16 DR. G. C. CHATTERJEE: THE CULTIVATION OF TRYPANOSOMA, ETC. lilled with bluish-stained granules. No other structure could THE CULTIVATION OF TRYPANOSOMA be made out. The posterior end (that opposite to the OUT OF THE LEISHMAN-DONOVAN aagellum end) was finely drawn out as it were into a small flagellum. BODY UPON THE METHOD OF In the moist hanging-drop preparation made on the third CAPTAIN L. ROGERS, I.M.S. lay the appearance of the fully developed parasite was most interesting. In examining the specimen under 1/16 th inch BY G. C. CHATTERJEE, M.B., oil immersion lens I found several elongated flagellate ASSISTANT BACTERIOLOGIST, MEDICAL COLLEGE, CALCUTTA. bodies moving slowly across the field by a lashing side-to- side movement of the this end the front (With Coloured Illustration.) flagellum, being of the moving parasite. The movement was distinctly slow, much slower than that of an FOLLOWING the method of L. ordinary’ trypanosoma my teacher, Captain Rogers, (trvpanosoma Brucei or Evansi). No wriggling movement I.M.S., for cultivating Leishman-Donovan bodies in citrate could be made out. The thick flagellum end was ’distinctly of sodium solution I have succeeded in developing trypano-. seen moving among the broken-down red corpuscles which soma from the Leishman-Donovan bodies. were pushed out by the jerking movement of the flagellum. In one field .I a a The patient from whom the blood for making the culture found group of these parasites lying in clump, their anterior ends being free, reminding one was taken by spleen puncture was an inhabitant of Sylhet. of the rosette formation of trypanosoma Lewisi by Laveran He gave a history that three members of his family had died, and Mesnil.2 The free ends showed the movement of the recently from fever with enlarged spleen and oedema of the flagella. In the free ones no movement in the posterior end legs. He had been suffering from the fever for six months of the parasite was seen. The are in the and was anæmic. The reached down to the following peculiarities noticeable parasites very spleen described above: the of the micronucleus at the was There was no (1) position umbilicus but the liver not enlarged. anterior end of the body of the parasites ; (2) the long, marked pigmentation. The temperature of the patient at thick anterior flagellum ; (3) the absence of (or, if present, the time of the puncture was 102° F. rudimentary) undulating membrane; and (4) the rudimentary On account of the of these The following procedure was adopted for taking the blood posterior flagellum. presence from the patient and for cultivating the parasites found in it. characters they would appear to be less closely allied to the class such as Brucei and The skin over the region of the spleen was cleaned with soap trypanosomidæ, trypanosoma and water and then washed with a 1 in 20 carbolic lotion. trypanosoma Evansi, than to the class of trypanopis is characterised A five cubic centimetre syringe, sterilised in a 1 in 20 carbolic described by KeysSelitZ,3 which by the of a micronucleus at the anterior a lotion and washed in boiling water, was used for puncturing possession end, long anterior its from the micro- the spleen. After drawing out the blood it was emptied thick flagellum taking origin a and a into a test-tube containing one cubic centimetre of 5 per nucleus, rudimentary, undulating membrane, hardly cent. citrate of sodium (the test-tube with the citrate solu- discernible posterior flagellum which takes no part in the tion being previously autoclaved at 115° C.). The test-tube movement of the parasite. In I to indebtedness to wsa then placed in a beaker which was put inside an ice-box. conclusion, beg express my Captain A stained slide preparation of the blood made on the first Rogers, officiating professor of pathology, Medical College, for me the and for day showed a good number of distinct Leishman-Donovan Calcutta, kindly allowing to publish paper bodies, from three to four being found in a single field. On revising it. DESCRIPTION OF THE PLATES. the next day a stained specimen made from the citrated Plate 1 is drawn from a crowded field blood showed increase of the in so comparatively showing great parasites number, numerous developed Leishman-Donovan bodies on the third day much so that from 200 to 500 bodies could be counted in a stained with Leishman’s stain. Drawn under a 1/12 th inch oil immersion single field instead of the three or four seen on the first day. lens. No fully developed body is seen here ; several dividing flagellated parasites as well as several elongated Leishman-Donovan bodies with- The showed increased they were dis- ’ parasites development; out any flagella are seen. in was tinctly larger size. The micronucleus distinctly Plate 2.