we rarely meet the severer symptoms of the disease, such as the sudden and abrupt onset of unconsciousness, the petechiæ or diffuse hemorrhages so frequent in the epidemic forms of the disease, and the paralysis which appears very early in the epidemic forms. In fact, in an epidemic it is not infrequent to be called to the bedside to see a child who within a few hours has become unconscious and absolutely paretic to an extent as not even to show the rigidity and the Kernig sign, which is seen and gradually develops so classically in the sporadic cases. In the sporadic cases we rarely see those excessive hemorrhages in infants which are seen in the epidemic form.

It must, therefore, be admitted that though on the whole the symptomatology of the sporadic is exactly similar to that of the epidemic form of the disease, the sporadic form runs a much milder course. As we analyze both forms more deeply, we find that the purulent exudates are more frequently obtained in the epidemic than in the sporadic cases of the disease. Lumbar puncture in the sporadic cases exceptionally reveals a purulent fluid at the outset. It is true a certain proportion of the sporadic cases are purulent, but not to the extent as is seen in the epidemic forms of the disease.

In a word, cerebrospinal meningitis of the meningococcic type very much resembles pneumonia as it is seen in adults in the sporadic and epidemic forms. Any one who has lived through an epidemic of pneumonia must admit that the picture is a violent and a virulent one in its type, and so with meningitis. We have the same infection, but in the epidemic form it is of a violent and virulent type, and with children the younger the subject the more fatal the disease.

These facts are so self-evident that it is surprising they are so constantly lost sight of, and that in considering any mode of therapy we do not stop not only to consider the violence of the infection, but the age of the patient. For this reason I have thought it would be useful for every one at this time to get a picture of the natural history and prognosis of cerebrospinal meningitis, especially if the experience which reflects the prognosis extends over a long period of time and the methods of treatment have been uniformly the same and carefully carried out in all details through a number of years.

Taking up the sporadic form of meningococcic cerebrospinal

meningitis, I have been fortunate to have at my disposal the records of cases treated since 1899 up to the epidemic years of 1904-1905. We first began the systematic treatment of cerebrospinal meningitis in 1899. This consisted in the first place of a careful study of the symptoms and the performance of lumbar puncture repeated as often as we found the symptoms to warrant it. That is, a patient suffering with cerebrospinal meningitis would come in with mild symptoms. If there was delirium, high fever, with the development of the signs of fluid in the ventricle as evinced by the Macewen sign, lumbar puncture was performed. After such a puncture, if the symptoms did not abate, the fever continued, as well as the delirium and the Macewen sign persisted, proving that there was a continued hydrocephalus, the patient was again punctured. In this way some patients were punctured two, three, four, and five times, as necessity called for. During 1899-1900 we had 8 cases, all proving by lumbar puncture to have been meningococcic in type. During 1901, 1902 and 1903 there were 13 cases, thus giving us a total of 21 sporadic cases. Of these sporadic cases 8 died, a mortality of 38 per cent.; of these 8 which proved fatal, 6 were below one year of age, thus showing that in the sporadic form the disease was most fatal among the infants below one year of age, and equally so below two years of age. If we could deduct from the total number of 21 cases those which were below one year of age, we would have 15 cases, with only two deaths, a mortality of 13 per cent. From this a mere glance will tell us that meningitis of the meningococcic type in its sporadic form is a comparatively mild disease.

I say this with a certain amount of confidence, although the number of cases is limited, for we are now having a certain number of sporadic cases which seem to duplicate our experience in these years. On the other hand, in sporadic meningitis we have been fortunate by methods of therapy, which consisted mainly in the systematic application of lumbar puncture repeated at intervals, in obtaining recoveries even below one year of age. Two infants of this tender age recovered of these 21 cases, and 2 recovered between the ages of one and two years. It is in the sporadic cases especially that we occasionally see after one lumbar puncture the temperature drop and convalescence practically inaugurated, the temperature not rising subsequently to any extent. This phenomenon is not so frequent nor so persistent as is seen under the new method of therapy, that of serum. Under serum

therapy there are more cases which act in this manner than under previous forms of therapy.

Taking up the epidemic years of 1904 and 1905, the history of the disease is a more violent one. Among the cases are some which died within a few hours after admission to the hospital. This, it is understood, is the exception in the sporadic cases, but not uncommon in epidemic cases. Here the picture of the disease is more of sthenic type, the symptoms being developed in their most florid form.

The first epidemic year was 1904. There were 39 cases and 21 deaths, a total mortality of 53 per cent., and of these 21 deaths 13 were below two years of age. If we consider the unimproved cases of these 13 as not fatal, II died, but I would prefer to consider these fatal cases as they were discharged from the hospital in a marantic condition, with an incurable and increasing hydrocephalus, so that from a curative standpoint the mortality was practically 100 per cent. Some of these infants were four months of age, some six months of age, showing the tender age of the patients. Deducting these 13 cases from the total of 39 would leave 26 cases above two years of age, of which 9 died, a mortality of 34 per cent.

