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Supplement to the “F.M.S. Government Gazette," July 11,1924. 


Printed on Latex Paper. 


FEDERATED MALAY STATES. 


ANNUAL MEDICAL REPORT FOR THE YEAR ENDING 

31st DECEMBER, 1923. 


I.—ADMINISTRATION. 

STAFF. 



The total staff of the Medical Department, Federated Malay States, including all 
branches, on the 31st December, 1923, was 726. It was divided as follows: 

Hospitals Branch ... ... ... ... ... ... ... 626 

Health Branch ... ... ... ... ... ... ... 48 

Institute for Medical Research ... ... ... ... ... 16 


Central Mental Hospital 
Veterinary Branch ... 


14 

99 


2. The following were the principal changes which took place : 

Dr. F. E. Wood continued to act as Principal Medical Officer until 1st April, 1923, 
when Dr. R. Dowden returned from leave, when he resumed his appointment as 
Senior Medical Officer, Perak. 

Dr. Wellington, Senior Health Officer, returned from leave and resumed his duties 
on 8th February, 1923, and Dr. Cosgrave, who had been acting for him, took up his 
appointment as Senior Medical Officer, Selangor. 

During the year the following were appointed Medical Officers : 

Dr. B. Cross ... ..27th April, 1923 


Dr. V. M. Mathews 
Dr. H. P. Hodge 
Dr. J. G. Dunlea 
Dr. J. E. Phillips 


25th May, 1923 
21st July, 1923 
3rd August, 1923 
3rd August, 1923 


PROMOTIONS. 

Dr. I. P. Masters promoted Senior Medical Officer, Pahang, with effect from 
3rd June, 1921. 


Dr. D. T. Skeen promoted Senior Medical Officer, Negri Sembilan, with effect 
from 6th May, 1921. 

Dr. A. K. Cosgrave promoted Senior Medical Officer, Selangor, with effect from 
1st July, 1922. 


TRANSFERS. 

Dr. W. M. Chambers transferred to Straits Settlements Service on 21st July. 
1923. 

Captain J. W. Hoflin transferred from the Health Branch to act as Personal 
Assistant to the Principal Medical Officer on 1st October, 1923. 

Mr. H. J. Benjafield, Chief Sanitary Inspector, transferred to the Municipality, 
Singapore, on 15th November, 1923. 


RETIREMENTS. 

Dr. W. S. Milne retired on pension on 18th April, 1923. 

Dr. A. A. Woods retired on pension on 1st June, 1923. 

Dr. W. J. Symes terminated his services on 15th August, 1923, on expiration of 
his agreement. 

Dr. E. R. Stone tei*minated his services on 12th April, 1923. 









2 


DEATH. 

It is with deepest regret that the death of Dr. H. Mowat who died on 
22nd August, 1923, is reported. 

Assistant Surgeons. —The following were appointed during the year: 

Mr. M. K. Lukshumyah on 6th April, 1923. 

Mr. V. E. Gabriel on 6th April, 1923. 

Mr. G. A. Lopez on 13th September, 1923. 

Mr. G. H. Oorloff on 13th September, 1923. 

Mr. S. Subramaniam on 13th September, 1923. 

Mr. A. Sivakolunthu on 13th September, 1923. 

Mr. Makan Singh on; 16th September, 1923. 

RETIREMENT. 

Mr. M. Sangarappillad retired on pension on 3rd October, 1923. 

RESIGNATIONS. 

Mr. Yeoh Hone Soo resigned the service on 2nd March, 1923. 

Dr. J. L. Gregory, Health Officer, resigned the service on 5th August, 1923. 

European Nursing Staff. 

APPOINTMENTS. 

Miss S. Smith, Sister, on 10th March, 1923. 

Miss C. F. Johnson, Sister, on 5th May, 1923. 

Miss E. C. Bosden, Sister, on 23rd May, 1923. 

Miss E. M. Gilbert, Sister, on 27th July, 1923. 

Miss J. Gladwin, Sister, on 6th September, 1923. 

Miss E. H. Hayes, Sister, on 8th September, 1923. 

Miss E. M. Li. Bryant, Sister, on 15th September, 1923. 

Miss E'. M. Ditcham, Sister, on 28th September, 1923. 

Miss E. M. Goulding, Sister, on 26th October, 1923. 

PROMOTIONS. 

Miss E. J. McCarthy, Sister, promoted to Matron, Grade II, from 30th November, 
1923. 

Miss L. M. Jacobs, Sister, promoted to Matron, Grade II, from 30th November, 
1923. 

Miss M. Begg, Sister, promoted to Matron, Grade II, from 30th November, 1923. 

TRANSFER. 

Miss M. E. T'homlinson, Sister, transferred to Ivelantan on 4th May, 1923. 

RETIREMENT. 

Miss V. E. H. Foley, Matron Grade I, retired on pension on 30th November, 1923. 

RESIGNATIONS. 

Miss A. H. Ward resigned on 10th March, 1923. 

Miss A. Campbell resigned on 7th June, 1923. 

Miss J. Dunsmore resigned on 13th September, 1923. 

Miss H. Burtson resigned on 17th August, 1923. 

Miss M. M. Millard’s service terminated on 30th August, 1923, on expiration of 
agreement. 

Miss E. A. Haywood was invalidated home on 2nd August, 1923. 


3 


Financial. 

3. (a) Statement of Revenue for the year 1923- 

Revenue (Hospital Fees, licences, etc.) ... ... $ 246,499 

(6) Statement of Expenditure for the year 1923 (Personal 

Emoluments and Other Charges) . 3 317 516 


Principal Medical Officer .. 

Senior Medical Officer, Perak ... 

>> )> Selangor 

>> >> Negri Sembilan 

>> >, Pahang 

Senior Health Officer, F.M.S. 

Director of Government Laboratories. 

Medical Superintendent, Central Mental Hospital 
Medical Hostel, Singapore 


$ 119,009 
995,524 
832,730 
388,069 
233,788 
319,309 
115,286 
264,433 
49,363 


Total ... $3,317,516 


II.—PUBLIC HEALTH. 

* 

(a).—G eneral Remarks. 

4. The general health of the Federated Malay States may be considered as 
satisfactory as, assuming that the population has increased at the same rate as during 
Ihe intercensal period and judging from the sickness and death-retvrns, the health of 
the country during the year 1923 was better than that of any year under record for 
the past ten years. 

5. The general death-rate for 1923 was 24.40 per mille as against 25.75 per mille 
for 1922 and 29.18 per mille for 1921. 

6. The reason for this improvement must to a great extent be ascribed to the 
efforts of the various authorities, public and private, which have been concerned with 
the prevention and abatement of disease. 

7. The number of in-patients treated in hospitals was 87,310 with 6,762 deaths, 
giving a death-rate of 8.05 per mille as compared with 92,690 with 7,334 deaths and 
a death-rate of 7.91 per mille in 1922. 


The distribution of patients in the different States is shewn below: 


States. 

1922. 

1923. 

Cases. 

Deaths. 

Death- 

rate. 

Cases. 

Deaths. 

Death- 

rate. 

Perak 

42,567 

3,350 

7.87 

41,097 

2,994 

7.29 

Selangor ... 

30,455 

2,419 

7.94 

27,571 

2,220 

8.04 

Negri Sembilan ... 

14,417 

1,149 

7.97 

13,725 

1,131 

8.24 

Pahang 

5,251 

416 

7.92 

4,917 

417 

8.48 

Total ... 

92,690 

7,334 

7.91 

87,310 

6,762 

8.05 


8. The reduction in number of in-patients is accounted for by the fact that 
chronic cases—unless helpless—are sent to Port Swettenham Decrepit Camp and also 
by the fact that the majority of ambulatory cases are now treated as out-patients. 
This also accounts for the slightly higher death-rate in hospitals as only acute cases 
are admitted. 



































4 


9. The principal diseases commonly treated in hospitals were malaria, venereal 
■diseases, ankylostomiasis, dysentery, diarrhoea, beri-beri, pneumonia and pulmonary 
tuberculosis. The following table shows the number of cases and deaths during the 
years 1922 and 1923: 




1922. 



1923. 


Disease. 

No. of cases. 

No. of deaths. 

Percentage of 

deaths. 

No. of cases. 

No. of deaths. 

Percentage of 

deaths. 

Malaria 

26,072 

1,403 

5.38 

21,082 

1,062 

5.03 

Venereal diseases... 

5,312 

84 

1.58 

4,892 

65 

1.32 

Ankylostomiasis ... 

4,223 

347 

8.22 

4,029 

300 

7.44 

Dysentery... 

3,553 

1,294 

818 

23.02 

3,310 

711 

21.48 

Diarrhoea ... 

116 

8.96 

1,253 

771 

81 

6.46 

Beri-beri ... 

1,122 

1,672 

140 

12.4S 

107 

13.87 

Pneumonia 
Pulmonary tuber- 

761 

45.51 

1,815 

711 

39.17 

culosis ... 

2,214 

1,062 

47.97 

2,157 

1,006 

46.64 


10. Malaria. —The number of cases treated in hospital shows a decrease of 
4,990 while the death-rate has decreased to 5.03 as against 5.38 in 1922. This is very 
satisfactory and can be attributed partly to better diagnosis of “fevers” and partly to 
the active propaganda carried out by the Malaria Advisory Board. Of the total 
number of 21,082 cases of malaria 1,252 were “type undiagnosed”. A number of 
these cases can be considered as not malaria. Every effort is being made to correctly 
diagnose malaria and the number of cases of “type undiagnosed” is rapidly decreasing. 

11. Venereal Diseases. —The total number of cases treated was 4,892 with 
■05 deaths. It is extremely difficult to induce the public to come for early treatment. 
The distribution of pamphlets and posters by the Committee for Public Health 
Education has continued. Venereal diseases clinics, centres and propaganda are being 
actively organised with a specialist in charge. A successful commencement has been 
made at the District Hospital, Kuala Lumpur, where an up-to-date venereal diseases 
•clinic has been established which is working exceedingly well. Injections of N.A.B. 
compounds necessary for cases of syphilis are given at all Government hospitals. 


The following are the figures for the different States: 

States. 1922. 1923. 

Perak. 10,888 ... 15,550 

Selangor ... ... ... ... ... 6,802 ... 10,282 

Negri Sembilan ... ... ... ... 1,451 ... 2,739 

Pahang ... ... ... ... ... 549 ... 1,104 


12. Ankylostomiasis. —A total of 4,029 cases were treated in 1923 as compared 
with 4,223 for 1922. The disease is very prevalent and the above figures are only for 
cases who were treated for this disease alone. A great number of patients admitted 
into hospitals suffer from this disease. A mass campaign will be undertaken in 1924. 

The Committee for Public Health Education has issued a pamphlet on this subject 
in English, Chinese, Malay and Tamil. The pamphlet is being distributed throughout 
the country. 

13. Dysentery and Diarrhoea. —The total number of cases treated in hospitals 
was 4,563 with 792 deaths and a death-rate of 1.73 as against 4,847 cases with 
934 deaths and a death-rate of 1.78 per mille in 1922. The types were as follows : 

Amoebic. Deaths. Bacillary. Deaths. Diarrhoea. Deaths. 

1,400 ... 305 ... 1,910 ... 406 ... 1,253 ... 81 

14. Beri-beri .—The number of cases treated in hospitals decreased from 1,122 in 
1922 to 771 in 1923. The death-rate for 1923 was slightly higher being 13.87 as 
against 12.48 for 1922. 

The subject of beri-beri is dealt with at length in the report of the Director of 
Government Laboratories, which is attached. 

The improved conditions on mines and estates and the better feeding accounts 
largely for the reduction in the figures for this disease. 

15. Fneumpnia. —There was a slight increase in the numbers treated but a 
decrease in the death-rate which was 39.17 as against 45.51 for 1922. Intravenous 
iodine treatment has been freely used with success. 





























5 


16. Pulmonary Tuberculosis .—The total number of cases treated in, hospitals 
during the year was 2,157 with 1,006 deaths and a death-rate of 46.64 as against 
.2,214 with 1,062 deaths and a death-rate of 47.97 in 1922. 

The mortality rate is very high, but it must be realised that only chronic and 
acute cases come to hospitals for treatment. The death-rate for the whole of the 
Federated Malay States was 1.39 per mille which is the lowest for ten years. 

This disease was the subject of a press campaign during the year, but there was 
no occasion for any alarm, as the figures show, though there is reason to adopt all the 
preventive measures possible, and this is largely the work of the Sanitary Boards. 
In one district the disease was made notifiable but outside Government practice, 
no case was reported. The fact is that the private practitioner dare not report cases. 
•One Chinese doctor who reported a case of plague was boycotted, lost his practice and 
had to leave the country, yet public sympathy would support action against plague 
more readily than against phthisis, for the former disease is better known and more 
dreaded by the ignorant classes. 

Sanitoria are advocated, but persons infected now object to removal to Port 
Dickson where there are special wards. In every hospital of any size there is special 
accommodation for tubercular cases, and the percentage of cases of T.B. infection is 
a good index of the incidence of the disease, for in the later stages the patients' 
relatives and friends are obliged to send them into hospitals as they become intolerable 
in private houses. A special enquiry was made and returns were called for. These 
reveal no increase or alarming incidence of tuberculosis in the hospitals. 

The main object of the population in this country is to make money; they have 
still little belief in many of the facts of Western medicine. 

It has been seriously proposed that every suspected case, even before the tubercle 
bacillus was recovered from the sputum, should be forcibly examined and segregated. 
This is unthinkable and would not be tolerated. 

Early cases with slight physical signs do not consider that they are seriously ill 
at all, they want a bottle of medicine and a quick cure and invariably would refuse 
one, two, or three years sanatorium treatment. 

This year one can only repeat the former advice, that education, light and air are 
the only true remedies. 

17. Smallpox .—The total number of cases notified was 32 with nine deaths. 
An outbreak in Perak was responsible for 23 of these cases and for all the deaths. 

The outbreak was traced to a Malay who 1 had come from Mecca on an infected 
fihip and had developed the disease after release from the Penang quarantine station. 
Its spread was due to unvaccinated Malays,. Energetic vaccination stopped the 
epidemic. 


18. Plague .—Sixteen cases with ten deaths occurred during the year. All these 
cases came from an area in Kuala Lumpur where plague amongst house rats appears 
to be endemic. There is little tendency to spread and up to date there never has been 
a real epidemic. 


19. Yaws .—The treatment of cases of yaws by injections of N.A.B. compound 
was continued. A total of 40,815 injections were given. The number of cases treated 
in each State is shewn in comparison with the number in 1922 in the following table : 


States. 

Perak ... 
Selangor 
Kegri Sembilan 
Pahang 


1922. 1923. 

11,474 ... 14,149 

1,700 ... 4,381 

3,749 ... 9,358 

6,049 ... 3,247 


Total ... 22,972 


31,135 


The campaign against this disease was continued throughout the year with 
satisfactory results. Few cases are admitted to hospitals, during the year 278 cases 
only were treated as in-patients, but the total number treated was 31,135. Although 
a number were treated as out-patients, the majority were treated in their own 
kampongs. Medical Officers and Assistant Surgeons pay periodical visits to the 
outlying districts and find little difficulty in persuading people to undergo treatment. 

In the Batang Padang and Kuala Kangsar districts of Perak, the Medical Officers, 
with the aid of presents, such as beads, bangles, cigarettes and tobacco, have been 
able to get into touch with the sakais who live along the Pahang Road. Having 
persuaded them to have injections for yaws in the first place, the results were so good 
that they are now only too willing to receive treatment and ask for it. 






6 


In Pahang a very rigorous campaign was commenced in the latter part of 1922. 
Its aim was complete eradication of the disease by systematic treatment of all affected 
cases, as ascertained by yaws census taken throughout the whole State. The campaign 
has been continued throughout the year, but its original aim has not yet been achieved. 
About 500 cases, scattered in the various districts, stubbornly refused treatment. 
Persuasion by District Officers, Penghulus and Officers of the Medical Department 
proved futile, and they remain a permanent focus of infection from which the disease 
continues to spread. Fortunately a great many of the fresh infections come for 
treatment promptly so that the disease is kept in check to some extent. 

Though this is gratifying, it is greatly to be deplored that the small group of cases, 
responsible for the continued spread of the disease, is so completely beyond control. 
Compulsory treatment would cure everybody in a very short time and could prevent 
the occurrence of fresh cases. Legislation with this object in views appears to be the 
only solution. It is the only way by which the scourge of yaws can be, once and for 
all, completely eradicated. 

20. Influenza .—There were 2.219 cases with 80 deaths during the year as 
compared with 1,653 cases with 46 deaths in 1922. The disease was of a mild type. 

21. Eye Diseases .—The clinics at the Ipoh and T'aiping Hospitals have continued 
successfully. 

22. Out-patients .—One thousand five hundred and thirty-five new cases were 
seen and examined during the year, an increase of 257 over the year 1922. There were 
9,011 attendances, an increase of 2,651 over the figures for 1922. 

23. In-patients .—Two hundred and thirty-four cases were admitted for conditions 
of the eye which necessitated urgent treatment or operation. The principal diseases 
were conjunctivitis, trachoma, ulcers of the cornea and keratitis and cataract. 

That there is a great deal of suffering and loss of vision, amongst the native 
population is evidenced by the fact that of 1,535 cases seen, nearly 4 per cent, had 
one or both eyes disorganised—the result of infection and neglect. Facial paralysis 
with a tendency to close the eye on the affected side was a condition frequently met 
with. Syphilitic and gonorrhoeal infections are responsible for a large percentage of 
blindness. The advisability of establishing eye clinics at various centres in the other 
States is having serious consideration.. 

In a series of examinations of the eyesight of children of different nationalities the 
vision of Malay children in the vernacular schools was found to be excellent. In the 
English speaking schools the stress of near work was evident and errors of refraction 
are relatively common. 

Errors of refraction play a small part amongst the natives of this country whilst 
diseased conditions, the result of infection or injury, form the majority of cases. 

Eye clinics in charge of Assistant Surgeons are established in Taiping and Kuala 
Lumpur and have done good work. 


24. Operations .—The number of 
jw is shewn below: 

operations undertaken during the 

year 

States. 

Major. 


Minor. 


1922. 

1923? 

1922. 

1923. 

Perak . 

404 

551 

1,901 

4,651 

Selangor 

293 

337 

1.174 

1,293 

Kegri Sembilan 

68 

61 

1,024 

1.115 

Pahang 

16 

12 

329 

266 

Total ... 

781 

961 

4,428 

7,325 


25. Vaccinations .—During 1923, the total number of vaccinations performed 
was 77,724 as against 65,201 in 1922. They are distributed as follows: 


States. 

Perak ... 
Selangor 
Kegri Sembilan 
Pahang 


1 922. 
43,644 
12,054 
5,422 
4,081 


Total ... 65,201 


1923. 

53,926 

11,075 

6,366 

6,357 


77,724 











7 


The considerable increase in cases vaccinated in Perak is due to the outbreak of 
smallpox in the Selama, and Ului Selama districts which necessitated the vaccination 
of a large number of adults. The increase in vaccination in Pahang is greatly due to 
the strict enforcement of the Enactment introduced in July, 1922. The figures show 
an increase of about 56 per cent, on the previous year, which must be regarded as 
very satisfactory when the difficulties of controlling evasion in a State so situated as 
Pahang are considered, and are a credit to the Senior Medical Officer, Medical Officers, 
Assistant Surgeons and staff. 

26. Women’s Hospitals and Wards. —The numbers attending the women’s 
hospitals and wards are increasing yearly which goes to show that the Lady Medical 
Officers are gaining the confidence of the female population, and it proves that it is 
only by Lady Medical Officers that the women of this country can be reached. It is 
hoped that the number of Lady Medical Officers will be increased so that in the near 
future women will be as willing to go to hospital for treatment as are men. In every 
women’s hospital and ward the number of maternity cases have increased. In the 
General Hospital, Kuala Lumpur, 315 patients were confined, an increase of 100 over 
the numbers for 1922. 

27. Inspection, of Schools. —This was continued throughout the year in some 
cases by the Health Branch, in others by the Medical Officers and Lady Medical 
Officers. This is not a very satisfactory method and Inspectors of Schools (Medical 
Officers and Lady Medical Officers) are urgently needed. 

The most prevalent diseases met with are enlarged spleens, scabies, anaemia and 
many of the children are infected with worms. The children as a rule fail to keep 
their teeth clean. Cases of yaws are now infrequent. The personal hygiene of the 
children and the sanitary conditions of the schools in the outlying districts leave much 
to be desired. A good water supply and latrine accommodation is badly needed in 
many schools. The numbers of children with enlarged spleens varies considerably in 
different districts. 

Frequent visits are paid to the schools near the main roads by the travelling 
dispensaries which distribute medicines and treat minor complaints. Quinine is 
supplied to the schools by the Health Department through the Inspectors of Schools 
in the various States', 


LEPER ASYLA. 

28. Kuala Lumpur. —During the year under review there has been no occurrence 
of special interest to report. The satisfactory state due to the reorganisation of the 
Asylum in 1922 has continued throughout the year. The total number 1 of inmates at 

the end of the year was 348. Three births took place during the year. 

• 

The question of dealing with the healthy children of lepers, which was raised by 
the Infant Welfare Advisory Board, has had the consideration of Government and 
steps are being taken to find suitable accommodation for these children. 

A Hindu Temple was erected through the kindness and generosity of 
Mr. Coomarasamy and opened on the 24th of August. This temple has the effect of 
keeping the Indian lepers in the Asylum, and not one attempted to abscond during 
the Indian, festivities. 

The members of the Far Eastern Association of Tropical Medicine paid a visit to 
the Asylum on 10th September, 1923, and were much impressed by the contentment 
shown by the lepers. 

29. Pulau Pangkor Laut. —This Asylum is for Malays only; 61 cases of leprosy 
•were treated during the year. There were nine deaths. The present accommodation 
is limited but more will be provided for in 1924. 

The general health of the patients has been quite satisfactory. All cases were 
treated with chaulmoogra oil by the mouth and in addition 44 cases were treated by 
intramuscular injection of E.C.C.O. with encouraging results. Two cases were 
discharged on parole during the year. 

30. Taiping Leper Wards. —One hundred and twenty-six cases were treated with 
three deaths Sixty-one patients out of the above number were transferred to Pulau 
Jereiak and to the female leper ward in Penang. Cases, have been treated with 
E C C.O. and the Tai Foong Chee treatment has been, tried. The results are not 
very" encouraging as the patients as a rule refuse treatment so soon that no real results 

can be obtained. 


8 


31. Treatment of Leprosy .-—The treatment of lepers in the Kuala Lumpur 
Asylum is given in detail: 

(i) Six were selected for treatment with eight weekly injections of .45 grms. of 
neosalvarsan at the beginning of the year. None of the cases showed 
any marked improvement. 

