106 THE CONFERENCE ON CHOLERA IN ST. PETERSBURG.

much schooling as ordinary children, and in organising any- scheme of tuition that fact should be kept in view.

The question remains as to what body is to assume thereins of government. It is to be hoped that the MetropolitanAsylums Board, which already controls numerous medicalinstitutions, will see its way to take this added responsibility,- otherwise it would be feasible to create an entirely newauthority consisting of representatives from all the unionsinterested. In whatever hands the management may ulti-mately be vested, it is, I think, of great importance that thewhole of the metropolitan schools should be in touch with the proposed institution. To secure that end it would be well- two maintain the school, not by contributions from individualunions, but directly from the Metropolitan Common PoorFund, thereby spreading the charge over the whole Londondistrict.

The adoption of a scheme for the collective treatment ofophthalmia, such as I have outlined in the above remarks, is, Iwould submit, a matter of pressing importance. Such a scheme,placed on a sufficiently broad basis, appears to offer the onlysatisfactory plan of coping with a disease that has been a’scourge in the pauper schools of London from time im-memorial. A suitable building is ready and waiting at Han-well. Should not advantage be taken of so hopeful an oppor-tunity ? It would be the conversion of a scientist’s visionunto a substantial, a praiseworthy and a salutary reality.

Welbeck-street, W.

THE CONFERENCE ON CHOLERA INST. PETERSBURG.

(FROM OUR SPECIAL CORRESPONDENT.)(Continued from p. 52.)

DR. GREBENTSCHIKOFF, continuing his statistical accountof the epidemic and of the mode of its dissemination, statedthat the first case of cholera in Russia occurred in Kaachka, a station on the Transcaspian Railway, on May 19th (31st).The channel by which the infection crossed the frontier isr--Lnknown. Many other parts of the Transcaspian and Samar- cand provinces were affected in May and June, and fromJune 6th (18th) suspicious cases began to be admitted intothe Baku hospitals. How the disease reached Baku is un-known, but there is evidence that the first patient there was.a foreign labourer, who had come from Persia through the’Transcaspian province and who stayed at a certain house inBaku which became one of the chief centres of infection in’that town, furnishing no less than forty patients in the firstweek of the epidemic. The disease raged violently in Baku,.and the panic-stricken inhabitants Red in all directions,carrying the infection with them. In the first half of June’cholera had affected most of the towns lying on the CaspianSea and had penetrated into the Caucasus. Thence ittravelled to Europe by two great routes-on the one handby the Volga and on the other by railway to the basinof the Don, the first of these being by far the quickest.’The speaker proceeded to trace the course of the epidemicby each of these routes, enumerating the "governments" orprovinces affected during each succeeding month. He"exhibited the following table, showing the area and popula-tion of the districts in which the disease was present during- each of the months from May to November. The whole ofthese immense areas was of course not actually affected bycholera. Many large districts remained free from the disease,but every "government" has been included from which areturn has been received, although only one "uyezd"(district) or even only one village in the "government " mayhave suffered from the disease. With this limitation thedisease was present:

In May over 484,000 square versts with 700,000 inhabitants.In June ,, 2,753,000 " 15,286.000 "

In July 7,271,000 " 63,466,000 "

In Augtxst 7,645,000 " " 77,895,000 "

In September 7,868,000 " ,, 87,346,000 "

In October 6,965,000 " 87,725,000 "

In November 1,662,000 " 69,787,000 "

The disease has spread mainly along the course of the rivers ;it affected the whole systems of the Volga, the Don, theDnieper, the Ural and the Obi, every part of the CentralAsiatic provinces, the systems of the Vistula and WesternDwina and finally the whole of the St. Petersburg districtand two ’’uyezds

’’ of the Olonetz governments.

From a table of the numbers of cases and deaths reportedfrom every government throughout the Empire to the

beginning of December it appeared that the Caucasus sufferedmost severely from the epidemic, the second in order of

severity being the Central Asiatic provinces, the thirdSiberia, particularly the government of Tobolsk, and finallythe country of the Don Cossacks and the following Europeangovernments : Astrakhan, Saratof, Samara, Simbirsk, Voronej,Orenburg and Tambof. Charts were shown indicating by curvesthe course of the epidemic week by week in every government,and from these it appeared that the cholera rapidly (in thecourse of two or three weeks) attained its greatest intensity,that it remained at this height for one or two weeks, and thenin a few districts gradually subsided; but more often therewas a remission lasting one or two weeks, then the curve againrose. the second rise being followed by a gradual fall. In cer-tain towns even a daily chart showed a similar double rise andremission. The means by which cholera was introduced intoa given locality have remained in the immense majority of casesunknown. In twenty-eight governments, however, infor-mation had been furnished to the Medical Department on thispoint, and the speaker proceeded to repeat in detail each ofthese cases. The general conclusion to be drawn was thatpollution of the drinking-water was in almost every case thechannel by which the disease was spread.

