fection of the eye, the midwife, nurse and mother must follow the instructions given them. 7. It is desirable to furnish parents in all the cantons with distinct instructions and warnings as to the danger of blindness for the new-born and the danger of others becoming infected. This would be best accomplished by the civil officers. at the time of reporting births. OTOLOGY. IN CHARGE OF R. JOHNSON HELD, M.D., Assistant Surgeon, Manhattan Eye, Ear and Throat Hospital, New York (Ear Department); Attending Otologist, New York Red Cross Hospital. Vaccine Therapy in Joseph C. Beck, M. Suppurations of the D., Chicago, is the Nose and Ear; Also Technique for Determining Opsonic Indices. author of this paper in the Laryngoscope, May, 1908. The facts and theories upon which opsonic treatment is based are as follows: I. Bacteria affecting the body are attacked by leucocytes, which ingest them. 2. The number of bacteria which can be ingested is of varying quantity. 3. The number of bacteria which can be ingested depends upon their preparation by substances present in the plasma of the blood, known as opsonins. The exact nature of opsonins is not known, but it is known that they are not identical with the agglutions, antitoxins, etc., which are also found in the plasma. Their action is not on the leucocytes, but on the bacteria, which they prepare for ingestion. Opsonins are present in normal blood as well as in the blood of infected individuals. The opsonic strength of normal blood is practically constant, but varies slightly with the individual and general health, nutrition, etc. The opsonic strength of an infected individual is lower than that of a normal individual, and the relation between the number of bacteria ingested by the leucocytes of the infected person to the number of bacteria ingested by the leucocytes of a healthy individual, gives us a value which we call "the opsonic index." For instance, if 10 bacteria are ingested on the average by the leucocytes of a healthy person, and five of the same bacteria by the leucocytes from an infected person, the opsonic index of the latter would be .5. The opsonic index of an infected person may be increased by injecting into him killed cultures of his infecting organisms. For instance, if an infection is due to the staphylococcus albus, some of these particular germs are taken, grown on suitable culture media, and when sufficient quantity has been obtained, the culture is washed off with .85 per cent. sodium chloride solution, to which a little carbolic acid has been added. The mixture, well shaken, is standardized to contain 300,000,000 cocci to the cubic em.. which represents one hypodermic dose. It is important to inject cultures made from the particular infecting organisms. because it is well known that even such well-known organisms as the staphylococcus albus are subject to greater variation in virulence. Futhermore, this prevents errors in the diagnosis of the infecting germs. I. METHOD OF DETERMINING OPSONIC INDICES. In a small test-tube place about two cubic em. of a solution containing 11⁄2 per cent. of sodium citrate and .85 per cent. sodium chloride. Clean the finger with soap and water, followed by alcohol; prick the finger, and allow 15 drops of blood to flow into the solution in the test-tube, mixing well. The sodium citrate prevents coagulation of the blood. The test-tube is now taken to the centrifuge and centrifuged until all the solid particles of the blood are thrown down. The red blood corpuscles being the heavier, will form the lower layer, the leucocytes appearing as delicate, grayish film (known as "cream") on the surface of the reds. The supernated liquid has dissolved in it the plasma of the blood, and is withdrawn by means of a delicate pipette, care being taken not to disturb. the cream. The test-tube is then filled with .85 per cent. sodium chloride solution, the corpuscles well shaken up, and the mixture again centrifuged. The corpuscles will then arrange themselves as before, and after withdrawing the supernated liquid, we will have freed themi from the original plasma and the sodium citrate that was previously added. means of special tubes, known as capsules, a quantity of blood is collected from the patient (capsule half filled). Capsules of blood are similarly collected from several healthy individuals (two or three). The capsules are placed in the incubator at 37° C. for about five minutes, when the blood will be found to have coagulated. The capsules are then centrifuged, the clot being thrown down, leaving the clear serum above. Meanwhile, a suspension of the particular bacteria has been made by taking a loopful from the culture and mixing thoroughly with a quantity of .85 per cent, salt solution, the amount of the solution being such that the mixture will be turbid, the turbidity to be judged only by experience. By We now have prepared: (a) the cream consisting of washed leucocytes; (b) a suspension of the infecting bacteria; (c) serum from patient; (d) serum from several normal individuals. We now take a pipette with a long capillary stem. At a distance of about 5 millimeters from its tip we make a mark with a blue pencil. We now draw from the cream sufficient to fill the stem up to the blue pencil mark. Then we remove the pipette from the cream, drawing the volume a little ways up to the stem so as to leave an air space. Then dip the same pipette into the suspension of bacteria, of which we draw up an equal quantity. We leave another air space and draw up an equal quantity of serum from the patient's capsule. We now blow the contents of the pipette