- Email: [email protected]
CORPORAL PUNISHMENT IN SCHOOL
1027 It is not the bladder
or
its
controlling mechanism,
but the
whole child who needs investigation and help. in the treatment of enuresisarises from the between paediatrics and child psychiatry, so that the paediatrician too often sees only the function, and
The
difficulty
separation
the personality, and such commonfactors as maturation, opportunities for play, and sensible education of the mother in understanding both sides of her child’s nature, so often do not appear at all. It has been our custom, in our treatment at the Institute of Child Psychology, to provide a ground-floor room with a cement floor sloping to the outside, with illumination from a waterproof ship-side lantern, which is fitted with sinks at different heights, water toys of all sorts, and pots and jars and hose-pipes. Here, clothed in wellingtons and mackintosh, a child can work out in real water the drives, fantasies, and experiments, and-with the aid of the therapist-clarify the puzzles which lurk in his mind and perhaps tip the balance towards expression of all these through his own water reserves the
psychiatrist only
sense
at
Serum-proteins were within normal limits. L.E. cells were found in the blood-smear. Treatment with corticotrophin The pyrexia ceased was started a month after admission. within a few days and the diarrhcea stopped with astonishing rapidity. The anal fissure healed shortly thereafter. This man is out and about on 50 mg. cortisone daily. These 2 cases represent a chronic form of systemic lupus erythematosus which appears to be commoner than its acute manifestations.l Both presented without superficial skin lesions or albuminuria. The clue to diagnosis in such cases seems to be recognition of the association of recurrent febrile illnesses, such as pneumonia, pleurisy, pericarditis, conjunctivitis, colitis, &c., with involvement of other systems, notably the joints and lymph-glands. Examination of the blood for North Middlesex Hospital, London, N.18.
night.
As Dr. Jackson (April 16, p. 822) has so wisely pointed out, rate of maturation varies enormously in different children (though surely he is incorrect in putting the lower
limit for bladder control at three years ?), and giving up the desire for elementary water-play is a function of
maturation. Institute of Child Psychology, London, W.11.
MARGARET LOWENFELD.
THE DIFFICULT APPENDIX
SIR,-Mr. Kerr ends his interesting article
of April 9 "have regarded McBurney’s point as If2 in. below the midpoint of the line joining the umbilicus to the right anterior superior iliac spine." This implies that there is some choice as to where McBurney’s point may be placed. This is not true, as is shown by the following quotation from McBurney’s
with the sentence :
original paper " And I believe that in every case the seat of greatest pain, detervtlaned by the pressure of one finqer, [italics by the author] has been very exactly between an inch and a half and two inches from the anterior spinous process of the ilium, on a straight line drawn from that process to the umbilicus. This may appear to be an affectation of accuracy, but, so far as my experience goes, the observation is correct." An asterisk after this sentence points to a footnote which
reads
as
follows :
" Since
reading this paper I havecarefully observed three other cases. In two the point of pain shown by pressure with one finger was two inches and in the other an inch and seven-eighths from the anterior spine." George Washington University ALEC HORWITZ. Medical School, Washington, D.C. CHRONIC SYSTEMIC LUPUS ERYTHEMATOSUS SiB,—Your valuable leading article of April 16 prompts me to report 2 cases I have seen recently. A woman of 45 was admitted to hospital in November, 1953, with pneumonia. She had had four attacks and a rheumatoid arthritis during the previous six years. She was found to have bilateral basal bronchopneumonia, a rheumatoid form of arthritis, enlarged glands in the right axilla, and scleroderma of the hands. Ib was 48%. The serum albumin/globulin ratio was reversed and L.E. cells were found in the blood-smear. Pyrexia persisted for weeks despite treatment with antibiotics. There was an immediate remarkable response to corticotrophin. Pyrexia ceased and expectoration of sputum stopped with astonishing rapidity. This patient was discharged on 50 mg. of cortisone daily, but later the kidneys were involved, with albuminuria and ursemia, and she died about a year after discharge. A man of 49 was admitted to hospital in June, 1954, following five to six weeks of diarrhoea, with blood and mucus in the stools, and painful swelling of both legs. Similar attacks of diarrhoea and pain and swelling in the legs had occurred at intervals for the past five years. He had had many attacks of episcleritis in the previous ten years. He had low fever, episcleritis in the left eye, cellulitis of the left leg, and an anal fissure. A barium enema showed appearances typical of ulcerative colitis. Hb was 75%. "
1.
