877
industries. Yes, of course, requirements are changing and, to make a bad pun, new developments are continually demanding further study in greater depth. This flexibility is the credo of
is high because it is a sleep-associated hormone. each hormone augments the other’s effect on A.D.H. Normally, but if after a derangement of circadian rhythms the two hormones were 180° out of phase, they would antagonise each other with unpredictable results. Missing one night’s sleep might correct this because it would leave unaffected the cortisol rhythm, which is endogenous, while completely suppressing the early morning rise in prolactin, which depends upon sleep itself. Since both cortisol and prolactin influence Na+ and K+ excretion (and not always in the same direction), any uncoupling of their circadian rhythms may alter the Na+/K+ ratio.
good occupational medicine. Occupational, together with military, naval,
3 Wild Hatch, London NW11
SIR,-One is
not accustomed to read arrant nonsense in vour editorials, but my gorge rose when I read what you wrote about offshore medicine: "... the term embraces clinical and preventive skills not brought together elsewhere in medicine." What else do you go on to describe but occupational medicine? I feel that it is almost insulting to those doctors, both at home and abroad, who continue to practise just those skills required in this and other hazardous occupational environments. I can personally speak for those in the oil and mining
medicine, make fascinating
and aviation and varied demands of its doctors,
apparently insufficiently appreciated by you. You are correct, in the formal sense, when you say that "no specific postgraduate qualifications are needed to practise it", but you must know that good doctors, both civilian and service, are increasingly equipping themselves with qualifications while at the same time steps are being taken by at least one of the Royal Colleges in association with the Society of Occupational Medicine to formalise training in occupational medicine, bringing it into line with other specialties, as required under E.E.C. regulations. Meanwhile, occupational physicians, full-time and parttime, are maintaining and improving their skills to cope with both the mundane daily problems of hazardous work and the occasional major episodes requiring all the skills which you list. Health Unit, Central Middlesex Hospital, London NW10 7NS
Occupational
G. E. FFRENCH
A.D.H.
outpue)
GILLIAN M. SKUTSCH
SUSPECTED TRANSPLACENTAL COXSACKIE INFECTION
SIR,-A woman of 29 had been well during her second pregnancy until the 37th week when she had a febrile illness with acute abdominal pain and tenderness on palpation of the rectus abdominis muscles. This lasted for 2 days, but recurred more acutely 2 days later. She recovered slowly over the next 5 days, during which time the muscle tenderness continued; Bornholm disease was diagnosed.
Delivery at full term was normal and the baby, who weighed 3.93 kg, seemed normal. However, 12 weeks later a tendency to deviate his head and eyes to the left was noted, and examination revealed a right-sided hemiparesis. The infant is now 1 year old, and his development seems otherwise normal.
SWEAT-ELECTROLYTES IN MANIC-DEPRESSIVE ILLNESS
SIR,-The finding by
Dr Paschalis and his
3, p. 502) that the level of potassium in
colleagues (Sept.
sweat
from manic-
is higher than normal in the manic phase and lower than normal in the depressive phase may be an important clue to the causation of this illness. It is supported by Helmsley and Philips’ who showed that skin conductance is higher in manics than in depressives. In one case, the potassium (K+) level was 82 mmol/l and the sodium (Na+) level was 244 mmol/1. This K+ is 12 times the Na+ 5 times normal. Thus not only is the Na+/K+ ratio abnormal but the sweat itself is too concentrated. This points to water retention and the involvement of antidiuretic hormone (A.D.H.). Lithium, the drug of choice for mania, antagonises the activity of A.D.H. in the kidney, causing diuresis.2 Paradoxically, however, manics excrete larger volumes of urine than do depressives,3 suggesting that manics may pass too much water via the kidney and too little via the sweat glands, and vice versa for depressives. In normal people, night sweats are associated with nocturia and both are believed to be caused by low A.D.H. activity. Manic-depressives often switch from one phase to the other in the early hours of the day4 and it has been claimed that a single night of sleep deprivation can cure depressive attacks, at least in some persons. This suggests that some factor present during the night is responsible for the attacks and again may implicate A.D.H. because cortisol (which suppresses A.D.H. output6) is lowest at 2-3 A.M. while prolactin (which stimulates
depressive patients
1 Helmsley, D. R, Philips, H. C. Br J. Psychiat. 1975, 127, 78. 2. Beck, N., Davis, B. B Endocrinology, 1975, 97, 202. 3 Weil-Malherbe, H., Ström-Olsen, R. J. ment. Sci. 1958, 104, 696. 4 Jenner, F A., Gjessing, L. R., Cox, J. R., Davies-Jones, A., Hullin, R. Hanna, S. M. Br. J. Psychiat. 1967, 113, 895. 5 Bhanji, S., Roy, G A. ibid. 1975, 127, 222. 6 Vilhardt,H. Actaendocr. 1970, 65, 490. Horrobin, D F., Mtabaji, J. P., Manku, M. S. Endocrinology, 1976, 406 7
P.,
99,
Left-sided cerebral
atrophy
on
computerised tomography.
