Postgrad Med J: first published as 10.1136/pgmj.5.56.129 on 1 May 1930. Downloaded from 4I)STHTIRE GR~ADUATE NEDlUAL J Ou1?NAL VOL. V. MAY, 1930. No. 56.

CONTENTS PAGE THE TREATMENT OF GENERAL PARALYSIS BY 1...... 29 By THOMAS TENNENT, M. B.GIas. THE ROLE OF HYDROLOGY IN MEDICAL PRACIICF ...... 137 By MATTHEW B. RAY, D.S.O., M.D.EDIN. POST-GRADUATE NEWS ...... 142

N OTICE ...... 14 5

FELLOWSHIP OF MEDICINE AND POST-GRADUATFE MEDICAL ASSOCIATION.- copyright.

SPPECIAL COURSES ...... i;

THE TREATMENT OF genieral paralysis was recorded in 1798 by Haslam, who was then Apothecary of GENERAL PARALYSIS BY Bethlem Hospital. It was not, however, uLntil 1I822 that the conldition was recognized, MALARIA. http://pmj.bmj.com/ by a Fi-ench psychiatrist named Bayle, as a By THOMAS TENNENT, disease entirely based upon a known patho- NI.B.GLAS. logy. His description of the pathological Assisttant Medicall Officer, Maudslky Hospital. changes and of the clinical symptoms holds good in its essentials to-day. ITr has long been regarded that the outlook From this time unitil the discovery of the in general paralysis is most unfavourable, true niature of general paralysis many factor-s on October 2, 2021 by guest. Protected and that it is one of the most fatal diseases were elaborated to account for its xtiology, affecting the human race. Until recently all anid equially nLumerous and varied were the efforts to treat this condition proved worth- remedies suggested. The latter included less, and a fatal terminationi within a few such diverse methods as venesection, cautery years was the inevitable outcome. Remis- to the head and spine, baths of varying sions throughout the course of the illness temperature, purgatives and electricity. were recognized, but aiy claim of recovery Iron, potassium bromide, quinine, silver aroused, in the minids of most, giave doubts nitrate and digitalis were the more prominent as to the diagnosis. Fortunately this state drugs advocated. of affairs has changed and remissionis inay These methods of treatment held promill- now be iniduced by prompt and appropriate ence at various stages and, until a better treatment. uniderstanding of the xtiology was obtained, The first cliical accounlt of a case of little lheadway from the therapeutic angle Postgrad Med J: first published as 10.1136/pgmj.5.56.129 on 1 May 1930. Downloaded from 130 THE TREATMENT OF GENERAL PARALYSIS BY MALARIA was made. In I857 the relationship between such as pneumonia had set in, and it sug- general paralysis and syphilis was stressed gested to him that treattnent might be by Esmarck and Jessen, who reported three more effective still if directly produced by cases of syphilis followed by general infectious disease. paralysis. Thereafter there developed a Other two observations were reported controversy as to the nature of the causa- meantime bearing on this point anid are tion which lasted over fifty years, and was worthy of note. only settled by the researches of Wassermann (i) Bercovitz pointed out that neuro- and Noguchi. syphilis was extremely rare in certain areas Meantime treatment had progressed of China, although syphilis was extremely chiefly along two channels, the specific and common ; malaria in these districts was non-specific forms of therapy. It is witlh endemic. the chief variety of the latter that I propose (2) In I9I3 Pilcz and Mattauscliek to deal to-day, namely, the treatment by the analysed the case histories of over four induction of malarial fever. thousand officers and men of the Austrian The beneficial effect of fever in the army who had become infected with syphilis. psychoses generally had been recognlized They pointed out that those who during their and observed since the days of Hippocrates first year after infection had developed an and Galen. Many centuries later Pinel acute febrile illness such as pneumonia or elaborated among the conditions tending er-ysipelas did not later develop neuro- to produce a "permanency of cure" a syphilis. On the other hand, practically quartan a little fever. Clouston, over forty without exception, those who developed copyright. years ago, wrote: " I believe some day we neuro-syphilis had not suffered from an acute shall hit on a mode of producing a local febrile illness during the first year after inflammation or manageable septic blood- infection by syphilis. Fortified by these poisoning by which we shall cuit short or observations von Jauregg, in I917, thirty cure attacks of acute mania." This observa- years after his original suggestions, inocu- tion then, that the onset of a febrile illness lated his first series of nine cases of general

