7 1035

now if considered necessary after the examinationof the throat. Widal tests fur typhoid fever havebeen discuntinuetl for the same reason. The figuresgiven relate to the years J 920-25, during’ whicli32,188 restaurant employees and 9869 milk dealers wereexamined ; of all those examined, 155 were rejectedby-the health department for tuberculosis, and 45 furvenereal disease. Temporary cards were issued to95 persons who had tuberculosis orvenerea.l disease,but whose condition was not active. Although theexamination is compulsory, probably timse foodhandlers who came to the diagnostic clinic were

persons who felt reasonably certain that they werefree from the evidence of communicable diseases :this self-selectioii undoubtedly had some influencein keeping- down the percentage of tuberculous andvenprent diseased individuals among those examined.Considerable stress is laid upon the importance uf theexamination being made by physicians specially appointed to do tins work ; obviously it relieves the Iprivate doctor of the respmnsibility- of taking away hispatient’s employment. Dr. Fine conjunents upon thesmall number of food handlers rejected by privatedoctors im Newark, Kansas City, and New York City.In Newark itself there have been fewer rejections eachyear since lt)l’0 ; this may be taken as an indicationtha.t as persons with tuberculosis or venereal diseaseknow that they will not be certified fit for cruploy-ment as food handlers, they secure other occupations.Dr. Fine concludes his interesting survey bysummarising the arrangements made for the examina-tion of food handlers in other countries, which he ’,finds very inadequate.

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CREMATION AND DEATH CERTIFICATION.

A CIRCULAR letter will be addressed shortly to Ithe medical profession by the Crematiun Society ofEngland. signed by the Citairiiiai-i of the Society,Prof. Chalmers lllitchell, Sir Thomas Horder, and Mr.Herbert T. Ilerring, honorary secretary of the Society,in which it is pointed out that certain reforms arenecessary in the interests of the medical professionas well as of the public in respect to the disposalof bodies bv cremation. The Births and DeathsRegistration Act, 1926, comes into force next July,and imposes upon the medical practitioner importantpublic duties, without remuneration in the case ofburial, but in the case of cremation procedure iscontrolled by separate regulations. These regulations,which are laid down by statutory rules and ordersunder the Crernation Act, 1902, enact (under Form B)that the body must be seen and identified after death,and the fact of death certified by the registered medicalpractitioner who attended deceased in the last illnessand who can certify the cause of death. This serviceis remunerated as a rule with the fee for an ordinaryprofessional visit. But in disposal of the body bycremation a second medical certificate (under Form C)must be given, in which the identity of the deceased.the fact of death, and other particulars-verifying theanswers set out in Form B—must be given either byan independent medical practitioner, of not less thanfive years’ standing, who has been appointed by thecremation authority for the purpose, or, if such anappointment is not made, by a practitioner of fiveyears’ standing who holds one of the followingappointments : medical officer of health, policesurgeon, certifying surgeon under the Factory andWorkshop Act, 1901, medical referee under theWorkmen’s Compensation Act. or who is physicianor surgeon to a public general hospital containingnot less than 50 beds. It is to the circumstancesconnected with Form C that the circular letter refers,pointing out that the medical man signing it oughtto receive fair remuneration. The Cremation Actrequires the form to be signed by medical practi-tioners of five years’ standing, either appointed by acremation authority or being the holders of certainPublic appointments, and the Cremation Societydesires to bring before the medical profession thenecessity of - increasing the opportunities of the

cremation authorities to use their power of appoint-ment. Cremation is slowly becoming more frequentin this country, where it has always been advocatedby an influential section of the medical profession,so that it is reasonable for the Society to invite theattention of general practitioners to their opportunityof collaboration. The remuneration suggested by theSociety for ceutificates under Form 0 is " the usualfee for a iirst professional visit," and the direct objectof the circular letter is to invite doctors to communicatewith the Cremation Society and signify willingness insuch circumstances to sign these confirmatoy rnedicalcertificates required by the Cremation Act. listscan then be furnished tn the cremation authorities,who will know where to turn in making their appoint-ments. and who will be expected to recognise theresponsibility incurred. and to make their selectionsaccordingly.

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PULMONARY INFECTION FOLLOWING

OPERATION.

IT is not always realised how useful is a patient’sability to cough, and thus expel infective material fromthe lungs and bronchi. If (as is said) there is alwayssome inhalation of septic secretions during anaesthesia,.then a patient’s liability to post-operative pneumoniadepends on the degree to which his power of coughingis conserved. An estimate of this power might thereforebe some guide to whether there was a likelihoodof his contracting the complication. Such an estimateis not impossible, for the efficiency of a cough dependson the depth of the initial inspiration and the forcebehind the succeeding expiratory effort—which isderived almost entirely from the abdominal muscles—and it is just these two factors that are estimated bymeasuring the vital capacity, that is to say, themaximal amount of air that can be breathed outafter the deepest possible inspiration. This essentiallyis the argument which forms the basis of a recentpaper 1 by Dr. E. D. Churchill and Dr. DonaldMcNeil, of Boston. They found that after operationson the right upper quadrant of the abdomen thepatient’s vital capacity was on the average reducedby 70 per cent. on the first day, after which a steadyimprovement took place, until on the fourteenth daythe reduction was only 20 per cent. After cleanappendicectomies and operation for uncomplicatedinguinal herniæ, there was a fall of 50 per cent. on thefirst day, and a normal figure was obtained by theeleventh day ; after non-abdominal operations noreduction was observed. This diminution in vitalcapacity is attributed mainly to the abdominalmuscles being held in voluntary or involuntary spasm,so as to protect the injured part from painful move-ment, and also in part to inspiration being restrictedby a tight abdominal binder ; in a normal individualsuch a binder was found to reduce the vital capacityby 30 per cent. Other less important factors wereposture, the effect of sedative drugs, and abdominaldistension. In support of their findings, Dr. Churchilland Dr. McNeil quote figures given by E. C. Cutlerand A. M. Hunt,2 with whose results their measure-ments closely correspond. They reach the generalconclusion that the chances of pulmonary complica-tions increase as the patient’s preoperative vitalcapacity approaches his theoretical tidal air require-ment, but the evidence they give is insufficient forproof. Cases of cardiac and pulmonary disease wereexcluded from the series, and the height and weight ofpatients, though they were observed, are not recorded.The results of the investigation are what might beanticipated. A tight abdominal binder clearly limitsboth costal and diaphragmatic inspiration, and a fullexpiration is obviously impossible when the abdominalmuscles have recently been incised. Other thingsbeing equal, the postoperative variations observedare probably due to variation in the stoicism of

1 Surgery, Gynecology, and Obstetrics, April, 1927, Part I.,p. 483.

2 Arch. Surg., 1920, i., 114 ; and Arch. Int. Med., 1922,xxix., 449.