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TREATMENT OF REGULAR MENORRHAGIA
622 relation to the occupation. As isolated incidents, they have to be accepted in the rough and tumble of everyday life, but if a man is to lose his job because he is constantly inefficient they assume greater significance. Quoting from examples in my own records, the wife may have parkinsonism or the husband may be up half the night in attendance on an elderly relative with senile dementia. To remedy these as individual cases is one thing ; to estimate the relative significance of them to occupational efficiency it is necessary to know of the whole picture of social problems in the community. Nothing is taken away from the individual clinician if it is suggested that his work in regard to a specific occupation is as firmly linked with the health department, as the local centre of sociomedical services, as should be his practice within any single home.
The
community does
not consist of
healthy, stable,
contented, well-housed individuals, but of families and individuals of various physical and mental calibre living under all sorts of conditions. Their health in their occupations cannot be separated from their general way of life. Until widespread communal studies of morbidity in relation to occupation can be made, no efficient occupational health service can be established. The present trend is for individual pressure groups to put forward their particular case without reference to the. over-all needs of the nation or the economical use of sociomedical facilities, either at present available or expanded where A separate clinical service would merely necessary. duplicate the present general-practitioner and specialist facilities, -while any creation of a separate preventive service with an epidemiological outlook would inevitably overlap with the work of the health department, which is already responsible for prevention and aftercare outside the place of work. The key to an improvement of occupational mental and physical health is an extension of the work of the present sociomedical team through wise coordination by those in a position to observe the community and draw on the facilities available. W. S. PARKER Medical Officer of Health.
Brighton.
TREATMENT OF REGULAR MENORRHAGIA SrR,,-I have been very interested in the remarks on causation and treatment of idiopathic menorrhagia by Dr. Swyer (Aug. 15). I have had occasion recently to treat 7 patients with this condition, in which no obvious cause could be found. Encouraged by earlier reports,i-9 and because of success in a case of menorrhagia associated with infective hepatitis and a low plasma-prothrombin time, I have treated these 7 patients with vitamin K orally. The dose used was 10 mg. three times daily for seven days, starting on the first day of the menses, and continuing for three consecutive months. This treatment was successful in all patients, and none so far have relapsed-the longest interval has been one year. In 4 of these cases the plasma-prothrombin time was prolonged, as measured by the Quick one-stage method ; but subsequent efforts to coiafirin these findings were unsuccessful-all patients had had oral vitamin K in the interval. A patient, aged 35, para 14, had had menorrhagia for severalI months. No local or general cause was found. On March 9, 1953, the plasma-prothrombin time was 29 seconds or 20% protlironibin ; on May 7 (after treatment with vitamin K) it was 16 seconds or 67% prothrombin. The menstrual cycle prior to treatment was 8-10/28 days, with many clots. Since treatment the cycle has been 2-3/28 days, and there have been no clots. This patient is now conroletelv cured.
In
effort to ascertain what step, if any, in the blood-clotting mechanism was involved, an investigation using controls has been undertaken. However, because of delay in finding suitable cases, some time must elapse before any conclusioi-i can be reached. Meanwhile, because of the clinical success with vitamin K, we shall continue to use it empirically. D. T. O’DRISCOLL. Galway, Eire. an
WHAT IS ULCERATIVE COLITIS?
SiR,-Mr. Brookeis right to draw attention to the uncertainty which surrounds the definition of ulcerative colitis. Precision in this definition is,
as I pointed out in a postgraduate lecture, no mere academic nicety but closely related to pathology, treatment, and prognosis.
Some of your readers who have been critical of Mr. Brooke’s conclusions, though sympathetic with his aims, may be interested to hear of this paper which sets out along identical lines but reaches different conclusions. Whilst, as Dr. Naish (Aug. 1) indicates, the approach through aetiology is abortive and, as Mr. Brooke himself agrees, microscopy is unhelpful, a distinction based upon anatomical distribution is of little validity unless it can be related to other aspects such as prognosis or indications for treatment. It is on precisely these mutually related grounds that the definitions I favour rest. Briefly, I suggest that for all practical purposes four separate entities may usefully be differentiated-namely, (i) Crohn’s ileitis, with or without " skip " lesions in the colon ; (ii) ulcerative colitis (or proctocolitis) which invariably involves the rectum and extends thence in continuity ; (iii) segmental colitis, which involves neither ileum nor rectum and extends both in continuity and in skips ; and (iv) proctitis (without colitis) which may be specific or idiopathic. This terminology is demonstrably related to gross pathology, symptomatology, choice of treatment, and prognosis ; it invokes no new concepts but indicates the lines upon which a thoughtful analysis of non-malignant lesions of the colon may profitably be based. I believe that if progress is to be made, a hypothetical and arbitrary distinction is needed between a number of closely related lesions. A really authoritative comment from, say, the St. Mark’s Hospital group would, I am sure, be generally welcomed. Department of Surgery, University of Liverpool.
