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which has given rise to a good deal of comment in theisland; and the Jamaica Institutp, Museum and PublicLibrary, which are well worth visiting. The Museumcollections aim at representing as completely sas possiblethe fauna and flora of the island, along with its geology andanthropology.The marnmals are repre ented by various species of bats,

the Jamaica cone.y (Caproonys brachjurus), the manatee, mon-goose, etc. The stnakes, lizards, chelonians, the crocodile,and the amphibians of the island are all represented. Of theinvertebrates, many insects, decapod crustaceans, scorpions,arachnida, and myriapods are shown. The echinodermata-star-fishes, sea urchins, sea cucumbers-are fully illustrated;and the cv,;enterates-sea anemones, corals, sea fans-are alsoshown. A considerable collection has been made of objectsconnected with the Arawaks, the extinct aboriginal inhabi-tants of the island. They include a large series of stoneimplements, mostly petaloid in shape, all carefully finished,and some highly polished. Others are wedge shaped or chisel-shaped, while a few are made of shell. From the numerouskitchenrmiddens or refuse heaps are shown eollections ofperforated shells, broken pottery, fish, coney and crab bones,and ashes. The relics from eaves consist of hlman skulls andbones, and the more perfect examples of Indian pottery.Photographs of var-ious rock carvings are on view, and severalexamples of aboriginal images. Slavery relics includeanironcage-gibbet, in which criminals were hung to die of starva-tion.In the rooms of the Institute are held the examinations of

the Jamaica Medical Council, the quarterly meetings of theJamaica Branch of the British Med4cal Association, and thoEeof other local societies.The fruit and vegetable market at Kingston is only a few

minutes' walk from the parish church, and should certainlynot be missed, as it affords an excellent opportunity forstudying the ways of the natives. It is a scene of bustle andexcitement, heightened every now and then by lively alter-citions between sellers and buyers, mostly of the female sex,with gesticulations, which to one unused to such scenesappear likely to end in taring out one another's hair or atleast scratching of an adversary's face. Nothing comes ofit, however, but words, words, words, and the sacne thing isgoing on all over the market. Over a shop door near the.nqrket the following cheerful notice is exhibited in largeletters:

l'-he best black and gnld coffin-ware supplied. If requiredon Sundays apply at

Within easy reach of Kingston, by buggy or electric tram,are two public gardens, (Castleton and Hlops Gardens, bothmiintaine(d by the G(overnmernt and both well worth a visit,as well for their display of tropical foliage at its best, as mayb, -een by tthe accompanying illustration taken from a partof Castleton Gardens, as for the many plants and trees ofmedical interest. At Hope Gardens otie of the trves whichflrst attrafts the visitor is the magnifics-nt Poingiana reyia(Flamboyante) from Madagascar, a gorgPous acacia with darkgreen leaves and abundant bracts of scarlet flowers; theSm,ilax utilis, or Jamaica sarsaparilla, is also there, and theCupania edulis or Blighia sapida, with its crimson fruit thesiz4 of apples- There also may be found the bael-fruit tree(gle marmado.), the allamanda catbartica, with its largeyellow flowprs; the passion flower, with its fruit the size ofa small melon, and a plantation of sugar canes. The khus-k 'us grass (Azndropogon), which is very fragrant and is usedfor punkahs in India, is cultivated here. The balsam of Peru(Myroxylum tolu;fera) and the Norantea guinensis, with itsl trge crimson spikes, are also found here.Even in the extensive grounds of the Constant Spring

Hotel there are crotons of various bright hues, the hibiscusred and yellow; the travellers' tree, of which you tap thebase of the leaf and a watery fluid fit for drinking comes out;the cannon-ball tree (Courapile guinensis), also a tree whoselong pods rattle on all day in the wind, which the ungallantnatives have christened woman's tongue. In these grounds,too, are the Erythroxylon coca, from which cocaine is pro-cured; the Paypa, from which papaine comes, and which hasa fruit the size of a large apple, good to eat; stephanotis,tte mango tree, the bamboo, pineapples, pimento, and theanona or-sweet shop, one of whose varieties (Chrimoya) hasbeen called by Clements Markham the masterpiece ofcreation. Roses do not seem to succeed well in this garden,but both at Bellevue and Mandeville I was shown some veryfine blooms, chiefly, if I remember rightly, of Gloire deDPloU.

Looking over the extensive hotel grounds from my bed-room window in the early morning, and watching the purplehaze steal over the mountains not far off, near the tops ofwhich satvera1 residei ces have been built, it struck me thatsomewhere among these hills there might be found a spotwhere the Atraveller -in -eaarch -of reUt- and relaxalion, andpossibly of health, might-pitch his-tent, temporarily at allevents, and live free from business worries, telegrams, andletters-" the world forgetting, by the world forgot "; and Idetermined to investigate this matter before going furtherafield. I may note that at this hotel I for the first time sleptunder a mosquito net, a fine gauze tiEsue which et velops thewhole bed, being suspended by a hook from the cefing.

NOVA ET VETERA.THE INFLUENCE OF FEAR ON MEDICAL RELIEF.

