POST-MASTECTOMY MORALE

181 add. This is the fact that no surgeon can have regular, full, and reasonably varied operating sessions without at least a moderate waitinglist. This is because patients requiring surgery do not attend outpatient departments in a regular order. Thus, in order to utilise expensive theatre facilities, surgical registrars, and consultants (i.e., existing resources) efficiently,

recognised, that

I would like

quite a large waiting-list

to

is in fact essential.

Broadgreen Hospital, Liverpool L14 3LB.

D. P. B. TURNER.

ENDOTOXIEMIA IN MAN SIR,-Your editorial comment on our article (June 24, p. 1381) expresses the view that better bacteriological data will be needed before one can justify the role we ascribe to the intraintestinal flora in the response to major trauma. Evidence of the presence of a septic process is not merely the presence of bacteria, but the gross or microscopic features of the expected inflammatory response. A bactersmia as well as an endotoxaemia of intestinal origin can develop when the barrier function of the gut wall is damaged, whether by poor flow, kinins, or lysosomal enzymes released from a site of injury. In such circumstances the capacity to

inflammatory response may be weakened or develop lost altogether. This can account for the absence of a septic process in the presence of a bacterasmia and an an

endotoxxmia. Several recent but this contention:

as

yet

unpublished findings support

(1) The Limulus lysate test does not become positive for endotoxin when reacted with living bacteria until the count per ml. of saline is in excess of 5 x 103. Since such counts were rare in the blood or tissues before death, or at necropsy up to 24 hours afterwards, the positive test was not produced by living bacteria. (2) Of 20 patients who died with endotoxin in the liver (which in the normal state is always free of endotoxin), overt or significant sepsis was present in only 6. The plasma was positive for endotoxin in 12, and negative in 3. No plasma was obtained for the test in 5. (3) Endotoxic shock which results in death within 12 hours or less has been regularly produced in white adult New Zealand rabbits with a normal intestinal flora by various types of trauma -e.g., a 30% immersion burn, a 3-hour infusion of various kinins, a 1-hour occlusion of the superior mesenteric artery, or a lethal intravenous dose of endotoxin. A gram-negative bacterxmia is frequent, but a septic process is not found at necropsy. Since March this year, and until today, the same types of trauma have not evoked this response in a large series of such rabbits from the same and other breeders. In a search for the cause we observed (a) that the bactersmia, when present, was exclusively grampositive ; that the intestinal flora were almost always exclusively gram-positive; (c) that the bacterial counts per g. of csecal content were 105 or less, as compared to 1010 or more in rabbits with the usual flora; (d) that the assay for endotoxin was 0-125 mg. or less per g. of csecal content, in contrast to 3 mg. or more per g. in rabbits with the usual flora; and (e) that several hours after direct injection of a dose of living and killed gram-negative bacteria equivalent to 50 mg. of endotoxin into the gut, the same types of trauma produced fatal endotoxic shock.

(b)

MEAN CONTENT

(ug.)

OF

ENDOTOXIN,

PER

g. AND

PER WHOLE

(4) The accompanying table from a paper now in the press" shows that, in rabbits with a normal flora receiving an intravenous dose (250 g.) of endotoxin that is lethal within some 12 hours, the amount of endotoxin present in the liver is far more than the On the other hand, rabbits without a gramamount injected. negative flora treated likewise are alive the day afterward, without endotoxin in the blood, without the functional or structural damage observed in the animals with normal flora, and with no endotoxin in the liver. These data show that an endotoxxmia, once present,. whether it is initiated by a septic process or not, mobilises more endotoxin (in the form of living or disintegrated bacteria) from the intestine. In this way the endotoxaemia can become self-sustaining and so produce fatal shock. These data also affirm the thesis that the intraintestinal gram-negative bacteria play a critical role in the body’s response to major injury. Department of Surgery, Harvard Medical School, Boston City Hospital, Boston, Mass. 02118, U.S.A.

