636

personal interest in the supervision of the con-

struction of the launch by Messrs. Burn and Co.,Howrah ; to Major F. Norman White, I.M.S., foregpert advice; and to Major E. D. W. Greig, C.LE.,I.M.S., for the trouble taken in equipping the

laboratory with everything necessary for medicalresearch. The launch recently left Calcutta en

route for Bombay, where it will be handed overto the military authorities for transmission to thefront. It will be in charge of Major S. R. Christo-phers, C.I.E., I.M.S., the director of the CentralResearch Institute, Kasauli, whose services havebeen placed at the disposal of the general officercommanding, and who has been selected as DeputyAssistant Director Medical Services (Sanitary) onthe lines of communication in Mesopotamia.

The Cocaine Habit.The Commissioner of Police, Calcutta, in a recent

order to all police officers, states that cocaine caseswhich are sent up for trial by the police are mostlyinstances of seizures made by chance or on suspicionby officers on night rounds. Street hawkers areoccasionally captured, and now and then a den israided and consumers are arrested in large numbers.What is required is a special effort for the arrestand conviction of the large smugglers who financethe business and own large stocks. The ExciseDeputy Commissioner states that special rewardswill be given to officers who secure adequatepunishment for an offender of this class. As theTIne is, as a rule, easily paid out of profits, it is.advisable, he states, to press the examining magis-trate to impose imprisonment instead of a fine.A conference attended by representatives of theExcise Departments of Delhi, the Punjab, and theUnited Provinces was recently held at Delhi todiscuss inter-provincial measures for the preventionof cocaine smuggling.

Feb. 14th.

REPORT OF THE MEDICAL OFFICER OFTHE LOCAL GOVERNMENT

BOARD FOR 1914-15.

THIS report has just been published as a supplement to theforty-fourth annual report of the Local Government Board.Under the stress of war conditions its length has been greatlycurtailed, and in other respects its character has beenmodified as compared with its predecessors. Dr. Arthur

Newsholme, medical officer of the Board, announces that thework of the Medical Department now centres almost entirelyaround the military position ; accordingly the account ofwork undertaken in this connexion occupies a prominentplace in his report.

Between the civil and military medical staffs there for-tunately prevails complete harmony and collaboration, theadvantage of which to both services is abundantly manifest.In August, 1914, official instructions were addressed fromWhitehall to the medical officers of health throughout thecountry to cooperate with the military medical staffs ofthe several camps, offering such assistance as their localknowledge enabled them to afford. The general super-- vision of the work was entrusted to the Board’s medicalstaff, many of whom were detached for this specialservice. Their duties, in concert with the army medical-officers, consisted in safeguarding the health of the new

troops, and especially in minimising the risks of infec-tious disease, which are inevitable where large numbers ofmen are massed together under temporary conditions.The medical staffs of both services being in almost dailytouch, it has been practicable to deal effectively with localconditions inimical to health. The high efficiency of theBoard’s action is officially recognised by the Army Council,

1 Wyman and Sons, Fetter-lane. (Cd. 8153 ) Price 6½d.

vho cordially appreciate the assistance which, under centralguidance, the local public health authorities have renderedsince the outbreak of war. The Council declare that assist-ance to have been "invaluable in safeguarding the health ofjhe forces and in preventing the spread of infectious diseaseto an extent which would been otherwise impracticable."Between the Naval Medical Department and the local

sanitary authorities similar cooperation has been established,at the instance of the Admiralty, in so far as the naval

camps, depots, and billets are concerned.From a volume easily obtained we select for comment two

sections which appear conspicuously deserving of attentionin view of existing emergencies. In the first, the generalextension of provision for maternity and child-welfarecentres is ably advocated ; in the second, the recentbehaviour of typhus fever in Europe is portrayed, with

especial reference to its prevalence among our Allies.

