course of the treatment, are not very frequent and rarely has the case terminated fatally during relapse when the treatment with the serum has been resumed without delay and vigorously pushed.

There remains one more topic to be mentioned. The indications given by the first series of serum-treated cases were to the effect that in the great majority of instances recovery from the disease would be complete. The facts brought out by the far larger series of cases on which this article is based, confirm the earlier view which we expressed. The number of complications which arose in them was small, and the only persistent defect noted was deafness. This lamentable condition occurred in a few instances only, and it was, more often than not, noted early in the disease before the serum injections were begun.

PAPER ON THE SERUM TREATMENT OF MENIN

GOCOCCIC MENINGITIS.

BY FRANK S. CHURCHILL, M.D.

I have had the opportunity to watch the effect of the Flexner antimeningitic serum upon II cases of undoubted meningitis-9 of the meningococcic type, 2 undetermined. Four of these have died the 2 undetermined cases and 2 of the meningococcic type. Thus, 7 of the 9 cases of the latter variety have recovered, all without serious sequelæ.

All the cases were clinically meningitis and a diagnosis of the gross lesion could have been made without lumbar puncture, though, of course, not the type of the disease present. The chief interest in the cases has, of course, been in noting the effect of the serum. This has been striking. It has been noted upon the general condition of the patient, upon the temperature and leukocyte curves, upon the color and contents of the spinal fluid.

Usually the first effect noticed clinically has been the change in the patient's mentality. He would seem brighter and more tational after the first, second or third dose of the serum, as the case might be, and this improvement continued steadily until the patient was well. It was a curious sight to see the patient lying in bed with head markedly retracted, yet perfectly quiet and without pain, interested in his surroundings, for the rigidities persisted after the mental state began to clear up. Kernig's sign was particularly persistent in some cases.

The leukocyte curve was an interesting phenomenon. There was, of course, a considerable leukocytosis at the outset of treatment, but after the use of the serum there was almost invariably a drop in the leukocyte curve, together with a drop in the temperature curve.

The effect of the serum upon the spinal fluid was striking. At the outset of the disease the fluid was, of course, cloudy; in 2 cases, purulent. Examination of the first specimen of fluid obtained generally showed considerable numbers of leukocytes of the polymorphonuclear variety and also meningococci, varying

in numbers with the intensity of the disease. Subsequent punctures showed a fluid less cloudy, and, by actual count, a diminishing number of cells and organisms. The latter were found both extra- and intracellular.

In view of what we now know of this antimeningitic serum, I believe we are justified in this opinion: given a case, evidently meningitis, it is our duty to do a lumbar puncture, and if we obtain a cloudy fluid to inject the serum at once into the spinal canal, subsequent injections being determined by the results of the bacteriological examination of the spinal fluid. If this show the presence of the meningococcus, the serum should be repeated every day for three or four days if necessary. If relapses occur, we should resort to the serum again.

THE SERUM TREATMENT OF EPIDEMIC CEREBROSPINAL MENINGITIS, BASED ON A SERIES OF

FORTY CONSECUTIVE CASES.

BY CHARLES HUNTER DUNN, M.D.,

Boston, Mass.

The report is based on a series of 40 consecutive cases of epidemic cerebrospinal meningitis, treated with Dr. Flexner's antimeningitis serum. All cases in which the diplococcus intracellularis' was found in the cerebrospinal fluid, without regard to the type of case or the stage of the disease, are included in the series. The antiserum was administered in all cases by injection into the cerebrospinal canal according to the technic recommended by Dr. Flexner and described in a previous publication. As soon as a suspected case was reported to me, lumbar puncture was at once performed. If the cerebrospinal fluid obtained was cloudy, the antiserum was injected at once, without waiting for the bacteriologic examination of the cerebrospinal fluid, and if fluid was clear no antiserum was given until subsequent examination revealed the presence of the diplococcus intracellularis.

In those cases in which a rapid and marked improvement in the symptoms occurred after the first injection, accompanied by a permanent fall of temperature to the normal, no further injection was given. In those cases in which this did not occur, the injections were repeated daily until nervous and subjective symptoms were completely relieved and the temperature had reached the normal, or until four doses had been given. In resistant or relapsing cases further doses were given according to circumstances. The routine dose was 30 c.c.; in many instances larger doses were given, the maximum being 45 c.c. In some instances, when the amount of fluid obtained was small, and in all instances when too great an increase of intradural pressure was feared, smaller amounts were injected, the minimum being 10 c.c. This was the general routine; there were some exceptions.

The serum has been used in 45 cases of epidemic cerebrospinal meningitis, but cases still pending are not included in the series. Of the 40 finished cases nine patients have died and

thirty-one have recovered. This is a mortality of 22.5 per cent. and a rate of recovery of 77.5 per cent. Of the 31 cases in which the patients recovered, two were left with sequelæ, one being deaf and one both blind and deaf. The recovery was complete in 29 cases, or in 72.5 per cent.

The type of disease prevailing this year in Boston and vicinity was no milder than that which prevails every year.

I have not been able, for purposes of comparison, to collect enough cases treated in Boston and vicinity this year without the antiserum. It is possible, however, to compare the mortality at the Children's Hospital this year under the use of the antiserum with the mortality in other years under other methods of treatment, as sufficient cases have been treated in this hospital each year to afford a basis for such a comparison. While the number of cases treated each year varies, the average yearly number for the last ten years is twenty. This comparison also throws light on the comparative value of the treatment with the antiserum and of other methods.

It appears that the lowest mortality of any year before this was 58 per cent., and that it varied between 58 per cent. and 80 per cent., but that this year, under the use of the Flexner antiserum, the mortality has shown a remarkable drop to only 19 per cent.

The 9 fatal cases in the series throw a certain amount of light on the limitations of the value of the serum. Of these nine, five were cases seen late in the course of the disease, at a time when the patients were in the well-known chronic stage, unconscious, and without fever or active symptoms. In one of these the serum was not given until the patient was actually moribund. Of the other 4 cases, one was of the fulminating type, one a very severe case, and one patient died of an intercurrent bronchopneumonia, coming on after the temperature had come down to normal and all meningeal symptoms had subsided. The last case was one of average severity, in which the serum appeared to produce a slight improvement in the beginning, but which later appeared uninfluenced by the antiserum, advanced into the chronic stage, and a fatal result ensued after many weeks of illness.

My belief in the great value of the Flexner antimeningitis serum is based not chiefly on its apparent effect on the mortality of the disease, but on the very marked and striking effect which