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930 TUBERCULIN TESTING OF CATTLE.—THE DEATH CERTIFICATE. Annotations. 11 Ne quid nimis." TUBERCULIN TESTING OF CATTLE. WITH the assistance of the Medical Research Council as a coordinating centre the tuberculin test is attaining great accuracy and precision in the diagnosis of bovine tuberculosis. Two reports have been issued by the Tuberculin Committee of the Council, which has now been at work for eight years. In the former of these, 1 dated 1925, the Committee found the subcutaneous test to be satisfactory enough under laboratory con- ditions, but subject on the farm to many fallacies and defects of interpretation. They were concerned therefore to introduce a modification of the intra- dermal test which would be suitable for ordinary field work. This has now been done and the double intradermal test, as it is called, is the subject of the report 2 before us, the technique being described in detail in an appendix. The report is based upon the experience of 77 veterinary surgeons who replied to a questionaire, drawn up by Prof. Buxton and Dr. MacNalty, which comprised 11 questions designed to elicit not only the surgeon’s experience of the test but also his views on the problems and difficulties arising in the conduct of the test. The replies admit of compact summary, for it appears that the new method is being increasingly used and approved by veterinary surgeons throughout the country for the testing of graded herds ; its trustworthiness has been amply confirmed by the results of post-mortem examination. Put in a few words, the double intra- dermal test is simple, clean, and easily performed under farm conditions, its technique is easily acquired, it saves the time of surgeon and stock-owner, it does not disturb farm routine, it has little or no effect upon milk yield, and it may be applied without risk to pregnant cows and to very young animals. One surgeon describes it as a real godsend to the single- handed country practitioner. It is true that a certain percentage of doubtful reactions have occurred, the proportion varying widely in individual practice, but the Committee explain these doubtful reactions as due on the one hand to concentration on local reaction to the exclusion of such clinical factors as pain, heat, and tenderness, and on the other to the well-known insensitiveness to tuberculin of animals with chronic advanced tuberculosis. The former difficulty is to be surmounted by acquiring a sense of proportion, the latter by finding gross signs of tuberculosis on physical examination. In the small percentage of cases which may still appear doubtful, the proposal is to retest by the double intradermal method using sterile broth as a control. It may prove possible to render the test more conclusive by increasing the strength of tuber- culin employed, this to be done without increasing the bulk of the present dose (0-1 c.cm.). One great advantage of the experience gained is the elimination of other tuberculin tests ; the ophthalmic test is now regarded as untrustworthy, and other subsidiary tests are left to the discretion of the veterinary surgeon. And, finally, the intradermal test is comparatively little influenced by the previous application of other methods of testing, which is as much as to say that the practice of " doping " or " faking " a suspected cow with tuberculin before submission to the veterinary surgeon will now be futile. Apart from its application to veterinary medicine the work of Prof. Buxton and Dr. MacNalty will most certainly react on the use of tuberculin in human practice where a higher standard of scientific precision is equally to be desired. 1 See THE LANCET, 1925, i., 831. 2 The Intradermal Tuberculin Test in Cattle. By J. Basil Buxton and A. Salusbury MacNalty. Medical Research Council, Special Report Series No. 122. H.M. Stationery Office. 1928. Pp. 64. 1s. 6d. THE DEATH CERTIFICATE. WHEN the law of death certification was altered two years ago, the changes failed to satisfy those reformers who wanted something more than half a loa,f. Their criticisms of the present system, with its serious risk of premature burial and the non-detection of crime, did but repeat what had already been said by a Select Committee of the Ilouse of Commons in 1893 and by a Departmental Committee in 1910. A vigorous pamphlet by Sir George Greenwood,1 whose death occurred suddenly last week, now sums up these criticisms afresh. He cites an answer given by the Minister of Health in the House of Commons in 1923 to the effect that in the previous five years 31,332 deaths had been uncertified in England and Wales; he mentions the recent estimate of a London coroner that some 5000 people are buried every week in England and Wales whose death certificates have been given without the body being seen by the certifying doctor ; and he recalls the saying of Dr. Richardson some 40 years ago that he did not know one medical man of extensive practice who, in the course of it, had not met with a case of secret murder. What the reformers wanted, of course, in 1926 was not the Government’s Births and Deaths Registration Bill (which was passed into law at the end of that year), but the Bill framed by the Special Committee of the Federation of Medical and Allied Services. The latter Bill proposed to enact that a medical certificate of the fact of every death or still- birth must be given by a registered medical practi- tioner who has viewed and examined the dead body and is satisfied that life is extinct. The most audible objection to this proposal was the difficulty of finding the money for the doctor’s fee. The relatives would not object, replied the reformers, if the fee for this post-mortem visit were made recoverable like the fees for- visits during the patient’s life-time ; the cases of poor people could be met by a simple exten- sion of the panel system or the poor-law rules. The reformers, however, were defeated ; some of the medical members of the House of Commons trans- ferred their support to the Government’s Bill, and Sir Kingsley Wood declared that a complete medical examination in every case, as the reformers desired, " would mean very considerable expense and would set up a universal and compulsory requirement for a very small chance indeed." A much less drastic change was made. The form of medical certificate of the cause of death now shows the date when the certifying doctor last saw the deceased alive, and further shows whether or not he saw the deceased after death. Regulations under the Act of 1926 require that the registrar shall report to the coroner inter alia any case where the deceased was not attended by a registered medical practitioner during his last illness and also any case where it appears that the deceased was seen by the certifying doctor neither after death nor within 14 days before death. Sir George Greenwood’s lively pen attacks the Minister of Health, the Registrar-General, and all bureaucrats in Government offices because the law does not go far enough and because its provisions are to be sought in a multiplicity of statutes and statutory rules and orders. Legislation in advance of public opinion is unlikely, and, unless some sensa- tional case occurs, the education of public opinion is a slow process. The Acts are certainly in a dismal tangle, but the new code of statutory regulations, long as it is, is a vast improvement on its predecessors. As a former member of the House of Commons Sir George Greenwood will know that Parliament no longer seems willing to find time to legislate directly upon such matters as that code contains. To that extent his allegation of bureaucracy comes too late in the day. Indeed, the public may see a less offen- sive bureaucracy in the present system than in the proposed intrusion into their homes of the doctor 1 The Law of Death Certification. By Sir George Greenwood. Humphrey Milford, Oxford University Press. 1928. 2s 6d.
