BRITISH MEDICAL JOURNAL
409
10 FEBRUARY 1979
increased maternal as well as neonatal mortality operation is best attempted under general and morbidity. anaesthesia, administered by an anaesthetist R R MACDONALD experienced in obstetric anaesthesia. J S SCOTT The Maternity Hospital, G A CRAIG Leeds Bradford, W Yorks
I
Lancer, 1978, 2, 1349.
SIR,-Neonatal morbidity after the use of Kielland's forceps is an important topic, but I wonder if Drs M L Chiswick and D K James (6 January, p 7) are justified in inferring that the increased morbidity they observed can be attributed to the use of the forceps themselves in as many of their cases as they claim. The only circumstance in which there is an indication to use Kielland's forceps is that in which there is malposition of the fetal head in the second stage of labour, when for fetal or maternal reasons it is deemed desirable to expedite the delivery, and then only if there is no significant absolute cephalopelvic disproportion. In most cases where these forceps are used (66 cases out of 81 in the series reported) there is sufficient relative cephalopelvic disproportion, caused by deflexion of the fetal head (caused in its turn by the malposition), to prolong the second stage of labour; and this brings with it an increased risk of fetal hypoxia. It is also possible that the malposition of the fetal head alone could cause hypoxia, and there is some evidence for this in the paper (15 of the 8i fetuses in the forceps group were hypoxic without there being any delay in the second stage). Could it not be these factors which were responsible for the observed fetal morbidity, rather than the use of the forceps per se? If this is the case one should use Kielland's forceps earlier in the second stage, before the adverse effects on the fetus caused by the malposition of its head have been felt, rather than abandon their use altogether. These remarks do not apply, of course, to the neonatal morbidity caused by birth trauma; but its incidence in the series reported would have been markedly reduced if excessive force had not been used. As an alternative to caesarean section, consideration might have been given in the discussion to the techniques of manual rotation or delivery by the Ventouse apparatus. R M BALLARD London SEll
SIR,-The results reported by Drs Malcolm L Chiswick and David K James (6 January, p 7) on the use of these forceps to overcome midcavity obstruction or delay are interesting and disappointing. They should not, however, be attributed to the type of forceps used. The mid-cavity forceps operation, especially if rotation of the head is required, is a major procedure. Accurate diagnosis is essential, as are skill and gentleness, and in addition experience and courage-the two latter qualities in order to recognise when the operation should be abandoned and caesarean section performed. Great strength is not necessary. In my opinion these patients should not be entrusted, without supervision, to anyone below the rank of senior registrar. I have on occasions thought that attempting the operation under pudendal block seemed to render it more difficult. As a result of this experience I am now of the opinion that the
Trials in breast cancer SIR,-On 23 November 1978 the Cancer Research Campaign sponsored a meeting to review the progress of the United Kingdom multicentre collaborative trial of adjuvant hormono-chemotherapy in poor-risk patients with ea:ly carcinoma of the breast. This meeting provided an opportunity for the steering committee of that study to meet with the organisers of the King's College Hospital breast cancer trials. Both groups agreed on the following points: (1) It is justifiable to conduct adjuvant therapy studies in poor-risk early breast cancer patients while still retaining a control arm. (2) There is sufficient evidence both on theoretical and experimental groundsl-3 and in work done in advanced disease4 5 to study the potential advantages of combining chemotherapy and hormone therapy over either modality alone as adjuvant treatment. (3) Both groups have launched trials of similar design that will study different aspects of this problem. Their cumulative results will be of great value but will depend on recruiting sufficient numbers of patients to each trial. (4) It is regrettable that, despite the overwhelming evidence supporting the need for such studies, the majority of poor-risk early breast cancer patients in this country are not entered into any trial where the value of adjuvant therapy can be assessed. We therefore ask that clinicians in charge of eligible patients will give serious thought to collaborating with one or other of these studies. (5) Centres which enter a substantial number of patients will be provided with secretarial or other assistance in order to facilitate the conduct of the trial. Further information can be obtained from either of us regarding both trials, so that clinicians can choose which they would feel most appropriate for them to join. Royal Free Hospital, London NW3
