IIO CLINICAL BACTERIOLOGY AND FLEMATOLOGY 



at the body temperature, wrap some flannel or cotton-wool 

 round it, putting the culture-tubes in contact with this, and 

 then wrapping' more cotton-wool round the whole. 



If the cerebro-spinal fluid has clotted when you reach the 

 laboratory, withdraw a piece of the clot (which is usually soft 

 and friable) with a platinum loop or pipette, and prepare films 

 by rubbing it on the surface of clean slides. If it has not 

 coagulated, centrifugalize it and spread films from the sedi- 

 ment. Prepare two, staining one by a simple stain, such as 

 carbol thionin or methylene blue, and the other by Gram, fol- 

 lowed by a counterstain, such as neutral red. Meningitis is 

 indicated by the turbidity of the fluid and the presence of 

 numerous leucocytes : the specific nature of the meningitis by 

 the discovery of the specific organism. 



It is advisable also, if it can be done, to count the number 

 of leucocytes per cubic millimetre in the manner described 

 on p. 293. If repeated punctures have to be made this will 

 give very valuable indications for prognosis. 



As regards treatment, repeated lumbar punctures are prob- 

 ably the most important measure : the procedure should not 

 be delayed an instant if the pressure symptoms, such as head- 

 ache, retraction of the head, vomiting", slowing of the pulse, 

 are increasing, or if the temperature rises continuously, or if 

 there are indications of heart failure. The question of the 

 injection of a specific serum into the spinal canal after lumbar 

 puncture should also be considered, and also the use of a 

 vaccine. Opinions are divided with regard to the efficacy of 

 both these procedures, but I think most would agree that in 

 the present uncertain state of our knowledge the patient ought 

 to be given any additional chance that either or both of these 

 measures may offer. When serum is used the simplest method 

 is to use a large (20 c.c.) syringe : do the lumbar puncture 

 with the needle which fits it, holding it by a pair of Spencer- 

 Wells forceps, the two being sterilized locked together. 

 Take the amount of serum you propose to inject into the 

 syringe (10 or 20 c.c. for an adult, less in proportion for a 

 child); allow the cerebro-spinal fluid to escape into a sterilized 

 measure. If the fluid is under normal pressure, withdraw 

 about three-quarters of the amount you propose to inject; if 

 it is under raised pressure, allow it to escape until the pressure 

 (as judged by the rate of flow) is approximately normal, and 



