Lumbar Puncture 
OF THE 
Subarachnoid Space with Report of Cases 
BY 
RALPH JAY WENN33K, M. U. 
Visiting Physician to St. Clair Hospital; Visiting 
Physician to the German Hospital 
CLEVELAND 
Keprint from the Cleveland Journal or Medicine, Dec,, lsim. Lumbar Puncture of the Subarachnoid Space with 
Report of Cases 
BY RALPH JAY WENNER, M. D. 
Visiting Physician to St. Clair Hospital; Visiting Physician to 
The German Hospital 
LUMBAR puncture of the subarachnoid spy.ce was first performed by 
i Quincke on man in 1891, and described by him shortly after, his object 
being at that time to relieve the pressure i /mptoms of hydrocephalus. 
The operation being more simple and much less dangerous, was intended 
to take the place of trephining or puncture through the fontanelle. As a 
therapeutic measure the operation has seemingly proved a failure, but Licht- 
heim, in 1893, published an article in which he called attention to its un- 
doubted value as a diagnostic agent. If strict asepsis and antisepsis are 
observed there is practically no danger connected with the operation. In 
my cases I used an ordinary small-sized aspirating needle, sterilized, without 
the syringe being attached. It is necessary, of course, to be very careful in 
inserting the needle, as in several cases, by too free manipulation, the needles 
have been broken off and left sticking. When the needle strikes an obstruc- 
tion it is always well to partially withdraw it before reinserting, and it may 
even be necessary to choose a new site. The needle is inserted in the adult 
between the third and fourth lumbar vertebrae, and in the child between the 
fourth and fifth. There is no danger of wounding the cord, for in the adult 
it only extends to the first lumbar vertebra, and in the child to the third. 
The danger of wounding the nerves is nil, as these are so tough that the 
needle readily glances off from them. In the child the needle may be in- 
serted between the spinous processes in the median line as the processes are 
usually widely separated, but in the adult the puncture is made about a 
finger’s breadth to the side of the spinous process, the needle being directed 
slightly upward and inward. 
The depth of the insertion varies from 2 cm to 8 cm, The amount of 2 
fluid withdrawn may vary from a few ccm to 100 ccm. The fluid may come 
away drop by drop, or with a spurt, thus indicating the condition of cerebral 
pressure. In my cases raising the head and shoulders caused the fluid 
to flow more rapidly. The patient should be placed in a position to give the 
greatest possible convexity to the spinal column, thus giving prominence to 
the spinous processes, which should be marked and counted several times, 
from above downward, to insure against any mistake in location. It is 
claimed that a line passing through the cristae ilii invariably passes through 
the body of the 4th lumbar vertebra. (Jacoby N. Y. Med. Jour. Dec. 28-95). 
In the majority of cases an anesthetic is not necessary, but where there is 
much muscular rigidity, cutaneous hyperesthesia, or convulsions, it is much 
safer to have the patient anesthetized. The after-treatment of the site of 
puncture consists in covering the spot with iodoform-collodion. 
What are the possible dangers attending the operation? Infection of 
the site of puncture may occur. The needle may by injudicious manipu- 
lation be broken. In three cases of cerebellar tumor reported, death fol- 
lowed the puncture in from 6 to 40 hours, but it seems to me manifestly un- 
fair to take it for granted that the puncture was the cause of death, for cases 
of cerebellar tumor die when not punctured. 
Wentworth reported his first case of lumbar puncture in the Boston 
Medical and Surgical Journal December ’95, in which, after 5 or 6 ccm of 
fluid had been withdrawn most alarming symptoms occurred; the pulse rose 
to 250 beats per minute, (by stethoscope) the patient screamed and was rest- 
less, the extremities were cold, and the color bad. This condition passed 
away in about 30 minutes, and the patient made a good recovery in a few 
days. 
