126g.1 xENDHTcmBit¢xa;]MEIA JOItA VACCINE TREATMENT OF CHRONIC BRONCHITIS AND ASTHMA. [JUNE 14, 1913. The Nose and Naso-ph7ary-nx. Chronic Gonorrhoeal Arthriti8. Rheumatoid arthritis in connexion with septic polypi in I believe this to be duLe to a mixed infection of the the nasal cavities is not uncommon. In a girl aged 18, gonococcus and staphylococcus. The joints are character- who had rheunmatoid arthritis well started in the joints istic. There is swelling and often oedema in the tendon of the fingers of both hands, a vaccine containing sheaths around, well seen in the wrist-joint, marked pain, Micrococcus catarrhalis and Staphylococcus aureus was and a very early tendency to stiffness and limitation of made from her own discharge. There was in this pus no movement of a most obdurate character. Adhesions forml attempt at all at phagocytosis. She was vaccinated, but both witlhin the joint and around it within the fibrous phagocytosis was most marked after, the second inoculation capsule, tending early to fix it. Any attempt at forcible of the'vaccine. The polypi were then removed and she movement is painful and only tends to again light up the made a complete recovery from her joint trouble, having trouble. had no recurrence, either in the joints or of the polypi. A vaccine should be made from the urethra by inserting Chronic suppuration in the sphenoidal and frontal the loop well into the meatus. The gonococcus grows sinuses and in the antrum of Higlhmiore are.again possible best on slightly alkaline agar the surface of wlliclh las foci of infection. I have opened a knee-joint for acute been smeared witlh decomlplemnentized blood serum. I pneuinococcal infection following on a pneumococcal am very indebted to Dr. D'Este Emery for drawing my infection of the maxillary antrum. attention to this and sending lue some tubes. I give 100 million gonococci and 150 million staphylo- Chronic Otorrhoea. cocei for a preliminary dose, and inicrease it to even I have seen one case of rheumatoid arthritis of both knee- 500 million gonococei. and 1,000 million staplhylococei, joints clear up in a middle-aged woman after vaccine provided the reaction is not great. After the second dose inoculation combined with clearing out of the antrum and an anaesthetic is given, a'nd the adlhesions in the joint middle ear. Here, again, few bacteria were intracellular. broken down. I have seen no lharm follow this proceeding, It is therefore very important in cases of these metastatic and witli nmassage and daily movements while under the joints to make a thorough exanmination to exclude a influence of vaccines I have patients back at their work primary focus in the mouth, nose, tllroat, and ear. again wlhose joints have been given up as hopeless. Bought vaccines do not appear to act so well as autogenous The Lungs. in these cases, and this has been most marked in some of Rheumatoid joints have been associated with bronchitis my cases. Gonococcal arthritis is perhaps one of tlle and bronchiectasis. I remlember a case of the disease types of case which best lends itself to auLtogenous associated with bronchitis in which the pneumo-bacillus vaccination. was isolated. A vaccine was prepared and given and the Combined with this the chronic gleet should receive joint condition improved markedly, and finally the patient attention, and the best method I find is massaging the went back to work. penis over a stout metal bougie passed into the uretlhra, followed by the insertion of a protargol bougie. Copaiba The Intestinal Tract. should at the same time be administered by the mouth. Rheumatoid arthritis is often associated with dyspepsia, and I have seen it in association with chronic gastric ulcer and chronic appendicitis. With both these conditions there is a degree of intestinal stasis. I have frequently VACCINES IN THE TREATMENT OF CHRONIC opened the abdomen and found the condition of pericolitis BRONCHITIS AND OF ASTHMA.