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OPSOCLONIA A RARE OCULAR SIGN IN POLIOENCEPHALITIS
508 and dosage (Weil and Galabert 1938). Lesser degrees of cutaneous damage from surface application of thorium-X are described by Airey (1945), who, with several years’ experience, had seen slight atrophy and telangiectasia in a glossy skin from its long-continued use, but no serious ill effects. Case 6 in the present series developed an erythema of the scalp after twelve months’ treatment. There was no vesiculation, and the erythema had persisted unaltered six months later. The reddened area corresponds to the area painted and not to the scalp area. Regrowth had started on the crown of the head only, and for this treatment had been continued. Because of reason occasional shortages in the supply of thorium-X, due to uncertainty about the amount required, this case was treated fortnightly, each half of the scalp alternately. There may thus have been overlapping of the areas painted, with consequent treatment of some areas fortnightly. It is intended to follow up this case with serial biopsies and photographs. Though thorium-X is commonly applied fortnightly or even weekly, it is well to recall that its first disintegration product, an indifferent gas with a halflife of about I min., may possibly diffuse further into the skin before transformation into more active states and cause demonstrable degeneration at a depth of 0-2--0-3 mm. (Lomholt 1923). This degeneration continues for a fortnight (Lomholt 1936), and Peck (1930) has shown that fair skin takes twenty-three days and dark skin forty-nine days to recover completely ; but even then hyperpigmentation may persist for months. Roxburgh (1944) states that the redness persists two_ or three weeks and then gradually fades and is replaced by pigmentation. SUMMARY
A series of 24 cases of alopecia areata, including 3 cases of total alopecia, were treated with applications of thorium-X in varnish, for periods ranging from a few weeks to a year. From this series all cases were excluded in which improvement might have been attributable to concurrent somatic or psychological treatment. Of the 24 cases 22 responded with satisfactory regrowth, and there were 2 failures. One case after partial regrowth developed an erythema of the scalp which has now lasted six months. It is suggested that in this case, the first of its kind so far reported, treatment of adjacent areas overlapped and was in fact given fortnightly instead of monthly as in the other cases. Cases of total alopecia responded with partial regrowth. Hitherto, treatment of such cases with thorium-X had failed, possibly because treatment had been given weekly. The tendency, previously reported, to regrowth being pigmented at once was confirmed in the cases of total alopecia, only. In 1 case with bald patches on the scalp and beard regrowth occurred on the scalp only. Thorium-X is very efficacious in the therapy of alopecia areata and superior to local treatment with light, besides taking less time. Treatments, however, should not be repeated on the same area more often than once a month.
monthly’
My thanks are due to Dr. E. -Miles, medical superintendent, Oldchurch Hospital, for permission to publish these cases.
OPSOCLONIA A RARE OCULAR SIGN IN POLIOENCEPHALITIS
D. E. MARMION M.A., M.B. Camb., M.R.C.P.
J. SANDILANDS
MEDICAL REGISTRAR
HOUSE-PHYSICIAN
THE PRINCE OF
M.B. Edin.
WALES’S HOSPITAL,
PLYMOUTH
THE current epidemic of acute anterior poliomyelitis is notable for the high proportion of cases with involvement of the brain stem. We have recently seen several cases in which ocular signs dominated the picture, and one we
consider
striking enough
for
publication.
