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length of service of officers invalided has increased from twoyears in 1903 to three years and a third in 1911.

Reference to the charts of the invaliding and death-rateshere reproduced demonstrates in a very striking manner thelarge decline which has been effected in both rates duringthe last nine years. It will be seen that in 1904 the

invaliding rate was as high as 63 per 1000, and this wasfollowed the next year by a death-rate of over 28 per 1000.There was then a decline in both rates until 1908, followedby a rise in the invaliding rate of 1909 to just over 48 per1000, while in the ensuing year, 1910, the death-rate rosefrom 17-3 per 1000 to 20-4, after which, in 1911, theinvaliding rate has declined to 25- 2, and the death-rate to 13 9 per 1000.These latter figures are the lowest that have hitherto

obtained in British West Africa. Previous statistics, cover-ing the period of 17 years-from 1881 to 1897 inclusive-show that 554 European officials employed in the Gold Coastproduced a death-rate of 75- 8 per 1000 per annum ; and of258 employed in Lagos the death-rate was 53- 6 per 1000per annum, figures which justified the sad reputation of WestAfrica as the " white man’s grave."

Resnlts of Discoveries drL l’ropacal Hygiene.The wonderful improvement that has been effected since

this time must be ascribed to the practical application of themodern discoveries of tropical medicine and hygiene. It is

unnecessary here to enlarge on the enormous value of thework which has proved the connexion between, for instance,malaria and the anopheles mosquito, yellow fever and thestegomyia, and plague and the rat; but it is through suchmeans that many places in West Africa which were formerlyliterally death-traps are now being rendered, to say the leastof it, habitable. Credit for the application of the recognisedprinciples of tropical medicine and sanitation is due to theColonial Office and to the local administrations of thesecolonies and protectorates who have consistently authorisedand approved expenditure on sanitation-such as the drainingof marshes, I I anti-mosquito campaigns, the demolition ofinsanitary areas, the reconstruction of native towns andstations, and the control of water-supplies, &c., with theintention of improving the conditions of life, not only fornon-official and official Europeans, but for the African nativesalso.

No similar statistics are published concerning the in-

validing and death-rates of non-official Europeans, including,for instance, merchants, miners, and missionaries ; but astudy of the Annual Medical Reports of the Colonies showsthat the fall in these rates, although present, is less markedthan in the case of officials. That this is unfortunately thecase is due to circumstances over which the Government haslittle or no control. For instance, a reasonable segregationfrom collections of native inhabitants can be obtained for the

dwellings of officials, whereas the trader commonly residesand sleeps over his store, more or less surrounded by natives,while the missionary also remains in constant touch with hisflock. It is an undoubted fact that this absence of segrega-tion is an important factor in the illnesses and mortality ofsuch non-officials and, with the increasing importance anddevelopment of West African industries, such as gold-mining,tin-mining, and the cultivation and export of palm-oil, rubber,cocoa, &c., it cannot be too strongly impressed on Africanmerchants and firms who send their representatives to liveI I on the Coast" that it is their duty, as well as to theiradvantage, to do all in their power to ensure at least thattheir employes shall sleep in buildings outside the nativetowns.

Trest African Medical Staff.It may, I think, be fairly claimed that some credit for the

improvement I have described is due to the service to whichI have the honour to belong-The West African MedicalStaff. This service was formed in 1902 by the amalgamationof the medical departments of the various West Africanadministrations, and then consisted of about 110 men. In1908 a Departmental Committee was appointed by theSecretary of State for the Colonies to consider the organisa-tion, &c., of the staff and, following the Committee’s report,several far-reaching improvements and changes were intro-duced. Not the least of these were the formation of a

distinct sanitary branch of the staff in West Africa and theinstitution of an advisory medical and sanitary committee forTropical Africa at the Colonial Office. To the sanitary

department is entrusted, under the principal medical officerof each colony, the important work of dealing with epidemicand endemic disease from the point of view of the publichealth, and the prophylaxis of the same. Its duties arenumerous and onerous, and its formation has been justifiedin many ways, particularly in its prompt dealing with theoutbreaks of yellow fever which occurred in 1910 and 1911.

, At the present time the total number of officers in the-West African Medical Staff exceeds 200, the increase beingnecessitated by the formation of new " stations

"

requiredthrough the opening up of the country and the markedcommercial activity which prevails, and, as far as possible,all new recruits undergo a training in tropical medicineat either the London or Liverpool Schools before leavingEngland for West Africa.