-* of a membranous kind affecting peristalsis. I can recall cases of marked amelioration in rheumatoid joints after By J. H. HARVEY PIRIE, M.D., F.R.C.P.E., gastro-enterostomy and ileo-sicmoidostomy, and Mr. FORMERLY ASSISTANT PATHOLOGIST, ROYAL INFIRMARY, EDINBURGH. Arbuthnot Lane has had cures. In this type of case vaccines do not produtce much benefit. The condition CHRONIC bronchitis, with a tendency to frequently recur- causing the stasis must be removed. An x-ray examina- ring acute attacks, and asthma, with or without bronchitis, tion should be mnade after a bismuth meal and any stasis have this at least in common from the point of view witlh or kinlks looked for. If the intestine can be proved to be which I am here concerned-namely, that they are fre- working efficiently, a very careful bacteriological examina- quently obstinate in their character and difficult to cure. tion of the urine should be made. If organisms are found Any method, tllerefore, whiclh gives better or rnore per- -notably B. coli, in the absence of intestinal stasis-a manent prospects of relief than those commonly in use vaccine sshould be made, and in this special type of case seenis worthy of trial, and I lhope to show by a survey of I have seen a great deal of good follow. the cases I have lhad under treatment during the past three years that in vaccine therapy we lhave a remedy Leutcorrhoea. which, if it does not always effect a comnplete cure, does, This often dates from a confinement, and in a number of at least in most instances, give considerable relief, even in cases I have examined I have found a displaced uterus cases where otlher measures have failed more or less and retention of some products of conception whlich have completely. become adherent to tlle uterine wall. Any inflammatory RECURRENT BRONCHITIS. condition in the uterine annexes will by contraction tend The cases upon wlhicll this opinion is based are selected to deviate tlle uterus and cause passive congestion with ones-not in the sense that I lhave picked out all tllose in leucorrhoea. Ctultures taken fromn inside tlle cervix in which the results are good and discarded the others, but these cases have shown mixed infections, the commonest in the following respects: (1) All are cases in which the form of organismis being the B. coli, a diplococcus, and complaint was of some standing. (2) All lhave been under staphylococci. other forms of treatment for varying periods, but with Tlhe vaccine base should be given prior to rectifying more or less want of success. As, however, in most the uterus, so as to raise the immunity. I have seen instances the other methods of treatment (medicinal, many cases made worse by curettings and other operative lhygienic, etc.) were continued witlh, any difference in the procedures performed when the patient's immuunity was results may fairly be attributed to the additional factor- low, but I have never seen anything- but good follow that is, the vaccine. (3) Only those whlich have been when the surgical procedures have followed the second under observation, or have been followed up, for some inoculation of the vaccine. time have been included. This excludes cases whiclh have ,When once the primary focus is cut off and the only been under treatment quite recently and in whicll it patient's immunity raised to the particular infection, is too soon to speak with any certainty as to the results; local treatment by Bier's bandage, Scott's dressing, etc., also those in which treatment was only carried out for to induce an artificial hyperaemia with blood now en- very short periods and then, for one reason or another, riched with opsonins, may be instituted. It is useless given up. If the latter group were included, the failures to resort to these local measures, and baths and spa would certainly bulk larger, but it would hardly be fair to treatment alone; the symptoms only and not the cause judge a method by cases in which treatment had not been aLre treated. For contractions I usually apply extension given a reasonably long during vaccine. treatment. I have not seen drug cata- trial. phloresis do any good. * Read before the Medico-Chirurgical Society of Glasgow. JUNE 14, 1913.] VACCINE TREATMENT OF CHRONI-C BRONCHITIS AND ASTHMA. [TDzBJ 1269

vaccines were with doses ranging from 40 to 200 million resulted in complete Autogenous always employed, prepared freedom from bronchitis which has lasted up to date for almost usually from the sputum (obtained as free from contami- a year. In this case, however, the honours must probably be nation as possible, after cleansing of the mouth by brushing shared between the vaccine and the surgical measures in the anid rinsing out with boiled water), occasionally from nose. (Cure.) swabs taken from the naso-pharynx. The details of pre- CASE IV. of the vaccine have been modified from time to F., aged 22, who for three years has suffered from chronic paration bronchial catarrh, worst in winter, with frequent " catching of time, but it has been my invariable practice to include in colds," which often amount to actual bronchopneumonia. She it all organisms found abundantly both in film preparations is free from cough