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CIGARETTE SMOKING IN THE ARMY.
384 the
Annotations. 11
whole, the mortality statistics relating
to
our
largest
provide legitimate general ground for congratulation to the sanitary authorities and medical officersof health upon whom rests the responsibility for their health
towns in 1909
Ne quid nimis."
condition and progress. If, however, this health progress is fully maintained it will be necessary for the ratepayers to show more active interest in public health administration and to bring public pressure to bear upon the sanitary authorities in those provincial towns, the mortality statistics of which still compare most unfavourably with those of the county of London.
to be
ENGLISH
URBAN
MORTALITY IN 1909.
THE Registrar-General’s returns continue to afford evidence of the improving sanitary condition of the population residing in the largest English towns. According to the returns for the 52 weeks ending on Jan. lst it appears that the crude rate of mortality last year in the 76 largest English towns, having an estimated population little short of 16,500,000, did not exceed 14.7per 1000, against 15 9, 15-4, and 14-9 in the same towns in 1906, 1907, and 1908. The death-rate last year in these towns was, indeed, lower than in any previous year on record, and was 0 - 8 per 1000 below the mean rate in the four preceding years 1905-08. In London, with an estimated population of nearly 5,000,000, the crude death-rate last year was only equal to 14 - 2 per 1000, against 151, 14 -6, and 13 - 8 in the three preceding years. The death-rate in London last year thus very slightly exceeded the unprecedentedly low rate in 1908, but was 0 -5 per 1000 below the mean rate in the four One of the most satisfactory features of years 1905-08. the constant decline of our urban mortality in recent years is the marked decrease in the fatality of epidemic disease.
CIGARETTE
SMOKING
IN
THE
ARMY.
Lieutenant-General Sir L. J. Oliphant, C.B., commanding the Northern Command, has just issued special orders prohibiting excessive cigarette smoking by young soldiers serving in his command, and has directed medical officers detecting cases of injury to health produced by cigarette smoking to draw the attention of commanding officers concerned with a view of prohibiting the use of cigarettes by the men in question for a specific period. Restriction of cigarette smoking amongst the rank and file of the army hasonly recently attracted the attention of some of our military commanders, foremost amongst whom we may mention the name of Field Marshal Lord Grenfell. This distinguished officer, while Commander-in-Chief of H.M. forces in Small-pox, measles, scarlet fever, diphtheria, whooping- Ireland, during his visits to military hospitals was struck cough,"fever"(almost exclusively enteric), and diarrhoea by the harm that the increasing prevalence of cigarette have long been classed and specially dealt with in the smoking appeared to be doing to the health of the army, and Registrar-General’s returns as the principal epidemic diseases. alluded to it in general orders as not alone a military The death-rate from these epidemic diseases during last year question but one of national importance. Lord Grenfell in the 76 largest English towns did not exceed 1 -42 per 1000, appealed to the Irish Command to give earnest thought against 1-95, the mean rate in the five preceding years, to combat the pernicious habit of cigarette smoking, 1904-08, in which the rate ranged from 2 -49 in 1904 to 1. 54 which, he thought, was gradually but greatly affecting the in 1907. In London the death-rate last year from these efficiency of the troops, and he directed all commanding epidemic diseases was not higher than 1.31 per 1000, officers to impress on those under their command the evils against a mean rate of 1.72 in the five preceding years. that invariably result from this excess. With a view of It is noteworthy that notwithstanding the excessive aggrega- helping men to overcome the habit the Commander-intion of poverty in London the death-rate both from all causes Chief ordered that cigarette smoking was to be prohibited at and from the principal epidemic diseases has in recent certain times when, on the other hand, no similar restriction years been distinctly lower than the similar rates in the 75 as regards pipe smoking would be made. For instance, the other large English towns, having populations exceeding smoking of cigarettes was not to be permitted when 50,000, thus affording conclusive evidence of efficient men were on fatigues or under arms on any occasion, sanitary administration by the county and borough authori- including field operations and manoeuvres. There can be The markedly low death-rate little doubt that excessive smoking of ready-made cigarettesties of the metropolis. during last year from the principal epidemic diseases ieLis encouraged by their cheapness, and it may be to some the largest English towns was in great measure due to thE ! extent responsible for cardiac affections. It is generally low summer temperature, with frequent and abundant rain agreed that tobacco smoking has a toxic effect