BRITISH MEDICAL JOURNAL
10 MAY 1975
315
energy shocks were successful then. The initial shock was unsuccessful in 7 %O (two out of 28) of patients with primary fibrillation, but a second shock of identical energy was successful in both patients. The success of the second shock when the initial one has failed29 may be related to the decreased impedance with successive shocks.30 Apart from allowing smaller and lighter defibrillators these lower energy shocks cause less myocardial damage. Our findings indicate the need for further investigation of the energy needed for defibrillation. Tacker et al.28 claim that defibrillators should have a much higher output capacity than they do at present, but high capacity output instruments would be much heavier, more cumbersome, and more expensive and, therefore, less generally available. If it is confirmed that lowenergy direct current shocks, particularly when repeated, will almost invariably correct ventricular fibrillation a cheap and generally available pocket defibrillator will be a possibility.
Requests for reprints should be sent to Dr. J. F. Pantridge. References Bainton, C. R., and Peterson, D. R., New England Journal of Medicine, 1963, 268, 569. 2Adgey, A. A. J., et al., Lancet, 1969, 1, 1169.
3
Pantridge, J. F., and Adgey, A. A. J., in Textbook of Coronary Care, ed. L. E. Meltzer and A. J. Dunning, p. 95. New York, Charles Press, 1972. Lown, B., and Ruberman, W., Modern Concepts of Cardiovascular Disease, 1970, 39, 97. 5Koch-Weser, J., New England Journal of Medicine, 1971, 285, 1024. 6 Koch-Weser, J., Archives of Internal Medicine, 1972, 129, 763. 7Burgess, M. J., et al., American Journal of Cardiology, 1971, 27, 617. 8 Pantridge, J. F., and Geddes, J. S., Lancet, 1967, 2, 271. 9 Nagel, E. L., et al., Journal of the American Medical Association, 1970, 214, 332. 10 Cobb, L. A., et al., Circulation, 1970, 41 and 42, Suppl. III, p. 144. 1 Gearty, G. F., et al., British Medical_Journal, 1971, 3, 33. 12 Rose, L. B., and Press, E., Journal of the American Medical Association, 1972, 219, 63. 13 Grace, W. J., and Chadbourn, J. A., Diseases of the Chest, 1969, 55, 452. 14 Crampton, R. S., et al., Virginia Medical Monthly, 1972, 99, 1191. 15 White, N. M., et al., British Medical Journal, 1973, 3, 618. 16 Chiang, B. N., et al., Annals of Internal Medicine, 1969, 70, 1159. 17 Lown, B., and Wolf, M., Circulation, 1971, 44, 130. 18 Hinkle, L. E., jun., Carver, S. T., and Plakun, A., Archives of Internal Medicine, 1972, 129, 732. 9 Mirowski, M., et al., Archives of Internal Medicine, 1970, 126, 158. 20 Lown, B., and Axelrod, P., Circulation, 1972, 46, 637. 21 Friedberg, C. K., Circulation, 1972, 45, 179. 22 Peleska, B., Circulation Research, 1966, 18, 10. 23 Tacker, W. A., jun., et al., New England Journal of Medicine, 1974, 290, 214. 24 Tacker, W. A., jun., et al., American3Journal of Cardiology, 1974, 33, 172. 25 Lappin, H. A., New England Journal of Medicine, 1974, 291, 153. 26 Lown, B., in The Current Status of Intensive Coronary Care, ed. L. E. Meltzer and J. R. Kitchell, p. 36. New York, Charles Press, 1966. 27 Lawrie, D. M., et al., Lancet, 1967, 2, 109. 28 Tacker, W. A., jun., et al., American Heart Journal, 1974, 88, 476. 29 Mackay, R. S., and Leeds, S. E.,Journal of Applied Physiology, 1953, 6, 67. 30 Geddes, L. A., et al., Circulation, 1974, 49 and 50, Suppl. III, p. 99.
SHORT REPORTS Carcinoma of the Oesophagus with "Swallow Syncope" Swallowing is an unsual cause of syncope. In all the patients so far described in which an oesophageal lesion was found, it was benign. We describe a patient in whom swallow syncope was the presenting symptom of carcinoma of the oesophagus.