CHARLES WELLS.
TRAUMATIC RUPTURE OF THE NORMAL SPLEEN IN CHILDREN
SIR,-In connection with Mr. Pender’s interesting article in your last issue I would like to give a brief casehistory illustrating two further points : .
A girl of 7 years fell over in the school playground with several other children. She was later sent home with abdominal pain and visited at least three times by her doctor, who, being unable to make a firm diagnosis, rang up the hospital for advice, as a result of which she was admitted 24 hours after the fall. On examination there was no bruising, but the most notable features were the rapid, grunting respiration, with a distinct " catch " in it, and the accuracy with which she pointed out a small area low in the left posterior triangle of the neck as being extremely painful. On these grounds a diagnosis of ruptured spleen was made. Operation was through a midline incision for rapidity, since her condition was not good ; but the spleen was so firmly bound to’the posterior abdominal wall by congenital adhesions that a transverse extension cutting the left rectus had to be added. °
1.
2. 3. 4. 5. 6. 7. 8.
Adams, W. Therap. d. Gegenw. 1942, 83, 439. Ballon, K. Csl. Gynœk. 1943, 2, 13. Baranowski, T. Amer. Rev. Sov. Med. 1945, iii, 173 Dietz, R. Münch. med. Wschr. 1941, 88, 1009. Gubner, R., Ungerleider, H. E. Industr. Med. 1944, 13, 301. Libansky, J. Cas. Lék. es. 1944, 26, 782; Ibid, 1944, 37, 811. Olesen, M., Kaal, S. Nord. Med. 1944, 22, 1022. Rubsamen, W. Arch. Gynœk. 1942, 173, 319.
9. Schafer, G.
Zbl.
Gynœk,
1947
68,
126.
The type of rapid, shallow, grunting respiration which this patient exhibited, with the " catch " denoting diaphragmatic irritation, has often helped me to make this diagnosis in adults when in doubt ; on one occasion 1.
2.
Brooke, B. N. Lancet, 1953, i, 1220. Wells, C. Ann. R. Coll. Surg. Engl. 1952, 11, 105.
The
community does
not consist of
healthy, stable,
contented, well-housed individuals, but of families and individuals of various physical and mental calibre living under all sorts of conditions. Their health in their occupations cannot be separated from their general way of life. Until widespread communal studies of morbidity in relation to occupation can be made, no efficient occupational health service can be established. The present trend is for individual pressure groups to put forward their particular case without reference to the. over-all needs of the nation or the economical use of sociomedical facilities, either at present available or expanded where A separate clinical service would merely necessary. duplicate the present general-practitioner and specialist facilities, -while any creation of a separate preventive service with an epidemiological outlook would inevitably overlap with the work of the health department, which is already responsible for prevention and aftercare outside the place of work. The key to an improvement of occupational mental and physical health is an extension of the work of the present sociomedical team through wise coordination by those in a position to observe the community and draw on the facilities available. W. S. PARKER Medical Officer of Health.
Brighton.
TREATMENT OF REGULAR MENORRHAGIA SrR,,-I have been very interested in the remarks on causation and treatment of idiopathic menorrhagia by Dr. Swyer (Aug. 15). I have had occasion recently to treat 7 patients with this condition, in which no obvious cause could be found. Encouraged by earlier reports,i-9 and because of success in a case of menorrhagia associated with infective hepatitis and a low plasma-prothrombin time, I have treated these 7 patients with vitamin K orally. The dose used was 10 mg. three times daily for seven days, starting on the first day of the menses, and continuing for three consecutive months. This treatment was successful in all patients, and none so far have relapsed-the longest interval has been one year. In 4 of these cases the plasma-prothrombin time was prolonged, as measured by the Quick one-stage method ; but subsequent efforts to coiafirin these findings were unsuccessful-all patients had had oral vitamin K in the interval. A patient, aged 35, para 14, had had menorrhagia for severalI months. No local or general cause was found. On March 9, 1953, the plasma-prothrombin time was 29 seconds or 20% protlironibin ; on May 7 (after treatment with vitamin K) it was 16 seconds or 67% prothrombin. The menstrual cycle prior to treatment was 8-10/28 days, with many clots. Since treatment the cycle has been 2-3/28 days, and there have been no clots. This patient is now conroletelv cured.
