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The development of the treatment of milk fever during the last five-years
THE
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COMPARATIVE PATHOLOGY AND
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SEPTEMBER 30, I902.
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THE DEVELOPMENT OF THE TREATMENT OF MILKFEVER DURING THE LAST FIVE· YEARS.!
By]. SCIIMIDT, Veterinary Surgeon, Kolding, Denmark. IN the year I897, in Vol. IX. of the lVlaanedskrzjtJ. Dyrla:g-el', and subsequently in Vol. IX. of the lVlonatsllefte fiil' practz~rclle Tilieriteilkunde, I published an article concerning the cause and treatment of milk-fever, in which I adopted the view that the treatment ought to be directed against the cause of the disease, which was to be sought in the formation of some toxic substance in the udder. Very soon thereafter the udder treatment was adopted by members of the profession throughout the civilised world. This was doubtless mainly the result of a strong feeling in favour of an improved method of treatment, and partly it was due to the early collection and publication of extensive statistics regarding the results of the new method of treatment by Professor C. O. ] ensen. After the publication of these statistics the profession in this country were provisionally satisfied with the theoretical basis of the treatment, and during the next few years nothing new regarding the subject was published. Somc criticisms might have becn expected, especially concerning the question of etiology, but nothing of the kind appeared. Since an efficient method of treating the disease had been discovered, it was in the meantime considered best not to experiment with other agents, which might possibly prove injurious to the udder. In foreign journals, on the other hand, very numerous articles made their appearance, some containing criticisms regarding the causal conditions, and others expressing a strong doubt as to the 1
N
Tra,nslated from the "Berliner Thierarztlichc lYochenschrift,"
Augm~t
lH02.
I9 2
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identity of the disease with those cases occurring at unusual times, or criticising the treatment. For the most part, however, these criticisms were either of the nature of a repetition of facts already well known, or were based on observations that were few in number or imperfectly considered. On that account they failed to find general acceptance among the members of the profession. It will probably still be remembered that the statistics of the results obtained in this country showed that, out of 1701 patients, 1407, or 82'7 per cent., completely recovered.1 In foreign countries also similar statistics regarding the results of the iodide of potassium treatment had been collected and published. The results thus shown were approximately the same, but at several places they were not quite so good as those obtained in this country. A few examples may be quoted. Nevermann 2 has summarised the results. obtained with this method of treatment by forty-one German veterinary surgeons. The number of animals trcatcd was 358, and of these 82'68 per cent. recovered. In Switzerland, Rusterholz 3 has reported regarding 197 cases, of which 78'17 per cent. ended in complete recovery. From Schleswig-Holstein and Lauenburg, Eiler 4 reported regarding 803 patien ts, of which 76'6 per cent. recovered. In 1899, Carl Sass 5 of Vienna gave the particulars of 60 cases, of which 75 per cent. ended favourably; and in 1901 he reported regarding 172 patients, among which the proportion of recoveries was also 75 per cent." Regarding the -results obtained in America there is a report,7 dated April 1901, from Iowa Experimental Station, according to which 119 patients out of 166, or 72 per cent., recovered without any complication. This result was considered very satisfactory in America. These figures show that at several places the proportion of recoveries has scarcely been so high as that obtained in Denmark, and the explanation appears to lie partly in the fact that on an average treatment was not begun so early after the onset of the symptoms, and partly in the circumstance that in many cases too small a quantity of liquid was employed; but probably the main reason of these less favourable results was that sufficient care was not exercised in the pumping in of air and in the massage of the udder. As is well known, the original method of treating .the udder consisted in the injection of 1 litre of a 1 per cent. solution of iodide of potassium, together with atmospheric air, and the sul:isequent massage of the gland. It may perhaps also be remembered that the treatment appeared to yield a better result when one introduced a large quantity of air into the udder than when the iodide solution was injected by itself. On different hands doubts were expressed regarding this point. Even Professor Jensen's observations on the figures which he collected 1
2 3
4 5 6
7
"Maanedskr. f. DyrlaJger," Vol. X., p. 247. "Berliner Thierarztl. 'Vochenschrift, " 1899, p. 1. "Schweiz. Archiv," 1899, Part 4. "Berliner Thieriirztl. 1Vochenschrift," 1901, p. 261. Idem, 1899, p. 155. Idem, 1901, p. 201. "Parturient Paralysis and the Schmidt Treatment." By John J. Repp.
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gave the impression that the introduction of air into the udder had no special importance, although it was not possible to come to a definite conclusion on the matter, since the majority of the veterinary surgeons did not report the necessary particulars. However, the consequence was that faith in the advantage of injecting air along with the solution was to some extent weakened, and it was therefore not long before a number of practitioners, both here and abroad, tried the effect of the treatment minus the injection of air. Indeed, a German veterinary surgeon patented a sterilisablc apparatus which insured that air was not introduced along with the iodide solution. l There are not available any statistics with regard to such experiments, but it has been alleged that, as a rule, quite good results have also been obtained without air. From what we now know regarding the action of the air-a point to which I shall subsequently refer at greater length-it may well be accepted that its more or less extensive employment partly explains how it was that some practitioners within a short period had several fatal cases in succession, while some of their colleagues in the same district and at the same time had not lost a single case. A determining- factor in such circumstances may also have been the degree of care with which the massage of the udder, after the injection, was carried out, for without the co-operation of the air it is a matter of great difficulty to cause the solution to penetrate into every part of the udder. After the effect of iodide of potassium solution without air had been tried here and there, it was not long beforc some practiti6ners, both here and abroad, tried the injection of boiled water, either alone or combined with more or less indifferent medicinal substances, especially common salt and Iysol. At first this method of treatment was generally adopted only in cases where the practitioner had been unexpectedly called to attend a case of the disease and had no iodide of potassium with him, and indeed in the first cases thus treated thc intention was to follow with an injection of the iodide solution as soon as possible. Sometimes, however, this intention was not carried out on account of the patient's prompt recovery. Concerning this method of treatment I have received oral reports from my Danish colleagues, and also several written communications. One of the latter narrates, among other things, that one practitioner for a long period treated every case by injecting 4 litres of lukewarm water into the mlder, and that he had thereby obtained just as good results as with other methods of udder treatment. This shows that much depends upon the quantity of the agent employed. But, inasmuch as the practitioner just referred to had, out of twenty cases treated with water only, two in which the cows became permanently dry, without any inflammation of the udder, one also sees at the same time that even such an indifferent agent as water may in certain circumstances have an injurious effect on the secretion of milk. I shall not do more than mention here the fact that, besides solution of iodide of potassium and boiled water, a few other substances soluble in water have also been tried (such as iodine, iodide of sodium, bromide of potassium), for sufficient information reg-arding the results 1
"Hauptner's Oatalogue," 1900, No. 2348.
