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.
The following is a general statement of the rules applicable to
vessels coming to European ports from India through the Suez
Canal: All vessels that have been ten days or longer at sea after
departure from an infected port are allowed to pass through the
canal without question and without precaution. Suspected vessels
or those which have been at sea less than ten days since departure
from an infected port, and which are provided with a medical officer
and a properly equipped disinfecting plant, are allowed to pass
through the canal in quarantine. This means that while passing
through the canal there shall be no communication between those
on board the vessel and those on the land. Other suspected vessels
are compelled to proceed to the Wells of Moses for disinfection.
Here the passengers and crew are disembarked, isolated for twenty-four
hours, and their effects disinfected. At the same time the
contents of the ship undergo disinfection. If the plague be found
on board, all passengers, as well as the crew, are detained for a period
not exceeding ten days. All clothing, the cargo, and the ship
itself are disinfected. When a vessel passes through the Suez
Canal in quarantine, notice of that fact is telegraphed to the country
to which the vessel is going, and it is not allowed to land elsewhere.
Should the plague appear in any European country, the following
rules were formulated to prevent its spread: (1) Whenever a
case of the plague appears in any country the sanitary authorities of
that country must give immediate notice to all other countries represented
in the conference. This notice may pass through diplomatic
or consular agencies, or it may be sent directly by telegraph.
After this the sanitary authorities of the country in which the
plague has appeared shall inform other countries at least once a
week concerning the progress of the disease and the measures resorted
to to prevent its spread.
(2) When an infected person enters a country by rail or other
conveyance overland, disinfection of his person and personal effects
is made obligatory. Land quarantine is condemned, and it is recommended
that modern disinfection be practiced in its stead. Each
country, however, may reserve the right to close its frontier against
any other country in which the disease exists. It is recommended
that medical inspection along the frontier be established in
connection with custom-house examinations, in order to prevent unnecessary
delay in travel. Passenger trains and postal cars are
not to be detained at any frontier, but if a car be found to contain
a real or a suspected case of the plague, this car shall be detached
from the train at the frontier or at the nearest station thereto and
its contents disinfected.
(3) Travelers coming from infected countries may be, at the
discretion of the sanitary authorities, detained under observation
for a period not exceeding eight days. Individual governments
are allowed to take any special measures that may be deemed wise
against the importation of the disease by means of gypsies, vagrants,
and immigrants.
In formulating the above-mentioned rules to prevent the importation
of the plague into Europe the members of the Venice
Congress seem to have been thoroughly convinced that the longest
period of incubation possible in this disease is ten days. It seems
to have been assumed that if a vessel had been for ten days or
longer at sea after departure from an infected port, and no cases of
the plague had developed up to that time, there could be no danger
of this vessel carrying the infection. It appears to me that a safer
course would have been to require inspection of all persons and
things going on board a vessel leaving an infected port, and the
thorough disinfection of certain things, at least, on such vessels arriving
at uninfected ports. The disinfection of a ship and its cargo
by means of steam is not at present a very costly procedure.
Since the plague, if it reaches America at all, must come to us
by sea, it may be of special interest to inquire concerning outbreaks
of this disease on board ship. In making this inquiry we
will confine ourselves to such cases as have occurred within the past
two years. In March, 1897 (I have been unable to ascertain the
exact date), the transport Dilwara left Bombay, bound for Southampton,
with a regiment of English soldiers, together with their
wives and children. On March 18th, while the vessel was in the
Red Sea, a child died of the plague and was buried at sea. On arriving
at Suez the persons who had been in immediate contact with
the child were transferred to the Wells of Moses and properly disinfected.
After this had been done, the vessel was allowed to pass
through the Suez Canal in quarantine. No fresh case occurred,
and the vessel arrived at Southampton April 6th. Here all articles
which might possibly contain infection were disinfected, the
passengers were allowed to go to their homes, and the troops were
placed in barracks. No other cases resulted.
