LIBRARY OF THE University of California. RECEIVED BY EXCHANGE Class OI'SOXINS AND \'A('('IXI-:s IX MKDICIXI-: AXD Sl'I.MlKin'. \(»i;.\IAN KDW .\i;i) DITMAX, A.M.. M.D.. IN (OM.Ar.oii.vrio.v with XATll.WlKl. I'.. l-OTTKi;. .M.J). ERXKST ]!. l'.i;.\l)LKV. M.D. Suliiiiitlcd ill I'ailial KuHilluiciil of tlic i;c(|uirciiu'iils l(ir tlic Dcuifc <'l Dottur lit Pliiliisdphy ill tlic Ka<'iilty of Piiic Science. C'nhinihia rnivcrsity. Ill ]8!K") Deny!? and Leclef^ iirst called attention to the efPect of blood serum on phagocytosis by knicocytes. From tlie careful experiments ("/( rilro ihev concluded that in an immunized ralihit the leucocytes obtain I heir power of engulfing the bacteria from some property of the serum. The immunized animal fights tlie bacteria, first, l)y the direct action of its serum; second, by its leucocytes.- The latter always owe to the serum the commencement of their power. In 189T Bordet-' was nnable to confii'in their results. In th.e same year ^lennes^ showed that the immunity of guinea-pigs inoculated with toxins or cultures of jjneumococci depends on a modiiication of their serum whereby an active phagocytosis is induced, and that this is not 1. "Sur le mecanisme tie I'iuimuiiite chez le lapin vaccine coutre le snv;il()ci)ccii>: pyog.," La Cellule, 1895, vol. xl, p. 198. 2. A summary of their conclusions is as follows : (ai The serum of normal ralibits exercises no bactericidal action on tlic siiri>tit- cvcciis iiyogenvs. (b) The .serum, of a rabbit on whom a certain degree of immunity to strepto coccus has been conferred by vaccination, will delay the development of streptococcus for several hours and will sometimes exhibit a true bactericidal power. (c) Leucocytes from a nornuil rabbit added to (he serum of a normal rabbii exhibit only a feeble phagocytic power to streptococcus. The leucocyles die lieforc their usual term of life. (dj Leucocytes from a normal ral)l)it added to the serum of a vaccinated rabbii cuergetically destroy streptococcus. Tlie leucocytes preserve their normal duration of life. (e) Leucocytes from a vaccinated ratil)it added to its own serum act the same as above (d). (f)- Leucocytes from a vaccinated ra'oltit added to the serum of a normal rabl)it act as above (c). (g) If a dose of streptococcus, let^hal for a normal rabbit, is injected into the pleura of a vaccinated ralibit. the serum prevents the development of a pleurisy. (h) If a dose of streptoioccus capable of producing erysipelas in a normal rabbit is injected under the skin of a vaccinated ralibit the infection is prevented especially by leucocytes. 3. Ann. de I'lnstitat I'asteiir. ISIIT. p. liol. note. 4. "Antipneumokokken Serum und der Mechanismus der Ininuinitiit des Kanincbcn gegen den Tneumokokkus." ysclu'. f. Ilyg.. 1897. toI. xxv. j). 41:;. 183478 r^ o^ due to any special activity of ilic leucocytes. Ja 100'^ Leishnian'' devised a luetliod of ([Uantitativeiy estimating the j)lia. "Motlind of lOslimatins I'liagocytip Powit," nri(. Med. .loin-.. T.kpl', p, 7.'!. t>. I'roc. of IJoyal Soc, vol. l.xxii, p. ^o~ . 7. Tl»<' foUowinfr pxperimfiils were rpsponsihic for llich- conclusions : (ii) Staph.vlfn'occiis •'Uiulsioii • washed corpuscles + .\a("l solulioii ai :!7 C. I'd- 1.") minutes = no phagocylosis. Add scrum; phagocytosis occurs. (b) 'riu-pp vols, washed coi-pii.scles + :> vols, serum al :!7 t '. fni- 1.", uiiiuilcs. ilicu heated to (>() (". (dest.-oyiiiR the thermolahiie opsonin i, Cool | 1 vi.l. emulsion staphylococci at ;'.7 (". for 1."» minnlcs. result is little or no phajiocylosis. (c) Three vols, serum -|- 1 vol. emulsion slajihylococci at :>7 (". for 1 .1 minutes, then heated to »;() C. + a vols, (orpuscles at :'.7 (". for 1.'. minutes, result is marked phaKocytosis. IIenct>. action of serum is mainly to modify the bacteria in such a way as to render them a pr<-y to the iihauocyiosis. The organisms which are ilius acted on are staphylococci, si rcptoco.-ri. yonococcus pneumococciis, MU-iiivih-ciih tiicUttimis. vibrio of Asiatic cholera, and colon, pest! typhoid, tubercle, anthrax, lu-oteu.s and dysentery bacilli. M. Xeitfeld and Itimpau ; "fel)er die Antil I" minutes 1 l.ij liii minutes ]4 - L'.'i miiinles ].-,■> 4."> minuics I H 4 1 liDur I's .■> - lioiii's Too ninn.v Ik (■cnnl For slight (lillcreiices in time, liowcvci-. tlie error is fortunately a >iiiall one. For the sake of accuracy the capillary i)ii)ettes should be approximately of the same caliber. 1;'.. A scale of opalescence hy wliicli to .iudme of tlie thickness of the liaiterial sus- pension can be made by having a series of liiljes of barium sulphate of (iitleieiit con- centrations. (McFarland.) The '•leupoc-ytic frcnin" of tlio wasliod forpusclcs sliould bo used fn-sli, a> ot'iu'v- wisp the leiieoeytcs stitk tofrothor. and it should he as tliick as possible in order to make good smears. SMKARS AXU COL'XTING. Smears are made best by iising a slide with eorner broken off and the end made rough with a file. They should be fairly thick and are more easily made by pushing the slide.§ In counting, the edges of the smear are selected as most of the leucocytes col- lect there and at the end, and it is better to take isolated leucocytes or at most groups of two or three, as the counts for these are more uniform than when large masses of leucocj-tes are enumerated. ^Ye have found it necessary to count a larger number of leucocytes than did Wright and Douglas in order to get a fair average, consequently we have usually counted 100 leucocytes in working with the tubercle bacillus, and 50 to 60 when using the cocci and colon bacillus. The time that it takes to complete a set of observations depends largely on the worker, but after the bloods are collected and the tubes opened, one should in an afternoon be able to make all preparations and make slides of fifteen test sera, using each to two different bacteria. The enumeration takes time and depends very much on the quality of the smears. With practice one can count on an average about five slides an hour, sometimes more, but often less. To make an index of two or three sera to a single germ should not take more than two hours ( two workers ) . XATURE OF OrSOXIXS. Eehition io Amboceptors. — Savtclienko" and Dean^-'' regard certain opsonins and amboceptors as identical. Hektoen^" regards opsonins as distinct from amboceptors, and in proof of his opinion states that nnder certain circumstances normal serum may possess lytic, but not opsonic powers, and vice versa; again, that immunization may give rise to opsonic, but not to lytic substances ; and, further, that heat may destroy tlie opsonic power without affecting the lytic amboceptors and vice versa. Tbus. while opsonin for anthrax bacilli, present in the serum of normal dogs, is destroyed by heating at G0° C. for thirty minutes, the amboceptor for anthrax bacilli, present in the serum of normal dogs, is not affected by heating at 65° C. for thirty minutes. Moreover, while the serum of \vhite rats is normally anthracidal owing to the presence of a thermo- stabile substance that is inactivated l)y neutralization of the serum with oxalic acid, the same senmi contains a thermostabile opsonin for anthrax bacilli, which, however, is not inactivated by oxalic acid. Relation of Opsonins to To.rins and Complements. — Walker's^' ex- periments with diphtheria bacilli and tubercle bacilli showed that toxins as well as opsonins produce an effect on phagocytosis, but that thev act §Wright rubs the slides with a very fine emery paper obtained at a jewlei's and uses a smooth smearer. 