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antenatal department of the Royal MaternityHospital, Edinburgh. In nine of the cases theabortions were preceded by a full-time, ofteninstrumental, labour. Two of the 19 patients weresuffering from toxaemia, five from cervicitis, one frompyelitis, and two from valvular disease of the heart.All showed general debility made manifest by anaemia,emaciation, sallowness, listlessness, headaches,constipation, and loss of appetite and strength. Allhad enjoyed fairly good health until their firstpregnancy, after which this chronic ill-healthdeveloped. The majority lived in the poorer districtsof Edinburgh, where both fresh air and sunlightmight have been lacking. The average number ofpregnancies was five in the short space of five and ahalf years-and this might be of some significance.Dental caries or pyorrhoea was present in 11, andseptic tonsils in five. All were treated in much thesame way, with repeated doses of neokharsivan anda special diet which was rich in calcium. They alsohad special treatment for the cervix, teeth, &c.,where necessary. The results were, in the main,satisfactory. -

Abdominal Hysterotomy.Dr. THEODORE HAULTAIN reported 28 cases in

which abdominal hysterotomy was done by the staffof the Royal Maternity Hospital during the last threeand a half years. The commonest indication (12cases) was severe toxic hyperemesis. The othersincluded albuminuria with persistent high blood

pressure in the earlier months of pregnancy (5) ;toxic pyelitis leading to persistent hyperemesis (3) ;and myocarditis (3). The operation was also donetwice in association with myomectomy for degeneratingfibroids invading the decidual lining of the uterus,and once each for acute toxic chorea gravidarum,hydatidiform mole and acute phthisis. Only onepatient died, a mortality-rate of 3’6 per cent., andthis was thought remarkable since more than halfthe patients were almost in extremis before operation.This rate compared favourably with the 20 per cent.mortality of 25 cases of vaginal hysterotomy forsimilar indications in the three previous years. The

comparative safety of the abdominal route was dueto the rapidity and ease of the operation, and to theabsence of the severe shock and bleeding sometimesassociated with vaginal hysterotomy. In cases with

dehydration-a frequent cause of death in toxic cases-the peritoneal cavity could be filled with saline.Furthermore, for suitable patients, sterilisation couldbe done at the same time, and in cases of hydatidiformmole the growth could be removed completely and withcertainty. Induced abortion between the third andsixth month was painful and tedious, especially inprimiparae. So far it had not been found that theoperation had any bad effect on future conception.One of the patients had had two children since theoperation for hyperemesis in 1927.

Dr. C. D. KENNEDY gave an account of four successfulcases of abdominal hysterotomy, two of them forsevere pregnancy toxaemia, one for an acute exacer-bation of a chronic nephritis, and one for acutechorea gravidarum. The first three were operated onunder spinal the fourth under general anaesthesia.

OPHTHALMIC DISEASES IN COUNTY DowN.—A reportto the Down County Council states that there are

529 blind people in the county, 20 of whom are under16 years of age, and 6 between 16 and 20. The childrensuffering from external diseases of the eye number 863,3833 suffer from defective vision, and 620 from squint.Other ailments bring the number of children in CountyDown in need of remedial treatment up to more than20,000-55 per cent. of the total.

TUBERCULOSIS CONFERENCE.

LONDON, JULY 3RD-5TH.

THE sixteenth annual conference of the NationalAssociation for the Prevention of Tuberculosis was

opened by the Minister of Health, who referred to thesignificant fall in the death-rate from tuberculosis.The unification of public assistance with the healthservices, he said, would enable the local authoritiesto visualise the problem as a social rather than anindividual one. Without adequate after-care ofthe patient much of the expenditure incurred intreatment and prevention might be wasted.

Sir GEORGE NEWMAN spoke on the origin and socialpurpose of the

Local Government Act, 1929.He traced the development of the Act out of theReform Bill of 1832, and outlined its relation totuberculosis. Now, for the first time in history, apublic medical tuberculosis service was placed in thehands of one authority, concerned in public health,public assistance, and education. The disease, hesaid, was essentially connected with such socialproblems as poverty and housing, and social andsanitary improvements during the last sixty yearshad produced a remarkable decline in the disease asa whole. The Act made it possible to apply in verymany areas the principles of the scheme designed byDr. Lissant Cox for Lancashire.

