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since 1906. No doubt this menacing rise is largely the result of war conditions, and as far as that isthe case its permanence is the less to be feared.One manifestation of these war conditions can bemeasured numerically, and proves to be account-able for a considerable share in the increaseobserved. During the war several English lunaticasylums have been evacuated of their customaryinmates in order to devote the buildings to militarypurposes. This led to some overcrowding, whichis one at least of the factors leading to the increaseof tuberculous fatality occurring in asylums. In

any event, the heightened asylums mortality, whichmay be regarded as a direct outcome of the war,accounts for 41 per cent. of the total increasein deaths by tubercle since 1914. There isaccordingly good ground for hope of a fall inthis mortality on the restoration of peacefulconditions. The serious increase in tuberculous

mortality is confined to ages from 5 to 25, whereit ranges from 21 to 42 per cent. It has been

suggested that the rise might be due to work in thefactories. This might certainly account for the chiefpart of it-namely, that at ages 15 to 25. But itis noteworthy that the usual comparatively smallmortality at 5 to 15 has also risen to a significantextent, and factory conditions obviously cannotaccount for this rise. Possibly these children havesuffered from some dietary changes, such as

deprivation of fat. Whatever the cause may be, ithas not affected children under 5 years, at whichage the decline in mortality which has been anotable feature of the history of tuberculosis inEngland during the present century has continued,if in lesser degree.The two other great scourges of the population,

malignant disease and venereal disease, showas yet no sign of abatement. The total deathsascribed to syphilis in 1917 numbered 2177;the deaths of civilians corresponded to a mor-

tality of 61 per million living at all ages. Asalmost two-thirds of the deaths from syphilisare those of infants in their first year of life,it might have been anticipated that the largedecrease of births would have led to a fall in

syphilis mortality. On the contrary it was higherthan it had been since 1895. The new measures forthe control of venereal disease have been littleassociated with Poor-law and largely with hospitalpractice. And by a process of exclusion it seemsprobable that the war has actually increased thenumber of deaths of infants, particularly illegitimateinfants, although it has had comparatively littleeffect in increasing illegitimacy. As for malignantdisease, the deaths referred to cancer in 1917amounted to 41,148, of which 18,145 occurredamong males and 23,013 among females. Theseare the highest figures for both sexes and implythe heaviest crude mortalities yet recorded. Un-

fortunately the years are very few respectingwhich a similar statement might not have beenmade. Part of the increase is surely owing to theexclusion from the population of a large number ofmen furnishing very few deaths from cancer, buteven after correction the increase remains appre-ciable. The rate for females is not influenced bythese considerations, and is reported to have beenpractically unchanged since 1916. So far as malemortality in 1917 at ages 45 and upwards is com-parable with that of 1911-14, which is taken asrepresenting the most recent experience underpeace conditions, there has been some slightdecline at ages up to 65. accompanied by much

more considerable increases at-later ages. Whilethese changes may be partly due to errors inestimation of population, they are consistent withthe apparent tendency of the disease to becomemore and more one of old age; but although thistendency has hitherto shown itself chiefly in thefemale sex, it is less clearly manifest for that sexin the present comparison. The cancer deaths ofnon-civilians registered in this country numberedonly 362, of which 189 were those of men aged 40years and over. There were thus only 173 militarydeaths at

"

service ages," or more than one-fifth ofthe total deaths by cancer among males aged 15 to40. It seems probable that this total includes thecancer mortality of the whole army, so that the18,145 male deaths registered may be regarded asrepresenting practically the complete mortality ofthe year, notwithstanding the absence of so large aportion of the normal population. Cases met withon foreign service have doubtless, as a rule, beensent home before death, and the deaths of any meninvalided out of the service on account of cancerwould be included with the civilian total.