-From the same specimen, selected from several fields. increased in size and was less circumscribed and was No. 3 is a fully developed parasite curled upon itself. elongated in shape. The micronucleus was situated at one Calcutta. end of the oval body instead of being in the middle. The contents of the body of the parasite were more granular; numerous dividing ones were seen. No flagellate forms were CHILD STUDY AND THE TREATMENT OF found on this day. PARALYSIS IN CHILDREN. On the third day the stained slide from the blood showed 1 a remarkable appearance. In many of the fields were seen BY ALFRED A. MUMFORD, M.D. LOND., M.R.C.S. ENG. elongated Leishman-Donovan bodies with a thick flagellum. HONORARY PHYSICIAN TO THE GREENGATE DISPENSARY, SALFORD. In some portions of the field they were seen in thick clumps, the clumps consisting of from 30 to 40 flagellate bodies. THE art of walking and of standing as carried on by a In these clumps were seen all the stages from a simple human seems at first to ba Leishman-Donovan body to a fully developed trypano- fully-developed being sight soma-like body. Several dividing ones were also seen hardly more difficult of acquisition than the swinging of a possessing two flagella, two macronuclei, and two elongated jointed pendulum. On more careful examination, however, bodies to each other but lying parallel possession ;;- each stage of movement and each position of rest are found a micronucleus situated transversely to the body. single to be gained only as the result of many trials and not a few Several bodies were found which were indistinguishable from fa which have a of an ordinary Leishman-Donovan body except by the possession ilures, placed complex arrangement many of a long flagellum. Besides these there were the fully de- muscles under the control of the will. It is difficult to over- veloped ones, in which the body was elongated (much longer estimate the fact that each additional accomplishment is than a Leishman-Donovan body) an n rrow and provided only acquired after much individual effort of the child with a long thick flagellum. The flagellum was longer than and is not the mere exercise of an inherited nervous the body of the parasite and was thicker than the flagellum or, inisation. The intricate nature of the muscular arrange- of an ordinary trypanosoma (trypanosoma Brucei or Evansi). ment is clearly brought out when by a partial paralysis of It took its origin from the micronucleus situated at one end the limb some constituent element is thrown out of action. of the parasite ; in many the micronucleus was connected to Defective or discordant movements then result. A similar the flagellum by a portion of darkly stained protoplasm. complexity is noticeable in the movements of the upper as of A vacuole-like organ was seen near the micronucleus ; in the lower limb. This is evidenced by the fact that in some it was found towards the middle of the body of the extension of the hand on the forearm we not only contract parasite. The macronucleus was found situated in the the extensors but almost, though not quite, simultaneously middle of the body and was elongated in shape and not so we also contract the flexors of the wrist with a little less defined as in the Leishman-Donovan body. No undulating I vigour. By this means we provide not only a break which membrane could be made out. The body of the parasite was 2 Doplein and Sv. Prowazek : Handbuch der Pathologischen Mikro- organismen von Wassermann und Kolle, S. 933, fig. 45. 1 The detailed description of the flagellate bodies given here is 3 C. Keysselitz : Uber Trypanopis Grobbenii, Archiv für Protiste confirmatory of that already noticed by Captain Rogers. kunde, S. 367. PLATE I.

PLATE II.

TO ILLUSTRATE DR. CHATTERJEE’S AND CAPTAIN ROGERS’S PAPER ON CULTIVATION OF TRYPANOSOMA OUT OF THE LEISHMAN-DONOVAN BODY.

