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The pace of progress in the neurosciences and in clinical neurology was accelerating toward the end of the 19th century, yet neurology in 1870 was still in an early developmental stage. The significance of muscle stretch reflexes in the clinical diagnosis of neurologic diseases was not yet realized; the spinal tap and the utility of spinal fluid examination were unknown; and no imaging of any kind other than medical art and photography was available. The year 1870 was one of strife and unrest in most parts of the world, but it was also a year studded with events that promised a brighter future. In fledgling form, Neurology Was There.

We read with great interest the article by Haimovic and Beresford1on transient unresponsiveness in the elderly. The importance of this previously undescribed entity cannot be overstressed. We would like to add our experience to emphasize its underrecognized occurrence and apparently benign prognosis. In a single month, there were three patients admitted to our institution for profound unresponsiveness in whom the full workup during the episode, including routine laboratory tests, toxicology screen, electrocardiogram, arterial blood gases, spinal tap, electroencephalogram, computed tomographic scans, and magnetic resonance imaging, revealed negative results. All three patients returned to baseline within 12 hours of admission. Two patients had recurrent episodes of total unresponsiveness, again returning to baseline within a few hours of each episode. The full workup, excluding spinal tap and magnetic resonance imaging, was repeated in both patients, again failing to explain the unresponsiveness. A repeated electroencephalogram done during the episode showed only

"A spinal tap! What for? We have the MRI, CT, EEG, EMG, SEP, MMPI, and I even did a history and physical. Just what can we learn from the CSF?" A familiar conversation with the house staff—just give them this book. There has not been a good book on spinal fluid for many years. This likely reflects our distraction in high-technology brain imaging procedures. We have neglected one of the best diagnostic methods easily available to us. There are 11 chapters, with the major contributions by the two editors. They cover history, anatomy and physiology, production and flow, collection, injection, infections, proteins, immunology, cytology, and cytopathology. The authors are all experienced clinicians so that theory is introduced as it relates to clinical problems. The illustrations are excellent and the color plates are superb. The chapters on cytopathology illustrate the potential diagnostic possibilities offered by examination of the spinal fluid. House

Levels of gamma-aminobutyric acid (GABA) in CSF were measured in patients with Parkinson's disease (n = 14) and sex-matched controls (n = 14). One patient underwent a spinal tap before and after treatment. The mean (+/- SD) CSF GABA levels were 200 +/- 70 pmole/mL in controls and 121 +/- 52 pmole/mL in patients with Parkinson's disease. In the untreated patients with Parkinson's disease, the CSF GABA level was 95 +/- 31 pmole/mL (n = 7) and in those who were treated with levodopa and carbidopa the level was 144 +/- 53 pmole/mL (n = 8). No significant difference was seen in plasma GABA levels between the controls and patients with Parkinson's disease. The decreased GABA level in CSF, which was elevated by levodopa, supports the concept that in Parkinson's disease, the GABA-dopamine interaction in the substantia nigra may be an important compensatory mechanism counteracting the dopamine neuronal loss.

To the Editor.— Heparin prevent the activation of the intrinsic coagulation pathway, inhibits the thrombin-mediated conversion of fibrinogen to fibrin, and at high dosages inhibits the aggregation of platelets. Uncommonly, thrombocytopenia can occur. 1 Bleeding complicates the use of heparin in 3% to 33% of patients, an incidence higher than that occurring with the use of oral anticoagulants. 2 Careful review of the English language medical literature failed to disclose a report of a spinal epidural hematoma complicating the use of heparin, unless a previous spinal tap had been performed. 3,4 There have been two case reports describing the development of spinal epidural hematomas following lumbar puncture. In both, the procedure was performed shortly before starting heparin administration. 3.4 Report of a Case.— A 21-year-old man was admitted to a Tucson, Ariz, hospital in July 1973 with thrombophlebitis of the lower extremities, a condition that had been recurrent and complicated

In Reply. —Dr Abram agreed that intrathecal therapy with methylprednisolone acetate carries risks; however, he believed that epidural injections are safe and that inadvertent subarachnoid injections are rare. The posterior interspinous ligaments are entered by inadvertency in a variable number of procedures, but not the 42.5% I quoted due to typographical error. The introducing of medications into ligaments is quoted by some authors at 25%,1which is obviously not as serious as accidental spinal taps, which occur from 0.5% to 2.5%.1These facts are more impressive when it is realized that methylprednisolone acetate administered by the intrathecal route gives rise to (radiographically proven) arachnoiditis in virtually 100% of patients.2 Winnie et al3originally recommended the use of methylprednisolone acetate epidurally, followed in 1978 by a report of meningitis and severe neurologic damage4. After Delaney et al5studied the use of a similar steroid compound in cats

To the Editor.— In response to Dr Magnussen's letter (Archives37:398-399, 1980), we have the following comments. 1. Considerations of space and brevity prevented us from providing detailed serial data on each patient. However, it is clearly stated under the "Materials and Methods" section that "in all patients whose condition did not show obvious improvement... antibiotic therapy was withheld on the basis of a shift to mononuclear predominance." 2. The (admittedly poor) phrase "in up to 100% of patients" meant that although 100% of the cases in our study showed the shift, previous retrospective studies had occasional cases where the polymorphonuclear leukocytes persisted. 3. The repeated spinal tap is performed because the patient's condition is not improving and there is significant doubt regarding the diagnosis. In the occasional patient in whom the spinal fluid still shows a polymorphonuclear predominance, we would consider it risky to continue to withhold antibiotic therapy. The