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THE LANCET.

LONDON: SATURDAY, AUGUST 12, 1911.

THE CHOLERA.

The Cholera.IN another column a valued correspondent deals in a

suggestive manner with the present situation of cholera in

Europe, while our correspondent in New York draws attentionto the apprehensions in the United States. The fears, freely.expressed by numerous epidemiologists at the close of last

year, that a recrudescence of cholera would be seen in

Europe during the present summer, and that the diseasewould again become epidemic, have unhappily been realised.Cholera already appears to be extending from two chief

centres-Italy and Turkey-and is now threatening a numberof countries into which the infection has been imported. Ourreaders will remember that the epidemic which prevailed in

Italy last year subsided about January of the present year,the last cases being notified at Taranto in the extreme southof the Italian peninsula. Nothing more was heard of thedisease until early in June, when almost simultaneouslyannouncements appeared that cholera was epidemic in certain

places which had last year suffered severely from its ravages,including Naples and Palermo, with their adjoining districts.

Up to the middle of July upwards of 1400 cases have beenofficially notified in a period of about five weeks. So far as

can be judged by the published figures the virulence of the

existing strain of the cholera organism in Italy is not great,the recorded case mortality rate being a little less than 31

per cent. More recently extensions of the infection have

occurred in Northern Italy, groups of cases having been

reported in the province of Genoa at Spezzia and elsewhere,and at Leghorn on the coast of Tuscany. In some other

districts " cholerine its said to be prevalent, and there issome suggestion that certain outbreaks of so-called typhoidfever" are in reality manifestations of cholera infection.

Naturally some alarm has been created, and one result hasbeen the postponement until next April of the meetingof the International Congress on Tuberculosis, which was,to have been held at Rome in September. Correspondentsin the continental press allege that the true incidence ofcholera in Italy is not recorded in the returns published bythe Italian Government, and that the occurrence of outbreaks’is being concealed by the authorities in order that foreignvisitors may not be frightened away. The statement is also

made in the continental papers that as many as 200 cholera

cases have occurred in quite a short period at Venice, anda number of others at Rome, without either of these towns

appearing in the official list of infected places, and further,that no notification of these cases in Rome and Venice has

been made to the European Powers as required by the termsof the Paris Convention. It is asserted that the policy ofconcealment practised at Naples last year is being repeatedat the present time at other infected towns. How much

truth there is m these allegations we are not in a position at

present to say, but the suggestion is a very serious one anddemands immediate attention.

From Italy cholera has been carried into France, a groupof cases having occurred at Marseilles, and also into certaindistricts in Austria, including Trieste, Gratz, and Cattaro inDalmatia on the eastern shore of the Adriatic, the source ineach instance being traced to some Italian infected district.In some cases we hear that the eating of infected oysters orother shellfish by tourists in certain infected localities in

Italy had resulted in attacks of cholera. On shipboard thedisease has been carried from Naples and Palermo by Italian

emigrants to the United States of America, 25 cases havingalready occurred in connexion with the port of New Yorkand one at Boston. Some of the attacks occurred during the

voyage across the Atlantic, others after arrival at the

quarantine station when the passengers were undergoingfive days’ observation, while yet others occurred after

the termination of the detention period in quarantineand after the passengers had proceeded to their destina-

tions. These occurrences have given serious cause for

alarm to the American port sanitary officers, who saythat while it is comparatively an easy task to preventthe entrance into the States of persons ill with cholera, it isfar more difficult to deal with cholera bacilli carriers who are

themselves on arrival apparently in good health. On the

advice of its medical experts the Government of the UnitedStates has issued a fresh order to the national, State and

local quarantine officers, collectors of customs, shipowners,and agents, and to all others whom it may concern, that,with a view to diminish the danger from bacilli carriers,steerage passengers from ports or places infected by cholerashall be detained for ten days for observation, unless afterfive days (the previous period of detention) they are foundnot to be bacilli carriers. The importation of food by the

arriving Italian emigrants was also forbidden. These new

measures, however, in less than a fortnight were sup-

plemented by another order, dated July 19th, providingthat all steerage passengers arriving at ports in the

