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840 THE CHOLERA EPIDEMIC. (BY THE BRITISH DELEGATE TO THE CONSTANTINOPLE BOARD OF HEALTH.) Cholera in Russia. CHOLERA still lingers in Russia, as shown by the following returns (in continuation of the figures published in my last letter in THE LANCET of Feb. llth, p. 395) :- Week ending Nov. 20 th ...... 30 cases, 16 deaths. " " ., 27th ...... 34 " 18 " " " Dec. 4th ...... 13’ " 9 " " 19 " llth ...... 37 " 18 " " " ,, 18th ...... 14 " 5 " " " ,, 25th ...... 2 " 3 " The above are "corrected" figures; the following are uncorrected " - Week ending Jan. 1st ...... 4 cases, 1 death. " " " " 11 8th ...... 2 " 4 " " " " 15th ...... 9 " 6 " " " " 22nd ...... 2 ,, 1 " The cases and deaths in the bulletins for Jan. 1st and 8th all occurred in the Ekaterinoslav government, those in the bulletin for Jan. 15th in the governments of Podolia and Kief, and those in the bulletin for Jan. 22nd in the govern- ment of Podolia. (All the above dates are according to the Old Style.) Cholera in Austria. On Dec. 10th the Austrian Minister of the Interior de- clared officially that no case of cholera had occurred on Austrian soil since Nov. 7th, and that from the beginning of the outbreak on August 23rd there had been only 15 cases with 5 deaths. The last case was that of a major in the army, who arrived at Graz on Nov. 5th and was apparently already sickening with an attack of cholera ; he had come from Pancsova, in the county of Torontal, which had already been declared an infected district. Cholera in Hzzngary. On Dec. 30th it was officially stated that no fresh case of cholera had occurred in any part of Hungary-Croatia and Slavonia included-for five days, and the whole country was declared "clean." The following additional figures have been received for the outbreak in Croatia and Slavonia;- Between Nov. 5th and 12th there were 9 cases and 8 deaths, occurring in six different places, situated in five different counties; between Nov. 12th and 19th there were 11 cases and 4 deaths in six places, in four different counties ; and between Nov. 19th and 26th there were 4 cases and 2 deaths in four places. All these cases were confirmed bacterio- logically. Between Nov. 26th and Dec. 4th no further cases occurred ; but between the 4th and 10th 2 cases, both fatal, occurred in the county of Srien, and between the 10th and 17th 1 case in that of Agram. Cholera in -Italy. The latest returns from Italy are as follows :- In the week ending Dec. 14th 38 cases and 11 deaths ; of these, 3 cases and 1 death occurred in the province of Aquila, 1 case in that of Caltanisetta, 9 cases and 4 deaths in that of Caserta, 6 cases and 1 death in that of Lecce, 9 cases and 2 deaths in that of Palermo (including 7 cases and 1 death in the Palermo lunatic asylum), 3 cases and 3 deaths in that of Rome, and 7 cases in that of Salerno. In the week ending Dec. 21st there were 18 cases and 2 deaths, distributed as follows :-1 case and 1 death in the province of Caltanisetta, 4 cases in that of Caserta, 9 cases in that of Lecce, 3’ cases and 1 death in that of Palermo (all in the asylum above alluded to), and 1 case in that of Salerno. No detailed returns have been received here since the last-named date, but it is declared officially that since Jan. 31st no further case of cholera has occurred on Italian territory. . Cholera in Constantinople and Turkey in Europe. The cholera outbreak in this city came to an end early in January. In the week ending Jan. 2nd there had been 62 cases and 46 deaths ; in that ending Jan. 9th the figures fell to 17 cases and 20 deaths ; and between the 10th and 13th 10 more cases and 8 deaths were registered. The last new case occurred on the llth, and ten days later Constantinople was declared free. The totals since the beginning of the epidemic on Sept. 13th were placed at 1318 cases and 793 deaths, among the civil population. Since the middle of January remarkably severe weather has been prevalent in Constantinople and neighbourhood. In Salonica no cases have been reported since Dec. 31st, and the whole of European Turkey seems to be now free from cholera. Cholera in Asiatic Ttirleey and aniong Returning Pilgrims. The following have been the recent weekly returns from Smyrna :- Week ending Jan. lst ...... 