Cranial-nerve Palsies with Herpes following General Anaesthesia

J. H. Humphrey, M. McClelland
1944 BMJ (Clinical Research Edition)  
During a period of four months 13 cases of cranial-nerve palsies following general anaesthesia have occurred at this hospital. The cases occurred in three small groups, with free intervals of four and nine weeks between. Two of the affected persons died, while the remainder are at various stages of recovery. The degree of severity varied from subjective trigeminal anaesthesia only to a complete picture of encephalitis, but the main features were remarkably constant and readily recognized.
more » ... y recognized. Twenty-four to forty-eight hours after use of a genera.l anaesthetic the patient complained of a sense of coldness, numbness, or tightness round the lips, which in most cases during the course of the next two or three days had spread to involve the whole distribution of the fifth nerve on both sides. This subjective anaesthesia was usually associated with analgesia and anaesthesia over the same area, and in nearly every case there was difficulty in swallowing solid food owing to its "getting lost in the mouth." Three of the cases also showed motor fifth-nerve weakness. About the third post-operative day, in the majority, there appeared circumoral herpes of the febrile type. At this time, in those persons showing further involvement, affection of other cranial nerves became apparent-e.g., diplopia, facial weakness, palatal weakness, and tremor or deviation of the tongue. In those cases which showed improvement this began on the fifth to the tenth day, and the milder cases recovered rapidly (almost completely in a fortnight), whereas the severer cases still had residual subjective changes after five months. The herpes had disappeared by the end of ten days. On no occasion did we observe affection of the first, second (including rough testing of the visual fields), ninth, or eleventh nerve, but all the other cranial nerves were involved in one or more cases. Taste over the posterior one-third of the tongue was not tested, and the ninth nerve may have been involved. Only one patient had an extensor plantar response, and that was unilateral. None ran unduly high temperatures during the post-operative period. Six vomited more severely than we normally expect after operation, and five were noticeably depressed, listless, or confused for two or three days. Three only complained of severe headache. A typical history is that of Case 4. A Typical Case (No. 4) A woman aged 25 was subjected to appendicectomy for acute appendicitis on July 30, 1943. Premedication was by morphine gr.'1/6 and hyoscine gr. 1/150. The anaesthetic employed was a combination of intravenous pentothal with cyclopropane and a little ether, given by closed circle with CO. absorption. The operation was a short' one and the anaesthesia was without incident. On Aug. 1 she complained that she had had a feeling of coldness of the face with double vision for 24 hours. At the same time there was some difficulty in opening and closing the mouth. On examination the left pupil was larger than the right. The reactions to light and accommodation were normal. There was double vision in all directions. The position of the false image indicated that the * Other members of the staff contributing to the work were diplopia was of third-nerve origin. There was no nystagmus and the fundi were normal. Hypo-algesia and hypo-aesthesia affected all the trigeminal field of each side. The corneal reflexes were diminished and the jaw-jerk was depressed. No muscular weakness affecting the fifth nerve could be detected. Subjectively the lips felt cold and the face numb and swollen. Food placed in the patient's mouth felt cold. There was bilateral facial weakness affecting the upper and lower face. No other abnormality could be detected in the cranial nerves. There was no neck rigidity or retraction. The symptoms and signs remained unchanged until Aug. 2, when herpetic vesicles were found on the buccal mucous membrane on the left side of the mouth. These continued for three or four days. On Aug. 4 she complained of difficulty in swallowing. A lumbar puncture performed on the 6th yielded a clear fluid under normal pressure; no white cells were found. There was a gradual diminution in the cranial-nerve palsies; by Aug. 11 the difficulty in swallowing had disappeared, and by the 18th the diplopia had cleared. The scalp still felt abnormal. The skin over the forehead and the cheeks felt " swollen and stretched," and she complained of a peculiar tingling sensation around the nose. The tongue and the teeth still felt cold and numb. The pupils were equal in size and the external ocular movements were full. Hypo-algesia and hypoaesthesia were present over the whole distribution of the fifth nerve, but around the nose stimulation with a pin produced an exaggerated reaction. There was still left facial weakness.
doi:10.1136/bmj.1.4339.315 fatcat:4dbe3yafbjcgjjcvwz3vf3xpd4