348 GEOGRAPHY OF MORTALITY FROM BRONCHITIS, ETC.

In the same situations actinomycosis may be thecausative factor.

Malignant Disease.Malignant disease is one of the rarest causes of

sinus, but it must be borne in mind. In thisconnexion it is as well to mention that sinuses of longduration, perhaps usually associated with very deep-seated and chronic bone disease, may eventuallythemselves become engrafted with epithelioma,although this is a very rare event.

The Indications for Treatment.A sinus should never be allowed to persist without

an attempt at its diagnosis and cure. It is not onlyan annoyance, but a potential source of danger,because it may be a focus for continuous septicabsorption and it is liable to outbursts of acuteinfection. Chronic absorption may lead to a wholetrain of evil symptoms, sometimes even culminating inlardaceous disease. Tetanus has been known to ariseand malignant disease may certainly follow. For thesereasons every, sinus requires careful investigation :—

1. By ascertaining the history accurately and bycritical consideration of all the circumstances.

2. By ordinary examination with the object ofascertaining its relation to surrounding parts.

3. By X ray examination, in some cases with theaid of opaque injections.

4. By cautious use of the probe.5. By noting the effect of treatment.6. By reconsideration from time to time.From what has been said it is clear that the most

important indication is to discover and remove thecause, and if this is done the great majority will soonheal.

G. GREY TURNER, M.S. Durh., F.R.C.S. Eng.,Professor of Surgery in the University of Durham ;

Surgeon, Royal Infirmary, Newcastle-on-Tyne.

The Services.ROYAL NAVAL MEDICAL SERVICE.

Surg. Lt.-Comdr. (D) T. A. B. Corless is placed on Retd.List at own request.

Surg. Lt.-Comdr. A. W. Gunn to be Surg. Comdr.Surg. Lt. A. H. Harkins to be Surg. Lt.-Comdr.The following appointments are notified :-Surg.

Comdr.: C. H. M. Gimlette to President, addl., forthree months’ post-graduate course. Surg. Lt.-Comdrs.:A. W. McRorie to President, addl., for three months’ post-graduate course ; F. C. Hunot to y’oM’)M<M<<A,’ and W. E.Heath to Fisgard ; L. S. Goss to Suffolk; and J. C. Brownto Vivid, for Rodney. Surg. Lts. : N. A. Dickinson to Hermes ; ;and L. P. Spero to Adamant.

ROYAL NAVAL VOLUNTEER RESERVE.

Proby. Surg. Sub-Lts. F. T. Doleman and A. R. Thomasto be Surg. Sub-Lts.

ROYAL ARMY MEDICAL CORPS.Lt.-Col. J. H. R. Winder retires on ret. pay.Capts. to be Majs. : T. Menzies, D. H. Murray, E. Under-

hill, R. A. Mansell, and J. T. Scrogie.Lts. to be Capts. : C. R. Christian, C. W. Greenway,

R. J. Rosie, J. Huston, and E. G. Dalziel.

ROYAL HOSPITAL, CHELSEA.

Physician and Surgeon: Maj. E. A. Strachan, viceMaj. E. T. Potts, C.M.G., D.S.O., who has vacated the appt. I,

REGULAR ARMY RESERVE OF OFFICERS.

Col. T. C. MacKenzie, late R.A.M.C., having attainedthe age limit of liability to recall, ceases to belong to theRes. of Off. ’

TERRITORIAL ARMY.

Lt. A. H. Macklin to be Capt.E. J. G. Glass (late Offr. Cadet, Edinburgh Univ. Contgt.,

Sen. Div., O.T.C.), F. Lishman, J. N. Russell, F. Heywood-Jones, and M. S. Scott to be Lts.The King has conferred the Territorial Decoration upon

Lt.-Col. Andrew Johnstone Brown and Majs. Henry NevilleBurroughes and Ronald Ogier Ward.

ROYAL AIR FORCE.

Squadron Leader F. C. Jobson relinquishes his com-

mission on completion of service.

Special Articles.THE GEOGRAPHY OF MORTALITY FROM

BRONCHITIS AND PNEUMONIA.

NEARLY one-seventh of deaths from all causes

come under the two rubrics of bronchitis and pneu-monia, and a study of the incidence of these diseases,which the Registrar-General’s report! renders possible,is therefore of great importance. Such a study leadsinevitably to the conclusion that a large part ofmortality from these diseases is avoidable. A partof the teaching of Tables XLVI. and XLVII. in thereport can be seen graphically displayed in Figs. 1and 2. These diagrams show for three divisions ofEngland the male and female death-rates for theyears 1921-25 from bronchitis and pneumonia respec-tively at each of seven age-periods, in proportion tothe mortality for the same ages in England andWales stated as 100.

FIG. 1.

AGES 0 5 5 25 45 65 75 0 5 15 25 45 65 75Death-rates from bronchitis showing topographical variations.

