258 REPORT FOR 1908 OF THE ADMINISTRATIVE COUNTY OF LONDON.

their lumen. It is when the two factors-smallness of lumenand high rate of Row—cooperate, as in the case of a hyper-tonic arteriole, that resistance reaches its maximum. Nothingbetter shows the small effect of high rate of flow alone inopposing resistance than the comparatively small resistance(equivalent to about 20 mm. Hg) offered by the pulmonarycircuit, in spite of the fact that the mean rate of flow throughthis circuit is considerably greater than that through thesystemic circuit.

(c) Eddies. -Hitherto we have considered the flow of bloodin a portion of vessel devoid of branches. In such a case the

particles of blood flow, as we have seen, in parallel stream ttubes. This is true whether the vessel is straight or tmoderately curved. In the former case the.stream tubes are

straight; in the latter (as in a moderately tortuous vessel)they are curved, blood friction in each case being causedsimply and solely by a sliding of the parallel stream tubesone within the other. The particles constituting the moving column of blood do

not, however, always flow in this regular manner. In certaincases, as when a sharp twist of a vessel occurs (as in the arch of the aorta), or when the blood stream is diverted from themain trunk of an artery into a branch, or, again, when twobranches of a vein meet in a common trunk, the blood

particles no longer advance in parallel lines, but tend to crossone another at varying angles, thereby forming eddies, andthis leads to an augmentation of resistance. We shall see,however, that in the engineering of the vascular systemspecial precautions have been taken to reduce this source ofresistance to a minimum.

Influence of length of vessel on resistance.-Though resist-ance increases directly with length of vessel, it is importantto note that great length of vessel does not necessarily implygreat resistance. Many considerations prove this. Considerhow small is the fall of blood pressure in the larger systemicarteries, and in the entire pulmonary circuit; how easily theblood flows into the systemic veins when the systemicarterioles relax ; and again, how small is the amount of

pressure needful, even in the larger mammalia, to drive theblood from the systemic capillaries through the entire venoussystem into the right heart. The comparative independenceof resistance on mere length of tubing is further shown bythe fact that although the systemic circuit is made up of anumber of individual circuits of varying lengths (comparethe length of the coronary circuit, e.g., with that of the

femoral) they all offer much the same resistance. It is onlywhen the bore of the vessel is small, while at the same timethe contained blood is flowing rapidly, as in the case of thespermatic arteries, that length of vessel has marked influenceon resistance. 6

It should be observed that in so far as tortuosity increasesresistance it is by an increase in length of vessel and not byvirtue of the tortuosity as such, inasmuch as the tubestreams in a tortuous vessel (unless, perhaps, the tortuosityis extreme) remain parallel, eddies being thus absent. It is,indeed, easy to show that the flow of fluid through a flexibletube is practically unaffected by rendering it tortuous. Ithas to be remembered, however, that in the case of theblood-vessels tortuosity implies increase of length and mayin this way lead to increase of resistance, and it is conceiv-able that the tortuosity of certain vessels, such as the

coronary arteries and the spermatic arteries (in certainanimals—e.g., the ram and the bull), may be for the purposeof offering increased resistance, though I am doubtful ofthis. In other arteries, such as the facial and vertebral,the object of tortuosity is apparently to allow the vessels toadapt themselves to the movements of surrounding parts.

In pathologically tortuous arteries there is always loss ofelasticity, and there may be irregularities of the interiorfrom degenerative changes, both of which conditions makefor increased resistance. On the other hand, pathologicaltortuosity of blood-vessels is always accompanied by a

dilatation of them, and this tends to diminish resistance.By far the shortest vessels in the body are the capillaries,

which are probably not more than 1-2000th part the lengthof the entire systemic segment, a fact which helps to explainwhy these vessels offer so little resistance to the blood flow.

(To be continued.)

The question here arises whether the great length of thespermatic arteries may serve a physiological purpose by sheltering thecapillaries of the testes from the great pressure of the aortic blood, andwhether we have here a clue to the extra-abdominal position of theseorgans in the mammalia. Among other arguments against this view isthe fact that the ovaries are intia-abdominal.

ANNUAL REPORT FOR 1908 OF THE

MEDICAL OFFICER OF HEALTH OF

THE ADMINISTRATIVE COUNTY

OF LONDON.

11.1

CONTINUING our review of Part I. of this report we notethe reproduction from previous reports of the standardtables of mortality as well as of the usual diagramsshowing the incidence of the common infectious maladiesand of other prevalent diseases in the several metropolitanareas.

