24 January 1970 Leading Articles MBJox 1 8 7 lization o f t h e perforating veins will probably be used more than phlebography, b u t i t i s unlikely t o b e adopted f o r investigating a l l varicose veins because, apart from t he tech- nical assistance and skill needed, t h e apparatus i s expensive. Unea simple, inexpensive bedside method o f detection is devised, thermography is likely t o b e used i n t h e same w a y a s phlebography, f o r t he difficult recurrent case. B u t i f this addition to o u r methods o f investigation were t o b e used widely t h e results of t h e treatment ofvaricose veins would b e noticeably improved. Culdocentesis a n d Ectopic Pregnancy Classically, ruptured ectopic pregnancy presents a s a n acute surgical emergency, a n d it still contributes t o maternal mor- tality. B u t a less dramatic clinical picture i s more common, though t h e correct diagnosis c a n usually b e suspected from careful history-taking a n d examination coupled with a keen awareness o f the possibility. T h e clinical features include a short period of amenorrhoea or a recent abnormal period (though t h e menstrual history m a y b e normal), lower abdominal pain characteristically spasmodic a nd severe, tenderness, an d a scanty vaginal loss o f dark blood. Pelvic examination m a y elicit considerable a nd often exquisite p i n o n moving t h e cervix o r a mass i n t h e posterior or lateral fornices. n t h e chronic condition associated with tubal abortion o r mole, several of these features m a y b e absent an d diag- nosis m a y be difficult. Pregnancy tests a r e n o t usually helpful, a n d pelvic examination under anaesthesia an d examination o f th e endometrium f o r decidual change m a y give misleading results. Culdocentesis h a s long been advocated a s a means o f detecting haemorrhage, u t i t s popularity seems t o have declined i n Great Britain because o f a reputa- tion for unreliability.4 B u t i n Zambia, Drs. Cynthia Lucas a n d A . M Hassim have found t h e technique t o b e o f great value, a nd they report i n t h e B.M.7. this week (page 200) their experience with i t s u se i n 1 5 5 o f 1 9 9 cases o f suspected ectopic pregnancy. Culdocentesis provided t h e correct diagnosis i n 1 4 8 cases (55 negative a n d 9 3 positive). There were three false negative results (including t wo i n which t h e ectopic gestation h a d no t leaked blood into the peritoneal cavity) a n d four false positive results (two with pelvic infection and two with conditions which required laparotomy i n a n y case). I n t he remainder culdocentesis was n o t attempted a s the diagnosis was no t i n doubt. T h e technique, therefore, achieved a diagnostic accuracy o f 9 3 . This higher percentage o f correct diagnosis than i n other series (55 ,2 72 4 Drs. Lucas a n d Hassim attribute to their more frequent u s e of the procedure. J . T . Armstrong a n d colleagues reported a comparable diagnostic accuracy o f 89 . I Report o n Confidential Fnquiries into Maternal Deaths, England a nd Wales 1964-1966. London, H.M.S.O. 1969. 2 Bobrow, M L . , a n d Winkelstein, L . B . , American 7ournal of Obstetrics and Gynecology, 1955. 6 9 , 101. Armstrong, J . T . , Wills, S. H. , Moore, T . and Lauden, A . E . , Amen c a n Yourna o f Obstetrics and Gynecology, 1959, 7 7 , 364. 4 Douglas, C . P., British Medical 7ournal, 1963, 2 , 838. 5 Steptoe, P . C . , Laseroscopy i n Gynaecology. Edinburgh, E. an d S . Livingstone. 1967. 6 Franwenheim, H . , Geburtshilfe u n d Frauenheilkrankene, 1964, 2 4 , 470. 7 Sjvall,. A. , i n Steptoe, P. C., Laparoscopy i n Gynaecology, p. 57. Edinburgh, E . an d S . Livingstone. 1967. Lucas a n d Hassim found culdocentesis t o b e the most impor- tant single diagnostic a id in their cases. They usually per- formed i t as a side-ward procedure without a n anaesthetic, using a 5-in. (12.5-cm.) size 1 8 needle inserted into t he pouch o f Douglas f o r about 1 in. ( 2 5 cm.). I n Zambia pelvic infec- tion i s t h e most common differential diagnosis o f ectopic gestation, but with their technique t h authors have avoided t h e possible risk o f perforating a pyosalpinx o r adjacent bowel. Th e authors d o n o t favour laparoscopy because they find that pelvic adhesions m a y preclude a n adequate view or that t h e large trocar m a y damage adherent bowel. A different view seems to b e held both i n Britain a nd o n the Continent of Europe. P . C . Steptoe5 considers that the, possibility o f ectopic gestation i s o n e o f t h e principal indica- tions f or laparoscopy a n d that i t m a y also show other condi- tions n o t associated with haemoperitoneum which require laparotomy. H . Frangenheim6 noted that laparoscopy i n - creased t h e frequency o f diagnosis o f intact extrauterine pregnancies from 9 t o 2 3 . There w a s a relatively high incidence of acute cases i n t h e Zambian series, a n d i t m a y b e that t h e cases described b y Lucas a n d Hassim presented, o n average, a t a later stage o f t he condition than i s usual i n Britain. I t would b e interesting t o lnow t h e results o f laparoscopic examination i n a Zambian series similar t o those described this week. Though acute pelvic inflammatory disease is often thought t o contraindicate laparoscopy, A . Sjovall7 h a s used i t extensively without com- plications i n suspected acute salpingitis and found that t h e clinical diagnosis w a s often incorrect. Laparoscopy requires a n experienced operator a nd expert general anaesthesia, b u t it i s likely t o b e o f more value than culdocentesis as i t c a n contribute more t o t h e overall management o f a particular clinical problem than simply b y confirming or refuting the diagnosis o f haemoperitoneum. I n t h e developing countries, however, where facilities ma y b e limited a n d patients m a y tend t o present a t a n advanced stage of the condition, t h e simple technique of culdocentesis h a s obvious advantages a n d i s apparently o f great value. Though C . P. Douglas' considered that t h e number o f false positive results h e obtained i n acute salpingitis i n Jamaica limited t he value o f t h e technique, t h e excellent results reported b y Lucas a nd Hassim are likely t o encourage it s wider u s e f or t h e diag- nosis o f ectopic pregnancy i n similar circumstances. Computers f o r Transplantation Rejection o f transplanted tissue depends o n the recognition o f t h e donated tissue b y t h e recipient a n d i t s immune destruc- tion. T h e antigens that a r e recognized in this process ar e called histocompatibility factors. They include t h e substances of the red-blood-cell groups and also glycoproteins present i n a l l nucleated cell membranes b u t absent from r e d cells. These glycoproteins aredetected i n t h e laboratory by means of agglu- tination or cytotoxic effects o n white blood cells. Antisera a r e used from patients w h o have rejected transplants, recipients of multiple blood transfusions, o r patients w h o have become immunized a s a result of multiple pregnancies. Although t h e definition o f histocompatiilbity antigens is n o t y e t complete, i t i s - clear that in -man, as in several other mammalian species, there i s on e sng histtcompaibifty-
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