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of the worst districts are very bad indeed, although agood deal has been done to cleanse and improvethem. Considering that Cape Town is the nearest and mostconvenient port, the outbreak of plague there is, even apartfrom other serious considerations, likely to prove a sourceof much embarrassment under present circumstances. As

regards the war there are persistent rumours, for whichthere seems this time to be official grounds, that GeneralBotha is endeavouring to arrange terms for the sur-

render of his force, and there are signs in otherdirections that the foundations of the Boers’ resistanceare being roughly shaken. The time has come, as

we have already said, when the Boers must fight to liveinstead of living to fight as they have hitherto done. The r

sweeping method of procedure now being systematically xcarried on by the Briti-h forces clears the country of its s

supplies of horses, vehicles, and supplies, while the huge ]

captures of Boer convoys with cattle, horses, food, and 1munitions of war, must have told very eriously indeed on their resources. The collapse of the scheme of invasion ofCape Colony and the persistent pursuit of De Wet and hisforces cannot fail to have a disheartening effect on theBoers. There does not seem much room for doubting thataltogether the news from South Africa is more favourable.The progress of active military operations has been greatly

interfered with by the bad weather and heavy rains whichhave been prevalent of late. The casualty returns still givesad lists of sickness and losses (mostly from enteric fever) inaddition to those shorter lists attributable to wounds andinjuries.

MENTIONED IN DESPATCHES.

The following paragraph appears in a despatch which hasbeen received by the Secretary of State for the Colonies fromColonel Sir J. Willcocks, dated Cape Coast Castle, Dec. 25tb,1900:-"The various departments of the field force havebeen well administered. The medical, under Dr McDowell,principal medical officer, in my opinion has been as nearperfection as was possible in such a country. He was givenan absolutely free hand and nothing that was asked for orwanted was ever refused. The supplies from England havebeen sent out so promptly and in such a generous spirit thatit was the universal opinion that no force in the field couldhave been better treated."The following officers are mentioned as having done very

good work :-Dr. W. Murray, Gold Coast Medical Service ;and Dr. D. Gray, British Central Africa Medical Service.The following are excerpts from despatches. which have

been received from Vice-Admiral Sir Robert Harris,K.C.M.G., Commander-in-Chief on the Cape of Good HopeStation, reporting the proceedings of the Naval Brigades inSouth Africa :-

’’ Surgeon James G. Fowler has been most assiduous inhis attendance and duties towards the sick."Staff Surgeon Lilly and Surgeon Lomas were indefatig-able, and on the spot instantly to attend our wounded under

an exceedingly hot shell fire." "Fleet Surgeon James Porter of H.M.S. Doric" (also

specially mentioned for excellence of medical arrangements),"for the efficiency of the arrangements for attending thewounded with the limited staff at his command."

Major William Grant Macpherson, R.A.M.C., and Lieu-tenant-Colonel George Sterling Ryerson, M.D., are amongthe recently made Knights of Grace of the Order of theHospital of St. John of Jerusalem in England.

A SANATORIUM FOR WALTHAMSTOW.-A new

sanatorium, erected by the Walthamstow Urban DistrictCouncil at a cost of R30,000, was formally opened at

Chingford on Saturday last by the chairman of the SanitaryCommittee of the Council. The buildings, which are beauti-fully situated on the borders of Epping Forest, occupy a siteof about five acres and consist of an administrative block andthree pavilions. Each of the latter provides accommodationfor 14 beds, together with nurses’ rooms, bathrooms,lavatories, and discharging rooms. There is also a smallerpavilion for doubtful cases. Mr. J. J. Clarke, medical officerof health to the Council, made a short statement as to thefuture administration and work of the sanatorium and said that the staff would consist of a resident medical superinten-dent, matron, assistant matron, three charge nurses, and fourprobationers.

Correspondence."Audi alteram partem."

THE DUTIES OF HOUSE SURGEONS ATTHE EAST SUFFOLK AND IPSWICH

HOSPITAL.To the Editors of THE LANCET.

SiRS,-My colleague, Mr. C. C. Worts, and I yesterday.,received six weeks’ notice of the termination of our engage-ments as house surgeons here under circumstances whichseem to us gravely to affect the honour of the profession.It concerns the relations of house surgeons to the press. Ithas been for home years here the custom for the inclosedform to be filled in and handed in the evening to reporters.

[INCLOSURE.]EAST SUFFOLK AND IPSWICH HOSPITAL.

ACCIDENT ADMITTED.