Maternity Ceratres and Child TVeljare,Specially noteworthy among matters of war-time import-

ance is an instructive memorandum by Dr. Newsholme onmaternity and child-welfare centres carried out in connexionwith domiciliary health visitation, as an essential part ofnational effort for the protection of infant life. Thismemorandum should be studied in relation to a report by thesame authority on 11 maternal Mortality in Connexion withChild-bearing,"notice of which appeared at p. 1157 of ourissueof Nov. 20th, 1915. Under war pressure Parliament has beeninduced to offer to local authorities, through the NotificationofBirths (Extension) Act, grants in aid of work done by thoseauthorities or by voluntary agencies for the promotion ofmaternity and child-welfare work. In recent years such workhas extended rapidly, partly by voluntary agency and partlyunder statutory authority. Most of the authorities ofsanitary districts with populations of 20,000 have alreadystarted schemes of health visiting, and still smaller autho-rities are, or shortly will be, similarly engaged. Only whenfull advantage is derived by the local authority from theBirths Notification Act can such work be undertaken withfair prospect of success. Thus equipped, the authoritycan provide for the early visitation of every house in whicha birth has occurred, and suitable advice can be rendered bythe health visitor. When a reasonably accessible centre" "

exists, the mother is recommended to resort thither.But, inasmuch as a large part of the population live inremote country districts, long distances have sometimes tobe travelled in order to reach the centre. Consequently,experience shows that only about a quarter of the mothersvisited can be induced to attend. The establishment of acentre is usually the first step taken by a voluntary agency.Much valuable work has been done at voluntary centres bymeans of "infant consultations," the systematic weighingof infants, &c. But complete success cannot be achievedby such agencies unless associated with a complete systemof house visiting as set forth in the report. In all cases it is

necessary that the work of a centre should be directed bythe medical officer of health, whether this is provided by thesanitary authority or by voluntary agency, so that effectivecooperation may be secured between health visiting and thework of the centre.

Training ot health visito?’s.-The Local Government Boardare empowered to contribute half the salaries of healthvisitors ; consequently that authority is entitled to prescribethe qualifications of these officers. Experience shows thatthe most useful qualifications of a health visitor are usuallypossessed (1) by a trained nurse, (2) by a certified midwife,or (3) by a certified female sanitary inspector. Whateverher previous training may have been, the personal charac-teristics of the health visitor are extremely important. Tactand knowledge must be combined, and the best health visitoris one who regards her work as a mission in life, and whosekindliness of disposition commends her to the objects ofher care. It is essential that well-qualified women aloneshould be appointed, and that their remuneration should beadequate.

Antenatal and postnatal work.-The welfare of motherand child cannot properly be considered separately. About40 per cent. of the total deaths of infants occur within amonth of birth, and these are due largely to conditionsdetermined by the mother’s health during gestation. Tosecure medical supervision for the expectant or for the

nursing mother and her child is the main object of thecentre, where facilities should exist for medical consultations

637

and for the giving of hygienic advice. Throughout theperiod of breast-feeding the infant’s welfare depends abso-lutely on the mother’s health, and after this period theinfant’s health is still liable to vary directly with thematernal well-being, which naturally limits the care she canbestow on her offspring. Experience proves the desirabilityof getting into touch with the mother before the birth of herchild, and in order to obtain the best results for both, ofattending to the health of the mother for some time afterconfinement. Hence the work of the centre, as respectsboth mother and child, must be antenatal as well as

postnatal, and the same centre may conveniently beused for both purposes. The work of the centre mustin no case replace the family doctor. On the contrary,as a result of the detection of early symptoms of illness

many additional cases of illness will inevitably comeunder medical care for prompt, and therefore effective,treatment. By the willing coöperation of the localmedical profession the value of a centre will be increased,and accordingly it is desirable that this should be invariablysought. The cost of a centre will, of course, vary withlocal circumstances. The Local Government Board are

authorised to contribute a moiety of the sums spent on theupkeep of a centre when the expenditure is subject to theirapproval. The object of the antenatal work of the centre isto secure the removal of conditions adverse to the health ofthe expectant mother, and to ensure that the confinementhall take place in circumstances favourable to both motherand infant. The success of the postnatal work of the centrewill depend on the efficiency of health visitation under theNotification of Births Act. There is no similar machineryfor securing the olientele for an antenatal centre. Its

