478 In 6 of 8 cases with bulbar symptoms, the epidural anæsthesia was effective. Bulbar symptoms were not noted in the other 13 cases. In the 2 cases in which there was no effect, bulbar symptoms appeared as the initial manifestation. In 2 cases in which the treatment was started within 2-3 weeks of the appearance of suggestive bulbar symptoms, such as difficulty in swallowing salty soup, the symptoms disappeared after 1 or 2 block procedures. In these 2 cases, no bulbar symptoms appeared for a long period even at a stage when muscle power was worse than it had been before treatment. In patients with M.N.D. who responded to dibucaine block better effects were obtained in those with milder muscle atrophy, the site more recently affected responded better and for longer, and better effects were obtained in patients complaining, for example, of pain, fasciculation, muscle stiffness, tension, morning stiffness, sensations of heaviness, tightness surrounding the body, heat, or cold, and poor condition before
This method has been found to be useful in evaluating abnormal optic discs in a neurological unit and has the advar. tage of being rapid and, if necessary, repeatable. The equipment costs about £ 100. Further evaluation of the clinical application of the technique is in progress--e.g., in the measurement of arm-to-retina circulation-times in cases of suspected cerebral death. Department of Neurological Studies, Middlesex Hospital Medical School,
CHARLES CLARKE MICHAEL HARRISON
-
rainy days. While the effect is transient at present, a radical cure might anticipated in M.N.D. by early treatment. The mechanism may be the reduction in the predominance’2 of fine nerve fibres brought on by long-term block therapy, especially with
be
dibucaine.3 Department of Anæsthesiology, Faculty of Medicine, Shinshu University, Matsumoto, Japan
YOSHIO TERAUCHI
FLUORESCEIN RETINAL ANGIOGRAPHY AT THE BEDSIDE
SIR,—The clinical value of fluorescein photography of the fundus and retina is well established. Its main uses include the demonstration of retinal vascular lesions and the differential diagnosis of the abnormal optic disc where papilloedema is suspected. The equipment is, however, relatively expensive, a special side room is usually necessary, and, although a "visual report" can be given at the time by the photographer, several days are often required for the commercial developing of the film. In some centres fluorescein photography is not available, and even where it is the delay involved may limit its usefulness in the management of acute neurological disorders. An alternative is to observe the fluorescein angiogram with a specially adapted ophthalmoscope. This has proved rapid and reliable, especially when it has been important to confirm or refute a diagnosis ofpapilloedema before deciding how to investigate a patient with abnormal optic discs. A Keeler pantoscope is fitted with a cobalt-blue filter in the place of the usual polarised light filter. It can be run either from the mains via its transformer or it can be easily adapted to be powered by a 12 V battery with a rheostat in the circuit to alter the intensity of illumination. (This modification was originally designed for use during the 1975 British Everest expedition.) The pupils are dilated with a rapidly acting mydriatic such as tropicamide 1 % and a 5 ml bolus of 20% fluorescein sodium is injected intravenously. The patient is examined supine in a darkened room but complete blackout is unnecessary. The examination takes about twenty minutes. When experience has been gained of the normal fundus it has been found that a visual report of the fluorescein gives an accurate guide to vascular abnormalities in the retina. In the case of papilloedema increased blood-flow through dilated vessels on the disc itself, peripapillary leakage and residual staining of the optic disc are well seen. There have been few complications of the investigation in over fifty cases although several patients have felt nauseated.
optic
Okmaka, S. Tokyo. J. med. Sci. 1932, 46, 1006. Harris, J. B. and others. J. neurol. Sci. 1972, 15, 245. 3. Terauchi, Y. and others. Med. J. Shinshu. Univ. 1973, 17, 193. 1.
2.
