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CANCER AND DIET.MOST medical men will have been startled to find

in their morning papers last Saturday headlinesannouncing in more or less flamboyant terms a greatdiscovery in the treatment of cancer by diet, communi-cated to the meeting of the British Association inLiverpool by Dr. S. MONCKTON COPEMAN. Sensationalstatements on medical subjects which appear in thedaily press do not often demand comment from us,but in this instance weight is given to the statements ,,

by Dr. COPEMAN’S standing as a public man and one Ito whom preventive medicine is substantially indebt. On the basis of the newspaper reports Dr.COPEMAN is apparently of opinion that vitamin A,while of great importance to the young and growingorganism, is of comparatively little importance tothe adult. Now the effect of rationing during the waryears, especially in the Central European States, wasessentially a rationing in those foods, such as butterand milk, which in a normal dietary provide the fat-soluble vitamin A, and the disastrous effects of thisexperiment on a large scale do not bear out Dr.COPEMAN’S contention, which does not seem to bebased on any original investigation of his own. In

papersl2 published two years ago in our columnsthe workers from the Lister Institute attributed thehunger-osteomalacia which occurred in Vienna in1920 to a fat-soluble A deficiency. They also showedthat the disease affected chiefly middle-aged and oldpeople of both sexes. Moreover, Dr. COPEMAN seemsK) have overlooked the literature on the subject.In 1919 Prof. J. C. DRUMMOND3 undertook an experi-mental investigation designed especially to test thisvery point, and he concluded that the adult animalorganism requires a regular supply of vitamin A,although the daily requirement is of a smaller orderthan that necessary to ensure growth in a younganimal. Prof. DRUMMOND states that " there is

every reason that great care should be taken to ensurethat dietaries of adults contain an adequate supply offoodstuffs in which fat-soluble A is present.... In theabsence of this factor the resistance to diseases ofbacterial origin is seriously impaired." The state-ment by Dr. COPEMAN that an excess of vitamin Ain the diet might eventually become injurious is

contrary to all available experimental evidence.It is difficult to understand the rationale of Dr.

COPEMAN’s diet. It is not a vegetarian diet, for heallows ham and bacon. Were his premises correct,then the restriction of vitamin A, which is a factornecessary for the growth of a young animal, shouldhave a retarding effect on the growth of cancer. Butthe diet actually recommended by Dr. COPEMAN is nota diet free from this factor. He excludes animal fatscontaining vitamin A such as butter, eggs, and cream,but he adds lettuce and watercress which, as he him-self states, contain fat-soluble A. On the basis ofhis own arguments there is no reason why such a dietshould have any effect on the growth of cancer,unless he presumes, as he appears to do, that anamount of vitamin A insufficient to maintain the

growth of cancer cells is adequate to maintain thewell-being of the patient. But here again experi-mental evidence has been adduced to show that thegrowth of cancer cells proceeds quite independentlyof the presence or absence of vitamin A. Prof.DRUMMOND4 demonstrated in 1917 that the growthof cancer cells in rats is not inhibited by the complete

1 Elsie Dalyell and Harriette Chick : THE LANCET, 1921,ii., 842.

2 Margaret Hume and Edmund Nirenstein : Ibid., 849.3 J. C. Drummond : Biochem. Jour., 1919, xiii., 94.

4 Drummond : Biochem. Jour., 1917, xi., 325.

absence of the fat-soluble vitamin A, and that, illfact, it is not possible to bring about an inhibitionof tumour growth by employment of any dieteticrestrictions without the nutrition of the host becomingseriously impaired. More recently work in thelaboratories of the Imperial Cancer Research Fundhas led to exactly the same conclusion.5 In 1922 wo

published a paper by Dr. STANLEY WYARD6 in whichhe reported on the results obtained in cancer patientsby placing them on a diet deficient in vitamin A.This was done at the suggestion of Dr. COPEMANhimself, who was responsible for the composition ofthe diet. Dr. WYARD’S conclusion was that theresults were entirely negative. The diet now adoptedby Dr. COPEMAN differs from that which he recom-mended to Dr. WYARD in containing more vitamin A.It is difficult to gather what claims Dr. COPEMAN nowmakes for this new diet. It is said to alleviate pain.But the dismal history of cancer remedies shows thatthis claim is made for every remedy that has failedin other respects. He also claims an increased