success, therefore, will depend mainly on the coöpera-tion of doctors and midwives, and it is hr’ped thatmedical practitioners will encourage their poo’ r patientsto attend the antenatal clinics. In order tl) t all mis-

understanding may be removed it must be an invariablerule that if anything beyond hygienic advice is requiredat the centre the family doctor should be informed,and that no treatment of patients would be under-taken except at his request. For the patients ofmidwives antenatal centres should prove most valuable.Where the authority conducting the centre is also the localsupervising authority for midwives the inspector will be ableto explain to them the advantages thus attainable. Healthvisitors likewise will be in a similar advisory position. It is

only in those cases where the work of the centre is supple-mented by judicious home visiting in order to secure com-pliance with advice tendered that the full advantage of theformer can be. hoped for. Systematic home visitationfrequently leads to improvement in domestic cleanliness andto better preparation for the infant on its arrival. Whenthis is continued after confinement the mother can often bepersuaded to bring her infant for medical supervision at thecentre. Moreover, the value of a centre depends-almostentirely on the character of the medical advice available. Inthe words of the late Professor Budin, the distinguishedfounder of infant consultations, "An infant consultation isworth precisely as much as the presiding physician."

" Thisis even more true of the antenatal work of the centre. Butthe value of the operations of a centre is by no meansexclusively medical. The work of the health visiting staff isimproved by their contact with other workers and with thedoctor. The efforts of the mother are reinforced by thecounsel and help which she receives from the centre. And,incidentally, value attaches to the incentive derived fromseeing other children well cared for. The well-disposedmother will appreciate the fact that others like herself valuethe health and welfare of her child.

Typhu.s Fever and the E1t’J’opean "TVar.This section is from the pen of Dr. R. Bruce Low, a senior

inspector of the Local Government Board. After a carefulperusal, we regard it as presenting an excellent account cfthe past and present distribution of typhus in Europe.When the medical history of the war comes to be compiledthe writer will doubtless express gratitude to Dr. Low for Ione of the soundest pieces of epidemiological work ever con-tributed by the Medical Department at Whitehall. ]

It has been well said that the history of exanthematic 1

typhus is written in those dark pages of the world’s story iwhich tell of the grievous visitations of mankind by war,famine, and misery of every kind." In most civi.lised 1

countries much has been done in recent times to ameliorate-life conditions among the poor, in consequence whereofthere has been a significant decrease in the ravages of thispestilence, which previous to the war had almost disappearedfrom Western Europe. As a result of the present abnormalconditions typhus is again showing signs of attaining epidemic-proportions in Central Europe. Accordingly, the time seemsopportune for a brief account of this malady in the past as com-pared with the present. Moreover, we now learn that typhusis seriously endemic in Poland and Galicia, two of thecountries now involved in military conflict. In view of theshocking lack of personal cleanliness at one time prevailingamong the inmates of prisons and penitentiaries the frequentoccurrence of typhus in gaols and houses of detention i3

easily explained. Nor is it surprising that occasionallywhen prisoners awaiting trial for months together appearedin the dock in their foul and verminous garments typhusinfection was spread by them to gaolers and others, andsometimes even to the judge on the bench. In this waytyphus is believed to have been conveyed largely from townto country villages by tramps and beggars imprisoned forminor offences. It is on record that this pestilence has been<an almost invariable accompaniment of protracted militarycampaigns in the past. In such campaigns facilities for-

