CONGENITAL SYPHILIS IN A FIJIAN
1
638 Before the first pulmonary embolism the patient received 0.20 mg. digitoxin daily with some benefit, although even with this minimal dosage the number of premature beats rose slightly; with 0,30 mg. they became so frequent that the pulse-rate actually increased. With a change to other digitalis glucosides the result was the same ; and thus digitalis adminis- tration in sufficient dosage was prevented. After the first embolic episode, however, and simultaneously with the heart-failure, complete intolerance to digitalis developed, so that even the small dosage previously tolerated gave rise to numerous ventricular beats with an increased pulse-rate. With mercurial diuretics it was not possible to compensate for the lack of digitalis, and after the third pulmonary embolism the situation, of the patient again became critical, owing to the steadily progressing heart-failure. In an attempt to suppress the stimulating action of the digitalis on the ventricular foci from which the extrasystoles were originating, 2’5 g. pronestyl was administered daily with 0.40 mg. digitoxin. This met with full success. Within a fortnight, under this treatment combined with mercurial diuretics twice a week, complete compensation was achieved. The side-effect of the digitalis on the rhythm was almost entirely eliminated-only a very few premature beats were present from time to time-and the glucoside could now be given in a dosage never before tolerated which produced a sufficient inotropic action and slowed the pulse-rate to 80 per min. The patient has now resumed his professional work on a reduced scale. It should, however, be borne in mind that pronestyl has not the same effect on auricular premature beats. Anglo-Swiss Hospital, Alexandria, Egypt. FR. MAINZER. CONGENITAL SYPHILIS IN A FIJIAN SIR,—Stitt 1 states that amongst the Pacific Islanders a relative immunity to syphilis is found in spite of repeated exposure to infection from syphilitics of other races. In Fiji syphilis is widespread amongst Indians and part-Europeans, but it is doubtful if the disease has ever been recorded in a pure Fijian, though Lambert 2 quotes (without clinical details) one case described to him by Harper. The following is a description of a case of congenital syphilis in a pure-blooded Fijian. A Fijian girl, aged 23, of pure Fijian descent, born in the Tailevu district of Viti Levu, denied infection with yaws in childhood. At the age of 13 she came to live in Suva, where she remained throughout the war. In 1945 she was admitted to the Colonial War Memorial Hospital, Suva, where the Kahn reaction of her blood was found to be + + + +. She received a total of 3’0 g. neoarsphenamine and was then discharged. Though unmarried she was living with a pure- blooded Fijian when she became pregnant for the first time, and was admitted to the obstetrical annexe at the hospital on Aug. 27, 1950, suffering from an antepartum haemorrhage. Shortly after her admission she was delivered of a macerated male foetus ; the placenta was removed manually as it was adherent. The Kahn reaction of her blood was still + + + +. After 4 injections of neoarsphenamine she absconded. Microscopically the placenta was fleshy. Microscopical examination showed extensive fibrosis, endarteritis, and loss of blood-vessels from the villi-all typically syphilitic changes. The fcetus was almost full-term and was well macerated. Section of the liver stained by Levaditi’s method showed numerous spirochætes indistinguishable from those of Treponema pallidum. It is generally admitted by authorities that no case of congenital yaws has ever been observed (Stitt 3): yaws is said to be neither hereditary nor congenital.4 The present case therefore appears to be one of acquired syphilis in a Fijian girl with congenital syphilis in her offspring, and this indicates that there is no racial immunity to syphilis in Fijians. In the absence of racial immunity, the rarity of such a syphilitic infection must be ascribed to an acquired immunity. It is thought that infection with yaws in 1. Stitt’s Tropical Diseases. London, 1942 ; vol. i, p. 397. 2. Lambert, S. M. J. trop. Med. Hyg. 1931, 34, 117. 3. Op. cit. (footnote 1) p. 422. 4. Manson-Bahr, P. H. Manson’s Tropical Diseases. London, 1950 ; p. 626. childhood confers relative immunity to syphilis. Should this immunity become less pronounced, then syphilis could be as readily acquired by Fijians as by other races. In the many Fijian women now attending the antenatal clinic at the Colonial War Memorial Hospital in Suva the Kahn reaction of the blood is often found to be negative. It is therefore probable that, owing to the efficient control of yaws which has been established, many Fijian girls are never infected with it in childhood. The girl in question evidently escaped infection in early life, but was then exposed during the war years to syphilitic infection in Suva. In planning extensive anti-yaws campaigns amongst primitive people, consideration should be given to the ’possibility that their immunity to syphilis might thereby be destroyed. I have to thank Dr. J. M. Cruikshank, Inspector-General, South Pacific Health Service, for permission to publish this case. P. E. C. MANSON-BAHR Physician-Specialist, Fiji. THE FALSE " ACUTE ABDOMEN " SIR,—In his letter of Jan. 13 Dr. H. M. Royds Jones quotes a paper which Le Marquand and I wrote five years ago.’ We described a series of cases which clinically simulated perforated duodenal ulcer; instead of operating immediately we observed them for a few hours and we were rewarded by a complete change in the clinical picture with spontaneous recovery. Dr. Royds Jones describes a series which also recovered rapidly and spontaneously. He then proceeds to discuss our paper : he writes that we described an " epidemic of Bornholm disease." Reference to our article will show that we were not, at the time, convinced that we were dealing with an epidemic ; we considered many possible explanations but Bornholm disease was not among them. We suggested that the syndrome may have been due to a fornze fruste of perinephric infection. However in the course of time I have modified my own opinions : perinephric infection does, in a transient phase, mimic the " acute abdomen," but this explanation cannot be stretched to cover all the cases we described. I believe now that our series was a minor epidemic ; but I cannot allow these cases to be labelled as Bornholm disease. The original epidemic of Bornholm disease occurred on the Danish island of Bornholm, and the main features observed were severe fleeting pain and rigidity of muscles innervated by the thoracic part of -the cord. Since the work of Lewis and Kellgren 2 we know that lesions of almost any deep structure will elicit the response of rigidity and pain in the muscles of its segment. With the march of time Bornholm disease will prove to have e been an all-embracing title for many different lesions (their theoretical limit is equal to the total number of deep structures within the thoracic nerve territory multiplied by the total number of their pathogens !). Scientifically the. diagnosis of Bornholm disease should command as little respect as, for example, the diagnoses of sciatica or rheumatism. Certainly we must acknow- ledge that there are epidemics of severe transient pain and rigidity in the great trunk muscles ; but these epidemics must. be due to many different causes. Dr. Royds Jones’s case-histories are consistent with my speculations. He is to be congratulated on a series of observations, under difficult conditions, extending over twenty-three years. Suspected ulcer perforation was once an immediate signal for operation. The possibility of a " false acute abdomen " as discussed in this correspondence, should give pause for thought. There is now further additional argument against great haste to operate : the work of 1. Goldstone, B. W., Le Marquand, H. S. Lancet, 1946, ii, 267. 2. Lewis, T., Kellgren, J. H. Clin. Sci. 1939, 4, 47.
Transcript of CONGENITAL SYPHILIS IN A FIJIAN
638
Before the first pulmonary embolism the patient received0.20 mg. digitoxin daily with some benefit, although even withthis minimal dosage the number of premature beats roseslightly; with 0,30 mg. they became so frequent that thepulse-rate actually increased. With a change to other digitalisglucosides the result was the same ; and thus digitalis adminis-tration in sufficient dosage was prevented. After the firstembolic episode, however, and simultaneously with theheart-failure, complete intolerance to digitalis developed, sothat even the small dosage previously tolerated gave rise tonumerous ventricular beats with an increased pulse-rate.With mercurial diuretics it was not possible to compensatefor the lack of digitalis, and after the third pulmonaryembolism the situation, of the patient again became critical,owing to the steadily progressing heart-failure.
In an attempt to suppress the stimulating action of thedigitalis on the ventricular foci from which the extrasystoleswere originating, 2’5 g. pronestyl was administered daily with0.40 mg. digitoxin. This met with full success. Within a
fortnight, under this treatment combined with mercurialdiuretics twice a week, complete compensation was achieved.The side-effect of the digitalis on the rhythm was almostentirely eliminated-only a very few premature beats werepresent from time to time-and the glucoside could now begiven in a dosage never before tolerated which produced asufficient inotropic action and slowed the pulse-rate to 80 permin. The patient has now resumed his professional work ona reduced scale.
It should, however, be borne in mind that pronestylhas not the same effect on auricular premature beats.
Anglo-Swiss Hospital, Alexandria, Egypt. FR. MAINZER.
CONGENITAL SYPHILIS IN A FIJIAN
SIR,—Stitt 1 states that amongst the Pacific Islandersa relative immunity to syphilis is found in spite of
repeated exposure to infection from syphilitics of otherraces. In Fiji syphilis is widespread amongst Indiansand part-Europeans, but it is doubtful if the diseasehas ever been recorded in a pure Fijian, though Lambert 2quotes (without clinical details) one case described tohim by Harper. The following is a description of a caseof congenital syphilis in a pure-blooded Fijian.A Fijian girl, aged 23, of pure Fijian descent, born in the
Tailevu district of Viti Levu, denied infection with yaws inchildhood. At the age of 13 she came to live in Suva, whereshe remained throughout the war. In 1945 she was admittedto the Colonial War Memorial Hospital, Suva, where theKahn reaction of her blood was found to be + + + +. Shereceived a total of 3’0 g. neoarsphenamine and was thendischarged. Though unmarried she was living with a pure-blooded Fijian when she became pregnant for the first time,and was admitted to the obstetrical annexe at the hospitalon Aug. 27, 1950, suffering from an antepartum haemorrhage.Shortly after her admission she was delivered of a maceratedmale foetus ; the placenta was removed manually as it wasadherent. The Kahn reaction of her blood was still + + + +.After 4 injections of neoarsphenamine she absconded.
