picture and glandular enlargement was unimproved, but the critical relapse had been successfully bridged.

4. Hemophilia.-Young woman; family and personal history of hemophilia; unmarried, aged 19; was admitted to the hospital with severe uterine hemorrhage, which had been continuing for three months, in spite of medical and surgical treatment. She had terrific anemic, and was almost exsanguinated. The blood coagulation was delayed to four hours.

Normal human serum treatment was begun, 50 c.c. of serum was injected subcutaneously as the first dose; within six hours, there was marked improvement in the general condition, and diminution in the bleeding. Another dose of 20 c.c. given in 24 hours. From that time on hemorrhage completely ceased, the anemia improved wonderfully and she rapidly regained her health.

was

One year later, she had a relapse; this time she immediately asked for the serum treatment; 20 c.c. of normal horse serum was injected, and it promptly checked the hemorrhage.

The third important use of normal serum is in nutritional disturbance and in septic diseases.

A highly immune specific serum for any particular infection, is of course preferable to normal serum, if it can be obtained, thus diphtheric antitoxin for diphtheria, the antimeningitis serum for meningitis, etc., in conditions, however, in which specific sera of high potency have not been produced, normal serum may be used, sometimes with very encouraging results. Thus in subacute febrile rheumatism which after a time fails to respond to medicinal measures, great benefit is sometimes obtained by subcutaneous injection of normal serum. Case.-Woman aged 35 years, had been in the hospital for six weeks, suffering with polyarthritis, and fever, of rheumatic origin. She suffered from very considerable pain, and failed to respond to medication. Normal horse serum treatment was then begun. The first dose was followed by very considerable relief in pain.

After three doses, the patient was convalecsent and feeling well. I have seen similar results in gonococcus arthritis.

Likewise in septic pneumonia, the administration of normal serum is sometimes followed by very gratifying results.

If cultural examination has not been made, so that there is doubt as to whether the pneumococcus, streptococcus or other infecting organism is causing the disease, it is better to use normal serum rather than a pneumococcus specific serum for an infection which may be due to the streptococcus or other pyogenic organism.

SELECTION OF SERUM.

1. Human Serum.- Homologous (human) serum is far preferable to alien sera. The unpleasant symptoms of serum sickness, and the very occasional rare danger of true anaphalactic shock, which may follow sensitization with a foreign serum are almost entirely eliminated. The objection to human serum is the great difficulty to obtain it, especially in the large doses, that frequently have to be used.

2. Horse Serum and other foreign sera (rabbit). Normal horse serum has given the next best results to the human serum. Its great advantage is, that very large quantities can be obtained, and suitably prepared. The objections are the sensitization of the patient to an alien serum, with the relatively frequent complication of serum sickness, or the extremely rare complication of true anaphalaxis. Normal horse serum and horse serum containing immune bodies as in diphtheria antitoxin, and in the antimeningitis serum, all of which act the same as far as the sensitization to an alien serum is concerned, has been used in many thousands of cases. The symptoms of serum sickness which occur, while undesirable and annoying, are usually only a temporary disturbance, and otherwise usually do not cause any untoward effect. True anaphalactic shock, so very rarely occurs, that it ought not to be considered in important cases.

DR. DUKE: There are about as many hemorrhagic diseases as infectious diseases and the pathogenesis as varied. Hemorrhagica neonatorum is due to a poison, or anaphylaxis. Hemorrhagic disease of chloroform poisoning is due to absence of fibrinogen. Other diseases may be due to diseases of the blood vessels, and others seem to be due to diseases of the nervous system. Another hemorrhagic condition is due to absence of platelets. The literature is not reliable because the writers have been more interested in results. The writers have been dealing with six to eight types of disease, and have treated them under hemorrhagic diseases, with some benefit, others not. Therefore it is hard to say what horse serum has done. Hemorrhagica neonatorum should be treated, I think, with horse serum, because here pro thrombin is gone. Serum would not work at all on chloroform poisoning. Serum is free from fibrinogen, and that is what is lacking. Transfusion is ideal in chloroform poisoning because you get some fibrinogen. The type of hemorrhagic disease due to absence of blood platelets yields to injections of fresh serum, and why it is I do not know. Transfusion gives immediate results, and ideal in these cases. Ten per cent of normal amount of blood platelets is enough to stop hemmorrhage. Chloroform poisoning and purpura hemorrhagica would be helped, but only temporarily. Relief is immediate it is true, but only temporary. A very large per cent of these cases are due to low number of blood platelets. I have seen many cases with the platelets below normal. Some of these cases are menorrhagia, some intestinal bleeding, some from operations only, and these patients all show low platelet counts. There may be purpuric eruptions,

