750

6-0 per 1000 of the population, estimated at 4.613,812persons in the middle of last year. In the three pre-ceding years the rates had been 7’ 7, 8-9, and 9’9 9per 1000 respectively. Among the various metropolitanboroughs the lowest death-rates last year were 3’ 8 inStoke Newington, 3’9 in Hampstead, 4’ 3 in Kensingtonand in the City of Westminster, and 5 0 in Greenwich ; thehighest rates were 6 - 9 in St. Marylebone, 7 - 0 in Wands -

worth, 7’1 in Bethnal Green, 8’0 in Hackney, and 10’1 inDeptford. The prevalence of small-pox in London during1903 showed a great decline from that recorded in the pre-ceding year ; the number of new cases notified during theyear was 416, against 1702 and 7798 in the two precedingyears. This disease was proportionally most prevalent inthe City of Westminster, St. Pancras, Poplar, Southwark,Lambeth, Battersea, and Wandsworth. The number of small-pox patients admitted into the Metropolitan Asylums Hos-pitals was 414, against 1788 and 8455 in the two precedingyears ; four cases remained under treatment at the end ofthe year, against 666 and 14 at the end of the two pre-ceding years. The prevalence of scarlet fever during theyear under notice was considerably less than in thepreceding year; the number of new cases notified duringthe year being 12,531, against 13,809, 18,390, and 18,258 inthe three preceding years. Among the various metropolitanboroughs scarlet fever was proportionally most prevalent inSt. Marylebone, Bethnal Green, Bermondsey, Wandsworth,Deptford, Lewisham, and Woolwich. During last year10,808 scarlet fever patients were admitted into the Metro-politan Asylums Hospitals, against 10, 734, 14,959, and 15,133 in the three preceding years ; the number of cases remainingunder treatment at the end of the year was 1606, against2460, 3080, and 2327 at the end of the three preceding years.The prevalence of diphtheria during last year showed amarked decrease from that in the previous year ; 7738 newcases were notified, against 11,994, 12,154, and 10,735 inthe three preceding years. The greatest proportionalprevalence of this disease occurred in St. Pancras, Hackney,Poplar, Wands worth, Deptford, and Greenwich. The

Metropolitan Asylums hospitals contained 734 diphtheriapatients at the end of last year, against 1343, 1369, and 927at the end of the three preceding years ; the new casesadmitted, which had been 8777, 9090, and 7988 during thethree preceding years, further declined to 6158 last year.Enteric fever showed a considerably diminished prevalenceduring the year under notice, 2339 cases being notified,against 4306. 3195, and 3412 in the three preceding years ;among the various metropolitan boroughs this disease wasproportionally most prevalent in Stoke Newington, Hackney,Holborn, Shoreditch, Stepney, and Battersea. The numberof enteric fever patients admitted into the MetropolitanAsylums Hospitals during 1903 was 1247, against 2074, 1480,and 1806 in the three preceding years ; 246 cases remainedunder treatment at the end of December last, against 403,195, and 210 at the end of the three preceding years.Erysipelas showed the highest proportional prevalence duringlast year in Hackney, Holborn, Finsbury, Shoreditch,Bethnal Green, Stepney, Southwark, Bermondsey, and

Deptford. The 233 cases of puerperal fever notified duringthe year showed a decline of 79 from the number in 1902;21 cases belonged to Hackney, 19 to Fulham, 19 to Islington,18 to Lambeth, 13 to Southwark, 13 to Wandsworth, and 10to Stepney.During the year under notice 69,737 deaths of persons

belonging to London were registered, equal to an annual rateof 15 2 per 1000, against 18-6, 17 1, and 17’2 per 1000 inthe three preceding years ; the average rate in the ten years1893-1902 was 18 5 per 1000. Among the various metro-politan boroughs the lowest death-rates last year were 10 0 inHampstead, 11 - 1 in Lewisham, 12 4 in Wandsworth, 12’ 6 inStoke Newington, 13.2 in Paddington, 13 3 in Greenwich,and 13’5 in Woolwich ; while the highest rates were 18 2 inBethnal Green and in Poplar, 18’4 in Bermondsey, 18 6 inHolborn, 19 4 in Shoreditch, and 20’3 in Finsbury. Inthe five glOups of boroughs the rates of mortalitywere 13 9 in the west, 14’5 in the north and in thesouth, 18’ 3 in the east, and 19 0 in the central. To the

principal infectious diseases. 8088 deaths were attributedduring the year ; of these, 2925 resulted from diarrhoea, 2046from measles, 1627 from whooping-cough, 740 from diphtheria, 376 from different forms of "fever" (including thr, efrom typhus tever, 368 from enteric fever, and five from simplecontinued fever) 361 frum scarlet fever, and 13 from small-pox. These 8088 deaths were equal to an annual rate of