at times, but there are always rhles to be and in culture, so as to make as certain as possible of heard in the chest. Tuberculosis was suspected for a time, but including the actual offending germs. I believe this is tubercle bacilli have never been found in the sputum. Ex- because at we have no amination of the sputum at various times constan-tly yielded essential, present really satisfactory pneumococci and IlI. catarr7halis with oCcasionallv 111. portna- metlhod of determining which of the organisms found are tetrageinis or staphylococci. Vaccine treatment carried out pathogcnic and whiclh are not. It h-as also been my practically without intermission for a year, the dosage being endeavour to employ always strains of organisms but little pushed up to 200 million pneumococci and 500 million of each removed from those occurring in the human subject, and of the other organisms. After that treatment was stopped. Result one year later: Complete freedom from acute bronchial latterly nothing more remote than the first subcultures attacks, although there are still some moist sounds in the chest have been used. By making the original cultures fairly and occasional cough, but not sufficient to bother the patient thin, it is usually possible to obtain pure grow'ths in the much. (Practically cured.) next generation; where this has not been the case mixed growths have been employed to make up the vaccine, a&s CA' E V. F., aged 44, wlho had resided for a number of years in the potency is to my mind more important than extreme East Indies. Since her return to this country about five years accuracy in dosage of the individual organisms in a mixed ago she has suffered from almost constant bronchitis. Before vaccine. Anotlher important point in nmaking subcultures, coming under my care she had undergone almost a year's especially in dealing -witli such organismiis as the strepto- vaccine treatment in London, but with very little benefit. cocci and the Al. cattarrhtalis group, is tllat they should be Careful examination revealed nothing wrong beyond the bronchitis. Under treatment for six months with vaccines of mnade from several colonies, and not from one onily. So several organisms-pneumococci, streptococci, ll. catarrhalis, many strains of these organisms are probably quite non- and pneunio-bacilli. The composition of the vaccine was pathogenic that, until better means of differentiating them varied several times, and the dosage was pushed until as much are found, it is necessary to include a good representation as 1,000 million 11i. catarrhtlis and 500 million of mixe(lpneumo- cocci-streptococci were being given, doses which gave the so as to ensure having some of value. patient considerable general discomfort, but wvhicli did iniot result in any amelioration of the symptoms. The treatmenit Chr-on0ic or Frequ(enitly Reciirren)t Bronchlitis. was then given up, anid this wiiiter the patient has spenit in Bacteriology of 16 cases: Soutlth Africa, to see the effect of a warmer and drier climate, Pneumococci ...... 12 cases. but with wvhat result so far I have niot heard. (Failure.) Il. Caltarrhadis group ...... 12 Streptococci ...... 6 CASE VI. Staphylococci ...... 5 M., agled about 40, with chroniic naso-pharyngeal catarrh and Bacilli of Friedliijder group ...... 5 crepitatioiis near olne apex (tubercle pretty well excludled), ll. 1)a ra tetrrqen i...u ...... 3 ... every liow and again bronchitis and broniclhopieimoiia. UIiidenitified organisms ... 2 In March, 1912, sputuim. gave a growtlh of pneunococci, Mixed occuirred in all cases, and tlle ill. c(tinrludis, and a miniute motile Gram-negative bacillus growtlhs vaccines (whlichl grew on ordiinary agar). The patient was given a lave generally contained two or tlhree organisimis, soIie- vaccine containiing these three organisms for about fixve miionths, timiies eveni four. The most strikilng difference between with restulting conisi(lerable improvement both in hiis genieral this table and that given by Allen I is the complete absence health and in the local condition. In November, 1912, ul) till of the B. infliLenzae. This nmay be partly due to tlle fact wlhichl time he had been free from -any ba(l colds, his sputum. I and naso-pharyligeal secretionis were examined, anid Oli this that lhave not always used blood-agar for cuiltures, but as occasion a growth of AlI. cttartrhalis and streptococci was ob- filini preparationis were invariably examined I thlinik the tained. The patient was put on a vaccine of these organisms, chief reason is the rarity of this organism in