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40,000 new cases are seen in the outpatient depart-ment ; in another hospital only 7% of medical out-patients and about 25% of surgical outpatients arefound to require admission. In the staffing of out-patient departments MAITLAND believes that generalphysicians and general surgeons should be broughtto the fore, though they should be able to call onspecial knowledge or techniques. Science, he reasons,must be matched with humanism, and humanismgets short shrift where there are many separate,highly specialist clinics. Again on humanistic grounds,he is emphatic about the maximum number of bedsin the hospitals ; in their design they should respectthe unity of medicine by including a department ineach of the major specialties; but lay, medical, andnursing personnel should not be asked to supervise ahospital with more than 500-750 beds, even thougha larger number may be administered with equal ease.This is a welcome plea, particularly if it takes

psychiatry within its compass. As for the specialhospitals, he pointed out that in large centres such asLondon these were founded at a time when surgeonsand physicians in new branches, in peril of being over-borne by the main stream, withdrew to evolve theirspecial techniques. The peril is now past; and, rightlycontending that continued detachment is harmful,MAITLAND would bring them back into the communityof the general hospital. He allows, however, theremay be a case for the separation of maternity.With an eye to economy in skill he proposes that

those needing active treatment should be separatedfrom others who require only maintenance. This

precept is in fact followed in some hospitals caring forthe aged sick, notably the West Middlesex ; but hisfurther proposal-that recovery wards should be runin association with wards for the acutely ill-is morenovel. Such an arrangement would undoubtedly beeconomical; but implying, as it would, the transfer ofpatients from one ward to another, it cannot be saidto promote the mental comfort of the patient that heseeks to foster. This consideration is perhaps less

important with patients admitted for diagnosis iftheir stay is likely to be short. We are all familiarwith the patient who, simply because a particularinvestigation demands his presence in hospital, takesup a bed which might otherwise be occupied by anacutely sick man or woman. To avoid this there is astrong case for setting up a special investigation wardin close geographical and administrative proximity tothe outpatient department, where patients, until theirdischarge or admission to the hospital proper, wouldhave dormitory accommodation, with food provided,on a help-yourself plan, in a nearby dayroom.MAITLAND argues against vested interest in hos-

pitals ; despite their emotional appeal, " bigger andbetter " hospitals should not be the prime objectiveof the new service. Pride of place, he thinks, shouldgo rather to the public-health branch. Meanwhile

hospitals, handicapped by shortages, will pass on aheavy load to the local health authorities which areresponsible for the patient after his discharge. Herehe attaches great weight to a close nexus between thehospital management committee and the local healthauthority ; and he casts the hospital almoner for therole of liaison officer. For the operation of the serviceas a whole he pointed to JOHN STUART MILL’s dictum—" power at the periphery : wisdom at the centre."

Annotations

NEGOTIATION

As already explained, discussions between the medicalprofession and the Ministry of Health on the NationalHealth Service Act have so far been conducted bysubcommittees of the Negotiating Committee meetingofficials of the Ministry. A meeting between the fullNegotiating Committee and the Minister himself wasarranged for Nov. I and 12 ; but this has now been

postponed, at Mr. Bevan’s request, until Dec. 2 and 3.The postponement will enable him to make a closerstudy of the document he received from the NegotiatingCommittee on Nov. 7, in which they present theirobservations on a number of disputed issues affecting’general practice. Before members of the profession areasked to reach any decision about participation in theservice, they will receive a larger document whichwill contain the committee’s observations on all the

subjects under discussion, and the Minister’s replies toany criticism of his proposals.

PATIENTS AS SANATORIUM NURSES

EX-PATIENTS are now fairly often engaged as sana-torium nursing staff ; and on another page Dr. Watt andMiss Sheehan describe a successful scheme of the kindat the King George V Sanatorium, Godalming. Else-where Dr. Kissen 1 has told of a less satisfactory experi-ence at Bellefield Sanatorium, Lanark, where a processof continuous reablement of selected patients was

attempted.Five two-bed side-rooms of a ward (closed owing to lack of

staff) were converted into three double bedrooms, a sitting-room, and a dressing-room, for six patient-nurses, each ofwhom was provided with a rest chair. Meals were taken inthe main nurses’ dining-room-Dr. Kissen does not saywhether with the rest of the staff or separately. It wasintended to transfer each batch of six patients to the nurses’home as each fresh group of six was recruited. At the start