personal cleanliness are scarce, and change of clothing isoften unobtainable for weeks or months together, the resultbeing that soldiers become infested with lice. Under thesecircumstances the introduction of an incipient typhus case-may lead to disaster, each patient in turn increasing theopportunity for the specific infection of more body-lice.The modern etiology of typhus, with the discovery that thebody-louse is a vector of the fever virus, is of - specialinterest in this connexion. In the Napoleonic wars " fever,"probably typhus, is said to have caused serious disaster,80,000 French troops having succumbed to it during thememorable retreat from Moscow. In the Crimean campaigntyphus was rife among the British, French, Russian, andTurkish armies. In 1915 typhus appeared in Germany among-the Russian prisoners of war as well as among the civil andmilitary populations. In Austria, apart from Galicia, I500cases were observed during January, 1915, in provinces;which for many years had been exempt from the disease. Inthe same month typhus became epidemic among Turkish,troops in Erzeroum, causing, along with small-pox, at least1000 deaths daily, among whom were those of severalmedical men. At the present time typhus is endemic imseveral European regions, the chief among these being-Galicia and Poland.

Great Britain has in recent years suffered little fromtyphus, although some cases still occur in certain areas inthe North of England, and in Ireland and Scotland. It is.

possible that sporadic cases, due to imported infection, maypass unrecognised, owing to the fact that few of the youngergeneration of medical men are familiar with the disease,many of them having never seen a case. During the 4{>years 1869 to 1913 about 26,000 deaths from this diseaseoccurred in England and Wales, and in the course of thatperiod the incidence of attack is said to have almost steadilydecreased.France and Belgium.-Foci of typhus fever are said still

to exist in certain parts of Brittany, including the Depart-ments of Finistere and Morbihan ; but with these exceptionsthe disease does not seem to thrive in France. After the-

great wars of the First Empire France suffered severely from" fever," prot ably typhus, the armies having brought backinfection from Eastern and Southern Europe. Serious importa-tion of typhus occurred on the return of the French armies-from the Crimea, where they suffered severely. At least.10 per cent. of the troops are said to have been attacked,and half of that number perished. In 1893 about 1000,persons in the North of France appear to have suffered from

typhus fever, about 100 of whom were medical men, sisters-of mercy, or other attendants on the sick. Since that yeartyphus outbreaks have been rare in France, the deaths.recorded having been very few. The disease has now almostdisappeared from that country, as from other parts of WesternEurope. In Belgium there were several outbreaks of fever,probably typhus, in the course of last century, but since?then only sporadic cases have occurred. The disease is.

reported to have been present in Antwerp from 1903 toL906, but it is not certain that the cases occurring weretrue typhus.

638

R1tSsian Empire,-For many years past certain parts ofthis empire have been recognised as endemic centres oftyphus, and from time to time the diseasp. has become

epidemic in one locality or another. Most of Russia’s cam- 1paigns have been attended with outbursts of typhus. In the Crimean War about 100,000 cases were reported at

Sebastopol, and later the disease became seriously prevalentover almost the whole of Southern Russia. From the im-

portant cities of Moscow, Warsaw, Petrograd, and Odessatyphus seems to have been seldom absent for many pastyears. In May, 1914, there was a sharp outbreak at

Taganrog, on the shores of the Sea of Azov. Since theoutbreak of war and the subsequent fighting in Poland

typhus fever has been prevalent at Lodz, the prevalence’extending to the surrounding villages that were occupiedby the Germans. The disease has since been conveyedfrom Poland, presumably by Russian prisoners, to theinternment camps in Germany, and has spread thence to thecivil populations of the surrounding camps. It is probablethat when the records come to be published the period1914-15 will show a large increase of typhus in Russia

generally, especially in the spheres of operation of the greatarmies and in the concentration camps.

