kind of a clot. In such cases, if meningococcic meningitis is present, the serum may be injected into the ventricles of the child, care being taken not to increase the pressure so as to affect the respiration and pulse.

Occasionally, after the injection of serum, the respiration may be disturbed and the patient be in a condition of shock, the pulse small and the face pale. If this occurs while the injection is being given, some fluid should be allowed to run out of the canula. The gravity method, with very slight pressure is the only method that should be used in giving these injections. If shock really has occurred, artificial respiration should be done and atropine and epinephrine should be given hypodermatically.

When the symptoms show, in meningitis, that more antitoxin must be given (in cerebrospinal meningitis it should be given every twelve hours until the patient shows improvement, and then every twenty-four hours until the patient is apparently convalescent) the patient should lie on one side for one puncture and on the other side for the next puncture, so that the fluid in the lateral ventricles may better flow toward the spinal canal.

Lumbar puncture is often done to determine the presence or absence of syphilis by a Wassermann test of the spinal fluid. This test is often positive when the blood test is negative. Arsphenamine solutions are frequently given intraspinally for the treatment of cerebrospinal syphilis. It should be remembered that this is an arsenic treatment and may cause muscle pains, headaches, irritation of the kidneys, and possibly cause optic or aural neuritis. Arsphenaminized serum is also injected into the spinal canal. This spinal arsenical treatment of cerebrospinal syphilis will probably be less frequently utilized since it has been found that arsenic given intravenously reaches the cerebrospinal fluid.

Lumbar puncture should be considered a serious and not a simple procedure. Consequently, with every case of slight head symptoms or even a beginning meningismus, lumbar puncture should not necessarily be immediately done. It requires a careful decision on the part of the physician and perhaps of a consultant to decide that this operation is necessary for diagnostic purposes.

Wegeforth and Latham1 have recently shown that in septic conditions, without infection in the brain, lumbar puncture with the withdrawal of considerable fluid has perhaps, by too great negative pressure in the cerebrospinal canal, allowed the infection to spread to the meninges. They suggest that before such lumbar puncture a blood culture be made, and, if lumbar puncture is considered necessary, but a small amount of liquid be withdrawn, so as to minimize the possibility of this accident of unnecessary infection occurring. While such cases of meningeal poisoning from this reason may be very rare, it still does not militate against the necessity of always considering lumbar puncture a more than simple operation.

TREATMENT OF CEREBROSPINAL MENINGITIS

The cause of epidemic meningitis is the diplococcus intracellularis meningitidis, also called the meningococcus. Doubtless the sporadic form of this disease often termed basilar meningitis is frequently due to the same germ.

Although antimeningococcic serum was not recognized in the last revision of the Pharmacopoeia, the value of this treatment is positive. It has greatly reduced the mortality, and prevents some of the serious sequellæ following an attack of this disease. When the analysis of fluid withdrawn from the spinal canal shows that this disease is present, this antiserum should be injected in an amount of 5 to 10 mils less than the fluid withdrawn. The dose for an adult is ordinarily from 30 to 50 mils, and for infants and children from 5 to 20 mils. The antiserum should be given daily until the spinal fluid is free of germs. It has been suggested that antimeningococcic serum be also given subcutaneously. When the disease is severe, the serum may be given intraspinally every twelve hours for a few times. In mild cases once in twenty-four hours for four days is generally sufficient. All injections of fluid into the spinal canal should be given slowly and before the withdrawal of the needle the patient should be watched to note whether immediate symptoms of shock occur or there is much disturbance of the respiration. If shock or pressure symptoms occur fluid should 1 Amer. Journ. Med. Sci., Aug., 1919, p. 183.

be allowed to flow out of the canal. Hypodermic cardiac stimulation may be given if needed, and artificial respiration is occasionally necessary. Epinephrine solutions may be given intramuscularly, and seem to counteract this kind of shock. Fortunately, with good technique and with the small amount of fluid now injected, these symptoms rarely occur.

TREATMENT OF ANTERIOR POLIOMYELITIS

As yet there has not been developed a specific antiserum for this disease, but the blood serum of an individual who has had poliomyelitis, when injected into the spinal canal, has seemed to greatly modify the symptoms and diminish the seriousness of the sequellæ. The more recent the recovery from this disease, the more effective is the serum. The usual examination of the patient who is to be the donor of the serum must, of course, be made, namely, there must be no chronic disease present, and the Wassermann reaction must be negative. Such serum has been given intravenously as well as intraspinally. The amount given intraspinally is about 20 c.c., and much less to very young children. It may be given daily for several doses, but Amoss says it is of doubtful value after the febrile stage.

Rosenow has prepared a serum from the horse by immunizing him with the coccus found in the central nervous system in epidemic poliomyelitis. This antiserum has been used for protective and curative purposes, and certainly deserves further study and more clinical tests. Some recent clinical reports have apparently shown a reduction in the mortality of this disease when patients were treated with this antiserum.

TREATMENT OF CHOREA

This disease, though generally mild, may be very serious and fatal. Consequently, a recent report of a successful serum treatment is of sufficient interest to be recorded. Block' reports that both he and several colleagues have successfully treated serious cases of chorea by the following method: From 20 to 30 mils of fluid is withdrawn from the spinal canal of these patients into sterile tubes. These tubes are then kept on ice, 1 New York Medical Journal, May 29, 1920, p. 949.

and in severe cases of chorea twice daily 2 mils are administered subcutaneously with the ordinary hypodermic syringe. Improvement did not occur in a series of cases when the spinal fluid alone was withdrawn, but did occur when such fluid was injected subcutaneously in the dose mentioned. The final standing of this treatment can only be shown by future clinical

test.

PART VII

FOODS AND DIETS

The discussion of this subject is from the broad standpoint of the need of the body for the various elements of nutrition. It is also purposed to outline the values and uses of the various foods, but it is not intended to discuss the physiology of nutrition more than to state the fundamental basic principles for the practical advice given. A few facts are presented that every practitioner must know in order to properly treat his patients, as the age of "drugging" is past. It must now be the object of every physician to modify, if possible, disturbances of the system by changes in the food and drink before drugs are called upon for aid. As elsewhere stated, the better the clinician understands physiology, the better therapist he is.

Growth and body up-keep depend largely upon proteins; energy (work, heat, and physiologic activities) depends upon carbohydrates, sugar and fats. Salts are necessary for tissue building and for other chemical interaction of the body. Water is needed for tissue building, for circulation, for digestion, for most physiologic processes, for elimination of waste products, and for the necessary loss of heat.

Any exercise no matter how slight, even the difference between sitting and lying, increases the need for energy-giving foods. Growing boys and girls require about 25 per cent. more food, relatively, to their weight, than do adults, especially the energy foods. Men require more food than women; large men (not fat men) require more than small men, though a small man may require relatively more food than a large man. The more the exercise, the more the energy food required. An individual with fever requires more energy foods than when he is well and at rest, though ordinarily not as much as when he is well and at work.

The unit of measure of the fuel value or energy content of foods is the calorie, which is the amount of heat required to