744
those with associated trunk lesions were included. By contrast, in only 137 cases (15%) were the lesions confined to both legs, rarely being symmetrical, and, if associated trunk involvement was included, the figure rose to 240 (26-5%). Trunk involvement occurred in 232 patients (25-5%) of whom 72 had a moderate or severe scoliosis. The abnormal findings were confined to the arms in 72 cases (8%). Several years later Dr R. W. Webber and I did a similar survey in Tanzania.2The population sampled was 23 974, including 76 people with paralytic poliomyelitis. The pattern of palsies was similar to that seen in the Solomon Islands. There were 45 cases (59%) with a single lower limb involved, the proportion rising to 47 (62%) if there was associated trunk involvement. The figures for both lower limbs were 9 cases (12%) and 24 (31-5%), respectively. In 18 patients (23-5%) there was involvement of the trunk muscle, and in only 3 were the lesions confined to the arms. Although few infants were seen we rarely had difficulty in differentiating between a spastic paralysis and a flaccid paralysis with contracture formation. A history of febrile illness after which weakness of a limb was noticed was often given. I believe mothers quickly recognise limb weakness in their infants. Excellent papers on poliomyelitis have been published from the developing world, including an epidemiological one from Malawi3 and clinical ones relating to children in Nigeria4 and in Ethiopia.5 In all these series the commonest presentation was paralysis confined to a single lower limb. Sharrard6 has shown conclusively that in poliomyelitis there is a definite pattern of paralysis and paresis in the lower limbs which may lead to deformity with contracture formation, but he did not suggest that it is symmetrical. The illustrations of deformities in Huckstep’s 1975 textbook on poliomyelitis for developing countries7 are similar to those from Britain and America shown in Jones and Lovett’s book published in 1923, suggesting that the disease presents in the same way throughout the world. World Health Organisation criteria9 for diagnosing poliomyelitis are sound-namely, flaccid paralysis with atrophy with no decrease in sensation and a history of acute onset with no progression. On such criteria very few cases diagnosed as poliomyelitis in the developing world could be cases of spastic diplegia. Accident and Emergency Department, East Birmingham Hospital, Birmingham B9 5ST, UK
A. B. CROSS
1. Cross AB. Rehabilitation of the neglected poliomyelitis cripple in the Solomon Islands. MD Thesis, Queen’s University of Belfast, 1975. 2. Cross AB, Webber RW. A poliomyelitis survey the simple way: the Tanzanian experience Br Med J 1985; 291: 532-34. 3. Ward N, Lungu DW. A survey to determine the prevalence of poliomyelitis in Malawi. London: Save the Children Fund, 1977. 4. Collis RWF, Ransome-Kuti O, Taylor ME, Baker LE. Poliomyelitis in Nigeria. W Afr Med J 1961; 10: 217-22. 5. Barry BO. Review of infantile paralysis in Addis Aboba. Ethiop Med J 1964; 3: 3-12. 6. Sharrard WJW. Paralytic deformity in the lower limb. J Bone Joint Surg 1967; 49B: 731-747. 7. Huckstep RL. Poliomyelitis. Edinburgh: Churchill Livingstone, 1975. 8. Jones R, Lovett RW. Anterior poliomyelitis. In: Orthopaedic surgery. London: Henry Frowde/Hodder & Stoughton, 1923. 9. LaForce FM. Clinical survey techniques to measure prevalence and to estimate annual incidence of poliomyelitis in developing countries Geneva: World Health Organisation, 1979 (EPI/79/GENI).
