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SURGERY UNDER ADVERSE CONDITIONS
1028 fiducial limits of error (P=0’95) of 953-119%, as compared with 101-6% (91-7—112%) at the time of manufacture. All these figures are within the limits of the B.P. standard. A blood-sample subsequently obtained from the patient was analysed through the kindness of Novo Industri A/S, and contained antibodies against insulin which had a higher affinity for beef than for pig insulin; but no definite conclusions could be drawn from these findings in the absence of sera from patients treated with insulin from one species only. The patient, however, showed a clear difference in response to the two insulins. A careful comparison under inpatient conditions, with frequent blood-sugar estimations, showed that a daily dosage of 60 units of pure porcine i.z.s. resulted in a degree of control equivalent to that produced by 84 units of standard bovine i.z.s. His diabetic control remained satisfactory on 60 units of the pig preparation as an outpatient, but at his own request he was changed back to a standard beef insulin, of which he again required 84 units daily. Case 2.-A 40-year-old woman with uncomplicated diabetes mellitus of 10 years’ duration had been stable on 68-76 units ox I.Z.S. daily for nearly 4 years. On changing to mixed pork-beef I.Z.S. in May, 1966, she developed severe hypoglycaemia and was admitted to hospital in coma. She has since remained stable on her usual dose of bovine I.Z.S. Antibody studies have not yet been made in this case. Queen Mary’s Hospital For the East End, West Ham Lane, London E.15.
R. R.
DE
MOWBRAY.
INFECTED MEAT with read interest your leading article (Aug. 13, SIR,-I all the new Acts and Regulations on hygiene p. 377). Despite the figures for food poisoning in England and Wales, given in the annual report of the Ministry of Health, still remain fairly high. It is quite understood that there are difficulties in inspecting such places as food premises and public lavatories by public-health officials, for they have many other duties. Infected meat is probably the main source of nearly all the trouble. It is suggested that more and constant scrutiny is required of all live animals, with examination of samples of fxces and urine, especially where they are reared and housed, and that they should be followed up while they are awaiting slaughter in pens, byres, and slaughter-houses; the carcass and offal should be examined thereafter. Diagnosis of disease (salmonellosis) is required very early, so that action can be taken to prevent any animal or bird in an infected condition ever reaching the market or place of slaughter-in fact any place where infection could be passed on. All feeding materials should be thoroughly examined; and care should be taken about feeding-troughs-this is of great importance on farms. It has been found also that feeding-stuffs from abroad are often infected. All this would naturally require more inspection staff. ELLIOT B. DEWBERRY.
length of survival after orchidectomy and conventional radiotherapy and an arbitrary grading of the intensity of the stromal infiltration in each tumour. A positive and statistically significant correlation was found between more intensive infiltration and longer survival after treatment. Further studies are required to confirm this conclusion, but, at least in the special case of these neoplasms, there may well be " autoimmune " reactions by the patients against their tumours. Department of Pathology and Wessex Regional Neurological Centre, Southampton General Hospital, ANTHONY D. DAYAN. Shirley, Southampton.
SURGERY UNDER ADVERSE CONDITIONS p. 900) is to be congratulated on his article advocating listerism in surgery under adverse conditions. I am, however, a little surprised to see that he uses a 1/200 aqueous solution of chlorhexidine for wound irrigation, since this is ten times the concentration recommended by the manufacturers. This article is a break-through in surgical thought, because there is an extraordinary resistance to the use of antiseptics in surgery today, despite a high rate of hospital infection of wounds. This may be due partly to the fact that we have quite rightly regarded asepsis as the ideal after which we should strive, and partly to the fact that until fairly recently we did not possess effective and non-toxic antiseptics which we could apply directly to open wounds. I have on several occasions1 suggested that, in view of the inevitable imperfections of aseptic surgery, we should revert to some of the practices which Lister so successfully used. Lister showed, for example, that if silk sutures were first immersed in carbolic acid, primary healing followed, and the sutures did not give rise to sinuses, but became embedded in fibrous tissue. Now it is remarkable that the cheapest and best of all suture material for general use-namely, cotton-is still used by very few surgeons, because of the fear of sinus formation. I have, however, proved over a period of 10 years that Lister’s principle was right, and that cotton steeped in chlorhexidine does not give rise to sinuses. The routine irrigation of operation wounds with 1/2000 chlorhexidine, which has been my practice for many years, is, I am sure, a perfectly safe and reasonable procedure, and eliminates stray organisms which so readily multiply in the foci of devitalised tissue distal to such foreign bodies as
SIR,-Dr. Dick (Oct. 22,
ligatures.2 It is indeed most appropriate that Dr. Dick’s article has appeared in 1966, the year spanning the centenaries of Lister’s first antiseptic operation and of his first reports, published in 1867. Bridgend General Hospital, Quarella Road, Bridgend, Glamorgan.
