sider the importance of environmen¬ tal factors in familial melanoma etiol¬ ogy. Anderson et al (200:741, 1967) reviewed the family histories of 1,000 melanoma patients and found 28 (3%) kindreds with two or more members having melanomas. Twenty-two cases were able to be investigated in depth and it was found that in these kin¬ dred, melanomas occurred at an aver¬ age age of nearly ten years younger, and 27% had multiple primary mela¬ nomas. From analysis of the pedi¬ grees, it was felt that the incidence was far too great to be explained on the basis of chance, yet it would not fit the pattern of a single dominant, recessive, or sex-linked gene but more likely a polygenetic model working in association with environmental fac¬ tors. The studies of Wallace et al, from the Queensland Melanoma Proj¬ ect, reviewed 1,676 cases of melanoma and found 50 kindreds, of which 42 were studied with similar conclusions favoring a polygenic inheritance pat¬ tern in consort with environmental factors. While some of the familial mela¬ nomas may be on a hereditary basis, the recently reported non-blood-re¬ lated pairs also indicate that environ¬ mental factors may be playing some role; this should stimulate further in¬ vestigation. It is advisable to main¬ tain the term "familial melanomas" rather than "hereditary melanomas" until these issues are clarified. Charles R. Smart, MD Salt Lake
City
Birdsall N. Carle, MD Twin Falls, Idaho
Herniation of Rectus Muscle Incision To the Editor.\p=m-\TheMcVay hernia
Through Relaxing
re-
pair1 employing the ileopectineal (Cooper) ligament is frequently used to repair inguinal and femoral hernias. McVay2 stresses the need for a simple linear incision in the anterior rectus sheath to
prevent
suture line
tension, but admits that some surgeons might be hesitant to make a relaxing incision for fear of creating a
defect that could later allow muscle herniation. The relaxing incision must be made as medially as possible, where the external oblique aponeurosis fuses with the rectus sheath.
Report of a Case.\p=m-\A55-year-old man operated on for repair of a large indirect inguinal hernia. A McVay repair was performed in which the aponeurosis of the was
transversalis muscle Cooper ligament, and
sutured to the 5- to 7-cm relaxing
was a
incision was made in the anterior rectus sheath. The patient's recovery was uneventful. During his routine postoperative examination six weeks later, he was noted to have a tender bulge above the previous re¬ pair. At reexploration, this was found to be a herniation of rectus muscle through the relaxing incision. The 8x6-cm defect was repaired by imbricating the rectus sheath, and the patient was discharged three days later. He has remained well.
Comment—Herniation of rectus muscle through a relaxing incision in the anterior rectus heath is rare. In July 1974, Chester B. McVay, MD, in a personal letter stated that he had never encountered this complication in his series of more than 2,000 hernia
repairs.
It is doubtful that a previous defect present along the semilunar line in my patient. Herniation most likely resulted because the relaxing incision was placed too far laterally. was
by Dr. Cohen, along with nasal con¬ gestion, which occurs after cocaine use is stopped.
I found that medical attention fre¬ is sought for the congesti.on, and it is only after a careful history has been taken that information be¬ comes available about the person's use of cocaine. In such a situation, use of decongestants is not helpful, be¬ cause there is only further rebound after they are no longer taken. The best way to treat this problem is to convince the person to keep away from cocaine, and not to use any drug that will act as a decongestant until the congestion clears up by itself, which usually takes about five to ten days. Physicians in general should be alerted to this problem since people they would not suspect as being drug users are frequently in¬ volved in the use of cocaine.
quently
Sid Schnoll, MD
Edward H. Laughlin, MD School of Primary Medical Care The University of Alabama in Huntsville
1.
McVay CB,
rent methods of
Anson BJ: A fundamental
error
in
cur-
inguinal herniorrhaphy. Surg Gynecol
Obstet 74:746-750, 1942. 2. McVay CB: The anatomy of the relaxing incision in inguinal hernioplasty. Q Bull Northwestern Univ Med School 36:1-8, 1962.
Cocaine To the Editor.\p=m-\The article by Dr. Sidney Cohen (231:74, 1975) on cocaine certainly is important. There has been a great upsurge in the use of this drug. However, Dr. Cohen fails to talk about one of the important patterns of abuse most likely to be seen by the physician. Cocaine is being used by people who often abuse other drugs, but is, in fact, used infrequently by this group because of its expense. On the other hand, there has been a large increase in the use of cocaine by young, middle-class professionals. This latter group is made up of fairly affluent people, usually in their early to mid-30s; previous experience with drugs has been limited to marihuana and the occasional use of an
hallucinogen.
