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RECTAL BLEEDING AND INDOMETHACIN SUPPOSITORIES
577
recorded in this period. Since malignant melanoma commonly involves the C.N.S., the paralysis noted by Dr Wils and Dr van Gool would be best explained by the presence of spinal meningeal or spinal-cord melanoma (or it could be a tumour-related C.N.s. degeneration, a process occasionally seen in advanced and uncontrolled cancer). Certainly, until they have established the absence of metastatic spinal melanoma or cancer-related C.N.S. degeneration, their suggestion of a causal relationship between B.C.G. immunotherapy and neurological diseasein a case of uncontrolled malignant melanoma remains very doubtful.
in all)
were
so
University of Texas System Cancer Center, Texas Medical Center, Houston, Texas 77025, U.S.A.
DAVID J. HARTER.
SYNCOPE AFTER A COLD DRINK
SIR,—The dangers of a cold fizzy drink (Feb. 22, p. 463) one is very hot are, I think, well recognised by doctors, but they themselves do not always heed them.
when
In 1950 I
in Western Eritrea and with the temperature over 100°F in the shade, I took a deep draught of ice-cold beer and was instantly seized with a vice-like epigastric pain of great severity; I felt that I was going to faint and got up from my chair to go and lie down, but within a couple of seconds lost consciousness and fell on the floor. Those about me thought I was dead, since I appeared deathly pale and pulseless, but in a minute or two I came to and even went out to supper that evening. Doubtless in the heat my body temperature may have risen making the stomach more susceptible to an ice-cold drink which caused violent spasm and reflex circulatory failure. Needless to say, I have been somewhat cautious ever since about drinking cold beer in very hot weather. Military Hospital,
returning
to
was
at
thirsty
H. FOSTER.
SIR,—Reading through John Hunter’s Cases in Surgery (vol. I, p. 171), I came across the following which I thought relevant. It is called Fainting, Feb. 1, 1872. "
Slaughers Coffee House. Dr Maskelyne immediately after eating some tripe for supper and drinking a draught of cold water, he immediately felt an odd sensation in his Stomach; then the sensation of fainting took place. He got up from his chair to go, but was immediately obliged to sit down but he could not sit and fainted away. I immediately laid him along the floor. His breath was extremely slow; his pulse low, and not I a cold sweat came on all over him. cold water on his face: he began to recover and immediately vomited. He became low again fainted away then puked and recovered: and in a few minutes he did the same thing the third time: and then became perfectly well and continued so."
sprinkled
24
a
minute;
some
Haifa, Israel.
NISSIM LEVY EMERICH GASPAR.
Wimpole Street, London, Wl.
DAVID MORRIS.
suppositories.1 A boy of 15 years was admitted to our rehabilitation department because of rheumatoid arthritis of three years’ duration. He had been treated with steroids and salicylates, which had been tailed off because of gastrointestinal bleeding. A duodenal ulcer
Walls, J., Schorr, W. Br. med. J. 1968, ii,
ZINC, ACRODERMATITIS ENTEROPATHICA, AND CONGENITAL MALFORMATIONS SIR,-Following the observations of Moynahan,’- it has become clear that aberrant zinc metabolism is fundamental in the pathogenesis ofacrodermatitis enteropathica (A.E.).2-4 Profound hypozincæmia, characteristic of the untreated disease, is probably only one aspect of a more generalised inherited zinc-deficiency state. Moreover, many of the features of A.E. are similar to those of nutritional zinc deficiency in animals.1 In adult female birds5 and rats,*zinc deficiency has severe teratogenic effects. Surviving offspring have a high incidence and wide variety of major and minor congenital malformations. Prominent are abnormalities of the skeletal systemand of the central nervous system. 6,The former include incomplete or absent ossification centres with multiple bone deformities, and the latter hydrocephaly, hydranencephaly, and exencephaly, the forerunner of
anencephaly.e In the light of these animal data, it is pertinent to review the outcome of pregnancies in patients with A.E., which probably represents the most severe zinc deficiency state yet recognised in man. A.E. was often fatal in early childhood until the advent of diiodohydroxyquin therapy in 1953. Consequently, there have been few reported instances of survivors bearing children. Thus far, 3 reports of childbirth in patients with active A.E. have been found,9-11 and these concern the outcome of pregnancies in only 2 women.
The first 9 related to a 22-year-old woman who had a sponremission of A.E. at menarche, but relapsed at the time of her first pregnancy, which was complicated by polyhydramnios. The product of this gestation was a typical achondroplastic dwarf, weighing 5 lb. 4 oz. (2381 g.), who died half an hour after delivery. Subsequently, she delivered 3 children who were reported to be living and well.1O It is interesting to note that diiodohydroxyquin
taneous
RECTAL BLEEDING AND INDOMETHACIN SUPPOSITORIES SIR,-Since the introduction of indomethacin in the treatment of joint diseases, many side-effects have been described. However, we are aware of only one report on a local reaction in the rectum due to indomethacin
1.
