assortative mating

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of a patient who had episodes at 4-6-week intervalsfor 74 years. The other syndrome is anaphylactoidpurpura ; this disease is not at present classified withthe periodic diseases, but REIMANN thinks that if

proper records were kept some, at least, of thesepatients would show recurrences at definite intervals.The well-known familial periodic paralysis is probablyin a class by itself ; for it has none of the features ofthe other periodic syndromes.The aetiology of periodic disease is unknown. Many

theories have been proposed ; in particular, effortshave been made to implicate the endocrine system,but with little success. The only reasonably constantfeature is a disturbance of vasomotor function,possibly neurogenic. By knowing about these syn-dromes, however, we may avoid putting the patientthrough a great deal of unnecessary investigation andempirical treatment ; and we can help him to bearwith his disability in the knowledge that it is unlikelyto be progressively disabling and may well become lesssevere as the years go by.

International Medical LawIN the modern world the doctor’s freedom to serve

his patient, and the professional code he follows, arevery far from being assured. That the dangers arenot theoretical and imaginary, but painfully real,was made all too clear in the late war, not only bysuch happenings as those revealed by the Nurembergand Khabarosk trials but also by the violations offundamental laws of medicine and humanity imposedon doctors in occupied territories and elsewhere. Nowthat the borderline between the fighting Forces andthe home front tends more and more to disappear,it is surprising that the civilian practitioner wholeaves his home to bring relief to sick and wounded,and faces the dangers of war or civil strife, shouldlack even a minimum of legal safeguards, and thatonly members of army medical services enjoy theprotection of the Geneva Conventions.To insure immunity for civilian doctors in the

exercise of their calling during hostilities and occupa-tion is plainly a necessary task. But this is only oneof many problems affecting our profession whichawait solution through what is now becoming knownas International Medical Law. Hence it is welcomenews that two international bodies have lately beenformed to promote cooperation between doctors andlawyers all over the world with a view to clarifyingand giving legal recognition to the special status ofthe medical profession as a whole. The first of these

organisations, the Society for International MedicalLaw, with its seat in Paris, aims at a preliminaryexchange of ideas, while the second, with perhaps amore immediate and definite programme, proposes thecreation of an International Study Centre for MedicalLaw, which it is hoped will shortly be opened atMonaco. Statutes already drafted envisage that thiscentre shall collect and exchange information fromall countries concerning legal problems affectingdoctors, and undertake comparative studies in thisfield which will eventually enable it to draft statutoryprovisions and international agreements for con-

sideration by national organisations and internationalconferences. The centre is to be freely at the disposalof all individuals and organisations interested in thedevelopment of medical law, and from modest

beginnings it might well come to play a very useful

part. It will not concern itself with the ethics of

professional conduct in relation to patient and

colleagues (which is clearly a matter for the medicalprofession alone) ; but there is ample room for

investigating the relation of medical practitioners tothe law, and of the civilian doctor’s status in inter.national law. The protection of medical secrecy andthe status of medical experts in law-courts are bothsubjects which have lately been discussed in thesepages ; and there are many other questions arisingfrom the fact that the modern State may wish thedoctor to become its agent. More familiar but also

important are the ethics of blood-tests, narco-analysis,and euthanasia, for example ; and though the WorldMedical Association has begun to consider some ofthese different topics, and in 1949 adopted in principlean International Code of Medical Ethics, there is everyreason for their study and discussion, by lawyers anddoctors together, in the kind of way the Monacocentre is intended to permit.

Judicial guarantees which assure the practitionerof respect for his humanitarian work, and enable himto perform his task according to his conscience inpeace or war, might be not only a negative safeguardagainst the lowering of standards but also a positivestep forward in the uphill journey towards civilisation.

