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CEREBROSPINAL FLUID IN CARCINOMATOSIS OF THE MENINGES
408 Nose-bleeds became
embarrassingly frequent and the many alarming messages taxed our telephone and reception organisation to the full. At least 3 patients required treatment by cautery. The influenza was commonly associated with
vomiting (with or without abdominal symptoms), and this made many return visits and surgical consultations necessary. We estimated that vertigo was present in 1 out of every 7 adults, and in 1 out of every 10 children. It often lasted for only part of a day, but sometimes for as long as a week. In at least 2 adults nystagmus was observed with the usual influenza symptoms, but disappeared after two and three days ; neither case showed evidence of any intracranial lesion. The 4 patients with pure vertigo, or acute labyrinthitis, were treated with rest in bed, and a fluid diet (because of vomiting);Avomine ’ (promethazine-8-chlorotheophyllinate) was given in 2 cases. No other drug was used. The infectivity may be largely explained by the geography of this area : there are only a few transport services (used by practically everybody), few shops, and a high density of acute
"
labyrinthitis which I saw-and still see more spasmodically-in this practice. Whatever the aetiology-and the evidence suggests a virus infection-does it not seem possible that a syndrome which includes oculomotor complications might not demonstrate, in some cases, involvement of other cranial nerves The present state of our knowledge supports the wisdom of Dr. Leishman’s opinion that " epidemic " vertigo " is a preferable title to acute labyrinthitis." W. L. BURROWES. Corsham, Wilts.
’
population. No
case
of
encephalitis
occurred
the
has during period, The 1 case of influenzal or
appeared since, in our practice. meningitis was in a child, who has recovered.
The total number of influenza cases which the 6 of us treated during these six weeks we estimate at 980, out of a population at risk of approximately 16,000. "
Our experience suggests that " epidemic vertigo may be a single manifestation of an influenzal virus infection. One wonders whether the vomiting seen in this influenza epidemic was in fact cerebral in type, but masked by other signs and symptoms of influenza. A fuller report of this influenza epidemic and of its implications (especially in connection with the condition called epidemic vomiting) is being prepared by us for the research committee of the College of General Practitioners.
E. V. KUENSSBERG.
Edinburgh.
of a small series of of this peculiar syndrome in which he was able to demonstrate oculomotor complications is of particular interest to me. In the cases which I reported1 there were no such complications, but it might be of value to him to hear of a case which I have seen, but have not dared to publish in view of the inability to establish a definite
SiR,-Dr. Leishman’s report
cases
diagnosis. A healthy man, aged 40, suddenly developed vertigo and diplopia when walking home from a football-match. This was
followed by nausea and vomiting. On examination there was a left-sided third nerve lesion as evidenced by internal strabismus and some ptosis. There was irregular rotatory nystagmus to the left and partial lower left facial weakness, and the left hemipalate moved less well than the right. There were no other abnormalities in the central nervous system. The blood-pressure was 140/80 mm. Hg ; the heart-was normal in size and shape and regular in rhythm. There were no abnormalities in the respiratory system or the alimentary system, and the patient was apyrexial. When the patient was removed to hospital long-standing bilateral catarrhal deafness was found. X-ray examination of the chest and skull was negative. The blood picture was normal, and- lumbar puncture yielded clear colourless cerebrospinal fluid under normal pressure, with free dynamics ; laboratory examination of the cerebrospinal fluid did not reveal any abnormality. A full examination of the optic discs, fundi, and visual fields was carried out (but in the case of the visual fields this was not doneuntil some time after the onset of the disease),’and once again no abnormality was found. Botit the symptoms and the signs were transient, and the patient made a complete and uninterrupted recovery. Now, about three years later, the patient is leading a very active and strenuous life without any recurrence of trouble.
I admit that it is difficult, if not impossible, to exclude small localised thromboticlesion. It was also postulated that anterior poliomyelitis could not be ruled out. All I claim is that the sudden onset and the similarity of the presenting _symptoms, in an otherwise perfectly fit man, bear a striking resemblance to the cases of " acute a
1. Brit, med, J, 1952, ii, 1182.
STERILISATION OF SYRINGES SiR,-In your annotation of Jan. 22 you state that autoclaving is an unsatisfactory method of sterilisation because the syringes have first to be taken apart. If ’Vim’ syringes are used (and in my opinion these are the best syringes available in this country at the
present time) they can be assembled, placed in glass tubes, and routinely subjected to autoclaving at a temperature of 120°C (15-20 lb. pressure) for 20 minutes, and this I consider a most satisfactory method of sterilisation. W. N. ROLLASON. ROLLASOX.
Hull.
