482 n Paddington, the City of Westminster, Finsbury, Shore- VITAL STATISTICS OF LONDON DURING JULY, 1905. , litch, and Wandsworth, The 32 cases of scarlet fever were IN the accompanying table will be found summarisedL4 below the average for the corresponding periods of the complete statistics relating to sickness and mortality in the;en years ; the greatest proportional mortality from this City of London and in each of the metropolitan boroughs.lisease occurred in Fulham, Bethnal Green, Poplar, With regard to the notified cases of infectious disease it Lambeth, and Battersea. The 24 deaths from diphtheria appears that the number of persons reported to be sufferingihowed a decline of 97 from the corrected average number; from one or other of the nine diseases specified in the tableunong the various metropolitan boroughs this disease was was equal to an annual rate of 6 ’ 8 per 1000 of the population, proportionally most fatal in Kensington. Fulham, Hackney, estimated at 4,684,794 persons in the middle of the year. Bethnal Green, and Poplar. The 78 deaths from whooping- In the three preceding months the rates had been 5 6, 6 ’ 2, }ough were 53 below the average number in the correspond- and 6 ’8 per 1000 respectively. The lowest rates last month ing periods of the ten preceding years ; this disease were recorded in Kensington, the City of Westminster, St. showed the greatest proportional mortality in Fulham, Pancras, Holborn, the City of London, and Greenwich ; while Islington, Finsbury, Shoreditch, Stepney, Poplar, Lambeth, the highest rates occurred in Fulham, Shoreditch, Bethnal and Battersea. The 18 fatal cases of " fever showed a Green, Stepney, and Poplar. Small-pox was less prevalent decline of 15 from the corrected average number ; than it had been in the preceding month ; of the four cases Eour of the deaths belonged to Stepney, three to notified during July one each belonged to Islington, Islington, and two to St. Marylebone. The 361 deaths Finsbury, Bethnal Green, and Deptford. The Metropolitan from diarrhoea were 291 below the average number in Asylums hospitals contained three small-pox patients at the the corresponding periods of the ten preceding years; end of last month, against 16, nine, and four at the end of this disease was proportionally most fatal in Fulham, the three preceding months ; the weekly admissions averaged Hackney, Finsbury, Shoreditch, Bethnal Green, Stepney, one, against four, two, and two in the three preceding and Poplar. In conclusion, it may be stated that the months. The prevalence of scarlet fever was slightly greater aggregate mortality in London last month from the than in the preceding month ; among the various metro- principal infectious diseases was more than 45 per cent. politan boroughs this disease was proportionally most below the average. prevalent in Fulham, Shoreditch, Bethnal Green, Stepney, Infant mortality, measured by the proportion of deaths Poplar, Camberwell, and Deptford. The number of scarlet among children under one year of age to registered births, fever patients in the Metropolitan Asylums hospitals, which was equal to 112 per 1000. The lowest rates of infant had been 2152, 2236, and 2444 at the end of the three mortality were recorded in St. Marylebone, Holborn, the preceding months, had further risen to 2527 at the end of City of London, Camberwell, Lewisham, and Woolwich; last month ; the weekly admissions averaged 338, against and the highest rates in Kensington, Fulham, Hackney, 266, 302, and 301 in the three preceding months. Diph- Finsbury, Shoreditch, and Bethnal Green. theria was slightly less prevalent during July than in the preceding month ; the greatest proportional prevalence of this disease occurred in Stoke Newington, Hackney, Stepney, THE SERVICES. Poplar, and Woolwich. The Metropolitan Asylums hospitals contained 785 diphtheria patients at the end of July, against 719, 684, and 715 at the end of the three preceding ROYAL NAVY MEDICAL SERVICE. months ; the weekly admissions averaged 118, against 83, THE following appointments are notified :-Fleet Surgeon 89, and 111 in the three preceding months. The prevalence E. H. H. de Courtmacsherry, to Royal Naval Engineering of enteric fever was considerably greater than in the pre- College, Keyham. Surgeons : H. F. Iliewicz to the ceding month ; among the various metropolitan boroughs P01Verfnl,. J. Barry to the Centurion; G. E. Kennedy to this disease was proportionally most prevalent in Paddington. the Royal Oak; A. J. Pickthorn to the Ocean; and