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case of disease of that structure is mOre virulent than that from the normal intestine. We quote Adami (5), who says that under ordinary circum- stances the B. coli is incapable of forming ectotoxins, but when the intestinal mucosa is affected by trauma- tism from within or without, it may wander and cause inflammation and thus liberate toxins. It is necessary under these circumstances that bacterioly- sis take place through a breaking down and liber- ating of the resulting split products. I believe that a severe gastroenteritis or a severe acute disturbance of the gastroenteric functions is often the starting point and causative factor for the biochemical changes in the intestinal epjthelia and the B. coli that occur later on in the disease. The condition of chronic intestinal toxemia is not altogether unlike that of intestinal obstruction, in which the intestinal epithelia probably play an im- portant part, Cialis 20 Mg Best Price as shown by J. W. Draper's (6) experi- ments of causing the symptoms in animals by feed- ing heterologous jejunal and ileac epithelial cells. Murphy and' Brooks (7) also caused symptoms of intestinal obstruction and death in animals by inject- ing intravenously epithelial cells of isolated loops of the small intestines. They consider the symp- toms and cause of death to be due Cialis 20 Mg Best Price to absorption of a toxin which is formed by bacterial growth and does not pass through a normal mucous mem- brane. From clinical study of my cases, I believe that after an intestinal toxemia is once established, the effect on Cialis 20 Mg Best Price all the body cells may be of long duration. and that it is not merely a local condition, but a general one. It is essential to establish a diagnosis of chronic intestinal toxemia, which can only be accomplished by an exhaustive study and careful elimination of other diseased conditions which may coexist. The diagnosis of chronic intestinal tox- emia is based upon four chief factors, the history. the X ray and the symptomatology and physical signs. The Cialis 20 Mg Best Price history of these patients begins fre- quently with an attack of acute indigestion, and often a so called ptomaine poisoning following the ingestion of some easily decomposed or indigestible article of food. This is followed by a prolonged in- terference with the digestive system and by ner^'- ous disturbances, the latter frequently predominat- ing. The primary trouble is probably an intestinal putrefaction, the secondary a chronic intestinal tox- emia in which the colon bacillus, metamorphosed, plays the important role in the toxins hberated. Routine examination of the feces is made on every patient, but not, however, until they have been on a fixed diet for about a week. The value of exces- sive fermentation or putrefaction under these circumstances can be readily seen. Protozoa or para- sites should of course be excluded. Among the bac- teria that we have especially worked on are the streptococci and colon bacilli. In cases where there were an excessive number of streptococci, autoge- nous vaccines have been used with no apparent re- sults, but with the colon bacilli we have had sat- isfactory and, in some instances, remarkable re- sults. The type of case has been that which has been classed under the diagnosis of the chronic in- testinal toxemias. If the colon bacillus does play as important a role in this trouble as we think, the logical thing to do is to supplement Cialis 20 Mg Best Price our routine therapy by vac- cines or serum. Cialis 20 Mg Best Price The serum, so far, is not very prac- tical on account of the extreme toxicity Cialis 20 Mg Best Price the colon bacillus has on animals. This is, moreover, a chronic process, and time can be given to the body to Cialis 20 Mg Best Price form its own antibodies. Autogenous colon vac- cines have not been used very extensively, but have been given in colon infections of the genitourinary tract with more or less success. Stock colon vac- cines are used extensively, but are of little value on account of the large number of types of the colon bacillus. For the control test in the agglutination of colon bacillus infections, the serum agglutination test would be very valuable if it were reliable. A. G. Bennett, in his work with us on the subject, has found that the serum of other individuals not suffer- ing from toxemias of colon origin agglutinate also the colon bacillus. Dugeon found that the blood serum of a patient who has a hemic infection with the bacillus coli may not agglutinate the colon bacillus. This might be accounted for by the numerous dif- ferent strains of the colon organism. We have tried the patient's serum against their own organism without success. For Cialis 20 Mg Best Price this reason, agglutination tests have been discontinued on my cases. The opsonic index is unreliable, difficult, and has not been prac- ticed. Leukocyte and differential counts were done on a number of the early cases, but were discon- tinued, as no change after the vaccines was demon- strable. The conclusion is that the index of improvement is the patient's general improvement in the color of the skin, abdominal symptoms, the disappearance of colon crepitation, tenderness and splashing, the disappearance of the headache, neuralgias and mvalgias. and. above all. the mental improvement. The finding of colon bacilli in the hloocf is not necessary for the diagnosis of infection bv this organism; if we had to wait for that we might never Cialis 20 Mg Best Price make a diagnosis, because it is very May 25, 1918.] SATTERLEE: CHRONIC INTESTINAL TOXEMIA. 973 infrequently found. What we have to contend with is not the number of colon bacilli, but the virulence of the organism, and the degree of resistance of the individual. The organisms should be obtained from the cecal contents following a full dose of castor oil. The method of isolation of the colon bacillus and preparation of the vaccine follows the ordinary bacteriological routine for this particular organism. TiccHNic or Administration ok Vaccines. 'i'he initial dose is from ten to twenty-five million of the dead bacteria suiicutaneously, depending on