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SKIN FRAGMENTS REMOVED BY INJECTION NEEDLES
1178
Taylor, radiotherapist to the Southampton following conclusions:
area, who came to
the
(a) The five-year survival-rate is at least 13% better in the simple surgery group, and this is not explained by age differences in the two groups. (b) The incidence of local recurrence was low and similar in the two groups. (c) The incidence of distant metastases was higher in the radical group.
Taylor’s series seems to present a more promising picture of simple mastectomy than has appeared in other series; but, whatever differences may emerge from a comparison of simple and radical surgery in different places, it is at least abundantly plain that simple mastectomy gives no lower survival-rate, is less mutilating, and has a wider application than radical surgery. In the face of so many carefully assembled statistics it does seem surprising that such prejudice can still be exhibited against a method taught and practised some thirty years ago by Sir Geoffrey Keynes, and so ably advocated by Professor McWhirter in recent years. Though the tide of surgical opinion is slowly changing there still seem to be too many institutions in which hardy conservatism and Halsted-worship compel rigid adherence to the time-honoured (though possibly time-expired) operation Dr.
of radical mastectomy. After so many years of hard work it does seem a great pity that the Mayo Clinic workers are not in a position to give us a better picture of the problem of breast cancer, instead of harping upon such a well-worn and unproductive theme. REGINALD S. MURLEY. SKIN FRAGMENTS REMOVED BY NEEDLES
INJECTION "
SiR,ńThe surprisingly high incidence of coring " of skin fragments by needles reported by Mr. Gibson and Dr. Norris in your issue of Nov. 8 may account for contamination with skin staphylococci of 2% of blood collected for transfusion.1 In view of these findings it is surely no longer defensible to insert an open-ended needle through intact skin into the spinal theca, the epidural space, or the synovial cavity of ajoint. Southampton General Hospital, Southampton.
P. J. HORSEY.
HYPOTHERMIA, HYPERPYREXIA,
POLIOMYELITIS, AND ENCEPHALITIS SiR,ńYou have lately published two interesting contributions 23 on this has been of considerable
hyperpyrexia syndrome aetiology.
subject. Systemic hypothermia in selected children with the and in encephalitis of diverse
use
Thus, the hyperpyrexia syndrome of polioencephalitis may of itself be lethal unless promptly reversed; hypothermia for this condition has been used on my service since 1950 and was referred to in a talk before the American Medical Association in 1953.4 The youngest polioencephalitis patient (type-1virus) so managed was 9 months old and had a temperature of 109°F. There is a considerable economy of oxygen and insensible water-loss during systemic hypothermia which has been useful in various conditions (e.g., the viral forms of encephalitis, lead encephalopathy, salicylism). The longest period of time systemic hypothermia has been successfully applied-for its 1. Mollison, P. L. Blood Transfusion in Clinical Medicine. London, 1956. 2. Johnston, A. W., McLean, A. E. M., Morris, R. V., Ross, E. J. Lancet, 3.
4.
Sept. 27, 1958, p. 670. Edwards, G. E. ibid. Oct. 18, 1958, p. 852. Steigman, A. J. Amer. J. Dis. Child. 1954, 87,
343.
effect primarily on ventilation in this case-was in a 21/2-year-old boy with severe bulbospinal poliomyelitis whose ventilatory insufficiency was not completely overcome with assisted positive pressure. He was maintained at an average body temperature of 88°F for six weeks 5; this child, whose extremities are now moderately disabled from poliomyelitis, has recently entered school at the age of 6, has no intellectual impairment, and requires no ventilatory assistance. Johnston et al.1 have referred to the use of hypothermia in neurosurgical procedures and in head injuries.
It need hardly be said that such a therapeutic measure should not be undertaken lightly; but when indicated it should be instituted swiftly and under circumstances permitting of close constant supervision. Department of Pediatrics, University of Louisville, Kentucky.
