LONDON, SATURDAY 14 OCTOBER 1978
MEDICAL JOURN\TALT Enigmatic pelvic pain Last year in Britain over 10 000 women had diagnostic laparoscopies for lower abdominal painl-a statistic which emphasises both the frequency of this symptom and the difficulty of making a clinical diagnosis. The many possible organic causes of pelvic pain2 include bowel disorders such as diverticulitis and appendicitis, urinary tract infection, and gynaecological disease such as salpingitis or endometriosis. Abnormalities of the lumbar spine may also cause pain in the pelvis. All too often, however, no disease can be found in the pelvic organs or the spine, and indeed when the pain is of long standing a specific diagnosis can be made in only a minority of cases.2 In the remainder the complaint of pain in normal pelvic organs may have several diagnostic labels, including "congestive dysmenorrhoea" or "pelvic sympathetic syndrome," and it has recently3 been given the more charismatic name of "enigmatic pelvic pain." Women with this syndrome3-5 have usually borne children and are always premenopausal. They have a dull ache in the suprapubic area or in one or both iliac fossae, and pain may be referred to the inner thighs. The pain is at its worst before a menstrual period, and there is often deep dyspareunia, which may persist during the day after intercourse. There may be leucorrhoea, menorrhagia, or irritability of the bladder, but bowel dysfunction is infrequent-a finding which helps differentiate the pain from colon spasm. Why should pain occur in an apparently.normal pelvis? Over the years many reasons have been suggested, from sexual frustration to neuralgia.'" Probably the syndrome has several causes. One theory which has recently been re-examined3 5 is that there is a vascular disturbance producing "congestion" of the pelvic organs. Changes in pelvic blood flow occur during sexual arousal and other emotional disturbances.4 During pregnancy uterine blood flow increases tenfold to around 500 ml minute at term," and perhaps in some women the blood flow remains at a higher level after pregnancy despite involution of the uterus-though how this would cause pain is unexplained. A study5 of women with pelvic pain and vulval varicosities has shown that such patients may also have pelvic varicosities. In most patients, however, vulval venography is not practicable, and until we have a convenient method of measuring pelvic blood flow the concept of "congestion" will remain ill defined. Patients with unexplained pelvic pain are usually anxious, and the syndrome may be a stress disorder.:' In one psychiatric © BRITISH MEDICAL JOURNAL 1978. All reproduction riglhts reserved.
survey4 of women with pelvic congestion most were found to be "psychologically ill" and almost all had had their first symptoms during a time of stress. A recent British study9 of women undergoing laparoscopy for pelvic pain compared those with demonstrable disease to those with normal pelvic organs: patients in the latter group were significantly more neurotic and had less satisfactory sex lives. Perhaps sexual frustration may indeed cause congestion of the pelvic organs, but anxiety and depression may also result from persisting pain which doctors dismiss as imaginary.5 Though the problem is common, treating these unfortunate women remains as enigmatic as their pain. It has even been suggested10 that these patients need their pain, and that its removal would lead to psychosis and suicide. In some cases it is enough to reassure the patient that she has no serious disease. If the pain is thought to be psychosomatic then a sympathetic analysis of the problem is necessary,2 perhaps with the help of a psychiatrist-though immediate referral to a psychiatric department is not recommended9 because it often offends the patient. Suppressing ovulation by oral contraceptives may be tried, but this treatment may be hazardous for older women. The question of operative treatment is controversial. Ventrosuspension of the uterus has fallen out of favour, and appendicectomy for "chronic appendicitis" has few advocates. It is standard teaching that "there is no 'place for operative treatment of any kind"11 and that the surgeon who removes a normal uterus is to be pitied for his lack of clinical acumen.12 Nevertheless, some gynaecologists3 strongly recommend hysterectomy (with conservation of the ovaries) in severe cases, and claim immediate,-dramatic, and lasting relief of pain after operation. Others13 would consider hysterectomy only after obtaining the advice of a psychiatrist. Hysterectomy does not cure all patients, and subsequent treatment may be more difficult if operation fails. Even so, it has a place in the treatment of unexplained pelvic pain and should not be regarded by the gynaecologists as a confession of defeat. Working Party of the Confidential Enquiry into Gynaecological Laparoscopy, British Journal of Obstetrics and Gynaecology, 1978, 85, 401. 2 Jeffcoate, T N A, British Medical Journal, 1969, 3, 431. ' Mills, W G, .7ournal of the Royal Society of Medicine, 1978, 71, 257. 4 Duncan,. C H, and Taylor, H C, American J7ournal of Obstetrics and Gynecology, 1952, 64, 1. Hobbs, J T, Practitionier, 1976, 216, 529.