mastectomy specimens may be as high as 50%.1 The purpose of giving radiation therapy following tylectomy is to sterilise such microscopic disease. Five thousand rads delivered to the entire breast with an additional 1500 rads to the area of the primary tumour will result in a local control rate of about 90%.2 3 4 The radiation doses delivered, following tylectomy, in those studies quoted by Dr Tagart were considerably lower than this and resulted therefore in a local recurrence rate which was as high as 20-25%. It is also known that patients with a clinically negative axilla have about a 30% chance of having microscopically involved nodes on pathological examination. As may be expected, six of the 27 patients (22%) who had had no axillary dissection had a recurrence in the axilla. If these clinically negative axillae had received adequate irradiation (minimum tumour dose of 5000 rads in five weeks) the recurrence rate would have been less than 5* 4 7 I would have hoped that Dr Tagart, having observed the high incidence of local recurrences in his series, would have come to the natural conclusion of adding postoperative irradiation in adequate doses following partial mastectomy. Instead, unfortunately, he terminated his worthwhile trial in favour of total mastectomy. We have yet to convince our colleagues, the surgeons, that surgery is necessary for the removal of gross malignant disease and that irradiation is necessary for control of microscopic deposits. N A GHOSSEIN Department of Radiology, Albert Einstein College of Medicine, Yeshiva University, New York
'Rosen, P P, et al, Cancer, 1975, 35, 739. 2 Alpert, S, et al, Cancer, 1978, 42, 2054. Bataini, J P, et al, Cancer, 1978, 42, 2059. 4Calle, R, et al, Cancer, 1978, 42, 2045. Atkins, H, et al, British Medical J'ournal, 1972, 2, 423. Mustakallio, S, Clinical Radiology, 1972, 23, 110. Ghossein, N A, et al, Radiology, 1976, 121, 455. Cimetidine and duodenal ulcer
SIR,-Further to Mr J Alexander Williams's comments (20 January, p 169) on the lack of evidence for rebound perforation following cimetidine withdrawal, I report two cases. F SENANAYAKE A man of 65 with no previous gastric history had a successful repair of a thoracic aneurysm complicated by severe haematemesis. Gastroscopy showed M BAUM acute stress ulceration. Bleeding continued despite
King's College Hospital Medical School,
London SE5
Lippman, M E, et al, New EnglandJ7ournal of Medicine, 1978, 298, 1223. Meakin, J W, et al, in Adjuvant Therapy of Cancer, ed S E Salmon and S E Jones. Amsterdam, Elsevier, 1977. 3 Braunberg, H, et al, Lancet, 1973, 1, 163. 4Tormey, D C, et al, Proceedings of the American Association for Cancer Research, 1978, 19, 34. Cavalli, F, in Proceedings of 10th International Congress on Chemnotherapy, 1977, p 615. New York, Plenum 2
Press, 1977.
Partial mastectomy for breast cancer
SIR,-I read with interest the report of Mr R E B Tagart (4 November, p 1268) on partial mastectomy for operable breast cancer. It is no surprise that 37% of Nir Tagart's patients who underwent partial mastectomy, without postoperative radiotherapy, had a recurrence in the breast within three years. After all, the incidence of multifocal microscopic cancer in
medical treatment and Polya partial gastrectomy was performed. Histology later confirmed the diagnosis. Four days postoperatively, cimetidine in full dosage was restarted when fresh blood was aspirated from the stomach, being reduced to 400 mg at night at three weeks and stopped at 11 weeks. Three weeks later he was readmitted with perforation of a stomal ulcer, which was successfully oversewn. Serum gastrin concentration was normal and he remains well one year later. A man of 19 with a six-month history of indigestion had a perforated duodenal ulcer. This was treated by oversewing, followed by cimetidine in full dosage. He stopped cimetidine at four weeks and six weeks later presented with reperforation of the same ulcer. This was treated by vagotomy and pyloroplasty and 11 months later he remains well, with normal serum gastrin concentration.
