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the 500 and over who did not reply. As the inquiryconcerned ex-patients only it ignored that class ofcase when the onset of disease occurs during pregnancyor after parturition. W. B. Hendry 2 has discussedthe treatment of pregnant women and stated hisbelief that they should be left alone unless the lesionis active, in which case the pregnancy should beterminated during the first three months. Afterthe first three months he regards the prognosis asgrave whatever course is adopted, but it may besafer to allow the pregnancy to pursue a normalcourse, shortening the second stage of labour by theuse of forceps or pituitrin, or by performing Caesareansection under local anaesthesia. He sums up thesituation thus : "When an active lesion is presentin an unmarried woman, advise against marriage ;when the patient is already married, advise againstpregnancy; when pregnancy exists in the earliermonths, advise its termination ; when it has passedthe third trimester, watch and pray." At theBritish Medical Association meeting held at Notting-ham a few years ago R. A. Young produced a similarlyepigrammatic summary : " If a virgin no marriage ;if married no pregnancy ; if pregnant no confinement;for the mother, no suckling."At a joint meeting, reported in our last issue

(p. 186), of representative obstetricians and those

especially engaged in tuberculosis work, it was

agreed that at least 50 per cent. of women withactive tuberculosis are made iller by parturition, andthat it is difficult to differentiate the effect of

pregnancy from that of parturition. It is, therefore,safer for a woman with active tuberculosis not to bearchildren. If, however, she is already pregnant theattending physician has to decide whether the

pregnancy should be interrupted or allowed toterminate naturally, bearing in mind that there aresome tuberculous women on whom pregnancy hasno deleterious effect, and a few whose conditionseems improved by childbearing. In each case

it has to be considered whether an artificial termina.tion will be less harmful than the normal event tothat patient ; and here we have a conflict of evidenceand an insufficient number of published cases finallyto decide the point, for it is important to be guided,in this as in other matters, by actual experiencerather than by the opinions of great men. If a livingchild is born the next problem is whether the infantshould be breast-fed and for how long. It seemsclear that most infants gain from breast-feeding andthat the mothers do not lose, provided lactation isnot prolonged. Breast-feeding should thereforebe the rule unless contra-indicated in the individualinstance by the risk of infection from a woman withan open lesion ; the period of lactation might belimited to six months. On the liability of thechildren of tuberculous mothers to become infectedthe data are conflicting ; the figures of Matthews andBryant, referring to the 48 per cent. of good-classmothers who replied to a questionaire, can hardlybe taken as applying to the bulk of the population.Nor do figures dealing with babies provide informationas to their fate in later life, for they not only riskinfection but also inherit a poor resistance. Otherfactors in the problem are worth attention. ErnestWard showed that in 21 per cent. of 240 pregnanttuberculous women the onset of disease occurred

during pregnancy or after parturition, and that ofthese one half died within a few years, the prognosisbeing far worse in their case than in those whosedisease antedated pregnancy. 3 If pregnancy is to

2 Canad. Med. Assoc. Jour., 1930, xxiii., 805.3 THE LANCET, 1923, ii., 557.

be interrupted such cases might have to be con-

sidered especially suitable. Marriage apart fromconception usually improves a patient’s health, andadvice on contraception might be efficient whereadvice against matrimony would be futile. In anycase, it may be better to counsel a possible postpone-ment than attempt to impose an impossible prohibi-tion. There must, we think, be a freer interchange ofexperience, some remoulding of individual beliefs,and a larger body of observed facts at disposal beforevalid conclusions are reached.

AN INDEX OF RENAL EFFICIENCY.

