298 HEALTH OF THE NAVY IN 1925.

quently replaced by those of 1920. It seems strangethat similar regulations for Scotland are only nowappearing. It has been calculated that, with adeath-rate of 500,000 per annum, an area of500 acres must be set aside yearly if earth burialis the method of disposing of the dead. Such afigure indicates to burial authorities that cremationhas economic, as well as hygienic, advantages, yetcremation is but slowly overcoming the naturallyconservative feelings of the community. As THELANCET has remarked before, the only seriousargument against the burning of the dead is thesupposed danger that it may destroy the evidenceof foul play. We find that danger slight. Beforethe Cremation Act was passed in 1902 cases were

known in which persons had resorted to burningas a means of preventing an inquest. Since theCremation Act has been passed and the burning ofbodies has been meticulously regulated, it has neverbeen suggested that cremation has been used for theconcealment of crime. Murderers like CRIPPEN andARMSTRONG, whose guilt was established by evidencefrom the bodies of their victims, might have savedtheir necks if the bodies had been burnt and exhuma-tion thus made impossible ; but they knew betterthan to run the risk of the medical supervision andexamination which the Act enjoins.

In 1926, when Parliament wisely tightened upour system of death certification in the interests ofpublic safety, it was the danger of concealing crimeby earth burial rather than by cremation whichrequired attention. The Cremation Regulations forEngland were made more stringent last year, and itis hard to see what more effective safeguards againstfoul play could be devised.3 To summarise themonce more, cremation can take place only at a recog-nised ’crematorium. Except where an inquest hasbeen held and a coroner’s certificate given, no crema-tion is allowed until the death of the deceased hasbeen duly registered or a certificate has been givenin pursuance of Section 2 (2) of the Act of 1926,that the death of the deceased is not required bylaw to be registered in England. Cremation cannottake place without the following formalities : First,there must be an application on Form A, with statutorydeclaration by an executor or by the nearest survivingrelative ; if anyone else makes the application hemust show good reason why he does so, and why theexecutor or nearest relative does not. Then theremust be a certificate on Form B, by the registeredmedical practitioner who attended the deceased inhis last illness and who can certify definitely as tothe cause of death, and a confirmatory certificateon Form C by another medical practitioner possessingspecially prescribed qualifications. Forms B and Care not dispensed with unless there has been eitheran inquest or a special post-mortem examinationby an expert pathologist. The statutory functionsof the medical referee are particularly important.He must refuse to permit cremation unless satisfiedthat the fact and cause of death have been definitelyascertained ; " and, in particular, if the cause ofdeath assigned in the medical certificate be such as,regard being had to all the circumstances, might bedue to poison, to violence, to any illegal operation,or to privation or neglect, he shall require a post-mortem examination to be held, and, if that fails toreveal the cause of death, shall decline to allow thecremation unless an inquest be held and a certificategiven by the coroner in Form E." If it appearsthat death was due to poison or the other above-mentioned causes, "or if there is any suspiciouscircumstance whatsoever," the medical referee mustdecline to allow the cremation unless an inquestis held. Finally, he is not obliged to state any reasonif he disallows cremation. It is hard to imagine morestringent regulations. In the working of them thecountry has placed remarkable confidence in themedical profession, and it is for that profession toensure their successful operation and to remove anytrace of popular misapprehension.

3 See Conduct of Practice, p. 142 et seq.

Annotations.

HEALTH OF THE NAVY IN 1925.

" Ne quid nimis."

