CORRESPONDENCE.

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4.olrtsponbtnrt.
FATALITY RATES OF SMALL-POX IN 'l'HE
VACCINATED AND UNVACCINATED.
Sm,-lt is an almost universal medical belief (and I
share this belief) that the fatality rate among persons
attacked by small-pox il!l much greater, age for age, among
:t4e unvaccinated than among the vaccinated.
An interesting contradiction is furnished in the small-
po statistics of England and Wales for the four years
1923-26. 'l'he table furnishes the uum.bers of
cases of " small-pox ' in vaccinated and unvaecinated
persons o\'er 15 years of age, together with the numbers of
deaths and the fatality rates per cent., for each or these
years and for the whole period. The comparison is con-
filled to age 15 &nrl .over for the simple reason that
pl'actically all the cases under 15 are among the un-

Va.ccin..ted. Unva.ceinated.
"f.e&r .
Case
I Case Ca.ses Over
Deaths. :Mortality
Cases Ov<>r
Dea.ths. Morilllity
15 Years.
per cent.
!5 Years.
per cent.
--
1923 369 2 0.5. 734 2 0.3
1924 635 z 0.3 1;241 -
-
1925 933 3 0.3 1,824 - -
1936 2,073 6 0.3 *3,116
I
2 M6
------
I I
Tota.ls 4,010 13 0.3 6,915 4 0.06
Including 94 cues" doubtful" as to vaccina.tion state.
It will be observed that in each year the fatality rate
was greater amo11g .the v.accinated than .amoug the un-
:v:a.ecmated. In a total for these years of 11,01.9 cases,
4,910 nccuned among the vaccinated, with l3 deaths-a
fatality rate -of 0.3 per cent.-and o;915 {)ccurred among
:the unraccinated with 4 deaths-a fatality rate of 0.06 per
cent. That is to say, the fatality rate among raccinated
cases was just five times .as great as among unYaceinated
cases.
It :w:ould be inieresting to read possible exp:lanations of
this. statistical .anomaly which y.our reade-rs m.ay hav-e to
ofF.er. Clearly soine explanation is required, I suggest
that, in justice to n1.ccinati,_on, these figur-es call urgently
for:
1. A speeial inquiry into the hue cause of death of
all fatal cases oi " mild small-pox " in this oountry.
2. Revisiou of the rules of death regiskati.ou under
1\"hich a .death certified bv the doctor in attendance
as due to du:oi'lic uepluitfs, cerebral haemorrhage, or
other disease or courution unconnected with .small-po.x,
is and .ellt-ered in the vital statistics as a
death from small-pox.
j\'ote.-The .fig.ures qtu>ted .1u:e fJ:Om the annual reports of the
Chief Medical Ofticer, Ministry -of Health, 1923 (p. 37), 1924 (p. 37),
1925 (p. 38), 1928 {p. 39).
-1 am, etc.,
Obestet1icld, Jan. 4th. R. P. GARROW.
GAS GANGRENE FOLLOWING STREET
ACCIDENTS.
- Bm,-I have read with interest the reports of two cases
of ga.s gangrene following motor accidents, Dn. Marshall
IIDti Ellis, in you issue .of December 24th, 1927 (pp. 1183
&Dd 1184). It ill :tG be regretted that both these articles
oonv.ey the impre3Sioa that gas gangr-ene is very rare in
civil. ,practice, whereas it is not at all uncommon. -
Indeed, in tw.o of the hospitals with whiffi I am con-
DeC'bed the hOUSEH!urgeons and casualty officers ltave been
told to give pmphylactie injecti-ons of " anti-gas " S{'rum
a.t the same time as the antitetanie in all ('-ases of street
a-coidents with badly lacerated wounds and tissues.
During the past year I have had to perf-orm three amputa-
and several le8Se!-' local operatiOns for suCh inrections.
Two points of special intetest are to be nuted, witlt
regard to infecti.ons with B. welcldi: certain
districts and roads nppear to be much more heavily in-
fected than others (this corresponds to war-time experience,
when wounds sustaiued iu certain very limited districts
disp-layed a big incidence of gas gangrene, while tho8e from
areas two or three hundred yards away were practically
free); bacteriological investigation of a . series of stteet
accident wounds will reveal the organism in a large per-
centage of cases, but in only oompamtively few of these a1'e
there any of the clinical signs of infecti<m. A latent
infection of this kind may suddenly " light up " after an
interval of many days if the local resistance be loweted
by thrombosis or ligation of the main arterial supply.
It is .a mistake, frequently committed, to attempt the
early closure of wounds .of this type; they should be left
open, perhaps with continuous irrigation, after careful
excision of all foreign material and dead or damaged tissu-e.
Anti-gas serum, especially the polyvalent form which
pro\ed useful during the war, must be ghen in fairly large
doses, both for prophylaxis and treatment.-! am, etc.,
London, W., Jan. 3rd.
NoRMAN C. LAKE.
TREATMENT OF PROSTATIC ENLARGEMENT.
SIR,-1 should like to reply to the several criticisms of
my previous letter.
Mr. Leeming might, in all fairness, have quoted tho
statement in my letter correctly, as it was not my own but
taken from the Bradshaw Lecture l,Jy Sir Cuthbert Wallace.
Mr. Hey Gro,es's figures did not refer to London hospitals,
but to " all the available large hospitals in the kingdom."
Sir Cuthbert Wallace gives figures from four London hos-
pitals, and states that " the mortality of prostatectomy has
fallen from 20.2 to 14.5 per cent., but that the, total oper-
tive mortality has somewhat risen.". The figures ginu by
Mr. Leeming--of 3 per cent.-and those given by "Pro-
vincial Surgeon " of 11 il per cent., are tho&c to which all
surgeons aspire, and merely show that the modality rate .of
many .other surgeons n;mst be much higlwr than <>ne .had
imagined if the average modality is 14.5, taking Sir
Cuthbert Wallace's figures, and not considering :&Ir. Hey
Groves's coilcctive one of 40 per cent.
My intentioh was nwrely to point out that the mortality
ratl's quoted in the Bl'adshaw Lecture are still too high .and
that the chid hope for improving them was by encouraging
-and not discouraging-specialization in urology. I claim
no originality for this suggestion, as I find on teferring to
the accepted translation of the Hippocratic oath the follow-
ing sent!'ace, " I will not cut a perBOn wlw is su1fering
fmm stone, but will leave this to be done pmctitioners of
this work." This is the first mention of specialization in
the history of medicine-mid it is only .surprising that so
few of our la1ge general hospitals have up to the present
instituted special urological departments, such as flourish
in America and on the Continent.-! am, etc.,
T. CAREY EVANS.
London, W., Jan. 5th.
TETR.A.ETHYL LEAD.
SIR-" Medical N0tes in Parliament," in the .JouRNAL
of 3td, 1927 (p. lil59), included the following
passage:
One firm in this country has commenced blending tetra-ethyl
lead with petrol on a commercial scale. The Factory Depat1.meut
of the Home Ofliee is satimed that adequate precaut-ions are
being talren for protecting workers concel'Iled in the ptocess. '
Following this comes a . series of in the
public press of a motor spntt. well . known to
motorie,-ts on the other of the Atlantic for 1ts reputed
" anti-knock " qualities- under the term "ethyl gasoline."
This heralding of a substance with the objeet of pro-
moting its common use among a very large section of
the population raises important and -urgent issues M to
its dangers, reputeQ or real, by reason -of the }lresE'n<:e of
tetra-ethyl lead in the spirit, to which its principal " anti-
knock " virtues are due.
Reference to this B'ubject has a'lready been made by you