Cocaine has recently become a very fashionable drug with these people. Large quantities are usually found at
parties, and one way of displaying one's wealth is by how much cocaine the host can put on the table for the use of the party-goers. Because they are not the typical drug abuser, such individuals get into problems with an acute psychotic reaction, as described
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/04/2015
University of Pennsylvania Medical School
Philadelphia
Polycythemia Vera Among the Elderly To the Editor.\p=m-\Polycythemia vera has been reported to occur among octogenarians in Modan's review of the literature.1 Recently, Gunale and Zelkowitz2 reported a case in a 96-year\x=req-\ old patient. The Third National Cancer Survey3 has now released its
findings concerning polycythemia
in older individuals. The Third National Cancer Survey was a project of the National Cancer Institute, which collected data on the incidence of cancer among residents of seven metropolitan areas and two states during the three years 1969 through 1971. This population comprises more than 10% of the population of the United States. Polycythemia rubra vera was included as a reportable neoplasm for this survey since it may represent an early malignancy or a precursor of malignancy. During the time of the survey, two cases of polycythemia vera among nonagenarians were diagnosed; both individuals were 97 years old. Seventeen cases were diagnosed among persons aged 85 to 89. These 19 cases represent an average annual inci¬ dence rate of 4.3/100,000 population aged 85 and older, or about 65 cases in persons of this age group in the United States each year. In the age group 80 to 84, thirty-five cases of vera
polycythemia
vera
were
diagnosed
during
the three-year period, giving average annual incidence rate of 5.2/100,000 for this age group or a na¬ tional rate of about 120 cases a year. This is roughly equivalent to the inci¬ dence of Hodgkin disease in this age group, and about one-third that of an
granulocytic leukemia. It therefore appears that, while rare, polycythemia vera does occur among the elderly, with an annual rate in the United States of about 185 cases in persons 80 years old or older. acute
Susan S. Devesa, MHS John L. Young, Jr., DrPH Roger R. Williams, MD National Cancer Institute Bethesda, Md 1. Modan B: Polycythemia: A review of epidemiological and clinical aspects. J Chronic Dis 18:605-645, 1965. 2. Gunale SR, Zelkowitz L: Polycythemia vera in a
nonagenarian. JAMA 228:1148, 1974. 3. Cutler SJ, Devesa SS, Scotto J, et al: The Third National Cancer Survey: An overview of available information. J Natl Cancer Inst 53:1565-1575, 1974.
Cancer\p=m-\Attackor Retreat? To the Editor.\p=m-\Thecommentary entitled "Cancer\p=m-\Attackor Retreat?" (230:555, 1974) by Pekar draws broad conclusions about the National Cancer Program (NCP) that are illfounded and unsubstantiated and, therefore, misleading to those not
familiar with the substance of the program and the development of the plan. The purpose of this letter is to place Dr. Pekar's article in the proper perspective by calling attention to the principal shortcomings of his arguments. The National Cancer Institute (NCI) will gladly provide accurate information concerning the NCP and the NCP Plan to interested readupon request. Perhaps the greatest flaw in Dr.
ers
Pekar's article is that what appears key reference, An Analysis of Mid-Range Resources Requirements for a National Cancer Program, dated August 1972. It was only a draft and was superseded by the final and only official published version, dated March 1973, which supports the NCP Strategic Plan. Because of the revisions made to the draft version before final publication, many of which affected key portions of his ar¬ guments, Dr. Pekar uses erroneous assumptions and data to support his conclusions. It is unfortunate that he used a substantial amount of space in a respected publication and what must have been a considerable amount of his own time and effort in developing an argument based on an invalid reference. He undoubtedly would have avoided such an embarto be his
rassment if he had
only researched his paper properly by checking with the NCI to be certain he was analyz¬ ing the proper document. It is also important to note that Dr. Pekar draws broad, sweeping conclu¬ sions about the National Cancer Pro¬ gram in total from a review and cri¬ tique of a single report concerned only with a preliminary analysis of pro¬ gram resources. This was but one of several reports addressing various aspects of the National Cancer Pro¬ gram Plan. Dr. Pekar demonstrates throughout the body of his article and through omissions in the reference list that he did not read several key documents directly relating to his topic, most importantly the NCP Strategic Plan itself which deals with the scientific content of the program. He confuses "program" with "plan" and "project area" with "project," and treats planning estimates, which are
always subject to uncertainty,
as
if they represent accurate statements of fact. By reading the NCP Strategic Plan and official versions of the perti¬ nent supporting documents, Dr. Pe¬ kar could have avoided such confusion and would have been better able to place resources projections in proper perspective in relation to the total program and plan. It is doubtful that he would have then drawn such mac¬ roscopic conclusions about the pro¬ gram from such relatively micro¬
Needless to say, Mr. McShulskis and Mr. Brown have stated that a new revision has been compiled. I would certainly hope that this is the case because of all the inconsistencies that appeared in the authorized document. It is important to note that it was also claimed my analysis was inac¬ curate and erroneous. If this be the case, then I call upon the NCI to address the questions raised in my article. Furthermore, the NCI should also open the National Cancer Plan to public scrutiny by lifting the NCP from its proprietary and confidential status. In addition, my claim that the NCP will have a most devastating ef¬ fect on noncancer biomédical research is still to be answered. Like all re¬ search scientists, I am most anxious that these issues be resolved and re¬ search continued. I do not want prom¬ ising noncancer biomédical research retarded by political favoritism of one branch of research at the expense of another. It is unfortunate that such a weak analysis was published and used in preparing the NCP and that the NCI didn't consider the implication of such an analysis, especially if poorly done. Responsible people take reports such as this as an approximation of reality and assume that responsible individ¬ uals would not prepare such a report if it was not so. Peter P. Pekar, Jr., PhD Estech, Inc.