expectation of life. From the reports published inthe press it is impossible to see how Dr. COPEMANjustifies this claim. How many cases has he hadunder observation Has he selected his cases or

has he chosen his cases indiscriminately ? Andhow does he calculate the expectation of life of a

patient afflicted with cancer and not undergoing histreatment 7

Dr. COPEMAN may complain that we are criticisinghis statements on incomplete reports. But it isthese reports which have been laid before a layaudience and circulated widely in the press, and theirdetails have not been submitted to the judgmentand criticism of his peers. Dr. COPEMAN is a memberof the Departmental Cancer Committee, appointedby the Ministry of Health under the chairmanshipof Sir GEORGE NEWMAN, which has recently issued anexcellent memorandum on the whole cancer problem.The omission from this memorandum of any referenceto the effect of diet on the treatment of cancer suggeststhat Dr. COPEMAN has been unable to convince his

colleagues and has now appealed to a wider thoughless critical audience.

THE KITCHENER MEMORIAL MEDICALSCHOOL.

Lord KITCHENER on the occasion of his last visit tothe Sudan expressed a strong wish that there shouldbe a medical training school for Sudanese students atKhartoum, and no more suitable memorial for thegreat soldier could have been chosen than to foundsuch an institution. The proposal appealed to theSudanese Arabs as well as to KITCHENER’S owncountrymen, and as a matter of fact of the .813,00which had been subscribed by the end of last year, allbut k2000 came from the natives of the Sudan, whilein addition one Sudan merchant has handed over allhis property to trustees in order that on his death theincome, which will amount to some 21200 a year,may be devoted to the maintenance of the medicalstudents. There is pressing need for this medicaltraining school in order that young Sudanese doctors.may work under Government supervision to bringassistance to the inhabitants of vast districts whichare fever-ridden or subject to epidemic and endemicattacks of a dangerous and sometimes decimatingcharacter. In addition to malaria, tuberculosis,dysentery, enteric fever. small-pox, and syphilis,there remain to be treated sleeping sickness, kala-azar, bilharziasis, elephantiasis and leprosy, ankylo-stomiasis and ophthalmia, and the Government of theSudan is quite unable to deal with the medical and

5 Nineteenth Annual Report of the Imperial Cancer ResearchFund, 1922. 6 S. Wyard : THE LANCET, 1922, i., 840.

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sanitary needs of the immense areas unless a staff ofmedical men can be established, inured to the climateand familiar with the customs of the people.The experience of Khartoum Civil Hospital in the

case of a few selected youths has shown that theSudanese Arabs can be trained to be useful medicalassistants, and in April of last year, although sufficientfunds had not been raised, it was decided to commencethe medical school buildings. The immediate objectis to give a four years’ period of instruction to 12selected young men each year. The proposedcurriculum allots two years to pure and appliedscience and two years to medicine, surgery, mid-wifery, and hygiene, out-patient attendance beingrequired for the last three years ; a diploma will beconferred on successful candidates, practice beinglimited to the Sudan and based on certain specifiedconditions. This is the method by which it is designedto obtain a corps of conscientious assistants, accuratelytrained up to a definite standard, but as soon as theimmediate need for doctors has been met in this way,and a suitable teaching staff has been built up, it isproposed to extend the length of the medical courseand to bring the curriculum up to the standarddemanded by European medical schools. The mostpromising of the medical assistants will be referredback to complete this fuller course, in addition to otherselected youths from the Gordon Memorial College,Khartoum, who would have received preliminaryscientific instruction. For the medical school will bean integral part of the Gordon Memorial College, andthe trustees and executive committee of that Collegeare being asked to act for the school.The expenditure involved by the immediate scheme

