paratively short time the patient had a maximum temperature rarely over 101, often only 100, simply a feeling of coolness, little if any excessive perspiration, and a great diminution in the amount of sputum. The subsequent course of the case was slowly and surely downward, but the gratitude of the patient for that which to him seemed almost miraculous relief, was to my mind a fair index of the value of the treatment.

The fourth case was that of a gentleman eighty-two years of age, who had exhibited at intervals for nearly a year symptoms of what is commonly termed "angina pectoris." He also had been formerly afflicted by severe attacks of bronchitis, usually of six weeks' duration each. I saw him first in the attack of bronchitis under consideration, on July 5, 1911. His temperature was but little elevated, his pulse at times was as low as 42. Both lungs were exhibiting medium and coarse moist rales posteriorly; he was sleeping but little. Remedies as indicated were employed, the patient was kept as quiet as possible in bed, but although his environment and treatment was affording some benefit, his progress was very slow. Examination of the sputum showed the presence chiefly of pneumococci in large numbers, and after due conference with Dr. Watters, the patient was given on July 15 three minims of pneumococcus vaccine (strength 25 millions per c. c.). This was repeated at intervals of two or three days, and the patient's progress very markedly accelerated, so that at the end of three weeks from the inception of his attack he was practically well, a very happy man and a firm believer in the efficacy of vaccine therapy.

THE APPLICATION OF BACTERIAL VACCINES TO
SURGICAL WORK.*

BY GEORGE R. SOUTHWICK, M.D., L.R.C.P., Lond, M.R.C.S., Eng. The laboratory laid the foundations of asepsis in surgery and is contributing to a new and scientific development in medicine. The results obtained seem likely to materially help the surgeon. That miracle of the infinitesimal, the doctrine of immunity, the physiology of the white blood corpuscle, the opsonins, the toxins and the antitoxins; the antibodies, the antigens, etc., in the blood. serum and the harmonies which often determine the balance between health and disease, are all studied with the deepest interest. The pathologist sees in them new conceptions of disease and of those delicate, elusive, subtile processes of cell nutrition and metabolism. The physician watches with increasing interest the possibility of a real scientific practice of medicine. The great advance in medical science has not been along the line of antipyretics, coaltar derivatives, or synthetic remedies. It has been intimately associated with infinitesimal agents which can be recognized only by the most delicate tests of physiology. Present day medicine measures by the results obtained and not by the quantity taken.

The remedial agents derived from blood serum, or bacteria,

Read before the Massachusetts Surgical and Gynecological Society, December 13, 1911.

are classed as antitoxins, or antibodies; sera and vaccines. Antitoxins and sera are produced through the horse and when injected subcutaneously supply the patient with antitoxin or antibodies already formed in the horse serum. The physician thus produces passive immunity in the patient. Bacterial vaccines are cultures of bacteria killed by heat and suspended in physiologic salt solution. The injection of bacterial vaccines stimulates the body of the patient to produce a large supply of opsonins to prepare the bacteria for ingestion by the leucocytes, or the formation of antibodies to combat the disease. This is called active immunity.

Rules for the selection of a serum or a vaccine are not sufficiently defined, but, in a general way, sera containing a supply of. antibodies already manufactured by the horse are best adapted to general infections when the patient can not produce his own antibodies. These are the exceptional cases and are chiefly those where the early injection of a vaccine has not been given and the infection has far advanced, in diphtheria and in possible infection with tetanus before symptoms of tetanus have appeared.

Bacterial vaccines are more used for surgical cases and are especially adapted to conditions where the patient can manufacture antibodies in his own body and also for prophylaxis or the production of immunity in healthy individuals, as in the prevention of typhoid fever and for the treatment of localized infections. It is important to note that the earlier the vaccine is used, the better will be the results, as the body of the patient will be far better able to manufacture its own antibodies at the very beginning of the disease than if overwhelmed with the infecting germ at a late stage of the infection. The prophylactic injection of vaccine will not always enable the patient to overcome an infection at the time of operation, as other factors enter into the question, but there are reasons for believing that prophylactic vaccination will increase the immunity of the patient and improve the chances for an uneventful recovery.

