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A BROAD VIEW OF CANCER
837
There is need to develop techniques which are less mutilating-methods that are unassociated with discomfort in convalescence and which provide speedy healing. The back-cut has become a sine-qua-non of all anal operations, on the ground that a raw "
"
surface within the anal canal requires a gutter to the surface at the anal verge to ensure drainage. The method has served well in terms of ultimate cure but has accounted for much discomfort. Further, the thus removed is an extravaskin of inch perianal square tissue and of normal waste exposure of raw gant surfaces in a highly sensitive area. But sometimes-
when, for example, removing piles-it is neither necessary to remove perianal skin nor to leave unsutured the raw areas within the anal canal. J. A. FERGUSON has reported few complications and little morbidity in 8086 patients whose haemorrhoidectomy wounds were completely closed with catgut.s In the semiclosed method the wound edges are approximated by subcuticular sutures, and this has the advantage of allowing possible serous collections to escape rather than 8. See
Lancet, 1957, i, 1023.
Annotations A BROAD VIEW OF CANCER
EACH autumn the British Postgraduate Medical Federation begins its now familiar and famous series of lectures on the scientific basis of medicine. Designed for research-workers and specialists in training, these authoritative lectures are later given a wider audience by publishing them in book form, and the 1955-56 series has recently appeared.1 The Federation’s custom is to choose as first lecturer each year someone who is specially qualified to take a broad view, someone who can move back from the overwhelming mass of detail and from that standpoint serve as guide and encourager to those less fortunately placed. Last week Dr. Julian Huxley assumed this benevolent role, and his absorbing and comprehensive discussion of " some biological aspects of cancer " was itself a striking illustration of the force of his concluding point—that cancer research can only prosper if it is broadly based. Cancer must be a key subject for general biology, demanding the combined efforts of many experts —and, we might add, a Julian Huxley or two to piece their findings together. Pointing to various lines of research that promised well, Dr. Huxley chose some striking examples from recent work on lower organisms. Exposure to tars and diesel fumes had produced growths in certain fungi, and here was an abundant source of material for investigation. Plant galls, in which insects had induced disorganised growths for the benefit of the insect rather than the plant, might repay further study ; and the tumours evoked by applying thiocresol to the regenerating claws of hermit crabs should be reinvestigated, particularly from the point of view of growth-rate. Little is known for certain about the influence of the nervous system on human cancer, but there may be clues in some observations to which Dr. Huxley referred. Section of nerves in the cockroach had been followed by the appearance of tumours in the organs served by those nerves ; and damage to the sympathetic system of guineapigs (normally very resistant to tumour formation) had led to the development of growths. Is there conceivably some2 connection here with Sir Heneage Ogilvie’s reflections on the happy man who never gets cancer. It is sometimes said that human cancer is not inherited. Dr. Huxley pointed to the difficulties of an adequate 1. See Lancet, Oct. 12, 1957, p. 728. 2. Ibid, July, 6, 1957, p. 35.
spread submucosally. Nor is it necessary to protect such procedures with chemotherapeutic cover, as is advocated.9 In this country PARKS has method of submucosal excision of piles no whereby epithelium is lost and the wound edges fall into apposition without suture, though the mucosa may need to be held in place by one stitch after excision of prolapsed piJes.1O The advantages of these methods are considerable, since with them postoperative pain is less and the patient returns to work earlier-after a fortnight following PARKS’ procedure. The period in hospital need be no longer than seven days and may be shorter-a substantial gain when the numbers on surgical waiting-lists are taken into account. In operations for fissure or fistula preinfection existing complicates the problem of ensuring epithelial coverage, but this can be achieved with a little ingenuity.8 Thought on these lines may provide the intellectual breeze required to blow anal surgery and its attendant craftsmen out of the doldrums.
