1260 mind they are more like caricatures of breasts, and if it was myself that was involved I would prefer a neat mastectomy scar any day. 2. Goldsmith and Alday’ have remarked that, whereas the majority of mastectomy patients are mourning the loss of their breast during their first year and often demanding a reconstruction, the majority of women who are capable of adjusting to life’s difficulties have accepted their mastectomy and adjusted accordingly by the end of year one. Those who continue to demand reconstruction have far more deepseated psychological problems than the reconstruction of the breast will solve. 3.I have seen now 3 cases of recurrence on the chest wall, deep to the prosthesis, which was recognised very late because of the overlying prosthesis; and for these patients very little treatment was feasible because the recurrence was so advanced when diagnosed. 4.I have also seen a carcinoma in a woman in her early 20s who had previously had silicone inserts in both breasts. This patient was in a low-risk group for the development of breast cancer in that she had no family history, no previous history of breast trouble, and had had two babies before the age of 20 both of whom had been breast-fed for six months. The silicone mammoplasty had been performed after the birth of the second baby. The carcinoma was diagnosed approximately a year later.
The need is not for greater repair but for greater prevention by earlier diagnosis, less radical surgery, and better education of the public and medical profession. Dr. W. W. Cross Cancer Institute, 11560 University Avenue,
Edmonton, Alberta, Canada T6G 1Z2.
PATRICIA E. BURNS
IRRITABLE-BOWEL SYNDROME
SIR The effects of drugs in the management of the irritableare difficult to assess. We have lately been attempting to determine the efficacy of the various recommended therapeutic agents in our clinic. I.B.S. is diagnosed by exclusion after full investigation. All patients are then treated by a high-fibre diet and a therapeutic agent to relax smooth muscle. Some patients are also given a tranquilliser. During the period of study it has become clear that the dosage of an antispasmodic agent is as important as the choice of the agent. We have been impressed with the efficacy of mebeverine hydrochloride (’Colofac’, Duphar), as judged by the loss of abdominal pain and the change from hard pellets bowel syndrome (I.B.s.)
threads of stool to a more bulky motion. The bulk of the motion is increased still further by the simultaneous administration of the high-fibre diet. The high-fibre diet alone improves the symptoms in about 50% of patients, but with mebeverine as well 85% of patients are relieved of symptoms. During these studies the recommended dosage of mebeverine of 1 x 100 mg tablet four times a day was usually found to be inadequate. The 85% of patients who improve is related to the use of 2 x 100 mg tablets four times daily. Patients who had not improved on the usual recommended dosage immediately improved on the increased dose. Another group of 30 I.B.S. patients referred from general practice were already receiving a dose of 1 x 100 mg tablet of mebeverine three times daily. 28 of these patients improved symptomatically simply by increasing the dose to 2 x 100 mg tablets four times daily. Many patients with I.B.S. have an exaggerated gastrocolic reflex, and maximum effect is achieved when the tablets are taken about 20 minutes before the main
or
meals. Royal Cornwall Hospital (Treliske), Truro, Cornwall TR1
B. J. PROUT
3LJ.
DRUG TREATMENT IN CROHN’S DISEASE
SIR,—Iwas interested to read of Dr Montgomery’s experi(Dec. 6, p. 1149) with antimicrobial agents in Crohn’s
ence
1. Goldsmith, H. S.,
Alday, E. S. Cancer. 1971, 28,
1672.
disease. Like Dr Montgomery I have felt that uncontrolled pilot studies are justified in this condition, but experience with metronidazole here has so far been rather more encouraging than he reports. The dosage used has initially been 400 mg three times a day, higher than that used by Dr Montgomery but lower than reported by Ursing and Kamme.’ So far six patients have received metronidazole as the sole initial treatment for up to six months; three have shown considerable improvement, two moderate improvement, but one continued to deteriorate and required steroid therapy. Side-effects, however, have been troublesome. One patient developed peripheral neuropathy; this has been previously reported with prolonged treatment with metronidazole.2 This patient and one other have had arthralgia, which seems to be dose-related rather than related to activity of the disease; so far this has not necessitated discontinuing treatment. Ashford Hospital, London Road, Ashford, Middlesex TW15 3AA.
