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to the value of treatment in cancer may ultimatelybe drawn. In an introductory paragraph to a reporton the Natural Duration of Cancer,l he deprecates theuse of the word "cure" without qualification in assessingthe results of treatment of any chronic disease, andsuggests that a numerical measure of cure must takeaccount of three quantities: (1) the average durationof life of a person, of the same age as the patient, notknown to be suffering from the disease; (2) the

average duration of life of a person suffering fromthe disease and left untreated ; (3) the average dura-tion of life of a person suffering from the disease andtreated in the manner the value of which it is desiredto test. Of these quantities, one only, the averageduration of life from any age in the general population,is known at all accurately. The duration of life aftertreatment is known, but only to a rough approxima-tion, for certain forms of cancer. To collect informa-tion on the " natural" duration of life of cancer

patients is the object of this report. It is admittedthat really accurate knowledge of the average lengthof life of a cancerous process not radically treatedcan never be had because its onset is often insidious.There are some forms of cancer-for instance, cancerof the stomach-where the earliest indications ofdisease are almost wholly subjective. But there areother forms, cancer of the breast or of the tongue, forinstance, where something tangible, a lump or a sore,is given, and in these our measure of duration, still

only rough of course, still probably understated, isof real value. Dr. GREENWOOD believes that it isworth while to seek measures of natural duration atleast for cancers of tongue, breast, cervix uteri, rectum,and oesophagus.The data here analysed were obtained by the courtesy

of several hospital staffs and include 4238 cases

relating to seven primary sites. From records made byProf. W. S. I.,A7AP.US-1’.,IP.LOW (London), Sir GEORGEBEATSON (Glasgow), Dr. S. WyARD (London), Dr.POWELL WHITE (Manchester), and Mr. CARTER BRAINE(London) he finds the mean duration in months tobe 38-3, 20-9, 26-7, 16-5, 12-0, 14-5, 16-8 respectivelyin cancer of the breast, uterus, rectum, tongue andmouth, oesophagus, larynx, and stomach. There isno significant difference between the different sets ofaverages obtained. Dr. GREENWOOD finds no confirma-tion of the general opinion of clinicians that age atonset is an important factor. There seems to be littlerelation between age of onset and duration. The

ordinary arithmetic average duration, however, putsthe case in too favourable a light, since the existenceof a small -number of persons who survived a verylong time-for example, two breast cases and onerectal case lived over 30 years-has pulled up thearithmetic average. The mean and the median value-i.e., the value midway between the longest andshortest durations-are often far apart. While theactual arithmetic average duration of cancer of thebreast is over three years, half the patients are deadwithin a little more than two years and three months,25 per cent. do not live more than 18 months, andonly 25 per cent. survive beyond four years one

month. For cancer of the rectum the difference isless striking ; the arithmetic mean duration is onlythree months longer than the median value.The significance of the results from the statistical

point of view is discussed in some detail. Fromthe material at his disposal Dr. GREENWOOD hasconstructed a survivorship table, calculating thechances of survival from nought to six years after

1 Reports on Public Health and Medical Subjects. No. 33.Ministry of Health. 1926. London: H.M. Stationery Office,Pp.26. 9d.

onset of cancer in each region in untreated cases.

Taking cancer of the breast as an example, he showshow from the data of natural duration an attemptto measure the effects of treatment may be made.He is careful to point out that in the present stateof our knowledge a certain element of conjecture isinvolved, and that certain assumptions are inevitable.Accepting these assumptions we have the followingsummary results. The normal expectation of life ofa woman aged 55 is 18-87 years, the expectation oflife of a woman with untreated cancer of the breastis 3-25 years, the expectation of life of a woman

operated on under " average " conditions is 5-74 years,and of a woman operated on under the best conditionsis 12-93 years. To-day the annual quota of new casesof cancer of the breast in England and Wales isprobably at least 5000. Not more than half the patientsundergo the radical operation and of these fewerthan half again are operated on under the mostfavourable conditions. How many years of life willthese 5000 women, on the average, enjoy 2500 ofthem will have 3-25 years apiece, 1250 will have5-74 apiece, 1250 12-93 years each. The grandtotal is 31,462-5 years. Had each enjoyed thenormal expectation, the total would have been 5000multiplied by 18-87 or 94,350 years. If all had beenoperated on under the most favourable conditions,the quota of years would have been 64,650, more than30,000 years of life beyond what they may actuallyexpect. Sir GEORGE NEWMAN emphasises in a pre-fatory note the advantage enjoyed by those whosubmit to early operation in this form of cancer.

