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TUBAL OCCLUSION
1011 A pause would have been desirable if only because a staple article of diet and likely to be increasingly used as such, is not the only food which is
bread, itself
nowadays tampered with, preserved, or even misrepresented, despite legislation to prevent at least some of these happenings. As a profession we are inclined to take short-term views of cause and effect, and a sentence in the M.R.C. Conference report should be drummed into everybody : the absence of recognisable illness in an individual is not a sufficient criterion that his diet is nutritionally sound." I have got myself into trouble in the past because of ’
my objections, for quite clear reasons, to the pasteurising of milk as an end in itself ; amongst these objections is that we know from experimental work and simple observation that heat-treated milk loses something The usual more than part of its ascorbic-acid content. reply to this is that deficiencies are made up by other articles of food. If one by one the principal articles of food are going to be denatured with official connivance, where shall we finish up Everybody agrees that all sorts of what are called metabolic or constitutional diseases are on the increase ; while it would be stupid to assign their basic pathology necessarily to nutritional causes, at least it makes some of us wonder. There is plenty of evidence from nutrition experiments on laboratory animals that queer things can happen; even clearer is the evidence on a long-term basis from experience in feeding livestock generally, in which changes are more readily observed than in man. But the human animal, for better or for worse, is so resistant to abuses of its economy, whether nutritional or other, that lots of things which must be there to be seen are missed because we do not know what to look for. Since food is the most important of the triad governing life-food, warmth, and shelter-it ill behoves us to monkey about with food too much until we are more sure of our ground. A recent experience emphasises how much remains to be learnt about nutrition of quite a simple kind. For a number of years I have bred and reared cattle, and in a national show just a fortnight ago I won amongst other prizes one for a sixteen-month-old heifer. This rather surprised me as her nutritional state in the ring was not so good as it had been a few weeks before the show when she was brought in from the herd and given, with a companion, special scientific(’?) feeding, as is usual preparatory to such an event. On returning from the show she was turned out with others into an old orchard carpeted with rough old herbage, and within a fortnight she has found for herself a diet which has filled all the hollows that special attention did little to correct. So much for thinking one knows anything about feeding animals. What about human dietary-so easily influenced
by Authority. London,
W. R. THROWER.
W.I.
TUBAL OCCLUSION
SiR,—Last week Mr. Green-Armytage stated that there is danger in the doctrine that " among patients attending infertility clinics who are found to have blocked tubes, spasm, irritability, anaesthesia, nerves, or even frailty in deductions and methods, are the causes of tubal occlusion in all but 6-7% of cases." After reading this, it is instructive to turn to what Professor Polanyi says in the same issue : " Science is said to describe facts which are there whether you like them
or
not ...
The function which I attribute
here to scientific passion is that of distinguishing between demonstrable facts which are of scientific interest, and those which are not."
For many years now, I have taught and written that a miitimal criterion for tubal occlusion should be two negative tubal insuffiations at 250 mm. Hg, plus a
confirmatory hysterosalpingogram,
on
separate occasions.
Even this criterion is not proof-positive of non-patency of the tubes. For too many years a single insufflation finding of non-patency at 200 mm. Hg, or a single hysterosalpingogram which shows apparent non-patency, has been accepted by many gynaecologists as denoting tubal blockage. The importance of tubal spasm, simulating tubal blockage, can be easily demonstrated : every case which shows apparent non-patency at 250 mm. Hg under anaesthesia, should have a repeat -insufflation a few days later without anaesthesia, when normal tubal patency and function is seen in two out of every three such cases. This result has been obtained by me in more than 300 such tests and without the preliminary use of amyl nitrite or any antispasmodic. I am interested in Mr. Green-Armytage’s statement that tuberculosis alone accounts for 5-6% of all occlusions. In a paper presented before the Royal Society of Medicine in 1943, I propounded the view, for the first time, that tubal blockage may, in a considerable proportion of cases, be due to subclinical tuberculous
salpingitis. Royal Samaritan Hospital for Women, Glasgow, S.2.
ALBERT SHARMAN.
