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admissions averaged 2, against 29, 11 and 5 during May, Juneand July respectively. The prevalence of scarlet fever duringAugust showed a further :"light increase upon that recordedin recent months. This disease was proportionally mostprevalent in Holborn, Whitccha.pel, St. George-in-the-East,Limehouse, Mile End Old Town, Poplar, Newington, Ber-

mondsey and Plum stead sanitary districts. The MetropolitanAsylum Hospitals contained 3213 scarlet fever patients atthe end of August, against numbers increasing from 1142 to2763 at the end of the preceding six months ; the weeklyadmissions averaged 378, against 170, 200, 238 and 335 in thepreceding four months. Diphtheria showed the highest pro-portional prevalence during August in Hammersmith, West-minster, Bethnal Green, White chapel, St. George-in-the-East, Poplar and Battersea sanitary districts. There were310 cases of diphtheria under treatment in the MetropolitanAsylum Hospitals at the end of August, against numbersincreasing from 198 to 283 at the end of the preceding fivemonths ; the weekly admissions averaged 55, against 41,49 and 56 in the previous three months. Among the varioussanitary districts enteric fever was proportionally most pre-valent in Hackney, Holborn, Whitechapel, Poplar andGreenwich. The Metropolitan Asylum Hospitals contained93 enteric fever patients at the end of August, against 47,57 and 77 at the end of the preceding three months ; the

weekly admissions averaged 14, against 8, 10 and 16 in thepreceding three months. Erysipelas showed the highestproportional prevalence during the month under notice inSt. Pancras, Holborn, St. Luke, Shoreditch, White chapeland Bermondsey.The mortality statistics in the accompanying table relate

to the deaths of persons actually belonging to the variousmetropolitan sanitary districts, the deaths occurring in theinstitutions of London having been distributed among the Ivarious sanitary districts in which the patients had previouslyresided. The distribution of these deaths, and especially ofthose resulting from zymotic diseases, affords the most trust-worthy data that can be secured upon which to calculatereliable rates of mortality. During the five weeks endingSaturday, Sept. 3rd, the deaths of 6892 persons belonging toLondon were registered, equal to an annual rate of 16 ’9 per1000, against 16 9 and 17’8 in the preceding two months. Thelowest death-rates during August in the various sanitary dis-tricts were 8’7 in Hampstead, 11 ’5 in Lewisham (excludingPenge), 12’5 in St. George Hanover-square, 12’8 in St. James,Westminster, 13’3 in Hackney, 13’4 in Plumstead and 13’5in Paddington ; in the other sanitary districts the rates rangedupwards to 22 -0 in St. Martin-in-the-Fields, 22’3 in St. George-in-the-East, 22-4 in St. Luke, 22-5 in Rotherhithe, 23’8 in

Whitechapel, 24-7 in Holborn and 34-3 in St. Olave, South-wark. During the five weeks of August 1375 deaths werereferred to the principal zymotic diseases in London ; of

these, 722 resulted from diarrhoea, 219 from measles, 184from diphtheria, 152 from scarlet fever, 33 from "fever"(including 30 from enteric fever, 1 from typhus fever, and 2 fromill-defined fever) and not one from small-pox. These 1375deaths were equal to an annual rate of 3-4 per 1000, against3’1 and 3’9 in the preceding two months. Among the varioussanitary districts the lowest zymotic death-rates were recordedin St. George Hanover-square, St. James Westminster,Hampstead, St. Giles, St. Martin-in-the-Fields and City ofLondon ; and the highest rates in Hammersmith, St. George-in-the-East, Limehouse, St. Olave Southwark, Rotherhithe,Camberwell and Greenwich. The 219 deaths referred tomeasles exceeded by 14 the corrected average number in thecorresponding month of the preceding ten years ; among thevarious sanitary districts this disease showed the highest pro-portionate fatality in Kensington, Whitechapel, Limehouse,St. George Southwark, Rotherhithe, Camberwell andWoolwich. The 152 fatal cases of scarlet fever were 34above the average ; among the various sanitary districts thisdisease was proportionately most fatal in St. Martin-in-the-Fields, Whitechapel, Limehouse ; and St. Saviour SouthwarkThe 184 deaths referred to diphtheria exceeded by as manyas 79 the corrected average ; this disease showed the highestproportional fatality in Westminster, Holborn, Bethnal Green,Whitechapel and Battersea. The 65 fatal cases of whooping-cough were little more than a third of the average number ;this disease was not prevalent last month in any of the sani-tary districts. The 33 deaths referred to different forms of"fever" were 33 below the corrected average, and there wasno marked excess of fever mortality in any of the sanitarydistricts. The 722 fatal cases of diarrhoea were as many as272 below the average; this disease was proportionally most