Recent records of cases of women operated upon forundoubted cancer of the breast in various provincialcities, notably Leeds,2 confirm Dr. GREENWOOD’S

arresting conjecture that resort to early operationin cancer of the breast would, in the aggregate, addthousands of years to the active life of the nation.

NURSING HOMES.A Select Committee, appointed by the House of

Commons on March 2nd last to consider and inquireinto the question of the inspection and supervisionof nursing homes, and to report what legislation,if any, is necessary or desirable, have issued thisweek a well-considered and prompt report. 3 Evidencewas taken not only from medical and nursing associa-tions, but from many engaged with the administrationof public health in urban and rural districts, privatemedical practitioners, matrons and proprietors of

nursing homes, and such persons with direct expe-rience as nurses, patients, or visitors. The informa-tion from the witnesses was sought in reply to thetwo questions, whether the general conditions underwhich nursing homes are conducted render theirsupervision by a public body advisable, and, if so,how such supervision can be most effectively obtainedand exercised.The difficulty of defining the institutions to be

considered was met by a classification under which allnursing homes were placed in five classes, accordinglyas they provided accommodation for medical and

surgical cases; for maternity cases ; for cases

requiring special observation and treatment; forsenile and chronic cases ; and for convalescent cases.It will be seen that under the first two headingswe have the usual material of the general or special

2 A Report on the Late Results of Operation for Cancer ofthe Breast (Leeds). Reports on Public Health and MedicalSubjects. No. 31. Ministry of Health. 1926. London: H.M.Stationery Office. Pp. 20. 6d.

3 Report from the Select Committee on Nursing Homes(Registration). London: H.M. Stationery Office. 1926. 4d.

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hospital applied to particular people who, for one reasonor another" are being treated in private ; the functionsof institutions for the reception of the last two classesof cases are obvious ; but in considering institutionsprepared to shelter patients requiring special observa-tion and treatment the report may be called prophetic,inasmuch as, though such places are extremely needed,they are only just coming into existence. All nursinghomes may not fall neatly under this classification,if only because patients under two or three of thedifferent classes may, of course, be found under oneroof; but the category is a quite adequate one fromwhich to consider the need for supervision, and ofthis need there seems to be no doubt in the publicmind nor in the mind of the Committee. TheMinistry of Health was evidently alive to the greatdifficulty implied in the registration and inspectionof maternity homes fulfilling functions in regard ’’,to public health and child welfare, for, in the recom- Imendations, special exemption from supervision isprovided for publicly controlled institutions, whichcannot require the same sort of standardising thatmight be necessary for private adventures. ’Fromthe British Medical Association the Committee learnedthat that body would not object to the registrationof nursing homes where the registration authoritydelegated its duties to a committee upon which bothdoctors and nurses would be represented, ensuringalso that medical records and case-sheets would notbe open to lay inspection. The complaints receivedby the Committee came from doctors-mainlydirected to structural and sanitary defects in buildings ;from nurses-mainly directed to inadequate accommo-dation for patients and staff, poor quality of diet, andinadequacy of staff ; and from patients-confirmingfrom their aspect the views of the nurses. These

complaints were considered by the Committee underthe indicated headings of buildings, accommodation,staff, and treatment of patients, and in view of muchpublicity that has been given recently to the allegedneglect of patients in nursing homes, we woulddraw attention to one passage in the report : " TheCommittee do not intend to criticise the work carriedout by well-run nursing homes, for it is clear that inmany cases the owners or managers of these homesare making the very best of structurally unsuitablebuildings."On such clear-cut issues as could be formulated,

the Committee make concrete recommendationswhich will lead surely to " something being done."They find that legislation to secure registration andinspection of nursing homes should be introducedunder the supervision of county and borough councils,with power of delegation to a committee upon whichdoctors and nurses are represented, the inspection tobe carried out by the medical officers of health withtechnical assistance ; the inspection, they hold,should be limited to general questions and shouldnot embrace any inquiry into medical records or

the private affairs of patients. They hold that theterm " nursing home " should include all types ofhome-that is to say, maternity homes also-butnot any publicly controlled institutions. Charitable

organisations, they say, could be exempted by actionof the supervising authority for definite periods,

