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LEWIS and GESCHICKTER dismiss the hypo-thetical danger of inducing cancer by their

cestrogen therapy. They say :-" In Lacassagne’s experiments estrogen in excess

of one millionth of the body-weight of the mouse wasadministered at a single dose, and the dose was

repeated weekly throughout the life of the animal.A corresponding dosage in a patient weighing 50 Kg.would necessitate the administration of 50 mg. ofcrystalline estrogen at a single dose and the injectionswould have to be begun in early childhood andcontinued throughout life. The estrogen therapyused in chronic cystic mastitis is well below theamounts present in normal pregnancy. The safetyfactor in this form of therapy is therefore well withinall reasonable limits."

Such an argument may or may not be convincing.Wide differences in their reactions to oestrone areshown among mice ; and to forecast the reactionsof man on the basis of his weight would, we think,hardly be justified. In accordance with laboratorywork, chronic cystic mastopathy must be regardedas suggesting either an excessive production of, oran excessive reaction to, oestrogens ; and this, aswe have said, must lead to hesitation in givingadditional supplies. Experiments show that theinduction of cancer-whether by sex hormones, byX rays, by the compounds prepared by K.ENNAWAYand his colleagues, or by other chemical agents-is alengthy process. LoEB (1919) found that, to becertain of preventing mammary cancer in mice,removal of the ovaries must be done in early life. Inman, too, it is recognised that there is nearly alwaysan interval of years between exposure to a cancer-producing agent and the appearance of cancer.

It may be argued therefore that if a patientwith chronic cystic mastopathy is likely to getcancer the harm has already been done in pastyears and will not now be accentuated by anyfurther stimulation of the same sort ; and con-

ceivably this is true. On the other hand it maybe said that suppression of the activity of the

pituitary, which LEWIS and GESCHiCKTER describeas their aim, might be effected just as readilywith testosterone as with oestrone ; and testo-sterone is free from suspicion of causing eithercystic mastopathy or cancer. We are here,however, in a field where theoretical foundationsmay be found unsubstantial in practice. For

example, at one time it appeared probable thatthe regular administration of testosterone to micewould prevent their developing mammary cancer,because, like cestrone, testosterone interferes withthe output of gonadotropic hormones from thepituitary. This idea has not proved sound in

practice. LACASSAGNE 8 found that testosterone,given in considerable amounts to mice from infancyonward, did not prevent the appearance of spon-taneous mammary cancer nor of mammary cancerin response to oestrone. It is not known howfar, if at all, testosterone would prevent cysticmastopathy in mice.In discussing the hypothetical bearings of LEWIS

and GESCHlCKTER’s work we do not want to

express any opinion about its field of usefulness ;that must await the judgment of time. Our object

8 Lacassagne, A., C.R. Soc. Biol., Paris, 1937, 126, 385.

has been first to emphasise some laboratoryexperiences that at once are brought to mind bytheir paper, and secondly, to show that whilethese laboratory experiences cannot be ignored,they cannot be made the basis of any confidentcriticism, adverse or otherwise, of therapeuticpractice. There is indeed reason to regard sup-pression of the activity of the anterior pituitary,by whatever means attainable, as the most

promising prophylactic measure against cysticmastopathy and mammary cancer. In our issue ofJan. 8th Dr. CRAMER and Dr. HORNING reportedthat they have succeeded in preventing spon-taneous cancer of the breast, in mice otherwisesusceptible to this disease, by giving a preparationcontaining thyrotropic hormone, and this is a

procedure that may well owe some of its effective-ness to an interference with the activity of theanterior lobe of the pituitary gland.

AN INVENTORY AND ACTION THEREON

THE United States public health service has

just published the results of what is called a" national health inventory "-a systematic inquiryinto the prevalence of sickness in the United Statesand the various agencies in operation against it.The inquiry, for which a grant of$4,000,000 wasmade by the Works Progress Administration, tookthe form of a house-to-house canvass in 1935-36of 740,000 families living in 84 typical towns, largeand small, and comprising about 2,660,000 persons.Twenty-three rural counties were also included inthe inquiry. In this way a representative sampleof the population was studied, and the particularsobtained afford, it is thought, an adequate basisfor estimates that can- safely be applied to thewhole country. Similar surveys have previouslybeen carried out in America-notably that madein 1921-24 in Hagerstown by the late EDGARSYDENSTRICKER, the survey of the Committeeon the Costs of Medical Care in 1928-31, and theHealth and Depression study of 7400 wage-earners’families in 1933. But this inquiry was far morecomprehensive, and is probably the most completestudy of sickness prevalence yet made in anycountry.From the facts elicited it is estimated that in the

