Pioneers in the cisterna magna puncture.

At the beginning of the 20th century, cerebrospinal fluid (CSF) collection and analysis emerged as a promising aid in the diagnosis of diseases of the central nervous system. It was obtained through the established procedure of lumbar puncture, described by Heinrich Quinke in 1891. The search for an alternative way to gather the CSF emerged in animal research, highlighting the cisterna magna as a promising source, with relative safety when performed by someone trained. Described initially and in detail by James Ayer in 1920, the procedure was widely adopted by neurologists and psychiatrists at the time, featuring its multiple advantages and clinical applications. After a period of great procedure use and exponential data collection, its complications and risks relegated the puncture of the cisterna magna as an alternative route that causes fear and fascination in modern Neurology.

Pioneers in the cisterna magna puncture / Pioneiros na punção da cisterna magna

Abstract At the beginning of the 20th century, cerebrospinal fluid (CSF) collection and analysis emerged as a promising aid in the diagnosis of diseases of the central nervous system. It was obtained through the established procedure of lumbar puncture, described by Heinrich Quinke in 1891. The search for an alternative way to gather the CSF emerged in animal research, highlighting the cisterna magna as a promising source, with relative safety when performed by someone trained. Described initially and in detail by James Ayer in 1920, the procedure was widely adopted by neurologists and psychiatrists at the time, featuring its multiple advantages and clinical applications. After a period of great procedure use and exponential data collection, its complications and risks relegated the puncture of the cisterna magna as an alternative route that causes fear and fascination in modern Neurology.

Resumo No início do século XX, a coleta e análise do líquido cefalorraquidiano (LCR) despontavam como um promissor auxílio no diagnóstico das doenças do sistema nervoso central. Sua obtenção se dava através do consagrado procedimento de punção lombar, descrito por Heinrich Quinke em 1891. A busca por uma via alternativa na obtenção do LCR ganhou destaque nas pesquisas animais, destacando-se na cisterna magna promissora fonte, com relativa segurança quando executada por alguém treinado. Descrito inicialmente e de maneira pormenorizada por James Ayer em 1920, o procedimento foi amplamente adotado por neurologistas e psiquiatras à época, com destaque para suas múltiplas vantagens e aplicações clínicas. Após um período de grande uso do procedimento e exponencial obtenção de dados, suas complicações e riscos relegaram a punção da cisterna magna como via alternativa que causa medo e fascínio na Neurologia moderna.

Cerebrospinal fluid and lumbar puncture: the story of a necessary procedure in the history of medicine.

The aim of our work was to investigate the different historical stages that led gradually to the discovery of the anatomical structures that form and contain cerebrospinal fluid (CSF), until the Quincke idea, to collect the liquid directly at the lumbar level delivering to humanity a diagnostic tool present and absolutely irreplaceable in everyday clinical practice. This is done through consultation of all the historical medical literature, together with the critical examination of the original articles when available in the most rigorous chronological and speculative order, which enabled knowledge advancement.

[Quincke and his oedema]. / Quincke en zijn oedeem.

Heinrich Irenaeus Quincke (1842-1922), the son of a physician, was born in Frankfurt but was educated in Berlin where he also completed his medical studies in 1864. After a 'grand tour' that took him to Paris, Vienna and London, he was trained in Berlin, first in surgery and later in internal medicine, under Von Frerichs (1819-1885). In 1878, he became a professor of internal medicine in Berne; from 1883 he held the chair of medicine in Kiel, which he would hold for the next 30 years. In 1882, he published a synthesis of several observations of 'acute, circumscribed oedema of the skin'. Quincke accurately described the clinical features and distinguished the familial from the sporadic forms. He was correct in attributing the condition to increased vascular permeability, but he surmised the causal factors were neurogenic rather than humoral, according to current insights (excess of bradykinin due to external factors or hereditary deficiency of C1-esterase inhibitor). Quincke not only contributed to several other clinical observations, but also pioneered the lumbar puncture, initially not for diagnostic purposes, but to relieve headache in hydrocephalic children.

A history of acute bacterial meningitis.

Although meningitis was not yet known as such, its symptoms have been conceptualized in different ways and many theories about its causes have been formulated in the course of time. Terms like hydrocephalus and brain fever were used for different clinical manifestations of what today would be recognized as meningitis. Pathological-anatomical findings led to the emergence of the clinical entity from several old concepts of disease. Initially, diagnostic means were limited and therapeutic methods did not differ much from those that had been applied for centuries, even far into the nineteenth century. Discoveries in bacteriology and the introduction of the lumbar puncture provided a new paradigm for knowledge of the pathophysiology and treatment of what then became known with the term meningitis. The development of new therapeutic methods including antiserum, sulfonamides, and penicillin resulted in a decreasing mortality during the past century. Nowadays, with the use of antibiotics, bacterial meningitis can often be cured.

Idiopathic intracranial hypertension with Dan and beyond: the 2010 Jacobson Lecture.

Neuro-ophthalmologists frequently care for patients with idiopathic intracranial hypertension (IIH), although many questions remain unanswered regarding its diagnosis, pathogenesis, and treatment. The Friedman-Jacobson criteria for the diagnosis of IIH specify lumbar puncture (LP) opening pressure values that are largely based on experience with little supporting normative data. Until recently, there were sparse data to define normal values of the LP opening pressure in children. Papilledema, the sine qua non of IIH, may not always be present, but the frequency of true IIH without papilledema is controversial and the threshold for diagnosing it varies among clinicians. Concepts regarding the pathogenesis of IIH continue to evolve; venous hypertension is certainly implicated even though it is uncertain whether venous sinus stenosis is the cause or effect of increased intracranial pressure. The 2010 Jacobson Lecture discusses the evidence for some of the prevailing assumptions about normal lumbar puncture opening pressure, venous sinus stenosis, and the phenotypic continuum between chronic daily headaches and IIH.

