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spared much tribulation. Constipation in the breast-fedinfant is in fact only one of many imaginary disordersin paediatrics (Gordon 1951).

SUMMARY

1. The bowel rhythm was investigated in 1499 infantsseen in infant-welfare centres.

2. In breast-fed infants, in the first month, stools arefrequent, often 4 or more a day ; in the third, fourth,and fifth months, some 40% of such infants miss a day,and it is not uncommon for the delay to be a week ;in the second six months of the first year, breast-fedinfants go regularly once or twice a day.

3. In bottle-fed infants the initial frequency is not sodefinite. But it is exceptional for a bottle-fed infant tomiss a day, and should it do so, an organic lesion shouldbe suspected.

4. It is suggested that mistaken efforts to remedythe bowel infrequency of healthy breast-fed infants isone of the main causes of habitual constipation in laterlife. As breast-feeding is diminishing, both in incidenceand duration, chronic constipation may be expected tobecome less of a problem. There is indirect evidencethat this is already happening.

REFERENCES

Abdel Khalik, A. K., Erfan, H., Askar, A. (1932) Arch. Dis. Childh.7, 249.

Brennemann, J. (1948) Practice of Pediatrics. Hagerstown.Brown, P. W. (1937) Med. Clin. N. Amer. 21, 691.Chodak Gregory, H. H. (1934) J. State Med. 42, 632.Ellis, R. W. B. (1947) Child Health and Development. London.Fukushima, M. (1930) Orient. J. Dis. Child. 7, 38.Gesell, A., Ilg, F. L. (1943) Infant and Child in the Culture of

To-day. London.Gordon, I. (1942) Arch. Dis. Childh. 17, 139.

— (1951) Brit. med. J. i, 611.Graham-Stewart, A. (1928) Practitioner, 121, 183.Hurst, A. (1943) Med. Pr. Circ. 210, 375.

— (1919) Constipation and Allied Intestinal Disorders. London.Hutchison, R. (1933) Postgrad. med. J. 9, 457.Keith, A. (1915) West. Lond. med. J. 20, 150.Oldfield, J. (1943) Med. Pr. Circ. 210. 381.Plaunder, M., Schlossman, A. (1935) Diseases of Children. Phil-

adelphia and London.Smith, R. M. (1930) New Engl. J. Med. 202, 802.Spock, B. (1947) Pocket Book of Baby and Child Care. New York.Sunderman, F. W., Boerner, F. (1949) Normal Values in Clinical

Medicine. Philadelphia and London.Takai, S. (1935) Tohoku J. exp. Med. 27, 590.Watkins, A. G. (1948) Practitioner, 160, 278.Williamson, N. B. (1947) Handbook on Diseases of Children.

Edinburgh.

OPHTHALMOSCOPIC DETECTION OF

MICROFILARIA OF ONCHOCERCAVOLVULUS

J. W. R. SARKIESM.R.C.S., D.O.M.S.

COLONEL, INDIAN MEDICAL SERVICE (RETIRED) TEMPORARYOPHTHALMOLOGIST, COLONIAL MEDICAL SERVICE

MANY workers have described the observation ofmicrofilariae in the aqueous humour of the eye with aslit lamp and corneal microscope. Estrada (1942)published a series of 11 cases of onchocerciasis, in whichhe described microfilariae seen in the vitreous humourwith an ordinary ophthalmoscope, using lenses fromplus 20 to plus 50 dioptres ; the simplicity of this methodis very attractive, especially under rural conditions.It was decided therefore to compare results obtained,by ophthalmoscopy and by slit-lamp examination inuative schoolchildren and industrial workers of the lowerVolga district of the Gold Coast.

It was found that micronlariae could be seen in theaqueous humour with an ophthalmoscope incorporatinga plus 20D to a plus 28D lens, held 3-5-5-0 cm. from thecentre of the anterior chamber-i.e., at the focal distanceof the lens used. The whole of the pupillary area isilluminated by reflection from the fundus; and since theembryos are seen in silhouette, the margin of focus is

greater than with a corneal microscope using directillumination from a slit lamp. For this reason the

embryos can be recognised more rapidly and, in caseswhere they are scanty, are less likely to be missed withan ophthalmoscope. In none of the cases in this serieswere micronlarise seen in the vitreous humour withlenses of this power ; nor were they seen with a plus4D lens in the ophthalmoscope held at about 25 cm.from the eye, although other small opacities in thevitreous could be seen in this way.

All the persons were examined under a mydriatic,first with an ophthalmoscope and then with a slit lamp ;a dark room was not available, but the examinationswere made in a shady hut, a standard battery-modelLister Morton ophthalmoscope being used. The instru-ment is brought towards the eye, with the lightdirected on the optic disc (which in pigmented racesgives an appreciably brighter reflex than does the restof the fundus), until the pupillary margin of the iriscomes clearly into focus. At this point micronlariaecan be seen, if present, silhouetted against the illumi-nated pupil as tiny black threads swimming through theaqueous humour with a rippling motion; this motion isquite characteristic and differentiates micronlariae fromother opacities-e.g., cells in the aqueous humour, threadsof persistent pupillary membrane, and small particlesfloating in the lacrimal secretions on the anterior surfaceof the cornea. A microfilaria can be brought into clear

MICROFII.AK.1: FOUND BY OPHTHALMOSCOPY AND WITH

SLIT LAMP

focus by moving the ophthalmoscope slightly backwardsor forwards according to the position of the embryo inthe anterior chamber.

