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which recover completely and yet complete recovery is veryusual in sciatica. Dr. BRUCE acknowledges that in the

operation of nerve-stretching surgeons have found the sciaticnerve to be swollen and inflamed, but these observations hedismisses as untrustworthy. He appears to deny the existenceof any form of neuritis, for he asks, Why should there not beneuritis of such nerves as the ulnar ? 7 We can only answerthat neuritis of the ulnar is not at all rare. It may arise

from alcohol, diabetes, rheumatism, and leprosy ; it mayresult from the taking of arsenic and from several other

causes ; in fact, we should not have thought that at the

present time any physician would have denied in toto theexistence of neuritis in any form. That inflammation

of nerve-trunks does exist has been abundantly shown

by histological examinations and there is no & priorireason why the sciatic nerve should be specially exempt.One of the main arguments advanced by Dr. BRUCE

is that movement often aggravates the pain and that

rest is necessary for recovery, but every movement of the

hip-joint causes movement of the sciatic nerve and it

would be strange if bending did not cause pain to an acutelyinflamed nerve. When the inflammation becomes chronic

pain will be less marked on movement. To sum up, Dr.

BRUCE’s lecture should prove useful in calling attention tothe need for greater care in applying the name "sciatica"

"

and for not giving it to all cases of pain in the hip and

thigh, for many of these are associated with disease of the

hip-joint. His evidence as to the value of rest in treat-

ment should lead to a greater employment of one of the

most-important therapeutic measures in sciatica. But we

hold that he has failed to prove his contention that a true

sciatic neuritis does not occur.

The Milroy Lectures on PulmonaryTuberculosis.

THE publication of the Milroy Lectures of the RoyalCollege of Physicians of London was somewhat delayed inour columns in order that the author, Dr. H. TIMBRELL

BULSTRODE, might extend and amplify his work in

directions which the limits of time precluded him from 1following during the delivery of his addresses. As they Iappeared in our columns Dr. BULSTRODE’S lectures form

an excellent summary of what is known as to the causes,

prevalence, and control of pulmonary tuberculosis while

the free expression of personal views lends attraction to

the treatment of the various points.For centuries past there has been a common belief in

some parts of Europe that consumption is an infectious

disease and as early as 1782 stringent regulations wereenforced in Naples in order to attempt the stamping out ofthe malady. Dr. BULSTRODE points out that at the presenttime there may be said to be two schools of thought with

regard to the main channels of infection between man andman, the one school maintaining that the greatest dangeris to be attributed to the tubercle bacillus contained in the

dried sputum, whilst the other considers that there is more

potency for harm in the droplets thrown off by a tuberculouspatient during cough. The relative merits of these theories

invite discussion, but we prefer to follow the question raised

by Dr. BULSTRODE as to the actual measure of the com-

municability of the disease. We perfectly agree with his

statement that, while there can be no reasonable doubtthat pulmonary tuberculosis is under certain conditions

an infectious malady, there can be equally no questionthat its communicability is of a low order. The testimonyof experience, which is a more scientific test, we submit,than the records of certain laboratory experiments,must be sufficient to satisfy all medical practitionersthat the communicability of this disease can only be

contrasted, not compared, with that of diseases such as

small-pox, typhus fever, or whooping-cough. The profes-sional edict has gone forth, however, that "consumption"is an infectious disorder, and has given rise to much mis-

conception in the public mind, which is without properinformation upon the degree of infectivity implied. Unless

the lay mind is reassured as to this a great deal of unduealarm will be caused and, as a consequence, needless

suffering may be inflicted on affected individuals. Dr.

BULSTRODE gives examples which have been brought to hisnotice, the most flagrant, perhaps, being that of a rector whoforbade his curate to visit at a sanatorium for tuberculosis

because in the rector’s opinion the disease was as dangerousas small-pox." Whilst in no sense disputing the communica-bility of the disease, we join with Dr. BULSTRODE in

pleading for more caution in setting forth the facts to thepublic, who should be told not only the amount of risk

that they run but the best course to protect themselves

against that risk. For pulmonary tuberculosis beingadmitted to be an infectious; disorder, the problem naturallyarises as to the means to be adopted to prevent its dissemina-tion. The question of notification is a vexed one. We have

on the whole sided with those authorities who believe that

compulsory notification would not only fail to make any

appreciable difference in the incidence of the disease butwould tend to have disastrous consequences to the social

life of the community. Dr. BULSTRODE suggests that it

might, in the first instance, be well to limit notification tocases of pulmonary tuberculosis in which the condition

and environment of the patient are such that dangerto the public is liable to accrue. In support of this

view he quotes Professor KOCH, who, when referring

to the subject of notification, said : "Fortunately, it is

not at all necessary to notify all cases of tuberculosis, noteven all cases of consumption, but only those that, owingto their domestic conditions, are sources of danger to the

! people about them." This amounts to saying that the general sanitary surroundings of such patients should be

notified rather than the disease. We have frequently urgedL that the chief responsibility for arresting the spread of pul-imonary tuberculosis lies with medical men. It is their duty to educate their patients in the precautions which they should’ adopt to prevent themselves from being a danger to theirfellow creatures. Therein lies the preventive medicine ofl the future. Dr. BULSTRODE speaks in similar terms when he

L I says : "It is in the inculcation of the general principles ofr health, which include more air, more light, more cleanli-

ness, and generally better housing, that we are pursuingthe surest and the best tried road towards success."

