BRITISH MEDICAL JOURNAL
16
DECEMBER
sites listed have essentially the same diagnostic criteria. Certainly the aims and intentions of Drs Kreyberg and Whimster are laudable and every effort should be made to increase uniformity in tumour classification. However, diagnostic criteria and terminology should not be imposed for uniformity's sake alone but Public Health Laboratory, University Hospital, rather they should be shown to have value in Nottingham terms of biological significance, reproducibility, ***The BMJ was invited to the Ciba work- and international acceptance. L H SOBIN shop on the understanding that it was free to Cancer Unit, World Health Organisation, report the proceedings.-ED, BM7. Geneva
without supporting serology may be possible, the reverse is more likely. By the time a sufficient antibody titre has developed some lung resolution may have been in progress, eliminating the organism with or without antibiotic help. A D MACRAE
SIR,-Your timely and informative leading article (11 November, p 1319) would surely have aroused much interest and concern among physicians who would next deal with a patient with "atypical" pneumonia. Albuminuria, hyponatraemia, and abnormal liver function tests are commonly found in legionnaires' disease, but they are essentially non-specific findings, often encountered in other forms of respiratory infection. We have recently treated consecutively two patients with legionnaires' disease (diagnosed by fourfold rise in indirect fluorescent antibody titre). Both had no renal complications. However, we noted on initial investigations grossly elevated serum muscle creatine kinase activity, 1089 U/i and 1213 U/i (normal < 150 U/1) respectively. Rhabdomyolysis as the possible cause of acute renal failure in some patients with legionnaires' disease has been described.' We feel that estimation of creatine kinase activity is a useful biochemical screening test in this disease while awaiting serological confirmation. K C CHIN A K R CHAUDHURI W CAMPBELL LOVE
1711
1978
Raw donor breast milk for newborn babies
SIR,-Raw (unheated) breast milk is probably the best food for babies who are recovering from neonatal illness. Dr S Williamson and his colleagues from King's College Hospital (KCH) have recently reported their bacteriological criteria for giving raw breast milk to newborn babies (18 February, p 393). In the past year an area breast milk bank has been established in the Leicester Royal Infirmary Maternity Hospital (LRIMH) and we were therefore interested to estimate how much of our donor breast milk might be given raw, applying the KCH criteria. One hundred consecutive bottles of donor breast milk which were delivered to the milk bank were sampled for their bacteriology; 76 specimens were collected from the LRIMH, the remaining 24 coming from the distrct. The breast milk was collected into glass shells from the opposite breast during feeding. According to current practice mothers were asked to wash their nipples at least twice a day with soap and water; the shells were washed in soapy water and rinsed before and after use. Department of Infectious Diseases, About 2 ml of breast milk from each bottle Belvidere Hospital, was delivered to the laboratory in a sterile Glasgow universal container and dealt with immediately. Friedman, H S, Annals of Internal Medicine, 1978, Serial dilutions of milk between 10-1 and 10-' 88, 294. were made in nutrient agar (Oxoid), using a semiautomated diluter, and following overnight incubation at 37°C the number of Controversies in WHO tumour colony-forming units per litre was determined.' classification The results are shown in the figure. FortySIR,-The problems raised by Professor L four per cent of the mik specimens showed a Kreyberg and Dr W F Whimster (28 October, mixed bacterial growth. Of these organisms p 1203) are of immediate concern to those only those which are thought to be most involved in the histological classification of tumours. The so-called "provincial" points of 1cfi view do not reflect personal attitudes of the 300 experts involved in this collaborative work but are the result of limitations imposed by 00 today's knowledge and techniques. 0 The purpose of the World Health Organisa0 tion programme on histological classification of tumours is to promote international 0. 104 FL 00~~~~~0 communication and comparability of data by formulating reproducible diagnostic criteria *= hospit00o0 0 0. o *0o and a uniform nomenclature. As the classifica0 tions are site-specific, the definitions and O 6 8. 0 * 0000 terminology are site-specific. Attempts to '710 formulate more general guidelines to promote uniformity in nomenclature and in the definitions of certain tumours were made at Bcteloogy spcmnso ras ik of10 0~ ~ ~ ~~0 meetings of the heads of the WHO centres in 1973 and 1976 and are reflected in the more recent publications in the series. In fact, although the authors state that "the criteria Enterobacteriaceae Commensals Staphylococcus + streptococcus aureus for basically the same tumour type vary from faecalis centre to centre and from organ system to organ system," their table shows quite the Bacteriology of 100 specimens of breast milk; contrary since the tumours at five of the six 0 =hospital specimens, 0 district specimens.