McBurney, C. N.Y. med. J. 1889, 50, 676.
"
L.E.
cells may be
unex-
pectedly helpful. D. FERRIMAN.
CORPORAL PUNISHMENT IN SCHOOL
SIR,—The question of corporal punishment in school and the principle underlying it should be decided on the rational ground whether it is favourable or not to the health of children in general. As I see it this is a crucial and pressing issue, not perhaps especially for doctors but for any society seriously concerned with the health of its children. Perhaps therefore you will allow me to make some points on this question. The parent who nags his child to " concentrate," who censures him for incontinence, or thrashes him for pilfering is in the same boat with the teacher who cuffs his pupil for not attending to the board or for adding 2 and 3 to make 11. They are behaving exactly like the mechanist philosopher who by tradition has explained learning in terms of the law of use and the pain-pleasure principle. The former was based on the idea that repeated stimulation of a sensory nerve facilitated a muscle response : the latter that pain inhibited and pleasure facilitated a muscle response. In the last half century the Gestalt scientists have produced overwhelming mass of evidence against a mechanistic explanation of natural processes. They have established that the behaviour of living organisms is governed by the laws of organisation and they use the word " insightful " to characterise the behaviour of all conscious organisms. Let anyone reflect whether a child has ever learned to be generous, to control his bladder, to solve a problem in mathematics, to use crayon, brush, or tool through pain or fear or insightless drill." In fact, all these abilities are functions of the maturation and differentiation of the brain-muscle-gland organisation and the insight that depends on them. That physiological processes like the maintenance of the acid-base balance and of the constancy of the internal temperature are organised processes, justifies Cannon’s use of the phrase " the wisdom of the body." Cannon has further shown that when an animal is affected by any painful situation, it mobilises’its energy for muscle action designed to relieve the stress and restore the animal’s balance and unity. Pain is thus not a deterrent but a positive incitor to action on the part of an organised being like an animal or child. It is stress demanding resolution in action. I consider that sexual tension " grows out of " emotional tension in general and it is therefore easy to understand the two-way traffic between sexual and any other kind of emotional tension. I have known a child in whom masochistic behaviour had been evoked in infancy, flee from punishment in school as from mortal danger, and I have seen a hysterical reaction provoked in a teen-age girl at the mere witnessing of the punishment of other children. Any mode of education which uses punishment as a tool establishes a sado-masochistic relationship between child and parent on the one hand, and pupil and teacher on the other, which will colour the child’s whole life. But further, the unremitting punitive tensions in home and in school to which children are subjected in certain areas, are in my opinion a decisive factor in the production of serious " physical illness. If, as I believe, resistance is a condition of energy " of the child as a whole, then punishment will render him susceptible to illness by lowering his resistance. an
"
1.
Tumulty, P.
A.
J. Amer. med.
Ass. 1954, 156, 947.
1028 The
analysts maintain that the child can " adapt " by the punitive tensions of authority to build up his super-ego and other internal forces of resistance. He will then become a " good " person. But he will externalise his " unconscious sense of guilt " and many such individuals are always " looking for something to forbid " and cannot even observe the natural behaviour of children without experiencing an inner compulsion to lay hands on them. It is not surprising that analysis is confronted with the paradoxical situation of having to restore to broken lives the unity that they possessed in the beginning. Finally, what moral argument is there on behalf of punishment or the " threat of the withdrawal of love " as an instrument of education ? As Kenneth Walker in his and Sex : " It is a betrayal of every says Society spiritual value we profess to hold in reverence, to use love as a bait or a weapon of coercion." using
