estate CoUege of Agriculture 9t Cornell ^niberKttp 3tbaca, ^. I?. Uifirarp BIOLOGIC THERAPY A series of articles prepared under the auspices of the Council on Pharmacy and Chem- istry of the American Medical < Association AMERICAN MEDICAL ASSOCIATION 535 North Darborn Street CHICAGO The original of tliis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924003519042 BIOLOGIC THERAPY A series of articles prepared under the auspices of the Council on Pharmacy and Chem- istry of the American Medical Association AMERICAN MEDICAL ASSOCIATION 535 North Dearborn Street CHICAGO Copyright, 1921 BY THE American Medical Association CONTENTS PAGE Introduction 7 General Considerations Regarding Serum and Vaccine Therapy, Simon Flexner, New York 9 Antistrepticoccus Serum and Antistrepticoccus Vaccines, George H. Weaver, Chicago 14 Uses of Vaccines and Serums in Gonorrheal Urethritis and Its Complications, John T. Gerahty, Baltimore.. 17 Use of Antimeningococcus Serum in the Treatment of Epidemic Meningitis, Kenneth D. Blackfan, Balti- more 19 Serum Treatment of Bacillary Dysentery, Simon Flexner, New York 25 Use of Antitoxin in the Treatment of Diphtheria, Wil- liam H. Park, New York 29 Serum Treatment of Acute Poliomyelitis, Harold L. Amos, New York 34 Antipneumococcus Serum, Rufus Cole, New York 37 Use of Tetanus Antitoxin in Prevention and Treatment of Tetanus, Matthias Nicoll, Jr., Albany, N. Y 41 Acne Vaccine Therapy, Martin F. Engman, St. Louis ... 44 Vaccination Against Typhoid and Paratyphoid Fevers, F. F. Russell and H. J. Nichols, Washington, D. C. 46 Pneumococcus Vaccine, Russell L. Cecil, New York.... 49 Rabies Vaccine, A. M. Stimson, Washington, D. C 54 ■Pertussis Vaccine, Wilburt C. Davison, Baltimore 58 Cholera Vaccine, Oscar Teague, New York 61 Vaccination Against Plague, Oscar Teague, New York.. 63 Use of Vaccines in the Prevention and Treatment of Influenza and Its Sequels, Frederick P. Gay, Berke- ley, Calif 65 Foreign Protein Therapy in Acute Infections, Joseph L. Miller, Chicago 69 Nonspecific Protein Therapy in Arthritis, David M., Cowie, Ann Arbor, Mich 75 Intravenous Protein Injections in Urology and Dermat- ology, Harry Culver, Chicago 78 The Nonspecific Reaction, W. F. Petersen, Chicago 82 Serums and Vaccines in Therapy 87 Foreign Protein Therapy 90 PREFACE The articles appearing in this pamphlet appeared orig- inally as a series in The Journal of the American Medical Association. They aim to define the status of serum, vaccine and nonspecific-protein therapy at the time the articles were written. The wide interest shown in this series at the time of its publication and numerous requests for publication in more permanent form prompt the issuing of this reprint. BIOLOGIC THERAPY This series of articles dealing with serums, vaccines and nonspecific therapy has been prepared under the auspices of the Council on Pharmacy and Chemistry of the American Medical Association. The Council is constantly passing on products of this kind, marketed by various pharmaceutic houses, and it accepts for New and Nonofficial Remedies only those which are (1) licensed for interstate sale by the federal government, and (2) those which do not conflict with the Council's rules. The subject of immufiity, besides being relatively new, is beset with complexities. The agents often employed in the therapy of acute infections are complex biologic products; the literature concerning the efficiency of many of these agents presents a mass of conflictng evidence. These facts render judgment and decision difficult. It was for these reasons that it was deemed wise to submit to the Council and to the pro- fession at large concise, authoritative statements concerning indications and contraindications, methods of administration, dosage, the value and also the possible dangers of serums, vac- cines and nonspecific proteins in the treatment of various infectious diseases. Accordingly, a committee was appointed by the chairman of the Council consisting of the three mem- bers of the Council whose names are signed to this preliminary note. This committee enlisted the aid of authorities in the three fields of im-munity represented and placed before them the desires of the Council with the request that they assume full responsibility, first, for the selection of men for the presen- tation of each subject, and secondly, for the revision and edit- ing of the articles presented. Dr. Simon Flexner assumed responsibility for the series on serum therapy, Col. F. F. Russell for the series on vaccine therapy, and Dr. Joseph L. Miller for those on nonspecific protein therapy. Before publi- caton was authorized, each series was made the subject of a conference between the committee and those who were respon- sible for its preparation. These articles are presented to the profession to serve as a guide in the use of serums, vaccines and nonspecific proteins. L. G, RowNTREE, G. W. McCoy, Warfield Longcope. GENERAL CONSIDERATIONS REGARDING SERUM AND VACCINE THERAPY SIMON FLEXNER, M.D. NEW YORK The serum treatment of disease dates from the dis- covery and appHcation of diphtheria antitoxin by Behring and Roux, and the use o'f bacterial vaccines from the application of antityphoid vaccination to man by Wright. In recent years, numerous serums and vaccines have been tested as prophylactic or curative agents, usually first in animals and later in man. Pres- ent knowledge of the somewhat complex subject of immunity, to which the antiserums and vaccines are related, makes it possible to state the outstanding facts in the form of general principles which may be taken as guides to the practical use in man of these agents for preventing or treating disease. At the outset it should be understood that there is nothing occult or mysterious in the manufacture of serums and vaccines, and that any properly equipped and organized laboratory intent on doing so can turn out satisfactory products. Indeed, it is the very sim- plicity of the processes of manufacture which has led to wider commercial exploitation of these valuable agents than sound knowledge warrants. When diphtheria antitoxin was found to have a high therapeutic value in the treatment of diphtheria, the hope was entertained that as the bacterial incitants or causes of the various infectious diseases came to be known, each in turn could be made to yield a corre- sponding antiserum, and thus a high degree of thera- peutic control of these diseases would quickly be secured. As a matter of fact, this millenial hope has been realized in only a few instances, and expanding knowledge of the nature of the processes of infection, as well as the properties of the different bacterial agents causing disease, is gradually supplying the rea- sons for success, on the one hand, and of failure, on the other. Diphtheria antitoxin is still the outstanding example of a therapeutically active serum, while tetanus anti- toxin has a high protective but a lower therapeutic 10 BIOLOGIC THERAPY value. These two antitoxic serums — by which term is meant serums made from the poisons or toxins given off by the growing diphtheria or tetanus bacilli, for the poisons are the direct sources of the injury to the tissues and organs — act not directly on the infecting bacilli, but on their liberated toxins which they neu- tralize, after which the body readily rids itself of the bacilli themselves. Most of the infectious diseases, however, are induced not by these soluble and readily released toxins, but by poisons or toxins held by or closely bound to the bac- terial bodies themselves. The latter form of toxin is called endotoxin, to distinguish it from the other, and it so happens that not only is it given off with difficulty by the bacteria, but also that it is less well adapted for the immunization of animals, as for example the horse, which is the most suitable animal in which to produce the antiserums. Indeed, the endotoxin as contained in different bac- teria acts in a very capricious manner. Thus, in the form in which it exists in the typhoid bacillus, it does not lend itself well to the making of an antiserum; as it exists in the dysentery bacillus it lends itself some- what better to this purpose ; as it exists in the meningo- coccus it lends itself better still ; while as it exists in the various cocci — ^pneumococcus, streptococcus and staphylococcus — it hardly lends itself at all. The point of capriciousness is of great importance for practical medicine, and it can perhaps be illus- trated best by considering the special instance of the pneumococcus. But first we must bear sharply in mind the property called specificity in respect to the bacteria and their antiserums. This specificity is a very deli- cately balanced condition and one that is made evident chiefly through the immunity reactions of organism (bacterium) and antibody (antiserum). Thus we have learned that what we call pneumococci are not a single kind or species of bacteria, but that there are actually several kinds in the United States, at least three defined and many less well defined varieties, which formerly were all classed together. At present what we call Types I, II and III pneumococci are easily distinguished by immunity reactions, and all pneumo- cocci not falling into these three types are classed together as Group IV. The last group differs from GENERAL CONSIDERATIONS 11 the other or type classes in not being a single kind, but a heterogeneous mixture of pneumococci. The immense gain to therapeutics of this classifica- tion arises from the fact that a therapeutically active serum has been produced only from Type I pneumo- coccus._ Hence any one who treats pneumonia ration- ally with antipneumococcic serum must confine' his efiforts to cases of Type I pneumococcus pneumonia, proved such by laboratory tests; only these may be . treated with Type I antipneumococcic serum. To go beyond this simple demonstrable fact and attempt to treat pneumococcus infection by use of a so-called "polyvalent" antipneumococcic serum is not only futile, but in the present state of knowledge, unscientific. The outstanding need at present is to restrict the therapeutic employment of antiserums to what has been proved and is experimentally demonstrable, and not to resort to their empiric use on insufficient grounds of activity. A similar mental attitude toward "vaccines" is to be desired. Exact agreement or parallelism does not exist between the immunizing power of certain vaccines and their capacity to yield effective therapeutic antiserums. Thus, it was stated above that the typhoid bacillus does not yield such a therapeutic serum, and yet typhoid vaccination is an effective bar against typhoid bacillus infection (typhoid fever) ; similarly, although an active antistaphylococcic serum has not been produced, still staphylococcus vaccine is therapeutically valuable in furunculosis, etc. The antiserums are employed in two different ways, and in order to accomplish two quite dissimilar pur- poses : 1. As therapeutic or curative agents. To this use all the active antiserums are devoted. 2. As pro- tection after exposure to certain diseases (diphtheria), or after injury (tetanus antitoxin). The second use is a subordinate one except in the case of tetanus anti- toxin, regarding which it is the principal one. But the protection afforded by this so-called passive immunization is in all instances relatively brief and endures only for a few weeks. The facts regarding the use of vaccines are the reverse. Their main field of usefulness is protective; and as they induce active immunity, their effect is enduring. The length to which this protective vac- cination may be succcessfully and properly carried has 12 BIOLOGIC THERAPY not yet been determined. The outstanding success is typhoid-paratyphoid vaccination, but other successes relate to cholera and possibly to the type pneumonias. The curative value of "vaccines," on the other hand, is a subject far less easily dealt with. The ideajthat vaccines can be used to combat generalized infections, because when injected under the skin they utilize the local tissues to elaborate healing immunity substances (antibodies), is a mere hypothesis that has never been verified. The lymphatic internal organs are the only ones known to be active in producing them, and hence the inoculation of killed cultures or "vaccines" in acute infections may merely amount to the adding, as it were, of fuel to the flames. And what in this respect is true of the bacterial bodies as a whole, as they exist in the vaccines, is true also of extracts or other preparations made from them. SUMMARY Up to the present, certain general principles of immunity have been discovered which may be taken as guides to the practical use in man of serums and vac- cines. The manufacture of serums and vaccines has come to be a felatively simple matter under conditions of proper laboratory equipment and personnel. The great practical success achieved with diphtheria antitoxin and a few other antiserums, and with anti- typhoid vaccination, has led at times to wider exploita- tion of this class of therapeutic agents than sound knowledge warrants. As far as possible, the use of the antiserums and vaccines in man should be based on trustworthy tests proving their value in experimental infections in ani- mals. Because a therapeutically or prophylactically active serum or vaccine can be produced for one infec- tious micro-organism, it does not follow that a similarly active substance: can be produced for another. In eaoh instance, special studies of a precise character should be carried out in animals when possible, in order to determine whether or not a successful result has been achieved. The high expectations entertained, after the