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THE INDIAN MEDICAL SERVICE.
1788
discharge and hasmorrhage disappeared, general state of the patient improved.
and the
I
THE INDIAN MEDICAL SERVICE.
THE Public Services Commission took up the inquiry into the Medical Services on Nov. 21st. Surgeon-General Sir C. Pardey Lukis, Director. General of the Indian Medical Service, who was first examined, expressed WE have received from the Census Bureau at no views regarding probation and training, as the present Washington a report on the mortality of the Regis- system, he thought, was quite good. Out of the sanctioned tration Area of the United States for the year 1910. strength of 748 officers in the Indian Medical Service, only This report, which is the eleventh of the series, 722 posts had been filled up, of which 54 were Indians. Out of these 54, only 28 applied for civil employ. Before long appears as a folio volume of more than 600 pages, and would have the station hospital system for Indian troops is the work of Dr. Cressy Wilbur, chief statistician they on the same lines as for British troops. In his opinion it did The population whose a man no harm in being put to regimental duties for six years. of the Census Bureau. mortality statistics are now published amounts to He thought all Indian Medical Service officers should be placed 58’3 per cent. of the entire American Republic. The on the general list as regards selection for the grades of adding that there was no doubt that the territory thus inhabited, and designated the Regis- lieutenant-colonel, tration Area, occupies fully one-third part of the best men were not coming into the service. ’’ The reason In a preface for this," said Sir Pardey Lukis, "is that an impression has vast domain of the United States. abroad that the Indian Medical Service is going to be Dr. Wilbur intimates that, although the mortality got broken up. I am not saying it as my own impression, but it is records now presented are directly comparable with an impression at home." He gave figures to show that the the population statistics as enumerated at the number of Indians in the service of late years had increased thirteenth Census, full details respecting the latter considerably. Out of 72 new appointments 15 were Indians. are not yet available. Consequently, the general He hoped the training of candidates would be augmented by a course of study at the new Tropical Diseases School or crude death-rates alone can now be given. in In his opinion the training was satisfactory. Calcutta. derived Nevertheless, complete details of mortality, He had been much astonished at the figures which showed means of deaths with from comparison population, by the number of applications from candidates to enter the of corrected death-rates and life tables, together civil service. The figures were 52 per cent. Indians and 87 with an analysis of occupational mortality, are proper cent. of Europeans. He would have thought that they mised in a forthcoming volume, the preparation of would have been the other way round. In the cases of men which has already been commenced. Accordingly, who were to enter the civil service, witness did not think the present volume must be regarded as a continua- that service with the regiment should be too long. All tion of the series of annual reports already appointments for ordinary civil work were made by seniority of military rank, and, in his published, which deal generally with the mortality without regard to the ofquestion selection would be injurious. The any system opinion, of various parts of the country. By means of witness said that at 331 out of 475 of civil surgeons present tables in the text, which are comparable with were under orders for reversion to duties in the those published by the English Registrar-General, event of a general mobilisation. Themilitary number of men who the general tendency of mortality from all causes sought service in the Indian Medical Service had decreased. and from specified causes may be studied and Young men were, in fact, so fully occupied now in England comparison readily made with changes in foreign that a practitioner would have to pay 8 guineas a week for a countries. From one of these tables, relating to locum tenens instead of the 2 guineas which was paid a few be depending on a broken reed," 1910, it appears that the crude death-rate of the years ago. "We should " if we relied upon England and the said the witness, entire Registration Area was 15’0 per 1000 living, so far as we can colonies in the event of mobilisation. against 13’5 per 1000 in England and Wales. It ascertain, there are 1771 independent Here, practitioners holding was somewhat higher than the rates of 1908 and qualifications, Europeans and Indians. The Europeans are but with these exceptions was lower than in under contract with big firms and their services would not be any previous year respecting which statistics are available even if they were willing to come. Many of the extant. The present report, which has apparently Indian practitioners have large practices in big cities, and I been compiled with great care, marks a distinct cannot think they would give these up. Many of the advance in American vital statistics, and under the remaining men belong to the non-martial races, so would not able direction of Dr. Wilbur still further improve- be the kind of men we should desire. Some time ago we tried to find out the number of practitioners who would ment in this important direction may confidently be volunteer. We found 24, all Europeans, and these facts," looked for in the future. added the witness,"justify me in holding the opinion that the question of the war establishment is one of considerable
VITAL STATISTICS FOR 1910 OF THE UNITED STATES OF AMERICA.
1909,
"
proposed amalgamation of St. George’s Hospital and Westminster Hospital is now in jeopardy owing to a difference of opinion which has arisen on the question of a common site, and a meeting of governors of St. George’s Hospital will consider a proposal made by their house committee for sanction of the purchase of a site at THE
Wandsworth. ____
Sir Alfred Pearce Gould has sent to Prince Alexander of Teck, as chairman of the Middlesex Hospital, aeI000 which he received from " a friend," for the purchase of radium to be used in the treatment of the patients in the cancer wards of the
hospital.
____
THE London Post-Graduate Association, we informed by the secretary, is to be wound up at end of the year.
are
the
importance." The standard of training in the Indian medical institutions at Calcutta, Madras, Bombay, Lahore, and Lucknow, Sir Pardey Lukis thought, was good, and in some cases better than that given at home. The only defects were the noninsistence on practical training for students before granting them diplomas, the understaffing of colleges, and the want of development in special branches of study, such as throat and ear diseases. All examining bodies at home insisted that students should have attended confinement cases before they qualified themselves, which owing to existing conditions in India was not possible : for the M.B. examination in the Punjab University, a registrable qualification, students were not required to have practical training regarding women’s diseases. The M.B. of the Punjab University could go direct to the Indian Medical Service, and though he could get into the service he was not qualified. Therefore witness laid stress on the importance of insisting that students should undergo practical instruction in women’s and children’s diseases. He suggested that the marks should be raised from 600 to 700 in women’s and children’s diseases as in medicine and surgery.
