1039

ANNUAL REPORT (FOR 1901) OF THEREGISTRAR-GENERAL OF ENGLAND

AND WALES.

II.1

AMONG the many purposes served by the national recordsof English mortality from specified causes is this-that theyconstitute a standard by which may be measured the mor- altality from corresponding causes in particular administrative tl pcounties, urban and rural sanitary districts, the sanitary cir- ucumstances of which are, or ought to be, under constant o

medical supervision. In our editorial capacity we are fre- tlquently applied to by medical officers of health for standard p

data of this nature needed by them for the compilation of their local reports ; and here we pause to remind our official b

correspondents that within six weeks of the close of each h

year the Registrar-General publishes in his return for the n

fourth quarter the vital statistics concerning the country o

generally, the inclusion of which in the annual reports of tmedical officers of health is required by the Local Govern- dment Board. e

To return to the volume before us, we notice that in the preport for 1901 an attempt has for the first time been made t

to establish a normcc with which the several death-rates, not v

for urban districts alone but for rural districts also, may t

properly be compared. o

In consequence of the changes in the character of rural Icommunities that are constantly being effected by the è

"urbanising process" everywhere going on accurate dis- v

crimination between urban and rural aggregates of adminis- a

trative areas is found to be impracticable. The following Iexpedient, however, has been adopted as the best attainable ...

in present circumstances. A selection from among the i

English counties has been made so as to show in one list icertain counties that are chiefly urban in character and c

contain most of the industrial centres, and in another list I

certain counties that are exclusively rural or that contain Fonly a few small towns which, although technically styled Iurban, nevertheless partake of that character to a slight t

degree only. In this way a rough sorting of counties into iurban and rural has been established which, although not

r

ideally perfect, will nevertheless usefully serve the object in i

view-namely, that of furnishing criteria by which the ihealth conditions of individual urban and rural areas respec- Itively may be tested. ]

In the case of such diseases as pulmonary phthisis, entericfever, diarrhoea, or pneumonia it would be futile to comparethe mortality in a distinctively rural area such as that ofShropshire or of Somersetshire with the corresponding mor-tality in England and Wales, more than half of the popula-tion of which is essentially urban in character. Equallyfutile would it be to compare with the same standard the

mortality from any of these diseases in a vast urban com-munity like that of Manchester or Birmingham, for it will

readily appear on reference to the tables that the mortalityfrom every one of the diseases mentioned is enormouslygreater amid the unhealthy conditions of our crowded townsthan in the sparsely populated areas of our country districts.Therefore, in order that the mortality from a given cause ina rural area may be rendered fairly comparable with that inan urban area allowance must be made for differences of ageconstitution of the population.

In the earlier portion of this report a table is givenwhich shows that almost without exception the mortality inthe several counties that are mainly urban has been in-creased, whilst that in the mainly rural counties has beenreduced, by correction for the differences referred to. Thatthis is the case will clearly appear if the mortality ofLancashire, an essentially urban county, be contrasted withthat of Norfolk, which is mainly rural; for whilst the rates ofmortality uncorrected for age differences of population showan excess in the case of Lancashire amounting to only 20per cent., the corrected rates show an excess of 53 per cent.The explanation is obvious. for whereas in the increasingpopulation of Lancashire 85 per cent. of the people arefound living at ages from five to 65 years, and only 15 percent. at ages outside these limits, in the relatively stationary

1 The first notice was published in THE LANCET of Sept. 26th, p. 900.

population of Norfolk the proportions are 81 and 19 percent. respectively. Thus, of the population exposed to thehigh risk of mortality attaching to the beginning and theend of life there is a much larger proportion living inNorfolk than in Lancashire. It is, therefore, apparent thatwherever great differences exist in the age constitution ofcommunities their several death-rates must be modified inorder to allow of valid comparison.

Tuberculosis and cancer, two diseases the prevalence of’which has recently engrossed a large share of publicattention, are treated of in considerable detail in the

present report. From an interesting table which comparesthe mortality from pulmonary phthisis at several age groupsin quinquennial periods at the beginning and the endof the last quarter of a century we learn that in 1901this disease was fatal to 1487 per 1,000,000 of the malepopulation of England and to 1055 of the female, themale rate having decreased since 1876-80 by 28 per cent.and the female rate by not less than 42 per cent. Amongboth males and females the reduction in the death-rate-has been greatest at ages below 35 years. Males sufferedmore severely than females in London and in most of theother English counties, the male rate of mortality fromthis disease in the county of Warwick being nearlydouble the female rate. After correction for age differ-ences in the several populations the death-rate frompulmonary phthisis among males at all ages is higher inthe urban than in the rural counties by 29 per cent.,whilst among females the urban and rural rates are prac-tically identical. When, however, separate account is takenof the mortality at particular ages it is found that among’persons of both sexes at ages from 15 to 35 years thedisease is more fatal in the rural districts than in the urban,whilst at all other ages the reverse is the case. This

apparent exception in favour of the towns suggests com-parison with the case of pneumonia, the mortality fromwhich disease is greater at all ages in the town than