great value of antidiphtheria serum had been demonstrated, that all the infectious diseases of which the inciting bacteria were known would come under a similar form of control, has not been realized. GENERAL CONSIDERATIONS 13 And yet very substantial progress has been made. A part of this progress has been the recognition of the important part played by speqificity in serum and vac- cine therapeutics. A therapeutically effective anti- meningococcic serum must contain the immunity substances or antibodies for the tv^ro main strains and the important subsidiary strains of the meningococcus, and a similarly effective antidysenteric serum must Hkewise contain the antibodies for the Shiga and Flex- ner types of dysenteric bacilli. Thus far, a therapeu- tically effective antiserum has been produced only for Type I pneumococcus, and it is without value in any other form of pneumococcus pneumonia than that due to Type I pneumococcus. No scientific basis exists, therefore, for the manufacture or the administration of a so-called "polyvalent" antipneumococcic serum. Bacterial vaccines thus far have demonstrated their usefulness in the prevention of typhoid fever, and in a less degree of cholera and bacillary dysentery, and they may have an application to the prevention of the type pneumonias when these affections become, as they rarely do, epidemic. Bacterial vaccines also have a limited therapeutic application in certain types of local infection, as furunculosis. Their wider employment, or the employment of similar products, in the treatment of acute generalized infections is to be resorted to, if at all, with great caution and under the realization that a local elaboration of healing antibodies at the site of inoculation has not been conclusively demonstrated, and that the added bacterial material must reach the internal organs and thus the seats of disease. r. ANTISTREPTOCOCCUS SERUM AND STREPTOCOCCUS VACCINES * GEORGE H. WEAVER, M.D. CHICAGO Antistreptococcus serums have not proved of great value, and the routine treatment of all cases of strepto- coccus infection with serum is not desirable. In any case its use should always be preceded by a bacterio- logic diagnosis. The serum appears to owe its activity largely to the specific opsonins which it contains. The opsonins are not present in high concentration, and consequently only large doses of serum can be expected to possess therapeutic activity. In addition to the opsonins, active leukocytes are essential in the process of destruction of the streptococci, and so it is very important that treatment be instituted early in the infection before the phagocytic properties of the leuko- tytes have been reduced by the disease. Polyvalent antistreptococcus serums are prepared with the idea that they will be active in all sorts of streptococcus infections. It has been found in the case of anti- meningococcus and antipneumococcus serum that, as polyvalence increases, the curative power over each individual strain is less. This probably also holds true in antistreptococcus serum. It might be desirable to have serums prepared from each type of streptococcus so that each case could receive the serum corresponding to the type of infecting organism. Favorable conditions for the use of the serum exist in local infections in which the serum may be brought directly in contact with the bacteria, as in wounds, meningitis, pleuritis, etc. Wounds infected by strep- tococci may tie freely bathed with the serum. In strep- tococcus meningitis the serum may be injected intra- spinally in doses of from 20 to 30 c.c, and this may be combined with intravenous or intramuscular injections. Intrapleural injections of 30 to 50 c.c. may be given after aspiration. In general infections, intravenous or intramuscular injections may be used, the dose of * From the John McCormick Institute for Infectious Diseases. ANTISTREPTOCOCCUS SERUMS 15 serum in the former case being 20 to 50 c.c, in the latter, 50 to 100 c.c. The shock following very quickly on the injection of serum may itself be a danger. The usual serum reaction, developing its symptoms several days after the serum has been given, may add to the gravity of the patient's condition. The severe urticaria with intense itching, together with nausea and vomiting, which may be very persistent, interferes with the tak- ing of food and rest, and helps to use up the patient's reserve. In all cases the harm from severe intoxica- tion from large doses of foreign serum must be care- fully balanced against the possible benefit secured. When this is done, very few patients with general streptococcus infection will receive the serum. When it seems desirable to administer the serum, the patient's susceptibility to horse serum may be deter- mined by the intradermal injection of a small amount of the serum. In the absence of local reaction, serum may be given without hesitation ; but if a local reaction occurs, the patient should be desensitized by the admin- istration of a very small primary dose, followed at intervals by gradually increasing quantities. Streptococcus vaccines should always be autogenous. The importance of this is more apparent as the study of streptococci by more refined methods has shown that there are jnany strains of streptococci which differ among themselves in essential immunologic peculiari- ties. A vac'cine prepared from one strain might be worthless against an infection by another one. There is nothing to say in favor of a polyvalent streptococcus vaccine, supposed to be active against all types of strep- tococci. In multiplying the strains, the quantity of each becomes so reduced that the essential one, if pres- ent, is in such small amount as to be without thera- peutic effect. Streptococcus vaccines are contraindicated in acute and general infections. In these circumstances the body is already exerting all its powers to produce anti- bodies to counteract the infection. The addition of still more bacterial toxin results only in harm. In streptococcus septicemias, vaccines are useless. In sub- acute and chronic local streptococcus infections, autog- enous vaccines, given subcutaneously, sometimes act very favorably. This is especially true of infections 16 BIOLOGIC THERAPY of mucous surfaces unassociated with accumulations in poorly draining cavities. The initial quantity should be small, from 10 to 20 million, and in subsequent injections the amount should be gradually increased. Moderate local reaction is desirable, but general symp- toms usually indicate that the dose given has been too large. The reaction from one injection should subside completely before another is given. 11. USE OF VACCINES AND SERUMS IN GONORRHEAL URETHRITIS AND ITS COMPLICATIONS JOHN T. GERAGHTY, M.D. BALTIMORE Following the introduction by Wright of his views on vaccine therapy, this principle was applied exten- sively to the treatment of acute and chronic gonorrheal urethritis and its complications. For several years following the introduction of this form of therapy, the literature was filled with most conflicting statements regarding its value. Some observers were most enthu- siastic, while others noted no benefit from its employ- ment. It gradually became very evident in the minds of those best trained to judge that gonorrheal vaccines, as first suggested, were practically useless. Various modifications of gonorrheal vaccines were introduced by different workers to secure results, but all of these modifications, including polyvalent, autogenous and stock vaccines, have proved equally vajueless. The question of dosage has also received considerable atten- tion at the hands of many investigators, but no appre- ciable difference in results were obtained, whether the dosage was large or small. While the results following the use of vaccines in the treatment of acute and chronic gonorrheal infections of the urethra have been unproductive of definite results, one sometimes sees in the acute complications, such as arthritis and epididymitis, most brilliant responses. It has been shown, however, very definitely that the response is in no way the result of a specific action of the vaccine, as identical results have been obtained by the employment of other vaccines and foreign proteins. In most instances in which favorable results have been obtained in the gonorrheal complications, acute reactions have followed the use of the vaccine, such as temperature elevation and leukocytosis. These reac- tions are frequently quite alarming and are not entirely devoid of danger. 18 BIOLOGIC THERAPY It can be stated definitely that gonorrheal vaccine or any of its modifications is utterly useless in the treat- ment of acute or chronic gonorrheal urethritis. The occasional symptomatic relief in epididymitis and arthritis is not the result of specific action, and the benefit derived is not proportional to the risk incurred. In acute gonorrheal epididymitis, the intramuscular use of horse serum is followed in about 50 per cent, of the cases by a rapid subsidence of pain and tenderness. From 5 to 15 c.c. of serum is usually injected deep into the lumbar or gluteal muscles. In cases reacting favorably to this treatment there is marked sympto- matic improvement in from three to five hours. It should be noted, however, that it exerts no influence whatsoever on the pathologic process in the epididymis, and resolution is not accelerated, nor does it alter the course of the urethral infection. ni. THE USE OF ANTIMENINGOCOCCUS SERUM IN THE TREATMENT OF , EPIDEMIC MENINGITIS * KENNETH D. BLACKFAN, M.D. BALTIMORE Epidemic meningitis, cerebrospinal fever or spotted fever has occurred in sporadic or epidemic form almost continuously since the pandemic of 1904.^ Before the world-wide epidemic there was no specific treatment for this disease. Jochmann, KoUe and Was- sermann, and Flexner and Jobling first protected ani- mals against the meningococcus and later prepared a therapeutic serum. The results with antimeningococ- cus serum when injected into the lumbar subarachnoid space of patients have been so satis fastory that it is almost universally employed. The treatment of menin- gococcus meningitis was revolutionized by the specific serum. The mortality figures collected before serum treat- ment, compared with those following the use of the serum, leave no doubt as to the effectiveness of this form of therapy. During the preseriim period the mortality recorded was about 80 per cent, in this coun- try, 70 per cent, in England, 75 per cent, in France and 60 per cent, in Germany. Since the use of the specific serum, the gross mortality has been reduced to about 30.9 per cent. The importance of early administration of the serum is well illustrated by statistics that have been collected by different observers, given in the accompanying table. Unsatisfactory results from the use of antimeningo- coccus serum are due in a large part to the absence in the serum of antibodies for the infecting organism, to the serum's not being highly potent, and to lack of sufficiently intimate contact with the diseased process. During the late war an epidemic of menin- gitis in one of the belligerent forces was attended * From the Harriet Lane Home, Johns Hopkins Hospital, and the Department of Pediatrics, Johns Hopkins University. 1. The contributions of Dr. Simon Flexner have been used for reference in the preparation of this paper. 20 BIOLOGIC THERAPY COMPARATIVE MORTALITY REPORTED BY VARIOUS OBSERVERS * Christo- Flexner Netter Dopter mahos Levy Flack Per Per Per Per Per Per Treatment began Cent. Cent. Cent. Cent. Cent. Cent. Before third day 18.1 7.1 8.2 13.0 13.2 9.09 From fourth to seventh day . 27.2 11.1 14.4 25.9 20.4 After seventh day 36.5 23.5 24.1 47.0 28.6 50 * Flexner, Simon: Mode of Infection, Means of Prevention and Specific Treatment of Epidemic Meningitis, J. A. M. A. 69: 639 (Aug. 25), 721 (Sept. 1) 1917. by so high a mortality in spite of administration of antimeningococcus serum that this treatment was vir- tually discontinued. On investigation, however, it was found that the potency of the antimeningococcus serum that had been used was almost nil. With a properly standardized serum the mortality was reduced imme- diately. Similar instances have been reported. Antimeningococcus serum is prepared by immunizing horses with different strains of meningococci. The immunization is continued for a period of months or until a high degree of immunity has been reached. The horses are then bled, and the serum is preserved by the use of tricresol and kept sterile until used. A poly- valent serum standardized against all of the representa- tive strains of meningococci should always be employed in the treatment of meningococcic infections. If the response of the patient to the antiserum is not satisfac- tory, then agglutinating tests should be made to deter- mine whether the serum used contains agglutinins for the organism isolated from the patient. Monovalent serum should be used only after the type of meningo- coccus has been determined. Its superiority over the polyvalent serum made in this country has not been demonstrated. In the intraspinal treatment of epidemic meningitis there are several fundamental principles to keep in mind in order to secure the best results with the specific serum : 1. A serum potent for the causative meningococcus should be employed. 2. The serum should be injected as early as possible in the course of the disease. 