ence of residual urine as early as possible, so as to avoid toxemia from that cause. He spoke of the value of urotropin in some of these cases and emphasized the importance of carefully instructing these patients in the care of themselves.

Dr. W. F. Carver reported twelve monsters in his obstetrical practice, and mentioned particularly three cases of acrania which he had seen. All three were suspected of being multiple pregnancies, all presented hydramnios and all were girls. In their other particulars they were very dissimilar, so that no valid conclusions could be drawn.

The following resolutions were adopted:

unanimously

WHEREAS: The health and vital efficiency of the people of any country are the most valuable asset which the country can possess, and

WHEREAS: We believe that the life and health of the people can best be conserved by concentrating and enlarging the scope of the Government's activities along these lines and by placing the directions in the hands of an expert in public health affairs, and

WHEREAS: We believe that this can best be accomplished by consolidating the existing bureaus into a national department of public health, with a secretary of public health, who is a member of the cabinet, at its head, therefore be it Resolved; That the members of the Noble County (Indiana) Medical Society, individually and collectively, are in hearty sympathy with the plans and purposes of the Owen Bill (S. 6049) and earnestly urge our representatives in Congress to give their careful attention and support to this bill, and to all legislative measures which tend in the same direction; and further,

WHEREAS: We believe that no persons are so adequate to minister to the needs of the sick and apply the proper remedies as are the regularly qualified and licensed physicians of this country, and

WHEREAS: We believe that any course of action which would limit their freedom in the choice and application of such remedies as may appear needful in a given case, is subversive of the best interests of the people of this country, be it

Resolved; That while we, the Noble County Medical Society, are in full sympathy with the avowed purpose of the Cullom Bill, to limit and control the sale and use of habit-forming drugs, we feel that an injustice is done to the medical profession, and through them to the people at large by the provisions of Section IV of said Cullom Bill, and we earnestly urge upon our representatives in Congress that they endeavor to secure the amendment of said Section IV so as to read, "But that nothing contained in this section shall apply to licensed practitioners actively engaged in medical practice, to public hospitals, or to scientific or public institutions."

Drs. Hooke of Brimfield, Long of Kimmel, and the Vandevetters (husband and wife) of Ligonier, were elected to membership in the society.

The twenty-five members present were the guests of Drs. Scott and Luckey. Adjourned.

GEO. B. LAKE, Secretary.

BOOK REVIEWS

SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, PATH OLOGICAL AND HYGIENIC ASPECTS. By E. Heinrich Kisch, M.D. Translated into the English language by M. Eden Paul, M.D. Rebman Company, New York, 1910. Cloth, $5.00.

This volume dealing with the sexual life of woman, treats of its various phases in relation to the physical and mental development of the individual, both in the

state of health and disease. The several sexual epochs are differentiated and the changes peculiar to each are considered in detail.

The author gives not only his conclusions, the outgrowth of extensive experience and observation, but also quotes freely the theories and deductions of those who likewise have done extensive research along this line. The book will be of interest to both physicians and biologists. It treats of subjects not to be found in volumes on gynecology and obstetrics. The translation into English is very clear and readable.

A TEXT-BOOK OF OBSTETRICS: Including Related Gynecologic Operations. By Barton Cooke Hirst, M.D., Professor of Obstetrics in the University of Pennsylvania. Sixth revised edition. Octavo of 992 pages, with 847 illustrations, 43 of them in colors. W. B. Saunders Company, Philadelphia and London, 1909. Cloth, $5.00 net; half morocco, $6.50 net.

The thorough revision of this standard text-book on obstetrics is well illustrated by the new material added, of which there are seventy-seven pages and eighty illustrations, three of the latter in color.