Case Report A 74-year-old man was admitted to Kingston General Hospital, Hull, in September 1974 with a two-month history of recurrent syncopal episodes, which occurred only while he was eating or drinking. After each attack he immediately felt well and denied any prior chest pains or palpitations. There was no relevant past history, apart from angina pectoris for 12 years, but, on further questioning, he admitted that for two months he had noticed a sensation of his food "sticking" at the lower end of his sternum. Examination showed no abnormalities. The E.C.G. showed sinus rhythm with T wave inversion in the inferior leads. Other routine investigations were all normal. Continuous E.C.G. monitoring showed that whenever the patient ate or drank he developed definite sinus bradycardia (often as slow as 15 per minute) and on one occasion sinus arrest lasting six seconds. This was always associated with a feeling of lightheadedness. Atropine 1-2 mg, intravenously given 10 minutes before meals prevented these episodes. A barium swallow showed a large, dilated oesophagus with an irregular, fixed filling defect at the lower end. Fibreoptic endoscopy was performed (after the insertion of a temporary demand transvenous pacing catheter)
and a friable polypoid growth was seen encircling the lower end of the oesophagus. Biopsy of the growth showed a poorly differentiated adenocarcinoma which had infiltrated the submucosa of the oesophagus. At operation oesophagoscopy was repeated with the pacemaker switched off. The obstruction was seen at 40 cm and when the oesophagoscope was passed beyond this point the patient developed a profound sinus bradycardia. This recovered completely as soon as the oesophagoscope was withdrawn above this level. Partial oesophagogastrectomy with an oesophagogastric anastomosis was then performed via a left thoracotomy. Postoperative recovery was uneventful. Three months later he was eating and drinking without discomfort. An E.C.G. recording at that time showed sinus rhythm with no change in heart rate on swallowing.
Discussion Data on the 14 patients previously described with syncope on swallowing are summarized in the table. Syncope in relation to oesophageal carcinoma has not been reported before. In most reported patients syncope was due to disturbances of atrioventricular conduction; in only a minority of patients could digitalis be implicated as a contributory factor. In one patient His-bundle studies showed the block to be above the bundle of His.' In only one patient has syncope been attributed to sinus bradycardia with sinus arrest.2 Most authors postulate a vagovagal reflex mechanism. The abolition of the symptoms by atropine in our patient, also reported by others, supports the vagus as the efferent pathway; a vagal afferent pathway is also likely, though the possible role of the sympathetic nerves has not been explored.
Clinical and Pathological Features of Described Cases of Swallow Syncope Reference MacKenzie, 1906 .. .. Weiss and Ferris, 1934 .. Weiss and Ferris, 1934 .. Iglauer and Schwartz, 1936 .. Correll and Lindert, 1949 James, 1958 ..58 .. Deuchar and Trounce, 1960 Pedersen, 1963 Kopald et al., 1964 ..48 .. Tolman and Ashworth, 1971 . Sapru et al., 19713. .. Levin and Posner, 19724
Lichstein and Chadda, 19721 Alstrup and Pedersen, 1973'
.. ..
Age 25 64 59 55 67 63 63
45 56 85 64
Sex
M M F F M M M M M M F M M F
Known ischaemic Pathology heart disease Unknown .. .None .. None Oesophageal diverticulum Unknown. . . None .. None "Spastic oesophagus" .. None Oesophageal diverticulum .. Yes Oesophageal diverticulum .. Diffuse oesophageal spasm None .. Achalasia of the cardia Not stated Diffuse oesophageal spasm .. None .. Not stated Oesophageal stricture None . . . None Carcinomatous meningitis with demyelination of the vagus nerve. No oesophageal pathology. .. None None .. .Yes .. Diffuse oesophageal spasm None
Observed Arrhythmia A-V block
Complete heart block, ventricular arrest Sinus arrest Complete heart block A-V block with slow irregular rhythm A-V block leading to asystole Ventricular asystole Atrial fibrillation and ventricular asystole Nodal or sinus bradycardia, sinus arrest with nodal escape Sinus bradycardia Ventricular asystole A-V block A-V block A-V block
BRITISH MEDICAL
316
Our patient differs from most others described in that the symptoms and E.C.G. changes were readily reproduced on swallowing, without resort to balloon dilatation of the oesophagus. In addition his syncope was a presenting symptom of oesophageal carcinoma. Since an oesophageal lesion is commonly found in patients with "swallow syncope" we suggest that a barium swallow should be performed in all patients with this syndrome, even in the absence of dysphagia. We are grateful to Dr. R. W. Portal for permission to report on one of his patients and for his help with the preparation of the manuscript, and for the help of Mr. K. Moghissi who performed the operation.
