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mind they are more like caricatures of breasts, and if it was myself thatwas involved I would prefer a neat mastectomy scar any day.2. Goldsmith and Alday’ have remarked that, whereas the majority ofmastectomy patients are mourning the loss of their breast during theirfirst year and often demanding a reconstruction, the majority ofwomen who are capable of adjusting to life’s difficulties have acceptedtheir mastectomy and adjusted accordingly by the end of year one.Those who continue to demand reconstruction have far more deep-seated psychological problems than the reconstruction of the breastwill solve.3. I have seen now 3 cases of recurrence on the chest wall, deep to theprosthesis, which was recognised very late because of the overlyingprosthesis; and for these patients very little treatment was feasiblebecause the recurrence was so advanced when diagnosed.4. I have also seen a carcinoma in a woman in her early 20s who hadpreviously had silicone inserts in both breasts. This patient was in alow-risk group for the development of breast cancer in that she hadno family history, no previous history of breast trouble, and had hadtwo babies before the age of 20 both of whom had been breast-fed forsix months. The silicone mammoplasty had been performed after thebirth of the second baby. The carcinoma was diagnosed approximatelya year later.

The need is not for greater repair but for greater preventionby earlier diagnosis, less radical surgery, and better educationof 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 irritable-bowel syndrome (I.B.s.) are difficult to assess. We have latelybeen attempting to determine the efficacy of the various recom-mended therapeutic agents in our clinic. I.B.S. is diagnosed byexclusion after full investigation. All patients are then treatedby a high-fibre diet and a therapeutic agent to relax smoothmuscle. 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 choiceof the agent. We have been impressed with the efficacy ofmebeverine hydrochloride (’Colofac’, Duphar), as judged bythe loss of abdominal pain and the change from hard pelletsor threads of stool to a more bulky motion. The bulk of themotion is increased still further by the simultaneous adminis-tration of the high-fibre diet. The high-fibre diet alone im-proves the symptoms in about 50% of patients, but with mebe-verine as well 85% of patients are relieved of symptoms.

During these studies the recommended dosage ofmebeverine of 1 x 100 mg tablet four times a day was usuallyfound to be inadequate. The 85% of patients who improve isrelated to the use of 2 x 100 mg tablets four times daily. Pa-tients 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 ofmebeverine three times daily. 28 of these patients improvedsymptomatically simply by increasing the dose to 2 x 100 mgtablets four times daily. Many patients with I.B.S. have an

exaggerated gastrocolic reflex, and maximum effect is achievedwhen the tablets are taken about 20 minutes before the mainmeals.

Royal Cornwall Hospital (Treliske),Truro,Cornwall TR1 3LJ. B. J. PROUT

DRUG TREATMENT IN CROHN’S DISEASE

SIR,—I was interested to read of Dr Montgomery’s experi-ence (Dec. 6, p. 1149) with antimicrobial agents in Crohn’s

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 withmetronidazole here has so far been rather more encouragingthan he reports. The dosage used has initially been 400 mgthree times a day, higher than that used by Dr Montgomerybut lower than reported by Ursing and Kamme.’ So far six pa-tients have received metronidazole as the sole initial treatmentfor up to six months; three have shown considerable improve-ment, two moderate improvement, but one continued to de-teriorate and required steroid therapy. Side-effects, however,have been troublesome. One patient developed peripheralneuropathy; this has been previously reported with prolongedtreatment with metronidazole.2 This patient and one other havehad arthralgia, which seems to be dose-related rather thanrelated to activity of the disease; so far this has not necessit-ated 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,14 and insome institutions speech therapy is based on accurate theoreti-cal models of aphasia.

There are two approaches for dealing with aphasic strokepatients: (1) to try to improve their deficits and (2) to helpthem to live with their handicap. These two approaches arecomplementary, but whereas untrained volunteers can helpwith the latter, the former certainly requires professionaltraining, and there seems no reason for accepting empiricismas the basis for treatment. The speech therapist must aim toachieve a better understanding of the nature of aphasia, andfor this he must have a sound knowledge of neuropsychologythat will enable him to adapt his treatment for individualpatients. This part of the rehabilitation of an aphasic strokepatient is clearly outside the scope of the most willing un-trained volunteer.

