39

man by direct inhalation. Quite apart from considerationsof " public health," the eradication of bovine tuberculosiswill increase the efficiency of milk-production and thusimprove human nutrition. There is, therefore, everyreason for the medical and veterinary professions tocollaborate in aiding the farming community and publicto eliminate tubercle bacilli from the environment ofanimals and man in Great Britain.

SUMMARY

Only 18-20% of all cattle in Great Britain react totuberculin, but all these have to be regarded as infectious.The figure of

"

40%," which is so widely quoted, appliesonly to old cows.

Once established in the human lung, the bovinetubercle bacillus is just as virulent as the human, thoughthere is reason to think that it has greater difficulty inestablishing itself in the lung, and therefore less powerof spread from man to man. Scandinavian work hasshown that the most serious form of bovine-type pul-monary tuberculosis in man is caused by inhaling infec-tion from cattle, and in country districts about half ofall cases of human phthisis may be caused by bovine-typeinfection.The maps in fig. 2 show that in country districts in

Great Britain there is an inverse relation between theincidence of bovine tuberculosis and the total mortalityfrom human tuberculosis. Data from Denmark showthat, though the proportion of tuberculin-positive personsis greater in areas where there are tubercle bacilli in themilk, tuberculous disease is not so common in such areasas it is in areas where the milk is free from bacilli.As milk is freed from tubercle bacilli bv the eradication

of tuberculosis from cattle and by pasteurisation, morewill have to be done to protect adolescents from infection,and increase their resistance by immunisation with B.C.G.

Of about 9 million cattle in Great Britain, some11/2 million are now in attested herds which are main-tained free from tuberculosis. Area eradication of thedisease is to begin next autumn.A system of meat inspection organised by the Animal

Health Division could materially assist the scheme byproducing data on the incidence of tuberculosis.The attested herds scheme is now based on the " com-

parative " tuberculin test in which carefully standardised

mammalian and avian P.P.D. tuberculins are used. In

testing human beings, however, wide use is still made ofKoch’s Old Tuberculin. As this cannot be accuratelystandardised, its replacement by purified proteinderivative might be considered.As bovine tuberculosis is eradicated the risk of cattle

being infected from man will increase. People who lookafter cattle may need to be examined in order to preventinfection of the animals-as well as for other reasons.

Eradication of bovine tuberculosis will increase theefficiency of meat and milk production. Indeed, thismay prove to be its most valuable contribution to publichealth and well-being.

REFERENCES

Anderson, G. L. (1948) Vet. Rec. 60, 523.Anon. (1949) Fmrs’ Wkly, March 11.Arthur, G. H. (1948) Vet. Rec. 60, 530.Balmer, S. (1947) State Control of Bovine Tuberculosis in Switzer-

land. Inaugural dissertation, Berne. Abstracted in Vet. Bull.1947, 18, 189.

Blacklock, J. W. S. (1932) Spec. Rep. Ser. med. Res. Coun., Lond.no. 172.

British Medical Journal (1949) Editorial, i, 146.Bruford, J. W. (1948) Vet. Rec. 60, 378.Burke, H. E. (1940) Surg. Gynec. Obstet. 71, 615.Cobbett, L. (1917) The Causes of Tuberculosis. Cambridge.Cutbill, L. J., Lynn, A. (1944) Brit. med. J. i, 283.Dalling, T. (1948) Vet. Rec. 60, 527.Drolet, G. J. (1946) in Goldberg’s Clinical Tuberculosis. Philadelphia;

vol. I.Francis, J. (1947) Bovine Tuberculosis. London.- (1948a) Vet. Rec. 60, 302.- (1948b) Ibid, p. 361.— (1949) Lancet, ii, 549.- (1950) to be published.

MR. FRANCIS : references—continuedGreen, H. H. (1946) Vet. J. 102, 267.Griffith, A. S. (1937) Tubercle, 18, 529.- Munro, W. T. (1943) J. Hug., Camb. 43, 229.