-
D. JACKSON County Psychiatrist and Director, Cornwall Child Guidance Service.
A VISIT TO KOLTUSHI
SIR,—I found the article by Mr. Ruscoe Clarke and Dr. Leonard Crome (April 2) most interesting. Of interest, too, were the comments of last week of Dr. Mungo Douglas in that they represent a distaste for Pavlov’s work which is by no means unusual in the British profession. one cannot but contrast the meticulous objectivity of the Pavlov school with the doctrinaire disregard of facts shown by Dr. Mungo Douglas. Instead of criticising the experimental findings quoted by Mr. Clarke and Dr. Crome, he asks the rhetorical question : Is it a study likely to provide the kind of future we should all desire ..." If it can be shown that the great mass of data accumulated by the Pavlov school is all wrong, or if it can be shown that these facts are without relevance to, for
However,
"
example, gastric function, bronchospasm, or, by Pavlov, schizophrenia, then it is open to
as
suggested
Dr. Mungo to prove his case. But, in the scientific world at least, generalisations about vital freedom and enslavement cannot be accepted as a substitute for the dispassionate consideration of established facts. Personally I welcome all facts relating to conditioned reflexes since they touch on some very fundamental problems and suggest some interesting possibilities in clinical application. C. H. FOGGITT. Sheffield.
Douglas
PSORIASIS SPONDYLITICA
SIR,—Dr. Lydon (April 30) asks us to support the unitarian theory of the pathogenesis of the rheumatic diseases. This concept has, however, in the past, proved unhelpful in furthering our understanding of these disorders of connective tissue. Moreover, as Professor Kellgren has pointed out,l just as no sensible person would seriously suggest that all diseases of the nervous system have a single ætiological factor, so it is equally unlikely in the case of the diseases of the supporting structures. It is probable that research into the fundamental cause or causes of the rheumatic diseases will be easier once a greater knowledge of the normal anatomy and physiology of connective tissue and of the various clinicopathological entities which we call the rheumatic diseases has been acquired. As the expression of a useful piece of clinical observation, I, for one, welcome the term " psoriasis spondylitica used by Dr. Fletcher and Dr. Rose (April 2). One other point arises from Dr. Lydon’s letter : he is incorrect in regarding the arthritis of Reiter’s disease as indistinguishable from rheumatoid arthritis-it differs from it in the joint " pattern " and in its course. Reiter’s arthritis predominantly affects the joints of the lower "
1.
Kellgren, J. H. Brit. med. J. 1952, i, 1093.
limbs, especially the knees and the ankles’; it is also much more benign, and seldom leaves any permanent or crippling deformities except in the feet. J. F. BUCHAN.
London, W.1.
NON-PROGRESSIVE BREAST CANCERS SIR,—Further evidence of the common occurrence of
non-progressive, non-lethal lesions, in general indistinguishable microscopically from lethal breast cancer, appears to be requisite for a fuller realisation or acceptance of the limitations of treatment. Such evidence is obvious, I think, in the data of two series of cases cited
previously1 and other related data. In one series, stage 1 (i.e., confined to breast) constituted 50%, the 5-year survival-rate in the whole series was over 60% and in the stage-1 cases it was 85-6%. In the other series, the respective figures were -16%, 43%, and 81%. Consideration of all factors left no reasonable alternative to the deduction that the majority of stage-1 cancers in the first series were non-progressive lesions, and that they accounted, though not necessarily exclusively, for the unusually high 5-year survival-rate for the whole series and largely accounted for the high 85-6% rate in the stage-1 cases. The near equality of 85-6% and 81%, and the similarity of both with the rates usually obtained in stage-1cases, point to similarity in the material providing these rates. In other words, as the majority of the stage 1 forming 50% in the one series appeared to be non-pro. gressive lesions, it seems a reasonable deduction from the similarity of the survival-rates that the majority of stage-1 cancers in most series are similarly non-progressive lesions. The high proportion of non-progressive lesions in the stage-1cases could then explain, reasonably and consistently, the high survival-rates in the latter. In contrast to the contention that stage-1 lesions are progressivelethal cancers in an early and curable stage of development, this explanation is compatible with the persistence of level trends in age-specific mortality in spite of an increase in stage 1 in the treated cases, compatible, too, with the wide variations in reported survival-rates in different series, and with frequencies of stage 1 and of grade 1 as found at different durations.