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in these cases is not available, and it is certain that they were not better than those obtained with iodide of potassium. A few practitioners have tried the effect of injecting a small quantity of concentrated solution of iodide of potassium (ra grammes of iodide of potassium in 40 grammes of water) into each teat with an ordinary injection syringe, and it is alleged that in several cases good results were thus obtained. In several cases patients have been treated by injecting iodide of potassium under the skin or into the uterus, or giving it by the mouth, and in a few also by rubbing an ointment containing iodide of potassium into' the udder. However, a few experiments of such a nature with uncertain results are of little interest. Professor Peter has made an interesting experiment in which he g«ve intravenously ra grammes of iodide of potassi,um dissolved in 2 litres of boiled water. Five hours afterwards the cow got up. Subsequently Wessel employed the same method of treatment on three cows, of which one got up after six and the other after eight hours, while the third was slaughtered. In the same way, and owing to the same considerations as determined the use of water injections, the pumping of a large quantity of atmospheric air into the udder came to be tried. According to the reports that I have received, Andersen of Skanderborg was the first to whom it occurred, in the absence of iodide of potassium,to use air as the chief agent, the first time, however, in combination with boiled water, and with the intention to follow this up with iodide solution as sOon as possible. Subsequently on a few occasions he combined the air with iodide solution in decreasing doses, and ultimately he employed air alone. The fact that he was able to pump in a large quantity of air without any special preparation to that end was due to the circumstance that for the injection of iodide solution he used not a funnel but a syringe with a rubber ball, and this could also be used for the injection of air. Jakobsen 1 of Orbok was the first to report to a large number of his fellow-practitioners regarding the results of the air treatment of about fifty patients, for which purpose he used a special apparatus. The results led to further trials of this treatment, which was also gradually adopted by several other practitioners. In the autumn of 1901, and on several occasions since then, in the iVlaanedskrift f Dyrlceger, I requested those who had employed methods of treatment different from that originally recommended to favour me with reports regarding the method and the result. In consequence I have received from thirty-one colleagues more or less detailed reports regard1l1g the treatment of 914 patients. In the above-mentioned request I promised to make public a summary of the reports, either at a meeting of veterinary surgeons or in the Maanedskn/t f. Dyrlceger, and that promise I wiII now fulfil, at the same time expressing my thanks to those who were good enough to send me reports. Out of the 914 patients, 884, or 96'7 per cent., recovered, while twelve died, and six were slaughtered during the course of the disease. Twelve others were slaughtered at a later period on account of various complications, such as paralysis, laceration of muscles, 1
"Dyrlogemode c. Odense," 1900.
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pneumonia, and mastitis. Five cows were seized with inflammation of the udder after treatment, but in only one of these was the attack severe. In several instances, however, a catarrh of the udder appeared to set in, but it cannot be said definitely whether such was the case, for several practitioners suggested that such a condition was present in one or several quarters before the treatment was begun. rna good many cases one finds, before treatment, that coagula of casein are present in the first milk drawn off from one or several teats. At the same time most cases of udder disease arising after treatment are the result of insufficient cleanliness and disinfection, or of dust in the air of the byre. Inflammation of the lungs set in in three cases, but only one of these was fatal. The majority of the reports do not state definitely at what hour after treatment the patients were able to rise, but some give this information in each case, so that I am able to strike an average for the time at which this occurred. Ousen, of Vig, has reported regarding forty-five patients, all of which recovered. The time after treatment at which they got up varied from one to forty-six hours, and the average period was seven hours. Tobiassen, of Snoldelev, had sixty-three cases, of which sixty recovered and three were slaughtered, one of the latter on account of paralysis. In four of the cases no definite time is mentioned, but in fifty-six cases the time varied from three-quarters to thirty-six hours, the average being six and one-third hours. Clemann, of Hammershoj, treated thirteen patients, in which the symptoms of paralysis disappeared in from one to twenty-four hours after treatment, the average being seven hours. ] akobsen, of Orbok, in addition to several general reports regarding the results, has also sent me written reports from twenty-five owners, these containing the answers to a number of questions regarding the treatment of twenty-two patients. Of these animals one died and twenty-six were able to get lip after from one to fortyeight hours, the average being six and two-third hours after treatment. I have myself treated five patients by injecting air. Four got up at from two and a half to fourteen hours after treatment, the average being six and a half hours; while the fiftb, in which the disease was complicated with metritis, died. For the whole series of 140 cases above-mentioned, the average time at which they got up was six and two-third hours. In twentyfive cases it was necessary to repeat the treatment, and three of these had to be thrice treated before they were able to get up. Most of the cases received a subcutaneous injection of caffein as well as the intramammary injection of air. The majority of the practitioners expressed themselves as satisfied with the results, but two considered them unsatisfactory, and had returned to the iodide of potassium. For the injection of tbe air 'an apparatus provided with an indiarubber ball is generally employed, and in most cases the air is filtered through cotton wool, or made to bubble through a solution of iodide of potassium jn a small wide-mouthed flask. A long and a short glass tube are passed through the cork, the former being con-
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nected with the rubber ball, and the latter with a piece of rubber tubing armed with a milk catheter at its opposite end. Ordinarily one pumps in air until a sufficient degree of tension has been imparted to the udder. A few practitioners have suggested that the injection of air alone does not hinder the secretion of milk. I t is probable, however, that this was nothing more than an opinion, or that the belief was based on too small a number of observations. The above-mentioned reports by Jakobsen contain some remarks regarding the yield of milk. Out of twenty-six cows twenty-five returned to about the normal yield (ranging from six to twenty-three litres) after from one to fifty days, or an average of a week; but one cow became permanently dry. I have already mentioned a similar but even more unfavourable result in connection with the water treatment. By way of comparison with the iodide of potassium treatment I may mention that out of the 1744 cases referred to in Professor Jensen's statistics the treatment led to a permanently diminished secretion of milk in only two cases. Similar reports have also been published abroad. However, with either method of treatment it is only rarely that patients free from any complication experience any diminution whatever in the yield of milk; and it must therefore be considered an accident that one case of the kind happened in the series of twenty-four, and two in the series of twenty. In addition to the reports regarding the treatment with air and with water, I have also received favourable reports concerning the effects of the original iodide of potassium and air treatment from several members of the profession, to whom I tender my best thanks. However, it can no longer be doubted that the injection of air in larger amount than was originally employed, especially when combined with a dose of caffein, is a distinct improvement in the method of treatment. One need not on that account lose faith in the antitoxic action of the solution of iodide of potassium, and it is certain that a combination of iodide of potassium solution with an abundant quantity of air wiI! generally give the best results. A solution of iodide of potassium will mix immediately with the milk in the udder, and it can therefore in the diluted condition promptly penetrate into all the patent alveoli. Seeing that a number of these, especially in the undermost parts of the udder, are exposed to strong pressure when the cow is lying, and may th.ereby be cut off from the gland ducts, one must always carry out the somewhat difficult and not always successful work of massage in order to force the solution into as many of the alveoli as possible. This task may be rendered more easy, and its results may be considerably improved, by pumping in a large quantity of air after the injection of the solution of iodide of potassium, so as to force the latter into the alveoli. There is no difficulty about this when the patient.is lying, but if the animal is standing one must knead the udder a little after the injection of the liquid and before the introduction of the air, as otherwise some of the air may rise above the liquid. From the alveoli a part of the solution will first penetrate through the layer of epithelium, and during absorption through the secretory apparatus the liquid will certainly be able to exert a local antitoxic action. Thereafter the solution will
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be taken into the blood stream, where it will doubtless exert a general antitoxic action. The previously mentioned intravenous injections of iodide of potassium solution will also act in this way, and the desirability of producing an effect of this kind is now and again indicated, especially when the system is laden with toxic products from the alimentary canal or the uterus. And if by the use of iodide of potassium and a large quantity of air one were able to save even a small percentage of patients, and to hasten the recovery in general, this would represent a considerable gain, and prevent a number of disappointments. I have therefore for some time adopted a double method of treatment-viz., first the injection through the teat of a quarter of a litre of a 0'7 to I per cent. solution of iodide of potassium without air, and after that the injection of air. The latter can be carried out with the apparatus ordinarily employed for the injection of the iodide solution, the funnel being removed and replaccd .by a pump such as that already mentioned. In order to free the air from the dust of the byre, and at the same time to facilitate the work, I use a double apparatus, comprising a wide-mouthed litre-flask with a long and a short glass tube passed through the cork. The short tube is conneCted with a milk catheter by means of a piece of rubber tubing, while the long one is similarly connected with a tube containing cotton-wool. For the latter purpose a small metal cylinder does very well. If one wishes to carry the iodide solution in the apparatus an extra cork without any hole must be provided. In order to keep the apparatus sterile, I prefer to bring the solution in a separate flask, allowing it to cool a little on the way, and pouring it into the apparatus just before use. After the teats apd the adjacent part of the udder have been carefully cleansed with soap and water, a clean hand-towel is placed under the latter, and the teats are disinfected, the towel being at the same time moistened with the disinfectant liquid. It is best to allow an assistant to hold the litre-flask while one introduces the previously disinfected catheter into one of the teats. After that the operator himself takes the flask, turns it with the cork downwards, and allows a quarter of a litre of the solution to flow into the udder. \Vhen that has taken place one again turns the flask with the cork upwards, places it under the left arm in order to leave the hand free to prevent the rubber tube from being sharply bent, and with the right hand one pumps air through the tube containing the cotton-wool and also through the solution of iodide of potassium into the udder, until one of the quarters is made sufficiently tense. Before withdrawing the catheter preparatory to introducing it into another teat, it is advisable to knead the udder a little, as otherwise in light-milking cows part of the air introduced may immediately escape from the teat. Where there is any fear of heart failure, 5 grammes of caffein sodiosalicylicum may be added to the iodide solution, and in any case in which it appears to be necessary to repeat the treatment a pure solution of caffein may be pumped in along with air. Caffein sodiosalicylicum and iodide of potassium together form a clear solution, and the former is in no way injurious to the udder. By the aid of a dose of caffein one can certainly save many patients. A dilute solution of common salt is still very frequently introduced into the
