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published an excellent addendum on biting flies by Dr. Williamson, and another addendum on Instruction for the Public regarding malaria.

7. The Measurement of Malaria in Cyprus, March-April, 1913. I now come to the observations made during my own visit to Cyprus. It will be unnecessary in this report to discuss the various theoretical points that arise (as I did in previous reports of mine regarding my visits to West Africa, Egypt, and Mauritius), as the whole of this subject has been fully set forth in my book on "The Prevention of Malaria (Murray), with contributions by twenty of the leading workers against malaria throughout the world. I think, therefore, that we might take these points as being for the most part definitely accepted; and may proceed at once to their practical application in the case of Cyprus.

The first thing to ascertain was the exact amount of malaria now present in the Island. One method of measurement is to compare the admissions and attendances for malaria with the total admissions into all the hospitals and the total attendances at all the dispensaries for all diseases during a given year. The figures for this have already been recorded in section 5 above. The proportion of admissions for malaria was 19 per cent. of the total admissions into the hospitals during 1911, and the at- tendances for malaria were 21.8 per cent. of the total attendances at the dispensaries during the same year. The corresponding admission ratio for twenty-one Colonies studied by me was 160 per cent.; and the corresponding attendance ratio for twenty Colonies studied by me was 22:2 per cent.-so that these figures show that Cyprus stands roughly at about the average figure for the British possessions (exclusive of India and some other areas). Of course, some of the Colonies show much higher rates and others much lower ones; for instance, Lagos showed a malaria admission rate of 52-2 per cent., and Mauritius had an attendance rate of 329 per cent. On the other hand, there is little or no malaria in the Seychelles and some of the West Indian islands.

Another method for measuring malaria is to determine the proportion of children whose blood at a given date shows the presence of malaria parasites in large numbers. Unfortunately this method is very laborious and would not give any reliable results for a large area like that of Cyprus under many months work. Moreover, for other reasons discussed in my book, it is inferior as a method to the simple spleen tests, which are now being fairly generally employed. Ilence, directly I arrived in the Island, I suggested to Dr. Cleveland that a general spleen census should be taken on the lines advised by me and used in Mauritius and Ceylon. Dr. Cleveland at once issued instructions to the various District and Rural Medical Officers to carry out the work in the areas under them; and the results are given in extenso in Appendix VI.

Most of the studies were made on the children in the schools, because this gives great facilities, not only for the measurement of malaria, but also for the treatment of the school children who have enlargement of the spleen. The various medical men employed on the task visited certain schools and examined as

many of the children as they could in them. The children so examined were divided into four classes, namely:-

(1) Those without enlargement of the spleen;

(2) Those with small enlargement;

(3) Those with medium enlargement;

(4) Those with great enlargement.

For reasons given by me in my book, I class the enlargements

of the spleen so found under the numbers 1, 3, 6, and 9, because these numbers are likely to give roughly the comparative sizes of the organs with no enlargement, and small, medium, and great enlargement respectively. Of course, different medical officers are likely to differ considerably as to what exactly they consider to be a small, medium, or large spleen; but, nevertheless, for a large public health census of this nature, the figures are suffi- ciently accurate to give us a very good test as to the amount of malaria which is present, and which indeed has been present for some time past, in given area. The proportion of all the children with any enlargement of the spleen at all is called the spleen-rate. Another ratio, which I call the average spleen, is obtained as follows. The number of children with no enlarge- ment is added to three times the number of children with small enlargement, to six times the number of children with a medium enlargement, and to nine times the number of children with a great enlargement; and the total so obtained is divided by the total number of children examined. Obviously this figure gives the average size of the spleen for all the children concerned, according to the principles mentioned above.

There is always a certain amount of observational and also statistical error in all such estimates; and these can be taken into account if we please. But we are not seeking here an absolutely exact measurement, but only one which gives approximately the degree of prevalence of the disease in Cyprus.

The simple spleen-rate is the most free from observational error; but even this is subject to a considerable amount of it— a point which I now understand more strongly than before. This arises from the difficulty of saying whether a spleen which is just palpable under the ribs is really a pathological enlarge- ment at all, especially in the case of very young children. It has been stated that the spleen of healthy infants is often palpable, and the question arises whether it is not sometimes palpable also in the case of slightly older children. This question cannot be fully answered without making a similar study of a large number of children in non-malarious countries. I propose to undertake the work shortly in England, but cannot possibly complete it in time for this report. On the whole, I think that Dr. Patrick and myself accepted as enlarged spleens those which I should hardly have accepted as such in India or Mauritius-a circum- stance which tends to increase the spleen-rate of Cyprus in comparison with those countries. But I do not think that this point will make any really great difference in the total figures obtained.

Dr. Cleveland's results are as follows: -Out of 9,178 children examined in Cyprus 21:82 per cent. were found to have enlarged