1789 Sir Pardey Lukis next said that civil assistant surgeons had sections. If the whole of the Indian army was mobilised a better training than military, and that the former’s were large number of civil institutions would have to shut up. registrable qualifications. He suggested that students in Replying to further questions, Sir Pardey Lukis said that in the military assistant surgeon’s grade should have the same England a young practitioner after graduating went to quiet training as those in civil employ. He submitted in January, places and then went into big towns, but a young Indian 1911, to the Government of India a letter suggesting this would not do that. He was not aware of an impression among improvement, and a dispatch had been sent home. The only Indian members of the Indian Medical Service that only advantage the military assistants had was that after passing inferior posts were given to them ; such an impression was the examination they went with British troops and obtained an not justified. 75 per cent. of the European members of the excellent training, not only with soldiers, but with women service possessed the higher qualifications, and 153 officers He did not and children ; and in the treatment of women and children of the service had specialised themselves. they were better than the civil assistant surgeons. Military approve of the appointment of independent medical practiassistant surgeons had training in X ray work and bacterio- tioners as professors in Government colleges, but suggested logy, but he would like to see them from the very beginning the establishment of private institutions where the abilities receiving the same training as civil assistant surgeons. The of such men could be utilised. As to the desirability of defect in their training had an effect on their popularity. appointing Indian assistants to posts when vacancies The witness said, in reply to Lord lslington, that there was occurred in the department in which they had served for a number of years, Sir Pardey Lukis said that Indian no medical college entirely devoted to women in India, In Calcutta Rai Bahadur and this had generally an effect in keeping away the better assistants had done well. class of Indian women from taking to medicine. When Chunilal Bose had officiated at various times. Sir Pardey Lady Hardinge’s Medical College for Indian Women at Lukis added that the defects pointed out in the Punjab Delhi was opened he hoped a better class of women would University examination in his opinion existed in other join it. The scheme was complete and the names of the places too. selected students would be announced as soon as Her In reply to Mr. Sly, he said he would have no objection to Excellency returned to Delhi. There were 355 medical Indians being given a scholarship to proceed to England for missionaries in India -and they were serious rivals not only medical tuition after they had obtained their diploma. He to the civil surgeons but to independent practitioners also, would accept a scheme of study leave, applicable to military as missionaries treated practically for nothing in return. To assistant surgeons, civil surgeons, and Indian Medical stop medical practitioners who had no qualification from Service officers. Mr. Fisher : Considering the formidable list of duties practice a Bill was passed by the Bombay Legislative Council in March, 1912. A similar Bill introduced in the Madras which a civil surgeon has to do, would you be in favour of Council by the Hon. Dr. T. M. Nair, was under consideration, specialisation ? and one would be brought before the Bengal Council during Witness : I am quite in favour of the amalgamation of the the ensuing winter. An Imperial Act was also under sanitary with the bacteriological department, provided the But those Acts were not intended Director-General of the Indian Medical Service was head of consideration. to interfere with the practice of the Eastern system of their department with the Sanitary Commissioner as his medicine. staff officer. Sir Valentine There were only two places in India-Calcutta and Chirol, witness said that in view Answering Bombay-where independent medical colleges could be of the fact that personal claims must be subordinated to the established. He gave an account of the private medical Indian Medical Service which was essentially a military institutions in Calcutta. The hospital at Belgachia, in con- body, it was not hard to understand that no Indians nexion with the Albert Victor Hospital, was an excellent volunteered for war service. Also it must be remembered institution with a good surgical and medical staff, but was that of the total number of independent practitioners nearly badly handicapped for want of funds, and consequently for 1000 Indians belonged to non-martial races. In order to the necessary building and equipment. He had heard un- bring India up to the numerical standard of practitioners in officially that the Bengal Government had decided to Great Britain there would be required a total of 250,000 give 5 lakhs non-recurring and 50,000 a year recurring practitioners. I for the upkeep of this institution on condition that the To Sir Murray Hammick, Sir Pardey Lukis said that there college was affiliated to Calcutta University and the was no difference in the scale of pensions given to military necessary building and equipment for a hospital were pro- men and civil employes of the service, and there should be vided. This, Surgeon-General Lukis thought, would form a the same cadre in the provinces all over, so that efficient men could be imported from outside when necessary without great outlet for independent medical practitioners. Replying to questions concerning the unpopularity of difficulty. The second witness. Major R. F. Baird, I M.S., civil the Indian Medical Service with young men at home, Sir Pardey Lukis said: Personally, I believe that the Indian surgeon of Benares, who represented the United Provinces, Medical Service is now as safe as it ever was and that it said that the main causes of uncertainty regarding the presents as many opportunities for good careers as ever. I service was the possibility of a rush of private practitioners have been preaching that gospel for some little time, and I and a suggestion that a good number of civil work would be handed over to them. He considered that the medical trainwas horrified to find how little impression I could make. Mr. Ramsay Macdonald: Is the unpopularity of the ing obtained at home was superior to that given in India, service due to the assumption that the enrolment is not good and recalled the fact that the Indian University qualified or that the service itself is going to suffer at some future men had to undergo training in England before they could time? get into the service. In India the training was defective, Sir Pardey Lukis: The whole of this trouble has arisen especially in midwifery and children’s diseases. He advosince Lord Morley’s circular. The unpopularity of the cated, among other things, the giving of house surgeoncies service was due to the fear that one-third of the civil in big hospitals to private practitioners, and said that if a surgeoncies would be given over to independent medical civil surgeon had an extended private practice it increased men, and to military surgeons being absorbed by the Royal his efficiency, while during the military period of an Indian Medical Service officer’s career he gained no teaching expeArmy Medical Corps. Replying to Mr. Madge, Sir Pardey Lukis doubted whether rience. He advanced no objection to professorships being the Director-General should be joint secretary in the Home given in the colleges to independent practitioners. It was Department. urged that civil surgeoncies should be held by Europeans, In reply to Mr. Abdul Rahim, Sir Pardey Lukis said that the because tney ]3acL practice among European lamilies. tie cause of the unpopularity of the service was the insufficiency admitted that that argument could cut both ways ; but in of the salary given to members and the employment of the cases of Indian ladies it did not apply so strongly as they would not see any man at all. independent medical men in responsible posts. In examination by Mr. Gokhale, Sir Pardey Lukis said that Mr. Gokhale having interposed the remark that the in the event of civil surgeons reverting to military duty in times 1Jwrdah system was not so strong in other parts of the of war the positions thus made temporarily vacant would be- country as in the United Provinces, The number of -men filled by the assistant surgeons. Captain J. T. Parkinson, I.S.M.D., said that he repreliable for military service would cause a big dislocation, but sented 53 surgeons of the United Provinces of the Indian they would not all be recalled at once, but in six different Subordinate Medical Department. He said that it seemed a
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1790 .,anomalous to him that his department was calledI. subordinate. Mr. U. N. Bannerjee, representing the assistant surgeonsI of the United Provinces, said that his colleagues com , plained of the scale of pay and the exclusion from higheI .
