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PEPTIC ULCERATION IN A FAMILY
694
articled
occurred. On the contrary, in of acute adnexitis injection of penicillin into the parametrium seems to be of value, and is now used in
to
therapy.
FOOTBALLER’S ANKLE
SIR,-We have read with much interest Mr. McDougall’s Most osteo-articular lesions in athletes give rise as Mr. McDougall points out, but they are clearly demonstrated by radiographic examination, which shows areas of calcification in the articular ligaIn boxers, for ments or at the insertion of tendons. instance, La Cava2 has found areas of calcification on the dorsal aspect of the hands at the tendinous insertion of the radialis muscle.
symptoms,
no
The lesion of the astragalotibial joint in soccer and rugger has been well known for more players, wrestlers, and skiers than twenty-five years.34 According to Biolato and Foà,5e in trained subjects there is notable increase in elasticity of articular ligaments and therefore a wider range of excursion of the joint itself. In the ankle-joint there is enlargement of the tibiofibular mortise so that the astragalus takes part in dorsal and plantar flexion, abduction, and adduction of the foot. This abnormal mobility is the cause, according to Allaria,6 of the arthrosis of the tibiofibular syndesmosis found in skiers.
no
complications have
cases
The results have been very promising. In several cases correct diagnosis of endometriosis was established where adnexitis" had previously been diagnosed ; and in others the presence of extra-uterine pregnancy or ovarian tumour, diagnosed by this method, was invariably confirmed at subsequent laparotomy.
a "
Department of Obstetrics and Gynæcology, Sabbatsbergs Hospital,
Stockholm,
Sweden.
AXEL INGELMAN-SUNDBERG.
PEPTIC ULCERATION IN A FAMILY
SIR,—The accompanying figure, showing the pedigree
of an intermarrying Tripolitanian Jewish of interest in view of the stress now laid
family, may be on the psycho.
Such conditions may be due partly to repeated slight trauma to the articular surface 7; but they are largely due to repeated severe stretching of ligaments and tendons. This is in agreement with the concept of chronic entesitis," recently described by La Cava at the Argentine Congress of Sporting Medecine. "
Istituto Nazionale Medicina Sportiva, Stadio Torino, Rome, Italy.
A. VENERANDO G. LA CAVA.
PARAMETRIOGRAPHY
SIR,—Hysterosalpingography, pelvigraphy, and gynæcography are approved methods for the X-ray examination of the female genital organs. Arteriography can give information about adnexal tumours, but we lack a good objective method for studying the extension of a parametrium tumour or an infiltration of the parametrium. Gynaecological palpation gives information on the size of the tumour, but it is often impossible to decide whether the tumour belongs to the parametrium or not. In order to overcome these difficulties the following method has been worked out. some
patient is placed in the lithotomy position. Two long, slightly curved injection needles are inserted 2-3 cm. into the The
tissue about 5 mm. lateral to the cervix on each side parallel to the long axis of the uterus. The usual intra-uterine cannula is inserted into the external os and fixed, and a third needle or thin cannula is introduced into Douglas’s pouch. The patient is then placed in the supine position on the trochoscope table. During fluoroscopy 30 ml. of a solution consisting of equal parts of 0.25% lidocaine solution and 35% iodopyracet (’ Umbradil ’) plus 500,000 I.U. penicillin are injected into each parametrium. Then the first postero-anterior film is taken. After that 10-20 ml. ofEndografin’ (Schering) or similar viscous water-soluble contrast medium is injected through the uterine cannula during fluoroscopy. Films are taken in posterior-anterior, lateral, and oblique projections. If a tumour found on gynaecological palpation is not seen in the parametrium, the patient is placed in the prone position. The foot end of the table is elevated about 15°. 600-1000 ml. of carbon dioxide is instilled into Douglas’s pouch during fluoroscopy, and new films are taken. This method has been practised since July, 1955, in patients with acute adnexitis, in order to follow the
development of the inflammation, in some cases of sterility, and in cases where the findings on gynaecological examination have been inconclusive. In all, 40 women, been examined ; and so far
including outpatients, have
1. McDougall, A. Lancet, 1955, ii, 1219. 2. La Cava, G. Le fratture della mano nel pugilato. Rome, 1948. 3. Baetzner, W. Sportunfall und erste Hilfe. Berlin, 1928. Sport und Arbeitschaden. Leipzig, 1936. 4. Giannotti, M. Chirurgia delle lesioni da sport. Turin, 1939. 5. Biolato, D., Foà, A. Congr. int. Méd. Sport, 1933. 6. Allaria, A. Chir. Organi Mov. 1950, 1, 25; Studi Med. Chir. Sport, 1950, 10, 353. Atti 3 Giornata Reumatologica, 7. Venerando, A., Terzani, G.
