Alf Westergren, Stockholm .

Sanocrysin treatment.

Some observations and practical experience.

Since November 1924 sanocrysin treatment has been tried in the Medilcal Service TI (H. C. J . 4 c o n . 4 ~ ~ ~ ) of the Serafinier Hospital. Alltogether 20 cases have been treated, about half this number, however, should a t least for the present not be taken into account, the time of treatment or observation being too short. From the very start we proceeded partly with large doses, something like Mollgaard-Secher’s formula, partly with small doses.

Serum has been used only in 2 caSes of pulmonary tuberculosis. In one case of a malignant, exudative type, but with the patient’s general condition fairly good, no sanocrysin was given, only serum - altogether 80 cc. (of horse) during 5 days - but then the patient got considerably worse with a high persistant fever. As it is only too well known, serious cases of tuberculosis do not tolerate pareneral protein therapy and for many reasons i t seems as ilf, in such instances, serum ought to do tnore harm than good.

Combined sanocrysin-serum therapy was properly tried only in 2 cases of tuberculous menihgitis. In these instances namely, specially unfavourable conditilons of immunity were to be expegled. Sanocrysin was partly injected intralumbally b la Gennerich - 10, resp. 5 ctgr. together with 20 cc of serum - and a t the same time sanocrysin intravenously, and, somewhat later, also serum ihtra- venously was injected; but after about 24 hours both these cases had ended fatally under conditions pointing almost to a general lnxin shock. No obvious signs of local irritation from the sano- rrysin were observed. The guiena-pig test of cerehro-spinal fluid, taken at the postmortem examinati’on in one of these cases, showed n most positive reaction. Furthermore it may be mentioned that in one instance of fresh miliary tuberculosi’s, sanocrysin was tried (without serum), - altogether 2,5 gr. in doses 0,5 to 1 gr. with iniervals of 4 to G days, - without any noticeable effect,,

140

Concerning pulmonary tuberculosis, it, may first of all be stated that in 3 cases, thoroughly observed during 4-0 months, sanocrysin was administered in relatively small doses (10-50 ctgr.) with intervals of 4-10 days, and that these patients, presenting fairly benignant though incompensated processes in Turbans stage 11-111, at any rate do not seem to be deteriorated. Treatment with relatively small doses is going on in several cases, but as ye€ there can be no question of even trying to form an opinion as to the effect.

I will now demonstrate the course of treatment in 3 cases, where relatively large doses were used.

CASE I. (L. E). k woman, 24 yeam old, who had pleurisy 3 years ago, and now has coughed for 2-3 months. The general state of health good. A Turban's stage I with few rales. Roentgen-plate (demon&.) showed small spoh of a proliferative type on both apices. On 'a plate taken 6 wreks earlier the lesions showed a somewhat fresher character,

100 90 80 70 3 60 X

50 i' 40: 30 20 10 o.TB.+

Alh-urla 1%

CTmCeS I

CASE I.

On the diagram the temperature, the weight and the sedimentation reaction (one hour) are reproduced, as well as the haemoglobtn content of the blood (estimated by means of the SR-values), furthermore the finding of tubercle-bacilli in the slputum (the amount of which in this patient was very inconsiderable during the whole time, only some cc. per day) the quantity of urine and the presence of sediment and event. amount of alhu- men. The sanocrysin doses axe indicated on the upper margin of tlha diagram.

141

It will be found that after twice injecting 0,5 gr. of Yanocrysin, from which there was hardly any immediate feverish reaction, the SR-flgures in8crease from about 15 mm. to nearly 40 mm. During the fourth week the patient's general date of health was somewhat affected, the cough decidedly became more irritating, and the rales seemed somewhat increa- sed. This was probably an instance of f d reactison which retrogressed rather quickly. At the time of recommencement of the treatment (in the 7th week) the patient's general condition, SR etc;., began to improvc and no TB were found in the sputum. During the 12th week the patient showed a slight albuminuria. and lmsed weight, but the figures of the SB were only ineigniflcantly mfluenlced. An X-ray photo in the 15th wee$ revaaded r a a e r some further hprovemenrt, and bhe nales had almost disappeared. 3 monitihs later, however, Uh0 informatiion was received that TB had reappeared in t!he sputum, she bad a SR of 12 mm. and weighed 54 kilos.

The time sitated in the diagram undoubtedly represents a period nP improvement, but whetiher this can be attributed to the sanocrysin treatmeni is uncartlain or downright improbable, the m e being evidently a rather benignlant one, with a teademy towmcls reaovery already at the oommen- cement of the c m .

CASE I1 (0. S.). A man of 34 yews in paMxlar ly good general condi- tion). AppaJrentIy a Predi case ; the1 disease had appeared 9 months pre- viously with a haemoptysis, which recurred repeatedly afteavards. The Rmntgen-plate (demonstrated), however, showed a pronounced cirrhotic process, on the onle uppea. lobe.

100 90 80 9 7 o x k 60 2 50

30 20

2 M E

EbUd-bU.5. I+ .+t*

Alb-una 9 k%.

CASE 11.