It will be known to most of our readers that usefulsummaries of these facts are contributed by the countymedical officer of health to the weekly and quarterlyreturns of the Registrar-General, but in the present reportthey are presented in greater detail, the facts being groupedaccording to age and sex, and in some cases corrected forerrors in diagnosis.

Principal Epidemic Diseases.

Among diseases of the epidemic class the notification ofwhich is not at present compulsory measles has recentlyattracted much attention from the district health officers,who derive their information as to occurrence of cases mainlyfrom the teachers in elementary schools. Most of theannual reports show the number of cases thus coming toofficial knowledge, but the figures are obviously incompleteand do not correspond to the number of deaths frommeasles registered in the respective districts. As a result ofrecent changes in the birth-rate, the proportion of the popu-lation now living at the earlier ages has diminished to suchan extent that Sir Shirley Murphy has found it necessary tocalculate the mortality from this and other children’s diseasesin terms of the numbers living at ages under five years.From the results of this process for 1908 it appears that inthe sanitary area of Hampstead the deaths from measles didnot exceed 30 in each 100,000 living at this age, whereas theproportion rose to 558 in the same number living in BethnalGreen, 608 in Bermondsey, and 621 in Stepney. Social con-dition is found to determine very largely the mortality fromthis disease, the death-rate rising steadily with the increaseof overcrowding, as measured by the proportion of the popu-lation living more than two in a room in tenements of lessthan five rooms. For example, in those sanitary areas wherethe proportion of overcrowding did not exceed 7 - 5 per cent.the measles death-rate averaged 212 per 100,000 living atages under five years, whilst in those areas where 27 ’ 5 percent. of overcrowding existed the rate amounted to 457 in thesame number living. Among preventive measures, account isgiven of Dr. Kerr’s method for the limitation of measlesinfection with the least disturbance of education. Whenmeasles appears in a school the practice adopted is tomake closure of class-rooms depend on the number ofchildren who are not known to have already had measles, andwho are presumably susceptible to infection. The exclusionof susceptible children in preference to class-room closurehas often been found the most profitable course. It hasfurther been observed that in order to be useful closure ofschoolrooms must take place at the first manifestation ofdisease and before the whole class has become infected from

’ the earliest cases.

, Very similar to the behaviour of measles was that of. whooping-cough. In the year 1908 it was less destructive

. than in any previous year. The deaths in London at agesunder five years were at the rate of 184 per 100,000 living, ascompared with 421 in the decennium last completed. Whenthe London sanitary districts are grouped according to theproportions of the population living more than two in a roomthe mortality from whooping-cough varies almost exactly asdoes that of measles-i.e., it increases Pari _pass2t with theincrease of overcrowding. Thus, according to the experienceof the last eight years, whooping-cough was fatal to childrenunder five years old at the rate of 229 per 100,000 living inthe least crowded metropolitan areas, whilst it amounted to331 per 100,000 in the most crowded areas.

1 A previous notice of this report appeared in THE LANCET ofJan. 15th, p. 196.

259’REPORT FOR 1908 OF THE ADMINISTRATIVE COUNTY OF LONDON. [J

Compulsory Notification of Infectious Disease.The administrative advantages of compulsory notification

are growing steadily apparent each successive year, andnowhere more so than in the cases of scarlet fever and diph-theria, which diseases in their relation to elementaryeducation tax quite exceptionally both the skill and the

patience of medical officers of health. Under the Notifica-tion Act statistics of scarlet fever and of diphtheriaprevalence in London are now available for every year since1890. And in the present report diagrams are given showingthe ratio of cases to population, as well as the percentagefatality among the cases occurring in each month of the last17 years. The tables showing the distribution of scarlet feverattacks at various ages are exceedingly valuable, for the factsare now sufficiently numerous to eliminate error due to paucityof data. In both sexes the year of life in which the greatestproportion of scarlet fever attacks occur is the fourth, andthis is true for each of the periods from 1893-95 to 1906-08inclusive. In this connexion, however, Sir Shirley Murphyhas drawn attention to the fact that in consequence of thedeclining birth-rate the age constitution of the child

population has considerably changed, and it is certainthat this change will affect the figures in thesetables when the data of the next census are available.With the object of indicating recent changes in the ageincidence of scarlet fever, tables are appended which showthat the general decline observed at most other ages has notbeen experienced at ages 3, 4, and 5 years among males, orat ages 4, 5, and 20 years among females. According to theexperience of 1908 the first and second years of life are themost fatal to infants suffering from scarlet fever. The usualtable is inserted showing the relation of holiday influence toscarlet fever prevalence in London during 1908. From thisit appears that during the four weeks of summer holidayinfluence there was a decrease equal to 11 per cent. in thenotified attacks of scarlet fever amongst children of schoolage--i.e., from 3 to 13 years-whilst in the four weeksfollowing the weeks of holiday influence there was an