scopic arguments.
Chicago
John E. McShulskis Michael G. Brown
Department of Health, Education, and Welfare
Bethesda, Md
In Reply.\p=m-\Myfirst response is to mention that in the reference, An Analysis of Mid-Range Resources Requirements for a National Cancer Program, dated August 1972, it is
stated: "This report provides a summary of the as-
sumptions, rationale, references, and calculations used in preparing the National Cancer Program five-year (FY 1974-78) resource projects included in the National Cancer Program Strategic Plan."
Since,
as
it is mentioned
here,
the
report was the foundation of the Na-
tional Cancer Plan, I submit that this is not an invalid reference. I assume the NCI didn't consider it as such, since Mr. McShulskis signed it and the Associate Director of Program Planning approved it. Also, this publication was distributed to the US Department of Health, Education and Welfare, the NIH, and the NCI.
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/04/2015
Dr. Ratzkowski, Not Ratkowski. a In the BRIEF REPORT, "Day Care for Cancer Patients," published in the Oct 21 issue (230:430-431, 1974), the surname of Else Ratzkowski was misspelled Ratkowski in the byline, affiliation footnote, reprint address, and in the Table of Contents. Erroneous MEDICAL
Instructions \p=m-\In the
EMERGENCY
MANAGEMENT
article titled "Hyperthyroid Crisis," published in the Oct 28 issue (230:592-593, 1974), the first entry under "C. Adrenergic blocking agents" (p593) should read as follows: "1. Propranolol hydrochloride, 20 to 40 mg every six hours orally, or 1 to 2 mg intravenously over five to ten minutes every four to six hours. ..." As published, the word "every" erroneously appeared where the word "over" was intended.
City
Birdsall N. Carle, MD Twin Falls, Idaho
Herniation of Rectus Muscle Incision To the Editor.\p=m-\TheMcVay hernia
Through Relaxing
re-
pair1 employing the ileopectineal (Cooper) ligament is frequently used to repair inguinal and femoral hernias. McVay2 stresses the need for a simple linear incision in the anterior rectus sheath to
prevent
suture line
tension, but admits that some surgeons might be hesitant to make a relaxing incision for fear of creating a
defect that could later allow muscle herniation. The relaxing incision must be made as medially as possible, where the external oblique aponeurosis fuses with the rectus sheath.
Report of a Case.\p=m-\A55-year-old man operated on for repair of a large indirect inguinal hernia. A McVay repair was performed in which the aponeurosis of the was
transversalis muscle Cooper ligament, and
sutured to the 5- to 7-cm relaxing
was a
incision was made in the anterior rectus sheath. The patient's recovery was uneventful. During his routine postoperative examination six weeks later, he was noted to have a tender bulge above the previous re¬ pair. At reexploration, this was found to be a herniation of rectus muscle through the relaxing incision. The 8x6-cm defect was repaired by imbricating the rectus sheath, and the patient was discharged three days later. He has remained well.
Comment—Herniation of rectus muscle through a relaxing incision in the anterior rectus heath is rare. In July 1974, Chester B. McVay, MD, in a personal letter stated that he had never encountered this complication in his series of more than 2,000 hernia
repairs.
It is doubtful that a previous defect present along the semilunar line in my patient. Herniation most likely resulted because the relaxing incision was placed too far laterally. was
by Dr. Cohen, along with nasal con¬ gestion, which occurs after cocaine use is stopped.
