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Cistern puncture in intracranial birth injuries
CISTERN PUNCTURE IN INTRACRANIAL BIRTH INJURIES BY BERMAN S. DuNHAM, lVI.D., ToLEDo, Omo (Pediatrist to the Maternity and Children's Hospital)
value of cerebrospinal drainage in the diagnosis and treatment TofHEintracranial birth injuries is admitted by most authorities. In a consideration of this subject, certain features of the pathology and the disturbance o£ function should be noted. The usual lesion is an intracranial hemorrhage. Edema of the brain may be an important complication, however; or at times it may be the only finding. Vital disorders are due most frequently to an intracranial pressure from hemorrhage or edema. Sometimes traumatic shock and depletion o£ the general circulation from bleeding within the cranium are important factors in the morbid condition. Hemorrhages are located most frequently in the subarachnoid spaces over the cerebral and cerebellar surfaces. The source of the bleeding is usually from torn meningeal vessels or from lacerated sinuses or their tributaries, in association with tears of the tentorium or falx, incident to labor. 1 Intraventricular hemorrhages from lesions of the choroid plexus, as well as localized epidural hematomata in association with fractures o.f the cranial bones, occur infrequently. The wall-like function of the tentorium, which separates more or less completely the cerebral from the lower subarachnoid spaces, has an important bearing on the location o£ a hemorrhage in respect to treatment. THERAPEUTIC AND DIAGNOSTIC CONSIDERATIONS The earliest attempts at relief from hemorrhage and pressure were made by the use of decompression. Death usually followed, due apparently to the multiplicity of the vascular tears, the impossibility of locating and repairing them, and the conversion of the closed subarachnoid space into an open one with a total release of pressure at the bleeding points. Later, it was found that lumbar puncture offered a means of control of the pressure within physiologic limits in many instances until the bleeding stopped spontaneously, with a record for recoveries far better than that from decompression. Decompression, however, may be the only hope for relief in lesions above an intact tentorium and inaccessible, therefore, to drainage from below. lVIany babies with intracranial hemorrhage fail to receive benefit from lumbar puncture because only dry lumbar taps have resulted. In other instances only a little blood, possibly from punctured vessels of the spinal plexus, has been obtained. This experience has been so 8.3.')
834
THE AMERICAN JOURNAL OF OB:o;TETRICS AND GYNECOLOGY
common that some clinicians~ consider lumbar puncture to be of little value as a means of relief. It is not <·crtain whether these dry taps are due simply to failure to enter the spinal subarachnoid space of the newborn infant or to clotting of the escaped blood in the canal. Undoubtedly the element of personal skill enters into the matter somewhat, but clotting also must be a factor in late cases of intracranial bleeding of severe degree. It is a common observation that during an attempt to obtain spinal fluid, even in normal babies, the needle often injures the vascular spinal plexus with a resultant drainage of blood. From this fact confusion arises frequently in the diagnosis of cases of suspected birth injury in which blood is found in the lumbar fluid as to whether or not this blood really comes from the cranial cavity. CISTERN PUNCTURE
In instances of suspected birth injury with dry lumbar taps or blood of uncertain origin in the spinal fluid, it has been my practice during the last two years to puncture the cisterna magna. At this latter site the fluid is practically free from contamination of blood from the operation itself, because the blood vessels are principally extradural at this location. The desired amount of fluid is always easily obtained, more direct access to the site of the trouble is gained, and all danger from hernia of the brain is obviated. The technic is safe in trained hands and is also easily acquired. About the same time that my earliest cases were undergoing treatment by cistern ·puncture, Brady 3 employed, independently, the same method in two cases. The technic of cistern puncture has been described by W ege:forth, Ayer and Essick 4 in their original contribution. 'l'he application to infants has been set forth clearly by Porter and Carter. 5 In newborn infants the usual landmarks are often ill-defined because of changes in the shape of the head and neck from molding, edema or other trauma. :M:y preference in the infant, therefore, is to modify somewhat the foregoing technic. After the usual surgical preparation and anterior flexion of the head in the midline, the approximate position of the posterior rim of the foramen magnum is located by deep palpation. The ordinary lumbar puncture needle is then inserted a few millimeters above this point in the midline and in line with the glabella until the occipital bone is touched. The needle is then displaced downward, carrying the soft tissues with it, until the point of the needle slips under the posterior rim of the occipital bone. The needle is then cautiously pushed forward and upward, in line with the midpoint between the glabella and the anterior fontanelle, until the sudden "give" of the needle indicates the piercing of the oeeipito atlantal ligament, and withdrawal of the obturator should be followed by drainage of fluid from the cistern.