Only 3-5% of Polya partial gastrectomies are followed by stomal ulceration. A study of 360 cases did not include any developing within six months, and only one case of perforation was recorded.' Initially our first patient had
410
BRITISH MEDICAL JOURNAL
had no hyperacidic peptic ulceration. As regards the second patient, simply oversewing perforations leads to further surgery in 20% of cases in five years. This is extremely rarely required within two months.2 The occurrence and timing of recurrence of ulceration in both cases strongly suggests that cimetidine treatment or its withdrawal was implicated. When H2-blockade of acid-secreting cells is withdrawn, it is more likely to lead to excessive sensitivity to normal stimuli than to hyperplasia. A S BULMAN
All worked themselves up into a frenzy because their babies had not had their "cholesterol" (sic), although all five babies are making excellent progress. I am, of course, familiar with the multifarious properties of this substance but colostrum deficiency would appear to be a new iatrogenic disease of the maternal mind, springing from the same sources which are responsible for so much unnecessary anxiety today. HERBERT BARRIE
Kingston Hospital,
London W6
Charing Cross Hospital (Fulham),
Kingston-upon-Thames, Surrey lWychulis, A R, et al, in Surgery, Gynaecology and Obstetrics, 1966, 122, 89. 2Illingworth, C F S, et al, British Medical Journal, 1946, 1, 787.
SIR,-The discussion about cimetidine and duodenal ulcer by Dr J H Baron and others (20 January, p 169) has important implications for general practitioners as well as hospitalbased specialists. If, as is suggested, progressively more patients are being treated medically then the disease becomes one which should be treated in the primary care situation. There seems to be agreement that rapid relapse after one or more full courses of treatment warrants referral for surgery even if many patients would prefer the unknown risk of long-term drug therapy to the known risk of operation. What is not clear, in general practice, is which patients should be started on treatment. I, and some of my colleagues, felt initially that the criteria should be relatively rigid. All patients should have had a duodenal ulcer demonstrated radiologically or endoscopically or should have suffered a catastrophe such as haemorrhage or perforation in the past. This may lead to numbers of patients with classical symptoms being referred to outpatients for expensive, time-consuming, and unpleasant diagnostic procedures. If, as Mr J AlexanderWilliams states, patients are being referred to him with a diagnosis of duodenal ulcer but with symptoms uncontrolled by cimetidine, and that this almost certainly indicates that the pain is due to something else, then surely we have in our hands a diagnostic weapon which can relieve hospitals and patients of a tiresome burden. It could be argued that at least in the younger patient with upper abdominal pain a therapeutic trial of cimetidine for one week should be carried out as a first step in investigation. The same argument would hold for differential diagnosis of retrosternal pain when reflux was a consideration. My experience so far has suggested that the answers given by such a policy are helpful. MICHAEL DRURY Department of Medicine, University of Birmingham
Colostrum deficiency SIR,-I wonder if anybody has ever seen a baby die for want of colostrum. Only this week I saw five very agitated mothers who evidently thought that theirs might. One had respiratory distress and another a large cleft palate, and a third persistently vomited all his "unique maternal gift." The mother of the fourth had a complicated delivery and was herself unwell, while the fifth had inverted nipples and was unable to produce any colostrum or milk.