12 cases, 8 deaths. " " " " 8th ...... 36 " 20 " " " " l5th ...... 38 " 27 " " " ,, 22nd ...... 86 " 51 " " " ,, 29th ...... 69 ., 32 " " " Feb. 5th ...... 15 " 11 " I " ., " 12th ...... 5 " 3 " The last case here occurred on the 7th, and Smyrna has now been declared cholera-free. In all 341 cases and 213 deaths have been recorded in the town. Recently a few cases of suspected cholera have occurred in the neighbourhood of Broussa, and in that of Zunguldak on the Black Sea. Otherwise the whole of Asia Minor appears to be now free from the disease. The same statement may be made in regard to the Bagdad vilayet ; 5 cases and 5 deaths occurred here (at Kerbela, one of the Shiah holy cities) on Jan. 1st and 2nd, and none have been reported since. The outtreak of cholera among the returning pilgrims, the beginning of which was reported in my last letter, has caused a consider- able, but not excessively high, mortality. In Mecca the following cases and deaths have been recorded:- Between Dec. 26th and Jan. 15th...... 119 cases, K6deaths,. " Jan. 16to" " 22nd ...... 24 " 26 " " 23rd " 28th ...... 10 " 10 " Since the last-named date Mecca appears to have been free from the disease. The totals here are put at 153 cases with 142 deaths. These figures are in all probability below the truth. In Jeddah the disease was first seen about Jan. 10th ; ;. the first cases occurred among the troops. The outbreak in this port seems to have been limited to about a score of cases, and on Feb. 9th it was telegraphed that no further cholera bulletins would be issued, the outbreak appearing to be at an end. From Yanbo only irregular and imperfect reports have been received ; on Jan. 8th it was reported that 7 cases and 2 deaths had occurred there ; and on Jan. 13th the totals were said to be 24 cases and 21 deaths. No further news has been received from Yanbo. An outbreak of cholera, in regard to which it has proved difficult to obtain exact information, has occurred in the Yemen, in the neigh- bourhood of Hodeidah. The first cases were seen in the village of Badjil, 25 miles to the north-east of Hodeidah, ; between Jan. 9th and 16th 48 cases of cholera and 37 deaths were recorded here ; two fatal cases were also seen at Zeidieh, a village to the north. Between the 16th and 21st 10 further cases, with 9 deaths, occurred at Badjil. On the 21st it was reported that cholera,, "confirmed bacteriologically," was prevalent among the troops in Hodeidah, causing many cases and deaths ; that 3 cases and 2 deaths had occurred among the native population ; and that it was reported "unofficially" that cholera existed among the troops at Menaba. Three cases of the disease occurred in the Camaran lazaret, among pilgrims returning to the Yemen and carried on board the s.s. Budre;the first case was isolated on Jan. 8th, the second on the 9th, and the third on the 17th. Vice consular reports from Hodeidah also state that cholera had, according to " I unofficial " reports, broken out among recruits on a trans- port steamer, the s.s. Saiyar, and that between Jan. 17th and .19th 50 cases of the disease and 18 deaths had occurred among them. Large numbers of troops are still being poured into the Yemen, where the bulk of the Arab tribes are in revolt, and it is generally believed that both the Turkish army and the Arabs are suffering from a more or less severe outbreak of cholera ; but, as already stated, it is most difficult to learn the true fads. As was anticipated, the infection was carried from Mecca to Medina by the caravans of returning pilgrims. Apparently tle first infected group arrived at Medina on Jan. 4th; it had had 5 cases and 4 deaths from cholera. Succeeding caravans arrived in the same condition ; they reported that the disease had appeared
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Page 1: THE CHOLERA EPIDEMIC