.appointments.
t
Assistant Surgeon J. Malir, speaking for the LS.M.D. Railway Sections, was the first witness on the third day of sitting. He stated that assistant surgeons of railways demanded, inter alia, the same privileges as were granted to the Indian Medical Service. They performed the same duties as civil surgeons, and it was only in exceptional cases that the aid of civil surgeons was requisitioned, and then only for consultation. He knew many cases where military assistant surgeons were serving under civil assistant surgeons, and he As regards the comparative training saw no objection to it. of civil assistant and military assistant surgeons, the superiority of the former existed in theory only. In practice the military had more outdoor work to do and they gathered
Dr. Bhawat Ram Sawhney (representing the Punjab, Medical Union) was the first witness taken on the second day of sitting. He agreed th?,t no Indian should enter the ,Indian Medical Service without holding British qualifications. He urged the recruitment in England of a staff of ,professors for medical colleges in India. He was not in ,favour of Indian Medical Service officers taking professorial ’work, believing that deterioration in efficiency of medical more practical experience. practice was due to entrusting work to Indian Medical Major R. M. Dalziel, I.M.S., superintendent, Central Jail, .Service officers who had no experience of that work. In Punjab, said that the jail service was not popular, and diffiteaching hard work was required and great interest should culty was experienced in getting officers to enter the branch. ,be evinced. Indian Medical Service officers with the Indian medical officers had conducted the jails so well in necessary training, qualifications, and ability made good previous years that he could not see the need for any change. ,professors, but he was of opinion that they lost freshness and He was not in favour of transferiing superintendents from did not obtain after coming out to India the experience one province to another on promotion ; but he advocated essential for teaching. He urged the reduction of the present promotion in the same province to the Inspector-Generalship. medical organisation by half and the substitution of private He was of opinion that by inter-provincial transfers there .practitioners. He thought that private practitioners could was a likelihood of interference with seniority claims of be encouraged without the adoption of any change so other officers, so that in one province an inspector-general sweeping as to have serious effect on the Indian might be senior to the next man by a few months. The Medical Service. He remarked that London hospitals central jails in big cities gave a good scope for the training Indian student, of superintendents. He did not agree that assistant surwere closing their doors against the ’but better understanding would change that attitude. geons should take charge of jails. He did not think there It was advisable for Indians to study in India, but would be any advantage in appointing a separate medical ’hue would have all full surgeons trained in England. He officer in addition to the superintendent who could give an added that his experience of training colleges in India was opinion on the prisoners’ health. He also did not agree _gained 35 years ago, and improvements must have been made that the governorship and surgeoncy of a jail should be held since then. He knew, for example, that the professors now by different men. Lieutenant-Colonel Browning-Smith, I.M.S., Sanitary ,went on study leave. Lieutenant-Colonel H. Smith, civil surgeon, Amritsar, Commissioner, Punjab, said that for the sanitary departthought that Lord Morley’s circular had still influence in ment of the Indian Medical Service officers drawn the service. There was a feeling of uncertainty ahout the from the military were better than those in civil A medical officer of a regiment had heavy ,future. He would make all Indian candidates go to England. employ. He thought If they did so it would be to their advantage. They would work to do as to sanitation of troops. be placed on a similar footing to that of Europeans. He many Indians particularly fitted for sanitary work in view thought the standard of Indian colleges was "up to the of their knowledge of public health and their acquaintance ,times," and there was not the social life and rough-and- with the language and customs of the people ; on plague tumble of an English college. He would restrict the duty they had been of very great use to him. He had two ,number of Indians who desired to enter the service deputy sanitary commissioners, one of whom was an to 20 per cent. "The medical practice in the Punjab,"" Indian. He suggested that promotion in the sanitary continued witness,"is as overstocked as is the Punjab department should be from one list for all India. The :]3at."" Most Indians, witness continued, had agreed language problem certainly presented a difficulty, but he did In the sanitary depart, ,to leave nouunations to the Indian Medical Service with the not think it was insurmountable. Government, and that the number of Indians in the service ment a European officer would have more authority with -should be restricted to a maximum of 20 per cent. He said the people than would an Indian private practitioner. The that the scope for corruption and bribery open to a civil Punjab Municipal Act gave large powers to sanitary officers, surgeon engaged in legal work was enormous, and that, as but it’was a dead letter, and to that, and because they were English practitioners understood it, there was no sach thing not yet educated up to it, was due the apathy of local bodies. as professional etiquette in certain classes of practitioners in He quite saw the advantage of women doctors in sanitary India. work, but he did not think they had arrived at that stage yet. Lieutenant J. F. Fleming, Deputy Superintendent of In the Punjab there was no officer who corresponded to the .Lunatic Asylums in Lahore, stated that though the sub- English inspector of nuisances : but he was training men to ordinate department were entitled to a month’s privilege that end. Special plague officers were doing medico-surgical leave in the year, they were not given that, and they had no work, but they should be placed under the Sanitary Com’holiday in the year, not even on Sundays or public holidays. missioner as their work came under the sanitation head. So iHe objected to the placing of their department on an far as administrative work was concerned the Sanitary Comequality with civil assistant surgeons. Without makingi missioner should be under the Inspector-General of Civil .any suggestion as to the limitation of Indians in the Indian Hospitals ; but on technical matters connected with sanita4Tedical Department, he was of opinion that Europeans tion he objected to that and suggested that the Sanitary wielded greater influence and commanded more respect Commissioner should be independent. The awakening of ’from the people. public interest in sanitation was proceeding apace in India, Mr. Mirza Yaqub Beg, civil assistant surgeon, Punjab, and it had progressed so far as to justify a considerable suggested the creation of more posts for civil surgeons, so increase in the staff. ’that officers with the necessary qualifications of civil Major J. C. Robertson, Sanitary Commissioner with the assistant surgeons might have a reasonable chance of Government of India, advocated an all-India sanitary and ’holding higher appointments. He stated that in view of bacteriological department. There was difficulty in attractthe hard work and incessant travelling civil surgeoncies ing officers to the department, and at the present time there shonld be given to the younger members of the department. was an insufficiency of men available for the service. During ’Civil assist: nt surgeons in his province claimed exemption the past year men outside the medical service had been from the provisions of the Arms Act. That was a privilege recruited into the department, but it was too early yet to ’they shoulri be entitled to in view of the number of state any result of the experiment. It was essential that dacoities and other outrages that were committed in parts of Indians should be -recruited to the department, one of the the Puujab. The conditions of salary and pension were objects in this being to arouse the interest of the people. At matters of complaint. Their pay was not adequate con- present he would, however, prefer European superior officers sidering their arduous duties. Witness advocated retire- because,of their wider knowledge. He would be disposed ment on pension after 20 years’ service on the ground that to give superior posts to the best of the Indians from the
1791 three years and applied themselves to the study of sanitation, and thought there existed a good opening for the employment of women doctors. He laid stress on making the department more attractive. Dr. A. Lankester, honorary secretary to the Medical Missionary Association of India, stated that he had 22 years’ experience in medical work in this country and was of opinion that there should be a considerable increase in the staff of the medical service in India, and private agencies should be called in more and more to help the Government. He thought that the civil surgeons were overworked and that there was great scope for an increase in the personnel of the service.