is modest, but substantial, and the money is urgentlyrequired that the project, while under weigh, may becompleted without delay and its consequent embarrass-ments. All capital expenditure up to now has beenmet, and 220,000 remain towards the endowmentfund. The close estimates of annual expenditureshow that 23000 per annum will be required, toprovide for which an endowment fund of 260,000 isneeded, but this amount has already been reduced bysubstantial sums ; 240,000 at any rate is still requiredat once. Owing to the Government being preparedto lend the services of its scientific and medical staffduring the initial years of the enterprise, to carry outthe teaching in addition to their other duties, theexpenditure in this direction is extraordinarily small,while the school is fortunate in that the WellcomeTropical Research Laboratories are installed in theGordon College a short distance from the medicalschool, and the director of these Laboratories willassist in the scientific and medical teaching. If, as allbelieve, those who help themselves are the people whodeserve to be helped, the claim of the Sudanese isa strong one. The natives showed the greatestloyalty throughout the war, they contributed over634,000 to the Red Cross Fund, and, as has been said,the first 213,000 subscribed in the Sudan for the medicalschool buildings was for the most part given by thenatives of the country. The need then is real andurgent; the work has been begun with confidence inthe strength of the appeal; those most directlyinterested have done their utmost to forward themovement ; and the sum asked for is small. Inthese circumstances we hope that those responsiblefor the Kitchener Memorial Medical School will havetheir anxiety with regard to money speedily removed.

WE understand that the British Red Cross Societyis in close touch with the Japanese Embassy inLondon, and is working in conjunction with acommittee formed at the Japanese Embassy, with a’view to providing assistance for Japan. So far thequestion of sending personnel to that country has notarisen. Present information goes to show that whatis required is food and clothing, and it is not con-sidered likely that doctors and nurses will be sent outunless a definite appeal to do so is received from theJapanese Red Cross.

Annotations.

THE HOSPITAL ALMONER AND SOCIAL

SERVICE.

" Ne quid nimis "

WHEN Florence Nightingale went to the Crimea.she found that it was impossible to apply medicaltreatment without at the same time attending tothe more personal and economic wants of her patients." The fact is," she wrote to Sidney Herbert, " Iam now clothing the British Army." The socialservice work of the present-day hospitals is an outcomeof precisely this same necessity, and although thealmoners’ departments of the voluntary hospitalshave always modestly avoided the limelight, an ever-increasing need continues to develop this side of ourvoluntary hospital system. In this work St. Thomas’sHospital blazed the trail during the pioneer days.when vicarious charity was blindly attempting to dealwith an impossible problem. Starting in 1905 as a.Social Service Office in connexion with the CasualtyDepartment, the almoner’s work has steadily increaseduntil the St. Thomas’s office deals with 16,000inquiries in one year, and raises more than E5000apart from invested income ; and there would seemto be every prospect of social service work of all kindsincreasing as time goes on. In these days the raisond’etre is not far to seek. Few patients presentthemselves for treatment at hospital who have notgot some economic problem the solution of which is.intimately related to the cure of theirillness. Physician,.nurse, and almoner are interdependent. As a goodexample of this question the latest St. Thomas’sreportl states that during the last seven months of1922, 295 children were recommended by the out-patient surgical staff for operation for enlarged tonsils.and adenoids. Before operation the homes of thesecases were all visited by the almoner, and it was foundthat 200 had homes where the children could receivesimple post-operative treatment, whilst 95 had to be-admitted to the wards on account of unsatisfactoryhome conditions. Amongst those refused were foundchildren who, after operation, would have had toshare a bed with two or even three other children, orwould have had no proper bed at all. In the reportof the almoner of the Royal London Ophthalmic-Hospital, Moorfields,2 the value of such inquiries is

again emphasised, especially in cases of ophthalmianeonatorum, where every effort, economic andmedical, must be made to prevent permanentblindness.The following up of cases which have been dis--

charged from hospital is yet another service fallingto the lot of the social service departments. Boththe St. Thomas’s and the Moorfields reports show hownecessary this task may be in the case of blind patients,.for whom suitable employment, on leaving hospital,is often difficult to find. The Moorfields report pointsout that the giving of small sums of money will notsolve the problem of the future for a man who isgoing blind ; he must probably face a year or two ofstraitened circumstances whilst he is learning a

suitable trade, and it is during this period thatsympathetic backing from the hospital means every-thing to him. Some day, perhaps, we shall see estab-lished in London a special employment bureau whichwill concern itself entirely with the welfare of thosedischarged hospital patients who are only fit forcertain occupations and can only work under favour-able conditions. Such an invalid employment bureauis greatly needed, but it would require the utmostsympathetic cooperation on the part of employers,trade unions, doctors, and social service workers.Probably only those who work in the departments-

1 Annual Report on the Work of the Social Service Depart-ment, Samaritan Fund and Nocote Trust. 1922.Report of the Samaritan Fund and the Work of the

Almoner’s Department. 1922.