1192

South Persia.-Lt.-Col. (Temp. Col.) H. Burden; C.1.R, I.M.S.; Westminster, St. Marylebone, Hampstead, Stoke Newington, Capt. (Temp. Lt.-Col.) H. R. B. Gibson, I.M.S. and the City of London ; and the highest in Shoreditch, Black Sea.-Temp. Capt. G. G. Bruce ; Temp. Capt. (acting Major) Bethnal Green, Poplar, Battersea,Wandsworth, and Deptford. A. Dick ; Temp. Capt. J. Elder; Temp. Capt. (acting Major) J. D. One case of small-pox was notified during April from the Port Gunn ; Temp. Capt. G. B. Wild; Capt. R. Chevassut ; Capt. F. B. of London. The prevalence of scarlet fever was slightly less Jago; Capt. G. E. Tilsley; and Capt. W. A. Weatherhead, all of the than in the preceding month ; this disease was proportion- R.A.M.C. ally most prevalent in Shoreditch, Bethnal Green, Poplar, Kurdistan and Persia.-Capt. (acting Major) J. M. Weddell, Southwark, Deptford, and Greenwich. The Metropolitan R.A.M.C.; Lt.-Col. (Temp. Col.) J. A. Hamilton, C.M.G., I.M.S. Asylums Hospitals contained 1795 scarlet fever patients at the end of the month, against 2476, 2266, and 1981 at the the three the admissions FOREIGN end of preceding months ; weekly DECORATIONS. averaged 223, against 280, 279, and 240 in the three preceding JtaKaM. months. Diphtheria was somewhat less prevalent than in Order of the Crown of Italy.-Cavalier: Hon. Col. Sir A. Ogston, April; the greatest prevalence of this disease was recorded K.C.V.O., R.A.M.C. (T.F.); Bt. Maj. A. D. Grif7ith, R.A.M.C. (T.F.). in St. Pancras, Shoreditch, Bethnal Green, Poplar, Battersea, The number of under Serbian. and Wandsworth. diphtheria patients I treatment in the Metropolitan Asylums Hospitals, which Orderof the White Eagle" with Sworcis."-lst Class: Col. Sir A. E. had been 1971, 2003, and 1964 at the end of the three Wright, K.B.E., C.B., F.R.S., late A.M.S. 4th Class: Maj. C. L. Dunn, numbered 1937 at the end of I.M.S.; Surg. Lt.-Col. B. Pare.!’, C.M.G., D.S.O., Royal Horse Guards. preceding months, April; 5th Class : Temp. Capt. E. W. Archer, R.A.M.C.; Temp. Capt. G. H. the weekly admissions averaged 221, against 263, 240, Brown, R.A.M.C. ; Temp. Capt. G. S. Coghlan, M.B.E.,S.Afr.M.C.; late and 260 in the three preceding months. The pre- Temp. Capt. A. M. Fisher, R.A.M.C. ; Temp. Capt. J. W. Grice, valence of enteric fever was about half that in the R.A.M.C. ; Temp. Capt. E. E. Herga, M.C., R.A.M.C. ; Temp. Capt. three preceding months; of the 22 cases notified during 0. S. Kellett, R.A.M.C. ; Temp. Capt. F. H. Looney, R.A.M.C. ; the month, 3 belonged to Kensington, 3 to Islington, 2 to Temp. Capt. E. H. Ba,iney, B.A.M.C.; Capt. G. W. Rose, R.A.M.C. 2 to and 2 to Wandsworth. There (S.R.); Temp. Capt. W. J. Symes, R.A.M.C. Marylebone, Lambeth, were 29 cases of enteric fever under treatment in the Metro- politan Asylums Hospitals at the end of the month, against 25, 30, and 38 at the end of the three preceding months; the admissions 4, 6, and 6 in the three URBAN VITAL STATISTICS. weekly averaged against 4, preceding months. Erysipelas was proportionally most prevalent in St. Marylebone, Holborn, Finsbury, Bethnal and Woolwich. The 39 cases of VITAL STATISTICS OF LONDON DURING Green, Greenwich, puerperal fever included 7 in Wandsworth, 5 in Battersea, 4 in 1920. Lambeth, APRIL, and 3 in Islington. The 21 cases of cerebro-spinal fever IN the accompanying table will be found summarised included 3 in Islington, 3 in Bethnal Green, and 2 in South- statistics relating to sickness and mortality in .the City of wark, while the 2 cases of poliomyelitis belonged to London and in each of the metropolitan boroughs. With Lambeth. cases it The statistics in the table to regard to the notified of infectious disease, appears i mortality relate the deaths that the number of persons reported to be suffering from onei of civilians actually belonging to the several boroughs, the or other of the ten diseases notified in the table was equal to I deaths occurring in institutions having been distributed an annual rate of 6’7 per 1000 of the population, estimated at among the boroughs in which the deceased persons had 4,358,309 persons; in the three preceding months the rates previously resided. During the four weeks ended May lst. had been 8-5, 7-7, and 7-1 per 1000. Among the metropolitan the deaths of 5145 London residents were registered, equal boroughs the lowest rates from these diseases last month to an annual rate of 15’4 per 1000; in the three preceding were recorded in Paddington, Hammersmith, the City of months the rates had been 14’6,16’6, and 17’6 per 1000. The

ANALYSIS OF SICKNESS AND MORTALITY STATISTICS IN LONDON DURING APRIL, 1920. (Speciany compiled for THE LANCET.)

