certain substances which protect it from,-not the organism itself, but from the toxins of this organism, and when the body is not in good health, it is an evidence that these protective substances, this auto-immunization as it were, is diminished, or lost, and consequently the body's resistance to the effect of the foreign organism is proportionately lost, and systemic infection takes place. Our whole modern therapy teaches that inoculation of the system with vaccines, stock or auto-vaccines, has the power of producing these same protecting anti-bodies, and thus bringing the system back to a state of resistence, of defense, against the invading organism, and the earlier this artificial immunization can be brought about just in inverse proportion will be the damaging effects of the micro-organism, the extent of the lesion against which the patient has to fight for a preservation of his life. There is much evidence that this method of treating streptococcic infections has been resorted to, but not as generally and as thoroughly as it deserves, which accounts, perhaps for the above-mentioned discouraging report as to recovery. Horder tried vaccines, or rather polyvalent sera, and reports recovery in only one case. It was given at first, 10cc hypodermically, and later, in the same amount, by the rectum, with complete disappearance of temperature, of a loud systolic murmur, and full recovery. This authority admits 50 that the lack of success in twelve (12) other cases thus treated might have been due to his having used stock polyvalent serum, while the organism in his cases might have been a streptococcus of an unusual nature! And so he urges this method of treatment in these words, 50a I should consider I was depriving my patients of the best hope of recovery if I did not employ this employ this principle of treatment." It is an accepted fact that one streptococcus will not protect against another. (Rau.) 51 "Experience has shown that the greatest success, in this method of treatment, is attained by the cultural separation of the exact strain peculiar to the patient,-by the preparation and use of a vaccine from this strain. (Turton and Parkins.) 52 Janeway reports a case treated with a serum, which recovered. Osler tried vaccine in two cases, but too late in the course of the disease to be efficacious. Latham and Hunt 53 report a case in which the clinical picture and the blood culture were very characteristic,-the only focal lesions were an unoperated appendicitis and many buried. stumps in the gums. He was given for 7 weeks the usual hospital treatment (see writer's case), with no results, then he received, by mouth, 1,000,000 to 2,500,000 auto-vaccine, in three doses, within a week, when the temperature became normal for seven (7) weeks, during this time the dose was increased to 5,000,000. Subsequently, as there were at intervals, irregular elevations of temperature, embolic complications, with much pain, the dose was increased to 30,000,000, with marked and permanent improvement,-temperature fell to, and remained normal, but the murmur did not disappear. For over a year the organism (the specific nature is not mentioned) had been obtained from both vein and finger puncture, but with the permanent Schottmuller reports one case died in spite of Davis, suggests this method of treatment as worthy of trial. Griffith, reports a case given 150,000,000 to 600,000,000 auto-vaccine, at first every 3 to 4 days, then every other day, but the case was lost to further observation. Cecil, used autogenous vaccines made from throat smears in a case of tonsillitis with subacute endocarditis, both killed and sensitized, usually subcutaneously, in large doses, 50,000,000 to 100,000,000, increasing the dose, about every 5 or 6 days, giving as high as 2 to 3,000,000,000. (Personal note.) Oille, used autogenous vaccine, in seven (7) Bell, Barr and Douglas,54 a case of sore throat, Sutcliff and Bayley 55 gave 10 to 50,000,000 in 57 Camac,56 used an auto-vaccine from the pulp of a diseased tooth, with marked benefit, and he says, "vaccines are the only rational therapeutic remedy, with radical removal of the focus. Warren and Herrick," report cases with vaccines, but their results seem to be no better than in the cases treated with salicates, or what they specify, as "palliative" treatment. It is not mentioned, in this report, at what stage of the disease, or by which route the vaccine was given. This by no means exhausts the list of those who have used vaccine treatment, and if the report is not quite favorable, it still suggests great possibilities, and the advisability of it being used in every case, for a long time, and in large doses, and conjointly with thorough and appropriate treatment of the focal lesion, which needs but to be sought for, to be found. Which route, by rectum, by mouth, subcutaneously, or intravenously is to be preferred, must be decided by the results following the future use of method of therapy. Rest, abundance of fresh air, of pure water, and good nourishment, in association with general tonics and general disinfectants, such as small doses of