NO 6144 PAGE 1041
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6 Theobald, G W, J3ournal of Obstetrics and Gynaecology of the British Empire, 1951, 58, 733. Taylor, H C, American Joournal of Obstetrics and Gynecology, 1949, 57, 211. 8 Hytten, F E, and Leitch, I, The Physiology of Human Pregnancy, 2nd edn, p 96. Oxford, Blackwell, 1971. 9 Beard, R W, et al, American J7ournal of Obstetrics and Gynecology, 1977, 128, 566. 10 Friederich, M A, and Labrum, A, in Controversy in Obstetrics and Gynecology II, eds D E Reid and C D Christian, p 772. Philadelphia, Saunders, 1974. 11 Jeffcoate, T N A, Principles of Gynaecology, 4th edn, p 543. London, Butterworths, 1975. 12 Howkins, J, and Stallworthy, J, Bonney's Gynaecological Surgery, 8th edn, p 824. London, Bailliere Tindall, 1974. 13 Josimovich, J B, in Controversy in Obstetrics and Gynecology II, eds D E Reid and C D Christian, p 776. Philadelphia, Saunders, 1974.
A hundred years of service Few people have ever heard of the Medical Missionary Association, yet its influence has spread to the far corners of the earth. The man in the street and the doctor in his consulting room may know of David Livingstone and Albert Schweitzer, and perhaps of Sir Wilfred Grenfell-but would either know that the MMA celebrates its centenary this year? To commemorate this event there was on 6 October a service of thanksgiving in All Souls Church, Langham Place, the doctors' church in the heart of medical London. On 19 October, in nearby Manson House, the opening scientific meeting of the 1978-9 session of the Royal Society of Tropical Medicine and Hygiene will have as its theme the contribution of medical missions to tropical medicine. These two events represent the two interlacing strands-spiritual and medicalof the MMA. The five doctors who met in London on 2 March 1878 to found the association saw no incongruity in combining these two concepts nor did they make any distinction between needy people at home and those abroad. Doctors north of the border had formed the Edinburgh Medical Missionary Association some 40 years previously and the London association was soon to show its Scottish counterpart that it, too, could do something practical "to help forward such Christian work, both at home and abroad, as may properly be within the spheres of medical agencies." This rather stilted wording was matched by the decision to do nothing more exciting than to create a hostel where impecunious medical students in London could be lodged and fed at low cost. But from 1885 onwards, successively in North London, Highbury, Chislehurst, and then Bloomsbury and Canonbury, the facilities provided by these hostels made it possible for Christian medical students to qualify in medicine and thereafter to offer their services to various missionary societies for work abroad. The Medical Missionary Association has over the years sent out a worthy succession of dedicated doctors to serve and train and investigate. In recent years the provision of state grants to medical students has reduced-but not entirely eliminated-the need for such a hostel: there are at present 10 students at Canonbury Place, enjoying the stimulating fellowship of each other and their warden. As Phyllis Thompson shows in her booklet Sent to Heal,' the past century has witnessed many changes in the activities of the MMA. The early photographs of serious-looking young men, sombrely clad in dark suits and ties, have been replaced by snapshots of a relaxed group of men and women from Britain and overseas, medical students, nurses, and physiotherapists in a fashionable diversity of clothing. In other ways,
BRITISH MEDICAL JOURNAL
14 OCTOBER 1978
too, there have been changes. An exhibition was organised by the association at the Royal Society of Medicine in 1962; it is now held annually at the Royal College of Surgeons in Lincoln's Inn Fields. The exhibition is more than a showpiece or an employment agency: it is a forum where the medical and spiritual needs of the world are presented to keen young doctors. Another new departure, a brain-child of Dr Harry Bennett, for nearly a quarter of a century the secretary of the MMA and its hostel, is a scheme known as OYSTER (One Year's Service To Encourage Recruiting). Graduate doctors wishing to serve for a short time at a mission hospital abroad are helped with the expenses of travel to and from their destination. Once they have seen the need, and have shared in alleviating it, some of them do indeed return for a longer, indefinite period. As Sir Clement Chesterman, the president of the Medical Missionary Association, writes in the foreword of Sent to Heal, "By sharing and caring, curing and preventing, the doctor and nurse can make it possible to believe that God is Love. But how can they be sent? That is the continuing task which the MMA can help to undertake in its second century." 1
Published by the MMA, 6 Canonbury Place, London Ni 2NJ, price 50p.
