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THE PRECONCEPTIONAL MENSTRUAL PERIOD
646 A SIGN OF GUT PERFORATION
SIR,-I describe here a diagnostic sign which may be present in cases of gastrointestinal perforation: it is the crepitations felt when a routine rectal examination is performed. The best way of eliciting this sign is by placing the patient in the knee-chest position and palpating for the crepitations caused by air compressed between the sacrum and the posterior wall of the rectum. I have found this sign in one case of gastrooesophageal perforation due to gastroscopy, two cases of gastric perforation due to benign gastric ulcer, and four cases of sigmoid perforation due to acute diverticulitis. 1st Medical Clinic, Faculdade Nacional de Medicina, University of Brazil, Rio de Janeiro, Brazil.
There have been instances, admittedly rare, when, in a patient complaining of infertility, I have been able correctly to give assurance that conception was imminent or had occurred, on learning that the patient had just completed an unduly short and scanty period. One can only speculate upon the mechanism of this alteration in menstruation which anticipates conception. I should be
interested to learn if any of your readers observation.
Occasional Book MEDICINE IN THE DOCK
CALF
and normal intestinal architecture. We hope to publish a more detailed report of our studies. This work was aided by grants from the National Vitamin Foundation and National Institutes of Health. Division of
Hepatic Metabolism and Nutrition, New Jersey College of Medicine and Dentistry, and the East Orange Veterans Administration Hospital, East Orange, New Jersey 07018. Clinical Research Center, University of Puerto Rico School of Medicine, San Juan 22, Puerto Rico.
HERMAN BAKER OSCAR FRANK SUSAN FEINGOLD HERMAN ZIFFER.
A. A. CINTRÓN-RIVERA.
THE PRECONCEPTIONAL MENSTRUAL PERIOD
SIR,-There is universal recognition of the possibility of in the calculation of the expected date of delivery from the date of onset of the last menstrual period. It is only rarely that the consequences of this uncertainty are unfortunate for the infant, but they can be so when elective termination of pregnancy is practised. The potential risk to the faetus whose maturity at birth proves to be a month less than the obstetrierror
cian’s estimate is referred
to
in the letter from Dr. Dunn
(Jan. 27, p. 208). May I draw attention
to a possible source of error in the calculation of the date of term ? During thirty years of obstetric experience I have been impressed by the number of cases in which the menstrual period preceding conception is abnormal, in that it is shorter and the flow is scantier than the patient’s usual pattern. This is generally interpreted as bleeding during the gestation, and in consequence the expected date of delivery is set a month earlier than it should be. A recent case, typical of several dozen of which I have records, was a primigravida who gave the date of her last normal menstrual period as March 3, 1967. Only after questioning did she admit that in the first week of April there had been a little bleeding for two days. A normal infant, weighing 7 lb. (3-2 kg.) and showing no evidence of postmaturity, was delivered on
Jan. 10,
1968.
a decade ago medicine still seemed to be climbing higher pinnacles of achievement. Today, it is in the dock. Even striking evidence of what earlier would have been considered to be progress, such as the first heart transplant, is
LESS than
to ever
suspect. The doctor has lost little of his hold
on
patients’
confidence, but his profession has no very flattering image, and medicine in the abstract is ceasing to command awe. Dr. Dannie Abse1 has suggested a number of reasons for this, and three in particular. First, medical education has become detached from clinical reality. For example, many medical students are likely to become general practitioners yet all are taught as if they were going to take up hospital appointments, so that when a G.P. starts to practise he finds, as Dr. Abse did, that " diseases hardly ever presented themselves according to the textbook description ". But it is not merely the content of the curriculum which leaves Dr. Abse dissatisfied. He is critical of the attitude to disease that permeates it. For a century, it has been assumed that disease is an organic phenomenon. That functional disorders exist has not been disputed; but it has been felt (and still is) that they are not disease, in the strict sense; and that the term too often masks the existence of an organic disorder not yet diagnosed. Recent research, Dr. Abse insists-particularly the work of Selye and others on the significance of stress in predisposing to or precipitating illness-has shown that disease is more often a matter of abnormal function than of damaged structure. This is an area which medical science has as yet barely begun to explQre; so, the setiology of a disorder is frequently unknown -" the diagnosis a question mark, the treatment symptomatic, the prognosis uncertain". Like Prince Rupert, medical science has swept some enemies from the field only to find it overrun by others. Yet medicine persists in treating disorders of function as if
organic by using drugs, and continuing to use when-as, for example, in the case of some tranquillisers-controlled trials have failed to demonstrate that they can do any more than a placebo. Here, Dr. Abse feels the profession has allowed itself to be gulled by the pharmaceutical industry: the time has come to impose stricter discipline on " the wild promotional activities of the drug drastic reforms industry’s advertising managers and P.R.o.s are required ". At this point the reader may well say, with some exasperation, My dear chap, we know all this ". But, as Freud used to say, there is knowing and knowing. A score of reports have appeared in the past few years exposing the deficiencies of medical education, and doubtless Lord Todd’s Royal Commission will, too; but what is the use of that when so little is changed ? Is it not time for the profession to begin asking itself whether it can evolve: or whether by preserving its independence it has, dinosaur-like, insulated itself from they
them
were
even
...