DUNHAM:
CISTERN PUNCTURE IN INTRACRANIAL BIRTH INJURIES
835
After a preliminary practice on the recent cadaver, no extraordinary difficulty shoold be experienced in the operation. Although the potential danger of injury to the medulla is seemingly great, the practical risk seems to be very slight. In 1985 cistern punctures on 450 collected cases by some fifty physicians, Ayer 6 was unable to trace any vital injury to the puncture itself. In my series of 78 cistern punctures on 25 infants and children for various therapeutic and diagnostic purposes during the last four years, no harm has ever been observed. One of these infants sustained 26 cistern punctures without apparent harm, while under treatment for cerebrospinal fever with
[Aro:,nm~-+ z+i:-+-=Lf--5 --=J~+=='9~+9
I
10Jr~i-tAT I
101
'
f----t-----,'f---1-~
-- _,
--]~ --··
---;---+--, - - <----,.,-
Chart I.-Case 1. Clinical course of basal intracranial hemorrhage with spinal block, treated by cistern puncture. Recovery. Solid blocks, whole blood ; shaded block, part blood.
spinal block. When the vital significance of birth injury to the immediate welfare of the patient as well as to later cerebral defects is considered, one may justifiably assume a risk that promises further possibilities for relief and cure. RESULTS l!'ROM CISTERN PUNCTURE
Ten newborn infants with birth injury have reeeived a total of 27 cistern punctures, ranging from one to eight each, as shown in Table I. Nine of these cases had an intracranial hemorrhage, of which one had a complicating edema of the brain as shown by necropsy. An-
hemorrhage hemorrhage hemorrhage hemorrhage and crrPbral
···-----~lllOJTh~~\'
Basal Basal Basal Basal Basal
I
·f~\H·mal
MorilJun
Critical Moribun
coagulation tinlP,
--··-- 1 day
3 days 1lh days
Birth Birth
Critical Critical
Critical
;) clays Birth :3 days
Critieal
BE~'ORE
,f
t'.J S
0
Normal Normal
,,
1() minut<'~ Normal
1
•)
1 2
:l
•)
~)
10
1:.!
] ti
~0
s 1
24-
~fONTHS
PRESENT AGE j
CISTERN
PUNC1'URES
Normal 25 minut<'<
0
lj
1
LUMBAR
SATIS~'ACTORY
Normal
n'lintltt'~.
LatP
Late Late Early Lato
Late Early
Lt>te
Latn
GOAGU· LATION TIMEt
_:_·--::::=:....:-=..::::.::=----~--==-..:.=:::::~.....:...:.. :~:=-.:::-_=:==--:="":":-"
Normal
__::____:.:::'
Trm.\T· MENT BEGUN
___ ..:_:'=:::--=-~:...__
GENERAL CONDITIO.!)[
Birth
TIME fiYMPTOMS FIRST
----=---==------~:_-_-:_-::-.::.-.::..-.:-~::::::=..:.:_:_':__:__:;:_"'::.:.
l'll(~Jilil
--
CASES
---- ··-:..:::==
*Normal developn1ent. 6 hl :-; vnund:-;.
-··--·
10
9
g
7
5 6
---~ ... .:..-:---·--
TYPE \H' LESJOX
-----------
Edema of l.Jmin Basal and rerebral hemorrhage aJJtl Basal hemorrhage
CASE
Normal Premature, 4lh pounds Normal Prematme, 4 pounds Normal Nonual 9 pounds Normal
DEVELOP· MEN'!'* OR WEIGHT AT BIRTH
3 1
_::::::::;~:..:_:_-..:~=-
-----
TABLE
Died
Died Died Cured Cured
Cure
Died
Cuw
def~o>ets
RPr:OY('ry,
HESULT
""
...q
C)
0 t:" 0
c
t
"'z><
z>t!
