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Medical Societies.ROYAL SOCIETY OF MEDICINE.

COMBINED SECTIONS OF EPIDEMIOLOGY,COMPARATIVE MEDICINE, AND

DISEASES OF CHILDREN.THE adjourned meeting of this Section (see THE

LANCET, Feb. 14th) for the discussion of theCONTROL OF TUBERCULOSIS AND THE MILK-SUPPLYwas held on March 2nd, Dr. JOHN McVAIL, Presidentof the Section of Epidemiology, being in the chair.

Dr. M. J. ROWLANDS spoke of his practical experi- ience in pig-farming, and ascribed the liability of cattleto tuberculous infection to the two factors of badfeeding and overwork.

The Vitamin Fadm’.

Nowadays, he said, there was practically no

vitamin-content in the diet of dairy cows, the wholeof the germ was taken out, and an animal that wasintended by Nature to produce sufficient milk for onecalf at a time when natural vitamin-rich foods wereprevalent was made to yield from one to two thousandgallons per annum, working for eight or ten monthswithout rest. Such a drain on the fat and proteinmust result in a low immunity. Among his pigs tuber-culosis had been very prevalent, even under the mostscrupulous hygiene, but he had completely eradicatedit in one year by attention to the vitamin-content ofthe diet, without any methods of isolation or dis-infection. Almost every prize animal in a certainfamous herd of cattle gave positive results with thetuberculin test, while the other members, not fed onartificial foods, showed a far smaller proportion ofreactors. The rarity of tuberculosis in sheep, horses,and bullocks was to be ascribed to their more naturallife. In collaboration with Dr. Chalmers Watson,of Edinburgh University, he had found that pigsfed on a vitamin-rich diet passed one-third less proteinin their stools than those fed on the usual substances.He had found it important to supply animal protein,as there was a conversion loss of 25 per cent. onvegetable protein. Slaughter of all tuberculouscows in the country would give immunity for twoyears only ; it was not possible to pull down all thecowsheds and they were full of tuberculosis ; sun-

light, cleanliness, segregation, and disinfection weregood measures, but would not eradicate the disease.The only satisfactory method was to increase thenatural immunity of the animals by providing a dietrich in carbohydrate, protein, mineral salts, andvitamins.

Pathogenicity of the Bovine Bacilliiq.Dr. A. S. GRIFFITHS, speaking from the point of Iview of the bacteriologist, showed a number of charts

illustrating the work of the bovine bacillus in humanpathology. The Royal Commission of 1911 haddisproved Koch’s statement that this form of tuber-culosis was without serious menace to man, andfurther investigations had served to confirm theirfindings. In gland tuberculosis the bovine bacillushad been found in 85 per cent. of cases under 5 yearsof age ; in 18’2 per cent. of adults. In bone and jointtuberculosis the percentages were 30’2 and 5’9 ; ’ Iin scrofuloderma 58’3 and 7’7 ; in lupus 66 and 17’6.There was evidence of a slight increase in the incidence Iof bovine infection since 1910. The animal form wasresponsible for 19 per cent. of genito-urinary tuber- 1

culosis of all ages, 1’1 per cent. of pulmonary disease 4

(found in three cases only), and 66’6 per cent. ofmeningitis, taken from the cerebro-spinal fluidduring life. Thus some 80 per cent. of the infections 1

that had entered by the alimentary tract were due 1to the bovine bacillus. These results had served to 1disprove Calmette’s assertion that phthisis entered c

via the abdominal glands, and there was no evidence 1

that the bovine form could be converted into thehuman. There was no clinical distinction betweensurgical cases of tuberculosis in laboratory animalsproduced by the two varieties ; and such evidenceas was available pointed to a slightly higher degreeof intrinsic virulence on the part of the bovine.The obvious corollary of such findings was the urgentnecessity for removing tubercle bacilli from milk.

