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CHOLERA IN THE PILGRIMAGE ANDELSEWHERE.

(BY THE BRITISH DELEGATE ON THE CONSTANTINOPLEBOARD OF HEALTH.)

THE record of the cholera outbreak in the Hedjaz sincethe time of writing my last letter 1 has fortunately been thatof a steadily declining epidemic. In Mecca the followingdeaths from cholera have been registered since Jan. 2Lst :-

Jan. 21st ...... 186 deaths Jan. 30th ...... 21 deaths" 22nd ...... 168 ,. 31st ...... 17 "

" 23rd ...... 117 " Feb. 1st ...... 14 "

" 24th ...... 64 2nd ...... 9 "

» 25th ...... 49 " 3rd...... 9 "

" 26th ...... B u 11 e t i n " 4th ...... 4 "

missing. " 5th ...... 3 "

" 27th ...... 25 deaths " 6th...... 4 "

" 28th ...... 18 " 7th...... 4 "

" 29th ...... 25 8tih ...... 0 "

Since Feb. 8th there appear to have been no further deathsfrom cholera in Mecca and on the 10th it was announcedthat the issue of daily bulletins would henceforth cease

unless fresh cases should occur. The marked diminution inthe number of deaths there, ending, it may be hoped, in theextinction of the epidemic, has coincided with the dispersalof ’the pilgrims. Few, if any, hajjis are now left in Meccaitself. The great Mahmel caravan for Medina and Damascusleft there on Jan. 31st ; it consisted of 7000 camels and wasaccompanied by an ambulance and a number of medicalmen. The report of its arrival at Medina may now beexpect3d at any moment.

In Medina there appear to have been no fresh cases ofcholera since Jan. 15th. In Jeddah there was a sharp risein the numbers of cases and deaths, coinciding with thereturn of the pilgrims from Mecca, as the following returnsshow :-

From Jan. 10th to Jan. 19th ...... 4 cases, 3 deaths." " 20th" " 26&h ...... 250 219 "

It " 27th,, Feb. 2nd...... 113 " 95 "

" Feb. 3rd " " 8th ...... 1 " 25 "

From Yanbo news has been received very irregularly. It

seems, however, that the disease had not died out there ashad been supposed. Between Jan. 3rd and 27th, 26 cases ofcholera with 25 deaths occurred there; and betweenJan. 28th and Feb. 3rd, 18 cases and 18 deaths. Some ofthe later cases appear to have occurred among pilgrimsarriving at Yanbo from Jeddah by sea.The marked subsidence of the cholera outbreak at Jeddah

is mainly to be attributed to the rapid departure of thepilgrims from that port, some for Yanbo, some for the southand countries situated beyond the Straits of Bab-el-Mandeb,and the rest for the Suez Canal and the north. Whether it wassolely due to this cause or whether it was not also partly dueto a real decline in the activity of the infecting material, itis impossible to say. It is nevertheless remarkable thatamong the many thousands of pilgrims who have alreadyarrived at the Egyptian lazaret of El Tor only three casesof cholera (bacteriologically proved) have so far beenobserved. Two of these cases were from the s.s. Mariout andone was from the s.s. Jigre. Other ships seem to have hadsuspicious deaths among their pilgrims during the voyagefrom Jeddah, and some have landed suspicious cases at the Torlazaret; but, as just stated, in only three has the existenceof cholera been actually proved. A rumour was recentlycurrent here that cholera had broken out in the Keneh

province of Egypt, but this has fortunately been shown tobe entirely without foundation.As pointed out in my last letter, the newly constructed

Hedjaz railway will this year be made use of by a largenumber of pilgrims returning northwards ; and the risk ofthe importation of cholera to Syria has been proportionatelyincreased. The disease has already reached the head of theline and attacked some of the soldiers employed on theworks. Information from these rather remote regions hasbeen scanty and contradictory, but the following summaryseems to represent as accurately as possible what has actuallyoccurred there. When the Mahmel caravan (with the holy