Hedvall, E. (1942) Acta med. scand. suppl. 135.Holm, J., Holm, M. (1945) Acta tuberc. scand. 19, 71.Krause, A. K. (1919-20) Amer. Rev. Tuberc. 3, 513.- (1928) Ibid, 18, 271.

Lichtenstein, A. (1924) Acta pœdiatr., Stockh. 3, 397.Lethem, W. A. (1946) Mon. Bull. Min. Hlth and publ. Hlth Lab.

Serv. 5, 80.Lurie, M. B. (1947) Amer. Rev. Tuberc. 55, 124.Madsen, T., Holm, J., Jensen, K. A. (1942) Acta tuberc. scand.

suppl. no. 6.Magnusson, H. (1942) Ibid, suppl. no. 135.Newsholme, A. (1927) Evolution of Preventive Medicine. London.Nielsen, F. W. (1947) Vet. J. 103, 252.Ostermann, A. (1908) Z. Hyg. Infekt Kr. 60, 410.Pinner, M. (1940) Amer. Rev. Tuberc. 42, 382.Ritchie, J. N. (1946) Proc. R. Soc. Med. 39, 213.- Stamp, J. (1948) Tubercle, 29, 34, 61.

Sigurdsson, J. (1945) Acta tuberc. scand. suppl. no. 15.Smith, T. (1898) J. exp. Med. 3, 451.Stamp, J. T. (1948) J. comp. Path. 58, 9.Wade, L. J. (1942) Amer. Rev. Tuberc. 46, 93.Webber, A. (1910) Tuberk Arb. 10, 1.Wilson, G. S. (1948) Brit. med. J. i, 627, 677.

GENERAL MEDICAL AND PHARMACEUTICAL

SERVICESAMENDING REGULATIONS

AMENDING regulations have been issued by theMinister of Health under the terms of the NationalHealth Service Act and of the amending Act, whichreceived the Royal Assent on Dec. 16. These regulationsdeal with the method of filling practice vacancies, theemployment of assistants, certificates to be providedwithout charge by practitioners, bulk prescribing forresidents of schools and institutions, and restriction of

advertising by contractors included in the pharmaceuticallists of executive councils. The effect of the new

regulations has been set out in a circular to executivecouncils.

Practice vacancies.-The new regulations provide fora modified procedure, from Feb. 1, for filling " declaredvacancies " (normally following the death or retirementof a doctor). It will be for the Medical Practices Com-mittee (or the Minister on appeal) to select the doctorto fill such a vacancy, even if the doctor is already onthe executive council’s medical list ; and all doctorswhose applications are refused, including those alreadyon the medical list, will be entitled to appeal.The regulations also embody the understanding that

where a selection has been made by the Medical PracticesCommittee (or on appeal the Minister) from a numberof applicants to fill a vacancy created by the deathor retirement of a doctor, the patients of the retiringor deceased doctor shall be transferred to the doctorselected by the Medical Practices Committee (or onappeal the Minister) unless the committee (or Minister)otherwise provide.Employment of assistants.-At present a doctor who

is refused ’consent by the executive council to theemployment of an assistant has no right of appeal ;but under the new regulations an appeal will lie to theMedical Practices Committee.The regulations also provide for the allocation scheme

to be amended so as to give a doctor who employs anassistant the right to have his list increased by a maximumof another 2400 patients if the Minister so decides. (Inone case the executive council has declined to allow adoctor employing an assistant to increase his list bythis maximum, even though the Medical PracticesCommittee had decided that there was room for thatassistant in the area and had granted his applicationfor inclusion in the medical list.) Assistants are no

longer to have their names included in the medicallist, or (in consequence) to have lists of patients oftheir own. This will be achieved by prohibiting doctorsunder the terms of service from employing assistantswhose names are included in the medical list. Theonly exceptions are : (a) part-time assistants who arealso practising separately on their own account, and who

1. The National Health Service (General Medical and Pharma-ceutical Services) Amendment (no. 2) Regulations, 1949.Statutory Instruments, 1949, no. 2341.

