THE ROYAL BERKSHIRE HOSPITAL.

ON THE CORRECTION OF DEATH-RATES.

678

(Rifle) : lst Volunteer Battalion the Northumberland application of this method leads to a corrected death-rate ’Fusiliers, Surgeon-Major and Honorary Surgeon-Lieutenant- considerably higher than that obtained by the Registrar’Colonel Duncan Stewart. Eastern Command (Artillery) : lst Cinque Ports Royal Garrison Artillery (Volunteers), Surgeon-Major James William Thornton Gilbert. In view of the approaching despatch of a draft of Royal Artillery to India, an order was recently issued at Woolwich that officers should ascertain the names of men, women, and children willing to be inoculated against enteric fever. Notwithstanding Lord Kitchener’s recent remarks on the subject at Simla, the only volunteer was one man of the

veterinary department.

The War Office has under experiment a number of ruck sacks-a bag of the Austrian type-which have been submitted to certain committees as a suitable method for the soldier to carry his belongings on service, as well as to replace the valise, which is now practically abolished in -the British army. The finger-print system is to be adopted in the United States Army as a means of identification of soldiers.

Correspondence. "Audi alteram

partem."

ON THE CORRECTION OF DEATH-RATES. To the Editors of THE LANCET. Dr. T. F. Pearse’s article on the " Correction of SIRS,-In Death-rates," assuming the accuracy of his arithmetical calculations, he correctly sums up their result when he points out that the death-rate in Calcutta in 1904, calculated at the age and sex rates of mortality prevailing generally in Bengal, would be equal to 36’ 6 per 1000, whereas the death-rate of the Bengal population calculated at the age and sex rates of mortality prevailing in Calcutta would be ’equal to 38’ 7 per 1000. It is, however, impossible to agree with Dr. Pearse when he asserts that the difference between these two corrected rates proves the insufficiency of the method adopted by the Registrar-General for the correction of the crude recorded death-rate in a town or district for abnormality of the age and sex constitution of the population. It is obvious that in the case dealt with the Registrar-General’s method shows what the death-rate in the Calcutta population in 1904 would have been if the sex and age rates of mortality had been the same as those that prevailed in the standard population of Bengal. The alternative method, on the

hand, shows what the death-rate in the Bengal population would have been in 1904 if the sex- and agerates of mortality had been the same as those that prevailed in the population of Calcutta. Could Dr. Pearse have expected that these two entirely distinct calculations would have yielded identical results ? As a matter of fact, this alternative method is adopted by the Registrar-General other

in his Decennial Supplement, but could not be used for his Annual Summary. Incidentally, the startling excess of the female rates of mortality recorded in Calcutta in 1904, shown in Dr. Pearse’s Table A, suggests the probability either of a considerable under-statement of the femafe population of that city at the census in 1901, or of its rapid increase between 1901 and 1904, or of some other error in the recorded facts, since the Bengal female deathrates, given in his Table B, are considerably below the male -death-rates, as is almost invariably the case in all trust- worthy mortality statistics. I am, Sirs, yours faithfully, NOEL A. HUMPHREYS. .Surbiton, August 27th, 19C6. -

To the Editors of THE LANCET. SIRS,—The method of calculating corrected death-rates described by Dr. T. F. Pearse in THE LANCET of August 25th, 1906, p. 500, is practically the same as that given by Dr. T. W. Hime in his "Practical Guide to the Public Health Acts," second edition, 1901, pp. 544-548. Dr. Hime in a footnote observes that his results for Bradford differ very materially from those of the Registrar-General (23 38 as against 21’ 31 for males) and that the results of the latter are " wrong." In the case of Bradford, therefore, not a very abnormally constituted population, as in the case of Calcutta, the

General’s method. There are, as Dr. Pearse notes, two methods of making the required correction. The RegistrarGeneral applies the mortality-rates adopted as a standard to the various age and sex groups of the population under consideration ; while the other method applies the mortalityrates obtaining in the population in question to a standard population. The latter is the method preferred by Dr. Pearse and by Dr. Hime. Its use is negatived in very many instances by the fact that mortality rates in sufficient detail are not obtainable for the populations under consideration, whereas the age and sex constitution of all important populationsis to be found in the census reports. Dr. Hime, in his application of method No. 2, adopts as his standard population a "standard million," constituted as was the population of England and Wales at the preceding census; Dr. Pearse uses a "miniature population" of 847,796, the census population of Calcutta, constituted as was that of Bengal at the preceding census. The result obtained would have been exactly the same in each case had the total census populations of England and Wales and of Bengal respectively been utilised. If this had been done in the case of Calcutta, for instance, the various age-and-sex group populations in Table D of Dr. Pearse’s article would have been increased in equal proportion (847,796 : 70,000,000, or, population of Calcutta : population of Bengal) and the calculated deaths in the same table would have been in. creased in the same proportion. Consequently the calcn. lated death-rate obtained would not have been affected. The same thing may be shown in the same way for Dr. Hime’s method, whence the practical identity of the two is obvious. If, then, apart from mere variations in detail of application there are two principal methods by which corrected deathrates may be calculated, both apparently at first sight satis-

factory in principle but yielding discrepant results, an important question arises as to which is to be preferred and why ? This matter is, however, beyond the scope of the present letter and, as pointed out- above, practical considerations will generally restrict the statistician to the method of the Registrar-General. I am,

August 31st,

Sirs,

yours

faithfully,

T. H. C. STEVENSON.

1906.