i:h
~ ,-.,
~
0 tlj m
0
> r
z
1;1
g
'-<
z
>
<:
~
t'1
~
>
!:
Ill
>-3
~
1:,;)
(X)
DUNHAM:
CISTERN PUNCTURE IN INTRACRANIAL BIRTH INJURIES
837
other baby had only edema. All patients presented manifest symptoms of injury; such as ocular disturbances in all, cyanosis and local twitchings or generalized convulsions in nine, and respiratory, cardiac, or temperature disturbances in eight. The general condition, when the babies were first seen, was classified in one case as poor, in seven cases as critical, and in two cases as moribund. Preliminary lumbar puncture was done in five cases. Three of these had dry lumbar taps. In Case 2 (Chart II) there was drainage of blood on initial lumbar puncture and a manifest reduction of pressure at the fontanelle. Only dry lumbar taps were obtained afterward, howAGE, DAYS
"IV r~
IOJ
'
2
1
105
170 150 PULSE
I~ '-.1
"""
60
I
....... ~ --"\
llESP 40
FLUID 20 LtJliBAR
"L".
cc•s
1
40
20 0
LCC
I
10
....,
I
130
ao
'
-
!'....
110
CISTEB!I "C''.
I -,)
N 95
8
v V' I v \ v-
I
190
7
A I
99
97'
6
/)
,..,
101
Dlll'
s
4
c
•
v
IV
c
IIa I I
-·
r\r-v h~ v v "'
"
~
1·--
1'-::-
VI
"""' r- ../
I """ ···-
c
c
I
'··-
B
Chart II.-Case 2. Clinical course of severe basal hemorrhage and cerebral Injury with spinal block and after one lumbar puncture, treated afterwards by cistern puncture. Recovery with moderate defects. Solid blocks, whole blood; shaded blocks, part blood.
ever, necessitating eight cistern punctures for continued relief from the symptoms of pressure and for eventual recovery. In Case 3 there was blood of questionable origin in the spinal fluid. A clear cistern fluid under increased pressure, obtained immediately afterward, together with prompt and permanent symptomatic relief, established the morbid condition in this case to be one of edema, rather than hemorrhage. Six patients recovered. Their present ages range from nine to twenty-four months. The mental and physical condition is normal in
888
THE AMERICAN JOURNAl; OF OBS'l'E'l'IUCS AND GYNECOLOGY
all, apparently, except in Case 2 in which there was manifest cerebral injury of moderate degree from the very beginning. Of the four deaths, two were complicated by prematurity, another by delayed coagulation and moribund eondition; the final case was also moribund when first seen. 'rhe beneficial effect of cistern puncture on the color, sensorium and general condition was often prompt and marked. Improvement, if any, was usually eviucnt within an hour and often while the needle was still in the cistern. A temporary increasl) of th!~ pulse rate was often noted during the first few hour~:~ after the puncture; but the characteristic trend of the pulse, temperature and respiration l:urves was downward, as shown in the charts. Rest, quiet, supportive measures and, when indicated, the tn1atmeni of coincident circulatory depletion and shock were essential for recovery. COl\'HIENT
It is believed that the results from cistern puncture differ in no essential respect from those of adequate cerebrospinal drainage by lumbar puncture. In all instances of failure of drainage by the latter method, from spinal subarachnoid block or missed puncture, however, sufficient drainage may easily be aecomplished by cistern puncture. The diagnosis of basal hemorrhage or edema of the brain may be readily established or disproved by means of cistern puncture in all instances of uncertainty after lumbar puncture with questionable contamination of blood or with dry taps. By those not well experienced in the technic of cistern puncture, this procedure should be reserved as a method of last resort after lumbar puncture has failed. In the hands of the pediatrist, preferably, or others well trained in cistern puncture, it may be employed advantageously from the very beginning. REPI!~RENC.I<;S
lEhrenfest, H.: Causation of Intn<•·I ani a! Hc•tno11lmges in the New-B\Jm, Ani. Jour. Dis. Child., December, 1923, xxvi, 303. 2Holt, L. E.: Diseases of Infancy and Childhood, Ed. 6, revised, New York, 1913, D. Appleton & Company, p. 106. sBrad.y, J. M.: Intracranial Hemorrhage in the New-Born, MPd. Clin. North America, March, 1924, vii, 1453. 4Wege:f:'orth, P., Ayer,, J. B., and Essick, C. R.: Method of Obtaining Cerebrospinal Fluid by Puncture of the Cisterna Magna, Am. Jour. Med. Sci., June, 1919, elvii, 789. r•Porter, L., and Carter, W. E.: Management of the Sick Infant, Ed. 2., revised, St. Louis, 1924, C. V. Mosby Company, p. 515. BAyer, J. B.: Puncture of the Cisterna Magna, Jour. Am. Med. Assn., August, 1923, lxxxi, 358. 203 COLTON BUILDING.