THE drawback of most of the tests of renal functionis that they require special technique or equipment.Herein lies the chief advantage of the " dilution andconcentration " test. The patient empties his bladderat 7 A.M. and then drinks 1000 c.cm. of water withinabout ten minutes. The urine is collected hourlyfor four hours and then two-hourly till 7 P.M. Fairlydry food is allowed for meals but no fluid until7 P.M. and then only enough to allay thirst. Thenormal kidney eliminates the whole of the ingestedfluid in the first four hours with a lowering of thespecific gravity of the urine to 1005 or less ; after thefirst four hours the specific gravity gradually rises to1020 or more. Failure to secrete the ingested fluidin the four hours or to produce a marked fall inspecific gravity with subsequent rise indicates impair-ment of renal function. Brink i reports very favour-ably on the clinical value of this test. Buck andProger 2 have compared it with the other tests ofrenal efficiency in 100 cases and find it not only moreeasily performed but also a more sensitive index ofrenal damage. They have further simplified it forthe benefit of ambulatory patients, so that the onlyspecimens of urine examined are the one passed twohours after the water is drunk and the one passed onrising the following morning. If the specific gravityof these specimens shows good dilution and concentra-tion respectively, no further examination is necessary,but if this test is unsatisfactory the case requires amore complete investigation.

SCOTTISH FAMILY DIETARIES.

THE purely quantitative aspects of nutrition no

longer occupy the pre-eminent position that theyheld 20 years ago. This is easily understood whenwe consider the striking demonstrations that havebeen made in recent times of the value of specificfood constituents in animal nutrition. Yet the

problem of how much protein, fat, and carbohydratea man should take to maintain himself in a state ofhealth has by no means lost its devotees. By themethod of direct experiment with individuals andsmall groups of men it has repeatedly been shownthat very great variations in the proportions of theseconstituents are compatible with normal health andefficiency. Nevertheless a systematic study of theamounts of these classes of foodstuffs habituallyconsumed by a given section of any communitymay be of academic interest even if its immediatepractical bearing is not at once obvious. Such a studyhas just been reported by Prof. E. P. Cathcart, F.R.S.,and Mr. A. M. T. Murray, Ph.D.3 3 St. Andrews was

1 Brink, C. D. : Clin. Jour., Jan. 7th, 1931, p. 6.2 Buck, R. W., and Proger, S. H. : New Eng. Jour. of Med.,

Dec. 25th, 1930, p. 1283.3 A Study in Nutrition. An Inquiry into the Diet of 154

Families of St. Andrews. Med. Res. Council, Spec. Rep. Ser.No. 151. H.M. Stationery Office. 1931. 1s.

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chosen for the investigation as representing a relativelywell-to-do community, and among the 154 familieswhose household budgets were scrutinised all classesof society from the richest to the poorest wereincluded. The diet had an average energy value,reckoned on the basis of the adult man, of 3119calories and contained 89 g. of protein, 119 g. of fat,and 411 g. of carbohydrate. The most strikingfeature of this analysis is the high proportion of fat,which is more than double the amount commonlyaccepted as the standard for a European. Yet,curiously enough, the composition of the diets studiedon this occasion is almost identical with that of the

average diet in the United States. It was noted that

although the amount of protein in the diet increasedwith a rise in the family income, the proportion ofthe total energy supplied by protein was remarkablyconstant in all the groups studied. The amount offat, on the other hand, increased both absolutelyand in proportion to the total energy value with anyincrease in financial resources. Further problemsthat are discussed include variations in the compositionof the diets according to the social class and occupationof the householders and the efficiency of the parents.The general impression is gathered that the populationof St. Andrews can be regarded as being wellnourished, suffering neither from gluttony nor foodshortage.

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EFFICACY OF SERUM IN DIPHTHERIA.

FOLLOWING a complaint by practitioners in thenorth of France that antidiphtheritic serum, althoughgiven in larger doses, is much less efficacious thanpreviously, an inquiry was instituted by the Com-mission of Serum and Vaccines of the Ministry ofPublic Health. The conclusion arrived at was thatthe serum is not to blame. J. Lignieres, in a" contribution to the study of the causes of insufficientactivity of antidiphtheritic serum " has reviewedthe facts and produced some valuable comments.In recent years, he points out, the dose of anti-toxin in the treatment of diphtheria has considerablyincreased. Thus in 1894, when serum therapy wasstarted and for a few years afterwards, only 40 c.cm. of serum was given on the first day to severe cases, ’ and the total injected throughout the treatment did not exceed 80-90 c.cm. At the present day inFrance the usual amount is about 300 c.cm. ofunrefined serum. Translating these quantities intoEhrlich units of antitoxin, 1500 units were formerlygiven in severe cases, whereas now 100-200,000units are normally injected and this amount is exceededin serious cases. In the United States and Argentinastill larger doses are given.

