Bronchorrhea following Stroke.

BACKGROUND: Stroke-induced excessive bronchial secretion is not rare, but seldom discussed. This study emphasizes its recognition, pathophysiology and treatment. METHODS: We prospectively collected data from 19 consecutive stroke patients with bronchorrhea who were admitted within 2 days of stroke onset. RESULTS: Sixteen of them (84%) suffered from ischemic stroke, and 3 patients (16%) had hemorrhage. All of them had brainstem involvement, and 11 of them (58%) had localized lesions in the dorsal lateral medulla. In 15 patients (79%), copious secretion developed within 3 days after stroke onset. The frequency of expectoration was variable with fluctuation, and half of the patients (47%) had to spit every 2-5 min during its climax. The duration of increased secretion ranged from 4 days to over 2 months. Half of the patients (53%) received anticholinergic treatment, and the response was fair to good. CONCLUSIONS: Our data provide clinical evidence that stroke patients with dorsal medulla involvement might present with bronchorrhea which seemed to be mediated via a parasympathetic mechanism. This is a treatable disease, and early diagnosis and treatment may greatly reduce patients' suffering, avoid antibiotics abuse, reduce the incidence of aspiration pneumonia, and shorten the length of hospitalization.

[Re-evaluation of using acupuncture needle as sphenoidal electrode in temporal lobe epilepsy].

In 1965, Feng of the Peking Union Hospital published an article entitled "Innovation in electroencephalography: the use of acupuncture needles as sphenoidal electrodes". It was a preliminary report, but surprisingly EEG records in the figures did not show definite spikes or sharp waves in the sphenoidal leads. In 1983, Feng and his colleagues reported a summary of 2,000 cases studied with acupuncture needle sphenoidal electrodes. This time, spikes or sharp waves were shown in EEG recordings. However, cases studied were several "paroxysmal disorders", including psychomotor seizure (155 cases), generalized seizure (765 cases), epileptic cephalgia (101 cases), syncope (104 cases), abdominal epilepsy (24 cases), encephalopathy (135 cases), brain tumor (32 cases), hemiplegia of unknown cause (43 cases), psychosis (34 cases), and others (607 cases). Therefore, there were many unknown cases and many cases that were not related to temporal lobe epilepsy. Surprisingly, the increase in detection by acupuncture needle electrode was higher for hemiplegia of unknown cause, brain tumors, and encephalopathies than for the temporal lobe epilepsy. Furthermore, the issue of no insulation of the acupuncture needle was not addressed. Therefore, we began in 1988 to reinvestigate the usefulness of uninsulated acupuncture needles as sphenoidal electrodes. We also compared the efficacy of anterior temporal electrodes (T1, T2) with those of acupuncture needle and EMG needle. Our results showed that when compared to the routine EEG recordings, acupuncture needle sphenoidal electrodes increased the yield of detecting anterior temporal spikes from 41% to 70%. Our data further showed that when compared to the EMG needle recordings, acupuncture needle recordings had the same detection rate, but the spike amplitude was slightly smaller (129 microv vs. 135 microv). Interestingly, we also found that anterior temporal surface electrode recordings were nearly as good as those of acupuncture needle and traditional insulated needle electrodes in the detection of anterior temporal spikes. Our data indicate that acupuncture needle sphenoidal electrode is as effective as the traditional insulated needle sphenoidal electrode in the detection of anterior temporal spikes. We agree with Feng that the use of acupuncture needle is easy, safe, and has minimal discomfort and complications. However, when the use of the acupuncture needle is not acceptable to patients or as in the pediatric group, anterior temporal electrode is an ideal alternative to acupuncture needle sphenoidal electrode.

Central hyperthermia in acute stroke.

BACKGROUND: Central hyperthermia is an unresolved riddle; this study tries to define its characteristics. METHODS: Seventy-four previously healthy patients who developed hyperthermia (> or =39 degrees C) within 24 h after stroke onset were enrolled. The lesion sites, nature of stroke, and clinical features were studied. RESULTS: Brainstem hemorrhage was the most common cause of hyperthermia (64%), followed by putamino-thalamus hemorrhage (24%), cerebellum hemorrhage (4%), large cortical infarct (4%), basilar artery occlusion (3%), and intraventricular hemorrhage (1%). Whatever the site of the lesion, all patients had brainstem involvement either by direct destruction or indirect compression. Three fourths of the patients reached 39 degrees C within 12 h of stroke, and 82% arrived at the maximum within 24 h. A peculiar finding of central hyperthermia was the marked fluctuation in body temperature within a short period, which was more severe initially then decreased gradually. Leukocytosis was seen in 60%, but shift to the left was rare (1%). The prognosis was grave, nearly 70% of the patients expired within 1 month, especially those with a temperature of >41 degrees C or those who reached 39 degrees C within 6 h after onset of stroke, or those who had severe fluctuations in temperature. CONCLUSIONS: Central hyperthermia is characterized by rapid onset of high fever, marked temperature fluctuation and high mortality. It is likely associated with brainstem (mainly pons) damage by direct destruction or indirect compression.

