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BENIGN AND MALIGNANT BREASTS
601 distribution space (fig. 3). The significance of this observation is not immediately apparent, but we feel that our findings indicate that it is not sufficient to measure just the plasma half-life of a substance when studying its metabolism.1 The T-1 is an index just as much of apparent distribution space as it is of metabolic clearance-rate and we would tentatively suggest that the prolonged Tl seen by Dr. Stimmler and his colleagues probably indicated an increased distribution space for insulin in these patients.
St.
P. H. SÖNKSEN M. C. SRIVASTAVA Department of Medicine, C. V. TOMPKINS Thomas’ Hospital, London S.E.1, and Middlesex Hospital, London W.1. J. D. N. NABARRO.
DISINTEGRATION OF STERILE-FLUID BOTTLES
SiR,-The possibility that bottles of sterile fluid which have been vacuum-packed will shatter owing to " waterhammer " when a giving set is inserted with the bottle held upside-down has been well documented by Mr. Shaw (Sept. 9, p. 530) for the American square-section bottle. Experience in Plymouth shows that this may also occur with a bottle having a round section. A nurse and her patient were wetted-and frightened-when the bottom of a Baxter-Travenol 5% dextrose bottle blew off as the giving set was inserted with the bottle upside-down. Fortunately, the bottle did not disintegrate and there was no injury due to glass. It may be that bottles of intravenous fluid should be entered other than with the seal uppermost. Hospital Microbiology and Public Health Laboratory, P. D. MEERS. Greenbank Hospital, Plymouth.
never
BENIGN AND MALIGNANT BREASTS SIR,-In an editorial (July 29, p. 217) you called attention to the need for more precise definition of precursor lesions to breast cancer. The cited references suggest, on the one hand, that various types of proliferative changes are associated with an increased risk of breast cancer. On the other hand, the lack of precision in classifying such changes tends to obscure their biological significance. May I call your attention to studies from this laboratory which bear on this question ? In 1969 Black and Chabon 2 reported a numerical grading system which provided a semiquantitative assessment of intraepithelial atypia in different locations of the mammary-duct system. The ability of this system to identify pre-cancerous mastopathy was tested under controlled conditions in a large series of reference and control cases.3 The numerical grading system was found to be distinctly better in identifying pre-cancerous changes than conventional histological terminology. The findings also showed that pre-cancerous mastopathy is commonly associated with immunogenic changes 2,4,5 which seem to influence the stage and survival-time in subsequent breast cancers.6 This should be taken into account in the therapy of so-called in-situ carcinoma. More
generally,
pre-cancerous
mastopathy provides unique
material for examining cancer-associated antigenic changes. These observations further emphasise your commenc on the need to correlate pathological observations with clinical realities. New York Medical College, Flower and Fifth Avenue Hospitals, New York 10029, U.S.A.
MAURICE M. BLACK.
ASSESSMENT OF PROGNOSIS IN MALIGNANT MELANOMA
SiR,-It has been drawn to our attention that there mention of the prognostic significance of treatment in our recent paper (Sept. 2, p. 455). We therefore wish to state that aU patients in this study had wide excision of the primary tumour as their initial treatment prior to the was no
assessment
of the
prognostic
University Departments of Dermatology and Pathology, Western Infirmary, Glasgow G11 6NT. 1.
HAZARDS OF INTRAVENOUS CANNULÆ SiR,—In reply to Dr. Knight’s letter (Aug. 26, p. 433) percutaneous cannulation of peripheral veins is frequently difficult in the collapsed patient and adequate transfusion may not be possible in the presence of peripheral vasoconstriction. A large-diameter cannula passed centrally by cut-down on a vein in the antecubital fossa overcomes these difficulties. Obviously transfusion of cold fluids should be avoided. Dr. Bethell (Aug. 26, p. 433) suggests subclavian-vein puncture as an alternative to our cut-down technique.1 It is true that percutaneous puncture of either the subclavian or internal jugular vein provides rapid access for infusion and central-venous-pressure measurement. However, these routes are particularly associated with many reported complications. They may be listed:
(1) Pneumothorax,2-surgical emphysema,’,3 hydrothorax,2,7,. haemothorax,3 mediastinal infusion.’,10 (2) Trauma to major vessels,3 accidental subclavian or carotid artery puncture,5,11 cardiac tamponade,".12 subclavian-vein thrombosis,’3 hsematoma formation.3,5,u (3) Trauma to brachial plexus3 or stellate ganglion.6
(4)
1. 2. 3.
4. 5.
score.
6.
RONA M. MACKIE DAVID C. CARFRAE ALISTAIR J. COCHRAN.
Sönksen, P. H., Srivastava, M. C., Tompkins, C. V. Lancet, 1971, ii, 491.
7.
8. 9. 10. 11.
2.