THE1 fear of the unknown has a great deal to do with the delayin attending at hospitals in India, and particularly in surgicalaffections. In England it is not now very common to seepatients with huge tumours in conspicuous situations, becausethey would certainly long ago have attracted the attention ofpersons who would have pointed out the ease with which theycould be removed, and the comparatively small amount ofpain and inconvenience with which the operation could bedone. Many such cases, however, do occur in India. In 1893I removed a growth weighing nearly 31b. from the neck of awoman who had resided quite close to a dispeneary for manyyears, but who, until it had actually begun to slough, had beendeterred by fear and misrepresentation from going for relief.In a still more remarkable case, a woman had a large tumourwhich hung from her neck by a long pediele, even as far asher waist. She had suffered for more than seven years, but,although she lived only three miles from the hospital, she waetoo terrified to seek relief. In three weeks, so simple was thecase, she was discharged quite well. In another very extra-ordinary case, a man of about 25 years of age met me on theroad as I was going one morning to my hospital and askedwhether I could remove a huge tumour whieh had beengrowing between his shoulders bince his birth, and whichhad prevented him from lying on his back. He had alwaysfear. d to have it removed, but his two wives had now got tiredof seeing him with such a disfigurement and such an incon-venient addition to lis bulk. The growth, whilh was like a]arge pillow, was about i8 in. long auid weighed more thoanio lb., was removfd with very littledifilculty. Every medicalman in India must have seen similar cases, and, have almostdaily met with patients who, havirg work. d themselves up toundergo preper treatmenit, have fled at the lais moment, orwh1eni they have heard from others exaggerated accounts ofwhat they have gone through in the hospital. So great is thedeterrent effect of the stories which patients and atten-dants tell the newcomer that unless the surgeon operateson the spot, as it were, he will often lose his patient. 1 havefrequpntly returned to the operating room, when on the pointof leaving for the day, on being told, for example, that astone case had arrived, in order to remove it at once, as if Ihad not done so the man who had, after much misgiving.decided to undergo anything that might be necessary, wouldsurely have been missing next day. This is really somethinglike battlefield surgery, and ought to ensure that the Indiansurgeon is fully qualified for such work. It is by no meanscertain, however, that full advantage is taken of this quiteexceptional experience.There are very many serious difficulties in our hospitals for

the superstitious Hindu of the lower classes. lt is not aninfrequent thing in Rajputana to find several, if not a wholewardlul of, women anxious to leave the day after a death,because they say they have felt the Bhut, or spirit, of thedeparted strike against them as they lay in their beds atnight. The popular, if not the classical or educated, idea isthat when a man dies his body, or rather his spirit whichretains the form of his body, remains suspended in the airupside down a short distance from the ground, and naturallyflaps against any one, perhaps mischievously, who is abouthis level, which happens to be about the height of a bed-cot.When the funeral rites and the following ceremonies, whielhspread over some days, have been properly perforkned thespirit is laid.The fear of being haunted by ghosts is another caut e of

disease. An asslstant-surueon gradually became unfitted forhis duties by ill-health. He lost weight, became ezceedinely

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melancholy, and soon ceased to have any confidence in him.self, and at last, when a prey to insomnia and dyspepsia,resigned his appointment. It was then ascertained that hethought that-he was haunted by the ghost of his predecessor,who had lived in the same official house as himself. A greatHindu lady had to be taken away from her home because eachtime'she returned to it she felt the all-pervading presence ofone of, her predecessors.Superstition attacks its apostles as much as their followers.

Some years ago a priest of one sect succeeded in supplantingthe head of another one and in establi"shing his own party asthe principal religious body in the State. His rival cursedhim, and said that, although he had apparent'y been suc-

cessful in obtaining his wishes, it would not profit him,because, while surrounded with good things, he would die ofhunger and thirst. This curse so preyed on the mind of thesupplanter that he dared not take either food or drink,because he thought he would become so full that he wouldburst. In a very short time he died of starvation.Great is the dread of the gods, especially of the god Shiva

and his Shakti, or female manifestation-PArvati, Bhawani,KAli, or Durga-and their myrmidons, or allied minordeities. Everywhere men and'women endeavour, by pro-pitiating these deities and their priests, to ward off diseaseand death, which are believed to be due to their anger. Theaboriginal religion of India is based on fear, and in thatrespect differs much from the Vedic faith of the Aryans.

Such, too, is the religion of most Bengalese, who sacrificeenormous numbers of goats at the shrine of the High Priestof Kali, near Calcutta, who, in a pamphlet which he pub-lished on " the plague and how to stamp it out," has shownhimself to be an enlightened man. Sitala, the Goddess ofSmall-pox, lives on young children, and must be propitiated;so that even after vaccination offerings should be made toher at her shrines to assuage her wrath, and all the tankswithin some miles of the child's home should be visited, inorder that he may be bathed in them. The late PrimeMinister of Jeypore told me that he had been inoculated as alad for small-pox because his parents thought that operationwas less offensive to the goddess than vaccination, but eventhen he was dragged round all the tanks and temples in theneighbourhood until he was quite worn out with fatigue, lestthe deity should still be angry. In like manner cholera isdue to the wrath of an offended deity, and pilgrimage, flight,and offerings must be resorted to in order to appease it.Of these, flight is the best and most certain, andis most ready to hand; and, as the villagers usuallyencamp in the jungle because they are welcome nowhereelse, it is most likely to be successful; and, in fact,the epidemic then often ceases. Fear has proved an equallypotent factor in dealing with plague, and it was to dispel suchfears that Pundit Haridas Shastri, the priest whom I havementioned, prepared his pamphlet. He advocates inoculationas well as many other most advanced measures, and shows, byquotation from many ancient Indian authorities, how theseproposals are quite in accord with them. Thus, ior example,he translates as follows a passage from Charaka, one of thefounders of Indian medicine:When Mahamari (plague) invades a city or town, the inhabitants

thereof should adopt the following means in order to save themselvesfrom destruction: They should be truthful in what they say, should becharitably disposed towards their fellow creatures; they should alwaysremain in a worshipful spirit, and preserve equanimity of mind; andthey should mzake the7nscives scarce and go elsewhere.Outside every village in many provinces will be found an

image, most often but a rude stone streaked with red paint,which represents the local god, who will revenge himself uponthe residents unless he receives due respect, and a light iskept up at his little shrine or some other suitable recognition'is made. He is generally known as the Bhumia, or Lord of theSoil, and not infrequently is the spirit of some landowner whowas unjustly slain when defending his rights on or near thespot. Sometimes he haunts the neighbourh6od as a ghost,and may be seen by people who are out late at night, or hemay take the form of a huge snake-generally of a blackcobra.When plague first began, its management was much

hindered by the fears of the people, who believed every foolishrumour. Our hospitals were tabooed because it was said thedoctors required victims to compound drugs; the gods wereoffended, and showed their wrath by sending the disease;and, in one instance, a goddess had driven* her chariot overthe country, leaving storm, plague, and famine wherever thewheels of her vehicle passed.

