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same limitation did not exceed 575 per 1,000,000. It is inthe case of diseases like cancer, which are fatal chiefly atparticular ages, that the necessity of correction of the death-rates after the method already referred to is especiallyapparent. The mortality from malignant disease at agesbelow 35 years is small and is generally disregarded, but ifthe cancer mortality in 1901 at all ages over 35 years bejudged of by the uncorrected rates it will appear to be

higher in the rural counties than in the urban, whereas if thecorrected rates be examined the opposite conclusion follows,for the rural mortality is in that case shown to be the lower.In the calculation of local cancer rates of mortality a seriouscomplication arises from the occurrence of the deaths of

many country patients in the hospitals of our great townsand their registration there. In addition to this it wouldbe absurd to assume that the place of every patient’s lastresidence before death had been also the place of origin ofhis disease.Among the other interesting matters dealt with in the

present volume we have only space left to notice one moresection which now appears for the first time-namely, thatrelating to infantile mortality. The mortality among infantsand very young children has always been regarded as a

valuable test of salubrity and for this reason Dr. Tathamhas thought well to devote to it special attention in the

present report. Two important new tables have now beeninserted. In one of them the mortality of infants under oneyear of age is calculated in terms of registered births in1901, and in the other the mortality of children under fiveyears old is shown as a proportion of the population estimatedto be living at that age in the middle of the year. Thesetables have been prepared to show the death-rates fromseveral causes in each of the English counties but on

examining critically the local mortality very great differencesbecame manifest according as the areas selected are urbanor rural in character. In another pair of tables the mortalityin the urban and rural list of counties before referred to isshown, from which it appears that both among infants intheir first year and among children of less thanfive years the mortality is considerably greater inthe urban group of counties than in the rural, andthis is true whether the total mortality or the mortalityfrom all the specified causes (with one exception) is put incomparison. It is noteworthy that at ages under one yearas well as at ages under five years, boys die more rapidlythan do girls and this is the case with respect to the ruralquite as markedly as to the urban districts.

In concluding our notice of this report we need only saythat in its present greatly improved form it will be found aserviceable and almost indispensable addition to the libraryof the medical officer of health.

THE CHOLERA EPIDEMIC IN SYRIA.

(FROM THE BRITISH DELEGATE TO THE OTTOMAN BOARDOF HEALTH.)..L.L..[!..!.t1..LL1..Ll...)

THAT a great part of the Syrian interior, and to a lessextent the coast, has been and is still being seriously ravagedby cholera there is unfortunately no room to doubt. The

probability of a still more extensive spread of the disease inthe near East and of its ultimate appearance in Europe itselfis so great that serious attention may be usefully directed tothe course the disease has followed hitherto, and no apologyis needed for giving in some detail what is known ofits behaviour in Syria during the past few months. Beforedoing so it will be convenient to recall the history ofthe epidemic in the Turkish empire since it first appearedthere some year and a half ago. This has been alreadygiven in detail in successive letters to THE LANCET 1 and maybe briefly summarised here.

Cholera broke out among the pilgrims to Mecca andMedina early in March, 1902. It caused a considerablebut not excessive mortality among them, and at theend of the pilgrimage almost disappeared from the

Hedjaz. At the end of May it appeared in the Yemenand through the summer and autumn was seriously prevalentin several places along this portion of the Arabian coast, asalso at Yambo and elsewhere. It reappeared in Medina in

1 THE LANCET, March 4th (p. 916), July 5th (p. 39), and Nov. 22nd(p. 1414), 1902, and Jan. 31st (p. 324), and April 11th (p. 1052) 1903.

September. The Assyr province has also been the scene ofa rather serious outbreak. Cholera was first recognised inEgypt in July and caused a widespread, though nota remarkably intense, epidemic, which lasted through theautumn and the early part of the winter. From Egyptcholera was carried to Syria at the end of September. Itwas the cause of a considerable mortality on the coast andin the interior of Palestine ; it appeared in the Hauran, andat the end of November it was reported from Damascus. It

was epidemic here until the middle of February, when it dis-appeared only to break out again a month later. Throughthe later months of the winter and early spring the diseasewas confined to Damascus. Its subsequent course here hasbeen as follows.

