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CŒLIAC INFERTILITY—FOLIC-ACID THERAPY
412 treatment with I.D.U. was planned. Although the result of the immunofluorescent microscopy was known within 6 hours of brain biopsy, it was not possible to start treatment until 24 hours after this. The delay was due to the time-consuming and painstaking method needed to prepare i.D.u. for intravenous use. A total dose of 11-5 g. of I.D.U. (approximately 550 mg. per kg. body-weight) was given over 8 days. His condition improved and he regained consciousness, but he is now hemiplegic, hemianopic, aphasic, mentally retarded, and incontinent of urine. Serial liver-function tests were carried out before and during treatment (s re accompanying table). The peak level
daily, and
LIVER-FUNCTION TESTS DURING I.D.U. TREATMENT
the 13th day after commenceThis corresponded with peak serumalkaline-phosphatase but not with the highest level of glutamic-oxaloacetic transaminase (S.G.O.T.). In fact, the S.G.o.T. level fell progressively during treatment. This may well have been due to diminishing circulating levels of He was never clinically cerebral S.G.O.T. iso-enzyme. jaundiced, nor was his liver enlarged. In addition to liver damage, there was partial alopecia and anaemia, with a haemoglobin of 62 g. per 100 ml. 20 days after starting treatment. This may have been due to gastrointestinal blood loss, although occult blood was found in the stools only on 2 days, 1 week after treatment was started. The blood film did not show the microscopic appearance of blood-loss or iron deficiency. Unfortunately, a serum-iron estimation was not done. We should like to make the following points concerning treatment of herpes simplex encephalitis. (1) Although a few untreated patients have made a complete or nearly complete recovery,3the sudden clinical improvement makes it likely that in this case the treatment altered the encephalitic process, as others have found. The toxic effects were transient and not severe. Early treatment with I.D.U. is therefore urged in patients with herpessimplex encephalitis; this especially in view of the depressing mortality and morbidity of the condition.4,5 (2) If treatment with I.D.U. is anticipated, pharmacists should be alerted as soon as possible, so that the necessary apparatus can be assembled and work-rotas rearranged, since 24 hours may elapse from the time the drug is acquired to the time the first solution is ready. (3) Hepatotoxicity is a complication of treatment with I.D.u., and should be anticipated.
of serum-bilirubin ment of treatment.
was on
We thank Dr. John Apley for permission to publish details of this boy’s illness, Mr. Huw Griffiths (Frenchay Hospital, Bristol) for performing the brain biopsy, Dr. Betty Brownell for the histological examination, and Dr. A. H. Tomlinson and Dr. F. O. MacCallum (The Radcliffe Infirmary, Oxford) for the immunofluorescent microscopy, and for their help with this case.
Royal Hospital for Sick Children, Bristol BS2 8BJ.
Tyler, R. H. Ann. intern. Med. 1966, 65, 1050. Haymaker, W., Lewis, K. R., Schwarz, E. Eight Colloquia on Clinical Pathology. Brussels, 1958. Hughes, J. T. Viruses Diseases and the Nervous System (edited by C. W. M. Whitty, J. T. Hughes, and F. O. MacCallum); p. 29. Oxford, 1969.
3. Breedon, C. J., Hall, T. C., 4. 5.
B. R. SILK A. P. C. H. ROOME.
CŒLIAC INFERTILITY—FOLIC-ACID THERAPY Sm,—The report by Dr. Morris and his colleagues (Jan. 31, p. 213), on the relief of infertility in coeliac disease by gluten-free diet, is of considerable interest. In view of the comment that the findings do not indicate whether or not folic-acid deficiency is connected with infertility, the
following case-history may be of importance. In April, 1968, a woman of 30 years was referred for a medical opinion on her backache. The relevant findings were: considerable osteomalacia with pseudofractures; dilated loops of small-bowel, with abnormal mucosal pattern on barium meal; a flat glucose-tolerance curve; a serum-folic-acid of 1 1 ng. per ml. ; a normal serum-vitaminB12 ; reduced D-xylose excretion; jejunal biopsy specimen showing flat mucosa; and a haemoglobin of 91°o. Notes from other hospitals recorded signs of coeliac disease at ages 2 and 13. She had had a forceps delivery of a live baby in 1963, at which time her haemoglobin had been 34%. She had been transfused and given a temporary course of folic acid. There had then been 5 years of involuntary sterility, though her periods were normal. In May, 1968, she was started on folic acid; in July of the same year she missed a period, and in March, 1969, she was delivered of a normal infant (by forceps, because of contracted pelvis). A further pregnancy ensued almost immediately, and in January, 1970, she was again delivered of a healthy infant. Therapy has been confined to folic acid and calcium with vitamin D. Diet has not been restricted. Folic acid was doubled during her pregnancies. Active bone disease has been como!ete!v controlled. St. Helier Hospital, Carshalton, CEDRIC HIRSON. Surrey.
