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AN UNUSUAL TWIN PREGNANCY
453 would have lost its protection. Indeed if sensitisation to taotile stimuli is an essential part of the mechanism of the ulcer stomach, one cause of the hypersensitivity
might
basis
be
insufficiency
one can
drink several
of
mucus
secretion.
On this
understand why nursing mothers who
pints
gastric pain.
of water
a
day
may
complain
London, W.C.1.
of
There is, in addition, a miscellany of findings which can be explained on the basis of the above suggestions. One can picture that at the end of a meal the stomach is still secreting mucin and that the process of digestion is then smoothing the sharp edges of particles. A few quiet moments before bodily movement shakes the gastric contents against the wall might add much to the protection of the mucosa. Then, one wonders whether the hourglass lesion is progressive because one part of the stomach wall is persistently touched by clinging food once a small uphill slope has been induced by spasm or fibrosis from a nearby ulcer. In subareolar muscle one region of the muscle network can remain sensitised without all being similarly affected. If this can happen also in the stomach, with an area near to a lesion ( ulcer) over-responsive to food and another not, then recumbency might relieve pain by position as well as by the absence of movement. Was Darwin sensitised by his diet and the motion on the Beagle so that he took refuge in lying down for much of the rest of his life ?f If tactile stimuli evoke the secretion of digestive juices the body must obviously have a mechanism for preventing the sides of the stomach from touching each other. This mechanism may consist of the air bubble in the stomach ; for this must spread the walls apart whatever the body’s position. In the nipple there is sometimes a tiny lesion which is not painful until the subareolar muscle contracts. When this kind of lesion develops, the areolar muscle is overresponsive to tactile stimuli not only on the nipple but also on the areola. If there is any substance in the analogy with the stomach, then the sequence in a patient with a gastric ulcer might be as follows : lesion (?ulcer) hypersensitivity of the neighbouring mucosa and underlying muscle ; contraction of the underlying muscle on receiving stimuli, possibly with accompanying secretion of gastric juice ; pain in the ulcer from the contraction. The sequence could also start from conditioned secretion of gastric juice (mealtime) either with linked contraction or with contraction after the gastric juice had stimulated the ulcer. This hypothesis, put forward to explain the hyperactivity of the stomach in some people, does not detract from the importance of other factors which have been thought to influence the tendency to gastric ulcer. Chief of these are Pavlovian conditioning, diurnal variation, and anxiety. If, however, experimental evidence confirms these conjectures, many patients may be able to obtain remission from their symptoms. They should forestall their times of hunger by frequent feeding and be told to take coating foods (thick soup, porridge, lightly boiled egg, or mashed banana perhaps) at the outset of their meals, to eat leisurely and avoid all foods which do not conform to their standard of smoothness after chewing, to rise leisurely from the table, and when alkalis are wanted to take them in a mucilaginous form. It might even be possible to prevent young people from sensitising the stomach wall, for perhaps they do it by running to school or to work after a bolted breakfast. Or does the sequence start with a lesion like a burn from hot foodIf these precautions are necessary for some people, let us hope they are not for many. What could be more tedious than a race of people avoiding rush on account of their health, introspectively sensing their chewed food before swallowing it, and centring their attention on >
their hypochondriac region or their bellyachei And the pause after meals makes washing-up harder. Obstetric Hospital, University College Hospital, MAVIS GUNTHER. AN UNUSUAL TWIN PREGNANCY an interesting example of a gestation occurring concurrently with a
SIR,-The following story is tubal live pregnancy.
