GENERAL E D I T O R : F.

H.

H.

GUILLEMARD,

M.D.,

FORMERLY LECTURER IN GEOGRAPHY IN T H E UNIVERSITY OF CAMBRIDGE.

THE

GEOGRAPHY OF DISEASE

London: C J. CLAY AND SONS,
CAMBRIDGE UNIVERSITY
AVE
Glasgow:

PRESS

MARIA

WAREHOUSE,

LANE.

50, WELLINGTON STREET.

Leipzig: F. A. BROCKHAUS.
New York:
T H E MACMILLAN COMPANY.
Bombay and Calcutta: MACMILLAN AND CO., LTD.

All

Rights

reserved

THE

GEOGRAPHY OF DISEASE.

BY

F R A N K G. CLEMOW, M.D.

EDIN.,

D.P.H.

CAMB.,

BRITISH DELEGATE TO T H E OTTOMAN BOARD OF H E A L T H ,
PHYSICIAN TO H . M. EMBASSY AT CONSTANTINOPLE,
SECRETARY FOR RUSSIA TO T H E EPIDEMIOLOGICAL SOCIETY /OF

LONDON,,

H O N . MEMBER OF T H E RUSSIAN NATIONAL H E A L T H SOCIETY, ETC.

CAMBRIDGE:
AT THE UNIVERSITY PRESS.
1903

Cambridge:
P R I N T E D BY J . AND C. F . CLAY,
AT T H E UNIVERSITY PRESS.

TO MY M O T H E R

PREFACE.

T

H E study of the manner in which disease is spread
over the earth's surface, or in other words the geography of disease, is a science of comparatively new growth,
and it may be regarded as still in its infancy. It is only,
indeed, within quite recent times that treatment of the
subject in at all a thorough manner has become possible.
Authentic materials for a study of the kind were formerly
not available, and it was not until the latter half of the
nineteenth century—marked as it has been by an enormous
increase in the means and rapidity of travel, by a vastly
greater intercommunication of nation with nation, by the
opening up of great tracts of the earth's surface hitherto
unexplored, and finally by an immense increase in our
knowledge of the causation and mode of spread of the
maladies affecting mankind—that an attempt to consider
the distribution of disease the world over became feasible.
Still more recently the demonstration of the origin and
manner of diffusion of malaria—giving rise, as it has, to the
hope of removing from mankind one of the worst of diseasescourges—has given an immense impetus to the study of
geographical pathology. The brilliant work of British and
Italian observers in this connection has in no country met
with more practical recognition than in the British Isles,
whose example in founding schools of tropical medicine
and journals dealing with the same subject has been followed by many other European nations.

PREFACE

vii

The revival—if it be not rather a new birth—of interest
in the distribution of diseases, and the recognition of the
extreme importance of the study, owe not a little to the
spirit of colonial expansion which has marked the history
of more than one nation in the latter years of the nineteenth century. In no nation has this spirit been so
active or led to such eminently practical results as in
our own country. England has slowly awakened to a
sense of her splendid position as the greatest colonising
force, and as possessing the greatest colonial empire the
world has ever seen ; and with a recognition of her greatness has come a recognition of her responsibility. In the
interests of the colonies in all parts of the globe, and of
the navy which connects and guards the whole, a knowledge of the diseases met with in various climes and in
various countries, and of the best methods of dealing with
them, is of the first importance ; and the necessity of a
special training in this subject for the large number of
medical graduates who annually leave the universities and
schools at home to practise under the most widely differing
conditions in the colonies abroad is no less obvious. Thanks
not only to private initiative but also to the wise statesmanship of the present Secretary of State for the Colonies,,
provision is now made for this special training, and means
afforded for a practical study of the subject, to one aspect
of which this present book is devoted.
Nor have other nations been behindhand in this work.
Hirsch's monumental volumes on Geographical and Historical Pathology contributed greatly to elevate this study as
a science, and to bring it on a level with the other medical
sciences. Many French, German, and Italian authors have
written books dealing with the subject which have taken
their places as classics. A number of journals in those
languages are now published, and in the columns of such
papers as the Archives de Medecine Navale, the Archiv fiir
Schiffs- und Tropen-Hygiene, the Annalidi Medicina Navale,

viii

PREFACE

J anus; and others, an abundance of material for study of
disease-distribution is available.
The principal sources of information upon which the
present work is based are enumerated in a list which will
be found at the end of the book. For the colonies I have
consulted the latest returns in the Official Health Reports
of each colony; and I am indebted to Dr Manson and the
Colonial Office for facilities to study those reports in the
library of the Office. I must also acknowledge my
indebtedness to the libraries of the Royal Statistical
Society, the Royal College of Physicians, and the Royal
College of Surgeons. Of the many books from which I
have borrowed information the most valuable have been
those dealing with the special subject of Geographical
Pathology, such as the writings of Hirsch, Davidson,
Manson, Lombard, and others ; but much additional information has been obtained from recent books of travel,
and from many official and unofficial publications dealing
with special countries, in which the facts as to diseaseprevalence have formed but a chapter, or even but a
paragraph. Of the many medical journals from which
much useful information has been extracted it will suffice
to name, in addition to those mentioned above, the Journal
of Tropical Medicine, the various Indian journals for India,
the Sei-i-Kwai
for Japan, the Medical Reports of the
Chinese Customs Service for China, and many American
and colonial journals for the United States and the
colonies. It has been impossible in the text to insert
references for every fact stated. Where references are not
given it may be accepted that the statement is based on one
of the authorities named in the list at the end of the book.
A few words must be said as to the classification of
diseases adopted in the following pages. In a work on
systematic Medicine some attempt to group diseases on
a scientific basis is of real importance. In a work such as
the present, which deals primarily with one aspect only of

PREFACE

ix

disease—its relation, that is to say, to the earth's surface—
a purely scientific basis of classification is less necessary.
The book will, it is hoped, prove useful as a work of
reference; and in such works some convenient arrangement
of the material, to the end that any fact looked for may be
rapidly and easily found, is of the first importance. " To
say the truth" (as Sir Thomas Watson wrote in his
classical Lectures) " I shall consider convenience and usefulness in framing my plan, rather than an appearance of
scientific precision." The only attempt made in these
pages to classify on an etiological or other basis will
be found in the separation of certain diseases of the
skin and those due to animal parasites from the large
group of other diseases. The last, forming the greater
part of the book, are grouped alphabetically.
When
a malady is known by more than one name, the simplest
name or the one most frequently used has been chosen to
determine its alphabetical position. While this arrangement has certain obvious disadvantages—as, for example,
the apparently greater prominence given to ainhum over
plague or malaria, and the grouping together of diseases so
wholly unlike as urinary calculus and scarlet-fever, typhusfever and gout, cancer and pneumonia—it has the great
compensating advantage of facilitating reference.
In the following chapters the greatest prominence is
of course given to the facts of the geographical distribution of each disease over our globe. In most instances
only a very brief account of the general characters and
etiology of the disease has been thought necessary, except
in the case of certain rare or little-known affections. The
history of each malady also, in most of the chapters, is little
more than a very brief summary. Only in the case of those
whose distribution has varied widely at different times (as
for example cholera, plague, and influenza), and where such
knowledge is essential to a complete understanding of the
relation of the disease to the earth's surface, is the history

PREFACE

X

given in any detail. . Finally, after a statement of the
known facts as to the distribution of the particular disease
in recent times, the factors which have seemed to determine
that distribution are discussed as fully as space will allow.
The systematic arrangement of the material followed
throughout the book has seemed to render an index
unnecessary.
This book was begun in London, within easy access
of splendid medical and general libraries, and of every
authority upon its subject-matter that it wasv desirable to
consult. It has been completed in a foreign country where
no such facilities exist. In correcting the proofs I have
consequently been unable in many instances to compare
the facts and figures contained in them with the original
sources from which they are quoted, but solely with my
MS. notes and abstracts from those sources. Should any
errors thus have crept in I can only trust that they are
not of great magnitude, or such as to affect any conclusions
that I may have based upon them.
F. G. C.
CONSTANTINOPLE,

March,

1903.

TABLE OF CONTENTS.
PAGE

Preface

.

vii

BOOK I.
GENERAL MEDICAL AND

SURGICAL

DISEASES.

T h e Geography of Disease, and the Factors which determine it
I
Ainhum
29
Beri-beri
33
Blackwater or Haemoglobinuric Fever
44
Calculus
54
Cancer
59
Cerebro-Spinal Fever
73
Chicken-pox
85
Cholera
,
88
Dengue
107
Diabetes Mellitus
113
Diarrhoea! Disorders
1. Cholera Nostras, Summer Diarrhoea, Infantile Diarrhoea,
etc.
119
2. Sprue (Psilosis)
127
3. Hill Diarrhoea
129
4. "Caribi," " E l Bicho," or " I n d i a n Sickness"
.
. 1 2 9
Diphtheria
'
131
Dysentery
148
Ergotism
163
Erysipelas
166
Goitre and Cretinism
170
Goundou, Anakhre, or Gros-Nez
180
Gout
183
Influenza
.
187
Leprosy
204
Liver Abscess
231
Malaria : Kala Azar
236

Xll

CONTENTS
PAGE

Measles
Mediterranean Fever
Mumps
Mycetoma (Madura Foot)
Ophthalmia, Trachoma, and other Eye Diseases
Pellagra
Plague
Pneumonia
Relapsing Fever
Rheumatism
Rickets
Scarlet Fever
Scurvy
Sleeping Sickness (Negro Lethargy)
Small-pox
Syphilis and other Venereal Diseases
Tetanus and Trismus Neonatorum .
. •
Tubercle
Typhoid Fever and "Typho-Malaria"
Typhus Fever
Whooping-cough
Yellow Fever

.

.

.

.

.

.

268
282
290
295
299
305
311
352
364
371
381
385
398
407
412
432
447
451
469
495
509
518

BOOK II.
DISEASES OF T H E SKIN.
Skin Diseases in General
Craw-craw
Oriental Sore
Tropical Phagedena
Pinta
Tinea Imbricata (Tokelau Ringworm)
Verruga Peruviana
Yaws

535
538
540
544
548
552
556
560

BOOK III.
ANIMAL PARASITES AND T H E DISEASES
ASSOCIATED WITH THEM.
Cestodes.
1. Taenia Solium
2.
„
Mediocanellata
3.
„
Nana

569
570
571

xiii

CONTENTS

PAGE

4.
5.
6.
7.
8.
9.

Taenia Madagascariensis
„
Flavo-punctata
„
Canina
„
Echinococcus: Hydatids
Bothriocephalus Latus
„
Mansoni

.

.

571
571
571
. 5 7 2
573
574

.

Trematodes.
1. Distomum Pulmonale vel D . Ringeri (Endemic
Haemoptysis)
2. Distomum Crassum vel D . Buski .
.
.
.
3.
„
Sinense
4.
„
Heterophyes
5.
„
Bilharzia Haematobia (Endemic Haematuria)
6. Other Trematodes

575
575
576
576

Nematodes.
1.
2.
3.
4.

582
582
583

Ascaris Lumbricoides
Oxyuris Vermicularis
Strongylus Gigas
Ankylostomum Duodenale (Ankylostomiasis and
Pani-ghao)
.
5. Trichocephalus Dispar
.
.
. . .
.
.
6. Trichina Spiralis
7. Filaria Medinensis (Guinea-Worm) .
.
.
.
8.
„
Bancrofti (F. Nocturna, F . Sanguinis hominis)
9.
„
Diurna
10.
„
Loa
11.
„
Demarquaii
12.
„
Ozzardi .
.
.
.
.
.
.
.
13.
„
Perstans
14.
„
Magalhaesi

Parasitic
A.

B.

576
581

583
592
593
594
600
609
609
610
610
611
612

Arachnidce and Insects.
Arachnidce.
1. Pentastomum Constrictum
2. Sarcoptes Scabiei

613
613

Insects.
1. Pulex Irritans
2. Cimex Lectularius
3. Larvae of various Flies
4. Pulex Penetrans (the Chigo or Sand-Flea)

614
614
614
615

List of Principal Authorities

.

620

XIV

MAPS AND CHARTS.
Distribution of Beri-beri
Distribution of Blackwater Fever

To face p. 34
.

.

.

.

Chart showing the Principal Routes by which Cholera
has spread in the Past

„

„

46

„

„

94

Map of Russia showing the Distribution of Cholera
in the Epidemic of 1892

page 100

Chart showing the Early Course of the Influenza
Pandemic of 1889-90

To face "p. 192

Distribution of Leprosy

„

„ 208

Distribution of Mediterranean or Malta Fever in
the Mediterranean Basin
Map showing Regions in which Plague was Endemic
or Epidemic between 1850 and 1894 . . .

„

„

„

„ 320

„

„ 336

„;

„ 524

284

Distribution of Plague between the years 1894 and
1902
Distribution of Yellow Fever

Charts showing Mortality from Yellow Fever in
Havana Epidemics
To follow p. 530
Distribution of Yaws or Frambcesia
.
.
.
To face p. 564

BOOK I.
GENERAL MEDICAL AND
SURGICAL DISEASES.

INTRODUCTION
T H E G E O G R A P H Y O F DISEASE, AND T H E
FACTORS W H I C H D E T E R M I N E IT.
T H E study which forms the subject of this volume differs in
many respects from a study of the geographical distribution of
more concrete objects, such as certain groups of animals, plants,
or minerals. Though constantly spoken of as if it were a material,
tangible entity, disease is, in fact, no such thing. It is only a
morbid phenomenon, or rather a group of morbid processes, in the
tissues of a particular animal organism. In the language of logic,
it is not even a phenomenon, but an epiphenomenon.
It is only in that class of diseases known or believed to be of
parasitic origin that there exists, in addition to the group of
intangible signs and symptoms which in ordinary language constitute the disease, a tangible, palpable something, the distribution
of which over the earth's surface may be justly compared with
the distribution of mammals or insects, herbs or trees. But, on
the one hand, it has not yet been shown that all, or nearly all,
diseases are of this character; and, on the other hand, even where
the parasitic origin of a human disease has been proved, it is well
to bear in mind that the parasite and the disease are not one and
the same thing, nor is their geographical distribution always or of
necessity identical. There is good reason to believe, for example,
that the parasites which are the known or suspected causes of
such diseases as cholera, blackwater fever, malaria, guinea-worm
disease, hydatids, and perhaps enteric and other fevers, may and
do exist for long periods together outside the human body, and
that there are uninhabited or sparsely inhabited tracts of the
earth's surface where these parasites remain in the soil, or in
c.

T

2

INTRODUCTION

water, or in the bodies-of- the lower animals, and where the human
disease associated with them is only set up when man visits those
tracts. In other words, the area of distribution of some disease
parasites may be wider than the area of distribution of the human
disease caused by them. In these instances the disease has a
'vider distribution potentially than actually. In others trie reverse
may be the case, and the area of distribution of the disease may
at any given moment be actually wider than that of the parasite
which gave rise to it. This, however, is exceptional, and can
only occur in the case of certain affections of long duration, such,
for example, as elephantiasis arabum, where the symptoms of the
disease remain long after the nlaria or other parasite which first
caused them has disappeared from the tissues.
Any deviation from the normal, physiological processes of
health comes into the category of disease. Such deviations are
as numerous in kind and causation as they are in degree. A large
proportion of them are due to local, temporary, individual causes.
Of the great group of diseases usually classed as surgical, perhaps
the majority would come under this definition. Fractures and
-dislocations, burns and scalds, sprains and bruises, and generally
the class of injuries due to " accidents " are all of this character,
.and a discussion of their geographical distribution would serve no
useful end. On the other hand there is a large group of diseases,
often classed as surgical, which are due, not to causes of the local
or transient character just alluded to, but to some more general
cause. Such diseases, for example, as " cancer," certain forms of
ulcer, urinary calculus, mycetoma, ainhum, trachoma and other
eye diseases, though frequently needing the aid of the surgeon in
their treatment, are truly on the border-land of medicine and
surgery. They show more or less definite relations to external
influences, they occur in more or less definite geographical areas,
and hence a study of their geographical distribution not only
offers many points of interest, but is essential to the solution of
problems which the often obscure etiology of such diseases
presents.
While on the one hand, therefore, only a few of the diseases
commonly classed as "surgical" will come within the scope of
the present study, a very large number, on the other hand, of
the great group of " medical" diseases will require consideration.
Even of these, however, not a few are due to other than general

INTRODUCTION

3

causes, or they present problems of comparatively little interest
to the student of geographical pathology, and will consequently
not be discussed here.
In the convenient, though not wholly satisfactory classification
of diseases usually adopted, it is customary to group certain
disorders together, such as the infective fevers, diseases due to
animal parasites, constitutional diseases and the like, and to place
the remainder in groups of diseases of the various "systems,"
such as the alimentary, the respiratory, or the circulatory system.
As knowledge advances the tendency is for these latter groups
to become smaller and smaller. Many diseases which were
formerly classified as affections of the respiratory system (as, for
example, diphtheria, pneumonia, and pulmonary consumption),
of the alimentary system (as cholera and dysentery), or of the
nervous system (as cerebro-spinal meningitis) are now known or
suspected to be due to a specific infection, and are removed from
the general class to some more definite class, as that of the
infective fevers or infective granulomata. As such, their geographical distribution presents points of the greatest interest, and
will be discussed in these pages. But there still remains a
considerable number of affections which must, for various reasons,
be passed over here. Some—for example, many diseases of the
genito-urinary and nervous systems—must be omitted because
their distribution, although presenting points of interest, is too
imperfectly known to be of value. Others must be passed over,
because their distribution, although more or less knowrn, offers
no special points of interest, or because the conclusions to be
drawn from its study are quite disproportionate to the large
amount of space needed to fully set it forth.
A study of the geography of disease would serve but little
purpose without constantly bearing in mind the causation- of the
various maladies dealt with. In no branch of Medicine has
knowledge advanced more . rapidly in modern times than in
etiology. With improved powers of the microscope ; with the
birth and development of the science of bacteriology; with an
ever-growing list of discoveries of parasitic infection in various
diseases; with increased knowledge of the relation of disease to
surrounding conditions, and its possible carriage by such media
as air, water, milk, dust, fomites; and finally with a wealth of
new observations upon the part played by insects and by certain
i—2

4

INTRODUCTION

of the lower animals in disseminating infection—much that was
formerly obscure and uncertain in the causation and mode of
spread of disease has been made clear.
A large number of maladies have now been shown, beyond the
reach of doubt, to be associated with the presence in the body
of certain parasites, belonging either to the animal world, or to
the still lower world of microscopic fungi. A still larger and
ever-increasing group of diseases are believed to be produced
in the same manner, though the specific organisms associated
with them have not as yet been identified. To these groups of
diseases the term parasitic, whether macro-parasitic, or microparasitic, may be conveniently applied. Until within the last
few decades only a small number of diseases—such as scabies,
and the various affections brought about by the intestinal worms,
by the Guinea-worm and other comparatively large animal organisms—were regarded as in any sense parasitic. The great
majority of maladies were believed to be due to such causes as
excess or diminution of some chemical constituent of the blood
or tissues, or to some change in the chemico-vital processes of the
body, brought about by errors in diet, by chill, or some other
similar, non-living, agent. It is still permissible to suppose that
some diseases, as, for example, diabetes, myxoedema, and perhaps
scurvy, rickets, and gout, are of this character. But modern
research has not only shown that the large group of infective or
zymotic fevers are as truly of parasitic origin as the itch or the
fluke-disease, but it has also shown that such superficially different
diseases as elephantiasis and tetanus, leprosy and pneumonia,
chyluria and malaria, endemic hsematuria and pulmonary consumption, are no less truly caused by parasites.
This process of gradually transferring diseases from the group
of affections of chemical or chemico-vital causation to the group
of parasitic diseases is constantly going on. A few years ago no
one would have ventured to regard pneumonia or rheumatic fever
as other than simple inflammatory processes, the result of chill.
But the one has been practically proved, and the other is suspected,
to be due to the agency of micro-parasites. It is, further, believed
by many that such diseases as "cancer," scurvy, rickets, gout,
urinary calculus, and a host of others, will ultimately prove to be
of microbial origin. Some observers have even hazarded the
suggestion that practically all diseases which are not due to

INTRODUCTION

5

such obvious external causes as poison, fire and frost, lightningstroke or traumatic injury will be found to be due to parasites.
This view is an extreme one, yet not a little might be said
in its favour. Disease is essentially a vital process—a deranged
action, it is true, of living tissues, leading sometimes to their death,
but, even then, still a living, vital process. The proof, then, if
that were possible, that it is in all or most cases set up by the
action of a living thing, would only harmonise with what we
already know of its nature and results. Moreover there are very
few diseases that are certainly known to be brought about by the
sole, unaided action of non-living matter on the human frame.
Apart from the mineral poisons, and certain harmful gases and
irritating dusts, the inanimate surroundings of man seem to have
little power of producing disease in him, however potent some of
them may be for traumatic injuries. Even the irritating dusts
(such as those which set up certain well-known trade diseases)
can scarcely be regarded as the sole agent in causing the disease,
but rather as preparing the tissues for the action of harmful microorganisms. But the case is different with the living surroundings
of man. The human animal passes his existence, as it were, in
a medium of minute living organisms. The dust in the air he
breathes is loaded with them; the water he drinks often swarms
with them; the earth he walks on, the food he eats, the clothes
he wears, all contain and bring into immediate contact with his
body countless numbers of such organisms. Fortunately they are
imperceptible to the unaided senses, and still more fortunately
the vast majority are harmless. Some are, perhaps, beneficial, and
may aid in the natural functions of the human body. Others are,
and perhaps always have been, quite innocuous. Others again,
there is reason to believe, were originally injurious and capable
of disturbing the normal processes of healthy life in man, thus
producing disease, but, as generation after generation has gone by,
man has acquired an immunity to their attacks. In regard to
many such micro-organisms the immunity acquired is, it may be
supposed, not merely an individual immunity, but a true racial
immunity, transmissible from generation to generation, and truly
permanent so long as man shall continue to live in an atmosphere
of these particular organisms.
There are other micro-parasites which appear to be harmless
to man so long as he remains in health, but attack him and set up

6

INTRODUCTION

disease as soon as his powers of resistance are in any way weakened.
Whether by original endowment, or by gradual adaptation to the
needs of his existence, certain protective forces are now known to
exist in the blood and tissues of the human body, which combat
and destroy any harmful micro-parasites that may enter it. These
forces are believed to be partly of the nature of cells (phagocytes),
partly of the nature of chemical substances.
Thousands of
harmful micro-parasites may enter the body with each breath or
with each mouthful, yet, provided the protective forces are present
in sufficient number and activity, the invading parasites are
destroyed or rendered harmless. But should these forces be
diminished in number or activity, as the result of depressing
influences, general or local disease is set up. Some of these
parasites appear to be widely diffused all around u s ; others are
found only in the more or less near neighbourhood of persons or
animals actually suffering from the disease they produce. As
examples of the former class may be named the various pyogenic
organisms. These exist, there is every reason to believe, in
considerable numbers, in the air or soil or dust, in most parts of
the world, and must constantly gain access to the healthy human
body; yet they do not set up suppuration unless and until they
reach a tissue the vitality of which has been already lowered by
chill or injury. In this group also may be placed some other
pathogenic organisms, as those of tetanus and, perhaps, pneumonia,
nasal catarrh, bronchitis, pleurisy, and others.
Finally there is a group of nocuous micro-organisms—including
the larger number of pathogenic organisms—which are fortunately
not found in abundance all around us, but only in the neighbourhood of a patient actually suffering from the disease they produce.
Some of these parasites, as, for example, those of certain of the
infective fevers, and the organism (not yet finally identified) of
syphilis, seem to be nocuous to most people, no matter what their
previous state of health, provided only that they are actually
introduced into the tissues, and that an immunity has not been
acquired by natural or artificial means. Others, as those of
measles and scarlet-fever, are specially nocuous to young children.
Some affect particular races. Some set up an acute febrile attack
of short duration, while others are the cause of prolonged, chronic
suffering and deformity.
Between the macro-parasites and the micro-parasites found

INTRODUCTION

7

in the human body, there is no true dividing line. The local
irritation and general reaction set up by the presence in the body
of a number of trichinae spirales, or of the echinococci of hydatid
disease, find their analogues in the ulcers of the intestine and the
febrile attack set up by the bacillus of typhoid, and in the bubo
and the acute fever and delirium of bubonic plague. It would
seem that a large proportion of the lower animal creation is
capable of inflicting injury on man. The mode of inflicting the
injury differs widely. Some animals have teeth and claws and
hoofs, with which they bite and scratch and kick. Others,
such as many snakes, the scorpion, tarantula, mosquito, flea,
and bed-bug can not only puncture or tear the skin but can
at the same time inject a poisonous substance, which may merely
cause local irritation or may be absorbed and produce general
symptoms and death. Others actually penetrate and take up
their abode in man's tissues, in which they spend the whole or a
portion of their existence.
The term parasite may be held to cover not only the lastnamed group, but also such organisms as lice, fleas, and bugs,
which do not themselves enter the tissues, but live on the surface
of the body and obtain nutriment from it. Closely analogous to
these are the intestinal parasites, such as the tape-worms, the
round, whip, and thread worms, which live in the intestinal canal,
and, as they do not penetrate to the tissues, may in a sense be
regarded as external parasites. A more serious form of parasitism
is that in which the parasite actually enters the tissues. Internal
parasites of this kind belong to very different zoological groups.
The highest are those of the Insecta class, such as the chigo, or
pulex penetrans. Slightly lower are the parasites of the Arachnida
class, such as the acarus of itch, and the demodex folliculorum.
Others belong to the sub-kingdom Annuloida, including, the
parasite of hydatid disease, the Guinea-worm, the blood filariae,
and the many other, nematode and trematode, worms which will
be discussed in later chapters. Still lower in the scale of creation
are the amoebae found in some cases of dysentery and in the
contents of some liver abscesses; the protozoal organism of
malaria; and the large group of schizomycetes, or bacterial
parasites, the true zoological position of which is still uncertain.
It would be beyond the scope of this volume to discuss in
detail the exact manner in which the micro-parasite produces the

8

INTRODUCTION

tissue changes which we call the disease. It is certain that in
many, it is possible that in all diseases of the acute infective
class, the multiplication of the micro-organism is associated with
the production of poisonous substances, or toxins, the absorption
of which leads to the febrile reaction and the other general
symptoms of the disease. The ultimate explanation of ail disease,
whether acute or chronic, infective or non-infective, is still to be
worked out by the joint labours of the physicist, the chemist, and
the pathologist. The molecular repulsions and attractions of
different cells or varieties of protoplasmic substances, the chemical
combinations and decompositions associated with morbid cellchanges, the altered functional activity of cells or tissues or organs
are all concerned in the production of the simplest disease.
A priori, nothing is perhaps more remarkable than that some
of the deadliest of human diseases should be due to the action of
the smallest and simplest of living creatures—organisms consisting
of a single cell of protoplasm, apparently differing in no w(ay from
the protoplasm which is the ultimate constituent of the cells of
the human body itself. Yet this is no more remarkable than that
the union of a single atom of hydrogen, a single atom of carbon
and a single atom of nitrogen—that is to say, of three out of the
four main chemical constituents of the human body—should
result in the formation of prussic acid, one of the most deadly of
known poisons, the absorption of which into the human body
causes instant death. That there is any true analogy between the
two phenomena it would perhaps be premature to suggest, but the
resemblance is at least a striking one.
It is unnecessary to dwell at greater length upon the subject
of parasitology, and the closely allied subjects of immunity and
the development of pathogenic from harmless organisms. For a
fuller consideration of these questions the reader is referred to
other text-books devoted to such subjects. No discussion on the
general causation of disease would have been complete without
some account, however brief, of what this comparatively new
science has taught us. It has discovered with certainty the cause
of many diseases, and it has shown in what direction the cause of
many others must be sought. Whether it is destined to explain
the causation of all disease and to reign supreme over the whole
domain of pathology, the future alone can show. For the present
it would seem permissible to retain the belief that at least

INTRODUCTION

9

some diseases are due to causes other than parasitic in their
nature.
Some—as for example myxcedema, and, as many
believe, exophthalmic goitre—are almost certainly due to a
diminution or excess in the tissues of certain substances produced by the action of a particular gland or set of glands; and
there is nothing at present to show that the changes in the
activity of these glands, leading to such diminution or excess, is
in any way due to parasitic agency. Other diseases, such as
epilepsy, some forms of rheumatism, migraine, neuralgia, atheroma
of the arteries, paralysis agitans, aneurisms of non-syphilitic
origin, locomotor ataxia, chronic Bright's disease, waxy kidney,
lymphadenoma, Raynaud's disease and many others, seem to
be due to disturbances in the chemico-vital processes of the
body or of special tissues, in the causation of which there is no
reason at present to suppose that living parasites have any share.
While the recognition of the parasitic origin of a large number
of diseases has thrown a flood of light, not only upon their
etiology, but upon their mode of spread and upon their relation
to surrounding conditions, it has not yet explained all that is
obscure in the natural history of disease. Even where—as, for
example, in the case of cholera or plague—the parasite has been
found, has been shown to be constantly associated with the
disease, and may, within certain limits, be spoken of as its cause,
there are still a number of phenomena in the behaviour of the
disease which require explanation. These phenomena are particularly found in connection with the class of epidemic infectious
fevers.
The sudden and marked changes in the behaviour of the
two diseases just named, the great variations in prevalence and
intensity of a score of other disorders, the appearance of a
disease in one country and its disappearance from another, all open
up a number of interesting questions to which at present no
quite satisfactory answer has been found. It has been suggested
that all these phenomena find analogies in the insect world.
The idea is no new one. The close resemblances between the
behaviour of epidemic diseases and the flights and disappearances
of insects was clearly recognised and discussed by many writers
in the eighteenth century. Linnaeus included in his published
works several memoirs by others on the subject. One of the
most interesting of the late Sir Henry Holland's essays discusses

IO

INTRODUCTION

the question at length. The knowledge gained since then by
the actual proof of the existence of micro-parasites as the
cause of disease—then only suspected—has scarcely altered the
character of the problem, though it has altered its terms. In
Linnseus's time, when an author hazarded the suggestion that
small-pox, measles, the plague and other diseases might be caused
by minute animals, he spoke of them as insects—"acari" of
different species. In Sir Henry Holland's time the microscope
had already shown the occurrence in nature of animals still
lower than insects—of infusoria, and similar minute, lowly
organisms, and it was to these that the causation of disease was
tentatively ascribed; while already the probability that other
still lowlier organisms existed and would ultimately be found,
was fully recognised.
The still lowlier organisms have now been found, in regard at
least to many diseases. And with their discovery, the terms of
the problem, as just stated, have changed. It is now known that
these diseases are not due to insects, but to forms of life infinitely
lower—almost, it would seem, at the lowest end of the scale of
creation. It is now known that if the general behaviour of these
diseases presents an analogy with that of insects, it is 'only an
analogy. The resemblance, it is true, is often very striking. Some
insects, for example, like some diseases, have permanent breedinggrounds in special and relatively limited areas. They are numerous
here in some years, rare in others. They may change their
breeding-grounds. They migrate in certain years to other areas ;
they fly in swarms or in small numbers; they take long flights
over thousands of miles and appear in countries where they were
before unknown; they disappear almost as suddenly as they
came, or they break up into patches, remain more or less permanently in the newly-invaded territory, or gradually die out.
In all these respects, their behaviour shows complete analogy
with the behaviour of such diseases as cholera or plague, influenza
or dengue.
But if the attempt be made to push the analogy too far, it
breaks down. Insects are highly organised creatures; they are
adapted to a highly developed form of social existence; they are
sentient; many of them have extraordinary powers of intelligence;
and finally they are endowed with powers of locomotion, enabling
them to pass over distances which in some instances may be

INTRODUCTION

II

measured by hundreds of miles. But the lowly micro-organisms
believed to be the causes of plague or cholera, of yellow-fever
or diphtheria, have none of these characters. It is more especially
in their powers of locomotion that they differ from insects. They
have, indeed, alone and unaided, almost no powers of locomotion.
The most that an individual micro-parasite can do in this respect
is to wriggle over short distances in a liquid medium, and the
most that the mass of micro-parasites can do is to spread in a
saprophytic state by multiplication at the edge, as a patch of
ringworm spreads. To pass from one region of the earth's surface
to another they are dependent upon the movements of other
things, animate or inanimate. They must be carried in the water
of a running stream; in the tissues of a man, a rat, or an insect;
in a bundle of " infected " goods; perhaps by the wind. Their
locomotion is involuntary. They cannot, as insects appear to do,
choose when and whither they will migrate. They cannot, when
their breeding-grounds become unsuited to them, or when their
supply of food seems failing, take wing in a body and fly, as
insects do, with almost conscious, intelligent, ordered movement
in a definite line to other and more hospitable lands. They seem
to be left—so far as locomotion is concerned—to the chapter of
accident.
Yet, in the natural history of many epidemic diseases there
are phenomena which it seems difficult to explain on the theory
of a mere accidental carriage of a micro-parasite. Much has been
written upon the "cyclical" character of many diseases. Not
merely such classical examples as influenza, cholera, and plague, but
other diseases, as diphtheria, scarlet-fever, small-pox, and measles,
have all shown a tendency to years of special prevalence, with
intervals of comparative inactivity. These "cycles" are of no
definite length; the average for any given disease is often widely
departed from by that disease. But they exist, and to ascribe
them to a mere chapter of accidents is an unsatisfactory explanation. Still less satisfactory is it in regard to such diseases as
cholera and plague and influenza, which remain for long years
together confined to certain limited areas, and at irregular intervals
spread, without apparent reason, to a large portion or the whole
of the inhabited world. No doubt in such instances the accidental carriage of the micro-parasite plays some part; probably of
more importance are the wide variations which may be supposed

12

INTRODUCTION

to take place from year to year in the vitality and powers of
multiplication of the micro-parasite; possibly there is some
additional factor, still to be discovered, to explain fully all that is
obscure in the behaviour of these diseases.
What that factor may be it is difficult even to surmise. The
micro-parasites of disease are an integral part of organic creation.
Like all other living creatures they are subject to the laws of
evolution, of the struggle for existence, and the survival of the
fittest. They are perhaps preyed upon by other micro-organisms
or by creatures less lowly in the scale of creation. The antagonism between different disease-germs has often been suspected,
though it has never yet been proved. From early historical
times it has been repeatedly noted that an epidemic of one
disease has been accompanied by a lessening or a disappearance
of some other disease. But the experience of one epidemic has
been contradicted by that of another of the same disease elsewhere or at a later date; and no proof has as yet been brought
forward of a constant, essential antagonism between any two
diseases, or the parasites that cause them.
But if there is no proved antagonism between any two diseasegerms, there may, for aught that is known to the contrary, be a
keen antagonism between one disease-germ and some other living
creature—animal, vegetable or fungoid. The wide fluctuations
from year to year in the numbers and activity of a given diseasegerm may perhaps depend not only upon fluctuations in its own
vitality and powers of multiplication, but also upon fluctuations in
the particular creature of which it is the normal prey. Should
this prove to be the case, then it may be supposed that when the
latter are numerous and active the former will be destroyed or
kept within normal limits, and that when the reverse is the case
the disease-germ will flourish uncontrolled, and the disease associated with it will become epidemic.
It may be that this, or something analogous to this is the
explanation of the " cyclical" variations of many epidemic
diseases. It presupposes, however, that a large portion, or even
a principal portion, of the life of a disease-germ is spent in a
saprophytic state, outside the human body, where alone it could
fall a prey to the other supposed living organism. It can scarcely
be applied in explanation of a large number of the infective fevers,
the micro-parasit§ of which appears to pass the whole, or almost

INTRODUCTION

13

the whole, of its existence in the tissues of persons actually
suffering from the disease. In regard to such diseases, if their
wide fluctuations from year to year are to be explained by fluctuations in the number and activity of external forces, favourable
or inimical to the parasites of those diseases, it seems almost
necessary to suppose that these forces exist within the human
body. In other words, while it is necessary to suppose that the
virulence and powers of multiplication of disease-parasites differ
widely in different years, it is equally necessary to admit the possibility that the receptivity of their human host, or his powers to
withstand their attacks, may also differ widely.
In olden days great epidemics were attributed either to such
highly improbable causes as eclipses of the sun or moon, combinations of the stars or planets, the appearance of a comet or some
other celestial event; or to such possible causes as great and
unusual incidents upon this globe itself—earthquakes, openings of
cracks and chasms in the earth's crust, inundations and overflows
of great rivers, the pestilential emanations from the unburied
bodies of persons overwhelmed by famine, by war, or by some
great cataclysm. There is nothing to show positively that one of
these particular events has been the cause of any of the great
historical epidemics of disease. Famine and war bring many
diseases in their train, it is true, and the emanations from masses
of unburied bodies may lead to the local prevalence of certain
diseases; but none of the historical pandemics of cholera, of
influenza, of plague, of small-pox, or of any other disease has
been traced to such causes. It is impossible now to accept
so simple an explanation of a plague pandemic as the opening
of a hole or gulf in the earth, in Chaldea, whence issued a
pestilential vapour that struck all it met with the plague—an
explanation which satisfied the historians of the time of Marcus
Aurelius.
Yet in regard to these earth-changes or terrestrial spasms
and their relation to disease, it may be well perhaps to guard
against over-scepticism, and to admit the possibility that such
explanations of epidemics, though never absolutely proved in any
individual instance, may contain a germ of truth. Some twelve
or thirteen years ago one disease—influenza—swept round the
entire globe, and more than round it. This behaviour of the
malady was attributed by some to great inundations in China;

H

INTRODUCTION

while others pointed out the close resemblance between the
sweep of the disease round the earth and that of the dust raised
some years before by the great cataclysm of Krakatau, near Java.
That dust was believed to have been carried in the course of a
few months not once, but many times, round the world. While
the Chinese inundation theory was certainly wrong, as the
last pandemic began, not in China, but on the borders of
European and Asiatic Russia, the other suggestion is deserving
of some consideration. The analogy between the behaviour
of influenza and that of the dust of the Krakatau eruption is
at least as striking as the analogy, already discussed at length,
between the behaviour of many epidemic diseases and that of
insect-swarms. Attention, it will be remembered, was drawn
to this latter analogy long before the true causation of such
diseases was known; and, although the suggestion that these
diseases were actually caused by insects was later shown to be
wrong, yet it went strikingly near the truth in that it presupposed
an animate instead of an inanimate cause for them. May not
the suggestion that earth-changes or terrestrial shocks share in
the causation of epidemics go equally near to some other, yet
undiscovered, truth—the sought-for, but yet unknown something
which seems to be needed to explain all the phenomena of
epidemic disease?
Attempts have been repeatedly made to classify diseases
on a geographical basis, grouping together those that have
a universal distribution, those that are found mostly in cold
or temperate climates, and those that occur mainly or solely
in tropical or sub-tropical countries. Such classifications are
always interesting, though they can never, from the nature of
things, be of a final character. With the exception of those disorders which are practically universal, almost no disease can
be said to have a permanent geographical distribution. Apart
from such marked examples as cholera, influenza, and the
other typical "epidemic" diseases, whose distribution varies
enormously from year to year, or from century to century, there
are many diseases whose limits of diffusion are not yet reached—
whose history is, so to say, " i n the making." Small-pox, for
example, has not, as yet, been introduced into New Guinea,
Tasmania, New Zealand, and many of the Pacific Islands. The
chigo has in the past few years spread for the first time in

INTRODUCTION

IS

history over the continent of Africa and appeared in Madagascar
and India. Sleeping sickness is gradually extending over wider
and wider areas in Africa. Syphilis has not yet reached the
possible limits of its diffusion, and Greenland, parts of America,
and of South Africa have not as yet seen the disease—though
it can scarcely be doubted that they will sooner or later, as their
traffic with the rest of the world increases. Plague has in the
past few years appeared in the western hemisphere and in many
places south of the equator; yet but a few years ago it was
held—and apparently with justice—that this malady could not
extend to the New World or to southern latitudes. Many other
examples might be quoted in illustration of the same fact, and of
the caution needed in any attempt to classify diseases on a
geographical basis.
Without aiming at any strict classification of this kind it will
suffice here to group together certain diseases whose distribution
over the earth's surface has been more or less alike.
Some diseases have an almost world-wide distribution. Cancer, diarrhceal disorders, mumps, measles, pneumonia, leprosy,
rheumatism, typhoid fever, tubercle, whooping-cough, and many
others have occurred at some time or other in almost all parts
of the inhabited world. They have shown themselves quite
independent of lines of latitude or isotherms.
Some diseases, as scarlet fever and diphtheria, are found mainly
in temperate or cool climates, and are rare or unknown in and
near the tropics. Others, as whooping-cough, cerebro-spinal fever,
rheumatic fever, scurvy, and typhus fever, though occurring to
some extent in all latitudes are more common of more severe, or
both, in the cooler parts of the earth.
In a few instances, of which malaria and dysentery are the most
striking, the reverse is the case, and the disease, though found
in almost all latitudes, becomes more common and more severe
towards the equator.
Many diseases are practically confined to warm latitudes;
among the most typical examples of this class are dengue,
mycetoma, liver abscess, phagedenic tropical ulcers, oriental sore,
yaws, the bilharzia disease, ankylostomiasis, the various filarial
disorders (elephantiasis, chyluria, etc.), the guinea-worm disease,
and many others.
Some have a still more restricted range and are found only

16

INTRODUCTION

in comparatively small portions of particular continents, as, for
example, verruga peruviana, ainhum and goundou.
Another important group includes certain diseases which
remain endemic in comparatively limited areas for long periods
together, and only at irregular intervals spread more or less widely
over the earth's surface. To this class belong cholera, plague,
and yellow fever. The first of these three diseases has several
more or less permanent endemic centres in the Far East, all in or
near the tropics; yet as an epidemic it has spread at times to
almost all parts of the world. The second has also many endemic
centres, but of a less permanent character, and not all in or even
near the tropics; its epidemic diffusion has in the past been quite
as wide as that of cholera. The third is endemic only on the
tropical coasts, eastern and western, of the Atlantic Ocean, and
its epidemic diffusion has been much more restricted than that of
either plague or cholera.
Ignoring for the moment the disturbing influence of season
and elevation above sea-level, the earth may be regarded as
becoming progressively warmer from the poles to the equator;
and this variation in temperature has clearly a powerful influence
upon the distribution of many diseases. But it is not the only
factor in determining their distribution, nor is it in all instances
the most important one. Even in regard to diseases caused by
micro-parasites the direct effect of temperature is by no means
uniform. The favouring action of warmth upon all living organisms
and the greater wealth and variety of the larger flora and fauna
of tropical and sub-tropical regions over those of the temperate
and cooler zones of the earth, might well warrant the expectation
that all such diseases would be more rife and more severe in the
former than in the latter. Yet this can scarcely be said unreservedly
to be the case. It would seem that the influence of climate upon
disease is shown rather in regard to the variety of disorders met
with than to the frequency or intensity of each disorder. As
might have been anticipated, the disease-list is a longer one in
warm countries than in cold. In most tropical and sub-tropical
lands all, or nearly all of the ordinary diseases of temperate climes
are found to exist, while there are in addition others that are
unknown in the latter. The disease-flora is, in brief, richer in the
warmer regions of the earth. But when each disorder of temperate
climes is considered separately, and traced from the pole to the

