405

The acid-control of the pylorus described by Cannonhas been criticised by many workers. Baird, Campbell,and Hern, in their experiments, found that the

emptying of the stomach occurred at rates by nomeans dependent upon the acidity of the contentsof the pyloric antrum, and often in the presence ofduodenal contents of a reaction definitely acid. Thelast part of their work deals with the problems ofachlorhydria. They found that of 60 normal studentsexamined only one showed this phenomenon whensubjected to repeated observations, and close examina-tion of this subject threw doubt on the question ofhis normality. It is admitted that for any adultthe definition of health is almost impossible, and onemay question whether the other 59 subjects examinedwould all have stood the test of searching clinicalinquiry in this respect. Large numbers of subjectsmust still be examined before a final answer to thisproblem can be given ; it remains certain that thereare a considerable number of persons with achlor-hydria living apparently normal lives. It is inconnexion with the aetiology of pernicious anemiathat this subject finds its most immediate interest.

OCCUPATIONAL MORTALITY AND INDUSTRIALUNREST.

THE student of medical sociology who turns tomortality records for some light upon the recentunrest among locomotive engine-drivers finds himselfat a loss. The most recent figures published (samplesfrom which are here given) refer, it is true, to 1910-12,but the comparative figure of the Registrar-General’sCornparatit’e illortality (England and Wales) in Certain

Occupations. (Ages 25-64.)

occupational group, "

engine-driver, stoker, cleaner "was equally satisfactory in 1900-02 and in 1890-92.At no period of life was the mortality experiencedexcessive, nor was any constituent cause of deathin excess. In the Statistical Bulletin of the Metro-politan Life Insurance Company of New York forDecember, 1923, some statistics of the longevity of" locomotive engineers " are quoted, from which theauthors infer that engine-drivers have an expectationof life " about as good as that for the average Americanmale of corresponding age," and remark that thespecial hazards of the occupation " seem not to reducehis longevity prospect below that of males in thegeneral population." We are rather surprised thatthe American experience is not more favourable.The group, as we have seen, enjoys in this countryone of the lowest rates of mortality of any group,a much lower rate than all occupied and retired males,and an appreciably lower rate than members of thecivil service. Calling the rate for all males 100,that for engine-drivers was 68, and for the civil service(clerks and officers) 77. This is hardly surprising,since the duties of the occupation can only be per-formed by physically select men, so that the rate ofmortality is hardly a simple criterion of the salubrityof the occupation itself.On the other hand, mortality data present real

excuse for unrest among dock labourers. Thisoccupational group has always stood high for death-rate ; in 1910-12 (the last published records) theirmortality was only exceeded (omitting occupationalgroups with special risks, such as silicosis among tin-miners and metal-grinders, and alcoholism among inn-servants and brewers) by costermongers, seamen, andmessengers. Dock labour is not a skilled industry,

and the unsuccessful of other trades tend to drift to it,as well as to messengering and cost ermongering.Here lies a reason for much of the high mortality ;but low wages, uncertainty of employment, andconditions of work undoubtedly also contribute theirshare, for these persons need a better rather than aworse environment than obtains under other occupa-tions. The dock labourer suffers in excess from alcoholicdiseases and has a reputation for industrial drinking.The contrast between dock labour, shipbuilding, andagriculture is great, although the weather exposurein each is similar. Reference to the great causes ofdeath which contribute to the total mortality disclosesthat, although all are high, the death-rates of docklabourers from respiratory diseases are particularlyexcessive.

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THE AFTER-CARE OF THE CANCER PATIENT.

THERE are few more tragic figures in human lifethan the sufferers from malignant disease who dailypresent themselves for treatment in our hospitals.Apart from the few fortunate ones, in whom a cureis effected, their days will often be numbered ;yet how often are they the most cheerful and courageousof patients. Any schemes for after-care, therefore,which shall make for a less distressing end should havea full measure of our sympathy. In the fourteenthreport of the Cicely Northcote Trust (October, 1922-October, 1923), recently issued by the Almoner’sDepartment of St. Thomas’s Hospital, a lead is givenin this direction. The cancer patient, unlike thephthisic, is often a person of middle age, and thereforeoften with a young family. Struck down in the yearsof greatest responsibility he must face the prospect ofa long illness with an ominous prognosis. Someoneis needed, therefore, who can " stand by," who willhelp the family to carry on and to make thosereadjustments to life which such a situation necessarilyentails. And here the almoner gets her chance-andher privilege. The patient may return home fromhospital with a wound to dress or with an inoperablesecondary or recurrent growth to deal with, and in theend there may be a long struggle with secondaryinfection, haemorrhage or bedsores.A small booklet on " Howto Nurse Cancer Patients,"i

by the late matron of Chelsea Infirmary, recentlypublished, well emphasises these points. Readingbetween the lines we can realise how the district nursewho sees the cancer patient in his last stages mustimprovise again and again to make bricks withoutstraw in the homes of the poor. The Cicely NorthcoteTrust report also stresses this point; not only medicalattendance, but nursing appliances such as hot-waterbottles, bed-pans, air-cushions, draw sheets, nlackin-tosh sheets, unlimited supplies of dressings, &c., are

required. Very little imagination is needed tovisualise the plight of these cases, and we wonder ifthe time has not come when no case of malignantdisease shall be discharged from hospital withoutdefinite provision being made for after-care. Suchprovision would naturally fall under two heads :(1) Adequate arrangements for watching and followingup the successful operation cases in view of thepossibilities of recurrence ; (2) suitable preparationsfor the last painful months of the inoperable casewho will require careful nursing-preparations whichmust envisage all the possibilities of sepsis. secondaryhaemorrhage, and the like. In these matters we mightfollow the lead of the after-care workers of maternity,child welfare, and tuberculosis schemes, in whichdepartments much valuable work is now being done.It is possible also that a systematic after-care schemefor patients with malignant disease might ultimatelyproduce useful statistics as to complications andsequelae, duration of life. and even errors of diagnosis.At present we class all these patients together in onegroup as cases [with a hopeless prognosis, whereascareful following up might shed a new light on someof these questions. In tins matter medical officers of

1 How to Nurse Cancer Patients. By E. S. Barton, R.R.C.London : The Scientific Press, Ltd. 1s. 3d.