JACOB FINE.

POST-MASTECTOMY MORALE SIR,-In the past few years there has been increasing: awareness of the effects on patients’ morale of certain operations. Much attention has been paid to patients withileostomies and colostomies, but until recently mastectomypatients have not always received much help. Although the position has improved, many hospitals still neglect this. important part of aftercare or organise it badly. The need is for early and satisfactory restoration of thepatient’s external appearance and also for early oppor-tunities to talk about her fears and difficulties. The surgeon should constantly instruct his assistants andnursing staff to help him in this vital task of talking to the patient and giving her sensible advice and reassurance. A prosthesis clinic " is very helpful. Such clinics havenow been running in the Taunton and Bridgwater Hospitals for some years. Held concurrently with the joint breastand radiotherapy clinics, they are staffed by a woman. fitter and a voluntary worker, herself a mastectomy patient. It is this lay helper who is most important in the wholeproject. Because she has suffered all the mental and physical stresses of a mastectomy, she is the only one able "

talk to the patient with real understanding. As often as possible the lay helper visits the patients. immediately after operation, to talk and help. At the earliest possible moment the patient is fitted with a breast form and encouraged to present a normal appearance toother patients, her visitors, and, most important, to her mirror. We have tried various prostheses, including theoil-filled variety, but all have proved unsatisfactory forimmediate (48 hours) postoperative use. to

1. Woodruff, P. W. H., O’Carroll, D. I., Koisumi, S., Fine, J.J. Dis. (in the press).

infect.

ORGAN, IN VARIOUS TISSUES OF RABBITS FOLLOWING INTRAVENOUS INJECTION* 100 (Lg. PER keg.*

OF

-

*

Data obtained after death or in survivors killed 24 hours after injection. group C had normal intestinal flora. A= No treatment. B = Pretreated with kanamycin in gut. C =No treatment. Intestinal fora exclusively or predominantly gram-positive.

t All rabbits except

182 With the help of a local firm of corsetiers, a satisfactory "breast form has now been developed. This is made of ’ Fibrofil ’ and filled with ’Kodel ’. A large (36 in. C cup) prosthesis weighs onlyoz. and is completely wash.able. It could be cheap to produce and is intended to be - sewn into the patient’s original brassiere. It can then be hand or machine washed. Patients are later reassessed by the clinic, and many are .also supplied with oil-filled prostheses. Many prefer oil:filled prostheses for social occasions and the lighter model for working and with bathing costumes and other sports-wear.

Samples

of this

prosthesis are being sent to surgeons at throughout Britain, and it is hoped that sufficient support will be received for a contract for supply

-various -to

centres

the National Health Service.

I thank Messrs. S. Leffman Ltd., of Bridgwater, Somerset, who have provided the material and have helped with the design of this prosthesis, and Mrs. Irene Boyce, who has spent a large amount of her time in helping with the clinics and with the development of the prosthesis itself. Taunton &

Somerset Hospital, Musgrove Park Branch, Taunton, Somerset.

A. C. AKEHURST.

and the proper disposal of their bodies. Fortunately in this instance the owner of the other birds was cooperative and had premises where the birds could be isolated. No further human cases seem to have occurred. Health Department, Borough of Camden,

PAUL BHANDARI.

London WC1H 9DB.

THE D.T.C.H.

SIR,-Your critical comments on the D.T.C.H. course have been answered by our Liverpool colleagues, whose views I endorse. But your second editorial of July 1, repeating some of the previous arguments (June 17), calls for a comment, since it throws doubt on the value of British postgraduate education relevant to tropical conditions. This country accumulated an unsurpassed experience overseas and I see no reason why it should not be transmitted by direct teaching to those of our colleagues from abroad who appreciate its value. Academic institutions in tropical countries capable of organising such comprehensive teaching can be counted on the fingers of one hand, and the applications vastly exceed the number of available places.

