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who speak in sentences. Dr. Tomb’s observations are ofmuch interest, but the inferences from his observations,on which he invites criticism, are open to question." It is obvious," he says, " that a child’s capacity forlearning languages does not depend on intelligence,for if this were the case it is reasonable to assumethat the parents would pick up the various vernacularsmore quickly than their children." Most psychologistswould grant that the linguistic capacity is not depen-dent on " general intelligence

"

alone, but is partly a" specific " innate capacity of the mind. Speechitself is an inborn instinct which, like all otherinstincts, lives by what it feeds upon and has itsperiod of maximum activity during the early years oflife. If no food be provided in the form of audiblespeech, as in the case of the child born deaf, theresult is the deaf-mute. If, on the other hand, threeor four languages be audible, all will be assimilatedwith equal ease, particularly during the early years.Let the admission of the deaf-mute into the deafschool be delayed until the age of (say) 10 or 12, andhis acquirement of speech will be difficult, because ofthe weakening of the instinct from lack of use. Ina similar way the Englishman transferred to Indiaafter attaining maturity has relative difficulty in under-standing and acquiring facility in the native dialects.It is not, then, so much a matter of intelligenceas of the functioning of an instinct, and Dr. Tomb’sobservations are confirmatory of what was previouslyknown. The further inference made that a child musthave a capacity for " intuitively placing the correctmeaning on spoken sounds " is, we think, more thanthe facts justify. Meaning is indicated or suggestedto the child in some manner other than speech, buthe must obviously have the capacity to grasp andremember the association.

SURGICAL EXAMINATIONS.

THE qualifications demanded of a surgeon are

many and exacting. Essentially he must have manualdexterity of a high order and his judgment must besound ; whilst a wisdom which comprehends morethan the knowledge of his actual craft is almost anecessary asset. The evolutionary changes of late

years have made him more and more independent ofhis medical colleague. The days have gone when thephysician’s advice as to the time and nature of anintervention in acute abdominal disease was soughtas a matter of course. The vivid pictures of theoperating-table have transformed the surgeon intoa clinician whose pre-operative opinion has become ofunassailable value. Whether it be in the realms ofneurology or of diseases of the abdomen or chest, wesee this change occurring, and perhaps a new genera-tion of specialists will arise who will treat indis-criminately the medical and surgical diseases of theparticular system of the body to which they havegiven their attention. At present the qualificationsof the aspirant to surgery are tested by examinationswhich are chiefly calculated to reveal his clinicalknowledge ; and this they do with efficiency. Histechnical ability remains a closed book to the exa-

miner. Yet how important manual dexterity is insurgery; every incision made is an irrevocable steptaken, after which, however skilfully performed, therecan be no absolute restitution to the status quo ante.Save in the case of nerves repair takes place solely byscar-tissue formation, and the body can never againbe quite so perfect as it was before the surgeon’sintervention. Sometimes the deviation from normalis so slight that it is not, or cannot be, noticed by thepatient, and naturally this ideal is more often reachedby the superlatively skilled than by the occasionaloperator. The remembrance of this fact indicates howessential it is to ensure reasonable technical abilityin all those upon whom diplomas in surgery are

conferred. To prevent that licensing of the incom-petent, of which he recentfy complained, Sir JohnO’Conor sends as a suggestion that " every candidate

1 THE LANCET, 1925, ii., 781.

for any surgical diploma shall present full notes ofcases with complete details (’ steps’) of ten majoroperations, on the living subject, performed byhimself-each record to be signed by the surgeon(teacher) who personally directed and assisted him ineach operation." As examples of those which heincludes in the category of major operations SirJohn O’Conor mentions those performed for septicfractures, arthrotomy, varicose veins, hydrocele,haemorrhoids, empyema, urinary extravasation, septicendometritis, and incomplete abortion. The principleis good, for too much care cannot be taken to rendermen proficient who propose to practise surgery. Analternative system might require candidates to haveheld an appointment equivalent to that of a firstassistant in a continental clinic for a definite periodlonger than the usual tenure of office of house surgeonsin this country. It is an undisputed fact that muchexperience and knowledge of technique can be acquiredby close association with a master surgeon, and if thecandidate were required to have performed operationsassisted by his teacher all reasonable steps would havebeen taken to render him proficient. There are,however, difficulties in carrying out such suggestionswith our present system of medical education.