fully
This does not imply that all the difficulties of differentiation confined to stage-1 cases. The wide difference in survival time even in well-advanced cancer, both untreated and treated, reflects wide difference in the degree of malignancy in such cases. That difference is not fully revealed even with grading of tumours by microscopy. Lewison, in the Halsted Clinic, carefullv re-examined sections from the tumours of patients who had survived ten years or more but found nothing on which to prognosticate the long survival.2 Murley et al. found approximately the same five- and ten-year survival-rates in cases clinically stage 1 but pathologically stage 2 (axillary involvement) as in cases clinically stage 2 but pathologically stage 1. The rates lay between those in stage 1 and those in stage 2 (clinically and pathologically).3 While the near equality of the survival-rates in the two groups could be due to chance, it may indicate a degree or distribution of malignancy somewhat representative of such An unidentified increase in such cases as those described. clinically stage-1 but pathologically stage-2 cases in series treated in successive quinquennial periods could thus be a factor in the progressive increase in survival-rates in the cases with axillary involvement as reported by several clinics. As Smithers et al. have emphasised,4 survival-rates are influenced by factors other than diagnosis and differentiation, such as difference in selection of cases after diagnosis, in staging criteria and their application, in detection of lymphatic involvement, in follow-up, in calculation of survival-rates, &c. However, when, in fifteen series of different time or place and for which the necessary data were available, the 5-year survivals of stage 1 were deducted from the over-all 5-year survivals, the net 5-year survival-rates then ranged from about 10% to about 30%, with the majority close to 20%. They thus approximated to what might be found in untreated are
1. 2. 3. 4.
Lancet, 1954, i, 251. J. Amer. med. Ass. 1953, 153, 905. Brit. med. J. 1953, ii, 787. Brit. J. Radiol. 1952, suppl. no. 4.
or
its
controlling mechanism,
but the
whole child who needs investigation and help. in the treatment of enuresisarises from the between paediatrics and child psychiatry, so that the paediatrician too often sees only the function, and
The
difficulty
separation
the personality, and such commonfactors as maturation, opportunities for play, and sensible education of the mother in understanding both sides of her child’s nature, so often do not appear at all. It has been our custom, in our treatment at the Institute of Child Psychology, to provide a ground-floor room with a cement floor sloping to the outside, with illumination from a waterproof ship-side lantern, which is fitted with sinks at different heights, water toys of all sorts, and pots and jars and hose-pipes. Here, clothed in wellingtons and mackintosh, a child can work out in real water the drives, fantasies, and experiments, and-with the aid of the therapist-clarify the puzzles which lurk in his mind and perhaps tip the balance towards expression of all these through his own water reserves the
psychiatrist only
sense
at
Serum-proteins were within normal limits. L.E. cells were found in the blood-smear. Treatment with corticotrophin The pyrexia ceased was started a month after admission. within a few days and the diarrhcea stopped with astonishing rapidity. The anal fissure healed shortly thereafter. This man is out and about on 50 mg. cortisone daily. These 2 cases represent a chronic form of systemic lupus erythematosus which appears to be commoner than its acute manifestations.l Both presented without superficial skin lesions or albuminuria. The clue to diagnosis in such cases seems to be recognition of the association of recurrent febrile illnesses, such as pneumonia, pleurisy, pericarditis, conjunctivitis, colitis, &c., with involvement of other systems, notably the joints and lymph-glands. Examination of the blood for North Middlesex Hospital, London, N.18.
night.
As Dr. Jackson (April 16, p. 822) has so wisely pointed out, rate of maturation varies enormously in different children (though surely he is incorrect in putting the lower
limit for bladder control at three years ?), and giving up the desire for elementary water-play is a function of
maturation. Institute of Child Psychology, London, W.11.
MARGARET LOWENFELD.
