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withdraw the fluid until we think the pressure is approximately normal in the rachidian space. We then introduce the serum, not with a syringe, but with a funnel. We have found that the funnel as advised by Quincke, a small funnel made of glass capable of holding about 20 c.c., is the best method of introducing the serum, or, for that matter, any fluid into the subarachnoid space, and saves the patient from any accident which might result from the use of a syringe. The pressure exerted by a syringe at all times against the respiratory and vascular pressure is certainly not as gentle a mode of introduction of serum or as safe as allowing the serum to flow into the canal. Thus no traumatism can possibly result, and the fluid finds its way against the negative pressure with the greatest of facility. We repeat the puncture if, after having punctured a patient and introducing the serum, we find that the symptoms do not abate and that the hydrocephalus has either persisted or returns. The temperature is scarcely a guide, but, rather, the general condition of the patient, and especially the presence or absence of hydrocephalus. In this way we think we have made the ideal procedure for the patient.

We have a record now of 13 cases of varying severity, cases which I must consider sporadic cases, but one or two of which approached in severity what we see during epidemics exclusively, the foudroyant symptoms, the hemorrhages, the rapid collapse and sinking of the patient at the start of the disease. I mean the severity of the symptoms gradually increased so that, as in one case, it was five days before coma or sopor intervened.

The ages of the patients treated varied from three and one-half months to five and one-half and eleven years; three were below

of
age,

and three were two years of age or younger. Of those below one year of age one was discharged cured at ten months of age. The others died. Of those from one year to two years of age, two of fifteen months, and one of two years, respectively, were cured; the remaining patients recovered.

In those children below one year of age who died, the youngest, three and one-half months of age, had been two weeks ill on admission, but was not by any means unconscious. The child received from 100 to 125 c.c. of serum. The temperature continued remittent, and was not in the least affected by the injections or punctures. The other case was admitted to the hospital twentytwo days after the onset of the disease, received four punctures and 66 c.c. of serum. The temperature could not be judged as

one year

being affected by the punctures in any way, as it was normal on admission. The child died a day or two after admission, and it is to be regretted that in both of these cases we did not get them at an earlier stage of the disease, as we cannot judge what would have been the effect had we received them at an early period. The first punctures in both cases were, of course, made immediately upon admission. The infant ten months of age, which recovered, was admitted fifteen days after the onset of the disease, with a temperature of 104' A turbid fluid was obtained, and the child received 35 c.c. of serum. The temperature dropped from 104° to 98.8°, and the child was discharged cured clinically.

Of the other cases below two years of age and two years, the first punctures were made immediately after admission, and they had been ill from seven to twenty-three days. One was discharged as cured, but inasmuch as there was hydrocephalus present on discharge of the patient, I think it, being a posterior basic case, from a clinical standpoint cannot be said to have been completely cured. I would simply call it improved.

Of the patients above two years of age the time of illness on admission to the hospital varied from five days to fifteen days. They all received serum varying from 15 to 30 c.c. at each puncture, and some of them had as many as four punctures before the disease was considered under control. The fluid in most cases after the first puncture cleared up gradually, and in one case it is stated after the second puncture the cultures were sterile, and so with the third puncture, and in some cases after the fourth puncture. But it must be noted in spite of this fact the children were sick enougn to be punctured not only on account of the run of the temperature, which was unchanged by the punctures, but the persistence of the hydrocephalus. This was especially marked in a boy of three years of age. The first puncture showed a white, cloudy fluid. Four punctures were made in this case, until the temperature would drop, and in all three punctures subsequent to the first the cultures and smears remained sterile. This should prove conclusively that the sterility of a fluid has very little to do with the clinical procedure in a given case, and I may say that in the epidemic a child mortally ill with meningitis would yield a fluid which was even cloudy, and the smears and cultures for some reason would remain sterile, and a subsequent puncture would show that there were meningococci present both in smear and culture, so that we have yet to learn a great deal as to why certain fluids are culturally sterile in a patient in whom a subsequent fluid will show meningococci, and also that the sterility of a fluid is not an indication that the patient necessarily does not need further puncture irrespective of serum.