upon the small fron t an which caused heart, although this effect varies greatly in intensity in. fall, mortality exceptionally infantile diarrhoea. The death-rate attributed to diarrhœa different individuals, and at the same time causes increased in the 76 towns, including London, was lower in 1909 thaii resistance to the blood stream by contracting the small in any recent year, and was considerably less than hal E arteries of the systemic circulation. The average British the rate from this disease recorded in these towns i recruit is on enlistment younger and in poorer physical each of the three years, 1904-05-06. The returns fo r condition than the recruit of any other civilised army. He last year, however, also show a remarkable declin e is very often an inveterate cigarette smoker and may have in the deaths referred to"fever," mainly enteric, th e enlisted after a period of privation, not being in the death-rate from which cause affords a trustworthy tes t best of condition to face even the present modified system of sanitary efficiency. The deaths referred to "fever " of physical training. Recruits undergoing their first drillsin the 76 English towns during last year did not exceeat the regimental depot are very receptive ; this is probably 954, against 1319, the average number in the five pre . the most impressionable time of their service, and it is then ceding years ; and in London the number recorded was that the first attempt might be made with some success to only 151, while the mean number in the five precedin g teach them to be moderate in cigarette smoking. Following The death-rate from "fever" in Londo non the same lines as Lord Grenfell’s appeal it would be a good years was 247. last year did not exceed 31’4 per 1, 000, 000 of the populi thing for the health of the army if all commanding officers were equally firm in drawing attention to the harm of overtion, whereas it was equal to 69-2 per 1,000,000 in tl 75 other large English towns. These figures afford furthEindulgence in smoking. We may note that the officer comevidence of more efficient and successful sanitation in Londcn manding the lst Seaforth Highlanders started a campaign than in the aggregate of the 75 large provincial towns. 0n some time back against cigarette smoking and directed io. .
385 battalion orders that cigarettes should never be smoked by any officers or men of his regiment when on any duty whatThe examples quoted are, we believe, more or less soever. but isolated, they are valuable. Over-indulgence in smoking is harmful, and the ready-made cigarette, being cheap to buy and convenient to smoke, is an inducement to such overindulgence. To smoke it entails but little sacrifice in money or trouble.
The chronically which actpd as a predisposing cause. inflamed condition of the left appendages and the adhesions the conclusion probable that a similar condition had existed on the right side before infection with the typhoid bacillus. On admission the patient denied any previous illness, but when the question of operation was discussed at her bedside she feared that her uterine appendages might haveto be removed.
Irendered
____
INTESTINAL PERFORATION IN ENTERIC FEVER SIMULATED BY PERFORATION OF A PYOSALPINX.
____
THE
LATE
DR.
EVAN
THOMAS.
ONCE
again the risks to which the profession is exposed in the carrying on of its work are exemplified in the death of -’ Evan Thomas of Newbridge. He contracted septicsemia AT a meeting of the Societe Medicale des Hôpitaux of Dr. Paris M. L. Galliard and M. Chaput have reported re-‘while doing a post-mortem examination on Jan. 8th, and < on Jan. 15th. He was educated at University College, cently a case of enteric fever in which intestinal perfora- died tion was simulated by a rare complication-perforation of aAberystwith, and University College, London, and held the pyosalpinx due to the typhoid bacillus. A woman, agedM.D., B.S. Lond. as well as the diplomas of the Conjoint 30 years, was admitted into hospital on May 28th, 1909. Board. He was formerly obstetric assistant to Dr. Herbert For three weeks she had complained of pain in the back andSpencer at University College and also held resident posts lassitude, but had taken to bed only for four days. Forat Highgate Infirmary and Hanwell Asylum. He was a - some days there had been diarrhœa. On admission theretypical example of what the surgeon should be-thorough were headache, stupor, furred tongue, a temperature ofin his work and keen on it, very conscientious, and kind 101.8° F., and a rapid pulse. The spleen was slightlyand sympathetic to his patients. He was a justice of the enlarged. The abdomen was tympanitic and there waspeace for the county of Monmouth. His remains were laid .gurgling in the right iliac fossa. Lenticular rose spots to rest at his birthplace, the village of St. Dogmaels, near were present. Typhoid fever at the eighth day wasCardigan. We offer our sympathy to his widow and two
