404 HOSPITAL POLICY.-EDUCATION IN CANCER PROBLEMS.

Correspondence.

HOSPITAL POLICY.HOSPITAL SAVINGS ASSOCIATION.

"Audi alteram partem."

To the Editor of THE LANCET.SIR,—I have just seen in your issue of Feb. 3rd a

letter signed by the vice-chairman and senior physicianof the West-End Hospital for Nervous Diseasesrelating to the scheme of the Hospital SavingsAssociation, and while I do not wish to enter into ageneral discussion on the merits of the scheme, I dowish to clear away misunderstandings.

Will you therefore allow me to state shortly :-1. The scheme involves no interference whatever

with the present independent management of hospitals.2. It is not an insurance scheme ; it does not set

out to bring new classes of patients to the hospitals,but only to enlarge and organise the collection ofcontributions from the classes who already use thehospitals ; it leaves unimpaired the right of thehospital to decide what cases are suitable for admissionto hospital treatment and the order of priority inwhich applicants, whether contributors or not, areadmitted.

3. The only alteration’ in the present almoningarrangements is that the inquiry as to means by thehospital becomes unnecessary in the case of contri-butors, because it will have taken place before thecontributor applies for hospital treatment. Hospitalincome limits have been defined, and every contributorwho applies for hospital treatment will bring withhim an authenticated statement that his income fallswithin them. In any case of suspicion the hospital willbe afforded full opportunity of investigation throughthe Association.

4. The payment, or non-payment, of medical staffsis a question of hospital management, and in suchquestions the Association is under a pledge to thehospitals not to interfere.

5. I can see nothing that " controverts the existingprinciples of the voluntary system " in collectingcontributions from wage-earners and using them tohelp the hospitals which have treated contributors.The one desire of all of us who have taken the lead inthis matter is to preserve the voluntary system. Theextent of the support which the scheme has alreadyreceived from hospitals, employers, and representativewage-earners drawn from many trades, confirms mein the confident belief that we shall succeed.

I am, Sir, yours faithfully,HAMBLEDEN,

Chairman, Hospital Savings Association.3, Grosvenor-place, London, S.W., Feb. 14th, 1923.

EDUCATION IN CANCER PROBLEMS.

To the Edator of THE LANCET.

SIR,—Dr. W. H. Woglom, Associate Professor ofCancer Research in Colombia University, New York, disagrees with your editorial view that " a campaignof education cannot diminish the incidence " of cancer.Personally I think his arguments regarding thekangri basket of Kashmir and the betel nut habit ofthe Philippine Islands are irrefutable.Now in this country the crucial question involved

is whether or no there be pre-cancerous conditions.On this point the writings of many of your contri-butors are pretty clear, and a recent example is affordedby the article of Dr. Ernest Shaw in your issue ofFeb. 3rd. He writes : " In view of the known factthat cancer arises in the great majority of cases in abreast already altered by inflammatory action thesmall operation of local removal would prevent theformation of cancer in a great many women." Ithink the large majority of surgeons will endorse this-opinion and they consider the removal of the breastfor degenerative mastitis one step in the fight against

cancer. No less an authority than Sir LenthalCheatle has emphasised the importance of this aspectof the case, though he prefers the word" proemial"

"

to " pre- cancerous."’ 1 The point remaining is whethera publicity campaign will induce women with mastitisto submit to surgery. Personally I think it will beof the greatest help.

There is another direction in which I should like toplead for a change of the editorial mind. Youapparently object to the word " control" with refer-ence to education in cancer problems, but in thedictionary by my side I find as synonyms for’"control," " to restrain, govern, overpower," and thatis what we must surely hope to do with cancer, and atonce. Let it certainly be granted that we cannotprevent a disease until we know its causation, but donot let us give up our effort to hinder its progress. Atthe Royal Society of Medicine on March 13th it isproposed to hold a discussion on the Urgent Need forEducation in the Control of Cancer, official notice ofwhich has, I expect, reached you by this time, and itis because I am to take part that I urge the acceptanceof the word " control." Its value lies partly in thefact that it begins with the letter " c," partly becauseit is in use all over America, where the Society for theControl of Cancer claims to have already done goodwork, and lastly because it appears to be exactly theright expression.-I am, Sir, yours faithfully,

Harley-street, W., Feb. 12th. JOSEPH E. ADAMS.

GASTRIC ULCER AND GASTRIC CANCER.To the Editor of THE LANCET.

SIR,—Dr. A. C. Jordan, writing in your issue ofFeb. 10th, states that a tense pylorus and a full parspylorica are present in gastric ulcer and that thebarium meal remains in the stomach for 50-70 hoursin such cases. Surely, Dr. Jordan refers only toextensive and comparatively rare pyloric obstruction,usually due to carcinoma at the pylorus, and some-times found also in very chronic duodenal ulcer closeto that sphincter. In chronic gastric ulcer, where apenetrating lesion is present along the small curvature,or the posterior surface of the stomach, no suchpyloric stenosis exists and the time of emptying showsno great delay, the meal completely passing out from2-4 hours. In gastric ulcer, where no penetration ispresent, but only an incisura to indicate its site-thatis to say, ulcer of a less extensive and chronic type-rapidity of emptying is the rule, often well under twohours. Even in ulcer situated at the pylorus, in themajority of patients, no delay in emptying is present.Only rarely is definite delay in emptying to be seen,and to rely upon such a sign to diagnose gastric ulcermust lead to inaccurate diagnosis in 99 per cent. ofcases.

Dr. Jordan speaks also of " a distended duodenumin a state of active peristalsis in such cases, makingstrong efforts to overcome a stubborn duodeno-jejunal kink." A strongly contracting duodenal firststage is not dilated, the muscular contractions reducingits lumen. Also, a stomach with chronic ulcer at theupper portion of the fundus does not show hyper-peristalsis of the duodenum. Hyperperistalsis ispresent in cases of gastric ulcer complicated by aduodenal lesion. I have seen such, and Lord Dawsonreported one case about a year ago and mentioned thatI had made the double diagnosis previous to operation.I have met this condition again since then. Theincidence of such cases is usually given at 4 per cent.of all gastric patients operated on. This is probablya high estimate.The duodeno-jejunal " kink " is present in every

case of gastric ulcer, but also in normal cases, and itsconnexion with gastric ulcer is probably as remote asits pathological existence ; unless Dr. Jordan refersto the normal duodeno-jejunal flexure. Hyper-peristalsis of the duodenum is usually found in duodenalulceration. It is often associated with deformity ofthe bulb, either spasmodic or organic, which may

1 Vide Brit. Med. Jour., June 3rd, 1922.