3. The sertim should be injected into the spinal canal or into the ventricles or both so that it comes directly in contact with the meningococcus. ANTIMENINGOCOCCUS SERUM 21 4. The chief action of fhe serum is to destroy the organism. For this reason it must be constantly present in as great a concentration as possible. Therefore it should be injected at frequent intervals and in as large amounts as are safe. 5. Serum should be discontinued only after the disappear- ance of the organisms and with improvement in the general condition of the patient. The frequency with which antimeningococcus serum is used depends on the severity of the infection and the duration of the infection before treatment is instituted. In a suspected case of meningitis, lumbar puncture should be performed ; and if a cloudy fluid is obtained, antimeningococcus serum should be administered with- out waiting for the bacteriologic report. Should the case eventually be shown not to be due to the meningo- coccus, no harm will have been done. In the cases of average severity when seen within the first two or three days after the onset, the injection should be repeated every twenty-four hours for three or four doses. In cases of greater severity the injection should be repeated every twelve hours for three or four doses, and thereafter every twenty-four hours. Even with improvement in the general condition of the patient and after the disappearance of visible organisms from the spinal fluid, it is advisable to give two or three suc- cessive doses to guard against a relapse. The per- sistence of the meningococci in the cerebrospinal fluid necessitates the continuance of daily injections of serum until the organisms have been destroyed. After serum treatment has been discontinued, lumbar puncture should be performed, after an interval of several days, and cultures and cytologic studies of the cerebrospinal fluid made. , The reappearance of the signs of meningitis is an indication to repeat lumbar puncture. The demonstra- tion of organisms by culture or in stained smears requires the further administration of serum. After the institution of treatment, if the symptoms of meningitis persist or if the symptoms reappear, even with failure to demonstrate organisms, or if it becomes impossible to obtain cerebrospinal fluid by lumbar puncture, the possibility of a hydrocephalus should be considered. Failure to obtain cerebrospinal fluid may be due to an exudate so thick that it will not flow through the lum- bar puncture needle. If one is confident that the spinal 22 BIOLOGIC THERAPY subarachnoid space has been entered, any one of the foregoing contingencies indicates the administration of serum into the ventricle, through the open fontanel or a trephine opening. Then the serum should be intro- duced directly into the lateral ventricle at twenty-four hour intervals. When possible, the serum is injected intraspinally as well. Improvement frequently follows promptly the intraventricular injection of serum. Sev- eral patients whom I have treated recovered after four or five intraventricular injections of serum. The amount of serum that is introduced into the spinal canal is determined by the amount of cerebro- spinal fluid withdrawn by lumbar puncture. The amount of serum injected should never exceed the amount of cerebrospinal fluid withdrawn. The amount for adults is from 30 to 60 c.c. In infants and children the amount varies from 10 to 20 c.c, or from 5 to 10 c.c. less serum than the amount of cerebrospinal fluid withdrawn. When only small amounts of cere- brospinal fluid are obtained, not more than 5 c.c. in children or 10 c.c. in adults should be injected. Larger doses can be introduced into the ventricles than into the spinal subarachnoid space, but here also the amount injected should not exceed the amount of cerebrospinal fluid withdrawn. • The proper method of introducing serum into the lumbar subarachnoid space and into the ventricle is the gravity method. By this method the serum runs in slowly and at a regular rate, and the normal circulatory and respiratory variations of the cerebrospinal fluid in the subarachnoid space are not disturbed. The injec- tion of serum with syringe is not recommended. Grave symptoms occasionally follow the introduction of serum into the spinal subarachnoid space. For this reason the lumbar puncture needle should be left in place for a few minutes after the serum has been given, so that the fluid may be removed qiiickly should they arise. The symptoms are due, as has been shown experi- mentally, either to increased cerebrospinal pressure or the too rapid introduction of serum. They are irregu- lar and rapid pulse, cyanosis, rapid and feeble respira- tions, and cessation of respiration. If these occur, cerebrospinal fluid should be withdrawn, respirations maintained by artificial means, and respiratory stimu- ANTIMENINGOCOCCUS SERUM 23 lants given. Too rapid or too complete removal of the cerebrospinal fluid also may be followed by collapse. Although the injection of antimeningococcus serum into the lumbar subarachnoid space has been attended by very considerable success, experience during the recent war has led a number of clinicians to revive a method advised several years ago, namely, the injection of serum into the blood as well as into the subarachnoid space. The intravenous administration is indicated theoretically by the occurrence of a primary ^jlood infection before the onset of the meningeal infection. This has been established by blood cultures in a certain proportion of cases. As a rule, however, it occurs early and is a transitory invasion. The chief and dan- gerous mobilization of organisms is in the meninges. It cannbt be denied that the intravenous injection of the serum is a logical procedure when the cases are recog- nized during the premeningitic stage of the disease. The diagnosis at this stage of the disease is difficult to make, and except in the midst of epidemics, the vast majority of the cases are not recognized before the development of the meningeal symptoms. After this time there is usually no bacteremia. A few observers contend that the course of the disease is shortened and the mortality is reduced by the combined intravenous and intraspinal method of treatment. Whether this is so only in cases of meningitis with an associated blood infection, or whether it applies as well to cases of men- ingitis without organisms in the blood, is not entirely proved by the available evidence. It would seem rational and advisable to give serum intravenously in all cases were it not for the fact that the intravenous injection of antimeningococcus serum is associated invariably with a severe systemic reaction. This reaction, in my experi- ence, has been much more severe than the reaction attending the injection of serum into the subarachnoid space. Whether this is a true anaphylactic reaction or an endotoxic reaction is not clear. Almost all observ- ers refer to the reaction that follows the intravenous injection of antiserum; there are but few records of its having been followed by serious consequences in adults. The reverse is true in children. I have seen two children whose, death was apparently hastened by its use, and for that reason I am inclined to discourage intravenous administration of serum in children except 24 BIOLOGIC THERAPY in meningococcemia, alone, or in those cases of men- ingitis in which the organism persists or reappears in the blood. Extreme care should be exercised when the serum is administered intravenously either to children or adults. The procedure advised is as follows : The patient first should be desensitized by a subcutaneous injection of 1 c.c. of serum. One hour later, from 80 to 150 c.c. (the dose for children is modified accord- ingly) is injected into the vein. The first 15 c.c. is injected by syringe or gravity method at the rate of 1 c.c. per minute. After that the serum is injected more rapidly. The injection is repeated according to the severity of the symptoms every twelve to twenty- four hours until the process has subsided. If symptoms (cyanosis, rapid pulse and collapse) occur, the injection should be discontinued and the attempt repeated later. The alarming symptoms are combated by 1 c.c. of epinephrin chlorid, 1 : 1,000 solution, and %oo grain of atropin by hypodermic injection. Treatment by the intraspinal method should be continued together with the intravenous method. In the treatment of the complications of meningo- coccus infection, such as arthritis and pericarditis, the antimeningococcus serum should be brought into direct cpntact with the infecting organisms. Serum disease occurs in from one third to one half of the patients treated with antimeningococcus serum The severe reactions following the intravenous or intra- spinal injection of serum are treated in the manner mentioned above. Whenever antimeningococcus serum is given, measures to combat these conditions should be at hand. True anaphylaxis, if it develops, requires the desensitization of the patient to horse serum if further injections are indicated. IV. SERUM TREATMENT OF BACIL- LARY DYSENTERY * SIMON FLEXNER, M.D. NEW YORK Bacillary dysentery occurs in all countries, but it is more frequent in tropical than in temperate climates and prevails little or much according to the state of sanitation of the region. The dysenteric bacilli are taken into the stomach with food or drink to which they have gained access, directly or indirectly, frorn the feces of cases of bacillary dysentery or from car- riers — convalescent or healthy — of the bacilli. In mode of communication, bacillary dysentery resembles typhoid fever ; but it is not preventable by vaccination as IS the latter disease, because of the severe local reaction that the injection of killed cultures of dysenteric bacilli sets up. ' VARIETIES Two groups of dysenteric bacilH exist. The first was discovered by Shiga in Japan and bears his name, the second by Flexner in Manila. All Shiga bacilli are identical, but there are several kinds of Flexner bacilH, distinguished from one another by minor cultural and immunity reactions. The distinction between the Shiga and Flexner groups of bacilH is, however, far greater; thus, while all the Flexner group react immunologically more or less to a serum prepared from one of its members, this immune serum has little effect on Shiga bacilli, and vice versa. In one essential respect all the dysenteric bacilli agree, namely, in inducing in man the symptoms and intestinal lesions of dysentery, which sometimes are mild and sometimes severe. Both g'roups pf bacilli are alike in this action, but infection on the whole with the Shiga bacilli tends to be more serious than infection with the Flexner group of bacilli. TOXINS The Shiga bacilli yield two toxins : one soluble, which is quickly passed into the surrounding medium, * From the Laboratories of the Rockefeller Institute for Medical Research. 26 BIOLOGIC THERAPY so-called exotoxin, and one more closely fixed to the cell protoplasm, so-called endotoxin. When both toxins are injected into the rabbit, the first attacks the central nervous system and the second attacks the intestinal tract. The Flexner bacilli yield only an endotoxin. ANTISERUMS When animals are injected with cultures of the Shiga bacillus, an aintiserum is obtained which con- tains antibodies both for the exotoxin and for the endotoxin. This antiserum is neutralizing for the poisons of the Shiga bacilli, and protective against infection with the living bacilli. When animals are injected with cultures of the Flexner group of bacilli, an antiserum is obtained neutralizing to the endo- toxins and protective against infection with the bacilli themselves. The horse is subject to immunization both with the Shiga and with the Flexner group of bacilli and the serum yielded constitutes the therapeutic antidysentery serum. Because of the differences existing between the Shiga and Flexner bacilli, it is usual to immunize horses separately to the two kinds. The serum obtained may be applied separately in the treatment of dysenteries induced by the Shiga or Flexner bacilli, respectively, as determined by precise bacteriologic examination, or after mixing together in cases of bacillary dysentery in which the particular infecting bacillus has not been thus determined. Such a mixed serum yields the so-called polyvalent antidysentery serum which, if potent, should contain antibodies for all the toxins contained in the Shiga and Flexner groups of bacilli. SERUM TREATMENT Many reports of the serum treatment of bacillary dysentery have now been made, and they are remark- ably concordant in attesting its value. Like all other acute infectious diseases subject to serum treatment, the earlier the antidysentery serum has been applied in the course of the attack, the more striking and con- vincing the result. The precautions to be observed .in the administration of the serum are identical with those practiced with other antiserums, and consist of cleanliness of operator and patient, sterility of syringe BACILLARY DYSENTERY 27 and other apparatus employed, and protection against hypersensibility (anaphylactic reaction). The antiserum is, as a rule, injected subcutaneously,' but may be injected intravenously when indicated in very severe cases. The dose varies with the age of the patient and the severity of the symptoms. The average dose for an adult is 20 c.c, for a young child 10 c.c. But in very severe cases the dose, given intra- venously, ranges from 50 to 100 c.c. In cases of ordinary severity, a single subcutaneous dose may be followed by such marked alleviation of the symptoms as not to caTl for repetition. In other and severer cases, the dose may need to be repeated in from twelve to twenty-four hours, and again in forty-eight hours. The effects of the injection of the serum tend to appear promptly. They consist first in the ameliora- tion, often within a few hours, of the nervous symp- toms and the general prostration. Usually within