- Email: [email protected]
ECHOENCEPHALOGRAPHY
430 the non-schizophrenic but mentally abnormal patients in the same wards as, and receiving diets similar to those of the schizophrenic patients, and this is also true of the paranoid and non-paranoid groups. Our experiments (unpublished) have provided two other pieces of evidence which argue against diet or constipation being responsible for the pink spot: (1) in volunteers fed with D.M.P.E., so far no " pink spot " has been recovered from the urine; and (2) altering the flora of the gut by giving neomycin does not modify the appearance of the pink spot in those in whom it has been detected. Nuffield Unit of Medical Genetics, R. E. BOURDILLON University Department of Medicine, A. PAULINE RIDGES. 3. Liverpool
were
severe right-sided hemichorea, affecting the right face and arm more than the leg, with a few movements on the left, and she had a slight hyperreflexia on the right with a flexor plantar response. She has never shown a temperature above 98.4OF. Her pulse has remained steady and regular at 70 per minute, with blood-pressure of 115/70 mm. Hg. She has evidence of mitral incompetence, aortic incompetence, and mitral stenosis, and her heart signs have not changed. There has never been any rash, arthropathy, nodules, splinter hxmorrhages, retinal hsemorrhages, or splenomegaly. On admission Hb was 94% (13-7 g. per 100 ml.), white blood-cells 11,000 per c.mm. (72% polymorphs), and the
moderately
ECHOENCEPHALOGRAPHY
SIR,-In commenting upon our joint study of echoencephain cerebral haemorrhage and infarction (Jan. 22), Mr. Richardson and Dr. Ambrose write (Feb. 5): The data
lography
"
indicate that the examination improves the than lumbar puncture and that in cerebral haemorrhage it was probably less reliable." This statement contains a logical fallacy which they seem to have overlooked. If you define cerebral haemorrhage, as we defined it for the purpose of our study, as a stroke in which at lumbar puncture blood or xanthochromia is found in the cerebrospinal fluid (c.s.F.), then neither echoencephalography nor indeed any other diagnostic method can improve on lumbar puncture. Why then bother with echoencephalography ? The reason is this: if we had found no significant difference in the incidence of shift of the midline structures in patients with and without blood in the c.s.F., we would have concluded that echoencephalography has no place in this particular situation. As it was we found a shift in 77% of cases with blood in the C.S.F., and in 3-9% of those without. We can therefore proceed as follows: if a patient with a stroke and without blood in the C.S.F. shows no shift of midline structures we are certainly not entitled to conclude that he does not have a haemorrhage. (We gave details of several cases of proven haemorrhage without a shift.) But if a patient with a stroke and without blood in the C.S.F. shows a shift then the chances that he has a haemorrhage are extremely high. Used in this way echoencephalography will reduce the number of hxmorrhages misdiagnosed as infarction. University Department of Clinical R. P. K. COE Neurology, The National Hospital, W.C.1. JOHN MARSHALL. Queen Square, London,
presented seem diagnostic rate
to
no more
CHOREA GRAVIDARUM
SiR,-In their review of chorea gravidarum Dr. Lewis and Dr. Parsons did not comment in detail on the amount of rheumatic activity present in their patients. They state in their introduction that " chorea gravidarum... ’is apt to be severe when it develops late in pregnancy’ with mental changes ... or with fever ". Perhaps subacute bacterial endocarditis may account for some of these cases, as seen in a woman who is at present in this hospital
patient, an Indian housewife of twenty-five years, is a immigrant to the United Kingdom. She has no personal or domestic problems. Her fifth pregnancy continued uneventfully, except that a systolic murmur was noticed, and the chest X-ray showed a prominent left atrium. She had no dyspnoea, and no previous history of chorea or rheumatic fever.