Throughout the month of April the number of cases of,and deaths from, cholera in Damascus varied from betweennil and three each day. Towards the end of the month therewere several days together during which no fresh case wasreported. But occasional cases continued to occur throughApril and May, and towards the end of May it was officiallyadmitted that the disease had appeared in several villagesoutside the town of Damascus itself. In the town theofficial figures would indicate that the cholera remainedcomparatively quiescent, causing only sporadic cases, untilthe second week in July, when it became more active, andthat since that date it has been truly epidemic. The follow-ing are the figures publit-hed in the official bulletins since thebeginning of the recrudescence of cholera on March 18thlast :-

Cholera in Damascus.

The totals are believed to be very considerably below thetruth.The first known cases of cholera outside Damascus duricg

the present summer occurred at Katana, the centre of adistrict of the same name, situated some three hours " (say,15 miles) to the south-west of Damascus. On inquiry, it wasascertained that on May 24th a woman inhabiting Katanawas attacked with symptoms of cholera but recovered. Herfather fell ill on the morning of the 25th and died at11 o’clock the same night. Three other persons were

attacked on the same day and died after illnesses varyingfrom five and a half to 20 hours. Another death occurred onthe 26th ; the patient, a woman, had suffered from dianhceafor several days previously. On the 27th a seventh person, aman, was taken ill at 6 o’clock in the evening and died sevenhours later. Cases continued to occur here until June 26th,since which date Katana has disappeared from the bulletins.It is not, however, quite clear whether this indicates acomplete cessation of the epidemic there.On June lst news was received of the appearance of

cholera at Zebdani, some 20 miles to the north-west ofDamascus, and having a station on the line of railway fromBeirut. The first case was that of a vegetable-seller whohad left the village for Damascus on May 20th and returnedto Zebdani on the 24th. He fell ill on the following morningwith colic, diarrhoea, vomiting, cramps, and cyanosis, anddied on the 26th. About the same time cases were reportedfrom Douma, a few miles east of Damascus. Two men fellill here with cholera on May 28th and died on the following

1041

day. A third had suffered from vomiting and diarrhoea, butwas convalescent when the other cases were reported.On June 6th the appearance of cholera in Ideyde, a village

of 500 inhabitants, four hours north-east of Damascus andin the district of Douma, was announced. The first knowncase was that of a man from Hedjani, a village in the neigh-bourhood of Ideyde, who died in a tent close to the lattervillage on May 28th, shortly after eating a hearty meal. Onthe same day an old man, aged 60 years, and a child, agedthree years, fell ill and died. On the 31iit the wife of aBedouin died, apparently from cholera, in another tent nearthe village. On June 2nd a man and a child, aged nineyears, fell ill and died suddenly. Two other persons werefound to have suffered from choleraic symptoms and wereconvalescent at the time of the inquiry.

It is clear, then, that about the last week in May and thefirst week in June the cholera infection had begun to spreadin all directions from Damascus as a centre. Villages werealready infected lying from 10 to 20 miles to the east, to thewest, to the north-west, and to the south-east. A little laterthe disease began to advance steadily northwards. OnJune 8th it was reported that seven cases of cholera, of whichthree had ended fatally, had occurred in the village of Kara,in the district of Nebik, 15 hours north (or north-north-east)of Damascus and 12 hours south of Homs. Both Nebik andKara are on the main line of communication which runsnorthwards from Damascus, through Homs and Hama, andultimately to Aleppo. This, as will be shown later, has beenone of the principal lines along which the present epidemico)f cholera in Syria has spread, a second route of importancebeing the valley of the Orontes river. On June 12th newswas received of a suspiciously high mortality in Hama itself.Hama, or Hamath-Epiphania, is a town of some size situatedabout the thirty-fifth parallel of latitude and rather morethan half way on the road from Damascus to Aleppo. Thefirst telegram from here reported numerous deaths in a shortspace of time in a certain quarter of the town. A sanitaryinspector was sent to inquire and he definitely announcedthat cholera existed in the Medina quarter of Hama. Theoutbreak here has been one of considerable severity, as

shown by the following figures :-

Cholera at Hama.