diagnosed. The evening temperature was 103°. On the children. 29th the temperature ranged from 104° to 104.7°, and the A FRENCH NAVAL SANATORIUM. The case ran an ordinary course, serum test was positive. and on June 12th the temperature had fallen to 990 and conWHILE we are still hesitating how to deal with the tubervalescence seemed to be imminent. But on the 13th the culous cases discharged from the Army and Navy the French patient complained of abdominal pains and there was slight Navy has opened a sanatorium at Brest for sailors and dockmeteorism. On the night of the 15th there were great yard workmen. In that large harbour there is an island, abdominal pain, nausea, and vomiting. When she was seen Treberon, which for some 200 years has been alternately a on the following morning the respiration was rapid, the eyes hospital and a quarantine station. It has a warm sunny The pulse was exposure, sloping gently from its northern cliffs to its were sunken, and the features were drawn. In May, 1909, Admiral Boue de 160 and small and the temperature was 104.3°. No urine southern sandy shore. had been passed. The abdomen was not tympanitic and Lapeyrere, the French Minister of Marine, then maritime showed no region specially tender to palpation, no swelling, prefect at Brest, was struck, when inspecting it, with the and no resistance even in the right iliac fossa. Vaginal promise it gave of usefulness as a sanatorium, and directed examination revealed nothing abnormal. Intestinal perfora- that cases should be sent there from the naval hospital at tion was suspected and laparotomy was performed under Brest by way of experiment. Accordingly, in June, 23 cases, spinal anaesthesia induced by novocaine, as chloroform would all with tubercle bacilli in their sputa, landed there under the not have been well borne. A little turbid fluid was found in care of Dr. Cazimian of the French Navy, who reports his The small intestine was examined experiences in the Archives de Médecine Navale for December, the peritoneal cavity. He spent three throughout its whole length but no perforation could be dis- 1909, in a very interesting paper. covered. There was only congestion of the lower part of the months on the island ; his staff was a steward, a ileum. The cascum and appendix were normal. On exploring good cook, and ten male nurses. The patients at most the pelvis pus and a greatly enlarged right Fallopian tube numbered 40 (64 passed through the sanatorium) and the were found. The left uterine appendages were sclerosed and principles of their treatment were fresh air, rest, and slight surrounded by adhesions. The uterus and right appendages overfeeding. In the barrack-rooms of the old quarantine were removed. Lavage of the peritoneum was not performed, station each patient had at night 2500 cubic feet of air space, but only dry wiping. No arrangement for drainage was and all the windows were kept open on the side away from made as the large communication between the vagina and the wind. Then by day each man took the stretcher given the peritoneal cavity ensured this. The patient’s condi- him on his arrival and put it in a sheltered place, under a tion after the operation was good, the evening tem- shed in wet weather or out among the trees when it was fine, On the 23rd the sutures were and thereon lay down and rested for hours. These men had perature being 101 - 60. removed from the abdominal wound. It had suppurated all come from treatment in the naval hospital, yet the and its edges were gangrenous at the level of the muscular added therapeutic influence of sanatorium treatment on the The evening temperature was 102°. 6bres. The wound island produced marked improvement. Their weight generally cicatrised without further incident and the patient left went up steadily during the first fortnight; they lost their hospital in good general health at the end of July. Exami- fever, sweats, and sleeplessness ; they gained appetite and nation of the specimen removed showed a much enlarged strength, and the pulmonary signs improved. Of 23 men Fallopian tube full of pus. On its posterior wall was a who had left the island when the reporter was relieved, only circular perforation with violaceous edges. There was no four had gained no benefit, but they, when they had arrived, lesion of the uterus. The pus contained the typhoid had each two or more lobes attacked ; all the rest (19) were The sanaM. Galliard and M. Chaput improved, and four are even reported cured. bacillus in pure culture. it seems likely to be but was torium the this unusual localisation of that only experimental, typhoid - suggested Dr. Cazimian >bacillus was due to previous lesions of the Fallopian tube, kept open at any rate through the winter. __
Annotations. 11
whole, the mortality statistics relating
to
our
largest
provide legitimate general ground for congratulation to the sanitary authorities and medical officersof health upon whom rests the responsibility for their health
towns in 1909
Ne quid nimis."
condition and progress. If, however, this health progress is fully maintained it will be necessary for the ratepayers to show more active interest in public health administration and to bring public pressure to bear upon the sanitary authorities in those provincial towns, the mortality statistics of which still compare most unfavourably with those of the county of London.
to be
ENGLISH
URBAN
MORTALITY IN 1909.