It is obvious that much has already been accomplished in.the improvement of health conditions on the West Coast byintelligent and steady efforts ; that much, however, remainsto be done is well recognised, and there can be no doubtthat the policy which has produced the results I have-referred to will be continued in the future.

ANNUAL REPORT FOR 1910 OF THEMEDICAL OFFICER OF HEALTH

OF THE ADMINISTRATIVECOUNTY OF LONDON.

11.1

A CONSTANT feature in the county medical officer’s reportsof recent years has been the prominence given to investiga-tions by members of his staff concerning the origin and mod&of propagation of enteric fever, with especial reference to,infection by certain articles of food.

Enteric lever in 1910.

Although in the metropolis generally the incidence of this.disease was not excessive in the year under notice, it i&

reported to have been abnormally prevalent in certain of theeastern districts, especially among the very poor. It is

interesting to note that of the total cases reported not lessthan 16 per cent. were imported from outside districts. Thatthe diagnosis of enteric fever in the homes of the labouring-classes is not always easy will appear from the circumstance-that of the cases certified as enteric and admitted to the hos-

pitals of the Metropolitan Asylums Board a considerable pro-portion are found to be suffering from other diseases. In the

year 1909 the errors in diagnosis amounted to 37.9 per cent.of the admissions.

Outbreak of Enteric Fever in Bethnal Green.

Having regard to an abnormal prevalence of this diseasein Bethnal Green, and to a less extent in Stepney and Poplarduring the autumn of 1910, a special investigation of thecircumstances was made by Dr. W. H. Hamer. As the inquiryproceeded it became manifest that the outbreak involved a.

larger area than was at first suspected, several localisedprevalences, coincident in time, having been observed inShoreditch, Islington, Holborn, Finchley, and St. Pancras,and even at Edmonton, which is outside the metropolitanarea. Altogether the inquiry extended to some 300 casesoccurring within the space of two months, at least two-thirdsof which were apparently attributable to some special cause.The outbreak was explosive in character, the dates of onsetof the several attacks suggesting that infection had been con-tracted almost simultaneously. Few of the cases were

secondary, and there appeared to be absolute absence ofintercourse or association among the sufferers in the severalinvaded houses. Examination of the ordinary sources ofinfection resulted in the elimination of the water and milk-supplies as possible causes of infection. Either fried fish orshell-fish, such as cockles and mussels, appears to have beengenerally regarded as responsible for the epidemic ; and, asregards the Bethnal Green area, fried fish alone is statedto have been the infecting medium, every one of the 50persons attacked having been known to be eaters of thatfood. It is instructive to note that the kind of fish impli-cated was plaice (including in this term flounders and dabs),

1 Previous notices of this report appeared in THE LANCET, April 20th.1912, p. 1068, and May 4th, p. 1218.

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Imperfect cleansing of the fish is believed to have beenan important factor in communicating infection to theconsumers.

Cerebrn-spinal Fever.In the course of the year under notice 115 persons (of

whom 10 died) were certified to be suffering from cerebro-spinal fever. This was not included among notifiablediseases in London until March, 1907, but in the remainderof that year 135 cases were notified, or more by 50 than thetotal reported in the whole of the following 12 months. Re-

specting all the cases notified careful investigation was madeby Mr. W. M. Wanklyn, "who could discover nothing thatthrew light on the causation of the disease." In no singleinstance was any one case found to be connected with anyother. It appears, further, that of the cases originallycertified, in only 40 did the final diagnosis agree with thatoriginally made ; that of these 40 no bacteriological or post-mortem examination was made in 12 cases, and that inanother 13 cases the disease was specified as post-basicmeningitis, which is regarded as a subacute form of cerebro-spinal fever. Mr. Wanklyn concludes that out of a total of115 only 15 cases remain in which the acute form as

originally diagnosed was confirmed bacteriologically.

Puerperal Fever. iBy the passing of the Midwives Act of 1902 the diseases I,

peculiar to the puerperal state became for the first itime really amenable to preventive measures. Under ISection I. of that Act, which came into force in 1910, nonebut certified women can practise midwifery habitually forgain except under the direction of a qualified practitionerof medicine. In 1910 the number of midwives whose namesappear on the London register was 3526, but of these onlyabout 420, or 13 per cent., were in actual practice ; theremaining 87 per cent. acted for the most part as

monthly or general nurses under medical supervision.Of the practising midwives, 53 were working entirely within Poor-law institutions or in lying-in hospitals -of course, under medical direction. 169 others were

attending patients on behalf of charitable institutions,receiving either a regular salary or else a fee for eachcase allotted to them. The remainder were practisingindependently.The arrangements for supervising the work of midwives

in London appear to be very complete, two lady medicalinspectors, Miss E. Macrory, M.B., and Miss M. A.