After splenectomy Unfortunately, the seat of melancholy, traditionally found in the spleen, is not extirpated by splenectomy. But the operation does remove one-quarter of the total human lymphoid tissue and a major mass of macrophages, and immunological abnormalities develop. These include an impaired clearance of bacteria such as pneumococci and other particulate antigens when there are low concentrations of circulating antibody,' 2 lower concentrations of IgM,3 and in many cases a fall in the amount of circulating tuftsin.4 5 (Tuftsin, newly described and named after Tufts University, is a naturally occurring tetrapeptide, probably manufactured by the spleen, which stimulates phagocytosis.) These immunological changes help to explain why many patients, particularly children, are more susceptible to infection after splenectomy.6 7 There is a distinct clinical syndrome in affected patients: mild, non-specific symptoms herald overwhelming collapse from sepsis, rapidly leading to death in more than half the cases. The infecting organism is most often Diplococcus pneumoniae8 and disseminated intravascular coagulation is a common complication.9 Four-fifths of cases occur in the first three years after splenectomy.'0 While this symptom complex is most common in children it also occurs in adults, especially those with an underlying primary disorder such as Hodgkin's disease.1' In such cases splenectomy is often only one of several factors predisposing to infection. Indeed, patients undergoing splenectomy for trauma have less risk of contracting infection than those whose operation was done on medical grounds. Nevertheless, overwhelming sepsis may occur in both circumstances.12 Why infection should be a smaller hazard after splenectomy for trauma than for other indications has not been clear, but some recent work by Pearson et al'3 may provide the answer. Using a non-invasive technique based on the changes in the appearances of red cells that occur after splenectomy, they found evidence of renewed splenic activity in 13 out of 22
MEDICAL JOURN\TALT Enigmatic pelvic pain Last year in Britain over 10 000 women had diagnostic laparoscopies for lower abdominal painl-a statistic which emphasises both the frequency of this symptom and the difficulty of making a clinical diagnosis. The many possible organic causes of pelvic pain2 include bowel disorders such as diverticulitis and appendicitis, urinary tract infection, and gynaecological disease such as salpingitis or endometriosis. Abnormalities of the lumbar spine may also cause pain in the pelvis. All too often, however, no disease can be found in the pelvic organs or the spine, and indeed when the pain is of long standing a specific diagnosis can be made in only a minority of cases.2 In the remainder the complaint of pain in normal pelvic organs may have several diagnostic labels, including "congestive dysmenorrhoea" or "pelvic sympathetic syndrome," and it has recently3 been given the more charismatic name of "enigmatic pelvic pain." Women with this syndrome3-5 have usually borne children and are always premenopausal. They have a dull ache in the suprapubic area or in one or both iliac fossae, and pain may be referred to the inner thighs. The pain is at its worst before a menstrual period, and there is often deep dyspareunia, which may persist during the day after intercourse. There may be leucorrhoea, menorrhagia, or irritability of the bladder, but bowel dysfunction is infrequent-a finding which helps differentiate the pain from colon spasm. Why should pain occur in an apparently.normal pelvis? Over the years many reasons have been suggested, from sexual frustration to neuralgia.'" Probably the syndrome has several causes. One theory which has recently been re-examined3 5 is that there is a vascular disturbance producing "congestion" of the pelvic organs. Changes in pelvic blood flow occur during sexual arousal and other emotional disturbances.4 During pregnancy uterine blood flow increases tenfold to around 500 ml minute at term," and perhaps in some women the blood flow remains at a higher level after pregnancy despite involution of the uterus-though how this would cause pain is unexplained. A study5 of women with pelvic pain and vulval varicosities has shown that such patients may also have pelvic varicosities. In most patients, however, vulval venography is not practicable, and until we have a convenient method of measuring pelvic blood flow the concept of "congestion" will remain ill defined. Patients with unexplained pelvic pain are usually anxious, and the syndrome may be a stress disorder.:' In one psychiatric © BRITISH MEDICAL JOURNAL 1978. All reproduction riglhts reserved.
