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PROLONGED VACCINE THERAPY IN TYPHOID FEVER.
564
.
most satisfactory manner, the post of resident medical officer at many provincial hospitals, and it was recently stated that Surgeon-General Sir Alfred Keogh had invited Dr. Flora Murray and Dr. Garrett Anderson, after seeing their work at the front, to come to London and take charge of a new military hospital to contain 500 beds, to be staffed entirely by women, women orderlies, the sisters. A point that has been under working a source of great difficulty with regard to the employment of women in other pursuits in competition with men has been a tendency on the part of women to undersell men. It is satisfactory to learn from Professor Marsh that those in authority are taking measures for the prevention of this tendency in medicine. It is understood that when medical men return from military service the medical women who have acted as their substitutes will retire in their favour. This will in some cases constitute hardship, but no other course is possible or desirable. We are glad to feel sure, however, that these women practitioners who have done good work will readily find other openings, in view, not only of the shortage of medical men, but especially because of the enormous development of official medical service that has already taken place, and will probably continue to take place when the war is over. SENILE PARAPLEGIA.
3. The spinal cord is evidently the seat of disease. There are ataxia and involvement of the sphincters in the early stage. The muscular atrophy appears to be more rapid than in the previous groups, and in the later stages trophic symptoms in the skin Professor Starr suggests that are more frequent. the pathological condition is venous congestion of the lower portion of the spinal cord leading perhaps to oedema. The prognosis in all cases is manifestly unfavourable, but there may be great variations in’the course and marked improvement, In the more or less temporary, under treatment. muscular cases a stimulating diet with meat and fatty foods, diminution in the amount of salt taken, and administration of alcohol and small doses of strychnine will cause some arrest of the degeneration and improvement in the symptoms. Warm baths at a temperature of 100° F. for 20 minutes and mild massage are beneficial. But in cases of neuritis baths and massage should be avoided on account of the tenderness, and warmth should be applied by heating the bed. In the spinal cases hot and cold douches to the back, massage of the back and limbs, and dry cupping of the spine are of service. The patient should lie prone so that gravity may aid in emptying the congested veins. Senile paraplegia is easily distinguished from spastic paraplegia due to lateral sclerosis, in which muscular rigidity with exaggerated knee-jerks are present. It should not be confounded with the paraplegic condition of slow onset appearing late in Parkinson’s disease, where the tremor is usually a prominent symptom and the gait is slow, shuffling, and stiff, with a tendency to fall.
IN the Medical Record of Jan. 30th Professor M. A. Starr has described one of the maladies of old age which has received little attention either in text-books or in other forms of medical literatureUnder this symptomatic title senile paraplegia. PROLONGED VACCINE THERAPY IN TYPHOID there appear to be included different pathological FEVER. conditions, which, however, present a similar clinical picture. Senile paraplegia begins after the Professor V. Pensuti publishes in a recent issue age of 65 years, the time depending upon the of Il Policlinico a further series of 69 cases of general vitality of the patient. He gradually typhoid fever treated by vaccines. These cases becomes more feebJe and notices first increasing seem to show that vaccine therapy in this disability in walking, going up stairs, or standing disease has an indisputable efficacy, possesses for any length of time. In the end he becomes the requirements of a specific treatment, and bedridden. In some cases the weakness is attended if in some cases the evidence of its utility by ataxia, which is more marked than the weakness. has not been immediately apparent later obserIn other cases pain is a prominent symptom and is vations on patients, and on the behaviour of the felt either on movement or on standing, although it course taken by the infection, render its applicamay occur spontaneously. It is particularly severe tion more clear and profitable. Having noticed after exertion and towards night. The pain is always that typhoid patients, whether they recovered attended by coldness of the feet and legs and not naturally or by vaccine treatment, were prone to infrequently by sensations of numbness and tingling. have relapses, Professor Pensuti took note of the Atrophy of the muscles is more marked than number of relapses occurring in a group of cases is usual in feeble old persons, and the tendon vaccinated with a limited number of injections. reflexes are lost. The limbs are usually flabby, He found a relapse occurred in about one out cold, and blue, and not infrequently oedema occurs of every four. He then had recourse to 31 new when the patient is out of bed. Occasionally loss cases in which, having vaccinated them with doses of control of the sphincters occurs late in the case. believed to be sufficient, he repeated for some time Pain in the back and round the loins is common a daily small injection of vaccine and kept and may cause insomnia. As a rule the hands and them under observation as long as possible after arms are not affected. The cases .seem to form the cessation of fever to notice whether relapses three pathological groups : 1. The primary disease took place. The doses employed were 12,500,000 lies in the muscles and may be likened to a slowly daily, and’in a child aged 5 years and in another aged progressive muscular dystrophy. 2. There is evi- 7 years 6,000,000. These injections were given for dently an active degenerative neuritis characterised 11 to 25 days and the period of observation lasted by spontaneous pain, burning and tingling, and for about three weeks. None of these cases had tenderness along the nerves. Areas of hyper- any relapse, although occasionally there were rises sesthesia and anaesthesia in the legs are not un- of temperature for a period of from four to six hours The anterior crural nerves appear to be with a maximum of 37°-38° C. With regard to the common. effect of the treatment on the duration of the more frequently affected than the sciatic, and not infrequently there is considerable pain in the rectum illness, Professor Pensuti records a fair number and bladder, showing that all the branches of the of cases in which the fever promptly came to sacral plexus are involved in the degeneration. an end; the effect on the general condition and
565 on the various symptoms was none the less marked, while albuminuria diminished and dis-
rapidly as to render it difficult not causal connexion between this fact and the vaccination.