A. W. FOWLER.
POSTOPERATIVE HYPOALBUMINÆMIA SIR,-Dr. Mouridsen and Professor Faber (Oct. 1, p. 723, suggest that hypoalbuminxmia following simple mastectomy 15 : related to loss of albumin into the operative wound site. They dismiss the possibility of plasma-volume dilution, though they admit that direct plasma-volume measurements were not made in these patients. Studies3 of human haemorrhage have shown that decrease in the albumin concentration is an invariable consequence o: blood-loss. Associated with this hypoalbuminxmia is an expanding plasma-volume. The time-course of the plasmavolume expansion indicates that the removed blood-volume:, refilled completely in about 24 hours in most instances. Two competing rates are present in the operated patient: (1) loss0:" fluid and protein into the wound; and (2) expansion of the
I
SPONTANEOUS REGRESSION OF CANCER SIR,-In your leading article (Oct. 22, p. 896) the possibility is mentioned that immunological factors may play some part in the natural processes of defence against neoplasms. Marshall and I have advanced the hypothesis that the stromal infiltration of lymphocytes, plasma cells, and germinal centres found in seminomas, dysgerminomas atypical teratomas of the pineal, and " germinal tumours of the mediastinum " represented an immunological response to the tumour by the host. At that time there was no direct evidence to support this view. In studies shortly to be published elsewhere,2 a relation was sought, in a series of patients with seminomas, between the 1. 2.
Marshall, A. H. E., Dayan, A. D. Lancet, 1964, ii, 1102. Dayan, A. D. Hosp. Med. (in the press).
G
1. 2. 3.
Fowler, A. W. Lancet, 1963, i, 387; ibid. i, 769; Br. med. J. 1965, Howe, C. W. Surgery Gynec. Obstet. 1966, 123, 507. Skillman, J. J., Awwad, H. K., Moore, F. D. Unpublished.
R. R.
DE
MOWBRAY.
INFECTED MEAT with read interest your leading article (Aug. 13, SIR,-I all the new Acts and Regulations on hygiene p. 377). Despite the figures for food poisoning in England and Wales, given in the annual report of the Ministry of Health, still remain fairly high. It is quite understood that there are difficulties in inspecting such places as food premises and public lavatories by public-health officials, for they have many other duties. Infected meat is probably the main source of nearly all the trouble. It is suggested that more and constant scrutiny is required of all live animals, with examination of samples of fxces and urine, especially where they are reared and housed, and that they should be followed up while they are awaiting slaughter in pens, byres, and slaughter-houses; the carcass and offal should be examined thereafter. Diagnosis of disease (salmonellosis) is required very early, so that action can be taken to prevent any animal or bird in an infected condition ever reaching the market or place of slaughter-in fact any place where infection could be passed on. All feeding materials should be thoroughly examined; and care should be taken about feeding-troughs-this is of great importance on farms. It has been found also that feeding-stuffs from abroad are often infected. All this would naturally require more inspection staff. ELLIOT B. DEWBERRY.
length of survival after orchidectomy and conventional radiotherapy and an arbitrary grading of the intensity of the stromal infiltration in each tumour. A positive and statistically significant correlation was found between more intensive infiltration and longer survival after treatment. Further studies are required to confirm this conclusion, but, at least in the special case of these neoplasms, there may well be " autoimmune " reactions by the patients against their tumours. Department of Pathology and Wessex Regional Neurological Centre, Southampton General Hospital, ANTHONY D. DAYAN. Shirley, Southampton.