significant for giving niilk raw have been included in the figure. Using the KCH criteria, 35 (46 %O) of the 76 hospital specimens could have been given raw compared with 5 (170/%) of those from the district. It is interesting that 15 (63°o) of the district specimens were contaminated by Enterobacteriaceae compared with only 15 (20%"' ) of the hospital-collected specimens. The neonatal unit of the LRIMH provides special and intensive care services for approximately 5000 babies born each year in the hospital and also an intensive care service for a further 5000 babies born elsewhere in the Leicester area. The babies to whom we are feeding heated bank breast milk at present include those (1) with a birth weight less than 1500 g; (2) being weaned off parenteral feeding; (3) post-surgery; and (4) who are unwell for any reason but who can be fed milk. If possible breast milk is continued for a minimum of two weeks. Each day an average of about 1000 ml of breast milk is delivered to the milk bank, an amount which is just adequate for our present needs. However, if this milk were to be given raw along the lines proposed by the KCH workers, then only about 400 ml of this milk could be given. While this amount could possibly be increased by giving more attention to the hygiene of milk collection we also believe that there is room for further study into the bacteriological criteria which need to be applied for donor human milk to be given raw. L CARROL M OSMAN D P DAVIES E BRODERICK Departments of Child Health and Microbiology, Leicester Royal Infirmary, Leicester
Cowan, S T, and Steel, K, Manual for the Identification of Medical Bacteria. Cambridge University Press, 1970.
Smear campaign SIR,-For 10 years and more doctors, in general practice and hospital, have been filling in meticulously great long forms giving intimate details of the patients from whom they take cervical smears. Presumably (hopefully) all this information is being collated somewhere and interpreted-yet we have had neither regular local feedback nor grand epidemiological statements based upon it. Little wonder, then, that we get fed up filling in the details or rely upon the mildest guesswork in doing so; it is more than time that we heard what has happened to the stuff and what, if anything, has been learnt from it either about the natural history of the disease in this country or the best timing for repeat smears. T R CULLINAN Department of Environmental and Preventive Medicine, St Bartholomew's Hospital Medical College, London EC1
SIR,-It is with some amazement that I observe the attitude of many of my colleagues with regard to the taking of cervical smears. I have stated on more than one occasion my attitude to cervical smear clinics and family planning clinics which all too often usurp the position of the general practitioner vis-a-vis
16
DECEMBER
sites listed have essentially the same diagnostic criteria. Certainly the aims and intentions of Drs Kreyberg and Whimster are laudable and every effort should be made to increase uniformity in tumour classification. However, diagnostic criteria and terminology should not be imposed for uniformity's sake alone but Public Health Laboratory, University Hospital, rather they should be shown to have value in Nottingham terms of biological significance, reproducibility, ***The BMJ was invited to the Ciba work- and international acceptance. L H SOBIN shop on the understanding that it was free to Cancer Unit, World Health Organisation, report the proceedings.-ED, BM7. Geneva
without supporting serology may be possible, the reverse is more likely. By the time a sufficient antibody titre has developed some lung resolution may have been in progress, eliminating the organism with or without antibiotic help. A D MACRAE
SIR,-Your timely and informative leading article (11 November, p 1319) would surely have aroused much interest and concern among physicians who would next deal with a patient with "atypical" pneumonia. Albuminuria, hyponatraemia, and abnormal liver function tests are commonly found in legionnaires' disease, but they are essentially non-specific findings, often encountered in other forms of respiratory infection. We have recently treated consecutively two patients with legionnaires' disease (diagnosed by fourfold rise in indirect fluorescent antibody titre). Both had no renal complications. However, we noted on initial investigations grossly elevated serum muscle creatine kinase activity, 1089 U/i and 1213 U/i (normal < 150 U/1) respectively. Rhabdomyolysis as the possible cause of acute renal failure in some patients with legionnaires' disease has been described.' We feel that estimation of creatine kinase activity is a useful biochemical screening test in this disease while awaiting serological confirmation. K C CHIN A K R CHAUDHURI W CAMPBELL LOVE
1711
1978
Raw donor breast milk for newborn babies