INTRODUCTION

"7

equator, it is not always found to become progressively more
common or progressively more severe. A gradation of this kind
was, it is true, mentioned above in regard to malaria and dysentery,
and to these may perhaps be added cholera and plague in their
epidemic manifestations. But a still longer list has already been
given of diseases which are commonest in temperate or hot
climates, and actually become rarer or less severe as the equator
is approached. It will, further, be shown presently that many—
almost the majority—of the ordinary infective fevers are most
prevalent in the cool and not the warm season of the year. That
this seasonal variation in disease is due not solely to changes of
temperature but also to other factors—such as the closer aggregation
of people in houses, lessened ventilation, diminished sunlight in
the cool season of the year—there can be little doubt; and the
same or similar conditions may to some extent be held to account
for the distribution of these diseases, on a large scale, over the
earth's surface.
The seasonal variation of diseases has an obvious, if indirect,
bearing upon their geographical distribution. In general terms
the diseases which have shown a tendency to prevail mostly in
the cooler season of the year, both in warm and cool latitudes,
have been small-pox, influenza, measles, diphtheria, croup,
whooping-cough, pneumonia, inflammatory affections of the respiratory passages, typhus fever, erysipelas, cerebro-spinal meningitis, puerperal fever, and rheumatism. On the other hand, many
affections of the digestive organs, as diarrhoea, dysentery, and
cholera, have always been most active in the warmer months.
Plague has been for the most part a warm-season disease in
temperate climates and a cool-season disease in the tropics.
Scarlet fever, relapsing fever, and many others have shown no very
definite or constant seasonal relations. In regard to a large
number of diseases, particularly those occurring in the tropics,
the seasonal variations have been less dependent upon temperature
than upon rainfall; in other words, they have been less a question
of the difference between cold and warm seasons than of the
diffeience between wet and dry seasons. In many warm countries
the wiole course of social life is largely determined by the annual
recurrence, at a more or less constant date, of " t h e rains"; and
each period of the year—whether it be the commencement of the
rains, the rainy season proper, the decline of the rains, or the dry
c.
2

i8

INTRODUCTION

season—has its own character in regard to the prevalence or
scarcity of some particular disease or diseases.
The influence of altitude above sea-level upon the distribution
of disease is far from uniform and is not always easy to determine.
The lowered atmospheric pressure and the lessened temperature
found at considerable heights are usually combined with a greater
freedom of the air from organic impurities, and with the presence
of a scantier population, living a more or less isolated existence,
and holding rare communication with the rest of the world. Such
conditions not only lessen the chances of the importation of
communicable diseases, but they are unfavourable to the prevalence and multiplication of the infecting material when imported.
Hence many diseases, as, for example, tubercle, cholera, malaria
and dengue, are rarer at high than at low levels. But in a large
number of instances a high altitude has proved no bar to the
epidemic, or even the endemic, occurrence of disease; and not
only those just named, but many other disorders that are most
common at low levels have prevailed with intensity at great
heights.
One disease—verruga peruviana—is found only at
altitudes exceeding 2500 feet above sea-level. The very obvious
fact that a high altitude in the tropics may present conditions of.
climate and temperature and, consequently, of disease prevalence
resembling those of the temperate or cooler zones is well
illustrated by the behaviour of typhus fever. When that disease
occurs in or near the tropics it is only or mainly at considerable
heights, while in more temperate zones it prevails indifferently at
high or low levels.
From the early days of medical observation the character of
the soil has been thought to exert a powerful influence upon the
prevalence and distribution of disease in man. The obviously
unhealthy nature of many low-lying, marshy lands, the remarkable
and apparently arbitrary distribution of some diseases, and the
knowledge, which must have been acquired at an early period,
that a dry porous soil is much healthier than a moist, impervious
one> would all tend to encourage this view; and it was further
strengthened by the belief, at one time universally held, that
many diseases were due to "miasmas" or harmful emanations
from the earth. The subject is one that has scarcely yet been
finally worked out; but it would seem that what may be called
the strictly geological characters of a soil have a less powerful

INTRODUCTION

19

influence upon disease distribution than its physical properties—
its temperature; its dryness or moistness; its perviousness or
imperviousness; its purity or impurity in regard to contained
organic matter; and its relation to human dwellings. It has
long been known, for example, that a damp and impervious soil
is peculiarly favourable to the prevalence of consumption, lung
diseases in general, rheumatism, and other affections; and there is
good reason to believe that it is a leading factor in the distribution
of diphtheria, and, possibly, of cancerous diseases. Cholera and
typhoid fever have shown on many occasions that they are largely
influenced by variations in the height of the water contained in
the soil. Diarrhceal disease, particularly the diarrhoea of infants,
has shown a marked parallelism with the rise and fall of the
temperature of the soil. Yellow fever, typhus fever, and perhaps
plague, Mediterranean fever, and other diseases, have seemed to
require, or at least to be favoured by,, the presence of organic
matter, and particularly of animal pollution in the soil.
Other pathogenic micro-parasites would seem to spend one
portion of their existence in the soil. The tetanus bacillus has a
wide distribution in many varieties of soil; the bacillus of malignant oedema is found mostly in soil containing much putrefying
matter, such as garden earth that has been recently manured; the
anthrax bacillus, the actinomycosis fungus, the mycetoma fungus,
would all seem to be capable of living in a saprophytic state for
longer or shorter periods in or on the soil. The micro-organisms
of typhoid fever, yellow fever, plague, and many other diseases
are thought to possess the same power. The soil, further, plays
an important part in the diffusion of some of the animal parasites
to which man is liable. The chigo flea lives in or on warm sandy
soils or oh the earthen floors of human dwellings. Ankylostomum
duodenale probably spends the larval stage of its life-history in
moist earth, and is transferred to man either by means of food
that has been contaminated by the earth, or by actual earth-eating
(geophagy).
Finally, earth-disturbance on a large scale has been frequently
followed by the appearance of certain diseases in an epidemic
form. The diseases that have been observed to occur under such
circumstances have been malaria, blackwater fever, ankylostomiasis, and that form of fever to which the name of typho-malaria
or malarial typhoid has (probably erroneously) been given.
2--2

20

INTRODUCTION

The exact influence of racial susceptibility or immunity upon
disease-distribution is not always easy to determine. Differences
of race are so commonly proved to be associated with differences
in mode of life, in degree of "acclimatisation," in amount of
exposure to infecting material, in readiness to take preventive
measures, and the like, that it is often far from easy to say
whether a difference in disease-incidence between any two given
races should not be ascribed to one or other of these factors and
not to a true difference in racial susceptibility. All that can
be positively stated is that some races do seem to, be more
susceptible to certain diseases than others, while in a few instances a true racial immunity may with some reason be suspected.
In the tropics, for example, the white races appear to be far more
susceptible to malaria, liver abscess, scarlet fever and typhoid fever
than the coloured races; while on the other hand they are much
less likely to become subjects of elephantiasis, chyluria and other
filarial diseases, the Guinea-worm, and many skin diseases, as, for
example, craw-craw, tinea imbricata, and pinta.
The African negro is peculiarly liable to tubercle, small-pox,
tetanus, and cerebro-spinal meningitis; and such diseases as
ainhum, goundou, and sleeping-sickness, and such parasites as
the filaria perstans, filaria loa, filaria diurna and some others are
solely or almost solely confined to the negro race. On the other
hand the negro enjoys a high degree of immunity from yellow
fever and, to a less extent, from malaria. To the skin diseases
named above as rare in the white races may be added yaws or
frambcesia, the frequency of which in any part of the world would
seem to be determined largely by the depth of colour—or in
other words by the amount of pigment in the skin—of the
population. The Mongolian races have shown themselves remarkably susceptible to many of the infective diseases, both acute
and chronic, and to ophthalmia and trachoma; and a few animal
parasites, as for example distomum pulmonale and distomum
sinense, seem to be almost peculiar to them.
That insanitary conditions on the one hand, and, on the
other, man's conscious efforts to remove these and to prevent and
control diseases of all kinds, have a very considerable share in
determining the distribution of disease can scarcely be questioned.
Sanitation and disease-prevention are both sciences of modern
growth. They are practised to a very limited extent in the large

INTRODUCTION

21

majority of territorial areas of which the inhabited earth is
composed, and are, for all practical purposes, entirely absent
from not a few. In only a very, small number of countries can
they be said to have reached a high level throughout. In none
have they attained the possible maximum. Their influence,
therefore, upon disease-distribution is still far from being as
powerful as it might be. They have not yet apparently succeeded
in completely and finally removing from the face of the earth
any of the known diseases to which man is liable; and it is easy
to point to a considerable list of disorders—tubercle, syphilis,
diphtheria, cancer and others—which, in spite of human effort,
have, taking the world as a whole, become more instead of less
rife in recent times. But on the other hand there is a vast and
ever-increasing mass of evidence proving clearly that the control
of many diseases is very largely in man's hands alone. A generally
raised level of personal and communal hygiene and an ordered
Public Health Administration in the more civilised countries
have not only markedly lessened the general death-rate from all
causes, but they have greatly reduced the power for evil of not
a few special diseases, and all but extinguished some. Even in
regard to the diseases named above as having become more
frequent in recent times, it was necessary to add the proviso
"taking the world as a whole," for three at least of the four
named have become less prevalent or less fatal in those countries
where serious efforts have been made to control them.
In England, where more persistent, more general, and more
costly efforts to improve sanitation and control disease have been
made than in any other country, it has been clearly shown that
these measures as a whole have almost extinguished typhus fever,
dysentery, and malaria; they have led to a marked reduction in
typhoid fever and pulmonary consumption; and they have shown
that such diseases as cholera and plague may for long periods
together, and in spite of repeated importation of the infection,
be kept at bay and at least prevented from gaining any serious
hold upon the country.
Special health measures have succeeded in all countries in
controlling special diseases. The draining of marshes and swamps
has practically freed Holland and England from malaria; and
similar works, combined with a war against the malaria-bearing
mosquito, are leading to a striking diminution of the same disease

22

INTRODUCTION

in Italy, the West Coast of Africa, C u b a a n d elsewhere. Provision
of a pure water-supply and care to prevent the consumption of
fouled water have had an enormous share in controlling such
diseases as cholera, dysentery, and typhoid fever. Careful inspection of meat has proved wholly successful in many countries
in preventing trichiniasis. The muzzling order and other measures,
particularly those concerned with the importation of animals from
abroad, have almost extinguished rabies and hydrophobia in
England. The introduction of vaccination by Jenner at the
end of the eighteenth century led to an enormous diminution in
small-pox in all those countries where it was practised; and the
disease has almost ever since been less or more prevalent just
in proportion as efficient vaccination and re-vaccination have or
have not been carried out. Methods of protective inoculation
against plague, typhoid fever, yellow fever and some other diseases
have been recently introduced with promising results; and in
regard to the first-named at least, the method has been so
extensively and successfully practised in India and elsewhere as
to rank already as an important factor in the local distribution
of the disease. Syphilis and other venereal disorders have been
controlled by judicious legislation and a healthier tone of public
and private morals. Scurvy is no longer the scourge that it was
at one time of gaols, barracks, and ships, and recent experience
has shown that even an Arctic expedition may be successfully
carried through without a single loss from this disease.
But when, on the other hand, no attempt is made to remove
insanitary conditions, and disease is allowed to run its own
course unfettered by any effort on the part of man to control
it, the results are very different. Every one of the maladies
named in the last two paragraphs, and a host of others—as
ophthalmia, diarrhceal diseases of all kinds, erysipelas, puerperal
fever, phtheiriasis and many other skin diseases, all the affections
associated with animal parasites—are not only more common,
but may literally run rife where man lives in the midst of filth
and refuse, where drainage and a pure water-supply are unknown,
and where organised public effort to control specific diseases is
absent or impotent.
In this resume of present-day knowledge as to the influence
of different external factors upon the distribution of disease, the
large class of " communicable " disorders has, of necessity, been

INTRODUCTION

23

most frequently mentioned. It is disorders of this class whose
geographical distribution presents most points of interest and is of
real service in explaining their nature and causation. In the
diffusion of such diseases man's movements must always take a
leading share. In the case of the chronic infective disorders, as
syphilis, leprosy and (perhaps) tubercle, man's movements have
apparently been alone responsible for their spread. In the case
of the acute infective fevers this factor must also be an important
one in their distribution : though in regard to many, as was
pointed out above, it is probably not the only one.
Instances of the carriage of disease by man from one part
of the earth's surface to another are innumerable—not only
by the movements of individuals but by the movements of
men in masses. Emigrants have carried leprosy and hydatids
from Iceland to Canada and the United States. Traders and
explorers have on countless occasions brought influenza, measles,
syphilis, small-pox, and many another disease to communities
where they were before unknown. Chinese labourers have been
the principal agents in the distribution of leprosy in Australia,
the Malay Peninsula, and the Far East generally. The great
movements of peasants in Russia, who leave their homes in
bodies and seek work in other parts of the country, have repeatedly
been the means of spreading syphilis, ophthalmia, cholera, and
other diseases.
Beri-beri, plague, yellow fever, cerebro-spinal
meningitis and many others have been transported by ships over
thousands of miles, and often without losing any of their virulence
by the way.
The movements of men associated with war have proved to
be great factors in the distribution of disease. Here, no doubt,
mere movement is not the only factor at work, but it has largely
aided the other factors concerned. Typhoid fever, malaria, socalled typho-malaria, syphilis, measles, scurvy, small-pox, have all
at some time or other been spread as the result of military movements. Typhus fever was widely diffused in Europe by the
Napoleonic wars, and rapidly diminished in prevalence when those
wars came to an end on the field of Waterloo. Leprosy was
carried by refugees during the disturbances in Crete a few years
ago to many parts of the Eastern Mediterranean. The Crusades
were believed to have aided in the diffusion of more than one
disease. It is, however, unnecessary to multiply instances further.

24

INTRODUCTION

There is scarcely a war in ancient or modern times which does
not furnish examples equally striking with those just quoted.
Pilgrimages to religious shrines have often aided in diffusing
disease. The great annual flow of Moslem pilgrims to and from
the western shores of Arabia has repeatedly been the means of
bringing cholera to the Red Sea and of spreading it widely elsewhere; and there can be little question that this annual concourse
of people also aids in distributing small-pox and other communicable diseases less striking and less dreaded than these. The
same statement holds good for those gigantic gatherings of
pilgrims at bathing and other religious festivals at Hardwar and
elsewhere in India; the constant flow of Shiite pilgrims to the holy
burying-grounds of Kerbela. and Nedjef near the Turco-Persian
frontier; and the annual gathering and dispersal of traders and
peasants at the great fair of Nijni Novgorod on the Volga.
The geographical distribution of " communicable" diseases
depends not a little upon the channel by which they are transmitted from man to man. This varies very widely. Some, as,
for example, syphilis, gonorrhoea, ophthalmia, and possibly oriental
sore, yaws, and other skin diseases require that the actual secretions
of an infected person shall reach the whole or abraded skin or
mucous membrane of a healthy person before the latter can
contract the disease. The term contagious should be strictly
limited to this class of disorder. In others the transmitted
material is less gross, and, whether of the nature of a microparasite or not, is given off by the patient's body, exists in the air
about him, and is carried to a greater or less distance by the air.
In typhus fever this distance is perhaps only a few feet, in smallpox it may be measured by fractions of a mile. The part played
by the air in the transmission of many other diseases has been
much discussed and is still uncertain. Dust, which is merely
a collection of particles, organic and inorganic, of " matter
misplaced," may contain the germs of infectious disease or even
fragments of the dried discharges of the contagious diseases, and the
air carrying such dust may thus be the bearer of the disease.
Ophthalmia, there can be little doubt, is often spread in this
way; typhoid fever is thought by many to be a dust-borne disease;
and in the aerial diffusion of small-pox it is reasonable to suppose
that dust containing fragments of dried small-pox scabs is the
main carrier of the infection. Malaria, at one time regarded as

INTRODUCTION

25

the type of an air-borne disease, is now known to be carried
not by mere air-currents but by the agency of winged insects.
In the case of some diseases the infecting material is carried
by water. Cholera, typhoid fever, and dysentery are all spread
very largely, perhaps mainly, by this means. Goitre and urinary
calculus have been thought to depend upon the consumption of
particular kinds of water. The bilharzia disease, ankylostomiasis,
Guinea-worm disease and other affections caused by animal
parasites are certainly or probably spread by the agency of water.
Several parasites of this nature pass the larval stage of their
existence in the bodies of some minute fresh-water animalcule
and gain access to man in one of two ways^-either through his
drinking water containing such infected animalcules or free larvae,
or from the larva-containing water coming into contact with the
surface of his body.
Some water-borne diseases may be carried over considerable
distances by this means. Cholera, the archetype of this class of
disease, has on several occasions been spread over a great part of
a large and populous city by a contaminated public water-supply ;
and there is good reason to believe that such immense streams as
the Elbe, the Volga, the Don, the Neva, and many other rivers have
been the means of carrying the cholera virus over very long
distances.
A large number of communicable diseases are transmissible
by means of infected clothes, linen, merchandise and other
fomites. The virus of small-pox, of scarlet fever, of measles, of
plague, and of many other diseases may cling to the furniture, the^
bed-linen, the clothes, or any and every inanimate object that
has been in the near neighbourhood of a patient suffering from
the disease. In this position it may retain its virulence for long
periods together, and if such infected articles are moved to other
places they may carry the virus with them and reproduce the
disease elsewhere. By this means infective diseases have been
carried over much longer distances than they have ever been
carried by the air or by water. It has probably been one of the
most powerful means of distributing many communicable maladies;
and there is reason to believe that in many of those instances of
apparent carriage of infection by human beings from country to
country or from hemisphere to hemisphere, the infecting material
has really been carried in the clothes or belongings of the person,

26

INTRODUCTION

and not in his tissues. This must always be the case when the
infection has been carried over very long distances—distances
which take longer to traverse than the incubation period of the
disease. It must equally certainly be the case in those well-known
instances where a person has come from an area where a particular
malady was epidemic to another area free from it, and where,
though not himself developing the disease, his arrival has been
followed by the appearance of the disease in other persons in
his immediate neighbourhood.
But man and his inanimate surroundings are not the only
means by which communicable disease is spread. The belief
that the lower animals are attacked at the same time as man by
epidemic diseases is almost as old as the history of disease itself.
In the early historical records of plague and pestilence nothing
is commoner than to find that a murrain among beasts and birds
or both prevailed at the same time as the human disease. Modern
observation has shown more precisely the true relation of the
lower animals to disease in man. It has shown that man
obtains the infection of some maladies, as, for example, anthrax,
glanders, farcy, foot-and-mouth disease, and hydrophobia, solely,
or practically solely, from animals already suffering from
them. Such diseases are, in fact, essentially animal affections,
and only attack man by accident. It has further shown that some
essentially human affections may accidentally attack the lower
animals, which thus become the carriers of infection. Human
influenza is believed to be transmissible to horses, cats, and other
_domestic animals. Diphtheria, or a disease closely allied to it,
has been seen in birds. A form of infectious pneumonia has been
known to attack parrots and be transmitted from them to man.
Scarlet fever may perhaps affect cattle; and it is still a debated
question whether the tubercular disease of cattle and other animals
is or is not transmissible to man. In at least one disease the
lower animals are not only capable of being attacked but appear
to be one of the principal means of diffusing the infection over
the earth's surface. The part played by the rat in the spread
of plague will be discussed in the chapter on that disease, where
it will also be shown that mice, monkeys, bandicoots, squirrels,
cats, and possibly marmots and other animals may all be carriers
of the infection.
Many of the animal parasites to which man is subject pass a

INTRODUCTION

27

portion of their existence in one or other of the lower animals,
and here the animal must be regarded as an essential, indispensable link in the transmission of the associated disease. Taenia
solium and trichina spiralis complete their life-history in the pig;
taenia mediocanellata in horned cattle; bothriocephalus latus in
certain fish; taenia echinococcus—the parasite of hydatid disease—
in the dog, sheep, or cattle. Such parasites can only pass to man
where he is brought into relation with animals, living or dead,
which are the subjects of them. Most of them gain access to his
body through eating imperfectly cooked beef, pork, or fish containing them. Others, as for example taenia echinococcus and
perhaps ascaris lumbricoides, probably escape from the animal in
the excreta, and are conveyed to man in dirty drinking water or
by contaminated hands or food.
Still lower in the scale of creation, many members of the
insect family are found to act as the carriers of disease. Houseflies, mosquitoes, fleas, bugs, lice—any or every insect that may
crawl on the body of a person suffering from an infectious disease
or batten on his excreta, and then pass to the body of another
person, may be the means of directly carrying the malady, through
some portion of infecting material clinging to its legs or body.
Or the insects may carry the infecting material to milk, or
water, or solid food, which would then give the disease to any
one swallowing it.
In other instances the infecting material, or in other words the
parasite, actually enters the insect's body. This would appear to
occur most usually, if not solely, in the case of diseases the
parasite of which exists in the peripheral circulation, and the only
insects capable of transmitting them are those which suck men's
blood. The most dangerous insect in this respect would seem to
be the mosquito. It has been shown to be the principal carrier
of the malarial organism. A mosquito, though possibly of an
other species, is the extra-human host of the filaria sanguinis
hominis (F. Bancrofti), and probably of many other varieties of
filariae; and strong evidence has recently been brought forward
that certain mosquitoes may be active carriers of the yellow fever
virus. Plague is also believed by some to be spread by the agency
of insects; not, however, by the mosquito, but by fleas and
other body-vermin found on man, on rats, or on other animals
suffering from the disease. The cockroach has been suggested

28

INTRODUCTION

as the possible host of some of the taeniae to which man is
subject.
Finally, and as probably the lowest of all animals in the scale
of creation that are capable of becoming the hosts of human
parasites, must be named a fresh-water cyclops which has been
shown to act in this way for the Guinea-worm; and it is far from
improbable that later observation will show that some similar
lowly organism is the extra-corporeal host of bilharzia haematobia
and other human parasites.
In the case of those human diseases, the parasite of which
passes half its life-history in some of the lower animals—whether
a mammal, fish, insect, or crustacean—it is clear that the
geography of the disease must be largely determined by that of
the particular animal in question. There are in fact three essentials for the prevalence of such diseases—the parasite, the human
subject, and the extra-human host. The geographical distribution
of such diseases may differ from that of either of these essential
elements taken separately; and in the absence of any one of them
it must rapidly die out. The influence, further, of such external
conditions as temperature, climate, elevation above sea-level, soil
and season, upon the distribution of the disease must be somewhat more complex than in the case of other diseases ; for such
influence must act not only on the parasite itself, and the receptivity of the human subject, but also on the numbers and
activity of the particular animal or insect which serves as the
extra-human host.
This rapid survey of the forces at work in determining the
geography of disease will, if it serve no other purpose, at least
show that the distribution of diseases is a highly complex matter.
In the case of each disorder to which man is liable, the areas of
the earth's surface in which that disorder is met .with, and its
differing degrees of frequency in different parts of those areas
must be regarded as the resultant of all, or of many of the
factors, the most important of which have been discussed in this
chapter.

AINHUM
D e s c r i p t i o n . This disease consists essentially in the appearance of a constriction or furrow at the base of one or more
toes. It is almost always the fifth or little t o e ; occasionally the
fourth, and never any of the others that is affected. It is at first
quite painless. The furrow becomes deeper and deeper, as if
the toe had been tightly ligatured with wire or string; ulceration
sets in; there is great pain and discomfort in walking, and the toe
finally separates by gangrene or is removed by a surgeon or by
the patient himself. The process may last several years; one
case, in South Carolina, lasted for 50 years. Its etiology is quite
unknown; of recent years some observers have adopted the view
that it is only a form of leprosy, but this view is combated by
others.
H i s t o r y . Attention was first called to the existence of this
disease on the West Coast of Africa by Clarke in i860, in a paper
read before the Epidemiological Society of London. Later it was
described by Corre, Crombie and other observers. But of the
history of the disease itself almost nothing is known.
G e o g r a p h i c a l D i s t r i b u t i o n . Europe. The disease has
never been met with in Europe. Ehlers has recorded an example
of " ainhumoid " mutilation of the little toe by leprosy in a Greek,
and shares the opinion of Zambaco Pasha and others that ainhum
is only a form,of leprosy. But this theory is still awaiting proof,
and up to the present no certain case of ainhum has been seen in
Europe.
Asia. In Asia the existence of the disorder has apparently
only been demonstrated in India and China. In India ainhum
is far from common, but is occasionally met with. Over thirty
years ago a French naval surgeon recorded cases occurring in

30

AINHUM

Pondicherry among Indians of the Tamil race 1 . Elsewhere in
India there are reports of cases from Calcutta, Bombay, Dacca,
and Goa. Recently a case of ainhum, or of a condition closely
resembling it, was observed in South Sylhet, Assam 2 . The patient
in this instance was a Hindu washerman, a native of Sylhet; but
the ainhumoid condition was complicated by the presence of
marked keratosis of the palms of the hands and soles of the feet.
It is only within recent years that ainhum has been recognised
in China. Hichins states that he has seen three or four cases of
the disease at Ningpo, on the east coast of China, in the course
of ten years 3 . Maxwell speaks of a case reported from Swatow,
and also records another seen by himself in Shang-po in southern
China early in 1899, in which the patient presented the characteristic affection of the little t o e ; but some 16 months later the man
was found to present unmistakable symptoms of leprosy4. It is
uncertain whether ainhum exists in the Pacific Islands.
Africa. Whether ainhum occurs to any extent in northern
Africa is not known. In Egypt the only mention of its occurrence
appears to be the record of certain cases at Cairo and Suez. At
Massowa on the Red Sea coast it is said to be unknown 5 . In
Algeria it has been seen (at Algiers).
The principal seat of ainhum is the West Coast of Africa. The
larger number of records of the disease come from the Gold Coast,
but it is found in many other parts of these shores, including
Senegambia. The Yorubas call it "ayun," the native word for
a file; while the word "ainhum," commonly applied to the
disease, is apparently derived from the language of the Nagos
tribe, and means " t o saw." Other tribes call it "guduram."
The exact distribution of the disease in this part of Africa is
uncertain; but the Kroo negroes seem to be the most liable
to it. One typical case, at least, has been seen in British Uganda,
in eastern Africa.6
Ainhum is also said to have been seen among the Kafirs in
South Africa, but fuller information on this point is wanting.
On the island of Nossi-Be, near Madagascar, and in Reunion
1
2
3
4
6

Collas, Archives de Med. Navale, 1867.
Dalgetty, Journal of Tropical Medicine, March, 1900.
Medical Repoi'ts of the Chinese Customs.
N o . 55 (1897-8).
5
fotirn.
Trop. Med.
Dec. 1900.
Rho.
Cook. Journ. Trop. Med.
J u n e 1, 1901.

AINHUM

31

cases of the disease have been met with. In the former island
it is known by the native name of "faddiditi."
America. Ainhum has been observed in negroes in some
parts of the United States, especially in the south. Thus there
are records of occasional cases in North and South Carolina, in
Louisiana, in western Virginia, and of one in Washington. It
has also been observed in Philadelphia and even in Canada, in
negroes coming from North Carolina.
It is present, but probably rare, in the West Indies; cases
are known to have occurred in Trinidad, in St Thomas, and at
Havana.
In South America Brazil would seem to be the only country
where ainhum has been seen to any extent; and probably, next
to West Africa, the disease is commoner in Brazil than anywhere
else. Moreira 1 from personal observation says that nearly all
the cases originate in the towns of Bahia, Rio de Janeiro,
and Pernambuco, and in Buenos Aires in the Argentine
Republic. In none of these places is the affection really a
common o n e ; and generally in Brazil it is thought that ainhum is
now rarer than it used to be. This has been explained by the
decrease in the number of African negroes among the inhabitants,
and also by the supposition that the offspring of negroes, born in
Brazil, may be less susceptible than their parents. It is perhaps
commoner than it seems to be, for, as Da Silva Lima first pointed
out, many of the affected negroes do not apply to a medical man
for treatment, but either cut oft* the affected toe themselves or get
a companion to do it for them.
In.Georgetown, British Guiana, one observer is said to have
seen as many as twenty cases 2 .

Factors governing the Geographical Distribution.
Ainhum is to some extent a race disease. The large majority of
cases are found in the negro races. Hence it is mainly found
where these races exist, as on the West Coast of Africa, in the
coast towns of Brazil, and in the southern States of America.
But while the negro race is most prone to it, it has also, exceptionally, been seen in Mongols in southern China, in Hindus
1
Monatshefte fur prakt. Dermatologie.
Translation in Journ.
March, 1901.
2
von Winckler, quoted by Moreira, loc. cit.

Trop.

Med.

32

AINHUM

of pure descent in India, and in a Hindu-Malagasy half-breed in
Reunion.
The causation of ainhum is quite unknown. Its relation to
leprosy is uncertain, but the majority of observers regard it as a
distinct and separate affection. Traumatism may have something
to do with its immediate development, and in several cases it has
followed on a slight injury to the toe. The male sex is more
liable than the female. It has not been seen in children and
is rare in old men, the prime of life being the period at which
negroes are most likely to develope it. Heredity may have some
influence in the production of ainhum, and there are many instances
on record of several members of a family, of more than one
generation, suffering from it.
There is nothing to show that climate, soil, elevation, dirt, or
insanitation have any influence on the prevalence of ainhum. It
is found, it is true, most commonly in tropical and sub-tropical
countries, but this may be simply due to the fact that the races
liable to it are found in such countries.

BERI-BEri
General Characters a n d "Etiology. Beri-beri or Kak-ke
is a rather widely distributed disease, of which two clinical types
are usually described, the wet or dropsical and the dry or paralytic.
Each form of the disease presents a rather complex but fairly
definite group of clinical symptoms and signs, which the reader
will find described in detail in any of the numerous recent
treatises on tropical medicine. Although the clinical pictures of
the two types of beri-beri are very different at first glance, they
both represent a group of pathological conditions that are apparently
the result of an inflammation of many peripheral nerves. What
this multiple peripheral neuritis is caused by is at present unknown.
It has been very generally held that it must be due either to
some living organism, multiplying in the tissues of the patient,
or to some toxine derived from micro-organisms growing in his
surroundings. Pekelharing and Winkler have described certain
bacilli and cocci as associated with the disease; Glogner, and
later Fajardo of Brazil, have found a form of plasmodium in the
red blood corpuscles of beri-beri patients analogous to the
parasite of malaria. Innumerable other conditions—such as
the consumption of decorticated rice, of damaged grain, of bad
fish, and other imperfections in dietary, climatic conditions,
malaria, ankylostomiasis, etc.—have been put forward as possible
causes of beri-beri, but for the present the etiology of the
disease remains uncertain. Perhaps the most widely held view
as to its causation is that which connects the disease with the
consumption of rice, but whether the poison is a chemical one
or of microbial origin has not yet been determined 1 .
1
A spore-bearing diplobacillus has been found by Capt. Rost, I.M.S.,
in the rice sold in bazaars in an infected district, and also in the blood of 32
beri-beri patients. Indian Med. Gazette, Dec. 1900.

C.

3

34

BERI-BERI

H i s t o r y . The oldest references to the existence of beri-beri
are found in Chinese medical writings. The word kak-ke is said
to occur in a work dating as far back as the year 200 B.C. The
disease is also said to be mentioned in a Japanese medical treatise
of the ninth century of our era. In the seventeenth century there
is mention of it in the East Indies and in India. Its appearance
in the Western Hemisphere is apparently an event of recent
occurrence, as it was not until the year 1866 that it became
epidemic in Brazil—a country which is now one of the principal
endemic centres of the disease in the west.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Pmicipal Endemic
Centres. The geographical distribution of beri-beri is not a
constant one. There are certain portions of the earth's surface,
principally in or near the tropics, where the disease appears to be
more or less permanently endemic. But, as the infection can be
carried for long distances by the movements of human beings,
it is frequently appearing in places hitherto free from it; and as,
in some of these places at least, it finds conditions which favour
its existence, the limits of its prevalence appear to be constantly
widening.
Beri-beri was first recognised and described by Dutch
physicians in the Dutch possessions in eastern Asia, and this
part of the world is still one of the principal seats of the disease.
A widespread epidemic in Brazil in 1866 drew increased attention
to the malady, and since that time it has been closely studied in
many countries where it has prevailed as an epidemic or become
more permanently domiciled.
In the Malay Peninsula and the adjoining archipelago beri-beri
is among the commonest of disorders. Its prevalence from year
to year varies considerably, and in some years it becomes truly
epidemic.
It probably never disappears altogether.
In the
Straits Settlements it was unusually active in 1895, but has been
somewhat less so since; in 1896 the number of cases admitted to
hospital in the Settlements was 2057, in the next year exactly one
more (2058), and in 1898 only 1329. A remarkable outbreak,
however, was observed in the latter year in the Singapore Prison.
Gaols are notoriously liable to be the scene of outbreaks of
beri-beri, but this prison had been practically free from the disease
from 1885 to 1897, only two cases being recorded in the whole
period of thirteen years; at the end of 1897 one or two cases

I

Occasional cases of Ben -ben
met with

|

Doubtful existence of Beriberi
as
an
endenut
disease

60
160

120

80

40

DISTRIBUTION

40

OF BERI-BERI

80

120

160

BERI-BERI

35

occurred, and in 1898 as many as 124 of the prisoners were
attacked by the disease1. Similar instances have been recorded
in other places.
Throughout the East Indian Islands beri-beri is endemic to a
greater or less degree. Whether it is so in each of the numerous
islands of the group is uncertain. It is undoubtedly common in
Labuan, British North Borneo, Sumatra, Java, Celebes, the Moluccas, and in many other smaller islands; prevailing in some, as
for example Borneo, specially on theVeoasts, in others becoming
epidemic at times among labourers in the mines or on the
plantations. Its degree of prevalence varies considerably.
In the men of the Dutch army in the Netherlands-Indies
(European and Asiatic) the recorded cases have diminished in
recent years 2 , but whether this indicates a lessening prevalence
of the disease generally or has been due to increased precautions
to prevent its development among the troops I am unable to state.
The evidence that beri-beri is a common disease in Siam,
Annam, Tongking, and Cochin China is less conclusive. It is
probably not a conspicuous disorder in Siam, as some recent
writers on the prevailing maladies of that country make no
mention of it. In 1892 or 1893, however, a severe epidemic
occurred in a gaol at Bangkok and caused a high mortality.
In Annam and Tongking it is said to be met with in the form of
sporadic cases and also in localised outbreaks.
In China beri-beri is said to have been endemic for ages, but
to be comparatively rare in the present day (Scheube). Manson
states that it has been seen in Shanghai, Tsuchou, Wanchow,
Foochow, Amoy, Swatow and Fatshan, and mentions several
epidemics that have occurred in the past in the gaol and among
the native population at Hongkong. It appears to be seen with
great frequency in the last-named island; in 1899 alone as many
as 197 deaths from this disease were recorded as occurring there
among the Chinese population, the highest mortality being in the
months of October, November, and December. In Swatow an
1
In 1898, of 25,345 admissions to the hospitals of the Straits Settlements
with 4139 deaths, 1329 admissions and 420 deaths were attributable to beri-beri
{Medical Report of the Straits Settlements, for 1898).
2
T h e number of cases of beii-beri in the Dutch army in the East in 1893
was 6174; there were 4994 in 1894; 5676 in 1895; 5780 in 1896, and only
2238 in 1897.

3—2

36

BERI-BERI

epidemic of beri-beri prevailed in 1895. It is certain therefore
that it does exist in China, and the statement that it is rare there
probably needs modification. The Chinese elsewhere seem to be
specially liable to it; and in Calcutta, for example, the disease is
practically confined to the Chinese inhabitants of that city.
Japan is almost as important an endemic centre of beri-beri
as the Malay Islands or Brazil. The disease is said to be met with
in all the islands of Japan, from north to south, and in the interior
as well as along the coasts, but particularly in large, low-lying,
damp, overcrowded cities. Further north the disease has been
seen in the Russian island of Sakhalin, but it is doubtful whether
it is endemic here 1 . It has also been met with in Formosa.
There is little mention of beri-beri in the Philippine Islands,
but in New Guinea it is endemic in places. It is at times very
prevalent in the crews of the pearling fleet in Torres Straits. In
Australia beri-beri was until recently believed to be unknown, but
lately a small epidemic occurred among a group of West Australian
natives and also among Chinese on the eastern sea-board of
Australia 2 . I find no mention of the disease occurring in New
Zealand, but it is said to have been recently introduced into Fiji3,
New Caledonia, and the Society Islands, and perhaps some other
islands in the Pacific.
Turning to the West it is found that in Burma beri-beri is
believed to be endemic, and has in recent times been epidemic as
far inland as Mandalay 4 . In India the Telugus from the East
Coast and Northern Circars appear to be peculiarly liable to this
disease; in 1897, out of a total of 137 cases of beri-beri recorded
in the native army in India, as many as 135 occurred in Madras
regiments, and nearly all the patients were of the race just
mentioned.
Less frequently the disease is observed on the
Coromandel coast, in the Carnatic, and on the Malabar coast,
and it probably exists in the interior, but to what extent is
uncertain. It is constantly seen in Calcutta, where the Chinese
1

I n the Russian health statistics there is no mention of beri-beri.
Molloy (Trans. Intercolonial Med. Cong., Australia, 1892) suggests that
beri-beri is endemic in A u s t r a l i a ; and Graham (Australian Med. Gazette, Nov.
1893) describes an allied disease as epidemic among the Chinese in Sydney.
See also letter fiom Neil MacLeod, M . D . , Brit. Med. Journal, A u g . 14, 1897.
3
Probably by plantation labourers from J a p a n .
4
M. J . E y i e , M.B., Lt.-Col. I . M . S . [Indian Med. Gazette, J a n . 1900),
furnishes some details of recent prevalence of beri-beri in Burma.
2

BERI-BERI

37

community in particular suffer greatly from it, cases of the
disease being daily treated at the Medical College and other
hospitals. In Ceylon it is said to have been very common at
one time, but to have now become very rare.
As south-eastern Asia is the principal home of beri-beri in the
Old World, so is Brazil its most important seat in the New World.
Since the great epidemic of the disease here in 1866 it appears to
have remained more or less permanently established in the country,
occurring in all parts of it, and at times becoming epidemic. In
Rio de Janeiro beri-beri has recently been unusually active; in
1898 from 15 to 20 deaths from the disease were recorded in
some weeks, and it was never absent from the mortality returns as
a cause of death in a single week. It is said that " at first it was
principally men in the navy who fell ill with beri-beri, next the
soldiers on shore, chiefly those of the police, but now [May, 1898]
we observe the sickness has in the same manner attacked private
persons without exception of sex and social position 1 ." So prevalent did the disease become in Rio de Janeiro on this occasion
that it was mentioned, along with yellow fever, in the President's
annual address to Parliament, as a matter requiring the attention
of Government.
In Paraguay beri-beri is said to have been epidemic in the past;
whether it exists there nowT, or in any other country of South
America besides the Brazils, may be doubted. I find no mention
of it as a cause of death in recent reports from Uruguay 2 and the
Argentine Republic, but attention has been called to the occurrence in British Guiana of cases of multiple neuritis which
present many points in common with beri-beri and would very
probably be unhesitatingly classed as examples of that disease if
met with in a country where it is known to be endemic 3 .
Endemic Centres of lesser hitensity.
There remain to be mentioned certain other portions of the earth's surface where beri-beri
has been met with and is perhaps endemic, but where the disease
1

Public Health Reports (Washington), 1899.
T. W. N. Greene {Brit. Med. Journal, Jan. 9, 1898) states that cases are
often seen in the British hospital at Monte Video, but they are mostly in men
of the Brazilian navy. In 25 years he never saw a case outside hospital, either
in the interior of Uruguay or in its capital, and therefore concludes that the
disease is not endemic there.
3
Fowler, Journal of Trop. Med., May, 1900.
2

BERI-BERI

38

is apparently less widely prevalent than in either south-eastern
Asia or the Brazils. It has been seen in many widely separate
parts of the African continent. In German East Africa cases
are occasionally recorded 1 ; in British East Africa it apparently
occurs only on the coast and as an importation from Asia. At
Massowa on the shores of the Red Sea it is said to be unknown;
but cases have been seen at Aden and also at Zanzibar. On the
West Coast the disease is certainly observed in the Gambia, from
one to four cases being returned in most recent annual reports
of the Colonial hospital there.
In the Belgian Congo beri-beri is probably still more prevalent;
it is said to be rare and benign among the white residents, but is
more frequent among the natives. The labourers, both of black
and yellow races, employed on the railway here suffered terribly
from the disease. It raged severely among the native inhabitants
in 1891-2, but has been much less prevalent since—a result
which has been ascribed to an improved r&gime, and particularly
to greater care as to diet 2 . In the Cameroons, on the other hand,
beri-beri has not been seen3.
To what extent beri-beri exists as an indigenous disease in
South Africa it is not easy to say. A few cases are admitted in
some years to the Durban Hospital, and in 1898 as many as ten
came under treatment; two of which were in European residents
of Durban who had never been outside the colony. In some
other years the few recorded examples of the disease in Durban
have been recognised as importations from elsewhere. At Pietermaritzburg it is said to be far from infrequent, occurring not only
among the coolie class but also among the European inhabitants.
In Mashonaland beri-beri is sometimes seen in the natives but
never in the white population.
Madagascar was the scene of an epidemic of beri-beri in
1866-7 which prevailed at Diego Suarez, in the extreme north of
the island, and though the disease is said not to be endemic in
the island generally, a few cases have been seen in the capital.
A disease of a peculiar character, described as "acute anaemic
dropsy," prevailed in Mauritius in 1878 and 1879; it presented
1

Ref. in Janus, 1896-7, p. 389.
Congres Nat. d Hygiene et de Cliniatologie Med. de la Belgique el du
Congo, 1897.
3
Plehn, James, 1896-7.
2

BERI-BERI

39

some points in common with the moist variety of beri-beri, but
differed from it in many important respects, "especially in the
absence of paralysis, in its more evident transportability by human
intercourse, by its attacking almost the whole population of certain
districts, and by the much smaller mortality [in proportion] to the
numbers affected." A similar disease is said to have prevailed in
Assam and Lower Bengal in 1877-80, and the outbreak in
Mauritius was ascribed to importation from India. Neither this
disease nor true beri-beri is now endemic in Mauritius.
In St Helena, on the other hand, the disease has certainly
been seen recently. In the (unprinted) hospital reports of the
colony for 1897 and 1898, as many as 13 cases of beri-beri are
included in the returns of the first year, and 8 cases with one death
in those of the second. No details are furnished as to their
source; but, unless they were examples of imported infection and
if the year in question wTas not an exceptional one, they would
indicate a considerable degree of prevalence of beri-beri in the
island, for in 1897 the number of cases of this disease exceeded
those of any other, and in 1898 were only exceeded by cases of
diseases of the skin, nervous, and respiratory systems. In the
Island of Ascension also a serious outbreak, spoken of as a
"recrudescence," of beri-beri occurred in 1898 among Kroomen
stationed on the island \
It must be regarded as doubtful whether beri-beri exists as
an endemic disease in any part of the North American continent
or the adjoining islands, though it has frequently been imported
to their shores. It is said to have been recognised (though
whether as an indigenous or exotic disease is not stated) in Cuba 2 ,
Guadeloupe, and other islands of the Antilles. A few cases are
occasionally mentioned in the health returns of Jamaica and of
Trinidad. Cases of a form of peripheral neuritis, supposed to be
beri-beri, have been reported as occurring in fishermen on the
North American coast.
Imported Cases of Beri-beri. There are many other countries
and islands to which beri-beri has been occasionally imported,
and without becoming even temporarily endemic has remained
1

Report on the Health of the Royal Navy for 1898.
Beri-beri is perhaps endemic in Cuba; occasional cases of and deaths
from the disease are observed at the present day at Havana; and it was
alarmingly prevalent at Matanzas in December, 1897.
2

40

BERI-BERI

entirely, or almost entirely, confined to the persons who have
imported it. Cases of the disorder are frequently admitted to
the Seamen's Hospital at Greenwich, the patients being usually
from ships newly arrived in the Thames, but not infrequently the
disease develops in the Asiatic crews of vessels which have been
lying up in the river for several months. A very large number
of instances of the carriage of infection of beri-beri by sea over
long distances are on record, and in this way the disease has been
imported to the coast, of California, to New Jersey, to the Bermudas,
to many English and probably many continental ports, to Cayenne
in French Guiana, to South Africa, and to many other parts of
the world. There would seem to be almost no limit to the
distance over which beri-beri can be transported by ships, and
sea-carriage is apparently the principal means by which the disease
has been and is being diffused over the earth's surface.
Ship Epidemics. Ships, indeed, under certain conditions, seem
to be peculiarly favourable, not merely to outbreaks of beri-beri
among the crews, but to its persistence for very considerable
periods, not only in the men originally attacked but even after a
complete change of crew. Such outbreaks, which are apparently
often associated with, if not due to, conditions of dirt, overcrowding, bad ventilation, and an imperfect dietary, were perhaps
more common in the past than they are at the present day. In
former years quite one-fourth or more of the personnel of the
Japanese navy were, it is said, annually attacked by the disease.
Examples of quite recent occurrence are also not wanting. Thus
in December, 1896, the barque "Lodestar" arrived at Falmouth
from Rangoon with a cargo of rice. During the voyage, when
near St Helena and already 92 days at sea, two men developed
symptoms of beri-beri, and later the whole crew were attacked
by the disease and three died. Subsequently this barque was sold
to German owners, was re-christened the "Steinbok " and entirely
remanned, mostly by Norwegians and Swedes, shipped in Amsterdam. On January 27th, 1898, she sailed from Java for New York
with a cargo of sugar; she touched at Bermuda in June, and
reported that on the voyage the whole of her crew, with one
exception, had developed symptoms of beri-beri. It is important
to add that as this boat had visited Java, where this disease is notoriously prevalent, the second outbreak may have been due to a fresh
infection, and not to persistence of infection from the first out-

BERI-BERI

4*

break. Another notable instance was that of the s.s. "Nour-elBahr " in the coastguard service on the Arabian coast of the Red
Sea. She arrived in the Camaran roads on September 21st,
1898, and in the middle of November twelve of the crew, all
Indians, fell ill with beri-beri. This was a new boat, freshly
arrived from Genoa where she was built, and the crew of 33
(28 of whom were Indians) had left Bombay seven months
before the appearance of the disease. In this instance, unless
it was of local origin, the infection must have remained latent
for seven months after its importation from Bombay. In the
same year a remarkable outbreak of beri-beri occurred on a Brazilian
man-of-war, the " Benjamin Constant." She was sent with a crew
of 250 officers and men to the north of Brazil on a voyage of
instruction, arid in the harbour of Para beri-beri broke out. She
went on to Pernambuco, and during the voyage ten men died of
the disease. In the harbour of Pernambuco eight more men died,
and 10 officers and 65 men of the crew were affected by the
malady.
In some of these and similar instances of. outbreaks of beriberi on board ship the insanitary conditions already briefly mentioned have seemed to contribute powerfully to the development
of the disease. Manson has described in lurid detail the hot,
steamy atmosphere in which the crews of some ships live, and the
"sodden state" of the dark, damp, overcrowded, unventilated
places they sleep in. Coming from a warm climate into cooler
British waters they light fires, block up every means of ventilation,
and bring about " a very good imitation of the tropical conditions
the germ of beri-beri requires for its development." " In other
words," it is added, " these lascar sailors create an incubator on
a large scale, which, should it chance to contain a beri-beri germ,
quickly becomes extensively infected and lethal."
Epidemics in Institutions.
It is a well-recognised fact that the
inmates of schools and gaols in the countries where beri-beri is
endemic are particularly liable to suffer from the disease. The
example of the Singapore prison has already been quoted, and a no
less striking instance is found in a severe and fatal outbreak which
occurred in the Rajahmandry gaol in the Madras Presidency in
the year 1898 1 . Labourers in mines and on plantations, or
1
Report on Sanitary Measures in India in 1898-99, p. 21.
Paper, Cd. 397.