increase of 45 per cent. in the notified attacks. Interestingexcerpts are quoted from the reports of district medicalofficers of health, giving particulars of the spread of scarletfever by means of mild and unrecognised cases, and withrespect to these Sir Shirley Murphy remarks that "theability to limit the spread of this disease depends on theopportunity for prompt detection of first cases. The absenceof a child from school is often the first indication that the childmay be ill. Any arrangements which can be made to secureearlier knowledge of the cause of this absence promise to lessenthe opportunity for infection of other members of the familyif the school child is suffering from an infective malady. Inthe same way such improved arrangements would lessen theprobability that a child suffering from a mild attack ofscarlet fever would return to school after a few days’absence and before it had ceased to be infectious." It is

satisfactory to learn that the proportion of notified cases ofscarlet fever admitted to the hospitals of the MetropolitanAsylums Board continues to be very large, averaging between85 and 90 per cent. in the last five years.Diphtheria prevalence in the metropolis has not varied

greatly in the course of the last five years, the cases notifiedhaving ranged from 1 4 to 1 - 8 in each 1000 of the popula-tion, and the case mortality from 8 4 to 10 per cent. of theattacks. It is desirable, however, to point out that boththese rates may be affected by the degree in which bac-

teriological methods are employed for diagnostic purposes,for it is certain that their systematic use leads to the detec-tion of clinically mild cases of diphtheria which otherwisewould probably have escaped notice. Sir Shirley Murphyreports that the use of bacteriological methods for adminis-trative purposes continues to increase in London. Inthe year under notice more than 8000 bacteriologicalexaminations were made, one-fifth part of which gavepositive results. Particulars are given of the procedureadopted in various districts for limiting the spread of diph-theria. For example, in Bermondsey whenever a case is

reported other members of the family are invited to submitto bacteriological examination, which is repeated after thepatient’s return home from hospital. Of 315 persons thusexamined, 13 were found harbouring diphtheria bacilli, andof these 4 subsequently developed that disease. In YB’ands-worth, on the occurrence of diphtheria in the schools, thethroats of all contacts are swabbed. The houses of absentees

are visited and all children with sore throats are treated’similarly. No child is allowed to return to school untilfound to be free from diphtheria bacilli. Again, inCamberwell all children who have been treated at homeare examined bacteriologically before return to school. Inthe quinquennial period 1903-07 diphtheria was most de-structive in the sanitary area of Poplar, and least so in theCity of Westminster and in Hampstead. In London gene-rally the incidence of attack was greatest upon both malesand females of the age of three years, whilst the incidenceof death was greatest among males of one year and amongfemales of three years old. In both sexes the fatalitywas greatest among infants under the age of one year.The usual table is repeated showing the influence of thesummer holidays on diphtheria prevalence among childrenof school age. From this we note that in the four weeks of

holiday influence there was a decrease of 1 per cent. in thenotified cases of diphtheria at ages 3-13, whilst in the fourweeks following the weeks of holiday influence the notified’cases showed an increase of 21 per cent. From an instruc-tive table showing the fluctuations of diphtheria prevalenceat the various ages, it appears that when the corrected ratesof 1906-08 are compared with those of 1893-95, the agesunder five have not shared equally with the older ages in thedecline of diphtheria incidence recorded in the table.

Enteric fever prevalence in London has shown little changeduring the last four years, the notified cases in each yearhaving been in the proportion of 3 per 10,000 of the popula-tion at all ages-a rate which compares favourably with thatof the decennium 1891-1900, which was 8 in the samenumber living. Among metropolitan districts in the period1898-1907 enteric fever was most prevalent in Poplar and in,Shoreditch, where the reported cases were equal to a rate of9 per 10,000 living; it was least prevalent in Lewisham,where the rate did not exceed 3’ in the same population.During the year 1908 the case-rate, the death-rate, andthe percentage fatality among the notified cases of entericfever were higher among males than among females. The

greatest incidence of attack was upon males at ages from15 to 20, and upon females at ages from 10 to 15. The