THE Registrar-General’s returns continue to afford evidence of the improving sanitary condition of the population residing in the largest English towns. According to the returns for the 52 weeks ending on Jan. lst it appears that the crude rate of mortality last year in the 76 largest English towns, having an estimated population little short of 16,500,000, did not exceed 14.7per 1000, against 15 9, 15-4, and 14-9 in the same towns in 1906, 1907, and 1908. The death-rate last year in these towns was, indeed, lower than in any previous year on record, and was 0 - 8 per 1000 below the mean rate in the four preceding years 1905-08. In London, with an estimated population of nearly 5,000,000, the crude death-rate last year was only equal to 14 - 2 per 1000, against 151, 14 -6, and 13 - 8 in the three preceding years. The death-rate in London last year thus very slightly exceeded the unprecedentedly low rate in 1908, but was 0 -5 per 1000 below the mean rate in the four One of the most satisfactory features of years 1905-08. the constant decline of our urban mortality in recent years is the marked decrease in the fatality of epidemic disease.
CIGARETTE
SMOKING
IN
THE
ARMY.
Lieutenant-General Sir L. J. Oliphant, C.B., commanding the Northern Command, has just issued special orders prohibiting excessive cigarette smoking by young soldiers serving in his command, and has directed medical officers detecting cases of injury to health produced by cigarette smoking to draw the attention of commanding officers concerned with a view of prohibiting the use of cigarettes by the men in question for a specific period. Restriction of cigarette smoking amongst the rank and file of the army hasonly recently attracted the attention of some of our military commanders, foremost amongst whom we may mention the name of Field Marshal Lord Grenfell. This distinguished officer, while Commander-in-Chief of H.M. forces in Small-pox, measles, scarlet fever, diphtheria, whooping- Ireland, during his visits to military hospitals was struck cough,"fever"(almost exclusively enteric), and diarrhoea by the harm that the increasing prevalence of cigarette have long been classed and specially dealt with in the smoking appeared to be doing to the health of the army, and Registrar-General’s returns as the principal epidemic diseases. alluded to it in general orders as not alone a military The death-rate from these epidemic diseases during last year question but one of national importance. Lord Grenfell in the 76 largest English towns did not exceed 1 -42 per 1000, appealed to the Irish Command to give earnest thought against 1-95, the mean rate in the five preceding years, to combat the pernicious habit of cigarette smoking, 1904-08, in which the rate ranged from 2 -49 in 1904 to 1. 54 which, he thought, was gradually but greatly affecting the in 1907. In London the death-rate last year from these efficiency of the troops, and he directed all commanding epidemic diseases was not higher than 1.31 per 1000, officers to impress on those under their command the evils against a mean rate of 1.72 in the five preceding years. that invariably result from this excess. With a view of It is noteworthy that notwithstanding the excessive aggrega- helping men to overcome the habit the Commander-intion of poverty in London the death-rate both from all causes Chief ordered that cigarette smoking was to be prohibited at and from the principal epidemic diseases has in recent certain times when, on the other hand, no similar restriction years been distinctly lower than the similar rates in the 75 as regards pipe smoking would be made. For instance, the other large English towns, having populations exceeding smoking of cigarettes was not to be permitted when 50,000, thus affording conclusive evidence of efficient men were on fatigues or under arms on any occasion, sanitary administration by the county and borough authori- including field operations and manoeuvres. There can be The markedly low death-rate little doubt that excessive smoking of ready-made cigarettesties of the metropolis. during last year from the principal epidemic diseases ieLis encouraged by their cheapness, and it may be to some the largest English towns was in great measure due to thE ! extent responsible for cardiac affections. It is generally low summer temperature, with frequent and abundant rain agreed that tobacco smoking has a toxic effect upon the small fron t an which caused heart, although this effect varies greatly in intensity in. fall, mortality exceptionally infantile diarrhoea. The death-rate attributed to diarrhœa different individuals, and at the same time causes increased in the 76 towns, including London, was