1844

from 1900 to the present year ; and in this report ‘

it is shown that in a very large proportion of the icases a permanent cure of the lupus has been ’effected, while in others much improvement has 1occurred. Only in a very few cases has no beneflt

-

resulted. ____

;

TROPICAL AND EXOTIC DISEASES.

Tropical medicine still continues its triumphal march with the result that 1913 has seen much real

I

progress in our knowledge of the origin, treatment,and prevention of the diseases most frequently metwith in the tropics. It is a matter of congratula-

‘

tion that the London School of Tropical Medicine ‘

has already obtained nearly three-fourths of the ‘

sum of 100,000 required to place its operations i

on a better and more substantial basis. The ‘

great event of the year was the Seventeenth 1

International Congress of Medicine in London, thisbeing the first occasion on which a section has "

been devoted exclusively to the subject of tropical n

medicine and hygiene. The success of this

section, which had for its president Surgeon-General Sir DAVID BRUCE, must have gratified its

‘

organisers. It more than justified its existence,for its meetings were thronged at every sitting bymembers from all parts of the world, some of whom 1were among the " giants of tropical medicine " ; and ithese distinguished men, by taking part in the dis-cussions, lent additional weight and dignity to theproceedings. Many valuable and interesting paperswere read at the meetings of the Section of TropicalMedicine, but we direct special attention to a series ’of discussions which were arranged by the officialsfor particular consideration by the members, thesubjects being plague, beri-beri, leishmaniasis,spirochoetosis, and sanitary organisation in the

tropics. :Discussions at the Seventeenth International ,

Congress of Medicine.The discu.ssion on plagqte was opened by a paper í

prepared by Professor S. KITASATO (Japan), whotestified to the value of the guinea-pig in the search Ifor plague-infected rat-fleas in human habita- I

tions. Major W. GLEN LISTON spoke on theepidemiological features of bubonic and pneu- I

monic plague, and on the immunity of Musrattus to plague infection. A very interestingdemonstration, with the aid of lantern slides, wasgiven by Dr. C. J. MARTIN and Mr. A. W. BACOT,of the Lister Institute, on the mechanism ofthe transmission of plague infection by rat-fleas. The relationship of the tarbagan to humanplague was dealt with by Dr. Wu LIEN TEH (G. L.TuCK), director of Plague Preventive Measuresin Northern Manchuria (whose paper was publishedin full in THE LANCET of August 23rd). Amongothers who took part in the discussion were Dr. R.Row (Bombay), Dr. F. J. VAN LoGHEM (formerly of

Java), Mr. J. CANTLIE (London), Dr. A. AGRAMONTE(Cuba), and Dr. DUNCAN WHYTE (China).The discussicn on beri-bel’i.-The importance

attached to this may be estimated by the numberof eminent men who took part in the debate. Dr.C. EIJKMANN (Utrecht), whose name has long beenbefore the scientific world as an investigator ofberi-beri, opened the discussion, and was followedby Dr. B. Noc]E[T of Hamburg. Dr. L. BRADDON(Federated Malay States), who was one of the veryfirst to press the " white rice " theory of the causa-tion of the disease, and Dr. C. FUNK (of the ListerInstitute), who described the neuritis-preventing

. vitamine" " found in the subpericarpal layers ofbhe rice grain, set out their views fully ; and thosewho also spoke included Dr. H. SCHAUMANN

(Hamburg), Dr. S. SHIBAYAMA (Tokio), Professor F.RHO (Rome), Dr. T. SHIMAZONO (Tokio), Dr. L. NATTAN-LARRIER (Paris), Dr. MALCOLM WATSON (BritishMalaya), Dr. J. TscIIUDNOwsKY (Paris), Dr. G. L.FINK (Burma), Dr. D. E. ANDERSON (London), Dr.AGRAMONTE, Dr. L. SAMBON (London), MissMAY YATES (London), Mr. CANTLIE, Dr. E. DE