during a psychosis frequently resulted in an paralysis with malaria, from a soldier who http://pmj.bmj.com/ improvement in the mental state, suggested had not been treated with any quinine. to Wagner vo-n Jauregg, in i887, the possi- Since then several thousands have been so biliiy of imitating this experiment of nature treated. for the cure of the psychosis. At that time TECHNIQUE. he mentioned malaria as one of the diseases suitable for such experimentation. He did The patient may be inioculated by either- not, however, employ this method then, but of two methods, namely, by bite, on October 2, 2021 by guest. Protected began to induce fever by injections of Koch's or by blood inoculation. tuberculin. In many cases, however, sooner If the former mpethod is adopted, then or later the disease recurred, and re-inocula- female mosquitoes of the group tion then proved of little value. Conse- are employed and are allowed to feed on the quen-tly he endeavoured to find a means patients. Such mosquitoes are readily which would produce better and more lasting obtainiable through the Ministry of Health. results, and this led to the employment of They are taken to the bedside in a glass con- typhus and later typhoid vaccine. In the tainer, the top of which is covered with course of these experiments he noted that muslin. The glass vessel is inverted over the most complete and lasting remissions the area of skin selected and the mosquitoes were obtained in patients in whom, during allowed to bite. It may be, however, that the course of treatment, an infectious disease the mosquito does not choose to feed at THE TREATMENT OF GENERAL PARALYSIS BY MALARIA 131 Postgrad Med J: first published as 10.1136/pgmj.5.56.129 on 1 May 1930. Downloaded from this moment, and so further attempts may have a deterrent effect on the inoculation. be necessary. It is therefore advisable to sterilize instri- The other method, by blood inoculation, inents, &c., by boilinig, but such must be has generally proved to be more advani- cooled prior to use. The exposure of the tageous; 2 to 5 c.c. of blood are taken from parasites to the influence of heat is inadvis- a patient either immediately before or during able. Rudolf founid that they were killed a febrile attack. If the inoculation is done if exposed to a temperature of 1200 F. for a in hospital, or in such circumstances that period of three minutes. Another cause of the two patients may be brought together, failure is the delaying of the inoculation after then the blood may be transferred direct. the blood has been withdrawn. If -such a if, howvever, the blood has to be transported, delay is necessary the blood should be kept then clotting must be prevented. This may on ice. It should, of course, be remembered be accomplished by adding an equal quantity that a few people possess an immunity to of 5 per cent. sodium citrate. Successful malaria which may account for the failure, results are obtained if the blood is simply as also may any antimalarial drugs taken dehbrinated. The blood is transferred just before or at the time of the inoculation. immediately from the syrinige into a sterile The incubation period is a variable factor test tube, and stirred briskly with a sterile anid usually extends from four to twenty-five glass rod. It should be stirred continuously days. If the patient's condition otherwise for twelve minutes, at the end of which is good, there is no necessity to keep him in period the fibrin is usually found collected bed durinig the day while the fever is devel- along the rod. oping. The temperature during the first The actual inioculationi may be given seveni days should be recorded at least twice copyright. subcutaneously, intramuscularly or intr-a- daily, and thereafter every four hours, until veniously. The site usually selected for sub- the onset of the fever. This is usually cutaneous inoculation is that betweena the preceded by headache, malaise and the scapula, but it mnatters little where the blood complaint by the patient. of feelinig out of is injected. It is desirable to move the sorts. He then welcomes bed. During the under the skin prior to with- rigor the temperature should be taken every needle about http://pmj.bmj.com/ drawal, thereby injuring some of the super- thirty minutes, and it is not uniusual to ficial vessels. The intramuscular method r-ecord temperatures over I050 F. No drugs does not differ materially from the subcu- should be administered to control the taneous. Either are useful where it is pyrexia. Tepid sponging of the patient is desired to keep the strain of the par-asite advocated if the degree of fever exceeds alive for the maximum period. I05° F. The intravenious metlhod is usually adopted As to the nature of the fever, this depends on October 2, 2021 by guest. Protected where the saving of time is important. The largely on the strain of parasite used. As inicubation period is frequently shortened, the benign tertian variety is that most and in my opinion the results of infection frequently employed, one expects the patienit are more dependable. Of course, one mnust to have a rigor every second day. Witlh take all precautions in such injectionis the passage of the infection through various against introducing air or blood-clot which patients and re-inoculation of some of these, would result in embolus formation. a double infection