W. P. Chelsea, St. Marylebone, Hackney, Shoreditch, Bethnal Dyer and C. R. Sheward to the President, for three months’ Green, and Stepney. The number of enteric fever patients study at West London Hospital. remaining under treatment in the Metropolitan Asylums VOLUNTEER CORPS. at the end of last month was hospitals 94, against 65, 80, fxarrrison 3rd Kent and 78 at the end of the three the Royal Artillery (Vol1lnteers): (Royal preceding months ; Bernard Hudson to be weekly admissions averaged 17, against 11, 14, and 10 in Arsenal) : Surgeon-Lieutenant (dated the three months. was July 8th, 1905). preceding Erysipelas proportionally lst Volunteer Battalion the Suffolk most in St. Rifle : Regiment : prevalent Paddington, Chelsea, Marylebone, Herbert to be Bethnal and The 16 Mayris Sylvester Surgeon-Lieutenant (dated Hackney, Shoreditch, Green, Stepney. 3rd Volunteer Battalion the Bedford- cases of fever notified the month included August 1st, 1905). puerperal during shire J. W. Bone his two in the of two in and two in Regiment : Surgeon-Captain resigns City Westminster, Stepney, commission 3rd Volunteer Southwark. (dated August lst, 1905). Battalion the East Richard William The statistics in the table relate to the deaths Surrey Regiment : mortality Brimacombe to be of to the various the Surgeon-Lieutenant (dated August lst, persons actually belonging boroughs, 1st Volunteer Battalion the Gordon deaths in institutions dis- 1905). Highlanders : occurring public having been G. M. Edmond his commission tributed the in which Surgeon-Major resigns (dated among boroughs the deceased persons The Prince of Wales’s Own 12th Mid- had resided. the four weeks August lst, 1905). previously During ending dlesex Robert Welsh the deaths of 4279 (Civil Service) : Acting Surgeon July 29th persons belonging to London Branthwaite, Cadet attached to the were to an annual rate of Corps (Civil Service), registered, equal 11’9 9 per 1000 ; Prince of Wales’s Own 12th Middlesex months the rates had been (Civil Service) in the three preceding 15 1, Volunteer Rifle to be and to 14’ and 12 ’ 1 1000. The rates last month from Corps, Surgeon-Lieutenant 0, per ranged be borne as Supernumerary to the Establishment (dated 6 - 9 in Lewlsham, 8’ 3 in Hampstead, 9 6 in Islington, July 31st, 1905). 14th Middlesex (Inns of Court) : The 9’8 8 in Camberwell, and 9’9 9 in Wandsworth, to 14’0 0 in undermentioned officer resigns his commission :-Surgeon- the City of London and in Stepney, 14’4 in Bethnal Green, Captain F. C. Wallis (dated July 17th, 1905). 14’ 6 in Fulham and in Poplar, 17’ 4 in Finsbury, and 28’ 9 in Shoreditch. The 4279 deaths from all causes in ARMY MEDICAL RESERVE OF OFFICERS. London last month included 604 which were referred to the Surgeon-Major A. B Wade to be Surgeon-Lieutenant- principal infectious diseases; of these, 91 resulted from Colonel (dated July 29th, 1905) Surgeon-Lieutenant- measles, 32 from scarlet fever, 24 from diphtheria, 78 from Colonel D. E. Flinn, having resigned his commission in the whooping-cough, 17 from enteric fever, one from ill-defined Volunteers, ceases to belong to the Army Medical Reserve pyrexia, and 361 from diarrhoea, but not any from small-pox of Officers (dated August 5th, 1905). or from typhus fever. No death from any of these diseases OUR ARMY MEDICAL SERVICE. was recorded in Stoke the Newington ; among metropolitan The is an extract from Lord Roberts’s address on caused the lowest death-rates in Chelsea, following boroughs they defence on lst at a of the of the of Imperial August special meeting City Westminster, Hampstead, City London, members of the London Chamber of Commerce at the Camberwell, and Lewisham ; and the rates in highest Mansion as in the 1905 : Fulham, Finsbury, Shoreditch, Bethnal Green, Stepney, and House, reported Times, August 2nd, as the I have Poplar. The 91 deaths from measles were but half of Alarming figures quoted are, they only apply to the combatant branch of the there are other branches the correct the various metro- army ; important average number; among upon the efficiency of which the success of a campaign in no small politan boroughs this disease was proportionally most fatal degree depends. One very important branch is the medical. There 483 was a great outcry ill this country during the South African war when rarely now do we meet with the fulminating death-dealing it became known that the number of medical officers and nurses was scarlet fever that used to be prevalent ?7 Scarlet insufficient and that there was a lack of proper hospital equipment epidemics fever is