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be diagnosed in the third trimester giving the obstetri-cian an opportunity to intervene. But at what cost? Thepre-term baby risks hyaline-membrane disease, infec-

tion, and perhaps disruption of mother/baby relation-ships. If a pregnancy is to be ended early then the ben-efits must unequivocally outweigh the disadvantagesboth in the neonatal period and more distantly. Whichis better: to be born too soon (prematurely) or to be borntoo small (light for dates)?Drawing on data from the Newcastle upon Tyne Sur-

vey of Child Development, the late Gerald Neligan andhis colleagues attempted to provide a long-term answer.’They report on 387 children who were born to New-castle mothers during 1960-62: 59 were of short gesta-tion (less than 36 weeks), 141 light for dates (weight lessthan the 10th centile for gestational age), and 187 con-trols (term babies of appropriate weight). The twoabnormal groups represent 10% of births then; meanbirth-weights of the groups were 2415 g (short ges-tation) and 2537 g (light for dates). At ages 5, 6, and 7years these children were assessed by conventional

neurological, anthropometric, and psychometricmethods and by reports on their behaviour frommothers, teachers, and psychiatrists. Care was taken toallow for distorting factors such as clinical abnormalitiesof pregnancy and labour, biological factors (sex andbirth rank), and postnatal environmental influencessuch as social class. The conclusions are clear: the

growth and performance of the short-gestation and thelight-for-dates children were worse than those of theterm children. Moreover, if the light-for-dates group isdivided into rather light for dates (weight 5th to 10thcentiles) and very light for dates (less than 5th centile)the degree of impairment of school-age performance wasproportional to the severity of intrauterine growth retar-dation, since the scores of rather-light-for-dates childrenwere intermediate between the very-light-for-dates andcontrol children. The most crucial finding was that theoverall attainment of the very-light-for-dates group wassignificantly worse than that of the short-gestationgroup-in other words, it is clearly better to be born toosoon than too small.What is the import of these results today, when some

of the study children will already have left school? Therisks from being born prematurely are being reduced.Prenatal therapeutics may help (steroids to prevent hya-line membrane disease; phenobarbitone for jaundice)and neonatal intensive care has improved the survival ofvery-low-birth-weight infants without appreciably in-

creasing handicap .2,3 Much remains to be done; even thechoice of food for very small babies is still controver-sial.4,5 The major adverse influences on the light-for-dates infant cease after birth and the benefits from im-provement in neonatal care for this group will bemarginal. Efforts must be directed towards early screen-ing of all pregnancies for the risk baby6 and to the

1 Born too Soon or Born too Small (Clinics in Developmental Medicine no.61). by G. A. NELIGAN, I. KOLVIN, D. SCOTT, and R. F. GARSIDE. 1976.London: Heinemann. Philadelphia: Lippincott. Pp. 101. £4.50.

2 Marriage, K. J, Davies, P. A. Archs Dis. Child., 1977, 52, 176.3 Stewart, A. L., Turcan, D. M., Rawlings, G. R., Reynolds, E. O. R. ibid.

p. 97.4 Wald, N, Cuckle, H., Stirrat, G. M., Bennett, M. J., Turnbull, A. C. Lancet,

1977, ii, 268.5. Fomon, S. J., Ziegler, E. E., Vazquez, H. D. Am. J. Dis. Child. 1977, 131,

463.6 Davies, D. P. Archs Dis. Child. 1977, 52, 296.

prompt diagnosis of placental insufficiency by observinggrowth and placental function. When this happens,labour may be induced before serious growth failureoccurs, or, more enticingly, intrauterine nutrition maybe enhanced and the baby allowed to thrive in itsnatural incubator. These remedies are expensive, es-

pecially for a service whose funds are threatened. TheLancet has consistently warned7,8 against complacencyabout the results of British perinatal practice and wewelcome the formation of the British Psediatric Perina-tal Group to foster research and education and as a pres-sure group. The Department of Health9 has promisedsupport for services concerned with prevention: howmuch more evidence must be offered before preventionof handicap is rated as important as maternal and peri-natal mortality, and maternity and neonatal services aredeveloped to an acceptable and uniform standard?