Although Homs lies considerably to the south of Hamaand between the latter and Damascus, it was not invaded bycholera until more than a month after the disease had wellestablished itself in Hama. The first known cases occurredhere on July 15th and between that date and the 31st 34cases and 21 deaths were reported. From August lst to 7ththere occurred 67 cases with 64 deaths and from August 8thto 14th as many as 146 cases and 161 deaths.

In the meantime cholera was continuing more or lessactively in the places already named in the near neigh-bourhood of Damascus and spreading to others. It is im-

possible to find on the best maps extant the names of manyof the villages to which the disease is said to have spreadand it would occupy too much of your valuable space totrace in detail the course of the epidemic in each of theseobscure localities. It will suffice to give their names, theirapproximate position, and the dates where known of the firstcases. This I have attempted to do in the table given onnext column.The course and intensity of the outbreaks of cholera in

these various villages have differed greatly. It must, how-ever, be remembered that the news received from many ofthem has been scanty and intermittent and the mentionof only a few cases from time to time in any particularvillage is no evidence that these are all the cases

that have occurred there. The date of the first case

or cases in any village has rarely been given with

accuracy. In many instances the name of a village hasonly appeared in the telegrams after the disease has beenpresent for weeks and already caused a high mortality.

Thus, for example, the first news from the village of Beytariawas that 26 persons had been attacked and that 23 diedwithin a week. From Telhab the earliest announcement was

I that the mortality from cholera had already reached ten per3 day. Still more striking was the first news from Der-Ali.! From this village, of only 250 inhabitants, it was reported on

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July 5th that 51 deaths had occurred there since June 17th,that 15 fresh cases had been declared on July 4th, and that43 Bedouins camped near the village had also died fromcholera. In like manner it was learnt from a report receivedat the beginning of August from the medical officer ofNebik that the disease existed in many villages that had notbeen mentioned in the daily telegrams and that in thosewhich had been mentioned the mortality had been much z,

higher than was indicated by the daily returns. The follow-ing were the figures given in this report as the totals of casesand deaths from the beginning of the epidemic to August 2nd(all the villages mentioned are in the district of Nebik) :-

The village of Rehebé mentioned in this report hadscarcely been referred to in any previous telegram andalmost the first notice of the existence of the disease therewas the announcement of 350 cases with 310 deaths. Asimilar statement is true of Admir with its sudden announce-ment of 150 cases and 120 deaths.

It will be gathered from these facts-and the conclusion isabundantly confirmed from other sources-that the actualcourse of the present epidemic, the extent of country whichit has covered, and its intensity in different places are

matters upon which it is impossible to speak with exactitude.All that can be said is that the greater part of the Syrianinterior-or hinterland, if the word be preferred-is moreor less severely affected ; that the disease has steadilyprogressed in all directions, but particularly northwards,from Damascus ; and that in all probability could the totalmortality be known it would prove to be a very high figure.That the disease is an acute form of cholera is clear from thevery short duration of many of the cases. The figures arefar too inexact to draw any conclusions from the proportionof deaths to reported cases.The above figures and statements refer exclusively to the

epidemic in the interior of the vilayet of Syria. Recentlyit has spread northwards to that of Aleppo and westwardsto the shores of both vilayets. The first place invaded bythe disease in the Aleppo vilayet was Djisri-Shagur, 12hours south-west of Aleppo, a town of some importance, onthe Nahr-el-Asi, or ancient Orontes, river. It is not quiteclear when the disease first appeared there. On July 20th itwas reported that ten cases had occurred there on the

previous day so that presumably it had been present therefor some little time before. The course of the outbreak therehas been as follows :—