40

in the latter capacity can build up lists of their own ;and (b) assistants whose names are included in themedical rist of an area on Feb. 1, when this part of theregulations takes effect.

Prescribed certificates to be issued without charge.-Bythe Amendment Act, a doctor may be required to issuefree of charge to his National Health Service patientsor their personal representatives only those certificates-being certificates reasonably required by the patientsunder, or for the purposes of, any enactment-whichare prescribed by regulations. A schedule to the regula-tions gives a provisional list of such certificates, towhich the General Medical Services Committee hasagreed, and to which a few additions may be made.The regulations also make it clear that a practitioneris not required to issue certificates to his patients ifthey are receiving treatment from unqualified persons.The provisional list comprises the following certificates :1. To support a claim or obtain a payment either personally

or by proxy, under the Family Allowances Act, 1945,the National Insurance (Industrial Injuries) Act, 1946,and the National Insurance Act, 1946.

2. To prove inability to work or incapacity for self-

support for the purposes of an award by the Ministerof Pensions, or to enable proxy to draw pensions, &c.,under the Pensions (Navy, Army, Air Force, andMercantile Marine) Act, 1939, the Pensions (MercantileMarine) Act, 1942, the Naval and Marine Pay andPensions Act, 1865, the Air Force (Constitution) Act,1917, the Personal Injuries (Emergency Provisions)Act, 1939, and the Polish Resettlement Act, 1947.

3. To procure extra- coal in cases of illness, extra milk,extra petrol, or extra rations, under the EmergencyPowers (Defence) Acts, 1939-45 and other statutes.

4. To obtain permission to import foreign drugs andappliances, or to export special foods with a sicktraveller or with infants, aged 2 years or less, underthe Import, Export, and Customs Powers (Defence)Act, 1939.

5. To enable a patient to have his sight tested-under thesupplementary ophthalmic services, in accordance withthe National Health Service Act, 1946.

6. To establish fitness to receive nitrous-oxide and air

analgesia in childbirth (Midwives Act, 1902). "

7. To secure registration of stillbirth (Births and DeathsRegistration Act, 1926).

8. To enable payment to be made to another person incase of mental disability of a person entitled to paymentfrom public funds, or to justify release of a patientfrom detention after absence on trial (Lunacy Act,1890). "

9. To establish unfitness for jury service (Juries Act,1922).

10. To establish unfitness to attend for medical examination(National Service Act, 1948).

11. To support late application for reinstatement in civilemployment where application has been delayed bysickness (Reinstatement in Civil Employment Act,1944).

12. To enable a disabled person to be registered as anabsent voter (Representation of the People Act,1949).

Bulk prescribing.-Under the new regulations therequirement that a prescription on form E.c.10 may beissued only for an individual patient is relaxed in respectof a practitioner who is responsible for the treatmentof not less than ten persons in a school or institutionwhere at least twenty persons are normally resident.Under these circumstances he may now issue a bulkprescription for two or more of these residents for whomhe is not receiving a dispensing capitation-fee, providedthat (a) the prescription is limited to drugs (other thandrugs to which the Dangerous Drugs Acts apply anddrugs which are, or contain, fourth-schedule poisons)included in the National Formulary or an official supple-ment ; and (b) it is endorsed by the doctor with thename and address of the school or institution and thenumber of residents for whose treatment the doctor isresponsible.

NEW YEAR HONOURS

THE list of honours published this week contains thenames of the following members of the medical profession:

Baron

LESLIE HADEN GUEST, M.C.. .B.C.S. ,

:M.p. for Southwark Nor,. 1923 and 1924, and for IslingtonNorth since 1927. For political and public services.

