MICROCOCCUS INTRACELLULARLS MENINGITIDIS 531 



to delay. Lumbar puncture, therefore, should be done as early as 

 the first suspicion is aroused, and, if meningococci are found, the 

 injection of serum should follow as rapidly as possible. 



It is probably best, in the long run, to inject serum immediately 

 upon obtaining a turbid fluid in a case in which the clinical suspicion 

 points strongly to epidemic cerebrospinal meningitis. 



The technique of serum injection consists in first withdrawing 

 spinal fluid by tapping the canal with a sterile needle and allowing 

 the fluid to flow out, of course without suction, holding a centrifuge 

 tube directly over the butt of the needle. The flow is allowed to 

 continue until the drops begin to come quite slowly, that is, a drop 

 every ten or twenty seconds, and then the serum is injected, either 

 by gravity or with a syringe through the same needle. It is im- 

 portant that the serum at body temperature shall enter the canal 

 very slowly, and, for this reason, the gravity method is advised. A 

 gravity arrangement can easily be constructed by attaching about 

 eighteen inches of catheter tubing, sterilized, to the end of the 

 needle with a small sterile funnel at the other end. The withdrawal 

 of large amounts of fluid suddenly sometimes causes trouble, the 

 patient breathing rapidly, and showing symptoms of threatened 

 collapse, but this is rare, and a ' little judgment in withdrawing 

 fluid which has been under considerable pressure too rapidly will 

 usually guard against accident. During the injection of the serum, 

 the patient should be carefully watched, since occasionally alarming 

 symptoms may arise from too rapid increase of internal pressure. 

 The physician must be on the alert for such symptoms and imme- 

 diately discontinue the injection for the time being. Flexner 40 

 advises 10 minutes for the injection of the entire amount of serum 

 used. 



The dosage of serum should, to some extent, depend upon the 

 amount of fluid withdrawn, and the amount injected should usually 

 be less by several centimeters than the amount withdrawn. The 

 average dose for an adult should be about 30 c.c., though more may 

 be given when large quantities of fluid have been withdrawn, and 

 when the case is very carefully watched by an experienced man. 

 Sophian 41 has recommended controlling the withdrawal of spinal 

 fluid and the injection 'of the serum by blood pressure measurements. 



40 Flexner, Bulletin, Eock. Inst. for Med. Ees., 1917. 



n, Epidemic Ccrebrospinal Meningitis, St. Louis, 1913, p. 54. 



