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ZOSTER ENCEPHALITIS
901
In a series of 43 cases with intraocular tension in excess of 50 mm. Hg (Schiotz) which were treated in this way Crews and Davidson 11 found that tension was satisfactorily reduced in all but 4. The series included 26 cases of " " closed-angle glaucoma. In 22 of these tension fell sharply from its high initial level to within normal limits within five hours; in 2 miotics, and in a further 2 miotics and acetazolamide, were needed to maintain control during this period. In 6 of the 26 cases, success was achieved after failure with miotics and acetazolamide. Similar control was obtained in the heterogeneous group of cases which comprise the remainder of the series. Immediate discomfort-headache, nausea, and vomitingcommonly accompanied the injection, and in 8 localised phlebitis later arose at the site of injection. The advantages of this rapid, if temporary, control of severe hypertension are apparent in ocular as in cranial surgery. ZOSTER ENCEPHALITIS
NEUROLOGICAL involvement in herpes zoster is by no means always confined to the posterior-root ganglia. 12 Sometimes lower-motor-neurone lesions develop : the commonest is facial palsy, in geniculate zoster; but involvement of the shoulder muscles supplied by c5 and c6 spinal roots is a recognised accompaniment of vesicles in these dermatomes,13 as is weakness of the quadriceps femoris with L2-3 zoster. Kendall 13 has reported cases in which involvement of the spinal cord was apparently due
herpes zoster. Encephalitis is generally thought to be a very rare complication, but Appelbaum et al. 14 have reported 14 instances. Most commonly symptoms of encephalitis started a few days after the rash appeared, the longest interval between the two being three months; but in several cases the rash appeared from three to nine days after the encephalitis. In the majority of patients the rash was in the dorsal dermatomes. Symptoms of cerebral involvement were commonly of sudden onset with fever, headache, vomiting, clouding of consciousness or delirium, and signs of meningeal irritation. Epileptic fits occurred in none of the 14 patients; the mental state was undisturbed in 5; and focal neurological signs were.rare (hemiparesis in 2 cases and cerebellar dysfunction in 1). The cerebrospinal fluid was usually under moderately increased pressure with an increase of cells, predominantly lymphocytes; the highest count was 500 per c.mm., but in to
2 cases The
no
cells
were
pathological findings have been those of a disseminated encephalomyelitis with lymphocytic infiltration in the perivascular spaces, microglial proliferation, and areas of partial demyelination. In occasional cases inclusion bodies have been found in involved nerve-cells.15 16
THE MEDICAL LETTER
WE welcome
but in 2
cases progress was slow and recovery was for several months. It was possible to assess delayed longer-term progress in 9 patients; the shortest follow-up was seven months and the longest ten years. Of these 9 patients 3 had neurological sequelae: 2 had a residual psychosis and hemiparesis; the nature of the sequelae in the 3rd case is not stated. There were no deaths in the acute stage of the illness, and the clinical descriptions suggest that in some of the patients the illness was a lymphocytic meningitis without definite evidence of encephalitis. In some, however, there was clinical evidence of cerebral involvement; and there are earlier reports of fatal cases of zoster encephalitis. The
11. Crews, S. J., Davidson, S. I. Brit. J. Ophthal. 1961, 45, 769. 12. Denny-Brown, D., Adams, R. D., Fitzgerald, P. J. Arch. Neurol. Psychiat. 1944, 51, 216. 13. Kendall, D. Brit. med. J. 1957, i, 616. 14. Appelbaum, E., Kneps, S. I., Sunshine, A. Amer. J. Med. 1962, 32, 25.
