Pari (Gazz. deli ospedali 1908 No. 65) agrees that oatmeal notwithstanding its richness in carbohy drates often gives the best results in diabetes. He gave a severe case 250, later 150 grms. daily with a greater reduction of acetone than was possibly by the strict meat diet. The ammonia also decreased and the body weight increased. Pari does not believe Naunyn and his pupil Lopetz that oatmeal is changed in the intestine to something which is not starch.

The only original work done on metabolism in diabetes that has come to our notice within the last few months takes up salt metabolism.

E. P. Joslin and Harry W. Goodall, Boston (Journal A. M. A., August 29), have studied the question whether the withdrawal of salts from the diet might lead, as a rule, to the production of an acidosis in a healthy person or to the aggravation of such a condition already existing in a diabetic patient. The result of their experiments, which were published in full in the Archives of Internal Medicine, July, 1908, i. 615, indicate that such is not the case. They have also investigated the occurrence of edema in diabetes, which is, they say, not infrequent in cases presenting marked acidosis and occurs coincidently with restrictions of the cabohydrates. These patients were given sodium bicarbonate, but the authors do not recognize this latter as a factor and they have never seen it cause edema in a mild case of diabetes. They consider the edema as probably due to the increased production of acids causing injury to the kidneys, thereby leading to retention of salt (not salts). This view appears to be supported by the history of some of their patients in whom the ingestion and excretion of chlorin was observed. Patients in diabetic coma rarely, if ever, show signs of edema, and show diminished chlorin in the urine if alkalies are given. If the withdrawal of salt from the diet in a severe case of diabetes prevents the occurrence of edema, as was observed the administration of salt should lead to salt retention and gain in weight. This was found to occur. In patients with deficient chlorin in the body, edema is not likely to occur, but they are more prone to coma because of the greater concentration of the acids in the system. The authors, therefore, advise the careful administration of salt along with sodium bi carbonate in the prophylactic and actual treatment of diabetic coma.

Book Notices

Writing the Short Story.

By J. Berg Esenwein, A. M., Lit. D. Cloth, 12 mo. 448 pages. Price, $1.25 net. Hinds, Noble & Eldredge, New York.

It is quite refreshing to come across a practical work which will be helpful in writing the shortstory. The fact that the author is one of the editors of Lippincott's Magazine is sufficient warrant to insure careful reading. This little work evidences careful thought and at the same time a thorough familiarity with the subject at hand. This volume is carefully gotten out and full of interesting information tracing the Short-Story back to its origin and showing the difference that lies between the shortstory and other literary forms. Among the many chapters, all of which are interesting, the following may be mentioned as containing matter of especial interest, namely, The Plot, Body of the Story, Ending the Story and Style. There is a good deal of

A Text-Book of Physiological Chemistry. By Olof Hammarsten, late Professor of Medical and Physiological Chemistry in the University of Upsala. Authorized translation from the Author's enlarged and Revised Sixth German Edition by John A. Mandel, Professor of Chemistry in the New York University of Belvue Hospital Medical College. 8 vo. 845 pages. Cloth, $4.00. Published by John Wyley & Sons, New York. It is a pleasure to welcome the Fifth English Edition of Hammarsten's excellent Text-Book of Psysiological Chemistry. This book has run through five editions in English since 1893, and it is perhaps sufficient to say that the present edition keeps up with the standard formerly set. The book has been thoroughly revised and most of it re-written. The foot-notes giving reference to the original literature are of great value, enabling one easily to get at the original source in the case of any desired topic.

The introductory chapter on animal oxidation and enzyme action is a fit introductory to the chemistry of life phenomena. Following this the peculiar organic substances of the body are considered and then the various tissues and organs. The last chapter includes a very comprehensive general study of the subject of metabolism.

Books, Pamphlets, etc. received.
From Longmans Green & Co., New York.
Further Advances in Physiology, Edited by Leon-
ard Hill, M. B. F. S. With diagrams.

From John Bale Sons & Danielson, London.
The Etiology and Nature of Cancerous and Other
Growths, by W. T. Gibson.

From Lea & Febiger, Philadelphia.

Thornton's Pocket Medical Formulary, by T. Quin Thornton, M. D., Philadelphia. Price $1.50 net.

From Samuel E. Earp, M. D., Indianapolis.

Bedside Clinic Summary of the Treatment of Acute Rheumatism at the Indianapolis City Hospital (reprint N. Y. Medical Journal, May, 1909.)

From Geo. M. Niles, M. D., Atlanta, Ga.
Aesthetic Alimentation (reprint Charlotte Medical
Jour., April, 1909.)

From John Van Doren Young, M. D., New York City. Sacral Suspension of the Uterus-A New Technique (reprint American Jour. of Surgery, March, 1909.)