* Including membranous croup. 1193 death-rates ranged last month from 9-3 in Chelsea, 10’2 in Hampstead, 12-6 in Wandsworth, 12-6 in Woolwich, 13’2 in Fulham, 13-2 in Lewisham, and 13-2 in the City of West- minster, to 16’9 in the City of London, 16-9 in Poplar, 18-4 Correspondence. in Bermondsey, 18’7 in Stepney, 19-5 in Holborn, 19’9 in Bethnal Green, and 22-3 in Shoreditch. The 5145 deaths from " Audi alteram partem." all causes included 507, which were referred to the principal infectious diseases; of these, 1 resulted from small-pox, 223 from measles, 18 from scarlet fever, 69 from diphtheria, HELMINTHIC INFECTIONS IN RELATION 125 from whooping-cough, 9 from enteric fever, and 62 from TO PELLAGRA. diarrhoea and enteritis among children under 2 years of age. Among the metropolitan boroughs the lowest death- To the-Editor of THE LANCET. rates from these diseases were recorded in Chelsea, the City of Westminster, St. Marylebone, Hampstead, Finsbury, and SIR,-I have read with very great interest, in the Lewisham, and the highest in St. Pancras, Bethnal Green, issues of THE LANCET for May lst and Sth, the and Battersea. Bermondsey, The death from small-pox was important and suggestive articles on pellagra by Dr. that of a Norwegian sailor, and occurred at the South Wharf A. D. and Dr. J. I. with the Shelter of the situated in Bigland Enright, together Metropolitan Asylums Board, article views in Berrnondsey. The 223 deaths from measles were 27 fewer informing leading summarising present than the average number in the corresponding period of regard to the difficult and debatable question of the the five preceding years; this disease was proportionally aetiology of this disease. While Dr. Bigland had no most fatal in St. Pancras, Hackney, Bethnal Green, need whatever to refer to the quotation of the late Dr. Southwark, Bermondsey, and Battersea. The 18 fatal cases Sandwith in connexion with his own article, I am only of scarlet fever exceeded the and included average by 2, too conscious that it may be held to apply to my case in 3 in Lambeth, 3 in Camberwell, 2 in St. Marylebone, and to that helminthic infections 2 in Wandsworth. The 69 deaths from were 19 venturing suggest may diphtheria constitute a definite factor in I am above the average number ; the greatest proportional mor- setiological pellagra. tality from this disease occurred in Hammersmith, Fulham, emboldened, however, to take this risk because of the Islington, Finsbury, Shoreditch, and Wandsworth. The 125 arresting fact, which I learn for the first time from Dr. fatal cases of whooping-cough showed a decline of 18 from the Enright’s paper, that an outbreak of pellagra occurred average; this disease was proportionally most fatal in St. also among the well-fed German prisoners at the Pancras, Islington, StokeNewington, Bethnal Green, Stepney, beginning of 1919. As stated in the report of the and Poplar. Nine deaths from enteric fever were registered Committee to the outbreak the an of 5. The 62 fatal cases appointed investigate during month, against average the Turkish in the autumn of 1918, of infantile diarrhoea were 5 in excess of the average; the among prisoners greatest proportional mortality from this disease occurred there was no occurrence of pellagra among the in Paddington, Kensington, Holborn, the City of London, Germans up to the time when the Committee had Shoreditch, and Deptford. In conclusion, it may be stated concluded its inquiry. that the aggregate mortality in London during April from When I had the honour of being appointed to under these principal infectious diseases was 2’7 per cent. below take the protozoological and other incidental parasito the average in the corresponding period of the five preceding work for the Commission, I the years. logical approached subject of pellagra, which was entirely new to me, with a mind perfectly open and unbiased. I mention ended (Week May 22nd, 1920.) this, because the first thing that struck me on studying English and Welsh Towns.