quinine, iron, arsenic, and salol asparin, dilute hydrochloric acid, are all worthy of consideration. And as very encouraging, therefore helpful, is the suggestion of some observers, "you start treatment with the belief, that if a murmur be present to consider it an old one." HISTORY OF THE WRITER'S CASE. Lilian S., age 44, American born,-saleslady by occupation,-married at age of 25, entered the service of the writer in the New York Infirmary for Women and Children, April 11, 1913, giving the following history: Family history negative. (Later mother died of cancer.) Personal history-she had, in childhood measles, whooping cough, and diphtheria,--and in adult life, frequently, tonsillitis,-the last attack was not dated. She had been absolutely free from any cardio-respiratory symptom, no dyspnoea, no oedema, no cyanosis, no cough, no expectoration, no heart palpitation. Her appetite had been good, no gastro-intestinal disturbance, save constipation. At no time had there been any kidney or bladder trouble. Her menstrual Her menstrual was normal, only since about three years the menses appear about every six months, there was only a very slight, non-troublesome leucorrhea. She has had three pregnancies,-the first and the third were normal in every way, full term, and the children are alive, the second was an abortion of twins, at ten weeks followed by profuse hemorrhage, but no other complication. The youngest child is twelve years old now,-last menses was five weeks ago. Patient has no bad habits. Present illness began about three weeks ago with a severe headache lasting all day,-three days later she experienced a peculiar feeling lasting a few hours, and each succeeding day she had the same sensation, which she described as a "creepy," ""chilly" sensation across the abdomen and up and down the back, of short duration, and followed by a subjective increase of temperature and fulness in the head, and, at night, quite a profuse perspiration. The relation of chill (chilliness), fever, and sweating in regard to time, was not obtained. membranes, no joint troubles. A few rose spots were noted on the chest for a couple of days, and one, later on the abdomen. At no time was there any trace of blood, of indican, of acetone or sugar in the urine, twice only there was a trace of albumen, but never any casts,-the "diazo" was repeatedly negative,--the reaction was acid, the specific gravity was between 1,010 and 1,026,-the average amount about 1,500cc daily, and there was not very much variation in daily quantity. The blood picture did not present anything of interest,-there was a slight leucocytosis, the lowest count being about 6,300, and the highest about 14,000.-the polynuclears kept about 65%,--the red cells were about 4,000,000, and the hemoglobin between 70% and 90%. Constipation was marked and persistent throughout the whole course of the disease, making a daily enema necessary, often even when large doses of Epsom salts, or rhubarb and soda, pheno-lax, cascara, or other mild laxatives had been given. Chills and chilliness, fever, and sweating, very variable as to time and severity, may be said to have been the significant symptoms in the case, and the fever, as is usual in these cases, presented nothing helpful in making a diagnosis. It might have been that of a second or third week of typhoid fever, or a remittent malarial fever,-a sepsis somewhere. In consequence, tests were made for typhoid and para-typhoid, for malaria, for tuberculosis, colon bacillus, kidney infection,-all proving negative, as well as every part of the body, separately investigated, smear from the vagina gave negative -even a results. There was no epistaxis, no cough, no insomnia, at any time, no gastric disturbance, save flatulence, and as already mentioned, constipation. Although she had been in bed only three days during these three weeks, she claimed to have lost 13 pounds. was Physical examinations-on admission,-was almost negative,-the patient was well nourished, good color,-mucous membranes were slightly pale, no palpable glands except a few very small ones in the neck,-no cough,-no oedema, no pigmentation, no nodules,-spleen and liver were not enlarged,-no tenderness or swelling of the joints,-lungs were negative, the heart regular in frequency and normal in strength, no murmur, no increase in size was detected on most careful examination by the writer. Some slight varicosities were noted on the lower limbs, but no petechiae. A few days after admission, an examination of the throat showed the tonsils enlarged, and one of them red and glistening. The culture of the throat smear showed only staphylococcus aureus,-nothing else. During the course of the disease, now and them examination demonstrated a very slight and very temporary increase of liver and spleen, not accompanied by any pain,-also the thyroid was slightly, and for a short time, enlarged, the heart outlines varied at times, with the sounds normal, though somewhat indistinct. During the whole course of the disease, no new features developed, none of the "pathognomonic symptoms," none of the "noteworthy" features of endocarditis, there