FREITAS CRISSIUMA (Brazil), Dr. L. G. CHACIN-YTRIAGO (Venezuela), Dr. C. NOEL DAVIS (Shanghai),and Sir PATRICK MANSON. The section passeda series of resolutions respecting the etiologyand prevention of the disease, embodying the viewsnow generally held as to the danger of white riceas a staple article of diet.The discussion on leis7mzania8is was opened

by Professor A. LAVERAN (Paris), who read a

paper prepared by himself and Dr. C. NICOLLE(Tunis) on Infantile Kala-azar. Sir WILLIAM B.LEISHMAN set out briefly the state of our

present knowledge of the leishmania infectionand its various forms. Others who took part in thedebate were Dr. Row, Dr. NATTAN-LARRIER, Dr.CRISSIUMA, Dr. B. GONDER (Frankfort-am-Main), Dr.AYRES KOPKE (Lisbon), Dr. A. SPLENDORE (Brazil),Professor RHO, Dr. ANDERSON, Dr. L. P. PHILLIPS(Cairo), and last but not least, Sir PATRICK MANSON.The discussion on siocla<etosis.-This was

opened by Professor S. HATA (Tokio) with a con-tribution to our knowledge of the cultivation of thespirochseta recurrentis ; he was followed by Dr. E.PRIMET (French Equatorial Africa), Dr. ANDREWBALFOUR (formerly of Khartoum), and Dr. S. T.DARLING (Panama Canal Zone). Sir WILLIAMLEISHMAN wound up the debate by discussing thequestion of granule shedding in spirochastosis, andshowed some instructive lantern slides in supportof his views.The discussion on, sanitary organisation in the

’opcs.&mdash;This was discussed at a joint meeting of theSection of Tropical Medicine and Hygiene and thatof Naval and Military Medicine. The debate was

opened by Sir RONALD Ross, who was followed by Staff.Surgeon Dr. HINTZE (of the German Colonial MedicalService), and among others who took part in thisinteresting discussion may be mentioned ColonelP. HEHIR, I.M.S., Colonel W. G. KING, I.M.S. (retired),Professor T. v. WASIELEWSKI (Heidelberg), Dr.

AGRAMONTE, Dr. C. BLACK (Western Australia),Dr. F. M. SANDWITH (London), Dr. C. F. HARFORD

(Leyton), Dr. G. OLPP (German West Africa), Dr.ANDERSON, Dr. ANDREW BALFOUR (London), Dr.

KOPKE, Dr. WATSON, Colonel BRUCE SKINNER,R.A.M.C. (London), Major LISTON, I.M.S., and SirPARDEY LuKis (Director-General, I.M.S.)..P)’es6<o to Si7&deg; Patrick Manson.-At

one of the closing meetings of the Sectionof Tropical Medicine of the SeventeenthInternational Congress of Medicine ProfessorBLANCHARD, of Paris, in the name of theInternational Society of Tropical Medicine, pre-sented, with the accompaniment of a graceful andsympathetic speech, to Sir PATRICK MANSON (" thefather of tropical medicine ") a handsome medalliondesigned specially by Professor RICHER, of the ParisSchool of Fine Arts, having on one side of it a like-ness of the recipient. The presentation was madeamid the enthusiastic plaudits of the members, butthe heartiness of his reception caused Sir PATRICKsome emotion, and it was with difficulty that he wasable to return his thanks.

1845

The Spread of Disease in Africa by Wild Animals and Insects. ’

The Secretary of State for the Colonies in August, ]

1913, appointed a committee to report upon thepresent knowledge available as to the parts played

I

by wild animals and tsetse fiies in Africa in the imaintenance and spread of trypanosome infectionsof man and stock; whether it is feasible to carryout an experiment with regard to game destructionin a localised area; whether it is advisable to

.attempt the extermination of wild animals locallyor generally with a view of checking trypanosomediseases; and whether any other measures shouldbe taken to obtain means for controlling theseinfections. The medical members of this committee,comprise Dr. A. G. BAGSHAWE, Dr. ANDREW BALFOUR,SirJOHNROSEBRADFORD, Dr. W. A. CHAPPLE, M.P., SirWILLIAM LEISHMAN, and Dr. C. J. MARTIN. ProfessorR. NEWSTEAD and Dr. P. CHALMERS MITCHELLare also members of the committee, of whichthe Earl of DESART is the chairman. It may beremembered that this subject was also raised in thefinal report of the Luangwa Sleeping Sickness Com-mission by Dr. ALLEN KINGHORN and Dr. WARRINGTONYORKE.