Microscopically the placenta was fleshy. Microscopicalexamination showed extensive fibrosis, endarteritis, and lossof blood-vessels from the villi-all typically syphilitic changes.The fcetus was almost full-term and was well macerated.Section of the liver stained by Levaditi’s method showednumerous spirochætes indistinguishable from those of
Treponema pallidum.It is generally admitted by authorities that no case
of congenital yaws has ever been observed (Stitt 3): yawsis said to be neither hereditary nor congenital.4 The
present case therefore appears to be one of acquiredsyphilis in a Fijian girl with congenital syphilis inher offspring, and this indicates that there is no racialimmunity to syphilis in Fijians.
In the absence of racial immunity, the rarity of sucha syphilitic infection must be ascribed to an acquiredimmunity. It is thought that infection with yaws in
1. Stitt’s Tropical Diseases. London, 1942 ; vol. i, p. 397.2. Lambert, S. M. J. trop. Med. Hyg. 1931, 34, 117.3. Op. cit. (footnote 1) p. 422.4. Manson-Bahr, P. H. Manson’s Tropical Diseases. London,
1950 ; p. 626.
childhood confers relative immunity to syphilis. Shouldthis immunity become less pronounced, then syphiliscould be as readily acquired by Fijians as by other races.
In the many Fijian women now attending the antenatalclinic at the Colonial War Memorial Hospital in Suvathe Kahn reaction of the blood is often found to be
negative. It is therefore probable that, owing to theefficient control of yaws which has been established,many Fijian girls are never infected with it in childhood.The girl in question evidently escaped infection in earlylife, but was then exposed during the war years to
syphilitic infection in Suva.In planning extensive anti-yaws campaigns amongst
primitive people, consideration should be given to the’possibility that their immunity to syphilis might therebybe destroyed.
I have to thank Dr. J. M. Cruikshank, Inspector-General,South Pacific Health Service, for permission to publish thiscase.
P. E. C. MANSON-BAHRPhysician-Specialist, Fiji.
THE FALSE " ACUTE ABDOMEN "
SIR,—In his letter of Jan. 13 Dr. H. M. Royds Jonesquotes a paper which Le Marquand and I wrote fiveyears ago.’ We described a series of cases which clinicallysimulated perforated duodenal ulcer; instead of
operating immediately we observed them for a fewhours and we were rewarded by a complete change inthe clinical picture with spontaneous recovery. Dr.
Royds Jones describes a series which also recovered
rapidly and spontaneously. He then proceeds to discussour paper : he writes that we described an " epidemicof Bornholm disease." Reference to our article willshow that we were not, at the time, convinced that wewere dealing with an epidemic ; we considered manypossible explanations but Bornholm disease was not
among them. We suggested that the syndrome mayhave been due to a fornze fruste of perinephric infection.However in the course of time I have modified my own
opinions : perinephric infection does, in a transient
phase, mimic the " acute abdomen," but this explanationcannot be stretched to cover all the cases we described.I believe now that our series was a minor epidemic ; butI cannot allow these cases to be labelled as Bornholmdisease.The original epidemic of Bornholm disease occurred on
the Danish island of Bornholm, and the main featuresobserved were severe fleeting pain and rigidity of musclesinnervated by the thoracic part of -the cord. Since thework of Lewis and Kellgren 2 we know that lesions ofalmost any deep structure will elicit the response of
rigidity and pain in the muscles of its segment. Withthe march of time Bornholm disease will prove to have ebeen an all-embracing title for many different lesions(their theoretical limit is equal to the total number ofdeep structures within the thoracic nerve territorymultiplied by the total number of their pathogens !).Scientifically the. diagnosis of Bornholm disease shouldcommand as little respect as, for example, the diagnosesof sciatica or rheumatism. Certainly we must acknow-ledge that there are epidemics of severe transient painand rigidity in the great trunk muscles ; but these
epidemics must. be due to many different causes. Dr.Royds Jones’s case-histories are consistent with myspeculations. He is to be congratulated on a series ofobservations, under difficult conditions, extending overtwenty-three years.
Suspected ulcer perforation was once an immediatesignal for operation. The possibility of a " false acuteabdomen " as discussed in this correspondence, shouldgive pause for thought. There is now further additionalargument against great haste to operate : the work of1. Goldstone, B. W., Le Marquand, H. S. Lancet, 1946, ii, 267.2. Lewis, T., Kellgren, J. H. Clin. Sci. 1939, 4, 47.
