CEREBROSPINAL FLUID IN CARCINOMATOSIS OF THE MENINGES

231 Should inflammation become

chronic.

masses

of

granulation tissue are formed. encroaching on the Inmeu of the siuus, burying the epithelium. and finally absorbing it (Jig. 3). With the epithelium hair partieles are similarly trapped in the granulation tissue, but. being unabsorhable, they retain their histological identily they can

often be found some millimetre outside the chronic sinus, yet they betray their origin by the common direction of their scales. The skin overlying the sacral lrilmuitLal sinus conhtlns unusually deep hair papilla’. In a formol-preserved

and therefore shrunk, specimen they

may be

up to

deep, well in

the subcutaneous fat. The follicles, though separate from the sinus. may he abnormally large and carry two hairs each. None of these features are demonstrable in the sacral skin of normal cont rols. It seems probable that they are an expression of the winch leads to the fully aame developmental formed sinus. They may be the precursors of undeveloped amses. timm.

I wish to thank Dr. A. D. Morgan for his help and advico ; mal Atr. F. F. Wilson and Mr. M. Cuthbertson for their help with the histological preparations. REFERENCES

Bland-Sutton, J. (1922) Tumours, Innocent and Malignant. 7th ed., London ; p. 532. Herrmann, G., Tourneux, F. (1887) J. Anal., Paris, 23, 498. Hodges, R. M. (1880) Boston med. surg. J. 103, 485. Kooistra, H. P. (1942) Amer. J. Surg. 55, 3. Kunitomo, K. (1918) Contr. Embryol. Carneg. Instn. 8, 163. Ochlecker, F. (1926) Dtsch. Z. Chir. 197, 262. Patey. D. H., Scarff, W. R. (1946) Lancet, ii. 484. (1948) Ibid, ii, 13. J. M. (1854) Amer. J. med. Sci, 28, 113. Cited by Kooistra Warren. (1942). Wendelstadt, H. (1885) Dissertation, Bonn. -

-

CEREBROSPINAL FLUID IN CARCINOMATOSIS OF THE MENINGES

anomaly

Discussion Discussion

Among developmentaliststhe precise mode of formation of the pilonidal sinus is undecided. the disparity between tail development and the cephalad movements of the spinal cord and skin introduces so many confusing factors that the segmental orientation of the sacral skin M difficult to assess. Though pilonidal sinuses are sometimes associated with other sacral developmental defects, it is well to remember that such defects often occur in crops; a causal relationship bet ween one and another is impossible to prove. Our findings on tracing the origin of the hair to the wall of the pilonidal sinus provide evidencethatthis is

E. F. MURPHY N.U.I., D.C.H.

M.D. SENIOR

REGISTRAR, SEACROFT HOSPITAL, LEEDS

CEREBROSPINAL fluid (C.S.F.) containing little sugar protein and many cells is often regarded as

and much

meningitis. That carcinoproduce a similar picture recognised (McCormack et al. 1953). Apart from Forster (1930) and Platt (1951), who refurred to the occasional recognition of tumour cells in the C.S.F., and Jacobs and Richland (1951) and Strange (1952). who reported low sugar levels, few workers have correlated the presence in the c.s.F. of neoplastic cells, much protein, and little sugar with the necropsy findings. The similarity to tuberculous meningitis is illustrated by the following case.

pathognomonic

of tuberculous

matosis of the meninges has only recently been

can

aged 64, was admitted to Seacroft HosJune 29, 1954, with the diagnosis of tuberculous meningitis. He had had pain in his trunk and limbs for twelve weeks; this had become worse gradually in the last month, when he had lost much weight and had developed pain and stiffness in his neck. Thirteen days before admission lie had a generalised convulsion with a period of unconsciousness. In the past he had been a miner and was in receipt of a pension from the Silicosis Board. On e.uarrr.irautiora lie was pale and wasted, with a very stiff neck and a positive Kernig’s sign. His cranial nerves were not affected, his optic fundi were normal, and there were no choroidal tubercles. His right lung showed emphysema with crepitations in the upper zone. Investigations.—Radiography on July 1 showed pneumoconiosis with parenchymal infiltration of the upper zone of the right lung. Lumbar puncture on July 1 produced C.S.F. containing lymphocytes 100 per c.mm., sugar 20 mg. per 100 ml., protein 130 mg. per 100 ml., and chloride 570 mg. per 100 ml. Diagnosis and Treatment.—In view of the history, the clinical state, and the above-mentioned findings tuberculous meningitis was tentatively Fig, 3-Granulation tissue entering lumen of sinus and absorbing squamous lining (x 50). diagnosed. Systemic chemotherapy and daily was begun. intrathecal therapy with a developmental defect. The notorious absence of Repeated lumbar punctures showed a persistently raised cella view when the hair within count, much protein, and little sugar (as little as 13 mg. per hairpapillae is no bar to such 100 ml.). Cytological examination showed clumping of the the sinus is recognised as " shed." Indeed, the ease with cells on at least one occasion. which hair can be teased out of a sinus in the living Outcome.—The patient died in coma with anuria and subject would make any other finding surprising. jaundice twenty-three days after admission. Summary Necropsy revealed carcinoma of the stomach with metastai3es in the ieptomeningos, liver, suprarenal glands, and lungs, with Serial section of pilonidal sinuses has demonstrated that their contained hair originates in their depth, and associated silicosis, bronchitis, and emphysema. There was no tuberculosis. The meningeal involvement was confined that the sinuses are therefore developmental defects. to the region of the basilar artery and the anterior mostly Alter infection, hair may penetrate the sinus wall and. surface of both cerebellar lobes. It was obvious on microscopy come to lie outside the sinus. Independent hair papillæ only ; to the naked eye it ’would have passed as a healing in the skin close to a sinus have been found to reach an tuberculous meningitis. The rest of the brain appeared unusual depth. normal. A man,

pital

on

streptomycin

232 These necropsy findings are exactly similar to those of McCormack et al. (1953), who attribute the low C.S.F.sugar level to the large demands of the active neoplastic cells for glucose. Carcinomatosis can only be distinguished from tuberculosis by finding malignant cells in the C.S.F. This distinction is of importance because the recognition of carcinomatosis saves the patient from the rigours of intrathecal antituberculous therapy.