value of cerebrospinal drainage in the diagnosis and treatment TofHEintracranial birth injuries is admitted by most authorities. In a consideration of this subject, certain features of the pathology and the disturbance o£ function should be noted. The usual lesion is an intracranial hemorrhage. Edema of the brain may be an important complication, however; or at times it may be the only finding. Vital disorders are due most frequently to an intracranial pressure from hemorrhage or edema. Sometimes traumatic shock and depletion o£ the general circulation from bleeding within the cranium are important factors in the morbid condition. Hemorrhages are located most frequently in the subarachnoid spaces over the cerebral and cerebellar surfaces. The source of the bleeding is usually from torn meningeal vessels or from lacerated sinuses or their tributaries, in association with tears of the tentorium or falx, incident to labor. 1 Intraventricular hemorrhages from lesions of the choroid plexus, as well as localized epidural hematomata in association with fractures o.f the cranial bones, occur infrequently. The wall-like function of the tentorium, which separates more or less completely the cerebral from the lower subarachnoid spaces, has an important bearing on the location o£ a hemorrhage in respect to treatment. THERAPEUTIC AND DIAGNOSTIC CONSIDERATIONS The earliest attempts at relief from hemorrhage and pressure were made by the use of decompression. Death usually followed, due apparently to the multiplicity of the vascular tears, the impossibility of locating and repairing them, and the conversion of the closed subarachnoid space into an open one with a total release of pressure at the bleeding points. Later, it was found that lumbar puncture offered a means of control of the pressure within physiologic limits in many instances until the bleeding stopped spontaneously, with a record for recoveries far better than that from decompression. Decompression, however, may be the only hope for relief in lesions above an intact tentorium and inaccessible, therefore, to drainage from below. lVIany babies with intracranial hemorrhage fail to receive benefit from lumbar puncture because only dry lumbar taps have resulted. In other instances only a little blood, possibly from punctured vessels of the spinal plexus, has been obtained. This experience has been so 8.3.')
834
THE AMERICAN JOURNAL OF OB:o;TETRICS AND GYNECOLOGY
common that some clinicians~ consider lumbar puncture to be of little value as a means of relief. It is not <·crtain whether these dry taps are due simply to failure to enter the spinal subarachnoid space of the newborn infant or to clotting of the escaped blood in the canal. Undoubtedly the element of personal skill enters into the matter somewhat, but clotting also must be a factor in late cases of intracranial bleeding of severe degree. It is a common observation that during an attempt to obtain spinal fluid, even in normal babies, the needle often injures the vascular spinal plexus with a resultant drainage of blood. From this fact confusion arises frequently in the diagnosis of cases of suspected birth injury in which blood is found in the lumbar fluid as to whether or not this blood really comes from the cranial cavity. CISTERN PUNCTURE
In instances of suspected birth injury with dry lumbar taps or blood of uncertain origin in the spinal fluid, it has been my practice during the last two years to puncture the cisterna magna. At this latter site the fluid is practically free from contamination of blood from the operation itself, because the blood vessels are principally extradural at this location. The desired amount of fluid is always easily obtained, more direct access to the site of the trouble is gained, and all danger from hernia of the brain is obviated. The technic is safe in trained hands and is also easily acquired. About the same time that my earliest cases were undergoing treatment by cistern ·puncture, Brady 3 employed, independently, the same method in two cases. The technic of cistern puncture has been described by W ege:forth, Ayer and Essick 4 in their original contribution. 'l'he application to infants has been set forth clearly by Porter and Carter. 5 In newborn infants the usual landmarks are often ill-defined because of changes in the shape of the head and neck from molding, edema or other trauma. :M:y preference in the infant, therefore, is to modify somewhat the foregoing technic. After the usual surgical preparation and anterior flexion of the head in the midline, the approximate position of the posterior rim of the foramen magnum is located by deep palpation. The ordinary lumbar puncture needle is then inserted a few millimeters above this point in the midline and in line with the glabella until the occipital bone is touched. The needle is then displaced downward, carrying the soft tissues with it, until the point of the needle slips under the posterior rim of the occipital bone. The needle is then cautiously pushed forward and upward, in line with the midpoint between the glabella and the anterior fontanelle, until the sudden "give" of the needle indicates the piercing of the oeeipito atlantal ligament, and withdrawal of the obturator should be followed by drainage of fluid from the cistern.