THE ROYAL BERKSHIRE HOSPITAL. To the Editors

of

THE LANCET.

SIRS,-Some few years ago I was appointed physician to the Royal Berkshire Hospital under the following rule: "No person shall be eligible for the office of physician to the hospital unless he be a medical graduate of one of the universities of Great Britain or Ireland and his name entered on the Medical Register; neither shall any person be eligible who practises or is connected in partnership with anyone practising surgery, pharmacy, or midwifery." Recently this rule was altered to the extent that the practice of mid. wifery was to be allowed if desired. At the same time it was decided that two assistant physicians should be elected who were to have beds allotted to them and to have charge of the out-patient department and a physician was to be elected to form a skin department. This matter was never brought before the staff as a whole, neither were the physicians asked if they were prepared to give up beds or to give up their out-patients. At the election of the assistant physicians neither of the two conformed to the mode of practice demanded for the physicians and subsequently a rule was passed to meet their mode of practice, and at the same time they retain beds and have charge of the out-patient department, and one takes charge of a skin department so that by no

chance does

a

physician have a skin case under his care.

I should be glad to have your opinion whether the physicians have been fairly treated in this matter and whether the governors are acting within their rights in taking away from the physicians the rights and privileges under which they came to take up the appointment in Reading. I am, Sirs, yours faithfully, FRANCIS HAWKINS. Reading, August 1st, 1906. An officer elected under one set of regulations has a ** distinct grievance if during his term of office the regulations are changed so as to affect his position. So far we are with Dr. Hawkins. But if in the opinion of the authorities the change is in the nature of a reform (i.e., if the authorities v