THE latest annual report 1 of the health of theNavy deals with the year 1925. It appears ninemonths after its predecessor.2 Its figures show fewersick, fewer deaths, and fewer sick daily, though moreinvaliding. Venereal disease is reduced, but tubercu-losis has increased, especially at the higher ages. In1925 the average number of men in the " totalforce " was 89,950, a slight increase. In additionthere were also 4060 marines at headquarters, addi-tional to the " total force " mentioned. This group ofmarines probably contains older men ; they havenumerous small injuries, and more invalids from heartdisease. They are remarkably free from venerealdisease, reporting no new case of syphilitic infectionand a total incidence of only 19 per 1000. Thefollowing comparative review shows the figures of theprevious year in parentheses. The decimals are ratesper 1000. The total cases amounted to 464-8 (486-2),of which wounds in action were 0-03 (0-04) and otherinjuries 87-4 (900); the cases of venereal diseasewere 71-7 (81-8), and of all other diseases 305-6(314-0). There were 254 (271) deaths, which gavea mortality of 2-82 (3-1). The chief causes of deathwere : effects of suffocation, 73 (69 in the loss ofSubmarine M.1) ; from tuberculosis, 37 (24) ; fromaccidents, 28 ; pneumonia, 14 (13) ; heart diseases,9 (6) ; septic infection, 8 (4) ; disease of intestines,7 (21) ; malignant disease, 7 (9) ; and enteric fever,3 (10). The chief causes of the 1412 (1272) invalidings,15-7 (14-5) per 1000, were : diseases of the eye,mostly errors of refraction, 256 (161) ; tuberculosis,224 (159) ; nervous diseases, 176 (191) ; diseases ofthe ear, 144 (108) ; circulatory system diseases,99 (80) ; diseases of the digestive system, 80 (57) ;venereal disease, 77 (239) ; including gonorrhoea, 63(206) ; and injuries, 58 (60). The death-rate fromdisease was 1-36 (1-78), the lowest hitherto recorded.Vaccinations and revaccinations, 21,558 (15,868), arenoted ; there were 2 (2) cases of small-pox. Ofenteric fever there were 40 (85) cases with 3 (10)deaths. A small group 01 I’l or 16 cases (no death)occurred in Emperor of India in the Mediterranean,ascribed to " infected food, probably supplied fromthe canteen " ; the cases were all mild, which isthought to be due to the recent preventive inoculationof all the patients (within 5-9 months). The figuresof tuberculosis were unfavourable last year, and thisyear there is a considerable increase : cases, 2-76(2-2) ; invalided, 2-49 (1-8) ; deaths, 0-4 (0-27).From the table on pp. 16-17 we gather that theincrease in invaliding is chiefly at ages over 25, andin men of over five years’ service, rather late for thedevelopment of tuberculosis that was present butlatent at entry. Do these cases occur more in largeor small ships ? P No explanation of the increase isoffered in the report. The heaviest incidence seemsstill to be on telegraphists, 12 (11). Non-pulmonarycases are this year for the first time separated fromthe others, and seem to prevail more at the earlierages. Pneumonia, 221 (182) ; deaths, 14 (13), hasslightly increased, but pleurisy, 140 (160), is less, andthere is less malaria, 258 (338), and less sandflyfever, 65 (79), though more dengue, 43 (18). Theincidence of venereal disease is less, 71-7 (81-8) ;China manifests its old baneful pre-eminence with211-3 (248-4) cases, new cases 168-0; marine head-quarters have an incidence of 19-19. There is anincrease in cases of gastric, 71 (33), and duodenal,52 (47), ulcers. There were no cases of scurvy reportedthis year, but 3 (2) of beri-beri. Scabies is a littleincreased, 11-1 (9-56) ; each case averages 5-71 days

1 Statistical Report of the Health of the Navy for 1925.H.M. Stationery Office. Pp. 139. 4s. 6d.

2 THE LANCET, 1927, i., 1045.

299THE ACTION OF LIGHT ON THE EYE.

under treatment. The account of the training shipsis meagre ; they seem to have had 5 cases of tubercleand some 35 of pneumonia, but there is no accountat all of the health of the cadets at Dartmouth.

ANEURYSMAL DILATATION OF THE LEFT

AURICLE.

IN chronic rheumatic carditis, especially whenmitral stenosis is the main lesion, the left auricleundergoes a certain amount of dilatation and hyper-trophy. The extent of this dilatation is, as a rule,surprisingly small in proportion to the work whichhas to be done. In rare cases, however, the auriclebecomes extremely dilated, and at autopsy its capacityis sometimes found to be nearly 2 litres. The reasonwhy this excessive or aneurysmal dilatation occursin some cases and not in others gives rise to con-siderable speculation, and is discussed in detail inthe current number of the Quarterly Journal ofMedicine by Dr. J. Crighton Bramwell and Dr. J. B.Duguid, who report two cases which came undertheir notice and review 18 others collected from theliterature. They found that the associated adhesivepericarditis and lesions of the mitral valve varied somuch that neither could be regarded as the primarycause of the extreme dilatation of the left auricle.The common lesion found was a localised ischaemicfibrosis of the auricular wall, and this, it is suggested,was due to embolic plugging of some abnormallysituated auricular branches of the coronary artery.In still rarer cases weakening of the auricular wall isdue to extension of disease from some neighbouringorgan. The dilatation takes place in an unusualdirection-the " horizontal dilatation " of some

writers. In most of the cases the dilated left auriclewas found to have extended under the right auricleand the superior vena cava to form the right borderof the heart, and in an extreme case such extensioncaused collapse of the lower lobe of the right lung.From this it might be deduced that the abnormaldistribution of the auricular branches of the coronaryartery affects mainly the right side of the left auricle,and that the axis of the intra-auricular pressure isinclined towards the right. It was often noticedthat the exercise-tolerance remained good for manyyears because, as Dr. Bramwell and Dr. Duguidpoint out, the brunt of the lesion falls on the auricle,whilst the ventricle remains healthy and is able tohypertrophy and maintain the circulation.

