Progress in Physical Therapeutics.

CONSTITUTIONAL DISEASES.

EDITED BY FRANCIS B. BISHOP, M. D.

Local Treatment by Electric Medication.

The extracts from the communication of Dr. Leduc published in La Nature, Paris, on December 29, as taken up in discussion by the lay press, call for certain consideration as to its straight interpretation. In this communication Leduc is quoted as saying that "If we place on each side of the human body a sponge saturated with iodid of potassium, the potassium will penetrate the tissues at the positive pole and the iodid at the negative.

"This simple fact may be the germ of a therapeutic revolution. Up to a recent epoch the introduction of a medicament by the electric current was considered to be a fact of little or no value; now we know it to be easy and regular, susceptible of determining at will local action on the skin and general toxic or therapeutic action throughout the organism, according to the electrolytic solution used, its intensity, and the length of time during which it is applied."

This plain statement of facts by Leduc is misconstrued by the lay press to indicate that drug medication applied in this way becomes strictly local, rendering it devoid of deleterious actions arising when administered by other routes. Undoubtedly the claims of Leduc that the drugs administered in this manner are active in affecting the local cells, is true. It is still a moot question, however, whether very often administrations of this sort are not fraught with the same questionable effects as when administered percutaneously, or through the alimentary canal. Most observers who are now familiar with the employment broadly of the physical agents find that by inducing local and general functional activity, nature is able to rid herself of poisons in the larger percentage of cases without the introduction of any medicament whatsoever. It is a question therefore whether the future of electrical medication to which Professor Leduc refers will not be altogether superseded by the intelligent employment of these agents.

[Editor.]

RADIOTHERAPY.

EDITED BY J. D. GIBSON, M. D.

The Induction of Auto-Vaccination in Tuberculosis by the X-rays. By H. D. McCullough, M. B., C. M. A condensed abstract from a paper in the London Lancet of January 27, 1907, Archives of the Roentgen Ray, for April, 1907.

This paper opens with reference to a paper published in the London Lancet of August 25, 1906, by Dr. Peter Patterson on "Observations on the Effect of Sterile Caseous Matter in the Treatment of Tuberculous Disease," in which the writer reported having succeeded in isolating from diseased tuberculous lymphatic glands an immunizing agent with which he vaccinated six patients, suffering from extensive tubercular disease, from which he deduced the following conclusions:

(1) Positive phases of opsonic index without the occurrence of the negative phases.

(2) Each rise in the positive phase was accompanied by minute elevation of the patient's temperature. This elevation. served as a reliable guide as to dosage.

(3) The normal index.was rapidly reached and easily maintained within normal limits without great variation.

McCullough observes "that such an immunizing agent elaborated in the living organism appears, therefore, to be an ideal vaccine, which it would be impossible to prepare in the laboratory any more than the Jennerian vaccine.

"There is a marked and important difference between the opsonic response evoked by vaccination with this product, and that evoked by the tuberculin of Koch," the latter not being a true vaccine.

"A true vaccine is a metabolic defensive product elaborated in vivo by the action of the minute lymphatic glands in the vicinity of the inoculated area. For tubercle, therefore, an ideal vaccine should be one elaborated in vivo from the accretion of phagocyted tubercle bacilli obtained from the glands of an animal inoculated with a strain of human tubercle bacillus." He calls attention to the fact that in tuberculous infection varying degrees of accidental infection produce both immediate and remote effects, which when slight may not

appreciably affect the general health, and the local and systematic effect may be so slight as to escape observation, and yet, a different opsonic response has been induced. Repetitions of such slight infections thus produce a partial acquired immunity. It would seem, therefore, that "conditions of environment which conduce to the acquirement of a disease, conduce also to the acquirement of a natural immunity. At the onset of infection there is a definite period of incubation, during which the bacilli adapt themselves to their altered environments, after which they begin to penetrate adjacent structures when the first line of defense of the organism, by lymphatic glandular activity, is called into play. . . . There is hyperemia at the site of infection, elevation, and general temperature and an alternating rise and fall of the opsonic index.

"In the vicinity of the inoculation there is an invasion of two varieties of leucocytes-the phagocytes attacking the tubercle bacilli, whilst another horde of leucocytes weave a neoplastic, encapsulating tissue for the purpose of segregation. The phagocytes attack the advanced guard of scattered opsonined bacilli, while the remaining leucocytes surround and imprison the massed bacilli, thus forming tubercles or enclosed localized foci, pending the development of further opsonines and incitor elements. Following this process, which constitutes the acute stage which is tided over, the changes characteristic of a chronic state set in."