DUNHAM:
CISTERN PUNCTURE IN INTRACRANIAL BIRTH INJURIES
835
After a preliminary practice on the recent cadaver, no extraordinary difficulty shoold be experienced in the operation. Although the potential danger of injury to the medulla is seemingly great, the practical risk seems to be very slight. In 1985 cistern punctures on 450 collected cases by some fifty physicians, Ayer 6 was unable to trace any vital injury to the puncture itself. In my series of 78 cistern punctures on 25 infants and children for various therapeutic and diagnostic purposes during the last four years, no harm has ever been observed. One of these infants sustained 26 cistern punctures without apparent harm, while under treatment for cerebrospinal fever with
[Aro:,nm~-+ z+i:-+-=Lf--5 --=J~+=='9~+9
I
10Jr~i-tAT I
101
'
f----t-----,'f---1-~
-- _,
--]~ --··
---;---+--, - - <----,.,-
Chart I.-Case 1. Clinical course of basal intracranial hemorrhage with spinal block, treated by cistern puncture. Recovery. Solid blocks, whole blood ; shaded block, part blood.
spinal block. When the vital significance of birth injury to the immediate welfare of the patient as well as to later cerebral defects is considered, one may justifiably assume a risk that promises further possibilities for relief and cure. RESULTS l!'ROM CISTERN PUNCTURE
Ten newborn infants with birth injury have reeeived a total of 27 cistern punctures, ranging from one to eight each, as shown in Table I. Nine of these cases had an intracranial hemorrhage, of which one had a complicating edema of the brain as shown by necropsy. An-
hemorrhage hemorrhage hemorrhage hemorrhage and crrPbral
···-----~lllOJTh~~\'
Basal Basal Basal Basal Basal
I
·f~\H·mal
MorilJun
Critical Moribun
coagulation tinlP,
--··-- 1 day
3 days 1lh days
Birth Birth
Critical Critical
Critical
;) clays Birth :3 days
Critieal
BE~'ORE
,f
t'.J S
0
Normal Normal
,,
1() minut<'~ Normal
1
•)
1 2
:l
•)
~)
10
1:.!
] ti
~0
s 1
24-
~fONTHS
PRESENT AGE j
CISTERN
PUNC1'URES
Normal 25 minut<'<
0
lj
1
LUMBAR
SATIS~'ACTORY
Normal
n'lintltt'~.
LatP
Late Late Early Lato
Late Early
Lt>te
Latn
GOAGU· LATION TIMEt
_:_·--::::=:....:-=..::::.::=----~--==-..:.=:::::~.....:...:.. :~:=-.:::-_=:==--:="":":-"
Normal
__::____:.:::'
Trm.\T· MENT BEGUN
___ ..:_:'=:::--=-~:...__
GENERAL CONDITIO.!)[
Birth
TIME fiYMPTOMS FIRST
----=---==------~:_-_-:_-::-.::.-.::..-.:-~::::::=..:.:_:_':__:__:;:_"'::.:.
l'll(~Jilil
--
CASES
---- ··-:..:::==
*Normal developn1ent. 6 hl :-; vnund:-;.
-··--·
10
9
g
7
5 6
---~ ... .:..-:---·--
TYPE \H' LESJOX
-----------
Edema of l.Jmin Basal and rerebral hemorrhage aJJtl Basal hemorrhage
CASE
Normal Premature, 4lh pounds Normal Prematme, 4 pounds Normal Nonual 9 pounds Normal
DEVELOP· MEN'!'* OR WEIGHT AT BIRTH
3 1
_::::::::;~:..:_:_-..:~=-
-----
TABLE
Died
Died Died Cured Cured
Cure
Died
Cuw
def~o>ets
RPr:OY('ry,
HESULT
""
...q
C)
0 t:" 0
c
t
"'z><
z>t!