Scotland at and this winter, although his general health has not been good, tile present time. In this connexion it may be stated that lie has ollyl had one bad attack of tonsillitis and pharyngitis, tile epidemic of so-called influeniza prevalent lhere tllis wlhicb, however, did not extend furtlher down the respiratory wrinter lhas, in my experience, been caused invariably tract. (Colisiderably improved.) either by pneuimococci or streptococci. Su)n)nanr of Result.s of Tr-eat)ment in the Si.rteell Cases. rIlTe following are slhort notes of 6 representative cases In 7 cases there is Inow such almost complete freedom from otut of tllese 16: colds aind bronchitis that they may be conisidered as practically cured. CASE I. In 4 there has been marked improvement, although they M., aged 40. Chrolicibronchitis and pharyDlgitis. In October, cannot be said to be quite cured; two of these are still under 1911, his spuitum slhowedl pneumococci and a fewv staphylococci. treatment. Doses containing 50 million of the former organiism onily were In 4 thle improvement has only been slight. In none of these put up and sent to his mYedical attendant with instructions to was treatment persevered with for over four months. give a half-dose at once when any acute exacerbation threatened, In 1 case there was 11O improvement even after eihfhteen otherwise to give a full dose once a week. The attacks were months of vaccine treatment. reported later to be cut short by this plan, and also to be less frequent. In December, 1912, the sputum showed pneumococci From tllese figures it may be said that vaccine and JI. catarrhalis to be dominant, and a fresh vaccine con- tlherapy taininig 50 million of the former and 200 million of the latter does hold out very considerable hope of effecting improve- wvas sent with similar instructions. The latest report (March, ment in clhronic bronchitis even in cases wlhlich lhave 1913) states that the patient "has been able for work all proved resistant to other modes of treatment, but-and winter, and lhas only had two comparatively trivial attacks of there is always a but-it cannot be said to be certain of bronchitis." (Greatly benefited.) doing so, and in all cases it should be made clea- to tlle CASE II. patient at the outset that fairly long continued or repeated F., aged 14, who for several years has suffered from almost courses of inoculation are likely to be necessary to obtain constant nasal and bronchial catarrh witlh acute " influenzal" good and lasting results. The average length of time for attacks. Neither the nasal nor the bronchial secretion showed whiclh these 16 cases weie under treatment, constantly or the presence of any B. influe1ezae, but from growths obtained a intermittently, was nine and a lhalf montlhs. vaccine was prepared contaiiiing 25 million pneumococci, 100 million ill. catarrhalis, and 60 million of an organism of the I would now advise any patient, even when supposed to 1B. Fried(lander group. Treatment with this at first, and later be cured, to lhave occasionally a few protective inoculations with double these amounts, for a period of six months at from against any organisms to which they are specially sensi seven to ten day intervals, has greatly improved the patient's tive, and more especially before the onset of winter. For general health and lessened the ten(lency to acute attacks, but this purpose either an autogenous vaccine imiiglht be em- there is still wheezing in the chest and a good deal of nasal discharge. Treatment is being continued with still larger ployed, or one of the several- so-called " combined vaccines (loses. (Greatly benefited.) for colds " wlhlich are on the market, and which aim at producing immunity against all of thle commoner cold- CASE III. causing germs. I have no personal experience of tlhe use M., aged 28, undergoing treatment for nasal obstruction, and who for two years has had increased susceptibility to attacks of of these, but one objection which they seem open to as bronclhitis. Sputum contained abundant pneumococci and no regards their use in Scotland is that none of them are other organism grew in cultures. Three months' treatment suited in their composition to the infections which are 1270 U THEIUBRITIS , ] VACCINE TREATMENT OF CHRONIC BRONCHITIS ANI) ASTkiMA. [JUNE 14, 1913. most common here at the present time, however suitable continued over a period of almost ten months, with the result they may be for other parts of the cou-intry. that the attacks are becoming much less frequent aind less severe. Treatment is being