48

with school attendances should be made to extend, in itsstrictest application, to the admission of convalescents tosuch gatherings as school treats. As the result of the

inquiry Dr. Low is inclined to hold that the first case

in the East Haddon diphtheria group occurred at a

rag shop in the village, and that it was probably due toinfected rags collected in the surrounding villages, wherethroat disease had been common, that the disease wasdiffused by contact in the village school and again at theschool treat; that absorption of the infection by milk mayhave aided in its distribution; that the disease was aggra-vated by the wetness of the prevailing weather; that thecarelessness and recklessness of ignorant persons still furtherled to the diffusion of the contagion ; and that it is impos-sible to ignore the fact that the defective sanitary circum-stances and deficient sanitary organisation in the villagemust have had important bearings on some of the results ofthe epidemic. As regards the latter, it must be rememberedthat Brixworth is a sanitary district which has persistentlydefeated the intentions of the Public Health Act by re-fusing to make a proper appointment of a medical officer ofhealth. Unfortunately, this instructive report has not beenplaced on sale. -

REPORTS OF MEDICAL OFFICERS OF HEALTH.

Oldham Urban District.-The year 1888 was characterisedin Oldham by the lowest death-rate on record-namely,20’3 per 1000, the improvement being most marked inchildren. A number of important questions affecting theborough are discussed by Dr. Niven, whose report is

admirably drawn up. Amongst these are those relating tosmoke nuisance, the discharge of hot water into the sewers,the condition of the streets and courts, the state of the tips,and the methods of sewage disposal. Distinct advance hasevidently been made in some matters affecting health inthe district, but in others Oldham still stands in much needof sanitary reform. It is quite evident that destructorsfor the disposal of refuse are much needed, but some ex-periments are in progress with a view to see whether thehouse ashes can be economically burned in the mill furnaces,and pending this, apparently, no decision will be come to.During 1888 Dr. Niven made a systematic inspection of thevarious streets and courts, a method of work which isalways of the greatest value for ascertaining accuratelywhat are the requirements of a sanitary district, andit is stated that, as a result, there has been more

work in house improvement than has ever been effectedbefore. On more than one occasion good work has beendone in Oldham with a view to lessen the prevalence ofinfantile diarrhoea and pulmonary consumption, and aseries of precautions as to both diseases has been issued byDr. Niven as to the means of prevention which should beadopted. As regards the latter disease, it is evident thatthe hints given are based on a firm belief in the communi-cability from person to person of the tubercle infection.There was a somewhat wide prevalence of small-pox in theborough during the year, and this leads Dr. Niven to givea summary of Dr. Barry’s report on the Sheffield epidemic.In Oldham, it is stated, small-pox was over eight timesmore fatal to the unvaccinated attacked than to the vacci-nated. The infectious hospital was largely used during theyear, and amongst 354 patients the deaths were at the rateof 8’7 per cent. The hospital, it is explained, is graduallybecoming more and more popular with the public, andadditions have recently been made to it which will securefor the nursing staff more accommodation and comfort

Ithan was formerly available.Portsmouth Urban District -During the year 1888 the

borough of Portsmouth exhibited marked improvement asregards public health, and especially in the matter ofinfectious diseases. The general death-rate from all causeswas 18’7 per 1000; the zymotic rate being 1’64. As to theprincipal zymotic diseases, it is satisfactory to note thatwhereas in 1851-60 the rate was 4-95 per 1000, it fell to 3-82during 1861-80, and that during 1881-88 it was furtherreduced to 2’93. Pulmonary phthisis has also undergone avery similar diminution. Measles was epidemic during thelatter part of 1888, and notwithstanding efforts to stay itduring periods of school closure, and by excluding scholarsfrom infected houses, and the fumigation of schools, freshcases continued to arise until February, 1889. No less than465 cases of scarlet fever occurred, a sudden increase in thedisease occurring in May in connexion with an infectedmilk-supply; the disease being due, according to Dr. Mumby,

to germs carried to the dairy by one of the men employedthere. The details of this occurrence are given at some-

