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general. References to his own experience show thatasthma can be-or behave as-a symptom of con-version hysteria or an anxiety equivalent, but suchcases are only on the surface of the problem. Dr.

Rogerson 2 indicates its more profound difficultieswhen he notes the impossibility of separating theintellectual and temperamental endowment of theindividual from his physical endowment, to disregardthe one and call the other constitution. Apparentcontradictions that have hitherto been used as

arguments in controversy present themselves no

longer as contradictions but as problems needingan answer. The appearance of allergic reactions in aninfant of six months, for example, calls for an

explanation of the curious clinical picture-a dis-

abling physical illness from infancy which appearsto respond to a modification of the psychic milieu.

This work, original as it is, does not stand alone.We have commented upon the results of the psycho-logical examination of gastric ulcer patients byDraper and Touraine,4 who found throughout thatgroup peculiarities which marked them, like theseasthma subjects, as possessing a specific personalitypicture. Similar results have been claimed in theexamination of migrainous subjects, and apart frompossible therapeutic applications, all these observa-tions point to some underlying general principle thediscovery of which may perhaps give a new directionto the study of physiological processes as influencedby that indefinite something that we call the psyche.

"CHRONIC CYSTIC MASTITIS"

DESPITE repeated efforts on the part of variouswriters to clarify the subject, by changes innomenclature and by fresh conceptions of the under-lying pathology, there still exists much confusionabout that condition of the breast which used atone time to be labelled and dismissed without moreado as "chronic cystic mastitis." Two conflictingviews now held by different schools of thought havenever been adequately balanced-one that thedisease is characterised by such an aberrant type ofepithelial activity as to make carcinomatous changea dangerous possibility in every case ; the other,that chronic cystic mastitis is essentially an exaggera-tion of a normal physiological change, and that

malignancy, when it does complicate the simpledisease, is as fortuitous as it is in the " normal "breast. The former view is upheld vigorously byCheatle and Cutler 5 ; the opposite opinion, atleast as regards the likelihood of malignant changein the affected breast, was re-stated only recentlyin our columns as the experience of Mr. Eric PearceGould. 6 The outcome of this disagreement is thatwhen a surgeon meets with the common type of"

lumpy " breast, he is embarrassed by the knowledgethat whatever line of treatment he may advise is

open to serious criticism. Dr. Percy Klingenstein 7in a recent paper draws comfort from a statement of

Bloodgood’s that cases of doubtful malignancytreated by radical operation have done well. Klin-

genstein himself does not advise such drastic measures.He quotes figures to show that conservative surgeryhas a definite place in the treatment of " chronicmastitis." Where some may be inclined to join issuewith him is in his recognition, with Cheatle, of6c

mazoplasia" as a physiological state, as distinctfrom cysts and intracystic and intraductal papillo-mata, which he regards as of true neoplastic forma-

4 See THE LANCET, 1934, ii., 661.5 Tumours of the Breast, London, 1931.

6 THE LANCET, 1935, ii., 899.7 Ann. Surg., 1935, ci., 1144.

tion. J. S. Rodman 8 is much impressed with theextent of epithelial development and involutioncharacteristic of the menstrual cycle. There doesnot seem to be any sound proof that the glandularmenstrual changes in the breast are as profound ashe believes. E. K. Dawson’s 9 observations on

normal breast tissue have, in fact, led her to an

opposite conclusion. While the gaps in our knowledgeof normal breast histology and physiology are stillso wide, it is a matter of difficulty to interpret themore generalised states of epithelial change,particularly, perhaps, in patients before the

menopause.The observations of Mr. Harold Burrows 10 are

suggestive. He found that in their response to

cestrogenic substances, the breasts of some of hismice showed more pronounced hyperplasia and lessmarked cystic dilatation, while in others a

pronounced dilatation was accompanied by relativelylittle hyperplasia, that, in fact, the two conditionsseemed to occur in inverse ratio. As far as these

experimental results go, they suggest that cystformation in itself, though pathological, may befound actually to carry a more favourable prognosisthan hyperplasia of the epithelium, for Burrowshas found the latter condition to result from a more