THE DIFFICULT APPENDIX
SIR,-Mr. Kerr ends his interesting article
of April 9 "have regarded McBurney’s point as If2 in. below the midpoint of the line joining the umbilicus to the right anterior superior iliac spine." This implies that there is some choice as to where McBurney’s point may be placed. This is not true, as is shown by the following quotation from McBurney’s
with the sentence :
original paper " And I believe that in every case the seat of greatest pain, detervtlaned by the pressure of one finqer, [italics by the author] has been very exactly between an inch and a half and two inches from the anterior spinous process of the ilium, on a straight line drawn from that process to the umbilicus. This may appear to be an affectation of accuracy, but, so far as my experience goes, the observation is correct." An asterisk after this sentence points to a footnote which
reads
as
follows :
" Since
reading this paper I havecarefully observed three other cases. In two the point of pain shown by pressure with one finger was two inches and in the other an inch and seven-eighths from the anterior spine." George Washington University ALEC HORWITZ. Medical School, Washington, D.C. CHRONIC SYSTEMIC LUPUS ERYTHEMATOSUS SiB,—Your valuable leading article of April 16 prompts me to report 2 cases I have seen recently. A woman of 45 was admitted to hospital in November, 1953, with pneumonia. She had had four attacks and a rheumatoid arthritis during the previous six years. She was found to have bilateral basal bronchopneumonia, a rheumatoid form of arthritis, enlarged glands in the right axilla, and scleroderma of the hands. Ib was 48%. The serum albumin/globulin ratio was reversed and L.E. cells were found in the blood-smear. Pyrexia persisted for weeks despite treatment with antibiotics. There was an immediate remarkable response to corticotrophin. Pyrexia ceased and expectoration of sputum stopped with astonishing rapidity. This patient was discharged on 50 mg. of cortisone daily, but later the kidneys were involved, with albuminuria and ursemia, and she died about a year after discharge. A man of 49 was admitted to hospital in June, 1954, following five to six weeks of diarrhoea, with blood and mucus in the stools, and painful swelling of both legs. Similar attacks of diarrhoea and pain and swelling in the legs had occurred at intervals for the past five years. He had had many attacks of episcleritis in the previous ten years. He had low fever, episcleritis in the left eye, cellulitis of the left leg, and an anal fissure. A barium enema showed appearances typical of ulcerative colitis. Hb was 75%. "
1.
McBurney, C. N.Y. med. J. 1889, 50, 676.
"
L.E.
cells may be
unex-
pectedly helpful. D. FERRIMAN.
CORPORAL PUNISHMENT IN SCHOOL
SIR,—The question of corporal punishment in school and the principle underlying it should be decided on the rational ground whether it is favourable or not to the health of children in general. As I see it this is a crucial and pressing issue, not perhaps especially for doctors but for any society seriously concerned with the health of its children. Perhaps therefore you will allow me to make some points on this question. The parent who nags his child to " concentrate," who censures him for incontinence, or thrashes him for pilfering is in the same boat with the teacher who cuffs his pupil for not attending to the board or for adding 2 and 3 to make 11. They are behaving exactly like the mechanist philosopher who by tradition has explained learning in terms of the law of use and the pain-pleasure principle. The former was based on the idea that repeated stimulation of a sensory nerve facilitated a muscle response : the latter that pain inhibited and pleasure facilitated a muscle response. In the last half century the Gestalt scientists have produced overwhelming mass of evidence against a mechanistic explanation of natural processes. They have established that the behaviour of living organisms is governed by the laws of organisation and they use the word " insightful " to characterise the behaviour of all conscious organisms. Let anyone reflect whether a child has ever learned to be generous, to control his bladder, to solve a problem in mathematics, to use crayon, brush, or tool through pain or fear or insightless drill." In fact, all these abilities are functions of the maturation and differentiation of the brain-muscle-gland organisation and the insight that depends on them. That physiological processes like the maintenance of the acid-base balance and of the constancy of the internal temperature are organised processes, justifies Cannon’s use of the phrase " the wisdom of the body." Cannon has further shown that when an animal is affected by any painful situation, it mobilises’its energy for muscle action designed to relieve the stress and restore the animal’s balance and unity. Pain is thus not a deterrent but a positive incitor to action on the part of an organised being like an animal or child. It is stress demanding resolution in action. I consider that sexual tension " grows out of " emotional tension in general and it is therefore easy to understand the two-way traffic between sexual and any other kind of emotional tension. I have known a child in whom masochistic behaviour had been evoked in infancy, flee from punishment in school as from mortal danger, and I have seen a hysterical reaction provoked in a teen-age girl at the mere witnessing of the punishment of other children. Any mode of education which uses punishment as a tool establishes a sado-masochistic relationship between child and parent on the one hand, and pupil and teacher on the other, which will colour the child’s whole life. But further, the unremitting punitive tensions in home and in school to which children are subjected in certain areas, are in my opinion a decisive factor in the production of serious " physical illness. If, as I believe, resistance is a condition of energy " of the child as a whole, then punishment will render him susceptible to illness by lowering his resistance. an
"
1.