length in the report. It is satisfactory to learn thatwhereas in 1887 only 9 per cent. of the scarlet feverpatients were removed to hospital, no less than 25<per cent. were isolated in 1888. Diphtheria caused 1’1deaths, and it is evident that Dr. Mumby regards thedisease as essentially a filth disease, for his experienceis to the effect that it is "most frequently causedby filthy and insanitary conditions." The compulsorysystem of notification is said to be working excellentresults, and it is to be hoped that the detection andamendment of unhealthy conditions which are ascer-

tained through its operation in connexion with cases ofenteric and continued fever are prodacing permanent-results. There is some evidence of this from the circumstance that during the last three years reported on the

total number of attacks of this disease have been 1249, 554,and 313 respectively. A useful chart, indicating the localityof a number of the cases of infectious diseases heard of, isincluded in the report, which also contains an account o9the current sanitary work.

VITAL STATISTICS.

HEALTH OF ENGLISH TOWNS.

IN twenty-eight of the largest English towns 4248 birtbo,and 4007 deaths were registered during the week endingDec. 28th. The annual rate of mortality in these towns,which had increased in the preceding five weeks from 18’2to 23’5, declined again last week to 21’9. During thethirteen weeks ending on Saturday last, the death-rate ir,these towns averaged 19’4 per 1000, and was 2’1 below themean rate in the corresponding periods of the ten years.1879-88. The lowest rates in these towns last week were11’6 in Norwich, 16’9 in Nottingham, 18’5 in Huddersfieldand 19’0 in Cardiff. The rates in the other towns rangedupwards to 26-7 in Liverpool, 27’0 in Preston, 28-7 inPlymouth, and 31’4 in Blackburn. The deaths referredto the principal zymotic diseases, which had been 378 and413 in the preceding two weeks, declined again last week to373; they included 140 from whooping-cough, 57 fromscarlet fever, 57 from measles, 52 from diphtheria, 3from "fever" " (principally enteric), 32 from diarrhoea,and not one from small-pox. No death from anyof these zymotic diseases was recorded during theweek in Huddersfield, while they caused the highest death-rates in Salford and Plymouth. The greatest mortalityfrom whooping-cough occurred inHalifax, Blackburn, Leeds,Portsmouth, Bristol, and Wolverhampton ; scarlet fever inSalford, Preston, and Plymouth ; measles in Birmingham and "fever" in Plymouth and Halifax. The 52 deathsfrom diphtheria in the twenty-eight towns included 26 inLondon, 6 in Manchester, 6 in Salford, 4 in Hull, 2 inLiverpool, and 2 in Plymouth. No death from small-poxwas registered in any of the twenty-eight towns. Nocase of this disease was under treatment at the end ofthe week in any of the Metropolitan Asylum Hospitals,and only 2 in the Highgate Small-pox Hospital. Thenumber of scarlet-fever patients in the Metropolitan Asylumand London Fever Hospitals at the end of the week was1609, against 1667 and 1594 on the preceding two Saturdays p103 cases were admitted to these hospitals during the week,against 154, 144, and 115 in the preceding three weeks.The deaths referred to diseases of the respiratory organs?which bad been 552 and 518 in the preceding two weeks,further declined last week to 467, and were G5 below thecorrected average. The causes of 97, or 2’4 per cent., orthe deaths in the twenty-eight towns last week were not.certified either by a registered medical practitioner or bya coroner. All the causes of death were duly certified inLeicester, Portsmouth, Blackburn, Bolton, Derby, andCardiff; the largest proportions of uncertified deaths werEJ!’registered in Liverpool, Brighton, Huddersfield, and Halifax.

HEALTH OF SCOTCH TOWNS.

