DIA GNO SIS— PRO PH YLA XI S 



1485 



Relapses. — These are not uncommon, and are usually mild in type. 



Setiuelse. — There is usually some permanent damage to the nervous system 

 in cases which recover. 



Diagnosis. — The cardinal early signs are: — (i) The sudden onset; (2) the 

 headache and sense of general illness; (3) the vomiting; (4) the fever; (5) stiff- 

 ness in the neck muscles ; (6) the presence of the meningococcus in the cerebro- 

 spinal fluid as obtained by lumbar puncture. 



The Differential Diagnosis has to be made from malaria, relapsing fever, 

 typhus, enteric, influenza, and pneumonia. 



From malaria it can be recognized by the absence of the leucopenia, the 

 presence of the leucocytosis, and the absence of malarial parasites from the 

 blood, as well as the absence of a large spleen. It may, however, occur in a 

 malarial subject, but the leucocytosis will be present. 



From relapsing fever it can be separated in the early stages by a blood ex- 

 amination revealing the absence of spirochsetes. 



From typhus it can be distinguished by the vomiting, by the stiffness in 

 the neck, and Kernig's sign. 



From enteric it may be diagnosed by the headache and delirium occurring 

 together, by the rigidity of the neck, Kernig's sign, and lumbar puncture. 



From influenza it may be differentiated by Kernig's sign and by lumbar 

 puncture, which may relie-\e some of the symptoms of a cerebral influenza. 



From pneumonia by the irregular pulsc-rate, the presence of Kernig's sign, 

 and the absence of those of consolidation of the lungs. 



Prognosis. — -This is always serious — firstly, quoad vitam ; secondly, with 

 regard to after-effects. 



Treatment. — Systematic daily lumbar puncture, with the withdrawal of a 

 few cubic centimetres of cerebro- spinal fluid and the intrathecal injection of 

 anti-meningococcal serum, in quantity to be judged by the amount of cerebro- 

 spinal fluid withdrawn at the time and by the blood-pressure and pulse-rate. 



In cases where the pus is very thick an attempt to wath the spinal canal by 

 intrathecal injections of warm sterile saline, followed by serum injections, may 

 be tried . 



In chronic cases or relapses vaccine therapy may be attempted. 



Symptomatic treatment and careful nursing are also required. 



Prophylaxis. — The proper method in prophylaxis is to avoid overcrowding, 

 bad hygiene, and to provide ample space, good ventilation, and ample and 

 good food for a community. When an attack has begun the sick and "their 

 attendants should be isolated, or the attendants should be constantly examined 

 bacterio logically and have systematic nasc-pharyngeal disinfection. 



Contacts should be isolated and examined bacteriologically on three separate 

 occasions, and have the naso-pharynx disinfected. 



A search for carriers should be made in the immediate neighbourhood of the 

 patient, and these carriers should be isolated and treated. 



The nose and fauces should be sprayed with a solution of i per cent, iodine, 

 2 per cent, menthol in parolin, or if this is too expensive with ^ per cent, 

 watery solution of formalin, which may be sniffed into the nose if an instru- 

 ment is too expensive. This solution of formalin is especially useful for 

 natives; it is rather too strong for Europeans. 



If this fails and the carriers be isolated and placed under improved sanitary 

 and dietetic conditions, vaccine treatment is beneficial, and may succeed when 

 under other conditions the natural vaccination of contained organisms will 

 fail. General vaccination of the population may be tried, but it is not certain 

 as yet whether it will be successful or not, as the application so far has been 

 limited. 



THE EXANTHEMATA. 



Scarlet fever has often been introduced into the tropics, but it does rot 

 spread. Thus we have seen cases introduced into Colombo from the steamers, 

 but there has never been an epidemic of scarlet fever in that town to our 



