BRITISH MEDICAL JOURNAL
21
MAY
Finally, no contemporary review of this subject should omit a reference to the very important article by Klein et a14 on "Large artery involvement in giant-cell (temporal) arteritis." J W PAULLEY Ipswich Hutchinson, J, Archives of Surgery (London), 1890, 1, 323. Horton, B T, Magath, T B, and Brown, G E, Proceedings of the Mayo Clintic, 1932, 7, 700. All Ibn Isa, Mernoranduin of a 10th Centuiry Oculist, translated by C A Woods, Chicago NW University, 1936. Cited by Hamilton, C R, Shelley, W M, and Tumulty, P A, Medicine, 1975, 50, 1. Klein, R G, et al, Atnnals of Internal Medicine, 1975, 83, 806.
2
***Dr Paulley is correct. Jonathan Hutchinson did describe one case, in an elderly porter at the London Hospital, in 1890, before Horton in 1932, just as others had described what Barber later termed polymyalgia rheumatica in 1957, but in each case the fuller description merited the attention it attracted. Dr Paulley is also correct in saying that the ophthalmic artery and its other branches become occluded more often than the central artery of the retina. Wilkinson and Russell1 in their necropsy study of 12 patients who died with active giant-cell arteritis found a high incidence of disease of the superficial temporal, vertebral, ophthalmic, and posterior ciliary arteries with less frequent disease of the internal and external carotid and central retinal arteries.-ED, BM7. Wilkinson, I M S, and Russell, R W R, Archives of Neurology, 1972, 27, 378.
SIR,-Although there is considerable overlap between polymyalgia rheumatica and giant cell arteritis it is doubtful whether arteritis is the underlying pathological process in the former (leading article, 23 April, p 1046). There is histological' and joint scintigraphic2 evidence that a proximal joint synovitis accounts for the symptoms of polymyalgia rheumatica. This is not an academic point. Although the symptoms of polymyalgia rheumatica respond to low doses of prednisolone, these are inadequate to prevent vascular occlusion from arteritis and there therefore seems no reason why anti-inflammatory analgesics should not be tried first. The large doses of corticosteroid necessary to treat arteritis have serious, unwanted effects in the elderly and should be administered only when there is clinical or histological evidence of an arteritis. On practical therapeutic grounds at least there therefore seems reason to retain the distinction between giant cell arteritis and polymyalgia rheumatica and not to combine them as polymyalgia arteritica. D R SWINSON Rheumatology Unit, Wrightington Hospital, Wigan, Lancs
2
1349
1977
Bruk, M I, Annals of the Rheumatic Diseases, 1967, 26, 103. O'Duffy, J D, Wahner, H W, and Hunder, G G, Mayo Clinic Proceedings, 1976, 51, 519.
SIR,-May I be allowed to comment on your very good leading article about polymyalgia rheumatica (23 April, p 1046) ? In my experience it is often necessary to give between 45 and 60mg of prednisolone daily to control morning stiffness and girdle pains; it may well be advisable to begin treatment with a smaller dose if there is any evidence of cardiovascular disease.