The annual rate of mortality in the eight Scotch towns’,which had been 23’6 and 26’1 per 1000 in the preceding twoweeks, declined again to 24’6 in the week ending Dec. 28th ;

: this rate exceeded by 2’7 that which prevailed during thesame week in the twenty-eight large towns. The rates in

, the Scotch towns last week ranged from 9’5 and 15-0 in

49

Perth and Leith, to 240 in Edinburgh, 24 5 in Dundee,and 29’1 in Glasgow. The 630 deaths in the eight townsshowed a decline of 37 from the number in the previousweek, and included 25 which were referred to measles, 17to whooping-cough, 12 to " fever (typhus, enteric, or ill-defined), 9 to diarrhcea, 8 to diphtheria, 6 to scarlet fever,and not one to small-pox; in all, 77 deaths resulted fromthese principal zymotic diseases, against 85 and 88 in thepreceding two weeks. These 77 deaths were equal to anannual rate of 3’0 per 1000, which exceeded by 1’0 themean rate last week from the same diseases in the twenty-eight English towns. The fatal cases of measles, which hadbeen 11, 20, and 26 in the preceding three weeks, were lastweek 25, of which 13 occurred in Glasgow and 12 in Edin-burgh. The 17 deaths from whooping-cough showed adecline of 10 from the number in the previous week, andincluded 8 in Edinburgh and 7 in Glasgow. The 12 deathsreferred to "fever" showed a considerable increase uponthe numbers in recent weeks ; 6 were returned in Glasgow,2 in Greenock, and 2 in Paisley. The 9 deaths fromdiarrhoea and the 8 from diphtheria corresponded with thenumbers in the previous week ; 5 from diphtheria occurredin Glasgow and 2 in Dundee. Three of the 6 fatal cases ofscarlet fever were returned in Leith. The deaths referredto diseases of the respiratory organs in the eight towns,which had increased in the preceding four weeks from 121to 11, further rose last week to 189, and exceeded thenumber in the corresponding week of last year by 94. Thecauses of 86, or nearly 14 per cent., of the deaths regis-tered in the eight towns were not certified.

HEALTH OF DUBLIN.

The death-rate in Dublin, which had been 27-8, 32 2, and33’9 per 1000 in the preceding three weeks, declined to 24-5in the week ending Dec. 28th. During the thirteen weeksending on Saturday last, the death-rate in the cityaveraged 26’6 per 1000, the mean rate during the sameperiod being 17’8 in London and 20’7 in Edinburgh. The166 deaths in Dublin last week showed a decrease of 63 fromthe number in the previous week; they included 6 whichwere referred to "fever," 3 to whooping-cough, 1 tomeasles, 1 to diarrhoea, and not one either to small-pox,scarlet fever, or whooping-cough. Thus the deaths from theseprincipal zymotic diseases, which had ranged in the pre-ceding four weeks from 26 to 13, further declined last weekto 11 ; they were equal to an annual rate of 1’6 per1000, the rate from the same diseases being 2’0 in Londonand 4’5 in Edinburgh. The 6 deaths from " fever" exceededthe number in the previous week by one; whereas thefatal cases of whooping-cough, measles, and diarrhoeashowed a general decline. The deaths both of infantsand of elderly persons were considerably fewer than thenumbers in recent weeks. One inquest case and 2 deathsfrom violence were registered; and 44, or more than afourth, of the deaths occurred in public institutions. Thecauses of 22, or more than 13 per cent., of the deaths in thecity were not certified.

Correspondence.

THE INFLUENZA OF 1847 AND 1857.

" Audi alteram partem."

To the Editors of THE LANCET.SIRS,&mdash;I am able, from personal recollections of the above

epidemics, to corroborate some of the statements by Dr.Wilks in your issue of last Saturday. Of the former andmuch more severe epidemic I have, indeed, no notes avail-able, and possibly my reminiscences may therefore be lesstrustworthy ; but in respect of the epidemic of 1857 I ammore assured, having given a portion of two clinical lecturesupon it in November of that year, which were printed in avolume entitled " Clinical Medicine, &c.," and published in1862. Here, at page 100, after enumerating the leadingsymptoms observed in 1857, it is added: But thoughcatarrh is frequent, and may be severe, the disease is esseit-tially a jever, not a catarrh. Nay, the catarrh may beabsent, or insignificant ; not unfrequently it is so." Ex-amples are then given of instances where catarrh mightreasonably have been expected to be more than usually

