719

patients, and in 2 instances the organisms were success-fully transferred to rabbits. The 5 patients were re-treated, and treponemes were again found in 3 of the re-treated patients and in 6 further patients of the originalgroup.5 In a study of treated late syphilis in the rabbit,23 animals with infections of 14-22 months’ durationwere treated with benzathine penicillin and the inguinalnodes were removed and examined a year later. Persist-

ing treponemes were demonstrated in 4 of the 18

surviving animals.The value of the F.v. technique in showing treponemes

in aqueous humour or in cerebrospinal fluid has beendemonstrated in a series of case-reports by LAWTONSMITH and his colleagues 6-11 and by GOLDMAN andGIRARD.12 One case 11 is of particular interest. A 77-year-old man with signs of tabes had eye changes and en-largement of the liver and spleen. Serum tests for

syphilis, including both the T.P.i. and F.T.A.-A.B.S. (fluo-rescent treponemal antibody-absorption) tests, were nega-tive and the cerebrospinal fluid showed only a raised pro-tein level and a slightly abnormal colloidal gold curve.Treponemes were found in the aqueous humour andcerebrospinal fluid and produced lesions in the squirrelmonkeys to which they were transferred. Treponemeswere also found in large numbers in biopsy materialfrom the patient’s liver.

It now seems established beyond reasonable doubtthat treponemes, presumably T. pallidum, may persist insome patients after the treatment of late infections withamounts of penicillin which are at present judged to beadequate. They have also been found in some untreatedpatients with clinical evidence of late lesions but whoseserological tests and cerebrospinal fluid findings are

otherwise negative. In these patients, the F.A. method ofdemonstrating the presence of treponemes is a very pro-mising diagnostic tool in carefully selected cases. It is alsoclear that these persisting treponemes can produce lesionsin animals; whether they are causing trouble in theirhuman host, or whether a stable host-parasite relation-ship has been established, is not known. According tosome of the case-reports, the patients had been treatedwith steroids; and this might well have upset a balancebetween treponeme and host.

Penicillin exerts a bactericidal effect only againstgrowing organisms. T. pallidum is a slow grower, witha generation time of about 30 hours. In early syphilis,multiplication of treponemes is at its maximum, but inthe late stage of the disease treponemes are fewerand are probably not actively multiplying so that peni-cillin may then be acting in unfavourable circumstances.No-one can yet say whether these observations will callfor modification of methods of treatment; but theyillustrate that syphilis is still a disease of surprises, andthe need for further research is plain.5. Yobs, A. R., Clark, J. W., Mothershed, S. E., Bullard, J. C., Artley,

C. W. ibid. 1968, 44, 116.6. Wells, J. A., Smith, J. L. Am. J. Ophthal. 1967, 63, 410.7. Smith, J. L., Israel, C. W. J. Am. med. Ass. 1967, 199, 980.8. Smith, J. L., Israel, C. W. Archs Ophthal. 1967, 77, 474.9. Smith, J. L., Israel, C. W., Harner, R. E. ibid. 1967, 78, 284.

10. Smith, J. L., Israel, C. W., McCrary, J. A., Harner, R. E. Am. J.Ophthal. 1968, 65, 242.

11. Smith, J. L., Israel, C. W. Br. J. vener. Dis. 1968, 44, 109.12. Goldman, J. N., Girard, K. F. Archs Ophthal. 1967, 78, 47, 716.

Annotations

INTERNATIONAL CLASSIFICATION OFBREAST TUMOURS

STATISTICIANS and demographers must feel there areas many classifications of disease as there are doctors,since lists of alternative names abound and discussionsflourish on why some have been adopted and othersdiscarded. The histological classification of tumours isan area where synonyms and parallel descriptions are

bound to proliferate as experience is gained, as theories ofhistogenesis advance, and as new subtleties are introducedin treatment which may change the course of the disease.International comparisons of incidence and of the effectsof treatment are obvious routes to new knowledge. Theywould be much simplified by international agreement ondetailed classification of tumours-a prospect which seemsremote.

