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tave for some time been in the habit of directing atten-tion. Mr. Jefferson deserves the thanks of anatomists for

carrying his anatomical knowledge into a clinical field<and confirming it by careful X ray studies; he alsodeserves support in his appeal for a better understanding ofthe very obvious functional arrangements of the muscles ofthe stomach.-Mr. P. T. Crymble contributes a paper onSome Factors Influencing the Position of the Small Intes-tine. His results are derived from the study of 56 adultsubjects, of which 6 were examined in serial frozen sections.--my. J. S. Fraser and Dr. J. K. Milne Dickie give a verywell illustrated account of a Reconstruction Model of the

’Right Middle and Inner Ear, and Dr. John Cameron- describes the Cranial Attachment of the Internal Lateral

Ligament of the Lower Jaw. Neither of these papersdemands any alteration of our general conception of thestructures exammed.-For the rest, the contributions dealwith variations and anomalies.-Mr. C. P. G. Wakelydescribes a case of Duplication of the Ureters.-Mr. S. V.Telfer records a case of Abnormal Disposition of the Peri--toneum, the anomaly being accompanied by an extensivehernia of the intestine into a peritoneal fossa situated on- the right side of the abdomen beneath the transverse

mesocolon.-Congenital Variation of the Pectoral Musclesis dealt with by Dr. Elbert Clark, who records a case ofentire right-sided absence of pectoralis minor, accompaniedby partial absence of the costosternal portion of pectoralisrnajor of the same side.-Two papers, one by Mr. T. B.Johnston and the other by Dr. John Cameron, deal with theMorphology of Persistent Portions of the Left SuperiorVena Cava.-Dr. R. J. Gladstone and Mr. W. Erichsen-Towell describe examples of, and discuss theories toaccount for, Fusion of the Atlas, and Manifestation of

Occipital Vertebra. -Professor W. P. Gowland gives a note ona Diarthrodial Articulation between the Clavicle and theCoracoid, and Mr. J. R. D. Holtby records a case of PartialLobulation of the Lung by Pressure of the Vena Azygos.-An- obituary notice of Charles Barrett Lockwood is bound up inthis issue.

Malaria e Malattie dei Paesi Caldi. Anno V., Fase. V. andVI. September-December, 1914. Rome : Via Farini 62.-Inthis issue there are three original communications on Leish-maniasis, one by Professor G. Mariani on oriental sore, withspecial reference to its histology, which is illustrated byreproductions of the microscopic appearances. He finds a

complete anatomical identity between the cutaneous formsof leishmaniasis of Asia and of the African and Europeanshores of the Mediterranean and those of America knownunder the names of pian-bois, boschyaws, and bauru ulcer.Dr. G. Pavoni investigates the biological diagnosis of thedisease, and finds that the deviation of the complementinvariably gives positive results in external leishmaniasis,while in the internal form the results are for themost part negative. Furthermore, the deviation is com-

plete and constant in cured cases, while in chronic,cases tending towards recovery it is often positive.It is invariably negative in children who are not the

subjects of the disease, so that a positive reaction is a

certain sign of a diagnosis of leishmaniasis. The antigenused was a watery extract of spleen. In this relation it is

’interesting to note that in the third paper, by Dr. F. La Cava,the use of strong measures by caustics, excision, and cauteryis deprecated. He states that the sore, if properly pro-tected, heals spontaneously, and, moreover, affords an

immunity against the general infection.-Other communica-tions of interest are by Dr. P. Macri on PruriginousDermatitis caused by the Acarus of Dry Favus ; by Dr. P.Vadala and Dr. F. Arezzi on Climatic Bubo in Messina ; byProfessor U. Gabbi on Ankylostomiasis ; and by Professor- G. Boeri on Am&oelig;boid Dysentery.