appeared
so
to admit
a
MEDICAL PRACTICE AT GILLINGHAM AND CHATHAM. (FROM I
HAD
two
OUR
reasons
SPECIAL
for
going
COMMISSIONER.)
to
Gillingham
to
see
how the
THE Lumleian lectures will be delivered at the present national conditions affect the well-being of the Royal College of Physicians of London by Dr. medical profession. Firstly, Gillingham, though not in the Sidney Martin, on Non-ulcerative Infections of the borough, is really an extension of Chatham, and personally concerned in much of the naval and military activity. Next, Colon, on March 18th, 23rd, and 25th at 5 P.M. i it may be remembered that Gillingham was one of the storm centres in the resistance organised by a large section of the medical profession against the working of the National Insurance Act.l Though two years have elapsed since on the occasion of a previous visit I described the attitude of Gillingham doctors towards the National Insurance Act, the practitioners who were opposed to the Act then have remained unchanged in their attitude and still refuse to go on the panel. It was therefore necessary to import medical men to make up the Gillingham panel. But in spite of this addition to their numerical strength the medical practitioners at Gillingham are fully employed, the war circumstances producing this result. Some of them may also find that the increase of their income is not in proportion to the increase of the work they have to do, but that is another question. The medical practitioners of Gillingham have had sufficient forethought not to allow themselves to be placed in the awkward position which I described a week or two ago to have overtaken their colleagues in Great Yarmouth.2 The British Medical Association suggested that the medical profession throughout the country should offer to attend gratuitously all the necessitous dependents of soldiers who had volunteered for the front. On August 7th, immediately after the declaration of war, at a special meeting of the London Panel Committee, the doctors on the panel were invited to express their willingness to attend, free of charge, necessitous dependents of reservists called to arms. This patriotic impulse, however, soon extended without anyone seeing at once whither a heedless generosity might lead. The medical practitioners of the entire kingdom, whether on the panel or not, offered their gratuitous services in this way, and instead of the dependents of the reservists it became the dependents of all those who enlisted. Nobody in those days foresaw the size of our army and no one knew anything for certain about the pay and allowances of the men. And to make the effect of miscalculation worse the word necessitous qualifying the dependents was withdrawn. Had that word been maintained no harm would have been done.
principal Sir Almroth Wright will deliver a special lecture before the Royal Society of Medicine on Tuesday, March 30th, at 5 P.M., on the Septic Infection of Wounds, in which he will lay before the profession the results of his investigations and research with the Expeditionary Force. AT a meeting of the Council of the Royal College of Surgeons in Ireland held on March 4th, Mr. F. Conway Dwyer, the President, being in the chair, Dr. Richard Travers Smith was elected to the Professorship of Materia Medica, Therapeutics, and Pharmacy in the Schools of Surgery.
IT has been decided that the annual meeting of the British Association for the Advancement of Science shall take place in Manchester in September. Owing to war conditions, however, in place of offering the customary elaborate social hospitality, it is held preferable, while maintaining unbroken the long continuity of yearly meetings, that the proceedings this year should be restricted to the more purely scientific functions.
ROYAL COLLEGE OF PHYSICIANS OF LONDON. MEETING
OF
COMITIA.
AN extraordinary Comitia was held on March 4th, Sir THOMAS BARLOW, Bart., K.C.V.O., the President, being in the chair. The following communications were received :-1. From the Secretary of the Royal College of Surgeons of England, dated Feb. 15th, reporting proceedings of the Council of that College on Feb. llth. 2. From the secretary of the Charity Commission, dated Feb. 19th, enclosing a scheme for the administration of the charity, to be called ’The British Hospital for Mothers and Babies," to the managing committee of which the College consented to send a Representative Member. It was resolved that it should be left to the President to nominate a representative.
