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ACUTE INTERNAL AND EXTERNAL OPHTHALMOPLEGIA WITH MUSCLE WEAKNESS
1001 of the letter. It is to be expected that distorted spectra will be obtained if interfering substances are present (especially in extracts of gastric contents and urine), but usually after careful inspection of such spectra the presence of a barbiturate can be its identification Dorset County Laboratory,
suspected, leading
to
Dorchester, Dorset.
by
other methods.
GORDON BACON.
were absent, except the supinator jerk. There was ataxia of all limbs and some impairment of vibration sense. The c.s.F. was normal. A few days later weakness of shoulder-girdle muscles was noted with glove-and-stocking loss of sensation for cotton-wool and pin-prick. He was treated with prednisone 40 mg. daily. There was a gradual recovery during the next six months.
jerks
Although these two patients lived in the same locality SIR,-I was very interested by the experiences of Dr. there was no evidence of contact. They were seen within George and Miss Matthews (April 20). After six years of a month of each other, and no similar cases have been barbiturate analysis by the Broughton method, we too encountered. Both made a full recovery, but in the first have accumulated a number of atypical graphs. case this was only possible with the help of a respirator. Our experiences with ’Carbrital’ and bemegride (’ Megiam grateful to Dr. G. E. Smyth and Dr. R. Sykes for permission mide’) are similar to those quoted.Tuinal ’ alone, however, to IreDort these cases. has always behaved quite normally, all the necessary criteria Royal Infirmary, BRYAN ASHWORTH. being obeyed in every case examined. Bristol. Curryfound bemegride to be much more labile to alkaline STOVE-IN CHEST hydrolysis than barbiturates and suggested that it might be was removed at hours N 380C for two in 0-5 SIR,-It stimulating to read the annotation on this effectively by heating sodium hydroxide. The efficacy of this method, in our hands, subject (April 20) since it demonstrates that a better seems to depend on a low bemegride/barbiturate ratio. A understanding of the physiological processes which are method which we have used as an alternative is simply to plot disturbed by this injury is becoming more widespread. the complete absorption curves after the hydrolysis procedure The essential functions which are severely disturbed are described by Broughton. In this way, if the type of barbiturate the venous return to the heart and pulmonary ventilation. and therefore its hydrolysis-rate is known an approximate Treatment to be effective must therefore aim to restore a quantitative result may be obtained. If the type is unknown normal respiratory cycle: intrapleural pressure variations then at least qualitative confirmation of presence of barbiturate from —55 two - 30 mm. Hg; and differences through the is possible. To overcome the difficulties of interference by it a has become routine in this to take bemegride cycle in both the intrapulmonary pressures and the great hospital sample of blood from all cases of suspected barbiturate overdose veins of 3 mm. Hg above and below atmospheric pressure. before treatment is started. The blood is then stored in the This can be achieved either by placing the patient in a refrigerator in case an analysis is needed. cuirass respirator or by the application of an impervious hard Group Pathological Department, patch over the area of paradoxical movement, by fixing it at the Royal Sussex County Hospital, Brighton. J. G. H. COOK. edges, and by encouraging breathing exercises. The method described by Schrire1 is good, but a simpler procedure was ACUTE INTERNAL AND EXTERNAL first employed in air-raid casualties from Plymouth in 1941; OPHTHALMOPLEGIA WITH MUSCLE WEAKNESS two or three years ago it was brought into use again for stove-in SIR,-The recent correspondence 3has brought to chests arising from motor accidents. Since it requires no special apparatus or training, it seems worth recording. mind two similar cases seen in 1961, both of which made Wool is laid lightly over the stove-in area, and 6 in. plaster a complete recovery. are placed to form a patch over this and an area at bandages A married woman of 61 years was admitted to the Manchester least 4 in. larger in all dimensions than the depressed and Royal Infirmary under the care of Dr. G. E. Smyth in April, mobile area; the plaster should fit closely to the chest wall 1961. She had been well until two weeks before admission around the depression. When the plaster has set, the wool is when a dry cough developed. The cough persisted and she removed; the plaster is accurately replaced and fixed with later complained of sore throat and fever, for which she was elastoplast strips which should not be tightly stretched and given oral penicillin. Three days before admission she com- must not encircle the chest. It is kept in place for 8-10 days. plained of diplopia (vertical). Next day she began to have Active breathing exercises are begun at once. vertigo, followed within forty-eight hours by frontal headache, The rapid improvement in the patient’s condition which weakness of all limbs, difficulty in swallowing, and nasal speech. results from this simple procedure is remarkable. This injury There was also loss of feeling in the fingers and toes. is not common in civil practice but carries a high mortality.22 Examination on April 8, 1962, showed total ophthalmoplegia This will not be improved by positive-pressure ventilation, (bilateral) with ptosis, immobile palate, nasal speech, and even through a tracheostomy, quite simply because that method ataxia of all limbs. Later the same day left facial weakness was interferes materially with the free venous return to the heart. noted, tendon jerks
