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innocent male defendant, and it would be in his interestto submit to the tests. Unfortunately for him, hischances of having the full range of tests done in thiscountry are remote ; only a few laboratories, con-nected with the National Blood Transfusion Service,possess the necessary testing sera. He might getABO, MN, and Rh tests done, and this would givehim a 50-50 chance of proving his innocence. Evenif he can get these tests done, however, the courtmay not accept the results. For instance, about twoyears ago we reported 5 a case of a paternity disputeconcerning two children in which 1 out of 5 bloodtests showed that the male defendant could not bethe father; this evidence was not accepted as con-clusive. Such evidence would almost certainly havebeen accepted by. courts accustomed to hearing theresults of blood tests.The increase in the range of blood-group tests makes

it all the more regrettable that Lord MERTHYR’SBastardy (Blood Tests) Bill was a war victim when ithad passed the Select Committee of the House ofLords and was to go forward for the third reading.By this measure the court or either party could havedemanded blood tests ; experience in other countrieshas shown how valuable such evidence can be. TheBill also specified that the tests must be done

by medically qualified practitioners ; today this is

unnecessary, and would in fact exclude some of theleading experts in this field. It might be possible todesignate nationally controlled laboratories for the

purpose, provided that they had the staff to deal withthis extra work.

5. Lancet, 1950, i, 418.6. Brit. J. Tuberc. 1952, xlvi, 5.7. Lancet, 1951, i, 1364 ; 1951, ii, 33; Feb. 9, 1952, p. 305.

Gaps in the Tuberculosis ServiceTUBERCULOSIS is having much well-deserved atten-

tion just now, and the various regions are attackingits problems in ways appropriate to local conditionsand mood. Nevertheless there are still gaps, some ofwhich have lately been pointed out by Dr. B. A.DORMER, who as chief tuberculosis officer for theUnion of South Africa sees them with the impartialeye of an onlooker. He mentions the failure of some

teaching hospitals to interest themselves in tubercu-losis, and the disadvantage-proved by a study ofcase-records-of not having a thoracic team associatedwith a teaching hospital. He welcomes the appoint-ment of chest physicians, and believes that they shouldalways have beds under their charge. In some regions,he finds, they have both tuberculosis and non-

tuberculosis beds at the local general hospital, tubercu-losis wards in the local infectious-diseases hospital,and some beds in the local sanatorium ; and this, hethinks, is the ideal. " A chest physician without bedsis a tuberculosis officer of the old school under anothername, and will achieve nothing." This judgment isunduly harsh : there are various ways of using chestphysicians profitably, as recent surveys have shown 7 ;but it is noteworthy that this is how the situationstrikes an expert from abroad.

Dr. DORMER reminds us that the growing interestin tuberculosis has meant also more efficient diagnosisand treatment of other chest conditions : bronchiec-tasis, asthma, emphysema, and carcinoma of thebronchus are being seen more often by chest physicians,

and are being treated earlier. But he thinks that theassociation between chest physician and thoracic

surgeon is seldom close enough : " In some areas theyconduct parallel clinics in competition." They shouldclearly work as a team ; and presumably in mostplaces that is what they do. One thoracic surgeon, heestimates, should be able to do the surgical work fortwo chest physicians. He shares our suspicion thatthe present elaborate system of mass-radiographyunits, each with its team of ten or eleven members, ’," exists to discover comparatively few cases oftuberculosis each year " ; and he would have this

diagnostic apparatus put at the service of the chestphysician, to radiograph the sections of the communityin which he is most likely to find tuberculosis. Sinceover 95% of notifications of pulmonary tuberculosisoriginate with the general practitioners he proposesthat miniature attachments, fitted to X-ray plantsin chest clinics, should provide practitioners with anX-ray service all round the clock. The fact that