Tumulty, P.
A.
J. Amer. med.
Ass. 1954, 156, 947.
1028 The
analysts maintain that the child can " adapt " by the punitive tensions of authority to build up his super-ego and other internal forces of resistance. He will then become a " good " person. But he will externalise his " unconscious sense of guilt " and many such individuals are always " looking for something to forbid " and cannot even observe the natural behaviour of children without experiencing an inner compulsion to lay hands on them. It is not surprising that analysis is confronted with the paradoxical situation of having to restore to broken lives the unity that they possessed in the beginning. Finally, what moral argument is there on behalf of punishment or the " threat of the withdrawal of love " as an instrument of education ? As Kenneth Walker in his and Sex : " It is a betrayal of every says Society spiritual value we profess to hold in reverence, to use love as a bait or a weapon of coercion." using
-
D. JACKSON County Psychiatrist and Director, Cornwall Child Guidance Service.
A VISIT TO KOLTUSHI
SIR,—I found the article by Mr. Ruscoe Clarke and Dr. Leonard Crome (April 2) most interesting. Of interest, too, were the comments of last week of Dr. Mungo Douglas in that they represent a distaste for Pavlov’s work which is by no means unusual in the British profession. one cannot but contrast the meticulous objectivity of the Pavlov school with the doctrinaire disregard of facts shown by Dr. Mungo Douglas. Instead of criticising the experimental findings quoted by Mr. Clarke and Dr. Crome, he asks the rhetorical question : Is it a study likely to provide the kind of future we should all desire ..." If it can be shown that the great mass of data accumulated by the Pavlov school is all wrong, or if it can be shown that these facts are without relevance to, for
However,
"
example, gastric function, bronchospasm, or, by Pavlov, schizophrenia, then it is open to
as
suggested
Dr. Mungo to prove his case. But, in the scientific world at least, generalisations about vital freedom and enslavement cannot be accepted as a substitute for the dispassionate consideration of established facts. Personally I welcome all facts relating to conditioned reflexes since they touch on some very fundamental problems and suggest some interesting possibilities in clinical application. C. H. FOGGITT. Sheffield.
Douglas
PSORIASIS SPONDYLITICA
SIR,—Dr. Lydon (April 30) asks us to support the unitarian theory of the pathogenesis of the rheumatic diseases. This concept has, however, in the past, proved unhelpful in furthering our understanding of these disorders of connective tissue. Moreover, as Professor Kellgren has pointed out,l just as no sensible person would seriously suggest that all diseases of the nervous system have a single ætiological factor, so it is equally unlikely in the case of the diseases of the supporting structures. It is probable that research into the fundamental cause or causes of the rheumatic diseases will be easier once a greater knowledge of the normal anatomy and physiology of connective tissue and of the various clinicopathological entities which we call the rheumatic diseases has been acquired. As the expression of a useful piece of clinical observation, I, for one, welcome the term " psoriasis spondylitica used by Dr. Fletcher and Dr. Rose (April 2). One other point arises from Dr. Lydon’s letter : he is incorrect in regarding the arthritis of Reiter’s disease as indistinguishable from rheumatoid arthritis-it differs from it in the joint " pattern " and in its course. Reiter’s arthritis predominantly affects the joints of the lower "
1.