Black, M. M., Chabon, A. B. in Pathology Annual (edited by S. C. Sommers); p. 185, New York, 1969. 3. Black, M. M., Barclay, T. H. C., Cutler, S. J., Hankey, B. F., Asire, A. J. Cancer, N.Y. 1972, 29, 338. 4. Black. M. M., Chabon, A. B. in Immunity and Tolerance in Oncogenesis (edited by L. Severi); p. 923. Perugia, 1970. 5. Black, M. M. J. natn. Cancer Inst. (in the press), 6. Black, M. M., Cutler, S. J., Barclay, T. H. C. 1972, Cancer, N.Y. 29, 61.
Air embolism.9,14
Both Dr. Knight and Dr. Bethell discuss the use of the Intracath ’,a needle-round-cannula system. The hazards of cannular embolism from this system, due to the needle transecting the cannula, are well recognised.5,8,l1,15 The Department of Health and Social Security 16 has drawn attention again to this problem and recommends the use of cannulx introduced over the needle in preference to the intracath type.16
12.
13. 14. 15. 16.
Colvin, M. P., Blogg, C. E., Savege, T. M., Jarvis, J. D., Strunin, L. Lancet, 1972, ii, 317. Matz, R. New Engl. J. Med. 1965, 273, 703. Smith, B. E., Modell, J. A., Gaub, M. L., Moya, F. Archs Surg., Chicago, 1965, 90, 228. Mogensen, J., Viby, Kvisselgaard, N., Branat, M. R. Saertr. Nord. Med. 1971, 86, 1298. Doering, R. B., Stemmer, E. A., Connolly, J. E. Am. J. Surg. 1967, 114, 259. Parikh, R. K. Anæsthesia, 1972, 27, 327. Aulenbacher, C. J. Am. med. Ass. 1970, 214, 372. Pruitt, B. A., Stein, J. M., Foley, F. D., Moncrief, J. A., O’Neill, J. A. Archs Surg., Chicago, 1970, 100, 399. Jernigan, W. R., Gardner, W. C., Mahr, M. M., Milburn, J. L. Surgery Gynec. Obstet. 1970, 130, 520. Adar, M., Mozes, M. J. Am. med. Ass. 1970, 214, 372. Longerbeam, J. K., Vannix, R., Wagner, W., Joergenson, E. Am. J. Surg. 1965, 110, 220. Bolasney, B. L., Shepard, G. H., Scott, H. W. Surgery Gynec. Obstet. 1970, 130, 342. O’Donough, J. J., Altmeier, W. A. ibid. 1971, 133, 397. Jackson, D. M. Personal communication. Wellmann, K. F., Reinhardt, A., Salazar, E. P. Circulation, 1968, 37, 380. Department of Health and Social Security. D.H.S.S. file no. R!B 1026/18, March 3, 1972.
St.
P. H. SÖNKSEN M. C. SRIVASTAVA Department of Medicine, C. V. TOMPKINS Thomas’ Hospital, London S.E.1, and Middlesex Hospital, London W.1. J. D. N. NABARRO.
DISINTEGRATION OF STERILE-FLUID BOTTLES
SiR,-The possibility that bottles of sterile fluid which have been vacuum-packed will shatter owing to " waterhammer " when a giving set is inserted with the bottle held upside-down has been well documented by Mr. Shaw (Sept. 9, p. 530) for the American square-section bottle. Experience in Plymouth shows that this may also occur with a bottle having a round section. A nurse and her patient were wetted-and frightened-when the bottom of a Baxter-Travenol 5% dextrose bottle blew off as the giving set was inserted with the bottle upside-down. Fortunately, the bottle did not disintegrate and there was no injury due to glass. It may be that bottles of intravenous fluid should be entered other than with the seal uppermost. Hospital Microbiology and Public Health Laboratory, P. D. MEERS. Greenbank Hospital, Plymouth.
never
BENIGN AND MALIGNANT BREASTS SIR,-In an editorial (July 29, p. 217) you called attention to the need for more precise definition of precursor lesions to breast cancer. The cited references suggest, on the one hand, that various types of proliferative changes are associated with an increased risk of breast cancer. On the other hand, the lack of precision in classifying such changes tends to obscure their biological significance. May I call your attention to studies from this laboratory which bear on this question ? In 1969 Black and Chabon 2 reported a numerical grading system which provided a semiquantitative assessment of intraepithelial atypia in different locations of the mammary-duct system. The ability of this system to identify pre-cancerous mastopathy was tested under controlled conditions in a large series of reference and control cases.3 The numerical grading system was found to be distinctly better in identifying pre-cancerous changes than conventional histological terminology. The findings also showed that pre-cancerous mastopathy is commonly associated with immunogenic changes 2,4,5 which seem to influence the stage and survival-time in subsequent breast cancers.6 This should be taken into account in the therapy of so-called in-situ carcinoma. More
generally,
pre-cancerous
mastopathy provides unique
material for examining cancer-associated antigenic changes. These observations further emphasise your commenc on the need to correlate pathological observations with clinical realities. New York Medical College, Flower and Fifth Avenue Hospitals, New York 10029, U.S.A.