Age and death in breast carcinoma
SIR,-I was interested to read your leading article (27 January, p 211) on the above subject. During the last year before my retirement some 18 months ago, I decided to review all my cases of carcinoma of the breast, to see whether anything of interest might turn up. Despite the small number-about 400-this was a fairly mammoth task, and when it was finished I found that I had really nothing to offer, so did not publish. The survey, however, provided me with two surprises. The first surprise was that, contrary to what one had always thought, age seemed to have little or no bearing on prognosis and old people seemed to fare no better-or worsethan youngsters. The second fact that emerged -not altogether a surprise-was that small local recurrences treated with subsequent surgery did not seem to prejudice the ultimate result. I was warmly surprised at the number of younger people, either with or without local recurrences, who were alive and well at the 10-year milestone, despite having had no radiotherapy or chemotherapy. Do we sometimes err on the side of overtreatment, or is that the rationalisation of an old surgeon who is a little out of harmony with the modern young oncologist ? ROBIN BURKITT Farnham Common, Bucks
Premenstrual tension syndrome
SIR,-Your leading article on premenstrual tension syndrome (27 January, p 212) clearly documented the conflicting data relating to the aetiology of this common problem with reports of both an increase and a decrease in plasma progesterone, oestradiol, prolactin, and aldosterone levels. However, you failed to mention the obvious conclusion that whatever the details of the hormone imbalance, and no doubt they vary from case to case, the ultimate cause of premenstrual tension must be a change in plasma hormone values from the time of ovulation. The symptoms for this common condition can usually be relieved by ablating these hormone changes. This can be done simply by the combined oestrogen-progestogen birth control pill given continuously, thus avoiding ovulation and menstruation; a more successful method is the insertion of a 75 mg or 100 mg oestradiol implant into the fat of the abdominal wall. With this method endometrial hyperplasia is avoided by the administration of 5 mg norethisterone for five days each month. It is our experience that many of these implant patients who have their symp-
10 FEBRUARY 1979
toms completely abolished by this technique will complain of their own characteristic premenstrual tension symptoms during one or two of the five days of the progestogen, suggesting the likely cause of the syndrome in many of these patients. JOHN STUDD King's College Hospital, London SE5
SIR,-One of the now well documented and accepted, yet still sadly neglected, causes of tension and depression in women is included under the blanket heading of the premenstrual syndrome. The possible aetiology is discussed in your excellent leading article (27 January, p 212). At one time I was using intramuscular progesterone with success in the relief of these symptoms, although the method did not appear to be generally accepted.' It seemed that here was a logical form of treatment for a universal problem which had a more reliable physiological explanation than was generally considered at the time. If the endocrine basis of this very common problem can be shown to be the cause, then the prescription of any form of psychotropic medication is inappropriate. DAVID WAXMAN Department of Psychological Medicine, Central Hospital, Middlesex, London NW10 I
Waxman, D, British
Medical_Journal, 1968, 4, 188.
SIR, I am surprised that in your otherwise excellent leading article on premenstrual tension (27 January, p 212) you repeat the myth that progesterone therapy is "expensive." You cite a reference from that well-known journal Current Medical Research and Opinion' in support of this statement. I hasten to say that I have no criticism of this particular paper, except that it repeats this strange claim (seen in the advertising literature of a rival product2) that progesterone is "expensive." I have no axe to grind for either therapy, but I do think we should get our facts straight. I have recently put a number of women on progesterone suppositories-so to speakand I took the precaution of finding out the cost first, using my trusty MIMS. The truth is that one cycle's treatment with progesterone (Cyclogest suppositories) normally costs £4 20. One cycle's treatment with the rival synthetic progestational agent which you mention in your leader (dydrogesteroneDuphaston) costs £6 70. Which is more expensive ? DAVID DELVIN Chislehurst, Kent
2
Kerr, G D, Current Medical Research and Opinion, 1977, 4, suppl 4, p 29. Duphar Laboratories, Duphaston in Premenstrual Syndrome, p 12.
