.i,i,„„i: 400 l«l«J CORNELL UNIVERSITY LIBRARY BOUGHT WITH THE INCOME OF THE SAGE ENDOWMENT FUND GIVEN IN 1891 BY HENRY WILLIAMS SAGE RC 400X66'"'""""''™"*'-"'"^^ fifSMi,"^' ""•'' '" health and in dis 3 1924 012 460 816 The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924012460816 CEREBROSPINAL FLUID IN HEALTH AND IN DISEASE CEREBROSPINAL FLUID IN HEALTH ^ND IN DISEASE BY ABEAHAM LEVINSON, B.S., M.D. ASSOCIATE IN PEDIATKICS, NOETHWESTEEN UNIVERSITY MEDICAL SCHOOL; ASSO- CIATE PEDIATRICIAN, SARAH MORRIS CHILDREN'S HOSPITAL OF THE MICHAEL REESE HOSPITAL, CHICAGO; ATTENDING PEDIATRI- CIAN, MOUNT SINAI HOSPITAL, CHICAGO; ATTENDING PHYSICIAN, children's DEPARTMENT, CHI- CAGO-WINFIELD TUBERCULOSIS SANITARIUM WITH A rOEEWOED BY LUDVIG HEKTOEN, M.D. WITH FIFTY -SIX ILLUSTRATIONS, INCLUDING FIVE COLOR PLATES ST. LOUIS C. V. MOSBY COMPANY 1919 Copyright, 1919, By C. V. Mosby Company To Hni TO Wi-ioii THE Practice of ifEui- ciNE Constitutes an Ideal Kathek Than a Pbofession, To Him Who Combines Clinical Insight AND Scientific Research, To HiM Who Sees in Medicine Both a Science and a Philosophy, This Little Volume is Respectfully Dedicated. FOEEWOED By Ludvig Hektoen, M.D. The author was kind enough to ask me if I would look over his manuscript and then tell him whether it seemed to me worthy of publication. Later, when I told him that in my opinion he had produced a valuable little book, he re- quested me to state the reasons for this :^avorable opinion in the form of a foreword. This I can do in a feAV brief statements. In the first place, on reading the manuscript, I soon be- came aware that the author had come to his task with not only a large experience behind him in the examination by various methods of the cerebrospinal fluid as an aid in diagnosis, but with a highly creditable record in the sci- entific study of this fluid as well. Evidently he had been drawn to his work on the cerebrospinal fluid because of its attractiveness as a field of research, as well as on ac- count of its importance in diagnosis. It is to this happy combination of true philosophic inter- est and first-hand practical knowledge on the part of the au- thor that the book owes its chief merit, namely, thorough- ness and freshness in the parts dealing with fundamental problems, as well as in those dealing with practical mat- ters. In the second place there could be no doubt in re- gard to the timeliness of a work of this kind. Indeed it seemed to me that a definite want would be supplied; for, in spite of an increasing importance in medicine, there was as yet no comprehensive book on all phases of the cerebrospinal fluid. John MeCormick Institute For Infectious Diseases, Chicago. 7 PREFACE Of recent years the study of body fluids has been engag- ing the attention of many physicians and scientists. Par- ticularly marked has been the interest in the study of cere- brospinal fluid. Through recent investigations of this fluid, we have gained a great deal of information regarding the diagnosis and nature of many diseases and a much clearer conception of the general physiologic processes in the body. Further investigations on the subject will open up new possibilities in science and medicine, for there is hardly an- other body fluid that presents so favorable an opportunity for the study of physiologic and pathologic processes in the human body as the cerebrospinal fluid. Cerebrospinal fluid is of great physiologic importance for various reasons. . It is the clearest and most transpar- ent of all the fluids of the body. It is clearer than blood, than bile, and even clearer than urine, and under normal conditions experiments may be made on it without fear of clot formation or color change. Furthermore, cerebro- spinal fluid, like blood and urine, can be removed from the living body without injury to the system. This gives one the opportunity of working with processes in the living body — a distinct advantage over the study of dead tissue. From the standpoint of pathology also, cerebrospinal fluid presents an exceptional opportunity for study. The slightest change in the color of the fluid, the smallest in- crease in the protein content or in the cell count, all of which are easily discernible, indicate the presence of a pathologic process. One is able to follow the course of disease throughout all stages by noting the various changes 9 10 ■ PREFACE the cerebrospinal fluid undergoes from time to time. These changes may be manifested not only by the presence of the causative organisms themselves, but just as frequently by specific physical, chemical, cytologic and physicochem- ical processes. A close study of the changes in the cere- brospinal fluid under pathologic conditions throws light, not only on the specific diseases of the nervous system, but on the condition of other systems. One can readily see, therefore, how large is the scope for the study of cerebro- spinal fluid. In this book I shall discuss cerebrospinal fluid in its vari- ous phases, and shall attempt to show the nature of the fluid in its normal state and to point out the deviations in processes of disease. I shall incorporate the results of my own clinical and experimental studies as well as the observations of the many workers who have added to our knowledge by their researches on cerebrospinal fluid. This little book is sent out as an humble contribution, as I am fully aware of its many shortcomings and omissions ; but if it saves the busy practitioner the irksome task of consulting countless sources for information on cerebro- spinal fluid, I shall feel that the work has not been in vain. And if perchance it should serve to stimulate even one zealous student to help solve some of the problems pre- sented, I shall feel that my effort has been amply rewarded. Many of the investigations that have found their way into this volume would not have lieen possible without the constant cooperation of certain institutions and individ- uals. I, therefore, take this opportunity of expressing my gratitude to them collectively and individually — to the at- tending staff, internes and nurses of the Michael Eeese Hospital in general, and the Sarah Morris Hospital for Children in particular, to Dr. Katharine Howell, serol- ogist of the Nelson Morris Institute for Medical Re- search, to Professor P. C. Becht of the Dei)artment of Pharmacology of the Northwestern University, and to Dr. PREFACE 11 G. Bartelmez of the Department of Anatomy, University of Chicago. Particular thanks are due to Professor Ludvig Hektoen of the University of Chicago for his helpful suggestions and for his careful reading of the manuscript, and to Pro- fessor Shiro Tashiro of the Department of Biochemistry of the University of Cincinnati for his tireless assistance in checking up many of the experiments. Thanks are also due the editors and publishers of the many journals for their permission to republish some of my articles that ap- peared in their journals. A. Lbvinson. Chicago, 111. CONTENTS CHAP TEE I PAGE IIisTOKY OF Cerebrospinal Fluid 17 CHAPTEE II Anatomy and Physiology of Cerebrospinal Fluid 30 Location, 30; Formation and Absorption, 34; Permeability, 38; Function, 40; Origin, 41. CHAPTEE III Methods op Obtaining CerebkospinaT; Fluid prom the Living Body . 49 Lumbar Puncture, 49; Untoward Effects of Lumbar Puncture, 53; Technic of Lumbar Puncture, 54; The Spinal Puncture Needle, 57; Eeasons for Failure to Obtain Fluid, 63; Pressure, 64; Collection of the Fluid, 69; Cranial Puncture, 71.' CHAPTEE IV Properties op Normal Cerebrospinal Fluid . 75 Physical Properties, 76; Amount, 76; Color, 76; Lack of Sedi- ment, 76; Pressure, 77; Specific Gravity, 79; Chemical Composi- tion, 79 ; Physicoehemical Properties, 94 ; Specific Gravity, 94 ; Viscosity, 95; Conductivity, 95; Surface Tension, 95; Freezing Point, 95; Eefractometrio Index, 96; Eeaction of Normal Cere- brospinal Fluid, 96; Alkaline Eeserve, 105; Biochemical Proper- ties, 107; Amylolytic Power, 107; Proteolytic Power, 107; Gly- colytic Ferment, 107; Fibrin Ferment, 107; Alexin, 107; Hemoly- sin, 108; Toxicity, 108; Bactericidal Action, 108; Cytology, 108; Type of Cell, 110. CHAPTEE V Pathologic Cerebrospinal Fluid 113 Increase in Amount of Fluid, 116; Pressure, 116; Foam, 117; Cells, 117; Pellicle, 118; Crystallization, 120; Permanganate or Organic Index, 123; Protein, 125; Precipitation, 125; Sugar, 129; Turbidity, 131; Physical Chemistry, 132; Protein Charges, 133; The Colloidal Gold Eeaction, 137; Mastic Eeaction, 137; Ninhy- drin Eeaction, 137; Changes in the Eeaetipn of the Cerebrospinal Fluid, 138; Bacteriologic, 146; Immunologic, 147; Agglutination, 147; Hemolysin, 147; Wassermann Eeaction, 148. 13 14 CONTENTS CHAPTER VI Methods or Examination of Cerebrospinal Fluid tor Diagnostic Purposes 150 Physical, 150; Color, 150; Foam, 151; Pellicle, 151; Cliemieal, 152; Increase of Protein, 152; Globulin Tests, 153; Noguchi, 154; Boss- Jones, 154; Nonne-Apelt, 154; Kaplan Method, 155; Pandy, 155; Sulphosalieylie Mercuric Chloride Method, 155; Relative Value of the Grlobulin Tests, 156; The Permanganate Test, 157; Sugar, 158; Chlorides, 161; Physieochemical Methods, 162; Lange Gold Chloride Test, 164; Mastic Test, 166; Cytologic Examination, 167; The French Method of Cell Counting, 167; Chamber Method of Cell Counting, 168; Comparative Value of the Two Methods, 169; Type of Cells, 170; Bacteriologic, 171; Culture Media, 171; Direct Smear, 172; Immunologic, 172; Macroscopic Method, 172; Microscopic Method, 175; Precipitation of Cerebrospinal Fluid with Antimeningococeus Serum, 176; Guinea Pig Inoculation, 177; Neutralization Test, 177; The Wassermann Reaction, 177. CHAPTER VII Cerebrospinal Fluid in Various Diseases 183 Uremia, 183; Diabetes Mellitus, 183; Chorea, 183; Epilepsy, 184; Mongolian Idiocy, 184; Psychoses, 185; Lues, 185; Hydrocepha- lus, 188; Spina Bifida, 188; Hemorrhage of the Brain, 188; Tu- mors of the Brain, 189; Compression of the Cord, 189; Encepha- litis, 189; Meningism, 190; Tuberculous Menin^tis, 190; Men- ingococcus Meningitis, 194; Pneumococcus Meningitis, 200; Streptococcus Meningitis, 202; Influenza Meningitis, 203; Colon Meningitis, 203; Syphilitic Meningitis, 203; Cerebrospinal Fluid in Poliomyelitis, 205. CHAPTER VIII Intraspinal Treatment 209 Intraspinal Treatment of Meningococcus Meningitis, 209; Unto- ward Effects of Serum, 216; Aggravation of Symptoms, 217; Serum Rash, 217; Intraspinal Treatment of Pneumococcus Meningitis, 217; Intraspinal Treatment in Tuberculous Meningitis, 219; Influ- enza Meningitis, 219 ; Poliomyelitis, 219 ; The Swift-Ellis Treatment, 220 ; Intraspinal Treatment of Tetanus, 221 ; Intraspinal Treatment of Chorea, 222. CHAPTER IX Summary APPENDIX Appendix 224 226 ILLUSTRATIONS PIG. PAGE 1. Albertus do Haller 20 2. Francois Magendie 22 3. Lumbal- region of skeleton of a one-year-old child 26 4. Lumbar region of skeleton of a six-year-old child 27 5. Section of human brain (Color Plate) 30 6. Diagram of Fig. 5 32 7. Chorioid plexus detached from the ventricles 33 8. Specimen illustrating the importance of spinal puncture for diag- nostic purposes 50 9. Opposite view of Fig. 8 51 10. Section of cauda equina of a dog 55 11. Plexus of veins, the puncture of which is responsible for blood obtained during spinal puncture 56 12. Various types of lumbar puncture needles 58 13. Modified Quincke apparatus for measuring the cerebrospinal fluid pressure 65 14. Author's spinal puncture needle and manometer 67 15. Photograph showing ventricular puncture in an infant (front view) 72 16. Photograph showing ventricular puncture in infant (side view) 73 17. Crystallization of nonmeningitie cerebrospinal fluid 89 18. Crystals of evaporated nonmeningitie cerebrospinal fluid .... 90 19. Crystals of sodium chloride in a 1 per cent solution of dextrose 90 20. Average change in the H-ion concentration of nonmeningitie fluid on standing " 99 21. Change in H-ion concentration of nonmeningitie fluids on stand- ing at room temperature under various conditions 103 22. Photomicrograph of stained pellicle from cerebrospinal fluid of a pneumococcus meningitis 119 23. Pellicle formation in miningitis 120 24. Crystals formed in test tube on spontaneous evaporation of cere- brospinal fluid from a ease of tuberculous meningitis .... 121 25.- Spontaneously evaporated cerebrospinal fluid from a case of tubercu- lous meningitis 121 26. Spontaneously evaporated cerebrospinal fluid from a ease of pneu- mococcus meningitis 121 27. Crystals from an evaporated fluid in a case of tuberculous menin- gitis 122 28. Crystals from an evaporated fluid of a case of pneumococcus men- ingitis 123 29. Photograph showing the typical ratio of precipitates by the two precipitants 126 15 16 ILLUSTRATIONS 30. Apparatus for cataphoresis of proteins .... 134 31. Change in the H-ion concentration of three types of cerebrospinal fluid 142 32. Different effects of corking on tuberculous and epidemic fluids 144 33. Fuchs-Bosenthal chamber for counting cells in cerebrospinal fluid 168 34. Neubauer blood counting chamber Avhich may be used for cerebro- spinal fluid 1*58 35. Photograph showing agglutination of meningococci by the macro- scopic method 173 36. Microscopic method of agglutinating meningococci 174 37. Agglutination of meningococci by the microscopic method . . . 175 38. Lange colloidal gold test in case of cerebrospinal lues . . 187 39. Lange colloidal gold test iu case of tabes 187 40. Lange colloidal gold test in case of general paresis 187 41. Lange gold chloride reaction in a case of tabes dorsalis (Color Plate) 188 42. Lange gold chloride reaction in a case of general paresis (Color Plate) " 188 43. Lange colloidal gold test in a case of tuberculous meningitis . . 192 44. Lange gold chloride reaction in a ease of tuberculous meningitis (Color Plate) 192 45. Lange gold chloride reaction in a case of meningococcus meningitis (Color Plate) 195 46. Lange colloidal gold test in a case of meningococcus meningitis . 195 47. Photomicrograph showing direct smear from cerebrospinal fluid of case of meningococcus meningitis 196 48. Twenty-four-hour culture of meningococci grown in ascitic dex- trose agar 197 49. Photomicrograph of pure meningococcus culture 198 50. Photomicrograph of smear from cerebrospinal fluid of pneumococ- cus meningitis 201 51. Photomicrograph showing direct smear from cerebrospinal fluid of case of mixed strei^tococcus and pneumococcus meningitis . 201 52. Photomicrograph showing direct smear from cerebrospinal fluid of case of influenza meningitis 204 53. Photomicrograph of pure culture of influenza bacilli 204 54. Lange colloidal gold test in case of epidemic poliomyelitis . . 205 55. Instrument for the introduction of antimeningocoecus serum by the gravity method 212 50. Temperature and pulse chart of a case treated by antimeningocoecus serum 214 CEREBROSPINAL FLUID CHAPTER I HISTORY OF CEREBROSPINAL FLUID The existence of water on the brain in pathologic cases was known to the ancients. Hippocrates is credited with tapping the ventricles in hydrocephalus. We have nothing to show, however, that the ancients knew of the existence of fluid in normal persons. There is no mention of cere- brospinal fluid in the early writings of Hippocrates. In the later Hippocratedian collection the brain is spoken of as a gland. The glandular nature of the brain in this in- stance, however, does not refer to the cerebrospinal fluid, but to the so-called secretion which the ancients believed was poured down from the brain into the pharynx. Heroph- ilus in his writings shows that he knew of the existence of the ventricles and of the chorioid plexus, but not of the function of the chorioid plexus or of the contents of the ventricles. It seems but natural to suppose that Heroph- ilus who dissected hundreds of human bodies should have ImoAvn of the existence of cerebrospinal fluid in the ventricles. We wonder if it could be possible for so keen an observer as he not to notice the presence of a large amount of fluid in the cavity of the brain on cutting it open. Yet, in giving a description of the ventricles which he speaks of as the seat of the soul, he makes not the slightest reference to the presence of any fluid in the brain. There is a possibility, of course, that the lost books of Herophilus may have contained some reference to cerebrospinal fluid. One finds the same silence on the subject in other ancient 17 IS CUiREBROSPINAL FLUID authorities. Erasistratus of Julis (330-250) describes four cavities in the brain, but he makes no mention of fluid in them. Galen, who was thoroughly familiar with the construction, of the ventricles, speaks of an "excrementi- tial liquid, expressed from several places in the brain into the ventricles, especially the fourth, where this liquid is stored and then purged into the nose through the ethmoid bones and inf undibulum. " The fluid referred to, however, may not be the cerebrospinal fluid. Hemesius of Emersa (born 340 a.d.) gives a minute analysis of the ventricles and the localization of mental power within them, but he does not speak of the fluid they contain. One would nat- urally turn to Vesalius for a description of cerebrospinal fluid, for it is a well-known fact that Vesalius knew the ehoi'ioid plexus and, tiierefore, must also have observed the fluid. Yet, though he devotes page upon page to a discus- sion of the localization of the soul, he merely mentions a watery humor of the brain, but gives no description of any humor that would indicate that he had the cerebrospinal fluid in mind. Mention of the presence of a fluid in the brain is found in the writings of Varolius (1543-1575). This scientist, who described the pons that bears his name, denied the existence of pneuma in the ventricles, and in- sisted that it was fluid and not pneuma that filled up the cavity of the ventricles. However, he gives no description of the fluid he recognized. The real discovery of cerebro- spinal fluid is attril)ute(l to Contugno. Dominico Contugno is responsible for many discoveries in medicine. He dis- covered intestinal lesions postmortem in a case of typhoid; demonstrated the presence of albumin in urine on boiling; and discovered the aqueduct in the internal ear known subsequently as the aqueductus Contugni. In 1784 he made the important discovery of the presence of cerebrospinal fluid in living fishes and turtles, although he could not de- tect its presence in man. Though Contugno usually gets the credit for the discovery of the cerebrospinal fluid, HISTOKY 19 Bilanehoni claims that Valsalva prior to Contugno found "an ounce of a certain liquid in cutting the cord membrane of a dog, a fluid resembling that seen in articulations." The absence of a method whereby normal cerebrospinal fluid could be demonstrated in living beings was respon- sible for the lack of interest shown in the investigations of this fluid. Whatever interest there was, was contined to pathologic cases. In 1727 Stalpartius Vander Wiel de- scribed a case of injury to the head in which a clear watery fluid was seen to escape from the ear for several days after the injury. In 1764 Robert Whytt appeared with a descrip- tion of tuberculous meningitis. He divided the disease into three stages according to the behavior of the pulse, and attributed the various manifestations of the disease to the presence of a serous exudate. In 1768 he published the results of his work on acute hydrocephalus under the title "Observations on Dropsy of the Brain." Under the head- ing of acute hydrocephalus he included all forms of acute brain disease. For a clear-cut description of cerebrospinal fluid in nor- mal persons we must turn to the writings of Albertus de Haller (Fig. 1). In the "First Lines of Physiology" in the third Latin translation, we find the following descrip- tion : "The fluids, which, being deposited from the blood into other vessels, are. said to be secreted, seem reducible to four classes. The first consists of viscid fluids, coagulable by a heat of about 150°, by alcohol, and by strong acids, although generally, in the living animal, they escape in the form of vapor and after death are compacted into a gela- tinous substance. To this class belong the liquor and hali- tus of the ventricles of the brain, the pericardium, pleura, peritoneum, tunica vaginalis, amnois, joints, renal capsules, and probably of the womb, with the juices of the stomach and intestines, and lastly the lymph generally knoA\Ti." A little further Haller goes on as follows: 20 CEREBROSPINAL ELUin "Have lympliatic vessels been seen with certainty in the brain? They have been described in the large chorioidal plexns amongst tlie tibers of tlie olfactory nerve, and in the pia mater. For my own part, I have never seen them, and it is probable that there are none, since there are no con- glomerate glands in the brain, whicli are always found near these vessels. As for the various accounts which are given of the pituitary glands, to the infundibulum and of the ducts which lead from tlience into the veins of the head, absorlung water from the ventricles, they are not sup- Fig. 1.— Alberhis tie llalk'r (170S-1777). ported l)y any anatomic demonstration; which makes it probal)le tliat the vapor, which is secreted into the ventri- cles of a healthy person, is, in like proportion, al)Sorbed again by the inhaling veins; and that if there be any excess, it descends through the bottom of the ventricles to the basis of the skull, and into tlie loose cavity of the spinal marrow. Tliat this is the case, appears from the palsies, whicli ensue after apoplexies and from the watery tumors in the lower part of the spinal marrow, in hydrocephalic patients." HISTORY 21 Haller thought that the fluid not only was secreted in the hollow tubes of the medulla, but that it also flowed into the small tubes of the nerves. In the quotation that follows may be found part of Haller 's explanation of the mechan- ism of irritability, the original conception of which was advanced by Glisson. "Upon the whole, it seems to be certain that, from the vessels of the cortex, a liquor is secreted into the hollow tubes of the medulla, which, being continued into the small tubes of the nerves^and propelled to their extremities, is the cause of both sense and motion. But there will be a twofold motion in that humor; the one slow and constant from the heart; the other, not continual, but exceedingly swift, which is excited either by sense or any cause, as motions arising in the brain." It is evident from Haller 's own statement that he knew of the existence of cerebrospinal fluid in the ventricles and of the course of its circulation. However, with all his knowledge he does not seem to have been aware of the real nature and composition of the fluid. It was left to Magen- ■die (Fig. 2) (1825) to give us an accurate description of the workings of the fluid, especially the fluid at the base of the brain. We are indebted to him for a clear-cut con- ception of the physical appearance and protective func- tion of the cerebrospinal fluid. The following is taken from Magendie's treatise on Physiology: "But there is a disposition unlaiown to Bichat, which I have recently discovered, and which contributes in a man- ner extremely efficacious to the conservation and defense of the medulla. "The canal which is formed around the medulla by the pia mater, and which is lined by the arachnoid, is a great deal larger than is necessary to contain the organ; but dur- ing life the whole interval is filled up by a serous liquid, which strongly distends the membrane and which spouts out to many inches in height from a small puncture made 22 CEIiKiniOSPlNAL I-TATID in the dura mater. An analogous arrangement is also to be observed around the brain and cerebellum. It is easy to conceive how efficacious must be the protection thus de- rived from the liquid which surrounds the spinal marrow, and in. the midst of wji-ich it is suspended like the fetus in utero ijVi^ith 'tliis difference that it is fixed in its position by the^igamentum dentatum, and the different spinal nerves. "Besides tlie different envelopes of the l)rain of which we have s])okeii, and the dni'a mater which covers it in its -Francois Mapendic (l/8.vlS55). whole extent, this sul)stance is everywhere snrrounded with a veiy fine serous membrane the principle use of which is to yield a thin fluid, -which lubricates the brain. The arachnoid peneti-ates to all the cavities of the brain." It is evich'nt, therefore, that iMagendie knew not only of the existence mid ajiiiearance (if the cerehrosi)inal fluid, but that he \\'as also awai'e of llie most significant fnnction of the Ihiid — namely, ils protective nature. As soon as J\[agen(lie ojiened the way for the stndv of cerebrospiiud HISTORY 23 fluid, a number of other investigators followed in Ms path. Luschka and Eckar studied the fluid from an anatomic standpoint. Cavazzani performed numerous experiments on dogs to determine the physiologic character of the cerebrospinal fluid. Naunyn made a study of the physics of cerebrospinal pressure. Shortly after, in 1842, Lange's Anatomy appeared and in it were nine pages devoted ex- clusively to the discussion of cerebrospinal fluid, — a dis- cussion that was both lucid and graphic. Almost simultaneously speculation began as to the source of cerebrospinal fluid. Carl Schmidt, in 1850, expressed the view that the cerebrospinal fluid was not a mere trans- udate from the blood. Faivre, in 1853, advanced the the- ory that the fluid was a secretion. Numerous investiga- tions followed the promulgation of this idea, and lumdreds of experiments were undertaken by anatomists, patholo- gists, physiologists, and chemists, experiments that are be- ing carried on to this very day. With the discovery of a method whereby cerelirospinal fluid could be removed from the living body, a new era was ushered into the history of this fluid. One of the first means of obtaining the cerebrospinal fluid was by remov- ing it from the skull. This operation was fraught with many difficulties. It involved the use of a great num- ber of instruments and necessitated trephining of the skull and the making of a scalp wound. A great improvement was made on this method in 1855. Corning injected 20 minims of a 2 per cent solution of hypochlorate of cocaine into a space situated between the spinous processes of two of the inferior dorsal vertebrae of a dog. Five minutes after the injection there were marked evidences of incoordination in the posterior ex- tremities. A few minutes later there was pronounced weakness in the hind legs, but there were no signs of feeble- ness in the anterior extremities. The faradic current 24 CERBBKOSPINAL FLUID showed that there was no reflex action of the hind legs, but the anterior extremities responded quickly. Corning then injected 30 minims of a 3 per cent solu- tion of cocaine hypochlorate between the spinous processes of the eleventh and twelfth dorsal vertebrae, in a man suf- fering from spinal weakness. As there was no numbness noticeable, he injected 30 minims more in the same spot about six or eight minutes later. In ten minutes the' man complained that his legs felt "sleepy," and brush appli- cations showed that sensibility was greatly impaired. As a result of his experiments Corning came to the conclusion that local medication by means of spinal punc- ture could prove of great therapeutic value in relieving a number of morbid conditions of the cord. Unforttmately, however. Corning left us neither a description of the tech- nic he employed nor of the type of needle he used. More- over, his operation was attended with a great degree of risk in that he introduced the needle too high up in the spinal colmnn, thus incurring the danger of injury to the cord. In 1891 W. Essex Wynter reported the drainage of cere- brospinal fluid in four cases of tuberculous meningitis. He treated his first case in 1889, making an incision in the skin of a patient suffering from tuberculous meningitis. In the incision which was made a little to one side' of the spine of the second lumbar vertebra, he introduced a Southey tube and a trocar. When he felt that the point of the trocar liad struck against the lamina, he directed it slightly down- ward, forced it through the ligamentum and theca, and then inclined it toward the median line. When the trocar was withdrawn, clear fluid rushed out into the Southey tube. A fine, India-rubber tube Avas then connected to facilitate continuous drainage. The symptoms of the disease sub- sided immediately, altliougli the patient subsequently died from tuberculous meningitis. From 1889 to 1891, Wynter treated three more cases of tuberculous meningitis, r- HISTOEY 25 all of them showed improvement for a while, although they subsequently succumbed to the disease. Charles A. Morton (1891) followed the method outlined by Wynter. In discussing the pathology of tuberculous meningitis with reference to its treatment by tapping the spinal subarachnoid space, Morton says: ' ' What symptoms can be relieved by it only the practice of the operation can show; that out of four cases operated on in the Middlesex Hospital in one there should have been contraction of the unduly dilated pupils, and in another slight improvement in the general condition, is encourag- ing when we remember that drainage was not maintained in all the cases. The operation does no harm and as the patient is already comatose, no anesthetic is required." Morton, we see, tapped the patient when he was already in comatose condition. Although he does not state def- initely jiTst what technic he employed, he does, at the be- ginning of his article speak of the recent procedure "of tapping the subarachnoid space of the spinal cord in cases of tuberculous meningitis." This would seem to indicate that he followed the method of Wynter ; namely incision of the skin, introduction of a trocar between the vertebrae and the use of a continuous drain. For the simplification and perfection of the spinal punc- ture we must turn to Quincke. Corning, who was the first to use spinal puncture, employed an operation that was fraught with danger to the cord, as the point at which he introduced the' needle Avas too high up in the spinal canal. Wynter, it is true, did his puncture in the lumbar region, but his method necessitated the use of a large trocar, a continuous drain and a large incision in the skin. The procedure of Quincke was a vast improvement over those of his predecessors, both from the standpoint of simplicity and of safety. Quincke used only a plain needle and he so perfected the technic of spinal puncture that there is little that can be improved in his original method. 26 CEREBEOSPINAL FLUID At the Tenth Congress for Internal Medicine, Quincke reported two cases of hydrocephahis treated by means of withdrawal of the cerebrospinal fluid. The first was one of chronic hydrocephalus in which the fluid was removed by trephining and in Avliicli the contractures of the extrem- ities and of the neck subsequently disappeared. The sec- ond was that of a child in which lumbar puncture resulted in great improvement. From tliese and similar observa- Fig. 3. — Drawing accompanying original article on lumbar puncture by Quincke, repre- senting lumbar region of skeleton of a one-year-old child. tions Quincke concluded that spinal puncture for thera- peutic purposes was indicated in marked cerebral pres- sure, especially in cases of tuberculous meningitis and acute hydroccplialus. Quincke not only described the tech- nic of spinal puncture, but lie also measured the pressure of the ceicbrospinal fluid and dctci-mined its chemical com- position so far as he Avas able M'ith the chemical technic at his command. (Figs. 3 and 4.) HISTORY 27 For two years after Quincke's experiments with Spinal puncture no reports appeared in literature regarding its use. It was not until 1893 that Lichtheim called attention to spinal puncture as a valuable aid in diagnosis, and two years later, in 1895, Fiibringer reported 107 punctures in eighty cases. In America, Browning, in 1894, reported a Fig. 4. — Drawing accompanying original article on lumbar puncture by Quincke, repre- senting lumbar region of skeleton of a six-year-old child. series of spinal punctures and G. W. Jacoby, in 1895-6, re- ported 30 punctures. Since 1896 spinal puncture has been quite generally adopted as a routine procedure for diag- nostic and therapeutic purposes. Bacteriology, serology, and chemistry have all played an important role in shaping the history of the cerebrospinal 28 CEREBROSPINAL FLUID fluid. A s for bacteriology, there is hardly a discovery that does not bear a more or less direct relation to the history of cerebrospinal fluid. The discovery of the tubercle bacillus by Eobert Koch changed the name of acute hydro- cephalus to tuberculous meningitis, and the conception as to its nature accordingly. The discovery in 1885 by Leich- tenstern of intracellular diplococci, later elaborated with greater accuracy by Weichselbaum (1887), changed the name of "spotted fever" and "epidemic cephalalgia" to meningococcus or epidemic meningitis, and the discovery of pneumococcus by Frankel and of influenza bacillus by Pfeiffer did much to clear up the understanding of meningitis by introducing system where chaos previously reigned. Serology has added a great deal to the diagnostic and therapeutic uses of the cerebrospinal fluid. Bordet's dis- covery of complement fixation, Ehrlich's work on immu- nity and Wassermann's serologic test all found practical applications in the cerebrospinal fluid. However, prob- ably the most beneficial contribution in the field of serol- ogy was the discovery of antimeningococcic serum by Joch- mann, in Germany and by Flexner in America and the in- troduction of the intraspinal injection of the serum by Flexner. Chemistry, too, has had its share in shaping the history of the cerebrospinal fluid. It has sho\\Ti us the composi- tion of this, the clearest of body fluids, and has shed light on the diagnosis of meningitis and other affections of the central nervous system. Finally, the recent offspring of science, physical chem- istry, is making its impress also on the history of cerebro- spinal fluid. The li-ion concentration, cataphoresis, the Lange colloidal gold tost, the ninhydrin reaction and the precipitation tests, all of which are based on physicochem- ical principles, have thrown light on diseases of the central HISTORY 29 nervous system in general and on the composition of body- fluids in particular. "We see that it would hardly be an exaggeration to say that the history of cerebrospinal fluid in many respects is but a miniature history of modern medicine. Bibliography Contugno : De Ischiade nervosa Commentarius, Dissertation de Sandifort, 1769, ii, 411. Jour, de phyaiol. exper., 1769, vii, 83. Corning: Spinal Anaesthesia and Local Medication of the Cord, New Yorlc Med. Jour., 1885, xlii, 483. Haller: Physiologie des Menschen, 1766 Levinson: History of Cerebrospinal Fluid, Am. Jour. Syph., 1918, ii, 267. Longet: Anatomie et Physiologie due Systeme Nerveaux, 1842, i, 193. Magendie: Memoire sur un liquids qui se trouve dans le crane et la col- onne vertebrale de I'homme et des animaux mammiferes, Compt. rend. Acad. d. sc, Jan. 10, 1825. Magendie: Eeeherches Physilogiques et Cliniques sur le Liquide Cephalo- Eaohidieu ou Cerebrospinal, Paris, 1842. Morton: The Pathology of Tuberculous Meningitis with Eeference to i'- Treatment by Tapping the Subarachnoid Space of the Spinal Cord, Brit. Med. Jour., 1891, ii, 840. Quincke ; tJber Hydrocephalus, Verhandlungen der Cong, f iir Innere Med., 1891, X, 321. Whytt : Observations on the Dropsy in the Brain, Works of Eobert Whytt, 1768. Wynter: Pour Cases of Tubercular Meningitis in Which Paracentesis of the Theca Vertebralis was Performed for the Eelief of Fluid Pressure, Lancet, London, 1891, i, 981. CHAPTER II ANATOMY AND PHYSIOLOGY OF CEREBRO- SPINAL FLUID LOCATION The brain and spinal cord are surrounded throughout their length by a bed of fluid called the cerebrospinal fluid (Liquor cerebrospinalis, liquide cephalorachidien, Zerebro- spinalfliissigkeit). Besides the fluid that surrounds the brain and cord there is also a small quantity of fluid in the ventricles of the brain. The subarachnoid space is situated between the inner vascular layer of the meninges, the pia, and the outer thin layer of the meninges, the arachnoid. It is subdivided into numerous compartments by means of delicate trabeculse which run from the pia to the arachnoid. The subarachnoid space is not of the same depth everywhere. In some • places it is quite wide and the trabeculse are quite long, whereas in others, especially over high convolutions of the brain, the opposite is the case, the space being very small and the trabeculfe very short. The various wide spaces are known by special terms suggestive of their form. Among the most important are the cisterna magna, which is lo- cated between the under surface of the cerebellum and the medulla; the cisterna pontis which is the continuation of the subarachnoid space of the spinal cord upwards to the floor of the cranium ; and the cisterna basalis which is sit- uated in front of the pons. The subarachnoid space of the cord, like that of the brain, is subdivided by trabeculse, or septa, and is also quite wide. In addition to the fluid fontainc^d in the subarachnoid space of the brain and cord there is fluid in the ven- 30 5. — Section of human brain showing t!ie chorioid yilex intercommunications of the brain ventricles LIS, the (See Fi] ■xtent, ANATOMY AND PHYSIOLOGY 31 tricles of the brain: the two ]at<-ral, the third, the fourth, and the fifth ventricles (Figs. 5 and 6). Lining the ventricles there is a tuft of blood vessels, cov- ered by a single layer of epithelium called the chorioid plexus (Figs. 5, 6 and 7). This plexus is an ingroA\i;h or folding of the pia, the layer of the meninges immediately adjacent to the brain. Two-thirds of the blood supply of the plexus in man is furnished by the anterior chorioid branch of the internal carotid artery which enters the plexus at the anterior end of the descending cornu. The remainder is supplied by the posterolateral chorioid artery, a branch of the posterior cerebral. These arteries break up into ...rtorioles, the larg- est of which are visible to the naked eye. After passing through the network of capillaries, the blood returns through the chorioid vein to the internal cerebral veins where it joins its fellow and forms the cerebral vein, or vein of Galen. The walls of the blood vessels of the chorioid plexus, measure, in some tufts, 0.2 mm. in thickness, Avhile in oth- ers they form only a thin membrane between the lumen and cuboidal cells on the surface. Much variation exists also in the size of the lumina. Sundwall divides the vessels of the chorioid plexus into two groups: (1) The vessels with thick walls, which as a rule, possess narrow lumina and have the same general structure as the small arteries. Weigert's stain shows a well-developed internal elastic layer, which in most in- stances is corrugated. In the media, which is quite well developed, fine, wavy, elastic fibers may be seen. The fibers may be traced to the cuboidal cells for which they frequently form a basic membrane. (2) The second group of vessels are those with comparatively thin Avails and wide lumina. These may be regarded as veins or sinuses. No muscular tissue can be made out in the walls of this second group, the Avails being composed almost entirely of CEREBROSPINAL FLUID COn.f^HT. 'AN. CENT. Fig. 6. — A diagram of Fig. 5. Tiie ventricles are deeply shaded. The outlines of the ventricles which appear in Fig. 5 are indicated by continuous lines. On the right side the position of the underlying ventricular cavities is also indicated by shading, but the outline is a broken line. .S"". PEL., Septum pellucidum. F. M., Foramen of Monro. F. III., Third ventricle. N. L., Lentiform nucleus. C. I.. Internal capsule. COR. INF., Inferior horn of lateral ventricle. THAL.. Optic thalamus. HIP., Hippocampus. FIM., Fimbria. PL. COR., L,ateral chorioid plexus. COR. POST., Posterior horn of lateral ventricle. v. IV., Fourth ventricle. PL. COR. V. IV., Reflected chorioid plexus of fourth ventricle. CAN. CENT., Position of central canal. COR. ANT., Position of anterior horn of lateral ventricle. N, CAUD., Caudate nucleus. S. C, Fissure of Rolando (central sulcus)'. FX., Fornix cut through at column of the fornix. PL. COR., LAT., Lateral chorioid plexus. PL. COR. V. III., Reflected chorioid plexus of third ventricle positum. COR. INF., Position of the inferior horn of lateral ventricle. CL. P., Left half of pineal body. AQ. SYL., Aqueduct of Sylvius. P?,'^rn?