On July 20th three cases of cholera occurred at Idilp,another townlet of some importance, three or four hourseast of Djisri-Shagur, and between it and Aleppo. Theoutbreak there has apparently not been a serious one, thereported cases in the four successive weeks numbering four,five, four, and two, and the deaths four, four, five, and tworespectively. Other villages in which cholera has appearedin the Aleppo vilayet have been the following : Kespan andKirk-Boutjouk, both in the district of Djisri-Shagur, firstinvaded on July 21st ; Maharah (position not named), firstinvaded on July 31st ; Xahli, on August 2nd ; Binieh, in theIdlip district, at the end of July ; Muara (date not named) ;and Eriha. on August 12th. Cases also occurred in thelazaret at Khan Sheikhun, this village lying on the frontierline between the two vilayets of Syria and Aleppo. Fromthe positions of the above-named places, so far as they are

Known, it will ne seen tnat tne cnoiera nas aavancea well onthe way towards both Antioch and Aleppo, but neither ofthese cities has as yet become infected.Up to July 22nd the epidemic was confined to places in

the interior. On that date the first case occurred on thecoast in the important port of Tripoli. On the 24th a

second case occurred and for several days only occasionalsporadic cases were reported, but at the beginning ofAugust the numbers began to rise considerably and on the4th it was reported by telegram that the inhabitants were ina state of panic, that they were leaving the city by sea andland, and that scarcely half the population remained. Thelast statement appears to have been an exaggeration, but itis certain that a large number of refugees have fled fromTripoli in the last fortnight-in some instances carrying theinfection with them. In Tripoli itself the official figureshave been as follows :—

Finally, two cases of cholera have been reported in thelast few days from Beirut, whither the disease has beencarried by refugees from Tripoli. The first case here was thatof a sanitary guard, placed on board a sailing ship thathad arrived from Arvat, an island near Tripoli, on August 6th.He developed symptoms of cholera on the llth. Althoughthe captain of this boat denied having touched at an infectedport, it was ascertained that he had not only called at Tripolibut had taken in vegetables and water there. A second casealso occurred on the llth. The patient was a young womanwho was undergoing quarantine in the lazaret at Beirut. Shehad been a passenger on a sailing ship which arrived fromTripoli on August 7th. She died on the 13th. She is saidto have lost several relatives from cholera in Tripoli and herfellow passengers, 220 in number (on a sailing ship so smallthat the crew consisted of but three men), were mostly refugeesfrom that port.As already stated, it is extremely difficult to form an

accurate idea of the total mortality that the present epidemichas caused. The official bulletins, down to the last one pub-lished on August 17th, have reported 3182 cases and 2631deaths since March 18th. But it is very probable that werethe truth known these figures would have to be doubled oreven trebled. Even from the towns and villages the infor-mation received is imperfect, while almost nothing is knownof what is occurring among the Bedouin and semi-nomadpopulation.Constantinople, August 19th.

PS.-Since writing the above, news has been received ofthe appearance of cholera in Biredjik, an important townon the Euphrates river some 60 miles north-east of

Aleppo. On August 16th there were four cases and threedeaths here, on the 17th one case and one death, and onthe 18th two cases. It is noteworthy that the disease hasspread so far to the north and east as Biredjik withoutappearing in Aleppo first, although the latter city is in adirect line between the other infected places and Biredjik.It is to be feared that cholera, having reached the Euphratesriver, will now spread to Armenia on the one hand and toMesopotamia on the other.August 20th.

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MEDICINE AND THE LAW.

A fxccr3age-monger Inaprisoned.CASES of the exposure for sale of food unfit for human

consumption have a certain amount of similarity in theirgeneral features. The Exeter magistrates, however, on

Sept. 25th dealt with a miscreant whose offence was evenmore recklessly dangerous and more crudely disgusting thanis usual. A quantity of herrings had been consigned fromGrimsby to a fi,,,h merchant at Exeter who had refused to

accept delivery of them. The Great Western Railway