I found that medical attention fre¬ is sought for the congesti.on, and it is only after a careful history has been taken that information be¬ comes available about the person's use of cocaine. In such a situation, use of decongestants is not helpful, be¬ cause there is only further rebound after they are no longer taken. The best way to treat this problem is to convince the person to keep away from cocaine, and not to use any drug that will act as a decongestant until the congestion clears up by itself, which usually takes about five to ten days. Physicians in general should be alerted to this problem since people they would not suspect as being drug users are frequently in¬ volved in the use of cocaine.
quently
Sid Schnoll, MD
Edward H. Laughlin, MD School of Primary Medical Care The University of Alabama in Huntsville
1.
McVay CB,
rent methods of
Anson BJ: A fundamental
error
in
cur-
inguinal herniorrhaphy. Surg Gynecol
Obstet 74:746-750, 1942. 2. McVay CB: The anatomy of the relaxing incision in inguinal hernioplasty. Q Bull Northwestern Univ Med School 36:1-8, 1962.
Cocaine To the Editor.\p=m-\The article by Dr. Sidney Cohen (231:74, 1975) on cocaine certainly is important. There has been a great upsurge in the use of this drug. However, Dr. Cohen fails to talk about one of the important patterns of abuse most likely to be seen by the physician. Cocaine is being used by people who often abuse other drugs, but is, in fact, used infrequently by this group because of its expense. On the other hand, there has been a large increase in the use of cocaine by young, middle-class professionals. This latter group is made up of fairly affluent people, usually in their early to mid-30s; previous experience with drugs has been limited to marihuana and the occasional use of an
hallucinogen.
Cocaine has recently become a very fashionable drug with these people. Large quantities are usually found at
parties, and one way of displaying one's wealth is by how much cocaine the host can put on the table for the use of the party-goers. Because they are not the typical drug abuser, such individuals get into problems with an acute psychotic reaction, as described
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/04/2015
University of Pennsylvania Medical School
Philadelphia
Polycythemia Vera Among the Elderly To the Editor.\p=m-\Polycythemia vera has been reported to occur among octogenarians in Modan's review of the literature.1 Recently, Gunale and Zelkowitz2 reported a case in a 96-year\x=req-\ old patient. The Third National Cancer Survey3 has now released its
findings concerning polycythemia
in older individuals. The Third National Cancer Survey was a project of the National Cancer Institute, which collected data on the incidence of cancer among residents of seven metropolitan areas and two states during the three years 1969 through 1971. This population comprises more than 10% of the population of the United States. Polycythemia rubra vera was included as a reportable neoplasm for this survey since it may represent an early malignancy or a precursor of malignancy. During the time of the survey, two cases of polycythemia vera among nonagenarians were diagnosed; both individuals were 97 years old. Seventeen cases were diagnosed among persons aged 85 to 89. These 19 cases represent an average annual inci¬ dence rate of 4.3/100,000 population aged 85 and older, or about 65 cases in persons of this age group in the United States each year. In the age group 80 to 84, thirty-five cases of vera
polycythemia
vera
were
diagnosed
during
the three-year period, giving average annual incidence rate of 5.2/100,000 for this age group or a na¬ tional rate of about 120 cases a year. This is roughly equivalent to the inci¬ dence of Hodgkin disease in this age group, and about one-third that of an
granulocytic leukemia. It therefore appears that, while rare, polycythemia vera does occur among the elderly, with an annual rate in the United States of about 185 cases in persons 80 years old or older. acute
Susan S. Devesa, MHS John L. Young, Jr., DrPH Roger R. Williams, MD National Cancer Institute Bethesda, Md 1. Modan B: Polycythemia: A review of epidemiological and clinical aspects. J Chronic Dis 18:605-645, 1965. 2. Gunale SR, Zelkowitz L: Polycythemia vera in a
nonagenarian. JAMA 228:1148, 1974. 3. Cutler SJ, Devesa SS, Scotto J, et al: The Third National Cancer Survey: An overview of available information. J Natl Cancer Inst 53:1565-1575, 1974.