For the most part the addition has been in the chapter on operations which has been extended to include the operations consequent upon the child-bearing process at all periods. As the author justly states in his preface, many of these gynecologic operations belong to obstetrics just as truly as does the application of forceps; for instance, pan-hysterectomy for chorioepithelioma, the operative correction of retrodisplacement following childbirth, or salpingo-oophorectomy for ectopic pregnancy, etc. Indeed much more attention has been paid to all questions of gynecology than in previous editions because the author believes that the specialist in obstetrics should also be an expert in every department of gynecology. In fact, Dr. Hirst maintains that even the general practitioner should be prepared to give proper advice on all complications of child-bearing and its relation to gynecology.

A commendable feature by way of a section on the causes and treatment of sterility has been added. The author certainly makes a conservative estimate when he says that in at least 20 per cent. of sterile marriages the fault lies with the male. It would seem that the wide prevalence of gonorrhea in the male would account for a much greater percentage of sterility and particularly of one-child sterility, of which latter this source of infection is probably the most prolific cause.

The chapters on the pathology of the puerperium have been slightly condensed, though not materially altered in substance.

As has been said, the greatest change in this revision is the addition of much matter and many details concerning the various obstetric and gynecologic operations, in conformity to the previously-expressed views of the author upon the close relationship of the two

branches.

The literature throughout the volume has, of course, been brought up to date.

The work remains, as formerly, one of the standard obstetric texts and its thorough revision should make it more popular than ever.

VOLUME III

ORIGINAL ARTICLES

THE DIAGNOSIS AND TREATMENT OF CEREBROSPINAL MENINGITIS.*

W. D. HOSKINS, M.D.

Lecturer on Diseases of Children, University of Indiana
School of Medicine.
INDIANAPOLIS, IND.

Cerebrospinal meningitis, while not a common disease, occasionally is epidemic, and sporadic cases not infrequently occur. Its high mortality, serious sequelae and some recent innovations in treatment justify its consideration.

The disease first appeared, or at least was first recognized in America, about one hundred years

It had previously been recognized and described in Geneva in 1805. Epidemics have occurred throughout the United States at irreg

ular intervals. The last severe one was in New

York City, from 1904 to 1908. There were about four thousand persons affected, with approximately three thousand deaths.

LOCAL EPIDEMICS.

The disease has not been widely epidemic in Indiana since the Civil War. At that period it was quite prevalent, few counties escaping its visitation. Pathetic evidences of its ravages still exist in many communities, in the form of physical or mental defectives who were children at that time.

ETIOLOGY.

The contagious character of the disease has long been recognized but the method of transmission was for a long time unknown. It spreads from the patient to the attendants, but is probably not transmitted through a third person, or

*Read before the Indiana State Medical Association, October 8, 1909.

NUMBER 7

by fomites. Like pneumonia, it is only moderately contagious, many of those exposed escaping the infection.

Weichselbaum, in 1887, isolated and described. the specific organism and called it, from its appearance and location, the diplococcus intracellularis meningitidis.

The presence of the specific organism in the secretions of the nose and throat in most of the cases recently examined makes it probable that the disease is transmitted in this way. A nasal discharge was noted in 13 per cent. of the cases, apparently a small per cent., but probably as large as the per cent. having nasal discharge in diphtheria.

One investigator (Scheurer) found the specific organism in the nasal secretion of all of his series of 18 cases.

Investigations made during the recent New York epidemic show that meningococci are usually found in the nose and nasopharynx of most cases of meningitis during the first twelve days. After the fourteenth day these can seldom be demonstrated. The organism was found in the secretions of 10 per cent. of persons in contact with the disease.

Recent epidemics have afforded opportunity for careful study of the organism with modern laboratory methods, and several interesting and valuable additions have been made to our knowledge of the disease. For example, Dr. Still some years ago described a type of meningitis which is called in England the posterior basic type. It differs in some ways from the typical epidemi cases. It occurs sporadically and has not been regarded as contagious. Its manifestations are not so violent as the epidemic variety, yet in infants and children it is usually fatal.

Intracellular diplococci are present in the exudate but their identity with or relation to the organisms found in the epidemic variety are not proven. Further study has shown that this

organism of the sporadic cases has not only the same intracellular location and morphology, but that its staining and cultural features are the

same.