References Lichstein, E., and Chadda, K. D., American Journal of Cardiology, 1972, 29, 561. 2 Kopald, H. H., et al., New England Journal of Medicine, 1964, 271, 1238. Sapru, R. P., et al., British Heart3Journal, 1971, 33, 617. 4 Levin, B., and Posner, J. B., Neurology, 1972, 22, 1086. 5 Alstrup, P., and Pedersen, S. A., Acta Medica Scandinavica, 1973, 193, 4
365.
JOURNAL
10 MAY 1975
Discussion The complications of fractures after electric convulsion treatment have been reported.' 2 In a patient with a fracture any coexisting injury to the central nervous system with increased muscle tone can produce severe displacement of the fracture. Any lesion which cuts off the descending tract from the red nucleus and leaves Deiter's nucleus intact leads to decerebrate rigidity,' and this happens in brain stem injury. This results in full extension of the hips and knees and plantar flexion of the ankles. The arms may be extended or flexed and they are held firmly in this position. The fluctuation in the level of consciousness determines the severity of the brain stem injury. If, after a head injury, consciousness is not lost or is rapidly gained no serious degree of injury to the brain stem will occur. The importance of this observation is that the original trace of resistance present on testing joint movement in the patient will not be followed by decerebrate rigidity and the fracture may be treated by conservative methods provided that the slightly increased muscle tone is not displacing the fracture. I should like to thank Mr. D. F. Paton, F.R.C.S., for permitting me to report the details of his patient.
The Cardiac Department, Kingston General Hospital, Hull HU3 1UR I. W. TOMLINSON, M.B., B.S., Registrar K. M. FOX, M.B., M.R.C.P., Registrar
Treatment of Fractures of the Long Bones in Brain Stem Injury The partial maintenance of the position of a reduced fracture by the stabilizing action of the muscles with constant normal tone is well known. If the muscle tone becomes abnormally increased the muscles will displace the fracture by anteroposterior displacement or overlapping. Traction will only increase the abnormal tone of the muscles through the stretching reflex and displacement will increase. This is true in the conservative treatment of fractures of long bones associated with decerebrate rigidity due to brain stem injury, and this paper emphasizes the danger of such treatment.
Kelly, J. P.,3Journal of Bone and Joint Surgery, 1954, 36B, 70. 2Newbold, H. I., Diseases of the Nervous System, 1958, 19, 385. 3 Rowbotham, G. F., Acute Injuries of the Head, 4th edn. Baltimore, Williams and Wilkins, 1964. 1
Whittington Hospital, London N19 SNF P. MERIANOS, M.D., Orthopaedic Registrar
Reversible Infertility in Male Coeliac Patients Though infertility reversed by treatment with a gluten-free diet has been reported in women with coeliac disease' it has not been reported in men. In our group of 40 men with coeliac disease, we encountered two in whom infertility was corrected after treatmnent for three and five years with a gluten-free diet.
Case Report An 8-year-old boy, knocked unconscious by a car, had brisk reflexes with a positive Babinski sign and some generalized spasticity. There was a fracture deformity of the right femur. An x-ray examination of the skull and cervical spine showed no bony injury but that of the right femur showed oblique fracture at the junction of the middle third to the distal third. The diagnosis was a closed oblique fracture of the right femoral shaft associated with brain stem injury. He was kept under observation and traction with a 1-8 kg weight in a Thomas splint was applied to the femur. An x-ray examination showed a 2-5 cm overlapping, and an anteroposterior displacement. The traction weight was increased by 1-8 kg. Two days later blood was noticed on the crepe bandage around the thigh, and there was a 3-75-cm wound with a spike of bone protruding. This was treated by suturing the wound and applying skeletal traction. There was still persistent overlapping and anteroposterior displacement (see figure). Clinical examination at the time showed generalized rigidity with elbows in flexion, wrists in palmar flexion, and feet in equinus. Two days later the thigh bandage was again wet with blood, and another wound, 2-5 cm long, was found in a different position from the previous one, with the spike of the proximal fragment of the fractured femur protruding through it. There was some redness of the skin around the wound and some skin crepitation. Gas gangrene was suspected. The patient had a total wound excision, muscle biopsy, and swab for culture. In addition, an open reduction and internal fixation of the fracture using a six hole plate was performed. Antibiotics were started after operation. The culture proved negative.