^''',V Po"'''"" of posterior horn of lateral ventricle. r? r ,J'-7,^"\^^"^'"^'^ °* cerebellar peduncles. «. L. V. IV., Lateral recess of fourth ventricle. nd septum inter- ANATOMY AND PriY.SIOLOGY 33 white fibrous connective tissue and are so similar tlirough- out in their structure that they can not l)e differentiated into intima, media, and adventitia. Only liere and there may be seen a few fine elastic fibers. The Avails contain numerous small vessels and capillaries (vasa vasoruni) of varying caliber. They are rich also in nuclear elements, such as endothelial cells, connective- tissue cells and interstitial granule cells. The cerebrospinal fluid in one ventricle of the brain com- municates directly A\'ith the fluid in the other ventricles Fig. 7. I'hotograpli of a chovioiil plexus dt-taclied from Ihe ventritles. through the various openings connecting them. The only exception to this rule is the fiftli ventricle which contains very little or no fluid. Thus, the fluid in the lateral ven- tricles flows int(j the third through the foramen of Monro, and the fluid in the third comnranicates with that in the fourth l)y means of the aqueduct of Sylvius. (Figs. 5 and G.) The cerebrospinal fluid of the subarachnoid space com- municates with the fluid in the ventricles of the brain throuo-h the foramen of Magendie which opens into the 34 CEREBIIOSPINAL FLUID posterior part of the fourth ventricle and through the foramina of Luschka and numerous otlier apertures which open into the lateral ventricles. Some authors, notahty Schmorl, claim that no communication exists between the cerebrospinal fluid in the ventricles of the brain and the fluid in the subarachnoid spaces of the brain and cord. They base this claim on two observations: (1) the finding of bile in cases of icterus in the cerebrospinal fluid of the cord, but not in the fluid of the ventricles ; (2) by Schmorl 's finding of a positive Nonne-Apelt reaction in the cerebro- spinal fluid of the cord and a negative reaction in the fluid of the ventricles. My own observations do not bear out the conclusion of Schmorl. I examined both the spinal and ventricular fluid in cases of meningitis and found them quite alike in both their globulin and bacterial content. In fact, in my cases, the ventricular fluid at times gave much stronger globulin reactions than did the fluid from the spinal canal. How- ever, the best evidence that a communication exists be- tween the ventricles of the brain and the subarachnoid spaces is the commonly observed fact that in hemorrhages into the ventricles the fluid obtained by lumbar puncture contains coagulated blood. It is also well known that when a colored fluid is injected into the ventricles, it can be re- covered by lumbar puncture in a few minutes. Vice versa, if the colored fluid is injected between the atlas and axis it can be recovered from the lateral ventricle. It is also well known that a tense fontanelle will go down with the withdrawal of cerebrospinal fluid by lumbar puncture. All this points to a direct communication between the ven- tricles of the brain and the subarachnoid space. FORMATION AND ABSORPTION The rate of formation of cerebrospinal fluid is still a matter of conjecture. Falkenhcim and Naunyn observed ANATOMY AND PHYSIOLOGY 35 that from 1 c.e. in six minutes to 1 c.c. in forty minutes flowed out of a cannula introduced into the subarachnoid space of a dog. In another dog, weighing 23 Idlos, they observed as large a flow as 240 c.c. of fluid in twenty-four hours and in still another dog, weighing 20 kilos, they re- ported a flow of 36 c.c. in twenty-four hours. According to these experiments there does not seem to be any rela- ' tion between body weight and the rate of formation of cerebrospinal fluid nor between the rate of formation and the arterial pressure. In the numerous reports of cases of cerebrospinal rhinorrhea, the amount of fluid flowing out from the nose varied from 96 c.c. to 720 c.c. per day. Til- laux, for instance, reports a case in which there was com- munication between the subarachnoid space and tlie dura and in which the daily flow of cerebrospinal fluid from the nose averaged one-fourth of a liter. Wallace MacKenzie reports a case of cerebrospinal rhinorrhea where the 'aver- age flow of fluid per hour was one ounce, making a total of 720 c.c. in a day. In trauma of the spinal column even greater amounts of fluid have been observed, as in the case of Giss in which there was a flow of fluid measuring from one and one-half to two liters. It seems likely, however, that the large amounts of cerebrospinal fluid observed in cases of trauma are no indication of the normal rate of formation in cerebrospinal fluid, as.it is well known that whenever there is irritation of a serous membrane there is an increase of the fluid in the cavity. So far a~s we know, no one has as yet determined the rate of formation of cerebrospinal fluid under normal condi- tions. One point, however, has been quite definitely es- tablished by Falkenheim and Naunyn and that is that there is a constant secretion and absorption of the fluid. That the cerebrospinal fluid has a circulation has been shown by Magendie, but the mode of circulation has not been entirely established. It is thought that the fluid starts in the ventricles of the brain, that it passes through 36 CEREBROSPINAL FLUID the foramina of Magendie and Luschka into the subarach- noid space of the brain, then downward along the posterior aspect of the spinal cord. On reaching the end of th^ cord the fluid passes upward along the anterior surface of the cord. Some of the fluid is absorbed there. The rest spreads over the convexities of the hemispheres from whence it is absorbed. The data on the absorption of the cerebrospinal fluid are not numerous. Duret was able to introduce 583 c.c. of wa- ter into the subarachnoid of a dog in the course of two hours. Naunyn and Schreiber introduced 400 c.c. of phys- iologic salt solution into the subarachnoid space of a dog, weighing 9% kilograms, in the course of an hour and three quarters, using 100 mm. mercury pressure for the injec- tion. Falkenheim and Naunyn showed that the absorption is rapid even when the fluid is injected Avith a very little force. Dandy and Blackfan injected 1 c.c. of phenolsul- phonephthalein into a dog after withdrawing 1 c.c. of cere- brospinal fluid. They examined the quantity of phenolsul- phonephthalein excreted in the urine by a colorimetric method, and found that in the first hour after the injection there were 16.6 per cent of phenolsulphonephthalein ex- creted in the urine; in the second, 17.8 per cent; in the third, 13.6; in the fourth, 7.2 per cent; in the fifth, 4.5 per cent; in the sixth, 2.2 per cent; in the seventh, 1.3 per cent; and in the eighth, 1.3 per cent. From these experiments they concluded that the absorption of the cerebrospinal fluid is fairly regular for a period of from three to four hours, and that it diminishes progressively after this time. They set a minimum of four to six hours for the comple- tion of absorption of the fluid, making four to six renew- als in 24 hours. The above, however, can not be talien as an index for the rate of absorption of the cerebrospinal fluid, as phenol- phthalein is a foreign substance, and, as is well known, a foreign substance is rapidly eliminated from the body, ANATOMY AND PHYSIOLOGY 37 without reference to the absorption poAver of the body fluids. One, for instance, is not justified in saying that since 60 per cent of a dye is excreted in the urine in two hours by the kidney, 60 per cent of the water of the blood is excreted in two hours. Foreign substances are ehm- inated by a special mechanism and bear no relation to the absorption of the body fluids. So far the rate of absorption of cerebrospinal fluid has not been determined, and Ave believe will not be deter- mined so long as the rate of formation of the fluid is not known, for the rate of absorption naturally depends on the rate of formation. As for the channel through which absorption of the cerebrospinal fluid takes place, there is a divergence of opinion. Mott considers the perivascular lymphatics as the channel of absorption. It has been proved by others, also, that a portion of the fluid is drained by the lymphat- ics into the deep cervical glands, and that a small portion flows into the lymph vessels of the nose, the perilymph spaces of the labyrinth of the ear and in the perineural sheets. This is somewhat substantiated by the cases of cerebrospinal rhinorrhea reported in the literature. It has been found, however, that normally the absorption by way of the lymphatic system removes only a. very small quantity of the fluid. Hill, Ziegler, and Spina showed that methyl blue injected into the subarachnoid space can be recovered from the stomach in twenty minutes, while it takes hours before the lymphatics of the neck are discol- ored by the stain. Dandy and Blackfan introduced a can- nula into the thoracic duct after they had injected phenol- sulphonephthalein into the subarachnoid space and found that there was very little absorption by the lymph, com- pared with that by the blood. These and many other experiments indicate that the greatest amount of cerebrospinal fluid is absorbed into the blood stream proper. According to Schwalbe, Key and 3y CEREBROSPINAL FLUID Betzius, the Pacchionian bodies perform the function of absorbing the fluid, but according to recent studies these bodies are concerned only little in this absorption. Bohn, Reiner and Schnitzler advocate the idea that the fluid is absorbed by the stomata of the meninges. This theory, however, has no real foundation, and at present the weight of evidence is in favor of the absorption of the cerebro- spinal fluid by a process of diffusion into the blood from the subarachnoid space of the brain, and particularly of the cord. PERMEABILITY It is conceded by most observers that under normal con- ditions no foreign substances, or at least very few, pass from the blood into the cerebrospinal fluid. This resist- ance of the meninges to the entrance of a foreign substance is held to be due to the impermeability of the meninges, although, if we accept the view that the cerebrospinal fluid is secreted by the chorioid plexus Ave should speak rather of the impermeability of the chorioid plexus. Various ex- periments have been made to demonstrate this property of the chorioid. Cavazzani injected potassium iodide into dogs intraperi- toneally and recovered only very small amounts of it in the cerebrospinal fluid. Sicard, Lewandowsky, and Rotky repeated the experiment and could not detect potassium iodide in the cerebrospinal fluid at all. Lewandowsky found that a few centigrams of sodium ferrocyanide in- jected into subarachnoid space rapidly produced toxic symptoms while four to six grams injected into the jugular vein in rabbits of the same weight produced no specific symptoms. This could not have been attributed to the so- lution employed, for a 10 per cent salt solution injected into the subarachnoid space produced only slight effects. Lewandowsky was also i\h\e to sliow the transmissibility of only very small traces of strychnine in the cerebrospinal ANATOJIY AND PHYSIOLOGY 39 fluid of animals, but none in man. Von Jaksch and Sicard could not detect the presence of mercuric salts after inunc- tion into the skin. Livon and Bernard could detect sal- icylates, but in very small amounts, in the cerebrospinal fluid of a dog after intravenous injection. Antitoxin also passes over into the cerebrospinal fluid only in traces. Behring injected hens both subcutaneously and intravenously with tetanus toxin and found that they suffered no ill effects. However, when he injected the same amomit of toxin into the subdural space the hens died from typical tetanus. Mestrezat found that when sodium nitrate is adminis- tered to a normal individual before a spinal puncture is made, the fluid shows very little or no nitrate, while in cases of meningitis, the drug is present in large quantities. There are a few chemical substances, however, that do seem to be transmitted from the blood into the cerebro- spinal fluid, namely, hexamethylamine, alcohol and chloro- form. Hexamethylamine has been shown by Crowe, Hold and Ratsky to be present in the cerebrospinal fluid of both man and animal after administration by mouth. This observation has led to the suggestion of giving hexamethy- lamine in meningitis and poliomyelitis. Alcohol was shown by Schottmiiller and Schumm to accumulate in the cerebro- spinal fluid in even larger amounts than in the blood. Of pathologic products, acetone, acetoacetic acid, lactic acid and bile have l)een found to pass over into the cere- brospinal fluid quite readily even when the meninges were not affected. I found the chlorides in the fluid to be increased in nephritis and the sugar to be increased in diabetes. Some of the experiments on the impermeability of the meninges and chorioid plexus are not entirely convincing because they deal with negative evidence. Very fre- quently also the technie and method have been at fault. It is certain, however, that there is a vast difference be- 40 CEREBROSPINAL FLL'ID tween the transmissibility of chemical and immune sub- stances in health and in disease and although we may not know positively Avhether the meninges or chorioid plexus are entirely impermeable in health, we do know that they become permeable in disease — a fact of great importance in the genesis and also in the diagnosis and treatment of the diseases of the meninges. FUNCTION That the cerebrospinal fluid has a mechanic function there is no doubt. The fluid forms a water bed around the cord and brain and thus prevents the jarring from external trauma. The fluid also equalizes the pressure between the brain and the cord. Magendie, many years ago, pointed out the following: "The cerebrospinal fluid which is barely mentioned in the classical Avorks, not only fills out the empty spaces in the skull and spinal canal, it has a greater function, mainly to exert a continual and regulated pressure on the neuron masses." However, a number of other functions are ascribed to cerebrospinal fluid. Mott believes that it is the function of the fluid to give up carbon dioxide and water to the blood and to take up oxygen and sugar. Gushing, and later Fra- zier, suggested that the fluid may be the medium of dis- tribution of the active principle of the pituitary to the tissues of the central nervous system, which is essential to metabolism. Halliburton considers the fluid as a Locke modification of Einger's solution. The sugar, as in Locke's solution, serves to supply the energy, the protein serves to repair the wear and tear resulting from the ac- tion of the nervous system, and the fluid as a whole acts as an ideal, physiologic salt solution bathing the neurones and maintaining their osmotic equilibrium. According to Gaskel the neural tube is a primitive di- gestive canal, and the cerebrospinal fluid a primitive gas- ANATOMY AND PHYSIOLOGY 41 trie juice. Dandy calls attention to the gill-like appear- ance of the chorioid plexus, a fact that inclines him to be- lieve that the chorioid plexus and the cerebrospinal fluid are concerned in respiration. Pettit and Girard hold that the fluid has an internal secretion. Still another theory of recent origin voices the opinion that the fluid serves as a destroyer of toxic substances introduced into the cere- brospinal nervous system. Of the various theories advanced in regard to the func- tion of the cerebrospinal fluid that of mechanic function has an unquestionable basis. All the other theories are open to objection of one kind or another; they lack in suf- ficient evidence. Mott's theory that the cerebrospinal fluids gives up CO2 and water to the blood seems illogical since the circulation of the fluid is entirely too slow and therefore inadequate to carry CO2 to the blood. Fra- zier's suggestion needs further confirmatory evidence. The theories of Dandy and of Gaskel do not appear at all plausible. As to the theory that the fluid destroys toxin, the objection may be raised that very few toxins are able to get into the cerebrospinal canal under normal condi- tions, as shoA\Ti in the discussion on permeability. Of all the theories, the only one that has a firm basis is that of mechanical function. ORIGIN The question of the origin of cerebrospinal fluid is one that has engaged the attention of many physiologists and chemists, and even today the problem is far from settled, although attempts have been made to solve it through the aid of histology, chemistry, physiology, and pathology. Carl Schmidt (1850) was the first to voice the opinion that cerebrospinal fluid was a secretion and not a transudate by virtue of the difference in the chemical composition of the blood and the fluid. P'aivre (1854) also spoke of the inti- mate relation between the fluid and the chorioid plexus. 42 CEKEBKOSPINAL FLUID Luschka, Schlaepfer, Yoshimura, Ernst, Kafka, Mott and Meek found the existence of vacuoles in the chorioid plexus, and all, with the exception of Meek, connected the globules with the secretion of cerebrospinal fluid. Mott examined the chorioid plexus of human beings soon after death and on staining with methylene blue, he found the cells of the chorioid plexus to contain many vacuoles. This, he believed, proved conclusively that the chorioid cells secreted some substance. He compared the epithelial cells of the chorioid with those of the lacrymal glands. Physiologic evidence as to the secretion of the chorioid plexus was also brought forth by many observers. Kafka found that, after an injection of pilocarpine, the epithelial globules of the chorioid plexus were multiplied. Cavaz- zani showed that lymphagogues did not affect the cerebro- spinal fluid. His observation that the alkalinity of cere- brospinal fluid was considerably less than that of the blood also led him to the conclusion that cerebrospinal fluid was a secretion. Cappelleti came to the same conclu- sion regarding the origin of the cerebrospinal fluid. He found that ethyl ether and pilocarpine increased the flow of the fluid, whereas atropin and hyoscyamin retarded the flow. Pettit and Girard found that the administration of pilocarpine, muscarin and ether to animals produced a marked increase in the secretion of the plexus. Dixon and Halliburton brought about an increase in the flow of the fluid by injecting chorioid extract. They claim that the chorioid plexus contains a hormone which when liberated into the blood becomes the precursor and regulating me- dium of the secretory activity of the plexus. Interesting contributions to the chemical phase of the problem have been made by Schmidt, Polanyi, Schottmiiller and Schumm. The work of Schmidt has been mentioned. Polanyi concluded, from the small protein content and the high molecular concentration of fluid in cases of hydro- cephalus, that the fluid is not a transudate. Schottmiiller ANATOMY AND PHYSIOLOGY 43 and Schumm claimed that the fluid is not subordinate to the blood, as they had found the fluid in some cases to con- tain alcohol in as great and greater quantities than the blood. Leopold and Bernhard subscribe to the view of Gushing that the cerebrospinal fluid is secreted by the chorioid plexus on the ground that they were unable to find uric acid in the fluid in normal individuals. Evidence from pathologic conditions, as to the secretive powers of the chorioid plexus has been furnished by other observers. Charles and Levy report a case of hydroceph- alus in which there was hypertrophy of the chorioid plexus. Dandy and Blackfan occluded the aqueduct of Sylvius by a gelatine capsule and produced thereby an internal hydro- cephalus. This would tend to show that the fluid is se- creted above the aqueduct and most likely by the chorioid plexus. That part of the fluid might come from the ven- tricles themselves the work of Francini would indicate, as he noticed secretory phenomena of the ependyma cells of the ventricles after ether injections. On the other hand, there are observations that would tend to show that cerebrospinal fluid is not a secretion. Mestrezat, on the basis of chemical analysis of the blood plasma and the cerebrospinal fluid, concluded that the fluid is not a filtrate, a transudate, or a secretion, but a dialy- sate of blood plasma produced by a passage through special epithelial cells. McClendon, on physico-chemical ground, claimed that the cerebrospinal fluid was an ultrafiltrate. From the various data presented, one would be inclined to believe that the chorioid plexus is the seat of the origin of the cerebrospinal fluid. It is quite plausible to assume that the plexus is located in the ventricles for some purpose and most likely for the secretion of the cerebrospinal fluid. Yet the evidence brought forward to prove these points is not altogether convincing. Mott's observation of the existence of vacuoles in the chorioid plexus, an observation that has been corroborated 44 CEEEBEOSPINAL FLUID by Luschka, Findlay and Galeotti, does not necessarily indicate that the chorioid plexus secretes cerebrospinal fluid. Meek believes that the vacuoles are due to the melt- ing of the fat in the epithelial cells of the chorioid through the action of such hardening fluids as alcohol and xylol, for chorioid cells which have not been subjected to alco- hol and xylol do not show vacuoles. Pettit and Girard be- lieve that these vacuoles are due to mechanical injury and to postmortem changes. Becht argues that secreting cells should not show vacuoles at all, but should be smaller than ordinary cells. He points out the fact that secreting cells in the parotid and other glands become smaller dur- ing the period of activity, whereas those of the chorioid plexus become larger. He notes other differences as well. While, in most glands, during the period of activity the cytoplasm is differentiated into an inner granular layer and an outer clear zone with well-defined nuclei, in the chorioid plexus, during activity, the very opposite takes place. The cytoplasm becomes differentiated into an inner clear and an outer granular zone and the nucleus can hardy be distinguished from the nucleus of the resting cells. Cavazzani's evidence regarding the alkalinity of the cerebrospinal fluid does not hold good, because the methods used for the determination of the alkalinity were not the proper ones, and with newer methods, the acidity of the fluid is the same as that of the blood. As for the effect of pilocarpine in increasing the amount of cerebrospinal fluid, this does not necessarily show that the fluid is a secretion. The increase in the secretion can just as readily be attrib- uted to the action of the drug on the blood vessels. As for the chemical evidence brought forth by Polanyi, is it not plausible to assume that the cerebrospinal fluid may come from the blood, and that the smaller content of protein in the fluid, be due to the changes the fluid under- goes during the process of filtration? Schottmiiller 's ob- servation that there may be a greater amount of alcohol in ANATOMY AND PHYSIOLOGY 45 the cerebrospinal fluid than in the blood may be explained on the ground of slower absorption in the cerebrospinal canal than in the blood. ' Until it is possible to remove the chorioid we shall not know conclusively whether the chorioid is the seat of the secretion of the cerebrospinal fluid. All that we can say at present with any degree of certainty is that there is con- vincing proof to show that the cerebrospinal fluid is pro- duced above the aqueduct of Sylvius. ^ The fact that nearly all constituents of the blood are present in the cerebrospinal fluid, and that the physico- chemical properties of the cerebrospinal fluid are practi- cally the same as that of the blood, would make one believe that the cerebrospinal fluid is a direct product of the blood, most likely separated out by the chorioid plexus. The data presented in this, chapter may be summarized in the following points: 1. The cerebrospinal fluid is contained in the subarach- noid space of the brain and cord. 2. The fluid in the various ventricles is in direct com- munication with each other and with the fluid of the cord. 3. The cerebrospinal fluid has a circulation. 4. The rate of formations of normal fluids is unknown. So is the rate of absorption. 5. Absorption seemingly takes place by a process of dif- fusion from the subarachnoid of the cord and to a lesser extent from the subarachnoid of the brain. Some absorp- tion also takes place by the lymphatics draining into the deep cervical glands, into the lymph vessels of the nose,/ perilymph spaces of the labyrinth and into the perineural sheets. 6. The cerebrospinal fluid, or rather the chorioid plexus, is not permeable, or very little so, under normal conditions. 7. The fluid exerts a mechanical function in that it equal- izes the cerebrospinal pressure. The numerous other func- tions attributed to the fluid need further substantiation. 46 CEEEBROSPINAL FLUID 8. The origin of cerebrospinal fluid is unknown. There is evidence pointing toward the theory that the chorioid plexus is the seat of origin of the fluid. There is also evi- dence pointing to the assumption that the fluid is a direct product of the blood. It is, therefore, plausible to assume that the chorioid plexus plays the role of separating the various constituents of the cerebrospinal fluid from the blood. Bibliography Achard and Ribot: Passage de I'iodure de potassium dams liquide eephalo- racliidean normal, Compt. rend. Soc. de biol., Paris, 1909, Ixvi, 916. Beeht: Observation on the Formation of Cerebrospinal Fluid, Proo. Am. Physiol. See., Boston, 1914, xxxii. Blumenthal and Jacob: Zur Therapie des Tetanus, Berl. klin. Wchnschr., 1898, XXXV, 1079. Bohm: Experimentelle Studien iiber die Dura Mater des Menschen und der Saugethiere, Virchows Areh. f. Path. Anat. 1867, xlvii, 218. Cappelleti : L 'eeoulement du liquide eerebro-spinale par la fistula Cephalo- raehidienne en eonditiones normales et sous 1 'influence de quelques, medicaments, Areh. ital. de biol., 1901, xxxvi, 299. Cavazzani: Contributo alia fisiologie del liqnido eerebro-spinale, Centralbl. f. Physiol., 1901, xv, 216. Crowe: On the Excretion of Hexajnethylenajnin-(Utropin) in the Cerebro- spinal Fluid and Its Therapeutic Value, BiuU, Johns Hopkins Hosp., 1909, XX, 102. Gushing: Physiologische und Anatomische Beobachtungen iiber den intra- erajiiellen Kredslauf, etc.. Mitt. a. d. Grenzgeb. d. Med. u. Ohir., 1902. ix, 77.S. Cushing: Studies on the Cerebrospinal Fluid, Jour. Med. Research, 1914, xxxi, 1. Dandy and Blackfan: Internal Hydrocephalus, Am. Jour. Dis. of Child., 1914, viii, 406. Dean: Intracranial Pressure, Jour. Path., 1892, i, 26. Dixon and Halliburton; Cerebrospinal Fluid, I. Secretion of the Fluid, Jour. Physiol., 1913, xlvii, .'^41. Dixon and Halliburton: The Rapidity of Absoi-ption of Drugs Introduced Into the Cerebrospinal Fluid, Jour. Physiol., 1912, xliv, Proc. Physiol. Soc, p. vii. Faivre: Recherches sur la Structure du conarium et des plexus chotoides Chez I'homme et chez les animaux, Compt. rend. I'Acad. d. sc, 1854, xxxiv, 424. Faivre: Etude sur le conarium et les plexus choroides de I'homme et des animaux, Ann. d. sc. nat. Paris, 1857, vii, 52; Gaz med. de Paris, 1854, No. 36. Falkenheim and Naunyn: Uober Hirndruck, Arch. f. exper. Path. u. Phar- makol., 1887, xxii, 261. Findlay: The Choroid Plexus of the Lateral Ventricles of the Brain, Their Histology, Normal and Pathological (in Relation-^specially to Insanity), Brain, 1899, xxii, 161. Frazier: The Cerebrospinal Fluid in Health and Disease, Jour. Am. Med. Assn., 1915, Ixiv, 1119. ANATOMY AND PHYSIOLOGY 47 Geigel: Die KoUe des Liquor cerebralis bei der Circulation im Schadel, Arelx. f. d. ges. Physiol.; 1905, cix, 337. Halliburton: Cerebrospinal Fluid, Jour. Physiol., 1889, x, 232. Goldmann: Vitalfarbung am, Zentralnervensystem; Beitrage zur physio- pathologie des Plexus ehoroideus und der Himhaute, Berlin, 1913. Halliburton : Possible Function of the Cerebrospinal Fluid, Lancet, London, 1916, ii, 779. Halliburton and Dixon: Choroid Plexus and Secretion of C S. Fluid, Jour. Physiol., 1910, xl, 30. Hektoen: Occurrence of an Isolated Antibody in the Cerebrospinal Fluid, Jour. Infect. Dis., 1913, xii, 1. •^ill: The Physiology and Pathology of the Cerebral Circulation, London, 1896; Allbutt's System of Medicine, 1899, vii, 239. Kafka: Ueber die Bedingungen und die praktische und theoretisehe Be- deutung des Vorkommens hammelblutlosender Normalambozeptoren und des Komplements ini Liquor cerebrospinalis., Zeitschr. f.d. ges. Neurol u. Psych., 1912, ix, 132. Knoll: tjber die Druckschwankungen in der Cerebrospinalfliissigkeit, Sitz- ungsberichte der Akad. d. Wissenschaft, 1886, xciii, 227. Kolmer and Sekiguelii: Experiment on Passive Transfer of Antibodies from the Blood to the Cerebrospinal Fluid, Jour. Immunology, 1918, iii, 101. Kramer: The Function of the Choroid Gland and Its Relation to the Tox- icity of Cerebrospinal Fluid, Jour. Am. Med. Assn., 1911, Ivi, 265. The Circulation of Cerebrospinal Fluid and Its Relation to the Pathogenesis of Poliomyelitis, New York Med. Jour., 1912, xev, 1532. Lewandowsky: Zur Lehre von der Cerebrospinalfliissigkeit, Ztschr. f. klin. Med., 1900, xl, 480; Neurol. Centralbl., 1901, p. 447. Leyden: Beitrage und Untersuehungen zur Physiologie und Pathologie des Gehirns, Virchows Arch., 1866, xxxvii, 519. Luschka: Zur lehre von der Secretionzelle, Arch. f. Physiol. Heilk., 1854, xiii, 1. Luschka: Die Adergeflechte des menschlichen Gehirns, Berlin, 1855. Luschka: Ueber die Communication der vierten Himhohle mit dem Suba- raehnoidelraume, Zeitschrift fur rationelle Medicin, 1859, Dritte Reihe, vii, 68. Magendie: Recherches physiologiques et cliniques sur le liquide cephalo- rachidien ou cerebro-spinal, Paris, 1842. Mare, See: Sur la communicationes des cavites ventriculares de I'encephale, Rev. mens, de Chir., 1878-1879. McClendon: The Formation and Composition of the Cerebrospinal Fluid, Jour. Am. Med. Assn., 1918, Ixx, 977. Meek: A Study of the Choroid Plexus, Jour. Comp. Neurol, und Psychol., 1907, xvii, 286. Mott: Cerebrospinal Fluid, Lancet, London, 1910, ii, 1; Brit. Med. Jour., 1904, ii, 1554. Olmer and Tian: Permeabilite des meninges normales au salicylates de lithium, Compt. rend. Soc. de biol., 1909, Ixvi, 894. Pettit and Girard: Sur la function Seeretoire et la morphologie de plexus choroides, Arch, d' Anat. Micro., 1902-1903, v, 213. Rous: Clinical Studies of the Cerebrospinal Fluid, Am. Jour. Med. Sc, 1907, cxxxiii, 567. Reichardt: Zur Entstehung des Hirndrucka bei Hirngeschwiilsten und an- deren Hirnkrankheiten und fiber eine bei diesen zu beobachtende beson- dere Art der Hirnschwellung, Deutsoh. Ztschr. f. Nervenh., 1905, xxviii, 306. 48 CEREBROSPIKAL FLUID Schlaepf er, V. : Ueber den Bau und die Funktion der Epithelzellen des Plexus ohoroideus in Beziehuny zur Granuladehr und mit besondere Beriick- siehtigung der Vitalen Farbungsmethoden, Beitr. z. path. Anat. u. z. allg. Patli., Suppl. vii, 101. Schmidt, Carl: Charakteiistik der epidemischen Cholera, Leipzig und Milan, 1850, 148. Schmorl: Liquor eerebrospinalia und Ventrikelflussigkeit, Verhandl. d. deutsch. path. Gesellsch., Eilang-en, 1910. Sieard: Les injections sous-araelmoidiennes et le liquide cephalo-rachidien ■dans les maladies mentales. Bull, de la Soc. med. des hop. de Paris, June, 1901. ■- Spina: Untersuohungen iiber die Resorption des Liquors bei normalen und erhbhten intrakrauiellen Druck., Arch. f.d. ges. Physiol., 1901, Ixxxiii, 120. Spina : Experimentelle Beitrage zur Kenntniss der Hyperamie des Hirna, 1898, Wien. med. Bl., 247. S.pina: Tiber den Einfluss des hohen Blutdruckes auf Cerebrospinal Mussig- keit, Pflugerg Arch., 1900, Ixxx, 370. Sundwall: The Choroid Plexus with Special Reference to Interstitial Granular Cells, Anat. Rec, 1917, xii, 221. Weed: Studies on the Cerebrospinal Fluid, Jour. Med. Research, 1914, xxxi, 1. Weil and Kafka: tJber die Durchgangikeit der Meningen, besonders bei der progressiven Paralyse, Wien. klin. Wehnsehr., 1911, xxiv, 335. Weil and Kafka: Weitere Untersuohungen iiber den Hamolysingehalt der Zerebrospinalfliissigkeit bei akuter Meningitis und progressiver Paralyse, Med. Klin., 1911, vii, 1314. Yoshimura: Das histochemische Verhalten des menschlichen Plexus choroideus, Obersteiner 's Arbeiten, 1910, xviii. Zalozieeki: Zur Frage der Permeabilitat der Meningen insbosondere Im- munstoffen gegeniiber, Deutsch. Ztschr. f. N'ervcnh., 1913, xlvi, 195. Ziegler: Beitrag zur Anatomie des Plexus chorioideus Deutsch. Ztschr. f. Chir., 1902, Ixvi, 509. CHAPTER III METHODS OF OBTAINING CEREBROSPINAL FLUID FROM THE LIVING BODY Before the day of spinal puncture the removal of cere- brospinal fluid from the body was effected with a great deal of difficulty. The usiial method of removing cerebro- spinal fluid from dogs was by means of a fistula between the occiput and the atlas. From human beings cerebro- spinal fluid was obtained through an accidental flow of fluid from the nose or ears. There are about twenty such cases on record. Another way of obtaining cerebrospinal fluid from the living body, but one used only very rarely, was an open operation either on the head or on the vertebral column. At present there are two reliable methods in use for the removal of cerebrospinal fluid from man or animal. One is spinal puncture, more properly called, lumbar puncture, and the other is cranial or ventricular puncture. Both procedures are comparatively simple and can be carried out under ordinary conditions at the hospital or at home. Lumbar puncture is preferable for many reasons. We shall, therefore, discuss it more exhaustively. LUMBAR PUNCTURE The first lumbar puncture by Quincke in 1891 was done for therapeutic purposes. Since his time, however, we have learned a great deal about the value of lumbar punc- ture for diagnostic as well as for therapeutic purposes. Therapeutically, lumbar puncture is done for the relief of increased intracranial pressure as in hydrocephalus, de- lirium tremens, eclampsia, encephalitis and other eon- 49 50 CEIU'^r.liOSlM NAL FLl'in Yulsivc condilioiis. Of .i^rcal ^■alue is lumbar pmieture for the inir]i()S(' of iii.jeeliu.n' scrum iu eases of epideiuic meuin- oitis. and for the Swift-h'llis treatmeut of syphilis. Luiii- ])ar puuclure is also done liy souie for the relief of geueral edema iu eases of uepliritis. Kceeutly, .1. M. Brady re- Fig. x, — SlU'i'iiiU'n illiistratinK 1 hr imii'iiiaiu'c nl spinal piiiu-tnr.' fur iliagimstic lUir- poses. S. e. rnlrrr.l (lie Imspital with s\-ini)t( mis nt |inciniiiniia ami uitii iiiarla'it cyanosis. Al lirsl sl^lil tlieri.' sia-iiird In In- iin iiiiiicalinii fnr a spinal imiicture, lint wlifii cniiviilsinns srl 111. ri. piincliirc was ilmic, Tlu' liuiii \vi llui rawii was very iLirliid and shnw'ril piiriiiiinrncri in iliiijct siiir.ai' .is wi'll ,as in culturn. The liostmortcm sliowed a wcll-ileliiusl cMiil.aU' nf iIk' nu'iiiii^cs. Ilir r.xiniaic C(intainiii>^ many pneuniococci. ]>(irl(Ml lliicc cases of iiiciiiiiu'eal hemorrhai;*' which recev- ei'cd after iimihai' |imicliire. Cure by spiual ])iuicture lias also heeu re])()rted in two cases of diaheies iusi])idus. As a general rule, llieicfoi-e, a spiual puncture sliould he made LlTiVLBAE PUNCTURE 51 in all cases showing- signs of increased intracranial pres- sure. Diagnostically, lumbar pnnctnre is of great value in cerebrospinal lues, liemorrliage of the brain, tumors of the cord, poliomyelitis, etc. It is particularly valua1:)le in tlie diagnosis of all forms of meningitis and poliomyelitis. ■^4 jMg. y, — Oiiiiosifc vi^'w rif Fig. S, (Sic i'"ig. 8 for dcscriplioTi. ) The following eases are cited to sliow how important a diagnostic measure spinal puncture may be: S. C, entered tlie Juispital with symiitdins of pneumonia and cyanosis. The lung hudings were iiuh'finitc. There was very little rigidity of the neck and no other syiiiptonis pointing to a meningitis. At first sight there seemed to be no indication for a spinal puncture, but when convulsions set in a puncture was made. The tiuid withdrawn was turbid and showed pneumococci in smear and culture. The postmortem showed the lungs to be congested, but no pneumonia. The cerebrum, however, was covered 52 CEREBROSPINAL FLUID with a gelatinous, greenish gray, purulent material several millimeters thick and very Arm; the exudate was located on the upper and lateral sur- faces of tlie brain. (t'lRS. 8 and 9.) The smears as well as the cultures showed gram-positive cocci. Although in this case not much couhl be done therapeu- tically even if the process had been recognized earlier, the spinal puncture was of great value. It served to es- tablish a positive diagnosis in a case in which a meningeal exudate existed with few if any of the meningea,l symp- toms that usually accompany such a condition. The case that follows illustrates even more vividly the importance of lumbar puncture: S. W., ten years old. Sick for five days. Complained of pain in lumbosaoraJ region, and also in the right hip, radiating to the sole of the foot at the time; occasionally there was pain in the left shoulder. When first seen the temperature was 102° F. There was tenderness to touch in the lumbo- sacral and gluteal regions, slight rigiditj^ of the neck, slight Kernig and contralateral Brudzinski signs. The diagnosis by several physicians was neuritis. On lumbar puncture a very turbid fluid was obtained under great pressure. Bacteriologic examination showed meningococci and several hun- dred cells per cubic millimeter. All globulin tests were positive. The patient was given several doses of antimeningococeus serum and recovery followed. In tliis case lumbar puncture was a life-saving measure. In the next case meningitis could hardly have been discov- ered without lumbar puncture as the general symptoms were so indefinite. F. R., aged eight months. Sick one day with fever and constipation. Had attack of cyanosis for a few minutes. General examination was nega- tive. Lumbar puncture was done and to the great surprise of the physicians, the fluid was found very turbid and full of meningococci. These cases are but few of a great number coming under my observation that illustrate the extreme importance of lumbar puncture. There are very few counterindications to lumbar punc- ture. In cases of tumors of the cerebrum and cerebellum, it is true that puncture is not so safe as under ordinary conditions. Even then, however, a lumbar puncture may be done with little trepidation if the pulse and reflexes of LUMBAR PUNCTUKB 53 the patient are watched and if the amount and pressure of the cerebrospinal fluid are closely observed. Untoward Effects of Lumbar Puncture Cases of death from spinal puncture have been reported. These, however, usually occurred in cases of brain tumor, and death in most instances was attributable to shock. Of the many hundreds of punctures that have come under my observation, I saw only one case of death during puncture. Of other dangers attending spinal puncture the following may be mentioned: Piercing of the aorta, injury to the nerves, and breaking of the needle. As to piercing of the aorta, it must be said that this is a very rare occurrence, and when it does happen it is due to poor judgment on the part of the operator as to the depth to which the needle should be introduced. Injury to the nerves is a complication that can easily be averted if the puncture is made at a low level in the lumbar region, preferably between the third and fourth vertebrae. Brealdng of the needle may result from undue force. If the needle is broken directly beneath the skin, it is best to incise the skin and remove it. If it is broken deeper, how- ever, which is generally the case, it is best to leave it alone for a while. If no complications occur in several days, it is advisable to leave the needle in. If severe pain or sup- puration occurs, a radical operation should be done and the needle removed. There are some less severe complica- tions that may follow lumbar puncture. The most impor- tant of these are headache following the puncture, pain of the lower extremities, and edema of the skin, especially af- ter repeated punctures. The cause of headache after lumbar puncture is a mat- ter of speculation. It is generally attributed to the re- moval of too great an amount of fluid at one sitting. Head- ache, however, sometimes follows even after the removal of a small amount of fluid. MacRobert has recently sug- 54 CEREBROSPINAL FLUID gested that headache following lumbar puncture may be due to the nonclosxire of the puncture hole in the arachnoid. The arachnoid tissue in a case of this kind, the author says, is pulled through the dural opening when the needle is withdrawn. This results in prolonged epidural leakage and in the lack of support of the medulla, a condition which gives rise to severe headache. This explanation sounds plausible although it requires corroboration be- fore we can accept it. When headache does occur after lumbar puncture the best method of treatment is to put the patient flat on his back for several hours. Oc- casionally it becomes necessary to resort to drugs for re- lief of the condition. Sodium and potassium bromide or salicylates may then be employed. Rarely is it necessary to use stronger remedies than these. Pain of the extremities after lumbar puncture is usually due to injury of one of the filaments of the cauda equina. Eest in bed is usually all that is necessary to relieve this condition. Edema of the skin in the lumbar region is an infrequent complication. I have seen it in but two cases and then after repeated punctures. When it does occur in infants, the lumbar region should be given a rest and if necessary to introduce serum, it should be injected into the ventricles of the brain instead. When edema of the skin occurs in adults, warm cloths should be applied to the edematous re- gion and serum given intravenously until the edema sub- sides, after which intraspinal introduction of serum may be resumed. In general, lumbar puncture wlien indicated should not be feared because of complications. Technic of Lumbar Puncture To do a spinal puncture properly one must take into con- sideration a number of important factors. 1. The anatomic relations of the cord and its membranes at the lumbar region. LUMBAR PUXCTI'RE 55 Tlie cord, in the adult, ends at the first Iiiniliar vertelira, and in the child, at the second vertebra, seldom at the third. {'ly:. 10. — Section of canda L-(|inna of a dog. A. Membranes intact; B, Dura and arachnoii cut open. 56 CEREBROSPINAL FLUID The cord has its ending in the conus meduUaris, the apex of which is continuous with the fiilum terminalis. Through- out its entire length the cord is surrounded by three mem- branes, the dura, the arachnoid and the pia. The accom- panying drawing (Fig. 10) shows the membranes surround- ing the cord and the cauda equina in a dog. The same re- lations also hold good in man. 2. The structures encountered between the skin and the cord, which are as follows from without inward: (a) Skin. Subcutaneous fascia. Fat. Deep fascia. Multifidus muscle. Vertebral arches. (b) (c) (d) (e) (f) (g) (h) (i) Ligamentum flavum. Dura. Arachnoid. Fig. 11.— Plexus of veins, the puncture of which is responsible for blood obtained during spinal puncture. (Gray's Anatomy.) 