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an alimentary response due to the apparatus ; ABBOTTet al. devised a system of small metal capsules, eachcontaining a flexible diaphragm carrying an electriccontact which closed at known pressures. The methodwas ingenious but complex ; but it does indicate thatstrain gauges could perhaps be useful. BRODY et al. 6measured pressure changes with an open tube in thegut and an optical manometer ; the mass introducedwas small, and the inertia within the system veryslight.

Motility has been investigated by the even lessdirect method of measuring electrical potentials.ALVAREz 8 applied electrodes to the thin abdominalwall of a small old woman and compared the gastro-

gram withvisible peristalsis. At that time he coulduse’ an intragastric electrode only in patients withachlorhydria, on account of the voltage variationsset up, in others, by fluctuations in the level of acidin the gastric juice bathing the terminals. Usingnon-polarisable electrodes, one in the stomach andone on the skin, ADAIR and GOODMAN 9 found a differ-ence of potential (the stomach being negative to skin)which increased after milk was ingested. Later inexperimental work with QUIGLEY and BARCROFT,1o

7. Abbott, W. O., Hartline, H. K., Hervey, J. P., Ingelfinger,F. J., Rawson, A. J., Zetzel, L. Amer. J. med. Sci. 1940, 199,879.

8. Alvarez, W. C. J. Amer. med. Ass. 1922, 78, 1116.9. Adair, G. S., Goodman, E. N. J. Physiol. 1936, 87, 35P.

10. Quigley, J. P., Barcroft, J., Adair, G. S., Goodman, E. N.Amer. J. Physiol. 1937, 119, 763.

these workers came to the conclusion that the gastricpotential did not depend on the pH of the stomachcontents or on activity due to secretion or motility;ALVAREZ and MAHONEY 11 had already observed

changes in potential at times when no movementcould be observed. Now MORTON 12 has developedan electrogastrograph on which he records directcurrent due to secretory activity with superimposedalternating current due to action-potentials arisingfrom motility. He uses the same system of non-polari-sable monopolar electrodes with the active pole inthe stomach, placing the independent electrode onthe skin over the right delto-pectoral groove near theshoulder ; and he believes that the total of potentialsbuilt up at cellular and tissue interfaces, which formbarriers to diffusion between the two terminals, mustbe nearly zero and can therefore be ignored. MORTONhopes that these methods may make clear the mecha.nism of motility. Both he and GOODMAN 13 beforehim have diagnosed early carcinoma of the stomachfrom the form of the tracing ; and IVIoRTOrr has alsodemonstrated variations from normal pattern in thepresence of peptic ulcer, and has differentiated betweengastric and duodenal ulcer. These empirical findingssuggest that the electrogastrograph may prove usefulin clinical practice ; but the method is still at the

experimental stage.11. Alvarez, W. C., Mahoney, L. J. Ibid, 1922, 58, 476.12. Morton, H. S. Ann. R. Coll. Surg. Engl. 1954, 15, 351.13. Goodman, E. N. Surg. Gynec. Obstet. 1942, 75, 583.

Annotations

PALLIATION IN CANCER

DESPITE heartening progress in the treatment of

malignant disease there are still many patients withcancer for whom there can be no cure. The manage-ment of each one of these has its own peculiar difficulties,but it is clear from a discussion, on Jan. 5, by the sectionof surgery of the Royal Society of Medicine that thereis a wide choice of useful palliative techniques.The limitations of surgery in this field were clearly

stated by Mr. H. T. Simmons. One of the surgeon’smost valuable contributions is in the relief of pain byremoval of the primary neoplasm; but the circum-stances in which this should be attempted dependlargely on his judgment and experience. Incompleteexcision of a tongue cancer can cause only harm, whereasin carcinoma of the stomach gastro-enterostomy alone ismost unsatisfactory. In the small and large intestine therelief of obstruction by a by-pass is immensely valuable ;but colostomy in an old man with an inoperable rectalcancer only adds another trouble and does nothing torelieve the distressing bleeding and tenesmus. Mr. H. R.Thompson has found, from the records of St. ]BHtrk’sHospital, that 17% of a large number of patientssubmitted to what was believed to be a palliativeoperation were still alive 5 years later. But often,said Mr. Simmons, a heroic operation is planned andexecuted only to show the surgeon’s audacity and tech-nical skill. Such an operation will be justified onlyif it brings considerable relief.

