The Oliber-Sharpey Lectures ON THE CEREBRO-SPINAL FLUID

1910 The Lancet  
last lecture I endeavoured to point out to you the physiology of the cerebro-spinal fluid. I discussed its physical and chemical properties, its source, its destination, and its functions. To-day I propose to consider the pathology of the cerebro-spinal fluid. I will throw on the screen a lantern slide indicating the pathological conditions which may occur in the fluid. TABLE L-Cereb'l'(I-spínal F11âd and Pathological Conditions. PROPERTIES, SUBSTANCES, &C. First as regards its physical
more » ... ts physical properties. Even in marked pathological conditions, such as general paralysis of the insane, the fluid may appear clear like water, and only on further investigation may its pathological changes be discovered. Occasionally, however, the fluid may be turbid, purulent, serous, fibrinous; its colour may be yellow, being tinged with bile, red from the presence of blood, or brownish-red from the presence of altered blood. In my experience, however, which is a large one, I have very seldom seen the fluid other than like clear water, excepting always the presence of blood from the puncture of a small vessel during the performance of the operation. There is little to be said about its specific gravity, nor about the reaction. A rough estimate has been made of the tension by 1 Lecture I. was published in THE LANCET of July 2nd. 1910, p. 1. the number of drops per minute ; 60 drops is considered the normal average. With hypertension an increased number of drops will occur. As regards the rest of the table there is little to be said except as to the presence of drugs. As a rule drugs do not pass into the cerebro-spinal fluid, and most observers have not confirmed Majendie's original observations relating to the passage of potassium iodide into the cerebro-spinal fluid, a fact upon which Majendie laid great stress as showing the manner in which this drug benefited in such a marked degree certain diseases of the nervous system. Recently an important observation has been made by Ager. He has obtained satisfactory results following the administration of urotropine in meningeal affections ; the drug is said to be excreted in the cerebro-spinal fluid in half hour to one hour after ingestion, and to exert a marked antibacterial effect. It was first employed in a case of cerebrospinal fistula following trephining for cerebral tumour, in which the discharge became purulent. After the administration of 30 grains daily for a week the temperature became normal and recovery ensued. Experiments made on animals have been confirmatory. It is known that tetanus toxin does not pass into the cerebro-spinal fluid, but to this I have already referred in my first lecture. I may, however, remark that we should not expect the tetanus toxin to be eliminated by the choroidal gland, but from the capillaries in the nervous substance. Here the affinity of the toxin for the nervous matter would exert itself immediately. Upon the escape of the toxin from the blood-stream there should be in consequence no toxin free to pass into the subarachnoid space from which the fluid is withdrawn. CHEMICAL ALTERATIO8. I will now pass on to certain chemical alterations, dwelling more especially upon those to which we have given attention in the laboratory at Claybury. Proteins.-The amount of protein in normal cerebro-spinal fluid is especially low (about 0-03 per cent.); serumglobulin may be present in slight amount, but albumin is absent. In acute and chronic inflammatory conditions, in fact in all conditions where there is leucocytosis, there is excess of globulin, and albumin and nucleo-proteins are present. In cases of progressive degeneration, in spite of the large excess of fluid, the amount of proteins is found to be greatly increased. This excess consists of globulins, nncleo-proteins, and a small amount of albumin, the greater part being coagulable by heat between 3°-80° C. The excess of globulin is the most marked, and Noguchi describes the following method for its detection in a small quantity of bloocl-free cerebro-spinal fluid. Boil for a few seconds two parts of the cerebro-spinal fluid with five parts of a 10 per cent. butyric acid solution (in 0-9 per cent. sodium chloride solution); then add one part of normal sodium hydrate solution (4 per cent.) and boil again briefly. Noguchi states that the fluid of parasyphilitic cases gives a granular or flocculent precipitate on allowing the tube to stand for a short time, and that cases of alcoholic psychosis, dementia prasoox, imbecility, epilepsy, and many other non-specific diseases do not give any precipitate, but that cases of tuberculous meningitis, pneumococcic meningitis, and epidemic cerebro-spinal meningitis give an enormous amount of precipitate. I have applied this test to a considerable number of fluids, and have obtained a positive reaction in many non-specific cases, in fact, in all cases of dementia, whether non-specific or specific, and have found that the amount of precipitate is proportional to the degree of degeneration of nervous tissue, being most marked in the progressive degeneration of general paralysis of the insane. Another test for the globulin present consists in allowing the flnid to flow gently on to the surface of a saturated solution of ammonium sulphate, when a characteristic white ring appears which intensifies on standing. A rough indication of the excess of protein can also be obtained by precipitating the total protein content of the cerebro-spinal fluid with three times its volume of absolute alcohol after rendering it faintly acid with acetic acid. Lipoids. -In the normal fluids no lipoids are present, but in degenerative conditions of the nervous system, whether primary or secondary, lipoids are present in the form of cholesterol, or, as it was formerly termed, cholesterin, an alcohol of the terpene series containing neither phosphorus nor nitrogen. This substance, the method for detEcting B
doi:10.1016/s0140-6736(01)55707-4 fatcat:dn3mwx2zffhzhfad66vdkowowe