SIR,-It is ironic that while we are in the midst of an epidemic of Crawford and Dr Hobbs think that most in the third world may not be poliomyelitis at all. Acute poliomyelitis occurs in endemic form in developing countries and cases of diplegia are also seen. Occasionally, however, poliomyelitis occurs in epidemic form; in India 200 000-300 000 new cases are acute
poliomyelitis, Dr
cases
reported every year.12 During the past 8 months we have seen 230 new patients with acute poliomyelitis, the vast majority within a week of onset. Crawford and Hobbs’ impression that in the tropics only the lower limbs are affected is not borne out by examination of these patients. 45% had poliomyelitis below one year of age when the infant had not started walking, but even in these infants it is easy to distinguish between poliomyelitis and diplegia because in poliomyelitis the whole episode is so acute and the limbs go limp so suddenly that any
mother can notice the difference immediately. When the child has already started walking the sudden onset of paralysis is too striking to be missed. During this epidemic we sent some of the samples of stool and blood to the London School of Hygiene and Tropical Medicine. The preliminary results show that poliovirus type I was grown from the stool and the blood showed very high titre antibody against
type I. Poliomyelitis remains a serious problem in the tropics and the impression that it occurs only sporadically is not valid. Epidemics if vaccination coverage is poor. Vaccination programmes in many developing countries have controlled this disease to a large extent.3In other countries the programme needs to be pursued vigorously so that calipers can be dispensed, as hoped for by the World Health Organisation.
can occur
Department of Paediatrics, Hospital,
Nishtar
TARIQ IQBAL BHUTTA
Multan, Pakistan
1. Anon. WHO news and activities. Bull WHO 1990; 68: 115-16. 2. John TJ. Poliomyelitis in India: prospective and problems of control. Rev Infect Dis 1984; 6 (suppl 2): 438-41. 3. John TJ. The role of Indian Academy of Paediatrics in expanded programme of immunization. Indian Pediatr 1985; 22: 91-95.
Flumazenil
as an
anti-epileptic agent
SIR,-Dr Savic and colleagues (Jan 19, p 133) report the use of flumazenil
antiepileptic agent and in the reversal of tolerance. benzodiazepine We have compared the effect of intravenous flumazenil in doses of 0-5, 1-0, and 3-0 mg on interictal electroencephalographic epileptic activity with that of diazepam 10 mg and placebo in a single-blind, single-dose, cross-over study. The ten patients taking part all had a mixture of either simple or complex partial seizures and secondarily generalised seizures of various aetiologies. Our results confirm those of Savic et al. Flumazenil at a dose of 3 mg had a significantly greater effect on spike count than did placebo for the first 40 minutes after injection (p < 0-05), its effect being similar to that of diazepam in magnitude and duration. In four patients, the lowest dose of flumazenil (0-5 mg) was sufficient to cause a in the amount of interictal substantial reduction as
an
electroencephalographic epileptic activity.1 Thus, we agree that flumazenil or related drugs may have an antiepileptic potential; its effects on clinical seizures and in the reversal of benzodiazepine tolerance should be further investigated. Chalfont Centre for Epilepsy, National Hospital, Chalfont St Peter, Buckinghamshire SL9 0RJ, UK; and Reckitt & Colman Psychopharmacology Unit, Bristol
Y. M. HART J. W. A. S. SANDER H. MEINARDI
D. J. NUTT S. D. SHORVON
YM, Meinardi H, Sander JWAS, Nutt DJ, Shorvon SD. The effect of iv flumazenil on interictal electroencephalographic epileptic activity: results of a placebo controlled study. J Neurol Neurosurg Psychiatry (in press).