MAURICE M. BLACK.
ASSESSMENT OF PROGNOSIS IN MALIGNANT MELANOMA
SiR,-It has been drawn to our attention that there mention of the prognostic significance of treatment in our recent paper (Sept. 2, p. 455). We therefore wish to state that aU patients in this study had wide excision of the primary tumour as their initial treatment prior to the was no
assessment
of the
prognostic
University Departments of Dermatology and Pathology, Western Infirmary, Glasgow G11 6NT. 1.
HAZARDS OF INTRAVENOUS CANNULÆ SiR,—In reply to Dr. Knight’s letter (Aug. 26, p. 433) percutaneous cannulation of peripheral veins is frequently difficult in the collapsed patient and adequate transfusion may not be possible in the presence of peripheral vasoconstriction. A large-diameter cannula passed centrally by cut-down on a vein in the antecubital fossa overcomes these difficulties. Obviously transfusion of cold fluids should be avoided. Dr. Bethell (Aug. 26, p. 433) suggests subclavian-vein puncture as an alternative to our cut-down technique.1 It is true that percutaneous puncture of either the subclavian or internal jugular vein provides rapid access for infusion and central-venous-pressure measurement. However, these routes are particularly associated with many reported complications. They may be listed:
(1) Pneumothorax,2-surgical emphysema,’,3 hydrothorax,2,7,. haemothorax,3 mediastinal infusion.’,10 (2) Trauma to major vessels,3 accidental subclavian or carotid artery puncture,5,11 cardiac tamponade,".12 subclavian-vein thrombosis,’3 hsematoma formation.3,5,u (3) Trauma to brachial plexus3 or stellate ganglion.6
(4)
1. 2. 3.
4. 5.
score.
6.
RONA M. MACKIE DAVID C. CARFRAE ALISTAIR J. COCHRAN.
Sönksen, P. H., Srivastava, M. C., Tompkins, C. V. Lancet, 1971, ii, 491.
7.
8. 9. 10. 11.
2.
Black, M. M., Chabon, A. B. in Pathology Annual (edited by S. C. Sommers); p. 185, New York, 1969. 3. Black, M. M., Barclay, T. H. C., Cutler, S. J., Hankey, B. F., Asire, A. J. Cancer, N.Y. 1972, 29, 338. 4. Black. M. M., Chabon, A. B. in Immunity and Tolerance in Oncogenesis (edited by L. Severi); p. 923. Perugia, 1970. 5. Black, M. M. J. natn. Cancer Inst. (in the press), 6. Black, M. M., Cutler, S. J., Barclay, T. H. C. 1972, Cancer, N.Y. 29, 61.
Air embolism.9,14
Both Dr. Knight and Dr. Bethell discuss the use of the Intracath ’,a needle-round-cannula system. The hazards of cannular embolism from this system, due to the needle transecting the cannula, are well recognised.5,8,l1,15 The Department of Health and Social Security 16 has drawn attention again to this problem and recommends the use of cannulx introduced over the needle in preference to the intracath type.16
12.
13. 14. 15. 16.
Colvin, M. P., Blogg, C. E., Savege, T. M., Jarvis, J. D., Strunin, L. Lancet, 1972, ii, 317. Matz, R. New Engl. J. Med. 1965, 273, 703. Smith, B. E., Modell, J. A., Gaub, M. L., Moya, F. Archs Surg., Chicago, 1965, 90, 228. Mogensen, J., Viby, Kvisselgaard, N., Branat, M. R. Saertr. Nord. Med. 1971, 86, 1298. Doering, R. B., Stemmer, E. A., Connolly, J. E. Am. J. Surg. 1967, 114, 259. Parikh, R. K. Anæsthesia, 1972, 27, 327. Aulenbacher, C. J. Am. med. Ass. 1970, 214, 372. Pruitt, B. A., Stein, J. M., Foley, F. D., Moncrief, J. A., O’Neill, J. A. Archs Surg., Chicago, 1970, 100, 399. Jernigan, W. R., Gardner, W. C., Mahr, M. M., Milburn, J. L. Surgery Gynec. Obstet. 1970, 130, 520. Adar, M., Mozes, M. J. Am. med. Ass. 1970, 214, 372. Longerbeam, J. K., Vannix, R., Wagner, W., Joergenson, E. Am. J. Surg. 1965, 110, 220. Bolasney, B. L., Shepard, G. H., Scott, H. W. Surgery Gynec. Obstet. 1970, 130, 342. O’Donough, J. J., Altmeier, W. A. ibid. 1971, 133, 397. Jackson, D. M. Personal communication. Wellmann, K. F., Reinhardt, A., Salazar, E. P. Circulation, 1968, 37, 380. Department of Health and Social Security. D.H.S.S. file no. R!B 1026/18, March 3, 1972.