! in the country. The explanation probably lies eitherin the circumstance that migration frequently takes placeof young country-bred adults to the towns or in thenature of the diseases themselves. It may reasonably besupposed that as a rule the more vigorous of the youngpeople are attracted to the towns in expectation of lucrativeemployment and we know that a portion of these eventuallyfall victims either to pulmonary phthisis or to pneumonia.The course of the former disease is generally chronic, itsi victims tending to become incapable of sustained exertionfor a considerable period before death. The course of- pneumonia, on the other hand, is generally so rapid as to

prevent the patient’s removal to long distances from theplace of attack. Consequently, in the former case manyof the patients return to their native places and their deathsf are there recorded ; in the latter case such return will almost- certainly be the exception. Moreover, the longer the period- of residence in a town the less is the probability of return tothe country in case of disablement ; in the first place, the

3 previous home is less likely to be available, and in the-- second place the patient is more likely to be tied to the town1 by the responsibilities of a family.from these considerations it might almost have been fore-yseen that the increase of mortality from pulmonary phthisis.s in rural districts caused by the return of natives from the. towns would be limited to a small group of ages. The tablen shows that this has actually been the case, for in both sexesn after the thirty-fifth year this mortality in the rural counties-e is seen to be much lower than in the urban.

From cancer the mortality in England and Wales duringn 1901 was the highest on record. Among males it was fatalQ at the rate of 691 per 1,000.000 living, which exceeded the decennial average rate by 16 per cent. Among females then rate was 985 per 1,000,000, or 9 per cent. in excess of thet average. The present report contains two new tables whicht show for males and for females separately the relative-h frequency with which cancer affects the different parts of’f the body. The ages at death of the victims to cancer arealso stated. The statistics of 1901 confirm those of previous0 years in showing that malignant disease is much more fatalt. among women than among men, but it still remains true-g that this is because of the tendency of cancer to affectre the generative and mammary organs of the female ratherr than those of the male. In the year 1901 the male- y deaths from malignant disease less those from afEec-

tions of the organs referred to were equal to a rate of. 673 per 1,000,000 living, whilst the female rate with the-

1040

same limitation did not exceed 575 per 1,000,000. It is inthe case of diseases like cancer, which are fatal chiefly atparticular ages, that the necessity of correction of the death-rates after the method already referred to is especiallyapparent. The mortality from malignant disease at agesbelow 35 years is small and is generally disregarded, but ifthe cancer mortality in 1901 at all ages over 35 years bejudged of by the uncorrected rates it will appear to be

higher in the rural counties than in the urban, whereas if thecorrected rates be examined the opposite conclusion follows,for the rural mortality is in that case shown to be the lower.In the calculation of local cancer rates of mortality a seriouscomplication arises from the occurrence of the deaths of

many country patients in the hospitals of our great townsand their registration there. In addition to this it wouldbe absurd to assume that the place of every patient’s lastresidence before death had been also the place of origin ofhis disease.Among the other interesting matters dealt with in the

present volume we have only space left to notice one moresection which now appears for the first time-namely, thatrelating to infantile mortality. The mortality among infantsand very young children has always been regarded as a

valuable test of salubrity and for this reason Dr. Tathamhas thought well to devote to it special attention in the

present report. Two important new tables have now beeninserted. In one of them the mortality of infants under oneyear of age is calculated in terms of registered births in1901, and in the other the mortality of children under fiveyears old is shown as a proportion of the population estimatedto be living at that age in the middle of the year. Thesetables have been prepared to show the death-rates fromseveral causes in each of the English counties but on

examining critically the local mortality very great differencesbecame manifest according as the areas selected are urbanor rural in character. In another pair of tables the mortalityin the urban and rural list of counties before referred to isshown, from which it appears that both among infants intheir first year and among children of less thanfive years the mortality is considerably greater inthe urban group of counties than in the rural, andthis is true whether the total mortality or the mortalityfrom all the specified causes (with one exception) is put incomparison. It is noteworthy that at ages under one yearas well as at ages under five years, boys die more rapidlythan do girls and this is the case with respect to the ruralquite as markedly as to the urban districts.