(ii) Antimony tartrate was and is still being given to ulcerative cases. The 
largest number on the roll was 31. This drug is given intravenously 
biweekly. The solution is always freshly prepared, 1 grain being 
dissolved in 10 c.c. of sterile distilled water, and filtered. The initial 
dose is 0.5 grain or 5 c.c. of the solution; subsequent injections being 
raised to 1 grain or 10 c.c. Many cases showed marked improvement, 
sloughing ulcers taking on a reddish and healthy look and granulating 
after a few injections. This treatment has no effect on nodular cases. 

(iii) The preparation known as E.C.C.O. has been given a whole year’s trial 

extending from 12th July, 1922, to 11th July, 1923. It consists of the 
ethyl esters of the fatty acids of chaulmoogra oil combined with creosote, 
camphor and olive oil prepared according to the formula of Dr. Muir. 
E.C.C.O. was given intramuscularly into the buttock, the initial dose 
being 0.5 c.c. increasing by 0.5 c.c. until 5 c.c. which was continued 
weekly throughout the year. Thirty-nine cases were recorded but only 
twenty-seven came under this treatment for the full twelve months.. 
Of these 27 cases only ten have shown any improvement. 

(iv) Thymol Morrhuate .—Two injections of 1 c.c. were given intramuscularly to 

eleven patients on 24th September, 1923, and 1st October, 1923. It was 
discontinued owing to much pain and swelling. 

(v) Tai Foong Chee .—The Chinese name for chaulmoogra nut, together with 
two other seeds, Pak Chut Lai and Foh Mah Yan, has found much favour 
with the inmates. Two parts of the former and one part each of the 
latter all thoroughly ground up and mixed, and a varying quantity of 
from, 4 to 1 drachm is taken orally daily. 

This treatment began on 4th April, 1923, and on 31st December, 1923, the number 
on the roll has increased to 161. Several lepers had been treating themselves 
with these drugs before this. Only nine of them could give definite and reliable 
histories of having taken them, from one to six years. The improvement these 
nine people showed has been remarkable. Encouraged by the results of these persons, 
more regular and extensive treatment with these drugs is now' on trial. The treatment 
is a popular one with the patients regardless of age or nationality and works out on an 
average of $20 per month for 100 patients. 

32. X-Ray and Electrical Treatment .—This was under the charge of Dr. Mowat, 
Radiologist, until his regrettable death on 22nd August, when the department was 
taken over by Dr. Harrison. 

The following is a comparative statement of the treatment given during the vears 
1921, 1922 and 1923 : 



1921. 


1922. 

1923. 

Screening 

58 

. • . 

33 

r»o 

i€> 

Radiograms taken 

357 

. . . 

482 

684 

Electrical treatment 

796 

• • • 

996 

800 

X-Ray treatment 

70 

• . • 

109 

38 

Radiant heat baths ... 

— 

... 

254 

110 

Total . 

.. 1,281 

... 

1,874 

1,705 

VETERINARY DEPARTMENT. 


33. Rinderpest .—There were two outbreaks of rinderpest amongst buffaloes,, 
one of which was in the Kuantan district of Pahang where there were 51 cases with' 
49 deaths. There was no evidence as to the original source of this infection. The 
outbreak had not finished by the end of the year. The other outbreak occurred in the 
quarantine station, Port Dickson, among a shipment of 33 buffaloes just imported 
from Siam. All the 33 buffaloes died or w r ere destroyed, 31 cattle in the immediate 
vicinity of the quarantine station were inoculated with anti-rinderpest serum. 

No cases occurred in Perak or Selangor except that during December a tongkang 
with 49 cattle and buffaloes arrived at Port Swettenham, Selangor, from the West 
Coast of Siam with two cases of rinderpest on board, four animals having died during 
the voyage. None of the animals w r ere allowed to land. The importation of cattle 
from Siam by sea has been prohibited until further notice. 


9 


84. Foot-and-Mouth Disease. —Mild outbreaks of this disease amongst cattle 
occurred in various districts and the quarantine stations; altogether there were 
1,085 cases with one death. 

In every case where an outbreak occurred its spread was stopped by effective 
quarantine restrictions. 

85. Babies. —Only one case of rabies has occurred during the year. This occurred 
in a dog in Bahau town, Negri Sembilan. The source of this infection could not be 
traced, the dog affected being said to' have been continuously in Bahau for over 
two years. 

The muzzling order in Kuala Lumpur where cases of rabies had occurred during 
the previous six years was rescinded in March, 1923. 

36. PI euro-Pneumonia. —The outbreak which started in 1922 continued. There 

were onlv three cases, of which one died and two were destroyed. An outbreak 

occurred amongst goats in the Matang district in Perak in April. Three goats died 

and nine others were destroved. The other three States were free from this disease. 

«/ 

37. Swine Fever. —There were no cases of swine fever during the year under 
review. 

88. Surra. —Three cases of surra amongst dogs were discovered in Taiping in 
October and November. All were destroyed. 

VETERINARY QUARANTINE STATIONS. 

89. Port Swettenham. —Eight thousand five hundred and nineteen animals passed 
through this quarantine station, of which number 4,233 were quarantined for ten days. 

40. Bukit Sentul. —Three hundred and twenty-seven cattle were quarantined, 
these animals being from Singapore and Kedah. 

41. Kuantan.— 1 The total number of animals passed through this station 
was 1,751. 

42. Perak. —The total number of cattle and buffaloes imported and passed 
through the quarantine station was 5,248 as against 2,672 in 1922. They were 
distributed as follows: 


Port Weld 


... 2,192 

Parit B untar 

... ••• ••• ••• ••• 

839 

Selama 

... ... » • • , , , ••• ••• 

... 1,049 

Upper Perak 


333 

Teluk Anson 


835 


Total 

VETERINARY PROSECUTIONS. 

... 5,248 


43. There were 1,176 prosecutions resulting in 1,138 convictions. The fines 
imposed amounted to a total of $9,018. 

PUBLIC HEALTH. 

( b ). —General European Population. 

44. The general health of the European population has been good; there was 
very little sickness and invaliding. The total European and American population as 
estimated at the end of June, 1923, was 6,226. There were 126 births giving a 
birth-rate of 20.24 per mille and 34 deaths with a death-rate or 5.46 per mille. 

It is impossible to obtain figures for illness and invaliding of European or others 
as there are many private practitioners who could not supply these figures nor spare 
the time to collect facts. 


(c).—G eneral Native Population. 

45. Vital statistics, estimated population per year, birth and death-rates, infantile 
mortality, etc., etc., will be found in the report of the Senior Health Officer, Federated 
Malay States. 


III.—SANITATION. 

46. The Health Branch of the Medical Department has been grievously under¬ 
staffed during the whole of 1923, and great credit should be given to the admirable 
efforts made by the Senior Health Officer and the very limited number of Health 
Officers at his disposal. The results attained fully justify these remarks. 

The Health Officers were very busy with the work of the Mosquito Destruction 
Boards, and the reduction in the number of malarial cases and the death-rate must 
be largely ascribed to their efforts. 





















10 


The Railway Health Officer assisted by the Railway Engineers has done very good 
work and has fully justified the creation of the post. 

There were no epidemics of any magnitude during 1923. 

Owing to the paucity of staff it was impossible to keep adequate supervision over 
the estates. Schools were inspected as far as possible, this duty being shared by the 
Hospital Medical Officers, Health Officers, Assistant Surgeons and Sanitary Inspectors. 
The Lady Medical Officers made useful inspections of girls’ schools wherever possible. 
Eour laws and three lists of rules affecting public health were gazetted during 1923. 

47. The Senior Health Officer points out that in towns the death-rates are 
influenced by diseased persons coming in from rural areas for treatment or greater 
comfort. If they die at the end of a month’s residence the death falls upon the town 
where the patient had been residing. They are therefore misleading death-rates and 
are probably too high. The town death-rates are also influenced by the presence of 
large hospitals. 

The health for 1923 has been, good and the best on record. To a large extent 
this highly satisfactory result must be ascribed to the efforts of the public and private 
authorities to combat disease. 

The death-rate, 24.40' per mille, is the lowest ever recorded. Nearly half the 
deaths are classified under the general heading “Fevers”—the percentage is 45.75 of 
the total deaths. Dvsentery and diarrhoea have a death-rate of 1.55 per cent, against 
1.78 in 1922. 

48. Pulmonary tuberculosis 1.39 per cent, and pneumonia 1.17 per cent, against 
1.76 and 1.31 in 1922. The birth-rate Was 25.66 per mille against 25.65 per mille 
in 1922, 

49. Ankylostomiasis—the death-rate this year is 0.28 per mille and was 0.41 
last year. 

50. Beri-beri for 1922 had a, death-rate of 0.33 per mille and in 1923 it stands 
at 0.27. There is a fall in the death-rates for all the principal diseases and they are 
the lowest on record for ten years. 

51. Enteric fever shows a rise 0.02 against 0.01 for 1922. I believe the apparent 
rise is due to' Medical Officers being more on the alert to detect it. 

52. Tetanus also shows a rise 0.04 against 0.02; this is due to the diagnosis of 
cases in the new bom at Infant Welfare: Centres. 

53. The infant mortality rate has risen from 170.83 per mille in 1922 to 180.07 
in 1923, but it has fallen from 240 to its present figure in three years and compares 
very favourably with infant death-rates in other tropical countries where 600 to 
800 deaths per mille are common. 

The rise of 10 1 per mille proves that a centre in one town will not control the 
death-rate. Centres are being organised in Taiping, Ipoh and Seremban, but more 
Lady Medical Officers are badly required. 

54. The large towns show a fall in the death-rate everywhere, except in Taiping, 
for the past seven, years and even there the death-rate is the lowest for the past 
six years. The town is old and insanitary and active measures on the part of the 
Sanitary Board are called for. This town has the highest birth-rate of the four towns 
which to some extent accounts for the high death-rate. 

55. Special attention is directed to the great fall in Seremban’s death-rate from 
36.16 in 1921 and 27.93 in 1922 to 24.78 in 1923. In the towns the malarial 
death-rates are low except in Taiping. The constant rain in Taiping is a fertile source 
of breeding places for mosquitoes. 

56. The town death-rates from phthisis are not high, Ipoh and Taiping being 
higher than the other two. With only 3.61 and 3.73 deaths per mille for Ipoh and 
Taiping, there is no cause for panic or alarm. The phthisis curve has remained 
stationary year after year until 1923 when it was the lowest on record. 

57. The infant mortality rates in Seremban are too high and an Infant Welfare 
Centre is much needed; it will be started in 1924. The death-rate in Taiping is also 
too high but the conditions in that old town, are unfavourable to infant life. 

58. Quinine distribution is much appreciated by the population, and this has 
played its part in, the lowering of the malaria death-rate. So. far as possible the 
distributors keep records of the amount expended and the persons to whom it is 
supplied, but nothing should be permitted to hamper easy distribution to the people. 


11 


59. The death-rate at the Port Swettenham Quarantine Camp was 0.28 per cent. 

60. In connection with the small outbreak of plague in Kuala Lumpur the 
remarks under the Senior Health Officer’s para. 82 should be qualified by the remark 
that every effort was made to close or demolish the infected houses, but such action 
was opposed in Court and the Magistrate declined to make an order on, points of laiw 
cited. 

61. Under section 87, pulmonary tuberculosis, although the regulations have 
provided for more light and air in the houses than is required in England is true, but 
they are frequently evaded and vigorous action by the Sanitary Boards is called for. 

Overcrowding is also extremely common and highly dangerous. This is also a 
Sanitary Board problem. 

62. Night-soil disposal. The disgusting habits of a portion of the population 
greatly tend to increase the incidence of ankylostomiasis. Smoke latrines were tried 
and failed as some of the population do not object to the smell of ordure, but they do 
object to a common latrine. 

A proposal from the Medical Department to make it illegal to use night-soil as 
manure for vegetables was not adopted by Government as a similar proposal from, the 
same official made in 1905. 

63. The question of estate labourers health and sanitation, and medical attendance 
as well as prevention, of disease on: estates is the subject of a special enquiry by 
Government in 1924 and a report will be submitted in due course. 

64. A certain amount of education by propaganda was carried out during the year 
by the Malaria Advisory Board, the Committee for Public Health Education and the 
Infant Welfare Advisory Board, who issued posters and pamphlets. 

Lectures in the Malay language on malaria, illustrated by lantern slides were 
given in schools and kampongs throughout Selangor and Pahang. These were well 
attended and should prove themselves to have been of great value in educating the 
rural population in the means of preventing malaria and mosquito breeding. The 
lectures will be extended to Perak and Negri Sembilan during 1924. 

Exhibits showing anti-malarial measures and Infant Welfare: work were displayed 
at the Agri-Horticultural Show held in July at Kuala Lumpur. 

These were well attended and it is, calculated that at least twenty thousand people 
of all nationalities visited these exhibits. 

65. The following were publications that were issued during the year: 

Pamphlet on malaria in English and Jawi. 

Pamphlet on plague in English only. 

Pamphlet on convulsions in four languages. 

Posters on, malaria, in four languages. 

Posters on “How to rear an infant during the first year of life,’’ in four 
languages. 

Posters on “Keep your baby’s bottle clean,’’ in four languages. 

Posters on “Lockjaw,’’ in Chinese. 

Pamphlets on “Venereal diseases,’’ in Chinese. 

Posters in four languages, “Risk of plague”. 

Circulars re “N.A.B. injections,” in four languages. 


IV.—METEOROLOGY. 

Rainfall in, inches ini the principal towns: 

Average monthly rainfall. 

Kuala Lumpur ... ... ... ... ... ... ... 7.75 

Ipoh ... ... ... ... ... ... ... ... 7.97 

Taiping ... ... ... ... ... ... ... ... 12.84 

Seremban, ... ... ... ... ... ... ... ... 5.38 

Kuala Lipis ... ... ... ... ... ... ... 8.25 

The high rainfall in Taiping has probably a good deal to do with the high 
death-rate there. 
















12 


V.— HOSPITALS AND DISPENSARIES. 

67. Out-patients .—The number of out-patients treated by all hospitals, 


dispensaries and travelling dispensaries for 1923 
433,111 in 1922, distributed as follows: 

was 527,414 as compared with 

• 

States. 

1922. 

1923. 

Perak 

150,157 

190,990 

Selangor 

128,806 

159,403 

Negri Sembilan 

81,711 

92,692 

Pahang 

72,437 

84,329 

Total ... 

433,111 

527,414 

The increase in the number of out-patients 

is probablv due 

to the restarting 

of the travelling dispensaries towards the end of 

the year 1922. 

These travelling 


dispensaries get in touch with the villages, in outlying districts whose inhabitants 
would not in the ordinary course of events take the trouble to come long distances to 
the district hospitals. 

They are very useful in dealing with the yaws campaign and in the inspection of 
outlying schools. They are quite our most useful service out of doors. 

INFANT WELFARE WORK. 

68. Infant Welfare work is carried out at the Town Dispensaries in Kuala 
Lumpur, Ipoh and Taiping, but the attendances of women and children at these 
dispensaries are increasing so very rapidly that the question of providing separate 
accommodation for Infant Welfare work is becoming very urgent. In Kuala Lumpur 
it is intended to move the Town Dispensary work to another building and increase the 
present Town Dispensary and use it entirely as an Infant Welfare Centre. 

69. Kuala Lumpur .—The number of attendances during 1923 were women 
3,559, children (from one to five years) 2,872, and infants (under one year of age) 
5,777, a. total of 12,008 as against 4,075 in 1922. The number of visits paid by Health 
Visitors during the year was 6,549. 

70. Taiping .—The Medical Officer reports that it is a great uphill fight against 
the ignorance and superstition of the poor Chinese, Tamils and Malays. From 
notification of birth all new-born babies are visited at once. Some of the parents 
appreciate this attention and attempt to follow the advice given and la-ter come up to 
the centre. The majority however pay little attention and a few absolutely refuse 
to see the Sister or Nurse. The centre, however, has done valuable work and is 
gradually being appreciated. At the end of the year there were over 200 infants on 
the books and the majority of these are brought to the centre at least once a month. 

The total attendances were 4,440 as against 743 in 1922. 

71. Ipoh .—This centre has been considerably handicapped by having no Nursing 
Sister, consequently it has been carried on with difficulty more especially in the absence 
of a. Lady Medical Officer during the latter half of the year. 

The total number of attendants was 7,086 as against 1,793 in 1922. 


VI.—PRISONS. 

72. During 1923, the general health of the prisoners and the sanitation have been 
satisfactory. The chief diseases prevalent were malaria, dysentery, diarrhoea and 
anky lostom i asis. 

The total number treated during the year in the different gaol hospitals was 
1,280 ! with 32 deaths, and a death-rate of 2.5 as against 1,736 with 27 deaths, and a 
death-rate of 1.67 for 1922, distributed as follows : 


Place. 

1922. 

1923. 

Cases. 

Deaths. 

Per¬ 

centage. 

Cases. 

Deaths. 

Per¬ 

centage. 

Pudu Gaol, Kuala Lumpur 

421 

5 

] .18 

316 

6 

1.89 

Gaol, Taiping 

604 

17 

2.81 

465 

17 

3.65 

„ Batu Gajah 

348 

3 

.08 

188 

6 

3.19 

„ Papan 

65 

2 

3.06 

11 

• • a 

... 

„ Seremban ... 

240 

2 

.82 

258 

2 

0.77 

„ Kuala Lipis 

15 


• • • 

17 

1 

5.88 

,, Kuantan ... 

43 


... 

25 



Total ... 

1,736 

29 

1.67 

1,280 

32 

2.5 












































13 


73. There were five cases of enteric fever admitted to the T'aiping Gaol Hospital. 
All recovered. 

74. Eighty-one cases of ulcers on the legs were admitted to Taiping. These were 
caused by stone chips when, stone breaking. The provision of leg shields has prevented 
any further occurrence of these sores on, the legs. 

75. There was an outbreak of diarrhoea in the Seremban Gaol, a total of 62 cases 
were treated of which 45 were admitted to hospital. This was probably due to the 
substitution of toughay for green peas. On stopping the toughay diarrhoea almost 
stopped and only five cases were admitted during the remainder of the year. Toughay 
was supplied from 10th June, 1923, to 5th August, 1923. 


VII.—SCIENTIFIC. 

Comments on the Reports of the Director of Government Laboratories and the 
Medical Superintendent, Central Mental Hospital. 

REPOET OF THE DIRECTOR OF GOVERNMENT LABORATORIES. 

76. The volume of work performed by the various branches of the Institute for 
Medical Research is rapidly increasing, and great credit is due to the staff for the way 
in which they have coped with it. It is hoped that additional assistance will be 
available in, 1924. 

77. The Director gives an interesting account of melioidosis, formerly known as 
pseudopestis, and gives notes upon the first case known to have occurred in a 
European. Apart from anything else the acute course and rapid death of the majority 
of the cases, together with the symptoms, have caused it to be frequently mistaken for 
•cholera and unnecessary alarms have been caused in the past. 

78. Further valuable observations have been made on the use of quinine in 
malaria. These are being carried further. 

79. The Director records the deliberations of the Far Eastern, Association of 
Tropical Medicine on beri-beri and details the measures adopted to combat the disease. 

80 1 . A rare case of typhoid septicaemia was discovered. 

81. During a small outbreak of plague in Kuala Lumpur the serum, treatment 
proved to have no effect on the mortality. Examinations of live rats disproved an 
old theory held by some that the comparative immunity enjoyed by the Federated 
Malay States from plague was due to the slight rate of flea infection of the rat 
population. The index for Xenopsylla cheopis was 3.0. 

82. Four thousand one hundred and twenty examinations of blood for the 
Wassermann Reaction were made against 3,984 in 1922. Five hundred and sixteen 
specimens were examined for agglutination with the typhoid group against 

393 in 1922. 

In 1922, 118 were positive and 151 in 1923. On the whole for a tropical country 
the cases of fevers of the typhoid group are rare. 

83. Thanks to the efficient destruction of stray dogs by the police, rabies gave 
no trouble in 1923>. 

84. During 1923 thirty-nine cases were positive for B. diphtheriae against 
Twenty-nine in 1922. In each year one case of Vincent’s Angina was identified. 

85. Treatment with insulin was carried out during the year. Its value seems 
to vary. 

86. There were five important publications from the Institute during 1923. 

87. The reports of the Malaria Bureau and Chemical Laboratories are records 
•of hard work well done. 

REPORT OF THE CENTRAL MENTAL HOSPITAL. 

88. The total number of patients shows an increase of 150 patients, over 1922. 
It is explained in the Medical Superintendent’s Report attached. 

Recent melancholia was the commonest form of mental disease seen. 

Endeavours are made to assist discharged patients, with good results. 

Gastro-intestinal complaints including intestinal parasites, diseases of the blood 
or blood-vessels, malaria, syphilis and alcohol are given as causes of mental disorders. 



14 


Chinese rather than Indians head the list of cases due to alcoholism and this is 
probably a result of the restrictions on opium smoking. The Medical Superintendent’s 
remarks on this subject are noteworthy. 

89. The death-rate for 1923 is higher than that of 1922 by .42 per cent., but the 
total death-rate is well below the average for the past ten years. 


90. Although phthisis heads the list of the causes of death there were only 
twenty-two deaths from; this disease out of some 1,580' patients remaining on 
December 31st, 1923; yet, as is well known, a Mental Hospital is usually full of 
tubercular cases and these figures show no cause for alarm,. There was one suicide 
during the year. 

91. The farms, anti-malarial work, etc., ha,ve been conducted with success. 

92. The changes of the staff referred to by the Medical Superintendent are 
unavoidable as the Assistant Surgeons do not like the work. Every effort was made 
to obtain an Assistant Superintendent from England without success. The terms 
offered do not appear to attract candidates. 

93. Police escorts for the insane must still be supplied or the medical estimates 
will grow unduly and we may lose more important services. 


94. The following reports are attached as appendices : 

A.—Report of the Director of Government Laboratories. 


B. — 

C. — 

D. — 

E. — 


Malaria Bureau, Institute for Medical Research. 

Chemical Laboratories, I.M.R. 

Senior Health Officer, Federated Malay States. 

Medical Superintendent, Central Mental Hospital, Tanjong 
Rambutan. 


16th April, 1924. 


R. DOWDEN, 

Principal Medical Officer, Federated Malay States. 


15 


Table 1. 


Return of Diseases and Deaths (in-patients) for the year 1923. 


Diseases. 

Remaining in 

Hospital at 

the end of 

1922. 

Yearly total. 

Total cases 

treated. 

Remaining in 

Hospital at 

the end of 

1923. 

• GO 

a .2 
<5 

m 

!—] 

c3 

Q) 

Q 

Beri-beri ... ... . 

96 

675 

107 

771 

101 

Cerebro-spinal fever ... 

• • • 

12 

8 

12 

• . • 

Chicken-pox ... 

5 

76 

1 

81 

2 

Cholera 

. . . 

... 

... 

... 

. .. 

Dengue 

... 

32 

... 

32 

... 

