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present influences the result as it reacts acid with thisindicator and not with litmus. With litmus the optimumpoint I find to lie at what may be called the acid edgeof the amphoteric zone. The same person will haveno difficulty in getting a bouillon constant in reactionat different times, but might find a different end-point from that stated to be the optimum for him.The object of fixing the titration point is to secure freedomof the bouillon from the clumps of apparently dead bacilliwhich form a scum or sediment in the tube and give rise tovery puzzling pseudo-reactionq. Their influence on the resulthas been considered by Widal so serious a source ofexperimental error that the habitual examination of a controldrop to which no serum has been added is insisted on in everycase. This disturbing element is even more troublesome indealing with solutions of dried blood than with fluid serum.We have, however, been able to eliminate it permanently bypaying strict attention to the culture media and the reactionhere recommended is that which has been used from thefirst in my own observations except during two periods of afew weeks each. On both these occasions an accidentaldeparture from the method of preparing the culture led tounsatisfactory results, which promptly disappeared when theformer routine was resumed.

If the culture is less acid than 3-5 per cent. to phenol-phthalein the growth is more abundant and gives withintwenty-four hours both scum and deposit in which clumps ofmotionless bacilli appear. On the other hand, with bouillonmore acid than 3’5 per cent. the motility becomes greatlylessened and is lost at about 4 per cent. acid. The serumreaction, though still obtainable, is retarded. Between5 and 6 per cent. it is difficult to obtain any satisfactorygrowth, the limit of growth varying in different races.With serum in agar the reaction of the media has not the

same degree of influence. With the colon bacillus the

tendency to form clumps of motionless bacilli is greater thanin the case of typhoid and the tendency to yield pseudo-reactions is correspondingly greater. We find, however, thatby using a somewhat more acid bouillon than for typhoid(about 4 per cent. acid to phenol-phthalein will answer) thedensity of the growth can be controlled in a similar mannerand the tendency to pseudo-reactions disappears.2

I am, Sirs, yours faithfully,Montreal, Nov. 30th, 1897. WYATT JOHNSTON, M.D.WYATT JOHNSTON, M.D.

"PROPOSED AMENDMENTS OF THENOTIFICATION ACT."

To the Editors of THE LANCET.

SiRS,-As you observe in your leading article of Nov. 20thand as Dr. Young and Mr. Garstang state in their letters inyour issues of Nov. 6th and 20th it is generally admittedthat some amendment of the present Notification Act isnecessary ; but surely a more general agreement of opinionis desirable before a Bill is drafted. There are two importantmatters which seem to have been so far omitted and whichit is desirable should be included in any future legislation onthe subject. The one is that certainly all cases of phthisis-preferably all cases believed to be tuberculous in origin-should be included in the schedule of diseases to be notified.The other that all cases of " fever " after childbirth and mis-carriage should also be notified if occurring during the firstfourteen days after delivery. With these important additionsI should agree generally with Mr. Garstang’s suggestions, theonly great exception being that I should strongly support thepresent fee of half-a-crown being retained.

I am, Sirs, yours faithfully,Braintree, Essex, Dec. 6th, 1897. THOMAS CARR.THOMAS CARR.

"THE COMPARATIVELY STATIONARYDEATH - RATE IN PRIVATE

OBSTETRIC PRACTICE."To the Editors of THE LANCET

SiRs.-In THE LANCET of Oct. 2nd you granted space toa oommunication from me under the above heading. Uponthinking over the matter afterwards I regretted that I had

2 The influence of the acidity or alkalinity of the culture medium hasalready been referred to by Bates Block and by myself before theAmerican Medical Association (June, 1897), and by D. MacTaggart andmyself in a communication at the Montreal meeting of the British

not adopted the literary methods so familiar to us all inboyhood during our researches into the writings ofG. P. R. James et hoe genus onanc and so have indicated thefull scope of the matter with which I dealt by adding an.alternative title. My subject would then have beenexpressed in some such terms as "The ComparativelyStationary Death-rate in Pfivate Obstetric Practice or The-Sorrows of carrying out Asepsis." I am firmly convincedof the tragic truth of the opening paragraph ofDr. Jellett’s "Short Practice of Midwifery which wasrecently so favourably reviewed in your columns: "Itis not an exaggeration to say that the most essentialknowledge in midwifery is the knowledge of asepsis.A practitioner who knows nothing of the science and art ofmidwifery, except that it is absolutely necessary that hishands and instruments be sterile, will save more life than the-most accomplished obstetrician who does not practiseasepsis." The overwhelming importance of the subject itself,together with the interest recently taken in the discussion,upon the causes as to why, during the last twenty years, the.relative positions of the great maternity hospital and private.obstetric practice have been so radically altered, to the greatdisadvantage of the latter as regards the rate of mortality,lead me to hope that you may allow me to supplement andamplify a little my former letter. In it I attempted to showby the simple recital of an everyday experience that the diffi-culties to a great extent proceed from the ignorant miscon-ception of the patient or her friends. In the case to whichI referred the difficulty arose from a 11 nurse " objecting to.my methods, firstly, because I washed and scrubbed myhands so much that I appeared over-fastidious, and secondly,because by refraining from making unnecessary vaginalexaminations I did not earn my fee by "helping" thepatient as I ought. A few days after my letter appealed inyour columns I had, however, an equally instructive expe-rience in which the difficulty arose from the patient herself.The case was a very tedious primipara, with contractedoutlet, requiring forceps in the end, and when it was allover the patient expressed herself in most grateful terms forthe care taken of her in her troubles. The nurse upon this.occasion was a very intelligent and capable one and hadbeen trained at Queen Charlotte’s Hospital. Upon talkingmatters over with her she complained of the difficulties of’carrying out asepsis. She said she was much amused byher patient after I had made my first call just at the