absorbed by some subjects. Seven of the 18 subjects were normal volunteers who had never previously received lithium medication; this was also so for five of the 11 patients, while the other six patients had not received lithium for at least three months. Although the shapes of the plasma lithium curves would of course be different if single doses of the various preparations were given to subjects stabilised on lithium, there is no reason to suppose that the rates of absorption and excretion would differ greatly under these conditions provided the single dose was administered not less than 10-12 h after previous lithium ingestion. However, in order to study these findings further under practical conditions we have investigated the effect of substituting the same daily dosage (400 mg) of lithium carbonate BP for one of the controlledrelease preparations (Priadel) in a group of 11 patients stabilised on the latter. Plasma lithium was determined on three occasions at weekly intervals before the substitution and again one, two, and three weeks after the switch, blood being taken in each case not less than 10 h after the last lithium dose. No significant differences between the pre- and postsubstitution mean plasma lithium levels were observed. The range of daily oral dosage was JOHN R GOLDING 400-2000 mg. While the protocol of this investigation does Harrogate Royal Bath Hospital, Harrogate, N Yorks not preclude the possibility of different diurnal plasma lithium patterns, the similar baseline levels obtained with the two preparations confirms our previous conclusion that there Malignant hypertension secondary to is no basis for administering Priadel in preferidiopathic arteritis of the aorta ence to lithium carbonate BP. R P HULLIN SIR,-The very interesting case reported by Dr R A Wall and others (23 October, p 977) Regional Metabolic Research Unit, Royds Hospital, is the third such case to be reported from the High Ilkley, W Yorks Ndola Central Hospital, Zambia.' 2 The similarities between the patient reTyrer, S, et al, Psychological Medicine, 1976, 6, 51. ported by Dr Wall and his colleagues and our second one are very close. Both were young (16 and 20 years respectively) and had malig- Predicting child abuse nant renovascular hypertension, but renal function was well preserved and hypertension SIR,-The papers from the Park Hospital, was easily controlled, in our case by drugs and Oxford, in the past two years have opened up in their case by nephrectomy and a diuretic. the possibilities for helping families long Their description of the histological appear- before a disaster occurs. Dr Margaret A Lynch and Mrs Jacqueline ance of the resected renal upper pole artery is very similar to our description of the aortic Roberts (5 March, p 624) are right in saying changes in the necropsy specimen in our first that "there seems to be a need for co-ordinating all disciplines, both in the hospital and in the case-degeneration of the media. community." This could be done by holding MARK N LOWENTHAL some antenatal examinations in the home. With the reorganisation of the Health Service Department of Medicine, Baragwanath Hospital, community midwives are now based in South Africa hospitals in close contact with consultant Lowenthal, M N, Doctor, S A, and Fine, J, Post- units. When a midwife finds that a family graduate Medical 7ournal, 1968, 44, 928. scores highly on a number of factors she can 2 Lowenthal, M N, Patel, D C, and Pillai, K M, Lancet, discuss the significance of this with the family 1971, 1, 295. and alert the health visitor and family doctor. Advantages of this suggestion are: (1) Prediction of child abuse in an informal way. Absorption of lithium from controlled- (2) Reduction of the size of antenatal clinics. After booking, antenatal checks in the early release preparations and middle months of pregnancy are medically SIR,-We have reported1 the 24-h plasma dull and can be looked on as a waste of skilled lithium profiles of 18 fasting subjects who obstetricians' time. Removal of about half were given single oral doses of one or more these examinations would free the doctors for of either the standard BP or two controlled- complicated situations where they are really release preparations of lithium carbonate. needed. (3) Increase in the role, interest, and Although the controlled-release tablets showed responsibility of community midwives. (4) slow release in vitro, this was not so in vivo. Saving of money by transferring medical There was no difference in the rate of absorp- time from cost-intensive hospitals to the tion and excretion between the BP preparation primary care team-generally found to be used (Camcolit) and one controlled-release cheaper. It is hoped that obstetricians, midwives, preparation (Priadel), while the other slowrelease preparation (Phasal) was ineffectively and paediatricians will collaborate, perhaps at
Loss of vision may occur very suddenly without an increase of symptoms and without a spread of symptoms to affect the temples or scalp. I myself have missed a case of polymyalgia with arteritic lesions which produced blindness. The patient was a proven rheumatoid who complained of sudden increase of pain in both shoulders. As her erythrocyte sedimentation rate (ESR) was only marginally raised at 18 mm in 1 h I dismissed the diagnosis of polymyalgia even though I thought of it. She returned to the clinic the following week blind in one eye, a temporal artery biopsy proving positive. Involvement of the facial artery occurs occasionally, such patients often being referred to an ear, nose, and throat surgeon. Lastly, I have encountered polymyalgia apparently as a systemic manifestation of a neoplasm; one useful guide here is that whereas symptoms abate with steroids the ESR remains very high. I think that polymyalgia is the only condition in which I prescribe the appropriate drug from a hospital clinic. Any such patient is at risk from arteritis causing visual loss; it is my practice to ask the patient to remain in the clinic until the result of the ESR is to hand.