Diphtheria 


22 

7 

22 

1 

Dysentery, amoebic ... 

72 

1,328 

305 

1,400 

60 

„ bacillary ... 

103 

1,807 

406 

1,910 

72 

Endocarditis-infective 

. . • 

. . • 

•.. 

• •. 

. . . 

Enteric 

11 

135 

33 

146 

8 

Erysipelas 

1 

95 

16 

96 

4 

Gonorrhoea 

88 

1,629 

6 

1,717 

91 

Influenza 

61 

2,158 

80 

2,219 

65 

Kala Azar 


... 

. •. 

.. . 

... 

Leprosy ( a ) Nodular 

91 

107 

12 

198 

98 

( b ) Anaesthetic 

16 

90 

5 

106 

18 

(c) Mixed infection 

317 

183 

41 

500 

348 

Malaria (a) Tertian ... 

138 

4,019 

100 

4,157 

103 

(&) Quartan 

36 

911 

28 

947 

28 

(c) Aestiva-autummal ... ... 

277 

9,405 

686 

9,682 

216 

(, d ) Chronic malaria 

117 

4,635 

170 

4,752 

134 

(e) Black-water 


9 

1 

9 

.. . 

(/) Mixed infection 

11 

320 

29 

331 

9 

( : g ) Type undiagnosed 

34 

1,218 

48 

1,252 . 

13 

Measles 

9 

Li 

146 

1 

148 

8 

Malta fever ... 


... 

.. . 

... 

... 

Plague... 


16 

10 

16 


Pneumonia 

63 

1,752 

711 

1,815 

66 

Rabies... 

. . . 

2 

... 

2 

. .. 

Pyrexia of uncertain origin ... 

11 

238 

1 

249 

5 

Relapsing fever 

... 

•.* 

... 


• • • 

Rheumatic fever 

12 

228 

•. • 

240 

5 

Rheumatism ... 

8 

113 

1 

121 

4 

Septicaemia 

3 

86 

72 

89 

1 

Trypanosomiasis (sleeping fever) ... 


... 

... 

... 

. . 

Small-pox 


7 

... 

7 

1 

Syphilis (a) Primary 

33 

524 

2 

557 

39 

(5) Secondary 

100 

1,448 

27 

1,548 

56 

(c) Inherited 

.. . 

12 

1 

12 

.. . 

(d) Tertian ... 

26 

417 

34 

443 

41 

(e) Other syphilitic diseases 

3 

16 

1 

19 

. . . 

Tetanus 

6 

35 

23 

41 

.. . 

Tuberculosis ... 

196 

1,961 

1,006 

2,157 

196 

Whooping cough 


9 

1 

9 

. . . 

Yaws ... 

8 

270 

.. . 

278 

7 

Yellow fever ... 

• •. 

... 

... 



Other infective diseases 

26 

418 

35 

444 

19 

( Alcoholism 

... 

19 

1 

19 

... 

Intoxications < Morphinism 

1 

6 

1 

7 


( Others 

... 

13 

, , 

13 


Anaemia 

38 

885 

187 

923 

35 

Anaemic-pernicious ... 

... 

... 

. .. 


... 

Diabetes 

4 

76 

7 

80 

5 

Exophthalmic goitre ... 

... 

1 

... 

1 

... 

Gout ... 

... 

1 

... 

1 

.. . 

Leucocythaemia 

... 

... 

... 


... 

Hodgkin’s disease 

. ... 

1 

... 

1 

... 

Myxoedema ... 

... 


... 


... 








Remarks. 















































16 


Table 1—( cont .) 


Return of Diseases and Deaths (in-patients) for the year 1923— (cont.) 



C -*3 q-i 
•5 <3 O 

Yearly total. 

CO 

CD . 

CJ 

.5 a o 


Diseases. 

Remaining 

Hospita 

the enc 

1922. 

Admis¬ 

sions. 

Deaths. 

Total cas 

treated 

Remaininj 

Hospita 

the era 

1923. 

Remarks. 

Purpura 







Pickets 

... 

2 

... 

2 

2 


Scurvy 

... 

125 

32 

125 

3 


Other general diseases 

91 

728 

179 

819 

93 


Neuritis ... 

11 

207 

2 

218 

11 


Meningitis 

2 

38 

27 

40 

... 


Myelitis ... 

1 

18 

4 

19 

5 


Local Diseases. 

Diseases of the nervous system— 

Sub-section 1 — 







Hydrocephalus ... 

• • • 

3 

2 

t» 

O 



Encephalitis 

.. . 

... 

... 

. •. 

... 


Abscess of brain 

... 

7 

3 

7 

• • • 


Congestion of brain 

... 

... 

... 

... 

... 


Other diseases of brain... 

9 

150 

37 

159 

25 


Sub-section 2 — 







Apoplexy 

. • . 

8 

4 

8 

.. • 


Paralysis 

62 

233 

54 

295 

45 


Paraplegia 

2 

4 

3 

6 

1 


Hemiplegia 

5 

10 

3 

15 

2 


Epilepsy ... 

2 

97 

10 

99 

6 


Neuralgia 

5 

144 

•. . 

149 

o 


Hysteria ... 

... 

19 

21 

19 

1 


Other nervous disorders 

14 

178 

192 

6 


Sub-section 3 — 

Mental diseases— 







Idiocv ... 

1 

10 


11 



Mania ... 

• • • 

109 


109 

• • • 


Melancholia ... 

... 

42 


42 

.., 


Dementia 

... 

28 


28 

1 


Delusional Insanity ... 


105 


105 

... 


Other mental diseases 

8 

132 

2 

140 

5 


Diseases of the eye— 







Conjunctivitis 

9 

367 

1 

376 

11 


Keratitis 

3 

40 


43 

7 


Ulceration of cornea 

20 

149 


169 

16 


Iritis 

8 

59 


67 

O 

O 


Optic neuritis 

1 

4 


5 

1 


Cataract 

30 

114 


144 

38 


Other eye diseases 

85 

351 

1 

436 

94 


Diseases of the ear— 







Inflammation 

2 

37 

. . • 

39 

2 


Other diseases 

o 

O 

198 

4 

201 

6 


Diseases o£ the nose ... 

1 

78 

... 

79 

6 


Diseases of the circulatory system— 







Pericarditis 


29 

21 

29 



Endocarditis 


7 

5 

7 















































































































17 


Table 1—( cont .) 


Return of Diseases and Deaths (in-patients) for the year 1923— (cont.) 


Diseases. 

Remaining in 
Hospital at 
the end of 
1922. 

Yearly total. 

Total cases 
treated. 

Remaining in j 
Hospital at 
the end of 
1923. 


• CC 

m ~ 

'2 .§ 

< 

cr. 

z 

<=> 

Local Diseases— (cont.) 







Diseases of the circulatory system— (cont.) 







Valvular mitral 

21 

209 

79 

230 

20 


Aortic 

6 

34 

18 

40 

3 


Tricuspid 

• • • 

3 

• • • 

3 

• • . 


Pulmonary 

.. . 

1 

• • • 

1 

. . . 


Areterial sclerosis ... 

1 

14 

2 

15 

1 


Aneurism ... 


28 

5 

28 

3 


Other diseases of heart 

7 

105 

38 

112 

6 


Diseases of the respiratory system— 







Laryngitis ... 

2 

27 

1 

29 

2 


Bronchitis ... 

107 

2,771 

62 

2,878 

118 


Broncho-pneumonia 

10 

239 

99 

249 

4 


Abscess of lung 

• • • 

, ,, 

... 

... 

... 


Gangrene of lung ... 


18 

14 

18 

,,, 


Empyema ... 

10 

54 

17 

64 

4 


Emphysema 


1 

... 

1 

. .. 


Pleurisy 

9 

23(5 

24 

245 

11 


Other diseases of the respiratory system 

22 

678 

24 

700 

21 


Diseases of the digestive system — 







Stomatitis ... 

1 

99 

3 

100 

4 


Caries of teeth 

3 

89 

• • • 

92 



Glossitis 

1 

4 

... 

5 

• • • 


Sore throat 


29 

1 

29 

. •. 


Inflammation of tonsils ... 


131 

... 

131 

6 


Gastritis 

8 

348 

12 

356 

12 


Ulceration of the stomach 

2 

37 

17 

39 

2 


Haematemesis 


1 

• • • 

1 



Dilatation of stomach 


1 

• • • 

1 



Stricture of stomach 


... 

... 

... 

, ,, 


Dyspepsia ... 

20 

421 

4 

441 

15 


Enteritis 

2 

123 

42 

125 

6 


Appendicitis 

2 

107 

12 

109 

>7 

t 


Colitis 

1 

99 

4 

100 

4 


Ulceration of the intestines 


9 

5 

9 



Sprue 

2 

61 

8 

63 

6 


Hernia 

14 

165 

10 

179 

8 


Diarrhoea ... 

35 

1,218 

81 

1,253 

49 


Constipation 

7 

584 

• • • 

591 

5 


Colic 

8 

248 

... 

256 

1 


Haemorrhoids 

6 

186 

2 

192 

6 


Intestinal Ostruction 


8 

5 

8 

». • 


Heapatitis-acute ... 

3 

90 

5 

93 

4 


Abscess 


62 

16 

62 

2 


Cirrhosis 

31 

391 

162 

422 

28 


Jaundice 

2 

164 

22 

166 

3 


Peritonitis ... 

2 

79 

64 

81 

2 


Ascites 

3 

73 

17 

76 

4 


Other diseases of the digestive system ... 

14 

565 

62 

579 

16 



Remarks. 
























































































18 


Table 1—( cont .) 


Return of Diseases and Deaths (in-patients) for the year 1923— (cont.) 



* dt s 

Yearly total. 


r* -t3 

_ O 


Diseases. 

Remaining 

Hospital 

the end 

1922. 

Admis¬ 

sions. 

ao 

ct 

Q 

Total casei 

treated. 

Remaining 

Hospital 

the end 

1923. 

Remarks. 

Local Diseases— {cont.) 

I 

| 






Diseases of the lymphatic system— 







Splenitis 

8 

170 

2 

178 

1 


Inflammation of lymphatic gland 

19 

312 

... 

331 

20 


Suppuration of lymphatic gland 

10 

193 

1 

203 

8 


Lymphangitis 

6 

56 


62 

4 


Elephantiasis 


3 

. 

3 

139 

1 


Other diseases of the lymphatic system 

4 

135 

17 

11 


Diseases of the urinary system— 







Acute nepliiritis 

Bright’s disease 

19 

374 

110 

393 

40 


29 

312 

124 

341 

18 


Pvelitis 

• • • 


... 

... 

... 


Calculus 

2 

24 

2 

26 

1 


Renal colic... 


3 


3 



Cystitis 


4 

... 

4 

• • • 


Vesical calculus 


1 

. * • 

1 



Suppression 

... 

3 

... 

3 



Hsematuria... 


,, , 

... 




Chyluria 


. • • 


. . • 



Other diseases of the urinary system 

Diseases of the generative system — 

5 

136 

13 

141 

11 


Male organs— 







Urethrale fistula 

1 



1 



Phimosis... 


15 


15 



Stricture ... 

1 

62 

1 

63 

2 


Prostatitis 


2 


2 

1 


Soft cancre 

26 

556 

... 

582 

39 


Condyloma 



• • • 




Inflammation of scrotum 


13 

2 

13 

1 


Hydrocele 

3 

65 


68 

1 


Orchitis ... 

1 

120 


121 

5 


Epididymitis 

1 

49 

1 

50 

3 


Abscess of testicle 

2 

12 


14 



Other diseases of the male generative system 

18 

297 

io 

315 

is 


Female organs— 







Ovaritis ... 

2 

77 


79 

2 


Ovarian cyst 


2 

... 

2 



Endometritis 


20 

l 

20 

2 


Displacement of uterus 


4 

... 

4 

.... 


Vaginitis... 


12 


12 



Amenorrhoea 


22 


22 



Dysmenorrhoea ... 


43 

... 

43 

4 


Menorrhagia 


15 


15 



Leucorfflioea 


13 


13 



Abortion... 

3 

152 

4 

155 

7 


Delayed labour ... 

4 

54 

8 

58 



Postpartum haemorrhage 


4 

4 

4 



Retained placenta 

2 

20 

1 

22 










































































































19 


Table 1—( cont .) 


Return of Diseases and Deaths (in-patients) for the year 1923— (cont.) 



d 

•E a 

o 

Yearly 

total. 


•rZ OS 
v “ © 


Diseases. 

Remaining 

Hospita 

the end 

1922. 

Admis¬ 

sions. 

Deaths. 

_ 

Total case: 

treated. 

Remaining 
Hospita 
the end 
1923. 

Remarks. 

Local Diseases— (cont.) 

Female organs— (cont.) 





1 


Premature birth 


99 

48 

99 



Pueperal septicaemia 

2 

73 

26 

75 

1 


Mastitis ... ... ... ... ... ... 


5 


5 



Abscess of breast ... ... ... ... 

1 

6 


7 



Other diseases of female generative system ... 

36 

1,041 

51 

1,077 

63 


Diseases of organs of locomotion—- 







Osteitis ... ... ... ... ... ... 

1 

16 

2 

17 



Arthritis ... ... ... ... ... ... 

13 

206 

3 

219 

16 


Spondylitis... ... ... ... ... ... 

2 

6 

1 

8 

1 


Bursitis ... ... ... ... ... ... 


10 


10 



Other diseases ... ... ... ... 

26 

476 

16 

502 

31 


Disease of connective tissue— 







Cellulitis 

35 

482 

48 

517 

42 


Abscess 

72 

1.706 

35 

1,778 

91 


Elephantiasis 


1 


1 



Other diseases 

8 

182 

19 

190 

8 


Diseases of the skin— 







Urticaria 


17 


17 

1 


Eozema 

11 

361 


372 

19 


Boil... 

2 

108 


no 

6 


Carbuncle ... 

8 

60 

1 

68 

4 


Herpes 

4 

59 

1 

63 

2 


Psoriasis 

1 

20 

... 

21 



Oriental sore 

282 

2,773 

45 

3,055 

i 73 


Tinea 

1 

44 


45 

1 


Scabies 

33 

1,094 

3 

1,127 

35 


Acne 






Prickly heat 


10 


10 



Other diseases of the skin 

223 

3,080 

28 

3,303 

196* 


Injuries— 







General 

24 

782 

28 

806 

32 


Local 

183 

4,678 

111 

4,861 

157 


Surgical operations Major ... 

51 

800 

110 

851 

62+ 


Minor ... 

147 

7,166 

49 

7,313 

179+ 


Tumours 

11 

262 

61 

273 

14 


Malformations 

15 

31 

2 

46 

20 


Poisons 

1 

82 

8 

83 

Q 

o 


Other diseases 

2 

25 

4 

27 

2 


Parasites—Animal.— 







Protozoa 


1 


1 



Trematoda (flukes) 


3 

2 

Q 

O 



Cestoda 


... 


... 

... 


Taenia Solium 


4 

... 

4 



Taenia Saginata 


3 

... 

3 

1 





1 





* Ulcers 1848. 


t h!ot included in totals. 






























































20 


Table 1—( cont .) 


Return of Diseases and Deaths (in-patients) for the year 1923— (cont.) 


Diseases. 

Remaining in 

Hospital at 

the end of 

1922. 

Yearly total. 

Total cases 

treated. 

Remaining in 

Hospital at 

the end of 

1923. 

Remarks. 

. 0D 

00 £ 
o 

Deaths. 

1 

t 

Nematoda— 






• 

Ascaris 

7b 

2,429 

29 

2,507 

71 

' 

Tricocephalus dispar 

,,, 

97 


97 



Trichina 







Dracunculus 


1 


1 



Filariasis ... 

3 

14 


17 



Strongylus ... 

.., 

... 


... 

• • • 


Ankylostomiasis ... 

169 

3,860 

300 

4,029 

141 


Oxyuris 


10 


10 



Others 

2 

61 

... 

63 

4 


Insecta— 

1 

l 






Myiasis 

1 

10 


11 

... 


IN o discoverable diseases and under observation 

195 

3,309 

1 

3,504 

127 


Total ... I 

j 

4,362 

82,158 

6,760 

86,520 

4,093 






















































1 

4* 

2 

1 

17 

4 

1 

2 

>3 

6 

>6 

37 

>5 

>3 

6 

5o 

13 

9 

1 

3 

7 

3 

5 

!2 

1 

1 

1 

1 

1 

2 

1 

1 

1 

3 

3 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

2 

1 

1 

1 

4 

1 

11 

6 


21 


Table 2. 

MEDICAL STAFF AT 31st DECEMBER, 1923. 

Principal Medical Officer 
Senior Medical Officers 
Chief Surgeons 
Opthalmic Physician 

Medical Officers, 5 acting as Health Officers 

Lady Medical Officei*s 

Financial Secretary 

Assistant Medical Officers 

Assistant Surgeons 

Dressers, Special Grade 

Dressers, Grade I. 

Dressers, Grade II. 

Dressers, Grade III. 

Dresser Probationers. 

Head Sisters 
European Sisters 

Asiatic Nui'ses and Nurse Probationers 
Native Midwives. 

HEALTH BRANCH. 

Senior Health Officer 
Health Officers 

Chief Sanitary Inspectors (one acting as Personal Assistant to P.M.O.) 
Assistant Surgeons 
Health Inspectors, Grade I. 

Health Inspectors, Grade II. 

Probationer Health Inspector. 

INSTITUTE FOR MEDICAL RESEARCH. 

Director 
Bacteriologist 
Assistant Pathologist 
Chemist 

Assistant Chemists 
Malaria Research Officer 
Librarian 

Laboratory Assistant, Grade I. 

Laboratory Assistants, Grade II. 

Laboratorv Assistants, Grade III. 

Laboratory Assistant, Probationer. 

CENTRAL MENTAL HOSPITAL. 

Medical Superintendent 
Senior Assistant Physician 
Assistant Physician 
Second Assistant, Physician 
Inspector 

Assistant Inspector 
Dresser, Grade II. 

Dresser, Grade III. 

Matron 

Nurses 

Work Mistress 

Steward 

Storekeeper 

VETERINARY BRANCH. 

Veterinary Surgeons 
Assistant Veterinary Surgeon 
Veterinary Inspectors 
Veterinary Assistants and Probationers. 


ANNUAL REPORT OF THE INSTITUTE FOR MEDICAL RESEARCH, 
FEDERATED MALAY STATES, FOR THE YEAR 1928. 


MELIOIDOSIS. 

This subject has been further studied during the year and additional evidence has 
been obtained in demonstration of the specific character of the disease. 

Most cases of melioidosis hitherto reported had not been examined by a. medical 
man before death but during 1928 two cases were met with, both of which had been 
cnder observation in hospital for some days. These cases are of special interest as 
clinical notes are available and as one of them, is the first recorded case in which the 
disease has been identified in a European. A detailed account of the cases will be 
published separately. 

In neither case was the nature of the disease recognised during life and this has 
been true in all but four of the forty-eight cases in which melioidosis has been 
diagnosed. In one of the four cases B. whitmori was cultivated from the blood, in 
another from the urine, in a third from a pustular eruption, in the fourth the 
suspicions aroused by a, “positive” agglutination test were confirmed by the cultivation 
of the bacillus from an abscess which appeared later. 

As in animals, so in man the patient may die from a fulminating acute septicaemia 
or the disease may run a more chronic course. The signs and symptoms of the chronic 
form of the disease are dependent upon the distribution of the lesions. We have seen 
one patient in which the brunt of the disease fell upon the urinary system, and the 
prominent symptoms were due to lesions of the kidney, ureters and bladder. In the 
majority of our cases the illness commenced as an acute septicaemia,; if the patient 
did not succumb within the first few days he passed into the typhoid-like state of 
chronic septicaemia and abscesses formed in different organs. Every patient died in 
less than four weeks except two; one of these recovered after a long illness, while 
the other is still an invalid with abscesses, sinuses and chronic suppuration in the 
bones of his feet and legs, now more than two years after the commencement of the 
malady. 

In the two patients who form the subject of this special report the onset of the 
disease was gradual. In other cases the illness has been characterised by a sudden 
onset, accompanied by collapse and sometimes by a purging so violent as to suggest 
the diagnosis of cholera. 

There are no definite clinical signs by which the disease can be recognised: a 
certain diagnosis can be made only by the cultivation of the causative organism. 
A positive” agglutination reaction is of value as presumptive evidence, particularly 
d the titre of the serum increases after an interval, but this reaction is obviously of 
little value in the ordinary acute form of the disease. The organism, has been 
cultivated from the blood and the urine of human cases and also from pustules and 
abscesses when these have been present. In one case of infection, in a, rabbit it was 
cultivated from the faeces. Where the lungs are involved, a,s they usually are, the 
injection into a guinea-pig of sputum or of material obtained by puncture of the lung 
might make the diagnosis clear. In cases of obscure fever associated with enlargement 
of the liver, this organ should be explored with a needle and glycerine agar slopes and 
animals should be inoculated with the material obtained. Whenever an abscess of the' 
liver is aspirated or drained, glycerine agar slopes and guinea-pigs should be inoculated 
with the pus. We consider it probable that, in Malaya at least, some cases diagnosed 
as amoebic abscesses are really cases of melioidosis. 

W hen we come to, deal with the epidemiology of the disease, and attempt to learn 
in what wav man becomes infected, we must confess ourselves still in difficulty. 
Melioidosis, can be conveyed to rodents by subcutaneous inoculation, by introducing 
the 'virus into the nostrils or by feeding. In. animals subcutaneous inoculation is- 
followed by a local lesion before generalisation takes place, but there was no history' 
of any such manifestation in our two patients. Infection by inhalation is unlikely 
except where a number of cases are closely associated. We are of opinion that the 
disease was conveyed to these men by the ingestion of food which had been 
contaminated by rodents infected with melioidosis. 

Summary. 

Two fatal cases of melioidosis are described. The first a robust Indian labourer- 
the second a well-nourished, muscular European. 

In the first case the onset was gradual with irregular fever and pain in the- 
epigastrium. There were no physical signs of disease at first, except enlarged spleen • 
later there were signs of. consolidation at the bases of both lungs. The patient was 
constipated at first but diarrhoea came on towards the end and he collapsed and died 
at the end of the third week of his illness. 



oq 

At the autopsy there were small patches of consolidation in the lungs and these 
patches were composed of minute suppurating tubercles. In the liver there were 
similar aggregations of small suppurating tubercles and two circumscribed abscesses. 
The gall bladder was thickened. The spleen was enlarged and contained septic- 
infarcts and abscesses. In the caecum there were some small superficial ulcers. 
B. whitmori was cultivated from the lungs, spleen, liver and gall bladder. 