-In the 96 English and Welsh the available literature was the vehement manner in towns, with an aggregate civil population estimated at which the partisans of the two chief rival views- nearly 18 million persons, the annual rate of mortality, namely, the parasitic-infective hypothesis and that of which had been 14-2, 13’8, and 13’8 in the three preceding dietetic insufficiency-maintained and defended their fell to 13’2 1000. In with a weeks, per London, popula- attitudes. In the course of own examina- tion of million the annual death-rate respective my nearly 4 persons, tions I obtained not the indication that was 12-0, or 0-5 per 1000 below that recorded in the slightest any previous week, while among the remaining towns the protozoan, spirochsetal, or other minute organism could rates ranged from 4-3 in Eastbourne, 4-5 in Enfield, and be incriminated in connexion with the disease. The 5-4 in Oxford, to 20-3 in Blackburn, 23-7 in Sheffield, one finding which did make considerable impression and 25-2 in Tynemouth. The principal epidemic diseases on my mind was the prevalence of helminthic infec- caused 291 deaths, which corresponded to an annual rate of and in a lesser of 60 from tions, particularly ascaris, degree of 0-9 per 1000, and comprised 103 from measles, The actual of the whooping-cough, 56 from diphtheria, 53 from infantile diar- trichocephalus. percentage findings rhcea, 14 from scarlet fever, and 5 from enteric fever. eggs in the stools of Turkish pellagrous cases were : Measles caused a death-rate of 1-6 in Swansea, 1-7 in ascaris, 31’5 per cent. ; and trichocephalus, 21’6 per Wimbledon and in Blackburn, 1-8 in Newport (Mon.), and cent.; and, as I state in my own section of the report, 3’0 in Wigan; and whooping-cough of 1’6 in Middlesbrough " these figures by no means indicate the real proportion and 1-9 in Carlisle. The deaths from influenza, which had of Turkish prisoners infected, which- I estimate to and 216 in the three fell to been 202, 201, preceding weeks, have been twice as and more," and included 72 in 31 in 10 each in certainly high probably 211, Sheffield, London, for reasons there of it is to Birmingham and Manchester, and 8 in Rhondda. There given. (Eggs ankylostomum, be were not found in But I also were 1894 cases of diphtheria, 1734 of scarlet fever, and noted, any case.) 1 of small-pox under treatment in the Metropolitan Asylums examined, as controls, the stools of German prisoners Hospitals and the London Fever Hospital, against 1916, in the hospital-men in a nominally normal condition 1757, and 6 respectively at the end of the previous week. as regards their bowels-and found that they were The causes of 31 of the 4491 deaths in the 96 towns were also infected to a considerable extent with the above uncertified, of which 4 were registered in Birmingham, and in a less than were the 3 each in and Gateshead. nematodes, although degree London, Liverpool, Turks. Ascaris was found in 15 per cent. of the stools Scotch ToM-Hs.—In the 16 largest Scotch towns, with an examined, and here again the actual proportion was aggregate population estimated at nearly 2 million persons, much This observation the annual rate of which had been undoubtedly higher. surprised mortality, 18-3, 18-4, me somewhat, because these eggs occurred only most and 16-9 in the three preceding weeks, fell to 15-6 per 1000. The 375 exceptionally in British stools. deaths in Glasgow corresponded to an annual rate ’ of 17-6 per 1000, and included 17 from influenza, 12 from As a result of my own work and of the entirely measles, 6 each from small-pox and infantile diarrhoea, 5 negative findings on the bacteriological side I formed from diphtheria, 4 from whooping-cough, and 3 from scarlet the opinion that if any parasite were concerned in the fever. The 76 deaths in Edinburgh were equal to a rate of causation of the disease it must be one or more of these 11-6 per 1000, rand included a fatal case each of diphtheria well-known intestinal nematodes. Could ascaris and infantile diarrhoea. very (say) be regarded as a possible setiological factor? I Irih Toir)ts.-The 171 deaths in Dublin corresponded to an knew that ascaris, as a cause of or annual any general systemic rate of 21-5, or 0-9 per 1000 above that recorded in the was not considered and included 15 from 6 disturbance, usually seriously. And, previous week, whooping-cough, of there could not be in case between these from and 2 each from infantile diarrhoea and course, any measles, nematodes and the sole relation of influenza. The 124 deaths in Belfast were equal to a rate pellagra binding of 15-7 per 1000, and included 6 from infantile diarrhoea, cause and effect comparable to that obtaining in 3 each from scarlet fever and influenza, 2 from diphtheria, the case of many microbic diseases. Because such and 1 each from measles and whooping-cough. helminthic infections are known to occur in many