now a almost exanthem. More and appliances. Civil surgeons and nurses w ere hurriedly entrained, mild, non-pyrexial additional field hospitals were despatched, and the timely aid afforded by frequently than not the child has little or no ra&h, is per- private persons was eagerly accepted. But the fact remains that for the fectly well after a couple of days’ slight feverishness, and first few months of the war the medical ere arrangements quite unequal returns to school in a week. fever is now as often to cope with the strain put upon them. For this I do not think anyone Typhoid can be blamed. Certainly not the medical officers, who were most accompanied with constipation as with diarrhoea, and small- devoted and untiring in their endeavours to overcome the enormous pox as modified by vaccination is almost unrecognisable difficulties with which had to contend. It had been they generally an In these circumstances mistakes do accepted that the mM’mttm strength of any force despatched from this except by expert. country would not exceed two army corps-sav, 75.000 men—whereas the and will occur, giving cause for the uninitiated layman to force actually employ ed amounted to bstween 300,000 and 400,000 scattered blaspheme and the profession to be condemned in consequence. over a area rail and for the vast with inadequate transport, greater part Recognising this fact and that the mistakes are not always without roads. But it will not be possible on any future occasion to make allowances for failure in the medical arrangements. We have due to ignorance alone, what means have we as a profession been taught by sad experience that we must be prepared for a much or what means have the various sanitary bodies for the more larger force being sent into the field than was contemplated before the effectual checking or stopping of these errors and their -South African war and a much larger percentage of disease. Yet at results ?7 With the of the present we are not, much better off as regards medical requirements profession, course, encouragement than we were in 1899; for although the Royal Army Medical Corps was of more perfect study of the various infectious disorders and increased bv 125 officers and 1200 other ranks under Mr. Brodrick’s the modifications met with will immediately occur to one. régime. out of its own establishment it can now only provide for an With to the various the of expeditionary force 55,000 strong. It has been proposed to supple- regard sanitary bodies, provision inent the personnel by the addition of 45 per cent. of civil surgeons ancl shelters for observation, of some provision for bacteriological 37 per cent. of civil subordinates, which would provide for a force investigation, for the examination of slides, for the supply 73,000 strong; and certain further proposals have been made bv the of tubes for Widal the examination and of Board which if would enable the Medical reaction, staining Advisory adopted Royal Army the of antitoxin have done Corps to deal with a force 140,000 strong. But both these proposals are sputum, supply (how many still only under consideration, nothing has been done. and, as matters these ?), and lastly, the willing cooperation of the medical now stand, the balance of any larger force than 55,000 would have to officer of health in consultation in difficult cases. take the field ithout trained establishment whatever. friendly any properly With to the could not No help could possibly be afforded to the army in India, which would regard Metropolitan Asylums Board, be sadly in need of medical aid in the event of a prolonged war. it provide some observation wards where cases of doubtful nature could remain under observation for a few hours and not be pushed straight into the wards ?7 It must be remem- bered, too, that cases admitted with one kind of dit-ea-e have been inoculated with others during their stay in these hos- Correspondence. pitals, so that errors occur inside as well as outside. To lessen the evil effects of these errors and the disrepute that 11 Audi alterslm partem," they bring to the profession must be my excuse for ventila- ting my protest and urging the necessity of finding a MISTAKES IN THE DIAGNOSIS OF remedy if possible. I am, Sirs, yours faithfully, INFECTIOUS DISEASE. Kensington, August 8th, 1905. RICHARD BEVAN. To the Editors THE LANCET. of ANATOMICAL PECULIARITIES OF A SiRs,-The statement of the chairman of the statistical committee of the Metropolitan Asylums Board last week and GALL-BLADDER. the pointed prominence given to it by the