s At the conclusion of his lectures Dr. BULSTRODE speakss in still stronger terms when advocating practical measures1 for the control of pulmonary tuberculosis. He would have the- older children educated in the principles of health. He woulds have also periodically the physical examination of all school

616

children with a view to improving the health of those prone totuberculosis or who may already be suffering from the diseasein an unrecognised though not unrecognisable form. The

direct and indirect results which would accrue from this

would soon make themselves felt in the direction of an

unwillingness on the part of the people to occupy slumsor to dwell in places where the sun rarely penetrates, whilelocal authorities would become more alive to the value of

public health. Next Dr. BULSTRODE recommends a systemof compulsory insurance against sickness and invaliditysuch as obtains in Germany which, it is important to

note, makes for the provision of sanatoriums. Lastly, andmost important of all, he places the need for better housingand improved conditions of employment of the workingclasses-" more light, more air space, better ventilation, and

greater cleanliness in the home, the workshop, and the

factory." There will not be a dissenter from these views

among medical men, while one of the most valuable deduc-

tions to be made from Dr. BULSTRODE’S words is that a little

instruction to the patients and their friends from practi-tioners attending cases of pulmonary tuberculosis will havemore influence in the prevention of the disease than the

enforcement of laws. Legal enactments cannot fail to

produce a considerable amount of friction and will

cause attempts at concealment of early cases of disease ;whereas it is the aim of the medical profession to

diagnose cases of pulmonary tuberculosis at the earliest

stages, not only on account of the better prognosis whichtreatment then affords, but also in order to warn others of

the danger. A large number of early cases already escaperecognition, as the sufferers do not seek medical advice;still more would this occur if it became known that

all such cases would be notified. The patients wouldbe afraid that a sort of ban would be placed upon them asbeing a source of infection, and doubtless such would to acertain extent be the case ; whereas a few kindly words ofinstruction and direction from the medical practitioner wouldreduce the fear of infection to a minimum.

The Rules of the Central MidwivesBoard.

THE rules framed by the Central Midwives Board in

accordance with the provisions of the new Midwives Act

have been approved by the Privy Council and were publishedin THE LANCET of August 22nd, p. 555. The original draftrules as drawn up by the Board and submitted to the

General Medical Council were accompanied by a minorityreport signed by three out of the five medical members of

the Board. It is to be regretted that there should have

been so serious a want of unanimity amongst the membersof the Board. Many of the rules involve matters uponwhich only trained medical men can come to a proper

conclusion and it is most unfortunate that the views of

a majority of the medical members seem to have been

overruled in many instances by the votes of the laymembers. The Privy Council has, however, with the

assistance of the representations of the General Medical

Council, made a number of alterations in the draft rules

from the form in which they first appeared, and has

considerably improved them by adopting some of the

suggestions put forward in the minority report. But

even in their final form we cannot entirely agree with the

regulations as laid down by the Privy Council. Also-

the new Board has commenced its official career bymaking what we believe to be a serious mistake. It.

has determined for some reason which we fail to appre-ciate to hold its meetings in private. Not only has it

decided not to admit the public but we gather that it

does not intend to publish its minutes. In view of the

amount of opposition amongst many members of the pro-fession raised by the new Act any attempts to throw a veilof secrecy over the proceedings of the Board appear to usmost injudicious.The question of the preliminary education of the midwife

is one of some difficulty. The rules state that candidates

must satisfy the Board that they have reached a certain

standard of general education. No definite standard is, how-

ever, laid down, and the objection of the dissentients thatunless this is done the passing or rejection of candidates must

depend largely upon the caprice of the examiners in different

parts of the country seems to us a fair one. Their further

contention, that no medical practitioner should be recognisedas a teacher by the Board unless he holds an appointmenton the staff of a recognised lying-in institution, or has chargeof the lying-in ward of a workhouse hospital approved by theBoard, is an important one. Improperly trained and irre-sponsible persons have often taken up the coaching of

candidates for the examination of midwives instituted bythe Obstetrical Society of London, and failing strict regu-lations upon the subject there can be no doubt that

this practice will increase to a considerable extent. But

even supposing the teachers to be all competent, when weconsider the range of subjects which are laid down in the

syllabus for the examination it becomes doubtful whether

the minimum period of instruction-viz., three months-isreally sufficient. We should like to have seen the periodincreased to six months, but no doubt the Privy Council wasinfluenced by the question of expense, since it is imperativethat the cost of training should be kept as low as possible.The range of the subjects of the examination is in the

case of midwives a difficult matter to determine. The

duties of a midwife in regard to her patient cannot betoo clearly stated and the limits of what she oughtto practise should be rigidly defined. No doubt the

midwife should not be allowed to assume that she

is at liberty to use all her knowledge in ordinary circum-stances ; but cases of emergency will arise where, in

the absence of medical assistance, a midwife who did

not use all her knowledge might well be responsiblefor the death of the patient. For example, under the

subjects of the examination we find "haemorrhage, its

varieties, and the treatment of each," while in the minorityreport was the statement, "The treatment of heemor-

rhage cannot be any part of a midwife’s duties." If we

are to understand by the word "duties" " merely dutiesunder normal conditions," we quite agree that the treat-

ment of haemorrhage is removed from the midwives’ sphere,but to suppose that in conditions of emergency the treat-

ment of haemorrhage is no part of the midwife’s dutyappears to us absurd. While there can be no question butthat the midwife should be clearly instructed that she mustsend for medical assistance whenever haemorrhage occurs,yet she must be at liberty in a case of urgency-and such