1350
the instigation of their area review committee on non-accidental injury, to start pilot schemes along these lines. RICHARD STONE London W2
(6) Relapses are a typical feature of this illness and may occur even after several years of good health.4
produce involuntary movements in the same way as chloroquine.
Last year a research group was formed to study the aetiology and epidemiology of this syndrome. Our investigations so far indicate that the illness may accompany the more common viral infections and that the unique fatigue pattern may be due to mitochondrial damage. As objective manifestations of the disease can still be present over 30 years after the initial illness we should be glad to hear from former sufferers who were members of the medical and nursing staff of the Royal Free Hospital or other institutions which have experienced outbreaks. Communications should be sent to the honorary secretary of the group (JVD) at the address below.
Elmdene Alcoholic Treatment Unit, Bexley Hospital, Bexley, Kent
SIR,-We would like to take the opportunity of commenting on the important points made by two recent correspondents, Dr P C Corry and Mr G T Meredith (23 April, p 1084). There is certainly a need to look at larger samples than we were able to include in our study (5 March, p 624). However, we should not be deterred from considering preventive action simply because the percentage of newborns "at risk" seems to be so large. In our experience intervention frequently does not have to be massive. Open recognition of the parents' difficulties in caring for the child A M RAMSAY can result in a more positive attitude towards E G DOWSETT existing services, which can often be adapted J V DADSWELL to provide the help the family needs.' W H LYLE Our data were collected at the maternity J G PARISH hospital. Thus most information, not unBenign Myalgic Encephalomyelitis naturally, was concerning the mother. This Research Group does not mean that all the children were Public Health Laboratory, battered by their mothers. We have found that Royal Berkshire Hospital, both parents are often deeply involved in the Reading, Berks abuse of their child, irrespective of who actually I Ramsay, A M, Update, 1976, 13, 539. inflicts the injuries; it is not necessarily 2 Parish, J G, IRCS Journal of international Research Communications, 1974, 2, 22. helpful to concentrate on "who did it." 3 Leon-Sotomayor, L, Epidemic Diencephalomyelitis. Sometimes the parent who is not the identified New York, Pageant Press, 1969. 4 Marinacci, A A, and Von Hagen, K, Electromyography, abuser in one incident subsequently batters 1965, 5, 241. the same child or marries another battering partner. MARGARET A LYNCH Mechanism of chloroquine induced JACQUIE ROBERTS involuntary movements Human Development Research
Unit,
Park Hospital for Children, Headington, Oxford
Beswick, K, Lynch, M A, and Roberts, J, British Medical,Journal, 1976, 2, 800.
Icelandic disease (benign myalgic encephalomyelitis or Royal Free disease) SIR,-We were interested to read your expert's reply to the question on the nature of Icelandic disease (9 April, p 965). We should like to present the following additional information: (1) None of the names in common use is completely descriptive of this syndrome, which is not truly benign, is not always myalgic, and has no proved connection with hysteria or neurasthenia.' (2) The sufferers are usually parents of young children or members of the armed Forces or of the teaching, nursing, or medical professions. The classic illness has a biphasic pattern with an initial episode of gastrointestinal or upper respiratory tract infection, with or without a rash and lymphadenopathy, affecting either the patient or juvenile members of the family. (3) The most characteristic presentation is profound fatigue and muscular weakness coming on during the day and increasing in severity with exercise-a diurnal rhythm contrary to that found with other forms of depression. (4) Other symptoms that may accompany the initial illness or a relapse include muscular fasciculation, paraesthesiae, and disturbance of vision, with which nystagmus may be seen. Autonomic disturbances such as orthostatic tachycardia, vasomotor instability, and episodes of pallor are often prominent. Encephalitic disturbances include severe depression, emotional lability, and difficulty in concentration. (5) Physical findings may include atypical lymphocytes in the peripheral blood, hepatitis, electromyographic evidence of myelopathic and neuropathic disorders, and abnormal glucose tolerance curves.2 3
21 MAY 1977
BRITISH MEDICAL JOURNAL
S K MAJUMDAR
Potts, A M, in Physiological Pharmacology, ed W S Root and F G Hofmann, vol II, part B, pp 329-397. New York, Academic Press, 1965. Rollo, I M, in The Pharmacological Basis of Therapeutics. ed L S Goodman, A Gilman, A G Gilman, and G B Koelle, 5th edn, p 1051. New York, Macmillan, 1975.