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rectum, and for various reasons it is well to adhere to the practice. It may be regarded as proved that in the course of milk-fever a marked absorption of liquid takes place from the tissues in the peripheral parts of the body, and after an injection of a solution of common salt that will be in part absorbed instead of the excretion liquids which are saturated with metabolic products. In this way also one helps to strengthen the action of the heart, and contributes to the removal of the dry excrement. On the other hand, the internal administration of aloes, antimony, coffee, and other substances has been rightly abandoned on' account of the danger of thereby setting up pneumonia. It is of much importance for the course of the disease that the animal should be maintained in a natural position, and to that end attendants must remain with the cow. The patient must not be allowed to lie flat on the side, because tympanites is then apt to set in; or with the neck downwards, as in that position regurgitated stomach contents and saliva may easily flow into the lungs. \Vhen the os uteri has not contracted, and protrudes between th~ lips of the vulva, the hind quarters of the cow must be elevated, and if necessary a couple of stitches may be put through the labia in order to prevent a prolapse of the uterus. In view of a possible relapse, patients that have been treated ought not to be milked for several hours after they have got up. For the first two days after recovery they must not be milked too dry, and not oftener than thrice daily. In the article already mentioned I said that the after-birth, when it does not come away, is almost always very easily detached. This is most frequently the case, but since then I have seen instances in which it was not possible to detach the cleansing. In several such cases I gave up the attempt, and found that this had no influence on the course of the disease. As is well known, it is very important that treatment should be begun at an early stage of the disease, for, although patients that are already very severely affected may be cured, there is great danger of pneumonia, rupture of muscles, etc., when treatment is long delayed. Although it is sometimes difficult enough to arrive at a positive diagnosis, it is best to call the attention of our clients to the fact that in most cases they ought themselves to make a provisional and probable diagnosis. vVith this object any recently calved cow that shows indefinite symptoms of disease ought to be taken out of the stall, and made to walk a few paces. If the animal then moves with an uncertain or swaying gait, it will generally be found that the case is one of milk-fever at an early stage. By adopting this plan one may help to save many patients. The effect of the double method of treatment is seen so quickly that a quite striking improvement may be observable within a quarter of an hour, especially if the patient was markedly comatose before the treatment was begun. The treatment is easy to carry out-easier than the introduction of solution through a funnel and >;ubsequent massage of the udder. The apparatus can be kept sterile, and on~ can thus avoid infecting the udder. I have now treated in this way fifty-one patients, all of which have recovered. Of these, forty-eight remained free from any complica-
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tion, a nd we re able to stand after from one to sixteen hours, the average period being five hours. The other three animals also quickly rec o ve ~ed, but they lay somewhat longer, two on account of paralysis ? f a hllld .leg, and the other owing to retention of the placenta and Inflammation of the uterus. In none of these cases was a repetition of the treatment necessary, and in a ll of them the secretion of milk returned to the normal. . It is certainly very doubtful whether it would be profitable, with a vIew to preventing the disease, to allow all or the majority of cows a very sparing diet during the latter period of pregnancy, for that has the effect of diminishing the yield of milk for some time, and the loss thus incurred would generally be g reater than that occasioned by th e occurren ce of cases of milk-fever. Now that we are able to cure nearly roo per cent. of the cases of this disease, and that us ually within a few hours, the loss from it will be comparatively slig ht. For the same reason it will, as a rule, no t pay to have recourse to very active methods of preven tion , for suchprocedures-the injection of solutions into the udder, for example-also have the effect o f diminishing the yield of mille As has already been mentioned , the theory on which this treatment of milk-fever is founded has come in for severe criticism in some of the foreign journals. After h a vin g been silent for five years I may be permitted to refer to some examples. One critic has proceeded on the ass umption that no absorption, either of toxic substances or iod ide of potassium, can take place from an excretory organ, such as the udder, and on that ground he was un a ble to recognise the importance , of the treatment. It is a fact, however, that absorption does ta ke place from the udder, and it is proved by what one can observe durin g the treatment. The udder is precisely an organ in which the process of absorption is very active. A very acute hypothesis has been put forward in an a rticle published by Dr Aronsohn 1 This author treated fourteen cases by t he intra-mammary injection of from one-half to two litres of boiled water or saline solution, and in thirteen of these the result was good. On the assumption that the pressure o f the water injected must have interfered with the supply of bl ood to the udder, and thereby have dimi nished the amount of milk secreted, he concludes that the disease mu st depend upon an an;:e mia of the brain , consequent upon the la rge supply of blood diverted to the udder after cal ving. This is precisely the opposite of the o ld theory put forward by Franck. A ronsohn thinks that the bra in gets to o little blood in proportio n to its requ irements Franck that it ae ts too much. But, on the· other hand, the theor; approxim ates v~ry closely to the .one o~ which the ud de r treatment is based. Th e udder, as the startmg pomt, and the brain, as the terminal station , are the sa me, and only the connecting link of th e auto-intoxication is left out. There is, therefore, occasion to consid er whether the author is not possibly right, since the scientific proof of the correctn ess of the auto-intoxication ~heory the ex perimental demonstration of the presence of the tOXlll. and of its effects- has not yet been furnished. There would also b.e lllterest in provin g whether Aronsohn's theory or the contrary one IS correct, I
Berliner Thicriirztl ,,-ochenscbrift, HlOO, p. 217,
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and that would not be difficult. Moreover, that has already been done in an article by Witt,l and several other strong reasons against the theory might be cited. 1 will, however, refrain from doing so, as our proper subject is the treatment of the disease. I will, however, permit myself to go somewhat more minutely into the question of the diagnosis of those rarer and more disputed cases which resemble milk-fever, for it is of special importance to ascertain whet her these should be treated in the same way as ordinary cases. During the five years that have elapsed since the general introduction of the udder treatment we have very often seen such cases run a typical course and make a quick recovery, whereas in former times cases of that kind usually had a fatal ending. It might, however, be assumed th at recovery in these cases was due to a general effect of the iodine. I n order to obtain information on this point, I treated two patients in which the symptoms of inilk-fever were fully developed by the simple injection of air into the udder. One of these cows was attacked five and a half weeks after parturition. Sh e lay stretched out on her side, and was very comatose; when her head was raised it fell again as in a dead subject. The temperature was 36.8° c., the heart-beats could not be felt, and the fa:ces in the rectum were dry and in the form of small balls. Hal f an hour after the air was pumped into the udder the cow was able to hold her head up, and three hours later she got up. The other patient was attacked a month before calving. She had been dry, but on several occasions during the four days before she was attacked she had been milked. The cow had been grazing on a damp meadow, and the udder had been somewhat tense. She exhibited a more restless form of the disease, although she was paralysed, and she got up two and a half hours after the treatment. Tobiassen's report contains an account of two cases, one of which was attacked three weeks and the other four months after calving. These patients were also treated by pumping air into the udder, with the result that one of them got up after four hours, and the other after half an hour. It is to be hoped that the last word has not yet been said regarding the conditions of milk secretion, and one is justified in expecting that a better knowledge of these conditions will also bring about a better understanding of the causes of the periodic alterations in the composition of the milk, upon which the before-mentioned cases of the disease appear to depend. ~e know, however, that light and darkness, and alterations in the temperature and diet, have an influence on the composition of the blood and milk, and also on the functions of the cells of the udder. \i\Tc also know that the adhesiveness or viscosity of milk is distinctly altered by pasteurising; milk thus treated 110 longer adheres to the glass. This change is already perceptible at 30° c., but it becomes most distinct at temperatures between 65 and 80°. 2 A similar effect to that observable in a glass must also be produced in the udder. Cooling of the latter below the normal temperature mu st thus increase the viscosity of the milk, and cause a thick layer of it to become deposited on the walls of the alveoli. We kllow, further, that during the period of lactation the 0
I :;!