Wilson's disease in Taiwan.

Wilson's disease (WD) has been studied in Taiwan since 1960s. The study can be divided into three periods: (1) The first period was 1960s, represented by the work of Dr. JB Tu who worked in the U.S. Naval Medical Research Unit No. 2 (NAMRU-2); (2) The second period was 1970s, represented by the work of Dr. ML Leu who also worked in NAMRU-2. During these two periods, d-penicillamine was introduced to Taiwan via NAMRU-2, primarily as study drug; and (3) The third period was 1980s and afterwards. Tu and Leu reported the clinical manifestations, tissue concentrations of copper, and therapeutic effects of d-penicillamine including cupriuresis, reduction of copper content in tissues, and prognosis. Our studies after 1980s included clinical manifestations, evoked potentials to detect the extent of CNS involvement, effect of superimposed hepatitis B infection on clinical manifestations and prognosis, and WD with cerebral white matter involvement. The present review highlights above investigations.

[Eradication of opium smoking in Taiwan during the Japanese colonial period (1895-1945)].

Eradication of opium smoking during the Japanese colonial period is one of the most proud medical accomplishments in Taiwan. The mission was accomplished mainly due to a governmental policy of gradual prohibition in 1897 and the establishment of the Government Center Hospital for Opium Addicts in 1930. Professor Tsungming Tu, medical director of the Government Center Hospital, was responsible for the unique medical treatment of opium addiction there. The latter consisted of an immediate withdrawal of opium smoking which was partly substituted by small amounts of morphine in gradual reduction, and at the same time special pills were given to enhance the sympathetic activity also to lessen the withdrawal symptoms. By such treatment, the habit of opium smoking could often be eliminated in a few weeks. The success rate was 46%. Shortly after the World War II, the number of opium smokers in Taiwan became negligible. In early colonial period, however, there were grass roots movements as well as private efforts by physicians of Western medicine to treat opium addiction. In 1898, the Flying Phoenix Society which was a laymen organization worshipping deities began to use supernatural power to force the addicts to stop opium smoking. More than thirty thousand were enlisted and the success rate was 58%. In 1908, the enthabitual treatment in a private correction infirmary called 'Newmatou' consisted of a substitute treatment using morphine to replace opium and a gradual reduction in morphine dosage afterwards. All addicts were hospitalized until treatment goal was achieved. Among 55 addicts thus treated, 53 (96%) were ridded of opium smoking habit. The treatment method was almost identical to that employed by Professor Tu. Another physician, Dr. Ching-yue Lin, who worked at the Red Cross Hospital in Taipei, also used substitute treatment, replacing opium by heroine, and obtained a success rate of 80%. Dr. Lin published his comprehensive study on opium addiction and treatment in the Journal of the Formosan Medical Association in 1908. Therefore, Dr. Tu's enthabitual treatment seemed to be not so unique. Previous treatments employed by physicians at 'Newmatou' infirmary and by Dr. Lin at the Red Cross Hospital were strikingly similar or nearly the same. This review may help us reassess the prevailing opinion regarding the history of eliminating opium smoking in Taiwan.

[Centennial of the nobel prize for Golgi and Cajal--founding of modern neuroscience and irony of discovery].