Insurance companies' attitude to psychiatric illness SIR,-In recent issues you have printed letters from two psychiatrists expressing concern at the harsh attitude towards minor psychiatric illness taken by insurance companies, and the untoward experiences of five neurotic patients are mentioned. Dr J T Hutchinson (9 March, p 775) describes excessive loading against those who seek life insurance and Dr A B Sclare (16 April, p 1031) from his experience with employees of insurance companies becoming patients stresses the lack of confidentiality, punitive attitudes towards mental illness, and absence of discrimination between mild and serious psychiatric illness. Although I would agree that the attitudes of the companies should be enlightened and informed, it is worth mentioning that the neuroses do carry a slightly increased risk of premature mortality as demonstrated in the studies by Babigian and Odoroff,l by Innes and Millar,' by Keehn et al3 and by me.4 Further findings on the extent of this increased death risk will be published soon, but figures have generally been about 15 times those for the matched general population. It would seem reasonable that psychiatrists should ask the insurance companies to take the psychiatric diagnosis into account in their assessment of weighting so ihat neuroses and other disorders can be differentially weighted. This would result in a slightly increased premium for neurosis which should by no means be prohibitive. ANDREW SIMS
SIR,-I read with interest the report by Drs E M Umez-Eronini and Elspeth A Eronini on chloroquine induced involuntary movements (9 April, p 945). May I throw some light on the probable mechanism of these movements ? Chloroquine and phenothiazines combine avidly with melanin both in vitro and in vivo; this is believed to be based on a charge transfer reaction facilitated by the presence of electrons in the fused coplanar ring structures of both chloroquine and phenothiazines.' University Department of Psychiatry, Melanin is a derivative of DOPA (phenyl- Queen Elizabeth Hospital, alanine -* tyrosine -* dihydroxyphenylalanine Birmingham
(DOPA) -* DOPA-quinone -* melanin). Chloroquine, a 4-aminoquinoline derivative, crosses the blood-brain barrier, and the brain and spinal cord contain 10-30 times the amount present in plasma.2 It is quite logical to infer from the structure-activity relationship that chloroquine may also avidly combine with the dopaminergic receptors (like melanin) and thus by blocking those receptors (like phenothiazines, butyrophenones, metoclopramide, etc) in the nigrostriatal system it may produce involuntary movements. It is another example of drug-induced extrapyramidal disorders. In the light of this it is better not to give patients with chloroquine induced involuntary movements phenothiazines like chlorpromazine, which may aggravate the situation. Anticholinergic anti-Parkinsonian drugs like benztropine, benzhexol, orphenadrine, ethopropazine, procyclidine, etc should be given in these cases as their action is not dependent on the dopaminergic receptors in the nigrostriatal system. It needs to be mentioned that other members of 4-aminoquinoline family like amodiaquine, cycloquine, and hydroxychloroquine may also
Babigian, H M, and Odoroff, C L, American3Journal of Psychiatry, 1969, 126, 470. Innes, G, and Millar, W M, Scottish Medical journal, 1970, 15, 143. 3Keehn, R J, Goldberg, I D, and Beebe, G W, Psychosomatic Medicine, 1974, 36, 27. ' Sims, A C P, Lancet, 1973, 2, 1072. 2
Maintenance digoxin
SIR,-Concerning Dr B J O'Driscoll's comments (16 April, p 1028) on our paper (19 March, p 749), comparison with pioneering studies is difficult because of historical emphasis on digitalisation rather than maintenance therapy, the fact that digitalis used to be pushed until cardiotoxicity occurred, and differences in concomitant therapy. Although Sir James Mackenzie' in 1910 obtained the best response in failure associated with "rapid" atrial fibrillation, he did not consider that decreasing the rate was the primary mechanism: "The good results obtained by the use of digitalis are doubtless due to the specific action of the drug on the function of tonicity." Windle2 in 1917 demonstrated the value of digitalis in patients with pulsus alternans, while
21
MAY
Finally, no contemporary review of this subject should omit a reference to the very important article by Klein et a14 on "Large artery involvement in giant-cell (temporal) arteritis." J W PAULLEY Ipswich Hutchinson, J, Archives of Surgery (London), 1890, 1, 323. Horton, B T, Magath, T B, and Brown, G E, Proceedings of the Mayo Clintic, 1932, 7, 700. All Ibn Isa, Mernoranduin of a 10th Centuiry Oculist, translated by C A Woods, Chicago NW University, 1936. Cited by Hamilton, C R, Shelley, W M, and Tumulty, P A, Medicine, 1975, 50, 1. Klein, R G, et al, Atnnals of Internal Medicine, 1975, 83, 806.