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In short, nothing was too foolish to be believed. Vaccina-tion has been hindered in many places by the report that theoperation was done in order to discover a child who was theImam Mehdi of the Mohammedans, or the Kalki AvatAra ofthe Hindus, both of whom are expected about this time. Itis said that these infants will have' milk instead of blood intheir veins. Every one has heard of the Imam Mehdi, andthe last-named is the tenth incarnation of Vishnu, the secondmember of the Hindu Trinity, who it is hoped will shortlycome and inaugurate a new age on the earth.The fear which arises from superstition is not always con-

fined to the ignorant, but may influence the well educatedman, and even the specialist, so difficult is it for an in-dividual to emancipate himself from his early environment;thus, for example, there was an Indian medical graduatewithin my knowledge who had not allowed his child to bewashed for more than a year after its birth lest it shouldbecome a victim to epidemic disease. In this and manysimilar cases it is probable that the women of the houee weretoo strong for its master. It is for this reason that I wouldlike to see the establishment of courses of lectures in Indianmedical schools on the effect of indigenous beliefs andhabits and customs on the practice ot medicine, as wellas the teaching of hygiene, and the introduction ofsuch matters more freely into the general education ofthe country. TheEe ideas are opposed because theIndian often affects to disbelieve in the importance ofthe subject, and in the influence of early training, of evena diametrically opposite system, on a man's future opinions,or else he thinks the subject too trivial for consideration inthe universities. The professors in our medical schools alsosometimes raise the objection that their students haye toomany things to study, and add that these things are dealtwith by them in their regular lectures. Yet, is it not. mostimportant that the future teachers in our medical schools forthe hospital assistant class, and the general practitioners ofthe country, should be especially well grounded in thesesubjects so that they may feel their great importance, whichthey are not likely to do if they are kept in the background?In urging my friend, Major Bedford, I.M.S., to write theexcellent Manual of Hygiene for Indian &hools which he hasrecently published, I laid particular stress on the importanceof showing how the practice of true sanitary and hygienicmeasures was not opposed to any Indian religion or. casteregulation, and I asked him to illustrate his subject bycopious references to Indian habits and customs, all of whichhe has done.In order to divert the attention of a god or demon who has

an evil eye upon, or an evil design against, a child, its parentswill sometimes dress it, if it is a boy, in the garments of agirl, and even arra,nge its hair like that of a female. A littleboy, who was thus dressed, in order to avoid the fate of anelder brother who had died, was brought to me and operatedupon for stone. In a similar case, the boy had lost threebrothers, because it was said that the family bad incurred theanger of a spirit, who was once the Chief of the State, andwhoin consequence of his sudden and unhappy death had becomea Bhumia. The effects of fear may, however, be got over,if there is some stronger emotion. Hindu women rely abso-lutely, in most cases, on their husbands or sons. An elderlywoman was once brought to me with a large scirrhus tumourof the breast, and was taken into the operation room at herown request, in order to undergo the operation, but onarriving there she became so alarmed that- we could not.proceed, and she was removed. In less than five minutes,however, she returned, having had a short conversation withher son, who successfully overcame all her scruples, and sheunderwent the operation without any further difficulty.

T. H. HENDLEY, C.I.E., Colonel I.M.S. (Ret.)

MEDICAL MAYOR.-Dr. Alfred Charles Mayo. an ex-Presidentof the East Anglian Branchof the British Medical Asseciation,has been elected Mayor of Great Yarmouth.FOUR new Hebrew wards at the London Hospital, erected

through the generosity of the late Mr. E. L. Raphael, wereconsecrated and opened on November 14th by Mr. LeopoldRothschild.

Dr. EDmuND CAUTLEY will read a paper on the managementof the milk supply in towns, at a special meeting of thecouncil of the Charity Organization Society to be held onMonday next, at the Royal United Service Institution.Whitehall, S.W., at 4.30 p.m.; the chair will be taken byMr. E. W. Brabrook, C.13.

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1472 Ea~~~~~Jou,w.] LITERARY NOTES. [Noy. 26, 1904.~~~~~~~~~~~~~~

LITERARY NOTES.A NEW journal, La Revue H'itoriue et Midicale, the scope of

which is indicated by its title, has just appeared in France.The editor is Dr. Paul Triaire, well known to all who areinterested in the history of medicine by his commentary onthe letters of Gui Patin, and his books on Larrey andR6camier.The November number of the .7ournal of Pathology and

,Jacteriologiy contains, among other communications, papersby Sir Lauder Brunton and Mr. T. J. Bokenham on the powerof the liver to destroy diphtheria toxin; by Dr. Alec R.Ferguson on the histology of the skin in variola; and Mr.J. W. Thomson Walker on osteomata of the brain. TheJournal is, as usual, excellently printed and beautifullyillustrated.Messrs. Longmans, Green and Co. have in the press a book

entitled A Common Humoral Factor of Disease, by Dr.Francis Everard Hare, late Consulting Physician to theBrisbane General Hospital, and Inspector-General ofHospitals for Queensland. The work is described as "adeductive investigation into the primary causation, meaning,mechanism and rational treatment, preventive and curative,of the paroxysmal neuroses (migraine, asthma, epilepsy,etc.), gout, high blood pressure, circulatory, renal and otherdegenerations." Dr. Hare is the author of The Cold BathTreatment of Typhoid Fever and The Mechanism of theParoxysmal Neuroses.

