Tuberculosis of the nasal accessory sinuses, because of its relative infrequency, has prompted the writers to review the literature and report the clinical study of a quite typical case. In a review of the case reports of other observers, one is impressed by the difficulty of determining, in spite of careful study, whether the process in the sinuses was primary or secondary. Most of the cases were well advanced when first seen, many of them with complicating or coincident tuberculosis in other parts of the body, so that even careful necropsy study failed to establish positively a primary lesion in the sinuses, except in very few cases. Hajek! states that tuberculosis of the ethmoid labyrinth is extremely rare, and occurs apparently as a primary disease less frequently than as a process secondary to tuberculosis of the septum. He has seen two cases of primary tuberculosis of the ethmoid which he has not published. Finder" collected three primary cases from the literature, to which he added a fourth, and Lund" reported another case. van Hoogenhuyze and deKleyn" report two cases of a unilateral ethmoid lesion which extended to the maxillary sinus, causing nasal obstruction and purulent discharge from the naris of the same side, and without eye symptoms. Operation revealed caseous masses of typical tuberculous granulation tissue, containing giant cells and tubercle bacilli. Both cases were cured. Kurzak" describes in great detail the case of a man of twenty years who complained first of pain over the eyes and in the left upper and lower jaws, followed several months later by diplopia and diminished vision, first in the left, then in the
precluded clinical trial; second, because sulfadiazine itself was found to be extremely nontoxic and safe for human administration.11Accordingly it was tried in 13 cases of acute malaria in Negro patients, 7 vivax infections, 5 falciparum and 1 quartan. The dosage was the same for all patients, 6 Gm. the first day and 4 Gm. daily for the next five days, given by mouth at four hour intervals during the day. The results are summarized in table 2, in which it can be seen that sulfadiazine exerted a very definite influence against all three types of human malaria. In 2 patients with vivax infections, R. J. and M. M., and 1 with falciparum infection, M. C., this amount of the drug was unable to check the infection. There were no toxic reactions to the drug except in patient S. F., who seemed to respond with fever that promptly sub¬ sided on withdrawal of the drug. COMMENT It is impossible to state with certainty whether patients have been cured after recovery from their acute attack of malaria following the use of promin or sulfadiazine. There are several authenticated instances in which blood donors have transmitted malaria to recipients as long as twenty-five years after their initial attack. During the interim these donors had lived in nonmalarial areas and were symptom free. The absence of parasites in the blood smears of chronic human infec¬ tions has no meaning, and it is not possible to subinoculate infected tissue into lower animals for diagnostic purposes as there are no known susceptible ones. Since all patients were discharged and returned to infected territory, any subsequent attacks could as well be new infections as relapses.In the present study no attempt was made to deter¬ mine the most efficient dosage of promin because the necessity of intravenous administration limited its use¬ fulness. The results obtained showed that patients responded best when the maximum concentration of the drug was present in the blood at the time of, or shortly before, the sporulation of the parasite. This is in agree¬ ment with the finding that, -irrespective of the amount given, the drug is excreted extremely rapidly. It seems likely that all the patients would have responded in a satisfactory manner if the drug had been given over a longer period of time, with each dose preceding or immediately following each expected paroxysm.No explanation was found for the variation in the response of different species of malaria parasites to sulfonamide drugs. It is possible that the effect of sulfanilamide may be correlated with virulence of the infecting organism. P. knowlesi, the most virulent of the experimental malaria parasites, is more readily inhibited by sulfanilamide than are less virulent species, just as virulent strains of streptococci are inhibited by concentrations of sulfanilamide which do not affect less "virulent strains. Accordingly various chemicals which were known to be more powerful bacteriostatic agents than sulfanilamide were tested against experimental malarias. It was believed that a drug which produced a...
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