Pilliet, M.B., having been appointed by the County Councilfor the purpose. All practising midwives, except those actingin hospitals under medical direction, are subject to supervisionby the Council’s medical inspectors, in order to secure com-pliance with the rules of the Central Midwives Board as tocleanliness, the right use of disinfectants, the keeping of

registers, and the sending of notices to the local supervisingauthority. In the event of a case of septic nature, or of

persistent high temperature occurring in a puerperal patient,or in case of inflammation of the infant’s eyes, a special visitis paid to the midwife in charge by one of the lady medicalinspectors, who is always available for instruction of themidwives in matters of difficulty or of uncertainty.Occasionally the medical inspector accompanies a midwifeeither to a confinement or on a subsequent visit in order toascertain whether the midwife’s work is efficient. In thecourse of the year under notice 1571 visits to midwives werepaid by the lady medical inspectors.The notified cases of puerperal fever numbered 292 in the

year under notice, and were slightly more than those notifiedin the preceding year. The term puerperal fever has beenexpunged from the nomenclature of the Royal College of

Physicians, and as a substitute the preferable term" puer-peral septic disease " is now used by the Registrar-General toinclude puerperal septicaemia, pygemia, and sapraemia, as wellas peritonitis and metritis occurring in connexion with partu-rition. Of the 292 notified cases, 102 proved fatal, a casemortality of 35 per cent. In addition to the deaths frompuerperal septic diseases, 148 deaths from accidents of child-birth are recorded by the Registrar-General as occurring inLondon during 1910. Among these are included cases ofeclampsia, pulmonary embolism, puerperal mania, andpneumonia occurring after confinement. We presume, how-ever, that for preventive purposes all cases in the group lastmentioned will be investigated with the same care as are cases

definitely referred to puerperal fever, although the Registrar-General may still classify them separately.

Ophthalmia Neonatorum.Under the provisions of the Midwives Act the means are

now for the first time available to a sanitary authority fordealing at their source with the troubles which in past yearshave caused much serious impairment or loss of eyesight tothe labouring classes. Sir Shirley Murphy lays great stresson the necessity for prompt medical treatment on the occur-rence of inflammation of the eyes, however slight. In allcases where such help is requested by a midwife one of theCouncil’s lady inspectors at once visits the infant in order tosecure that timely medical treatment shall be supplied.During the year under notice 160 requisitions for medical aidwere received from London midwives on account of inflam-mation of the eyes of infants. In 141 of these cases theresulting treatment was completely effectual, and in themajority of the remaining cases partial recovery took placewith more or less opacity of the cornea.

Malignant Disease.

Although the mortality from cancer in its various formswas slightly lower in 1910 than in the year immediatelypreceding, it still considerably exceeded the average inrecent previous years. In the present as in previous reportsthe attempt has been made to ascertain the existence of anyrelation between the incidence of cancer and the socialcondition of the patients, whether the latter be measured bythe degree of overcrowding or by the percentage of childrenscheduled for compulsory education. For this purpose the

metropolitan boroughs are arranged in five groups, and thedeath-rates from malignant disease in each group have beencorrected as completely as possible. The result shows thatneither in the year under notice nor in past years can anyrelation of the kind suggested be discovered. In this respectthe behaviour of malignant disease differs entirely from thatof pulmonary tuberculosis, the mortality from which hasrepeatedly been shown to depend largely on the relativestate of nutrition or on the poverty of the persons affected.

Infantile Mortality.Measured by the proportion of deaths under one year to

registered births, infantile mortality in 1910 was equal to103 per 1000, a rate which is lower than in any previousyear on record. Graphic representation of the behaviour-of infantile mortality in the last half-century is givenin a valuable diagram which shows the mortality ineach successive year in relation to the mean rate of the

period 1858-1910. In the five years 1905-09 infant mortalitywas lower in London than in any other large Englishtown except Bristol. Compared with foreign and colonialcities, London infantile mortality was lower than in

