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THE Diagnosis of Serous Meningitis Is One That Sugar-Content

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THE Diagnosis of Serous Meningitis Is One That Sugar-Content 546 THE CANADIAN MEDICAL ASSOCIATION JOURNAL SEROUS MENINGITIS BY GEORGE F. BOYER, M.D. Toronto THE diagnosis of serous meningitis is one that sugar-content. This is an uncommon condition is made sufficiently often to justify some in children and will be passed over at present. discussion of its merit, and an examination of 2. The form of serous ineningitis which is the conditions that enter into its etiology. The associated with the infectious fevers, and most term "meningism" is constantly coupled with typically seen with, or just following, measles, that of "serous meningitis," and unless this and usually presents changes in the pressure, condition is identified definitely and absolutely cytology, and chemistry of the cerebro-spinal with a cerebro-spinal fluid normal in appear- fluid. ance, cytology and chemistry, we are at the start 3. Meningitis sympathetica. This is the form confused in the use of two different terms. of serous mening(fitis that is of most interest to Therefore, at the outset, in the course of these us to-day, as a clinical problem. In its true remarks, meningism will be characterized by a form it is but a defence phenomenon, and cerebro-spinal fluid normal in all points except should be associated in one 's mind with that of increased pressure. This term was in- acute infection, with or without suppuration in troduced by Dupre in 1894, and has been re- the upper respiratory passages or their acces- sponsible for some confusion since, for some sory sinuses; or it might result from the menin- authorities still assert that "in some instances geal reactions around adenitis, deep cellulitis. there may be twenty, thirty, or even more cells, thrombophlebitis outside the cranial cavity, but the fluid is clear, and no organisms are or even brain-abscess. This condition is charac- found." If this definition is accepted, we can- terized clinically by symptoms and signs of not differentiate serous meningitis from it. A meningitis; the cerebro-spinal fluid showing an "meningism" is properly the state in which a increase in amount and in pressure, a slightly patient presents clinically the symptoms and granular appearance, an increase in globulin signs of meningeal irritation, of variable in- content, an increase in cells (either lymphocytes tensity but in reality benign; and, on lumbar or polymorphonuclears, or both), and a fluid puncture, the cerebro-spinal fluid is found to be which is culturally sterile. practically normal. Serous meningitis, on the 4. Aseptic meningitis. This form is but the other hand, has been associated with four dif- meningeal reaction which may result from the ferent groups, or stages, of somewhat similar injection of sterile foreign substances (usually findings, but all of these manifest more or less sera) into the subarachnoid space. Even distinctive changes in the cerebro-spinal fluid. stovaine is credited with producing this re- This condition is identified with infection, tox- action. The cerebro-spinal fluid may be under aemia, or direct irritation after the intrathecal great increase in tension, may be opalescent, or injection of sera, and such like. These result frankly purulent with marked cell changes, in a change in the secretion and absorption (one with polymorphonuclear cells predominating. or both), local or general, of the cerebro-spinal Globulin is increased, but the sugar-reaction is fluid. ifot changed, and the fluid shows no signs of For the sake of classification, serous menin- bacteria, either by smear or culture. gitis may be grouped under the following For the purpose of this paper, consideration headings:- will be given chiefly to that type of serous 1. The usual acute form, associated with meningitis termed sympathetic meningitis, and alcoholism, anaemia, etc., and characterized by my remarlks will be limited mainly to a con- signs of coma and the cerebro-spinal fluid sideration of the changes in the cerebro-spinal changes, of increased pressure, and increased fluid and their possible explanation. Before globuliln, but without change in the cytology or doing this, however, it might be wise to diaress BOYER: SEROUS MENINGITIS 541 -~ sufficiently long to consider briefly such impor- ventricles, cisternae, and lumbar sac, i.e., the tanit points as the origin, circulation, and ab- height of the fluid columns in the manometers is sorption of this fluid, the evidence available on the same horizontal plane; the fluids are to-day suggesting that it varies in its normal uniformly clear and colourless and do not clot; and abnormal characteristics at different places and cells are absent in the ventricle, although in the same cerebro-spinal system, in the frequently a few are found in cisternal and cytology of the normal cerebro-spinal fluid, and lumbar fluids, under what must be considered