2
***Dr Paulley is correct. Jonathan Hutchinson did describe one case, in an elderly porter at the London Hospital, in 1890, before Horton in 1932, just as others had described what Barber later termed polymyalgia rheumatica in 1957, but in each case the fuller description merited the attention it attracted. Dr Paulley is also correct in saying that the ophthalmic artery and its other branches become occluded more often than the central artery of the retina. Wilkinson and Russell1 in their necropsy study of 12 patients who died with active giant-cell arteritis found a high incidence of disease of the superficial temporal, vertebral, ophthalmic, and posterior ciliary arteries with less frequent disease of the internal and external carotid and central retinal arteries.-ED, BM7. Wilkinson, I M S, and Russell, R W R, Archives of Neurology, 1972, 27, 378.
SIR,-Although there is considerable overlap between polymyalgia rheumatica and giant cell arteritis it is doubtful whether arteritis is the underlying pathological process in the former (leading article, 23 April, p 1046). There is histological' and joint scintigraphic2 evidence that a proximal joint synovitis accounts for the symptoms of polymyalgia rheumatica. This is not an academic point. Although the symptoms of polymyalgia rheumatica respond to low doses of prednisolone, these are inadequate to prevent vascular occlusion from arteritis and there therefore seems no reason why anti-inflammatory analgesics should not be tried first. The large doses of corticosteroid necessary to treat arteritis have serious, unwanted effects in the elderly and should be administered only when there is clinical or histological evidence of an arteritis. On practical therapeutic grounds at least there therefore seems reason to retain the distinction between giant cell arteritis and polymyalgia rheumatica and not to combine them as polymyalgia arteritica. D R SWINSON Rheumatology Unit, Wrightington Hospital, Wigan, Lancs
2
1349
1977
Bruk, M I, Annals of the Rheumatic Diseases, 1967, 26, 103. O'Duffy, J D, Wahner, H W, and Hunder, G G, Mayo Clinic Proceedings, 1976, 51, 519.
SIR,-May I be allowed to comment on your very good leading article about polymyalgia rheumatica (23 April, p 1046) ? In my experience it is often necessary to give between 45 and 60mg of prednisolone daily to control morning stiffness and girdle pains; it may well be advisable to begin treatment with a smaller dose if there is any evidence of cardiovascular disease.