ALEX
J. STEIGMAN.
ANASTOMOSIS IN THE CORONARY CIRCULATION
Sir-My interest in the recent papers of Dr. Laurie and Dr. Woods 6prompts me to draw attention to some of my preliminary unpublished findings on the anastomosis in the coronary circulation. Their statement6 that " the serious effects of atherosclerosis are seen in... the heart (coronary-artery " disease) has not gone unchallenged,89 and is certainly at variance with our own findings 10 and those of other pathologists in this country. Their conclusions7 about the incidence of anastomosis again differ from those of the pioneers in this field "ńthat is, of those who have used the same technique. In spite of the fact that their material consists only of Bantu hearts, they state that the " majority of healthy people over the age of 4 years have functionally important coronary anastomosis ", implying that the results are applicable to Europeans as well. This is not correct. My own interest in this subject was stimulated by the article of Brink,l2 which Dr. Laurie and Dr. Woods seem to have overlooked. The material investigated so far consists of 65 Bantu hearts (ages 2 1/2 to 99 years) and 32 European hearts (ages 3 to 80 years). Injection was done according to Schlesinger’s latest specifications, with the modification that the left coronary artery was first perfused with the radiopaque mass for a period of three minutes and subsequently by the right coronary artery, These injections were done under a pressure corresponding to that of the mean blood-pressure of the individual. In the European group, 21 of the 32 cases showed no communications of arteriolar size, and in the Bantu group 14 of the 66 cases showed no communications. Although this is a very small series, it does indicate a striking difference in the coronary anastomosis patterns of Bantu and
European. We certainly agree with the findings of Dr. Woods and Dr. Laurie that a large percentage of the Bantu do have coronary anastomosis of functional significance, but this does not apply to Europeans. Is this racial difference in the coronary anastomosis blood-supply not perhaps one of the many reasons why the Bantu so seldom suffer from the severe effects of atherosclerosis such as coronary thrombosis and myocardial ischasmia ? Institute for
Pathology,
Pretoria, South Africa.
W.
J. PEPLER.
Steigman, A. J., Vallbona, C. Int. Rec. med. gen. Pract. 1955, 168, 351. Laurie, W., Woods, J. D. Lancet, 1958, i, 231. Laurie, W., Woods, J. D. ibid. Oct. 18, 1958, p. 812. Becker, B. J. P. ibid. 1958, i, 1019. Walker, A. R. P., Simson, I. W. ibid. p. 1126. Higginson, J., Pepler, W. J. J. clin. Invest. 1954, 33, 1366. Zoll, P. M., Wessler, S., Schlesinger, M. J. Circulation, 1951, 4, 797. 12. Brink, A. J. Clin. Proc. 1949, 8, 137. 5. 6. 7. 8. 9. 10. 11.
Taylor, radiotherapist to the Southampton following conclusions:
area, who came to
the
(a) The five-year survival-rate is at least 13% better in the simple surgery group, and this is not explained by age differences in the two groups. (b) The incidence of local recurrence was low and similar in the two groups. (c) The incidence of distant metastases was higher in the radical group.
Taylor’s series seems to present a more promising picture of simple mastectomy than has appeared in other series; but, whatever differences may emerge from a comparison of simple and radical surgery in different places, it is at least abundantly plain that simple mastectomy gives no lower survival-rate, is less mutilating, and has a wider application than radical surgery. In the face of so many carefully assembled statistics it does seem surprising that such prejudice can still be exhibited against a method taught and practised some thirty years ago by Sir Geoffrey Keynes, and so ably advocated by Professor McWhirter in recent years. Though the tide of surgical opinion is slowly changing there still seem to be too many institutions in which hardy conservatism and Halsted-worship compel rigid adherence to the time-honoured (though possibly time-expired) operation Dr.
of radical mastectomy. After so many years of hard work it does seem a great pity that the Mayo Clinic workers are not in a position to give us a better picture of the problem of breast cancer, instead of harping upon such a well-worn and unproductive theme. REGINALD S. MURLEY. SKIN FRAGMENTS REMOVED BY NEEDLES
INJECTION "
SiR,ńThe surprisingly high incidence of coring " of skin fragments by needles reported by Mr. Gibson and Dr. Norris in your issue of Nov. 8 may account for contamination with skin staphylococci of 2% of blood collected for transfusion.1 In view of these findings it is surely no longer defensible to insert an open-ended needle through intact skin into the spinal theca, the epidural space, or the synovial cavity of ajoint. Southampton General Hospital, Southampton.