Parliamentaiy

42

BERI-BERI

employed in large engineering operations, also appear to be peculiarly prone to its attacks. At Banka and Billiton, in the Eastern
Archipelago, the tin-mining population has frequently suffered from
beri-beri. In Borneo, where beri-beri is regarded as essentially
a jungle-disease, coolies labouring on the estates are frequently
attacked by it. In the Belgian Congo the labourers employed in
constructing the railway suffered terribly from the disease. In
Japan it is said to be particularly prevalent in the mining districts
of Kiushiu.
In like manner bodies of troops have from time to time been
attacked by beri-beri. At Atjeh in Sumatra the troops have
suffered severely from it. In the Japanese army it was very
prevalent in former years.
It is probable that in all these instances overcrowding and
bad hygiene play an important part in fostering the disease.
Finally the occurrence of remarkable outbreaks of beri-beri in
lunatic asylums has to be mentioned, as opening up some difficult
and hitherto unsolved problems in the etiology and epidemiology
of the disease. A well-known example is that of the Tuscaloosa
Asylum, in Alabama, U. S. A. In this institution, which usually
contains some 1200 inmates, a few cases of beri-beri developed at
the end of 1895; they were not severe or apparently of an
infectious character. But in the very hot and dry summer of
1896 the disease became epidemic in the asylum, 71 cases in all,
of which 21 ended in death, being recorded. The larger number
of the .patients were white persons, but negroes were also attacked,
and in them the disease was more severe and fatal.
An analogous outbreak occurred in the Richmond Lunatic
Asylum at Dublin in the years 1894-97. The disease first
appeared here in the autumn of 1894, and by the end of the
year it had attacked no less than 174 persons, and caused 25
deaths. The building was much overcrowded at the time, and
there seemed to be little doubt that this had in some way contributed to the outbreak. In 1896 there was a fresh epidemic of
the disease in the asylum ; it was somewhat milder than the first,
and was the cause of only 115 attacks and 8 deaths. In the
following year a third outbreak occurred, and in this no less than
246 persons suffered from the disease and 11 died. The cause
of this, as of other asylum epidemics of beri-beri, has hitherto
remained obscure. About the same time smaller outbreaks of

BERI-BERI

43

the disease occurred in the Suffolk County Asylum at Melton in
the winters of 1894-5 and 1896-7; and in 1895 a similar
epidemic was reported from the Arkansas State Asylum at Little
Rock, Arkansas State. A few cases of an analogous disease have
also been observed in at least two German lunatic asylums 1 , and
in a French asylum at Saint Gemmes-sur-Loire (Le Dantec).
1

Conolly Norman, F.R.C.P.E, Brit. Med. Journal, Sept. 24, 1898..

B L A C K W A T E R or
HAEMOGLOBINURIC F E V E R .
General C h a r a c t e r s a n d E t i o l o g y .
Haemoglobinuric
Fever or Blackwater Fever is by some regarded as a severe form
of malarial infection, by others as a distinct and separate disease.
It is characterised by fever; the passage of dark, almost black,
urine; bilious vomiting; severe lumbar pain, and other symptoms.
It usually attacks European residents in those countries where it
is endemic in the second or third year after their arrival. It is
one of the most deadly diseases that have to be feared by the
European compelled to reside in tropical Africa, or in the
other countries where it prevails. Its relation to malaria and to
the tick fever of cattle will be briefly discussed later. Its exact
etiology is unknown. Blackwater fever is essentially an endemic
disease, but it can take on epidemic characters both in countries
where it is permanently endemic, and occasionally in other
countries where it is not usually met with.
H i s t o r y . The disease was first described by French naval
surgeons, who observed it in the island of Nossi-Be, off Madagascar.
Comparatively little is known of the history of the disease itself.
It is possibly only of recent introduction into India, as the earlier
writers on Indian diseases make no mention of it. In many other
parts of the world where it is now known to exist attention has
only quite recently been called to it. But there is nothing to
show that the fever had not existed in some of these countries
before, remaining unnoticed, or at least unrecorded. On the
other hand, the disease certainly seems capable of appearing,
under special conditions, in countries believed to be hitherto
free from it. As an example may be mentioned the outbreak

BLACKWATER OR H E M O G L O B I N URIC FEVER

45

among labourers employed in cutting the canal through the
Isthmus of Corinth.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. In Europe
haemoglobinuric fever has occasionally appeared in the form of
localised prevalences, usually for short periods and under special
circumstances. It has been recognised in Sicily and also in the
Roman Campagna. In Sardinia it has been seen, and in 1885
twenty cases of the disease developed in prisoners in a gaol at
Castiadas. During the construction of the canal through the
Isthmus of Corinth it prevailed as an epidemic among the
labourers; and elsewhere it has been associated with soil-disturbance on a large scale. It has also been seen in Rhodes and
other islands in the Greek Archipelago. A few cases have been
observed in England and France in persons returning from Africa
or other places where the disease is endemic.
Asia. In Asia the disease is not common. It is, however,
occasionally met with in India, China, and the eastern Peninsula,
although some observers have denied its occurrence here. Thus
it is said to be far from uncommon in Assam and the Duars. It
is not unknown in other parts of India, but the evidence for its
existence is scanty, and it would appear to be a rare disease here.
Many of the leading writers on Indian diseases (as, for example,
Chevers, Maclean, Fayrer, and others) make no mention of this
fever. But Firth and Notter have described some doubtful cases
as occurring at Mian Mir, Amritsar, and Meerut 1 . Recently some
cases, apparently free from doubt as to their nature, have been
seen in the Darjiling Tarai, or swampy forest-belt at the foot of
the eastern Himalayas, and one case was seen at Sylhet2. In the
Dutch possessions in Malaysia the disease first came under observation after the Atjeh war of 1874-78. Cases occurred at various
places in Java, Celebes, and Borneo. Its occurrence at Singapore
is doubtful.
In French Cochin China it is said to have been occasionally
seen. In China it must be very rare. Manson never saw a
certain case in Amoy, Hongkong, or Formosa, and similar
negative evidence is forthcoming from others from Shanghai,
Hongkong, and north and south Formosa. No mention of the
1
2

Army Medical Department, Appendix to Report for 1885.
Baldwin Seal, Journ. Trop. Med.y Feb. 1899, P- l19'

46

BLACKWATER OR H ^ M O G L O B I N U R I C

FEVER

disease has apparently been made by any of the writers in the
Medical Reports of the Chinese Imperial Maritime Customs
during the ten years ending in 1899. ^n the Chinese army,
on the other hand, haemoglobinuric symptoms were said to
have been frequent in 1885 on the borders of Tongking and
the Chinese province of Kwang-si, and a few cases have been
seen at Fatshan.
Australasia.
In Australasia and the Pacific Islands blackwater
fever is also either unknown or extremely rare, and generally
throughout the Far East the disease is either absent or very
exceptionally met with. In New Guinea, however, cases of the
disease have been seen.
Africa. In Africa, on the other hand, the reverse is the case.
The tropical and subtropical portions of this continent are the
principal homes of hsemoglobinuric fever, which in many places
is the cause of a very serious degree of mortality among European
residents. While in Algeria it is said to be quite unknown 1 , it is
particularly prevalent along the West Coast from the Senegal to the
Kuanza. It is endemic in the valleys of the Senegal, the Gambia,
the Niger, and the Congo Rivers. At JBathurst (Gambia) in 1898,
of four deaths among the Europeans, two were due to haemoglobinuric fever. In the French Sudan it is particularly severe.
At certain French settlements on the Gaboon and on the Gold
Coast, 38 per cent, of the European residents were, a few years
ago, annually attacked by the disease; and on the Upper Senegal
28 per cent., at Cazamance and on the Rio Nunez 15 per cent.,
at Cay or 8 per cent., and at St Louis and Goree from 1 to 3 per
cent, of the European inhabitants, according to the same estimate,
annually suffered from an attack of this fever2. At Sierra Leone
and at Cape Coast Castle Europeans are no less liable to it; and
at the last-named place it is the principal cause of mortality. In
the Congo Free State it is a prolific source of invaliding and death.
One estimate has placed the mortality from this cause in a group
of Congo Free State employees between the years 1878 and 1892
at from 11 to 12 per cent, of the total mortality from all causes.
Of 23 deaths among Baptist Missionary Society missionaries on
the Congo six were due to this malady. In 1896 it became epidemic
in Boma. At Chisamka, Angola, in Portuguese West Central
1
2

Brault.
Ref. in Trans. Epidem. Soc, N. S., vol. XII., p. 123.

DISTRIBUTION

OF

BLACKWATER

FEVER

BLACKWATER OR H E M O G L O B I N U R I A FEVER

47

Africa, cases of the fever have been observed at a spot 300 miles
from the west coast and 400 miles south of the Congo 1 .
In British Central Africa blackwater fever is a frequent
disease, and about 10 per cent, of the European residents, it is
estimated, are attacked by it. In this part of Africa it is said to
be more common on elevated; than on low-lying ground, but the
reverse appears to be the case elsewhere. It is known in British
East Africa, in Uganda, in Gennan East Africa, and at least one
case has been seen in Somaliland2.: In Uganda it is thought to
be increasing in frequency.
It is frequently seen on the banks of the Zambesi and the
shores of Lake Nyassa 3 , and unmistakable cases of the disease
have been met with in the Shire highlands. It has been observed in Mashonaland, though it is not common there, and even
as far south as the colony of Natal it has, though exceptionally,
been seen.
It is common in Madagascar, not only in the lower-lying
regions, but also in the more elevated district of Antsianaka,
where it prevails especially in the cool season. It is also common
at Nossi-Be (where the disease was first described as a separate
entity); and at Mayotta in the Comoro Islands it is very
prevalent.
North and Central America. In North America haemoglobinuric
fever has been met with as an indigenous disease in the southern
States, especially in Florida, Georgia, and the States in the basin of
the Mississippi river. In the West Indies it is sometimes seen,
and in Cuba it is not infrequent; in Jamaica it is less so, and one
observer there saw three cases only in the course of twenty years;
occasionally a single case of the disease is recorded in the annual
reports of the Island Medical Department. In Martinique and
other French West Indian possessions it is said to prevail; but in
St Vincent, St Lucia, and other British possessions in the West
Indies it is probably not common, as no mention of it is apparently
found in any of the recent annual health reports of these islands.
In regard to Trinidad, however, Dr Bennett, the Government
Medical Officer, has himself seen one case of blackwater fever and
has heard of two others in the island; while in 1901 five fresh
1
2
3

Massey^Joum. Trop. Med., Feb. 15, 1901. *
Crosse, Epid. Soc. Trans., N. S., vol. xvni., p. 114.
W. ¥oQ\e,Journ. T?-op. Med., Jan. 1899.

48

BLACKWATER OR H ^ M O G L O B I N U R I C

FEVER

cases of the disease were recorded there. In British Honduras
also cases have been met with.
South Ame7-ica. In Venezuela this form of fever is said to be
exceedingly prevalent and particularly deadly in the plains, but
less common in the highlands 1 .
The disease is apparently endemic in British Guiana; several
sporadic cases are mentioned in the Surgeon-General's report for
the year 1898-99 as occurring in Cotton Tree district and in
other parts of the colony. In Brazil it has not been met with,
and with regard to the other portions of South America there is
an absence of information which may be held to indicate that the
disease is rare if not unknown.

Factors Governing the Geographical Distribution.
The difficulties surrounding the diagnosis of hsemoglobinuric
or blackwater fever, the uncertainty as to its specific nature
and causation, and the confusion which of necessity has arisen
between this disease and other analogous diseases, such as
paroxysmal haemoglobinuria, renders any exact account of its
geographical distribution almost impossible. Our knowledge of
its true position in the category of disease is at present imperfect.
It is only in comparatively few countries that its existence has
been determined with accuracy. These have been named above,
and their position is shown in the accompanying map. But it is
far from certain whether the disease does not exist, actually or
potentially, in many other countries besides those named. If
there is any truth in the theory (which will be referred to later)
that hsemoglobinuric or blackwater fever in man is the same
disease, and due to the same cause, as "redwater fever" or
"tick fever" in cattle, then it is clear that the geographical
distribution of this disease, or at least of the micro-parasite which
produces it, is wider than is at present believed. Australia and
South Africa, for example, would have to be mentioned with
other countries as important homes of the disorder. But until
further light is thrown upon this subject it would serve but little
purpose to treat the two diseases as one and the same. It is not
known that they are due to the same parasitic cause, and even if
that were proved, there is still an absence of proof that in those
countries such as Australia, South Africa, and Texas, where the
1
Ackers (of Caracas), quoted by Manson, Epid. Soc. Trans.,
vol. xii., p. 126.

N. S.,

BLACK WATER OR HAEMOGLOBIN URIC FEVER

49

parasite is widely spread in animals, it affects man to any extent.
It is better, therefore, to confine the present consideration of the
disease to those countries where it is known to exist in man.
The limits of prevalence of black water fever, though they
cannot be stated with absolute accuracy, appear to be approximately as follows. In Europe it has not been seen as an indigenous disease further north than Italy. In Asia, Assam and
(perhaps) the southern portion of China appear to represent the
most northerly limits of the affection. In the Western hemisphere it has not been recognised north of the " Southern United
States." In the southern hemisphere hsemoglobinuric fever has
not been observed further south than the latitude of Natal, and
there only as an exceptional, and perhaps imported disorder.
In general terms the utmost limits of latitude in which this disease
has been proved to exist may be said to be the 45th parallel to
the north and the 35 th parallel to the south of the equator.
Briefly, then, hsemoglobinuric fever prevails principally in the
tropical and subtropical portions of Africa and in Madagascar,
and to a less extent in the corresponding area of North, Central,
and South America, and the West Indies. It is rare but not
unknown in India and the Far East, and has been seen in certain
parts of Europe, principally on the shores of the Mediterranean.
It is mainly therefore a disease of warm or hot climates.
It prevails principally, but far from solely, in low-lying regions.
In Africa it is very frequently seen along the valleys of the great
rivers, such as the Senegal, the Zambesi, the Congo, and the
Niger; and in America the Mississippi valley is mentioned as a
region where the disease is common. But it is also met with at
considerable heights, as for example in the Shire highlands and
on the high plateaux of Madagascar, while, as already pointed
out, in Venezuela it occurs in the high lands, though it is more
common and assumes a severer form in the plains. In its
endemic areas it is variable in its prevalence. " It may not be
seen for years in a district and then numbers of cases may occur
within a short time."
Its relation to race is uncertain. Most authorities are agreed
that it attacks Europeans far more than the natives; but the late
Dr G. F. Reynolds stated that in Western Africa it attacked natives
more frequently than Europeans 1 . In the Belgian Congo old
1

C.

Journ. Trop. Med>, 1899, P* r45*
4

50

BLACKWATER OR H/EMOGLOBINURIC

FEVER

Africans frequently suffer from it. In the Antsianaka district of
Madagascar, on the other hand, the Hovas, who are as prone as
the white residents to all forms of malaria, are said to be immune
to haemoglobinuric fever \ It is to be noted also that some
Europeans appear to be immune to the disease, and may live for
long periods in places where it is endemic without contracting it.
Estimates vary widely as to the proportion of European residents
in such places who may be expected sooner or later to suffer from
it, but one good observer places it as low as only 10 per cent.2
When Europeans are attacked it is generally during the second or
third year of their residence.
Recently the analogy between blackwater fever and paroxysmal
haemoglobinuria in man and "Texas fever," "redwater fever"
or "tick fever" in cattle has attracted much attention.
The
relationship of blackwater fever to paroxysmal hsemoglobinuria is
uncertain, but Sambon has shown that the symptoms and morbid
anatomy of the two diseases are practically identical. Without
going so far as to regard them as one and the same disease, he
points out that the high mortality of blackwater fever (in which
alone it seems to differ from the other) may be due to the fact
that it usually attacks " t h e wrecks of severe tropical malaria."
The same author is of opinion that blackwater fever is probably
due to a protozoal parasite which, if not identical with, is
very similar to, that which produces Texas fever in cattle. This
disease, which has been shown to be associated with, if notcaused by, a blood parasite to which the name Pyrosoma
bigemvium has been given, has been recognised not only in
Texas, but in South Africa, Australia, Roumania, on the shores
of the Danube, and in the Campagna near Rome. The fever
described by Koch as prevalent in German East Africa is probably
of the same nature. It is believed that the parasite gains access
to the blood of the cattle through the bites of the cattle-tick,
Boophilus bovis; it has, at any rate, been shown that animals
never become infected unless they have fed in a field previously
infected with this tick. In South Africa, Edington has successfully practised a method of prophylactic inoculation against the
disease in cattle, and a similar method has been recently tried,
1

Laffay, Archives de Med. Navale, Oct., 1899.
Crosse, circular on Blackwater Fever for the Medical Department,
Brit. Central Africa.
2

BLACKWATER OR H^EMOGLOBINURIC FEVER

51

with satisfactory results, in Queensland.
In this colony the
disease was first imported in 1894; it has spread, in consequence
of the absence of restrictive measures, far to the south of the Tropic
of Capricorn, but has not yet obtained a footing on the dry western
plains of Australia, and is (or was in 1898) confined to the more
humid eastern seaboard 1 . The results of inoculation were most
successful in this colony. Dr Tidswell reported in 1899 that
17,960 head of cattle had then been inoculated with the blood of
animals that had already passed through an attack of the fever,
and it had been found that, whereas before the introduction of
this practice the mortality had been between 60 and 70 per cent.,
it fell afterwards to between 3 and 5 per cent.2
Whether hsemoglobinuric fever in man is due to the same
organism as the redwater fever of cattle is uncertain. Proof of
the transmission of the organism from the cattle-tick to the human
host is at present wanting.
The exact relationship of haemoglobinuric fever or blackwater fever to malaria has not, as already pointed out, been
finally determined. It appears, however, to be no longer open to
doubt that the condition of hsemoglobinuria with fever frequently
occurs in malarial subjects in whom the malaria parasite is present;
that it may also occur in persons who have never suffered from
malaria and in whom the malarial parasite cannot be found; and
that its geographical distribution corresponds to that of malaria
only to the extent that it is found in many notoriously malarial
regions on the earth's surface, but in far from all, and that there
are wide tracts or whole countries in which malaria even in severe
forms is endemic where haemoglobinuric fever is unknown or
extremely rare. It seems probable that persons who have suffered
or are suffering from malaria^ are more liable than others to
attacks of the disorder. On the West Coast of Africa, where blackwater fever is the most fatal type of fever met with, it has been
observed that " the more malarious a district is, the more malignant and fatal is the type of blackwater fever met with there 3 ."
1
See a paper on "Queensland's Progress" by Sir Horace Tozer, Agent
Genl. for Queensland, read at the 3rd Ordinary Genl. Meeting of the Royal
Colonial Institute.
2
Report by Dr. Frank Tidswell to the New South Wales Government,
Journ. Trop. Med, May, 1899.
3
G. F. Reynolds, Journ. Trop. Med., Jan., 1899. Dr Reynolds himself died from blackwater fever the month after his paper appeared.

4—2

52

BLACKWATER OR H^EMOGLOBINURIC

FEVER

In the Belgian Congo old Africans the subjects of chronic
paludism are said to be specially liable to attacks of blackwrater
fever1.
In their seasonal relations the two diseases have also much in
common. In some parts of the West African coast both malaria
and blackwater fever are least prevalent during the rainy season
and in the dry season, and most so during the periods of transition
from one of these seasons to the other. But this parallelism
between the two diseases is far from being universal, and at Lagos
cases of blackwater fever are said to occur all through the year
and quite independently of the presence or absence of malaria 2 .
If haemoglobinuric fever is in truth only an intensified form of
malaria it is at least remarkable that, as just pointed out above,
its geographical distribution should be so much more circumscribed than that of the various other forms of fever included
under the general term "malaria." Ordinary "malaria" is widely
prevalent in India, China, and the Far East generally, and yet, as
already shown, blackwater fever though met with in these regions is
a rare disease there. From both English and French possessions
in Eastern Asia multitudes of invalids return yearly to Europe,
many suffering from " malaria" in one of its numerous forms, yet
cases of hasmoglobinuric fever are practically unknown among
them. Among invalids returning from Africa, on the other hand,
the disease is far from uncommon.
Like malaria, blackwater fever is said to have appeared
concurrently with earth disturbance. Laffay has recorded this
fact in connection with the prevalence of the disease in
Madagascar. Crosse also records that the fever has become
much more prevalent in recent years in the Niger Territories
and this he attributes to the turning up of virgin soil for coffee
and other plantations. Before 1886 the disease was unknown
in those regions, and it was only after the introduction of
extensive coffee plantations that it began to prevail.
"It
is significant," this author adds, "that our first three gardeners
died from blackwater fever, and that for some considerable time
cases only occurred near the plantations; and as plantations
became more common, so the disease spread to the other stations
1

Congres National d'Hygiene et de Climatologie Medicale de la Belgique et
du Congo> 1897.
2
Strachan, Journ. Trop. Med., Feb., 1900.

BLACKWATER OR H^EMOGLOBINURIC FEVER

53

in the territories 1 ." The occurrence of blackwater fever among
the labourers employed in constructing the canal through the
Isthmus of Corinth has been already mentioned as an example of
the association of this disease with soil disturbance on a large
scale.
A few years ago it was suggested that blackwater fever is
nothing more than the result of quinine poisoning. This view
was first propounded by the Italian observer, Tomaselli, and has
been supported by no less an authority than Koch. But the
arguments on which the theory is based are scarcely convincing,
and an abundance of observations have been published tending
to disprove it.
1

Guy's Hospital Gazette, Oct., 1898.

CALCULUS (STONE IN T H E
URINARY PASSAGES).
General C h a r a c t e r s a n d E t i o l o g y . Stone may form in
any part of the urinary tract. Hence renal, ureteral, vesical and
urethral stones are all met with. The chemical constituents vary
widely. Uric acid, urates, oxalates, various phosphates, calcium
carbonate, cystin, xanthin, and concretions of blood and fatty
matters are the principal varieties of substances found in urinary
calculi. Two or more of these are often seen together in the
same stone.
The mode of formation of a stone is uncertain. In some a
foreign body forms the nucleus; in others the ovum of a bilharzia
worm; in the majority no definite nucleus is discoverable, and it
is surmised that excess of earthy constituents in the renal secretion,
combined with an habitually concentrated condition of the urine,
leads to deposit of one of the salts named, and that this forms
a nucleus around which fresh deposits are successively formed,
leading to the production of a stone. The matter is, however,
still a subject of controversy, and it is probable that the true
pathology of calculus is less simple than it appears. Gout is
probably a strong predisposing factor in the production of some
kinds of stone.
G e o g r a p h i c a l D i s t r i b u t i o n . Europe. Urinary calculus
is met writh to some extent in all European countries. In England
it is not a particularly common disorder; in Scotland it is rather
more frequent, but in Ireland it is exceedingly rare. In England
the Eastern and Southern counties and the West Riding of
Yorkshire formerly furnished a larger number of cases of the
disease than other counties. I have no recent information in
regard to France, but the tendency of the disease has been to
decrease there during the last century. In Holland it was at one

CALCULUS

55

time very frequent, but is now less so. In Germany stone is, or
was several decades ago, rare, except in a small portion of the
Duchy of Altenburg, and in parts of Old Bavaria and Upper
Swabia.
In Denmark, Norway, Sweden, Iceland, and Finland stone is
very rare. In Russia, on the other hand, while infrequent in the
extreme north, the disease is very common in many of the central
governments. The recently published returns do not give the
figures for each government separately, and the territorial groups
for which statistics are available are unfortunately, so far as
concerns European Russia, more of administrative than of geographical interest. It will, however, be useful to give the figures
for the principal divisions of both European and Asiatic Russia.
I have worked out the proportions from the reports of cases
treated both in and out of hospitals in each of the years
named:—
Cases of Urinary Calculus per million

inhabitants.

The first two columns of this table comprise the greater part
of European Russia. I cannot account for the great difference in
the frequency of stone between those governments with and those
without the system of local self-government known as the Zemstvo.
It is true that the second column includes a greater proportion of
governments in the north of the country than the first; but the
Baltic provinces are also in the north, and they return more cases
of stone than any other part of Russia. The only statement,

56

CALCULUS

indeed, in regard to European Russia which these figures justify,
is that stone,is very common on the shores of the Baltic, less so
in most other parts of the country, still less so among the Don
Cossacks, and least so in Russian Poland.
Concerning the rest of Europe it seems that calculus is very
rare in Switzerland, but not infrequent in Hungary, Italy, and in
parts of Turkey and Greece. Recent information in regard to
Spain seems to be lacking.
Asia. The figures given in the table on page 55 seem to
indicate that calculus is very much rarer in all parts of Asiatic
Russia than in European Russia. The returns from the former,
however, in regard to this as to all other diseases, are much less
complete and reliable than those from the latter.
In Asia Minor, Arabia, Syria, Mesopotamia, Persia, and
Afghanistan, urinary calculus is remarkably common. But of
all Asiatic countries India is the one in which stone is most
frequently seen. It is, indeed, probably more prevalent here
than in any other part of the world. The urate and oxalate of
lime stones are the varieties most often seen. Rare in Madras,
they are extraordinarily common in the Punjab, and even more
so in Hyderabad in Sindh. Freyer states that " broadly speaking,
stone is mainly confined to the Punjab, North-West Provinces
and Oudh, the upper part of Bombay (Sindh and Gujerat) and,
to a lesser extent, Central India—that is, chiefly to the great
alluvial plains watered by the Indus and upper half of the
Ganges 1 ." In Farther India stone is found to be common in
Bangkok, and still more so in some other parts of Siam (Gowan).
It is rare, on the other hand, in the Malay Peninsula.
In China stone is seen principally in and near Canton; it is
extremely frequent here, but in other parts of the empire it is only
occasionally seen.
In Australia, New Zealand, and the Pacific Isles, calculus is
said to be a very rare disorder.
Africa. The natives of Upper and Lower Egypt are very
subject to urinary calculus. In Abyssinia, in Morocco, and in
Algiers the disease is also somewhat common; it is less so in
Tunis; and in Nubia, Uganda, and the great zone of tropical
Central and Western Africa it is remarkably rare. Information
as to its prevalence in South Africa seems to be incomplete.
1

Brit. Med. Association, 1901.

CALCULUS

57

America. Rare in Alaska, stone is comparatively common in
many parts of Canada. In the United States it is, or was, most
frequently seen in Kentucky, Tennessee, Virginia, Ohio, the
North of Alabama, and perhaps Missouri l ; while in the rest of the
States it appears to be comparatively infrequent.
The data for Central and South America are extremely scanty,
but they seem to indicate that calculus is rare throughout, with
the possible exception of Entre Rios and perhaps certain parts
of Brazil.
F a c t o r s c o n c e r n e d in t h e D i s t r i b u t i o n . Climate can
scarcely be regarded as having any very direct influence upon
the frequency of stone. The disease is very common in tropical
India, in the temperate zones of Europe, and in the decidedly
cold Baltic provinces of Russia. It is, however, rare in the far
north of both hemispheres. If climate has any effect on the
production of stone, it is probably an indirect one. In India,
for example, the area where stone is common is, according to
Freyer, "characterised by the scantiness of its rainfall as compared with the rest of India." " It is further characterised," he
adds, " by great alterations in temperature, being intensely hot in
summer and cold in winter. These two conditions—the scanty
rainfall and intense heat—promote excessive perspiration, most
of the fluids of the body thus passing off by the skin and leading
to concentration of the urine. It is reasonable to suppose that
this condition would be more likely to facilitate the deposition of
crystals in the urinary passages than that prevailing over the rest
of India where the rainfall is heavy and the temperature equable,
thus checking the perspiration and leading to dilution of the
urine. It is very suggestive that even in the stone-producing
region itself the incidence of stone is, as a rule, in direct
proportion to the scantiness of the rainfall and the intensity of
the heat." Similar conditions, however, prevail in the Caucasus,
Central Asiatic Russia, and elsewhere, without being associated
with great frequency of stone.
Calculus occurs on every variety of soil, and the belief
formerly held that it was commoner on chalk formations than
on others does not seem to be any longer tenable.
The nature of the food usually eaten does not seem to have
Gross, quoted by Hirsch.

58

CALCULUS

any influence on stone formation. Animal and vegetable eaters
are found to be equally liable. The water drunk is, however,
more liable to suspicion. The presence of lime salts in drinking
water has long been regarded as predisposing those who drink
it to stone. The evidence on this point is extraordinarily contradictory and inconclusive, and there is not room here to discuss
it. Briefly it would seem that, while excess of this constituent in
water has often been found associated with prevalence of stone, it
is by no means necessary to such prevalence, for stone may occur
with frequency in regions where the water is free from lime salts.
That stone and "endemic hsematuria" undoubtedly occur
with great frequency in the same parts of Africa has long been
known; but the explanation has only been forthcoming since the
discovery of the bilharzia hgematobia and its relation to the
haematuric disease. In the endemic areas of this disease stone
is found to be frequently produced by deposits forming round
a bilharzia ovum in the urinary passages.
The female sex is much less liable to urinary calculus than
the male. The effect of race is uncertain; but the pure-blooded
negro enjoys a remarkable, if not absolutely complete immunity
from the disease.

CANCER or MALIGNANT DISEASE.
Under the term " malignant growths " or " cancer " is included,
it need scarcely be said, a considerable variety of different pathological conditions. It is very possible that some of these differ
from the others entirely in their mode of production, and it may
well be that a fuller knowledge of their nature will demonstrate
the impropriety, from a scientific point of view, of grouping
together phenomena so distinct as, for example, epithelioma and
sarcoma. It has however become the custom among those who
prepare mortality or disease statistics to form a special group
under some such heading as that given to this chapter, and in
many instances no attempt is made to differentiate the statistics
of the various kinds of growth included under this heading. The
principal forms of growth thus grouped together are the varieties
of carcinoma, sarcoma, and epithelioma, which, while probably of
"developmental" origin, all present that character of "malignancy"
which it is .unnecessary here to define more^fully. This group of
growths has a very wide geographical distribution, but like most
other forms of disease their distribution is far from even over the
earth's surface, and in some happy countries, such as the Faroe
Islands and Arabia, they are said to be almost, if not quite
unknown.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. In England
cancer or malignant disease annually causes between twenty-six
and twenty-seven thousand deaths, and there has for many years
past been a steady and almost unbroken rise not only in the
total number of deaths from this cause, but also in the proportion
which it bears to the population. The Registrar-General, in his
report upon the mortality in England and Wales for the decennium
1881-1890, pointed out that the death-rate from cancer or

6o

CANCER OR MALIGNANT DISEASE

malignant disease had risen from 384 per million living of all
ages and both sexes in 1861-1870, to 468 in the succeeding
decennium, and to 589 in the decennium 1881-1890.
This
rise was partly accounted for by the transference, during the
years 1885 to 1890, of a considerable number of deaths from
other groups to this group in consequence of further inquiries
made into the cause of doubtful deaths, in accordance with a
system which was not in practice in previous years. It was,
further, partly accounted for by improved methods of diagnosis,
a certain proportion of deaths formerly ascribed to other causes
being now more correctly attributed to malignant disease. But
after these sources of fallacy have been eliminated, a large
difference between the figures for the earlier and the later periods
remains and can only be explained as due to a really increased
prevalence of this form of disease. The annual figures, published
since the year 1890, have shown that this increase is maintained.
In the years 1891 to 1900 the annual mortality from this cause
per million living has steadily risen from 692 in the former year to
828 in the latter. During the 28 J years ending in 1897 the average
increase in mortality from malignant disease had been as high as
3*i per cent, per annum in males, and 1*9 per cent, per annum in
females, but the proportional mortality still remains considerably
higher in females than in males. The area of greatest prevalence
of malignant disease before 1890 was situated in and around the
counties of Huntingdon and Cambridgeshire, and consisted of
the districts of Stamford, Bourn, Spalding, and Holbeach in
Lincolnshire, Oundle and Peterborough in Northamptonshire,
and the entire counties of Huntingdonshire and Cambridgeshire,
with the exception of the registration districts of Caxton, Linton,
and Newmarket. In 1881-1890 this area had a mean population
of over 300,000, and its crude cancer-mortality rate was 859 per
million, or 46 per cent, higher than the general English rate. In
the preceding decennium the excess over the general English
rate had been 44 per cent. After correcting for age and sex
distribution, and taking the death-rate for age-groups above 35
only, it was found that the highest cancer rates were in Huntingdonshire, Cambridgeshire, Sussex, and North Wales; and the
lowest in Monmouthshire and Derbyshire.
In Scotland the mortality from cancer or malignant growths
increased from an average of 580 per million per annum in the

CANCER OR MALIGNANT DISEASE

6l

decade 1881—90 to 730 in each of the years 1895 and 1896, and
to 770 in 1897. In Ireland a very marked rise has also been
observed, the cancer mortality in the years 1881-90 being
equivalent to a ratio of 410 per million, while in the preceding
decade it had been only 340 per million inhabitants. In 1900
it has risen to 600.
In France there is also reason to believe that cancer is
increasing. The official statistics, however, include "cancer and
other tumours " under a single heading and it is possible that the
term "other tumours" may include some new growths of a
benignant character. The deaths from these causes in French
towns of over 10,000 inhabitants steadily rose from an average
of 840 per million in 1887-1890 to 1050 per million in 1898.
These figures referring to urban populations only cannot, of
course, be compared with those for the British Isles, which apply
to urban and rural populations together.
Other European States in which cancerous diseases prevail to
a considerable extent appear to be the Low Countries, Germany,
Norway, Sweden, Switzerland, Greece, and Austria. In all of these
countries there is reason to believe that they are increasing in
frequency.
In Holland this group of diseases has become considerably
more prevalent in the past decade; in the year 1889 the total
deaths registered from this cause were 3411, and the ratio per
million of the population was 750; but in each succeeding year
(with one slight exception) the mortality has steadily increased,
until in the year 1898 the number of deaths from these causes
was 4685 and the ratio per million of the population was 930,
or considerably higher than that observed in the English " cancerarea " already described.
In Germany cancer is said to be somewhat less common than
in England or in Sweden, but is yearly increasing in frequency.
In Denmark, at least in the urban population, deaths ascribed
to malignant disease have also increased in number in recent
years. There have been considerable fluctuations in the annual
returns under this heading, but on the whole the tendency is
towards a regular increase. The deaths from cancer of the
stomach rose from 299 in 1892 to 385 in 1896 and 377 in 1897 ;
those from cancer of the uterus from 106 in 1892 to 118 in 1897 ;
those from cancer of the female breast, in the same period, from

62

CANCER OR MALIGNANT DISEASE

32 to 66, and those from cancer in other parts from 400 to
493. Deaths from cancer in all these forms, taken together,
rose in the six-year period from a total of 837 to 1054. This
indicates a very high degree of mortality, and in this portion of
the Danish population deaths from cancer exceed those from all
the principal acute febrile diseases taken together. The lastnamed figure represented a mortality in the urban population of
over 1300 per million.
A similar increase has been observed in Norway. In the
quinquennium 1881-1885 cancer yearly caused an average of
945 deaths, or 5 '6 per cent, of the mortality from all causes; in
1886-1890 these figures rose to 1083 for the average annual
number of deaths from the disease, and 5*84 for the percentage
ratio. In the four following years the total deaths from cancer
were respectively 1224, 1278, 1405, and 1449, and the percentage ratios to total deaths from all causes were 6*44, 5*9,
6*39 and 6*2 respectively; the last-named figure being equivalent
to a mortality-rate of about 700 per million living.
In Sweden the death-rate from cancer in 1886-7 was no
less than 950 per million.
The returns of cancerous diseases in the Russian Empire are
very incomplete, and no figures are in fact available to enable an
opinion to be formed as to the relative frequency of these maladies.
Each successive year, however, certain groups of " cases " and of
" d e a t h s " from these causes are recorded in two tables dealing
with diseases treated " i n s i d e " and "outside" the hospitals
respectively. The figures in these tables do not represent more
than a small proportion of the total cases of and deaths from the
various diseases included in them, but it is probable that they
represent more or less nearly the same proportion each year, and
it is therefore interesting to note that so far as they go they seem
to represent a marked increase in the mortality from cancer, and a
great increase, followed by a slight fall, in its prevalence in recent
years. Thus this special group of cases of cancer rose from an
average of 48,506 in the years 1887-92, to 70,005 in 1893, t n e n
fell to 65,025 in 1894, rising again to 69,329 in 1895. The group
of deaths, on the other hand, rose from an average of 3,408 in the
years 1887-92, to 3,942 in 1893, 4,092 in 1894, and 4,529 in
1895. These figures indicate a very marked rise in the period in
question; and if the total numbers of cases and deaths have

CANCER OR MALIGNANT DISEASE

63

followed the same course as the numbers in these special groups,
it would appear that cancerous diseases have recently become
much more frequent in Russia as they have elsewhere.
In Austria cancerous diseases are said to be far from rare, but
I have not succeeded in obtaining recent statistics for their degree
of prevalence. Switzerland is also spoken of as a country in which
this class of disease is particularly fatal. In Bohemia cancer is
believed to be on the increase; in Prague, at least, cases of the
disease are said to be more commonly seen than formerly1.
In Servia cancer would appear to be comparatively rare. In
the year 1894-5 only 156 deaths were ascribed to this cause in a
population of 2,312,484. The mortality rate per million living
was therefore 67 ; and the deaths from " c a n c e r " were only 1*92
per cent, of the total deaths from all causes. In European
Turkey all forms of malignant growths are seen, but no statistics
as to their frequency are available for comparison with other
countries, and I cannot learn that they are either exceptionally
common or the reverse. In Greece cancer is frequent, and is
said to have become more so in recent years.
In Italy cancer gives rise to a considerable annual mortality.
In the decennium ending in 1896 there was an increase in the
number of deaths returned under this heading, the mortality
figure having risen from 428 per million living in 1887 to 496 in
1896. The rise was not quite an unbroken one, and it will be
seen that the mortality from this cause in Italy was in 1896 about
the same as it was in England four decades ago. Cancer is
distinctly more prevalent in England and a fortiori in Sweden than
it is in Italy.
In Iceland malignant growths are very rare, and in the Faroes
they are said to be quite unknown.
Asia. For the greater part of the Asiatic continent no
accurate information as to the prevalence of malignant disease
is available, and with one or two exceptions it is only possible to
assert in regard to Asiatic countries that cancer is believed, on
more or less good authority, to prevail in a greater or less degree.
For many parts of the continent no information of any kind is to
be obtained. The following are the principal features of the
distribution of this class of disease in Asia so far as is known
1

Dr Skalicka at Conference of Czech Naturalists and Physicians, 1901.

