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the very great multiparity of the poor as compared with therich, and falls in with Dr. Eden’s previous statement asregards the great predominance of multiparity in cancer ofthe cervix over cancer of the corpus uteri.

It being accepted by all that multiparity is one of the

contributory causes of cervical cancer, and knowing thegreat fertility of the poor as compared with the better classes,one would expect a very large preponderance of cervicalcarcinoma among the poor.As to the reason why multiparity encourages the incidence

of cancer, it is certain that any scar tissues and tissues

exposed to continued irritation are more liable to cancerthan healthy organs. This also explains the association ofcancer of the body of the uterus with fibroids, the pressureof the fibroids possibly leading to some change in the mucousmembrane that produces carcinoma.

I am, Sir, yours faithfully.R. LEONARD LEY, M.B., B. C. Cantab, M.R.C.S. Eng.,

June 11th, 1912. L.R.C.P. Lond.

THE MEDICAL PROFESSION AND THENATIONAL INSURANCE ACT.

To the Editor of THE LANCET.

SIR,-I am given to understand from more or less officialsources that the two chief points in the profession’s protestagainst the medical administration of the Insurance Act willnot and cannot be granted by the Chancellor of the Ex-chequer nor by the Insurance Commissioners : I refer to

(1) the £2 a week income-limit ; and (2) the 8s. 6d. capitationgrant in cases where that method of payment is adopted(indeed, the Act implicitly seems to contemplate no othermethod).

If this be true, is it not time that the profession was madeaware of the fact, and I would like to ask, What must nowbe the attitude of the profession ? Time is rapidly passing,and though I believe we are organising pretty rapidly againstunjust and ungenerous treatment, our efforts are at presentbeing somewhat scattered in aim owing to doubts as to theexact and precise object against which they should be

directed ; it is high time these efforts were focussed andstrengthened. I am, Sir, yours faithfully,

FRED. J. SMITH.

To the Editor of THE LANCET.

SIR,-In an article in the Daily Mail of June 3rd on thelabour unrest, entitled "What we Want," Mr. VernonHartshorn, putting the case for the labouring classes as

regards the present social upheaval, makes the followingstatement : ’’ The demand which members of the BritishMedical Association are making for what represents to thema fair minimum living wage stands on exactly the samefooting as the underground workers’ claim to a guaranteedminimum which represents his modest estimate of a

livelihood." Then he adds: "Both claims are beingadvanced by the same methods. The doctor puts forwardhis claim on the grounds of justice and his indispensablevalue to the community. The underground worker does thesame. The doctor is prepared to strike if his claim is notconceded. So is the underground worker." This is a so

frequently repeated misstatement that it must be definitelycontradicted as widely and as emphatically as possible, and Iam glad to see that you have disposed of it in the leadingarticle in THE LANCET of June lst. The doctor does not

propose to " strike " at all in the sense in which the word isgenerally used. He does not refuse to do the necessarywork. He will continue to tend the sick as he has alwaysdone on the terms he has always accepted-viz., that theindividuals served should pay him for services renderedon a scale commensurate with their capabilities-and to attendto urgent and emergency cases without question to hisprobable payment therefor, and to give his services withthe generosity that has always characterised the professionas a whole in those cases where payment is out of thequestion. What he does refuse to do is to work on aparticular plan and for a particular fee that is being thrustupon him against his sense of right and justice. If thedoctor resigns all his contract practice and refuses to workthe Insurance Act, not a single individual in the whole

country will be absolutely deprived of the necessary attend-ance in his hour of need. He will be in just the sameposition as he is to-day. Surely it requires no more

than ordinary intelligence to see the difference betweenthat course and the course of any body of industrial

workers-say coal-miners or transport men-who, unlessand until their demands are conceded, stop all work of thatkind, refusing to do it themselves or to allow others to doit, whereby the community at large and every individual init is deprived of the particular necessary of existence for hisown use. Each individual sick person will be able to receivethe service that his necessity demands for such fee as he canafford, or even in fitting cases for none at all, even thoughall club contract practice is repudiated and the profession asa whole refuses to work the medical benefit of the InsuranceAct. In short, the doctor does not "strike."

I am, Sir, yours faithfully,June 6th, 1912.

__________________

K. M.

THE CONFERENCE ON CONSUMPTION ATMANCHESTER.