naval returns, there having been only four cases and no’ death. The most fatal disease was pneumonia, causing 36 deaths (0-30 per 1000) ; after which come enteric fever with 29 deaths (0-24) and tuberoulosis with 22 deaths, and organic heart disease with the same number (0- 18 per 1000). The chief causes of invaliding were heart disease (2-70), nervous diseases’ (2’ 45), and tuberculosis (1’ 83 per 1000) ;, the last-named only is a reduction on the quinquennial average (2 - 06). On comparing the figures for the different naval commands it is seen that the East Indies Station suffered most, having an admission ratio of 948 per 1000, with 45 invalidings and He thought there would be a great advantage in Government 5’ 55 deaths. Malaria caused 37’55 and pyrexia 12 admissions hospitals taking private practitioners as honorary surgeons. per 1000, the other chief causes of sickness being digestive The initial benefit would be with the practitioner, but and venereal diseases and affections of the skin and ultimately the gain would be a double one. He thought it connective tissue. The healthiest commands were the most important that a Medical Act should be introduced into Mediterranean with 503 and the Home Fleet with 556, India. He advocated making the civil side of the Indian admissions per 1000. Medical Service the premier branch and recruiting from there Prevalence of Chief Diseases. into the military side. The normal condition was one of peace. The diseases of most frequent occurrence in the Navy may To ease the present burden of our work he would place the non- now be considered in regard to their prevalence and distri-medical charge of jails in the hands of non-medical officers. bution. Before to these it may be mentioned that alluding He advocated the abolition of private practice among civil of 3 cases small-pox occurred throughout the whole He only 1 surgeons, but would compensate them for their loss. case from each of three ships on the China Station force, ;. suggested that hospitals in districts should be placed under- one of these was fatal. In two instances the patients had the charge of outside practitioners, and that in cities a to be retained on board ship for periods of six and seven certain number of beds should be placed under their charge. ’days respectively. No extension of the disease occurred, in spite of the inevitable closeness of contact with the rest of the crew, a fact which speaks highly for the protection afforded vaccination. by THE HEALTH OF THE NAVY IN 1912. Influenza (1413 cases) caused less sickness than has been usual of late years ; the admission ratio was 11$2, com-THE statistical report on the health of the Navy for the pared with 21-24 per 1000 for the preceding quinquennium. year 1912 is the first to appear over the signature of Surgeon- The disease itself was mostly of a mild type, and there were General Arthur W. May, who became Director-General in the no deaths; it occurred in all the commands except the latter part of the present year. The returns continue to Cape, most of the cases being on the Home Station and in show an improvement for the Navy as a whole, which is the Home Fleet. Scarlet fever prevailed in epidemic form extremely satisfactory. The total force for the year 1912 on the Home Station, where there were 334 cases andl amounted to 119,540, of which number 92,120 were serving in 4 deaths ; 199 cases were admitted from the boys’ tra-’nmg the Home Fleet or on the home station, the remaining 27,420 ship Impregnable, the epidemic continuing throughout the being distributed among the seven fleets and squadrons year, but being of a mild type. Diphtheria was again, as in serving abroad. For the Navy as a whole the number of cases 1911, prevalent on the Home Station, 167 out of the totali of sickness has been 642 5 per 1000 of strength, compared with 194 cases being admitted from this command, and of these 666’ 6 for the preceding five years’ average, 1907-1911 ; the 107 occurred at the Shotley training establishment ; none daily sick have been 25 16, compared with 27-67 ; the deaths were of a severe character. Fleet-Surgeon R. H. Browne. 3’30, compared with 3 24 ; and the final invalidings 16’92, remarks that some of the carrier cases dealt with were compared with 16- 44 per 1000. The last two items are very extremely intractable to treatment, and an appreciable slightly in excess )f the ratios for the year preceding, as well number developed diphtheria later. He did not find prophyThe highest admission ratio, lactic inoculation to be"of any material value." Seven as of the quinquennial average. 948 per 1000, occurred on the East Indies Station, but this was cases were returned by the Donegal, of the North American below the quinquennial average of 988, though considerably squadron, 6 being boys ; these were attributed to infection higher than the ratio for 1911-viz., 876. The deaths on from Shotley, carried in the clothing or bedding. Enteric fever caused 140 admissions and 29 deaths. On the this station (5’55 per 1000) were, on the other hand, very much below the average ratio of 9, 43. The highest ratio of Home Station 18 cases occurred on board the Vivid, most of daily sick, 35’ 8, was met with, as usual, among the men on them probably contracted at Plymouth ; in 4 instances, the Irregular List, including crews on passage to and from also in 5 cases on the Impregnable, the eating of shellfish foreign stations, and those of the vessels on the west coast was thought to be the cause. To a similar origin were of America and on detached service. Next comes the Home attributed several cases in the Home Fleet. At Ascension Station, with an average of 33’ 75, and the East Indies Island 15 cases followed on the flooding of water catchment Station with 33, 51 ; while the healthiest command was that areas by heavy tropical rains, owing to which the drinkingof the Home Fleet, with a daily sick ratio of 21’ 04 per 1000. water became polluted. On board the Formidable, of the The difference between the health of the Home Fleet and Home Fleet, 10 cases occurred, without obvious connexion, that of the Home Station was more marked than usual. but apparently originating within the ship. Fleet-Surgeon The latter force consists of men at the depots and on train- H. C. Arathoon made an exhaustive investigation, and ining ships, at the hospitals, and at the Royal Naval College clined to the belief that the disease originated on board. at Greenwich. No definite vehicle of infection could be discovered, The chief cause of admission to hospital was disease but the yeast used in baking was found to contain It is probable that in many of the digestive system, with 111 admissions per 1000. bacilli of the coli group. Next after this came venereal disease, for which the, i instances the temperature reached in the interior of ! ratio was 106 per 1000, a considerable improvement on the a large loaf may not be high enough to destroy the bacilli. Of Mediterranean fever 4 cases only occurred average for the preceding quinquennium, 1907-1911, which was 119-8; the average number daily sick, 6-14 per 1000, throughout the whole Navy. One in the Home Fleet is was also a reduction on the quinquennial ratio of 7’ 84. The! stated to have been a sequela of an attack originally sustained other chief diseases of importance, such as pneumonia (3-74Iin 1905 ; the other three were on the Mediterranean Stationadmissions per 1000), malaria (2-55), and tuberculosis (2 ° 32), one, a Maltese, who drank unboiled goats’ milk at his own were below the quinquennial averages ; but for rheumatic; home ; another, a sailor who developed the disease while in fever there were 906 admissions, constituting a ratio of 7 57’ hospital in Malta suffering from pneumonia; for the third, per 1000, which is an increase on the preceding average of. who had not been ashore for more than a month, no explana6-95. The disease returned under this heading must, how-. tion could be found. A greater number of deaths occurred ever, have been of a very mild type, as only one deathifrom pneumonia than from any other disease-viz., 36, occurred among the 906 cases. Mediterranean (formerlygiving a ratio of 0-30 per 1000, slightly below the quincalled Malta) fever has practically disappeared from the: quennial average of 0-32.. Of the 448 cases, 197 were-, >
discharge and hasmorrhage disappeared, general state of the patient improved.
and the
I
THE INDIAN MEDICAL SERVICE.
