REFERRED PAIN IN VISCERAL DISEASE.

749

CORRESPONDENCE REFERRED PAIN IN VISCERAL DISEASE.

To the Editor

of THE

LANCET.

on Prof. D. W. CarmaltTender Rib Cartilage as a sign of Cholecystitis in THE LANCET of March 19th again raises the question of the nervous mechanism of referred pain in visceral disease. I am inclined to believe that the explanation of the phenomenon described by Prof. Carmalt-Jones is that a hyperalgesic area of skin and subcutaneous tissue was pressed against the rib cartilage, not that the rib cartilage itself was tender; a point which might be settled by subcutaneous infiltration with novocain. The major question, however, remains. Does a viscero-sensory reflex as described by Mackenzie exist Or is Mr. Morley’s later theory to hold the field I have just read Mr. Morley’s recently

SiR,-Your annotation

Jones article

on

abdominal pain, peritoneo-cutaneous radiation as an theory explanation of certain clinical phenomena. He asserts that a viscero-sensory reflex does not

published interesting monograph in which he postulates

on

a

occurrence of hyperand tenderness as being deep algesia, superficial from the cerebroreferred sensitive phenomena highly spinal nerves of the parietal peritoneum. Yet on page 151 Mr. Morley says : " When we explore an abdomen under a general anwsthetic such as ether, we find a complete absence of intestinal

exist, and seeks to explain the

movement. The small intestine which we know from X-ray observations to be under normal conditions, in constant peristaltic movement, lies completely immobile in the opened abdomen. This immobility appears to be due to a reflex effect from stimulation of the parietal peritoneum by our incision, giving rise to an efferent impulse down the splanchnic nerves and an inhibition of intestinal movement." (The italics are mine.)

Surely Mr. Morley here postulates a true viscerosensory reflex ?z? Again, how often have we all picked up the skin and subcutaneous tissue of the abdominal wall and elicited visible peristalsis in cases of obstruction. How other can this phenomenon be explained than by the existence of a viscero-sensory reflex I am, Sir, yours faithfully, DAVID LIGAT. St. Leonards-on-Sea, March 23rd, 1932.

tion dated from

a

previous labour or abortion. I would

modestly suggest that

where there is a prolongation of the red lochia the haemorrhage is secondary to an acute or chronic inflammatory condition of the tissues of the uterus. In the case of the last 910 deliveries at this hospital, the prolongation of the red lochia after the seventh or eighth day, occurring in 72 of these, has been regarded as a sign of morbidity. Evidence of antenatal sepsis, malposition or abnormal labour was found in 55 per cent. of these cases. The question therefore arises, Can these cases be controlled by treatment7 The answer is Yes, by glycerin irrigation, which, by promoting free drainage, relieves the inflammation which is responsible for the haemorrhage. Again, these women in whom the lochia are prolonged, provide about 50 per cent. of our cases of puerperal sepsis. As a result of a careful investigation of 340 consecutive deliveries I have found that 80 of them showed signs of sepsis, 40 of them having pyrexia and 40 having prolonged red lochia after the first week without pyrexia. It is illogical, in my opinion, in estimating the part played by sepsis, to select as instances of sepsis only those who showed a rise of temperature. We must realise that there are degrees of sepsis and of inflammation and this is a fact which is not sufficiently appreciated. In many cases of peritonitis in women following childbirth or miscarriage, it is difficult to trace the origin of the infection, but if careful inquiry is made into their history it will be found that these patients have had prolonged lochia for some weeks. This, to my mind, is an indication that the uterus was left in a condition of chronic inflammation. Finally, although it is difficult to draw a dividing line clinically between what is physiology and what is pathology after delivery or abortion, I would suggest that where the red lochia persist beyond the seventh or eighth day glycerin treatment is to be commenced; otherwise, the high rate of morbidity now existing will continue. I am, Sir, yours faithfully, A. REMINGTON HOBBS. St. Mary Abbots Hospital, Kensington, W., March 22nd, 1932. THE INSURANCE OF PEDESTRIANS.

THE DURATION OF THE RED LOCHIA. To the Editor of THE LANCET. SiR,-The interest of Mr. Chassar Moir’s able article in THE LANCET of March 12th centres in the fact that

’.1.’Q 0 t/tC Editor

I

of ’1HE LANCET. SIR,-You are to be thanked by drivers and walkers alike for the temperate tone of the article in your issue of March 19th on the proposal that motorists shall be liable to pay -damages whether or not a road accident was caused by the driver’s negligence, and whether or not the walker contributed by his negligence. This well-meant but most undesirable proposal enshrines the walker’s suicidal notion that he has rights but no duties on the carriage way. This notion is the indirect cause of countless mishaps. The French provision of a small fine of one franc (2d.) for a jay-walker has the opposite psychological effect and No doubt the saves life by inducing responsibility. absence ofany footway to long stretches of country roads in England is a reproach, but as the voting power of motorists is only about one-twentieth of that of walkers, the motorists are not chiefly to blame (especially as they pay ;E60,000,000 a year to the exchequer as motorists in addition to their contribu-

large number of women after confinement suffer from intermittent or persistent bleeding from the uterus for varying periods beyond the text-book standard. If these cases are not treated it is my belief that many of them will later find their way to the gynaecological wards to undergo curettage or even hysterectomy. In a lecture to the Blackburn Division of the British Medical Association in 1928 I quoted some statistics from welfare centres. One centre recorded that during the year 50 women who had been confined were found to be still bleeding for weeks or even for months afterwards, and 20 of these cases actually came from St. Mary Abbots Hospital. As a result of a long series of observations, I have no doubt in my own mind that the haemorrhage was secondary to an inflammatory condition of the uterus. Prof. Robert Donaldson has also informed me that tion to the highway rates). 70 per cent. to 80 per cent. of curettings received from I am, Sir, yours faithfully, the gynaecological department were inflammatory in MERVYN O’GORMAN. Embankment-gardens, S.W., March 29th, 1932. type and that probably in many cases the inflammaa