3. The plexus of veins on the posterior wall of the body of the vertebra (Fig. 11). If these are struck by the spinal puncture needle the resultant fluid is bloody. Another matter for consideration in lumbar puncture is the position of the patient, particularly if the patient is a child. While in an adult the physician may do the LUMBAR PUlSrCTURE 57 puncture with the patient in either the sitting or reclin- ing position, in a child he should not attempt the punc- ture with the patient in any but a reclining posture. In all cases of meningitis the patient should be in the lying posture when the puncture is performed. I always made it a practice to puncture with the patient in a recumbent position. The patient may be placed on either right or left side, the right being the preferable one for the pa- tient, who should be arched so as to widen the interverte- bral space. The skin should be prepared very carefully for the punc- ture. Soap and water, alcohol and iodine should be used for cleansing purposes. Eubber gloves should be worn and all other aseptic precautions must be taken to minimize the danger of infection of the meninges. As a rule neither a general nor a local anesthetic is called for in doing spinal puncture. It may be necessary to resort to an anesthetic in maniacal cases, although I have not encountered a single case in which I could not get along without it. Sophian suggests that the patient be given water to drink during lumbar puncture. He found that this procedure made an anesthetic unnecessary. As a rule, however, even this is not necessary. The Spinal Puncture Needle Eegular spinal puncture needles are now made measur- ing from 7 to 9 cm. in length and 0.6 to 1.2 mm. in thick- ness with a stylet to fit the needle (Fig. 12). Some needles are made Avith valves for the measurement of the pressure of the fluid. Most needles on the market are made of steel, although there are some nickel-plated ones and some made of platinum iridium. If meningitis is not suspected a nee- dle with a small lumen will do, but if there is the slightest suspicion of meningitis a needle with a large lumen should be used. In children it is always best to use a needle with a large lumen, so that in case the fluid is thick it will not 58 CEREBROSPINAL FLUID clog up the needle. The needle should be boiled and cooled before using. It should also be examined A^ery closely for rust. Quincke's advice that the needle be introduced directly in the midline in children and 5 to 10 mm. to the side in M I J.. iliiiiMiniiiili Fig. 12. — \'arious types of lumbar puncture needles. adults, holds good to this day. If the needle is inserted in the third or fourth interspace, cerebrospinal fluid may be withdrawn without injury to the nerves. A good landmark for the guidance of the needle may be made by drawing LUMBAR PUNCTURE 59 a horizontal line through the vertebral column across the crests of the ilium. I usually draw this line with tincture of iodine on a swab. This strikes the interspace between the third and fourth vertebra. It is often quite difficult to feel the intervertebral space in fat people and in very young children. Because of this difficulty extreme care is necessary in cases of this kind. "How much of the needle should be introduced into the canal?" is one of the first questions that greets the inex- perienced operator. In consulting literature on the sub- ject I found very little information about the length of the needle, the only tabulated data available being by Quincke, who, however, cites only a few cases. Table I Measukements by Quincke AGE DEPTH 11/^ years 2. cm. 7 t ( 2.5 i t 3. t i 3. t i 2.7 (3.5) cm. 3.2 2 1 1 2.5 1% ft 2. 25 1 1 1.5 6. 6.5 (4.7)" 39 it 5 plus " 22 1 1 5.2 i I I measured the length of the needle in a series of several hundred cases, adopting the following procedure: When ready to remove the needle from the spinal canal after ob- taining a good flow of fluid, I grasped the needle close to the patient's skin between the thumb and index finger, pulled it out, and measured it from the point held by the fingers to the tip. 60 CEREBROSPINAL FLUID Table II Measxikements or Needle in Children NAME AGE LENGTH OF NEEDLE IN CM. R. R. 4 : months 2.0 E. D. 5 1 1 2.2 A. J. 6 it 2.0 A. S. 6 a 2.3 L G. 6 tt 2.5 E. H. 7 1 1 2.5 E. G. 8 i t 2.4 E. G. 9 ii 2.2 A. C. 12 li 2.2 S. K. 12 1 1 2.0 A. N. 14 1 1 2.8 A. N. " 14 1 1 2.5 J. S. 21 li 3.5 M. M. 22 1 1 3.0 T. K. 2 years 2.7 T. K. o t i 2.1 R. P. 2 " 7 mos. 2.4 r. w. 3 ( I 4.0 J. M. 3 t( 2.0 M. H. 3 i I 2.8 M.K. 3 i ( 2.9 McM. 4 I C 3.2 H. 4 i ( 2.9 P. 0. 4 ti 2.8 W. J. 5 I I 3.2 R. L. 6 I I 3.0 A. G. 7 tt 4.0 G. M. 8 (t 3.5 S. L. 8 (( 3.5 S. B. 9 I i 3.7 S. B. 9 it 3.4 S. B. 9 t t 4.0 E. D. 9 I t 3.8 R. A. 10 t t 3.6 L. G. 12 t I 3.2 L. G. 12 t t 3.6 Table II gives the measurements of the needle made in chiklren from four months to tAvelve years of age and Table III gives the measurements in adults of various ages. I in- clude here but a few of tlie several hundred of measure- ments made. In cases in which the results were similar I tabulated but one measurement; in cases of the same age LUMBAR PUNCTURE 61 Table III Measurements op Needle in Adults AGE length of needle in cm. S. G. 16 T. R. 20 C. 25 P. 26 K. 27 Mrs. D. 29 L. 29 A. C. 30 E. 30 D. 30 H. 30 E. 30 A. C. 30 T. 31 J. T. 31 Mrs. D. 32 A.C. 33 L. N. 33 M. 34 P. 34 S. G. 34 S. 34 M. 35 M. 35 E. 35 H. 36 M. W. 37 I.G. 37 D. 37 8. S. 38 J. J. 39 S. 40 P. 40 M. 40 W. 40 E. 40 E. 42 W. 43 K. 43 M. B. 44 J. A. 44 W. 44 S. 45 F. 46 Mrs. B. 48 M. 48 years 5.4 4.8 5.0 5.3 5.8 4.9 5.5 5.6 4.5 5.4 5.2 5.8 5.6 5.5 10.0 5.1 4.1 5.1 5.1 5.2 4.5 4.6 5.7 4.8 5.5 4.1 5.3 5.5 5.9 5.0 7.0 6.0 6.4 4.9 5.0 6.4 5.0 6.3 4.5 4.9 5.8 5.5 5.5 4.9 4.9 5.3 (very fat) (very fat) ^Cont'd p. f)2) 62 CEEEBROSPINAL FLUID Table TII- -Cont 'd Measurements of Needle IN Adul TS NAME AGE . LENGTH OP NEEDLE IN CM. L. 48 years 5.5 S. 52 " 5.2 E. 53 " 5.1 B. 53 " 10.0 (very fat) B. 53 " 6.0 H. 54 " 5.2 W. 55 " 5.3 s. 55 " 6.7 D. 57 " 5.4 A. 57 " 5.6 M. E. 60 " 4.1 F. 60 " 5.9 K. 60 " 6.0 B. 60 " 5.9 S. 61 " 5.9 W. 65 " 8.0 where tlie measurements were different several measure- ments are tabulated. In some cases the results of several measurements are given for the same patient to show the length of the needle at different punctures. As is seen from the tables the needle requires a length varying from 2.0 to 4.0 cm. in children up to twelve, and a length varying from 4.1 to 10 cm. in people over sixteen years of age. The variations in the adult may be attributed to several fac- tors. Physique is one; the direction taken by the operator in inserting the needle is another, an oblique insertion nat- urally requiring a greater length of needle than a straight insertion. The location of the interspace is another fac- tor, the higher the point of insertion, the greater being the length of the needle required. Some clinicians use as the place of introduction the space between the second and third lumbar vertebrse, others the space between the first and second. It is also interesting to note that the length of needle inserted varies at different punctures in the same patient. This is due to the fact that the canal is quite wide and that fluid may l)e removed whether the nee- LUMBAR PUNCTURE 63 die is near the anterior or near the posterior surface of the canal. When the needle passes the dura, a snap is felt. The stylet should then be removed and the fluid allowed to run into the pressure apparatus or into tubes. Reasons for Failure to Obtain Fluid There are times when no fluid can be obtained in spite of all efforts. Among the factors responsible for the failure to obtain fluid, the most important are the following: 1. The needle may not have been inserted far enough into the canal. 2. The needle may have been introduced too far into the canal. In such cases the material exuding from the inter- vertebral disc may clog up the needle. 3. The presence of blood in the fluid. The presence of blood is by far the most common cause of failure in lumbar puncture. It may be due to hemor- rhage of the brain or to piercing some vein of the plexus in the spinal canal. If the presence of blood in the fluid is due to the striking of the plexus of veins, the exuding fluid has the color of fresh, venous blood. If it is due to a hemor- rhage, the blood in the fluid is a dark red, and if the hemor- rhage is one of long standing, clotted particles of blood may be seen clinging to the needle or coming out of the lumen. If no fluid is obtained the stylet should be reintroduced into the needle to clear it of any particles that may be clogging the lumen, and it should then be withdrawn again. If there is still no sign of fluid the needle should be moved a little deeper or withdrawn slightly. If fluid is still not forthcoming, the needle should be removed and reintro- duced one space higher. If after this procedure there is still no fluid an ethylchloride spray applied to the thigh may accelerate the flow. If after repeated trials no fluid escapes, one may ascertain whether the spinal canal has 64 CEREBROSPINAL FLUID been reached by the following method: The first needle is left in its original position, and a second needle is intro- dnced one space higher. A solution of sterile salt is in- jected into the higher needle. If the first needle is in the canal, the salt solution will flow out of it. When this hap- pens it indicates that in all probability no fluid can be ob- tained. As a rule one should be careful about pronounc- i]]g a puncture dry. A failure to obtain fluid may nearly always be attributed to some fault in the technic. If the case shows symptoms of meningitis in spite of the fact that no fluid can be obtained by the spinal route, it may concern a basilar meningitis in which it often happens that the connection between the brain and cord becomes clogged. In such a case ventricular puncture should be done. The technic of ventricular puncture will be de- scribed later. Pressure The measurement of the pressure of the cerebrospinal fluid is very significant from the standpoint of diagnosis as it furnishes an almost immediate clew as to the existence of a pathologic condition. It should, therefore, be used in connection with lumbar puncture whenever possible. Various forms of apparatus have been described for the determination of the cerebrospinal fluid pressure. Quincke used an ordinary glass tube with a one-millimeter bore bent at the top, and an ordinary tape to measure the pres- sure : an arrangement like the one used by Quincke may be made at any laboratory by taking heavy glass tubing of one-millimeter bore, bending it at right angles below, and connecting it with hard rubber of one-millimeter bore to a tip fitting into an ordinary spinal puncture needle. The point to which the fluid reaches can be marked off and the height can then be measured on a slide or with a tape meas- ure (Fig. 13). I used this arrangement for some time, but although it is of value, it is not accurate enough. The LTTMBAR PTTNCTURE 65 disadvantage of the Quincke apparatus lies in the fact that it talves too mucli time to attacli tlie glass tuhing to the needle. It frequently liapi^ens that the pressure of the Fig. 13. — Modified (Juinclcc aiiliaratus fur nic-asur tlie cercliruspinal fluid pressure. fluid is so great that as soon as the stylet is removed from tlie needle, the fluid bursts out, and several cubic centime- ters of fluid are lost before the tip of the pressure ap- paratus can be connected to the needle. In tliis way the 66 CEREBROSPINAL FLUID real pressure value can not be ascertained, as it is known that once a few cubic centimeters of fluid are removed, the oi'iginal cerebrospinal pressure is not maintained. Several other types of apparatus have been described. One is by Kroenig, utilized principally for the purpose of withdrawing fluid from suspected cases of brain tumor. The caliber of the measuring tube is so small, that it only takes a few drops to fill it, and when the column of fluid shows no oscillation, no more fluid should be withdrawn. Some authors have used a mercury manometer. In nor- mal cases, however, I have found the pressure to be too small to be measured in millimeters of mercury, as each millimeter of mercury corresponds to 13 mm. of water. Thus, for instance, when the pressure of the fluid is 65 mm. of water, the mercury manometer registers only four and one-half or five, making too great an error in the reading. As for the objections raised against the ordinary one mm. bore that it is too small and that it exerts capillary trac- tion, it must be said that after all since the value of pres- sure reading lies in the comparison between the normal and pathologic capillary traction' is not a great factor. In my experiments on pressure I have been using an ap- paratus which allows no loss of fluid and which has the added advantage of being simple. The apparatus (Fig. 14) consists of a specially devised needle and a glass manometer. The needle is the ordinary, medium-sized, spinal punc- ture needle with a short piece of glass mounting. The glass tubing enables one to see whether the spinal canal has been reached with the first puncture. In the ordinary spinal puncture needle, one must withdraw the stylet en- tirely before one can see whether or not the spinal canal has been reached, thus running the risk of losing some fluid before the pressure can be measured. With the glass tub- ing on, one need only withdraw the stylet beyond the glass tubing, and if the spinal canal has been reached, the fluid LUMBAR PUNCTURE 67 withdrawn will be seen immediately tlirougli the glass. On the other hand, if no fluid makes its appearance, the stylet can be inserted again and another attempt made. i'"ig, 14. — Author's spinal puucture needle and manometer; A, glass tubing in the needle; B, stoptock; C, upper! projection of the needle into which the manomfeter is in- troduced; D^ glass manometer. The fear of breaking the glass on boiling the needle and sterilizing it is not a very strong objection. I have boiled needles, repeatedly, without ever breaking the glalss. 68 CEREBROSPINAL FLUID The glass tubing may be slipped into the needle instead of being mounted, making possible the use of any form of spinal puncture needle. At the distal end of the glass tub- ing the needle has a three-way stopcock, the distal end of which is about three-fourths of an inch long. This length is required in order to allow space from the stopcock to the end of the needle so as not to lose any of the fluid as is the case when the valve of the stopcock is near the end of the needle. The stylet of the needle is long enough to reach from the distal to the proximal end of the needle. The manometer consists of a long glass tube of one mm. bore which is inserted into the projecting end of the nee- dle. The glass tubing is 800 mm. long as this was the highest pressure attained in any case, and for convenience sake, it is divided into two portions with a metal cap at the top of the first portion so that the other one can be screwed on. This makes it convenient to carry the manom- eter in any small instrument case. Thick glass tubing is used for it so that it does not break easily in handling. A metal tape is attached to the glass to measure the pressure. This, however, can be done away with and a ruler used in- stead, or have the glass tuliing graduated. The needle (with the piece of glass tubing at the end, the stopcock and its prolongation with the stylet inside) is in- troduced into the spinal canal. After a snap has been felt, so that one is reasonably certain the subdural canal is reached, the stylet should be removed to a point beyond the glass attachment. If fluid is seen in the glass tubing, the stopcock is turned at right angles so that the handle points upwards. The long glass tube is then attached and the stopcock turned so that the handle points opposite the manometer. The fluid will then rush into the tube. When the fluid has mounted to the highest point, the pres- sure is read off in millimeters of water. If no fluid is seen coming out when the stylet is removed beyond the glass tubing, the stylet should be reintroduced until the operator LUMBAR PUBTCTURB 69 feels it is in the cajial. It should then be removed beyond the glass and the measurement taken. The handle is now turned parallel to the needle and the fluid is collected in test tubes. The whole needle, including the glass attach- ment, stopcock, and prolongation is not any heavier than an ordinary medium-sized spinal puncture needle. If no pressure apparatus is available, counting the drops and noting the force with which the fluid comes out from the needle will give a clew to the pressure, anything above ten drops per minute indicating an abnormal condition. I should like to remind the reader once more that the pres- sure must be taken at the very beginning, as after several cubic centimeters of fluid have been removed, the pressure lets up and determination then becomes practically value- less. Collection of the Fluid Some persons collect cerebrospinal fluid in graduated medicine glasses, so as to be able to measure the exact amount. This method of collection, however, is not advis- able as it is hard to keep the fluid sterile in a wide glass, and it is also hard to observe the characteristic pellicle. I therefore, advise the collection of cerebrospinal fluid in test tubes. The test tubes in which the fluid is to be collected should be sterile and chemically clean. It is best to use tubes of uniform size. The glass of the tube should not be too thick and its opening should be stoppered with a cotton plug, unless special tests requiring a slow escape of CO2 are to be made. For the sake of uniformity and because of the difference in the cell content of various portions of the cerebrospinal fluid, the following method has been found useful in cases where a quantity greater than 5 c.c. of fluid is withdrawn : ■ Several drops of the fluid are allowed to run out of the needle to make sure that the fluid is free from blood. The 70 CEEBBEOSPINAL FLUID entire amount is then collected into three tubes of uniform size. In the tirst test tube is run the first 2 c.c. of fluid. This amount is used for several different examinations: (1) cytologic examination; (2) direct smear for microT organisms if the fluid is turbid; (3) cultures; (4) 1 c.c. for the permanganate test. The contents of the first tube should be examined immediately. If it is not examined immediately, the test tube with its contents should be placed in the incubator. In the second test tube, 3 to 5 c.c. of fluid is collected. If the pressure is not increased the contents of this test tube should be used for the globulin tests, Wassermann and Lange. If the pressure is increased the test tube should be put into a tube rack for the formation of a pellicle. Care should be taken that the mixture is not disturbed. If there is a large amount of fluid present a third and fourth tube should be taken. Into the third tube should be run from 5 to 8 c.c. of fluid. This fluid should be used for (1) the second portion of the permanganate test; (2) the Eoss-Jones, Noguchi and Nonne, and the sulphosali- cylic-mercuric chloride tests; (3) Lange test; (4) Wasser- mann test; (5) sugar content; (6) centrifugation, for the examination of organisms. Into the fourth tube should be run all the rest of the fluid desired for collection. In normal cases where the pressure is not increased only 5 to 10 c.c. of fluid should be withdrawn. In all cases of increased pressure a greater quantity of fluid should be removed. In delirium tremens, 10 c.c. usually suffices to quiet the patient. In meningitis, 15 to 40 c.c. may be with- drawn on account of the greatly increased amount of fluid in the canal. Even in the severe cases of meningitis, how- ever, it is not advisable to remove more than 40 c.c. at one sitting on account of the danger of inducing shock. The quality of the pulse is a good guide as to the amount of fluid to remove. LUMBAR PXJNCTUEE 71 A'fter the needle is withdrawn collodion should be put on the wound and the skin should be washed off if iodine has been applied before the puncture. The patient should be put to bed immediately after the puncture to prevent headache or dizziness. CRANIAL PUNCTURE When no cerebrospinal fluid can be drawn by way of lumbar puncture and it is found urgent to obtain some for diagnostic or therapeiTtic purposes as is the case when meningitis is suspected or present, cerebrospinal fluid may still be obtained by cranial routes, either from the sub- arachnoid of the brain or from the ventricles. The amount of fluid obtainable from the subarachnoid space at best is small and the procedure is difficult. It is therefore always advisable to remove the fluid from the ventricles. The technic employed for a ventricular puncture in infants when the anterior f ontanelle is not yet closed, is as follows : The patient is placed on the back with the head close to the edge of the table. The head around the region of the anterior fontanelle is shaved, and washed Avith alcohol and ether. Iodine is applied to the surface. The needle to be used should be sterilized and all other necessary aseptic precautions should be taken. A short spinal punc- ture needle or an ordinary Luer needle should be used. The stylet should be left in the needle the same as in lumbar puncture, for if the stylet is removed brain tissue may clog the needle and prevent the flow of fluid. The needle should be introduced from 1% to 1% inches deep and the stylet re- moved. The needle should be inserted into the anterior an- gle of the anterior fontanelle, in a somewhat oblique direc- tion, a little to one side of the median line (Figs. 15 and 16) as piercing of the longitudinal sinus will give blood in the fluid. After the desired amotmt of fluid is obtained, the needle is removed and collodion applied to the punctured surface. 72 CEEEBROSPINAL FLUID 111 adults, cranial puncture is most generally made for therapeutic purposes, especially for the relief of intra- cranial pressure. It necessitates the use of a hore or a tre- phine to get through the skull. The method used is that of Kocher, consisting of a trephine opening 2. .5 cm. from the Fig. 15.— rhotograph showing ventricular puncture in infant. Dark circular spot shows needle in position. (Front view.) mcdinn line and 3 cm. in front of the coronal or frontopa- rietal suture. The needle is then passed inward and slightly backward for a distance ol' 4 or 5 cm. when the lateral ven- tricle is reached. The ()])erati()n, in general, is a rather complicated one and calls for precision and careful LUMBAR PUNCTUEE 73 surgical teclmie. It should tlierofore l)e used only avIiou absolutely necessary. The rule should l^e to do a luml:)ar puncture whenever possi))le, but when fluid can neither be obtained nor introduced Ijy way of lunil^ar puncture, then ventricular puncture should be made, especially in the case op infants. Fig. 16. — Photograjjh shuwing \'fntriciilar jmncture in infant. (Siilc view.) Bibliography Br;idy: Lumbar Punetuve in Meningeal Hemorrhage of the New Born, Jour. Am. Med. Assn., 1918, Lxxxi, 347^ OurscJiman: Ciier die theraiieutisidie Bedeutung der Lumlial|>uiilitioii, Die Therapie der Gegeuwart, 1912, lii, 242. Punkliauser: Erfahru7igen iilier Lunilialjmnlvtion liei Gei.stesliraiikcn, Kor- respondeiizl J. f. Sehweiz. Arzte, 1907, xxvii, 3.3. Graham: Spinal Puncture in JJialietes Insipidus, .Jour. Am. Med. Assn., 1917, Ixix, 1498. 74 CEREBROSPINAL FLUID Gumpreclit : Gefahren bei der Lumbalpunklion plbtzliche Todesfalle darnaeh., Deutsch. med. Wchnaehr., 1900,. xxvi, 386. Juvara: Topographie de la region loml)aire en vue de la ponction du canal rachidien, Semaine mfid., 1907, No. 9. Kvoenig: iJbei- Lumbalpunktion bei Eolampsie, Zentralbl. f. Gynak., 1904, xxxix, 1153. Kroenig und Gauss: Anatomisclie und physiologisehe Beobaehtung eraten tausend Riickenmaiksanasthesien Miinchen. med. Wchnsehr., 1907, liv, 1969. Lcvinson: Measuvements of the Spinal Puncture Needle, Jour. Lab. and Clin. Med., 1917, iii, 127. Levinson : An Improved Si-inal Puncture Needle and Pressure Apparatus, Jour. Am. Jled. Assn., 1919, Ixxii, ?,U. MacEobert: The Cause of Lumbar Puncture Headache, Jour. Am. Med. Assn., 1918, Ixx, 1350. Neisser and Pollak : Die Hirnpunktion und Punktion des Gehims und seiner Haute durch den intakten Schadel, Grenzgebiete der Mediz. und Chirurg., 1904, xiii, 807. Ossipow: Tiber die pathologisehe Veranderungen welche in dem Central Ner- vensystem von Tieren durch die Lumbalpunktion hervorgerufen werden, Deutsch. Ztsehr. f. Nervenh., 1901, xix, 105. Pfeiffer : Tiber explorative Hirnpunktion zur Diagnose von Hirn, Arch. f. Psych, u. Nervenh., xlii. No. 2. Quincke: Tiber Hydrocephalus, Verhandl. d. Cong. f. inn. Med., 1891, x, 321. Quincke: Die Teohnik der Lumbalpunktion, 1902. Quincke : Ueber Lumbalpunktion, Deutsch. Klin., 1906, vi. Schemensky: Lumbalpunktion bei Typhus, Deutsch. Med. Wchnsehr., 1915, xli, 696. Skoog: Cerebrospinal Fluid Pressure, Jour. Am. Med. Assn., 1917, Ixix, 1064. CHAPTER IV PROPERTIES OF NORMAL CEREBROSPINAL FLUID The term "normal" as applied in the literature to cere- brospinal fluid is often misleading. The mere fact that cerebrospinal fluid has been removed from a living person is indicative of the presence of some abnormality of the nervous system that prompted the puncture. Often the bac- teriologic and qualitative chemical tests on a given specimen of fluid are negative, yet quantitative chemical analysis will show an alteration in the chemical or physical chem- istry of the fluid. Furthermore, fliiid removed postmortem can hardly be considered normal, for it has usually under- gone marked chemical and physicochemical changes be- fore examination. For instance, fluid removed postmortem has been shown by Myers to contain three and one-half times as much potassium oxide as fluid removed during life. I also found a marked difference between fluid removed during life and after death. In the former case the fluid was slightly alkaline and in the latter, distinctly acid. "Normal" as applied to cerebrospinal fluid should, there- fore, be considered merely as a relative term; the term " nonmeningitic " perhaps would be still more accurate to designate the condition of the fluid where there may be some pathologic condition of the nervous system, such as brain tumor, hydrocephalus or the like, but no involvement of the meninges. In the discussion following in this chapter I shall state so far as possible whether the cerebrospinal fluid under discussion was withdrawn during life or postmortem, and whether it was obtained by lumbar or by ventricular punc- ture. I shall also endeavor to indicate the diagnosis of the respective cases so that the reader may be able to form an opinion regarding the type of the fluid in question. 75 76 CEREBKOSPINAL FLUID PHYSICAL PROPERTIES Amount The amount of fluid normally present in the ventricles and in the subarachnoid space has been variously stated. Contugno found between 125 and 156 c.c. in both; Magendie found between 62 and 372 c.c; Luschka found only 25 c.c. According to Magendie, the normal amount of cerebro- spinal fluid in a medium-sized man is 62 c.c. Of this amount, Magendie says, the ventricles contain from 20 to 30 c.c, and the subarachnoid space of the cord the greatest part of the remainder. It may be interesting to note that al- though there is from 60 to 150 c.c. of cerebrospinal fluid present in the subarachnoid space and the ventricles, it is generally inadvisable and often impossible to remove more than 10 c.c. of fluid from a patient at one sitting. Color Normal cerebrospinal fluid is clear and colorless, pro- vided no blood has been removed with it during the punc- ture. The fluid does not change color upon standing if it is corked with a cotton plug, unless, of course, it has be- come contaminated by bacteria or moulds, in which case the fluid becomes turbid. Lack of Sediment Normal cerebrospinal fluid shows no pellicle or sediment of any kind. This is because of the fact that the cell con- tent, as well as the protein content, is very small, and fibrin is either entirely absent or present only in very small traces. The lack of sediment is helpful in differentiating normal or nonmeningitic fluid from fluid in cases of menin- gitis, especially tuberculous, in which the diagnosis is dif- ficult because of the clearness of the fluid. PROPERTIES OF NORMAI. CEREBROSPINAL FLUID I I Pressure Observations on the pressure of normal cerebrospinal fluid have given various results in the hands of different workers. Magendie found that the pressure of the cere- brospinal fluid is positive. Falkenheim and Naunyn claim that it is necessary for the maintenance of the blood circula- tion of the brain that the cerebrospinal fluid remain at a certain pressure and they estimate the pressure under nor- mal conditions to vary between 50 and 200 mm. of water (4 to 16 mm. Hg) for a child one month to one year of age with a correspondingly higher pressure for an adult. Quincke gives 40 to 60 mm. of water as the normal pres- sure for children, and 150 for adults; Adamkiewicz gives 80 to 100 mm. of water, and Sicard gives 200 as the normal pressure. Many factors are responsible for these discrep- ancies, the most important of them being the type of the pressure apparatus, the insertion of the needle, the age of the patient, the position of the patient during the puncture, the position of the head, the respiratory movements, and such external factors as coughing, sneezing and crying. (a) Different pressure apparatus give different pressure values. In some forms of apparatus fluid is lost and there- fore too small values are obtained. (Cf. Chapter III.) The position of the needle is also responsible for variation in pressure. A deeper insertion of the needle into the canal gives a higher pressure than a slight insertion, and vice versa. (b) Age also plays a part in the pressure of the fluid. Quincke found pressure in children to be less than that in adults. He gives 40 to 60 mm. water as the pressure in children, and 150 mm. water as the pressure in adults. I also found the pressure to be lower in children than in adults. My figures showed a pressure variation of from 45 to 90 mm. water in children in a quiet recumbent posture and 130 to 150 mm. water in adults. 78 CEREBROSPINAL FLUID (c) The position of the patient during puncture has a marked influence on the pressure, the pressure in the sit- ling position being mucli higlier than in the recumbent po- sition. Kroenig found the pressure in the lying posture to be 120 mm. of water and in the sitting posture 410 mm. of water. E. Cotton and M. C. Salz found the normal pres- sure in the recumbent position to be 200 to 230 mm. of water and in tlie sitting position to l)e 400 to 420 mm. water. I found the normal pressure in the recumbent position in children under ten to vary between 45 and 90 mm. of water and in the sitting position to vai'v between 150 and 230 mm. of water. In adults, in recumbent position the pressure varied between 130 and 150 and in the sitting position be- tween 200 and 250. (d) Flexion of the head on the chest lessens the pressure and extension of the head raises the pressure, the difference between the two varying from 150 to 230 mm. of water. (e) Magendie commented on the effect of the respiratory movements on tlie pressure of the fluid. He observed that the cerebrospinal fluid showed movements corresponding to the respiration, the pressure falling during inspiration and rising during expiration. This observation has been confirmed by many workers. I have observed it frequently. The variation between inspiration and expiration, hoAV- eyer, is small, the difference averaging from 10 to 15 mm. of water. (f) The relation between the pressure of the cerebro- spinal fluid and the pulse beat was pointed out by Falken- heim and Naunyn. This is noticeable, however, only when the pressure is high, above 300 mm. of water. (g) Coughing, crying, sneezing or any other strain may increase the pressure from 50 to 100 nmi. of water. Summarizing, it may be said that the normal pressure of the cerebrospinal fluid is influenced by many factors. As a general rule, liowever, the pressure varies from 45 to 90 mm. in children, and from 130 to 150 mm. in adults. PROPERTIES OF NORMAL CEREBROSPINAL FLTTTD 79 Table IV Cerebrospinal Fluid Pressure in Normal Individuals Expressed in Millimeters op Water Author adult child lying sitting lying sitting 40-60 Quincke 150 Adamkiewicz 80-100 Kroenig 125-150 410 Cotton and Salz 200-300 400-420 Boveri 170-200 Levinaon 130-150 200-250 45-90 150-230 These figures are for tlie recumbent position. They are very much higher for the sitting position. The '\nthdrawal of several cubic centimeters of cerebrospinal fluid lessens the pressure temporarily, but in a very short time it re- turns to normal. So it frequently happens that when two punctures are made in one day, the pressure is found to be the same in both cases. Specific Gravity The specific gravity of normal cerebrospinal fluid varies between 1.001 and 1.008. Hoppe found the gravity in a case of spina bifida to be 1.001 and in one case of hydro- cephalus to be 1.005. Halliburton found the gravity of normal fluid to be 1.007 to 1.008, and Kafka found it to vary between 1.002 and 1.008. Zdarek gives the specific gravity of normal cerebrospinal fluid as 1.0078, Polanyi as i:012 (15 degrees); 1.007 and 1.005. Mestrezat found it to be 1.0076, and Nawratski found it to be 1.0073 to 1.008. In a series of nonmeningitic cerebrospinal fluids examined by the pyknometer I found the specific gravity to vary be- tween 1.0064 and 1.0070. CHEMICAL COMPOSITION In spite of the large amount of work on the chemical com- position of the cerebrospinal fluid, there are many funda- 80 CERBBKOSPINAL FLUID mental questions pertaining to the chemistry of this fluid that have not yet been answered. The reason that our in- formation regarding the chemistry of cerebrospinal fluid is not as definite and as accurate as it might be, is that the amount of fluid one is obliged to work with under nor- mal conditions is usually so small (5 to 10 c.c.) that it hardly permits any quantitative separations. It is but recently that microchemical methods have been devised for body fluids, and even now, with improved meth- ods, it is hardly possible to make an entire quantitative analysis on one normal specimen of cerebrospinal fluid. This scarcity of fluid necessitates working on one chemical substance at the time or the use of a mixture of fluids for the determination of the various chemical constituents, a procedure adopted by Mestrezat. One can readily see that data gathered in this way can not be very accurate, espe- cially since the chemical character of the fluid is affected by such factors as the condition of the patient, and the age of the fluid. It is surprising to note, however, that with all of the drawbacks some of the chemical determinations of the very early investigators still hold good, particularly the determinations of the organic matter, and of the amount of the total solids and chlorides. I shall present here data obtained from the literature, following the experiments so far as possible in chronologic order to show the evolution of chemical methods as ap- plied to cerebrospinal fluid. I shall give a complete table at the end of the discussion showing the results of the work by various authors on the chemistry of the cerebrospinal fluid. One of the earliest determinations of the chemical com- position of cerebrospinal fluid was that of Lassaigne who examined the cerebrospinal fluid of a horse after death. The fluid A\'as obtained for the chemist l)y Magendie. The analysis gave the following composition per 100 parts: PROPERTIES OF NORMAL CEREBROSPINAL FLUID 81 Water 98.180 Osmazome 1.104 Albumin 0.033 Sodium Chloride 0.610 Sodium bicarbonate 0.060 Phosphate and traces of calcium carbonate 0.009 Lassaigne could not find any soluble phosphates in the liquor. The same author examined the cerebrospinal fluid of an old woman and found the following per 100 parts: Water 98.564 Osmazome 0.474 Albumin 0.088 Sodium and potassium chloride.... 0.801 Animal matter and free calcium phosphate 0.036 Sodium carbonate and calcium phos- phate 0.017 Among the early workers in this field was Hoppe. He madd a chemical analysis in two cases of spina bifida and three cases of internal hydrocephalus. In one case of spina bifida, he removed 22 to 35 c.c. of cerebrospinal fluid at a sitting. (The author unfortunately does not give the method he employed in the removal of the fluid. ) He found the fluid very alkaline. (Here again the author does not say what indicator he used, or how long after removal of the fluid from the body, he examined it). On heating, the fluid became slightly turbid, but on addition of acetic acid, flocculi appeared. The fluid reduced copper oxide and gave the following quantitative results in grams per 1000: FIRST SECOND THIRD PUNCTURE PUNCTURE PUNCTURE Albumin 1.62 2.64 2.46 Water extractive 0.70 0.35 0.42 Alcohol extractive] g g^ 2.48 2.23 vel It I and soluble salt J 7.52 8.21 Insoluble salt 0.25 0.15 0.28 Giving — Dry substance 12.51 13.12 13.28 Water 987.49 986.88 986.72 82 CEKEBROSPINAL FLUID From the second case of spina bifida the author obtained 500 c.c. of cerebrospinal fluid, in the first puncture, and 435 c.c. in the second puncture. The reaction of the fluid in this case was also stated to be alkaline. On boiling, very little if any turbidity occurred. On the addition of acetic acid slight flocculency occurred. Quantitative analysis showed the following in grams per 1000 : FIRST PUNCTURr, SECOND PUNCTURE Albumin 0.25 0.55 Extractives 2.30 2.00 Soluble salts 7.67 7.20 Insoluble salts 0.45 0.45 Dry Substance 10.67 10.20 One case of hydrocephalus in a five-month-old girl gave Hoppe the following in grams per 1000: albumin 0.70, ex- tractives, 1.57, soluble salts 7.67, insoluble salts 0.53, giv- ing dry substance 10.47. Another case of hydrocephalus gave Hoppe the follow- ing in grams per 1000: albumin 11.79, alcohol extractives 0.84, water extract 0.48, soluble salts 7.54, insoluble salts 0.35, and dry matter 20.99. It is evident, however, from the author's description of the fluid of the last case which he says was of a greenish yellow color and showed a large sediment, absence of sugar and numerous cells, that the case was one of meningitis. Halliburton also was one of the first to study the chem- ical composition of cerebrospinal fluid. He found no coag- ulation of the fluid at 56° C. and no fibrin on the addition of serum or fibrin ferment. He found further that practi- cally all the protein present in the cerebrospinal fluid was precipitated by saturation with magnesium sulphate. The analysis of cerebrospinal fluid in a number of cases gave Halliburton the following results in parts per 1000 : PROPERTIES 01? NORMAL CEREBROSPINAL FLUID 83 CASE 1. CASE 2. CASE 3. FEMALE AOB 19 CHILD AGE DAYS 11 CHILD — AGE 13 WEEKS PIEST TAPPING rOURTH TAPPING Water 989.75 989.877 991.658 Solids 10.25 10.123 8.342 Proteins 0.842 0.602 0.199 Extractives 0.631 3.028 and 9.626 Salts 7.890 5.115 It is interesting to note in this connection the part taken by Halliburton in the discussion concerning the nature of the reducing substance in the cerebrospinal fluid. As early as 1852, Deschambs and Bussy described the presence of a copper-reducing substance in cerebrospinal fluid, a finding corroborated by numerous other workers. However, the character of this substance has been made the subject of a great deal of discussion. Quincke, Comba, Friedenthal, Pan- zer and others considered it to be a dextrose. Halliburton however, supported by Mathien, Gauthies and others ex- pressed the view that the reducing substance was pyro- catechin. Langstein thought that a portion of the reducing substance was galactose and Dubos believed that it was a xanthine body. Recent investigations have settled this con- troversy, the phenylhydrazin, the fermentation test, and the polariscope definitely proving its identity as a dextrose. Even Halliburton now admits that this reducing substance is a dextrose. The early investigations on the chemistry of cerebro- spinal fluid were made on cases of hydrocephalus or spina bifida. Of recent years some work has been done on the chemistry of cerebrospinal fluid of comparatively normal persons. The work of Mestrezat, of Leopold and Bern- hard deserves special attention in this connection. There are many additional facts on the chemical constituents of the cerebrospinal fluid scattered throughout the literature, some of which are included in the table at the end of the chapter. 84 CEREBROSPINAL FLUID Mestrezat, in a series of analyses, found the following chemical composition of cerebrospinal fluid, expressed in grams per 1000 parts: fixed matter 10.65 to 11.00, with an average of 10.93 ; organic matter 1.75 to 2.65 with an aver- age of 2.13; mineral matter 8.50 to 9.00, with an average of 8.80; protein 0.13 to 0.30 with an average of 0.18. He fonnd no fibrinogen, no albnmose or peptones, or nncleo- protein and mucin. He also noted the absence of cholin, and cholesterol (or only a very small trace of choles- terol). Amino acids were present on the average in the amount of 0.010, nrea on the average of 0.06, varying be- tween the extremes of 0.03 and 0.10. The presence of am- monia was questionable, total nitrogen was found on the average of 0.197, with the extremes of 0.196 to 0.198; sugar (reducing matter and glucose) on the average of 0.53, with the extremes 0.48 to 0.58. Total organic acids were pres- ent on an average of 0.30. There was, however, no acetone found ; chlorides on the average of 7.32, with the extremes of 7.25 to 7.40; total phosphorus on the average of 0.080 in terms of P2O5 with the extremes of 0.029 to 0.031; in- organic phosphorus on the average of 0.012 in terms of P2O5 ; organic phosphorus on the average of 0.018 in terms of P2O5 ; total sulphur on the average of 0.056 with the ex- tremes of 0.028 to 0.071 ; inorganic sulphur on the average of 0.010 in terms of SO3 ; organic sulphur on the average of 0.046 in terms of SO3; nitrates on the average of 0.009; no nitrites; sodium 4.346 as NaaO; potassium 0.251 as K2O; ratio of K20/Na20 1/17.3 ; calcium 0.095 as CaO ; magnesium 0.050 as MgO. Leopold and Bernhard determined the nonprotein nitro- gen of normal cerebrospinal fluid. They found that the nonprotein nitrogen varied between 17 and 26 mg. per 100 c.c. of cerebrospinal fluid the average amount being 21 mg. The urea varied between 7 and 13.5 mg. per 100 c.c. of fluid, the average amount being 9.9 mg. The creatinine varied between 0.7 and 1.5 mg. per 100 c.c. of fluid, the average PROPERTIES OF NORMAL CEREBROSPINAL FLUID 85 amount being 0.9 mg. The sugar content varied between 0.07 and 0.1 per cent, the average content being 0.07 per cent. My own work on the chemistry of cerebrospinal fluid is concerned mostly with the constituents that have or were expected to have a direct bearing on the differential diag- nosis and pathogenesis of various diseases, including the protein content, the organic index, the sugar content, lactic acid, and urea, among the organic constituents, and the chlorides, the phosphates and CO2 among the inorganic constituents. The organic index was determined by the permanganate method of Meyerhofer, taking the amount of permanganate required to oxidize the organic sub- stance in the cerebrospinal fluid as an index (the method will be described in detail in Chapter VI). The protein was determined by precipitating the cerebrospinal fluid with equal amounts of 5 per cent trichloracetic acid, with a pinch of kaolin, filtering off the inorganic constituents and determining the nitrogen in the sediment by the Kjel- dahl method and multiplying by the factor IST x 6.25. The sugar was determined by the Kowarsky method and also by the Lewis and Benedict method. Occasionally, the Epstein microchemical method was used. Urea was determined by the Folin method, acetone was determined qualitatively by the sodium nitroprusside method. Lactic acid by Uf- felmans reagent, noting the drops of cerebrospinal fluid re- quired to change the reagent to a canary yellow. The chlorides were determined by the Seelman method, the phosphates by the uranium acetate method and the CO2 by the Van Slyke method for the determination of alkali reserve and then calculating out the CO2 from the results obtained, or the alkali reserve was obtained by methyl red titration. I should like to emphasize here that the fluid has been nonmeningitic, but nevertheless not always absolutely normal. Tables V, VI, and VII show some of the average findings in nonmeningitic fluids. 