Cancer\p=m-\Attackor Retreat? To the Editor.\p=m-\Thecommentary entitled "Cancer\p=m-\Attackor Retreat?" (230:555, 1974) by Pekar draws broad conclusions about the National Cancer Program (NCP) that are illfounded and unsubstantiated and, therefore, misleading to those not
familiar with the substance of the program and the development of the plan. The purpose of this letter is to place Dr. Pekar's article in the proper perspective by calling attention to the principal shortcomings of his arguments. The National Cancer Institute (NCI) will gladly provide accurate information concerning the NCP and the NCP Plan to interested readupon request. Perhaps the greatest flaw in Dr.
ers
Pekar's article is that what appears key reference, An Analysis of Mid-Range Resources Requirements for a National Cancer Program, dated August 1972. It was only a draft and was superseded by the final and only official published version, dated March 1973, which supports the NCP Strategic Plan. Because of the revisions made to the draft version before final publication, many of which affected key portions of his ar¬ guments, Dr. Pekar uses erroneous assumptions and data to support his conclusions. It is unfortunate that he used a substantial amount of space in a respected publication and what must have been a considerable amount of his own time and effort in developing an argument based on an invalid reference. He undoubtedly would have avoided such an embarto be his
rassment if he had
only researched his paper properly by checking with the NCI to be certain he was analyz¬ ing the proper document. It is also important to note that Dr. Pekar draws broad, sweeping conclu¬ sions about the National Cancer Pro¬ gram in total from a review and cri¬ tique of a single report concerned only with a preliminary analysis of pro¬ gram resources. This was but one of several reports addressing various aspects of the National Cancer Pro¬ gram Plan. Dr. Pekar demonstrates throughout the body of his article and through omissions in the reference list that he did not read several key documents directly relating to his topic, most importantly the NCP Strategic Plan itself which deals with the scientific content of the program. He confuses "program" with "plan" and "project area" with "project," and treats planning estimates, which are
always subject to uncertainty,
as
if they represent accurate statements of fact. By reading the NCP Strategic Plan and official versions of the perti¬ nent supporting documents, Dr. Pe¬ kar could have avoided such confusion and would have been better able to place resources projections in proper perspective in relation to the total program and plan. It is doubtful that he would have then drawn such mac¬ roscopic conclusions about the pro¬ gram from such relatively micro¬
Needless to say, Mr. McShulskis and Mr. Brown have stated that a new revision has been compiled. I would certainly hope that this is the case because of all the inconsistencies that appeared in the authorized document. It is important to note that it was also claimed my analysis was inac¬ curate and erroneous. If this be the case, then I call upon the NCI to address the questions raised in my article. Furthermore, the NCI should also open the National Cancer Plan to public scrutiny by lifting the NCP from its proprietary and confidential status. In addition, my claim that the NCP will have a most devastating ef¬ fect on noncancer biomédical research is still to be answered. Like all re¬ search scientists, I am most anxious that these issues be resolved and re¬ search continued. I do not want prom¬ ising noncancer biomédical research retarded by political favoritism of one branch of research at the expense of another. It is unfortunate that such a weak analysis was published and used in preparing the NCP and that the NCI didn't consider the implication of such an analysis, especially if poorly done. Responsible people take reports such as this as an approximation of reality and assume that responsible individ¬ uals would not prepare such a report if it was not so. Peter P. Pekar, Jr., PhD Estech, Inc.
scopic arguments.
Chicago
John E. McShulskis Michael G. Brown
Department of Health, Education, and Welfare
Bethesda, Md
In Reply.\p=m-\Myfirst response is to mention that in the reference, An Analysis of Mid-Range Resources Requirements for a National Cancer Program, dated August 1972, it is
stated: "This report provides a summary of the as-
sumptions, rationale, references, and calculations used in preparing the National Cancer Program five-year (FY 1974-78) resource projects included in the National Cancer Program Strategic Plan."
Since,
as
it is mentioned
here,
the
report was the foundation of the Na-
tional Cancer Plan, I submit that this is not an invalid reference. I assume the NCI didn't consider it as such, since Mr. McShulskis signed it and the Associate Director of Program Planning approved it. Also, this publication was distributed to the US Department of Health, Education and Welfare, the NIH, and the NCI.
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/04/2015
Dr. Ratzkowski, Not Ratkowski. a In the BRIEF REPORT, "Day Care for Cancer Patients," published in the Oct 21 issue (230:430-431, 1974), the surname of Else Ratzkowski was misspelled Ratkowski in the byline, affiliation footnote, reprint address, and in the Table of Contents. Erroneous MEDICAL
Instructions \p=m-\In the
EMERGENCY
MANAGEMENT
article titled "Hyperthyroid Crisis," published in the Oct 28 issue (230:592-593, 1974), the first entry under "C. Adrenergic blocking agents" (p593) should read as follows: "1. Propranolol hydrochloride, 20 to 40 mg every six hours orally, or 1 to 2 mg intravenously over five to ten minutes every four to six hours. ..." As published, the word "every" erroneously appeared where the word "over" was intended.