lower in 1909 thaii resistance to the blood stream by contracting the small in any recent year, and was considerably less than hal E arteries of the systemic circulation. The average British the rate from this disease recorded in these towns i recruit is on enlistment younger and in poorer physical each of the three years, 1904-05-06. The returns fo r condition than the recruit of any other civilised army. He last year, however, also show a remarkable declin e is very often an inveterate cigarette smoker and may have in the deaths referred to"fever," mainly enteric, th e enlisted after a period of privation, not being in the death-rate from which cause affords a trustworthy tes t best of condition to face even the present modified system of sanitary efficiency. The deaths referred to "fever " of physical training. Recruits undergoing their first drillsin the 76 English towns during last year did not exceeat the regimental depot are very receptive ; this is probably 954, against 1319, the average number in the five pre . the most impressionable time of their service, and it is then ceding years ; and in London the number recorded was that the first attempt might be made with some success to only 151, while the mean number in the five precedin g teach them to be moderate in cigarette smoking. Following The death-rate from "fever" in Londo non the same lines as Lord Grenfell’s appeal it would be a good years was 247. last year did not exceed 31’4 per 1, 000, 000 of the populi thing for the health of the army if all commanding officers were equally firm in drawing attention to the harm of overtion, whereas it was equal to 69-2 per 1,000,000 in tl 75 other large English towns. These figures afford furthEindulgence in smoking. We may note that the officer comevidence of more efficient and successful sanitation in Londcn manding the lst Seaforth Highlanders started a campaign than in the aggregate of the 75 large provincial towns. 0n some time back against cigarette smoking and directed io. .
385 battalion orders that cigarettes should never be smoked by any officers or men of his regiment when on any duty whatThe examples quoted are, we believe, more or less soever. but isolated, they are valuable. Over-indulgence in smoking is harmful, and the ready-made cigarette, being cheap to buy and convenient to smoke, is an inducement to such overindulgence. To smoke it entails but little sacrifice in money or trouble.
The chronically which actpd as a predisposing cause. inflamed condition of the left appendages and the adhesions the conclusion probable that a similar condition had existed on the right side before infection with the typhoid bacillus. On admission the patient denied any previous illness, but when the question of operation was discussed at her bedside she feared that her uterine appendages might haveto be removed.
Irendered
____
INTESTINAL PERFORATION IN ENTERIC FEVER SIMULATED BY PERFORATION OF A PYOSALPINX.
____
THE
LATE
DR.
EVAN
THOMAS.
ONCE
again the risks to which the profession is exposed in the carrying on of its work are exemplified in the death of -’ Evan Thomas of Newbridge. He contracted septicsemia AT a meeting of the Societe Medicale des Hôpitaux of Dr. Paris M. L. Galliard and M. Chaput have reported re-‘while doing a post-mortem examination on Jan. 8th, and < on Jan. 15th. He was educated at University College, cently a case of enteric fever in which intestinal perfora- died tion was simulated by a rare complication-perforation of aAberystwith, and University College, London, and held the pyosalpinx due to the typhoid bacillus. A woman, agedM.D., B.S. Lond. as well as the diplomas of the Conjoint 30 years, was admitted into hospital on May 28th, 1909. Board. He was formerly obstetric assistant to Dr. Herbert For three weeks she had complained of pain in the back andSpencer at University College and also held resident posts lassitude, but had taken to bed only for four days. Forat Highgate Infirmary and Hanwell Asylum. He was a - some days there had been diarrhœa. On admission theretypical example of what the surgeon should be-thorough were headache, stupor, furred tongue, a temperature ofin his work and keen on it, very conscientious, and kind 101.8° F., and a rapid pulse. The spleen was slightlyand sympathetic to his patients. He was a justice of the enlarged. The abdomen was tympanitic and there waspeace for the county of Monmouth. His remains were laid .gurgling in the right iliac fossa. Lenticular rose spots to rest at his birthplace, the village of St. Dogmaels, near were present. Typhoid fever at the eighth day wasCardigan. We offer our sympathy to his widow and two
