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A SYNDROME SIMULATING ACUTE ABDOMINAL DISEASE
506
Letters MILITARY SERVICE
to
the Editor
FOR
MEDICAL STUDENTS
SIR,-Your leader of Sept. 21 discusses alternative ways in which medical students may meet their obligation of military service. As you point out, the more useful
and more convenient-namely, to serve after qualifying - will be impracticable for the next two years or so. May I then suggest another possibility which I believe would meet the present situation as well as future
requirements ? Why not split up
the whole term of military service for medical students into two independent periods ? The prospective doctor could serve the first half of his term conveniently between school and university, thereby filling at least part of the interval that will elapse before he finds his place at a medical school. During this time he would have a general ordinary military training with the rank and file, though of course not a complete technical training in any of the specialised weapons and highly mechanised military craft which he does not require. Later, after qualification, he would complete his term of military service as a junior Service medical officer. This scheme proved its merits in Imperial Germany before, and with appropriate modifications during, the first world war. Such a system would not only provide all the advantages and opportunities of the second alternative outlined in your leader but would also have some additional effects beneficial both to the doctor and to the fighting men under his care. (1) The medical student need not sacrifice too much of his precious time to purely military training but still has all the benefit a healthy young man can derive from military life. (2) During his shortened military training he acquires an intimate first-hand knowledge of the sort of job the soldier (or sailor or airman) has got to do. (3) If, as he should, he serves with the rank and file instead of with a selected group he gets to know something of the mentality of the ordinary man. This will stand him in good stead in civilian as well as military practice. (4) Last, but not least, he sees some of the methods and tricks used by comrades to evade duty. This knowledge will help him considerably as a doctor in assessing his patients’ complaints. E. G. W. HOFFSTAEDT. Wolsingham, Co. Durham. A SYNDROME SIMULATING ACUTE ABDOMINAL
DISEASE
.
SIR,-The letters following our paper of August 24 have suggested two possible explanations of the group of cases that we described-infective hepatitis and Bornholm disease. Dr. Oram suggests that subicteric forms of infective hepatitis could have caused the syndrome. We agree that acute abdominal symptoms, rarely simulating surgical emergencies, may usher in the early stages. But at the time our wards contained many cases of obvious infective hepatitis, not one of which showed the syndrome described. It seems unlikely that subicteric cases would show more severe symptoms. The question of Bornholm disease requires more careful consideration, and we admit that it might well have been included in the differential diagnosis. Neither of us has had experience of this disorder, which from the multiplicity of the symptoms described would appear to include a variety of pathological conditions. We are grateful to Dr. Evans for drawing our attention to Dr. Scadding’s excellent article, but our cases differ considerably from his, the symptoms being mostly abdominal while his were mainly thoracic. Pleural rub was absent in all our patients. We rejected an epidemic origin of our cases (perhaps wrongly) because they were unrelated, and because no minor varieties of the same syndrome were seen on the medical side of the hospital, as might have been expected in an epidemic. We are aware that a small percentage of cases of Bornholm disease may simulate abdominal emergencies, but nearly 100 % of our cases presented with acute abdominal symptoms. The hypothesis that abortive staphylococcal 1.
Scadding, J. G.
Lancet, 1946, i, 763.
retroperitoneal infection could be the cause of the syndrome was suggested to us because one of our cases developed a perinephric abscess. Dr. Evans objects to this hypothesis and says that one of his cases had a tuberculous apical abscess " but this does not make the rest tubercular." However, we stressed the perinephric abscess because it was possibly a significant lesion. It was capable of providing an explanation which we put forward quite humbly. At least it may stimulate inquiry, and should it be correct it will have rescued a series of cases from the dumping ground of varied conditions called Bornholm disease. Incidentally we wonder if Dr. Evans has noticed a letter from Dr. Cayley2 on " The apparently acute abdomen in pulmonary tuberculosis." B. W. GOLDSTONE. H. S. LE MARQUAND.
Reading.
MYTH AND MUMPSIMUS
SiB,—I regret that Dr. Forbes in his mention of .
on the rubbish-heap did not include our antiquated Imperial system of weights and measures. I can recall the expectation fifty years ago that in the next British Pharmacopaeia the metric system would be in sole use. What is the explanation of the retention of the older system ? Is it a wise caution, or is it just pure, thrawnness ? It is not a mere question of nomenclature. A scientific system like the metric would tend to create a scientific outlook in its users. R. M. FRASER. Knock, Belfast.
