594
BRITISH MEDICAL JOURNAL
5 MARCH 1977
threatening injuries of 86" . Only 280o of unbelted occupants escaped injury, compared with 420 of those who were belted. Nearly a quarter of those who were thrown out of the vehicle were killed, accounting for nearly one-half of all deaths in the series-seat belts give important protection in this case. The controversial issue of the occupant being trapped by a seat belt when the vehicle catches fire or is submerged in water was also studied. Only three vehicles in the whole series caught fire, and in only one of these was the occupant trapped-and he had already died of injuries before the fire started. A much higher rate of belt wearing was found among cars with "automatic" (coil inertia) belts than with static belts. Seat belts also reduced the severity of penetration injuries, and severe injury to the head and spine was twice as common among car occupants not wearing belts. These findings are important in view of the increase in cases of permanent incapacity resulting from road accidents. In the United States roughly half of all injuries of the spinal cord occur as a result of motor vehicle crashes-amounting to 5315 cases in 1974, or 25 per million population.4 Of these, 3377 survived long enough to be admitted to hospital and only 388 were discharged as functionally recovered. No fewer than 477 people died after admission; 1091 patients survived with quadriplegia and permanent impairment and 1501 with paraplegia and permanent impairment. Over half the victims were aged 16-35, and there were over twice as many men as women. The costs to the community are enormous, notwithstanding the decreased life expectancy. The Melbourne conference did little to clear up the controversy whether airbags or seat belts offer the more practicable and effective method of injury protection. Those favouring seat belts pointed out that the airbag may be ineffective in protecting the occupant unless he is already restrained by a lap belt, and that the airbag provides protection only during the initial impact. Probably the best protection is to be obtained by using both. Meanwhile, our priority in Britain must be to increase the frequency of seat belt wearing. Increasing the rate to 8500 of front seat occupants would reduce the annual number of fatal and serious injuries by 13 000.
recent Henry Windsor Lecture' presented a five-year follow-up study of 1130 patients. Only in 1973 did an international meeting agree on a method of staging melanoma by degree of invasion, so that there may be difficulties in comparing Dr Davis's figures with those published from other centres, but his survival rates are the best yet recorded. Using histological criteria described by McGovern et a12 the Queensland project reported a 1000( survival for stage 1; 93-1 ", for stage 2; 80 6", for stage 3; and 37 811() for stage 4 lesions. Compared with the universally gloomy prognosis given for malignant melanoma a generation ago these figures show a remarkable improvement. How far is the better outlook for patients with melanoma due to health education about cancer ? The major source of finance for the Queensland project has been the Queensland Cancer Fund-a fund-raising organisation which takes an interest in cancer on a wide front-research, education, patients' welfare, and provision of buildings and equipment. Expenditure over the years has totalled $A2 450 000, and of this $500 000 has been used for education directed at both the general public and the medical profession. In the year ended December 1975 the fund's educational activities included public forums, professional seminars, the distribution of brochures, posters and films, and presentations on press and radio. The Queensland Health Education Council, a Statefinanced body, is also active in cancer education, and both these activities seem to have been of benefit. One opinion poll conducted by an independent body after the national cancer education campaign last year showed that Queenslanders are 170, more likely than other Australians to have an optimistic attitude about the chances of a cure for an early cancer. The achievements of both the fund and the project are encouraging not only in terms of the possibility of a cure of melanoma if treated early in its biological life but also as an indication of the value of education about the detection and early treatment of cancer. Unfortunately, however, Queenslanders still show little sign that they have learnt how important it is to protect both themselves and their children from the damaging effects of the sun's rays.
