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The ankle jerks of 200 consecutive patients admitted to a geriatric department were assessed on the second or third hospital days by two independent observers. The test consisted of a "plantar" rather than Achilles tendon strike with a standard patellar hammer. 188 patients had ankle jerks. This finding is at variance with most previous reports on the subject. This difference may be due to, amongst other factors, the timing and method of testing.

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A 62 year old Irish woman with an eight year history of probable coeliac disease developed brain stem signs, unilateral facial numbness and weakness, wasting and anaesthesia in both lower limbs. Over the next two years, a progressive deterioration in neurological function and in intestinal absorption, and the development of anaemia led to a suspicion of malignancy. Bone marrow biopsy revealed malignant histiocytosis. Treatment with cytotoxic drugs led to a transient, marked improvement in intestinal structure and function, and in power of the lower limbs. Relapse was associated with bone marrow failure, resulting in overwhelming infection. Post mortem examination confirmed the presence of an unusual demyelinating encephalomyelopathy affecting the brain stem and the posterior columns of the spinal cord.

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Cranial nuclear magnetic resonance (NMR) scans were performed on 13 healthy volunteers and 140 patients with a broad spectrum of neurologic disease and compared with x-ray computed tomography (CT) scans. The NMR scans included a variety of sequences reflecting proton density, blood flow, T1, and T2 as well as transverse, sagittal, and coronal images. White matter, gray matter, and cerebrospinal fluid were clearly distinguished in the normal brain with inversion-recovery (IR) sequences, and normal progressive myelination was demonstrated in infants and children. Acute hemorrhages displayed short T1 values, but other pathologic processes such as infarction, infection, demyelination, edema, and malignancy were associated with long T1 values. Cysts had very long T1 values (about that of cerebrospinal fluid). Spin-echo (SE) sequences showed increased values of T2 in a variety of conditions and highlighted lesions against the relatively featureless background of the remaining brain. With inversion-recovery scans, different stages of infarction were recognized in the hemispheres. NMR was more useful than CT in demonstrating brainstem infarction. The white matter lesions in demyelinating diseases were well demonstrated with NMR scans. Many more lesions were observed in multiple sclerosis with NMR than with CT. Benign tumors were well seen and usually had shorter T1 values than malignant tumors. Mass effects from tumors were generally better demonstrated with NMR than with CT, including more subtle mass effects such as displacement of the external capsule. Abnormalities were seen in diseases of the basal ganglia, including marked atrophy of the head of the caudate nucleus in Huntington chorea. Advantages of NMR imaging include the high level of gray-white matter contrast, lack of bone artifact, variety of possible sequences, transverse, sagittal, and coronal imaging, sensitivity to pathologic change, and lack of known hazard. Disadvantages include lack of bone detail, limited spatial resolution, lack of contrast agents, and cost. Promising directions for future clinical research include developmental neurology, tissue characterization with T1 and T2, assessment of blood flow, and the development of contrast agents. Much more detailed evaluation will be required, but NMR seems to be a potentially important addition to existing techniques of neurologic diagnosis.

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Ten patients with multiple sclerosis (MS) were scanned by means of cranial X-ray computed tomography (CT) with and without intravenous contrast enhancement, and by nuclear magnetic resonance (NMR) using an inversion-recovery sequence. Altogether 19 lesions varying in size between about 7 mm X 5 mm and 13 mm X 8 mm were demonstrated by CT. They were all situated in the periventricular region. Two patients also showed moderate ventricular enlargement. In addition to these abnormalities 112 further lesions were demonstrated on the NMR scans. These lesions varied in size from 4 mm X 3 mm to 12 mm X 7 mm and were particularly well seen in the periventricular region and brainstem. Care is required in the assessment of NMR scans to exclude artefacts, background noise, and mottle as well as normally situated grey matter and partial volume effects from cerebral sulci. NMR nevertheless demonstrates abnormalities in MS on a scale not previously seen except at necropsy.

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An analysis is presented of 220 cases of possible neurotoxic reactions to halogenated hydroxyquinolines reported from outside Japan. In 80 cases insufficient information was available for adequate comment and in 29 a relationship to the administration of clioquinol could be excluded. Of the remainder, a relationship to clioquinol was considered probable in 42 and possible in 69 cases. In six of the probable cases the neurological disturbance consisted of an acute reversible encephalopathy usually related to the ingestion of a high dose of clioquinol over a short period. The most common manifestation, observed in 15 further cases, was isolated optic atrophy. This was most frequently found in children, many of whom had received clioquinol as treatment for acrodermatitis enteropathica. In the remaining cases, a combination of myelopathy, visual disturbance, and peripheral neuropathy was the most common manifestation. Isolated myelopathy or peripheral neuropathy, or these manifestations occurring together, were infrequent. The onset of all manifestations (except toxic encephalopathy) was usually subacute, with subsequent partial recovery. Older subjects tended to display more side effects. The full syndrome of subacute myelo-optic neuropathy was more frequent in women, but they tended to have taken greater quantities of the drug.

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Two patients are described who developed sensory neuropathy after the ingestion of 30.6 and 114 g metronidazole respectively. The drug, widely used in gastroenterological and gynaecological practice, has not hitherto been considered neurotoxic. The implications are stressed in relation to the differential diagnosis of patients with gastroenterological disorders who develop peripheral neuropathy.

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We have investigated the action of pimozide in tardive dyskinesia induced by prolonged administration of phenothiazines. Improvement was recorded in a double blind study of 18 patients treated with maximum tolerated dosage (mean 18.8 mg/day) for 6 weeks. There was no deterioration in the therapeutic action of pimozide over this time. Parkinsonism and sedation were the main adverse effects. They were corrected by reduction of the dose of pimozide, but often recurred so that further adjustments of dosage were necessary. Our findings support the view that tardive dyskinesia is produced by a disturbance in the balance of central transmitters such that dopaminergic transmission is increased.

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The clinical actions of levodopa in Parkinsonism, given with and without an extracerebral decarboxylase in hibitor, L-alpha-methyldopahydrazine, were compared. Twenty-one patients were investigated in a "double-blind cross-over" study, administering levodopa in maximum tolerated dosage. L-Alpha-methyldopahydrazine failed to augment the overall therapeutic actions of levodopa but it consistently alleviated nausea. It is concluded that L-alpha-methyldopahydrazine will prove useful in the management of some Parkinsonian patients who have difficulty in taking levodopa alone.

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