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CEREBRO-SPINAL FLUID PRESSURE
1355 of hydrochloric acid in a sealed tube in a water bath for a few minutes will, when cooled, yield obvious crystals of lead chloride from which the characteristic reactions of lead may be obtained. The hydrolysis with the water of body fluids is doubtless slower, but judging from the description of cases none the less effective. This substance will no doubt be used largely by the medical profession and by their carusing patients, and if due care is taken very little harm will result. Physicians will, however, be well advised to remember that a new and somewhat insidious form of lead poisoning may occur in subjects whose vocations are not usually associated with this risk.
designed
for this purpose
was
described
by Kausch in
1908, but it only permitted the removal, for purposes
of examination, of a srec:men of fluid mixed with saline, and this is a great disadvantage. In the apparatus which Dr. Kilgore has himself devised these difficulties are overcome. The lumbar puncture needle communicates laterally with one end of a miniature barrel which is divided into two halves by a rubber diaphragm, the other end of the barrel being attached to a U-tube. Before use the instrument is sterilised and filled with normal saline solution. After puncture the stilet is withdrawn, and if it has entered the subarachnoid space the pressure rises in the lumen of the needle, and the rubber diaphragm bulges towards the U-tube. The vertical limb of this tube is raised or lowered until the pressure on the two LATE RESULTS OF ARTIFICIAL PNEUMOsides is equal, as shown by the return of the diaphragm THORAX. to its normal position, and the height of the column TREATMENT by artificial pneumothorax has been of saline indicates the pressure. Cerebro-spinal fluid in vogue so long that a fairly accurate estimate of mav then be removed by opening a stopcock on the its later effects can now be formed. The sceptic is other side of the needle, and by closing this stopcock not so likely to be convinced by the isolated case the pressure can be measured from time to time created yesterday, however brilliant the result, as in the same way. Dr. Kilgore says that until fluid is the pressure may remain constant, or by series of cases running into three figures and withdrawn re-examined after a lapse of several years. In a there may be a steady fall. In one case this fall series of this kind recently described by Dr. H. Bjelkel seemed to be due to a drop in the blood pressure 111 patients had been given the treatment at his caused by puncture of the membranes. In a case of sanatorium during the past ten years. They were tabes dorsalis the pressure remained the same during classified according as their disease was of a chronic the removal of 10 c.cm. of fluid. The great effect and productive or of an exudative character, and which removal of a small amount of fluid may have on the pressure was shown in the case of a patient news of their ultimate fate was obtained by correwith tuberculous meningitis. With the withdrawal Of 41 the whose disease was exudative, .spondence. five belonged to the second and 36 to the third of the first cubic centimetre the pressure fell from ’Turban-Gerhardt stage of the disease. As many as 400 to 320 mm., and it went on falling very rapidly ’23 were’discharged from the sanatorium as improved, as the next few cubic centimetres of fluid were while four left it unchanged, and 14 in a worse condi- removed. Readings taken with an instrument that tion than on admission. Very few of these 41 patients could not show the pressure before the removal of would in this case have given an error of 20-50 were found to have survived ; only five were still fluid cent. Dr. Kilgore has nothing to say of the but per and of these had left the several alive, recently sanatorium. Thus the conclusion to be drawn from clinical significance of pressure readings, but suggests these figures is that when the disease is rapidly pro- that the types of pressure-volume curves occurring compression at various levels, or with gressive and exudative the prospects of arresting it with spinal of various coma kinds, may turn out to be useful in artificial none too are by pneumothorax good. Very different is the outlook for the patient whose infection is comparatively benign and chronic, for of ’70 such patients in Dr. Bjelke’s material as many A QUESTION OF NOMENCLATURE. as 58 were found to be still alive. During the first " SCIATICA is a rare and unusual disease," writes :five years of the period under review most of the "patients selected for pneumothorax suffered from the Dr. H. T. Patrick in a recent Bulletin of the Life exudative form of the disease, and when a five-year Extension Institute of New York. On the other in his well-known book survey was made of their fate, it was found that of hand, Mr. Wilfred Harris says the 48 treated up to 1922 no fewer than 29 had died, on Neuritis and Neuralgia, " Sciatica is a very common and only ten were fit for work. But among the complaint." It is all a question of nomenclature. 