86 CEREBROSPINAL FLUID Table V The Pebmanganate Index in Nonmeningitic Fluid NO. DIAGNOSIS PERMANGANATE INDEX PIKST TUBE SUBSEQUENT TUBES 1 Typhoid 1.8 1.6 1.7 2 Pneumonia 1..3 1.3 3 Pneumonia 1.4 1.2 1.0 4 Tetany 1.3 1.2 .5 Epilepsy 1.3 1.1 6 Grippe 1..T 1.4 Table VI Sugar Content in Nonmeningitic and Nonluetic Cases sugar other NO. diagnosis content TESTS 1 Alimentary 0.116 Chemical and Intoxication baoteriologic - tests negative 2 Pneumonia with 0.108 All tests meningism negative 3 Insanity 0.108 Negative 4 Uremia 0.067 Negative 5 Insanity 0.058 Negative 6 Insanity 0.048 Negative 7 Otitis Media 0.032 Negative 8 Erysipelas 0.144 Negative 9 Renal Insufficiency 0.048 Negative 10 Pneumonia and meningism 0.032 Negative 11 Pneumonia 0.088 Negative 12 Brain tumor also right ovarian cyst 0.116 Negative 13 Cerebral spastic paralysis 0.06 Negative 14 Hydrocephalus 0.104 Negative 15 Insanity 0.118 Negative 16 Hematogenous Jaundice 0.12 Negative 17 Epilepsy — had menin- gitis one year previouslj • 0.068 Negative 18 Encephalitis, 0.048 Negative 19 Cerebellar tumor, re- peated convulsions 0.072 Negative 20 Brain tumor 0.068 Negative 21 Multiple sclerosis 0.148 Negative 22 Localized encephalitis recovered. 0.140 Negative (Cont'd p. 87) PROPERTIES OF NORMAL CEREBROSPINAL FLUID 87 Table ,VI— Cont'd Sugar Content in Nonmeningitic and Nonluetic Cases NO. DIAGNOSIS SUGAR OTHER content TESTS 23 Acidosis (?) 0.104 Negative 24 Normal 0.086 Negative 25 Normal 0.09 Negative 26 Normal 0.106 Negative 27 Normal 0.064 Negative 28 Normal 0.088 Blood sugar— 0.088 Negative 29 Normal 0.108 Negative 30 Normal 0.064 Negative 31 Normal 0.07 Negative Table VII Chlorides in Nonmeningitic Fluid DIAGNOSIS chlorides (in gms. per 100 c.c.) Psychosis 0.74 Alcoholic psychosis 0.72 Alcoholic psychosis 0.60 Meningism 0.72 Pneumonia 0.60 Psychosis 0.68 Psychosis 0.70 Tertiary lues 0.75 Chorea 0.70 Table VIII Urea in Nonmeningitic Fluid NO. DIAGNOSIS urea in gm. per 100 c.c. 1 Psychosis 0.032 2 Meningism 0.090 3 Psychosis 0.042 4 Psychosis 0.064 5 Meningism 0.070 6 Psychosis 0.043 The amount of CO2 in the cerebrospinal fluid varied in my cases with the time the fluid has been standing after re- moval from the body. The longer it stands before exami- 88 CEREBBOSPINAL FLUID nation the less CO2 it contains. In fluid examined immedi- ately after withdrawal from the body, the CO2 varies be- tween 0.110 gm. and 0.124 gm. per 100 c.c. In fluid exam- ined five to six hours alter it has been removed from the body, the CO2 varies between 0.098 gm. and 0.106 gm. per 100 c.c. Table IX shows some of the amount of CO2 ob- tained in volumes per cent. Table IX Total Carbonate op Nonmeningitic Cerebrospinal Fluid and Its Relation to the H-Ion Concentration no. diagnosis PH total carbonate in VOLUME PER cent I Dementia Precox 7.4 58.75 2 Psychosis 7.4 55.72 ( I ( ( 7.7 51.52 3 Cerebrospinal Lues 7.5 55.72 ( i 1 1 7.6 54.83 4 Psychosis 7.4 57.54 ( I i I 8.1 50.47 5 Tabes 7.4 63.68 1 ( 11 8.1 54.08 6 Chorea 7.5-7.6 63.0: I i 1 1 8.1 52.48 7 Encephalitis 7.7 51.3 Lactic acid was present in traces. It took, as a rule, 15 to 20 drops of cerebrospinal fluid to change the color of 5 c.c. of Uffelman's reagent to canary yellow. Acetone was negative in all nonmeningitic fluid, so was also ammonia. Crystallization I evaporated a number of specimens of cerebrospinal fluid, after precipitating and filtering off the protein. The resultant crystals (Figs. 17 and 18) resemble those of so- dium chloride (Fig. 19) in most respects. When we now examine cerebrospinal fluid for the con- stituents it contains we find the following amounts : water, 98.60 to 99.124 per cent; solids, 0.876 to 1.631 per cent. Of the solids, 0.175 to 0.265 per cent is organic matter and the PROPERTIES OF XORMAI. CEREBROSPINAL FLl'IT) 89 rest mineral matter. Tlie or,t;aiiic matter is made up xjrinei- pally of protein, sugar and nrea. Protein is present in amounts varying- l)et-we(.'n 0.013 and 0.07 ; sugar is present in amounts var3'ing l;)etween 0.032 and 0.144 per cent. The l)ulk of the inorganic matter consists of chlorides and Fig. 17.— Crystallization of nunmeningitic cereljrosiiiiial fluid. A. Crystals obtained after the protein has been removed from the fluid by precipita- tion and the filtrate evaporated on steam bath. (Natural size.) B. Same fluid showing the crystals. ( iMagnified 24 tunes.) C. Clump of crystals of same fluid. (iMagnified 45 tunes.) D. Single crystal. (Magnified 45 times.; 90 CRr.EBr.OSPTNAT. FLUID Fig. 18. — Crystals of evaiioraU-d nonmeningitic ccrt-brosiiinai lluid. (MagniHed 24 diamettrs. j PROPERTIES OF NORMAL CEREBROSPINAL FLUID 91 e* 0-* o rHCq o .Hr-1 do o>^ iH 6 (N« ^ oo o (^ oo o d o 00 r-t ^ m — o EC o o d o O) 6 § IZi o d MO 1ft -* t^ (N-^ Oo ■* d^d d o d o « oo oo o lOO rHlO N OOO CO OO O do o oo d J CO (N ■< Q lOO OO lO »oo 00^ H ^ oo ON -!*< -^t^t^ Ol« u OrH (MGO o oo coo lOO ■<*< lO »o MOJ coo -*« »o inco oo O 01 0) t>^ o C0« coco K coco ooo X coco 00 CO OCft OiOi OJ CiOi oo QD o » g« M o Pf gS w rt ■4 ^ ■ P [C Pi E^ oJ K^ >. < H <: p p o H S > ■< h h^ o u el 3 o o to P Oh 3 55 s z s o iz; a ^s O a O S i^B « s B 5 s Q 2 o h Ih o 1 1 Z CO U 2: 92 CEREBROSPINAL FLUID fl 'S +3 1^ g oo o aa (D ,g lizi »oi> r^O oo oo IS o do o Pi H cS >0 1-1 a^ cot- r-IO oo 66 •3 CD CO t-lfl SK OCJ iHrH tHCO B OO do oo 66 dd Ci_, cfi .^T3 (^ o'3 O .^ < ft; H ^ OOM N« THin or- 1 co- i>in (Nt> OO o tHCO OO 66 d dd dd 2x CO ta S SI o "S lOlO ffl +3 b-«D o o Eh »-t(N (N dd d PKOPERTIES OF NORMAL, CEREBROSPINAL FLUID 93 bicarbonates, the chlorides being present in amounts vary- ing between 0.60 and 0.74 per cent. Both of these constituents are present in much greater quantities than potassium, calcium or magnesium. It is interesting to compare the chemical composition of the cerebrospinal fluid with that of other body fluids, not- ably blood, lymph, and aqueous humor. In comparing the Table XI Chemical Composition of Cerebrospinal Fluid Compared with That op Blood BLOOD SERUM cerebrospinal OP A MAN 25 CONSTITUENT FLUID IN GM. TEARS OLD PER 1000 (by SCHMIDT) IN GM. PER 1000 Water 996.67 908.84 Dry substance 10.93 91.16 Organic Substance 2.13 82.58 Albuminoid 0.18 Albumose and Peptones Amino Acids 0.010 0.0099 Urea 0.06 0.10-0.30 Ammonia ? 0.04-0.010 Reducing Substance 0.53 1.0-1.50 (Glucose) Chloride (as Sodium 7.32 5.86 Chloride) Direct alkalinity as Na^CO 1.25 3.26 Ashes 8.80 8.574 Na,0 K,0 4.346 0.251 3.438 0.317 CaO 0.095 0.162 MgO FeA Pfi, (total) SO3 (total) CO2 (of ashes) CI 0.050 0.002 0.030 0.056 0.550 4.448 0.073 ? 0.375 0.130 0.90-130 3.556 Ratio of KO to Na,0 1/17.3 1/10.8 chemical composition of the cerebrospinal fluid with that of the blood we find that they both contain practically the same constituents, and that some of the constituents are present in the same amounts in both. This is particularly true of sugar and urea. I often found sugar to be present in the 94 CEREBROSPINAL FLUID same amounts in both the fluid and in the blood. Cullen and Ellis found a difference of less than 2 mg. per 1000 c.c. in the amounts of urea in the fluid and the blood, in 63 per cent of their determinations. The urea content of the fluid varied from 22 to 46 mg. and that of the blood serum be- tween 20 to 42 mg. The other chemical constituents, on the contrary, are present in much smaller proportions in the fluid than in the blood. The protein in the fluid varies between 0.013 and 0.07 whereas that in the blood plasma varies between 6.95 and 7.76 per cent. The calcium content of the fluid, ac- cording to Halverson and Bergeim, is only one-half that of the blood, the calcium in the fluid being 0.005 gm. per 100 c.c, while that in the blood plasma .or serum is 0.01 per 100 c.c. Table XI of Mestrezat shows the chemical constit- uents of the cerebrospinal fluid and the blood. PHYSICOCHEMICAL PROPERTIES OF NORMAL CEREBROSPINAL FLUID There is no line of scientific investigation where so many factors enter into the results obtained as in physicoehemical determinations. Temperature, barometric pressure and es- pecially the time the fluid has been standing before it is examined count a great deal. So it comes that while the chemical data found in the literature of several years ago are in the main confirmed by newer investigations, some of the older physicoehemical data are found incorrect when newer methods are used, and when the various factors influencing physicoehemical findings are taken into con- sideration. Especially is this true with regard to the reac- tion of the cerebrospinal fluid and the alkali reserve. Specific Gravity The specific gravity of normal cerebrospinal fluid to which I have already referred in the discussion of the phys- ical properties of normal cerebrospinal fluid, belongs also PKOPERTIES OF NORMAL CEREBROSPINAL, PLUID 95 in a discussion on physicochemical properties of the fluid, since specific gravity forms the basis of many physico- chemical constants. The specific gravity varied in my cases between 1.0064 and 1.0070, and according to other authors, it varies between 1.001 and 1.008. Viscosity Polanyi found the viscosity to vary between "1.020 and 1.027 at a temperature of 38° C, taking the viscosity of water as 1. I examined the viscosity of several cerebro- spinal fluids, by means of the Ostwald apparatus, and found it to vary between 1.0424 and 1.0489 compared to water. Conductivity Polanyi examined the conductivity of the cerebrospinal fluid of hydrocephalus and found it to be 0.01136; 0.01280; 1 0.01527; and 0.01452 at 20° C. (Formula ). Ohm X Cm. My examination gave the conductivity as .01513, .01365, and .01513 at 25° C. Surface Tension Polanyi found the surface tension to be 7.35, 7.15, 7.16 and 7.20 dynes at 20° C. Freezing Point Grenet found the freezing point of normal cerebrospinal fluid to be -.38° to -.56° C. Quincke found it to be -.56° to -.75°. Polanyi found it to be -.566°, -.570°, -.678°, -.583°. Mott found it to be -.51° to -.56°. Mestrezat found the average to be -.576°, with the extremes varying be- tween -.57° and -.59°. My findings showed the freezing point to vary between -.56° and -.58°. In general it must be said here also that the interval between the removal of 96 CEREBROSPINAL FLUID the cerebrospinal fluid from the body, and the time of the examination is a great factor ; although the variation in the freezing point on standing is not nearly as much as is the case with H-ion concentration, or with the alkali reserve. Refractometric Index Polanyi found the refractometric index to be 1.3499 at 23° C, 1.33^16 at 21° C, 1.33579, at 20.3° C, and 1.33554 at 20° C. I found it to be 1.73516 at 23° C. Reaction of Normal Cerebrospinal Fluid All through the older writings, the statement is found that the cerebrospinal fluid is alkaline in reaction, the al- kalinity being given as a rule as half that of the blood. Cavazzani examined the fluid of two cases of hydroceph- alus, and found a neutral reaction. Concetti found the fluid alkaline three times, and weakly alkaline four times. Von Jaksch found the alkalinity to equal 20 c.c. of n/10 acid solution. Kafka used n/10 HCl and cochineal as an indicator, and found that on an average, 20 c.c. of acid was necessary to neutralize 100 c.c. of fluid. According to Mott, the alkalin- ity of the fluid corresponds to 0.1 per cent of sodium hy- drate. Of late, the -entire conception of the reaction of body fluids has changed due mainly to the work of Michaelis, Sorenson, Henderson and Van Slyke. The reaction of body fluids is now spoken of in terms of hydrogen and hydroxyl ions, which is expressed either in the terms of hydrogen- ion concentration, or in terms of Ph, the latter term indi- cating the negative exponent of the hydrogen-ion concen- tration, for instance Ph 7.1 = 1 x lO'^-'N. The H-ion concen- tration can be determined in a number of ways, the most important of which are the compensation method of Mich- aelis or of Hildebrandt, and tlie indicator method of Sor- enson. Practically all of these metliods have been used PROPERTIES OF NORMAL CEREBROSPINAL FLUID 97 recently for the study of the cerebrospinal fluid. The re- sults, however, have not been uniform. Bisgaard exam- ined the fluid against a borate mixture, 5.7 plus HCl, and found that the fluid Avas more acid than the borate mixture. Polanyi determined the H-ion concentration of one fluid drawn from a case of hydrocephalus, by the compensation method with the use of the Farkas-Szilisch electrode. He found the H-ion concentration to be 9.084 X 10. Hurwitz and Tranter, who used the Levy Rown- tree-Marriott standards, found the Ph of normal fluids to vary between 8.15 and 8.30 with an average of 8.26, this being somewhat lower when the fluid was dialyzed, the average then being 8.11. Weston found the dialyzed fluid to vary between 7.9 and 8.3 with an average of 8.12. I have examined the H-ion concentration in over four hundred normal cerebrospinal fluids, or to be more accurate, fluid from cases that proved to be nonmeningitic in char- acter. The series includes cases of nephritis, gastrointes- tinal intoxication, pneumonia, paresis, alcoholic psychosis, dementia precox, brain tumor, epilepsy and many other con- ditions. I used the methods of Michaelis and Hildebrandt for the determination of old fluids and the Levy-Rowntree- Marriott method, or an indicator corresponding to this method, in fresh fluid. I found that when the fluid is ex- amined immediately after its withdrawal from the body, the H-ion concentration expressed in terms of Ph ranges from 7.4 to 7.6. In only two cases have I found an H-ion concen- tration of fresh fluid to be 7.7. However, if the fluid has been standing a short while, the reaction changes very quickly toward the alkaline side. As a rule, standing half an hour changes the reaction to a Ph of 7.5 to 7.6 ; standing one hour changes the reaction to a Ph of 7.7; standing two hours changes it to 7.9 or 8.0. From two hours on, the change in the reaction toward the alkaline side is rather small, some fluids changing in twelve hours to 8.1, and re- maining at this concentration no matter how long it stays ; 98 CEEEBEOSPINAL FLUID Table XII H-ION CONCENTEATION OF NORMAL C'EKEBKOSPINAL FLUID BY Oti-IEE AUTHOKS AUTHOR METHOD EMPLOYED Ph FRESH OLD REMARKS Cavazzaui Tartaric acid Neutral Interval of standing not in- dicated. 2 cases of hydro- cephalus also dogs Concetti Alkaline 3 times, vifeakly acid 1 time. Interval of standing not in- dicated. Myers Litmus Neutral or faintly alkaline Bisgaard Phenol- phthalein Less than 8.1 Kopetzky Litmus Phenol- phthalein Less than 8.0 Turner Acid ■ Fluid in stoppered bottles retained acidity Fluid in unstopper- od bottles became , alkaline Polanyi Farkas- Sziliseh electrode 9.0 Hurwitz and Tranter Levy- Eowntree- Marriott method 8.15 8.30 average- 8.1 "Weston Levy- Rowntree- Marriott method 79-8.3 average- 8.12 Felton, Hussey and Bayne- Jonea Levy- Bo wntree- Marriott method 7.7-7.9 8.6 other fluids changing to 8.3 or even 8.6 in course of twenty- four hours or longer. In Table XI, I give the Il-ion concentration in some of my cases showing average results, indicating the method used by the letters a, b, c; "a" represents the gas-chain method, "b" the alkalinized phenol phthalein compared to the Sorenson standards, and "e" the Levy-RoAvntree-Marriott indicator compared to the standard colorimetric tubes. A typical cliange in the H-ion concentration is illustrated PROPEKTIES OF NORMAL CEREBROSPINAL FLUID 99 in the curve shown in Fig. 20. The results obtained by phenolphthalein compared to the Sorenson standards, are often marked with an additional + and - signs. This means that Ph of the cerebrospinal fluid was higher or lower than the figure given, but how high or how low was not deter- mined. ■ These findings have been so constant that I believe we can account for the high Ph obtained in normal cerebro- spinal fluid by the authors quoted. They examined the Fig. 20. — Average change in the H-ion concentration of nonmeningitic fluid on standing. fluid after it had been standing for some time, which naturally gave a very low H-ion concentration, or a high Ph. Interesting in this connection is the work of John Turner who not only knew of the high H-ion concentration of the fluid, but was also aware of the fact that the concen- tration changes on standing. To quote him: "In all the cases of this series and in twenty examined fifteen years ago, I have obtained an alkaline reaction (and not amphoteric) to litmus paper, but with phenol- phthalein the great majority have an acid reaction. The de- 100 CEREBROSPINAL FLUID Table XIII H-IoN Concentration of Nonmeninqitic Spinal Fluid DIAGNOSIS Ph CASE Immediate K Hour 1 Hour 2 Hours 1 2 3 4 5 6 7 8 9 Tic 8.0 (b) 10 11 8.0 (b) 13 14 Tubercle of brain 7.4 (b) 7.4 (b) 15 16 7.4 + (b) 7.4 + (b) 18 7.5 (c) 7.4 (c) 21 7.5 (c) 22 7.9 (c) 7.7 (c) 7.7 (c) 25 7.5 (c) 7.6 (c) 7.5 (c) 7.5 (c) 26 29 8.0 (c) 30 8.0 (b) 31 7.4 (c) 7.4 (c) 7.7 (c) 7.5 (e) 7.4 (c) 7.4 (c) 7.5 (c) 7.5 (c) 7.4 (c) 7.5 (c) 7.4 (c) 7.4 (c) 7.4 (c) 7.5 (c) 7.4 (c) 7.4 (e) 7.5 (c) 7.9 (c) 32 33 34 35 36 37 38 39 40 General naresis 41 7.6 (c) 7.8 (c) 42 Psychosis 43 Mixture 44 7.7 (c) Mixture General paresis 7.4 (c) 45 46 7.7 (c) 7.4 (c) 7.4 (c) 7.5 (c) 7.5 (c) Mixture 47 48 49 50 Poliomyelitis ? 7.6 (c) gree of acidity, however, is in many cases very slight. A very faint pink solution of phenolphthalein was poured into two small beakers, so that the tint in both was similar PROPERTIES OF NORMAL CEREBROSPINAL FLUID Table XIII — Continued H-ION Concentration of Nonmbninqitic Spinal Fluid 101 Ph 3 Hours 4 Hours 5 Hours 12 Hours 18 Hours 24 Hours 2 Days and Over 8.56 (a) 8.14 (a) 8.6 (a) 9.08 (a) 8.3 (a) 7.89 (a) 8.0 + (b) 8.6— (b) 8.6— (b) 8.0 + (b) 8.6— (b) 8.0 (b) 8.6— (b) 8.0 (c) 8.0 (c) 8.4 (c) \- • ■ ■ 8.2 (c) 8.0 (c) 8.1 (c) 8.1 (c) 8.1 (a) 8.1 (c) 8.1 (c) 8.1 (c) 8.1 (a) 8.1 (c) 8.1 (a) 8.1 (c) 7.7 (a)* 7.7 (c) 8.1 (c) 8.1 (c) 8.1 (c) 8.1 (c) 8.2 (a) 8.1 (a) 8.2 (c) • Corked. in looking down at them as they stood upon a porcelain slab. A little of the fluid was then added to one beaker and generally the pink color was immediately discharged. I 102 CEREBROSPINAL FLUID found that the fluid left unstoppered in my room, where gas is constantly burning, rapidly becomes alkaline, whereas similar fluid in stoppered bottles retained its acidity, and that in my later examinations where this source of fallacy was recognized and excluded, the results tend more and more to be uniformly acid with phenolphthalein. " I have endeavored to find the factors that are responsi- ble for the changes taking place in the H-ion concentration of nonmeningitic cerebrospinal fluid. T found that when I put a part of the cerebrospinal fluid right after its with- drawal from the body into a desiccator containing twenty per cent sodium hydrate, and allowed it to remain in the desiccator from ten to thirty minutes, the acidity of the fluid was greatly decreased, the Ph being in a very short time 7.7 to 7.9. Changes in H-" Tabi,iv XIV Concentration on Removal of CO2 Desiccator Bv Exposure to Alkali in Pll CASE FLUID DRAWN IM- EXPOSED TO EXPOSED TO EXAMINED Ph. ATELY 190 6:55 p. m. 7.4 12 minutes 7:07 p. m. 7.7-7.8 190 6:55 p. in. 7.4 20 minutes 7:15 p.m. 7.8 190 6:55 p. m. 7.4 20 minutes 7 minutes after 20 minutes exposure to alkali 7:22 p. m. 7.8-7.9 190 6:55 p. ni. 7.4 27 minutes 38 minutes after 27 minutes exposure to allcali 7:55 p. m. 7.8-9 190 6:55 p. m. 7.4 20 minutes 13 hours 11:22 a.m. 8.1 188 7:03 p. m. 7.4 10 minutes 7:13 p. m. 7.7-7.8 188 7:03 p. m. 7.4 30 minutes 7:33 p. m. 7.8 188 7:03 p. m. 7.4 30 minutes 3 minutes 7:36 p. m. 7.8 186 7:45 p. m. 7.4 6 minutes 7:51 p.m. 7.6-7.7 186 7:45 p. m. 7.4 25 minutes 8:10 n. m. 7.9 This shows that the removal of CO2 from the fluid causes a decrease in the H-ion concentration of the fluid. To make certain, however, that the increase in the Ph of the cerebrospinal fluid is entirely due to CO2, I performed the following experiment. I divided a fluid into two por- tions: one portion I corked tightly after its removal from the body, and coated with a layer of paraffin, and the other portion I left in a nonsol glass tube. The two portions of PROPERTIES OF NORMAL CEREBROSPINAL FLUID 103 the fluid were examined twenty-four hours later. I found that the fluid which had been corked very tightly retained the original H-ion concentration, giving a Ph of 7.4 to 7.6 in twenty-four hours; while the fluid that had been left in a cotton plugged test tube gave a Ph of 8.1 or higher in twenty-'four hours, which is the ordinary change taking place in cerebrospinal fluid. This shows that the decrease in the H-ion concentration in the cotton-plugged tube was not due to formation of ammonia or other alkaline sub- stance, but to the loss of CO2 from the fluid into the air. I have furthermore shoMm that when the tube containing Tn ~ ^^~ 83 «.? «.l 10 x? 7b 7.5 7.4 £54 ejs: ^ z::: ' ^ C2i '^ r -1 '>.°'-1 ^ 1 / c ?>* |.' / ...-•' ie.i A ^ J / rf-i ^' Ct 56 2/ F— ^ ,.— ' S'— — I, 1 2 3 4 5 fe 7 8 9 10 II IZ 13 14 15 Hours Fig. 21. — Change in H+ concentration of nonmeningitic fluids on standing at room temperature under various conditions. Case 169. Plugged with cotton. Case 190. Im- mediately after withdrawal, exposed to CO2 free air in desiccator (dotted line) and later left with cotton plug. Case 2101>. Plugged with cotton; Case 210c, the same fluid as b, but corked with a cork — a few bubbles at the top. Case 204. Six c.c. tube, half filled, and tightly corked; cotton plugged fluid was same as Case 210b (8.1). Case 213. Almost perfectly sealed with cork, without any air bubble above the fluid. fluid is corked tightly, but some space is left between the fluid and the cork, there will be some change in the H-ion concentration of the fluid, the H-ion decreasing slightly although not nearly as much as the fluid standing in the cotton-plugged tube (Table XV) (Fig. 21). I have also measured the total carbonates in fresh and old fluid and found it to run parallel with the H-ion concentration as 104 CBKBBROSPINAL FLUID Table XV H + Concentration of Fluids Standing in Corked Tubes NUM- BER AQE DIAGNOSIS DATE DRAWN DATE EXAMINED INTERVAL STOPPERED WITH Ph Mixture 210a 27 38 Alcoholic Alcoholic p.m. 6/25/17 - 7:15 6/25/17 - 7:20 p.m. 6/26/17 - 7:16 6/25/17 - 7:20 Immediately Immediately 7.4 7.4 210b 27 38 Alcoholic Alcoholic 6/ 5/17 - 7:15 6/25/17 - 7:20 a.m. 6/26/17 - 8:00 13 hours Cotton 8.1 210c 27 38 Alcoholic Alcoholic 6/25/17 - 7:15 6/25/17 - 7:20 6/26/17 - 8:00 12 hours Paraffined cork (few bubbles below cork) 7.5-7.6 211a 43 46 Alcoholic Alcoholic 6/25/17 - 7:28 6/25/17 - 7:37 6/25/17 6/25/17 Immediately Immediately 7.5 211b 43 46 Alcoholic Alcoholic 6/25/17 - 7:28 6/25/17 - 7:37 6/26/17 - 8:10 121^ hours Cotton 8.1 211c 43 46 Alcoholic Alcoholic 6/25/17 - 7:28 6/25/17 - 7:37 6/26/17 - 8:10 12}^ hours Paraffined cork 7.5-7.6 211d 43 46 Alcoholic Alcoholic 6/25/17 - 7:28 6/25/17 - 7:37 6/26/17 -11:17 15H hours Paraffined cork replaced after 3 c.c. removed for exam, at 8:10, leaving 3 c.c. space in 6 c.c. tube. 7.6 212 55 Alcoholic 6/25/17 - 7:48 6/25/17 - 7:52 4 minutes 7.4 b 55 Alcoholic 6/25/17 - 1-A8- 6/26/17 -11:05 15 hours Paraffined cork 7.5-7.6 c 55 Alcoholic 6/25/17 - 7:48 6/26/17 -11:30 16 hours Cotton 8.2 d 55 Alcoholic 6/25/17 - 7:48 p.m. 6/28/17 -12:30 Cotton 7.9 213 39 Alcoholic 6/25/17 - 8:00 6/25/17 - 8:02 2 minutes 7.5 b 39 Alcoholic 6/25/17 - 8:00 6/26/17 -11:25 15M hours Paraffined cork 7.5-7.6 218 lyr. Pneumonia 6/26/17 - 1:30 6/26/17 - 1:30 Immediately 7.6-7.6 b lyr. Pneumonia 6/26/17 - 1:30 6/28/17 -12:30 47 hours Paraffined cork 7.5-7.6 c lyr. Pneumonia 6/26/17 - 1:30 6/28/17 -12:30 47 hours Cotton 8.2 204 46 42 38 Pulmonary tuberculosis Alcoholic General paresis 6/18/17 - 7:15 6/18/17 - 7:20 6/18/17 - 7:30 6/18/17 - 7:30 15 minutes 10 minutei Immediately 7.4 b 38 General paresis 6/18/17 - 7:30 a.m. 6/19/17 - 7:30 12 hours Cotton 8.1 c 38 General paresis 6/18/17 - 7:30 6/19/17 - 7:30 12 hours Paraffin; left 3 c.c. space above volume of liquid. 7.6-7.7 205 29 34 36 Alcoholic Alcoholic Alcoholic 6/18/17 - 7:40 6/18/17 - 7:46 6/18/17 - 7:53 p.m. 6/18/17 - 7:53 11 minutes 8 minutes Immediately 7.4 b 36 Alcoholic 6/18/17 - 7:53 a.m. 6/19/17 - 7:65 12 hours Cotton 8.1 c 36 AlcohoUc 6/19/17 - 7:53 6/19/17 - 7:65 12 hours Paraffined; 1 c.c. of space left on top of fluid 7.6-7.6 PROPERTIES OF NORMAL CEREBROSPINAL FLUID 105 shown in Table IX. To show further that ammonia, even if absorbed from the air, is a negligible factor, I made the following experiment: A fluid was divided into two por- tions, one of which was exposed to ammonia-free air in a desiccator, and the other left at the ordinary laboratory temperature. After thirty minutes I examined the two fluids for their li-ion concentration and found it to be the same in both cases, showing that the usual decrease in the H-ion concentration of a fluid is not due to absorption of ammonia from the air. When we compare H-ion concentration of normal cere- brospinal fluid with that of the blood, we find that they are both the same. The H-ion concentration of the blood also ranges between a Ph of 7.4-7.6 inTmediately after being re- moved from the body. Alkaline Reserve I determined the alkaline reserve on the amount of CO2 present in the cerebrospinal fluid as bicarbonate, by means of the Van Slyke alkaline reserve apparatus. Table XVI shows the alkaline reserve in nonmeningitic fluid: Table XVI Alkaline Eeserve of Nonmeningitic Cerebeospinal Fluid NO. DIAGNOSIS ALKALINE RESERVE 1. Tabes 56.5 2. Poliomyelitis 45.7 3. Uremic coma 52.0 4. Meningism 47.5 5. Chorea 63.0 6. Dementia i^recox 58.75 7. Psychosis 55.72 S. Cerebrospinal lues 55.72 9. Psychosis 57.54 The above shows that the alkaline reserve of nonmenin- gitic cerebrospinal fluid varies between 45.7 and 63.0, the average being between 52 and 57 %> of CO2 found by the cerebrospinal fluid at 0° temperature, at 760 barometric pressure, which is about the same as the alkaline reserve of blood. 106 CBEBBKOSPINAL FLUID > H n < J g C 2; O ALKALINE RESERVE to (J H-ION CON- CENTRATION IN TERMS OF Ph. o C5 1 > w IS CD '~^ CO o )— 1 "■ — H is 0} H rH GO O H CD 1-- f— 1 I— t O O O O «5 50 O r-l GO »f5 i-H t-H O O d d S ^ fa CD CO CO t> UO CO d d t- as d d CD 00 to >o d o 1" tn O u > o t- o o I— < 1— 1 e< 00 o o r-< T— I 2 i" fa a «^ o &( GO rH O O O l-H t— 1 o o T? O CD t- O O o o t-l I-< a K & < % 4-1 N ■M to a o en a GJ Z ■ O & S •z. o o a. >> a 1 ^ 1 PROPERTIES OF NORMAL CEREBROS:?INAL FLUID 107 BIOCHEMICAL PROPERTIES The data on the biochemical properties of normal cere- brospinal fluid are conflicting in nature. Up to date most of the biochemical findings reported on have been negative, but it is possible that with more accurate methods posi- tive biochemical properties may be found. Amylolytic Power Toison and Lenoble found that the cerebrospinal fluid of hydrocephalics possesses amylolytic power. Cavazzani reports the same. Galletta, however, says that he found this to be true in only two out of eleven cases examined. Mestrezat found no amylolytic power in the normal cere- brospinal fluid or very slight traces of it. Proteol3rtic Power Link and Pollack report finding a peptolytic enzyme in normal cerebrospinal fluid. In three cases of hydroceph- alus and one case of spina bifida examined for the presence of pepsin or trypsin Halliburton found no trace of either. Miller found no proteolytic enzyme or antienzyme in nor- mal cerebrospinal fluid. Galletta found a fat-splitting enzyme in three of seven cases. Clerc found none. Glycoljrtic Ferment Cavazzani found glycolytic ferment in the cerebrospi- nal fluid. However, neither Panzar, Lewandowsky, nor Mott could find the presence of any glycolytic ferment. Fibrin Ferment Normal fluid contains no fibrin ferment. Alexin Normal fluid contains no alexin. 108 CEKEBEOSPINAL FLUID Hemolysin Normally no hemolysin is found in the fluid. Toxicity Normal fluid is not toxic, compared to pathologic fluid which is toxic. Bactericidal Action The question as to whether normal fluid has a bacteri- cidal action has not yet been settled. CYTOLOGY The study of the cell content and of the cell elements of the cerebrospinal fluid Avas inaugurated in France by Rav- ant, Sicard, Nagoette and Widal in 1901, and has since been recognized as a very important phase of the study of the cerebrospinal fluid. The exact number of cells in normal cerebrospinal fluid is a matter on which authorities who have worked with the fluid do not agree. Fuchs and Rosenthal found to 2 cells per c.mm. in normal fluid, Rehm found 1 to 5 and even 6 to 9, and Gennerich found 8 cells in the fluid of one healthy person. There are others who give the niTmber as 5 to 20 per c.mm. The reason for the wide discrepancy is the fact that different investigators have employed different meth- ods in determining the number of cells. There are some who count the cells in the centrifuged fluid, using a certain amount of fluid in a graduated centrifuge tube and taking one drop of the sediment on a slide (the so-called French method), and others who count the cells in counting cham- bers. It is easy to see how these two methods will give en- tirely different results, the difference being at times as high as 50 or 60 per cent. Even those who count the cells in a counting chamber, get variations in their results due to the type of chamber they use. The Fuchs-Rosenthal PROPERTIES OF NORMAL CEREBROSPINAL FLUID 109 chamber, for instance, gives a smaller percentage of error than the ordinary leucocyte counter. The greatest source of errors responsible for the discrepancy of findings by various authors however, is the admixture of blood in the cerebrospinal fluid, for no matter how clear the fluid may look there may be some blood cells obtained by the passage of the needle through the tissue, which would in turn result in enormous errors, when figured out as their number per c.mm. In addition to the above factois, the amount of cerebrospinal fluid used for counting and the use of a stain may account for the difference in the reports of the various authors. I found the number of cells in normal fluid to be between 4 and 6 per c.mm. I have, therefore, adopted this number as an arbitrary standard, anything above 6 cells per c.mm. being suspicious, and anything above 10 cells per c.mm. be- ing indicative of some pathologic condition of the central nervous system. I, of course, make certain that the cere- brospinal fluid contains no blood to begin with. Fischer claims that the result obtained in the cell count of fluid obtained by lumbar puncture is not indicative of the cell count in the cerebrospinal fluid contained in the ventricle of the brain. This, however, has been found by Nonne not to be true. The cell content in the fluid of the lumbar region, and that of the ventricle are found to run parallel to each other. I have found that the cell content in the different portions of the cerebro- spinal fluid does differ, the first tube containing more cells than the subsequent fluid. I believe that this may be due to a contamination of blood cells in the first portion of the fluid. In' this connection, it is interesting to point out that one author advises shaking the patient from side to side before doing a lumbar puncture, in order to stir up the cells and distribute them evenly which, of course, is very absurd. 110 CEREBROSPINAL FLUID Type of Cell Normally, no red blood cells are found in the fluid, the cells in the fluid always being leucocytes. The normal type of leucocyte in cerebrospinal fluid is the small lymphocyte, which is the size of a red blood cell or slightly smaller or larger than the red blood cell. The nucleus of the lymphocytes of normal cerebrospinal fluid is round or slightly oval. It is seldom irregular. The nucleus fills up the largest part of the cell leaving a very small cell body. No granules can be detected in the cells, as a rule. The nucleus stains intensively with methyl-violet, while the cell body does not. Large lymphocytes do occur in normal fluid but not very frequently. It has been observed that there very seldom exists a combination of large and small lymphocytes in the same specimen of fluid that gives no other pathologic findings. Large lymphocytes, however, always should make one think of some diseased condition of the central nervous system. The origin of the cells in the cerebrospinal fluid is not fully determined. The cells in normal fluid would seem to be of hematogenous origin as they are small lymphocytes with occasional large forms which are also found in the blood. On the other hand, the cell forms in the fluid of pathologic conditions are often very different from those in the blood and this suggests some other source for the cells. The fibroblasts, for instance, would point to a his- togenic origin of the cells. It is possible, of course, that ' the cells do originate in the blood and during their trans- mission into the cerebrospinal fluid or while in the cerebro- spinal fluid may change forms. Szecsi suggested that some cells originate in the blood, while fibroblasts and other such elements have a histogenie origin. I believe that un- der normal conditions the cells in the cerebrospinal fluid originate in the blood and have the same characteristics as the cells in other parts of the body. PROPERTIES OF NORMAL CEREBROSPINAL FLUID 111 Bibliography Eisgaard: Untersuehungen iiber die Eiweiss und Stiekstoffverhaltnisse der Cerebrospinalfliissigkeit sowie iiber die Wasserstoffionen-Konzentration, Biochem. Ztschr., 1914, Iviii, 1. Cavazzani: "fiber die Cerebrospinalflussigkeit, Centralbl. f. Physiol., 1892, xiv, 6, 393. Weiteres iiber die Cerebrospinalflussigkeit, Centralbl. f. Physiol., No. 6, 145. Concetti: Chemische Untersuohungen iiber die Hydrocephalusflussigkeit von Kindem, Arch. f. Kinderh., 1898, xxiv, 161. Connal: A Study of the Cerebrospinal Fluid in the Infective Diseases with Special Reference to Cerebrospinal Fever, Quart. Jour. Med., 1910, iii, 152. Coriat: Cerebrospinal Fluid in Hydrocephalus, Am. Jour. Physiol., 1903, X, 111. Cottin and Saloz: La Mesure de la pression du liquide eephalo-rachidien. Rev. de Med., 1916, xxxv, 511. CuUen and Ellis : 'i'fle Urea Content of Human Spinal Fluid and Blood, Jonr. Biol. Chem., 1915, xx, 511. Felton, Hussey, and Bayne-Jones: The Reaction of the Cea-ebrospinal Fluid, Arch. Int. Med., 1917, xix, 1085. Hildebrandt : Some Application of the Hydrogen Electrode in Analysis, Re- search and Icachmg, Jour. Am. Chem. Soc, 1913, xxxv, 817. Henderson: The Theory of Neutrality Regulation in the Animal Organism, Am. Jour. Physiol., 1908, xxi, 427. Hoppe : Ueber die chemische Zusammensetzung der Cerebrospinalfliissigkeit, \^irchows Arch., 1859, xvi, 391. Hui-witz and Tranter : On the Reaction of the Cerebrospinal Fluid, Arch. Int. Med., 1916, xvii, 828. Kafka: Die Cerebrospinalflussigkeit, Ztschr. fiir die gesammte Neurologie und Psychiatric, Referrate, 19, vi. Part 4, 321. Landau and Halpern : Beitrage zur Cnemie der Cerebrospinalfliissigkeit, Bioohem. Ztsch., 1908, ix, 72. Levy, Rovnitree, Marriott: A Simple Method for Determining Variations in the Hydrogen-ion Concentration of the Blood, Arch. Int. Med., 1915, xvi, 389. Levinson: The Hydrogen-ion Concentration of Cerebrospinal Fluid, Jour. Infect. Dis., 1917, xxi, 556. Leopold and Bernhard: Studies in the Chemistry of the Spinal Fluid of Children, Am. Jour. Dis. Child., 1917, xiii, 34. 'Miohaelis, L.: Die Wasserstoffionenkonzentration, Berlin, 1914. Mott: The Cerebrospinal Fluid, Lancet, 1910, ii, 1. Palmer, W. W. and Henderson, L. J. : Chemical Studies in Acid Base Equilib- rium and the Nature of Acidosis, Arch. Int. Med., 1913, xii, 153. Pfeiffer, Kober, Field: Nephelometric Study of the Proteins of Cerebro- spinal Fluids, Proc. Soc. Exper. Biol, and Med., 1915, xii, 7. Poldnyi: Beitrage zur Chemie der Hydrocephalusflvissigkeit, Biochem. Ztschr., 1911, xxxiv, 205. Satta, Gastuldi: Antityptie Power of Cerebrospinal Fluid, Biochem. Et. Therap. Sper. 2, 49-56, Ztschr. Immunit. (Ref.) 3, 814. Sehultze: Krankheiten der Hirnhaute, Nothnagel, ix, 1894. Soltmann: The Chemistry of Cerebrospinal Fluid, Jour. Am. Med. Assn., 1903, p. 1569. Sbrenson: XJel;er die Messung und Bedeutung der ^Vasserstofftonenkonzen- tration bei biologischen Prozcssen, Ergebnisse der Physiologie, 1912, xii, 393. 112 CEBEBKOSPINAL FLUID Toison and Leiioble: Note sur la struetuve et sur la composition du liquide ceplialo-raeliidien ehez I'liomme, Compt. rend. Soc. de biol., 1891, xliii, 373-379. Turner: JiJxamination of the Cerebrospinal Fluid as an Aid to Diagnosis in Certain Cases of Insanity, Jour. Ment. So., 1910, Ivi, 485. Van Slyke: A Method for Determination of Carbon Dioxide and Carbonates in Solution, Jour. Biol. Chem., 1917, xxx, 347. Weston: The Reaction of the Oerebrosi^inal Fluid in the Psychoses, Jour. Med. Beseareh, 1917, xxxv, 367. Zdarek: Ein Beitrag zur Kcnntniss der Cerebrospinalfliissigkeit, Ztschr. f. physiol. Chem., 1902, xxxv, 202. CHAPTER V PATHOLOGIC CEREBROSPINAL FLUID Cerebrospinal fluid reacts to all processes that affect the central nervous system. The changes taking place in the fluid under pathologic conditions are due to two causes: systemic and meningitic. The systemic changes are due to metabolic disturbances in the body such as nephritis or diabetes. The meningitic changes are due to affections of the meninges. These may be divided into (1) simple ir- ritation of the meninges or of the brain tissue; (2) in- fection of the meninges. Irritation of the meninges may be produced by mechanical disturbances in the cra- nial cavity, or by the action of metabolic or infectious toxins. The latter condition is termed serous meningitis by some, and meningism by others, the latter term being used to describe all conditions wherein the meninges are irritated by some toxic substance which increases the amount and pressure of the cerebrospinal fluid without changing the chemical composition of the fluid or affect- ing its sterility. This is the condition that often exists in pneumonia, influenza, and otitis media. Simple irritative changes produce only physical alterations in the fluid or at most only slight physicochemical changes. Changes pro- duced by the entrance of bacteria into the fluid, on the con- trary, take on a varied character and may be physical, chemical, cytologic, and bacteriologic. These changes may appear singly or in various combinations at one and the same time. Some authors voice the opinion that the irri- tative and infectious changes differ in degree only, and not in character. I believe, however, that although there are changes common to both conditions, those in infections 113 114 CBEEBROSPINAL FLUID are different in type from those of simple irritation. Fur- thermore, the reaction is specific for each type of infection. Just how bacteria may enter the cerebrospinal fluid is still a matter of controversy. There are two ways in which they caji make their entrance : one is through the circula- tion and the other is by direct continuity from the nose or from the ears. For a long time it was thought that the attack of the meninges in epidemic meningitis or in poho- myelitis was by way of the lymphatics of the nasal mucous membrane, the bacteria passing through the cribriform plate of the ethmoid directly into the meninges. How- ever, the fact that the meningococcus in many cases may be cultivated directly from the blood in the early stages of meningitis, and that arthritis and iridochoroiditis often complicate meningitis would make one believe that the meningeal infection is most frequently hematogenous. The recent work of Austrian on experimental meningitis is also suggestive of the septicemic nature of meningococcic in- vasion. In tuberculous meningitis the infection hardly ever reaches the meninges directly from the nose. It is usually part of a general miliary tuberculosis of which the menin- gitis is a terminal process. From the work of Albrecht and Ghon, we know that the primary process of tubercu- losis usually takes place in the lung, and gives rise to an enlargement of the hilus glands, which in time either be- comes retrogressive with calcification, or goes on to a gen- eral miliary tuberculosis. According to this explanation, what happens in tuberculous meningitis, then, is first a tuberculous infection in the lung tissue proper ; second, an infection of the hilus glands; and third, an invasion of the meninges by way of the blood. It takes some time before the protective wall of the meninges is broken through by the tubercle bacilli, but they finally break through and in- fect the meninges. That tuberculous meningitis is a part of PATHOLOGIC CEREBROSPINAL FLUID 115 a miliary tuberculosis is seen on autopsy, miliary tubercles being found in the lungs, liver, and spleen in all cases. The pneumococci act much like the tubercle bacilli and meningococci in their relation to meningitis. Not every pneumonia, it is true, produces a pneumococcus meningitis but almost every pneumococcus meningitis is the result of a pneumococcus septicemia. Some observers claim that they have found pneumococci in the cerebrospinal fluid in uncomplicated pneumonia, but this seems very unlikely. There is no apparent reason why pneumococci in the fluid should produce meningitis in one instance and not in an- other. It is probably safe to assume that if no meningitis is produced there are no bacteria in the cerebrospinal fluid. The nervous system is the master system of the body, and Nature has provided it with protection by surrounding it with cerebrospinal fluid and with three layers of meninges, one of which, the dura, is especially heavy and firm. In addition, Nature also protects the meninges with the heavy walls of the skull and spine and in spite of the fact that the nervous system is a delicate system, and that the cere- brospinal fluid is not microbicidal it is not easy for bacteria to gain access to either. In certain cases the meningococci and other bacteria find their way into the cerebrospinal fluid through the crib- riform plates of the ethmoid. The nasal mucous membrane may harbor pneumococci and streptococci, meningococci and influenza bacilli, and it is conceivable that when the system is in a low state of resistance, the bacteria may en- ter the meninges directly. The cerebrospinal fluid in these cases, instead of being a means of protection for the cen- tral nervous system, serves as a good medium for the dis- semination of the bacteria. Still another route for the entrance of bacteria into the cerebrospinal fluid is the ear. In advanced cases of otitis media or mastoiditis, the bacteria may enter the brain substance, in which case they produce a brain abscess or 116 CBEBBROSPINAL FLUID the meninges, in which case they produce a meningitis. This happens most frequently in infections "with the pneu- mococcus, and with the