Mr. G. P. MAl. expressed the disappointmentexperienced by certain of the veterinarians at theprevious discussion on hearing the promulgation ofsuch counsels of despair as pasteurisation and theimmunising value of a few live bacilli in the milkdrunk. He believed there were certain hopeful featuresin the situation, such as the increase in the number offarms supplying certified and grade A milk, and thereduction of the proportion of reactors in the herdsfrom 50 per cent. 20 years ago to less than 5 per cent.at the present time. He referred to the remarkableimprovement in the hygienic conditions of housingwhich resulted from the work of Dr. StenhouseWilliams at Reading, where it had been proved thatclean milk could be produced in old buildings withoutmaterial alteration, and the farmers had been satisfiedthat the production of such milk and the eradication oftuberculosis from their herds was a sound commercialproposition. He admitted the force of the two objec-tions raised-viz., the increase of cost to the consumerand the danger of distributing reactors to othercentres, but thought there was no reason why grade Amilk could not become the staple supply of the countryif only the doctors would support it. This could besold at a profit by the addition of 1d. per quart to theretail price. The dissemination of reactors, also,only resulted in their becoming collected in the herdsof owners who were not anxious to provide testedmilk, and such herds would become known to themedical officer of the district. Mr. Male emphaticallyurged the reintroduction of the Tuberculosis Order ;he had helped to work it during the short period itwas in force and could speak to its efficacy. Its.cost might be some 80,000 per annum, but the costof sanatorium treatment for children infected withbovine tuberculosis would go a long way towardsmeeting that sum. In the 12 months of the Order’s.life over 1500 milk samples containing tubercle bacillihad been traced to their source and the animalsslaughtered. There must be close cooperation betweenthe medical officers of health and the veterinaryinspectors so as to encourage in every way the pro-duction of certified or grade A milk, with regularinspection of herds once every three months.

The Farner’ Point of View.Dr. STENHOUSE WILLIAMS spoke strongly of the

distress it had caused him to hear the worst specimenof farmer held up to the meeting as a type. TheBerkshire farmers had taken immense trouble torender their cows perfectly clean. The cows werebrought in, washed thoroughly, and the workers thenchanged their coats, washed themselves and, seatedon a clean stool, milked into covered sterilised buckets,which were subsequently placed into sterilised con-tainers over sterilised coolers, and thence into a

sterilised ten-gallon churn which was sealed, marked,and unventilated. The retailer in his turn put themilk into a sterilised receiver, and thence into asterilised bottle, capped and sealed it, and it was thusdelivered, fresh and clean, to the consumer’s housefor ld. per quart extra. Dr. Stenhouse Williamsquoted one such instance of a farmer who had clearedhis herds at considerable financial loss, and when hethen offered his milk to the local hospital at theordinary rate his contract was refused. The dealersalso refused his milk, and hehadto start a dairy businessat his own expense in order to get his milk on themarket. Within two years it formed one-sixth of thetotal supply of the town. Such a story was a reproachto the medical profession, and one reason why theconsumption of grade A milk was not widespread wasthat the doctors failed to support it. The alternative

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was pasteurisation, as in New York, where it wasbeginning to be questioned whether the large amountof latent scurvy might not have some connexion withthe high percentage of pasteurised milk. In hisopinion the far better way was to support the idea offresh, clean, tuberculin-tested grade A milk, notforgetting that this country could boast the mostintelligent farmers in the world.

Importance of Expert hzspect2orz.Sir LAYTON BLENKINROP agreed that the veterin-

arians had been much disappointed at the apparentsatisfaction with pasteurisation ; he had no doubt that- hygienic conditions and the placing of herds under thecontrol of practised veterinary surgeons would resultin the eradication of the disease. The best help to thefarmer was to give him the advice of competentclinical experience, and no one was keener to followsound advice than the British farmer. His experiencewith glanders and mallein-testing in the army had ledhim to believe that the first essential was recognitionof the symptoms of the disease. He agreed as to thenecessity for urging the reintroduction of the Tuber-culosis Order.