absorbed by some subjects. Seven of the 18 subjects were normal volunteers who had never previously received lithium medication; this was also so for five of the 11 patients, while the other six patients had not received lithium for at least three months. Although the shapes of the plasma lithium curves would of course be different if single doses of the various preparations were given to subjects stabilised on lithium, there is no reason to suppose that the rates of absorption and excretion would differ greatly under these conditions provided the single dose was administered not less than 10-12 h after previous lithium ingestion. However, in order to study these findings further under practical conditions we have investigated the effect of substituting the same daily dosage (400 mg) of lithium carbonate BP for one of the controlledrelease preparations (Priadel) in a group of 11 patients stabilised on the latter. Plasma lithium was determined on three occasions at weekly intervals before the substitution and again one, two, and three weeks after the switch, blood being taken in each case not less than 10 h after the last lithium dose. No significant differences between the pre- and postsubstitution mean plasma lithium levels were observed. The range of daily oral dosage was JOHN R GOLDING 400-2000 mg. While the protocol of this investigation does Harrogate Royal Bath Hospital, Harrogate, N Yorks not preclude the possibility of different diurnal plasma lithium patterns, the similar baseline levels obtained with the two preparations confirms our previous conclusion that there Malignant hypertension secondary to is no basis for administering Priadel in preferidiopathic arteritis of the aorta ence to lithium carbonate BP. R P HULLIN SIR,-The very interesting case reported by Dr R A Wall and others (23 October, p 977) Regional Metabolic Research Unit, Royds Hospital, is the third such case to be reported from the High Ilkley, W Yorks Ndola Central Hospital, Zambia.' 2 The similarities between the patient reTyrer, S, et al, Psychological Medicine, 1976, 6, 51. ported by Dr Wall and his colleagues and our second one are very close. Both were young (16 and 20 years respectively) and had malig- Predicting child abuse nant renovascular hypertension, but renal function was well preserved and hypertension SIR,-The papers from the Park Hospital, was easily controlled, in our case by drugs and Oxford, in the past two years have opened up in their case by nephrectomy and a diuretic. the possibilities for helping families long Their description of the histological appear- before a disaster occurs. Dr Margaret A Lynch and Mrs Jacqueline ance of the resected renal upper pole artery is very similar to our description of the aortic Roberts (5 March, p 624) are right in saying changes in the necropsy specimen in our first that "there seems to be a need for co-ordinating all disciplines, both in the hospital and in the case-degeneration of the media. community." This could be done by holding MARK N LOWENTHAL some antenatal examinations in the home. With the reorganisation of the Health Service Department of Medicine, Baragwanath Hospital, community midwives are now based in South Africa hospitals in close contact with consultant Lowenthal, M N, Doctor, S A, and Fine, J, Post- units. When a midwife finds that a family graduate Medical 7ournal, 1968, 44, 928. scores highly on a number of factors she can 2 Lowenthal, M N, Patel, D C, and Pillai, K M, Lancet, discuss the significance of this with the family 1971, 1, 295. and alert the health visitor and family doctor. Advantages of this suggestion are: (1) Prediction of child abuse in an informal way. Absorption of lithium from controlled- (2) Reduction of the size of antenatal clinics. After booking, antenatal checks in the early release preparations and middle months of pregnancy are medically SIR,-We have reported1 the 24-h plasma dull and can be looked on as a waste of skilled lithium profiles of 18 fasting subjects who obstetricians' time. Removal of about half were given single oral doses of one or more these examinations would free the doctors for of either the standard BP or two controlled- complicated situations where they are really release preparations of lithium carbonate. needed. (3) Increase in the role, interest, and Although the controlled-release tablets showed responsibility of community midwives. (4) slow release in vitro, this was not so in vivo. Saving of money by transferring medical There was no difference in the rate of absorp- time from cost-intensive hospitals to the tion and excretion between the BP preparation primary care team-generally found to be used (Camcolit) and one controlled-release cheaper. It is hoped that obstetricians, midwives, preparation (Priadel), while the other slowrelease preparation (Phasal) was ineffectively and paediatricians will collaborate, perhaps at
Loss of vision may occur very suddenly without an increase of symptoms and without a spread of symptoms to affect the temples or scalp. I myself have missed a case of polymyalgia with arteritic lesions which produced blindness. The patient was a proven rheumatoid who complained of sudden increase of pain in both shoulders. As her erythrocyte sedimentation rate (ESR) was only marginally raised at 18 mm in 1 h I dismissed the diagnosis of polymyalgia even though I thought of it. She returned to the clinic the following week blind in one eye, a temporal artery biopsy proving positive. Involvement of the facial artery occurs occasionally, such patients often being referred to an ear, nose, and throat surgeon. Lastly, I have encountered polymyalgia apparently as a systemic manifestation of a neoplasm; one useful guide here is that whereas symptoms abate with steroids the ESR remains very high. I think that polymyalgia is the only condition in which I prescribe the appropriate drug from a hospital clinic. Any such patient is at risk from arteritis causing visual loss; it is my practice to ask the patient to remain in the clinic until the result of the ESR is to hand.