severe, but where, in point of fact, it was absent, or slight,the febrile symptoms being far the most prominent.Alluding to the previous epidemic of ten years before(1847), I then remark upon " a succession of cases (inthe Edinburgh Royal Infirmary) such as I have never-

seen since that time. In the course of a few weeks-there occurred-I forget exactly how many-but upwardsof half a dozen cases of inflammation of all the greatserous membranes conjointly - double pleurisy, peri-carditis, peritonitis. Most of them were fatal; indeed,they seemed to come into the house only to die ; so rapid,,so uncontrollable were the symptoms, that no time wasgiven for the application of remedies, even had remediesbeen clearly indicated." I have a most vivid impression to.this hour, and even after so much longer hospital experi-ence, of the quite unique character of the impress givento the cases in hospital during the epidemic of 1847. Butthen it ought to be added that this particular influenzaepidemic, besides being in itself everywhere more severe-than that of 1857, followed in the wake of the Irish famineof 1845-46, with all the consequences-scurvy, dysentery,epidemic typhus and relapsing fevers, &c.,&mdash;which more

directly succeeded, and almost led up to, and mingled

with, the influenza. The epidemic of 1857, on the other-hand, occurred in the midst of a period of comparativequiescence as regards all other febrile and epidemic-diseases. Its influence upon the.disease and mortalityin my own wards, however, was not inconsiderable, andwas noticed in detail in the clinical lecture above referredto. In a subsequent lecture I adverted to the tale ofthe epidemic as told by the death-rate, using for thepurpose the weekly return for London, Nov. 21st, 1857,in comparison with the same week in the ten previous.years. I will not trouble you with the details of this,.but they are well worthy of being studied anew in con-nexion with the present or impending epidemic. Brieflystated, the result of my survey was that the mean mor-tality of the ten preceding years was raised by one-seventh;that bronchitis, pneumonia, phthisis, andwhooping-cough, all!showed a largely increased mortality ; while that from otherepidemic diseases was exceptionally low, and that apoplexy,paralysis, and some other diseases of the two extremes oflife, shared in the general increase of the death-rate duringthe admitted prevalence of influenza, even when "influenza"

>?

itself, as a distinct nominal factor in the mortality,scarcely appeared at all, until towards the close of theepidemic, the " gentle hints and solicitations of the registrarin the weekly reports " appeared to have taken some effect,.and the apparent influenza mortality, as stated, rose to

, twenty-two. It is obvious, therefore, that if the progress of, the epidemic in this country or elsewhere is to be traced by: the death-rate, regard will have to be had to the considera-i tions now alluded to.-I am, Sirs, yours obediently,

W. T. GAIRDNER.

"CLINICAL TEACHING ON FEVERS INGLASGOW."

To the Editors of THE LANCET.SiRS,&mdash;As a clinical teacher of fever I naturally take a.

deep interest in the position which has arisen in Glasgow,and hope that the difficulties may be overcome, so that.Dr. Allan will continue to instruct students practically in a.most essential branch of medicine. With your remarks inTHE LANCET of the 21st ult. I cordially agree, the closingsentence excepted, which reads as follows: "We doubt ifin any other school in the country a clinical teacher of fevers.could boast of forty pupils." At the City Hospital here,

during the winter and summer sessions of 1888-89, 180students availed themselves of the weekly cliniques on fever,and for the winter session of this year 150 have enrolledtheir names. Our plan is this : the students are divided into.

batches of thirty; these attend for four weeks, at the end ofthat time being replaced by thirty more. In this waynearly all the number have the opportunity of seeingexamples of the continued fevers, the exanthemata, diph-theria, and erysipelas. Care is taken that in the typhuswards inspection is made by the students individually, whileno crowding round the bed is permitted. Last year nostudent contracted any of the diseases to the contagion ofwhich he was exposed, while this year one has been laid upwith scarlet fever under circumstances which rendered it

probable that he caught the infection in hospital. When