twenty-four hours the tenesmus and colic disappear and the stools become markedly reduced in number. Along with this improvement there goes diminution in the blood and mucus content of the discharges, coincident with which there is a return of their fecu- lent character. According to the severity of the attack, the stools return to normal in from two to five days. Acute cases of bacillary dysentery are especially subject to the serum treatment, but cases in theit second to third week may still be favorably influenced, as may also relapses in the course of convalescence from acute attacks. On the other hand, chronic cases and the recrudescences in the course of chronic dysen- tery, even if originally induced by the dysentery bacilli, do not as a rule respond to the serum. It should be added that the employment of the serum does not contraindicate the usual eliminative and die- tetic forms of treatment. MORTALITY The - mortality from bacillary dysentery varies widely. As already stated, the Shiga bacillus infec- tions tend' to be severer than the Flexner group infec- tions, but this relation may be reversed. Different outbreaks and epidemics show fatalities ranging from 5 to 50 per cent. Certain comparisons have been insti- 28 BIOLOGIC THERAPY tuted between serum treatment cases and cases- not so treated. In general, it may be stated that mild out- breaks in which the ordinary mortality is from 10 to 15 per cent, may give a fatality of from 1 to 2 per cent, under the serum treatment, and the severer epidemics in which ordinarily the mortality range is wider, reaching even 50 per cent., may under the serum treat- ment fall to about 10 per cent. SERUM PROPHYLAXIS The polyvalent antidysentery serum may be used to prevent infection with dysenteric bacilli. Perhaps the especial circumstances under which this mode of use is indicated is in institutional outbreaks of the disease. The usual prophylactic dose is 5 c.c, injected subcu- taneously. It is important, however, to bear in mind that the protection thus afforded endures only twelve to fourteen days. SERUM DISEASE The administration of antidysentery serum, as of all other serums prepared in the horse, may be fol- lowed by the symptoms of serum disease. These symptoms, while sometimes producing discomfort, are not serious and are to be combated in the manner fol- lowed in other and more familiar instances (as diph- theria) in which they arise. V. THE USE OF ANTITOXIN IN THE TREATMENT OF DIPHTHERIA WILLIAM H. PARK, M.D. NEW YORK Antitoxin as used is prepared by a precipitation of the antitoxin and "soluble" globulin from the serum? of immunized horses. By this process a considerable portion of the serum proteins are eliminated, while the antitoxin properties are retained. The local lesions and the constitutional eiTects of uncomplicated diphtheria are almost wholly due to the action of the specific diphtheria toxin. It is true that there are also endotoxins; but these are much less poisonous and probably do slight damage except when the lungs are invaded. The complications of diph- theria, for example, pneumonia, are frequently due to other bacteria, such as the pneumococci and strep- tococci. The treatment of early uncomplicated diphtheria is therefore largely directed to the neutralization of the toxin by antitoxin. When the disease has existed for some days or when complications, such as pneumonia due to other micro-organisms, have arisen, the use of antitoxin, while still indispensable, is no longer equally effective, as it has no power whatever to neutralize other poisons or beneficially to affect cells already injured. Fortunately, the diphtheria toxin requires considerable time to penetrate the deeper tissues and pass by the lymph stream to the blood and from the capillaries to the tissues of the body. In uncomplicated diphtheria the patient recovers, if the toxin is neutralised by the antitoxin before it has caused irreparable injury. The proper administration of antitoxin requires, therefore, that it be given so as to reach the toxin in sufficient amount at the earliest practical moment. Antitoxin, unlike most remedies, is slowly absorbed into the general blood stream from the tissues when given subcutaneously. This characteristic influences 30 BIOLOGIC THERAPY the methods used in administering it. ITius, if a child weighing 25 pounds receives 10,000 units subcutane- ously, there will be a gradual accumulation of anti- toxin in the blood which will reach about 1.5 units in each cubic centimeter at the end of twelve hours. An intramuscular injection is absorbed about three times as rapidly. An intravenous injection makes the whole amount of antitoxin immediately available. The potency of the blood would amount to about twelve units per cubic centimeter. As it is necessary for anti- toxin to enter the blood stream before it passes to the tissues that are in contact with the toxin, it is evident that the intravenous method has an immense advantage. The dosage of antitoxin in a patient cannot be deter- mined as in a test tube by the amount of toxin present. In no case is sufficient toxin elaborated to require more than 100 units of antitoxin to bind it completely. Immensely larger doses are properly given so as to AMOUNT OF ANTITOXIN IN THE TREATMENT OP A CASE Late Mod- Severe and Mild Cases Early erate and Mallg- Moderate Early Severe* nant* Units Units Units Units Infants, 10 to 30 lbs. in weight, under 2 yrs.. 2,000 to 3,000 3,000 to 5,000 5,000 to 10,000 7,500 to 10,000 Children, 30 to £iO lbs. in weightj under 15 yrs. . 3,000 to 4,000 4,000 to 10,000 10,000 to 15,000 10,000 to 20,000 Adults, 90 lbs. and over in weight 3,000 to 5,000 5,000 to 10,000 10,000 to 20,000 20,000 to 50,000 Method of ad- ministra t i o n advised Intramuscular Intramuscular Intravenous Intravenous * When given intravenously, the smaller amounts stated. reach the free toxin everywhere quickly and in ade- quate amount. Antitoxin remains in the body for sev- eral days. When given intramuscularly or subcutane- ously, the blood has its highest antitoxin value from twenty-four to seventy-two hours after the antitoxin globulin has been injected into the tissues. When given intravenously, the blood's greatest antitoxin content is at the moment of injection. Thus, in the case of the child of 25 pounds, the blood would contain at the end of forty-eight hours, if given a single dose of 10,000 ANTITOXIN IN DIPHTHERIA 31 units subcutaneously or intramusciilarly, about four units per cubic centimeter, and if given intravenously, about eight units. This persistence of the antitoxin in the blood for a number of days is not grasped by most physicians. On this misunderstanding is due the use of the multiple dose. Observations extending over years in the hospitals of New York City have added clinical to experimental evidence that a single dose of sufficient quantity is all that is required in any case. If the first dose is sufficient, later injections, though not harmful, are useless. An insufficient first dose, however, cannot be wholly compensated for by later injections. Founded on the foregoing considerations, the directions for the use of antitoxin may be con- densed as in the accompanying table. Cases of laryngeal diphtheria, moderate cases still active and seen late at the time of the first injection, and moderate cases of diphtheria occurring as a com- plication of the exanthems should be classified and treated as "severe" cases. In all cases a single dose of the proper amount, as indicated in the schedule, is recommended. Before the remedy is administered, the skin should be sterilized at the point of injection with tincture of iodin or other disinfectant. The syringe should be thoroughly sterilized. It is better not to employ mas- sage over the point of injection, when the antitoxin is given intramuscularly or subcutaneously. In cases of any severity in which diphtheria is sus- pected, and in cases of croup, it is far better to admin- ister the remedy at once, making a culture at the same time, than to delay the treatment until a diagnosis has been verified by bacteriologio examination. One large dose -given early is far more efficacious than the same amount in divided doses. Antitoxin for intravenous injection should be highly potent and show no tur- bidity. It must be warmed to the body temperature and given very gradually. One minute should be allowed for the injection of each cubic centimeter. IMMUNIZATION When children or adults have been exposed to diph- theria, they may be protected from the disease by the subcutaneous administration of from 500 to 1,000 units, 32 BIOLOGIC THERAPY ' the smaller dose being sufficient for infants and young children. The protection does not last longer than from two to four weeks. The injection should be repeated if danger of infection persists longer than three weeks. Before immunizing members of a house- hold exposed to diphtheria, it is often advisable to determine by the Schick test whether they have natural immunity and are therefore not in danger of contract- ing the disease. Three toxin-antitoxin injections pro- duce permanent immunity in about 90 per cent. of. the nonimmunes. DELETERIOUS EFFECTS OF ANTITOXIN GLOBULIN Deleterious effects of antitoxin globulin are probably not due to the antitoxin as such but to the accompany- ing globulin. An intravenous injection may be fol- lowed by a chill and an accompanying rise of tempera- ture which lasts for about two hours. Rather fre- quently, from two to seven days after the antitoxin injection an urticarial rash develops, and with this there may be a slight rise in temperature. Much more rarely, scarlatiniform or other types of rashes with a rise of several degrees of temperature and other constitutional disturbances occurs. Complete recovery always ensues. Entirely distinct from these slight effects are occasional severe disturbances. A few minutes after an injection about one in every thousand persons develops a rapid and feeble pulse, nausea and a feeling of suffocation. With stimulation and, if necessary, artificial respira- tion, recovery soon ensues. Those who frequently suf- fer from attacks of asthma are liable to an attack after an antitoxin injection. There have also been recorded a few deaths. These have occurred chiefly and perhaps wholly in cases of status lymphaticus. About one death has occurred for every 70,000 persons injected, and these deaths, with possibly two exceptions, have fol- lowed the first serum injection. The fear of repeating a serum injection because of having sensitized the patient is almost wholly groundless. There need be no fear in giving a second intramuscular or subcutaneous injection to any person who has not suffered severely from the first. The only difference in the effects of the two injections will be that the serum reaction will ANTITOXIN IN DIPHTHERIA 33 follow almost immediately the second injection. If the second injection is given intravenously after a con- siderable lapse of time, it should be given even more slowly than the first. If it is necessary to give anti- toxin to persons who are liable to attacks of asthma, it is well to give it In divided doses. One-tenth c.c. of serum every fifteen minutes will usually be borne with- out disagreeable effects. VI. THE SERUM TREATMENT OF ACUTE POLIOMYELITIS* HAROLD L. AMOSS, M.D. NEW YORK A definite and enduring immunity is established by an acute attack of poliomyelitis both in the human being and in the experimentally infected monkey, and in both instances the convalescent serum contains sub- stances neutralizing the poliomyelitic virus. Flexner and Lewis ^ were able by the intraspinal injection of convalescent serum both from monkey and from man to delay and in some cases prevent altogether the onset of the disease in monkeys which had received intra- cerebral injections of the virus. Netter and his asso- ciates ^ have used human convalescent serum injected intraspinally in the treatment of human cases, with some degree of success. More recently, Amoss and Chesney ^ employed combined intraspinal and intra- venous injections of relatively large amounts of the convalescent serum with still more promising results. THE SERUM Attempts to produce an immune serum for the virus of poliomyelitis in animals other than the monkey have thus far not been successful. At present persons who have recovered from an acute attack of poliomyelitis constitute the only available source of serum for treat- ment. The collection and testing of serum require considerable time, so that they should be undertaken as early as possible after the appearance of epidemic poliomyelitis in a region. The treatment is scarcely adapted to the sporadic disease. Netter has used as a source of the therapeutic serum persons who have had an attack as remote as thirty * From the Laboratories of the Rockefeller Institute for Medical Research. 1. Flexner, Simon, and Lewis, P. A.: Experimental Poliomyelitis in Monkeys, J. A. M. A. 54:1780 (May 28) 1910; 55:662 (Aug. 20) 2. Netter, A.: Bull, de I'Acad. de mM., Series 3, 74:403, 1915 Netter, A., and Salanier, M.: Bull, et mem. Soc. med. d. hoo. de Paris' Series 3, 40:299, 1916. 