Rome, 1955; p. 169.
Familywith
7
cases
of peptic ulcer (black =duodenal ulcer ; Figures indicate age at onset.
hatched=
-
gastric ulcer).
somatic ætiology of duodenal ulcer. 7 members of the family had peptic ulcer ; of these I know personally (a), (b), and (c), and in the remainder the diagnosis was connrmed radiographically. Wright et al.1 recently described a family in which 9 out of 13 living siblings, have duodenal ulcers. A. YUVAL. Dorot, Negev, Israel. KETONURIA—A FALLACY IN ROTHERA’S TEST
sideroom work and in Rothera’s fallacies urine-testing test for ketones. There would appear to be one fallacy which may occasionally cause confusion.
SiR,,-The standard textbooks state that there
on
are no
diabetic,
A male aged 56, was admitted to hospital for review and stabilisation. Mild ketosis and glycosuria were present on admission. The glycosuria rapidly disappeared on adjusting the insulin dosage, but. despite the absence of other clinical or biochemical evidence of ketosis, routine urine tests by the nursing staff repeatedly showed " acetone present." The ferric-chloride test was negative, and on checking the nitroprusside test the addition of ammonium hydroxide led to an immediate colour reaction, but the colour was not the typical purple normally seen in ketonuria. Investigation revealed that the patient was receiving an aperient containing a small amount of phenolphthalein, and this drug, excreted in the urine, was producing the colour change in the presence of free alkali.
This fallacy in Rothera’s test is not generally recognised and might, if overlooked, lead to insulin overdosage. It was found that urine containing phenolphthalein did not produce a colour change on ’Acetest’ tablets, and the Ames Company Ltd., which manufactures these tablets, has kindly confirmed this by more accurate investigations. The use of the tablet method of testing for ketones will, therefore, avoid this fallacy, which should perhaps be recognised in the teaching of medical and nursing students. I am indebted to Dr. J. A. W. McCluskie for permission to publish this case. Western Infirmary, A. Glasgow.
1.
CAMERON MACDONALD.
Wright, J. T., Grant, A., Jennings, D. Lancet, 1955, ii, 1314.
articled
occurred. On the contrary, in of acute adnexitis injection of penicillin into the parametrium seems to be of value, and is now used in
to
therapy.
FOOTBALLER’S ANKLE
SIR,-We have read with much interest Mr. McDougall’s Most osteo-articular lesions in athletes give rise as Mr. McDougall points out, but they are clearly demonstrated by radiographic examination, which shows areas of calcification in the articular ligaIn boxers, for ments or at the insertion of tendons. instance, La Cava2 has found areas of calcification on the dorsal aspect of the hands at the tendinous insertion of the radialis muscle.
symptoms,
no
The lesion of the astragalotibial joint in soccer and rugger has been well known for more players, wrestlers, and skiers than twenty-five years.34 According to Biolato and Foà,5e in trained subjects there is notable increase in elasticity of articular ligaments and therefore a wider range of excursion of the joint itself. In the ankle-joint there is enlargement of the tibiofibular mortise so that the astragalus takes part in dorsal and plantar flexion, abduction, and adduction of the foot. This abnormal mobility is the cause, according to Allaria,6 of the arthrosis of the tibiofibular syndesmosis found in skiers.
no
complications have
cases
The results have been very promising. In several cases correct diagnosis of endometriosis was established where adnexitis" had previously been diagnosed ; and in others the presence of extra-uterine pregnancy or ovarian tumour, diagnosed by this method, was invariably confirmed at subsequent laparotomy.
a "
Department of Obstetrics and Gynæcology, Sabbatsbergs Hospital,
Stockholm,
Sweden.
AXEL INGELMAN-SUNDBERG.
PEPTIC ULCERATION IN A FAMILY
SIR,—The accompanying figure, showing the pedigree
of an intermarrying Tripolitanian Jewish of interest in view of the stress now laid
family, may be on the psycho.
Such conditions may be due partly to repeated slight trauma to the articular surface 7; but they are largely due to repeated severe stretching of ligaments and tendons. This is in agreement with the concept of chronic entesitis," recently described by La Cava at the Argentine Congress of Sporting Medecine. "
Istituto Nazionale Medicina Sportiva, Stadio Torino, Rome, Italy.