Berliner Thieriirztl 'Vochenschrift, 1900, p. 253. 'l'ijdschrift voor Veeartsenijkunrle," No.2, IDOl, V. Kroon.
.,
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number of colostral corpuscles is liable to some variation. Recent investigations would appear to show that the colostral corpuscles are uninuclear lcucocytes endowed with the power of amceboid movement, in virtue of which they are able to ingest fat droplets. If their activity resem bles that of the ordinary leucocytes it is improbable that their appearance in large numbers can be regarded as a link in the chain of events that cause milk-fever; it may be supposed with more probability that they exert a purifying, and thus a beneficial, action in the udder. Since the disease usually sets in during the colostral period, and especiaJly during the early stage of that period, one might well suppose that in milk-feve r these corpuscl es would be present in smaller numbers than in the milk of healthy cows at the same period. But the most fr equent occurrence of the disease durin g the colostral period, and the fact that as a rule the udder i s in a state of tension at the onset of the disease, point to exactly opposite conditions; and it would therefore be of special interest, an d perhaps also of practical importance, to investigate t he conditions by comparing the colostral milk of a large number of healthy cows with that of milk-feve r subjects, includin g among the latte r both cases occurring during the colostral period and those th at set in at a later period of lactation. , I t would also be interesting to ascertain what effect is produced on the milk by marked lowering of the temperature of the udder. It is possible that we might in thi s way arrive a t a better understanding of the exciting causes of the disease. Meanwhiie one may to some extent explain the occurrence of cases of the disease at an unusua l p eriod of lactation by reference to the periodical abnormalities in the function of the udder; a nd since the udder treatm ent furnishes a n excellent test for milk-fever, and the above-mentioned experiments yielded the S2 me results in the exceptional cases as in the ordinary ones, it may be regarded as proved that these exceptional cases are identical with milk-fever, and o ught to be treated in the same way. The last question which we will discuss here is the one as to how the udder treatment acts. It is well kn own that iodid e o f potassium e xerts an antitoxic action; but, since the local application of water or of air al so has a distinctly curative effect, we may conclude that the action is mainly a local one, and in th e case of the last t wo agents confined to th e epithelial lining of the udde r. Thi s raises the question to which several of my correspond ents haye referred in their reports-viz., whether it may perhaps be the comparatively high pressure set up in the udder that is resp onsible for the effects of the treatment, since that must to some extent diminish the blood supply to the udder, and therefore also the amount of milk secreted. As already mentioned, this view has been espoused by Dr Aransohn . But although the pressure may help s lig htly to diminish the a mount of milk secreted, it cannot be of any decided importan ce in bring'in g a bout recovery, for fundamenta lly different physical influ ences cannot lead to the same result. Numerous cases ca n be cited from practIce to prove that the pressure is not the active age nt. In the treatment of many cases a litre or more of milk has been withdrawn fro m the udder before the introductio n of a litre of iodid e solutio n, and, although in such a case the pressure within the udder cannot have been increased, an almost instantan eous improvement in the condition of
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the patient has set in, and recovery has taken place within a few hours. Other members of the profession have suggested that the success of the treatment depends on oxidation within the ,udder. Although this may be possible when air is introduced along with the solution, oxidation must be considered excluded when the iodide solution or boiled water is employed without any air. Since various more or less indifferent substances have approximately the same effect, and since their action is strengthened by using a large quantity of water or of air, either along with the solution or alone, one must suppose that most importance attaches to the contact of the agents employed with the epithelial' lining, and especially to the extension of this contact by massage to all parts of the udder. 'Whether the toxic substance is formed simultaneously in all parts of the udder-that is to say, in all the alveoliwe do not yet know. The abnormal conditions of the udder which determine the formation of the toxin may quite well be restricted to certain definite parts of it, and the main object in treatment in that case would be to act on these parts. \Ve now know that this can be best achieved by calling in the aid of air introduced into the udder. The contact of the udder with a foreign substance must cause a slight irritation of the epithelial lining, the result being that the secretion of milk and the formation of toxin are so far diminished that the system is itself able to complete the process of recovery. I think I have now given an objective account of the development of the treatment of milk-fever during recent years.' In view of the results obtained, the experimental period may be regarded as at an end, and each of us must now do his share in keeping the treatment within scientific lines.
GERM INFECTION IN TUBERCULOSIS! A SKETCH OF THE PRESENT STATE OF THE QUESTIOK.
By GEOH.GE OGILVIE, B.Sc., M.B., Edinburgh, M.R.C.P., London Physician to the French Hospital, and to the Hospital for Epilepsy and Paralysis, Regent's Park, London. THE evidence in favour of congenital tuberculosis has during the last few years been collected and critically examined independently by a number of authors (Hauser, Mosny, Kuss, Scheimpftug, Diirek, etc.). The common result of their laborious researches is the collection of a very small number of authenticated cases of intrauterine tuberculosis, about twenty in human beings. The number given by Kuss (forty) is certainly too high, that admitted by Hauser (eighteen) perhaps a little too low. Of course, this result does not warrant conclusions with regard to the relative frequency of such an occurrence, because almost exclusively positive observations have been published. All that one is entitled to infer from these statistics is the fact that conI
Reprinted from the" British Medical Journal," 13th Sept. 1902.