64

CANCER OR MALIGNANT DISEASE

at present, but later and fuller knowledge may very probably
throw a different light upon the subject.
In Persia cancer is said to be either very rare or almost
unknown. In the Caucasus, on the other hand, it is perhaps far
from uncommon; in the returns of the Tiflis municipal hospital
patients of all nationalities are mentioned as suffering from this
form of disease, Russians and Armenians being apparently more
liable than persons of other races 1 . Throughout the Arabian
plateaux and in Syria cancer is said to be extremely rare, if not
unknown. In Asia Minor it occurs, but as to its relative frequency
information is lacking.
Hitherto it has been generally thought that the natives of
India were comparatively free from malignant growths, but this
opinion was probably based on insufficient knowledge of the facts.
Dr Leonard Rogers, Professor of Pathology in the Medical College,
Calcutta, states that the records of autopsies performed in the
College Hospital furnish figures which "show that malignant
diseases not only occur in natives of India, but may be said
to be common among them." Buchanan, on the other hand,
does not think that cancer or other malignant disease is by any
means so common among natives of India as in Europe, and he
adds that among British and native troops, and among prisoners
(for all of whom accurate statistics exist) there are very few
admissions to hospital recorded for these diseases. It is to be
noted, however, that these statistics only refer to a limited class
of the population in regard to sex, age, and occupation, and are no
true indication of the frequency of these affections. From a
recent correspondence in the columns of the Lancet it may be
gathered, from numerous rather conflicting statements, that while
cancerous growths do occur in India, both among Hindus and
Mohammedans, they are probably considerably less frequent than
in many European countries.
In Kashmir malignant disease is met with, but with no great
frequency, in spite of the presence of many rivers which annually
overflow their low-lying banks—conditions which have elsewhere
been believed to favour the prevalence of cancer. Epithelioma
of the thigh is seen here in men, produced by local irritation, and
cancer of the female breast is also met with.
3
Statistics of Caucasian Pathology.
(in Russian).

By Dr I. I. Pantiukhof.

Tiflis, 1898

CANCER OR MALIGNANT DISEASE

65

In Ceylon cancer showed a marked increase in the early
years of the last decade, the registered deaths from this cause
rising from 129 in 1891 to 235 in 1893; but there has since
been a diminution, and in 1897 the deaths from cancer were
only 177, indicating a mortality ratio of about 54 per million.
In Farther India and the Malay Peninsula malignant disease
is not common. Gowan, during four years' residence in Siam,
states that he occasionally saw cases of osteo-sarcoma, and also of
epithelioma, but had never come across a case of cancer of the
female breast. Another observer, Rasch, states that he never
met with sarcomatous disease in Siam 1 , and in the Laos country
cancerous disease generally would seem to be equally rare 2 .
In the East Indian Islands this form of disease must also be
rare. Nieuwenhuis never saw a case of either carcinoma or sarcoma
in the natives of Borneo, and he adds that in consequence of the
scanty clothing worn by the people it would be difficult to overlook cases were the disease at all common 8 . It is, however,
known there, and in Java cases of carcinoma have been occasionally seen by at least one observer, among the hill tribes of
that island 4 .
The Chinese appear to be more liable to malignant growths
than other eastern races, and immense sarcomatous tumours have
been described by writers in the Chinese Customs Medical
Reports, as observed by them in natives of the country. Of the
relative frequency of this form of disease in the greater part
of China, however, little appears to be known with accuracy.
Maxwell has recorded, in the southern province of Fokien, the
occurrence of most of the forms of malignant disease, but is of
opinion that there are " many fewer cases than at home."
In Corea cancer is said to be far from common; the forms
most often met with are myeloid sarcoma of the jaw and
epithelioma of the tongue and mouth 5 .
Australasia.
In New Guinea cancer must be very rare, at
any rate among the natives. Sir William MacGregor states that
only one case of the disease has been seen in a native of British
1
2
3
4
5

C.

Janus\ 1896-7, p. 445.
Hanson, Pacific Medical Journal, Jan. 1902.
Ref. in Janus, 1899, p. 422.
Kohlbriigge, Janus, 1897-8, p. 221.
Chinese Customs Med. Reports, No. XLVIII. 1894.

66

CANCER OR MALIGNANT DISEASE

New Guinea, and that it was in a person who had lived for many
years more like a European than an islander 1 .
In Australia, on the other hand, cancer is prevalent to a considerable degree, and in some parts of the continent it is increasing
in frequency. In Queensland the mortality from this cause was
284 per million inhabitants in 1893 ; in the following year it rose
to 358; in 1895 ^ w a s 4 r 7 5 m 1896, 392; and in 1897, about
the same (391). In Western Australia, however, though the total
number of deaths from cancer rose on the whole (not without
marked annual fluctuations) from 20 in 1889 to 55 in 1898, the
estimated population in the same period increased in a much
more rapid proportion (from 43,698 to 168,129); consequently the
ratio of cancer deaths per million inhabitants fell from 458 per
million in the first year of the period to 327 in the last. It is
obvious that to a great extent the increase of population in this,
and also in other divisions of Australia, has been due to immigration, and the figures indicating the mortality from cancer or any
other disease have proportionally less value. A large number of
the deaths occurring in these ten years may have been in persons
who developed the malignant growth elsewhere, and it is impossible to judge, from these figures alone, whether the conditions
obtaining in Western Australia are favourable or otherwise to the
prevalence of malignant disease.
The same limitations must be borne in mind in regard to the
presence and recent history of cancer in South Australia. Here,
with a larger, but less rapidly growing population than in Western
Australia, the crude death-rate from this group of diseases increased
considerably in the same decade. Thus the total annual deaths
returned under this heading rose from 133 in 1889 to 184 in
1898; but as the estimated population during the same interval
only rose from 311,112 to 362,897, the cancer mortality had
increased from 427 per million in the first year of the period to
507 per million in the last. The returns recently published for
1900 indicate a still further rise, to 590 per million.
In Tasmania the deaths from cancer in the successive years
1894 to 1897 were equivalent to 500 per million in 1894, 470 per
million in 1895, 58° in 1896 and 480 in 1897. It is stated in the
Report of the Central Board of Health for 1897 that "during the
1

Annual Report on Brit. New Guinea for 1897-8.

CANCER OR MALIGNANT DISEASE

6j

last ten years there has certainly been no marked tendency
towards an increase in the prevalence of this disease in Tasmania,"
and these figures bear out the statement. It will be observed
that the cancer mortality in Tasmania is about equal to that in
Southern Australia, but above that in Western Australia or
Queensland.
In New Zealand, on the other hand, the mortality from this
group of diseases has increased considerably in the same period.
In 1889 the deaths under this heading were 260, and there has
been an almost unbroken increase in this figure up to the year
1898, when it was 471. The population in the same period rose
from 616,057 to 743,463, and the mortality rate from cancer
therefore rose from 422 to 633 per million. In New Zealand
cancer would seem to be decidedly prevalent—more so than in
Western Australia, Queensland, Southern Australia, or Tasmania,
but still a considerably less fertile cause of death than in England,
Sweden, or Holland. In New Caledonia the disease is said to be
very uncommon.
Africa. Throughout the African continent cancer is very
much less frequent than in Australia or in many parts of Europe.
This class of diseases is according to some authorities very rare
in British P>ast Africa, but it has recently been stated that in
Uganda cases of malignant disease (especially of sarcoma of the
jaws) are not rarely seen, but that on the whole these diseases
are not nearly so frequent as at home, and that they run a slower
course 1 . In general the black races of Africa appear to suffer
remarkably little from, though they are not entirely immune to,
malignant growths. Livingstone never met with a case among the
Makalolo or the Barotse on the Upper Zambesi. In Abyssinia,
one observer has, however, described cancer as rather frequent,
and in Algeria cancerous growths of all kinds are common, both in
natives and Europeans 2 . In Western Africa cases of cancer have
been exceptionally seen; Plehn mentions two cases of sarcoma
and two of osteo-sarcoma as occurring in natives in the Cameroon
district. On the Gold Coast, and adjoining coasts, cancerous
diseases aie said to be rare. At Lagos, during a practice of
fourteen years' duration Dr Johnson saw only five cases of cancer
1

A. R. Cook, Journ. Trop. Med., June ist, 1901.
Brault, who states that epithelioma "pullule en Algerie sur les
Europeens," while sarcoma is often seen among the natives.
2

s—2

68

CANCER OR MALIGNANT DISEASE

in native patients, and in each case the sufferer had lived as
Europeans live. Similarly in Bechuanaland and in Mashonaland
malignant disease seems to be decidedly uncommon.
In Mauritius cancer is also far from common, and it is said to
cause only one-eighth of the mortality which arises from the same
cause in England. Both carcinoma and epithelioma are met
with on the island.
North and Central America. Malignant disease is prevalent
to a considerable extent in both Canada and the United States.
In British Columbia it was the cause of 2 2 deaths in Victoria in
1896, out of a population of 20,000. This was equivalent to a
mortality of 1100 per million living; but being the mortality of a
single city only, where possibly many deaths from cancer occur
in persons drawn from elsewhere, this figure is not to be compared
with those already given for whole countries. In New Brunswick
malignant disease is also the cause of a considerable mortality;
and in Nova Scotia it is not only on the increase, but is grouped
with tuberculosis as causing together with that class of diseases
no less than 40 per cent, of the total number of deaths at the
principal hospital in Halifax.
In the United States generally malignant disease is prevalent,
and is, in many places, distinctly increasing as a cause of death.
In Massachusetts this increase has been extraordinarily great and
comparatively steady. In the year 1856 the cancer mortality in
that State was only 190 per million/but in 1895 it had risen to a
maximum of 700. In the first twenty years of that period the
mortality figure was 300, in the second 560. Or taken in five-year
periods the death-rate from cancer per million inhabitants in
Massachusetts, during the past forty years, has been as follows:
230, 270, 330, 370, 450, 540, 590, and 640. Part of this increase
is recognised as due to improved knowledge and more accurate
methods of diagnosis, but this cannot possibly account for a rise
of between 200 and 300 per cent, in the cancer mortality in forty
years. In seven of the principal cities of the United States
for which statistics are available an equally striking increase has
been observed in recent times. The greatest rise has been in
San Francisco, where the deaths from this cause, which in 1866
had been only 165 per million inhabitants, were no less than
1036 per million in 1898. In Boston the cancer death-rate nearly
trebled itself between 1863 and 1887; it then fell slightly, but

CANCER OR MALIGNANT DISEASE

69

has again increased in the last few years. In the seven cities of
New Orleans, Philadelphia, Boston, New York, San Francisco,
St Louis, and Baltimore the mortality from cancer rose from
354 per million living in 1870 to 664 per million living in
18981. On the whole the Southern States are said to be less
affected than the Northern.
Of the prevalence of cancer in the West Indies little is
known. It is probably not common.
In Central America cancer is, at least in some States, comparatively rare. This appears to be the case in Guatemala, where
in 1894 the deaths from this group of diseases in a population
of 1,431,506 were only 60. The cancer mortality for that year
was, therefore, only 42 per million, a rate which, in comparison
with that of many European countries, is a very low one.
South America. In some South American countries malignant
disease gives rise to a considerable annual mortality. Trustworthy figures as to its frequency here are, however, for the
most part lacking. In Brazil it is common in some provinces;
in that of Buenos Aires the annual deaths returned under this
heading are particularly high. In Guiana cancer is not very
prevalent. In Uruguay it is a frequent cause of death; in
1897 401 deaths from malignant disease were recorded in this
Republic, which is equivalent to a mortality of 477 per million
of the population. Cancer accounted for 3*28 per cent, of the
mortality from all causes.

Factors governing the Geographical Distribution of
M a l i g n a n t G r o w t h s . From the above rapid summary it will
be observed that cancerous diseases are comparatively common
in the following countries:—In Great Britain, France, Holland,
Sweden, Norway, Austria, Switzerland, Greece, and to some extent
Germany ; in Australia; in New Zealand ; in China; in some parts
of Canada; generally throughout the United States; and probably also in Brazil, Uruguay, and some other parts of South
America. They are rare or unknown, on the other hand, in
Iceland and the Faroe Isles, in Servia, in Persia, in Arabia,
in Corea, in New Guinea, generally throughout the entire continent of Africa, and in some Central American States, as, for
example, Guatemala.
American Journal of the Medical Sciences, Feb. 1900.

yo

CANCER OR MALIGNANT DISEASE

The conditions which determine the geographical distribution
of malignant disease are not fully known. From what is known
as to the etiology of the various forms of growths grouped
under this heading it is probable that racial proclivities have a
considerable share in determining their prevalence. The black
races appear to enjoy a remarkable immunity from cancerous
tumours. The yellow races are more prone to suffer; and in
the Chinese malignant growths of great size are sometimes met
with. But it is the white races that are most liable to their
development. The Jews have been thought by some to be
rather less liable to cancer than other races, but the evidence
on the point is conflicting.
The precise influence which climate, soil, elevation, humidity,
and other local conditions have upon the prevalence of cancer
is also unknown. Certain countries and certain special areas
in those countries have been shown to be associated for long
periods together with a high mortality rate from cancer. Generally speaking, but not without exceptions of considerable
importance, these cancer areas are low-lying, damp, often on
clay or other retentive soils, and watered by streams or rivers.
High-lying, dry districts on the limestone, chalk, or other porous
soil, enjoy a relative, but far from complete immunity. On the
other hand, cancer has been found prevalent at considerable
elevations, and in districts where the soil was entirely chalk.
It is fully recognised that areas where cancer is common and
areas where it is rare may adjoin; and it has been pointed out
that even the opposite banks of the same river may show a
marked difference in the rate of mortality from malignant disease.
In a certain number of instances a succession of cases of cancer
has been reported from one and the same house; and it has
been thought that in such houses there must be some local
condition or set of local conditions peculiarly favourable to
the development of this class of growths. But whether these
are not instances of mere coincidence, or whether in truth such
" infected " houses exist is still open to doubt. The term " cancerhouse" has been sometimes employed to designate a house
of this nature.
Perhaps the most striking feature in the recent history of
cancerous diseases has been the tendency they have shown
to increase in many parts of the world. Although the increase

CANCER OR MALIGNANT DISEASE

71

may in some instances be apparent rather than real, and due
partly at any rate to greater accuracy of diagnosis and registration,
it has in many instances been far too marked to be accounted
for entirely in this way; and it is now very generally admitted
that diseases of this group have become really more frequent in
recent years than they were formerly. The European countries
in which an increase in cancer prevalence has been most clearly
shown appear to be the following:—England, Scotland, Ireland,
France, Holland, Denmark, Norway, and (perhaps) Russia. No
less striking—perhaps even more striking—than the increased
frequency of cancer in Europe, has been the simultaneous increase
in this class of diseases in Australia, in New Zealand, in some
parts of Canada, and in the United States. In the States the
recent rise in cancer mortality has, indeed, been more marked,
perhaps, than in any other country. A large number of theories
have been advanced to account for this strong tendency on the
part of cancerous diseases to become yearly more and more
widely prevalent and fatal; but no quite satisfactory explanation
of the fact has as yet been found. Some have even questioned
whether it is indeed a fact, but the evidence of the increase
in cancer prevalence is unfortunately too strong to admit of
serious question.
It has been frequently suggested that cancer and malaria are
antagonistic diseases, and that where the one is common the
other is absent or rare The figures given in this chapter, if
compared with those quoted in the chapter on malaria, will
be found to lend considerable support to this view. Cancerous
diseases are certainly very common in the northern European
countries—Norway, Sweden, and Denmark, where malaria, on
the other hand, is very rare or unknown. They are frequent
and increasing in Holland and England, both at the present day
almost free from malaria. In Australia, New Zealand, Tasmania,
Canada, and the United States cancer is remarkably prevalent,
while malaria is, in at least many of these countries, very rarely
seen. The reverse is also found to hold good in several
instances, and in many highly malarious countries, such as
Persia, Siam, the Laos country, many of the West Indian Islands,
Corea, New Guinea, Mauritius, and many parts of Africa,
malignant growths are notably infrequent. The most marked
exceptions to the apparent rule have been the rarity of both

J2

CANCER OR MALIGNANT DISEASE

diseases in Iceland, the Faroe Islands, and the central plateau
of Arabia; and the frequency of both in Italy, and perhaps
in China and Brazil.
When the statistics of smaller areas are compared the inverse
ratio of prevalence between the two diseases is also to some
extent observed. Kruse has published (in the Munch. .Med.
Woch} 1901, No. 48) tables showing the mortality from each
in the various provinces of Italy. Though quoted by him as
leading to conclusions adverse to the theory in question, these
tables seem to an unbiassed reader to show in a rough but
decided manner that, whether large or small areas be taken,
cancer is found to be more or less prevalent as malaria is more
or less rare.
The diminution of malaria in many European countries in
recent years and the increase of cancer in the same countries
are facts which may also indicate this relation of the two diseases.
Some have gone so far as to suggest that the antagonism is a
really fundamental pathological antagonism, and that the inoculation of a cancerous subject with the protozoon of malaria
might be tried as a cure for intractable malignant growths.
Further evidence is needed before this relationship of the two
diseases can be accepted. It may show that no such antagonism
between the two exists in individual cases. It will more probably
show that the two are antagonistic only in the sense that there
is some general condition, or set of conditions, the presence of
which is favourable to the prevalence of one disease and adverse
to that of the other. What these conditions are is at present
quite uncertain.
1
Ref. in British Medical Journalj March 1, 1902, where the tables are
quoted in full.

CEREBRO-SPINAL F E V E R
(EPIDEMIC CEREBRO-SPINAL

MENINGITIS).

General Characters a n d E t i o l o g y . Epidemic cerebrospinal meningitis, or cerebro-spinal fever, has been recognised
as a specific fever since its appearance in southern Europe
some seventy years ago; the Germans have given it the name
of 'cerebral typhus'; and these various titles indicate that the
most prominent feature of the disease is a severe affection of
the nervous system. The disorder is, in brief, a specific fever
in which the principal lesion is an inflammatory condition of the
membranes of the brain and spinal cord—just as in enteric
fever the principal lesion is an affection of the intestinal glands,
in plague, of the lymphatic glands or lungs, and in cholera,
of the mucous lining of the bowels. The pathological changes
are associated with the presence in the tissues of a micro-organism,
first demonstrated by Weichselbaum, who gave it the name of
diplococcus intracellularis meningitidis.
H i s t o r y . This disease has always shown a distinct tendency
to recur in epidemics of longer or shorter duration; and according
to Hirsch four principal epidemic periods may be differentiated.
In the first period, 1805—1830, the disorder occurred in the
form of isolated outbreaks in different parts of Europe and,
to a greater extent, in the United States. In the second period,
1837—1850, there were widespread epidemics in France, Italy,
Algiers, the United States, and Denmark. In the third period,
1854—1875, t n e disease was diffused through a great part of
Europe, the adjoining portions of Asia, the United States, and
some parts of Africa and South America. The fourth period

74

CEREBRO-SPINAL

FEVER

was described as " a return to merely casual epidemic outbreaks,
or to more or less considerable groups of cases here and there
within its former distribution area." This latter description
applies to some extent to the behaviour of the fever during
the past two decades; but in quite recent years there has been
again a tendency to renewed activity in the disease; and to
the four periods described a fifth might perhaps be justly added.
Jaeger 1 , indeed, is of opinion that there is now (he wrote in 1899)
" a n epidemic period of this disease," and he points to its
wide prevalence all over the United States, in Germany, in
France, and in Greece.
Recent Geographical
Distribution.
Europe.
In
England cerebro-spinal fever is a very rare disorder, and in
the past only occasional and slight epidemics have been recorded.
In Scotland it appears to be almost, if not quite, unknown, and
in Ireland, with the exception of some well-known epidemics
among the recruits of the Royal Irish Constabulary in certain
Dublin barracks, the disease has also been rare. Generally
the British Isles have been far less. affected by this malady
than most of the other European countries. France, on the other
hand, has been the scene of frequent epidemics, occurring
especially among troops in barracks; and the same is true of
Germany, where a very large number of outbreaks have been
reported within the last four years. In Jlolland and Belgium
the fever has been as rare as in England. In Denmark it is
probably commoner; from 5 to 34 deaths from this cause have,
at least, been annually reported between the years 1892 and
1897 in the Danish urban population alone. Sweden has been
rather frequently visited by it; the northern limit of the disease
in this country is stated to have been the 63rd parallel of
latitude (Hirsch). It is met with in European Russia, where it is
no very great rarity; in the years 1893—1895 the number of
registered cases of the disease in different parts of that country
varied between 7 and 50 per million inhabitants—the lowest
figures occurring in the territory of the Don Cossacks and the
highest in the Baltic provinces and Poland. In Austria-Hungary
cerebro-spinal fever is said to have been comparatively rare in
the past, and in Spain and Portugal it is perhaps still rarer.
1

Deutsche Med. Woch., July, 1899.

CEREBROSPINAL FEVER

75

In Italy, on the other hand, especially in the southern provinces
and in Sicily, the disease is common; it was epidemic there
in the years 1893 and 1894, causing a total mortality throughout
the peninsula equal to 66 and 41 per million respectively in the
two years. In the Balkan peninsula generally this fever has not
been frequently seen, but neither in Turkey nor Roumania is it
altogether unknown, and in Greece a certain number of cases
occur every winter and on rare occasions epidemics.
Asia. Epidemic cerebro-spinal meningitis would seem to
be a very much less common disease in Asiatic than in European
Russia. The number of cases registered in the three years
1893 to 1895 m t n e Caucasus varied between 4 and 6 per
million inhabitants per annum, the average for the six preceding
years having been 6 per million. In Russian Central Asia the
corresponding figures had been from 0*5 to 1 per million in
the three years named, and an average of t per million for the
six preceding years; while in Siberia the returns showed from
2 to 10 cases per million in the triennial period, and an average
of 6 per million in the six preceding years. These figures
are only a remote approximation to the truth, but they show
that the disease is not altogether unknown in any of the great
geographical divisions of the Russian Empire.
At least two epidemics have been recorded in Asia Minor;
the first at Magnesia, near Smyrna, in the year 1869, and the
second in Smyrna itself in the following year. Two years later
a few cases of the disease occurred in Jerusalem, and in 1874-5 a
slight epidemic was reported from Persia. Whether more recent
epidemics have occurred in these countries I am not able to
say.
In India this malady is by no means of rare occurrence.
It especially attacks the inmates of Indian gaols, and certain
gaols have been the scene of repeated small outbreaks of the
fever1. The history of the disease in this country is incomplete,
but apparently it has only been known there within the last
score of years. The first mention of it in the health reports of
the Indian Government is found in the Sanitary Commissioners'
Report for 1881. Between that year and the year 1892 the
1
As for example the Alipur Central Gaol, Calcutta, in which no less than
eleven outbreaks of the disease occurred between 1885 and 1898.

76

CEREBROSPINAL

FEVER

statistics of the Indian army and of Indian gaols furnished
a total of 333 cases and 259 deaths 1 . None of the three
Presidencies escaped, and epidemics were also reported from
Burma, the Andaman, and the Nicobar Islands. The principal
outbreaks, however, were in Bengal and Bombay, and the Bengal
gaols suffered especially. Cases also occurred in the Bombay
and Lahore gaols; and in part of the Kangra district of the
Punjab the malady is said to have been "very prevalent every
year/' and to have caused an epidemic of some severity in 1894.
How far the general population in India is affected by this
disease it is impossible to say. It is apparently rarely seen
in Ceylon : only one death from it was recorded in the island
in the year 1895, o n e m ^ 9 6 , and none in any other year between 1890 and 1897.
The evidence for the existence of cerebro-spinal fever in
China is excessively scanty. Coltman 2 , who spent many years
in the country, expresses his belief that the disease is not
unknown there, his own child having suffered from an attack ;
but he was unable to find any reports of it from other sources.
I have come across no mention of it in the reports of the
medical officers in the Chinese Customs Service; and if this
fever exists in China it is probably very far from common.
Australasia.
The disorder is probably exceedingly rare in
Australia. Until quite lately no report of its occurrence there
was known, and even in recent years the only references to it
I have found have been the records of one death from this
cause in Queensland in 1897, of one death in South Australia
in 1892 (the only death of the kind in this colony in the ten
years 1889 to 1898), and of the entire absence of this disease
as a cause of death in Western Australia in the same decade.
Nor were any deaths from the fever recorded in New Zealand
during the same ten years,—a fact which may be taken to
show tfiat, if not unknown, it must be excessively rare and mild
in that colony.
Of the existence or frequency of this disease in the Pacific
Islands little appears to be accurately known. One case was
recorded as occurring in a Polynesian inhabitant of Fiji in the
1

Moorhead, Transactions ofist Indian Medical Congress, 1894.
The Chinese: their Present and Future; Medical, Political, and Social.
By Robert Coltman, Jnr., M.D., 1891.
2

CEREBRO-SPINAL FEVER

77

year 1897, but beyond this I have met with no recent record
of the disorder. A small epidemic, however, occurred there in
the year 1885 \
Africa. Whether this disease exists or occasionally causes
epidemics in Egypt and the Sudan is uncertain, but it seems
very probable that some outbreaks of a malady hitherto called
by another name are really of the nature of cerebro-spinal fever.
Slatin Pasha in his interesting record of captivity in and escape
from the Sudan has referred to certain outbreaks of fever which
attacked the native population of the Ghezireh and the Sudanese troops stationed near Omdurman. These outbreaks were
spoken of as "typhus," but from the recent report of Capt.
H. E. H. Smith, R.A.M.C., it seems that the epidemics in
question, which prevail mostly in the autumn in the neighbourhood of the Sudanese capital, are probably of the nature of
epidemic cerebro-spinal meningitis 2 .
In Abyssinia, Tripoli, and Tunis there are, so far as I am
aware, no records of the existence of this disease. In Algeria
many epidemics of it have occurred in the past; it was apparently
introduced to the colony by French troops in the year 1840, and
prevailed rather severely there in 1841-2, 1844, x 845-6, and
with special severity in 1846-7. A later outbreak occurred
here in 1868.
On the West Coast of Africa there appear to be almost no
records of the occurrence of cerebro-spinal fever, with the single
exception of a remarkable outbreak which recently occurred at
Cape Coast among a number of coolies brought from Mombasa
in East Africa for duty with the Ashanti .Field Force 3 . This
was regarded as the first known outbreak of the disease on this
coast, but the evidence was uncertain. The carriers, it seems,
came in three transports; the first batch of 1500 men were
apparently free from the complaint, but among the second
batch of 1500 some were probably already affected by it, and
after their landing the disease spread to a great many other
persons. From these facts it must be regarded as an example
of imported infection, but whether from East Africa—whence
1
Trans. Epidem. Soc. London, N.S. Vol. vil. Sir W. MacGregor has
recently spoken of the appearance of the disease in Indian coolies in Fiji.
2
Ref. in Indian Medical Gazette, Sept. 1899.
3
Jfourn. Trop. Med., Nov. 1900.

7%

CEREBRO-SPINAL FEVER

these transports originally sailed—or from elsewhere there is
nothing to show. With the exception of this epidemic, the only
other record of cerebro-spinal fever on the Atlantic shores of
Africa is the bare mention of the disease among the maladies
known in the Cameroons 1 .
In South Africa, on the other hand, there is good reason to
believe that cerebro-spinal meningitis is a much less rare complaint. How long the disease has existed in this part of the
continent is uncertain, but it was apparently in 1883 that it began
to prevail widely in Cape Colony, and in the following year a
certain belt of the colony was visited by an epidemic of some
severity. It subsided in 1890, but in that year a small outbreak
was observed in Natal, mostly among natives; of the fourteen
cases known to have occurred on this occasion nearly all ended
in death. More recently there is mention of a severe epidemic
of the fever at Tijgerberg in the northern part of Cape Colony
in 1897 ; and in the same year an outbreak of some severity
occurred at Malmesbury in the same colony, followed in 1898 by
a less extensive recurrence.
North and Central America. The North American continent
has in the past been more repeatedly and extensively visited by
cerebro-spinal fever than any other. Twenty years ago Hirsch
wrote that "hitherto the headquarters of the disease, both as
regards wideness of diffusion and severity of the outbreak, have
been the United States, where its area extends from Canada to the
Gulf of Mexico, and from the Atlantic to the Prairie States of
Minnesota and Iowa." In a footnote the same author adds that
he has seen no accounts of the disease in Georgia, Florida, or
Arkansas, but that he is not prepared to conclude from this
absence of evidence that these States have escaped it.
This frequency and wide diffusion of the fever in the western
continent are still among the most striking features in its
epidemiology. For many years past repeated outbreaks of the
disease have occurred in widely separated regions, but usually
in villages and in country districts. Recently some of the larger
towns have also been affected. In 1893 an epidemic appeared
in New York. In 1896, 1897, and 1898 epidemics occurred
in Boston, and in 1898 cases of the disorder were recognised in
1

Albert Plehn, Janus, 1896-7.

CEREBRO-SPINAL FEVER

79

Baltimore and other towns. In the latter year cerebro-spinal
fever prevailed—usually, it is true, in a mild form—in twentyseven of the States and in the District of Columbia. Prof. Osier,
in his address to the West London Medico-Chirurgical Society
in 1899, drew attention to the renewed diffusion of the disorder
in the United States, and described it as the fourth successive
" wave " or epidemic period of the disease in the States in the
nineteenth century (the fourth epidemic period referred to by
Hirsch and spoken of above did not apparently affect America).
Canada is perhaps less widely troubled by this disorder than
the States; but it is said that in Alaska cerebro-spinal fever is
very commonly seen, and it is even spoken of as one of the
many dangers inseparable from gold-mining in that remote and
inhospitable country.
In Mexico and the Central American 'States nothing seems
to be known in regard to the presence or absence of cerebrospinal fever. I find no mention of it in recent reports from
British Honduras. But in some of the West Indian Islands
it is certainly known. In Jamaica, for example, it must be very
far from uncommon. At Half-way ,Tree in that island as
many as 12 cases of the disease occurred in the year 1897-8, all
of which ended in death. A few cases were also recorded in
the same year in the eastern district, and in the health reports
for the year 1898-9 the absence of any cases of cerebro-spinal
fever in the returns from all parts of the island is noted as
very exceptional, and as being the first occasion for many years
in which such a thing had happened \
South America. Whether epidemic cerebro-spinal meningitis
occurs in any part of South America I am not in a position to
say. The absence of positive records can scarcely be taken
to prove that the disease does not exist there, as it is among the
lesser known disorders, and may be easily confused with other
cerebro-spinal affections of an inflammatory character. In the
past it was rumoured that cerebro-spinal fever had been prevalent
in Brazil and in Monte Video in the year 1840, but the rumour
was unconfirmed.
Outbreaks at sea. There remain to be mentioned certain
1
It is noteworthy that among the recent epidemics of this disease in
Calcutta was one which occurred in the depot of the Jamaica Government
Emigration Agency in that city, in the latter part of 1900.

8o

CEREBRO-SPINAL FEVER

outbreaks of this disease which have been reported as occurring
on ships at sea. One occurrence of this nature has already been
mentioned above, in the instance of the three transports which
arrived at Cape Coast from Mombasa in East Africa, with some
of the coolie passengers already showing symptoms of cerebrospinal fever. Another example recently recorded is that of
the s.s. "Clyde," an emigrant ship carrying a large number
of persons from Calcutta to Georgetown in British Guiana. In
the former instance, that of the three transports at Cape Coast,
the published facts throw no light on the original source of the
infection. The disease does not appear to have shown itself
until towards the end of a long voyage, and the majority of
cases occurred after the ships' arrival. Eut on board the
" C l y d e " the first case developed three days after the ship left
Calcutta, and as it is well known that cerebro-spinal fever
is no rarity there it may be presumed that the emigrants in
question brought the infection on board with them when they
embarked in that city. The " Clyde" appears to have left
Calcutta on January 24th, 1900, and arrived in Georgetown on
May 9th. The outbreak was confined to the occurrence of four
cases, between January 27th and March 19th. An interva] of
no less than forty-one days occurred between the third and last
cases.
An outbreak presenting remarkable analogies with the above
occurred on another emigrant ship, also carrying coolies from
Calcutta to Georgetown in British Guiana. This boat, the
"Elbe," left Calcutta on October 18th, 1900, and reached Georgetown on January 5th, 1901, and during the voyage 17 cases of
cerebro-spinal fever with 14 deaths occurred. The first patient
developed symptoms the very day of embarkation, only 9 or 10
hours after leaving the coolie depot in Calcutta, and as other
cases of the disease had already occurred there, there can be
no doubt that the outbreak on board was due to an infection
imported from the depdt.
F a c t o r s c o n c e r n e d in t h e G e o g r a p h i c a l D i s t r i b u t i o n
of Cerebro-spinal F e v e r . It cannot escape notice that the
facts as to the geographical distribution of cerebro-spinal fever
over the earth's surface are very imperfectly known. This is
no doubt true of many other of the diseases dealt with in these
pages, but it is more especially true of the one now under

GEREBRO-SPINAL FEVER

81

consideration. Some of the reasons for this have just been
pointed out in referring to the absence of information concerning
this disease in South America. Cerebro-spinal fever is a malady
that is not always easy to differentiate from ordinary idiopathic,
traumatic, or tubercular meningitis, or from several other pathological conditions of the brain and spinal cord and their coverings.
The aid of bacteriology in the diagnosis of a given case has
only recently become possible, and the bacteriologist and the
means for making a bacteriological inquiry are not always at hand.
It is therefore practically certain that the area of prevalence of
this, as of many other diseases, is much wider than the known
records of its occurrence would imply.
Its known area of prevalence is, however, a wide one at
the present day, and is probably always becoming wider. With
the (uncertain) exception of South America it is found in all
the great continents. Its northerly limit varies in the two hemispheres ; in Sweden it is said to cease at the 63rd degree of
latitude, and it is absent from Iceland and the Faroe Islands;
but in Alaska it exists in the region of the gold-fields, which are
on the very borders of the Arctic circle. In the south it is
common at the southern extremity of Africa, and an occasional
case is seen in Australia.
The title, so frequently given to this disease, of epidemic
cerebro-spinal meningitis expresses one of its most interesting
features—its tendency to occur in the form of epidemics. The
epidemics vary very widely in their extent and intensity, and in
not a few instances outbreaks have occurred of so limited a
character-—the disease attacking a mere handful of people—that
the word "epidemic" is quite out of place in connection with
them. In some instances observers have even been hardy enough
to diagnose single isolated cases of disease as of this nature, but
in general terms epidemicity is one of the main characters of the
fever. The epidemics are usually curiously irregular in their
relations both to space and time. They do not as a rule pass
steadily through a country from one end of it to another, like
a cholera or an influenza epidemic.
They rather tend to
occur as a number of isolated outbreaks, here and there, in
different parts of a country, the separate outbreaks showing little
or no relation with each other. It is, indeed, usually impossible
to trace any connection between them. So also in regard to time,
c.

6

CEREBROSPINAL

82

FEVER

an individual outbreak often shows no definite course, with a
distinct beginning,-a rise to a maximum degree of prevalence, and
a distinct decline to extinction. An epidemic may linger on for
months or even a year in a given place, and it may recur at
irregular intervals in the same village or district, showing that the
infection is really—at least for the time being—endemic in that
particular spot.
The exact manner in which the infection is spread is not
known, but this tendency to recur in certain places seems to show
that the virus of the disease can exist for longer or shorter periods
outside the human body. This "saprophytic" existence of the
microparasite is rendered still more probable from a study of
those repeated outbreaks of the disease which have been observed
in such institutions as barracks and gaols, where it would seem that
the infection clings to a building for long periods together. Some
of these instances have been already referred to. The most
striking have been met with in Indian gaols. Thus for example,
in the Alipur central gaol, in Calcutta, the first known epidemic
of this disease occurred in 1885, and in the next decade nine
more outbreaks were recorded in the same gaol; then after an
interval of three years an eleventh outbreak—confined to three
cases—occurred (in 1898)\ Of similar import were the facts
connected with the outbreak of cerebro-spinal fever at sea, in the
s. s. " Clyde," already alluded to. That forty-one days should have
elapsed between the 3rd and 4th cases in this outbreak can only
be explained by supposing that the infection clung in some way to
the vessel itself or its contents during that period. In this respect
the behaviour of the disease presents not a little analogy with that
of beri-beri.
If cerebro-spinal fever is directly infectious from person to
person—in the sense that scarlet-fever and measles are in ordinary
parlance " contagious "—it is so probably in a low degree. In
most epidemics no connection can be traced between individual
cases. Sometimes several persons are attacked more or less
simultaneously; and, in like manner, it has occasionally been
observed that several isolated outbreaks in districts at a considerable distance from each other have arisen at or about the
same time. Both these observations seem to show that the
1

Indian Medical Gazette, June, 1899.

CHART SHOWING THE PRINCIPAL ROUTES BY WHICH CHOLERA HAS SPREAD IN THE PAST

CEREBRO-SPINAL FEVER

83

disease is spread less by direct transmission of a virus from one
person to another than by the exposure of several persons or
communities to a common source of infection.
There seems nevertheless to be good reason for believing that
the virus of cerebro-spinal fever can be and is carried from place
to place by means of human beings. Hirsch has quoted a
number of instances in which the movements of troops have
seemed to contribute to the spread of the disease. Its appearance in Algeria many years ago was thought to be due to an
importation of infection by the French, and three examples have
already been quoted above (the transports at Cape Coast, the
" C l y d e " and the " E l b e " ) in which the disease was apparently
carried long distances by sea.
The relations of this disease to temperature are briefly as
follows. The actual height of the thermometer is without influence
in its production. It can exist equally well in tropical, temperate,
and sub-arctic climates. The view formerly held that one of the
most important determining causes of an outbreak was a low
temperature was based on imperfect knowledge of the area of
distribution of the disease. A disorder which can cause severe
epidemics in Indian gaols, among the poor of Jamaica, and on the
tropical coasts of Western Africa cannot in any way be dependent
for its causation upon absolute cold. The recent history of the
malady has in fact thrown much newT light upon its relations
to temperature and to many other external conditions. How far
this apparent change in the behaviour of the disease is due to the
mere absence or imperfection of the earlier records for many
countries, or how ^far it is a real change it is not easy to say.
But it seems certain that in the last two decades cerebro-spinal
fever has spread to, and become widely diffused in, countries
where formerly it was unknown. Sixteen years ago Hirsch wrote
that "hitherto it has been confined really to temperate and
subtropical latitudes; it has not penetrated into the cold zone
except to a very slight extent; while the tropics and the whole of
the southern hemisphere have escaped it altogether." Some
time, however, before those words were published the disease had
already appeared in many parts of India, and the recent outbreak
in connection with coolies for the Ashanti Expedition, referred to
above, seems to show that it exists or can exist in tropical Africa.
In Southern Africa also the prevalence of the disease seems to
6—2

84

CEREBRO-SPINAL FEVER

date only from tolerably recent times. It may be accepted, therefore, as beyond question that the area of prevalence of this fever
is now a much wider one than formerly, and that conclusions
based on our present knowledge of its distribution may be upset
by later behaviour of the disease.
For the present it may be stated, in regard to its relation to
temperature, that while absolute cold is certainly not necessary
for its production, a relative degree of cold seems to be of some
importance. In temperate climates epidemics have most often
occurred in the cold season of the year, and changes of temperature
seem to favour their development—possibly by their effect on the
individual, whose resisting powers may be lowered by a fall in the
thermometer, or possibly by some more indirect action.
The distribution of cerebro-spinal fever shows little definite
relation to elevation above sea-level or to the nature of the soil.
Wetness of the soil appears to be without influence, unless perhaps
in an indirect manner by rendering the individual more susceptible
to the virus. Racial differences have perhaps some importance in
determining the geographical distribution of the disease, but to
what extent is uncertain. All races have suffered from it, but it
has been thought that negroes are particularly susceptible. How
far this increased susceptibility is really due to racial difference
and how far to difference in habits or in exposure to infection is
unknown. It would appear that among the determining factors of
an epidemic of this disease the character of the surroundings of
the individual plays a very important part. The frequency with
which children or persons of early adult life alone suffer from
it, and the fact that attacks are exceedingly liable to occur in individuals who are in a state of fatigue or exhaustion from some
unusual or excessive degree of labour or physical exercise, or
after exposure to cold and wet, all tend to confirm this statement.
So also does the tendency shown by the disease to become
epidemic in towns, and especially in the poorest quarters, where
dirt, overcrowding, and general insanitary conditions are found
at their worst. In this respect cerebro-spinal fever shows a certain
analogy with yellow fever and with dengue.

CHICKEN-POX (VARICELLA).
Chicken-pox being a mild disorder, rarely resulting in death,
mortality returns are of little value as indications of its prevalence.
In the case of many countries it is difficult to find any mention at
all of the disease, as owing to its comparatively trifling nature it
is often not referred to at all by writers on the diseases prevailing
in those countries. Most writers on the geographical distribution
of diseases ignore chicken-pox completely.
H i s t o r y . Chicken-pox was for long regarded as a mild form
of small-pox. The name "varicella" is as old as the Arabian
writer Rhazes. Fuller, in 1730, and later Heberden, in 1767,
established the difference between the two diseases.
Recent Geographical Distribution.
Europe.
The
disease is probably more or less common in all European
countries. In England and Wales it causes one or two hundred
deaths in most years, but some of these are believed by the
Registrar-General to be due to small-pox. This confusion between
small-pox and chicken-pox is doubtless common to other countries.
The official returns for most other European States that I have
consulted make no mention of this disease. It is undoubtedly
known in Russia, where it is called "Windy-pox" (vietrtanma
ospa) ; it is not infrequently seen at the hospitals in St Petersburg
and other large towns, and is probably common in the country.
At Constantinople it is more or less constantly present and often
of a severe character. In Malta many cases of chicken-pox are
registered in some years.
Asia. In many parts of Asia chicken-pox is far from rare.
It is said to be very common in India 1 . In Rajputana it is
1

Buchanan, Journ. Trop. Med., Sept. 1899.

86

CHICKEN-POX

(VARICELLA)

occasionally epidemic. In Ceylon it appears to be frequently
seen; in 1895, 350 cases of the disease were recorded in the
island; in 1896 the recorded cases rose to 579; and in 1897
they were 508 in number. It is probably rarer in Malaysia;
Kohlbriigge never saw it in Java 1 . A few cases, however, of a
mild type occurred among the Dutch troops in the Indies in 1897.
In China chicken-pox is probably very prevalent. It is frequently seen in Shanghai 2 , and is one of the commonest of contagious disorders in the Chung-king district 3 . It was epidemic at
Kiukiang in the spring of 18984. It is also known in the Fo-kien
province.
Australasia.
Chicken-pox is seen sometimes in Fiji. In
Australia it is far from uncommon, occasional cases being recorded in recent reports from Queensland, New South Wales,
Victoria, Western and South Australia.
Africa. In Africa chicken-pox is certainly known on the West
Coast, and is very common in the south. Of its prevalence elsewhere little seems to be known. I find mention of the disease in
recent reports from Sierra Leone, Lagos, and the Gold Coast.
In Uganda it is very common. In South Africa also it is very
prevalent; in the health-reports of the Cape and other colonies
for recent years cases or epidemics of chicken-pox are frequently
mentioned as met with not only in many parts of Cape Colony,
Namaqualand, Griqualand West, the native territories of Tembuland, the Transkei, and Pondoland, but also in Johannesburg
in the Transvaal, where it appears to have been frequently seen
before the war. The indigenous races of South Africa seem to be
very susceptible to the disease, and it sometimes prevails very
severely amongst them.
It is certainly met with in Mauritius.
America. In North America chicken-pox is an endemic
disease, at times becoming epidemic. Frequent mention of it is
found in reports from Ontario, Manitoba, and other Canadian
provinces. It was epidemic in Montreal in 1897. It is probably
also fairly common in the United States, where occasional outbreaks of the disease are observed. It is not unknown in the
West Indies, cases being sometimes recorded in Jamaica.
1
3

Janus', 1897-8, p. 221.
Ibid. No. 45.

2
4

Chinese Cust. Mec Reports, No. 41.
Ibid. No. 56.