A recent number of the Tribune M&licale contains an articleby the late Dr. A. Dureau, Librarian of the Paris Academy ofMedicine, on the last year of the existence of the FrenchAcademy of Surgery. It is generally stated that the Academywas suppressed by a decree of the Convention dated Augusti8th, 1792. By the terms of that decree, however, onlyuniversities, schools and colleges were suppressed, and theAcademy continued to hold its weekly sittings till August22nd, 1793, when as the result of a further decree of the Oon-vention, whereby "all academies or literary societies patentedor endowed by the nation" were suppressed, it ceased toexist. During the twelve months which it survived its rivalthe Faculty of Medicine, the Academy continued its scientificwork llndisturbed by the political storm raging outside.Among the subjects discussed were aneurysm, Caesareansection, extrauterine pregnancy, and amputation throughjoints. One sign of the times is to be found in a newduty imposed on the Academy, that of examining candi-dates for appointment as chirurgien-major and sous-aide in thegendarmerie, and the navy. The Academy was also asked toappoint commissioners to examine the vehicles intended forthe transport of the sick and wounded of. the armies of theRepublic ; to draw up reports on the organization of hospitals,etc. On July i8th, I793, in consequence of the smashing bycertain individuals of a marble statue of Louis XIV,which stood in the great hall, the Academy appointed aCommittee with full power to destroy " all effects, furniture,and other objects, which may present any traces of theascien r6gime," and to replace them by Republican emblems.Evidently political feeling was beginning to run high withinthe precincts of the Academy, for after the sacred words" Libertd et Egalit6," had been inscribed on the walls of theAmphitheatre, they were effaced by some reactionary hands.The Academy thereupon ordered that the doors of theamphitheatre were to be kept locked, except during thehours of lecture. All this, however, failed to avert its doom.In the Chemist and Druggist of October 22nd the following

history of Fowler's solution is given: Thomas Fowler was anapothecary who kept a drug shop in York from 1760 to 1774.In the latter year he relinquished trade and went to Edinburghto study medicine. He graduated M.D. in 1778 and settled inpractice at Stafford, where he was appointed Physician to theinfirmary. Later he returned to York, where he acquired alarge practice. He died in i8oi. In his time appeared apatent medicine under the title of "Tasteless Ague and FeverDrops," or theymay have been two medicines. "TastelessAgue-dropsI"and "Tasteless Fever-drops " are separatelyscheduled in the Medicine-Stamp Act of I812. In a treatise,entitled Medical Reports of the Ejects of Arsenic in the Cure ofAgues, Remitting Fevers, and Pertodic Headaches, published byFowler in I786, he writes: "When the Patent Ague-dropsbegan to acquire some reputation in this country they wereoccasionally adopted in the hospital practice of this place[the Stafford Infirmary], and were found efficacious." Thenhe tells how " Mr. Hughes, the apothecary to the infirmary

(whose industry, attention, and abilities in his professionalline justly merit applause)," had set to worlk to imitate thissecret remedy, and had come to the conclusion that it was apreparation of arsenic. Fowler's formula, as ultimatelyarrived at, was given as follows:Recipe Arsenici Albi in Pulverem subtilissimum triti

Salis alkalint-fifit vogetabilis purificati,singulorum granaSexaginta quatuor

Aqua, fontanw destillatn Libram dimidiamImmitantur in Ampullam florentinam quAf in Balneo Arena posit&.

Aqua lente ebulliat donec Arsenicum perfecti Solutuin fierit. DeindeSolutioni frigidie adde

Spiritus Lavandulte compositum unciam dimidiamAquoe fontanae destilatoe Libram dimnidiam, plus vel minusadeo ut Solutionis Mensura Libra una accurata fit, velpotius Pondere uncie quindecim cum dimidia.

Dr. Fowler reminds his readers that of course troy weightsare intended. He adds the spirit of lavender, he explains,merely for the sake of giving the mixture a medicinal appear-ance, lest patients entrusted to drop it for themselves mightbe tempted to use it with too much freedom. Also, becauseof the disagreeable association of ideas with arsenic he pro-poses to call the medicine "Mineral Solution." He appendsdetails of some of his cases, and states that he had used theremedy in 247 cases of ague, that in 171 of these cures hadresulted, of which 27 had been after relapses. Of the others45 were cured between arsenic and bark, 24 had failed prin-cipally through the irregular attendance of the patients, and7 were still under treatment. Fowler, says our contemporary,was unquestionably the pioneer of the modern mecdicinalemployment of arsenic, but it is clear that he was himselfpioneered by a patent medicine.The Smithsonian Institution has recently issued Researches

in Helminthology and Parasitology, by the late Dr. JosephLeidy. The various papers of Professor Leidy on this subjectmake a book of 248 pages.' To the collection is added abibliography of his contributions to science consisting of <S9titles. The series has been edited by Joseph Leidy, jun.,D.RIn Messrs. Sotheby's large sale-room there may now be

seen an exceptionally fine collection of old book-bindings.They belonged to the late Professor W. H. Corfield, who wasa noted lover of old books and a thorough connoisseur inbinding. The other portion of his library, some 500 lots wassold in June last for something under .7o0 It is consiaereddoubtful whether in any 6ther private collection so remarkablea series of English bindings can be found. There arerepresented early craftsmen like John Reynes, the rare" M.D." Cambridge binders like the famous Garret, Godfrey,Royal binders such as Samuel and Charles Mearne, later menlike Roger Payne. The total amount realized by the sale was45,0I0 i6s. 6d.Major Arthur Griffiths, in his interesting Fsfty Years of

Public Service, recently published, says that when he enteredthe army the medical examination was by no means so severeas it is now. In illustration of this statement, he tells thefollowing story:-A contemporary got through with flying colours, and, although some

doubts of his eyesight were hazarded, he was passed. At the door heturned and said, " I think I ought to tell you that I've got a glass eye,"but they did not go back upon their decision. A candidate with ratherinferior powers of vision implored the man who went in just before totell him exactly what happened. The latter reported that ke was takento the window and desired to say what he saw in the street. It was a'bus passing, drawn by grey horses. When our friend's turn came hewas asked exactly the same question and gave exactly the same reply." What! " cried the doctor, " you can see that omnibus ? " (which wasturning the corner). ' You must have an uneommon long sight.You're all right."When Major Griffiths was stationed at Montreal, there wasin the garrison an officer who may be regarded as one of thepioneers of the invasion of the sanctuary of medicine bywomen, although, so far as we are aware, her name is nevermentioned in the history of that movement:The P.M.O., Qr Principal Medical Officer in the command, was In-

spector-General Barry, who was fully proved to have been of the femalesex. It was an established fact that when stationed at the Cape shehad fought a duel, and there was a belief that she had at one timepassed through the married state. Suspicions of her true sex wereoonstantly rife, and her appearance was always suggestive of femininity.A certain extravagance of dress was always noticeable in her, she worea great silk bow on the breast of the uniform frock coat, dandifiedpatent leather boots, and long-flingered white kid gloves, and alwaysappeared in a long curly chesnut wig.Major Griffiths also tells of aprison doctor who recommendedthe release of a " lifer" on the plea that the man's health wasso precarious that he could not possibly live to complete hissentence!