1. Hart
Vibration-induced carpal-tunnel syndrome SIR,-Disturbed function of the median nerve distal to the wrist is significantly correlated with exposure to vibrations from handheld tools.1 However, disturbed function of the distal branches of the ulnar nerve--a nerve not passing through the carpal tunnel-is also correlated with exposure to vibrations .2 A narrowed carpal tunnel may not be the only reason for vibration-induced neurological damage in the hands. The ulnar nerve could be compressed in the sulcus nervus ulnaris, but observations on both manand laboratory animals° indicate that vibrations might affect the peripheral nerves directly as well as indirectly through surrounding tissue oedema. This effect could offset surgical carpal tunnel decompression in vibrationinduced carpal-tunnel syndrome (CTS). In 1985, surgical carpal tunnel decompression was completed on 191 hands (58 in males, 133 in females) at Sabbatsberg Hospital, Stockholm. 16 patients (18 hands, all men) had a history of
those with associated trunk lesions were included. By contrast, in only 137 cases (15%) were the lesions confined to both legs, rarely being symmetrical, and, if associated trunk involvement was included, the figure rose to 240 (26-5%). Trunk involvement occurred in 232 patients (25-5%) of whom 72 had a moderate or severe scoliosis. The abnormal findings were confined to the arms in 72 cases (8%). Several years later Dr R. W. Webber and I did a similar survey in Tanzania.2The population sampled was 23 974, including 76 people with paralytic poliomyelitis. The pattern of palsies was similar to that seen in the Solomon Islands. There were 45 cases (59%) with a single lower limb involved, the proportion rising to 47 (62%) if there was associated trunk involvement. The figures for both lower limbs were 9 cases (12%) and 24 (31-5%), respectively. In 18 patients (23-5%) there was involvement of the trunk muscle, and in only 3 were the lesions confined to the arms. Although few infants were seen we rarely had difficulty in differentiating between a spastic paralysis and a flaccid paralysis with contracture formation. A history of febrile illness after which weakness of a limb was noticed was often given. I believe mothers quickly recognise limb weakness in their infants. Excellent papers on poliomyelitis have been published from the developing world, including an epidemiological one from Malawi3 and clinical ones relating to children in Nigeria4 and in Ethiopia.5 In all these series the commonest presentation was paralysis confined to a single lower limb. Sharrard6 has shown conclusively that in poliomyelitis there is a definite pattern of paralysis and paresis in the lower limbs which may lead to deformity with contracture formation, but he did not suggest that it is symmetrical. The illustrations of deformities in Huckstep’s 1975 textbook on poliomyelitis for developing countries7 are similar to those from Britain and America shown in Jones and Lovett’s book published in 1923, suggesting that the disease presents in the same way throughout the world. World Health Organisation criteria9 for diagnosing poliomyelitis are sound-namely, flaccid paralysis with atrophy with no decrease in sensation and a history of acute onset with no progression. On such criteria very few cases diagnosed as poliomyelitis in the developing world could be cases of spastic diplegia. Accident and Emergency Department, East Birmingham Hospital, Birmingham B9 5ST, UK
A. B. CROSS
1. Cross AB. Rehabilitation of the neglected poliomyelitis cripple in the Solomon Islands. MD Thesis, Queen’s University of Belfast, 1975. 2. Cross AB, Webber RW. A poliomyelitis survey the simple way: the Tanzanian experience Br Med J 1985; 291: 532-34. 3. Ward N, Lungu DW. A survey to determine the prevalence of poliomyelitis in Malawi. London: Save the Children Fund, 1977. 4. Collis RWF, Ransome-Kuti O, Taylor ME, Baker LE. Poliomyelitis in Nigeria. W Afr Med J 1961; 10: 217-22. 5. Barry BO. Review of infantile paralysis in Addis Aboba. Ethiop Med J 1964; 3: 3-12. 6. Sharrard WJW. Paralytic deformity in the lower limb. J Bone Joint Surg 1967; 49B: 731-747. 7. Huckstep RL. Poliomyelitis. Edinburgh: Churchill Livingstone, 1975. 8. Jones R, Lovett RW. Anterior poliomyelitis. In: Orthopaedic surgery. London: Henry Frowde/Hodder & Stoughton, 1923. 9. LaForce FM. Clinical survey techniques to measure prevalence and to estimate annual incidence of poliomyelitis in developing countries Geneva: World Health Organisation, 1979 (EPI/79/GENI).