were no painful nodes, no pigmentation, no petechiae of skin or mucous Finally, after some hesitation on the part of the writer, a bacteriemia was considered probable, and a blood culture was made,-resulting in the positive find of the "STREPTOCOCCUS VIRIDANS," May 6th, three weeks after the patient had been admitted to the hospital, six weeks after claimed onset of the disease. The following is the report of the bacteriologist of the New York Infirmary for Women and Children, Dr. Elise L'Esperance:--"the first blood culture made was negative after 48 hours' incubation. This blood culture, however, after six (6) days' incubation showed, on agar plates, a few fine white colonies growing very slowly. In stained smears this organism proved to be a gram positive micrococcus, occurring in short chains, smaller and shorter than the streptococcus longus. These colonies were transferred to glucose-agar, to ascitic-agar, to blood-agar plates, and to inulin. The blood-agar plates showed no hemolysis, and the colonies and media immediately around them were of a distinct green color. The inulin was not fermented. The growth of this organism was so slow on agar plates that two weeks' incubation was required to obtain sufficient material for a vaccine. An autogenous vaccine was prepared from these cultures, according to a method used by method used by Elser and Huntoon, of the Cornell Medical University Laboratory, and tested for sterility on agar and in broth." The writer is very much indebted to Dr. L' Esperance for these cultures and for her successful isolation of the organism, and to Dr. Huntoon for the preparation of the vaccine. A second and a third culture of the blood failed to develop any organism, but the first culture had been very thoughtfully immediately utilized to make a culture and this preparation was given to the patient, intravenously, each time,--eleven (11) weeks after claimed onset of the disease,-eight (8) weeks after admission to the hospital, four (4) weeks after the organism was first found in the blood,—and only after the usual hospital treatment had been tried out. This consisted of, at first, the usual typhoid precautions, careful diet, etc., asparin, dilute hydrochloric acid, urotropin, strychnine,--later, on account of persistent constipation, on one hand, and persistent chills, fever and sweating on the other hand, asparin was stopped, and quinine was given, but with no better results, fever, chills, sweating, and constipation persisted. Finally, on June 2d, following a chill the temperature rose to 104°, and for the first time the patient complained of pain radiating from the left axilla along the flexor surface of the arm, lasting for two days. At this time although the outlines of the heart seemed slightly increased with the sounds not quite as forcible as heretofore, the action was regular, and no murmur was detected, and nothing could be found to account for the pain. June the 4th, the first intravenous injection was given, one minum of the auto-vaccine which was equal to 66,000,000 dead bacteria. Following this injection, for the first time the patient complained of pains in her limbs, but as no marked reaction was noted the injection was given daily by Dr. Hubert, the house-physician, up to June the 9th inclusive, increasing the dose one minum daily, so that by this date, June 9th, six (6), minums were given,-June 10th no injection was given, as it was considered that a maximum dose had been reached for the present. June 11th, only two (2) minums were given. June 12th, three (3), minums were given,this was followed by headache, pains in the joints and some general malaise,-which may have been due to her menses which appeared the next day. June 13th, two (2) minums were given. June 14th no injection was given. June 15th again two (2) minums were given. June 16th no injection was given as heart sounds seemed a little weak, although the patient felt very well. June 17th five (5) minums were given, this was followed by a complaint of feeling very tired, and although lasting only a short time, patient claimed that this was not a new sensation, as after every injection she had had a heavy feeling in the legs, from the thighs down, but it lasted such a short time she had not spoken of it. June 18th seven minums were given, with no bad results,-patient was on the roof all the day. June 19th nine (9) minums were given,-there was a complaint of frontal and parietal headache, and aching in the eyes, which could have been the effect of the sun, patient spending most of the day on the roof. June 24th nine minums again administered. and patient felt no bad effects. June 28th, a final nine (9) minum dose was given, this dose equaling 600,000,000 bacteria, and later in the day, the patient was discharged. All chills or chilliness, and sweating and fever had ceased,-temperature, always taken in the rectum, had been, for nine (9) days before discharge, 98, 4 A. M., and 99, 4 P. M. In all fifteen (15) injections were given in twenty-four (24) days, from June 4th inclusive to June 28th inclusive, the highest dose having been nine (9) minums equalling 