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The numbers given are over and above the medical menwho, on account of compulsory service, do duty as one yearmen in subordinate medical establishments.The proposals for the Army Medical Department in

Bavaria were agreed to without discussion for the financialyear 1903-04. The proposed cost for the department, in-cluding cost of medicines, pay of pharmaceutical assistants,and so on, would reach the sum of 1,408,415 marks. Not-

withstanding certain economies, nothing has been withdrawnwhich could interfere with the desire to attract the best mento the corps and to maintain a high scientific standard. For

study allowances for junior medical offlc,7rs fit for promotionsome 25,500 marks are voted and for the military medicalacademies of the reserve classes some 10,250 marks. Some12.000 marks go to allowances for professors and travellingexpenses of those who study at the academies. While actuallyemployed all officers of the medical department study for afixed period before each grade promotion. The practicalexamination takes places during the manoeuvres. Some15,092 marks are allotted to anatomical museums, models ofsanitary matériel, &c., and as in Germany no academy orinstitute is unprovided with a library 5600 marks are for themilitary medical libraries which, not like the Spanish,contain new instead of old books, very few classics, and alarge number of reviews and monographs in variouslanguages.There is a supplementary vote of 2,271,740 marks for the

construction and repair of pavilions in the military hospitalsand 65,000 marks- for field sanitary viat6riel which is to beof the most up-to-date type. Every year, or almost everyyear, supplementary votes up to 490,000 marks go to thisobject. The Germans always recognise that the army intime of peace is a preparation for war and that the ArmyMedical Department is very much more than a corps of merehospital assistants.

TWELFTH ANNUAL REPORT (FOR 1903)OF THE MEDICAL OFFICER OF HEALTHOF THE ADMINISTRATIVE COUNTY

OF LONDON.

IN a leading article in THE LANCET of Jan. 21st on theannual report of the county medical officer of health we

discussed certain administrative changes that had recentlybeen effected in the public health department at Spring-gardens, changes which we believe to have been absolutelynecessary in order that the purely sanitary work of the

Council might be coordinated with the new educational func-tions which have devolved upon that body in consequence of Ithe dissolution of the London School Board.

We now proceed to consider that section of the countymedical officer’s report which treats of the prevalence of

epidemic and infectious disease in London during the periodto which it relates. It will be remembered that in each ofhis successive annual reports since 1889, in which yearpowers were acquired for the compulsory notification ofinfectious disease, Sir Shirley F. Murphy has published uni-form statistics concerning the age and sex-incidence ofattack and death by the notifiable diseases, together withappropriate remarks on the measures necessary for theircontrol. In his present report he has summarisedthe information collected during the last 14 years,and in a useful chart has shown the mean dis-tribution of six of the most important of thesediseases in each week and month of the year. This chartusefully supplements the diagrams prepared by Dr. W. Ogleand published in the Registrar-General’s annual summary for1890. Over these diagrams, however, the present chartpresents the manifest advantage that the curves relate, notto the death-rates but to the rates of attack by the severaldiseases. Moreover, Sir Shirley Murphy’s chart deals witha more recent period-in fact, with the entire period thathas elapsed since the publication of Dr. Ogle’s diagrams,and on both these accounts it will be the more interestingand valuable to the student of epidemiology.Although it is impracticable to reproduce this chart in

our present issue we insert the following table whichgives the principal information graphically illustrated in the

chart-namely, the mean relative incidence of attack by the-several diseases in successive months of the year :-

Being based on the aggregate notifications of 14 year&in a population approaching five millions, the Londonpractitioner of medicine may rely with some confidence or&

the figures here given as representing the probable future-incidence on season of the several diseases in question.As in former reports, we notice the familiar table showing

the excess or diminution in the year 1903 of the moreimportant diseases causing death in the administrative--county as compared with the corrected annual average in theprevious ten years. From this table we see that with two

exceptions the mortality from every one of the 20 diseases.included therein has declined, in most cases considerably-Following upon two years of epidemic prevalence the-incidence of small-pox in London in 1903 was comparativelyslight. The mortality due to that disease was inconsiderable,the deaths registered in the administrative county amountingto only 13 from small-pox and three from cow -pox and other’effects of vaccination. In the first 14 weeks- of 1903 the’largest number of cases of small-pox notified in any one weekdid not exceed five. During this period, however, the disease-was prevalent to a considerable extent in some of the largeprovincial towns, more than 4000 cases being notified in oneor other of them during the quarter, whilst only 74 cases’occurred in London. It is, therefore, not surprising thatinfection was repeatedly imported into London from the-