TREATMENT OF IRITIS, INTERSTITIAL KERATITIS, Erc., BY

ACETOZONE.I

679

believe that an alteration in the regulations will be for the had been under treatment off and on for 12 months in the department of a large metropolitan hospital. At good of the institution which they administer and of the ophthalmic the first visit to the Croydon General Hospital on patient’s public which it serves) it is right that the change should be Dec. 16th vision was on Dec. 20th it was Three weeks conclusion as to the made. We cannot express any legality later vision was normal and the eye appeared to have made a of the action of the governors. As to its advisability, our perfect recovery. The patient was seen about ten days ago general view is that any modification of hospital rules which and the eye remains free from all traces of deposit. (b) A tends to break down artificial barriers, purporting to divide second case of sympathetic iritis. This patient came to the the medical profession into classes and sections, is for the Western Ophthalmic Hospital on Nov. 17th with vision reduced to fingers (Dr. F. Hewkley). On Nov. 24th good of the profession and of the public. Very large vision was counting on Dec. 1st it was , and slight keratitis ; questions are opened by this aspect of the matter.-ED. L. punctata; on Jan. 19th there was no trace of deposits even under high magnification. This patient was seen three weeks ago and the eye seemed to be free from all THE TREATMENT OF IRITIS, INTER- trace of disease with the exception of a little uveal pigment STITIAL KERATITIS, &c., BY on the lens. In all nine cases of interstitial keratitis, several of ACETOZONE. extreme severity, were treated by acetozone. In one case To the Editors of THE LANCET. not only was the cornea absolutely opaque and salmonbut bulged in a most alarming way. In the courseSIRS,-During the last 16 months I have treated all my coloured of six weeks the corneas had cleared sufficiently for the cases of intra-ocular inflammation on the assumption that to get about and the vision is now .lo - --/6’ In a they were the result of bacterial action and with gratifying patient results. The post hoc ergo propter hoc fallacy of basing the second case one eye was entirely lost before the child came constitutional treatment on such history as is obtainable under my care and the sight in the other was reduced to from the patient has been so far the rule of practice and the seeing hand movements at a few inches. This, however, relieved in less than a week, although all previous possibility that there may be no connexion between the was constitutional disease and the intra-ocular inflammation remedies used in an ophthalmic hospital had proved unavail and the mother’s gratitude was profound. The child is habitually lost sight of. Are we to ignore the possibility of ing still under treatment but as the disease had lasted for many that have no with venereal connexion disease organisms and the corneas were leucomatous before the child causing iritis in persons who are the victims of syphilis ?7 months Iritis would not be diagnosed as gonorrhceal iritis in a came under my care it is improbable that there will be any considerable improvement in vision. A third case that has syphilitic subject were it not for the urethral discharge. In been under treatment for over six months gave excellent this form of iritis it is practically certain the ocular conresults as regards vision (f), although the patient was unable dition is due to circulating toxins, and if we may assume as to carry out his instructions properly on account of his work. much in syphilis, rheumatism, &c., results very important One case with salmon patches recovered in three monthsfollow, for bacteriology furnishes us with proof of the im- with vision and another in eight weeks with vision 6. The in of for treatment, as, instance, early diphtheria, portance in which disease the antitoxin is almost useless after the remainder are still under treatment. The acetozone treatment has also been used in a case of fourth day. A most unsatisfactory feature of constitutional neuro-retinitis that progressed rapidly in spite of syphilitic and the slowness treatment in syphilis rheumatism is of its The disease was promptly action. If in these diseases early treatment is imperative pil. hyd. c. creta, II. t.d. became and visioneasily in six the discs normal, arrested, and we must infer the toxins have done their worst specific remedies will have little effect. Toxins being almost cer- weeks. The results in all forms of iritis were admirable and so in interstitial keratitis when seen within a week tainly albumoses, it follows that the blood should be hurried equally or so of the commencement of the disease. Indeed, in the as frequently as possible through the liver to convert these latter two or three days at times suffice to remove the and in to the skin order that bodies into urea and kidneys the urea may be excreted, and this metabolism will be corneal opacity and nothing remains but a little keratitis facilitated by systematic exercise and copious potations of punctata. In future cases there is no reason why the treatment should not be combined with inunction but in nearly water. I have made it a routine practice for several years to all the cases treated by acetozone mercury has been tried for six weeks and in some cases for several months. The inquire into the condition of the bowels in all cases of eye at least to acetozone is the price and this is a cononly objection in that are inflammations and find, especially children, they sideration if the drug has to be used for several weeks. that so it the association frequent foul, being mostly very In the treatment of such Doubtless in iritis this would be inconsiderable and the can scarcely be a fortuitous one. Three-grain doses have excellent cases I used to begin by the internal administration of money wisely spent. resorcin or salol, but the former sometimes produced quasi- results but it is not unlikely larger doses could be given The use of the drug by means of carboluria and the latter was apt to make the patient ill. with advantage. have its drawbacks, but this method has capsules may in could be that as found acetozone, Having typhoid fever, used with advantage as an intestinal and general antiseptic advantages, and in eye diseases there is not the objection in eye diseases I gave it first in three-grain doses dissolved in to the exhibition of the remedy in solid form which might be four ounces of water. Subsequently I increased the amount offered in the case of enteric disease. However administered of water largely and my present method is as follows. The there is no doubt it should be given in eye cases with a much quantity of water than in typhoid fever. The limitapatient drinks a tumbler of water and takes a three-grain larger tions as to space prevent my taking up the bacteriology of the of acetozone walks after which he capsule immediately, to deal with this on another occasion. briskly for ten minutes and then takes a second glass of subject but I Ipropose am, Sirs, yours faithfully, water and again walks for ten or 15 minutes. Four doses CHARLES WRAY, F.R.C.S. Eng., are taken daily-before breakfast, in the middle of the Surgeon, Western Ophthalmic Hospital; Ophthalmic morning, in the middle of the afternoon, and in the evening. Surgeon, Croydon General Hospital and The results have been satisfactory ; so much so that one will Croydon Infirmary. never revert to the old methods, and especially as it is probable that still better results will be obtainable by the COEXISTENCE OF DISEASES. supplementary use of recognised drugs, such as the inunction of mercury, &c. To the Editors of THE LANCET. Altogether I have used the acetozone-hydrotherapeutic treatment in 45 cases of iritis, interstitial keratitis, &c., SiRS,-I read with much interest your annotation on the and also in one case of syphilitic optic neuritis and two Coexistence of Diseases in THE LANCET of August 25th, cases of sympathetic ophthalmia. If the cases of iritis p. 515. In it the following sentence occurs : "The result of an infectious disease occurring in a tuberculous subject does are seen early, say, before the fourth day, the patient not infrequently experiences relief from pain in a very few hours not essentially differ from that found when a healthy subject and we frequently find all redness gone by the sixth or is attacked except that in the former the powers of resistseventh day. We should, of course, as a routine procedure ance are less and not infrequently an intercurrent affection is so badly borne as to threaten seriously the patient’s life." dilate the pupil as much as possible at the first visit. The following cases treated by acetozone are of interest. That recalled to my memory a case that came under my (a) A case of sympathetic iritis with keratitis punctata that notice some three years ago in which scarlet fever,