A boy, aged 2 years 11months, a healthy son of middle. class parents, was on holiday when he suddenly developed difficulty and unsteadiness in walking. Next day it was noted that he squinted and moved his eyes in a curious jerky manner ; he was also feverish, irritable, and off his food. The following morning he vomited shortly after getting up, and later that day was admitted to hospital. On admission he was rather flushed, talkative, and emotionally labile; laughing one moment and in tears the next. His eyes were the most arresting feature. He had a variable internal strabismus of the left eye, and both eyes showed
rapid jerking nystagmoid movements of variable amplitude, occurring in groups of up to half a dozen, the first of each group of jerks being the largest in amplitude and the rest following in decrescendo. There was no distinction between rapid and slow phases as in true nystagmus ; the movements were usually in the horizontal but sometimes in the vertical or oblique planes, and there was occasionally a rotatory element. The movements were identical in the two eyes (with due allowance for the strabismus). The movements occurred most often just before the gaze came to rest upon a point of fixation, but they also took place at other times, and were intensified by emotion. So far as it was possible to ascertain, they did not interfere with vision. There were also a fine flutter of the eyelids associated with the movements of the eyeballs; tic-like twitching of the corners of the mouth ; a rapid head-nodding tremor of small amplitude, in any plane, as though the balance of the head on the neck was slightly unstable ; a slight degree of intention tremor of the upper limbs ; and a very ataxic gait, the child walking with evident difficulty and distress on -a wide base, staggering and clutching at any available support. There were no other abnormalities ; reflexes brisk and equal; no muscular weakness, tenderness, or spasm; no meningism ; and no fever after the first day in hospital. Lumbar puncture on twooccasions gave a normal fluid without increase in pressure ; a blood-count was within
normal limits.
Progress.-The strabismus started to improve three days after admission and had vanished after a further three days. The other signs, including the emotional lability, increased for about four days after admission, remained stationary for a day or two, and then declined slowly. By the twelfth day in hospital the child was normal, and he was discharged on the fifteenth day. A tentative diagnosis of polioencephalitis was made despite the normal cerebrospinal fluid. DISCUSSION
The striking principal feature
ocular phenomenon which was the of this case is apparently very rare and has received little attention in the literature. Strickland (1947), however, has referred to what is probably the
REFERENCES
Airey, F. S. (1945) Proc. R. Soc. Med. 38, 142. Bazy, L., Coste, F. (1938) Bull. Soc. méd. Hôp. Paris, 54, 117. Corsi, H. (1943) Lancet, ii, 346. Deucher, W. G., Leigh-Smith, A. (1943) Schweiz. med. Wschr. 73, 1092.
Hamperl, H. (1936) Virchows Arch. 298, 376. Hernaman-Johnson, F. (1946) Rheumatism, 3, 21. Isaak, L. (1942) Arch. Derm. Syph., Chicago, 45, 560. Lomholt, S. (1923) Acta radiol., Stockh. 2, 448. (1936) Proc. R. Soc. Med. 29, 1401. Loup, P. (1937) J. Urol. méd. chir. 43, 238. —
MacLeod, J. M. H., Muende, I. (1946) Practical Handbook of the Pathology of the Skin, London, p. 232. Nagelschmidt, K. F. (1916) Dtsch. med. Wschr. 42, 191. Peck, S. M. (1930) Arch. Derm. Syph., Chicago, 21, 916. Roemheld, L. (1937) Dtsch. med. Wschr. 63, 675. Roxburgh, A. C. (1944) Common Skin Diseases, London. Semon, H. C. G. (1940) An Atlas of the Commoner Skin Diseases, Bristol, p. 8. Thomas, E. W. P. (1945) Brit. J. phys. Med. 8, 72. Waisman, M., Kepler, E. J. (1941) J. Amer. med. Ass. 116, 2004. Weil, M. P., Galabert, R. (1938) Pr. méd. 46, 294. Weissenbach, R. J. (1938) Bull. Soc. franç. Derm. Syph. 45, 50. Zadek, I. (1937) Folia hœmat., Lpz. 56, 398.
509 "
same or a closely similar sign under the name of prefixation tremor," noted in the early stages of three cases of poliomyelitis ; so perhaps in the present epidemic it may prove to be less rare than heretofore. According to the usual conception and authoritative definitions of the term (Myers 1925, Riley 1930), the sign we have described cannot be considered a true nystagmus, though there is a superficial resemblance ; on the other hand, it has a certain family likeness to It is therefore interesting to find that myoclonus. Orzechowski (1927) described under the name " opsoclonia"" or myoclonic ataxia " a condition almost exactly resembling it. He speaks of very rapid and unequal movements, which usually take place in the horizontal plane." He states that the movements are seen chiefly when the eyeballs change their position, and he notes the decrescendo effect of each group. Cerebellar signs of slight degree were always present (hypotonia, tremors, ataxia, &c.), and he also notes the tremor of the eyelids and particularly emphasises emotional lability. All examples that had come to his notice occurred in cases of non-epidemic encephalitis. Orzechowski’s opinion is that this phenomenon is caused by a lesion of the basal ganglia, with or without a disturbance of the cerebellum or its connexions ; he envisages the possibility that a cerebellar lesion alone might cause it, but considers it unlikely. Physiologically he classes the disorder with myoclonus, and considers that it is related to the various disorders of muscular movement observed during and after encephalitis, and sometimes in other conditions. VTe suggest that the name " opsoclonia " is very apt for the phenomenon we have described, and that it is almost certainly used in the sense intended by its author. "
"
as a
-
oi
disease
A
of a case of probable poliobizarre type of nystagmoid It is suggested that this is movement of the eyes. with that previously described under probably identical the name " opsoclonia " by Orzechowski in 1927.