JOURNAL OF
COMPARATIVE PATHOLOGY AND
THERAPEUTICS. ====----:- ----:c-:c-_-_-____ -=_-_______ VOL. XV.-No. 3. -
SEPTEMBER 30, I902.
PRICE 2S.
6d.
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THE DEVELOPMENT OF THE TREATMENT OF MILKFEVER DURING THE LAST FIVE· YEARS.!
By]. SCIIMIDT, Veterinary Surgeon, Kolding, Denmark. IN the year I897, in Vol. IX. of the lVlaanedskrzjtJ. Dyrla:g-el', and subsequently in Vol. IX. of the lVlonatsllefte fiil' practz~rclle Tilieriteilkunde, I published an article concerning the cause and treatment of milk-fever, in which I adopted the view that the treatment ought to be directed against the cause of the disease, which was to be sought in the formation of some toxic substance in the udder. Very soon thereafter the udder treatment was adopted by members of the profession throughout the civilised world. This was doubtless mainly the result of a strong feeling in favour of an improved method of treatment, and partly it was due to the early collection and publication of extensive statistics regarding the results of the new method of treatment by Professor C. O. ] ensen. After the publication of these statistics the profession in this country were provisionally satisfied with the theoretical basis of the treatment, and during the next few years nothing new regarding the subject was published. Somc criticisms might have becn expected, especially concerning the question of etiology, but nothing of the kind appeared. Since an efficient method of treating the disease had been discovered, it was in the meantime considered best not to experiment with other agents, which might possibly prove injurious to the udder. In foreign journals, on the other hand, very numerous articles made their appearance, some containing criticisms regarding the causal conditions, and others expressing a strong doubt as to the 1
N
Tra,nslated from the "Berliner Thierarztlichc lYochenschrift,"
Augm~t
lH02.
I9 2
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identity of the disease with those cases occurring at unusual times, or criticising the treatment. For the most part, however, these criticisms were either of the nature of a repetition of facts already well known, or were based on observations that were few in number or imperfectly considered. On that account they failed to find general acceptance among the members of the profession. It will probably still be remembered that the statistics of the results obtained in this country showed that, out of 1701 patients, 1407, or 82'7 per cent., completely recovered.1 In foreign countries also similar statistics regarding the results of the iodide of potassium treatment had been collected and published. The results thus shown were approximately the same, but at several places they were not quite so good as those obtained in this country. A few examples may be quoted. Nevermann 2 has summarised the results. obtained with this method of treatment by forty-one German veterinary surgeons. The number of animals trcatcd was 358, and of these 82'68 per cent. recovered. In Switzerland, Rusterholz 3 has reported regarding 197 cases, of which 78'17 per cent. ended in complete recovery. From Schleswig-Holstein and Lauenburg, Eiler 4 reported regarding 803 patien ts, of which 76'6 per cent. recovered. In 1899, Carl Sass 5 of Vienna gave the particulars of 60 cases, of which 75 per cent. ended favourably; and in 1901 he reported regarding 172 patients, among which the proportion of recoveries was also 75 per cent." Regarding the -results obtained in America there is a report,7 dated April 1901, from Iowa Experimental Station, according to which 119 patients out of 166, or 72 per cent., recovered without any complication. This result was considered very satisfactory in America. These figures show that at several places the proportion of recoveries has scarcely been so high as that obtained in Denmark, and the explanation appears to lie partly in the fact that on an average treatment was not begun so early after the onset of the symptoms, and partly in the circumstance that in many cases too small a quantity of liquid was employed; but probably the main reason of these less favourable results was that sufficient care was not exercised in the pumping in of air and in the massage of the udder. As is well known, the original method of treating .the udder consisted in the injection of 1 litre of a 1 per cent. solution of iodide of potassium, together with atmospheric air, and the sul:isequent massage of the gland. It may perhaps also be remembered that the treatment appeared to yield a better result when one introduced a large quantity of air into the udder than when the iodide solution was injected by itself. On different hands doubts were expressed regarding this point. Even Professor Jensen's observations on the figures which he collected 1
2 3
4 5 6
7
"Maanedskr. f. DyrlaJger," Vol. X., p. 247. "Berliner Thierarztl. 'Vochenschrift, " 1899, p. 1. "Schweiz. Archiv," 1899, Part 4. "Berliner Thieriirztl. 1Vochenschrift," 1901, p. 261. Idem, 1899, p. 155. Idem, 1901, p. 201. "Parturient Paralysis and the Schmidt Treatment." By John J. Repp.
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gave the impression that the introduction of air into the udder had no special importance, although it was not possible to come to a definite conclusion on the matter, since the majority of the veterinary surgeons did not report the necessary particulars. However, the consequence was that faith in the advantage of injecting air along with the solution was to some extent weakened, and it was therefore not long before a number of practitioners, both here and abroad, tried the effect of the treatment minus the injection of air. Indeed, a German veterinary surgeon patented a sterilisablc apparatus which insured that air was not introduced along with the iodide solution. l There are not available any statistics with regard to such experiments, but it has been alleged that, as a rule, quite good results have also been obtained without air. From what we now know regarding the action of the air-a point to which I shall subsequently refer at greater length-it may well be accepted that its more or less extensive employment partly explains how it was that some practitioners within a short period had several fatal cases in succession, while some of their colleagues in the same district and at the same time had not lost a single case. A determining- factor in such circumstances may also have been the degree of care with which the massage of the udder, after the injection, was carried out, for without the co-operation of the air it is a matter of great difficulty to cause the solution to penetrate into every part of the udder. After the effect of iodide of potassium solution without air had been tried here and there, it was not long beforc some practiti6ners, both here and abroad, tried the injection of boiled water, either alone or combined with more or less indifferent medicinal substances, especially common salt and Iysol. At first this method of treatment was generally adopted only in cases where the practitioner had been unexpectedly called to attend a case of the disease and had no iodide of potassium with him, and indeed in the first cases thus treated thc intention was to follow with an injection of the iodide solution as soon as possible. Sometimes, however, this intention was not carried out on account of the patient's prompt recovery. Concerning this method of treatment I have received oral reports from my Danish colleagues, and also several written communications. One of the latter narrates, among other things, that one practitioner for a long period treated every case by injecting 4 litres of lukewarm water into the mlder, and that he had thereby obtained just as good results as with other methods of udder treatment. This shows that much depends upon the quantity of the agent employed. But, inasmuch as the practitioner just referred to had, out of twenty cases treated with water only, two in which the cows became permanently dry, without any inflammation of the udder, one also sees at the same time that even such an indifferent agent as water may in certain circumstances have an injurious effect on the secretion of milk. I shall not do more than mention here the fact that, besides solution of iodide of potassium and boiled water, a few other substances soluble in water have also been tried (such as iodine, iodide of sodium, bromide of potassium), for sufficient information reg-arding the results 1
"Hauptner's Oatalogue," 1900, No. 2348.