48 mm. (Westergren) remained steady. The white blood-cell count settled at 8000 per c.mm., and the E.S.R. is now 15 mm. in the lst hour. Her antistreptolysin titre was 20 units per ml. Throat swab and high vaginal swab showed no pathogens. On admission, blood-urea was 58 mg. per 100 ml., with some red blood-cells in the urine which were thought to be contaminants. Blood-urea and urine have since remained normal. Electrocardiography showed no signs of active carditis. The chest X-ray showed appropriate cardiomegaly. The electroencephalogram showed excess of theta activity, maximal in the right temporal region. Two blood-cultures taken at an interval have demonstrated Streptococcus viridans sensitive to penicillin and erythromycin. The patient was treated for the 1st three weeks with phenobarbitone and amylobarbitone sedation without much effect. Following the result of the blood-culture she was treated with intramuscular penicillin, and erythromycin and probenecid. Within forty-eight hours of starting treatment the chorea
erythrocyte-sedimentation rate (E.S.R.) in the 1st hour. The haemoglobin has
improved strikingly. In this patient there
was
never
any clinical evidence of
endocarditis, but her chorea improved when the Strep. viridans bacterixmia was treated with full antibiotic therapy. Regional Neurological Unit, Brook General Hospital, London, S.E.18.
ANN COXON.
MATERNAL HYPERVENTILATION AND THE FŒTUS SIR,-The report of Motoyama and his colleagues (Feb. 5) cannot be accepted as providing unassailable evidence that hyperventilation of the mother, by inducing maternal hypocarbia (or a rise in maternal pH), tends to lead to fcetal asphyxia. One would have welcomed more information, in particular on the manner in which the ewes were hyperventilated and on the changes in maternal hsemodynamics. My reluctance to accept that there is good correlation between maternal hypocarbia and fcetal hypoxia stems from my findings in man, largely reported elsewhere. 1Samples of maternal arterial (M.A.) blood (drawn at the time of delivery), and of blood from the umbilical artery (u.A.) and umbilical vein (u.v.) were obtained in 23 "clinically ideal cases "3 delivered by elective caesarean section under spinal analgesia, and were assayed for oxygen saturation and acid-base balance. Pertinent ratios were as follows:
The
recent
Her pregnancy continued to four weeks after term without pre-eclampsia. Ten days before delivery she developed 2 right-sided hemichorea, but remained at home until she went into labour. The delivery was normal, and the baby, 3720 g (8 lb. 3 oz.) in weight, did not show signs of chorea. Wher seen at this hospital twenty-four hours later she was calm anc quiet. The slightly impulsive behaviour she has shown sinc( then has been attributed to sedation. She showed dysarthria
The
31-9 mm. Hg (range 24.7—39.5; values of oxygen saturation in cord blood in the two groups in which the maternal PC02 was above or below the maternal mean were: mean
s.D.4-04).
1. 2. 3.
M.A.
Pco2
The
was
mean
Crawford, J. S. Am. J. Obstet. Gynec. 1965, 93, Crawford, J. S. ibid. (in the press). Crawford, J. S. Biologia Neonat. 1965, 8, 131.
37.
were
severe right-sided hemichorea, affecting the right face and arm more than the leg, with a few movements on the left, and she had a slight hyperreflexia on the right with a flexor plantar response. She has never shown a temperature above 98.4OF. Her pulse has remained steady and regular at 70 per minute, with blood-pressure of 115/70 mm. Hg. She has evidence of mitral incompetence, aortic incompetence, and mitral stenosis, and her heart signs have not changed. There has never been any rash, arthropathy, nodules, splinter hxmorrhages, retinal hsemorrhages, or splenomegaly. On admission Hb was 94% (13-7 g. per 100 ml.), white blood-cells 11,000 per c.mm. (72% polymorphs), and the
moderately
ECHOENCEPHALOGRAPHY
SIR,-In commenting upon our joint study of echoencephain cerebral haemorrhage and infarction (Jan. 22), Mr. Richardson and Dr. Ambrose write (Feb. 5): The data
lography
"
indicate that the examination improves the than lumbar puncture and that in cerebral haemorrhage it was probably less reliable." This statement contains a logical fallacy which they seem to have overlooked. If you define cerebral haemorrhage, as we defined it for the purpose of our study, as a stroke in which at lumbar puncture blood or xanthochromia is found in the cerebrospinal fluid (c.s.F.), then neither echoencephalography nor indeed any other diagnostic method can improve on lumbar puncture. Why then bother with echoencephalography ? The reason is this: if we had found no significant difference in the incidence of shift of the midline structures in patients with and without blood in the c.s.F., we would have concluded that echoencephalography has no place in this particular situation. As it was we found a shift in 77% of cases with blood in the C.S.F., and in 3-9% of those without. We can therefore proceed as follows: if a patient with a stroke and without blood in the C.S.F. shows no shift of midline structures we are certainly not entitled to conclude that he does not have a haemorrhage. (We gave details of several cases of proven haemorrhage without a shift.) But if a patient with a stroke and without blood in the C.S.F. shows a shift then the chances that he has a haemorrhage are extremely high. Used in this way echoencephalography will reduce the number of hxmorrhages misdiagnosed as infarction. University Department of Clinical R. P. K. COE Neurology, The National Hospital, W.C.1. JOHN MARSHALL. Queen Square, London,
presented seem diagnostic rate
to
no more
CHOREA GRAVIDARUM
SiR,-In their review of chorea gravidarum Dr. Lewis and Dr. Parsons did not comment in detail on the amount of rheumatic activity present in their patients. They state in their introduction that " chorea gravidarum... ’is apt to be severe when it develops late in pregnancy’ with mental changes ... or with fever ". Perhaps subacute bacterial endocarditis may account for some of these cases, as seen in a woman who is at present in this hospital
patient, an Indian housewife of twenty-five years, is a immigrant to the United Kingdom. She has no personal or domestic problems. Her fifth pregnancy continued uneventfully, except that a systolic murmur was noticed, and the chest X-ray showed a prominent left atrium. She had no dyspnoea, and no previous history of chorea or rheumatic fever.