fatal in Paddington, Fulham, Islington, St. George-in-the-East, Poplar, Rotherhithe and Greenwich. In conclusion,it may be stated that the mortality in London during Augustfrom these principal zymotic diseases was nearly 18 per cent.

below the average, owing to the fact that the mortality from

whooping-cough and from diarrhoea was unusually low.Infant mortality in London, measured by the proportion

of deaths under one year of age to registered births,was equal to 177 per 1000 during August; the lowest rates ofinfant mortality were recorded in St. George Hanover-

square, St. James Westminster, Hampstead, St. Martin-in-the-Fields and City of London ; the highest rates inHammersmith, St. Saviour Southwark, St. George South-wark, St. Olave Southwark, Rotherhithe and Wands-worth.

THE SERVICES.

ARMY MEDICAL SERVICE.

Surgeon-Captain W. A. Morris, Army Medical Staff, hasbeen appointed to the staff of the Royal Victoria Hospital,Netlev.

MOVEMENTS OF THE MEDICAL STAFF.

Deputy-Surgeon-General Comyn has resumed duty at Brad-ford. Surgeon-Captain Dixon has been transferred fromAldershot to Preston for duty. Surgeon-Captain Eldertonhas joined at Portland and Surgeon-Captain Hains has,rejoined at Devonport. Brigade-Surgeon-Lieutenant-ColonelC. A. Maunsell has assumed the duties of Principal MedicalOfficer, Cork district. Surgeons-Captain Russell and PerryMarsh have arrived at Gibraltar for a tour of service. Surgeon-Captain Hardy has proceeded to Chichester. Surgeon-MajorPeyton and Surgeon-Captain Frayer have quitted the Belfastdistrict on leave before embarkation for duty abroad. Surgeon-Captain Wild has reported himself in Edinburgh. Brigade-Surgeon-Lieutenant-Colonel Stevenson has assumed theduties of Professor of Military Surgery at Netley. Surgeon-Major Lamprey has reverted to general duty in the Home-’District. The death of Surgeon-Major J. Lauder, retired pay,and lately employed at Penally, is reported. The deaths fromcholera at Murree of Surgeon-Colonel Allan and Surgeons-Captain H. N. Kenny and Fowler are also reported. Surgeon-Captain Addison has embarked for India on a tour of service.Brigade-Surgeon-Lieutenant-Colonel Murray has left Bermuda.for England on leave of absence. Surgeon-Lieutenant-ColonelFairland has arrived in England from Bermuda on appoint-ment to the Assistant Professorship of Military Medicine at.Netley. Surgeon-Captain Baird has embarked for a tour ofservice in India.

INDIAN MEDICAL SERVICE.The services of Surgeon-Captain Alcock, Surgeon Naturalist,

Marine Survey of India, have been placed at the disposalof the Home Department for employment as DeputySanitary Commissioner of the Metropolitan Circle in

Bengal. The services of Brigade-Surgeon-Lieutenant--Colonel G. Thomson, medical adviser to his Highness theMaharaja of Patiala have been placed at the disposal of theGovernment of India in the Military Department. Assistant-

Surgeon Lallubhal B. Kaji, L.M. and S., has been ap-pointed to act as Medical Officer in Charge, Larkhana.