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in these cases is not available, and it is certain that they were not better than those obtained with iodide of potassium. A few practitioners have tried the effect of injecting a small quantity of concentrated solution of iodide of potassium (ra grammes of iodide of potassium in 40 grammes of water) into each teat with an ordinary injection syringe, and it is alleged that in several cases good results were thus obtained. In several cases patients have been treated by injecting iodide of potassium under the skin or into the uterus, or giving it by the mouth, and in a few also by rubbing an ointment containing iodide of potassium into' the udder. However, a few experiments of such a nature with uncertain results are of little interest. Professor Peter has made an interesting experiment in which he g«ve intravenously ra grammes of iodide of potassi,um dissolved in 2 litres of boiled water. Five hours afterwards the cow got up. Subsequently Wessel employed the same method of treatment on three cows, of which one got up after six and the other after eight hours, while the third was slaughtered. In the same way, and owing to the same considerations as determined the use of water injections, the pumping of a large quantity of atmospheric air into the udder came to be tried. According to the reports that I have received, Andersen of Skanderborg was the first to whom it occurred, in the absence of iodide of potassium,to use air as the chief agent, the first time, however, in combination with boiled water, and with the intention to follow this up with iodide solution as sOon as possible. Subsequently on a few occasions he combined the air with iodide solution in decreasing doses, and ultimately he employed air alone. The fact that he was able to pump in a large quantity of air without any special preparation to that end was due to the circumstance that for the injection of iodide solution he used not a funnel but a syringe with a rubber ball, and this could also be used for the injection of air. Jakobsen 1 of Orbok was the first to report to a large number of his fellow-practitioners regarding the results of the air treatment of about fifty patients, for which purpose he used a special apparatus. The results led to further trials of this treatment, which was also gradually adopted by several other practitioners. In the autumn of 1901, and on several occasions since then, in the iVlaanedskrift f Dyrlceger, I requested those who had employed methods of treatment different from that originally recommended to favour me with reports regarding the method and the result. In consequence I have received from thirty-one colleagues more or less detailed reports regard1l1g the treatment of 914 patients. In the above-mentioned request I promised to make public a summary of the reports, either at a meeting of veterinary surgeons or in the Maanedskn/t f. Dyrlceger, and that promise I wiII now fulfil, at the same time expressing my thanks to those who were good enough to send me reports. Out of the 914 patients, 884, or 96'7 per cent., recovered, while twelve died, and six were slaughtered during the course of the disease. Twelve others were slaughtered at a later period on account of various complications, such as paralysis, laceration of muscles, 1
"Dyrlogemode c. Odense," 1900.
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pneumonia, and mastitis. Five cows were seized with inflammation of the udder after treatment, but in only one of these was the attack severe. In several instances, however, a catarrh of the udder appeared to set in, but it cannot be said definitely whether such was the case, for several practitioners suggested that such a condition was present in one or several quarters before the treatment was begun. rna good many cases one finds, before treatment, that coagula of casein are present in the first milk drawn off from one or several teats. At the same time most cases of udder disease arising after treatment are the result of insufficient cleanliness and disinfection, or of dust in the air of the byre. Inflammation of the lungs set in in three cases, but only one of these was fatal. The majority of the reports do not state definitely at what hour after treatment the patients were able to rise, but some give this information in each case, so that I am able to strike an average for the time at which this occurred. Ousen, of Vig, has reported regarding forty-five patients, all of which recovered. The time after treatment at which they got up varied from one to forty-six hours, and the average period was seven hours. Tobiassen, of Snoldelev, had sixty-three cases, of which sixty recovered and three were slaughtered, one of the latter on account of paralysis. In four of the cases no definite time is mentioned, but in fifty-six cases the time varied from three-quarters to thirty-six hours, the average being six and one-third hours. Clemann, of Hammershoj, treated thirteen patients, in which the symptoms of paralysis disappeared in from one to twenty-four hours after treatment, the average being seven hours. ] akobsen, of Orbok, in addition to several general reports regarding the results, has also sent me written reports from twenty-five owners, these containing the answers to a number of questions regarding the treatment of twenty-two patients. Of these animals one died and twenty-six were able to get lip after from one to fortyeight hours, the average being six and two-third hours after treatment. I have myself treated five patients by injecting air. Four got up at from two and a half to fourteen hours after treatment, the average being six and a half hours; while the fiftb, in which the disease was complicated with metritis, died. For the whole series of 140 cases above-mentioned, the average time at which they got up was six and two-third hours. In twentyfive cases it was necessary to repeat the treatment, and three of these had to be thrice treated before they were able to get up. Most of the cases received a subcutaneous injection of caffein as well as the intramammary injection of air. The majority of the practitioners expressed themselves as satisfied with the results, but two considered them unsatisfactory, and had returned to the iodide of potassium. For the injection of tbe air 'an apparatus provided with an indiarubber ball is generally employed, and in most cases the air is filtered through cotton wool, or made to bubble through a solution of iodide of potassium jn a small wide-mouthed flask. A long and a short glass tube are passed through the cork, the former being con-
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nected with the rubber ball, and the latter with a piece of rubber tubing armed with a milk catheter at its opposite end. Ordinarily one pumps in air until a sufficient degree of tension has been imparted to the udder. A few practitioners have suggested that the injection of air alone does not hinder the secretion of milk. I t is probable, however, that this was nothing more than an opinion, or that the belief was based on too small a number of observations. The above-mentioned reports by Jakobsen contain some remarks regarding the yield of milk. Out of twenty-six cows twenty-five returned to about the normal yield (ranging from six to twenty-three litres) after from one to fifty days, or an average of a week; but one cow became permanently dry. I have already mentioned a similar but even more unfavourable result in connection with the water treatment. By way of comparison with the iodide of potassium treatment I may mention that out of the 1744 cases referred to in Professor Jensen's statistics the treatment led to a permanently diminished secretion of milk in only two cases. Similar reports have also been published abroad. However, with either method of treatment it is only rarely that patients free from any complication experience any diminution whatever in the yield of milk; and it must therefore be considered an accident that one case of the kind happened in the series of twenty-four, and two in the series of twenty. In addition to the reports regarding the treatment with air and with water, I have also received favourable reports concerning the effects of the original iodide of potassium and air treatment from several members of the profession, to whom I tender my best thanks. However, it can no longer be doubted that the injection of air in larger amount than was originally employed, especially when combined with a dose of caffein, is a distinct improvement in the method of treatment. One need not on that account lose faith in the antitoxic action of the solution of iodide of potassium, and it is certain that a combination of iodide of potassium solution with an abundant quantity of air wiI! generally give the best results. A solution of iodide of potassium will mix immediately with the milk in the udder, and it can therefore in the diluted condition promptly penetrate into all the patent alveoli. Seeing that a number of these, especially in the undermost parts of the udder, are exposed to strong pressure when the cow is lying, and may th.ereby be cut off from the gland ducts, one must always carry out the somewhat difficult and not always successful work of massage in order to force the solution into as many of the alveoli as possible. This task may be rendered more easy, and its results may be considerably improved, by pumping in a large quantity of air after the injection of the solution of iodide of potassium, so as to force the latter into the alveoli. There is no difficulty about this when the patient.is lying, but if the animal is standing one must knead the udder a little after the injection of the liquid and before the introduction of the air, as otherwise some of the air may rise above the liquid. From the alveoli a part of the solution will first penetrate through the layer of epithelium, and during absorption through the secretory apparatus the liquid will certainly be able to exert a local antitoxic action. Thereafter the solution will