Nordentroft, E L, Effect of Mandatory Seat Belt Legislation in Denmark. Paper read at 6th International Conference of the International Association for Accident and Traffic Medicine, 31 January-4 February 1977. 2 Andreasson, R, Medical Exemtiptions fromiz Seat Belt Requiremnents. Paper read at 6th International Conference of the International Association for Accident and Traffic Medicine, 31 January-4 February 1977. Transport and Road Research Laboratory, Alleviation of Injuries by Use of Seat Belts. Crowthorne, Leaflet LF 633, January 1977. 4 Smart, C N, and Sanders, C R, The Costs of Motor Vehicle Related Spinal Cord Inijuries. Washington, DC, Insurance Institute for Highway
Davis, N C, et al, Auistralian and Nezw Zealand J7ournal of Suirgery, 1976, 46, 188. McGovern, V J, et al, Medical Jour^nal of Auistralia, 1967, 1, 123.
Safety, 1976.
Melanoma in Queensland Much of the state of Queensland (which extends from latitude 10°S to 29°S) is very dry. But even on the moist coast-where most of the population live-the hours of sunshine are long, the population is addicted to outdoor pursuits, and the incidence of damage to the skin by solar irradiation is very high. This last unfortunate fact has been turned to good advantage by the Queensland Melanoma Project. Established in 1963, the project has published some 40 papers on its experience of melanoma in Queensland. From its inception the project co-ordinator has been Dr Neville Davis, who in a
Sex and juvenile diabetes In contrast to the mass of data on adult-onset diabetes, we have little accurate information on the overall prevalence of juvenile diabetes. Estimates1 2 Of its prevalence vary from 1 in 1200 to 1 in 6000 children under 17-almost all insulindependent juvenile diabetics. A mild, often asymptomatic, type of diabetes has recently been described in children,3 but the number affected is unknown. Indeed, the distribution of juvenile diabetes may resemble the adult pattern, in that studies often find as many previously unknown as known diabetics.2 Population statistics of disease frequency are approximate at best, and it is against this somewhat suspect background of incomplete information that sex ratios in juvenile diabetes should be viewed. The US Department of Health found4 a small excess of females in the diabetic population under 25 in the years 1959-65. The exact ratio varied from year to year-a pheno-
BRITISH MEDICAL JOURNAL
5 MARCH 1977
menon which has been more striking in adult diabetes.5 6 A survey among children under 16 years in Erie County, New York,7 found a similar sex distribution, but again the differences were very small. On the other hand, a recent British report8 showed the reverse, the male prevalence up to age 26 being 3-2 per 1000 and the female prevalence 2-8. The most accurate information about diabetic children in Great Britain and Ireland is to be found in a register sponsored by the British Diabetic Association. Notifications between 1972 and 1974 showed an excess of boys from 0 to 4 years and from 11 to 15 years and of girls from 5 to 10 years.9 Overall there were more boys (1279) than girls (1145), and the minimum annual incidence for both sexes combined was 8 cases per 100 000. Added weight is lent to these figures by the very close similarity of sex ratios in diabetic Israeli children of equivalent age groups.'0 Can these sex differences be satisfactorily explained ? Both genetic" and environmental factors are thought to be important in juvenile diabetes. There is mounting evidence, mostly circumstantial, that viruses may initiate the pathogenetic process in some cases of insulin-dependent diabetes.'2 Coxsackie B,'3-15 mumps,'6 and rubellal7 viruses have each been implicated. Now sex differences are known to occur in the incidence of childhood viral infections. In both Britain'8 I"' and the United -States2" Coxsackie B infections are twice as common in boys as in girls, and a similar male preponderance has been described in outbreaks of Coxsackie A virus,21
echovirus,2: and poliovirus24 infections. Boys may come into closer contact with each other during play than girls, but this seems unlikely to be the whole explanation. The newly described Y-linked histocompatibility locus25 raises the possibility of hereditary sexual differences in susceptibility to adenovirus,22