On July 6, 1897, one of the crew of the Carthage, of the Peninsular
and Oriental Company's line, was attacked with the plague. The
ship was then in the Arabian Sea. Two days later the sick
man, with two other members of the crew detailed to attend him,
was landed at Aden. Six days later a second member of the crew
was attacked with slight symptoms of the plague. This fact was
reported when the vessel passed Malta. The Carthage had intended
to stop at Marseilles, but, on account of the plague on board,
continued its course to England. Both of these patients were isolated
by being placed in a large boat hung at a height at the side
of the vessel so as to avoid communication with others on the ship.
When the vessel arrived at Plymouth the passengers were allowed
to depart to their respective homes. The only precaution that was
taken consisted in ascertaining the destination of each person, and
informing the health authorities of the places to which these people
were going. The Carthage had on board a steam disinfector, and
everything that had been exposed to the infection was thoroughly
disinfected. On arrival at the port of London the second patient
was isolated until he recovered. No cases developed in England.
On December 7, 1897, the Caledonia arrived at Plymouth, England,
from Bombay, without touching at any Mediterranean port.
While in the Red Sea two lascars developed symptoms of the
plague. They were landed at Suez, and no further outbreak occurred.
When the ship reached Plymouth one hundred and sixty
passengers were landed, and their names and addresses forwarded
to the local authorities of their respective destinations. After
proper disinfection, the ship proceeded to London.
In December, 1898, a case of plague developed on the Golconda
while at Marseilles, on her way from Bombay to London.
The ship proceeded immediately, the patient was landed at Plymouth,
proper disinfection was carried out, and no other cases developed.
This is a proof that the assumption that a vessel is safe
from infection after ten days have passed since leaving an infected
port is fallacious, as this time was exceeded between Bombay and
Marseilles.
The report that the Nippu Maru recently arrived at San Francisco
with the plague on board has proved to be erroneous.
In September, 1896, a Portuguese-Indian steward died at the
Seamen's Hospital, at Greenwich, England, very suddenly. This
man was in the hospital for only forty-eight hours, and no one suspected
the plague at that time. On the last day of October of the
same year another patient in the same hospital was taken ill and
died with symptoms of the plague. Bacteriological examinations
of the glands of the body of the second man were made, and a
bacillus which presented the well-known characters of the plague
bacillus was found. The vessel on which the Portuguese steward
came to England left Bombay about the end of August, 1896.
There was at that time no official knowledge of the existence of the
plague in Bombay, but it probably existed there. This is another
evidence of the fallacy of the belief in the ten days' period of
incubation. It seems quite evident to me that the English authorities
lay too much stress upon the period of incubation. A
man leaving Bombay or any other infected port may carry the
bacillus under his finger nails, elsewhere on his person, or in his
clothing, and may not become infected until many days after leaving
the infected place. Careful inspection and thorough disinfection
of all vessels coming from infected ports should be insisted
upon. It has been abundantly demonstrated by the history of the
plague, as well as that of other infectious diseases, that the old plan
of detention in quarantine is a relic of bygone times. Detention
is cruel, dangerous, and inefficient; inspection and disinfection are
rational and efficacious.
The modes of infection with the bacillus of the plague are as
follows: (1) By inoculation. The history of the present epidemic
in Asia recounts several instances of inoculation with the plague
bacillus. On June 22 or 23, 1896, while making a post-mortem
examination, Professor Ayoama, of Tokio, one of the Japanese
commissioners sent to Hong Kong to study the plague, scratched
the third finger on his left hand; on June 27th he again scratched
himself on the end of the right thumb; on the evening of June 28th
he felt ill, and had a temperature of 101.6° F.; he slept well during
that night, but during the afternoon of June 29th he had a temperature
of 105° F. At that time a bubo was found in the left axilla,
and there was well-marked lymphangitis of the right arm. Professor
Ayoama has described his own case as follows: "On June
28th, after having finished a dissection, I took my meal about half
past two and did not enjoy it. After the meal I went upstairs,
when at certain movements of the arm I felt a slight pain in the
left armpit, and on feeling with my finger I found some slightly
enlarged glands present. In the evening I felt very ill, depressed,
and languid, burning hot along the whole of the back, while the
thermometer showed normal temperature. As Mr. Kitasato and
I had invited guests that evening, I was present at supper. I had
no appetite, and felt so languid that I often wished to withdraw.
