574 BERLIN.

is repeated and a family is decimated ; in others t

& single member of the second generation succumbs. Not infrequently, again, an adolescent or young adult idevelops phthisis although the family bill of health (

is clear of any taint of the disease and no source of infection can be traced. The origin of the chronic fibroid type of tuberculosis common in later life is 1

equally uncertain, and it is often doubtful in any (

particular case whether the infection is of recent dateor whether declining vitality has caused a smoulderingfire to blaze. Where much is obscure certain facts are patent.

That a member of a family suffering from manifesttuberculosis is a grave source of danger to all its members has been recognised since Koch’s discovery,and, indeed, was recognised before it, and provisionfor the examination of contacts is considered to bean essential part of all antituberculosis schemes.When a case of tuberculosis is notified a health visitorcalls at the home of the sufferer, and though the adoles-cent members of the family are apt to decline toattend the dispensary, maternal anxiety can usuallybe depended upon to produce two or three infantsor children of school age. These are martialled beforethe tuberculosis officer, a physical examination ismade, the signs of manifest tuberculosis are lacking,and a much-relieved parent returns with her wonderingoffspring to the home where infection abides. Finally,a record of negative results for the contacts is dulyreturned to swell the satisfactory statistics of thecounty medical officer, regardless of the fact that topronounce an infant " free from any trace of thedisease," because auscultation and percussion failto reveal obvious signs of tubercle is about as usefulas to palpate its chin and report that there is noevidence of a beard.The familial spread of tuberculosis can never be

prevented by such perfunctory methods and slipshodwork. It is notorious that pulmonary tuberculosis isonly recognisable by physical signs in the chest whenthe disease is firmly established. The " early case "of the sanatorium is not an early case of tuberculousinfection ; the sound of cracking timbers, the fall ofdecayed masonry are not the signs by which a housinginspector determines incipient decay in a building.For too long the threatenings of imminent collapsehave been mistaken for the first warnings of danger.The slogan of the propagandist, that consumption iscurable in its early stages, is only true if appliedto stages whose detection requires far greater delicacythan that of palpation, percussion, and auscultation.

In this connexion the work of E. L. Opie and F. M.McPhedran.1 of Philadelphia, deserves more attentionthan it has yet received in this country. Theirinvestigation of tuberculous contagion in familieshas been based upon evidence obtained from the Iintracutaneous tuberculin test, correlated withinformation from skiagrams, and supplemented bythe usual physical examination. In this way bothcontact and non-contact families have been subjectedto a searching examination, the results for each

family being set out on an ingenious record cardshowing diagrammatically the condition of eachmember as revealed by the various tests employed.The age of each member is also shown and the durationof exposure to infection in the case of " contact

"

families is graphically indicated.The tuberculous are divided into (a) those with

manifest disease recognisable by physical signs,sputum tests, &c., and (b) those with latent diseaseonly revealed by radiographic examination andtuberculin tests. Latent infection in the child isdue to implantation of the tubercle bacillus in thelymphatic system of the lungs and is revealed bynodes in the lung field or by enlargement of thetracheobronchial glands ; the radiographic appear-ance of these foci has been compared with post-

1 The Contagion of Tuberculosis. By Eugene L. Opie, M.D.,and F. Maurice McPhedran, M.D. The American Review ofTuberculosis, October, 1926. Spread of Tuberculosis withinFamilies. By Opie and McPhedran. Journal of the AmericanMedical Association, No. 1926.

mortem findings and their signincance has beenproved. The adult type of latent infection—whichis, however, occasionally found in children—ischaracterised by involvement of the lung apex, whichmay be the seat of tuberculous deposits or mayexhibit a thickening of the apical cap. It is claimedthat the X ray findings are confirmed by the intra-cutaneous test, though the latter is more delicateand supplies evidence of infection at an earlier stage.

If the conclusions of Opie and Mcl’hedran are

correct, they ought to be generally applied as far asmay be possible. They are as follows :-

1. When latent tuberculosis is taken into con-

sideration, tuberculosis exhibits the chanacters ofa contagious disease and affects all children of house-holds within which some members, suffering withtuberculosis, scatters tubercle bacilli.