continued. (Considerable improve- The dosage of the vaccines employed has varied con- meint.) siderably in the different cases, but the general tendency CASE IV. has been to increase the amounits given, pushing, the dose MI., aged 51, lad suffered from bronchitis and asthma since in each individual case until olne is arrived at wliich childhood, aind had also an old tuberculous lesion at oile produces after inoculation some definite reactioll in the apex, wlhich lhas for mainy years appeared to be quite quiescenit. First culture alnmost pure pneumococci, a few 31I. c(ltorlh--hailis, way of general discomfort, slight feverishness usually, and diphtlheroid bacilli. After two months' weeklv iinjections and not infrequently some temporary aggravation in the of an autogenious pneumnococcal vaccine in doses of from 50 to amount of the bronclhial secretioln. 120 millioni there was distinict improvemenit in the patienit's Vaccine treatment is not, of course, recoDmmended to the breatlhlessniess anid in the frequency of the astlhmatic attacls. A second(l examiniationi of the sputum gave a growth of the same exclusion of other measures, but simply as an " extra" organisms, but a vaccinie was made up containinlg pineunmo- where these fail to give satisfactory relief. The oidiniary cocci 100 million, J1. catarrhalis 150 million, and diphthieroid medicinal and hygienic measures applicable slhould be bacilli 25 million. Treatmenit wvith this was con1tinued for employed, and, in particular, I consider it hlighly impor- three months, injectionls Woing given weekly. At the enid tant to cleanse the nose and naso-pharynx at least twice of this time the patient volunteered the statement that hiis asthma was very much improved, and that although lhe daily with some form of douchle and swab to remove seemed to be bringing up more sputum, it came very much mechanically at least some of the offending organisms more easily. He theni wislied to try witliout further treatment, which are constantly lurking in these situations, ready to and since that time-nearlya year ago-has not been hieard infect the lower respiratory passages wlhen given a suit- from. (Considerably improved.) able opportunity. CASE V. A STHMA. F., aged 50, witlh bronchitis and asthma of ten years' stand- In the case of asthma we have to deal with a disease ing. Organisms from sputum: Pneumococci, long-chained which is different from bronellitis, in that it is by no streptococci, and abundant bacilli of the Friedlhnder group; means of purely bacterial origin, but without goilng into oIn a later occasion a few colonies of II1. catarrhalis. Treatnment and I for four months with a vaccine of mixed streptococci and the vexed questions of its etiology patlhology, shall pneumoccci 60 to 180 millionl, and bacilli 200 to 400 million merely say here that I amu of opinion tlhat in miiany cases produced some improvement, but not sufficien-t to induce tlle microbic infection is one, and an imaportant one, of the patient to conitinue treatment for longer, as she objecte(d to factors which mnay precipitate an asthlmnatic attack. This the pain and stiffness incidental to the injections. (Sliglht is probably especially the case wlhere there is bronehitis or improvement.) infection of some other part of the respiratory tract CASE VI. associated with the spasmodic asthmatic attacks. MI., aged 40, who has siffered from asthma since infancy. Cultures both from the sputum and direct from the niaso- Asthma. Bacteriology of 15 cases: pharynx gave a growth of pneumococci, llI. catarrh-lwlis, some in character to Allen's S. Pneumococci ...... present in all cases. streptococci correspoondinig m71axhinmusb, Ml. catarirhalis group 14 and a few leptothrix-like organisms. Four months' treatment 11 with pneumococcal-streptococcal (25 to 100 and 3.L Staphylococci ... 8 million) ,,7 I? c(ltirrholis J100 to 200 millioni) vaccine has produced very dis- Streptococci ... ,,~ 6 ,, B. of Friedlander group ,,7 6 ,, tilnct improvement. Treatment is beinig persevered with. Diphtheroid bacilli... ,, ~ 3 I,, (Conisiderable belnefit.) M1. pa ratetrageni nis ... ,, I case. CASE VII. B. Mfle ae ...... ,, 1. ,, F., aged 20, with asthma, bronclhitis, and nasal catarrh of ter Unidentified organism ,, 1 ,, years' standing. rrlle patient has had nine operations on the nose, with in one inistanice about a year's relief from asthma. Slhe Mixed infections are commoner in mny cases than in has also tried residence abroad, and is particularly carefuil in those recorded by Allen. 