In
effort to ascertain what step, if any, in the blood-clotting mechanism was involved, an investigation using controls has been undertaken. However, because of delay in finding suitable cases, some time must elapse before any conclusioi-i can be reached. Meanwhile, because of the clinical success with vitamin K, we shall continue to use it empirically. D. T. O’DRISCOLL. Galway, Eire. an
WHAT IS ULCERATIVE COLITIS?
SiR,-Mr. Brookeis right to draw attention to the uncertainty which surrounds the definition of ulcerative colitis. Precision in this definition is,
as I pointed out in a postgraduate lecture, no mere academic nicety but closely related to pathology, treatment, and prognosis.
Some of your readers who have been critical of Mr. Brooke’s conclusions, though sympathetic with his aims, may be interested to hear of this paper which sets out along identical lines but reaches different conclusions. Whilst, as Dr. Naish (Aug. 1) indicates, the approach through aetiology is abortive and, as Mr. Brooke himself agrees, microscopy is unhelpful, a distinction based upon anatomical distribution is of little validity unless it can be related to other aspects such as prognosis or indications for treatment. It is on precisely these mutually related grounds that the definitions I favour rest. Briefly, I suggest that for all practical purposes four separate entities may usefully be differentiated-namely, (i) Crohn’s ileitis, with or without " skip " lesions in the colon ; (ii) ulcerative colitis (or proctocolitis) which invariably involves the rectum and extends thence in continuity ; (iii) segmental colitis, which involves neither ileum nor rectum and extends both in continuity and in skips ; and (iv) proctitis (without colitis) which may be specific or idiopathic. This terminology is demonstrably related to gross pathology, symptomatology, choice of treatment, and prognosis ; it invokes no new concepts but indicates the lines upon which a thoughtful analysis of non-malignant lesions of the colon may profitably be based. I believe that if progress is to be made, a hypothetical and arbitrary distinction is needed between a number of closely related lesions. A really authoritative comment from, say, the St. Mark’s Hospital group would, I am sure, be generally welcomed. Department of Surgery, University of Liverpool.
CHARLES WELLS.
TRAUMATIC RUPTURE OF THE NORMAL SPLEEN IN CHILDREN
SIR,-In connection with Mr. Pender’s interesting article in your last issue I would like to give a brief casehistory illustrating two further points : .
A girl of 7 years fell over in the school playground with several other children. She was later sent home with abdominal pain and visited at least three times by her doctor, who, being unable to make a firm diagnosis, rang up the hospital for advice, as a result of which she was admitted 24 hours after the fall. On examination there was no bruising, but the most notable features were the rapid, grunting respiration, with a distinct " catch " in it, and the accuracy with which she pointed out a small area low in the left posterior triangle of the neck as being extremely painful. On these grounds a diagnosis of ruptured spleen was made. Operation was through a midline incision for rapidity, since her condition was not good ; but the spleen was so firmly bound to’the posterior abdominal wall by congenital adhesions that a transverse extension cutting the left rectus had to be added. °
1.
2. 3. 4. 5. 6. 7. 8.
Adams, W. Therap. d. Gegenw. 1942, 83, 439. Ballon, K. Csl. Gynœk. 1943, 2, 13. Baranowski, T. Amer. Rev. Sov. Med. 1945, iii, 173 Dietz, R. Münch. med. Wschr. 1941, 88, 1009. Gubner, R., Ungerleider, H. E. Industr. Med. 1944, 13, 301. Libansky, J. Cas. Lék. es. 1944, 26, 782; Ibid, 1944, 37, 811. Olesen, M., Kaal, S. Nord. Med. 1944, 22, 1022. Rubsamen, W. Arch. Gynœk. 1942, 173, 319.
9. Schafer, G.
Zbl.
Gynœk,
1947
68,
126.
The type of rapid, shallow, grunting respiration which this patient exhibited, with the " catch " denoting diaphragmatic irritation, has often helped me to make this diagnosis in adults when in doubt ; on one occasion 1.
2.
Brooke, B. N. Lancet, 1953, i, 1220. Wells, C. Ann. R. Coll. Surg. Engl. 1952, 11, 105.