THE ACTION OF LIGHT ON THE EYE.

SOME weeks ago we gave a brief account 1 of thework of E. D. Adrian and Rachel Matthews on thedischarge of impulses of the optic nerve of the congereel when the eye is exposed to light. These investi-gators have continued their researches, and in a furtherpaper 2 describe more particularly the initial stages ofthe process and the effect of flashes of light of shortduration-i.e., they deal mainly with the processesinvolved in the excitation of the retinal elements andbut little with the subsequent nervous changes. Themethods employed were much the same as those usedin the previous work. Special attention was given todetermining the reaction time-the period betweenthe beginning of the exposures to light and thebeginning of the response in the retina or nerve-and to the effect of intensity and duration of theflash of light on the nerve reaction time. It wasfound that for a given intensity of light, flasheswhich exceed a certain critical duration all givethe same reaction time and a discharge of the samemaximal impulse-frequency in the optic nerve. Withshorter durations the reaction time is longer and theimpulse-frequency is smaller. Using flashes somewhatshorter than the critical duration, it was found thata definite quantity of light (intensity x duration) over

1 THE LANCET, 1927, ii., 1247.2 Journal of Physiology, 1927, lxiv., 279.

a given area always produces a definite reactiontime and a response of definite impulse-frequency.whatever the intensity of the light. These resultshold good not only for changes in the intensity andduration of the flash, but also for changes in the areailluminated. A definite quantity of light (intensity xduration x area) produces the same reaction time,though the retinal area illuminated varies from0 -08 to 0-9 mm. diameter. The processes leading toexcitation may be divided into a primary change,coinciding with the flash and forming a productproportional to the quantity of light received, and asecondary change outlasting the flash and leadingultimately to the excitation of the nervous structures.The rate of the secondary change is a linear functionof the amount of " light product " or

" light effect " found in the primary change. The relation betweenarea and intensity must mean that the total effectof the light is transmitted to some region whoseextent is independent of the area illuminated. Theeffect might be diffused widely over the retina. orconcentrated on a small number of nervous pathswhich have an overlapping distribution on the retinalsurface. In either case, the transmission of thelight effect must take place rapidly as part of theprimary change, and the secondary change must occurin the region to which the light effect is transmitted.We understand that Dr. Adrian will summarise

his important observations in a book, entitled " TheBasis of Sensation : the Action of the Sense-Organs," 3which is now in the press.

LIFE INSURANCE IN THE TROPICS.

THE interest of life insurance in the tropics tomedical men lies chiefly in its property as a definitequantitative assessment of the extra risks to the lifeand health of a person who lives and works underclimatic conditions to which he is racially unadapted.Apart from the especial responsibility of those whoexamine candidates for insurance, the subject isvital to all medical men practising in hot countries.The peculiar position of Britain as the administratorof large areas of the tropics gives it perennial import-ance, but it has been raised rather more acutely ofrecent years by the " white Australia " policy.Considering the money and lives involved, the certainknowledge which exists about these extra risks issurprisingly scanty, and the consciousness of this

deficiency provoked an interesting discussion at ameeting of the Section of Tropical Diseases of theRoyal Society of Medicine on Feb. 2nd. As Dr.J. F. C. Haslam pointed out in his opening paper,the health administrators of the Commonwealth areclaiming that the increased risks are due solely totropical disease, which in the absence of a nativepopulation is practically unknown in NorthernAustralia, and that a hot climate of itself is no menaceto health. The difficulty is to get evidence. Dr.Haslam quoted Sundstroem, whose material was toosmall to give force to his results, and read part of aletter recently published by Sir James Barrett, 4who considers that the matter has been settled byseveral generations of successful colonists. Sir LeonardRogers, in the subsequent discussion, produced post-mortem figures showing that one-third of the mortalityin India is due to tropical disease. Even if theAustralian authorities are right, however, the variationbetween tropical countries is so great that theirconclusion would be of little help elsewhere. Moreover.individuals and races vary tremendously, and southernEuropeans may be expected to tolerate conditionswhich northerners might find impossible, in spite ofthe vehement assertions of Cilento to the contrarv.A perusal of the very able Review of Literature on thePhysiological Effects of Abnormal Temperatures andHumidities, published by the U.S.A. Public HealthDepartment last year, will not, as Dr. Haslam

3 To be published shortly by Messrs. Christophers, 22, Berners-street, London, W.1.

4 Brit. Med. Jour., 1927, ii., 1244.