Appletons' Popular Science Monthly, September 1899

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Established by Edward L. Youmans

APPLETONS' POPULAR SCIENCE MONTHLY

EDITED BY WILLIAM JAY YOUMANS

VOL. LV

MAY TO OCTOBER, 1899

NEW YORK D. APPLETON AND COMPANY 1899

COPYRIGHT, 1899, BY D. APPLETON AND COMPANY.

[Illustration: EDUARD OSCAR SCHMIDT.]

APPLETONS' POPULAR SCIENCE MONTHLY.

SEPTEMBER, 1899.

ARE WE IN DANGER FROM THE PLAGUE?

BY VICTOR C. VAUGHAN,

PROFESSOR OF HYGIENE IN THE UNIVERSITY OF MICHIGAN.

In an article on the plague in this journal, in May, 1897, the writer answered this question as follows: "Yes, there is danger; but this, being foreseen, may be easily avoided. Thorough inspection of persons and disinfection of things from infected districts will keep the disease out of Europe and America. Only by the most gross carelessness could the plague be permitted to enter either of these continents."

It will be of interest to take up this subject again, and study it in the light of the history of the plague since the article referred to was written. The plague first appeared in western India, at Bombay, where it still prevails. We are without any exact information concerning its introduction into that city. Before the outbreak of the disease at Bombay the mortality had increased so markedly that it was a subject of discussion for three meetings of the Grant Medical Society. The increase was attributed to the filthy condition of the streets. This society made an investigation of the increased mortality, and presented a report on the same to the municipal authorities. Instead of heeding the warning, the authorities jeered at the society, and refused to allow the report to be read.

Dr. Viegas appears to have been the first physician to recognize the existence of the plague in the city. In a paper read before the Grant Medical Society on November 24, 1896, he discussed the possible and probable avenues by which the disease had found its way into the town. He stated that sugar and dates had been mentioned as means by which the plague was imported, but, if this had been the case, he thought it strange that the infection had not been conveyed from Bagdad and Bassorah, inasmuch as these articles come almost exclusively from those places. Again, it was thought possible that the clothes of the sick or of the dead from the plague in China might have been brought over to Bombay, but Dr. Viegas was unable to find any evidence in support of this theory. It had also been claimed that rats sick with the plague had come by ship from Hong Kong, and had infected the rats about the docks in Bombay. This theory, Dr. Viegas held, was not supported by any facts. In short, Dr. Viegas found some objection to every theory that had been proposed, and leaves us in doubt as to his own views concerning the avenue by which the plague reached Bombay. He is quite confident, however, that the filthiness of the city is to blame for the rapidity with which the disease spread.

In a report by Lieutenant-Colonel Weir on the plague in Bombay a statement is made that the disease was imported from Suez. Early in September, 1896, four very suspicious deaths were reported, but, as none of these had been attended by medical men, no definite conclusion could be reached concerning them. The first case was reported by Dr. Viegas late in September, 1896. The patient was a native who had not been out of the city for months. The first case reported among Europeans occurred on November 12, 1896. During the winter of 1896 and 1897 the disease prevailed most alarmingly, and reached its highest mortality during the week ending February 9, 1897, when the deaths from all causes in Bombay numbered 1,891. During the summer of 1897 the disease declined, and led to the belief that the measures that had been put in operation would prove successful. This hope, however, was not realized, and during the winter of 1897 and 1898 there was a recrudescence of the disease. During the summer of 1898 the disease again abated, to appear with renewed strength during the winter of 1898 and 1899. During the last week in March, 1899, the total number of deaths from all causes in Bombay reached 2,408, and the deaths from plague alone numbered more than 250 a day. It will be seen from these figures that the plague still rages with undiminished virulence in the capital of western British India. The abatement of the disease during the summer months and its increased severity during the colder season are not directly due to the effects of temperature. In the warm season many of the natives sleep out of doors, while during the colder weather they crowd into small, unventilated, filthy rooms. It is the opinion of practically all observers at Bombay that the recrudescence of the disease during the winter is due to this overcrowding.