From Bureau of American Ethnolgy Bulletin 34. Physiological and Medical Observations Among the Indians of Southwestern United States and Northwestern Mexico, by Ales Hrdlicka.

From The Northwestern University Medical School, (Chicago Medical College.)

The Quarterly Bulletin of the Northwestern University Medical School, June, 1909, Vol. XI, No. 1. From Treasury Department, Washington, D. C. Digest of Comments on the Pharmacopoeia of the United States of America (Eighth Decennial Re vision). By Murray Galt Motter and Martin 1 Wilbert.

COMPLETE SERIES, VOL. LVIII, No. 7

NEW SERIES, VOL. III, No. 7

$2.00 YEARLY

By D. L. HARRIS,

City Bacteriologist, St. Louis.

Much has been written within the last two years concerning the use of serum in the treatment of epidemic meningitis. In this country the serum prepared by Doctors Flexner and Jobling has been employed with marked success. While at the present time it may be definitely affirmed that the death rate has greatly diminished following its use, there are many problems connected with its administration which can be settled only after a very large number of carefully recorded clinical and laboratory data have been collected.

Dr. Flexner's work on the production of this serum was begun during an outbreak of epidemic meningitis in New York City in 1904 and 1905. At this time there were recorded some four thousand cases with a mortality of about 85 per cent. A commission, of which Dr. Flexner was a member, was appointed to study this disease and seek some means for lessening its terrible mortality. The result of Dr. Flexner's work was the production of a specific serum. In brief, the serum is prepared by injecting a horse with meningeococci, first subcutaneously, then intravenously, and lastly with an antolysate, the doses being gradually increased and the process involving several months. Sometime later the horse is bled and the serum is secured in much the same manner as in the preparation of diphtheria antitoxin and put in small vials, each containing 15 ce. Doctors Flexner and Jobling collected and analyzed over four hundred cases in which the serum treatment had been used. A brief

up

Author's abstract of a paper read before the East St. Louis Medical Society, June 28, 1909.

reference to some of their findings may be of interest to you. The largest percentage of recoveries occurred in patients between five and ten years of age, the mortality in these cases being only 11.4 against an average mortality of 70 or 80 per cent before the use of the serum. As would be expected, the mortality rate was found to depend very largely upon the duration of the disease at the time of the initial injection of serum. Thus of the cases treated on or before the third day of the disease the mortality was 16 per cent; of those treated between the fourth or seventh day there was a mortality of 23.8 per cent; of those who did not receive treatment until the seventh day or later, the mortality was 35 per cent. In 25 per cent of those who recover this occurs by crisis. One of the most striking results of the serum treatment has been the remarkable freedom of the convalescents from complications and sequelae.

Recovery from cerebro-spinal meningitis was often more to be feared than death itself. Its sequelae include blindness, deafness, idiocy and various forms of paralysis. In some epidemics of the past as many as 90 per cent of recoveries have been accompanied with some permanent impairment. In the four hundred cases analyzed by Doctors Flexner and Jobling deafness was noted seven times, blindness and deafness once, mental impairment once and choroiditis once. These authors conclude: "It is our belief that the analyses of histories of cases of epidemic meningitis which have been presented in this article furnish convincing proof that the anti-meningitis serum, when used by the subdural method of injection, in suitable doses and at proper intervals, is capable of reducing the period of illness; of preventing in large measure the chronic lesions and types of the infection; of bringing about complete restoration to health in all but a very small number of the recovered, thus less

ening the serious deforming and permanent consequences of meningitis; and of greatly di minishing the fatalities due to the disease."

Just what constitutes "suitable doses" and "proper intervals" cannot at present be fixed absolutely. A much larger number of cases with careful observation and study must be recorded before fixed rules can be laid. To this end, Dr. Flexner is supplying the serum for those cases in which careful clinical and laboratory records can be made.

When the serum was first employed the dosage was from 5 to 10 cm. and often this was given subcutaneously. Experience has shown that larger doses must be given and that these must always be administered subdurally. It is customary to administer 30 or even 45 cc. as soon as the diagnosis can be made, and this amount is given even though a less quality of cerebro-spinal fluid has been withdrawn. No ill effects have been noted following the injec

tion of this amount.

It is advisable to repeat the injection daily for at least three successive days, giving 30 cc. each day after the first. After this we are in the habit of waiting several days to note the effect. Upon the first indications of a return of the symptoms the injections are resumed.

Immediately after each withdrawal the withdrawal the cerebro-spinal fluid is carefully examined for the presence of diplococci. And as long as these are found, it is my belief that the serum should be continued. It is very rare, however, that we have been able to discover the organism after the third injection, and often they disappear completely after the first. Another striking proof of the value of the serum is that in no case have we been able to cultivate the organism after the first injection of

serum.