(FROM OUR OWN CORRESPONDENT.)

THE fourth annual conference of the National Associationfor the Prevention of Consumption and Other Forms ofTuberculosis was held at the Milton Hall, Manchester, onJune 5th, 6th, and 7th. It was attended by about 600delegates, including representatives of the principal civic

authorities of the United Kingdom. The delegates werewelcomed by the Lord Mayor, who gave a conversazione intheir honour. The University authorities also gave a recep-tion in the Museum of the University.

Opening Address.Professor E. W. HOPE, medical officer of health of Liver-

pool, presided and delivered an opening address in whichhe showed how the great sanitary undertakings, especiallymunicipal schemes for the supply of pure water to cities, werecoincident with the great decline in the death rate from tuber-culous disease. The experiences of the city of Manchesterhad accumulated a large amount of valuable materialfor the elucidation of the modes of spread of consumption.The control of poor dwellings was a great difficulty.Many homes became notoriously unhealthy from the point ofview of consumption, not because the building itself wasvicious in its plan or construction, but because of the way inwhich it was occupied ; the subletting, the overcrowding,the insufficient cubic space and consequent foul, vitiated air,as everybody knew, favoured the development and spread oftuberculosis. The proper control of houses such as these wasa problem of great magnitude in every large town, and con-stituted an important element in the control of tuberculosis.In Liverpool it was found that formerly the mortality fromphthisis over large areas of this class of dwelling averaged4 per 1000 per annum, but after clearance and rehousingschemes had been carried out the rate was reduced to 1’ 9per 1000. In Liverpool at one time 18,000 sublet housesaccommodated 160,000 people, but the standard of air-spacehad been increased from 250 cubic feet per head, not

including children, to 400 cubic feet for each man, woman, andchild. At present there were only two convictions for over-crowding where formerly there were seven. Other factors inthe reduction of the death-rate were open-air schools, theprinciple of which should be applied to all schools, and thepurification of the milk-supply. Without healthy homes con-sumption could not be eradicated. Health congresses andexhibitions were most valuable aids in the education of thepublic. Probably one of the reasons of the decline in popularityof sanatoriums amongst the public generally was the extrava-gant hopes that had been built on them by uninformed persons.Regarding the milk-supply, Professor Hope said it was alamentable thing that owing to the inertness of so manyrural sanitary authorities the condition of large numbers ofcountry cowsheds was bad in the extreme. The consequencewas that the cows were riddled with tuberculosis and themilk was contaminated. But, one after another, greattowns had actually been forced to seek Parliamentary powersto prohibit the importation into their districts of thediseased products of cows kept in the filthy and insanitarycowsheds of country places, and the fact stood out that the

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milk from cows kept within the precincts of cities was freerfrom tuberculosis, and consequently purer and more whole-some, than that coming from many rural districts, with theirgreater facilities and more healthy surroundings, were theseonly availed of. But it was only the large towns which hadthese powers, and the milk excluded from these centresfound its way into unprotected communities. Liverpool ’,(following the lead of Manchester) obtained powers of thiskind in the year 1900, and it was a fact, the interpretation ofwhich Professor Hope left to others, that coincidently withputting these powers into operation two things had followed.One was that the tuberculous milk from the country had largelydiminished year by year in amount, and the other was thattuberculosis amongst young children (who were the greatestmilk consumers) had diminished also in an almost corre-

sponding degree.Tuberculosis in Childhood.

r The whole of the rest of the day and part of the second ‘

day were devoted to the discussion of the question oftuberculosis in childhood.’ Dr. R. W. PHILIP (Edinburgh) read a paper on thePrevalence of Tuberculosis in Childhood. Tuberculosis ofthe adult and adolescent was the harvest of seed sown inchildhood. He thought they were too prone to confine theirattention to the completed picture of the disease. Fresh airmust be brought into the poor man’s nursery. He urged theimportance of detecting the presence of tuberculosis inschool children.

