March 18, 1896.]
sway." On the outbreak of the disease in Canton many persons, especially the well-to-do, removed into the country, thus forming fresh foci for its dissemination; and in the same way the outbreak in Hongkong no doubt arose from persons having migrated from Canton to Hongkong while actually suffering from the disease or during the short incubation period.
Apart from the risk of future outbreaks in South China, its presence there is fraught with danger to more northern ports. All attempts to keep out the plague by examination of steamers and quarantine regulations, such as have been adopted at some of the coast ports, must in the end prove futile, seeing that no control is exer cised over the ingress of the disease by junks and other craft. Besides, there is nothing to hinder its spread overland, just as it reached Canton from Pakhoi. If it came to Canton by sea it
is rather remarkable that Hongkong, which is nearer to, and in direct communication with, Pakhoi, should have been visited by an outbreak nearly two months later than Cauton. In Hongkong improved house accommodation and hygienic arrangements may in the future pre- vent the plague attaining the same serious dimen- sions as in the severe outbreak of 1894; but what
of the Chinese cities, where overcrowding, in- sanitary arrangements, and filth provide the conditions so necessary for its propagation: His tory repeats itself: the disease may remain com- paratively quiescent for a few years, but will surely be again called into activity under the same fostering conditions as preceded the pre-
sent outbreak.
CAUSATION,
History shows that previous epidemics have been preceded or attended by certain conditions and circumstances pointing to a causal con- nection.
1-Filthy and insanitary Surroundings.-- The sanitary arrangements of Canton are similar to those existing in other large cities of China. Public water-closets are established all over the city, from which loh feces and urine are daily removed and utilised as manure for the surrounding country. A drainage system can scarcely be said to exist, unless we regard as such the ditches that run under the large paving stones of the streets, and receive rain water and refuse matter washed into them from the houses and shops. The city being flat, there is no fall to empty those drains, and as no municipal control is exercised over the cleans- ing of them, this duty devolves on individual householders, who, of course, attend only to the sections which more immediately concern them. Consequently the drains are more often than not choked up, and are practically cesspools con- taining fermenting animal and vegetable refuse. In the smaller streets waste material fiuds its way into open side ditches, which are usually in the same neglected condition. Several canals enter the city, and as the tide has a rise and fall of about five feet twice in the twenty-four hours, a certain amount of rubbish is carried off in this way. When, however, the river is abnormally low, as during the early part of the year, these canals are like stagnant pools, thick with decomposing matter.
The water supply is equally defective. People living near the river use the river water, which, containing as it does the refuse of the immense boating population, is of course very impure. The majority depend on surface wells, which exist all over the city. These merely contain surface and tidal water which has percolated through a porous soil sodden with the filth of centuries. Bad at the best of times, one
can readily imagine the chemically impure state of the water in these wells, almost empty after such a prolonged period of drought.
To persous imbued with Western ideas of sanitation this state of affairs must sound very unwholesome, and no doubt would prove most deadly but for the attention which Chinese in general bestow on the proper cooking of their food and drink. As cities in China go, Canton is comparatively clean and healthy, and, so far as concerns immunity from epidemic diseases in general, may even compare favourably with eastern cities boasting of more elaborate sanitary arrangements.
2.-Prolonged Drought.-The rainfall in Can- ton during the winter months is very small, but - during the past winter and spring was excep-
tionally so.
CHINA OVERLAND TRADE REPORT.
Thus :-
1893. November
: December 1894. January
February March
inches
0.01
0.80
0.31 1.87
2.99
Intelligent Chinese regarded this absence of rain as the most important factor in the pro- pagation. and dissemination of the disease, rendering as it did both wells and drains more filthy than usual.
3.Epizootics among the Lower Animals.– In addition to the mortality among rats, we learn from Mr. Rocher that in Yunnan cattle, pigs, and dogs die in great numbers previons to the outbreak of the plague. Rats, however, suffer more than other animals, and are thus said to give warning (pco hain, for they tumble about and die in the streets."
quently extended.
The same circumstance was noted in Canton both previous to and during the epidemic. From districts of the city where the disease had lasted for some time rats entirely disappeared, but kept on dying in other parts to which it subse- They would come out of their holes in broad daylight, run and tumble about in a dazed condition and die. Certain officials took steps to have all dead rats collected, offering about ten cash per head. Up to 8th May it was stated that the officer in charge of the west gate had in this way collected 292,000, which were duly interred outside the city. So
237
klender and unreliable information obtainable from outside sources. Rain fell copiously Huring the month of May and beginning of June, so that many streets were under water; the temperature remained comparatively low. But both these factors seemed to favour the pro- pagation of the disease, as by the beginning of June it was rife in the western suburbs as well as in the surrounding towns and villages.