CHICKEN-POX

(VARICELLA)

87

Factors governing the Geographical Distribution of
Chicken-pox.
Chicken-pox is undoubtedly a widely-spread
disorder. Its exact distribution cannot, it is true, be determined
for the present, owing not only to the absence of information in
regard to its existence in many countries, but also to the
uncertainty of diagnosis which often surrounds this disease, and
the ease with which it may be "confused with mild or modified
small-pox. Still, in spite of these difficulties, there is a sufficiency
of evidence to show that chicken-pox prevails under a great variety
of conditions and in countries widely apart. It can certainly
exist just as well in the tropics as in temperate climates, though it
is perhaps more common in the latter.
Chicken-pox is essentially a disease of child-life, especially
attacking children under five years of age. It sometimes takes on
epidemic characters, but such outbreaks are usually more or less
localised in character, and show no regularity in time of recurrence or in the number of persons attacked.

CHOLERA.
Cholera is a disease which for long periods, and in some
instances permanently (if our limited historical knowledge will
permit the use of such a word in regard to any disease), remains
endemic in certain countries, at varying intervals spreads more
or less widely elsewhere, and from time to time becomes pandemic,
extending over a great portion of the inhabited world.
T h e E n d e m i c C e n t r e s of Cholera. It has long been
customary to regard Lower Bengal—the flat, marshy, malarial
country of the Sundarbans and the delta of the Ganges—as
the endemic home of cholera, whence extensions of the disease
to other parts of India and thence to other countries were to
be always traced. It is certain^ however, that at the present
day cholera is endemic, in the fullest sense of the term, in many
other parts of India, in Farther India, in China, and perhaps
in Japan.
In India itself the region mentioned above is, doubtless, a
most important area of endemic cholera; it is perhaps the oldest,
it is certainly among the worst. But it is not the only one. From
the discussion on cholera at the first Indian Medical Congress in
1894, and from the annual returns of the Sanitary Commissioners
with the various Governments of and in India, it is clear that cholera
is endemic in many other parts of the country. It is certainly so
in the Bombay Presidency. Capt. Herbert, I.M.S., stated at the
Congress that the difference between Bombay and Bengal in regard
to the endemicity of cholera is one of degree only, and that the
same might probably be said of Madras and Berar. If British
India, this observer added, could be divided into endemic and
non-endemic areas of cholera, the latter would Qnly include Sindh
and the Punjab, and even in the easterly districts of the Punjab

CHOLERA

89.

a mild type of the disease is endemic. It is certain that in mosj;
years—in all recent years—ctiolera prevails more or less in most
portions of British India, including Assam. There are years of
great prevalence, such as 1877, 1887, 1891-2, and 18.97, a n d
there are periods of,slight prevalence, but it is rarely entirely
absent from any province, excepting Sindh. How far in these
"cholera years" the excessive prevalence in any given province
is due to an importation from Lower Bengal or elsewhere, or to
a revival of local infection is uncertain. The factors governing
its spread are to some extent known. In all the Indian provinces,
and even in the great endemic area of Lower Bengal, where
the virus may be supposed to be permanently and widely
present, carriage of infection by human beings and its diffusion
by contamination of water-supplies are constantly observed.
It has been pointed out also that an appearance of western
extension from Bengal is sometimes brought about when no
such extension has really taken place, because the seasonal
commencement of cholera activity is early in Lower Bengal,
occurring before the hot weather has far advanced, and it is
delayed more and more as one travels westward and the annual
rainfall diminishes, until in the Punjab the ordinary epidemics
come during and towards the end of the rains. In the areas of
endemic prevalence, and of epidemic extension in India, localised
outbreaks of great violence are not infrequent.
In Farther India cholera is as truly endemic as in India
proper. Lombard speaks of Bangkok as " u n veritable foyer
de cholera." In the plains of Cambodia cholera appears invariably to become epidemic in the hot season. In Annam it
is said to begin to prevail each year with the rains. It is
constantly epidemic, if it be not truly endemic, in Cochin China.
In Lower Tongking it is admittedly endemic (Rey) and frequently
severely epidemic. In the Straits Settlements cholera seems to
have been prevalent every season in recent years, and it may
be doubted whether the infection is on each occasion newly
imported—though on many occasions it has been thus imported
by coolies from China 1 .
That cholera is endemic in some parts of China no longer
admits of doubt. At Shanghai it is spoken of as " more or less
1
I am informed, however, by Prof. W. J. Simpson that the infection is
" almost always" so imported.

CHOLERA

go

endemic, making an annual appearance generally toward the
end of summer 1 ." At Chinkiang an epidemic of cholera usually
decimates the native population in the hot season 2 . At Hankow
and at Ichang, both on the Yangtze-kiang, the disease appears
each year in the hot months 3 . At Pakhoi it prevails in most
years between July and September 4 . At Lung-chou (near Pakhoi)
it has been epidemic in most recent years 5 .
From the evidence of the medical officers in the Chinese
Customs service it appears then that cholera is truly endemic
in thejplaces just named, if in no other parts of China. Manson
also states that the disease is endemic in Canton. It is scarcely
possible to suppose that the annually recurring epidemics in all
these places are due to successive introductions of infection from
India or elsewhere, and the conclusion is unavoidable that they
are merely a seasonal revival of an endemic disease, just as
happens in Lower Bengal and other parts of India. As cholera
in its endemic homes in India occasionally causes severe and
widespread epidemics, while in other years it is quiescent, so also
in China there are " cholera years " and years of little cholera. At
Ichang the memorable epidemic years were 1850, 1864, 1883, and
1892. In 1892 cholera was extremely prevalent in many parts
of China, particularly in the Yangtze-kiang valley. In 1895
epidemics, in some places of " appalling" violence, prevailed
throughout a great portion of the country; in Peking alone
cholera caused over 50,000 deaths. It is noteworthy that while
1892 was a great "cholera year" in India, 1895 w a s n o t > though
in the previous year the disease had been more than usually active
there.

Epidemic Extensions of Cholera to Countries near
t h e E n d e m i c C e n t r e s . While the endemicity of cholera in
the countries already named may be regarded as fully established,
there are some other countries or islands in the Far East where
the disease is at times endemic, at times absent altogether. In
these countries cholera has been imported from India or China,
has given rise to severe epidemics, and has remained for the time
being truly endemic, for a longer or shorter period: 4t has then
disappeared and apparently remained absent altogether until a
1
2
3

Cox, Chinese Ctist. Med. Repoi'ts, No. 55.
Lynch, Ibid. No. 50 and No. 54.
4
Ibid. No. 41 and No. 44.
Ibid. No. 42.

5

Ibid. No. 50.

CHOLERA

91

fresh importation has started the cycle again. This has happened
repeatedly in Ceylon and Japan.
In Ceylon large numbers of
cases of cholera occur every year, but the disease is apparently
not permanently endemic in this island. The infection is repeatedly imported from India. A violent epidemic occurred in
Ceylon in 1892, and each year since that date a very large though
diminishing mortality from cholera has been annually reported
from the island.
In Japan among recent epidemic years may be mentioned the
years 1877, 1882, 1886, and 1890. These outbreaks were of very
great violence, and were followed by recrudescences of an infection
for the time endemic in the island. It may indeed be questioned
whether cholera is not now as truly endemic in Japan as in China.
A recent writer in the Sei-i-Kwai Medical Journal has called
special attention to the fact that since 1877 "cholera has appeared
every year in Japan " (the italics are his). In Corea cholera has
been frequently imported.
In some of the East Indian islands local extensions of cholera
have also been repeatedly observed, though some of these islands,
as for example Amboina, are said to have enjoyed a remarkable
immunity from the disease. Java experienced a severe epidemic
in 1901, and the disease is possibly truly endemic here. In German
New Guinea cholera is said to have been introduced by a steamer
in 1896, and to have become for the time being endemic there,
as also in New Britain and in the Bismarck Archipelago, though
it had not (in 1897) spread to the British Solomon Islands 1 .
To the west of India similar occasional extensions of cholera
are not infrequently observed. Afghanistan, Persia, and Arabia
are all instances of countries which, while taking a prominent part
in the great pandemics of cholera, are also visited by the disease
at other times. The infection on these occasions appears to be
always imported from India, and either a serious epidemic may
follow, or the disease may become truly endemic for a longer
or shorter period. Cholera was in this manner practically endemic in Persia from 1852 to 1861 and from 1865 to 1872.
Cholera has often spread very widely from its eastern habitats
without becoming truly pandemic. It has several times broken
out among the pilgrims at, or en route to, the Moslem Holy Places in
Colonial Report for the British Solomon Islands, 1897.

9

2

CHOLERA

Arabia. In 1823 it spread as far as Astrakhan at the mouths of
the Volga, but did not produce a European epidemic, possibly
because of the stringent measures taken by the Russian authorities.
There is in fact no true dividing line between a widespread
epidemic and a pandemic, the terms being merely conveniently
used to indicate a wide or a very wide (but never truly universal)
extension of the disease outside those countries where it is more
or less permanently present.
It would appear that the virus of cholera finds in certain
countries conditions suited to its existence for very long periods,
and perhaps, as in Lower Bengal, permanently. In others
the conditions favour the existence of an imported virus for a
considerable number of years, after which the disease disappears
altogether and remains absent until it is again imported. It
is possible that the countries named above—such as Farther
India and China,—which are now endemic homes of cholera, may
not remain so permanently. How long the disease has already
been endemic in these is uncertain, but in some—e.g. China—it
has almost certainly been endemic for the last twenty or thirty
years. When the infection is carried still farther from India, as
for example to Europe, it usually dies out after from one to five
years of irregular and varying prevalence. It is probable, however,
that India is the true original nursery ground of cholera, whence
the disease has been carried to the other countries where it is
now endemic.
T h e Great P a n d e m i c s of Cholera. To Europeans the
greatest interest attaches to those occasional extensions of cholera
which from time to time visit not only Europe, but a very
considerable portion of the inhabited earth's surface. These
so-called pandemics have occurred at irregular intervals of ten,
twenty, or more years, and have not always followed the same
course or covered the same ground. What causes this disease,
or influenza, or plague, thus occasionally to spread widely
throughout the world after long periods of inactivity is not known,
and any explanation of the phenomenon is largely based on
speculation. It is not due to any meteorological conditions
alone; and the views formerly current as to an "epidemic
constitution" of the atmosphere, or as to the influence of great
earth changes as manifested by earthquakes, inundations and the
like, are no longer entertained as explanations of the pandemic

CHOLERA

93

extensions of disease. The true relation of the micro-organisms
associated with these diseases to their causation is also as yet not
sufficiently established to justify the assertion that some acquired
virulence and power of diffusion and resistance to outside influences on their part will fully explain these occasional pandemics, though it is very probably an important part of the
explanation.
In regard to cholera it is established, practically beyond a
doubt, that carriage of the infection by human beings and its
diffusion by water are important factors, but probably not the
sole factors, in the extension of the disease. The carriage of
infection by human beings is probably the principal explanation
of the fact that cholera, in its pandemic extensions, follows the
great routes of trade and travel. Its diffusion by water explains
the fact that cholera follows the course of streams and rivers, and
appears to spread more rapidly along the great lines of human
communication when these are also water-ways (streams or rivers)
than when they are not.
The pandemics of cholera have always started from India.
They have usually been preceded by a year or years of unusual
activity of the disease in India, and sometimes as for example
in 1891-2 by its great prevalence throughout the Far East. The
diffusion of cholera westward into Europe has been frequently
accompanied by a diffusion eastward into China, Farther India,
and elsewhere. The disease, as just stated, has almost invariably
followed the great routes of trade and travel. The principal
routes traversed by cholera in the past have been the following :—(1) From India to Afghanistan, Persia, Russian Central
Asia, the Caspian, the Caucasus, Astrakhan, the Volga or
shores of the Black Sea or both, and so to Europe generally
(as in 1830 and 1892). (2) A more northerly route, through
Cabul, Bokhara, and Khiva, to Orenburg on the Ural river, and
so to European Russia (as in 1829). This and the first route
are sometimes followed in one and the same epidemic. (3) From
India to China, and thence probably through Tibet, to Kashgar,
Khokand, Yarkand, and Bokhara, and so to the west (as in
1841-44). (4) From India to the Red Sea, Arabia, Egypt, and
thence to Syria, Palestine, Asia Minor, and through these or
directly from Egypt to Turkey, and up the Danube to Europe
generally (as in 1864-5). (5) From India to the shores of

CHOLERA

94

the Persian Gulf, Mesopotamia, Asia Minor, and thence to
Europe.
It is important to note that on several occasions these routes
have been combined; the disease following, at or about the
same time, two or more of the great lines of communication
in the East.
Without entering into the controversial question of the early
history of cholera epidemics, it will be useful, and indeed essential
to an understanding of the geographical distribution of the disease,
to give a rapid summary of the course followed by the known
epidemics of cholera in the past century.
Historical Summary of the great Cholera Epidemics or Pandemics.
The first wide extension of cholera outside India appears to have
taken place in 1819 and following years. In 1819 the disease spread
along the coasts of the Malay Peninsula; in 1820 it was in Siam,
and was terribly rife in China: in 1820-22 it spread to Oman and
Muskat in Arabia, to several places on the Persian Gulf, and
through Mesopotamia and Persia to the Caspian Sea. In 1822
it was again rife in Mesopotamia, and was largely spread as a
result of the war between Persia and Turkey. In that and the next
year it passed up through the Caucasus and reached Astrakhan,
but—thanks to the energetic measures put in force there, or to
some other cause—failed to spread into Europe 1 . It reached
Syria and Asia Minor, but did not invade Egypt. In 1823 this
epidemic apparently came to an end \ but in the meantime
(in 1819) cholera had been imported by a ship from India
into Mauritius and Bourbon (now Reunion) in the south, causing
a serious epidemic in the former, and in 1820 it appeared in
Zanzibar and Somaliland.
The next extension of cholera began in 1828. In that year
cholera was in Arabia. It probably spread in 1829 through
Cabul to Khiva, Herat, and Bokhara, and thence to Orenburg
in Russia.
It was probably carried to Orenburg either by
caravans from Bokhara or by nomad Kirghiz from there or from
Khiva. In 1829-30 it was epidemic in Persia. In 1830 it
spread up the Volga, just as it did more recently in 1892, and
soon invaded the greater part of European Russia. In that and
the following year it was very rife in many parts of Russia, and
1

In Astrakhan 371 cases of cholera, with 192 deaths, occurred in 1823 ;
and at Krasnoe-Yar, 20 miles away, 21 cases, with 13 deaths (Arkhangelski).

CHART SHOWING T H E PRINCIPAL ROUTES BY WHICH CHOLERA HAS SPREAD IN T H E PAST

CHOLERA

95

particularly among the troops engaged in the Russo-Polish war.
In 1831 cholera also spread widely in Arabia, and caused the
death of nearly one-half of the pilgrims to the Holy Places of
El Islam. Asia Minor and Egypt also suffered. In Europe
few countries escaped. Turkey, Bulgaria, Austria, Germany,
France, Italy, Spain, Portugal, Norway, Sweden, and the British
Isles were all invaded in 1830-32, and from the latter it spread to
America. In America cholera broke out in 1832 at Quebec,
Montreal, New York, and Philadelphia, spread along the St
Lawrence and the shores of Lakes Ontario and Erie, and
finally appeared in almost all parts of the United States, in
Mexico and in Cuba. In the Old World cholera prevailed in
1836-7 in Palestine, in Somaliland, in Zanzibar, and in Algeria,
as well as in many parts of Europe, where it had remained more
or less endemic since its first introduction in 1830.
The year 1840 marked the commencement of a third extension
of cholera. In that year the disease spread along the coasts of
the Malay Peninsula, and was introduced by British vessels into
China, where it raged severely in 1841--3. In 1842 cholera
appeared in the north of Burma, apparently by extension from
China. In 1844 it was rife in Kashgar, Yarkand, Khokand and
Bokhara, and in all these places it appears that the infection
was originally derived from China; possibly it was carried along
the great trade-route from China through Tibet to these
Central Asiatic provinces. In 1844-45 cholera was epidemic
in Afghanistan and in Central Asia, and it would seem that
after the westerly extension from China just described the infection took a south-easterly turn from Bokhara back through
Afghanistan to the Punjab. The original westward course was,
however, also continued, and before the end of 1845 cholera
appeared in Persia, and in 1846 in Mesopotamia, and to a
disastrous extent among the Haj pilgrims in the Hedjaz; it also
appeared at Aden and in Oman. In 1847 it prevailed over
most of the districts already named, and from Persia spread to
Asia Minor, the Caucasus, Astrakhan, and the Volga basin, to
many places in central and southern Russia, and to Constantinople.
The year 1848 was one of the worst " cholera years " on record.
The disease burst out at Mecca and Medina, ravaged Wallachia
and Moldavia, and spread all over Russia, Finland, and Sweden.
In 1848 and particularly in 1849, ^ e w countries in Europe escaped

96

CHOLERA

its ravages. It is noteworthy, however, that in Austria and Spain
cholera did not spread to any great extent, and that Portugal and
Greece remained quite free.
Almost the whole of England
suffered, but the behaviour of the disease was very capricious in
this country. In 1849 Tunis, Oran, and Algiers were invaded,
and in 1848 and 1849 epidemic cholera was more or less rife
in Canada and the United States. In 1850 Egypt and the
whole African sea-board of the Mediterranean and some islands
in that sea were visited, and the disease spread over Mexico
and California, Cuba and Jamaica. In 1851 isolated outbreaks
occurred in Poland, Silesia, and Pomerania, and again in Cuba
and Jamaica, and for the first time cholera appeared in Grand
Canary Island. The disease appears to have then almost, if not
quite, died out in the West for a time. But the respite was very
brief and cholera was in the meantime very active in the East.
In Persia and Mesopotamia it was widely epidemic in 1851,
and in 1852 spread thence to Russia through the Caucasus and
Astrakhan. This new invasion of the south-east of Russia began
before the remains of the former epidemic had quite ceased in
Polish Russia on the west. At this time and until 1861 cholera
was truly endemic in Persia and Mesopotamia. In 1853 it was
more or less active in Russia, Denmark, Norway, England,
Germany, Holland, Bessarabia, Moldavia, Wallachia, Piedmont,
Barbary, and Portugal, and for the third time America was invaded.
In 1854-5 cholera was pandemic, raging in Europe and in North
America as well as in many parts of Asia. A few cases occurred
in Dutch Guiana in 1854; it was epidemic in British Guiana
in 1857, and in 1855 an< ^ I ^ 5 ^ ^ w a s widely epidemic in Brazil.
In 1857-8 the disease quite died out in the greater part of
Europe and America, only to reappear in many places in 1859.
In 1858 cholera was raging on the shores of the Red Sea.
Mauritius had been invaded a second time in 1854, and was
the scene of three subsequent epidemics between that year
and 1862.
In i860 a great revival in cholera activity was recorded in
India; in 1862 the disease was severely epidemic in Peking, Taku,
Tientsin and other places in northern China, and in 1864 the
first signs of a renewed westward extension were observed. From
Sindh cholera spread to Persia, Hadramut, Yemen, and Somaliland.
In 1865 it raged at Makalla and Mocha, and spread into the Hedjaz

CHOLERA

97

Abyssinia, and Egypt, where it caused a terrible mortality. Thence
it passed to some places on the Dardanelles, to Cyprus, to Syria,
Palestine, and Asia Minor. From Constantinople cholera passed up
the Danube into the heart of Europe, and also into the Caucasus,
which on all former occasions had been invaded from the East
and not from the West. The Russian shores of the Black Sea
became infected, and finally Italy, France, Spain, Portugal, Malta,
Gozo, and England, all suffered from more or less extensive outbreaks. Imported cases occurred also at New York, and in
Guadeloupe the disease became epidemic.
In 1866 cholera prevailed widely in most of the places
affected in the preceding year, and extended in addition to St
Petersburg, Bavaria, Saxony, Prussia, Belgium, and Holland, and
in fact over the greater part of Europe. It was largely diffused
by the operations connected with the campaign in Prussia, Austria,
and Italy. In this year cholera again attacked the Mecca pilgrims,
was active in Mesopotamia, Persia, and the Caucasus; and in
England reappeared in Southampton and caused an epidemic
in London and over the greater part of the country. From
England the disease again spread to America, was widely carried
through the United States by the movements of recruits, and also
appeared in Cuba.
In 1867 it was still present in Galicia,
Switzerland, Dalmatia, Montenegro, Albania, Sardinia, and in
a few places in Russia; it had died out in Arabia, Egypt, Mesopotamia, and the greater part of Turkey in Asia. In 1868 cholera
completely disappeared from Europe; but in Africa it spread in
1867 through Abyssinia to Central and Southern Africa, appearing
on the East Coast in 1868 and reaching Zanzibar in 1869. In 1868
it broke out for the first time in history on the West Coast of Africa,
in the French settlement of St Louis, in Senegal, whither it was believed to have been imported by Moorish trading caravans from
north-eastern Africa. It thence spread to Bathurst, and southward
along the West Coast and into the interior. In 1867-8 cholera was
also epidemic in Nicaragua, Honduras, Brazil, the Argentine Republic, Paraguay, Uruguay, Bolivia and Peru, and the Pacific Coast.
Meanwhile, in the East cholera had again spread from India
into Afghanistan, into Kashmir, and into Persia in 1867. In the
two following years it was widely epidemic in Persia, and in 1869
it broke out at Kief in western Russia, and in Nijni-Novgorod
after the great Fair.
c

7

98

CHOLERA

The year 1870 marked the commencement of a most intense
cholera prevalence in Europe, and during the next three years it
was estimated that not less than one million lives were sacrificed
to the disease. It was extremely rife in Russia and in Prussian
Poland in 1870. In 1871 it broke out in Asia Minor and in
Constantinople, and in 1872 in many parts of Austria-Hungary,
the Roumanian Principalities, Prussia, and Belgium. It was several
times imported into England, but no epidemic resulted. In 1873
cholera began to subside in Europe, but remained in Russia, in
the Netherlands, and in Munich until 1874.
In the meantime cholera had spread in Central Asia, invading
Balkh in 1871, and Khokand, Tashkent, Bokhara, and other
places in 1872. In 1870-1 it also spread to Arabia and Nubia,
again attacking the Mecca pilgrims. In 1873 the disease appeared
in New Orleans and in many places in the Mississippi valley.
There now followed a period of eight years, during which
cholera was apparently confined to its endemic homes in the East 1 .
But in 1881 and 1882 the disease was again terribly rife among
the Mecca pilgrims and widely spread through the Hedjaz. In
1882 it was epidemic in Bokhara and Afghanistan, and from 1882
to 1884 was widely spread throughout Egypt; in 1884 it appeared
at Toulon, Marseilles, Genoa, Naples, and other places in Italy,
where it remained until 1886-7. Spain was lightly visited by
cholera in 1884 and severely in 1885.
Another great western extension of cholera began in the year
1892. In 1891 the disease had been unusually active in India,
and in 1892 it caused one of the highest mortality-rates on record
in that country. From India it spread through Afghanistan to
Persia, crossed the Russo-Persian frontier, and was then carried
by the Transcaspian railway both eastward and westward. Eastward it passed to Samarkand, Tashkent, and thence to the greater
part of Siberia; westward it reached the Caspian. It soon crossed
that sea, and invaded the Caucasus on the one hand and
Astrakhan on the other. It rapidly spread up the Volga and
more slowly along the shores of the Black Sea, until the greater
part of European Russia was more or less infected by the disease.
1
Hirsch, however, appears to be in error in stating that "from 1875 t o t n e
end of 1880 it [cholera] had shown itself at no point of the globe out of India."
It was severely epidemic in Japan in 1877-79 ; and was present in several
parts of China during the five-year period in question.

CHOLERA

99

In the same year it also became severely epidemic at Hamburg,
in Germany, and in some parts of Austria, Hungary, Turkey, and
Arabia; and isolated cases were recorded in England, France,
Belgium, Holland, Denmark, Norway, Italy, Servia, Morocco, and
the United States.
In 1893 the disease was again rife in Russia, especially in the
Ukraine in the south-west, while the Volga provinces and the
Caucasus in the south-east, which had been most severely affected
in 1892, suffered but little. Cholera also prevailed to some extent
in many parts of France, Holland, Belgium, and Germany (where
Hamburg was again the scene of an epidemic). Hungary, Austria,
Bosnia, and Roumania were all invaded. It was more or less
prevalent in many parts of Italy, and in some places in Spain,
Tunis, Algeria, Senegambia, and the Canary Islands. The Haj
pilgrims suffered from a terrible outbreak of the disease, which,
according to an estimate of the Grand Sherif of Mecca caused
50,000 deaths. Imported cases again occurred in the United
States and also in Brazil. A considerable number of strictly
limited outbreaks of cholera occurred this year in England.
In 1894 the disease was still active in many parts of Russia,
especially in the Polish and other western governments. In
Germany cholera was widely prevalent; in Galicia there was a
very fatal epidemic; in Turkey, Belgium, Holland, and Hungary
the disease was present, and it had not quite disappeared from
France. In 1895 ^ w a s a g a m epidemic in Volhynia, Podolia,
Kief, and other parts of western Russia, in Galicia, in European
and Asiatic Turkey, in Morocco, in Egypt, and in Japan. Finally
in 1896 cholera disappeared from Russia, and apparently from
Europe; but it was widely epidemic in Egypt. In all these
years the infection was frequently imported to England, but
without giving rise to any epidemic. In 1899 t n e malady appeared
at Bushire, and at Basra and some other places on the Persian
Gulf. As usual, the outbreak here occurred at the time of the
date-harvest, when thousands of people are congregated together
under the worst possible conditions of sanitation. Finally, while
these pages are passing through the press, cholera has caused
a considerable mortality among the pilgrims to the Hedjaz,
and in many parts of Egypt; while it is reported to be raging
in Manchuria and at numerous places on the Russo-Chinese
frontier.
7—2

CHOLERA

100

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25

30

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Cases of C?tolera>per
100.000 Inhabitants
j In the unshaded
{Provinces there were fa
Wmn 100castsp. lOO.OQOJnha

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3

—

Map of European Russia and the Caucasus,
showing the distribution of Cholera in 1892 (from the beginning of the epidemic
to December ist).

CHOLERA

IOI

The shading in the accompanying map represents a varying ratio of cases
of cholera per 100,000 inhabitants. The numbers inserted in the different
governments and provinces correspond to the numbers in the following table:
Name of
Government
or Province

No.

( Daghestan
I.
II. 0>
Terek
0
III. p
Stavropol
IV. 0
Kuban
p
Baku
V. C
VI. &< Kars
>
VII. H Zakataly
VIII.
Erivan
IX. 0
Elizavetpol
P
X. 0
Tiflis
P
XL P ' V Kutais

3

Cases of
cholera

per 100,000

inhabitants
3912

1

1.
2.

34-

56.
78.
910.
11.
12.

*314.
1516.
1718.
19.
20.
21.
22.

\strakhan
"he Don Cossacks
cjaratof
csamara
cSimbirsk
Voronezh
^
(Orenburg
?ambof
I^ublin
I3enza
ICursk
I£azan
\Jfa
/iatka
^
ICief
cIt Petersburg
I^ijni Novgorod
Iikaterinoslav
ICharkof
?aurida
] Cherson
IBessarabia
i

3384
2115
1944
1607
1468
1309
1308
IO79

749
6
2494

1812
1721
1556
1028

894
746
733
536
483
397
380

No.
2324.
25.
26.
27.
28.
29.
30.
3i32.

35343536.
3738.
3940.
41.
42.
4344.
4546.

353
343
336

4748.

290

50.

280

5i52.

258

49.

^55

53-

215
219

5455-

Name of
Government
or Province

Podolia
Perm
Yaroslavl
Riazan
Tula
Orel
Poltava
Tchernigof
Radom
Moscow
Kielce
Volhynia
Kostroma
Olonetz
Vladimir
Warsaw
Mogilef
Plo9k
Livonia
Minsk
Pskof
Lomza
Grodno
Tver
Novgorod
Piotrkow
Vologda
Kaluga
Courland
Smolensk
Vilna
Vitebsk
Siedlec

Cases of
cholera

per 100,000

inhabitants
148
150
104

90

84
71
70
70

99
68
52

49
3i
27

*9
17
16
12

8
8
6
8
5
3
2
1
1

o-6
1

0-3

o*5
O'l
211

*94

The only parts of Russia which escaped the epidemic altogether in 1892
were the governments of Archangel and Esthonia; the Polish governments of
Suvalki and Kalisz, and the Principality of Finland. These are consequently
omitted both from the table and the map.

102

CHOLERA

Factors governing the Geographical Distribution of
Cholera. It will be seen that in its epidemic or pandemic spread
westwards cholera has been mainly confined to the northern
hemisphere. The occasions on which it has crossed the equator
have been the following:—in 1820, 1837, and 1869, it appeared
in Zanzibar 1 ; in 1819 and four times between 1854 and 1862
it was epidemic in Mauritius; it has recently appeared in New
Guinea, a few degrees south of the equator; and it was epidemic,
in one or more years between 1855 an< ^ 1868, in Brazil, Paraguay,
Uruguay, the Argentine Republic, Bolivia, and Peru.
In considering the geographical distribution of cholera it is
more easy to name those countries where the disease has never
appeared than those where it has at some time prevailed. Some
doubtful sporadic cases only have occurred in Iceland (in i860).
The Faroe Islands have never been visited. In Norway Bergen
has been the most northerly limit of cholera. Finland has almost
entirely escaped its ravages. No other European country has
quite escaped the disease. But in saying this it is not intended
to imply that all parts of those countries have been the scenes of
cholera epidemics; on the contrary, there are many towns and
many districts of considerable size which have always been
fortunate enough almost or quite to escape the disease; as, for
example, Rouen, Versailles, Lyons, Sedan and the Vosges
district in France; Baden and Wiirtemburg in Germany; several
towns in Russia, and so forth. The disease is notoriously
capricious in its behaviour, though possibly a fuller knowledge
will in time enable us to explain phenomena that now appear to
be capricious. In Siberia the northerly province of Yakutsk
seems to have escaped cholera in all the past epidemics of the
disease; Kamtchatka has also never been visited, and generally
in Siberia the northerly limit of cholera appears to have been
about the 60th parallel of latitude. In Europe, on the other hand,
the disease has on many occasions been mildly epidemic considerably to the north of this, e.g. in the Archangel government.
1
Isolated cases of what is described as ' * apparently a not very rapid form
of cholera " were seen by Pruen in Equatorial Africa ; epidemics of cholera he
never saw or heard of there. There is no other evidence to show that true
cholera exists in this part of the world, and the cases described were perhaps
cases of an acute diarrhoeal disorder other than cholera. The Arab and the
African, S. T. Pruen, M.D., London, 1891.

CHOLERA

IO3

In the western hemisphere, Greenland, Newfoundland, and the
northern portions of Canada have never been visited by cholera.
Some parts of Central America, the Bermudas, and several West
Indian Islands have been equally fortunate. In South America,
Venezuela and Chile have also escaped hitherto, and, so far as
the absence of positive records justifies the assertion, the same
is true of Patagonia and the Falkland Islands. The infection
has been several times imported to the shores of South Africa
(one of the most recent instances occurred in Durban in 1890),
but has never gained a footing there, and Australia and New
Zealand seem to be equally unsuited for the spread of cholera, or
have been equally successful in dealing with imported infection.
The complete immunity of the Andaman Islands, so close to the
principal home of the disease, is even more remarkable.
That cholera is largely spread by the movements of human
beings is shown firstly by the part that pilgrimages have taken in
its development, secondly by the fact that the course and rapidity
of its diffusion have often varied with the course and rapidity
of the usual means of human communication, and thirdly by the
disease always following the great routes of trade and travel.
The commencement of the last pandemic of cholera in 1892 was
associated with the movements of a vast body of pilgrims dispersed from the great bathing festival at Hardwar in northern
India. This and other fairs have on many previous occasions
played a similar part, though it is important to add that they
have in many years been attended by equally large numbers of
pilgrims amongst whom cholera has appeared without being followed
by any wide extension of the disease. This happened in 1891,
wrhen three deaths from cholera occurred in pilgrims to Hardwar,
yet no epidemic resulted, although in the following year the same
measures of precaution seemed powerless to prevent the development there of one of the greatest and widest epidemics of cholera
ever known. The dispersing pilgrims in 1892 carried the infection
with them and became foci of the disease in many parts of India.
That they were the sole factor in starting the epidemic must however be doubted. Cholera had been unusually prevalent in India
in the previous year without their taking any part in its diffusion,
and it had already been unusually active in the North-West
Provinces in 1892 before the Hardwar Festival (an exceptionally
numerously attended one, though less so than that of 1891) of that

104

CHOLERA

year was held. It is probable therefore that the movements of
the Hardwar pilgrims only contributed to an extension of cholera
which would have occurred in any case.
The great annual pilgrimage to Mecca and Medina has on
many occasions been not only the scene of terrible outbreaks of
cholera, but the means of dispersing the disease far and wide;
and smaller pilgrimages, such as those to the shrines of Meshed
in Persia, and the many local fairs and festivities in India, have
frequently aided in spreading the disorder. So also the movements
of large bodies of peasants in Russia, the dispersion of traders and
others after great fairs such as that of Nijni-Novgorod, and the
movements of troops in war-time (in this case aided by other
conditions than mere movement) have all powerfully contributed
to the diffusion of cholera. But a full consideration of all the
facts will usually lead to the conclusion that the disease is not
solely spread in this manner.
The same remark applies to the diffusion of cholera by water.
That the disease can be, and is spread in this way to an immense
extent, and perhaps more than by any other means, can scarcely
be denied. The last epidemic furnished innumerable examples of
this. In Russia such great rivers as the Volga, the Neva, the
Vistula, the Dnieper, and the Don all became seriously contaminated by the cholera virus in 18921, and at Hamburg the Elbe
was the principal distributor of the infection.
In London in
1854 the disease was diffused by a contaminated public watersupply, and the same thing has been observed over and over
again, not only in countries where cholera has become epidemic,
but in India and even in Lower Bengal itself, where, if anywhere,
cholera is permanently endemic. But this spread of the infection
by water—no more than its diffusion by human beings—is not the
whole explanation of the behaviour of the disease. There are
phenomena—particularly the quiescence of cholera for several
years in its endemic homes, and its wide extension outside them
in other years under apparently identical conditions—which
cannot be explained by these considerations alone, and which
involve problems too wide and too controversial to be discussed
here.
1
" T h e Spread of Cholera by Water." By Frank G. Clemow, M.D.,
D.P.H.
Transactions of the 8th International Congress of Hygiene and
Demography. Buda-Pest, 1894.

CHOLERA

I05

Cholera, it will be seen, remains endemic for very long periods
only in tropical countries. In some subtropical countries, such as
Persia and Mesopotamia, it has remained endemic for a longer
series of years than in the temperate countries of Europe or
America. That local conditions, and not climate alone, have
some share in determining this behaviour of the disease, is,
however, clear from the fact that cholera has remained endemic
in Russia for a longer series of years than in other European
countries with warmer climates. Warmth is, in fact, not the only
condition needed for cholera prevalence, though it is an important
one. This is shown by the rarity and mildness of the disease in
northern Europe and its absence from northern Siberia. The
influence of warmth was remarkably demonstrated by the distribution of cholera in Russia in the year 1892. The intensity of
the epidemic decreased with something like mathematical regularity
as the disease travelled from south to north, and though other
factors,—such as a loss of virulence in the cholera virus as it
travelled further, and an increasing preparedness on the part of
the authorities to meet and deal with the disease—may have
been at work, it is scarcely possible not to believe that a
diminishing temperature was the most important factor. The
map on p. 100 shows, by means of shading, this remarkable
distribution of the disease in Russia in 1892. Many other
considerations—especially the subsidence of cholera in Europe
in the winter and its recrudescences in summer—prove further
the great influence of warmth upon its prevalence. The disease
has, however, exceptionally prevailed in quite cold weather, and,
as stated above, it has been seen as far north as Archangel and,
doubtfully, in Iceland.
An immense number of other influences are at work in
determining the geographical distribution of cholera. Race is
probably of no great consequence, but the black races seem to
be more susceptible than the white. Elevation is of importance,
low-lying, alluvial countries seeming to suffer much more than
those more elevated; but this rule is not without marked
exceptions. A country or district which has suffered severely
in one year is often visited mildly or escapes altogether the
next year; but exceptions to this rule are also observed, not
only in Europe, but also in India. Soil, meteorological conditions,
the degree of intelligence and civilisation of the people, and

io6

CHOLERA

many other local conditions all play a considerable part in the
distribution of cholera. To what extent the disease can always
be kept at bay by well-directed measures is perhaps uncertain.
Certainly a high level of Public Health administration, combined
with great care in preventing the spread of imported infection,
has in a vast number of instances proved successful in saving a
country from a cholera epidemic. These instances have, however,
all occurred in countries far removed from the original source of
the disease in the East, and it has yet to be proved that they would
be equally successful in countries nearer to India.
Lastly, perhaps the most important factor of all in the
geographical distribution of cholera is distance from the endemic
homes of the disease. Those countries and islands which are
farthest removed from India, and have consequently less constant
and direct communication with her, escape altogether or are
visited rarely. Those countries, on the other hand, such as Farther
India, China (where for the present cholera is as truly endemic as
in India), Persia, Mesopotamia and Central Asia, between which
and India there is a constant stream of intercommunication, are
the most liable to epidemic recurrences. It is more than probable
that this relative immunity to cholera of countries distant from the
source of the disease is due, not only to their less constant and
direct communication with India, but also to the greater distance
over which the virus has to be carried, with consequently increased
chances of its dying on the way or greatly losing its virulence.

DENGUE.
General Characters and Etiology.
Dengue, Dandy,
or Breakbone Fever is a highly infectious febrile disease,
characterised * by severe rheumatoid pains in the joints and
limbs, and in some cases by a cutaneous eruption of varying
character and duration. The cause of this disease is quite
unknown, but it presents all the characters of a specific infective
fever, and is very possibly of microbial origin. The microbe,
if it exists, has not, however, been discovered. The malady can
apparently remain for long periods as an endemic, but it is seen
most characteristically as an epidemic, or, at irregular intervals, as
an almost pandemic disorder.
G e o g r a p h i c a l D i s t r i b u t i o n . Dengue appears to be mainly
a disease of tropical and subtropical zones, but it can occur and
give rise to epidemics of some severity in comparatively temperate
countries. Whether dengue is to be regarded as permanently endemic in any part of the world appears uncertain, the records of the
disease dealing almost entirely with recurring epidemic prevalences.
In this respect it presents many analogies with influenza, both
diseases occurring from time to time in the form of localised
outbreaks, and at intervals spreading with extraordinary rapidity
over very large areas of the earth's surface. Dengue has, however,
at no time become truly pandemic in the sense that influenza has
on many occasions; though the area which it has covered in some
epidemics has been of very considerable size, as for example in
1870—73, when it was seen as far west as the southern United
States, and as far east as China and Formosa. Even in its widest
epidemic prevalences, however, it does not spread very far outside
tropical and subtropical latitudes.
Moreover it retains a much more sporadic and capricious
character than influenza. In the years just named, for example,

io8

DENGUE

dengue was present, between the easterly limit of Formosa and
the westerly limit of the United States, solely in Burma, India,
China, the East Indies, Arabia, Aden, the East African coast, Zanzibar, Mauritius, and Reunion, whereas influenza, in its epidemic
prevalences, usually attacks every country, and sometimes every
inhabited place in every country (with the exception of isolated
communities) between the extreme limits of, its extension.
Dengue resembles influenza further, not only in its tendency to
attack a very large proportion of the inhabitants of a place in
which it breaks out, but in the extraordinary speed with which
these large numbers of persons develop the disease; so that—just
as in the case of influenza—it is common to read of " nearly the
whole" or of "three-fourths" of a community being "simultaneously" attacked. It is probable that these expressions are
not to be taken quite literally, but it is certainly true that the
disease does attack very large numbers of persons, and that it
may do this in a very short period of time. Trustworthy estimates
have placed the proportion of a community attacked at as high a
figure as two-thirds of the population (at Mauritius in 1873), at
three-fourths of the population (at Smyrna and at Amoy), and
even higher (at Jaffa and St Thomas). In some of the annual
outbreaks of this disease at Beirut in Syria I am informed on
excellent authority that almost the entire population are attacked.
Recent Endemic Prevalence in certain Countries. If dengue is
truly endemic at the present time in any part of the earth's
surface it is probably so only in certain tropical and subtropical
countries. In India it is occasionally seen among the natives,
but I am aware of no trustworthy statistics proving its degree of
prevalence in the Indian peninsula. Many epidemics of the
disease, on the other hand, have been recorded here in the past.
I n Egypt dengue is said, on good authority, to be met with in a
sporadic form every year during the damp months of autumn,
dying out in December. In Beirut, on the Syrian coast, dengue
would appear to be truly endemic, and every year, usually in the
autumn, an epidemic of greater or less severity occurs. From
time to time epidemic outbreaks of the disease are also reported
from Tripoli, where an outbreak of this kind occurred as recently
as November, 1901.
It is possibly also endemic in East Central Africa; Pruen
observes that it occurs there sporadically (he ascribed it to the

DENGUE

IO9

use of impure drinking-water); and another traveller in East
Africa, Scott-Elliot, states that " i n the colony zone, at a height
of 5000 to 7000 feet, there is a curious kind of rheumatism or
{
dengue fever/ which affected many of my men 1 ." It is also
said to be seen sporadically on the West Coast, at Senegambia 2 .
In the West Indies there is some reason to believe that dengue
is more or less permanently endemic. It is sometimes seen in
Cuba; it was epidemic there in 1897, at the same time as yellow ,
fever, but as Cuba was at the time under exceptional conditions
owing to the war, and as dengue, also accompanied by yellow fever,
was epidemic in Texas at the same time, this outbreak was quite
possibly due to an imported infection and not to excessive activity
of an indigenous disease. In the Bermudas dengue is said to
occur sporadically from time to time. It is sometimes seen also
in British Guiana.
Epidemics or Pandemics of Dengue. Historical
Summary.
The epidemic extensions of dengue have been marked by
great irregularity, both in regard to time and to the countries
attacked. The history of the disease is far from completely
known, as it has only been distinctly differentiated in the last
century, and is even now not always easy of diagnosis from other
disorders. But so far as recorded facts enable us to follow its
history the principal epidemics in the past have been the
following :—
In 1779 dengue was prevalent in Batavia and Egypt; in 1780
in Spain, Zanzibar, India (the Coromandel Coast), and possibly
in Philadelphia. In 1818 it broke out at Lima. In the years
1824-28 there was a wide prevalence of the disease; it spread
over a great part of the Ganges delta, extending as far inland as
Berhampur; it appeared on the Coromandel Coast, at Gujerat
and Rangoon; it (probably) raged at Zanzibar; it prevailed from
1826-28 in the south of the United States, in the West Indies,
and at Carthagena and Bogota in South America. Whether any
of the countries intervening between the wide limits here named
were affected by the disease at this time there is apparently no
evidence to show.
1
A Naturalist in Mid-Africa.
G. F. Scott-Elliot, M.A., F.L.S., etc.
London, 1896, p. 189. Cook, on the other hand, never saw a case during
four years' residence in Uganda.
2
Two cases of dengue were admitted to the Colonial Hospital, Gambia, in
1898; none in 1897; one in 1890. See the Colonial Hospital Reports.

no

DENGUE

In 1835 a limited outbreak of dengue was seen in Arabia; in
1836 in India; in 1837 in Bermuda; in 1844 in India; in 1845
in Egypt; in 1847 m India; in 1845-48 in Senegambia; in
1845-49 in Rio de Janeiro; in 1847-56 repeatedly in Tahiti;
in 1850 in the southern United States; in 1851 in Mauritius and
Re'union, and at Callao and Lima; in 1853-54 in India; in 1854
in the southern United States and in Havana; in 1856 in
Senegambia and at Benghazi in Tripoli; in i860 in Bermuda and
in Martinique; in 1863 in Bermuda; in 1864 in Cayenne; in
1865-67 in Senegambia, in Spain, and in Teneriffe; in 1868 in
Port Said.
What is spoken of as a third pandemic of dengue began in
Zanzibar in 1870 ; the scattered portions of the earth's surface
affected by the disease in that and the following three years have
been already enumerated. In India, during this epidemic, dengue
spread from Bombay, Calcutta, and Madras along the lines of
communication to most parts of the east and west coasts of the
peninsula and inland to the foot of the Himalayas.
More recent limited outbreaks of dengue have occurred at
Benghazi in Tripoli in 1878; on the coast of the Gulf of Mexico
in 1880; in New Caledonia in 1884-85 ; in Fiji, for the first time
in 1885 ; at Port Said in the same year, and widely throughout
Egypt in 1887. In 1889 dengue spread to both shores of the ^Egean
Sea and to most of the islands of the Greek Archipelago excepting
Crete. Beirut, Jaffa, Smyrna, Constantinople, Salonika, and Athens
were all visited, and the epidemic is said to have spread all over
Asia Minor and the Lebanon. Still more recently there is mention
of an epidemic at Amoy, on the coast of China. Canton had also
been the scene of an outbreak at some earlier date. In 1895-96
dengue was twice epidemic in Cochin China 1 . In 1897 an
epidemic of the disease broke out in Queensland and caused
as many as 97 deaths. Four cases of this disease had been
recorded in the preceding year, but before 1896 dengue had
apparently been absent from the colony for some time 2 . In that
year the malady, as already stated, was epidemic, together with yellow
fever, in Cuba and in Texas. In 1898 seventeen cases of dengue
were admitted to the Durban Hospital, Natal, so that probably
there was an epidemic there in that year. In November, 1901,
1
2

Nogue, Arch, de Med. Nav. et Colon. Dec. 1897.
Reports of the Registrar-General. 1896 and 1897.