United States from infected places shall be subjectedto a bacteriological examination, and shall not be admittedto entry into the States until it has been determined by thisexamination that they are not carriers of the cholera bacillus.It is obvious that these new regulations, necessitating as

they do bacteriological examination of the fasces of largenumbers of persons, will entail a considerable amount of

additional work upon the staff of the State and portauthorities. In our opinion, it would be very difficult to

carry out such systematic examination at English ports. It

is not denied that much more care is necessary in America

than with us in England to prevent danger arising from theintroduction of cholera germs into a country where it is

admitted frankly that sanitary circumstances and adminis-tration generally are not so satisfactory as with us, andwhere in some places particularly the public water-supplieshave not been sufficiently safeguarded or protected from ex-cremental pollution. These extra precautions now enforced inAmerica may be regarded as the penalty paid for postponingnecessary sanitary reforms until danger has actually arisen.

In Turkey, the second centre of diffusion of the cholera

infection, the disease has of late been extremely prevalent in

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parts of Asia Minor, especially in Smyrna and Samsun and inthe districts along the southern shores of the Black Sea. In

Constantinople cases have been occurring, sporadically, it issaid, but here, as elsewhere in Turkey, the authorities fortheir own purposes have minimised the outbreak. There is

evidence that the infection is spreading in the Turkish

provinces ; an outbreak is now reported among the soldierson service in the disturbed districts of Upper Albania. From

Turkey cholera has been conveyed into Greece and Bulgaria,and perhaps also into Roumania, but this as yet lacks con-firmation. It is somewhat strange that so little has beenheard of cholera this year from Russia, where for three years in

succession the malady has been widely epidemic and where in1910 no fewer than 216,000 cases were reported with 101,000deaths. Scattered groups of cases have, however, been

already reported in June or July in the basin of the Volga inthe governments of Kazan, Samara, and Astrachan ; in

Southern Russia at certain Black Sea ports in the govern- Iments of Kherson and Ekaterinoslav, and at Baku on the

Caspian Sea. There is an entire absence of mention of

cholera at St. Petersburg which has usually in past yearssuffered severely ; it is possible that this present immunitymay be due to the measures recently taken to "sterilise" "

the water for the city’s public supply taken from the

polluted River Neva. It is said that now first of all the

water is clarified by the addition of sulphate of aluminium,then sent through rapid filters and afterwards passedto the 11 sterilising " towers, where it is mixed with

ozonised air by means of Otto injectors. In Western Russia

a few cases have been notified in the government of Minsk,which is near the borders of Poland, and at least one fatalcase has occurred in Vitebsk on a raft coming down the riverDwina (or Duaa), which is navigable for upwards of 400miles of its course, and which flows into the Baltic Sea at

Riga. It has generally in former years been the Baltic portswhich were regarded as the greatest source of danger fromcholera to this country. Up to the time of writing there isno indication of any present danger from that quarter.Should cholera invade the Baltic ports in August or

September less danger is to be apprehended than if they hadbecome infected earlier in the year, as there would be less

time for the epidemic to develop before the advent of thecolder weather, when commonly the infection spontaneouslysubsides. But in England we place our reliance mainly inthe excellence of our sanitation and administration to protectus from the dangers which chance importation of cholerainfection might bring to us, as we have pointed out on manyprevious occasions in these columns.

