treated by a student with a 5 per cent solution of phenol. The skin sloughed, forming an ulcer which healed in about three weeks, leaving-as you will observe -a peculiar scar, simulating keloid, having an area now, after forty-one months of contraction, measuring 4.0x2.0 cm., and elevated 0.2 cm. above the surrounding skin. There is no apparent connection of this injury with the subsequent infection-it is mentioned as evidencing a tendency in the patient's cutaneous tissue to break down under chemical irritation with atypical healing.

Shortly after this ulcer had healed, on June 15, 1906, over three years ago, the patient removed a wart from one of the fingers of his right hand, leaving an opening into the subcutaneous tissue which did not readily close. While this condition existed he received orders to care for some sick calves, afflicted with a disease which caused dyspnea, with considerable salivation. In giving them medicine it was necessary for him to introduce his right hand into their mouths, with the natural consequence that it became covered with their slobbery saliva. In a few days he sickened and called in Dr. Wm. Dillon, of Urbana, who kindly placed his records at my disposal, writing me under date of August 18, 1906, substantially as follows:

In regard to Mr. J.'s illness: I was called to his room about 9 p. m., June 27, 1906. I found him lying down with perspiration in large drops over his face, pulse full and rapid, temperature about 103° F. Pain about axilla. Axillary glands indurated and enlarged. There was a small unhealed place in the center of a spot on one of his right fingers from which I could press out a little serum, but no soreness. I ordered fomentations during the night, with magnesia sulphate internally. The following morning there was less pain but more fever, and I had him removed to a hospital, where the treatment was continued. The glands returned to their normal size so far as could be detected, but fever and sweating continued. About the third day in hospital painful tympanites developed, also swelling along the general direction of the pectoralis tendon from a little below the armpit to near the eleventh rib. This was the first appearance of localization. I called in Dr. Newcomb, who aseptically incised the tissues down through the deep fascia. A little serum escaped. Wound packed with iodoform gauze and fomentations continued. The magnesia was stopped, as it was always followed by severe

bloating and pain. About five days after the incision pus began to discharge and was of ordinary appearance. There was a large abscess which discharged freely. I ordered the abscess washed out every day and fomentations continued. All this time the fever lasted, but not so high, nor so fast a pulse. The swelling decreased, the appetite improved. He gained strength but slowly. About July 22 the second incision was made and the entire cavity washed out with bichloride and dressed with dry dressings. Now the patient rapidly improved and the abscess walls united so that when irrigated the fluid would extend but a short distance in any direction. The pus, by July 30, had almost ceased. Temperature normal, pulse normal, patient bright, no sweating. I told him he could go home the last of the week if he continued to improve.

First Experiences with Patient.

I first saw the patient on August 19, 1906. On entering my office a limitation of motion in the right shoulder and a marked cervical scoliosis were evident. He was pale, anemic, pulse 106, temperature 98° F. At the anterior margin of the right axilla, along the border of the pectoralis major, appeared a long scar, presenting at its upper end a small orifice discharging a thin, blue-green serum. A second opening existed to the axillary side of the scar, about an inch below the first sinus. No swelling, some redness, tenderness slight, shoulder-joint motion limited, evidently from scar contraction. A flexible, sterilized probe, introduced into the sinus with strict asepsis, passed under the clavicle for some distance towards the vertebræ, so that the general clinical picture simulated a cervical Pott's. But a few days' study satisfied me that there was no vertebral disease, nor could I find evidence of any shoulder-joint trouble.

in the direction of the original incision, was curetted, and the patient received considerable X-ray treatment, with steady failure of his vital forces, until the latter part of March, 1907, some nine months. after the original infection, when, on the suggestion of the hospital authorities, he was taken from the institution to end his days among his friends. Here I saw him on March 28, 1907, since which time he has been continuously under my care. He presented then the typical picture of advanced chronic sepsis. He was thin, haggard, with a marked hippocratic facies, scoliosis more evident, temperature running a classical hectic curve (morning remissions to 98° F., evening readings varying around 102° F.) the pulse constantly between 120 and 139, having the appearance of impending death. Locally the margins of the sinus had broken down to form along the thoracic wall a deep, ragged ulcer as large as the palm of one's hand with sinuses radiating upwards, forwards and downwards, honeycombing the tissues in the pectoral region, while over the third and fourth right costo-chondral junctions. appeared bluish-red depressed areas, evidently marking points at which pus was about to appear.

The former bluishgreen discharge was now almost colorless, very profuse, and of a thin, serous nature, soaking large gauze dressings daily. But with all this local and constitutional disturbance, the various internal organs were in good functional condition, without signs of amyloid. And his surroundings were almost ideal. He had a light, airy, second-story room at the southeast corner of a big, comfortable, clean farmhouse in the middle of a 300acre farm, with a private porch, ample sunlight and most devoted nurses.

Three Successive Operations. On April 6, 1907, under chloroform anesthesia by Dr. Pickard, with Dr. W. F. Scott assisting me, I removed inflamed periosteum and perichondrium, with subjacent necrotic tissue at the points indi

cated by the discolored skin, curetting from all accessible places the various sinuses, scraping out large quantities of soft, pale, pulpy friable granulations, with free hemorrhage easily checked by pressure. The patient was put to bed in an exhausted condition-while my consultants cheerfully foretold an early lethal termination.

On May 6, 1907, I performed a second similar operation, attacking new, fresh necrotic areas over the second and fifth costo-chondral junctions. The result of these two operations was a considerable improvement in the pulse curve, which now rarely went over 110, while the temperature did not pass above 101°, but no local change except the healing of one. sinus which had invaded the tissues from the lower margin of the ulcer.