Gratuitous gttendccnee on Reoruits. Doubtless the practitioners of the three towns-Rochester, Chatham, and Gillingham-were better acquainted with the conditions of military and naval service than their London brethren, and indeed than doctors in most of the other parts of the country. In any case, they refused to attend gratuituously all the dependents of soldiers or sailors. They saw no reason why they should thus attend families who had always paid medical fees and were now better off than before the war. Every medical practitioner, panel or not, showed himself most willing to give free and devoted attention to necessitous dependents, and a great deal of work is being done, but not for the well-to-do ’ gratuituous RED CROSS WORK IN DEVONSHIRE.-At present families of men who have enlisted. there are 21 Red Cross hospitals, which are occupied by ’, It was the more necessary to draw the line somewhere as wounded soldiers, in the county of Devon. the civil medical practitioners do a great deal of gratuitous THE LATE DR. A. F. LEGGE.-Our Aberdeen work for the army. At Gillingham no less than 10,000 soldiers were billeted on the or lodged in any correspondent writes : " The late Dr. A. F. Legge, who was building that could be made population available for such a purpose. killed in the recent riot at Singapore, was the son of the late Rev. James Wilson Legge, teacher at the Aberdeen There was no military medical staff attached to this large Grammar School. He graduated M.B., Ch.B., at Aberdeen body of recruits, and they were, of course, liable to the sickness affecting a population of this description. University in 1912, and was for a time house surgeon in ordinary the Aberdeen Royal Infirmary, and subsequently house When one of these recruits falls ill in a private house where he is billeted, and he or the landlord sends for a medical at the Aberdeen last
physician
Royal Asylum. Early year he went to Singapore to take up duty in the asylum there, and on the outbreak of war volunteered for service with the contingent of the Malay Federated States. When in Aberdeen Dr. Legge was a prominent and popular figure, taking a worthy part in the social and athletic life of the city and university."
a small fee is occasionally forthcoming ; but more often it is not. There is no guarantee that the medical attendant will receive anything for the trouble he has taken. Then it sometimes happens that one or more of
man,
1
2
THE THE
LANCET, March 22nd, 1913, p. 854. LANCET, Feb. 13th, 1915, p. 342.
.
most satisfactory manner, the post of resident medical officer at many provincial hospitals, and it was recently stated that Surgeon-General Sir Alfred Keogh had invited Dr. Flora Murray and Dr. Garrett Anderson, after seeing their work at the front, to come to London and take charge of a new military hospital to contain 500 beds, to be staffed entirely by women, women orderlies, the sisters. A point that has been under working a source of great difficulty with regard to the employment of women in other pursuits in competition with men has been a tendency on the part of women to undersell men. It is satisfactory to learn from Professor Marsh that those in authority are taking measures for the prevention of this tendency in medicine. It is understood that when medical men return from military service the medical women who have acted as their substitutes will retire in their favour. This will in some cases constitute hardship, but no other course is possible or desirable. We are glad to feel sure, however, that these women practitioners who have done good work will readily find other openings, in view, not only of the shortage of medical men, but especially because of the enormous development of official medical service that has already taken place, and will probably continue to take place when the war is over. SENILE PARAPLEGIA.
3. The spinal cord is evidently the seat of disease. There are ataxia and involvement of the sphincters in the early stage. The muscular atrophy appears to be more rapid than in the previous groups, and in the later stages trophic symptoms in the skin Professor Starr suggests that are more frequent. the pathological condition is venous congestion of the lower portion of the spinal cord leading perhaps to oedema. The prognosis in all cases is manifestly unfavourable, but there may be great variations in’the course and marked improvement, In the more or less temporary, under treatment. muscular cases a stimulating diet with meat and fatty foods, diminution in the amount of salt taken, and administration of alcohol and small doses of strychnine will cause some arrest of the degeneration and improvement in the symptoms. Warm baths at a temperature of 100° F. for 20 minutes and mild massage are beneficial. But in cases of neuritis baths and massage should be avoided on account of the tenderness, and warmth should be applied by heating the bed. In the spinal cases hot and cold douches to the back, massage of the back and limbs, and dry cupping of the spine are of service. The patient should lie prone so that gravity may aid in emptying the congested veins. Senile paraplegia is easily distinguished from spastic paraplegia due to lateral sclerosis, in which muscular rigidity with exaggerated knee-jerks are present. It should not be confounded with the paraplegic condition of slow onset appearing late in Parkinson’s disease, where the tremor is usually a prominent symptom and the gait is slow, shuffling, and stiff, with a tendency to fall.