DR. MUMFORD: CHILD STUDY & TREATMENT OF PARALYSIS IN CHILDREN. 17

prevents a jolt or excessive action but we also guide the legs alternately. These early movements, which are pre- resulting movements into a more precise and definite cursory to walking, seem to be partially reflex in character. channel. ’ Though the child cannot actually walk or stand he has a considerable control over the movements There are considerable number of cripple children " already gained by suffering from congenital spastic paraplegia who show in a which he will presently be able to do so. very marked degree an irregular or abnormal innervation’ Another element in standing-viz., balancing of the head which is very instructive in any analysis of the movements and trunk-is next acquired. At first the child calls to his of the limbs. The difference that should normally exist aid the hands and arms and balances himself by grasping his between the’ innervation of the antagonistic groups by mother’s dress or some other object. This is half way to which the predominant group receives more and the bi-pedal progression. The position of the feet at this stage cooperating group less than its share of volitional of learning is very characteristic. The legs are separated impulses is well marked in these cases. This latter and widely apart, the toes are turned inwards, and there is a cooperating group, though it .is’ insufficiently innervated, vigorous flexion of the great toe and the digits so that the is not usually completely paralysed. The result of this feet seem to be actually gripping the floor. This stage is as regards the legs is that spasm occurs in the predominat- generally acquired by the twelfth month. (Fig. 1.) ing group such as the adductors and internal rotators, and paralysis of the abductors and external rotators. FIG. 1. A more or less complete inability to use the limb naturally results. The cause of this disarrangement’of innervation is generally that some portion of the cortex of the brain, or some portion immediately subjacent to the cortex, has been injured by disease generally before birth. From this cause the normal impulses do not arise from the cortex to set the limbs in action. To this must be added the fact that peripheral impulses of muscular and tactile sense also fail to reach the cortex and help in the elaboration by which the irregular and aimless movements of infancy become organised into orderly purposive movements. When the original disease has ceased to be active more or less recuperation of tissue occurs. The less injured areas become capable of discharging impulses and of receiving peripheral sense impressions. In cases of spastic paraplegia both these occur later than in the healthy child. There is in them a long period of listlessness, apathy, and paralysis. The children also generally suffer from defective speech. Mental deficiency is also common. Such cerebral impulses as do occur are irregular and unequally distributed to the different muscle groups, consequently the combined spasm and paresis already referred to result. If by the time the child is six or eight years old he has, of himself, acquired sufficient muscular coordination to be able to get about on crutches, orthopaedic surgery is able to deal with the case and provide a more or less satisfactory limb. In the severer forms of this disease little or no benefit accrues from such treatment. The extent of the spontaneous cure depends partly on the amount of brain tissue still left uninjured ; it of a normal child to show the also on the means that are taken to Diagram important part played depends largely the toes in are so flexed that ameliorate the condition Further by standing ; they tightly by the child’s attendants. they seem actually to grip the "floor. The toes are directed examination of this condition will, I believe, enable us to inwards and the feet separated. accomplish considerably more than has hitherto been generally supposed. Every fresh effort made by the child, Before the child acquires the power of maintaining an erect and of there is and especially every successful effort, in achieving a new position walking upright very frequently an intermediate of on all fours organised movement becomes in its turn a very potent stage progression (Fig. 2). therapeutic agent. FIG. 2. A number of cases of infantile spastic paraplegia were taken into the Greengate Dispensary about six months ago. They were apparently hopeless cases. A course of exercise-treatment was planned upon lines to be presently described. So much benefit has already accrued that it seems advisable to bring forward the methods adopted for the examination and criticism of those who have to deal with similar problems. These methods are based on a study of the natural order in which the normal child acquires control of the muscles used in walking and in standing. A brief description of the order of this development is therefore perhaps not out of place. The movements of a very young infant largely consist of those of the head and neck, the eyes, and the coarser movements of the arm and leg. The order and degree in which these pass from spontaneous aimless movements into voluntary purposive movements have already been described by me in Brain (autumn number, 1897). At the age of three or four months normal infants have sufficiently acquired voluntary power over the spinal and other muscles to be able to sit upright and to look about them. An important part of their education in coordination has been obtained by kicking against the bed, &c., and so arousing the muscular and tactile senses ; by this means they gain a knowledge of the force to be Diagram composed from a photograph by Dr. S. Buckman, exerted and also a of the showing a child, aged ten months, with plantigrade progres- knowledge position; by sion. Transactions of the Cotteswold Naturalists’ Field Ciub, sixth