County boroughs and rural districts in each of threesections of England-north, midland, and south-are contrasted in each instance for males and females.separately. Wales has been omitted from the com-parison, but it may be stated broadly that it is onlysurpassed in its unfavourable mortality by thenorth of England. It will be seen that in county

1 The Registrar-General’s Statistical Review of England andWales for the year 1925. Text. H.M. Stationery Office. 5s.

349BERLIN.

boroughs, both for males and females, the death-rate from bronchitis is much higher in the north thanin the midlands, and higher in the midlands thanin the south at most ages. The same excess is shownin rural districts in the north, though on an appreciablylower scale. Similar remarks apply to the mortalityfrom pneumonia, with differences in detail whichcan be best studied in the diagrams.

FiG. 2.

Similar death-rates from pneumonia. -- -

IWhy should the population in the northern areas,

and particularly in urban districts, thus sufferexcessively ? One naturally thinks of the severe

climatic conditions of the north, of its excessiverainfall and humidity, of its deficiency in sunshine,and of its fogs. These might be assumed to apply bothin urban and rural districts ; but the diagrams showthat although rural, like urban, mortality from thesediseases is excessive, the rural excess is at a muchlower absolute level than the urban. Taking thefigures for males the relative death-rates at ages0-5 in county boroughs in the north and southrespectively for bronchitis are as 152 :84, and inrural districts in the north and south respectively areas 133 : 47. At ages 25-45 the corresponding figuresare 172 : 60 and 56 : 26. Similar differences can betraced in the figures for pneumonia. It is clear thatclimate does not form an adequate explanation ofthese differences between north and south, nor ofthe differences in north and south between towns andcountry districts. That climate does not form anadequate explanation is further indicated, as pointedout in the Registrar-General’s report, by the figuresVI hich show that the infant diarrhoea rate of the northis more than double that of the south, that of themidlands being intermediate in regard to bothdiarrhoea and respiratory diseases. Here are the

figures for diarrhcea in the north and south respec-tively :-

County Rural

Relative death-rates fro boroughs. districts.

Relative death-rates from North 154 85diarrhoea and enter- " -- 154= ...... 85

itis, that of England South .... 63 32being stated as 100 )South .... bj ...... 32

Diarrhoea in large measure, given other equalconditions, is a measure of summer temperature.Yet the north suffers excessively from it. As statedin the Registrar-General’s report, simultaneousexcesses of 74 per cent. for mortality supposed to bepromoted by cold and of over 100 per cent. for

mortality known to be promoted by heat cannotboth be explained on the score of climate. It isevident that conditions other than climate are notequal; and that in regard to diarrhoea, as in regardto bronchitis and pneumonia, evils exist to an extentwhich is not equalled in the midlands and still lessin the south. What are these ? Do industrialoccupations explain the difference ? If so, the excessivemortality from bronchitis and pneumonia ought tooccur chiefly at the working ages of life ; whereasthe diagrams show that it is great at all ages,and in rural districts is greatest in childhood forbronchitis. That industrial occupations, althoughdoubtless concerned, do not give the chief key to thesituation is especially indicated by the differencesfound between the bronchitic mortality of childrenunder 5 in north and south. In the north this is152:133 for male children in county boroughsand in rural districts respectively; and 68 : 47 incorresponding parts in the south. Here evidentlyoccupational evils are not primarily concerned.

It may be safely stated then that quite irrespectiveof differences in climate or in occupational conditionsthere is a terrible excess of bronchitis and pneumoniain northern districts, rural as well as urban, thoughespecially in urban districts. That this difference isnot due in the main to unfavourable climate is furthershown by the fact that in summer these same northerndistricts, rural and urban, have an excessive diarrhoealdeath-rate, although the summer temperature inthe north is much less favourable to epidemic diarrhoeathan that in the south. There is needed more detailedlocal analysis both of northern, midland, and Welshfigures, by means of which it would be practicable tobring out possible important differences in the inci-dence of these diseases. Meanwhile it may be takenas almost axiomatic that all that is involved in theword " sanitation," and in the standard of housingand of life in general, are lower and less satisfactoryin the north than in the rest of England ; and thisgeneral conclusion should cause searchings of heartand serious efforts at generalised reform on the partof public health authorities throughout the crowdedindustrial and rural districts of the north.

BERLIN.

(FROM OUR OWN CORRESPONDENT.)

Official Recognition of " Natural Medicine."THE parliament of Thuringia has granted the sum

of M.100,000 (JMOOO) as a first instalment towardsthe construction of a State clinic for natural medicinein Jena. This has led to a protest by the medicalfaculty of Jena University, in which it is shown thatso-called natural medicine is not a special science,and that its methods-so far as they are valuable-are used by the medical profession. The facultypoints out that it would be dangerous to patients ofthe clinic if these methods alone were employed for thetreatment of disease, to the exclusion of others whichlong experience has shown to be useful. Exceptionis taken to the Government’s action in adopting theplan without asking the opinion of the medical facultyof Jena or the medical chamber of Thuringia. The

money spent on the new clinic would, it is thought,be more usefully devoted to improvement of the old