TREATMENT OF ACUTELY PERFORATED PEPTIC ULCERS
SIR,-One of the most interesting observations in Mr. Moore’s article (Jan. 22) is that of the failure of radio-opaque material to traverse the pylorus in some cases of duodenal perforation. This is the common of perforation, and those who favour the adoption type of " conservative " or " aspiration " treatment may well have to consider the efficacy of suction in these cases. ElsewhereIhave suggested that by aspiration one can only withdraw some of the gastric contents, and in cases of duodenal perforation it may not be possible to suck away the duodenal and small-intestinal fluid which wells up from paralysed loops of bowel. In my opinion too much reliance is placed on aspiration by the advocates of nonoperative treatment, and Mr. Moore’s radiological findings support the conception that pyloric spasm or oedema is present to a degree which must diminish the value of aspiration. Department of Surgery, University of Liverpool.
J. A. SHEPHERD.
CEREBROSPINAL FLUID IN
CARCINOMATOSIS OF THE MENINGES
SiR,—These changes are as yet inadequately appreciated, Murphy (Jan. 29) again draws attention to the
and Dr.
syndrome. He mentions the difficulty in distinguishing the condition from tuberculous meningitis. The similarity to the c.s.F. changes in subacute meningitis are obvious, and yeast infections must also be considered. The neoplastic process may result from metastasis (usually from a bronchial neoplasm) or may represent a gliomatosis of endogenous Brain tumour may be simulated, as in the case recorded by Valaitis 2; electroencephalographic abnormalities suggestive of a deep cerebral lesion
origin.
were
present.
A further interesting feature of the case was the finding in the first C.s.F. examination of only 8 cells per c.mm., with a pressure of215 mm. of water and a protein content of 190 mg. per 100 ml. This low cell-count was not constant, and one week before the patient’s death the level was 4905 cells per c.mm. In the subsequent discussion. H. H. Merritt points out that the combination of increased pressure, pleocytosis, and decreased glucose content of the c.s.F. may be encountered in sarcoidosis-; he quotes Pennell. who described this association with sarcoidosis in 1951.3 Victoria Hospital, Burnley.
J. SHAFAR.
1. Brit.med. J. 1950, i, 438 ; Lancet, 1951, i, 176. 2. Valaitis, J. J. Amer. med. Ass. 1954, 156, 719. 3. Pennell, W. H. Arch. Neurol. Psychiat. 1951, 66, 728.
embarrassingly frequent and the many alarming messages taxed our telephone and reception organisation to the full. At least 3 patients required treatment by cautery. The influenza was commonly associated with
vomiting (with or without abdominal symptoms), and this made many return visits and surgical consultations necessary. We estimated that vertigo was present in 1 out of every 7 adults, and in 1 out of every 10 children. It often lasted for only part of a day, but sometimes for as long as a week. In at least 2 adults nystagmus was observed with the usual influenza symptoms, but disappeared after two and three days ; neither case showed evidence of any intracranial lesion. The 4 patients with pure vertigo, or acute labyrinthitis, were treated with rest in bed, and a fluid diet (because of vomiting);Avomine ’ (promethazine-8-chlorotheophyllinate) was given in 2 cases. No other drug was used. The infectivity may be largely explained by the geography of this area : there are only a few transport services (used by practically everybody), few shops, and a high density of acute
"
labyrinthitis which I saw-and still see more spasmodically-in this practice. Whatever the aetiology-and the evidence suggests a virus infection-does it not seem possible that a syndrome which includes oculomotor complications might not demonstrate, in some cases, involvement of other cranial nerves The present state of our knowledge supports the wisdom of Dr. Leishman’s opinion that " epidemic " vertigo " is a preferable title to acute labyrinthitis." W. L. BURROWES. Corsham, Wilts.
’
population. No
case
of
encephalitis
occurred
the
has during period, The 1 case of influenzal or
appeared since, in our practice. meningitis was in a child, who has recovered.
The total number of influenza cases which the 6 of us treated during these six weeks we estimate at 980, out of a population at risk of approximately 16,000. "
Our experience suggests that " epidemic vertigo may be a single manifestation of an influenzal virus infection. One wonders whether the vomiting seen in this influenza epidemic was in fact cerebral in type, but masked by other signs and symptoms of influenza. A fuller report of this influenza epidemic and of its implications (especially in connection with the condition called epidemic vomiting) is being prepared by us for the research committee of the College of General Practitioners.