SUBLUXATION OF THE SACROILIAC JOINT SIR,-Mr. Miller (Jan. 24, p. 193) appears to have misinterpreted my letter (Jan. 10, p. 93). I was discussing the possibility of a genetic weakness in the sacroiliac joint, and not, as he infers, a disease process ". This weakness may predispose to postural defects, and to chronic rheumatism in other regions in later life. In my preamble I suggested that, to relieve pain in other regions, treatment should be directed mainly towards relief of spasm in the buttock muscles of the longer leg and " trigger spots " in the tensor fasciae latx as far down as the ilio-tibial band. Thus, Mr. Miller’s comments on the treatment of sacroiliitis are not relevant to my letter. In fact, I mentioned that patients were unaware of pain in this area and were surprised to find that this region was very painful on deep pressure. I did not say that the physical signs of a subluxation were my discovery. I stressed them simply to remind doctors about them. I must admit I am "
with the osteopathic literature; I am more concerned with the trigger-spot theory, which I pioneered 30 years ago. I do not decry osteopathy, and have found it most useful in certain phases of rheumatic processes. Mr. Miller and I apparently agree on one point, that in a subluxed sacroiliac joint-the weakest joint in the bodythere is lateral tilting of the pelvis. We disagree on treatI do not approve of manipulation of a weakened ment. sacroiliac joint in the presence of intense muscle spasm. I have seen too many cases of acute disc lesions follow as a result. In mild cases it frees the joint by breaking down adhesions that soon re-form, necessitating frequent treatments over the years. It has no permanent effect on muscle spasm. Manipulation of the joint is only indicated, in my opinion, after the muscle spasm has been dispersed and the blood-supply to the affected tissues restored by means of
not conversant
daily, and
LIVER-FUNCTION TESTS DURING I.D.U. TREATMENT
the 13th day after commenceThis corresponded with peak serumalkaline-phosphatase but not with the highest level of glutamic-oxaloacetic transaminase (S.G.O.T.). In fact, the S.G.o.T. level fell progressively during treatment. This may well have been due to diminishing circulating levels of He was never clinically cerebral S.G.O.T. iso-enzyme. jaundiced, nor was his liver enlarged. In addition to liver damage, there was partial alopecia and anaemia, with a haemoglobin of 62 g. per 100 ml. 20 days after starting treatment. This may have been due to gastrointestinal blood loss, although occult blood was found in the stools only on 2 days, 1 week after treatment was started. The blood film did not show the microscopic appearance of blood-loss or iron deficiency. Unfortunately, a serum-iron estimation was not done. We should like to make the following points concerning treatment of herpes simplex encephalitis. (1) Although a few untreated patients have made a complete or nearly complete recovery,3the sudden clinical improvement makes it likely that in this case the treatment altered the encephalitic process, as others have found. The toxic effects were transient and not severe. Early treatment with I.D.U. is therefore urged in patients with herpessimplex encephalitis; this especially in view of the depressing mortality and morbidity of the condition.4,5 (2) If treatment with I.D.U. is anticipated, pharmacists should be alerted as soon as possible, so that the necessary apparatus can be assembled and work-rotas rearranged, since 24 hours may elapse from the time the drug is acquired to the time the first solution is ready. (3) Hepatotoxicity is a complication of treatment with I.D.u., and should be anticipated.
of serum-bilirubin ment of treatment.
was on
We thank Dr. John Apley for permission to publish details of this boy’s illness, Mr. Huw Griffiths (Frenchay Hospital, Bristol) for performing the brain biopsy, Dr. Betty Brownell for the histological examination, and Dr. A. H. Tomlinson and Dr. F. O. MacCallum (The Radcliffe Infirmary, Oxford) for the immunofluorescent microscopy, and for their help with this case.