In 1906, Golgi and Ramón y Cajal shared the Nobel Prize in Physiology or Medicine "in recognition of their work on the structure of the nervous system". However, it was an unusual occasion in the history of Nobel Prize award because their views on the structure of the nervous system were not only different but even opposite, creating the "storm center of histological controversy". Furthermore, the new staining method Cajal had employed to study the nervous system was developed by Golgi, creating an irony of discovery. In 1873, Golgi revolutionized the histological study of the nervous system by developing a new staining method, "la reazione nera" or black reaction, which allowed good visualization of axons, dendrites and glia. But because his stain was so selective, staining only about 3 percent of neurons, he was unable to see clearly how the neuronal processes ended as they approached other neurons. Consequently, he embraced the popular belief that neuronal processes physically fuse with each other--the "reticular theory". On the other hand, Cajal was incidentally introduced to the Golgi stain 14 years after its discovery and immediately realized its beauty. He found that better results could be produced by staining more intensely and cutting thicker sections. He further observed that the Golgi stain worked best on non-myelinated axons. The search for brains containing non-myelinated axons led him to study birds and very young mammals, including embryos. Cajal obtained fascinating results by modifying the Golgi stain and by studying avian and young mammalian brains. From those studies, Cajal was able to infer that axons and dendrites ended freely and did not physically anastomose. Therefore, he strongly advocated the "neuron theory". Golgi seemed to be too headstrong and too conservative to relinquish his belief that neurons constitute a network which reacts as a whole. On the other hand, Cajal's hard work using the Golgi stain led to new understanding on the structure and function of the nervous system, and earned him "the founder of modern neuroscience". This centennial occasion may be further impressed by Cajal's comment on the shared Nobel Prize that "what a cruel irony of fate of pair, like Siamese twins united by the shoulders, scientific adversaries of such contrasting character!".

Axonal polyneuropathy after acute dimethylamine borane intoxication.

OBJECTIVE: To study a patient with axonal polyneuropathy due to acute dimethylamine borane (DMAB) intoxication. PATIENT: Confusion and drowsiness in the acute stage, followed by cognitive impairments and polyneuropathy, are reported in a chemical factory worker after acute exposure to DMAB. RESULTS: Nerve conduction studies indicated axonal polyneuropathy, particularly in the motor nerves. Sural nerve biopsy studies 3 months later revealed an axonal degeneration with a mild decrease of fiber density in the large myelinated fibers. Quantitative sensory testing also disclosed an impairment of pinprick, temperature, and touch sensations. Cutaneous nerve biopsy studies 9 months later demonstrated a moderate loss of epidermal nerves. During the follow-up period of 1.5 years, the clinical features and serial nerve conduction studies showed a steady improvement. CONCLUSIONS: Since DMAB is a new product and has been widely used recently in the manufacturing of semiconductors and electronics, we conclude that DMAB intoxication may produce motor-predominant axonal polyneuropathy and that the establishment of a threshold limit value is warranted.

Congenital myotonic dystrophy: variability in muscle involvement and histopathological process.

In order to understand the involvement of specific muscles in congenital myotonic dystrophy type 1 (DM1), we studied the clinical manifestations, and the genetic effects on various tissues in 2 siblings with congenital DM1. The distal leg muscles were more severely involved than the thigh muscles, as seen in the skeletal muscle magnetic resonance imaging. Molecular genetic analysis of the myotonic dystrophy type 1 protein kinase showed an elongation of the CTG triplet repeats between 850 and 1400 in the leukocytes, skin, fat, tendon, and muscles. Muscle biopsies showed a significant difference in the fiber type distribution between these two congenital DM1 patients. One revealed a prominent involvement of the tibialis anterior muscle with a predominance of type 1 fibers, similar to those muscle fiber distributions in older congenital or classic DM1 patients, suggesting a neurotrophic influence during muscle development. Another revealed a predominance of type 2 fibers in all muscle specimens, and dystrophic changes were observed in the peroneus longus muscle indicating a delayed differentiation or maturation of muscle fibers. We conclude that despite nearly the same number of CTG repeats in the leukocytes, highly individual variability of muscle differentiation may occur at teenagers of congenital DM1 in addition to different pathological findings in various skeletal muscles of patients with congenital DM1.

Central nervous system effects in acute thallium poisoning.

We report the central nervous system manifestations, neuropsychological studies and brain magnetic resonance image (MRI) findings of two patients with acute thallium intoxication. Neurologically the patients suffered from confusion, disorientation, and hallucination in the acute stage, followed by anxiety, depression, lack of attention, and memory impairment, in addition to peripheral neuropathy. Neuropsychological tests revealed an impairment of memory function, including reversed digital span, memory registration, memory recall, memory recognition, similarity, proverb reasoning, and verbal fluency. High concentrations of thallium were found in the urine, blood, and drinking water of these two patients. Brain MRI showed lesions in the corpus striatum in one patient. During the follow-up periods, the clinical manifestations and neuropsychological studies showed a slowly progressive improvement, and a follow-up brain MRI 1.5 months later demonstrated a resolution of the lesions. We conclude that thallium intoxication might induce encephalopathy, and brain MRI studies demonstrated the acute-stage brain lesions in a severe intoxicated patient. In addition, neuropsychological tests also confirmed memory deficits, although the brain lesions in the corpus striatum might resolve.