Distinct differences, however, are found to exist in agglutination reaction. The organism from the sporadic cases is not agglutinated by serum from an epidemic case and vice versa.

The consensus of opinion now is that they are different strains of the same organism and that the variety of manifestations, bacteriological and clinical, are probably due to variations in viru. lence rather than to different organisms.

Like most acute infections, cerebrospinal meningitis is most likely to attack children. In the New York epidemic 15 per cent. of the cases were under 1 year and 67 per cent. were children under 10 years of age. That one-third of all cases are adults is evidence that the immunity afforded by maturity is only partial and imperfect.

The period of incubation seems to vary, but is usually from a few days to a week. The invasion period of several days is characterized by discomfort, feverishness and headache. An abrupt onset is so frequent, however, that it is commonly regarded as typical. It seems rather strange that this abrupt onset is more frequent in adults than in children. These prodromal symptoms do not differ from the invasion of any acute infection.

SYMPTOMS.

Of all the symptoms, headache is the most constant. It occurs early and is usually persistent. It may be dull in character, but more often is sharp and excruciating and is a more prominent feature in adult cases than in children. The pain may be diffuse but is commonoly most intense at the occiput, and, like most severe occipital headaches, is apt to be accompanied with. nausea and vomiting. Vomiting occurs at some period in practically all cases.

Soon after the onset of the headache, or at least after it has become severe, a stiffness or rigidity appears in the muscles of the neck. This symptom varies from a slight, almost imperceptible soreness in the very mild cases, to the most positive rigidity in the severe forms. Motion of the head is usually painful, and passive motion elicits a feeling of resistance.

This rigidity later involves not only the cervical but all the spinal muscles. The rigidity of the neck is one of the earliest symptoms and, with the possible exception of headache, the most constant.

Opisthotonos is so frequently present as to be characteristic. Spasm of the extremities is pres

ent in children in from 60 to 75 per cent. of cases, strabismus in 50 per cent. and paralysis in about 20 per cent., or in one out of three or four cases with spasm.

Kernig's sign, if present, is of distinct value as a sign of meningitis. It is not present in every case, so its absence is of negative value. In the mild form chilliness or mild rigors are usual. In the severe infections well-marked chills are common. They are not apt to continue.

As in other acute infectious diseases, chills are not usual in children, but are likely to be replaced by convulsions, which occur in about 50 per cent. of all cases in children.

FEVER.

The temperature is notably irregular. It follows no typical course, but may be high at times and again low. Some fever is usually present throughout the attack.

The degree of fever present is of little value in prognosis. A high fever does not necessarily indicate a severe infection and vice versa.

The pulse rate is seldom markedly increased. It may be slow and is notably uncertain and irreg ular. It bears no constant relation to the temperature. Relative slowness of the pulse to the temperature is frequent in children, is not infrequent in adults, and may be regarded as characteristic. The respiration is usually accelerated. It is characteristically irregular and toward the last may be of the Cheyne-Stokes type.

The abdomen is distended at times, sunken at others, and is of little value in diagnosis. The blood examination shows a marked leucocytosis.

Hyperesthesia of the skin and special senses is frequently present, amounting at times to a disthesia. Tenderness is usually complained of on pressure over the limbs and along the spine, being especially marked in the cervical and lower The tendon reflexes show occipital regions.

nothing characteristic, being frequently exaggerated in the exciting stage and absent in the depressed stage.

MENTAL STATE.

Notwithstanding the acute character of the pain, the mental condition tends to dullness and apathy. The patient desires to be let alone.

Delirium of variable intensity is common in children, frequent in adults, followed in severe cases by coma. Herpes is a sign of some value, being present in about the same per cent. of cases as it is in pneumonia. While in the popular mind petechiæ are so generally associated with the disease as to designate it spotted fever, they are probably present in less than 20 per cent.

After the patient has begun to improve, or has even made considerable progress toward recovery, relapses frequently occur and are often fatal.

DIAGNOSIS.