Language Research Laboratory,Centio de Estudos Egos Moniz,Hospital de Santa Maria,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 isnot necessarily cheaper than bottle-feeding. His figure of14p/day as the cost of breast feeding is derived from an inap-propriate extrapolation of the data from the National FoodSurvey. It seems equally inappropriate to base an alternativeestimate of (l lp) on 1 litre of milk. This can hardly be consid-ered a cheap source of calories nor an acceptable amount toadd to the usual diet. On the other hand, it is misleading incomparing the costs of breast and bottle feeding to ignore thecapital costs of bottle feeding (i.e., approximately £10 for asterilisation kit, bottles and teats, travelling container, sterih-sation tablets, and, perhaps, a bottle warmer). Variable costsof bottle feeding must include fuel and sugar besides milkpowder (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.

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slices of buttered white bread (30g, 240 kcal for the butter and100g, 250 kcal for the bread’) at an approximate cost of 4-5p.

M.R.C. Epidemiology Unit (South Wales),4 Richmond Road,Cardiff CF2 3AS.

CAROL A. WESTLAKEDEE A. JONES

ECTOPIC PREGNANCY AND THE I.U.C.D.

SIR,—I support the views expressed by Mr Weekes and DrSutherst (Dec. 6, p. 1144) on pelvic infection in the aetiologyof ectopic pregnancy and their reservations on the conclusionsof Dr Beral6 on the role of the intrauterine contraceptive device(i.u.c.D.) as given in your editorial (Nov. 15, p. 963).The diagnosis of pelvic inflammatory disease is unsatisfac-

tory, and the numbers of cases coded as salpingitis andoophoritis in the Hospital In-patient Enquiry are suspect. Clin-icians form a spectrum of opinion from those recognisingdefinitive symptoms and signs only (missing the mild cases) tothose readily applying the disgnosis to obscure symptoms andtreating some patients unnecessarily.The traditional microbiological diagnosis is from samples

taken from the endocervical canal. This is often unsatisfac-

tory. In South Glamorgan, the isolation-rate for Neisseria

gonorrhœœ in salpingitis by this means is usually 1-3%, butwith strict attention to technique it has been raised to 29% .7Some infections may be caused by mycoplasmas and chla-mydix, but few hospitals have the facilities to isolate them.There is a local secretory immune system in the endocervix

producing IgA.8 Failure to isolate convincing pathogens fromthe endocervix could be due to their elimination there by thissystem, while their progress in the tubes continues unchecked.

Laparoscopy should be undertaken more often but is not theultimate solution to diagnosis. It may reveal many unexpectedcases of pelvic inflammatory disease and, conversely, refutemany clinical diagnoses;9 but cases can still be missed. 10Dr Beral singles out the ’Graviguard’ (copper 7) l.U.C.D. as

possibly causing a greater increase in ectopic pregnancy thanother coils. If the underlying cause is ascending infection, it isunlikely to be gonococcal, since the copper content of this coilis gonococcicidal. 11

Cardiff Royal Infirmary,Newport Road,Cardiff CF2 1SZ. R. A. SPARKS

NORMAL=10±2

SIR,—I was interested to read Professor Lennox’s letter

(Nov. 29, p. 1085) because I have been canvassing a similarapproach for some time amongst my clinical and laboratorycolleagues.

Professor Lennox’s scheme has been suggested before12 andis undoubtedly the logically and statistically correct solution tothe problem, but "normal=0" is a rather strange concept tomany people and gives no idea of the magnitude of the rangein relation to the mean. I have therefore suggested that thenormal should be 10 ± the number of standard deviations, give-ing a range of 8-12 or +20% which seems to be the normalrange for many clinical measurements. A normal of 100,although there is the historical precedent of haemoglobin, givesa spurious air of precision to the measurement. Where appro-priate, however, there is nothing to prevent reporting to 0.1S.D.