The Cornhill Magazine for March includes a further instal-ment of Sir Arthur Conan Doyle’s "Western Wanderings"

"

and of Mrs. David G. Ritchie’s -’Two Sinners." "Behind-the Mask " is a topical poem over the well-known initialsC. L. G.," from which the last verse may well be quoted :-

He always kept a smiling face,He never groused when he was soaking ;

And in the very tightest placeBecame most prodigal of joking.

He jested in the jaws of Death;He kept at bay that grim marauder;And with his very latest breathWas imitating Harry Lauder.

An Editor-" writes of " A Newspaper in Time of War, " and

with much psychological acuteness declares his approvalof the Censorship. ’’ It is, of course," he says, "very unintelli-gent-that is the source of its strength. The collective

intelligence of a body of men, individually clever, is alwaysvery low, a psychological fact to which is due the successof Parliamentary Government in this country. As a racewe would never endure to be governed by a man of genius-except maybe temporarily in time of supreme crisis. Wetried the experiment once with Cromwell and replaced himby Charles II. and his corrupt ministers-a typically Britishsequence of choice. When this war is over we shall politelybut very firmly shove Lord Kitchener out of the War Officeand replace him by an Arnold-Forster. And we shall beright! The profoundest thing in our deep political instinctis its distrust of genius. We use it-occasionally-but wealways hate it and distrust it. And we are right. Geniusmay win an empire, but only honest stupidity can hold one."In every department where science holds sway this is exactlythe British spirit which it is hoped that the war may abolish.

THE ANNUAL REPORT OF THE MEDICALOFFICER OF THE LOCAL GOVERNMENT

BOARD FOR 1913-14.(Concluded from p. 382.)

II.IN the section following that on infant life protection

the medical officer deals with the question of administrativecontrol of infectious disease, the local incidence of whichwas shown in March last, when the third annual statementrespecting notifiable disease was issued by the LocalGovernment Board. 1

In a comprehensive table relating to the county of Londonand to England and Wales as a whole the number is givenof cases reported in each of the years 1911-13, together withthe corresponding case rates for the several diseases.

Scarlet Fever.The history of scarlet fever incidence in 1913 is interesting,

inasmuch as it shows that although for the most part thecases exhibited the mild type prevalent in recent years, themildness was by no means uniform everywhere. The recordsof 1913 confirm the experience of previous years, when insome northern areas of England scarlet fever exhibited

exceptionally high fatality. In a recent epidemic in theSunderland rural district the disease is reported to haveshown a marked septic tendency, characterised by unusuallysevere inflammation of the throat, with enlargement of thecervical glands and rhinitis, thus indicating a reversion tothe severer type prevalent in former years.

Diphtheria.Diphtheria mortality showed in 1913 a fall of 60 per cent.

from the rate of 1901. Nevertheless, the behaviour of thedisease during the year was in some respects peculiar.As in the year 1912, the highest London attack-rates were reported in Woolwich and in Greenwich, thelowest in Kensington. Among other administrative countiesthe attacks were most frequent in Flintshire and least so inWest Suffolk. In the course of the year several localprevalences of diphtheria were investigated by the Board’smedical staff. Outbursts of the disease occurred inSherborne, Dorchester, and Rochford, in all of which infectionwas spread mainly by personal contact. Instructive parti-culars are given of the investigation of an outbreak ofdiphtheria in South London attributable to milk infection. 2In this case the difficulty of tracing the source of infectionwas increased by the circumstance that the milk was

derived from numerous widely distributed farms in thecounties of Surrey and Sussex as well as from the dairyman’sown cows in London. Credit is due to the health officersof the respective districts for their prompt recognitionof the cause of the outbreak, as well as for their adroitnessin accomplishing its suppression. The efficiency of pasteuri-sation when properly employed in rendering harmless a milkcontaminated by an easily killed organism like the diphtheriabacillus was abundantly proved by this outbreak. Dr. J.