beginning of her tedious labour expressing a hope that Iwould not come again. Upon the nurse asking for someexplanation of this the patient bad replied : " Oh, he rubbedhis hands so much that they must have been very dirtybeforehand, and it is such a curious thing for a doctor tohave had such dirty hands as to require all that scrubbing.’’

As I have before said, the woman was herself in the endvery grateful for services rendered, and the nurse soon

removed her misconceptions as to the object of the

scrubbing; but what can one think of the line of reasoning 2’It is such erroneous deductions, together with the old beliefin empirical methods, which constitute the greatest diffi-

culty in faithfully following asepsis in private practice..Amongst these empirical methods none can be more mis-chievous than the idea that an ordinary vaginal examinationis made with the object of "helping" the patient out of’her trouble-a belief which is practically universal amongstthe women of London. It is in connexion with this that Pwish to point out that the fault does not rest entirely witheither the patient or her friends. It has long been one ofthe stock commonplaces of feeble wits that the practising ofthe art of medicine amounts to an infinite capacity forhumbug. This criticism, however, is but an exemplificationof the truth of Byron’s famous lines :-

Believe anything that’s false beforeYou trust in critics who themselves are sore."

The critics in this case are simply ordinary specimens ofhuman nature who are self-conscious of the fact that whenthey themselves seek medical advice they expect to be-" humoured." But, granting all that can be urged onthis score, surely there is no need for anything morethan an explanation to the patient of the simple truth-namely, that a vaginal examination in an ordinary case

Medical Association not yet published. I would emphasise the import-ance of paying special attention to the condition of the culture in orderto get the best results where dry blood is used. A very full considera-tion of standardising media by phenol-phthalein is given by G. Fullerin the Journal of American Public Health Association for 1895(October).

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is made for purposes of diagnosis and not with anyidea of "helping" the patient. I have made inquiryupon this subject and I find that the experience of others;amongst London women confirms the impression which Ihave myself formed concerning the ideas prevalent amongstthe items which go to form the very numerous clientele

yclept "guinea midwifery." The patients, one and all,believe that if the medical man allows a single pain to passin his presence without making a vaginal examination he isnot honestly earning the aforesaid guinea. From merely.silently acquiescing in these ideas it is but a step to" helping the patient in a more active manner by stretch-ing the cervix with the fingers, than which no procedurecan be more risky if practised as a routine measure.

Lacerations are then inevitable, and their risk from theseptic point of view is in no way lessened, but ratherancreased, by the classically futile reitection, "they arebut little ones." From the stretching of the cervix tothe application of the forceps is but another short step.I observe that at the recent meeting of the British MedicalAssociation at Montreal a provincial English practitioner.asserted that he believed that his brethren in Lancashireresorted to the forceps in I I not less than 25 or 30per cent. of all cases, or even more." However astonish-ing such a statement may seem in itself, it is stillmore so when contrasted with the figures of thegreat maternity hospitals, whether abroad or at home.Some carry the craze in favour of things bearing thelegend .’ made in Germany" even into the matter ofstatistics. Science of course is cosmopolitan, and in suchmatters merely patriotic considerations are beside the mark.It is, however, common sense to say that beyond questionthe rational plan would be to quote the figures of the greatmaternity hospitals which minister to people drawn from thepopulation with which we ourselves are concerned in ourpractice. I therefore make no excuse for taking as mycriterion the tables of the Rotunda Hospital during theperiod which I feel sure will always be looked upon as thegolden age there-namely, the seven years (1889-1896) ofthe mastership of Dr. Smyly. Of the latter it may bewell said that, like his illustrious compatriot the "Bobs "- of Rudyard Kipling’s Ballad, he "doesn’t advertise,"so his name is not so well known on this side of the Channelas that of some continental specialists. I feel sure, however,that the many Englishmen who enjoyed both the pleasureand privilege of attending the obstetric and gynaecologicalpractice of the Rotunda during his mastership will recognise Iin my humble tribute nothing more than the record of an estab-lished fact, without any disparagement either expressed orimplied of the long line of distinguished men who have filledthat position. During these seven years Dr. Smyly, both byprecept and example, unceasingly insisted upon the limita-tion of the use of the forceps to cases in which the followingconditions were fulfilled : (1) that the greatest diameter ofthe head should have passed the brim ; (2) that the mem-branes should be ruptured and retracted over the presentingpart; and (3) that the os should be sufficiently dilated toallow the head to pass through without any risk of causing’laceration of the cervix.As a result of this teaching amongst the 8997 labours

which occurred during the seven years recourse was had tothe forceps in 267 cases, being not quite 3 per cent. We<?an therefore appeal as successfully and proudly as PrinceHal to the "men (and women) whose limbs were made inEngland (and Ireland)." " I venture to ask for the powerfulsupport of THE LANCET in helping to bring about a similarstate of things in private practice and thereby to get rid of’the reproach of the stationary death-rate.