description is given encephalitis exhibiting a
indebted to Dr. T. H. G. Shore, under whose care was admitted to hospital, for permission to describe the case ; and to Dr. N. S. Alcock, who saw the patient as neurological consultant, for his opinion and advice. are
the patient
REFERENCES
Myers, J. L. (1925) Amer. J. med. Sci. 169, 742. Orzechowski, K. (1927) J. Psychol. Neurol. 35, 1. Riley, H. A. (1930) Arch. Ophthal., N.Y. 4, 640, 885. Strickland, B. (1947) Lancet, Sept. 6, p. 369.
Dr. Med. PROFESSOR OF
SURGERY,
CENTRAL
MAN is
<
Dr. Med. HON. CAUSA
HOSPITAL, ÖREBRO,
"
points out, uncommon
not way to a
die is from cardiac syncope or pulmonary embolism while on the bedpan." Lying down is no protection against such fatal.
=
complications, but, if anything, the opposite. One of our assistants, Dr. M. Fellander, has analysed the
surgical
depart-
ment’s statistics of thromboses and pulmonary emboli in patients not prophylac t i c a lly treated with nr
Wheet-chair, with
seat
fitting
over w.c.
pan.
dicou-
marol, and finds a death-rate from pulmonary embolism of 0-14% in 36,789 cases. To encouragespontaneous emptying of the bowels in way which would suit the convenience and susceptibilities of the patients an endeavour was made to arrange for the act of defaeca-tion to take place in a sitting position with knees drawn up and in privacy, for many people feel strongly that they should be alone in this situation. One of us (G. B.) therefore designed a portable chair that could be wheeled up to the bedside and then, with the patient on it, pushed out to the w.c. and arranged over the basin there (see figure). a
ADVANTAGES AND INDICATIONS
This
REVOLT FROM THE BEDPAN AND THE ENEMA G. BOHMANSSON H. MALMROS
and
convalescence. As THE LANCET!
benarin
SUMMARY
We
The patients regarded the omission of enemas manifest lack of proper care, and the nurses at first took up almost the same attitude. It was clear that some substitute would have to be found for the enema, and that the superstitious belief in the necessity of daily evacuation would have to be dispelled. Early getting up after operations has long been practised in our surgical department as a prophylactic against thrombosis and a means of shortening the period
patients.
to
arrangement obviates
move
himself,
the necessity for the patient and possesses the following advantages :
(1) Defaecation takes place in a sitting posture and in privacy. (2) Offensive odour in the ward is avoided. (3) Cleansing of bedpan and portable closet-pails may be
PHYSICIAN-IN-CHIEF
eliminated.
