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WHEN TO REMOVE THE I.U.D.
1095
exclusively the proportion
becomes as high as 3-4%. The close the health visitor is to a doctor’s general practice the more her time is devoted to the elderly. I wonder, do you regard even 3-4% as enough ? Matters of policy were deliberately excluded from the report, and people will be making up their own minds on many vital issues of policy concerned with the reorganisation of the health services in general and health visiting in particular. It is important that you have called attention to this, and I hope that the results of the survey-initiated by professionals with a very keen interest in the matters touched upon-will be used to guide the difficult decisions that the medical professions have to take about their future more
and I presume that this is when impregnation took place. It would seem that the sperms were able to pass the uterine cavity, conception occurred, and in the interval between conception and tubal passage to the uterus the endometrium had sufficiently recovered from the removal of the I.U.D. that it no longer presented a hostile environment to implantation. I suppose we should remember to remove the I.U.D. in the second half of the menstrual cycle so as to prevent this type of pregnancy, just as we should be sure to insert the i.u.D. in the first half of the cycle. Mayfair Chambers, 48 The Terrace, Wellington, New Zealand.
GRAEME R. DUNCAN.
role. 50 Broom
Close, Teddington, Middlesex.
TYRRELL MARRIS.
MULTIPLE SCLEROSIS: OCCUPATION AND SOCIAL GROUP AT ONSET
SiR,—Iwas-
very interested in Professor Russell’s (Oct. 16, p. 832). Although we have not analysed our cases in Bristol for their social class, my feeling is that they do not match Professor Russell’s groups, and that the
article
incidence would be equal in all social groups. Perhaps this is because we work in an industrial area which does not really correspond accurately with Oxford. In Professor Russell’s figures there may be a selection of cases related to the higher proportion of social class one and two in the Oxford area. Also, would he not be likely to see cases referred to him from a distance in social classes one and two ? Professor Russell will remember the investigations we did at Oxford in 1946 and 1947, which confirm the subsequent view of Dean and Kurtzkeabout the importance of environmental factors before the age of 15. He will remember the five cases of multiple sclerosis living near to each other who went to the same village school in a Berkshire village during the war years, who all developed multiple sclerosis about five to eight years after this period. One wonders whether some environmental hazard which we fail to recognise lowers the resistance of nervous tissue to some viral agent, and that we are really dealing with a disease of more than one factor. It has always struck me it would be easier to investigate the incidence of multiple sclerosis in native-born White South Africans who develop the disease tor a factor of this kind, since it is much easier to investigate an abnormal factor in an area where the disease is relatively rare, as in South Africa, than in Britain where it is relatively common. Department of Neurology, Royal Infirmary, A. M. G. CAMPBELL. Bristol.
WHEN TO REMOVE THE I.U.D.
Sirwish to bring to the notice of readers a possible hazard of removing an intrauterine device (I.U.D.) in the first half of the menstrual cycle. I removed a Lippes loop from a young woman on the 14th day of her menstrual cycle because of persistent heavy bleeding in the preceding periods. She did not menstruate subsequently, and was pregnant. Other contraceptive methods have been used with meticulous care, and no coitus occurred for several days after removal of the I.U.D. However, coitus had occurred 2 days before the removal of the i.u.D. 1. Dean, G., Kurtzke, J. F. Br. med. J. 1971, iii, 725. Campbell, A. M. G., Herdan, G., Tatlow, W. F. T., Whittle, E. G. Brain, 1950, 73, 52.
2.
COMPLEMENT-FIXING AND FLUORESCENT ANTIBODIES IN DIAGNOSIS OF E.B.-VIRUS INFECTIONS
SIR,-Antibodies to the Epstein-Barr (E.-B.) virus particle, detectable by immunofluorescence, and complementfixing antibodies to an E.-B. virus soluble antigendevelop during the course of infectious mononucleosis.3,4 Their
prevalence in the normal population has inhibited in the diagnosis of infectious mononucleosis and, more importantly, in the investigation of other conditions in which the E.-B. virus may be implicated. Fluorescent
wide their
use
antibodies to the E.-B. virus are often present in sera taken during the acute phase of infectious mononucleosis, but complement-fixing antibodies to the soluble antigen develop slowly,5 and low levels of these may be expected at this time. This differential rate of antibody development could afford a means of identifying recent infections with E.-B. virus, and we have therefore applied both tests to four groups of individuals with the following results. (Details of laboratory methods, patients, and controls are
given elsewhere.5) Low levels of complement-fixing antibodies (arbitrarily taken as 1/16 or less), together with fluorescent-antibody titres of 1/8 or greater, were observed in sera from 26 of 49 patients (53%) tested within three months of the onset of infectious mononucleosis. This proportion is significantly higher than those observed in the three control groups. These were: (a) Acutely ill patients with other conditions, 6 of 74
(8%);
x22-7, r<00005.
