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PHENYLBUTAZONE IN SUPERFICIAL PHLEBITIS
839 PHENYLBUTAZONE IN SUPERFICIAL PHLEBITIS Sir,-Dr. Gillhespy’s -observation (April 6) on the
effect of phenylbutazone in superficial be explained by its anticoagulant action, and described by Humble.l investigated If in fact this is the correct explanation, phenylbutazone might not offer any advantage over the established anticoagulants, since its effect in this respect would appear to be variable and unpredictable. DAVID WHEATLEY.
tion, four days) surely the mortality-rate in the first month is the
therapeutic
phlebitis could
EMULSIFIERS AND CORONARY THROMBOSIS SIR,-Much has been published in the daily press lately on the increase in the number of cases of coronary thrombosis, the main suspicion being directed at the amount of animal fat consumed by the class of person most likely to be afflicted. May I, just a layman, point a finger of suspicion at certain substances which are being used in ever-increasing quantities in many of the common items of food more than likely to be eaten by the same class of persons. I refer to glyceryl monostearate and other emulsifiers which enable fats to be mixed easily with water, and I would suggest that when they are consumed in the diet in large quantities they may be absorbed and alter the state of the fat in the blood and so possibly be responsible for the damage to the arteries and cause thrombosis. Taking this matter a step further, the use of detergents, which are also emulsifiers, for washing up crockery, and which are not properly rinsed off, can introduce into the digestive organs another substance which may alter the state of the fat in the blood. Glyceryl monostearate is used as a crumb-softener in much of today’s bread, in ice-cream to increase the bulk or volume from a given weight of fat, in cake-mixes to enable the house-wife to make quicker cakes, and in prepacked cakes which remain soft for many days. I think investigations along these lines might prove very profitable, although I must confess I send this letter with trepidation. F. J. ROBERTS. FRACTURES OF THE FEMORAL NECK
SIR,—Mr. Newman (March 30) paid
a generous tribute factual review by Dr. Murray and Mr. Young (March 23) of fractures of the neck of the femur treated at the Southern General Hospital, Glasgow. He noted a high mortality-rate and, while accepting the likelihood of error in any statistical comparison, suggested that this was evidence against delay in operation. As an illustration that we are dealing here with a particularly poor-risk group, it should be said that some of our cases have been discharged home from other city hospitals as being unfit for surgery and thence admitted to our wards by the Beds Bureau. The high mortality quoted (33% overall, 26% for operative cases, and 48% for those treated conservatively) is also a measure of the difficulties of disposing of geriatric cases from acute surgical wards. Mr. Newman compared this with an average mortality of 168% among 564 patients treated surgically, collected from the literature. The mortality-rate for our 139 patients treated surgically was 14% in the first twenty-
to
a
eight days. This would surely provide a fairer figure for comparison, as far as American publications are concerned at least, it is rare for a bed in an American hospital to be occupied by the same patient for twenty-eight days. Few of our patients went home within twelve weeks. Certainly if we are to compare the results of immediate operation (within twenty-four hours) with those of elective operation (average time from fracture till opera-
since
1. Humble, J. G. Empire Rheumatism Council Butazolidin. Nov. 13, 1953.
Symposium
on
figure
to take.
Southern General Hospital, Glasgow, S.W.1.