greatest incidence of death was upon males from 35 to 45,and upon females from 25 to 45. The proportional fatalityamong the notified cases was highest among males of 55years and upwards, and among females between the ages of45 and 55. The behaviour of enteric fever in recent years-has been peculiar in this respect, that several local pre-valences of the disease have occurred in poor populations,and lasting often for a considerable period. In the yearunder notice two such prevalences are reported, one inBethnal Green, the other in Shoreditch. By the courtesy ofDr. G. P. Bate, Dr. Hamer was allowed the opportunity ofinvestigating the former outbreak, whilst Dr. L. T. F. Bryettsupplied him with the means of investigating the latter.It would appear that both Dr. Bate and Dr. Bryett con-sider the prevalences in these respective districts to be dueto infection from person to person, whilst Dr. Hamer, on thecontrary, sees reason for thinking them to have been causedby an infected food-supply. In both districts the localityimplicated was occupied by very poor persons living undersqualid conditions. In Shoreditch it was found that innumerous instances two or three, or even more, cases hadoccurred in a single house. The epidemic in Bethnal Greenoccurred in the months of September and October, whilstthat in Shoreditch extended over a much longer period.

Ticberculous Phthisis in London.In his remarks on the behaviour of mortality from

pulmonary tuberculosis or tuberculous phthisis in themetropolis Sir Shirley Murphy is able to report a furthercontinuance of the decline which has been observed inrecent years, the death-rate from that disease havingbeen equal to 1-32 per 1000 living at all ages, which isthe lowest metropolitan rate on record, but is higher thanthe rate in England and Wales by 0 - 21 per 1000. If theLondon rates for the periods 1901-04 and 1905-08 be com-pared we find that the mortality has declined by 13’ 2 per cent.By studying the distribution of fatal phthisis in its relationto age and sex Sir Shirley Murphy arrives at the conclusionthat with the decline of phthisis mortality in London altera-tion is taking place in the age incidence of death. Com-

paring the mortality in 1901-07 with that of the five

decennial periods immediately preceding he tells us that,broadly speaking, the decline in phthisis mortality among

260 MEDICINE IN SOCIETY IN THE FOURTH CENTURY A.D.

persons above the age of 15 years has been most markedamong females, while among persons below that age thedecline has been more nearly the same in both sexes. Thisbehaviour of the figures he regards as consistent with thehypothesis that improvement in the conditions of home lifehas been a material factor in the decline, inasmuch as homeconditions would probably affect males above the age of 15in a less degree than females, while both sexes under thatage would probably be more evenly affected. A well-knowntable of former reports is repeated here, showing the closerelation which exists between social conditions as measuredby "overcrowding and excessive phthisis mortality. Thetable relates to the period 1901-08, and from it we learn thatwhereas in the least overcrowded metropolitan districts thedeath-rate from phthisis is equal to 1 . 062 per 1000, in themost overcrowded districts it is nearly double that amount,or 2’ 080 per 1000. Sir Shirley Murphy gives an account ofthe various administrative measures either existing or in

contemplation for the control of phthisis prevalence in themetropolis, and to them we purpose to refer on a futureoccasion.

(To be continued.)

MEDICINE IN SOCIETY IN THE FOURTH

CENTURY A.D.

MEDICINE and kindred studies have always possessed a ]

charm for non-medical persons, and this for various reasons.There is one class the members of which are always glad tohave the opportunity of meeting " dear Doctor ———," in thehope that they may obtain some information of value withoutthe necessity of paying a fee. Others discuss medicalmatters which they do not understand, but which they fancythey would like to, probably on the principle of " omne

ignotum pro magnifico " ; and others, again, put forwardmedical or physiological problems from a genuine wish toobtain knowledge about their bodies. All these classes aremuch in evidence at the present day, and every medical manwho mixes much in general society must be aware howfrequently medical matters are discussed at social gatherings.Appendicitis has had its day, and the fashionable lady ofthe hour instead of asking her neighbour as to the health ofher children, languidly inquires, "And how is your opsonicindex’? " Mutatis mutandis, however, all this is nothing new,for Plutarch in his "Symposiacs" " has collected the sub-stance of various conversations, " which both at Rome and inGreece we have disputed on amidst our cups and feastings."

"

Among the subjects discussed were various questions dealingwith medicine and natural philosophy, and a great part ofthese Macrobius, circa A.D. 380, 11 sifted for his Saturnalia.Practically nothing is known of Macrobius apart from hisworks. But among his friends were some of the great menof the day, and we may mention Praetextatus, Symmachus,Flavian, Caecina Albinus, and Servius, the well-known com-mentator on Virgil. Macrobius introduced all these peopleinto his " Saturnalia," a, treatise which he wrote for the useof his son, and which may be called a fourth-century"Complete Gentleman." It dealt mainly with Virgil as

being "omnium disciplinarum peritus," and the work iswritten as a symposium. The persons of the dialogues arerepresented as meeting during the Saturnalia, which lastedthree days, at the houses of Praetextatus, Flavian, and