1350
the instigation of their area review committee on non-accidental injury, to start pilot schemes along these lines. RICHARD STONE London W2
(6) Relapses are a typical feature of this illness and may occur even after several years of good health.4
produce involuntary movements in the same way as chloroquine.
Last year a research group was formed to study the aetiology and epidemiology of this syndrome. Our investigations so far indicate that the illness may accompany the more common viral infections and that the unique fatigue pattern may be due to mitochondrial damage. As objective manifestations of the disease can still be present over 30 years after the initial illness we should be glad to hear from former sufferers who were members of the medical and nursing staff of the Royal Free Hospital or other institutions which have experienced outbreaks. Communications should be sent to the honorary secretary of the group (JVD) at the address below.
Elmdene Alcoholic Treatment Unit, Bexley Hospital, Bexley, Kent
SIR,-We would like to take the opportunity of commenting on the important points made by two recent correspondents, Dr P C Corry and Mr G T Meredith (23 April, p 1084). There is certainly a need to look at larger samples than we were able to include in our study (5 March, p 624). However, we should not be deterred from considering preventive action simply because the percentage of newborns "at risk" seems to be so large. In our experience intervention frequently does not have to be massive. Open recognition of the parents' difficulties in caring for the child A M RAMSAY can result in a more positive attitude towards E G DOWSETT existing services, which can often be adapted J V DADSWELL to provide the help the family needs.' W H LYLE Our data were collected at the maternity J G PARISH hospital. Thus most information, not unBenign Myalgic Encephalomyelitis naturally, was concerning the mother. This Research Group does not mean that all the children were Public Health Laboratory, battered by their mothers. We have found that Royal Berkshire Hospital, both parents are often deeply involved in the Reading, Berks abuse of their child, irrespective of who actually I Ramsay, A M, Update, 1976, 13, 539. inflicts the injuries; it is not necessarily 2 Parish, J G, IRCS Journal of international Research Communications, 1974, 2, 22. helpful to concentrate on "who did it." 3 Leon-Sotomayor, L, Epidemic Diencephalomyelitis. Sometimes the parent who is not the identified New York, Pageant Press, 1969. 4 Marinacci, A A, and Von Hagen, K, Electromyography, abuser in one incident subsequently batters 1965, 5, 241. the same child or marries another battering partner. MARGARET A LYNCH Mechanism of chloroquine induced JACQUIE ROBERTS involuntary movements Human Development Research
Unit,
Park Hospital for Children, Headington, Oxford
Beswick, K, Lynch, M A, and Roberts, J, British Medical,Journal, 1976, 2, 800.
Icelandic disease (benign myalgic encephalomyelitis or Royal Free disease) SIR,-We were interested to read your expert's reply to the question on the nature of Icelandic disease (9 April, p 965). We should like to present the following additional information: (1) None of the names in common use is completely descriptive of this syndrome, which is not truly benign, is not always myalgic, and has no proved connection with hysteria or neurasthenia.' (2) The sufferers are usually parents of young children or members of the armed Forces or of the teaching, nursing, or medical professions. The classic illness has a biphasic pattern with an initial episode of gastrointestinal or upper respiratory tract infection, with or without a rash and lymphadenopathy, affecting either the patient or juvenile members of the family. (3) The most characteristic presentation is profound fatigue and muscular weakness coming on during the day and increasing in severity with exercise-a diurnal rhythm contrary to that found with other forms of depression. (4) Other symptoms that may accompany the initial illness or a relapse include muscular fasciculation, paraesthesiae, and disturbance of vision, with which nystagmus may be seen. Autonomic disturbances such as orthostatic tachycardia, vasomotor instability, and episodes of pallor are often prominent. Encephalitic disturbances include severe depression, emotional lability, and difficulty in concentration. (5) Physical findings may include atypical lymphocytes in the peripheral blood, hepatitis, electromyographic evidence of myelopathic and neuropathic disorders, and abnormal glucose tolerance curves.2 3
21 MAY 1977
BRITISH MEDICAL JOURNAL
S K MAJUMDAR
Potts, A M, in Physiological Pharmacology, ed W S Root and F G Hofmann, vol II, part B, pp 329-397. New York, Academic Press, 1965. Rollo, I M, in The Pharmacological Basis of Therapeutics. ed L S Goodman, A Gilman, A G Gilman, and G B Koelle, 5th edn, p 1051. New York, Macmillan, 1975.