63 patients treated during the last five years, as the constant advance in our knowledge of the many as 53 were found on inquiry to be fit for work. pathology of disease, the need of a standardised All but two of the 111 patients forming the whole nomenclature becomes ever more pressing. Some series were sputum-positive before treatment, whereas years ago anatomists set an example by holding a 62 were discharged without tubercle bacilli in the conference to consider their own terminology, and :sputum, or indeed any sputum at all. No case of although unanimity was not reached, there is at least an international terminology for any teacher gas embolism marred these results. to use if he cares to do so. Clinicians still wander at their own free will. Continental equivalents were left out of our " Nomenclature of Diseases " in its CEREBRO-SPINAL FLUID PRESSURE most recent edition, and the term " sciatica " appears VARIOUS methods have been used to measure only in the index of the Nomenclature with the alterations in the pressure of the cerebro-spinal fluid remark, " see Diseases of Nerves." In the " Interbefore and during its withdrawal by lumbar puncture, national List " (of causes of death) the term appears but they all have their disadvantages, as Dr. E. S. under " Hysteria and Neuritis," subsection " HysKilgore points out in a paper in the Joacrnal of the teria, Neuralgia." The two contradictory statements American -3ledical Association for Nov. 26th. The quoted above can only be reconciled by a recognition mercury U-tube manometers and aneroids or other of the fact that the term sciatica is being used to types of spring-gauge manometers are difficult to designate two different conditions. Sciatica, the sterilise and of doubtful accuracy, especially at low " common complaint," is pain in the region of distripressures. The simple upright tube from the lumbar bution of the sciatic nerve, its components or branches. puncture needle, which shows the height to which Sciatica, the " rare disease," is pain due to "an the spinal fluid will rise, is fairly reliable, except inflammation of the interstitial tissue of the sciatic when the pressure is very high. Dr. Kilgore thinks, nerve or its roots," as defined in " Modern Technique " however, that accuracy is specially important in (THE LANCET, 1926, i., 991). Even if the latter these very cases, and to be correct the readings h,ve to definition is accepted, it is doubtful if Dr. Patrick is be taken before any fluid is withdrawn. An instrument correct in assuming that only ten cases out of every hundred of the " common complaint " are examples 1 of the " rare disease," though Putti and other conTidsskrift for Den Norske Laegeforening, Nov. 1st. ____
diagnosis.
With
____
designed
for this purpose
was
described
by Kausch in
1908, but it only permitted the removal, for purposes
of examination, of a srec:men of fluid mixed with saline, and this is a great disadvantage. In the apparatus which Dr. Kilgore has himself devised these difficulties are overcome. The lumbar puncture needle communicates laterally with one end of a miniature barrel which is divided into two halves by a rubber diaphragm, the other end of the barrel being attached to a U-tube. Before use the instrument is sterilised and filled with normal saline solution. After puncture the stilet is withdrawn, and if it has entered the subarachnoid space the pressure rises in the lumen of the needle, and the rubber diaphragm bulges towards the U-tube. The vertical limb of this tube is raised or lowered until the pressure on the two LATE RESULTS OF ARTIFICIAL PNEUMOsides is equal, as shown by the return of the diaphragm THORAX. to its normal position, and the height of the column TREATMENT by artificial pneumothorax has been of saline indicates the pressure. Cerebro-spinal fluid in vogue so long that a fairly accurate estimate of mav then be removed by opening a stopcock on the its later effects can now be formed. The sceptic is other side of the needle, and by closing this stopcock not so likely to be convinced by the isolated case the pressure can be measured from time to time created yesterday, however brilliant the result, as in the same way. Dr. Kilgore says that until fluid is the pressure may remain constant, or by series of cases running into three figures and withdrawn re-examined after a lapse of several years. In a there may be a steady fall. In one case this fall series of this kind recently described by Dr. H. Bjelkel seemed to be due to a drop in the blood pressure 111 patients had been given the treatment at his caused by puncture of the membranes. In a case of sanatorium during the past ten years. They were tabes dorsalis the pressure remained the same during classified according as their disease was of a chronic the removal of 10 c.cm. of fluid. The great effect and productive or of an