It is impossible to give any correct estimate of the mortality, as no official records of burials Jare kept. Comparing the estimates obtained from various sources, we believe the mortality from the beginning of the epidemic to the middle of Juno (the date of writing) to have been about 40,000—a large number, but, in a city with a population of about 1,500,000, by no means excessive when compared with the rayages of this fell disease in other cities. In the great plague of London (1665) it was
estimated that 60,000 deaths occurred in a population of 500,000.
Although a goodly number of well-to-do people fell victims to the pestilence, the chief sufferers were the poor-overcrowded and badly housed. The people who escaped the scourge
the
those in most marked degree were living in upper stories and the boating popula- tion. With the exception of those put in boats after falling sick, scarcely a case was noted on the river. Many well-to-do people, observ. ing this immunity, removed from their houses and made their homes on the water. Judging from this circumstance, therefore, and also from far as we can learn, no other animals were the fact that rats living in the ground and affected. With a view to ascertain the cause
drains were the first animals to fall victims, we of death. we from time to time/examined the infer that the specific poison emanated from the bodies of these rodents and noted the following soil. What the specific poison may be is not postmortem appearances :—
determined, but no doubt the insanitary con- 1-Stomach distended and filled with particles ditions referred to, exaggerated by a prolonged of food, sand, and indigestible sub- period of drought, provided a specially suitable stances; mucous membrane red and in-nidus for its growth and dissemination. flamed towards the pyloric end. Liver much enlarged and congested, and containing (a) encysted tapeworms (pro- bably Taenia saginata)—these were pre- sent in every case, in some as many as nine cysts being noted; (b) ova of dis- tomata, usually found in patches near the anterior border-in some the whole liver substance was infiltrated with ova. 3.-Congestion at base of langs present in some
about 40 per cent.
4-Glandular enlargement was present in 30 per cent. of those examined, but in a much less marked degree than in the human subject.
answer
Is the disease in man and animals identical Should bacteriological examination give an in the affirmative, then we must recognise that these rodents are active agents in transmitting the disease from place to place for long distances overland.
We regret that, owing to the strong anti- pathy of the Cantonese to any foreign inter- ference either in the treatment or postmortem examination of these cases, we have been unable to obtain any evidence bearing on the pathological conditions present in the human subject. Much light will most probably be thrown on the pathology of the disease by the band of scientists who are engaged in in- vestigating the question in Hongkong.
COURSE AND SYMPTOMS.
A few stray cases occurred in the beginning of March, but it was not until the end of the month that attention was awakened, on account of its fatal prevalence in a poor neighbourhood near the south gate of the city, and also in Nan- sheng-li, a quarter occupied by Mahommedans, anong whom the mortality was very high. At this time the type of the disease was exceedingly severe-of those attacked quite 80 per cent. dying. Towards the middle of April the cases we saw were of a milder type; but the disease subsequently became more severe and extended its boundaries to other parts of the city and also to Honam, the maximum mortality being reached about the middle of May. At the Fang Pien So," an institution inside the north gate, we had opportunity from time to time of examining patients, and were thus enabled to form a more accurate estimate of the progress of the disease than by the
* Proved by Kitasato and Yersin shortly after the date of writing.
The immunity enjoyed by residents on the foreign Settlement of Shamien is remarkable, | seeing that it is separated only by a creek some twenty yards wide from houses where cases of the plague occurred. Not only did foreigners living on the Settlement enjoy excellent health, but no case of plague occurred among their servants living on the premises; the rats also, up to the date of writing, remain healthy and lively.
J
The disease is not markedly contagious; it affects chiefly those occupying the same rooms and coming in close contact with the affected. Casual visitors, especially if there is free ventilation, are not liable to contract the dis- ease. In its mode of spread, and in the limited area to which the poison extends beyond the body of the victim, the affection bears a remark. able likeness to typhus, although the course and symptoms show little or no affinity to that
disease.
The malady runs no regular course. and has no characteristic eruption or day of crisis. With or without premonitory symptoms, such as malaise or rigor, ferer sets in suddenly, rising to 105 deg. or even 107 deg. F., accompanied by headache, thirst, great restlessness. giddiness and subsequently stupor. In from eight to twenty- four hours a glandular enlargement occurs in the neck, axilla, or groin; in a few hours the swelling may reach the size of an egg, is hard and acutely tender. Coma supervenes, and death occurs in 48 Cases lingering hours from the onset or sooner. on for several days are regarded as hopeful, al- The date of though relapses are liable to occur. appearance of the bubo is most uncertain, and may occur at any stage of the fever; we have zeen it as late as the fifth day, and as early as the onset of the fever. In a few cases vomiting of blood has been observed; in others petechia appear, but no characteristic eruption. In milder cases glandular enlargements are absent, the prominent symptoms being fever and diarrhoea with great restlessness and giddiness. Boils may appear during convalescence. Post- mortem lividity is very pronounced, giving rise to the term black plague."
**
The chief sufferers are women and children, most probably because, leading a more-in-door life, they are more freely exposed to the source of contagion. We have frequently remarked the number of female children suffering from the disease. A medical friend has suggested that as in wet weather Chinese stay in-doors,
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