RESULTS

The results are given in the accompanying table. The

persons examined consisted of two groups, both highlyselected in that they attended a normal school or earnedtheir living under fairly competitive conditions ; this

probably explains the relatively low percentage of

persons shown to have onchocerciasis by skin sweatswho had micronlariae in the eye. Of the 55 with embryosin the aqueous humour these could be seen with an ophthal-moscope in 54, whereas with a slit lamp they were seenin only 35. In the solitary case diagnosed with the slitlamp alone, one embryo only was found, and it hadattached itself to the posterior surface of the peripheryof the cornea, outside the pupillary area.

COMMENTS

There is no doubt that, if a minute search were made inevery case with the slit lamp, microfilariae would beseen even more often than with an ophthalmoscope.Such a search is often precluded by fatigue and]y lackof cooperation on the part of the patient. Therefore,when the mioronlariae are scanty, ophthalmoscopyoffers a greater chance of success. In remote areas ofAfrica, where the disease is prevalent, the simplicity ofthe apparatus has obvious advantages ; for the doctor

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in such regions it provides a rapid means of diagnosingocular involvement in the earliest stages.

Certain limitations must be considered. When theare so opaque that the red retiex is abolished,microhlaria) cannot be seen by ophthalmoscopy. Suchconditions as cataract and plastic iritis occur in advancedonchocerciasis and give rise to gross opacities ; at thisstage, in endemic areas, the diagnosis can usually be madeon clinical grounds, confirmed if necessary by conjunctivalsuipping. When infestation of the eye is heavy, thepupils often do not dilate with mydriatics ; in thesecases the micronlarhc are usually sufficiently numerousto be seen with the smaller field available.For surveys of large numbers of people and for the

preliminary selection of cases, ophthalmoscopy hasconsiderable advantages. For a more minute examina-tion of the eye, however, it does not take the placeof the slit lamp.

I wish to acknowledge the advice and assistance of Dr. M. H.llughes, who has made clinical and laboratory investiga-tions of most of the cases, and with whom I hope to elaboratethe findings later. My thanks are due to Dr. R. L. Cheverton,director of medical services, Gold Coast, for permission topublish this report.

REFERENCE

Estrada, A. T. (1942) Amer. J. Ophthal. 25, 1445.

LIPOID PNEUMONIA (NON-INHALATION)IN CARCINOMA OF THE LUNG TREATED

BY RADIOTHERAPY

S. J. DE NAVASQUEZM.D. Loud.

READER IN PATHOLOGY IN THE

UNIVERSITY OF LONDON

J. R. TROUNCEM.D. Lond., M.R.C.P.MEDICAL REGISTRAR,

GUY’S HOSPITAL, LONDON

A. B. WAYTEM.B. Lond., D.M.R.E.

ASSISTANT SURGEON, RADIOTHERAPY DEPARTMENT,GUY’S HOSPITAL, LONDON

LIPOID pneumonia, is usually due to the inhalation ofmineral or vegetable oil which irritates the pulmonaryepithelium, causing fibrosis (Pinkerton 1928, Paterson

1938). Lipoid pneumonia arising without the inhalationof such oil has not yet been reported ; and, althoughfibrosis in the lungs after irradiation has been fullydescribed (Warren and Spencer 1940, Widmann 1942),the possibility of lipoid pneumonia resulting from in<1Blia-tion seems to have been overlooked. III the case described

below lipoid consolidation of the lung was found aftera pulmonary carcinoma had been treated by radiotherapy.

Fig. I-Radiograph showing opacity in righttracheobronchial angle with collapse of rightupper lobe.

Fig. 2-Fields of entry and dose distribution at level of tumour (A.B infig. 5).

CASE-RECORD

A woman, aged .>6, was admitted to Guy’s Hospital underDr. Douthwaite in June. 1949, with two months’ history ofpain in the right upper chest with breathlessness and cough.

’ 0 e,:cum.inatiom she had partial colJapse of the right upperlobe, with a rounded mass in the right tracheobronchialangle (fig. 1). Bronchoseopy showed that the right upper-lobebronchus was filled with new growth, which on section provedto be anaplastie oat-celled carcinoma.

Ti-ecititieiit.----Slie was given a course of deep X-ray therapyin July, 194’). Deep irradiation at 215 kV with Thoraeus 1filtration and a half’value layer in copper of 1,85 mm.was used. Six fields of entry, each 10 X 10 cm., were

arranged routid the chest (fig. 2). Two fields were treatedeach day with a surface dose of 350 r, a total dose to eachfield of 2800 r being given in twenty-eight days. This gavean aggregate tumour dose of about 4000 r units. Fig. 2shows the approximtae dosage distribution within the thoraxat the level of the tumour.

Procaine penicillin 300,000 units was given daily throughoutthe course of radiotherapy in an attempt to control secondaryinfection and minimise the risk of lung gangrene.

.P;’o/’e.-.&mdash;The patient’s condition improved and fig. 3shows the radiological appearances ten weeks after the courseof radiotherapy. At the beginning of October, 1949, however,she again noticed increasing breathlessness, and this rapidlybecame worse. She developed pain in the left side of herchest and was readmitted to Guy’s in November, 1949.

0)1 readll/&Igrave;8sion she was extremely dyspnooic and distressed.Her temperature was 97’F, but her respirations 40 per minute.Examination of the chest showed some impaired resonanceat both with harsh rhonchi and with a left-sided pleuralrllb. Hadiography revealed fairly dense shadows spreading

Fig. 3-Radiograph ten weeks after radiotherapy,showing almost complete disappearance ofshadows.

Fig. 4-Radiograph ten weeks after that shownin. fig. 3, showing bilateral symmetricalshadows, in middle thirds of lungs,corresponding to areas irradiated.