Serbia.-In the course of the Balkan campaign Serbiasuffered severely from typhus, which became prevalentamong the troops in 1912. The epidemic was at its heightduring the spring of 1913 More than 100 cases were treatedin the hospital at Belgrade, where the mortality was higherthan in the military camps. Simultaneously with the epi-demic in the army similar prevalence occurred among theTurkish prisoners of war in Serbia. Of 440 cases in onedistrict 370 were Turks and only 70 Serbians. Thedisease was most fatal among the former. Apparently afresh importation to Serbia of a virulent strain of typhusinfection took place after the sanguinary battles of 1914,when about 70,000 Austrian prisoners were interned there.About Christmas of that year the disease broke out among2500 Austrian prisoners interned at Uskub ; up to March,1915, about 1000 of these prisoners had been attacked, manyof whom died. By this time the epidemic was widespreadover Serbia. In the town of Kragujevatz there were in March14,000 typhus cases. From certain towns and villagesthe whole population disappeared, having either fallenvictims to fever or else fled elsewhere for safety. As usualin such epidemics, the medical attendants suffered heavily.Out of 360 Serbian doctors 100 succumbed to the disease.English, French, and American doctors and nurses were alsoattacked, many of them fatally. It is stated that owing tothe pressure of applicants the hospitals became over-

crowded. In one hospital with 1400 patients the staff atfirst consisted of 6 doctors and 12 nurses, but typhus killed3 of the former and 8 of the latter, so that eventually only3 doctors and 4 nurses were available for 1400 patients. Atthe date of the report the number of cases in this epidemichad not been published, but in February, 1915, it was statedthat 500 typhus deaths were occurring daily. In an articlepublished in England last August it was estimated that

during the six months’ duration of the Serbian epidemicabout 80,000 persons were attacked. It is hoped that thecrisis has now been passed, and that this terrible epidemicis dying out. Dr. Low gives interesting and full details oftyphus incidence in several other European and Asiaticcountries, and for those reference must be made to thevolume itself.

THE SERVICES.

ROYAL NAVY MEDICAL SERVICE.THE undermentioned have been entered as Surgeons for

temporary service in His Majesty’s Fleet: W. F. R. Castleand D. J. Max.

Fleet-Surgeon S. Croneen has been placed on the RetiredList with a gratuity.

ARMY MEDICAL SERVICE.Lieutenant-Colonel J. P. Silver to be temporary Colonel

whilst Assistant Director of Medical Services of a Division.Colonel C. E. Nichol, C.M.G., D.S.O., on completion of

four years’ service in his rank, is retained on the ActiveList.

ROYAL ARMY MEDICAL CORPS.G. ’A. Bannatyne to be temporary Lieutenant-Colonel

whilst employed at the Bath War Hospital.

H. &. Powell to be temporary Honorary Lieutenant-Colonelwhilst employed at the Guildford War Hospital.Temporary Honorary Major Sir John Collie to be tem-

porary Honorary Lieutenant-Colonel.T. E. Holmes to be temporary Major whilst employed at

the Bagthorpe War Hospital.Temporary Captain S. Fleming to be temporary Major.B. Hudson to be temporary Honorary Major whilst serving

with No. 2 Red Cross Hospital. Temporary Captain L. Maclagan-Wedderburn relinquishes

his commission.The undermentioned temporary Lieutenants to be tem-

porary Captains : S. D. Fairweather, E. Taunton, J. Caton-Shelmerdine, E. S. Gooddy, G. M. Mayberry, J. Kirton,H. Peters, W. F. Morgan, R. Condy, E. B. Leech,B. Wallace, H. E. Gamlen, E. L. Horsburgh, T. T.Higgins, G. B. Macgregor, T. Lovett, S. C. West-wood, A. Merrin, M. A. Swan, E. S. B. Eames, G. A.Borthwick, H. L. Mann, H. W. Ward, M. J. Mottram, D. F.Shearer, J. F. Steven, D.S.O., A. C. Giles, J. Ferguson,L. H. C. Birkbeck, T. J. S. Moffett, R. C. Matson, E. C.Hardwicke, S. J. Henry, S. W. Coffin, L. G. Brown, P. E.Lones, R. J. McN. Love, P. W. McKeag, A. Paterson, J.McCulloch, F. D. Atkins, J. T. Gunn, J. R. Murray, C. T.Neve, V. J. Woolley, H. G. Oliver, J. J. Crawford, J.McDonnell, J. S. Taylor, R. A. Steven, F. E. R. Laborda, C.McShane, and H. H. Sampson.The undermentioned to be temporary Lieutenants :-E. K.