Dr. D. NABARRO said he had no doubt that herdscould be freed and kept free for a time, but this freeingof them resulted in a lowering of their immunity ;he was not quite convinced of the desirability of sodoing, nor was he sure that small doses in milk didnot confer a valuable immunity. Of course, cases ofgross udder disease or advanced tuberculosis must beslaughtered, but to destroy all reactors was going toofar. He believed in the mutability of the bacillus andthat the rarity of bovine infection in adults was to beaccounted for by its alteration after long sojourn in thehuman body. He referred to the work of Collie,Beattie, and others on acid-fast bacilli which could bemodified by passing through guinea-pigs into bacillihaving all the characteristics of tubercle. He urgedthat these important results should be further investi-gated, and that such unsolved problems should be putto the test before the country embarked on a wholesaleslaughtering of cattle.

Dr. NATHAN RAW expressed it as his opinion thatpractically all surgical tuberculosis was bovine andbore no relation to pulmonary disease. Some 10,000children were lost annually through the work of thisbacillus and some 5 per cent. of the million dairy cowsin the country were suffering from tuberculous diseaseof the udder. Slaughter was no solution ; the mosthopeful method of attack was to immunise the calvesas they were born. Until this process could becompleted pasteurisation or boiling of uncertified milkshould be made universal. He had never seen anyill-effects from the use of pasteurised milk. He urgedthat the Tuberculosis Order should be re-enforced,remarking that Parliament was anxious to take anysteps that would ensure a pure milk-supply for thecountry. The Reading testing centre was a model forthe country, but it would be some time before such astandard could be made universal.

Dr. H. ScuRFUTLU said that the towns which hadhad milk clauses in force showed no evidence of anyreduction of the tuberculosis incidence. He referredto the insidious way in which the infection creeps into free herds and asked how this was to be explained.Was it due to the fact that a cow might have anearly infection which did not give a positive reaction,or was it due to the doping of animals with tuber-culin ? It was known that a tuberculin test renderedthe animal negative to subsequent tests for a certaintime. He urged the standardisation of tuberculinand the restriction of testing to competent veterinarysurgeons, every cow tested to be marked in some way.He most cordially agreed with the importance of thevitamin diet, and the necessity for spreading institutessuch as that of Reading over all the country. Inhis experience, if sufficient care were taken in followingup a sample of tuberculous milk swiftly an infectedudder was always found to account for it. ]lie agreedthat veterinary surgeons of clinical aptitude werenecessary.

Prof. F. T. HOBDAY spoke of the seriousness of thispossibility of doping cattle ; any unscrupulous dealerhad only to get a syringe and some tuberculin torender his cows negative to any test. There shouldbe some control. He believed in the immunisationmethods and thought they were well on the way toa successful issue. The country could be free oftuberculous cattle in 20 years by this method.

Dr. HENRY GRAY believed in total eradication asthe only way of getting rid of the disease. It was notfor the medical profession to consider costs and adopttinkering methods ; it was for them to say what oughtto be done to prevent tuberculosis in children and forthe public to determine whether it would pay theprice or not. Neither housing nor vitamins wouldsettle the difficulty ; there was only one cause ofthe condition and that was infection.

Sir WILLIAM HAMER spoke in favour of feedingand housing methods, having reference to the remark-able results achieved by these measures amonghuman beings.

Sir LEONARD RonKRS pointed out that all milk inIndia had to be boiled, and the children did very wellon it. In his opinion pasteurisation was the bestmethod until the disease could be eradicated in cattle,and grade A milk made the supply of every home.The PRESIDENT, in concluding a good discussion,

spoke of its vast importance and great interest.He deprecated any suggestion as to the existence oftwo sides in this matter ; there was no contradiction;pasteurisation was merely a temporary precautionwhile the work of eradication was being completed.A resolution calling upon the Council of the Society

to urge upon the Government the immediate re-

enforcement of the Tuberculosis Order was carriedunanimously. -

SECTION OF EPIDEMIOLOGY ANDSTATE MEDICINE.

