1842

primitive races will have an opportunity of examining a

series of 83 crania of a primitive tribe of negroes obtainedfrom a remote part of the Congo Free State. Mr. Rickman J.

Godlee has presented a series of casts illustrating the cases oftorus palatinus recently described by him. Mr. Shattock’s pre-parations to show the manner in which fat deposits are madein various members of the vertebrate form an instructive series.

Through Mr. T. P. Legge a specimen has been obtained fromWestern Australia to exemplify the operation of infundibula-tion practised by the aborigines of that part. Of the 90

specimens added to the pathological and teratological series,there are several of exceptional importance, and all of themshow some new feature of diseased action.

POOR-LAW MEDICAL OFFICERS’ ASSOCIATION.

As will be seen by a notice in another column the annualmeeting of this association, which is to be held in the verycentre of London-that is to say, the Guildhall-will include

a conference of the Poor-law Medical Officers of England andWales upon the recent reports of the Royal Commission onthe Poor-laws and Relief of Distress. It is particularlyhoped that as many Poor-law medical officers as possiblewill attend this conference, for three of the Royal Commis-sioners are to be present, and the papers to be read are

practical. It is probable, therefore, that the discussion

which will ensue will deal with the highly important subjectmatters in a valuable way, and that much light may be shedon the difficult question of the administrative methods

necessary to amend our existing system of medical relief.

EXCESSIVE URBAN MORTALITY IN IRELAND.

THE relatively high rate of mortality that prevails in theurban population of Ireland has scarcely received the atten-tion that the subject deserves. The returns issued by theregistrars-general for the several parts of the United Kingdomshow that while the death-rate during last year did not exceed13’8 and 15-2 2 per 1000 respectively, in London and Edin-burgh, it was equal to 23’0 in Dublin City and to 21’ 5 in itslarger registration area. This excessive urban mortalitywas not, however, confined to Dublin. It appears from

the Annual Summary issued by the Registrar-General for

Ireland, that the annual death-rate during the 53weeks of last year, in 22 of the principal urban

districts of Ireland (including Dublin), was equal to

20 2 per 1000, whereas the death-rate during the same

period in 76 of the largest towns in England and Wales(including London) did not exceed 14 ’ 9. The rate of urban

mortality in Ireland shows a marked excess, moreover, notonly in comparison with the rate of urban mortality inEngland and Scotland, but also when compared with themean rate of mortality in the whole population of Ireland.The above-mentioned death-rate of 14 ’ 9 per 1000 last yearin the 76 large English towns exceeded the mean death-ratein the entire population of England and Wales by but 0 - 2 2

per 1000; whereas in Ireland the mean rate in the 22

urban districts exceeded the rate in the entire population ofIreland by no less than 2 - 5 per 1000. This marked excess of

urban mortality in Ireland, whether compared with rates ofurban mortality in other parts of the United Kingdom, or withthe death-rate in the entire population of Ireland, calls for fulland careful investigation. It is a well-known fact, to which

special attention has been drawn in connexion with old-agepensions in Ireland, that the Irish population is abnormal asregards its age-constitution, containing as it does an undue

proportion of elderly persons, the result of the long-con-tinued emigration of young adults. The crude annual death-rate in Ireland was equal to 17 ’ 7 per 1000 both in 1907 andin 1908 ; but corrected for this exceptional age-constitution

on the hypothesis of an age-constitution identical with thatprevailing in England and Wales, the Irish death-rate in each,of those years is reduced to 16-1 per 1000. This corrected

rate, however, compares unfavourably with the death-rate inEngland and Wales, which did not exceed 15 - 0 in 1907 and14 ’ 7 in 1908. The Irish returns unfortunately do not afford themeans for correcting the Irish urban rate of mortality forthe abnormal age-constitution of the urban population, butas the age-constitution of urban populations is invariablyconducive to a lower rate of mortality than the age-constitu-tion of rural populations, it may safely be assumed that theexcess of mortality in the Irish towns, measured by the crudedeath-rate, is understated. The fact, therefore, that themean uncorrected death-rate in the 22 Irish town districts

during last year exceeded the death-rate in the whole ofIreland by 2’ 5 per 1000, or more than 14 per cent., affordsconclusive evidence of unsatisfactory sanitary condition inthe towns, calling for more efficient sanitary administration.

THE PROPHYLAXIS OF YELLOW FEVER.