infections. An investigation of schoolchildren aged 9-12 years found higher mean serum insulin concentrations in girls than in boys one hour after a 50-g oral glucose load.26 The antagonistic action on insulin of higher serum concentrations of oestrogen and growth hormone in the prepubertal girls was suggested as a possible cause. There is substantial evidence that female hormones may influence the onset and clinical course of diabetes in later life: pregnancy may unmask latent diabetes or aggravate pre-existing disease, and multiparous women are much more likely to develop diabetes than women with no children.27 Surprisingly, the effect of parity is delayed for many years. Oral oestrogens may cause deterioration of glucose tolerance,28 and some women experience changes in diabetic control related to the menstrual cycle. Diabetic coma,2" urinary tract infections,3" and skin conditions such as necrobiosis lipoidica diabeticorum31 and lipoatrophy32 are all commoner in women than in men, and the normal life expectation advantage of women over men is abolished in female diabetics by the susceptibility to coronary disease.33 Microangiopathic complications affect the sexes equally. Juvenile diabetes may lend itself to subdivision into separate entities with different aetiologies.34 : One suggestion is that individuals may vary in their genetic susceptibility to diabetogenic viruses.36 37 The excess of males with childhood diabetes may be explained by the tendency for enterovirus infections to be commoner in boys than girls.' 8- 2() Furthermore, the prevalence of infections with different virus types varies from year to year and country to country; this might explain temporal and geographical variations in sex incidence. Beardmore, M, and Reid, J J A, British Medical Journal, 1966, 2, 1383. Jarrett, R J, British J'ournal of Hospital Medicine, 1976, 16, 200. 3 Tattersall, R B, Quarterly J7ournal of Medicine, 1974, 43, 339.
I
2
595
Jloslin's Diabetes Mellituts,
11th edn, ed Marble A, et al, p 13. Philadelphia, Lea and Febiger, 1971. 5 Malins, J M, FitzGerald, M G, and Wall, M, Diabetologia, 1965, 1, 121. 6 Nicholson, W A, British Medical3Journal, 1971, 4, 465. 7Sultz, H A, Schlesinger, E R, and Mosher, W E, American Journal of Public Health, 1968, 58, 491. Wadsworth, M E J, and Jarrett, R J, Lancet, 1974, 2, 1172. 9 Bloom, A, Hayes, T M, and Gamble, D R, British Medical Journal, 1975, 3, 580. '"Cohen, T, Nelken, L, and Wolfsohn, H, Diabetes, 1970, 19, 585. Penrose, L S, and Watson, E M, Proceedings of the American Diabetes Association, 1945, 5, 165. 12 Steinke, J, and Taylor, K W, Diabetes, 1974, 23, 631. 13 Gamble, D R, and Taylor, K W, British 1969, 3, 631. 14 Gamble, D R, et al, British Medical3Journal, 1969, 3, 627. 5 Gamble, D R, Taylor, K W, and Cumming, H, British Medical3Journal, 1973, 4, 260. 6 Sultz, H A, et al, J7ournal of Pediatrics, 1975, 86, 654. 17 Forrest, J M, Menser, M A, and Burgess, J A, Lancet, 1971, 2, 332. 18 British Medical Journal, 1971, 2, 178. 19 British 1972, 1, 453. 211 Lennette, E H, Magoffin, R L, and Knouf, E G,3Journal of the American Medical Association, 1962, 179, 687. 21 Connolly, J H, and O'Neill, H J, Ulster 1971, 40, 146. 22 Sutton, R N P, et al, Lancet, 1976, 2, 987. 23 Connolly, J H, and O'Neill, H J, Ulster Medical Journal, 1972, 41, 155. 24 Hall, W J, Nathanson, N, and Langmuir, A D, American Journal of Hygiene, 1957, 66, 214. 25 Lancet, 1976, 2, 1008. 2t; Florey, C du V, Lowy, C, and Uppal, S, Diabetologia, 1976, 12, 313. 27 Pyke, D A, Lancet, 1956, 1, 818. 28 Spellacy, W N, American Journal of Obstetrics and Gynecology, 1969, 104, 448. 29 Hockaday, T D R, and Alberti, K G M M, British Journal of Hospital Medicine, 1972, 7, 183. 30 Thornton, G F, Medical Clinics of North America, 1971, 55, 931. 31 Braverman, I M, Medical Clinics of North America, 1971, 55, 1019. 32 Pyke, D A, Postgraduate Medical3Journal, 1971, 47, January suppl, p 54. 33 Pyke, D A, Postgraduate Medical Journal, 1968, 44, 966. 34 Cudworth, A G, British Journal of Hospital Medicine, 1976, 16, 207. 35 Bottazzo, G F, and Doniach, D, Lancet, 1976, 2, 800. 36 Nelson, P G, et al, Lancet, 1975, 2, 193. 37 Nelson, P G, Pyke, D A, and Gamble, D R. British Medical Journal, 1975, 4, 249.