survey4 of women with pelvic congestion most were found to be "psychologically ill" and almost all had had their first symptoms during a time of stress. A recent British study9 of women undergoing laparoscopy for pelvic pain compared those with demonstrable disease to those with normal pelvic organs: patients in the latter group were significantly more neurotic and had less satisfactory sex lives. Perhaps sexual frustration may indeed cause congestion of the pelvic organs, but anxiety and depression may also result from persisting pain which doctors dismiss as imaginary.5 Though the problem is common, treating these unfortunate women remains as enigmatic as their pain. It has even been suggested10 that these patients need their pain, and that its removal would lead to psychosis and suicide. In some cases it is enough to reassure the patient that she has no serious disease. If the pain is thought to be psychosomatic then a sympathetic analysis of the problem is necessary,2 perhaps with the help of a psychiatrist-though immediate referral to a psychiatric department is not recommended9 because it often offends the patient. Suppressing ovulation by oral contraceptives may be tried, but this treatment may be hazardous for older women. The question of operative treatment is controversial. Ventrosuspension of the uterus has fallen out of favour, and appendicectomy for "chronic appendicitis" has few advocates. It is standard teaching that "there is no 'place for operative treatment of any kind"11 and that the surgeon who removes a normal uterus is to be pitied for his lack of clinical acumen.12 Nevertheless, some gynaecologists3 strongly recommend hysterectomy (with conservation of the ovaries) in severe cases, and claim immediate,-dramatic, and lasting relief of pain after operation. Others13 would consider hysterectomy only after obtaining the advice of a psychiatrist. Hysterectomy does not cure all patients, and subsequent treatment may be more difficult if operation fails. Even so, it has a place in the treatment of unexplained pelvic pain and should not be regarded by the gynaecologists as a confession of defeat. Working Party of the Confidential Enquiry into Gynaecological Laparoscopy, British Journal of Obstetrics and Gynaecology, 1978, 85, 401. 2 Jeffcoate, T N A, British Medical Journal, 1969, 3, 431. ' Mills, W G, .7ournal of the Royal Society of Medicine, 1978, 71, 257. 4 Duncan,. C H, and Taylor, H C, American J7ournal of Obstetrics and Gynecology, 1952, 64, 1. Hobbs, J T, Practitionier, 1976, 216, 529.
NO 6144 PAGE 1041
1042
6 Theobald, G W, J3ournal of Obstetrics and Gynaecology of the British Empire, 1951, 58, 733. Taylor, H C, American Joournal of Obstetrics and Gynecology, 1949, 57, 211. 8 Hytten, F E, and Leitch, I, The Physiology of Human Pregnancy, 2nd edn, p 96. Oxford, Blackwell, 1971. 9 Beard, R W, et al, American J7ournal of Obstetrics and Gynecology, 1977, 128, 566. 10 Friederich, M A, and Labrum, A, in Controversy in Obstetrics and Gynecology II, eds D E Reid and C D Christian, p 772. Philadelphia, Saunders, 1974. 11 Jeffcoate, T N A, Principles of Gynaecology, 4th edn, p 543. London, Butterworths, 1975. 12 Howkins, J, and Stallworthy, J, Bonney's Gynaecological Surgery, 8th edn, p 824. London, Bailliere Tindall, 1974. 13 Josimovich, J B, in Controversy in Obstetrics and Gynecology II, eds D E Reid and C D Christian, p 776. Philadelphia, Saunders, 1974.