SURGERY UNDER ADVERSE CONDITIONS p. 900) is to be congratulated on his article advocating listerism in surgery under adverse conditions. I am, however, a little surprised to see that he uses a 1/200 aqueous solution of chlorhexidine for wound irrigation, since this is ten times the concentration recommended by the manufacturers. This article is a break-through in surgical thought, because there is an extraordinary resistance to the use of antiseptics in surgery today, despite a high rate of hospital infection of wounds. This may be due partly to the fact that we have quite rightly regarded asepsis as the ideal after which we should strive, and partly to the fact that until fairly recently we did not possess effective and non-toxic antiseptics which we could apply directly to open wounds. I have on several occasions1 suggested that, in view of the inevitable imperfections of aseptic surgery, we should revert to some of the practices which Lister so successfully used. Lister showed, for example, that if silk sutures were first immersed in carbolic acid, primary healing followed, and the sutures did not give rise to sinuses, but became embedded in fibrous tissue. Now it is remarkable that the cheapest and best of all suture material for general use-namely, cotton-is still used by very few surgeons, because of the fear of sinus formation. I have, however, proved over a period of 10 years that Lister’s principle was right, and that cotton steeped in chlorhexidine does not give rise to sinuses. The routine irrigation of operation wounds with 1/2000 chlorhexidine, which has been my practice for many years, is, I am sure, a perfectly safe and reasonable procedure, and eliminates stray organisms which so readily multiply in the foci of devitalised tissue distal to such foreign bodies as
SIR,-Dr. Dick (Oct. 22,
ligatures.2 It is indeed most appropriate that Dr. Dick’s article has appeared in 1966, the year spanning the centenaries of Lister’s first antiseptic operation and of his first reports, published in 1867. Bridgend General Hospital, Quarella Road, Bridgend, Glamorgan.
A. W. FOWLER.
POSTOPERATIVE HYPOALBUMINÆMIA SIR,-Dr. Mouridsen and Professor Faber (Oct. 1, p. 723, suggest that hypoalbuminxmia following simple mastectomy 15 : related to loss of albumin into the operative wound site. They dismiss the possibility of plasma-volume dilution, though they admit that direct plasma-volume measurements were not made in these patients. Studies3 of human haemorrhage have shown that decrease in the albumin concentration is an invariable consequence o: blood-loss. Associated with this hypoalbuminxmia is an expanding plasma-volume. The time-course of the plasmavolume expansion indicates that the removed blood-volume:, refilled completely in about 24 hours in most instances. Two competing rates are present in the operated patient: (1) loss0:" fluid and protein into the wound; and (2) expansion of the
I
SPONTANEOUS REGRESSION OF CANCER SIR,-In your leading article (Oct. 22, p. 896) the possibility is mentioned that immunological factors may play some part in the natural processes of defence against neoplasms. Marshall and I have advanced the hypothesis that the stromal infiltration of lymphocytes, plasma cells, and germinal centres found in seminomas, dysgerminomas atypical teratomas of the pineal, and " germinal tumours of the mediastinum " represented an immunological response to the tumour by the host. At that time there was no direct evidence to support this view. In studies shortly to be published elsewhere,2 a relation was sought, in a series of patients with seminomas, between the 1. 2.
Marshall, A. H. E., Dayan, A. D. Lancet, 1964, ii, 1102. Dayan, A. D. Hosp. Med. (in the press).
G
1. 2. 3.
Fowler, A. W. Lancet, 1963, i, 387; ibid. i, 769; Br. med. J. 1965, Howe, C. W. Surgery Gynec. Obstet. 1966, 123, 507. Skillman, J. J., Awwad, H. K., Moore, F. D. Unpublished.