commonly
described
a
9. Turell, R. Treatment in Proctology. Baltimore, 1949. 10. Parks, A. G. Brit. J. Surg. 1956, 43, 23.
of cancer proneness in a species which is to many different types of cancer and exposed to such varied genetic and environmental influences. There was, however, distinct evidence of cancer proneness in man, and more comparisons between monovular and binovular twins was one way of exploring the matter further. Some racial differences were apparent in which genetic predisposition seemed to predominate : for example, the incidence of cancer of the breast in Japanese women was only a sixth of that in European women. Among the copious work on genetic influences in animal cancers, changes in tumour susceptibility had shown how apparently unrelated genes could amplify or abate the likelihood of cancer ; and suitable selection in different lines of mice might delay the onset of tumour formation. The incredibly high cancer-rate in grey horses (over the age of 15 years the incidence was 80%, nearly all melanomas) was another of Dr. Huxley’s suggestions for more
analysis subject
detailed inquiry. How near we now stand to what Dr. Huxley called the biochemical " kernel of cancer none can confidently but there is no say ; doubting that the wide " biological " nutcrackers he advocated are the ones most likely to get at it quickly. "
A CONCEPT OF ANÆSTHESIA ALL doctors with an interest in anaesthetics are familiar with Guedel’s1 description of four stages of general anæsthesia—analgesia, delirium or excitement, surgical anaesthesia, and respiratory paralysis. Each stage is recognisable from the typical pattern of signs, largely associated with respiration. Guedel’s classification was devised at a time when ether was the commonest anæsthetic, and in the complete sense it is applicable only to this and similar agents. Newer agents do not respect such an orderly sequence : the capacity of intravenous thiobarbiturates severely to depress respiration and circulation in light anaesthesia, and of muscle relaxants to simulate most of the signs of anaesthesia yet produce no anaesthesia, are well known. Moreover with combinations of drugs the idea of anaesthetic depth is invalid, though there is still need for a guide to the degree of anaesthesia. If the orthodox stages are to be retained, they must be restated in modern terms.23 Analgesia is an essential feature of the first stage, but this is also characterised by 1. Guedel, A. E. Inhalation Anesthesia. New 2. Mushin, W. W. Anœsthesia, 1948, 3, 154. 3. Laycock, J. D. Ibid, 1953, 8, 15.
York, 1937.
There is need to develop techniques which are less mutilating-methods that are unassociated with discomfort in convalescence and which provide speedy healing. The back-cut has become a sine-qua-non of all anal operations, on the ground that a raw "
"
surface within the anal canal requires a gutter to the surface at the anal verge to ensure drainage. The method has served well in terms of ultimate cure but has accounted for much discomfort. Further, the thus removed is an extravaskin of inch perianal square tissue and of normal waste exposure of raw gant surfaces in a highly sensitive area. But sometimes-
when, for example, removing piles-it is neither necessary to remove perianal skin nor to leave unsutured the raw areas within the anal canal. J. A. FERGUSON has reported few complications and little morbidity in 8086 patients whose haemorrhoidectomy wounds were completely closed with catgut.s In the semiclosed method the wound edges are approximated by subcuticular sutures, and this has the advantage of allowing possible serous collections to escape rather than 8. See
Lancet, 1957, i, 1023.
Annotations A BROAD VIEW OF CANCER
EACH autumn the British Postgraduate Medical Federation begins its now familiar and famous series of lectures on the scientific basis of medicine. Designed for research-workers and specialists in training, these authoritative lectures are later given a wider audience by publishing them in book form, and the 1955-56 series has recently appeared.1 The Federation’s custom is to choose as first lecturer each year someone who is specially qualified to take a broad view, someone who can move back from the overwhelming mass of detail and from that standpoint serve as guide and encourager to those less fortunately placed. Last week Dr. Julian Huxley assumed this benevolent role, and his absorbing and comprehensive discussion of " some biological aspects of cancer " was itself a striking illustration of the force of his concluding point—that cancer research can only prosper if it is broadly based. Cancer must be a key subject for general biology, demanding the combined efforts of many experts —and, we might add, a Julian Huxley or two to piece their findings together. Pointing to various lines of research that promised well, Dr. Huxley chose some striking examples from recent work on lower organisms. Exposure to tars and diesel fumes had produced growths in certain fungi, and here was an abundant source of material for investigation. Plant galls, in which insects had induced disorganised growths for the benefit of the insect rather than the plant, might repay further study ; and the tumours evoked by applying thiocresol to the regenerating claws of hermit crabs should be reinvestigated, particularly from the point of view of growth-rate. Little is known for certain about the influence of the nervous system on human cancer, but there may be clues in some observations to which Dr. Huxley referred. Section of nerves in the cockroach had been followed by the appearance of tumours in the organs served by those nerves ; and damage to the sympathetic system of guineapigs (normally very resistant to tumour formation) had led to the development of growths. Is there conceivably some2 connection here with Sir Heneage Ogilvie’s reflections on the happy man who never gets cancer. It is sometimes said that human cancer is not inherited. Dr. Huxley pointed to the difficulties of an adequate 1. See Lancet, Oct. 12, 1957, p. 728. 2. Ibid, July, 6, 1957, p. 35.