lumber that should be thrown
TUBERCULOUS ENDOMETRITIS AND STERILITY
SiR,-Your annotation of Sept. 7 says : (1) "The association between sterility and tuberculous endometritis has been recognised only in the last few years...." (2) "His [Halbrecht’s] conclusion that occult, subclinical tuberculous - endometritis is one of the cardinal causes of sterility in general and of tubal occlusion in particular may have come as something of a shock to English workers...." (3) " It will be interesting to see whether, with further experience, similar reports appear in this country." These statements require correction, not only in the interests of scientific accuracy but also because of the implication that the knowledge, to say nothing of original research, was new to " English workers." Only a few of the main facts can, be dealt with here, but we should like to present a more accurate picture of the present-day knowledge of the relationship between tuberculous endometritis and sterility. A detailed account is, in fact, at present in the press, forming a portion of a paper being read by one of us (Sharman) at the Congress of the South African Medical Association this month. A study is made of 94 cases of tuberculous endometritis in a consecutive series of 1712 cases of primary sterility (5-5%) -this is the largest series ever recorded. In 1943 one of us (Sutherland 1), in a paper on Unsuspected Tuberculosis of the Endometrium, discussed at length the clinical aspects and pathology of the condition : the literature was fully reviewed. It was pointed out that the high incidence of sterility in endometrial tuberculosis was striking and that this causal factor had been stressed by Steinsick (1923)," Daniel (1925),3 Halban and Seitz (1926),4and Vogt (1928).5 The incidence was given as 7-2 % in 212 patients (Steinsick), 7’0% in 71 patients (Schockaert and Ferin6), and 5-1 % in 390 patients (Sharman). No relevant reference was found prior to 1922, not even in the excellent and exhaustive monograph by Norris in 1921.’ In 1943 one of us (Sharman 8) reported to the Royal Society of 2. Cayley, F. E. de W. Brit. med. J. Sept. 14, p. 403. 1. Sutherland, A. M. J. Obstet. Gynæc. 1943, 50, 161. 2. Steinsick. Diss. Tübingen, 1922, quoted by Vogt (ref. 5). 3. Daniel, C. Gynéc. et Obstét. 1925, 11, 161. 4. Halban, J., Seitz., L. Biologie und Pathologie des Weibes, 1926, vol. v, p. 367. 5. Vogt, E. Z. Tuberk. 1928, 51, 114. 6. Schockaert, J. A., Ferin, J. Bull. Soc. roy. beige Gynéc. Obstét.
1939, 15, 407. Norris, C. C. Gynecological and Obstetrical Tuberculosis, New York, 1921. 8. Sharman, A. Proc. R. Soc. Med. 1943, 37, 67 ; J. Obstet. Gynæc. 1944, 51, 85. 7.
Letters MILITARY SERVICE
to
the Editor
FOR
MEDICAL STUDENTS
SIR,-Your leader of Sept. 21 discusses alternative ways in which medical students may meet their obligation of military service. As you point out, the more useful
and more convenient-namely, to serve after qualifying - will be impracticable for the next two years or so. May I then suggest another possibility which I believe would meet the present situation as well as future
requirements ? Why not split up
the whole term of military service for medical students into two independent periods ? The prospective doctor could serve the first half of his term conveniently between school and university, thereby filling at least part of the interval that will elapse before he finds his place at a medical school. During this time he would have a general ordinary military training with the rank and file, though of course not a complete technical training in any of the specialised weapons and highly mechanised military craft which he does not require. Later, after qualification, he would complete his term of military service as a junior Service medical officer. This scheme proved its merits in Imperial Germany before, and with appropriate modifications during, the first world war. Such a system would not only provide all the advantages and opportunities of the second alternative outlined in your leader but would also have some additional effects beneficial both to the doctor and to the fighting men under his care. (1) The medical student need not sacrifice too much of his precious time to purely military training but still has all the benefit a healthy young man can derive from military life. (2) During his shortened military training he acquires an intimate first-hand knowledge of the sort of job the soldier (or sailor or airman) has got to do. (3) If, as he should, he serves with the rank and file instead of with a selected group he gets to know something of the mentality of the ordinary man. This will stand him in good stead in civilian as well as military practice. (4) Last, but not least, he sees some of the methods and tricks used by comrades to evade duty. This knowledge will help him considerably as a doctor in assessing his patients’ complaints. E. G. W. HOFFSTAEDT. Wolsingham, Co. Durham. A SYNDROME SIMULATING ACUTE ABDOMINAL
DISEASE
.