1’76 per 1000 ; the corresponding rates in the three

preceding years were 2 - 23, 2 - 22 and 2 - 21 per 1000 andand the decennial average 2-60 per 1000. Among thevarious metropolitan boroughs the death-rates from these

principal infectious diseases ranged from 0-58 in Hamp-stead, 0 86 in the City of London, 0-96 in Lewisham,1-00 in the City of Westminster, 1-10 in Woolwich, and1-14 in Chelsea, to 2’24 in Bethnal Green, 2’22 in Fulham,2-32 in Finsbury, 2-36 in Stepney, 2-90 in Shoreditch, and2- 99 in Poplar. The fatal cases of small-pox numbered 13,against an average of 200 in the ten preceding years ; ofthese 13 cases, four belonged to Stepney, four to Lambeth,three to the City of Westminster, and two to Poplar. The2046 deaths referred to measles showed a decline of 505 fromthe corrected average number ; among the various metro-

politan boroughs this disease was proportionally most fatal inSt. Pancras, Finsbury, Shoreditch, Bethnal Green, Stepney,Poplar, and Battersea. There were 361 fatal cases of scarletfever registered last year, against an annual average of 784 inthe ten preceding years ; the highest death-rates from thisdisease were recorded in St. Marylebone, St. Pancras,Finsbury, Poplar, Bermondsey, and Deptford. The deathsfrom diphtheria, which had averaged 2170 in the ten

preceding years, declined last year to 740 ; among thevarious metropolitan boroughs the greatest proportionalmortality from this disease was recorded in St. Marylebone,Hackney, Bethnal Green, Poplar, Deptford, and Greenwich.The 1627 fatal cases of whooping-cough showed a decline of435 from the corrected average number ; this disease wasproportionally most fatal in Kensington, St. Marylebone,Islington, Finsbury, Poplar, and Battersea. The 376 deathsreferred to different forms of "fever" were 292 below thecorrected average in the ten preceding years; among thevarious metropolitan boroughs the highest "fever" death-rates were recorded in Fulham, St. Marylebone, StokeNewington, Hackney, Finsbury, the City of London, Shore-ditch, Poplar, Southwark, and Battersea. The 2925 fatalcases of diarrhoea showed a decline of 754 from the correcteddecennial average ; the greatest proportional mortality fromthis disease occurred in Fulham, Shoreditch, Stepney,Poplar, and Southwark. In conclusion, it may be statedthat the aggregate mortality in London last year from theprincipal infectious diseases in the aggregate was 32-5 percent. below the average.

Infant mortality in London last year, measured by theproportion of deaths under one year of age to registeredbirths, was equal to 130 per 1000, against 158, 148, and 139in the three preceding years. The rates of infant mortalityin the various metropolitan boroughs ranged from 88 in

Hampstead, 92 in Lewisham, 95 in Holborn, 96 in St.Marylebone, 108 in Woolwich, and 109 in Wandsworth, to142 in Chelsea, 145 in Kensington, 148 in Southwark, 154 inPoplar, 158 in Bermondsey, and 171 in Shoreditch.

THE SERVICES.

ROYAL ARMY MEDICAL CORPS.THE undermentioned Majors to be Lieutenant-Colonels

(dated Feb. 2nd, 1904):-R. J. Geddes, D.S.O., D. V.O’Connell, A. Dodd, G. Wilson, J. M. Reid, T. B. Winter,F. S- HeustoD, C.M.G., G. F. Gubbin, M. O’D. Braddell,J. J. C. Donnet, and H, M. Sloggett.Major J. Will is seconded for service under the Foreign

Office (dated Feb. 20th, 1904). Captain F. S. Walker isplaced on temporary half-pay on account of ill-health (datedFeb. 19th, 1904).