I have had an opportunity to observe the results of the serum treatment in 14 cases of cerebro-spinal meningitis. Of this number 2

died. The rest have recovered. Of those who recovered the only permanent impairment was deafness, which occurred in case No. 9.

I will not burden you with a minute recital of the course of each case, but will give a brief review of such of them as illustrate most strikingly the success of this treatment. I wish

to acknowledge my indebtedness to the physicians in the City Hospital and to Drs. Elsworth Smith, Walter Baumgarten and W. E. Wiatt for records in these cases.

Case 1.-Patient is a colored girl 8 years old who was taken sick this morning (April 30th) at 1:30, when she vomited and complained of intense headache. Her condition continued to grow worse and early in the morning she did not talk or notice those around her. Nine hours after the onset she became very restless, screamed and moaned, and later on the mother noticed that the child's head was drawn back and that "she rested on her back on her head and heels." On admission at 8:50 p. m. the child was crying, screaming, very restless, with marked cervical rigidity and some opisthotonos. Kernig's sign on both sides. The knee jerks were absent. The pupils were contracted. A number of puncture was made at 9:15 p. m. (20 hours after the onset), and 45 cc. of turbid fluid was withdrawn. The first fluid escaped under considerable pres sure so that it spurted several inches when the spinal canal was entered. The examination of this fluid showed the presence of meningeococci. Following this 45 cc. of serum were injected. The temperature at the time of admission was 103.2, the pulse 112, the respir ation 32. On the following morning the temperature had dropped to 99.8, the patient was resting quietly and had slept fairly well during the night.

On the following day she was very restless, although the physical and mental condition had greatly improved. In the afternoon 38 cc. of spinal fluid was withdrav n and 30 cc. of serum injected. Except for the restlessness and irritability, her condition steadily improved.

On the third day 40 cc. of somewhat clearer fluid was withdrawn and 30 cc. of serum injected. The temperature on this day reached normal. Meanwhile her sensorium had cleared entirely, the rigidity and retraction of the head greatly diminished. The knee jerks were still absent.

On the fourth day 30 cc. of fluid was withdrawn and 30 cc. of serum injected. Patient had a very comfortable night following this,

became more quiet and her general condition improved and strength returned.

Within a week following her admission all symptoms of the meningitis had disappeared excepting some slight stiffness in the muscles of the neck, presence of Kernig's sign and absence of knee jerks. Her recovery was uneventful and complete excepting for the first two weeks her pulse rate was rather high and her temperature varied between 98 and 99 and a fraction. She was discharged on the 22nd day after her admission when all signs of meningitis had disappeared, and for several days she had been playing around the ward. There were no complications and no sequelae.

Case 2.-Female, age 61. On March 17th she complained of sore throat but continued with her usual work. At midnight she awoke with a severe chill followed by vomiting and later purging. The following morning her temperature was 100.6 and she developed severe headache and pain in the back of the neck.

at

At noon she was drowy with a temperature of 106. She was first seen by her physician, Dr. Walter Baumgarten, at 2 p. m., which time her temperature was 105.4; pulse 116; resp. 130. She complained of severe headache and pain in the back and neck. Kernig sign was not present. A small petechial rash was noted on the chest, both front and back. Shortly afterward this rash extended to the neck and arms.

At 8:30 p. m. of the same day she was comatose; pupils contracted. The neck was rigid and Kernig's sign marked on both sides. Patellar and plantar reflexes were absent. Leucocyte count 28,600.

At 11 p. m. March 18th, 30 cc. of turbid cerebro-spinal fluid were withdrawn and 30 cc. of serum injected. This fluid contained polymorphonuclear leucocytes and numerous in tracellular diplococci.

The following morning at 9 o'clock she was rational. Her temperature dropped to 99. The hypersensitiveness disappeared. Leucocyte count 14,000. The petechial rash was marked all over the trunk and upper and lower extremities. On the evening of the same day patellar and plantar reflexes had returned.

At 10 p. m. a lumbar puncture was made,

but no fluid obtained. 30 cc. of serum injected.

The next morning patient felt greatly prostrated. Her mental condition had entirely cleared. The signs of meningitis had greatly diminished, and the leucocyte count had dropped to 8,000. No fluid was obtained from a lumbar puncture made and 30 cc. of serum was injected.

Except for the tremendous prostration the patient felt very comfortable. Pulse irregular, and there were other evidences of myocarditis. Recovery from this prostration was very slow but steady. The recovery was complicated by an effusion in the right knee, which, however, gradually disappeared. There was at one time for a period of two or three days partial deafness. This disappeared and she suffered no other complications. She has entirely recovered.

Microscopical examination. No cerebrospinal fluid was obtained after the first puneture. Numerous intracellular-gram-negative diplococci were found in the fluid. The organism was obtained in pure culture on blood se

rum.