they were engaged for a 24-hour week with a 4-hour day, theduty periods being in the morning, afternoon, and evening ofsuccessive days; they were not asked to take night duty.Later it was found possible to increase the hours to 36 a weekwith a 6-hour day, sometimes broken by a long rest-period.The patients were paid at the rate of student nurses for thehours actually worked, and this very low rate of remuneration-for a 24-hour week they got 118. 8d.-was one of the chiefcauses of failure ; for most of the girls lived in Glasgow,a half-crown return journey away; and had they chosen togo home for convalescence instead of working they wouldhave received the basic tuberculosis allowance of 258. a week.

Nevertheless 11 girls took part in the scheme, including 2from another sanatorium. Their lesions were inactive, andthey were all free from symptoms and had been up all dayand on graduated exercise for some time. Most of them

spent a week or two at home before beginning work. Theywere warned thoroughly about the proper use of leisure, butonly 4 seemed to take the warning to heart ; most of them

spent much time at entertainments in Lanark and Glasgow,and their long off-duty times-put to such improper use-roused the resentment of the permanent staff.The patients were evidently not happy in the work, for

Dr. Kissen reports many petty squabbles ; and only 1 patientis still on the staff after some ten months’ service. Theywere advised to stay a year, to enable the medical staff toassess their condition and working capacity, but 6 resignedafter less than three months, 3 after less than four months,and 1 after five months. On the whole their physical healthhad improved, Dr. Kissen considers, despite a slight loss ofweight after taking up work. The scheme was abandonedwhen the closed ward was reopened, and though there havesince been requests by other patients to join the scheme, itcan hardly have been said to have proved a success.

One or two reasons for the greater success at Godalmingare immediately apparent. Only really fit staff are

engaged, and they have to be able to do a full day’s1. Kissen, D. M. Tubercle, Lond. 1947, 28, 185.

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work ; they are not segregated from the rest of thenurses but share the same mess-rooms and sitting-rooms. Their leisure is more controlled : they mayattend dances, but tennis is forbidden, and they must bein by 10.30 P.M. unless they have the medical superin-tendent’s permission to stay out later. Moreover, theyare a much-valued section of the staff. It must be recog-nised, however, that the aim in the two schemes wasrather different : Dr. Kissen set out with the deliberateintention of reabling convalescent patients, whereas Dr.Watt employs only patients who are thoroughly fit.Dr. Kissen’s experiment has been useful in drawingattention to the special difficulties encountered when areablement scheme is attempted in a sanatorium mainlystaffed by full-time healthy nurses.

CASTRATION AND ŒSTROGEN IN PROSTATIC

CANCER

No-ONE now doubts that in prostatic cancer temporaryrelief can be obtained from either castration or theadministration of oestrogen. Yet the rationale of these

procedures remains in part unknown. Either of them,though in different ways, will check the supply of

androgen on which the development, maintenance, andactivity of the normal prostate depend: oestrogens willreduce the supply of pituitary gonadotrophin and so inhibitthe capacity of the testicles to supply androgen, whereascastration will cut off the supply of androgen directly.And any condition in which the concentration of androgenin the blood is greatly diminished will be accompaniedby ischaemia and atrophy of the prostate gland and otheraccessory male genital organs. It seems reasonable toassume that the consequent shrinkage of these organswould at once lower the tension in the affected parts andso alleviate pain, and that the local ischaemia wouldretard the growth of a tumour. An inquiring man, how-ever, will wonder whether such a simple explanationcovers the whole problem. He may ask if a malignantgrowth in the prostate is ever, apart from the blood-supply, to some degree dependent on androgen for itsvigour. Cancer cells are usually regarded as uncontrolledby the tissues of the host ; but this may not be a universalrule. Malignancy varies in degree, and it is conceivablethat some cancer cells are not so entirely undifferentiatedas to be irresponsive to the normal hormones.Some clinicians regard the giving of oestrogen to

patients with prostatic cancer as a more potent remedythan castration, though castration is the readier way tostop the main supply of androgen. If this view is correct,oestrogen must exert some beneficial effect which removalof the testicles does not afford. Possibly oestrogencurtails the output of androgen by the adrenals as wellas by the testicles, whereas castration would not havethis effect. Meanwhile it has to be remembered that no

general anticarcinogenic property has been demonstratedin oestrogen, the reactions to which are mainly confined tothose tissues which it regulates in health-namely, theorgans concerned with reproduction. Elsewhere in thisissue Dr. Ludford and Dr. Dmochowski report that stilb-cestrol had no specific inhibitory effect on growth ofthe mouse tumours used in their experiments.