Contribution of a snake venom toxin to myasthenia gravis: the discovery of alpha-bungarotoxin in Taiwan.

Myasthenia gravis (MG) is now recognized as an autoimmune disorder in which antibodies to acetylcholine (ACh) receptor lead to impairment of neuromuscular transmission. The discovery of alpha-bungarotoxin by Chang and Lee in 1963 has played a crucial role in establishing the new concept of MG. However, isolation of bungarotoxins from the venom of Taiwan banded krait, Bungarus multicinctus, was accomplished in the poorly funded and under equipped laboratory of the Department of Pharmacology, National Taiwan University, during the post-WWII period of economic depression and research isolation. Because alpha-bungarotoxin binds specifically and irreversibly with the muscle type nicotinic ACh receptor, it was used to localize ACh receptor and to isolate the ACh receptor protein, opening up a new era of receptor studies. It was also used to produce an antibody to ACh receptor and eventually an experimental autoimmune model of MG and clinical confirmation. The discovery of alpha-bungarotoxin has been considered the most important contribution to neurosciences from Taiwan.

[Neurological diseases in late 19th century Taiwan--medical reports of the Chinese Imperial Maritime Customs].

Western medicine was introduced to Taiwan in 1865 when Dr. James L. Maxwell, a missionary doctor of the English Presbyterian Church, established a hospital in nowadays Tainan. The period of the missionary medicine lasted for over 30 years until Japanese took over. During this period, however, official records of diseases in Taiwan that were based on Western medicine were scanty or not available. Fortunately, port surgeons stationing respectively in Tamsui and Kelung in the north and in Takow and Taiwan-fu in the south reported semi-annually diseases seen in the ports, foreign communities and missionary hospitals that they volunteered to work. The diseases reported by port surgeons were either cases or summary of cases with classification and statistics. Their medical reports covered from 1871 to 1900. The data show that neurological diseases and/or disorders in the late 19th century Taiwan were uncommon, comprising only 2-3% of total diseases. The data further show that common neurological diseases were leprosy, opium smoking, syphilitic dementia (GPI), paralysis, hysteria, neuralgia, epilepsy, mania, sciatica, meningitis and ataxia. Stroke was uncommon while Parkinson's disease and Alzheimer's disease were not mentioned, indicating that neurological diseases related to old age and neurodegeneration were not yet a threat to health. Similarly, headache, insomnia, anxiety and depression, hallmark of functional disorders of the modern society, were also not mentioned, suggesting that these disorders were indeed rare or did not cause sufficient concern for patients to seek help from doctors of Western medicine.

Dopamine transporter binding study in differentiating carbon disulfide induced parkinsonism from idiopathic parkinsonism.

Long-term exposure to carbon disulfide (CS(2)) may induce parkinsonian features. There may be confusion in distinguishing between CS(2) parkinsonism and idiopathic parkinsonism, especially for workers who developed parkinsonian features in viscose rayon plants. We performed clinical examinations, and laboratory studies including magnetic resonance imaging (MRI) and dopamine transporter (DAT) studies with (99m)Tc-TRODAT-1 brain single photon emission computed tomography (SPECT) in three workers who had long-term exposure to CS(2). Patient 1 had polyneuropathy, and encephalopathy with tremor; patient 2 had polyneuropathy, and encephalopathy with parkinsonian features; and patient 3 had pure parkinsonian features without polyneuropathy or cerebellar signs. The treatment with l-dopa was effective in patient 3, but non-effective in patient 2. Brain MRI revealed multiple high signal intensities over the subcortical white matter, basal ganglia, and/or even the brainstem in patients 1 and 2, but normal in patient 3. In DAT studies, the bindings were normal in patients 1 and 2 and was decreased in patient 3. We conclude that CS(2) exposure may induce polyneuropathy, and cerebellar dysfunction in addition to parkinsonian features and that brain MRI may show multiple lesions in the cerebral white matter and basal ganglia. In addition, DAT with (99m)Tc-TRODAT-1 brain SPECT may provide a useful information in differential diagnosis between CS(2) parkinsonism and idiopathic parkinsonism.