Inquiry into the Nature and Frequency of WestAfrican Coast Fever.

The Colonial Office, in view of the conflictingopinions expressed respecting the fevers occurringon the West Coast of Africa, appointed in 1913 asmall Commission of experts to study the natureand relative frequency of such fevers, and espe-cially as regards yellow fever and its possible minormanifestations among natives and others in WestAfrica; and to study the clinical course, pathology,and mode of infection of such fevers and thediseases for which they may be mistaken; thenature of bilious remittent, malignant bilious re-

mittent, "inflammatory," endemial and "acclima-tising," and other forms of fever was to be investi-gated under the direction of this Commission, themembers of which are Sir JAMES KINGSTON FOWLER(chairman), Sir RONALD Ross, Sir WILLIAM LEISHMAN,and Professor W. J. R. SIMPSON.

Special Investigation of Diseases in India.

Special investigations are now in progress inIndia respecting the etiology, treatment, and pre-vention of a number of diseases, includingkala-azar, plague, cholera, relapsing fever, and

dysentery, the cost of which is defrayed, in wholeor in part, by the Indian Research Fund Associa-tion, which was founded in 1911. In this con-nexion we may refer to an article publishedin Science Progress by Sir PARDEY LUKIS, whichshows how at present the practical application ofscientific investigations is now being made use ofin India with resulting great improvement in thesanitary circumstances of the Indian people, accom-panied by welcome developments in local sanitaryadministration. The Central Research Institute islocated at Kasauli under the charge of Major S. R.CHRISTOPHERS, I.M.S. The Third All-India SanitaryConference has not been held during 1913, but takesplace in January, 1914.

Pellagra.Pellagra, though not, strictly speaking, a tropical

disease, is regarded by most people as an exotic,though lately Dr. L. SAMBON and others have re-ported some 40 cases in England, Scotland, andWales, while Dr. F. E. RAINSFORD sent to the

columns of THE LANCET the notes of a case occurringin Ireland. The investigations of the Pellagra Com-mission are being continued, and in this connexionDr. SAMBON has recently visited the United Statesof America, where it is estimated some 30,000persons are at present suffering from the disease.The malady is reported to be prevalent, amongother places, at Porto Rico, the Panama Canal Zone,the Philippines, and the Sandwich Islands. Thedifference of opinion as to whether this disease isdue to a specific infection or a toxin, or is due to adeficiency of some essential substance in the diet,has not yet been settled, though researches by Dr.SAMBON and other experts are in progress, as wellas investigations by an American Commission. Arecent report by Dr. HUGH S. STANNUS shows thatpellagra is endemic in Nyasaland.

According to our custom we give a short summaryof the reported occurrences of the three exoticdiseases, cholera, plague, and yellow fever, as wellas of small-pox in various parts of the worldduring 1913 so far, at least, as the information hasbeen obtainable.

Cholera in India and the Far East.