Dr. J. PARLANE KINLOCH dealt with those aspectsof the Act especially applicable in Scotland. Therate of decline in mortality had been greater, but thetotal death-rate was still greater in that country thanin England and Wales. The new Act had given animpetus to the development of regional schemes ofhealth administration, and institutional authoritiesand doctors were being organised in a way whichwould bring the medical profession into a new relation-ship with the hospitals. The tuberculosis clinicwould be brought into organic union with otherhealth service clinics and research would be stimulated.

Dr. NORMAN PATRICK said that attempts were stillon foot in Northern Ireland to consolidate the LocalGovernment Acts, following England and Scotlandas closely as possible. The greatest difficulty was thecoordination of the tuberculosis and maternity andchild welfare services.

Councillor G. A. GRIFFITHS said that in practicechief medical officers had to do what their localauthorities told them, and thought that an inspectionof the workers’ pantries would reveal the origin oftuberculosis. In the West Riding of Yorkshire onlythree kinds of shops kept going to-day : the margarineshop, the American meat shop, and the pawnshop.

Councillor P. McKENNA urged a subsidy to provideadequate housing for discharged patients.

Dr. W. BOLTON ToMSON warmly supported this

suggestion, and paid tribute to the work done atSheffield in allocating houses to the hospital com-mittee for the use of tuberculous patients.

Councillor G. BRETT said that in Leeds 6 per cent.of all new houses were earmarked for tuberculousfamilies and another 6 per cent. for the preventionof overcrowding, but without a subsidy this onlytouched the fringe of the problem ; the trouble wasto find houses at a rent which these families couldafford.

Dr. E. E. PREST spoke of the importance of minortuberculosis, and advocated the treatment of peoplewho were "feeling ill " rather than of people with

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shadows in their chests. Early treatment was theonly means of ensuring perfect cure ; people willingto go to a sanatorium might be exempted fromnotification.

EFFECT OF THE ACT ON INSTITUTIONAL TREATMENT.

Dr. J. A. WILSON described the Act as a measurewf promise rather than of fulfilment. It should

remedy the inadequacy of beds which had compelledlocal authorities to board out patients. To use thenew accommodation to the best advantage a newsurvey of the disease was desirable. There had beenimportant changes in its natural history duringrecent years : alteration in the age-distribution andthe type. The case-mortality at ages over 25 hadbeen markedly reduced in pulmonary tuberculosis,especially in females, and the non-pulmonary formshad shown a very marked reduction in the case-

mortality under one year, with a much slower reductionin the 1-5 years age-period. These forms, other thanmeningitis, seemed to be decreasing in virulence.The highest incidence of the disease occurred in thesmaller types of - house, and institutional accom-

modation must therefore be estimated on theassumption that there could be little home treatment.A five-year inquiry in Glasgow dealing with 2500patients had shown that one bed was required forevery five registered cases, in the ratio of 4 maleto 3 female beds. The disease had proved to beto a large extent a hospital one, so that the proportionof hospital to sanatorium beds should be 7 to 1,although in both types of institution the turnoverwas about two patients per bed per annum. Fornon-pulmonary cases the ratio of hospital beds toregistered patients had been 1 : 3-3, equallydistributed between the two sexes, but with only onepatient per bed per annum. The use of X rays in

diagnosis had largely removed the necessity forobservation wards, but some provision had still to bemade for a group of chronic respiratory conditions inchildren, usually associated with enlargement of theroot glands and seen after epidemics of measles.