Tetracycline preparations for children
SIR,-I must take issue with Dr P G Brock and Maryanne Roach (13 January, p 126) over the use of tetracyclines in the management of infections in children and in pregnant women. Tetracyclines are valuable drugs, but are never the sole effective agent for any given infection. Erythromycin is effective against the vast majority of strains of Mycobacteria pneumoniae,l 2 and, unlike the tetracyclines,
409
10 FEBRUARY 1979
increased maternal as well as neonatal mortality operation is best attempted under general and morbidity. anaesthesia, administered by an anaesthetist R R MACDONALD experienced in obstetric anaesthesia. J S SCOTT The Maternity Hospital, G A CRAIG Leeds Bradford, W Yorks
I
Lancer, 1978, 2, 1349.
SIR,-Neonatal morbidity after the use of Kielland's forceps is an important topic, but I wonder if Drs M L Chiswick and D K James (6 January, p 7) are justified in inferring that the increased morbidity they observed can be attributed to the use of the forceps themselves in as many of their cases as they claim. The only circumstance in which there is an indication to use Kielland's forceps is that in which there is malposition of the fetal head in the second stage of labour, when for fetal or maternal reasons it is deemed desirable to expedite the delivery, and then only if there is no significant absolute cephalopelvic disproportion. In most cases where these forceps are used (66 cases out of 81 in the series reported) there is sufficient relative cephalopelvic disproportion, caused by deflexion of the fetal head (caused in its turn by the malposition), to prolong the second stage of labour; and this brings with it an increased risk of fetal hypoxia. It is also possible that the malposition of the fetal head alone could cause hypoxia, and there is some evidence for this in the paper (15 of the 8i fetuses in the forceps group were hypoxic without there being any delay in the second stage). Could it not be these factors which were responsible for the observed fetal morbidity, rather than the use of the forceps per se? If this is the case one should use Kielland's forceps earlier in the second stage, before the adverse effects on the fetus caused by the malposition of its head have been felt, rather than abandon their use altogether. These remarks do not apply, of course, to the neonatal morbidity caused by birth trauma; but its incidence in the series reported would have been markedly reduced if excessive force had not been used. As an alternative to caesarean section, consideration might have been given in the discussion to the techniques of manual rotation or delivery by the Ventouse apparatus. R M BALLARD London SEll
SIR,-The results reported by Drs Malcolm L Chiswick and David K James (6 January, p 7) on the use of these forceps to overcome midcavity obstruction or delay are interesting and disappointing. They should not, however, be attributed to the type of forceps used. The mid-cavity forceps operation, especially if rotation of the head is required, is a major procedure. Accurate diagnosis is essential, as are skill and gentleness, and in addition experience and courage-the two latter qualities in order to recognise when the operation should be abandoned and caesarean section performed. Great strength is not necessary. In my opinion these patients should not be entrusted, without supervision, to anyone below the rank of senior registrar. I have on occasions thought that attempting the operation under pudendal block seemed to render it more difficult. As a result of this experience I am now of the opinion that the
Trials in breast cancer SIR,-On 23 November 1978 the Cancer Research Campaign sponsored a meeting to review the progress of the United Kingdom multicentre collaborative trial of adjuvant hormono-chemotherapy in poor-risk patients with ea:ly carcinoma of the breast. This meeting provided an opportunity for the steering committee of that study to meet with the organisers of the King's College Hospital breast cancer trials. Both groups agreed on the following points: (1) It is justifiable to conduct adjuvant therapy studies in poor-risk early breast cancer patients while still retaining a control arm. (2) There is sufficient evidence both on theoretical and experimental groundsl-3 and in work done in advanced disease4 5 to study the potential advantages of combining chemotherapy and hormone therapy over either modality alone as adjuvant treatment. (3) Both groups have launched trials of similar design that will study different aspects of this problem. Their cumulative results will be of great value but will depend on recruiting sufficient numbers of patients to each trial. (4) It is regrettable that, despite the overwhelming evidence supporting the need for such studies, the majority of poor-risk early breast cancer patients in this country are not entered into any trial where the value of adjuvant therapy can be assessed. We therefore ask that clinicians in charge of eligible patients will give serious thought to collaborating with one or other of these studies. (5) Centres which enter a substantial number of patients will be provided with secretarial or other assistance in order to facilitate the conduct of the trial. Further information can be obtained from either of us regarding both trials, so that clinicians can choose which they would feel most appropriate for them to join. Royal Free Hospital, London NW3