600,000,000 bacteria. LATER HISTORY. Fifteen months after patient had been discharged "cured," she returned to the hospital, September 14, 1914, with the history of having been perfectly well during these fifteen months, working as a saleslady in a large department store, till about a week ago, when she had headache, "cold and pains in her bones." The pains after three days, disappeared, but the headache persisted. HER doctor had made a diagnosis of "grippe." On first examination, after admission to the hospital, the diagnosis of typhoid fever was made, on the rose spots, the slightly enlarged spleen and the type of fever, and this was confirmed, later, by a (slowly developed) Widal reaction, and the course of the disease, which was quite typical, quite severe, though no complications arose. Culture of the blood grew a negative bacillus, mobile, morphologically typhoid bacillus. The patient made a perfect recovery, and was discharged "cured," November 11th, after two months in the hospital. The writer is indebted to Dr. Helen Baldwin, in whose service the patient was treated, for these notes in reference to the typhoid fever. July, 1916, this patient was kind enough to come to the writer's office one evening, on her way home from business. She reported having been perfectly well all this time,--had not missed a day from her work, was feeling "better than ever. Her heart was normal, on examination. She was having her teeth and gums treated by a dentist. November 15, 1916, patient reported "feeling fine, not a moment's illness since in your office in July." SUMMARY REMARKS. It is evident from the literature quoted, and from the writer's case presented in this paper, 1, that streptococcus viridans can be present on a healthy tissue, and not cause local or systemic infection. 2, that it can cause a local lesion unaccompanied by a systemic infection. 3, that a systemic infection is due to some past or present focal lesion. 4, that a systemic infection of this nature, as such, is very difficult, at times, to recognize. 5, that a systemic infection of this nature, can be present without endocarditis. 6- that when an endocarditis is present it may be an old lesion, and if old or new, it may be slight or severe, or any grade in between. 7, that the organism is to be found much more frequently, locally and in the blood, than has been thought, recognized, or considered. (Schottmuller.) 8, that an investigation for a local focus, and when found proper treatment of the same, combined with the very earliest blood cultures, is imperative, as the best means of reaching a quick and correct diagnosis, thus indicating the therapy which is to overcome the organism, prevent or limit the lesions, and save the life of the patient. The "bacteria-free healing or healed" cases described by Libman may be considered as a proof that in some place, at some time, the organisms were present, unchecked, till Nature probably supplied her own vaccines, her own anti-bodies,--but too late to prevent permanent damage. What Rosenow and Davis say in reference to fibro-cystic ovaries, namely "if eradication of the primary focus of infection had been controlled early, it might have prevented the sclerotic degeneration of the ovary,"-holds good in regard to the heart in these streptococcic infections. 9- that auto-vaccines, not stock vaccines, should be used more generally in larger doses, and often repeated, in the earliest stage of the disease. Whether by mouth, rectum, subcutaneously, or intravenously, more general use alone will decide, as each method has its advocates. But, the quick response to the intravenous administration of the auto-vaccine in the writer's patient, with permanent recovery (the first case thus treated of this infection as well as the writer could determine),-certainly speaks in favor of this route.* 10, that by means of 8 and 9 many indefinite diseases, of mild or severe form, may be cleared up, and become susceptible of treatment and cure. 59 11—, that recoveries do take place, as proved by the cases quoted, and by the case reported in this paper. "If a case recovers, the physician may attribute it to early treatment" (Horder)." In the writer's case the patient was seen early,― every symptom was immediately carefully considered and treated,--and the auto-vaccine was given at a comparatively early stage of the disease, before any endocarditis developed,--consequently, before any secondary foci developed,and, only after the administration of the vaccine, did the symptoms disappear, and recovery result. N. Y. Medical Jour., 1914, Feb. 7. 11. Jour. Infect. Diseases, 1913. 12. Trans. Archives Int. Med., 1915, Jan. 13. Munch. Med. Wochenschr., 1903, May. 14. Jour. A. M. A., 1916, April 15. 15. Med. Record, 1916, April 29. 16. Trans. Archives Int. Med., 1915, Jan. 17. Med. Record, 1916, April 29, 802. 18. Quart. Jour. Medicine, 1914, xxii-291. 19. Lenhartz-Northnagel, 1903, 389. 20. Lenhartz-Northnagel, 1903, 389. 21. Jour. A. M. A., 1914, Sept. 12. 