provinces, but in addition to this we learn that it was from.time to time introduced from abroad.Although the mortality from measles in 1903 was below

the decennial average, London nevertheless suffered more-

severely from that disease than did the great provincialtowns, with four exceptions. In the course of the year 1903the order of the London County Council came into force,extending to measles certain legal provisions for the preven-tion of infectious disease, except the requirement of noti-fication. Whether or not the new order leads to the givingof more prompt information concerning absentees fromschool on account of measles is a question as to whichthere exists much difference of opinion. To what extent itis possible under existing conditions to limit the spread ofmeasles cannot yet be stated generally but it is as wellto note that many metropolitan medical officers of health

regard the new powers with satisfaction. They recognisethe value of these powers as an educational influence in

impressing the dangerous nature of measles upon parents.and persuading them to abstain from the common practiceof allowing children suffering from that disease to come into"contact with their fellows. Although during the holiday s-the chief source of information, that of the school, i&wanting, Sir Shirley Murphy provisionally approves ofthe Council’s new order, the effects of which are being-carefully watched by certain of his medical colleagues.

In proportion to population the cases of scarlet fevernotified in 1903 were fewer than in any previous yearsince 1891 ; the case mortality among the reported cases wasalso considerably below the average. If the mortality ofscarlet fever be stated, not in terms of cases notified but as aproportion of the population affected, London would appearto have suffered less heavily from this disease in 1903 thanhave any of the great English towns except West Ham, Hull,.and Leicester. In commenting on the low fatality (2’ 9 penr-

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cent. of the attacks) and on the low case-rate of scarletfever in 1903, Sir Shirley Murphy recognises the mildness ofthe disease in London. With diseases of this nature thedifficulty of finding explanation for the occurrence ofrecognised cases is very great, inasmuch as mild un-

recognised cases must often give rise to cases in which thesymptoms are sufficiently pronounced for recognition, thesource of infection being thus obscured. In a populationsuch as that of London the chances of exposure to infectionby unidentified cases are much greater than in sparselyinhabited districts; it is therefore satisfactory to record thatDr. G. Newman was able to trace infection to an antecedentcase in 90 out of 283 cases occurring in Finsbury, whilstDr. F. G. McCleary succeeded similarly in 96 out of 448cases reported in Battersea. As in past years schoolinfluence was again powerful during 1903 in determiaingthe spread of infection among children of school age. Theeffect of school closure during the holidays in interrupt-ing the autumnal rise of scarlet fever in London is con-

spicuously shown in a diagram which may well be comparedwith the corresponding diagram for enteric fever, alsoincluded in the report; this diagram does not show anysimilar interruption. The table given above, which is basedon experience in London during a long series of years,indicates the seasonal prevalence of scarlet fever; themonths of September, October, and November are thereshown to be the period of greatest prevalence and themonth of March the period of least prevalence of thisdisease.

Diphtheria is another disease the prevalence, if not the

fatality, of which is closely connected with attendance atschool. Both the attack-rate and the case-mortality of

diphtheria were lower in 1903 than in any year since 1891.The table shows a striking similarity in the seasonalincidences of scarlet fever and diphtheria, for which the onlydiscernible cause is the common one of school infection.Sir Shirley Murphy gives the now familiar table showingthe percentage increase or decrease of attacks of diphtheriain the four weeks of "holiday influence" (i.e., the thirty-first to the thirty-fourth week) in contrast with that in thefour weeks respectively preceding and following the periodof holiday influence; and with respect thereto he remarksthat "the interruption of the autumnal rise during the

period of the summer holiday previously referred to in thecase of scarlet fever, is equally conspicuous in the case ofdiphtheria." In the year 1903 London experienced a lowermortality from diphtheria than did any of the greatprovincial towns, Leeds, Sheffield, and Leicester aloneexcepted. We learn that in the course of 1903 only a fewlocalised outbreaks of this disease were observed, all ofwhich were traceable to school attendance. In Paddingtonten cases occurred among children attending a certainschool, which was closed in consequence, with the resultthat no further cases occurred. In Chelsea seven cases

occurred in a school, anct in Finsbury seven cases in oneschool and ten in another, a ’relationship between whichoccurrences was established by Dr. Newman. Sir Shirley.Murphy goes on to suggest that the appreciation of the partplayed in the dissemination of diphtheria by " carrier cases

"

must inevitably lead to a fuller examination of "contacts."Fortunately, as regards diphtheria, bacteriological methodsare available for this purpose, and it is clear that the more

completely the examination of " contacts " is carried out themore thorough will be the control over the extension of diph-theria. In a community like that of London the difficultiesin the way of complete success are doubtless great. Theyneed not, however, prevent steps being taken for the pre-vention of school attendance by children who althoughhighly infective nevertheless present no clinical symptoms ofthe disease.