is frequiently obtainied, The causes of failure to develop malaria the febrile attacks occurring daily. This may result from faulty administration, or allows the patient little time to recover from may rest in the patient himself. his attacks and is very exhausting. More With regard to the administration, it is r-ecently the quartan variety has been important to remember that antiseptics may employed, and its use is advocated in Postgrad Med J: first published as 10.1136/pgmj.5.56.129 on 1 May 1930. Downloaded from 132 THE TREATMENT OF GENERAL PARALYSIS BY MALARIA debilitated subjects. Here there is an it is of great imnportance. The appearance interval of two days between the rigors,. of jaunidice is also an indication for delaying most valuable where the general condition the next paroxysm. is not very good. Attention at this time If it is desired to cur-tail the fever then it should be paid to the condition of the may be accomplished by the adtinlistratioin bowels and a look-out kept foir retention of of a small dose of quinine, 3 or 4 gr. of urine. Cardiac drugs, such as (ligitalis, quininie sulphate. This will temporar-ily str-ophanthus or caffeinie, are giveni regularly arrest the fever. There is no further pyrexia during the fever. Von Jauregg advocates as a rule for at least seven days, and if the their administration at the beginning of the patient's general condition improves during rigor and again when the fever reaches its that period the fever may be allowed to highest peak. Blood-films should be ex- continue again. If such is considered amined at daily intervals throughout the inadvisable, fturther doses of quinine may pyrexia. The number of parasites found be administered and the fever stopp)ed varies greatly in different subjects. Some altogether. have few parasites in a field, and yet are It should be borne in minid, however, that more uLpset clinically by the fever than the best results are usually obtainied follow- others who show numerous parasites. Of ing a series of ten to twelve pyrexial attacks. great value, however, is a rapid increase in Re-inoculation with malaria is possible in the number of parasites seen in each field, many cases and a further course of fever and it should be taken as a warning sign. may be given if no improvement follows If the general condition remains satis- the original fever. In some, however, it is factory the fever is allowed to continue until impossible to re-inoculate with malaria; copyright. the patient has had ten rigors. Thereafter immunity develops after one attack. Only it is discontinued by the administrationi of rarely are patients immunie to the original quinine sulphate or hydrochloride, io gr. inoculation, and, as a rule, such patients being given three times a day for a few days. have been resident in tropical countries The effect is rapid, the fever subsides and during some period of their life. It is the parasites disappear from the blood. claimed for quartan fever that inoculation http://pmj.bmj.com/ Attached to this form of treatment there by this strain is frequently possible after an are certain dangers which must be fully initial course of fever of the tertian variety. appreciated, and for these onie must be con- Recurrence of the fever is rare following stantly on the look-out, prepared to abort upon blood inoculation. It is more frequent the fever. A most important indication for after inoculation by mosquito bite and may stopping the fever is a sudden drop in occur several months after the original strength, characterized by apathy and fever. on October 2, 2021 by guest. Protected listlessness in the interval between the paroxysms. Cardiac weakness is the fre- EFFECT OF THE FEVER. quent cause of death, and shows itself as It is important to remember that mental an irregularity or weakness of the pulse, phenomena may be exhibited during the weakened heart sounds, cedema and pul- fever attributable to the malaria. Most monary congestion. An increase in the frequently this is a state of cotnfusion with pulse-rate of over i6o beats a minute, or hallucinations, usually auditory in type. in the respiratory rate of over 6o a minute Delusions, persecutory in nature, sometimes should be taken as danger signals. A small occur and the patient may become restless quantity of albumin is found in the urine and excited. As a r-ule the confused state during the fever and need not be regarded clears when the fever is discontinued. The seriously unless the amount increases, when more marked physical effects are a marked THE TREATMENT OF GENERAL PARALYSIS BY MALARIA 133 Postgrad Med J: first published as 10.1136/pgmj.5.56.129 on 1 May 1930. Downloaded from anaemia and a distinct loss of weight. The forty as relieved and nine as not improved. degree of anaemia may be profound. Colonel Twenty-six of tlhese, between 1924 and I927, James has stated that in primary attacks of lhad either died at home or had been re- the naturally acquired disease the loss of admitted to hospital, so that