agreeable effects have thus far been observed from its employment among an increasing number of patients, and a general upward tendency has been exhibited in many instances. The remedy was invariably denied to incipient cases. The skiagraph (Fig. 67) illustrates the extensive pathologic changes in an individual exhibiting frequent cough and copious expectoration, with a resulting entire disappearance of tubercle bacilli. The tuberculin has been thought to be of value in several cases of tuberculous laryngitis. Improvement has also followed its application in a few additional cases of glandular tuberculosis. In my own practice, with one exception, neither the bacilli emulsion nor the autogenetic vaccines have been given more frequently than once in five days. Neither have I found it advisable in many cases to resort to progressive increase of dosage. This, perhaps, explains the absence of intolerance in my later experience, as contrasted with previous occasional manifestations of local reaction with headache, fever, malaise, and loss of appetite for a few days following the injections. In but few instances has the agent been used for patients presenting a temperature of over 100° F. It is interesting to note, however, that Krause has recently reported excellent results from the administration of tuberculin to febrile patients. He reports a permanent disappearance of the fever in all cases, and suggests, at least, a tentative administration of the remedy among a few patients who have resisted all other

measures.

Recently I have had occasion to employ the tuberculin in 6 cases exhibiting persisting fever of from 102° to 103° F. daily, despite prolonged rest in bed in the open air. In 3 cases no appreciable effects were noted; in one the temperature receded within a few days to normal and has remained so for four weeks; in 2 cases the temperature has gradually receded to the neighborhood of 99° and 99.5° F.

Special bacterial vaccines have been prepared for twelve recent cases of severe mixed infection, making a total of twenty-seven patients to whom the homologous vaccines have been administered.

In the use of both the tuberculin and the bacterial vaccines among cases observed during the past few months, the dosage has been determined without reference to the opsonic index. This course has been pursued because determinations of the index sufficiently frequent to afford a basis for substantial accuracy of dosage were almost impracticable. It was found that even in carefully selected cases of pulmonary tuberculosis, the range of variation in the opsonic findings was so great as to suggest the impropriety of any arbitrary or conventional dosage without recourse to detailed clinical study. There was found to be no fixed relation between the opsonic variations and the character of the clinical manifestations. In view of the unavoidable sources for error in estimating the index, and the confusing interpretations as to the dosage, it was decided to permit the character of clinical manifestations to be the sole guide for tentative medication. The results obtained have demonstrated fully that, for practical purposes, approximate accuracy of judgment in this respect may be derived from a continuous vigilant study of the subjective and physical data. In the light of later experience it is questionable if, for general usage, the clinical method of dosage, influenced solely by the symptomatic course, is to be displaced by the laboratory method, controlled by the observation of the opsonic index. The same conclusions have been reached by

Trudeau, Baldwin, Brown, and other clinicians in various parts of the country.

It is recognized that, amid the many complicating conditions inherent to the disease and its management, many difficulties obtain in establishing the value of any therapeutic agent. It is fair to assume, however, from the accumulating mass of evidence, that the use of tuberculin and bacterial vaccines is in accord with modern theories relative to the production of artificial immunity.

As a result of my investigations, which were pursued largely along clinical lines, the following conclusions are suggested:

1. In general it may be stated that the administration of bacilli emulsion is of undoubted efficacy in some cases of long-standing afebrile pulmonary tuberculosis.

2. That the remedy also possesses possibilities of an injurious influ

ence.

3. That the demonstration of an increase in cough and expectoration shortly after the injection is not necessarily indicative of its harmful. effect.

4. That the persistence of these clinical manifestations, together with fever and greater physical weakness, despite an attempted discrimination regarding the dosage, may be accepted as definitely conclusive of its detrimental action.

5. That, in the event of severe mixed infection with considerable temperature elevation, it is highly inexpedient, as a rule, to attempt. the production of an increased tuberculo-opsonic power until after the amelioration of the secondary infection.

6. That the administration of bacterial vaccines derived from the secretions of the patient is often indicated in the presence of the constitutional and bacteriologic evidences of mixed infection.

7. That, in view of the numerous possibilities of error incident to the opsonic findings, discriminating clinical study is absolutely essential in the determination of the size and frequency of the dosage.

8. That despite the uncertainties of action of autogenetic vaccines, a justification for their employment is found in the desperate character of the cases to which they are given, and their superiority over the various sera formerly used.

9. That in some cases bacterial vaccines present possibilities of benefit far beyond the limits of former therapeutic efforts.

10. That the rôle of the opsonic index in vaccine therapy still remains an experimental study, to be approached with the utmost conservatism, but in a spirit of receptive inquiry. The data thus far presented suggest that this feature should remain for the present sub judice.

INDEX

ABSCESS, tuberculous, in bone and joint | Apex-beat, changes in location, 172

Bier treatment of tuberculous joints,460 | Bronchopneumonia after pulmonary
Bladder, cystoscopic examination, in