Extra-genital Syphilis.

Of the patients treated for syphilis alone, 69 or 0.6 per cent. showed evidence of extra-genital infection. In 1921-22 the corresponding figures were 86 and 0.8 per cent.

Age Incidence.

A comparison between the age-classification of patients for the last two years is given hereunder :

Although smallpox continued prevalent in parts of England, Scotland was fortunate to escape throughout the year any outbreak of this disease. Medical officers of health were on the alert and several suspicious cases were brought to notice, but none of these was confirmed after examination by our medical officers. The only verified case was discovered in the burgh of Aberdeen in the person of a ship's engineer, who appeared to have contracted the disease while with his ship at Goole twelve days before he returned to Aberdeen. Prompt action was taken by the Medical Officer of Health. All contacts were vaccinated and the patient's wife and family were placed in quarantine, and no further case occurred.

Vaccination.

In accordance with the arrangements, mentioned in previous Reports, for the supply of calf lymph to local authorities for the vaccination and re-vaccination of the general public, we continued during 1923 to issue supplies of lymph to medical officers of health on requisition, the net cost being repayable by the local authorities. As there was no outbreak of smallpox the demand for lymph was small, but during the year medical officers of health were supplied with a quantity sufficient for 9045 vaccinations.

In addition we continue to supply free to parish medical officers lymph for the vaccination of the children of paupers and defaulters. During the year a total of 2106 doses was issued for this purpose.

NOTIFICATION OF CHICKENPOX.

In 1920 and 1921 we issued regulations making chickenpox compulsorily notifiable in Scotland during the period 1st October, 1920, to 30th September, 1921. At the latter date the need for the notifi

cation of chickenpox had in our opinion ceased to exist and accordingly the regulations were allowed to lapse.

In view, however, of the occurrence of smallpox in a number of districts in England in 1923, and the fact that the disease was of so "mild" a type that its spread was due, in some instances, to its being mistaken for chickenpox, we considered it desirable that chickenpox should again be made notifiable throughout Scotland. We accordingly issued further regulations requiring every medical practitioner who might be attending a person suffering from chickenpox to notify the case to the medical officer of health of the area. These regulations had effect for the period 23rd July to 31st December, 1923, when, in view of the continued freedom from smallpox, they were allowed to lapse.

ENTERIC FEVER.

During recent years there have been few serious outbreaks of enteric fever in Scotland, but in 1923 several outbreaks involving a considerable number of cases came to our notice and were investigated by our medical officers.

At the beginning of the year an epidemic on a large scale occurred in the burgh of Campbeltown. In all, 168 cases of enteric fever were notified in January and February. The disease was fortunately of a mild type, and only two deaths occurred. On investigation the source of infection was traced to the milk from a dairy farm, where it was discovered a milker had been unwell about the middle of January but had continued to milk for some days thereafter. The nature of her illness was confirmed by examination of her blood, which gave a positive Widal reaction, but the source of her infection. could not be traced. After the supply of milk from this dairy had been stopped for a period and the milker prohibited from work, the outbreak very quickly died down.

It is of interest to record that a prosecution was instituted against the farmer from whose dairy the infected milk had come, and that he was fined by the sheriff for continuing to employ the milker while she was suffering from infectious disease.

During the year our attention was drawn to the occurrence of enteric fever in two district asylums.

In one of these institutions cases had taken place at intervals for some years, but it was not until 1922 that cases occurred in considerable number. Our assistance having been asked by the General Board of Control, one of our medical officers, along with the medical staff of the asylum, made a careful investigation into the outbreak.

It was discovered that from June, 1916, till September, 1923, there had been 62 cases of enteric fever in the asylum, of which 55 were females, including 3 nurses. Of the 52 female insane patients, 15 died, and there were 2 deaths among the 7 male patients. The milk supply and the water supply being above suspicion, careful examination was made of the inmates, with the result that there were found among the female patients 7 carriers of typhoid bacilli. Two of these had had enteric fever in the asylum, but so far as could be ascertained the other 5 had not suffered from the disease while under observation in the institution.

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At the other district asylum the outbreak began in November, 1922, and up till the end of January, 1923, there occurred among patients and staff 25 cases, of which 5 were fatal. Here again an investigation was carried out by one of our medical officers and the asylum medical staff, but though everything pointed to a carrier or carriers being the source of infection, it was not found possible to fix on any particular person as the start of the outbreak.

Arising out of these and similar outbreaks of enteric in asylums, we have discussed with the General Board of Control the methods by which accommodation may best be provided for the treatment of known lunatic typhoid carriers in Scotland.

We have had under consideration a township in Sutherlandshire where enteric fever has occurred at intervals during the last two years, the first recognised case being in April, 1922. Unfortunately in this and some subsequent cases there was delay in calling for medical attention, with the result that when they were seen by the doctor the patients were too far advanced in the disease to recover. This delay no doubt also contributed to the spread of the disease.