14. Ann. de I'lnstitut Pasteur. 1902. xvi, p. 107. 15. Proc. Royal Soc, 1905. Ixxvi, p. 506. 16. The .Tot-kxal A. M. A.. May 12. 1906. p. 1411. 17. "The Relative Influence of Blood Fluids and Bacterial Toxins on Phagocytosis," .Tour. Med. Research. Xov.. 1905, p. 173. intlepenclontly of one auotlior. Opsonins may be considered analogous to toxins and complements in so far as they have two distinct groups, Jiaptophore and opsoniforc. Like complements, opsonins may be neu- tralized or bound by various salt solutions, Ca, Ba, MgCL, K^SO^, XaHCOa, etc., and so prevented from acting on bacteria. Relation of Opsonins to " Stimulins." — In his treatise on "Immun- ity/' Metchnikoff described a series of experiments conducted by himself, Gengou, Klemperer, Besredka, and others, in which the introduction of serum, sometimes normal, sometimes immune, into the serum sacs of experimental animals demonstrated a greatly enhanced phagocytic ac- tivity in the leucocytes of the exudation subsequently removed from the sac for examination. To the substance which these observers conceived to l)e present in such sera they gave the name "stimulin," and to the presence of these "stimulins" in immune sera Metchnikoff and his school attril)uted an important role in the processes of both active and passive immunization. Wright and Douglas" endeavored to determine whether unhealed serum contained "stimulins" in addition to opsonins. They found the same difference between the action of heated and unheated serum toward staphylococci heated to 115° C. as toward living germs. Their expecta- tions were based on the fact that typhoid bacilli heated above 70° C. acquire a resistance to bacteriolytic eifect. Although their experiments witli particles of India ink and carmine wore unsatisfactory, unheated serum seemed to facilitate their phagocytosis slightly more effectually than heated serum. Staphylococci and unheated serum were digested in an incubator for varying times and then divided into two portions. The first was immediately mixed with corpuscles, the second was first heated to 60° C. and then mixed. In every case the phagocytic power was greater when the heating was omitted and no difference could be detected in specimens left in the incubator fifteen minutes from those left one hour; thus they were obliged to leave the question unsolved. In 190.5 Leishman^** showed that sera derived fi'om cases of Malta fever or enteric fever, or from animals immunized with living cultures of the germs of these diseases, contain substances which when added to normal human blood are capable of increasing the phagocytic activity of the leucocytes of that blood. He also showed that these substance? were specific and thermostabile, withstanding a temperature of 60° C. for fif- teen minutes. No evidence of the presence of these substances could be found in the sera of nomial men or animals. He also showed that these substances were not identical with agglutinins, that llioy acted directly on the leucocytes and not on the bacilli. ^Vri'tchuikofl' suggested IS. "Some Experinn'iits in ConnofUon wilh Stimiilii)s," Trans. I'atli. Snc. Kondon. 1005, Ivi, p. .344. the naiiii' '•opsonic' sensitizers" for these siihstances. W'l'i^dit sii,2:fjeste(] tliat they niiiiht he tliermostahile opsonins in spite of the fact that opsonins act only on the hacteria, while these substances, if the work and statement of Leishnian are to be accepted as correct, act on the leucocytes. Effect on Opsonins of Various Conditions and Agencies. — 1. Stand- ing: The opsonic power of serum kept at 2° C. is practically unchanged in ten days, but it is destroyed in three days if the serum be kept at 37° C. Without referring to the temperature, "Wright and Douglas say, "Opsonic power of blood disappears gradually on standing. In five or six days it is only about one-half as much as the original." 2. SiinligJtt: Exposure to l)right sunlight for three hours reduces opsonic value about one-third. 3. Heat: The opsonic power of any serum is but little impaired l)y heat below 50° C. but that of normal serum is rapidly destroyed at tem- perature of 60° C. or above. ISTormal human serum contains an opsonin for typhoid bacilli that resists heating aljovo 60° C, and there is an opsonin for anthrax bacilli in the serum of white rats that resists heating to 70° C. Dean^' believes that some of the opsonin is unaltered even by heating to 60° C, because on exposing bacteria to heated serum for a longer period than fifteen minutes some phagocytosis occurred. Immune opsonins are more resistant than the nonnal. Leishman^-'' and his co-workers showed that the serum of persons vaccinated against typhoid fever contained sufficient opsonins to promote some degree of phagocytosis after heating to 56° C. Hektoen^'' mentions that he has several times noted a typho-opsonin in the serum of convalescents from typhoid wdiich resists heating to 70° C. for thirty minutes. Immune hem-opsonins are also thermostal)ile. Dilution : The opsonic power of serum is diminished in proportion to the dilution. Simon-'' has utilized this j^rinciple in estimating the opsonic content of serum. 5. Chemicals and Drugs: Hektoen and Euediger-'^ showed that the opsonic action of serum may be diminished or inhibited by solutions iso- tonic with the serum of CaCL, BaCL, SrCl., MgCL., K^SO^, XaHCO,, KagHjCgOT, jSTaoCoO^, K^re(CX)g, formalin, lactic acid and chloro- form. They suggest that certain so-called negatively chemotactic sul)- stances, of which lactic acid is a good example, owe their effect to neutralization or destruction of the opsonin. The diminution of resist- ance produced by lactic acid to various infections and ascribed to its direct repulsion of phagocytes is, therefore, perhaps dependent primarily 19. Jour, of Hyg.. lOO."., v. 380. 20. Johns Hopkins Hosp. Rep., Jan.. 1000. 21. "Studies in Pliagooytosis," Jour. Infent. Dis.. 1005. vol. ii. pp. ]-J'.t. 141. on tlu' anti-opsonif action of tlic acid. 'I'lic addition of potassium iodid in small amounts of serum does not intei-rere with its opsonic power." Tlic administration of potassium iodid has no influence on the opsonic index. The iodid eruption is not associated with a low opsonic index. Owing to the fact that nuclein has a bactericidal action and may cause leucocytosis when introduced into the blood stream, the idea occurred to Huggard and Morland,-^ in 1905, to determine whether thesa manifestations were also accompanied by any change in the opsonic index after the employment of nuclein or yeast. After a single dose of 3 gm. of yeast the opsonic index dropped for two davs and then rose some distance above the normal. As has been noted, this rise in opsonic index occurred at the time when the leucocy- tosis was diminishing and below normal. Huggard and Morland also made the observation that some of the lowest opsonic indices in cases of tuberculosis under their observation occurred in heavy smokers. 