Cholera was prevalent in various provinces ofIndia, and so far as can be gathered from thelimited amount of information available up to date,about 150,000 deaths were registered from the diseaseduring the first nine months of the year. Theworst sufferers were Bengal, the United Provincesof Agra and Oudh, the Madras Presidency, theCentral Provinces, and the new province of Biharand Orissa. The disease was continuously presentduring the year in Calcutta, where about 1200deaths were recorded up to September. In BombayCity cholera caused about 125 deaths in the sameperiod. The malady appeared during 1913 at theBurmese ports of Rangoon, Bassein, and Moulmein,and at Madras and Negapatam in the MadrasPresidency. In Ceylon 30 fatal cases occurredat Colombo; and in the Straits Settlements at

Singapore about 200 cases were reported. Thedisease was reported to have occurred on thewest coast of the Malay Peninsula, and about70 fatal cases were certified in Bangkok, thecapital of Siam. Cholera was prevalent inIndo-China, outbreaks being reported in Annam,Cambodge, Cochin China, Laos, and Tonkin. TheDutch East Indies suffered again from cholera in1913, the islands of Java, Sumatra, Borneo, andCelebes being affected. In the Philippine Islandsthe malady appeared in August at Manila, causingover 70 deaths up to November. In China cholerawas present in Amoy, Swatow, Canton, Hong-Kong,Foochow, Chuan-Chow, and elsewhere. Several

prefectures in Japan were invaded by choleraduring the year, and cases were notified at the

ports of Kobe, Nagasaki, and Yokohama, as well asin the island of Formosa.

Cholera in the Near East.

Cholera was epidemic in Asia Minor and theHedjaz up to the end of 1912, and in the early part

: of 1913 a few cases were heard of in these regions,the disease then seeming to disappear altogether.It was not until July that cholera once more brokeout in Asia Minor at Smyrna, where up to September

L about 300 persons had been attacked. The malady, also reappeared in August in the Red Sea provinces. of Turkey at the port of Hodeidah in Yemen, where some 123 cases were notified up to September,; chiefly among the Turkish troops.

1846

Cholera in Europe.Cholera was acutely epidemic at the end of 1912

in Constantinople and in its vicinity, especially atTchatalja, where the Turks made their final standto arrest the advance of the then victoriousBulgarians. In the early part of 1913 news camefrom Bulgaria and Macedonia that cholera had beenintroduced by Turkish prisoners, and by the sickand wounded soldiers sent home from the seat ofwar in Thrace. When Adrianople capitulated in thespring cholera broke out among the captive Turks,the infection extending also to the Bulgariancaptors. The condition of the respective camps wasextremely insanitary, and we have the authority ofthe special correspondents of the London papersfor the statement that thousands of persons wereattacked and that many died ; how many will prob-ably never be definitely known. Cholera did notbecome widely epidemic in the Balkan States untilthe summer months ; up to ’ October 10,937 personshad been attacked in Bulgaria, of whom more than3500 died; in Servia from July till October nearly7000 cases were reported, of which about 3000 provedfatal; and in Roumania from August to October5656 attacks were notified, 2908 of which had a fataltermination. Cholera broke out in Greece at thePiraeus among a batch of Bulgarian prisoners, andit was currently reported that the Greek army hadalso become involved. Cases, too, occurred in

Macedonia, particularly in Salonica, whither manyrefugees had flocked and where many sick andwounded had been sent. Cholera also appeared inBosnia and Herzegovina during the autumn, andthe infection spread to Hungary (630 cases) andCroatia-Slavonia (494 cases), as well as to severaltowns and districts in Austria, including Vienna,Marienbad, and Prague, but there was no epidemicin the last-named towns. In Russia some cases ofcholera from Constantinople occurred at Odessaearly in 1913, but the infection did not then spread.During August, however, a number of places in thegovernment of Kherson were invaded by the

malady, including the port of Kherson, where 40cases were notified. Some attacks also occurred inOdessa in September, as well as in several localitiessituated in the governments of Poltava, Bessarabia,Taurida, Ekaterinoslav, and Kieff. At the close of1913 the disease seems to be subsiding with the ’,advent of wintry weather, but there is danger that in the coming year a recrudescence of cholerain South-Eastern Europe may occur if sufficientprecautions be not taken.