SWEDEN
The experience gained during the past eight years has enabled us to widen more and more the indications for the use of the portable w.c. chair. Patients and nurses are extremely satisfied, and bedpans are used only by the patients who have to lie down all the time-e.g., those with fractures of the lower extremities in extension, large hip plasters, paresis of the lower extremities, and moribund patients. Newly delivered women and patients who have
constructed that defecation is best effected in a sitting posture with drawn-up knees, so that the abdominal muscles can come into play. It is therefore unphysiological to defsecate while lying down. In 1938 one of us drew attention in a lecture to the unnecessary giving of enemas in our hospitals, and showed that at one hospital about 60,000 were administered in about 160,000 attendance days. Enema treatment to such an extent at our hospitals is liable to give patients the impression that the healthy ought also to have recourse to enemas if they do not have a daily evacuation. Patients with chronic constipation often admit that their constipation started in hospital, where they received felt obliged to enemas, and that they continue them. When we tried to limit or discontinue the use of enemas, we met with strong resistance from both nurses and so
subsequently
undergone cholecystectomy, gastric resection, or operation for vaginal prolapse are allowed to use the chair one or two days after the operation. Fever is no contraindication, provided the w.c. is kept well heated. The non-compensated heart is undoubtedly strained far less when evacuation takes place in a sitting posture than lying down. Enemas and bowel washings are practically eliminated. No increased tendency to hernia, heart1.
Lancet, 1946, i, 820.
A series of 24 cases of alopecia areata, including 3 cases of total alopecia, were treated with applications of thorium-X in varnish, for periods ranging from a few weeks to a year. From this series all cases were excluded in which improvement might have been attributable to concurrent somatic or psychological treatment. Of the 24 cases 22 responded with satisfactory regrowth, and there were 2 failures. One case after partial regrowth developed an erythema of the scalp which has now lasted six months. It is suggested that in this case, the first of its kind so far reported, treatment of adjacent areas overlapped and was in fact given fortnightly instead of monthly as in the other cases. Cases of total alopecia responded with partial regrowth. Hitherto, treatment of such cases with thorium-X had failed, possibly because treatment had been given weekly. The tendency, previously reported, to regrowth being pigmented at once was confirmed in the cases of total alopecia, only. In 1 case with bald patches on the scalp and beard regrowth occurred on the scalp only. Thorium-X is very efficacious in the therapy of alopecia areata and superior to local treatment with light, besides taking less time. Treatments, however, should not be repeated on the same area more often than once a month.
monthly’
My thanks are due to Dr. E. -Miles, medical superintendent, Oldchurch Hospital, for permission to publish these cases.
OPSOCLONIA A RARE OCULAR SIGN IN POLIOENCEPHALITIS
D. E. MARMION M.A., M.B. Camb., M.R.C.P.
J. SANDILANDS
MEDICAL REGISTRAR
HOUSE-PHYSICIAN
THE PRINCE OF
M.B. Edin.
WALES’S HOSPITAL,
PLYMOUTH
THE current epidemic of acute anterior poliomyelitis is notable for the high proportion of cases with involvement of the brain stem. We have recently seen several cases in which ocular signs dominated the picture, and one we
consider
striking enough
for
publication.
A boy, aged 2 years 11months, a healthy son of middle. class parents, was on holiday when he suddenly developed difficulty and unsteadiness in walking. Next day it was noted that he squinted and moved his eyes in a curious jerky manner ; he was also feverish, irritable, and off his food. The following morning he vomited shortly after getting up, and later that day was admitted to hospital. On admission he was rather flushed, talkative, and emotionally labile; laughing one moment and in tears the next. His eyes were the most arresting feature. He had a variable internal strabismus of the left eye, and both eyes showed
rapid jerking nystagmoid movements of variable amplitude, occurring in groups of up to half a dozen, the first of each group of jerks being the largest in amplitude and the rest following in decrescendo. There was no distinction between rapid and slow phases as in true nystagmus ; the movements were usually in the horizontal but sometimes in the vertical or oblique planes, and there was occasionally a rotatory element. The movements were identical in the two eyes (with due allowance for the strabismus). The movements occurred most often just before the gaze came to rest upon a point of fixation, but they also took place at other times, and were intensified by emotion. So far as it was possible to ascertain, they did not interfere with vision. There were also a fine flutter of the eyelids associated with the movements of the eyeballs; tic-like twitching of the corners of the mouth ; a rapid head-nodding tremor of small amplitude, in any plane, as though the balance of the head on the neck was slightly unstable ; a slight degree of intention tremor of the upper limbs ; and a very ataxic gait, the child walking with evident difficulty and distress on -a wide base, staggering and clutching at any available support. There were no other abnormalities ; reflexes brisk and equal; no muscular weakness, tenderness, or spasm; no meningism ; and no fever after the first day in hospital. Lumbar puncture on twooccasions gave a normal fluid without increase in pressure ; a blood-count was within
normal limits.