A guinea-pig inoculated in the anterior nares with pus from the liver died 
nine days later with caseous infiamation of the nasal passages and inguinal glands 
from which B. whitmori was recovered. A guinea-pig inoculated subcutaneously with 
pus from the liver died on the twenty-fifth day with abscesses in the lymphatic glands 
from which B. whitmori was cultivated. A guinea-pig inoculated subcutaneously with 
a culture of the organism died within sixteen hours from septicaemia and B. whitmori 
was recovered from the heart and spleen. A guinea-pig inoculated subcutaneously 
with an attenuated culture died on the twenty-fifth day with suppurating buboes and 
with abscesses in the liver and lungs from which B. whitmori. was cultivated. 
Two horses were inoculated subcutaneously with cultures of the strain of B. whitmori 
cultivated from the patient. An abscess developed at the site of inoculation in each 
case but the local lesion healed and the animals have so far remained healthy. 

In the second case the illness commenced gradually with pain after food, occasional 
vomiting and looseness of the bowels. The temperature became high and of the 
swinging type, accompanied by rigors and sweats. The liver was enlarged. The 
patient died on the twenty-fifth day. 

At autopsy, two large abscesses were found in the liver; the gall bladder was- 
thickened and there were a few small superficial ulcers in the caecum. B. whitmori 
was cultivated from the liver abscess. No amoebae were found. 

Two wild rats were inoculated subcutaneously with a culture from this case and 
both died from septicaemia in less than twenty-four hours; B. whitmori w r as recovered 
from the heart’s blood. The result of inoculation of a guinea-pig was the same. 
A guinea-pig inoculated in the nostril died on the fifth day with a cheesy deposit in 
the nose and septicaemia. Another guinea-pig inoculated in the same way, but after 
the organism had been subcultivated repeatedly, died on the twelfth day, with caseous 
tracheal glands containing B. whitmori. A rabbit inoculated subcutaneously died in 
•thirty-six hours from septicaemia with tubercles in the peritoneum. B. ivhitmori was 
cultivated from the peritonium and from the heart’s blood. A monkey fed on a culture 
remained healthy. A pony inoculated intravenously has apparently recovered after a 
week’s fever. 

MALARIA AND QUININE. 

In the annual report for 1922 reference was made to Dr. Fletcher’s observations, 
■on rectal injections of quinine. His experiments showed that the injections were 
irritating and sometimes caused pain and tenesmus; that the passing of blood and 
mucus is a usual sequel; that the injections are quickly returned and are of little 
therapeutic value. 

These conclusions w r ere greatly at variance with established opinion. The Medical 
Research Council and the Medical and Sanitary Advisory Committee of the Colonial 
'Office, after consideration of the report, asked that further investigations should be 
made. These investigations have now been completed and a detailed report of them 
will shortly be published. The following is a summary of the results: 

(1) Injections given to guinea-pigs were returned too quickly to allow 
satisfactory absorption of quinine to take place. 

(2) A series of rectal injections, two each day for at least six days, were given 
to two groups of men infected with malaria. The first group," consisting of 
ten patients, received 20 grains of quinine bihydrochloride, dissolved in four ounces 
of salt solution, at each injection. The second group, which comprised six men, 
received the same quantity of quinine, but it was dissolved in eight ounces of 

* saline instead of four ounces. 

In the first group, out of seventy-one injections, sixty-one were returned 
dining the first twenty minutes; none was retained permanently; the average time 
of retention was thirteen minutes. Quinine was found in the urine only thirty-six 
times out of 132 injections. 

In the second group of thirty-two injections in which the time was noted, 
three were retained permanently and the average time of retention for the 
remaining twenty-nine was seventeen minutes. Twenty-five were returned within 
twenty minutes. Quinine was found in the urine after thirty-three out of 
fifty-seven injections. In many of the cases where quinine was present the 
amount was very small. When 10 grains twice a. day were given by the mouth, 
instead of 20 grains by the rectum, abundant quinine appeared in the urine. 


24 


(3) In eleven out of the sixteen cases of malaria in the two groups, 40 grains 
-of quinine bihydrochloride given daily per rectum failed to get rid of asexual 
parasites within a week. Quinine was then administered to these patients by the 
mouth with the result that the parasites quickly disappeared. 

(4) Eectal injections containing 2^ grains and 5 grains to the ounce were 
given to a healthy European but he was unable to retain them for more than ten or 
fifteen minutes and the absorption from 60 grains injected into the rectum 
appeared to be inferior to the absorption from 2^ grains given by the mouth. 

(5) The presence of mucus and membranous shreds, passed by patients 
undergoing treatment with rectal injections of quinine, demonstrates the irritating 
action of the drug upon the mucous membrane. 

(6) In view of these results we reiterate our former conclusion (Fletcher, 1923) 
that “quinine is too irritating for administration per rectum. It should not be 
given by this route if any other means are available’’. 

BERI-BERI. 

In 1922 the question, of international action for the control of beri-beri was referred 
by Government to the Health Committee of the League of Nations and during the 
year inquiries were made in Malaya and other countries of the Far East by a 
representative of the League. It is understood that these inquiries did not disclose 
any satisfactory basis for international action through the intermediary of the League. 

At the Fifth Congress of the Far Eastern Association of Tropical Medicine held in 
Singapore, September, 1923, the question of beri-beri was discussed at length. In the 
course of a discussion the vitamin deficiency view, as a complete explanation of the 
causation of beri-beri was opposed by Dr. Noel Bernard of Saigon, who postulated the 
existence of a secondary factor of infection as did his predecessor, Breaudat, at the 
1913 Congress. Professor Megaw, who has studied the question of beri-beri and 
epidemic dropsy in Calcutta, stated the case against the vitamin deficiency view of 
beri-beri causation. In support of the vitamin deficiency theory Dr. Kiewiet de Jong 
of Java asserted that the theory which claimed beri-beri to be an avitaminosis was one- 
of the best established truths of medical science. 

Following the discussion in open Congress, the Council of the Association and a 
Sub-committee on beri-beri further discussed the question of beri-beri control through 
international action, the methods of standardisation of rice and the commercial and 
economic considerations involved. Official delegates to the Congress submitted 
statements on these questions. The statements of official delegates revealed a 
divergence of views which excluded the possibility of international action at present. 

The resolutions finally adopted by the Congress are as follows : 

1. The Fifth Congress of the Far Eastern Association of Tropical Medicine has 
considered the proposals of the Philippine Islands delegation for international 
action in the control of beri-beri, and has taken note of the views of the official 
delegates of Governments represented in the Congress. 

2. The Association is of opinion that consequent upon the divergence of views 
disclosed in the statements of official delegates, any international convention is at 
present impracticable. 

3. The Association reaffirms its opinion that beri-beri is a disorder of nutrition, 
and that in the Far East the principal factor in its causation is a, diet of which 
overmilled rice forms the staple. 

4. The Association recommends that interested Governments be invited to 
promote further research in the following questions in relation to beri-beri control: 

(a) the standardisation of rice; 

( b ) the effects of transport and storage on rice; 

(c) economic considerations. 

5. The Association recommends that each of the Governments interested and 
the International Health Board of the Rockefeller Foundation be invited to 
nominate a representative on a “Beri-beri Committee” which shall report at the 
next Congress. The names of such representatives should be notified to the 
General Secretary-Treasurer. 

6. The Association considers that, in the meantime, individual Governments 
should take such action for the control of beri-beri as may be suited to local 
conditions in their respective countries, and should devote special attention to 
devising and applying practical methods of improving the diet of the general 
population with regard to the too exclusive use of overmilled rice, and should be 


25 


requested to make available to the next Congress of the Far Eastern Association, 
of Tropical Medicine systematic observations and statistical data showing the 
results of these methods. 

7. The Association considers that educational methods of control on the basis 
of the available scientific knowledge should be vigorously applied in all countries. 

In the Federated Malay States the following measures have been taken to restrict 
the use of overmilled rice : (a) Pamphlets in English and Chinese and advertisements 
in Chinese newspapers have been published pointing out the dangers of white 
(overmilled rice) and the advantages of early hospital treatment for beri-beri; 
(b) Undermilled rice is being produced in the Government rice mill for use in hospitals 
and public institutions; (c) Government is encouraging the production for local 
consumption of undermilled rice in small estate mills. 

The fall in the incidence of beri-beri in the Federated Malay States during the past 
ten years has been so notable that it is thought that simple measures will suffice 
within a few years to abolish the disease. Even now the recorded incidence of the 
disease is believed to be in excess of its real incidence. Because of its ill-defined 
clinical character, “beri-beri” is a convenient diagnosis for any condition of which 
weakness of the legs is a feature. Within the past year we have seen cases diagnosed 
as beri-beri which turned out to be such widelv different conditions as “traumatic 
myelitis” and “septicaemia plague”. 

TYPHOID SEPTICAEMIA. 

Dr. W. Fletcher, Bacteriologist, and Mr. J. E. Lesslar, Assistant Pathologist, 
have reported a case of typhoid septicaemia without typhoid ulcers, a very rare 
condition. Their paper, of which the following is a summary, will be published 
elsewhere : 

1. Two strains of B. typhosus, the one agglutinable, the other non- 
agglutinable, were isolated from the blood of -a. elderly Chinese labourer whose 
blood serum agglutinated B. typhosus in high dilutions. 

2. B. dysenteriae, Flexner, type, X, was isolated from his faeces on each of 
the four occasions it was examined. 

3. The patient died about six weeks after the commencement of his illness. 
There were two old pigmented scars just above the ileo-caecal valve but no typhoid 
ulcers. There was no marked thickening or inflamation of the gall-bladder, but an 
agglutinable strain of B. typhosus was cultivated from it. 

4. It is an open question whether the patient was a chronic carrier of 
B. typhosus and the septicaemia, the result of infection from an old focus in the 
gall-bladder, or whether on the contrary the gall-bladder had become recently 
infected as the result of a general septicaemia. 

PLAGUE. 

There was a small outbreak of plague in Kuala Lumpur during the months of 
April and May. Some cases of the septicaemia form, of the disease presented 
considerable difficulty in, diagnosis and the laboratory was able to render assistance in 
this connexion. 

Two hundred doses of anti-plague vaccine were issued for prophylactic inoculation. 
Anti-plague serum was used in the treatment of cases but without any favourable 
result. 

With the object of discovering cases of plague that might have escaped recognition 
before death, films were examined from dead bodies within the Kuala Lumpur Sanitary 
Board area. Of 179 specimens all were negative for B. pestis ; in eight of these 
undiagnosed malaria was proved to be the cause of death. 

Bats taken in the areas where cases of human plague occurred were systematically 
examined. Of 1.037 rats received from the Health Officer, Kua-la, Lumpur, 25 were 
found infected. 

Live rats examined showed a, flea index of 3.0 and all fleas were of the species 
Xenopsylla cheopis, the most efficient carrier of plague. It has been surmised that 
freedom from serious outbreaks of plague in the Federated Malay States might be due 
to the absence of an efficient transmitting agent, but this has proved to be untrue. 

CHOLERA. 

Apart from a small outbreak in the quarantine camp at Port Swettenham in 
December the country was free from, cholera, throughout the year. 

Of eight specimens received for examination, three were positive for the cholera 
vibrio. 


26 


VENEREAL DISEASES. 

The number of blood specimens received for examination by the Wassermann test 
for syphilis was 4,387; of these 4,120 were examined, the remainder being for one 
reason or another unsuitable, with a positive result in 1,992 cases. 


A comparison.' of the results in Kahn’s test and the Wassermann tests in 
2,690 specimens resulted as follows: 


Kahn’s Test. 


Wassermann Test. 




(1) Weak positive. 

(2) Positive. 

(3) Negative. 

(1) Weak positive 

218 

66 

65 

87 

(2) Positive 

... 1,112 

... . 100 

867 

145 

(3) Negative 

1,097 

45 

124 

928 

Anti-complementary 

263 

27 

114 

122 

Percentage of 

agreement (1), 

(2) and (3) 

... 83.47 


) > 

(1) 

and (2) 

... 82.55 


1 1 

(3) 

... ... ... 

... 84.59 



Of 263 specimens which were anti-complementary by the Wassermann test, 
53.61 per cent, were positive and 46.39 per cent, negative by Kahn’s test. 

Forty-seven specimens were examined by the direct method for spirochaeta pallida 
with a positive result in seven cases. 

Twenty-five specimens were examined for gonococci in special cases with a positive 
result in fourteen. 


ENTERIC FEVERS. 

Five hundred and sixteen specimens of blood were examined by the agglutination 
reaction; 140 gave a positive result with B. typhosus, four with B. paratyphosus A. 
and seven with B. paratyphosus B. 


RABIES. 

Four specimens only were received for examination and two were positive, 
one from Seremban and one from Malacca. In 1922, twenty-seven specimens were 
received and in fourteen of these Negri bodies were identified. 

The freedom of the country from rabies during the year may be fairly attributed 
to the highly efficient measures taken by the Police Department for the destruction of 
unlicensed dogs. 

A number of house dogs were inoculated with anti-rabic vaccine by way of 
experiment in this method of rabies prevention but, in the absence of rabies among 
non-inoculated animals, there has been no opportunity of determining the value of 
this measure. 

DIPHTHERIA. 

One hundred and thirty-one specimens were received for examination by culture 
of B. diphtheriae . In 39 cases the specific organism was identified. In one case the 
characteristic spirochaetes and fusiform bacilli of Vincent’s Angina were found in 
smears. 

Thirty-six tubes of diphtheria anti-toxin were issued for use in treatment. 

CEREBRO SPINAL FEVER. 

Fifty-seven specimens of cerebro-spinal fluid were received for examination. 
In eleven, of these the meningococcus was identified, in seven the pneumonoccus, in 
one the influenza bacillus, in two streptococci and in one the tubercle bacillus. 

Forty tubes of anti-meningocoecus serum, were issued for use in treatment. 

LEPROSY. 

One hundred and thirty-two specimens were examined for the presence of 
B. leprae; of 66 smears of nasal discharge, 19 were positive, and of 66 smears of 
■exudate from nodules, 46 were positive. 

TUMOURS. 

One hundred and nine specimens of tissues were examined. Of these eight proved 
to be adeno-carcinoma, twelve epithelioma, one lymphosarcoma, three melanotic 
sarcoma and nine other forms of sarcoma. In one specimen, a polypoid growth from 
the nose of a Tamil, Rhinosporidium kinealyi was identified. 






27 


DIABETES AND INSULIN. 

One hundred and eighty-two specimens of urine and blood were examined for the 
quantitative estimation of glucose in connexion with the insulin treatment of diabetes. 
The results of insulin treatment have varied greatly in different cases; some of this 
variation may be due to instability in the composition of insulin in tropical conditions. 


DYSENTERY. 

One hundred and forty-seven specimens of faeces from cases of supposed dysentery 
were examined by microscopic and bacteriological methods with the following results: 


B. dysenteriae, Flexner 
>. Shiga 

Entamoeba histolytica 
Balantidium coli 
Negative 


Total 


27 

2 

31 

1 

86 


147 


MEDICO-LEGAL. 

Thirty-six specimens of blood stains were examined by the precipitin test for 
human blood; 25 gave a positive result. 

MISCELLANEOUS. 

There were 1,385 miscellaneous examinations; urine for the presence of quinine, 
blood films for parasites in special cases, sputum for the tubercle bacillus, and other 
clinical laboratory tests. Autogenous vaccines were prepared in 70 cases. 

Eighty tubes of tetanus anti-toxin and 138 tubes of anti-streptococcus serum were 
issued for use in prophylaxis and treatment. 

CHEMICAL LABORATORIES AND MALARIA BUREAU. 

Reports on the work of the 'Chemical Laboratories by Mr. H. Marsden, Acting 
Chemist-in-Charge, and on the work of the Malaria Bureau by Dr. H. P. Hacker, 
Malaria Research Officer, are appended. 

PUBLICATIONS. 

The following publications were issued: 

Notes on the treatment of Malaria with the alkaloids of Cinchona. W. Fletcher. 

Vitamins and Diet. A. T. Stanton. 

The control of Beri-beri in tbe Far East. A. T. Stanton. 

Observations on human intestinal protozoa in Malaya. M. W. Jepps. 

Protozoa of the human mouth in Malaya: Entamoeba gingivalis and 
Trichomonas sp. M. W. Jepps. 

STAFF. 

Mr. J. Shelton, Assistant Chemist, was transferred from the Geological 
Department and assumed duty on January 22nd. 

Dr. W. Fletcher, Bacteriologist, was on leave from, 26th January to 25th October. 

Mr. R. W. Blair, Chemist, proceeded on long leave on 14th November. 

Mr. S. Aloysius resigned the post of Librarian on 31st May and was replaced by 
Mr. V. Nagalingam on 1st September. 

Mr. Yeo Seng Lee was appointed Probationer Laboratory Assistant with effect 
from 9th April. 

A. T. STANTON, 

Director of Government Laboratories, 
Federated Malay States. 















ANNUAL REPORT OF THE MALARIA BUREAU, INSTITUTE FOR MEDICAL 
RESEARCH, FEDERATED MALAY STATES, FOR THE YEAR 1923. 


Monthly reports on the progress of work have been issued and tlie present report 
is a review of the subjects mentioned in those reports. 

FIGURES RELATING TO FIELD AND LABORATORY WORK. 

Figures showing the amount of material collected and dealt with in the laboratory 
appear in each of the monthly reports and the following are the total figures for 
the year: 


Breeding places described 


... 2,946 

Larvae identified microscopically 


... 54,011 

Adults bred out and identified ... 


... 13,415 

Adults caught in houses ... 


... 9,030 

Adults tested for egg-laying capacity ... 


1,760 

Adults examined for malaria parasites ... 


681 

Blood specimens examined for malaria parasites 

679 


SEASONAL PREVALENCE OF SPECIES. 

This subject has been studied continuously during the past three years and the 
first two years’ results were reported in detail in the Annual Report for last year, 
'lhe present year’s results are very similar, and it is proposed to summarise the 
-conclusions that may be drawn from them and to stop this method of work. 

A. vagus has proved capable of laying fertile eggs and of emerging as adult from 
its larvae in each month during the whole period of the experiment. A. aconitus has 
proved capable of laying eggs throughout the whole period with the exception of July 
of this year. The completeness of the records with regard to these two species 
probably depends only on the readiness with which they can be obtained, forming, as 
they do, 90 per cent, of the specimens caught at the observation stations chosen by 
Dr. Lamborn. 

Fortunately one, A. vagus, is a typical small pool breeder and the other is an 
equally typical representative of the large pool or swamp fauna. 

Ini addition the following species have been proved capable of emerging as adults 
from their larvae in each month consecutively over a period of at least a year: 

Small Pool Breeders.— 

A. maculatus. 

A. karwari. 

A. kochi. 

Swamp Breeders.— 

A. barbirostris. 

A. hyrcanus. 

A. aconitus. 

A. fuliginosus. 

A. subpictus var. malayensis. ■ 

Jungle Breeders.— 

A. leucosphyrus. 

A. asiaticus. 

There can be little doubt, therefore, that anophelines in this country have no 
definite breeding season but breed throughout the year, and this may be regarded as 
proved for A. vagus. 

The prevalence of species does vary, however, at different times of the year. 
Curves were given in the last year’s report showing the relation that rainfall bears to 
the monthly proportion between small pool breeders and swamp breeders, and in 
general, the curves for the present year are very similar to those of last year. 

The rainfall was again greater at the beginning and end of the year, and the peaks 
on the rainfall curve occur in the same two months, namely, March (10.95 inches) 
and October (13.17 inches). The intervening months were the driest parts of the year 
and the curve reaches its lowest points in June (4.85 inches) and July (2.33 inches). 














29 


At the Malaria Advisory Board’s cooly lines the pool breeders form 98.5 per cent, 
of the 5,845 specimens caught. They reach the maximum of 100 per cent, during 
•the dry months of June, July and August, but fall to 95.5 per cent, in October and 
to 89.7 per cent, in December owing to the appearance of swamp breeders after the 
heavy rains of October. 

At the house on Petaling Hill the small pool breeders form 52.2 per cent, of the 
1,672 specimens caught. In February they form 33.4 per cent, of the catch and 
increase to 54.1 per cent, after the high rainfall of March, decreasing during the 
drier weather to their lowest point, 27.9 per cent, in July. At the end of the dry 
weather they increase rapidly to their maximum, 79.2 per cent, in September and 
decrease with the onset of rain in October to 48.3 per cent, and to 28.1 per cent, in 
November. The first rise in frequency was attributed in the last year’s report to the 
increase of small pools during wet weather and the second larger rise to* the swampy 
areas becoming suitable for these species during dry weather, and the fact that the 
third year’s results agree so closely with those of the first two years gives support to 
this view. 

The general conclusion that may be reached from this work is, therefore, that 
anophelines breed all through the year and increase in frequency when conditions 
become suitable. This is opposed to the idea, which is commonly held by planters 
that it is safe to fell or prune vegetation during August and September on the 
assumption that A. maculatus does not breed then. It would seem dangerous to 
make conditions suitable for any species at any time of the year. 

WORK AT KENT ESTATE. 

During 1922 a change in fauna was noticed in certain drains on this estate and 
A. kochi was observed to take the place of A. maculatus. In May out of 454 specimens 
only one larva was A. kochi and the rest were A. maculatus. In November there 
was less breeding but out of 33 specimens 25 were A. kochi and only 8 A. maculatus. 

During the present year 930 yards of drain, far away from houses and outside the 
oiling areas, were marked out and visited once a week to determine whether the 
change would recur, and if so at what time of the year. 

With regard to the species found the year may be divided into the following 
four periods: 

(1) From January to March 28th A. kochi was present but was far out¬ 
numbered by A. maculatus of which 3,644 specimens were caught as against 
253 of A. kochi. 

(2) From this time up to August 2nd A. kochi was not caught at all, and 
all the 1,996 specimens found were A. maculatus. 

(3) At the next examination, on August 10th, a complete change had taken 
place. A. kochi had returned, 39 specimens were found and only 4 of A. maculatus. 
A. kochi remained predominant up till October 17th, 942 specimens being obtained 
against 40 1 A. maculatus. 

The decrease of A. maculatus was as marked as the increase of A. kochi. 
In the last two weeks of the previous period the catches were 72 and 48, but 
during this period never more than eight were caught at one visit, and in the last 
two weeks A. maculatus was absent altogether. 

(4) The last period, from October 24th to the end of the year, started with 
such heavy rain that the drains were flooded and no collections were obtained. 
When the first collection was made on November 14th, A. maculatus had returned 
and was breeding freely, 122 specimens were caught and only two of A. kochi. 
It maintained its predominance till the end of the year, affording 250 specimens 
against 73 of A. kochi. 

These records show that A. maculjatus was predominant during the first period, 
a. period of abundant rainfall, and replaced A. kochi after the heavy rainfall of March 
when the water would be fresh and clean. They show that A. kochi became abundant 
and ultimately replaced A. maculatus during the dry period of the year when the water 
would become progressively fouler. These facts lead to the conclusion that polluted 
water inhibits A. maculatus and favours A. kochi, and the fact that A. maculatus 
returned after the drains had been cleansed by the floods of October adds confirmation. 