P. J. HORSEY.
HYPOTHERMIA, HYPERPYREXIA,
POLIOMYELITIS, AND ENCEPHALITIS SiR,ńYou have lately published two interesting contributions 23 on this has been of considerable
hyperpyrexia syndrome aetiology.
subject. Systemic hypothermia in selected children with the and in encephalitis of diverse
use
Thus, the hyperpyrexia syndrome of polioencephalitis may of itself be lethal unless promptly reversed; hypothermia for this condition has been used on my service since 1950 and was referred to in a talk before the American Medical Association in 1953.4 The youngest polioencephalitis patient (type-1virus) so managed was 9 months old and had a temperature of 109°F. There is a considerable economy of oxygen and insensible water-loss during systemic hypothermia which has been useful in various conditions (e.g., the viral forms of encephalitis, lead encephalopathy, salicylism). The longest period of time systemic hypothermia has been successfully applied-for its 1. Mollison, P. L. Blood Transfusion in Clinical Medicine. London, 1956. 2. Johnston, A. W., McLean, A. E. M., Morris, R. V., Ross, E. J. Lancet, 3.
4.
Sept. 27, 1958, p. 670. Edwards, G. E. ibid. Oct. 18, 1958, p. 852. Steigman, A. J. Amer. J. Dis. Child. 1954, 87,
343.
effect primarily on ventilation in this case-was in a 21/2-year-old boy with severe bulbospinal poliomyelitis whose ventilatory insufficiency was not completely overcome with assisted positive pressure. He was maintained at an average body temperature of 88°F for six weeks 5; this child, whose extremities are now moderately disabled from poliomyelitis, has recently entered school at the age of 6, has no intellectual impairment, and requires no ventilatory assistance. Johnston et al.1 have referred to the use of hypothermia in neurosurgical procedures and in head injuries.
It need hardly be said that such a therapeutic measure should not be undertaken lightly; but when indicated it should be instituted swiftly and under circumstances permitting of close constant supervision. Department of Pediatrics, University of Louisville, Kentucky.
ALEX
J. STEIGMAN.
ANASTOMOSIS IN THE CORONARY CIRCULATION
Sir-My interest in the recent papers of Dr. Laurie and Dr. Woods 6prompts me to draw attention to some of my preliminary unpublished findings on the anastomosis in the coronary circulation. Their statement6 that " the serious effects of atherosclerosis are seen in... the heart (coronary-artery " disease) has not gone unchallenged,89 and is certainly at variance with our own findings 10 and those of other pathologists in this country. Their conclusions7 about the incidence of anastomosis again differ from those of the pioneers in this field "ńthat is, of those who have used the same technique. In spite of the fact that their material consists only of Bantu hearts, they state that the " majority of healthy people over the age of 4 years have functionally important coronary anastomosis ", implying that the results are applicable to Europeans as well. This is not correct. My own interest in this subject was stimulated by the article of Brink,l2 which Dr. Laurie and Dr. Woods seem to have overlooked. The material investigated so far consists of 65 Bantu hearts (ages 2 1/2 to 99 years) and 32 European hearts (ages 3 to 80 years). Injection was done according to Schlesinger’s latest specifications, with the modification that the left coronary artery was first perfused with the radiopaque mass for a period of three minutes and subsequently by the right coronary artery, These injections were done under a pressure corresponding to that of the mean blood-pressure of the individual. In the European group, 21 of the 32 cases showed no communications of arteriolar size, and in the Bantu group 14 of the 66 cases showed no communications. Although this is a very small series, it does indicate a striking difference in the coronary anastomosis patterns of Bantu and
European. We certainly agree with the findings of Dr. Woods and Dr. Laurie that a large percentage of the Bantu do have coronary anastomosis of functional significance, but this does not apply to Europeans. Is this racial difference in the coronary anastomosis blood-supply not perhaps one of the many reasons why the Bantu so seldom suffer from the severe effects of atherosclerosis such as coronary thrombosis and myocardial ischasmia ? Institute for
Pathology,
Pretoria, South Africa.
W.
J. PEPLER.
Steigman, A. J., Vallbona, C. Int. Rec. med. gen. Pract. 1955, 168, 351. Laurie, W., Woods, J. D. Lancet, 1958, i, 231. Laurie, W., Woods, J. D. ibid. Oct. 18, 1958, p. 812. Becker, B. J. P. ibid. 1958, i, 1019. Walker, A. R. P., Simson, I. W. ibid. p. 1126. Higginson, J., Pepler, W. J. J. clin. Invest. 1954, 33, 1366. Zoll, P. M., Wessler, S., Schlesinger, M. J. Circulation, 1951, 4, 797. 12. Brink, A. J. Clin. Proc. 1949, 8, 137. 5. 6. 7. 8. 9. 10. 11.