K.C.V.O.

HAROLD KINGSTON GRAHAM-HODGSO-N, C.V.O., M.B. Durh.,F.R.C.P.

Director, X-ray department, Middlesex Hospital, London.

K.B.E. (Civil)THOMAS ERNEST VICTOR HURLEY, C.B., C.M.G., M.D., M.S. Melb.,

F.R.C.S., F.R.A.C.S.

Consulting surgeon, Royal Melbourne Hospital. For

public services.Knights Bachelor

HAROLD ESMOND ARNISON BOLDERO, D.M. Oxfd, F.R.C.P.Dean, Middlesex Hospital medical school: registrar,Royal College of Physicians of London.

JOHN ALEXANDER CHARLES, M.D. Durh., F.R.C.P.A deputy chief medical officer, Ministry of Health.

FRANK ARNOLD GUNASEKERA, C.B.E., M.R.C.S,Senator, Ceylon.

WILLIAM WILLIS DALZIEL THOMSON, M.D. Belf., F.R.C.P., D.L.Professor of medicine, Queen’s University, Belfast.

THOMAS GEORGE WILSON, C.M.G., M.D. Sydney, F.R.C.O.G.Director of obstetrics and gynaecology, Universityof Adelaide. For public and philanthropic services.

C.B. (Military)Surgeon Rear-Admiral JosEpn ARCHIBALD MAXWELL, C.V.0.,

c.B.E., M.B. Dubl., F.R.C.S.E., K.H.S., retd.Major-General FRANCIS ROBERT HENRY MOLLAN, o.B.E., M.c.,

L.R.C.P.I., late R.A.M.0-Air Vice-Marshal TERENCE ;CHARLES Sr. CLESSIE MORTON,

O.B.E., M.D. Edin., F.R.Q.P., K.H.P.

C.M.G.

ERIC HOWARD MA29LEY LuE:E, M.B.Surgeon, Wellington public hospital for over 25 years ;chairman of the council, British Medical Association(New Zealand branch).

C.B.E. (Military)Surgeon Captain THOMAS NORMAN D’ARCY, L.B.c.r.i., R.N.Group-Captain ANDREW HARVEY; M.B. Belf., R.A.F.

C.B.E. (Civil)Miss JANET KERR AITKEN, M.D. Lond., F.R.C.P.Consulting physician, Elizabeth Garrett Anderson

Hospital, London ; member of the council, RoyalCollege of Physicians of London.

ROBERT VIVIAN BRADLAW, M.D.S. Durh., F.R.C.S., F.D.S. B.C.S.yDean, faculty of dental surgery, Royal College of Surgeonsof England ; professor of oral pathology, University ofDurham.

CLIFFORD VINEY BRAIMBRIDGE, M.V.O., M.A., M.B. Camb.F.R.C.S.E.

Senior surgical specialist, Kenya.Miss IDA CAROLINE MANN, M.A. Oxfd, M.B., D.SC. Lond.,

F.R.C.S. (Mrs. Gye).Senior surgeon, Royal London Ophthalmic (Moorfields)Hospital.

ERNEST ALEXANDER NICOLL, M.A., M.D. Camb., ]f.R.C.S.E.Surgeon-in-charge, Berry Hill Hall Miners’ rehabilitationcentre and consulting surgeon to the Miners’ Welfare.Commission.

FREDERICK TAVINOR REES, M.C., B.SC. Wales, M.R.C.S.Director-general of medical services, Ministry of Pensions--

O.B.E. (Military)Surgeon Captain ALFRED EDWARD FLANNERY, L.R.C.P.I., B.N

O.B.E. (Civil)OKINADE AJIBADE, L.R.C.P.E.

For public services in Nigeria.

41

EDGAR SCOTT BOWES, M.R.C.S.Chairman, Poole centre, St. John Ambulance Association.