upon a glass plate and mix thoroughly by drawing up and blowing out several times. After mixing the mixture is drawn well up into the stem of the pipette, the tip of the pipette sealed in a flame, the pipette marked on its bulb for identification and laid aside. We now take equal quantities of the sera from the capsules of blood collected from the normal individuals and mix them together in a little test-tube. This mixed serum is called "the pool." The object of mixing several sera rather than relying on one serum is to overcome fluctuations which are present in normal sera (fluctuating opsonic strength). Another longstemmed pipette is now taken, a distance marked off from its point as before, and equal quantities of cream, bacterial suspension and pool serum taken and mixed, drawn up into the pipette, the end of the pipette sealed, its bulb marked for identification and laid aside. It will be noticed that these two pipettes vary only in that one contains patient's serum in the mixture, while the other is made up with pool serum. The two pipettes are now taken, placed in the incubator at 37° C. for 15 minutes. They are then removed from the incubator, the contents of each is separately blown on a glass plate, drawn back and forth several times to insure mixture (this second mixing is required because the corpuscles tend to settle during incubation), and now a drop of the mixture is blown onto the end of a perfectly clean glass micro cine; especially the absence of tetanus must be insured. The author has treated II cases of sinus and ear suppuration by this method. All these cases had, previously to the vaccination treatment (autogonous), the usual accepted method of treatment without the desired results. All of them were scopical slide and the drop spread evenly subjected to the opsonic index, which was over the slide. At least three slides (two to be held in reserve for accidents) should be made from each pipette. The slides are now stained with Nocht's stain and examined with the microscope. The number of bacteria in each of 50 leucocytes is counted on each side. As before stated the relation between the number of bacteria ingested by the leucocytes on the patient's slides compared with the number ingested by leucocytes obtained from the control slides gives us the opsonic index. As will be noticed, the serum was the only variable factor in the preparation of these slides; therefore the variation in the number of bacteria ingested must be due to this difference of sera, and the substance in the sera which is responsible for this variation is "opsonin." II. PREPARATION OF VACCINE. A culture of the specific germs is washed off with salt solution and carbolic acid, as before stated, standardized, placed in homœopathic phial (number for staphylococci being 300,000,000, other organisms requiring a strength of from 50,000,000 up) subjected to a temperature of 60° C. for a half to one hour in order to kill the organisms, a higher temperature to be avoided so as not to interfere with the chemical action of the bacterial ferments. A control culture is made from the vaccine, and in certain cases also guinea-pig inoculations, to insure sterility of the vac lower than the normal; one as low as 0.3 and the nearest to the normal was 0.76. In all but one case, and that was one of chronic bilateral sinus infection, in which more than one index was taken, I depended almost exclusively on the clinical manifestations as an index and used the average time of 10 days between the times of vaccination. Complete records were kept on the observations, such as reaction and other symptoms, and will be published in detail in a subsequent paper. Suffice it to say at this time that without exception there is a distinct improvement, and some of the cases are cured, although not long enough time has elapsed in the chronic cases to be absolutely certain. So far as complications or accidents are concerned in this treatment I must say that not in one case was there a single bad result, and only one that gave me any thought and anxiety, and that was the following: In the case of subacute unilateral sinus disease of staphylococcus pyogenous aureus infection, at the second injection into his left arm there followed what clinically one would diagnose as an erysipelas, with marked infiltration from the point of inoculation above the elbow down to the finger tip, but absolutely no general symp toms. The patient felt as well as he ever did, and there was no infection of the axillary glands. Most of the cases showed slight general disturbances for from an hour to four hours after the vaccination, such as nausea, malaise and slight head ache, and occasionally a slight rise of present time I have the following cases temperature. The specific technique of vaccination is as follows: Scrub up thoroughly the part where the injection is made, either the arm or interscapular region, and under strictly aseptic precautions draw up into a hypodermic syringe the dose prescribed, usually one cubic centimeter of the vaccine, and inject subcutaneously, seal up the puncture with collodion. As said above, about 10 days are allowed to elapse, when a second vaccination is made and so often repeated in those intervals. until the patient is cured. If one should observe that a patient reacts badly and becomes markedly depressed after the injection, it is necessary to prolong the interval. In conclusion I wish to say that at the under treatment, but not sufficient length of time has elapsed for me to even report any partial results: Three cases of chronic nasopharyngitis, all staphylococcus