Case 3. A boy 17 years old. Previous history negative, the parents stating that the boy had never before been sick. On April 7th the boy complained of a sore throat. On the day following he also complained of slight headache, although he attended school. On the 9th he complained of an increase in the severity of the headache and did not eat supper in the evening. He retired early in the evening and about 1 o'clock on the morning of the 10th his mother was awakened by hearing him vomiting in an adjacent room. He did not get up the next morning for breakfast and on being questioned by his father, about 8 o'clock, he complained of very severe headache and general muscular pains in the back and neck. A few minutes later his father found him unconscious and his physician summoned at once found him unconscious, with distinct rigidity, slight retraction of the neck, marked Kernig and a temperature of 103. At 2 p. m. temperature by the axilla was 103, respiration 20, pulse 106. He had leucocytosis of 26,000. He was in a stupor and could not be aroused. He

groaned when moved or when the reflexes were examined. The Kernig was marked, the knee could not be extended more than an angle of 100 degrees. The knee jerks were absent, plantar reflex present, the pupils slightly unequal and slightly dilated. A lumbar puncture was made and about 42 cc. of cloudy fluid withdrawn. 45 cc. of Flexner's serum injected. The patient's condition continued unchanged excepting that the pulse gradually dropped to 90 by 7 p. m., the temperature remaining 103.4 in spite of the cool baths. At 9 p. m. the temperature reached 105 in the axilla, the patient was very restless. At 10 o'clock the breathing became very short and difficult, the circulation became impaired, feet and extremities were cold, temperature rose to 106 and the patient died at 11:30.

Bacteriological smears of the cerebro-spinal fluid showed the presence of numerous gramnegative intra-cellular diplococci. A pure culture of gram-negative diplococcus was obtained upon blood serum.

Case 4.-White boy, aged 15. Onset with a chill and vomiting. First injection of the serum on the 5th day of the disease. Total amount injected 195 cc. Total amount of cerebro-spinal fluid withdrawn 460 cc. Complete recovery by crisis.

Case 5.-White boy, age 15. First injec tion of serum on the first day of the disease. Total amount injected 210 cc. Total amount of cerebro-spinal fluid withdrawn 460 cc. Number of injections seven. Complete recovery.

Case 6.-Age 2 years. First injection of serum on the seventh day of the disease. Total-amount of serum injected 75 cc. Total amount of cerebro-spinal fluid withdrawn 164 cc. Number of injections, three. Result, complete recovery.

Case 7.-Age 4. First injection of serum on the third day of the disease. Total amount of serum injected 120 cc. Number of injec tions four. Total amount of cerebro-spinal fluid withdrawn 206 cc. Result, recovery.

Case 8.-Married woman, age 55. First injection of the serum on the fourth day of the disease. Number of injections six. Total amount of serum injected 192 cc. Result, re

covery.

Case 9.-White female, age 3. First injection of serum on the third day of the disease.

Total amount of serum injected 120 cc. Number of injections four. Total amount of cerebro-spinal fluid withdrawn 305 cc. Patient developed complete deafness during second week.

Pa

Case 10.-Colored girl, age 17. First injection on sixth day of the disease. Total amount injected 75 cc. Number of injections, two. Total amount of fluid withdrawn 98 cc. tient was discharged recovered, but returned 16 days later with relapse. After her re-admission 255 cc. of serum were injected. Number of injections, 7. Total amount of fluid withdrawn 363 cc. Discharged the 62nd day after onset of the first attack, recovered.

Case 11.-Boy, 19 years old. First injection of serum on the first day of the disease. This patient had an exceedingly prostrating attack. The leucocytes in the spinal fluid were overwhelmed with diplococci, as many as 100 organisms being found in some of the cells. After a few days of apparent improvement, patient's condition grew worse, and he died on the 23rd day. This case was complicated by lues, seconday stage.

Case 12.-White female, age 4. First injection of serum on the third day of the disease. Number of injections, three. Total amount of serum injected 105 cc. Total amount of cerebro-spinal fluid withdrawn 104 cc. Complete recovery.

Case 13.-White male, aet. 2 1-2. First injection of serum on second day of the disease. Number of injections, two. Total amount of serum injected 60 cc. Total amount of fluid withdrawn 55 cc.

Case 14.-Male, white, aet. 10 months. First injection of serum on the third day of the disease. Number of injections, nine. Total amount of serum injected 270 CC. Total amount of spinal fluid obtained 237 cc. plete recovery.

Com

SOME OPHTHALMIC PRACTICES SEEN IN VIENNA IN 1908.

By W. EMIL KLOKKE, M. D., St. Louis.

Trachoma treatment is carried out in vig orous manner at the Fuchs Clinic, these patients numbering between 40 and 50 per day, being treated from 7:30 to 8:30 o'clock in the