Professor Janson, the Professor of Statistics in the St.Petersburg Academy and author of several importantworks on economical questions, read a short but interestingpaper on the Value of Statistics. He pointed out the import-ance of recognising the first case of cholera or any otherepidemic disease. The only certain means of doing this wasby a thorough and constant system of notification and registra-tion of all diseases, more particularly of infectious diseases.He recommended the adoption of registration of deaths suchas is in use in all Western European countries. He alsodwelt on the necessity of recording all the circumstancessurrounding every case of an epidemic illness, as only in thisway can general conclusions on any particular point bearrived at.A paper was read by Dr. Tolstoi on Precautionary Measures

directed against the Dissemination of Cholera. In discussingthe question of quarantine he pointed out certain anomaliesin the quarantine laws existing in ports on the Black Sea.

The efficiency of cordons, the medical inspection of pas-sengers, the disinfection of luggage, the measures taken alongthe rivers, particularly the Volga, were all briefly reviewed.The following questions were submitted to the conference fordiscussion in committee :-(1) Quarantine regulations, cordonsand military isolation of places ; (2) "observation points ;"(3) general inspection of passengers ; and the followingadditional points-(a) the means of determining the first caseof cholera ; (b) the means of localising the infection.An important communication was read by Dr. Rozanof on

General Precautionary Measures before the appearance ofCholera. He discussed the efficieneyof the special Sanitary Com-missions and their relation to the sanitary authorities alreadyin existence. These commissions, it should be explained,were formed early in June, in accordance with a Governmentorder, in every town forming the centre of a "govern-ment" or uyezd throughout the country, with the object ofimproving the sanitary condition of the town and districtbefore the approach of the epidemic. On this subjectDr. Rozanof put the following questions to the conference :1. To what extent are special sanitary commissions necessaryin the struggle with the epidemic in view of the other

sanitary authorities already existing ? ? 2. How should suchcommissions be constituted ? ? 3. What should be their rela-tion to the Government and local authorities ? ? 4. Whatshould be the limit of their powers and what is to be thesource of their revenue ? ? 5. What should be the relationbetween the Sanitary Commissions and the Medico-StatisticalBureaux 6. What should be the organisation and the dutiesof subcommissions ? (Last summer subcommissions, con-

sisting of sanitary and police inspectors, were formed in eachquarter of the larger Russian towns to inspect and improvethe sanitary condition of every building in that particularpart of the town.) 7. What should be the number and con-stitution of the bodies of sanitary overseers, inspectors &c.,and their relation to the police’! ‘? Passing on to discussthe many questions relating to the sanitation of in-habited localities Dr. Rozanof pointed out that whereverthe sanitary condition of a town or district had been

satisfactory the cholera epidemic had either passedit by altogether or claimed but few victims. He deplored the

107REPORTS OF MEDICAL OFFICERS OF HEALTH.

fact that such localities were but few in number and gaveseveral instances of towns in an extremely insanitary con- dition and quite unprepared to meet an epidemic of cholera.As in the other papers the points discussed were put in theform of questions and submitted to the committees as

follows: 1. Measures of sanitation in inhabited localities.:2. The results of sanitary inspections carried out last summer.3. Data for judging of the possibility of cleansing the soiland removing of refuse in towns and villages. 4. The means of providing a pure water-supply. 5. The means of inspect-ing crowded institutions, such as night refuges, lodging-houses, factories &c. These questions have been discussed in committee under the presidency of Professor Kapustin and certain conclusions have been arrived at. The committeedeclare that special sanitary commissions are necessary and’very useful institutions, especially in places where there is no’medico-sanitary organisation under the zemstvo. Wherethere is such an organisation they are most useful if they act in conjunction with the authorities already exisitng.’Their success has been so great that they will probablyremain in constant existence, though only formed to meeta special danger. The sanitary councils or commissions

’existing in the Moscow, Saratof and some other govern- ments might be taken as types of institutions which, with certain alterations, could be converted into special sanitary commissions. With regard to their relation to Government and other local authorities, it has been decided that in most cases this should be determined in the constitution of the commission. In order to ensure united action the com-missions should have the rights of committees of publichealth. Finally, as to the limits of their powers the com-mittee consider that this is already provided for in certain.articles in the orders of the Medical Council. The ques- tion as to the necessity for Government commissions calledforth a lively discussion and was ultimately decided in the;affirmative.

Demonstrations have been given daily in bacterioscopy in’the laboratories of the Imperial Academy of Medicine, in the’clinical institute named after the Grand Duchess HelenaPavlovna and in the Alexander Hospital in Memory of the’Emancipation of the Serfs. Demonstrations in disinfectionbave also been given to members of the Conference in the Oldenberg Institute of Experimental Medicine and in the.Alexander Hospital in Memory of Botkin.A report of the proceedings of the Conference will, it is

hoped, be published shortly.

THE LONDON POST-GRADUATE COURSE.