Professor S. DELÉPINE gave an account of the infectivity ofhuman and bovine tuberculosis. Tuberculosis could be com-municated from animal to man as well as from man to man.The sputum of tuberculosis, even when dried and floating asdust, was infective. Among children under five years therewere only 100 cases of lung disease to 850 cases of disease ofother organs, while between 35 and 45 years of age therewere 100 cases of lung disease to less than 6 of other forms.It was impossible to resist the conclusion that children weremore likely to be infected through their food. Tuberculouscows’ milk, as he had proved both by experiments and obser-vations, constituted the most important infecting materialof bovine origin. Whatever the channel of infection, somebacilli might pass into the blood and give rise to tuberculosisin various parts of the body. Localised tuberculosis of thelymphatic glands, bones, liver, spleen, and other organs, whennot associated with pulmonary tuberculosis, was generallydue to infection through the alimentary tract.

Dr. NATHAN RAW dealt with the same subject. He statedthat 20-25 per cent. of the cows in the country were tuber-culous, and in 2 per cent. the udders were infected. Abdo-minal and other forms of tuberculosis were common, butconsumption was rare in children under 12. The other formsof tuberculosis were of bovine origin, and consumption wasof human origin. The nation would do well to spend£2,000,000 in getting rid of cows affected by tuberculosisof the udders. He urged the boiling of milk. Dr. J. E. SQUIRE stated that the death-rate from tuberculousdiseases was low during school age and highest before andafter it.* Mrs. LESLIE MACKENZIE showed lantern slides of open-airschools and country homes which had been established bythe Edinburgh school board.Mr. E. D. TELFORD (Manchester) spoke on the hospitalschool. He advocated an extension of such schools forchildren afflicted with surgical tuberculosis. The ordinaryhospitals could not cope with them, their wards being crowdedwith acute diseases. All that was necessary to save thesechildren was that they be maintained in a special institutionunder proper conditions of hygiene and surgical treatmentfor a length of time sufficient for their cure. They must gethold of these cases early, place them in a specially equippedinstitution, maintain them there for an indefinite time-

usually two or three years-and under these conditions notonly would the great majority be saved, but they would besaved without deformity. Some provision should be madefor teaching them, since they were often mentally above theaverage.On the second day the discussion on tuberculosis in

children was continued. The difficulty of early diagnosisof the disease in children largely accounted for the varyingestimates of the rarity or otherwise of the disease.The paper by Mr. H. J. GAUVAIN, of the Treloar Cripples’

Hospital and College, attracted much attention. It willshortly be published in THE LANCET.

Mrs. M. D. POWER SWEENEY gave a paper with manydetails of the question of open-air schools, including theircost. In London the gross cost per head per year was aboutE24, against less than f,7 in the ordinary schools.

Ventilation of Work-places.Dr. A. RANSOME dealt specially with the necessity of pro-

viding fresh air in work places. Previously it had been foundthat it was not the humidity in weaving-sheds that was thecause of trouble, but the foul air. The standard of ventila-tion first established in this country for work-places was 9 percent. carbon dioxide per 10,000 of air. He regretted thatthe new Home Office regulations lowered the standard to 11per 10,000.The following resolution was unanimously adopted :—

That this association protests against any lowering of the standard oventilation in any of the work-places in the kingdom, and that a copy ofthis resolution be forwarded to the Home Secretary.

National Insurance Act and Tuberculosis.The afternoon was devoted to the discussion of the powers and

duties of sanitary authorities and the working of the NationalInsurance Act in connexion with tuberculosis.

Dr. W. LESLIE MACKENZIE dealt with the new duties

imposed on local and central authorities by sanatoriumbenefits.

Dr. H. W. MCCONNEL, of the Kelling Sanatorium, com-plained that no mention of the after-care of patients dis-charged from sanatoriums was made in the Act.

Dr. A. K. CHALMERS, medical officer of health ofGlasgow, said that in Scotland, where the people occupiedtenement houses, the idea of sanatorium treatment wasabused. The average cost per bed for sanatoriums, he said,was not less than £300.

Mr. F. E. FREMANTLE, medical officer of health for Hert.fordshire, stated that in this country sanatoriums had actuallybeen erected at a cost of £100 and even E50 per bed.The TOWN CLERK of Dundee and Dr. F. E. WYNNE, medical

officer of health of Wigan, criticised the Interim Report ofthe Tuberculosis Committee.vu rrmay Councellor ARTHUR NEAL (Sheffield) dealt

both eloquently and exhaustively with the different questionsraised in the Interim Report, which he regarded as a

valuable document for local authorities. He took a veryoptimistic view of the provisions of the new Act, even asregards its finance. He believed that the working of theAct would pay the local authorities, not only in health andhappiness, but even in money.