Medical_Journal,
Medical_Journal,
Medical_Journal,
Breast conservation in mammary carcinoma In recent years publications on the management of primary carcinoma of the breast have been dominated by the radicalversus-conservative controversy, complicated recently by a superimposed debate on the place of adjuvant systemic chemotherapy. Perhaps of more interest to the average woman than whether or not her axilla should be entered is the place for breast conservation in the treatment of primary carcinoma. Contrary to the stereotype image, today's breed of surgeon is in fact well aware of the psychological insult that may result from mastectomy. This gives a compassionate motive for preserving the breast, but there is also a widely held view that should the public be aware that a lump in the breast need not necessarily imply a mastectomy women would present themselves earlier in the development of the disease. A recent study by Watts' was started with these motives in mind. He described a series of 200 cases spread over seven years in which subcutaneous mastectomy was followed by reconstruction using a silicone implant. Selection of favourable cases presenting with small carcinomata made comparison with conventional treatment of little value. Nevertheless, the local recurrence rate of 60 and the fact that there were only four deaths from carcinoma suggest that this method of treatment warrants serious consideration. Watts's conclusions, however, were couched in emotive language and should not go without challenge. "Perhaps most important of all," he wrote, "is the ,
BRITISH MEDICAL JOURNAL
5 MARCH 1977
threatening injuries of 86" . Only 280o of unbelted occupants escaped injury, compared with 420 of those who were belted. Nearly a quarter of those who were thrown out of the vehicle were killed, accounting for nearly one-half of all deaths in the series-seat belts give important protection in this case. The controversial issue of the occupant being trapped by a seat belt when the vehicle catches fire or is submerged in water was also studied. Only three vehicles in the whole series caught fire, and in only one of these was the occupant trapped-and he had already died of injuries before the fire started. A much higher rate of belt wearing was found among cars with "automatic" (coil inertia) belts than with static belts. Seat belts also reduced the severity of penetration injuries, and severe injury to the head and spine was twice as common among car occupants not wearing belts. These findings are important in view of the increase in cases of permanent incapacity resulting from road accidents. In the United States roughly half of all injuries of the spinal cord occur as a result of motor vehicle crashes-amounting to 5315 cases in 1974, or 25 per million population.4 Of these, 3377 survived long enough to be admitted to hospital and only 388 were discharged as functionally recovered. No fewer than 477 people died after admission; 1091 patients survived with quadriplegia and permanent impairment and 1501 with paraplegia and permanent impairment. Over half the victims were aged 16-35, and there were over twice as many men as women. The costs to the community are enormous, notwithstanding the decreased life expectancy. The Melbourne conference did little to clear up the controversy whether airbags or seat belts offer the more practicable and effective method of injury protection. Those favouring seat belts pointed out that the airbag may be ineffective in protecting the occupant unless he is already restrained by a lap belt, and that the airbag provides protection only during the initial impact. Probably the best protection is to be obtained by using both. Meanwhile, our priority in Britain must be to increase the frequency of seat belt wearing. Increasing the rate to 8500 of front seat occupants would reduce the annual number of fatal and serious injuries by 13 000.