PSITTACOSIS

SIR,-Iread your editorial (July 8, p. 72) with particular ’interest, since a confirmed case of this disease recently in Camden. The patient was a 17-year-old girl
,employed by a pet shop specialising in the importation of exotic birds, situated in another borough. She and an -older man occupied a small furnished room containing a sink and hot-water supply in a house in multiple occupa- tion, sharing a water-closet with other residents. At the time of her admission to hospital she had no less than 7 tropical birds in four cages in her room. One bird, a .couney, was ailing, and the room also contained a freerange tortoise and

large black rat in another cage. During 1the six weeks previous to her illness 4 tropical birds that a

she had also kept in this room had sickened and died. .2 of these were disposed of in the dustbin, the others

being refrigerated by a local taxidermist to await his ,attention. The bird which was ill was slaughtered with her consent, and examination at the Royal Veterinary College confirmed that it had psittacosis. I was concerned about the remaining birds, since it seemed possible that their excreta might well be highly infectious. Her partner, who remained in the room, developed - symptoms similar to those of the patient in hospital, and was successfully treated by a course of oxytetracycline. Although no laboratory investigations were undertaken, it -seems probable that he too had psittacosis. He continued 1o live in the room, and was not willing for the birds to be slaughtered. A compromise solution was reached whereby he moved the birds to his office in a block where there were no residents, and the room was fumigated with formaldehyde gas for a period of six hours. The cages in which the birds had been kept were disinfected by exposure to high-pressure steam and by washing with formaldehyde. Although our disinfectors wore masks we have decided, for the future, that the cages of birds suspected of having psittacosis should be treated by superheated steam and then discarded, the owners being suitably compensated. This measure appears reasonable to avoid the risk of infection spreading to our staff and others. In this case the potentially infected birds presented a -problem. It would seem that no powers exist to enforce their isolation, and indeed no pet shops or boarding establishments will accept them for fear of infecting their stock. No powers appear to exist to enforce their slaughter

In the case of the London School of Hygiene and Tropical Medicine, as in the case of Liverpool, only mature candidates requiring special training in their chosen subjects are accepted for the courses leading to diplomas in tropical public health, clinical medicine of the tropics, or for the The fact that the selected postgraduate conjoint D.T.M.&H. students come from many countries gives the curriculum a truly international aspect-surely an important advantage in today’s world. This multinational character of our courses has been fully recognised by the World Health Organisation sponsoring 75% of our students, whose experiences are exchanged at seminars in which they are active participants. At the time when postgraduate teaching of doctors shows a striking increase in Germany,

overseas

France,

Belgium, Holland, Switzerland, Czechoslovakia, Poland, Hungary, Yugoslavia, why should this country with its unique store of basic and applied medical and biological knowledge opt out of its historic role ? The time will certainly come when the main training-centres will shift to overseas countries, but that day has not yet arrived. Last year’s Conference on Medical Education, Research and Medical Care in Developing Countriesdiscussed this problem at length, and I am sure that you will recognise that the two schools of tropical medicine are responding to the felt need and fulfilling their obligations to

this country and to the developing world. Ross Institute of Tropical Hygiene, London School of Hygiene and Tropical Medicine, London WC1E 7HT.

L.

J. BRUCE-CHWATT.

SIR,-My colleague Professor Bruce-Chwatt has shown the letter he is sending to you and I wish to associate myself with everything he says. Your attack on the diploma of tropical child health (Liverpool) was, I believe, ill-chosen, me

and your further attack on the conduction overseas of examinations for the diplomas granted by the Royal Colleges is also unfortunate. You glibly state that the latter has " nothing to do with education: it is certification ", but in saying this you close your eyes to the point that it is certification of the result of an educational process. Without the certification and the effort required to obtain it there is little doubt that the majority would find the urge to cover the particular educational field less impelling. As one who personally took the Membership examination when it was 1. Trans. R. Soc. trop. Med. Hyg. 1972,

65, 709.