THE Public Services Commission took up the inquiry into the Medical Services on Nov. 21st. Surgeon-General Sir C. Pardey Lukis, Director. General of the Indian Medical Service, who was first examined, expressed WE have received from the Census Bureau at no views regarding probation and training, as the present Washington a report on the mortality of the Regis- system, he thought, was quite good. Out of the sanctioned tration Area of the United States for the year 1910. strength of 748 officers in the Indian Medical Service, only This report, which is the eleventh of the series, 722 posts had been filled up, of which 54 were Indians. Out of these 54, only 28 applied for civil employ. Before long appears as a folio volume of more than 600 pages, and would have the station hospital system for Indian troops is the work of Dr. Cressy Wilbur, chief statistician they on the same lines as for British troops. In his opinion it did The population whose a man no harm in being put to regimental duties for six years. of the Census Bureau. mortality statistics are now published amounts to He thought all Indian Medical Service officers should be placed 58’3 per cent. of the entire American Republic. The on the general list as regards selection for the grades of adding that there was no doubt that the territory thus inhabited, and designated the Regis- lieutenant-colonel, tration Area, occupies fully one-third part of the best men were not coming into the service. ’’ The reason In a preface for this," said Sir Pardey Lukis, "is that an impression has vast domain of the United States. abroad that the Indian Medical Service is going to be Dr. Wilbur intimates that, although the mortality got broken up. I am not saying it as my own impression, but it is records now presented are directly comparable with an impression at home." He gave figures to show that the the population statistics as enumerated at the number of Indians in the service of late years had increased thirteenth Census, full details respecting the latter considerably. Out of 72 new appointments 15 were Indians. are not yet available. Consequently, the general He hoped the training of candidates would be augmented by a course of study at the new Tropical Diseases School or crude death-rates alone can now be given. in In his opinion the training was satisfactory. Calcutta. derived Nevertheless, complete details of mortality, He had been much astonished at the figures which showed means of deaths with from comparison population, by the number of applications from candidates to enter the of corrected death-rates and life tables, together civil service. The figures were 52 per cent. Indians and 87 with an analysis of occupational mortality, are proper cent. of Europeans. He would have thought that they mised in a forthcoming volume, the preparation of would have been the other way round. In the cases of men which has already been commenced. Accordingly, who were to enter the civil service, witness did not think the present volume must be regarded as a continua- that service with the regiment should be too long. All tion of the series of annual reports already appointments for ordinary civil work were made by seniority of military rank, and, in his published, which deal generally with the mortality without regard to the ofquestion selection would be injurious. The any system opinion, of various parts of the country. By means of witness said that at 331 out of 475 of civil surgeons present tables in the text, which are comparable with were under orders for reversion to duties in the those published by the English Registrar-General, event of a general mobilisation. Themilitary number of men who the general tendency of mortality from all causes sought service in the Indian Medical Service had decreased. and from specified causes may be studied and Young men were, in fact, so fully occupied now in England comparison readily made with changes in foreign that a practitioner would have to pay 8 guineas a week for a countries. From one of these tables, relating to locum tenens instead of the 2 guineas which was paid a few be depending on a broken reed," 1910, it appears that the crude death-rate of the years ago. "We should " if we relied upon England and the said the witness, entire Registration Area was 15’0 per 1000 living, so far as we can colonies in the event of mobilisation. against 13’5 per 1000 in England and Wales. It ascertain, there are 1771 independent Here, practitioners holding was somewhat higher than the rates of 1908 and qualifications, Europeans and Indians. The Europeans are but with these exceptions was lower than in under contract with big firms and their services would not be any previous year respecting which statistics are available even if they were willing to come. Many of the extant. The present report, which has apparently Indian practitioners have large practices in big cities, and I been compiled with great care, marks a distinct cannot think they would give these up. Many of the advance in American vital statistics, and under the remaining men belong to the non-martial races, so would not able direction of Dr. Wilbur still further improve- be the kind of men we should desire. Some time ago we tried to find out the number of practitioners who would ment in this important direction may confidently be volunteer. We found 24, all Europeans, and these facts," looked for in the future. added the witness,"justify me in holding the opinion that the question of the war establishment is one of considerable
VITAL STATISTICS FOR 1910 OF THE UNITED STATES OF AMERICA.
1909,
"
proposed amalgamation of St. George’s Hospital and Westminster Hospital is now in jeopardy owing to a difference of opinion which has arisen on the question of a common site, and a meeting of governors of St. George’s Hospital will consider a proposal made by their house committee for sanction of the purchase of a site at THE
Wandsworth. ____
Sir Alfred Pearce Gould has sent to Prince Alexander of Teck, as chairman of the Middlesex Hospital, aeI000 which he received from " a friend," for the purchase of radium to be used in the treatment of the patients in the cancer wards of the
hospital.
____
THE London Post-Graduate Association, we informed by the secretary, is to be wound up at end of the year.
are
the
importance." The standard of training in the Indian medical institutions at Calcutta, Madras, Bombay, Lahore, and Lucknow, Sir Pardey Lukis thought, was good, and in some cases better than that given at home. The only defects were the noninsistence on practical training for students before granting them diplomas, the understaffing of colleges, and the want of development in special branches of study, such as throat and ear diseases. All examining bodies at home insisted that students should have attended confinement cases before they qualified themselves, which owing to existing conditions in India was not possible : for the M.B. examination in the Punjab University, a registrable qualification, students were not required to have practical training regarding women’s diseases. The M.B. of the Punjab University could go direct to the Indian Medical Service, and though he could get into the service he was not qualified. Therefore witness laid stress on the importance of insisting that students should undergo practical instruction in women’s and children’s diseases. He suggested that the marks should be raised from 600 to 700 in women’s and children’s diseases as in medicine and surgery.