The results of chemical analysis of the water by Mr. R. W. Blair also confirms 
this conclusion since the oxygen absorbed and the albuminoid nitrogen followed closely 
the alterations in species and were low when A. maculatus was common and high 
when A. kochi predominated. Thus on March 28th when both species were present 
the albuminoid nitrogen was 0.036 parts per 100,000, and on April 4th when 
A. maculatus alone was present it fell to 0.012 parts, rising to 0.048 parts on June 6th 


30 


when, A. maculatus was still alone but less plentiful. When both were present but 
A. kochi the more common, on August ‘22nd, it had risen to 0.150 parts, and on 
October 10th when A. maculatus had died out it rose to 0.180 parts. On 
November 21st when A. maculatus had returned after the flooding of the drains it 
had fallen to 0.012 parts again. 

During the beginning and end of the year when A. maculatus was the prevalent 
species the characteristic alga throughout the drains was spirogyra but in September 
when A. kochi was predominant this alga could not be found and its place was taken 
by the blue-green algae spirulina and oscillaria. It may be, as Dr. Lambom suggested, 
that the spirogyra causes the prevalence of A. maculatus by acting as flood-material, 
but it is more probable that the change in the algae is a concomitant one depending" 
on the alteration of the condition of the water. 

The drains have been chosen so that the conditions in one part of the system can 
be altered artificially without affecting the rest of the area. Observations will be 
continued on the present lines throughout, 1924 in order to ascertain the amount and 
kind of the breeding that occurs in nature and then, it is proposed to use the area for- 
experiments. When the work is complete a report containing the full data, will be 
prepared. 

WORK AT SUNGEI BESI. 

Sungei Besi was visited once a week in order to test a, suggestion that A. karwari 
might be replaced by A. maculatus at some period of the year. The work differs from 
that done at Kent Estate in that no definite area was visited but a search was made for 
places in which these species are likely to breed. 

A. karwari was found all through the year, 1,778 adults bred out all proved to be 
A. karwari and only one A. maculatus was found in January. From the Kent Estate 
material 1,077 adults of A. maculatus were bred out and no A. karwari. 

There seems to be no seasonal relationship between these species therefore, and 
the reason why similar larva,© breeding in similar places should be A. karwari in, some 
districts and A. maculatus in others is still a mystery. 

KLANG WATER-SUPPLY. 

The Klang water-supply is unfiltered and comes through pipes and reservoirs in 
jungle some eight miles away. A visit was paid to find out whether viable mosquito 
larvae were being conveyed into 1 the town, through the pipes. 

In a closed mosquito-proofed service reservoir many specimens of midges, 
Chironomus spp., Tanytarsus spp., Trichotanypus spp. and a caddis-fly were found 
emerging but no mosquito, culicine or anopheline, was found. By filtering the water 
from taps through muslin living larvae and pupae of Chironomus, Corethra, etc., were 
found; but all these larval forms live submerged in the water and no evidence of the 
surface-living air-breathing larvae of mosquitoes was found. It seems unlikely that 
mosquito larvae would survive a, journey through the pipes and in Klang it is almost 
impossible for them even to get into the pipes because the water is not taken, from 
the surface but from a, floating intake so arranged as to collect water from a foot below 
the surface. 

WORK IN JOHORE. 

This investigation was undertaken, a,t the request of the management of an estate. 
Malaria was not regarded as a serious factor since the malaria sick rate in the Tamil' 
labour force was under 2 per cent, per month and had shown a progressive decrease 
during the past three years, but there had been cases among the European staff and 
the management was anxious about the future. Mr. Ampala.vanar spent two weeks 
on the estate with two collectors and prepared an excellent report on his findings. 

Much more malaria was found than, was suspected by the manager and the 
three men engaged in the field-work contracted malaria during their stay of a fortnight 
on the estate. The predominant species of anopheline was A. maculatus which was 
found in 173 or 72 per cent, of the 240 breeding places examined and formed 
70 per cent. (1,366) of the 1,938 specimens collected. Out of 342 adult anophelin.es 
caught in houses 335 or nearly 98 per cent, were that species. A. maculatus was the 
only species found carrying the parasites of malaria and as many as 23 were found 
infected out of 199 dissected—a, percentage of 11.5. 

The main value of this work is the additional experimental evidence that it affords 
for regarding A. maculatus as a dangerous species. But the main point of interest 
is that a large amount of malaria may exist on an estate, without showing a high rate 
for hospital admissions. The probable explanation of such cases is that the population 
has been stable or decreasing for some time and unless adequate precautions are taken 
a severe outbreak of malaria may be predicted when new labourers are recruited. 


31 


WORK AT SABAK BERNAM. 

The problem is the cause of an outbreak of malaria in the district which up to 
■recently had been free from malaria. Owing to the courtesy of the Manager of 
Torkington Estate a. field laboratory has been sent up on the estate which forms an 
excellent centre from which to follow the course of the outbreak and to study various 
problems in connection with malaria on the coastal plain. 

The most striking feature of the work has been the discovery of five infected 
specimens of A. barbirostris out of 103 specimens dissected for parasites. Three of the 
specimens were caught at Sabak Bemami but the others came from outlying parts of 
the district, one from near the coast 10 1 miles away and the other from across the 
Bernam River. There can be little doubt that this species, which does not appear to 
cause malaria in the other parts of the country, is an important factor in the outbreak. 
The work was being continued at the end of the year and a detailed report on the 
results will be issued in 1924. 


GENERAL. 

There seems to have been more contact of the laboratory with the outside public 
during the present year. Forty-eight reports were issued on specimens sent for 
identification as against 19 last year. Sixteen batches of specimens were sent out to 
Health Officers and other authorities. A demonstration of specimens was prepared 
for the Malaria Advisory Board’s stall at the Agri-Horticultural Society’s show in 
June. 

There have been more visitors to the laboratory and museum during the year and 
the Bureau was honoured by visits from the Conference of Health Officers in April 
and from the Far Eastern. Association of Tropical Medicine in September. 

H. P. HACKER, 
Malaria Research Officer. 


32 


ANNUAL REPORT OF THE CHEMICAL LABORATORIES, INSTITUTE FOR 
MEDICAL RESEARCH, FEDERATED MALAY STATES, FOR THE YEAR 
1923. 


Chemical investigations and routine ’analyses are carried out in the Chemical 
Laboratories for the following Government departments: Medical, Trade and Customs, 
Police, Railway and Public Works. 

The total number of samples examined during the year was 6,521 as compared 
with 2,702 in 1922. The increase is principally in samples of chandu dross and in 
counterfeit coins. 


I.—MEDICAL DEPARTMENT. 

The work for this department consists mainly in the examination of samples of 
milk, water and toddy. The total number of samples examined was 1,651. 

(a) Milks. 

The total number of samples analysed was 774 as compared with 657 in 1922 ; 
759 were samples of fresh milk and 14 samples of condensed milk. 

The majority of the samples of fresh milk were submitted under the provisions of 
“The Sale of Food and Drugs Enactment, 1913”. Certificates of analysis were issued 
in respect of 107 samples which failed to comply with the standards prescribed under 
this Enactment. Eighteen of these samples were deficient in milk fat, 86 were 
deficient in non-fatty solids, and three were deficient in both, that is, they were 
skimmed and watered. 

The number of samples received from each State, with the number and percentage 
of unsatisfactory samples, is shown in the table below; 

U nsatisfactory. 



Number received. 

Number. 

Percentage. 

Selangor 

... 485 

67 

13.8 

Perak 

... 242 

32 

13.2 

Negri Sembilan 

... 14 

7 

50.0 

Pahang 

... 18 

1 

5.6 


Fourteen samples of condensed milk were examined. These consisted of milk 
powder, unsweetened and sweetened condensed milks. 

( b ) Waters. 

Chemical analyses were carried out on 343 samples, and bacteriological 
examinations on 40 samples of water. 

Kuala Lumpur Supply .—The raw waters from the Impounding Reservoir and from 
the Intake Works at Ampang, and the filtered waters from Maxwell’s Hill and Weld 
Hill Service Reservoirs were examined weekly. 

The raw waters are filtered through sand filter beds. Owing to constructional 
alterations and the cleaning of the filter beds, there was no filtration during the 
following periods : 

Impounding Reservoir... ... 20th August, 1923, to 30th September, 1923 

Intake Works, Ampang ... 28th May, 1923, to 30th September, 1923 

Average analyses for each month and for the year are given in Table 1. 

Proposed New Supply for Kuala Lumpur .—During the period 15th May, 1923, to' 
30th July, 1923, samples of raw waters from the proposed intakes on the Sungei Sleh 
and Sungei Klang were examined weekly. As judged by the chemical and 
bacteriological results, the raw water from the Sungei Sleh is considerably better than 
the raw water from (1) the Sungei Klang, (2) the Impounding Reservoir, Ampang, 
(3) the Intake Works, Ampang. 

Klang Supply .—In last year’s report it was mentioned that it had been decided 
to treat this water with chlorine. A Paterson chloronome No. 2 (large) pulser has 
been erected by the Paterson Engineering Company at the Klang Service Reservoir. 
The raw water from the Ayer Kuning Reservoir has now been treated with chlorine 
since September, 1923. The addition of 0.5 part of chlorine per million effected a 
71 per cent, reduction in the number of bacteria. By increasing the dose of chlorine 
to 0.75 part per million the reduction in-the number of bacteria was increased to 
84 per cent. 






33 


The Kuala Lipis and Pekan water supplies were visited and reported on. 

Chemical investigations have been carried out in connection with Teluk Anson 
and Carey Island supplies. 

Thirty-three samples of water from Kent Estate were examined for the Malaria 
Research Officer. 

Four samples of the effluent from the new Activated Sludge Sewage Plant at 
Carcosa were examined. All the samples were inoffensive. 


(c) Toddy. 

Four hundred and sixteen samples of toddy were examined. The majority of the 
samples were from licensed toddy-shops. Two hundred and forty-nine of the samples 
were from the shops under the control of estate managers. 


In eight cases the acidity, calculated as acetic acid, exceeded 0.8 per cent., the 
highest being 2.5 per cent. No sample contained more than 10 per cent, of absolute 
alcohol by volume. 


The number of samples from each State, and the number in which the acidity 
exceeded 0.8 per cent, is shown in the following table: 


State. 

Selangor 

Perak 

Negri Sembilan, 
Pahang ... 


Number of Number of samples. 

Samples. Acidity over 0.8 per cent. 

237 ... 5 

135 ... 3 

27 ... — 

17 ... — 


(d) Liquors. 

Two samples of stout and one of gin were examined. 


(e) Oils. 

One sample of castor oil for medicinal use was examined. 

(/) Toxicological Analyses. 

Human Poisoning. —Three cases were investigated, poison being found in the 
viscera in two cases. 

(1) Hydrochloric Acid. —A native employed in a tinsmith’s shop accidentally 
drank spirits of salt and died. The oesophagus and the mucous membrane of 
the stomach were corroded. Free acid and chlorides were found in the vomit 
and in the stomach. 

(2) Arsenic. —An estate cooly was taken ill suddenly, collapsed and died. 
One-eightieth of a grain of arsenic was recovered from the stomach and 
contents, kidney and portion of the ileum,. 

(3) Morphine. —In this case the deceased had been taking large quantities 
of morphine by injection, for two or three years, and was known to have been 
supplied with eight grains daily. Morphine hydrochloride and strychnine sulphate 
were found in his house. The stomach and stomach contents were analysed. 
No morphine was found, but one-thirtieth of a grain of strychnine was found in 
the stomach and one-twentieth of a grain in the stomach contents. 

Other Animal Poisoning. —Viscera from four animals were examined for arsenic 
which was found in one case. 

Viscera from four rats were examined for barium carbonate, a common rat poison. 
No barium carbonate was found. 

Miscellaneous Exhibits for Poison. —One sample of bread, one medicine and 
one plant were examined. No poison was found in the bread or medicine. The plant 
was identified as Euphorbia tirucalli, the acid juice of which is well known in India 
as a purgative. 

( g ) Miscellaneous Samples. 

Forty-five miscellaneous samples included: 

Bloods for sugar (7), urine for sugar (5), quinine salts (7), cinchona 
febrifuge (1), disinfectants (3), tartar emetic (2), magnesium sulphate (1), bismuth 
subnitrate (1), neosalvarsan (2), other medicines (5), chloroform (1), carbon 
tetrachloride (1), methyl alcohol (2), iodine (1), bread (1), ghee (1), tea (1), 
coffee (1), roasted beans (2). 


34 


( h) Vitamin B Extract. 

The preparation of this extract from rice polishings, for use in the treatment of 
beri-beri, was continued throughout the year. During the year 5,192 fluid ounces 
were prepared, and 5,159 fluid ounces were issued to medical practitioners, dispensaries 
and hospitals. Seven hundred and thirteen ounces were issued free, the remainder 
was sold at 25 cents an ounce, this being the estimated cost of production. The 
revenue from this source was $1,111. 

II.—TRADE AND CUSTOMS DEPARTMENT. 

Work for this department consists chiefly in the examination of liquors in 
connection with the assessment of duty, and the examination of samples of chandu 
and clia-ndu dross under the Chandu Enactment. 

The total number of samples examined was 3,619 as compared with 719 in 1922. 

(a) Liquors .—In 61 samples the alcoholic strength was determined. 
Twenty samples were examined for denaturants, of which four did not contain the 
necessary ingredients. 

(5) Toddy .—The acidity and alcoholic strength were estimated in 59 samples. 

(c) Chandu. —Sixty-one samples of chandu and substances suspected to contain 
chandu were examined. Forty of these were found to be Government chandu, 
eight illicit chandu, one chandu prepared from Government chandu dross, and 
three imitation chandu containing no opium. Other samples were raw opium, 
exhausted dross and pills. 

(d) Chandu Dross .—The number of samples of chandu dross examined was 
3,402, as compared with 224 in 1922. 

The samples were graded as follows: 

Grade I .3,353 



(e) Deleterious Drugs .—Three samples were examined, of which two contained 
morphine hydrochloride. The other substance was a sample of “Jarda”, said to be an 
Indian smoking mixture consisting of tobacco, betel-nut and perfume. Tobacco was 
identified in this mixture and no deleterious drug was found. 

(/) Miscellaneous Samples .—Thirteen samples were examined including rubber 
coupons (5), oil for flashpoint (1), poppy seeds (1), toddy vinegar (1), alum (2), 
borax (1), and two, suspected ganja, one of which contained ganja,. 

III.—POLICE DEPARTMENT. 

The work for this department includes the examination of counterfeit coins and 
coining materials, stains for blood, exhibits for poison, liquors and toddy. 

(a) Coins and Coining Materials .—The number of exhibits examined was 993, of 
wdfich 967 were counterfeit coins, 19 genuine coins, three moulds, one piece of metal 
and three chemicals used in the manufacture of counterfeit coins. 

( b ) Stains .—The number of exhibits examined for blood was 106, of which 
43 gave positive results. Thirty-six of the exhibits which gave positive reactions for 
blood were examined by the precipitin test for human serum; 23 of these gave a 
positive reaction. The classification of the exhibits and the results of the tests are 


shewn in the table below : 




Exhibits. 

Number 

examined. 

N umber 
blood-stained. 

Number 
human blood. 

Iron weapons 

34 

10 

4 

Articles of clothing 

48 

25 

15 

Wood, mats, a,tap, etc. 

22 

8 

4 

Miscellaneous .... 

2 

— 

— 

(c) Toxicological Analyses .— 

-Twenty-four analyses were made 

of which 15 w 

human, viscera,. 




Human Poisoning. —Poisons 

were identified 

in only four cases. 



Potassium Cyanide. —Two, cases of suicide. 

(1) A Chinaman was found dead in a lodging-house. Post-mortem examination 
showed internal organ congested. The stomach contained about three ounces of a 
dark-coloured fluid with a strong smell of hydrocyanic acid. Potassium cyanide was 
detected in this fluid. 

(2) A Chinese woman, during a quarrel with her husband, a goldsmith, swallowed 
potassium cyanide. Potassium cyanide was detected in the viscera. 



35 


Arsenic. —T'wo cases. 

(1) A Chinese boy, aged four years, died 33 hours after a meal of rice, fish and 
Chinese cake. Post-mortem examination showed lips and tongue eroded, general 
inflammation of the alimentary canal and oesophagus and intestines inflamed. From 
the stomach and contents and liver one-fortieth of a grain of arsenic was recovered. 

(2) A male Tamil vagrant was found dead. Post-mortem examination showed 
liver, kidney and spleen congested, large and small intestines acutely inflamed and the 
entire mucous membrane a. bright red colour. On analysis a minute trace 
(six ten-thousandths of a grain) of arsenic was recovered from the liver. No arsenic 
was found in the stomach and contents. 

In another case of suspected human poisoning a male Tamil cooly suddenly 
became ill and died on the way to hospital. On analysis of the stomach and contentsr 
a small quantity of a substance which gave general alkaloidal reactions was recovered 
but the quantity of material was too small for identification. 

Other Exhibits for Poison. —'Six medicines, two powders and one curry were 
examined. Morphine hydrochloride w T as found in two of the medicines, no poison in 
other four. The two powders were suspected to contain datura but no datura was 
found. Powdered glass was found in the curry. 

( d ) Liquors .—Alcohol was estimated in 34 samples. 

(e) Toddy. —-Six liquids suspected to be toddy were found to be toddy. 

(/) Deleterious Drugs.—Four powders were received for examination for 
deleterious drugs. Three were found to be morphine hydrochloride, the other 
was lactose, a substance frequently used as an adulterant of morphine hydrochloride. 

(g) Miscellaneous Exhibits. —These included ganja (11), datura seeds (4), 
powders (3), cartridges (2), bomb (1) and one document. 

IV.—OTHER DEPARTMENTS. 

Twenty-six examinations were undertaken for other Government departments. 
These included eight waters, one piece of zinc and one sample of copper for the 
II ail way Department, seven waters, one sample of lime and one sample of scrapings 
from a water main for the Public Works Department, three photographic chemicals 
for the Survey Department, and three samples of milk and one toddy for the District 
Officer, Kuantan, 

V.—PRIVATE ANALYSES. 

Thirty-six examinations included: Rubber coupons (9), waters (8), samples of 
coke (5), oils for flash point (3), urines for sugar (2), milk (2), condensed milk (1), 
butter (1), whisky (1), other liquors (2) and exhibits for poison (2). 

The fees for these analyses amounted to $398. 

LEGAL PROCEEDINGS. 

Members of the staff attended Courts in various parts of the country on 
28 occasions. 

STAFF. 

Mr. J. Shelton, Geological Chemist, was transferred to this department and 
assumed duties on January 22nd. 

Mr. R. W. Blair, Chemist, proceeded on leave on November 14th. 

H. MARSDEN, 

Acting Chemist, Government Laboratories, F.M.S. 


36 


Appendix A. 

Total number of Analyses and Examinations made in the Chemical 

Laboratories during the year 1923. 

Medical Department.—• Number of Analyses. 

Milk. 774 

Condensed milk ... ... ... ... ... ... ... 14 

Waters, chemical ... ... ... ... ... ... ... 343 

Waters, bacteriological ... ... ... ... ... ... 40 

Sewage effluents ... ... ... ... ... ... ... 4 

Toddy ... ... ... ... . ... ... 416 

Liquors ... ... ... ... ... ... ... ... 3 

Oils, fixed ... ... ... ... ... ... ... ... 1 

Toxicological analyses ... ... ... ... ... ... 11 

Miscellaneous ... ... ... ... ... ... ... 45 

Trade and Customs Department.—• 

Liquors ... ... ... ... ... ... ... ... 81 

Toddy . 59 

Chandu ... . . ... ... 61 

Chandu dross ... ... ... ... ... ... ... 3,402 

Deleterious drugs ... ... ... ... ... ... ... 3 

Miscellaneous ... ... ... ... ... ... ... 13 

Police Department.— 

Coins and coining materials ... ... ... ... ... 993 

Articles for blood stains ... ... ... ... ... ... 106 

Toxicological analyses ... . ... ... ... 24 

Liquors ... ... ... ... ... ... ... ... 34 

Toddy 6 

Deleterious drugs ... ... ... ... ... ... ... 4 

Miscellaneous ... ... ... ... ... ... ... 22 

Other Departments.— 

Miscellaneous . 26 

Private Analyses.— 

Waters ... ... ... ... . 8 

Miik . ::: ;;; l 

Spirits . 3 

Toxicological analyses ... ... ... ... ... ... 2 

Miscellaneous ... ... ... ... ... ... ... 20 

Total ... 6,521 

































































37 


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38 


REPORT OF THE SENIOR HEALTH OFFICER, FEDERATED MALAY 

STATES, FOR THE YEAR 1923. 


HEALTH STAFF. 

1 . The sanctioned staff of the Health Branch of the Medical Department includes 
a Senior Health Officer, 15 Health Officers, 8 Chief Sanitary Inspectors (Europeans; 
and 28 Sanitary Inspectors (Asiatics). 

2. Up to date there never has been a sufficiency of Health Officers to fill the 
various posts and the work has been carried on with the aid of what assistance the 
Medical Branch could afford to give. 

3. For the greater part of the year the European staff consisted of the Senior 
Health Officer; 4 Health Officers; 6 Medical Officers and 8 Chief Sanitary Inspectors. 

The Asiatic staff was up to strength. 

4. The changes in the European staff were as follows : 

Dr. A. R. Wellington returned from leave in February and resumed duty 
as Senior Health Officer. 

Dr. J. G. Castellain reverted to the Medical Branch on the 12th of July. 

Dr. J. L. Gregory resigned on the 5th of August. 

Dr. E. H. Black proceeded on home leave on November 11th. 


REVENUE AND EXPENDITURE. 

5. The revenue collected during the year was $2,280 as against $1,565 for 1922. 
Practically the only revenue is that obtained for certificates issued under the 
Registration of Births and Deaths Enactment. 


The expenditure debited against the votes administered by the Health Branch was : 
Personal emoluments ... ... ... ... ... ... $160,054 

Temporary allowance ... ... ... ... ... ... 38,729 

Other charges annually recurrent ... ... ... ... 63,922 

Other charges special expenditure ... ... ... ... 21,502 


Clerical service 


$284,208 

35,101 


Total ... $319,309 


GENERAL REVIEW OF WORK DONE BY THE HEALTH BRANCH. 

6 . The duties of the members of the Health Branch include : 

(i) Vital statistics and work under the Registration of Births and Deaths 

Enactment. 

(ii) Malaria investigation and control, and anti-mosquito measures. 

(iii) Work under the following Enactments : 

(a) Quarantine and Prevention of Disease Enactment; 

(b) Sanitary Boards Enactment; 

(c) Sale of Food and Drugs Enactment; 

(d) Labour Code. 

(iv) General, including inspection of schools, Government lines, etc. 

7. The paucity of Plealth Officers necessitated cutting the coat according to the 
cloth. Certain duties which otherwise would have been done were left undone, and 
others were only partially done. 

