340

writing to mention that the Medical Research Council has agreed to support the development of its use for controlled trials of the treatment of pituitary disorders. There are still a number of problems to overcome, but we are hopeful that eventually this treatment will become available in Britain and that such trials can be undertaken.

of

a

D.C.

shock

can

therefore, there reflex in the and s.v.T.

treatment

T. D. R. HOCKADAY.

Churchill Hospital, Oxford.

A. H. LAING.

Royal Postgraduate Medical School,

R. B. WELBOURN,

London W12 0HS.

Chairman.

M. HARTOG, Secretary, M.R.C. Working Party Bristol Royal Infirmary, Bristol.

on

proton-beam therapy.

TREATMENT OF PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

SIR,-We were very interested to read the report of Dr Wildenthal and others (Jan. 4, p. 12) on the use of the diving reflex to treat paroxysmal supraventricular tachycardia. The following case-report illustrates both the efficacy and potential hazards of such a manoeuvre. A 41-year-old man was admitted to the coronary-care uriit with a one-week history of chest pain of increasing severity. The admission E.C.G. showed a regular supraventricular tachycardia (s.v.T.) of 180 per minute, and subsequent E.C.G.S showed an anterior myocardial infarct, confirmed by enzyme changes. His general condition was good. Carotid-sinus massage and practolol 10 mg. intravenously failed to produce sinus rhythm. He was later given intramuscular digoxin (0-5 mg.). His condition deteriorated over the next few hours; he became pale and sweaty, with a systolic blood-pressure of 90 mm. Hg. D.c. cardioversion was considered, but was thought to be hazardous because of the digoxin. At this stage immersion of the face in water at 15°C was tried. The effect was almost instantaneous, and is shown in

t Face immersion Effect of face immersion

on

supraventricular tachycardia.

the accompanying figure. A short run of ventricular ectopic activity was followed by normal sinus rhythm, which was maintained thereafter with an improvement in his blood-pressure and general condition. Sporadic ventricular ectopic activity was seen over the next 12 hours, which was treated with intravenous lignocaine. None had been seen in the 6 hours of S.v.T.

The diving reflex was thus effective in producing sinus rhythm where other more conventional methods of treatment had not succeeded. As mentioned by Wildenthal et al., face immersion can provoke ventricular arrhythmias, as shown by the present case. This, however, has also been described for carotid-sinus massageand chest thumps.2 While it is a very real hazard, its effects are short-lived, and must be weighed against the more protracted hazards of anti-arrhythmic drugs (e.g., the combination of verapamil and p-blockers 3) and D.c. cardioversion. The intensity of the vagal discharge can be regulated according to the water temperature 4 in much the same way as the intensity 1. Scherf, D., Bornemann, C. Dis. Chest, 1966, 50, 530. 2. Semple, T., Al Badran, R. H., Boyes, B. E. Br. med. J. 1968, i, 224. 3. Benaim, M. E. ibid. 1972, ii, 169. 4. Moore, T. O., Lin, Y. C., Lally, D. A., Hong, S. K. J. appl. Physiol. 1972, 33, 36.

a

of

Department of Cardiovascular Medicine, Radcliffe Infirmary, Oxford OX2 6HE.

Radcliffe Infirmary, Oxford.

With suitable precautions, place for the use of the diving patients with myocardial infarct

be varied.

may be

THOMAS PICKERING PAULA BOLTON-MAGGS.

NEGLECTED CŒLIAC DISEASE SIR,-Dr McCrae and his colleagues (Jan. 25, p. 187) are to be congratulated on tracing 100% of a series of 130 patients in whom coeliac disease had been clinically diagnosed in childhood and performing intestinal biopsy on 102 of these. Most of their findings confirm those of earlier studies on much smaller groups of patients. 1, They found that an original diagnosis on clinical grounds alone had a 57% chance of being correct, compared with the 50% chance reported by Cook et al.2 at the West Middlesex. When the original diagnosis had been supported by metabolic studies McCrae et al. found it correct in 70% of cases, compared with 90% described by Mortimer and her colleaguesat Hammersmith, studying patients originally diagnosed at Great Ormond Street Hospital. McCrae et al. were impressed by the paucity of symptoms in the untreated coeliac patients, but most of their patients were in their ’teens and twenties, an age-group well recognised for apparent remission of coeliac disease until some precipitating factor intervenes, such as pregnancy producing megaloblastic anaemia.3 They would probably have uncovered more ill-health if they had gone so far as to assess the effects of a gluten-free diet on their biopsyproven coeliac patients. It would be interesting to know how many of these patients, especially the older ones, would then volunteer remarks like, " I never realised I wasn’t well till I started this diet. I can do so much more now ". The Creliac Society (P.O. Box 181, London NW2 2QY) exists to help coeliac patients with the gluten-free diet and related problems. The Edinburgh workers concluded that when anaemia occurred in untreated coeliac patients iron deficiency was likely to be a more important factor than folate or vitaminB12 deficiency, many serum-folate levels being normal. Perhaps it is not surprising that this differs from the view expressed in Glasgow 4 where some degree of folate deficiency was found to be universal in coeliac children. The finding of such replete folate stores in so many untreated coeliac patients must be unique. In contrast, vitamin B12 deficiency is virtually never a significant factor in the production of anaemia in coeliac disease, presumably because the lower ileum, the site of B12 absorption, is less severely affected than the proximal small gut where iron and folic acid are absorbed. Finally, McCrae and his colleagues conclude with some interesting speculations about the prevalence of coeliac disease, but they do not mention the only study that can stand up to a critical analysis, the paper by Mylotte et al.6 Those workers found a prevalence of about 1 in 300 in Galway and concluded that coeliac disease was unusually common in their part of the world. This may or may not be true: there has been no comparable study anywhere else. West Middlesex

Hospital, Isleworth,

Middlesex TW7 6AF. 1.

JAMES STEWART.

Mortimer, P. E., Stewart, J. S., Norman, A. P., Booth, C. C. Br. med. J. 1968, iii, 7. 2. Cook, D. M., Evans, N., Lloyd, A., Stewart, J. S. Archs Dis. Childh. 1971, 46, 705. 3. Stewart, J. S. Clins Gastroenterol. 1974, 3, 109. 4. McNeish, A. S., Willoughby, M. L. N. Lancet, 1969, i, 442. 5. Hoffbrand, A. V. Clins Gastroenterol. 1974, 3, 71. 6. Mylotte, M., Egan-Mitchell, B., McCarthy, C. F., McNicholl, B. Br. med. J. 1973, i, 703.

Letter: Neglected coeliac disease.

340 writing to mention that the Medical Research Council has agreed to support the development of its use for controlled trials of the treatment of p...
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