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which does not rear a larger proportion of its children thando even the rural districts of the north.

Effective Fertility.In the report for 1913 there appears an interesting table

(not repeated in the present) in which comparison is carrieda stage further by stating the combined effect of the fertilityand early mortality of each population ; in other words, byshowing the extent to which it produces and rears children.The result may be regarded as its "effective fertility," andgives some indication of the degree in which success inpreservation of young lives is likely to compensate for failurein their production.The greatest effect of successful life preservation in com-

pensating for its non-production is naturally shown by com-parison of the county boroughs of the North of England withthe rural districts of the South. And it is noteworthy thatwhile the birth-rate of the former was 25’9 against 19’4 inthe latter, this difference would be reduced at age 5 to thatbetween 20’7 and 17’6, the survivors per 1000 living in eachcase. The advantage in regard to birth-rate held by thelarge towns in 1913 was still maintained on the attainment ofthe fifth year. The advantage in regard to fertility, on theother hand, was held by the rural districts (the higher birth-rates of the towns being accounted for by their higher propor-tion of women of conceptive age), and this advantage becamegradually accentuated by their more favourable mortality ex-perience. However stated, the fertility of Wales exceeds thatof England, and this has been the case in each of the threeyears 1911-13. The survivors at age 5 in Wales exceedthe births in the south of England in each of the geo-graphical areas, and the smaller towns of the principalityapproximate most nearly to the old-fashioned standard ofbirth-rate.

Cczuses of Infant MortalityIn the tables published since the Census year infant

deaths have been shown in the first month and in eachtrimester of the first year after birth. The mortality hasalso been recorded at the successive age-groups in eachof the five geographical divisions of England.

In 1914 infant mortality showed a decrease on that of thepreceding year from all the principal causes except whoop-ing-cough. The summer of that year was drier and warmerthan that of the preceding year, nevertheless the mortalityfrom diarrhoeal diseases fell from 19’3 in 1913 to 17’4,although the rate was still more than double that obtainingin 1912, when it was only 7-72 per 1000 births. The

mortality from tuberculosis in 1914 fell to 2-86 per 1000births, and was the lowest recorded except that of 1912. Thefall noticed in the previous year’s report in the mortalityfrom tuberculous meningitis was maintained, the rate being0-99, the lowest in the table. There was, however, a

corresponding rise in the loss of life from other forms ofmeningitis. The mortality from the indefinite group ofwasting diseases was the lowest since 1890. The loss of lifedue to premature birth and congenital defects was aboutequal to the average of recent years, during which it is

probable that many deaths have been returned under thisheading which would formerly have been attributed to

atrophy.The tables show that the mortality of male infants was

25 per cent. higher than that of female, and this is true ofmost of the causes except whooping-cough. The excess inthe death-rate of males was greatest in the second and thirdmonths of life, thereafter regularly decreasing. Infantmortality in the urban areas exceeded that in the rural by 28per cent., but this excess was very unevenly distributed overthe several age-groups, being only 6 per cent. in the first Imonth, whilst it rose to 49 per cent. at 9-12 months. Thechances of survival differ but little in town and country, butthe noxious influences of town life soon come into play,making themselves increasingly apparent as the first years oflife progress, and being especially noticeable in the secondand third years, when the urban excess generally approaches100 per cent. :The harmful effect of urban residence is conspicuous in

the case of respiratory diseases generally, but especially soin regard to diarrhoea, the mortality from which disease inthe towns was nearly twice as high as in the country.Syphilis shows an even greater variation with urban condi-tions, the mortality in the country districts, whether amonglegitimate or illegitimate infants, being about a quarber that

of the towns. It is most fatal in the first month after birth,and afterwards progressively less so. Overlying is anothercause of loss of infant life that is particularly commonin great towns, the deaths from this cause being four timesmore numerous in London than in the rural parts of England.