Preventive Control of Diphtheria.AT a meeting of this Section held on Feb. 26th,

with Dr. JOHN MCVAIL, the President, in the chair,Dr. WILL1AlVI ROBERTSON, medical officer of health,Edinburgh, read a paper on the above subject.Having remarked that the usual measures with regardto diphtheria had rather the appearance of lockingthe stable door after the steed was stolen and referredto the anxiety given to all public health departmentsby the presence of carriers, Dr. Robertson describedthe methods adopted in Edinburgh to secure a

svstematic immunisation of the school population.Explanatory leaflets and consent forms were distri-buted to all scholars under the age of 10 years.Parents were asked to consent to a preliminarySchick testing, then, if necessary, three preventiveinoculations and a final Schick testing. In the betterclass schools as many as 86 per cent. of the parentsconsented, but in the poorer districts the percentagesometimes fell to 10 when the percentage of consentswas 50 or less a second appeal sometimes broughtthe figure up to 70. When skilled workers wereemployed and the cooperation of teachers secured,it was possible to make the tests at the rate of 100 to120 an hour. It was found, as elsewhere, that theproportion of positive reactors was much higher inthe better social strata. It also appeared that passingthrough an attack of diphtheria did not confer alasting immunity, as judged from the Schick reaction.Experience had shown that in young children,aged 2-5, immunisation could properly be donewithout a preliminary Schick test. From thepreventive point of view, it would be expedient toconcentrate attention upon children of pre-schoolage. It was essential that the method should beapplied only by trained persons.

Sir WiLMAM HAMER wished to have more informa-tion as to the results, in particular with regard to theNew York experience.-Dr. O’BRIEN remarked thatthe mixture used in Edinburgh was, so far as guinea-pigs were concerned, much less toxic than thatemployed in New York. He referred to improvements

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already effected in the production of antitoxin andlooked forward to yet greater improvements.-Dr. S. MONCKTON COPEMAN remarked that in England,so far, only schools used by the wealthier classes andPoor-law schools had made much use of the method.The higher percentage of immunes in the poorerclasses was apparently due to more frequent normalexposure, because, in a higher grade school in Norfolk,where there was definite exposure to risk. the propor-tion of negative reactors had been found to be verylarge.--Sir GEORGE BUCHANAN hoped that it would bepossible to ascertain whether the subsequent attack-rate of the immunised children in New York waslower than that of those not immunised. He con-gratulated Dr. Robertson on this piece of work andinquired whether reactions on inoculation had givenrise to trouble, whether it had been found necessaryto warn parents.-Dr. MAJOR GREENWOOD deprecatedany premature attempt to

"

prove " the efficacy of

the process by statistics. At present the methodshould be regarded as a reasonable one, one to beaccepted by intelligent people ; in time a statisticalassessment would be possible.-Dr. RANDALL askedwhether immunisation had reduced the number ofcarriers.-Dr. TROTTER thought that the publichealth services in Scotland had a considerableadvantage over those in England both by virtue ofhaving somewhat greater powers and of being incloser contact with the people.-Dr. HUMF thoughtthat the small size of Edinburgh compared withLondon and the prestige of the medical schoolexplained the greater willingness of the populationto follow medical advice.-Dr. ScoTT thought thatthe variation of the proportion of natural immuneswas one of the most interesting problems from thestandpoint of immunology; the explanation bysubinfection was not really very satisfying.-Dr.FORBES said that Edinburgh stood alone in dealingwith the school population. In the south the methodhad been practically confined to large institutions.-Dr. REGINALD D17DFIELD remarked that, as in thematter of tuberculosis dispensaries, Edinburgh wasdoing pioneer work. He inquired as to the verificationof a history of previous diphtheria and also asked forinformation on the subject of carriers.--The PRESI-DENT tendered his congratulations and those of theSection to Dr. Robertson. It was difficult not tobe. envious of New York. Probably the medicalprofession required more education, and he thoughtthat Dr. Hume’s remarks on the medical atmosphere ofEdinburgh were highly relevant. He also deprecatedany premature statistical " proofs."

Dr. ROBERTSON, in his reply, said that it was tooearly to give statistical results, but in a school whichhad formerly given much trouble no cases had occurredamongst the immunised. It had not been foundnecessary to issue warnings as to reactions. Therewere some reactions at the age of 10-11, but they wereconfined to slight rises of temperature and localinduration. The method was not serviceable in theelimination of carriers. Carriers did not react.Histories of alleged diphtheria were verified fromnotification records.

LONDON ASSOCIATION OF MEDICALWOMEN’S FEDERATION.