Dr. C. KILLICK MILLARD, medical officer of healthof Leicester, did not share Mr. Neal’s optimism with

regard to the financial aspects of the Act. The reportdemanded 9000 sanatorium beds and the same number ofother hospital beds, with 250 to 300 dispensaries. These couldbe provided, the difficulty was their maintenance. Eachsanatorium bed would cost 25s. per week, and other hospitalbeds Sl, and each dispensary.f.lOOO a year. These figuresseemed to presage a heavy financial loss to the local autho-rities. The chronic consumptive-who was sure to breakdown after a course of treatment-would upset all financialcalculations.The Countess of ABERDEEN presided in the afternoon and

referred to the work of the Women’s Health Association inIreland and the good results achieved. In 1907 the deathsfrom all forms of tuberculous disease in Ireland were 11,679and in 1911 the number was 9623, a reduction of one-sixth,which was equal to 40 fewer deaths every week.

Miss M. E. BROADBENT, of the Children’s Aid Association,suggested grants to voluntary organisations by the InsuranceCommittees.

Mr. E. S. KEMP, of the London Charity OrganisationSociety, pointed out that most consumptives would be PostOffice contributors and their sick pay would soon beexhausted.

Other Papers and Lectures.Amongst others who took part in proceedings were

Professor G. SIMS WOODHEAD, Mr. JOHN PRIESTLEY, whospoke on the Special Factors making for the Extension ofTuberculosis in the School and the Measures of its Preven-tion, and Mr. C. E. LAST, of the Millfield Home for Childrenfor Pulmonary Tuberculosis, who dealt with Open-air Schools.The evening lectures were given by Dr. SQUIRE, Dr. R. W.

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PHILIP, and Professor SIMS WOODHEAD. The Conferencewas under’ the auspices of the city of Manchester and thecounty borough of Salford.

In connexion with the Conference an exhibition is beingheld in Salford with the object of educating the public inregard to the dread disease. The exhibition will be trans-ferred to Deansgate, Manchester, and then to the HulmeTown hall from June 21st to 27th.The Conference was extremely successful, the evening

lectures delivered by medical men dealing with wide questionsof the relation of the public to tuberculosis. Salford, too,is participating vigorously in the crusade against con-

sumption. The mayor stated that in 1879 the death-rate inSalford from phthisis was 29 per 10,000, but in 1910 it hadfallen to 13 per 10,000 owing to the improvement that hadbeen effected in housing and general sanitation, and in thehabits and material conditions of the people. There were400 deaths per annum in Salford from phthisis, while theconsumptive population of England and Wales was some-where about 300,000.

LEEDS.

(FROM OUR OWN CORRESPONDENT.)

A Large Scheme of Extension in Connexion with theGeneral Infirmary.

AT the usual monthly meeting of the city council a deputa-tion from the weekly board of the infirmary, accompanied byMr. William Middlebrook, the president of the King Edward.Memorial Fund, who was Lord Mayor at the time the fundwas started, had an opportunity of laying before the membersof the corporation a scheme of infirmary extension of very far-reaching importance. The standing orders were suspendedso that Mr. Charles Lupton, the chairman of the weeklyboard, should have an opportunity of explaining the scheme indetail.As has been mentioned in this column more than once the

need for extension of the infirmary is a very urgent one. Itwas wisely decided that so far as Leeds was concerned thebest memorial which could be raised to the memory of KingEdward would be a reconstruction of, and a substantialaddition to, the great institution which as Prince of Waleshe opened in the year 1868.The scheme of enlargement and of reconstruction which