The World Health Organisation, however, has graspedthis scabrous nettle, first in the classification of tumoursof the lung, and now for tumours of the breast in apamphlet edited by Prof. R. W. Scarff and Dr. H.Torloni which has 20 pages of English text and 40 verygood colour photomicrographs by Dr. W. Mutschlechner.Further editions in French, Russian, and Spanish are inpreparation. A team of twelve pathologists in ten countriesworked on 579 cases. An excellent preface summarisesthe reasons for making the attempt and the methodsused; and the actual classification proposed and somenotes on it occupy only 6 pages. A further 2 pages aredevoted to histological grading of the malignant varieties.The text is accompanied by a box of 50 35 mm. colourtransparencies, which are very good and would be usefulfor demonstrations to surgeons, though morbid anato-mists may find them no more helpful than the printedfigures.The classification is straightforward, and in the English

version the names are either descriptive of the histologicalappearances or conform to established theories of histo-

genesis. Thus, the term " cellular intracanalicularfibroadenoma " is given to the condition that has beencalled in English cystosarcoma phyllodes, Brodie’s

tumour, or giant fibroadenoma, to all of which there areobvious objections. Adenomas of the nipple, it is empha-sised, form a group of benign tumours with a structureclosely resembling sweat-gland adenoma.2 The schemecannot please everyone, but it is likely to be as generallyacceptable as any.

Difficulties are bound to arise when individual tumours

vary in structure. To put the matter as cautiously aspossible, variation is seen in a definite proportion of alltumours at all sites. The W.H.O. study suggests that atumour should be classified under as many different typesas are found in sections from different parts of it. Thiscourse opens a door very wide to differences of opinionand to the introduction of complexities that could cancelout the simplicity that has been achieved. The naggingthought is that the subject may be, in fact, too complexfor these simple divisions to be really useful.Even more difficult is the matter of grading, in which

Professor Scarff has long been interested.3 Correlations1. International Histological Classification of Tumours: No. 2. Histo-

logical Typing of Breast Tumours (edited by R. W. Scarff and H.Torloni). Geneva: W.H.O. 1968. £4 16s., S16.00, Sw. fr. 48. Obtain-able from H.M. Stationery Office, P.O. Box 569, London S.E.1, andother W.H.O. sales agents.

2. Handley, R. S., Thackray, A. C. Br. J. Cancer, 1962, 16, 187.3. Patey, D. H., Scarff, R. W. Lancet, 1928 i, 801.

720

of grading with prognosis are given with confidence, butwithout the detailed figures on which they were based.No mention is made of the influence on prognosis oftreatment, of the clinical staging of the disease at diagnosis,or the problem of occult metastases, though the referencesinclude work in which these points were examined, usingmany more cases,4 and other papers could be cited fromthe same school .5 6 In fact instructions are given forworking out a complex index based on formation oftubules in the tumour and of nuclear irregularities usinga single section of each " about 1-5-2 cm. square ".

Pathologists are far from unanimous in their viewson histological grading of breast tumours. Of Britishauthorities on tumours in general, Evans 7 acceptsthat grading may be useful as a guide to prognosis, butonly when clinical staging is considered as well. He

points out that the method gives no guide to the " bio-logical activity " of the growth-meaning time of meta-stasis and hormone dependence. Willis 8 rejects themethod altogether because of the wide variations in singletumours and the difficulties of interpretation. Both pointout that the medullary carcinoma with lymphoid infiltra-tion is anaplastic, but has a relatively good prognosis. Inthe original account of this variety, grading was carriedout for the 117 examples studied. 99 of these, however,were treated by radical surgery and no correlation wasfound between the prognosis and histological grading,clinical staging at diagnosis, or the amount of lymphoidinfiltration or of necrosis in the primary growth.The W.H.O. document is a bold attempt to clarify a

subject that is notoriously controversial. The system ofclassification proposed will be useful if it is adopted byvoluntary agreement between workers making inter-national comparisons using specific series of cases theyhave studied themselves; but it would be unfortunate ifthe high authority of the classification led to insistenceby medical authorities or editors that this system alone andin its entirety was to be used under other circumstances.