THOMAS GREGORY BURNETT, M.B. Manc.Chairman, Bulawayo Hospital advisory committee,Southern Rhodesia.

ERNEST THOMAS CONYBEARE, M.D., B.SC. Lond., F.R..C.P.Medical officer, Ministry of Health.

PATAGOD.1GE BERTRAM FEP.NAN----43, M.B. Lond., M.R.C.P.Professor of medicine, UniB ,rsity of Ceylon.

ROBERT SEARSON RODNEY FRANCIS, M.B.Of Hastings, New Zealand ; for services to the com-

munity in connexion with the treatment of tuberculosis.Miss MINNIE GosDEN, M.B. Lond.,

Senior pathologist, Sierra Leone. -

GEORGE VERT THOMSON McMICHAEL, M.B. Edin.Medical officer of health, Paisley.

DAVID GWILYM MORGAN, B.A. Oxfd, M.R.C.S.Administrative medical officer, United Cardiff (Teaching)Hospitals.

_

ARTHUR HAROLD MORLEY, M.B. Leeds, F.R.C.S.E.Surgical specialist, Tanganyika.

CHARLES ELIAS REINDORF, M.D. Durh.For public services in the Gold Coast.

ALFRED EATON SPAAR, F.R.C.S.E.Medical practitioner, Kandy.

JOHN HARGREAVES HARLEY WILLIAMS, M.D. Edin.Secretary-general, National Association for the Preventionof Tuberculosis.

M.B.E. (Military)Major MOHANDIRANGE DON SIMON JAYAWARDENA, L.R.C.P.E.

Ceylon Medical Corps (Reserve).

Public Health

Notification of Diseases of the Central NervousSystem ’,

NEW regulations 1 which caBM " into operation on

Jan. 1 introduce nomenclature consistent with theinternational standard classification of diseases, whichwas brought into use on the same date. They alsoslightly extend the scope of clinical conditions notifiableunder the heads of acute encephalitis and meningococcalinfection. -,’:’, ; -’

Acute Poliomyelitis.-Tlw distinction formerly madebetween acute poliomyelitis and acute polioencephalitiswas always a difficult one, and has never been adoptedin other countries. On the other hand, in Sweden andsome parts of the U.S.A. it has long been the practiceto report cases of acute poliomyelitis (including polio-encephalitis) under the sub-headings (e. " paralytic,"which includes cases with either transient or permanentparalysis, and (b) " non-paralytic," which includes caseswhere there is no paralysis but where the diagnosis wasmade on clinical signs with or without examination ofthe cerebrospinal fluid-it is recognised that in such casesthe diagnosis is often uncertain. If cases which arenon-paralytic when first notified and admitted to hos-pital become paralysed in hospital, the ordinary pro-cedure for correction of diagnosis by the hospital shouldbe applied.Acute Enceplaalitis.-This heading replaces the former

heading d encephalitis lethargica." It is very doubtfulwhether true encephalitis lethargica now occurs in thiscountry, and under the new sub-heading " infectiveencephalitis " can be included cases of all forms ofencephalitis, some of obscure aetiology, which are pre-sumed to be of microbic or viral origin. The sub-heading"

post-infectious " covers the forms of encephalitisoccasionally following, or associated with, certain well-defined infections-e.g., chickenpox, measles, mumps,and vaccinia.

Nleningococcccl ZMjfgcoM.—This heading includes, as

well as meningococcal meningitis (formerly notified ascerebrospinal fever), illness due to fulminant and otherforms of meningococcal infection 2 without an initialmeningitis.1. The Public Health (Acute Poliomyelitis, Acute Encephalitis,

and Meningococcal Infection) Regulations, 1949. See Lancet,1949, ii, 1238.