Elaborate lists of comparative symptoms in parallel columns for differential diagnosis between the various forms of meningitis have been tabulated. While each form may have its typical mode of onset, signs and symptoms, many of the symptoms are common to all forms of meningitis and their clinical differentiation is frequently difficult and often impossible.

Dr. Morse has well pointed out that meningitis in infancy differs in its onset and clinical course from that observed in older children, and that there is no characteristic mode of onset, sign or symptom that is pathognomonic of any certain

form.

The prodromal history, signs and symptoms regarded as typical of one form may be observed occasionally in other forms, and undue reliance upon these for differentiation will result in error.

With all the available features in the case-i. e., family and personal history, environment, mode of onset, signs and symptoms a differential diagnosis can usually be made.

With a vague or obscure history, an atypical onset and a common or general symptomatology, clinical differentiation is frequently impossible. Only a careful examination of the cerebrospinal fluid will supply the desired information.

The operation is not a particularly formidable one, but demands scrupulous cleanliness. It has been attended with so little inconvenience, is so free from danger ånd the results have proven of such value that the procedure is now regarded by those who have used it as a routine measure.

LUMBAR PUNCTURE.

The procedure, as its name implies, consists in the introduction of a needle or a trocar and canula into the lumbar region of the spinal canal for the purpose of withdrawing cerebrospinal fluid.

In a young child an ordinary long hypodermic needle will answer, as the canal in these is only 2 to 3.5 cm. from the surface; that is, 34 to 114 inches.

In adults a long aspirating needle of fair caliber or a small trocar and canula is preferable, as in muscular or fleshy adults the canal may be as much as 6 to 7 cm. ; that is, about 211⁄2 inches from the surface. The puncture may be made anywhere from the second or third lumbar intervertebral space to the space between the last lumbar and the first sacral vertebra, called by

Chipault the sacro-lumbar foramen. In any of these spaces there will be little probability of striking filaments of the cord; yet it is sufficiently high to enter the canal.

The simplest landmarks are probably the iliac crests, usually about on a level with the spinous process of the fourth lumbar vertebra. The puncture may be made in the child in the median line, but in the muscular adults the thickness and density of the ligamentum interspinosum makes it preferable to enter about 1/2 inch either to the right or to the left of the median line.

In acute cases an anesthetic is seldom required. I have found that the patient is usually sufficiently stupid to offer but little resistance. A passive condition is almost imperative, however, for a satisfactory puncture, inasmuch as a struggling child or a patient with an active delirium. may catch the needle between the bending vertebræ and snap it off in the spinal canal. I have had this accident happen, and the feeling produced is not a comfortable one. If there is any doubt about securing passiveness an anesthetic should be used, especially if the operator has not had experience. After the operation has been performed repeatedly, considerable dexterity is acquired in plunging the needle directly into the canal without having to feel the way. The beginner should not attempt any plunging, as he will probably strike the body of a vertebra, dull, bend or break his needle, and contaminate the fluid when he does find it with blood from the lacerated tissues. It is important that the fluid be free from blood, as its presence nullifies one valuable feature in diagnosis, viz., the character of its cellular content.

As to the position of the body: some prefer to have the patient sit up, claiming that the flow is thereby facilitated. An objection to this is that in very sick patients the position is a painful one, and is apt to produce restlessness, especially if it has to be maintained for some time. I prefer to place the patient on his side on a table or firm couch, have an attendant flex the head and legs, thus rounding out the spine and separating the spinous processes. In this position I have seldom failed to secure fluid.

In fibrinous, flocculent or heavy purulent fluid the needle will occasionally become occluded. If this occurs it should not be withdrawn, but the syringe be detached and a wire used to clear the needle. In this particular the trocar and canula is superior to the needle. It has the material disadvantage, however, of providing no suction. With a limpid fluid and a large canula the flow will usually be sufficiently rapid; yet, if much fluid is to be withdrawn and there is little or no

pressure, or the fluid fibrinous or flocculent, the process is tedious, and a good tight aspirating syringe greatly expedites the procedure.