So far the reaction from my colleagues has been almostmonotonously enthusiastic, even amongst clinical chemists,

5. McCance, R. A., Widdowson, E. M. Spec. Rep. Ser. med. Res. Coun. 1969,no.297.

6. Beral, V. Br. J. Obstet. Gynæc. 1975, 82, 775.7. Sparks, R. A., Davies, A. J. Br. J. vener. Dis. (in the press).8. Rebello, R., Green, F. H. Y., Fox, H. Br. J. Obstet. Gynæc. 1975, 82, 812.9. Jacobson, L., Westrom, L. Am. J. Obstet. Gynec. 1969, 105, 1088.10. Kenney, A., Greenhalf, J. O. Br. med. J. 1974, i, 519.11. Cohen, L., Thomas, G. Br. J. vener. Dis. 1974, 50, 364.12. Healey, M. J. R. Ann. clin. Biochem. 1969, 6, 12.

with the proviso that the actual measurements, in the appro-priate units, are reported as well. As Professor Lennox says,with modern calculators the conversion presents no problemand when, as in this hospital, the whole process is compu-terised, it would be little additional trouble. Our computer alsoknows the age and sex of our patients so that it could easilybe programmed to give suitably adjusted normals when appro-priate. ,

To give an opportunity for a thorough discussion of the prosand cons of such a system a meeting of the Section of Measure-ment in Medicine of the Royal Society of Medicine has beenarranged for April 26, 1976, under the title Simplification ofLaboratory and other Reports, and it is hoped that as manyas possible of those inerested will attend. Speakers on statistics,clinical chemistry, respiratory measurements, and on the clini-cal point of view have already been selected, but I would wel-come speakers from other disciplines and especially any whoare invincibly opposed to such a scheme.

It is also proposed to carry out a limited pilot trial of thescheme in this hospital.Northwick Park Hospital andClinical Research Centre,Watford Road, Harrow,Middlesex HA1 3UJ. B. M. WRIGHT

DO DIETARY LECTINS PROTECT AGAINSTCOLONIC CANCER?

SIR Lectins are plant proteins which have the ability tobind to the surface carbohydrates of many mammalian cells.They are thus endowed with a multitude of abilities,’ whichvary from one lectin to another. Broadly, their capabilities in-clude : (1) agglutinating erythrocytes; (2) agglutinating bac-teria ; (3) inducing lymphocyte transformation; (4) stimulatingmast-cell degranulation;:! and (5) agglutinating and damagingneoplastic (and embryonic) cells in preference to the normaladult equivalents.’ This last property endows some lectins witha protective effect against experimental carcinogenesis in

laboratory animals.3 Many lectins are toxic or naturally boundto toxins.

In spite of their ready availability and wide usage as labora-tory tools, little thought has been given to their biological role.In particular, the literature does not dwell on the obvious con-sideration that the mammalian alimentary tract must beexposed to many different lectins in the normal process of eat-ing and digestion. It is, however, a commonplace observationthat a meal of beans or other seeds (rich sources of lectins)increases intestinal motility as well as mucus and gas produc-tion, and it is reasonable to infer that the lectins in the foodare responsible. In this way, the body is protected from theirtoxicity. -

We theorise that the body’s response to lectins would protectagainst intestinal cancer by a number of possible mechanisms:(1) mast-cell degranulation would cause inflammation and in-creased mucus production, thus increasing faecal bulk andtending to sweep away malignant cells and carcinogens; (2)lectins would bind to the mucosal cells,4 inducing mitosis andincreasing epithelial turnover, thus allowing less opportunityfor a neoplastic cell to "take"; (3) a similar process wouldstimulate local lymphocytes non-specifically to cause cytotoxi-city ; and (4) the neoplastic cells themselves would be suscep-tible to direct damage by the lectin.

If this theory is correct, appropriate lectins by mouth shouldbe of use in the prophylaxis (and possibly treatment) of coloniccancer. It is worth noting in this context that diets naturallyrich in vegetable fibre will also be rich in lectins.5 A similar

1. Lis, H., Sharon, N. A. Rev. Biochem. 1973, 42, 541.2. Hook, W. A., Dougherty, S. F., Oppenheim, J. J. Infect. Immun. 1974, 9,

903.3. Inbar, M., Ben-Bassat, H., Sachs, L. Int. J. Cancer, 1972, 9, 143.4. Etzler, M. E., Branstrator, M. L. J. Cell Biol. 1974, 62, 329.5. Stoddart, R. W. Personal communication. 1975.