"The enmeshed encapsulated bacilli perish, and their toxins slowly diffused, produce incitor elements, and the leucocytes penetrate the tubercular foci with the ultimate formation of pus." The writer presents another hypothesis in which he supposes that "there are more active foci in which the bacilli have been encapsuled without previous opsonization. These living bacilli may proliferate and emerge; as the result of some bodily exertion they may emerge from their prison and thus cause auto-inoculations with exacerbation of the original malady. To meet such a contingency, however, there has been an elaboration of a tubercle-trophic vaccine in the lymphatic glands in the neighborhood of the original infection. The egress of this vaccine, however, is obstructed at the very moment when it is most needed; the glands are more or less imperviously encapsuled in neoplastic tissue. The happiest results sometimes follow the accidental admission of this vac

cine into the lymph stream. The surgical ablation of tuberculous glands, for instance, is often followed by the disappearance of other tubercular symptoms, and this may be due to the transudation of a minute quantity of vaccine into the circulation. This is in accordance with the high potency of an infinitesimal quantity of such vaccine when present in the lymphatic gland involved."

At this point the writer states abruptly the conclusion that · in a similar manner he believes the x-rays act by setting free the encapsuled vaccine, and states that it is the purpose of this paper to advance the hypothesis that the therapeutic action of the x-rays depends on the induction of auto-vaccination, and this in consequence of the resolvent action of the x-rays on the rudimentary neoplastic tissue, which encapsules the tuberculous glands. This action of the x-rays is followed by a slight rise of temperature, with corresponding increase of the opsonic index, and this without any negative phase.

Dr. Gibson, editor of this department, in a paper read before the American Electro-Therapeutic Association on September 19, 1906, under the title of "Tubercular Antitoxin," was first to call attention to the opsonic action of the x-rays in tubercular infection, and came to his conclusions through much the same process of reasoning as the writer of this paper. He stated in that paper that he had "come to the conclusion from clinical experience that we are causing with x-rays in advanced and suitable cases, a destruction of tubercular bacilli, bacteriolysis, which being absorbed into the blood, the toxin, becoming an endotoxin is very likely to be set loose in the blood and lymph stream, arousing a reaction with production of antibodies or amboceptors of Erlich, or possibly in their own mysterious way, increasing the opsonic index of the individual, even to the point of changing the negative chemiotaxis for an alsolute positive chemiotaxis, so that the phagocytosis may be increased sufficiently to take care of all the emergencies that may arise. In other words, in suitable cases you produce by means of x-rays an autospecific or tubercular toxemia, arousing a reaction in the host of the liberated toxins that may be of great benefit to the patient." He also calls attention to the fact that there is a wide difference in the class of cases in which the x-rays have given better results, than cases in which the tuberculin group of agents

are advised. For instance, these agents are recommended to be used only in cases where there is an elevation of temperature. In the cases reported in this article, and the position taken, with reference to the opsonic effects of the x-ray in tubercular processes, this article gives Dr. Gibson distinct priority in having recognized and called attention to the opsonic action of the x-ray. [Editor.]

Dr. McCullough calls attention to the fact that the Roentgen rays are known to have a specific selective action on morbid tissue, independent of any inflammatory process. This selective action may proceed without any signs of irritation or apparent modification of the integument. In small doses the rays have a stimulating effect on the growth of hair, whereas, with larger doses, vesiculation, ulceration, and sloughing are induced.

He quotes Dr. Lewis Jones as saying that the "gradual onset of radio-dermatitis after a latent period shows that the lesion is a tropho-neurotic one, due to damage sustained by the superficial nerves."

The writer infers that the nerve filaments primarily affected produce paresis of the capillaries, passive hyperemia, analgesia, and finally necrosis. Belot is quoted as follows: "The hyperemia set up by the X-rays provokes an abundant migration of leucocytes from the vessels. The leucocytic infiltration commences at the periphery of the tubercular focus and penetrates by narrow tracks into the substance of the lupus nodules, the leucocytes being ultimately transformed into the fusiform cells of fibrous connective tissues. The lupus cells degenerate by vacuolization; the nuclei lose their affinity for stains, necrose, and become absorbed, and replaced by cicatricial growth."

"The most important point with regard to lupus is the localization of the inflammatory reaction and its concentration exactly at the diseased point, in consequence of the degeneration of the lupus nodules themselves. There is in this respect a resemblance between the action of the Roentgen rays and that of tuberculin, which also sets up inflammatory action which is limited to the tuberculous nodules."

It is well known, moreover, that neoplastic tissue is, in almost every detail, a rudimentary replica of the tissues affected, and such tissues are highly susceptible to the radiations of the Roentgen tube.

He says that for the past two years he has been in the habit of using the x-rays as a resolvent of glandular enlargements with the result "that almost invariably the unsightly disfigurements disappeared with alternate soft swelling and shrinkage.