At half past eleven I hurried to my room, when I found my temperature
was 39° C. I took one gramme of quinine, and slept well.
Next morning I awoke and noticed, on the under side of the left
ring finger, a small, whitish-yellow blister, and then, along the
back of the hand, a red line. From this time I remembered nothing
for more than two weeks."
Dr. Ishigami, another of the Japanese commission in Hong
Kong, also inoculated himself with the plague while making a post-mortem
examination.
A patient, while delirious with the pneumonic form of the
plague, expectorated into the face of an English nurse caring for
him. Within a few hours the eye on that side of the face became
inflamed; later the parotid and cervical glands became involved,
and the nurse died. Other illustrations of inoculation with the bacillus
of the plague might be given. Dr. Wyssokowitch and Dr.
Jobobat believe that the bacillus can penetrate the unbroken skin.
In support of this belief they report some experiments made by
them upon macaque monkeys. They found that when a needle
was dipped in the culture of the plague bacillus and drawn across the
palm of the hand of one of these monkeys, without making any
visible scratch, the animal speedily developed the disease. However,
this does not prove that the bacillus will penetrate the unbroken
skin of man.
(2) By inhalation. That the pneumonic form of the plague
results from inhalation of the bacillus can not be doubted. Monkeys
caused to inhale the bacillus develop this form of the disease.
(3) By deglutition. That the disease may be acquired by taking
the bacillus into the alimentary canal has been demonstrated
by experiments upon animals of various kinds.
The sputum of patients suffering from the pneumonic form of
the disease is filled with the bacilli. The germs are also found,
sometimes at least, in the discharges from the bowels and kidneys.
That the infection may be transported in clothing and rags has been
long known. The following extract from a memoir by Sir John
Hay, then minister from England to Morocco, indicates that the
plague was introduced into Morocco in 1826 by means of infected
articles of clothing: "The danger from plague by contagion can not,
however, to my mind be called in question. That dire disease was
introduced into Morocco about the year 1826 by an English frigate,
which our Government had dispatched to Alexandria, where the
plague was then raging, to convey from that port to Tangier two
sons of the Sultan, returning from a pilgrimage to Mecca. No
case of plague or other illness had occurred on board the frigate
during the voyage, and the Sultan's sons and other passengers were
allowed to land at Tangier.
"The customs officers, being suspicious that, in the numerous
boxes brought by the pilgrims who had been permitted to embark
with the Moorish princes, contraband goods were being smuggled,
caused some of the cases to be opened. One contained Egyptian
wearing apparel, which the owner said he had bought second hand,
and subsequently confessed had belonged to a person who had died
of the plague in Alexandria. The two Moorish officials who
opened the boxes were attacked with the plague that night and
died in a few hours. The disease spread rapidly throughout Morocco,
carrying off eighty per cent of those who were attacked."
I mention these facts in order to emphasize the desirability of
disinfecting all articles liable to carry the infection coming from
infected places.
Professor Haffkine's preventive inoculation against the plague
is still being largely employed in India. This consists in injecting
hypodermically sterilized cultures of the bacillus. No curative
action is claimed for this treatment, but it is believed to be protective
against the disease. It is stated that more than eighty thousand
people in India have undergone this form of vaccination, and
that the death rate among these has been exceedingly low. However,
it is well to be careful in accepting statistical statements on
a matter of this nature. In the first place, it is probable that only
the more intelligent will submit to vaccination, and these will also
employ other means of protecting themselves against the disease.
