1321 CANCER CLINICS ONE THE LANCET LONDON:: S. T Z7RD Y, DECEMBER 23, 1939 GET TOGETHER WE hear much of active service, but the conditions of stat...

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S. T Z7RD Y, DECEMBER 23, 1939

GET TOGETHER WE hear much of active service, but the conditions of stationary warfare in the winter months have condemned a large part of the medical profession to something more like inactive service. On another page Professor RYLE suggests a recipe to counteract boredom and maintain interest and efficiency, and it is natural that one regius should go back to another for an illustration of what he has in mind and recall the well-known chapter in " aequanimitas on the educational value of the medical society. Curiously enough, OSLER was not by nature a clubbable person. Marian Osborne who lived in the same house at Montreal when he became the " baby professor" at McGill, and used to watch him coming down the street at a swinging pace with the spring on the ball of the foot, noted the early struggle to overcome his lack of elocution, his shyness and the Osler reserve. It is an encouragement to us all to think of OSLER not as born complete with the qualities that make a medical society successful. When he wrote that no class of man needs friction so much as physicians and no class gets less-"the daily round of a busy practitioner tends to develop an egotism of a most intense kind to which there is no antidote "-he was speaking of things of which he knew, and was well aware of the tendency of solitary work to make a man touchy, dogmatic, intolerant of correction and (his own phrase) abominably self-centred. To this mental attitude, said OsLER, the medical society is the best correctiveand a man misses a good part of his education who does not get knocked about a bit by his colleagues in discussions and criticisms. Professor RYLE looks back on the last war as one of his most vivid and instructive experiences. The good comradeship, the absence of the competitive evil, the living and working at close quarters, the unanimous effort to do the best possible for the individual sick or wounded; all this, he remarks, provided an atmosphere not yet inherent in less united civilian organisations. In any medical society it is this factor of personal contact which supplies the dynamic. The member of a live society feels that his job is not solitary and he gets the chance of a working friendship with someone whose approach to life and medicine is congenial to his own. Moreover there is in our present situation the added advantage of relative juvenility and it should hardly be necessary to revive the rule of an old Gloucestershire society to admit no new member whose age exceeds 40. It is admitted, however, that the social age of many venerable officers of medical societies remains at "



vigorous prime.

striking result of the dislocation of ordinary hospital organisation has been the urgency of the public demand that facilities for treating cancer should again be provided. The campaign to make known the importance of early diagnosis has clearly carried conviction. With this in mind the section of the Chief Medical Officer’s report which deals with cancer merits careful study. He begins by pointing out that the number of deaths attributed to cancer shows the customary rise. Cancer of the mouth, including lip, tongue, mouth, tonsil and jaw, accounts for 2308 male and 432 female deaths; stomach 7063 male and 5748 female; colon and rectum 6125 male and 5554 female; lung 2930 male and 823 female; breast 6922 and uterus 4462. The grand total being 68,605. These are among the most important cancers, and some of them are the accessible growths curable in the early stages. The National Cancer Service, defined in the Cancer Act 1939, represents the effort of the Minister of Health to coordinate through the local authorities the diagnosis and all the methods of treating cancer-surgery, radium and X rays. The existing facilities for the surgical treatment of cancer are thought to be adequate, though it is recognised that if the service succeeds in bringing patients to treatment at an early stage increased facilities will be required. The stock of radium and the deep X-ray apparatus with the specialised medical staff necessary for radiotherapy are not so easily obtained. Excluding London, there are now 18 radium centres set up by the National Radium Commission, and new centres will probably be required. Local authorities will have to unite to make centres, or will make arrangements with suitable voluntary hospitals. Their schemes will be submitted to the minister, who will have the help of a specially appointed subcommittee of experts on cancer on which all the branches of medicine concerned with treatment and administration are represented. This committee should in our opinion advise against any great increase in the number of centres. Even common forms of cancer are seen in a very small number of cases per unit of population, and because the study of a number of similar cases always makes for greater efficiency in treatment, as many as possible should be collected at large major centres, where the best that can be offered of surgery, radium and X rays is available. It is proposed to establish consultative and diagnostic clinics in smaller towns in the region, staffed by visiting experts from the centre. These clinics will be held when possible in local general hospitals. It is clear that it must be possible for the visiting surgeon to recommend the transfer of patients to the centre for special investigations or surgery requiring a high degree of skill. A good example is an abdomino-perineal excision of the rectum where the advantage of having a surgeon who performs this operation often is great. The number of centres where first-class radiotherapy can be given is limited not so much by


the expense of the apparatus as by the supply of trained therapists. It is only within the’last few years that it has been recognised that efficient radiotherapy is the province neither of the surgeon, who occasionally implants radium, nor of the radio-diagnostician giving what time he can to X-ray therapy. To use both radium and X rays to the best advantage some surgical training and a good grasp of radiation physics are needed, and for the purposes of the act clinical knowledge of cancer in all its manifestations as well. To ensure that radiation treatment is in competent workers, and to give

charge of really opportunities for

a high degree of centralisation effective than the creation of individual treatment units.