streptococcus hemolyticus. Less frequently bacteria make their way into the cere- brospinal fluid through wounds of the skull and spine, es- pecially through fractures of the skull. Whichever way the bacteria enter the cerebrospinal fluid, once there, they produce changes in the meninges or brain and give rise to many alterations in the fluid. Some of the changes are common to all pathologic processes in the meninges or brain, whereas others are specific to cer- tain bacteria or toxic substances. Increase in Amount of Fluid It is the rule that whenever there is irritation in some serous cavity, the fluid normally present is increased in amount. This is true of the pleural cavity, the peritoneum, pericardium, and also of the meninges. Any irritation of the meninges, therefore, increases the amount of cerebro- spinal fluid, the increase in some cases being only moder- ate, in others very great. Is every case of increased cere- brospinal fluid to be termed a serous meningitis as Quincke proposed? It would seem less confusing to use E. Dupre's term of meningism for all cases where the fluid shows only physical changes and reserve the term meningitis for all processes producing chemical, cytologic and bacteriologic changes. The name, however, makes little difference. The important fact is that there are two classes of irritation of the meninges. It should be noted that the more acute the irritation, the greater the amount of fluid accumulating in the ventricle and in the subarachnoid spaces. Pressure With the increase in the amount of fluid in the subarach- noid there is naturally an increase in the pressure of the fluid, so that we very seldom have a pathologic process of PATHOLOGIC CEEEBKOSPINAL FLUID 117 the meninges without a corresponding increase of the pres- sure of the fluid. Here also the character of the process and the degree of its acuteness determine the increase in pres- sure. Foam I found that all pathologic fluids produce a foam on shak- ing. When a test tube is filled one-third to one-half its size with fluid, and is shaken for two or three minutes, a heavy foam one to two inches in thickness forms, persist- ing for half an hour or longer. When normal fluid is shaken in a test tube only a thin foam forms, disappearing in a few minutes. The foam is present in all pathologic fluids, but it is of greater size and duration in acute infections of the meninges. Eecently Zingher described the formation of a heavy foam in poliomyelitis which corroborates my observations. It seems but natural to think that the foam production is due to the CO2 in the fluid. Close observa- tion, however, does not bear this out. I found repeatedly that a foam formed just as readily in fluid in Avhich all the CO2 had been driven off, if the fluid was pathologic. The foam, therefore, is best explained by the increased amount of protein in the fluid. Cells Any infection of the meninges gives rise to an increased number of cells in the cerebrospinal fluid. The cells in disease are derived from the congested blood vessels of the meninges, the number of the cells varying with the causative organism and with the acuteness of the process. The character of the cells also differs with the type of the inflammation. In acute inflammations the polynuclear cells prevail and in subacute or in chronic inflammations the lymphocytes are the rule. In general paresis, according to Alzheimer, plasma cells predominate. Does an increase in the cells of the cerebrospinal fluid mean a corresponding increase in the white cells of the 118 CEREBROSPINAL FLUID blood? This interesting question has been studied by- many authors who found that although the leucocytes in the blood are usually increased in meningitis, the leuco- cytes in the blood and those in the fluid do not necessarily run parallel. There are cases of meningitis in which sev- eral thousand cells per c.mm. have been found in the cere- brospinal fluid, but only six to eight thousand leucocytes per cubic millimeter in the blood. There are other cases on the contrary where there is a high leucocytosis of the blood and only a slight increase in the cells of the cerebrospinal fluid. In addition to these changes common to all pathologic fluids, there are changes peculiar to special types of dis- ease. The changes are manifold, physical, chemical, phys- icochemical, and bacteriologic. I shall discuss here the mechanism of the various changes and leave the descrip- tion of the methods for the next chapter. Pellicle In addition to the physical changes which make their appearance in the cerebrospinal fluid under all pathologic conditions of the meninges, such as an increase in the amount, in the pressure, and the foam of the fluid, there is one change which takes place in the cerebrospinal fluid that is fairly characteristic for various diseases. This is the formation of a pellicle. In most acute diseases of the meninges a pellicle or a net of fibrin and blood cells forms in the fluid on standing. The time it takes a pelhcle to form varies with the charac- ter of the disease. In suppurative meningitis, the pellicle forms in a very short time. In tuberculous meningitis, it takes from twelve to twenty-four hours for the pellicle to form, although I have seen it form in as short a time as one hour. Some authors have described a pellicle formation in poliomyelitis and in lues of the central nervous system. I have observed a pellicle in poliomyelitis only very rarely. I PATHOLOGIC CEEEBROSPIlSrAL FLUID 119 have, however, observed a certain sediment in some cases of tabes dorsalis and in certain cases of cerebrospinal lues. The sediment formed was flocculent in type, resembling the floccnli formed l»y the Noguehi test, or after the addition of sodium hydrate to the fluid of tuberculous meningitis. The pellicle consists of a separation of the heavier ele- ments of the cerebrospinal fluid, so that microscopically Fig. 22. — Pliotomicrograph of stained pellicle from cerebrospinal fluid of a pneumococcus meningitis. one can see in the i)ellicle many leucocytes on a fibrinous background. (Fig. 22.) The formation of a pellicle depends on three factors: (1) fibrin; (2) fibrin ferment; (3) blood cells. Of these three factors the most important is the filn-in, although the other two also play an important role. The addition of blood serum to the cerebrospinal fluid accelerates the formation of a pellicle, but it is generally inadvisable to add blood serum, as it interferes ^vi{\\ chemical tests. The pellicle not only indicates the existence of a patho- logic condition, luit also, I believe, serves to show the phys- 120 CEREBROSPINAL FLUID ical ehaiigos produced in various fluids. Fig. 23 illus- trates tlie various forms of i)elliele in various diseases as observed early before autolysis takes place. Crystallization Another physical phenomenon which takes jilace in cere- lirospinal fluid on standing, is the formation of crystals, C. D. E. F. Fig;. 23. — I'elliclc formation in meningitis. H. A. Normal. B. Meningococcus meningitis, fairly early. C. Meningococcus menin- gitis, advanced ( sulijluir-]il!)). PATHOLOGIC CEREBROSPINAL FLUID 127 Table XX Comparison op Amount of Sediment prom the Metallic and Alkaloidal Precipitation with Nonmeningitic Fluids MEASUREMENTS OF THE DEPTH OF SEDIMENT IN MM. AFTER 24 HOURS NUMBER DIAGNOSIS 1 Psychosis 2 Tic 3 General paresis 4 Delirium tremens 5 General paresis 6 Psychosis 7 General paresis 8 General paresis 9 Psychosis 10 Psychosis 11 Psychosis 12 Meningism 13 Dementia precox 14 Alcoholic 15 Psychosis 16 Psychosis 17 Psychosis 18 . Psychosis 19 Meningism HgCU Sulphosalicylic Acid 4Ji 3 W2 3 33^ 3 3 3 3 3 4 3 2^ 3 Table XXI Amount op Sediment prom the Metallic and Alkaloidal Precipitation FROM Fluid of Tuberculous Meningitis MEASUREMENTS OP THE DEPTH OP SEDIMENT IN MM. AFTER 24 HOURS 1 10 2 15 3 10 4 11 5 6 6 7 7 9 8 13 9 11 10 10 11 6 12 10 13 20 Sulphosalicylic Acid 4 4 3J^ 5 3 3 6 5 7 4 3 4 5 128 CEREBEOSPINAL' FLUID Table XXII Measurement of Sediment from Metallic and Alkaloidal Precipitation FROM Fluid in Epidemic Meningitis Before Serum was Given measurements of the depth of sediment in mm. after 24 hours HgCl2 Sulphosalicylic Acid 1 1 8 2 2 7 3 1 20 4 1 10 5 7 20 These findings which can be utilized for diagnostic pur- poses speak in favor of my contention that there are spe- cific changes produced by various disease processes which manifest themselves both chemically and physicochemically. Although the fluid in cases of tuberculous meningitis contains less orga;nic substances than the fluid of epidemic meningitis as the table on organic' index shows, still the mercuric chloride solution produces a heavier sediment in tuberculous meningitis than it does in epidemic meningitis. Table XXIII shows further that the precipitants in ques- tion do not bear any quantitative relation to the amount of protein present in the cerebrospinal fluid. In determining Table XXIII MEECU- SULPHO- KIC SALIOYL' APPEAK- AMOUNT chloride IC ACID CASE DIAGNOSIS anoe OF SEDI- SEDI- of fluid PROTEIN MENT After 24 hours MENT After 24 hours 230 Tuberculous meningitis Clear 0.1% 20 mm. 5 mm. 231 Tuberculous meningitis Clear 0.1% 18 mm. 7 mm. 232 Tuberculous meningitis Clear 0.9%. 14 mm. 6 mm. 233 Epidemic meningitis Turbid 0.3% 5 mm. 20 mm. 234 Epidemic meningitis Turbid 0.25% 7 mm. 20 mm. PATHOLOGIC CEREBROSPINAL FLUID 129 the amount of protein present in the fluid I used the method of Esbach, except that I used half the proportions ad- vised for urine. I also added to the cerebrospinal fluid and the reagent, one drop of a 10 per cent solution of acetic acid. I put the entire solution into a small centrifuge tube which I allowed to stand for 24 hours undisturbed. I did not, however, centrifuge the mixture. Sugar The study of sugar in the cerebrospinal fluid in its rela- tion to certain diseases of the meninges, has occupied an important place in the literature. Kopetzky found an en- tire absence of sugar in all cases of meningitis. His method of determination was qualitative, however, not quanti- tative. Connall reported an absence of sugar in all acute infections of the meninges. Schloss observed an absence of sugar in some cases of tuberculous meningitis and a small amount in others. Hopkins found a smaller amount of sugar in the fluid of syphilitics than in any other condi- tion except meningitis. My own work on sugar in path- ologic cerebrospinal fluids with Strouse gave no alteration in the fluid of lues which ^ve found to contain a normal amount of sugar and gave an increase of sugar in diabetes, and either an entire absence of sugar in various forms of meningitis, or its presence in small or normal amount. Ta- bles XXIV, XXV and XXVI give some of our results. Table XXIV Sugar Content in the Cbrebbospinal Fluid of Lues NAME WASSERMANN TEST SUGAR content P. N. Strongly positive 0.104% M.L. Strongly positive 0.104 P.O. Positive 0.064 M.L. Strongly positive 0.048 J.J. Positive 0.070 J.L. Positive 0.074 E.M. Suspicious 0.080 130 CEREBKOSPINAL FLUID Table XXV SuGAE Content in Cerebrospinal Fluid of Diabetes NAME Cereb SUGAR CONTENT rospinal Fluid Blood Urine T. G. D.E. M.B. 0.076 0.38 0.28 0.080 0.42 0.24 Sugar Content IN THE Table XXVI Cerebrospinal Fluid op Meningitis NAME DIAGNOSIS SUGAR J. P. Tuberculous meningitis Absent E.L. Tuberculous meningitis 0.08% A.M. Tuberculous meningitis Absent M.E. Tuberculous meningitis 0.038 M.L. Tuberculous meningitis 0.032 I. W. Tuberculous meningitis 0.024 O.C. Meningococcus meningitis Absent H.F. Meningococcus meningitis 0.024 M.K. Meningococcus meningitis 0.028 J.E. Meningococcus meningitis Absent M.H. Meningococcus meningitis Absent S.N. Pneumocoocus meningitis Absent E.S. Pneumococcus meningitis Absent Among the other chemical constituents that undergo changes in certain diseases, are urea, phosphates, cholin, and cholesterol. In nephritis and uremia the urea has been found to be 3.7 per cent and even as high as 4.5 per cent, compared to 0.003 and 0.090 per cent in normal fluid. Some workers have also observed an increase of urea in the fluid in cases of arteriosclerosis with symp- toms pointing to an involvement of the central nervous system. Phosphates were found by Donath to be increased in conditions of rapid nerve degeneration, such as pro- gressive paralysis, tabes dorsalis and tumor of the brain. Mott and Halliburton found cholin in the fluid and also sometimes in the blood in cases of severe nervous lesions, especially in paresis. Donath found cholin in the fluid of epileptics and paretics, the largest amount being present in the latter. Pighini reported the presence of cholesterol in cases of general paralysis, dementia precox, and epi- PATHOLOGIC CEREBROSPINAL FLUID 131 lepsy. It was found to be present in 88 per cent of general paralysis, in 66 per cent of epilepsy, and in 43 per cent of dementia precox. The chlorides were increased in the cases of nephritis I examined. In the cases of meningitis I examined the chlo- rides differed with the type of infection as seen from Ta- ble XXVII. Table XXVII Chlorides in Meningitic Fluid NO. DIAGNOSIS CHLORIDES IN GM. PER 100 C.C. 1. Streptococcus meningitis 0.80 2. Meningococcus meningitis before serum 0.70 Same patient after serum 0.72 3. Pneumoeoccus meningitis 0.60 4. Tuberculous meningitis 0.50 Lactic acid was increased in the cases of suppurative meningitis I examined. It usually took only 5 to 6 drops of cerebrospinal fluid to turn 5 e.c. of Uffelman's reagent to canary yellow instead of 18 to 20 drops required for non- meningitic fluid. Acetone was present in some cases after the fluid had been standing for several days. In a case of influenza meningitis there was a deep "violet ring such as occurs in urine loaded with acetone. On a number of fluids from meningococcus meningitis the nitroprusside test for acetone gave a deep green ring. Turbidity By using one c.c. of cerebrospinal fluid in a test tube one- third inch in diameter, and adding to the fluid small por- tions of decinormal sodium hydrate and decinormal sul- phuric acid, I was able not only to detect the presence of a pathologic process, but also to get a clue as to the type of the disease. Normal cerebrospinal fluid shows no tur- bidity on the addition of either sulphuric acid or of sodium 132 CEREBEOSPINAL FLUID hydrate. The fluid of tuberculous meningitis, however, is not affected by sulphuric acid, but is precipitated by a very small amount of sodium hydrate. The fluid of suppurative meningitis, which is turbid to begin with, is cleared up by sodium hydrate and is not affected by sulphuric acid. PHYSICAL CHEMISTRY Among the most important changes that make their ap- pearance in pathologic conditions of the nervous system are those of a physicochemical character. Although not all physicochemical changes are of diagnostic value, they are all of significance in that they bring out specific changes typical of special diseases. What is more, further investigations on the physicochemical changes taking place in pathologic cerebrospinal fluids give promise of an even wider range of information that can be applied with equal effectiveness to pathologic conditions of other body fluids, such as blood and urine. Table XXVIII will show some of the variations found in physicochemical constants in various pathologic conditions of the cerebrospinal fluid. Table XXVIII Physicochesiical Findings in Various Forms op Meningitis specific gravity VISCOS- ITY TREEZING POINT CONDUC- TIVITY H-ION CONCEN- TRATION ALKALINE RESERVE Epidemic meningitis 1.0075 1.0434- 1.0735 -.55° to -.57°C. .011629 Immed. & On Stand- ing Increases slowly or may be- come more acid 18- 38% of CO, bound by the fluid Tuberculous meningitis 1.00693- 1.00626 1.0693 -.47° .013660 7.4- 7.6 Increases to 8.1 & higher 33- 58% of CO, PATHOLOGIC CEREBROSPINAL FLUID 133 A comparison of these figures with those given for nor- mal fluid (Chapter IV) shows the great variation between the physicochemical constants of pathologic and normal fluids. Other authors have reported even greater differ- ences. Achard, Loeper and Lanhry found the freezing point of fluid from tuberculous meningitis to be -.44°, and that of epidemic meningitis -.46°, whereas the freezing point of normal fluid usually varies between -.56° and -.58°. PROTEIN CHARGES It is well known that the electrical chaige of a protein depends on the reaction of the medium. In acid solution, proteins become electropositive, and in alkaline solutions they become electronegative, as shoMTi in Table XXIX. Table XXIX Showing Cataphoresis op Proteins; Figures Taken from Michablis SUBSTANCES Casein Serum Albumin Oxyhemoglobin Gelatin 11+ MOVES TO 4.9 X 10-* 4.1 X 10-5 1.3 X 10-5 1.2 X 10-' — 2.1 X 10-5 2.0 X 10-5— 19 X 10-5 1.1 X 10-5— 1.9 X 10-5 2.4 X 10-' 1.2 X 10-' 1.5 X-10-5 1.2 X 10-5 _ 3 5 X 10-5 3.9 X 10-5 Cathode Stand still Anode Cathode Stand still Anode Cathode Anode Anode Stand still Cathode It is thus seen that one way of precipitating protein is to let it combine with some radicle to form an insoluble protein salt. From the standpoint of the electrical charge of the protein such a protein is necessarily either a positive protein radicle forming a protein salt with nega-- 134 CEREBROSPINAL FLUID tively charged ions (alkaloidal precipitants), such as tungstic, picric, tannic acid and the like, or a negatively- charged protein combining with a positively charged metal (metallic precipitants) such as Cu, Ag, Hg, Zn, and Ph. If these protein salts are sufficiently insoluble, a precip- itate will come down. To ascertain whether the difference in the acidity of the cerebrospinal fluid under various conditions as discussed below is great enough to produce different electrical states of the proteins in the fluids, I have made a series of observa- Fig. 30. — -Apparatus for cataphoresis of proteins, after Michaelis. tions. The apparatus used was the one recommended by Michaelis. (Fig. 30.) The fluids were placed in 3, care being taken to see that there was no bubble inside the core of the stopcocks. Tubes 2 and 4 were filled with 3 per cent sulpho salicylic acid, and the upper portions (1 and 5), with distilled water. To one electrode was added CuCla and to the other NaCl; a silver electrode was put in the anode and a copper electrode in the cathode. The poles were connected to a light circuit with 110 volt constant current, with an ordinary lamp in the circuit as resistance. The object was to determine the PATHOLOGIC CEREBROSPINAL FLUID 135 pole to which the protein would move. The migration of the protein from the cerebrospinal fluid was detected by the formation of a precipitate with sulphosalicylic acid in the arm. This method, of course, is necessarily crude. For an accurate test it would be necessary that the H-ion concentration, the osmotic pressure of the precipitants and of cerebrospinal fluid be the same for each experiment — a procedure almost impossible on account of the variation in the fluid. Furthermore, under these conditions, positively charged protein has a better chance of forming precipi- tates at the cathode, while negatively charged protein, which moves to the anode, must change its charge at the anode in order to combine with sulphosalicylic acid. In other words, the amount of negatively charged protein to be pre- cipitated at the anode depends not only on the amount of protein that moves to the anode, but also on the strength of the acidity of the precipitating agent at the anode. Al- Table XXX REStTLTS OF CaTAPHORESIS ON FlUID FROM CaSES OF TuBEHCULOUS MENINGITIS CATAPHORESIS NUMBER TIME AFTER WITHDRAWAL Cathode Anode 1 2 hours I w 1 2 days 1 i 1 2 days i 2 2 hours i 2 3 hours i 3 1 day i 4 3 hours » 5 24 hours 'tf i Indicates heavy precipitate. J, Slight precipitate. 136 CEREBROSPINAL ELTJID Table XXXI Results of Cataphohesis on Fluids from Epidemic Meningitis CATAPHORESIS NUMBER INTERVAL REMARKS Cathode Anode 1 1 day 1 1 1 day 1 2 20 hours w 2 3 days 1 3 3 days M 3 2 days i 1 Fluid bloody 3 4 5 3 hours 8 hours 3 hours I 1 i 1 i Unusually alkaline fluid; cases brought in from another hospital; ad- ministration of serum not ascertained. 6 1 i i 6 17 hours 1 7 1 i i 7 2 days 1 » Indicates heavy precipitate. J, Slight precipitate. though this method is quite crude it is convenient for de- tecting the charge of protein in the cerebrospinal fluid. Tables XXX and XXXI show some of the results ob- tained on cerebrospinal fluid with the cataphoresis experi- ment. As is seen from the tables, a considerable amount of the protein in epidemic meningitis moves toward the cathode, showing the presence of positively charged protein in the cerebrospinal fluid of that disease. In tuberculous menin- gitis, however, the precipitate moves toward the anode, PATHOLOGIC CEREBROSPINAL FLUID 137 showing that the protein in that case is negatively charged. This again indicates the occurrence of specific biochemical changes in various diseases. The Colloidal Gold Reaction Lange has applied the work of Zsigmondy avIio found definite measures of the protective action of colloids on the precipitation of gold suspensions by sodium chloride, to the protein of cerebrospinal fluid. Lange found that nor- mal cerebrospinal fluid when diluted with 0.4 per cent so- lution of sodium chloride does not affect the solution of col- loidal gold, while pathologic fluid produces characteristic changes for various diseases. The exact mechanism of the gold chloride reaction is not well known, but we have here a distinct physicochemical reaction that not only signifies the existence of a pathologic state of affairs, but also indi- cates its nature as this test produces specific discolorations in certain diseases. Mastic Reaction The Lange test has been simplified by Emanuel by em- ploying a solution of mastic, the resin of the bark of Pis- tacia lentiscus, a tree of the Terebinthaceae. The mastic test works on the same principle as the Lange, and fur- ther corroborates the physicochemical specificity of dis- ease. Ninhydrin Reaction Noble has applied the ninhydrin reaction of Abderhalden to the cerebrospinal fluid and found that in tuberculous meningitis a blue to a blue-violet color appears on boiling 0.5 to 1 c.c. of spinal fluid with 0.1 c.c. of 1 per cent ninhy- drin solution for about one-half minute. Other workers have confirmed his observations. 138 CEKEBROSPINAL FLUID Changes in the Reaction of the Cerebrospinal Fluid Kopetzky applied the acidosis theory of Fischer to cere- brospinal fluid, claiming that the fluid presents an acidity of varying degree in all conditions which give rise to pres- sure symptoms of the brain. Kopetzky used litmus paper for his determination of the reaction and he also titrated the cerebrospinal fluid against decinormal sodium hydrox- ide solution. He expressed his results in grains of deci- normal hydrochloric acid solution, estimated for 100 c.c. of cerebrospinal fluid, using a one per cent phenolphthalein solution as an indicator. I studied the reaction of cerebrospinal fluid in disease from various points of view using the titration, the H-ion concentration and the alkaline reserve methods for this pur- pose. Originally I determined the reaction of the cere- brospinal fluid by titrating the fluid against n/100 sulphu- ric acid. The following method was used : In each of three Erlenmeyer flasks with a capacity of 50 c.c, 20 c.c. of distilled water was measured, all of the flasks being of the same height and width. Into each flask was put 1 drop of a 0.2 per cent solution of methyl red. This produced a straw-red color which was the neutral point. Then 1 c.c. of the fluid to be examined was placed in one of the flasks by means of a graduated pipette. This turned the solution still deeper yellow. The flask was now titrated with n/100 sulphuric acid until the neutral point was obtained. This was compared with the other two flasks, all three flasks being placed on a porcelain stand. When the neutral point was reached the reading was taken and then one more drop of the sulphuric acid was intro- duced. A bright red color appeared. In order to check the result 1 drop of n/100 NaOH was added. This gave the solution a straw color. Another drop was added which changed it to yellow, thus proving that the end point had not been overrun. This procedure gave no difficulty in obtaining a sharp end point. PATHOLOGIC CEREBROSPINAL FLUID 139 With this method it was found that normal or nonmenin- gitic fluid required between 1.5 and 2.6 c.c. n/100 to reach the end point which would correspond to an alkaline re- serve varying between 33 and 58 per cent total CO2. Fluid from epidemic meningitis required between 0.7 and 1.3 c.c. of n/100 sulphuric acid which would correspond to an al- kaline reserve varying between 18 and 29 per cent total CO2 and fluid from pneumococcus meningitis, the same amount. Tuberculous meningitis, however, acted the same as nonmeningitic fluid, requiring 1.5 to 2.6 c.c. of n/100 sul- phuric acid to reach the end point. (Table XXXII.) After I had completed my investigation of the reaction of the cerebrospinal fluid by means of this titration method, it was realized that the fluid on which the work had been done had been standing too long before examination to give an accurate idea of the real acidity of the fluid. I was also aware of the fact that the titrable acidity did not rep- resent the true hydrogen-ion concentration of the fluid al- though it does tell the titrable acidity or alkaline reserve. I, therefore, decided to determine whether there was a sim- ilar variation in the free hydrogen-ion concentration be- tween the normal and meningitic fluids of special types. To make the test the gas-chain method of Michaelis was used, and, benefiting by the experience with nonmeningitic fluid, I endeavored to examine fluid as soon after removal from the body as possible. To carry out the immediate examination it was often necessary to resort to the indicator method, using the Levy-Kowntree-Marriott standard and a special indicator, checking both indicators by the gas-chain ap- paratus. In over a hundred cases of meningitis examined and checked by the above methods, the following observa- tions were made : Fluid from cases of tuberculous meningitis differed in no respect from that of normal cases, the Ph being 7.4-7.6 immediately after withdrawal and ascending to 8.1 or 140 CEREBROSPINAL FLUID Table XXXII Titration of Cebebhospinal Fluid With Methyl Eed as Indicator DIAGNOSIS o w S O ., hJ o S O f« Q " to m M S S 8 td fc^ " OTHER TESTS REMARKS A— NONMBNINGITIC 1 11 yrs. Epilepsy 2.2 c.c. Negative o 12 yrs. Typhoid 2.2 Negative 3 8 yrs. Encephalitis (?) 2.4 Negative 4 40 yrs Lues 2.2 Wassermann Positive 5 Adult Cerebrospinal lues 1.8 Wassermann Positive 6 Adult Insanity 1.9 Negative 7 Adult Insanity 2.0 Negative 8 Adult Nephritis 2.2 Negative 9 11 mos. Otitis media, pneumonia 1.5 Negative 10 5% mos. Erysipelas 1.9 Negative B— MENINGITIC 11 11 yrs. Meningococcus meningitis 0.9 c.e. Before serum Increased pressure. 41,200 cells, 100% polymorphonuclear. Meningococci in smear and culture. After 3 doses of serum acidity 2.0 C.C. 12 10 yrs. Meningococcus meningitis 0.9 c.c. Before serum 2,400 cells, 99% polymorphonuclear. Meningococci in smear and culture. 13 4 yrs. Meningococcus meningitis 0.7 c.c. Before serum Several thousand cells per c.mm. 95% lymphocytes. Meningococcus in direct smear and culture. After serum 1.5 C.C. 14 Pneumococcus meningitis 0.9 CO. Chemical tests positive. Pneumococci in culture. 15 Pneumococcus meningitis 1.1 c.c. Pneumococcus in culture. 16 3 yrs Tuberculous meningitis 1.9 c.c. 'l\ibercle bacilli found in C.S. fluid. 17 20 mos. Tuberculous meningitis 2 c.e. 2.1 c.c. All chemical tests positive. Autopsy. ' PATHOLOGIC CEREBROSPINAL FLUID 141 higher. In some tuberculous fluids the H-ion concentra- tion decreased in a much shorter time than in normal fluid (Table XXXIII). H+ □ ONOENTRATION OF Table XXXIII Fluid feom TcBEKonLoirs Meningitis No. Ph Imme- diate Hour 1 Hour 2 Hours 3 Hours 4 Hours 5 Hours 12 Hours 18 Hours 24 Hours 2 Days orOver 1 8.69(a) 8.98(a) 7.9 (a)* 8.0-|-(b) 2 3 8!o (b) 4 8.6 (b) 8.6 (b) 5 6 7 8 9 10 7.4 (b) 7.4 (b) 7.4 (b) 7.4 (b) 7.4 (b) 8.0 (b) 8.0 +(b) 8.2 (c) 8.2 (c) . 11 7.6 (c) 8.2 (c) 12 13 7.4 (b) 14 7.4 (c) 15 8.0(c)* 8.1 (c) 16 17 8.0 (c) 8.8 (a) 7.8 (c)* 8.1 (c) 8.5 (a) 8.2 (c) 18 8.1 (c) 19 7.4 (c) 8.1 (c) 20 21 7.4 (c) 7.8 (c) 7.9 (c) 8.1 (c) 8.1 (c) 8.4 (a) 22 23 24 7.7 (c) 25 26 7.6 (c) 7.4 (c) 7.6 (c) 7.6 (c) 7.8 (c) 7.75(a) 7.7 (c) 7.8 (c) 27 28 7.4 (c) 7.6 (c) * Corked Fluid from cases of epidemic meningitis showed an H-ion concentration slightly higher than that of normal, the Ph being 7.2 to 7.5 immediately after withdrawal, the average being 7.3. The greatest deviation from normal, however, was observed in fluid allowed to stand, the H-ion concen- tration then decreasing slowly in some cases, remaining stationary in others, and increasing in still others. Usu- ally the graver the condition of the patient, the more turbid the fluid, and the longer the retention of the acidity. Administration of serum altered the H-ion concentration of the fluid, generally decreasing it. Cases of pneumococ- 142 CEREBEOSPIlSrAL FLUID cus meningitis showed a strong resemblance to those of epidemic meningitis. (Tables XXXIV and XXXV.) (Fig 31.) The slightly higher H-ion concentration of the fluid in epidemic meningitis as compared to normal, on im- mediate examination of the fluid, can be explained, I be- lieve, by the bacterial fermentation of the dextrose in the fluid as indicated by the absence of sugar or the les- sened amount of it in meningococcus meningitis — a fact «.t «./ S.I to TJ TT 7.6 U 7.i 11 n - O! «-■ ^ ■ - fl-ii^' .vV r' r' ^ c^]^ I ceo selfc ■J)^ ^ ^*^' Not^ ^^^\ n>;eft ___ .-' " ^- __^-^ r-^' — r Jill «rr>. mem •"ft S.no SCtM. mg.v en C 1 — ' 1 — 1 Ml) ^ — ^/ ^ "^ E :-de enin f-tiS 1 1 "i l—J raif lis) 1 f 7^ / Epi dsmi rtne Wi-n^ tisC seve e ca SO. :o.s* 20C Cno ben ■"g> ven> u ' 1 ^ * 5 6 7 8 9 10 11 11 n /4 15 16 n 18 19 20 21 23l Fig. 31. — Change in the H+ concentration of three types of cerebrospinal fluid. that has been brought out by several investigators. As for the mechanism responsible for the slow decrease in the H- ion concentration of epidemic fluid, there are several possi- bilities to be considered, such as a slower loss of CO2 in the fluid upon standing, a constant CO2 production by the cells present in the sediment of the fluid; lactic acid formation due either to further fermentation of sugar by the bacteria in the test tube or to a destruction of the cells on standing of the fluid. PATHOLOGIC CEEEBKOSPINAL PLUID 143 Table XXXIV H+ CONCENTHATION OF FlTTID OF EPIDEMIC MENINGITIS BefOHE ADMINISTRATION OP Sehum Ph No. Imme- diate H^u, 1 Hour 2 Hours 3 Hours 4 Hours 5 Hours 12 Hours 18 Hours 24 Hours 2 Days orOvcr 1 7.4 (b) 2 3 7.4 (b) 7.0 (b) 4 ?i n 7.8 (e) 5 7.7 (c) 7.8 (c) 6 7.4 (e) 7 7.2 (c) 8 7.1 (c) 9 ?:^ U 7.8 (c) 7.4 (c) 7.7 (c) 7.6 (c) 10 11 7.4 (c) 12 13 7.2 fe) 7.3 (c) 7.3 (c) 7.2 (c) 7.1 (a) 14 15 7.2 tc) 7.8 (c) 16 17 7.7 (cj 7.7 (aS 7.6 (c) 18 7.3 (c) 7.4 (c) 7.9 (c) 19 6.6 (c) 20 7.4— (c) 7.5 7.3— (c) 7.4 7.3 (c) 8.1 (c) 7.8 (c) 7.8 (a) 7.8 Ca) 7.9 (c) 6.0 (a) 21 22 Table XXXV H-IoN Concentration of Fluid of Epidemic Meningitis After Administration OF Serum Ph No. Imme- diate H^ur 1 Hour 2 Hours 3 Hours 4 Hours 5 Hours 12 Hours 18 Hours 24 Hours 2 Days orOver 1 2 3 4 7.4— (b) 7.0 (b) 5 7.4 (b) 6 7.4 (b) 1-4 (b) 7.1 (c) 7 7.0 (b) g 7.1 (b) 9 10 . !.,: i . . 7.4 (c) 7.6 (c) 7.8 (c) 11 12 7.3 (c) 7.7j (c) 13 14 7.2 {a 15 7.1 (c) 7.9 (c) 8.1* 7.7 (c) 16 17 7.3 (c) 7.6—7 (e) 7.7— (0) 7.7—7.8 (c) 18 7.4 8.2 * Diagnosis was not settled^ 144 CEREBROSPINAL FLUID I found that the Il-ion concentration of these fluids in- creased from 7.4 to 7.0 upon standing in tubes tightly corked, thus indicating that there is not only no loss of CO2, but that there is also a formation of certain acids on stand- ing. Nonmeningitic and tuberculous fluids give quite dif- ferent results (Tables XXXVI and XXXVII) . (Fig. 32.) With the view of further ascertaining the cause of this increase of acidity the following experiments were made: r„ ~ j-i «.o 1.1 V.I l.b ^^ 7.4 7.3 7.2 7.1 1.0 ^ ." ' / i,V-i < ^ "^ , .«^' r ' 1 ^ ^;-W ^ ^ 7i w\ f - ^ ^ - - c »»«_ ■"•i yj 2P')b < \ ^ n ^P '■^ \ ^J. ^ 2 4 (> t 10 12 14 lb It 20 2Z 14 hljilULi. Fig. 32. — Different effects of corking on tuberculous and epidemic fluids. Case 219a, tuberculous meningitis, cotton plugged; b, same fluid, tightly corked (no air above). Case 232a, tuberculous meningitis, cotton plugged; b, same fluid, corked (no air above). Case 223a, epidemic meningitis, cotton plugged; b, same fluid, tightly corked (no air above) ; Case 230a, epidemic meningitis, cotton plugged; b, same fluid, tightly corked (no air above.) In one chamber of the biometer (Tashiro) was put 1 c.c. of tuberculous meningitic fluid, and exactly the same amount of epidemic fluid in the other chamber. It was found that the tuberculous fluid gave off more CO2 than the epidemic, showing that although both tuberculous and epidemic fluids give off CO2 constantly, tuberculous fluid PATHOLOGIC CEEEBKOSPINAL FLUID Table XXXVI Tuberculous Fluid, Corked 145 FLUID DATE DRAWN DATE EXAMINED INTERVAL HOW STOPPERED Ph B. 6/28/17 9:10 7.4 B. 6/28/17 3:05 5 hours Cork 7.4 B. 6/28/17 3:05 5 hours Cotton 7.9 A. C. 7/13/17 11 a. m. 7/13/17 11 a. m. Immediately 7.5-6 7/13/17 7/14/17 11 a. m. 24 hours Cork 7.5-6 7/13/17 7/14/17 11 a. m. 24 hours Cotton 8.0 Table XXXVII Fluid from Epidemic Meningitis, with Cork and Cotton Stopper DIAGNOSIS DATE DATE INTERVAL STOPPERED Ph DRAWN EXAMINED WITH Epidemic 6/30/17 6/30/17 Immediate 7.3 meningitis 12:20 p.m. 12:20 p.m. 6:35 p.m. 6}4 hours Paraffined cork 7.0 6:35 p.m. 634 hours Cotton plug 7.7 Epidemic 7/6/17 7/6/17 Immediate 7.4 meningitis 2:30 p.m. 2:30 p.m. 7/7/17 18 hours Paraffined cork 7.3 8:30 a.m. 7/7/17 18 hours Cotton 8.2 8:30 a.m. Epidemic 7/11/17 7/11/17 Immediate 7.4-7.5 meningitis 11:30 a.m. 7/12/17 17 hours Paraffined cork 7.4 4:30 p.m. 4:30 p.m. 17 hours Cotton 8.1 Epidemic 7/11/17 7/11/17 Immediate 7.3-7.4 meningitis 1:30 p.m. 1:30 p.m. 7/12/17 7:30 a.m. 18 hours Paraffined cork 7.0 18 hours Cotton 7.8 Epidemic 7/14/17 7/14/17 Immediate 7.3 meningitis 7/15/17 22 hours Paraffined cork 7.1 22 hours Cotton 7.9 146 CEREBROSPINAL FLUID loses more CO2 than does epidemic. This suggests that the increased acidity in epidemic meningitis is not due to a greater production of CO2 but probably to the production of some other acid, very likely lactic acid. Further work on the subject showed a greater amount of lactic acid in the fluid of epidemic and other forms of suppurative meningitides than in that of normal or of tu- berculous meningitis. Furthermore, upon standing, the fluid of suppurative meningitides showed an increase in its lactic acid content. This was more marked in the fluids that contained many polymorphonuclear leucocytes. Many fluids that showed no acetone immediately after with- drawal, showed traces of it when allowed to stand for a day or two. These changes indicate that the increase, on standing, of the H-ion concentration of fluids from sup- purative meningitides is due to a constant formation of organic acids, resulting from the decomposition of the cells in the fluid. BACTERIOLOGIC Cerebrospinal fluid is sterile, even after it has passed through the nose as suggested by the cases reported in the literature. Any bacteria in the fluid, is, therefore, indica- tion of the existence of some pathologic process in the body, unless it is known that the bacteria are the result of some external contamination of the fluid after its removal. The cerebrospinal fluid is one of the best mediums for the growth of bacteria. They grow in it luxuriantly. However, at times it is very difficult to isolate the bacteria from the fluid. Some bacteria, such as the pneumococcus and streptococcus grow easily on ordinary culture media; others, notably meningococci and influenza bacilli grow only on special media and at that with difficulty, while still others, like the tubercle bacilli can hardly be grown at all. PATHOLOGIC CEREBEOSPINAL FLUID 147 IMMUNOLOGIC Immunology has thrown a great deal of light on the diagnosis and pathology, of diseases related to the nervous system. The various agglutination tests help to differenti- ate the various types of meningococci. The hemolysin re- action indicates a permeability of the meninges. The neu- tralization test assists in the diagnosis of poliomyelitis, and the Wassermann test is an invaluable aid in the diagnosis of syphilis of the nervous system. Agfglutination The agglutination test is based on the principle that various bacteria agglutinate when they are brought into contact with their respective sera. This principle is uti- lized for the identification of meningococci and pneumo- cocci. Hemolysin It has been found by a number of observers that normal cerebrospinal fluid contains no antisheep hemolysin, whereas the spinal fluid in some cases of meningitis and poliomyelitis has been found to contain hemolysin. The hemolysin test is of value as corroborative evidence of an inflammation of the meninges although the results of the test up to date are not constant enough to be of diagnostic value. Hauptmann found that the cerebrospinal fluid of patients suffering from lesions of the central nervous system in- hibits the hemolysis of erythrocytes which is usually pro- duced by a solution of saponin. He considers the inhibi- tion of hemolysis in cases of this kind to be due to choles- terin produced by the degeneration of nervous tissue. 