2. Banks, H. S. Lancet, 1918, ii, 635, 677.

. Typhoid in a LinerFrom the liner s.s. 3looltan some 45 members of the

crew are now in hospital ; and in 30 of these the diagnosisof typhoid fever has been confirmed. Stool specimenshave demonstrated 5 ambulant exeretors. Among thepassengers there have been 8 cases-1 each from NorthernIreland, Scotland, Lowestoft. Oldham, Shrewsbury,Sunderland, Twickenham, and Wandsworth. The datesof onset, where known, suggest that the source ofinfection arose during the last three weeks of the voyageand persisted until the vessel docked in the Port ofLondon on Dec. 15. Chloramphenicol is proving ofgreat value in treatment.

PoliomyelitisIn the week ended Dec. 24, notifications in England

and Wales were: poliomyelitis 71 (87), polioencephalitis10 (6). Notifications in the previous week are shown inparentheses.

The Third QuarterENGLAND AND WALES

Provisional figures published in the Registrar-General’s quarterly return 1 show that the stillbirth andthe infant-mortality rates for the September quarter,1949, were the lowest ever-recorded for any quarter.Births.-The number of live births registered was 183,278,

giving a rate of 16-6 per 1000 total population, which may becompared with 17-5, 20-0, and 19-8 in the third quarters of1948, 1947, and 1946 respectively. The number of illegiti-mate births, included in the total, was 9248, or 5-0% of thetotal births registered, compared with 10,186 or 5-3%, in thecorresponding quarter of 1948. There were 4104 stillbirths

registered during the quarter, giving a rate of 21-9 per 1000live and still births, compared with 4447 and the previouslowest rate of 22-7 in the same period a year ago.

- Deo/M.—101,207 deaths were registered during the quarter,giving a rate of 9-2 per 1000 total population. This compareswith 101,545 deaths and a rate of 9-3 for the correspondingquarter of 1948, and an average death-rate of 9-3 for the thirdquarters of the five years 1943-47. Deaths from acute polio-myelitis and polioencephalitis (provisional total, excludingnon-civilians) numbered 250, compared with 60, 83, 27, and28 in the four preceding quarters.Deaths of children under one year of age numbered 4883,

representing an infant-mortality rate of 26 per 1000 relatedlive births, compared with 5514 deaths and a rate of 28 per1000 in the same period last year, which was the previouslowest rate recorded for any quarter. The diarrhoea death-rate for children under two years was 2-6 per 1000 births.

VoM’oZ 7M.C7’e<M<!.&mdash;The births registered exceeded the deathsby 82,071, the corresponding increases for the third quartersof 1946, 1947, and 1948 being 112,642, 119,409, and 90,313.

Survey of Sickness.-Out of 3509 men interviewed, 2186reported having had some illness or injury in May and therewere 1478 consultations with doctors ; out of 4323 womeninterviewed, 3167 reported having had some illness or injuryin the same month and there were 1856 consultations withdoctors. Illness or injury of some kind during a month inthe period April, May, June was reported by 68-1% of allpersons interviewed ; the average incapacity was 0-90of a day_per month. Among housewives, 76-5% reportedhaving had some illness or injury during a month.

SCOTLAND

In Scotland 2 the death-rate was the lowest ever

recorded ; the death-rate from tuberculosis was lower,and for both respiratory and non-respiratory forms therates were better than the average. The maternal-mortality and the infant-mortality rates were the lowestever recorded in Scotland.

Births.-Live births numbered 23,322, giving a rate of17-9 per 1000 population, compared with 24,389 and a rateof 18-7 in the corresponding quarter of 1948. The proportionof illegitimate births-5-5%-was 0-2 below that for thethird quarter of 1948, and 1-4 below the average. The

1. The Registrar-General’s Quarterly Return of Births, Deaths,and Marriages : Quarter ended Sept. 30, 1949. H.M.Stationery Office. Pp. 29. 1s.

2. Quarterly Return of the Registrar-General, Scotland : Births,Deaths, and Marriages registered in the Quarter ended Sept. 30,1949. H.M. Stationery Office. Pp. 28. 1s.