onily forty red cells may be from 250,000 to over patients were alive and not under care in a i millioni during a single febrile paroxysm. mental hospital three or four years after they Improvement in this respect is ustually rapid originally came under certificate. Of the dutring convalescence, when tonics of iroin total number I,I73, only 157 or 14 per cent. and arsenic are valuable. With regard to were alive in I927, and i,oi6 were dead. loss of weight, this is as a rule also rapidly These figures show that long-lasting spon- gained. This regain of weight is sometimes taneous remissions in general paralysis are of prognostic value. It has frequently been rare. found that those who do not regain all or He made similar investigations of all cases part of the weight lost do niot show a marked of general paralysis who had been treated by improvement in their menital state. malaria in the same period. The number of The assessment of results obtained follow- cases so treated was 438. Of these he foun-d ing this treatment is complicated by the fact that there were livitng, in I927, 247 6f whom that spontaneous remissions have long been io8 had been discharged from hospital; 191 known to occur in the course of the illness. patients had died in the interval. Patients improved and were well enough to It will be seen from these figures that 56 be discharged from hospital. Some resumed per cent. of the treated cases were alive, wor-k and appeared to their friends to lhave whereas only I4 per cent. of untreated cases recovered. Their improvemnent was in- were alive in I927. Conclusive evidence is copyright. variably ascribed to whatever treatment had thus furnished that treatment by malaria been given. As a rule, however, their does extend life. remission was only of short duration, It is interesting to note the results reported necessitating their re-admission to hospital. in the first cases of general paralysis treated A study of the literature shows that by malaria. Of the nine cases treated in spontaneous remissions occurred in about I9I7 by Wagner von Jauregg, three patients http://pmj.bmj.com/ io per cent. of general paralytics. Some have maintained a state of good remission record figures slightly above this, others for over a period of ten years. Of twenty- below. The duration of such remissions five cases treated between September, I9I9, lasted as a rule a matter of monthls, and only and March, I920! eighteen were originally in a very few cases did they extend into a discharged enjoying a remission of varying few years. Meagher has recently made a degree, seven of whom had a full remission. detailed study of the cases of general In I928 only one of these seven had relapsed on October 2, 2021 by guest. Protected paralysis admitted to the English County and died. The remaining six were still and Borough Mental Hospitals in I923 and enjoying a full remission. Thus of the first 1924, and his results are very interesting. thirty-four cases treated between I9I7 and He investigated the subsequent histories of March, 1920, nine, or 26 per cent., were en- all certified cases of general paralysis ad- joyinig a full -remission in 1928 after periods mitted to these hospitals in that period who varying from eight to eleven years. had not been treated with malaria. The Altogether several thousand cases have number of cases so invest'igated was 1,173. been submitted to this treatment in all the He found that of those there had been stages of the disease. A rough analysis of discharged from hospital a total of sixty-six the results shows that one-tlhird of the patients, or 6'2 per cent. Of these only patients improve sufficienitly to leave hospital, seventeeni were discharged as recovered, one-third show improvement but require to 134 THE TREATMENT OF GENERAL PARALYSIS BY MALARIA Postgrad Med J: first published as 10.1136/pgmj.5.56.129 on 1 May 1930. Downloaded from remain in hospital, and the remaining third patient after 30 years of age. If accom- die. panied by any neurological signs such as in- The questioni that now arises is, are there equality, or irregularity in outline of the any factors which help to determine the pupils, fine tremors around the angle of the effect of treatment ? There are. What mouth, or of the fingers or tongue, or any appears to be the most important factor is speech defects, a blood Wassermann ought the duration of the illniess before treatment. to be done. If this gives a positive result, Von Jauregg has stated that improvement then examination of the cerebrospinal fluid may be obtainied in ioo per cent. of patients is essential in the best interests of the if only early cases are treated. I should like, patients. therefore, at this point to stress the value of Another point of value is the frequency of a diagnosis while the disease is in its early the inicidence of congestive and convulsive stages. The type of illniess in which the attacks of general paralysis. The onset of greatest number of remissions occurs is the such attacks