were unobtainable, and vibration sense was in all limbs. The plantar responses were flexor. The impaired C.S.F. was normal. Two days later there had been further progression with bilateral facial weakness, limb paraesthesiae, and dyspncea. A tracheostomy was performed and artificial respiration instituted. Prednisone (40 mg. daily) was given. After a week, voluntary respiration was again possible and the: pupils reacted to light. There was a gradual but complete: recovery during the next three months, and at the end of that time the tendon jerks had returned. Stool cultures were
negative. A man of 65 was admitted to Stepping Hill Hospital, Stockport, in May, 1961. He had had a cough three weeks previously, followed by headache with vertigo and double vision. He also complained of dysphagia. He had bilateral paralysis of external ocular movements, but the pupils reacted sluggishly to light. Speech and movements of the palate were normal. Tendon 1. Broughton, P. M. G. Biochem. J. 1956, 63, 207. 2. Curry, A. S. J. Pharm. Pharmacol, 1957, 9, 102. 3. Kelly, R. E., Gibberd, F. B. Lancet, April 6, 1963, p. 770. 4. Bickerstaff, E. ibid. April 20, 1963, p. 889.
The method has been used to salve four patients during the past 3 years. The use of the limpet would be excellent, especially for cases where the sternum was involved in the depression, but the essential aim of all treatment must be the interposition at the earliest possible moment of an impervious barrier between atmospheric pressure outside the chest and the negative pressure within. Until this is generally recognised, the mortality from this injury will remain high. Bridge of Earn Hospital, A. IAN L. MAITLAND. Perthshire.
SIR,-I read your annotation (April 20) with dismay. I suggest that surgical fixation of the chest wall is obsolete. If it is effective it is probably unnecessary, and simple strapping over a pad is enough. In any case, if the injury is in any way extensive, mechanical fixation of the chest wall should be resorted to only as an aid to assisted or controlled
respiration.
1. 2.
Schrire, T. S. Afr. med. J. 1962, 36, 516. Sillar, W. J. roy. Coll. Surg. Edinb. 1962, 7, 101.
suspected, leading
to
Dorchester, Dorset.
by
other methods.
GORDON BACON.
were absent, except the supinator jerk. There was ataxia of all limbs and some impairment of vibration sense. The c.s.F. was normal. A few days later weakness of shoulder-girdle muscles was noted with glove-and-stocking loss of sensation for cotton-wool and pin-prick. He was treated with prednisone 40 mg. daily. There was a gradual recovery during the next six months.
jerks
Although these two patients lived in the same locality SIR,-I was very interested by the experiences of Dr. there was no evidence of contact. They were seen within George and Miss Matthews (April 20). After six years of a month of each other, and no similar cases have been barbiturate analysis by the Broughton method, we too encountered. Both made a full recovery, but in the first have accumulated a number of atypical graphs. case this was only possible with the help of a respirator. Our experiences with ’Carbrital’ and bemegride (’ Megiam grateful to Dr. G. E. Smyth and Dr. R. Sykes for permission mide’) are similar to those quoted.Tuinal ’ alone, however, to IreDort these cases. has always behaved quite normally, all the necessary criteria Royal Infirmary, BRYAN ASHWORTH. being obeyed in every case examined. Bristol. Curryfound bemegride to be much more labile to alkaline STOVE-IN CHEST hydrolysis than barbiturates and suggested that it might be was removed at hours N 380C for two in 0-5 SIR,-It stimulating to read the annotation on this effectively by heating sodium hydroxide. The efficacy of this method, in our hands, subject (April 20) since it demonstrates that a better seems to depend on a low bemegride/barbiturate ratio. A understanding of the physiological processes which are method which we have used as an alternative is simply to plot disturbed by this injury is becoming more widespread. the complete absorption curves after the hydrolysis procedure The essential functions which are severely disturbed are described by Broughton. In this way, if the type of barbiturate the venous return to the heart and pulmonary ventilation. and therefore its hydrolysis-rate is known an approximate Treatment to be effective must therefore aim to restore a quantitative result may be obtained. If the type is unknown normal respiratory cycle: intrapleural pressure variations then at least qualitative