month the child exhibits sufficient pleasure in December, 1899. organised muscular action to enjoy pushing his feet against the floor when the attendant holds the body and allows the This is generally carried on by the child balancing his body feet to dangle; and by the ninth or tenth month rhythmic on two hands and one foot, using the knee of the remaining movements of extension and flexion take place in the two leg as a paddle to push himself along. The everted position 18 DR. MUMFORD : CHILD STUDY & TREATMENT OF PARALYSIS IN CHILDREN. of the hands and soles of the feet exhibited in these move- to be a reason for stopping the treatment temporarily. ments of progression may be described as displacement ones. Spasm also occurred on any excitement. The next stage The movements were apparently originally adapted for a consisted in an attempt to imitate the four-footed fluid medium but when used by the child against a rigid method of progression. The child was laid on his face, resisting medium such as the floor they result in moving the a bar fixed to a chain was placed in his hands, and while body of the child. Progression on all fours causes a great improvement in the muscles of the trunk. It also develops FIG. 4. the abductors and external rotators of the thigh and helps to coordinate these with the adductors and internal rotators. The importance of understanding this stage is very great when we come to study the symptoms of spastic paraplegia of infancy. It is owing to the weakness of the external rotators and the abductors of the thigh that spasm occurs in the adductors and internal rotators when the child attempts to walk. The confusion causes the legs to become useless for walking or standing. The duration of the period of four- footed progression in the normal child is much influenced by the methods adopted in his early training. It is frequently entirely passed over. One observer records that his daughter who was entirely left to her own devices began to creep about on all fours by the end of the fifth month; by the end of the tenth month she moved briskly about on all fours like a monkey. She made no attempt at this time to raise the body into an erect position. Another observer writing in Nature, July, 1900, gave a photograph of a child, aged ten months, who also showed this four-footed progression very completely. After a febrile illness occurring a little later this power became completely lost. The method which a child naturally follows in acquiring control over his limb movements has suggested the line adopted in the treatment of the cripples at Greengate Dispensary. The teacher or masseur began by steadily practising flexion and extension of the almost useless legs. After a time he practised a slow external rotation and A normal child, 22 months old, able to stand on his feet when circumduction of both thighs. He constantly massaged all the arms and shoulders cooperate in supporting him. the muscles to stimulate them to healthy action and to over- face downwards he was to himself come the rigidity. These exercises were practised for a few lying encouraged pull forward. The mere in this is for it minutes at a time at least 12 or 14 times a day. The child’s lying position good, extension of the with some attention was directed to these movements that produces hips together abduction. constantly exercise in this leads almost they might be permanently engraved on his memory and so Voluntary position automatically to a certain amount of external rotation and a separation FIG. 3. of the thighs. In the early stages the legs themselves hardly seem to participate at all in the forward movement but remain inert; presently, however, they definitely do partici- pate and a step forwards to quadrupedal progression is FIG. 5.

A normal child, about 20 months old, helping to raise himself by means ot a curtain; he is able to use his legs when assisted by his arms. able to stand become organised in the cerebral cortex. Presently an attempt A normal child, 22 months old, alone with the feet and the knees not quite extended; the arms was child when on his to separated made by the lying back make these are held out to assist balance. movements voluntarily and without the accompanying spasm. As soon, however, as the child was held upright secured. About this time the child can be taught voluntary and the legs were allowed to dangle the spasm returned on movements of abduction and circumduction of the thighs the child making any exertion. Spasm was always held and also alternate flexion of the two legs. When by means DR. JOHN HADDON: DIET IN CHRONIC DISEASES. 19 of these movements a fair degree of flexibility and a diminu- ribs was very sensitive to touch. There was no distension tion of the spasm have been secured a further stage may be but some dulness on both sides, due probably to fæcal matter, tried and the child encouraged to put his feet upon the floor. and fæces could be felt in the intestines. There were Like an infant, his body must at first be securely held. Then splashing in the stomach and abdominal pulsation. The again following the lines of normal progress the child may be pulse was weak and the heart sounds were feeble, without encouraged to balance himself by holding on to the side of any murmur. She was too weak even to sit up. She the bed or a suitably constructed walking frame. was ordered to have nothing except water. On the Attention has now to be paid to the movements of the 29th, about 2 A.M., her sisters, who were nursing her, shoulders and the arms. Reference to Figs. 3 and 4 shows thought that she was dying and sent for her medical that in normal children the muscles of the shoulders and attendant who ordered an enema of beef-tea and brandy the arms play a very considerable part in maintaining the in teaspoonfuls by the mouth. When I saw her in the fore- balance of the body at this