exudative character, and which removal of a small amount of fluid may have on the pressure was shown in the case of a patient news of their ultimate fate was obtained by correwith tuberculous meningitis. With the withdrawal Of 41 the whose disease was exudative, .spondence. five belonged to the second and 36 to the third of the first cubic centimetre the pressure fell from ’Turban-Gerhardt stage of the disease. As many as 400 to 320 mm., and it went on falling very rapidly ’23 were’discharged from the sanatorium as improved, as the next few cubic centimetres of fluid were while four left it unchanged, and 14 in a worse condi- removed. Readings taken with an instrument that tion than on admission. Very few of these 41 patients could not show the pressure before the removal of would in this case have given an error of 20-50 were found to have survived ; only five were still fluid cent. Dr. Kilgore has nothing to say of the but per and of these had left the several alive, recently sanatorium. Thus the conclusion to be drawn from clinical significance of pressure readings, but suggests these figures is that when the disease is rapidly pro- that the types of pressure-volume curves occurring compression at various levels, or with gressive and exudative the prospects of arresting it with spinal of various coma kinds, may turn out to be useful in artificial none too are by pneumothorax good. Very different is the outlook for the patient whose infection is comparatively benign and chronic, for of ’70 such patients in Dr. Bjelke’s material as many A QUESTION OF NOMENCLATURE. as 58 were found to be still alive. During the first " SCIATICA is a rare and unusual disease," writes :five years of the period under review most of the "patients selected for pneumothorax suffered from the Dr. H. T. Patrick in a recent Bulletin of the Life exudative form of the disease, and when a five-year Extension Institute of New York. On the other in his well-known book survey was made of their fate, it was found that of hand, Mr. Wilfred Harris says the 48 treated up to 1922 no fewer than 29 had died, on Neuritis and Neuralgia, " Sciatica is a very common and only ten were fit for work. But among the complaint." It is all a question of nomenclature. 63 patients treated during the last five years, as the constant advance in our knowledge of the many as 53 were found on inquiry to be fit for work. pathology of disease, the need of a standardised All but two of the 111 patients forming the whole nomenclature becomes ever more pressing. Some series were sputum-positive before treatment, whereas years ago anatomists set an example by holding a 62 were discharged without tubercle bacilli in the conference to consider their own terminology, and :sputum, or indeed any sputum at all. No case of although unanimity was not reached, there is at least an international terminology for any teacher gas embolism marred these results. to use if he cares to do so. Clinicians still wander at their own free will. Continental equivalents were left out of our " Nomenclature of Diseases " in its CEREBRO-SPINAL FLUID PRESSURE most recent edition, and the term " sciatica " appears VARIOUS methods have been used to measure only in the index of the Nomenclature with the alterations in the pressure of the cerebro-spinal fluid remark, " see Diseases of Nerves." In the " Interbefore and during its withdrawal by lumbar puncture, national List " (of causes of death) the term appears but they all have their disadvantages, as Dr. E. S. under " Hysteria and Neuritis," subsection " HysKilgore points out in a paper in the Joacrnal of the teria, Neuralgia." The two contradictory statements American -3ledical Association for Nov. 26th. The quoted above can only be reconciled by a recognition mercury U-tube manometers and aneroids or other of the fact that the term sciatica is being used to types of spring-gauge manometers are difficult to designate two different conditions. Sciatica, the sterilise and of doubtful accuracy, especially at low " common complaint," is pain in the region of distripressures. The simple upright tube from the lumbar bution of the sciatic nerve, its components or branches. puncture needle, which shows the height to which Sciatica, the " rare disease," is pain due to "an the spinal fluid will rise, is fairly reliable, except inflammation of the interstitial tissue of the sciatic when the pressure is very high. Dr. Kilgore thinks, nerve or its roots," as defined in " Modern Technique " however, that accuracy is specially important in (THE LANCET, 1926, i., 991). Even if the latter these very cases, and to be correct the readings h,ve to definition is accepted, it is doubtful if Dr. Patrick is be taken before any fluid is withdrawn. An instrument correct in assuming that only ten cases out of every hundred of the " common complaint " are examples 1 of the " rare disease," though Putti and other conTidsskrift for Den Norske Laegeforening, Nov. 1st. ____
diagnosis.
With
____