confirmation of presence of barbiturate from —55 two - 30 mm. Hg; and differences through the is possible. To overcome the difficulties of interference by it a has become routine in this to take bemegride cycle in both the intrapulmonary pressures and the great hospital sample of blood from all cases of suspected barbiturate overdose veins of 3 mm. Hg above and below atmospheric pressure. before treatment is started. The blood is then stored in the This can be achieved either by placing the patient in a refrigerator in case an analysis is needed. cuirass respirator or by the application of an impervious hard Group Pathological Department, patch over the area of paradoxical movement, by fixing it at the Royal Sussex County Hospital, Brighton. J. G. H. COOK. edges, and by encouraging breathing exercises. The method described by Schrire1 is good, but a simpler procedure was ACUTE INTERNAL AND EXTERNAL first employed in air-raid casualties from Plymouth in 1941; OPHTHALMOPLEGIA WITH MUSCLE WEAKNESS two or three years ago it was brought into use again for stove-in SIR,-The recent correspondence 3has brought to chests arising from motor accidents. Since it requires no special apparatus or training, it seems worth recording. mind two similar cases seen in 1961, both of which made Wool is laid lightly over the stove-in area, and 6 in. plaster a complete recovery. are placed to form a patch over this and an area at bandages A married woman of 61 years was admitted to the Manchester least 4 in. larger in all dimensions than the depressed and Royal Infirmary under the care of Dr. G. E. Smyth in April, mobile area; the plaster should fit closely to the chest wall 1961. She had been well until two weeks before admission around the depression. When the plaster has set, the wool is when a dry cough developed. The cough persisted and she removed; the plaster is accurately replaced and fixed with later complained of sore throat and fever, for which she was elastoplast strips which should not be tightly stretched and given oral penicillin. Three days before admission she com- must not encircle the chest. It is kept in place for 8-10 days. plained of diplopia (vertical). Next day she began to have Active breathing exercises are begun at once. vertigo, followed within forty-eight hours by frontal headache, The rapid improvement in the patient’s condition which weakness of all limbs, difficulty in swallowing, and nasal speech. results from this simple procedure is remarkable. This injury There was also loss of feeling in the fingers and toes. is not common in civil practice but carries a high mortality.22 Examination on April 8, 1962, showed total ophthalmoplegia This will not be improved by positive-pressure ventilation, (bilateral) with ptosis, immobile palate, nasal speech, and even through a tracheostomy, quite simply because that method ataxia of all limbs. Later the same day left facial weakness was interferes materially with the free venous return to the heart. noted, tendon jerks
were unobtainable, and vibration sense was in all limbs. The plantar responses were flexor. The impaired C.S.F. was normal. Two days later there had been further progression with bilateral facial weakness, limb paraesthesiae, and dyspncea. A tracheostomy was performed and artificial respiration instituted. Prednisone (40 mg. daily) was given. After a week, voluntary respiration was again possible and the: pupils reacted to light. There was a gradual but complete: recovery during the next three months, and at the end of that time the tendon jerks had returned. Stool cultures were
negative. A man of 65 was admitted to Stepping Hill Hospital, Stockport, in May, 1961. He had had a cough three weeks previously, followed by headache with vertigo and double vision. He also complained of dysphagia. He had bilateral paralysis of external ocular movements, but the pupils reacted sluggishly to light. Speech and movements of the palate were normal. Tendon 1. Broughton, P. M. G. Biochem. J. 1956, 63, 207. 2. Curry, A. S. J. Pharm. Pharmacol, 1957, 9, 102. 3. Kelly, R. E., Gibberd, F. B. Lancet, April 6, 1963, p. 770. 4. Bickerstaff, E. ibid. April 20, 1963, p. 889.
The method has been used to salve four patients during the past 3 years. The use of the limpet would be excellent, especially for cases where the sternum was involved in the depression, but the essential aim of all treatment must be the interposition at the earliest possible moment of an impervious barrier between atmospheric pressure outside the chest and the negative pressure within. Until this is generally recognised, the mortality from this injury will remain high. Bridge of Earn Hospital, A. IAN L. MAITLAND. Perthshire.
SIR,-I read your annotation (April 20) with dismay. I suggest that surgical fixation of the chest wall is obsolete. If it is effective it is probably unnecessary, and simple strapping over a pad is enough. In any case, if the injury is in any way extensive, mechanical fixation of the chest wall should be resorted to only as an aid to assisted or controlled
respiration.
1. 2.
Schrire, T. S. Afr. med. J. 1962, 36, 516. Sillar, W. J. roy. Coll. Surg. Edinb. 1962, 7, 101.