IT cannot be said that the specific germ of yellow feverhas yet been discovered, but there is a general consensus ofopinion that it is an ultra-microscopic organism which defies-detection by the present means at our disposal. Based,however, on the discovery that the transmitting agent of thedisease is a mosquito, the Stegomyia fasciata (or calopus asit is termed by American experts), the mode of spread ofyellow fever and its prophylaxis have been fully and care-fully worked out during the last few years. Dr. G. M.

Guiteras, who has taken a conspicuous part in this work,has recently prepared a pamphlet on the ’’ Prophylaxis ofYellow Fever," which has been issued by Surgeon-GeneralW. Wyman, chief of the United States Public Health andMarine Hospital Service, as Bulletin 17 of the Yellow FeverInstitute. In this pamphlet Dr. Guiteras sets out the

principles on which prophylaxis of the malady is based.He emphasises the great importance of early diagnosis of thisdisease with a view to immediate notification, since it is awell-established fact that the stegomyia can only becomeinfected by biting a yellow fever patient some time duringthe first three days of the illness, but not afterwards. It is

therefore necessary at once to protect the patient from thebites of non-infected stegomyia: during those first three days,and afterwards to secure the protection of healthy personsfrom the bites of infected insects. It is admitted that earlydiagnosis is in many cases extremely difficult, and for thisreason Dr. Guiteras urges that all cases of febrile disturbance,the cause of which cannot be satisfactorily traced in localitieswhere yellow fever has appeared, should be regarded, atall events for the first three days, as true yellow fever,and properly protected against the bites of mosquitoes.Dr. Guiteras places great importance on educating thepublic as to facts concerning yellow fever and the

way in which it is spread, so that their help may begiven in the measures directed against the transmittingagent. He points out that if war against mosquitoes’generally were declared, not only would the diffusion of

yellow fever be checked but also that of malaria. All

important facts as to the transmission of the malady bymosquitoes should be taught in public and private schools as.well as in colleges in those areas where yellow fever is

liable to appear. Children should be taught to dread a

mosquito as they now do other insects. Public opinionshould be so guided as to make it regard the mosquito, notonly as a disagreeable pest, but also as a very dangerous one.All collections of water should be abolished or covered with

oil, and all cisterns should be screened securely with fine-meshed metallic gauze. Regular and systematic house-to-house inspection should be carried out weekly if possible to,

1843

see that no " water containers " exist capable of harbouring a

mosquito larvae. The use also of small fish in collections of r

water which cannot otherwise be dealt with is recommended, t

Lastly, the removal of all unnecessary obstructive vegeta- t

tion and the screening of doors and windows of dwellings should be carried out in infected areas. The complete exter- c

mination of mosquitoes, it is admitted, is hardly practicable, a

but relative extermination is well worth attempting and is r

likely to diminish the danger. In times of serious epidemics f

of yellow fever Dr. Guiteras would go so far as to invoke the t

aid of "martial law," since he regards the present powers i

.available under the Republican Government to be inadequate to secure house-to-house inspection and compulsory removal of all cases to hospital. With "martial law" to sup-

port the health officials, he contends that the pro-

phylactic measures which he advocates could be better

enforced in every detail, and outbreaks of yellow fever

would thus be more effectually controlled. In connexion with Dr. Guiteras’s recommendations it is interesting to notethat in most of our own West Indian colonies much the same (

measures are now being, and for some time back have been,successfully enforced. From a letter quite recently written to the Times by Sir Rubert Boyce, who had been sent to theWest Indies to advise the local governments respecting a tthreatened epidemic of yellow fever, we learn that pupil (

teachers, sanitary inspectors, and others are now being trained by means of lectures, demonstrations, and healthprimers to take part in a determined effort to rid (these colonies of mosquito-carried disease. It is now (

a punishable offence to harbour mosquito larvæ uponthe premises, and already a considerable number of con- ]

victions have been secured with fines varying from ls.

to 40s. A careful study is being made of the local ]

breeding-places of mosquitoes, and also investigations astothe natural enemies of mosquito larvæ. One of theseenemies has been found in the small fish named "millions," ,quantities of which are now being exported to other tropical countries on this account. Both Dr. Guiteras and Sir Rubert

Boyce are convinced that if the measures above indicated were effectually and persistently carried out, yellow feverwould not often trouble those fair and fertile regions inwhich it so often appears, to the legitimate alarm of theinhabitants and the detriment of trade and commerce.

FALSE ECONOMIES IN THE ROYAL ARSENALHOSPITAL.