2. Recognition of latent apical tuberculosis hasdemonstrated that tuberculous infection is transmittedto adults and to adolescent children, and has shownthat approximately one-half of the partners ofhusbands and wives with open tuberculosis are

infected after marriage.3. Duration of exposure to open tuberculosis is

an important factor in determining the characterand severity of the resulting infection ; in instancesof recognisable tuberculosis of tracheobronchial lymphnodes the average duration of contact with tuber-culosis has been approximately four and a half years,and instances of latent apical tuberculosis nearlytwice as much.

4. Dispensaries for the care and control of tuber-culosis should be organised so that spread of latentinfection within the family may be recognised andprevented. A chart for each family, depicting theseverity of latent and manifest disease disclosed byquantitative tuberculin reactions and roentogeno-logical examination, will forcibly direct attention toeffective means of control.

5. Latent tuberculosis often becomes manifest.Certain forms of latent infection foretell the approachof clinically recognisable disease. These are (1) infec-tion recognisable by the tuberculin reaction during

- the first two years of life, (2) tracheobronchial tuber-culosis in children recognised by roentogenological

; examination, and (3) latent apical tuberculosis inadolescent children. Children with these forms of

i tuberculous infection should be examined at frequentintervals and treated as though they had recently

- arrested tuberculosis.6. All adults in whom latent apical tuberculosis

has been recognised should receive the same care aspatients with arrested phthisis.

BERLIN.

(FRmr OUR OWN CORRESPONDENT.)

Abortion in Russia and in Germany.THE Breslau Medical Society recently discussed the

consequences of legalised abortion in Russia. Thenew legislation in that country recognises no differencebetween children born in and out of wedlock, andthe Soviet has decreed that any abortion sanctionedby a medical commission and performed in a publichospital by a doctor will not be regarded as criminal.As a result of this decree so many women appliedfor abortion that the hospitals were soon overcrowdedand private sanatoriums had to be used. The Sovietauthorities intended that abortion should no longerbe concealed, and that women who wished theirpregnancy to be interrupted should be able to getthis done under favourable circumstances. Theywanted to prosecute those who make a business ofartificial abortion, and not the mothers who seek tohave the operation performed. Needless to say, theresult has been a great increase of abortion, andaccording to Dr. Niedermeyer, who opened thediscussion, only a nation of such vitality as Russiacan stand such legislation. Abortion performed by

575PUBLIC HEALTH SERVICES.

quacks for money is now rare, though it has not yetdisappeared. Septic complications have very muchdecreased, as abortion in the great majority of casesis performed under hygienic conditions. This is,however, the only favourable aspect of the newrégime. It is stated that repeated abortion causesvarious troubles, and Russian gynaecologists in thisconnexion report injuries to the uterus and neighbour-ing organs, concretions which have produced severecomplications at later pregnancies, and mentaldisturbance. Placenta praevia and atony of theuterus during labour have become more common.Dr. Niedermeyer warned Germany not to follow theRussian example.

In the discussion Dr. Rosenfeld stated that althoughartificial abortion is a criminal offence in Germany,nevertheless about 500,000 abortions are performedannually-some even put the figure at 800,000-andonly 1000 to 2000 offenders are prosecuted. Thenumber of cases in which pregnancy is prevented bycontraceptives and pessaries cannot be ascertainedby statistical means. Germany has, notwithstanding,an annual surplus of more than half a million. Sincelegislation against artificial abortion is thus ineffective,it is desirable that it be performed not by quacksbut by qualified medical men. Prof. Fraenkel,head of the gynaecological clinic at Breslau University,said that abortion, even if performed under themost favourable conditions, led to disease much morefrequently than did normal birth. Leaving aside allpolitical and social arguments, he warned the facultyagainst performing abortion on other than strictlymedical grounds.Under the present German criminal law interruption