840

THE CHOLERA EPIDEMIC.

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

Cholera in Russia.CHOLERA still lingers in Russia, as shown by the following

returns (in continuation of the figures published in my lastletter in THE LANCET of Feb. llth, p. 395) :-

Week ending Nov. 20 th ...... 30 cases, 16 deaths." " ., 27th ...... 34 " 18 "

" " Dec. 4th ...... 13’ " 9 "

" 19 " llth ...... 37 " 18 "

" " ,, 18th ...... 14 " 5 "

" " ,, 25th ...... 2 " 3 "

The above are "corrected" figures; the following are

uncorrected " -

Week ending Jan. 1st ...... 4 cases, 1 death." " " " 11 8th ...... 2 " 4 "

" " " 15th ...... 9 " 6 "

" " " 22nd ...... 2 ,, 1 "

The cases and deaths in the bulletins for Jan. 1st and 8thall occurred in the Ekaterinoslav government, those in thebulletin for Jan. 15th in the governments of Podolia andKief, and those in the bulletin for Jan. 22nd in the govern-ment of Podolia. (All the above dates are according to theOld Style.)

Cholera in Austria.On Dec. 10th the Austrian Minister of the Interior de-

clared officially that no case of cholera had occurred onAustrian soil since Nov. 7th, and that from the beginning ofthe outbreak on August 23rd there had been only 15 caseswith 5 deaths. The last case was that of a major in thearmy, who arrived at Graz on Nov. 5th and was apparentlyalready sickening with an attack of cholera ; he had comefrom Pancsova, in the county of Torontal, which had alreadybeen declared an infected district.

Cholera in Hzzngary.On Dec. 30th it was officially stated that no fresh case of

cholera had occurred in any part of Hungary-Croatia andSlavonia included-for five days, and the whole country wasdeclared "clean." The following additional figures havebeen received for the outbreak in Croatia and Slavonia;-Between Nov. 5th and 12th there were 9 cases and 8 deaths,occurring in six different places, situated in five differentcounties; between Nov. 12th and 19th there were 11 casesand 4 deaths in six places, in four different counties ; andbetween Nov. 19th and 26th there were 4 cases and 2 deathsin four places. All these cases were confirmed bacterio-

logically. Between Nov. 26th and Dec. 4th no further casesoccurred ; but between the 4th and 10th 2 cases, both fatal,occurred in the county of Srien, and between the 10th and17th 1 case in that of Agram.

Cholera in -Italy.The latest returns from Italy are as follows :- In the week

ending Dec. 14th 38 cases and 11 deaths ; of these, 3 casesand 1 death occurred in the province of Aquila, 1 case inthat of Caltanisetta, 9 cases and 4 deaths in that of Caserta,6 cases and 1 death in that of Lecce, 9 cases and 2 deathsin that of Palermo (including 7 cases and 1 death in thePalermo lunatic asylum), 3 cases and 3 deaths in that ofRome, and 7 cases in that of Salerno. In the week endingDec. 21st there were 18 cases and 2 deaths, distributed asfollows :-1 case and 1 death in the province of Caltanisetta,4 cases in that of Caserta, 9 cases in that of Lecce, 3’ casesand 1 death in that of Palermo (all in the asylum abovealluded to), and 1 case in that of Salerno. No detailedreturns have been received here since the last-named date,but it is declared officially that since Jan. 31st no furthercase of cholera has occurred on Italian territory.

. Cholera in Constantinople and Turkey in Europe.The cholera outbreak in this city came to an end early in

January. In the week ending Jan. 2nd there had been 62cases and 46 deaths ; in that ending Jan. 9th the figures fellto 17 cases and 20 deaths ; and between the 10th and 13th10 more cases and 8 deaths were registered. The last newcase occurred on the llth, and ten days later Constantinople

was declared free. The totals since the beginning of theepidemic on Sept. 13th were placed at 1318 cases and 793deaths, among the civil population. Since the middle of

January remarkably severe weather has been prevalent inConstantinople and neighbourhood. In Salonica no cases

have been reported since Dec. 31st, and the whole of EuropeanTurkey seems to be now free from cholera.