ruptured
A young woman, aged 23, was seen on April 12, 1953, and sent to the Bristol General Hospital as a suspected ectopic gestation. She had had a sudden attack of abdominal pain during the evening of her admission ; the pain was colicky and intermittent. There was no vaginal bleeding. Her last normal menstrual period was on Feb. 16, 1953. A laparotomy was performed by Miss Mabel Potter ; a left tubal gestation was found and a left salpingectomy was performed. She made a good recovery and was discharged on May 6. She came to see me on May 7, complaining of dysuria and pain in the right loin, and was treated for cystitis. She reported once again on May 29 with early morning sickness. She appeared to be fourteen weeks pregnant ; and Mr. T. F. Redman confirmed this finding. She has now continued with the normal pregnancy and it seems certain that she had a twin pregnancy, one of which was an ectopic. The specimen was re-examined in the light of these findings and a tubal pregnancy was confirmed. The Health Centre, H. I. HOWARD. Bristol, 4. was
CORTICOTROPHIN IN MUMPS ORCHITIS
SiR,-In inflammatory diseases corticotrophin (A.c.T..) and cortisone prevent destructive changes in and around the cells : hyperaemia is controlled, exudation is markedly decreased, and the invasion by leucocytes is suppressed. Because corticotrophin has proved beneficial in inflammatory processes, it was given a trial in two cases of mumps orchitis. These two cases were chosen, because of the severity of the testicular involvement, from among more than twenty patients with mumps orchitis. The first patient was a 20-year-old man in whom bilateral had been diagnosed for four days when the right testicle became involved. This complication began with chill, increase of the temperature to 40’4°C, joint pains, and dragging sensation in the right groin. During the following days the right scrotal region with the testicle became enlarged, and reached its maximum on the third day when it was the size of an orange. The inflamed testis had the appearance of a big hydrocele ; it caused considerable pain, and the patient was very distressed. On the same day the patient was given 100 i.u. of long-acting corticotrophin (’ Cortico-Depot,’ Nyco 1 2). Rapid clinical improvement followed the administration of this preparation. Two hours later the tenderness of the testicle diminished, and in the evening the swelling had subsided and the pain was less pronounced. The following day the tenderness had nearly disappeared, the decrease of the swelling continued, and the overlying skin had lost its inflamed appearance. Recovery was uneventful. In the other patient, an 18-year-old man, left-sided orchitis was diagnosed on the fifth day after the onset of parotitis. He felt tension in the left inguinal region and heaviness in the scrotum. There was soon tension of the skin and swelling of the left testis to the size of a small orange. The overlying skin was inflamed and thinned out. The condition was very painful, and general malaise developed. Because of a complicating pancreatitis there was abdominal pain and tenderness, nausea, and vomiting. On the morning of the fourth day after the onset of the orchitis 100 i.u. cortico-depot was given intramuscularly in a single injection. The clinical improvement was dramatic so far as the involvement of the testicle was concerned. Swelling, scrotal tenderness, and pain subsided, as in the first patient, during the first twenty-four hours. There was also a decrease of the nausea and vomiting, but the abdominal pain and tenderness did not seem to be improved. After thirty-six hours, however, there was a recrudescence of the symptoms and signs of orchitis. A second injection
parotitis
Acta endocr., Copenhagen, 1. Holtermann, H., Thorsdalen, N. 1953, 12, 81. 2. Solem, J. H., Holtermann, H. Lancet, 1952, i, 468.
might
basis
be
insufficiency
one can
drink several
of
mucus
secretion.
On this
understand why nursing mothers who
pints
gastric pain.
of water
a
day
may
complain
London, W.C.1.
of
There is, in addition, a miscellany of findings which can be explained on the basis of the above suggestions. One can picture that at the end of a meal the stomach is still secreting mucin and that the process of digestion is then smoothing the sharp edges of particles. A few quiet moments before bodily movement shakes the gastric contents against the wall might add much to the protection of the mucosa. Then, one wonders whether the hourglass lesion is progressive because one part of the stomach wall is persistently touched by clinging food once a small uphill slope has been induced by spasm or fibrosis from a nearby ulcer. In subareolar muscle one region of the muscle network can remain sensitised without all being similarly affected. If this can happen also in the stomach, with an area near to a lesion ( ulcer) over-responsive to food and another not, then recumbency might relieve pain by position as well as by the absence of movement. Was Darwin sensitised by his diet and the motion on the Beagle so that he took refuge in lying down for much of the rest of his life ?f If tactile stimuli evoke the secretion of digestive juices the body must obviously have a mechanism for preventing the sides of the stomach from touching each other. This mechanism may consist of the air bubble in the stomach ; for this must spread the walls apart whatever the body’s position. In the nipple there is sometimes a tiny lesion which is not painful until the subareolar muscle contracts. When this kind of lesion develops, the areolar muscle is overresponsive to tactile stimuli not only on the nipple but also on the areola. If there is any substance in the analogy with the stomach, then the sequence in a patient with a gastric ulcer might be as follows : lesion (?ulcer) hypersensitivity of the neighbouring mucosa and underlying muscle ; contraction of the underlying muscle on receiving stimuli, possibly with accompanying secretion of gastric juice ; pain in the ulcer from the contraction. The sequence could also start from conditioned secretion of gastric juice (mealtime) either with linked contraction or with contraction after the gastric juice had stimulated the ulcer. This hypothesis, put forward to explain the hyperactivity of the stomach in some people, does not detract from the importance of other factors which have been thought to influence the tendency to gastric ulcer. Chief of these are Pavlovian conditioning, diurnal variation, and anxiety. If, however, experimental evidence confirms these conjectures, many patients may be able to obtain remission from their symptoms. They should forestall their times of hunger by frequent feeding and be told to take coating foods (thick soup, porridge, lightly boiled egg, or mashed banana perhaps) at the outset of their meals, to eat leisurely and avoid all foods which do not conform to their standard of smoothness after chewing, to rise leisurely from the table, and when alkalis are wanted to take them in a mucilaginous form. It might even be possible to prevent young people from sensitising the stomach wall, for perhaps they do it by running to school or to work after a bolted breakfast. Or does the sequence start with a lesion like a burn from hot foodIf these precautions are necessary for some people, let us hope they are not for many. What could be more tedious than a race of people avoiding rush on account of their health, introspectively sensing their chewed food before swallowing it, and centring their attention on >
their hypochondriac region or their bellyachei And the pause after meals makes washing-up harder. Obstetric Hospital, University College Hospital, MAVIS GUNTHER. AN UNUSUAL TWIN PREGNANCY an interesting example of a gestation occurring concurrently with a
SIR,-The following story is tubal live pregnancy.