On July 6, 1907, I performed what was intended for a radical operation, by making a deep, curved incision from the lower border of the ulcer, anteriorly to the sternum, separating the entire pectoral flap of muscles, reflecting them back over the shoulder and exposing this region for general curettage. This maneuver was facilitated by the fact that practically all the intermuscular septa and fascia were gone, and their places taken by sinuses lined with abundant pale, flabby granulation tissue. The ribs were exposed, and one sinus apparently penetrated the pleural cavity. (I say "apparently," because exploration of its course was carefully avoided.) It curved around the lower border of the third rib, was of about the size of a darning needle, while through it tiny bubbles of air were drawn in and forced out during the respiratory excursions.

After thorough scraping of all other lesions the flap of muscle was sutured back into place. The patient did not react well, it being several days before he ceased vomiting and the general immediate result of this intervention was the actual spread of the infection, as it followed each suture and needle puncture

into new regions, reaching around also into the intermuscular septa and subcutaneous tissue of the back, a region previously uninvaded. About a month before this operation, on June 3, an abscess developed over the lower end of the sternum, which continued to grow. On July 30 I opened a large abscess on the back of the arm, and on August 15 a sinus pointing just below the edge of the cartilage of the sixth and seventh ribs.

Post-Operative Progress.

During all this time the wound had been dressed by daily irrigation through drainage tubes or along the sinus tracks.

Fig. 1.

Showing the Cicatrix on the Anterior Surface of the Body, Outlined Marginally with India-ink for Better Definition.

All sorts of fluids had been used-normal saline, plain sterilized water, iodin water, hydrogen peroxide, pure and in solutions of varying strengths, bichloride and phenol dilutions, with no appreciable improvement. On September 2, 1907, I made a radical change-permanently abandoning all forms of irrigations and

substituting plain, dry, sterile dressings -with immediate marked improvement in the general condition. The temperature fell to 99° and remained there, while the pulse varied between 90 and 100. There had been nervous digestive disturbances, so that any unwelcome suggestion, e. g., the discussion of an anesthetic, or the odor of ether, etc., would cause a prompt and thorough emesis. Yet, he had gained 10 pounds in bodily weight in five months, but with the cessation of irrigation the digestive derangement ceased, he took and retained large amounts of food, with cod liver oil, sevetol, etc., so that in the next five months he gained 26 pounds, with corresponding physical improvement. By the middle of January, 1908, he was practically as you see him today, strong, robust, healthy appearing, but with absolutely no improvement whatever in the local lesion, which remained stationary, discharging daily large quantities of sero-pus, necessitating copious aseptic dressings.

Bismuth Paste Treatment.

At about this time Dr. Emil Beck announced the result of his work in the treatment of certain unhealed sinuses by the bismuth paste method. I hastened to apply this to the case in hand, using one of Dr. Beck's syringes, which he kindly gave me, and closely following his technic. Injections were given January 22 and 28, 1908, with no especial result except that the patient's weight fell off a little. In order to give the paste a little better chance I decided to curette the granulations from the sinuses again, and then to make a third injection. This I did on February 10, 1908, and on the morning of February 11 I found my patient with a pulse of 140, temperature 102°, rusty sputum and consolidation of the left lower lobe. In the fight for his life of the following few days I had the benefit of consultations with, and advice from, Professors Preble, Kerr and Stubbs, as well as the constant encour

aging presence of Dr. Pickard, who has been my friendly mentor throughout long months of this malady. A typical crisis occurred on the seventh day, with uncomplicated convalescence. One peculiar phenomenon presented itself on the third morning of the seizure, when the patient suddenly expectorated a single mouth ful of pure pus, of which the anatomic origin was never satisfactorily located.

On February 26, 1908, he returned to his home, having lost 17 pounds, which he proceeded to regain. At this time, through the courtesy of Prof. Ormsby, I secured from the research laboratory of Parke, Davis & Co. a supply of staphylococcus vaccine, varying doses being injected on March 14, and for a month afterwards, without effect. Thorough search was now made by Prof. Ormsby for evidences of blastomycosis, actinomycosis and tuberculosis, with negative results. Prof. Hektoen now generously placed at my disposal his laboratory facilities, and his assistant, Dr. Dr. D. J. Davis, readily isolated from the pus a streptococcus which grew abundantly in almost pure cultures, but presented no identifying morphologic characteristics. The patient's opsonic index to this organism was subnormal.

Serum Injections.

On April 16, 1908, I injected the dead bodies of 500 million autogenous cocci obliquely into the subcutaneous tissue of the right thigh. In two days an induration appeared at the site of injection. Twelve days from date of puncture fluctuation was evident at this point. On May 6, twenty days from the injection, the skin here grew purplish. Two days afterward, on May 8, under aseptic precautions, I aspirated some of the contents of the swelling, which, on examination. by Dr. Davis, proved to be a sterile, chemical pus. On May 15, twenty-nine days after injection, the skin finally broke down and the contents escaped, leaving a superficial ulcerated area, which slowly cicatrized across from the margins, ulti

mately healing on July 3, 1908, seventyeight days after the date of injection.

This history is that of each inoculation made obliquely, leaving the vaccine in the subcutaneous tissue. As the weeks I went on I lessened the dose to 250 million, 60 million, 10 million, and each one caused the breaking down of connective tissue, the formation of sterile chemical pus, the death of the overlying skin from starvation-an open ulcer-slow healing, so that we finally had an absolute clinical demonstration of the method of local spread of this coccus, namely, by the secretion of toxins, which, by their chemical action on the connective tissue