As a therapeutic agent, the operation has seemingly not been attended 
by great success, although attempts have been made by Caille (Archiv Ped- 
iatrics August, ’96) to medicate the parts directly affected in tubercular 
meningitis, through the lumbar puncture. Remembering the mysterious 
effect celiotomy has upon a tubercular peritonitis, we will wait anxiously 
the result of his experiments, hoping that the means are at hand by which 
we will be able to strike this dread disease, the diagnosis of which as Jacoby 
says is a death warrant, on its own soil, and in its own stronghold. It is 
also claimed that withdrawal of fluid through a lumbar puncture, relieves the 
extreme headache of brain tumor, although for a short time following the 
puncture the pain is more severe. 3 
Jacoby (N. Y. Med. Jour. Jan. 4th, ’96) reports two cases of spinal men- 
ingeal hemorrhage due to injury, followed by paralysis of the lower extremi- 
ties, loss of control of the sphincters and so forth, in which puncture, per- 
mitting the escape of bloody fluid, was followed by complete recovery in 
one case, in the other case weakness of the peronei and extensors, and loss 
of knee-jerk remaining. 
As a diagnostic agent, withdrawal of fluid from the subarachnoid space 
demands the attention of every diagnostician, for along this line it is no 
longer an experiment. Autopsies confirming diagnoses have been made suf- 
ficient in number to warrant its being placed in the front rank as an aid in the 
diagnosis of certain diseases of the brain, and possibly of the spinal cord. 
The only case of tubercular meningitis recorded, in which the diagnosis 
was made positively, terminating in recovery, is reported by Freyhan. In 
this case two punctures were made, a week apart, tubercle bacilli being found 
each time (Wolfstein Archiv Pediatrics Mar. ’96). The search for tubercle 
bacilli is sometimes a tiresome procedure requiring plenty of patience and 
perseverance. In one case that I know of, 50 slides were examined before 
one bacillus was found. It is always well to clinch the diagnosis by animal 
inoculation and cultures. 
The summary of Dr. Wentworth’s paper on puncture of the subarach- 
noid space (.Archiv Pediatrics Aug. ’96) is so terse and to the point, that I 
will give it; 1. “The normal cerebrospinal fluid contains neither cells nor 
fibrin, and is perfectly clear. 
2. In cases of meningitis, the cerebrospinal fluid is invariably cloudy 
when withdrawn. The degree of cloudiness is to some extent proportionate 
to the amount and character of the exudation in the meninges. 
3. The cloudiness is caused by cells. The character of the cells dif- 
fers with the variety of the meningitis. After withdrawal more or less of 
fibrin is formed in the fluid. The presence of these cells and fibrin is path- 
ognomonic of inflammation in the meninges. 
4. The cloudiness is oftentimes so slight that close inspection is neces- 
sary to detect it. 
5. The operation is not difficult to perform on infants and young chil- 
dren. It is not dangerous if strict cleanliness is observed. 
6. The differential diagnosis between the different kinds of meningitis 
can be made by microscopic examination of the sediment, by cultures taken 
from the fluid, and by inoculation experiments. 4 
7. Inoculation experiments afford the surest way of determining tuber- 
cular meningitis. It is of value to distinguish between the different va- 
rieties in order to ascertain if tubercular meningitis is recovered from. 
8. In normal cerebrospinal fluid a faint trace of albumin is present, 
about 1-50 of one percent or less, by quantitative analysis. In meningitis, 
the amount of albumin is increased, and has varied from 1-30 to 1-10 of one 
percent. 
9. In one case, a diagnosis of general infection with staphylococcus 
pyogenes aureus was made from cultures taken from the cerebrospinal 
fluid.” 
Lichtheim has constantly found varying quantities of sugar, in cases of 
tumor of the brain, and seems to regard a considerable quantity of sugar in 
the cerebrospinal fluid, proving the patient is not a diabetic, as a circum- 
stance which would lead one to suspect tumor of the brain. On tubercular 
meningitis examination of the blood will often throw considerable light, 
for in this disease, unaccompanied by suppuration, the number of leucocytes 
rarely exceeds 10,000, as has been demonstrated by V. Limbeck. If there 
be a slight increase in the number of leucocytes, it is usually of the small 
mononuclear variety known as lymphocytes. In cases of tubercular menin- 
gitis, the cloudiness of the cerebrospinal fluid was found to be caused by 
leucocytes, the lymphocytes preponderating. In cases of purulent menin- 
gitis the polynuclear neutrophiles were in the majority. 