, The mortality unsatisfactorily ascribed to "convulsions" was,

in London only about half that reported in the rest of the,

country. This accords with the opinion previously expressedconcerning the superiority of death certification in the

metropolis. It has often been insisted that this indefiniteterm, the use of which continues to show decline, shouldonly be employed when the condition causing convulsionscannot be ascertained.

(To be concluded.)

THE BRITISH DENTAL ASSOCIATION:ANNUAL MEETING.

WAR INJURIES AND GUNSHOT FRACTURES OF THE JAWS.THE annual meeting of the British Dental Association

this year was entirely given to the consideration of practicalproblems connected with jaw injuries received during thewar. Mr. W. H. DOLAMORE (London), the President of theAssociation, delivered an address, to which we call attentionin a leading article.Upon the first dayThe Early Treatment of Gunshot Fracture of the Ja7vs

was considered.Dr. V. H. KAZANJIAN (Harvard Surgical Unit, B.E F.)

was the principal speaker. He remarked that the condi-tions of the present-day warfare have caused an enormousnumber of injuries to the head, face, and jaws. These maybe of such a nature as to lead to death soon after admissionto a general hospital. Dr. Kazanjian’s experience is thatthe more common causes of these fatalities are : 1. Secondaryhaemorrhage, particularly in cases where the path of the -

bullet is in the vicinity of large vessels. 2. Extensiveinflammation and suppuration in the mouth, which, extendingto the air passages, may cause septic pneumonia. 3. Ex-tensive fracture of the upper jaw, which may involve thecranial bones and lead to intracranial infection. There arealso a certain number of cases in which, owing partly tounavoidable causes and partly to lack of treatment, thefollowing complications have been seen : The infection inthe mouth may spread and cause necrosis and unnecessaryadditional loss of tissue. - In treating patients who havefractures of the maxillas the presence of dangerous illnessmay be the first consideration. As soon as the generalphysical condition warrants it, the proper steps are taken tore-establish normal function of the jaws and to reducepossible deformities of the face. The treatment adopted atthe general hospital, where the men usually arrive withinthree or four days after receiving their wounds, is as follows.The patients are put to bed and given a complete rest. Free

drainage is established from the external wounds; hypo-chlorous acid dressings with hot fomentations are applied toreduce suppuration and inflammation. Except in cases ofsecondary haemorrhage or other urgent complication no

attempt to suture soft parts or to set the bones, nor indeedto do any operation, is undertaken, until the initial shockand weakness have disappeared. Great attention is paidto the local condition of the mouth, the gums andteeth being painted with tincture of iodine ; hourly douchesof hydrogen peroxide and other antiseptic fluids are used.To facilitate the removal of pus, sputum, and dried secre-tions from the nose and mouth the parts are sprayed with thefollowing solution : 01. menth. pip., m ss ; liq. cresolis sap.111. ij ; paraffin, liq. 3 j. Accumulations of tartar upon theteeth are thoroughly removed. At times the mouth woundsare packed with iodised gauze, which is changed veryfrequently. Excessive dribbling of saliva is overcome by theuse of small hand pumps (or saliva ejectors) which thepatient is instructed how to use. With regard to diet, thepatients have generally to be fed upon liquid food, adminis-tered by means of a tube carried far back into the mouthor into the oesophagus if necessary. Nasal feeding is

never used, and rectal feeding only rarely resorted toPatients fed in this manner sometimes lose weight for aweek or two but after that steadily gain, even if a fluid

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diet must be adhered to for a month or two. The operativeprocedure is as follows. Wherever possible the patient is

given a rest of several days’ duration before operation. Atthe operation, in addition to the removal of particles ofshell or bullets, septic and broken teeth and loose

portions of bone are removed. Regarding heamorrhageduring the operation, the path of the projectile should becarefully considered in order that all possible sources of

hoemorrhage may be recognised beforehand. Dr. Kazanjian’.

has invented a very ingenious holder for controlling hæmor-rhage from the lingual artery; it consists of a piece of heavywire about 8 or 10 inches long, bent to a U shape, with afinger of modelling composition or vulcanite rubber on eachend. One end is placed in the floor of the mouth and theother externally under the chin, between the hyoid bone andthe lingual side of the mandible, and the tissues are pinchedat the site of fracture by the use of elastic bands about theclamp. Dr. Kazanjian also showed many ingenious splintsand devices for supporting the soft tissues and hard parts.Extensive use is made of local anaesthesia to diminish thepain in fixing splints, &c. For these purposes the nerve-blocking method is chiefly employed.