i:h
~ ,-.,
~
0 tlj m
0
> r
z
1;1
g
'-<
z
>
<:
~
t'1
~
>
!:
Ill
>-3
~
1:,;)
(X)
DUNHAM:
CISTERN PUNCTURE IN INTRACRANIAL BIRTH INJURIES
837
other baby had only edema. All patients presented manifest symptoms of injury; such as ocular disturbances in all, cyanosis and local twitchings or generalized convulsions in nine, and respiratory, cardiac, or temperature disturbances in eight. The general condition, when the babies were first seen, was classified in one case as poor, in seven cases as critical, and in two cases as moribund. Preliminary lumbar puncture was done in five cases. Three of these had dry lumbar taps. In Case 2 (Chart II) there was drainage of blood on initial lumbar puncture and a manifest reduction of pressure at the fontanelle. Only dry lumbar taps were obtained afterward, howAGE, DAYS
"IV r~
IOJ
'
2
1
105
170 150 PULSE
I~ '-.1
"""
60
I
....... ~ --"\
llESP 40
FLUID 20 LtJliBAR
"L".
cc•s
1
40
20 0
LCC
I
10
....,
I
130
ao
'
-
!'....
110
CISTEB!I "C''.
I -,)
N 95
8
v V' I v \ v-
I
190
7
A I
99
97'
6
/)
,..,
101
Dlll'
s
4
c
•
v
IV
c
IIa I I
-·
r\r-v h~ v v "'
"
~
1·--
1'-::-
VI
"""' r- ../
I """ ···-
c
c
I
'··-
B
Chart II.-Case 2. Clinical course of severe basal hemorrhage and cerebral Injury with spinal block and after one lumbar puncture, treated afterwards by cistern puncture. Recovery with moderate defects. Solid blocks, whole blood; shaded blocks, part blood.
ever, necessitating eight cistern punctures for continued relief from the symptoms of pressure and for eventual recovery. In Case 3 there was blood of questionable origin in the spinal fluid. A clear cistern fluid under increased pressure, obtained immediately afterward, together with prompt and permanent symptomatic relief, established the morbid condition in this case to be one of edema, rather than hemorrhage. Six patients recovered. Their present ages range from nine to twenty-four months. The mental and physical condition is normal in
888
THE AMERICAN JOURNAl; OF OBS'l'E'l'IUCS AND GYNECOLOGY
all, apparently, except in Case 2 in which there was manifest cerebral injury of moderate degree from the very beginning. Of the four deaths, two were complicated by prematurity, another by delayed coagulation and moribund eondition; the final case was also moribund when first seen. 'rhe beneficial effect of cistern puncture on the color, sensorium and general condition was often prompt and marked. Improvement, if any, was usually eviucnt within an hour and often while the needle was still in the cistern. A temporary increasl) of th!~ pulse rate was often noted during the first few hour~:~ after the puncture; but the characteristic trend of the pulse, temperature and respiration l:urves was downward, as shown in the charts. Rest, quiet, supportive measures and, when indicated, the tn1atmeni of coincident circulatory depletion and shock were essential for recovery. COl\'HIENT
It is believed that the results from cistern puncture differ in no essential respect from those of adequate cerebrospinal drainage by lumbar puncture. In all instances of failure of drainage by the latter method, from spinal subarachnoid block or missed puncture, however, sufficient drainage may easily be aecomplished by cistern puncture. The diagnosis of basal hemorrhage or edema of the brain may be readily established or disproved by means of cistern puncture in all instances of uncertainty after lumbar puncture with questionable contamination of blood or with dry taps. By those not well experienced in the technic of cistern puncture, this procedure should be reserved as a method of last resort after lumbar puncture has failed. In the hands of the pediatrist, preferably, or others well trained in cistern puncture, it may be employed advantageously from the very beginning. REPI!~RENC.I<;S
lEhrenfest, H.: Causation of Intn<•·I ani a! Hc•tno11lmges in the New-B\Jm, Ani. Jour. Dis. Child., December, 1923, xxvi, 303. 2Holt, L. E.: Diseases of Infancy and Childhood, Ed. 6, revised, New York, 1913, D. Appleton & Company, p. 106. sBrad.y, J. M.: Intracranial Hemorrhage in the New-Born, MPd. Clin. North America, March, 1924, vii, 1453. 4Wege:f:'orth, P., Ayer,, J. B., and Essick, C. R.: Method of Obtaining Cerebrospinal Fluid by Puncture of the Cisterna Magna, Am. Jour. Med. Sci., June, 1919, elvii, 789. r•Porter, L., and Carter, W. E.: Management of the Sick Infant, Ed. 2., revised, St. Louis, 1924, C. V. Mosby Company, p. 515. BAyer, J. B.: Puncture of the Cisterna Magna, Jour. Am. Med. Assn., August, 1923, lxxxi, 358. 203 COLTON BUILDING.