3. Amoss, H. L., and Chesney, A. M.: J. Exper. Med. S5:5S1 (April) 1917. POLIOMYELITIS 35 years, although he states that the best results were obtained with serum from persons who had passed through an attack of the disease more recently — from six weeks to two years previously. If the serum is obtained from a patient who has passed the febrile stage and is in good physical cjondition, there appears to be no danger of transfer of the virus. COLLECTION OF THE SERUM Before blood is taken for the collection of serum, the donor is given a physical examination, and a Wasser- mann test is made with the blood. The amount of blood which may be withdrawn varies with the body weight and condition of health, and is in general from 500 to 700 c.c. in the case of an adult, and from 200 to 250 c.c. with the average child of 10 years. The serum separated from the clotted blood is inactivated at 55 C. for one hour and tested for sterility, then transferred to small sterile bottles. For general use outside the hospital it is preserved with 0.2 per cent, tricresol. The bottled serum, which should be free of hemoglobin, fat or particulate matter, is kept in the icebox until used. Serum from different individuals may be mixed, or "pooled." DOSAGE AND INTRASPINAL ADMINISTRATION The administration of serum after the febrile period has passed is of doubtful value; hence it is desirable to make the diagnosis early in • the attack ; in some instances this can be done before the onset of any paralysis. During epidemic! a microscope should be carried to the bedside, and while the needle is still in place during lumbar puncture the fluid is examined for cells and globulin. If the diagnosis of poliomyelitis is regarded as positive, the intraspinal injection of serum may be given immediately through the same needle, without a second lumbar puncture. The amount injected varies according to the amount of spinal fluid withdrawn and the estimated pressure. With the patient in the horizontal position, the fluid is withdrawn until only four or five drops per minute continue to escape. The amount of fluid in cubic centimeters less 10 is the amount of serum to be injected by the gravity method; however, if the pressure of the fluid is very 36 BIOLOGIC THERAPY great at the moment of lumbar puncture, correspond- ingly less should be given. The serum should be warmed to 38 C. before injection. INTRAVENOUS INJECTION After the intraspinal injection is accomplished, warmed serum (38 C.) is injected into one of fhe arm veins or, in small children, into the jugular vein. The amount to be given ranges from 40 c.c. in children up to 2 years to correspondingly larger amounts in older children ; a child of average weight at 9 years should receive from 80 to 100 c.c. While it is inadvisable to use serum even slightly tinged with hemoglobin intra- spinally or intravenously, it may be given subcutane- ously. Deeply colored serum should be discarded. The intraspinal and intravenous injections may be repeated after twenty-four hours if the temperature has not approached normal. SUMMARY Such definitely promising therapeutic results as have been obtained with serum in monkeys suffering from experimental poliomyelitis and in man suffering from the epidemic disease are limited strictly to the employ- ment of convalescent serum, in man from recovered human patients, administered either intraspinally alone, or, as seems better, both intraspinally and intravenously at the same time, early in the course of the disease and during the febrile period. VII. ANTIPNEUMOCOCCUS SERUM RUFUS COLE, M.D. NEW YORK Pneumococci have been divided on the basis of their immunologic reactions into four types. All of the pneumococci of each of the three types, named Types I, II and III, have immunologic properties very specific for each type. An immune serum that will protect mice against lethal doses of any strain of pneu- mococcus of one of these types will protect mice against all other strains of the same type, but it will not protect mice against lethal doses of any strain of any other type. Consequently, in any case of pneu- monia due to pneumococci of one of these types an immune serum can have therapeutic value only if the serum has been prepared by the immunization of horses against the particular type of pneumococcus which is the inciting agent in that case. The various strains of pneumococci of Type IV possess a high degree of individual specificity, so that it would not be practical to prepare or employ in treatment an immune serum efifective against pneumococci of this type. For certain reasons it is not probable that an immune serum against Type III pneumococci would be therapeutically effective in man. So far as Type II serum is con- cerned, clinical studies have shown that it is not pos- sible at present to obtain sufficiently favorable results to justify the routine employment of this serum. On the other hand, we now have evidence that the serum of horses immunized to Type I pneumococci is of great value in the treatment of cases of pneumonia due to Type I pneumococci. In view of the therapeutic efficacy of Type I serum, it is important that in every case of lobar pneumonia the type of pneumococcus concerned should be deter- mined at once. The so-called mouse method is the best for determining the type. The serum to be used is prepared by the repeated injection of horses, first with dead, then with living cul- tures of pneumococci. Type I. The serum should be of such potency that 0.2 c.c. of the serum will regularly 38 , BIOLOGIC THERAPY protect a mouse against at least 0.1 c.c. of an eighteen hour broth culture of pneumococcus, Type I, of such virulence that 0.000001 c.c. of the cuhure alone will kill a mouse of 20 gm. weight within forty-eight hours. In all cases of acute lobar pneumonia due to pneumo- coccus Type I, immune serum is indicated, and the treatment should be undertaken as early in the disease as possible after the type has been determined. The serum is injected intravenously. The amount of serum to be injected at the first dose is from 90 to 100 c.c, and this dose should be repeated every eight hours until the fall of temperature and amelioration of symptoms indicate that the infection has been overcome. The serum injected should be at body temperature, and it should be injected very slowly. The total amount required in the average case is from 200 to 300 c.c, though in severe cases, treated late in the disease, it may be necessary to employ much larger amounts, even as much as 1,000 c.c. The effectiveness of the serum is indicated by the following facts: 1. The blood of the patient becomes sterile following the injection of the serum. 2. The progression of the local lesion in the lung is arrested. 3. The subjective and objective symptoms of the dis- ease are ameliorated. 4. The mortality of the disease is reduced. The mortality rate in cases of lobar pneumonia due to pneumococci, Type I, not treated with serum has been shown to be from 25 to 30 per cent, or higher. Dn the other hand, among 195 cases treated with serum in the Hospital of the Rockefeller Institute, only eighteen deaths have occurred, a case mortality rate of but 9.2 per cent. Reports of 300 additional cases treated with serum have been collected from the litera- ture, making a total of 495 cases. The case mortality rate in these 495 cases has been 10.5 per cent. SERUM REACTIONS Following the injection of the large amounts of serum, certain untoward effects may occur. 1. Anaphylactic Reaction. — This type of reaction may also occur following the injection of foreign serum ANTIPNEUMOCOCCUS SERUM 39 by any method or for any purpose. It may be guarded against by proper methods. 2. So-Called Thermal Reaction. — This may occur from twenty minutes to an hour following the adminis- tration of the serum. It is probably identical with the reaction that may occur following the parenteral injec- tion of any kind of foreign protein. It is usually not serious, but is not believed to have any therapeutic value and should be prevented so far as possible. 3. Serum Disease. — Mild symptoms of serum dis- ease appear in about half the treated cases, severe attacks -only rarely, or in not more than 10 per cent, of the cases. • DESENSITIZATION Certain individuals are especially subject to anaphy- lactic reactions; they are asthmatics and patients who have previously received therapeutic or prophylactic injections of serum. In order to determine whether this hypersensitive state exists, it is well to inject intra- dermally 0.2 c.c. of a 1 : 10 dilution of horse serum with a control injection of an equal amount of physio- logic sodium chlorid solution. If sensitiveness is pres- ent, usually within five minutes a genuine urticarial wheal develops at the site of injection of the serum, and this increases slowly in size to that of a half dollar ; the wheal in turn is surrounded by a larger area of erythema. In all patients before the administration of therapeu- tic doses of antipneumococcus serum, it is also well to inject from 0.5 to 1 c.c. of serum subcutaneously a few hours before the intravenous injection. This will serve to overcome slight degrees of hypersensitiveness. If, however, it is found that marked hypersensitiveness exists, it is necessary to resort to slow desensitization. This is effected by injecting small amounts of the serum, at first subcutaneously, beginning with 0.025 c.c. and doubling the dose every half hour until 1 c.c. is given; then injecting 0.1 c.c. intravenously and doubling the dose every half hour until 25 c.c. can be given without untoward reaction. Four hours later, 50 c.c. may be given; and finally after an interval of eight hours, treatment may be continued in the usual manner. Fortunately, it is rarely necessary to resort 40 BIOLOGIC THERAPY to this tedious procedure. In all patients it is well to g-ive the first part of the first intravenous injection very slowly; this will serve as a desensitizing measure as well as an added means of detecting hypersensitive- ness. In order to combat promptly any severe anaphy- lactic symptoms, the physician should be prepared to inject 0.6 c.c. (10 minims) of 1:1,000 suprarenal extract (epinephrin). VIII. USE OF TETANUS ANTITOXIN IN PREVENTION AND TREATMENT OF TETANUS MATTHIAS NICOLL, Jr., M.D. State Deputy Commissioner of Health ALBANY, ■ N. Y. The "fulminating type of tetanus which occurred so frequently during the early months of the World War, when antitoxin for immunization was difficult to obtain, is not so commonly encountered in civil life, in which the symptoms of the disease are likely to develop more gradually and after aii- incubation period of a week or longer. It cannot be stated that experience gained during the war has modified to any extent the best medical opinion as to the dosage and methods of administra- tion of antitoxin, but it has emphasized the immense value of antitoxin in the prevention of tetanus and demonstrated the importance of freely cutting away -all dead tissue within and about extensively lacerated and contused wounds {debridement of the French). PREVENTIVE TREATMENT In every case of open wound accompanied by lacera- tion and crushing of tissue ; of punctured wounds made by iron nails, knives, sea shells, large splinters, etc., which cannot be .thoroughly sterilized; bullet wounds, blank cartridge wounds, or any wound into which city dirt or garden soil has been visibly or probably ground, an immunizing dose of tetanus antitoxin of 1,000 units should be given subcutaneously (500 units in the case of young children), the wound at the same time receiv- ing thorough surgical treatment. In those cases in which the wound continues to slough or show signs of infection, and in gunshot and deep seated wounds in which the condition of the wound tract cannot be definitely determined, the dose should be repeated within a week, and in certain cases again repeated after the same interval. 42 BIOLOGIC THERAPY CURATIVE TREATMENT The value of antitoxin in the treatment of tetanus depends directly on the promptness and method of administration. Every hour lost after the development of symptoms adds to the gravity of the prognosis. The subcutaneous method of administration is of extremely doubtful value; the intravenous method, even when massive doses are thus given, has proved very dis- appointing, while the value of the intraspinal method has been demonstrated beyond question.