALYTICA).

I. THE RECENT CASE.lPARESiS has for long been regarded as a hopeless

condition in which treatment was of no avail. Thisis not now an accurate view. Life can be prolongedand remissions encouraged by prompt treatment andproper care.proper care.

Early Diagnosis.Early cases offer the most favourable prognosis.

Character changes in early middle life, or later, shouldprovoke a minute search for the well-known physicalsigns of general paralysis on the part of the practi-tioner. If there is any doubt specimens of the bloodand cerebro-spinal fluid should be obtained forth-with, so that any uncertainty can be quickly resolved.The refinement and accuracy of modern methods ofdiagnosis should ensure the recognition of paresis ata very early stage. Advanced cases may improveunder treatment, but psychical defect nearly alwaysremains.

Malaria Therapy.The malarial treatment offers new hope in the

treatment of paresis. It is the natural result of thealmost despairing use of substances which have hadsome unknown stimulating effect on -tissue resistance,indicated by a sharp leucocytosis and accompaniedby pyrexia. Injections of such substances as nucleinicacid, sodium nucleinate, phlogetan, and lecithin havebeen followed by improvements. Sera have also beenused, and vaccines prepared from a variety oforganisms have been tried.The treatment of paresis by inducing an attack of

benign tertian malaria gives results which hithertohave never been attained. Not every case of paresisis fit for treatment by malaria, and several considera-tions must be weighed carefully before it is decidedupon, but the method can be advised for everysuitable case. An important factor is the age of thepatient. The older he is the less satisfactory theresult, and the greater the risk of a fatal issue. Fora patient older than 45 the treatment entails increasingrisks, and results may be poor. The response seemsto be best in the classical elated or manic patient.The depressed paretic, the tabo-paretic, and theslowly dementing forms of the disease give less satis-factory results, though exceptions do occur. Renaldisease, the presence of jaundice, cardiovasculardisease, and marked anaemia increase the risk ofmalarial therapy and may even contra-indicate itsuse. A careful examination and frank discussion withthe family should precede treatment when patientsare suffering from conditions which will add to thedangers of the pyrexial period. :

Technique. ,

The treatment consists in infecting the patientwith benign tertian malaria, and allowing the malariato continue unchecked until 10 to 14 rigors haveoccurred, when the fever is controlled by the adminis-tration of quinine. The best means of producinginfection is to take 3 c.cm. of blood from a patientalready under treatment, preferably during a febrileattack, and injecting it subcutaneously in the sub-scapular region of the recipient. After an interval,which varies from 6 to 21 days, the rigors commenceand should be allowed to continue as long as thepatient can safely tolerate them. Another method

1 An article by Dr. James on the Treatment of GeneralParalysis: II. The ChronicCase, will appear in this series next

week.

is the use of suitable infected mosquitoes, which areprocurable with the generous assistance of the Ministryof Health. The mosquitoes are brought to the patientin glass containers which are applied to the skin,and are allowed to bite freely. In my opinion, themalaria produced by mosquito bite is less easy tocontrol by quinine than that produced by infectedblood, and relapses of the fever more frequent.During the pyrexia confusion, delirium, and hallucina-tions are common, and wild excitement may occur.On the whole the patients are fairly tractable. Thetreatment will necessarily confine the patient to bed,though he may be allowed up between the first twoor three rigors. The pyrexia varies, but temperaturesof 104° to 106° F. are common. The fever may betertian, with rigors on alternate days, but is oftendouble tertian, the paroxysms taking place daily.Regular examinations of the urine should be made.

Albumin is sure to appear, but need not cause alarmunless it becomes large in amount. Pronouncedalbuminuria, the appearance of jaundice or markedcollapse are indications for arresting the course ofthe malaria, but it must be remembered that thebest results follow 10 to 14 rigors. No treatmentmust be allowed during the rigors save sponging whenthe temperature rises to 105° or more.The administration of quinine by the mouth arrests

the malaria in a most effective manner. Quininesulphate, or hydrochloride, gr. x. t.d.s. for three days,produces a rapid subsidence of the fever, and theparasites disappear from the blood. The quinineis even more effective if given intramuscularly,and when there is an urgent need to control thepyrexia it may be given intravenously. The patientwill have lost weight, may be weak and ansemic, butas convalescence becomes established the mentalcondition should improve, and may continue to

improve for three or four months after the cessationof the treatment. During this period novarsenobillonor sulfarsenol should be administered intravenously.It is well not to begin with too large a dose, and toincrease the doses gradually. The malarial treatmentmay be carried out at home, in a nursing home, orhospital. The room of the patient is best renderedmosquito-proof by framing the windows and doorwith fine net. A frame may be made also for the bed,which can with advantage be protected.The patient should be instructed to return for a

course of treatment by arsenical compounds everysix months during the remission of his symptoms.Lumbar puncture is useful in giving laboratoryinformation as to the result of the treatment. TheWassermann reaction remains positive, but thereshould be a pronounced fall in the lymphocyte countand a diminution in the globulin content.

Other Methods.Trial is being made of a method for inserting

salvarsanised serum into close contact with thesurface of the brain by performing cisternal puncture.When convalescence after the malaria is establisheda dose of N.A.B. is given, and after 30 minutes someounces of blood are withdrawn, from which the serumis extracted. The following day, under a generalanaesthetic, a needle is inserted into the cisternamagna, and the serum introduced, first withdrawinga similar quantity of cerebro-spinal fluid. Six injec-tions are given at weekly intervals and very markedimprovement has been recorded. Tryparsamide,a sodium salt of N-phenylglycineamide-p-arsonic acid,is also being used for the treatment of paresis. It isone of the substances which apparently passes thechoroid plexus, and though there are definite risksassociated with its use, it may be advised whereother methods have failed. It is best given intra-venously in doses of from 1 to 3 g. dissolved in10 c.cm. of sterile distilled water. Not less than eightdays should intervene between the injections, andeight injections complete the average course. Oculardisturbances are the chief risk. They may be tem-porary, but complete and permanent blindness hasresulted in some cases from the use of tryparsamide.