Annotations

ASSORTATIVE MATING

THE idea that like marries like was originally due toKarl Pearson, and his suggestion has been in the mind ofsocial psychologists ever since it was made. We knowvery little with certainty about the forces of inclination,opportunity, and interpersonal attraction which makehuman beings fall in love with one another. In the studyon which their book is based, Dr. Eliot Slater andMrs. Moya Woodside set out to see whether, in a groupof Service neurotics, the personality of the patient andhis wife could be correlated. The statistical presentationof their findings is not very easy to assess, but a goodmany suggestive facts were unearthed-not so muchin answer to the main question, but through a quantity ofmaterial on the " natural history " of neurosis and ofmarriage in our society before and during the war, whichwas gleaned from psychiatric interviews.Both in the test (neurotic) and the control groups,

there was a tendency for husbands and wives to resembleone another in temperament and intelligence (t=0-36in intelligence, with a lower positive correlation for

temperament and for predisposition to neurosis, givingan over-all correlation of 0-13). " Neurotic husbands scoresignificantly higher than the control group, and thosewho are happily married score significantly lower thanthe less happily married." This would suggest that thebetter the adjustment, the greater the range of choiceof partner, though it makes no allowance for increasedpredisposition to neurosis from contact with a neuroticpartner. There is also a higher degree of homogamyin the more than in the less happily married. The happilymarried were readier to have children (cause and effectare not analysable here). In all respects neurosis provedas great a handicap to marital happiness in statisticalterms as it appears to be in medical experience. It iseasy to be impatient with such surveys as confirming theobvious, but confirmation of many " obvious " phenomenais badly needed where psychiatric planning is to dependon the result.Some of the results on the sociology of courtship are

less expected. The commonest over-all place of meeting C,

1. Slater, E., Woodside, M. Patterns of Marriage. London : Cassell.1951. Pp. 311. 17s. 6d.

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was the street, with work, dance halls, and cafes follow-ing. Love at first sight was rare (13/400), and dislikeat first sight was about equally common-more frequentin women than in men. " The average courtship startswith no strong feelings on either side, and after it haslasted one or two years it becomes a settled thing thatthe couple will marry." About 36% of men and 50% ofwomen denied sex relations before marriage (this seemsto refer only to coitus, and excludes petting which wasnot much in evidence) : there was a slight positivecorrelation between " premarital chastity " and economicstatus, eventual happy marriage, and family planning.When both partners had little sexual desire this was oftenthankfully accepted by both.As with most social surveys, this series revealed a

confused background of social disorganisation, not allof it due to the war. Politics tended to be simplifiedinto a uniform distrust and contempt for ’’ Them ’’ ;religion was no longer a numerically significant factor.The success of the average English man and womanin adjusting to life in a society which provides themwith relatively little group support is all the more

striking; and the authors refrain from the traditionalistjeremiad with which such results are usually greeted.The main problem, however, remains unsolved. Far

fuller studies covering anthropometric, photographic, andpsychological comparisons (the inventory test used hereis a crude one) are needed to give us a true idea ofhomogamy. Freudian work would suggest that these beextended to cover parents, especially the father of thewife and the mother of the husband. Antipathies arealso well worth studying. The book is, as Damon Runyonwould say, "more-ish"-it raises as least as manyquestions as it lays. Its very failings, however, pointstill more clearly the need for proper statistical analysisof the factors incriminated by psycho-analysts and socialpsychiatrists in the production of misfits. The day of theFreudian paper based on two illustrative cases is not

yet over ; but the union between statistical method andpsycho-analytical theory is already fertile, and shouldbe regularised by marriage as soon as possible.DIAGNOSIS OF MALIGNANT GASTRIC ULCER

DESPITE improved anaesthesia and operative techniquethe prospects of radical cure of gastric carcinoma bysurgical resection remain sadly disappointing. Onemain reason for this bad outlook is the late stage atwhich the disease is often diagnosed or at which thepatient first comes for medical advice. This may bebecause the onset of the symptoms is insidious, or insome cases because the symptoms are thought to bedue to a simple benign peptic ulcer. It is not alwaysremembered that a long history of dyspepsia or of ulcersymptoms does not necessarily rule out carcinoma, orthat a malignant ulcer may be of very slow growth andfor a long time may closely simulate a, benign ulcer.It is, however, often precisely in those cflrcinomatawhich most resemble chronic peptic ulcers that surgeryoffers the best results, and any investigations throwinglight on the distinctions between benign and malignantulceration of the stomach deserve special study.Boudreau and his colleagues have made a detailed