W. SILLAR.
CYTOLOGICAL DETECTION OF UTERINE CANCER SIR,—Dr. Anderson (April 6, p. 738) is quite correct when he states clearly that cytology is no longer an untried method in the research stage, but in the Birmingham study1 of the value of cytology in gynaecological practice which we carried out at the request of the Royal College of Obstetricians and Gynaecologists, the establishment of the technique in the hands of technicians (none of whom is medically qualified) amounted to research. First of all we had to show that in our hands the technique would confirm the presence of obvious cancer A lower of the cervix, which was soon established. in cancer of the was inevitable however, efficiency, corpus for cells are not shed regularly or may be swamped with blood. The most important part of our research, however, was to find out for ourselves how many cases of cancer we were missing in routine investigation of outpatients. To keep our clinical practice up to a high standard we used a questionnaire and we inspected the cervix with great care. Since 1954 we have abandoned the detailed questionnaire and simply write down on our case-sheets in the outpatient department that this patient has or has not carcinoma of the corpus or cervix. We are thus tied down as clinicians, leaving the cytologist " a chance to claim a pick-up " for the technique, should cancer cells be obtained from a clinically normal case. How many cases were we missing, for obviously 1 per 10,000 would have made the technique valueless, whereas 2% would have made it almost obligatory for our or for any gynaecological clinic ? We found that in 2250 patients (in two years) we had missed 1 case of early cancer of the cervix. We also missed 1 case of carcinoma of the corpus which escaped our exploratory curette, but the risk to her life was less in that postmenopausal bleeding would have made hysterectomy obligatory
without positive smears. Our conclusion was therefore that, in our practice, cytology was almost never required to reach a diagnosis of uterine carcinoma. But cytology led us to discover 8 examples of carcinoma-in-situ which would have escaped our usual investigations. We have now screened over 5000 patients and the figure of 3 per 1000 is being maintained. With many hundreds of hours of microscopy was this a reasonable " harvest " We concluded that it was and in this came into line with many centres in the U.S.A. and elsewhere, including this country. M. J. D. Noble and M. E. Attwood have applied this " search " technique to diabetics (Dr. J. M. Malin’s patients) and this study is ready for publication. Their harvest " is greater than in our outpatients, not only for invasive but also for " in-situ " lesions. Studies are also continuing in the field of therapy ; for instance, 13 of our cases of carcinoma-in-situ have been " treated " simply by deep ring biopsies-i.e., we have the beginnings of information on therapy. Dr. Anderson suggests that although cytology per se is not research the technique can be used as part of research into the natural history of cancer. I suggest that the operative word " can " should be replaced by " must," but in this my colleague, Dr. C. W. Taylor, director of pathology, Birmingham Hospital for Women, does not entirely agree with me. My opinion is based not simply on the fact that it takes hundreds of hours of microscopy to discover 1 case of carcinoma-in-situ but that each case should be a subject of study to offset the time-consuming work by the cytologist. "
1.
H. C., Taylor, C. W., Attwood, M. E. Gynæc., Brit. Emp. 1956, 63, 801.
McLaren,
J. Obstct.
effect of phenylbutazone in superficial be explained by its anticoagulant action, and described by Humble.l investigated If in fact this is the correct explanation, phenylbutazone might not offer any advantage over the established anticoagulants, since its effect in this respect would appear to be variable and unpredictable. DAVID WHEATLEY.
tion, four days) surely the mortality-rate in the first month is the
therapeutic
phlebitis could
EMULSIFIERS AND CORONARY THROMBOSIS SIR,-Much has been published in the daily press lately on the increase in the number of cases of coronary thrombosis, the main suspicion being directed at the amount of animal fat consumed by the class of person most likely to be afflicted. May I, just a layman, point a finger of suspicion at certain substances which are being used in ever-increasing quantities in many of the common items of food more than likely to be eaten by the same class of persons. I refer to glyceryl monostearate and other emulsifiers which enable fats to be mixed easily with water, and I would suggest that when they are consumed in the diet in large quantities they may be absorbed and alter the state of the fat in the blood and so possibly be responsible for the damage to the arteries and cause thrombosis. Taking this matter a step further, the use of detergents, which are also emulsifiers, for washing up crockery, and which are not properly rinsed off, can introduce into the digestive organs another substance which may alter the state of the fat in the blood. Glyceryl monostearate is used as a crumb-softener in much of today’s bread, in ice-cream to increase the bulk or volume from a given weight of fat, in cake-mixes to enable the house-wife to make quicker cakes, and in prepacked cakes which remain soft for many days. I think investigations along these lines might prove very profitable, although I must confess I send this letter with trepidation. F. J. ROBERTS. FRACTURES OF THE FEMORAL NECK
SIR,—Mr. Newman (March 30) paid
a generous tribute factual review by Dr. Murray and Mr. Young (March 23) of fractures of the neck of the femur treated at the Southern General Hospital, Glasgow. He noted a high mortality-rate and, while accepting the likelihood of error in any statistical comparison, suggested that this was evidence against delay in operation. As an illustration that we are dealing here with a particularly poor-risk group, it should be said that some of our cases have been discharged home from other city hospitals as being unfit for surgery and thence admitted to our wards by the Beds Bureau. The high mortality quoted (33% overall, 26% for operative cases, and 48% for those treated conservatively) is also a measure of the difficulties of disposing of geriatric cases from acute surgical wards. Mr. Newman compared this with an average mortality of 168% among 564 patients treated surgically, collected from the literature. The mortality-rate for our 139 patients treated surgically was 14% in the first twenty-
to
a
eight days. This would surely provide a fairer figure for comparison, as far as American publications are concerned at least, it is rare for a bed in an American hospital to be occupied by the same patient for twenty-eight days. Few of our patients went home within twelve weeks. Certainly if we are to compare the results of immediate operation (within twenty-four hours) with those of elective operation (average time from fracture till opera-