Since the plague has prevailed at Bombay for nearly three years, it may be well to inquire concerning its probable continuance at that place. In making this inquiry we may learn something of the sanitary condition of the city and the habits of its inhabitants. Bombay is the metropolis of western India, and is situated on a long, narrow island running almost north and south. The city is located near the southern end of this island, with its harbor to the east and its sewage outfall to the west. Its population of about nine hundred thousand is a very mixed one, consisting of Hindoos of different castes, of Mohammedans, of Eurasians, and of Europeans. Differences in race, in religion, and in caste make it exceedingly difficult to carry out sanitary measures and to look after the sick. The mean temperature is about 79° F., and the relative humidity seventy-seven per cent. A considerable portion of the island is below high-water level, and consequently the sewage must be removed by means of pumps. The mean maximum temperature of the ground eleven feet below the surface is 84.9° F., and the mean minimum temperature is 80.9° F. It will be seen from these figures that organic matter must undergo rapid decomposition both on the surface and in the sewers. The water supply, which is said to be excellent, is so carelessly drawn upon by the natives that, although sufficiently abundant if used properly, it sometimes becomes scant. It not infrequently happens that the sewers will not carry the volume of water turned into them. For this reason, together with the tropical rains, the soil often becomes water-logged. Indeed, the surface in some sections of the city may be, not inappropriately, compared with a fermenting muck-heap. Besides the fixed population, there is a constant current of people flowing to and fro between the island and the mainland. When there is any opportunity for the employment of a large number of unskilled laborers, hundreds and thousands from the surrounding country pour into the city. These people know nothing of sanitary appliances, they lodge in the most densely crowded parts of the city, and often a dozen of them will hire a single room, not more than ten feet square, in which they eat and sleep. It is said that seventy per cent of the inhabitants of Bombay live in "chawls." These are tenement buildings of from five to seven stories high, built on the "flat" system. A narrow hall, at the end of which is a latrine, runs through each story, and from this doors open into rooms eight by twelve feet in area. In one of these houses from five hundred to eight hundred people live. These buildings are crowded together, with only narrow, dark alleys between. Into these alleys the inhabitants of the houses on both sides throw all kinds of refuse. In many parts of the city fecal matter is deposited in boxes or baskets, and these, when filled, are carried on the heads of scavengers to certain designated places and the contents dumped into the sewers. It may be of interest to note, in passing, that these scavengers seem to be largely immune to the plague and all other infectious diseases.

This is a brief description of the sanitary condition of the city into which the bubonic plague found its way nearly three years ago. How long is it likely to remain? Before attempting to answer this question we might ask what means have been employed to eradicate the disease. On October 6, 1896, the municipal health commissioner issued an order to the effect that all cases of the plague were to be segregated, their houses disinfected, by force if necessary, and their sick to be taken to the hospital. Health inspectors visited all parts of the city, and carefully went through the great tenement houses looking for those sick with the plague. When such were found they were immediately sent to a hospital. Later, four camps were prepared, with facilities for accommodating about twenty thousand people. An attempt was made to transfer all the residents from a certain section of the city to these camps, and detain them there while their residences were being disinfected. After this had been done these people were allowed to return to their homes, and another twenty thousand were taken to the camps. This attempt, however, was never fully carried out. A high-caste Hindoo prefers death at any time to association with one of inferior caste. Every attempt at segregation of the sick led to more or less disturbance; and finally, in March, 1898, serious riots resulted. These were begun by Mohammedans, who followed a medical officer to the hospital and burned the building and hospital supplies. A plague inspector and three English soldiers were stoned to death. Since the riots attempts at segregation of the sick have been practically abandoned. Numerous hospitals have been provided, in order that those differing in religion or in caste might be cared for at different places. Under certain restrictions those sick with the plague are allowed to remain in their homes. It will be seen from these statements that it is not probable that the plague will be driven by human agency out of Bombay. The Hindoos believe that when the plague finds its way into a city it will remain for six years. The probabilities are that this belief will be strengthened by the history of the present epidemic in Bombay. Nothing short of an extensive conflagration, destroying a large part of the city, can thoroughly disinfect this place, in which the plague has already dwelt for nearly three years. I think, therefore, that we must conclude that it is quite certain that for several years yet Bombay will remain an infected city.

