Richard P. Newman

Results of treatment for squamous carcinoma of the lower gum.

The records of 61 patients with a diagnosis of squamous carcinoma of the lower alveolar ridge were reviewed. The overall two‐year survival was 67% with a local or regional failure of 5%. The majority of patients were treated with surgery initially with an excellent local control of 98%, if the patient who died in the postoperative period and the patient lost to follow‐up are excluded. Radiation therapy should be used postoperatively for those patients whose cancer exhibits some of the adverse findings such as extensive nodal metastasis, perineural invasion, or inadequate margins of surgical resection.

Effortful and automatic memory Effects of dopamine

Article abstract-With advancing age, there are changes in both cognitive functions and neurotransmitter metabolism. Dopamine plays a role in learning, memory, and related cognitive processes. We evaluated the effects of supplemental dopamine in precursor form (levodopa) on various aspects of memory in elderly normal volunteers in a controlled, double-blind study. Access to semantic memory and automatic processes were unaffected, but levodopa reliably facilitated effortful memory processing. Levodopa may be useful clinically in attenuating impairments in effortful cognitive tasks. Different neural systems probably mediate different forms of cognition.

Disappearing palatal Myoclonus

Two patients had palatal myoclonus that disappeared. In one, the palatal myoclonus disappeared completely during all stages of natural sleep only to return again when he awoke, persisting as long as he remained awake. In the other patient, palatal myoclonus was continuous for 2 years, became erratic for 6 months, and then disappeared completely, although she could induce it voluntarily. These cases demonstrate that palatal myoclonus is not always: independent of the sleep-waking cycle, persistent throughout life, and independent of cortical control.

Dystonia in untreated Parkinsonism

While parkinsonism and dystonia generally are distinct clinical syndromes, both may be prominent features even prior to the use of antiparkinsonian medications. In 10 patients with typical parkinsonism, coincident dystonic features included neck, upper extremity, oromandibular, unilateral upper-lower extremity, and unilateral foot dystonia. Six patients were first affected before the age of 45. For some, dystonia preceded parkinsonism (for 1/2 to 20 years). Limb symptoms tended to be unilateral; in seven patients, parkinsonism also was limited to that side. While levodopa was adequate for improvement of parkinsonism, dystonic symptoms benefited from the combination of levodopa with a dopaminergic ergot. The dystonic features (which also can result from parkinsonian therapy) often add pain and disability to the deficits in parkinsonism. The coexistence of dystonia may constitute a distinctive syndrome of parkinsonism and points to possible etiologic mechanisms shared by these two extrapyramidal disorders.

Selective paralysis of downward gaze caused by bilateral lesions of the mesencephalic periaqueductal gray matter

A patient who had selective paralysis of downward gaze caused by bilateral lesions of the dorsolateral mesencephalic periaqueductal gray (PAG) matter is reported. Her necropsy findings differed from all previous reports of the syndrome, in that regions of the mesencephalon that have been considered as critical for executing downward gaze (dorsomedial to red nuclei, rostral interstitial nuclei of the medial longitudinal fasciculus [ri MLF]) were normal. These lesions may have produced the syndrome by involving the caudal portions of the nuclei of the posterior commissure (subcommissural), from which one of the commissural systems used by the ri MLF originates. It is also possible that the syndrome was produced by selective destruction of PAG neurons that generate downward impulses or by interruption of posterior commissure fibers containing downward impulses that travel through the dorsolateral PAG before terminating in the more ventral mesencephalon.

Dystonia: Treatment with bromocriptine

As with parkinsonism, certain dystonias may involve disturbances in dopaminergic neurotransmission. The effects of bromocriptine, 18-150 mg/day (mean, 72.5), were studied in 15 patients with a variety of dystonic disorders, using a double-blind, crossover format. Of the 13 patients completing several weeks of medication, seven improved more than 10% and two worsened, on clinical ratings, while five recognized improvement in disability. Dopaminomimetic agents such as bromocriptine, used in the dose range effective for treating parkinsonism, may yield symptomatic improvement with several patterns of dystonia.

Myelopathy due to spinal metastasis from adenocarcinoma of the gallbladder

The first case of a gallbladder carcinoma with metastasis to dura and epidural space causing myelopathy is described. The mode of metastasis remains obscure because there was no involvement of liver or retroperitoneal veins. It is possible that the spread was by the vertebral venous plexus, which could account for a spinal metastasis in the absence of liver involvement.

Hyperbaric Chamber Treatment-Reply

In Reply.— We thank Dr Winter and acknowledge his criticism as being appropriate and correct.