COUNCIL OF WAR ON ALIMENTARY CANCER

THE task of the Medical Research Council in decidingwhich projects to support with its shrinking finances isfar from easy. Even in palmier times the Council had totry to do more than make arbitrary judgments betweencompeting claims. Today it sees a great need to defineworthwhile objectives-not only worthwhile in the

desirability of their goal but also justified in the likeli-hood of yielding fruitful results. The Council also hasa responsibility to guide medical researchers inBritain towards promising areas and to point them to-wards unexplored territory which deserves investigation.

Cancer research is not short of enthusiasts in any ofits aspects, and throughout Britain cancer epidemiology,immunology, clinical management, and diagnosis hasbeen explored for a long time. Yet, while the results insome areas-lymph-node lymphoma, leuksemia, epider-mal neoplasms, head-and-neck cancer-have shown use-ful benefit from research, gastrointestinal cancer still

presents a doleful picture. About 1 person in 5 in theUnited Kingdom dies of cancer, and alimentary neo-plasms account for 28% of all these deaths. Even thefive-year survival (not a particularly stringent test of

therapy) is only 6% for gastric carcinoma and 27% forcolorectal cancer. One of the few bright spots is a declin-ing incidence of gastric carcinoma in the United King-dom, though the reason for this is a mystery.

It was this gloomy state, with no sign of improvement,which encouraged the Council to hold a review meetingin April, 1977, at which workers, well informed aboutdifferent aspects of alimentary malignancy, might pooltheir information, discuss it, and thereby enable theCouncil to point the way forward and direct itsresources aright. A readable summary of that meetinghas been published’ and deserves careful consideration.It was written by a small group of participants with feetfirmly on the ground. While picking out promising direc-tions of research, it equally emphasises the problemslikely to arise in their exploitation. Thus, though point-

7. Lancet, 1976, i, 729.8. ibid. 1976, ii, 941.9. Priorities for Health and Personal Social Services in England. Department

of Health and Social Security, 1976.1. Review of Gastric and Colo-rectal Cancers: report of a conference held on

2 and 3 April, 1977, in Edinburgh. Copies available free from the Medi-cal Research Council, 20 Park Crescent, London W1N 4AL.

646

ing to the many possible dietary influences on alimen-tary cancer, it emphasises the "complex interactions ofdifferent factors, which encourage the weaving of intel-lectual cats-cradles of hypotheses and counter-hypo-theses".

Epidemiological studies are more feasible, but may beexpensive, and this report doubts their cost-effectiveness.More may be gleaned from family studies: for example,twins and man-and-wife studies can help to distinguishbetween environmental and genetic causal factors. Theauthors of the summary were enthusiastic about a labor-

atory search for carcinogens, and pick out for specialmention the nitrosamines, which are known to be car-cinogenic and which can be produced from the nitratesand nitrites used in food preservatives. They praise thework on gut bacteria (particularly, nuclear dehydro-genation clostridia [N.D.C.] which may manufacture car-cinogens and, while epidemiological studies on the popu-lation’s gut bacteria are progressing, they believe that asystematic laboratory examination should be under-taken of the various dehydrogenated sterols produced byN.D.C.

In the realm of diagnosis, screening of the symptom-free population is not encouraged, but uneasiness isvoiced at delays in diagnosis of those with symptoms. Inmentioning experience in the United States with faecaloccult-blood testing (often by patients themselves), thereport does not point out that this is a test widely usedat the bedside by American physicians, while in GreatBritain it is wrongly regarded as a laboratory investiga-tion, which increases its cost considerably. Exfoliativecytology is praised as a possibly effective method of

screening high-risk groups, though the abbreviated

report fails to clarify how this is to be done and what thedifficulties are in patient-acceptability.

Carcinoembryonic antigen has an airing, and it mustbe wondered whether the Medical Research Council hasnot missed the boat in setting up a trial to ask whatvalue it has in the diagnosis and management of earlyrecurrent rectal cancer. We would predict the answer tobe "very little". Nevertheless, the search for chemicalmarkers of malignancy is rightly encouraged, thoughthe dream of a screening test for cancer done on a fewml of blood is obviously far from reality.