1 The pueumococcus found in all looking after herself, buit withal has very frequenitly to lhave my cases seems to take the p]ace of the streptocoeci whieh recourse to sprays and other asthmatic remedies. Before treatment was commenced she was showing nlo tendenicy to he records from 96 per cent. of his. Many of hiis strepto- improvement either in frequency or severity of attacks, but cocei occurred either in exceedingly long chains or as a was rather drifting into chronic invalidism. Examination of form which he calls S. maximuts, the individuals being swabs an(I sputa on, numerous occasions always showed the large and somne of them in each chaini Gram-negative. I presence of piieumococci and 311. catarrhalis, aInd at tiTnes of have met with both forms amongst my cases. Carmalt such organisms as staphylococci, streptococci, dplihtheroid bacilli, .1. paratetr?'gemis, anid bacilli of the Friedlander group. Jones regards an organism whlich probably belongs to tlhe The vaccinies emiployed lhave always contained the first two Micrococcus catarrhalis group as a possible cause of organisms, an(l at times somie onie or more of the others; com- asthma. paratively small (loses hiave been employed throughlout. Treat- CASE I. ment was commence(d in May, 1911, and has beenl kept up since F., aged 28, who bas suffered from bronchitis with occasional that time, the injections bein;g given as a rule weekly. Iln the asthmatic attacks-not, however, of a very severe nature-for summer of 1911 she was comparatively well,-but'this was not several years. The first examination of the sputum, obtained unusual, as she was always freer in summer than in winter. during an attack, gave a growth of Mll. catarr7halis and diph- The winter of 1911-12, however, showed a marked improvement theroid bacilli, and a vaccine was prepared. containing upon any past winter for a number of years. In the summer of 100 million of each. A half-dose was given first, theni three 1912 the injections were reduced for a time to fortnightly, but full doses. A second examiniation of the sputum showed the as in the autumn thiere was a tendency to recurrence of attacks, presence also of pneumococci; 25 million of these were added the vaccines were again given weekly, and have been continued to the vaccine and administration continued weekly for three so u)p till the presenit time. The patient has come through this months, the dosage being gradually pushed to double the winter-a particularly trying one-with only one cold, which original amounts. Treatment was then stopped, and four soon cleared up, and a very slight asthmatic attack, and she months later (April, 1913) the patient reported that she had been has been able to participate in all sorts of e2xercise and social free from asthmatic attacks, although she still had some events. (Practically cured.) bronchial catarrh. (Considerable improvement.) CASE VIII. CASE II. F., aged 55, for many years had been troubled with frequently F., aged 37, with chronic bronchitis and asthma of long recurrinig attacks of brolnchitis and 'asthma, especially in standing. Greatly emaciated. Organisms: Pneumococci and winter; latterly they had been becoming more common and M1[. catarrhalis. A dose of vaccine, containing only 16 million of less easy to throw off. In September, 1910, sputum gave a the former and 50 million of the latter, brought on niext day ani growth of 11. catarrhalis and pneumococci, and a vaccine was attack of acute bronchitis. A subsequent injection of half prepared containinig 200 million of the former and 25 million of those amounts was also followed l)y considerable reaction. the latter. Twelve doses of this were given at intervals of Treatment was persevered with for three months at about ten- about a weeli, save for two intermissions during acute attacks. day intervals; in no instance was a bigger dose than 20 milliou During January and February, 1911, the patient was free from pneumococci and 60 million 11l. catarrhalis given, and every acute exacer'bations, but in Marcli hal an attack, when, in dose was followed by considerable discomfort and frequently addition to the same organisms as before, pneumo-bacilli were by an actual asthmatic atiack. As no improvement was taking obtained in culture. A fresh vaccine containing 300 million place, further treatment was declined. (Failure.) .31. catarrithalis, 50 million pieumococci, pneunio-bacilli in amoulnts ranging from 50 to 200 million, was made up and giveen CASE III. weekly. In AMay the patient stated that she had passed the best F., aged circa 40. Severe asthmatic attacks for several years; winter and spring she lhad had for twelve years. Vaccines no bronchitis. Also suffers from cystitis. Cultures from the sto ped in June, 1911, and thepatient remained almost free 'from sputum onl several occasions always yielded ppeumococei and polss till January. 