diagnosed. The evening temperature was 103°. On the children. 29th the temperature ranged from 104° to 104.7°, and the A FRENCH NAVAL SANATORIUM. The case ran an ordinary course, serum test was positive. and on June 12th the temperature had fallen to 990 and conWHILE we are still hesitating how to deal with the tubervalescence seemed to be imminent. But on the 13th the culous cases discharged from the Army and Navy the French patient complained of abdominal pains and there was slight Navy has opened a sanatorium at Brest for sailors and dockmeteorism. On the night of the 15th there were great yard workmen. In that large harbour there is an island, abdominal pain, nausea, and vomiting. When she was seen Treberon, which for some 200 years has been alternately a on the following morning the respiration was rapid, the eyes hospital and a quarantine station. It has a warm sunny The pulse was exposure, sloping gently from its northern cliffs to its were sunken, and the features were drawn. In May, 1909, Admiral Boue de 160 and small and the temperature was 104.3°. No urine southern sandy shore. had been passed. The abdomen was not tympanitic and Lapeyrere, the French Minister of Marine, then maritime showed no region specially tender to palpation, no swelling, prefect at Brest, was struck, when inspecting it, with the and no resistance even in the right iliac fossa. Vaginal promise it gave of usefulness as a sanatorium, and directed examination revealed nothing abnormal. Intestinal perfora- that cases should be sent there from the naval hospital at tion was suspected and laparotomy was performed under Brest by way of experiment. Accordingly, in June, 23 cases, spinal anaesthesia induced by novocaine, as chloroform would all with tubercle bacilli in their sputa, landed there under the not have been well borne. A little turbid fluid was found in care of Dr. Cazimian of the French Navy, who reports his The small intestine was examined experiences in the Archives de Médecine Navale for December, the peritoneal cavity. He spent three throughout its whole length but no perforation could be dis- 1909, in a very interesting paper. covered. There was only congestion of the lower part of the months on the island ; his staff was a steward, a ileum. The cascum and appendix were normal. On exploring good cook, and ten male nurses. The patients at most the pelvis pus and a greatly enlarged right Fallopian tube numbered 40 (64 passed through the sanatorium) and the were found. The left uterine appendages were sclerosed and principles of their treatment were fresh air, rest, and slight surrounded by adhesions. The uterus and right appendages overfeeding. In the barrack-rooms of the old quarantine were removed. Lavage of the peritoneum was not performed, station each patient had at night 2500 cubic feet of air space, but only dry wiping. No arrangement for drainage was and all the windows were kept open on the side away from made as the large communication between the vagina and the wind. Then by day each man took the stretcher given the peritoneal cavity ensured this. The patient’s condi- him on his arrival and put it in a sheltered place, under a tion after the operation was good, the evening tem- shed in wet weather or out among the trees when it was fine, On the 23rd the sutures were and thereon lay down and rested for hours. These men had perature being 101 - 60. removed from the abdominal wound. It had suppurated all come from treatment in the naval hospital, yet the and its edges were gangrenous at the level of the muscular added therapeutic influence of sanatorium treatment on the The evening temperature was 102°. 6bres. The wound island produced marked improvement. Their weight generally cicatrised without further incident and the patient left went up steadily during the first fortnight; they lost their hospital in good general health at the end of July. Exami- fever, sweats, and sleeplessness ; they gained appetite and nation of the specimen removed showed a much enlarged strength, and the pulmonary signs improved. Of 23 men Fallopian tube full of pus. On its posterior wall was a who had left the island when the reporter was relieved, only circular perforation with violaceous edges. There was no four had gained no benefit, but they, when they had arrived, lesion of the uterus. The pus contained the typhoid had each two or more lobes attacked ; all the rest (19) were The sanaM. Galliard and M. Chaput improved, and four are even reported cured. bacillus in pure culture. it seems likely to be but was torium the this unusual localisation of that only experimental, typhoid - suggested Dr. Cazimian >bacillus was due to previous lesions of the Fallopian tube, kept open at any rate through the winter. __