Symmachus. At the meetings they discussed various

subjects, and among others sundry medical and scientificsubjects which are treated in Book VII. The book

opens with a discussion on the art of conversation. It is

extremely bad taste, says one of the characters in thebook, Eustathius, to ask a man a question in company unlesshe knows his subject well. For in that case he will eitherhave to confess his ignorance, which will put him to shame,or else he must answer rashly and at haphazard when againhis ignorance will sooner or later be apparent (VII. 2, 5).Praetextatus remarked, "Come, now, all you men, let us talkof something fitting conviviality, not so much about eating asabout the nature of our bodies or other matters, especially ashere is our friend Disarius, who is specially fitted from hislearning and his art for the discussion of matters such asthese, and let each one of us put a question in turn"(VII. 4, 1).

All the guests decided that Praetextatus should ask thefirst question, and accordingly he said, "I wish to knowwhether a simple or a varied diet (simplex an multiplexcibus) is the more easily digested and which is the betterfor health ? " Disarius, who is described as the leadingphysician of the day at Rome (Qai tune Romae praestarevidebatur ceteris medendi artem professis, I. 7, 1), promptlyreplied : " If any unskilled person had asked me this question,I should have told him (since common people always learnbetter from example than from reason) to look at cattle,whose diet is simple and uniform, and which are far morehealthy than human beings. But those cattle which are

picked out to be fatted and are fed on spiced cake (ofEa)often fall ill. Then, too, I should ask him: ’What wouldyou think of a physician who showed so gross neglect in thetreatment of a fever patient as to order him a mixed dietand not a simple one ?’ Again, a variety of food is to beavoided just as much as mixing your drinks. Everyoneknows that a man who drinks different kinds of wine sud-denly gets drunk, and that, too, without having taken verymuch." Disarius went on to say that Praetextatus being alearned man did not want example but reason, and he thenlaunched out into a long discourse upon the physiology ofdigestion which we may summarise as follows :-.." Indi-gestion arises either from the quality of the juice into whichthe food is converted, so that it is unfitting for the humor’which occupies (obtinuit) the body, or from the variety ofthe food itself, so that the natural forces are not powerfulenough to break down all the substances with which theyhave to deal. If a man takes one food alone he knows atonce whether it suits him or no; if it does not, he knows thatthat particular food is to be avoided. A mixed diet, on theother hand, produces a variety of juices and the humours ’which are produced thereby do not agree with one another.Moreover, the blood into which these are translated by theagency of the liver is neither properly fluid nor pure, andpasses turbulently into the veins. Hence arises a very fountainof diseases from the warring of the discordant humours.

Again, in a mixed diet the various substances are not all

digested at the same rate and so the sequence of the digestiveprocess is upset. All food really undergoes four digestions,and, besides, there are four forms of energy (quattuor sunt innobis virtutes) which deal with the food. The first is that bywhich the food is attracted into the stomach, the second thatby which it is retained, the third is that by which it is trans-muted from one thing into another, and the fourth is that bywhich the transmuted food is separated into that which isused in the body and that which is cast out. The four

digestions are the following : the first in the stomach ; thesecond in the liver; the third in the veins and arteries, wherethe watery part is separated and goes into the bladder andthe pure, fattening blood is distributed all over the body ;while the fourth is that process by which every member ofthe body takes up what is necessary for it. All this elaboratearrangement is likely to be upset by a mixed diet." This

argument having met with the approval of the company,Evangelus, who is the rude young man of the book, exhortsEustathius to argue on the other side, which he proceeds todo at great length. Disarius replies that Eustathius hadtreated the subject as a matter of dialectic, but that hehimself had argued as a physician. "But,"he adds, I I tryboth and experience will teach you which is the better forhealth."

Considerations of space forbid us to give in detail all theproblems which are discussed, but we may mention some ofthem. Flavianus asks, Why, according to Aristotle,do women very rarely get drunk but old men do so

easily ? Disarius is of opinion that the system of a womanbeing very moist and her body being full of pores the wineevaporates very quickly, whereas an old man has a dry, hardskin, through which the wine cannot easily pass, whence itascends to the very seat of the mind. Evangelus asks why aman becomes giddy if he spins round. Disarius answersthat the body can move in seven different ways-forwards,backwards, to the left, to the right, upwards, downwards,and with a rotational movement. Of all these motions thelast alone is found in divine bodies such as the stars, andordinary animals are not accustomed to it. Hence, if theyare spun round, the" spiramentum," " by which the brain andindeed all the senses of the body are governed, is over-whelmed by the humours, and dizziness, tottering, and lossof sight supervene. But by practice the spiramentum can