House Surgeon.When we came into office some weeks ago we refused to

follow out that custom on the ground that it lay with thepatient only or his nearest relatives to decide what informa-tion, if any, was to become public property. A housesurgeon is not in a position to know whether any informa-tion would or would not be prejudicial to a patient. Eventhe knowledge that a man has had a broken leg mighthinder him again getting employment in certain positions Itis our duty to give the patient’s family information abouthim, and to them we referred the reporters. We take ourstand on the principle that it is unprofessional conduct togive the press information, as a general rule at all events,and we also regard it as highly inexpedient in these days ofEmployers’ Liability Acts and insurance to give such in-formation. Some time ago Mr. Elkington, the editor ofthe East Anglian Daily Times, called on my colleague anddemanded that we see his reporters, saying A daily papermust be run." Mr. Worts said he would not stand in theway of his getting any information as he best could legiti-mately, but that we would give none ourselves. The editoris a member of the weekly board of this hospital. OnFeb. 20th we were called up to the weekly board and thefollowing resolution was read to us :-That the house surgeons be instructed to give such information to

the press -with reference to accident cases as may be reasonable andsufficient in accordance with precedent.Moved by Mr. Fosdeck, seconded by Dr. Casley. We refusedto obey the resolution or to resign and were then told thata letter of dismissal would be sent to us.

. Now, by their own rules (which I inclose), Nos. 22 and 77,the weekly board, not being specially summoned, were exceed-ing their powers both in making a new rule and in dismissingus. However, next week, on Feb. 27th, a specially sum-moned meeting of the board of management was held todiscuss our dismissal, and if deemed advisable to dismissus. We were not summoned. The meeting was adjournedfor a week. Meanwhile, on March 4th, the medical staffmet together, Dr. Casley alone being absent, and theyunanimously resolved that our attitude was ethically correct.They also suggested that we be asked to give information tothe press after asking the patient’s permission. OnMarch 6th the resolutions of the staff were read to the board,but were ignored as irrelevant. The resolution dismissingus was passed by a majority of ten ; only four voted against

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it-viz., Dr. W. A. Elliston (President of the British MedicalAssociation), Dr. T. Warner, Dr. W. W. Sinclair, andMr. Felix Uobbold (president of the hospital). Dr. Casleyvoted for the resolution. Mr. Branford Edwards, Dr. R. W.Brogden, Dr. H H. Brown, and Dr. F. Ward were present butdid not vote. Later we were served by the secretary withsix weeks’ notice, no reason being given for our dismissal.Now, even if our view of the ethics of the question be

regarded as unduly strict-though I do not for one

instant assent to that-still it would have been easy for theboard to have arranged for information to have been givento the press by the secretary or some other official. Todismiss us is as unnecessary, even from their point of view,as it is unjust from any point of view. I am confident thatI am fully justified in placing the matter before the pro-fession and in asking for the support of THE LANCET.

I am, Sirs, yours faithfully,RICHARD KAY, M.B. Lond.,

March 7th, 1901. Senior House Surgeon. ,

* Dr. Kay and Mr. Worts have acted throughout inaccord with medical ethics. We trust that the board willreconsider their action and will suppress all personal feelingsin dealing with the matter. The question is not only whatis fair to the house surgeons or due to the press. Theinterests of the patients must be put first. We deal withthe matter in a leading article.-ED. L.

"THE STATISTICS OF GASTRIC ULCER,WITH SPECIAL REFERENCE TO GASTRIC

HÆMORRHAGE, ITS FREQUENCYAND FATALITY."

To the Editors of THE LANCET.

SIRS,-In my address on Gastrorrhagia before the Medico-Ohirurgical Society of E jinburgh, in attempting to elucidatethe difficult question of treatment I thought it desirable tomake use of the statistics collected by well-known autho-rities : (1) on the frequency of gastric ulcer ; (2) on itsfatality ; (3) on the frequency of gastrorrhagia ; and (4) onits fatality. From these statistics I hoped to show the

importance of the subject and to deduce conclusions thatwould help to make the subsequent discussion useful.

Dr. Byrom Bramwell, in a clinical lecture published in THELANCET of March 9th, p. 687, states that these conclusionsare not in accordance with his own experience, and he objectsto the method of taking the mean of the figures given by thevarious authorities whose statistics are made use of, and alsoto some of the statistics which were published about 40 yearsago and which, I would mention, have become classical andare accepted by all authorities on the subject to-day. I fullyagree with Dr. Bramwell as to the difficulty of basing argu-ments on a statistical foundation, for objections can generallybe raised against all statistics ; but it seemed to me that thequestions I was considering were such as could only besettled on statistical evidence, and by using only thosestatistics approved of by everyone who has written on thesubject, and in taking the mean of the figures, I thought Iwas adopting a basis for my arguments almost abovecriticism.

It will be more convenient to take each set of statisticsseparately.

1. As to the freqeuncey of gastric ulcer.-The usual estimate I,accepted by all authorities is that 5 per cent. of the wholepopulation suffer at some period of their lives from simpleulcer of the stomach. In 32,052 necropsies collated andanalysed by Welch, ulcers or scars caused by them werefound in 4’7 per cent., but Dr. Bramwell raises objections tothe post-mortem method of estimation-(1) because all openulcers are not found ; (2) because cicatrices of former ulcersare often missed ; (3) because superficial ulcers probably donot leave a cicatrix when they have healed ; and (4) becausesome of the scars found may be due to other causes thanulcer, such as syphilis, tubercle, &c. ; but as Dr. Bramwelldoes not press the last objection we will omit it from the

argument, for it is well known that other causes (thanulceration) of cicatrices in the stomach are very rare indeed.