*
.* ..*:.
Case Histories The first patient was investigated for infertility at the age of 29 in 1964. He had been married for nine years. A physical examination was normal, as was his sexual function. His wife had been investigated a year earlier and no abnormalities found. In 1970 his G.P. referred him for investigation of aphthous ulcers. Tests showed a low serum folate level, faecal fats 19 g/dy, and subtotal villous atrophy on jejunal biopsy. Coeliac disease was diagnosed and a gluten-free diet started in September 1970. In 1974 repeat jejunal biopsy showed mucosal return to normal, and his wife gave birth to a healthy 7 lb (3-175 kg) male infant.
Seminal Fluid Analyses Date
Count (Millions/ml)
Case 1 Before gluten-free diet 13.10.64 20.10.64 16.3.65 30.3.65 20.4.65 18.5.65 1.6.66 After gluten-free diet 20.9.71 28.9.71 5.10.71 10.11.71 17.1.74 Case 2 Before gluten-free diet 1.7.52 8.7.52
After gluten-free diet
The displacement of the fracture persists. The skeletal traction did not improve the position of the fracture.
Vol (ml)
4.2.74 11.2.74
% Motility o
2-0 2-0 2-0 2-5 1.0 2-0 1-5
40 7-5 30
2-0 50 40
1F0
20 5 5 50 5 30 10
2-0 2-0 3-5 1-5 2-0
1.0 10 50 32-0 10 0
5 5 50 20 50
2-0
2-0
4-0 4-0
1.0
1.0
20 10
5
5
42 60
10 MAY 1975
315
energy shocks were successful then. The initial shock was unsuccessful in 7 %O (two out of 28) of patients with primary fibrillation, but a second shock of identical energy was successful in both patients. The success of the second shock when the initial one has failed29 may be related to the decreased impedance with successive shocks.30 Apart from allowing smaller and lighter defibrillators these lower energy shocks cause less myocardial damage. Our findings indicate the need for further investigation of the energy needed for defibrillation. Tacker et al.28 claim that defibrillators should have a much higher output capacity than they do at present, but high capacity output instruments would be much heavier, more cumbersome, and more expensive and, therefore, less generally available. If it is confirmed that lowenergy direct current shocks, particularly when repeated, will almost invariably correct ventricular fibrillation a cheap and generally available pocket defibrillator will be a possibility.
Requests for reprints should be sent to Dr. J. F. Pantridge. References Bainton, C. R., and Peterson, D. R., New England Journal of Medicine, 1963, 268, 569. 2Adgey, A. A. J., et al., Lancet, 1969, 1, 1169.