any other city except Paris, Amsterdam, and Stockholm.An instructive table is inserted which shows the numberof survivors at the beginning of each month in the firstyear of life, and the probability of living for one month fromthe commencement of each month of the first year, out of100,000 infants born in 1910. In another table the prob--ability is shown of living one month from the beginning ofeach month of life in the last six years of the decade endedin 1910. Worthy of attentive study are the increasingprobabilities of living obtaining in the later years includedin this table. In order to illustrate the effect of what istermed "social condition" on the rates of mortality atdifferent periods of the first year of life another table isinserted, by which the infantile mortality in each of fivegroups of districts can be compared. The standard adoptedfor determining the " social condition " of borough.populations is the percentage of children between the

ages of 5 and 14 that are scheduled by the councilfor education purposes. With this object the metropolis hasbeen divided out into five groups of different grades of socialcondition. In the boroughs comprising Group I. less than82 per cent., and in those comprising Group V. more than97 per cent. of the children are thus scheduled. Markeddifferences in the mortality among infants under 1 year ofage are shown to exist when the best and worst groups ofdistricts are contrasted. In compliance with the orders ofthe Local Government Board the reports of the Londondistrict medical officers contain tables showing the mortalityfrom certain specified causes at different periods of the first

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year of life. At present the numbers tabulated are com-paratively small, but when similar returns are available for aconsiderable series of years the results will be extremelyvaluable for preventive purposes. Even already the steadydecline in tuberculosis mortality among infants shown in thestatistics for the last quinquennium are highly encouraging.

REPORT OF THE SANITARY COMMIS-SIONER WITH THE GOVERNMENT

OF INDIA FOR 1910.

THIS report, the first to appear over the signature ofDirector-General Sir C. P. Lukis, I.M.S., follows in the mainthe arrangement adopted by previous Sanitary Commissioners,with the exception that the initial section on meteorology isomitted. The most important statistical matter is, however,retained in an appendix, and the chief points of climaticinterest are referred to in the section on the health of the

general population.health of the European Army in India.

The average strength of European troops in India

(excluding officers) during 1910 was 72,491. Of this force,576.5 per 1000 were admitted to hospital ; 31-9 per 1000were on an average constantly sick in hospital, 4’ 66 per 1000died, and 7’77 per 1000 were invalided home. All theseratios were considerably below those for the previous year,which were the lowest that had ever been recorded before.The immense improvement that has taken place in the healthof the troops within recent years is evidently not a temporaryphenomenon; it has "come to stay." Every disease of

importance has shared in this decrease, except tubercle ofthe lungs and respiratory affections. The chief cause ofdeath is still enteric fever ; but this amounted to little morethan one-third of the mortality of the previous year, and lessthan a quarter of that of the quinquennial average for1905-09. An important result of this marked improvementin health and lessening of the rates of invaliding andmortality has been that the number of men yearly broughtout to India has been reduced, and as it is these new arrivalswho are the youngest soldiers and most susceptible to disease,the reduction in their number reacts favourably on the ratesof mortality, sickness, and invaliding.

The forces in India are divided into a Northern and aSouthern Army. The former, with a strength of 38,006 men,has divisions at Peshawar, Rawal Pindi, Lahore, Meerut, andLucknow, with three brigades on the Afghan frontier ; thelatter (32,327) has divisions at Quetta, Mhow, Poona,Secunderabad, and in Burma, with a brigade at Aden. Therehas always been a difference in the health statistics of thesetwo armies, but this year it was less noticeable than usual,the northern force having had an admission rate of 616 and adeath-rate of 5 per 1000, while in the Southern Army thecorresponding figures were 542 and 4° 21. In the formermalaria (158 6 per 1000), venereal disease (54’ 4), and pyrexiaof uncertain origin (43’ 4) caused the greatest number ofadmissions to hospital ; in the latter the same three diseaseswere the most important, but malaria (105-7) and uncertainpyrexia (30’ 4) were much less frequent, and venerealdisease (64’7) somewhat more so than in the northern force.Enteric fever caused 0 58 deaths per 1000 in the Northernand 0 - 74 in the Southern Army.On comparing different parts of India in regard to the

total amount of sickness-that is, the greatest number of menconstantly sick in hospital-we find that this was as highas 44’1 per 1000 on the Western Coast (Colaba, Calicut,&c.), while in Bengal and Orissa it was only 24’ 5 and in theDeccan 29 - 4 per 1000. The admission. rate was highest inthe North-West Frontier, Indus Valley, and North-WestRajputana group of stations (913-1), and lowest in Bengaland Orissa (388.5). The individual stations that have beenmost conspicuous for sickness have been Delhi, with anadmission ratio of 1420 per 1000 and 51’ 8 constantly sick, andPeshawar, with 1367 admissions per 1000 and 38 constantlysick. Attock, Muttra, Agra, and Nowgong also had admis-sion ratios of over 1000 per 1000 strength. On the other hand,Secunderabad had the lowest admission rate (262), also thelowest number constantly sick (20’5), while Rangoon, FortWilliam, Barrackpore, and Belgaum bad less than 4UO per1000 admissions to hospital. Practically all the important

unhealthy stations are in Northern India, and nearly all thehealthy ones of any considerable size are in the SouthernCommand.