Dispensary (Sind), from July 29th, 1892, during the absenceof Assistant Surgeon M. G. Thadani. Surgeon-CaptainJ. 1YI. D. Smyth has been appointed to act as Superintendent,Lying-in-Hospital, Madras, during the absence of Surgeon-Lieutenant-Colonel A. M. Branfoot, M.B., on leave. Surgeon-Captain E. H. Wright has been appointed to act as ResidentSurgeon, General Hospital, during the employment ofSurgeon-Captain Smyth on other duty. Surgeon-CaptainD. G. Marshall, 1. M. S., has been appointed to the Civil MedicalCharge of Roorkee, in addition to his military duties, fromthe date of taking charge from Surgeon-Captain H. J.Pocock. Surgeon-Captain J. J. Pratt, Civil Surgeon, Gonda,on being relieved by Surgeon-Lieutenant-Colonel C. Cameron,has been transferred to the Bahraich district. Surgeon-Major H. K. McKay, Officiating Civil Surgeon, Nagpur,has been appointed to be Honorary Surgeon, Nagpur Volun-teer Rifie Corps, vice Surgeon-Major G. F. A. Harris, I.M.S.,on furlough, and who has been placed on the rolls as a

supernumerary. On being relieved by Surgeon-Captain D. WScotland, M.B., Assistant Surgeon Surendra Nath Barat,Officiating Civil Surgeon and Superintendent of the Gao],.

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Betul, has been appointed to the Main Dispensary, Sani;ur.Brigade - Surgeon - Lieutenant - Colonel S. B. Hunt, IndianMedical Service, has been appointed to officiate as Principal.,Medical Officer of a District Command, during the absenceof Surgeon-Colonel C. Sibthorpe on furlough. Surgeon-Lieutenant W. C. Sprague, M.D., has been appointed to actas Civil Surgeon, Dhulia, during the absence of Surgeon-.lllajor Ii. A. Dalal, M.B., on privilege leave. Surgeon-Major’C. L. Swaine, M.D., Madras Establishment, Medical Officer,2nd Infantry, Hyderabad Contingent, has been appointed toofficiate as Sanitary Commissioner, Hyderabad AssignedDistricts, during the absence on furlough on medical certifi-cate of Surgeon-Lieutenant-Colonel C. Little, M.D. Surgeon-Major G. Shewan, Officiating Civil Surgeon of Balasore, is toofficiate as Civil Surgeon of Shahabad during the absence onfurlough of Surgeon-Major R. Macrae. Surgeon-CaptainW. G. Thorold, Civil Surgeon, Kheri, is to officiate as Civil,Surgeon, Gorakhpur, during the absence on privilege leave ofSurgeon-MajorJ. Moran. Surgeon-Captain G. J. H. Bell, Bengal’Establishment, whose services have been placed at the

,disposal of the Chief Commissioner, is appointed to be

Superintendent of the Insein Gaol.NAVAL MEDICAL SERVICE.

The following appointments have been made :-Fleet Sur-geon Valentine Duke to the Dreadnought (dated Sept. 13th,1892). Surgeons : Hugh W. Macnamara to the Boyal Sovereign(dated Sept. 6th, 1892) ; Horace B. Marriott to the Colossusand George Ley to the Hotspur (both dated Sept. 13th, 1892).

VOLUNTEER CORPS.

Artillery: (Duke of Cornwall’s) (Western Division Royal.Artillery) : Joseph Thomas Harty, Gent., to be Surgeon-Lieutenant (dated Sept. 10th, 1892).-Rifle 1st VolunteerBattalion, the Buffs (East Kent Regiment) : Surgeon-Lieu-tenant J. H. Mitcheson resigns his commission (dated,Sept. 10th, 1892).-Surgeon-Lieutenant J. G. McCann resignshis commission (dated Sept. 10th, 1892).-2nd VolunteerBattalion, the Oxfordshire Light Infantry : Surgeon-CaptainJ. A. Rigge to be Lieutenant (dated Sept. 10th, 1892).-lst Volunteer Battalion the Northamptonshire Regiment :- Surgeon-Captain G. S. Payne to be Surgeon-Major ; to resignhis commission ; also to be permitted to retain his rank, andto continue to wear the uniform of the Battalion on hisretirement (dated Sept. 10th, 1892). - 3rd (the Buchan)Volunteer Battalion, the Gordon Highlanders: The under-mentioned Surgeon-Captains to be Surgeon-Majors (datedSept. 10th, 1892) : N. Lawrence and R. M. Wilson.

THE CHAIR OF PATHOLOGY AT NETLEY.

To the Editors of THE LANCET.SIRS,—I have read in THE LANCET a letter from Dr.