The National Insurance Bill.ON Friday in last week the Chancellor of the Exchequer

briefly reviewed what had been done in Committee of theHouse of Commons in respect of the National Insurance

Bill, and while he drew attention to points of difficultyahead, he congratulated the House upon having made verysubstantial progress. As far as the profession of medicine isconcerned-and on every side of this far-reaching measurewe find medicine directly or indirectly affected-the clausesof the Bill as amended in Committee, though not escaping

criticism, have been received by our readers with satisfaction.Dr. CHRISTOPHER ADDISON’S valuable amendment, by whichthe administration of medical benefits was transferred

to the Local Health Committees, has naturally called forth a

protest from the Friendly Societies. The President of the

National Conference of Friendly Societies, a body which issaid to represent a membership of 6,000,000, with funds of.640,000,000, is quoted in the press as saying that there isconsiderable dissatisfaction throughout the Kingdom in coix-

sequence of the amendment, "whereby a plan which hadresulted in an amicable understanding between FriendlySocieties and their medical men was taken away."The President of the National Conference of FriendlySocieties has been living, it would seem, in a

fools’ paradise if he really believes that the rela-

tions between the medical profession and the FriendlySocieties have hitherto been cordial. While we grant now,as we have done often in our columns, that in some instances

the medical officer to clubs and medical aid associations has

been properly treated, the evidence has always been over-

whelming that such cases were the exception and not the rule.Our columns have over and over again described the distressingcircumstances which marked contract medical work done

under the auspices of medical aid associations, and the wishwas unanimous in the medical profession to be free from thecontrol for the future of the Friendly Societies in the matterof the distribution of medical benefits. We have no doubt

whatever, as the President of the National Conference of

Friendly Societies is reported to have said to a repre-sentative of the Daily Telegraph, that the societies would

have been prepared, if the discretion had been left with

them, to increase the allowances made to their medical

officers; they must have been only too well aware that

no other course was open to them. But the medical

profession has felt all along that in the hands of the

societies their interests were not safe ; in the past the

complaints of the medical officers of the societies were

too often not attended to ; their professional position wasnot recognised ; their efforts to obtain adequate remunera-tion even met with determined resistance. If those favour-

able concessions, which we now learn that the FriendlySocieties would have been willing to make under the Bill,had been spontaneously offered, or had been granted yearsago in response to the numerous protests of their medical

officers, the public would be more ready to see the objectionswhich are seen by the Friendly Societies to Clause 13 as nowamended. But with full experience of what the relations

between Friendly Societies and their medical officers have

been in the past we rejoice at the transfer of the distributionof medical benefits to the Local Health Committees.

Clause 14 as amended may on reflection, we think, be

considered, as we termed it last week, a medical triumph.We admit to the full the simplicity and advantage of a wagelimit, but we have never been able to shut our eyes to thefact that the arguments which would be brought forward

against such a proposal in the House of Commons would

; inevitably prevail. The process of ascertaining whether the! wage limit had or had not in any individual instance

! been exceeded would be difficult and vexatious ; employment,’ though much better than heretofore, and though never so

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precarious in the upper grades of labour as in the lower, isstill an uncertain thing, and many of the insured personswill hardly know exactly what their average incomes are ;lastly, the conditions of employment in different centres,and in town and country, vary so largely that a man

making on an average £75 a year in one place may be

substantially richer than a man making £104 in another.

Of course the agreement of the House of Commons to theclause definitely committed the medical profession to a formof contract practice, but it would seem that a majority ofour readers are reconciled to this principle, so long as safe-

guards can be maintained against any oppressive methods ofits application. The position will now be fair or unfair tothe medical profession according as the Local Health Com-mittees are able to make adequate arrangements with themedical profession, and Dr. ADDISON’s admirable amendmentsecuring local option in respect of contracts ought to fulfilhis expectations as set out in our Parliamentary report. The

Local Health Committees are to be appointed with the

approval or at the instance of the Insurance Commissioners(one of whom is to be a medical practitioner) by the countycouncils, the county borough, and the contributors, and uponthese bodies the local sanitary authorities and the medical

profession will be represented. The county medical officer ofhealth will attend the meetings. In these circumstances it

seems to us that our position should be safe. Resistance to

the legitimate recognition of those upon whom, after all,

depends the whole working activity of the Bill has been suffi-

ciently demonstrated in the House of Commons during therecent discussions in Committee to be small and factious. We

have ourselves always believed that the people of this country,a country which has stood in the van of civilisation by reasonof its splendid charities and its organised sanitary service,probably desired efficient medical service, and therefore wouldbe willing to grant the necessary facilities for obtaining it.