ecchimosis, hemorrhage from the nose, and death. I feel that horse serum is not indicated always, and is used in cases often that are not serious enough to warrant its danger, for it leaves the patient predisposed to serum sickness. A person with horse serum once would nst want antimenigițic serum injected into the spinal canal. It is difficult to say how horse serum stops hemorrhage. It could be due to improving the coagulability of the blood, but it is thought that horse serum does not change the time. When human serum is injected into an animal, the platelets clump, and clog the capillaries, and this may be the posfible cause of the relief of hemorrhage by the use of horse serum.

DR. B. H. ZWART: Several years ago, when diphtheria antitoxin was first used successfully in treatment of diphtheria, I found that it could be used to a great advantage in treatment of other throat conditions, accompanied with fever, or a follicular tonsillitis. Also I found in cases of sepsis, patients often seemed to get along better when diphtheria antitoxin was used. Was it the horse serum in these cases that did the work.

DR. HAL FOSTER: In one case of profuse nose bleeding, that had continued a long time, where adrenalin had been used, horse serum stopped the hemorrhage, and the patient recovered. I have seen a number of cases of this kind.

DR. FRANK HALL: To me the whole proposition is mysterious. The result of many of our experiments show valuable things that we cannot explain. The results of Dr. Zwart in the throat diseases were no doubt due to the horse serum. During the past few months our laboratory furnished to a number of doctors, a large amount of rabbit's serum. Rabbit's serum has worked beautifully in hemorrhagic measles. This serum, it seems, whips up something in some sort of a way that gets results. I do not think there is any immunity established from horse serum. I think it is due the proteid products injected, metabolism is increased, and all processes are increased in their action, and as time goes on, we will find more of the value of alien serum and its stimulations. Relative to what Dr. Duke has said about dangers of giving antimeningitic serum afterwards, it is impracticable. If we stood back on such possibilities as these, we would not do anyting in most of our troubles. This is too remote to be of any value.

As far as serum sickness is concerned, I saw much of this during our last epidemic of meningitis, but when rashes developed, we did not stop. It is alarming, yet, I do not think it leaves permanent injury. What I did observe was, when serum was given in small doses, there was more serum sickness, than where it was given in large doses. I think it is a bad idea to give small doses of even diphtheria antitoxin. Here our experiments show good results from therapeu

tic measures we cannot explain, but why stand back because we cannot explain their action. Why wait till your patient is dead. I get tired of working on the dead myself. On many of the severe diseases, your chemical drugs help, but you do not have time to wait for their action. You want something that acts quick. Serum is the only thing you have at hand that does work quick. Of course when we know the cause of our trouble, we can use the specific serum, but when you cannot diagnose the causative agent, use some serum that will bring about this stimulation and give results. I will never forget a case I saw with Dr. Zwart, where a man had cut off two fingers in a paper cutter. He got a streptococcic infection of the stumps, his pulse was 140, temperature 105, and we gave him diphtheria antitoxin, with a prompt and rapid improvement. This impressed me as ode of the best results of foreign serum.

Dr. SCHORER: Very frequently of course, we know in trying to immunize individuals, we have difficulty so far as curative action is concerned. Some of these difficulties come from the fact we are unable to get the antibody to the seat of infection, and for this reason we resort to various measures. We may resort to incision of an abscess. May apply the antibody to the area of infection, as in meningitis, or in tetanus, and then we also get the antibody to the part by some method of hyperemia, as rubefacients, etc. Finally we may use Bier's method. Lauderbach many years ago found, that in cases of pulmonary stenosis, with the lungs dry, these individuals died of pulmonary tuberculosis, while those of mitral insufficiency with moist lungs, got well of their pulmonary tuberculosis. By these various methods, hyperemia, etc., we are not getting the action of the normal serum. There are undoubtedly a large number of conditions in which normal serum is of advantage, and these are particularly hemorrhagic conditions. I realize there are certain diseases where normal horse serum is going to do good, but if we are going to use it without diagnosis, we are going backward. We should always make diagnosis first, if at all possible. Then, perhaps if we cannot, then use the

normal serum. We are taking a step backward to simply give a shot of this without first making a diagnosis. If we can get results with the normal serum, then we should get results surely with the anti

serum.

