From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.nutrition
Subject: Re: Cause of numbness?
Date: 22 Aug 1998 05:08:57 GMT

In <361f0856.287307780@news.panix.com> donwiss@no.spam.com (Don Wiss)
writes:

>On Wed, 19 Aug 1998, Larry Rossi <lrossi@ix.netcom.com> wrote:
>
>>Is there any particular nutritional imbalance that could cause numbness
>>(loss of sense of touch) and poor circulation in my extremities?

Wiss:

>Yep. What you are asking about is called peripheral neuropathy. It is
often caused by nutritional deficiencies, especially deficiency of B
vitamins.<



Comment:
  In fact, in America, peripheral neuropathy is almost never caused by
vitamin deficiency, and almost never responds to nutritional repletion
(including B12 shots). This is an urban nutritional myth.  Such myths
are of the logical form: "Deficiency of vitamin X causes Y symptom.
Therefore, patients presenting with Y symptom generally have deficiency
of vitamin X."  Favorite Adelle Davis reasoning.

    In America, the most common peripheral neuropathy is caused by
diabetes.  There is also a peripheral neuropathy of unknown etiology
which presents in geriatrics, and which goes by various names.  "Senile
peripheral neuropathy" will give you the idea.  It's basically an age
related degeneration (probably), though like all age-related
degenerations, it doesn't happen at the same time to everyone.  And it
does NOT respond usually to vitamins (God knows, I've tried).

   Don Wiss thinks that everything is caused by celiac disease, and
that's worth checking in peripheral neuropathy.  However, be prepared
for very few "hits."

   Finally, I should remind all that peripheral neuropathy has very
little to do with the "circulation."  People often think they have poor
circulation because they can't feel anything.  That hardly ever
happens.  Poor arterial circulation causes pain, and pain which varies
with rest vs exercise.  Poor venous circulation may cause edema (which
arterial problems do NOT), but any neurological deficit is caused by
the edema and tissue swelling, not the circulation per se.  Edema can
cause some numbness, but be aware that most people with edema have
perfectly good feeling, leading me to guess that people with both edema
and numbness may have primary nerve damage problems to begin with,
which just haven't been apparent.



                                     Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.nutrition
Subject: Re: Cause of numbness?
Date: 24 Aug 1998 08:35:10 GMT

In article <36376899.443045621@news.panix.com>,
Donwiss@no.spam.com (Don Wiss) wrote:

>>On 22 Aug 1998, sbharris@ix.netcom.com(Steven B. Harris) wrote:
>>  In fact, in America, peripheral neuropathy is almost never caused y
>>>vitamin deficiency,>>

>Typical Steve Harris
>Just like his Alzheimer's thread in sci.med. Thinks
>he knows it all. I quote from The Merck Manual: "Nutritional
>deficiency and  metabolic disorders may result in polyneuropathy.
>Deficiency of B vitamins is often the cause (eg, in alcoholism,
>beriberi, pernicious anemia, isoniazid-induced pyridoxine deficiency,
>*malabsorption syndromes*, and hyperemesis gravidarum)."

>Is Steve Harris saying The Merck Manual is wrong?
>>

Comment:
If you'll read it carefully, Einstein, you'll see that there's no
contradiction between anything the Merck says, and what I said.  All
these things MAY cause peripheral neuropathy.  In fact, however,
even put together they cause only a tiny fraction of what the
clinician sees in the US, which is not "nutritional peripheral
neuropathy."


Harris:
> and almost never responds to nutritional repletion
>(including B12 shots).

Wiss:
>Well, if one has a malabsorption syndromes they are malabsorbing all
>sorts of minerals and vitamins. Including malabsorbing any taken
>orally. As for B12 shots you are just supplementing a single B
>vitamin. The Merck uses B vitamins in the plural.


Comment:
    The Merck is not using language in a way which can be understood
with precision.  It says nutritional neuropathy can be caused by a
lack of B vitamins, and then gives a list of diseases which are each
known to be caused by lack of a single B vitamin.  So is it using the
term plurally to refer to the different vitamins associated with
this list of diseases?  Or as some deliberate endorsement for the
treatment of neuropathy with many B vitamins at a time (what you seem
to think is the case, and which seems to me to be unlikely).