1 Published in THE LANCET of Feb. 8th, 1908, p. 455.

carpet) was on its way down to Medina and Mecca early inJanuary (or late in December), Arabs from Medina, comingalong the pilgrims’ road to meet it, brought with them theinfection of cholera and communicated it to the troops at aplace called Hedieh. A telegram from Nazim Pasha, director-general of the railway construction works, dated Jan. 7th,stated that over 30 cases of cholera and 10 deaths hadoccurred among the troops under his orders in Medina.These troops had, it was added, been camped outside thetown in separate groups ; it was further added that over 30cases and 24 deaths had been registered in the second

company of the railway battalion stationed beyond Hedieh,followed (on Jan. 4th) by six deaths and 17 suspected casesin the same company. Then it was reported that a case hadbeen seen at El Ola, about 100 miles north of Hedieh ; thiscase recovered and a telegram dated Jan. 19th stated that nonew case had been seen there for 11 days. Another telegramstated that at no time bad cholera been seen at any point ofthe line between Damascus and Bir-ul-jedid, but this is incontradiction with the report of the case at El Ola, which iswell to the north of Bir-ul-jedid. On Jan. 21st Dr. SelamiPasha, head of the special medical mission sent fromConstantinople for the sanitary control of the line,telegraphed from Damascus that the disease had reached the1074th kilometre. This apparently corresponds with theposition of Bir-ul jedid or is perhaps slightly to the north ofthat place ; 191 cases of cholera were said to have been seenaltogether, besides 19 others, with three deaths, among thesoldiers. Later, however, the occurrence of "191 cases" "

was absolutely contradicted. A series of telegrams weresent off by the same authority between Jan. 25th andFeb. 2nd, from which the following may be gathered.On Jan. 25th it was stated that the whole of theline south of El Ola was considered to be contaminated.On Jan. 26th a telegram from Zamrud stated that Dr. SelamiPasha had gone there to make a personal inquiry as thenews obtainable had been so contradictory. Zamrud wasthen considered to be the terminus of the line; it liesbetween El Ola and Bir-ul-Jedid. The telegram continuedto the effect that no case of cholera had been seen at Hediehfor four days, that one fatal case had occurred at the 1074thkilometre, and that the military authorities had informedhim verbally that further south sporadic cases had occurredat many points. On the 28th Dr. Selami Pasha telegraphedfrom Medaini-Salih, the station north of El Ola, stating thatbetween Jan. 15th and 26th there had been 42 cases and 16deaths around and beyond Bir-ul-jedid and Hedieh, and thata quarantine station had been established at Bir-ul-jedidwhere ordinary passengers (not pilgrims) were subjected toten days’ quarantine. A large supply of permanganate ofpotassium had been distributed there and elsewhere for thedisinfection of wells and other water-supplies. The quarantinestation for pilgrims had been established at Medaini-Salih.The telegram of Jan. 29th definitely contradicted the formerreport of "191 cases," and stated that the disease hadadvanced only as far north as kilometre No. 10712, where itexisted among labourers on the line Farther north the linewas declared to be quite free from infection. Later

telegrams continue to report the occurrence of a few casesand deaths among the labourers and troops at Hedieh,Bir-ul-jedid, and elsewhere.From the above summary it may be concluded that, so far

as is known at present, cholera has not spread along theHedjaz railway beyond El Ola, which is roughly about300 kilometres north of Medina ; but that at and beyondBir-ul-jedid and Hedieh it has been more or less epidemicparticularly among labourers and troops employed on theconstruction of the line.The pilgrims’ quarantine station has, as just stated, been

established at Medaini-Salih. A detailed scheme of measuresin connexion with the return of the hajjis by this route hasbeen put into force, but any account of it must be reservedfor a later letter.The nine cases of cholera in Constantinople, which were

mentioned in my last letter, were followed by two others,isolated respectively on Jan. 23rd and 28th. Since the last-named date no further case has been observed, and it is

hoped that the sporadic outbreak is over. All measures

imposed on departures from this city and on arrivals there-from in other Turkish ports have been suppressed.