(Estrogens, however, possess the capacity of increasingthe connective-tissue stroma, with an excessive depositionof collagen, in many organs of the body, including theprostate. This reaction has been recorded by numerousobservers and has been discussed with abundant histo-logical detail by Mosinger 1 in a comprehensive mono-graph based on the results of giving large doses of

oestrogen weekly to guineapigs. The practical importanceof this reaction needs further experiment in connexionwith the treatment of cancer ; for it has been thoughton reasonable grounds that the speed of neoplasia may

1. Mosinger, M. Le Problème du Cancer, Paris, 1946.

occasionally be restricted by the local development offibrous tissue-in fact, deposits of collagen have seemedto represent a definite, if ineffectual, curative attempt.Until this point has been quite elucidated, these con-siderations suggest that a combination of castration withthe administration of oestrogen may be more beneficial inprostatic cancer than either remedy used alone.

MALARIA IN NORTHERN CLIMES

THE spread of malaria as an endemic disease is limitedby temperature, the northern limit for benign tertian andfor quartan malaria in Europe being the summer isothermof 60°F, and that for malignant tertian 70OF.l Tempera-ture also governs the development of the sexual form ofthe plasmodium in the mosquito. This development takes10-14 days at a temperature of 77°F and 14-18 days ata somewhat lower temperature, and does not take placeat all if the temperature is permanently below 59°F.2Moreover, in temperate climates malaria tends to havepeaks in spring and autumn. Swellengrebel and DeBuck 3 showed that, in the Netherlands, the springpeak was due to infection which had been acquired theprevious autumn and had remained latent during thewinter. An even longer incubation has been fullyproved by Hernberg’s account 2 of the outbreaks oftertian malaria in Finland, which lies north of thesummer isotherm of 60°F-i.e., beyond the bounds ofendemic malaria.

Finland had been almost entirely free from malaria forabout twenty years when the infection was reintroducedthere during the late war by Finns who had been fightingthe Russians. By the end of the summer of 1941, 57isolated cases had been reported ; there were 583 casesin 1942, 262 in 1943, and 892 in 1944. These were nearlyall in soldiers. The civilian cases numbered none in1941, 75 in 1942, 53 in 1943, and 17 in 1944 ; and someof these patients were probably demobilised soldiers.After general demobilisation in 1945, however, therewas a great spread of malaria among civilians, the totalfor 1945 being estimated as 1252 cases, excluding relapses.Hernberg investigated 856 of these cases. In spite ofthe high susceptibility of children to malaria therewere no cases in children under 15 years of age, andthere were not many in youngsters of 15-20. Theseasonal incidence is illuminating. Between Februaryand April, 1945, the mosquito-free period, there were142 cases, and the peak of incidence was in May (440cases) and June (352 cases), whereas in July and August,while mosquitoes were most abundant, the number ofcases fell off rapidly. Hernberg says :

"As 24-36 days must be assigned in Finland to full

development of a complete picture of disease in trans-mission of infection from man to man via the mosquito,half the number of cases would have been infected alreadybefore the middle of April-i.e., before there were anymosquitoes at all-providing the infection had occurredin that year."The seasonal incidence and the great preponderance of

military cases show that most of the patients must havebeen infected the previous year while in military serviceelsewhere. Further, the geographical incidence in manycases was too disconnected for infection to have arisenwhere the malaria developed ; and in some districts thesummer temperature was too low to permit infectionby mosquito bites that year. The view that infectioncame from hibernating mosquitoes is put out of courtby the appearance of malaria in districts which hadbeen free the year before. A questionary sent to 868

patients showed that all but 13 of the 596 who repliedhad been in military service the previous year in the1. Christophers, S. R. British Encyclopædia of Medical Practice,

London, 1938, vol. VIII, p. 304.2. Hernberg, C. A. Acta med. scand. 1947, 127, 342.3. Swellengrebel. N. H., De Buck, A. Malaria in the Netherlands,

London, 1938 ; see also Lancet, 1938, ii, 894.