Cholera in Asiatic Ttirleey and aniong Returning Pilgrims.The following have been the recent weekly returns from

Smyrna :-Week ending Jan. lst ...... 12 cases, 8 deaths.

" " " " 8th ...... 36 " 20 "

" " " l5th ...... 38 " 27 "

" " ,, 22nd ...... 86 " 51 "

" " ,, 29th ...... 69 ., 32 "

" " Feb. 5th ...... 15 " 11 "

I " ., " 12th ...... 5 " 3 "

The last case here occurred on the 7th, and Smyrna has nowbeen declared cholera-free. In all 341 cases and 213 deathshave been recorded in the town. Recently a few cases

of suspected cholera have occurred in the neighbourhoodof Broussa, and in that of Zunguldak on the Black Sea.Otherwise the whole of Asia Minor appears to be now freefrom the disease. The same statement may be made inregard to the Bagdad vilayet ; 5 cases and 5 deaths occurredhere (at Kerbela, one of the Shiah holy cities) on Jan. 1stand 2nd, and none have been reported since. The outtreakof cholera among the returning pilgrims, the beginning ofwhich was reported in my last letter, has caused a consider-able, but not excessively high, mortality. In Mecca thefollowing cases and deaths have been recorded:-

Between Dec. 26th and Jan. 15th...... 119 cases, K6deaths,." Jan. 16to" " 22nd ...... 24 " 26 "

" 23rd " 28th ...... 10 " 10 "

Since the last-named date Mecca appears to have been freefrom the disease. The totals here are put at 153 cases with142 deaths. These figures are in all probability below thetruth. In Jeddah the disease was first seen about Jan. 10th ; ;.the first cases occurred among the troops. The outbreakin this port seems to have been limited to about a score ofcases, and on Feb. 9th it was telegraphed that no furthercholera bulletins would be issued, the outbreak appearing tobe at an end. From Yanbo only irregular and imperfectreports have been received ; on Jan. 8th it was reported that7 cases and 2 deaths had occurred there ; and on Jan. 13ththe totals were said to be 24 cases and 21 deaths. Nofurther news has been received from Yanbo. An outbreak ofcholera, in regard to which it has proved difficult to obtainexact information, has occurred in the Yemen, in the neigh-bourhood of Hodeidah. The first cases were seen in the

village of Badjil, 25 miles to the north-east of Hodeidah, ;between Jan. 9th and 16th 48 cases of cholera and 37 deathswere recorded here ; two fatal cases were also seen at Zeidieh,a village to the north. Between the 16th and 21st 10 furthercases, with 9 deaths, occurred at Badjil. On the 21st it was

reported that cholera,, "confirmed bacteriologically," wasprevalent among the troops in Hodeidah, causing many casesand deaths ; that 3 cases and 2 deaths had occurred amongthe native population ; and that it was reported "unofficially"that cholera existed among the troops at Menaba. Threecases of the disease occurred in the Camaran lazaret, amongpilgrims returning to the Yemen and carried on board thes.s. Budre;the first case was isolated on Jan. 8th, thesecond on the 9th, and the third on the 17th. Vice consularreports from Hodeidah also state that cholera had, accordingto " I unofficial " reports, broken out among recruits on a trans-port steamer, the s.s. Saiyar, and that between Jan. 17thand .19th 50 cases of the disease and 18 deaths had occurredamong them. Large numbers of troops are still beingpoured into the Yemen, where the bulk of the Arab tribesare in revolt, and it is generally believed that both theTurkish army and the Arabs are suffering from a more or lesssevere outbreak of cholera ; but, as already stated, it is mostdifficult to learn the true fads. As was anticipated, theinfection was carried from Mecca to Medina by the caravansof returning pilgrims. Apparently tle first infected grouparrived at Medina on Jan. 4th; it had had 5 cases and 4deaths from cholera. Succeeding caravans arrived in thesame condition ; they reported that the disease had appeared