IN the Medical Record of Jan. 30th Professor M. A. Starr has described one of the maladies of old age which has received little attention either in text-books or in other forms of medical literatureUnder this symptomatic title senile paraplegia. PROLONGED VACCINE THERAPY IN TYPHOID there appear to be included different pathological FEVER. conditions, which, however, present a similar clinical picture. Senile paraplegia begins after the Professor V. Pensuti publishes in a recent issue age of 65 years, the time depending upon the of Il Policlinico a further series of 69 cases of general vitality of the patient. He gradually typhoid fever treated by vaccines. These cases becomes more feebJe and notices first increasing seem to show that vaccine therapy in this disability in walking, going up stairs, or standing disease has an indisputable efficacy, possesses for any length of time. In the end he becomes the requirements of a specific treatment, and bedridden. In some cases the weakness is attended if in some cases the evidence of its utility by ataxia, which is more marked than the weakness. has not been immediately apparent later obserIn other cases pain is a prominent symptom and is vations on patients, and on the behaviour of the felt either on movement or on standing, although it course taken by the infection, render its applicamay occur spontaneously. It is particularly severe tion more clear and profitable. Having noticed after exertion and towards night. The pain is always that typhoid patients, whether they recovered attended by coldness of the feet and legs and not naturally or by vaccine treatment, were prone to infrequently by sensations of numbness and tingling. have relapses, Professor Pensuti took note of the Atrophy of the muscles is more marked than number of relapses occurring in a group of cases is usual in feeble old persons, and the tendon vaccinated with a limited number of injections. reflexes are lost. The limbs are usually flabby, He found a relapse occurred in about one out cold, and blue, and not infrequently oedema occurs of every four. He then had recourse to 31 new when the patient is out of bed. Occasionally loss cases in which, having vaccinated them with doses of control of the sphincters occurs late in the case. believed to be sufficient, he repeated for some time Pain in the back and round the loins is common a daily small injection of vaccine and kept and may cause insomnia. As a rule the hands and them under observation as long as possible after arms are not affected. The cases .seem to form the cessation of fever to notice whether relapses three pathological groups : 1. The primary disease took place. The doses employed were 12,500,000 lies in the muscles and may be likened to a slowly daily, and’in a child aged 5 years and in another aged progressive muscular dystrophy. 2. There is evi- 7 years 6,000,000. These injections were given for dently an active degenerative neuritis characterised 11 to 25 days and the period of observation lasted by spontaneous pain, burning and tingling, and for about three weeks. None of these cases had tenderness along the nerves. Areas of hyper- any relapse, although occasionally there were rises sesthesia and anaesthesia in the legs are not un- of temperature for a period of from four to six hours The anterior crural nerves appear to be with a maximum of 37°-38° C. With regard to the common. effect of the treatment on the duration of the more frequently affected than the sciatic, and not infrequently there is considerable pain in the rectum illness, Professor Pensuti records a fair number and bladder, showing that all the branches of the of cases in which the fever promptly came to sacral plexus are involved in the degeneration. an end; the effect on the general condition and
565 on the various symptoms was none the less marked, while albuminuria diminished and dis-
rapidly as to render it difficult not causal connexion between this fact and the vaccination.
appeared
so
to admit
a
MEDICAL PRACTICE AT GILLINGHAM AND CHATHAM. (FROM I
HAD
two
OUR
reasons
SPECIAL
for
going
COMMISSIONER.)
to
Gillingham
to
see
how the
THE Lumleian lectures will be delivered at the present national conditions affect the well-being of the Royal College of Physicians of London by Dr. medical profession. Firstly, Gillingham, though not in the Sidney Martin, on Non-ulcerative Infections of the borough, is really an extension of Chatham, and personally concerned in much of the naval and military activity. Next, Colon, on March 18th, 23rd, and 25th at 5 P.M. i it may be remembered that Gillingham was one of the storm centres in the resistance organised by a large section of the medical profession against the working of the National Insurance Act.l Though two years have elapsed since on the occasion of a previous visit I described the attitude of Gillingham doctors towards the National Insurance Act, the practitioners who were opposed to the Act then have remained unchanged in their attitude and still refuse to go on the panel. It was therefore necessary to import medical men to make up the Gillingham panel. But in spite of this addition to their numerical strength the medical practitioners at Gillingham are fully employed, the war circumstances producing this result. Some of them may also find that the increase of their income is not in proportion to the increase of the work they have to do, but that is another question. The medical practitioners of Gillingham have had sufficient forethought not to allow themselves to be placed in the awkward position which I described a week or two ago to have overtaken their colleagues in Great Yarmouth.2 The British Medical Association suggested that the medical profession throughout the country should offer to attend gratuitously all the necessitous dependents of soldiers who had volunteered for the front. On August 7th, immediately after the declaration of war, at a special meeting of the London Panel Committee, the doctors on the panel were invited to express their willingness to attend, free of charge, necessitous dependents of reservists called to arms. This patriotic impulse, however, soon extended without anyone seeing at once whither a heedless generosity might lead. The medical practitioners of the entire kingdom, whether on the panel or not, offered their gratuitous services in this way, and instead of the dependents of the reservists it became the dependents of all those who enlisted. Nobody in those days foresaw the size of our army and no one knew anything for certain about the pay and allowances of the men. And to make the effect of miscalculation worse the word necessitous qualifying the dependents was withdrawn. Had that word been maintained no harm would have been done.
