362 STREPTOCOCCIC INFECTIONS 



given here may require great alteration in the future. In several 

 and rapidly progressing septic cases, such as those due to post- 

 mortem wounds, etc., the use of serum is indicated, and offers the 

 best chance of success. In view of the very great benefit which 

 is frequently derived from this measure, it appears highly im- 

 proper to wait until a vaccine is prepared. This should be taken 

 in hand at once, so that a homologous vaccine may be ready if 

 subsequent events suggest its use, but in the meantime serum 

 should be employed. The use of minute doses of a stock vaccine 

 (5 to 10 millions per dose) may be considered, and there 

 appears to be no reason why they should not be given along with 

 the serum. If practicable, opsonic estimations should be taken, 

 but the streptococcus is not as a rule a very satisfactory organism 

 to work with. In the absence of such observations, doses of the 

 size mentioned above may be given every three or four days. 



In chronic septicaemia or ulcerative endocarditis of streptococcic 

 origin the use of vaccines offers more prospect of success, though 

 even here cures have been brought about by means of the serum, 

 which should be used whilst cultures are being taken from the 

 blood and a vaccine prepared. At present it seems desirable to 

 use careful opsonic control in cases of this class. An excellent 

 illustrative case treated by Douglas should be referred to for 

 details. Here the doses were 5 tc 12 millions, and the 

 injections were given each time the index fell. The case was 

 certainly one of septicaemia, but the evidence for the existence of 

 ulcerative endocarditis is not conclusive. 



In chronic local inflammatory disease of streptococcic origin 

 vaccine treatment is probably the best, but here ordinary methods 

 (especially Bier's) may be of more advantage. In the absence of 

 opsonic control, the doses may begin at 10 millions and rise to 

 100 millions, and be given once a week. 



Erysipelas does not usually require specific treatment, and in 

 severe cases serum often answers well. The use of vaccines has 

 not been tried on a sufficiently large scale to allow us to judge of 

 its value. A case under my care of recurrent erysipelas, in which 

 attacks had occurred about every three weeks with some degree 

 of regularity for a year, was apparently cured by a few doses of 

 vaccine, commencing at 25 millions and rising to 50 millions, and 

 administered once every ten days. In some chronic cases of 

 erysipelas it is probable that there is a considerable amount of 

 haemic immunity, but the protective substances are unable to 



