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We check the antibody-rate, but we do not use it as thearbitrator for acting or not acting.There are other, simpler reasons for the deplorable

absence of preventive measures against poliomyelitis in

developing countries. Governments with a poliomyelitisproblem hesitate to venture on an enterprise which soonwould collapse because of lack of funds, personnel, com-munications, and transport. Live polio vaccine is veryunstable; it may arrive in good condition at the airport of atropical country having travelled half around the world,but it will deteriorate within days because there are noproper means of handling, storage, and distribution. Theless fragile Salk vaccine is so expensive (pharmacy price inAbidjan$1-50 per shot) that few can afford it.

FRANZ E. PERABO.

JUNIOR HOSPITAL STAFF IN TRAININGSIR,-We discussed this correspondence over lunch and

we all agreed. There were two registrars, one senior

registrar, and one general practitioner. Three nationalitieswere represented; the only thing we had in common wasthat we were all over thirty.We capped one another’s stories about our longest spell

on duty, our biggest operating list, and what our chiefsaid when after six months we asked for a week’s leave.We agreed that early on it was important to get as muchpractical experience as possible in daily contact with thepatient and that meetings and conferences could wait untilone was a little more senior.Dr. Buckley-Sharpe (Sept. 19, p. 609) himself says that

several doctors looking after each patient does not providesatisfactory care. Limiting the size of one’s list means

restricting one’s experience, skill, and knowledge. Sincepatients will continue to be ill outside the hours of 9 to 5,it seems we simply have to carry on. This is one of the

problems which just has to be faced and which cannot besolved by a letter to one’s M.P. Everybody who takes upmedicine reallv knows what is in store for him.

King Edward VII Hospital,Rivelin, Sheffield.

E. G. HERZOGSurgeon Superintendent.

DESIGN OF SKIN FLAPS

SIR,-Your annotation of Aug. 22 (p. 405) suggests thatthe concept of a length/width ratio may be fallacious. 1

Subsequent criticism stated that " until these findings areconfirmed in man their relevance must stay confined to the

pig".’ 2We have made hundreds of flaps in rats, rabbits, dogs,

and pigs.2-4 On none of these species has there been anyrelationship between the width of a single pedicle and thelength of survival. The only important thing in determininghow much skin will survive is the inherent vascularity ofeach flap, and that can be determined as soon as the flap iscompleted by the injection of a vital dye. We have alsoreviewed over 200 radical mastectomies in which wideflaps are made. Again we found that the amount of sur-viving skin was dependent only on the residual blood-supply,some of the nutrient vessels having been cut in raising theflap. Again survival could be predicted by the use offluorescein dye. 2

Touro Research Institute,New Orleans,

Louisiana 70115.

M. BERT MYERSGEORGE CHERRY.

1. Milton, S. H. Br. J. Surg. 1970, 57, 502.2. Myers, M. B. Surgery, 1964, 56, 935.3. Myers, M. B., Cherry, G. J. surg. Res. 1967, 7, 399.4. Myers, M. B., Cherry, G. Plast. reconstr. Surg. (in the press).

SCREENING FOR BREAST CANCER

SIR,-Dr. Stark and Mr. Way (Aug. 22, p. 407) are to becommended for extending the scope of their cervical-cancer clinic and offering facilities for the early detection ofbreast carcinoma. This rational approach is probably themost economical method of providing a breast-screeningservice and it is to be hoped that similar facilities shouldbe made available to other cervical-cancer clinics.

Thermography should be used with caution as a screeningprocedure, since the diagnostic accuracy is low, and Evans 1found that only 39% of patients with breast cancer werediagnosed by this method.

In our series, thermograms were performed with a

’Pyroscan’ on 150 patients referred for mammography, andamong these were 28 patients who were later proved byhistological examination to have breast carcinoma. In 19

patients there was good correlation between the mammo-graphic, thermographic, and histological findings; 5 patientshad a normal thermogram, but radiological and histologicalevidence of carcinoma was present. In 1 patient there wasclinical and thermographic evidence of carcinoma with anormal mammogram. 3 patients had equivocal clinical find-ings and suspicious mammograms with a positive thermo-gram which strongly influenced the preoperative diagnosis.

In the 19 patients with good radiological and thermo-graphic correlation, one carcinoma was occult and 2 wereless than 2 cm. in diameter. The remaining masses were allover 4 cm. in diameter and 2 were inflammatory types ofcarcinoma.

The one patient who had a positive thermogram and anegative mammogram presented with a small subcutaneousnodule, which proved to be a 1.5 cm. acinar and trabecularcelled carcinoma. The mammogram showed an unusuallydense breast.

False-negative thermograms were found in 5 patients, 3of these tumours were not palpable and in 1 of these therewas radiological involvement of the skin. The 2 othertumours were less than 3 cm. in diameter, they were diffuseadenocarcinomas, and in 1 the overlying skin was thickened.In all these cases the calibre of the veins was normal and in3 of them the tumour was near the surface of the breast.

Thermography had a definite influence on the clinicalmanagement of 3 patients. They presented clinically withvague breast masses. The mammograms showed diffusemasses all over 3 cm., having the appearance of cysts withperiodical œdema, but with distended veins in theirvicinity. The unequivocal hot spot on the thermogramprompted the correct diagnosis.A disturbing feature of breast thermography is the high

incidence of false-positive results-12 in our series. 4 ofthese were shown to have benign lesions and the remainderhave shown no evidence of abnormality on clinical andradiological follow-up (in 3 patients the suspicious thermo-graphic features disappeared).

In our experience, thermography is a valuable adjunct tomammography and clinical examination, but it can be un-reliable in detecting small carcinomas. The diagnosticaccuracy may be improved in future and the number offalse-positive results reduced with equipment capable ofhigh spatial and thermal resolution.2 At present it seemsthat women with breast carcinoma can be given false re-assurance from thermography alone and many others witha false-nositive diagnosis mav suffer needless anxietv.

Diagnostic X-ray Department,Royal Surrey County Hospital,

Guildford. JOHN L. PRICE.

1. Evans, K. T. Br. J. Surg. 1969, 56, 782.2. Dodd, G. D., Zermeno, A., Marsh, L., Boyd, D., Wallace, J. D.

Cancer, 1969, 24, 1212.