  It's stupid to argue over this like some kind of exegesis.  The Merck
manual is not holy scripture.  It gives a few general principles.  The
reason it gives no numbers is because it doesn't have any.  Nor any
references for papers with numbers, either.  You're once again getting
pap, or knowledge in a qualitative form, which often is
not worth much in clinical decision-making.

    This is not to say that the Merck is the lone culprit in this.  So
much of what young doctors are given to read says "X may respond to Y"
without saying if the response rate is 0.1 % or 60%.   The difference
is important.  One of the reasons a doctor is no good without a decade
or so of treating real patients is that it takes that long to get a
feel for such numbers.  Peripheral neuropathy, but for rare cases,  is
simply not a nutritional disease in America.   I treat ALL my
patients with what would be described by most doctors as
"megavitamins", including at least 10 RDAs of the B vitamins.  Their
peripheral neuropathy doesn't go away.

  I have diagnosed one bona-fide case of "wet beri-beri" in an
alcoholic man recently, and although his edema and orthostatus resolved
on multivitamin therapy, he never even HAD peripheral neuropathy.
That's how rare the thiamin form is.

>Harris:
>This is an urban nutritional myth.  Such myths
>are of the logical form: "Deficiency of vitamin X causes Y symptom.
>Therefore, patients presenting with Y symptom generally have
>deficiency of vitamin X."  Favorite Adelle Davis reasoning.


>Don Wiss
>Certainly worth investigating. One would be rather remiss to not
>investigate all the possibilities. But then back in that Alzheimer's
>thread you got berated for your unwillingness to investigate other
>possibilities
>of dementias.


Comment:
   No, for it was clear that I DO investigate them routinely, as does
every other geriatrician.  I got berated for thinking the investigation
is usually futile, which indeed it usually is.  And I was berated by
somebody who it appears has no experience, or possibly just a little
knowledge from the Merck manual (Merck makes a geriatrics manual, too
for all you "people of one book"--- but alas, it's not the bible,
either.)

    The truth, in medicine, where such it is, is in the primary
literature.  The research studies with numbers and statistics.  The
texts synthesize this, and often they do a good job.  But they don't do
well on the issue of futility.  You can read a dozen causes of
reversible peripheral neuropahty in the average text, without
getting a feeling for how often you can expect to have this do your
patient any good, even though you look for them all.

    At this point, any neurologists reading this thread are invited to
comment.



Harris:
>    In America, the most common peripheral neuropathy is caused by
>diabetes.

Wiss:
>>What percentage of diabetics have peripheral neuropathy?

Comment:
>  That depends on the type of diabetics.  And how carefully you look.
>But it approaches 50% for type II diabetics, by far the most common
>type.

Wiss:
>Are you aware of the numerous studies that find that around 7% of Type
>I diabetics have celiac disease, almost all undiagnosed? And if 7%
>have measurable damage to the intestinal mucosa there would be even
>more that are gluten sensitive, but it just hasn't yet progressed to
>the stage where mucosal damage can be measured.


Comment: So?



Harris:
> There is also a peripheral neuropathy of unknown etiology
>which presents in geriatrics, and which goes by various names.
>"Senile peripheral neuropathy" will give you the idea.


Wiss:
>It's only of unknown etiology as the medical community hasn't yet
>figured out the cause. There is a reason for everything.


   Comment: Oh, undoubtedly.  That doesn't mean YOU know it, and I
don't, however.


Harris:
> It's basically an age
>related degeneration (probably), though like all age-related
>degenerations, it doesn't happen at the same time to everyone.  And it
>does NOT respond usually to vitamins (God knows, I've tried).



Wiss:
>You blame lots on old age. If you studied hunter/gatherer populations,
>like Staffan Lindeberg's Kitava study, you'd find that they get old
>without these problems.


Comment:
>I've read that study.  It doesn't mention peripheral neuropathy, or
>that anybody looked for it.  But if it's really proven that this
>doesn't happen to the elderly in hunter-gatherer societies, that will
>still not prove a nutritional cause.  Or a reversable cause.

Wiss:
>>Since more than half of our diet is foods humans didn't
>>evolved to eat, they is every reason to suspect its involvement in
>>degenerative diseases.


Comment:
    Nonsense.  Since degenerative diseases by and large show up long
after reproductive age, evolution isn't even an issue.