No virus studies were done during the mother’s acute illness, but 7 months post partum she had serum neutralisation-antibody titres of 1/128 to Coxsackie B2 and 1/256 to Coxsackie B viruses. A computerised tomogram of the baby’s brain when he was 3 months old showed extensive cerebral atrophy on the left side (see figure). At the same age his rubella-antibody titre (by hxmagglutination inhibition) was 1/8, and the dye-test titre for Toxoplasma and complement-fixation titres for cytomegalovirus were negative. Neutralisation-antibody titre to Coxsackie B2 was 1/256, and negative for the other Coxsackie B viruses. 4 months later the infant’s Coxsackie B2 antibody titre had fallen to 1/64. The baby probably had an infection with Coxsackie B2 virus at the age of 3 months: since he had been well up to that time and since his mother while pregnant had probably had Bornholm disease it is likely that the virus gained access to the fetus some 3 weeks before birth. The high Coxsackie B2 titres and
industries. Yes, of course, requirements are changing and, to make a bad pun, new developments are continually demanding further study in greater depth. This flexibility is the credo of
is high because it is a sleep-associated hormone. each hormone augments the other’s effect on A.D.H. Normally, but if after a derangement of circadian rhythms the two hormones were 180° out of phase, they would antagonise each other with unpredictable results. Missing one night’s sleep might correct this because it would leave unaffected the cortisol rhythm, which is endogenous, while completely suppressing the early morning rise in prolactin, which depends upon sleep itself. Since both cortisol and prolactin influence Na+ and K+ excretion (and not always in the same direction), any uncoupling of their circadian rhythms may alter the Na+/K+ ratio.
good occupational medicine. Occupational, together with military, naval,
3 Wild Hatch, London NW11
SIR,-One is
not accustomed to read arrant nonsense in vour editorials, but my gorge rose when I read what you wrote about offshore medicine: "... the term embraces clinical and preventive skills not brought together elsewhere in medicine." What else do you go on to describe but occupational medicine? I feel that it is almost insulting to those doctors, both at home and abroad, who continue to practise just those skills required in this and other hazardous occupational environments. I can personally speak for those in the oil and mining
medicine, make fascinating
and aviation and varied demands of its doctors,
apparently insufficiently appreciated by you. You are correct, in the formal sense, when you say that "no specific postgraduate qualifications are needed to practise it", but you must know that good doctors, both civilian and service, are increasingly equipping themselves with qualifications while at the same time steps are being taken by at least one of the Royal Colleges in association with the Society of Occupational Medicine to formalise training in occupational medicine, bringing it into line with other specialties, as required under E.E.C. regulations. Meanwhile, occupational physicians, full-time and parttime, are maintaining and improving their skills to cope with both the mundane daily problems of hazardous work and the occasional major episodes requiring all the skills which you list. Health Unit, Central Middlesex Hospital, London NW10 7NS
Occupational
G. E. FFRENCH
A.D.H.
outpue)
GILLIAN M. SKUTSCH
SUSPECTED TRANSPLACENTAL COXSACKIE INFECTION
SIR,-A woman of 29 had been well during her second pregnancy until the 37th week when she had a febrile illness with acute abdominal pain and tenderness on palpation of the rectus abdominis muscles. This lasted for 2 days, but recurred more acutely 2 days later. She recovered slowly over the next 5 days, during which time the muscle tenderness continued; Bornholm disease was diagnosed.