infection (mild). Two cases chronic tubercular laryngitis (ulcerated). Four chronic purulent otitis media bilateral in tubercular individuals, in which a positive ophthalmic reaction was obtained. Two cases of atrophic rhinitis in tubercular subjects, one in non-tubercular subject. All these tubercular patients are treated by tuberculin injections instead of the autovaccine. The article closes with an excellent bibliography. LARYNGOLOGY AND RHINOLOGY. UNDER THE CHARGE OF S. J. KOPETZKY, M.D., Assistant Surgeon, Manhattan Eye, Ear and Throat Hospital, New York (Ear Department); Attending Otologist, N. Y. Children's Hospital and Schools, R. I. tient had sneezing attacks, or epistaxis, the latter especially playing the part of so-called "vicarious hæmorrhages." With special reference to all these conditions, nasal examinations were performed by Küttner upon a considerable number of been positively demonstrated that the sexual organs, both male and female, are occasionally capable of exerting a certain influence upon the nose. Thus, for in-private patients, as well as hospital cases, stance, the connection between the menstrual process and the nose has been illustrated by case histories contributed by a number of observers (Yoal, Peyer, Endriss, Y. N. Mackenzie, Elsberg, Girod, Fliess, etc.). All these cases were characterized by a more or less wellmarked congestion of the nasal mucosa, an increased repletion of the cavernous spaces, the determination of paræsthesias, associated with an exaggerated reaction toward local stimuli, etc.; sometimes there was an increase of secretion, or the pa during the menstrual period, the clinical material including all ages from puberty to the menopause, in individuals with or without dysmenorrhea, and with or without nasal disease. Certain nasal manifestations were repeatedly noted during menstruation, which were evidently directly referable to its presence, such as vicarious epistaxis, also sometimes congestion of the nasal mucosa and swelling of the cavernous tissues of the turbinates. However, his general experience led Küttner to the conclusion that in the vast majority of all cases the menstrual period takes its course without producing any demonstrable change, subjective or objective, in the interior of the nose. He therefore does not agree with Fliess and his followers in the assumption that most women present a swelling of one or both lower turbinates during menstruation, as compared to the rest of the month. similar condition is regarded by him as of exceptional occurrence. A Cases of vicarious epistaxis are likewise exceptional, and Fliess is not correct in his statement to the effect that vicarious bleeding from the nose, on account of its relative frequency, has come to be considered as the type of vicarious menstrual hæmorrhages. According to a compilation published by Puech, the proportion of vicarious menstrual hæmorrhages is as follows: Bleeding from the stomach, 32; from the breasts, 28; from the lungs, 24, and from the nose, 18. In another statistical series published by Krieger the frequency of vicarious hæmorrhages from the lungs is likewise mentioned as superior to that of nasal hæmorrhages. Further illustrations of the connection existing between the sexual organs and the nose are furnished by certain reports concerning exacerbations of a number of nasal diseases, such as ozæna, hypertrophic rhinitis, vasomotor rhinitis, etc., during each menstrual period, or cases of nasal disease which could be cured only after the removal of a simultaneous sexual disease (Y. N. Mackenzie, Peyer, Endriss, Herzog, etc.). The nerve-paths which connect the sexual apparatus with the nose have been studied especially by Yolyet and Lafont, Dastre and Morat and Francois Franck; also Trautmann. Three avenues enter into consideration on the part of the nose, which may serve for the transmission of stimuli active in this connection: (1) The olfactory nerve, the stimulation passing from the olfactory nucleus to the optic thalamus, from here possibly through the long posterior fasciculus to the floor of the rhomboid fossa (fourth ventricle), the point of communication. with the nuclei of a number of other cerebral nerves. (2) The sympathetic, which communicates with the sexual organs through the hypogastric and solar plexus by the action of the trigeminal and deep petrosal nerves. (3) The first and second branch of the trigeminal, which communicate with the sympathetic, and the remaining cranial nerves, through the intermediation of the spheno-palatine ganglion, and probably also the Gasserian ganglion (Franck). The associated sensations here entering into consideration are apparently transmitted through the various trigeminal branches. Opinions differ widely as regards the conditions governing vicarious bleeding from the nose. Yoal, who probably stands for the majority, assumes an active congestion of the cavernous spaces, which finally becomes so severe as to result in rupture of the normal vascular wall, and with it of the mucosa. Bresgen, on the other hand, maintains that these hæmor rhages do not originate in a normal mucosa, but are almost invariably based upon a diseased condition of the mucous membranes or the blood vessels. Bresgen's view is supported by the observation that menstrual bleeding from the nose, according to Küttner, Baumgarten, Rèthi, etc., generally takes place at Kisselbach's space, namely, a part devoid of cavernous tissue, in which the vast majority of nasal hæmorrhages due to injuries originate. On the other hand, the fact must be kept in mind that in certain cases these vi |