Dr. K. J. ACTON-DAVIS said that the problem ofnon-pulmonary tuberculosis was an entirely differentone in children and in adults ; in the adult there wasnearly always a pulmonary lesion as well, and theprognosis, therefore, was far more serious. It wasnow generally agreed that the best method of treat-ment was in special State or State-aided institutions,with after-care in clinics at these hospitals, with thehelp of the schools. In London the treatment of

surgical tuberculosis in children was as nearly perfectas it could be, but in smaller boroughs patientssometimes had to wait for vacancies in charitableinstitutions. It was among the adult cases that

improvement might be expected from the new

arrangements. The voluntary hospital was not theplace for the treatment of tuberculosis ; conservative treatment could not get a fair trial.

Dr. R. S. WALKER said that Paddington hadincorporated the poor-law hospital into the tuber-culosis scheme some years ago, and the guardians hadinvited the tuberculosis officer to join their visitingstaff. Endeavours were made to induce patients toenter hospital from overcrowded homes for longperiods of rest. They were willing to go into a

hospital that was near home.

THE GRANT IN AID.

Dr. F. E. FREMANTLE, M.P., who opened a discussionon the effect of the change rom percentage to blockgrant, said that the great drawback of the percentagegrant had been that the more an authority spent the

more it benefited, and he quoted figures showing theinequitable distribution that had prevailed. Theblock grant gave local authorities a security whichenabled them to establish schemes over a period ofyears, and was based on the definite principle ofneed, including the five factors of population, rateablevalue, unemployment, mileage, and-most importantfrom the tuberculosis point of view-the proportionof children to the population. Under the new systeminstitutions could be pooled and counties wouldgradually be able to build up magnificent schemes ofinstitutional provision, nursing and health-visiting,and laboratory and consultant services.

Dr. F. J. HENDERSON CouTTS reviewed thediscussions which had waged round the problem of theblock grant, and said that medical inspection mustcontinue much as before if efficient administrationand suitable development were to be secured, buttime would be saved in discussing trivial details ofexpenditure. The percentage grant had undoubtedlyacted in the past as a stimulus to development, andthere was a certain danger in the inelasticity of anall-round grant.

Mr. H. L. FRASER described the development oftuberculosis schemes in Scotland, and thought thatthe new system would certainly assist the poorercounties. It was important that non-pulmonarytuberculosis should be treated in a few large centresrather than in many small centres.

Major WALTER ELLIOT said that the Act had beendesigned to make the local and central authoritiespartners in health work, and the local authority mainlyresponsible for expenditure. At the quinquennialrevision the expenditure of the local authority as awhole would attract to it a greater revenue; thereforeservices could be floated up by quinquennial increasesfrom the Treasury. This concession by the Treasurywas of the utmost importance. Any system could bemade to work by goodwill and public opinion, andin his opinion this Act gave the greatest possible scopeto goodwill and enlightened public opinion. We hadlearnt in the twentieth century the necessity of dealingwith a citizen as a citizen and not as a passenger, aparent, a prisoner, or any other one aspect of his civiclife. Only along that avenue was it possible to bringhome the other great lesson-that failure in publichealth was failure in economy. To keep a sick man,still more to keep a focus of infection, was much moreexpensive than keeping a Rolls-Royce. Progressivepoor law authorities had grasped this fact beforethe Act, and had developed large and expensivehealth services. This showed the relative unimpor-tance of the system of grants. Unified authoritieswould be able to drive home the economic loss inevery department of life.Alderman DAVID ADAMS thought that the block

grant had material defects, as it need not necessarilybe expended on public health services. In distressedareas there would be a great temptation to put it tothe relief of the rates. Expenses were bound to fallon the local authority, and the quinquennial recon-sideration was cold comfort.

Position of the General Practitioner.

Opening a discussion on the relationship of the

general practitioner to the treatment of tuberculosis,Dr. G. LISSANT Cox said that if the tuberculosisofficer were the Cinderella of the public healthservices, it was doubtful whether the general prac-titioner was the good fairy or the ugly sister. Hedid not do nearly as much as he might do in thetreatment and prevention of tuberculosis, and hisfailure was to be ascribed to the conditions under

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which he worked, and his training as a student.Cooperation between him and the tuberculosis officermust be effective. He must have time to examinehis patients carefully, and he ought to have a specialtraining in tuberculosis, like that provided by theScottish medical schools. Patients suffering fromtuberculosis were rarely seen in general hospitalsto-day, and the education of the practitioner thereforecalled for a close connexion between the tuberculosisdispensaries and the teaching hospital. Moreover,eexaminers almost always produced cases with oldchronic fibroid phthisis, instead’of early cases. Thetuberculosis officer must be an expert, but no matterhow good he was the results of his labour would bemeagre if the general practitioner could not play hispart in the tuberculosis campaign.

