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MAMMOGRAPHY
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distinction between a simple and a polyarteritis-nodosa form of rheumatoid neuropathy especially if the latter really has a characteristic mononeuritic form, since detection of this form would suggest a developing polyarteritis nodosa with more serious implications than the simple, apparently non-necrotising, form of rheumatoid arteritis. Moreover Bleehen et al. thought that in polyarteritis-nodosa neuropathy there was evidence that corticosteroids and also penicillin or other antibiotics had a deleterious effect. In disclosing a necrotising type of arteritis the Middlesex Hospital workers were able to demonstrate the value of nerve-nutrient artery-muscle biopsy which includes examination of a cutaneous nerve adjacent to the biopsied muscle together with the nutrient artery to the nerve. MAMMOGRAPHY
WHEN a woman with disease of the breast comes to her doctor the first questions he must answer are whether this is cancer or likely to become cancer. The earliest manifestation of cancer is a lump; hence, in season and out, surgeons have ruled that no lump must be permitted to remain in the breast. Find the lump; remove it; and send it to the pathologist. The rule brooks no exception. Even the most obviously benign lump (a fibroadenoma in an adolescent girl, for example) must be removed and microscopically examined, both because its continued existence is a source of worry to the patient and her relations, and because-admittedly in exceptional circumstances-the alarm may prove to have been justified.
equal part with of the breast, can, it now seems, be equally helpful in the diagnosis and prognosis of breast disease. Younggives figures from various centres which indicate a high degree of accuracy of diagnosis by means of a special technique of radiography applied to the breast. Can the radiologist reveal a lump which has eluded the clinician ? Holmes2 describes six cases in which mammography disclosed cancer or changes suggesting cancer. In some, the biopsy specimens later gave no evidence of malignancy, but the previous positive X-ray findings prompted another exploration which brought the cancerous area to light. As Youngremarks, asymptomatic, non-palpable breast tumours only a few millimetres in diameter were detected radiographically by Egan3 and Gershon-Cohen.4 Lumps of this size cannot easily be identified clinically. In the course of regular six-monthly radiography of the breast in 1055 women without overt breast lesions, Gershon-Cohen4 discovered carcinomas in 35.
Radiologists,
who
already play
surgeons in the treatment of
an
cancer
Youngcites French workers5 who say that the oedema associated with the rapidly growing and fatal " " inflammatory carcinoma of the breast can be detected earlier radiologically than clinically. This form of cancer (often erroneously linked with pregnancy) is a diagnostic pitfall; and here, also, preliminary radiography may be useful. Cancer of the breast is bilateral in 2% of cases, and mammography of the contralateral breast might identify most of these cases.1 For recognition of the lesion in the, breast, the radiologist relies essentially on outlining the contours of a circum1. 2. 3. 4. 5.
Young, B. Proc. R. Soc. Med. 1963, 56, 772. Holmes, P. ibid. p. 775. Egan, R. L. Amer. J. Roentgenol. 1963, 89, 129. Gershon-Cohen, J. J. Amer. med. Ass. 1961, 176, 1114. Surmont, J., Desprez-Curely, J. P., Picard, J. D., Babinet-Robas, J., Szigeti, B. J. Radiol. Electrol. 1961, 42, 346.