Ma xarvim 11472 Mbme" iolmNAvi LITERARY NOTES. LNov. 26, I9go4.

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Nov. 26, 90*4.] REPORT OF LOCAL GOVERNMENT BOARD. [ ov- '473

REPORT OF THE LOCAL GOVERNMENT BOARD,1903-4.*

THE volume before us, consisting of some 950 pages, is theannual Domesday Book of the English people. Of all officialreports presented to Parliament few, if any, are concerned sointimately with the life and conditions of the people as thisannual report of the Local Government Board. It covers awide ground both in administration and in the range ofsubjects. The first 218 pages form the actual 'report of thePresident of the Board (the Right Hon. W. H. Long, M.P.),and the remainder of the bulky volume is constituted ofappendices and returns. The President's Summary is dividedinto sections, as follow: (i) The Local Government Act, i888,and County Councils; (2) the Local Government Act, 8894 ;

(3) Relief of the Poor; (4) the Public Health and LocalAdministration; and (5) Local Taxation and Valuation. Wecan only refer here to some of the most prominent facts, andto matters concerning public health and State medicine. TheMedical Supplement has already been referred to in theBRITISH MEDICAL JOURNAL.

EXTENT OF PAUPERISM.Many of the fundamental facts of the report deal with

pauperism. As judged by the number of paupers relieved onthe last day of the last week in each month of the year(excluding vagrants and lunatics), there appears to have beenan increase in the aggregate of the years 1901-3. The rise was,however, less general than that reported last year. Theincrease took place mainly in Leicester and other counties ofthe North-Midland Division and in Lancashire. There wasagain a decrease in the South-Western Division, com-prising the counties of Wilts, Dorset, Devon, Cornwall, and8omerset. It is well known that the classification of paupersis, broadly, into (a) indoor, (b) outdoor, and (c) insane.Of the indoor paupers the mean number for 8904 iS 240,947for England and Wales (including London), which gives aratio of 7.2 per i,ooo of the estimated population. Then therewere 597, 123 outdoor paupers (including lunatics in asylums),making a total mean number of 838,070, or 25 per i,ooO of thepopulation. If the vagrants and insane be excluded, the totalbecomes 722,270 and the ratio per ,000, 28.6. These are thehighest returns since 8goo, and the total of 838,070 is consider-ably higher than the highest average reached in any of thepreceding twenty-four years in the tables given. A noticeablefeature in the pauperism of the last twenty-five years is theincrease in the numbers of the paupers receiving indoorrelief. The numbers of the outdoor poor in the same periodhave shown no material change. Considered, however, inrelation to the population, the average number of paupers,excluding vagrants and lunatics, is, with three exceptions,the lowest in the quarter-century. There has been, on theother hand, a consistent yearly increase of insane paupers,amounting in the period I884-8894 to I8.9 per cent., and inthe following decade (I894-8904) to 23,236, or 28.7 per cent. Themean number of vagrants who received relief is still high,being over 82,000. The total expenditure exclusively relatingto the relief of the poor during the year ended at Lady Day,8903, amounted to /12,848,323, which represents an average

charge of 7s. 9gd. per head on the estimated population. Theparticulars of expenditure are set out at length in the report.An interesting light is thrown upon the question of the

increase of indoor paupers by the lucid report in the appendixfrom the pen of Mr. H. Jenner-Fust, the Inspector for thedistrict of Lancashire and Westmorland. He attributes thisincrease in part to three broad conditions. First, there hasbeen a scarcity of work in most industries. Secondly, theWorkmen's Compensation Act, I897, is spoken of as preventingfrom obtaining employment large numbers of men between50 and 6o years of age, who though able to work and earn theirown living, are thought to be not quite so active as youngermen and slightly more liable to meet with accidents. Then,thirdly, there is the greater comfort of our workhouses andthe want of strict separation of the really able-bodied fromthe old and infirm. It may be right, as Mr. Jenner-Fust says,that the latter class should be made comfortable, but if, as issometimes the case, this comfort is accompanied by too muchfreedom to come and go as they like, to receive constant visitsfrom friends, and to do no work at all, the deterrent influenceof the workhouse is seriously interfered with. The funda-mental principle in respect of the legal relief of the poor is

I

that the condition of the pauper ought to be, on the whole,less eligible than that of the independent labourer. But apublic institution, if properly arranged, secures to an inmatea larger amount of bodily comfort than is enjoyed by anordinary independent labourer in his own home, in respect ofventilation, warming, light, meals, etc. Hence the only modeconsistent with humanity of rendering the condition of thepauper inmate of a public establishment less eligible thanthat of the independent labourer is to subject him to such asystem of labour, discipline, and restraint as shall be sufficientto outweigh in his estimation the advantages which he derivesfrom the bodily comforts which he enjoys.

SMALL-POX AND OTHER INFECTIOUS DISEASES.The Board reports that in 8903 there was a marked reduction

in small-pox in the metropolis, and, indeed, in all other notifi-able diseases. The total number of cases of all notifiablediseases in 1903 was 22,890, the lowest return of the lastdecade, following 39,997 for 1902, which is the highest in thedecade. Small-pox fell from 7,796 cases in 1902 to 486 in I9O3,and, with the exception of typhus fever, all the chief infec-tious diseases showed a similar decline. Of typhus fever therewere 22 cases as against 4 in 8902. It is interesting to observethe steady rise in the percentage of admissions to hospital tonotifications. In I894 of scarlet-fever cases 63.9 per cent. weresent to hospital, whereas in 8903, 84.2 per cent. were admitted.In 1894 of diphtheria 38.8 per cent. were admitted, whilst in8903 78.2 per cent. were admitted; and in 1894, 20.2 per cent. ofthe cases of enteric fever were admitted, as against 52.4 percent. in 8903. Reference is also made to the efficacy of diph-theria antitoxin, owing to the use of which the diphtheriamortality has fallen from 40.7 per cent. in I889 to I I.0 per cent.in 1902. From the vaccination returns completed for I9OI itappears that in England and Wales of 929,882 children whosebirths were registered 78 per cent. were successfullyvaccinated, I I per cent. died unvaccinated, 0.3 per cent. werecertified as "insusceptible," and 4.3 per cent. of the wholefurnished certificates of conscientious objection. Of the entirenumber of children whose births were registered in I9OI, 83.0per cent. were not finally accounted for as regards vaccinationat the time the returns were made, which is less than that forany year since I890.