For the non-researching clinician the passages on

therapy are useful. The wide variations in results fromdifferent centres certainly need explaining. If one centrecan produce a five-year survival of 41% for gastriccancer, why cannot all the others do so? The haphazard-ness of studies of chemotherapy and radiotherapy inthese diseases is well illustrated. Because proper con-trolled trials are arduous and time-consuming to set up,the suggestion is that interested centres might formsemi-permanent links (as have the British Breast Group)so that, once such questions as definition, staging, anddata collection have been ironed out, whole series oftrials could easily be mounted. All over the countrythere are clinicians sufficiently motivated to participatebut lacking the time, resources, and number of patientsto do the trials on their own. They only need coordinat-ing for useful inquiries to be conducted, and the super-iority of British studies of clinical management overNorth American ones (for reasons related to health-caresystems) makes it important for this initiative to betaken.

CARDIAC REHABILITATION

IT is 25 years since Levine and Lown’ challenged thedogma of prolonged immobilisation for patients withacute myocardial infarction by proposing their "arm-chair treatment". Until then, patients were kept in bedfor 6 weeks or longer, partly on the grounds that a firmmyocardial scar was not formed for at least 6 weeks,2and partly because of the curious observation that rup-ture of the myocardium was more common in mental-hospital patients,3 presumably because they were men-tally deranged and would not stay in bed.

Since then the period of confinement to bed and hos-pital has become progressively shorter, and now it is

generally advocated (and backed by evidence from con-trolled studies4-6) that mobilisation for patients with un-complicated infarction should start on the 3rd and 4thday, leading to discharge home after 8-10 days. For thefew patients whose infarction is complicated by cardiacfailure, mobilisation should be delayed, but even forthem it is usually unnecessary to delay discharge muchbeyond 2 weeks. At the same time it is becoming recog-nised that the natural history of the disease demandsthat patients with infarction should be admitted to hos-pital as early as possible and that paramedical staffrather than medical practitioners may be best fitted toorganise this and to give emergency treatment duringthe very acute stage.’ Thus the rationale of hospitaltreatment for infarction has been strengthened by theknowledge that most of the lethal complications arise inthe very acute stage and that recovery from uncompli-cated infarction is rapid.

After discharge from hospital the most important aimfor the patient is a return to normal, productive, andhappy life. Undoubtedly cardiac rehabilitation shouldstart in the coronary-care unit, where the patient cannearly always be told truthfully that the early dangerousphase of his illness is over and that rapid recovery is

expected. When this positive and reassuring idea is

repeated by doctors and nurses during the patient’s stayin hospital and subsequently, patients rarely fail to

become fully rehabilitated and to return to work within4 to 8 weeks of the infarct. Thus, for most patients car-diac rehabilitation is merely a component of good medi-cal management. 8Much has been written about more detailed aspects of

cardiac rehabilitation, and two new publications de-scribe the proceedings of a conference on rehabilitation9and the results of a controlled triapo in which the prog-nosis of 180 patients given physical training starting 10weeks after the infarct was compared with that of 200patients who had no physical training but performed amonthly ergometric test. This trial failed to show anysignificant effect on mortality or recurrent infarction inthe trainers after 31 months, although both death and

1. Levine, S. A., Lown, B. J. Am. med. Ass. 1952, 148, 1365.2. Mallory, G. K., White, P. D., Sakedo-Salgar, J. Am. Heart J. 1939, 18, 647.3. Jetter, W., White, P. D. ibid. 1944, 21, 783.4. Tucker, H. H., Carson, P. H. M., Bass, N. M., Sharratt, G. P., Stock, J. P P

Br. med. J. 1973, i, 10.5. Chatuverdi, N. C., Walsh, M. V., Evans, S. A., Munro, P., Boyle, D. M.

Barber, J M. Br. Heart J. 1974, 36, 533.6. Hayes, M. J., Morris, G. K., Hampton, J. R. ibid. p. 395.7. White, N. M., Parker, W. S., Binning, R. A., Kimber, E. R., Ead, H W.,

Chamberlain, D. A. Br. med. J. 1973, iii, 618.8. Seldon, W. A. Bibl. cardiol. 1977, no. 36, p. 118.9. Critical Evaluation of Cardiac Rehabilitation (edited by J. J. Kellerman and

H. Denolin). Bibl. cardiol. 1977, no. 36.10. Palatsi, I. Acta med. scand. 1976, suppl. no. 599.