SIR,-Raw (unheated) breast milk is probably the best food for babies who are recovering from neonatal illness. Dr S Williamson and his colleagues from King's College Hospital (KCH) have recently reported their bacteriological criteria for giving raw breast milk to newborn babies (18 February, p 393). In the past year an area breast milk bank has been established in the Leicester Royal Infirmary Maternity Hospital (LRIMH) and we were therefore interested to estimate how much of our donor breast milk might be given raw, applying the KCH criteria. One hundred consecutive bottles of donor breast milk which were delivered to the milk bank were sampled for their bacteriology; 76 specimens were collected from the LRIMH, the remaining 24 coming from the distrct. The breast milk was collected into glass shells from the opposite breast during feeding. According to current practice mothers were asked to wash their nipples at least twice a day with soap and water; the shells were washed in soapy water and rinsed before and after use. Department of Infectious Diseases, About 2 ml of breast milk from each bottle Belvidere Hospital, was delivered to the laboratory in a sterile Glasgow universal container and dealt with immediately. Friedman, H S, Annals of Internal Medicine, 1978, Serial dilutions of milk between 10-1 and 10-' 88, 294. were made in nutrient agar (Oxoid), using a semiautomated diluter, and following overnight incubation at 37°C the number of Controversies in WHO tumour colony-forming units per litre was determined.' classification The results are shown in the figure. FortySIR,-The problems raised by Professor L four per cent of the mik specimens showed a Kreyberg and Dr W F Whimster (28 October, mixed bacterial growth. Of these organisms p 1203) are of immediate concern to those only those which are thought to be most involved in the histological classification of tumours. The so-called "provincial" points of 1cfi view do not reflect personal attitudes of the 300 experts involved in this collaborative work but are the result of limitations imposed by 00 today's knowledge and techniques. 0 The purpose of the World Health Organisa0 tion programme on histological classification of tumours is to promote international 0. 104 FL 00~~~~~0 communication and comparability of data by formulating reproducible diagnostic criteria *= hospit00o0 0 0. o *0o and a uniform nomenclature. As the classifica0 tions are site-specific, the definitions and O 6 8. 0 * 0000 terminology are site-specific. Attempts to '710 formulate more general guidelines to promote uniformity in nomenclature and in the definitions of certain tumours were made at Bcteloogy spcmnso ras ik of10 0~ ~ ~ ~~0 meetings of the heads of the WHO centres in 1973 and 1976 and are reflected in the more recent publications in the series. In fact, although the authors state that "the criteria Enterobacteriaceae Commensals Staphylococcus + streptococcus aureus for basically the same tumour type vary from faecalis centre to centre and from organ system to organ system," their table shows quite the Bacteriology of 100 specimens of breast milk; contrary since the tumours at five of the six 0 =hospital specimens, 0 district specimens.
significant for giving niilk raw have been included in the figure. Using the KCH criteria, 35 (46 %O) of the 76 hospital specimens could have been given raw compared with 5 (170/%) of those from the district. It is interesting that 15 (63°o) of the district specimens were contaminated by Enterobacteriaceae compared with only 15 (20%"' ) of the hospital-collected specimens. The neonatal unit of the LRIMH provides special and intensive care services for approximately 5000 babies born each year in the hospital and also an intensive care service for a further 5000 babies born elsewhere in the Leicester area. The babies to whom we are feeding heated bank breast milk at present include those (1) with a birth weight less than 1500 g; (2) being weaned off parenteral feeding; (3) post-surgery; and (4) who are unwell for any reason but who can be fed milk. If possible breast milk is continued for a minimum of two weeks. Each day an average of about 1000 ml of breast milk is delivered to the milk bank, an amount which is just adequate for our present needs. However, if this milk were to be given raw along the lines proposed by the KCH workers, then only about 400 ml of this milk could be given. While this amount could possibly be increased by giving more attention to the hygiene of milk collection we also believe that there is room for further study into the bacteriological criteria which need to be applied for donor human milk to be given raw. L CARROL M OSMAN D P DAVIES E BRODERICK Departments of Child Health and Microbiology, Leicester Royal Infirmary, Leicester
Cowan, S T, and Steel, K, Manual for the Identification of Medical Bacteria. Cambridge University Press, 1970.
Smear campaign SIR,-For 10 years and more doctors, in general practice and hospital, have been filling in meticulously great long forms giving intimate details of the patients from whom they take cervical smears. Presumably (hopefully) all this information is being collated somewhere and interpreted-yet we have had neither regular local feedback nor grand epidemiological statements based upon it. Little wonder, then, that we get fed up filling in the details or rely upon the mildest guesswork in doing so; it is more than time that we heard what has happened to the stuff and what, if anything, has been learnt from it either about the natural history of the disease in this country or the best timing for repeat smears. T R CULLINAN Department of Environmental and Preventive Medicine, St Bartholomew's Hospital Medical College, London EC1
SIR,-It is with some amazement that I observe the attitude of many of my colleagues with regard to the taking of cervical smears. I have stated on more than one occasion my attitude to cervical smear clinics and family planning clinics which all too often usurp the position of the general practitioner vis-a-vis
