Gallstone ileus is a surgical emergency that occurs almost exclusively in the elderly. It is of increasing significance with current demographic changes. Clinical records and diagnostic imaging of 15 consecutive patients treated for gallstone ileus at one hospital over a 6-year period were reviewed. The median patient age was 80 years. Six plain-film diagnoses were made correctly. Contrast studies provided a diagnosis of intestinal obstruction in four patients. Abdominal X-ray findings were assessed incorrectly in two patients, with one false-positive and one false-negative result. The median preoperative hospital stay was 2 days. Three patients had Bouveret's syndrome, two of whom required a gastrostomy and enterolithotomy, and one of whom required a gastroenterostomy. The remaining 12 patients underwent enterolithotomies. Only one patient underwent a cholecystectomy. There was one postoperative death. No patient had biliary symptoms on follow-up. Gallstone ileus is a difficult clinical and radiologic diagnosis. Enterolithotomy alone is adequate treatment in the elderly, and subsequent cholecystectomy is not mandatory.

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In a previous paper ( I ) we have demonstrated the lipoidal nature of serum antitrypsin and have discussed the various methods which may be employed to remove the antitrypsin from the serum; i. e., by extraction, or by the saturation or oxidation of the unsaturated carbon bonds of the fatty acids on which the antitryptic property depends. In view of the fact that practically all sera contain proteolytic ferments, we undertook to determine whether or not sera from which the protective substance had been removed, with resulting exposure of the serum proteins, would be toxic for the homologous animal; and if so whether complete removal of the lipoids was necessary to produce toxic effects. Apart from the interest that such a study would have in relation to the production of the so called anaphylatoxins, we felt that numerous pathological conditions, which at present are not wholly understood, might possibly have their basis in a protein intoxication,--a true auto-intoxication in the sense that the toxic substances were formed from the serum or cellular protein of the host, and without reference to the gastro-intestinal tract. We have in mind particularly such conditions as arteriosclerosis, nephritis, asthma, and acute acidosis in infants. The work of Longcope (2) supports this idea. He observed that repeated injections of egg albumen into sensitized dogs and cats caused nephritis and other organic lesions.

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 antimeningitis 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 lessening the serious, deforming, and permanent consequences of meningitis; and of greatly diminishing the fatalities due to the disease.

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Two of the fatal cases were of the fulminating type, and one (Case VI) was injected first with the serum at the end of the second day and again on the fourth day of the illness and died three hours after the second injection. The fulminant cases died six hours and ten hours respectively after the first serum injection. The total number of cases treated with the antiserum at Akron being eleven it is obvious that little value can be attached to the results stated in percentages. However, the following comparison may be made. Nine cases of meningitis untreated with the antiserum: Eight or 89 per cent. died and one or I I per cent. recovered. Eleven cases treated with the antiserum: Eight or 72 per cent. recovered and three or 27. 3 per cent. died. Eliminating from the calculations the fulminating cases as being beyond reach of treatment, the figures obtained are : Nine cases treated with the antiserum: Eight or 89 per cent. recovered and one or I I per cent. died. City Hospital, Akron, Ohio, Service of Dr. W. S. Chase. Cas~ I. V. I-i. White female, aged 12 years. School girl. Present Illness.-At I a. m. April 28, patient complained of pain in legs and stomach; at 4 a. m. became nauseated and vomited. She remained in bed during the greater part of the day and vomited frequently. Late in afternoon arose and walked out for 15 minutes. At 7 P-m. she became unconscious and voided urine involuntarily. She was restless and noisy until 2 a. m., April 3o, when she slept for 2 hours; then the restlessness returned. Rigidity of neck and slight retraction of the head were first noticed on the 3oth instant. Admitted to hospital that day. Physical Examination.-Patient unconscious and restless and screaming, neck rigid, head retracted, pupils equal and react to light, patellar and abdominal reflexes absent, Kernig's sign marked, Babinski not present, herpes on lips. Temperature 99.6 °, pulse IOO, respiration 24. May I. Totally unconscious, restless and noisy; temperature ranged from 99.60 to lO2.2°; pulse from 92 to 16o. May 2, io a. m. Lumbar puncture, 15 c.c. of opalescent fluid withdrawn. Microscopical examination showed Gram-negative diploeocci within and outside of pus cells. Temperature from 99.6 ° to lO2 °. May 3. Condition unchanged. May 4, 6 a. m. Temperature lol.8°:-8.3o a. m. IO c.c. opalescent fluid withdrawn by lumbar puncture and ro c.c. antimeningitis serum injected.-IO a. m. Temperature lOO°.-lO.4O a. m. Convulsion involving face, eyes and left hand lasting two minutes.-II.2I a.m. Second convulsion, which continued until relieved with chloroform.-I.5O p. m. Continuous nystagmus of both eyes; twitching of arms and upper lip; reflexes of extremities and cornea absent.-3 p. m. Convulsions continue except when controlled with chloroform. Kernig's sign more marked than before; rigidity of neck increased; convulsions controlled with chloroform until 5.3o p. m., nystagmus continuous between convulsions.-6 p.m. Temperature lO2.2°.-8 p. m. 99.8°.-8.45 p. m. Conscious.-9.3o p. m. Convulsion controlled with chloroform.-I2 mid...