Splints and Appliances.Upon the second day the subject of appliances and

splints was dealt with by Mr. MONTAGU F. HOPSON, whospoke upon the Reduction of Displaced Portions of Bone

by Immediate and Gradual Methods and the Retentionof Parts in Normal Position during the Period of Union.Mr. Hopson observed that everyone is agreed that the earliersome sort of splint is applied the better, and that experiencehas proved that the after-treatment is often much hamperedby the injudicious application of external pressure bybandaging and by the premature suturing of wounds of thesoft parts unless some form of intra-oral splint is inserted tomaintain the fragments of fractured bones in approximatelytheir normal relations. For immediate use in the field hesuggests the well-known Hammond wire-splint, or infavourable cases bands clamped upon the teeth and unitedwith wire bows or ligatures. These splints should always bereplaced as soon as the patient arrives at the nearest

hospital. As a general rule, it may be said that wherethere are firm teeth in each fragment a fixed splint is themore useful ; on the other hand, where one or more frag-ments are devoid of teeth, a removable apparatus is oftencalled for, and this may be of necessity of an inter-dentalform, using the sound jaw as a basis against which thefractured fragments of the opposite jaw may be steadied.Mr. Hopson considers that splints should be constructed toconform, as far as possible, to the following general rules :(1) Simplicity ; (2) a fixed splint should be aseptic and easilycleaned by irrigation ; (3) sites of fractures, compound tothe mouth or through an external wound, should beuncovered, both for drainage and for free irrigation ; (4)a splint that of necessity covers soft tissues should beremovable for cleaning ; (5) splints with extra-oral attach-ments should be avoided, so far as possible, as they addto the discomfort of the patient.

Mr. J. E. SPILLER (London), speaking uponThe Restoration of Lost Parts by Prosthetic Apparatus,

described the method adopted by Claude Martin, of Lyons,for the construction of part of an artificial jaw invulcanite or metal. The advantages claimed by ClaudeMartin in favour of immediate replacement of lost partsby artificial appliances were : (1) Diminution of sepsis;(2) fixation of the fragments ; (3) prevention of retro-cession of the tongue by temporary suture to the

apparatus ; (4) the almost immediate aid to mastication,deglutition, and speech ; (5) the maintenance in position ofthe soft parts and the prevention of cicatricial bands;(6) suppression of the constant escape of saliva. Mr. Spiller,however, considers that Martin did not foresee (1) the largeamount of sepsis and infection which are invariably present;(2) the frequency of destruction of a large amount of the softtissues ; (3) the advances in surgical methods, especially inbone-grafting. He pointed out the importance of having afirm scaffolding around which soft tissues may be built orbone grafted in, and considers that dental appliances forthis purpose should be readily removable by the wearer forcleansing purposes ; that they should cause no irritation ordestruction of the remaining tissues ; that the constructionshould be as simple as possible to facilitate repair at anysubsequent time.

Dr. G. VILLAIN (Paris) read a paper upon’ The Physiological Treatment of Fractitres and Dislocations.; He pointed out that if a fractured jaw was to perform its

normal function and not merely to be united in any position,a state of muscular dynamic equilibrium must be restored.