Bacterial vaccines are classed as heterogeneous, or stock vaccines, and autogenous. Heterogeneous vaccines are made from cultures of selected strains of pathogenic organisms. Autogenous vaccines are made from cultures obtained from the patient and prepared for injection into the same patient. Mixed vaccines are used occasionally and are sometimes combined with the pneu

mococcus.

Stock vaccines are used to a great extent, as the infecting organism can not be obtained in many cases when the signs of infection first appear and valuable time would be lost in waiting for material and preparing the vaccine.

Autogenous vaccines are more economical and are always at hand. Special emphasis needs to be laid on the importance of the very early use of the vaccine.

Autogenous vaccines are more desirable when circumstances permit, as they are the same bacteria which infect the patient. It is often desirable to begin treatment with stock vaccine and follow

it up with the autogenous. Autogenous vaccine can be prepared to advantage from pus at the time of operation and used when ready for prophylactic purposes without waiting for signs of infection to appear.

Mixed vaccines are used for infections with two or more germs with pneumococcic infection.

No cases in literature are known to me where any serious harm has come from the use of vaccines or where it has interfered with other therapeutic treatment, but the purpose of the vaccine may be defeated by using too much vaccine and by too frequent repetition of the dose.

The repetition of the dose is determined best by the opsonic index, but this involves time and laboratory facilities at the disposal of comparatively few physicians. The clinical symptoms often are sufficient. The injection is frequently followed by a lower temperature corresponding to the negative phase. The temperature rises again in twenty-four to forty-eight hours, often within two degrees of its former level; a presumably positive phase and a smaller dose of the vaccine can be given.

It is desirable to use a fresh preparation of vaccine, as the question of deterioration with age has to be considered.

The principle of prophylaxis by vaccination is closely allied to conferred immunity, a splendid example of which has been seen in the results of immunizing against typhoid fever the soldiers of the United States army on the Mexican border. Not a soldier so treated contracted typhoid fever.

It is possible that other agents than vaccines, such as ferments and enzymes activated in the presence of calcium, may promote phagocytosis. The writer knows two cases of persistent furunculosis and carbuncles involving considerable areas and of more than six months duration, which both surgical treatment and vaccines. failed to materially benefit. The internal administration of yeast was quickly followed by the permanent cure of both patients.

It seems probable that chemical agents may increase the opsonic content of the blood, and if so, why not other remedial agents? The pneumococcus grows poorly in ordinary bouillon culture and soon perishes. Add calcium carbonate to the broth culture of pneumococcus and the culture grows vigorously.

Infections with the pathogenic cocci, especially the staphylococcus pyogenes aureus, appear to be the most amenable to treatment. Infection with the colon bacillus is more difficult to treat.

Vaccines act best when mingled with the blood serum which contains the opsonins. The surgeon opens an abscess, pus escapes, tension is relieved, the abscess cavity collapses, blood serum rushes in and mingles its opsonins with the vaccines present. The opsonic index is raised and the patient improves, even though no vaccine has been given.

This seems to explain the remarkable results sometimes following simple exploratory incisions in tubercular peritonitis. The serum filling the peritoneal cavity has exhausted its opsonin con

tent. A fresh supply of serum flows in, rich in opsonins, antibodies, or similar agents, and a rapid cure follows. The same is true of many cases of pleuritic effusion, of tubercular origin, which are cured by tapping. Bier's treatment for hyperæmia is founded on it. Cellulitis in its various forms appears to be especially susceptible to treatment by vaccines, and abscesses are in a similar class.

Old sinuses following operation, erysipelas, puerperal sepsis, empyema with pneumococcic infection and even ischiorectal abscesses in tuberculous individuals have been apparently benefited.