E. V. KUENSSBERG.
Edinburgh.
of a small series of of this peculiar syndrome in which he was able to demonstrate oculomotor complications is of particular interest to me. In the cases which I reported1 there were no such complications, but it might be of value to him to hear of a case which I have seen, but have not dared to publish in view of the inability to establish a definite
SiR,-Dr. Leishman’s report
cases
diagnosis. A healthy man, aged 40, suddenly developed vertigo and diplopia when walking home from a football-match. This was
followed by nausea and vomiting. On examination there was a left-sided third nerve lesion as evidenced by internal strabismus and some ptosis. There was irregular rotatory nystagmus to the left and partial lower left facial weakness, and the left hemipalate moved less well than the right. There were no other abnormalities in the central nervous system. The blood-pressure was 140/80 mm. Hg ; the heart-was normal in size and shape and regular in rhythm. There were no abnormalities in the respiratory system or the alimentary system, and the patient was apyrexial. When the patient was removed to hospital long-standing bilateral catarrhal deafness was found. X-ray examination of the chest and skull was negative. The blood picture was normal, and- lumbar puncture yielded clear colourless cerebrospinal fluid under normal pressure, with free dynamics ; laboratory examination of the cerebrospinal fluid did not reveal any abnormality. A full examination of the optic discs, fundi, and visual fields was carried out (but in the case of the visual fields this was not doneuntil some time after the onset of the disease),’and once again no abnormality was found. Botit the symptoms and the signs were transient, and the patient made a complete and uninterrupted recovery. Now, about three years later, the patient is leading a very active and strenuous life without any recurrence of trouble.
I admit that it is difficult, if not impossible, to exclude small localised thromboticlesion. It was also postulated that anterior poliomyelitis could not be ruled out. All I claim is that the sudden onset and the similarity of the presenting _symptoms, in an otherwise perfectly fit man, bear a striking resemblance to the cases of " acute a
1. Brit, med, J, 1952, ii, 1182.
STERILISATION OF SYRINGES SiR,-In your annotation of Jan. 22 you state that autoclaving is an unsatisfactory method of sterilisation because the syringes have first to be taken apart. If ’Vim’ syringes are used (and in my opinion these are the best syringes available in this country at the
present time) they can be assembled, placed in glass tubes, and routinely subjected to autoclaving at a temperature of 120°C (15-20 lb. pressure) for 20 minutes, and this I consider a most satisfactory method of sterilisation. W. N. ROLLASON. ROLLASOX.
Hull.
TREATMENT OF ACUTELY PERFORATED PEPTIC ULCERS
SIR,-One of the most interesting observations in Mr. Moore’s article (Jan. 22) is that of the failure of radio-opaque material to traverse the pylorus in some cases of duodenal perforation. This is the common of perforation, and those who favour the adoption type of " conservative " or " aspiration " treatment may well have to consider the efficacy of suction in these cases. ElsewhereIhave suggested that by aspiration one can only withdraw some of the gastric contents, and in cases of duodenal perforation it may not be possible to suck away the duodenal and small-intestinal fluid which wells up from paralysed loops of bowel. In my opinion too much reliance is placed on aspiration by the advocates of nonoperative treatment, and Mr. Moore’s radiological findings support the conception that pyloric spasm or oedema is present to a degree which must diminish the value of aspiration. Department of Surgery, University of Liverpool.
J. A. SHEPHERD.
CEREBROSPINAL FLUID IN
CARCINOMATOSIS OF THE MENINGES
SiR,—These changes are as yet inadequately appreciated, Murphy (Jan. 29) again draws attention to the
and Dr.
syndrome. He mentions the difficulty in distinguishing the condition from tuberculous meningitis. The similarity to the c.s.F. changes in subacute meningitis are obvious, and yeast infections must also be considered. The neoplastic process may result from metastasis (usually from a bronchial neoplasm) or may represent a gliomatosis of endogenous Brain tumour may be simulated, as in the case recorded by Valaitis 2; electroencephalographic abnormalities suggestive of a deep cerebral lesion
origin.
were
present.
A further interesting feature of the case was the finding in the first C.s.F. examination of only 8 cells per c.mm., with a pressure of215 mm. of water and a protein content of 190 mg. per 100 ml. This low cell-count was not constant, and one week before the patient’s death the level was 4905 cells per c.mm. In the subsequent discussion. H. H. Merritt points out that the combination of increased pressure, pleocytosis, and decreased glucose content of the c.s.F. may be encountered in sarcoidosis-; he quotes Pennell. who described this association with sarcoidosis in 1951.3 Victoria Hospital, Burnley.
J. SHAFAR.
1. Brit.med. J. 1950, i, 438 ; Lancet, 1951, i, 176. 2. Valaitis, J. J. Amer. med. Ass. 1954, 156, 719. 3. Pennell, W. H. Arch. Neurol. Psychiat. 1951, 66, 728.