Closely allied to the subject of the prevention of infectiousdiseases is the provision of hospital accommodation, uponwhich Mr. Baldwyn Fleming (the Inspector for the UnionCounties of Dorset and Southampton, and parts of Wilts andSurrey) makes some interesting observations. He states thatin his districts the provision of isolation hospitals progressesin spite of " the unfortunate agitation which has occurred insome parts against the utility of isolating infectious fevers."Without entering into medical questions, which Mr. Flemingrecognizes as beyond his sphere, he deplores any relaxation ofeffort to provide hospital accommodation. He takeg up hisposition on three or four broad principles: that personal con-tact is at least one method of the conveyance of infection;that the resources of the ordinary working-class home are notadequate for the proper treatment of infectious diseases; thatthe nursing of cases at home inflicts hardship and risk uponthe other inmates of the home and upon their neighbours;and that the nursing resources necessary for home treatmentof cases are inadequate; and, therefore, he concludes that thewhole question is not covered simply by statistical results asregards case-mortality and the incidence of the disease incertain areas.

VAGRANCY.The annual report again contains a large body of facts con-

cerning the great unsolved problem of vagrancy. The numberof these persons does not apparently decrease, if we are tojudge by the numbers receiving relief, which now is alwaysbetween 6,ooo and io,ooo, and, of course, they are a con-tinually shifting body of men: here to-day, gone to-morrow;so that in actual practice it means that in some districtsmore than 200,000 vagrants are admitted to Poor-law insti-tutions in the year. Further than that, it must not beforgotten that this class of the community give trouble to theState in at least two ways-they are frequently the origin ofcriminal trouble and annoyance, and they convey infectiousdisease from one locality to another. Under the Poor Lawthey may be divided into three main classes: (I) those whocannot work; (2) those who can work but will not; and (3)those who can work and will. The last, it is to be feared,is a small proportion of the total. They are mostl#of a class of casual labourers who are not, as a rule, thrifty orfond of work, and are only employed when workmen are

Thirty-third Annual Report of the Local Government Board, 1903-4,218pages, with appendice3 1.836, and charts.

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'474 M.L'J0.flI.AL1 THE CAUSATION OF INSANITY. lNov. 26, 1904.

scarce. The marked increase in the number of vagrants hasbeen held to be due to (i) depression in trade, (2) close of thewar,,(3) exit of able-bodied inmates from workhouses, and (4)the treatment meted out to these people by the guardians incertain unions. It is fairly well proved that the guardians aresometimes themselves to blame for much of the vagrancywhich. exists, inasmuch as they have never systematically andgenerally exhausted the powers which theyat present possess.The same difficulty is met with elsewhere. "TThe want of theuniform treatment which is so desirable," says Mr. Fleming,"is to be observed on the Bench as well as the Board ofGuardians, and casuals soon learn to turn the leniency of thejustices to the best advantage." Mr. Fleming also raises, inhis report to the President of the Board, the interesting ques-tion as to why labour is scarce in rural districts alongside theincrease of vagrants and casual labourers.. He attributes thiswell-known condition, in part, to the fact that we are dealingwith the first generation of a "well-educated" lower class,which finds the rural district too dull for its tastes, of toolittle earning value for its ambitions, and affording in itskinds of employment too little comfort for their standard ofcomfort. For example, we hear much of the requirementsnecessary in a milker, cleauliness and so forth. But one ofthe great difficulties in dairy farming is to obtain milkers ofany kind; a milker has to be up before four o'clock in themorning seven days in the week all the year round. That is ahardship which the exacting milk consumer is liable to forget,and though the wages are not exceptionally low, the condi-tions are such that;men who can obtain other employmentdo so.

FOOD ADULTERATION.Probably the only other matter in the report of general

interest to the maedical profession is concerned with thequestion of food adulteration. The total number of samplesof food analysed in 1903 was 78,097, showing an increase ofmore than- 5,000 samples over 1902. There is still much to bedesired in the way of uniformity of sampling in differentdistricts, for whilst in some districts one sample is taken toevery 233 persons, in other districts one is taken to every gooor i,ooo persons. Penalties also vary, as do prosecutions.As a rule the penalties 'are far too low to exercise anydeterrent effect on processes of adulteration, which is usuallya remunerative practice. Milk, as in previous years, is byfar the most common article sampled, and there is evidencein the report to show that, on the whole, milk sent to Londonis above standard, and that therefore the presumption is thatadulteration of milk sold in the metropolis is due to theLondon vendors or contractors. On this account it isprobable that the refusal of metropolitan magistrates toconvict, unless there is a sufficient adulteration to reduce thequality of milk much below standard, may be responsible forthe escape of many offenders. We should like to see heavierpenalties for repeated offences, for by such means thevendor of " accidentally ". poor milk would escape, and theregular and systematic defrauder would be heavily penalized.The report contains a full record of the examinations of themetropolitan water supply, and several interesting reports onthe social question of the education and boarding-out ofchildren under the Poor Law.

THE CAUSATION OF INSANITY.WE have already on more than one occasion' referred to theFifty-eighth Report of the -Commisgioners in Lunacy dealingwith the distribution, amount, and causation of lunacy inEngland and Wales in the year I903; but the information itcontains gives so much food for reflection that no excuse isnieded for dealing with certain points not hitherto fullyconsidered.