CANCER IN RELATION TO OCCUPATION.

AN investigation into the Statistics of Cancer inDifferent Trades and Professions by Dr. MatthewYoung and Mr. W. T. Russell, with the collaboration ofDr. John Brownlee and Dr. E. L. Collisl has just beenpublished as a green book (Special Report SeriesNo. 99) by the Medical Research Council. The workhas been made possible by the courtesy of theRegistrar-General in affording facilities of access tocertain documents in his possession. These includedcards on which were coded the sex, age, specific trade,and cause of death of men who died in 1910,1911, and1912. On 46,118 cards which recorded deaths frommalignant disease the site of the tumour was for themost part noted, and it has thus been possible to makea detailed survey of the relation of cancer to occupa-tion. A brief introduction is followed by a discussionof previously published data. The methods ofanalysis used in this investigation are then set out.There follow sections on the incidence of cancer in theprincipal sites in different occupations, and on therelationship between different types of cancer, betweencancer in different sites and syphilis, and betweencancer and chronic alcoholism. The conclusions of theinvestigation are then briefly summarised. The closeassociation of some types of cancer with exposure toparticular risks-for example, chimney-sweeps’ cancerand mule-spinners’ cancer-has been confirmed, butno conclusive evidence has been obtained of such aconnexion between the nature of the employment andother forms of cancer, notably internal forms. Insome occupations excessive smoking and drinking,which is permitted or facilitated by the nature of theoccupation, appears to be the important predisposingfactor and not anything inherent in the employmentitself, while the incidence of syphilis in differentoccupational groups seems to have some associationwith that of lingual cancer. With the main conclusionthat occupational risk is only one of several predis-posing causes of cancer in different instances and underdifferent circumstances all are likely to agree.

It was hoped that such an examination might givefurther information as to the wide influence ofsubstances already recognised as harmful, or mighteven disclose other injurious substances. But thedifficulty of interpreting the material has proved verygreat, and the result of a praiseworthy and laboriouseffort appears on the whole to be disappointing. Inmany trades or occupations the number employed issmall and consequently the number of deaths is liableto considerable random error. Again, as is made clearin the foreword to the report, statistical science is stillin a developmental stage, and there exists difference of

1 H.M. Stationery Office. 1926. Pp. 50. 1s. 6d.

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opinion between persons equally competent to judgeas to the applicability of particular methods of com-paring figures. For example, the strong preferenceexpressed by the authors for the use of the so-called lifetable death-rates over standardised death-rates is notshared by some of their colleagues, and there are othertechnical points over which experts are not yet in agree-ment. The use of the method of proportional mortalityhas the disadvantage that the proportion of cancer ofany particular site in one occupational group may behigh simply because within that group the rate ofmortality from cancer of another site is low, and themajority of the Statistical Committee of the Council are Iof opinion that conclusions based upon this method andunconfirmed or incapable of confirmation by a studyof the site rates themselves should be accepted withreserve. However, sufficient material is provided inthe tabular matter of this report, and in datapreviously published, to permit other investigators totry and elucidate this complex subject by pursuingresearch on different lines.

MEDICAL PRACTICE IN CHINA.

THE status of qualified medical men in China,whether missionaries or otherwise, is likely to be veryuncertain if the rights which they have enjoyed asforeigners should be abolished. At present no protec-tion is afforded them comparable to that which theprofession has in England, America, and elsewhere.If a doctor in China has no status from a treaty hemay be sued in a Chinese court and have to meetvery heavy claims for damages, as was illustratedquite recently when a German doctor lost a patientafter an operation and had to pay$3000 damages.The Chinese custom of paying the doctor as long asthe family is in health need not complicate the situa-tion, for after all it is but an illustration of contractpractice, but the immediate difficulty is that thereis no sort of medical registration. People with themost rudimentary knowledge--embryonic medicalstudents or even hospital coolies-frequently set upin practice on their own, and such organisations asthe China Medical Association and the China MedicalMissionary Association are quite unable to controlthe unqualified practitioners. If no protection formedical men is arranged at the Extra -TerritorialConference their work in the future will be carriedon with great risk and difficulty. If failure leads tofinancial disaster it may be supposed that onlysimple cases will be undertaken. There is little reasonto think, however, that the Chinese Governmentwould not welcome, in the interests of the medicalprofession among its own nationals, the setting upof a register of properly qualified medical men. Perhapsthe plan followed by the Japanese when they tookover Korea may be adopted. At first they had torecognise the existing native practitioners and doctorsholding British degrees (these are still recognised).Only a five years’ recognition within a limited areawas granted to a large number of American doctors,but after the matter had been taken up diplomaticallythose who were already at work in Korea were givenfull permission to practise. Since then every new-comer from America has had to take a Japanesemedical examination, and though an elaborate systemof certificates and reports has been instituted anddoctors are constantly under inspection, the net result,it is said, has been to the advantage of medicalstandards. t"!!’"’>,