Case 1. A. M., male, age 40, of Scotch descent, and good family his- 
tory, contracted syphilis five years ago. I saw the patient first June 2, 
when he was suffering with numerous syphilitic ulcers on both legs. These 
improved rapidly under treatment, until the middle of July, when they were 
entirely healed. About July 1 he commenced to complain of excruciating 
pains, limited to the right side of the head, always worse at night, which re- 
fused to yield to ordinary remedies. Iodid of potash was given to the limit 
of toleration. August 1 I was sent for by friends of the patient, and found 
him semi-stupid, complaining of pain in the head and nausea, but he had not 
vomited. His condition becoming worse, he was sent to the hospital. 
His pupils were sluggish, reacting to light slowly, temperature elevated, 
pulse fast and weak, both eyes showing choked disc. Owing to the tempera- 
ture, pulse, pain worse at night, extreme restlessness of an automatic char- 
acter, stupidity, and extreme pain localized in the right temporal region, a 
diagnosis of syphilitic meningitis was made, with a probable gummatous 5 
growth in the region of the pain, at the same time conceding the possibility 
of tumor, which, owing to lack of focal symptoms, could not be localized. 
On August 24, the patient having been without sleep or rest for four 
days, lumbar puncture was performed, and 25 ccm of fluid having an almost 
imperceptible cloudiness, were withdrawn; 12 ccm were given to Dr. Ohl- 
macher for bacteriologic examination. The fluid proved to be sterile, 
and cultures and animal inoculation gave negative results. The fluid that 
I retained showed fibrin shreds and some leucocytes, the majority being 
polynuclear. Fehlings solution gave an immediate test for sugar, throwing 
down a heavy red sediment. The bismuth test also gave positive results. 
There was 1-20 of one percent of albumin. Coverglass preparations 
failed to reveal the presence of any bacteria. There was no rise in pulse or 
temperature following the puncture. The patient almost immediately went 
off into a quiet sleep, the first for four days, and after awakening was much 
brighter than he had been for three weeks. This amelioration continued for 
about a week, when all his untoward symptoms returned. From Septem- 
ber 2 on the patient failed rapidly, was stupid and had convulsions. On 
the evening of September 6, the second puncture was performed, and 
35 ccm of cloudy fluid containing flakes were withdrawn. 
The operation seemed to diminish the amount of restlessness, but be- 
yond this no effect was noticed. The amount of sugar in the fluid was 
considerable. By the centrifuge the amount of albumin was one-fourth of 
one percent. The sediment showed fibrin and some polynuclear leucocytes. 
Coverslip preparations failed to show bacteria. The patient died on the morn- 
ing of September 9. 
Autopsy on the head alone showed a thickening of the dura mater 
above, with some adhesions between dura and skull, particularly marked 
about the region where pain was so intense, and numerous points of ad- 
hesion between dura and brain. Section of the hardened brain showed a 
large tumor in each lobe of the cerebrum, springing from the lateral ven- 
tricles, and cavities in each lobe of the cerebellum, connected with each other 
but not with the fourth ventricle. This interesting case I hope to be able 
later to present to the society in detail. 
Case 2. J. D.,.farmer, age 56, was injured in a runaway August 30. 
The pupils were sluggish. There were involuntary action of the bowels, 
stupor and delirium. The temperature was elevated, and the pulse fast. 
Through the kindness of Dr. C. B. Hummiston, I was permitted to make a 6 
puncture, but could not obtain a single drop of fluid. The needle was with- 
drawn and inserted twice, going in about cm, and I am quite positive that 
I was in the subarachnoid space. The patient died in three days, and no 
autopsy was obtained. 
