818 PROPHYLACTIC INOCULATION AGAINST ENTERIC FEVER AND PLAGUE.

play ; to observe the rules of games and to obtain thus theadmirable discipline of athletics; and to enjoy themselvesmuch more intelligently and keenly, with commensurate

improvement to mind and body, than they can now do in the

existing disorderly conditions.

Prophylactic Inoculation AgainstEnteric Fever and Plague.

WITH the spread of knowledge respecting the preventionof disease there is a growing tendency, among the educatedclasses at least, to avail themselves of the means which

science has suggested for imparting artificial immunityagainst certain infections. The family medical adviser maynow, for instance, be asked as to the desirability in the caseof persons proceeding to take up duties for the first time inthe Far East of obtaining this protection against enteric

fever and plague prior to their embarking on the journey.The European who proceeds to India or elsewhere in theEast is to a large extent at the mercy of his native servants,whose filthy habits and uncleanly customs give rise to seriousrisk. He can himself exercise little or no control over the

storage or preparation of the food which is brought to histable. Besides this there is the constant danger from

infective dust, from flies acting as carriers of infection, andfrom other causes which bring the specific organism of entericfever into his house and into association with his food and

drink, and as to which no forethought on his partcan prevent the possible danger. So that there is in

this way continual exposure to chances of enteric fever

infection from unknown sources which cannot be foreseen

and guarded against. For this reason it is, in our opinion,very desirable that all persons proceeding to the Far East,and particularly those under 25 years of age going to India,should submit to antityphoid inoculation before theyleave this country. Since this method for affording pro-tection against enteric fever was first introduced by SirALMROTH WRIGHT in 1897, a considerable mass of evidencehas been accumulating in its favour. A committee of expertsappointed by the Army Council in 1904 has already, in aninterim report after an exhaustive inquiry, reported stronglyin favour of inoculation; and the Army Council has

in consequence sanctioned its re-introduction into the

British army as a voluntary measure. The final reportof the committee of experts is, we believe, now in pre-

paration and will doubtless supply a large amount of

evidence in support of antityphoid inoculation, as fore-

shadowed by the interim report. Improved and modifiedmethods of preparing the antityphoid vaccine have

been introduced by Colonel Sir W. B. LEISHMAN, pro-fessor of pathology at the Army Medical College, and asa result the temporary discomfort which accompanies the"reaction" caused by the inoculation has been reduced to aminimum. The operation may now be regarded as a com-paratively trivial affair, free from any recognisable danger.It may be mentioned that to secure efficient protection it is

necessary that two separate inoculations of the vaccine

should be made, with an interval of ten days between them.The duration of the protection conferred by efficient inocula-tion is said to be about two years, after which time, shouldspecial danger from enteric fever still be present in the

locality where the European is residing, it will be advisableto submit to re-inoculation.

But with most people fear of plague is stronger than fear ofenteric fever, though we hold that the danger from the latterdisease is by far the greater of the two. It has to be remem-

bered that the European as a rule is much less susceptible to

plague infection than the native races, especially the Hindus,and that Europeans in India comparatively seldom contractthe disease. Occasionally, however, medical men and nurses

may fall ill of plague, but the medical men in these cases not

infrequently become infected through post-mortem woundsand the nurses through their necessarily close contact withtheir patients, who may be suffering from virulent pneumonicor septicasmic plague before the condition has been fullyrecognised. The protective value of HAFFKINE’S prophylacticis unquestionable; but while admitting the advantages which

may be derived from it by those who are compelled to

come in close contact with virulent cases of plague, we are,on the whole, content to advise its use by Europeans in theFar East only in certain circumstances, and we regard it,therefore, as not essential that the inoculation should

be performed before leaving England. The danger of

plague to the European in the Far East is becoming less.The amount of plague in India, for example, has showna remarkable reduction during the last two years, and thenumber of infected localities has been greatly diminished

in the course of the present year. There are, however,some persons, courageous enough in other matters, who

display a morbid and exaggerated fear of plague infection.If such persons can, by submitting to inoculation with

HAFFKINE’s prophylactic fluid before leaving England, obtaina freedom from anxiety and establish a sense of securityagainst the disease, we see no reason why their medicalattendants should not advise that the operation be performedat home, bearing in mind that in competent hands it is a

comparatively trivial procedure and that the risks attendingit are practically nil. It has, however, to be remembered thatthe duration of this protection against plague is believed tobe shorter than that obtained from the antityphoid vaccine,and for this reason it may be necessary, under conditions of

continued direct exposure to plague infection, to have the

inoculation repeated in six or 12 months’ time.

Annotations.

THE EXPENDITURE OF THE LONDON HOSPITALS.

" Ne quid nimis."

A STATISTICAL report has just been published by the

directors of King Edward’s Hospital Fund for London

showing the ordinary expenditure of 66 of the London

hospitals in the year 1908. Although very large sums areannually subscribed for the support of hospitals in the

metropolis, it is notorious that, owing to want of uniformityand of due economy in administration, a considerable

portion of the money formerly subscribed for hospitalpurposes failed to accomplish the desired object-namely,the relief of suffering and of disease among the poor. The

inauguration of King Edward’s Hospital Fund for Londondeveloped the work already undertaken by the MetropolitanHospital Fund of bringing order into hospital finance.The Prince of Wales, now President of the Fund,

819

’has throughout his office taken an active part in

securing for this undertaking a sound financial basis,.and to his keen personal interest it is due that considerable- economy has already been effected in metropolitan hospital.administration. Although reports of a similar character havebeen prepared annually for the directors’ information eversince the year 1903, we learn from Mr. H. R. Maynard, thesecretary of the Fund, that the present is the first occasion

on which a full statistical report has been offered for sale tothe public. In preparing these reports the primary objectsof the directors are to assist individual hospitals to secure anincreased degree of control over their own expenditure bycomparing the cost of working at different institutions ; toenable the managers to observe the result of comparisonfrom year to year ; and, generally, to encourage economyin hospital expenditure without sacrificing efficiency. It

is worthy of note that the appendix tables in these reportsare based on comparisons of average cost, not of minimum.cost, There is no suggestion that the cheapest hospital is,necessarily the best, or that it ought to be regarded as amodel for future imitation. It is obvious that in order to

.secure fair comparability it is necessary to deal exclusivelywith hospitals of which the conditions are approximately- similar. For this reason a considerable number of special.and some other hospitals are omitted from the list.