Williams, J. McHaffie, C. D. Coyle, N. Garrard, L. G.Reynolds, H. Mohan, J. J. Tate, G. L. Pillans, W. L.Paterson, D. J. Bedford, E. L. Hopkins, L. J. O’Donovan,A. F. Wilson-Gunn, W. H. Pearse, J. R. Brown, C. B.Tudehope, A. Traill. M. Moran, L. M. Mayers, A. R.Mitchell, W. 0. Welply, J. A. West, and S. McNaughton.The undermentioned to be temporary Honorary Lieu-

tenants :&mdash;A. W. Adams, N. M. Cummins, W. L. Thomas,L. ap I. Davies, and T. Anwyl-Davies.The undermentioned temporary Lieutenants relinquish

their commissions:&mdash;J. G. S. Macpherson, H. Porter, J. A.Cowie, W. Irving, E. Johnson, A. L. Grant, H. A. Sharman,J. H. J. V. Coats, A. C. Sandston, G. H. F. Graves, W. S.Baird, E. W. H. Cruickshank, L. Pern, A. W. C. Lindsay,C. H. L. Rixon, L. S. Morgan, and W. H. Lambert (onaccount of ill-health).Canadian Army Medical Corps: Majors to be temporary

Lieutenant-Colonels: J. E. Davey and P. G. Goldsmith.Captains to be temporary Majors: L. W. MacNutt, J. G.Hunt, and A. S. Donaldson. Lieutenants to be temporaryCaptains: R. Brault and S. Traynor. Lieutenants to betemporary Lieutenants: R. P. Smith and W. M. McLaren.South African Medical Corps: To be temporary Lieu-

tenant-Colonels : P. G. Stock (Officer of the Permanent De-fence Force), A. B. Ward, G. H. Usmar, and G. R. Thomson.To be temporary Majors: T. L. Sandes, R. N. Pringle, C. M.Murray, R. A. St. Leger, H. C. Baker, E. F. B. Wilson, E.N.Thornton, M. S. Power, J. C. A. Rigby, and M. G. Pearson.To be temporarv Captains: W. L. Gordon, H. R. Lawrence,S. Liebson, J. Grainger, A. G. Forbes, G. J. Joubert, T.Welsh, C. M. N. May, M. B. Lawrie, P. J. Monaghan, I. W.Brebner, E. B. Brooke, R. D. Parker, H. E. H. Oakley,A. R. Friel, W. Thomas, A. S. Wilson, J. Drummond, E. W.Dyer, and G. H. Coke.

SPECIAL RESERVE OF OFFICERS.

Royal Army Medical Corps.Lieutenant (on probation) A. A. Duffus resigns his

commission.TERRITORIAL FORCE.

Royal Army Medical Corps.London (City of London) Field Ambulance : Captain F. V.

Denne, from Attached to Units other than Medical Units, tobe Captain.Lowland Field Ambulance : Lieutenant (temporary

Captain) N. MacIones to be Captain.West Riding Field Ambulance: Major W. S. Kerr to be

temporary Lieutenant-Colonel whilst in command of a FieldAmbulance. J. M. Pringle to be Lieutenant.Wessex Casualty Clearing Station: Lieutenant C. Telfer

to be Captain. W. S. Richardson to be Lieutenant.West Lancashire Field Ambulance: A. S. Parkinson to be

Lieutenant.South Midland Field Ambulance : E. G. Anderson to be

Lieutenant.London Sanitary Company: Captain D. P. M. Farquharson,

from Attached to Units other than Medical Units, andLieutenants A. E. Rayner, C. D. Edwards, and 0. Cattlintobe Captains. W. Johnstone to be Lieutenant.South Midland Casualty Clearing Station: Major P. S.

Hichens to be temporary Lieutenant-Colonel whilst incommand of a Casualty Clearing Station.East Anglian Field Ambulance: Lieutenant R. D.

Langdale-Kelham to be Captain.Highland Field Ambulance: Lieutenant C. G. Skinner

to be Captain.