regional boards are now responsible for hospitals,sanatoria, infectious-disease wards, dispensaries, andchest clinics should leave medical officers of healthfreer to develop their other duties of preventiveteaching and aftercare ; but Dr. DORMER did not findmany of them engaged in vigorous educational cam-paigns : indeed, most of them left education in chestdiseases to health visitors and chest physicians. Hethinks it odd that the M.o.H., so fully aware of hisresponsibility in preventing diphtheria, smallpox,whooping-cough, and measles, feels so little concern.for tuberculosis. General practitioners, he hints,should also be taking more responsibility for thetuberculous ; they do not realise that all but 5% ofcases of tuberculosis are referred from their surgeries,that most of them are diagnosed too late, and that atany one time half the positive-sputum cases on thedispensary registers are under their care.Had he been reviewing the bed situation Dr. DORMER

might have commented on another important gap inour service-namely, the lack of adequate provisionfor patients with uncontrolled chronic disease. The

danger to which others are exposed by these deteriorat-ing cases is well recognised in London, where it presentssome special features. Sir ALLEN DALEY’S last report 9to the London County Council reminds us that I per1000 of London’s population are known to have activeor quiescent tuberculosis, and a further 4 per 1000may be presumed to have unrecognised disease. This

gives an incidence of 1-5% in the London population,of whom about a quarter are producing tuberclebacilli in the sputum. Moreover there is evidence, thereport says, that " minimal " and " sputum-negative

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lesions are more infective than we have hithertobelieved. Tuberculin surveys show that by their fifthbirthday 10% of London children have already metsufficient infection to develop a positive tuberculinreaction ; and the fact that the death-rate has beenfalling ever since 1860 means among other things, asthe report grimly notes, that patients have moreyears in which to infect others. The Londoner, more-over, encounters infection not only among his 31/2million fellow-citizens but also among non-Londonerswho come in to town to work, shop, or be amused.8. Ibid, 1950, ii, 750 ; Jan. 26, 1952, p. 199.9. Report of the Medical Officer of Health and School Medical

Officer, 1950. Published by the L.C.C., County Hall, West-minster Bridge, S.E.1. Pp. 162. 2s. 6d.

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Living quarters, too, are crowded : a post-warhousing survey showed that in Holborn, in 1947,nearly a third of the residents were living underconditions of gross overcrowding. Industrial andcommerical buildings have multiplied at the expenseof dwellings, which are now more often than notbuilt in vertical layers, so that the number of peopleper acre of ground has increased, and their chancesof meeting and inhaling each other’s breath are there-fore greater. Scattered through this vast concourseof people—in public transport, shopping queues,cinemas, theatres, inns, milk-bars, public lodging-houses, schools, stadiums, lifts, picture galleries,hospitals, council chambers, and their own homes—are not only unrecognised infectious cases but alsopatients with old chronic disease who either believethemselves harmless or have ceased to care what harm

they do to others.On the unrecognised case we are slowly but surely

catching up. Mass radiography, used not only onpatients referred by general practitioners but on

other groups likely to show a high incidence (contacts,people exposed to dust hazards, people working incrowded industrial centres, school-leavers, entrantsto the Forces, nurses), will in time sift out most of theearly cases in coming years. But, unless we do some-thing about them, the old chronic cases will still bethere, sowing a fresh crop of infections every year oftheir lives. It was right to concentrate first on givingbetter care to the early cases—to those for whomsomething can be done. And an important means ofpreventing spread of the disease is to make new casesnon-infective as soon as possible. But the time hasnow come when we must surely pay more attentionto the existing reservoirs of the disease.What is the present fate of these chronically sick