THE "MEDICAL TREATMENT" OF EMPYEMA

AT a meeting of the Societe Médicale des H6pitauxof Paris MM. P. Emile-Weil and Loiseleur calledattention to a " medical treatment" of empyemawhich had given excellent results-puncture andinjection of air, which enables the last drop of pusto be evacuated, followed by injection into thepleural cavity of 2 c.cm. of a .1 in 20 solution ofmethylene-blue. The chest is then examined dailywith the screen for reproduction of pus. If thisoccurs rapidly the case is passed on to the surgeonfor operation. If, on the other hand, the pus isreproduced slowly and in diminishing quantity, thegeneral condition improving meanwhile, the treat-ment by puncture is repeated. Twelve cases were sotreated, of which 11 were consecutive to influenzaand one to removal of a projectile from the chest.Five of the empyemas involved the main pleuralcavity and 7 were partial (3 affecting the posteriormediastinum, 1 the whole mediastinum, 1 dia-phragmatic, and 2 axillary). Bacteriological exa-

mination showed that 5 were pneumococcic, 1

streptococcic, 3 due to mixed infection, and 3amicrobial. All the patients were cured except one,who was in a desperate condition when he cameunder treatment from cardiac and pulmonarycomplications. In 7 cases surgical operation waseventually necessary. Thus the delay was notprejudicial. A typical case was one of empyemaof the whole pleural cavity with streptococci andbacilli. June 13th, 1918, first puncture, 4’8 litres ofpus withdrawn; June 28th, second puncture, 1 litre;July 25th, third puncture, 450 c.cm., August 12th600 c.cm., August 24th 900 c.cm. of thick blackishamicrobial fluid withdrawn. Oct. 7th 500 c.cm.withdrawn. Recovery was then complete. Inanother case there was double empyema. Onthe right side the posterior mediastinum wasaffected. On Sept. 10th 300 c.cm. of thick puswere withdrawn and air and methylene-bluewere injected. No more pus was reproduced. Onthe left there was an encysted axillary collection ofpus which was discharging into the lung. On

Sept. 9th 300 c.cm. of pus were withdrawn; on the12th 100 c.cm.; on the 19th 100 c.cm.; on Oct. llth200 c.cm.; on the 29th 150 c.cm.; and on Nov. 6th120 c.cm. After this, no more pus was expectorated,and at the end of November radioscopy showed that

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recovery was complete. In a third case therewas posterior diaphragmatic pneumococcic pleurisyafter influenza. On Oct. 7th 30 c.cm. of thick puswere removed; on the 17th 150 c.cm.; on Nov. 2nd150 c.cm.; on the 14th 100 c.cm.; and on the 26th150 c.cm. Recovery was then complete. The time

required for complete recovery under the treatmentvaried from a month and a half to four months.The time may seem long, but it should be remem-bered that the patients were kept under observa-tion until.radioscopy showed disappearance of thepneumothorax.

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WAR, WEATHER, AND WATER-SUPPLY.

THE report, issued this week, by Sir AlexanderHouston, Director of Water Examination, Metro-politan Water Board, on the results of theChemical and Bacteriological Examination of theLondon Waters for the 12 months endedMarch 31st, presents some interesting featuresarising out of two factors-the war and adversemeteorological conditions. The period of thewar has been fertile in introducing new depar-tures from old waterworks’ procedure, and these,in spite of many difficulties, have resulted in

greater security and the saving of largesums of money. A number of diagrams and

figures adds to the value of the report,referring chiefly to the presence of suspendedmatters as an indication of the bad, good, or

indifferent work of the filters, particularly in theflood time experienced in February last. Similarlyexamples are given of suspended matters inchlorinated river water in relation to filtration, theseries concluding with illustrations of algas andother growths. These researches are obviously ofgreat importance to the well-being of the com-munity, and we propose to return to the subject.

