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672 the protection. In general, temporary moist dressings are preferable to powders or ointments. True generalised vaccinia practically never occurs, though morbilliform or erytliematous eruptions are common about the time of the maximum reaction. They disappear without treatment. Times of Vaccination and Duration of Immunity. Vaccination of infants, says Dr. Leake, is attended with less general reaction and fewer complications than vaccination of older children. It is, therefore. best done as soon after birth as practicable. preferably before teething. There are four advantages to be gained by early vaccination : (1) the ’’ take " is apt to be mild; (2) it tends to make the secondary vaccination, required at school age, a much less serious affair than if the school vaccination were primary ; (3) protection against small-pox is gained for the pre-school years ; (4) the scar of an infantile vaccination fades more completely than scars of primary vaccinations performed later. The immunity afforded is lost by different individuals at different rates. Some need to be vac- cinated more often than once in live years to maintain full protection ; others may be vaccinated less frequently than once in 20 years and still maintain high immunity. A primary vaccination with one successful revaccination, or even a single successful vaccination, will, as a rule, protect throughout life from the milder forms of small-pox, but this is far from being true in the severer outbreaks. Second attacks of sniall-pox are rare, but do occur. If there is danger of exposure to a severe form of small-pox, all persons who have not been vaccinated within one year successfully—that is, with vaccine known to be of full potency-should be vaccinated. Successful vaccination performed on the day of exposure to infection will almost always give complete protection against small-pox, and vaccination up to a few days before the onset at least makes the attack milder than it would otherwise have been. Vaccination during the few days before onset will allow the vaccination and small-pox eruption to develop simultaneously without either influencing the other. Epidemiology. In conclusion, Dr. Leake points out that outbreaks of small-pox occur of all grades of severity, some with a mortality of 70 per cent. among those attacked and some with a mortality of 0-01 per cent. " Since 1896 a mild form has been increasingly prevalent in the United States and countries in communication with the United States, having a fatality of about 0’1 per cent. among the unvaccinated. The strains of the disease present just previously had been much more severe, and from time to time outbreaks are now occurring with a fatality-rate of about 30 per cent. in the unvaccinated. Each of these strains in general breeds true to its respective type, and mild cases contracted from severe give rise in turn to severe nd fatal cases. There is no deiinite grade of severity or of fatality that we can consider characteristic of small-pox, and it is probable that almost all of the epidemics called " alastrim," &c., have been mild forms of small-pox. All forms of small-pox inxxnunise against each other and all may be prevented by the same vaccination. Exposure to a severe form is much more likely to give rise to infection than exposure to a mild form, and it takes a higher grade of vaccinal immunity (more recent vaccination) to protect against a severe strain than against a mild strain. In moderately well-vaccinated communities, such as Germany, epidemics of mild type are entirely prevented, and outbreaks of severe type much diminished. On the other hand, in poorly vaccinated communities, where isolation is nevertheless practised, such as England and the greater part of the United States, mild strains spread more diifusely than severe because they are not taken so seriously by those attacked nor by the public at large, and because the attack is not severe enough to keep the patient in bed and isolated. The mildness of the form of small-pox commonest at present is one reason for endeavouring to make preventive vaccina- tion as harmless and as mild as possible." Dr. Leake closes a valuable summary by pointing out that epidemics cannot be stopped by isolation without vaccination. Public Health Services. MENTAL HOSPITAL REPORTS. REPORTS of work done last year in Scottish Mental Hospitals are reaching us with commendable promptitude. The Royal Edinburgh Hospital, Morningside, is always in the van of progress, and its 867 patients have every possible opportunity of recovery. The great majority of them are on a voluntary basis. and the medical superintendent voices his protest at the ridiculuus law which makes it a misdemeanour to treat voluntary patients in rate-aided institutions. " Strange as it may seem," he remarks, " the existing Lunacy Laws... seem to have been devised with the perverse object of obstructing anyone desiring to obtain medical relief.... No one can be admitted to a public mental hospital until his disease ha. become thoroughly established or his conduct has become a public nuisance or a scandal. Even then he is not permitted ’to receive treatment till his application for admission has been dealt with after the manner of the detention of a criminal." All concerned in this work will agree with his dictum that " such a method of treating a sick person and of handling a question of public health is cruel and an abomination to anyone inspired by medical sentiments and ideals." An outstanding event of the year at torningside was the opening of a country nursing home for patients with nervous ailments. For the poorer patients the managers have converted a block into a psychopathic hospital fur 50 people ; this is almost ready for use. Very shortly the building of a new out-patient wing will be commenced ; here it is hoped to hold a free daily psychiatrical clinic. The mental out-patient clinic at the Royal Infirmary has been attended by 180 patients since it was opened 12 months ago, and is doing inestimable work in the homes of its patients as well as within the infirmary building. The occupational therapy department continues to perform invaluable services, while the cinematograph and wireless often excite interest in apparently hopeless cases. The Glengall Hospital at Ayr houses 600 patients,. and showed a recovery-rate for 1926 of 36 per cent. men and 40 per cent. women, with a death-rate of 14 per cent. The most notable feature among the new admissions was the improved standard of general health-the best ever recorded—while the proportion of senile cases dropped from 20 per cent. to 7 per cent. The death-rate from general paralysis of the insane was remarkably high-45 per cent. men and 9 per cent. women. The medical superintendent ascribes the record increase to greater sexual incontinence following over-reliance on antisyphilitic treatment and the use of contraceptives. There were only two’ deaths each from cancer and tuberculosis. Apart from mild epidemics of measles and gastro-intestinal catarrh, the general health of the community was good. A number of patients had parole within and beyond the grounds. Five nurses and four attendants. obtained their M.P.A. certificate during the year. The Stirling District Mental Hospital had a slight. increase in the number of inmates (850) during the year ending May, 1926. The board is also responsible for 102 boarded-out cases, 144 mental defectives, and 82 patients in Poor-law institutions. Twelve voluntary patients were admitted during the year, and eight of them were rate-supported. There was a recovery- rate of 39’3 per cent. and a death-rate of 11’7 per cent. Twelve of the fatal cases were general paralytics. Twenty-one patients were sent out on trial and all were able to stay at home. There were no epidemics. The new reception hospital is in use for recent cases ; operating and dental rooms have been equipped, and apparatus installed for X ray, high frequency,.