When the plague was first announced at Bombay a large number of its inhabitants, estimated at about three hundred thousand, left the city. There can be but little doubt that with these the germs of the plague were carried into the surrounding country. From Bombay the disease has spread out in every direction, until it has found its way into nearly every part of India. To-day the three large commercial cities of British India--Bombay, Calcutta, and Madras--are all infected. The manner of the introduction of the disease into Calcutta is somewhat uncertain, several different accounts being given as authentic. Dr. Cantlie says on this point: "The first case dealt with and reported upon in Calcutta gives an interesting history. The patient, a lad seventeen years old, came from Bombay, where evidently he had been exposed to infection, as his sister, who accompanied him, had seen several cases of plague in Bombay. Fifteen days before leaving Bombay he had noticed swelling first in one groin and then in the other, but never felt ill until his arrival in Calcutta, on September 24th. He was seen and carefully examined in Calcutta by honest observers, and a diplobacterium identical with the Kitasato bacillus was found in his blood. Not only so, but the clinical symptoms of plague were most manifest."

Another authority would have it that the plague was brought to Calcutta from Hong Kong by a British regiment which had been engaged in cleansing infected houses at Hong Kong. On this point Dr. Simpson makes the following statement: "In January, 1895, the regiment went to Calcutta, and this disease was first diagnosed as syphilis, then as malarial fever with bubo, and finally the cause was declared to be unknown. In June, 1896, one of the medical officers of the regiment was attacked with fever, and the glands of the neck, axilla, and groin were all enlarged. A goodly number of similar cases were met with in the town; moreover, the rats became sick, and the grain stores swarmed with diseased and dead rats. In spite of opposite evidence, it was well-nigh certain that plague in a sporadic form had been in Calcutta since 1895 or 1896."

The bacillus of the plague has undoubtedly found Calcutta quite as well prepared for its reception as Bombay. In discussing a medical report on the sanitary condition of Calcutta, the Pioneer Mail makes the following statement: "London, with its population of over 4,000,000, has about 36,000 people to the square mile. In the thirteen wards of Calcutta there are only four below this figure; the remainder have from 46,000 to 144,000 per square mile, three wards containing actually over 100,000. Colootolah is most densely populated; the houses are literally crammed with people. One case is quoted where 250 persons were living in a space that should accommodate only 50. In a hut seven feet in length, breadth, and height five men were found, and several instances are given where similar conditions obtained. In our barracks 600 cubic feet per man is the minimum space allowed. In these _bastis_ the space runs from 157 to 49 cubic feet. This would be bad enough if everything were clean and sweet in and about the huts, but, as the medical board puts the case, 'here we find an allowance per head going as low as practically one thirtieth of that given in barracks, and no ventilation, with filth _ad libitum_ both in the room and in its surroundings, to say nothing of the filthy persons of its occupants, the sewage in the adjacent drains, and the accumulated filth in the neighboring latrines; and to this may be added the fact that the subsoil on which the huts are built is soaked through and through with sewage matters and littered with garbage and filth of all kinds.' The narrow gullies which give access to these huts are in keeping with the general character of the _bastis_, and we may well wonder that epidemic disease is not always present."

The probabilities are that the plague will continue in Bombay, Calcutta, and Madras until it dies out from want of susceptible material. It is not at all likely, with the conditions in these cities, such as have already been described, that sanitary measures sufficiently energetic to destroy the bacillus will be resorted to. For some years to come these cities are likely to harbor the infection, and will remain, as they are now, nurseries for the disease.

The plague has not confined itself to the large cities of India, but has spread all over that country. It has extended into the northwestern provinces, has crossed the frontier, and passed into Baluchistan and Afghanistan. In many of the interior cities it has proved quite as fatal, in proportion to the population, as at Bombay and Calcutta. At Poonah the mortality has during some weeks been as high as eighty per cent of the cases, and four hundred deaths a week have been reported. At Sholapore, in the Punjab, far to the northwest of Bombay, the disease has prevailed in epidemic form.