(b) Healthy medical students and
nurses, 5 of 37
(13%);
x2=12-7, n<00005.
(c) after
Patients with infectious mononucleosis tested 5-22 months of illness, 2 of 19 (10%); r=0003 (exact test).
onset
The combined use of immunofluorescence and complement-fixation tests may thus provide useful information in the investigation of infections with the E.-B. virus, perhaps especially in epidemiological studies. We are grateful to Dr. Hillas Smith for access to patients and to Dr. M. de L. Coutinho for collection of specimens. This work was carried out with the financial support of the Cancer Research Campaign and of the Joint Research Committee, Kine’s College Hospital.
R. N. P. SUTTON Department of Medical Microbiology, King’s College Hospital Medical School, E. J. P. ALMOND S. D. MARSTON. London S.E.5. Royal Free Hospital Infectious Diseases Unit, Coppetts Wood Hospital, London N.10.
R. T. D. EMOND.
Henle, G., Henle, W. J. Bact. 1966, 91, 1248. Vonka, V., Benyesh-Melnick, M., Lewis, R. T., Wimberly, I. Arch. ges. Virusforsch. 1970, 31, 113. 3. Niedermann, J. C., McCollum, R. W., Henle, G., Henle, W. J. Am. med. Ass. 1968, 203, 205. 4. Gerber, P., Deal, D. R. Proc. Soc. exp. Biol. Med. 1970, 134, 748. 5. Sutton, R. N. P., Marston, S. D., Emond, R. T. D. J. clin. Path. (in the press).
1. 2.
exclusively the proportion
becomes as high as 3-4%. The close the health visitor is to a doctor’s general practice the more her time is devoted to the elderly. I wonder, do you regard even 3-4% as enough ? Matters of policy were deliberately excluded from the report, and people will be making up their own minds on many vital issues of policy concerned with the reorganisation of the health services in general and health visiting in particular. It is important that you have called attention to this, and I hope that the results of the survey-initiated by professionals with a very keen interest in the matters touched upon-will be used to guide the difficult decisions that the medical professions have to take about their future more
and I presume that this is when impregnation took place. It would seem that the sperms were able to pass the uterine cavity, conception occurred, and in the interval between conception and tubal passage to the uterus the endometrium had sufficiently recovered from the removal of the I.U.D. that it no longer presented a hostile environment to implantation. I suppose we should remember to remove the I.U.D. in the second half of the menstrual cycle so as to prevent this type of pregnancy, just as we should be sure to insert the i.u.D. in the first half of the cycle. Mayfair Chambers, 48 The Terrace, Wellington, New Zealand.
GRAEME R. DUNCAN.
role. 50 Broom
Close, Teddington, Middlesex.
TYRRELL MARRIS.
MULTIPLE SCLEROSIS: OCCUPATION AND SOCIAL GROUP AT ONSET
SiR,—Iwas-
very interested in Professor Russell’s (Oct. 16, p. 832). Although we have not analysed our cases in Bristol for their social class, my feeling is that they do not match Professor Russell’s groups, and that the
article
incidence would be equal in all social groups. Perhaps this is because we work in an industrial area which does not really correspond accurately with Oxford. In Professor Russell’s figures there may be a selection of cases related to the higher proportion of social class one and two in the Oxford area. Also, would he not be likely to see cases referred to him from a distance in social classes one and two ? Professor Russell will remember the investigations we did at Oxford in 1946 and 1947, which confirm the subsequent view of Dean and Kurtzkeabout the importance of environmental factors before the age of 15. He will remember the five cases of multiple sclerosis living near to each other who went to the same village school in a Berkshire village during the war years, who all developed multiple sclerosis about five to eight years after this period. One wonders whether some environmental hazard which we fail to recognise lowers the resistance of nervous tissue to some viral agent, and that we are really dealing with a disease of more than one factor. It has always struck me it would be easier to investigate the incidence of multiple sclerosis in native-born White South Africans who develop the disease tor a factor of this kind, since it is much easier to investigate an abnormal factor in an area where the disease is relatively rare, as in South Africa, than in Britain where it is relatively common. Department of Neurology, Royal Infirmary, A. M. G. CAMPBELL. Bristol.