WOOLWICH, or at all events that very large portion of theresidents who are connected with the Royal Arsenal, is

seriously disturbed by a rumour that the medical depart-ment of the Arsenal is to be cut down-presumably to saveexpense to the War Office. Some years ago the numberof medical officers was increased from three to four,and the small hospital, which had been almost exclusivelyused for accident cases occurring in the works, was added to,and surgical cases of all kinds occurring among the

employees were admitted and operated upon, greatly to

the advantage of the men, as there is no general hospital inthe neighbourhood that can be counted upon as certainlyavailable. The Woolwich and Plumstead Cottage Hos-

pital on Shooter’s Hill has only a very small number of beds,although it is fully equipped for the most serious opera-tions. At Greenwich, though there is, besides the Seamen’sHospital, the Miller Hospital, the accommodation is stilltoo limited, and consequently the Arsenal employees havegreatly valued the opportunity afforded them of surgical aidwithin the walls of the Arsenal itself. This accommodationis now, it is understood, to be put an end to, only cases ofaccident while at work or exceptionally urgent ones,such as strangulated hernia or acute appendicitis, being

admissible. The number of medical officers ’ is to beeduced to three and further economies will be effected

)y the reduction of the nursing staff. Henceforth,therefore, a workman suffering from hernia, varicose

eins, chronic appendicitis, fistula, or tumour, instead)f being operated on in the Arsenal hospital, where thereare always expert military surgeons able and willing torelieve him, must go to swell the numbers already waitingfor admission to Guy’s or some other London hospital. Wetrust that the Government will pay more heed than it seemsinclined to do to the opinions of its own officials in Wool-wich, and will recognise the tragedies which may follow onany cheeseparing in respect of the surgical equipment of theArsenal.

____

ABDOMINAL ARTERIO-SCLEROSIS.

ONLY within recent years has the fact been recognised-principally in consequence of the work of German observers-that arterio-sclerosis of the abdominal arteries may cause

distressing abdominal symptoms, an abdominal analogue ofangina pectoris. This fact is important, for abdominal

arterio-sclerosis is not uncommon, and when it producessymptoms these are misunderstood and regarded as due togastric and intestinal affections. The diagnosis is not diffi-

cult if the practitioner bears in mind the possibility ofsuch a condition ; if he does not, a mistake is inevit-

able. In the Journal of the American Medical Associationof June 5th Dr. H. L. Akin has pointed out the fre-quency with which the symptoms of arterio-sclerosis in theabdomen are regarded as due to gastric disorder and hasreported a number of cases. A stockman, aged 56 years,who had enjoyed good health, " began to have trouble withhis stomach." He took only two meals a day-a heartydinner and supper. In the morning he felt well, but afterdinner or supper if he walked a quarter or half a mile heexperienced a feeling of fulness in the epigastrium and painunder the ensiform cartilage running down the left arm. He

felt oppressed as if he could not breathe and must stop for atime. On stopping he belched up much gas and then couldproceed without further trouble. If he sat still for half an

hour after meals he generally had no symptoms. If hedrank much fluid with his meals, especially ice-water or tea,he generally had an attack. His bowels acted regularly. Hewas a large meat eater and was subject to attacksof gout about every six months. The aortic second soundwas accentuated ; the pulse was 90 and of high tension. The

urine contained a little albumin, but no casts. The acidityof the gastric juice was normal. As this was the first case

of the kind which Dr. Akin observed he regarded it as

simply gastric. He prescribed three meals a day, restrictionof meat, and rest, which gave temporary relief. Then a

typical attack of angina pectoris showed the true nature ofthe case. In a second case a healthy farmer, aged 55 years,began to have gastric symptoms. After supper his stomachbecame distended with gas and he had a feeling of

oppression so that he could not lie down. Eructation

gave immediate relief. He was treated without effect

by many practitioners for dyspepsia and then for dilata-tion of the stomach. Examination showed a doubleaortic murmur, an enlarged ascending aortic arch, andgeneral arterio-sclerosis. Rest and vaso-dilators followed

by potassium iodide gave much more relief than the gastrictreatment. In other cases the symptoms are intestinal,pains around and below the umbilicus coming on two orthree hours after meals, and tympanites. In such cases

Ortner has found after death the aorta thickened and

calcified, a thick deposit of lime salts about the mouths

of its branches, especially the mesenteric arteries, and thesmall branches of the latter rigid and contracted. The