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Serous Meningitis

fluid, albumin, cerebrospinal, type, disturbances, increased and time

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SEROUS MENINGITIS The term serous meningitis is primarily anatomical and as such is ambiguous. As already mentioned in the introduction, tuberculous meningitis is a definite type of the serous form, which for practical rea sons we have discussed separately. Furthermore a second type has been pointed out which causecl by fulminating infections with pyog,eztic germs, if death from toxcetnia occurs before the purulent process has had time to develop.

Another type is characterized by a more or less acutely beginning exudation of the meninges, perhaps of the ependyrna, which is excited by any kind of inflammatory irritation, eoncerning the nature of which we shall speak later on, and which permanently or at least for ft consider able period betrays no tendency' to become purulent. In such cases the serous exudate is usually not copious and only distinguishable from the normal cerebrospinal fluid and fluid altered by stasis by microscopic chemical peculiarities. As also the histological changes of the meninges, of the ependyina and parts of the brain lying beneath them are not decidedly marked ancl are difficult to interpret, it is easily understood that for a long time there existed misconception of the relations between the trifling post-mortem disclosures and the oftentimes severe meningeal symptom-complex; and this gave rise to the designation" pseuclomenin gitis" or "meningismus." Dupre, who coined the word "men/mg/sniffs" defines it as follows: "the complex of symptoms caused by the lesions of the meningocortical zones and independent of any perceptible anatomic change." Thus he really- discards all meningeal and cortico-encephalitic sources, however, as was later recognized, unjustly.

Some of the conditions which Dupre and many of his successors describe as meningismus, are without doubt cases of serous meningitis while others are conditions which are probably caused by autointoxica Rolls or vasomotor disturbances and which we arc accustomed to count among functional disturbances so long as we do not understand the fine cellular pathology which causes them. The view, that the term menin gismus embraces heterogeneous diseases and is convenient rather than scientific, very soon curbed the great enthusiasm which the word origi nally aroused, and to-day not only German but also nearly all the French authors advise its abandonment.*

Returning from this digression, to serous meningitis, it is possible when we have to deal with ft case of meningitis to determine its nature primarily by- employing lumbar puncture. The cerebrospinal fluid is seldom under increased pressure. The aspirated fluid is clear: but the fact that it contains cellular elements, fibrin, and that its albumin is increased is evidence that meningitis is present, and enables us at once to make an important differential diagnosis from the functional (Lis order.s due to intoxications or osmotic disturbances.

The rising intracranial pressure, which in the beginning is often absent, may be recognized—by the abnormally increased tension of the fontanelles only in infancy—as is the ease in the other meningitides. in older children it can be established only by lumbar puncture.

The microscopical demonstration in the sediment obtained by centrifugation, of variable quantities of leueocytes, mostly small mono nuclear; the formation of a delicate spiderweb-like fibrin coagulum; and the abnormally heavy precipitation of albumin by Brandenberg's albumin test establish the inflammatory origin of the disease, but alone do not enable us to differentiate between tuberculous and other forms of serous ineningiti.s. This portentous decision can only be made by reviewing all the other clinical points which the case presents, and by bacteriologic investigation. Particularly under these circumstances the demonstration of tubercle bacilli, the technic and difficulties of which we have commented upon, attains great significance.

In every suspicious case the cerebrospinal fluid, obtained with aseptic precautions, should be studied culturally and by animal experi ments. While a positive result of bacterial examination is of great value, conversely a negative result must be estimated most carefully, since it by no means proves the absence of all microorganisms, We shall return to this point.

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