London W1N 8AA
ORAL INFECTION IN PÆDIATRIC SALMONELLOSIS
SIR,-During investigation of epidemic salmonellosis in a newborn nursery, we observed that the causative organism Salmonella oranienburg, was often isolated from milk in feeding bottles after use but never before feeding. The source of contamination seemed to be the infants’ mouths, so a bactenological survey was done to investigate this possibility. Swab specimens taken from mouths were cultured overnight in selenite cystine broth (Difco) and in dulcitol selenite enrichment,and planted on DCLS agar (Difco). Stool specimens or rectal swabs were cultured in the same manner. Isolates were identified by standard biochemical and agglutination methods.2 All 18 infants in the nursery at the time were cultured, and 14 yielded S. oranienburg from stool culture while 9 had positive mouth cultures (2 with negative stools). The infection-rate was thus 89% (16/18). Isolation of salmonella from tonsils has been frequentlg reported, as have occasional isolations from sputum.) However, a 50% mouth-infection rate seems unusual, and this may constitute a source for spread of salmonellæ within a nursery-a source as important as fseces or environmental nidi. Since most used milk bottles cultured were positive forS, oranienburg, this indicated that bottle disinfection immediately after use, before cleaning, might reduce distribution of salmonellae in the nursery. Nursing tasks affecting the head area of infants (i.e., nasal tube feeding, face washing, or hair combing) should all be considered infectious hazards. Adequate disinfection of hands and potential fomites after these operations needs to be emphasised to nurses. Furthermore, our data suggest that oral culture may be a useful supplement to stool culture in the investigation of nursery salmonellosis. Microbiology Department, U.S. Naval Medical Research Unit
no. 2,
Jakarta Detachment, APO San Francisco, California 96356, U.S.A. Pædiatric Department, R. S. Fatmawati, Cilandak, West Java, Indonesia
WARREN R. SANBORN MURAD LESMANA
KOESNO
SEWAGE WORKER’S SYNDROME
SIR,-A clinical investigation was done among workers ata sewage-treatment plant in Gothenburg, Sweden, who occasionally had acute attacks of chill, fever and malaise. An agè’ matched population not exposed to sewage acted as cortrols Sera from randomly selected blood-donors were used as cotrols in some of the tests. The sewage was heat-treated and transformed intc powder. The dust concentration in the plant ranged benwees 0 .5 and 4 - 0 mg/m3. Considerably higher levels were present occasions when the sludge-treating equipment had to°° 1. Raj, H. Appl. Microbiol. 1966, 14, 12. 2. Ewing, W. H., Martin, W., J. in Manual of Clinical Microbiology (edited by E. H. Lennette, E. H. Spaulding, and J. P. Truant), p. 189 Washigton, 1974. 3. Wilson, G. S., Miles, A. A. Topley and Wilson’s Principles of Bacteriology and Immunity; p. 1928. London, 1966.
This method has been found to be useful in evaluating abnormal optic discs in a neurological unit and has the advar. tage of being rapid and, if necessary, repeatable. The equipment costs about £ 100. Further evaluation of the clinical application of the technique is in progress--e.g., in the measurement of arm-to-retina circulation-times in cases of suspected cerebral death. Department of Neurological Studies, Middlesex Hospital Medical School,
CHARLES CLARKE MICHAEL HARRISON
-
rainy days. While the effect is transient at present, a radical cure might anticipated in M.N.D. by early treatment. The mechanism may be the reduction in the predominance’2 of fine nerve fibres brought on by long-term block therapy, especially with
be
dibucaine.3 Department of Anæsthesiology, Faculty of Medicine, Shinshu University, Matsumoto, Japan
YOSHIO TERAUCHI
FLUORESCEIN RETINAL ANGIOGRAPHY AT THE BEDSIDE
SIR,—The clinical value of fluorescein photography of the fundus and retina is well established. Its main uses include the demonstration of retinal vascular lesions and the differential diagnosis of the abnormal optic disc where papilloedema is suspected. The equipment is, however, relatively expensive, a special side room is usually necessary, and, although a "visual report" can be given at the time by the photographer, several days are often required for the commercial developing of the film. In some centres fluorescein photography is not available, and even where it is the delay involved may limit its usefulness in the management of acute neurological disorders. An alternative is to observe the fluorescein angiogram with a specially adapted ophthalmoscope. This has proved rapid and reliable, especially when it has been important to confirm or refute a diagnosis ofpapilloedema before deciding how to investigate a patient with abnormal optic discs. A Keeler pantoscope is fitted with a cobalt-blue filter in the place of the usual polarised light filter. It can be run either from the mains via its transformer or it can be easily adapted to be powered by a 12 V battery with a rheostat in the circuit to alter the intensity of illumination. (This modification was originally designed for use during the 1975 British Everest expedition.) The pupils are dilated with a rapidly acting mydriatic such as tropicamide 1 % and a 5 ml bolus of 20% fluorescein sodium is injected intravenously. The patient is examined supine in a darkened room but complete blackout is unnecessary. The examination takes about twenty minutes. When experience has been gained of the normal fundus it has been found that a visual report of the fluorescein gives an accurate guide to vascular abnormalities in the retina. In the case of papilloedema increased blood-flow through dilated vessels on the disc itself, peripapillary leakage and residual staining of the optic disc are well seen. There have been few complications of the investigation in over fifty cases although several patients have felt nauseated.