Undoubtedly difficulties may yet arise between the Local

Health Committees and the local medical profession, but inour view the present attitude of the public towards themedical profession is a warrant for the belief that in

questions of dispute we shall get a fair hearing. The desire

of the Local Health Committees will be to ensure the publichealth of the local communities.

There is still considerable anxiety felt with regard to theposition of the voluntary hospitals under the Bill. The

belief is general that the out-patient departments will berelieved, but that any benefit that may accrue to the hos-

pitals in this manner will be lost by an increased pressureupon the in-patient department. Hopeful people see in

the measure a promise of the introduction of order into the

dispensation of medical charity. Less cheerful people fearlest the voluntary subscriptions to hospitals, both of

employer and employed, should fall off when compulsorypayments to invalidity insurance begin. If the hospitalshad been placed in the same position as sanatoriums withregard to sick benefits their pecuniary position would be lessanxious, but the control of the Local Health Committees,which would have followed, might have been very difficultto carry into effect. The obvious method of preventing thewaste of labour that takes place in the out-patientdepartments of voluntary hospitals, and at the same time

of dealing with the curse of hospital abuse, is to bringthe out-patient departments of the hospitals into touch withthe work of the general practitioner, the out-patient depart-ments being used mainly in a consultative capacity. Before

the vast scheme of the National Insurance Bill was outlined

the suggestion made by most who gave heed to a verydifficult situation was the development of provident dis-

pensaries, whereby these institutions would become sorting-houses for the out-patient departments. Under this idea,through the machinery of the dispensaries those patientscould be ascertained who could not pay adequate fees. The

medical officers of the dispensaries would recommend to

the hospitals the suitable cases for treatment, and in

this way the hospitals would be supplied with the properscientific cases without having their charity abused, while

quite poor patients would obtain the advantages of coöpera-tion in medical treatment. If the Local Health Committees

were placed in a position to subsidise the hospitalsthey would form a direct link between private contract

practice and the out-patient departments of the greatcharities ; but we think that in any event the work of thesebodies must have an enormous effect in the near future on

our national health.

Annotations."Ne quid nimis."

THE WEATHER OF JULY.

FOR several years the summers in this country have beenboth too cold and too wet. The farmer has also sometimes

had occasion to deplore the persistent rain and the lack ofseasonable heat. This year it is possible that the mischiefresulting from the lack of rain has been almost, if not quite,equal to that caused by the gloom and wet of the fewsummers preceding. The wind direction on which the tem-

perature at all times of the year so much depends wasgenerally favourable for warmth. As a rule, it came froma southerly point of the compass, often from south-east.

Reaching this country from the heated continent aftersuch a short sea passage as the English Channel the

air was perceptibly warmer than usual on its arrival.If it had come from the westward after a longpassage over the relatively cold waters of the Atlanticthe sunshine in these islands would hardly have raisedits temperature to 90°, except perhaps in East

Anglia. In this country great summer heat which is at

all permanent is dependent on two principal factors. The

barometer must be high, or rather so, and uniform over a

wide area, so that the flow of air from whatever quarter maybe light; and the sky must be sufficiently denuded of cloudto allow much sunshine. However high the temperaturemay be it begins to fall soon after the wind becomes reallystrong-i. e., a steady flow of air at the rate of upwards of 25miles an hour-and great heat is never maintained for morethan a day or so with an overcast sky. The weather of Julywas dry in all parts of the kingdom, but the duration of thedrought was much longer in the south-eastern and southerncounties of England than elsewhere. Over a large area inthose districts the drought, according to Dr. Mill, the well-known rainfall authority, was the most severe, taking theextremely high temperature into consideration, of which

there is any record. Longer droughts have been experi-enced, but in the present case the 25 rainless dayswere nearly all abnormally hot, and the humidity of the