right of the midline. This murmur which is of peculiar roughness entirely obscures the first sound in the pulmonic area. No other murmurs could be detected.

In view of the history, the association of tuberculosis, and the results of physical examination, I felt justified in making the diagnosis of Pulmonary Stenosis of congenital origin, with secondary far advanced pulmonary tuberculosis.

On March 4th, about two weeks after the first interview, there was detected in the right external jugular vein, a venous pulse synchronous with systole, which was assumed to indicate relative tricuspid insufficiency, which condition was found to be present at autopsy.

The patient pursued the ordinary course of a faradvanced, uncared for case of pulmonary tuberculosis, doing an amount of manual labor surprising in one presenting such evidence of cardiac as well as pulmonary changes. The temperature finally assumed the hectic type, the pulse varied between 120 and 140, the respirations between 30 and 40, the patient remaining up and about most of the time despite advice to the contrary. She finally died on January 2, 1910, about ten months after first coming under observation. The terminal events were not observed clinically.

Autopsy (limited to heart and lungs). For the performance of this autopsy under difficulties, my thanks are due Dr. E. C. Thrash, Professor of Pathology, Atlanta School of Medicine.

Heart The heart is firmly bound to the pericardium by a large number of dense adhesions, so that it is impossible to remove the heart without tearing its substance. On examination of the right auricle, it appears normal except that in the fossa ovalis along its upper margin there appear three cribriform openings in the inter-auricular septum. The largest of these openings is 2 mm. in diameter, the other two about .5 mm. The edges of the tricuspid valves are greatly thickened along

the insertion of the chordae tendinae, thus preventing perfect coaptation of the edges, on closure of the valves. The entire ostium venosum is so stenosed that the little finger can with difficulty be introduced to the base of the pulmonary valves from the cavity of the right ventricle. The pulmonary orifice is 8 mm.. in diameter. The three leaflets of the valve are greatly thickened, and nodular from their base to near the margins, which furnish a surface smooth enough to permit accurate coaptation of the margins. Each leaflet is about 9 mm. in length along its margin. The leaflets are three in number and not fused. The distance from base to free margin measured in the sinuses of Valsalva is 13 mm. Each of the three leaflets is thrown into folds.

There is no communication between the pulmonary artery and the aorta, both of which occupy their normal relative positions. The pulmonary artery is only 8 mm. in length, dividiing into right and left branches. The vessel is about 1 cm. in diameter and very thin walled. The mitral valve is competent, though there is some thickening along the marginal cusp.

The aortic valve is normal, each cusp measuring 20 mm. along the free margin, while the distance from base to free margin measured in the sinuses of Valsalva is 10 mm.

The inter-ventricular septum is intact throughout. The walls of the right ventricle are hypertrophied, measuring at the thickest part 13 mm., as compared with 15 for the left ventricular wall. The papillary muscles are much more strongly developed on the right side of the heart.

Lungs-Both lungs present the lesions of tuberculosis. Multiple cavities appear in the right lung, with a very small amount of air containing area, while the left lung presents the pathological picture of acute tuberculous pneumonia, throughout the greater part of its

extent.

It will be seen that the heart just described hardly

conforms to either of the two generally recognized types of stenosis most frequently met with. The absence of septal defect and rechtlage of the aorta should probably mean that the changes took place rather late in the development of the heart. On the other hand there is a distinct hypoplasia, or rudimentary condition of the tract extending from the base of the right ventricle where the conus begins, on throughout the pulmonary artery. On the other hand the thickeninng of the valves would seem to indicate inflammatory changes of a chronic nature. Accurate conclusions are therefore to be drawn with difficulty, and I submit the case as it stands.

822 Candler building.

A FURTHER REPORT CONCERNING THE USE OF

VACCINES IN ACUTE AND CHRONIC

INFECTIONS.

Edgar Paullin, B.A., M.D., Atlanta, Ga.

Since the presentation of my paper two years ago before this Association on "The Results of Vaccine Therapy in Acute and Chronic Infections," numbers of articles dealing with various phases of this subject have appeared in the literature; so much so that it is no longer possible for one to even review all of the data relating to this subject. No attempt will then be made in this paper to give the opinions of others or the results of their work. My own series of cases now being large enough to permit the deduction of certain generalizations.

The views previously expressed have undergone little change except that a more extended experience and further observation of the cases have caused me to modify the dosage of many of the vaccines; particularly is this true in the cases of tubercular lymph glands and the use of tuberculin.

Many members of the profession fail to distinguish between a vaccine and a serum, as a result of this confusion in the minds of some regarding the terminology perhaps it will not be amiss if these substances are again defined. "A vaccine is any chemical substance which, when introduced into the organism, causes there an elaboration of protective substances.' On the other hand a serum is the substance removed from the blood of another animal, which has been vicariously inoculated, and contains protective substances, the protective sub

stances in this serum being present because of the fact that the animal has been injected with large doses of bacterial vaccine or toxine. The two things then are in should be no confusion of

no way similar and there

names.

In the blood of normal individuals there are various protective substances; in the blood of individuals the subjects of chronic infections one or more of these protective substances is diminished and it is diminished in such a manner that to this particular infection the body can offer but little resistance; as a result of this, without outside aid, the tendency with most chronic infections is to steadily get worse. If we bring to bear in these cases the stimulating effect of vaccine, in many, the disease is arrested and in many more eventually cured. By injecting a vaccine then we hope to bring about in the body of an individual a specific and active immunity to his particular infection and the degree of this immunity can be judged by the condition of the focus of infection and the condition of the patient. Consequently for an active immunity to develop in this way the injection must take place over long periods of time.

With these few words of introduction relative to the prinicples upon which the foundation of the treatment rests, the cases are herewith given you. While various and almost all kinds of infections have been treated with the vaccines it will not be possible within the time limit. to present, in detail, all of the cases. It would seem best that the infections which are most common and most amenable to proper treatment should first be brought to your attention.

The first group of cases then would be tubercular lymph-adenitis. Of this infection I now have records of sixty-four cases. Of this number forty-eight are regarded as well; nine are improved; and seven of the cases I have been unable to trace, and the result is therefore not known. Eight cases have had relapses, but these have been easily relieved by the administration of a few