"
necessary evolution.
Adv. clin. Chem. 1962, 5, 173. Baker, H., H., Sobotka, Frank, O., Sobotka, H., Ho, P. P., Cohen, N., Janowitz, H., Ziffer, H., Leevy, C. M. J. Am. med. Ass. 1964, 187, 119. Baker, H., Frank, O., Feingold, S., Ziffer, H., Gellene, R. A., Leevy, C. M., Sobotka, H. Am. J. clin. Nutr. 1965, 17, 88.
1. Baker,
confirm this
A. W. ANDISON.
CARLOS ALBERTO LEITE.
JEJUNUM AND FOLATE ABSORPTION SIR,-We have lately studied eight patients with sprue who did not absorb 5-mg. doses of synthetic folic acid. Folic-acid absorption was restored in these patients by the oral administration of a combination of 5 g. lyophilised calf jejunum with 5 mg. of synthetic folic acid. After ingestion of this combination, the serum-folate, as measured by Lactobacillus casea, rose to normal folate-absorption levels within 4 hours.! The factors in calf jejunum that re-established folic-acid absorption were heat-stable and did not require prior incubation with folic acid to bind or conjugate the added folic acid. Preliminary results indicate that the calf-jejunum/folic-acid combination also re-established absorption of other nutrients
can
H.
Consider the second of Dr. Abse’s criticisms: that the tends to think of disease as an entity, rather than as
profession
1. Medicine
Pp. 352.
on
Trial.
42s.
By DANNIE ABSE.
London: Aldus Books.
1967.
SIR,-I describe here a diagnostic sign which may be present in cases of gastrointestinal perforation: it is the crepitations felt when a routine rectal examination is performed. The best way of eliciting this sign is by placing the patient in the knee-chest position and palpating for the crepitations caused by air compressed between the sacrum and the posterior wall of the rectum. I have found this sign in one case of gastrooesophageal perforation due to gastroscopy, two cases of gastric perforation due to benign gastric ulcer, and four cases of sigmoid perforation due to acute diverticulitis. 1st Medical Clinic, Faculdade Nacional de Medicina, University of Brazil, Rio de Janeiro, Brazil.
There have been instances, admittedly rare, when, in a patient complaining of infertility, I have been able correctly to give assurance that conception was imminent or had occurred, on learning that the patient had just completed an unduly short and scanty period. One can only speculate upon the mechanism of this alteration in menstruation which anticipates conception. I should be
interested to learn if any of your readers observation.
Occasional Book MEDICINE IN THE DOCK
CALF
and normal intestinal architecture. We hope to publish a more detailed report of our studies. This work was aided by grants from the National Vitamin Foundation and National Institutes of Health. Division of
Hepatic Metabolism and Nutrition, New Jersey College of Medicine and Dentistry, and the East Orange Veterans Administration Hospital, East Orange, New Jersey 07018. Clinical Research Center, University of Puerto Rico School of Medicine, San Juan 22, Puerto Rico.
HERMAN BAKER OSCAR FRANK SUSAN FEINGOLD HERMAN ZIFFER.