DENGUE

III

the disease became epidemic in Beirut and Tripoli, in Syria, and
a few isolated cases occurred a little later in Constantinople.
Finally, in British New Guinea dengue has recently been imported
and has attacked the natives, but without doing much harm \

Factors governing the Geographical Distribution
of D e n g u e . The known geographical range of dengue is a
restricted one in regard to latitude. The disease appears to be
confined to a belt running round the world, the northern limit
of which may be placed in Europe at about the 41st degree
(Constantinople); in Asia not higher than the 33rd degree
(Northern India), and in America at about the 40th degree
(Philadelphia). The southern limit of the belt would seem to be
about the 30th degree of south latitude in Africa (Durban); the
2^5th or 26th degree in Australia (Queensland); and the Tropic
of Capricorn in South America (Rio de Janeiro). Within this belt,
which is practically the tropics plus a strip of the earth's surface
on either side of the tropics, dengue has been able at times to
prevail widely in both hemispheres.
That temperature is one of the leading factors in defining
the range of dengue is therefore exceedingly probable. A warm
or hot atmosphere seems to be essential for its prevalence. This
is further shown by its behaviour in individual outbreaks. Almost
without exception the onset of cold weather has always put an
end to an epidemic of dengue. The only apparent exceptions
have been certain epidemics in the West Indies, which occurred
in cool weather; but the term " c o o l " must be taken as having
but a relative significance here, as the minimum temperature
at the time was as high as 64 0 (Hirsch). Temperatures near the
freezing-point are said to arrest an epidemic completely.
Certain other conditions seem to be also necessary for the
prevalence of dengue. Dirt, insanitation, and overcrowding have
appeared to favour its development. Towns have usually suffered
more severely than rural districts, and particularly those portions
of the towns affected where the general conditions of hygiene have
been most defective. In this respect, as Hirsch and others have
pointed out, dengue presents some analogy with yellow fever. A
further point of analogy is found in the tendency dengue has
shown to occur along coast-lines and to avoid penetrating far into
1

Sir W. MacGregor.

112

DENGUE

the interior of countries. A low elevation above sea-level is
apparently more favourable than a high one.
This disease appears to be almost entirely independent of such
conditions as the race, age, or sex of the community attacked.
All ages and both sexes are liable to it, and an apparent immunity
observed in certain races in some outbreaks has not been maintained when the same races have been exposed to its attacks
elsewhere. A similar indifference is shown by dengue to the
nature of the soil on which it prevails, whether as regards its
physical or its geological characteristics.
The clinical and other characters of this disease point
to its being one of the acute infective fevers, but the microorganism associated with it, if there be one, has not yet been
discovered. That the disease is infectious from person to person
is practically certain. Corre and others have quoted a large
number of instances in which dengue has been spread by the
arrival of a ship with cases on board. Instances are also known
in which a person has visited an infected locality and on his
return thence introduced the disease to a place hitherto free from
it. The fact that medical men and nurses have also rather
frequently suffered from its attacks may be held to be further
proof of the considerable degree of infectivity possessed by the
disease. It is still a moot point, just as in the case of influenza,
whether this is the only or the principal manner in which dengue
is spread when it becomes epidemic, or whether the great
rapidity of its diffusion and the occasional occurrence of what
seems to be a simultaneous outbreak in a large proportion of
a community do not require some other explanation. It is
probable, however, that the rapidity and the "simultaneity" of
these epidemic outbreaks have been somewhat exaggerated, and
that dengue is, at any rate to a very great extent, spread from
person to person.
In some epidemics animals have been believed to suffer from
an analogous disorder at the same time as human beings, but no
proof has ever been adduced that this disease can in fact attack
the lower animals.

DIABETES MELLITUS.
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . The general characters of diabetes mellitus are too well known to require detailed
description here. The causation of diabetes is uncertain. Hereditary influences, temperament, racial predisposition, all perhaps
have some share in it, and there can be no question that
disturbances of the nervous system are largely concerned in
its production. Some have hazarded the suggestion that this
disease, like so many others, will prove to be of micro-parasitic
origin. But no facts in support of this suggestion have as yet
been brought forward.
H i s t o r y . The oldest known mention of this disease seems
to occur in one of the early Hindu writings—the Ayur Veda of
Susruta. References to diabetes, or at least to glycosuria, are
frequent in the writings of the Grseco-Roman and Arabian
physicians, and throughout medieval times. Towards the end of
the eighteenth century the study of the disease was placed on a
scientific basis by the work of two English physicians, Dobson and
(later) Rollo. In recent times much light has been thrown on
the nature and cause of diabetes by the investigations of Pavy,
Naunyn and others.
G e o g r a p h i c a l D i s t r i b u t i o n . Europe. Diabetes mellitus
is increasing in frequency in the British Isles. In England and
Wales the mortality from this cause has steadily risen from an
average of 57 per million in the years 1881-90 to 86 per million
in 1900. Among the specially liable group of males above 45
years of age the mortality-rate is very much higher. Thus in the
years 1881-90 the diabetes deaths among persons between 45
and 55 was 134 per million; between 55 and 65, they were 282;
between 65 and 75 they were 397; and over 75 they were 314
c.

8

ii4

DIABETES MELLITUS

per million. In Scotland diabetes is somewhat rarer than in
England, and in Ireland it is still less prevalent.
In France diabetes also appears to have become more
frequent in recent years. In Paris, at least, there has been a
steady rise in the mortality from this cause in the past four
decades; in 1891 the death-rate rose to 140 per million of the
population.
Although statistics relating to the prevalence of this disease in
other European countries are largely wanting, there is evidence
from many of them to show that diabetes is not a rare disease.
When statistics are available they tend to show a rise in the
mortality from this disease similar to that observed in the British
Isles and in France. Thus in Denmark the deaths from diabetes
in the urban population rose from 48 (about 60 per million) in the
year 1892 to 87 (over 100 per million) in 1897. In Norway the
diabetes death-rate is about equal to that of England and Wales.
In Russia, in the three years 1893, 1894, 1895 there was a steady
rise in the number of cases of diabetes treated both inside and
outside the hospitals. Cases of, and deaths from the disease were
reported in those years from all parts of European Russia,
including the Baltic and Polish provinces, and the Don Cossack
territory.
In Italy diabetes seems to be rarer than in England or in
Denmark, but here also its frequency is increasing. Between
the years 1887 and 1896 the deaths ascribed to it in the whole of
Italy continuously rose from 17 per million in the first year to 27
in the last.
Diabetes undoubtedly exists in Turkey in Europe. In Constantinople it is seen with some frequency; but I am unable to
satisfy myself that it is of more common occurrence here than
elsewhere in Europe, in spite of the unmeasured consumption of
sweetmeats of all kinds by the inhabitants and the sedentary,
inactive life led by the majority.
Asia. Diabetes is certainly met with in the Caucasus and
Transcaucasia, though it is probably not a common disease here.
The returns do not give the separate figures for the flat Caucasus
proper and the hilly regions of Transcaucasia. From Russian
Central Asia a few cases of diabetes are yearly reported, but the
returns from these provinces are very imperfect, and it is impossible
to state whether the disease is common or rare here. The same

DIABETES MELLITUS

115

remark equally applies to Siberia. The disease statistics for the
Siberian provinces are for the country as a whole, and not for each
province separately.
With regard to Arabia, Syria, Asia Minor, Mesopotamia,
and Persia, medical literature affords no information as to the
presence, absence, or frequency of this disease.
In India, on the other hand, diabetes is known to be a
disorder of very considerable frequency. The Hindus here suffer
much more than the Mohammedans. It is said to be particularly
common among the educated Bengalis. The Jains, whose only
animal food is milk and butter, escape it, and so also do the
Sadhus, Yogees, and Chorbays of Muttra, who live almost entirely
on sweets1. In Ceylon, also, diabetes would seem to be as
prevalent as in India. Whether the disease exists in any of the
East Indian islands is uncertain. It is said to be unknown among
the hill tribes of Java 2 . It is occasionally seen in China 3 .
Australasia.
In Australia diabetes is probably a rare disorder.
Occasional cases are seen in the hospitals of New South Wales;
and in Western Australia it is the cause of a few deaths in most
years. In New Zealand on the other hand this disease must be
very much more common than in Australia, and here, as in Europe,
it is becoming more frequent. In 1889 t n e deaths from diabetes
in New Zealand were only 14 (about 22 per million); in 1898
they had risen to 48 (about 64 per million). It is therefore nearly
as common in this colony as in the mother country. Nothing
seems to be known concerning the existence of diabetes in the
Pacific Islands,
Africa. Diabetes certainly occurs in Egypt, in Algeria, and in
Morocco. It is relatively common in Tunisia, particularly among
the natives; the Mussulman and Jewish population suffer from it
here much more than the Christian inhabitants. On the other
hand diabetes appears to be absent from the pathology of Western
and Central Africa, and is seen but rarely in Madagascar.
America. Osier states that in America diabetes is a rarer
disease than in Europe. The last census gave a death-rate of
only 38 per million for this disease. It is however increasing in
frequency in the United States, as in Europe. In Mexico it has
been seen and is perhaps common. In some of the West Indian
1
2

Transactions 1st Ind. Medical Congress, 1894.
3
Kohlbrugge,y<a/m.y, 1897-8.
Coltman, op. cit.
8—2

n6

DIABETES MELLITUS

islands, as Jamaica and Grenada, an occasional death from it is
recorded.
For South America the evidence in regard to this disease is
conflicting, and scarcely justifies any more definite assertion than
that it occurs, but with great rarity, in Brazil and Peru, and that it
is perhaps unknown in British Guiana.

Factors governing the Distribution of Diabetes. This
disease occurs indifferently in tropical, sub-tropical, and temperate
climates. It is apparently commonest in the highly civilised
countries of Europe and in India. It is, perhaps, a disease of
civilisation. Luxury, a sedentary life, a neurotic temperament,
and town life all seem to favour the production of diabetes in the
individual, and these are found at their highest development in the
most civilised countries. Mental strain, worry, anxiety, "nervewear" also serve to predispose to diabetes. All these factors
increase as civilisation advances, as the city population increases
at the expense of the rural population and as the "struggle for
life" becomes keener, and to this may perhaps be attributed in
part, if not wholly, the recent increase in frequency of this
disease in so many countries.
Race has probably not a little influence upon the prevalence of
diabetes. The Jewish race has shown a remarkable tendency to
suffer from it, not only in Europe, but in the United States and
in Algeria. The negro race is not exempt, and in a series of 77
cases recorded by Futcher in America as many as one-tenth of
the patients were negroes. In India, as stated above, the Hindus
suffer more than the Moslems, while the Jains and some other
races escape.
The belief has often been expressed that an exclusively or
mainly farinaceous diet is largely responsible for the production
of diabetes. The prevalence of the disease in India and Ceylon
to some extent supports this view. But there are some considerations of weight against it. Thus in many other countries
outside India the natives live practically on nothing but farinaceous food and yet do not develope diabetes • and in India
itself the Jains under similar conditions escape it, and so also do
Hindu widows, who never touch animal food1.
The male sex is very much more liable to be the subject of
1

1894.

Ko'ilash Ch. Bose, I. M. S.

Transactions \st Ind. Medical Congress,

DIABETES MELLITUS

117

diabetes than the female, and the disease is mainly—though not
exclusively—one of advanced years. Children have occasionally
suffered from it, and even infants under one year of age have been
known to develope it. There is nothing to prove that insanitary
conditions favour its prevalence; and in London and elsewhere it
has been shown to occur more often in the well-to-do than in the
poorer classes of the community.

DIARRHCEAL DISORDERS.
i.

T H E DIARRHOEA OF I N F A N T S , CHOLERA N O S T R A S ,
S U M M E R DIARRHCEA, ETC.

2.

SPRUE

3.

H I L L DIARRHCEA.

4.

" C A R I B I , " " E L BICHO," OR " I N D I A N

(PSILOSIS).
SICKNESS."

The Principal Varieties of Diarrhceal Disorders.
Diarrhoea is, it need scarcely be said, a symptom of many morbid
conditions, and not as a rule a disease in itself. It is unnecessary
to enumerate the very large number of causes which may give rise
to loose evacuations. Many of these causes are local, accidental,
or temporary in their character, and,' as such, it would be
purposeless to attempt to discuss the geographical distribution
of the symptoms to which they give rise. In most countries
diarrhceal diseases contribute largely to the sum of annual
mortality, but it is usually impossible to distinguish in the
returns what proportion of the deaths is due to diarrhoea of local,
accidental, or temporary causation, and what to the more specific
forms of diarrhoea which will alone be discussed here.
Some forms of diarrhoea may be conveniently regarded as
almost constituting specific diseases in themselves, inasmuch as
they are probably the result of certain constant causes or groups
of causes, they show distinct seasonal or climatic variations, or
they bear definite relations to elevation above sea-level, or to
the age of the persons attacked. Among these is the diarrhoea
of infants, which is one of the most prolific causes of infantile
mortality. Another is the so-called cholera nostras, or summer
diarrhoea, from which many people suffer in the summer months,
and which is probably in part due to the consumption of unripe

DIARRHCEAL DISORDERS

119

or over-ripe fruit, or of fruit in excess. A third form is the
so-called hill diarrhoea, met with at high elevations in India and
elsewhere. Sprue or psilosis is a fourth form of affection of the
alimentary tract in which diarrhoea is a more or less prominent
symptom. "Caribi" or "Indian sickness," " E l Bicho," and
"epidemic gangrenous rectitis," all probably the same disease,
form yet another distinct variety of diarrhceal disorder.
1.

T H E DIARRHOEA OF I N F A N T S , C H O L E R A N O S T R A S ,
S U M M E R DIARRHCEA, ETC.

In most countries a very large number of children die in
the first years of life from diarrhceal troubles. To what extent
these troubles are due to one specific cause and may therefore
be regarded as a specific disease cannot be determined. Diarrhoea
is such a constant symptom in infantile diseases, it is so easily
brought about by teething, by improper feeding, neglect, and other
temporary and accidental causes, that unquestionably much of the
so-called cholera infantum or infantile diarrhoea is due to no one
specific disease. But the remarkably definite relation which the
mortality of infants from diarrhoea shows to variations of temperature
seems to indicate that a considerable proportion of it is due to a
definite cause or group of causes which varies in activity with the
variations in temperature, and that in this sense a certain proportion of the deaths from so-called infantile diarrhoea may be
justifiably regarded as due to a more or less definite disease or
group of diseases.
It is probable that the deaths from infantile diarrhoea form
a very notable proportion of the deaths from diarrhoea generally
recorded in the vital statistics of many countries. It is, however,
rarely possible to determine accurately what this proportion is,
and the returns for "diarrhoea" as a whole, or for "dysentery
and diarrhoea " are alone available. Although infantile diarrhoea
contributes largely to the sum of these returns, the diarrhoea of
elderly persons, and cholera nostras, together with the diarrhoea
from temporary or accidental causes already alluded to, form the
majority of the recorded cases. Dysentery will be dealt with in
a separate chapter.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. In England
and Wales the deaths from " dvsentery and diarrhoea " fell from an

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DIARRHCEAL DISORDERS

annual mean of 1076 per million in the decade 1861-70 to one of
935 in the next decade, and to 674 in the years 1881-90. The
fall has not been maintained, for though the mortality from these
causes was as low as 358 per million in 1894, it rose to 902 in the
following year, and has since been respectively 564, 871, and 727
in the years 1896, 1897, and 1900. Dysentery being all but extinct
in this country, almost the whole of the deaths in this group may
be regarded as due to diarrhoea. These deaths are vastly more
numerous in densely-crowded urban populations than elsewhere,
and hence the highest mortality ratios are constantly returned
from such districts as those of London, the East and West
Ridings of Yorkshire, Lancashire, Leicestershire, Nottinghamshire,
Staffordshire, and Warwickshire. In the East Riding the mortality
from this cause has in some years been as high as from 1500 to
2000 per million.
In Scotland the deaths from the same causes fell from an
annual mean of 453 per million in 1888-90 to $60 per million
in 1896; in 1897 the ratio rose again to 510 per million.
In the larger French towns (those with over 10,000 inhabitants)
deaths from "diarrhoea and gastro-enteritis" have varied in the
last decade between 1550 and 2020 per million inhabitants;
while "maladies choleriformes" caused in the same period a
mortality varying between 20 and 270 per million. The higher
figures under the latter heading fell in the cholera years of 1892
and J 893.
]n Belgium the mortality ratio from "cholera" (?nostras),
"enteritis and diarrhoea" together rose considerably between
1870 and 1897; in the year 1897 it was nearly, 1250 per million
inhabitants.
In Holland, on the other hand, the mortality
ratio from "diarrhoea" steadily fell from about 450 per million
in 1889 t o about n o per million in 1898. In Germany infantile
diarrhoea causes an excessively high mortality, particularly in
large and densely populated towns, and in some, as for example
Berlin, the death-rate from this cause has increased with the
growth of the population. In Bavaria and Swabia very high
death-rates from " cholera nostras" (which here appears to
include all forms of diarrhoea except dysentery) are annually
recorded.
In Denmark the deaths from "cholerine and acute intestinal
catarrh " vary considerably from year to year; in each of the years

DIARRHCEAL DISORDERS

121

1896 and 1897 the mortality from this cause in the principal
Danish towns was rather less than 1300 per million living. In
Norway the deaths from " diarrhoea acuta, cholera nostras, and
enteritis " showed some tendency to increase between 1881 and
1894; the mortality from these causes in the latter year was
about 540 per million. The corresponding mortality ratio in
Sweden in the years 1891-96 was between 300 and 400 per
million per annum.
Diarrhceal diseases are excessively rife in European Russia.
The official statistics of that country now return deaths from
"simple cholera" only; and this term appears to include all
forms of diarrhceal disease excepting Asiatic cholera and dysentery. Among the statistics of a large number of registered
cases of various diseases, the term "gastro-intestinal catarrh"
also appears, and exceedingly high figures are always inserted
under this" heading. There can be no question that diarrhceal
disorders are among the commonest of all maladies in Russia.
They are closely associated with the frequent use of polluted
water-supplies, with the nature of the usual diet of the peasantry
(which consists largely of sour black rye-bread, fermented cabbagesoup, salted herring and raw cucumbers, melons and other fruit),
with excessive alcoholism, and generally with the low level of
knowledge among the bulk of the population, leading to neglect
of sanitation, improper feeding of infants, and other harmful
conditions. A form of hsemorrhagic diarrhoea is said to be very
common in children in southern Russia, owing to the large
amount of raw vegetables and fruit eaten by them. Among
Bashkir children, who consume this dangerous diet to a less
extent, this form of diarrhoea is rarer.
In Austria-Hungary, and particularly in Hungary, "cholera
infantum " and " cholera nostras " give rise to high annual deathrates, and in Switzerland the enteritis of infants also causes a large
sacrifice of infantile life. Throughout Italy diarrhceal diseases
{enteritis, diarrhoea, colitis, etc.) are prolific causes of death;
the mortality from them rose, with some fluctuations, from 3159
per million in 1887 to 3683 per million in 1895. In Spain
and Portugal diarrhceal disorders are widely prevalent, and
no doubt the causes of their prevalence are largely the same
as those already mentioned as acting in Russia. In most, if
not all of the countries of the Balkan Peninsula diarrhoea, and

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DIARRHCEAL DISORDERS

particularly infantile diarrhoea, is extremely common, especially
in the summer months. In Constantinople these disorders are
the cause of a considerable annual mortality.
The distribution of diarrhoeal disorders in Europe is to a
very great extent determined by temperature. The warmer the
temperature of the summer months, the more prevalent and fatal
do they become. Hence they are comparatively uncommon
in the north and excessively common in the south. In Iceland
diarrhoea is but little seen, and in the Faroe group it is only
moderately frequent. In Malta and other Mediterranean islands
enteritis is often very prevalent in the summer.
Asia. The same law holds good to a considerable extent in
Asia. Diarrhoea is, however, met with as a common disease
throughout the greater part of Siberia; though probably more rife
in the south than in the north. It is certainly extremely prevalent
in the Caucasian provinces, where gastro-intestinal catarrh is the
cause of more deaths than perhaps any other single disease.
In the Central Asiatic provinces of Russia, with their high
summer temperature, and where sanitation is as yet of necessity
of a primitive and oriental character, diarrhoeal disorders prevail
to an enormous extent. The same statement appears to be
equally applicable to Syria, Mesopotamia, and Persia. In Asia
Minor these ailments are exceedingly common. At Trebizond
severe dysenteric forms of gastro-intestinal catarrh are often
observed, In Arabia diarrhoeal diseases are among the most
frequent of maladies. The annual mortality from these affections
among the pilgrims to the Hedjaz is enormous; it appears to be
largely attributable to the very polluted water of the wells which
form the sole water-supply on the long caravan routes between
the ports of Jedda and Yanbo and the holy places of Mecca
and Medina. This water is said to be frequently extremely foul,
and to have in many instances a strong smell of sulphuretted
hydrogen.
The prevalence of diarrhoeal diseases in India will be again
briefly discussed in the chapter upon dysentery, as in Indian
statistics dysentery and diarrhoea are grouped together. In India
generally the deaths from diarrhoea are very numerous, and are
highest in the months of August, September, and October, that
is to say in the latter half (or more) of the rainy season. They
have risen enormously during the recent years of drought and

DIARRHOEAL DISORDERS

123

famine. It is of interest to note that in 1891 and 1892 when
cholera was extraordinarily rife in India and became pandemic
elsewhere, other diarrhoeal disorders were showing no unusual
activity.
In Ceylon diarrhoea at times causes acute epidemics, and on
some occasions at least (e.g. in 1892 and 1897) these have been
traced to the consumption of rice ^ made from paddy which had
been kept for use as seed, and had therefore become stale.
Throughout Farther India and China, in the East Indian
Islands, and in Japan, diarrhoeal affections are among the commonest of diseases, attacking both the indigenous and foreign
inhabitants of these countries and islands. In China diarrhoea
causes a vast amount of mortality in children and adults.
Australasia.
In Australia diarrhoea would seem to be quite
as frequent a cause of death as in many European countries. In
Queensland " diarrhoea" and " enteritis " taken together caused
a mortality of between 1000 and 1200 per million per annum
between 1893 a n d 1897. In New South Wales, Victoria, and
Western Australia, these diseases appear to be somewhat less
common. In New Zealand, in the years 1889-98, this group
of disorders gave rise to an annual mortality of from 300 to 500
per million per annum. In most of the islands of the Pacific
diarrhoea is a frequent disorder, especially among children, and
in the warm season.
Africa. In Northern and Central Africa diseases of this
class are commonly met with.
In the equatorial portion of
the continent, both in the centre and on the east and west
coasts both natives and Europeans suffer largely from diarrhoea.
It is mentioned as causing considerable trouble to the members
of almost every exploring expedition that has ventured into the
interior of the Dark Continent. It is prevalent in Morocco,
Algeria, and Tunis; it is extremely common in Egypt. In the
colonies along the western shores of Africa it is rife, and here,
as well as in Central Africa generally, it is said to be particularly
prevalent after the first rains have washed surface and other
pollutions into the streams from which drinking water is taken.
It is frequently associated with carelessness in the disposal of
human excreta, which are often allowed to pollute watercourses.
It is largely avoided in many European colonies where precautions
are taken to ensure a pure water-supply. On the West Coast of

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DIARRHCEAL DISORDERS

Africa diarrhoea appears to be as common on the sea-board as
inland, but on the east it is said to be both more frequent and
more severe on the interior plateau than on the coast.
In many parts of South Africa diarrhoea is very prevalent.
At the Grey Hospital, for example, in King William's Town this
is in some years, next to typhoid fever, the commonest disease
that comes under treatment, and at many other of the colonial
hospitals cases of diarrhceal disorders are exceedingly numerous.
Diarrhoea was very prevalent in many places in 1897, owing to
the drought of that year; at Aberdeen, at Aliwal North, and in
the Jamestown sub-district it was epidemic. At Worcester a
severe outbreak of diarrhoea caused an enormous increase in
mortality among the natives in 1898. During the recent military
operations in South Africa many of our men suffered severely from
this disorder; and it is noteworthy that among the forms of
diarrhoea observed was one associated with acid, frothy, liquid,
green stools, and much scalding about the anus, which was
believed to be brought about by the large amount of sand
swallowed in the dust-storms which frequently visited the camps.
In Madagascar, in the Seychelles, and in the Mascarene
Islands (Mauritius etc.) diarrhoea is very common.
North and Central America. The tendency for diarrhoea to
become more prevalent and severe as warmer latitudes are approached is well seen in North America; but there are not
lacking important exceptions to the rule. Thus in Greenland
diarrhoea is said to be the chief sickness in the winter months,
and a form of cholera has even been epidemic here and in
Labrador in the past. In other parts of Canada diarrhceal
disorders always help to swell the annual mortality, and the
diarrhoea of infants appears to be prevalent to a considerable
degree. Davidson states that the provinces along the Atlantic
coast suffer less than others, and that Quebec shows an extremely
high death-rate from diarrhceal diseases. They appear to have
been less conspicuous causes of death here in more recent years,
thanks probably to the same care as to water supplies that has
so reduced the death-roll from enteric in the Quebec province.
These diseases also seem to be less prevalent or less fatal
now in Manitoba and British Columbia than they were some
years ago.
In most parts of the United States diarrhceal disorders are

DIARRHCEAL DISORDERS

125

very common, and cause a high annual mortality. In Massachusetts this group of diseases, which here includes "dysentery,
cholera infantum, diarrhoea, cholera nostras, and enteritis," caused
an annual mortality of 21 n per million inhabitants in 1856-75,
and of 1834 per million in 1876-95. Of the diseases named
cholera infantum is the most important, and this alone has caused
an annual mortality varying between 640 and 1580 per million
living (of all ages) in the years 1856-95. Throughout the States
generally diarrhceal disorders are a cause of a greater mortality
than in England, cholera infantum being especially frequent and
fatal. These diseases are certainly more prevalent in the States
than in the higher latitudes of Canada.
In Mexico and throughout Central America diarrhceal disorders
are extremely prevalent. Frequent mention of them is found in
the annual reports on the health of British Honduras, where the
general infantile mortality, doubtless partly through their agency,
is very high. In Guatemala "diarrhoea" alone accounted for 1292
deaths (about 900 per million inhabitants) in 1894.
Reports from most of the West Indian Islands seem
to indicate a marked frequency of diarrhoea. In Jamaica a
form of septic diarrhoea is one of the most prevalent diseases at
Port Royal. In many of the Leeward Islands, and in Trinidad,
Grenada, Barbados, and elsewhere, diarrhceal disorders are very
frequent. To what extent the deaths from this cause in Mexico,
Central America, and the West Indies are deaths of infants is not
clear.
South America. In the tropical portions of South America
diarrhceal diseases are no less prevalent than in most other
tropical countries. In the Guianas they are the cause of a considerable annual mortality. Throughout Brazil diarrhoea is a
common disease, but appears to be less prevalent in the
southern provinces of Sao Paulo, Parana, Sta Catharina and
Rio Grande do Sul than in the warmer provinces further north.
In Uruguay the deaths from "enteritis," "infantile gastro-enteritis"
and " entero-colitis " together caused, in 1897, 63*15 per 1000 of
the deaths from all causes, and a mortality of little short of 1000
per million inhabitants. In the Argentine Republic diarrhoea is
certainly a common disorder, and it is probable that it is more
or less prevalent in the western countries of the South American
continent.

126

DIARRHCEAL DISORDERS

Factors governing the Geographical Distribution
of Diarrhceal D i s o r d e r s .
The causes of diarrhoea are
practically ubiquitous, and consequently, as the above brief
summary of facts shows, the condition itself is ubiquitous.
On the whole, diarrhceal disorders of all kinds are more
common, and to some extent more severe, in hot countries
than in warm, and in warm countries than in cold. The mean
annual temperature of a given portion of the earth's surface is,
however, of little importance; and in temperate climates the most
important factor in the prevalence of diarrhceal diseases seems to
be the height of the temperature in the warm season of the year
alone; hot summers in any country being almost invariably associated with diarrhoea prevalence, although cold winters may reduce
the annual mean temperature in those countries to a comparatively
low level.
In England it was long ago shown by Ballard that it is the
temperature of the soil and not that of the air which seems to
determine the spread of diarrhoea; he demonstrated that " t h e
summer rise of diarrhceal mortality does not commence until the
mean temperature recorded by the 4-foot earth-thermometer has
attained somewhere about 56° F., no matter what may have been
the temperature previously attained by the atmosphere or recorded
by the i-foot earth-thermometer." It is probable that a like though
not quite identical statement might be made concerning most
countries. It appears, however, that the temperature at which
diarrhoea begins to be prevalent is not everywhere the same. It is
less a question of absolute than of relative temperature. The records
of earth-thermometers are not available for most countries, but
there is probably a rough annual parallelism between their records
and those of the air-thermometer; and it is certain that in many
temperate countries diarrhceal diseases begin to be more than
usually prevalent not when the air-thermometer records a particular
temperature common to all, but when the summer heats, whatever
they may be in the given place, begin to make themselves felt.
In New York, for example, the temperature in May is about 540,
and in Berlin about 55'4° F . ; diarrhoea is then but slightly active;
in June the average temperature rises in both cities to 6i° and
the diarrhoea mortality increases seven-fold. In Melbourne similar
facts are observed. But in Queensland, where the average winter
temperature is about 6o°, diarrhoea shows no special activity at

DIARRHCEAL DISORDERS

12/

that temperature, and it is only when the mean monthly temperature rises to nearly 700 that the diarrhoea mortality markedly
rises1.
The other causes which determine the geographical distribution
of diarrhceal diseases are too numerous to discuss at length. Many
forms of diarrhoea are the result of neglect of sanitary measures,
ignorance, improper food, excessive indulgence in certain foods
and alcohol, and other quite preventable causes. Race appears
to have no very striking influence, all races showing a liability to
diarrhoea if exposed to the causes of it. Acclimatisation is undoubtedly possible, and the waters of some rivers, as for example
the Neva in St Petersburg, always cause diarrhoea in new-comers,
though taken with impunity by persons accustomed all their lives
to drink of them.
2.

SPRUE

(PSILOSIS).

General C h a r a c t e r s . Sprue, or psilosis, is now recognised
as a distinct morbid condition, in which an inflamed, bare, aphthous
and eroded condition of the mouth and tongue, much wasting and
anaemia, and certain other features which will be found described
in most text-books, are, in addition to a definite form of diarrhoea,
the most prominent symptoms. Its relation to hill-diarrhoea is
uncertain, but as the latter is much more common in men than
in women, while sprue shows no such relation to sex, it is possible
that they are separate diseases. The cause of sprue is as yet
unknown.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . This disease is
probably essentially tropical or subtropical in origin, but as in
some instances the symptoms do not develope until the subject
has left the tropics for a considerable time it is actually met with
in temperate countries. In England and on the continent of
Europe cases of sprue have been seen, but the patients have
always been persons who have lived in the tropics and almost
certainly contracted the disease during their previous residence in
some country where it is endemic. Southern China and the southeast of Asia generally seem to be the principal homes of sprue.
In China, at Wenchow, it is spoken of as " o n e of the most
formidable tropical diseases " which are met with, and in HongStawell, Intercolonial Medical Journal, March 20, 1899.

128

DIARRHCEAL DISORDERS

kong it is of somewhat frequent occurrence. In Cochin-China
a form of chronic diarrhoea is spoken of, a residuum of dysentery,
which may perhaps be sprue. The disease is also said to be
known in North China and Japan. Some doubt has been
entertained as to whether the disease is met with in India. Some
have asserted that " b o t h primary sprue and secondary sprue,
following on dysentery, acute enteritis," and similar bowel troubles
are common among the natives of India. Giles, on the other hand,
doubts if true psilosis is ever seen in that country ; and Moorhead
states that it is rare in India 1 . In the Malay Peninsula it is
certainly met with. It is also mentioned as occurring in the Straits
Settlements, but is probably not very common there, only two
cases of sprue being recorded in the hospitals, prison hospitals,
and lunatic asylum at Singapore in the year 1898. Manson
speaks of it as "especially common" in the countries already
mentioned, and also in Java, Manila, Ceylon, tropical Africa, and
the West Indies. Probably the term "especially common" is
to be understood in a relative sense, as the disease is scarcely
mentioned by some writers on the most prominent maladies of
these countries.
Sprue is probably fairly common in some of the. West Indian
Islands; it is said to have caused " many " deaths at St Michael
in Barbados in 1898. It would appear also to be not unknown
as far south as Natal, in South Africa, as two cases of psilosis
were among the admissions to the Durban Hospital in 1898,
but whether these patients had contracted the disease elsewhere is
not stated.
Further knowledge as to the etiology, and greater certainty
in the diagnosis of sprue, are needed before its geographical
distribution can be adequately determined. Some (e.g. Buchanan)
have regarded famine diarrhoea as essentially the same disease as
sprue, and if this be so, its distribution must be much wider than
it is at present generally believed to be. A tropical or subtropical climate and a high degree of atmospheric moisture seem
to be conditions favourable to the occurrence of the disorder.
Trans. 1st Indian Med. Congress, 1894.

DIARRHCEAL DISORDERS

3.

I29

H I L L DIARRHCEA.

A form of diarrhoea is not uncommonly seen in Europeans
vho have resided for some time in the plains of India and thence
>roceeded direct to a hill-station. It is probable that changes
)f temperature, of barometrical pressure, and of other conditions,
tcting on the alimentary canal of subjects already rendered
iusceptible to such changes by a -prolonged residence in the
)lains, are the principal causes of this malady. How far it is to
)e regarded as a specific disease is uncertain. Sir J. Fayrer and
)ther writers have treated it as identical with sprue, but it has
ilready been mentioned that there are certain considerations which
)oint to their being different diseases. Hill-diarrhoea usually takes
he form of the passage of loose colourless stools, as a rule in the
norning, between the hours of 3 and n a.m., together with
latulence and other dyspeptic symptoms. It generally yields in
i few days or weeks to treatment, but in some cases it may
lecessitate a return to the plains, when it usually ceases at once.
Further information is needed before the geographical distri3ution of * hill-diarrhoea can be accurately stated. Up to the
present most*of the published descriptions of it have come from
[ndia. The conditions which seem to be essential to its development are certainly found more commonly in India than elsewhere.
Simla, Kasauli, Chakrata, Sabathu and Dugshai, all of which are in
the western Himalayas, are said to be particularly affected by hilliiarrhoea (Davidson), but it is also occasionally seen at Mount
Abu, Darjiling, and other hill-stations.
Outside India an identical or analogous form of "hillliarrhcea" has been seen in South Africa, and even in Europe,
md it is probable that this affection has a wider distribution than
s generally believed.
4.

"CARIBI," " E L BICHO," OR E P I D E M I C
GANGRENOUS RECTITIS.

Under these names a disease characterised by a rapidly
;preading phagedaena of the rectum, spreading upwards from the
mus, or starting in the colon, is met with in Guiana, Venezuela,
Brazil, and probably also in Fiji. In Guiana it is called " Caribi"
)r the "Indian sickness." In 1856 it caused a serious epidemic
c.
9

130

DIARRHGEAL DISORDERS

among the Indian tribes of that country. Whether it still exists or
recurs there is not clear; I have come across no mention of it
in recent reports on British Guiana. Manson quotes a full
description of the disease as seen in Venezuela, where the natives
ascribe its occurrence in children to the habit of chewing the
green, tender stalks of unripe maize, of which they are very fond
on account of their sweetness. It appears to attack the lower
animals—principally fowls, but also dogs and calves—in Venezuela.
In some of the marshy districts and low humid localities in the
tropical parts of Brazil an exactly similar disease is described as
occurring, and it is here called " E l Bicho." Dwellers in towns
where putrid emanations abound also suffer from i t ; and the
Indian population when they leave their mountains to reside in
the hot and humid plains are subject to its attacks.
Whether the analogous disease seen in Fiji is the same as this
is uncertain. Corney describes it as an epidemic gangrenous
stomatitis with an analogous condition of the rectum, and states
that it is the most fatal of all the diseases he has met with in
the South Seas 1 . No mention of gangrenous stomatitis is made
in the brief references to " C a r i b i " and " E l Bicho," and it is
therefore impossible to assert definitely that they are the same
as the Fiji malady. It would be a remarkable fact if one and
the same disease should be met with in, and apparently confined
to, certain tropical portions of South America and an island in the
Pacific five or six thousand miles away.
1

Trans. Epidemiol. Soc. 1887-8.

DIPHTHERIA.
General C h a r a c t e r s a n d E t i o l o g y .
Diphtheria is
essentially a specific fever, probably caused by the entrance of
a microbe or microbes into the tissues, with local production of a
peculiar membranous inflammation and ulceration, usually, but
not invariably, in the throat and upper respiratory passages, and
the absorption of powerful toxins which may leave behind the
acute attack severe or slight paralytic symptoms. The disease
thus briefly defined has a very wide distribution, and as a cause of
general mortality it ranks prominently among the acute infective
fevers. The Klebs-Loftier bacillus is generally regarded as the
specific bacillus associated with diphtheria, but some believe that
the disease is the result of a combined infection with this bacillus
and other micro-organisms, of which certain of the pyogenic
streptococci and staphylococci appear to be the most important.
The true relation of " croup " to diphtheria is uncertain. In
most countries the two are dealt with together in the public health
returns.
H i s t o r y . Diphtheria is probably a very ancient disorder.
Hirsch mentions (doubtful) references to a disease that might
have been diphtheria in the Talmud, and in the Hippocratic
collection. Later Greek medical writers make mention of a
throat affection which may with greater certainty be regarded as
diphtheria. In medieval and recent times there are numerous
accounts from many parts of the world of epidemics of malignant
sore throat, and there seems no good reason to doubt that many
of these were epidemics of diphtheria.
It was not, however, until the early part of the century just
closed that the true specific character of diphtheria was recognised
and established, mainly by the labours of the French physician
9—2

132

DIPHTHERIA

Bretonneau, who published his treatise in 1821. The bacillus
associated with the disease was first described by Klebs in 1883,
and was first cultivated by Loffler in 1884. Ten years later the
" serum " treatment of diphtheria was introduced. The effect of
this treatment has been to diminish to a very marked extent the
fatality of the disease, and this result has been reflected in many
countries by a diminished general death-rate from diphtheria.
When therefore, as in most instances, death-statistics are alone
available, caution is necessary before accepting a lower diphtheria
death-rate occurring in any country within the last 7 or 8 years as
proof of lessened prevalence of the disease.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. In England
and Wales diphtheria is the cause of a considerable, but for the
present diminishing, annual mortality. The recent history of the
disease in this country has been somewhat remarkable. In the
decennium 1861—1870 diphtheria caused an annual mortality of
185 per million living; in the next decennium this figure fell to
1 2 1 ; but in the ten years 1881-90 it rose again to 163. In 1891
there was a further increase to 173, in 1892 to 222, and in 1893
the diphtheria deaths were no less than 318 per million of the
population. This was the highest rate since registration was
introduced with the exception of the years 1858 and 1859, when
the diphtheria death-rate was 339 and 517 respectively. Since
1893 there has been a decline, and the deaths from diphtheria in
the years 1894—1900 have varied between 245 and 291 per million.
It is probable that this diminution is associated with the introduction of the serum treatment. Diphtheria has long shown a
marked tendency to prevail in certain districts. As long ago as
1884 the areas of highest diphtheria mortality in England and
Wales were defined as follows:—the largest has its base in the
south-eastern counties of Sussex, Hampshire, Surrey, and Kent,
and extends upwards through Middlesex, Hertfordshire, Essex,
Cambridgeshire, and Bedfordshire, and it occasionally includes
Lincolnshire, Norfolk, and Nottinghamshire; the second and
smaller area has as its nucleus the whole of North Wales and
the adjoining county of Shropshire, and tends to spread through
Herefordshire and other counties bordering on Wales, in some
years extending into South Wales, Monmouthshire, and even
across the Bristol Channel into Somersetshire. Since the year
1884 these areas of special diphtheria prevalence have each year

DIPHTHERIA

*33

maintained their reputation. The first or south-eastern diphtheritic region is more constant than the other, which is sometimes
called the western or Welsh diphtheritic region.
The tendency for diphtheria occasionally to become epidemic
is well seen in England and Wales, and each year a certain number
of localised epidemics are investigated by the medical officers of
the Local Government Board.
The figures quoted above for England and Wales refer to
diphtheria alone, but it is probable that many of the deaths
returned as due to croup are in reality due to diphtheria. Taken
together, the mortality from the two diseases has fallen from
a maximum of 389 per million in 1893 to 281 in 1897, which was
the lowest mortality from these diseases since the year 1891.
In Scotland the mean annual mortality from diphtheria was
214 per million in the years 1881-90; this figure has steadily
fallen in succeeding years to 180 in 1895, 160 in 1896, and 140 in
1897. In Ireland the mean mortality figure from this disease in
the years 1881-90 was only 70 per million inhabitants. In the
next decade it rose to 75, and in 1900 to 81.
In France the diphtheria mortality has markedly diminished
in the last 15 years. In the towns with over 10,000 inhabitants,
the deaths from this disease averaged 610 per million population
in 1886-90; the ratio fell to 540 in 1891, and 510 in each of the
two following years. In 1894 there was a more marked fall, and
the decrease has been maintained until in 1897 and 1898 the ratio
was only 120 per million inhabitants. It can scarcely be doubted
that this recent fall in diphtheria mortality in France has been
due in part, though probably not wholly, to the introduction of
the serum treatment.
In Holland the diphtheria mortality has markedly decreased
of recent years; between 1889 and 1892 it had been about
stationary at 140 or 150 per million living, but in 1893 it rose to
200. Since that year it has almost uniformly declined, until in
1898 it was only 90 per million. The mortality from croup,
which is returned separately in Holland, has also steadily fallen
from a maximum of 210 in 1889 to a minimum of 50 per million
in 1898.
In Belgium there has been an equally marked decline in the
mortality from diphtheria and croup. Since 1881 the two diseases
have been grouped together, and the average yearly number of

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deaths caused by them in the decennium 1881—1890 was 4216
(in the two previous decennia it had been 5843 and 4761 respectively) but in 1895 the deaths from these causes, in spite of
an increasing population, had fallen to 2383, and in 1,897 to
1734, or 266 per million inhabitants.
In Germany the mortality from diphtheria and croup is
high and exceeds that from any other of the principal zymotic
diseases. In 1894 the deaths from these causes amounted to 1308
per million inhabitants, a rather lower figure than the mean of the
preceding seven years (1887— 1893) which had been 1383 per
million, but much higher than the corresponding figures for the
British Isles, Holland, or Belgium.
In the separate portions of the German empire the_ mortality
from diphtheria has shown very great fluctuations, with a tendency
to decrease in some States, but in others to increase. Thus in
Prussia in the nine years 1886 to 1894 the total deaths have
varied between a minimum of 36,160 (in 1891) and a maximum
of 55,401 (in 1893), and there has been no uniform increase or
decrease in the mortality for any consecutive period. In Saxony
the first year of the period was the highest (with 6483 deaths),
and on the whole the tendency has been towards a diminution
in the number of deaths from this cause.
In Wiirtemburg,
on the other hand, the later years of the period showed a
marked increase; the deaths in the years 1893 and 1894 being
considerably more than four times as numerous as in- the years
1887 and 1888.
In Bavaria and in Swabia in the ten years 1889—1898 diphtheria was a prolific cause of sickness. In each of these countries
it occupied the third place in the list of fatal diseases.
In Denmark, at any rate in the urban population, the deaths
from diphtheria and croup have very markedly diminished in
recent years. From diphtheria alone the number of registered
deaths in the urban population uniformly fell from 676 in 1892 to
198 in 1897 ; those from croup similarly diminished from 346 to
84 in the same period; and those from,both diseases from 1022
to 282. The diminution, which is somewhat less striking when
the figures for the whole Danish kingdom are taken, cannot be
wholly ascribed to the introduction of the serum treatment, as it
commenced before this form of treatment began to be practised.
Diphtheria has been seen in the past in Iceland.