THE spring- term, 1893, will commence on Monday, Jan.16th, and will consist of twelve courses of lectures and demon- strations at the following hospitals and institutions, viz. theHospital for Consumption and Diseases of the Chest,Brompton, the National Hospital for the Paralysed and theEpileptic, Queen-square, the Hospital for Sick Children,,-Great Ormond-street, the Royal London Ophthalmic Hospital,Hoorfields, the Hospital for Diseases of the Skin, Blackfriars,Bethlem Royal Hospital for Lunatics, the London ThroatHospital, the Bacteriological Department, King’s College, the Parkes Museum Courses of Lectures and Demonstrations onMorbid Anatomy and G-ynsecology and a course of Clinical’,Lectures on Medicine and Surgery at the Central London SickAsylum, Cleveland-street, W. The steady growth of the

undertaking is well shown by comparing the five coursesof the first term with the .twelve courses of the tenth,giving 121 entries in 1890, 172 in 1891 and 223 in 1892.The men who enter continue to come chiefly from the British Isles and our own foreign possessions, whilsta considerable sprinkling is drawn from the United States- of America. Most of the men possess good degrees and high qualifications, and several lecturers from our Colonies have come to study the methods of teaching employed in themetropolis. The opening of the Poor Law Infirmaries has enabled the committee to invite the cooperation of several distinguished emeritus professors, and their vast experiencehas thus been made available for clinical teaching, whilst allass of material hitherto unused has been placed at their disposal. The medical schools have found that this under-’:aking in no way clashes with their work, and, in fact, serves’;o supplement it. All the varied wants of practitioners, whether they have come from distant parts of the world or

are living in our midst, have as far as possible been met.They have entered for a whole term, half a term (one month)or for one week, at proportionate fees, or they have attendedall the lectures at one hospital for a term or for half a term,as best suited their wants and wishes. A full prospectus canbe obtained from Dr. Fletcher Little, 60, Welbeck-street, W.

Public Health and Poor Law.LOCAL GOVERNMENT DEPARTMENT.

REPORTS OF MEDICAL OFFICERS OF HEALTH.

Kensington Parish.-The death-rate for this parish during1891 was 18 4 per 1000, or 1’8 above the decennial average and3’0 below that for the metropolis as a whole. The zymoticrate was 1’6 per 1000. Dealing with this latter group,Dr. Dudfield refers to measles and points out that it yetremains to be proved whether great advantage would accruefrom its inclusion amongst the notifiable diseases. This is a

point as to which opinion varies a good deal, but as to whichit is to be hoped we may soon have such information as hasaccumulated in different parts of the country. Of 323 casesof scarlet fever that were recorded 206 were removed tohospital. The work of the sanitary inspectors is recorded, asis also the action taken under a number of different headings,such as offensive trades, refuse removal, slaughter-houses,dairies &c. ; but a large part of the volume is taken up withgeneral questions of legislation, the work of the MetropolitanAsylums Board, metropolitan sewage purification &c. In fact,the volume might not only properly bear, but well merit,a title indicating a work of much wider scope.Birkenhead Urban District.-This report constitutes the

last of an excellent series of annual reports by Mr. Francis ’Vacher, who has since resigned his post as medical officer ofhealth. The death-rate for 1891 was 20-9 per 1000, thezymotic rate being 2’63, and amongst the latter group ofdiseases there figured 38 cases of typhus fever, a disease theprevalence of which should make Birkenhead determine thatit will not rest until it has abolished it. Notification revealed1007 cases of infectious disease, but some cases, includingmild cases of typhus fever, must have remained unnotified. Inanother respect the borough needs to mend its ways, for itstill retains old-fashioned midden privies, and refusenuisances are by no means exceptional. Only 47 casesof infectious disease were removed to the isolation hospital ;but it is to be hoped that when Birkenhead possesses ahospital which has some pretence of meeting its needs theauthority will do something more than merely touch thefringe of this subject, and that they will no longer finepeople even 2s. a day for going into the hospital for the pro-tection of the public health. According to Mr. Vacher,however, matters move very slowly as to this in the borough.Birkenhead is certainly not one of the progressive boroughsin this and other respects ; but it is not for the want ofexcellent skilled advice.

Cardiff Urbart -District.-The death-rate in Cardiff during1891 was 22 -0 per 1000, the zymotic rate being 2 -1. Dr.

Walford enters in much detail into the question of vitalstatistics and of the distribution, seasonally and otherwise, ofdiseases belonging to the zymotic group, and he illustrates thevarious points by means of some excellent tables and

diagrams. He also reports that systematic inspection of thedistrict is maintained, and he points out that new by-lawshave been obtained as to a number of matters bearing uponpublic health. Analysis of foods was made in 154 cases andin 13 cases they were found to be adulterated. In each casea fine varying from 10s. to ;E5 was imposed, the smaller finesbeing in the main imposed in the case of milk-supplies, thepurity of which is so important to healthy infant life, whilstthe larger one was reserved for a margarine case.

County of Essex.-Dr. Thresh has again reviewed andsummarised the annual reports of medical officers of healthwithin the administrative county of Essex. The report dealsseparately with subjects such as death-rates, sanitary progress,prevalence of certain diseases &c., and then it gives a sum-mary of each of the reports on the several component sanitarydistricts. A report of this class must have very considerablelocal value ; above all, it affords to the different sanitaryauthorities concerned a means of comparing the several phases