press (with respect To the Editors of THE LANCET. mistakes and of of the to the 2000 loss 12,000 ratepayers’ SIRS,-The following may be of interest in count xion with and is no doubt intended money), on the face of it implies, Dr. Fergmon Lemon’s case of abnormality of the gall-bladder so to a reflection on the of the London do, grave competency reported in THE LANCET of May 13th, p. 1265. I had occasion medical men and draws marked attention to the:r inability recently to make a necropsy on the body of an Italian to the various infectious disorders to diagnose correctly who was killed by an explosion of dynamite in a mine in this which they may in their daily round be called and the district. On opening th abdomen I noticed that the’gall- thereof to the I am to acknow- consequences public. willing bladder was apparently absent. On turning up the liver a ledge that it is unfortunate so many should have occurred slight elevation of the usual colour of the gall-bladder and that not has the been to all intents and only money was seen on the under surface of the right lobe about purposes wasted but also that the patients have been two inches from the anterior border. On incision it proved into contact with diseases which needlessly brought they to be a normally sized gall-bladder containing bile, almost themselves did not suffer from-a much more serious matter entirely embedded in the liver substance. As in Dr. than loss of and but is there to be said money time ; nothing Lemon’s case, the coat of the gall-bladder was marked off on behalf of the who is called on poor practitioner suddenly very definitely from the liver substance but unlike his case to make an immediate of the case and to act on diagnosis was of normal thickness. The cystic duct ran for some it? As one of these and one whose latter, diagnosis having distance through the liver substance, emerged at a small been reviewed has been found I be allowed to wanting, may fissure of its own near the transverse fissure, and joined the plead extenuating circumstances in mitigation of judgment hepatic duct in the usual situation. The fissuring and and some of the circumstances in which explain possible lobulation of the liver were most irregular but the gall- some of these errors occur ? bladder, liver, and all other organs were quite healthy. The case to which I was called was one of apparently I am, Sirs, yours faithfully, diphtheria and I gather from the general statement in the H. GERALD LOUGHRAN. newspapers that many or most of the errors occurred in Western Australia, July 7th, 1905. diagnosing this disorder. I say apparently it was one of diphtheria, for all the clinical symptoms were identical with LONDON SANITATION. those of that disorder. It occurred in the house of a training home for servant girls, with no possible accommodation for To the Editors /1 THE LANCET. isolation. What was one to do? Theoretically one ought SIRS,-I desire to bring under your observation a most to have isolated the patient until one had taken a swab objectionable and insanitary practice which takes place on from the throat and had this examined and the diagnosis six days of the week during the fruit season in London. confirmed or otherwise. In the circumstances, how- Carts bring to Covent Garden Market from the surrounding ever, I took on myself the responsibility of notify- country baskets of strawberries, other fruits, and vegetables, ing the case and of having it immediately removed, and return to the country with the empty baskets packed and with all that I now know (and I have had a very with, and in contact with, horse dung and other manure. considerable acquaintance with diphtheria) I should in the I have not the least doubt that these same baskets are again circumstances assume the risk again, and I have the approval filled up the following day with market produce to be brought of the medical officer of health for the action. Now, Sirs, to Covent Garden and that the same thing is repeated day not only is there considerable difficulty in the correct recog- after day, the only cleansing that the baskets get being nition of the various membranous sore-throats but since probably a washing with cold water, if even that. This joining the profession (I am sorry to say a good many year" practice may be constantly seen on the roads that lead.out ago) the typical symptoms of various of the infectious of London and more particularly on the Hounslow-road. diseases have been more or less altered. For instance, how I returned from West Africa a few weeks ago and was