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135

In the Faroe Islands it is now a rare disease. At the end of
the decade 1871—1880 it was prevalent there to some extent, but
throughout the next decade it diminished greatly, u n t i l i n 1889
and 1890 not a single case of the disease was reported. In each
of the four succeeding years, however, a small number of cases
of, and deaths from diphtheria and croup occurred in the islands.
In Norway the mortality from diphtheria has remained comparatively stationary in recent years.
In the quinquennium
1886-90 there had been a considerable rise in the number of
deaths from this cause over the preceding five-year period, the
number of deaths per annum in the two periods being respectively
1025 and 1648; but in 1891 the number fell to 1592, in 1892 to
1230, and in 1893 and 1894 it was respectively 1469 and 1438.
The deaths from croup have diminished very greatly, from an
average of 369 in 1881—1885 to only 140 in 1893 and 182 in
1894. The ratio of deaths from both together was in 1891
approximately 880 per million, and in 1894 approximately 800.
These diseases have therefore been much more prevalent recently
in Norway than in England and Wales.
In Sweden diphtheria and croup appear to be slightly less
prevalent than in Norway. The mortality from these causes
together was 815 per million per annum in the seven years
1880-86; it fell to 566 in the next period of seven years, but
again rose in 1894 to 735 per million.
In Russia in Europe diphtheria and croup prevail to a remarkable extent, though less so than in Hungary, Croatia and
Slavonia, or Servia. In the years 1893 to 1895 the annual
mortality from these causes in European Russia was 1470 per
million living, which was higher than the mortality in any other
European country with the exception of those just named. Both
diphtheria and croup are very widely spread throughout the
country. In the extreme north, however, they are rare, and in
the government of Archangel with a population of over 350,000
inhabitants, only 4 cases of diphtheria and no deaths were registered in 1893, 3 cases with 2 deaths in 1894, and 8 cases with no
deaths in 1895. No part of European Russia is free from the disease,
and since the year 1894 it has become very widely epidemic. In
188*1—1884 there was a similar epidemic prevalence of diphtheria
in Russia, but the case-mortality then was nearly twice as high as
it is now since the introduction of the serum treatment.

136

DIPHTHERIA

In Switzerland diphtheria and croup are much less prevalent
than in some other countries. They showed great fluctuations in
the ten years ending in 1897. In a group of 15 towns with a
population exceeding 10,000 the highest annual number of deaths
in that period was $6$ in 1890, the lowest 152 in 1897. The
marked and steady diminution since the year 1894 may be in
part due to the introduction of the serum treatment, but it is
noteworthy that almost equally striking diminutions in the mortality from these causes had occurred in the preceding years before
this form of treatment was practised. The rates which the deaths
from diphtheria and croup in these 15 Swiss towns bore to the
population were approximately 730 per million in 1890 and 250
per million in 1896.
In Austria the mortality from the two maladies under consideration remained remarkably steady in the years 1889 to 1894
inclusive, each year something over 28,000 deaths being ascribed to them. These diseases are a particularly high cause of
mortality in that country; in the seven years 1880 to 1886 they
caused an annual number of deaths equivalent to 1484 per million
inhabitants; in 1887—1893 the mortality fell to 1271 per million,
and in 1894 it was slightly lower. In Hungary and Fiume, on the
other hand, the mortality from diphtheria and croup rose from
1129 per million per annum in 1880—1886 to no less than 2135 m
1887—1893. This latter figure has in Europe been exceeded
only in Croatia and Slavonia—where in the same two successive
seven-year periods the mortality from the two diseases rose from
1596 to 2510 per million living per annum—and in Servia,
the figures for which country are given below. Here diphtheria
is the cause of an even higher mortality than in Croatia and
Slavonia.
For Spain trustworthy figures appear to be wanting, but there
is reason to believe that diphtheria and croup are prevalent there
to a considerable extent. In Gibraltar they are annually the
cause of a large number of deaths, and of recent years have been
particularly active.
A very marked decline in the mortality from diphtheria alone
has been observed in Italy of recent years. It fell from 835 per
million in 1887 to 409 in 1890, and after remaining, with slight
fluctuations, about this latter figure, it further fell to 239 per
million in 1895 a n d 2 °5 m 1896. The mortality-rate from

DIPHTHERIA

137

diphtheria and croup together in Italy fell from 956 per million
in 1887 to 501 in 1890, and to 298 in 1896.
Of the prevalence of diphtheria or croup in the countries of
the Balkan peninsula it is impossible to speak with statistical
accuracy, with the single exception of Servia. In that kingdom
diphtheria is the cause of a higher mortality than in any other
European country for which definite figures are available. In the
years 1887 to 1893 the annual mortality from this cause (deaths
from croup being probably included) was equal to 2378 per million
of the population; but in 1894-5 the diphtheria deaths rose to no
less than 4295 per million, the actual figures being 9934 deaths in
a population estimated at 2,312,484. The deaths from this cause
in Servia in that year far exceeded those from any other disease or
group of diseases and constituted as many as 15*58 per cent, of
the deaths from all causes.
Diphtheria is by no means rare in European Turkey. In
Constantinople the disease is known, and is at times epidemic;
it was particularly prevalent there in the early part of 1898. In
many villages of the Salonika province and in Salonika itself
diphtheria has become endemic in recent years. In Kavala it
recently (19P1) caused a rather severe epidemic.
In Malta diphtheria is an annual factor in the mortality of
the island. It has become less 'common in recent years than it
was formerly. In 1885 as many as 536 cases of the disease were
recorded in the island; in the following year only 192 cases
occurred, and then a steady and almost uniform decline in the
number of cases followed, to a minimum of 6 cases only in
1896. In 1897 8 cases, and in 1898 14 cases of the disease were
recorded. But an epidemic occurred in 1901, in which out of
172 cases 52 proved fatal.
In Cyprus the disease occasionally becomes epidemic, as for
example in 1889.
Asia. Throughout Asia generally diphtheria appears to be less
prevalent than, in Europe, the only marked exception to this rule
occurring in the northern plains of the Caucasus.
In the Caucasus and Transcaucasia diphtheria has in recent
years prevailed with very varying degrees of severity in different
parts of the country. In the years 1887 to 1892 the extremely
mountainous province of Daghestan was practically free from the
disease, and in the more or less mountainous governments of

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DIPHTHERIA

Baku, Elizavetpol, Tiflis, and Erivan low mortality rates from
diphtheria were recorded. On the other hand in the flat steppes
of the Terek, the Kuban, and Stavropol, which together constitute
the Caucasus proper, an excessively high degree of diphtheria
prevalence was observed in those years. In the years 1893—1895
a somewhat similar' distribution of the disease was maintained.
In the year 1895 the mortality from diphtheria alone in the
government of Stavropol was no less than 4300 per million
(approximately), and similarly high figures were observed here in
the preceding years.
In Central Asiatic Russia diphtheria is met with throughout
but is not excessively prevalent. In the provinces of Askhabad,
Samarkand, Viernoe and Tashkent, the mortality from this cause
is particularly low; it is higher in Turgai, and in Uralsk diphtheria
was the cause of a high and increasing mortality in the years 1893
to 1895. Among the Bashkirs, on the borders of European and
Asiatic Russia, diphtheria is said to be practically unknown.
Throughout Siberia the malady is commonly met with except
in the extreme north, and is at times particularly fatal. In
the northerly government of Yakutsk it is, however, almost
unknown; in 1887—1894 not a single case was registered,
and in 1895 only 5 cases with 1 death. Elsewhere in Siberia the
returns of diphtheria were, for the most part, not high in each of
the years 1887 to 1895. In the convict island of Sakhalin 17
deaths from this cause occurred in 1895, a mortality of 654 per
million. In Siberia as a whole the recorded annual mortality
from diphtheria in the period 1887—1895 has oscillated about
100 per million inhabitants; but here, as also in Central Asia,
the returns are far from accurate, and it is probable that a large
number of cases yearly escape record.
In Asia Minor diphtheria is far from rare. In 1898 an
epidemic of the disease broke out at Malali, a village 8 hours
from Trebizond, and severe epidemics have been recorded elsewhere in the peninsula. At Erzerum it is occasionally seen, and
in Mitylene, Samos and other islands off the coast. The disease
has also been met with in Baghdad {e.g. in 1885). In Persia
it certainly exists and is seen from time to time at Teheran.
In Syria it is far from rare. It was severely epidemic at Aleppo
in the summer of 1900, while in Tripoli and Jaffa it is not uncommon.

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139

In India, and generally throughout the tropical and'subtropical
portions of Asia, diphtheria is apparently exceedingly rare. It is
not mentioned in the reports on the health of the troops in India
and is probably not endemic in the peninsula. Cases have
however, been reported from time to time from Calcutta, Darjiling
and elsewhere.
In Ceylon 7 deaths from this cause were registered in 1896,
and 2 in each of the years 1897 and 1898.
The disease is almost unknown in Farther India. It is not
mentioned by some recent writers on the principal diseases of
Siam, while one states that it is unknown there. In the Malay
Peninsula it is very rare; in the Straits Settlements only 5 cases
of the disease were recorded in 1897, and 3 in 1898.
It is probably equally infrequent in the Malay islands; in Java
it is said to be quite unknown.
In China, on the other hand, diphtheria, though a rare disease,
is undoubtedly met with. Until comparatively recently it was
believed that diphtheria did not occur in that country, but in the last
decade evidence of its existence there has accumulated. Isolated
cases of the disease have been mentioned by many writers in the
Chinese Customs Medical Reports,—at Newchwang, at Pakhoi,
at Chung-king and elsewhere. Cases have also been reported
from Tientsin, Peking, Chinan-fu, P'ang Chuang and Ching-chou.
It is said to be much more fatal in the native Chinese than in
European residents. At Shanghai it is " no longer an interesting
rarity " and appears to be increasing in frequency. In Formosa it
is rare, but in 1891 a small epidemic of diphtheria prevailed in
the natives of Tamsui in the north of the island, and caused the
deaths of 20 children. In Hongkong, and generally throughout
the southern part of China, diphtheria appears to be still rare,—
more so than in the north of the country.
In Japan diphtheria is a far more prevalent disease than in
China. In 1893 and 1894 cases occurred in all parts of the
country, excepting in Okinawa Ken, and " its fierceness" was
said to be "increasing year by year 1 ." By this was probably
meant that the severity of the disease in individuals was increasing; the actual numbers of cases and deaths being less in
1894 than in 1893. The figures in the two years were 5726 cases
1

Annual Report of the Central Sanitary Bureau attached to the Home
Department of the Imperial Japanese Government. Tokyo, 1897.

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DIPHTHERIA

with 3205 deaths in 1893, and 5308 cases with 2903 deaths in
1894 in a population of approximately forty million. The mortality
in each year was consequently between 70 and 80 per million
inhabitants. This would indicate a degree of prevalence of
diphtheria in Japan about the same as that of the disease in
Holland or Ireland. It is much less than the corresponding
figure for the adjoining island of Sakhalin, which has already
been given.
Australasia.
Diphtheria has not of recent years been a
very conspicuous disease in Australia. It is, however, found
more or less all over the continent and in some parts appears to
be increasing. In the following figures diphtheria and croup are,
apparently, dealt with together.
In Queensland only 42 deaths from diphtheria were recorded
in 1897, or less than 90 per million of the population. This
figure must be received with caution, as it indicates deaths only,
and relates to a period subsequent to the introduction of the
serum treatment. In New South Wales diphtheria has occupied
a far from conspicuous place in the recent death-returns. In
Victoria also the disease is apparently not very prevalent, though
in recent years it has shown signs of increasing. In Melbourne
and other towns it has at times become epidemic within the last
decade. In 1895 t n e recorded cases in that city (which had a
population of over 450,000) were 69, and the deaths 8 ; in 1896
the cases were 98 and the deaths 10; and in 1897 the cases were
139 and the deaths 7. These figures indicate an increasing
prevalence with a diminishing case-mortality, which may have
been due to the disease becoming milder, or to a wider use of the
serum treatment. At Horsham, Victoria, a very severe epidemic
of diphtheria prevailed between July 1898 and June 1899. In
South Australia the recorded deaths from diphtheria rapidly
diminished from 174 in 1890 to only 21 and 22 in 1896 and
1897 ; the figure for 1898 was 38. As the population in that
period considerably increased, the fall in diphtheria mortality was
very striking, and the more so as it is only since 1894 that the
diminution could even in part be ascribed to the introduction of
the serum treatment. In Western Australia, on the other hand,
the reverse has been the case, and here a slight increase in the,
mortality from diphtheria was observed in the same period; in
1890 and 1891 only 3 deaths from this cause were recorded in

DIPHTHERIA

141

each year, but in 1897 and 1898 the deaths rose to 26 and 34
respectively. As the population more than trebled itself in that
period the rise is less in reality than it seems. The mortality
here is still low in comparison with that in England and Wales.
In Tasmania 114 cases of diphtheria with 13 deaths were
recorded in 1896 and 150 cases with 12 deaths in 1897, in an
estimated population (on December 31st, 1896) of 166,113
persons. In recent years the case-mortality has fallen very
considerably owing to the wide use of the serum treatment.
In 1896 the disease was recorded as being somewhat widely
epidemic in Hobart.
In New Zealand a marked fall in the recorded deaths from
diphtheria was observed between the years 1892 and 1898. The
195 deaths from this disease recorded in 1892 exceeded considerably the deaths in the preceding three years, but then a
steady fall set in, until only 45 deaths were recorded in 1898.
In the later years the fall must in part be ascribed to the
introduction of the serum treatment, but as a decrease had set in
before that treatment began to be used it is probable that there has
really been a diminished prevalence of diphtheria in New Zealand
in the years in question.
Africa. In some countries along the northern shores of
Africa diphtheria is not only a comparatively rare disease but
when it occurs it usually assumes a benign form.
In Tunis arrangements for the bacteriological diagnosis of
diphtheria have existed since 1894, and it has been clearly
demonstrated that the disease is a great rarity there. It was
most prevalent in 1894, when 61 deaths from this cause were
recorded. The cases met with are usually remarkably mild and
are often only recognised by the subsequent occurrence of
paralytic sequelae. In Algeria, on the other hand, diphtheria
and croup together were, at least prior to 1890, a cause of very
high mortality.
Throughout Central Africa generally diphtheria is, so far as is
known, a rare disease. Fuller and more careful observation,
particularly with the aids to diagnosis which bacteriology alone
affords, may show that it is more prevalent than is at present
believed. One observer (F. Plehn), by the discovery of the
bacillus in 14 negroes in the Cameroon district, has established
the existence of the disease in Western Africa although it

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142

had been stated before on good authority that diphtheria did
not occur there.
In British East Africa it has also been stated that diphtheria is
unknown, but fuller knowledge may possibly show that this statement is equally incorrect. One observer, however, during four
years' residence in Uganda never saw a true case of the disease1.
As the cooler portions of the African continent are approached
diphtheria gradually becomes a more conspicuous disease, though
in no part of South Africa is it so prevalent as in many European
countries. In British Bechuanaland it was epidemic in 189192 ; and about the same time it prevailed in Basutoland. In
the Annual Reports on the Public Health of the Cape of
Good Hope for the years 1897 and 1898 mention is made of
small numbers of cases of diphtheria in many places throughout
Cape Colony. Thus in the Aliwal North district several cases
occurred about the same time in 1897, in places widely scattered;
in the Jamestown district and at Colesberg one or two cases were
recorded; and at Barkly East an outbreak of the disease prevailed at
the end of 1896 and beginning of 1897. The coloured population
is not entirely free from it, as shown by the occurrence of one or
two cases among them at Murraysburg in 1898. In the native
territories of Tembuland, the Transkei, and Pondoland diphtheria
is, according to the evidence of natives, frequently seen, but the
statement requires confirmation. It was prevalent in and around
Wynberg in 1898. It is probably rare, if existent at all, in
Mashonaland.
In Mauritius diphtheria is endemic, but the mortality it causes
is very low, being only about 25 per million inhabitants. It
occurs only in the form of isolated cases and is said never to
become epidemic. It is here more a disease of the country than
of towns, and of the cooler inland districts than of the coasts.
The whites suffer most and the Indian residents the least.
North and Central America. Diphtheria is met with throughout the greater part of Canada with varying degrees of frequency.
In many of the provinces it is exceedingly prevalent and one of
the most prolific causes of death of all diseases. In Canada the
returns for diphtheria and croup are dealt with together. In
Quebec it appears, from the Report of the Board of Health of
1

Cook, Journ. Trop. Med. June 1, 1901.

DIPHTHERIA

H3

that province for the year 1896, that diphtheria is the most
frequent of all contagious diseases met with in the province. It
is constantly present in one place or another, sometimes as isolated
cases, sometimes as an epidemic, sometimes mild, and sometimes
very severe. It is one of the highest factors in the mortality of
the province. In the seven years ending in 1896 there had been
no general epidemic of the disease, but many partial epidemics,
and on the whole it had shown a tendency to diminish. In
Ontario diphtheria is also widely prevalent; the mortality caused
by it has been practically stationary since 1887, and is far higher
than that from scarlet or enteric fever. In New Brunswick the
disease would appear to be scarcely less prevalent, and occupies
a leading position among the causes of mortality throughout the
province. In Nova Scotia diphtheria is said to be " t h e most
prevalent and fatal of all germ diseases "; it usually occurs in the
form of scattered epidemics. In Manitoba the disease has become
more frequent in recent years; in the four years 1894 to 1897
the recorded cases in the province were 83, 112, 223, and 235
respectively.
Diphtheria is in most years a factor in the mortality throughout
the United States. In 1897 the only States in which no deaths
from this cause (croup being here included with diphtheria) were
recorded, at least in the urban population, were those of Arkansas
and New Mexico, both in the south. In the towns of Arizona,
which adjoins New Mexico, only 6 deaths, in those of Mississippi 6,
in those of North Carolina 3, in those of South Dakota 2, and in
those of Virginia 9, were registered in the same year. States,
on the other hand, in which the diphtheria mortality in the urban
population was high in that year, were those of New York,
Pennsylvania, Massachusetts, and Maryland. In Massachusetts
diphtheria has been more prevalent of recent years than
formerly; in the 20-year period 1856—1875 t n e deaths from
this cause (diphtheria and croup together) in the urban population
were equivalent to 720 per million living; but in the period 1876—
1895 t n e Y n a ( ^ increased to an equivalent of 960 per million.
In the State of Michigan, in the neighbourhood of the great
lakes, there have been marked fluctuations in the prevalence of
diphtheria; in 1881 it caused a mortality in the cities and towns
of that State of 1226 per million, but this figure has since more or
less steadily diminished, and in 1895 the deaths from this cause

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DIPHTHERIA

were only 260 per million of the population; in 1897 the mortality
had risen again to 492 per million. In Ohio about the years
1883 and 1884 diphtheria was so prevalent as to be spoken of
as a "terrible scourge."
In general the prevalence of diphtheria in the United States
appears to be less in the south than it is in the north. In Central
America the disease is of incomparably less frequency, and, it
would appear also, of less severity than further north. In Mexico
it is both rarely met with and is benign in character.
In the West India Islands diphtheria is a rare disease. It is
scarcely mentioned in the annual health reports of the various
British possessions in this group. A few mild cases occurred
in Trinidad in 1898; 3 cases in the southern Port of Spain
district, 5 in that of Arima, and 2 in that of Gran Couva. One or
two cases were observed in Jamaica in 1897. Sporadic examples
of "diphtheritic sore-throat" occurred in St Vincent in 1896.
Elsewhere in the West Indies the disease has appeared in recent
years only as single cases or has been entirely absent. In the
Bermudas one case was observed in 1898.
South America. In British Guiana diphtheria is exceptionally
met with. Three cases of the disease with one death were
registered in the colony in 1898. In Brazil diphtheria is said to
have been endemic since i860, but not to rank as one of the
fatal diseases of the country, while croup is the cause of only a
small mortality. Diphtheria is also met with in Peru.
In the Uruguay Republic diphtheria was the cause of 144
deaths in 1897, out of a population of some 800,000. In the
Argentine Republic the disease is also frequently met with; it was
particularly prevalent here in the years 1889 and 1890; in 1897
diphtheria and croup together caused 353 deaths in Buenos Aires
province, of which number 105 were returned from the northern,
77 from the central, 170 from the southern, and 1 from the
Patagonian region of the province.

Factors governing the Geographical Distribution
of D i p h t h e r i a . It will be seen that diphtheria is almost a
world-wide disorder. It is however mainly a disease of the
temperate zones, and becomes comparatively rare as the tropics
or the poles are approached. In Europe it has been most
prevalent recently in Germany, Norway, Sweden, Central and
Southern Russia, Austria-Hungary, and Servia, while it has been

DIPHTHERIA

145

very much less so, or at any rate less fatal, in the British Isles,
Holland, Belgium, Denmark, Switzerland, and Italy. In Asia it has
been extraordinarily active in the plains of the northern Caucasus,
and has caused severe epidemics in some parts of Asia Minor; it
has also become prevalent to some extent in Japan. For the rest of
the continent it may be said that diphtheria is a comparatively rare
disorder, particularly in the extreme north (Northern Siberia) and
in India, Farther India, and the East Indian islands. In Africa,
it is generally a rare disease, and is only found with any marked
degree of frequency in the southern, or temperate portion of the
continent. Similarly in the New World, diphtheria is but little
seen in the tropical and sub-tropical belts—including Mexico,
Central America, the West Indies, and Guiana, while in the
northern United States, in Canada, and in Uruguay and Argentina it is of frequent occurrence.
Diphtheria bears a close resemblance to scarlet fever in its
distribution. Both are mainly diseases of the temperate zones,
but both can occur either sporadically, or even epidemically, in
tropical and even in sub-arctic regions.
It may justly be concluded then that temperature is a powerful
factor in determining the distribution of this disease, and that
extremes of heat or of cold are unfavourable to its prevalence.
Heat is probably more unfavourable than cold, for while diphtheria
is found as a severe endemic in no tropical country, it is endemic
and a cause of high mortality in such cold countries as Norway
and Sweden. This conclusion is further justified by the seasonal
relations of the disease. Diphtheria in many temperate countries
is found to be most active in the autumn and winter, and least so
in the warmer summer months.
Altitude and the nature of the soil are probably factors of
considerable importance. Low-lying areas are generally believed
to be more favourable to diphtheria prevalence than high altitudes.
This has been doubted by Hirsch and others, but a general survey
of the recent history of the disease certainly tends to support the
statement. A striking illustration has been furnished by the
behaviour of the disease in the Caucasus in the past few years.
The highest mortality of any country for which definite statistics
are published has occurred in the flat, low-lying plains of the
Caucasus proper, while in the high mountainous provinces of
Transcaucasia, on the other hand, there has been a strikingly low
c.

10

DIPHTHERIA

146

diphtheria mortality. The comparative infrequency of the disease
in Switzerland also lends support to the view that diphtheria
prefers low altitudes. The rule, however, is not without important
exceptions, such as the occurrence of epidemics on the Himalayan
slopes, and the recent high degree of diphtheria mortality in
Norway.
A damp soil is also very commonly regarded as favouring the
endemic prevalence of the disease, and probably a continued
residence in a damp dwelling is of even greater importance. The
influence of race has never been fully determined. All the great
divisions of the human family, including pure Mongols and fullblooded negroes, seem to be capable of becoming subjects of the
disease, though probably both their susceptibility to attack and their
power of recovery when attacked vary greatly. In China, for
example, the disease is said to be much more intense and fatal in
natives than in European residents, while in the United States the
white races suffer much more than the black.
The disease shows definite age relations. It is mainly a
disorder of childhood, and is commonest between the ages of
three and twelve. Diphtheria is acutely infectious, and it is now
generally admitted that it is largely spread among children between
these ages by means of their attendance at schools. The late
Sir Richard Thome showed very clearly how powerful "school
influence" might be in the propagation of the disease. As he
pointed out it brings together in the closest relations the members
of the community at the most susceptible age, and not always
under the best hygienic conditions, while the habits of kissing, of
transferring sweets from mouth to mouth, the joint use of drinkingcups and the like are obviously ready means of spreading the
infection1.
Sir R. Thorne further believed that the special
conditions of aggregation of children in schools might act in a
still more serious way, by " manufacturing " as it were " a form of
disease of particular potency for spread and for death." Elsewhere
he expressed the same idea in other terms, and spoke of " t h e
possible occurrence of what may perhaps be looked upon as
the progressive development of the property of infectiveness." The
relation of the ordinary sore throats which sometimes precede a
diphtheria epidemic to the true diphtheritic affection is uncer1

Milroy Lectures, 1891.

DIPHTHERIA

H7

tain, but it seems possible that, given certain conditions, the
intensity and infectiveness of the virus of the former may be
gradually increased until it is capable of producing, in place of a
simple, almost non-infective inflammation, the highly infective
condition known as diphtheria. Space will not permit of a fuller
discussion of this suggestion here. The problem presents close
analogies with that of the true relation between cholera and the
simple diarrhoeas which are so often observed about the commencement of a cholera epidemic; or that of the exact relation
between pestis minor and true plague.
Whatever the explanation may be, diphtheria does from time
to time cause epidemics not only in schools but in larger communities, such as whole villages and towns; and there is reason
to believe that it also occurs epidemically over still wider areas,
effecting whole countries and even whole continents. Hirsch has
shown that these cycles of epidemic or pandemic prevalence are
extremely irregular both in time and in the areas covered. The
recent history of the disease seems to show that in most temperate
countries it is more or less widely endemic, and that its fluctuations
from year to year or from decade to decade, while often very wide
and striking in any one country, are by no means the same for
all countries. In many European countries, for example, there
has in recent decades been a marked decrease in diphtheria
prevalence, while in others there has been a no less marked
increase, or the disease has been stationary. The decrease has
been most noticeable in France, Belgium, Denmark, Switzerland
and (especially) Italy. In Hungary on the other hand there
has been a marked increase, while in Germany, Norway, Sweden,
Russia, and Austria the disease has been either stationary, or
has fluctuated irregularly.

10—2

DYSENTERY.
General Characters and Etiology.
It is customary,
in the case of many countries for which statistical data of disease
prevalence exist, to group together dysentery and diarrhoea under
a single heading. Inasmuch, however, as the two conditions are
probably totally distinct, it would serve little purpose to discuss
their geographical distribution together.
Dysentery is now
generally regarded as etiologically a specific disease, or, perhaps,
a group of allied diseases, of which one form is associated with,
and possibly caused by, the amoeba colt. Diarrhoea, on the other
hand, is a symptom of a large number of pathological conditions,
and is due to a vast variety of different causes. In the present
chapter dysentery will, so far as is possible, be dealt with alone.
While, as just stated, the cause of one form of dysentery
is very possibly the amoeba colt, it is not yet certain that all
forms are due to this or to any one invariable cause. Some
have ascribed it to the action of the bacterium coli commune
(Celli and Fiocca); others to the action of streptococci (Jancarol) ;
while Flexner of Philadelphia claims to have isolated a group of
bacilli, allied to the colon bacillus, which he believes to be the
specific cause of the disease, and to be probably identical with
those isolated previously by observers in Japan. Some have
believed that the pathological condition to which the name of
dysentery is applied is only a manifestation of malaria, and they
have pointed in support of this view to the frequent occurrence
of dysentery in malarial subjects, and to the undoubted fact that
in many malarious countries dysentery is particularly common,
and vice versa. But a study of the geographical distribution of
the two diseases shows clearly that they are far from constantly
found together, and that there are many parts of the earth's

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149

surface where the one is common and the other unknown.
The
same statement may also be made in regard to the distinction
between dysentery and diarrhoea, already alluded to. Dysentery,
howrever, has this in common with many forms of diarrhoea, that
it appears to be largely associated with impurities of water-supplies,
and that when pure water is supplied to a given community in
which either dysentery or these forms of diarrhoea have been
prevalent, they have to a great extent, if not entirely disappeared.
There are many forms of dysentery, and it is probable that
the term is often used in a very loose manner. Too little is yet
known of the intestinal flora and fauna and their relation to the
disease to make the presence or absence of any of them a test of
the specific nature of any dysenteriform disorder which may be
endemic or epidemic in a given place or country. Pathologically,
the disease is distinct and characteristic enough. But it is open
to question whether, in many of the countries where dysentery is
spoken of as prevalent, the presence either of true dysenteric
ulceration of the intestine or of the amoeba colt or the other
organisms named above has been demonstrated; and it is,
therefore, possible that in some of these countries other diarrhoeal
diseases have been regarded as dysentery.
The term tropical dysentery is very frequently used, but true
dysenteric ulceration of the bowels, together with\the discovery
in the bowel contents of one of the organisms mentioned, has
been observed in many extra-tropical parts of the world; and it
would seem desirable to avoid the use of this term, if it is intended
to be synonymous with acute dysentery. Chronic forms of
dysentery are met with in countries where it is not endemic,
in persons who have contracted the disease in countries where it
is endemic.
Recent Geographical Distribution.
Europe.
The
diminution of dysentery in Europe in recent times has apparently
gone hand in hand with improvements in sanitation and hygiene,
and it is more than probable that the principal factors in this
reduction of the disease have been the*improvements in watersupply and drainage.
In the British Isles dysentery is now almost entirely a thing
of the past. Cases of the disease are occasionally seen, but
usually in persons who have contracted it abroad, 'or in inmates
of asylums. It appears to be an undoubted fact that true dysentery

ISO

DYSENTERY

is endemic in many of our larger institutions for the insane, and
it is said to attack especially the feeble and debilitated and to
show no predilection for any particular form of insanity, or for
any age or either sex. The heading " diarrhoea and dysentery "
still remains in the Registrar-General's Reports, but it is probable
that almost the whole of the figures grouped under it are accounted
for by various diarrhceal diseases other than dysentery.
In Europe generally dysentery is far more prevalent in the
south than in the north. In many northerly countries it is almost,
if not quite unknown. In Norway and Sweden, for example,
no mention of it is found in the statistical returns of disease.
In Denmark, also, only from o to 6 deaths from it were annually
recorded in the urban population in the years 1892-97 inclusive.
In the Low Countries it is somewhat more common, but is
decreasing as a cause of mortality. Holland has returned from
10 (the lowest) to 41 (the highest) deaths from dysentery in the
years 1889-98. In Belgium the deaths from the disease steadily
fell from a mean of 881 per annum in the years 1871-80 to only
264 in 1897 ; the last figure was equivalent to a ratio of about
40 per million.
That the disease cannot exist in northern latitudes, however,
it is impossible to assert. On the contrary, there is proof that it
has in times past been epidemic—even malignantly so, as for
example in i860,—in Iceland, and is now occasionally seen there
in a mild form. It is also met with in the far north of Russia,
and some deaths from the disease are yearly reported from the
town and government of Archangel. Throughout European
Russia generally dysentery is more or less endemic.
In the countries of Central Europe dysentery is more common
than in the north. In Germany it is said to be most prevalent in
the Prussian districts of Bromberg, Oppeln, Gumbinnen, Dantzig,
and Liineberg. In Dantzig it is endemic, and at times takes on
an epidemic character; it was very prevalent in 1895, when over
one thousand cases of the disease were recorded. It is said to be
more common on the plains than in the higher lands.
In Austria-Hungary the malady seems to be still more common;
it is said to be most fatal in Galicia, Bukowina, and Dalmatia, and
least so in Upper and Lower Austria and Salzburg, where, on the
other hand, diarrhoea is said to be most prevalent. The deaths
from dysentery {Riihr) in Austria in 1896 were at the rate of

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151

about 90 per million inhabitants 1 , and in Hungary, where the
disease appears to be still more prevalent, they were at the rate of
about 230 per million in 1897.
In Switzerland, on the other hand, the disease is said to be
unknown. In Italy and the rest of southern Europe it is rather
prevalent. It seems to be increasing in Italy, where it is said to
occur most often in the south of the peninsula. In Spain, also,
where dysentery is frequent, it is particularly so in the southern
provinces. It is perhaps in the countries of the Balkan peninsula
that dysentery is most prevalent in Europe. It is spoken of as
one of the most fatal diseases in the low lands of Roumania and
Bulgaria, and as generally diffused throughout Eastern Roumelia
and Macedonia. In Servia it caused a mortality of about 680
per million in 1894; it prevails here especially in low-lying
regions, and is said to be comparatively rare in the hilly districts
of this and of the other Balkan countries. It is probably common
in Turkey; it is certainly frequently seen in Constantinople and
in some parts of the Salonika province, and it is endemic but
mild in character in many parts of Greece.
It is met with also in many of the islands of the Mediterranean,
such as the Ionian Islands and Crete. The French Marine
Infantry suffered considerably from the disease in the latter
island in 1896-7.
Asia. In the Caucasus dysentery is frequently seen; in Tiflis
the Tatars and Russians are said to suffer from it more than
other races.
The disease is not unknown in Siberia, and in Vladivostok
and along the Russo-Chinese frontier it seems to be more or less
endemic. Deaths from this cause are yearly reported from all the
Siberian provinces without exception. They are comparatively
numerous in the south, but are reckoned by units only in the far
northerly province of Yakutsk.
In Persia and the adjoining parts of Turkey in Asia dysentery
certainly exists.
At some places, such as Suleimaniye and
Khanikin on the Turco-Persian frontier, true acute dysentery
seems to be endemic. In Teheran the European inhabitants
sometimes suffer considerably from the disease. At Basra, at
1
In T885-87 the mean mortality from dysentery in Austria was as high as
440 per million (Davidson).

152

DYSENTERY

the head of the Persian Gulf, grave forms of the disorder are not
uncommon.
It is known in Arabia, and one of the commonest causes of
death among the Moslem pilgrims at Mecca and Medina is a
chronic form of dysentery which, no doubt, is not wholly of local
origin. In Syria the disease is met with at Jaffa, and at Aleppo it
is the most prevalent of all maladies.
In India the returns of dysentery and diarrhceal diseases are
grouped' together. Both groups of disorders are very prevalent,
nor is this surprising in view of the polluted character of the
water frequently drunk by the natives, and their- habits of constantly bathing in, and drinking, the very foul water of tanks,
rivers, and streams.
From the returns of the European and native armies in India
some idea may be gathered of the frequency and distribution of
these diseases in different parts of the country. In the decennium
1886-95 the annual admission-rate for "dysentery and diarrhoea"
in both armies was 30 per 1000 strength and the death-rate 0 7 3 ,
or 730 per million. In most of those years Bengal and Orissa
gave the highest ratios for dysentery. In the years 1891-95, on
the other hand, the highest ratios were returned from the Burma
coast district, Bengal-Orissa, Burma (inland), and South India
following in the order named. Low dysentery-ratios were recorded
on the West Coast, in the Indus valley, in Central India, and in
the Hills. In the Rajputana States the disease is neither common
nor severe. The native troops suffer considerably more than the
European troops in India generally, but they are much better able
to withstand an attack of the disease, the case-fatality rate in
natives being less than one-fifth of what it is in Europeans.
Dysentery is a common disease of gaols in India, and prevails
especially when these institutions are at all overcrowded. The
famine of the past few years, with its consequent ills—particularly
starvation and the ingestion of improper articles of food—has
enormously increased the death-rate in the general population.
In each of the years 1895 a n ^ 1896 t n e recorded deaths in India
from dysentery and diarrhoea were at the rate of about 1100 per
million, but in 1897 the ratio rose, in consequence of the famine,
to i860 per million, and has probably been still higher since.
The recorded deaths from these causes in 1897 were 403,833 in

DYSENTERY

153

number. What proportion of these were due to dysentery alone
it is impossible to say.
In Ceylon dysentery is exceedingly common, and from time to
time becomes epidemic in certain parts of the island.
In Farther India both dysentery and diarrhceal diseases are
also exceedingly prevalent. In Siam dysentery is the most fatal
of alL diseases, in some years causing more deaths than cholera,
malaria, and enteric fever together; it is very frequent in the Laos
country, and breaks out every year in the plains of Cambodia.
In French Cochin-China dysentery accounts for no less than 28
per cent, of the mortality from all causes, paludism coming second
and causing 24 per cent. At Saigon the disease is said to have
diminished greatly since the water-supply has been improved. In
Annam and Tongking it is very widely prevalent, attacking both
natives and European residents. In the Malay Peninsula and
Straits Settlements dysentery of a mild type is frequently
seen.
In many parts of China dysentery is rife. At Tientsin it
prevails in most years. In Ningpo a mild type of this disorder is,
next to malaria, the most common disease in the native population.
At Hankow it becomes prevalent every year, and at Shanghai
cases are frequently recorded. In the Government Civil Hospital
at Hongkong the disease is one of the commonest that comes
under treatment. At Lung-chou it is not infrequently seen;
and in Canton it is a common disorder. All round the neighbourhood of Wuhu, on the Yangtze-kiang, it is said to be very
rife. In a word dysentery is found, more or less, throughout
China; it appears to be met with in the north (at Peking for
example) as well as in the south, but perhaps to a less extent, and
in Corea it becomes widely prevalent in the summer and autumn
of most years.
In Japan dysentery is endemic and "gradually extends its
dominions year by year." In 1893 there was a very severe
epidemic of this disease, and as it was spoken of as the " severest
epidemic ever experienced" it is clear that others must have
preceded it. The recorded cases were no less than 167,305 and
the deaths 41,282, figures which were more than double the
corresponding returns of the preceding year. The disease prevailed over the greater part of the archipelago. In the following
year it was very nearly as rife, and the numbers of cases and deaths

154

DYSENTERY

were but little less than in 1893, places which had escaped in the
first year being attacked in the second. The recorded deaths in
1893 were equal to about 1000 per million inhabitants, but it is
probable that they were below the truth. Since that year there
has been an annually recurring epidemic of greater or less severity
in Japan, at least until the year 1898.
In many of the islands of the Malay Archipelago dysentery is
known, but its degree of prevalence varies very widely in the
different islands. In Java it is endemic, and was at one time a most
serious cause of mortality in the European troops of the Dutch
army in the Indies, but improved sanitation and particularly the
digging of wells with good water have greatly diminished its
activity. Stokvis states that between 1869 and 1878 the deaths
from this cause in the Dutch troops were no less than 13 per 1000
per annum: the first well was sunk in 1875, and already in 1879-83
the mortality from this cause had fallen to 4*2; still later in 188488 it fell to the low figure of 0 7 per 1000. It is interesting to
note that in the report on the Dutch troops in the Indies in 1897
tropical dysentery is spoken of as very rare, and only 3 cases in
Europeans and 6 in natives were recorded in the year, out of a
strength of over 17,000 of the former and over 24,000 of the latter.
In Borneo dysentery is neither common nor severe; at Labuan
2 or 3 cases are admitted to the colonial hospital each year.
In Celebes the disease is somewhat prevalent on the coasts.
Ternate, Amboina, and Timor suffer only to a small extent.
In the Philippine Islands dysentery is met with, but of a mild
type.
Australasia.
In British New Guinea dysentery is the most
serious disease among the inhabitants. Sir William MacGregor, in
his annual report for 1897-98, stated that a few years before
dysentery was practically unknown here, but it had been imported
in an epidemic and contagious form within the preceding three or
four years, and, like all new diseases when introduced among an
aboriginal people, it had raged with very great severity and caused
many deaths. It had been carried all along the coast, but did not
seem to have extended inland.
In many parts of Australia dysentery is endemic, and at times
epidemic. It appears to be decreasing in Queensland, where the
mortality from this cause steadily fell from 484 per million in 1893
to 134 per million in 1897. It was formerly very much more

DYSENTERY

155

1

prevalent , but now it is spoken of as " n o t a frequent or fatal
disease in adults, except when it from time to time takes an
epidemic form from some cause more or less ascertainable, when
it is generally confined to a special locality in the vicinity of the
generating cause." Polluted water appears to be the most frequent source of origin. In Victoria the disease is not very
common, but in 1896 it became widely epidemic in a severe
form in the neighbourhood of Leigh. In New South Wales
dysentery is seen, but not very frequently.
In South Australia the returns for dysentery and diarrhoea are
grouped together, and the degree of prevalence of the former
cannot be ascertained from them alone. In Tasmania dysentery
is said to be less common than in Australia. In New Zealand it
is far from frequent; only 15 deaths from this cause were registered
in the colony in 1898. In Australia and New Zealand the degree
of prevalence of dysentery appears to decrease more or less
regularly as the cooler regions of the south are approached.
In the former it is said to be by no means rare in the aborigines.
In many of the Polynesian Islands dysentery is a conspicuous
disease. In Fiji it accounts for more admissions to the colonial
hospital at Suva than most other diseases. The malady seems to
have been brought to these islands with the advent of a European
population, and on some plantations it has been known to
become epidemic in a most malignant form, carrying of! almost
every labourer on the estate. Sir W. MacGregor has recorded
the instance of a certain plantation on which 115 labourers were
employed, every one of whom, with the single exception of a boy,
was carried off by dysentery. In New Caledonia it is met with,
but is not of a severe type. In Samoa and the Sandwich Islands
dysentery is among the commonest of all diseases.
Africa. Along the northern shores of Africa dysentery is more
or less prevalent. In Morocco it is seen principally along the
coasts. In Algeria it is said to be one of the most fatal diseases
of the country, especially in the province of Of an 2 . In Tunisia
it is endemic, but of a benign character.
1

The mean mortality from dysentery in Queensland in 1883—1888 was no
less than 1158 per million (Davidson); in 1897 it was about one-ninth of this.
'l The excess of dysentery in the Oran province is ascribed to the large
amount of sulphates of soda and magnesia in the drinking water—an
explanation which would seem rather to apply to an excess of ordinary
diarrhoea than of true dysentery.