Prinoipal Diseases.Malaria is by far the most common cause of sickness

amongst the troops, and is likely to retain this position inspite of all that has been done to remove the conditions thatbring it about; 23 per cent. of the admissions to hospitalwere due to this cause. In addition, 6- 54 per cent. ofadmissions were for pyrexia of uncertain origin and 1 - 23 percent. for sandfly fever, a heading which appears in the

present report for the first time. The total admissions forthese three affections were 132, 37-7, and 7.1 per 1000respectively. Malaria prevailed especially at Delhi, wherethe cases numbered 712 per 1000, Peshawar (652), andAgra (535). The year was not, however, a bad one formalaria on the whole, though Peshawar suffered more

than last year from this cause. It is noted that inPeshawar and Agra the rainfall was considerably inexcess of the average, and to this doubtless the prevalenceof fever was due. Antimalarial measures are being vigor.ously carried out in all stations affected. Those directed

against the parasite in the human host include the searchfor and discovery, the segregation under mosquito curtainsin separate wards or tents, and the quinine treatment, of allsoldiers, whether suffering from fever or not, who harbourparasites in their blood ; a six weeks to four months courseof after-treatment ; and the administration of quinine twicea week as a prophylactic to all soldiers in a malariousstation. The transfer of convalescent malaria cases to thehills also appeared to lessen the risk of spread. The dosageof quinine varied: in Delhi, 10 grains were given on twoconsecutive days of the week from May lst to Sept. 18th;then 5 grains daily in addition until Nov. 23rd ; then 10 grainstwice a week until Dec. 16th. The practice generallyfollowed was 10 grains twice a week in solution with a littlemagnesium sulphate from June or July to the end of November.It would seem that, now that quinine administration is beingcarried out on a large scale, some definite results might bearrived at as to the best dosage, by careful comparativeobservations under (practically) precisely similar conditions,company by company, or barrack compared with barrack. Aconsiderable proportion of the soldiers use mosquito curtains,either at their own expense or provided from regimentalfunds. Antilarval operations have been systematicallycarried out in nearly every cantonment in the plains, amosquito brigade supervised by a medical officer dealing withbreeding places section by section. The work of Major F.Smith, D.S.O., R.A.M.C., sanitary officer for the RawalPindi Division, is specially alluded to. This officer collected12 different species of anophelines and four culicines, two ofthese mosquitos being new species. He does not, however,speak hopefully of the results of antilarval operations so far.Captain A. B. Smallman, R.A.M.C., and Lieutenant-ColonelA. Buchanan, I.M.S., have also made quantitative estima-tions of the parasite in the peripheral blood at Quetta andNagpur respectively.

Uncertain pyrexia was much less prevalent than inthe year 1909 ; some of these cases were probablyphlebotomus fever and some paratyphoid. Sandfly fever

(pappatasi or phlebotomus fever) is now given a sepa-rate heading, but cases were returned as such at onlyten stations, and chiefly at Peshawar and Attock. The

Sanitary Commissioner states that "it appears doubtful ifits great importance as a cause of sickness among Europeantroops in India has yet been widely realised." Accord-ingly, a full description is given of the disease and of thecharacters of the various flies in India that are popularlycalled "sandflies," with particulars as to the identifica-tion of P. pappatasi, and the preventive measures

necessary.Venereal diseases come second in order of frequency in

causing sickness, with an admission ratio of 58.9 per 1000,compared with 67’8 in 1909, 100 in the quinquennium1905-09, and 273 in 1897-1906. This remarkable reductionis due to "earnest cooperative effort, not only betweencombatant and medical officers, chaplains, the authoritiesof the Royal Army Temperance Association and other civilianofficials, but between all these and the men themselves."There is, as usual, greater prevalence in the Southern Army,especially in the Secunderabad and Burma Divisions. The

system of continuous treatment is found to be most effective