48 mm. (Westergren) remained steady. The white blood-cell count settled at 8000 per c.mm., and the E.S.R. is now 15 mm. in the lst hour. Her antistreptolysin titre was 20 units per ml. Throat swab and high vaginal swab showed no pathogens. On admission, blood-urea was 58 mg. per 100 ml., with some red blood-cells in the urine which were thought to be contaminants. Blood-urea and urine have since remained normal. Electrocardiography showed no signs of active carditis. The chest X-ray showed appropriate cardiomegaly. The electroencephalogram showed excess of theta activity, maximal in the right temporal region. Two blood-cultures taken at an interval have demonstrated Streptococcus viridans sensitive to penicillin and erythromycin. The patient was treated for the 1st three weeks with phenobarbitone and amylobarbitone sedation without much effect. Following the result of the blood-culture she was treated with intramuscular penicillin, and erythromycin and probenecid. Within forty-eight hours of starting treatment the chorea
erythrocyte-sedimentation rate (E.S.R.) in the 1st hour. The haemoglobin has
improved strikingly. In this patient there
was
never
any clinical evidence of
endocarditis, but her chorea improved when the Strep. viridans bacterixmia was treated with full antibiotic therapy. Regional Neurological Unit, Brook General Hospital, London, S.E.18.
ANN COXON.
MATERNAL HYPERVENTILATION AND THE FŒTUS SIR,-The report of Motoyama and his colleagues (Feb. 5) cannot be accepted as providing unassailable evidence that hyperventilation of the mother, by inducing maternal hypocarbia (or a rise in maternal pH), tends to lead to fcetal asphyxia. One would have welcomed more information, in particular on the manner in which the ewes were hyperventilated and on the changes in maternal hsemodynamics. My reluctance to accept that there is good correlation between maternal hypocarbia and fcetal hypoxia stems from my findings in man, largely reported elsewhere. 1Samples of maternal arterial (M.A.) blood (drawn at the time of delivery), and of blood from the umbilical artery (u.A.) and umbilical vein (u.v.) were obtained in 23 "clinically ideal cases "3 delivered by elective caesarean section under spinal analgesia, and were assayed for oxygen saturation and acid-base balance. Pertinent ratios were as follows:
The
recent
Her pregnancy continued to four weeks after term without pre-eclampsia. Ten days before delivery she developed 2 right-sided hemichorea, but remained at home until she went into labour. The delivery was normal, and the baby, 3720 g (8 lb. 3 oz.) in weight, did not show signs of chorea. Wher seen at this hospital twenty-four hours later she was calm anc quiet. The slightly impulsive behaviour she has shown sinc( then has been attributed to sedation. She showed dysarthria
The
31-9 mm. Hg (range 24.7—39.5; values of oxygen saturation in cord blood in the two groups in which the maternal PC02 was above or below the maternal mean were: mean
s.D.4-04).
1. 2. 3.
M.A.
Pco2
The
was
mean
Crawford, J. S. Am. J. Obstet. Gynec. 1965, 93, Crawford, J. S. ibid. (in the press). Crawford, J. S. Biologia Neonat. 1965, 8, 131.
37.