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be taken into the blood stream, where it will doubtless exert a general antitoxic action. The previously mentioned intravenous injections of iodide of potassium solution will also act in this way, and the desirability of producing an effect of this kind is now and again indicated, especially when the system is laden with toxic products from the alimentary canal or the uterus. And if by the use of iodide of potassium and a large quantity of air one were able to save even a small percentage of patients, and to hasten the recovery in general, this would represent a considerable gain, and prevent a number of disappointments. I have therefore for some time adopted a double method of treatment-viz., first the injection through the teat of a quarter of a litre of a 0'7 to I per cent. solution of iodide of potassium without air, and after that the injection of air. The latter can be carried out with the apparatus ordinarily employed for the injection of the iodide solution, the funnel being removed and replaccd .by a pump such as that already mentioned. In order to free the air from the dust of the byre, and at the same time to facilitate the work, I use a double apparatus, comprising a wide-mouthed litre-flask with a long and a short glass tube passed through the cork. The short tube is conneCted with a milk catheter by means of a piece of rubber tubing, while the long one is similarly connected with a tube containing cotton-wool. For the latter purpose a small metal cylinder does very well. If one wishes to carry the iodide solution in the apparatus an extra cork without any hole must be provided. In order to keep the apparatus sterile, I prefer to bring the solution in a separate flask, allowing it to cool a little on the way, and pouring it into the apparatus just before use. After the teats apd the adjacent part of the udder have been carefully cleansed with soap and water, a clean hand-towel is placed under the latter, and the teats are disinfected, the towel being at the same time moistened with the disinfectant liquid. It is best to allow an assistant to hold the litre-flask while one introduces the previously disinfected catheter into one of the teats. After that the operator himself takes the flask, turns it with the cork downwards, and allows a quarter of a litre of the solution to flow into the udder. \Vhen that has taken place one again turns the flask with the cork upwards, places it under the left arm in order to leave the hand free to prevent the rubber tube from being sharply bent, and with the right hand one pumps air through the tube containing the cotton-wool and also through the solution of iodide of potassium into the udder, until one of the quarters is made sufficiently tense. Before withdrawing the catheter preparatory to introducing it into another teat, it is advisable to knead the udder a little, as otherwise in light-milking cows part of the air introduced may immediately escape from the teat. Where there is any fear of heart failure, 5 grammes of caffein sodiosalicylicum may be added to the iodide solution, and in any case in which it appears to be necessary to repeat the treatment a pure solution of caffein may be pumped in along with air. Caffein sodiosalicylicum and iodide of potassium together form a clear solution, and the former is in no way injurious to the udder. By the aid of a dose of caffein one can certainly save many patients. A dilute solution of common salt is still very frequently introduced into the
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rectum, and for various reasons it is well to adhere to the practice. It may be regarded as proved that in the course of milk-fever a marked absorption of liquid takes place from the tissues in the peripheral parts of the body, and after an injection of a solution of common salt that will be in part absorbed instead of the excretion liquids which are saturated with metabolic products. In this way also one helps to strengthen the action of the heart, and contributes to the removal of the dry excrement. On the other hand, the internal administration of aloes, antimony, coffee, and other substances has been rightly abandoned on' account of the danger of thereby setting up pneumonia. It is of much importance for the course of the disease that the animal should be maintained in a natural position, and to that end attendants must remain with the cow. The patient must not be allowed to lie flat on the side, because tympanites is then apt to set in; or with the neck downwards, as in that position regurgitated stomach contents and saliva may easily flow into the lungs. \Vhen the os uteri has not contracted, and protrudes between th~ lips of the vulva, the hind quarters of the cow must be elevated, and if necessary a couple of stitches may be put through the labia in order to prevent a prolapse of the uterus. In view of a possible relapse, patients that have been treated ought not to be milked for several hours after they have got up. For the first two days after recovery they must not be milked too dry, and not oftener than thrice daily. In the article already mentioned I said that the after-birth, when it does not come away, is almost always very easily detached. This is most frequently the case, but since then I have seen instances in which it was not possible to detach the cleansing. In several such cases I gave up the attempt, and found that this had no influence on the course of the disease. As is well known, it is very important that treatment should be begun at an early stage of the disease, for, although patients that are already very severely affected may be cured, there is great danger of pneumonia, rupture of muscles, etc., when treatment is long delayed. Although it is sometimes difficult enough to arrive at a positive diagnosis, it is best to call the attention of our clients to the fact that in most cases they ought themselves to make a provisional and probable diagnosis. vVith this object any recently calved cow that shows indefinite symptoms of disease ought to be taken out of the stall, and made to walk a few paces. If the animal then moves with an uncertain or swaying gait, it will generally be found that the case is one of milk-fever at an early stage. By adopting this plan one may help to save many patients. The effect of the double method of treatment is seen so quickly that a quite striking improvement may be observable within a quarter of an hour, especially if the patient was markedly comatose before the treatment was begun. The treatment is easy to carry out-easier than the introduction of solution through a funnel and >;ubsequent massage of the udder. The apparatus can be kept sterile, and on~ can thus avoid infecting the udder. I have now treated in this way fifty-one patients, all of which have recovered. Of these, forty-eight remained free from any complica-
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tion, a nd we re able to stand after from one to sixteen hours, the average period being five hours. The other three animals also quickly rec o ve ~ed, but they lay somewhat longer, two on account of paralysis ? f a hllld .leg, and the other owing to retention of the placenta and Inflammation of the uterus. In none of these cases was a repetition of the treatment necessary, and in a ll of them the secretion of milk returned to the normal. . It is certainly very doubtful whether it would be profitable, with a vIew to preventing the disease, to allow all or the majority of cows a very sparing diet during the latter period of pregnancy, for that has the effect of diminishing the yield of milk for some time, and the loss thus incurred would generally be g reater than that occasioned by th e occurren ce of cases of milk-fever. Now that we are able to cure nearly roo per cent. of the cases of this disease, and that us ually within a few hours, the loss from it will be comparatively slig ht. For the same reason it will, as a rule, no t pay to have recourse to very active methods of preven tion , for suchprocedures-the injection of solutions into the udder, for example-also have the effect o f diminishing the yield of mille As has already been mentioned , the theory on which this treatment of milk-fever is founded has come in for severe criticism in some of the foreign journals. After h a vin g been silent for five years I may be permitted to refer to some examples. One critic has proceeded on the ass umption that no absorption, either of toxic substances or iod ide of potassium, can take place from an excretory organ, such as the udder, and on that ground he was un a ble to recognise the importance , of the treatment. It is a fact, however, that absorption does ta ke place from the udder, and it is proved by what one can observe durin g the treatment. The udder is precisely an organ in which the process of absorption is very active. A very acute hypothesis has been put forward in an a rticle published by Dr Aronsohn 1 This author treated fourteen cases by t he intra-mammary injection of from one-half to two litres of boiled water or saline solution, and in thirteen of these the result was good. On the assumption that the pressure o f the water injected must have interfered with the supply of bl ood to the udder, and thereby have dimi nished the amount of milk secreted, he concludes that the disease mu st depend upon an an;:e mia of the brain , consequent upon the la rge supply of blood diverted to the udder after cal ving. This is precisely the opposite of the o ld theory put forward by Franck. A ronsohn thinks that the bra in gets to o little blood in proportio n to its requ irements Franck that it ae ts too much. But, on the· other hand, the theor; approxim ates v~ry closely to the .one o~ which the ud de r treatment is based. Th e udder, as the startmg pomt, and the brain, as the terminal station , are the sa me, and only the connecting link of th e auto-intoxication is left out. There is, therefore, occasion to consid er whether the author is not possibly right, since the scientific proof of the correctn ess of the auto-intoxication ~heory the ex perimental demonstration of the presence of the tOXlll. and of its effects- has not yet been furnished. There would also b.e lllterest in provin g whether Aronsohn's theory or the contrary one IS correct, I