Rothschild Hospital,
Agordat
camp very hot and
Circular South Road, Colchester C02 7UD.
above 40 in
had been found by barium-meal examination, and it was felt that indomethacin suppositories would be safer. They were started in February, 1968; on a dosage of three 50 mg. suppositories daily he improved, and severe back and joint pains diminished greatly. In August, 1968, while he was on continuous indomethacin treatment, rectal bleeding developed. Rectosigmoidoscopy disclosed severe, inflammation of the mucosa with profuse bleeding in the distal 12 cm. Higher up, the mucosa appeared normal. Barium enema was entirely normal. The indomethacin suppositories were stopped, and sigmoidoscopy repeated three weeks later. On this occasion there was no bleeding. The mucosa appeared granular up to 12 cm. At a depth of 8 cm. a small polyp was seen and excised; histological examination showed moderate chronic non-specific and intense acute inflammatory infiltration with partial necrosis of the mucosa. Because of the lack of response to any other analgesic or anti-inflammatory agents, indomethacin treatment was resumed, and repeated rectoscopic examinations showed that the intensity of the mucosal inflammatory changes was directly related to dose; three suppositories daily for 1-2 weeks resulted in profuse rectal bleeding, while on one suppository daily the inflammatory reaction was much less and there was almost no bleeding.
52.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Moynahan, E. J. Lancet, 1974, i, 399. Neldner, K. H., Hambidge, K. M. Unpublished. Michaelsson, G. Acta derm-vener., Stockh. 1974 54, 377. Thyresson, N. ibid. p. 383. Kienholz, E. W., Turk, D. E., Sunde, M. L., Hoekstra, W. G. J. Nutr. 1961, 75, 211. Hurley, L. S. Am. J. clin. Nutr. 1969, 22, 1332. Calhoun, N. R., Smith, J. C., Jr., Becker, K. L. Clin. Orthop. 1974, 103, 212. Warkany, J., Petering, H. G. Teratology, 1972, 5, 319. Vedder, J. S. J. Pediat. 1956, 48, 212. Epstein, S., Vedder, J. S. Archs Derm. 1960, 82, 189. Verburg, D. J., Burd, L. I., Hoxtell, E. O., Merrill, L. K. Obstet. Gynec. 1974, 44, 233.
recorded in this period. Since malignant melanoma commonly involves the C.N.S., the paralysis noted by Dr Wils and Dr van Gool would be best explained by the presence of spinal meningeal or spinal-cord melanoma (or it could be a tumour-related C.N.s. degeneration, a process occasionally seen in advanced and uncontrolled cancer). Certainly, until they have established the absence of metastatic spinal melanoma or cancer-related C.N.S. degeneration, their suggestion of a causal relationship between B.C.G. immunotherapy and neurological diseasein a case of uncontrolled malignant melanoma remains very doubtful.
in all)
were
so
University of Texas System Cancer Center, Texas Medical Center, Houston, Texas 77025, U.S.A.
DAVID J. HARTER.
SYNCOPE AFTER A COLD DRINK
SIR,—The dangers of a cold fizzy drink (Feb. 22, p. 463) one is very hot are, I think, well recognised by doctors, but they themselves do not always heed them.
when
In 1950 I
in Western Eritrea and with the temperature over 100°F in the shade, I took a deep draught of ice-cold beer and was instantly seized with a vice-like epigastric pain of great severity; I felt that I was going to faint and got up from my chair to go and lie down, but within a couple of seconds lost consciousness and fell on the floor. Those about me thought I was dead, since I appeared deathly pale and pulseless, but in a minute or two I came to and even went out to supper that evening. Doubtless in the heat my body temperature may have risen making the stomach more susceptible to an ice-cold drink which caused violent spasm and reflex circulatory failure. Needless to say, I have been somewhat cautious ever since about drinking cold beer in very hot weather. Military Hospital,
returning
to
was
at
thirsty
H. FOSTER.
SIR,—Reading through John Hunter’s Cases in Surgery (vol. I, p. 171), I came across the following which I thought relevant. It is called Fainting, Feb. 1, 1872. "
Slaughers Coffee House. Dr Maskelyne immediately after eating some tripe for supper and drinking a draught of cold water, he immediately felt an odd sensation in his Stomach; then the sensation of fainting took place. He got up from his chair to go, but was immediately obliged to sit down but he could not sit and fainted away. I immediately laid him along the floor. His breath was extremely slow; his pulse low, and not I a cold sweat came on all over him. cold water on his face: he began to recover and immediately vomited. He became low again fainted away then puked and recovered: and in a few minutes he did the same thing the third time: and then became perfectly well and continued so."
sprinkled
24
a
minute;
some
Haifa, Israel.