1912, when a-fairly severe' atta'ck'occurred, .A. catarrhialis. Treatment was commenced with 12i- million of the organi'sms found being pneumococCi andApnenmo-bacilli. the former and 100 million of the latter, the dosage being soon A small dose of vaccine was given and the attack cleared up increased to double those amoui4ts. Injecticns weekly were quickly, then four larger doses were given during the niext JUNE -14: 1093. ME'MORANDA. [IMDIBafiJOs I2, month. She lhadl one further slight asthlmatic turn in April. During the summer of 1912 slhe remained quite free; this winter slhe has Ilot been tinder observation, but at Christmas gtenrnrantia: time she wrote sayinig she had had no further attacks. (Practically cured.) MEDICAL,- SURGICAL, OBST1ETRICAL. CASE IX. POISONING BY AND F., aged 18, with bronchorrhoea, constanit colds, and asthma MORPHINE ATROPINE. of At least six years' stalnding. Tonsils and adenoids have been POISONING by morphine and atropine is so uncommon that removed, but without much improvement. In January, 1912, the following case seems worth recording. she was put on an autogeinous vaccine of pneumococci (75 A young woman was- found in bed' unconscious at million) anld Mll. catarrhalis (200 niillion) weekly. In September 7.30 a.m. She was cyanosed, the breatbing was shallow on one containing pneumococci 125, pneumobacilli 100, Al. and catarrhalis 300, and staphylococci 300 million. In December, irregular, tending to the Cheyne-Stokes in character. 1912, the- dosage was commenced to be pushed. Pneumococci The pupils were equal and contracted, but not to pin- 200 up to 500, Al. catarrhalis 300 to 800, and staphylococci points, and the conjunctivae were injected. There was 300 to 800 million, with excellenit results. The patient at the complete absence of rcflexes. The skin was dry and the present time (April, 1913) has been free from asthma for four pulse small-120. A letter was found to her months, althougli she still has some bronchial discharge, and writteni catches -cold rather freely. Treatment is being continued, but mother whiclh made it clear that it was a case of suicide. now with rather smaller doses. (Much improved.) An empty hlypodermic tube w-as found wlhich when full would have contained 21 grains of imiorphine. Subse- Summsnary. quently, after death, two other tubes were found hidden Of the 15 cases 6 must be excluded from the present under the mattress of lher bed. In all, supposing the tubes survey as having been for too short a time under treat- had originally been full, she would have taken 7 grains of ment to state the permanency of the results.; of the morphine, and J grain of atropine. She lhad vomited, remaining 9 (those given above)- apparently in the-night, and possibly after the first doses Of morphine, so that tlhe exact amounit taken is uncertain. 2 may be regarded as practically cured and free from It is unnecessary to go into the asthma; details of the treatnment. 5 have been considerably improved; The stomach wvas waslhed out wuith solution of potassiunm 1 shows only slight improvement; and permanganate, and injections of stryclhnine were given 1 has not been benefited at all. subsequently. Artificial respiration was performed, and slhe was bled on two occasion-s. lThe bleedings appeared to These figures are, as miglht be expected, not quite so do good for a time, as she breathed better and was less favourable as in the case of simple chronic bronchitis, but blue afterwards. they are at least sufficiently encouraging to warrant a At 10 p.m. the corneal reflex had returned, but she was trial of vaccines in intractable cases of asthma. Here still unconscious. At 2 a.m. she was founid to have a tem- again, however,, prolonged treatment is necessary. My perature of 105 F. Slhe was very blue, and breathing cases have been. receiving injections, constantly or inter- in short jerky respirations, with intervals in which sllo mittently, for, on an average, oveF ten months, and in the did not breathe at all. The corneal reflex was again two instances in wlhich the best results have been obtained lost. With artificial respiration, etc.,, she lingered on till for nearly as long as two years. 