Lieutenant-Colonel J. G. Harwood is granted the tempo-rary rank of Colonel whilst officiating as Principal MedicalOfficer of the Poona District. Lieutenant- Colonel P. Mal-vancy is appointed to the medical charge of the PrincessLouise Hospital at Alton, Hants.

VOLUNTEER CORPS.Riffle 1st Roxburgh and Selkirk (The Border): George

McKellar to be Surgeon-Lieutenant (dated March 5th, 1904).Brigade-Surgeon-Lieutenant-Colonel E Jones, Senior MedicalOfficer, Welsh Volunteer Infantry Brigade, resigns his com-mission and is granted the honorary rank of Surgeon-Colonel, with permission to wear the prescribed uniform(dated Jan. 22nd, 1904).

ROYAL ARMY MEDICAL CORPS (VOLUNTEERS).The Glasgow Companies : Captain D. Christie, from

751

Argyll and Sutherland Brigade Bearer Company, to be

Captain (dated March 5th, 1904). The London Companies :Lieutenant-Colonel and Honorary Colonel J. E. Squireresigns his commission, with permission to retain his rankand to wear the prescribed uniform (dated March 5th,1904). The Manchester Companies : The undermentionedgentlemen to be Lieutenants : Wilfred Edwin Rothwell

(dated March 5th, 1904), and Alfred Francis Thompson(dated March 5th, 1904).

VOLUNTEER INFANTRY BRIGADE BEARER COMPANY.Sussex and Kent: Captain C. J. Jacomb-Hood is appointed

to command under paragraph 55A Volunteer Regulations,vice Major J. Turton, appointed Senior Medical Officer,Sussex and Kent Volunteer Infantry Brigade (datedFeb. 3rd, 1904).THE REPORT ON THE HEALTH OF THE NAVY FOR 1902.Some excellent reading will be found in the present

volume in an article by Deputy Inspector-General TheodoreJ. Preston, R.N. (retired), under the heading of a "Reporton Journals of Medical Officers examined at the PublicRecord Office, extending from 1793 to 1856." Unfortunately,as it happens, the medical officers of those times had adistaste for clerical work but this did not arise from thewant of any interesting material. The extracts are, speak-ing generally, very short and the information is very scantybut what there is is curious and often quaint and interesting.Taken as a whole, Deputy Inspector-General Preston’s papergives a survey of the state and progress of the naval medicalservice within the dates i-peci&ed. As a sample there is a

very brief, and therefore disappointing, reference to AdmiralNelson’s gunshot wound and amputation of the right arm inthe journal of the Theseus, July 24th and 25th, 1797, andsubsequently on August 20th in the journal of the Seahorse.In this connexion it will be remembered that THE LANCETof March 5th (p. 684) contains an interesting communicationon " Nelson as a Patient." The notes and extracts fromjournals touch on all sorts of subjects, such as the constitu-tion and personnel of the medical service, medical, surgical,and sanitary matters, epidemic and endemic diseases, food,clothing, and water-supply.

MEDICAL OFFICERS OF THE GUARDS.A Royal Warrant has been issued to the effect that "All

regulations authorising the transfer of an officer of our RoyalArmy Medical Corps to our regiments of Foot Guards shallbe cancelled. Medical officers who have already been

gazetted to our regiments of Foot Guards shall elect, withinsuch time as may be prescribed by our Army Council,whether they will remain therein or be transferred to ourRoyal Army Medical Corps. Medical officers who elect toremain in our regiments of Foot Guards shall be eligiblefor promotion under Article 383A of the Pay Warrant up to,but not beyond, the rank of Surgeon-Lieutenant-Colonel.Those who elect to be transferred to our Royal Army MedicalCorps shall take rank and seniority therein as follows :-A Brigade-Surgeon-Lieutenant-Colonel-as a Lieutenant-Colonel selected for increased pay with seniority from thedate of promotion to his present rank. A Surgeon-Lieut-tenant Colonel-as a Lieutenant-Colonel not selected for increased pay with seniority from the date of promotionto his present rank. A Surgeon-Major-as a Major, withseniority from the date of his original promotion to therank of Surgeon-Major or Major."