recent Henry Windsor Lecture' presented a five-year follow-up study of 1130 patients. Only in 1973 did an international meeting agree on a method of staging melanoma by degree of invasion, so that there may be difficulties in comparing Dr Davis's figures with those published from other centres, but his survival rates are the best yet recorded. Using histological criteria described by McGovern et a12 the Queensland project reported a 1000( survival for stage 1; 93-1 ", for stage 2; 80 6", for stage 3; and 37 811() for stage 4 lesions. Compared with the universally gloomy prognosis given for malignant melanoma a generation ago these figures show a remarkable improvement. How far is the better outlook for patients with melanoma due to health education about cancer ? The major source of finance for the Queensland project has been the Queensland Cancer Fund-a fund-raising organisation which takes an interest in cancer on a wide front-research, education, patients' welfare, and provision of buildings and equipment. Expenditure over the years has totalled $A2 450 000, and of this $500 000 has been used for education directed at both the general public and the medical profession. In the year ended December 1975 the fund's educational activities included public forums, professional seminars, the distribution of brochures, posters and films, and presentations on press and radio. The Queensland Health Education Council, a Statefinanced body, is also active in cancer education, and both these activities seem to have been of benefit. One opinion poll conducted by an independent body after the national cancer education campaign last year showed that Queenslanders are 170, more likely than other Australians to have an optimistic attitude about the chances of a cure for an early cancer. The achievements of both the fund and the project are encouraging not only in terms of the possibility of a cure of melanoma if treated early in its biological life but also as an indication of the value of education about the detection and early treatment of cancer. Unfortunately, however, Queenslanders still show little sign that they have learnt how important it is to protect both themselves and their children from the damaging effects of the sun's rays.
Nordentroft, E L, Effect of Mandatory Seat Belt Legislation in Denmark. Paper read at 6th International Conference of the International Association for Accident and Traffic Medicine, 31 January-4 February 1977. 2 Andreasson, R, Medical Exemtiptions fromiz Seat Belt Requiremnents. Paper read at 6th International Conference of the International Association for Accident and Traffic Medicine, 31 January-4 February 1977. Transport and Road Research Laboratory, Alleviation of Injuries by Use of Seat Belts. Crowthorne, Leaflet LF 633, January 1977. 4 Smart, C N, and Sanders, C R, The Costs of Motor Vehicle Related Spinal Cord Inijuries. Washington, DC, Insurance Institute for Highway
Davis, N C, et al, Auistralian and Nezw Zealand J7ournal of Suirgery, 1976, 46, 188. McGovern, V J, et al, Medical Jour^nal of Auistralia, 1967, 1, 123.
Safety, 1976.
Melanoma in Queensland Much of the state of Queensland (which extends from latitude 10°S to 29°S) is very dry. But even on the moist coast-where most of the population live-the hours of sunshine are long, the population is addicted to outdoor pursuits, and the incidence of damage to the skin by solar irradiation is very high. This last unfortunate fact has been turned to good advantage by the Queensland Melanoma Project. Established in 1963, the project has published some 40 papers on its experience of melanoma in Queensland. From its inception the project co-ordinator has been Dr Neville Davis, who in a
Sex and juvenile diabetes In contrast to the mass of data on adult-onset diabetes, we have little accurate information on the overall prevalence of juvenile diabetes. Estimates1 2 Of its prevalence vary from 1 in 1200 to 1 in 6000 children under 17-almost all insulindependent juvenile diabetics. A mild, often asymptomatic, type of diabetes has recently been described in children,3 but the number affected is unknown. Indeed, the distribution of juvenile diabetes may resemble the adult pattern, in that studies often find as many previously unknown as known diabetics.2 Population statistics of disease frequency are approximate at best, and it is against this somewhat suspect background of incomplete information that sex ratios in juvenile diabetes should be viewed. The US Department of Health found4 a small excess of females in the diabetic population under 25 in the years 1959-65. The exact ratio varied from year to year-a pheno-