WHEN TO REMOVE THE I.U.D.
Sirwish to bring to the notice of readers a possible hazard of removing an intrauterine device (I.U.D.) in the first half of the menstrual cycle. I removed a Lippes loop from a young woman on the 14th day of her menstrual cycle because of persistent heavy bleeding in the preceding periods. She did not menstruate subsequently, and was pregnant. Other contraceptive methods have been used with meticulous care, and no coitus occurred for several days after removal of the I.U.D. However, coitus had occurred 2 days before the removal of the i.u.D. 1. Dean, G., Kurtzke, J. F. Br. med. J. 1971, iii, 725. Campbell, A. M. G., Herdan, G., Tatlow, W. F. T., Whittle, E. G. Brain, 1950, 73, 52.
2.
COMPLEMENT-FIXING AND FLUORESCENT ANTIBODIES IN DIAGNOSIS OF E.B.-VIRUS INFECTIONS
SIR,-Antibodies to the Epstein-Barr (E.-B.) virus particle, detectable by immunofluorescence, and complementfixing antibodies to an E.-B. virus soluble antigendevelop during the course of infectious mononucleosis.3,4 Their
prevalence in the normal population has inhibited in the diagnosis of infectious mononucleosis and, more importantly, in the investigation of other conditions in which the E.-B. virus may be implicated. Fluorescent
wide their
use
antibodies to the E.-B. virus are often present in sera taken during the acute phase of infectious mononucleosis, but complement-fixing antibodies to the soluble antigen develop slowly,5 and low levels of these may be expected at this time. This differential rate of antibody development could afford a means of identifying recent infections with E.-B. virus, and we have therefore applied both tests to four groups of individuals with the following results. (Details of laboratory methods, patients, and controls are
given elsewhere.5) Low levels of complement-fixing antibodies (arbitrarily taken as 1/16 or less), together with fluorescent-antibody titres of 1/8 or greater, were observed in sera from 26 of 49 patients (53%) tested within three months of the onset of infectious mononucleosis. This proportion is significantly higher than those observed in the three control groups. These were: (a) Acutely ill patients with other conditions, 6 of 74
(8%);
x22-7, r<00005.
(b) Healthy medical students and
nurses, 5 of 37
(13%);
x2=12-7, n<00005.
(c) after
Patients with infectious mononucleosis tested 5-22 months of illness, 2 of 19 (10%); r=0003 (exact test).
onset
The combined use of immunofluorescence and complement-fixation tests may thus provide useful information in the investigation of infections with the E.-B. virus, perhaps especially in epidemiological studies. We are grateful to Dr. Hillas Smith for access to patients and to Dr. M. de L. Coutinho for collection of specimens. This work was carried out with the financial support of the Cancer Research Campaign and of the Joint Research Committee, Kine’s College Hospital.
R. N. P. SUTTON Department of Medical Microbiology, King’s College Hospital Medical School, E. J. P. ALMOND S. D. MARSTON. London S.E.5. Royal Free Hospital Infectious Diseases Unit, Coppetts Wood Hospital, London N.10.
R. T. D. EMOND.
Henle, G., Henle, W. J. Bact. 1966, 91, 1248. Vonka, V., Benyesh-Melnick, M., Lewis, R. T., Wimberly, I. Arch. ges. Virusforsch. 1970, 31, 113. 3. Niedermann, J. C., McCollum, R. W., Henle, G., Henle, W. J. Am. med. Ass. 1968, 203, 205. 4. Gerber, P., Deal, D. R. Proc. Soc. exp. Biol. Med. 1970, 134, 748. 5. Sutton, R. N. P., Marston, S. D., Emond, R. T. D. J. clin. Path. (in the press).
1. 2.