and stated that his health was so much improved he was making arrangements to resume business.

From my report of this last case, I do not wish you to get the erroneous impression that I am claiming to have cured a case of locomotor ataxia. On the contrary, my object is merely to show that a patient afflicted with a narcotic drug addiction, complicated with a chronic disease, and one as serious as locomotor ataxia, can be cured of his addiction as readily and as easily as an uncomplicated case, and all the organs put in such perfect working order that by the application of the proper palliative and remedial agents, he can be enabled to live in comparative comfort and attend to his duties.

These cases I do not consider unusual or remarkable, but they are simply an exposition of what can be accomplished with the delicate human machinery when all of its parts are nicely cleaned, oiled and adjusted.

In submitting this article for publication I think it advisable, in justice to the treatment and the physicians who may read it, to offer a few words of advice and caution.

In the first place, for the successful administration of hyoscine in the treatment of these addictions, experience and skill are the prime requisites, as much so as they are in the successful performance of a delicate surgical operation.

In the first case reported I have given the clinical history in order that a clear understanding may be had of the general procedure, but empiricism is impossible, as each separate case is a law unto itself, and the physician who attempts to treat morphinism by a routine administration of hyoscine is only courting certain failure, and such failures are doubly unfortunate, for they not only elicit adverse criticism of a treatment that is invariably successful in the hands of an experienced administrator, but do inestimable damage to the patient, in that his confidence is destroyed in the efficacy of the only practical method of curing his addiction.

In the next place it is unwise and disastrous to attempt the treatment of these patients, even by a physician experienced in this work, save in an institution especially equipped for the purpose, as it is absolutely necessary that the physician be in constant attendance during the administration of hyoscine in order to promptly meet all exigencies which may arise. After the active treatment is completed it is of prime importance that the patient be under your direct control and supervision, as on the proper conduct of the after-treatment, consisting of a suitable diet, systematic physical training, baths, massage, etc., depends, in a large measure, the success of the treatment and the consequent complete restoration of the patient to vigorous mental and physical health.

RECENT ADVANCES IN DIAGNOSING, TREATING AND COMBATING EPIDEMIC MENINGITIS.*

By VIRGIL THOMPSON, M.D.,
Littleton, Colo.

This disease, which has been defined as "an acute infectious disease with a characteristic local lesion in the meninges and tissue of the brain and spinal cord," is one which has and is bringing into action the best resources of modern science in the solution of the problems which are presented by this disease to the medical profession. The results are satisfying in a degree to the scientist, but to the patient there comes only the benfits of what has been termed a "masterful inactivity," which benefits, indeed, are not in any way to be depreciated. Recent advances have been made along the line of making the diagnosis and treatment not more certain, but more scientific. We all hope, however, that this work is the foundation for those researches which will make the treatment more satisfactory to the patient.

As to the diagnosis, a great advance was made when the diplococcus intracellularis meningitidis was isolated and shown to be the etiological factor in the disease. Unfortunately the microscopic findings in the individual case come too late to admit of anything in the way of prophylaxis. The diagnosis of this disease seems to be a simple matter in most cases. The only diseases with which it may be confounded are pneumonia, typhoid fever with cerebral symptoms and other forms of meningitis.

The typical picture of a case of epidemic meningitis is as follows: A patient with a history of previous good health is suddenly stricken with an evidently serious illness. There is severe headache, vomiting, fever and a rapid pulse. The headache increases, though the vomiting may pass away, rigidity of the muscles of the neck becomes apparent, followed in a short time by opisthotonos. The patient now lies in a semi-conscious, stuporous, delirious or comatose condition. He lies on his side, the head retracted, the knees drawn up and the hands holding the head. There may or may not be a characteristic eruption, though formerly the diagnosis depended upon this eruption, which gave to the disease the dread names of spotted fever and black death. The temperature is high at times, but may fall to normal or subnormal. There may be signs of hyperesthesia of the nervous system. There seems to be nothing new in late observations as to most of the *Read before the Alumni Association of the Denver and Gross College of Medicine.

symptoms, except as the working out of the pathology of the disease throws light on their causes.

The following may be dismissed with a word:
The fever.

The temperature in epidemic meningitis is not characteristic, being irregular, in some cases subnormal, and extremely high in the same day. In cases, however, lasting a week or more there may be a gradual rise to a certain point and then gradually decline.

The pulse is usually rapid. Irregularity of rhythm and force is characteristic.

The respiration is irregular and sighing, with variable depth. Cheyne-Stokes breathing is not as common as in the tubercular type.