1789 Sir Pardey Lukis next said that civil assistant surgeons had sections. If the whole of the Indian army was mobilised a better training than military, and that the former’s were large number of civil institutions would have to shut up. registrable qualifications. He suggested that students in Replying to further questions, Sir Pardey Lukis said that in the military assistant surgeon’s grade should have the same England a young practitioner after graduating went to quiet training as those in civil employ. He submitted in January, places and then went into big towns, but a young Indian 1911, to the Government of India a letter suggesting this would not do that. He was not aware of an impression among improvement, and a dispatch had been sent home. The only Indian members of the Indian Medical Service that only advantage the military assistants had was that after passing inferior posts were given to them ; such an impression was the examination they went with British troops and obtained an not justified. 75 per cent. of the European members of the excellent training, not only with soldiers, but with women service possessed the higher qualifications, and 153 officers He did not and children ; and in the treatment of women and children of the service had specialised themselves. they were better than the civil assistant surgeons. Military approve of the appointment of independent medical practiassistant surgeons had training in X ray work and bacterio- tioners as professors in Government colleges, but suggested logy, but he would like to see them from the very beginning the establishment of private institutions where the abilities receiving the same training as civil assistant surgeons. The of such men could be utilised. As to the desirability of defect in their training had an effect on their popularity. appointing Indian assistants to posts when vacancies The witness said, in reply to Lord lslington, that there was occurred in the department in which they had served for a number of years, Sir Pardey Lukis said that Indian no medical college entirely devoted to women in India, In Calcutta Rai Bahadur and this had generally an effect in keeping away the better assistants had done well. class of Indian women from taking to medicine. When Chunilal Bose had officiated at various times. Sir Pardey Lady Hardinge’s Medical College for Indian Women at Lukis added that the defects pointed out in the Punjab Delhi was opened he hoped a better class of women would University examination in his opinion existed in other join it. The scheme was complete and the names of the places too. selected students would be announced as soon as Her In reply to Mr. Sly, he said he would have no objection to Excellency returned to Delhi. There were 355 medical Indians being given a scholarship to proceed to England for missionaries in India -and they were serious rivals not only medical tuition after they had obtained their diploma. He to the civil surgeons but to independent practitioners also, would accept a scheme of study leave, applicable to military as missionaries treated practically for nothing in return. To assistant surgeons, civil surgeons, and Indian Medical stop medical practitioners who had no qualification from Service officers. Mr. Fisher : Considering the formidable list of duties practice a Bill was passed by the Bombay Legislative Council in March, 1912. A similar Bill introduced in the Madras which a civil surgeon has to do, would you be in favour of Council by the Hon. Dr. T. M. Nair, was under consideration, specialisation ? and one would be brought before the Bengal Council during Witness : I am quite in favour of the amalgamation of the the ensuing winter. An Imperial Act was also under sanitary with the bacteriological department, provided the But those Acts were not intended Director-General of the Indian Medical Service was head of consideration. to interfere with the practice of the Eastern system of their department with the Sanitary Commissioner as his medicine. staff officer. Sir Valentine There were only two places in India-Calcutta and Chirol, witness said that in view Answering Bombay-where independent medical colleges could be of the fact that personal claims must be subordinated to the established. He gave an account of the private medical Indian Medical Service which was essentially a military institutions in Calcutta. The hospital at Belgachia, in con- body, it was not hard to understand that no Indians nexion with the Albert Victor Hospital, was an excellent volunteered for war service. Also it must be remembered institution with a good surgical and medical staff, but was that of the total number of independent practitioners nearly badly handicapped for want of funds, and consequently for 1000 Indians belonged to non-martial races. In order to the necessary building and equipment. He had heard un- bring India up to the numerical standard of practitioners in officially that the Bengal Government had decided to Great Britain there would be required a total of 250,000 give 5 lakhs non-recurring and 50,000 a year recurring practitioners. I for the upkeep of this institution on condition that the To Sir Murray Hammick, Sir Pardey Lukis said that there college was affiliated to Calcutta University and the was no difference in the scale of pensions given to military necessary building and equipment for a hospital were pro- men and civil employes of the service, and there should be vided. This, Surgeon-General Lukis thought, would form a the same cadre in the provinces all over, so that efficient men could be imported from outside when necessary without great outlet for independent medical practitioners. Replying to questions concerning the unpopularity of difficulty. The second witness. Major R. F. Baird, I M.S., civil the Indian Medical Service with young men at home, Sir Pardey Lukis said: Personally, I believe that the Indian surgeon of Benares, who represented the United Provinces, Medical Service is now as safe as it ever was and that it said that the main causes of uncertainty regarding the presents as many opportunities for good careers as ever. I service was the possibility of a rush of private practitioners have been preaching that gospel for some little time, and I and a suggestion that a good number of civil work would be handed over to them. He considered that the medical trainwas horrified to find how little impression I could make. Mr. Ramsay Macdonald: Is the unpopularity of the ing obtained at home was superior to that given in India, service due to the assumption that the enrolment is not good and recalled the fact that the Indian University qualified or that the service itself is going to suffer at some future men had to undergo training in England before they could time? get into the service. In India the training was defective, Sir Pardey Lukis: The whole of this trouble has arisen especially in midwifery and children’s diseases. He advosince Lord Morley’s circular. The unpopularity of the cated, among other things, the giving of house surgeoncies service was due to the fear that one-third of the civil in big hospitals to private practitioners, and said that if a surgeoncies would be given over to independent medical civil surgeon had an extended private practice it increased men, and to military surgeons being absorbed by the Royal his efficiency, while during the military period of an Indian Medical Service officer’s career he gained no teaching expeArmy Medical Corps. Replying to Mr. Madge, Sir Pardey Lukis doubted whether rience. He advanced no objection to professorships being the Director-General should be joint secretary in the Home given in the colleges to independent practitioners. It was Department. urged that civil surgeoncies should be held by Europeans, In reply to Mr. Abdul Rahim, Sir Pardey Lukis said that the because tney ]3acL practice among European lamilies. tie cause of the unpopularity of the service was the insufficiency admitted that that argument could cut both ways ; but in of the salary given to members and the employment of the cases of Indian ladies it did not apply so strongly as they would not see any man at all. independent medical men in responsible posts. In examination by Mr. Gokhale, Sir Pardey Lukis said that Mr. Gokhale having interposed the remark that the in the event of civil surgeons reverting to military duty in times 1Jwrdah system was not so strong in other parts of the of war the positions thus made temporarily vacant would be- country as in the United Provinces, The number of -men filled by the assistant surgeons. Captain J. T. Parkinson, I.S.M.D., said that he repreliable for military service would cause a big dislocation, but sented 53 surgeons of the United Provinces of the Indian they would not all be recalled at once, but in six different Subordinate Medical Department. He said that it seemed a
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1790 .,anomalous to him that his department was calledI. subordinate. Mr. U. N. Bannerjee, representing the assistant surgeonsI of the United Provinces, said that his colleagues com , plained of the scale of pay and the exclusion from higheI .