6. Daboia Venom: The opsonic index is diminished on digestion of serum with daboia venom. "^ RELATION^ OP OPSOXIXS TO LEUCOCYTOSIS. From the fact that leucocytosis is of almost universal occurrence in the course of infections, it might be thought that some relationship existed between the quantity and equality of the leucocytosis and tb.e opsonic content of the serum. In their research on the therapeutic effect of the administration oi' yeast in tuberculosis, Huggard and Morland-^ found that, after a pre- liminary rise, the number of leucocytes remained constantly below nor- mal. As the opsonic index in these cases was at first low and later high, it was apparent that there was no direct relationship here between leucocytosis and opsonic index. The same results were obtained by Bulloch and Ledingham.-* They employed tallianin and sodium cinna- mylicum, both of which increased the number of leucocytes without increasing the opsonic index, thereby showing also the lack of relation- ship between the two. SOURCE OF OPSONINS. Up to the present time very little has been determined concerning the source of tlie opsonins, but Denys and Leclef, AVright and Douglas, and Xeufeld and IJiiiipau have all shown that the opsonin exists in the blood serum and not in the leucocvtes. '2'1. Western : "Influence of Potassium Iodid on Kesistanoe of RIood Fluids to Staiihylococeus Albus," Brit. .Tour, of Dermatology. irtO.">, August. '_'."?. "Action of Yeast in Tuberculosis and Its Influence on the Opsonic Index," Lancet, June :i, UKt.". p. 141>:?. 24. "Treatment of Tuberculosis by Tuberculin," Lancet, Dec. 21, 1005, p. 1C03. Tlic lack of any relation between opsonins and leucocytosis might be regarded as some evidence against Metcbnikoff's belief that the leucocytes themselves furnish opsonin to the senmi. RELATIONT OF VIKULEXCE OF J5ACTERTA TO OPSOXIXS. Denys and Leclef-^ (1905), Ilektoen and l^uediger-* (1005) and Hektoen and Horton^" (1906) have confirmed Metchnikoft's funda- mental conception that the increase of virulence of a certain organism goes hand in hand with its resistance to phagocytosis. They worked with streptococci, staphylococci, pneumococci and anthrax bacilli. Hektoen^" shows the effects of different degrees of virulence in the following way : Virulent organisms, freed from anti-opsonic substances by washing, on being heated at 65° C. for thirty minutes, are not opsoni- fied when treated with nonnal serum. Similar treatment of the avirulent strains has no effect on their phagocytability. Virulent streptococci which are not rendered phagocytable for rabbit and guinea-pig leucocytes bv normal serum (rabbit, guinea-pig, human) are taken up to some extent by human leucocytes after treatment with human serum. It is also kno^\^l that virulent cocci are subjected to phagocytosis under the influence of immune serum, and, further, that immunization of animals with virulent cocci increases the opsonin in the serum. From their work, consequently, it may be concluded that the insusceptibility of virulent cocci to phagocytosis probably does not depend on any lack of affinity for the opsonin, but rather it would seem on increased resistance to its peculiar action. Avirulent bacteria also probably differ from the non- virulent in producing substances which are harmful to the phagocytes. Helctoen suggests that the relative susceptibility of various bacteria to phagocytosis under the influence of normal serum may be quite an accurate index, of which practical use might be made, of virulence. SPECIFICITY OF OPSOXIXS. The results obtained by AVright and Douglas and by Bulloch'-" indi- cate the specificity of the opsonins, but to us the question seems as yet unsettled. Wright and Douglas" assume that a high degree of specificity exists, though their experiments, in which there was a decrease in the staphylococcic-opsonic index of serum to which typhoid Ijacilli had been added, would suggest that different bacterial opsonins possessed part of their power in common. Bulloch-" bases his conclusions on the follow- ing experiments: Serum after being digested at 37° C. with staphylococci was freed from the bacteria by centrifugalization, when it was found that the supernatant, clear serum had lost all opsonic power for staphylococci, 25. Cent. f. Bakt.. 1898. vol. xxiv. p. GSo. •2G. Lancet, Dec. 2, 190.">, p. 1603. 10 but '"■largely retained" the opsonins for tiilxTcle l)acilli: and, conversely, serum digested at 37° C. with tuhercle bacilli and cleared by centrifu- galization lost its tuberculo-opsonic power, hut retained that for staphy- lococci. Simon, using his dihition method for estimating phagocytosis, has repeated these experiments a number of times, and in every case the opsonic power for staphylococci and for colon bacilli declined in about the same ratio. Our experiments also give opposite results from those of Bulloch, Xormal "pooled" serum from four healthy men was used in our test. Tliis was divided into three parts and placed in tuVjes. In one tul)e stapliylococci were thoroughly mixed with the serum, in another colon bacilli were mixed with the serum, and the third tul)e was used unal- tered as a control. These were placed in the incubator at 37.. 5 C. for forty-five minutes, and at the end of that time were subjected to cen- trifugalization at high speed for thirty to forty minutes. The serum digested with stajihylococci showed an opsonic index (the control tube being taken as 1.0) against staiihylococci of 0.55, against colon, 0.12. The serum digested with colon l^acilli gave an index against stapliylococci of 0.26, but against colon of lA. The high figures for the staphylococcic-opsonic index of the serum digested with staphylococci (0.55) and for the colon-ojjsonic index of serum digested with colon bacilli (1.4) are without doubt due to the fact that the bacteria were not thrown down completely by centrifugaliza- tion; but the results are given, as they show that staphylococci take from serum not only the opsonin for staphylococci. InU also that for colon, and vice versa. XOX-BACTEKIAL OPSONIXS. Opsonins for other cells than bacteria have been described. Hektoen^'"' found opsonins for blastomycetes and probably trypanosomes. Barrat'-' and Hektoen have observed the presence of hem-opsonins in the sera of normal animals. We, working with human sera, have observed it twice in the serum of colored people with tuberculous lesions. It is now well known that there are different kinds of substances inimical to bacteria and their products in blood serum, e. g., antitoxins, agglutinins, precipitins, lysins, and opsonins. Antitoxins neutralize the l^oisonous effects of certain bacterial toxins, the best known being those of diphtheria, tetanus, and l)otulismus. When, however, we investigate the blood fluids of animals inoculated with vaccines and bacterial prod- ucts other than those mentioned, it is found impossible to demonsti'ate the existence of antitoxins, or, at any rate, the quantity of antitoxin is so slight that it eludes demonstration. On studying the experimental 27. Proc. Royal Soc, H)().'