Kenneth Campbell, also a paragraph of subject matter statingthat great dissatisfaction has been caused by the appointmentof a professor of pathology in the person of a civilian medicalman. I beg to suggest that the appointment at Netley maybe open to all members of her Majesty’s services, includingthe medical officers of the Royal Navy, if there be any fittedfor such a distinguished position. They, I think, have anequal opportunity with their military confreres of obtainingan equal experience in that peculiar branch of pathologyrequired for these appointments, and as they have nothingin their own service to look forward to in the way ofprofessional honours, I think it would be almost an injusticeto exclude them from a remote chance of obtaining a well-known and honourable position in the medical world. I mayadd that it would be a generous and chivalrous oppor-tunity for military officers to show a real act of kindness to,in many ways, their less fortunate brother officers.

I am, Sirs, yours faithfully,GEORGE EDMONDS, Surgeon, R.N.

H.M.S. Abyssinia, Bombay, Aug. 22nd, 1892.

THE NEW WAIt MINISTER.The appointment of Mr. Campbell-Bannerman to the post

of War Minister is, we believe, generally regarded withsatisfaction by different branches of the army. He has thereputation of being a clear-headed and excellent man of’business, and there are at the present time a number ofmatters claiming his consideration which will speedily putthese qualifications to the test.

THE DEPRECIATED RUPEE.The fall in the value of the rupee, which does not yet

seem to have reached its downward limit, will probably

compel the Government to take some steps before long.The present rate of exchange inflicts a great hardship on allmarried officials and soldiers serving in India with wives andfamilies to support in this country. Numerous meetingshave taken place in various parts of India, and resolutionsand petitions have been forwarded to the Government ofthat country. The finances of India, with its depreciatedsilver currency, must be a matter of extreme difficultv, notonly to the Government there, but to the Minister for Indiain this country, and it is not, unfortunately, the only com-plicated and difficult subject with which the Governmentwill soon have to grapple in earnest.

MILITARY SERVICE IN GERMANY.The question of reducing the term of service in the army

still occupies a share of public attention in Germany, not-withstanding that most of it is taken up with the larger andmore pressing consideration of the existing cholera epidemic.The heavy financial burden imposed on the nation in the shapeof taxes, and the strain induced by the withdrawal of such alarge portion of the population from industrial pursuits, havenaturally led the Germans to consider whether the present limitof three years’ training with the colours might not be reducedto two, without detriment to the army and certainly withadvantage to the country. These proposals are backed up bythe Liberal party in Germany, and it seems probable thatsome compromise will be effected by which a two years’limit will be generally adopted for the Infantry, with theunderstanding that all conscripts who have not perfectedtheir military training in that time will be required to extendit with the colours for three years, or until they have reachedthe required standard of efficiency.

’

THE GERMAN ARMY MANŒUVRES AND THE CHOLERA.In consequence of the prevalence of cholera the manoeuvres

of the German Army have been countermanded by order ofthe Emperor. Although the epidemic at Hamburg has notextended so as to involve any places in the vicinity of ttatcity to any extent, it has been deemed prudent to avoid ther;sk attending the concentration of large bodies of troops atthe present time and their subsequent dispersion to differentparts of the empire.

THE BLACK MOUNTAIN EXPEDITION.Officers of the British and Indian Army Medical Services

are, of course, as keen to obtain information about any littleexpedition that may be going on, and to be included in it, asofficers of other branches of the army. For one thing, pro-motion sometimes comes that way, and for another, oppor-tunities for distinction or the exhibition of enterpriseoccasionally present themselves, and, in any case, field servicealways adds something to experience in the way of field

hospital administration and management, transport and newlydevised or applied methods of treatment required by thenature of the country traversed or by the special character ofthe expedition itself. In all these respects India affords anexcellent training ground. At the present time there is morethan one of these small expeditions on hand in that country.There is the expected movement of the Black Mountain forcefor possible service in the Gomul Pass, the occupation of theKuram Valley by a small body of native troops in accordancewith the request of the Ameer of Afghanistan, with the viewof preserving order in that neighbourhood, and Lord Roberts’sprojected military mission and conference with the Afghanruler, not to say anything of the possible development ofaffairs in the Pamirs, a matter which concerns the ChineseGovernment rather than that of this country.

