240 



nirilTHERIA IN THE TKOPICS 



Seasonal 

 incidence 



A Khartoum 

 case 



I have gone through the laboratory records from July, ]{)03, to November, 1910, and, 

 during this period, I find only 24 cases of diphtheria have been diagnosed bacteriologically. 

 Of these, swabs from nine came from Khartoum, one being certainly a case in which 

 infection took place in Egypt or on the way to Khartoum. In ten cases the swabs were 

 sent from Omdurman, while Atbara (2), Shendi (1), and Dongola (1), supplied tiie remainder. 

 There were only 4 cases in Europeans, one of which was imported. 



No less than 1/) of the 24 examinations were made in September, October or November, 

 the greatest number being in October. There were three in December, two in January, two 

 in March, one in February and one in August. It is possible that this greater tendency 

 for cases to occur in the autumn is due to the influx of persons from Egypt at this 

 season. No doubt carrier cases are introduced but, as a rule, the disease does not 

 spread, possibly on account of the dryness of the atmosphere. That it may become 

 epidemic in the Sudan is shown by an outbreak which occurred early in January, 1910, 

 amongst Arabs in certain villages not far from the Nile in the Upper Nile Province, and 

 which caused 19 deaths out of a total of 2G attacked. The natives themselves recognised 

 the disease which they call " Luhana " and which was laryngeal in type, as mentioned 

 by the Medical Officer in charge of Dueim, whose interesting report I have seen, thanks 

 to the courtesy of Colonel H. B. Mathias. 



The climate in these more southerly regions is of course more humid, and there 

 were stagnant water pools in the neighbourhood of the villages scourged by the epidemic. 



Of the 24 cases mentioned, three are described as " coccal," and a fourth, a contact 

 case, as doubtfully coccal. One has to distinguish between cases which show coccal 

 forms in swabs from the fauces and those in which coccal forms appear iu culture on 

 agar or blood serum. What first drew my attention to the subject was the finding of 

 what was practically a pure culture of curious cocci in films made from a swab sent from 

 a case at Atbara vhich, clinically, was typical diphtheria and which proved fatal. These 

 cocci showed Neisser's granules when stained by his method and gave characteristic 

 B. diphtheritv colonies on Loeffler's serum. Unfortunately my specimens of this case were 

 lost in the fire, and, though I met with one or two other coccal cases, it was not until 

 late in 1909 that I had a chance of making any detailed study of the condition. At that 

 time we had some diphtheritic material in the laboratory from a case of considerable 

 interest (vide infra) which had occurred in Khartoum. 



On December 10 one of our native laboratory attendants who, amongst other things, 

 had been sterilising old cultures, complained of a sore throat. I examined him, found 

 patches of membrane in his fauces and discovered enlarged and painful glands beneath 

 his lower Jaw angles. He had no temperature. His throat was swabbed and typical 

 R. diphtheria}, together with a mixed flora, found in films made direct from the swab. The 

 swab w^as rubbed over a slant of Lcoffier's serum. Colonies all of one type, morphologically 

 like those of U. diphtlierite, but microscopically composed wholly of Gram-negative cocci 

 appeared within 24 hours (Incubation at 37' C). Either because the significance of 

 this result was not at the moment recognised, or for some other reason which I have 

 forgotten, these coccal cultures were not followed up. 



The man was isolated as a very mild " contact " case and, the supply of antitoxin 

 being limited, was given formamint in the form of tablets. He sucked these with such 

 vigour that his throat was clear on the following day and his glands had improved, but, 

 on December 15, a yellow, follicular plug was seen on the right tonsil. On swabbing, 

 this yielded only Gram-negative diplococci, to all appearance identical with those which 

 developed on the serum cultures made on December 10. They contained granules which 