A hundred years of service Few people have ever heard of the Medical Missionary Association, yet its influence has spread to the far corners of the earth. The man in the street and the doctor in his consulting room may know of David Livingstone and Albert Schweitzer, and perhaps of Sir Wilfred Grenfell-but would either know that the MMA celebrates its centenary this year? To commemorate this event there was on 6 October a service of thanksgiving in All Souls Church, Langham Place, the doctors' church in the heart of medical London. On 19 October, in nearby Manson House, the opening scientific meeting of the 1978-9 session of the Royal Society of Tropical Medicine and Hygiene will have as its theme the contribution of medical missions to tropical medicine. These two events represent the two interlacing strands-spiritual and medicalof the MMA. The five doctors who met in London on 2 March 1878 to found the association saw no incongruity in combining these two concepts nor did they make any distinction between needy people at home and those abroad. Doctors north of the border had formed the Edinburgh Medical Missionary Association some 40 years previously and the London association was soon to show its Scottish counterpart that it, too, could do something practical "to help forward such Christian work, both at home and abroad, as may properly be within the spheres of medical agencies." This rather stilted wording was matched by the decision to do nothing more exciting than to create a hostel where impecunious medical students in London could be lodged and fed at low cost. But from 1885 onwards, successively in North London, Highbury, Chislehurst, and then Bloomsbury and Canonbury, the facilities provided by these hostels made it possible for Christian medical students to qualify in medicine and thereafter to offer their services to various missionary societies for work abroad. The Medical Missionary Association has over the years sent out a worthy succession of dedicated doctors to serve and train and investigate. In recent years the provision of state grants to medical students has reduced-but not entirely eliminated-the need for such a hostel: there are at present 10 students at Canonbury Place, enjoying the stimulating fellowship of each other and their warden. As Phyllis Thompson shows in her booklet Sent to Heal,' the past century has witnessed many changes in the activities of the MMA. The early photographs of serious-looking young men, sombrely clad in dark suits and ties, have been replaced by snapshots of a relaxed group of men and women from Britain and overseas, medical students, nurses, and physiotherapists in a fashionable diversity of clothing. In other ways,
BRITISH MEDICAL JOURNAL
14 OCTOBER 1978
too, there have been changes. An exhibition was organised by the association at the Royal Society of Medicine in 1962; it is now held annually at the Royal College of Surgeons in Lincoln's Inn Fields. The exhibition is more than a showpiece or an employment agency: it is a forum where the medical and spiritual needs of the world are presented to keen young doctors. Another new departure, a brain-child of Dr Harry Bennett, for nearly a quarter of a century the secretary of the MMA and its hostel, is a scheme known as OYSTER (One Year's Service To Encourage Recruiting). Graduate doctors wishing to serve for a short time at a mission hospital abroad are helped with the expenses of travel to and from their destination. Once they have seen the need, and have shared in alleviating it, some of them do indeed return for a longer, indefinite period. As Sir Clement Chesterman, the president of the Medical Missionary Association, writes in the foreword of Sent to Heal, "By sharing and caring, curing and preventing, the doctor and nurse can make it possible to believe that God is Love. But how can they be sent? That is the continuing task which the MMA can help to undertake in its second century." 1
Published by the MMA, 6 Canonbury Place, London Ni 2NJ, price 50p.
After splenectomy Unfortunately, the seat of melancholy, traditionally found in the spleen, is not extirpated by splenectomy. But the operation does remove one-quarter of the total human lymphoid tissue and a major mass of macrophages, and immunological abnormalities develop. These include an impaired clearance of bacteria such as pneumococci and other particulate antigens when there are low concentrations of circulating antibody,' 2 lower concentrations of IgM,3 and in many cases a fall in the amount of circulating tuftsin.4 5 (Tuftsin, newly described and named after Tufts University, is a naturally occurring tetrapeptide, probably manufactured by the spleen, which stimulates phagocytosis.) These immunological changes help to explain why many patients, particularly children, are more susceptible to infection after splenectomy.6 7 There is a distinct clinical syndrome in affected patients: mild, non-specific symptoms herald overwhelming collapse from sepsis, rapidly leading to death in more than half the cases. The infecting organism is most often Diplococcus pneumoniae8 and disseminated intravascular coagulation is a common complication.9 Four-fifths of cases occur in the first three years after splenectomy.'0 While this symptom complex is most common in children it also occurs in adults, especially those with an underlying primary disorder such as Hodgkin's disease.1' In such cases splenectomy is often only one of several factors predisposing to infection. Indeed, patients undergoing splenectomy for trauma have less risk of contracting infection than those whose operation was done on medical grounds. Nevertheless, overwhelming sepsis may occur in both circumstances.12 Why infection should be a smaller hazard after splenectomy for trauma than for other indications has not been clear, but some recent work by Pearson et al'3 may provide the answer. Using a non-invasive technique based on the changes in the appearances of red cells that occur after splenectomy, they found evidence of renewed splenic activity in 13 out of 22