Page 2: THE CHOLERA EPIDEMIC

841

among them at Rabigh (or Rabouk)—the important point on the most westerly of the three roads from Mecca to Medina. Iand the spot where it is generally thought a new port willsome day be made, destined to replace Jeddah, and perhapsto be the terminus of the railway between Mecca and thecoast. On the 10th as many as 14,000 pilgrims arrivedfrom Mecca in the day, and 51 cases of cholera with 25deaths were recorded among them. The disease also pre-vailed among the inhabitants of the town, and a score or soof cases occurred daily for some time. By Jan. 27th 400;,ases and 510 deaths had been registered. It may be notedthat infected caravans continued to arrive from Mecca, bothby the most westerly and the most easterly roads ; and thatamong some 7000 pilgrims arriving in Medina from Yanbo nocase of cholera occurred, showing that in all probability theoutbreak at Yanbo has not been a very severe one. Thelatest returns from Medina show that only 3 or 4 cases areoccurring there daily. :

Cholera on the Hedjaz l2aihvay.The first pilgrim train left Medina for the north on Jan. 5th,

with 429 pilgrims. Groups of from 300 to 500 pilgrims con-tinued steadily to arrive at the Tebuk lazaret once or twiceaday. Among the first groups to reach the lazaret three suspected cholera cases occurred, and these were subsequently lconfirmed bacteriologically. Since then apparently no cases (of the disease have been seen there. It has to be remembered,that the Tebuk lazaret is still an improvised one, though it already possesses most of the essentials of such an institution. 1Some alarm was created recently by the report that cholerabad occurred among pilgrims arriving at Damascus, after ibaving done their quarantine and other measures at Tebuk ;but fortunately this report appears to have been quite unfounded, and so far as is known no case of cholera has

1yet occurred north of the lazaret of Tebuk. Some suspicious 1cases have been more than once reported as occurring in the (trains between Tebuk and Damascus, but none of these have been confirmed ; indeed, they have all been officially declared (not to have been cases of cholera. The pilgrims are sub- jected to a final medical visit on their arrival at the’Kadem (terminus of the railway in Damascus. The movement

(northwards of pilgrims still continues, and so long as it con- tinues there must always be a danger of cholera appearing 1among them at Damascus or elsewhere, in spite of themeasures executed at Tebuk.

Cholera in Persia. Cholera appears to have lingered in many parts of Persia i

throughout the month of December. A telegram from Teheran, dated Jan. 7th, stated that cholera ’’ existed posi- tively" at the end of December in the towns of Hamadan, Kerman, and Mohammera, and that, "according to all

appearances," the provinces of Ghilan, Kaskin (? Kazvin), Khorassan and Kaian (?) were not yet completely free from ithe disease. On Jan. 22nd another telegram stated that no case had occurred in any part of Persia since the 20th. 1

Constantinople, Feb. 17th. _________________.

THE DANGEROUS WATER-SUPPLY OFCHERBOURG.

(FROM A CORRESPONDENT.)

CHERBOURG, the French naval port, lies at the mouth ofthe river Divette, and in the lower part of its basin. It is a town of some 43,000 inhabitants, of whom 16,000 are employed in the arsenal or are in the army or navy. It has ! a sinister reputation as the town in France, Toulon only- excepted, the most seriously and constantly infected with enteric fever. The enteric death-rate of Toulon in the ten 1

years 1897 to 1906 is stated at 0-86 per 1000 living, thatof Cherbourg at 0- 71 per 1000, while Paris only lost 0-15 per 4