In view of the general tendency to increaseeven these massive doses of antitoxin, it is imperativeto consider whether such large quantities are reallynecessary to get satisfactory results, and at the sametime to remember that these results are not superiorto those previously obtained with weaker antitoxin. iWhy therefore is a much more powerful antitoxinneeded Various suggestions have been made,based on the lateness of treatment, associated micro-organisms, the resistance of the patient, the type ofepidemic, and the virulence of the bacillus. Thesefactors which may influence any one case have alwaysexisted, and do not suggest any solution to the problem.Lignieres considers that the toxin is at fault. Theoriginal serum made by Behring was comparativelyweak in antitoxin, but Roux improved considerablyon this, while Roux and Martin indicated the

1 Bull. de l’Acad. de Med., 1930, civ., 698 and 720.

optimum conditions for obtaining the toxin. In1894 Anna Williams isolated from a case of tonsillardiphtheria a strain of diphtheria bacillus known asPark-Williams No. 8, which for producing a powerfultoxin has probably not been surpassed by any otherstrain. It is this strain of diphtheria bacillus whichis used almost exclusively throughout the world forproducing antitoxin, and which has been responsiblefor the extremely high titre sera obtained. Butit is 36 years since this strain was isolated, and duringthat time it has been grown exclusively on artificialculture media. The question now arises whetherits pathogenic power (as apart from its capacity toproduce toxin) has not changed. Fatal cases of

diphtheria have occurred in which antitoxin appearedto have no effect whatever, but organisms isolatedfrom such cases have proved to be much inferior tothe Park-Williams strain in their power to elaboratetoxin. Owing to the supreme toxigenic power of thePark-Williams strain, it has been universally adopted,and no attempts have been made to replace it.

Lignieres considers this to be a grave mistake. Hethinks that there is a distinct difference between

pathogenicity for the human being and toxicity forthe guinea-pig, and quotes similar examples with otherorganisms. The effect of successive cultivation onartificial media is to reduce the pathogenic power, andvaccines and sera derived from such organismsbecome less and less effective. The conclusionarrived at is that a recently isolated bacillus, thoughnot so toxic as the Park-Williams strain, would producea better serum, more powerful in its bactericidalaction, and more efficacious from the therapeuticpoint of view. The bactericidal action of the serummust not be ignored, for observations have shownthat in severe cases the bacillus invades the bloodstream, and can be isolated from internal organs.The good results of immunisation by the anatoxinof Ramon are ascribed by Lignieres to the fact thattoxins from different types of recently isolatedbacilli are used. He suggests therefore that antitoxinshould be made from a mixture of recently isolatedlocal strains of diphtheria bacilli. This antitoxinshould be tested against the Park-Williams anti-toxin, now in use. The importance also of theI bactericidal action of the serum should not be over-looked when treating severe cases of diphtheria.

This thesis of Lignieres is worthy of the carefulconsideration of all who are concerned with themanufacture and use of diphtheria antitoxin.

DUST DISEASES.IN another column Prof. Lyle Cummins relates the

results of an examination of the lungs of coal-miners,in which he has been engaged for some years past.These satisfy him that the anthracosis of coal-minersis a dual condition in which the retention of coal dustin the lungs is due to a state of fibrosis indistinguishablefrom that found in silicosis. One characteristicfeature of silicosis is however absent in the case ofcoal-miners-namely, the increased liability to tuber-culosis. In order to explain why lungs so damageddo not more readily succumb to tuberculosis, thetheory is advanced that the active principle oftuberculin is absorbed by the coal dust in the lungs-an adsorption which, it is stated, carbon particleseffect in vitro. Were this so it should follow thatthe soot-laden lungs of city dwellers would be moreresistant to tubercle than those of country folk ;but mortality records point to the reverse. Even

though coal-miners on the whole escape tuberculosis,on some fields they experience excessive mortalities