since
1. Humble, J. G. Empire Rheumatism Council Butazolidin. Nov. 13, 1953.
Symposium
on
figure
to take.
Southern General Hospital, Glasgow, S.W.1.
W. SILLAR.
CYTOLOGICAL DETECTION OF UTERINE CANCER SIR,—Dr. Anderson (April 6, p. 738) is quite correct when he states clearly that cytology is no longer an untried method in the research stage, but in the Birmingham study1 of the value of cytology in gynaecological practice which we carried out at the request of the Royal College of Obstetricians and Gynaecologists, the establishment of the technique in the hands of technicians (none of whom is medically qualified) amounted to research. First of all we had to show that in our hands the technique would confirm the presence of obvious cancer A lower of the cervix, which was soon established. in cancer of the was inevitable however, efficiency, corpus for cells are not shed regularly or may be swamped with blood. The most important part of our research, however, was to find out for ourselves how many cases of cancer we were missing in routine investigation of outpatients. To keep our clinical practice up to a high standard we used a questionnaire and we inspected the cervix with great care. Since 1954 we have abandoned the detailed questionnaire and simply write down on our case-sheets in the outpatient department that this patient has or has not carcinoma of the corpus or cervix. We are thus tied down as clinicians, leaving the cytologist " a chance to claim a pick-up " for the technique, should cancer cells be obtained from a clinically normal case. How many cases were we missing, for obviously 1 per 10,000 would have made the technique valueless, whereas 2% would have made it almost obligatory for our or for any gynaecological clinic ? We found that in 2250 patients (in two years) we had missed 1 case of early cancer of the cervix. We also missed 1 case of carcinoma of the corpus which escaped our exploratory curette, but the risk to her life was less in that postmenopausal bleeding would have made hysterectomy obligatory
without positive smears. Our conclusion was therefore that, in our practice, cytology was almost never required to reach a diagnosis of uterine carcinoma. But cytology led us to discover 8 examples of carcinoma-in-situ which would have escaped our usual investigations. We have now screened over 5000 patients and the figure of 3 per 1000 is being maintained. With many hundreds of hours of microscopy was this a reasonable " harvest " We concluded that it was and in this came into line with many centres in the U.S.A. and elsewhere, including this country. M. J. D. Noble and M. E. Attwood have applied this " search " technique to diabetics (Dr. J. M. Malin’s patients) and this study is ready for publication. Their harvest " is greater than in our outpatients, not only for invasive but also for " in-situ " lesions. Studies are also continuing in the field of therapy ; for instance, 13 of our cases of carcinoma-in-situ have been " treated " simply by deep ring biopsies-i.e., we have the beginnings of information on therapy. Dr. Anderson suggests that although cytology per se is not research the technique can be used as part of research into the natural history of cancer. I suggest that the operative word " can " should be replaced by " must," but in this my colleague, Dr. C. W. Taylor, director of pathology, Birmingham Hospital for Women, does not entirely agree with me. My opinion is based not simply on the fact that it takes hundreds of hours of microscopy to discover 1 case of carcinoma-in-situ but that each case should be a subject of study to offset the time-consuming work by the cytologist. "
1.
H. C., Taylor, C. W., Attwood, M. E. Gynæc., Brit. Emp. 1956, 63, 801.
McLaren,
J. Obstct.