148 CEREBROSPINAL FLUID Wassermann Reaction The Wassermann reaction has done a great deal to change our conception of diseases in general and of syph- ilis in particular. Most authors consider a positive Was- sermann test of the cerebrospinal fluid to be specific for syphilis of the central nervous system. Positive tests are reported to have been found in the fluid of other condi- tions, such as leprosy and beriberi, still it is practically pathognomonic of lues, especially in harmony with the clin- ical condition and the history of the case. A negative Was- sermann, however, does not always rule out syphilis. Bibliography Apelt and Sehumm: Untersiichungen iiber Phospliorsauregehalt der Spinal- fliissigkeit, Arch. f. Psych., 1908, xliv, 2. Ardin-Delteil : Note sur la toxicite du liquide ceiihalo-raohidien des para- lytiques generaux, Montpel. Med., 1904, xviii, 103. Austrian: Experimental Meningococcus Meningitis, Bull. Johns Hopkins Hosp., 1918, xxix, 183. Ball: The Value of Spinal Fluid in Diagnosis, Interstate Med. Jour., 1913, XX, 1109. Boyd: The Clinical Importance of Cerebrospinal Fluid, Brit. Med. Jour., 1914, i, 961. Chmielewska: Le liquide cephalo-raehidien dans les hemorragies du nevraxe, Thfese de Geneve, 190.5. Cimbal: Chera., physikal. u. morpholog. Ergebnisse an 240 Spinalpunktionen und deren diagnostisehe und therapeutische Verwertung; Therap. d. Ge- genvv., 1906. Donath: Das Vorkommen und die Bedeoitung des Cholins in der Zerebrospinal- fliissigkeit bei Epilepsie u. organischen Erkrankungen des Nervensystems, Ztsehr. f. physiol. Chem., 1903, xxxix, 526. Donath: Die Phosphorsauregehalt der Cerebrospinalfliissigkeit bei verschiede- nen Nervenkrankheiten, Ztsehr. f. physiol. Chem., 1904, xlii, 141. Grunberger : uber den Befund von Acetessigsaure in der Zerebrospinalfliissig- keit bei Coma diabeticum, Ztsehr. f. inn. Med., 1905, xxv, 617. Guillain et Pa rant: Sur la presence d'Albumines coagulables par la chaleur dans le liquide cephalo-raehidien des iparalvtiques generaux, Bev. neurol., 1903, xi, 406. Halliburton: Biochemie der peripheren Ncrven, Ergebniss der Physiol, 1905, iv, 23. Hauptmann: Eine biologische Eeaktion im Liquor Cerebrospinalflfisslgkeit bei organischen Nervenkrankheiten, Med. Klin., 1910, vi, 181. Herrick: Early Diagnosis and Intravenous Serum Treatment of Epidemic Cerebrospinal Meningitis, Jour. Am. Med. Assn., 1918, Ixxi, 612. Kauffman: ijber angeblichen Befund von Cholin in der Lumbalfliissigkeit, Neurol. Centralbl., 1908, xx, 966. Kcpetzky: Meningitis, Nature, Cause, Diagnosis, and Principles of Surgical Belief, Manhattan Eye, Ear and Throat Hospital Eeports, 1913. Landois : Lehrbuch der Physiologie. PATHOLOGIC CEREBROSPINAL FLUID 149 Launois et Boulud : Sur la Teneur en suere du liquide oeplialo-rachidien, Kev. neurol., May, 1904. Lockemann: Nachweis von Fleischmilchsaure im Blut, TJrin und Cerebro- spinalfliissigkeit, Miinchen med. Wchnschr., 1906, liii, 299. Latiner: Das Verhalten des Reduktionsindex in dem normalen und patho- logisehen Zerebrospinalfliissigkeit, Wien. klin. Wehnsehr., 1911, xxiv, 783. Mayerhofer: Zur Charakterislik und Differential Diagnose des Liquor Cere- brospinalis, Wien. klin. Wclinschr., 1910, xxiii, 651. Mott and Halliburton: The Chemistry of Cerebrospinal Fluid, Lancet, Lon- don, 1901. Myers: The Cerebrospinal Fluid in Certain Forms of Insanity With Special Eeference to the Content of Potassium, Jour. Biol. Ohem., 1909, vi, 115. Pighihi: tjber den Cholesteringehalt der Lumbalflussigkeit einiger Geistes- krankheiten, Hoppe-Seylers Ztschr. f. physiol. Chem., 1909, Ix, 508. Reichmann: Zur Physiologie und Pathologic des Liquor cerebrospinalis, Deutsch. Ztschr. f. Nervenh., 1911, xlii, 279. Eubenstone: Cerebrospinal Fluid and Its . Diagnostic Significance, New York Med. Jour., 1913, xeviii, 1210. Tashiro: Chemical SigTi of Life, Chicago, 1917. Thomson: A Note on Certain Peculiar Crystals Found in the Cerebrospinal Fluid from a Case of Septic Meningitis, Lancet, London, 1915, 653. Zsigmondy: Colloids and the Ultramicroseope, New York, 1909. CHAPTPJR VI METHODS OF EXAMINATION OF CEREBROSPINAL FLUID FOR DIAGNOSTIC PURPOSES In the following pages I shall outline the methods em- ployed in the examination of cerebrospinal fluid for the purpose of detecting the presence of pathologic processes. I shall describe only those methods that have been proved to be both simple and practical. PHYSICAL No special apparatus is required for the physical exami- nation of the cerebrospinal fluid with the exception of that used for the determination of the pressure of the fluid. All other physical examinations can be made by the naked eye. The amount of fluid Avithdrawn can be measured either in a graduate or it may be estimated. If the amount of fluid easily AvithdraA\Ti from the patient in recumbent position exceeds 10 c.c. a pathologic condition should imme- diately be suspected and the fluid carefully examined. Color The color of the fluid furnishes one of the best indica- tions of the existence of an abnormal condition. Normal fluid in its natural state is colorless. Any change in color is therefore significant. The best way to examine the fluid for color is to hold it up against the light with a background of black or yellow. The glass of the tube con- taining the fluid should be thin enough to show the color clearly and the tube itself should always be kept in the same position toward the light. Daylight naturally is better for the observation of color than artificial light. The specific 150 EXAMINATION FOE DIAGNOSTIC PURPOSES 151 changes of color in different conditions, in the various types of meningitis, and in conditions known as xanthochromia and in jaundice, will be described under their respective headings. Foam If only five or ten c.c. of fluid is removed the tube con- taining the fluid should be shaken and watched for the formation of foam. The length of time the foam persists should be observed, and its character noted, as both fur- nish a clew as to the presence and intensity of pathologic processes. If more than 10 c.c. is removed, the first tube, containing 2 to 3 c.c, should be put away for various examinations (Cf. Chapter III). The second tube, containing 3 to 5 c.c, should be left undisturbed for pellicle formation. The third tube, containing preferably between 9 and 10 c.c, al- though 5 c.c. will also do, should be tested for foam for- mation. After the foam has subsided, the fluid in this tube may be used for any purpose desired. PelKcle In looking for a pellicle, one must be careful not to dis- turb the fluid. It is therefore best to put the tube aside for this purpose, as soon as the fluid is collected. As for the best conditions under which a pellicle will form, no set rules can be given. Generally, a pellicle will form either at room temperature or in the cold. My experience has shown that a pellicle forms more easily at room temper- ature than on ice. Hence, the tube in which the pellicle is expected to form should be left at room temperature, abso- lutely undisturbed. Another point is that the pellicle must be examined not later than twenty-four hours after the withdrawal of the fluid, as autolysis often takes place, so that the pellicle undergoes changes on standing for two or three days. 152 CEREBROSPINAL FLUID CHEMICAL Many qualitative and quantitative chemical tests have been used by various scientific workers. Not all of the tests, however, are necessary or applicable for routine diag- nostic purposes. The quantitative determination of urea may be of value, as urea has been found to be greatly increased in the cere- brospinal fluid in cases of uremia and nephritis and at times also in arteriosclerosis. However, since the urea con- tent of the blood is also greatly increased in these condi- tions it is best to reserve this test for the determination of urea in the blood and to keep the fluid for other tests. The determination of phosphates has not been found practical because of its uncertain diagnostic value. The chemical examinations of the cerebrospinal fluid for diagnostic purposes should therefore be limited to albumin and globulin tests, permanganate index, sugar, and chlo- rides. In a rapid examination of the fluid all but the glob- ulin test may be dispensed with as the globulin increase is the one factor common to all inflammatory processes, whereas the sugar and chloride content often remain un- changed. In making the chemical tests one should make sure that all the vessels employed are chemically clean. Increase of Protein A number of qualitative tests have been described for the detection of an increase in protein. One is the acetic acid test of Moritz which consists of the addition of a few drops of a 5 per cent acetic acid solution to 2 c.c. of cere- brospinal fluid. If a precipitate forms, an increase of pro- tein is indicated. Another one is the nitric acid test. A few drops of nitric acid are added to the fluid, and a heavy cloud is produced if the protein content is increased. How- EXAMINATION FOn DIAGNOSTIC PUEPOSES 153 ever, neither of these two tests is employed to any great extent. The quantitative protein determination has been used by various workers for the diagnosis of meningitis and other pathologic conditions. Bybee and Lorenz employed the Brandenburger method for urinalysis for the determination of albumin, Mestrezat used a colorimetric method for this purpose. Probably the simplest method for the determi- nation of albumin in cerebrospinal fluid is the following : A glass tube, five to six millimeters in diameter and six to six and one-half inches in length is stripped by a piece of adhesive plaster, or fastened by a rubber band to an Es- bach albuminometer. The small tube is filled with cerebro- spinal fluid to a level corresponding to mark "U" on the Esbach tube, and with the Esbach reagent to a level corre- sponding to mark "R" on the albuminometer. The two tubes are allowed to stand for twenty-four hours, and the amount of precipitate in the small tube is then read off on the Esbach albuminometer, the result being expressed in grams of albumin per liter. GLOBULIN TESTS Several globulin tests have been proposed. Among the most important of them are the Noguchi, Ross-Jones, Non- ne-Apelt, the Pandy, and the sulphosalicylic mercuric chlo- ride tests. In doing any globulin test one must make sure at the beginning that the fluid is perfectly free of blood. Should there be any blood present in the fluid the globulin test will be positive even if no pathologic process exists. The effect of centrifugation on the fluid is not marked. I found very little difference between the globulin reaction of centrifuged and uncentrifuged specimens. The cells present in the fluid neither interfered with nor accelerated the positiveness of the globulin test. A description of the various globulin tests follows: 154 CEKEBROSPINAL FLUID Noguchi Two-tenths c.c. of cerebrospinal fluid is transferred by means of a pipette to a small test tube, preferably a regular Noguchi tube. Five-tenths c.c. of butyric acid solution (5 c.c. of butyric acid to 45 c.c. of physiologic salt solution) is added to the fluid; this mixture is boiled for a few seconds and 0.1 c.c. of a 4 per cent aqueous NaOH solution is poured into it and it is boiled again for a few seconds. If there is an increase in the globulin of the fluid a fine or coarse granular, flocculent deposit is formed in from five to twenty minutes. If no flocculence makes its appearance within two hours, or if nothing more than a slight opales- cence is present, it shows that the globulin is not increased. Ross-Jones The Ross-Jones test consists of the superimposition of 0.3 c.c. of a saturated solution of ammonium sulphate upon an equal amount of cerebrospinal fluid. The ammonium sulphate solution is prepared in the following manner: 85 grams of ammonium sulphate is put into 100 c.c. of water and boiled in an Erlenmeyer flask until no more salt goes into solution. This is then filtered and used for the test. If the solution has an acid reaction the results will not be accurate. If the globulins in the fluid are increased an opaque ring develops at the point of contact of the fluid and ammonium sulphate. Nonne-Apelt Phase I. — The constituents used for the Nonne-Apelt test are the same as those used for the Ross-Jones, except that equal parts of the cerebrospinal fluid and saturated am- monium sulphate are mixed instead of being superimposed one upon the other. A white precipitation forms in three minutes if the reaction is positive (euglobulin). Phase II. — The precipitate is filtered, one drop of a 10 per cent acetic acid is now added to the filtrate and the EXAMINATION FOR DIAGNOSTIC PURPOSES 155 mixture is boiled. A precipitation forms if the reaction is positive (serum albumin). Zaloziecki has modified the Nonne test, Phase I, in that he uses only 0.5 c.c. of cerebrospinal fluid instead of the original method of using 2 c.c. It has been found that 0.5 c.c. is just as accurate as is 2 c.c. Kaplan Method Five-tenths c.c. of cerebrospinal fluid is heated and boiled twice. Then 3 drops of a 5 per cent solution of butyric acid in physiologic salt solution is added to the test tube and is followed immediately by 0.5 c.c. of a supersaturated solution of ammonium sulphate. The mixture is now set aside for 20 minutes. An excess of globulin is indicated by a thick granular precipitate. Pandy One drop of cerebrospinal fluid is added to one c.c. of a concentrated solution of carbolic acid (1 part of phenol crystals to 15 parts of water). A bluish white ring or cloud results if an excess of globulin is present. Sulphosalicylic Mercuric Chloride Method • One c.c. of cerebrospinal fluid is introduced into each of two small tubes of uniform height and width, (about 0.3 cm. in diameter) ; into one of the tubes 1 c.c. of a 3 per cent sulphosalicylic acid is introduced, and into the other 1 c.c. of a 1 per cent mercuric chloride. If the fluid is pathologic, a heavy precipitate forms in the tube containing the sulpho- salicylic acid; if the fluid is normal only a slight turbidity appears. The tubes are then allowed to stand for twenty- four hours, after which the sediment in them is measured and compared. Under normal conditions the sediment found after 24 hours in either of the two tubes is very slight ; in all suppurative meningitides, however, the precip- 156 CEREBROSPINAL FLUID itation ^dth the sulphosalicylic is very heavy, often being three times the size of the precipitation obtained with the mercuric chloride. In tuberculous meningitis, the opposite reaction takes place, the precipitation with the mercuric chloride usually being three times as heavy as that obtained with sulphosalicylic acid. Relative Value of the Globulin Tests It would be well to emphasize the fact that there is no one test for the diagnosis of pathologic conditions that can be considered absolutely final. Furthermore, even all the tests together are at times unreliable, unless supported by additional observations. A careful worker soon learns that to make a correct diagnosis he must take into account the entire picture of the disease gained from both clinical and laboratory observations. There are so many possibilities for error in laboratory work that unless one combines the clinical with the laboratory results, he is apt to arrive at erroneous conclusions. As for the relative value of the dif- ferent tests, the experience of different workers varies. I found the sulphosalicylic mercuric chloride test the most helpful chemical or physicochemical test in the diagnosis of tuberculous meningitis. Early in the course of the dis- ease when other tests could not be depended on for definite results this test gave a positive reaction in the diagnosis of tuberculous meningitis. Many of my colleagues report a similar experience with this test. Of the other globulin tests, the Noguchi has been found the most reliable. The Eoss-Jones has at times been known to give a negative reac- tion when the other tests showed a positive reaction. The Nonne, Phase I, is not so sensitive as the Noguchi or even the Eoss-Jones although with a well-prepared ammonium sulphate solution the test is fairly reliable. As for the Pandy, it is very sensitive, but at times it precipitates even normal cerebrospinal fluid so that one is often at a losfe to know what is the borderline between normal and patho- logic fluid. EXAMINATION FOR DIAGNOSTIC PURPOSES 157 The Permanganate Test The test was described by Mayerhofer in 1910 for the determination of organic substances in cerebrospinal fluid, the method having originally been described by Kubel- Thiemieh for the determination of organic substances in water. Mayerhofer showed that every cerebrospinal fluid oxidizes, or, as he termed it, reduces, permanganate, and that fluid in cases of meningitis has a higher oxidation in- dex than normal fluids or even those of meningism. One c.c. of cerebrospinal fluid is introduced into an Er- lenmeyer flask by an accurately graduated pipette; 50 c.c. of distilled water and 10 c.c. of diluted H2SO4 (1 part H2SO4 and three parts H2O) are added, and the mixture is brought to a boiling point; 10 c.c. of a deeinormal perman- ganate solution is then introduced into the flask and the so- lution is boiled for exactly ten minutes. At the end of this time 10 c.c. of deeinormal oxalic acid is put into the flask, whereupon the red or yellowish-red color turns white. Ti- tration is now carried on drop by drop from a burette con- taining the permanganate solution until the color of the so- lution in the receptacle turns red and remains so for a num- ber of minutes. The number of cubic centimeters of per- manganate required to produce the end reaction is then read off and the figure is taken as the permanganate index. In doing this, one must make certain that 10 c.c. of n/10 permanganate equals 10 c.c. of n/10 oxalic acid. It is also necessary to ascertain how much permanganate is required to oxidize the water and the H2SO4 and this amount should be subtracted from the number of cubic centimeters of per- manganate required to oxidize the cerebrospinal fluid solu- tion. For example, if 4 c.c. of n/10 permanganate was re- quired for the cerebrospinal fluid and 0.5 c.c. permanganate for water and H2SO4, the 0.5 c.c. should be subtracted from the whole number, leaving the reduction index only 3.5. Boveri simplified the permanganate test. He uses 1 c.c. of cerebrospinal fluid and 1 c.c. of a 1 per cent permanganate 158 CEREBKOSPINAL FLUID solution. If the cerebrospinal fluid is normal, there is no change of color on contact of the fluid with the permaur ganate. In all pathologic fluids, a yellow ring forms on contact. When the fluid and the permanganate solution come into contact, the change in color appears in a few sec- onds or at most in a few minutes. The quicker the reac- tion, the more pathologic the fluid. Sugar The qualitative determination of sugar in the cerebro- spinal fluid by Fehling's solution is of no special diagnos- tic importance as by this method only an absence of, but not a decrease in, the sugar content can be detected. The quantitative determination, however, is of diagnostic significance. Several methods have been employed for sugar determi- nation, the most accurate one being the Lewis and Benedict method, originally described for blood sugar. The tech- nic is as follows: 2 c.c. of cerebrospinal fluid is put into a 25 c.c. volumetric flask containing 5 c.c. of distilled water, 15 c.c. of saturated picric acid solution is added, water filled up to 25 c.c. and the whole solution is shaken and filtered. Eight c.c. of the filtrate in duplicate are put into large Jena test tubes for determination; 2 c.c. saturated picric acid solution and 1 c.c. of a 10 per cent sodium carbonate solu- tion are added ; the contents of the tube is evaporated over the flame until precipitation occurs, 3 c.c. of water is added and the tube heated again to the boiling point, in order to dissolve the precipitate ; the contents of the tube is now transferred to a 10 c.c. volumetric flask, cooled, filled up to the mark with water, shaken and filtered through cot- ton into a colorimetric flask; the color is compared in a Dubosque colorimeter either with a dextrose standard, freshly made up every time, or with a permanent standard consisting of 0.064-mg. picramic acid and 0.1 gm. sodium carbonate in 1000 c.c, and the results are calculated. EXAMINATION FOB DIAGNOSTIC PURPOSES 159 Epstein described a rapid mierocliemical method for the determination of sugar in the blood which I believe may easily be applied also to the cerebrospinal fluid. The principle is the same as that of the Lewis-Benedict method, except that a permanent standard is used and smaller quantities of the fluid to be tested are used. It differs from the blood sugar test in that in the determiniation of sugar in the cerebrospinal fluid, no sodium fluoride or potassium oxalate has to be used as is the case in sugar of the blood. The apparatus consists of the following: (a) Sahli-Gower hemoglobinometer stand and a gradu- ated tube. (b) Two standard color tubes, one for measuring quanti- ties of sugar ranging from 0.05 to 0.1 per cent and the other for measuring quantities of sugar over 0.1 per cent. (c) A test tube (% by 4 inches) graduated at 1.0 c.c. and 2.5 c.c. (d) A special pipette graduated at 0.1 c.c. and 0.2 c.c. (As will be seen later, this pipette may be dispensed with.) (e) A test tube suitable for boiling fluid. The procedure is as follows: 0.2 c.c. of cerebrospinal fluid is drawn up with the pipette of the apparatus or any other graduated pipette into the large graduated test tube. Distilled water is then drawn up into the pipette and dis- charged into the graduated test tube, till the fluid reaches the 1.0 c.c. mark; picric acid is added to the 2.5 c.c. mark, and the tube shaken vigorously; the contents are filtered through a small filter, or centrifuged for 2 to 3 minutes ; 1 c.c. of the filtrate is now withdrawn, put into the boiling tube and heated carefully over the naked flame. The con- tents of the tube is boiled until all but 2 or 3 drops of the solution is evaporated. Five-tenths c.c. of a 10 per cent soda solution is now added and the tube heated again until the contents are down to a few drops, the color of the fluid being changed from yellow to deep red or reddish brown. Three or four drops of distilled water are added and the 160 CEREBROSPINAL FLUID tube warmed gently. The contents are next transferred to graduated tube 1. The boiling tube is rinsed several times with a few drops of water, the tube being warmed with each rinsing. The volume of the fluid is then made up to mark 50 on the scale. The color of the resulting solution is now compared with one of the two standard tubes A or B. If the fluid tested is darker than the standard A which represents 0.05 per cent of sugar, and is lighter than stand- ard B which represents 0.1 per cent of sugar, the first standard is used for comparison. The solution in the graduated tube is gradually diluted with water until the color matches. The percentage of sugar on using standard A is figured out. Each reading on scale being 1/1000. For example, if the reading is 86 then 86/1000 = 0.086 per cent. If B is used, the figure on the scale is multiplied by 2 divided by 1000. For example, if the reading is 73, then 73 X 2 _ Q_-,^4g_ 1000 I have checked the Epstein method against the Dubosque colorimetric with a standard solution of dextrose. The de- termination by Epstein method usually gave a higher read- ing of dextrose than the amount originally started with. The percentage of error, however, was small. I think it could be accounted for by the fact that the picramic used by Epstein in the standard tubes loses some of its potency in time; the result of it being that the solutions to be tested gave a higher percentage of sugar than the solution really contained. I have also encountered difficulty in using the pipette designated by Epstein for drawing up the fluid. The lumen of the pipette was too large so that when I suc- ceeded in getting 0.2 c.c. of cerebrospinal fluid, the fluid would run out of the tube before I had a chance to empty it into the test tube. This difficulty, however, Avas done away with by calil)i-ating my own tubes, using graduated pipettes and ordinary centrifuge tubes for that purpose, so that I had a double check on the amount used. I let the spinal EXAMINATION FOR DIAGNOSTIC PURPOSES 161 fluid drop down into the centrifuge tubes up to the 0.2 c.c. mark on the tube, using the same tube for the purpose of centrifugation. Chlorides For the quantitative estimation of chloride in the cere- brospinal fluid, the Seelman method originally described for the determination of chloride in urine is the most prac- tical. It requires only 0.5 c.c. of fluid and the results are quite accurate. Two solutions are prepared for the test. Solution 1 con- sists of the following : Anhydrous, crystallized silver nitrate, (C. P.) 29.055 gm. 25% nitric acid in distilled water 900. c.c. Cold saturated solution of ammonioferrie alum in distilled water 50. " Distilled water, q. s 100. ' ' Solution 2 consists of: Ammonium sulphocyanate ~ g™- Distilled water 1000 c.c. Solution 2 is intentionally made too strong, and must be standardized by adding distilled water in such an amount that exactly the last drop of 2 c.c. of this solution will bring about the end reaction when added to 1 c.c. of Solution 1. The end reaction consists of a reddish-brown color, which does not disappear on moderate stirring. If the second last drop produces a discoloration which disappears rather slowly, and the last drop a deep brown color, the solution must be still further diluted, until the discoloration on the addition of the last drop is a light reddish-brown, which does not disappear on stirring fifteen to twenty seconds. The test proper is made as follows: 0.5 c.c. of cerebro- spinal fluid to be tested is placed in a porcelain dish, 1 c.c. of Solution 1 is then added and the mixture is stirred for about a minute with a glass rod. Solution 2 is now added drop by drop by means of a 2 c.c. pipette graduated to at 162 CEREBROSPINAL FLUID least .05 c.c. and the mixture is stirred until the brown color developing after each drop disappears. The amount of Solution 2 which has been used to bring about the end reaction is now read off, and the difference between this and 2 is equal to the number of grams of sodium chloride per 100 c.c. of the specimen tested. If for example, it takes 1.26 c.c. of Solution 2 to bring about the end reaction, the amount of chloride in 100 c.c. of cerebrospinal fluid equals 2. - 1.26 which equals 0.74 per cent of chlorides. PHYSICOCHEMICAL METHODS If determined accurately, specific gravity, viscosity, sur- face tension and freezing point, are of some value in eluci- dating diagnosis of pathologic conditions. However, since accurate determinations of physicochemical constants re- quire a great deal of care and consume a good deal of time, I do not recommend most of them for routine laboratory- use. I believe, for instance, that specific gravity, to be of any value, should be determined by a pyknometer, the de- termination of specific gravity by the urinometer method being very inaccurate, and requiring more fluid than can be spared even in pathologic conditions. The pyknom- eter, however, is a delicate instrument, and consumes a great deal of time in drawing up the fluid without bubbles, in weighing the instrument, and also in keeping it at a constant temperature. It is, therefore, best to leave it out in ordinary laboratory work. The determination of the H-ion concentration and of the alkaline reserve of cerebrospinal fluid, however, is of greater value than some of the other physicochemical con- stants. As has been shown in Chapter V the li-ion concen- tration and the alkaline reserve varies in the different types of meningitis especially after the fluid stands uncorked. This makes it of diagnostic importance to say nothing of the scientific interest attached to it. I would, therefore, ad- EXAMINATION FOR DIAGNOSTIC PURPOSES 163 vise to determine the H-ion concentration and the alkaline reserve whenever a sufificient amount of cerebrospinal fluid can be spared after other more important tests have been made. The method for the H-ion concentration in routine laboratory work, I would recommend, is that of Levy- Eowntree-Marriott. This method requires only 3 c.c. of cerebrospinal fluid and very few apparatus. The gas-chain method, although more exact, requires 7 to 8 c.c. of fluid and is highly complicated. The technic of the Levy-Eown- tree-Marriott method is as follows: Three c.c. of cerebrospinal fluid is collected directly from the lumbar puncture needle, or from another test tube into a nonsol glass tube. To this is added 0.2 c.c. of the in- dicator which consists of a solution of 0.01 per cent of phenolsulphonephthalein. The tube with the cerebrospinal fluid is now compared in a special stand with one of the series of sealed standards ranging from a Ph of 6.6 to a Ph of 8.6. If sufficient fluid has been obtained, it is advisable to de- termine the H-ion concentration immediately after the fluid has been removed from the body and also several hours later. If no large amount of fluid can be spared, the H-ion concentration should be determined only once, im- mediately after the removal of the fluid from the body. It must always be kept in mind that the H-ion concentration changes on standing and the time factor must be taken into consideration in order to arrive at any conclusion. Some authors have used a dialyzing tube for the deter- mination of the H-ion concentration of the cerebrospinal fluid by the indicator method. I have, however, found that with the exception of severe cases of epidemic menin- gitis where the protein content is very high, no dialysis is necessary and that the result obtained by the indicator method corresponds quite well with those obtained from the gas-chain method, especially in Ph reading of 7.0 to 8.1 164 CEREBROSPINAL FLUID For the determination of the alkali reserve, the Van Slyke method is the most accurate and requires the least amount of fluid. Lange Gold Chloride Test The Lange test is a very sensitive one and is quite helpful in detecting various forms of syphilis of the nerv- ous system and often also in discovering the type of meningitis. It is a test, however, which calls for extraordi- nary care and precision on the part of the one who is mak- ing it. To begin with, the vessels in which the solutions are used must be perfectly clean. Secondly, the vessels must be neutral in reaction. Thus, after the glassware has been cleaned with bichromate solution, for instance, sufficient water should be run through the vessels to make the reaction neutral. The water used in making up this so- lution must be doubly distilled, and if possible, trebly dis- tilled. The pipettes used for measuring the cerebrospinal fluid and sodium chloride solution must be accurately grad- uated. Great care must also be taken not to blow the pipette in emptying the solution, for the introduction of saliva or carbon dioxide into the solution will greatly interfere with this delicate physicochemical reaction. There is one point, however, in which the Lange test requires less precaution than other tests and that is, in the matter of the time inter- vening between the drawing of the cerebrospinal fluid and the application of the test. While in an examination for pellicle or for the cells of the cerebrospinal fluid time of standing is a great factor, the examination with colloidal gold may be made, even after the cerebrospinal fluid has been standing for some time. The solution for the test is prepared in the following manner : To 1000 c.c. of doubly distilled water, which is heated slowly to 60° C, 10 c.c. of a 1 per cent gold chloride solu- tion and 7 c.c. of a 2 per cent solution of K2CO3 are added. EXAMINATION POR DIAGNOSTIC PURPOSES 165 The mixture is then rapidly heated to 90° C. The flame is then removed and 5 c.c. of a 1 per cent formaldehyde solu- tion is added quickly. The solution should at once assume a ruby red color. The solution when ready for use should be transparent, should be neutral in reaction, and should be precipitated by 1.7 c.c. of a 1 per cent sodium chloride solution in one hour. The solution usually re- mains indefinitely without spoiling, although it is best to keep it in a bottle wrapped in dark paper. The technic of examining cerebrospinal fluid for the col- loidal gold test is as follows : A series of 10 large test tubes are put in a test tube rack and numbered. In the first test tube 0.2 c.c. of cerebro- spinal fluid is poured and to it is added 1.8 c.c. of a 0.4 per cent solution of sodium chloride. Into each of the other tubes, 1 c.c. of sodium chloride is poured. The contents of the first tube are then thoroughly mixed and 1 c.c. of the amount is poured into the second tube. The contents of the second tube are then mixed and 1 c.c. of its solution is emptied into the third tube. And so the processes con- tinue with all the tubes, until 1 c.c. of the solution in the ninth tube has been emptied into the tenth tube. The solu- tion in the tenth tube is then thoroughly mixed and 1 c.c. of its contents is removed and discarded. This leaves each tube with a content of 1 c.c. and gives the following series of dilution 1 :10, 1 :20, 1 :40, 1 :80, 1 :160, 1 :320, 1 :640 ; 1 :1280 ; 1:2560, 1:5120. Five c.c. of the prepared colloidal gold solu- tion is then added to each test tube and the tubes are put away and the changes taking place in them observed. Gen- erally some change occurs in a very short time, but it is best not to attempt to judge the reaction before the lapse of an hour and it is still better to wait until the next day, for sometimes it takes 24 hours for a completion of the reaction. The tubes should be read in daylight as artificial light may cause a false interpretation of the changes. 166 CEKEBROSPINAL FLUID Mastic Test The mastic test Avliich has been described by Emanuel has been used by some observers with success and those observers recommend it for use in routine exami- nation of cerebrospinal fluid. The principle is the same as that of the Lange gold chloride and the advantage claimed for this test is the fact that the mastic solution is easily made up, much more easily than the gold chloride solution. Until we get further data on the subject, I would suggest that between the two tests, the Lange and the mas- tic, the tirst is preferable. However, when time permits, the mastic test should be employed for corroborative evi- dence. The technic described for the mastic test is that of Emanuel modified by Cutting. The technic follows: A stock mastic solution is made by dissolving 10 gm. of gum mastic in 100 c.c. of absolute alcohol. The solution is filtered. This stock solution keeps indefinitely if well corked. To 2 c.c. of this solution 18 c.c. of absolute alcohol are added, and insufflated rapidly into 80 c.c. of distilled water, this makes an emulsion of mastic which is opales- cent when held to the light. This solution can be used im- mediately or after several days; indeed, the reactions seem to be more easily read when a solution is employed which has stood for at least a few hours. Next, a 1.25 per cent sodium chloride solution is made with distilled water, and to each 99 c.c. of this salt solu- tion is added 1 c.c. of a 0.5 per cent solution of potassium carbonate made up with distilled water. Then six small test tubes are placed in a rack. These tubes should have been washed thoroughly in tap water, then in denatured alcohol, to remove any old mastic adher- ing to the sides of the tubes, rinsed in distilled water and dried, conveniently in the hot air oven. To the first tube 1.5 c.c. of the combined salt and potassium carbonate so- lutions are added, and to the others 1 c.c. each. Then 0.55 c.c. of spinal fluid is added to the first and after thorough EXAMINATION FOE DIAGNOSTIC PURPOSES 167 mixing, 1 c.c. is transferred from the first to the second, 1 c.c. from the second to the third, and so on, the last cubic centimeter that remains over from the next to the last tube being thrown out, and no spinal fluid being put in the con- trol. Now to each tube, 1 c.c. of the mastic solution is added and stirred thoroughly with a glass rod, care being- taken to wash the rod with distilled water before going to the next series. It is best to finish each group before be- ginning another. The racks are set away, and in from twelve to twenty- four hours the end results can be read. If the racks are placed in an incubator at 37.5° C, the precipitation is com- plete in from six to twelve hours. CYTOLOGIC EXAMINATION The examination of the cells in the cerebrospinal fluid is of extreme importance diagnostically and should be in- cluded in every routine examination of the fluid. There are essentially two methods of counting the cells; one is the sedimentation, or French method, and the other is the counting chamber method. The French Method of Cell Counting This method, originally described by Ravant, Sicard and Widal, is as follows : 3 to 4 c.c. of fluid is centrifuged for forty -five minutes. The fluid is then poured off and a few drops of the sediment are drawn up into a pipette of small caliber, and put on a glass slide, making a smear of uni- form thickness. The slide is dried in the air, fixed in the flame, and stained with methyl blue or with Wright stain and examined under the microscope with the high power or oil immersion lens. The number in each field is now read. The results of this examination are recorded as follows : 0-3 cells per field — normal 4-6 cells per fleld — suspicious 7-20 cells per field — ^abnormal 20-150 cells per field — markedlj' pathologic I(i8 CKKHBTiOSPINAJj KHMD Chamber Method of Cell Counting Either a special couiitiiig eliaiuher for spinal fluid, such as the Fuchs-Tvosenthal comitiiift' cliainher, or the ordinary leucocyte chanilier, sucli as tlie Tliouia-Zeiss or Neuhauer cliainher may he used. The Fuclisdioseiitlial cliainher (Fig. '.VS) is lai-ger than the ordinary leucocyte cliainher, heing 16 nmi. square and i).'2 mill, deep, whereas the Tiioma-Zeiss chamher is only 1 mm. square and O.l mm. deep. (Fig. ?)4.) The cells are counted in the following way hy the Fuclis- Eosenthal method : the Huid is drawn u]) into a white l)loo' hlood counting chamber for count- ing the cells in cerebrospinal fluid any of the standard chamhm's answer the ]iurpose quite well. The same solu- tion used for staining tlie cells in the Fuchs-Rosenthal' chamher is also used here, nanudy, nietliyl violet 0.2 gm., glacial acetic 5 c.c. and water to lt)0 c.c. Tlie methyl violet is drawn up into the pipette to mark 1.0 and tlie spinal fluid EXAMINATION FOR DIAGNOSTIC PURPOSES 169 to mark 11. This gives a dilution of 1 :10. Since the ruled surface of the blood counting chamber has an area of 9 square millimeters and the deptli of the chamber is %o milli- meter, the total count of the ruled surface will be the amount contained in the entire volume which is %o cubic millimeters. To obtain the number of cells in one cubic millimeter % of the entire cell count has to be added to the number found. Since to ten parts of the spinal fluid, one part of counting fluid was added the result obtained corresponds to %o of the number of cells in a cubic millimeter of pure spinal fluid. Therefore, in order to obtain the number of cells in one c.mm. of spinal fluid, we have to make allowance for this by adding % to the result obtained. This gives the number of cells per cubic millimeter of undiluted cere- brospinal fluid. Example: Let us suppose that the chamber contains 90 cells in its nine fields. A counting chamber %o c.mm. volume contains 90 cells. Then le.mm. will contain i% x 90 cells = 100 cells. In other worfls, 100 cells are contained in one cubic millimeter of space which contains nine parts of spinal fluid and one part of methyl violet. In ten parts of fluid, therefore, we will have 111 cells. Comparative Value of the Two Methods The centrifuge method of counting the number of cells in the spinal fluid is open to several rather serious objec- tions. First of all the method is not accurate enough as it is not always easy to measure the exact amount of fluid put into the centrifuge tube. Moreover, the size of the drop taken from the sediment of the fluid can not possibly be the same at all times. Furthermore, the force of centrifu- gation and the rate of velocity of the centrifuge are iih- portant determining factors. Still another drawback is the fact that the centrifuge method requires a great amount of fluid for counting, more than can usually be spared. For precise results, I should therefore, reconunend the use of the blood or fluid counting chamber. Plowever, when a rough estimate of the number of cells is all that is re- 170 CERBBKOSPINAL FLUID quired, the centrifuge method is perhaps the more con- venient one to use. Another point in its favor is the fact that it enables one to study the type of the cell on one and the same slide. There is one thing, however, that can not be emphasized too strongly and that is, that whatever method is em- ployed, the examiner should thoroughly familiarize him- self with it and should use it as a standard, so that he can easily detect even a slight increase in the cells of the spinal fluid. Another thing to remember is that the cells should be counted immediately after withdrawal of the fluid from the body, as they undergo autolysis upon standing. When the cerebrospinal fluid is blood stained, the speci- men may still be utilized for cell counting, if only a rough count is desired. It is known that under normal conditions the blood contains one lymphocyte to three leucocytes. To obtain the number of lymphocytes, therefore, the white blood cells in the spinal fluid should be counted and the re- sult divided by three. Type of Cells In doing a differential cell count, care must be taken to count only the white cells and not the red cells or the de- bris. When the fluid is turbid as in epidemic or in pneumo- coccus meningitis, a differential cell count may be made on the fluid directly without centrifugation. As a rule, however, it is best to centrifuge the fluid from fifteen to thirty minutes through about 1500 revolutions. If the fluid contains only a very small amount of protein, some egg albumin may be rubbed on the slide to prevent the smear from being washed off. The fluid may be stained with Wright's stain, or with other blood stains such as Jenner's, Leischman's, or eosin hematoxylin and the cells counted according to their type and the cell count ex- pressed in percentages. As a rule, however, no special stain is needed for tlie differential cell count, for usu- EXAMINATION FOE DIAGNOSTIC PURPOSES 171 ally the gram stain shows the cells quite well and also stains the organisms at the same time. If tuberculous meningitis is suspected, the special carbol fuchsin stain should be used, as it shows the tubercle bacilli and also stains the cells well. BACTERIOLOGIC One must be very careful in doing bacteriologic work on spinal fluid, for there are many technical factors that may interfere with the success of the work. Such factors may be wrong media, insufficient length of time for the or- ganism to develop, contamination of the media, dirty slide, overheating of the slide, (protein particles often look like bacteria) and faulty stains. At times, I have found or- ganisms in a spinal fluid smear done by a novice that did not belong to the spinal fluid, but were introduced while in the centrifuge tube, or were on the slide used for a urine examination. Culture Media One drop on a platinum needle or several drops are planted on a culture medium. The kind of media to plant the spinal fluid on depends on the type of organism looked for. Most organisms grow on plain agar. Meningococci have given some workers great difficulty in that they do not grow easily on ordinary media. I, however, have grown meningococci successfully on ascitic dextrose agar and also sheep blood agar. It is strongly advisable to im- plant every specimen of cerebrospinal fluid on several me- dia, such as blood agar, ascitic dextrose agar, and glucose and agar. The culture should be examined microscopically after twenty -four hours' incubation, and also after forty- eight hours, as some organisms do not manifest their char- acteristics till after forty-eight hours of incubation. In addition to the culture media, it is a good plan to put the spinal fluid left over in the test tube directly into 172 CEREBROSPINAL FLUID the incubator and to examine it twelve to twenty-four hours later for organisms, as it has been found that some organisms, especially the meningococci, will show up well after the spinal fluid has been incubated for several hours. Direct Smear Several cubic centimeters of spinal fluid are centrifuged in a centrifuge tube for several minutes, the supernatent fluid is poured off and the sediment is put on a slide and stained. Where suppurative organisms are suspected it is best to stain with both methyl blue and gram stain. When .tubercle bacilli are searched for, the fluid should be al- lowed to centrifuge at high speed for forty-five minutes to one hour and stained by the Ziehl-Neelsen method. If there is more than one tube of cerebrospinal fluid, it is ad- visable to examine the pellicle formed in the tube for tu- bercle bacilli. In my hands this has given good results. If the spinal fluid is very thick, the smear may be taken from the uncentrifuged spinal fluid. IMMUNOLOGIC Among the immunologic tests in routine cerebrospinal fluid examinations are agglutination tests for meningococci and pneumococci, precipitin tests of cerebrospinal fluid with antimeningococcus seriim, the neutralization test for anterior poliomyelitis, and the Wassermann test. Two ag- glutination tests have been described for the meningococ- cus; the macroscopic and the microscopic. Macroscopic Method A polyvalent antimeningococcus serum which has been proved by appropriate tests to agglutinate estabUshed strains of meningococcus in dilutions from 1 :200 to 1 :2000 is used. EXAMINATION FOR I>IA(iNOSTIC PXTp^posES 173 A meuiiio-ococcus culture, preferably ouly 24 hours old, grown on ascitic dextrose agar or on blood agar is washed down with 2 or 3 c.c. of an 0.8 per cent sterile salt solution ; 0.2 c.c. of this nieningococcns emulsion is added to a series of small test tubes each one containing 0.8 c.c. of various serum dilutions such as 1:10, 1:20, 1:40, 1:80, 1:100, 1:500, 1:1000, 1:2000 strength. This is mixed and incubated over- night (15 to 20 hours) at 5G'-' C. Controls of meningococcus .4. D. /■:. f. Fig. 35. — Photagrajili showing agglutination of niL'ningococci Ijy tlic macroscopic tiiethoj. A. limnlsion of meningococci + 1 ;1U tiiliition of antimeningococcus scrtmi. ^. Control of cniulsion of meningococci + salt solution. C. Emulsion of meningococci + 1 :1'>0 diltition of antimeningococcus serum. D. Control. Jv. limulsiou of meningococci + 1 :o40 flilution of antimeningococcus serum. F. Control. emulsion added to 0.8 c.c. of salt solution are also incu- bated. If the culture in question is meningococcus, a floc- culent precipitate will be seen in the tubes containing the bacterial enmlsion and antimeningococcus serum, the heavi- ness of the precipitate depending on the amount of dilution. The controls will be free fi'om precipitate. A true menin- 174 c i':r,EF,r,osPi NAL flu id T^ ** •* :.*.;'*:' A. AgKlnllnatiiHi liv spt-citic serum. /« • - 4. , 'M. r>. Abs^'HCu (if agyliiliiiatinii wilh nurnial linrsc sfruin. Fig. .