BRITISH MEDICAL JOURNAL
5 MARCH 1977
menon which has been more striking in adult diabetes.5 6 A survey among children under 16 years in Erie County, New York,7 found a similar sex distribution, but again the differences were very small. On the other hand, a recent British report8 showed the reverse, the male prevalence up to age 26 being 3-2 per 1000 and the female prevalence 2-8. The most accurate information about diabetic children in Great Britain and Ireland is to be found in a register sponsored by the British Diabetic Association. Notifications between 1972 and 1974 showed an excess of boys from 0 to 4 years and from 11 to 15 years and of girls from 5 to 10 years.9 Overall there were more boys (1279) than girls (1145), and the minimum annual incidence for both sexes combined was 8 cases per 100 000. Added weight is lent to these figures by the very close similarity of sex ratios in diabetic Israeli children of equivalent age groups.'0 Can these sex differences be satisfactorily explained ? Both genetic" and environmental factors are thought to be important in juvenile diabetes. There is mounting evidence, mostly circumstantial, that viruses may initiate the pathogenetic process in some cases of insulin-dependent diabetes.'2 Coxsackie B,'3-15 mumps,'6 and rubellal7 viruses have each been implicated. Now sex differences are known to occur in the incidence of childhood viral infections. In both Britain'8 I"' and the United -States2" Coxsackie B infections are twice as common in boys as in girls, and a similar male preponderance has been described in outbreaks of Coxsackie A virus,21
echovirus,2: and poliovirus24 infections. Boys may come into closer contact with each other during play than girls, but this seems unlikely to be the whole explanation. The newly described Y-linked histocompatibility locus25 raises the possibility of hereditary sexual differences in susceptibility to adenovirus,22
infections. An investigation of schoolchildren aged 9-12 years found higher mean serum insulin concentrations in girls than in boys one hour after a 50-g oral glucose load.26 The antagonistic action on insulin of higher serum concentrations of oestrogen and growth hormone in the prepubertal girls was suggested as a possible cause. There is substantial evidence that female hormones may influence the onset and clinical course of diabetes in later life: pregnancy may unmask latent diabetes or aggravate pre-existing disease, and multiparous women are much more likely to develop diabetes than women with no children.27 Surprisingly, the effect of parity is delayed for many years. Oral oestrogens may cause deterioration of glucose tolerance,28 and some women experience changes in diabetic control related to the menstrual cycle. Diabetic coma,2" urinary tract infections,3" and skin conditions such as necrobiosis lipoidica diabeticorum31 and lipoatrophy32 are all commoner in women than in men, and the normal life expectation advantage of women over men is abolished in female diabetics by the susceptibility to coronary disease.33 Microangiopathic complications affect the sexes equally. Juvenile diabetes may lend itself to subdivision into separate entities with different aetiologies.34 : One suggestion is that individuals may vary in their genetic susceptibility to diabetogenic viruses.36 37 The excess of males with childhood diabetes may be explained by the tendency for enterovirus infections to be commoner in boys than girls.' 8- 2() Furthermore, the prevalence of infections with different virus types varies from year to year and country to country; this might explain temporal and geographical variations in sex incidence. Beardmore, M, and Reid, J J A, British Medical Journal, 1966, 2, 1383. Jarrett, R J, British J'ournal of Hospital Medicine, 1976, 16, 200. 3 Tattersall, R B, Quarterly J7ournal of Medicine, 1974, 43, 339.