^ Every patient, especially with the history of a wound, however slight, but also without any such obtainable history, who presents the symptoms of a stiff jaw, coming on suddenly with tenseness of the masseter muscles on attempting to open the mouth, or with tonic spasm of the abdominal muscles causing a boardlike resistance to the touch, unless such symptoms can be definitely accounted for otherwise than by tetanus infection, should receive as soon as possible an intra- spinal dose of tetanus antitoxin of not less than 10,000 units, this dose to be repeated within twelve hours, and again repeated in twenty-four hours if symptoms continue. With the first intraspinal dose it is advis- able to give an intravenous dose of 5,000 or 10,000- units, with the object of immediately neutralizing any toxin present in the blood. Further use of antitoxin is of doubtful value. METHOD OF ADMINISTRATION The technic of administering an intraspinal dose of tetanus antitoxin is identical with that of the admin- istration of antimeningitis serum. On theoretical grounds, in order to facilitate the thorough dissemina- tion of the antitoxin throughout the spinal canal, it is advised to dilute the antitoxin with sterile physiologic sodium chlorid solution up to an amount of from 15 to 30 c.c. — the former in the case of young children. The use of general anesthesia is necessary when opis- thotonos is so marked as to render impossible the 1. Nicoll, Matthias, Jr.: Intraspinal Administration of Antitoxin in Tetanus, J. A. M. A. 64: 1982 (June 12) 1915. Parlt, W. H., and Nicoll. Mattlna-s, Jr.: Experiments on the Curative Value of the Intraspinal Admmistration of Tetanus Antitoxin, J. A. M. A 63-23'i (July 18) 1914. TETANUS ANTITOXIN 43 introduction of the needle between the spinous proc- esses, or if convulsions are continuous and easily incited. Serum should never be forced into the canal, but should flovif in slowly by gravity. The operation of administering antitoxin intraspinally is not a difficult one, but should never be undertaken by the inexperi- enced. In the event of no one of experience being obtainable, an intravenous dose of 10,000 units should be given at once rather than delay. In addition to the specific treatment the patient should be freed from every possible source of irritation, from noise, bright light, and fussy attention. The use of sedatives is usually indicated, but conservatism in the administra- tion of depressing sedatives is extremely advisable. SERUM COMPLICATIONS The administration of serum intraspinally, when properly performed, is subject to the same but no greater risk than the administration of serum intra- venously. Anaphylactic symptoms occasionally occur after an intraspinal dose of serum, and almost as rapidly as when the serum is introduced into the blood. If there is a reason to suppose that a patient is sensitized to horse serum, it is well to introduce the intraspinal dose unusually slowly and to stop the flow of serum imme- diately if the symptoms are very threatening ; or a few drops of serum may be introduced into a vein to test out the presence of sensitization before an intraspinal does is administered. However, in view of the fact that severe anaphylaxis has rarely been reported, and of the extremely bad prognosis in acute tetanus, the possible dangers attendant on the administration of tetanus antitoxin should be minimized and the risk incurred. IX. ACNE VACCINE THERAPY MARTIN F. ENGMAN, M.D. ST. LOUIS Although there are various controversial opinions as to the value of acne bacillus suspensions in the treat- ment of acne vulgaris, we are justified in saying that in certain types of this disease vaccines are of consid- erable value and act with specific effect. It must be admitted that B. acnes is the specific causative organ- ism of the disease known as acne vulgaris, or "poly- morphic acne" of Sabouraud. The histologic and bacteriologic study of the lesions of this disease demon- strates its causative relationship. The specific effect of the acne bacillus suspensions (vaccines) are best seen in the types of acne vulgaris known as acne indurata, and certain forms of cystic, acne in which the lesions lie deeper in the cutis. These vaccines have less effect on the more superficial types known as acne simplex and acne pustulosa, owing probably to the protection offered to the organisms by the walls of the follicles, as in these types they lie more superficially and are less accessible to immune bodies. Acne vaccines should be used in the types just men- tioned. In njy opinion, failure to obtain proper thera- peutic results in the use of this method has been due to the administration of too large doses or to too frequent administration of the vaccine. The acne bacillus is a difficult organism to cultivate on artificial mediums; autogenous vaccines, therefore, are almost prohibitive for common use in most instances on account of the time lost in making the preparation. Stock vaccines, properly checked and controlled, have been just as efficient. The initial dose should be from 3 to 5 million, to be repeated in from five to seven days. The interval should be gaged according to the reaction to the dose, which is usually exhibited by the appearance of a few new lesions within forty-eight hours after the injection. On the third day after the injection, comedones may be expressed and the lesions opened if necessary. The manipulation of the lesions at this time helps bring the ACNE VACCINE THERAPY 45 immunizing blood to the part and it is at the height of the "tidal wave of immunity." Local hyperemia in the form of hot towels or that resultant from manipu- lation should be used on the third day after each injec- tion and not before then. If, after a few such doses, new lesions continue to appear after the third day, a larger dose of from 7 to 10 million should be given and continued until a proper therapeutic result is obtained, when the interval of administration should be lengthened to two weeks, then three weeks, and finally four weeks, thus continuing the remedy in a prophylactic manner. If there is an outcrop of many new lesions within forty-eight hours after injection, the dose should be lessened and the interval of dosage extended. How- ever, if many new lesions appear after the third day, it is an indication for a much larger dose. In no instance should more than 15 million be administered in any injection. The staphylococcus vaccine in acne vulgaris is of little if any value. The same thing may be also said of the staphylococcus part of mixed acne bacillus and staphylococcus vaccines. Acne varioliformis, which occurs later in life than acne vulgaris and is of staphy- lococcus genesis, is markedly influenced by vaccines of Staphylococcus albus when given in suspensions of from 50,000 to 100,000 every five to seven days. Therapeutic effects in the deeper forms of acne vul- garis with properly prepared stock vaccines are, in some instances, remarkably beneficial. In the treatment of many hundreds of cases of acne vulgaris by this method, I have seen no untoward effects from treatment with the exception of a slight local reaction at the point of subcutaneous injection. Wall Building. X. VACCINATION AGAINST TYPHOID AND PARATYPHOID FEVERS* F. F. RUSSELL, M.D. AND H. J. NICHOLS, M.D. WASHINGTON, D. C. The value of antityphoid vaccination has been repeatedly demonstrated, and there is no question of its power to prevent infection. The protection is not absolute; some cases occur among the vaccinated, but their number is small. The results in the army are fully as good as if ndt better than those obtained against smallpox with vaccinia. Antityphoid vaccine, as usually administered, is a suspension in physiologic sodium chlorid solution of killed typhoid bacilli, together with their soluble products from young agar cultures. A thick suspen- sion is first made and is then standardized so that 1 c.c. contains 1,000 million bacteria. The paratyphoid bacilli A and B are treated similarly to produce the paratyphoid vaccine. At present a triple typhoid vaccine is used which contains 1,000 million typhoid bacilli and 750 millions of each of the two paratyphoids in each cubic centimeter. Sensitized living vaccines or serovaccines have been advocated by Besredka and others, but since they all contain living bacteria capable of multiplication under suitable conditions outside the body, there is some dan- ger from their general use ; experience has shown that ample protection may be obtained from killed bacteria, which are entirely safe. Lipovaccines have recently been advocated by Le Moignic, Whitmore and others because of the sim- plicity of the single dose ; this would be a great advan- tage if the amount of protection conferred were equal to that given by the saline vaccine ; but as gaged by the presence of agglutinins, the response is greatly inferior. The vaccine is regularly given in three doses, a week to ten days apart ; no harm arises from longer or * From the Army Medical School. ANTITYPHOID VACCINE 47 shorter intervals, but they are less convenient and the resulting immunity may not be so high. The best time of day for administration is about 4 in the afternoon, because if a general reaction supervenes, the greater part of it will be over before the next morning. The best site for the vaccination is the upper arm at the insertion of the deltoid, where the subcutaneous tissue is loose, The vaccine must always be adminis- tered subcutaneously, and never into the skin or into the muscles or veins. In the latter localities, absorption is rapid and the general reaction may be severe. A local reaction is almost invariably present, usually consisting of a red and swollen area, the size of the palm of the hand. The redness and swelling may extend to the wrist or upward to the clavicle; the axillary lymph nodes may be swollen. Nothing more than symptomic treatment is necessary, as the aseptic inflammation subsides within a day or two. Occa- sionally, induration or fluctuatioli may be detected, but no incision or drainage is necessary. The general reaction may be absent or mild or severe. It consists of headache, malaise, a rise of temperature, in severe cases to 104 or 105 for a short time, accompanied by nausea, vomiting and perhaps diarrhea and temporary albuminuria. These reactions ordinarily subside in a few days, and leave no sequelae. A week after the first dose, agglutinins and other antibodies begin to appear in the blood, and increase to a maximum about three weeks after the third dose, after which time they gradually diminish. The immunity, however, does not disappear at the same time, but continues to be present, no doubt in a dimin- ishing degree for years. After typhoid fever itself, which gives immunity for life, the antibodies in the blood are no longer detectable after about six months. The duration of the immunity is difficult to estab- lish, but it seems to be a matter of years rather than months. Much depends on the amount of exposure. For soldiers, who must have the maximum immunity obtainable, since in campaign they may have no other protection, revaccination should be carried out on the appearance of any typhoid fever among them. The same rule should apply to campers, contractors' gangs, lumbermen, civil engineers' f orces,and the like. Revac- cination among nurses, attendants and physicians con- stantly exposed to infection should be carried out 48 BIOLOGIC THERAPY annually. Children, 2 years old or more, bear the vac- cination better than adults, and should be revaccinated at two to three year intervals, the best time being just before going to the country on their summer vacation. INDICATIONS FOR VACCINATION Typhoid fever is still a common disease, particularly among young persons, and the possibilities of infection from water, milk and from temporary and permanent bacillus carriers are always present. The chances of infection are greater in the country districts than in the larger cities, and in backward than in highly civil- ized countries. Travelers are more exposed than natives, even in the same locality. In addition, the indications point to the wisdom of vaccinating all con- tacts of typhoid fever cases, in the same way that smallpox contacts are vaccinated. CONTRAINDICATIONS Since the basis of any vaccination is to obtain pro- tection against a possible danger, the vaccination is contraindicated when the danger from the vaccine itself is as great as the danger from the fever. Mor- tality tables indicate that the danger of infection is everywhere present, although the chances are much greater in some localities than in others. The danger from the vaccine itself is greatest in the case of appli- cants suffering from chronic disease of the kidneys. No one suffering from acute illness should be vac- cinated until his temperature has returned to normal and convalescence is well established. In the presence of an epidemic, tuberculosis of the lungs, either latent or active is not a contraindication. Neither typhoid fever nor vaccination seems to have any harmful effect on the progress of the tuberculosis. XL PNEUMOCOCCUS VACCINE RLTSSELL L. CECIL, M.D. NEW YORK Pneumococcus vaccine is a suspension of killed pneumococci in broth or salt solution. When the sus- pension is composed of a single strain of pneumococ- cus, the vaccine is "monovalent"; when the vaccine consists of several different strains, or types, of pneu- moccocus, it is "polyvalent." Autogenous pneumococ- cus vaccine is usually monovalent; most of the stock pneumococcus vaccines on the market are polyvalent. METHOD OF PREPARATION Pneumococci are cultivated from eighteen to twenty- four hours on plain or glucose broth. The culture after killing may be used directly or it may be centrifuged, and the sediment of bacteria be suspended in physiologic sodium chlorid solution. Finally it is heated at 55 C. for one-half hour to kill the pneumo- cocci, and the vaccine standardized by the Wright method or by means of a nephelometer. Cultures are taken to test the sterility of the vaccine, and tricresol is added to a concentration of 0.3 per cent, as a pre- servative. Pneumococcus lipovaccine is a modified vaccine, very similar to the saline, except that the bacteria are sus- pended in some vegetable oil instead of salt solution. It possibly is more slowly absorbed than the saline vaccine, and the reactions are not so sharp. Its anti- genic value, however, has been questioned, and it is not being manufactured at present by the army, nor has a government license been issued for interstate sale. METHOD OF ADMINISTRATION Pneumococcus vaccine is almost always administered subcutaneously. The proper method of giving the vac- cine is to pinch up the skin, and insert the needle well under the dermis. Intracutaneous injections may excite severe local reactions. Pneumococcus vaccine, if injected intravenously, induces a sharp constitutional reaction (chill, fever, so BIOLOGIC THERAPY leukocytosis, etc.) similar to that following the intra- venous injection of typhoid vaccine. This is the so-called "nonspecific protein reaction," which follows the intravenous injection of any foreign protein, and is occasionally employed in the treatment of certain forms of arthritis. Under ordinary circumstances, however, the intravenous injection of pneumococcus vaccine is strongly contraindicated. DOSAGE For therapeutic purposes, pneumococcus vaccine is administered in doses varying from 10 to 1,000 million pneumococci, or even more. For prophylaxis, much larger doses are used. In the U. S. Army from 3 to 9 billion was