Case 3. J. H., age 35, fell down a flight of stairs, striking on a stone 
flagging, sometime during the night of September 10, and was not found 
until four o’clock on the morning of September 11. I saw the patient 
at 10 A. M. September 11, for Dr. House, at which time he was semi- 
conscious, with a pulse of 130, temperature 102.6°; the right arm and right 
side of the face were paralyzed, muscular movements in right leg were slow 
and weak, the tongue deviated to the right, the pupils were irregular and 
reacted sluggishly to light. The patient was continually making efforts to 
roll over to the right, and several times he succeeded in rolling himself out 
of bed. His condition being considered very serious, he was transferred 
to St. Clair Hospital, where a lumbar puncture was performed, and 
10 ccm of bloody fluid withdrawn. This, after being allowed to stand six 
hours, showed a sediment composed of red blood corpuscles, great numbers 
of polynuclear leucocytes and considerable fibrin. There was a faint trace 
of sugar, and one percent of albumin. 
Owing to the marked focal symptoms, the patient was trephined by Dr. 
House over the right arm-center. Upon removing the button of bone, the 
dura was found tense and bulging. Upon incision, about a teacupful of 
bloody fluid similar in appearance to that obtained by puncture gushed 
out. No clot was found. Following the withdrawal of the fluid the pulse 
became much slower, and the patient’s condition seemed better, but this 
was only temporary, for in a short time the pulse was up to 160 beats per 
minute. The patient died on the afternoon of September 12. Autopsy 
showed bloody fluid in both ventricles, a clot in the left lobe of the cerebrum, 
interrupting some of the fibers of the internal capsule, and a clot about the 
size of a hickory nut in the anterior portion of the right lobe of the cerebel- 
lum. There was also a great quantity of bloody fluid between the dura and the 
brain. It seems quite probable that the clot in the cerebellum was the cause 
of the tendency to roll over. 
Case 4. J. F., male, age 40, was injured September 14, by colliding 
with a wagon, and falling on his head. The patient was unconscious, with 
contracted pupils, stertorous breathing, a pulse of 120, and temperature of 7 
101°. Through the kindness of Dr. J. E. Cook I was permitted to make 
puncture, drawing off 20 ccm of dark bloody fluid. On being allowed to 
stand six hours, the red corpuscles were thrown down, leaving the super- 
natant fluid distinctly cloudy. Microscopic examination of the sediment 
obtained by the centrifuge showed great numbers of red cells losing their 
hemoglobin, also numerous polynuclear neutrophiles, and some fibrin. 
Purdy’s method showed 10 percent of albumin; the fluid also showed a trace 
of sugar. 
The patient died September 17, and the postmortem examination was 
made 12 hours afterwards. The dura was so tightly adherent to the skull- 
cap, that in lifting, force sufficient to tear the dura was required. The 
dura was adherent to the brain an inch on either side of the longitudinal 
sinus throughout its entire extent; these adhesions were all recent. A clot 
about the size of a hand was found between the dura and the brain, on the 
left side, occupying the anterior and middle fossae. The under surface of 
the anterior lobe was considerably softened, and a deep fissure in the same 
locality seemed to warrant the belief that there was laceration of brain 
substance. The left lateral sinus was ruptured, and this seemed to be the 
source of most of the hemorrhage. The right lateral ventricle contained a 
large softened clot. There was no fracture of any portion of the skull. 
Therapeutically, the result of the puncture in the last two cases was 
negative; in the first case, however, it seemed to me that the amount of 
benefit derived from the operation warranted its performance. In the first 
case it was possible to bar out tubercular meningitis and purulent menin- 
gitis. The large amount of sugar in the fluid made me feel certain that a 
growth of some kind would be found, in connection with any other condition 
that might be present. In cases 3 and 4 I felt sure of the presence of bloody 
fluid in the ventricles, and owing to the dark bloody fluid in case 4, an intra- 
ventricular clot was suspected. However, one puncture in a case of this 
kind is not sufficient to warrant a positive diagnosis of bloody fluid in the 
ventricles, for the possibility of wounding a vessel while making the punc- 
ture must always be taken into consideration. 
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