I
2
595
Jloslin's Diabetes Mellituts,
11th edn, ed Marble A, et al, p 13. Philadelphia, Lea and Febiger, 1971. 5 Malins, J M, FitzGerald, M G, and Wall, M, Diabetologia, 1965, 1, 121. 6 Nicholson, W A, British Medical3Journal, 1971, 4, 465. 7Sultz, H A, Schlesinger, E R, and Mosher, W E, American Journal of Public Health, 1968, 58, 491. Wadsworth, M E J, and Jarrett, R J, Lancet, 1974, 2, 1172. 9 Bloom, A, Hayes, T M, and Gamble, D R, British Medical Journal, 1975, 3, 580. '"Cohen, T, Nelken, L, and Wolfsohn, H, Diabetes, 1970, 19, 585. Penrose, L S, and Watson, E M, Proceedings of the American Diabetes Association, 1945, 5, 165. 12 Steinke, J, and Taylor, K W, Diabetes, 1974, 23, 631. 13 Gamble, D R, and Taylor, K W, British 1969, 3, 631. 14 Gamble, D R, et al, British Medical3Journal, 1969, 3, 627. 5 Gamble, D R, Taylor, K W, and Cumming, H, British Medical3Journal, 1973, 4, 260. 6 Sultz, H A, et al, J7ournal of Pediatrics, 1975, 86, 654. 17 Forrest, J M, Menser, M A, and Burgess, J A, Lancet, 1971, 2, 332. 18 British Medical Journal, 1971, 2, 178. 19 British 1972, 1, 453. 211 Lennette, E H, Magoffin, R L, and Knouf, E G,3Journal of the American Medical Association, 1962, 179, 687. 21 Connolly, J H, and O'Neill, H J, Ulster 1971, 40, 146. 22 Sutton, R N P, et al, Lancet, 1976, 2, 987. 23 Connolly, J H, and O'Neill, H J, Ulster Medical Journal, 1972, 41, 155. 24 Hall, W J, Nathanson, N, and Langmuir, A D, American Journal of Hygiene, 1957, 66, 214. 25 Lancet, 1976, 2, 1008. 2t; Florey, C du V, Lowy, C, and Uppal, S, Diabetologia, 1976, 12, 313. 27 Pyke, D A, Lancet, 1956, 1, 818. 28 Spellacy, W N, American Journal of Obstetrics and Gynecology, 1969, 104, 448. 29 Hockaday, T D R, and Alberti, K G M M, British Journal of Hospital Medicine, 1972, 7, 183. 30 Thornton, G F, Medical Clinics of North America, 1971, 55, 931. 31 Braverman, I M, Medical Clinics of North America, 1971, 55, 1019. 32 Pyke, D A, Postgraduate Medical3Journal, 1971, 47, January suppl, p 54. 33 Pyke, D A, Postgraduate Medical Journal, 1968, 44, 966. 34 Cudworth, A G, British Journal of Hospital Medicine, 1976, 16, 207. 35 Bottazzo, G F, and Doniach, D, Lancet, 1976, 2, 800. 36 Nelson, P G, et al, Lancet, 1975, 2, 193. 37 Nelson, P G, Pyke, D A, and Gamble, D R. British Medical Journal, 1975, 4, 249.
Medical_Journal,
Medical_Journal,
Medical_Journal,
Breast conservation in mammary carcinoma In recent years publications on the management of primary carcinoma of the breast have been dominated by the radicalversus-conservative controversy, complicated recently by a superimposed debate on the place of adjuvant systemic chemotherapy. Perhaps of more interest to the average woman than whether or not her axilla should be entered is the place for breast conservation in the treatment of primary carcinoma. Contrary to the stereotype image, today's breed of surgeon is in fact well aware of the psychological insult that may result from mastectomy. This gives a compassionate motive for preserving the breast, but there is also a widely held view that should the public be aware that a lump in the breast need not necessarily imply a mastectomy women would present themselves earlier in the development of the disease. A recent study by Watts' was started with these motives in mind. He described a series of 200 cases spread over seven years in which subcutaneous mastectomy was followed by reconstruction using a silicone implant. Selection of favourable cases presenting with small carcinomata made comparison with conventional treatment of little value. Nevertheless, the local recurrence rate of 60 and the fact that there were only four deaths from carcinoma suggest that this method of treatment warrants serious consideration. Watts's conclusions, however, were couched in emotive language and should not go without challenge. "Perhaps most important of all," he wrote, "is the ,