Priestley, the medical officer of health of Lambeth, at onceresorted to this prophylactic, which apparently cut short theepidemic. Inquiry from all other sources having provedfruitless, important positive information was elicited by

1 THE LANCET, April 4th, 1914, p. 993.2 THE LANCET, June 6th, 1914, p. 1628.

500

Dr. S. Child, medical officer of he-11th for West Sussex, whodetected sores on the udders and teats of some cows at amilk farm at Horsham ; added to which the hands ofthree out of the four milkers at the farm were

found similarly affected. From the sores on the handsof two of the milkers virulent diphtheria bacilli were

isolated, but the swabs taken from the throats gave negativeresults. Consideration of all the circumstances suggests theprobability that the sores on the milkers’ hands were causedin the process of milking by contact with the sores on theteats of the cows. On this hypothesis, the explanation ofthe outbreak appears to be that sores on the cows’ teatsbecame infected with diphtheria from some unknown source,and that the infectivity of the milk for its human con-sumers was increased by accidental infection of the milkers’hands from the diseased teats. The extreme virulence ofthe infective organism is proved by the fact that in thecase of one of the milkers affected the condition ofthe ulcerated finger was such as to require amputation.The operation having been performed, the amputatedfinger was sent to the Clinical Research Association withthe result that a virulent diphtheria bacillus was isolated,which on inoculation into a guinea-pig caused the deathof the animal in 48 hours. The foregoing investigationis instructive as showing that active diphtheria bacilli cansurvive in other situations besides the human throat,

Typhus Fever.There has been no serious occurrence of this disease in

England during the year under notice, the total number offatal attacks in 1913 being only 12. In several instancestyphus fever was notified in error ; and of the 18 casescertified as from this disease 7 have subsequently been held tohave been wrongly diagnosed. Occasionally a case of truetyphus is mistaken for one of enteric fever, and is notifiedunder the latter name. For these reasons all notified casesof enteric fever where the symptoms are anomalous are

deserving of the closest scrutiny. Of the 11 notified cases

(probably or certainly typhus) one occurred in Bermondsey,another in Shoreditch, and two in Stepney. Four caseswere notified in Liverpool, one in Wigan, and one in theurban district of Cowes. In certain parts of Eastern

Europe typhus fever is endemic, and foreign returns indicateits prevalence in parts of Austria, especially in Galicia, andto some extent in Russia. It has been described as the

pestilence which commonly accompanies or follows war.

Accordingly, it is desirable, at the present time, thatmedical officers of health should be constantly on the watchfor its appearance.

Enteric Fever.

No interruption is recorded in the steady fall of entericfever fatality which England has experienced for many pastyears. Compared with 1901 the death-rate of 1913 hasdeclined by 70 per cent. Throughout that year the incidenceof attack was on the same low scale as that obtaining in1912. In England and Wales the sickness-rate was 22 per100,000 living, as against 38 and 23 respectively in the twcpreceding years. As usual, the rates varied enormously,ranging among administrative counties from 4 per 100,000 irHereford and in Montgomery to 47 in Northumberland anc50 in Lancashire. An outbreak of enteric fever occurred ai

Kenilworth, in which circumstances pointed to the publi(water-supply as the probable cause of mischief.3 3 Or

investigation it became clear that an "adit," fronwhich this supply was derived, must have received wate:from a brook fouled by the discharge from a stornoverflow of a section of the Kenilworth sewers. Toward;the end of the year 41 persons were attacked witlenteric fever, 26 of whom fell ill within a week Some daypreviously there occurred in Kenilworth a general prevalenceof gastro-enteritis, which wa,s probably, though not certainlyconnected with the sewage pollution of drinking waterThe foregoing occurrences at Kenilworth furnish yeanother illustration of the necessity of keeping under constant observation the purity of public water-supplies. Lon,immunity from water-borne infection may induce fals

impressions of security unless local possibilities of COD

tamination are sought for and remedied. Special importance now attaches to this matter, in view of the possibilitof military operations, which, besides increasing the demanupon local water-supplies, might expose the sources of thossupplies to danger of pollution. As in previous year:

3 THE LANCET, May 9th, 1914, p. 1346.

occasional outbreaks of enteric fever have been officiallyattributed to the eating of shell-fish contaminated bysewage. In reporting upon a recent epidemic of this diseasein Portsmouth, involving the illness of 14,0 persons, the-medical officer of health. expressed the belief that most ofthe enteric fever in that town is due to eating shell-fishwhich has been contaminated with sewage. Althoughattention has frequently been drawn to this danger in hisreports the warnings have fallen on deaf ears. The shell-fish are regularly collected from obviously polluted places,at times within 100 yards of the sewage outfall. The-health officer further points out that when once the shell-fishare gathered there is nothing to indicate whether or notthey come from a polluted source so long as they appearfresh, although they may be loaded with typhoid bacilli.Dr. J. Niven’s report for Manchester contains particularsof an investigation by Dr. B. M. Cunningham on the relationof mussels to enteric fever. The inquiry related to 108 casesoccurring in that city. In every case uncooked mussels badbeen eaten within three weeks of the onset of fever. One-third of the patients were beer-drinkers to excess, amongwhom the eating of shell-fish is a well-known habit; thiscommodity being habitually purveyed outside the publichouses, or even in the bars. The facts elicited supportedthe conclusion that the mussels were probably the cause ofenteric fever.

Tuberculosis.The more accurate knowledge of the behaviour of tuber-

culosis gained under recent provisions for its notification has.considerably increased the efficiency of measures for itsadministrative control. Incidentally a large addition is thuscaused to the work of the Board’s medical department,corresponding to which is the fuller treatment of thesubject noticeable in Dr. Newsholme’s recent reports.As far as can be judged from another year’s experiencethe notification of tuberculosis has been accompanied by lessinconvenience and friction than was originally anticipated.In some instances the public health possibilities of notifica-tion have not been realised, in consequence whereof onlyimperfect action has resulted. Nevertheless, it is believedthat with the fuller development of tuberculosis schemes thepublic health advantages dependent on notification will bemore uniformly secured. One of the principal difficultieshitherto encountered has been that in certain instancesdismissal from service has followed the knowledgethat an employee was suffering from tuberculosis. In

regard to domestic servants, for example, the advice is

given that the first interview after notification shouldtake place at the office of the medical officer of health,rather than at the employer’s house. Again, in the case ofa school teacher with open tuberculosis, the aim should be-to adopt a course which, besides minimising risk of infec-tion, may conduce to the personal interest of the sufferer.In both the foregoing circumstances this can best be effected.by consultation with the patient’s own doctor. In theevent of the school teacher becoming unfit for the dischargeof his duties, the anticipation of a pension, due at a laterstage, in such cases may diminish the hardship involved.The general decline in the mortality from tuberculosis

observed in recent previous years has continued in the yearunder review. In the present report details are given of thelocal distribution of the fatal cases and their incidence onage and sex ; but for these statistics reference is necessaryto the original, as they do not admit of summary in a briefnotice like the present.

It frequently happens that the first notified case is notthe first clinical case of tuberculosis in a family ; and from

the standpoint of prevention the detection of such earlycases is important. Examination of contacts sometimesdiscovers patients in an earlier stage of disease than thenotified patient. The probability of effecting a cure is verymuch greater where the disease has been recognised before

’ bacilli commence to be discharged in the sputum. Con-sequently the success of any scheme for dealing with

’ tuberculosis must depend on accuracy of diagnosis of’

early cases. At the time of notification a large pro--

portion of cases of pulmonary tuberculosis are found’

to be in an advanced stage. Late notification ismainly due to the patient’s neglect to obtain medical

advice; but in not a few cases there appears to have been medical delay in recognising the disease. In these cases

examination of sputum would have ensured earlier and moresatisfactory treatment.