Dr. J. COHEN pointed out that late notification was.as often the fault of the patient as of the practitioner,and should be attacked along the lines of educationalwork by the dispensaries. In large towns hometreatment was very seldom possible or advisable, andthe sanatorium provided education as well as treat-ment. Many tragedies followed the return to anovercrowded home, and it was difficult to see how toprevent them with the present housing conditions.A lack of interest in the dispensary among doctorsmight be due to lack of effort on the part of thedispensary to cooperate with the practitioner. The

patient was treated at the dispensary and visited bythe nurse, and did not keep in touch with his owndoctor. It would be better for him to be seen moreoften by his general practitioner, who would send

. periodical reports to the tuberculosis officer. Dispen-i saries often prescribed medicine when the case shouldp more properly be referred to the practitioner. Local

practitioners might be invited to take an active partin the work of the dispensaries, the tuberculosisofficer acting as consultant and supervisor. Publiceducation should be one of the main functions of thedispensary. Practitioners would greatly appreciatea clinical report with patients returning to them from Iisanatoriums.

Dr. WiLHAM BRAND remarked that the insuredpatient was entitled to treatment for tuberculosisas much as for other diseases, and deplored the factthat patients who ought to be in bed insisted ondragging themselves out to the doctor’s consulting-Toom or the dispensary. With the ascendancy of

hygienic habits the cult of the medicine bottle and.gallipot would disappear, and domiciliary treatmentwould become a much simpler problem. At presentthe two difficulties that constantly confrontedpractitioners and tuberculosis officers were in the

prevention of reactivation when quiescence had been ’’

achieved in a sanatorium, and, secondly, in a speedydiagnosis of reactivation. Team-work was the firstnecessity in an attempt to make domiciliary treat-ment of much greater advantage than it was at

present. The general practitioner could not standalone, for any of his cases might require the otherforms of treatment provided by the local authority-e.g., extra diet, hospital treatment, light treatment,or financial help in obtaining proper food or a separatebed. Moreover, the specially trained tuberculosisofficer, equipped with modern refinements of diagnosis,could give great help in the difficult problem of earlydiagnosis.

Dr. V. J. GLOVER said that in Liverpool as muchtreatment as possible was given by the generalpractitioner, and uninsured patients were treated atmunicipal expense, the doctor being paid three

shillings for each attendance. The cost of treatmentwas ;f6000 a year, and of medicines ;f2000 a year

per 1000 patients under treatment. The scheme hadworked successfully since 1913, and there was nofear that the practitioner would lose a case throughnotifying it.

Dr. VERE PEARS ON spoke of the need for simplifyingand improving the teaching of students, and said thattuberculosis dispensaries should be staffed by generalpractitioners. The great drawback to domiciliary’treatment was the economic condition of the home.In Bergen, Norway, general practitioners were givena six weeks’ holiday at the public expense to study insanatoriums.Alderman TAYLOR strongly opposed treatment by

the general practitioner, who, he said, did not knowenough about it, while the panel doctor was also fartoo busy.