. Dr. Villain considers that mandibular fractures should be; classified according to the causes or sources of irregularity

-for example, post-elevators, inter-elevators, pre-elevators,with or without loss of substance. The study of these forcesincludes the investigation of the resultant of each group of

, forces : lowering, elevation, protrusion, retraction, lateral

, movement ; then the examination of the resultant of forcesin the combined action of all the masticatory muscles at hemoment of trituration of foodstuffs. One of the examples

, given was that of a pre-elevating unilateral left fracturewith loss of substance. In- considering the resultant offorces brought to bear upon such a fracture one understandswhy it is that in closing the mouth the extremity of thelarge fragment rises more rapidly than the centre of this

. fragment, obliging the patient to bite in two movements-first movement, the mandible rises, pivoting on the leftcondyle, the teeth on the edge of the fracture-line obtaincontact with their antagonists; second movement, the jaw

, pivots partly round this point and partly round the right’ condyle in order to ensure the occlusion of the intermediary

teeth then making contact with their antagonists. Dr.Villain’s paper was fully illustrated by pictures and diagrams,and will probably form a permanent contribution to our

knowledge of this subject.The afternoon of this day was given to the consideration of

The Restoration of Lost Portions of the Jaw by Surgical Means.Bone-grafting was the topic round which the discussion

ranged. In opening it the PRESIDENT spoke of the con-

troversy which had arisen as to the function of the peri-osteum in the formation of new bone. He quoted experi-ments conducted in Germany by Axhausen to solve this

problem. Axhausen found that living bone entirelyderived of its periosteum became encysted, and that thelife of the periosteum and medulla and the formation ofnew bone depended upon the ease with which thelymph could reach the cells. Nothing prevented thismore than muscle fibres left on the bone ; the thicknessof the fibrous layer of the periosteum was also of greatimportance. At the cut margins of the periosteum thecells are immediately in contact with the lymph, whilstelsewhere this must first penetrate the fibrous layer beforereaching them ; also, the newly formed vascular tissue earlybrings to them the nourishment essential to productiveactivity. Hence at these cut margins there is rapid cellmultiplication and early bone development. Therefore it isadvised that long incisions should be made through thecovering periosteum of a graft, especially where the fibrouslayer of the periosteum is thick. Axhausen considers thatif the ends of the graft are pointed infection is more likelyto occur than in cases where it is fixed by a wire suture.

In view of the interest aroused by McEwen’s work inthis country these statements were very interesting. Inthe resulting discussion, while some speakers reportedsuccessful cases of bone grafts and all desired to see themethod more widely used, on the whole the feeling seemedto be that up to the present time the results obtained wererather disappointing.On the third day Mr. J. F. COLYER (London) opened a

discussion uponThe Treatment of Ununited Fracture and Malunion.

He said that most of the cases which came under hiscare were those of non-union or malunion, and that itwas his routine practice to have the cases radiographedimmediately upon entry into the hospital and to examinethem carefully for any possible septic foci. In his experiencenon-union is usually due to (1) sepsis ; (2) undue mobility ;(3) presence of foreign bodies in the wound ; (4) loss ofsubstance. In order to diminish sepsis and to lessen therisk of subsequent infection it is Mr. Colyer’s practice toremove the tooth on either side of the fracture. He exhibitedskiagrams in which it was clearly shown how easily organismsor their toxins may pass down the periodontal membraneand keep up infection in the bone, and he also quotedcases, which had been under treatment at various hospitalsfor many weeks without union occurring, in which bonyunion speedily ensued after the removal of septic teeth.

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Mr. Colyer has often found that septic teeth lead to a

spreading osteomyelitis. In treatment he always endeavoursto obtain bony union, if necessary re-establishing occlusionby means of dentures at a later stage ; the aim in treatmentshould be to fit men to return to military duty as speedily aspossible. With this object, in the cases where there hasbeen loss of bony tissue in the horizontal ramus, Mr. Colyerextracts the upper molar teeth and allows the ascendingramus on the affected side to swing forward and to unitewith the horizontal ramus. This treatment results in firm bonyunion and restoration of good masticating power at the expenseof a shortening of the horizontal ramus upon the affected sidewhich is so slight as to be very little noticeable. Withreierence to appliances, Mr. Colyer avoids the use ofwire splints and ligatures which may irritate the gum. Hehas made use of double metal Gunning splints, sometimes Iallowing them to be removable and sometimes fixing themwith a good antiseptic cement, such as the oxyphosphate ofcopper. In reducing displacements he makes use of thesemetal splints, adjusting the upper and lower splints in themouth so that the tissues are stretched and the displacementis partly reduced. A period of rest follows, and then thesplints are again adjusted and the parts stretched until theirnormal relationship has been attained.