In 1905 there were 35 cases in my service, of which 17 died. In none of these cases have we included any which have not been distinctly proven by lumbar puncture to be of the meningococcic type. There was thus in this year a total mortality of 48 per cent. Of these 17 deaths, however, 10 were below two years of age, and in them it might be said that the mortality was fully 100 per cent., for if seven died and three were simply unimproved, that is, developed either hydrocephalus or marasmus of an extreme type hopelessly incurable, we can scarcely speak of a cure, therefore these three were no better than fatal cases, so that although there was a mortality of 70 per cent., from the standpoint of success in therapy, the mortality was practically 100 per cent. below two years of age. If we deduct those cases which died below two years of age from the total mortality of 17, and from the total number of cases which were admitted during this epidemic year, we are left a mortality of 7 deaths in 25 cases; that is, 28 per cent. It is thus seen that it would be quite unfair to consider any mortality in this year of the violent type without considering the tender age of some of those affected in order to get a definite idea of the picture. It may be said in addition, the ages of these chil

dren ranged from four months to twelve years of age. Thus of the two epidemic years of 1904 and 1905 we had 51 cases above two years of age, with a mortality of 31 per cent., and, considering the patients below two years of age in the mortality, there was a total mortality of 50 per cent. This includes patients on whom there was only an opportunity to make one lumbar puncture, and in whom death occurred within a few hours after admission to the hospital. Nothing has been excluded for the sake of statistics, but the moribund cases have been included in this statistic with the favorable cases. We had 23 cases in these two years below two years of age, of which 78 per cent. died outright, and the remainder were unimproved-that is, those who were discharged with incurable hydrocephalus, idiocy, and marasmus, and which might be considered as practically fatal sooner or later.

From the study of these two sets of statistics one of the sporadic cases of cerebrospinal meningitis and the other of the epidemic form, we see that in the sporadic cases we have succeeded in saving by simple lumbar puncture 4 children below two years of age; in the epidemic cases we have not succeeded in saving any. When I say 4 cases recovered, I mean complete and actual recovery, as far as can be judged from the clinical standpoint. No such cases occurred in the epidemic years. On the other hand, if we deduct from our statistics the cases below two years of age, both in the epidemic and sporadic forms of the disease, we find that in the sporadic form we had 15 cases, with a mortality of 13 per cent., and in the epidemic form we had 51 cases, with a mortality of 31 per cent.

With this history of the disease, we can approach with a certain amount of satisfaction a form of therapy which will hold out an improvement even on these statistics. We can scarcely ask an annullment of mortality. There will always occur cases in either form of the disease which therapy will never reach, no matter how brilliant the conception of the therapy. We see this in diphtheria. No one will deny the great blessing to mankind that the serum treatment of diphtheria has come to be. We have even believed that certain severer forms of diphtheria are becoming. less frequent than before the serum therapy. The severer laryngeal types are not so common to-day, even in epidemics of the disease, and this is certainly a great gain. In other words, by the constant application of a form of therapy conceived on a

logical basis of antagonism to the bacteria attending the disease, it seems that the actual poison has been diluted and the picture of the disease is a much milder one to-day than before the application of the serum therapy, and thus it may be of other diseases.

Considering cerebrospinal meningitis treated by serum we have to offer 13 cases of the disease occurring in one service, and treated with the exception of the application of the serum, in the identical manner that the cases were treated which have just been spoken of. That is, they were systematically punctured, they were repeatedly punctured, they were punctured only on indications as above detailed in the epidemic and sporadic years, but when punctured they received the serum. They received the serum under conditions exactly similar to those of cases occurring years ago, at a time when the serum did not exist. Our serum cases were thus under the same identical régime as the other cases, and we think that this is of decided advantage not only to the patients, but to others.

It makes quite a difference in the application of such a therapy how such a therapy is applied. A therapy applied by inexperienced hands, no matter how brilliant the therapy, is not given the same chance as in the hands of those who are skillful. We make this remark simply in passing, because any form of therapy will at first labor under a great disadvantage for lack of skillful application and method.

It may not be amiss here to outline very briefly our method of giving the serum to patients. No patient is punctured in my service in cerebrospinal meningitis unless there is distinct indication for that puncture. In this way I impress those around me that I do not believe in the dictum that the earlier the puncture the better. This dictum, I think, is rather mechanical on account of the panicky feeling to do something immediately which it engenders, and does harm to the patient. To be punctured, a patient must show symptoms of pressure and indications of cerebrospinal fluid. There must be not only delirium and sopor, but distinct signs of increase of fluid in the ventricles of the brain, as shown by percussion of the skull. When we get the so-called Macewen percussion note, however slight, in a patient who evinces the symptoms of cerebrospinal meningitis, we proceed to puncture. The puncture is carried out strictly according to Quincke's injunctions. We puncture in the median line in children and adolescents. We