I am, Sirs, yours faithfully,M.D.

FREEMASONRY.-The Rahere Lodge, No. 2546.-An ordinary meeting of the Lodge was held at Frascati’sRestaurant on Dec. 14th, W. Bro. Walsham, W.M., inthe chair. Messrs. Hampton and Miles were admitted tothe third degree and Bros. Auden, Marshall, Bill, Cripps-Lawrence, Adams, We&tbrook, Trechmann, and SurgeonFolliott, R.N., to the second degree by Bro. Gilbertson. Mr.J. B. Christopherson, M.B., B.C. Cantab., was initiated intoMasonry by Bro. E. C. Cripps, and Bro. Arnold Izard, ofthe Isaac Newton University Lodge, was elected a joiningmember. Forty brethren with their guests afterwards dinedtogether.

THE EPIDEMIC OF TYPHOID FEVERAT BELFAST.

(FROM OUR SPECIAL COMMISSIONER.)

(Continued from p. 1561.)IT has already been pointed out that one of the most

serious defects of Belfast is the nature of the soil on whichthe town is built. The necessity of a good system of drainageis twofold ; first, to dispose of the sewage ; secondly, to keepthe subsoil dry and to prevent floods. So far back as 1866the late borough surveyor, Mr. Montgomery, drew up ascheme for intercepting all the sewers which then emptiedabreast of the town into the tidal River Lagan and conveyingthe sewage away into the Lough. It is important to note,however, that Mr. Montgomery emphatically declared thathis scheme was only suited to Belfast as it then stood andhe could not answer for the future. Now it has taken thirtyyears of contests and squabbles to carry out this schemeand the question arises as to whether it is still suitable tothe present condition of the town, for in the interval thepopulation has just about doubled. The late Sir JosephBazalgette reported favourably upon this scheme when it wasfirst presented. The Belfast Corporation promoted a Bill in1870 to carry out these plans and also to reclaim a largearea of tidal lands from the Lough. But the cost was sogreat that the Bill came to grief before reaching the Com-mittee stage. The question was not revived till 1885 when thepresent borough surveyor, Mr. Bretland, presented an

amended scheme of sewage interception to the corporation.This was also favourably reported upon by the lateSir Joseph Bazalgette and adopted by the BelfastTown Council. Finally, in 1887, the Belfast Main DrainageAct was passed by Parliament. The total cost was estim-ated at about f.300.000. Low.level main sewers are nowbuilt on both sides of the river and connected together by adouble syphon that passes under the water. The contents ofthis low-level section are pumped up near the northernextremity of the city into a high-level main interceptingsewer at Duncrue-street. From this point the sewage flowsby gravitation to a covered storage reservoir which is

designed to hold 5.000,000 gallons of sewage between highwater and half ebb. It is then discharged and it wasbelieved that the ebb current would suffice to carry thesewage out to sea. The construction of this reservoir was amatter of great difficulty on account of the unstable natureof the ground. No less than 7000 piles had to be drivendown so as to make a foundation. In spite of this one ofthe walls of the reservoir began to give way, but it has beeningeniously consolidated by the construction of buttresses.The discharge into the tide is throagh a covered timber

sewer one mile in length. It is placed below the low-waterlevel under the bed of the Lough, but the reservoir is at asufficient height to give a working head to ensure the dis-charge of the sewage. Then twenty-five acres of land by theside of the reservoir have been redeemed from the sea, sothat if it should be thought necessary there is room totreat the sewage before discharging it into the Lough.Whether this will have to be done or not is a matter onwhich opinions are at present divided. In the summer,when the wind blows from that direction, there are unplea-sant odours, but is this due to sewage laid bare on mudbanks by the receding tide or to the accumulation of rankvegetation? Again, is this vegetation due to the sewage? Some persons affirm that it existed before the building of thesewage outfall; others maintain that it is getting worse andworse every year. In any case there is the ground allready at hand to establish works for the treatment of thesewage. If a nuisance has been created in the Lough thecondition of the River Lagan as it passes through the townhas very much improved. This is proved by the fact thatsea trout now come up the river at spawning time whenthey want to get to the fresh water. Though these fish wereformerly unknown they may now be caught in the Lagan asfar up as the locks which of course they are unable to pass.The most urgent question, however, is that of the drainage

of the town itself. Has a scheme which was intended for a

population of about 150,000 proved effective when applied toa population of more than 300,000, and will it long remaineffective considering that this population is increasing at therate of about 10,000 persons per annum 7 This is all the more