scribed opacity, and on displaying various types of calcification. These are not entirely specific, and other signs mentioned by Samuel,6 such as nipple retraction or skin thickening and dimpling, should not need radiography for their detection. Not even the most enthusiastic advocate suggests that radiography can or should supplant clinical examination and biopsy in the diagnosis of breast lesions. Surgeons have long known that the well-defined tumour -usually the medullary type-carries a better prognosis than the infiltrating kind. Radiography, apparently, can distinguish this circumscribed tumour as well as mucoid and gelatinous growths early on in their evolution.1 Recognition at an early stage of these less malignant types of cancer could justify less radical operations. Yet even here one, hesitates. As Young says, " we are slowly realising that no two tumours are alike ". In the present stage of its development mammography must never be made an excuse for delaying microscopic examination of every unusual lump in the breast. ESTABLISHING THE CAUSE OF POLYURIA
OCCASIONALLY the diagnosis of diabetes insipidus from psychogenic polydipsia presents considerable difficulty, and several tests have been suggested to differentiate between them. These have included administration of nicotine or hypertonic saline and dehydration, but none has proved entirely satisfactory. The deprivation of water for a period-often hours-required for some tests is extremely distressing and may be dangerous for a patient with severe diabetes insipidus; and a shorter deprivation test, depending on differences between serum and urine osmolarity, has been proposed by Dashe et al.7 All subjects with renal disease were excluded by other means. The test consisted in withholding water for 61/2 hours and taking samples of serum and urine at the beginning, the middle, and the end of this period. In the control group of patients the level of serum osmolarity remained very constant throughout the test, and the ratio of urine to serum osmolarity during the last hour ranged from 1.9 to 5-2. Half the patients with known diabetes insipidus had a high, and the other half a normal, serum osmolarity at the beginning of the test; but the latter showed the biggest changes at the end of the test. None showed in the last hour a change in the urine-to-serum ratio as great as in any of the control subjects. The chief interest lay in a small group of patients with psychogenic polydipsia and of volunteers who had accustomed themselves to drink eight litres daily. Two of the former initially had a subnormal level of serum osmolarity; but all the others were in the normal range and, in contrast to the patients with known diabetes insipidus, these subjects had normal serum osmolarity throughout the test. Moreover they all showed a greater ratio of urine to serum osmolarity than any of the patients with known diabetes
insipidus. This simple test, therefore, differentiated completely between psychogenic polydipsia and true diabetes insipidus in the hands of its originators, and it commonly picked out patients with known pituitary disease that was not severe enough to require treatment with vasopressin. A test of this kind might well be adopted as a routine nrncedure. 6. 7.
Samuel, E. Proc. R. Soc. Med. 1963, 56, 770. Dashe, A. M., Cramm, R. E., Crist, C. A., Habener, J. F., Solomon, D. H. J. Amer. med. Ass. 1963, 185, 699.
distinction between a simple and a polyarteritis-nodosa form of rheumatoid neuropathy especially if the latter really has a characteristic mononeuritic form, since detection of this form would suggest a developing polyarteritis nodosa with more serious implications than the simple, apparently non-necrotising, form of rheumatoid arteritis. Moreover Bleehen et al. thought that in polyarteritis-nodosa neuropathy there was evidence that corticosteroids and also penicillin or other antibiotics had a deleterious effect. In disclosing a necrotising type of arteritis the Middlesex Hospital workers were able to demonstrate the value of nerve-nutrient artery-muscle biopsy which includes examination of a cutaneous nerve adjacent to the biopsied muscle together with the nutrient artery to the nerve. MAMMOGRAPHY
WHEN a woman with disease of the breast comes to her doctor the first questions he must answer are whether this is cancer or likely to become cancer. The earliest manifestation of cancer is a lump; hence, in season and out, surgeons have ruled that no lump must be permitted to remain in the breast. Find the lump; remove it; and send it to the pathologist. The rule brooks no exception. Even the most obviously benign lump (a fibroadenoma in an adolescent girl, for example) must be removed and microscopically examined, both because its continued existence is a source of worry to the patient and her relations, and because-admittedly in exceptional circumstances-the alarm may prove to have been justified.
equal part with of the breast, can, it now seems, be equally helpful in the diagnosis and prognosis of breast disease. Younggives figures from various centres which indicate a high degree of accuracy of diagnosis by means of a special technique of radiography applied to the breast. Can the radiologist reveal a lump which has eluded the clinician ? Holmes2 describes six cases in which mammography disclosed cancer or changes suggesting cancer. In some, the biopsy specimens later gave no evidence of malignancy, but the previous positive X-ray findings prompted another exploration which brought the cancerous area to light. As Youngremarks, asymptomatic, non-palpable breast tumours only a few millimetres in diameter were detected radiographically by Egan3 and Gershon-Cohen.4 Lumps of this size cannot easily be identified clinically. In the course of regular six-monthly radiography of the breast in 1055 women without overt breast lesions, Gershon-Cohen4 discovered carcinomas in 35.