spread submucosally. Nor is it necessary to protect such procedures with chemotherapeutic cover, as is advocated.9 In this country PARKS has method of submucosal excision of piles no whereby epithelium is lost and the wound edges fall into apposition without suture, though the mucosa may need to be held in place by one stitch after excision of prolapsed piJes.1O The advantages of these methods are considerable, since with them postoperative pain is less and the patient returns to work earlier-after a fortnight following PARKS’ procedure. The period in hospital need be no longer than seven days and may be shorter-a substantial gain when the numbers on surgical waiting-lists are taken into account. In operations for fissure or fistula preinfection existing complicates the problem of ensuring epithelial coverage, but this can be achieved with a little ingenuity.8 Thought on these lines may provide the intellectual breeze required to blow anal surgery and its attendant craftsmen out of the doldrums.
commonly
described
a
9. Turell, R. Treatment in Proctology. Baltimore, 1949. 10. Parks, A. G. Brit. J. Surg. 1956, 43, 23.
of cancer proneness in a species which is to many different types of cancer and exposed to such varied genetic and environmental influences. There was, however, distinct evidence of cancer proneness in man, and more comparisons between monovular and binovular twins was one way of exploring the matter further. Some racial differences were apparent in which genetic predisposition seemed to predominate : for example, the incidence of cancer of the breast in Japanese women was only a sixth of that in European women. Among the copious work on genetic influences in animal cancers, changes in tumour susceptibility had shown how apparently unrelated genes could amplify or abate the likelihood of cancer ; and suitable selection in different lines of mice might delay the onset of tumour formation. The incredibly high cancer-rate in grey horses (over the age of 15 years the incidence was 80%, nearly all melanomas) was another of Dr. Huxley’s suggestions for more
analysis subject
detailed inquiry. How near we now stand to what Dr. Huxley called the biochemical " kernel of cancer none can confidently but there is no say ; doubting that the wide " biological " nutcrackers he advocated are the ones most likely to get at it quickly. "
A CONCEPT OF ANÆSTHESIA ALL doctors with an interest in anaesthetics are familiar with Guedel’s1 description of four stages of general anæsthesia—analgesia, delirium or excitement, surgical anaesthesia, and respiratory paralysis. Each stage is recognisable from the typical pattern of signs, largely associated with respiration. Guedel’s classification was devised at a time when ether was the commonest anæsthetic, and in the complete sense it is applicable only to this and similar agents. Newer agents do not respect such an orderly sequence : the capacity of intravenous thiobarbiturates severely to depress respiration and circulation in light anaesthesia, and of muscle relaxants to simulate most of the signs of anaesthesia yet produce no anaesthesia, are well known. Moreover with combinations of drugs the idea of anaesthetic depth is invalid, though there is still need for a guide to the degree of anaesthesia. If the orthodox stages are to be retained, they must be restated in modern terms.23 Analgesia is an essential feature of the first stage, but this is also characterised by 1. Guedel, A. E. Inhalation Anesthesia. New 2. Mushin, W. W. Anœsthesia, 1948, 3, 154. 3. Laycock, J. D. Ibid, 1953, 8, 15.
York, 1937.