British edition of the Medical Letter
on
circulated to all doctors on the list of the Northern Ireland General Health Services Board. Much of the British edition will differ from the American only in the names and prices of drugs; but some American articles, dealing with drugs not available in Britain or with problems not relevant in this country, will be replaced by other articles from previous issues. In the States, the arrangement has been that an editorial board in New York chooses the topic and commissions one or two draft articles, which are then reviewed not only by the board itself and by special consultants but also by the medical directors of the companies concerned; which means that the finished article is a corporate effort, representing a collective view. For the British edition this process will be repeated to some extent. The four quarto pages, resembling typescript, are posted direct to subscribers18 and can be read in less than a quarter of
hour. The editor is Dr. Andrew Herxheimer, of the London Hospital Medical College, and the advisory council for the British edition consists of Dr. Richard Asher, Prof. A. C. Dornhorst, Dr. J. D. P. Graham, Dr. D. R. Laurence, Prof. A. G. Macgregor, Dr. J. D. N. Nabarro, and Dr. Michael Shepherd.
an
EXPIRED-AIR RESUSCITATION IN UNUSUAL
POSITIONS
found.
prognosis was in general good, the patients recovering from the acute illness in one to three weeks;
a
Drugs and Therapeutics, which is now to be published fortnightly by Consumers’ Association Ltd. As we have explained previously,17 the object of this fortnightly bulletin is to provide unbiased, authoritative, and up-todate assessments of drugs, particularly of new ones. It was founded in the United States nearly four years ago by a group of doctors who were disturbed by the difficulty of obtaining impartial information. In that country it has nearly 30,000 subscribers, and it has been also widely read in Northern Ireland, where a reproduction has been
generally believed that expired-air resuscitation performed only with the patient in the supine position. Yet there is no reason why it should not be successfully carried out with the patient in any position, provided only that his mouth and nose are accessible to the IT is can be
mouth of the rescuer. Ulmer et aI. 19 describe two cases in which the patients were placed in the lateral head-down position owing to bleeding from the hypopharynx. Inflation with expired air was performed in this position, and the blood was allowed to run out of the mouth between inflations. The position was further studied in three volunteers who were anaesthetised and paralysed. They were turned into the " stable side position ", which is widely accepted as a 15. Hassin, G. B., Rubins, I. A. J. Neuropath. 1944, 3, 355. 16. Cheatham, W. J. Amer. J. Path. 1953, 29, 401. 17. See Lancet, 1961, i, 380. 18. Obtainable from Consumers’ Association Ltd., 14, Buckingham Street, London, W.C.2., on subscription only (£3 3s. per annum). 19. Ulmer, W. T., Harrfeldt, H. P., Reif, E., Reichel G. German Med. Mon. 1962, 7, 73.
In a series of 43 cases with intraocular tension in excess of 50 mm. Hg (Schiotz) which were treated in this way Crews and Davidson 11 found that tension was satisfactorily reduced in all but 4. The series included 26 cases of " " closed-angle glaucoma. In 22 of these tension fell sharply from its high initial level to within normal limits within five hours; in 2 miotics, and in a further 2 miotics and acetazolamide, were needed to maintain control during this period. In 6 of the 26 cases, success was achieved after failure with miotics and acetazolamide. Similar control was obtained in the heterogeneous group of cases which comprise the remainder of the series. Immediate discomfort-headache, nausea, and vomitingcommonly accompanied the injection, and in 8 localised phlebitis later arose at the site of injection. The advantages of this rapid, if temporary, control of severe hypertension are apparent in ocular as in cranial surgery. ZOSTER ENCEPHALITIS
NEUROLOGICAL involvement in herpes zoster is by no means always confined to the posterior-root ganglia. 12 Sometimes lower-motor-neurone lesions develop : the commonest is facial palsy, in geniculate zoster; but involvement of the shoulder muscles supplied by c5 and c6 spinal roots is a recognised accompaniment of vesicles in these dermatomes,13 as is weakness of the quadriceps femoris with L2-3 zoster. Kendall 13 has reported cases in which involvement of the spinal cord was apparently due
