A hundred years ago: Treatment by bacterial vaccines
I have mentioned before that rest is an important factor in the treatment of infective processes, whether accompanied by bacterial inoculation or not. I may illustrate this by the usual surgical procedure in the treatment of tuberculous disease of the hip joint. Rest is all important. Movement brings about the liberation of auto-inoculations, overdoses, negative phases, flaring of the infection, and so on. Rest, when it abolishes these untoward symptoms, also brings the opsonic index to what might be termed the habitual low-tide mark of the patient. Bacterial inoculation, suitably carried out, can so regulate the index as to keep it constantly above the normal line. The benefit is great to the joint, as well as to the general well-being.
Perhaps with tuberculosis – and we had better go on with this infection, as we have drifted deep into this part of the subject – the most favourable cases are those of young children infected with tuberculous glands. I am firmly of the opinion that a delicate child, with a few shotty glands in the neck and a few in the groin, has probably many more shots in the locker of the mediastinum and mesentery.
The most remarkable instance I have had of this kind was a baby of eleven months, always crying and whining, pale, wasted, big-bellied, who had bad nights, and to whom milk seemed poison. All I could find were small glands in his neck and in his groin. His opsonic index was .3. Dr. Wells tells us that babies have no indices, and that they grow their indices as they cut their teeth. But anyhow this baby's indices grew rapidly under inoculation, together with himself; and three months after the first injection he was a sturdy child, able to take milk well, and behave as normal babies do. This is now
18 months ago, and he has shown no sign of falling off. Far more commonly infected with tuberculosis are children from five years and upwards. Thin, pale, fretful, easily tired, with grey patches round their eyes, no appetite, a few glands in neck and groin, they present a picture seen by hundreds in a children's outpatient department.
Amongst the better classes, they are all too common. Food and change of environment, except at the seaside, does little good. Opsonically they are generally low; probably the auto-inoculations are slight, and the stimulus to self-immunisation correspondingly feeble; the slow toxin absorption is gradually pulling them down. They emerge into youth, usually delicate, but at this age generally eventually immunise themselves.
I have had considerable experience in general practice with this type among the well-to-do, and, during the last three years, I have invariably adopted the course of tuberculin inoculations. At first, in 1905, the doses were about 1/1,000th to 1/2,000th of a m.g., now they have been reduced to 1/4,000th to 1/5,000th. With such a dose given at varying intervals, according to the opsonic necessities of the case, the results are most satisfactory. The children became less fretful and more high spirited, they eat better; their skins become mottled and glow with health; they are no longer delicate.
I would, however, caution you not to abandon them too early; after six or eight months they will often begin to drop back again; and there is danger of further tuberculosis infection perhaps even in their joints, but seldom in their lungs.
I was asked the other day with reference to these particular children if inoculation made them more dependent upon it than if they had never had it.
My questioner was not an Irishman, but it sounded as if he was. What he meant was, "Did they go back to a worse state after inoculation, and was it therefore necessary always to continue it?" My belief is that they can be gradually immunised out of the tuberculous because it is possible gradually to space out the inoculations; but, at the same time, I think no sane man would venture an exact forecast in tuberculous infection. It is sufficient that they rapidly become robust, and do not waste their early years, precious for development, in fighting the tubercule bacillus.
Tuberculous meningitis in one case absolutely failed to respond to inoculation, although the patient did respond when primarily attacked with a tuberculous pleurisy a year before.
I blame myself that night I lost sight of her, and did not continue the inoculations. Wright informed me that he had had a similar experience in a case of tuberculous meningitis.
In tuberculous disease of bone the surgeon may be greatly helped by bacterial inoculation; guided by the opsonic index, as has been shown during the last three years at St. Mary's Hospital in particular.
The staphylococci, upon which Wright1 elaborated his principle of opsonic investigation and bacterial inoculation, do not call for special notice.
The principles enunciated above, as regards blood stream and drainage, of course particularly apply in this infection. I notice that the dermatologist is particularly scathing in his criticism of bacterial inoculation for acne; but if he merely inoculates, and does not take care to soften the indurated patches and help the peripheral circulation, he violates the fundamental principles. I have in mind a lady of fashion, who had one small disfiguring patch on her right cheek, at times red and hard, but seldom forming pustules. Staphylococcic inoculation did no good, until, following Bier's cupping method, I covered the patch with a heated wineglass. This worked far better than hot fomentations, and in a week the patch, which had existed for two years, had gone.