^6. — Alicr.tSi-onic iiu-IIiikI nf a^tJuti u,il i iig nu'iii nynn icci. ( 'rnnnulilT. ) EXAMINATION VOK DTAUNOSTIC PURPOSES 1/0 ,^-oe()('<'us is coinitlcicly ai;;<;lutiiiat(Ml in 1 :200 dilution of polyvalent scniiii. Jt is usually also a,i;',i;iutinato(l in higher dilutions (Fig. 35). The otlici' gi^aiu-uogative cocci arc usu- ally ]U)t agglutinated at all and never in greatei' dilutions than 1:100. Micrococcus llavus sometimes agglutinates in polyvalent and monovalent meningococcus serum in 1:50 di- lutions but may be diffei-entiated from the meningococcus by its cultui-al pi'operties. o7, — Agglutination fif nietiingocncci ijy the niicrosco|)ic itiethml. ( Ma^niihcatioti 8(111 (liameti-rs. I Microscopic Method A more ra])id method than the macroscopic for the ag- glutination of meningococci lias ]jeen described by Tunni- cliff. Equal ])arts of antimeningococcus sei-um, whole hu- man ))l()()d in sodium citi'ate solution (one ])art of blood to 2 per cent sodium citi-ate in salt solution), and a suspension of organisms are incubated for ten minutes and then stained and examined. Normal horse serum with a sus- pension of organisms is used as control. In the mixture with normal horse serum there is very little or no clump- 176 CEREBROSPINAL FLUID ing of the meningococcus, while in the mixture containing antimeningococcus serum there is decided agglutination (Figs. 36 and 37). The suspension of the organisms is made by adding one or two colonies of the original culture to two or three drops of salt solution. One drop of serum is drawn up in a bent capillary tube, and the upper point marked, then an equal amount of citrated blood and later the suspension of the organisms are drawn up. The con- tent of the pipette is now carefully mixed and heated for ten minutes at 36° C, or left at room temperature for twenty minutes; after incubation the content is blown out on a glass slide, spread with cigarette paper and stained unfixed with carbol thionin or fixed with lieat and stained with methylene blue. Either of the agglutination tests gives good results. I would advise that whenever possible both tlie macroscopic and microscopic agglutination should be carried out; when the time is limited the microscopic method can be depended upon. Agglutination of pneumococci is utilized to determine the type of the organism. Type I, Type II and Type III, an- tipneumo coccus serum l)eing used for that purpose. Precipitation of Cerebrospinal Fluid with Antimeningo- coccus Serum According to Vincent and Ballot normal cerebrospinal fluid does not form any precipitate with antimeningococcus serum, while fluid from meningococcus meningitis is pre- cipitated, when incubated with antimeningococcus serum. The technic of the test is as follows : The spinal fluid is centrifuged till it becomes clear. Two to five drops of anti- meningococcus serum are then added to 50 and 100 drops of the clear spinal fluid. The sp^^iinens are incubated at 50° C. for eight to fourteen Jiours. If the fluid is one of me- ningococcus meningitis, the mixtui'c becomes turbid. A tube EXAMINATION FOR DIAGNOSTIC PURPOSES 177 containing spinal fluid to which no antimeningococcus se- rum has been added is used as a control. While other workers have confirmed the observation of Vincent and Ballot, it has been pointed out that at times fluids from other types of meningitis will show the same reaction with antimeningococcus serum. One of the diffi- culties of the test is that often it is impossible to clarify the spinal fluid of meningococcus meningitis even after cen- trifugation for a long period. This test should therefore be performed only when there is sufficient fluid left over from other more necessary tests. Guinea Pig Inoculation It is often necessary to employ the inoculation test to de- cide whether or not the process is tuberculous in nature. Five to 10 c.c. of cerebrospinal fluid is injected into the groin of a guinea pig. A month later 0.1 mg. of Old Tuber- culin is injected into the axilla of the pig. If the meningitis is tuberculous in nature the pig usually dies the morning after the injection of the tuberculin. Tubercles are found postmortem in both the spleen and the inguinal glands. Neutralization Test Some authors employ the neutralization test in polio- myelitis. The technic of this test is as follows: A fatal dose of active virus is mixed with the suspected fluid ob- tained during the stage of recovery. This mixture is in- cubated and injected intracerebrally into a monkey. Fail- ure of the disease to develop in the monkey indicates neu- tralization of the virus. The Wassermann Reaction It is impossible to describe all the details of the "Wasser- mann reaction in a small volume. I shall therefore, limit myself here to only those factors in the "Wassermann 178 CEREBROSPINAL FLUIIJ reaction that have a special bearing on the subject of cere- brospinal fluid. Principle. — The blood serum and cerebrospinal fluid of persons affected with syphilis contains syphilitic anti- bodies. The presence or absence of syphilitic antibodies in the system is demonstrated by the complement-fixation test, or the Wassermann test as it is more commonly known. The substances necessary for complement fixation are: antigen, fluid to be tested, and complement. An antigen is a substance which, when injected into an animal, causes the organism to react by the formation of antibody. The fluid to be tested supplies, if positive, the syphilitic antibody. Complement is a substance present in fresh blood serum which is necessary for the binding of antigen to anti- body. The Wassermann reaction is called a complement- fixation test although it is not really a complement fixation in the strictest sense of the term unless a suspension of spirochetes is used as an antigen. Different kinds of antigen are used for the Wassermann test, (a) an aqueous extract of syphilitic liver (original method); (b) an alcoholic extract of syphilitic liver; (c) an alcoholic extract of normal liver; (d) an alcoholic ex- tract of heart (either human or beef) reinforced Avith cho- lesterin; (e) ether soluble, acetone insoluble extract of heart. At present alcoholic extracts of heart are generally used as antigen. The complement consists of blood serum of healthy guinea pigs diluted with sterile normal salt solution. The amboceptor (antisheep antibody) is contained in the serum of rabbits immunized with washed sheep cor- puscles. If the cerebrospinal fluid contains syphilitic antibodies, the antigen combines with the syphilitic antibody and the complement, so that when antisheep amboceptor and sheep cells are added, the complement is already boimd and there- EXAMINATION FOR DIAGNOSTIC PURPOSES 179 fore hemolysis can not take place. If thei'e are no syphilitic antibodies in the fluid, the complement unites with the antisheep antibody or amboceptor and the sheep corpuscles and produces hemolysis. Table XXXVIII shoM's the process in the Wassermann reaction of both syphilitic and nonsyphilitic cases. Table XXXVIII I. Antigen I. Antigen + Syphilitic Antibody + Complement II. Antibody or Antisheep II. Complement Amboceptor + -j_ Antibody or Antisheep Sheep Corpuscles Amboceptor + Sheep Corpuscles The amount of fluid used for the Wassermann test is not always the same. Some use as little as 0.2 c.c. of fluid, whereas others, notably Thomson, use as much as 1.0 and even 1.2 c.c. It has been found that the small amounts do not give positive results as frequently as the larger. This fact, I believe, explains the great number of negative Was- sermann reactions on cerebrospinal fluid by the older authors who used very small amounts for the tests. On the other hand, large amounts of cerebrospinal .fluid such as Thomson advises are likely to be anticomplementary. Schottmiiller 's suggestion that various amounts of the fluid be used for the same test, is, I believe the most commend- able plan. Schottmiiller advises the use of a series of Wassermann tests with fluid varying in amount from 0.2 to 1 c.c. and with dilutions of salt solution. 180 CEEEBEOSPINAL FLUID Table XXXIX TUBE 1 TUBE 2 TUiBE 3 TUBE 4 TUBE 5 c.e. e.e. C.C. C.C. C.C. Cerebrospinal Fluid 0.2 0.4 0.6 0.8 1.0 NaCl Solution 0.8 0.6 0.4 0.2 Antigen 1.0 1.0 1.0 1.0 1.0 Complement 1.0 1.0 1.0 1.0 1.0 Amboceptor plus cor puseles 2.0 2.0 2.0 2.0 2.0 It is advisable to carry the amounts of cerebrospinal fluid even further than is indicated in Table XXXIX. It is best to make the Wassermann test with freshly drawn cere- brospinal fluid. If the test can not be made immediately after the withdrawal of fluid, it should be put away in the ice box without preservative. The cerebrospinal fluid is Table XL Examination op Cerebeospinal Fluid for Diagnostic Purposes Very Important Immediate Examination For Amount Color Foam Cell Count Differential Count Cultures Direct Smear Noguchi Eoss-Jones Sulphosalioylic Mercuric Chloride Examination after 24 hours Presence or absence of pellicle Measurement of sulphosalicylic and mercuric chloride sediment. Examination of cultures Lange Wassermann Chlorides II Less Important Permanganate index Sugar H-ion Concentration Alkali Eeserve Cataphoresia Mastic Test EXAMINATION FOR DIAGNOSTIC PURPOSES 181 not inactivated. Preliminary titrations must be made on antigen, complement and amboceptor before the test is set up. The proper dose of antigen I believe to be one-fourth of anticomplementary unit and the proper dose of comple- ment and amboceptor to be two units each. Control tubes of the cerebrospinal fluid should be set up with the test. The cerebrospinal fluid, salt solution, antigen and com- plement are incubated for one hour at 37.5° C. Then the antisheep amboceptor and the sheep corpuscles are added and the solution is returned to the incubator where it is allowed to remain from 30 minutes to 2 hours. At the ex- piration of this time, it is taken out and examined. If hemolysis is present the test is negative ; if there is an inhi- bition of hemolysis, the test is positive. Bibliography Alzheimer: Einige Methoden zur Fixierung der zelligen Elemeiite der Cere- brospinalfliissigkeit, Centralbl. f. Nervenh. u. Psychiat., 1907, xxx, 449. Andernach: Beitrage zur Untersuchung des Liquor cerebrospinalis mit be- sonderer Beriicksichtigung der zelligen Elemente, Arch. f. Psychiat., 1910, xlvii, 806. Black, Eoseeberg and McBride: The Colloidal Gold Test, Jour. Am. Med. Assn., 1917, Ixix, 1855. Blumenthal: Serodiagnose der Syphilis, Dermat. Ztschr., 1910, xvii, 1. Boveri: Di una nuova reazione del liquido cefalo raohidano, Riv. di patol. nerv., 1914, xix, 280. Cutting: A New Mastic Test for the Spinal Fluid, Jour. Am. Med. Assn., 1917, Ixviii, 1810. Emanuel: Eine neue Eeaktion zur Untersuchung dea Liquor Cerebrospinalis, Berl. klin. Wchnsehr., 1915., lii, 792. Epstein: An Accurate Microchemical Method of Estimating Sugar in the Blood, Joiuir. Am. Med. Assn., 1914, xiii, 1667. Fuchs and Rosenthal : Physikalische, chemische u. anderwertigp Untersuch- ungen der Oerebrospinalfliissigkeit, Wiener, med. Presse, 1904, xlvii, 44. Grulee and Moody: Lange's Colloidal Gold Chlorid Test on the Cerebro- spinal Fluid in Congenital Syphilis, Jour. Am. Med. Assn., 1913, bci, 13. Lange: Die Ausflockung koUoidalen Goldes durch Zerebrospinalfliissigkeit bei luetischen Aifektionen des Zentralnervensystems, Ztschr. f. Chemo- therap., 1913, i, 44. Lowrey: Cerebrospinal Fluid Tests, Especially the Gold Reaction in Psychi- atric Diagnosis, Jour. Nerv. and Ment. Dis., 1917, xlvi, 186. The Mastiche and Potassium Permanganate Tests Applied to the Cerebro- spinal Fluid of the Insane, Boston Med. and Surg. Jour., 1917, cbcxvii, 115. Mann and van Saun: Value of Chemical Tests on the Serums and Spinal Fluids of Syphilitics, New York Med. Jour., 1918, cvii, 783. 182 CEREBROSPINAL FLUID Miller, Brush, Hammers and Felton: A Further Study of the Diagnostio Value of the Colloidal Gold Reaction, Together with a Method for the Preparation of the Eeagent, Bull. Johns Hopkins Hosp., 1915, xxvi, 391. Noguehi : The Relation of Protein, Lipoids and Salts to the Wassermann Reaction, Jour. Exper. Med., 1909, xi, 84. Eine fiir die Praxis geeignete leicht ausfuhrbare Methode der Serumdiag- nose bei Syphilis, Miinchen. med. Wchnschr., 1909, Ivi, 494. Serum Diagnosis of Sj-philis, J. B. Lippincott Co., 1910. Nonne: Weitere Erfahrungen ( Bestlitigungen und Modiflkationen) iiber die Bedeutung der 4 Eeaktionen (Pleocytose, Phase I. Wassermann Reaktion im Serum und im Liquor spinalis) fiir die Diagnose der syphilidogenen Him- und Riiekenmarkskrankheiten, Dritte Jahresvers. d. Ges. deutscher Nervenarzte, Eef. x. Ztschr. f. Nervenh., 1910, xxxviii, 291-307. Nomie and Apelt : "iiber f raktionierte Eiweissausf allung in der Spinalfliissig- keit, Arch. f. Psychiat., 1907, xliii, 433. Pandy: uber die neue Eiweissprobe fiir die Zerebrospinalfliissigkeit, Neurol. Zentralbl., 1910, xxix, 915. Redlich, Potzl, and Hess: Untersuchungen iiber das Verhalten des Liquor cerebrospinalis bei der Bpilepsic, Ztseh. f. ges. Neurol, u. Psychiat., 1910 ii, 715. Ross and Jones: On the Use of Certain New Chemical Tests in the Diagnosis of Goneral Paralysis and Tabes, Brit. Med. Jour., 1909, i, 1111. Seelman: Simple Test for Estimating Chlorides in the Urine Founded on Volhard's Method, Jour. Lab. and Clin. Med., 1916, i, 444. Swift and Ellis: Method of Cell Counting in Cerebrospinal Fluid, Jour. Exper. Med., 1913, xviii, 164. ' Szecsi: Zur Technik der Cheni. und Zytolog. Untersuchung der Lumbal- fiUssigkeit, Monatschr. f. Psychiat. u. Neurol., 1910, xxvii, 152. CHAPTER VII CEREBROSPINAL FLUID IN VARIOUS DISEASES Uremia In uremia the fluid is often increased both in amount and pressure, especially if there are convulsions. The cells may or may not be increased in number. The chlorides are of- ten increased to 0.8 or 0.85 gm. per 100 c.e. of fluid. The urea is greatly increased in amount. According to Locke- mann and Fiith the lactic acid in the fluid is also increased in amount. Diabetes Mellitus The cerebrospinal fluid is normal in appearance and pres- sure in cases of diabetes mellitus. It is chemically nega- tive in all respects but in its sugar content, which is greatly in excess of normal. Foster found the sugar in the fluid of 12 cases of diabetes to vary between 0.5 per cent and 3 per cent. My highest finding was 0.38 per cent. In one case I found the sugar content in the cerebrospinal fluid to be even higher than that of the blood. Acetone and diacetic acid may also be found in large amounts in the cerebro- spinal fluid of patients suffering with diabetes mellitus. Chorea Dupre and Damns found a distinct lymphocytosis in the cerebrospinal fluid of a chorea in a boy of eighteen. Ba- bonneix found a lymphocytosis in two of five cases. Thomas and Tinel found a distinct lymphocytosis in a girl of thirteen, suffering from chorea. They found a similar condition in two of four other patients examined a few months later. Gatow-Gatovski found a hypertension in one case of chorea. 183 184 CEREBROSPINAL FLUID Eichardier, Lemaire and Sotirdel found a lymphocytosis in twelve out of fourteen cases and hypertension in ten. In three cases, symptoms were somewhat relieved by punc- ture. A number of French observers found a positive Was- sermann in chorea and because of this finding, argued in favor of the specific nature of chorea. Leopold and Bern- hard found the cerebrospinal fluid in chorea to be normal in the chemical and cytologic tests. In the cases of chorea 'that came under my observation, the cerebrospinal fluid was normal in all respects, including the Wassermann. The cerebrospinal fluid in Huntington's chorea or hered- itary chorea is normal in all respects. The various experi- ences cited above incline me to the belief that the exami- nation of spinal fluid is of no special value in the diagnosis' of chorea. Epilepsy During an epileptic attack the cerebrospinal fluid is in- creased both in amount and in pressure. During the in- tervals between attacks, both the amount and pressure of the fluid may or may not be increased. In epilepsy due to cerebrospinal lues, the cells and globulin content are in- creased ; in idiopathic epilepsy, both the cells and the glob- ulin content are normal. The same is true of the Wasser- mann reaction. Mongolian Idiocy In Mongolian idiocy the cerebrospinal fluid is often nega- tive physically, chemically and bacteriologically. Steven- son found the fluid from a large number of cases to give a typical luetic gold chloride curve. Some of the cases exam- ined by me gave positive Wassermann and Lange tests; many of them, however, gave negative tests. I, therefore, do not subscribe to the view that all cases of Mongolian idiocy have a luetic origin. There are some that are luetic by coincidence only. CEREBROSPINAL FLUID IN VARIOUS DISEASES 185 Psychoses In psychosis the fluid is not uniform. In alcoholic psy- chosis the quantity of fluid that can be removed in one sit- ting is greatly increased, it often being possible to remove as much as 30 to 40 c.e. easily. The pressure is greatly in- creased in this type of psychosis, running, as a rule, from 150 to 300 mm. of water in height. The fluid is clear and colorless ; the protein is not increased, and the cells are usu- ally normal both in number and type, although occasion- ally I have noticed an increase in the cell count ranging from 26 to 30 cells per cubic millimeter. A number of authors who have been able to detect the presence of alcohol in the cerebrospinal fluid of alcoholic psychosis, suggest that the test for alcohol be used for diagnostic purposes. Dementia precox gives a normal fluid as a rule. Earely is the pressure increased. Paranoia also shows no devi- ation from the normal. The fluid in general paresis is not constant. In the majority of cases the fluid is increased in amount and pressure ; the cell count is high, 30 to 40 per cubic millimeter; both the globulin and the Wassermann tests are positive. In a small percentage of cases, all the findings are negative with the exception of increase in amount and pressure of the fluid. Lues The findings in the cerebrospinal fluid in acquired lues depend on whether or not the nervous system is involved. If there is no involvement the fluid is negative, including the Wassermann test. If there is involvement there is an increase in the amount of the fluid, in the content of the protein, and in the number of the cells in the fluid, the cells being principally lymphocytes. The Wassermann is also positive. Nonne speaks of four reactions in connection with syph- ilis of the nervous system: positive Wassermann reaction 186 CEREBROSPINAL FLUID of the blood, increased globulin, lymphocytosis and posi- tive AVassermann reaction of the cerebrospinal fluid. Nonne's results may be summarized in Table XLI. Table XLI WASSERk.ANN PHASE I LYMPHO- -WASSEEMANN TEST IN TEST IN BLOOD GLOBULIN CYTOSIS CEREBROSPINAL FLUID General paresis 100% Positive 95-100% Positive 957o 100% positive if large quantities of fluid are used. 100% positive if large quantities of fluid are Tabes without 60-70% Positive 85-90% Positive 90% paresis Cerebro- spinal lues 80-90% Positive 100% used. 100% positive if large quantities of fluid are used. In syphilis of the nervous system tlie gold chloride test gives a positive reaction in the syphilitic zone, the reaction varying with the type of the disease. In cerebrospinal lues the discoloration is in Tubes 1, 2, 3, 4, 5, and 6; (Fig. 38) in tabes the discoloration is inconstant, but is usually in Tubes 2, 8, 4, and 5 and sometimes in 6. (Figs. 39 and 41.) In paresis, the discoloration is usually in the first six tubes and sometimes also in the seventh and eighth. (Figs. 40 and 42.) Table XLIl GENERAL PARALYSIS TABES CEREBROSPINAL SYPHILIS Num- ber of cases % Num- ber of ca.ses % Num- ber of cases % 39 30 45 60 41 8 54 ? 35 64 56 73 93 88.8 73 88 100 90 90 94 92.1 87.5 9 5 11 ? 12 15 66.6 60 54.5 50 66.6 53 8 6 4 16 Marie, Levaditi and Yamanouchi. . . Stertz Noguchi and Moore 50 Morgenroth and Stertz Plaut 25 Schutze Smith and Candler Noguchi, RosanofF, and Wiseman . . . Total 4,32 90 52 56.2 34 19 CEREBROSPINAL FLUID IN VAEIOUS DISEASES 187 LANGE COLLOIDAL GOLD TEST o o s s s '' J J s la — « 5 Clear _ 4 Pale Blue 3 Blue i *f ■*> 2 Violet / -^ J \ V )( 1 Red Blue ST ORed kf Fig, 38. — Case of cerebrospinal lues. Wassermann + + + +. LANGE COLLOIDAL GOLD TEST a s s s s '' -' J- ^ M 5 Clear *' = 4 Pale Blue 3 Blue 2 Violet )t~ *s 1 Red Blue !*v N«- H^ ORed ^16- ■* Fig. 39. — Case of tabes. LANGE COLLOIDAL GOLD TEST o s s s s ^^ i i 1 „ ex s ^ ID SCloir ^. ., *' ' ^ 4 Pale Blue ) Blue k \ 2 Violet 1 Red Blue ORed \ ^»^. M. Fig. 40. — Case of general paresis. Wassermann + + +. 188 CEREBROSPINAL FLUID The incidence of positive Wasserman reaction in the cerebrospinal fluid of lues is seen from Table XLII of Noguchi. Hydrocephalus As was pointed out in the chapter on normal cerebro- spinal fluid, the older writers considered the cerebrospinal fluid of hydrocephalus as normal fluid. Eecent investiga- tions have corroborated the truth of this observation. With the exception of the increase in the amount of the cerebrospinal fluid, the fluid of hydrocephalus shows no chemical, physieochemical or bacteriologic changes of any kind. Only infrequently does one find an increase in the protein content of hydrocephalic fluid. The amount of fluid which can be withdrawn from the subarachnoid space de- pends on the form of the hydrocephalus, whether it is in- ternal or external. If the foramina of Magendie and Luschka are blocked, very little fluid may be obtained by lumbar puncture. If the communication is open a great deal of fluid may be obtained by lumbar puncture. The pressure also depends on the amount of cerebrospinal fluid in the subarachnoid of the cord, being greatly increased where there is free communication. Spina Bifida The fluid is usually increased in amount in this condi- tion, as is the protein. Hemorrhage of the Brain Cerebrospinal fluid removed soon after the hemorrhage occurs is bright red in color due to the admixture of the blood; and contains many red and white blood cells. As time progresses the cerebrospinal fluid becomes more yel- low in color and the red cells become less in number. The amount of fluid, as a rule, is not increased. The protein is increased due to the addition of the protein from the blood. All other tests are negative. CEREBROSPINAL PLXJID IN VARIOUS DISEASES 189 Tumors of the Brain In tumors of the brain, the amount of cerebrospinal fluid may or may not be increased. The protein is usually not increased. Occasionally one finds an increase in the num- ber of the cells, all of which are lymphocytes. Compression of the Cord Compression of the spinal cord gives rise to a number of manifestations of the cerebrospinal fluid. In tumors of the cauda equina and conus medullaris the Froin's syn- drome usually makes its appearance. The syndrome shows the following characteristics: (1) xanthochromia or yel- lowish discoloration of the cerebrospinal fluid; (2) massive coagulation of the fluid; (3) an increased number of lymphocytes. In tumors situated at higher levels of the cord, there is an excess of globulin present, but no increase of the cells. There may or may not be a yellowish discoloration of the fluid. In extramedullary compression of the cord there is usually a yellow discoloration of the fluid and an increase in the globulin, but no increase in the cells. Discoloration of the fluid alone, does not indicate compression of the cord, as this condition may be due to the presence of an old hemorrhage of the brain, or even to a puncture of the plexus of veins surrounding the cord. Encephalitis It is difficult to establish a diagnosis of encephalitis dur- ing life. After death encephalitis is seen as a feature of poliomyelitis, of meningitis, and of hydrocephalus. The cerebrospinar fluid in encephalitis, therefore, responds to the condition it accompanies. In poliomyelitis the fluid shows the changes of this disease ; in meningitis it gives the reactions typical of the organism causing the infection. In encephalitis following acute infectious diseases, such as 190 CEREBROSPINAL FLUID pertussis and measles, the cerebrospinal fluid is increased in amount and in pressure. The cells are either normal or slightly increased in numlter. The globulins are not in- creased, as a rule. In the recent epidemic of encephalitis lethargica the cerebrospinal fluid was colorless and showed a slight increase in the cell count and in the globulin content. Meningism In many infectious diseases, notably, pneumonia and grippe and cases of otitis media and also in some cases of intestinal intoxication, there are often syrnptoms of cere- bral irritation, simulating a meningitis, although no bac- teria are found in the fluid and no meningeal exudate makes its appearance. To cases of this character, E. Dupre has given the name of meningism. The fluid in these con- ditions is generally increased i]i amount, sometimes even to the same extent as in a severe case of meningitis. The pressure of the fluid is also higher than normal. The color, however, is unchanged and the number of cells is in- creased only slightly or not at all. The globulin as well as the bacteriologic tests are usually negative. Only occa- sionally is there an increase in the globulin and in the cells. Caution, however, must be exercised not to make a prema- ture diagnosis of meningism in all instances of negative findings of the fluid, for it frequently happens that cases of tuberculous meningitis and poliomyelitis in the early stages of the disease, give no other changes in the cerebrospinal fluid but an increase in the amount of the fluid. Tuberculous Meningitis The amount of fluid in tuberculous meningitis varies with the stage of the disease, being'greater in the initial than in the paralytic stage. The pressure at the onset of the disease is very high, ranging between 300 and 700 mm. water in height. The pressure remains high during CEREBROSPINAL FLUID IN VAPJOUS DISEASES 191 the irritative stage but decreases during the stage of coma. The fluid is usually clear and transparent throughout the disease, although occasionally it becomes opalescent; it shows a heavy foam on shaking. On standing from one hour to an entire day a pellicle forms, the pellicle being generally suspended in the center with processes project- ing from its sides. There is an increase in the number of cells which range from 30 to 150 per c.mm., most of them being small lymphocytes, although early in the disease there may be a preponderance of polymorphonu- clear leucocytes. The protein in the fluid is also greatly increased in amount. The albumin content ranges be- tween 0.1 and 0.2 per 100 c.c. in adults. Fibrin and fibrin- ogen are present in small amounts as is indicated by the presence of the pellicle in the fluid. Albuihose and pep- tone are absent, as a rule, as is also mucin. The fluid of tuberculous meningitis also shows other variations from normal. The permanganate index is above 2 as compared with the index in nonmeningitic fluid which is below 2. The chlorides are lessened in tu])erculous men- ingitis, usually running below 0.6 gm. per 100 c.c. and some- times falling as low as 0.5 gm. per 100 c.c. The sugar con- tent varies, sometimes equaling the amount in normal fluid and sometimes falling below that of normal. As a rule, however, the sugar content ranges between 0.5 gm. and 0.6 gm. per 100 c.c. Phosphates, according to Apelt and Schumm, are present in amounts varying between 0.0034 and 0.0049 per cent. The physicochemical constants also show a deviation from normal. The average density is given as 1.002, al- though in my cases, I found it to vary between 1.00626 and 1.00693. The viscosity varies between 1.0693 and 1.0694. The conductivity is given by Fuehs and Rosenthal as ranging from 0.097 and 0.0225, with an average of 0.0127. The freezing point is usually lowered running between 0.45 and 0.55. 192 CEEEBROSPINAL FLUID The H-ion concentration averages a Ph of from 7.4 to 7.6 immediately after the removal of the fluid from the body, with an increase in the alkalinity upon standing, so that one-half hour after withdrawal the Ph of the fluid becomes 7.7 or 7.8. Twenty-four hours after withdrawal the Ph LANGE COLLOIDAL GOLD TEST e 8 Q s 3 -' -'- .1 s 5 Cle., 4 Pale Blue ■^ 3 Blue ^ 2 Violet r V / N 1 Red Blue ORed Jf- w w ^ Fig. 43-A. — Case of tuberculous meningitis. LANGE COLLOIDAL GOLD TEST o o 5 S s '* ..i .1 1 g ^ u 3 Clear ■t Pale Blue 3 Blue 2 Violet Sf it \i: 1 Red Blue ^ ^ ^ ORed ' ^\ " 1 - ■j^-r— Fig, 43-B. — -Case of tuberculous meningitis. becomes 8.1, 8.2 or even higher. The alkali reserve runs parallel with the H-ion concentration. The gold chloride reactions give a discoloration corre- sponding to Tubes 5, 6, and 7, sometimes to Tubes 7, 8, or 9. (Figs. 43 and 44.) The ninhydrin test shows a discolora- tion with the fluid of tuberculous meningitis. CEEBBEOSPINAL FLUID IN VAKIOUS DISEASES 193 The cataphoresis shows most of the protein moving to- ward the anode. Upon evaporation long crystals form in the fluid. The sulphosalicylic mercuric chloride ratio is marked, the precipitate with mercuric chloride being three times as great as that of the sulphosalicylic on stand- ing. Tubercle bacilli are found in the centrifuged fluid only after a careful search. They are often found more easily in the pellicle. Inoculation of the cerebrospinal fluid of tuberculous meningitis in guinea pigs produces a miliary tuberculosis in the animal in course of one to six weeks. From a diagnostic standpoint the following are the most important changes in the cerebrospinal fluid of tubercu- lous meningitis : Increase in amount and pressure, increase in the number of cells with a relative lymphocytosis, posi- tive Noguchi, Ross-Jones, and Nonne tests, sulphosalicylic mercuric chloride ratio, high permanganate index, low chlorides, Lange curve, and above all the presence of tu- bercle bacilli in the fluid, and the development of tubercles in guinea pigs after inoculation. The following case will illustrate the cerebrospinal fluid findings in a case of tuberculous meningitis: D. H., eleven and one-half years of age, entered the hospital complain- ing of headache, vomiting, extreme constipation, anorexia, and weakness. The onset was slow with vomiting and headache, the vomiting being pro- jectile in type. The patient became listless and sleepy. Examination showed marked symptoms of meningeal irritation. A spinal puncture was performed. The fluid obtained was clear and under marked pressure. The cell count showed 320 cells per cubic millimeter, 98 per cent of which were lymphocytes and 2 per cent polymorphonuclear leucocytes. The Noguchi and Eoss-Jones globulin tests were strongly positive. The permanganate index was 3.0. The mercuric chloride sediment was four times the size of the sulpho- salicylic sediment. The direct smear showed no organisms. The blood showed 80 per cent hemoglobin, 5400 leucocytes per cubic millimeter, of which, 58 percent were neutrophiles, 20 per cent small mononuclear and 12 per cent large mononuclear. The Widal reaction was negative, so were the blood cultures. The child became progressively worse and another spinal puncture was done the next day with practically the same findings as the first specimen with the additional finding of a pellicle when the fluid was allowed to stand. A third puncture showed all globulin tests to be positive, the gold 194 CEREBROSPINAL FLUID chloride reaction was also cliaracteristic of tuberculous meningitis. The patient died after staying twelve days in the hospital. The postmortem showed a grayish white, purulent exudate at the base of the brain, meas- uring 0.5 cm. in thickness, the exudate covering the region of the hypo- physis and the right optic nerve. A part of it also extended to the right of the longitudinal fissure in the region of the parietal lobe. The exudate showed the presence of tubercle bacilli. Caseated glands were found in the hilus of the lung. Meningococcus Meningitis In meningococcus meningitis, the amount of tlie cerebro- spinal fluid is increased, and as a rule, 20 to 40 c.c. can easily be removed In' one lumbar puncture. This increase in the amount of the fluid is a constant feature of meningo- coccus meningitis throughout the disease. Only very sel- dom does it happen that the amount of the fluid is not in- creased. Cases of this kind usually have an occlusion of the subarachnoid space somewhere along the tract of the cerebrospinal stem. The pressure of the fluid in meningococcus meningitis is also increased ranging between 300 to 700 mm. water high. In two of my cases the pressure was as high as 800 mm. of water. The color of the fluid of meningococcus meningitis varies from a slight opalescence at the onset of the disease to a yellowish green later in its course. The yellowish green color is the product of the meningococcus. On standing it sometimes becomes a pronounced green. The fluid contin- ues turbid throughout the course of the disease. It rarely happens that the fluid in the early stages of epidemic men- ingitis is clear and colorless. On standing one-half hour or longer the fluid forms a sediment that changes in character with the development of the disease. (a) In the early stages of the disease, the pellicle is made up of a yellowish-white network, the reticuli being close together and forming an opaque layer. The upper portion of the network is balloon- or dome-shaped and the base or lower portion is flattened in appearance. The whole net- CBRBBKOSPlHrAL FLUID IN VARIOUS DISEASES 195 work resembles a small bursa. It usually does not reach the Tipper level of the fluid and generally it is seen inclin- ing toward one side of the tube. (b) In the more advanced stages of meningitis, the sedi- ment formation is firmer. It generally spreads out along one side of the tube in the form of a heavy film. (c) In still more advanced cases, a sediment of yellow granules may be seen attached to one side of the tube. These granules are an indication that the disease has pro- gressed to an advanced stage. (d) In the very grave cases the sediment is thick and falls by gravity to the bottom. LANGE COLLOIDAL GOLD TEST o s s ..» g ^' ..s i J S ^ in 5 Cl.ar 4 Pale Blue A 3 Blue J Vt 2 Violet X 1 Red Blue r -*' ORed Fig. 46. — Case of meningococcus meningitis. When the meningitic process recedes, the pellicle or sedi- ment takes on a character the reverse of the one that ap- peared at its formation. The chemical changes are marked. The organic index determined by the permanganate is high, ranging between 5 and 7. The protein content is greatly increased ranging between 1 and 7 per cent. The Noguchi, Eoss-Jones, Nonne and Pandy globulin tests are strongly positive. A 3 per cent sulphosalicylic acid solu- tion gives a heavy sediment on standing, measuring from 10 to 20 mm. in height, while a 1 per cent mercuric chloride solution gives a sediment much lower than the sulpho- 19(5 CEREBROSPINAL FLUID salicylic acid. Tlie sugar is usuall)^ absent or greatly di- ininislied during the active stage of the disease. Lactic acid is present in the fluid in large quantities. The chlorides are nsually the same as normal, although they may be present in quantities less than normal. Among the iDliysicochemical changes tliat take place in meningococcic meningitis the following are important: Cataphoresis shows that the protein migrates to the cath- ode pole. The H-iou concentration is increased and it con- tinues high for a long time after the removal of the fluid I'ig. -I". — I'h:jtu:nicrogra[ih showing direct smear from cerebrospinal fluid of case of meningococcus meningitis. from the l)ody. The alkali reserve does not run parallel with the Il-ion concentration. Tlie viscosity is 1.0434 to 1.0735. The gold chloride test shows the greatest discolor- ation in Tubes 7, 8, and 9 (Figs. 45 and 46). The cytologic changes are distinct. The leucocytes are increased in number, varying from 50 to several thousands per cubic millimeter. Tlie greatest percentage of the cells (90 to 98 per cent) is made up of polymorphonuclear leuco- cytes, although the lymphocytes are also present in greater number than in normal fluid. The Ijacteriologic findings are fairly constant. A gram- CEEEBKOSPISAL FLVID IN YAEIOUS DISEASES 197 negative biscuit-shaped organism is nsually fonnd in tlie direct smear within the lencocytes, some being fonnd also outside of the leucocj'tes (Fig 47). The number of or- ganisms found in the smear of epidemic meningitis is not nearly so great as that found in the smears from pneumo- Fig. 48. — Twenty-four-hour culture of meningococci grown on ascitic dextrose agar. The culture which has been originally ohtained from a case of meningococcus menin- gitis has been transplanted several times on artificial media, hence the heavy growth in twenty-four hours. coccus fluid. It sometimes happens that early in the disease the organisms in the direct smear are very scanty in num- ber, but after the first or second dose of antimeningococcic sernni, there is a shower of organisms in the fluid. 198 CEKEBROSPIiSrAL FLUID On ascitic dexlrose ag'ar, tiie menin^'ococci visually grow in pure culture (Fi,ii,'s. 48 and 49) although it is not al- "ways easy to grow them. The meningococci can be differ- entiated from the pnoumococci b}^ the gram stain, the me- ningococci l)eing gram-negative and the pneumocoeci gram- positive. It is also possible to differentiate the two by the agglutination test. On the other hand, it is very difficult to differentiate the meningococci from other gram-negative cocci such as gonococcus, micrococcus catarrhalis, and dip- loeoccus nmcosus. ] lowever, since these organisms rarely "'-•^ \ T >i > *.'•/ r%*l ,.'• i rt. -•.••'ft. ' Tv- • i'"^ ^ » *- V - '. \ " J, -^ T.; , ■ •« < , ' . ' ■"-' *fl ■'f. ^» Fig. -f9. — I'liotoniicrograph of oure mcningiic- -^ 3 Blue 2 Violet 1 Red Blue ¥r- V' ^ *> ORed t.^ k Fig. 54. — Case of epidemic poliomyelitis. First week of disease. It is usually colorless, only occasionally being opalescent. On shaking the fluid, a thick foam is produced which does not disappear for some time. The permanganate index is slightly above the normal averaging 1.5 to 2.5. The protein is usually increased in amount, generally giving positive globulin tests, although once in a while the globulin tests are negative. The gold chloride test in the preparalytic stage, shows either no change at all, or a change in the luetic zone only. (Fig. 54.) After the subsidence of the acute symptoms, from the second to the twelfth day, the reaction may be most prominent in the meningitic zone. The cells in this condi- 206 CEREBROSPINAL FLUID Cataphoresis to anode Guinea Fig Inoculation shows Tubercles , Cataphoresis to cathode,, agglutination . tests, precipita- tion of fluid with anti- meningococcus serum o 1 . 1 o 2 Si, e 01 U o Z 1 U o Z ifli ii a Is d 3 S !iii ii |i < z z z z Z Z z 1 1 < a £ d - = l tl, O t, o S 6S s d < a - 0. c d J d 1 d 1 i > o 6 01 O d I c IS 6 S ■* a I 3 a E !i U5 us s s a a a a a a a 1 a a f Of a a il i* i 1 o Oh 1 1 h as p II 7« d 1 a 1^ 6g 1| l5l si O d o s d O z z i z 11 1= a. ? iiii 1 i o Z 3 z ;^ i o Z o Z o z o G 1 III 75 3 -o 'I hi u 1 i o i o o 1 •a d i i 3 o 14 ale Z si t- Is li 7 o us us i Ol 1 E a s 1 s z a 1 s 1 d Ii II} 1:^ B a 11 a a Sgjii ■g.U6 5, 11 CEREBROSPINAL FLUID IN VARIOUS DISEASES 207 tion are increased in number, 90 per cent of them being of the small, mononuclear type. The increase manifests itself in the preparalytic stage and lasts fourteen to sixteen days after the onset of paralysis. The cells are greatest in num- ber during the first week after the onset of paralysis. The largest percentage of cells (60 to 90 per cent) is of the small lymphocyte type, except in the very early stage of the disease when the predominating cell may be the poly- morphonuclear. The bacteriology of poliomyelitis is still an open ques- tion. Flexner and Lewis found a filtrable virus. Mathers, Nuzum and Rosenow report the finding of a micrococcus in the brain and cord. Nuzum reports the presence of the coccus in the cerebrospinal fluid. The organism, accord- ing to these authors, is grown best on a 1 per cent glucose broth medium, incubated under aerobic conditions. Other workers dispute the specificity of this microorganism in poliomyelitis. At the present state of our knowledge no positive diagnosis can be made of poliomyelitis by the fluid findings alone. The history of the case and its prog- ress must always be taken into consideration as well. Bibliography Accliiote: Poliomyelite antorieure aigue et lymphocytose, Kev. neiirol., 1911, xix, 711. Apelt and Schumm: Untersuchungen iiber Phosphorsauregehalt der Spinal- fliissigkeit, Arch. f. Psychiat., 1908, xliv, 2. Arzt and Boese: tjber Paratyphusmeningitis im Sauglingsalter, Wien. Win. Wehnsohr., 1908, xxi, 217. Ayer and Viets: Spinal Fluid Findings Characteristic of Cord Compression, Jour. Am. Med. Assn., 1916, Ixvii, 1707. Bailey: Cryoseopy of Cerebrospinal Fluid in Epidemic Cerebrospinal Menin- gitis, Med. Rec, 1905, Ixvii, 215. DuBois and Neal: Streptococcus Meningitis With Report of u. Cured Case, Arch. Pediat., 1915, xxxii, 28. Dupre: Le Meningisme, Congres francais de Medeeine, 1894, Paris, 1895, i, 411. Elsberg and Bochfort: Xanthochromia and Other Changes in the Cerebro- spinal Fluid, Jour. Am. Med. Assn., 1917, Ixviii, 1802. Ferrier: Cytologic du Liquide Cephalo-Rachidien dans la Leucennie, Compt. rend. Soc. de biol., 1908, 803. Flexner and Lewis: The Nature of the Virus of Epidemic Poliomyelitis, Jour. Am. Med. Assn., 1909, liii, 2095. Flexner and Noguchi: Experiments on the Cultivation of the Microorgan- ism Causing Epidemic Poliomyelitis, Jour. Exper. Med., 1913, xviii, 461. 208 CEREBROSPINAL FLUID Fraenkel, E. : tjber das Verhalten des Gehirns bei akuten Infektionakrank- heiten, Virchows Arch. Beiheft 1908, p. 194. Froin: Le liquid eephalo-rachidien dans I'hemorragie cerebromeningee, Gaz. d. hop., 1913, Ixxvi, 1005. Futh and Loekemami : tJber den Nachweis von Fleisshmilchsaure in der Cere- brospinalflussigkeit Eklamptiseher, Arch. f. Gynecol., 1905, Ixxvi. Ghon, Mueha and Muller: Zur der akuten Meningitis, Centralbl. f. Bakt. u. Parasitenk., xli, 1. Hartwich: Bacterium coli im Liquor Cerebrospinalis, Berl. klin. Wehnschr., 1911, xli, 18, 795. Jacob, P. : Echinococcus und Zerebrospinalfliissigkeit, Fortschr. d. Med., 1903. Joehmann, G. : Meningitis cerebrospinalis Epidemiea, Mohr Staehelin Hand- buch d. inn. Medizin. Lesser; Tabes und Paralyse im Lichte der neuren Syphiliserforschung, Berl. klin. Wehnschr., 1908, 1762-1764. Mathers: The Etiology of Acute Epidemic Poliomyelitis, Jour. Infect. Bis., 1917, XX, 113. Mathers: Some Bacteriologic Observations .