Fifty years ago when someone came in the emergency room with a headache the question was, "Should I do a lumbar puncture?" As a medical student I was happy to observe the intern or resident perform the puncture. I wanted nothing to do with putting a needle in someone's back. I was afraid I would hit the spinal cord and paralyze the patient.
As an intern I could no longer hide. I had to do the LP. First you had to look in the eyes with an ophthalmoscope and see if there was papilledema or venous pulsations. You were afraid of a temporal herniation. Once you convinced yourself there was no papilledema you had to perform the puncture. You placed your hands on the iliac crests and where your thumbs met that's where the needle went.
You would measure opening and closing pressure and hoped the opening pressure didn't keep rising. I saw that happen to a resident. We watched the clear column of spinal fluid rise and rise getting close to panic level, then it stopped. The resident left to have a cigarette. (Many smoked back then)
Fever and a stiff neck meant meningitis.
Stiff neck without a fever meant subarachnoid hemorrhage.
The puncture was often traumatic so the first vial would often contain blood but cleared with the second or third sample.
If the blood was present at the same level in all three vials there was an intracranial bleed. Back in the day a lumbar puncture was part of the fever work up,(Check the coags.)
Fevers were ubiquitous, I got to be very good at the lumbar puncture.
Today the lumbar puncture is not performed as often. There is no need to carry an opthalmoscope, the ct scan is better to determine papilledema and hemorrhage.
The Ct scan has been of great help in diagnosing an acute headache. How did we get along without it? The lumbar puncture is now performed by the interventional radiologist or the anesthesiologist after getting a ct scan.
Fifty years ago the Ct scan was just becoming available and the MRI was non existent.
Diagnosis and treatment has changed. This chapter states "greater than 90% of patients in primary care who present with a complaint of headache will have migraine."
The credit belongs to the steadfast primary care physician that won't miss the other 10% and refer the patient to a headache specialist or obtain a CT or MRI. Also a sed rate so as not to miss temporal arteritis and its complications.
When I was a medical student a young man came into the hospital with headache and paralysis on the left side of his body. The LP was negative.
I did a medical student's history and learned that migraines ran in the family. Several members on both sides of the family had migraine though this patient denied a history of migraines.
The diagnosis was "migrainous hemiplegia." The headache resolved and this was thought to be his first presentation of migraine. Maybe yes, maybe no but I would have like to have a Ct scan and MRI to support the diagnosis.
Not bad for a medical student.
Chapter 13 written by Peter Goadsby was very instructive. A Lot has changed.
YOU ARE READING
ON READING HARRISON'S PRINCIPLES OF INTERNAL MEDICINE FOR THE LAST TIME
Non-FictionI'm forty years into the practice of medicine and reflect on my reading of Harrison's Principles of Internal Medicine from medical student to old doctor. It happened so fast. "Life is short the craft is long."