Progress.-The strabismus started to improve three days after admission and had vanished after a further three days. The other signs, including the emotional lability, increased for about four days after admission, remained stationary for a day or two, and then declined slowly. By the twelfth day in hospital the child was normal, and he was discharged on the fifteenth day. A tentative diagnosis of polioencephalitis was made despite the normal cerebrospinal fluid. DISCUSSION
The striking principal feature
ocular phenomenon which was the of this case is apparently very rare and has received little attention in the literature. Strickland (1947), however, has referred to what is probably the
REFERENCES
Airey, F. S. (1945) Proc. R. Soc. Med. 38, 142. Bazy, L., Coste, F. (1938) Bull. Soc. méd. Hôp. Paris, 54, 117. Corsi, H. (1943) Lancet, ii, 346. Deucher, W. G., Leigh-Smith, A. (1943) Schweiz. med. Wschr. 73, 1092.
Hamperl, H. (1936) Virchows Arch. 298, 376. Hernaman-Johnson, F. (1946) Rheumatism, 3, 21. Isaak, L. (1942) Arch. Derm. Syph., Chicago, 45, 560. Lomholt, S. (1923) Acta radiol., Stockh. 2, 448. (1936) Proc. R. Soc. Med. 29, 1401. Loup, P. (1937) J. Urol. méd. chir. 43, 238. —
MacLeod, J. M. H., Muende, I. (1946) Practical Handbook of the Pathology of the Skin, London, p. 232. Nagelschmidt, K. F. (1916) Dtsch. med. Wschr. 42, 191. Peck, S. M. (1930) Arch. Derm. Syph., Chicago, 21, 916. Roemheld, L. (1937) Dtsch. med. Wschr. 63, 675. Roxburgh, A. C. (1944) Common Skin Diseases, London. Semon, H. C. G. (1940) An Atlas of the Commoner Skin Diseases, Bristol, p. 8. Thomas, E. W. P. (1945) Brit. J. phys. Med. 8, 72. Waisman, M., Kepler, E. J. (1941) J. Amer. med. Ass. 116, 2004. Weil, M. P., Galabert, R. (1938) Pr. méd. 46, 294. Weissenbach, R. J. (1938) Bull. Soc. franç. Derm. Syph. 45, 50. Zadek, I. (1937) Folia hœmat., Lpz. 56, 398.
509 "
same or a closely similar sign under the name of prefixation tremor," noted in the early stages of three cases of poliomyelitis ; so perhaps in the present epidemic it may prove to be less rare than heretofore. According to the usual conception and authoritative definitions of the term (Myers 1925, Riley 1930), the sign we have described cannot be considered a true nystagmus, though there is a superficial resemblance ; on the other hand, it has a certain family likeness to It is therefore interesting to find that myoclonus. Orzechowski (1927) described under the name " opsoclonia"" or myoclonic ataxia " a condition almost exactly resembling it. He speaks of very rapid and unequal movements, which usually take place in the horizontal plane." He states that the movements are seen chiefly when the eyeballs change their position, and he notes the decrescendo effect of each group. Cerebellar signs of slight degree were always present (hypotonia, tremors, ataxia, &c.), and he also notes the tremor of the eyelids and particularly emphasises emotional lability. All examples that had come to his notice occurred in cases of non-epidemic encephalitis. Orzechowski’s opinion is that this phenomenon is caused by a lesion of the basal ganglia, with or without a disturbance of the cerebellum or its connexions ; he envisages the possibility that a cerebellar lesion alone might cause it, but considers it unlikely. Physiologically he classes the disorder with myoclonus, and considers that it is related to the various disorders of muscular movement observed during and after encephalitis, and sometimes in other conditions. VTe suggest that the name " opsoclonia " is very apt for the phenomenon we have described, and that it is almost certainly used in the sense intended by its author. "
"
as a
-
oi
disease
A
of a case of probable poliobizarre type of nystagmoid It is suggested that this is movement of the eyes. with that previously described under probably identical the name " opsoclonia " by Orzechowski in 1927.