THE ASSIGNED CAUSES.It is not proposed to discuss whether the steady increase

of insane persons "reported to be under care, from I8.67per io,OOO of population on January ist, I859, to 34.71per sio,ooo of population on January ist, 1904, implies a realincrease of insanity or a greater proportional use of asylums, orin part the operation of both of these factors. We content our-Selves for the present with discussing the assigned causes ofinsanity given in Table XXII, Appendix A, of the report.This table shows the yearly average of assigned causes ofinsanity during the five years I898-1902. The Commissionersare careful to point out that this returnis only approximately true; nor. must it be forgotten that more thanone antecedent may be present in a single case, rendering it often

1 septeniter l7th, p. 683; October 22nd, p. IIOI.

a matter of difficulty to diotingulsh between the predisposing condi-tions and the exciting cause of any given attack of mental derange-ment.'With this statement in view, we may next give the classifi-

cation adopted by the Commissioners, except that we have;lumped together such causes as sunstroke, puberty, fevers,etc., which were apparently responsible for only a small shareof the total cases.

Proportion per Cent. of Assigned Causes of Insanity, based onthe Average Annual Figures for the Five Years 1898-1902. :

Causes of Insanity. Male. Female.

Moral.Domestic trouble (including loss of relatives andfriends) ... ... ... ... 3.8 8.6

Adverse circumstances (including business anxietiesand pecuniary difficulties)... 5-7 3.5

Mental anxiety and '"worry" (not included underthe above two heads) and overwork ... ... 5 7 5 9

Religious excitement . . .2 z.6Love affairs (including seduction) . o.5 .Fright and nervous shock ... ... ... ... 0.7 I.7

Physical.Intemperance in drink ....... ............... 22.89 s

, 9 sexual ... ... ... ... ... ... 0.9 0.5Venereal disease ... ... ... ... ... ... 3.6 o.&Self-abuse (sexual) ... ... ... ... ... ... 2.1 0.2Sunstroke. ... ... ... ... ... ... 1.5 0.1Accident or injury ... ... ... ... ... ... 42 0.7Parturition and the-puerperal state ... ... - 5 &ChaDge of life ... ... ... ... ... ... - 5 4-Old age ... ... ... ... ... ... ... ... 7.18.2Other bodily diseases or disorders ... ... ... .. I3.9 22.7Previous attacks . .. ... ... ... ... ... I6.I 22.6Hereditary influence ascertained ..... I8 6 24.4.Congenital defect ascertained ... ... ... .. 6.o 4-oUnknown ... ... ... ... ... ... ... ... '7.2 15.4

In the preceding extract from Table XXII of the Commis-sioners' Report, the relative frequency of the different assignedcauses is indicated. The caveat which the Commissionersthemselves issue is obviously necessary. There has been noattempt in the final classification to place each case under asingle heading. The totals " represent the entire number ofinstances in which the several causes (either alone or in com-bination with other causes) were stated to have produced themental disorder," and one case may therefore appear underseveral heads. Under these circumstances it is difficult, andindeed impossible, to appraise the value of the percentagesgiven in the preceding table. One thing is quite certain, thattheir value is relatively small, and must remain so until moreaccurate information is obtainable or a more scientific classi-fication is adopted. It must be admitted that whateversystem be adopted, the difficulties of obtaining accurateinformation in mental diseases are extremely great. A criticalattitude is easy to maintain-constructive suggestions offermuch greater difficulty.

CRITICISMS AND SUGGESTIONS.We venture, however, to make the following criticisms and

suggestions.First, truth is disguised, and what value the figures would

otherwise possess is almost lost by the fact that generalparalysis of the insane is classed with other forms of insanity.We are told that in 3.8 per cent. of the total male cases ofinsanity, venereal disease was an assigned cause. What wouldhave, been the proportion had the statistics for generalparalysis been separately stated? To give the percentage ofassigned causes,for all forms of insanity together appears tobe just as wise a procedure as it would be to give the propor-tion of total cases of cancer, enteric fever, typhus fever, andtuberculosis all lumped together, which are supposed to bedue to injury, to infected milk or water, to personal infection,or to overcrowding.

Secondly, some of the items in the above table shouldclearly appear in separate tables. For instance, the informa-tion that i6.i per cent. of the male and 22.6 per cent. of thefemale patients had suffered from previous attacks throws nolight on the causation of the present attack, apart from theinformation which is lacking as to the form of insanity andthe cause of the first attack. Similarly the information thatin i8.6 per cent. of the male patients and 24.4 per cent. of thefemale patients hereditary influence was ascertained wouldhave an appreciable value if the percentage were given foreach form of insanity separately.In the final issue it must be admitted that the statementa

of ascribed c'auses are in the main merely statements of ante-

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cedents ascertained with more or less accuracy and complete-ness, and the ascribed causes, although antecedents, cannot beshown to have been invariable unconditional antecedents.There is no such thing as a simple cause followed by a simpleeffect. If we aceept the definition of Mill, Herechell, audother logitians, that the cause of any phenomenon is the sumtotal of all its antecedents, and if we agree that it is the objectof an etiological investigation to discriminate by carefulanalysis between the relevant and the irrelevant, we have aproblem which in the case of insanity is one of the mostcomplex that can be attacked.This being so, it is supremely desirable that each form of

insanity should be separately treated in a statistical state-ment; that cases in which one assigned cause only is dis-covered, should be carefully separated from those in whichthe assigned causes are multiple; and that in each form ofinsanity careful classification of cases according to age andsex should be given.