3
Pantridge, J. F., and Adgey, A. A. J., in Textbook of Coronary Care, ed. L. E. Meltzer and A. J. Dunning, p. 95. New York, Charles Press, 1972. Lown, B., and Ruberman, W., Modern Concepts of Cardiovascular Disease, 1970, 39, 97. 5Koch-Weser, J., New England Journal of Medicine, 1971, 285, 1024. 6 Koch-Weser, J., Archives of Internal Medicine, 1972, 129, 763. 7Burgess, M. J., et al., American Journal of Cardiology, 1971, 27, 617. 8 Pantridge, J. F., and Geddes, J. S., Lancet, 1967, 2, 271. 9 Nagel, E. L., et al., Journal of the American Medical Association, 1970, 214, 332. 10 Cobb, L. A., et al., Circulation, 1970, 41 and 42, Suppl. III, p. 144. 1 Gearty, G. F., et al., British Medical_Journal, 1971, 3, 33. 12 Rose, L. B., and Press, E., Journal of the American Medical Association, 1972, 219, 63. 13 Grace, W. J., and Chadbourn, J. A., Diseases of the Chest, 1969, 55, 452. 14 Crampton, R. S., et al., Virginia Medical Monthly, 1972, 99, 1191. 15 White, N. M., et al., British Medical Journal, 1973, 3, 618. 16 Chiang, B. N., et al., Annals of Internal Medicine, 1969, 70, 1159. 17 Lown, B., and Wolf, M., Circulation, 1971, 44, 130. 18 Hinkle, L. E., jun., Carver, S. T., and Plakun, A., Archives of Internal Medicine, 1972, 129, 732. 9 Mirowski, M., et al., Archives of Internal Medicine, 1970, 126, 158. 20 Lown, B., and Axelrod, P., Circulation, 1972, 46, 637. 21 Friedberg, C. K., Circulation, 1972, 45, 179. 22 Peleska, B., Circulation Research, 1966, 18, 10. 23 Tacker, W. A., jun., et al., New England Journal of Medicine, 1974, 290, 214. 24 Tacker, W. A., jun., et al., American3Journal of Cardiology, 1974, 33, 172. 25 Lappin, H. A., New England Journal of Medicine, 1974, 291, 153. 26 Lown, B., in The Current Status of Intensive Coronary Care, ed. L. E. Meltzer and J. R. Kitchell, p. 36. New York, Charles Press, 1966. 27 Lawrie, D. M., et al., Lancet, 1967, 2, 109. 28 Tacker, W. A., jun., et al., American Heart Journal, 1974, 88, 476. 29 Mackay, R. S., and Leeds, S. E.,Journal of Applied Physiology, 1953, 6, 67. 30 Geddes, L. A., et al., Circulation, 1974, 49 and 50, Suppl. III, p. 99.
SHORT REPORTS Carcinoma of the Oesophagus with "Swallow Syncope" Swallowing is an unsual cause of syncope. In all the patients so far described in which an oesophageal lesion was found, it was benign. We describe a patient in whom swallow syncope was the presenting symptom of carcinoma of the oesophagus.
Case Report A 74-year-old man was admitted to Kingston General Hospital, Hull, in September 1974 with a two-month history of recurrent syncopal episodes, which occurred only while he was eating or drinking. After each attack he immediately felt well and denied any prior chest pains or palpitations. There was no relevant past history, apart from angina pectoris for 12 years, but, on further questioning, he admitted that for two months he had noticed a sensation of his food "sticking" at the lower end of his sternum. Examination showed no abnormalities. The E.C.G. showed sinus rhythm with T wave inversion in the inferior leads. Other routine investigations were all normal. Continuous E.C.G. monitoring showed that whenever the patient ate or drank he developed definite sinus bradycardia (often as slow as 15 per minute) and on one occasion sinus arrest lasting six seconds. This was always associated with a feeling of lightheadedness. Atropine 1-2 mg, intravenously given 10 minutes before meals prevented these episodes. A barium swallow showed a large, dilated oesophagus with an irregular, fixed filling defect at the lower end. Fibreoptic endoscopy was performed (after the insertion of a temporary demand transvenous pacing catheter)
and a friable polypoid growth was seen encircling the lower end of the oesophagus. Biopsy of the growth showed a poorly differentiated adenocarcinoma which had infiltrated the submucosa of the oesophagus. At operation oesophagoscopy was repeated with the pacemaker switched off. The obstruction was seen at 40 cm and when the oesophagoscope was passed beyond this point the patient developed a profound sinus bradycardia. This recovered completely as soon as the oesophagoscope was withdrawn above this level. Partial oesophagogastrectomy with an oesophagogastric anastomosis was then performed via a left thoracotomy. Postoperative recovery was uneventful. Three months later he was eating and drinking without discomfort. An E.C.G. recording at that time showed sinus rhythm with no change in heart rate on swallowing.
Discussion Data on the 14 patients previously described with syncope on swallowing are summarized in the table. Syncope in relation to oesophageal carcinoma has not been reported before. In most reported patients syncope was due to disturbances of atrioventricular conduction; in only a minority of patients could digitalis be implicated as a contributory factor. In one patient His-bundle studies showed the block to be above the bundle of His.' In only one patient has syncope been attributed to sinus bradycardia with sinus arrest.2 Most authors postulate a vagovagal reflex mechanism. The abolition of the symptoms by atropine in our patient, also reported by others, supports the vagus as the efferent pathway; a vagal afferent pathway is also likely, though the possible role of the sympathetic nerves has not been explored.