It can be scea from bhe dliagram thal the patic'nt h'ad distinct fcverisn reactions (and also sb~o'ng subjective sentialions) after Uhe sanowysdn injectiom, but his c'ondit,ion8 must onl the whole bse mgarded as eatirely irnaffeoted. Before the oommen~mcnlt of th'e treatment them was a hasty dcarease of the SR (after a previous haemoptysis). During the c'ourse of [,he cure the SR-curve dhows a decided tenden'cy to temporary rises. (Possibly a foaal reacti'on occurred during the 7tnh and 8th week.) The breatment was interrupted in the I l t h week by an inkrm-eni t angina. (Now the in,crease of the SR was much more pronounced than during the treatment.)

CASE 111 (Th.). A man of 27 years, who, c'onitrary to tJhe tw,o ppoceeding examp,les, suffered from an obviously inalignant tuberculosis.. He had had laryngeal symptoms for 9 moniths, otIhmwise eubjeotiveiy well un#t,iI a montrh before his admittanice whm within a short time he beoarne ailing, began to cough #and grow thin. His general s;tate of health was somewhat lowered, the temperature, as appears from the diagram, rather afebrilc. The Rcentgen-plate (demonstr.) shows a rather extensive process of chiefly confluating broncho-pneumonic type with a few small fresh cavities. The stetmoopic chan,ges were c80nsidwably lass pronounced. He exhibitied moreover a ni'oderaklly extensive laryn,geal tuberculosis of malignant typc, but without bad dmtructionis. (By the way it may be mentioned that amongst, our cases have been no 1,ess than 6 ones complicated with laryngeal tuberculosis', and these have been treated with a certain predilection, in t,hc

Week I 2 3 4 5 6 7 8 9 10 11 12 13 14

90 80 $ 70 2 60 50 -E

Z b -6ac I+ .+++

47%.

Alb-uria I%. Tm.r

CASE I11

143

hope of straightway seeing some local changes, which, however, oouJd ollily be observed in this particular instance.)

The treatment was in this ease coinpara~vely carefully pursued witih doses of 0,5 gs., md the patienit showed slight ilmmediate reactions. Alrea- dy after the 3rd injection (in the 4 t h week) a very slight alburninulria was observed (traces of albumen for 2 days). After trhe 4bh injection (5th week) a slight albumiinmia reappeared, immediately followed by a purple exanbhema, succeeded by a sevePe exanmema, resembling memks, and In the meantme occumed the Wst reaction from the larynx rn the form of a general edema, which increased rapidly. During the 8th and 9th weeii this laryngeal edema completely dominated the clinical symptoms, later it decireased to a great extant. The patient's eandition, however, rapidly changed for the wmee and he expikwd a fortnight a m the time stated in the diagnam.

Even, if the prognosis was undoubtedly Porn the beginning exceedingly bad, it Seems as if the eanocrysin treatment probably accelwated the course of events. I regret that time does not permit any detailed diwmssion.

There is furthermore another case I fell bound to mention. (No diagram.) A girl 1 4 years old, with all symptoms pointing to a fairly fresh and malignant pulmonary tuberculosis of moderato extension, iknproved quite remarkably in all respects, quickly and evidently, after 2 intramuscular injections of 10 ctgr. of sano- crysin. Now, it is possible that this was the only one of our cases suitable for the treatment - ilf as a matter of fact this had anything at all to do with her recovery. Such an effect seems hardly to accord with Mollgaard's views on the directly bactericide actiton of sanocrysin. It seems to me that stress should be laid upon the fact that cases are rather seldom m,et with, which a priori , according to Mollgaard's princilples, can be considered as really suitable for sanocrysih treatment.

At any rate for the present time we cannot attribute the gold treatment an essential therapeutic efficacy in any of our cases. Of course the moment has not yet arrived to draw any definite conclu- sions about the practical clinical value of the sanocrysin, but so much seems to be certain, that the method of treatment as ihdi- cated by Mollgaard and Secher is not suiitable for a11 cases. We are thus - unfortunately - compelled to try, with all the means a t our disposal, to elucidate our experiences, not only as regards the diffcrcnt types of tuberculosis, but also regardihg in what phase of the struggle of the organism against the dilsease an intervention is indicated. Among our clinical expedients to such a purpose, 1

144

have been partibularly interested in the sedimentation reaction, though I certainly do not claim its being the only source of guidance in this connection. But I wish to point out its use first of all in helping to form an opinion as to whether we have we won more by a certain specific method than by the usual hygienic-dietetic treat- ment, e. g. Before commencing a cure, each case ought consequently, if possible for several months, to be observed by means of repeated sedimentation tests. With regard to the dilrect and immediate influence of sanocrysin on the SR-curve should be mentioned, that the injections hardly need to cause more than an unessential, short transitory increase of the SR-figures, even when distinct feverish reactions appear. That, on the contrary, serum injections cause an increase of the sedimentation, sometimes to a rather considerable degree, is certain, and, furthermore, I consider proved that focal reactions and deterilorations of the tuberculous processes are followed by increased SR-figures (except in bad cachexia). - My experience is not as yet sufficient to allow my pronouncing any decided opinibn, but I believe every precaution should be taken before venturing on the use of such a remedy as sanocrysin, when the SR-curve is in the ascent.

As appears from the aforementioned results, our experiences of sanocrysin treatment, can not be called favourable, but they are certainly much to inadequate to be cited iin support of any condem- nation. I am convinced that under certain conditions sanocrysin can exercise ti therapeutic effect, not only in animals but also in human beings. Our immediate aim, however, must be to a r r i h at such a knowledge of what is going on in each individual organism, that we can avoid acting in the dark.