D.
J. HOLDSTOCK
EXPERTS AND AMATEURS IN STROKE THERAPY
SIR,-As you report in your editorial (Nov. 1, p. 859), speech therapy for dysphasia after stroke is usually empirical, and most of the published comparative series are not hopeful. But there are a few promising individual results,14and in some institutions speech therapy is based on accurate theoretical models of aphasia. There are two approaches for dealing with aphasic stroke patients: (1) to try to improve their deficits and (2) to help them to live with their handicap. These two approaches are complementary, but whereas untrained volunteers can help with the latter, the former certainly requires professional training, and there seems no reason for accepting empiricism as the basis for treatment. The speech therapist must aim to achieve a better understanding of the nature of aphasia, and for this he must have a sound knowledge of neuropsychology that will enable him to adapt his treatment for individual patients. This part of the rehabilitation of an aphasic stroke patient is clearly outside the scope of the most willing untrained volunteer. Research Laboratory, Centio de Estudos Egos Moniz, Hospital de Santa Maria,
Language
Lisbon, Portugal.
A. CASTRO-CALDAS
COST OF BREAST-FEEDING
SIR,-We disagree with Dr Buss’s method of calculation (Oct. 18, p. 766) and with his inference that breast-feeding is not necessarily cheaper than bottle-feeding. His figure of 14p/day as the cost of breast feeding is derived from an inappropriate extrapolation of the data from the National Food Survey. It seems equally inappropriate to base an alternative estimate of (l lp) on 1 litre of milk. This can hardly be considered a cheap source of calories nor an acceptable amount to add to the usual diet. On the other hand, it is misleading in comparing the costs of breast and bottle feeding to ignore the capital costs of bottle feeding (i.e., approximately £10 for a sterilisation kit, bottles and teats, travelling container, sterihsation tablets, and, perhaps, a bottle warmer). Variable costs of bottle feeding must include fuel and sugar besides milk powder (and National Dried Milk, which is subsidised, is rarely used by mothers). A more sensible way of costing the supplementary 500 kcal recommended for lactating mothers is to consider two large 1. Ursing, B., Kamme, C. Lancet, 1975, i, 775. 2. Ramsay, I. D. Br. med. J. 1968, iv, 706. 3. Albert, M. L., Sparks, R. W., Helm, N. A. Archs
Neurol., Chicago, 1973, 29, 130. 4. Glass, A. V., Gazzaniga, M. S., Premack, D. Neuropsychologia, 1973, 11, 95.
The need is not for greater repair but for greater prevention by earlier diagnosis, less radical surgery, and better education of the public and medical profession. Dr. W. W. Cross Cancer Institute, 11560 University Avenue,
Edmonton, Alberta, Canada T6G 1Z2.
PATRICIA E. BURNS
IRRITABLE-BOWEL SYNDROME
SIR The effects of drugs in the management of the irritableare difficult to assess. We have lately been attempting to determine the efficacy of the various recommended therapeutic agents in our clinic. I.B.S. is diagnosed by exclusion after full investigation. All patients are then treated by a high-fibre diet and a therapeutic agent to relax smooth muscle. Some patients are also given a tranquilliser. During the period of study it has become clear that the dosage of an antispasmodic agent is as important as the choice of the agent. We have been impressed with the efficacy of mebeverine hydrochloride (’Colofac’, Duphar), as judged by the loss of abdominal pain and the change from hard pellets bowel syndrome (I.B.s.)
threads of stool to a more bulky motion. The bulk of the motion is increased still further by the simultaneous administration of the high-fibre diet. The high-fibre diet alone improves the symptoms in about 50% of patients, but with mebeverine as well 85% of patients are relieved of symptoms. During these studies the recommended dosage of mebeverine of 1 x 100 mg tablet four times a day was usually found to be inadequate. The 85% of patients who improve is related to the use of 2 x 100 mg tablets four times daily. Patients who had not improved on the usual recommended dosage immediately improved on the increased dose. Another group of 30 I.B.S. patients referred from general practice were already receiving a dose of 1 x 100 mg tablet of mebeverine three times daily. 28 of these patients improved symptomatically simply by increasing the dose to 2 x 100 mg tablets four times daily. Many patients with I.B.S. have an exaggerated gastrocolic reflex, and maximum effect is achieved when the tablets are taken about 20 minutes before the main
or
meals. Royal Cornwall Hospital (Treliske), Truro, Cornwall TR1
B. J. PROUT
3LJ.
