question whether the ascarides had any direct relation to the disease, and involves the much larger inquiry whether undiscovered other influences, operating on or through the intestinal surface, may perhaps have been associated with the parasites. APPENDIX. No. 9. On certain Epidemics in Northern Europe, by the The very important questions remain, whether the disease is communicable from person to person, and, if so, what are the laws of its communicability. From the large experience which has now been Medical Officer collected on the subject, it may, I think, confidently be inferred that the disease, if directly communicable from person to person, is communicable only in a very low degree. Such communicability as is familiar to us with typhus, smallpox, and other eruptive fevers, cerebrospinal meningitis does most assuredly not possess. To this extent, the tendency of the disease to prevail only in small compact epidemics is in my opinion a conclusive argument. But that the disease is incommunicable cannot, I fear, at present be maintained :-for the French military experience alleges that outbreaks of it in garrisons have sometimes so definitely followed the arrival of infected soldiers from other garrisons that the arrival could not well be acquitted of contagiousness; and unless those observations have been fallacious, it must be deemed a problem of great importance to determine under exactly what conditions and circumstances the sick have thus been enabled to propagate their infection to the healthy. The principles on which such investigations ought to be conducted are now fairly understood by men of science, and it is to be hoped that the problem which I state may soon be solved. Meanwhile, in my opinion the importability of the infection of the disease cannot at the utmost be deemed more than a danger of very subordinate rank. And I think it extremely probable that, if the disease is directly communicable from person to person, or is in any manner diffusable by personal intercourse, its powers of thus spreading itself are only of so low a degree that, with ventilation and cleanliness and good sanitary appliances, they may, for practical purposes, be virtually set at naught. It is fortunate that cerebro-spinal meningitis does not prevail in very large epidemics. For, to the persons whom it attacks, it is one of the most dangerous of diseases. In thirteen epidemics concerning which M. Boudin gives statistics, there were collectively 809 deaths among 1,304 patients; in some of the worst epidemics the mortality seems to have been as high as 80 per 100; and the disease, as now prevailing in Germany, seems to be showing at least its average, very terrible, fatality. Evidently, then, at present it can be no satisfactory task to speak o the treatment of the disease. So far as results have yet been codified, medicine seems universally to have been powerless against the disease, and perhaps in some cases to have lessened the patient's chances of recovery. The officers who have just reported to the Prussian Government on the epidemics prevailing about Dantzig advert (like many preceding writers) to the "sudden collapse which often baffles all remedies." And evidently a disease which tends to that issue will not admit that generally depressing treatment be used against it, except (if at all) with the very utmost circumspection. It is on record that one French practitioner who tried bleeding for the disease, lost 30 of his first 31 cases, while a second, using similar treatment, lost 21 out of 22; and though other practitioners have alleged that in their hands this treatment has been of good effect, certainly it could not be admissible, except under very close and careful qualifications with regard to the circumstances of its employment. Mercury has been freely tried, and seems to have been at least useless. Opium has been strongly recommended by some French practitioners, and perhaps under some circumstances has APPENDIX. No. 9. On certain Epidemics in Northern been of advantage. In various processes of disease which resemble meningitis in their nature, the local application of cold, judiciously and skilfully made, has given to modern medecine some very notable successes; and to it, more than to any known resource of the art, I should myself have been disposed to look hopefully in the present instance. Europe, by the Ten years ago, indeed, it was the report of an eminent German writer* Medical Officer. that, in epidemic meningitis, that most effective of antiphlogistics could not commonly be borne by the patient. But, more recently, improved means have been found for the medical utilization of cold. And Dr. Thudichum (who has seen something of meningitis on the Continent, and has favoured me with a memorandum on the recent epidemics in Bromberg and Ottmachau) tells me that present experience in Germany is in favour of this principle of treatment. Concerning whatever progress is to be made in the treatment of the disease, as well as concerning whatever is to be learnt of its causes, I shall continue to look anxiously to the countries where epidemics are now prevailing. As there is no country in the world where the medical sciences are better cultivated than in Germany, so it may reasonably be hoped that, during the visitation which that country is now suffering, important light may be thrown on the causes, prevention, and treatment of a disease which hitherto is most imperfectly understood. It may also be hoped that the course which the Lords of the Council have taken, in directing observations to be made of the present foreign epidemics, will ensure for this country an immediate participation in whatever useful knowledge our German contemporaries may acquire. April 19, 1865. (Signed) JOHN SIMON. No. 10. On Fevers at St. Petersburg, by Dr. Whitley. No. 10.