>, vol. lx.\v. p. r>L'4. 11 typhoid and cliolera infections, rfeiffer sliowed that the protective prop- erties of the imnuine sera in these diseases are due to the presence of lysins. Experiments made in succeeding years have shown, however, tliat this doctrine of lysis is not of universal application. The study of immunity against microbes, like pneumococcus, staphylococcus, strepto- coccus, gonococcus and tu])erclo bacillus, has led to the greatest diversity of opinion; some claiming antitoxic properties, others lytic, and others phagocytic properties for the different sera. INFLUENCE OF VARIOUS IXFECTIOXS ON OPSONINS. In view of these facts, it is of interest to determine what infections influence the opsonin formation in the l)ody as well as the effect of vac- cines and antitoxins on opsonins. The tuberculo-opsonic index in healthy individuals has been esti- mated by Bullocli-^ in a series of thirty-four medical students and thirty- two nurses. The average for the sixty-six cases was 0.95 with a maxi- mum of 1.20 and a minimum of 0.80. In twenty individuals Urwick'-^ obtained an average of 1.006. We have made eighty-one observations on nineteen supposedly normal per- sons and have obtained an average opsonic index of 0.988 with a maxi- mum of 1.25 and a minimum of 0.73."'' IJrwick-'' also proved that the tuberculo-opsonic index in healthy people does not vary except within narrow limits from day to day. Our series of nineteen normals estimated during the past three months shows the following variations in four persons: 0.84 to 1.18, 0.81 to 1.10, 0.88 to 1.10, and 0.92 to 1.06. Wright and Douglas' nor- mals varied between 0.85 and 1.2. The tuberculo-opsonic index in different varieties of tuberculosis has been studied by a number of observers. Bulloclr^ examined 150 cases of lupus from the mildest type to the most chronic and intractable and obtained an average index of 0.75, the figures being as follows : Opsonic index Between No. of Cases. Percentage. 0.2 and 0.3 3 2 0.3 and 0.4 3 2 0.4 and 0..5 21 14 0.5 and O.G 29 19.0 0.6 and 0.7 33 22 0.7 and 0.8 22 14.8 0.8 and 0.9 18 12 0.9 and 1.0 7 4.6 1.0 and 1.4 14 9.3 Urwick examined fifty-four cases of tuberculosis, including a number of cases of phthisis in various stages. In many of them, especially of 28. "Opsonic Content in Lupus," Trans. Tath. Soc, London, 1905, vol. xvi, p. 334. 29. Brit. Med. .Tour., 1905, July 22. 30. For the material used throughout our work we wish to express our thanks to the staffs of the New York. St. Luke's, Roosevelt, City, French, Ruptured and Crip- pled, and Hudson Street Hospitals, and to Dr. Linsly R. Williams. 13 plitliisis, the index was al)Ovo normal, witli variations from 0.3 to 2.6. In thirtv-three cases of phthisis twenty-five showed an index al)ove 1.0, seven hehnv 1.0, and one was at 1.0. "Wriiilif and Douglas^^ examined sixteen eases of tuberculosis, includ- ing tuberculosis of skin and subcutaneous tissues, tuberculous laryngitis, cystitis, peritonitis, prostatitis, and tuberculous glands. The indices ranged from 0.-4 to 0.9. We have made observations on thirty-nine cases of tuberculosis as follows: Tuberculosis of bones, including spine, hip, knee, ankle, tarsus and tibia, in all 22; above 1.0 in five cases, below 1.0 in fourteen, and normal in three. Fourteen cases of pulmonary phthisis varying from O.-Ll to 1.37; "above 1.0 in one case, below^ in eleven, and normal in two; and isolated cases of lupus and tuberculous glands ranging from 0.96 to 1.5 J. We have estimated the tuberculo-opsonic index in a series of patients with various infectious diseases. Table 1 shows our results.^- TABLE 1. -Tuberculo-Opsuxic Index ix sion of p.acilli generally Various Infectious Diseases. IN 1.6 Per Cent. NaCl. Emul- Diagnosis. Index. hip and .spine 1.14 spine 0.7:-! spine 0.92 spine 1.01 spine and empyema 0.80, 0.8U Tb. empyema and peritoneum. . . . 1.02. 1.02 knee 0.78 hip 0.46 hip, with temp l.Od hip with temp 1.17 hip. with temp 1.13 hip with temp n.Sd hip 1..59 hip. apvresia o.7."> hip 0.86 hip 0.8.-. anlile O.oO anlile 0.7.'), etc. anlile O.'.to, etc. anl tb n..-.i) tb 0.9:! Tb Tb Tb Tb Til Tb. Tb. Tb. Tb. Tb. Tb. Tb. Tb. Tb. Tb. Tb. Tl). Tb. Tb Pulmonary Pulmonary Pulmonary Pulmonary I'ulnionary Pulmonary Pulmonai-y Pulmonary tb. tb. tb. tb. lb. tb. 0. .-)(!. 0.2.-. (1.41 (1.87 0.91 o.ss 0.89 Diagnosis. I'ulnionary tb Pulmonarv tb Tb. larsus Tb. ghinds. jaundice Intrathoracic growth tb. glands.. Sycosis and debility. F. II. of tb. As. tb. pneumonia Ac. tb. pneumonia Pneumonia I'lieumonia Pneumonia I'neumonia 120, ]'(]stpniMini. 1.00 5. Tb. hip and sinus 1 ..-.9* 1 .00 «. Tb. knee, apvre.xia 0.78 0.80 7. Tb. anlcle . ." 0.89 0.76 8. Tb. ankle 1.12 1.20* 9. Tb. pulmonaiv 0.91 .... 10. Tb. pulmonary . 87 . 90 11. Tb. glands, jaundice 0.96 .... 12. Tb. glands, of mediastiiuim 1 ..->0* 0.90 13. I'leurisy tb. V (chest fluid) 0.78 (blood serum ) . 89 .... 14. Syphilis (secondary) 1 .02 0.83 15. (ion. arthritis 1 . 09 1 .20* 16. Typhoid 1.01 0.77 17. Typhoid . 68* 1 . l.'j 18. Typhoid . 68* 1.07 19. Pneumonia 0.92 .... 20. Pneumonia 1 . 20* . .-)4» 21. I'neumonia 1 . (II . 94 22. l^neumonia ] .10 .... 23. Abscess of liyer 1 . 06 . 93 24. Abscess of liyer 1.10 0.61* 25. Empyema . 75* .... 26. Empyema, post-pneumonic . 86 .... 27. Icterus catarrhalis n . 98 .... 28. Appendicitis, post-op 1 . 04 1 . 09 .... 1 . 00 29. (^hronic gon. arthritis 0.67* .... 30. (^'hronic gon. arthritis 1.15 .... 31. Tb. meningitis . 90 .... 32. I'ulmonary tb . 67* 33. Empyema of gall-bladder 1.02 34. Normal o . 98 1 . ctiis. Case 24 is the most 0.88 1 .10 0.91 1 .(16 . 94 1 . 06 1 . 50* 0.17* 1 .17 . 83 1 . ( 12 0.74* 0.89 0.81 1.43 1.10 0.88 1 . 03 1 .04 . 92 . 9,S 1.01* 15 rcmarkal)le case in the series. This patient liad an enormous al)sces3 of tlie liver which had heen operated on about a weelc l)efore these figures were obtained. Cases 23 and o'.] wouhl al^^o indicate a certain specificity of tlie opsonins. Staphylococcus. — Wriglit reported twenty cases of localized sta])liy- lococcic infection, viz., furuncles, acne, sycosis, etc., witli indices varying from 0.1 to 0.88, with an average for the twenty of 0.62. In twenty-five cases with uncomplicated localized staphylococcic lesions, Bullocli reports that the index was "below normal constantly." A\'e have been unable to find a list of indices of normal individuals to staphylococci. AVe have estimated the indices of ten normal persons to staphylococcus and found them to range between 0.82 and 1.20, the average for nineteen determi- nations being 0.98.