Plague in India.Up to the end of October, 1913, more than

200,000 cases of plague had been notified in India, andof these upwards of 171,000 had terminated fatally.The provinces which had the highest plaguemortality during the ten months in questionwere the United Provinces of Agra and Oudh, withmore than 88,000 deaths; the new province ofBihar and Orissa, with over 25,000 fatal cases ; thePunjab, with nearly 19,000; and the Presidency ofBombay, with not far short of 19,000. The epidemicof 1913 reached its height in March and April, andto those two months more than 90,000 deaths fromplague were referred. There is a great probabilitythat the year 1913, when completed, will show aconsiderable reduction of the plague mortality inIndia as compared with 1912, when 306,088 deathswere registered from the disease, and 1911, when nofewer than 846,873 victims were certified to haveperished from the malady.

Plague in the Far East.Plague was epidemic in Indo-China, including

Annam, Cambodge, Cochin China, and Tonkin ; alsoin the Quan-Tcheou-Wan leased territory, wherenearly 1500 deaths occurred. It was fatally pre-valent also in the Dutch East Indies, especiallyin the island of Java, where more than 9000 cases.were recorded. In Siam there was an outbreak at

Bangkok comprising some 60 fatal cases. Plague,was widely diffused over China, many cities, dis.tricts, and ports being invaded by the infection.At Amoy about 300 deaths were recorded ; in Hong-Kong the annual epidemic included 335 fatal cases,.and there was an epizootic among rats. Shanghai,too, yielded cases both in man and in the rat; andat Canton in April and May plague caused 270,deaths. Other places attacked were Swatow, Fung-shan, Ampo, Kityang, Chao-Chow-fu, and Pakhoi;. ;.at this last-named port 2000 persons lost their livesfrom plague. Chao-Yang was also invaded, andcoincidently an unusual mortality was observedamong rats and mice. In Japan some cases occurredin the latter part of the year at Yokohama, and therewere 140 cases notified in Formosa. In the

Philippine Islands the disease continued to crop upin sporadic fashion at Manila during the year, a fewinfected rats being also discovered. Scattered cases,.too, came under notice in the Hawaiian Islands,where also some plague-stricken rodents were

found.

Plague in the Near Eccst.The annual outbreak occurred at the Hedjaz port

of Jeddah early in the year, among the victims.being the registrar of the British Consulate. AtAden 80 cases and 58 deaths occurred, and thedisease was also reported to be present in theSultanate of Oman. In the Persian Gulf plagueappeared at the port of Bushire in April, and themalady was epidemic in the two Persian provincesof Kermanshah and Khorassan from May to,

September. A few cases occurred at the port ofBasra, probably imported from Bushire. In AsiaMinor plague cases were reported at the ports ofAdalia and Trebizond, and in the Lebanon district.

Plague in Africa.In Egypt up to the end of November 649 plague

cases had been notified, 95 being referred to.Alexandria and 25 to Port Said. At the Italian

port of Massowah on the Red Sea coast of Erythreaan outbreak occurred in May comprising more than50 cases. In British East Africa plague was pre-valent during the first half of 1913, nearly 260’cases being notified in Mombassa, Nairobi, Kisumu,and other places; many infected rats were alsofound. In the Muanza district of German EastAfrica 236 fatal cases of plague were reported, andthere was a coincident epizootic among rats. Onthe island of Mauritius up to the end of November280 cases of plague had been notified and about 400’infected rodents had been discovered. In Moroccothe disease occurred at Mehedia, Casablanca, atRabat, and El Arish. In Tripolitania plague caseswere reported at Tripoli and Derna. In the CanaryIslands, at Santa Cruz de Teneriffe some fatal caseswere registered during February.

Plague in Europe.There was very little plague in Europe during

1913. In Russia about 30 cases were notified in the

territory of the Don Cossacks; and in the govern-ment of Astrachan, in a region said to be anendemic centre of plague, a number of cases-

1847

mostly of the pneumonic type were reported.During August 10 cases were registered in Greeceat the Piraeus, the infection being traced to Egypt.Later the disease appeared in Athens, but did notspread. A single case was landed at the Austrianport of Trieste in November from the s.s. America.