The clinical appearances of the fluid withdrawn is of some diagnostic value. In the cerebrospinal variety the characteristic appearance is purulent or sero-purulent. Tubercular meningitis, on the contrary, yields a fluid that is usually clear or only slightly turbid. This gross appearance of the fluid is of limited value and subject to many variations and exceptions, but it may at least be said to be suggestive.

For a bacteriological examination the fluid may be centrifuged, or allowed to settle; the sediment smeared, stained and examined. Usually quite readily and almost always by careful, patient search the organism present can be detected. In the few cases in which this procedure gives negative or uncertain results recourse may be had to culture growths, or to animal inoculations, or to both.

A further procedure in the microscopical examination of the fluid is of positive value, and that is the determination of the variety of cells present. In the cerebrospinal cases the cells present are decidedly of the multinuclear variety. In the tubercular cases the lymphocytes preponderate.

TREATMENT.

Our former methods of treatment have been symptomatic and empirical. We cannot feel assured that they have been more than palliative. Morphin or its derivatives should be used to control the pain. While some writers discredit the coal-tar products, I believe phenacetin supplements the anodyn effect of morphin or codein. Ice bags to the head and hot tub baths give some relief. Counter-irritation, while generally practiced, is of doubtful utility. A mild counterirritant does no harm, but blisters are easily produced, and these are frequently followed by sloughing. Bier's hyperemic treatment, by compressing the neck, has been tried in a few cases, with apparently favorable results.

Lumbar puncture has been used not only for diagnosis, but as a therapeutic measure. While it has not succeeded in materially reducing the mortality, it is unquestionably indicated in certain Relief of pressure symptoms is often

cases. marked.

THE QUANTITY OF FLUID TO BE WITHDRAWN. Most writers, I have found, suggest removing 15 to 30 c.c. There can, in my opinion, be no arbitrary rule. The amount withdrawn should depend upon the age and condition of the patient, the type and stage of the disease, the clinical

appearance of the fluid itself, whether clear. turbid or purulent. If the fluid is clear and apparently normal, enough should be removed to centrifuge and examine, and to relieve pressure if it exists.

If, on the other hand, the fluid is found to be markedly turbid, fibrinous or purulent, I have no fixed limit, but remove all I can get. With such conditions present I regard it as analogous to draining an abscess.

SERUM THERAPY.

At the time of the great fatal epidemic in New York City, 1904 and 1905, a medical commission. was appointed, consisting of the city's most eminent and capable physicians. They were asked to examine the causes and conditions giving rise to the outbreak, investigate the method or methods of its transmission and recommend measures for its eradication and control.

To Dr. Simon Flexner, a member of the commission and medical director of the Rockefeller Institute for Medical Research, was assigned the task of experimenting on the production of an antimeningitis serum. While the details of his methods have not been published, it is understood that by successive inoculation of the horse he has evolved a serum of considerable potency. The results achieved with it so far surpass any method of treatment we have heretofore employed that they may almost be said to be sensational. To my mind the discovery bids fair to mark an epoch in medical history analogous to that of the discovery of diphtheria antitoxin.

The serum has been under experiment now between two and three years. It has been used in various epidemics widely distributed—in Ireland and Scotland and in this country from Massachusetts to California.

By courtesy of Dr. Flexner the serum is available to the profession in Indiana. I will be glad to supply it free of charge to any physician who has a case of cerebrospinal meningitis and who wishes to test it. The only conditions imposed are that a careful clinical record of the case be kept and bacteriologic examinations made of the cerebrospinal fluid, and that these records and reports be returned promptly.

The effect of the serum on the cerebrospinal fluid is phenomenal. The turbidity promptly clears up, the purulent. condition is markedly diminished.

The meningococci are materially reduced in ber, and of these a much larger per cent. are found within the leucocytes, indicating a diminished virulence of the organism, or an increased phagocytic activity of the cells, or both.