ALCOHOL AND THE CAUSATTON OF INSANITY.Tn the last annual report of the Commissioners in Lunacy,

"intemperance in drink" is stated to have been the assignedpredisposing cause of 220 male and 88 female, the assignedexciting cause of x,812 male and 795 female, and as eitherexciting or predisposing cause (where these could not be dis-tinguished) of 217 male and 92 female cases of insanity occur-ring during thp five years 1898-1902 in county and boroughasylums, etc. Otherwise stated, this means that, in 22.8 percent. of the men and in 9.5 per cent. of women admitted tothese institutions, alcoholism was the assigned cauee ofinsanity. Bearing in mind the precautions which are I r)-perly given by the Commissioners as to drawing inferencesfrom assigned causes, it cannot be coneidered sati3-factory that there is so little trustworthy information asto the alcoholic history of insane patients. Nor can asystem of classification be considered satisfactory whichenables Dr. Clouston, on the strength of the statisties of theEdinburgh Asylum for 1903 to conclude that in 42.3 ppr cent.of the cases of insanity excess in alcohol was assigned as thecause of their disease, while in the London County CouneilAsylums 21.per cent. of the male cases of insanity, and in theMontrose Asylum, 8 per cent. are said to be due to alcoholism.Such divergences as are here represented cannot reasonablybe ascribed to corresponding differences in the amount ofintemperance in Montrose, London, and Edinburgh. It isevident that there has been some difference of system inascertaining the antecedents of cases of insanitv, and that inthe minds of some medieal superintendents alcoholism loomsni rp largely as a possible caume of insanity than in that ofothers.

I le subject is one of too great importance to be left in itspresent uncertainty. There is a growing feeling of uneaRinessamong the public that the facts as to al?oholism are under-stated in many of the official tables of insanity, and thatDr. Clouston's figures not improbablv represent a somewhatclose approximation to the facts. When we remember thatalcohol notoriously causes nervous degeneration; that chronicindulgence stopping short of intoxication is more apt to pro-duce deleterious effects on the nerve centres than occasionaldrunkenness; that, furthermore, although drunkenness isgenerally admitted to have declined, the amount of alcoholconsumed per head of population has not declined. there isstrong a priori ground for suspecting that this steady exees-kive donsumption of alcohol must be responsible for seriousmischief to the brains as well as to the other organs of thepopulation. The official statistics are extremely unsatis-factory, and they might at once be made more satisfactorythan they now are in two directions: First, by classifyiriec ises of insanity-each form of insanity being separatt lytabulated- according to the previous occupation of thepatient; this would soon reveal whether any fnrm ofinsanity was excessive-in the same way as are gout,eirrhosis of the liver, phthisis, etc., among publicans, dray-men, and the like. Secondly, the cases of insanity amonglife teetotallers and among those who had been teetotallersfor, say, three to five years before becoming insane should betabulated separately. The remarkable differences which asimilar system has shown in the experience of the. UnitedKingdom Temperanoe Institution as to longevity makes itnot improbable that similar differences might be shown by asimilar classification of cases of insenity.

It may be urged that this involves heavy additional workfor the already overburdened medical offlcrs of asylume.With properly-arranged schedules and systematio methods

of Inquiry the work need not be much more than at present.Even if the increase were large, however, information thusobtainable would possees so much value, as throwing light onone of the mo't serious social probl* ma of the day, that theauthorities responsible for the administration of lunaticasylums ought to have no hesitation in incurring the neces-sary expenditure.

GENERAL MEDICAL COUNCIL.NOTES.

THE eightietb session of the General Medical Council-begsnon Tuesday, November 22nd, when the President deliver6dthe customary address, and the Council, after sitting for twohours, adjourned in order to allow time for certain com-mittees to meet to complete their reports.

The President's Address as usual foreshadowed the work ofthe Council, and it would seem that it ought to be possibleto conclude the session at an early date; in fact the mostimportant announcement made by the President was that -itwas his intention to resign the position at the close of thissession, though retaining for the present his seat upon theCouncil as representative of the University of Edinburgh, ofwhich he is Principal. Sir William Turner has been acourteous and most efficient Chairman, and his retirementwill be a matter of regret to all the members of the Council.It is, we believe, the first time that the President of theCouncil has reverted to the status of an ordinary member.

A Maea.-Sir William Turner, in announcing his resigna-tion of the chair, took occasion to present to the,Council ahandsome silver gilt mace. A vote of tbanks to him for thisgift was proposed and seconded in graceful terms by the twotreasurers, Dr. Pyc-Smith and Mr. Tomes, and carried byacclamation. The Council will, we understand, entertain theretiring President at dinner on November 26th.

Returns of Examinatlons -A motion by Mr. George Brownto refer the tahulated returns of the examinations admittingto the Ryal Naval and Army Medical Examinations to theExamination Committee for report was the cause of somevryptic utteranees. Mr. Brown held in his hand a paper thecontents of which he wished to refer also to the Committee,and the purport of which he was about to disclose to theCouncil, when he was stopped on a point of order. FromScottish and Irish members came protests against the dis-closure of the contents of this mysterious document; theyasserted that if Mr. Brown disclosed the nature of the pro-positions which it contained they must discuss them thereand then at length; while an Engli,.h member plaintivelyprotested that BE had not the smallest idea what it was allabout, and could not vote intelligently upon Mr. Brown'smotion unless he knew. The document was not read, but itwas, we are told, that part of the recent annual report of theRoyal College of Surgeons of England in which evidence wasadvanced in support of the proposition that the holders ofthe diplomas of the English Conjoint Board were sueeesbfulin the examination for admission to the services in far largerproportion than those holding Scottish and Irish diplomas.

" Bona-fide" Medieal Students.-An important queation wasraised as to the meaning to be attached to the phrase, " theproper training and instruction of bona-fide medical studentsas pupils," occurring in the notice regarding the emplo) mentof unqualified persons as assistants or otherwise issued by theCouncil on November 24tb, 1897. Mr. Jackson said thathe was aware of cases in which unqualified assistants hadbeen employed for a long period of years on the 'allegationthat they were medical pupils. A resolution of the Councilpissed in 1893 relating to the fifth year of medical studydirected that it ahould be devoted to clinical work,and recognized that six months of the period mightbe pa8sed as a pupil to a registered practitioner posEessingopportunities of imparting practical knowledge satisfactorilyto the medical authorities. Having rehearsed this resolution,the President laid it down that should the question of Aheinterprptation of the phrase "bona-fide medical students aspupils" arise in a case of alleged covering, it would restwith the person accueed to prove that the asFistant emplbyedwas in fadt a bona-fide medioal student undergoing traningand instruction,

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