training therapists, will be


DEGREES OF INSANITY IN LAW MEDICINE and the law do not regard responsibility from the same angle. The Atkin committee, containing a strong forensic element, obviously desired to discourage the " mistaken notion " that all insane persons are irresponsible. " The farreaching effect of granting immunity to every one who can be said to be of unsound mind- is perceived," it observed, " when the medical conception of unsoundness of mind is considered." The medical man’s anxiety that insanity and irresponsibility should be not identified arises in a different way; the identification, it is feared, might deprive mental patients of such legal powers-e.g., the making of a will-as they now possess. In non-criminal contexts the law has evolved its own classifications of insanity. The 17th century took the person who was non compos mentis and classified his condition under three types bf dementia-naturalis, accidentalis (subdivided under furor, rabies, mania and so on), and affectata-i.e., drunkenness. To come down to modern times, legal writers have pointed out that section 341 of the Lunacy Act of 1890 allowed lunatic" to include" idiot," although in the Idiots Act of 1886 (repealed and replaced by the Mental Deficiency Act of 1913) lunatic " on the one hand and " idiot " or imbecile " on the other were mutually exclusive terms. Recently the laws which have permitted incurable unsoundness of mind to be a ground of divorce in England, Scotland and Northern Ireland have linked the dubieties of the mental state with the solid fact of five years’ continuous detention in a mental hospital. Here the courts accept a very different standard from that of criminal irresponsibility. As to wills the existence of insanity in a testator at the time when he makes his will creates a "



presumption against testamentary capacity; conan asylum has strengthened the But the presumption can be presumption. rebutted by evidence that the insanity or delusions finement in

irrelevant to the matters which form the subject of the will, or by evidence of a lucid interval at the material moment. A lucid interval is not merely the cessation or suppression of the symptoms of mental disease nor, according to Lord Eldon in the Holyland case, need it be a are

complete restoration to the mental vigour previously enjoyed. Lord Eldon, it may be added, should have been a good judge of lucid intervals. As Lord Chancellor to George III during the periods of the King’s unfortunate disability, he

had to decide from time to time whether his sovereign was mentally fit to give the royal assent to Acts of Parliament or to approve rcyal commissions for the purpose. There was a period in 1804, in the midst of war, when the establishments of the armed forces of the Crown might have lapsed for want of the royal assent to a Mutiny Act. Lord Eldon fortunately found the King able to assent. There was grave doubt in 1811 when the Lord Chancellor almost miraculously found His Majesty fit to assent to the bill appointing a regent. Lord Grey, in a House of Lords debate, thought that Eldon’s hasty opinion, formed during a brief interview, was hardly sufficient to outweigh the considered conclusions of the King’s medical attendants. Campbell, who wrote Eldon’s life, relates that the Lord Chancellor always stoutly asseverated that the royal signature was never obtained, nor the royal pleasure taken on any act of State, when the royal mind was not clear and collected. This statement, he added candidly, it is very difficult to credit.

GESTURE SoME years ago a deaf-mute patient presented himself at the National Hospital, having had a mild stroke. An incomplete right-sided paralysis passed off quickly, but it left him with an inability to express himself by way of his accustomed signtalk. Aphasia had in fact occurred in a mute person. This case led Dr. MACDONALD CRITCHLEY to explore that older instinctival language-the language of gesture-and he has recorded his findings in a delightful little book,1 Evidence from developmental and comparative philology suggests that gesture may have preceded verbal speech. But it is more than a parent, .for gesture has expanded in company with its offspring. From it have sprung such art-forms as miming, pantomime, and aspects of dancing, and such everyday actions as saluting, shaking hands, and kissing. Demosthenes considered that the first, second and third points in oratory were movement -but now the microphone has robbed the publicspeaker of the language of gesture, and until television comes into its own he must rely more upon the reason than the emotions of his audience. Dr. CRITCHLEY would separate gesture from pantomime. Gesture, he says, should be used only for movements which accompany speech for the sake of emphasis, while pantomime is dumbshow aiming at expressing an idea. The salute is then pantomime; the uplifted hands of the soldier as he cries " Kamerad is gesture. This distinction is too flimsy to be of great value, though it has a certain convenience. In both these actions, the underlying emotional intention "

1. The Language of Gesture. By Macdonald Critchley, M.D., F.R.C.P. London: Edward Arnold and Co. 1939. Pp. 128. 5s.