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MR MUNSTER: REFERENCES

1. Lancet, 1974, ii, 817.2. Howard, R. J., Simmons, R. L. Surgery Gynec. Obstet 1974, 139, 771.3. Munster, A. M., Artz, C. P. S. med. J., Nashville, 1974, 67, 935.4. Munster, A. M., Eurenius, K., Katz, R. M., Canales, L., Foley, F. D., Mor-

tensen, R. F. Ann. Surg. 1973, 177, 139.5. Leguit, P., Meinesz, A., Zeijlemaker, W. P., Schellekens, P. T. A., Eijsvoo-

gel, V. P. Int. Archs Allergy appl. Immun. 1973, 44, 101.6. Munster, A. M., Eurenius, K., Mortensen, R. F., Mason, A. D. Transplan-

tation, 1972, 14, 106.7. Mahler, D., Batchelor, J. R. ibid. 1971, 12, 409.8. Daniels, J. C., Cobb, E. K., Lynch, J. B., Lewis, D. L., Larson, D. L.,

Ritzmann, S. E. Surgery Gynec. Obstet. 1970, 130, 783.9. Eurenius, K., Mortensen, R. F. Int. Archs Allergy appl. Immun. 1971, 40,

707.10. Schoenenberger, G. A., Burkhardt, F., Kalberer, F., Muller, W., Stadtler,

K., Vogt, P., Allgöwer, M. Surgery Gynec. Obstet. 1975, 141, 555.11. Constantian, M. B., Menzoian, J. O., Nimberg, R. B., Schmid, K., Mannick,

J. A. Clin. Res. 1975, 23, 410A.12. Zan-Bar, I., Nachtigal, D., Feldman, M. Transplantn Proc. 1975, 7 suppl.

1, 341.13. Rapaport, F. T., Sampath, A., Kano, K., McCluskey, R. T., Milgrom, F. J.

exp Med. 1969, 130, 1411.14. Ablin, R. J., Milgrom, F., Rapaport, F. T., Beutner, E. Vox sang. 1969, 16,

13.

Methods and Devices

TRIAL OF NEW CERVICAL SPATULA

R. BOURNE J. O. W. BEILBY

Bland-Sutton Institute of Pathology, Middlesex HospitalMedical School, London W1

Summary A trial comparing the relative values of the’Armovical’ and Ayre’s spatulæ showed a sig-

nificant improvement of the former over the latter in samplingendocervical epithelium. No such difference was found in theirability to detect epithelial atypia. However, it was confirmedthat if (at each attendance of a patient) the cervix was sampledtwice instead of once the incidence of atypical smears was in-creased.

Introduction

SATISFACTORY cervical smears’ should theoretically includeendocervical as well as ectocervical material since one in eightcases of carcinoma-in-situ is confined to the endocervicalcanal.2 3 smears taken by the Ayre’s spatula, widely used inthe United Kingdom, are frequently lacking in endocervicalepithelium and the custom of reporting the absence of endocer-vical cells often induces doubt that the patient has been relia-bly screened for cervical cancer.

It was therefore arranged to compare the Ayre’s spatulawith a modified plastic spatula (’Armovical’) designed to sam-ple the endocervix/

Methods and Materials

Between November, 1974, and October, 1975, Ayre andarmovical spatulae were used to collect paired smears from10 690 women, mainly in their third decade, who were attend-ing a family-planning clinic. The smears were taken by a totalof 26 doctors and 25 nurses.

In the first half of the study the procedure was for the Ayre’sspatula to be used first, followed by the armovical, an orderwhich was reversed in the second half of the trial.The smears were examined by two teams of technicians, one

team screening the Ayre’s smears and the other the armovical.The absence of endocervical material was reported if no un-equivocal sheet or clump of typical columnar cells was seen.Atypical smears were passed to one of us (J.B., R.B.) to grade.

Results

When the Ayre’s spatula was used first (table I) 25% of thesmears contained endocervical cells, whereas when it was usedsecond (table n) the number was increased to 33%. When the

armovical spatula was used first (table n) 38% of the smearscontained endocervical cells compared with 52% when it wasused second (table I).

In both sequences the use of the armovical spatula’ resultedin a higher rate of recovery of endocervical epithelium(P<0001).