the dose of saline vaccine ; from 30 to 40 billion of the lipovaccine. In the case of saline vac- cine, three injections were given at seven day inter- vals, the first dose 3 billion, the second, 6 billion and the third, 9 billion. The lipovaccine was administered in one dose. REACTIONS Both the local and the general reaction vary greatly in different individuals. The smaller the dose, the milder the reaction. It is therefore desirable to divide the total dosage into as many inoculations as circum- stances make practicable. It should always be remem- bered, however, that up to a certain point, the larger the total dose, the higher will be the immunity con- ferred. In general it may be said that reactions to pneumo- coccus vaccine are similar to those following injections of typhoid vaccine. Within twenty-four hours fol- lowing the injection an area of redness and induration appears at the site of the inoculation, which is usually 2 or 3 cm. in diameter, but may be larger. Occa- sionally small sterile infiltrations, which disappear spontaneously, follow the injection of large doses. Such reactions appear to be an expression of cuta- neous hypersusceptibility. The constitutional reaction to pneumococcus vaccine is usually insignificant. In many cases it is entirely absent. In a small percentage of cases, vaccination is followed by headache or backache, general malaise, chilly sensations and rise in temperature. These symptoms, however, are of short duration. PNEUMOCOCQUS VACCINE 51 INDICATIONS FOR USE Prophylactic vaccination against pneumonia is indi- cated whenever large groups of individuals are living together under abnormal conditions. Pneumococcus vaccine has been used with succcess among the mine workers of South Africa and more recently in the United States. During the late war, pneumococcus vaccine was used extensively in some of the American army training camps as a prophylactic against lobar pneumonia. At Camp Upton, New York, Cecil and Austin ^ vaccinated 12,519 men against pneumpcoccus Types I, II and III. Three or four doses of saline vaccine were given at intervals of five to seven days with 'a total dosage of 6 to 9 billion of Types I and II, and 4 to 6 billion of Type III. The men were under observation ten weeks after vaccination, and during that time, no cases of pneumonia of the three types vaccinated against occurred among the men who had received one or more injections of vaccine. In a control of approximately 20,000 men, there were twenty-six cases of pneumonia, Types I, II and III, during the same period. Alto- gether, there were seventeen pneumonias of all types among the vaccinated 40 per cent, of the camp, and 173 pneumonias of all types among the unvaccinated 60 per cent, of the camp. Following the Camp Upton experiment, Cecil and Vaughan ^ undertook to vaccinate the troops at Camp Wheeler, Ga., against lobar pneumonia, using, in this instance, pneumococcus lipovaccine in place of the saline vaccine which had been employed at Camp Upton. The dosage employed in all cases was 1 c.c. of lipovaccine containing approximately 10 billion each of pneumococcus Types I, II and III. Of the entire camp strength, 13,460 men, or about 80 per cent., were vaccinated. The men were under observation from two to three months following vaccination. During this period, there were thirty-two cases of pneumo- coccus Types I, II and III pneumonia among the vaccinated four fifths of the camp, and forty-two cases of pneumonia of these types among the unvac- 1. Cecil, R. L., and Austin, J. H.: J. Exper. Med. »8: 19 (July) 1918. 2. Cecil, R. L., and Vaughan, H. F.: J. Exper. Med. 39:457 (May) 1919. 52 BIOLOGIC THERAPY cinated one fifth of the camp. The weekly incidence rate for pneumonia of all types among the vaccinated troops was conspicuously lower than, that for the unvaccinated troops. It will be seen from these figures, however, that the results of pneumococcus vaccination at Camp Wheeler were not so striking as those obtained at Camp Upton the previous winter. This difference was probably due to several factors, among which might be mentioned the influenza epidemic, which swept over the camp before vaccination against pneu- monia had been completed, and the use of a lipovaccine instead of a saline vaccine. Since this experiment was carried out, it had- been shown by Lewis and Dodge ^ that typhoid lipovaccine has less antigenic power than typhoid saline vaccine. Cecil and Blake * have tested the value of pneumo- coccus vaccine as a prophylactic against experimental lobar pneumonia in monkeys. They found that small subcutaneous doses of vaccine were not sufficient to protect monkeys against a subsequent pneumonia, though they did modify favorably the course of the disease. More recently, Cecil and Steffen ^ have found that when large subcutaneous or small intravenous doses of pneumococcus vaccine are used, the immunity against experimental pneumonia in monkeys is com- plete. Reports of the latter experiments have not yet been published. Industrial workers who are exposed to the cold and wet, also firemen and policemen, might be vaccinated against pneumonia with advantage. Certain persons are susceptible to pneumonia and suffer from repeated attacks of the disease. It is probable that a polyvalent pneumococcus vaccine might prevent further attacks of, the disease. THERAPEUTIC USE OF PNEUMOCOCCUS VACCINE Pneumococcus vaccine has been recommended by some investigators in the treatment of lobar pneumo- nia. There is very little experimental evidence, how- ever, in favor of such vaccination. Rosenow and 3. Lewis, P. A., and Dodge, F. W.: J. Exper. Med. 31: 169 (Feb 1 1920. '' 4. Cecil, R. L., and Blake, F. G.: J. Exper. Med. 31:519 (Mavi 1920. . ' 5. Cecil, R. L,, and Steffen, G. I.: Unpublished experiments. PNEUMOCOCCUS VACCINE S3 Hektoen,^ and more recently Rosenow,^ have advo- cated the use of partially autolyzed pneumococci in the treatment of pneumonia. The antigen is prepared by growing virulent strains of pneumococci of the differ- ent types in glucose broth from eighteen to twenty-four hours, centrifugalizing, and suspending the sediment in salt solution so that 1 c.c. contains about 15 billion, pneumococci. The suspension is shaken with ether and then incubated at 2,7 C. until autolysis has occurred, that is, until 95 per cent, of the organisms have become gram negative, and 5 c.c. of the suspension produce few or no toxic symptoms in guinea-pigs. The dose of this vaccine for adults is 1 c.c. administered sub- cutaneously every day until the temperature reaches normal. In a disease of so varied and uncertain a clinical course as lobar pneumonia it is a matter of great diffi- culty to be certain that a favorable or unfavorable out- come in a given case is the result of the giving or with- holding of vaccine or other proposed remedial agent, and not to the many factors which may possibly deter- mine the question of death or recovery. It is therefore believed that the greatest caution should be observed in recommending the treatment of pneumonia by vaccines of whatever modification, until the results are confirmed by large and well controlled series of cases. In subacute pneumococcus infections, such as unre- solved pneumonia, sinusitis or bronchitis, pneumo- coccus vaccine may be of therapeutic value. CONTRAINDICATIONS Pneumococcus vaccine is contraindicated in acute infections and in chronic pulmonary tuberculosis and nephritis. It should not be administered in large doses to patients with chronic cardiac disease, or to invalids, or to pregnant women after the fifth month. 19 East Sixty-Fifth Street. 6. Rosenow, E, C, and Hektoen, Ludwig: Treatment of Pneumonia with Partially Autolyzed Pneumococci, J. A. M. A. 61 : 2203 (Dec. 20) 1913. 7. Rosenow, E. C. ; Partially Autolyzed Pneumococci in the Treat- ment of Lobar Pneumonia, J. A. M. A. 70:759 (March 16) 1918. XII. RABIES VACCINE A. M. STIMSON, M.D. Surgeon, United States Public Healtli Service WASHINGTON, P. C. Rabies vaccine is prepared in a number of different ways from the same basic material, the fixed virus of rabies. It is important to realize that the one funda- mental and essential step in the preparation of rabies vaccine has been taken by accorriplishing the conversion of the virus of rabies from the condition in which it is found in Nature to the state in which it is known as fixed virus. The subsequent handling apparently is of less importance since, as far as can be judged, equiva- lent results may be obtained with vaccines prepared by various methods of treating the fixed virus. Fixed virus may be prepared from the virus as found in Nature (street virus) by serial passage through a large number of relatively nonresistant animals. The rabbit is commonly used. Changes in the properties of the street virus are indicated by a progressively shortening incubation period of the resultant disease, by a tendency to produce the paralytic rather than the violent form of the disease, by a reduction or loss of infectivity when given subcutaneously to relatively resistant animals, and by changes in the appearance of the Negri bodies which are asso- ciated with rabies. The virus is spoken of as„"fixed" when these changes have ceased to progress, at least with sufficient rapidity to be readily observa- ble. Nominally, this coincides with the period when the incubation period in rabbits, inoculated intracere- brally, has been reduced to seven days ; but there is evidence that further changes at a very slow 'rate of progress do continue beyond this period. In practice, it is the custom for laboratories beginning the produc- tion of rabies vaccine to avoid the delay incident to preparing their own fixed virus from street virus, by securing a strain of the former from some other laboratory. In the common parlance of the laboratory, the term "rabies virus" means not only the micro- organism causing the disease, but also the tissue in which it is contained as well; and unless otherwise RABIES VACCINE S5 defined, it would be understood to mean the brain or spinal cord of a rabid animal. The further treatment of the fixed virus in order to prepare the vaccine may proceed according to several recognized methods, the intent of which is either to accomplish graduation of the dosage, or to secure a further attenuation of virulence, to preserve against rapid deterioration, or merely to provide the material ♦ in a form convenient for use. Of these methods the most commonly employed are: emulsification of the virus and graded dilution in salt solution ; reduction of virulence by slow desiccation for definite periods, fol- lowed by preservation in glycerin ; removal of diffusible TBEATMENT FOB ADULT Day of Treat- ment First Second Third Fourth Fifth Sixth Seventh Eighth Ninth... Tenth Eleventh Cord, Amount Dried, Days 6 5 4 3 3 2 2 1 5 4 i Of Cord Cm. 1 1 , 1 0.6 0.5 0.5 0.6 0.6 0.5 0.6 0.5 • Day of Cord, Amount Treat- Dried, of ment Days Cord Cm. Twelfth 3 0.5 Thirteenth 3 ' 0.5 Fourteenth.... 2 0.6 Fifteenth 2 0.5 Sixteenth 4 0.6 Seventeenth. . . 3 0.5 Eighteenth 2 0.5 Nineteenth 3 0.5 Twentieth 2 0.5 Twenty-flrst... 1 0.5 substances by dialysis; rapid desiccation in a frozen condition, and treatment by various chemicals, notably by phenol. The advocates of each of these methods can adduce arguments as to the convenience, economy or suitability for some special purpose of the method which they employ; but it is believed that there is no acceptable evidence to show that any one method is preeminently more efficacious in conferring immunity to rabies than others. Some methods have, however, been subjected to more extensive practical application than others. Whatever the method employed, the final substance to be used for injection consists of a liquid suspension of more or less modified fixed virus ; and this is admin- istered in a series of subcutaneous injections, given for a period of time which may vary according to the method used, up to a maximum of three weeks. It has been found possible, and is theoretically advan- 56 BIOLOGIC THERAPY tagious, to modify the schema of injections employed originally by Pasteur in using the virus attenuated by slow desiccation. For example, the plan of injections now employed in the Hygienic Laboratory, U. S. , Public Health Service, eliminates the use of long dried and presumably inert material, while retaining roughly Pasteur's idea of administering a succession of courses of injections of increasing virulence. This schema is admittedly arbitrary, and is supported more by the* evidence of long usage than by strictly scientific con- siderations. Immunization with rabies vaccine is, of course, of the active type, and requires considerable time, and is made possible in its application in practice only by the fact that the incubation period of rabies is rela- tively extremely long. During this period the immu- nization must be accomplished. In some instances in which the exposure has been exceptionally severe, the incubation period is destined to be too short to permit the establishment of active immunity, and in these cases the preventive treatment must fail. In other cases, moreover, even though the exposure is not severe beyond the ordinary, the individual seems inca- pable of responding to the treatment by developing immunity. The counterpart of this condition is seen- experimentally in the varying response of rabbits to injections of rabies vaccine, as manifested by the rabi- cidal property of their serums. It is generally accepted, and there is experimental evidence in support of the belief, that the maximum degree of immunity is not developed until about two weeks after the completion of the treatment. The exact evaluation of the protection afforded by treatment