8 . Work under the registration of births and deaths was behind-hand and extra 
clerks had to be employed to bring the records up-to-date. 

9. Work in, connection with Malaria and Mosquito Destruction Boards took up 
much of the time of the Health Officers. In this line the European Sanitary Inspectors 
rendered valuable assistance. 


10. Under the Quarantine and Prevention, of Disease Act the work was shared 
with the Medical Branch. There were no epidemics of any magnitude. The few 
outbreaks there were, were checked before they had developed far. 

11. Under the Sanitary Boards Act the work was chiefly done by Sanitary 
Inspectors under the supervision of the Chairman, Sanitary Board, the Health Officer 
acting as Adviser only. 







39 


12 . Under the sale of Food and Drugs Act little was done as the pressure of 
other duties prevented the attention being given to the subject which its importance 

merited. 

13. Work under the Labour Code suffered and the estates and estate hospitals 
were not visited as often as they would have been had there been the staff available. 

14. School inspection was mostly done by the Sanitary Inspectors, as was also 
the inspection of Government lines. 

15. During the year a new scheme for Sanitary Inspectors was approved by the 
Secretary of State for the Federated Malay States and the Straits Settlements. 

16. The Fifth Congress of the Far Eastern Association of Tropical Medicine was 
held in Singapore in September. The Senior Health Officer attended as one of the 
Federated Malay States delegates. 

After the close of the meetings the majority of the delegates made a tour through 
the Federated Malay States, where they were socially entertained and made acquainted 
with matters of medical and hygienic interest. 

HEALTH LEGISLATION. 

17. The Laws influencing the Public Health passed in 1923 were : 

The Burials Enactment Amendment; 

The Midwives Enactment; 

The Labour Code, 1923; 

The Children’s Enactment; 

Also Buies under the following : 

The Sanitary Boards Enactment; 

The Deleterious Drugs Enactment; 

The Sale of Food and Drugs Enactment. 

VITAL STATISTICS. 

18. Populations are estimated from the census figures which are believed to be 
accurate. Immigration and emigration have much more influence on the population 
than have births and deaths, and the numbers are steadily increasing despite the 
fact that the death-rate is often higher than the birth-rate. 

Accurate data of the number of immigrations and emigrations especially those by 
rail are not available and tables cannot be prepared. 

19. Increase in population is calculated on the arithmetical increase basis as 
experience has shown this to be more reliable than the geometrical basis. 

20. Births and deaths figures are obtained from notifications made under the 
Births and Deaths Begistration Enactment which applies everywhere. The total 
number of births and deaths is approximately correct. The accuracy of the diagnoses 
as to the causes of deaths is in. the majority of cases open to question for only a small 
proportion of those who died had been attended by medical men during their last 
illnesses. In each of the four large towns every uncertified body is viewed by a qualified 
Assistant Surgeon who interrogates the friends of the deceased and forms a diagnosis. 
In the rural districts these duties are carried out by the Police. 

21. With regard to deaths in towns—owing to the difficulty of getting proper 
fixed addresses—it has been customary to debit a death against a town when the 
deceased resided there for one month or over previous to death. 

22. The large towns all contain hospitals which cater not only for the town people 
but those of the surrounding area. Towns attract chronic cases of disease and thus 
it often happens that a person so ill as to be unfit for work drifts to a town and there 
remains in a hospital or a common lodging-house until he dies. If he survives a month 
his death is debited against the town though strictly it should be debited against the 
district where the disease was contracted. 

23. The above explanation is necessary in order that towns shall not be judged 
on their death-rates alone. Kuala Lumpur has over 1,000 hospital beds and all cases of 
malaria which died there and which were debited against the town did not contract 
the disease in the town. 

24. In the Straits Settlements the qualifying period is three months. Three 
months is a fairer period and in future years three months will be the qualifying period 
for the Federated Malay States. 


40 


25. Assuming that the population has increased at the same rate as during the 
intercensal period and judging from the sickness and death returns furnished to the 
department the health of the people during the year 1923 was better than that of any 
year under record. 

26. The reason for this improvement must to some extent be ascribed to the 
efforts of the various authorities, public and private, past and present, who 1 have been 
concerned with the prevention and abatement of disease; but how much is due to these 
sources and how much to nature it is impossible to say. 

27. The general death-rate was 24.40 per mille, this being the lowest yet recorded 
for any year. Nearly half the deaths (45.75 per cent.) were attributed to “fevers” 
a large proportion of which were probably malaria. 

28. Dysentery and diarrhoea accounted for 6.33 per cent, of the total deaths, 
pulmonary tuberculosis for 5.70 per cent, and pneumonia for 4.77 per cent. Comments 
on these diseases will be found under their respective headings. For convenience of 
comparison statistics have been arranged under the headings Federal, State, Large 
Towns. 

29. Because of the peculiar age and sex distribution and the fact that the labour 
of the country is largely imported males from 20 to 45 years of age, and because of 
the fact that the majority of the labourers passed the doctor before being accepted the 
death figures cannot be compared with countries where the population is indigenous. 
With normal age and sex distribution the death-rate would probably be more than twice 
what it now is. 


30. 


VITAL STATISTICS (FEDERAL). 

Population. 

The population of the Federated Malay States as estimated was at the end of 


June, 1923, 1,389,667. 

The race distribution was as follows : 


Europeans and Americans 

. 6,226 

Eurasians 

. 3,329 

Malays and other races of the Archipelago ... 

. 531,067 

Chinese ... 

. 508,342 

Indians. 

. 335,089 

Others 

. 5,614 


Total ... 1,389,667 


Births. 

31. Thirty-five thousand six hundred and fifty-three births were registered during 
the year, giving a birth-rate of 25.66 per mille of population. In 1922 the number was 
34,906 and the rate 25.65. 

The following table shows the number of births and birth-rates according to races : 


Race. 

No. of births. 

Birth-rate. 

Europeans and Americans 

126 

20.24 

Eurasians 

102 

30.64 

Malays and other races of the Archipelago .. 

. 19,250 

36.25 

Chinese ... 

. 9,084 

17.87 

Indians 

. 7,023 

20.96 

Others 

68 

12.11 


Deaths. 

32. Thirty-three thousand nine hundred and fourteen deaths were registered, 
giving a death-rate of 24.40 per mille. The number of deaths in 1922 was 35,028 and 
the rate was 25.74. 

The distribution of deaths among the several races was as follows : 


Race. 

No. of deaths. 

Death-rate. 

Europeans and Americans 

34 

5.46 

Eurasians 

42 

12.62 

Malays and other races of the Archipelago 

... 13,111 

24.69 

Chinese ... 

... 12,016 

23.64 

Indians 

... 8,635 

25.77 

Others 

76 

13.54 


















41 


33. The deaths and death-rates for the total population for the last ten years were 
as follows : 


Y ear. 

Population. 

1914 

. 1,136,500 

1915 

. 1,172,336 

1916 

. 1,208,177 

1917 

. 1,244,018 

1918 

. 1,279,859 

1919 

. 1,315,700 

1920 

. 1,351,541 

1921 

. 1,304,825 

1922 

. 1,360,876 

1923 

. 1,389,667 


Table Showing Causes of 

Diseases. 

Malaria 



Dysentery and Diarrhoea 
Pneumonia 

Pulmonary Tuberculosis 
Ankylostomiasis 
Beri-beri 
Syphilis ... 

Enteric 
Tetanus ... 

Diphtheria 
Convulsions 
Other diseases ... 


Deaths. 

Rate per mi lie. 

39,000 

34.31 

33,899 

28.92 

36,985 

30.60 

42,514 

34.17 

67,639 

52.85 

38,645 

29.37 

43,705 

32.34 

38,077 

29.18 

35,028 

25.74 

33,914 

24.40 

ATHS IN 1923. 

No. of deaths. 

Rate per mille. 

. 15,516 

11.17 

2,142 

1.55 

. 1,619 

1.17 

. 1,934 

1.39 

388 

0.28 

378 

0.27 

89 

0.06 

29 

0.02 

62 

0.04 

8 

0.01 

. 3,364 

2.42 

. 8,385 

6.03 


35. The following table shows the deaths and death-rates from the principal 
■diseases for the last ten years : 


Year. 

Malaria. 

Dysentery and 
diarrhoea. 

Pulmonary 

tuberculosis. 

Beri-beri. 

Deaths. 

Rate. 

Deaths. 

Rate. 

Deaths. 

Rate. 

Deaths. 

Rate. 

1914 

13,634 

11.99 

5,235 

4.60 

1,655 

1.45 

1,223 

1.07 

1915 

15,208 

12.97 

3,148 

2.63 

1,995 

1.70 

871 

.74 

1916 

17,627 

14.58 

3,197 

2.64 

2,193 

1.81 

757 

.62 

1917 

18,750 

15.07 

4,942 

3.97 

2,446 

1.96 

1,207 

.97 

fl918 

31,515 

24.62 

4,280 

3.34 

3,184 

2.48 

1,277 

.98 

1919 

16,975 

12.90 

3,712 

2.82 

2,445 

1.86 

939 

.71 

1920 

20,595 

15.24 

3,804 

2.81 

2,634 

1.95 

431 

.32 

1921 

17,168 

13.16 

2,999 

2.30 

2,255 

1.73 

422 

.32 

1922 

15,570 

11.44 

2,419 

1.78 

2,393 

1.76 

443 

.33 

1923 

15,516 

11.17 

2,142 

1.55 

1,934 

1.39 

378 

.27 


VITAL STATISTICS (State figures for comparison). 


36.— 


Birth Table. 


State. No. of 

Perak ... ... ... ... 16, 

Selangor ... ... ... 10, 

Negri Sembilan ... ... 4, 

Pahang ... ... ... 4, 


births. 

Birth-rate per 
1,000 living. 

1922 Birth-rates. 

274 

26.14 

26.59 

120 

23.81 

23.64 

893 

25.79 

24.60 

366 

28.68 

28.68 


* High figure due to influenza epidemic. + Influenza epidemic year. 




































































37 .— 


Birth Statistics of different nationalities. 


State. 

Europeans 

and 

Americans. 

K unis inns. 

Malays and 
other races 
of the 

Archipelago. 

Chinese. 

I ndians. 

Others. 

Births. 


Births. 

Birth-rate. 

Births. 

-C> 

3 

Births 

■£ 

£ 

Births. 

Birth-rate. 

Births. 

Birth-rate. 

Perak 

40 

20.99 

1 

27 ! 26.84 

8,997 

30.20 

4,204 

18.85 

2,908 20.32 

32 

10.08 

Selangor 

70 

25.74 

55 ! 32.87 

3,552 

36.31 

3,101 

17.71 

3,322 22.79 

20 

9.89 

Negri Sembilan 

7 

0.97 

15 28.30 

3.100 

39.03 

1,111 

15.73 

645 i17.38 

15 

15.60 

Pahang 

3 

9.69 

5 j 40.05 

3,001 

34.08 

008 

10.74 

148 | 16.10 

1 

1.55 


38.— Death Table (State figures for comparison). 


htate. 

Perak 
Selangor 
Negri Sembilan 
Pahang 


No. of deaths. 

15,613 

9,933 

4,679 

3,689 


Death-rate. 

25.07 

23.37 

24.67 

24.24 


1922 Death-rate 

25.93 

25.31 

26.60 

25.11 


39.— Deaths and death-rates of different nationalities. 


State. 

Europeans 

and 

Americans. 

Eurasians. 

Malays and 
other natives 
of the 

Archipelago. 

Chinese. 

Indians. 

Others. 

Deaths. 

d 

Deaths. 

03 

Ph 

| 

i 

« 

Rate. 

Deaths. 

Rate. 

Deaths. 

Rate. 

Deaths. 

Rate. 

Perak 

10 

7.30 

11 

10.98 

6,197 

24.97 

5,771 

25.51 

3,571 

24.95 

47 

23.64 

Selangor 

13 

4.78 

24 

14.35 

2,417 

24.71 

3,892 

22.22 

3,574 

24.53 

13 

6.43 

Negri Sembilan 

2 

1.99 

t- 

( 

13.18 

1,903 

23.90 

1,532 

21.69 

1,221 

32.89 

14 

14.63 

Pahang 

3 

9.68 



2,594 

24.55 

821 

22.61 

269 

29.37 

2 

3.09 


40.— Table showing deaths and death-rates from principal diseases. 


State. 

Malaria. 

Dysentery and 
diarrhoea. 

Pulmonai 

tuberculos 

y 

is. 

te. 

Beri-beri. 

y} It ate. 

Deaths. 

Rate. 

X 

g 

Q 

. 

Ra 

Deaths. 

Rate. 

C3 

P ' 1923. 

1 

1922. 

| 

1923. | 1922. 

1 

1923. 

1922. 


1922. 

Perak 

1 

7,758 j 12.46 

12.29 

782 

| 

1.26 1.42 

949 

1.52 

1.83 

79 

0.13 

0.15 

Selangor 

4,031 | 9 48 

9.96 

821 

1.93 : 2.39 

629 

1.48 

2.00 

105 

0.25 

0.34 

Negri Sembilan 

1,998 1 10.53 

11.51 

275 

1.45 2.40 

268 

1.41 

1.69 

112 

0.59 

0.64 

Pahang 

1,729 i 11.36 

12.10 

264 

1.73 0.74 

88 

0.58 

0.84 

82 

0.54 

0.64 


INFANTILE MORTALITY. 

41. There were 6,420 deaths of children under one year of age. The infantile 
mortality rate or rate per 1.000 births was 180.07; the rate for 1922 was 170.83. 


Infantile Mortality Table. 


State. 

Death of children 
under 1 year 
of age. 

Death-rate pe 
1,000 births. 

Perak 

. 2,770 

170.21 

Selangor ... ■ 

. 1,907 

188.44 

Negri Sembilan 

. 885 

180.87 

Pahang ... . 

. 858 

196.52 



























































43 



Deaths from 

Zymotic Diseases. 


State. 

Plague. 

Cholera. Smallpox. 

Cerebro-spinal 

meningitis. 

Perak ... 

1 

— ... 9 

19 

Selangor 

9 

— ... — 

— 

Negri Sembilan 

— 

— ... — 

4 

Pahang 

— 

— ... — 

— 


43.— Death-rates of principal diseases for the last seven years. 


Year. 


Perak. 


Selangor. 


Negri Sembilan. 

Pahang. 


Dysentery and 
diarrhoea. 

2 _o 

s 1 

£ 3 


f J 

b 

75 .5 

pT° 

P u 1 m o n a r y 
tuberculosis. 

s 

fer. 

l! 

5 b 

75 .5 

.j’SS 

2 © 
o § 

S 

Dysentery and 
diarrhoea. 

‘-4 X 

-**oe 
“ c 

O o 

2 £- 
~ 3 
,_, ^ 

1917 

15.81 

2.58 

2.25 

12.75 

4.38 

1.47 

18.81 

4.26 

2.80 

14.00 

1.30 

1.14 

1918 

Unreliable. 


20.29 

3.78 

1.62 

36.31 

5.84 

4.93 

26.62 

1.63 

1.41 

191S 

... 13.45 

2.21 

1.83 

10.23 

3.59 

2 39 

17.15 

4.77 

1.39 

13.22 

1.27 

1.01 

1920 

... 15.82 

2.21 

2.11 

13.13 

3.77 

1.89 

18.18 

4.31 

2.37 

15.24 

1.19 

0.94 

1921 

... 13.32 

1.54 

1.78 

1 1.80 

3.29 

1.85 

13.07 

3.42 

1.68 

16.61 

1.19 

1.18 

1922 

... 12.29 

1.42 

1.83 

9.96 

2.39 

2.00 

11.51 

2.40 

1.69 

12.10 

0.74 

0.84 

1923 

... 12.46 

1.26 

1.52 

9.48 

1.93 

1.48 

10.53 

1.45 

1.41 

11.36 

1.73 

0.58 


44.— Vital statistics for the four large towns, Kuala Lumpur, Ipoh, 

Seremban and Taiping. 


Town. 

Estimated 

population. 

Births. 

Deaths of persons who 
previous to disease 
had resided in town 
one month. 

No. 

Rate per 
mille. 

No. 

Rate per 
mille. 

Kuala Lumpur 

88,009 

2,001 

22.74 

1,689 

19.19 

Ipoh 

40,399 

904 

22.38 

813 

20.12 

Seremban ... ..: 

19,210 

456 

23.74 

476 

24.78 

Taiping 

21,462 

735 

34.24 

718 

33.45 , 


ft 


45 .— Table showing corrected death-rates during the last seven years. 


Year. 

[ 

Kuala Lumpur. 

Ipoh. 

Seremban. 

. 

Taiping. 

Population. 

Death-rate. 

Population. 

Death-rate. 

| Population. 

6 

cts 

<D 

Q 

: Population. 

1 

•0}U.T-l[}U0Q 

1917 

63,064 

28.45 

31,032 

32.67 

13,620 

55.35 

22,859 

31.00 

1918 

64,686 

38.34 

32,150 

35.92 

14,082 

81.66 

23,481 

41.61 

1919 

66,308 

26.36 

33,238 

23.56 

14,544 

45.38 

24.721 

37.45 

1920 

67,930 

30.00 

34,357 

22.64 

15,006 

34.05 

25,434 

39.90 

1921 

... 81,197 

27.02 

37,194 

20.38 

17,479 

36.16 

21.178 

50.05 

1922 

84,476 

21.36 

38,895 

21.78 

13,398 

27.93 

21,296 

35.08 

1923 

... 88,009 

19.19 

40,399 

20.12 

19,210 

24.78 

21,462 

33.45 


* Influenza year, figures probably very inaccurate. 





















































44 


46.— Table showing corrected deaths and death-rates for 'principal diseases. 


Town. 

Malaria. 

Dysentery and 
diarrhoea. 

Pulmonary 

tuberculosis. 

Beri 

-beri. 


Deaths. 

Hate. 

Deaths. 

Rate. 

Deaths. 

Rate. 

Deaths. 

Rate. 

Kuala Lumpur 

181 

2.06 

156 

1.77 

256 

2.91 

30 

0.34 

Ipoh 

60 

1.48 

54 

1.34 

146 

3.61 

o 

O 

0.07 

Seremban ... 

55 

2.86 

61 

3.18 

47 

2.45 

12 

0.62 

Taiping 

149 

6.94 

61 

2.84 

80 

3.73 

1 

0.05 


47.— 

Town. 

Kuala Lumpur 
Ipok 

Seremban 
Taiping ... ... 735 


Deaths under 1 year. Rate per 1,000 births. 


373 

186.41 

119 

131.64 

140 

307.02 

148 

201.36 


Infantile Mortality Table. 
Births. 

2,001 
904 
456 


48.— Table shoiving corrected death-rate in the four towns for the past. 

six years. 


Year. 

Kuala Lumpur. 

Ipoh. 

Seremban. 

Taiping. 

Malaria. 

Dysentery and 
diarrhoea. 

P u 1 m o n a r y 
tuberculosis. 

Malaria. 

Dysentery and 
diarrhoea. 

Pulmonary 

tuberculosis. 

Malaria. 

Dysentery and 
diarrhoea. 

Pulmonary 
j tuberculosis. 

Malaria. 

Dysentery and 
diarrhoea. 

Pulmonary 

tuberculosis. 

1918 . 

6.08 

4.05 

3.43 

7.52 

3.85 

4.72 

40.83 

10.01 

3.48 

22.32 

2.63 

2.03 

1919 

4.69 

3.35 

3.24 

6.32 

5.35 

3.09 

19.18 

7.70 

3.71 

16.78 

3.52 

2.42 

1920 . 

5.08 

2.49 

3.48 

5.64 

2.64 

3.75 

8.99 

5.00 

3.40 

19.14 

2.99 

1.57 

1921 

5.25 

3.63 

3.22 

11.24 

2.39 

4.54 

11.76 

16.71 

6.23 

25.06 

6.06 

3.95 

1922 . 

2.79 

2.18 

3.33 

4.50 

1.62 

2.54 

10.44 

5.92 

6.35 

5.45 

1.50 

1.74 

1923 . 

2.06 

1.77 

2.91 

1.48 

1.34 

3.61 

2.86 

3.18 

2.45 

6.94 

2.84 

3.73 


MOSQUITO-BORNE DISEASES. 

49. The mosquito-borne diseases of this country are Malaria, Eilariasis, and 
Dengue. 

Filariasis. —Embryoes of Filaria nocturna are not uncommonly present in the blood 
of natives, especially in Hylam Chinese, but elephantiasis is rare. 

Dengue is not a rare disease but not being notifiable statistics concerning it are 
unknown. 


MALARIA AND ANTI-MALARIAL MEASURES. 

50. As usual, malaria easily heads the list as the most important cause of sickness 
and death. 

In many of the towns malaria is notifiable. Notification is practically confined to 
Medical Practitioners and officers in charge of hospitals. Owing to the apathy shown 
by many to western medicine a considerable proportion of the cases are not seen by 
doctors and therefore not reported. The chief value of notification lies in the clues 
afforded to the Health Authorities as to the existence of breeding places of malaria¬ 
carrying anophelines. Each case notified is made the subject of enquiry. 

51. The number of deaths registered as due to fevers was 15,516 or 45.75 per cent, 
of the total number. The death-rate was 11.17 per mille population or about that of 
the total death-rate for England. This is the lowest recorded for the last ten years. 

52. Malaria was an essential causative factor in many deaths attributed to other 
diseases. Reckoned in dollars, there is no doubt that the annual loss of this country 
through malaria runs into seven figures and perhaps into eight. 



































































45 


Malaria Prevention. 

53. Experience in the Federated Malay States has proved that malaria prevention 
by anopheline reduction is (when done in the right way) a sound economic problem 
where persons are grouped together as in towns, in villages, or on estates. 

54. The Government’s machinery lor promoting efficiency in anti-malarial 
operations consists of the Malaria Advisory Board and the Mosquito Destruction 
Boards. 

55. The Malaria Advisory Board is a Central Committee formed for the purpose 
of collecting information with a view to advising generally as to the methods which 
should be adopted for the control of malaria. 

56. The Mosquito Destruction Boards are local bodies with executive powers 
appointed by the British Resident to deal with the mosquito situation in their respective 
areas. 

57. The Chairman of the Malaria Advisory Board is the Principal Medical Officer, 
and the Vice-Chairman, the Senior Health Officer; the Chairmen of the Mosquito 
Destruction Boards are wherever possible the local Health Officers. 

58. The Malaria Advisory Board met periodically and minutes of the meetings 
were published. 

59. The Mosquito Destruction Boards continued to perform good service. Minor 
works such as open ditching and oiling were carried' out by the Board’s staff; major 
works such as subsoil draining were performed by the Public Works Department under 
the supervision of the Executive Engineer who is ex officio a member of the Board. 

60. Arrangements were made for the Health Officer, Railways, to be ex officio 
a member of every Mosquito Destruction Board whose area was cut by the railway. 
In this way close co-operation between the Railway Health Authority and the Board 
was ensured. 