^^ Three cases were examined at intervals during several months and showed variations in one case between 0.84 and 1.20, in another between 0.85 and 1.10, and in a third betw^een 0.90 and 1.02. Pneumococcus. — While Dr. Eosenow affirms that during the course of pneumonia up to and shortly after the crisis there is probably no increase in the pneumococcic-opsonic index, MacdonakP* has found that at the commencement of the infection, while the temperature is in the ascend- ant, and during the fastigium, the opsonic index is below normal. With the onset of crisis, there is a striking rise in the opsonic content, the index rising critically as high as 1 .6. Typhoid. — In convalescent typhoid fever patients a well-marked increase in the opsonin for typhoid bacilli has been noted, the index in some cases reaching as high as 4.0. Streptococcus. — Euediger^" has noted an increase in the strei^tococcic- opsonic index of erysipelas serum. Tables 4, 5, 6 and 7 show the effect of various infections on the opsonic index to staphylococcus, colon bacillus, gonococcus and pneumo- coccus, the first cases in the tables being caused by the specific organism employed. TABLE 4» — Opsonic Indices to Stai'hylococcus PyooEXES Aureus. 1. Abscess of liver 0.9.3 17. Typhoid fever 1.1.'> 2. Abscess of liver 0.61 18. Typhoid fever I.OT .S. Appendicitis post-oper 1.09 19. Cirrhosis, Folin's diet n.4.. 4. Acne 0.7.5, 1.2 20. Gonorrheal arthritis ... 1.20, 1.01 5. Furuncle 0.86 21. Tubercular arthritis 0.90 6. Dermatitis vegetans 0.82 22. Tubercular hip and spine 0.72 7. Acne 0.94 23. Tubercular hip and spine .... 0.66 8. Empyema 0.95 24. Tubercular hip and spine .... 0.78 9. Empyema of gall-bladder 1.02 •2'>. Tubercular hip with temp, ab- 10. Pleurisy, serofibrinous 0.93 scess 1.00 11. Meningitis cerebrospinal 1.01 2(>. Tubercular hip with sinus.... 1.00 12. Meningitis cerebrospinal 1.02 27. Tubercular knee 0.80 13. Meningitis cerebrospinal 0.84 28. Tubercular auUle 0.7tf 14. Pneumonia 112 29. Tubercular ankle 1.20 15. Pneumonia 1.09 .•?(). Pulmonary tuberculosis 0.90 16. Typhoid fever 0.77 ."1. I'neumonia 0.9S 3.S. The average count for at least three normal sera which have shown very slight variations was taken as 1.00. 34. Practitioner, November. 1905. 16 or those diseases in which the staphylococcic-opsonic indices were below normal, two were caused by staphylococcus infections and three occurred in other conditions. Of those in which the indices were above normal, one was caused by staphylococcus infection and two occurred in other conditions (Table 4). In the twelve normal cases in which the colon-opsonic index was ob- tained, the range extended from 0.81 to 1.19. These figures may, then, be used to define the normal limits of the colon-opsonic index in Table 5 of diseases due to the colon bacillus and other infections or diseased conditions. TABLE 5. — Ofsoxic Indices to Colon Bacillis. 1 Abscess of liver... 0.17. 0.10, 0.2(5 10. Tub. glands, jaundice 1. ■2. Abscess of liver 0.46 lio. Empyema 1.17 .S. Abscess of liver 1.50 21. Empyema 0.S3 4. Appendicitis (postop.) 0.7.'5 22. Osteomyelitis of femur O.i.j .'). Fecal fistula 0.32 23. Diabetes 0.6.J 0. Peritonitis (postop.) l.OO 24. Normal 1.10 7. (Jallstones 1-1 25. Normal 0.88 8. (iallstones with jaundice .... l.O.^ 26. Normal 0.81 0. (Jallstones 1-08 27. Normal l.lo 10. Empyema of gallbladder . . . . 1.43 28. Normal 1 no 11. pyonephrosis 1-49 20. Normal l.oo 12. CVstitis and paralysis agitans. 1.10 30. Normal l.oo 13. Icterus catarrhalis 102 31. Normal 0.9 14. Typhoid fever 0.94 32. Normal 0.82 15. Typhoid fever 1 .06 33. Normal 1.18 16. Abscess of spleen 0.73 34. Normal 1.19 17. Empyema (postpneu.) 0.83 35. Normal 1.02 18. I'ulnionary tuberculosis 1.06 Among the colon infections (Cases 1 to 13, Table 5) the index is below the normal in four conditions in which the liver, vemiiform appendix and intestine were involved, and above normal in three conditions in which the liver, kidney and gall bladder were the organs involved. Six of the thirteen cases were normal. Of the diseases due to other causes than colon infections the index is below the normal in three cases, one case of diabetes and two inflammatory conditions; but in none is the index above normal. In the four normal cases in which the gonococcic-opsonic index was obtained, the range extended from 0,9 to 1,09, These figures may, then, be u.sed to define the normal limits of the gonococcic-opsonic index in Table G. Six of these cases have indices below the normal, though but one has an index below 0.75 and three have indices above 1,09, TABLE C. Ol'.SOMC I.NUICKS to OoNOCOCCfS. Gonorrheal epididymitis, subacute 0.62 Gonorrheal epididymitis, subacute 0.77 Gonorrheal epididymitis, svibacute 0.99 Gonorrheal epiilidymitis, subacute 0.87 Gonorrheal epididymitis, subacute 0.88 Gonorrheal epididymitis, subacute 1-01 Gonorrheal urethritis, subacute, 5 days 0.97 Gonorrheal urethritis, 7 days '••95 Gonorrheal urethritis, 2 months 0.9(1 Gonorrheal urethril is. 4 months 0.77 Gonorrheal urethritis, 4 months l-0."> Gonori-heal urethritis, ('» weeks 0.83 Gonorrheal ui'ethritis, 8 months 1.23 Gonorrheal arthritis 1-23 Tubercular pleurisy 1-00 Normal 0.88 Normal 1-1 Normal 1-15 Normal 0-91 INFLUENCE OF ANTITOXINS ON OFSONINS. The varied influence of chemicals and drugs on opsonins has already been mentioned and helps to explain the different effects on opsonins and phagocytic action of toxins of which diphtheria and tuberculosis toxins may be taken as examples. E. L. Walker-'*' has shown that, while diphtheria bacilli are less susceptible to phagocytosis by human blood after destruction of the toxins by heating from 90° to 100° C, tubercle bacilli are more susceptible to phagocytosis after destruction of the tox- albumins by heating to from 80° to 100° C. Another interesting factor, and one which needs to be further devel- oped, is the influence of antitoxins on opsonins. Bradshaw and Glynn'' have recently reported nine cases of normal men who had received diph- theria antitoxin and whose indices to tubercle bacilli averaged only 0.73. In one the index was 0.47 after three months. Walker-'^ has shown that diphtheria antitoxin will apparently not neutralize these affinities of the toxin of the diphtheria bacillus which stimulate phagocytosis. Bordet, Aronson, v, Lingelsheim and others have noted the greatly increased phagocytosis of streptococci in the presence of antistreptococcus serum. At present the principal serum used for therapeutic purposes in infections in the healing of which phagocytic immunity may be regarded as an essential phenomenon, is antistreptococcus serum. Hektoen affirms that in tests' made a year ago by Dr. Euediger and himself the anti- streptococcus sera then in general use in this country were all shown to possess a lower opsonic index for various streptococci than normal horse serum, many samples being without any opsonic power, presumably on account of their age. Eesults of a similar nature were obtained by us with a specimen of antipneumococcus serum which was five days old, and also with an antigonococcus serum sixteen days old, which proved to have the most marked beneficial therapeutic efl^ect.'® It is difficult to 35. Liverpool Med. and Chir. Jour., May. 190G. 36. We desire to express our thanks to Dr. Torrey. Cornell University Medical Col- lege, for the antigonococcus sera employed and for numerous cultures. 