Radiologists,
who
already play
surgeons in the treatment of
an
cancer
Youngcites French workers5 who say that the oedema associated with the rapidly growing and fatal " " inflammatory carcinoma of the breast can be detected earlier radiologically than clinically. This form of cancer (often erroneously linked with pregnancy) is a diagnostic pitfall; and here, also, preliminary radiography may be useful. Cancer of the breast is bilateral in 2% of cases, and mammography of the contralateral breast might identify most of these cases.1 For recognition of the lesion in the, breast, the radiologist relies essentially on outlining the contours of a circum1. 2. 3. 4. 5.
Young, B. Proc. R. Soc. Med. 1963, 56, 772. Holmes, P. ibid. p. 775. Egan, R. L. Amer. J. Roentgenol. 1963, 89, 129. Gershon-Cohen, J. J. Amer. med. Ass. 1961, 176, 1114. Surmont, J., Desprez-Curely, J. P., Picard, J. D., Babinet-Robas, J., Szigeti, B. J. Radiol. Electrol. 1961, 42, 346.
scribed opacity, and on displaying various types of calcification. These are not entirely specific, and other signs mentioned by Samuel,6 such as nipple retraction or skin thickening and dimpling, should not need radiography for their detection. Not even the most enthusiastic advocate suggests that radiography can or should supplant clinical examination and biopsy in the diagnosis of breast lesions. Surgeons have long known that the well-defined tumour -usually the medullary type-carries a better prognosis than the infiltrating kind. Radiography, apparently, can distinguish this circumscribed tumour as well as mucoid and gelatinous growths early on in their evolution.1 Recognition at an early stage of these less malignant types of cancer could justify less radical operations. Yet even here one, hesitates. As Young says, " we are slowly realising that no two tumours are alike ". In the present stage of its development mammography must never be made an excuse for delaying microscopic examination of every unusual lump in the breast. ESTABLISHING THE CAUSE OF POLYURIA
OCCASIONALLY the diagnosis of diabetes insipidus from psychogenic polydipsia presents considerable difficulty, and several tests have been suggested to differentiate between them. These have included administration of nicotine or hypertonic saline and dehydration, but none has proved entirely satisfactory. The deprivation of water for a period-often hours-required for some tests is extremely distressing and may be dangerous for a patient with severe diabetes insipidus; and a shorter deprivation test, depending on differences between serum and urine osmolarity, has been proposed by Dashe et al.7 All subjects with renal disease were excluded by other means. The test consisted in withholding water for 61/2 hours and taking samples of serum and urine at the beginning, the middle, and the end of this period. In the control group of patients the level of serum osmolarity remained very constant throughout the test, and the ratio of urine to serum osmolarity during the last hour ranged from 1.9 to 5-2. Half the patients with known diabetes insipidus had a high, and the other half a normal, serum osmolarity at the beginning of the test; but the latter showed the biggest changes at the end of the test. None showed in the last hour a change in the urine-to-serum ratio as great as in any of the control subjects. The chief interest lay in a small group of patients with psychogenic polydipsia and of volunteers who had accustomed themselves to drink eight litres daily. Two of the former initially had a subnormal level of serum osmolarity; but all the others were in the normal range and, in contrast to the patients with known diabetes insipidus, these subjects had normal serum osmolarity throughout the test. Moreover they all showed a greater ratio of urine to serum osmolarity than any of the patients with known diabetes
insipidus. This simple test, therefore, differentiated completely between psychogenic polydipsia and true diabetes insipidus in the hands of its originators, and it commonly picked out patients with known pituitary disease that was not severe enough to require treatment with vasopressin. A test of this kind might well be adopted as a routine nrncedure. 6. 7.
Samuel, E. Proc. R. Soc. Med. 1963, 56, 770. Dashe, A. M., Cramm, R. E., Crist, C. A., Habener, J. F., Solomon, D. H. J. Amer. med. Ass. 1963, 185, 699.