61. Under the supervision of the Health Officer, Railways, anti-malarial works 
such as draining and oiling were carried out at 20 stations with good results. Payment 
was made to numerous Mosquito Destruction Boards and Estate Managers for work 
done on Railway Reserves in their respective districts. 

62. The night mail trains were regularly sprayed with “Lotal” with the result 
that there was a marked abatement in the mosquito nuisance. 

The expenditure on anti-malarial work by the Health Officer, Railways, was 
$32,638. 

63. During the year the Senior Health Officer accompanied by the Anti-malaria 
Engineer visited the Mosquito Destruction Board areas, inspected the works and 
conferred with the authorities. 

64. At the Fifth Congress of the Ear Eastern Association held in Singapore m 
September, the Senior Health Officer read a paper on the solution of the malaria 
problems at Gemas, showing how empirical methods had failed and a scheme based on 
entomological investigation had succeeded. Through the co-operative efforts of the 
Health Staff and the Railway Engineers a very malarious station was turned into 
something approaching a health resort permitting the abolition of the Gemas bonus 
and the Gemas leave. Altogether a saving of $50,000 a year was effected. 

65. After the Congress the majority of the delegates visited Gemas and were 
shown the works which had brought about the result. The delegates paid a visit to 
Kuala Lumpur, where the Anti-malaria Engineer demonstrated the extensive subsoil 
drainage work of the town. 

66. Apart from the work in connection with the Malaria Advisory Board and 
Mosquito Destruction Boards the anti-malarial activities of the Health Branch included 
the teaching of mosquitology, propaganda, investigation and quinine distribution. 

67. The teaching of mosquitology continued throughout the year. All the 
Inspectors are trained in both laboratory and field work and are competent to make 
accurate anopheline surveys. 

68. Lectures and lantern demonstrations have been given in schools and 
kampongs. In every district there have been numerous mosquito surveys. 

69. The arrangement by which medical men, estate managers and others can 
obtain free advice and assistance in anti-malarial work continued. 


46 


Quinine Distribution. 

70. The free distribution of quinine continued to be carried out by the Health 
Branch. 1,179,400 tablets of quinine were issued to the various Health Officers and 
the Senior Medical Officers for ultimate distribution to the public through the Police, 
the Education Department and the Penghulus. 

71. Owing to the favourable reports received of cinchona febrifuge a stock was 
obtained. This drug is cheaper than quinine and said by some to be just as efficacious 
in the treatment of malaria. 

72. The European Chief Sanitary Inspectors have again proved their worth in the 
tackling of mosquito problems. The Asiatic Inspectors have afforded valuable 
assistance. 

The Health Staff, the Malaria Engineering Staff and the Malaria Research Staff 
worked in harmony and have been mutually helpful. 

MEASURES TAKEN FOR PREVENTING THE INTRODUCTION AND SPREAD OF 
INFECTIOUS AND CONTAGIOUS DISEASES. 

Quarantine and Port Health Work at Port Swettenham. 

73. During the year, 30 ships with immigrant labourers were boarded and 
inspected. The labourers were landed at the Quarantine Station. One ship was 
infected with smallpox, one with cholera, one with chicken-pox, and from one a case of 
cerebro-spinal meningitis was removed. 

74. The number of immigrants who entered the Quarantine Station, Port 
Swettenham, was 17,756, the number remaining on the 1st of January, 1923, was 527 
making a total of 18,283. The largest number on any one day was 1,413 on October 7th. 

Thirteen thousand nine hundred and fifty-eight immigrants received routine 
anti-ankylostome treatment. 

Seventeen thousand seven hundred and fifty-six vaccinations were performed. 

75. The number of infectious cases were cholera 4, smallpox 1, chicken-pox 14, 
measles 42, cerebro-spinal meningitis 4, mumps 2, and enteric 1. All these cases 
either came from ships or developed the disease in the camp. They are therefore 
not debited against any of the States. 

In the endeavour to prevent the spread of cholera 419 persons were injected with 
cholera vaccine. The sick were treated by Roger’s method. For their work in 
connection with this outbreak the Health Officer and Deputy Health Officer received 
the thanks of Government. 

76. Many camps being empty and accommodation required for the housing of 
decrepits the latter were temporarily housed there, the Medical Officer being placed 
in charge of the decrepits and of the Camp Hospital. 

77. During the year 1,202 immigrants and decrepits were treated in the hospital. 
The total number of deaths among those quarantined was 51 or 0.28 per cent. Influenza 
complicated by pneumonia was responsible for 32 out of the 51 deaths. 

78. Observations were made to determine the source of influenza and lung- 
diseases and graphs were made showing the admissions from day to day dating from 
the arrival of the steamers. The conclusions arrived at were that infected persons 
landed from ships and spread the disease in the camps. Every effort was made to stop 
the spread by frequent inspections, and isolation of all suspects. 


Infectious Diseases outside the Quarantine Camp. 

79. The following table shows the cases of infectious diseases reported and the 
State in which they originated. 


State. 

Smallpox. 

Cholera. 

Plague. 

Diphtheria. 

Cerebro-spinal 

meningitis. 

; Cases. 

Deaths. 

to 

0 

CO 

o 

Deaths. 

Cases. 

Deaths. 

to 

0 

CO 

O 

Deaths. 

Cases. 

Deaths. 

Perak 

23 

9 



2 

1 

6 

4 

4 

o 

O 

Selangor 

1 




14 

9 

6 

2 

4 

2 

Negri Sembilan... 

8 






5 

1 

»> 

o 

2 

Pahang ... 

... 

... 







] 

1 

Total 

32 

9 



16 

10 

17 

~ 

12 

8 























47 


80. The smallpox outbreak in Perak was traced to a Malay who had come from 
Mecca on an infected ship and had developed the disease after release from the Penang 
Quarantine Station. Its spread was due to unvaccinated Malays. Energetic 
vaccination stopped the epidemic. 

Routine vaccination continued to be under the control of the Medical Branch. 
In epidemic times the Health Branch renders assistance. 

81. The plague cases all came from an area in Kuala Lumpur, where plague 
among the house rats (raws grisieventer ) appears to be endemic. From time to time 
for reasons unknown the virulence of the causative organism becomes enhanced and an 
epizootic spreads among the rodents. When this happens isolated cases of human 
disease occur. There is little tendency to spread and up to date there never has been 
a real epidemic. The immunity of humans is ascribed to the consistently high 
atmospheric temperature which is detrimental to flea propagation. The average number 
of fleas per rat is less than two. The Beat is X. cheopis. 

82. The 16 cases which occurred were spread over three months, and only in one 
or two cases was there more than one infection from one house. The measures taken 
were prophylactic inoculation, rat catching and disinfection of premises. Houses 
where infection had occurred were not closed because one house was as bad as another 
and closure simply meant emigration of rats next door. Previous experience had 
shewn that the chances of a second infection in the same house were very small. The 
health authorities as in previous outbreaks asked for complete demolition of this very 
old and shaky block of houses. Up to date they have not been demolished. 

83. Cerebro-spinal cases are from time to time spotted in this country. All have 
been sporadic and the source of infection has never been traced. 

Sporadic cases of diphtheria occur. The source of infection is seldom discovered. 

Enteric fever—36 cases were reported. In most instances an endeavour was 
made to trace the source of disease. 

84. In this country when a sporadic case of enteric comes under notice it is 
usually weeks after the invasion and the search for a source is almost hopeless. 

The number of deaths registered during the year as enteric was 29 giving a death- 
rate of .02 per mille. 

85. Dysentery is not a notifiable disease and incidence figures are not known to 
the Health Department. The number of deaths from dysentery and diarrhoea was 
2,142 giving a death-rate of 1.54 per mille population. 

Pulmonary Tuberculosis. 

86. The death-rate for the whole country was 1.39 per mille, this being the lowest 
recorded for the last ten years. The rates for all the four States were less than those 
for 1922. With regard to the four large towns the rates were down in Kuala Lumpur 
and Seremban, but up in Ipoh and Taiping. As explained above, the method of debiting 
deaths against towns is such that no definite conclusions can be drawn from one year’s 
rates. The rates for all towns were below the average. 

87. During the year there was much discussion on the subject of pulmonary 
tuberculosis in the four large towns, it being held by some that the disease is rapidly 
increasing owing to improper house construction. 

Statistics show that there has been no increase. 

88. The rapid progress of the disease in the majority of cases, even when treated 
under the best conditions in hospitals, would seem to prove that the natural immunity 
of the native is low. 

Attention should be directed against overcrowding and the filthy habit of 
indiscriminate spitting. 

89. Helminthic Diseases .—The only one of importance in this country from a 
public health point of view is ankylostomiasis. Ninety per cent, of the natives of 
this country are infected, but the cases which show symptoms are rare and the deaths 
recorded as due to this disease gave a death-rate of 0.28 per mille. As it is not unusual 
for a dresser who finds an egg in a stool to diagnose ankylostomiasis, the chances are 
that the real death-rate is less than that given. 

90. Efforts have been and are being made by the health authorities to prevent 
the spread of this disease, but it is difficult to convince either Europeans or Asiatics 
of the seriousness of ankylostomiasis when so many are infected and so few show 
symptoms. 

All immigrants quarantined at Port Swettenham received anti-ankylostome 
treatment. 


48 


SCAVENGING, NIGHT-SOIL AND DK AIN AGE, ETC. 

Night-soil Collection and Disposal. 

91. With the exception of a few private plants which deal with isolated units 
there are no water carriage sewage systems in the Federated Malay States. Most of 
these small plants are working satisfactorily and it is to be hoped that this system 
will replace the offensive commode arrangements in use in even the best of our private 
houses. 

92. In the towns and some of the villages the pail system with daily removal 
is in use. Disposal is by trenching. 

93. The Chinese look upon human excrement as a most valuable fertilizer, anti 
there can be no doubt that in spite of the precautions taken by the health authorities 
a considerable amount finds its way to the Chinese vegetable gardens which abound 
near the towns. It would be of economic benefit to all if this valuable manure were 
sterilized by heat and then handed over to the agriculturists. The natural soil bacteria 
would soon render the sterile organic matter fit for plant food. One of the great 
difficulties experienced in trenching operations is that of getting detailed instructions 
carried out by the low caste coolies who alone engage in this work. Such people spoil 
the best schemes if not closely watched and fly breeding results. 

94. Night-soil disposal in rural areas varies with the races concerned. Tamils 
defaecate anywhere. Malays and other Mohamedans prefer to defsecate in a stream 
or pond. The various Chinese races carefully conserve excretions for use as manure. 

Collection and Disposal of Refuse. 

95. In the large towns and in many of the small ones scavenging is well done, and 
the neatness of the streets is well above the average of the East. 

Disposal is not always so satisfactory. The belief that an incinerator must 
necessarily be a nuisance is almost universal and it is difficult to convince authorities 
that a plant properly designed and constructed can be run so as to be inoffensive even 
to those living next door. 

96. The idea that it must be a nuisance has caused most of our incinerators to be 
placed at such a distance from the houses that proper supervision is impracticable 
and fly breeding in the unburnt refuse is common. Where there are no incinerators 
the method of disposal is dumping. This always results in fly breeding, which is the 
reason why Health Officers oppose the filling with rubbish of low lying areas in towns 
and villages. 

Attempts have been made to prevent breeding in such fillings but so far with 
little success. 

Drainage. 

97. Street drainage is controlled by the Sanitary Boards, anti-malarial drainage 
by the Mosquito Destruction Boards. As mentioned above, open ditching is carried 
out by the Board’s staff and subsoil piping by the Public Works Department. 

Clearance of Bush. 

98. In this country clearance of bush covering wet hill foots has given rise to 
much malaria. The Malaria Advisory Board have issued warnings of the danger of 
clearing valleys unless at the same time they are thoroughly drained. 

In the Straits Settlements Labour Ordinance there is a clause forbidding the 
clearing of valleys except with the permission of the Health Officer. 

Clearance of bush or undergrowth of public lands is done by the Sanitary Boards 
or Mosquito Destruction Boards. 

Water Supplies. 

99. In the majority of cases towns are supplied with water derived from 
uninhabited catchment areas and passed through the filters. Both slow sand 
beds and rapid mechanical filters are in use. 

100. In the alluvial plains of Krian and Lower Perak river water passed through 
the Jewell gravity filters is distributed for many miles through the pipes. Cholera, 
which formerly was an almost annual event in these districts, is now rarely met with. 


PUBLIC HEALTH EDUCATION. 

101. The Public Health Education Committee was appointed by Government 
to promote the spread of knowledge on questions of hygiene and sanitation. This 
Committee, which contains both medical men and laymen, officials and non-officials, 
met periodically under the chairmanship of the Principal Medical Officer. The minutes 
of the meetings were published. 


49 


102. ' From time to time information of public health interest was sent to the Press. 
Articles drawing attention to important facts were printed as advertisements. 
Pamphlets on plague, pulmonary tuberculosis, ankylostomiasis, venereal diseases and 
convulsions were distributed. 

103. Popular lantern lectures on malaria were given in numerous schools and 
kampongs. Lectures to congregations of Europeans and others were given by certain 
of the Health Officers. 

104. General hygiene is one of the regular subjects taught in the schools. 

The Education Department is desirous of extending this teaching and the Health 
Department is anxious to assist. Unfortunately the number of Health Officers is so 
small and the ground they have to cover so great that little assistance can be given. 

105. The school teaching of hygiene is most important as only through the children 
can real progress be made. For success in public health work it is necessary to have 
the sympathetic co-operation of the masses, and that sympathetic co-operation will 
only become manifest when the masses understand the benefits of sanitation. 

The saying that old dogs cannot be taught new tricks is just as true for Asia as 
it is for Europe, and the hope for salvation lies in the education of the children. 

SCHOOL INSPECTION. 

106. The duties of school inspection were shared with the Medical Branch. 
Altogether 215 visits of inspection were made by the Health Staff. In many schools 
the sanitary conditions as regards water supply and latrine accommodation are 
unsatisfactory. 

107. Each school has a stock of Government quinine which is issued by the School 
Master free of charge to those requiring the drug. 

108. Travelling dispensaries belonging to the Medical Branch visit periodically 
for the purpose of supplying medical treatment. 

MATERNITY AND INFANT WELFARE. 

109. The Infant Welfare Advisory Board—the body appointed by Government 
to collect information and issue advice—met at intervals during the year. The minutes 
of each meeting were published. 

110. The Infant Welfare Centre in Kuala Lumpur continued to do good work. 
The attendances have steadily increased and it is now necessary to extend the 
accommodation. The vote for this work is with the Medical Branch. During the 
coming year a similar institution will be started in Ipoh. 

111. The Chinese Maternity Association of Selangor, which maintains a free 
lying-in hospital in Kuala Lumpur, met regularly during the year. The hospital is very 
popular and beds are almost always full. Negotiations are proceeding for the provision 
of additional wards. 

The Perak Chinese Maternity Association maintains a free lying-in hospital in 
Ipoh. This institution is very well run and deservedly popular. 

112. In February, the Midwives Enactment of 1922 was Gazetted. This 
Enactment, the objects of which are to secure the better training of midwives and the 
regulation of their practice, is applicable to such Sanitary Board areas as the Chief 
Secretary to Government shall direct and appoint. 

WORK UNDER THE LABOUR CODE. 

113. One of the most important duties of the Health Department is to co-operate 
with the Labour Department with the object of ensuring a reasonable standard of 
sanitation for those who come under the Labour Code. 

The responsibility for the protection of health and the cure of disease lies with 
the employer of labour and it is his duty to engage the staff necessary for that purpose. 

The duty of the Health Officer is to inspect on behalf of Government and to report 
whether the sanitary conditions prescribed by Government for the protection of labour 
are being carried out. 

ESTATES. 

114. In the Federated Malay States there are 1,384 estates which send in 
sickness and deaths returns. Besides there are many small estates of less than 
100 acres from which no returns are received. Owing to the insufficiency of staff it 
lias not been possible for the Health Officers to pay the requisite number of visits to 
estates. 




50 


115. Details of the distribution of estates and estate hospitals and the frequency 
of visits by Health Officers is given below : 


State. 

Health district. 

Estates. 

Estate 

Hospitals. 

No. 

No. of 
visits by 
H.O. 

No. 

No. of 
visits by 
H.O. 



Perak North 

273 

124 

25 

39 

Perak ... 


Kinta 

135 

67 

6 

12 


( 

Perak South 

250 

258 

26 

38 


( 

Bernam 

8 

12 

2 

4 

Selangor 

; 

Selangor Coast 

189 

T24 

34 

32 


l 

Selangor East 

204 

219 

23 

53 

Negri Sembilan 


All districts 

270 

29 

43 

42 

Pahang 

... 

All districts 

55 

49 

8 

11 

Federated Malay States 

1,384 

882 

167 231 


Supplementary visits were paid by Chief Sanitary Inspectors and Sanitary 
Inspectors. 


116. There is room for improvement in sanitation on estates especially in the 
case of water supplies and the disposal of night-soil. 

Estate hospitals are usually satisfactory in so far as the buildings and equipment 
are concerned but the medical supervision is not infrequently below the standard desired 
by the Health Officer. 

117. The Senior Health Officer and the Controller of Labour paid a visit to 
Malacca for the purpose of enquiring into the system of medical control in vogue there. 
The system is - satisfactory so far as it goes but it does not go far enough. 

A Committee has been appointed by the Federated Malay States Government to 
enquire into the question of sanitation and medical treatment on estates. 


118. The distribution of labour was as follows 




Indians. 

Others. 

Total. 

/ 

Perak North 

20,964 ... 

4,486 

25,450 

Perak 

Kinta 

Lower Perak and Batang 

5,940 ... 

2,122 ... 

8,062 

( 

Padang ... . 

20,020 ... 

2,856 ... 

22,876 

r 

Bernam 

1,336 .. 

— 

1,336 

Selangor ... 

Coast 

Kuala Lumpur, Ulu Selangor 

34,722 

1,011 

35,733 

( 

and Ulu Langat 

14,831 

4,264 ... 

19,095 

Negri Sembilan . 

. All districts 

16,392 ... 

13,286 ... 

29,678 

Pahang ... 

.. All districts 

1,805 

3,241 ... 

5,046 


Total, F.M.S. ... 

116,010 ... 

31,266 ... 

147,276 

119. The table below sets out the mortality 

rates among 

estate labourers 

during 

the past thirteen 

years, that is, since the Health 

Branch took 

over the supervision of 

health condition 

on estates. 




Year. 

Total number of 
estate labourers. 

Deaths. 

Death-rate 
per mille. 


1911 

. 143,614 

9,040 

62.9 


1912 

. 171,968 

7,054 

41.02 


1913 

. 182,937 

5,592 

29.6 


1914 

. 176,226 

4,635 

26.3 


1915 

. 169,100 

2,839 

16.78 


1916 

. 187,030 

3,299 

17.61 


1917 

. 214,972 

3,906 

18.71 


* 1918 

. 213,425 

9,081 

42.55 


1919 

. 216,573 

3,384 

15.16 


1920 

. 235,156 

4,367 

18.57 


1921 

. 175,649 

3,195 

18.19 


1922 

. 159,279 

2,556 

16.05 


1923 

. 147,276 

1,924 

13.06 


There were 

1,593 deaths among the 116,010 Indian estate labourers during the 

year giving a mortality of 13.73 per mille. 





Influenza year. 



























































51 


120. Return of malarial admissions and deaths of Indian labourers and others 
in estate and Government hospitals. 


Divisions. 

Malaria admis¬ 
sions to estate 
and Govt, 
hospitals. 

jB'd ^ 

£ 5 o 

^ 53 • 

■£. '*T. 30 

•r 3) 

c* c5 

*.S©’S 

s 

Total admissions 

to estate and 

Govt, h o s - 

pitals. 

Total labourers 

employed, all 

nationalities. 

Total deaths. 

Death-rate p e r 

mills. 

C 

m 

Deaths, Indian 

labour force. 

Death-rates, 

Indian labour 

force. 

Number of 

estates. 

Number of estate 

hospitals. 

Selangor East ... 

4,241 

112 

7,942 

19,095 

258 

13.51 

14,831 

240 

16.18 

204 

23 

Coast, Selangor 

4,115 

151 

14,209 

35,733 

432 

12.09 

34,722 

426 

12.27 

276 

34 

Pahang ... 

1,446 

29 

5,087 

5,046 

129 

25.56 

1,805 

56 

31.02 

55 

8 

Negri Sembilan 

5,249 

125 

12,315 

29,678 

485 

16.34 

16,392 

391 

23.85 

270 

43 

Perak North 

4,224 

74 

10,917 

*5,450 

255 

10.02 

20,964 

246 

11.73 

273 

25 

Kinta 

1,394 

27 

2,971 

8,062 

153 

18.98 

5,940 

77 

12.96 

135 

6 

Lower Perak and 
Batang Padang 

1.819 

53 

9,628 

22,876 

208 

9.09 

20,020 

153 

7.64 

250 

26 

Sabak Bernam .. 

154 

2 

679 

1,336 

4 

2.99 

1,336 

4 

2.99 

8 

2 

Total ... 

22,642 

573 

63,748 

147,276 

1,924 

13.06 

116,010 

1,593 

13.73 

1,471 

167 


Mines. 

121. The average population engaged in mining during the year was 96,662. 
Mines are not required to send in sickness and death returns and the sick-rates and 
death-rates are unknown. 

As the great majority of miners are Chinese whose habits are more hygienic than 
those of the Tamils forming the bulk of the estate population, the sick and death-rates 
on mines were probably lower than those on estates. 

Owing to the lack of staff no mines were visited. 


A. R. WELLINGTON, 

Senior Health Officer, F.M.S. 


0 














































52 


REPORT OF THE MEDICAL SUPERINTENDENT, CENTRAL MENTAL 

HOSPITAL, TANJONG RAMBUTAN. 


Sir,—I have the honour to forward the thirteenth annual report of the Central 
Mental Hospital, that for the year 1923. 



Males. 

Females. 

Total. 

2. There remained on 31st December, 1922 

... 838 ... 

212 ... 

1,050 

Admitted during 1923 

... 358 ... 

Ill 

469 

/ (a) recovered 

160 

34 ... 

194 

) (b) relieved 

19 ... 

4 ... 

23 

ischargc ... ^ no ^ j m p rovec [ 

4 ... 

2 ... 

6 

f (d) not insane ... 

2 ... 

— 

2 

Absconded 

37 ... 

1 

38 

Died 

74 ... 

28 ... 

102 

Remaining on 31st December, 1923 

... 900 ... 

254 ... 

1,154 

In addition there were Singapore patients— 




' Remained on 31st December, 1922 

142 ... 

87 

229 

Admitted during 1923 

— 

50 

50 

Discharged 

4 ... 

1 

5 

Absconded 

1 

— 

1 

Died 

8 ... 

10 ... 

18 

Remaining on 31st December, 1923 

... 129 ... 

126 ... 