principal Sir Almroth Wright will deliver a special lecture before the Royal Society of Medicine on Tuesday, March 30th, at 5 P.M., on the Septic Infection of Wounds, in which he will lay before the profession the results of his investigations and research with the Expeditionary Force. AT a meeting of the Council of the Royal College of Surgeons in Ireland held on March 4th, Mr. F. Conway Dwyer, the President, being in the chair, Dr. Richard Travers Smith was elected to the Professorship of Materia Medica, Therapeutics, and Pharmacy in the Schools of Surgery.
IT has been decided that the annual meeting of the British Association for the Advancement of Science shall take place in Manchester in September. Owing to war conditions, however, in place of offering the customary elaborate social hospitality, it is held preferable, while maintaining unbroken the long continuity of yearly meetings, that the proceedings this year should be restricted to the more purely scientific functions.
ROYAL COLLEGE OF PHYSICIANS OF LONDON. MEETING
OF
COMITIA.
AN extraordinary Comitia was held on March 4th, Sir THOMAS BARLOW, Bart., K.C.V.O., the President, being in the chair. The following communications were received :-1. From the Secretary of the Royal College of Surgeons of England, dated Feb. 15th, reporting proceedings of the Council of that College on Feb. llth. 2. From the secretary of the Charity Commission, dated Feb. 19th, enclosing a scheme for the administration of the charity, to be called ’The British Hospital for Mothers and Babies," to the managing committee of which the College consented to send a Representative Member. It was resolved that it should be left to the President to nominate a representative.
Gratuitous gttendccnee on Reoruits. Doubtless the practitioners of the three towns-Rochester, Chatham, and Gillingham-were better acquainted with the conditions of military and naval service than their London brethren, and indeed than doctors in most of the other parts of the country. In any case, they refused to attend gratuituously all the dependents of soldiers or sailors. They saw no reason why they should thus attend families who had always paid medical fees and were now better off than before the war. Every medical practitioner, panel or not, showed himself most willing to give free and devoted attention to necessitous dependents, and a great deal of work is being done, but not for the well-to-do ’ gratuituous RED CROSS WORK IN DEVONSHIRE.-At present families of men who have enlisted. there are 21 Red Cross hospitals, which are occupied by ’, It was the more necessary to draw the line somewhere as wounded soldiers, in the county of Devon. the civil medical practitioners do a great deal of gratuitous THE LATE DR. A. F. LEGGE.-Our Aberdeen work for the army. At Gillingham no less than 10,000 soldiers were billeted on the or lodged in any correspondent writes : " The late Dr. A. F. Legge, who was building that could be made population available for such a purpose. killed in the recent riot at Singapore, was the son of the late Rev. James Wilson Legge, teacher at the Aberdeen There was no military medical staff attached to this large Grammar School. He graduated M.B., Ch.B., at Aberdeen body of recruits, and they were, of course, liable to the sickness affecting a population of this description. University in 1912, and was for a time house surgeon in ordinary the Aberdeen Royal Infirmary, and subsequently house When one of these recruits falls ill in a private house where he is billeted, and he or the landlord sends for a medical at the Aberdeen last
physician
Royal Asylum. Early year he went to Singapore to take up duty in the asylum there, and on the outbreak of war volunteered for service with the contingent of the Malay Federated States. When in Aberdeen Dr. Legge was a prominent and popular figure, taking a worthy part in the social and athletic life of the city and university."
a small fee is occasionally forthcoming ; but more often it is not. There is no guarantee that the medical attendant will receive anything for the trouble he has taken. Then it sometimes happens that one or more of
man,
1
2
THE THE
LANCET, March 22nd, 1913, p. 854. LANCET, Feb. 13th, 1915, p. 342.