THE ARMY ESTIMATES.Mr. Arnold-Fordter must have found himself in an unusual

and somewhat difficult position on the occasion of his intro-ducirg the Army Estimates in the House of Commons. Thepresent is a period of transition, indeed, almost of revolution,so far as the army and the War Office are concerned. TheWar Minister spoke warily, but nevertheless favourably, ofthe reports of the War Office Reconstruction Committee andit seems nearly certain that, so far as all the main principlesare concerned, the committee’s recommendations will be

adopted by the Government, although strongly opposed bySir Henry Campbell-Bannerman. Mr. Arnold-Forster addednothing to our knowledge, however, about the intentions ofthe Government regarding the position of the Army MedicalService under the new scheme. The Army Estimates showa reduction of some ;&8,000,000, attributable mainly tothe expenditure on the Boer war having come to an endand, on less satisfactory grounds, to a reduction in thestrength of the Foot Guards and recruiting generally.

RUSSIAN ENGINEERS’ SPLENDID CONTRIBUTION TO THERED CROSS SOCIETY.

’ The directors of the Putilcff Engineering Works ofSt. Petersburg, the Krupps of Russia, are placing a sanitaryinfirmary train at the disposal of the field forces in con-nexion with the war in the Far East. The cost ofthis train, says the Novoe Vremya, will be over 100,000roubles (.E1O,000). It will consist of an engine, a tender, andten wagons and is at the present moment being rapidly gotready in the special model factory of the firm. The latest

improvements have been introduced into the fittings of thewagons for removing the seriously wounded to the smallestdetail and everything in connexion therewith answers to thelatest requirements of science and the exactions of clinicalpractice and experience. For the medical staff, dispensary,kitchen, &c., special wagons are fitted and all is arranged toyield the greatest comfort and practical use.

RUSSIAN MILITARY HOSPITAL TRAIN.On Feb. 24th, says the Novoe Vremya, the Russian Empress

inspected the military sanitary train No. 13 for the eat ofwar, consisting of 13 wagons. Of these two are reception.wagons for diagnosing cases, four are fitted with " " Krüger" "frames for the seriously wounded, two are for the slightlywounded, and one is for officers. In one wagon there is the-kitchen and there is one set apart for the servants. The trainwas fitted up in the Alexandrovsk factory of Nikolaevsk infive days. A senior medical officer, five sisters of mercy,.and 30 field medical officers from the Nikolaevk MilitaryHospital will go with the train.

Correspondence.

ON PARACENTESIS AND THE USE OFTHE ASPIRATOR IN PNEUMOTHORAX.

" Audi alteram partem."

To the Editors of THE LANOET.

SIRS,-In a short article on the above subject whichappeared in a recent issue of THE LANCET several importantquestions are raised upon which, as my name is therereferred to, I should like to make some comment.

Strange as it may seem, pneumothorax is not always.attended by urgent symptoms. The urgent symptoms arenot merely mechanical in origin but depend chiefly uponthe embarrassment and physiological disturbance in boththe respiration and the circulation in the lungs, for though,the mechanical conditions remain the same the urgentsymptoms gradually subside if the lungs and heart havetime to adjust themselves to the altered conditions. The

greater the disturbance the more severe the embarrassmentand the more severe the symptoms. Thus the paradox isexplained that the symptoms of pneumothorax are the more-severe the more healthy the patient has previously been.Per contra, in phthisis, for example, pneumothorax is not

altogether uncommonly discovered by accident, as there maybe no symptoms to mark its occurrence, for it makes butlittle difference to the condition of respiration whether theone lung be useless because it is tuberculous or because it iscollapsed. Yet even in persons apparently healthy pneumo-thorax may be latent-i.e., it may occur without markedsymptoms.

In traumatic pneumothorax, with which especially thearticle referred to dealt, the symptoms are almost invariablysevere, but then the diagnosis is not so easy. Rupture of thediaphragm may permit the passage of some of the abdo-minal viscera, the intestines, of course, chiefly, into the

pleural cavity and will give rise to the same mechanicalconditions and similar symptoms as pneumothorax.The diagnosis could only be made by careful physicalexamination of the chest and abdomen but usually the

patients are too ill to stand much investigation.When pneumothorax occurs not only is the one lung com-

pletely collapsed, but owing to the displacement ofthe mediastinum and heart the other ung, too, is

partly collapsed, so that the total respiratory capacitymay be reduced to about one-third of the normal. With

large pleuritic effusion the mechanical conditions may be thesame and yet no urgent symptom be present. The differenceis due to the fact that in pneumothorax the disturbance is