One of our medical officers investigated the outbreak in the spring At that time it was impossible to state definitely the source of infection, but it was clear than when once introduced the disease had spread by personal contact between members of families and their relations and neighbours who visited them. The water supply, which consists of dip wells, was found to be unsatisfactory, and though our medical officer did not consider the wells to be the source of infection, there is some possibility that they would become contaminated. We have taken up with the local authorities the question of a proper water supply to the township, and we understand that the proprietor is making arrangements to introduce a new supply.

Small outbreaks of enteric occurred in Dundee and Carnoustie during the summer. Five cases occurred in Dundee, all of whom were found to be infected with bac. typhosus. Two of these cases appeared to have received the infection in Carnoustie, the remainder probably in Dundee.

At the same time there occurred in Carnoustie seven cases of paratyphoid B. and one case of typhoid. Enquiry was made in order to discover the origin of infection in both these outbreaks, but no definite source could be discovered. It is possible on the facts ascertained that the outbreak was due to the presence of an undiscovered carrier.

During the summer and autumn outbreaks of paratyphoid B. occurred in the Burghs of Ayr and Prestwick and the surrounding district. In all, 10 cases occurred in Ayr and seven in Prestwick, and 23 in the County. There was reason to believe that the disease had been spread by the agency of milk, but some facts were inconsistent with this. Another suggestion was that the disease was flyborne, the flies coming from a farm dungstead which presumably was specifically infected through human excreta. It seems probable, however, that the source of infection was an undiscovered carrier of paratyphoid B., though no clear evidence was obtained to confirm this theory before the outbreak died down.

Enteric Carriers.

The investigation of the problem of carriers of enteric fever infection, referred to in previous Reports, is still proceeding under the supervision of Professor C. H. Browning of Glasgow. The cost is being met by the Medical Research Council. By courtesy of the Corporation of Glasgow three carriers have been inmates of Belvidere Hospital, where they have been under the observation of Professor Browning. After various therapeutic procedures had failed to alter the excretion of typhoid bacilli, two of the patients submitted themselves to operation on the gall bladder, and since the operation examination of fæces and urine has taken place at regular intervals over a period of six months and has yielded each time negative results. Professor Browning is not yet prepared to say that the patients have been freed from the enteric infection, but is continuing the periodical examinations.

TYPHUS FEVER.

Only two cases of typhus fever were brought to our notice during the year. Both of these occurred in a model lodging-house in Glasgow. Some delay took place before the first case was discovered and diagnosed and it was not found possible to trace the source of infection. The second case, which was infected by the first, proved fatal.

CEREBRO-SPINAL MENINGITIS.

During the year medical officers of health intimated 93 cases of cerebro-spinal meningitis. Of this number 65 occurred in Glasgow. Deaths from the disease numbered 62, of which 45 occurred in Glasgow. The cases presented no features calling for special remark.

The Medical Research Council are working at present on the production of an immune serum for therapeutic use against cerebrospinal fever. As this work has been retarded by scarcity of material, the Chief Medical Officer of the Ministry of Health asked pathologists isolating meningococci from the cerebro-spinal fluid of cases of meningitis to send cultures of freshly isolated strains to the Medical Research Council. We made a similar request to some of the principal Scottish medical officers of health, who agreed to supply the Council with the required cultures when these were available.

ENCEPHALITIS LETHARGICA.

While 1923 was marked by a low incidence of the more common infectious diseases, the obscure disease "acute encephalitis lethargica" increased considerably. Cases were reported by medical officers of health of widely different areas, and these were not confined to populous industrial districts, but occurred also in rural areas such as Easter Ross and Aberdeenshire. We obtained from various medical officers of health and from our own medical officers full reports on a number of the cases, but it was generally found impossible to trace any source of infection or to discover any connection between different cases.

The total number of cases that came to our notice during the

year was 189, of which 125 occurred in Glasgow. From the returns of the Registrar-General for Scotland it appears that in 1923, 79 deaths from this disease took place in the sixteen larger towns of Scotland.

From Easter Ross 8 cases were reported, 2 of them occurring in 1922; 3 of the cases reported in 1923 were fatal. There was also one case in Mid Ross, which recovered. The outbreak, with its heavy mortality, gave rise to anxiety and even alarm in the locality. The cases were miles apart from one another, were not connected in any way, and all arose in a purely agricultural area. Our medical officer reported that in his opinion they were all cases of encephalitis lethargica, in most of which there was a tendency to sleepiness but not to marked lethargy. In those that died, death was evidently due to involvement of the respiratory centre. In the cases that survived, convalescence as a rule was long.

It was also found impossible to trace any connection between the cases that occurred in considerable numbers in Glasgow, and owing to the wide variations in symptoms the Medical Officer of Health reported that it was exceedingly difficult to present a composite picture of the cases.

INFECTIOUS DISEASES HOSPITALS.

APPROVAL OF PLANS."

During the year plans submitted by the following local authorities were approved in terms of Section 66 (3) of the Public Health (Scotland) Act, 1897, viz. :

We sanctioned a proposal to dispose of Dalmally Infectious Diseases Hospital in the Lorn District of Argyllshire.

The efficiency of hospital treatment in many districts is affected