inl persons in the forties and exalted manic variety. It is quite likely fifties is to be remembered and investiga- that the fact that such patients come unider tions made as to their real nature. observation at a muclh earlier period thani In this connectioon greater use might be those presentinig depressive or neurasthenic mnade by general practitioners of the psychi- symptoms partly accounts for this. A similar atric out-patient depairtments now -attached reason might partly explain the relative to nearly all general hospitals, or the out- greater frequency of remissions among men patients departments of neurological and than women. The age factor has been psyclhiatric hospitals. It is recognized that advanced by some investigators, who state there has been difficulty in obtaining copyright. that increase of age is a deterrent factor. adequate treatment for patients who were This, however, does not appear to be not certifiable. It was impossible for such greater than what would be expected at ani to enter, eveni as voluntary boarders, any of age when the recuperative powers are not so the rate-aided mental hospitals, had they been active as formerly, and I have obtained a willing to do so. This state of affairs may full remission in a man over 6o years of age be retnedied under the new Mental Treat- treated within the first month of presenting ment Bill tnow before Parliament. As it is http://pmj.bmj.com/ symptoms. easy for patients who are certifiable to re- It is therefore of extreme importance that ceive proper treatment, we have at the such cases should come under treatment at Maudsley Hospital restiricted our admission the earliest possible moment. Only too fre- to those cases in the early stages who would quently, when taking the anamnesis of such not be admitted to a mental hospital. If, how- patienits, one hears from the relatives that ever, careful observation is made patients on October 2, 2021 by guest. Protected they have been complaining for a period of may be treated at home, in nursing homes, years. The symptoms frequently are very or in general hospitals. If treated at home, vague. The most frequent early menital a day and a night nurse would require to be phenomenia involves changes in c-haracter provided. It is, of course, advisable, and and mood. Irr.itability, restlessness, memory duiring the sumnmer months essential, to pre- changes and defective judgment are the vent mosquitoes getting in contact with the earliest features in some; others again be- patients during the fever. This may be donie come indifferent, apathetic, and desire to be by fixing suitable netting over the windows left alone. That suchlymptoms are not patho- and door. It may be accomplished more gnomonic of general paralysis is granted, simply by erecting a wooden frame around but their incidence in this condition should the bed, which may then be enclosed with always be remembered in the investigation suitable gauze netting. of any indefinite nervous complaint in a Is it then desirable or expedient to treat THE TREATMENT OF GENERAL PARALYSIS BY MALARIA 135 Postgrad Med J: first published as 10.1136/pgmj.5.56.129 on 1 May 1930. Downloaded from all cases of general paralysis by malaria, cell-content of the blood. It is kniown that whatever the stage of the illness ? Most in both malaria and relapsing fever, which observers are agreed that it is, provided there has also been employed in the treatment of are no signs of disease which contra-indicate general paralysis, the mononuclears are its use, such as renal or cardio-vascular increased. It has therefore been suggested disease. Surprising results are sometimes that this increase may partly account for obtained in those who appear to be advanced the benefit which results. cases, and consequently the ultimate out- Another theory is that the malarial para- come is a matter of doubt. It is also sites may act as and give rise to the important to remember that the rate of production of whiclh may act on improvement following treatment may be the spirochaete. Plaut suggests, on account very slow, anid is only manifested in its full of this possible biological reaction, that an degree many months after the treatment is infecting organism should be employed concluLded. As a rule, in advanced cases more closely related to the spirochoete, and one can onily hope to arrest the disease, and consequently he has advocated the use of it is a matter of opinion whether the gain to relapsing fever. such patients who are transferred to what Various other suggestions have been made, are regarded in mental hospitals as " good- but as yet we are ignorant of the true working dements" is a material one. mechanism. One has to assume that there is a destructive or at least a deleterious effect MECHANISM OF MALARIAL THERAPY. on the spirochbtes as a result of malarial therapy, sinice they are practically never The mechanism of malarial therapy obtained in the brain of those who have copyright. remains a matter of conjecture. Various