Delivery at full term was normal and the baby, who weighed 3.93 kg, seemed normal. However, 12 weeks later a tendency to deviate his head and eyes to the left was noted, and examination revealed a right-sided hemiparesis. The infant is now 1 year old, and his development seems otherwise normal.
SWEAT-ELECTROLYTES IN MANIC-DEPRESSIVE ILLNESS
SIR,-The finding by
Dr Paschalis and his
3, p. 502) that the level of potassium in
colleagues (Sept.
sweat
from manic-
is higher than normal in the manic phase and lower than normal in the depressive phase may be an important clue to the causation of this illness. It is supported by Helmsley and Philips’ who showed that skin conductance is higher in manics than in depressives. In one case, the potassium (K+) level was 82 mmol/l and the sodium (Na+) level was 244 mmol/1. This K+ is 12 times the Na+ 5 times normal. Thus not only is the Na+/K+ ratio abnormal but the sweat itself is too concentrated. This points to water retention and the involvement of antidiuretic hormone (A.D.H.). Lithium, the drug of choice for mania, antagonises the activity of A.D.H. in the kidney, causing diuresis.2 Paradoxically, however, manics excrete larger volumes of urine than do depressives,3 suggesting that manics may pass too much water via the kidney and too little via the sweat glands, and vice versa for depressives. In normal people, night sweats are associated with nocturia and both are believed to be caused by low A.D.H. activity. Manic-depressives often switch from one phase to the other in the early hours of the day4 and it has been claimed that a single night of sleep deprivation can cure depressive attacks, at least in some persons. This suggests that some factor present during the night is responsible for the attacks and again may implicate A.D.H. because cortisol (which suppresses A.D.H. output6) is lowest at 2-3 A.M. while prolactin (which stimulates
depressive patients
1 Helmsley, D. R, Philips, H. C. Br J. Psychiat. 1975, 127, 78. 2. Beck, N., Davis, B. B Endocrinology, 1975, 97, 202. 3 Weil-Malherbe, H., Ström-Olsen, R. J. ment. Sci. 1958, 104, 696. 4 Jenner, F A., Gjessing, L. R., Cox, J. R., Davies-Jones, A., Hullin, R. Hanna, S. M. Br. J. Psychiat. 1967, 113, 895. 5 Bhanji, S., Roy, G A. ibid. 1975, 127, 222. 6 Vilhardt,H. Actaendocr. 1970, 65, 490. Horrobin, D F., Mtabaji, J. P., Manku, M. S. Endocrinology, 1976, 406 7
P.,
99,
Left-sided cerebral
atrophy
on
computerised tomography.
No virus studies were done during the mother’s acute illness, but 7 months post partum she had serum neutralisation-antibody titres of 1/128 to Coxsackie B2 and 1/256 to Coxsackie B viruses. A computerised tomogram of the baby’s brain when he was 3 months old showed extensive cerebral atrophy on the left side (see figure). At the same age his rubella-antibody titre (by hxmagglutination inhibition) was 1/8, and the dye-test titre for Toxoplasma and complement-fixation titres for cytomegalovirus were negative. Neutralisation-antibody titre to Coxsackie B2 was 1/256, and negative for the other Coxsackie B viruses. 4 months later the infant’s Coxsackie B2 antibody titre had fallen to 1/64. The baby probably had an infection with Coxsackie B2 virus at the age of 3 months: since he had been well up to that time and since his mother while pregnant had probably had Bornholm disease it is likely that the virus gained access to the fetus some 3 weeks before birth. The high Coxsackie B2 titres and