Plague in North and Sotcth America.In California, where the ground squirrels are

known to be suffering from enzootic plague, twohuman cases, both fatal, were reported in 1913 ;and at Seattle, in the State of Washington near theCanadian boundary, nine plague-infected rats werediscovered in November. In South America some400 cases were reported in the State of Ecuador,chiefly at the seaport town of Guayaquil, and laterreports’state that the disease was spreading into theinterior. The information available from Peru isextremely meagre, but it is known that plaguewas prevalent, especially in the departments of

Lambayeque, Lima, and Libertad, and that morethan 530 cases had been notified. The reportsfrom Chili are also very scanty, but the diseasewas known to be prevailing in Iquique and otherplaces. The government officials in the Argentinedo not publish news respecting exotic disease, butconsular reports show that plague had occurredat Rosario and in its vicinity, as well as atdifferent places in the provinces of Tucuman,Parana, Cordoba, and Entre Rios. In July it wasreported that plague was present in Montevideo,the capital of Uruguay. Sporadic cases occurredin Brazil at Rio de Janeiro, some 36 notificationsbeing received up to October. About 20 attackswere certified at Port Allegre. There was also an

epidemic of plague at Bahia, about 150 cases beingnotified; and at Pernambuco about half a dozenfatal instances were certified.

Yellow Fever on the West Coast of Africa.During 1913 yellow fever appeared in Portuguese

West Africa at Kiusembo, and there was a sharpoutbreak at Accra, in the Gold Coast, where casescontinued to occur from March to October. Amongthe Europeans attacked at Accra were the wife ofthe Governor and his aide-de-camp; cases alsooccurred in the Gold Coast colony at Quitta andCape Coast. In September the presence of thedisease was reported in the German Protectorate ofTogoland, at Lome, where cases had occurred duringthe previous year; also at Dakar in French WesAfrica in November. In Southern Nigeria yellowtfever became prevalent at Lagos in March, theprevalence extending to other places in the colony,including Wari, Ibadu, Yoruba, Forcados, and

Abeocuta; a single ship-borne case was landed atCalabar in October. At the request of the Governor,Dr. H. SEIDELIN, of the Liverpool Yellow FeverBureau, was despatched to the colony to assist inmaking special researches with a view to thediscovery, if possible, of the specific parasite of thedisease and to make other investigations. Dr.J. E. L. JOHNSTON and Dr. J. W. ScoTT MACFIE, inTHE LANCET, have reported the finding of the

paraplasma flavigenum in the blood of cases, andalso in dogs at Lagos.

Yellow Fever i-m South America.

Yellow fever, formerly endemic in Rio de Janeiro,the capital of Brazil, has by means of modern pro-phylactic methods been completely banished fromthe city except for occasional imported cases frominfected ports. But recently in the absence of the ’,disease the enforcement of the measures has gradu-ally slackened. During 1913 some cases were

reported among the residents, the origin of theinfection not being traced to outside sources. Sixdeaths were certified up to October, and it is nowfeared that the endemicity of yellow fever may bere-established in Rio de Janeiro if care be not taken.Other places which suffered in Brazil were Bahia, ,

where 70 cases were notified, among whom was theBritish chaplain, whose case proved fatal, andManaos, where 40 deaths occurred. A few caseswere also heard of at Pernambuco and Ceara, anda single ship-borne case at Para. In Venezuela somecases occurred at Caracas, and in the republic ofColombia the presence of the disease was reportedat Carthagena, the infection having been broughtfrom the interior. Ecuador suffered somewhatseverely from yellow fever during 1913, an epidemicoccurring in Guayaquil and extending to Milagro,Naranjito, Duran, Bucay, Aqua Piedra, Yaguachi,and Babahoyo.