NATIONAL HOSPITAL FOR THE PARALYSED AND

EPILEPTIC.-A post-graduate course started on Feb. 1st

and will go on until March 26th. It includes demonstrationsin the out-patient clinic on Monday, Tuesday, Thursday,and Friday afternoons, and a series of lectures by Dr. J. G.Greenfield, on the Pathology of the Nervous System, onMondays at noon. If there are enough applicants there willalso be lectures on the anatomy and physiology of the nervoussystem and clinical demonstrations on methods of examina-tion. Further particulars may be had from the Dean of theMedical School of the Hospital, Queen-square, Bloomsbury,London, W.C. 1.

Modern Technique in Treatment.A Series of Special Articles, contributed byinvitation, on the Treatment of Medical

and Surgical Conditions.

CLIX.TREATMENT OF HYSTERICAL DISORDERS

IN CHILDREN.

HYSTERICAL disorders below the age of pubertyare not common, but do occur more frequently, evenin quite young children, than is often supposed.Methods of treatment directed towards the immediatedisabilities or symptoms of hysteria seldom fail.Greater difficulty is experienced in preparing againsttheir recurrence. The hysterical temperament, whenpresent, is inherent, not acquired, and, as Charcotsays, " once hysterical, always liable to hysteria."

Hysteria is a condition difficult to define satis-factorily owing to the diversity of its symptoms,and to the lack of any known anatomical lesions onwhich to base its pathology. Definitions have beenadvanced by physiologists and psychologists, manyof which are adequate up to a point, but none aresufficiently comprehensive to be entirely convincing.At the present day hysteria is generally consideredto be a purely psychical disorder. The views ofBabinski, Janet, and Freud are well known and neednot be set out here. There are at least two out-standing features in the composition of hystericalsubjects-namely, the presence of a neurotic tempera-ment, with want of emotional balance and controlof the will, and an unstable condition of the sympa-thetic nervous system. These are really the sourcesfrom which hysterical disorders spring. Evidenceof sympathetic vaso-motor instability is more readilyseen in the adult in such symptoms as flushings,faintings due to abdominal vascular distension withcerebral anaemia, and coldness and cyanosis of theextremities affected by hysterical palsies, oftenassociated with absence of bleeding on pin-prick.Savill was the first to emphasise the importance ofthe role played by the sympathetic nervous systemin hysteria, and even went so far as to state thatmost of the motor disorders of hysteria might beaccounted for by local disturbances of the cerebralcirculation. He was much impressed by the similarityof many hysterical motor disorders to those producedby definite vascular lesions in the brain. The continua-tion of the symptoms in the hysterical cases forindefinite periods after the supposed vascular dis-turbance he attributed to the psychical state of thepatient. Although it is hardly possible to agree withall of his hypotheses, yet his theory of hysteria isdecidedly attractive by reason of the effort made toformulate a pathological basis.

Hysterical Manifestations in Childhood.The commonest hysterical disorders in childhood

are related to the motor system, and consist of

paraplegias and monoplegias. Both spastic andflaccid types occur, but the loss of power is seldomcomplete, and shows variations in degree from dayto day. In the spastic form, which is the commonest,some degree of flexion spasm or contraction is oftenpresent at the joints, and severe pain is usually com-plained of. Hysterical pain and spasm localised to asingle joint, usually the hip, is sometimes observed,and may simulate very closely organic hip-jointdisease. Spinal rigidity resembling caries is anotherhysterical manifestation sometimes met with inchildren. That curious condition known as astasia-abasia, in which the patient can scarcely stand orwalk, and yet is able to perform all movements ofthe legs voluntarily when lying in bed, may also beobserved. Sensory manifestations by themselves areexceedingly rare, but may be present in associationwith paralysis, and usually assume the stocking and