Mr. Lupton unfolded to the corporation was, as he said, onewhich had been thought out mainly in the interests of theinfirmary, but it had appeared to the board to be one whichwould effect such an improvement in the access to certainimportant parts of the city and would be such a great publicimprovement that the board had adopted the bold course ofpurchasing a large amount of property to the east and northof the infirmary, feeling confident that the scheme wouldcommand the sympathy and the support of the public and ofthe corporation. To the north and east of the present build-ings there is a large amount of property to which the term’’ slum "may without impropriety be applied. Practically thewhole of this has been bought by the infirmary, and thecorporation is now asked to repurchase from the infirmaryas much of this property as may suffice for the constructionof a new wide thoroughfare which would continue the line ofCalverley-street, which runs between the town hall and themunicipal buildings, and curving to the west would strikeFenton-street some distance to the north of the infirmary.All the property to the south and west of this projectedstreet would be available for the extension of the infirmary,and it has been secured by the institution. The streetswithin its area would be abolished, for their place would bemore than taken by the new thoroughfare, and room for theexpansion of the infirmary would be secured which wouldprobably make the future of the institution secure for manyyears to come. It is not an absolutely essential part of thescheme, but it would greatly add to its excellence, especiallyfrom the point of view of its being a public improvement, ifin addition to constructing the new road the corporationshould, as has been suggested, demolish the existingproperty at the back of the town hall. Were thisdone a large open space would be formed between thetown hall and the eastward extension of the infirmary. Ofcourse, the scheme would cost a good deal, but in view of the

value of the proposals the cost is small. The purchase ofthe land necessary for the construction of the street and thelaying out of the street would amount to £50,000. It wouldbe necessary to expend .631,000 on the purchase of plots tothe east of the proposed street, so that a sum of £81,000 isessential for the carrying out of the infirmary ideals. If inaddition to this the corporation decides, as it is hoped itwill, to create an open space as explained above an additional.E50,OOO will be required. It is, of course, true that some-

thing may be reasonably set against this in the way ofthe sale of surplus property and in an increase ofrateable value, but in any case the money wouldbe well spent considering the immense improvementwhich would be effected in the neighbourhood. Should thearea requisite for the construction of the street and the landto the east thereof be taken, as is suggested, by the corpora-tion for a sum of .621,649, the additional area at the disposalof the infirmary for immediate and future extensions willhave cost some £50,000. It may be remembered that theKing Edward Fund amounts to about £110,000, though it ishoped that the full amount which was asked for-namely,.6150,000, may be ultimately obtained. About £50,000,therefore, will be available for building and reconstruction.It is intended to build one new large ward pavilion serialwith those at present existing on the south aspect of theinfirmary, with accommodation for about 100 patients ; toconstruct a suite of operating theatres for which thereis urgent need, and to extend the accommodation for thenursing staff. These with certain minor but necessary aimsmust demand the immediate attention of the authoritiesof the infirmary. Room will also be secured for the additionof two extra ward pavilions of the same size as that whichis to be immediately commenced, so that for many years itis felt that the present site will be adequate to the require-ments of the infirmary.

It is gratifying to find that, so far as can be seen, thescheme has commended itself to all parties in the corpora-tion. The infirmary stands high in the estimation of the

public of Leeds, and it is with a feeling of pride that theycan look forward to the carrying out of the great schemewhich has been outlined.

BRISTOL

(FROM OUR OWN CORRESPONDENT.)

Bristol Health Exhibition and Conference.INSTEAD of following the example set by many of the large

English towns and having a "health week," Bristol has hada health exhibition and conference at the Victoria Rooms,under the auspices of the Nurses’ Social Union. Some wereat first disposed to cavil at this decision, but it is nowgenerally acknowledged that the exhibition is admirable fromthe educational point of view. Many interesting exhibitswere sent by the General, Children’s, and Eye Hospitals, butthe majority came from the Nurses’ Social Union itself.These were divided into 13 sections, and many of them wereof the utmost practical value. One section, for example,consisted entirely of " expedients "-i.e., devices to showhow much in the way of nursing appliances might bemade of simple and inexpensive material, such as is

likely to be available in an emergency in a cottage.Other sections of particular interest were exhibits of

cookery appliances economising fuel, and a group relatingto baby and infant care. In one corner was a realisticwaxwork group depicting a surgical case in a slum roombefore and after the visit of the district nurse. Variousadmirable demonstrations of infant care, simple needlework,and similarly practical subjects were given several timesdaily. One small side room was occupied by exhibitsdesigned exclusively for medical practitioners and nurses ;this contained an interesting series of wax models and

pamphlets. There were also a number of stalls, one ofwhich, under the management of the health committee of thecity council, exhibited a set of microscopic and other pre-parations illustrative of pathogenic bacteria and their modesof dissemination. The Red Cross Society, the ambulancebrigades, and boy scouts have given displays in the adjoiningrink, and every day has had its special dramatic and otherentertainments. The first day of the exhibition was reserved