Hippocrates
(470-400 B.C.) spoke of "water on the brain," i.e. hydrocephalus.
In
1692 Valsalva noted a watery fluid around the spinal cord of a dog,
when cutting through the cord. At that time it was common practice to
decapitate cadavers when dissecting them, resulting in CSF leaking out
before the brain and cord were examined.
In
1764 Domenico Cotugno explained, in his landmark description of cerebrospinal
fluid, "De ischiade nervosa
commentarius," " The reason
that anatomists have never yet observed this collection of water about
the brain and in the spine is owing to the common preposterous method
of dissecting; for when they are about to examine the brain, they commonly
cut off the head from the neck; this means that the tube of the Dura
Mater, which ascends by the spine of the neck, being cut through, all
the water that is collected about the brain and the spinal marrow flows
out and is foolishly lost" (Sakula).
Standard
practice in the 1800s was to inject anesthetic (cocaine or morphine)
as close as possible to the site that needed to be anesthetized. Experimenting
on a dog, Corning injected 20 minims of 2% cocaine "into the space situated
between the spinous processes of two of the inferior dorsal vertebrae."
This resulted in loss of sensation and incoordination of the hind legs
of the dog. Although he did not recognize it, Corning had injected cocaine
into the subarachnoid space. No mention was made of withdrawing CSF
( Lee).
In
December 1890, Quincke performed three lumbar punctures on a comatose
21-month-old boy suspected of having tuberculous meningitis. Quincke
punctured the subarachnoid space in the lumbar area with a needle and
passed a cannula between the third and fourth lumbar spinal arches to
drain CSF. The child recovered. In April 1891, Quincke relieved the
headache of a 25-year-old man with hydrocephalus by means of lumbar
puncture. Previously in 1888, Quincke had removed CSF from the cerebral
ventricles of a 12-year-old boy through holes trephined in the skull
( Sakula).
In
February 1889, an Englishman, Walter Essex Wynter, had done a lumbar
puncture on a 3-year-old boy suffering from meningitis following an
ear infection. Wynter made an incision at the midline at the second
lumbar vertebra and cut down to the dura where he passed a Southey’s
tube (see definition) In an attempt to relieve increased intracranial
pressure, Wynter subsequently did lumbar punctures on three other children
with tuberculous meningitis All four patients died. Because Wynter did
not report these cases until the May 2, 1891 issue of Lancet, Quincke
is usually credited with performing the first lumbar puncture (Sakula).
A
Southey’s tube was a hollow metal tube into which a trochar could be
inserted. It could be advanced subcutaneously or into the peritoneum
to drain massive pedal edema or ascites, respectively.
"Bier
and Hildebrandt gave each other spinal anesthesia through injections
of cocaine solution into the lower (lumbar) areas of their backs; the
aim was to block the nerves in the lower part of the body. They took
careful notes of the experience. The initial thrust of the needle caused
no pain beyond the usual jab and a short, mild stabbing sensation in
one leg. Bier felt a mild tugging sensation when Hildebrandt began the
injection. But Hildebrandt was nervous, and much of the solution trickled
down Bier’s back. They waited ten minutes before Hildebrandt pricked
Bier’s thigh with a pin. It hurt: not enough cocaine had penetrated
the spine.
When
the more experienced Bier injected the solution into Hildebrandt’s back
just a few drops escaped. Within seven minutes Hildebrandt could feel
pinpricks only as pressure; tickling of the sole of the foot hardly
bothered
him. A minute later Bier
drew a large curved needle through the skin of Hildebrandt’s thigh.
Again his assistant sensed no pain. Two minutes later Bier thrust a
needle into Hildebrandt’s thigh bone; he felt nothing. Bier squeezed
Hildebrandt’s skin between the teeth of a hooked forceps. Hildebrandt
perceived the pinching only as pressure.
Thirteen
minutes after the spinal injection, Bier put the lighted end of his
cigar on Hildebrandt’s legs. The burn caused no pain. Hard hammer blows
against his shins were painless. On and on, Bier battered Hildebrandt.
Pulling out pubic hair felt
like lifting a skin fold, whereas plucking hairs from the chest was
painful. Strong pressure and tugging on Hildebrandt’s testicles produced
no sensation.
It
took forty-five minutes for the effect of the drug to wear off and normal
sensitivity to return.
The
two doctors dined together that evening, drinking wine and smoking several
cigars. They went to bed about eleven o’clock. Bier, whose body had
absorbed almost no cocaine, slept soundly and awoke refreshed. When
he finished his customary morning stroll, he found he had a slight headache.
At
the clinic he found Hildebrandt looking wan; he had not slept and was
able to stand only with great effort. Later that morning Hildebrandt
had a severe headache, which may have been due to a hangover or to the
spinal injection, followed by an attack of vomiting. By mid-afternoon
he was forced to go to bed. Although still suffering from a headache,
he returned to work the next day." (Altman)
|