SIR,-It is ironic that while we are in the midst of an epidemic of Crawford and Dr Hobbs think that most in the third world may not be poliomyelitis at all. Acute poliomyelitis occurs in endemic form in developing countries and cases of diplegia are also seen. Occasionally, however, poliomyelitis occurs in epidemic form; in India 200 000-300 000 new cases are acute
poliomyelitis, Dr
cases
reported every year.12 During the past 8 months we have seen 230 new patients with acute poliomyelitis, the vast majority within a week of onset. Crawford and Hobbs’ impression that in the tropics only the lower limbs are affected is not borne out by examination of these patients. 45% had poliomyelitis below one year of age when the infant had not started walking, but even in these infants it is easy to distinguish between poliomyelitis and diplegia because in poliomyelitis the whole episode is so acute and the limbs go limp so suddenly that any
mother can notice the difference immediately. When the child has already started walking the sudden onset of paralysis is too striking to be missed. During this epidemic we sent some of the samples of stool and blood to the London School of Hygiene and Tropical Medicine. The preliminary results show that poliovirus type I was grown from the stool and the blood showed very high titre antibody against
type I. Poliomyelitis remains a serious problem in the tropics and the impression that it occurs only sporadically is not valid. Epidemics if vaccination coverage is poor. Vaccination programmes in many developing countries have controlled this disease to a large extent.3In other countries the programme needs to be pursued vigorously so that calipers can be dispensed, as hoped for by the World Health Organisation.
can occur
Department of Paediatrics, Hospital,
Nishtar
TARIQ IQBAL BHUTTA
Multan, Pakistan
1. Anon. WHO news and activities. Bull WHO 1990; 68: 115-16. 2. John TJ. Poliomyelitis in India: prospective and problems of control. Rev Infect Dis 1984; 6 (suppl 2): 438-41. 3. John TJ. The role of Indian Academy of Paediatrics in expanded programme of immunization. Indian Pediatr 1985; 22: 91-95.
Flumazenil
as an
anti-epileptic agent
SIR,-Dr Savic and colleagues (Jan 19, p 133) report the use of flumazenil
antiepileptic agent and in the reversal of tolerance. benzodiazepine We have compared the effect of intravenous flumazenil in doses of 0-5, 1-0, and 3-0 mg on interictal electroencephalographic epileptic activity with that of diazepam 10 mg and placebo in a single-blind, single-dose, cross-over study. The ten patients taking part all had a mixture of either simple or complex partial seizures and secondarily generalised seizures of various aetiologies. Our results confirm those of Savic et al. Flumazenil at a dose of 3 mg had a significantly greater effect on spike count than did placebo for the first 40 minutes after injection (p < 0-05), its effect being similar to that of diazepam in magnitude and duration. In four patients, the lowest dose of flumazenil (0-5 mg) was sufficient to cause a in the amount of interictal substantial reduction as
an
electroencephalographic epileptic activity.1 Thus, we agree that flumazenil or related drugs may have an antiepileptic potential; its effects on clinical seizures and in the reversal of benzodiazepine tolerance should be further investigated. Chalfont Centre for Epilepsy, National Hospital, Chalfont St Peter, Buckinghamshire SL9 0RJ, UK; and Reckitt & Colman Psychopharmacology Unit, Bristol
Y. M. HART J. W. A. S. SANDER H. MEINARDI
D. J. NUTT S. D. SHORVON
YM, Meinardi H, Sander JWAS, Nutt DJ, Shorvon SD. The effect of iv flumazenil on interictal electroencephalographic epileptic activity: results of a placebo controlled study. J Neurol Neurosurg Psychiatry (in press).
1. Hart
Vibration-induced carpal-tunnel syndrome SIR,-Disturbed function of the median nerve distal to the wrist is significantly correlated with exposure to vibrations from handheld tools.1 However, disturbed function of the distal branches of the ulnar nerve--a nerve not passing through the carpal tunnel-is also correlated with exposure to vibrations .2 A narrowed carpal tunnel may not be the only reason for vibration-induced neurological damage in the hands. The ulnar nerve could be compressed in the sulcus nervus ulnaris, but observations on both manand laboratory animals° indicate that vibrations might affect the peripheral nerves directly as well as indirectly through surrounding tissue oedema. This effect could offset surgical carpal tunnel decompression in vibrationinduced carpal-tunnel syndrome (CTS). In 1985, surgical carpal tunnel decompression was completed on 191 hands (58 in males, 133 in females) at Sabbatsberg Hospital, Stockholm. 16 patients (18 hands, all men) had a history of