Insurance companies' attitude to psychiatric illness SIR,-In recent issues you have printed letters from two psychiatrists expressing concern at the harsh attitude towards minor psychiatric illness taken by insurance companies, and the untoward experiences of five neurotic patients are mentioned. Dr J T Hutchinson (9 March, p 775) describes excessive loading against those who seek life insurance and Dr A B Sclare (16 April, p 1031) from his experience with employees of insurance companies becoming patients stresses the lack of confidentiality, punitive attitudes towards mental illness, and absence of discrimination between mild and serious psychiatric illness. Although I would agree that the attitudes of the companies should be enlightened and informed, it is worth mentioning that the neuroses do carry a slightly increased risk of premature mortality as demonstrated in the studies by Babigian and Odoroff,l by Innes and Millar,' by Keehn et al3 and by me.4 Further findings on the extent of this increased death risk will be published soon, but figures have generally been about 15 times those for the matched general population. It would seem reasonable that psychiatrists should ask the insurance companies to take the psychiatric diagnosis into account in their assessment of weighting so ihat neuroses and other disorders can be differentially weighted. This would result in a slightly increased premium for neurosis which should by no means be prohibitive. ANDREW SIMS
SIR,-I read with interest the report by Drs E M Umez-Eronini and Elspeth A Eronini on chloroquine induced involuntary movements (9 April, p 945). May I throw some light on the probable mechanism of these movements ? Chloroquine and phenothiazines combine avidly with melanin both in vitro and in vivo; this is believed to be based on a charge transfer reaction facilitated by the presence of electrons in the fused coplanar ring structures of both chloroquine and phenothiazines.' University Department of Psychiatry, Melanin is a derivative of DOPA (phenyl- Queen Elizabeth Hospital, alanine -* tyrosine -* dihydroxyphenylalanine Birmingham
(DOPA) -* DOPA-quinone -* melanin). Chloroquine, a 4-aminoquinoline derivative, crosses the blood-brain barrier, and the brain and spinal cord contain 10-30 times the amount present in plasma.2 It is quite logical to infer from the structure-activity relationship that chloroquine may also avidly combine with the dopaminergic receptors (like melanin) and thus by blocking those receptors (like phenothiazines, butyrophenones, metoclopramide, etc) in the nigrostriatal system it may produce involuntary movements. It is another example of drug-induced extrapyramidal disorders. In the light of this it is better not to give patients with chloroquine induced involuntary movements phenothiazines like chlorpromazine, which may aggravate the situation. Anticholinergic anti-Parkinsonian drugs like benztropine, benzhexol, orphenadrine, ethopropazine, procyclidine, etc should be given in these cases as their action is not dependent on the dopaminergic receptors in the nigrostriatal system. It needs to be mentioned that other members of 4-aminoquinoline family like amodiaquine, cycloquine, and hydroxychloroquine may also
Babigian, H M, and Odoroff, C L, American3Journal of Psychiatry, 1969, 126, 470. Innes, G, and Millar, W M, Scottish Medical journal, 1970, 15, 143. 3Keehn, R J, Goldberg, I D, and Beebe, G W, Psychosomatic Medicine, 1974, 36, 27. ' Sims, A C P, Lancet, 1973, 2, 1072. 2
Maintenance digoxin
SIR,-Concerning Dr B J O'Driscoll's comments (16 April, p 1028) on our paper (19 March, p 749), comparison with pioneering studies is difficult because of historical emphasis on digitalisation rather than maintenance therapy, the fact that digitalis used to be pushed until cardiotoxicity occurred, and differences in concomitant therapy. Although Sir James Mackenzie' in 1910 obtained the best response in failure associated with "rapid" atrial fibrillation, he did not consider that decreasing the rate was the primary mechanism: "The good results obtained by the use of digitalis are doubtless due to the specific action of the drug on the function of tonicity." Windle2 in 1917 demonstrated the value of digitalis in patients with pulsus alternans, while