prolonged administration of cestrin, and to be a

later effect than is cystic dilatation. It seems

likely that the localised lesions of the breast, suchas adenomata (whether of the fibro-adenoma, or theadeno-fibroma type); blue-domed cysts; papillo-mata ; and intracanalicular fibromata, are in patho-genesis more similar to " chronic cystic mastitis "than was at one time generally thought. Encapsulationof these tumours may be very imperfect, as is wellknown to the surgeon who attempts their removal underlocal anaesthesia. A more or less generalised changein the surrounding breast tissue is not infrequent.In sections right through a breast which is the siteof " chronic cystic mastitis " all the above changes-papillomata, fibrosis, cysts, and adenomata-maybe found in miniature, as it were. This consideration

complicates the treatment of tumours clinicallylocalised. Rodman regards all these changes as

aberrations due to interference with the propergrowth and involution characteristic of the sexual

cycles.When we attempt to come to conclusions about

the prognosis and treatment of this condition, wemeet the further difficulty that the criteria are

missing on which, in individual cases, the transitionfrom simple to malignant hyperplasia may be decided.Also-and it should be possible in time to fill this

gap in our knowledge-there is a great paucity in theliterature of follow-up results of cases treated by themore conservative measures. What we want toknow is whether these patients return later withcancer. Klingenstein followed 54 patients who hadbeen treated by partial breast excision, and foundthat, with two exceptions, they remained free of

malignancy for periods of 2-11 years. The twoexceptions developed cancer of the breast, one

seven years and the other one year after operation.Klingenstein quotes a report of Greenough andSimmons on 83 cases of cystic mastitis, treated bylocal operation, in 4-8 per cent. of which cancer laterdeveloped. Rodman follows Cheatle in acceptingthe incidence as being 15-20 per cent. in patientsover 35. He advises watching patients over this

8 Amer. Jour. Surg., 1935, xxvii., 452.9 Edin. Med Jour., 1934, xli., 653.

10 Brit. Jour. Surg., July, 1935, p. 191.

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age for two months. If a lump in the breast, whichhas been diagnosed as benign, does not in this timeshow evidence of disappearance, he advocates simpleamputation. In patients under 35, he would watchfor changes in the swelling before, during, and afterthe menstrual period ; if there is no change he wouldamputate. The significance of a serohaemorrhagicdischarge in these cases is considered by Klingenstein.He regards it as indicating the advent of intracysticor intraductal epithelial proliferation. Few surgeonswould take the risk of not removing the breast in acase of mastitis complicated by a serous or sero-

haemorrhagic discharge, spontaneous or induced bygentle massage in the direction of the nipple. The

great importance of sending every breast removed forpathological examination, if it were not otherwiserecognised as a wise precaution, would be provedby the difficulty in recognising diffuse intraductcarcinoma. The macroscopic similarity between thisadmittedly rather rare condition and " cysticmastitis " has been sufficiently demonstrated.

THE BIRTH CONTROL MOVEMENT

THE National Birth Control Association, withwhich the Birth Control Investigation Committee isincorporated, has published this week its fifth annualreport, and a history of five years of work offers tothe governing body a good opportunity to summarisethe past, review the present, and indicate plans forthe future. When this Association started in 1930the Ministry of Health had issued no memorandadefining the powers of local authorities in the matterof giving birth control instruction, and no localauthorities had opened clinics although there were16 voluntary bodies of this description. The staffconsisted of the secretary and there were no localbranches. To-day the Association has 28 localbranches and the staff consists of seven; includingthree organisers-by no means an extravagant staffconsidering the amount of ground that is covered.The Ministry of Health has issued 3 memoranda,66 municipal and 47 voluntary clinics have been

established, 42 local authorities send patients to

private doctors or clinics, 56 have passed favourableresolutions, while 14 have expressed themselveswilling to lend or hire premises to local branches forvoluntary clinics. The total expenditure, apart fromresearch, has come to just over E6000 for five years’work.The present situation indicates that the next five

years should show an increasingly rapid development.In 1934 the circular issued by the Ministry of Healthelucidated previous provisions and made it clearthat the maternity and child welfare authority hasthe power to give advice at a gynaecological clinic toall women in need of medical counsel. The 56 localauthorities mentioned above as having shown a

favourable attitude towards the work must beinduced to implement their goodwill; but therestill remain over 250 child welfare authorities in