. but they do not agree that a nursing home shouldgo free of inspection on the grounds of the residenceor the control of a medical practitioner. They recom-mend that appeals against refusal or cancellation ofregistration should be made to a referee appointedby the Minister of Health, and that all homes, includingmaternity homes, should be brought under one com-prehensive scheme. Action should follow on this report.

Annotations.

INTERNATIONAL RED CROSS CONFERENCEON THE WELFARE OF THE SEAMAN.

" Ne quid nimis."

BETWEEN June 28th and July 5th an itinerantconference was held in Oslo, Bergen, and Trondhjemwith the object of uniting the Red Cross Societies ofthe world in a movement for bettering the health ofthe sailor. The British representatives were Mr. L.Bowden, Dr. Butler (of the International LabourOffice), Surgeon-Commander L. F. Cope, R.N.,Colonel L. W. Harrison, Dr. C. Lillingston, Dr. F. N.Kay Menzies, Mrs. Neville Rolfe, Dr. Norman White,and Mr. Murray-Williams. The aim of the con-

ference, which was organised by the Norwegian RedCross Society and the League of Red Cross Societies,was to bring together the representatives of thenational Red Cross Societies of the maritime countriesof the world and certain other organisations such asthe International Labour Office, to study the measuresalready taken in Norway for the welfare of the sea-man, and to confer over steps to be taken in thefuture for his welfare. Of the many items on theagenda, which included the international standardisa-tion of a medicine chest and medical manual for shipsnot carrying a doctor, that which elicited the mostlively discussion was the plan devised by Dr. HaraldEngelsen, of the Norwegian Red Cross, for a networkof medical stations under the Red Cross for seamenin every port. It was his original intention that theRed Cross should choose one doctor in every portto act as the agent of the Red Cross, putting hissurgery at the service of the sick seaman, who wouldpay the ordinary doctor’s charges and who would,if he required specialised treatment, be passed onto a specialist or a hospital where he could receivesuch treatment. It was argued by Dr. Engelsen infavour of this scheme that the seaman would benefitby having a doctor found for him and guaranteedby the national Red Cross Society of the country ;also that the patient would have the advantage ofcontinuity of treatment as he travelled from onecountry to another in the charge, so to speak, ofRed Cross doctors who would be more or less intouch with each other, information as to diagnosisand treatment being carried by the patient from onedoctor to another. The Secretary-General of theNorwegian Medical Association (Dr. Jorgen Berner),gave the blessing of his Association to this suggestion,although it entailed granting a monopoly to only onedoctor in each port. The attitude of the foreigndelegates to the scheme might be described as one offrank, but friendly, criticism. They were agreed asto the desirability of linking up the welfare work forseamen under one single international organisation,such as the League of Red Cross Societies, but theydid not see how the Norwegian scheme in its entiretycould be accepted by every other maritime country.The first three resolutions, unanimously adopted bythe conference, gave expression to this feeling. Theywere :

1. That bureaux for furthering the health and generalwelfare of seamen be established in seaports throughoutthe world in close liaison with, and as a further developmentof, such national and international action in this field as hasalready been taken.

2. That each bureau be placed in a prominent position atthe water-side. The chief function of these bureaux wouldbe to furnish (a) treatment or information as to whereappropriate medical advice and treatment can be secured,(b) postal facilities such as addresses to which the seaman’sletters might be sent, and (c) information as to the localrecreational and social facilities and sleeping accommodation.

3. That such seamen’s bureaux should be distinguishedby a common badge of world-wide application.To assure continuity of future action, the con-

ference adopted as a further resolution, that-"The League of Red Cross Societies should invite the

International Labour Office, the Health Organisation of the