It was apparent that the second rather than the first spatulaused was more successful at endocervical sampling whether itwas Ayre’s or armovical (P<0.001). In the Ayre’s/armovicalsequence (table I) parous women were found to be more likelyto yield endocervical cells whichever spatula was used

(P<0.001). In the armovical-Ayre’s sequence (table II) no suchrelationship to parity was apparent.

Table III shows that a total of 139 (3.0%) paired smearswere abnormal, 119 (2.6%) of which were Ayre’s and 105(2.3%) armovical. Histological examination in the cases wheresmears were atypical enough to justify cone biopsy revealed 4carcinoma-in-situ and 1 severe dysplasia. Table IV shows thata total of 135 (2.2%) paired smears were atypical; these in-cluded 109 (1.8%) Ayre smears and 102 (1.7%) armovical.The 5 cases where cone biopsy was recommended were positivefor both spatulx, and histologically all 5 showed carcinoma-in-situ. One patient had a biopsy recommended on the armovical

TABLE I-PRESENCE OR ABSENCE OF ENDOCERVICAL CELLS IN 4649PAIRED SAMPLES EXAMINED IN AYRE’S/ARMOVICAL SEQUENCE

TABLE I!&mdash;PRESENCE OR ABSENCE OF ENDOCERVICAL CELLS IN 6041PAIRED SAMPLES EXAMINED IN ARMOVICAL/AYRE’S SEQUENCE

TABLE III-RELATIVE FREQUENCY AND DISTRIBUTION OF ATYPICAL CELLSIN 4649 PAIRED SAMPLES EXAMINED IN AYRE’S/ARMOVICAL SEQUENCE

TABLE IV-RELATIVE FREQUENCY AND DISTRIBUTION OF ATYPICAL CELLSIN 6041 PAIRED SAMPLES EXAMINED IN ARMOVICAL/AYRE’S SEQUENCE

1331

smear, whilst the Ayre’.s smear was negative. This patient wastransferred to another hospital, but has not been biopsied.When comparing the results of both sequences (tables ill

and iv) there is no difference (better than p<0-05) between the

spatula’ in detecting atypical cells. However, the Ayre’s spatulais likely to yield atypical cells more often when it is used firstin the sequence (P<0-01) and the armovical when used second

(p<O.05).

DiscussionThe accepted practice of sampling the cervix with an Ayre’s

spatula and making one smear is questioned. Without resort-ing to complicated collecting techniques for routine screening,the number of patients with endocervical cells in their smearscan be increased by taking a second cervical sample at each at-tendance. It was found that when the armovical spatula wasused, it was better at sampling the endocervix with the firstscrape than the Ayre’s was with the second. Furthermore, atthe second scrape its performance was even better, showingover twice as many patients with endocervical cells in theirsmears. Therefore if endocervical sampling was the main cri-terion for efficient cervical screening examination of the secondarmovical specimen only would appear ideal. However, pre-vious workers have reported a discrepancy of atypical elementswhen two simultaneous smears were collected,S 6 and we haveconfirmed this. The presence of exfoliated atypical cells in the

cervical mucous plug may have something to do with this dis-crepancy, but random sampling of cells must also play a part.Consequently it is considered preferable to examine both

smears, or a single smear consisting of the pooled materialfrom both spatulae. Pooling of material has been shown to beas accurate as separated material,7 and in preliminary trials wehave shown that two cervical smears can be pooled on one slideto make a preparation that is microscopically acceptable.Further work is in progress to prove the value of these prep-arations as a routine screening procedure.We thank Sir Norman Talbot for help and advice and the staff

of the Margaret Pyke Centre for their cooperation; the staff of theBland-Sutton Institute Cytology Laboratory for the extra workburden they shouldered; Mr. M. M. Boddington and Dr A. I. Spriggs(Oxford) for helpful advice; and Mr A. McGill, Computer ServicesDepartment, Middlesex Hospital Medical School for statistical ana-lysis.

REFERENCES

1. Richart, R. M., Vaillant, H. Cancer, 1965, 18, 1478.2. Foote, F. W., Jr., Stewart, F. W. ibid, 1948, 1, 431.3. Pryzbora, L. A., Plutowa, A. ibid, 1959, 12, 263.4. Wachtel, E., Gordon, H. Lancet, 1974, ii, 26.5. Sedlis, A., Walters, A. T., Dalis, H., Hontz, A., Lo Scuito, L. Acta cytol.