.appointments.
t
Assistant Surgeon J. Malir, speaking for the LS.M.D. Railway Sections, was the first witness on the third day of sitting. He stated that assistant surgeons of railways demanded, inter alia, the same privileges as were granted to the Indian Medical Service. They performed the same duties as civil surgeons, and it was only in exceptional cases that the aid of civil surgeons was requisitioned, and then only for consultation. He knew many cases where military assistant surgeons were serving under civil assistant surgeons, and he As regards the comparative training saw no objection to it. of civil assistant and military assistant surgeons, the superiority of the former existed in theory only. In practice the military had more outdoor work to do and they gathered
Dr. Bhawat Ram Sawhney (representing the Punjab, Medical Union) was the first witness taken on the second day of sitting. He agreed th?,t no Indian should enter the ,Indian Medical Service without holding British qualifications. He urged the recruitment in England of a staff of ,professors for medical colleges in India. He was not in ,favour of Indian Medical Service officers taking professorial ’work, believing that deterioration in efficiency of medical more practical experience. practice was due to entrusting work to Indian Medical Major R. M. Dalziel, I.M.S., superintendent, Central Jail, .Service officers who had no experience of that work. In Punjab, said that the jail service was not popular, and diffiteaching hard work was required and great interest should culty was experienced in getting officers to enter the branch. ,be evinced. Indian Medical Service officers with the Indian medical officers had conducted the jails so well in necessary training, qualifications, and ability made good previous years that he could not see the need for any change. ,professors, but he was of opinion that they lost freshness and He was not in favour of transferiing superintendents from did not obtain after coming out to India the experience one province to another on promotion ; but he advocated essential for teaching. He urged the reduction of the present promotion in the same province to the Inspector-Generalship. medical organisation by half and the substitution of private He was of opinion that by inter-provincial transfers there .practitioners. He thought that private practitioners could was a likelihood of interference with seniority claims of be encouraged without the adoption of any change so other officers, so that in one province an inspector-general sweeping as to have serious effect on the Indian might be senior to the next man by a few months. The Medical Service. He remarked that London hospitals central jails in big cities gave a good scope for the training Indian student, of superintendents. He did not agree that assistant surwere closing their doors against the ’but better understanding would change that attitude. geons should take charge of jails. He did not think there It was advisable for Indians to study in India, but would be any advantage in appointing a separate medical ’hue would have all full surgeons trained in England. He officer in addition to the superintendent who could give an added that his experience of training colleges in India was opinion on the prisoners’ health. He also did not agree _gained 35 years ago, and improvements must have been made that the governorship and surgeoncy of a jail should be held since then. He knew, for example, that the professors now by different men. Lieutenant-Colonel Browning-Smith, I.M.S., Sanitary ,went on study leave. Lieutenant-Colonel H. Smith, civil surgeon, Amritsar, Commissioner, Punjab, said that for the sanitary departthought that Lord Morley’s circular had still influence in ment of the Indian Medical Service officers drawn the service. There was a feeling of uncertainty ahout the from the military were better than those in civil A medical officer of a regiment had heavy ,future. He would make all Indian candidates go to England. employ. He thought If they did so it would be to their advantage. They would work to do as to sanitation of troops. be placed on a similar footing to that of Europeans. He many Indians particularly fitted for sanitary work in view thought the standard of Indian colleges was "up to the of their knowledge of public health and their acquaintance ,times," and there was not the social life and rough-and- with the language and customs of the people ; on plague tumble of an English college. He would restrict the duty they had been of very great use to him. He had two ,number of Indians who desired to enter the service deputy sanitary commissioners, one of whom was an to 20 per cent. "The medical practice in the Punjab,"" Indian. He suggested that promotion in the sanitary continued witness,"is as overstocked as is the Punjab department should be from one list for all India. The :]3at."" Most Indians, witness continued, had agreed language problem certainly presented a difficulty, but he did In the sanitary depart, ,to leave nouunations to the Indian Medical Service with the not think it was insurmountable. Government, and that the number of Indians in the service ment a European officer would have more authority with -should be restricted to a maximum of 20 per cent. He said the people than would an Indian private practitioner. The that the scope for corruption and bribery open to a civil Punjab Municipal Act gave large powers to sanitary officers, surgeon engaged in legal work was enormous, and that, as but it’was a dead letter, and to that, and because they were English practitioners understood it, there was no sach thing not yet educated up to it, was due the apathy of local bodies. as professional etiquette in certain classes of practitioners in He quite saw the advantage of women doctors in sanitary India. work, but he did not think they had arrived at that stage yet. Lieutenant J. F. Fleming, Deputy Superintendent of In the Punjab there was no officer who corresponded to the .Lunatic Asylums in Lahore, stated that though the sub- English inspector of nuisances : but he was training men to ordinate department were entitled to a month’s privilege that end. Special plague officers were doing medico-surgical leave in the year, they were not given that, and they had no work, but they should be placed under the Sanitary Com’holiday in the year, not even on Sundays or public holidays. missioner as their work came under the sanitation head. So iHe objected to the placing of their department on an far as administrative work was concerned the Sanitary Comequality with civil assistant surgeons. Without makingi missioner should be under the Inspector-General of Civil .any suggestion as to the limitation of Indians in the Indian Hospitals ; but on technical matters connected with sanita4Tedical Department, he was of opinion that Europeans tion he objected to that and suggested that the Sanitary wielded greater influence and commanded more respect Commissioner should be independent. The awakening of ’from the people. public interest in sanitation was proceeding apace in India, Mr. Mirza Yaqub Beg, civil assistant surgeon, Punjab, and it had progressed so far as to justify a considerable suggested the creation of more posts for civil surgeons, so increase in the staff. ’that officers with the necessary qualifications of civil Major J. C. Robertson, Sanitary Commissioner with the assistant surgeons might have a reasonable chance of Government of India, advocated an all-India sanitary and ’holding higher appointments. He stated that in view of bacteriological department. There was difficulty in attractthe hard work and incessant travelling civil surgeoncies ing officers to the department, and at the present time there shonld be given to the younger members of the department. was an insufficiency of men available for the service. During ’Civil assist: nt surgeons in his province claimed exemption the past year men outside the medical service had been from the provisions of the Arms Act. That was a privilege recruited into the department, but it was too early yet to ’they shoulri be entitled to in view of the number of state any result of the experiment. It was essential that dacoities and other outrages that were committed in parts of Indians should be -recruited to the department, one of the the Puujab. The conditions of salary and pension were objects in this being to arouse the interest of the people. At matters of complaint. Their pay was not adequate con- present he would, however, prefer European superior officers sidering their arduous duties. Witness advocated retire- because,of their wider knowledge. He would be disposed ment on pension after 20 years’ service on the ground that to give superior posts to the best of the Indians from the
1791 three years and applied themselves to the study of sanitation, and thought there existed a good opening for the employment of women doctors. He laid stress on making the department more attractive. Dr. A. Lankester, honorary secretary to the Medical Missionary Association of India, stated that he had 22 years’ experience in medical work in this country and was of opinion that there should be a considerable increase in the staff of the medical service in India, and private agencies should be called in more and more to help the Government. He thought that the civil surgeons were overworked and that there was great scope for an increase in the personnel of the service.