mastectomy specimens may be as high as 50%.1 The purpose of giving radiation therapy following tylectomy is to sterilise such microscopic disease. Five thousand rads delivered to the entire breast with an additional 1500 rads to the area of the primary tumour will result in a local control rate of about 90%.2 3 4 The radiation doses delivered, following tylectomy, in those studies quoted by Dr Tagart were considerably lower than this and resulted therefore in a local recurrence rate which was as high as 20-25%. It is also known that patients with a clinically negative axilla have about a 30% chance of having microscopically involved nodes on pathological examination. As may be expected, six of the 27 patients (22%) who had had no axillary dissection had a recurrence in the axilla. If these clinically negative axillae had received adequate irradiation (minimum tumour dose of 5000 rads in five weeks) the recurrence rate would have been less than 5* 4 7 I would have hoped that Dr Tagart, having observed the high incidence of local recurrences in his series, would have come to the natural conclusion of adding postoperative irradiation in adequate doses following partial mastectomy. Instead, unfortunately, he terminated his worthwhile trial in favour of total mastectomy. We have yet to convince our colleagues, the surgeons, that surgery is necessary for the removal of gross malignant disease and that irradiation is necessary for control of microscopic deposits. N A GHOSSEIN Department of Radiology, Albert Einstein College of Medicine, Yeshiva University, New York
'Rosen, P P, et al, Cancer, 1975, 35, 739. 2 Alpert, S, et al, Cancer, 1978, 42, 2054. Bataini, J P, et al, Cancer, 1978, 42, 2059. 4Calle, R, et al, Cancer, 1978, 42, 2045. Atkins, H, et al, British Medical J'ournal, 1972, 2, 423. Mustakallio, S, Clinical Radiology, 1972, 23, 110. Ghossein, N A, et al, Radiology, 1976, 121, 455. Cimetidine and duodenal ulcer
SIR,-Further to Mr J Alexander Williams's comments (20 January, p 169) on the lack of evidence for rebound perforation following cimetidine withdrawal, I report two cases. F SENANAYAKE A man of 65 with no previous gastric history had a successful repair of a thoracic aneurysm complicated by severe haematemesis. Gastroscopy showed M BAUM acute stress ulceration. Bleeding continued despite
King's College Hospital Medical School,
London SE5
Lippman, M E, et al, New EnglandJ7ournal of Medicine, 1978, 298, 1223. Meakin, J W, et al, in Adjuvant Therapy of Cancer, ed S E Salmon and S E Jones. Amsterdam, Elsevier, 1977. 3 Braunberg, H, et al, Lancet, 1973, 1, 163. 4Tormey, D C, et al, Proceedings of the American Association for Cancer Research, 1978, 19, 34. Cavalli, F, in Proceedings of 10th International Congress on Chemnotherapy, 1977, p 615. New York, Plenum 2
Press, 1977.
Partial mastectomy for breast cancer
SIR,-I read with interest the report of Mr R E B Tagart (4 November, p 1268) on partial mastectomy for operable breast cancer. It is no surprise that 37% of Nir Tagart's patients who underwent partial mastectomy, without postoperative radiotherapy, had a recurrence in the breast within three years. After all, the incidence of multifocal microscopic cancer in
medical treatment and Polya partial gastrectomy was performed. Histology later confirmed the diagnosis. Four days postoperatively, cimetidine in full dosage was restarted when fresh blood was aspirated from the stomach, being reduced to 400 mg at night at three weeks and stopped at 11 weeks. Three weeks later he was readmitted with perforation of a stomal ulcer, which was successfully oversewn. Serum gastrin concentration was normal and he remains well one year later. A man of 19 with a six-month history of indigestion had a perforated duodenal ulcer. This was treated by oversewing, followed by cimetidine in full dosage. He stopped cimetidine at four weeks and six weeks later presented with reperforation of the same ulcer. This was treated by vagotomy and pyloroplasty and 11 months later he remains well, with normal serum gastrin concentration.