22. Trans. Archives Int. Med., 1915, Jan. *The vaccine was injected each time by Dr. Anna Hubert, the house-physician, and so carefully and so successfully that there was never the least local disturbance. Trans. Archives Int. Med., 1915, Jan. Am. Jour. Med. Sciences, 1913, Nov. 25, vol. cxlvi-625, footnote p. 9. Quart. Jour. Med., 1909, April, vol. i, No. 7. VIA'S REPLY.* BY KATE C. MEAD, M.D., MIDDLETOWN, CONN. Sir Arthur Newsholme, the eminent English statistician, says that infant mortality is the most sensitive index we possess of social welfare. And then he adds: "If babies were well born and well cared for, their mortality would be negligible. The infant death-rate measures the intelligence, health, and right living of fathers and mothers, the standards of morality and sanitation of communities and governments, the efficiency of physicians, nurses, health officers, and educators."-[Bulletin of the Chicago School of Sanitary Instruction. This quotation, though of recent date, applies not only to the unenlightened families of the twentieth century, but to the most highly educated classes of the past ages. Being well-born and well-cared-for are relative terms, and if we today who are well-born can use our brains and our funds in caring for the ignorant, the time may come when all babies will have as good a chance to live as seems to fall to the lot of the babies of the educated classes at present.1 Two *Reprinted from Medical Record. B THE WOMAN'S MEDICAL JOURNAL hundred years ago the babies even of the nobility in Europe were seldom well-born or well cared for. Queen Anne of England, who died in 1714 at the age of 69, bore fourteen children, only one of whom lived more than a few hours or weeks; and the one survivor, upon whom the fate of the nation seemed to hang, died before he was eleven years old. That the early deaths of these royal infants was an index of the lack of general intelligence of that age is shown in the general debased state of morals and religion. The recorded conversation at social functions ran upon preserving the English Constitution, but not at all on saving the constitution of babies, although one-sixth of all English infants died of sepsis, and half of the rest died of what we now class as preventable diseases. This high mortality was common to countries even fifty years ago, but gradually it all enlightened has been lowered until now, in the United States, only 15 percent of the babies die in their first year, a decrease which seems commendable when we find that, though we are eighteenth in a list of the infant mortality of different countries, Italy has a rate of 16 percent, Germany 19, Austria 22, and Russia 26. But why should we be content before we have reduced our death rate to that of Sweden in the first rank, with its infant mortality of only 72 percent? This question leads us to look into our municipal housekeeping, where, as Sherman H. Kingsley has shown, the weakest spot is continually marked by the presence of the little white hearse, the most sensitive index to the enlightenment of any community being its infant mortality. Or, as Holt has pointed out, it is not the unfit, but the unfortunate baby that dies, and this baby who was born in the midst of poverty or unenlightenment dies or grows up sickly in its home, or perishes sooner in a foundling asylum. These early deaths in any case, then, are the index to our poor economies in municipal housekeeping. That the death rate of infants in foundling asylums is enormous may be seen from statistics quoted by Dr. Philip Van Ingen, who finds that the rate in New York State's foundling homes is 422 to the thousand, while the death rate of the babies in the slums of New York City is hardly more than one-fifth of that number. That the deaths in these foundling homes are mostly unnecessary is seen by the comparison with the death rate of foundlings in Sweden, which is only 4 percent, but we shall see that there are good reasons for this difference. Sweden has not only hospitals for sick babies, but small boarding homes for well babies, and large asylums for mothers with their babies. By such methods New York City has cut down its infant deaths 17 percent in the past five years—that is, by boarding 44 percent of its foundling babies in small homes where each individual may have a mother's attention, under the supervision of doctors and nurses. babies the foster mother receives $15 a month, For caring for marasmic and for healthy babies $10. In this way, Dr. Josephine Baker tells me, the infant mortality was cut in half, at an expense to the public treasury of 69 cents a day; whereas the foundling 11 asylums were formerly allowed from $1 to $2.29 a day for each infant, graft not eliminated, and funerals to be paid for.2 ever, the cost of running the homes for mothers In Stockholm, howand babies is very much less than in New York,. diem, being only 14 cents, and, as the mothers the amount spent for food for each mother, per hygiene, there is little need for doctors and nurse their own babies and help do the work of the home while learning the principles of infant nurses. in large institutions rather than in boarding Not only has New York City discovered that If, as Prof. Irving Fisher has shown, a baby's |