Yellow Fever in Mexico and the West Indies.A few cases of yellow fever were reported during

1913 in the province of Yucatan at Merida andMaxcanu. The disease was also epidemic in theprovince of Campeachy, in the town of that name,from May to October, and also in the port ofCarmen in the same province. Some cases were

reported at Puerto, Mexico, in the province of VeraCruz.The only reported occurrences of yellow fever

that have come to our knowledge in the WestIndies were some cases in Trinidad and in

Cuba; on two occasions a ship with infected

persons on board arrived at the port ofHabana. The first instance was in July, when thes.s. Hydra arrived from Manaos with the captainill, reporting also that four passengers had diedfrom yellow fever on the voyage. The secondinstance occurred in August, when the s.s. MorroCastle arrived with a yellow fever case on board-namely, a passenger from the infected town of

Campeachy, who had shipped on board the vessel atthe Mexican port of Progresso in Yucatan.

Small-pox in Europe.An outbreak occurred in Sweden during April

and May at Stockholm, comprising 37 cases, theinfection having been brought from Russia. Asusual, the malady was very prevalent in EuropeanRussia, epidemics being reported in St. Petersburg,Moscow, and Warsaw, and in less degree in Odessa,Batoum, Riga, and Libau. Small-pox often followsin the wake of armies in the field, and this wasobserved in the Balkans. At Constantinople themalady was epidemic during most of the year andalso at Salonica, from which infection was carriedby refugees on ships to the ports of Fiume andTrieste, where the infection spread. The occur-

rence of small-pox was reported in the Austrianprovinces of Galicia, Bohemia, Dalmatia, Moravia,Carinthia, and the Tyrol, as well as in some partsof Hungary. Small-pox was severely epidemic inEastern Servia and other parts of the BalkanPeninsula and in Greece. In Italy cases were

notified in some of the large towns, includingPalermo, Naples, Turin, and Rome. There weresome serious epidemics in Spain, especially inBarcelona and Madrid, and in less amount in Cadiz,Almeria, Seville, Valencia, and Cordova. At Lisbon123 cases were notified up to September, and a fewinstances were observed at Gibraltar and in Malta.In Switzerland small-pox appeared in several

cantons, including Argau, Lucerne, Ziirich, Basle,Grisons, Vaud, and St. Gall. In Germany 84 cases

1648

were notified up to September, 35 being foreigners,mostly Russians. Berlin, Hamburg, Bremen, Breslau,Kehl, and Strasburg furnished most of the cases.In Luxemburg a few instances came under observa-tion, and at Losser, in Holland, an outbreak com-prising 34 cases was observed. During the firsthalf of 1913 there were 81 notifications of small-

pox in Belgium. It is difficult to get preciseinformation as to this disease in France, but it isknown that a fatal outbreak occurred in Marseilles,and that cases were reported in Paris, Nice, Nantes,Limoges, and Toulon.

Small-pox in Africa.In Egypt more than 2000 cases were recorded up

to October, 91 of them being referred to Alexandriaand 89 to Cairo. Outbreaks were reported in

Algeria, at Constantine and Oran. In South Africathe presence of the disease was noted at Durbanand Johannesburg as well as in other places; andoutbreaks occurred in Zanzibar and in British EastAfrica. Small-pox was epidemic in Somaliland andalso in Abyssinia at the end of 1912, but no informa-tion concerning its occurrence in 1913 has beenreceived as regards either of these countries. Asevere epidemic occurred in Mauritius, comprisingmore than 1000 cases, but not of a very severe type.

Smallpox in America.

Small-pox was epidemic in various parts of theUnited States in a mild form, and some townsalso suffered, including New York, Chicago, andBaltimore. In Canada the same mild type wasnoted, outbreaks occurring in various provinces,including British Columbia, Manitoba, Ontario,Quebec, and Nova Scotia. Cases were also reportedin Newfoundland. In Mexico small-pox was widelyepidemic, and its diffusion was no doubt facilitatedby the movements of the Federal and revolutionaryarmies in the field, infection being at times carriedby refugees across the Mexican frontier to Texasand other places in the United States; more than700 cases were noted in Mexico City. Cases of

small-pox were reported in Honduras and CostaRica. In Peru epidemics occurred in Ancon, Callao,Chancay, Huaco, and Lima; and in Chili at

Santiago, Valparaiso, and Iquique, as well as else-where. In Argentina the presence of small-poxwas recorded at Buenos Aires, and a few cases werereported in Uruguay at Montevideo. Brazil fre-

quently suffers from outbreaks of small-pox, and in1913 the disease was epidemic in Rio de Janeiro(355 cases up to September) and in Pernambuco,where 367 deaths were registered in nine monthsfrom the disease; also at Para, Bahia, and Manaos.In the West Indies scattered cases were certifiedin Barbados, Grenada, and Trinidad.