In regard to serum disease. I do not know how many of you ever had this. I have had it. It is not a "cinch." It is possible to have sudden death of your patient from administering serum I saw a man in Milwaukee die very suddenly, and I do not believe we should ever use horse serum in an individual unless there is an indication. It does produce sickness many times, and I feel there is an objectionable feature.

DR. A. SOPHIAN (closing): First in reply to Dr. Schorer's remarks. It goes without saying that there must be a proper indication for any remedy, whether it be a drug or a serum, before it is used. Therefore, of course accurate diagnosis must first be made. I have seen a great many cases of serum sickness, but certainly do not consider it an objection to the use of serum in important cases. Dr. Zwart asked about diphtheria antitoxin. Much diphtheria antitoxin of low grade has been used instead of normal serum, especially where normal serum could not be obtained. In non-diphtheritic conditions it acts purely as a serum.

In regard to anaphylaxis. True anaphylaxis is very rare. In important cases the uncommon danger of anaphylaxis shock must not be considered. In the epidemic of meningitis at Dallas a large number of cases had been sensitized with normal serum at some previous time. In no case did anaphylaxis occur though serum sickness was quite frequent, but apparently caused no serious damage. During the epidemic I advised the use of the sera as a temporary protection, especially in those who were intimately exposed to the disease. One of these immunized developed meningitis about two months later. The intra-spinal administration of serum caused no disturbance. In known cases of sensitization to foreign serum, it may be wise as a safeguard to administer a small dose subcutaneously at first before the larger doses are administered.

Topeka, Kan.

Even if a patient does give a truthful and intelligent history we still may have conditions to deal with that can only be determined by a gastric analysis. Suppose for instance that a patient gives all the classical symptoms of hyperacidity. It shouldn't mean anything to us except a vague general condition as we still have several possibilities, differing materially, to distinguish between: First, are these symptoms due to a real increase of acid, or are they due to a decreased resistance of the gastric mucous membrane which causes the normal gastric juice to irritate, or are these symptoms the result of a slight increase in acid and a slight increase of gastric wall irritability? Second. We may have We may have another condition here which is not at all uncommon. In an exaggerated case of hyperacidity the acid is increased through an increased activity of the parietal cells, this increased activity causes hypertrophy of these cells until they reach a size where they can no longer increase their secretion. Any cell, or group of cells, which is over-stimulated for a certain length of time will degenerate, and that is what these cells do. As these cells degenerate the total acidity is disminished, although the remaining parietal cells are still over-secreting. It is easy to see how this condition may continue until one might find a subacidity from a degeneration of a large part of the parietal cells when the remaining cells were still in an unhealthy state from trying to do the work of those which had degenerated. In such a case one would get a history of hyperacidity all the way through, although the condition would be one of subacidity.

Besides a gastric juice analysis being a necessity to a correct diagnosis of stomach troubles, it is very helpful in eliminating the stomach and establishing a diagnosis of reflex pain.

Of course by observation and elimination, nearly any digestive abnormality can finally be correctly diagnosed without a gastric analysis, but this takes time and every day's delay in improving the patient's condition is

dence and enthusiasm which will be very detrimental even when the proper treatment is begun. The time to find out definitely about a digestive trouble is during the first forty-eight hours.

Next in importance to the gastric analysis, is the examination of the stool, and we are just beginning to realize how important this is since we have begun investigating for hook

worm.

There is absolutely no way to diagnose hookworm, in most cases, except by examining the stool, and we are finding out all the time that hookworm, like malaria, is not confined to any southern locality, but is found all over the country, although it is more frequent in the South. A hookworm patient may present almost any symptoms, or no symptoms at all, and if a physician waits for a senile, anemic or sluggish patient before examining the stool for these parasites, he is going to overlook by far the greater number of his cases. We were rather lax in examining the stools of the general run of patients until a few months ago, but our observations since then have convinced us that it is a good deal safer to examine the stools of all patients presenting symptoms of gastric or intestinal distress, to say nothing of a great many other conditions, and we do not allow ourselves to be misled by any geographical location. In the last two months I have treated cases of hookworm from Arkansas, Texas, Missouri and Illinois and I am sure that I have overlooked them in as many other states.

I wish to give a synopsis of the histories and symptoms of a few hookworm cases to illustrate how different they may be.

Mr. B., Van Buren, Ark.; I saw patient first on the 21st of May, 1912; he was so weak that he could hardly walk, had had a stroke of paralysis affecting one whole side a few weeks previously. Walked on crutches and dragged his foot; was very short of breath and both feet were edematous. Patient gave a history of having from five to forty bowel movements a day. and of having had this condition, off and on, for nine years. I examined