18 sa}' wliether this was due to tlie age of the serum or to the fact that gonococci do not ext-ito the formation of opsonins in immune sera. Our results, indicating the effect of age on immune sera, are sliown in Table 8. TABLE 8. — Effect of Age on Immune Sei!a. Anti-pnpumoc. sei-um, rabbit : Indox. Scrum 5 days olO <•.<> Serum fresh 1 ■<> Auti-diphther. serum. Board of Health serum (old) 0.4* Anti-gonoc. serum, rfibbit : Hi days old 0.07* 30 days old 0.17* Goat 12 days old 0.00* ♦Normal human serum taken at 1.0. These results would tend to show the importance of using sera which may depend for their action on their opsonic content, while the}' are still veiy fresh. It is more than possible that in infections in which leucocy- tosis is marked, such as pneumonia, streptococcus and staphylococcus infections, the failure hitherto to ol^tain the desired results with the use of immune sera prepared by adaptation against these organisms may be explained by the rapid diminution of opsonins here shown. INFLUENCE OF VACCINES ON OPSONINS. The material which has been employed for therapeutic inoculations in other than tuberculous infections has consisted of a culture of the organ- ism causing the infection, grown in broth or on agar. In the latter case a suspension of the bacteria is made in normal salt solution. After ster- ilization by exposure to a temperature of from G5° to 75° C. for half an hour and the addition of 0.5 per cent, lysol, this material, which is known as the '"vaccine,"* is ready for inoculation. This suspension may be standardized by determining the number of bacteria per cubic centimeter ofiluid.3^ On the inoculation of any vaccine there is at first a period of dimin- ished resistance to the organism employed. This is shown by a decline in the antibacterial pow'er of the blood, the so-called "negative phase." Suc- ceeding this there is an inflowing of and consequent increase in the protective elements of the blood. This is the "positive phase," or the 2>eriod of increased resistance. Most of these protective elements rapidly disappear, but leave behind a more or less permanent increase over the original. Wright speaks of the whole sequence as the "law of the ebb and flow and reflow and subsequent maintained high tide of immunity." Figure 1, selected from an article by Wright,^^ illustrates this "law." This train of events succeeds inoculation of vaccine sufficient to cause a constitutional disturbance. When only a small dose of vaccine is given, the negative ])hase may be so insignificant and of such short duration as ♦Wright's nomienclature and explanation. '.',7. "Some New Procedures for the Kxaminatiou of the Blood," Lancet. .July lliOii. 19 not to 1)0 eapahle of measurement, and the p(jsitive phase will he corre- spondingly diminished. On the other hand, it.' the dose of vaccine is too large, the negative phase will l)e unduly prolonged, and a positive phase may not appear at all. The question of dose, then, is of the greatest importance, for, if too little is employed, no therapeutic effect will result. On the other hand, too large a dose is dangerous and so lowers the resist- ance of the host as to favor the multiplication of the hacteria. Such clangers with a single inoculation are, of course, greatly magnified by repeated inoculations. If a series of such inoculations are attempted dur- ing the negative phase there will result a further fall in the protective substances or a '•cumulation in the direction of the negative phase." Sooner or later a point will be reached when the organism will cease to respond to inoculation, and further doses of vaccine will not only do no (. n a <^ 10 u 11. V3 n \ 5 ifc n IS \<^ ioj. ix 7.1 ijf a-S i-t xo -Mr. 1.9 ! l.« J. \1 L \i . 2 1.5 r '•f- J L . 7 1.3 / \ \.% -S I " t I.I n- .. / - 5 ^ L 1.0 A ^ 7 A l\ .r" -^ f .« 1 V 51 •1 I 7 ^ u — . _j _J Case of a physician wlio had suffered from boils for four years (Proe. Roy. Soc, 1904-.5. vol. xxiv, p. 1.50). A. Inoculated with 2,000 millions sterilized staphylococci derived from patient. B. The same repeated. good, but may bring the content of the blood in protective substances to a lower level than that from which it originally started. AVright^® considers tliat the result of the vaccination can not be esti- mated from the character of the constitutional disturbance, and with some reason urges the daily determination of the opsonic index to measure the effect. He advises the smallest possible initial dose sufficient to produce an}^ negative phase and reinoculation only after the subsequent positive phase has begun to diminish. CLIXICAL APPLICATIOX OF IXOCULATIOX OF VACCIXES. Stapliylococcus Infections. — Wright has cited twenty cases of very obstinate staphylococcus infection, including sycosis, boils, acne, etc.. 38. "General Principles of Therapeutic Inoculation of Vaccines on Result of Tuberculous Infections."' Lancet. Dec. 2, 1005. p. 1000. 20 wliicli lie had treated by vaccination. Tliese cases were selected as being particularly intractable. Various medical and surgical measures had previously been tried without success. Some were apparently cured by the vaccination, all showed a marked improvement. He suggested the possible utility of vaccinating patients before operations, especially oper- ations on the nose and mouth, also of thus treating gleet, bronchitis, ozena, bacteriuria, etc. The following cases of staphylococcus infections have been treated by the author by the administration of staphylococcus vaccines : H. M, Furunculos^is. Recurring furunciilosis of the back of the neck : an active furuncular process at the time of first observation. Opsonic index then .75. A vaccine was made from the infecting organism — staphylococcus — and two inoculations were given, the first 300,000.000 sterile organisms, followed by an- other of 600,000.000 in five days. Opsonic index, 1.5. The fui'uncle disappeared and the patient was free from trouble for four months. Then another furuncle appeared. Opsonic index, .7. An inoculation of 300,000.000 sterile staphylococci was given. Index rose to 1.6 on the second day, was 1.4 on the third day, and on the fifth day had fallen to 1. Another inoculation of 600.000,000 was given, the index rising in two days to 1.3. The furuncle healed. No more furuncles ap- peared during the subsequent eight months. Boy in Roosevelt Hospital, aged 14. Pyemic multiple abscesses. For two weeks before onset of trouble he and his whole family had had an epidemic of pimples and sores on the skin. Five days before admission to the hospital ho struck his leg; the result was pain, swelling, temperature of 105. Incision gave only temporary relief. He became delirious. At the hospital the compact bone of the internal surface and anterior border of the tibia was removed from the whole shaft. The exposed bone was dark, soft and spongy, and cont^iined pus foci. Irrigation was ineffective, and at the end of four days the knee became inflamed and full of pus; the leg was amputated. Staphylococcus pyo- genes aureus was found in the blood at this