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.