Berliner Thicriirztl ,,-ochenscbrift, HlOO, p. 217,
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and that would not be difficult. Moreover, that has already been done in an article by Witt,l and several other strong reasons against the theory might be cited. 1 will, however, refrain from doing so, as our proper subject is the treatment of the disease. I will, however, permit myself to go somewhat more minutely into the question of the diagnosis of those rarer and more disputed cases which resemble milk-fever, for it is of special importance to ascertain whet her these should be treated in the same way as ordinary cases. During the five years that have elapsed since the general introduction of the udder treatment we have very often seen such cases run a typical course and make a quick recovery, whereas in former times cases of that kind usually had a fatal ending. It might, however, be assumed th at recovery in these cases was due to a general effect of the iodine. I n order to obtain information on this point, I treated two patients in which the symptoms of inilk-fever were fully developed by the simple injection of air into the udder. One of these cows was attacked five and a half weeks after parturition. Sh e lay stretched out on her side, and was very comatose; when her head was raised it fell again as in a dead subject. The temperature was 36.8° c., the heart-beats could not be felt, and the fa:ces in the rectum were dry and in the form of small balls. Hal f an hour after the air was pumped into the udder the cow was able to hold her head up, and three hours later she got up. The other patient was attacked a month before calving. She had been dry, but on several occasions during the four days before she was attacked she had been milked. The cow had been grazing on a damp meadow, and the udder had been somewhat tense. She exhibited a more restless form of the disease, although she was paralysed, and she got up two and a half hours after the treatment. Tobiassen's report contains an account of two cases, one of which was attacked three weeks and the other four months after calving. These patients were also treated by pumping air into the udder, with the result that one of them got up after four hours, and the other after half an hour. It is to be hoped that the last word has not yet been said regarding the conditions of milk secretion, and one is justified in expecting that a better knowledge of these conditions will also bring about a better understanding of the causes of the periodic alterations in the composition of the milk, upon which the before-mentioned cases of the disease appear to depend. ~e know, however, that light and darkness, and alterations in the temperature and diet, have an influence on the composition of the blood and milk, and also on the functions of the cells of the udder. \i\Tc also know that the adhesiveness or viscosity of milk is distinctly altered by pasteurising; milk thus treated 110 longer adheres to the glass. This change is already perceptible at 30° c., but it becomes most distinct at temperatures between 65 and 80°. 2 A similar effect to that observable in a glass must also be produced in the udder. Cooling of the latter below the normal temperature mu st thus increase the viscosity of the milk, and cause a thick layer of it to become deposited on the walls of the alveoli. We kllow, further, that during the period of lactation the 0
I :;!
Berliner Thieriirztl 'Vochenschrift, 1900, p. 253. 'l'ijdschrift voor Veeartsenijkunrle," No.2, IDOl, V. Kroon.
.,
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number of colostral corpuscles is liable to some variation. Recent investigations would appear to show that the colostral corpuscles are uninuclear lcucocytes endowed with the power of amceboid movement, in virtue of which they are able to ingest fat droplets. If their activity resem bles that of the ordinary leucocytes it is improbable that their appearance in large numbers can be regarded as a link in the chain of events that cause milk-fever; it may be supposed with more probability that they exert a purifying, and thus a beneficial, action in the udder. Since the disease usually sets in during the colostral period, and especiaJly during the early stage of that period, one might well suppose that in milk-feve r these corpuscl es would be present in smaller numbers than in the milk of healthy cows at the same period. But the most fr equent occurrence of the disease durin g the colostral period, and the fact that as a rule the udder i s in a state of tension at the onset of the disease, point to exactly opposite conditions; and it would therefore be of special interest, an d perhaps also of practical importance, to investigate t he conditions by comparing the colostral milk of a large number of healthy cows with that of milk-feve r subjects, includin g among the latte r both cases occurring during the colostral period and those th at set in at a later period of lactation. , I t would also be interesting to ascertain what effect is produced on the milk by marked lowering of the temperature of the udder. It is possible that we might in thi s way arrive a t a better understanding of the exciting causes of the disease. Meanwhiie one may to some extent explain the occurrence of cases of the disease at an unusua l p eriod of lactation by reference to the periodical abnormalities in the function of the udder; a nd since the udder treatm ent furnishes a n excellent test for milk-fever, and the above-mentioned experiments yielded the S2 me results in the exceptional cases as in the ordinary ones, it may be regarded as proved that these exceptional cases are identical with milk-fever, and o ught to be treated in the same way. The last question which we will discuss here is the one as to how the udder treatment acts. It is well kn own that iodid e o f potassium e xerts an antitoxic action; but, since the local application of water or of air al so has a distinctly curative effect, we may conclude that the action is mainly a local one, and in th e case of the last t wo agents confined to th e epithelial lining of the udde r. Thi s raises the question to which several of my correspond ents haye referred in their reports-viz., whether it may perhaps be the comparatively high pressure set up in the udder that is resp onsible for the effects of the treatment, since that must to some extent diminish the blood supply to the udder, and therefore also the amount of milk secreted. As already mentioned, this view has been espoused by Dr Aransohn . But although the pressure may help s lig htly to diminish the a mount of milk secreted, it cannot be of any decided importan ce in bring'in g a bout recovery, for fundamenta lly different physical influ ences cannot lead to the same result. Numerous cases ca n be cited from practIce to prove that the pressure is not the active age nt. In the treatment of many cases a litre or more of milk has been withdrawn fro m the udder before the introductio n of a litre of iodid e solutio n, and, although in such a case the pressure within the udder cannot have been increased, an almost instantan eous improvement in the condition of
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the patient has set in, and recovery has taken place within a few hours. Other members of the profession have suggested that the success of the treatment depends on oxidation within the ,udder. Although this may be possible when air is introduced along with the solution, oxidation must be considered excluded when the iodide solution or boiled water is employed without any air. Since various more or less indifferent substances have approximately the same effect, and since their action is strengthened by using a large quantity of water or of air, either along with the solution or alone, one must suppose that most importance attaches to the contact of the agents employed with the epithelial' lining, and especially to the extension of this contact by massage to all parts of the udder. 'Whether the toxic substance is formed simultaneously in all parts of the udder-that is to say, in all the alveoliwe do not yet know. The abnormal conditions of the udder which determine the formation of the toxin may quite well be restricted to certain definite parts of it, and the main object in treatment in that case would be to act on these parts. \Ve now know that this can be best achieved by calling in the aid of air introduced into the udder. The contact of the udder with a foreign substance must cause a slight irritation of the epithelial lining, the result being that the secretion of milk and the formation of toxin are so far diminished that the system is itself able to complete the process of recovery. I think I have now given an objective account of the development of the treatment of milk-fever during recent years.' In view of the results obtained, the experimental period may be regarded as at an end, and each of us must now do his share in keeping the treatment within scientific lines.
GERM INFECTION IN TUBERCULOSIS! A SKETCH OF THE PRESENT STATE OF THE QUESTIOK.
By GEOH.GE OGILVIE, B.Sc., M.B., Edinburgh, M.R.C.P., London Physician to the French Hospital, and to the Hospital for Epilepsy and Paralysis, Regent's Park, London. THE evidence in favour of congenital tuberculosis has during the last few years been collected and critically examined independently by a number of authors (Hauser, Mosny, Kuss, Scheimpftug, Diirek, etc.). The common result of their laborious researches is the collection of a very small number of authenticated cases of intrauterine tuberculosis, about twenty in human beings. The number given by Kuss (forty) is certainly too high, that admitted by Hauser (eighteen) perhaps a little too low. Of course, this result does not warrant conclusions with regard to the relative frequency of such an occurrence, because almost exclusively positive observations have been published. All that one is entitled to infer from these statistics is the fact that conI
Reprinted from the" British Medical Journal," 13th Sept. 1902.