The temperature after the injection of the serum in some of these cases fell by crisis from 104° to 98°. In one case it fell from 103° to 99° by lysis, and in one remaining case the puncture had no effect, and only fell and rose to a varying extent after the injections until either cured or fatal issue resulted. The amount of serum injected with punctures varied, and we can say in a general way that the amount of serum introduced equalled that of cerebrospinal fluid withdrawn from the patient. Some patients received one puncture, others as many as four, according to the necessities of the case.

The sickest child treated with the serum was a little girl four and one-half

years

of

age. Hers was a case which approached in the picture, as nearly as we had seen in sporadic cases, the epidemic type of the disease. I saw her at her home. She was absolutely unconscious, paralytic on the right side of the body, and had a conjunctivitis as a result of her affection, with purulent discharge. She suffered from a double pneumonia, and had all the marked symptoms of cerebrospinal meningitis, with the exception of the hemorrhages. I gave, as my duty dictated, a grave prognosis, but advised immediate puncture. She was removed to the hospital, a great distance, and was immediately punctured and an injection of the serum introduced. In this case three punctures were made. It cannot be said that the temperature remained down for any length of time after any puncture, except after the second or third puncture. After the first puncture the temperature dropped from 104° to 98°; within thirty-six hours it rose again, and then after a second puncture it fell from 102° to 99° in twenty-four hours, and then rose again, and after the third puncture it fell gradually to 100°. This child gained consciousness after the first puncture; the hydrocephalus, however, persisted, and she was repeatedly punctured until she became rational after the third puncture. The second puncture was made two days after the first puncture; the third puncture was made four days after the second.

I have 13 patients thus far treated with the serum, two of which are under observation, two of which died; the remainder recovered with the exception of one, which was discharged improved. A résumé of these cases will be given by Dr. Flexner in his complete report, and they are to be found under the heading of cases coming from the Mount Sinai Hospital.

I think it would be rather premature and unfair in every way to draw any conclusions as to the serum until we have seen a larger material and until we have tried it in an epidemic of the violent type, such as we passed through in 1904 and 1905. On the other hand, it may be said that the serum of Flexner not only makes a very favorable impression, but is certainly a factor which cannot be excluded from the therapy of cerebrospinal meningitis, no matter what our subsequent conclusions may be. It certainly does appear that with the serum as we perfect it we may have an improvement in the percentage of recoveries. It is hard to say sincerely whether taking the cases I have treated I shall continue to have the same good fortune to save all but 2 cases of 13. Even if the cases I have lost were below one year of age, judging from the results obtained elsewhere, we may still meet with cases which we cannot save by the serum, and it would certainly be very unreasonable to expect a continuance of such a very high percentage of recoveries as we have just shown.

A CASE-APPARENTLY OF TUBERCULOUS MENIN

GITIS IN WHICH THE AFTER HISTORY MAKES
IT PROBABLE THAT THE DIAGNOSIS WAS MIS-
TAKEN.

BY EDWARD M. BUCKINGHAM, M.D.,

Boston, Mass.

The patient, a boy of seventeen months, had malaise for one to two weeks, with cephalic cries. April 10th, Dr. J. W. Redmond was called because of some shuffling in walking, confined to one foot. No tenderness. In the next four days there were vomiting and convulsions. No history of tuberculosis nor of syphilis. Dr. Redmond asked me to see the child on the 14th. The difficulty in walking had then nearly disappeared; there was strabismus; the pupils were dilated and sluggish, the right being more dilated than the left. Knee jerks were unequal, the right being most marked. Kernig sign marked. Babinski present, but slight. Head not retracted. Ears and gums negative. Provisional diagnosis of tuberculous meningitis. Lumbar puncture was performed, the fluid running at first under considerable pressure; perhaps 10 or 12 c.c. withdrawn.

The pathological report by Dr. Leary is as follows: Specimen received from Dr. Redmond consists of 372 c.c. of clear, colorless, watery fluid. This was shaken down in a centrifuge, without obtaining any visible sediment. The lower portions of fluid were smeared on slides and stained by Wright. Careful search resulted in the findings of eighty-nine cells, all but three of which were lymphoid cells. Diagnosis: Chronic inflammatory, probably tuberculous, meningitis.

The pressure symptoms were very quickly relieved, and in about a week the child had recovered health. He remained well May 20th, when Dr. Redmond last saw him. This after history is compatible with its being one of the comparatively few cases of cerebrospinal meningitis, in which there are prodromal symptoms and in which the cerebrospinal fluid contains an excess of mononuclear cells.

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