DIAGNOSIS OF THYROTOXICOSIS
SIR,-I was interested to read last week’s letter by Dr. Freeman and Dr. Mattingly on the diagnosis of doubtful cases of thyrotoxicosis. The differentiation of thyrotoxicosis from an anxiety state is one of the common problems of general practice, and one which often involves referral to hospital with The expensive and time-consuming investigations. measurement of sleeping pulse-rate would be a very simple investigation in general practice if it were possible to use a fairly short-acting hypnotic such as intramuscular paraldehyde ; and I would be interested to know whether a true resting pulse-rate is obtainable in this way. If so, admission to hospital for three days, as suggested by your correspondents, would seem unnecessary and
extravagant. J. TUDOR-HART. J. TUDOR-HART.
London. IV.11.
A SHORT SMALL INTESTINE ASSOCIATED WITH FIBROSIS OF THE LIVER
SiR,—The article by Dr. Raeburn and Dr. Brafield calls attention to the association of a short small intestine with fibrosis of the liver. This association does not seem to be always present, as the following case shows.
(June 9)
A woman, aged 55, had had intermittent vomiting for the months. A barium-meal investigation revealed partial obstruction at the duodenojejunal flexure.. The proximal 4 inches of the jejunum showed constant narrowing of the lumen with rigidity of the walls and complete loss of the mucosal pattern. The small gut appeared to be short but was otherwise normal. A diagnosis of malignant neoplasm of the
past six
jejunum At and
was
suggested.
necropsy (Dr.
W. I.
Leslie)
a
congenitally
short
jejunum
ileum, measuring 8 feet together, was found. The proximal part of the jejunum was bound by firm adhesions
appeared to be narrowed and somewhat kinked, but its wall was not infiltrated by growth. There was a scirrhous carcinoma in the distal half of the pancreas. The spleen showed nothing abnormal apart from intense congestion. The liver was firm and was not enlarged ; on section, numerous metastatic tumour nodules were found widely distributed throughout the parenchyma. to the tail of the pancreas ; its lumen
In this case of congenitally short small intestine no evidence of fibrosis of the liver was present. Possibly the short jejunum, being in closer contact with the tail of the pancreas than is usual, caused chronic irritation by intermittent pressure, thus contributingzn to the development of cancer in this region. A. ELKELES. London, AV.1.
bread, itself
nowadays tampered with, preserved, or even misrepresented, despite legislation to prevent at least some of these happenings. As a profession we are inclined to take short-term views of cause and effect, and a sentence in the M.R.C. Conference report should be drummed into everybody : the absence of recognisable illness in an individual is not a sufficient criterion that his diet is nutritionally sound." I have got myself into trouble in the past because of ’
my objections, for quite clear reasons, to the pasteurising of milk as an end in itself ; amongst these objections is that we know from experimental work and simple observation that heat-treated milk loses something The usual more than part of its ascorbic-acid content. reply to this is that deficiencies are made up by other articles of food. If one by one the principal articles of food are going to be denatured with official connivance, where shall we finish up Everybody agrees that all sorts of what are called metabolic or constitutional diseases are on the increase ; while it would be stupid to assign their basic pathology necessarily to nutritional causes, at least it makes some of us wonder. There is plenty of evidence from nutrition experiments on laboratory animals that queer things can happen; even clearer is the evidence on a long-term basis from experience in feeding livestock generally, in which changes are more readily observed than in man. But the human animal, for better or for worse, is so resistant to abuses of its economy, whether nutritional or other, that lots of things which must be there to be seen are missed because we do not know what to look for. Since food is the most important of the triad governing life-food, warmth, and shelter-it ill behoves us to monkey about with food too much until we are more sure of our ground. A recent experience emphasises how much remains to be learnt about nutrition of quite a simple kind. For a number of years I have bred and reared cattle, and in a national show just a fortnight ago I won amongst other prizes one for a sixteen-month-old heifer. This rather surprised me as her nutritional state in the ring was not so good as it had been a few weeks before the show when she was brought in from the herd and given, with a companion, special scientific(’?) feeding, as is usual preparatory to such an event. On returning from the show she was turned out with others into an old orchard carpeted with rough old herbage, and within a fortnight she has found for herself a diet which has filled all the hollows that special attention did little to correct. So much for thinking one knows anything about feeding animals. What about human dietary-so easily influenced
by Authority. London,
W. R. THROWER.
W.I.