Captain H. M. HOLT, R.A.M.C., read a paper onDiet.

Captain Holt said that diet should be considered from twostandpoints&mdash;(<x) the nutritional value of the food supplied ;(b) the mechanical use of such food as an auxiliary inrestoring the natural movements .of the jaws. For this

purpose four diets have been introduced, leading the patienton from a fluid to a solid diet. A diet is fluid, the regulationmilk diet and beef-tea diet forming its basis, and suchextras as arrowroot, cornflour, and semolina are introduced togive variety. B diet consists of minced foods, C of stewedfoods. Beef, mutton, and stewed rabbit are mixed with

finely minced vegetables and potatoes. The object ofthis diet is to bring gradually into work the muscles attachedto the jaws without bringing too much strain to bear uponthe freshly united bone. D diet is the ordinary diet ofmilitary hospitals ; in using it a gradual transition fromboiled to roast meats is carried out.

In addition to the papers there was an interesting museumcontaining appliances for supporting fractured jaws, tornsoft parts, skin flaps, &c. This museum, which is at thehouse of the Royal Society of Medicine, Wimpole-street,remains open until Saturday, June 24th, and is well worth avisit.Demonstrations were also given showing the restoration

of lost parts by means of sculptural methods, by LieutenantDERWENT WOOD, A.R. A., and by means of modified gelatine,by Dr. PONT (Lyons) and Mr. H. BALDWIN (London). Someof the reproductions of soft parts by these means are to beseen in the museum.

NOTES FROM INDIA.

(FROM OUR OWN CORRESPONDENTS.)

The Bombay Medical Act.AMONG a variety of subjects recently discussed by the

Bombay Legislative Council was an amendment introducedin the Bombay Medical Act allowing the Poona municipalityto continue its aid to an Ayurvedic dispensary which hadbeen in existence for years in that town. The Collector’sruling that under the Act it could not be supported out ofthe public funds had caused much dissatisfaction, and ledto an animated debate in the council on the comparativemerits of the indigenous and the Western systems ofmedicine. One honourable member flippantly observed thatboth the systems cured as many as they killed, addingthat people managed to live in the old days, beforethe introduction of Western medicine, about as well as

they did now. The fervour with which the indigenoussystem was upheld by several Indian members of thecouncil is truly patriotic, but there is only one Ayurvedicdispensary aided by a municipality in Western India. TheGovernment seem to have strong internal doubts as to itsvalue. But it is very popular with the multitude, and there-fore they have agreed to make a concession to popular

feeling by a modification of the Act, ensuring it the con-tinuance of municipal aid. It is as well, says the Advocateof India, that the Government have refrained from makingthe alteration in the law so comprehensive as to render itapplicable to all Ayurvedic or Unani dispensaries that amunicipality might choose to help; as a provision of this .

nature would have operated against the real well-being ofthe public.

Bombay Presidenoy Hospital.Lord Willingdon, as President of the Bombay Branch of

the Imperial Indian Relief Fund, has received the followingletter from General J. G. Maxwell, Commanding the Forcesin Egypt, regarding the work of the Bombay PresidencyGeneral Hospital :-YOUR EXCELLENCY,-I cannot let the Bombay Presidency General