herpes zoster. Encephalitis is generally thought to be a very rare complication, but Appelbaum et al. 14 have reported 14 instances. Most commonly symptoms of encephalitis started a few days after the rash appeared, the longest interval between the two being three months; but in several cases the rash appeared from three to nine days after the encephalitis. In the majority of patients the rash was in the dorsal dermatomes. Symptoms of cerebral involvement were commonly of sudden onset with fever, headache, vomiting, clouding of consciousness or delirium, and signs of meningeal irritation. Epileptic fits occurred in none of the 14 patients; the mental state was undisturbed in 5; and focal neurological signs were.rare (hemiparesis in 2 cases and cerebellar dysfunction in 1). The cerebrospinal fluid was usually under moderately increased pressure with an increase of cells, predominantly lymphocytes; the highest count was 500 per c.mm., but in to
2 cases The
no
cells
were
pathological findings have been those of a disseminated encephalomyelitis with lymphocytic infiltration in the perivascular spaces, microglial proliferation, and areas of partial demyelination. In occasional cases inclusion bodies have been found in involved nerve-cells.15 16
THE MEDICAL LETTER
WE welcome
but in 2
cases progress was slow and recovery was for several months. It was possible to assess delayed longer-term progress in 9 patients; the shortest follow-up was seven months and the longest ten years. Of these 9 patients 3 had neurological sequelae: 2 had a residual psychosis and hemiparesis; the nature of the sequelae in the 3rd case is not stated. There were no deaths in the acute stage of the illness, and the clinical descriptions suggest that in some of the patients the illness was a lymphocytic meningitis without definite evidence of encephalitis. In some, however, there was clinical evidence of cerebral involvement; and there are earlier reports of fatal cases of zoster encephalitis. The
11. Crews, S. J., Davidson, S. I. Brit. J. Ophthal. 1961, 45, 769. 12. Denny-Brown, D., Adams, R. D., Fitzgerald, P. J. Arch. Neurol. Psychiat. 1944, 51, 216. 13. Kendall, D. Brit. med. J. 1957, i, 616. 14. Appelbaum, E., Kneps, S. I., Sunshine, A. Amer. J. Med. 1962, 32, 25.
British edition of the Medical Letter
on
circulated to all doctors on the list of the Northern Ireland General Health Services Board. Much of the British edition will differ from the American only in the names and prices of drugs; but some American articles, dealing with drugs not available in Britain or with problems not relevant in this country, will be replaced by other articles from previous issues. In the States, the arrangement has been that an editorial board in New York chooses the topic and commissions one or two draft articles, which are then reviewed not only by the board itself and by special consultants but also by the medical directors of the companies concerned; which means that the finished article is a corporate effort, representing a collective view. For the British edition this process will be repeated to some extent. The four quarto pages, resembling typescript, are posted direct to subscribers18 and can be read in less than a quarter of
hour. The editor is Dr. Andrew Herxheimer, of the London Hospital Medical College, and the advisory council for the British edition consists of Dr. Richard Asher, Prof. A. C. Dornhorst, Dr. J. D. P. Graham, Dr. D. R. Laurence, Prof. A. G. Macgregor, Dr. J. D. N. Nabarro, and Dr. Michael Shepherd.
an
EXPIRED-AIR RESUSCITATION IN UNUSUAL
POSITIONS
found.
prognosis was in general good, the patients recovering from the acute illness in one to three weeks;
a
Drugs and Therapeutics, which is now to be published fortnightly by Consumers’ Association Ltd. As we have explained previously,17 the object of this fortnightly bulletin is to provide unbiased, authoritative, and up-todate assessments of drugs, particularly of new ones. It was founded in the United States nearly four years ago by a group of doctors who were disturbed by the difficulty of obtaining impartial information. In that country it has nearly 30,000 subscribers, and it has been also widely read in Northern Ireland, where a reproduction has been
generally believed that expired-air resuscitation performed only with the patient in the supine position. Yet there is no reason why it should not be successfully carried out with the patient in any position, provided only that his mouth and nose are accessible to the IT is can be
mouth of the rescuer. Ulmer et aI. 19 describe two cases in which the patients were placed in the lateral head-down position owing to bleeding from the hypopharynx. Inflation with expired air was performed in this position, and the blood was allowed to run out of the mouth between inflations. The position was further studied in three volunteers who were anaesthetised and paralysed. They were turned into the " stable side position ", which is widely accepted as a 15. Hassin, G. B., Rubins, I. A. J. Neuropath. 1944, 3, 355. 16. Cheatham, W. J. Amer. J. Path. 1953, 29, 401. 17. See Lancet, 1961, i, 380. 18. Obtainable from Consumers’ Association Ltd., 14, Buckingham Street, London, W.C.2., on subscription only (£3 3s. per annum). 19. Ulmer, W. T., Harrfeldt, H. P., Reif, E., Reichel G. German Med. Mon. 1962, 7, 73.