THE FOREIGN SERVICE TOUR.As the one serious grievance which now afEects medical

officers of executive rank is the length of the tour of serviceabroad, it is to be hoped that Mr. Campbell-Bannerman willsee his way to a favourable consideration of it. We do notpretend to know on what grounds it was originally decided to

. increase the length of the tour from five years to six at some’

stations and from three years to four at others ; but it hasbeen stated in Parliament that the obstacle to a resump-tion of the old rule is the increase of expense which it

’ would involve. This appears to us a most lame and

t impotent conclusion ; for if an economy has really been,

effected at the cost of much suffering and iucon-venience to the Service there can be no good reasonfor persisting in it. It is not a question of increase of

b expense at all, but of resuming an expenditure whichy has been unwisely retrenched. It should have been

696

apparent from the moment that officers on half-pity wereappointed to home stations that the effect would be to curtailthe amount of home service for those on the effective list,yet that very moment was chosen to lengthen the tour abroad,thereby accentuating the grievance. If the employment ofhalf-pay officers at home facilitated a reduction of the effectivestaff, surely the economy was sufficient without seeking forfurther savings at the price now paid for it in the loss ofhealth and prolonged expatriation imposed upon the MedicalStaff. There are many officers who hold that it is unjust inprinciple to fill up so many of the desirable stations at homefrom the half-pay list. This is perhaps rather a one-sidedview ; but it must be conceded that it is unjust so to prolongthe term of service abroad that a career in the Medical Staffbecomes one of perpetually recurring exile.

Correspondence.

HALSTED’S OPERATION FOR THE RADICALCURE OF INGUINAL HERNIA.

"Audi alteram partem."

To the Editors of THE LANCET.

SIRS,-In THE LANCET of Sept. 10th, Mr. Frederick

Page reports a case of radical cure of an inguinal hernia byHalsted’s method, and compares the operation with that of

Bassini, rather to the disadvantage of the latter. Now Ihave performed Bassini’s operation eight times with the mostsatisfactory results, and I happen to be just as enthusiasticallyin favour of it as Mr. Page appears to be in favour of that ofHalsted, and I wish to point out that Mr. Page has been-quite unintentionally I do not doubt-a little unfair on thequestion of the merits of the operation that bears the nameof the distinguished Italian surgeon. In contrasting therelative advantages of the two operations Mr. Page says:"By every other method the canal is left occupied by the cordand recurrence is common....... Recurrence is far less likelyto occur-i. e., by Halsted’s method."

Mr. Page may possibly be in possession of statistics whichhe regards as sufficiently trustworthy to prove that Halsted’soperation is less likely to be followed by a recurrence of theoriginal hernia than is that of MacEwen, though I venture tothink that the short time that the former procedure has beenbefore the profession does not allow of any approach to

dogmatism upon the point; but I venture to assert that hecannot have the same reason for preferring it to Bassini’s, forthe simple reason that-at any rate to the best of my know-ledge-all the statistics that have been published concerningthe operation show an entire absence of failure. Bassinireports in his original paper 108 cures (lasting for a period offrom one to four years after the date of operation) that hewas able to trace out of the 262 cases that he had done; whilePaul Berger has repeated the operation thirty times withouta failure. It is in face of figures such as these that I ventureto think that Mr. Page’s statements bear a little hardly uponthe operation. For my own part, the reasons that incline meto favour Bassini’s operation in preference to all others arebriefly these :-By means of it the external abdominal ring isfirmly sewn up opposite the point at which the cord emergesfrom the internal, and conversely the internal ring is firmlyoccluded behind the point at which the cord passes into thescrotum, and thus a new oblique inguinal canal is formed andthe rings are reinforced in the valvular manner that naturehas planned. In MacEwen’s operation, and still more so inHalsted’s, the track through which any second hernia has tomake its way is the shortest possible, and a direct openinginto the abdominal cavity exists through which the cord hasto pass, and therefore the chance of averting the recurrenceof the hernia lies solely in the thoroughness and solidity ofthe occlusion of the ring. I freely admit, however, that thispreference is a theoretical one and that there is at present nodirect practical proof of it, and that is just the reason thathas induced me to write this note to point out that it is

perhaps a little premature to laud one particular operation atthe expense of others without supporting the dictum upon thebasis of practical statistical experience.