Hitherto full advantage has perhaps not been takenof the neurosurgeon’s power to allay pain. There is a

reassuring precision in spinothalamic tractotomy for

painful lesions in the lower half of the body, and divisionof the glossopharyngeal nerve and of the posterior rootsof the upper cervical nerves for intractable mouthtumours is less attractive only because it involves asomewhat complicated cerebellar exposure. But Prof.Norman Dott frankly admitted the shortcomings of

leucotomy, which leaves the physical aspects of painunaffected although the patient ceases to be distressedby its ravages. Respite is bought only at the cost of

flattening and shallowing of the whole affective

personality. No less important than the relief of painis the preservation of essential neural function-for

example, when vision is threatened by an intracranialmetastasis or the spinal cord by an osseous deposit.Hormonal therapy is clearly valuable in the palliation

of cancer of the parasexual organs, but its effectivenessin any particular patient is largely unpredictable. The

mounting experience of adrenalectomy has proved thatthe benefit may be dramatic, although we must continueto balance the severity of the operation against the

palliation achieved. A preliminary report from Mr.

Murray Falconer suggested that hypophysectomy is

technically possible, and that in the hands of an expertwe can expect an acceptably low mortality. This typeof work, with its accompanying problems of endocrinereplacement, should be confined to centres with specialfacilities. The suggestion by one speaker that the manage-ment of every patient with inoperable cancer should beconsidered by a panel of experts, each of whom knowsthe limitations of his own technique as a palliative, wasregarded by the meeting with some misgivings-thecare of the patient might pass to a

" muddle of doctors."Of drugs, morphine is our standby in the terminal

stages : " it exists to be given and not merely to be with-held." Nurses are often reluctant to give it in adequatedoses, even though the problem of addiction seldom arises.There is too much persistence of the Calvanistic line ofthought, which prompted Professor Dott to quote theScots saying that " ye canna buy the grace o’ God owerdear." On the other hand, the patient will in no waybenefit if a diagnosis of inoperable cancer is, by itself,made the justification for administering an opiate:its greatest merit is in the relief of pain and we mustreserve it for this purpose. There can ,be no harm in the

early and continuous use of analgesics, and severalspeakers made a good case for administering chlorproma-zine, especially when vomiting is intractable.

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The burden of care of the patient in his latter daysfalls mainly on his general practitioner, whose point ofview was expressed by Dr. G. F. Abercrombie. He

complained that hospitals too often fail to tell their

patients anything, with the natural result that the generalpractitioner is put at a grave disadvantage from the veryoutset. But it was clear from the later discussion thatnot everyone would willingly follow his practice of alwaystelling cancer patients the truth. He argued that weusually underestimate their ability " to take it " ;he had been deeply impressed by their fortitude andby the mental adjustment that seemed to follow quitenaturally. He saw nothing good in the dissimulation bydoctor and relatives that must inevitably follow whenthe true diagnosis is withheld, and had never had goodreason to regret telling the truth. In this regard weshould campaign strenuously against the view, so

commonly held by laymen, that a cancer death is alwaysnoering and painful. Dr. P. W. Nathan took quite theopposite point of view. He felt that we have no moralduty to reveal the truth and that there is a good case forthe cultivated deliberate lie. To judge by the viewsexpressed by other speakers, the majority practiceMs somewhere between the two extremes. In the earlvstages the patient’s powers of self-deception areencouraged, and the truth is told only when the physicianis satisfied that the patient wants it or when this seemsto be in the interest of himself or of his relatives. Bydelay we may sometimes deny a responsible patienthis only chance of putting his house in order. Dr. C. J.Gavey wisely put the case for frequent visiting in suchcases, even when nothing overt is achieved ; often,when there is a close bond of understanding betweenpatient and doctor, there comes a time when the truth,although unspoken, is equally revealed by an exchangedglance or a squeeze of the hand. Mr. Simmons deploredthe casual attitude of the surgeon who leaves the inoper-able case to his registrar at the end of the list. At notime must the patient feel abandoned, and the nurses andthe relatives no less need constant encouragement.

It seems clear from this discussion that the choiceof method will depend partly on the site of the tumourand on its natural history, but even more on the patient’scharacter, age, and responsibilities, and his position insociety.

1. Darmady, E. M., Brock, R. B. J. clin. Path. 1954, 7, 290.2. Report of the Central Pathology Committee of the Ministry of

Health on the Sterilisation of Hospital Equipment. H.M.(54)118.