1974, 18, 291.6. Shulman, J. J., Hontz, A., Sedlis, A., Walters, A. T., Balin, H., Lo Scuito,

L. Am. J. Obstet. Gynec. 1975,121, 1024.7. Wilbanks, G. D., Ikomi, E., Prado, R. B., Richart, R. M. Acta cytol. 1968,

12, 157.

Reviews of Books

Nutrition and the Developing Nervous SystemPHILIP R. DODGE, M.D., ARTHUR L. PRENSKY, M.D., RALPH D.FEIGIN, M.D., Washington University School of Medicine, SaintLouis, Missouri. St Louis: Mosby. London: Kimpton. 1975. Pp.538.$49.50; &pound; 27.25.

NOT many textbooks of neurology say much about nutri-tional neuropathology. Those that do contain little more thana few notes on specific conditions such as beri beri. Neverthe-less the chances are that nutritional neuropathology affects im-mensely more people in the world than all the patients theworld’s neurologists will ever see. Every neurologist knowsabout Wernicke’s encephalopathy which is not a widespreadscourge in the underprivileged world, yet most of the world’schildren are seriously underfed when their brains are growingfast, and this seems to reduce their eventual achievement inways that classical neurology will not easily detect. There is agreat upsurge of interest in the effects of malnutrition on the

developing brain and this volume is, therefore, timely. DrDodge and his coauthors have written a very learned text in-deed, and it is unlikely that anyone will tackle the subject socomprehensively for a long time. Two substantial sections onnormal cerebral maturation and the role of nutrition in

general somatic growth introduce a critical account of the in-fluence of undernutrition on the growth and development ofthe nervous system. Neither of the first two sections will satisfythe orthodox developmental neurologist or the nutritional

anthropometrician since they concentrate largely on those im-portant other terms and indices of neurological, behaviouraland somatic development which enable the main subject to beseriously studied. There follow three shorter sections on

minerals, vitamins, and diseases of aminoacid metabolism andtheir influence on brain development. We are left, correctly,with a feeling that the colossal human importance of the sub-ject is matched only by the difficulties of investigating it andour consequent ignorance. One central issue is the matter ofvulnerable periods in the physical development of the brain,and it is a pity-and rather surprising-that this is not veryclearly discussed. Specifically the recent finding that thehuman brain-growth spurt (which supposedly correspondswith its vulnerable period to undernutrition) extends well intothe second year of postnatal life, and possibly beyond, is

ignored in favour of the earlier idea that it ends shortly afterbirth. The matter is of great practical importance, since it ismuch easier to promote good brain growth postnatally than inthe fetus. The size and erudition of this book, the first seriousone of its kind, whatever its detailed deficiencies, reveals anappreciation of the infinite complexities of the subject. DrDodge and his colleagues will have rendered an important ser-vice if they stimulate a wider interest and further seriousresearch into this very pressing human problem.

UrologyEdited by JOHN BLANDY, F.R.C.S., London Hospital Medical Col-lege. Oxford: Blackwell. 1976. Pp. 1303 (2 vols). &pound;46.

BLANDY ’76, a full-bodied volume with a clean, fresh

approach which encourages further acquaintance and shouldkeep well. This is the best urological textbook yet. There arelittle over 100 urological surgeons in Britain from which aredrawn most of the 35 authors for this two-volume treatise ofBritish urological practice. Professor Blandy has contributed anumber of sections personally and has skilfully directed theothers to produce a uniform book illuminated by manyhundreds of clear line drawings and photographs. Reading itis a pleasure and if it is picked up for a specific purpose it posi-tively encourages further unnecessary investigation (of thebook, that is)-a rare attribute in a 1300-page work. A booklike this has to serve many purposes. The urologist will use itas a ready source of reference when confronted by a difficultor unusual problem or preparing a lecture. He will not be dis-appointed. The concise text is a summary of up-to-date factsand opinions from which the most experienced will find some-thing of help, interest, or information, backed by modern ac-cessible references. The student of urology can find within ita framework on which to build his clinical experience. Fromhis point of view the book is free from those irritating, unsup-ported dogmatic statements found in most authoritarianvolumes. The person who will probably use it most frequentlyis the general surgeon with an interest in urology who is work-ing alone and for whom the book provides a digest of the ex-perience and attitudes of his full-time colleagues. For his pur-pose it is the best alternative yet to a friendly clinicaldiscussion over a cup of tea. In an underfinanced health serviceone man and a copy of this book may yet replace the desirabletwo-man urological department.