-REPORT (May 10th 1865) by Dr. GEORGE WHITLEY on the 1864-5. In the early part of the month of April last, I received instructions from the Medical Officer of the Privy Council to proceed forthwith to St. Petersburg, for the purpose of ascertaining for the information of the Lords of the Council the nature of the fever or fevers then epidemically prevailing there. I was especially directed to learn whether any fever then existing in St. Petersburg was of a kind not habitual to the United Kingdom, or (if not different in kind) was modified in any important particular from forms with which English practitioners are familiar. Pursuant to these instructions, I arrived at St. Petersburg on the 15th of last month, when Her Majesty's Ambassador had the goodness to put me into communication with the Ministers for Home and Foreign Affairs, and with the various medical authorities, civil and military, from all of whom I received every facility for the prosecution of my inquiry. With such assistance, I was soon enabled to ascertain that no form of fever, or other disease unfamiliar to English practitioners, had prevailed in St. Petersburg. Continued fever, typhoid or typhus, *Hasse, in Virchow's "Handbuch der Pathologie und Therapie," vol. i, part 1. p. 461. † Professor Esmarch's paper on the Use of Cold in Surgery (translated in 1861 for the New Sydenham Society) marks, in my opinion, an epoch in the matter to which I refer. His method of refrigeration is to use india-rubber bags made of any required shape, and filled with ice, snow, or some freezing mixture. No. 10. commonly prevails somewhat extensively there, but in August last, APPENDIX. cases of a form of fever unknown to the practitioners of that city, began to present themselves, which, however, Dr. F. Hermann, chief physician of the Aboukhow Hospital, soon ascertained and declared St. Petersburg, to be the relapsing or famine fever so well described by Scotch and by Dr. Whitley. Irish authors, and others. The further course of the epidemic, and concurrent testimony of other physicians, having fully confirmed the accuracy of this view, it appears unnecessary to enter into any details here as to the nature of the disease. Before proceeding to give an account of the severity of the epidemic, a few words concerning the sanitary state of St. Petersburg generally, and especially since the autumn of last year, may be of use. This city with its swampy foundation and copious rainfall, surrounded on all sides by water, and exposed to extreme changes of temperature, affords, even in the best years, a very unhealthy sojourn for the poorer inhabitants. The population, which amounts to about half a million, is distributed over a large area; but, notwithstanding this, much overcrowding takes place amongst the poor, and since the autumn of last year an unusual number of labourers have flocked to St. Petersburg without a corresponding increase of house accommodation. when I called the attention of the Minister of the Interior to a statement in English journals that 43,000 more labourers than usual were living in the city this winter, he merely remarked that he believed that the figures were not quite correct. One case was mentioned to me in which 60 men were found lying closely packed on the floor of one room wrapt in their sheepskins, with door and windows closed to keep out the cold. The atmosphere of this room was stated to be so charged with carbonic acid that a candle would scarcely burn in it. Thus, The following official return from the various hospitals of St. Petersburg gives an approximate view of the severity of the present epidemic, though, doubtless, many cases have occurred which are not included in this return, not only at a dispensary which I visited, but amongst the poor at their own homes. NUMBER OF PERSONS admitted into the CIVIL and MILITARY HOSPITALS of ST. PETERSBURG from the Commencement of the present Epidemic to March 1st, 1865. APPENDIX. No. 10. On Fevers at St. Petersburg, by Dr. Whitley. The epidemic reached its height in the months of January and February last, when the admissions into the civil and military hospitals, for all diseases, sometimes amounted to 300 a day, while the mortality in February 1865 was double that of February 1864. In addition to the unhealthy state of the dwellings of the poor mentioned above as constant for St. Petersburg, and the unusual crowding during the present winter, the chief food of the lower classes, bread, cabbage, and fish, were scarce and inferior in quality, and vegetables in general much destroyed by early frost. Further, an almost tropical heat in June and the beginning of July was succeeded by a cold damp autumn and an early, unusually severe winter. If we bear in mind also that the water supply is taken from the river Neva, and often much polluted by surface drainage, and that large quantities of very inferior spirits are consumed by the poorer inhabitants, it will at once be understood that an epidemic of relapsing fever, once introduced amongst such a population, might well assume proportions even more formidable than the present one. One set-off against the unsanitary conditions mentioned above may be of interest, viz., that even the poorest inhabitants of St. Petersburg take a steam bath at least once a week, generally on Saturdays, and I was able personally to convince myself at the dispensary that, although their clothing is often very dirty, their skin is cleaner than is usual amongst a similar