PREPARATION FOR PÆDIATRICS

As Professor Forfar 10 remarked last week, manypaediatric departments in this country are grievouslyunderstaffed and overburdened. Certainly, the clinicalwork-load of paediatricians (and their registrars) is exces-sive, and the undergraduate and postgraduate teachingand the planning that are increasingly desirable suffer

thereby. In the hospital regions there are still 85 single-handed paediatricians, and far too many inpatient unitssmaller than the minimum size of 60 beds necessary forcontinuous adequate pædiatric nursing. The paediatricdepartments of the London medical schools are poorlyprovided with accommodation and teachers. As a result,the image of paediatric care is less attractive than it couldbe, and this is one reason why there are not enoughapplicants for entry to general practice, hospital pxdiatrics,and the local-authority medical services. The presenttraining of paediatric senior registrars is too long and tooconfused: service demands interfere too much, the

4. Bloom, H. J. G., Richardson, W. W. Br. J. Cancer, 1957, 11, 359.5. Bloom, H. J. G. ibid. 1950, 4, 259.6. Bloom, H. J. G. ibid. p. 347.7. Evans, R. W. Histological Appearances of Tumours. Edinburgh,

1966.8. Willis, R. A. Pathology of Tumours. London, 1967.9. Richardson, W. W. Br. J. Cancer, 1956, 10, 415.

10. Forfar, J. O. Lancet, Sept. 21, 1968, p. 674.

M.R.C.P. examination in adult medicine is the wronghurdle to aim at, and contact with community services forchildren is too slight. Training is inadequate for the

management of the chronic disorders of childhood and the

neurologically determined learning difficulties of school-age children. To provide more adequately for service

needs, for better and wider education in paediatric care,for planning, and for advising the community, the numberof paediatricians must be substantially increased.

In 1942 Sir James Spence’s memorandum to theNuffield Provincial Hospitals Trust gave an impetuswhich provided all the provincial medical schools withprofessorial departments of child health. A symposiumheld on Sept. 10-13 by the Association for Study ofMedical Education and the academic board of the BritishPædiatric Association looks likely to prove a similarstimulant. Paediatricians from all parts of the United

Kingdom, and some from Europe and the U.S.A., dis-cussed the present structure of paediatric care, the pro-vision of training for those who give it, and the futurepattern and the training that will be required. Summingup, Prof. Douglas Hubble hoped that training schedulesto be devised by the B.P.A. academic board would beaccepted by the General Medical Council, and that a

solution to the M.R.C.P. difficulty would be a first part inphysiology, including its developmental aspects, and thatin a second part a paediatric test would be devised by pardi-atricians. He welcomed the suggestion of Dr. JohnHunt, president of the Royal College of General Practi-tioners, for a joint working party to study the roles ofhealth visitor, general practitioner, and local authorityin the care of children.

ELECTRONIC EDITORS

MANY of the ways in which computers can be used inmedicine are unique to that discipline; but others are not,and it would be a pity if the literature on this expanding,and often abstruse, subject were to become cluttered withapplications lifted almost bodily from other sciences. Thecollection of papers in the September issue of the BritishMedical Bulletin largely avoids this pitfall.

Computers have been used successfully in linguisticanalysis, but the failure, so far, to produce a satisfactorytranslating machine (and the quaint verse displayed at theexhibition on Cybernetics and Serendipity now at theInstitute of Contemporary Arts) suggests that machineshave but a limited grasp of the abstractions of language.It may be some time before the everyday phrases of theclinic can be routinely processed for the computer. Bates 1has used a high-level language to code patients’ descrip-tions during electric stimulation of the thalamus. Fivethousand phrases such as " Dim pins and needles in fingersof right hand " were made digestible by the use of 300words; the medical vocabulary being developed at King’sCollege Hospital already has 30,000 terms .2 Prof. JohnAnderson’s interest is in computer diagnosis, and he andtwo other contributors explore the possibilities.34 Boyleand Anderson 2 feel that, apart from the high costs andthe natural and reasonable antipathy which many cliniciansfeel for " robot diagnosis ", there are sound reasons whysuch a procedure may never become routine. Its value,they suggest, lies in differential diagnosis, and they illus-

1. Bates, J. A. V. Br. med. Bull. 1968, 24, 199.2. Anderson, J. ibid. p. 194.3. Boyle, J. A., Anderson, J. A. ibid. p. 224.4. Anderson, J. A., Boyle, J. A. ibid. p. 230.