My thanks are due to Dr. E. C. Benn, consultant physician, Seacroft Hospital, for permission to publish, and to Dr. W. Goldie, consultant pathologist, for the necropsy findings. REFERENCES

Forster, E. (1930) Z. ges. Neurol. Psychiat. 126, 683. Jacobs, L. L., Richland, K. J. (1951) Bull. Los Angeles neurol. Soc.

16, 335. McCormack, L. J.. Hazard, J. B., Gardner, W. J., Klotz, J. G. (1953) Amer. J. clin. Path. 23. 470. Platt, W. R. (1951) Arch. Neurol. Psychiat., Chicago, 66, 119. Strange, L. F. (1952) Paper read at meeting of American Neurological Association.

RETROSPONDYLOLISTHESIS AS A CAUSE OF PARAPLEGIA ROBERT ROAF B.M. Oxfd, M.Ch.Orth.

Lpool,

F.R.C.S.

ORTHOPAEDIC SUHGEON, UNITED LIVERPOOL HOSPITALS

RETROSPONDYLOLISTHESIS in the dorsilumbar region of the spine is a well-recognised clinical entity which causes local pain in the back and referred pain in the lateral aspect of the buttock. There is often an associated degenerativee arthritis of the hip-joint ; this may make it difficult to determine whether pain in the region of the hip-joint is due to primary disease of the hips or is referred from the spine. It is, however, unusual for retrospondylolisthesis to cause serious pressure symptoms and I have not been able to find any report in the literature of actual paraplegia being produced ; so it seems worth reporting the following case. Since treating this patient I have seen two further cases of retrospondylolisthesis with

slight spasticity of the legs and degrees of this condition are not

it is

possible that

mild

uncommon.

A married woman of 66, who was admitted to hospital on April 20, 1954, had had pain in the lumbar region for eight years, and pain in the left hip for six years, with progressive disability. During the last two years she had been able to walk only with assistance and inside the house, with hips and

knees flexed. For the last two years she had had intermittent urinary incontinence. One week before admission to hospital the pain in the left hip became worse and she had been bedridden. Her general health until recently had been good but the pain had lately kept her awake and she had lost a considerable amount of weight. She was a thin, rather querulous woman. Both hips and knees were flexed to 90° and fixed. Both legs were spastic. The tendon reflexes were not elicited: but there were extensor plantar responses on both sides. There was no detectable impairment of sensation. The arms and cranial nerves were normal. X-ray examination showed retrospondylolisthesis of D12 and Ll. Cervical myelography showed an almost complete block at the D12-Ll level. (Lumbar myelography was attempted but was unsuccessful owing to ossification of ligaments in the lumbar spine.) On April 27, 1954, laminectomy of Dll, D12, and Ll was performed. The dura mater was found to be constricted at D12—L1 ; after laminectomy the constriction disappeared and normal pulsation returned below the level of the lesion. A fine rubber catheter could be passed up and down the theca without resistance. Postoperative progress was slow but steady from almost the day after operation. Pain and cramp disappeared. Spasticity gradually abated and urinary control returned. Flexion deformities of the knees and hips had to be treated but she was ultimately discharged from hospital in September walking unaided and only slightly spastic. ’

Preliminary Communications STIMULATION OF NATURAL IMMUNITY TO ESCHERICHIA COLI INFECTIONS OBSERVATIONS ON MICE

IT has been recently shownthat differences in virulence of Escherichia coli strains for mice can be correlated in vitro with the survival-rate of the strains in the presence of mouse serum and complement. In this bactericidal system the avirulent strains were rapidly killed under conditions permitting 100% survival of the virulent organisms. During attempts to isolate the bacterial substrate for this reaction, a remarkable effect of the bacterial cell walls came to light. After injection of 0.05-0.2 mg. of Esch. coli cell walls, either intraperitoneally (i.p.) or intravenously (i.v.), mice showed greatly enhanced susceptibility to Esch.. coli infection if challenged i.p. within 2 hours but greatly reduced susceptibility if the challenge was delayed for 24 hours.-. This initial decrease in their resistance, followed in 24 hours by a great increase, is believed to be due to the rapid neutralisation by the Esch. coli cell walls of the normally effective serum defence mechanism, which within 24 hours is restored to a higher level than normal. EXPERIMENTAL

Preparation of Cell Envelopes.—Strains of Esch. coli or

Salmonella typhimurium were used. They were harvested in saline from 24 hours’ growth on nutrient agar. The suspensions were heated at 60°C for 30 min. and then centrifuged, washed, and suspended in saline to an approximate dry weight of 30 mg. bacteria per ml. 10 ml. of this suspension was shaken in the Mickle ,shaker together with 5 ml. of ballotini beads for 40 min.2 The glass beads and any intact bacteria were removed by centrifugation for 20 min. at 3000 r.p.m. in an M.S.E. minor angle centrifuge. The turbid supernatant was further centrifuged at 14,000 1. Rowley, D. Brit. J. exp. Path. 1954, 35 (in the press). 2. Few, A. V., Cooper, P. D., Rowley, D. Nature, Lond. 1952. 169, 283.