description is given encephalitis exhibiting a
indebted to Dr. T. H. G. Shore, under whose care was admitted to hospital, for permission to describe the case ; and to Dr. N. S. Alcock, who saw the patient as neurological consultant, for his opinion and advice. are
the patient
REFERENCES
Myers, J. L. (1925) Amer. J. med. Sci. 169, 742. Orzechowski, K. (1927) J. Psychol. Neurol. 35, 1. Riley, H. A. (1930) Arch. Ophthal., N.Y. 4, 640, 885. Strickland, B. (1947) Lancet, Sept. 6, p. 369.
Dr. Med. PROFESSOR OF
SURGERY,
CENTRAL
MAN is
<
Dr. Med. HON. CAUSA
HOSPITAL, ÖREBRO,
"
points out, uncommon
not way to a
die is from cardiac syncope or pulmonary embolism while on the bedpan." Lying down is no protection against such fatal.
=
complications, but, if anything, the opposite. One of our assistants, Dr. M. Fellander, has analysed the
surgical
depart-
ment’s statistics of thromboses and pulmonary emboli in patients not prophylac t i c a lly treated with nr
Wheet-chair, with
seat
fitting
over w.c.
pan.
dicou-
marol, and finds a death-rate from pulmonary embolism of 0-14% in 36,789 cases. To encouragespontaneous emptying of the bowels in way which would suit the convenience and susceptibilities of the patients an endeavour was made to arrange for the act of defaeca-tion to take place in a sitting position with knees drawn up and in privacy, for many people feel strongly that they should be alone in this situation. One of us (G. B.) therefore designed a portable chair that could be wheeled up to the bedside and then, with the patient on it, pushed out to the w.c. and arranged over the basin there (see figure). a
ADVANTAGES AND INDICATIONS
This
REVOLT FROM THE BEDPAN AND THE ENEMA G. BOHMANSSON H. MALMROS
and
convalescence. As THE LANCET!
benarin
SUMMARY
We
The patients regarded the omission of enemas manifest lack of proper care, and the nurses at first took up almost the same attitude. It was clear that some substitute would have to be found for the enema, and that the superstitious belief in the necessity of daily evacuation would have to be dispelled. Early getting up after operations has long been practised in our surgical department as a prophylactic against thrombosis and a means of shortening the period
patients.
to
arrangement obviates
move
himself,
the necessity for the patient and possesses the following advantages :
(1) Defaecation takes place in a sitting posture and in privacy. (2) Offensive odour in the ward is avoided. (3) Cleansing of bedpan and portable closet-pails may be
PHYSICIAN-IN-CHIEF
eliminated.
SWEDEN
The experience gained during the past eight years has enabled us to widen more and more the indications for the use of the portable w.c. chair. Patients and nurses are extremely satisfied, and bedpans are used only by the patients who have to lie down all the time-e.g., those with fractures of the lower extremities in extension, large hip plasters, paresis of the lower extremities, and moribund patients. Newly delivered women and patients who have
constructed that defecation is best effected in a sitting posture with drawn-up knees, so that the abdominal muscles can come into play. It is therefore unphysiological to defsecate while lying down. In 1938 one of us drew attention in a lecture to the unnecessary giving of enemas in our hospitals, and showed that at one hospital about 60,000 were administered in about 160,000 attendance days. Enema treatment to such an extent at our hospitals is liable to give patients the impression that the healthy ought also to have recourse to enemas if they do not have a daily evacuation. Patients with chronic constipation often admit that their constipation started in hospital, where they received felt obliged to enemas, and that they continue them. When we tried to limit or discontinue the use of enemas, we met with strong resistance from both nurses and so
subsequently
undergone cholecystectomy, gastric resection, or operation for vaginal prolapse are allowed to use the chair one or two days after the operation. Fever is no contraindication, provided the w.c. is kept well heated. The non-compensated heart is undoubtedly strained far less when evacuation takes place in a sitting posture than lying down. Enemas and bowel washings are practically eliminated. No increased tendency to hernia, heart1.
Lancet, 1946, i, 820.