^n Epidemic Poliomyelitis, Jour. Am. Med. Assn., 1916, Ixvii, 1019. Mohr, B. : Zur Pathologic des Liquor Cerebrospinalis, Deutsch. Ztsehr. f . Nervenh., xliv, 417. Nonne and Apelt: Tiber fraktionierte Eiweissausfallung, etc., Arch. f. Psychiat., 1907, xliii, 2. Nonne : Syphilis und Nervensystem, ed. 2, Berlin, 1909, 631-634. Nonne ami Holtzmann : Ileber Wassermann-Eeaktion im liquor spinalis bei Tabes dorsalis, sowie iiber quantitative Auswertung von Starkegradeu der Wassermannsehen Eeaktion bei syphilidogenen Krankheiten des Zentral- nervensystems, Monatschr f. Psychiat. u. Neurol., 1910, xxvii, 128. Nuzum and Herzog: Experimental Studies in the Etiology of Acute Epi- demic Poliomyelitis, Jour. Am. Med. Assn., 1916, Ixvii, 1205. Oseki: Makroskop. latente Meningitis u. Encephalitis bei akuten Infektions- krankheiten, Beitrage zur pathologischen Anatomic u. z. allg. Path., 1912, lii, 540. Pappenheim : Ueber die Polynukleose im Liquor cerebrospinalis, bei der progressiven Paralyse, Ztsehr. f. N. Heilk., 1907, xxviii, 10, 315. Quincke: Uber Meningitis serosa, Samml. klin. Vortr. v. Volkmann, 1893, p. 655. Eedlich, Potzl, and Hess : Untersuchungen iiber das Verhalten des Liquor cere- brospinalis bei der Epilepsie, Ztsehr. f. d. gea. Neurol, u. Psychiat., 1910, ii, 715; ibid., 1910, iii, 492. Rist, E.: Neue Methoden, etc., Centralbl. f. Bakteriol. u. ParaiS., 1901, xxx. Eomheld ; Zur Klinik postdiptherischer Lahmungen ; Liquorbefund bei post- diptheriseher Pseudotabes, Vortrag. Eef., Neurol. Centralbl., 1908, 1007. Eosenow, Towne and Wheeler: Etiology of Epidemic Poliomyelitis, Jour. Am. Med. Assn., 1917, Ixvii, 1202. Schottmiiller : Meningitis Cerel)rospinalis Epidemiea (Weichselbaum), Mun- chen med. Wehnschr., 1905, lii, 617, 1683, 1729. Schottmiiller : Zur Bedeutung einiger Anaerobier in der Pathologic, Mit- teilungen aus d. Grezgebeiten d. Med. u. Chir., xxx. Schottmiiller and Schumm: Nachweisj ■■•on Alkohol in der Spinalfliissigkeit von Saufern, Neurol. Centralbl., 1912, xxxi, 1020, Miinchen Med. Wehnschr., 1910. Schultzc: Zur Diagnostik der ak\iten Meningitis, Verhandl. d. Cong. f. inn. Med., 1867, p. 393. Staubli: Meningismus typhosus u. Meningotyphus, Deutsch. Arch. f. klin. Med., 1904-1905, Ixxx'ii, 90. Wollstein : Influenza Meningitis and its Experimental Production, Am. Jour, Dis. Child., 1911, i, 42. CHAPTER VIII INTRASPINAL TREATMENT Whenever there is a specific remedy for a disease of the central nervous system, it is of the utmost importance that the remedy be brought into direct contact with the central nervous system as early as possible. Even when no specific exists, it may be advisable to introduce some form of medication into the cerebrospinal fluid. The in- jection is made either intraspinally, or intraventricularly. Intraspinal Treatment of Meningococcus Meningitis The reports of Flexner and his associates, and the ex- perience of most physicians, have established the fact that the best and most successful way of treating meningococcus meningitis is by means of antimeningococcus serum. The mortality of cases of meningitis that received serum has been reduced to one-half, in some epidemics to one-third of the mortality of cases that received no serum, as is shown by Table XLIV from Sophian. Table XLIV Effect of Antimeningococcus Serum on Mortality prom Epidemic Meningitis CASES TREATED "WITH SERUM Number Percentage Mortality cases TREATED WITHOUT SERUM Percentage Mortality Flexner 1,400 31.4 70-80 Steiner 2,280 37.0 77 Nettor 100 28.0 49 Dopter 402 16.44 52.14 Levy 163 18.18 65 Sophian 161 15.5 209 210 CEREBROSPINAL FLUID The antimeningococcus serum now in nse is prepared by repeated injections of dissolved meningococci (culture autolysate meningococci extract) into a horse followed by injections of live meningococcus cultures. The cultures used are of various strains of meningococci, so that the serum is polyvalent. The serum is tested before it is put up in packages, by one of several methods : the complement-fixation method, the agglutination test, the opsonin content and the animal protection test. In England the agglutination test is used very extensively. In France the complement-fixation method is the one most generally employed. In America all four methods are used by various manufacturers. McCoy, Wayson and Corbitt of the United States Public Health Service, accept any serum which passes satisfac- torily, either by an agglutination or complement-fixation test as a suitable serum for therapeutic purposes. The antimeningococcus serum is usiially preserved with 0.2. per cent to 0.3 per cent of tricresol. The use of this pre- servative has given rise to a number of objections. Kramer ascribes some of the deatlis that had occurred after the in- jection of antimeningococcus serum to the use of tricresol which he claims has a very depressing effect on the medul- lary center. It has been found, however, that of the dif- ferent preservatives used, tricresol exerts the most marked bactericidal effect on the bacteria, and is a much less irritat- ing preservative than chloroform. It is therefore used ex- clusively in this country as a jircservative of antimeningo- coccus serum. Whenever a case presents itself that shows signs and symptoms of meningitis, and gram-negative cocci in the smear, no time should be lost in injecting the patient with antimeningococcus serum. AVe may even go a step further and say that whenever a turbid cerebrospinal fluid is obtained antimeningococcus serum should be injected immediately on tlie probability that the case is one of epi- IWTEASPINAL TREATMENT 211 demic meningitis. Of late the intravenous injection has been advocated, but even when intravenous injection of serum is employed the serum should be injected into the cerebrospinal canal also if there are indications of the pres- ence of meningitis. The following is the technic of intraspinal injection of serum : A lumbar puncture is done with the patient lying on his side. (The entire procedure is described in detail in Chap- ter III.) If the fluid removed is turbid, 15 to 30 c.c. of cerebrospinal fluid is withdrawn, the amount depending upon the pressure of the cerebrospinal fluid and the quan- tity of serum to be administered. One or two vials of anti- meningococcus serum which have been kept in the refrigera- tor are warmed in warm water to 98 or 99° F. The vial con- taining the serum is attached to a gravity tube made of rubber with small stylet to fit the lumbar puncture nee- dle (Fig. 55). The stylet of the gravity tube is now intro- duced into the lumbar puncture needle and the vial is low- ered slightly to allow the air bubbles that may be present in the gravity tube to escape. The process of emptying the vial should take from 10 to 15 minutes. If more than 15 c.c. of serum is to be administered, the second vial is at- tached to the gravity tube after the first vial has been emp- tied, and the fluid allowed to run in, care now being taken that no air bubbles are allowed to, enter the gravity tube during the removal of the vial. If the serum does not flow readily into the spinal canal the vial containing the serum should be lowered to allow the air bubbles to rise to the surface. If this does not bring the bubbles to the surface, squeezing the gravity tube may do it. This should be done very cautiously, however, to prevent the pushing of air bubbles into the spinal canal. If the serum still does not flow into the canal, it is advis- able to use a small sterile bulb on the vial to press in the fluid. This procedure has often given me good results. •2]:2 EI! EBIK )S 1' I N A \, Vh U 1 1 ) Some autliors advise the washing of the spinal canal Avitli sterile salt solution before the injection of the serum. In my opinion this procedure is neither necessary nor ad- visable. Fig. 55 -J iLstriimciit I'tj Uictinii of antinicningucuccus serum by tlic gravity mcthiid. As for tlie dose of serum to be administered at one time, no al)S()lute rule can ))0, given. S()])hian advises the use of blood pressure as iu\ index, a marked fall in blood pressure being an indication to stop the injection of serum. One may always guide oneself by the amount of fluid removed INTRASPINAL TREATMENT 213 inclining toward the larger rather than the smaller dose. For example, it is best to administer 30 c.c. of serum the first time if it is possible to remove 30 c.c. or more of cerebrospinal fluid. If not more than 15 or 20 c.c. of cerebrospinal fluid can be removed at one sitting an at- tempt should be made to introduce 20 c.c. of serum. If unsuccessful, at least 15 c.c. of the serum should be given. I believe that the principle of diphtheria antitoxin, that as much serum as possible be given at one time, can be ap- plied with the same beneficial effects, to the administration of antimeningococcus serum. How often the administration of serum is to be repeated is also a question that has not yet been definitely decided upon. However, much can be learned from a study of the cerebrospinal fluid and the clinical findings in the partic- ular case. As long as there are bacteria present and as long as the cells are numerotis and the patient's temper- ature is high, it is advisable to administer serum twice a day. It has been my plan to administer 30 c.c. of serum the first time, 30 c.c. the second, third and fourth times, making 120 c.c. in all, irrespective of the cerebrospinal findings. Then if the temperature continues high and the cerebrospinal fluid shows the presence of many cells after waiting one day I administer 30 c.c. additionally even if no bacteria are present. I then wait two days longer and if the case shows no change for the better I adminis- ter 30 c.c. more. The following case illustrates the method I usually follow: March 24, 1917, 7 P.M. F. A., age two and one-half years admitted to hospital with symptoms of meningitis. (See Fig. 56. Light line, pulse; black line, temperature.) March 24, 8 p.m. Spinal puncture done, 45 e.o. of cloudy fluid removed under increased pressure and 30 c.c. of antimeningococcus serum injected. Cerebrospinal fluid examination showed 53,280 cells per cubic millimeter, 98 per cent of which were polymorphonuclear. Noguchi, Eoss-Jones, and Nonne tests were all positive. Direct smear showed pus cells and gram-negative in- tracellular diplococci (meningococci). March 25, 8:30 A.M. Spinal puncture done, 40 c.c. of yellowish, cloudy- looking fluid removed under markedly increased pressure; 25 c.c. of serum .„N0 aUU/li ^ a ...S...v:vA vA Altendinfl Physician ... Interne l-VAli-J ^ i' tC 'ixAAAJJJ- WJJ',. J[l3 ■'* r ^ oX —J, :o^^ :-J5- - » Z. 01) - '- V X . " K ^ t: , KiK. Sf. liSTTRASPINAL TREATMENT 215 injected. Examination showed 12,000 cells per cubic millimeter, principally polymorphonuclears. Noguchi, Ross-Jones and Nonne were all positive. Meningococci were found in direct smear. March 25, 11:30 P:m:. Thirty -five c.c. cloudy, yellowish fluid removed under slightly increased pressure and 25 e.e. of serum injected. Bouillon cultures made March 24 showed meningococci. March 26. Twenty-five c.c. of cloudy fluid withdrawn and 25 c.c. of serum injected. Few meningococci found in direct smear, no growth appeared on cultures. March 27. Thirty c.c. of spinal fluid withdrawn and 25 e.e. of serum in- jected. Examination showed polymorphonuclears 85 per cent, lymphocytes 10 per cent, large mononuclears 5 per cent. Globulin tests positive. No growth on cultures. March 29. Thirty c.c. serum injected. No meningococci found in direct araear and no growth on cultures. April 2. Cultures made on March 30 and 31, and April 1 and 2 show no growth. THe following case I believe illustrates the fallacy of ad- ministering antimeningococcus serum in too small doses. D. B., entered the hospital with a history of restlessness, fever, and con- vulsions. The cerebrospinal fluid removed on entrance to the hospital showed 352 cells per cubic millimeter, all of which were polymorphonuclears. The direct smear showed numerous meningoeocei. Fifteen c.c. of antimeningo- coccus serum was administered intraspinally and repeated in 12 hours. A third dose of 15 c.c. of serum was given the next day, making a total of 45 c.c. of serum. Since no organisms could be found in the cerebrospinal fluid withdrawn by the third lumbar puncture, the physician decided not to ad- minister any more serum. The patient's temperature was down and she was discharged from the hospital as cured. Two weeks later the patient was re- admitted to the hospital with very severe meningeal symptoms. The cerebro- spinal fluid was turbid again and showed meningococci. Sufficient serum was administered this time. TTie child, however, did not improve. The meningi- tis became more severe and the patient died from the disease. If the patient had received sufficient serum, she would most likely have recovered from the disease and remained well. If no serum can be injected into the spinal canal the serum should be injected intraventricularly, especially in the case of infants. The procedure consists of the with- drawal of a certain amount of cerebrospinal fluid from the ventricles of the brain and of the injection into the ven- tricles of the brain of the desired amount of serum. Tf no cerebrospinal fluid can be obtained from either the spinal canal or ventricles, no attempt should be made to inject 216 CEREBROSPINAL FLUID serum into the spinal canal, but should be injected intra- venously. In adults the brachial vein may be used. In infants the sorum may be injected into the longitudinal sinus. Untoward Effects of Serum There are very few complications that follow the injec- tion of antimeningococcus serum and those that do occa- sionally present themselves are not severe enough to coun- terindicate the use of the serum treatment. Among the untoward effects sometimes following the injection may bo mentioned: 1. Shock. 2. Aggravation of disease symptoms — the so-called serum meningitis. 3. Serum rash. Shock occurs in a small percentage of cases. The symp- toms consist of respiratory failure and contraction of the pupils. The skin is usually pale but occasionally there is a flush of the skin and even an edema. When shock does occur, it can generally be attributed to the too rapid intro- duction or to the administration of too large an amount of serum. As a matter of prophylaxis it is therefore important that the serum be introduced very slowly and, if possible, in amounts not larger than the amount of cerebrospinal fluid removed. For safety's sake the blood pressure should bo watched and the serum discontinued if the pressure fall is extreme. It has already been pointed out in the discussion of lumbar puncture that it is dangerous to remove cere- brospinal fluid from a patient suspected of suffering with meningitis in the sitting position, because of the risk of pro- ducing shock and even death. When shock does occur, the administration of serum should be discontinued, and atro- pine in fairly large doses such as 1/300 in a child, and 1/100 to 1/50 in an adult should be administered liypodermatically. This method of treatment has given me very good results. If the atropine does not relieve the symptoms, one c.c. of INTRASPINAL TREATMENT 217 a 1:1000 solution of adrenalin chloride should be given hypodermatically. The occurrence of shock should not prevent one from introducing serum intraspinally into the same patient several hours later. In such cases, I would, however, advise the administration of a dose of atropine previous to the giving of the serum, so as to prevent the repetition of the occurrence. Aggn^avation of Symptoms Cases have been described in which the patient has be- come more ill after the administration of serum than be- fore. The exacerbation of symptoms, however, is only tem- porary and should not arouse any anxiety. Serum Rash Antimeningococcus serum, like every other foreign pro- tein introduced into the body, occasionally gives rise to a rash that makes its appearance several days after the ad- ministration of the serum. The rash may be macular or papular, but it usually occurs in the form of large blotches similar to those of any other serum rash. The eruption, as a rule, occurs on the fifth or sixth day after the adminis- tration of the first dose of serum. It usually starts from the point of injection of the serum, i.e., from the lumbar re- gion. It may involve only a portion of the body or the entire body. Severe symptoms, such as nausea, vomit- ing and temperature accompany the rash, but they are generally of very short duration. The appearance of the rash often arouses a suspicion of the coexistence of an acute exanthematous disease such as scarlet fever. However, the history of serum injection and the localization of the rash can generally be depended upon to settle the diagnosis. Intraspinal Treatment of Pneumococcus Meningitis Of late the use of antipneumococcus serum has become a matter of common practice in the treatment of pneumonia. 2l8 cekebros]:>inaL fluid One would, therefore, fee tempted to use the pneumococcus serum intraspinally in the treatment of pneumococcus men- ingitis. Broadbent reports four cases of pneumococcus meningitis that resulted in recovery after administration of antipneumococcus serum. He, however, gave the serum to his patient by mouth. Drought and Kennedy consider intrathecal injection of antipneumococcic serum mixed with a solution of sodium oleate as the most promising method of treatment. So far very few cases have been re- ported in which intraspinal injection of antipneumococcus serum has been used and of those that have been reported, none seein to have been followed with any marked degree of success. Pneumococcus vaccine has been used intraspinally by an English physician in the treatment of pneumococcus men- ingitis. He, however, does not report striking results, either. Optochin has been administered by some intraspinally for the treatment of pneumococcus meningitis. I saw one case of pneumococcus meningitis in which intraspinal injec- tions in one-half grain doses of optochin (ethyl cuprin hy- drochloride) were made and the patient, a child of twelve, recovered. The case in question, however, had also had an intraspinal injection of antimeningococcus serum previously and this may have been a factor in the recovery, for another case in which optochin was used did not re- spond favorably. One needs to see more than one case of recovery attributable to the use of optochin before he can endorse its use. Those who have used horse, serum in- traspinally do not report any apparent results from its use. In general, then, one can not make any positive statements about the good effects of intraspinal treat- ment in pneumococcus meningitis. However, until some- thing better can be found 1 would advocate repeated lum- bar punctures and the injection of polyvalent antipneumo* INTRASPINAL TREATMENT 219 COCCUS serum, or even ordinary horse serum if no other is obtainable, into the spinal canal. Intraspinal Treatment in Tuberculous Meningitis Of the numerous remedies advocated and tried for the treatment of tuberculous meningitis, none have been at- tended with success. Weak solutions of carbolic acid, cre- sol, iodine and urotropine have been given intraspinally. Tuberculin in various dilutions has also been adminis- tered. ' Thus far, neither intraspinal treatment nor any other form of treatment has been of any value in tu- berculous meningitis. A few cases have been reported, in the literature here and there of tuberculous meningitis re- sulting in recovery with healed tubercles; however, from the long list of cases tliat culminated in death, cases re-, ported both in the literature and in hospital records, one is inclined to doubt the diagnosis of "tuberculous menin- gitis" in those cases reported as having recovered. Influenza Meningitis Flexner describes a serum for influenza meningitis that is said to be specific. I treated several cases with it with- out any favorable results, nor did I find any cases of in- fluenza meningitis reported in the literature as having re- covered. Poliomyelitis The reports of Rosenow and Nuzum speak very optimis- tically of the serum treatment of epidemic poliomyelitis. They prepared a serum which they claim is specific against the organism found by them in the brain and cord and also in the cerebrospinal fluid of anterior poliomyelitis. The entire question, hoAvever, of the serum treatment of poliomyelitis is still a controversial one, so that it is im- possible at present to say just what valuation can be placed on the intraspinal treatment of poliomyelitis. 220 OBREBEOSPINAL FLUID The Swift-Ellis Treatment It has been the experience of many workers that the best results in the treatment of syphilis of the nervous system are obtained by introducing salvarsan (arsphenamine) or neosalvarsan (neoarsphenamine) into the spinal canal. Sal- varsan or neosalvarsan, however, has too irritating an ef- fect upon the meninges. The Swift-Ellis treatment is there- fore more efficient. The Swift-Ellis treatment is based on the principle that the blood serum of syphilitics who have been treated with neosalvarsan has a curative effect, and that the best results are obtained when salvarsanized serum is brought into direct contact with the central nervous sys- tem. The method is as follows : Salvarsan or neosalvarsan in the proper dose is injected into the patient intravenously, usually into the arm. One hour later 40 c.c. of blood is withdrawn from the patient by means of dry syringe and needle and collected into a sterile centrifuge tube. The blood is allowed to coagulate. The following day the serum is centrifuged for one-half hour till all the cells are sedimented. The centrifuge tube must be plugged with sterile cotton or with sterile rubber caps to prevent contamination of the serum. After centri- fugation 12 c.c. of serum is carefully pipetted off with a graduated pipette. The serum is diluted with 18 c.c. of normal salt solution, making a total of 40 per cent of serum. This mixture is heated at 56° C. for half an hour. Then a lumbar puncture is performed, 15 to 30 c.c. of cerebrospinal fluid is removed from the patient and the 30 c.c. of the serum-sodium chloride mix- ture is warmed to body temperature and injected into the spinal canal. Here also, as in any other intraspinal treatment the gravity method of injection should be used, to obviate the danger of shock, although some introduce the serum with a Luer syringe without untoward effects. Another precaution to take is to elevate the foot of the bed »ne hour after the injection. The patient should remain in INTRASPINAL TREATMENT 221 bed for at least one day after the treatment. The treat- ment is repeated once a week, till the "Wassermann, Lange and globulin tests on the cerebrospinal fluid become nega- tive, which usually takes four to five weeks. The Swift-Ellis treatment has many critics. Sachs, for instance, claims that marked paresis and tabes are not influenced favorably by this form of treatment. Halli- burton believes that "the intraspinal injection of salvar- san has been abandoned." Yet in spite of the various ob- jections raised the Swift-Ellis treatment has merit and should be used in selected cases of syphilis of the nervous system. I would only emphasize the great care with which it has to be carried out in order not to infect the patient and thereby set up a suppurative meningitis. Intraspinal Treatment of Tetanus When tetanus antitoxin is used as a prophylactic meas- ure it is usually injected intramuscularly. However, when the disease is fully developed intraspinal injection is in- dicated. Tetanus antitoxin when injected into the blood has been found to appear only in traces in the cerebro- spinal fluid. When injected directly into the cerebrospinal fluid by the intraspinous method, the serum comes directly into contact with the tetanus toxin and has a preventative if not a curative effect on the tetanus. Although there are other ways of administering tetanus antitoxin, the intraspi- nal form of administration is one of the most efficient in the treatment of tetanus, particularly if employed in sufficiently large doses. The method used in administering the serum is the same as that employed for the administration of meningococcus serum, namely, the withdrawal of cerebrospinal fluid and the injection of the serum by the gravity method,, in a some- what smaller amount than that of the fluid withdrawn. For instance, if 20 c.c. of fluid has been withdrawn, about 15 c.c. of serum should be injected. The amount injected may 222 CEREBROSPINAL FLUID range from 15 to 30 c.c. depending upon the quantity of fluid withdrawn. The intraspinal administration of serum by means of a syringe is now rareh' employed in the treatment of tetanus. Intraspinal injections of magnesium sulphate in the treatment of tetanus have been advocated by many authors, notably Meltzer. Intraspinal Treatment of Chorea Chorea has been treated by various authors by injecting some substance into the spinal canal of the patient. Lacuna used intraspinal injections of magnesium sulphate. Goodman used autoserum treatment and Porter used horse serum. The intraspinal magnesium sulphate injection produced no l3«neficial results in the cases reported by Heiman. Goodman reported a series of cases which he claimed Avere benefited by his autoserum treatment, which is administered in the following manner: The child is put to bed for four days or longer without medication. At the end of this period 45 or 50 c.c. of blood is withdrawn from a A'ein and rapidly centrifuged. The supernatant blood serum is then pipetted and kept on ice. A lumbar puncture is made and about 20 c.c. of cere- brospinal fluid is withdrawn. The blood serum is now heated to body temperature and 15 to 18 c.c. of serum is in- jected very slowly into the spinal canal. The patient should be made to retain the recumbent position for at least one hour after injection. One injection is usually sufficient. Occasionally, however, it is necessary to give two, three, or even four injections. Bibliography Amo5s: Notes on Tlie Ptaiulardization and jVclrainistration of Autimeiiingo- fofcio Sevum, Jour. Aiii. Med. Assn., 1917, Ixix, ll.'!7. Amoss and Chesney: Serum Ticalmcnt of Poliomyelitis, Jour. Exper. Med., 1017, XXV. 581. Broadbcnt: Treatment of Pneumopoecie Meniiitjitis, Brit. Med. Jour., 1916, 586. Flexner: Experimental Cerelnoxpinal Meniu},ntis and its Serum Tre;\tment,_ Jour. Am. iled. Assn., 1906, xlvii, 560. INTRASPINAL TREATMENT Ho riexner and Jobling: Serum Treatment of Epidemic Cerebrospinal Menin- gitis, Jour. Exper. Med., 1908, x, 141. Goodman: The Auto-Serum Treatment of Chorea, Arch. Pediat., 1916, xxxiii, 649. Groppert: Ueber Genickstarre, Ergeb. der Inneren Med., 1909, iv, 165. Jochmann: Versuohe zur Serodiagnostik und Serotherapie der epidemisehen Genickstarre, Deutsch. med. Wchnschr., 1906, xxxii, 788. Levinson: Pneumoooceus Meningitis, Illinois Med. Jour., 1917, xxxii, 270. McCoy, Wayson and Corbitt: Potency of Antimeningococcic Serum, Jour Am. Mod. Assn., 1918, Ixxi, 246. Neal and Abramson: A Comparison of Tricresol and Chloroform as a Pre servative in Antimeningitic Serum, Jour. Am. Med. Assn., 1917, Ixviii, 1035. Nuzum : The Production of an Antipoliomyelitic Serum, Jour. Am. Med Assn., 1917, Ixviii, 24. Nuzum and Willy: Specific Serum Therapy of Epidemic Poliomyelitis, Jour Am. Med. Assn., 1917, Ixix, 1247. Porter: Intrathecal In.iection of Horse Serum in the Treatment of Chorea Am. Jour. Dis. Child., 1918, xvi, 109. Eosenovv: The Production of an Antipoliomyelitis Serum in Horses, Jour Am. Med. Assn., 1917, Ixiv, 261. Sachs: Truth About Intraspinal Injections in Treatment of Syphilis of Nervous System, Jour. ^m. Med. Assn., 1917, 681. Swift: Intraspinal Treatment of Syphilis of the Central Nervous System, Jour. Am. Med. Assn., 1917, Ixix, 2092. Swift and Ellis: The Direct Treatment of Syphilitic Diseases of the Cen- tral Nervous System, New York Med. Jour., 1912, xevi, 53. The Treatment of Syphilitic Affections of the Central Nervous System, with Especial Eeference to the Us© of Intraspinous Injection, Arch. Int. Med., 1913, xii, 331. CHAPTER IX SUMMARY I have endeavored to show the varied character of the cerebrospinal fluid in health and in disease. In the con- sideration of normal fluid the following facts were empha- sized: (1) that the fluid is colorless; (2) that it circulates in the cerebrospinal canal; (3) that most of it is absorbed along the spinal cord and some of it in the cavity of the brain; (4) that it is impermeable to most chemicals; (5) that it exerts a protective function. Even under normal conditions cerebrospinal fluid is a most complex fluid con- sisting of from 98.602 to 99.124 parts of water and 0.876 to 1.398 of solids. The protein content of the fluid which is very small ranges from 0.013 to 0.07 per cent ; the mineral content, consisting principally of chlorides and carbonates, ranges from 0.850 to 0.950 gm. per 100 c.c. The other ele- ments contained in the fluid, are in the main, the same as those found in othe'r body fluids, although the proportions are different. I have also pointed out the fact that the H-ion concentra- tion of normal cerebrospinal fluid is practically the same as that of the blood (7.4-7.6) and that CO2 plays an important role in governing the reaction of the fluid, running parallel with the H-ion concentration. In the discussion of pathologic fluid, I pointed out the fact that there are two types of changes : systemic and men- ingitic, and that the meningitic changes are qualitative as well as quantitative and that the former are of as great if not greater significance than the latter. This was demon- strated by means of the cataphoresis tube, of specific pre- cipitation and various other tests. 224- SUMMARY 225 As to the factors responsible for the qualitative changes in various diseases no satisfactory explanation has yet been offered, but numerous investigations have convinced me that the changes are intimately associated with the hydro- gen-ion concentration. The marked differences noted in the H-ion concentration of different forms of meningitis bear out this contention. In the discussion of technic I described both the manner of withdrawing cerebrospinal fluid from the body and the method of examining it after withdrawal. Particular at- tention was given to those methods that are simple and practical enough to be employed by the physician who has no extensive laboratory facilities. Under changes in the cerebrospinal fluid in different con- ditions, I pointed out the various changes, their diagnostic significance and their relation to the clinical manifestations of the disease. In the chapter on intraspinal treatment I described both the methods of treatment definitely established and those still in the experimental stage. In conclusion, I should like to call attention to the fol- lowing lines of research which I believe are of fundamental value in clearing up some of the contested problems in medicine. 1. The origin and function of the cerebrospinal fluid. 2. The chemical and physicochemical changes taking place in the fluid in various diseases and the principles underlying these changes. The study of this subject will also shed light on the origin of the cerebrospinal fluid. 3. The chemical and physicochemical relation between the cerebrospinal fluid and other body fluids, especially blood. 4. The crystallization of the cerebrospinal fluid. The solution of these problems will open limitless oppor- tunities for research not only in the field of cerebrospinal fluid, but in that of every other body fluid. CEKEBnOSPINAL li-LUID APPENDIX Monographs on Cerebrospinal Fluid Anglada: Le liquide cephalo-rachiclien et le diagnostic par la ponction lom- baire, Baillieie et fils, Paris, 1909. Blumonthal: tJber Ceiebrospinalfliissigkeit, Ergebnisse d. Physiol., 1902, i, 1. Dircksen: Liquide Cephalo-Becidien y Composition cliimique et Concentra- tion Moleculairc Th^se de Paris, 1901. Mestrezat: Le liquide cpphalo-rachidien normal et pathologique. Valeur clinique et I'examen chimique. Syndromes liumoraux dan diverses affec- tions, A. MaUoine, Paris, 1912. Magendie: Reolierches Physiologiques et Clinques sur le Liquide Cephalo- Eachidien on Cerebrospinal, Paris, 1842. Milian: Le liquide cephalo-rachidien, Steinheil, Paris, 1904. Nonne: Syphilis und Nervensystem, Aelitzehnte Vorlesung. Plaut: Die Wassermannsche Serodiagnostik der Syphilis in ihrer Anwend- ung auf die Psychiatrie, Fischer, Jena, 1909. Plaut, Rehm and Schottmiiller : Lcitfaden zur Untersuchung der Zerebro- spinalfliissigkeit, Fischer, Jena, 1913. Quincke: tJber Lumbalpunktion, Die deutsche Klinik am Eingange des 20. Jahrhunderts, 1906, vi, 1, 351. English translation: Diseases of the Nervous System, 1910, 223. Eehm: Die Cerebrospinalflvissigkeit, pliysikalische, chemische und cyto- logische Eigensehaiten und ihre klinische Verwertung. Histologisehe und histopathologisehe Arbeiten uber die Grosshirnrindc (Nissl und Alzheimer), 1909, iii, 1, p. 201. Sicard: Le liquide cephalo-rachidien, Masson et Cie., Paris, 1902. Sorrentino: Semeilogia del liquide cefalo-rachidiano, Napoli, 1915. Thomson; The Cerebrospinal Fluid, William Wood & Co., 1901. INDEX Absorption of cerebrospinnal fluid, 34, 36 Acidity of cerebrospinal fluid (see Reaction of cerebrospinal fluid) Agglutination, 147 of meningococci, 172, 198 of pneumococci, 176, 202 Alkaline reserve of cerebrospinal fluid : in meningococcus meningitis, 196 in tuberculous meningitis, 192 normal, 105 pathologic, 132 Alkalinity of cerebrospinal fluid, -44 Amount of cerebrospinal fluid: increase in, 116 in meningococcus meningitis, 194 in tuberculous meningitis, 190 normal, 76 Amylolytic power of normal cerebro- spinal fluid, 107 Anatomy of cerebrospinal fluid, 30 of chorioid plexus, 31 of subarachnoid space, 30 Antimeuingoeoccus serum : amount administered, 212, 213 cerebrospinal fluid after treat- ment fl-ith, 199 in agglutination of meningococci, 172, 173, 17.3 indications for, 210 intraspinal treatment with, 209 methods of preservation, 210 methods of production, 210 methods of testing potency of, 210 precipitation of cerebrospinal fluid with, 176 teehnic of introduction, 211 untoward effects of, 216 Antipnenmococeus serum in aggluti- nation of pneumococci, 176 in treatment of pneumococcus meningitis, 217, 218 B Bacteriology of cerebrospinal fluid, general consideration of, 146 in colon meningitis, 203 in influenza meningitis, 203 in meningococcus meningitis, 196, 197, 198 in pneumococcus meningitis. 200, 201, 202 in poliomyelitis, 207 in streptococcus meningitis, 202 in tuljcreulous meningitis, 193 methods employed, 171 Biometer, 144 C Carbonates in nonmeningitic cerebro- spinal fluid, 88 Carbon dioxide, amount in normal fluid, 87, 91 effect on the hydrogen-ion con- centration of fluid, 102, 103, 142, 144 Cataphoresis, 134 in meningococcus meningitis, 136, 196 in tuberculous meningitis, 135, 193 Cells in cerebrospinal fluid (see Cy- tology) Cerebrospinal fluid: anatomy of, 30 location of, 30 history of, 17 physiology of, 30 absorption of, 36 circulation, of, 33, 3.j formation of, 34 rate of, 34 function of, 40 origin of, 41 in various diseases, 183 methods of examination, 150 methods of obtaining, 49 cranial puncture, 71 lumbar puncture, 49 227 2-28 INDEX Cerebrospinal fluid — Cont 'd properties of, normal, 75, (see Normal cere- brospinal fluid) pathologic, 113 Chemistry of cerebrospinal fluid: normal, 79 pathologic, 123 Chlorides in cerebrospinal fluid: meningitic, 131, 191 method of determination, 161 nonmeningitic, 87, 91 Cholesterol in cerebrospinal fluid, 130 Cbolin, 130 Chorea, cerebrospinal fluid in, 183 Chorioid plexus: blood supply cf, 31 structure of, 31 Circulation of cerebrospinal fluid, 33, 35' Collection of cerebrospinal fluid, method of, 69 (see Lum- bar puncture) Colloidal gold reaction, 137 (see Lange gold chloride test) Colon meningitis, 203 Color of cerebrospinal fluid: in compression of cord, 189 in hemorrhage of brain, 188 in meningococcus meningitis, 194 in pneumoeoccus meningitis, 200 normal, 76 pathologic, 150 Composition of cerebrospinal fluid, (see Chemistry) Compression of the cord, cerebro- spinal fluid in, 189 Conductivity of cerebrospinal fluid: normal, 95 pathologic, 132 Cranial puncture, indications for, 71 technie of, 71 Crystallization of cerebrospinal fluid: normal, 88 pathologic, 120 Cytology of cerebrospinal fluid: normal, 108 number of cells, 108 type of cells, 110 pathologic, 117 chorea, 183 compression of cord, 189 encephalitis, 189 epilepsy, 184 influenza meningitis, 203 lues, 186 Cytology of cerebrospinal fluid — Cont'd meningism, 190 meningococcus meningitis, 196 p n e u m coccus meningitis, 200 poliomyelitis, 207 psychoses, 185 streptococcus meningitis, 202 syphilitic meningitis, 203 tuberculous meningitis, 190 tumor of brain, 189 technie employed, 167 D Diabetes mellitus, cerebrospinal fluid in, 130, 183 Dry puncture, 63 E Elimination of phenolphthalein from subarachnoid space, 36 Encephalitis, cerebrospinal fluid in, 189 Epilepsy, cerebrospinal fluid in, 184 Examination of cerebrospinal fluid, methods of, 150 bacteriologic, 171 culture media, 171 direct smear, 172 chemical, 152 chlorides, 161 globulin, 153 permanganate, 157 protein, 152 sugar, 158 cytologic, 167 Chamber method, 168 French method, 167 guinea pig inoculation, 177 immunologic, 172 agglutination, 172 neutralization test, 177 precipitin test, 176 "Wassermann, 177 neutralization test, 177 physical, color, 150 foam, 151 pellicle, 151 physicoehemical, 162 Lange, 164 Mastic, 166 F Fibrin ferment in cerebrospinal fluid: normal, 107 pathologic, 119 Foam in pathologic cerebrospinal fluid, 117 INDEX 229 Formation of cerebrospinal fluid, 34 Freezing point of cerebrosi^inal fluid: normal, 95 pathologic, 132 Function of cerebrospinal fluid, 40 G Globulin in cerebrospinal fluid: in meningococcus meningitis, 125, 195 in pneumococcus meningitis, 200 in poliomyelitis, 205 in streptococcus meningitis, 202 in tuberculous meningitis, 125, 191 relative value of various tests, 156 tests for, 153 Glycolytic ferment in normal cerebro- spinal fluid, 107 Guinea pig inoculation, 177, 193 Hemolysin in cerebrospinal fluid: lack of, in normal, 108 presence of in pathologic, 147 Hemorrhage of brain, cerebrospinal fluid in, 188 History of cerebrospinal fluid, 17 Hydrocephalus, cerebrospinal fluid in, 188 Hydrogen-ion concentration of cere- brospinal fluid: general consideration of, 96 methods of determination, 163 normal fluid, corked, 102 fresh, 97 old, 97 pathologic, in meningococcus meningitis, 141, 196 in tuberculous meningitis, 141, 192 Innnunology, 147 agglutination, 147 methods of, 172 hemolysin, 147 Wassermann, 148 Influenza meningitis, cerebrospinal fluid in, 203 Inoculation with cerebrospinal fluid, 177, 193 Intraspinal treatment : of chorea, 222 of influenza meningitis, 219 Intraspinal treatment — Cont 'd of meningococcus meningitis, 209 of pneumococcus meningitis, 217 of poliomyelitis, 219 of syphilis of the nervous sys- tem, 220 of tetanus, 221 Lange gold chloride test, 137 in cerebrospinal lues, 186 in general paresis, 186 in meningococcus meningitis, 196 in poliomyelitis, 205 in tabes, 186 in tuberculous meningitis, 192 technic, 164 Location of cerebrospinal fluid, 30 Lnes, cerebrospinal fluid in, 185 Lumbar puncture, 49 history of, 24, 25, 49 indications for, 49 reasons for failure, 63 structures encountered in, 56 technic of, 54 measurement of pressure, 64 needle used, 57 untoward effects of, 53 M Mastic reaction, 137 technic of, 166 Meninges, permeability of, 38 Meningism, cerebrospinal fluid in, 190 Meningitis, cerebrospinal fluid in: colon, 203 influenza, 203 meningococcus, 194 (see Me- ningococcus meningitis) pneumococcus, 200 (see Pneu- mococcus meningitis) streptococcus, 202 syphilitic, 203 tuberculous, 190 (see Tubercu- lous meningitis) Meningococcus meningitis, cerebro- spinal fluid in; amount, 194 alkali reserve, 196 bacteriology, 196, 198 chemistry, 196 color, 194 cytology, 196 Lange gold chloride, 196 pellicle, 194 230 INDEX Meningococcus meningitis, cerebro- spinal fluid in — Cont 'd physieoehemical changes, 196 pressure, 194 sediment, 195 intraspinal treatment, 209 Mongolian idiocy, cerebrospinal fluid in, 184 N Xeutralization test in poliomyelitis, 177 Ninhydrin reaction, 137 Normal cerebrospinal fluid, 7.j amount, 76 biochemical properties, 107 chemistry of, 79 table of composition, 91, 92 color, 76 cytology of, 108 physical properties, 76 physieoehemical properties of: alkaline reserve, 103 conductivity, 95 freezing point, 95 hydrogen-ion concentration, of, 96 reaction of, 96 refractometric index of, 96 specific gravity of, 79, 94 surface tension of, 95 viscosity of, 95 Organic index (see Permanganate index of cerebrospinal fluid) Origin of cerebrospinal fluid, 41 Pellicle in cerebrospinal fluid, 118 in meningococcus meningitis, 194 in pneumococcus meningitis, 201 in tuberculous meningitis, 191 Permanganate index of cerebrospinal fluid, 85 normal, 86 pathologic, 123 technie, 157 Permeability of meninges, 38 Phonolphthalein, elimination of, from subarachnoid space, 36 Physical chemistry of cerebrospinal fluid : normal, 94 pathologic, 1.'12 Physiology of cerebrospinal fluid, 30 Pneumococcus meningitis, cerebro- spinal fluid in: agglutination, 202 amount, 200 bacteriology, 200 chemical analysis, 200 color, 200 pellicle, 201 physieoehemical changes, 200 protein, 200 sediment, 200 intraspinal treatment, 217 Poliomyelitis, cerebrospinal fluid in: amount, 205 bacteriology, 207 cytology, 207 Lange gold chloride test, 205 permanganate index, 205 pressure, 205 protein, 205 intraspinal treatment in, 219 Precipitation of cerebrospinal fluid, 125 metallic and alkaloidal, 126 methods, 153 with antimeningococcus serum, 176 Pressure of cerebrospinal fluid: method of measuring, 64 normal, 77 pathologic, 116 Protein of cerebrospinal fluid: in meningococcus meningitis, 195 in tuberculous meningitis, 191 method of determination, 152 normal, 81, 82, 83, 84, 91 pathologic, 125 protein charges, 133 Prctoolytic power of normal cerebro- spinal fluid, 107 Psychoses, cerebrospinal fluid in, 183 E Rste of formation of cerebrospinal fluid, 34 liractiou of cerebrospinal fluid: normal, 96 pathologic, 138 Refractometric index of normal cere- brospinal fluid, 96 S Sediment in cerebrospinal fluid, lack of, in normal, 76 n;pningococeus meningitis, 193 (,S(T Pellicle) tuberculous meningitis, 191 INDEX 231 Seium rash, 217 Specific gravity of cerebrospinal fluid: normal, 79, 94 pathologic, 132 Spina bifida, cerebrospinal fluid in, 188 Streptococcus meningitis, cerebro- spinal fluid in, 202 Sugar in cerebrospinal fluid: methods of determination, 158 normal, 83, 84, 86, 91 pathologic, 129, 130, 183, 191, 196 Surface tension of normal cerebro- spinal fluid, 95 Swift-Ellis treatment, 220 Syphilitic meningitis, 203 Tuberculous meningitis, cerebrospinal fluid in, 190 amount, 190 cataphoresis, 193 chemical changes, 191 hydrogen-ion concentration, 192 inoculation with, 193 Lange gold chloride, 192 pellicle, 191 permanganate index, 191 physicochemical changes, 191 pressure, 190 transparency of, 191 tubercle bacilli in, 193 viscosity, 191 Tumors of brain, cerebrospinal fluid in, 189 Turbidity of cerebrospinal fluid, 131 XJ Urea in cerebrospinal fluid, 89 nonmeningitie, 89 normal, 94 pathologic, 130 Uremia, cerebrospinal fluid in, 183 Viscosity of cerebrospinal fluid: in meningococcus meningitis 196 in tuberculous meningitis, 191 normal, 95 pathologic, 132 W Wassermann reaction, 148 in cerebrospinal lues, 186 in chorea, 184 in general paresis, 186 in mongolian idiocy, 184 in psychoses, 185 in syphilitic meningitis, 203 in tabes, 186 principle, 178 technic, 179 Xanthocromia, 151, 189 ^1.'l;■