In Russia the cholera epidemic appears to have come toan end. The figures published in my last letter brought therecord of the epidemic down to Dec. 18th (31st). FromDec. 19th (Jan. 1st) to Dec. 25th (Jan. 7th) no new case

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was reported ; in the following week, ending Jan. lst

(14th), two cases were reported from the Tomsk governmentin Siberia and none from any other part of the empire.Since that date the whole of the Russian Empire is declaredto have been quite free from cholera.Constantineple, Feb. 13th.

LIVERPOOL.(FROM OUR OWN CORRESPONDENT.)

The Royal Southern Hospital: Tropical Diseases.THE income of this charity for the past year was RIO, 177,

whilst the expenditure was 12,809, leaving a deficit of .62632.During 1907 the number of cases in the tropical diseasesward was less than usual. The individual cases amountedto 108. The nationalities of the patients were : English, 80 ;Irish, 11; Scotch, 5; Norwegian, 3; Bohemian, 2; EastIndian, 2; American, 1; Spanish, 1; Australian, 1; WestAfrican, 1 ; and Abyssinian, 1. The Liverpool corporationhas sanctioned a grant of R4000 to the proposed new out-patient department subject to the approval of the LocalGovernment Board.

The Liverpool Dispensaries.The charity known as the Liverpool Dispensaries consists

of three institutions situated in different parts of the cityand was founded in 1778. The committee is making anurgent appeal for R5COO, which amount is absolutely neces-sary to carry on the work. Rebuilding operations which areessential at the East Dispensary account for one-half the sumnamed and the other half is needed to put the finances on asound basis, the adverse balance being now R1035. Con-tributions promised include R500 from Mr. W. P. Hartley,R500 from Mrs. and Miss Holt, and R100 from Mr. WilliamClarkson.

The Renerval (If the Abattoirs Lease.At the meeting of the city council held on Feb. 12th a

motion was proposed that the council rescind its resolu-tion of July 1-8 th, 1900, expressing disapproval of Trowbridge-street or the neighbourhood as the site of an abattoir. Thetown clerk intimated that communications had beenreceived by the Lord Mayor from the committee andmedical staff of the Royal Infirmary, from the chairman ofthe Lying-in Hospital (both institutions being in closeproximity to the abattoir), and from the President of theLiverpool Medical Institution disapproving of Trowbridge-street or the neighbourhood as the site of an abattoir.Mr. T. H. Bickerton also forwarded a memorial signedby 378 medical practitioners disapproving of the presentsite and expressing the opinion that the public slaughterof animals should be carried out at a distance fromthe centre of the city. After considerable discussionthe council agreed to appoint a special subcommitteeto report to the council upon the desirability or otherwise ofthe corporation erecting, owning, and working dead-mea tmarkets and abattoirs ; the best sites for such businesses; th edesirability of rescinding the resolution passed on July 18th

e

1900 ; and to ascertain the terms on which the abattoir com-’pany would sell their property. The history of the abattoirsgoes back to the year 1838, when the corporation granted thecompany a lease of the land at present occupied for a term of75 years. In 1883 the company applied for a renewal of thelease which was opposed by the medical profession and otherresidents. In 1890 the application was renewed in the leaseof further opposition and the finance committee of the citycouncil recommended the council not to renew the lease.The city council, however, by a small majority instructed thefinance committee to renew the lease subject to suitable altera-tions. Nothing was, however, agreed upon and the matter wasleft in obeyance until 1897, when the city surveyor was in-structed to report as to the most suitable site for abattoirs. Thecity council passed a resolution in 1900 disapproving of thepresent site. The lease expires in five years and the medicalprofession and the hospital managers of the institutions inthe neighbourhood of Trowbridge-street anxiously lookforward to the fiat of the city council that the abattoirsbe placed outside the city bounds.