In the second place, there are many thousands of people exposed to
the infection, or at least live in infected districts, who have never
been vaccinated and who do not acquire the disease.
Three kinds of serum have been used as curative agents in the
plague. In 1896 M. Yersin began the use of a specially prepared
serum in China. The first cases treated with this preparation did
unusually well, and it was hoped that most valuable results would
follow from its more extended use. This serum is prepared after
the manner of the antitoxine used in the treatment of diphtheria.
That used most largely in India is made at the Imperial Institute
of Experimental Medicine in St. Petersburg. Numerous physicians
in India have reported upon the action of this serum, and
none of them favorably. Very recently Dr. Clemow treated fifty
cases with this serum, and compared them with fifty other cases
treated without the serum. Every other case was selected for the
serum treatment. The mortality was exactly the same in each
group, forty patients out of fifty dying.
The second serum is that prepared by M. Roux, of the Pasteur
Institute in Paris. This is practically the same as the preparation
made by M. Yersin, and the results obtained are equally unsatisfactory.
In 1897 the writer had the privilege of observing, both
at Paris and at St. Petersburg, the preparation of these agents, from
which at that time great results were expected. A third preparation
is made by Professor Lustig, of Florence. I have been unable,
so far, to find any detailed account of the method followed by
Professor Lustig in preparing his serum. From all that I can learn,
however, it is not a serum, but a sterilized bacterial culture; at any
rate, Lustig's preparation has proved probably least valuable of all.
At present (July, 1899) the plague prevails throughout India,
and has appeared at various places in Baluchistan and Afghanistan,
at Samarkand in the Transcaspian Province of Russia; in Persia,
at Bassorah and other points along the Persian Gulf; at several
places along the western shore of the Red Sea; at Suez and Alexandria;
at Tamatave, in Madagascar; at Port Lewis, Mauritius; at
Penang, in the Straits Settlements; at Amoy and Hong Kong,
China; and at numerous places in Formosa. For reasons already
given, it will not be at all surprising should the recent report that
the plague had appeared in Constantinople prove to be true. If
it once reaches that place, it is more than likely that it will become
scattered throughout the Balkan Peninsula. The sad death of
Professor Müller and his laboratory servant, at Vienna, from the
plague bacillus which Professor Müller brought from Bombay,
shows the necessity for caution in handling the germ of this disease.
Are we in America in danger of the plague? I will have to
answer this question very much as I did two years ago: "Yes, we
are in danger; but this danger, being foreseen, may be easily
avoided." In my opinion, our most vulnerable point is along the
Pacific coast. With the plague at Hong Kong, it is possible that
it may be transferred to Manila, and the transports bringing soldiers
to this country may also bring the infection. However, I
think the chances of this happening are small. The length of time
required to make the voyage from Manila to San Francisco is so
great that, with the infection on board, it would be almost certain
to manifest itself before reaching our shores, and, knowing its presence
on board a ship reaching San Francisco or any other point on
the western coast, thorough inspection and disinfection will keep
the disease out of this country. The probabilities are that for several
years to come the larger cities of India, at least, will remain
infected, and our sanitary authorities must be vigilant. The fact
that, if the plague reaches us at all, it must come by sea, that a long
voyage must be made before it can reach us, and that the disease
will most probably appear on board ship before arrival at any
American port—all these conditions are in our favor. The General
Government should take upon itself the control of all measures
to prevent the introduction of infectious diseases from without.
Quarantine detention is a relic of ignorance of the true
nature of infectious diseases. All transports and other vessels between
Manila and this country should be provided with proper
disinfecting apparatus. The Government should supply the
Marine-Hospital Service with every needed equipment, and if this be
done the plague can enter America only through incompetency in
that service. There is another source of danger on our Western
coast that must not be overlooked. The plague is now widely distributed
in Formosa, which is under the control of Japan, and our
intercourse with the last-mentioned country should be most carefully
watched.