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low figure. There may be many deformed foetuses inutero at present, and the youngest must be of almost fourmonths’ gestation. Those who must decide whether ornot to terminate these early pregnancies will have toassess very strictly the validity of statements that the drugwas given at the appropriate time to increase the riskof deformity. It is just possible that towards the end ofthe fourth month of gestation the grosser limb abnormal-ities could be detected by a radiologist who was awareof their nature.

The manufacturers’ stringent test of thalidomideindicated that its safety margin as a sedative was wide;but what has happened emphasises the need to excludeteratogenic effects of new products so far as this is

possible in animal experiment. Of equal importance,in view of the burden of human suffering that may havebeen caused, is the need for all concerned with themedical care of pregnant women and their children torecord with the greatest care the names of all drugs given,the dosage, and the date and duration of administration.This list should then be examined critically wheneverstructural or biochemical abnormality of the foetus arises.Such information should form a continuous record to be

passed from general practitioner to consultant and fromone specialist to another.

The Paradox of Gastric Cancer

FROM the Mayo Clinic comes the depressing yethardly surprising information that in carcinoma of thestomach duration of symptoms is unrelated to resect-ability or survival.1O Studying 1121 cases seen in1950-53,BARBER et al. found that, in the 572 where resection waspossible, duration of symptoms appeared neverthelessto be significant when related to size of lesion at the timeof operation. Patients with a growth of 4 cm. or moreat its greatest diameter showed twice the rate of survivalat five years when the symptoms had lasted less than ayear (24%) as when the symptoms had lasted more thana year (12%). But the position was reversed with lesionsof less than 4 cm. : only 29% of those with symptoms forless than two months survived five years, whereas 60%of those with symptoms for three months or more passedthe five-year mark. This peculiar paradox is probablyexplained by the fact that the group with small lesionsand longer symptoms included a greater proportion ofthose who originally had a simple gastric ulcer. So wecome full circle: duration of symptoms is no guide tochance of survival. Yet it is clear that the smaller the

growth at the time of resection the better the chances,since 54% of the group with the smaller growths livedto five years compared with 21% of the others. Unfor-tunately in only 23% of all those submitted to resectiondid the growth not exceed the arbitrary 4 cm. mark.Improved results are therefore likely to come only withdetection of the lesion when it is small. Can this be done ?

Here lies the rub, for if symptoms provide no guidewe must turn to some method of investigation; and howcan we know whom to investigate ? In Minneapolis10. Barber, K. W., Gage, R. P., Priestley, J. T. Surg. Gynec. Obstet. 1961,

113, 673.

HITCHCOCK and SCHEINER 11 have attempted to investi-gate all at risk and have been forced to the conclusionthat in terms of survival statistics this is an unrewardingmethod. Outpatients over the age of 50 attending theMinnesota University Hospital were submitted to thehistamine test-meal; in nine and a half years over twelvethousand patients were studied thus. Those with

anacidity or responding to histamine with less than 30degrees of free acid, together with those found to havepernicious anaemia and those with a family history ofgastric carcinoma, were submitted yearly to a bariummeal. Eventually the 119 patients in the family-historygroup were dropped from the study, since no case

developed in them over a period of seven and a halfyears. The detection-rate in the rest represented nomore than a threefold increase over the expected ratein the population at large-an increase of 2-6 times inthe hypochlorhydric group, but of 21-3 times in thosewith pernicious anxmia. These figures point to a possibleneed to conduct barium studies at routine intervals onall patients known to have pernicious ansemia, particu-larly since, of the 19 cases detected during the period ofinvestigation, the lesion was disclosed after the third orsubsequent review. Of this series half were foundto have no lymph-node involvement compared with anaverage of 20% in surveys of cases with symptoms; butSHAHON and WANGENSTEEN 12 found that of patientswithout symptoms only a third survived for five years-a figure less satisfactory than in cases with symptoms butwithout lymph-node involvement.13

Nevertheless the hunt for the early case continues.HITCHCOCK and SCHEINER have turned their attention to

gastric cytology, using von Bertalamffy’s method offluorescent staining by acridine orange to display D.N.A.and R.N.A.l4-a method which apparently has the

advantages over the Papanicolaou method of speed andeasier recognition. Other ingenious methods have beendevised. Following the lead of NAKAYAMA,15 WANGEN-STEEN and his associates 16 have tried autoradiographyafter an injection of 32P but, since the radiograph isobtained on a photosensitive emulsion coated on aballoon passed into the stomach, the method must betoo time-consuming for routine scanning of large groups.The results in 58 patients were rather better than can beobtained by orthodox radiography, and there were nofalse negatives. However successful this or other tests

prove to be, there will remain the problem of application-who shall be tested, and how many can be tested ? Itis difficult to believe that any of the methods introducedso far can ever be applied routinely to large numbers.The best hope lies in a biochemical test, since samples ofblood or urine can be obtained with ease, speed, andlittle or no discomfort. The lactic dehydrogenase groupof enzymes 17 may yet answer our need; but they are noteasily estimated.11. Hitchcock, C. R., Schemer, S. L. ibid. p. 665.12. Shahon, D. B., Wangensteen, O. H. Postgrad. Med. 1960, 27, 306.13. Shahon, D. B., Lunseth, J. B., Wangensteen, O. H. Univ. Minnesota med.

Bull. 1959, 30, 366.14. von Bertalanfy, L., Masin, M., Masin, F. Cancer, 1958, 11, 873.15. Nakayama, K. Surgery, 1956, 39, 736.16. Ackerman, N. B., Shanon, D. B., McFee, A. S., Wangensteen, O. H.

Ann. Surg. 1960, 152, 602.17. Wr6blewski, F., Gregory, K. 4th Int. Cong. clin. Chem. 1961, p. 62.