Gift by Lord Derby to the Bootle Hospital.Lcri Derby recently made a generous gift to the managers

of the Bootle Borough Hospital. A leasehold plot of landa9joining the hospital, containing about 1200 square yards,

was purchased from the Bootle corporation. Lord Derby hasvery generously presented to the institution the reversion infee simple of the property and cancelled the ground rent,thus converting the property into freehold land. Theoriginal site of the hospital was also presented by the thenEarl of Derby in 1869.

Feb. 25th. _________________

SCOTLAND.

(FROM OUR OWN CORRESPONDENTS.)

Appointment of Physioian-Superintendent to the RoyalEdinburgh Asylum.

THE directors of this important institution have electedMr. George M. Robertson, M.B. Edin., F.R.C.P. Edin.,to the post of physician-superintendent in place ofDr. T. S. Clouston who, as I recently intimated, had

resigned. The new superintendent is a graduate inmedicine of the University of Edinburgh, where he tookthe degree of M.B., C M., in 1885. He was electeda Fellow of the Royal College of Physicians, Edinburgh,in 1893. Soon after graduation he devoted himselfto lunacy by joining the staff of the asylum to whichhe returns as superintendent. It was when senior assistantto Dr. Clouston that he became the superintendent of theMurthly Asylum. From there he was moved to the StirlingDistrict Asylum at Larbert. He is a lecturer on insanity inthe Edinburgh Royal Colleges School of Medicine and in theMedical College for Women. He has written papers on avariety of subjects bearing upon his own department ofmedical work. He was employed by the Edinburgh DistrictLunacy Board as a medical expert to report on the plans forthe large and costly asylum which that board erected atBangour for the reception of pauper lunatics.

Clinical Meeting in the Edinburgh Royal Infirmary.As is the custom at this season the Edinburgh branch of the

British Medical Association have held a clinical meetingin the Royal Infirmary. As has been usual at these meetingsa large room was devoted to the exhibition of specimens andother objects of medical and surgical interest. In the after-noon a large number of patients, both surgical and medical,were shown, the demonstration taking place in the largesurgical theatre. Dr. Byrom Bramwell, as president of thebranch, presided. In the evening a dinner was held. The

meeting was largely attended and there was every indicationthat those attending appreciated the trouble which had beentaken in bringing interesting cases before them.’ The Dairies (Scotland) -Bill.

A consolidation Bill has been presented to the House ofCommons by Mr. Gulland and receives the support of SirJohn Batty Tuke and other prominent Members of Parlia-ment. The object of the Bill is to amend and to consolidatethe laws of dairies in Scotland. At present the law on thesubject is contained in four Acts of Parliament and threeOrders, all of which are consolidated in this Bill with a view togiving practical force to legislation and of supplementingexisting provisions.

Scottish Inter University Cnnferenee.An inter University conference, consisting of three medical

representatives from the University of St. Andrews, threefrom the University of Aberdeen, and four or five from theUniversity of Glasgow, was held in the Senate Room,Glasgow, last week. The conference, which was held inprivate, was convened by Principal Donald MacAlisterfor the purpose of discussing the question of the medicalordinances in force in the Universities represented withreference to a possible revision and the institution of newregulations. The deliberations of the conference, it is hoped,will result in either joint or independent action on thematter by the three Universities concerned.

Glasgow Medical Officer and Vaccination.Dr. A. K Chalmers, medical officer of health of Glasgow,

says in a report to the health committee that the Vaccina-tion (Scotland) Act, 1907, came into operation on August 28thlast and up to Dec. 31st the declarations of conscientiousobjection to vaccination lodged with the district registrarsaffected 474 children-251 males and 223 females. It wassignificant that only 87 of these children were more than ayear old, while 304 were under six months. It suggestedthat they would have a rapidly increasing number