The eruption is not pathognomonic, though it was formerly considered so. There may be no eruption whatever, or there may be roseolae, erythema, petechiae or ecchymoses. Herpes may be found in the different parts of the body.

Brain symptoms. The initial headache usually gives way to drowsiness and later stupor. Delirium becomes more marked and may become violent. In the cases which are to bave a favorable termination the patients may be roused from their stupor and give intelligent answers to questions put to them, and they later come out of their delirium in full possession of their mental faculties. There have been exceptions to this rule, in which the mental poise was never recovered.

The kidneys are subject to the same changes which may come to them in the course of any acute infectious disease.

Rigidity of the muscles of the neck is a nearly pathognomonic sign. The exceptions are in those cases in which the toxic condition is so severe in the beginning that muscular relaxation is produced at once. An attempt to overcome this rigidity produces marked dilatation of the pupils. This may be a valuable sign in differentiating this disease from gastro-intestinal diseases in children, which produce this symptom.

The blood examination would seem to be an important adjunct to the methods of diagnosis,. Leukocytosis is practically constant, though the count varies. This variation, moreover, is not in direct proportion to the severity of the case, and is therefore not a great aid to prognosis. This leukocytosis is of a polynuclear type and the count ranges from 11,000 to 55,000, with an average of 25,000. This is a point of differentiation from the tubercular type of meningitis, which rarely gives a count above 25,000.

Kernig's sign is of recent discovery, having been desrcibed in 1882. In this the leg cannot be extended fully when the thigh is placed at right angles to the trunk. This sign is

not pathognomonic of this disease, and is only useful in confirmation of a diagnosis based on other data.

Babinski's reflex was present, according to one author, in 4 out of 25 cases of epidemic meningitis, and absent in only 6 out of 26 cases of tubercular meningitis. This gives it some value as an aid in differential diagnosis.

Macewan's sign is described as a hollow note on percussion over the anterior horn of the ventricle, the head inclined to one side; percussion of the inferior frontal or parietal bone will give a tympanitic note. This sign is found more frequently in tubercular meningitis than in the epidemic form, thus becoming an aid in differential diagnosis.

Lastly under diagnosis comes the matter of lumbar puncture. In the fluid drawn off by the lumbar puncture there is found the specific organism of this disease. This organism is found within the body of the polynuclear leukocytes. Their presence is not constant in the cases well known to be of the epidemic form. In this it differs from tubercular meningitis, in which the etiologic organism is almost constantly found. So, then, given a case in which a differentiation must be made between these diseases where neither organism is found after prolonged search, the diagnosis of the epidemic form is justified.

As to the treatment of this disease, it is purely symptotomatic. I have found nothing in the literature to which I have had access which I would feel justified in using in a case of my own. Specifics have been exploited, only to be thrown aside. Serums have been prepared for which much was claimed, only to be discarded. The greatest value of lumbar puncture seems to be in its use in diagnosis and not in treatment. However, lumbar puncture would seem to be indicated in those cases where the severity of the symptoms depend on intraventricular pressure. The symptoms of intraventricular pressure are extreme headache and delirium, with the sudden development of symptoms of hydrocephalus, such as convulsions and stupor, dilatation of the pupils, and subnormal temperature, followed by a sharp rise.

As to the control of the disease, it is transmitted through the secretions of the mouth, nose and conjunctiva. Sanitary conditions seem to have much to do with its control. Crowded, dirty quarters, large gatherings of troops, etc., give conditions favorable to its spread.

It is not violently contagious, usually only one member of a family being attacked. Care for the secretions of the body and isolation of the patient would seem to be all that can be done to prevent the spread of this disease, which happily is so rare in our midst.

CONSERVATIVE SURGERY OF ARMS AND LEGS.

John Egerton Cannaday, M.D., surgeon-in-charge Sheltering Arms Hospital, Hansford, W. Va., concludes an article in J. A. M. A. as follows:

1. The conservative treatment of severe injuries to the arms and legs is essentially modern, and we should not do primary amputations (except in case of a limb being held by only a few shreds), but wait for shock to pass and for the patient to regain strength.

2. We should avoid the use of antiseptic solutions for irrigation and use instead normal salt solution.

3. Bones should not be permanently sutured, and we must not be in too great a hurry nor attempt too much in the beginning.

4. Moist gangrene calls for radical treatment.

5. Drainage is usually necessary and the rubber tube is preferred.

6. Good functional results may be obtained against great apparent odds and a saved limb is preferable to an amputation stump.