T h e e f f o r t s t h a t h a v e b e e n m a d e to d e t e r m i n e the n a t u r e o f the f e r m e n t -i n h i b i t i n g s u b s t a n c e s o f t h e b l o o d give n o definite i n f o r m at i o n c o n c e r n i n g t h e i r significance o r t h e i r c h a r a c t e r .A t one t i m e it w a s t h o u g h t t h a t the a n t i t r y p t i c Brieger and Trebing (z) stated that 9o per cent. of the patients suffering from carcinoma or sarcoma, whom they had examined, showed a n increase of antitrypsin in the blood. Von Bergmann and Meyer (2) confirmed this observation, though they also fl?und a similar increase in 24 per cent. of non-cancerous patients. Recent work indicates that the increased ferment-inhibiting action of the serum cannot he relied upon as a diagnostic test for cancer. It is frequently present in the acute infections, such as pneumonia, typhoid fever, etc. ; in chronic infections, such as tuberculosis and syphilis; in Graves' disease; and in severe anemias. The action of the serum has been ascribed, to chemical constituents and to specific immune bodies which act as antiferments. Meyer (3) believes that the antiferment is a true antibody, and that the ferments of the tissue cells act as antigens. He concludes that trypsin and leucoprotease are not so important in this respect. Eisner (4) and Wiens (5) also believe that the antiferment is a true antibody, ~out that the antigen is the ferment liberated by the polymorphonuclear cells. On the other hand, Jfirgensen (6) found no relation between the antitryptic index and leucocytosis. Halpern (7) inoculated dogs with the, pancreas of dogs, and found an increase in antitrypsin, but no increase in antipepsin. Eisner (4) studied the inhibiting action of serum against various ferments, and concluded that it possessed a special att~nity for trypsin. Some writers have asserted that the serum is more active against trypsin of the same species, but Weil (8) and others have disgroved this.Morgenroth (9) thought that he obtained a specific antirenin by inoculating animals with renin, while Achalme (io) states that he produced a specific antitrypsin by inoculating animals with trypsin. Other investigators repeated the work of Morgenroth and Achalme and have failed to confirm their results. Hamburger (II) showed that sodium chloride destroys pepsin in a neutral solution, thereby invalidating the evidence that a sl~ecifie antipepsin is present in the blood; immune bodies are active only in a neutral or slightly alkaline reac-

T h e r e s i s t a n c e of b a c t e r i a to e n z y m e action, because o f its imp o r t a n c e as a f a c t o r in the d e f e n s e o f the i n v a d i n g o r g a n i s m a g a i n s t the d e s t r u c t i v e agencies o f the host, has i n t e r e s t e d s e v e r a l o b s e r v e r s , a m o n g t h e m K r u s e ( I ) , F e r m i ( 2 ) , K a n t o r o w i c z ( 3 ) , a n d W e i n -I n f l u e n c e d p o s s i b l y by t h e epochal a d v a n c e s in p r o t e i n c h e m i s t r y a n d b y the fact t h a t b a c t e r i a l a n t i g e n s a r e p r o b a b l y p u r e l y p r o t e i n in c h a r a c t e r , w o r k e r s in i m m u n o l o g y have n a t u r a l l y i n v e s t ig a t e d w i t h g r e a t care the b a c t e r i a l p r o t e i n s , a n d the effect o f p r o t e olyric e n z y m e s u p o n them.