I heartily concur in these three objections, but surely theyonly make the position all the stronger, and one naturallyasks the question-If 5 per cent. of ulcers or cicatrices arepositively found in all necropsies, how many more must

escape observation, and how much does 5 per cent. under-estimate the frequency of gastric ulcer ?

Dr. Bramwell next objects to the statistics of Britishhospitals, so far as gastric ulcer is concerned, being com-pared with certain German hospitals where exact observa-tions have been made and noted in the post mortem roomsfor many years. Of course, it does not follow that the samepercentage of cases occurs in British hospitals, but it remainsto be proved by an equal number of careful observationsthat this is not the case before Dr. Bramwell’s opinion onthe subject can have the same weight as that of those greatauthorities whose estimates have hitherto been accepted byall who have written on the subject. The frequency of

gastric ulcer in the community outside hospitals must

always be a difficult matter to settle, as its estimation

depends so much less on exact post-mortem evidence andso much more on clinical observation, to which Dr. Bram-well justly raises objection; but, if I may judge by myown experience, I hlive had a far greater number of privatethan of hospital patients sent to me for an opinion withregard to the surgical treatment of gastric ulcer. This,however, is no more a proof of the greater prevalence ofgastric ulcer in the well-to-do than is Dr. Bramwell’sopinion as to gastric ulcer being less frequently found inthis class of patient, his opinion, so far as I can gather,being based chiefly on clinical evidence to which he has somuch objected. Autopsies or biopsies afford us the onlyabsolute proof of ulcer of the stomach, and without suchproof there must always be uncertainty. I can see no

need, therefore, to alter the numbers which, for making theimportance of the subject more tangible, I applied to thepopulation of a city like Leeds, which, for convenience’sake, I took at 500,000, though Leeds itself has actuallyonly a population of between 400,000 and 500,000.

2. The total mortality from gastric ulcer.-I was verymuch astonished to find Dr. Bramwell making use of theRegistrar-General’s returns for the purpose of disproving thestatistics I quoted, and I should like to ask if Dr. Bramwellreally seriously argues that the Registrar-General’s return ofdeaths from gastric ulcer can be pitted against the statisticsof such able physicians and keen observers as Brinton,Welch, Dreschfeld, Habershon, Mutler, Lebert, Tricomi, andothers ? How about the classification of subphrenicabscess, acute peritonitis, localised abdominal abscess,intervisceral fistuloa, gastric dilatation, general atrophy,marasmus, anmmia, and phthisis (of stomach origin) andulcus carcinomatosus, to say nothing of many other diseasesending in death which should have recorded as their firstcause ulcer of stomach ? I see that Dr. SpottiswoodeCameron has even pointed out to Dr. Bramwell one or twoof these sources of fallacy. I do not think, therefore, thatif, as Dr. Bramwell says, 17 deaths were reported as duedirectly to gastric ulcer and six to hæmatemesis in Leedslast year, it will be far from the mark to say that three orfour times as many would be likely to die directly or

indirectly from the complications due to the same disease.The difference in the views of various authorities who give

the rate of mortality in all cases of ulcer as varying from 10to 50 per cent. is really a question of the inclusion or notof the cases dying indirectly from ulcer, for if theyare included-and to my mind they should be-the mortalityis much greater than the profession at large really graspsand than Dr. Bramwell acknowledges. The subject ratherreminds me of arguments that were used a few years agowhen it was not unusual to hear it said that deaths neveroccurred from appendicitis, but I never hear that argumentused now ; and, with regard to ulcer, it only requires time toprove that the figures I have employed will not be far fromthe truth.

3 & 4. On the frequency of gastrorrhagia and its fatality.-Dr. Bramwell should really be careful before he accusesanyone of making a serious error, especially when he pits hisindividual experience and opinion against the expeJience ofthe authorities quoted from and whose statistics I will againrepeat: 11 Miiller, 11 per cent. ; Welch, 3 to 5 per cent. ;Brinton, 5 per cent. ; Debove, 5 per cent. ; Steiner, 6 36 perper cent. ; Lebert, 3 per cent. ; Dreschfeld, 3-2L per cent. ;and Rodman, 8 per cent." ; these numbers representing per-centages of fatal hæmatemesis in bleeding ulcers. Asdifferent authors estimate the percentage of b2ematemesis inall cases of gastric ulcer somewhat differently it is difficultto classify them on the same lines. I have therefore adoptedpurposely a low estimate in saying that 50 per cent. of allcases of ulcer of the stomach suffer from gastrorrhagia and