of persons with rabies vaccine is impossible. In order to accomplish such a valuation, we should have to know, on the one hand, what proportion of persons exposed to infection, and failing, to receive protective inoculations, succumbed to rabies ; and, on the other hand, the proportion of such deaths among exposed persons who did receive the inoculations. The difficulty lies in securing sufficiently large groups in both the treated and untreated classes in which all the data necessary for statistical comparison are well established. Was the biting animal certainly rabid? Was virus actually introduced into the wound ? Were RABIES VACCINE 57 the injuries in the two groups comparable as regards severity and location? These and other questions would require to be answered fully if we were to make an accurate estimate. The trend of the difference between the two groups, treated and untreated, is, how- ever, sufficiently definite. A much greater proportion of untreated exposed persons die from rabies than of the treated, according to the best available figures. There is a mass of experimental data to show that rabies vaccine does accomplish a specific immunizing effect. The administration of rabies vaccine is not entirely devoid of danger to the recipient. In a very small proportion of those receiving, it, a paralytic condition develops which may fairly be attributed to the treat- ment per se, or to a combination of this with a peculiar susceptibility of the patient. About one fourth of these cases end fatally, a complete recovery usually occurring in the remainder. Exposure to cold or chilling, fatigue, and the use of alcohol apparently predispose to the development of this condition, but cases are seen in which none of these factors have been operative. Other objectionable results of the treatment amount only to minor discomforts and inconveniences. Rabies vaccine, prepared by various procedures, is now available throughout all portions of the United States to the extent that it may fairly be said that no exposed person need die of rabies for lack of injec- tions. Many state boards of health are prepared to furnish it free of cost to the indigent, and the cost of the commercial preparations is not prohibitive except to the destitute, for whom other provisions could probably be made in almost every instance. XIII. PERTUSSIS VACCINE WILBURT C. DAVISON, M.D. BALTIMORE The announcement by Bordet and Gengou in 1906 of their hemoglobinophilic bacillus as the etiologic agent of pertussis stimulated the search for a prophy- lactic and curative vaccine or serum for this disease. Some authorities still maintain, however, that a filtrable virus may be the real cause, and the presence of the , Bordet-Gengou bacillus merely a coincidence, and that Koch's postulates have not been satisfactorily fulfilled. On the other hand, the Bordet-Gengou bacillus can be isolated from the sputum in practically all cases during the first two weeks of the disease, and complement fixation for it has been demonstrated in pertussis patients by several investigators. Others, however, are unable to confirm this. Bordet himself had inconclusive results from the therapeutic use of antiendotoxic serum in whooping- cough, yet many observers have reported favorable results for the curative and prophylactic use of per- tussis vaccines. Some of these reports have been writ- ten by physicians whose clinical judgment, is reliable ; but, unfortunately, many more have been deductions from insufficient and uncontrolled material that has been inaccurately analyzed. The more careful studies show that pertussis vaccine has practically no thera- peutic value. In some cases it has been noted that the number and severity of the paroxysms have been reduced, but the course and duration of the disease have been essentially unchanged. Nonspecific therapy, such as injections of Bacillus influenzae vaccines, the sterile ether extract of sputum of whooping-cough patients, sugar solutions, or even a change of air will bring about quite similar results. The natural immunity of many children to pertussis makes accurate conclusions in regard to the value of prophylactic vaccine exceedingly difficult. Many of the unvaccinated, when exposed to the disease, fail to acquire it, while a number of those inoculated succumb. PERTUSSIS VACCINE 59 Many enthusiastic reports have been published, but in most of these but few unvaccinated controls were observed. In a series of experiments that had adequate con- trols, negative results were obtained for vaccines used during the course of the aisease, and but doubtful immunization from prophylactic inoculations. In summing up the prolific and somewhat contradic- tory literature on this subject, it may be concluded that injections of Bordet-Gengou bacillus vaccines may have a slight though unreliable prophylactic effect, and that therapeutic inoculations are of practically no value. Further experiments are necessary to raise this pro- cedure from the limbo of nonspecific therapy. DOSAGE The earlier investigators used comparatively small doses of vaccine ; but if beneficial results are to be expected at all, the following dosage may be tried. This procedure has been used in a large number of cases, and no ill effects have been noted. The vaccines were made according to the usual Wright technic and rendered sterile by heating to from 58 to 60 C. for an hour. They should be used within four months of the date of manufacture. 1. For Prophylactic Use. — Three injections, one weekly, for three weeks. For children, 500, 1,000 and 2,000 million bacilli. For adults, 1,000, 2,000 and 3,000 million bacilli. Although the opinion has been expressed that the vaccine is worthless for therapeutic purposes, if it is desired to try it the following dosage may be employed : 2. For Curative. Purposes. — To a child over a year old, an initial subcutaneous injection of 500 million bacilli is given ; at the end of forty-eight hours anotlier dose containing 1 billion is administered, and after the lapse of another forty-eight hours a third dose of 2 billion. After an interval of five days the child is examined again. If the paroxysms are much milder but still persist, a dose of 4 billion bacilli is given, followed by 8 billion in three days and 10 billion after another lapse of three days. 60 BIOLOGIC THERAPY Should the paroxysms become more violent after the first three injections, a week should be allowed to elapse before the second series of three injections is given, and instead of 4 billion this series is started with only 2 billion. XIV. CHOLERA VACCINE* OSCAR TEAGUE, M.D. NEW YORK Cholera vaccine was the first of the bacterial vaccines used on a large scale with the idea of preventing a spe- cific disease in human beings. Ferran, during a severe cholera epidemic in Spain in 1885-1886, administered living cholera spirilla subcutaneously to about 40,000 persons without obtaining convincing evidence bi pro- tection. In 1894-1895, Haffkine, using more accurate methods, vaccinated about the same number of persons in India, and his statistics of the incidence of and mor- tality from cholera among the inoculated and uninocu- lated indicated a certain degree of protection in the former. He injected subcutaneously first a living, attenuated culture of Spirillum cholerae, and, one week later, a living culture of the same organism whose virulence for experimental animals was maintained at a high degree. The experiments of Ferran and Haff- kine were of fundamental importance in that they furnished the ^basis on which was built the prophylactic immunization against bubonic plague and typhoid fever. Since Haifkine's time a number of different methods of preparing cholera vaccine have been recommended. As different epidemics of cholera vary enormously in both virulence and duration, it is obviously very diffi- cult to compare the protective value of one vaccine with that of another employed during a different epidemic ; hence it would seem logical to regard the vaccine most generally used as a standard and to use this in the same epidemic as a measure of any new vaccine whose merits are to be determined. It would seem inadvisable to recommend any cholera vaccine for general use until such parallel tests have been carried out under satis- factory conditions. The standard cholera vaccine at the present time would consist of a culture of Spirillum cholerae grown on nutrient agar, suspended in physio- logic sodium chlorid solution, and killed by heating * From the Department of Bacteriology, Columbia University College of Physicians and Surgeons. 62 BIOLOGIC THERAPY- one hour at 53 C. The vaccine made at the government laboratory in Bombay contains 8,000 miUion organisms per cubic centimeter; 0.5 c.c. is administered sub- cutaneously at the first dose, and 1 c.c. as the second dose. It is being issued in increasing amounts in India year by year, and the few reports that are pubHshed are distinctly favorable. The local and general reac- tions are mild. The contraindications to its use are those that have been described for the typhoid vaccine. During the World War, several millions of men in the Austrian and German armies were given cholera vaccine (cultures killed by heat), and thousands of them, particularly the Austrians, spent months in dis- tricts where cholera was prevalent. It was considered that the relatively small amount of cholera in these armies was due in large measure to the vaccinations ; and the appearance of a much higher percentage of cases in certain groups of Austrian soldiers that had not been inoculated lent additional evidence to this view. It may be considered, then, that the administration or two (or three) suitable doses of cholera vaccine offers a marked degree of protection against cholera during the three months following vaccination, and perhaps some protection for six months or longer. This protection is not absolute : some of the vaccinated contract cholera. It is asserted by' a number of observers that cholera in the vaccinated runs a milder course than in the uninoculated, but further evidence seems necessary to establish this. Cholera carriers have been inoculated without untoward effect ; but the dura- tion of the carrier state is apparently not shortened thereby. On account of the acute onset and rapid course of the disease, one would not expect any benefit from the treatment of cholera with cholera vaccine. XV. VACCINATION AGAINST PLAGUE OSCAR TEAGUE, M.D. NEW YORK Antiplague inoculation was introduced in India by Haffkine in 1897. He used broth cultures, grown for six weeks at room temperature and heated ahalf hour at 65 C, to which was added 0.5 per cent, phenol (carbolic acid). The requisite dose was given sub- cutaneously. A single inoculation was usually admin- istered — occasionally, two. The reaction, both local and general, was much severer than one is accustomed to see at present from typhoid inoculations. In 1908, after an enormous number of antiplague inoculations had been performed in districts where plague was prevalent, Haffkine concluded from a study of the available statistics that inoculation reduces the liability to attack to less than one third of what it is in the uninoculated, and that the recovery rate in the inocu- lated is at least double that in the uninoculated. Bubonic plague can be readily reproduced in labora- tory animals, and prophylactic inoculations in these animals with subsequent infection with virulent plague bacilli have demonstrated that a vaccine made from twenty-four hour old agar cultures, suspended in saline solution and heated an hour at 65 C, calls forth a more efifective resistance against plague than does the Haffkine vaccine, and that a still greater degree of resistance is produced by the inoculation of a large dose of living plague bacilli from a culture whose viru- lence had been greatly reduced by artificial means. The killed agar cultures have been used for the immuniza- tion of human beings during plague epidemics, but have not displaced the Haffkine vaccine ; the avirulent living culture has not been as yet subjected to this practical test. The Bombay bacteriologic laboratory prepares all the antiplague vaccine that is used in India, and receives statistics of the incidence of plague in the inoculated and uninoculated. In the report for the year 1911, during which year 1,211,170 doses of the vaccine were 64 BIOLOGIC THERAPY distributed, Major Glen Liston, the director of the laboratory, reviews the evidence as to the value of the inoculations, after having eliminated certain obvious sources of error in the statistics. There is a rather close agreement between these figures and the earlier ones of Hafikine. Thus there appears to be no doubt that antiplague inoculation is an important factor in diminishing the morbidity rate and the death rate during an epidemic of plague. About 10,000,000 persons have died of plague in India during the last twenty years. Inoculation has encountered great opposition. If the natives had sub- mitted willingly and freely to inoculation, hundreds of thousands would undoubtedly have been saved. How- ever, even if inoculation had been carried out on a vast scale and the death rate had been reduced to a small fraction of what it has been, still plague in the rats would have been unaffected, and the cessation of inocu- lation would have brought about in two or three years the same high mortality in human beings as before. Prophylactic inoculations diminish the incidence of COMPARATIVE MOEBIDITT AND MOBTALITY FROM PLAGUE AMONG INOCULATED AND UNINOCULATED Inoculated Not Inoculated CD a. Ij s (D P. 03 a qT ■s« a O) o a u o a rt 3 CO s a<3 <3i ^ ,2 1 o ■M eS §- SSA o 53 3 rH G I— ( sA ^ < Q o eu