Small-pox in Asia.

During the first half of 1913 upwards of 75,000deaths from small-pox were registered in India, thePunjab being the province that suffered most.Prevalences of the disease were reported in thecities of Bombay, Madras, and Calcutta, as well asat Karachi, Rangoon, and Moulmein. Cases occurredin the Straits Settlements, Siam, Indo-China, andthe Dutch East Indies, a severe epidemic beingexperienced in Java. Small-pox was widely pre-valent in China in the Eastern and Northern pro-vinces, where little or nothing was done to checkthe spread of the infection. Outbreaks were

observed in Hong-Kong, Amoy, Hankow, Nanking,Shanghai, and Chungking. Several ports and cities

in Japan were invaded, including Nagasaki, Yoko-hama, Kobe, Tokio, and Osaka. The presence ofthe disease was reported at Vladivostok and else-where in the Russian Maritime Province. In AsiaMinor small-pox was epidemic in Beirut, Smyrnaand Mersina ; and minor prevalences were observedin Adana, Damascus, Tarsus, and Trebizond. Therewas a limited outbreak in Arabia at Aden.

Small-pox in Oceania.There was a small-pox epidemic of considerable

proportions in New South Wales at Sydney, whereover 1000 persons were attacked ; but the type wasof the same mild character as that observed inNorth America, and this may be accounted for bythe fact that the infection was introduced fromVancouver. Cases were also notified in SouthAustralia, Victoria, and Queensland, while over 100cases occurred in New Zealand. The presence of

small-pox in the Hawaiian Islands during the yearwas reported. The infection was imported by shipinto Samoa from Hong-Kong, but the resulting out-break did not assume any formidable dimensions.

PUBLIC HEALTH.

In noting, under the headings below, some of theoutstanding features of the year to be included in asection on "Public Health," we are again forced toreflect on the continued expansion of the subjectswhich come before those who take part in publichealth and sanitary administration in this country.The present year has given abundant evidence ofthis tendency; it has witnessed such new activitieson the part of the State as the general introductionof the local

"

tuberculosis officer," the passingthrough Parliament of the Mental Deficiency Act,the decision to make Exchequer contributions forgeneral school medical service, the foundation ofa new organisation to spend nearly JE60,000 a yearon medical research, and the appointment of a

Royal Commission to advise as to public action forthe repression of venereal diseases; while theInternational Medical Congress itself conspicuouslyillustrated the growing demand which medicalscience considers right to make for increased publicaction in connexion with disease investigation andprevention. Following the practice of previousannual summaries, we have left to a separatesection the question of exotic and tropical diseases,in the control of which public health administra-tion based on modern research has produced suchstriking results in recent years.

Acute Infectious Diseases.The United Kingdom has been free during the

year from any visitation of cholera or plague, saveperhaps for an occasional case occurring at sea

which has been dealt with at the port of arrival.The issue by the Local Government Board of thesecond annual return of the chief notifiable infec-tious diseases for the whole of England and Wales,together with available statistics of mortality, hasenabled stock to be taken of the general prevalenceof the acute infectious diseases during 1911 and1912 with satisfactory results, which appear tohave continued during 1913. Scarlet fever con-tinues to have a high rate of prevalence, and in thelast few months has been conspicuously epidemicin London, Birmingham, Manchester, and other

large provincial cities, but its type remainsmild, in marked contrast to that with which

physicians were familiar 20 or 30 years ago.Reports which have reached us from medical