A MEETING of this Association was held on Feb. 10th,Miss M. CHAD BURN being in the chair.Miss FRANCES IvENS read a paper on the ,

Prevention of Puerpera -4morbidity and JJ1: ortality. ’

She had long been interested in this subject froma gynaecological standpoint, and had welcomed anopportunity to make observations from the obstetricalside to determine to what extent the morbidity,immediate and remote, following childbirth was pre-ventable. Five years ago, with this object in view,she undertook, at the invitation of Dr. E. W. Hope, I

then medical officer of health of Liverpool, the super-vision of the new maternity home which was startedon his initiative. The home could only take in14 patients, but since its opening in 1920 1000 admis-sions had taken place. As far as possible, MissIvens saw every case before admission and made anexamination. A specimen of any abnormal dischargewas sent to the city bacteriologist for report. Casesof active syphilis or gonorrhoea were referred to aspecial institution, and cases of albuminuria, cardiacdisease, hyperemesis, &c., were admitted for ante-natal care. Cases requiring Caesarean section weresent on to the Stanley or Maternity Hospital. Atthis home before any internal examination is madethe vulva is shaved and washed with lysol solution.In emergency cases tincture of iodine is also used.During labour all those concerned with the case wearsterilised overalls and boiled gloves. The matron orsister conducts all normal cases with the assistanceof the pupil midwives, who are all trained nurses.Any perineal rupture is repaired at the earliestpossible moment with silkworm-gut. The wound iskept dry and is touched once daily with tincture ofiodine. During the puerperium the vulva is swabbedfour-hourly during the day with lysol solution and alarge sterile pad applied. The patient is encouragedto lie on her side for part of every day and to sleepin an exaggerated Sims position, which is not uncom-fortable. Anteversion of the uterus is thus encouraged.In cases of ruptured perineum micturition is performed’on the hands and knees so that the wound is notsoiled and catheterisation is avoided. Of 1000 patientsadmitted 206 were pre-maternity cases and 679 werematernity cases, of which 390 were primiparae and289 multiparse ; 118 were postnatal cases. MissIvens said that there had been no maternal mortalityamong these cases and no maternal morbidityaccording to C.M.B. Rules among the cases deliveredin the home.

Miss Ivens proceeded to classify the cases.

Contracted pelvis occurred in 130 cases, the highpercentage being probably due to the fact that aproportion of the cases were referred from outsideclinics, doctors, and midwives for special observa-tion and care. Of the total number of maternitycases (679), natural delivery took place in 601-88 percent. Among the complications met with were post-partum haemorrhage (three severe and two slight),adherent placenta, perineal tears, fibro-myomata,twin births (eight pairs), unreduced occipito-posteriorposition, placenta praevia (eight cases), prolapse ofcord, pelvic presentations (25 cases), face presentations(two), eclampsia (one as an emergency). Induction ofpremature labour was employed in 48 cases. Deliveryby forceps was effected in 30 cases and 29 patientsrequired Cfesarean section. As to the infants, 39 werestillborn or died in the first ten days, of which 22 werepremature ; 687 children were born and 648 remainedalive. Miss Ivens described 11 cases where there hadbeen some morbidity. Full details of this investiga-tion would shortly be published.

She recognised that it was unwise to draw definiteconclusions from such a small number of cases, butshe was inclined to believe that the results ledto the following among other conclusions: Thatlatent or pre-existing infection is responsible for aconsiderable percentage of cases of puerperal sepsis ;that the organism may not infrequently be isolatedfrom the urine during pregnancy; that inter-mittent albuminuria during pregnancy is an indicationfor bacteriological examination of the urine; that casesshould be removed from unsuitable surroundings andaccommodation in homes should be sufficiently amplefor patients to be admitted a day or two before labouris anticipated ; that rigidly aseptic technique is

important ; that well-trained midwives can delivera very high percentage of maternity cases if efficientantenatal care has been given and if skilled medicalhelp and, if necessary, institutional treatment can beobtained when required ; that in view of the needfor study of the origin and character of the infectingorganism in cases of fulminating puerperal fever