England and Wales which have taken no actionof any sort. The Association possesses evidencethat organising work produces quick results, the wordsof the report being :

" In many a town, an organiser who on her first visitwas greeted with suspicion and apprehension so that

many of those upon whom she called were afraid to discussbirth control, has at the end of a few months establisheda branch with a strong committee, influential supporters,and a flourishing clinic."

The public attitude to the work is shown by quota-tions from the reports of medical officers of health

and from borough councils, one from a Welsh urbandistrict council stating that a comparison with lastyear’s statistics shows that the number of womenattending on account of debility, due to too frequentchild-bearing, has increased from 18 to 26 per cent.There is also an increase in the number of patients.suffering from debility due to miscarriage or abortion.From the investigation committee, of which Sir

Humphry Rolleston is chairman and Dr. C. P. Blackerthe honorary secretary, and from the medical subcom-mittee, of which Dr. Helena Wright is chairman, comealso evidence of progress, and, as might be expected,the increased activities call for, while they justify,an increased income. The need, as stated, isremarkably modest ; the Association wants, in orderto pay its way and meet expansion, at least 1800per annum, but possesses an income of 1000 only.Its call for further support is amply justified, and thelatest record of work done should lead to the necessaryincrease of members. Subscriptions and donationsshould be sent to the hon. treasurer, National BirthControl Association, 26, Eccleston-street, London,S.W. 1. The annual subscription of members is Sl Is.

A BIOLOGICAL ASSAY OF LIVER EXTRACTS

MANY attempts have been made to devise a methodfor biological assay of liver preparations. Nonehas hitherto proved of practical use. It has hithertobeen essential to test all material of unknown potencyupon patients with Addisonian pernicious anaemia.Such patients should have a red cell count below2,000,000 per c.mm., and no complicating factorssuch as sepsis present. Recently however, two

promising lines of attack on the problem have.been proposed. Miller and Rhoads 1 by feedingswine with a modified form of the diet which

produces black tongue in dogs have produceda symptom-complex, not unlike that of per-nicious ansemia, which is relieved by the administra-tion of potent liver extracts. These observations

suggest that in the future such anaemic swine maybe used as test animals. Landsberg and Thompson 2and Jacobson 3 working independently have shownthat the guinea-pig reacts to the administration ofpotent liver preparations by a reticulocytosis.Jacobson employed adult male pigs weighing between300-800 g. and kept on a diet of oats, carrots, andlettuce. He found that 30-70 per cent. of theanimals showed a significant rise in the number ofreticulocytes following parenteral injection of activeliver preparations when first given. The uninjectedguinea-pigs offer no clue that might seem todifferentiate between the two classes of guinea-pigs-i.e., those that will react and those that will not.Further tests of initially non-reactive animals mayshow them later to have become reactive. Conditionsin the guinea-pig necessary for a reaction to occurare not yet clear. Using known reactive animals,it has been possible to show that for every activematerial there exists a minimal effective dose whichis termed the guinea-pig unit of haemopoietic activityand which is a quantitative expression of the degreeof activity. It would appear justifiable to concludethat the capacity to induce a reticulocytosis isconfined to materials effective in pernicious anaemia,since, when an assay on guinea-pigs of crude extractfrom human livers was made, a control healthy human

1 Miller, D. K., and Rhoads, C. P. : Jour. Clin. Invest., 1935,xiv., 153.

2 Landsberg, J. W., and Thompson, M. R.: Jour. Amer.Pharm. Assoc., 1934, xxiii., 964.

3 Jacobson, B. M.: Jour. Clin. Invest., 1935, xiv., 665 and 679.