United States on an average winter’s day about6,000,000 men, women, and children are unableto work, or attend school, because of illness oraccident ; that of these persons about 2,500,000suffer from chronic disease, 1,500,000 from influenza,pneumonia, bronchitis or other respiratory diseases,and 500,000 from accidents ; that for every deathreported there are on the average 16 cases of illnessdisabling for a week or longer ; and that on a

per-capita basis every man, woman, and childsuffers at least ten days’ incapacity annually fromillness lasting at least a week. As might be

expected, the prevalence of disabling sicknesswas relatively much higher among the poorermembers of the community. Persons with a total

family income under$1000 per annum but notreceiving relief experienced more than twice as

much disability as those in the highest income

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group, and persons receiving relief three times asmuch. In the representative urban populationstudied, 40 per cent. were members of families withannual family incomes of less than$1000, 65 percent. were in families with incomes of less than$1500, and 80 per cent. with incomes of less than$2000, and nearly half of the lowest income grouphad been in receipt of relief during 1935. It wasfound that the persons in the lower income groups,among whom sickness was most prevalent and whoconsequently were most in need of medical care,were precisely those who got least medical care.One of the most important conclusions that canbe drawn from this inquiry is that the greatmajority of the people of the United States areunable from family resources alone to pay for

adequate medical care in serious or prolongedillness. And 18,000,000 live in counties in whichno hospitals of any kind exist.Such are the outstanding facts concerning the

provision of medical care-not in some poor back-ward country of the Old World but in the richestof all countries, a country with illimitable resourcesand with a people famous for enterprise, inventive-ness, and energy. It is not surprising that thereshould be a rapidly growing feeling among theAmerican people that something effective must bedone to provide adequate health services for thenation. The problem is difficult, and requiresfor its solution the goodwill and cooperation ofmany interests, and especially of the medical

profession. Guidance might naturally be expectedfrom the representative organisatiori of the pro-fession, the American Medical Association withits 150,000 members, representing every depart-ment of medical practice. In this country suchguidance has not been lacking, and in its Proposalsfor a General Medical Service for the Nationthe British Medical Association has placed definitesuggestions before profession and public. TheAmerican Association, by contrast, seems to have

concentrated too much of its energies on thedestructive criticism of constructive proposalsput forward from other quarters medical and lay.It would be untrue, however, to say that it has.made no constructive suggestion. At a meetingof the Associations’ board of trustees last Decemberconsideration was given to the situation, and it wasnoted, first, that " a varying number of peoplemay at times be insufficiently supplied with neededmedical service for the maintenance of health andthe prevention of disease," and secondly, that" the means of supplying medical service differin various communities." It was accordinglyresolved :-

" That the American Medical Association stimulatethe state and county medical societies to assumeleadership, securing cooperation of state and localhealth agencies, hospital authorities, the dental,nursing and correlated professions, welfare agencies,and community chests’ in determining for each countyin the United States the prevailing need for medicaland preventive medical service where such may beinsufficient or unavailable ; and that such stateand county medical societies develop for each countythe preferable procedure for supplying the severalneeds, utilizing to the fullest extent medical and healthagencies now available, in accordance with theestablished policies of the American MedicalAssociation." 1

But this resolution hardly seems adequate to theoccasion. To expect that local committees of

practitioners, earning a livelihood in the most

exacting of all professions, should build up a

system of administration for coping with theformidable task of providing the American peoplewith the medical care they need is surely expectingtoo much. Such great expectations suggestunfamiliarity with the kinds of arrangementnecessary for the administration of services requiredto meet great national needs. Perhaps now that theresults of this inquiry have deeply moved publicopinion in America the Association may be inducedto try again.

ANNOTATIONS

THE NEW WESTMINSTER AT HOME

THE Westminster Hospital is rapidly taking formon its new site in the more populous part of the

Royal borough. The ground space available is twicewhat it was on the old site, and with its 400 bedsit is to be the finest small hospital in London. Noone has as yet ventured to dispute that. The Corona-tion wing, now well forward, faces across the fair

open space of St. John’s-gardens a completed buildingcontaining those accessories of a teaching hospital, theschools for nurses and medical students. Both are, of

course, also hostels : the nurses’ school in large degreewith its resident population, sisters, nurses, anddomestic staff, running up to 300 ; the medicalschool with twenty bedrooms for resident medicalofficers, besides quarters for resident engineer andcaretaker. Both schools are under the same roofand have in common their central heating and otherservices, with a kitchen which feeds all the students andalso teaches the nurses their sick-room cookery, whileall the bedrooms on both sides of the house are

furnished and fitted alike. The medical school wasin fact built with a substantial sum raised expressly

for that purpose, and it is emphasised that no chargecomes on the hospital funds for the furnishing andequipment of the students’ rooms. The same

emphasis is also laid on the fact that the reallybeautiful furnishing of the nurses’ common-rooms

has been made possible by anonymous gifts. Despitethese disclaimers it seems fitting that a teachinghospital should advertise to the world its indebted-ness to the nurses and medical students withoutwhom it could not carry on. What can be done onso urban a site to ensure the elements of healthyliving has been done. On the nurses’ side there is anextensive terrace, admirable roof-gardens and games-rooms, the larger given up to badminton. On themedical side there are gymnasium, billiard-room, andsquash-courts under the lecture theatre. Whilethere may be no surprises about the lay-out of thenurses’ home, apart from the care and thought thathave been given to comfort and convenience, themedical school reveals throughout the educative pur-poses of its designers who have freely availed them-selves of all that has appealed to them elsewhere as

1 J. Amer. med. Ass. Jan. 15th, 1938, p. 212.