SIR,-The letters following our paper of August 24 have suggested two possible explanations of the group of cases that we described-infective hepatitis and Bornholm disease. Dr. Oram suggests that subicteric forms of infective hepatitis could have caused the syndrome. We agree that acute abdominal symptoms, rarely simulating surgical emergencies, may usher in the early stages. But at the time our wards contained many cases of obvious infective hepatitis, not one of which showed the syndrome described. It seems unlikely that subicteric cases would show more severe symptoms. The question of Bornholm disease requires more careful consideration, and we admit that it might well have been included in the differential diagnosis. Neither of us has had experience of this disorder, which from the multiplicity of the symptoms described would appear to include a variety of pathological conditions. We are grateful to Dr. Evans for drawing our attention to Dr. Scadding’s excellent article, but our cases differ considerably from his, the symptoms being mostly abdominal while his were mainly thoracic. Pleural rub was absent in all our patients. We rejected an epidemic origin of our cases (perhaps wrongly) because they were unrelated, and because no minor varieties of the same syndrome were seen on the medical side of the hospital, as might have been expected in an epidemic. We are aware that a small percentage of cases of Bornholm disease may simulate abdominal emergencies, but nearly 100 % of our cases presented with acute abdominal symptoms. The hypothesis that abortive staphylococcal 1.
Scadding, J. G.
Lancet, 1946, i, 763.
retroperitoneal infection could be the cause of the syndrome was suggested to us because one of our cases developed a perinephric abscess. Dr. Evans objects to this hypothesis and says that one of his cases had a tuberculous apical abscess " but this does not make the rest tubercular." However, we stressed the perinephric abscess because it was possibly a significant lesion. It was capable of providing an explanation which we put forward quite humbly. At least it may stimulate inquiry, and should it be correct it will have rescued a series of cases from the dumping ground of varied conditions called Bornholm disease. Incidentally we wonder if Dr. Evans has noticed a letter from Dr. Cayley2 on " The apparently acute abdomen in pulmonary tuberculosis." B. W. GOLDSTONE. H. S. LE MARQUAND.
Reading.
MYTH AND MUMPSIMUS
SiB,—I regret that Dr. Forbes in his mention of .
on the rubbish-heap did not include our antiquated Imperial system of weights and measures. I can recall the expectation fifty years ago that in the next British Pharmacopaeia the metric system would be in sole use. What is the explanation of the retention of the older system ? Is it a wise caution, or is it just pure, thrawnness ? It is not a mere question of nomenclature. A scientific system like the metric would tend to create a scientific outlook in its users. R. M. FRASER. Knock, Belfast.
lumber that should be thrown
TUBERCULOUS ENDOMETRITIS AND STERILITY
SiR,-Your annotation of Sept. 7 says : (1) "The association between sterility and tuberculous endometritis has been recognised only in the last few years...." (2) "His [Halbrecht’s] conclusion that occult, subclinical tuberculous - endometritis is one of the cardinal causes of sterility in general and of tubal occlusion in particular may have come as something of a shock to English workers...." (3) " It will be interesting to see whether, with further experience, similar reports appear in this country." These statements require correction, not only in the interests of scientific accuracy but also because of the implication that the knowledge, to say nothing of original research, was new to " English workers." Only a few of the main facts can, be dealt with here, but we should like to present a more accurate picture of the present-day knowledge of the relationship between tuberculous endometritis and sterility. A detailed account is, in fact, at present in the press, forming a portion of a paper being read by one of us (Sharman) at the Congress of the South African Medical Association this month. A study is made of 94 cases of tuberculous endometritis in a consecutive series of 1712 cases of primary sterility (5-5%) -this is the largest series ever recorded. In 1943 one of us (Sutherland 1), in a paper on Unsuspected Tuberculosis of the Endometrium, discussed at length the clinical aspects and pathology of the condition : the literature was fully reviewed. It was pointed out that the high incidence of sterility in endometrial tuberculosis was striking and that this causal factor had been stressed by Steinsick (1923)," Daniel (1925),3 Halban and Seitz (1926),4and Vogt (1928).5 The incidence was given as 7-2 % in 212 patients (Steinsick), 7’0% in 71 patients (Schockaert and Ferin6), and 5-1 % in 390 patients (Sharman). No relevant reference was found prior to 1922, not even in the excellent and exhaustive monograph by Norris in 1921.’ In 1943 one of us (Sharman 8) reported to the Royal Society of 2. Cayley, F. E. de W. Brit. med. J. Sept. 14, p. 403. 1. Sutherland, A. M. J. Obstet. Gynæc. 1943, 50, 161. 2. Steinsick. Diss. Tübingen, 1922, quoted by Vogt (ref. 5). 3. Daniel, C. Gynéc. et Obstét. 1925, 11, 161. 4. Halban, J., Seitz., L. Biologie und Pathologie des Weibes, 1926, vol. v, p. 367. 5. Vogt, E. Z. Tuberk. 1928, 51, 114. 6. Schockaert, J. A., Ferin, J. Bull. Soc. roy. beige Gynéc. Obstét.
1939, 15, 407. Norris, C. C. Gynecological and Obstetrical Tuberculosis, New York, 1921. 8. Sharman, A. Proc. R. Soc. Med. 1943, 37, 67 ; J. Obstet. Gynæc. 1944, 51, 85. 7.