NISSIM LEVY EMERICH GASPAR.
Wimpole Street, London, Wl.
DAVID MORRIS.
suppositories.1 A boy of 15 years was admitted to our rehabilitation department because of rheumatoid arthritis of three years’ duration. He had been treated with steroids and salicylates, which had been tailed off because of gastrointestinal bleeding. A duodenal ulcer
Walls, J., Schorr, W. Br. med. J. 1968, ii,
ZINC, ACRODERMATITIS ENTEROPATHICA, AND CONGENITAL MALFORMATIONS SIR,-Following the observations of Moynahan,’- it has become clear that aberrant zinc metabolism is fundamental in the pathogenesis ofacrodermatitis enteropathica (A.E.).2-4 Profound hypozincæmia, characteristic of the untreated disease, is probably only one aspect of a more generalised inherited zinc-deficiency state. Moreover, many of the features of A.E. are similar to those of nutritional zinc deficiency in animals.1 In adult female birds5 and rats,*zinc deficiency has severe teratogenic effects. Surviving offspring have a high incidence and wide variety of major and minor congenital malformations. Prominent are abnormalities of the skeletal systemand of the central nervous system. 6,The former include incomplete or absent ossification centres with multiple bone deformities, and the latter hydrocephaly, hydranencephaly, and exencephaly, the forerunner of
anencephaly.e In the light of these animal data, it is pertinent to review the outcome of pregnancies in patients with A.E., which probably represents the most severe zinc deficiency state yet recognised in man. A.E. was often fatal in early childhood until the advent of diiodohydroxyquin therapy in 1953. Consequently, there have been few reported instances of survivors bearing children. Thus far, 3 reports of childbirth in patients with active A.E. have been found,9-11 and these concern the outcome of pregnancies in only 2 women.
The first 9 related to a 22-year-old woman who had a sponremission of A.E. at menarche, but relapsed at the time of her first pregnancy, which was complicated by polyhydramnios. The product of this gestation was a typical achondroplastic dwarf, weighing 5 lb. 4 oz. (2381 g.), who died half an hour after delivery. Subsequently, she delivered 3 children who were reported to be living and well.1O It is interesting to note that diiodohydroxyquin
taneous
RECTAL BLEEDING AND INDOMETHACIN SUPPOSITORIES SIR,-Since the introduction of indomethacin in the treatment of joint diseases, many side-effects have been described. However, we are aware of only one report on a local reaction in the rectum due to indomethacin
1.
Rothschild Hospital,
Agordat
camp very hot and
Circular South Road, Colchester C02 7UD.
above 40 in
had been found by barium-meal examination, and it was felt that indomethacin suppositories would be safer. They were started in February, 1968; on a dosage of three 50 mg. suppositories daily he improved, and severe back and joint pains diminished greatly. In August, 1968, while he was on continuous indomethacin treatment, rectal bleeding developed. Rectosigmoidoscopy disclosed severe, inflammation of the mucosa with profuse bleeding in the distal 12 cm. Higher up, the mucosa appeared normal. Barium enema was entirely normal. The indomethacin suppositories were stopped, and sigmoidoscopy repeated three weeks later. On this occasion there was no bleeding. The mucosa appeared granular up to 12 cm. At a depth of 8 cm. a small polyp was seen and excised; histological examination showed moderate chronic non-specific and intense acute inflammatory infiltration with partial necrosis of the mucosa. Because of the lack of response to any other analgesic or anti-inflammatory agents, indomethacin treatment was resumed, and repeated rectoscopic examinations showed that the intensity of the mucosal inflammatory changes was directly related to dose; three suppositories daily for 1-2 weeks resulted in profuse rectal bleeding, while on one suppository daily the inflammatory reaction was much less and there was almost no bleeding.
52.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Moynahan, E. J. Lancet, 1974, i, 399. Neldner, K. H., Hambidge, K. M. Unpublished. Michaelsson, G. Acta derm-vener., Stockh. 1974 54, 377. Thyresson, N. ibid. p. 383. Kienholz, E. W., Turk, D. E., Sunde, M. L., Hoekstra, W. G. J. Nutr. 1961, 75, 211. Hurley, L. S. Am. J. clin. Nutr. 1969, 22, 1332. Calhoun, N. R., Smith, J. C., Jr., Becker, K. L. Clin. Orthop. 1974, 103, 212. Warkany, J., Petering, H. G. Teratology, 1972, 5, 319. Vedder, J. S. J. Pediat. 1956, 48, 212. Epstein, S., Vedder, J. S. Archs Derm. 1960, 82, 189. Verburg, D. J., Burd, L. I., Hoxtell, E. O., Merrill, L. K. Obstet. Gynec. 1974, 44, 233.