stage. In the case of the cripple noon she had brought up three-quarters of a breakfast- children these muscles, like those of the leg, are very weak cupful of the greenish fluid since the day before and had and ill-developed. They need special attention. Accord- drunk six breakfast-cupfuls of water, mostly on the previous ingly parallel bars are arranged of such a height that when day. She had a natural motion in the morning, with the child is held upright, with his arms held straight down- traces of yellow, that which the enema had brought away wards, he can just grasp the bars while his feet touch before being of a dark colour throughout. The dulness on the ground. He then learns to hold himself from the ’, the right side of the abdomen had disappeared and there shoulder. was no splashing in the stomach. She cried out with pain When by these means a fair degree cf balance has been in the epigastrium, but there was no tenderness on pressure gained the child may be trained to use crutches. Volitional and the pain was intermittent, not lasting long. She had control over the coarser movements of the thighs and knees slept four hours in the night. Tracing No. 1 shows the has been gained but without the power of grasp in the character of the pulse and was the best that could be got. hands and the power of holding the arms and shoulders She was ordered to have five figs boiled and the soup from rigid ; this has been found to be useless. Whether further them given in tablespoonfuls every four hours, with water power can also be gained in the finer movements of the if she wished during the intervals. On the 30th she did ankle and foot must be decided by further experiments. not sleep but the pain was less severe. She had had three It may be that methods of orthopaedic surgery will alone pints of water and had vomited two pints of the greenish be efficacious-the children at Greengate Dispensary are fluid, darker than before, which was coloured no doubt by under the supervision of surgeons who have interested them- the fig soup. She was more cheerful and hopeful. Some- selves in this branch of work. Sufficient experience has ’, thing like an enlarged appendix could be felt in the right been gained to justify the workers at the Greengate Dis- side of the abdomen. There was no flatulence. The urine pensary in the prosecution of further researches. It is was normal. She was ordered to have five figs stewed, the hoped that others who have thought much upon this juice to be concentrated to a teacupful and given every four matter will offer suggestions or criticisms. hours. It may be added that these movements and exercises are On July lst the patient said that she had not slept in the evidently a source of real pleasure and joy to the child and night but had lain and talked to herself, which surprised that he increases in weight, in vigour, and in mental alert- her. She had had a scanty yellow motion ’with some black ness while they are being continued. Constant intermission pieces in it and had brought up very little fluid since the must be provided as he very readily tires. previous day. She said that she had pain after the fig Manchester. juice but had vomited nothing since she had it at 8 o’clock in the morning. She was ordered to have ten prunes stewed and their juice, alternately with that of the figs, at intervals DIET IN CHRONIC DISEASES. of four hours as before. Tracing No. 2 shows the pulse. On the 2nd she had for five hours in the The BY JOHN M.D. EDIN. slept night. HADDON, M.A., prune juice had caused her more discomfort than the fig juice. She looked much better and could sit up. There had As the subject of diet is receiving considerable attention, been a motion in the morning which was thin and smelt At noon she sucked the from some onions which more in America, the cases seem badly. juice especially following worthy had been cooked till were sweet. She was ordered to of recorded. they being have the prune and fig juice mixed and to take it alternately CASE 1.-The patient, an unmarried woman, aged 66 with the onions every four hours. years, had an illness when 18 years old which was said to be On July 3rd she had slept for three hours in the night. a gastric trouble and at that time she was ill for two She was said to have been very bad at 2 A.M. and could not Four ounces of were at and years. She had had similar attacks every seven years since speak. whey given 1 P.M. this was ordered to be continued four hours with one date and had been more or less an invalid. When seen in every between. On the 4th there was no complaint of weakness in consultation with her medical attendant on June 28th, 1904, the night. There was no motion or flatus passed and fasces I found that she had been in bed for six months and was could be felt in the left side but no distension. Fulness was being fed on Benger’s food, having one grain of morphine in still felt about the region of the appendix. She was ordered FIG. 1 (CASE 1).

FIG. 2 (CASE 1).

a suppository every night, and was reduced to a perfect to have eight ounces of whey every four hours and a date skeleton. She brought up, apparently by a kind of eructa- with it. She looked much better. On the 5th she had slept tion, fluid of a greenish colour, varying from half a pint to for four hours in the night and had had a motion which was a pint during the day. The bowels did not act except by ’’ hard and dark in colour. On the 6th she had slept for two medicine or an enema. She was taking food to relieve pain hours in the night. There had been a copious motion at which came on two hours after food and which the food 6 A.M., the hard portions of which were still dark in colour, relieved. She was supposed to be dying and looked as if she while the soft portions were yellow. were. The skin over the left side of the abdomen and the On July 7th she had a soft motion which was more