With the plague widely diffused over the Indian empire, what measures have been taken to prevent its spread to other parts of the world? There are two routes by means of which the disease may pass from India to Europe. One of these is by ship through the Red Sea, the Suez Canal, and the Mediterranean; the other is overland from the northwestern provinces of India through Afghanistan into southeastern Europe. In fact, there are three overland routes from northwestern India into Europe. One of these leads from Lahore, the capital of the Punjab, through Afghanistan into the Transcaspian Province of Russia. The Transcaspian Railway extends from Samarkand, a place of about thirty-five thousand inhabitants, through the desert to the Caspian Sea at Ouzoun Ada. The latter place is connected by steamer with Baku and the Russian railroad system. The second overland route starts from the northwestern provinces, or Afghanistan, or Baluchistan, passes through Persia, extending on up between the Caspian and Black Seas, and crosses the Caucasus Mountains in the neighborhood of Tiflis. Both of these routes are quite extensively traveled and pass through cities of considerable commercial importance. Samarkand has extensive manufactures of cotton and silk, and carries on considerable trade by means of the Transcaspian Railway with European Russia. The second route passes through Teheran, the capital of Persia, with a population of about two hundred and twenty-five thousand. This route is also largely employed by commercial travelers, especially from Russia. The third overland route passes through Persia and Turkey in Asia up to Constantinople. This route can not be called a commercial highway, but it is used to a considerable extent, especially by pilgrims, and since at no point do travelers along this route come in contact with European guards against the plague, it is most likely that the pest will find its way into Constantinople by this avenue, if at all. The first two overland routes are guarded by Russian medical inspectors. Russia has not been slow to protect itself against the introduction of this epidemic. In December, 1896, the following lines of action were determined upon, and have apparently since that time been carried out quite thoroughly: First, Russian medical men were sent to the larger cities of Persia, such as Teheran and Meshed, for the purpose of watching the approach of the plague. All Russian consular officers in Persia were requested to inform these medical men of every rumor of the epidemic. Second, points of embarkation on the Persian shore of the Caspian Sea have been watched, in order to detect suspicious cases that might pass to Russia along this route. Third, observation stations have been established along the frontiers of the Transcaspian Province. Inspection officers stationed at these places have been notified to close the frontier, with the exception of certain points where inspection stations have been established. Fourth, inspectors have also been placed to guard the region of Tiflis against the introduction of the plague from both Persia and Turkey. For the reasons above mentioned, it seems to me probable that if the plague reaches Europe, it will likely do so by way of Turkey in Asia, across the Bosporus into Constantinople. The large number of pilgrims passing along this route, with the Turk's well-known fatalistic belief, render it quite probable that infection gathered anywhere along the route may be carried into Europe. Since several places in Hedjaz, along the eastern shore of the Red Sea, have already become infected with the plague, it is by no means improbable that the disease may find its way into the Balkan Peninsula. There are also several centers of infection along the shores of the Persian Gulf. It will be seen from these statements that Mohammedan pilgrims are exposed to the infection. Indeed, already the disease has been detected among these pilgrims on steamships in the Red Sea.

Certain international measures for the restriction of the plague were formulated at the Sanitary Convention of Venice in 1897. Nearly all civilized nations sent representatives to this conference, and certain general rules were adopted. Recognizing the fact that Mohammedan pilgrims from infected districts in India, coming to Mecca and other places along the eastern shore of the Red Sea, would mingle with those of like faith from Turkey and northern Africa, special rules concerning pilgrims were adopted at this conference. It should be understood, however, that these rules are likely to prove efficient safeguards only among those pilgrims who travel by sea. In the first place, the conference made certain regulations concerning the construction and sanitary arrangements of pilgrim ships. The upper deck must be kept clear for these people, and on the main covered deck every pilgrim has to have at least sixteen square feet of surface. Every one embarking on a pilgrim vessel must pass a medical inspection. No sick person or one suspected of having an infectious disease is allowed to go on board. The number which the vessel is allowed to carry is determined beforehand, and the names of all passengers and their home residences are recorded. The ship must supply wholesome water and make provision for food, proper in quality and sufficient in quantity. Every vessel carrying pilgrims must have on board a medical officer and a disinfecting stove. Details are given concerning the sanitary regulations during the voyage. All pilgrims are landed on the island of Camaran, in the Red Sea, before being allowed to disembark on the last stage of their journey. The period of detention from healthy ships at this place extends through only three days. If no disease appears during this time, the pilgrims are allowed to embark again, and go directly to Jeddah. If disease appears either before or after landing at Camaran, the pilgrims are detained at least ten days from the date of the last case. Arriving at Jeddah, they are no longer under international sanitary regulations, and any control exercised over them at that time must be administered by Turkish authorities. Just here, in my opinion, lies the greatest danger so far as pilgrims are concerned. It is true that the conference made certain recommendations and formulated certain rules concerning the return of those pilgrims going to the north or into Egypt, but the fact must not be overlooked that these restrictions are applicable only to those who go by sea. No restrictions are placed upon Mohammedan pilgrims returning from Mecca to India. India is already so generally infected that such restrictions have been deemed unnecessary.