A. VENERANDO G. LA CAVA.
PARAMETRIOGRAPHY
SIR,—Hysterosalpingography, pelvigraphy, and gynæcography are approved methods for the X-ray examination of the female genital organs. Arteriography can give information about adnexal tumours, but we lack a good objective method for studying the extension of a parametrium tumour or an infiltration of the parametrium. Gynaecological palpation gives information on the size of the tumour, but it is often impossible to decide whether the tumour belongs to the parametrium or not. In order to overcome these difficulties the following method has been worked out. some
patient is placed in the lithotomy position. Two long, slightly curved injection needles are inserted 2-3 cm. into the The
tissue about 5 mm. lateral to the cervix on each side parallel to the long axis of the uterus. The usual intra-uterine cannula is inserted into the external os and fixed, and a third needle or thin cannula is introduced into Douglas’s pouch. The patient is then placed in the supine position on the trochoscope table. During fluoroscopy 30 ml. of a solution consisting of equal parts of 0.25% lidocaine solution and 35% iodopyracet (’ Umbradil ’) plus 500,000 I.U. penicillin are injected into each parametrium. Then the first postero-anterior film is taken. After that 10-20 ml. ofEndografin’ (Schering) or similar viscous water-soluble contrast medium is injected through the uterine cannula during fluoroscopy. Films are taken in posterior-anterior, lateral, and oblique projections. If a tumour found on gynaecological palpation is not seen in the parametrium, the patient is placed in the prone position. The foot end of the table is elevated about 15°. 600-1000 ml. of carbon dioxide is instilled into Douglas’s pouch during fluoroscopy, and new films are taken. This method has been practised since July, 1955, in patients with acute adnexitis, in order to follow the
development of the inflammation, in some cases of sterility, and in cases where the findings on gynaecological examination have been inconclusive. In all, 40 women, been examined ; and so far
including outpatients, have
1. McDougall, A. Lancet, 1955, ii, 1219. 2. La Cava, G. Le fratture della mano nel pugilato. Rome, 1948. 3. Baetzner, W. Sportunfall und erste Hilfe. Berlin, 1928. Sport und Arbeitschaden. Leipzig, 1936. 4. Giannotti, M. Chirurgia delle lesioni da sport. Turin, 1939. 5. Biolato, D., Foà, A. Congr. int. Méd. Sport, 1933. 6. Allaria, A. Chir. Organi Mov. 1950, 1, 25; Studi Med. Chir. Sport, 1950, 10, 353. Atti 3 Giornata Reumatologica, 7. Venerando, A., Terzani, G.
Rome, 1955; p. 169.
Familywith
7
cases
of peptic ulcer (black =duodenal ulcer ; Figures indicate age at onset.
hatched=
-
gastric ulcer).
somatic ætiology of duodenal ulcer. 7 members of the family had peptic ulcer ; of these I know personally (a), (b), and (c), and in the remainder the diagnosis was connrmed radiographically. Wright et al.1 recently described a family in which 9 out of 13 living siblings, have duodenal ulcers. A. YUVAL. Dorot, Negev, Israel. KETONURIA—A FALLACY IN ROTHERA’S TEST
sideroom work and in Rothera’s fallacies urine-testing test for ketones. There would appear to be one fallacy which may occasionally cause confusion.
SiR,,-The standard textbooks state that there
on
are no
diabetic,
A male aged 56, was admitted to hospital for review and stabilisation. Mild ketosis and glycosuria were present on admission. The glycosuria rapidly disappeared on adjusting the insulin dosage, but. despite the absence of other clinical or biochemical evidence of ketosis, routine urine tests by the nursing staff repeatedly showed " acetone present." The ferric-chloride test was negative, and on checking the nitroprusside test the addition of ammonium hydroxide led to an immediate colour reaction, but the colour was not the typical purple normally seen in ketonuria. Investigation revealed that the patient was receiving an aperient containing a small amount of phenolphthalein, and this drug, excreted in the urine, was producing the colour change in the presence of free alkali.
This fallacy in Rothera’s test is not generally recognised and might, if overlooked, lead to insulin overdosage. It was found that urine containing phenolphthalein did not produce a colour change on ’Acetest’ tablets, and the Ames Company Ltd., which manufactures these tablets, has kindly confirmed this by more accurate investigations. The use of the tablet method of testing for ketones will, therefore, avoid this fallacy, which should perhaps be recognised in the teaching of medical and nursing students. I am indebted to Dr. J. A. W. McCluskie for permission to publish this case. Western Infirmary, A. Glasgow.
1.
CAMERON MACDONALD.
Wright, J. T., Grant, A., Jennings, D. Lancet, 1955, ii, 1314.