798 PASSIVE IMMUNIZATION SERUM THERAPY 



cyanosed at first, regains a healthy color; the pain in the head, neck, 

 and limbs becomes less severe, although the neck and spine may remain 

 stiff for several days. Finally the mind becomes clear and the patient 

 is cheerful, and no longer irritable, apathetic, and hypersensitive. He 

 feels better and his appetite returns. When this favorable outcome 

 supervenes, the serum injections may be discontinued, to be resumed, 

 however, upon the first evidence of a relapse. The physician should be 

 on his guard for the appearance of acute hydrocephalus, which condition 

 is relieved by repeated lumbar puncture. 



The Serum Treatment of Cases with Thick Elastic Exudate. In very 

 severe cases the exudate may be so thick that it will not flow from the 

 needle. In these cases the serum should be injected in small doses under 

 pressure, and the injections repeated every eight to twelve hours. As 

 they are likely in any case to terminate fatally, the physician is justified 

 in taking the risk of increasing intracranial pressure. It may be well 

 carefully to inject a small amount of warm sterile salt solution, which 

 will dilute the exudate and possibly start a flow; or a second needle may 

 be inserted higher up, when a' thinner exudate is found, or washing may 

 be possible by injecting salt solution in the upper needle and draining 

 through the lower. 



The Serum Treatment of Cases with a Dry Canal and Cases of Posterior 

 Basal Meningitis. Occasionally a patient improves clinically and the 

 amount of cerebrospinal fluid becomes very scanty, the spinal tap being 

 dry, although it is certain that the needle has entered the subarachnoid 

 space. In such instances a small amount of serum may be injected, or the 

 injection may be dispensed with if the clinical condition continues to 

 improve. If, however, cases with dry canals present evidences of 

 toxemia and general aggravation of symptoms, small doses of serum 

 should be injected under pressure and the injections repeated as often as 

 necessary. The physician must be very cautious, however, for if there 

 are clinical evidences of severe intracranial pressure, it is probable that 

 there is an encapsulation 'of fluid within the ventricles, and shutting off 

 of the communication between the ventricles and the subarachnoid 

 space. In this posterior basic meningitis intraspinal injections are 

 dangerous and aggravate the process. In infants it is necessary to punc- 

 ture the ventricles through the anterior fontanel and in older children 

 and adults by trephining at Kocher's point, removing the fluid, and 

 if it is found to be cloudy or purulent, injecting serum. It may be 

 necessary to tap both ventricles alternately at intervals of several days, 

 depending upon the reaccumulation of fluid and pressure symptoms. 