Clinical and Pathological Features of Described Cases of Swallow Syncope Reference MacKenzie, 1906 .. .. Weiss and Ferris, 1934 .. Weiss and Ferris, 1934 .. Iglauer and Schwartz, 1936 .. Correll and Lindert, 1949 James, 1958 ..58 .. Deuchar and Trounce, 1960 Pedersen, 1963 Kopald et al., 1964 ..48 .. Tolman and Ashworth, 1971 . Sapru et al., 19713. .. Levin and Posner, 19724
Lichstein and Chadda, 19721 Alstrup and Pedersen, 1973'
.. ..
Age 25 64 59 55 67 63 63
45 56 85 64
Sex
M M F F M M M M M M F M M F
Known ischaemic Pathology heart disease Unknown .. .None .. None Oesophageal diverticulum Unknown. . . None .. None "Spastic oesophagus" .. None Oesophageal diverticulum .. Yes Oesophageal diverticulum .. Diffuse oesophageal spasm None .. Achalasia of the cardia Not stated Diffuse oesophageal spasm .. None .. Not stated Oesophageal stricture None . . . None Carcinomatous meningitis with demyelination of the vagus nerve. No oesophageal pathology. .. None None .. .Yes .. Diffuse oesophageal spasm None
Observed Arrhythmia A-V block
Complete heart block, ventricular arrest Sinus arrest Complete heart block A-V block with slow irregular rhythm A-V block leading to asystole Ventricular asystole Atrial fibrillation and ventricular asystole Nodal or sinus bradycardia, sinus arrest with nodal escape Sinus bradycardia Ventricular asystole A-V block A-V block A-V block
BRITISH MEDICAL
316
Our patient differs from most others described in that the symptoms and E.C.G. changes were readily reproduced on swallowing, without resort to balloon dilatation of the oesophagus. In addition his syncope was a presenting symptom of oesophageal carcinoma. Since an oesophageal lesion is commonly found in patients with "swallow syncope" we suggest that a barium swallow should be performed in all patients with this syndrome, even in the absence of dysphagia. We are grateful to Dr. R. W. Portal for permission to report on one of his patients and for his help with the preparation of the manuscript, and for the help of Mr. K. Moghissi who performed the operation.
References Lichstein, E., and Chadda, K. D., American Journal of Cardiology, 1972, 29, 561. 2 Kopald, H. H., et al., New England Journal of Medicine, 1964, 271, 1238. Sapru, R. P., et al., British Heart3Journal, 1971, 33, 617. 4 Levin, B., and Posner, J. B., Neurology, 1972, 22, 1086. 5 Alstrup, P., and Pedersen, S. A., Acta Medica Scandinavica, 1973, 193, 4
365.
JOURNAL
10 MAY 1975
Discussion The complications of fractures after electric convulsion treatment have been reported.' 2 In a patient with a fracture any coexisting injury to the central nervous system with increased muscle tone can produce severe displacement of the fracture. Any lesion which cuts off the descending tract from the red nucleus and leaves Deiter's nucleus intact leads to decerebrate rigidity,' and this happens in brain stem injury. This results in full extension of the hips and knees and plantar flexion of the ankles. The arms may be extended or flexed and they are held firmly in this position. The fluctuation in the level of consciousness determines the severity of the brain stem injury. If, after a head injury, consciousness is not lost or is rapidly gained no serious degree of injury to the brain stem will occur. The importance of this observation is that the original trace of resistance present on testing joint movement in the patient will not be followed by decerebrate rigidity and the fracture may be treated by conservative methods provided that the slightly increased muscle tone is not displacing the fracture. I should like to thank Mr. D. F. Paton, F.R.C.S., for permitting me to report the details of his patient.