A. A. CINTRÓN-RIVERA.
THE PRECONCEPTIONAL MENSTRUAL PERIOD
SIR,-There is universal recognition of the possibility of in the calculation of the expected date of delivery from the date of onset of the last menstrual period. It is only rarely that the consequences of this uncertainty are unfortunate for the infant, but they can be so when elective termination of pregnancy is practised. The potential risk to the faetus whose maturity at birth proves to be a month less than the obstetrierror
cian’s estimate is referred
to
in the letter from Dr. Dunn
(Jan. 27, p. 208). May I draw attention
to a possible source of error in the calculation of the date of term ? During thirty years of obstetric experience I have been impressed by the number of cases in which the menstrual period preceding conception is abnormal, in that it is shorter and the flow is scantier than the patient’s usual pattern. This is generally interpreted as bleeding during the gestation, and in consequence the expected date of delivery is set a month earlier than it should be. A recent case, typical of several dozen of which I have records, was a primigravida who gave the date of her last normal menstrual period as March 3, 1967. Only after questioning did she admit that in the first week of April there had been a little bleeding for two days. A normal infant, weighing 7 lb. (3-2 kg.) and showing no evidence of postmaturity, was delivered on
Jan. 10,
1968.
a decade ago medicine still seemed to be climbing higher pinnacles of achievement. Today, it is in the dock. Even striking evidence of what earlier would have been considered to be progress, such as the first heart transplant, is
LESS than
to ever
suspect. The doctor has lost little of his hold
on
patients’
confidence, but his profession has no very flattering image, and medicine in the abstract is ceasing to command awe. Dr. Dannie Abse1 has suggested a number of reasons for this, and three in particular. First, medical education has become detached from clinical reality. For example, many medical students are likely to become general practitioners yet all are taught as if they were going to take up hospital appointments, so that when a G.P. starts to practise he finds, as Dr. Abse did, that " diseases hardly ever presented themselves according to the textbook description ". But it is not merely the content of the curriculum which leaves Dr. Abse dissatisfied. He is critical of the attitude to disease that permeates it. For a century, it has been assumed that disease is an organic phenomenon. That functional disorders exist has not been disputed; but it has been felt (and still is) that they are not disease, in the strict sense; and that the term too often masks the existence of an organic disorder not yet diagnosed. Recent research, Dr. Abse insists-particularly the work of Selye and others on the significance of stress in predisposing to or precipitating illness-has shown that disease is more often a matter of abnormal function than of damaged structure. This is an area which medical science has as yet barely begun to explQre; so, the setiology of a disorder is frequently unknown -" the diagnosis a question mark, the treatment symptomatic, the prognosis uncertain". Like Prince Rupert, medical science has swept some enemies from the field only to find it overrun by others. Yet medicine persists in treating disorders of function as if
organic by using drugs, and continuing to use when-as, for example, in the case of some tranquillisers-controlled trials have failed to demonstrate that they can do any more than a placebo. Here, Dr. Abse feels the profession has allowed itself to be gulled by the pharmaceutical industry: the time has come to impose stricter discipline on " the wild promotional activities of the drug drastic reforms industry’s advertising managers and P.R.o.s are required ". At this point the reader may well say, with some exasperation, My dear chap, we know all this ". But, as Freud used to say, there is knowing and knowing. A score of reports have appeared in the past few years exposing the deficiencies of medical education, and doubtless Lord Todd’s Royal Commission will, too; but what is the use of that when so little is changed ? Is it not time for the profession to begin asking itself whether it can evolve: or whether by preserving its independence it has, dinosaur-like, insulated itself from they
them
were
even
...
"
necessary evolution.
Adv. clin. Chem. 1962, 5, 173. Baker, H., H., Sobotka, Frank, O., Sobotka, H., Ho, P. P., Cohen, N., Janowitz, H., Ziffer, H., Leevy, C. M. J. Am. med. Ass. 1964, 187, 119. Baker, H., Frank, O., Feingold, S., Ziffer, H., Gellene, R. A., Leevy, C. M., Sobotka, H. Am. J. clin. Nutr. 1965, 17, 88.
1. Baker,
confirm this
A. W. ANDISON.
CARLOS ALBERTO LEITE.
JEJUNUM AND FOLATE ABSORPTION SIR,-We have lately studied eight patients with sprue who did not absorb 5-mg. doses of synthetic folic acid. Folic-acid absorption was restored in these patients by the oral administration of a combination of 5 g. lyophilised calf jejunum with 5 mg. of synthetic folic acid. After ingestion of this combination, the serum-folate, as measured by Lactobacillus casea, rose to normal folate-absorption levels within 4 hours.! The factors in calf jejunum that re-established folic-acid absorption were heat-stable and did not require prior incubation with folic acid to bind or conjugate the added folic acid. Preliminary results indicate that the calf-jejunum/folic-acid combination also re-established absorption of other nutrients
can
H.
Consider the second of Dr. Abse’s criticisms: that the tends to think of disease as an entity, rather than as
profession
1. Medicine
Pp. 352.
on
Trial.
42s.
By DANNIE ABSE.
London: Aldus Books.
1967.