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.