Royal Hospital for Sick Children, Bristol BS2 8BJ.
Tyler, R. H. Ann. intern. Med. 1966, 65, 1050. Haymaker, W., Lewis, K. R., Schwarz, E. Eight Colloquia on Clinical Pathology. Brussels, 1958. Hughes, J. T. Viruses Diseases and the Nervous System (edited by C. W. M. Whitty, J. T. Hughes, and F. O. MacCallum); p. 29. Oxford, 1969.
3. Breedon, C. J., Hall, T. C., 4. 5.
B. R. SILK A. P. C. H. ROOME.
CŒLIAC INFERTILITY—FOLIC-ACID THERAPY Sm,—The report by Dr. Morris and his colleagues (Jan. 31, p. 213), on the relief of infertility in coeliac disease by gluten-free diet, is of considerable interest. In view of the comment that the findings do not indicate whether or not folic-acid deficiency is connected with infertility, the
following case-history may be of importance. In April, 1968, a woman of 30 years was referred for a medical opinion on her backache. The relevant findings were: considerable osteomalacia with pseudofractures; dilated loops of small-bowel, with abnormal mucosal pattern on barium meal; a flat glucose-tolerance curve; a serum-folic-acid of 1 1 ng. per ml. ; a normal serum-vitaminB12 ; reduced D-xylose excretion; jejunal biopsy specimen showing flat mucosa; and a haemoglobin of 91°o. Notes from other hospitals recorded signs of coeliac disease at ages 2 and 13. She had had a forceps delivery of a live baby in 1963, at which time her haemoglobin had been 34%. She had been transfused and given a temporary course of folic acid. There had then been 5 years of involuntary sterility, though her periods were normal. In May, 1968, she was started on folic acid; in July of the same year she missed a period, and in March, 1969, she was delivered of a normal infant (by forceps, because of contracted pelvis). A further pregnancy ensued almost immediately, and in January, 1970, she was again delivered of a healthy infant. Therapy has been confined to folic acid and calcium with vitamin D. Diet has not been restricted. Folic acid was doubled during her pregnancies. Active bone disease has been como!ete!v controlled. St. Helier Hospital, Carshalton, CEDRIC HIRSON. Surrey.
SUBLUXATION OF THE SACROILIAC JOINT SIR,-Mr. Miller (Jan. 24, p. 193) appears to have misinterpreted my letter (Jan. 10, p. 93). I was discussing the possibility of a genetic weakness in the sacroiliac joint, and not, as he infers, a disease process ". This weakness may predispose to postural defects, and to chronic rheumatism in other regions in later life. In my preamble I suggested that, to relieve pain in other regions, treatment should be directed mainly towards relief of spasm in the buttock muscles of the longer leg and " trigger spots " in the tensor fasciae latx as far down as the ilio-tibial band. Thus, Mr. Miller’s comments on the treatment of sacroiliitis are not relevant to my letter. In fact, I mentioned that patients were unaware of pain in this area and were surprised to find that this region was very painful on deep pressure. I did not say that the physical signs of a subluxation were my discovery. I stressed them simply to remind doctors about them. I must admit I am "
with the osteopathic literature; I am more concerned with the trigger-spot theory, which I pioneered 30 years ago. I do not decry osteopathy, and have found it most useful in certain phases of rheumatic processes. Mr. Miller and I apparently agree on one point, that in a subluxed sacroiliac joint-the weakest joint in the bodythere is lateral tilting of the pelvis. We disagree on treatI do not approve of manipulation of a weakened ment. sacroiliac joint in the presence of intense muscle spasm. I have seen too many cases of acute disc lesions follow as a result. In mild cases it frees the joint by breaking down adhesions that soon re-form, necessitating frequent treatments over the years. It has no permanent effect on muscle spasm. Manipulation of the joint is only indicated, in my opinion, after the muscle spasm has been dispersed and the blood-supply to the affected tissues restored by means of
not conversant