In proportion to population the reported cases of entericfever in London were fewer in 1903 than in any previousyear since the establishment of compulsory notification andthe deaths were fewer than in any year since 1869, in whichyear deaths from enteric fever were first separately classified.The seasonal distribution of attacks was strikingly similar tothe average, as shown in the table before referred to.Among the articles of food mentioned as possible causes

of infection by enteric fever are shell-fish, watercress, ice- creams, water, and milk. The extent to which contaminatedshell-fish is productive of this disease in London cannot bedetermined. In some cases there is evidence of the ingestion of shell-fish being followed by enteric fever at an intervalwhich corresponds with the incubation period of that disease; a

t in other cases there is the additional evidence that the shell-f fish had been obtained from polluted sources; whilst in others, again, the evidence does not amount to more thanE this, that a particular person suffered from an attack of- enteric fever after eating shell-fish at some time within thelimits of the incubation period.

. In several instances it appears that persons who were notifiedi as suffering from this disease had, within the incubationi period, eaten either ice-creams or watercress. In Hackneytwo localised outbreaks were attributed by Dr. J. K. Warry; to the eating of watercress. In one of these outbreaks 48cases of enteric fever were reported and in the other 62.

Inquiry as to the food-supply of the people in these affectedareas led to the exclusion of all articles of food except

watercress, and an inquiry as to the source from whichseveral samples of the watercress were detived led to thediscovery of serious contamination of the water in which ithad been grown. The only instances in which attacks ofenteric fever were attributed to milk occurred at Eltham ;these, however, were few in number and were probably dueto the admixture of polluted water with the milk.

To be continued.,)

THE CENTRAL MIDWIVES BOARD.

THE members of the Central Midwives Board met on: Jan. 19th, at 6, Suffolk-street, Strand, Dr. F. H. CHAMPNEYSj being in the chair.

The Board proceeded to consider under the provisions ofthe rules of procedure the proposed removal of the name ofMiss Edith Gregory, a certified midwife, from the MidwivesRoll, the charges alleged against her being that of signingfalse certificates in connexion with the training of candi-

dates for the examinations of the Obstetrical Society ofLondon.Mr. G. W. DUNCAN, the secretary of the Central Midwives

Board, stated the facts of the case. He pointed out that thematter came under the notice of the Board in consequence ofa communication from the Obstetrical Society of London

informing the Board that after consideration of thecase of a certified midwife, Miss Edith Gregory, thecouncil of the Obstetrical Society of London had resolvedthat her L.O.S. certificate should be forfeited. In the

opinion of Mr. Duncan the charges against Miss Gregoryrested on the reply which she had sent to the ObstetricalSociety of London admitting that she had signedcertificates required by nurses before admission to theexaminations to the Obstetrical Society of London indicatingthat the nurses had attended not fewer than 20 labours,whereas, in point of fact, that number of cases had not beenactually attended at the time Miss Gregory signed thecertificates. Miss Gregory, however, pointed out that sheunderstood that it was quite right to sign certificates so

long as the nurses would have completed the number of casesbefore the examination took place.

In the course of the evidence that was offered in supportof the charges against Miss Gregory it appeared that severalyears ago the Obstetrical Society of London was aware of thepractice that certificates were signed for nurses enteringthe examinations of the society without these nurses havingattended the required number of cases of labour, it beingunderstood that the requisite number of cases would be madeup to the proper total before the day of the examination.

Mr. C. E. GODWIN of the firm of Messrs. Godwin and Co.,solicitors, Winchester, addressed the Board on behalf ofMiss Gregory. In the course of his remarks Mr. Godwinstated that Miss Gregory had attended and supervised some500 confinements and that throughout the whole course ofthese cases not a single septic case had occurred nor had adeath taken place. That record, Mr. Godwin continued,was one which few could put before the Central MidwivesBoard. Miss Gregory was therefore a well-qualified mid-wife and if as the result of that day’s proceedings hername was taken off the Roll the Board would be defeatingthe main object of the Midwives Act which the Boardwas called upon to administer. In regard to the numberof cases attended by the nurses whose certificate Miss

Gregory had signed, he observed that these nurses hadattended a sufficient number of cases to be within a measure-able distance of the number required and during the month