optic
Okmaka, S. Tokyo. J. med. Sci. 1932, 46, 1006. Harris, J. B. and others. J. neurol. Sci. 1972, 15, 245. 3. Terauchi, Y. and others. Med. J. Shinshu. Univ. 1973, 17, 193. 1.
2.
London W1N 8AA
ORAL INFECTION IN PÆDIATRIC SALMONELLOSIS
SIR,-During investigation of epidemic salmonellosis in a newborn nursery, we observed that the causative organism Salmonella oranienburg, was often isolated from milk in feeding bottles after use but never before feeding. The source of contamination seemed to be the infants’ mouths, so a bactenological survey was done to investigate this possibility. Swab specimens taken from mouths were cultured overnight in selenite cystine broth (Difco) and in dulcitol selenite enrichment,and planted on DCLS agar (Difco). Stool specimens or rectal swabs were cultured in the same manner. Isolates were identified by standard biochemical and agglutination methods.2 All 18 infants in the nursery at the time were cultured, and 14 yielded S. oranienburg from stool culture while 9 had positive mouth cultures (2 with negative stools). The infection-rate was thus 89% (16/18). Isolation of salmonella from tonsils has been frequentlg reported, as have occasional isolations from sputum.) However, a 50% mouth-infection rate seems unusual, and this may constitute a source for spread of salmonellæ within a nursery-a source as important as fseces or environmental nidi. Since most used milk bottles cultured were positive forS, oranienburg, this indicated that bottle disinfection immediately after use, before cleaning, might reduce distribution of salmonellae in the nursery. Nursing tasks affecting the head area of infants (i.e., nasal tube feeding, face washing, or hair combing) should all be considered infectious hazards. Adequate disinfection of hands and potential fomites after these operations needs to be emphasised to nurses. Furthermore, our data suggest that oral culture may be a useful supplement to stool culture in the investigation of nursery salmonellosis. Microbiology Department, U.S. Naval Medical Research Unit
no. 2,
Jakarta Detachment, APO San Francisco, California 96356, U.S.A. Pædiatric Department, R. S. Fatmawati, Cilandak, West Java, Indonesia
WARREN R. SANBORN MURAD LESMANA
KOESNO
SEWAGE WORKER’S SYNDROME
SIR,-A clinical investigation was done among workers ata sewage-treatment plant in Gothenburg, Sweden, who occasionally had acute attacks of chill, fever and malaise. An agè’ matched population not exposed to sewage acted as cortrols Sera from randomly selected blood-donors were used as cotrols in some of the tests. The sewage was heat-treated and transformed intc powder. The dust concentration in the plant ranged benwees 0 .5 and 4 - 0 mg/m3. Considerably higher levels were present occasions when the sludge-treating equipment had to°° 1. Raj, H. Appl. Microbiol. 1966, 14, 12. 2. Ewing, W. H., Martin, W., J. in Manual of Clinical Microbiology (edited by E. H. Lennette, E. H. Spaulding, and J. P. Truant), p. 189 Washigton, 1974. 3. Wilson, G. S., Miles, A. A. Topley and Wilson’s Principles of Bacteriology and Immunity; p. 1928. London, 1966.