[Babinski's legacy]. / L'oeuvre de Babinski.

Joseph Babinski may be considered as a founder of modern neurology. Based upon a strict neurological examination, he was able to clarify a clinical distinction between hysterical and organic symptomatology. Besides his observation on the Sign, which made him world famous, his description of new concepts in cerebellar signs, his studies on reflexes constituted important landmarks in clinical neurology. But he was also a therapist, moving from palliative treatment to give a great impulse in the development of French Neurosurgery.

[In memory of the 160(th) birthday and the 80(th) anniversary of the death of Heinrich Irenäus Quincke, as well as of his description of angioedema 120 years ago]. / Heinrich Irenäus Quincke Aus Anlass seines 160. Geburtstages und 80. Todestages sowie seiner Beschreibung des Angioödems vor 120 Jahren.

In the year 2002 we celebrate the 160(th) birthday and the 80(th) anniversary of the death of Heinrich Irenäus Quincke, former head of the department of internal medicine at the University of Kiel from 1878 to 1908. Moreover we remember the description of the angioedema by Quincke in the "Monatsheften für Praktische Dermatologie" 120 years ago. Because his name is so tightly linked with angioedema, Quincke's other discoveries and achievements are scarcely recalled today. Some of his other accomplishments include the invention of the lumbar puncture, the initiation of the term siderosis, the study of the resorption of inorganic iron to treat iron-deficiency anemia and his early contributions to pulmonary surgery. Quincke was the first to describe the causative organism of animal favus, which today is known as Trichophyton quinckeanum. Quincke suspected a syphilitic infection as the cause of aortic aneurysms and recommended antisyphilitic therapy. In the beginning of his career in Kiel, Quincke gave lectures not only in internal medicine but also in dermatology and venerology, pediatrics, bacteriology and public health, until chairs were established for these disciplines. Quincke was for four terms Dean of the medical faculty and in 1900 Rector of the University of Kiel.

Magendie and the chemists: the earliest chemical analyses of the cerebrospinal fluid.

Having described the spinal fluid, François Magendie (1783-1855) called upon a number of chemists in Paris to analyze the material, in the effort to decide if it was a special secretion of the nervous system or simply a filtrate of the blood. J.L. Lassaigne (1800-1859) and J.P. Couerbe (1805-1867) responded. Their results, and those of some earlier investigators, are described. In the ensuing years of the nineteenth century, other investigators similarly conducted analyses of spinal fluid, but these were usually of single constituents in poorly defined diagnostic conditions. In 1909-1912, William Mestrezat (1883-1928) took advantage of the recently introduced technique of lumbar puncture, which by now had become hospital routine, and introduced the modern era of systematic analysis of many components of the spinal fluid, correlated with specific disease states.

The scientific history of hydrocephalus and its treatment.

Hydrocephalus cases were regularly described by Hippocrates, Galen, and early and medieval Arabian physicians, who believed that this disease was caused by an extracerebral accumulation of water. Operative procedures used in ancient times are neither proven by skull findings today nor clearly reported in the literature. Evacuation of superficial intracranial fluid in hydrocephalic children was first described in detail in the tenth century by Abulkassim Al Zahrawi. In 1744, LeCat published findings on a ventricular puncture. Effective therapy required aseptic surgery as well as pathophysiological knowledge--both unavailable before the late nineteenth century. In 1881, a few years after the landmark study of Key and Retzius, Wernicke inaugurated sterile ventricular puncture and external CSF drainage. These were followed in 1891 by serial lumbar punctures (Quincke) and, in 1893, by the first permanent ventriculo-subarachnoid-subgaleal shunt (Mikulicz), which was simultaneously a ventriculostomy and a drainage into an extrathecal low pressure compartment. Between 1898 and 1925, lumboperitoneal, and ventriculoperitoneal, -venous, -pleural, and -ureteral shunts were invented, but these had a high failure rate due to insufficient implant materials in most cases. Ventriculostomy without implants (Anton 1908), with implants, and plexus coagulation initially had a very high operative mortality and were seldom successful in the long term, but gradually improved over the next decades. In 1949, Nulsen and Spitz implanted a shunt successfully into the caval vein with a ball valve. Between 1955 and 1960, four independent groups invented distal slit, proximal slit, and diaphragm valves almost simultaneously. Around 1960, the combined invention of artificial valves and silicone led to a worldwide therapeutic breakthrough. After the first generation of simple differential pressure valves, which are unable to drain physiologically in all body positions, a second generation of adjustable, autoregulating, antisiphon, and gravitational valves was developed, but their use is limited due to economical restrictions and still unsolved technical problems. At the moment, at least 127 different designs are available, with historical models and prototypes bringing the number to 190 valves, but most of these are only clones. In the 1990s, there has been a renaissance of endoscopic ventriculostomy, which is widely accepted as the method of first choice in adult patients with aquired or late-onset, occlusive hydrocephalus; in other cases the preference remains controversial. Both new methods, the second generation of valves as well as ventriculostomy, show massive deficits in evaluation. There is only one randomized study and no long-term evaluation.

Complications of lumbar puncture.

This article reviews historical aspects and the following complications of lumbar puncture: cerebral and spinal herniation, postdural puncture headache, cranial neuropathies, nerve root irritation, low back pain, stylet associated problems, infections, and bleeding complications. The incidence of postdural puncture headache can be greatly reduced by pointing the face of the bevel in the direction of the patient's side, replacing the stylet and rotating the needle 90;dg before withdrawing the needle, and using the Sprotte atraumatic needle, especially in high risk patients.