Dr. Craig reports many interesting cases successfully treated by vaccines. Amongst others was a man sixty-five years old who entered the hospital at the end of a prolonged spree. He was on the verge of delirium tremens and had a very severe appendicitis. He was in such bad condition that it was considered hopeless to operate and the last rites of his church were administered. He was given a vaccine made from the interior of an appendix removed the day before from a very severe case of perforated appendix, the vaccine being ready for the patient in case he needed it. It consisted of a mixture of streptococci and colon bacilli. The patient made a remarkable recovery, was out of bed in a week and left the hospital four days later.

Dr. Duncan has made recently a strong plea founded on clinical experience for giving drop doses of the patient's own living pus per orem, till some sign of reaction or aggravation appears, such as pain in the wound, insomnia, headache or vomiting. Then his directions are to suspend the remedy and to wait until amelioration sets in. This treatment will remind many of the use of nosodes and the much despised Psorinum, about which there were many wordy battles twenty-five years ago.

The importance of the colon bacillus in all infections in the alimentary tract or appendix ranks in importance with that of the pneumococcus in most inflammations above the diaphragm, but less relatively is known about it. Turk fed animals on cultures of colon bacilli and produced quite constantly ulcers of the stomach, duodenum and other parts of the intestine. The favorable results obtained by vaccine treatment suggest its possible application to the early treatment of gastric and duodenal ulcer.

Opinions will continue to differ as to the merits of vaccine. treatment in surgery. There are many cases of recovery following vaccine treatment plus surgical aid, which would not be considered as cases likely to recover under the usual methods of treatment without the vaccine.

It may be asserted as axiomatic that with our present understanding of vaccine treatment, the latter should be considered a valuable supplement to surgical aid and subservient to it. It will never excuse the surgeon from the most vigilant asepsis in the operating room, nor in a departure from well established rules. of operative procedure, drainage or posture of the patient. On the other hand, the surgeon welcomes gladly any agent which will help him fight his arch enemy, septic infection.

The writer takes pleasure in acknowledging his indebtedness to Prof. Watters for the vaccines prepared by him and used under his supervision in the Homœopathic Hospital, also for the loan of charts of other cases than his own.

A series of twenty temperature charts illustrating, with the aid of the stereopticon, as many cases of septic infection give an excellent idea of the results of vaccine treatment. The cases include septic infections of hands, cellulitis, abscesses of different kinds, septic wounds, puerperal sepsis, erysipelas, peritonis, etc. All of these cases made good recoveries, and the effect of the vaccine on the temperature of the patient is readily seen on the charts.

Just as good results are obtained sometimes by surgical aid alone, but it seemed in some of these cases that surgery without the aid of vaccine treatment would have failed or convalescence would have been long. Three septic hands with an average of 102.1 degrees when treatment began showed a permanent normal temperature at the end of the third day after using the vaccine. Nine cases of a variety of seven septic wounds of several types with an average temperature of 103.6 degrees subsided to normal on the fourth day after vaccine treatment.

In the four cases of peritonitis, one associated with a suppurating and gangrenous appendix and another with a large focal fistula following laparotomy, the average high temperature was 103 degrees, and normal temperature was reached on the ninth day.

The cases mentioned are not selected but are strictly illustrative types of a large number of important surgical cases in which vaccines were used. They show results which warrant the opinion that vaccine treatment is a valuable adjunct to surgical aid which has given a happy ending in many cases where a fatal termination was otherwise to have been expected.

VACCINES AT THE MASSACHUSETTS HOMEOPATHIC HOSPITAL. *

BY W. H. WATTERS, A.M., M.D., Boston, Mass.

In a brief paper like the present one, it will be possible to merely give a short outline of the work with vaccines which has been carried out and is still being followed in the Massachusetts Homœopathic Hospital. Beginning in the winter of 1906-7, we now look back upon nearly five years of labor and experience. This time has brought many trials, but it has also brought greater pleasures and satisfaction at the results attained. About two thousand cases have been treated in ali, embracing a great variety of conditions in all ages, both sexes, and divers conditions. As a result, certain deductions may be made, following

↑ A brief summary of the more important cases shown by the stereopticon is given as space does not permit publication of the charts and remarks in detail on them.

* Read before the Massachusetts Surgical and Gynæcological Society, December, 1911.