1000 of her population by this disease. These figures are 1taken from a detailed account of an epidemic in Cherbourg (in 1909, which appeared in December and January in the Archives de Médecine Navale, written by Dr. L. E. F. Brunet, Médecin de premiere classe. His tables show that enteric :fever is every year present in Cherbourg, but that notable epidemics occurred amongst the Government employees ofall kinds (the people who are treated in the naval hospital)in 1889, 1898 and 1899, and in 1909, and that every single 1

epidemic was ascribed to the bad water-supply, which stillremains ever the same. I think that readers of THE LANCETmay find the story instructive.Cherbourg gets its water-supply, it appears, mainly

from the Divette, but also from brooks, from certain

springs, and from wells. People who live just above thetown use the Divette water exactly as they pump it up ; the navy has a station a mile above the town where theytake water from it-water they pipe to the arsenal forboilers, washing, and the like ; just below this is thetown’s intake-the water is allowed to settle and isfiltered before distribution as drinking water. Owingto the geological conditions of the district the springscannot be secured against pollution, but from them thebarracks are supplied, water intended for drinking being allsterilised before issue. Taps-" washing water only "-arefrequent throughout the barracks and the arsenal, and men willmake mistakes. Only one barrack has a supply in whichbacillus coli has never yet been found, and its men got offvery lightly in the last epidemic. The small houses of thedistrict, café, public-houses, lodgings affected by soldiersand sailors generally get their water from wells which areall suspected ; many have been closed as they contained toomany of the bacillus coli. As to conservancy, there is no

general system of water carriage, but there are a great numberof leaking cesspools and many pail-closets. The nightsoil isspread on the fields in the valley of the Divette above thetown or around the brooks mentioned, and it has been for

long believed that the water becomes charged habituallywith the bacillus coli and from time to time with thebacillus typhosus.

Medical men have for years been preaching about theterrible risk and the constant damage to the health of thegarrison and of the townspeople involved in this lack of pro-tection of the water-supply, but nothing thorough has beendone. In 1889 there were 394 cases of enteric fever in thenaval hospital with 75 deaths ; the director of the naval boardof health pointed out that it was not filters only, but a purewater-supply that was required, adding that it was the dutyof the board of health to emphasise the dangers, but the dutyof the superior authorities to remove them. A militarymedical officer, too, at the same time insisted on the need forpure water, but only Chamberland filters were installed. Asfar back as 1898 and 1899, 665 cases were treated in thenaval hospital with 189 deaths, and Director Rouvier wrotethat the navy must have good water for itself, and to shieldits men from infection must require the town, too, to geta good supply. Yet the source of supply remains as before,only the army and navy sterilise some water for theirmen, and the town seems to purify its water in somedegree by sedimentation and filtration. That is all thathas been done. The dangers are so well known to theinhabitants that they avoid drinking the water as far aspossible; some very scrupulously filter all they use, othersbuy the water of a particular spring, reputed safe, in bottlesfor drinking and personal washing ; others, again, drink

nothing but cider.Cherbourg is always liable to an outburst of enteric

fever, and some 30 deaths due to the disease occur

there every year. The story of the epidemic of 1909 is atypically instructive one. On Jan. 7th a case of illness wasreceived in the Naval Hospital and gave on the llth apositive Widal reaction. Eight cases in all were received

during January ; they were from the arsenal. On Feb. 6ththere came four men all from different parts of the

district, showing that the whole of the water-supplies wereinfected, 65 were received in the first fortnight of February,92 in the next fortnight, 59 and 69 in the successive

fortnights of March, by which time the epidemic was nearlyover, only 16 cases appeared in April, two in May, and six inthe next three months. There were 317 cases altogether, ofwhom 58 died. It appears that the only body of men whoconspicuously suffered little were the two regiments whosebarracks rejoice in the water-supply free from bacillus coli(13 cases and two deaths between the two regiments). Assoon as the existence of the epidemic was recognised all theemergency measures that could be taken to stop it were

suggested by the doctors and at once put in orders. They couldnot be expected to make any difference for a fortnight or threeweeks, and in the meantime everybody came to show sympathywith the sick. The Minister of Marine came, the Under-Secretary for War, many high functionaries, the Committee


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