people, some of whom live for many years ? Dr.C. R. LOWE and Dr. J. E. GEDDES 5 found that 22%of patients in four sanatoria in the Birmingham areawere there for social reasons only, and could have leftif there had been suitable residential homes forthem. Some had no home of their own, some hadformerly lived in lodgings, and some would have hadto share a bedroom or a bed if they had returned totheir families. Cases of this sort have occupied—sometimes for many years—beds needed for acutecases : LOWE and GEDDES mention two women whohad been in sanatoria, one for nine, the other fortwenty-one, years, and Dr. ESTHER CARLING tells usof a woman who has already spent twenty-three ofher thirty years in a sanatorium. Thus, as Dr. CARLINGsays, the service for the hopeful cases silts itself up.The tuberculosis wards of some general hospitals areused as a refuge for old chronic cases, who spend theirlast months or years there ; but waiting-lists for suchwards are long, and do not diminish. Again, if thesanatorium staff harden their hearts and send out a

patient because his bed is needed for a more hopefulcase they may be depriving him of his slight chanceof survival : Dr. CARLING mentions a girl who, forover two years, had been given every possible carein a sanatorium, culminating in pneumonectomy. Thisoffered a frail hope of recovery—provided she couldhave at least two more years of fostering care. Herbed was needed for others, but where was she to go ?Her home, unsuitable in any case, was in Ireland,

5. Lancet, Jan. 12, 1952, p. 92.

the journey was out of the question, and an ordinaryconvalescent home was thought to be too strenuous.Such patients, though they are past benefiting frommedical treatment or skilled nursing, need the sort ofcare that will segregate them from the general publicand enable them to live a life which is neither uselessnor unhappy even though it may be restricted. Theyare in much the position, as LOWE and GEDDES

point out, of the frail ambulant elderly patient, whoseplace is neither in the hospital nor in the residentialhome ; and like him they need appropriate hostels.Where are such hostels to be found ? According

to Dr. W. H. TATTERSALL,6 there are some countrysanatoria which almost fill the bill already. Theylack X-ray equipment and facilities for surgery, andare in effect country convalescent homes. He suggeststhat some of them should be relinquished to otherbranches of medicine, in exchange for a proportion 6fbetter-situated general hospital beds ; but it might,in fact, be better to make some of them into convales-cent homes for the tuberculous-in name, as in fact.

Besides patients -who are too ill to do withoutsome nursing care there are others-more able, or

both more able and more wilful-who would notconsent to live in such remote havens. Some indeedare fit to carry on with a job provided they are notallowed to be a danger to others. These need hostelsnear their work ; and the provision of such hostels is,under the National Health Service, one of the dutiesof the local authorities. London has already begunto provide them on a small scale. A plan to convertSt. Peter’s Hospital, Stepney, into a night sanatoriumfor 50 tuberculous men and an industrial workshopfor 150 patients was not, for financial reasons, sanc-tioned by the Ministry of Health ; but a hostel for35 tuberculous men, most of them in employment,has been established at Stoke Newington, and nodoubt others will follow. It seems quite clear that theprovision of more hostels and convalescent homes forchronic and infective cases is the next great step totake in the campaign against tuberculosis. It is notan expensive undertaking, as such things go-nothinglike as expensive’as it is to provide sanatorium bedsfor the fresh crops of cases sown annually by theseneglected carriers.

6. Ibid, Jan. 26, 1952, p. 202.

Isotope RadiographyWE publish this week a paper by Professor MAYNEORD

describing how he has taken radiographs using a radio-active isotope as a source of radiation. The potentialadvantages of so compact an

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X-ray unit," independentof electric supply, need no emphasis ; and, thoughthe necessary exposures are at present too long forthe method to have immediate practical applicationsProfessor MAYNEORD is hopeful that isotopes will beproduced which emit the right kind of rays in sufficientintensity to give satisfactory pictures with shorterexposures. Where the object to be radiographed is

stationary, and time is no object, even an isotope ofrelatively low power gives excellent results, and thefilms taken by placing the new midget apparatus insidea dried skull illustrates very plainly the convenienceof projections which avoid superimposed shadows.These radiographs of the jaw differ from any ever takenbefore ; and though the accompanying picture, obtainedby five minutes’ exposure of the living hand, has lessobvious technical merit, it should be regarded respect-fully as a part of radiological history.