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Lumbar Puncture Headache (See also page 159) This is a well-known phenomenon, attributable to a lowering of ICP by leakage of CSF through the needle track into the paravertebral muscles and other tissues Once begun, the headache may last for days or, rarely, even weeks Most characteristic is the relation of the headache to upright posture and its relief within moments after assuming the recumbent position Actually, the syndrome includes more than headache There may be pain at the base of the skull posteriorly and in the back of the neck and upper thoracic spine, stiffness of the neck, and nausea and vomiting At times the signs of meningeal irritation are so prominent as to raise the question of post lumbar puncture meningitis, although lack of fever usually excludes this possibility In addition to a low or unmeasurable CSF pressure if another spinal tap is performed (the CSF pressure is found to be in the range of 0 to 60 mmH2O), there are occasionally a few to a dozen white cells in the CSF, which may further raise concern of meningitis In the infant or young child, stiffness of the neck may be accompanied by irritability, unwillingness to move, and refusal of food If the headache is protracted, recumbency still reduces it, but a feeling of dull pressure may remain, which the patient continues to report as pain Many patients also report that shaking the head produces a cephalic pain Occasionally there will be a sixth nerve palsy or a self-audible bruit from turbulence in the intracranial venous system It has been recognized that low CSF pressure is associated on the MRI with prominent dural enhancement by gadolinium (Fig 30-4) and, when the syndrome is protracted and severe, there may be small subdural effusions (see below, under Spontaneous Intracranial Hypotension ) The use of a 22- to 24-gauge needle and the performance of a single clean (atraumatic) tap seemingly reduces the likelihood of a post lumbar puncture headache, as discussed in Chap 2 A period of enforced recumbency, though widely practiced as a means of preventing headache, probably does not lessen its incidence (Carbaat and van Crevel) The ingestion of large volumes of uids.

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In a P-type semiconductor, most of the current flows in a way that some people find peculiar and esoteric In a literal sense, in virtually all electronic devices, charge transfer is always the result of electron movement, no matter what the medium might be The exceptions are particle accelerators and cloud chambers apparatus of interest mainly to theoretical physicists The flow of current in a P-type material is better imagined as a flow of electron absences, not electrons The behavior of P-type substances can be explained more easily this way The absences, called holes, move in a direction opposite that of the electrons Imagine a sold-out baseball stadium Suppose 19 of every 20 people are randomly issued candles Imagine it s nighttime, and the field lights are switched off You stand at the center of the field, just behind second baseThe candles are lit, and the people pass them around the stands Each person having a candle passes it to the person on their right if, but only if, that person has no candle You see moving dark spots: people without candles The dark spots move against the candle movement The physical image you see is produced by candle light, but the motion you notice is that of candles absences Figure 19-2 illustrates this phenomenon Small dots represent candles or electrons Imagine them moving from right to left in the figure as they are passed from person to person or from atom to atom Circles represent candle absences or holes They move from left to right, contrary to the flow of the candles or the electrons, because the candles or electrons are being passed among stationary units (people or atoms) This is just the way holes flow in a semiconductor material

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