of pregnancyis always a crime, no exception being madefor medical men, even if it is urgently necessary inorder to preserve the life or health of the mother.Prosecution of medical men has been rare, but hasoccasionally been proceeded with on anonymous andother information. It is therefore satisfactory thatthe High Court at Leipzig has lately given a judgmentwhich will protect medical men against these unpleasantincidents. The opinion of the medical profession,and of some legal authorities also, that a specialprofessional right exists to interrupt pregnancy onurgent necessity is not maintained by the High Court,and a verdict of " not guilty " has been given onother grounds, less comprehensible, but none the lesssatisfactory to the medical profession. The courtstates that the interruption of pregnancy by a medicalman may be technically criminal abortion ... but thatthere is no criminal offence unless there is also criminalintent. The life of the mother must be valued higherthan the life of the child in the womb, and if anabortion is the only chance of saving the mother’s lifeit is not to be considered criminal. It may be notedthat the new criminal bill now under considerationcontains a clause that artificial abortion is not criminalwhen performed by a qualified medical man who con-siders that according to the principles of medicalscience no other course can save the life or the healthof the mother. The same principle holds good forperforation of the skull during childbirth.

Congress of Sick-Clubs.The annual congress of sick-clubs under the

Workmen’s Insurance Act was held this year atKonigsberg, where 1400 delegates met, representing10 millions of insured persons; the governmentwas also represented. The president alluded tothe care taken by the clubs not only of the sick, butalso of convalescents and children ; he also mentionedthe agitation against the clubs in a sentence which,without mentioning the medical profession, was

obviously directed against its leaders. Dr. Stein,of Geneva, spoke on the international insurance ofworkmen, and Prof. Adam invited the clubs to assistthe work of the Association for Health Instruction ;a resolution in favour of Prof. Adam’s proposalsbeing unanimously adopted. Other addresses urged ’’

the clubs to assist in the campaign against venerealdisease, infant mortality, and occupational diseases. i

The meeting one more showed the strength andimportance of the clubs. Their position has, unfor-tunately, been won partly in the face of medicalopposition and to the prejudice of the profession.

X Rays in Hospitals and in Private Practice.In Germany there is a marked tendency among

the public to underestimate the work of private medicalmen, and to resort as much as possible to hospitalsand sick-club institutions. The public believes thatthese institutions have more modern methods of curethan the average medical man or the private specialist,and that treatment is more effective if given at placeswhere there is a large staff. So far as X rays areconcerned this opinion is refuted by a recent statisticalrecord, in which the injuries to patients in publicand private institutions are compared. Of the19 genuine recorded cases of damage due to X raysused for diagnostic purposes, 16 occurred in publicinstitutions and three in private practice. Two of thecases were due to negligence and 17 to insufficientknowledge. Of 59 genuine cases of injury in thetherapeutic application of X rays, 29 occurred inhospitals and public institutions, arid 30 in privatemedical institutions. It is stated that in 22 of thesecases the medical man was in no way to blame.but that in 15 cases negligence, and in 23 insufficientknowledge, must be supposed, the cases being dividedequally among hospitals and private institutions.About 45 cases of injury were recorded in hospitalsand sick-club institutions, where the work is oftendone by young doctors or even by nurses. The privatepractitioner, on the other hand, has to do the workhimself and on his own responsibility. The injuriescaused by Rontgen rays were severe ; ten cases werefatal, and amputations were necessary in others.

Public Health Services.REPORTS OF MEDICAL OFFICERS OF HEALTH.

THE following are some of the 1926 statistics ofsix towns, five county boroughs, and one borough :-

Bristol.Dr. D. S. Davies suggests that just as we have

protected the nursing staffs in our hospitals fromdiphtheria, " so every school and every institutionought to insist upon the protection of its scholarsagainst diphtheria."

Several houses at Bristol have become infested witha mite (Glycyphagus domesticus) found in Algerianfibre imported for upholstery. These mites breedrapidly, and carpets, walls, and floors are quicklycovered with a fine coating of the insects, like dust.The condition is difficult to eradicate because the mite