Only 3-5% of Polya partial gastrectomies are followed by stomal ulceration. A study of 360 cases did not include any developing within six months, and only one case of perforation was recorded.' Initially our first patient had
410
BRITISH MEDICAL JOURNAL
had no hyperacidic peptic ulceration. As regards the second patient, simply oversewing perforations leads to further surgery in 20% of cases in five years. This is extremely rarely required within two months.2 The occurrence and timing of recurrence of ulceration in both cases strongly suggests that cimetidine treatment or its withdrawal was implicated. When H2-blockade of acid-secreting cells is withdrawn, it is more likely to lead to excessive sensitivity to normal stimuli than to hyperplasia. A S BULMAN
All worked themselves up into a frenzy because their babies had not had their "cholesterol" (sic), although all five babies are making excellent progress. I am, of course, familiar with the multifarious properties of this substance but colostrum deficiency would appear to be a new iatrogenic disease of the maternal mind, springing from the same sources which are responsible for so much unnecessary anxiety today. HERBERT BARRIE
Kingston Hospital,
London W6
Charing Cross Hospital (Fulham),
Kingston-upon-Thames, Surrey lWychulis, A R, et al, in Surgery, Gynaecology and Obstetrics, 1966, 122, 89. 2Illingworth, C F S, et al, British Medical Journal, 1946, 1, 787.
SIR,-The discussion about cimetidine and duodenal ulcer by Dr J H Baron and others (20 January, p 169) has important implications for general practitioners as well as hospitalbased specialists. If, as is suggested, progressively more patients are being treated medically then the disease becomes one which should be treated in the primary care situation. There seems to be agreement that rapid relapse after one or more full courses of treatment warrants referral for surgery even if many patients would prefer the unknown risk of long-term drug therapy to the known risk of operation. What is not clear, in general practice, is which patients should be started on treatment. I, and some of my colleagues, felt initially that the criteria should be relatively rigid. All patients should have had a duodenal ulcer demonstrated radiologically or endoscopically or should have suffered a catastrophe such as haemorrhage or perforation in the past. This may lead to numbers of patients with classical symptoms being referred to outpatients for expensive, time-consuming, and unpleasant diagnostic procedures. If, as Mr J AlexanderWilliams states, patients are being referred to him with a diagnosis of duodenal ulcer but with symptoms uncontrolled by cimetidine, and that this almost certainly indicates that the pain is due to something else, then surely we have in our hands a diagnostic weapon which can relieve hospitals and patients of a tiresome burden. It could be argued that at least in the younger patient with upper abdominal pain a therapeutic trial of cimetidine for one week should be carried out as a first step in investigation. The same argument would hold for differential diagnosis of retrosternal pain when reflux was a consideration. My experience so far has suggested that the answers given by such a policy are helpful. MICHAEL DRURY Department of Medicine, University of Birmingham
Colostrum deficiency SIR,-I wonder if anybody has ever seen a baby die for want of colostrum. Only this week I saw five very agitated mothers who evidently thought that theirs might. One had respiratory distress and another a large cleft palate, and a third persistently vomited all his "unique maternal gift." The mother of the fourth had a complicated delivery and was herself unwell, while the fifth had inverted nipples and was unable to produce any colostrum or milk.