   In many primitive societies, when you get chronic diseases, you die
pretty quickly, because there aren't too many nursing homes with 24
hour care.   That makes everybody else look pretty healthy.
Anthropologists (anthro apologists) say: "Damn, LOOK
at these people!  They all are mobile and none demented and
incontinent!" Sometimes anthropologists are pretty stupid.  In the
Eskimo, it's not that granny never gets hip arthritis or incontinence
or dementia.  She does.  It's  just that when she stops being useful,
she's left on an ice floe.  Bye bye.  Only healthy grannies left in
such societies.


Harris:
   Don Wiss thinks that everything is caused by celiac disease, and
that's worth checking in peripheral neuropathy.  However, be prepared
or very few "hits."


Wiss:
Uh, actually I have lots of hits. I have turned around many, many lives
on the Net.



  Comment: Uh, sure you have.   And kept statistics, which you're about
to publish any time now.

  Damn, how annoying I find people who claim their medical expertise is
to a long history of curing people they've never examined, or even
seen.  All done over the telephone.  Amazing.

 One day I'm going to log onto the pilot's forum under your name, and
tell them they haven't a clue, because I get much better flying results
with Flight Simulator.
                                        Steve Harris, M.D.
>

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.nutrition
Subject: Re: Cause of numbness?
Date: 24 Aug 1998 08:53:02 GMT

In <6rmqs7$gfc$1@nnrp02.primenet.com> "Gary Vincent"
<garyv@primenet.com> writes:

>Steven B. Harris wrote in message <6rljp9$1ns@dfw-ixnews5.ix.netcom.com>...
>
>>Comment:
>>  In fact, in America, peripheral neuropathy is almost never caused by
>>vitamin deficiency, and almost never responds to nutritional repletion
>>(including B12 shots).
>
>Hey Doc... turn to page 1520 in the Merck Manual (16th Edition). Start
>reading under the Diagnosis, Laboratory findings section.  Try the first
>sentence.  Or how about where it reads: "Nutritional deficiency and
>metabolic disorders may result in polyneuropathy. Deficiency of B
>vitamins is often the cause (eg, in alcoholism, beriberi, pernicious
>anemia, isoniazid-induced pyridoxine deficiency, *malabsorption
>syndromes*, and hyperemesis gravidarum)."


    Hey, Einstein, notice that it's talking about B vitamins being
common causes of nutritional deficiency neuropathies.  It doesn't say
that most neuropathies are the result of nutritional deficiency.


>Like most open minded docs I'm sure you will want to correct the above
>after research.


    Like most open minded docs I'll be glad to have you show me
research that says that most peripheral neuropathy is nutritional.  If
you can't comprehend what you read, however, that's going to slow you
down some.


>Fortunately, our Doc acceded to our suggestion of a B complex
>injection.

    If your doc gave you a B-complex injection, you have a quack for a
doc.  Or else somebody who has no ethical problems with placebos.


>It was the first evidence we discovered pointing to a possible
>malabsorbtion problem. Obviously it wasn't the solution, just a pointer
>to the final diagnosis. It *was* wonderful that over the next two days my
>wife became clear headed, was able to walk without dragging her toes, and
>was not experiencing shocks and numbness in her legs.

   Since nerves regrow at the rate of about 1 mm a day (an inch a
month), I'd say that was pretty remarkable, all right.   Methinks your
wife was dragging around for some other reason, probably related to
somatization.  Which means the problem was in her mind, not her
peripheral nerves.  NO neuropathy gets better that fast.  Even the
bonafide nutritional ones take months to heal.



> Her symptoms, of course, all
>returned as she continued to ingest food that turned out to be the
>underlying problem.

    Sounds like hysteria is the underlying problem.  If your wife did
have some kind of allergic or antibody mediated neuropathy, B vitamins
would not have affected it.



>Correct me if I'm wrong, but "unknown etiology" means the medical
>community doesn't know the answer. That does not mean there isn't an
>answer.

    Right.  It also doesn't mean there's an answer that's known to
everybody but the doctors.  Which is what seems to be the assumption on
this newsgroup.



> I am
>encouraged to hear you have tried vitamins as a solution. However, if
>were talking oral, then you don't get it.

    When my patients report chrome yellow pee, I "get it."  There are
no gut malabsorpion syndromes bad enough that they don't allow
megadoses of oral vitamins to give you enough vitamins.  If there were,
they'd be fatal.   If you have a gut, you can use it for vitamin
repletion, though megadoses may be required.  Quacks give B complex
shots.  Quack, quack.

                                  Steve Harris, M.D.