The Cardiac Department, Kingston General Hospital, Hull HU3 1UR I. W. TOMLINSON, M.B., B.S., Registrar K. M. FOX, M.B., M.R.C.P., Registrar
Treatment of Fractures of the Long Bones in Brain Stem Injury The partial maintenance of the position of a reduced fracture by the stabilizing action of the muscles with constant normal tone is well known. If the muscle tone becomes abnormally increased the muscles will displace the fracture by anteroposterior displacement or overlapping. Traction will only increase the abnormal tone of the muscles through the stretching reflex and displacement will increase. This is true in the conservative treatment of fractures of long bones associated with decerebrate rigidity due to brain stem injury, and this paper emphasizes the danger of such treatment.
Kelly, J. P.,3Journal of Bone and Joint Surgery, 1954, 36B, 70. 2Newbold, H. I., Diseases of the Nervous System, 1958, 19, 385. 3 Rowbotham, G. F., Acute Injuries of the Head, 4th edn. Baltimore, Williams and Wilkins, 1964. 1
Whittington Hospital, London N19 SNF P. MERIANOS, M.D., Orthopaedic Registrar
Reversible Infertility in Male Coeliac Patients Though infertility reversed by treatment with a gluten-free diet has been reported in women with coeliac disease' it has not been reported in men. In our group of 40 men with coeliac disease, we encountered two in whom infertility was corrected after treatmnent for three and five years with a gluten-free diet.
Case Report An 8-year-old boy, knocked unconscious by a car, had brisk reflexes with a positive Babinski sign and some generalized spasticity. There was a fracture deformity of the right femur. An x-ray examination of the skull and cervical spine showed no bony injury but that of the right femur showed oblique fracture at the junction of the middle third to the distal third. The diagnosis was a closed oblique fracture of the right femoral shaft associated with brain stem injury. He was kept under observation and traction with a 1-8 kg weight in a Thomas splint was applied to the femur. An x-ray examination showed a 2-5 cm overlapping, and an anteroposterior displacement. The traction weight was increased by 1-8 kg. Two days later blood was noticed on the crepe bandage around the thigh, and there was a 3-75-cm wound with a spike of bone protruding. This was treated by suturing the wound and applying skeletal traction. There was still persistent overlapping and anteroposterior displacement (see figure). Clinical examination at the time showed generalized rigidity with elbows in flexion, wrists in palmar flexion, and feet in equinus. Two days later the thigh bandage was again wet with blood, and another wound, 2-5 cm long, was found in a different position from the previous one, with the spike of the proximal fragment of the fractured femur protruding through it. There was some redness of the skin around the wound and some skin crepitation. Gas gangrene was suspected. The patient had a total wound excision, muscle biopsy, and swab for culture. In addition, an open reduction and internal fixation of the fracture using a six hole plate was performed. Antibiotics were started after operation. The culture proved negative.
*
.* ..*:.
Case Histories The first patient was investigated for infertility at the age of 29 in 1964. He had been married for nine years. A physical examination was normal, as was his sexual function. His wife had been investigated a year earlier and no abnormalities found. In 1970 his G.P. referred him for investigation of aphthous ulcers. Tests showed a low serum folate level, faecal fats 19 g/dy, and subtotal villous atrophy on jejunal biopsy. Coeliac disease was diagnosed and a gluten-free diet started in September 1970. In 1974 repeat jejunal biopsy showed mucosal return to normal, and his wife gave birth to a healthy 7 lb (3-175 kg) male infant.
Seminal Fluid Analyses Date
Count (Millions/ml)
Case 1 Before gluten-free diet 13.10.64 20.10.64 16.3.65 30.3.65 20.4.65 18.5.65 1.6.66 After gluten-free diet 20.9.71 28.9.71 5.10.71 10.11.71 17.1.74 Case 2 Before gluten-free diet 1.7.52 8.7.52
After gluten-free diet
The displacement of the fracture persists. The skeletal traction did not improve the position of the fracture.
Vol (ml)
4.2.74 11.2.74
% Motility o
2-0 2-0 2-0 2-5 1.0 2-0 1-5
40 7-5 30
2-0 50 40
1F0
20 5 5 50 5 30 10
2-0 2-0 3-5 1-5 2-0
1.0 10 50 32-0 10 0
5 5 50 20 50
2-0
2-0
4-0 4-0
1.0
1.0
20 10
5
5
42 60