255 

Criminal patients— 




Remained on 31st December, 1922 

65 ... 

2 ... 

67 

Admitted during 1923 

32 ... 

— 

32 

Discharged 

16 ... 

— 

16 

Absconded 

2 ... 

— 

2 

Died 

6 ... 

— 

6 

Remaining on 31st December, 1923 

73 ... 

2 ... 

75 

Kedah patients — 




Remained on 31st December, 1922 

71 

13 ... 

84 

Admitted during 1923 

39 ... 

11 

50 

Discharged 

12 ... 

4 ... 

16 

Absconded 

8 

— 

8 

Died 

9 

5 

14 

Remaining on 31st December, 1923 

81 ... 

15 

96 

Total remaining on 31st December, 1923 

... 1,183 ... 

397 ... 

1,580 

Percentage of recoveries 

... 41.36 per cent. 


,, of deaths on total treated 

... 6.89 ,, 

> > 


,, on daily average 

... 9.36 ,, 

> > 


An increase of 150 against 117 last year and 189 in 1921. 



The increase was to be noted in all classes of patients. 




3. There was an increase of 104 in the Federated Malay States patients against 
82 last year and 133 the year before. 

The Singapore patients increased by 26 against 39 the year before. Criminals 
increased by eight and Kedah patients by 12. The most marked increase was that 
amongst the Federated Malay States female patients who increased by 44 against 11 
in 1922 and 15 in 1921. 

4. Admissions .—The total admissions for the year were 601 against 604 in 1922. 
The admissions of most importance are the Federated Malay States admissions, as 
Table II; the others are more properly transfers, and it is with Federated Malay States 
figures that I shall, as usual, deal in my-table. 

Federated Malay States admissions numbered 358 men and 111 women giving a 
total of 469, which is the smallest we have had since 1920, though fifty over the average 
for the last ten years. This reduction is only on total however, as we have had an 
exceptionally heavy female admission, viz., Ill, which is 20 more than 1922 and 16 
more than 1921. 





































53 


5. I cannot tell what the great increase in Federated Malay States females is due 
to. Is it due to the fact that the number of women in the country is increasing, or 
that the trials of 1923 weighed more heavily on the women than the men? 

6. The common form of disease on admission was recent melancholia, 115 against 
102 last year, while recent mania which headed the list last year has fallen to second 
place with 86 appearances against 112 last year. Confusional insanity again occupies 
the third place with 53 and primary dementia again the fourth with 50. 

7. This shows three fewer cases of primary dementia than last year; but there 
were fewer admissions, and, as I pointed out last year, this is a disease which principally 
attacks young adults, and if it does not put them out of the running at once shows 
a tendency to recur,, and at the best leaves a weakened intellect behind. 

8. General paralysis made 22 appearances against 27 last year. 

9. Again there were some readmissions, but not so many as last year, principally 
due to the fact that we were able to help the discharged patients through after-care 
arrangements which we have been able to make. 

10. Discharges. —Numbered 225 against 244 in 1922 and 194 in 1921. There was 
a slight reduction under each head on total though we actually discharged one man 
more recovered than in 1922—161 against 160. 

11. The principal reduction was in female recoveries, of whom we discharged 
9 less—34 against 43. 

12. I still persisted in discharging patients “improved” who would have been 
classed as recoveries had I kept them a few weeks longer; but I believe it pays, as one 
feels that friends and relatives are beginning to see that this is primarily a hospital, 
and that our object is to cure and discharge our patients as soon as possible, and not 
merely shut them up and keep them out of harm’s way. 

13. Table III. Recoveries. —Number 194 against 204 in 1922 and 177 in 1921 
giving a recovery rate of 41.36 against 42.04 in 1922 and 35.68 in 1921. 

14. Though the recovery rate is below that of last year it is above the average 
for the last ten years which works out at 39.52. 

15. Table III which gives “the form of disease on admission of those discharged 
recovered” shows recent mania with 72 recoveries against 79 in 1922 and 62 in 1921, 
recent melancholia with 44 against 47 and 49 respectively, while confusional insanity 
and primary demantia appear 29 times and 14 times against 26 and 12: in each of 1922 
and 1921. 

16. The order is just the same as last year and year before, and the constancy 
of the figures is very remarkable. 

17. Table IV. Aetiology). —We have continued to send out forms to patients' 
friends and relatives to fill in what information they can give. In the great majority 
of cases when these reach their destination they are returned filled in more or less 
intelligently, and I must say that, on the whole, the information contained in them 
is of considerable value. I was struck with the number of cases in which the person 
mentioned as a friend or relative in the descriptive roll did not exist and of whom the 
patient when he improved denied all knowledge. Again a remarkable fact was that 
in a number of cases where the forms were returned by the Post Office as “address 
unknown” I was able to get the letters delivered by the Police or by some other 
channel. 

18. “Gastro intestinal system” again heads the list, and, though intestinal 
parasites have a considerable bearing, they are not the only trouble which is to blame. 
The point to be noted in this connection is that although 179 or 36.03 per cent, of 
patients suffered from intestinal parasites, only 117 cases were attributed to the 
“Gastro intestinal system”, and in nearly every case as a contributory cause. 

19. Next on the list are “Haemopoietic system” and “Cardiovascular 
degeneration”. These two usually appear as contributory, and in addition are usually 
more or less dependents on the other causes, which themselves appear in the list. 
The former depending primarily upon malaria and intestinal parasites, and the latter 
on syphilis or alcohol. Malaria again appears more frequently as a contributory cause, 
though it has been again made use of as a plea in murder cases. 

20. Next we have the two most important causes, alcohol and syphilis. I say 
two most important causes as, in the vast majority of cases these two appear as 
principal causes whereas Ithose we have already discussed are almost invariably 
contributory and, as I have told above, a greater number of the 65 cases of “Cardio¬ 
vascular degeneration” might be divided between syphilis and alcohol. 


54 


21. Syphilis appears only 25 times against 35 times, last year. This does not 
mean a decrease in syphilis is due to the fact that owing to being 
shorthanded most of the year I was unable to enquire into cases as carefully as m 
1922 and depended on the Wassermann test. As we cannot get the blood of every 
patient admitted tested, the whole matter is unsatisfactory, and will be so until it is 
possible to get all bloods examined. Could we have a Wassermann done on every 
patient I am confident that a great many of the patients returned under head “M”(no 
cause assignable) at present would be added to the cases assigned to syphilis, and 
probably bring syphilis near the head of the table. 

22. As to alcohol we find it appears on 42 occasions, usually as a primary cause, 
and, as I said with regard to syphilis, a considerable number of the 65 cases appearing 
under the head of “Cardio-vascular degeneration” might be added. 

23. I, as last year, wheri dealing with alcohol differentiated between Chinese and 
Indians, and found the startling figure of 34 'Chinese and only 8 Indians. Last year 
we had 37 Chinese and 26 Indians so that, though the total number of alcoholic cases 
is down, we see that the reduction is due to an extraordinary fall in the number of 
Indians whose trouble can be attributed to alcohol. 

24. This to my mind bears out my contention that the Chinese have taken to 
alcohol, and I fear this will go on and increase. There is a conspiracy on foot to stop the 
Chinese smoking opium with the result that they are turning to alcohol as a substitute, 
which from my point of view is vastly more dangerous. All I can say is that the day 
opium is cut off and alcohol substituted will certainly be a bad one for the Chinese, and 
I fear we may find an increase in such crimes as murder and rape. 

25. It is a remarkable fact that not one of my patients showed deprivation 
symptoms although no opium is supplied to anyone here. 

26. One patient was described on the friends’ form as an opium eater, but the 
man turned out to be a case of general paralysis of the insane which has never been 
associated with opium. In fact, in the opium-smoking days in this country, general 
paralysis of the insane was declared to, be unknown. I don’t mean to claim opium as 
a preventative of general paralysis of the insane, but merely mention a remarkable 
fact. This patient’s trouble was of course due to syphilis. 

27. “Critical periods” (puberty, adolescence, etc.) show a goodly list, but 
“privation and starvation” show a decrease, as does mental stress. 

28. Heredity appears 11 times as it did in 1922 but I am quite confident that 
it was really responsible for a considerably greater number, especially in cases of 
primary dementia. The people are not yet educated sufficiently far enough in their 
views of mental disease to willingly acknowledge “heredity” as a cause. 

29. Deaths .—The death-rate works out at 6.89 per cent, on the total treated and 
9.36 on the daily average, which figures are .42 and .57 per cent, higher than last year 
which was the lowest on record. 

30. This year’s figures are however below the average for the last ten years 
which is 10.92. 

31. I have pursued my policy of isolating all dysentery and phthisis cases, and 
also of not passing any patient into the general wards until he has been found to be 
clear of all intestinal parasites. When it is pointed out that 179 giving a percentage 
of 36.08 admitted, suffered from intestinal parasites of some sort the importance of 
this precaution can be realised. 

32. The principal causes of deaths were phthisis, dysentery (amebic 15, bacillary 4, 
chronic 4), general paralysis of the insane and malaria. 

33. All the above cases save general paralysis of the insane show a slight 
increase. Though phthisis heads the list I should like to point, out that though a 
mental hospital is one of the chief places for a high phthisis rate owing in many 
cases to the form of disease from which the patients suffer, mental cases being 
practically prone to phthisis, we only had 22 deaths during the whole year. 

34. Phthisis shows one more death than last year and three less than 1921 but 
1 regret to' record an increase of 7 deaths from dysentery, i.e., 23 against 16 last year 
and 31 in 1921. I cannot explain this increase save by the usual fluctuations from year 
to year that one always finds. We have continued our policy of isolating all dysentery 
cases and not returning them to the wards until they are no longer a danger. 

35. There is also a slight increase in deaths from malaria—16 against 12 last year. 



00 


36. Suicides. —I regret to say we had one suicide, a case of hanging. The patient 
was a Tamil, who had for years been working as grass-cutter attached to the cow-shed. 
He showed no suicidal tendency and never had, but was discovered hanging to the 
branch of a tree with his grass sack half full and his curve knife at the foot of the tree. 

37. Fatalities. —There were six fatalities, most of them being due to quarrels 
between patients with enlarged spleens. A blow in such cases usually means death 
due to ruptured spleens. One spleen weighed 3 lbs. 1 oz. 

38. These cases are most distressing, and most trying to those in charge of the 
hospital, but I do not see how they can be prevented. At home, patients fight too, but 
there, there are no enlarged spleens, and attendants are more alert. 

39. Abscondings. —Again we had a large number—49—but when patients have 
so much freedom as they’have here, such cases must occur. The policy of giving so 
much freedom may be criticised but I would point out that the object of a hospital 
is to cure, and if patients are shut up into wards continually they will never recover. 

40. Consequently patients whenever possible are sent out to work. 

41. This was the policy of all my teachers, and I am perfectly convinced that 
it is the right one. A large number of those who absconded returned, many of their 
own accord. The majority of the abscondings were from working parties, and in the 
majority of cases were due to the carelessness on the part of the attendants. 
A few more from the farms, and those supplied most of those who came back of their 
•own accord, the truth being that they went merely for a more extended stroll than usual 
and had no intention of absconding. 

42. Several cases actually got away from the wards, and they can only be 
ascribed to gross carelessness on the part of the attendants, and in addition, as a rule, 
•direct disregard to orders. 

43. Criminals .—There were 32 admissions, against 22 in 1922, and 16 discharges 
•against 8. There were also two escapes, but they were short term prisoners who were 
out of their term and were no longer in the criminal ward. Indeed it is a question if 
thej 7 should ever have been sent in as criminals. 

44. Of the admissions some had become insane while in gaol, some were found 
guilty but insane, and others were sent in under observation. 

45. Of the 8 discharges, 5 were not insane, and of them 3 were definitely 
malingering. Fortunately they were discovered and two were hanged, the third had 
the sentence commuted to imprisonment for life, and is now in the Convict 
Establishment. 

46. The type of mental disease amongst the criminals was much the same as 
amongst the ordinary patients. 

47. Singapore. —The Singapore patients were much the same, chronics and 
dements as usual. We had no male admission from Singapore but had 50 females sent 
in a batch for whom we put up a temporary ward. 

48. One interesting point with regard to the Singapore patients . is, that the 
Federated Malay States has now bought the wards put up by Singapore when the 
transfer of Singapore patients was first decided on, so that the Federated Malay States 
now owns all the wards at Tanjong Piambutan. 

Kedah. —There were 59 Kedah admissions against 54 last year and 16 discharges 
against 11 last year. 

49. Kedah patients are now being sent direct without any delay and the patients 
have now a good chance of recovery. One might now treat them as direct admissions 
and include them in the general tables, which I hope to do next year. 

50. New Buildings. —Again there was little or no 1 building in hand. 

51. There was merely a double clerks quarter, which was badly needed, and 
w’hich was not started until October, and of course is still under construction, which 
means that two members of the staff, a dresser and a clerk, are without quarters 
of their own. 

52. A much needed addition to the kitchen was completed during the year. 
This took the form of two small kitchens, one for Mohamedans and the other for 
Hindus. This, in addition to allowing of what we should have had long ago, seperate 
•cooking accommodation for Mohamedans and Hindus, relieves the congestion in the 
main kitchen, wdiich had been handed over to the Chinese. 


56 


53. My great regret is that this work, which was begun yery late, though not so 
late as the quarters, was not completed when the delegates to the Congress of the 
Ear Eastern Association of Tropical Medicine visited. However, I was able to point 
to them under construction as an improvement in hand. 

54. Farms. —The farms did well though the value of product was much less than 

1922. This was to a great extent due to a fall in prices. For example we supplied 
225,553 katis 2 tahils of vegetables (excluding those supplied to Ipoh Hospital) against 
212,351 katis 6 tahils in 1922. In addition our wood-cutters at Highfield supplied 
16,541^ piculs of firewood valued at $6,616.60. We supplied less milk but more pork 
than in 1922 and I hope to supply more of both in 1924. Some of our exchanges with 
the hill did not work out as well as I had hoped, but I have learned from my mistakes. 

55. The fruit farm has been an unqualified success and as time goes on should 
be one of the finest in the country. 

56. We have now under cultivation 234 acres. 

57. Before I leave this section I should like to put on record my indebtedness 

to the Agricultural Department and the Veterinary Department. 

58. Work. —I attach a list of the work done, and a valuation. As usual all the 
patients’ and attendants’ clothes were made and mended in the workshops. 

59. We have also done a great deal of levelling, draining, etc., which I shall deal 
with again in another paragraph. 

60. I do not wish anyone to run away with the idea, because the value of the 

work is shown, that the work is done with the idea of profit. It is not. The work is 

purely undertaken as a form of treatment for the patients and the fact that it 

happens to be profitable is merely an accident—a fortunate one I allow. 

61. Staff. —The staff has been satisfactory. 

In April, Dr. Stone, at the end of his two years’ agreement, went to Singapore, 
where he is acting Superintendent of the Asylum. 

62. In October, the staff suffered a great loss. Mr. Ah Fait, the Inspector, 
retired after 40 years’ Government service. 

63. Now that, he has retired, I hope, I may infringe the rule as to comment on 
individuals, and say how much he has done for the Central Mental Hospital. He had 
been my right-hand man from the day 1 opened this hospital, and no one will ever 
know how much of the organisation is due to Mr. Ah Fatt. 

64. Mr. Kanapathippillay has been promoted Inspector vice Mr. Ah Fatt and 
Mr. Ooi Cheng Yean replaces Mr. Kanapathippillay as Assistant Inspector. 

65. Mr. Pal was on leave from 19th February, 1923, till 6th July, 1923, and 
Mr. C. Murgiah acted for him. While Mr. Pal was on leave he was confirmed in the 
appointment as Senior Assistant Physician. 

66. Mr. Ah Fatt was on three months’ leave prior to retirement from July 1st. 

67. Mr. Tan Hong Ann was transferred, after having been here over a year, on 
17th July, 1923, on Mr. Pal’s return from leave. 

68. The vacancy amongsf the Assistant Physicians was filled on 7th April, 1923, 
by Mr. M. Luchumeyah who in turn was succeeded by Mr. Sabapathy on 6th October, 

1923. 

69. Mr. Murugiah left on 19th July, 1923, and was replaced by Mr. Vaithilingam. 

70. Amongst the dressers Mr. Masim Ali was appointed on 21st February, 1923, 
but left the service without notice a few months later; since when there has been a 
vacancy in the dresser staff. 

71. Mr. Mahmud bin Shaik Abdul Majid was appointed to the vacancy caused 
by Mr. Ah Fatt’s retirement on 15th October, 1923. 

72. Judging by the number of applications I had for the appointment, the dresser 
posts here must be very much more popular than the Assistant Surgeon ones. 

73. Mr. Chan Ah Choy, Clerk, Class II, was appointed to the staff on 8th June, 
1923, and on 1st July, 1923, Mr. Wong Piang Seong was transferred and was succeeded 
by Mr. C. L. Marcus. 

74. This was the only clerical change but I think one will agree that the above 
is a goodly list of changes in one institution in one year. 


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75. One of the most remarkable points about the staff is the haste with which 

Assistant Surgeons get out. The plea is always that they get no experience of general 
diseases. * 

There were no candidates for the Medico Phychological Association’s Nursing 
Certificate as I could not find time to lecture owing to the fact that I was attempting 
to do the Assistant Superintendent’s work as well as my own. 

76. The attendants were a greater trial than ever, and it now appears impossible 
to get even moderately reliable ones. I again tried Malay attendants, but had to my 
great regret to again give them up. They do not appear to take to the work, or show 
the slightest grasp of it. 

77. Maintenance. —The maintenance rate works out at $176.88 per head per 
annum against $182.14 in 1922, and $223 in 1921, so that the rate is still being reduced 
and I hope and believe will be further reduced without in any way reducing the 
efficiency of the hospital. 

78. General. —The Mental Diseases Enactment has had a year’s trial and so far 
has worked well. People have learned very quickly that they need no longer go to 
the Police or the Court, so that this delay is cut out. The only trouble 1 have had is, 
that several have thought that no certificate of any sort was needed, and just brought 
their ailing relative or friend along. We have also several voluntary boarders. 

79. I should, now we have got rid of the criminal idea, like to see Police escorts 
done away with, and the escorting of patients taken over by the Medical Department, 
to whom such a duty rightly belongs. 

80. So far there is only one point that I should like to see added to the Enactment 

and that is that now that admission to a Mental Hospital has been made easier, 

discharge should also be made easier. I should like to see the Medical Superintendent 
given power to discharge patients within the first three months without waiting for a 
board meeting. He could report at the next meeting. 

81. Of course this can be done as it is under the section which deals with the 
discharge on trial; still, a section as I suggested above would be an improvement. 

82. Anti-malarial work was proceeded with, and the scheme for the Sungei Bulat, 

which I explained last year, carried a step further. The concrete inverts are laid and 

the banks are sloped and partially sodded as far as the road which leads to Horten Farm 
and Highfield. We also made a concrete and stone bridge over the stream to carry 
the road. When the rainsi got too heavy to allow of work on the Sungei Bulat the 
parties who had work there were transferred to the piece of land which was taken 
over from Mr. Heintse, in 1921, and inverts laid for its whole length, and the bank 
sloped and sodded. The parties are now doing the same at a stream at the other 
side of Horten Farm, and by the time that it is finished the weather should be dry 
■enough to enable work in the Sungei Bulat to be resumed. 

83. We laid 1,878 feet of subsoil pipes, varying from 2 inches to 6 inches in 
diameter and we have just begun to make 8-inch pipes. We made, as a glance at 
the work return will show, close on 15,000 subsoil pipes. 

84. I hope to get a large section of the Sungei Bulat done in the coming year, 
as the draining of the whole reserve depends on this stream, and until it is dealt with 
no really satisfactory work can be done elsewhere. 

85. Our daily average malaria rate was, on cases .61, and individuals .56. In the 
case of attendants it was .25 and .21, respectively. 

86. Before closing this section I should like to thank the Health Officer, Ipoh, 
and the Executive Engineer, Mosquito Destruction Board, Taiping, for the advice they 
have given me, and the interest they have taken in the work. 

87. We have planted up 20 acres with batai trees to replace the timber cut out 
for firewood, and have prepared 19 acres for planting so that we should not run short 
•of firewood in the future. The value of the firewood we supplied to the hospital shows 
how serious a matter it would be if the timber was not replaced. 

88. With regard to the number of the different nationalities affected by the 
■different forms of disease, the most remarkable fact is that all 22 cases of general 
paralysis of the insane admitted were Chinese. It is extraordinary how the other races, 
save Japanese, appear almost immune from general paralysis of the insane. 

89. Another remarkable fact with regard to nationalities is, that although the 
male Chinese admissions were exactly twice as numerous as Tamils, there was only 
a slight difference in the female admissions—47 to 40. 


58 


90. Surgery .—We had several cases cf operation during the year. All were sent 
to Ipoh where the Chief Surgeon operated, and they all returned recovered. The list 
comprised amputation of the penis (cancer), (attendant) : ' 

Gall stones (attendant) ; 

Richter’s hernia (toty); 

Removal of ovarian cyst (patient); 

Mastoid operation (patient). 

91. In September, we had a visit from between 30 and 40 delegates to the 
conference of the Far Eastern Association of Tropical Medicine. 

Unfortunately the early part of the morning was wet, following a very heavy rain 
at night. Still the visitors saw everything to be seen inside and a good deal outside, 
but the state of the roads after the heavy rain prevented many from seeing some of 
the most interesting work, e.g., the work on the Sungei Bulat, and all, from seeing the 
fruit farms and other outlying parts. 

92. I had had the roads made up and had intended taking the delegates in cars, 
but our unmetalled roads became impossible to cars, especially cars kindly lent by 
the various Ipoh residents who had come forward and put delegates up, and sent them 
out to Tanjong Rambutan in their own cars. I bitterly regretted that my repeated 
request to have the roads metalled had been ignored, and the items cut out of my 
Public Works Department budget year after year. Had the roads only been metalled 
every delegate could have seen everything that was to be seen in the place. 

93. I have been without an Assistant Superintendent since April last. The 
hardest part of this is that the Colonial Office sent a man out to the Medical 
Department who had all the requirements I asked for. Had the Colonial Office told 
him of the vacancy he would have applied at once. 

94. Amusements. —Drafts, chess, cards, shimisoes, etc., were played in the 
wards by the patients. Sunday walks in the grounds were taken by the patients and 
those who were fit visited the town. The visit of a travelling circus or cinema was 
taken advantage of to take suitable patients. 

95. The sports were held in July and as usual went off well, and were thoroughly 
enjoyed by patients and attendants alike. 

96. The cricket team had a very good season indeed, but the football team was 
poor. 

97. May I, in closing my report, express my thanks to Government for the 
support and encouragement it has been good enough to extend to me. 


I have the honour to be, 

Sir, 

Your obedient servant, 

W. F. SAMUELS, 

Medical Superintendent, 

Central Mental Hospital, Tanjong Rambulan. 



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