study of 234 cases of gastric ulceration examined postmortem at Boston during the years 1940-49. Theyrightly comment on the uncertainties and differences ofopinion among experts as to the value of the usualclinical criteria for the diagnosis of carcinoma. Ofsuch criteria the age of the patient, the size of the ulcer,and the site of the ulcer in the stomach are three of themost important. As regards age, the only point ofsignificance brought out by this investigation was thatbenign lesions do not decrease in later life and thatthey are by no means uncommon in the aged-of the1. Boudreau, R. P., Harvey, J. P., Robbins, S. L. J. Amer. med.

Ass. 1951, 147, 374.

25 ulcers found in patients over 80 years of age, 18 werebenign. The size of the ulcer has been said to providea highly significant indication of its nature : the largerthe crater, the more likely it is to be malignant.Boudreau’s figures, like some others,2 do not altogethersupport this view ; approximately half the malignantulcers were less than 4 cm. in size, while 10% of thebenign ulcers were larger than this. The importantpoint to note from this necropsy series is that nearly20% of

" small " ulcers were inofact malignant, so thata small crater offers no guarantee of non-malignancy.Similarly the exact localisation of the ulcer is of littlevalue in diagnosis. The general opinion that ulcers onthe lesser curvature are rarely malignant, whereasprepyloric ulcers most usually are, is only half correct ;no area of the stomach is by any means immune to car-cinoma. Of the malignant ulcers in this series 39%were on the lesser curvature, while of 121 prepyloriculcers 87 were benign and 34 malignant. These figures,however, being based only on necropsy findings, do nottake into account ulcers removed surgically ; so

these proportions are not strictly those clinically to beexpected in life. It is interesting, however, to note thatof the prepyloric ulcers two-thirds were benign, and ofthe lesions on . the greater curvature one-half were

also benign.These necropsy figures underline once more the

importance of considering in all cases of gastric ulcerationthe possibility of malignancy and the danger of assumingtoo readily that an ulcer is benign merely because ofthe patient’s age or the size or situation of the lesion.

LOOKING AFTER THE STUDENT

IN congregation at Oxford on Nov. 6 the schemefor a university health service for undergraduates wasrejected. The main argument used to defeat the pro-posal was that it is impossible, by a health examination,to reveal a large enough amount of preventable illnessto justify an annual cost of some E6000. It was alsofelt that inadequate consultation had taken place betweencollege and university authorities, and perhaps insufficientdiscussion within the colleges themselves. There was

undoubtedly a fear that care for the health of under-graduates, which it was rightly thought should restwith the college authorities, might be taken from themand vested in some university official as yet unknownand untried.Though the two sides agreed that routine chest radio-

graphy is valuable, the opposers of the scheme preferredto rely on mass radiography carried out by the regionalhospital board, while the proposers feared that owing toexpense and difficulties in personnel this service mightnot always be available.. They also doubted whetherit would be fair to annex it solely for the universityfor the eight weeks of every Michaelmas term. Aboutother medical examinations there was less agreement.It was a moot point whether the doctor’s certificate ofhealth that some colleges demand on a student’s entry isadequate. Often the doctor does not wish to influencea candidate’s rejection, and again the certificate may besix or more months out of date. The Armv medicalexamination is not given to all the men students beforeentry and never to the women (a fifth of the student

population). One opposer of the scheme wished to relyon arrangements already existing in some of the colleges ;but these are variable, particularly for students in lodg-ings (at least a third of the total), and may involve theundergraduate in expense and delay in ohtaining adviceand treatment.The debate was pregnant with omission : no reference

was made to the most important cause of long absencefrom work-mental illness.3 Indeed the more conserva-tive members thought that too much attention to health

2. Lumsden, K. Gastroenterologia. 1950, 76, 89.3. See Parnell, R. W. Lancet, 1951, i, 731.