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I consider that nothing can be done with the marsh close to Syrianochorio; the village is too small to justify a great expense. It will therefore be an excellent site for an energetic quinine prophylaxis by itself. Efforts should also be made to prevent bilharzia infection in this village as, if care is not taken, that very serious disease is likely to spread in the Island,

(7) I am told that the general registration of births and deaths requires much improvement. The proposed Sanitary Department, with its Sanitary Inspectors, will probably be able to effect this without difficulty.

(8) Regarding the scheme for teaching medical men in Athens, I may remark that I mentioned it to Mr. Venezelos in Athens and to Professor Dr. Savas, and they authorised me to state that there could be no objections to it from them.

(9) I am much obliged to the various medical men who, in response to a request from Government, furnished me with their views on the prevalence of malaria within the areas served by them. I have used the information so obtained in compiling this Report; and hope that everything will be done to encourage similar interest in the subject on the part of all the medical men in the Island.

(10) The best way to keep accurate information regarding all the 738 centres of population in the Island would be to file in the office of the Chief Sanitary Officer a number of sheets, each of which refers to each centre of population and gives the sanitary data for it, including population, birth-rate, death-rate, spleen- rate, breeding pools, refuse heaps and all other necessary items. This file would be indispensable when the Sanitary Department comes to carry out general improvements.

POSTSCRIPT.

To Report on the Prevention of Malaria in Cyprus. Dated the

6th July, 1913.

1. Spleen-rates. In Section 7, page 38, I stated that there was some doubt as to whether a spleen which is just palpable under the ribs is or is not in a condition of pathological enlargement, and suggested that the only way to answer the question would be to examine a large number of children in a non-malarious locality, such as England. This work has now been done by Major Christophers, I.M.S., Major Perry, I.M.8., and myself in three large schools in London. On making a very careful study (by palpation only) of 469 children of over three years of age, we find:-

Number Percentage

Spleen not palpable

Spleen doubtfully palpable

Spleen palpable

458

98.9 or 97'65

6

1.28

5

1'07

Spleen below ribs

0

0:00

Total children examined

469

100.00

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I think that these figures will establish a very useful standard for comparison, because all the children were far removed from any possibility of malaria infection, while all three observers possess a large experience in this kind of work. The children were bent forward over the observer's knee in a position which relaxed the abdominal muscles, and the fingers were then pressed upwards under the ribs in search of the spleen. Only in 107 per cent. of them could that organ be felt; and in none was it enlarged sufficiently to be felt below the ribs. But in 128 per cent. of them it was doubtful whether what was felt was really the spleen or perhaps some intestinal content lying between that organ and the fingers. In the positive cases the enlargement, if any, was of the slightest degree and was probably due to various maladies of children which are known to affect the spleen to a small extent. The general picture presented was absolutely different to that seen in malarious areas.

I conclude, therefore, that the spleen-rates recorded in Appen- dix V. of my Report, and also probably in Appendix VI., and discussed in Section 7, were actually due to malaria within a possible error of between 1 per cent, and 2 per cent. For practi- cal purposes it will be safe, I think, to record all palpable spleens as being probably malarial—the small margin of error being negligible in comparative work, and the enlargements noted by us in London being so small as to be scarcely noticeable in rapid pathometric studies. It is understood, of course, that kala-azar is not present.

When discussing spleen-rates in my Report, I forgot to mention the enlarged spleen found amongst about 8 per cent, out of three hundred children of all ages in Egypt, examined by Day and Ferguson, and described by them in their paper in the "Annals of Tropical Medicine," November 1909, Vol. 3, No. 3. It will be remembered that this enlargement is generally associated with definite cirrhotic enlargements of the liver in about 2-3 per cent. of the cases. Further researches on the subject were made by my brother, Dr. E. H. Ross, then Medical Officer of Health for Cairo. He found that, out of 7,034 children, 483 or 68 per cent. had palpable spleen, and 1,015 or 14-4 per cent. had palpable livers. In 1909 I examined a number of children with him in Cairo, but we did not succeed in finding a single case. The condition has, however, been also observed in Syria. Day and Ferguson declare that it is not due to either kala-azar or malaria, though the symptoms may easily recall, the former.

If a similar disease occurs in Cyprus, it will only be declared by very careful study of the children in connection with the future spleen censuses which I have recommended. Probably, the best way to detect its presence will be to examine the liver as well as the spleen, and a frequent enlargement of the former will serve to raise suspicion. I should say, however, that this form of splenomegaly appears generally (though not always) to be of a very slight nature, the spleen being little more than only just palpable under the ribs, while the malaria spleen so frequently reaches a great size. Day and Ferguson's diseases may, however, possibly account for, say, 5 per cent. of the Cyprian splenomegaly; but this

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