improved after this treatment and have later theories have been elaborated but none are died of an. intercurrent disease. satisfactory. It has been suggested that the effect may be a direct result of the high OTHER FORMS OF PYREXIAL TREATMENT teinperature obtained during the fever, EMPLOYED. which thereby directly destroys the para- sites. The degree of fever attained durinig The advantages pertaining to treatment http://pmj.bmj.com/ the course of the illness is very rarely that by malaria may be summarized as follows:- required experimentally to prevent develop- (r) Frequent highi temperatures are pro- ment of the spirochaete. duced; (2) a great majority of people are That the improvement may be due to susceptible to the disease; (3) the rises of metabolic changes with a quickening of temperature recur at short intervals; (4) the metabolism and removal of waste products disease is readily controlled by quinine. on October 2, 2021 by guest. Protected has been suggested. If this were the real Unfortunately there are several disad- explanation, one might reasonably expect a vantages to this form of treatment. re-accummulation within the period during (i) The most important isthat the reaction which many of the remissions have lasted, produced in some patients is sometimes very and their relapse ere this. severe and produces a certain mortality. A further theory suggested is that the This necessitates a careful examination and improvement results from a mobilization of selection of cases to be submitted to this the defensive powers of the body resulting form of treatment. In all patients treated from a vital reaction of the total organism there is a severe degree of anasmia due to to the infectious disease. the destruction of the red cells, and jaundice Onie of the bodily reactions to svphilitic may develop. (2) The infecting organism infection is an increase in the mononuclear cannot be kept alive in culture or in labora- 136 THE TREATMENT OF GENERAL PARALYSIS BY MALARIA Postgrad Med J: first published as 10.1136/pgmj.5.56.129 on 1 May 1930. Downloaded from tory animals, and it must be transmitted by pain throughout the body. The fever lasted the mosquito or directly from patient to about four days, during which time the patient. (3) Objection has also been raised spirochates of relapsing fever were easily to the carrying over from one patient to found in the blood. At the end of this another of syphilitic blood with the infect- period the temperatur-e fell by crisis with ing organism. (4) There is also the practical marked sweating. Thereafter the patient difficulty arising through the fact that some felt more comfortable, his pains subsided, are notsusceptible to malaria, anid some have and he began to take nourishment freely only a limited number of paroxysms which again. He improved somewhat until about then spontaneously cease. the sixteenth day, when he had his first To overcome these difficulties two other relapse with the original symptoms. This methods have been advocatedand are worthy was expected to last about thi ee or four days of mention. In I9I9, Plaut and Steiner again and subside as before. Such inter- introduced the treatment by relapsing fever. missions and relapses should follow one They thought that the therapeutic action another regularly, and in the or-dinary in- might be intensified if a micro-organism fection as many as from five to eleven are were employed that was closely allied to the said to occur. I nistead of this, however, an Spirochceta pallida. irregular temperature developed, which per- This they claimed for the infecting organ- sisted after four days and showed no sign of ism of relapsing fever, namely, S. duttoni. abating. The patient complained of severe In addition, this organism could be kept pain throughout the, body and the spleen alive in laboratory animals and the fever was became enlarged. Arsenical compounds alleged to be less severe than malaria. More- wer-e administered, but they did not affect copyright. over, the fever was said to be readily con- the fever. This inability to control the trolled by the administration of arsenic. pyrexia was obviously a great difficulty' and This form of treatment was tried at the consequently this form of treatment was Maudsley Hospital in 1926. The infecting discontinued. organism was obtained by Dr. Golla, Director Solomon, on the other hand, could not of the Pathological Laboratory, direct from obtain a sufficiently virulent strain of relaps- Professor Plaut. The strain could be kept inig fever, and so he commenced the use of http://pmj.bmj.com/ alive in mice, but it required to be carried rat-bite fever or soduku. This fever has over from one mouse to another every fourth been met with in Japan and has been day. In the inoculation of patients the mentioned in their medical books for many mouse was killed and a small quantity of years. It has been recorded occasionally blood, i to 2 c.c., was removed aseptically in England, France and the United States.