naval returns, there having been only four cases and no’ death. The most fatal disease was pneumonia, causing 36 deaths (0-30 per 1000) ; after which come enteric fever with 29 deaths (0-24) and tuberoulosis with 22 deaths, and organic heart disease with the same number (0- 18 per 1000). The chief causes of invaliding were heart disease (2-70), nervous diseases’ (2’ 45), and tuberculosis (1’ 83 per 1000) ;, the last-named only is a reduction on the quinquennial average (2 - 06). On comparing the figures for the different naval commands it is seen that the East Indies Station suffered most, having an admission ratio of 948 per 1000, with 45 invalidings and He thought there would be a great advantage in Government 5’ 55 deaths. Malaria caused 37’55 and pyrexia 12 admissions hospitals taking private practitioners as honorary surgeons. per 1000, the other chief causes of sickness being digestive The initial benefit would be with the practitioner, but and venereal diseases and affections of the skin and ultimately the gain would be a double one. He thought it connective tissue. The healthiest commands were the most important that a Medical Act should be introduced into Mediterranean with 503 and the Home Fleet with 556, India. He advocated making the civil side of the Indian admissions per 1000. Medical Service the premier branch and recruiting from there Prevalence of Chief Diseases. into the military side. The normal condition was one of peace. The diseases of most frequent occurrence in the Navy may To ease the present burden of our work he would place the non- now be considered in regard to their prevalence and distri-medical charge of jails in the hands of non-medical officers. bution. Before to these it may be mentioned that alluding He advocated the abolition of private practice among civil of 3 cases small-pox occurred throughout the whole He only 1 surgeons, but would compensate them for their loss. case from each of three ships on the China Station force, ;. suggested that hospitals in districts should be placed under- one of these was fatal. In two instances the patients had the charge of outside practitioners, and that in cities a to be retained on board ship for periods of six and seven certain number of beds should be placed under their charge. ’days respectively. No extension of the disease occurred, in spite of the inevitable closeness of contact with the rest of the crew, a fact which speaks highly for the protection afforded vaccination. by THE HEALTH OF THE NAVY IN 1912. Influenza (1413 cases) caused less sickness than has been usual of late years ; the admission ratio was 11$2, com-THE statistical report on the health of the Navy for the pared with 21-24 per 1000 for the preceding quinquennium. year 1912 is the first to appear over the signature of Surgeon- The disease itself was mostly of a mild type, and there were General Arthur W. May, who became Director-General in the no deaths; it occurred in all the commands except the latter part of the present year. The returns continue to Cape, most of the cases being on the Home Station and in show an improvement for the Navy as a whole, which is the Home Fleet. Scarlet fever prevailed in epidemic form extremely satisfactory. The total force for the year 1912 on the Home Station, where there were 334 cases andl amounted to 119,540, of which number 92,120 were serving in 4 deaths ; 199 cases were admitted from the boys’ tra-’nmg the Home Fleet or on the home station, the remaining 27,420 ship Impregnable, the epidemic continuing throughout the being distributed among the seven fleets and squadrons year, but being of a mild type. Diphtheria was again, as in serving abroad. For the Navy as a whole the number of cases 1911, prevalent on the Home Station, 167 out of the totali of sickness has been 642 5 per 1000 of strength, compared with 194 cases being admitted from this command, and of these 666’ 6 for the preceding five years’ average, 1907-1911 ; the 107 occurred at the Shotley training establishment ; none daily sick have been 25 16, compared with 27-67 ; the deaths were of a severe character. Fleet-Surgeon R. H. Browne. 3’30, compared with 3 24 ; and the final invalidings 16’92, remarks that some of the carrier cases dealt with were compared with 16- 44 per 1000. The last two items are very extremely intractable to treatment, and an appreciable slightly in excess )f the ratios for the year preceding, as well number developed diphtheria later. He did not find prophyThe highest admission ratio, lactic inoculation to be"of any material value." Seven as of the quinquennial average. 948 per 1000, occurred on the East Indies Station, but this was cases were returned by the Donegal, of the North American below the quinquennial average of 988, though considerably squadron, 6 being boys ; these were attributed to infection higher than the ratio for 1911-viz., 876. The deaths on from Shotley, carried in the clothing or bedding. Enteric fever caused 140 admissions and 29 deaths. On the this station (5’55 per 1000) were, on the other hand, very much below the average ratio of 9, 43. The highest ratio of Home Station 18 cases occurred on board the Vivid, most of daily sick, 35’ 8, was met with, as usual, among the men on them probably contracted at Plymouth ; in 4 instances, the Irregular List, including crews on passage to and from also in 5 cases on the Impregnable, the eating of shellfish foreign stations, and those of the vessels on the west coast was thought to be the cause. To a similar origin were of America and on detached service. Next comes the Home attributed several cases in the Home Fleet. At Ascension Station, with an average of 33’ 75, and the East Indies Island 15 cases followed on the flooding of water catchment Station with 33, 51 ; while the healthiest command was that areas by heavy tropical rains, owing to which the drinkingof the Home Fleet, with a daily sick ratio of 21’ 04 per 1000. water became polluted. On board the Formidable, of the The difference between the health of the Home Fleet and Home Fleet, 10 cases occurred, without obvious connexion, that of the Home Station was more marked than usual. but apparently originating within the ship. Fleet-Surgeon The latter force consists of men at the depots and on train- H. C. Arathoon made an exhaustive investigation, and ining ships, at the hospitals, and at the Royal Naval College clined to the belief that the disease originated on board. at Greenwich. No definite vehicle of infection could be discovered, The chief cause of admission to hospital was disease but the yeast used in baking was found to contain It is probable that in many of the digestive system, with 111 admissions per 1000. bacilli of the coli group. Next after this came venereal disease, for which the, i instances the temperature reached in the interior of ! ratio was 106 per 1000, a considerable improvement on the a large loaf may not be high enough to destroy the bacilli. Of Mediterranean fever 4 cases only occurred average for the preceding quinquennium, 1907-1911, which was 119-8; the average number daily sick, 6-14 per 1000, throughout the whole Navy. One in the Home Fleet is was also a reduction on the quinquennial ratio of 7’ 84. The! stated to have been a sequela of an attack originally sustained other chief diseases of importance, such as pneumonia (3-74Iin 1905 ; the other three were on the Mediterranean Stationadmissions per 1000), malaria (2-55), and tuberculosis (2 ° 32), one, a Maltese, who drank unboiled goats’ milk at his own were below the quinquennial averages ; but for rheumatic; home ; another, a sailor who developed the disease while in fever there were 906 admissions, constituting a ratio of 7 57’ hospital in Malta suffering from pneumonia; for the third, per 1000, which is an increase on the preceding average of. who had not been ashore for more than a month, no explana6-95. The disease returned under this heading must, how-. tion could be found. A greater number of deaths occurred ever, have been of a very mild type, as only one deathifrom pneumonia than from any other disease-viz., 36, occurred among the 906 cases. Mediterranean (formerlygiving a ratio of 0-30 per 1000, slightly below the quincalled Malta) fever has practically disappeared from the: quennial average of 0-32.. Of the 448 cases, 197 were-, >