time. A focus of pus over the malleolus was also opened and drained. Eleven days later a focus on the left arm was opened, and during the next week two more foci were opened. Then there occurred symptoms of abdominal inflammation, which were not operated upon. Several more foci opened during the next month. The fibula was then resected. Sutures broke down. Much discharge. On November 27. after four- teen weeks of illness, with patient's condition one of chronic multiple pyemic abscesses without tendency to heal, inoculations were begun with a vaccine made from his own staphylococcus. Condition of wounds at time inoculations were begun were as follows: Leg — sinus — eight inches long along fibula. Left arm — small amount of discharge. Right elbow — considerable discharge. Abscesses in hands. Opsonic index, November 27 — 0.5. Three hundred million sterile staphylococci injected. After these inoculations, the condition was as follows: Right leg— healed. Left arm— healed. Abscesses in hand— healed. General condition markedly improved. Two cases of staphylococcus pyemia secondary to a local cellulitis were seen and inoculated by the author, four and three days before death, respectively. Each received 400,000,000 sterile staphylococci. Both had Ijeen running for days a high pyemic temperature, both had countless subcutaneous abscesses with some pulmonary involvement, and neither sliowcd anv iK'udiciiil vihvi I'vom llio inooulntion. 31 Colon Bacillus Infections. — Wright and EcicF'^ reported two cases of cholecystitis with persistent sinuses after operation. Both were inocu- lated with sterilized cultures of coll communis, and as a result of the inoculation the opsonic index rose above normal, in one case to 4.0, and both soon showed marked improvement, with closure of the sinuses. Nov. 28 Opsonic index 1.3 Dec. 1 " "... 10 12 13 14 15 16 17 18 1!> 6 2.6 1.3 1.7 .7 2.0 1.0 .8 1.3 1.4 1.7 1.9 i.r. 1.8 300,000,000 S. 300,000,000 600,000,000 600,000,000 P. A. injected. Case M. II. The following case of infection by the Bacillus coli communis was treated by the author: M. R. — On night of admission to the Roosevelt Hospital, the patient had been caught between the shaft and elevator. The compression was greatest about the hips. She immediately became unconscious. When her senses returned she had great pain in her abdomen and legs and a feeling of numbness and helplessness. 8he was brought to the Roosevelt Hospital shortly after regaining consciousness. X-ray showed a fracture of the pelvis. The patient was admitted to the hospital December 25, with a temperature of 96.4. During the next week the temperature rose steadily. A pelvic abscess formed pointing at a point to the left of the labia niajora. The patient's condi- tion became critical. She was operated on January 4, abscess opened and a sinus was found communicating with a large abscess cavity. About four ounces 39. "Note on Two Cases of Cholecystitis Tr«»ated with Inoculation of Bacillus Coli," and "Note on the Phagocytosis of Red Blood Cells. Relationship of Tempera- ture to Opsonic Curve in Acute Anthrax Infection," Lancet, Jan. 20. 1906, p. 159. 22 of foul smelling pus were evacuated. A piece of bone also came out and the wound was drained. For one week the temperature ranged from 100 to 104 daily, leucocvte count 14,000, 10,000 and then 21.000. Pulse increased from IIG to 130. and" the patient's condition became so much worse as to be considered Month |4Ur*^^4^'^LA*«l-nJU -- - ?*1 ■' • - - - f\ A \ r* c- s. r*— r 1 ' r^ M — — — — - i ? i ' i /' ^. 1"^ O ■- -- -- • -- ip /i J. ... A \> -- tiz /^ i — — — — — 0: _\ I — — — — Case A. II. The following case oi- streptococcus infection of Dr. A. J. Bristow and Dr. W. H. Pratt was seen with Dr. X. B. Potter : A. H. Female, aged 58 years. Dr. A. J. Bristow and Dr. W. H. Pratt, Brooklyn. February 25, rigors, fever, general muscular pains, intense headache. March 1, well. March 4, repetition of previous attack with more severe headache. March 10, well. March 11, tenderness over left side of neck. Fever, temperature 100 to 103. March 17, moderately circumscribed swelling of left submaxillary triangle. No fluctuation. Leucocytes 15,000, polyiuiclears 78 per cent. March 18, swelling less painful, less tender. Leucocytes 12.000, polynuclears 78 per cent. March 20, swelling more diflFuse, more painful. ^larch 21. leucocytes 10,000, polynuclears 75 per cent. March 23, swelling had extended to clavicles, more tender. Leucocytes 11,000, polynuclears 83 per cent. A long incision parallel with anterior border of sternocleidomastoid, tissues much thickened and infil- trated. Deep in submaxillary fossa small abscess cavity opened, pus evacuated, drainage. Culture: Htrept. longns and a bacillus. March 24. edge of wounds glazed. Very little discharge. Urine normal. March 20, intermittent pulse. March 27, severe pain in left leg. Some tenderness over internal condyle. March 28. infiltration of neck slowly disappearing. March 30, two slight convulsions limited to face and upper extremities, eyes to right. Face livid. Blowing niur- 25 mur over mitral. Marcli 31, pain in ri- E s 1 i : •-»—.• . ^ Case T. OM. all pathological physical signs, and cough and pain had disajjpcarcd. and by December 1:5, the temperature had fallen to normal, to remain there. The gain in weight had been eight pounds, and the patienfs general condition was excel- lent. Cod liver oil with malt was given througliout. 29 T. O'M., aged 19 years. Clnonie Pulmonary Tuberculosis. For eiglit months before presentation for tieatment, jjutient had eough, indigestion, pain in left chest. Has lost twenty pounds. Has had mucopurulent expectoration, but no hemoptysis. Some dyspnea and fever. Two (piarts of clear fluid were withdrawn iiK%ti^l<^i^v \ 1 i 4 f » lir < f H Alt m.if *n /rif w^ u;tu Case T. O'M. from the left chest. There was slight dullness over the right apex and the whole left chest with subcrepitant rales over the same area. Before the begin- ning of treatment the temperature frequently rose to lOO.G. After the inocula- Month Day of Lg tfcti Uti^tot ri > 4 f fc 7 y n (f,[| a(S,iA>r/t,l7 103' 102' 101 100 99' 98 97 hM. Vft*" :s» wmmm i?=2 i^nttui^ ^iCI 5^=G52ZgSe V Case T. OM. tions of tuberculin (B.F.) were begun, Dec. IG, 1907, the temperature did not rise above 99, and after January 6, remained at normal or below. The cough diminished markedly, great improvement in the patient's general condition resulted, and by February 17 he had gained ten and one-half pounds. At this 30 lime tlio same ])ortions of the luiijis were still affected, but the rales had become drier and less iiunioroiis. Cod liver oil with malt was administered throiij^hout tlie treatment. A. S.. aged 33 years. Chronic Pulmonary Tuberculosis. For three years this \\oman had a cough; at the end of the first year had hemoptysis. Cough got steadily worse; fever developed, but no night sweats. Dyspnea developed gradu- ally, and shortly before presentation for treatment she felt pain in the right chest. For one year she has had diarihea. and during the past two years her weight has fallen from 130 to 1 11 pounds. Tubercle bacilli Avere found in the sputimi. A course of tuberculin inoculations (B.F. ) was begun on Xov. 26. 