As the author of the first ever report documenting central nervous system involvement in Miller Fisher syndrome,1 I beg permission to discuss certain aspects of the work of Yukiet al on Guillain-Barré syndrome and Bickerstaff's brainstem encephalitis, an example of which was published in this Journal.2Twenty three years ago, I perused the literature in search of a diagnosis for a child I had seen in Iran. Eyeing incessantly a few certain guide posts in the neurological heavens (Babinski's response, internuclear ophthalmplegia, spasticity) I sailed the lore diligently, arriving at two inescapable conclusions: (a) that my patient with a midbrain lesion demonstrated by CT was an instance of Miller Fisher syndrome, hitherto a variant of Guillain-Barré syndrome; (b) that Bickerstaff's brainstem encephalitis and Miller Fisher syndrome are one and the same entity. With that perusal behind me, I thought it entirely sufficient to include Bickerstaff's work in my references and ended the article by the following statement: It is evident that our finding, if confirmed, raises questions regarding pathophysiology of Landry-Guillain-Barré syndrome, of which Fisher syndrome is a limited form. That pivotal observation has since been amply substantiated (see below for an incomplete list of references).

In 1982 the article became the subject of an editorial in theArchives of Neurology in opposition to my position. It was acknowledged parenthetically by Bickerstaff himself who eventually embraced my second conclusion even though he sided with the splitters, considering the entity of a separate disease. The arrival of MRI turned the tide entirely in favour of the lumpers soon after 3, confirming my impression of a need for a reappraisal indicated above. Electrophysiological studies pointed to the same conclusion—that is, Miller Fisher syndrom often, if not always, is …

Dr N Yuki yuki{at}dokkyomed.ac.jp