Kellgren, J. H. Brit. med. J. 1952, i, 1093.
limbs, especially the knees and the ankles’; it is also much more benign, and seldom leaves any permanent or crippling deformities except in the feet. J. F. BUCHAN.
London, W.1.
NON-PROGRESSIVE BREAST CANCERS SIR,—Further evidence of the common occurrence of
non-progressive, non-lethal lesions, in general indistinguishable microscopically from lethal breast cancer, appears to be requisite for a fuller realisation or acceptance of the limitations of treatment. Such evidence is obvious, I think, in the data of two series of cases cited
previously1 and other related data. In one series, stage 1 (i.e., confined to breast) constituted 50%, the 5-year survival-rate in the whole series was over 60% and in the stage-1 cases it was 85-6%. In the other series, the respective figures were -16%, 43%, and 81%. Consideration of all factors left no reasonable alternative to the deduction that the majority of stage-1 cancers in the first series were non-progressive lesions, and that they accounted, though not necessarily exclusively, for the unusually high 5-year survival-rate for the whole series and largely accounted for the high 85-6% rate in the stage-1 cases. The near equality of 85-6% and 81%, and the similarity of both with the rates usually obtained in stage-1cases, point to similarity in the material providing these rates. In other words, as the majority of the stage 1 forming 50% in the one series appeared to be non-pro. gressive lesions, it seems a reasonable deduction from the similarity of the survival-rates that the majority of stage-1 cancers in most series are similarly non-progressive lesions. The high proportion of non-progressive lesions in the stage-1cases could then explain, reasonably and consistently, the high survival-rates in the latter. In contrast to the contention that stage-1 lesions are progressivelethal cancers in an early and curable stage of development, this explanation is compatible with the persistence of level trends in age-specific mortality in spite of an increase in stage 1 in the treated cases, compatible, too, with the wide variations in reported survival-rates in different series, and with frequencies of stage 1 and of grade 1 as found at different durations.
fully
This does not imply that all the difficulties of differentiation confined to stage-1 cases. The wide difference in survival time even in well-advanced cancer, both untreated and treated, reflects wide difference in the degree of malignancy in such cases. That difference is not fully revealed even with grading of tumours by microscopy. Lewison, in the Halsted Clinic, carefullv re-examined sections from the tumours of patients who had survived ten years or more but found nothing on which to prognosticate the long survival.2 Murley et al. found approximately the same five- and ten-year survival-rates in cases clinically stage 1 but pathologically stage 2 (axillary involvement) as in cases clinically stage 2 but pathologically stage 1. The rates lay between those in stage 1 and those in stage 2 (clinically and pathologically).3 While the near equality of the survival-rates in the two groups could be due to chance, it may indicate a degree or distribution of malignancy somewhat representative of such An unidentified increase in such cases as those described. clinically stage-1 but pathologically stage-2 cases in series treated in successive quinquennial periods could thus be a factor in the progressive increase in survival-rates in the cases with axillary involvement as reported by several clinics. As Smithers et al. have emphasised,4 survival-rates are influenced by factors other than diagnosis and differentiation, such as difference in selection of cases after diagnosis, in staging criteria and their application, in detection of lymphatic involvement, in follow-up, in calculation of survival-rates, &c. However, when, in fifteen series of different time or place and for which the necessary data were available, the 5-year survivals of stage 1 were deducted from the over-all 5-year survivals, the net 5-year survival-rates then ranged from about 10% to about 30%, with the majority close to 20%. They thus approximated to what might be found in untreated are
1. 2. 3. 4.
Lancet, 1954, i, 251. J. Amer. med. Ass. 1953, 153, 905. Brit. med. J. 1953, ii, 787. Brit. J. Radiol. 1952, suppl. no. 4.