T am Sirs vnurs fmthfullv.

Weymouth street, W., Sept. 13th, 1892. FRED. F. BURGHARD.

1 Arch. f. Klin. Chir., 1890, t. xl., p. 429.

MIDWIVES AND ABNORMAL CASES..To the Editors of THE LANCET.

SIRS,—The enclosed report of an inquest lately held at theCoroner’s Court, Hammersmith, distinctly points to the

urgent call for some legislation that may prevent the sacrificeof maternal life from the crass ignorance and culpable, if notlegal, negligence of the midwife in not calling in medical aidtill treatment has become useless. I give you a few ofthe symptoms. The after-pains continued the whole puer-peral week, and, instead of daily being less, increased inseverity, the patient had no sleep till the eighth day,and then only from a strong opiate procured by the mid-wife from a chemist (another evil of counter-prescribing,for this dose masked the symptoms), when she obtainedsleep and said she was better. The after-pains from thesecond day were accompanied with nausea and sickness.The lochia were described to me as horribly offensive. The-temperature on my visit on the tenth was 103° ; respirationquick and short, the patient excited and rambling, theabdomen distended and tender. The poor woman was so iMthe night before I was called in that her husband and a.

lodger sat up with her all night. Surely any midwife oughtto have recognised these symptoms as very serious andobtained qualified medical assistance long before. I opposed,the late Midwifery Bill because it was prospective and wouldhave certificated this very ignorant woman and all the I Alrs.,Gamps " of her class, but I am not opposed to some usefullegislation demanded in the interest of those few women who,cannot protect themselves, and think as I advocated in myaddress (page 5), when contesting a seat on the MedicaLCouncil as a direct representative, midwives should onlybe allowed to act when a doctor has been already engagedand so to act under the eye and responsibility of a medicalman, and it would be better that they should be registeredas obstetric nurses rather than midwives. I ask for theinsertion of this letter, valuable and limited as your space is,because it will, I think, interest numbers of your readers andhave a practical value, bearing as it does on this questionnow engaging the thoughts of a large section of the

profession, but particularly the members of the selectcommittee of the House of Commons on the Midwives

Registration Bill. On a rich patient, the doctor would be theordinary attendant as is now the case ; on a poor patient theclub or parish doctor.

I am, Sirs, yours obediently,Sept. llth, 1892. FREDERICK H. ALDERSON, M.D.

ON THE USE OF IRON SALTS IN VARIOUSFORMS OF DIARRHŒA.

-, To the Editors of THE LANCET. _

SIRS, -Some few months ago, while engaged in the study ofBunge’s Physiological and Pathological Chemistry, as trans-lated by the late Dr. Wooldridge, I was much struck by his.theory of the action of iron in chlorosis. While thinking thisover, though not in entire agreement with him, I was im-

pressed by the idea that it was not only possible but probable’that iron might have a decided action in many cases ofdiarrhoea, by combining, as bismuth does, with the sulphu.retted hydrogen and alkaline sulphides, to form inert insoluble’metallic sulphides, and so check the diarrhoea by removingsecondary, if I may so call it, irritation. It did not appearto me to be necessary to give the astringent forms ofiron, on the assumption that, whatever forms of ironare given, it is probable that in the stomach theyare converted into the chlorides and ultimately inthe bowel after various changes into sulphides. Thesalt I chose for chief use was the citrate of iron andammonia, though in some cases I used Blaud’s pills. Forsome time now I have treated a large number of cases ofinfantile diarrhoea, in many cases apparently due to defective-sanitation, of irritative diarrhoea, and some of tuberculardiarrhoea by this means and with almost unvarying success.The rapidity with which the offensive smell of the motions.disappears has exceeded anything I had thought likely, andhalf-a-dozen of my cases have apparently been so suc-

cessful that I feel justified in suggesting that others mayhave a like success. In two or three cases too early astoppage of the treatment was followed by a return of aiioffensive diarrhoea, which was soon checked again by resumingit. In one case, in a woman, a very violent attack of fourdays’ duration, with intense griping and copious, watery_»