900

tle age of two years. Boiiing the cow’s milk given.as food gave no protection, and it was found that

the milk-supply played no part, unless of a generalkind, in introducing diarrhoea into the home. The partplayed by personal infection, direct or indirect, by flies

and the possible rôle of ground infection are carefullyexamined. Dr. Peters found that infection within the home- was probably the commonest method of contracting the

, disease. The evidence was in favour of personal infectionaDÒ fly carriage, and rather against ground infection. Com-

paijcg the diarrhoea curve with the curves of temperature andBy prevalence, it showed a delayed rise, variations with theirTw3ations, and a definite falling away from their declining.cÐ1Yes. Careful analysis of these curves proved to be quitecompatible with the theory of fly infection, but certain

ctucia) tests which Dr. Peters outlines as necessary to estab-Bsh this theory have still to be proved. This monograph isa thoughtful and valuable contribution to the literature of]I, devastating disease, and deserves careful consideration

by all who are concerned in its study.

VACCINATION IN BURMA.

THE triennial report on vaccination in Burma, by MajorH. So Harriss, I.M.S., Superintendent-General of Vaccination,has recently been issued. The total number of vaccinations

performed daring the period under review was 1,167.673, adecrease of 102,280 on the preceding triennium. The per-centage of successful primary vaccinations was 94-80, ascompared with 91-05 in the previous triennium ; that of

ammessful revaccinations was 62’71, as against the previous5-74. The average number of operations performed byeach vaccinator was 1472, as compared with 1721 in the

- previous period, a decrease of 249. In Lower Burma the

percentage of children successfully vaccinated was 25-56, as’compared with 26’27 for the previous triennium. No com-

parison for Upper Burma can be instituted, as registrationof births was introduced there only in 1907; but there isa steady decrease in the percentage of protected infants inLower Burma, and in Upper Burma so far as figures areforthcoming. As regards the general protection of the

lopulation, during the present triennial period the protectionpef 1000 was 30-49, as compared with 33’16 in the previousttienninm. There are three vaccine dep6ts in Burma-

BaB!ie3y, Meiktila, Rangoon, and 1,:)imwe, the last-namedhaving been opened during the past year. Special mentionis made of the excellent work of Captain H. A. Dougan,in charge of the Meiktila depot,. The introduc-tion of lanoline lymph for use in remote districts has

been attended with marked success at Akyab, where it

gave 94. 2 success as against 84’4 with glycerine lymph.Tavoy and Mergui also recorded 94-2 per cent. success

with lanoline lymph. Liebrich’s lanoline in tins giveswûformly good results, provided the lanoline in the centreof the tin alone is used. The vaccination expenditurehas Tjsec to R9.5,23,910, as compared with Rs.3,80,597in the previous triennium, an increase of Rs.1.43,313.Im view of the decrease in the total number of vaccinations

]mrformed these figures are recognised as unsatisftctory.This great increase of expenditure is ascribed to (a)increase in the number of native superintendents of vaccina-Mam and vaccinators ; (b) the employment of a large numberof peons in areas in which postal arrangements are defective;and (e) the increased pay of vaccinators for length ofservice. The three classes of officials concerned in

vaccination are the vaccinators, the native superintendents,and the civil surgeons. The vaccinators are said to be

mostly young inexperienced men in whom the BurmeseB Dye no trust ; further, they are not reliable, for 17 havehad to be dismissed during the season of 1910-11 for

falsification, fraud, or acceptance of gratuities. The

Lieutenant-Governor, in his resolution on the report,combats the idea that the percentage of men who

had to be removed is high, and believes that the

fault is largely due to lack of trustworthy and efficient

supervision. He considers it doubtful whether thenative superintendents, on a pay varying from Rs.25to Rs.60 a month, can be trusted to exercise adequatesupervision. On the other hand, civil surgeons with a largehospital at headquarters and several smaller hospitals at

different stations, who are vice-presidents of municipalities,superintendents of jails, and sanitary officers for the wholedistrict, to say nothing of doing a certain amount of privatepractice among European residents, cannot possibly find timeto inspect thoroughly the work of the vaccinators. MajorHarris, the Sanitary Commissioner, recommends the appoint-ment to headquarters hospitals of assistant surgeons, whichwould allow the superintendent of vaccination to proceed onthe prolonged tours necessary for the accomplishment of satis-factary inspection. He further recommends an increase in thenumber of Deputy Sanitary Commissioners to be constantlyon tours of inspection. With regard to the native superin-tendents, he considers that it would be a better practice topromote old and trusty vaccinators to such posts, both as beingmore reliable than the young and inexperienced native

superintendents at present appointed on passing an examina-tion, and as offering hope of promotion to the vaccinators. Heremarks on the general distrust, and in some cases even hostileattitude, to vaccination among the natives of Burma, whoin large part prefer the practice of inoculation. (It is worthyof notice, in view of the letters in our columns on August 26thand Sept 9th, and the further letter of "E. A. A." in thecurrent issue, that no reference is made in the report totattooing as a substitute for vaccination, although the

practice of inoculation is condemned.) This practice wasrendered illegal by the Prohibition of Inoculation Act, 1908,which, however, is in force in only two districts; and theSanitary Commissioner considers its extension to be urgentlyrequired, seeing that out of 20 districts reporting small-poxepidemics 11 reported inoculation, and in 6 epidemics weresaid to be the direct result thereof. The Burma VaccinationAct of 1909 gives power to health officers to enforce vacci-nation in certain circumstances in Rangoon and in other

places where it may be urgently required, and also providesfor the vaccination of coolies. To einsare the vaccination of

all newly born children a special combined birth and vacci-nation register has been introduced.

STRANGULATED HERNIA WITHOUT VOMITING.

VOMITING, at first of stomach contents and later of fsecalmaterial, is usually regarded as an essential symptom of

strangulated hernia. In his "Clinical Lectures " Sir James

Paget says : " If I were asked which of the signs of strangu-lation I would most rely on as commanding operation I

would certainly say the vomiting." However, in his

"system of Surgery" Sir Frederick Treves is not quite sodogmatic, for he says : 11 vomiting appears early, is a

marked and almost constant symptom." In the Journal ofthe American Mediaal Association of June 24th Dr. James R.Judd has reported a case of strangulated hernia which wasremarkable in the fact that vomiting was entirely absent.The patient, a Chinaman, aged 64 years, was admitted intohospital. He had been troubled for 15 years with an inguinalhernia which had gradually enlarged. On several occasionshe had difficulty in reducing it, but always succeeded in theend. He never wore a truss. Four days before admission thetumour increased in size and he could not reduce it. Hehad suffered considerable pain and the bowels had actedonce. According to his statement, which was corroborated