Age and death in breast carcinoma
SIR,-I was interested to read your leading article (27 January, p 211) on the above subject. During the last year before my retirement some 18 months ago, I decided to review all my cases of carcinoma of the breast, to see whether anything of interest might turn up. Despite the small number-about 400-this was a fairly mammoth task, and when it was finished I found that I had really nothing to offer, so did not publish. The survey, however, provided me with two surprises. The first surprise was that, contrary to what one had always thought, age seemed to have little or no bearing on prognosis and old people seemed to fare no better-or worsethan youngsters. The second fact that emerged -not altogether a surprise-was that small local recurrences treated with subsequent surgery did not seem to prejudice the ultimate result. I was warmly surprised at the number of younger people, either with or without local recurrences, who were alive and well at the 10-year milestone, despite having had no radiotherapy or chemotherapy. Do we sometimes err on the side of overtreatment, or is that the rationalisation of an old surgeon who is a little out of harmony with the modern young oncologist ? ROBIN BURKITT Farnham Common, Bucks
Premenstrual tension syndrome
SIR,-Your leading article on premenstrual tension syndrome (27 January, p 212) clearly documented the conflicting data relating to the aetiology of this common problem with reports of both an increase and a decrease in plasma progesterone, oestradiol, prolactin, and aldosterone levels. However, you failed to mention the obvious conclusion that whatever the details of the hormone imbalance, and no doubt they vary from case to case, the ultimate cause of premenstrual tension must be a change in plasma hormone values from the time of ovulation. The symptoms for this common condition can usually be relieved by ablating these hormone changes. This can be done simply by the combined oestrogen-progestogen birth control pill given continuously, thus avoiding ovulation and menstruation; a more successful method is the insertion of a 75 mg or 100 mg oestradiol implant into the fat of the abdominal wall. With this method endometrial hyperplasia is avoided by the administration of 5 mg norethisterone for five days each month. It is our experience that many of these implant patients who have their symp-
10 FEBRUARY 1979
toms completely abolished by this technique will complain of their own characteristic premenstrual tension symptoms during one or two of the five days of the progestogen, suggesting the likely cause of the syndrome in many of these patients. JOHN STUDD King's College Hospital, London SE5
SIR,-One of the now well documented and accepted, yet still sadly neglected, causes of tension and depression in women is included under the blanket heading of the premenstrual syndrome. The possible aetiology is discussed in your excellent leading article (27 January, p 212). At one time I was using intramuscular progesterone with success in the relief of these symptoms, although the method did not appear to be generally accepted.' It seemed that here was a logical form of treatment for a universal problem which had a more reliable physiological explanation than was generally considered at the time. If the endocrine basis of this very common problem can be shown to be the cause, then the prescription of any form of psychotropic medication is inappropriate. DAVID WAXMAN Department of Psychological Medicine, Central Hospital, Middlesex, London NW10 I
Waxman, D, British
Medical_Journal, 1968, 4, 188.
SIR, I am surprised that in your otherwise excellent leading article on premenstrual tension (27 January, p 212) you repeat the myth that progesterone therapy is "expensive." You cite a reference from that well-known journal Current Medical Research and Opinion' in support of this statement. I hasten to say that I have no criticism of this particular paper, except that it repeats this strange claim (seen in the advertising literature of a rival product2) that progesterone is "expensive." I have no axe to grind for either therapy, but I do think we should get our facts straight. I have recently put a number of women on progesterone suppositories-so to speakand I took the precaution of finding out the cost first, using my trusty MIMS. The truth is that one cycle's treatment with progesterone (Cyclogest suppositories) normally costs £4 20. One cycle's treatment with the rival synthetic progestational agent which you mention in your leader (dydrogesteroneDuphaston) costs £6 70. Which is more expensive ? DAVID DELVIN Chislehurst, Kent
2
Kerr, G D, Current Medical Research and Opinion, 1977, 4, suppl 4, p 29. Duphar Laboratories, Duphaston in Premenstrual Syndrome, p 12.
Tetracycline preparations for children
SIR,-I must take issue with Dr P G Brock and Maryanne Roach (13 January, p 126) over the use of tetracyclines in the management of infections in children and in pregnant women. Tetracyclines are valuable drugs, but are never the sole effective agent for any given infection. Erythromycin is effective against the vast majority of strains of Mycobacteria pneumoniae,l 2 and, unlike the tetracyclines,