paths of possible infection. normal conditions. The Wassermann and It is somewhat generally accepted to-day that colloidal tests, gold chloride, benzoin, and the cerebro-spinal fluid is the secretion of the mastic, are uniformly negative. choroid plexus of the lateral and fourth "While globulin (ammonium sulphate ring ventricles. With this, there is probably some test) is normally absent in all three fluids, small part of the fluid derived from the peri- slight but constant differences are seen in the cellilar spaces, both of which directly com- total protein-content, as indicated by tri- municate with the subarachnoid space. The chloracetic acid and sulphosalicylic acid tests, flow of cerebro-spinal fluid is from the peri- the greatest amount appearing in lumbar, less cellular and perivascular spaces into the sub- in cisternal, and the least in ventricular fluids. arachnoid space. The circulation of the While the normal figures vary, 30 mgm. per cerebro-spinal fluid, after it has escaped from 100 c.c. in lumbar, 25 in cisternal, and 10 in the ventricular system, is not well known. It ventricular fluids, would be considered as the is probably renewed in its entirety every four normal ratio. Conspicuous is the opposite hours, and this means a daily secretion of from iatio in regard to sugar-content. Sugar is six to seven hundred cubic centimetres. In TABLE I 1919, Dandy placed indian ink in the ventricles; COMPARATIVE FLUID EXAMINATIONS FROM VENTRICLE it first filtered into the cisterna; then the sub- AND LUMBAR SAC IN CASES OF GENERAL PARESIS* arachnoid spaces of the cerebellum filled, and Wassermann Total reaotion Cells Globulin protein the fluid spread outward anld upward into C. M. the sulci of the hemispheres. In forty-five to Lumbar Pos. 0.05 c.c. 45 + ++ Ventricle Neg. 1.0 c.c. 30 0 Normal seventy-five minutes it reached the more remote Lumbar Pos. 0.05 c.c. 14 ++ ++ parts of the longitudinal sinus. Phenolsulphon- Ventricle Neg. 1.0 c.e. 2 + + Lumbar Pos. 0.05 c.c. 10 + + ephthalein is absorbed and excreted much faster Ventricle Neg. 1.0 c.c. 6 0 Normal than this, so it may not be that the only main S. G. channel of absorption is through the arach- Lumbar Pos. 0.8 c.c. 2 + + Ventricle Neg. 1.0 c.c. 2 0 Normal villi into the large venous channels, as noidal R. C. is the accepted teaching to-day. It may be Lumbar Pos. 0.05 c.c. that a great deal of absorption of the cerebro- Ventricle Pos. 0.8 c.c. A. G. spinal fluid takes place in the tissue of the Lumbar Pos. 0.2 c.c. 2 + + + perivascular spaces. There are also significant Ventricle Neg. 1.0 c.c. 0 0 Normal data pointing to there being some downward A. F. Lumbar Pos. 0.3 c.c. 0 + + + circulation of the cerebro-spinal fluid in the Ventricle Pos. 0.3 c.c. 1 + + spinal canal, for, in 1921, Weigeldt found in Lumbar Poe. 0.1 c.c. 5 +-+j+ + + Ventricle Pos. 0.1 c.c. 3 + +- many fluids examined that albumin and cells Lumbar Pos. 0.3 c.c. 6 + + + + progressively increased from the cervical to the Ventricle Pos. 0.3 c.c. 0 - + lumbar region. It is also well established that H.P. Lumbar Pos. 0.6 c.c. 15 + + +++ the ventricular fluid may be colourless and the Ventricle Neg. 1.0 c.c. 2 + + spinal fluid bile-stained in icterus; in paresis Lumbar Pos. 0.2 c.c. 27 ++ + + Ventricle Neg. 1.0 c.c. 7 + Normal negative Wassermann reactions have been ob- Lumbar Pos. 0.2 c.c. 39 +++ +++ tained in the ventricular fluid and positive re- Ventricle Neg. 1.0 c.c. 0 + + Lumbar Pos. 0.2 c.c. 32 ++++ +++ actions in the spinal fluid in the same group of Ventricle Neg. 1.0 c.c. 2 0 Normal cases. Ayer and Solomon (The Human Cerebro- Lumbar Positive 13 + + + + + Spinal Fluid) state that, in normal cerebro- Cistern Positive 18 + + +++ spinal fluid, the pressure is similar in the * Table from The Hluman Cerebro-Spinal Fluid. 548 THE CANADIAN MEDICAL ASSOCIATION JOURNAL greatest in amount in the ventricular fluid tures which react are the adventitial cells of the (approximately .08 per cent) and least in the veins and capillaries and the neuroglia cells im- lumbar sac (averaging about .06 per cent), the mediately in contact with them. The adventitia cisternal fluid showing a value between these takes an extremely important part in the pro- two." duction of the cells of reaction; this is not sur- The table below shows in a convenient form, prising, seeing that the cerebro-spinal lymph in connection with a well-defined pathological flows directly into its spaces. Hence, when a state, figures for certain of the features re- toxin gains the central nervous system by the ferred to, compared according to location. lymph path the cells of the adventitial sheath It is thus evident that increase of cells and are the part of the vessel to be first attacked; globulin is more characteristic of extra- and should the irritant be weak or permeate the ventricular fluid, that is, the only really normal tissues slowly no other phenomena need occur cerebro-spinal fluid is that found near its for some time.
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