Tuberculosis and Education.Dr. W. L. BuRGEss stressed the importance of

cooperation and the need for each local representativeof the service to have a new and wider outlook. Theinfection was usually contracted in childhood, butthe child had a strong tendency to recover, andenvironment was an important factor in determiningthe course of the infection ; the education authority,therefore, had a most important part to play. Everyschool medical officer must have at his service askilled diagnostician able to recognise the child whorequired special attention from the tuberculosisdepartment. Intimate contact between the twoofficials was essential; they should confer daily, andthe tuberculosis officer must have free access to theschool clinic and the school. Both officers must

cooperate also with the nurse who visited the home ;the tuberculosis nurse knew a great deal about thehomes of the notified cases, but little about otherhomes or school life ; the school nurse knew all aboutthe school but little about the home. There shouldbe more systematic examination of contacts. Con-

tinuity of treatment through all ages and in everyenvironment was essential. The nursery school

provided an intermediate phase between home andschool where the two medical officers could look forfertile soil at a stage when prevention was a certainty.There was now no doubt of the value of open-airschools, but should not every school be an open-airschool? ‘ It would be wise to- assume that every childwas a potentially tuberculous child, for moderncivilisation made every child a contact. Benefitwould be derived from handing over to the schoolmedical officer the responsibility for the care of thepre-school child, and the nursery school must becomea recognised unit in the educational system.Education authorities could play an important partin the campaign by supplementing and correctingdiet.

Dr. GEORGE MACDONALD said that the open-airschool was not merely school in the open air, but a wayof life and a system of education and medical treat-ment. Its dining table should be a factor ofeducational value, and rest periods before and afterthe midday meal were very important. In Londonthe tuberculosis officer was part-time school medicalofficer to the school for tuberculous children, and oneof the dispensary nurses was part-time school nurse.The work of the school should include vocationaltraining and after-care.

Mrs. LEAH MANNING described the open-air schoolat Cambridge and its routine. The morning was givento work and the afternoon to rest and recreativelessons.

THE NURSERY SCHOOL.

Miss MARGARET MAcMiLLAN described the open-airnursery school which children entered at the age of

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two. By a growth and extension of this system shewas sure that the hospitals could in time be emptied.

Dr. BRIDIE O’CoNNOR said that a striking featureof the MacMillan open-air nursery school, where shewas medical officer, was the freedom from catarrhalconditions. Healthy gastro-intestinal and respiratorymucous membranes were a very great safeguardagainst invasion by the tubercle bacillus. It has beenshown that these children, most of whom came fromone-roomed homes, acquired increased resistance todisease, and very marked recuperative powers. The

pale, flabby, debilitated, rachitic, dull, and apatheticchild became sturdy, happy, contented, bright, andresponsive. There was a striking absence of com-

plications after measles.

ASSOCIATION OF AMERICAN

PHYSICIANS.

ANNUAL MEETING AT ATLANTIC CITY.

THE Association held its forty-fifth annual meeting Iat Atlantic City on May 6th and 7th under the Ipresidency of Dr. THOMAS MCCRAE, of Philadelphia.

Symposium on Coronary Disease.Dr. 0. KLOTZ and Dr. W. D. M. LLOYD (Toronto)

reported 44 cases of partial or complete coronaryocclusion verified at autopsy. In 26 there was

sclerosis with narrowing but not occlusion, and therewere 18 cases of thrombosis, all accompanied bysclerosis. The commonest location of the sclerosiswas in the descending portion of the left branch;next in the left coronary ; and last in the rightcoronary. Sclerosis obstructing the orifice was morecommon in the right than in the left coronary. Thethrombotic process appeared to be secondary and tookplace by dilatation with development of a thrombus.Under normal conditions anastomosis was free betweenthe right and left coronaries. When the left coronarywas involved and there was already a degenerativeprocess on the right much more severe damage to themyocardium resulted. When only the left coronarywas damaged the myocardium remained competent,anastomosis being enough to maintain circulation.

SYPHILIS.

Dr. A. S. WARTHIN (Ann Arbor) said that in1675 autopsies in his laboratory in Michigan during25 years there were 408 males and 86 females showingactive syphilitic lesions in the aorta or central nervoussystem. Between 1910 and 1919 the average was43 per cent. In the years 1919-29 332 cases of syphiliscame to autopsy and of these 172 had coronarysclerosis. There were 55 cases of coronary syphilisand 5 cases of coronary thrombosis. In both decadesit was found that the incidence of coronary sclerosiswas a little higher in autopsies on syphilitics as

compared with non-syphilitics. The figures showedthat death occurred ten years earlier, and suddendeath was commoner, among the syphilitics.