DRUG TREATMENT IN CROHN’S DISEASE
SIR,—Iwas interested to read of Dr Montgomery’s experi(Dec. 6, p. 1149) with antimicrobial agents in Crohn’s
ence
1. Goldsmith, H. S.,
Alday, E. S. Cancer. 1971, 28,
1672.
disease. Like Dr Montgomery I have felt that uncontrolled pilot studies are justified in this condition, but experience with metronidazole here has so far been rather more encouraging than he reports. The dosage used has initially been 400 mg three times a day, higher than that used by Dr Montgomery but lower than reported by Ursing and Kamme.’ So far six patients have received metronidazole as the sole initial treatment for up to six months; three have shown considerable improvement, two moderate improvement, but one continued to deteriorate and required steroid therapy. Side-effects, however, have been troublesome. One patient developed peripheral neuropathy; this has been previously reported with prolonged treatment with metronidazole.2 This patient and one other have had arthralgia, which seems to be dose-related rather than related to activity of the disease; so far this has not necessitated discontinuing treatment. Ashford Hospital, London Road, Ashford, Middlesex TW15 3AA.
D.
J. HOLDSTOCK
EXPERTS AND AMATEURS IN STROKE THERAPY
SIR,-As you report in your editorial (Nov. 1, p. 859), speech therapy for dysphasia after stroke is usually empirical, and most of the published comparative series are not hopeful. But there are a few promising individual results,14and in some institutions speech therapy is based on accurate theoretical models of aphasia. There are two approaches for dealing with aphasic stroke patients: (1) to try to improve their deficits and (2) to help them to live with their handicap. These two approaches are complementary, but whereas untrained volunteers can help with the latter, the former certainly requires professional training, and there seems no reason for accepting empiricism as the basis for treatment. The speech therapist must aim to achieve a better understanding of the nature of aphasia, and for this he must have a sound knowledge of neuropsychology that will enable him to adapt his treatment for individual patients. This part of the rehabilitation of an aphasic stroke patient is clearly outside the scope of the most willing untrained volunteer. Research Laboratory, Centio de Estudos Egos Moniz, Hospital de Santa Maria,
Language
Lisbon, Portugal.
A. CASTRO-CALDAS
COST OF BREAST-FEEDING
SIR,-We disagree with Dr Buss’s method of calculation (Oct. 18, p. 766) and with his inference that breast-feeding is not necessarily cheaper than bottle-feeding. His figure of 14p/day as the cost of breast feeding is derived from an inappropriate extrapolation of the data from the National Food Survey. It seems equally inappropriate to base an alternative estimate of (l lp) on 1 litre of milk. This can hardly be considered a cheap source of calories nor an acceptable amount to add to the usual diet. On the other hand, it is misleading in comparing the costs of breast and bottle feeding to ignore the capital costs of bottle feeding (i.e., approximately £10 for a sterilisation kit, bottles and teats, travelling container, sterihsation tablets, and, perhaps, a bottle warmer). Variable costs of bottle feeding must include fuel and sugar besides milk powder (and National Dried Milk, which is subsidised, is rarely used by mothers). A more sensible way of costing the supplementary 500 kcal recommended for lactating mothers is to consider two large 1. Ursing, B., Kamme, C. Lancet, 1975, i, 775. 2. Ramsay, I. D. Br. med. J. 1968, iv, 706. 3. Albert, M. L., Sparks, R. W., Helm, N. A. Archs
Neurol., Chicago, 1973, 29, 130. 4. Glass, A. V., Gazzaniga, M. S., Premack, D. Neuropsychologia, 1973, 11, 95.