ruptured
A young woman, aged 23, was seen on April 12, 1953, and sent to the Bristol General Hospital as a suspected ectopic gestation. She had had a sudden attack of abdominal pain during the evening of her admission ; the pain was colicky and intermittent. There was no vaginal bleeding. Her last normal menstrual period was on Feb. 16, 1953. A laparotomy was performed by Miss Mabel Potter ; a left tubal gestation was found and a left salpingectomy was performed. She made a good recovery and was discharged on May 6. She came to see me on May 7, complaining of dysuria and pain in the right loin, and was treated for cystitis. She reported once again on May 29 with early morning sickness. She appeared to be fourteen weeks pregnant ; and Mr. T. F. Redman confirmed this finding. She has now continued with the normal pregnancy and it seems certain that she had a twin pregnancy, one of which was an ectopic. The specimen was re-examined in the light of these findings and a tubal pregnancy was confirmed. The Health Centre, H. I. HOWARD. Bristol, 4. was
CORTICOTROPHIN IN MUMPS ORCHITIS
SiR,-In inflammatory diseases corticotrophin (A.c.T..) and cortisone prevent destructive changes in and around the cells : hyperaemia is controlled, exudation is markedly decreased, and the invasion by leucocytes is suppressed. Because corticotrophin has proved beneficial in inflammatory processes, it was given a trial in two cases of mumps orchitis. These two cases were chosen, because of the severity of the testicular involvement, from among more than twenty patients with mumps orchitis. The first patient was a 20-year-old man in whom bilateral had been diagnosed for four days when the right testicle became involved. This complication began with chill, increase of the temperature to 40’4°C, joint pains, and dragging sensation in the right groin. During the following days the right scrotal region with the testicle became enlarged, and reached its maximum on the third day when it was the size of an orange. The inflamed testis had the appearance of a big hydrocele ; it caused considerable pain, and the patient was very distressed. On the same day the patient was given 100 i.u. of long-acting corticotrophin (’ Cortico-Depot,’ Nyco 1 2). Rapid clinical improvement followed the administration of this preparation. Two hours later the tenderness of the testicle diminished, and in the evening the swelling had subsided and the pain was less pronounced. The following day the tenderness had nearly disappeared, the decrease of the swelling continued, and the overlying skin had lost its inflamed appearance. Recovery was uneventful. In the other patient, an 18-year-old man, left-sided orchitis was diagnosed on the fifth day after the onset of parotitis. He felt tension in the left inguinal region and heaviness in the scrotum. There was soon tension of the skin and swelling of the left testis to the size of a small orange. The overlying skin was inflamed and thinned out. The condition was very painful, and general malaise developed. Because of a complicating pancreatitis there was abdominal pain and tenderness, nausea, and vomiting. On the morning of the fourth day after the onset of the orchitis 100 i.u. cortico-depot was given intramuscularly in a single injection. The clinical improvement was dramatic so far as the involvement of the testicle was concerned. Swelling, scrotal tenderness, and pain subsided, as in the first patient, during the first twenty-four hours. There was also a decrease of the nausea and vomiting, but the abdominal pain and tenderness did not seem to be improved. After thirty-six hours, however, there was a recrudescence of the symptoms and signs of orchitis. A second injection
parotitis
Acta endocr., Copenhagen, 1. Holtermann, H., Thorsdalen, N. 1953, 12, 81. 2. Solem, J. H., Holtermann, H. Lancet, 1952, i, 468.