STERILISATION OF SYRINGESEVERY housewife knows that the hottest part of

a cooking-oven is near the top. Darmady and Brock,!in very thorough experiments with ovens for sterilisingsyringes, found a much higher temperature near the topof ordinary electric ovens, and this difference provedeven greater with two gas-heated ovens. An alternativemethod-namely, boiling-was investigated by testingwith thermocouples the temperature attained by indi-vidual syringes; and it was found that if the syringewas wrapped in lint before being placed in boiling water,100°C was not reached for 5 minutes or longer. Theother alternative-autoclaving-is unsatisfactory becausethe syringes have first to be taken apart.Clearly if ovens are to be used for sterilising syringes,

something must be done to equalise the temperaturethroughout the whole space ; otherwise the syringesplaced near the top of the oven may be overheated, whilethose at the bottom may not be sterilised. Darmady andBrock therefore tested electric ovens in which the circula-tion of hot air was aided by fans. In such ovens thetemperature of the syringes, provided that they were notpacked too tightly, rose rapidly and evenly to the desiredlevel. What this level should be seems still to be indispute; and the authors cite suggestions varying from140°C for 1 hour (electric oven with fan) to 160°-180°Cfor 2 hours. A report 2 issued by the Ministry of Health

specifies 160° 5°C for not less than 1 hour. Since

spores of different organisms have different thermal deathpoints, Darmady and Brock suggest that an authoritativebody should define the organism to be used for checkingsteriiisation by dry heat..From this valuable report certain principles emerge

for those setting up a syringe service : only electricovens with fans are suitable ; the oven must not beoverloaded with syringes, which must be packed loosely ;and the temperature of the syringe should be checkedagainst the temperature recorded by the oven’s thermo-meter. Finally Darmady and Brock show that an

electric oven with fan seems to work better if loadedwhile still hot-which is contrary to the M.R.O. memo-randum 3 and to the Ministry’s report.2

3. Medical Research Council War Memorandum no. 15. H.M.Stationery Office, 1945.

4. Nursing Times, 1954, 50, 1425.

THE HOME-CARE TEAM

WE all know that far too many people knock on thedoor of the Englishman’s castle and offer advice on health,infant welfare, surgical appliances, housing, drains,school attendance, delinquent behaviour, tuberculosis,mental ill health, and a variety of other topics ; andthat no two of these specialists will necessarily give thesame advice, even when (as occasionally happens)they are talking about the same thing. It has alwaysseemed desirable to reduce their numbers, and to have einstead a few people with a broader outlook. Some thinkthat if the health visitor and the district nurse couldhave more scope and appropriate training they could,with the family doctor, take in most aspects of familylife : and that, being already trusted family friends,thev are the right people to undertake this broad care.The opportunities for health teaching open to the

district nurse, working with the family doctor, havelately been described by Dr. J. L. Burn,4 medical officerof health for Salford. Home care, be thinks,-is bound togain in importance : psychological, medical, and financialreasons all favour the complementary use of the homeand the hospital in the care of the sick. Domiciliaryvisits by specialists-which he regards as one of the fineachievements of the National Health Service-havealready enabled many people to stay out of hospital,and have also ensured that many who need hospitaltreatment are admitted without undue delay. Thisservice, in his opinion, is being well and widely used :

- in one region only, in 1953, some 20,000 domiciliaryvisits were paid by consultants, and the numbers steadilyincrease. Earlier discharge of patients from hospital isnow being arranged in some areas, though some hos-pitals-not confident of the standard of home care whichnow can (and should) be provided-hesitate to attempt itas a fixed policy. If only one patient in twenty wasdischarged earlier, to the care of his family doctor andhis district nurse, it would greatly reduce the blockageof hospital beds and help the people on our hospitalwaiting-lists.

District nurses could be used more fully, Dr. Burnthinks, in the care of sick children : these sometimes

get less skilled nursing than they need-the nurse, likethe home help, being expected to give her attentionalmost exclusively to old people. Nor do paediatriciansget called in as freely as other specialists ; and indeedthe family doctor himself may not be called in till thelast minute. Such delays mean that some children’slives are lost unnecessarily. Dr. Burn urges that thehealth visitor should pay more routine visits to babiesin " black-spot " areas, and should press the parentsto call in the doctor early when a baby is ill. She shouldalso have far more official opportunity for collaboratingwith the district nurse, who in turn should be in closertouch with the doctor. All three-or their representatives-should have the opportunity of joining in discussions