Hospital retqrn to India without expressing our grateful thanks forthe services of this excellent unit. On Jan. 18th, 1915, this hospitalof 500 beds arrived in Alexandria. On Feb. 26th, the first patients,50 Indians from overseas, were admitted. On March 9th the hospitalwas temporarily converted for Europeans and utilised for thereception of Australian patients. On March 23rd the hospital wastemporarily lent to the French military authorities, and remaineda French hospital from that date until August 27th, 1915, when itagain became British. In March it was expanded by 100 beds,and in July by 200 more, but as a matter of fact the numberof beds was 875. During the period the hospital was opened ithas from time to time received Indian patients from overseasand those operating in Egyptian territory. From the openingof the hospital until March 10Gh, 1916, the following patientswere admitted: Indian, 1410; British, 1838 ; Australians, 498; NewZealanders 75; French, 1641; Russians, 3; total, 5463. The averagenumber per day was 411 and the largest number on any day 873. Thelargest number admitted on any one day was 362 (August 25th, 1915).The above constitutes an Imperial record which the Presidency maywell feel proud of, and I will be obliged if you will kindly convey thisletter with our thanks to the committee for their patriotism in allowinga hospital destined for Indian patients to be used so freely for Imperialpurposes.

1JIowr Ambulanoesfrom the United Provinoes.The United Provinces Special War Fund has already made

such good progress that his Honour Sir James Meston hasfelt justified in consulting Sir John Hewett at home as to thesteps necessary for purchasing on behalf of the people ofthe provinces a fleet of 50 ambulance cars.

Health of the British Troops in Delhi.There have been a few cases of small-pox among British

troops in the Delhi garrison ; otherwise the health of Delhicity is good.May 30th.

___________________

ROYAL MEDICAL BENEVOLENT FUND.

AT the last meeting of the committee, held on June 6th,18 cases were considered and Z190 were voted to 17 of theapplicants. The following is a summary of the cases

relieved :-

Widow, aged 40, of L.R.C.P.Edin. who practised at Cliffoney, coSligo, and died in 1912. After her husband’s death applicant opened asweet shop in a Scottish town, and managed to get on until she had toundergo an operation in May, 1915. The Fund then made her a grantof :B10. In April, 1916, her shop was blown up by a bomb from aZeppelin, and all her stock and furniture destroyed, and she was not

insured. Now wants help to re-establish herself. Voted 215.-Widow,,aged 45, of L.R.C.P.Edin. who practised in the East-Rnd of Londonand died in December, 1915. Applicant is partially paralysed, and wasleft practically unprovided for at her husband’s death, and hashad to live on the small sum the practice realised, of which onlyabout 270 is left. Has one son aged 6 years. Has no home, and isstaying with relatives who have promised to give all they can, whichonly amounts to 213 per year. Voted .e1O, in two instalments.Widow, aged 38, of L.S.A. Lond. who practised in North London up toa few years ago and latterly, and up to his death in March of thisyear, has been taking locums. Applicant was left unprovided for withfive daughters, aged 17 months to 10 years, and at present they arestaying with her mother, who cannot afford to keep them. Applicant’sfurniture is in store with a large debt owing on it. If she could get herfurniture she hopes to be able to make a living by taking in boarders.Only income B12 per annum, from a relative. An immediate specialgrant of E5 has been given, and the Guild are already investigatingthe case. Voted .e12 in 12 instalments.-Widow. aged 61, of M.R.C.S.Eng. who practised at Whitechapel and died in 1913. Applicant’s onlyincome is B28 per year, the income frum the investment of a life in-

surance, and 3s. per week from a son. Son-in-law used to help bypaying the rent, but owing to the war has had to discontinue this, soapplicant is in great difficulties. Voted B12 in 12 instalments.-Widow, aged 64, of M.D. Glasg. who practised at Glasgow and diedin 1908. Applicant was left totally unprovided for, and has triedto make a living by taking in lodgers, but recently has beenunsuccessful, and during the last year has only received E20from this source. Only other income &pound; 22 from other charities.Relieved twice, E24. Voted B12 in 12 instalments.-Widow,aged 51, of L.S.A.Lond. who practised at Leicester and died in1910. Applicant was unprovided for, with two daughters now 21 and22 years of.’age, and a son now aged 14. The girls are now both working,