In his prefatory remarks the secretary does not attemptto give a complete analysis of the expenditure of

- each of the London hospitals. For the detailed figuresrelating to maintenance and administration the reader

is referred to the statistical tables now published(in accordance with the revised system of accounts)in the annual reports published by the several hospitals.Appended to the present report there will be found a seriesof tables giving particulars of total expenditure, as well as ofexpenditure under various heads, at the larger London hos-pitals-namely, those containing an average of more than100 beds, and at certain of the smaller hospitals containingin each case an average of fewer than 100 beds. In these

cases all necessary details and statistical explanations willbe found, but no attempt is made to dogmatise on thedelicate question whether or to what extent the cost is

affected by differences in methods, or in efficiency of treat-ment. The financial results are set forth for the considera-tion of the authorities of the various hospitals, who arethus enabled to discover the existence of any excess of

expenditure and to ascertain whether that excess is prevent-able. As an illustration of the value of the methods

of comparison now adopted, it may be mentioned that thefigures for 1905 showed that, as compared with the figuresfor 1903, the 16 hospitals dealt with in the earlier reporthad effected economies valued at £ 21,000 per annum.

In 1906, when the number of hospitals had risen to 48, theadditional saving represented a further sum of £ 18,000 perannum. It can hardly be doubted that these economieswere in some measure due to the circulation of the com-

,parative figures. The report for 1908 deals with 66 hos-pitals, but as many of these were added last year and

probably did not receive the figures until too late to

affect their contracts for that year, no great change isto be expected in the present report. It is furtherto be noted that the report before us is the first inwhich the expenditure on in-patients is distinguished fromthat on out-patients, and for this reason it forms a trust-

worthy starting-point for comparison of the present withfuture years. In this report the cost per bed and perout-patient attendance respectively for the various itemsof expenditure at the hospitals in each group are nowfor the first time combined in a general table, and in anappendix the more important data are collated in a form

convenient for reference. We are pleased to observe thatMr. Maynard concludes his very able prefatory remarks witha graceful acknowledgment of the value of the work of thehospital officials, who have expended much time and care incarrying out the revised system and in filling up the formsand returns for the purposes of the report.

"ETHER DAY."

THERE can be few occasions which more deserve to be

perpetuated in the minds of men than that on which wasfirst demonstrated the possibility of anaesthesia during asurgical operation. It is this occasion-or rather its anniver-

sary-that the Massachusetts General Hospital celebrates

as Ether Day. For it was in the theatre of that hospital,on Oct. 16th, 1846, that William Morton kept a patientanaesthetised with ether while John Warren operated.We have only recently received a pamphlet containing theaddress delivered by Professor W. H. Welch of Johns HopkinsUniversity at the last celebration of that historic operation,and we suppose that a further address will be delivered next

month. The discovery of anaesthesia is associated withalmost as many different names as is the birthplace of

Homer. The claims of the rival towns in the latter case can

never be fairly judged, but in the former it is com-

paratively easy to see the part played by the different

men, although it may not be so easy to apportion their

share of fame. Whatever, though, may be the gratitudewith which we look back upon the enterprise of Long,the ingenuity of Jackson, the melancholy success and

failure of Wells, there still can be no doubt that

for practical purposes the foremost step was that taken byMorton on the occasion to which we have alluded. As Pro-

fessor Welch declared, it was success on that occasion whichmade the future certain for anaesthesia. Another publicfailure such as had ruined the hopes of Wells would have putthe clock back for many years. Nor is it to be disputed thatthe boon of painless surgery is the greatest gift of Americanmedicine to mankind and one of the most beneficent everconferred. There is a growing tendency to celebrate the giftwith too little thought of the giver. Doubtless this is due

largely to the multiplicity of claims which we havedescribed. New facts in the history of the matter are notnow likely to be disclosed, and we may agree with ProfessorWelch, who after careful consideration of all those at his

disposal confers the chief honour upon William Morton. It

is very likely indeed that Morton’s claims to the respect andgratitude of all posterity would have been less questionedhad it not been for his unfortunate attempt to keep secretthe exact nature of his great achievement. The part whichthe staff of the Massachusetts General Hospital at that

time played in defeating any such secrecy may be proudlyremembered by all who value professional honour.

THE FIFTH INTERNATIONAL DENTAL CONGRESS.BERLIN.

THE Fifth International Dental Congress was held in theReichstag from August 23rd to August 28th under the

presidency of Professor Walkhoff of the University of Munich.1600 members attended. A gracious message from His

Majesty the Kaiser wishing success to the Congress wascommunicated amidst great enthusiasm. The work ofthe Congress, which included addresses, papers, and

demonstrations, amounted to 360 items on the pro-gramme and was distributed over 12 sections. An

admirable collection of pathological dental specimens andprosthetic work was exhibited in the Great Hall ofthe Reichstag and constituted a leading feature of the

congress. Professor Dieck of Berlin, its organiser, wasawarded the medal of honour presented by the German