1907, and tlie dosage increased regularly, until on January 27 the dosage was 0.000,1 grams. Tlie temperature, which at first rose to 99 daily, remained below normal after •January 9. Tliere was a marked improvement in appetite and general appear- ance, and by Januaiy 27, she had gained ten pounds. The cough was much improved, but tubercle bacilli were still present in the sputum. At first there was slight dullness over the upper lobe of the right lung, with many subcrepitant rales, almost to the base. On January 27, the dullness had markedly diminished and the subcrepitant rales Avere confined to the right apex. Cod liver oil with u.alt was given throughout the treatment. Month Day of (^. "KfN-. _ t U K> TUr. iJiAsr.^ Case M. L. Mj. L., aged 48 years. Chionic Pulmonary Tuberculosis. For two years this man had a cough with pain in the chest, mucopurulent expectoration, loss of weight, weakness, slight fever — at times reaching to 100. Physical exami- nation showed slight dullness at tha right apex of the lung with many sub- crepitant rales at both apices. Tuberculin (B.F.) inoculations were begun Aug. 19. 1907, by the usual method, and were being continued ilarch 13, 1908. when the dosage had reached 0.001 grams. The temperature has gradually returned to normal, the cough has- ceased, and there has been a gain of ten pounds in weight with most marked improvement in the patient's general apix-arance and condition. The physical signs have become normal with tlu^ exception of an occasional dry click at one side. Cod liver oil with malt was administered tlnoughout the treatment. S. McL., aged 20 years. Cluonic Pulmonary Tuberculosis. Ten weeks before ol)servation on tliis patient commenced, she caught cold and developed a con- tinued cough with ])ain in the side, blood streaked sputum, which was afterward 31 found to contain tnberclp bacilli, fever, and great loss of weight. Well marked signs of dullness on percussion were found at the left apex with bronchial voici and numerous subcrepitant rales. She was confined to bed in St. Ijuke's Hospital for three weeks, witli much improvement, and on Dec. 2, 1007, received the first Month bay of I u. _^ h^ 103' 102' 101' 100 99" 98 97' mm a=:te iiiiliii f? i 5r' ?5? >a •^^r Case S. McL. of a series of tuberculin (B.F. ) inoculations, given by the usual clinic \ d / -\ / / A V, / / \ /\ r — ' — ' / \ \ / % / \ \ / / / ^ / i ^ / V : 1 J I y i ;i :; ^ t e . fy J _ ^ _ J _J _ L _ -A J M. J,, aged 35. Tuberculosis of hip joint treated with small doses of T.U. Result : marked improTement. ^ "^ ~^ -1 n ~ ~ " ... ft\ 1 rr rA ^ rr \ n 11 11 « 1.4 M > 3 ^ T 1 11 13 KT n •1 LI M 15 »n »» 31 » H t « ■9 n If 16 I1» to u Vi n IS ^9 ?^ f b , / S, IT- f / s ■ • , / \ ,j s, *■ / \ t. / \ / V 1 \ \1 ■5 / •vj A V| -^ \ \ -r ^ ^ / / -' s ^ ' \. / ^ / ■ ' ^ s / J > r 1 1 4 -\ H \ ^ H A ^ V J jrt ■A a} 3 ^ d 33 1 s. f r^ IT- ! i „ • j if J \ i _ L_ Case of tuberculous ankle. NO improvement clinicn lly. Several low indices occur in this series. In a nnniber of picked cases of "sanitarium cures" of phthisis in its early stages Bulloch constantly found low indices. Here, again, it would be important to know Avhether such cases relapsed, as so frequently happens. Bulloch believes the low index probably due to some hereditary or acquired imperfection in the 34 mechanism by whicli antibacterial substances are mamvfactiired. In this connection it is interesting to note that Simon has recently found the opsonic content of serum to be diminished in some cases by starvation. PRACTICAL VALUE OF OPSONIC IXDEX. In reviewing tlie work wliieh lias already iK'on accomplished on opsonins-*^ the question of wliat practical use they may have is one of greatest interest. Tlie great difficulty will arise from the fact, probably, that changes more or less profound are indicated at times only by slight variations of the indices, and that the variation is frequently not far beyond the limits of error in a method where opportunities for small errors in technic are numerous. Some aid in diagnosis may be had by determination of single indices; but before this can be considered a reliable method considerable work must be done to determine the degree of specificity of opsonins. AVright and Eeid's work indicates that some diagnostic aid may be obtained by comparison of serum and exudates, and by the methods of heated and unheated serum. A wider field of application will probably be in the control of inocu- lation of vaccines to determine the optimum dosage and regulation of frequency of the same, but this will be somewhat limited by the clinical difficulties of the method. A field as yet but little explored, in which it may prove of great use, is in the determination of susceptibility to infection, especially in the inherited susceptibility to tuberculosis. Perhaps its greatest usefulness will be found in the laboratory, wdiere it may prove to be a convenient and rapid method of testing the virulence of organisms and the strength of sera which are dependent on opsonins for their beneficial effects. 48. For additional literatm-e the reader is referred to: Wright: •"Treatment of Fnrunculosis. etc.. by Inoculation of Staphylococcus Vaccine." Lancet. March 2U. 1002; also "Treatment of Acne Furunculosis,"' Brit. Med. Jour., May 7. 1004; "Inocu- lation Treatment of Tuberculosis," Clinical .Journal, May 7. 1904 ; "Inoculation Treatment of Tuberculosis," Clinical Journal. Nov. 0, 1904 : "The Serum Reactions vol. Ixsvii, p. 104 ; "Therapeutic Inoculation of Bacterial Vaccines," Brit. Med. Jour., May 9, 190;^ : "Certain New Methods of Blood Examination with Some Indica- tions of Their Clinical Importance," Lancet, Jan. 23, 1904, p. 215 ; "A Short Treatise on Antityphoid Inoculation," London, 1004; "Measurements of liacterial Power of Blood." I'roc. Koyal Soc, 1002, August, vol. Ixxi, p. 54 ; "I*i-ocedures for Testing and Judging by Naked Eye of Agglutinating and Bacteriolytic Effects Exerted by Sera (Spontaneous Agglutination)," Lancet, 1003. July 25. p. 214; Lancet. 1004. Aug. (!, p. 411; Wright and IJeid : Proe. Boyal Soc, lOOfi. vol. Ixxvii. p. 104: Wright and Douglas: "Tuberculosis," Lancet, Oct. 22, 1004, p. 113S ; I'.u'.loch and Atkin : "Experiments on the Nature of the Opsonic .\ction of the Blood Serum." Proc. IJoyal Soc, 1005, vol. Ixxiv, p. 379; Smith, R. Greig : "Agglutination and Lf-ucocytosis," Proc. Linn. Soc. New South Wales, 1005, part 2, July 2t! ; Cheyene : "Wright's Method of Treating Tuberculosis," Lancet. Jan. 13, 100(>, p. 78 ; I'ark and Williams: Jonr. Exp. Med.. 1005, vol. vii, p. 403; Craw, J. A.: "Mechanism of Agglutination." Jour, of Hyg., January, 1905, vol. i. p. 12(5; Houston: "Dermatologii 'I'herapeutics." Brit. Med. Jour., 1005, vol. i, p. S54 ( .\ Reply): Pearce .uid Winne- Amer. Jour. Med. Sci., October, 1004. 35 111 sj)ilc of tile fad. Iit)\\ <'\i'i-. llial llic niftlniil for llic (lclci-|ii iiial ioii of till' opsonic iinlcx lia> iim |ir()\cii niii' of