10.45 a.m. The heart cointinued to beat for a short timelo W1ith regard to dosage, I have not found it advisable to after respirations lhad ceased. push tlle amounts to the same extent as in chronic Post mortem the braini, ltngs, kidneys, and other internal bronchitis. Asthmatics are usually too sensitive, and organs were deeply congested. The riglht heart was full large doses are apt even to excite actual attacks. Only of venous blood, and therc were ante-morintem clots in tle3 in one instance (Case ix) lhave doses which I would con- left ventricle. There wras only an ounce or two of urine sider at all large been found of advantage. in the bladder. Even more than in the case of broncllitis must other The points of interest in the case are: possible factors in the causation of the spasmodic dyspnoea l. The lengtlh of tinme that elapsed from thle timne sle Le attended to if good results are to be obtained, particu- was found utntil death, 2-71 lhours later. As slhe was deeply larly the state of the whole respiratory and alimentary comatose when found but was,heard nmoving in her room tracts. In a recent paper Charlton Briscoeo lays stress at abouit 1 a.m., it seems pir`obable that slhe took the poison upon septic absorption as playing a prominent part in the at that hour, wlhicil wouild mLiake the time about 33 hoours. production of asthzma, and insists on the inmportance of I can find no record of anythiing approaclhing this- time discovering the source of this absorption, and its removal before death in opiumiii or morplline poisoning. Was the if possible, also the employment of constitutional and prolongation of life due to the atropine ? special treatment by drugs, etc. The place for vaccines 2. The quiet pulse, wlichl varied, but was generallv at is as an adjunct to those m-ethods when they do not about 120, I consider due to the paralysis of the v'agus produce the desired results.. With this opinion I am in inhibitory centre. substantial agreement. 3. The abslence of sweating (again atropine), combined It should be stated tllat whilst I am wholly responsible witlh the almost total suLppression of urine, are perhaps for the vaccine treatment in most of the cases, in some answerable for the higlh temperature during the last eiglht instances treatment was commenced by the late Dr. hours of life. In fact, did she in the end die of uraemic James Miller, but the patients have since been under my poisonin?g ? charge. London. S.W. E. G. HUNT, M.D. REFERENCES. 1R. W. Allen: Bacterial Diseasesof Bespiration an7d Vaccines in their Treatmnent. London, 1913. 2Charlton Briscoe: Journ. of Vac- ETIOLOGY OF BERI-BERI. cinie Tterapy, February, 1913, p. 29. I NOTICE on perusing your columns fronm time to time that it seems to be more or less accepted nowadays by THE Medical Chamiber of Vienna has decided to "make a a large section of the profession ^that ber-beri should be careful investigation in the municipal schools of Austria looked upon as a " deficiency " disease-in other words, with reference -to scholastic hygiene. -When the investi- that it is due to the consumption of rice fromwhich tlle gation is complete the results will be taken as a basis for pericarp has been the formulation of principles to be applied to the whole remnoved, tlhe. pericarp being supposed scholastic medical service throughout the country. The to contain a necessary essential towards the. upkeep of details will be left to the local authorities. In the mean- the nerve fibre. Now during ten years of residence in time a society of school hygicie- has been formed at Southern Nigeria I saw a number of cases of beri-beri. Vienna. Of tlhese, however, four stand out clearly in my memory; COURSES of training in hygiene and tropical medicine ths6y'werc young Englishnen.whose Xlonss.I visitd.every for missionaries were established two years ago by the day, witlh whom I on nulmerous occasions had lunclh or Institute for Foreign Missions in Lombardy. At the present dinuer, as the case may have been, and consequently time some thirty young priests who propose to work as whose mode of life I was tlhoroughly acquainted witl). imissionaries are receivingiorstrnction.O-n April 5th they With regard- to these cases I can guaraintee that they were; exan+ined by a cpmmission comppsed of three lived as 'wel as anv ordinary yoiing men wnouldt live in dloctors., !There were also present at the examinations England..' There w^as at all.timnesan abundanece of fresh Dr. V+ogan6,. Bishop of Ezanv, the Director of the Insti- foodni the table: chickden, mutton, fish;A 'fuit, a;nd tute, and other clerics connected with foreign mrissions. reget^bles were alwvays~at hiand, and althoughi tliey miay