class elsewhere. The relapsing fever of the past winter in St. Petersburg offers few features worthy of special mention in reference to its rise and progress, its causes, its extent and fatality, its prevention or its treatment, resembling very nearly in these respects epidemics described as occuring elsewhere. It was impossible at the time of my visit to obtain an exact account of the proportion of cases in which glandular swellings, so-called buboes, occurred; but I ascertained that parotitis was rather common, often double, while any affection of the inguinal glands was much less frequent. Cases with these complications very commonly proved fatal. The treatment was chiefly expectant, and it did not appear that the use of quinine or any other medicine could check the relapses or modify the general course of the disease. The post-mortem appearances, also, with one exception, resemble so closely those described elsewhere as to render any lengthened notice of them unnecessary. The spleen was the organ most constantly affected to any considerable extent, the liver less frequently, while the kidneys were often but slightly congested. The exception alluded to was furnished me by Dr. Kremiansky, of the 1st Military Hospital, who states that of 720 autopsies made by him from the beginning of September 1864 to the middle of March 1865, 49 presented wellmarked hæmorrhagic inflammation of the dura mater. The paper he kindly sent me just as I was leaving St. Petersburg is a preliminary one only, and does not state how many of these persons died from fever, but the general table given above refers to about the same period. A similar post-mortem phenomenon does not appear to have been observed to any great extent at other hospitals; but the observations of Dr. Kremiansky are of interest in connexion with the epidemic cerebro-spinal meningitis prevalent in Prussia. Although the St. Petersburg epidemic of the past winter adds but little to our previous knowledge of relapsing fever, it affords a good illustration of the manner in which the disease is modified by the circumstances under which a population lives. The general table furnished by the various hospitals presents some striking differences in reference to the mortality in them, of which, had time permitted, I should have been anxious to seek for some satisfactory explanation; APPENDIX. but I have reason to hope that a young English physician, resident in St. Petersburg, will, ere long, publish a detailed account of the whole No. 10. On er Fers at epidemic. Most probably, however, the low rates of mortality would St. Petersburg, be found dependant upon a better previous position in life and more by Dr. Whitley. favourable conditions in reference to ventilation, &c., in the respective hospitals. The class of persons amongst whom the epidemic prevailed only a little less extensively than amongst the poor labouring Russian population were the military; but even here the better food and more healthy dwellings were generally accepted as sufficient to explain the comparatively low rate of mortality. Amongst the English and German work people and their families, amounting in number to several thousands, the epidemic has prevailed to a very slight extent only, with a low rate of mortality; while the upper classes have remained almost entirely exempt from that particular form of disease, thus furnishing one more striking instance of the connexion between relapsing fever and destitution, with its concomitant evils. No. 11.-REPORT (May 26th 1865) by Dr. JOHN BURDON SANDERSON on the EPIDEMICS of CEREBRO-SPINAL MENINGITIS prevailing about the LOWER VISTULA in the beginning of 1865. On the 7th of April I was instructed by the medical officer of the Privy Council to proceed without delay to Dantzic for the purpose of obtaining information for the Lords of the Council as to the nature, causes, prevention, and treatment of the disease reported to be prevailing epidemically in that town and in other places in the valley of the Vistula, and to report on the rise, progress, and extent of the epidemic. I accordingly left London on the morning of the 8th, and arrived in Berlin on the 9th. Having on the following day had the honour of an interview with his Excellency Herr von Mühler, Minister of Public Instruction, and having also conferred with Professor Hirsch, who had completed a similar investigation, undertaken by order of the Prussian Government, I proceeded on my journey, and reached Dantzic on the morning of the 11th of April. I at once placed myself in communication with H.B.M. Consul, W. A. White, Esq., with whom I waited upon the Prefect of the Department, and the General in command of the garrison. By the Prefect I was introduced to the Superior Medical Officer of the Department, Medicinal-und Regierungs-Rath, Dr. Keber, who received me with the utmost courtesy, and afforded me every possible facility in the prosecution of my inquiry. By this gentleman I was introduced to Oberstabsarzt Dr. Kuhn, physician in charge of the hospital of the garrison, to Oberstabsarzt Dr. Häser, physician to the town infirmary; to Sanitäts-Rath Dr. Hildebrandt, physician to the Marien Hospital; and to Dr. Abegg, physician to the Protestant Deaconesses Hospital, through whose kindness I had the opportunity of observing such cases of cerebro-spinal meningitis as occurred among the patients under their care during my stay in Dantzic. I subsequently visited those places in the valley of the Vistula, and in the adjoining rural districts, in which cases of meningitis were reported to exist. No. 11. On Cerebro-Spinal Meningitis about the Lower Vistula, by Dr. Sanderson, |