PROGNOSIS IN CORONARY THROMBOSIS.

Dr. LEWIS A. CONNER (New York) reported on287 cases of coronary thrombosis, 243 men and 44women, of whom 117 were private patients.Antecedent disease in 274 cases was as follows :arterial hypertension, 93 ; syphilis, 39 ; diabetes, 28(total 58-3 per cent.). The age of the patients atfirst attack was as follows : Before 35, 3 per cent. ;41-45 years, 11 per cent. ; and 50-60 °years, 22 per

cent. From 61-65 there was a very sharp dropthat is, 75 per cent of all cases occurred before the ageof 61. As regards sex, it was found that the womenlagged behind the men in the early cases, but a largeproportion of first attacks in women occurred between55 and 60 years. Of the 287 cases, 117 (45 per cent.)were still alive, and 28 had been lost sight of. Forty-six had died in the first attack ; 89 were well after thefirst attack, and 28 of these were well up to thesecond attack, when they died. The total durationof life varied from 3 months to 17 years after thefirst attack, and was grouped as follows :—

Cases. Cases. Cases.3 months 109 1 vears 40 . 9 years 4

6 .. .. 101 5 " " .. .. 25 10 " .. 4lyear 88 6 .. 17 11 .. 32 years 65 7 .. 15 12 .. 23 , .. 49 8 .. 7 17 .. 1

The relation of prognosis to severity of symptoms wasas follows : 68 per cent. died with very severe attacks ;10 per cent. died with mild attacks ; 31 per cent.recovered from very severe attacks 43 per cent.recovered from moderate attacks ; 26 per cent.recovered from mild attacks. Thus it seemed thatvery severe attacks are very often recovered from.In regard to previous symptoms, 38 per cent. had hadsymptoms and 62 per cent. had had no symptomsbefore the first attack. The interval between thefirst and second attacks in half the cases was lessthan one year, and in the others it was from 3 monthsto 18 years. In some cases there were more thantwo attacks. One patient had 7 attacks before hedied. Embolism occurred in 42 cases. An electro-cardiogram was made in 151 cases ; 21 patients hadnormal tracings, of whom 14 are living and 7 havedied. There was T wave change - in 37. Withauricular fibrillation or bundle branch block the

prognosis was very bad.These studies, said Dr. Conner, suggested that

coronary thrombosis - was a disease of early middlelife. If the underlying condition was arterio-sclerosis,perhaps some of the changes were occurring in otherorgans. Diabetes might be caused by thrombosisof the pancreatic artery, and renal embolism might bedue to thrombosis.

CHANGES IN ELECTROCARDIOGRAM.

Dr. R. W. SCOTT (Cleveland) reported (withH. S. FEIL, L. N. KATZ, and R. A. MOORE) experi-ments on the electrocardiogram in dogs. Underbarbital anaesthesia the ramus descendens of the leftcoronary artery was tied at various levels; theinferior vena cava was also ligated for five minutes.Ligature of the vena eava gave negative results,because the collateral circulation was extremelyabundant. If the coronaries were tied the chartshowed the influence of extrasystoles and tachycardia.Ligature of the descending branch of the left coronaryfor 30 minutes caused no marked R-T deviation, butfurther impairment of the vena cava produced R-Tdeviation as seen in coronary thrombosis. Develop-ment of an abnormal mechanism, such as tachy-cardia or extrasystoles, produced deformities of theR-T tracing typical of coronary occlusion.

Dr. E. P. CARTER (Baltimore) said that in the pastfew years there had been an attempt to use the

electrocardiogram in coronary disease to localise thesite of the insult as well as the extent of the myo-cardial damage. Not enough emphasis had been laidon the duration of the trauma or on a properly corre-lated clinical diagnosis. Smith’s early experimentalwork had laid great stress upon the ligation of thecoronary vessels, but it was now known that heat and.cold could easily upset any phase of the ventricular, is