TUBAL OCCLUSION
SiR,—Last week Mr. Green-Armytage stated that there is danger in the doctrine that " among patients attending infertility clinics who are found to have blocked tubes, spasm, irritability, anaesthesia, nerves, or even frailty in deductions and methods, are the causes of tubal occlusion in all but 6-7% of cases." After reading this, it is instructive to turn to what Professor Polanyi says in the same issue : " Science is said to describe facts which are there whether you like them
or
not ...
The function which I attribute
here to scientific passion is that of distinguishing between demonstrable facts which are of scientific interest, and those which are not."
For many years now, I have taught and written that a miitimal criterion for tubal occlusion should be two negative tubal insuffiations at 250 mm. Hg, plus a
confirmatory hysterosalpingogram,
on
separate occasions.
Even this criterion is not proof-positive of non-patency of the tubes. For too many years a single insufflation finding of non-patency at 200 mm. Hg, or a single hysterosalpingogram which shows apparent non-patency, has been accepted by many gynaecologists as denoting tubal blockage. The importance of tubal spasm, simulating tubal blockage, can be easily demonstrated : every case which shows apparent non-patency at 250 mm. Hg under anaesthesia, should have a repeat -insufflation a few days later without anaesthesia, when normal tubal patency and function is seen in two out of every three such cases. This result has been obtained by me in more than 300 such tests and without the preliminary use of amyl nitrite or any antispasmodic. I am interested in Mr. Green-Armytage’s statement that tuberculosis alone accounts for 5-6% of all occlusions. In a paper presented before the Royal Society of Medicine in 1943, I propounded the view, for the first time, that tubal blockage may, in a considerable proportion of cases, be due to subclinical tuberculous
salpingitis. Royal Samaritan Hospital for Women, Glasgow, S.2.
ALBERT SHARMAN.
DIAGNOSIS OF THYROTOXICOSIS
SIR,-I was interested to read last week’s letter by Dr. Freeman and Dr. Mattingly on the diagnosis of doubtful cases of thyrotoxicosis. The differentiation of thyrotoxicosis from an anxiety state is one of the common problems of general practice, and one which often involves referral to hospital with The expensive and time-consuming investigations. measurement of sleeping pulse-rate would be a very simple investigation in general practice if it were possible to use a fairly short-acting hypnotic such as intramuscular paraldehyde ; and I would be interested to know whether a true resting pulse-rate is obtainable in this way. If so, admission to hospital for three days, as suggested by your correspondents, would seem unnecessary and
extravagant. J. TUDOR-HART. J. TUDOR-HART.
London. IV.11.
A SHORT SMALL INTESTINE ASSOCIATED WITH FIBROSIS OF THE LIVER
SiR,—The article by Dr. Raeburn and Dr. Brafield calls attention to the association of a short small intestine with fibrosis of the liver. This association does not seem to be always present, as the following case shows.
(June 9)
A woman, aged 55, had had intermittent vomiting for the months. A barium-meal investigation revealed partial obstruction at the duodenojejunal flexure.. The proximal 4 inches of the jejunum showed constant narrowing of the lumen with rigidity of the walls and complete loss of the mucosal pattern. The small gut appeared to be short but was otherwise normal. A diagnosis of malignant neoplasm of the
past six
jejunum At and
was
suggested.
necropsy (Dr.
W. I.
Leslie)
a
congenitally
short
jejunum
ileum, measuring 8 feet together, was found. The proximal part of the jejunum was bound by firm adhesions
appeared to be narrowed and somewhat kinked, but its wall was not infiltrated by growth. There was a scirrhous carcinoma in the distal half of the pancreas. The spleen showed nothing abnormal apart from intense congestion. The liver was firm and was not enlarged ; on section, numerous metastatic tumour nodules were found widely distributed throughout the parenchyma. to the tail of the pancreas ; its lumen
In this case of congenitally short small intestine no evidence of fibrosis of the liver was present. Possibly the short jejunum, being in closer contact with the tail of the pancreas than is usual, caused chronic irritation by intermittent pressure, thus contributingzn to the development of cancer in this region. A. ELKELES. London, AV.1.