MIXED INFECTION IN HILUS PHTHISIS.

oimon, writing from a cniidren sanatorium inElberfeld, remarks that it is a common observationhow even a simple cold will provoke the return ofpulmonary sputum in arrested apical tuberculosis,and this without anything much in the way of

physical signs of an activation. In children, inwhom consumption affects much oftener the hilusof the lung, almost the same thing may be observed.Physical examination reveals more, however. Afteran influenza rales appear, generally on the morediseased side, and may persist for some time in thecorresponding lower lobe. The sputum is mucoid,contains epithelial cells, free nuclei, and only afew leucocytes and cocci. If the process is activeexudation takes place between the larger bronchi,the bronchial glands become affected and also thebronchial mucous membrane. Clinically there islittle to note beyond a rise of temperature, and thediagnosis rests on the above physical signs, withmore or less bronchial breathing, and upon theRoentgen picture. A small area round the hilus,either upward or downward, may be involved, andin the latter case the pleura may be affected ; little,however, can be made out on the front of the chest.Radiologically a shadow rather more than walnutsize is seen with, radiating from it, smaller shadows,sometimes in the form of strings towards apex orbase. When the acute stage is past these shadowscompletely disappear. In three or four weeks thepatient has completely recovered; progress of the

1 Internationales Centralblatt für die gesamte Tüberkulose-Forschung, April 30th, 1919.

pulmonary tuberculosis has never been observed.As exciting causes, besides the already mentionedinfluenza, follicular tonsillitis, and perhaps middle-ear disease, must be reckoned. Occasionally moresevere forms occur, meriting the name of a hiluspneumonia. There is more constitutional disturb-ance, the X ray picture is plainer, and the sputumcontains pneumococci as well as more leucocytes.The course is, however, favourable as before,though longer, perhaps six to eight weeks, induration. The disease is obviously not an exten-sion of the tuberculous process, while there arealso many points of differentiation from a centralpneumonia. The author gives various references.His description recalls somewhat the septicinfection of the lungs from above, described byDu Magny, which can simulate pulmonary tuberclevery closely. Undoubtedly, too, pulmonary tuber-culosis can be complicated for long periods bysuppurative affections of the upper air-passageslike those mentioned here-nasal sinusitis, forexample. "Mixed infection " in pulmonary tuber-culosis has of late been regarded as a lessserious condition than heretofore, and this view iscorroborated by Simon’s observations.

PRESENTATION TO SIR WILLIAM OSLER.

ON Friday, July llth, the eve of his seventiethbirthday, at 5.15 P.M., an anniversary book, writtenby his pupils, friends, and colleagues, is to be

presented to Sir William Osler, Regius professor ofmedicine at the University of Oxford, in the Libraryof the Royal Society of Medicine, London. Thepresentation will be made by Sir Clifford Allbutt,Regius professor of physic at the University ofCambridge. All members of the medical professionare invited to be present. An announcement of theprinted issue of the anniversary book appears inour Medical News column.

PRIMARY CARCINOMA OF THE DUODENUM.

THE rarity of primary carcinoma of the duodenum,of which G. D. Head 1 reports an example in a man,aged 74, is shown by the fact that Perry and Shawfound only 4 cases in 18,000 autopsies on examina-tion of the Guy’s Hospital Reports, and only 18cases were found out of 19,500 autopsies at theLondon Hospital. The clinical picture dependsupon the situation of the growth in the duodenum.Carcinoma above the biliary papilla presents thesymptoms of pyloric stenosis with or without haemat.emesis, and a palpable mass is usually present.Carcinoma in the second part of the duodenum isusually ushered in by a slowly developing icteruswithout pain or vomiting. The jaundice persists,vomiting develops, the liver becomes enlarged, thegall-bladder may be distended and palpable, andthe patient dies from inanition. A palpable massmay or may not be present. In cancer of the third

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part of the duodenum, of which Head’s case was anexample, the first symptoms consist of flatulenceand discomfort after meals, burning acid eructations,loss of appetite, and gradual emaciation. After,afew months vomiting occurs and persists till theend. There is marked cachexia and rapid lossof flesh. The bowels are obstinately constipated.The vomit always contains bile, which gives it alight-green colour. From time to time attacks ofintestinal obstruction occur, attended by incessantvomiting and obstinate constipation. No tumour,

1 Am. Jour. Med. Sci., 1919, clvii., 182-9.