In concluding our notice of this report we need only saythat in its present greatly improved form it will be found aserviceable and almost indispensable addition to the libraryof the medical officer of health.

THE CHOLERA EPIDEMIC IN SYRIA.

(FROM THE BRITISH DELEGATE TO THE OTTOMAN BOARDOF HEALTH.)..L.L..[!..!.t1..LL1..Ll...)

THAT a great part of the Syrian interior, and to a lessextent the coast, has been and is still being seriously ravagedby cholera there is unfortunately no room to doubt. The

probability of a still more extensive spread of the disease inthe near East and of its ultimate appearance in Europe itselfis so great that serious attention may be usefully directed tothe course the disease has followed hitherto, and no apologyis needed for giving in some detail what is known ofits behaviour in Syria during the past few months. Beforedoing so it will be convenient to recall the history ofthe epidemic in the Turkish empire since it first appearedthere some year and a half ago. This has been alreadygiven in detail in successive letters to THE LANCET 1 and maybe briefly summarised here.

Cholera broke out among the pilgrims to Mecca andMedina early in March, 1902. It caused a considerablebut not excessive mortality among them, and at theend of the pilgrimage almost disappeared from the

Hedjaz. At the end of May it appeared in the Yemenand through the summer and autumn was seriously prevalentin several places along this portion of the Arabian coast, asalso at Yambo and elsewhere. It reappeared in Medina in

1 THE LANCET, March 4th (p. 916), July 5th (p. 39), and Nov. 22nd(p. 1414), 1902, and Jan. 31st (p. 324), and April 11th (p. 1052) 1903.

September. The Assyr province has also been the scene ofa rather serious outbreak. Cholera was first recognised inEgypt in July and caused a widespread, though nota remarkably intense, epidemic, which lasted through theautumn and the early part of the winter. From Egyptcholera was carried to Syria at the end of September. Itwas the cause of a considerable mortality on the coast andin the interior of Palestine ; it appeared in the Hauran, andat the end of November it was reported from Damascus. It

was epidemic here until the middle of February, when it dis-appeared only to break out again a month later. Throughthe later months of the winter and early spring the diseasewas confined to Damascus. Its subsequent course here hasbeen as follows.

Throughout the month of April the number of cases of,and deaths from, cholera in Damascus varied from betweennil and three each day. Towards the end of the month therewere several days together during which no fresh case wasreported. But occasional cases continued to occur throughApril and May, and towards the end of May it was officiallyadmitted that the disease had appeared in several villagesoutside the town of Damascus itself. In the town theofficial figures would indicate that the cholera remainedcomparatively quiescent, causing only sporadic cases, untilthe second week in July, when it became more active, andthat since that date it has been truly epidemic. The follow-ing are the figures publit-hed in the official bulletins since thebeginning of the recrudescence of cholera on March 18thlast :-

Cholera in Damascus.

The totals are believed to be very considerably below thetruth.The first known cases of cholera outside Damascus duricg

the present summer occurred at Katana, the centre of adistrict of the same name, situated some three hours " (say,15 miles) to the south-west of Damascus. On inquiry, it wasascertained that on May 24th a woman inhabiting Katanawas attacked with symptoms of cholera but recovered. Herfather fell ill on the morning of the 25th and died at11 o’clock the same night. Three other persons were

attacked on the same day and died after illnesses varyingfrom five and a half to 20 hours. Another death occurred onthe 26th ; the patient, a woman, had suffered from dianhceafor several days previously. On the 27th a seventh person, aman, was taken ill at 6 o’clock in the evening and died sevenhours later. Cases continued to occur here until June 26th,since which date Katana has disappeared from the bulletins.It is not, however, quite clear whether this indicates acomplete cessation of the epidemic there.On June lst news was received of the appearance of

cholera at Zebdani, some 20 miles to the north-west ofDamascus, and having a station on the line of railway fromBeirut. The first case was that of a vegetable-seller whohad left the village for Damascus on May 20th and returnedto Zebdani on the 24th. He fell ill on the following morningwith colic, diarrhoea, vomiting, cramps, and cyanosis, anddied on the 26th. About the same time cases were reportedfrom Douma, a few miles east of Damascus. Two men fellill here with cholera on May 28th and died on the following