from the heart. This was diluted with saline Infection results from the bite of a rat on October 2, 2021 by guest. Protected and injected into the patient. As with infected with a spirochaete, 7norsus-mnuris. malaria, inoculations could be performed by The incubation- period varies considerably, either the subcutaneous, intramuscular or the average duration being about ten to twelve intravenous methods. After the fever had days. Thereafter at the site of infection a developed further inoculations could be sore develops. This area becomes red and made by direct blood inoculation from one swollen and an ulcer forms which is said to patient to another. The incubation period be not unlike a chancre. A lymphangitis varied from five to seven days. At the occurs from the infected area to the proximal onset of the fever the patient complained of lymph glands, which in turn become enlarged headache and general malaise. Thereafter and tender. The temperature now rises and the temperature rapidly rose to I03° F. and may reach I050F. or over. It is of the inter- io50 F. and was assQciated with generalized tnittent type and mnay drop within a few THE ROLE OF HYDROLOGY IN MEDICAL PRACTICE 137 Postgrad Med J: first published as 10.1136/pgmj.5.56.129 on 1 May 1930. Downloaded from hours to normal again. An eruption of remain positive. By this method a relatively purplish coloured spots spreads over the higher proportion of negative serological body, particular-ly the trunk, quite similar findings has been obtained, associated with to those found in the secondary stage of clinical improvement. syphilis. The patient feels ill with pains in In conclusioni, I would reiterate that there the muscles and joints. The illness may is no doubt as to the beneficial effects of continue with febrile exacerbationis for a malarial therapy, and also that such are in- per-iod of several months. It is said to creased if combinied with specific treatmenit. respond very quickly to arsphenamine, and A careful physical examination should be the dangers attaclhed to its use are few in carried out prior to submitting patients to number. It has been found that if the this treatment, to exclude the possibility of intr-avenous method of inoculation is em- renal, cardio-vascular or other disease. If ployed, the occurrence of a primary lesion there is no evidenice of such, then with with lymphangitis is apparen-tly avoided. proper skill and nursilng the treatmenit is The advantages claimed atre that the not such a serious matter as has sometimes organism can be maintained in laboratory been maintained. The factor of great value animals anid consequently they are always is the early diagnosis of such cases, and for available for use. The disease is less ex- this we must look for the greater co-operation hausting to the patient than malaria. It of the general practitioner. may be given to patients who are immune to malaria, and it is apparently possible to give it either before or after malaria without either A modifying the clinical course of THE ROLE OF HYDROLOGY copyright. condition. No results are as yet available as to the efficacy of this treatment, and at IN MEDICAL PRACTICE. present malaria remains the safest and- most POST-GRADUATE LECTURE DELIVERED FEBRUARY 11, 1930. effective form of fever therapy. The present consensus of opinion, howv- By MATTHEW B. RAY, ever, is in favour of a combination of non- D.S.O., M.D.EDIN.

specific therapy. Von Jauregg begins the Senior Physician, Thte British Red Cross Clinic for http://pmj.bmj.com/ specific treatment as soon as the fever is Rheumatism; Physician, The St. Marylebone General stopped. With the first dose of quinine he Dispensary. five days gives o03 grm. of neosalvarsan, 126.) later o045 grm. is given, and thereafter eight (Continued from p. intervals inijections of o-6 grm. are given at VAPOUR BATHS. of eight days. Varying doses of neosalvarsan, with or without bismuth, are generally The air is charged with water vapour, on October 2, 2021 by guest. Protected recommended to complete the treatment. which has a distinct "thermal" effect on Personally, I have employed treatment by the skin according to the temperature. The malaria in combination with tryparsamide, vapour bath has been in use from time which is an arsenical preparation with an immemorial, and the ancient method of unusually high degree of penetrability. In- preparing it was by placing a tub of hot travenous injections of 3 grm. are given as water in a building and throwing hot glow- soon as a diagnosis is made. The malarial ing stones into it. The vapour bath checks treatment is carried out as already described, evaporation from the surface of the body, and the injections are administered through- itn consequence of which heat is retained out the fever and at weekly intervals there- and the bodily tetnperature raised. after, so long as the serological findings After a varying period in the " vapour"