156

DYSENTERY

Few parts of the western shores of Africa seem to be free
from dysentery, and in many places it is one of the most serious
causes of illness and death. In Senegal it is the most fatal disease
in Europeans; it appears to be rife throughout the province, and
has been, at least in part, ascribed to the use for drinking purposes
of the waters of the Senegal river, which are extensively polluted
by human dejecta 1 . In Lagos dysentery is one of the most frequent
of diseases. It is very prevalent in the Cameroon district. On
the Gold Coast dysentery accounts for a large number of the
annual admissions to the colonial hospital. It is said, however, that
the disease is uncommon among Europeans in this colony, owing
to improved water supply, and that, though chronic dysentery is
fairly common among the natives, true acute dysentery is probably
extremely rare. It is very common on the Upper Congo in
European residents, but in the neighbourhood of the Cataracts
it is said to be less so than elsewhere, as a result of the greater
purity of the water here 2 . Among the natives dysentery and
diarrhoea are rife throughout the Belgian Congo, prevailing especially after the first rains have fallen and washed the surface and
soil impurities into the streams. This characteristic of the
disease is observed throughout the greater part of Central Africa.
Pruen, whose experience lay chiefly on the east side of the
continent, writes of dysentery, typhoid fever, and diarrhoea that
they all prevail most " when the showers first moisten the refuse
lying about and thus cause its decomposition, and then wash the
decomposing materials into the nearest stream."
On the eastern side of the African continent dysentery is
widely prevalent. In Egypt it appears to be one of the most
prolific causes of death. The British troops in the Sudan in
1,898 suffered considerably from it after the Omdurman campaign;
and in the Dongola campaign of 1896 it attacked large numbers
of our men. In Abyssinia it is one of the most prevalent
of all diseases.
It is noteworthy on the other hand that
at Massowa the Italian army of occupation suffered but little
from it.
In British East Africa it is common, and its prevalence is said
to be largely associated with impure water-supplies and with
1

Le Progres Medical, June, 1898.
Congres National d'Hygiene et de Climatologie Medicale de la Belgique
et du Congo, Compte Rendu, 1897.
2

DYSENTERY

157

excessive indulgence in alcohol. It prevails in a severe form
in the country between the Lualaba and Lomami rivers in Central
Africa, and in a milder form on the Upper Zambesi. Along the
shores of the Nyassa and Tanganyika lakes and on the highlands
to the east it is endemic. It is noteworthy that while dysentery
is more common but less fatal on the interior plateau than on*
the coast, diarrhoea is both more common and more severe in
the interior than on the coast.
Throughout the greater part of South Africa dysentery is a
very prevalent disorder. In Cape Colony and in Bechuanaland
it is among the most frequent of diseases; large numbers of cases
are annually treated at the provincial hospital at Port Elizabeth,
and at the Frere hospital, East London, dysentery and diarrhoea
on some days account for 50 or 60 per cent, of all the patients
seen. At Murraysburg acute dysentery prevailed at the end of
the year 1898, and many cases of the disease were treated at
Vryburg in the same year. In the native territories of Tembuland, the Transkei, and Pondoland it is the most common disease
among the natives. In Natal dysentery is said to be even more
prevalent than in Cape Colony, and to be more frequent on the
coasts than in the interior. Throughout South Africa generally
dysentery is believed to occur to a great extent independently of
diet, and to be rather dependent upon climate. True dysentery
seems to have been one of the many forms of diarrhceal disorders
from wrhich our troops suffered in the recent South African
campaign. In Mashonaland a mild type of the disease is said
to be common at certain seasons.
In Madagascar dysentery is endemic on the coast line, and is
met with commonly, but in a benign form, even on the central
table land, as at Antsianaka. The Hova troops suffered considerably from it during the French invasion a few years ago, and
the Hovas are at all times very liable to its attacks. In the
Seychelles it is the most frequent and fatal of all diseases. In
Mauritius it is only surpassed by malarial fevers as a cause of
death; in the first half of 1898 it accounted for 10 per cent,
of all deaths in the island; it is also prevalent in Rodriguez and
Reunion.
In the islands off the west coast of Africa the disease is met
with. In Madeira it was at one time the cause of destructive
epidemics, but is now usually mild and tractable. In the Cape

158

DYSENTERY

Verde Islands it is severely prevalent along the coasts, and it is
also frequent in Fernando Po and in St Helena.
North and Central America. The limit of prevalence of
dysentery extends far to the north in the western hemisphere,
and the disorder is met with near to, if not actually within, the
Arctic circle. * Dysentery is said to be seldom seen in Greenland,
but it is by no means rare in Labrador, among both Eskimos
and Europeans. Of the prevalence of the disease in other parts
of Canada little can be said with accuracy. I have found no
mention of it in recent health reports from the various Canadian
provinces. It appears, however, that the disease is known there,
and is moderately prevalent among the Indian tribes.
Of. the distribution of dysentery in the United States complete
information is also lacking. In the past it is said to have
" frequently assumed an epidemic form over larger or smaller
areas of the States, and certain cycles of years in a given locality
are marked by a high dysentery mortality/' Judging from the
returns of the disease in the United States army in the years
1839-59, dysentery would seem to have been more prevalent then
in the southern than in the northern part of the Republic, and at
the present day Osier states that the disease is still commoner in the
southern cities than in those of the north. In Baltimore it prevails
every summer and has on several occasions been epidemic. The
returns for Massachusetts have recently shown a very marked and
continuous reduction in the mortality from dysentery. Thus in
1856-75 the annual mean mortality from the disease in this State
was 510 per million; but it fell in the next period 1876-95 to only
160 per million. In the early years of the first period dysentery
was an epidemic disease of the summer months in Massachusetts,
prevailing more or less in almost every city and town, but recently
it has lost its epidemic character, and the hope is expressed that
at no distant date it may become extinct. Some cases of true
amoebic dysentery have been recorded in Kansas City, Missouri,
and an " epidemic bloody flux " has been observed as far north as
the State of Michigan.
In Mexico dysentery is widely endemic on the west coast, and
is present, but less frequent, on the east coast; in the past, it has
been on at least one occasion (1848) the cause of a violent
epidemic here.
In British Honduras dysentery is frequently seen, especially

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159

in the rainy season; it is noteworthy however that in the flat,
alluvial swamps of Stann Creek district it is rare. In Guatemala
it is common, and in 1894 it was the cause of 809 deaths, or
nearly 570 per million inhabitants. It is endemic in San Salvador,
not only in the low lands, but also at considerable elevations. In
Nicaragua it is severely endemic, and in Costa Rica it is next to
malaria the most common disease along the coasts, though less
frequent in the interior.
Dysentery is met with in many of the West Indian Islands.
In Cuba it is endemic, and during the recent troubles in that
island has been epidemic to a truly terrible extent. It was
estimated that in the Spanish army alone " enteritis and dysentery" were the cause of as many as 12,000 deaths, but what proportion of these were due to dysentery alone is not stated. In
Jamaica dysentery is also endemic; at Port Royal it is one of the
most prevalent of all diseases. In Guadeloupe and Martinique it
is common, and generally throughout the Leeward and Windward
Islands. In Grenada, St Lucia, and Barbados it is a prominent
cause of death; in Trinidad it is prevalent in some districts in a
peculiarly aggravated form, but it is noteworthy that in the town of
Arima the disease practically disappeared after the introduction of
a good water-supply. In Puerto Rico a mild epidemic of dysentery
occurred after a great hurricane in August, 1899.
South America. Scarcely any portion of the great South
American continent seems to be free from dysentery. In British
Guiana it is one of the principal diseases seen, and large numbers
of persons suffering from it are annually treated in the public
hospitals; the Indian tribes in the interior are also said to be attacked by it. In Dutch Guiana and in French Guiana the malady
is also frequently met with. In Brazil it appears to be common
throughout the country. Davidson quotes a number of authorities
to the effect that it is one of the severe endemic diseases of the
Para province in the north, that it is from time to time epidemic
in the Amazon valley, and is of rather frequent occurrence in
the provinces of Maranhao, Piauhi and Parahyba, in the south.
Epidemics have also occurred at Rio de Janeiro, and in Pernambuco the disease is seen, but not commonly.
Dysentery can scarcely be very common or fatal now in
Uruguay; in 1897 it caused only 9 deaths in the whole republic,
or less than 12 per million inhabitants. It is said however that

i6o

DYSENTERY

it is not rare along the Uruguayan coasts, and in the past has
given rise to very severe epidemics. It appears to be more prevalent and fatal in the Argentine Republic, and particularly in the
northern provinces. In the province of Buenos Aires the deaths
ascribed to dysentery in 1897 were 95 in a total population of
about one million. The disease is also endemic in Paraguay.
On the western side of South America dysentery is widely
prevalent. In Ecuador it is common in the rainy season. In
Peru it is endemic along the coasts, and is said by Hirsch to
occur in the interior, at such elevations as 8000 feet and even
13,000 feet (at Cerro Pasco) above sea-level. Dysentery is met with
in all parts of Chile.

Factors concerned in the Geographical Distribution
of D y s e n t e r y . The causes and conditions which determine the
present geographical distribution of dysentery are no doubt
numerous and complex. Climate has a considerable influence,
and the disease is on the whole more prevalent in warmer than
in cooler countries. It is now, for example, far commoner in
Southern Europe than in Central, and in Central than in Northern
Europe; it is more frequent in the south of Italy than in the north,
and the same is true of the Spanish peninsula and of France. In
the southern hemisphere it is found to diminish in like manner,
both in Australia and New Zealand, as latitudes more distant from
the equator are approached; and in the southern parts of both
Africa and South America it appears to be less rife than in the
tropical portions of those continents.
Dysentery would also
appear, to some extent, to increase in severity as well as in its
degree of prevalence as the equator is approached. But both
generalisations are not without important exceptions. The disease
was for example in times past exceedingly prevalent in many parts
of Northern Europe; it has been malignantly epidemic in Iceland
—an all but arctic island, and it is not unknown in Greenland.
Elevation seems to have some influence on its prevalence;
low-lying, marshy districts appearing to be the most favourable to its
activity. But there are numerous exceptions,to this rule; in the
elevated table-land of Madagascar, for example, it is quite common,
and, as just stated, it has been seen at a height of 13,000 feet in
Peru. Race has perhaps some influence on its distribution, but
no race seems to be immune to it.
Local conditions, of which polluted water-supply is probably

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161

the most important, play a leading role in determining the
distribution of dysentery; and many other examples are known,
beside those already quoted, of the diminution or disappearance
of the malady in a town or district after a pure water-supply has
taken the place of an impure one. Thus at Saigon, in French
Cochin China, and at St Louis de Senegal, on the west coast of
Africa, the establishment of a good water-supply led to a great
decrease in the prevalence of dysentery. In many isolated places
in the French colonies the use of Chamberland filters has been
followed by equally happy results, and similarly in the Fiji Islands
as soon as the houses of Europeans were provided with rainwater stored in metal tanks dysentery became very much rarer
than it had formerly been. Measures of sanitation generally,
particularly such as tend to drain and purify the soil, have aided
in diminishing or extinguishing the disease in many parts of the
world where it had previously prevailed.
The distribution of dysentery has varied much from time to
time. Its disappearance from certain parts of Europe in comparatively recent years, and its continued diminution in many
countries and increase in others, have already been alluded to.
In some parts of Europe in the past, as for example Sweden,
Iceland, and Germany, and in many countries in Asia, Africa, and
America in the present, dysentery has taken on epidemic characters,
but as a rule it remains more or less constantly prevalent in those
districts in which it is endemic. Of the cause of these epidemics,
or of the considerable fluctuations in endemic prevalence, little is
definitely known. The disease, however, often shows marked
seasonal relations in places where it is endemic.
Dysentery does not appear to be transmitted like smallpox
from person to person by direct infection or contagion, and consequently its distribution is not influenced by the movements of
emigrants or traders. The cause of it can, apparently, be carried
in drinking water, hence outbreaks have occurred on board ships
supplied with polluted water; in no other sense can it be called
a sea-borne disease. It does, however, sometimes appear in
countries previously free from it, as for example in New Guinea in
the case mentioned; and unless its appearance is due in such
instances to an acquired virulence of an indigenous and hitherto
harmless amoeba or bacterium or whatever else is the cause of the
disease, it can only be explained by an importation from elsewhere
c.

II

l62

DYSENTERY

of a something essential to its production. In what manner
dysentery can be thus carried from one country to another, however, is not clear.
Military operations, particularly in countries where dysentery
is endemic, have frequently favoured the activity of the disease.
In the French invasion of Madagascar; in the war in Uruguay
in 1867 ; in the recent troubles in Crete ; in the Spanish-American
war in Cuba; in the Peninsular War; in the Crimean War; in the
French operations in Tongking; in the recent war in South Africa,
and in many others, dysentery has caused considerable, and in
some instances, terrible havoc among the combatants of one or
both sides.
It has already been stated that dysentery has many points in
common with malaria, but that the geographical distribution of the
one does not correspond with that of the other. As examples of
places where malaria is absent but dysentery prevalent may be
mentioned the Seychelles Islands, Peyta in Peru, New Caledonia,
Barbados, and perhaps Hawaii. To these may be added the
island of Mauritius before the appearance of malaria there in
1866.

ERGOTISM.
Characters and E t i o l o g y . Ergotism is the name given
to a group of symptoms which follow on the consumption of
ergot. Ergot is a substance produced in the grains of rye by
a fungus, the Claviceps purpurea.
In some years a very large
proportion of the rye crop may be affected with this parasite,
and in peasant communities where rye is largely eaten ergotism
may, under these circumstances, become seriously epidemic.
There are two principal clinical varieties of the disease, the
gangrenous and the spasmodic. In both the illness begins with
vomiting, diarrhoea, abdominal pain and cramps—in brief, with
all the symptoms of irritant poisoning. To these are added other
symptoms—tingling and itching of the skin, giddiness, headache,
muscular pains and twitchings, and general depression. In the
gangrenous form gangrene occurs in some peripheral parts of the
body, as the toes, fingers, or, less commonly, the ears or nose.
In the spasmodic form, severe and painful spasms of the muscles
occur. Mental symptoms usually supervene, such as delirium,
melancholia, or dementia, and the disease frequently ends in
death.
H i s t o r y . It is thought that many of the medieval epidemics
described under the name of " Saint's Fire " (ignis sacer, ignis
S. Antonii) may have been of the nature of gangrenous ergotism.
Hirsch has tabulated a long list of such epidemics from the year
591 A.D. to the year 1879. The larger number of outbreaks of
gangrenous ergotism have occurred in France and Spain; and
of convulsive ergotism in Germany and Russia. These epidemics
appear to have been much more frequent in former centuries than
in recent times.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . With the exception
of a small outbreak in a New York prison early in the last century
and the occurrence of occasional cases in the Caucasus and Siberia
there seems to be no mention of ergotism outside Europe.
11—2

164

ERGOTISM

In Europe the disease has been most frequently seen in
France, Germany, Russia, and Sweden. In the British Isles
there is no record of ergotism during the past three centuries.
In France, on the other hand, there were nine such epidemics in
the 17th century, seven in the 18th, and three in the 19th. It is
noteworthy that in France the disease has usually taken the
gangrenous form. It has been most often seen in the upper
and lower basins of the Loire and in the Rhone valley. In
Belgium there was a small epidemic in 1845-6. In Holland, on
the other hand, as in England, the disease has not been seen for
the past three centuries. In Germany there were eleven epidemics
in the 16th century, ten in the 17th, twenty-one in the 18th, and
fifteen in the 19th. The majority have occurred in the north-west
and north-east portions of the country, only a few in the south-west
and Bohemia, and none in the central regions. The overwhelming
majority of outbreaks of ergotism in Germany have been of the
spasmodic form.
In Sweden ergotism was not infrequently seen, at least up to
the year 1867, particularly in the southern part of the country.
In Norway on the other hand the only mention of the disease
seems to relate to a small epidemic there in 1851.
In Russia, where rye-bread is the principal food of the
peasants, ergotism has on several occasions become epidemic.
It has been seen in many central and southern governments, but
apparently not in the extreme north. The most recent epidemic
of the kind seems to have been one that occurred in the northeasterly government of Perm in the autumn and early winter of
1895. ^ n Russia, and no doubt elsewhere, there is great difficulty
in persuading the peasantry that the diseased grain and the
symptoms of ergotism stand in the relation of cause and effect,
and in inducing them to take precautions to prevent the continuance of an epidemic. The Russian name for the disease,
" zlaia kortcha " or " malignant spasms," may be taken to indicate
that the nervous, rather than the gangrenous form is the commoner in that country. Among the places mentioned as scenes
of ergotism epidemics between 1832 and 1864 is the government of Tomsk, in Siberia. In Finland there have been at least
two epidemics (in 1840-4 and in 1862-3) and, as just stated,
cases have in recent years occurred in the Caucasus and Siberia.
Austria-Hungary seems to have escaped this disease, with the

ERGOTISM

I65

exception of an outbreak in Transylvania in 1857. Switzerland
and Italy have been the scenes of a few epidemics in the past;
while Spain seems to have been quite free from ergotism during
the last three centuries. The disease is occasionally seen in some
parts of Turkey but is not frequent.
F a c t o r s c o n c e r n e d in t h e D i s t r i b u t i o n . The relation
of the ergot-parasite of rye to the disease in man has been proved
beyond possibility of doubt. The parasite attacks other grasses,
but it is said to be poisonous only when growing in rye or possibly
in bromus-grass. Under certain conditions of season and weather
the parasite rapidly multiplies, and on some occasions a very high
percentage of the rye grains may be affected by it. In the outbreak
in Perm, just alluded to, as many as 17 per cent, of the grains
were found to be diseased in some districts.
The disease is most common in countries where rye bread, or
other food-stuffs made from rye, are commonly eaten.
The
peasantry naturally suffer most. Unhygienic conditions have
seemed to favour the development of the malady, and several
epidemics have been recorded in insanitary prisons, foundling
hospitals, and similar institutions. Children have frequently
suffered from it, but infants at the breast are said to escape its
attacks.
The diminution of ergotism in recent times has been attributed
to an improved knowledge of agriculture, to more careful cultivation
of the crops, to greater facilities for providing the poorer classes
with good and wholesome food-stuffs, and finally to increased
cultivation of the potato.
The distribution of the two types of ergotism is remarkable.
As already stated the gangrenous type has almost invariably been
seen in France and Spain, the convulsive in Germany and Russia.
The explanation of this is uncertain. It seems probable that
each set of symptoms is due to a particular poison; thus the
gangrenous form is thought to be due to the action of sphacelinic
acid, the convulsive to that of cornutin. It may be assumed,
therefore, that the conditions of soil and latitude in the more
southern countries tend to the production of the acid in the
growth of the ergot-parasite, while in more northerly latitudes
the cornutin is in excess. Possibly racial differences in the
peasantry of these countries have also something to do with
the development of the two types of the disease.

ERYSIPELAS.
General C h a r a c t e r s a n d E t i o l o g y . The symptoms of
erysipelas scarcely require description here. It is an acute, and
highly infective inflammation of the skin, believed to be caused
by the Streptococcus erysipelatis (or S. pathogenies longus).
H i s t o r y . Erysipelas is mentioned by the oldest writers on
medicine. It was formerly more common than it is now, and
there are records in the past of many epidemics of the disease in
hospitals, lying-in homes, and other institutions in Europe and
America. Hirsch has tabulated a long list of epidemics of a
peculiarly malignant type of erysipelas which have occurred
frequently in the United States since the year 1822.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. Erysipelas
occurs in all European countries. It is said to be especially
frequent in Iceland and the Faroes. It must be a common disorder, also in Norway, where in the years 1881 to 1894 it is
stated to have occupied a higher place in the mortality returns
than either rheumatic fever or syphilis. It appears to be prevalent throughout European Russia, but is somewhat less common
in the Don Cossack territory, and remarkably less so in the
Polish provinces. In Germany erysipelas is said to be much
less frequent in the northern plains than in the south. It appears
to be very common in Bavaria and Swabia. In England and
Wales erysipelas causes a yearly mortality of between 30 and 40
per million, but twenty years ago the annual mortality ranged
from 80 to 90 per million. In Switzerland, at least in the urban
population, the corresponding figure has varied, in the ten years
1888—1897, between 21 and 49 per million. In Italy the average
mortality has been placed at 150 per million. Erysipelas occurs
in Turkey in Europe, but I cannot discover that it is more
frequent there than elsewhere.

ERYSIPELAS

167

Asia. Erysipelas is certainly not unknown in Asia Minor,
Syria, or Persia. In India I have seen very typical cases of
the disease in Bombay and Calcutta, but in some parts of India,
as, for example, Rajputana 1 , it is said to be extremely rare.
There is mention of its occurrence in Ceylon, and cases are
sometimes treated in the Singapore prison. It is said to be
unknown among the hill tribes of Java; in Siam it is rare (Rasch);
in China very rare (Coltman); and in Japan perhaps equally so.
Australasia.
In Australia erysipelas would seem to be rarer
than in Europe; but of its occurrence or frequency elsewhere in
this part of the world little seems to be known.
Africa. Erysipelas occurs in Egypt, Tunis, Algiers, and other
countries, but whether frequently or not I am unable to say. It
is rare in British East Africa, and also in Madagascar. In Reunion,
on the other hand, Pelissier (in 1881) had seen many cases of the
disease. Plehn has seen one typical case of erysipelas in the
Cameroons.
America. Epidemics of erysipelas have occurred repeatedly
in Greenland, and also in Alaska. In many parts of Canada the
disease is seen with some frequency. There is recent mention
of it in Health Reports from Manitoba, Nova Scotia, and elsewhere. In the United States erysipelas seems to be a commoner
disorder than in England. It is said to be most prevalent on
the prairies and south-west central plains, and to be of frequent
occurrence in the Cordillera region, but is less common on
the Atlantic and Pacific coasts, and generally in the country east
of the Mississippi. The historical epidemics of a malignant type
of the disease in the States have been already mentioned.
In Mexico erysipelas is infrequent. There is recent mention
of its occurrence in British Honduras. In Guatemala it is perhaps
not a rare disease; it was the cause of 215 deaths there in 1894
(about 150 per million inhabitants). Occasional cases are seen
in the West Indies. In British Guiana 19 cases of erysipelas
were reported in 1898; I do not know whether this was an
exceptional or average number. For the rest of South America
recent information upon this disease seems to be wanting.
F a c t o r s c o n c e r n e d in t h e G e o g r a p h i c a l D i s t r i b u t i o n .
The information hitherto published as to the frequency, or even
1

Adams.

i68

ERYSIPELAS

as to the existence, of erysipelas in many parts of the world is so
imperfect, that much caution is needed in discussing the causes
which have led to its distribution aver the earth's surface. It is
not absent from any of the great geographical zones—tropical,
sub-tropical, temperate, and sub-arctic. It is perhaps more common
in cool or temperate climates than in hot ones, but even this rule
is not without exceptions. It is possibly more fatal in the cooler
regions of the earth than in the warmer.
In its seasonal relations erysipelas has shown a tendency to
prevail most in the cooler half of the year. The mortality from
the disease shows a rough tendency to vary inversely with the
amount of rain-fall. Cold east winds have been thought to favour
its occurrence. It is found at all altitudes and on all .varieties of
soil and geological structure. All races suffer from it, including
the negro, who was at one time thought to be immune to it.
The disease is highly infectious, but it seems to require the
pre-existence of some open wound, some small abrasion or
discontinuity of skin, or some absorbing surface (such as that of
the uterus after child-birth or a patch of eczema) before it can be
set up. Hence it is a less " infectious " disorder than, for example
typhus fever or influenza. In hospital wards, and particularly in
surgical wards, it was at one time a frequent source of serious
epidemics, the infection spreading rapidly from case to case and
from ward to-ward, often with disastrous results. Such "hospital
epidemics iy of erysipelas have been known to occur in hospitals
which were above reproach in regard to cleanliness, structure,
ventilation, absence of overcrowding, and general hygiene. But
the larger number of them, as also the continued recurrence of
sporadic cases of the disease, have been associated with some
hygienic defect, of which overcrowding, imperfect ventilation,
imperfect cleanliness, and (in some instances) the escape of foul
air from sewers or refuse heaps into the ward, have been the most
important. It can scarcely be questioned that the introduction
of the antiseptic and aseptic methods of treating surgical cases
has had an enormous share in lessening the frequency of hospital
erysipelas.
The mode of origin and even of transmission of erysipelas is
still a matter of some doubt. Cases of so-called idiopathic
erysipelas outside hospitals are by no means rare, and it is the
exception, rather than the rule, in such cases to learn of a definite

ERYSIPELAS

169

exposure to infection from a person already ill with the disease.
The bacteriology of the disease has not yet been finally worked
out, and the relation between Streptococcus erysipelatis and the
pyogenic streptococci is still uncertain. The morphological
and cultural differences between them are so slight that it has
seemed possible that the former might be no other than one of
the latter rendered unusually virulent by certain external conditions. What those conditions are, or whether under any
conditions a comparatively harmless pyogenic coccus can acquire
the power of producing erysipelas (not as a rule a suppurative
affection) is quite unknown.
The relationship between erysipelas and puerperal fever is also
as yet a matter of uncertainty ; on the whole, however, the evidence
points strongly to their affinity at least, if not to their identity.
Certainly women in child-birth run enormously increased risks of
puerperal fever, if attended by persons the subject of erysipelas.
Moreover, doctors and midwives and nurses attending on puerperal
fever patients have been known to develope erysipelas, while the
proportion of deaths from the latter disease in the newly-born
children of women with puerperal fever is unusually high. All
these facts point to the conclusion that there must be some very
close relationship between the two maladies.

GOITRE AND CRETINISM.
Goitre, or enlargement of the thyroid gland, and cretinism, or
a peculiar form of congenital idiocy, are two pathological conditions that are most conveniently dealt with together. Although
final proof of their exact relation to each other is perhaps wanting,
it is the general opinion of most observers that they are very
closely allied the one to the other, and that they are probably
both due to the same cause or set of causes; while strong
evidence of their kinship is found in the fact that large numbers
of cretins are themselves goitrous, and that equally large numbers
are the offspring of goitrous parents. The geographical distribution
of the two conditions may therefore well be discussed together.
H i s t o r y . Goitre has been known to exist as an endemic
disease in the Alps at least since the time of Pliny. Marco Polo
makes mention of its occurrence in Yarkand and other parts of
Central Asia in the 13th century ; and throughout later medieval
and more recent times there are frequent references to goitre
as occurring in many European countries and in some other parts
of the world. It is probable that most of the great centres of
goitre mentioned in the following paragraphs are of very considerable antiquity. Cretinism is apparently not referred to by
any writer before the 16th century.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. In the
British Isles neither goitre nor cretinism can be regarded as
common forms of disease. There are, however, certain parts of
the country in which goitre at least is endemic, and the most
important centre of the disease appears to be in the north and
centre of England, " in the valleys which drain the Pennine range
of hills, east and west, from the Border as far south as the Peak

GOITRE AND CRETINISM

171

of Derbyshire 1 ." The magnesian-limestone districts of the lastnamed county have long been regarded as peculiarly favourable
to the development of goitre, and " Derbyshire neck " is a name
not infrequently applied to the disease. Cretinism, on the other
hand, is much more rarely seen than goitre in England; but it is
said to be occasionally met with in Derbyshire, and in the dales
between Lancashire and Yorkshire. In Scotland and Ireland
both forms of disease seem nowadays to be exceedingly rare.
In some parts of Wales goitre appears to be somewhat frequently
met with.
In France goitre is said to be far from infrequent in some
parts, notably in Savoy and the Hautes-Alpes. Epidemics of the
disease have been recorded as occurring among soldiers in France,
but these have been regarded as " probably the result of forced
marches through goitrous districts, combined with scarcity of
food," and " in such districts the practice of carrying loads on the
head seems largely to increase the ratio of the disease 2 ." In the
valleys of the Hautes-Pyrenees, in the mountainous parts of the
department of the Rhone, and in the southern valleys of the Upper
Auvergne goitre and cretinism are, or were some years ago, most
commonly seen (Hirsch). In Germany the Black Forest is said
to be an important seat of these diseases, which occur particularly
in the lower valleys and are said to be unknown at the higher
points of the forest. In Bavaria, in Wiirtemberg, in Baden, and
in Hesse scattered centres of goitre and cretinism are met with.
The plain of North Germany and of the Netherlands is, on the
other hand, said to be quite free from both forms of disease, and
in Belgium they seem to be rare Sweden and Norway and
Denmark also appear to suffer but little from either.
In European Russia goitre is perhaps rather commoner. Some
years ago the shores of Lake Ladoga were regarded as peculiarly
goitrous districts, and possibly they are so still. But the most
reliable recent evidence points to the east and north-east of
European Russia as specially liable to this form of disease. From
1

The Goulstonian Lectures; 1899. " On the Pathology of the Thyroid
Gland," by Prof. G. R Murray, M.A., M.D. Hirsch, on the other hand, on the
authority of numerous writers in the eighteenth and first half of the nineteenth
century, believed goitre was commoner " i n the southern and midland counties
than in the northern and mountainous districts."
2
Di Pugin Thornton, in Quain's Dictionary of Medicine.

172

GOITRE AND CRETINISM

the conscription returns of the Russian army for the years 1893,
1894, and 1895, it seems that the governments between the
Volga and the Urals are the most goitrous. Thus in the government of Ufa the number of conscripts rejected on account of
goitre was in 1893 two, in 1894 five, and in 1895 nine (out of
17,000 to 22,000 conscripts). In that of Samara the corresponding
figures were 6, 2, and 3 (out of 20,000 to 27,000 conscripts). In
that of Perm they were 10, 10, and r7 (out of 20,000 to 27,000
conscripts); in that of Viatka they were 3, 4, and 2 (out of
24,000 to 32,000 conscripts); and in that of Kostroma the
numbers rejected were as high as 6, 12, and 23 in the three years
in question (out of only 10,000 to 14,000 conscripts). Elsewhere,
with the exception of some of the Polish governments, the
numbers of goitrous conscripts were very much lower. It would
seem from these figures that in the governments of Kostroma
and Perm goitre finds more favourable conditions for its endemic
existence than in any other part of European Russia, though
in comparison with such countries as Italy, Austria, and Spain
the figures cannot be held to indicate a very high frequency of
the disease in any of the districts mentioned.
In Austria both goitre and cretinism are very common;
occurring especially along the banks of the Danube, and particularly in the provinces of Styria and Carinthia, on the slopes and
valleys of the Carpathians, and in Transylvania, Galicia, and
Hungary. The valley of the Drave on the other hand is said to
be quite free from both diseases. Cretinism is particularly frequent
in these countries, and in 1896 the official statistics contained
returns of 10,08.6 cretins; they are most frequent in the provinces
of Styria, Carinthia, and Salzburg, where their numbers per
100,000 of the population were 215, 254, and 265 respectively.
In Dalmatia, on the other hand, the ratio fell to 30.
Switzerland has long been regarded as peculiarly favourable to
the existence both -of goitre and cretinism, and both forms of
disease are found with frequency in many parts of the country,
but especially in the Vallais. In Spain and in Italy both goitre
and cretinism are said to be of very frequent occurrence. In the
former country the southern slopes of the Pyrenees are, or were
some years ago, more especially affected by them, while in Italy
the district of Aosta and the valleys of the Alpine chain which
traverses Piedmont and Lombardy are mentioned by Hirsch as

GOITRE AND CRETINISM

173

being particularly goitrous. It appears certain that in Italy,
Spain, Switzerland, and Austria, both goitre and cretinism are
more widely prevalent than in the more northern European
countries.
Of the degree of frequency of goitre in the countries of the
Balkan peninsula little is accurately known. In the valleys of
Montenegro and perhaps in other valleys of the Balkan mountains
cretinism is met with to some extent. In some of the mountain
districts of Roumania (Moldavia and Wallachia) goitre is endemic,
while cretinism is met with sporadically. Goitrous persons are
occasionally seen in Constantinople, but the disease is not a
common one here. It is remarkable that the Constantinople
ha7tials or street porters, who carry astoundingly heavy weights on
their backs, and not infrequently pass a band round the forehead,
so that part of the weight is borne by the head and neck muscles,
are rarely, if ever, the subjects of goitre.
Goitre exists in Greece, but only in two villages in the
mountains of Phthiotis, and it is rarely complicated with
cretinism.
Asia. The existence of goitre on the European side of the
Urals has been pointed out above. The valley of the Ural river,
which for some distance divides Europe from Asia, is also described
as very favourable to the development of goitre. Kandaratski 1
states that the disease is widely prevalent all along the river valley,
and that the Russian inhabitants suffer from it no less than the
Cheremiss, Permiaks, Voguls, and Tatars who dwell in the same
region. In the Caucasus goitre is said to be frequently seen in
some valleys, but so far as may be gathered from the numbers of
conscripts rejected from the Russian army for this cause it would
seem to be mainly in the governments of Kutais and Tiflis in
Transcaucasia that the disease is at all common, while in the
plains of the Caucasus proper (Stavropol, Kuban, and Terek), north
of the mountain range, it appears to be unknown. In many parts
of Siberia, notably in the valley of the Lena and in the Altai
mountains, goitre is endemic.
In Asia Minor and in Mesopotamia centres both of goitre and
cretinism are met with. Syria, Arabia, and the table-land of Persia
have all been said to be quite free from both diseases. Hirsch,
1

At the 7th Conference of Russian Physicians, held in Kazan, 1899.

GOITRE AND CRETINISM

174

who quotes authorities for those countries, also cites a paper by
Burnes communicated to the Calcutta Medical Society in 1835,
in which Bokhara is added to the list of countries free from goitre
and cretinism. It is, however, certainly not so at the present day.
On the contrary, goitre is frequently met with in all parts of
Bokhara, but especially in Kalai-Khumba, the capital of Darwaz.
Here, it is said, on the authority of the Bek of the province, that
there is scarcely a family in which some cases of the disease are
not met with, and the same statement is made in regard to Karatag,
where goitres of enormous size are common (Grekof). Cretinism
is also not rare in Bokhara.
The Turkomans of both Russian and Chinese Turkestan
appear to suffer to a remarkable extent from goitre. In Yarkand,
Khokand, Kashgar, Kargalik, Utch-Turgan, and other places
goitres of great size are very frequently met with1. Contiguous
with this vast Central Asiatic area of goitre-prevalence are a
number of districts of northern India where the disease appears
to be no less common. Hutcheson 2 describes it as widely
prevalent throughout the northern part of the peninsula, but as
specially localised in certain well-defined areas, extending from
the Brahmaputra to the Indus. It is found in some Himalayan
valleys from end to end of the great range. In the Tarai district
it is very common, and in Nepal, particularly in the neighbourhood
of Khatmandu, the capital, as many as forty per cent, of the
population are said to be affected with the disease. Eastern
Bengal, Assam, and some parts of the North-West Provinces and
the Punjab are also not wholly free from it. In Rajputana and
generally throughout the plains of India goitre appears, on the
other hand, to be rarely seen.
In Farther India goitre seems to be much less commonly
prevalent than in India proper. In Burma the affection is said to
be unknown in Arakan and practically so in Pegu, though a
considerable number of cases are met with in the Irawadi and
Tenasserim divisions3. In the Kwala Kangsa district of Perak
in the Malay States, a mountainous limestone area, goitre is
endemic. In Siam the disease is, according to Rasch, exceedingly
1

Raemdonck, Report of Leprosy Conference in Berlin, 1897.
Brig. Surgeon Lt.-Col. G. Hutcheson, M.D., Transactions of the First
Indian Medical Congress. Calcutta, 1894.
3
Davidson.
2

GOITRE AND CRETINISM

175

rare. In some of the East Indian islands, on the other hand, both
cretinism and goitre seem to be quite common affections. Thus
Kohlbriigge observed them frequently among the hill tribes of
Java, and in many parts of Sumatra their comparative frequency
is well recognised.
In Northern China goitre appears to be widely endemic. In
some villages it has been estimated that one-sixth of the inhabitants are affected by the disease. Western Sze-chuan and Yunnan
in the south-west are also highly goitrous provinces, and in Tibet
there appears to be equally good reason for believing that this
form of disease is widely endemic.
Australasia.
Whether goitre or cretinism exist in the Pacific
Islands and in Australasia generally is doubtful; and in the
absence of positive statements to the contrary it may be accepted
that Australia, New Zealand, and the host of islands in their
vicinity are practically free from both forms of disorder.
Africa.
Comparatively little is known of the existence or
frequency of either of the diseases now under discussion in the
greater part of the African continent, at least at the present day.
Hirsch quotes a number of authorities (mostly of not very recent
date) for the statement that Lower Egypt, the Abyssinian basin,
the East and West Coasts, and the littoral of Algiers are free of
these diseases, while goitre is endemic on the Abyssinian plateau,
in a few places in Sennaar, on the slopes and in the valleys of the
Atlas {e.g. in Kabylia), in the mountainous parts of Morocco, and
to a very considerable extent in the basin of the Niger and in
the valleys of the Greater Sudan. In the centre of Africa goitre is
probably of rare occurrence. Pruen did not recollect to have
seen a single case during his sojourn in the interior, though on
the coast mild cases were not infrequent—the waters here being
impregnated with salts of lime. Cameron, on hearsay authority,
believed that the inhabitants of the country round Lake Kassali,
in the south of the Congo State, suffered greatly from goitre.
Cook says it is common in Uganda.
In the Azores and in Madagascar goitre, and perhaps cretinism,
are known to exist; but in Madeira the former is very rare and
in Mauritius it seems to be unknown.
North, Central^ and South America.
While goitre is not
unknown in some parts of the continent of North America, and is
even very prevalent here and there, it appears to be less common

176

GOITRE AND CRETINISM

than in either Europe or Asia, and it would also seem to have
diminished very considerably within recent years. Hirsch, writing
some years ago, gave a long list of districts in Canada and the
United States where the disease was endemic—beginning as far
north as the banks of the Saskatchewan river in Hudson Bay
Territory.
H e pointed out, however, that already from the
beginning of the nineteenth century a diminution in the extent
and frequency of goitre in this continent had been observed, and
it appears that this process has been continued up to the present
day. In 1893 Prof. Osier1 wrote to a large number of medical
practitioners in the localities said by Hirsch to be goitrous, and
ascertained that in several of these districts goitre had become very
rare if not quite extinct. At present the malady appears to be by
no means uncommon in the province of Quebec, and in Montreal
cases are not infrequently seen in hospital practice. In Ontario
it is very prevalent in the limestone regions at the end of Lake
Ontario 2 and is common in parts of Michigan. In the States
of Alabama, Virginia, and Vermont, where goitre was formerly
common, it is now very rare. Cretinism is thought by Osier to
exist nowhere as an endemic disease in any parts either of the
States or Canada, though sporadic cases of it are at times met
with.
In Mexico and New Mexico, on the other hand, cretinism is
said to be still endemic, while goitre was within the last half
century excessively prevalent throughout a vast area extending
through Mexico, Guatemala, San Salvador, Nicaragua, and Costa
Rica, and down the Cordilleras as far to the south as Chile. This
zone of goitre-prevalence has been compared with those of the
Alps in Europe and the Himalayas in Asia3. The frequency of
the disease increases in this Central and South American zone
from north to south, and the widest diffusion of goitre is found
on the eastern slopes of the southern Cordilleras, in the states of
the Argentine Republic. The river basins of the mountainous
parts of Paraguay are also goitrous, and throughout a great portion
of Brazil the affection is commonly met with, though cretinism
1

American Journal of the Medical Sciences, Nov. 1893.
In the asylum of Kingston, Ontario, of 600 inmates no less than 288
were affected by goitre. No cases of cretinism existed in the asylum.
8
Hirsch.
2

GOITRE AND CRETINISM

177

on the other hand is unknown as an endemic disease in Brazilian
territory.
Factors determining the Geographical Distribution
of Goitre and C r e t i n i s m . It will be observed that the
distribution of goitre over the earth's surface is an exceedingly
wide one. The disease has been observed in the far north
and in the tropics, and appears to occur quite independently of
all conditions of climate, season, or weather. It is apparently
uninfluenced by race—the North-American Indian, the European,
the Chinese, the Himalayan Indian, the Turkoman, and the white
and negro inhabitants of Brazil, Chile, and Central America all
suffering from it under certain conditions. It is, indeed, rather
in local circumstances and conditions that the causes of goitre
and the main factors in its geographical distribution are to be
sought. What these circumstances and conditions are is not
fully known. Altitude above sea-level appears to have but slight
influence. Goitre is found, it is true, more often among highlanders than dwellers in the plains, and its chief endemic areas
are in great hill ranges such as the Alps, the Himalayas, and the
Cordilleras. It is also rare on table-lands, very rare on low lands,
and seldom found on sea-coasts1. But to all these general statements there are very marked exceptions. Thus while goitre has
been found as high as 10,000 to 13,000 feet above the sea in the
Cordilleras it is also met with as truly endemic in the low-lying
Tarai at the foot of the Himalayas, in the northern plains of
France, and in the flat valley of the Danube.
The most important local conditions which are believed to
influence the prevalence of goitre in a district are connected with
the geological character of the soil and the nature of the watersupply. There is not space here to discuss this question in full,
but briefly it may be said that from a very large variety of sources
evidence is forthcoming that goitre is mainly found where people
live on a magnesian-limestone soil, and where the water drunk is
impregnated with the various salts of lime and magnesia. A
further development of this view is found in the suggestion that
it is not by this "dolomitic" character of the water drunk that
the existence of goitre (and, it should be added, cretinism, as
both are believed to be due to the same cause) is to be explained,
1
Hirsch says it has never been found hitherto on coast margins, but eases
of goitre have been seen on the east coast of Africa, vide supra.

C.

12

i78

GOITRE AND

CRETINISM

but by the presence of sulphide of iron or of copper, both of
which are more likely to be found dissolved in dolomitic waters
than in others. There are, however, many difficulties in the
unqualified acceptance of these views. For while a dolomitic
soil is often found associated with these diseases it does not seem
to be essential for their development. Thus goitre is found on
the sand and mud-banks of Eastern Bengal and Assam, on the
laterite of the Dacca and Maimensingh districts, on the calcareous
soil of the Trans-Gogra districts of the North-West Provinces, on
the alluvium and detritus of the Tarai, and on different kinds of
soil in the Punjab 1 . Then again in New Zealand, where large
masses of magnesian limestone lie exposed in the northern island,
goitre is, or rather was some decades ago, wholly unknown 2 .
Further, while goitre is found among people in the Ballia districts
of the North-West Provinces of India whose water-supply is not
of dolomitic origin, it is unknown at Mussuri and Naini-tal, where
the water-supply is of this nature. For the present then the
question of the part played by the chemical constituents of the
soil and of drinking-water in the production of goitre and cretinism
must remain an open one. Recently the suggestion has been
made that these diseases are not due to the action of any
special chemical substance contained in soil or water, but are, like
so many other diseases, of baeillary origin. Lustig and Carle
found a bacillus which they named the "bacillus liquefaciens " in
waters taken from districts in which goitre prevailed, but they were
unable to prove definitely that any relation existed between this
bacillus and the disease.
While both goitre and cretinism are essentially maladies of an
endemic character, the former has on rare occasions become
distinctly and undeniably epidemic. A large number of instances
of epidemics of goitre have been recorded in the past in France,
and not a few in Germany and elsewhere. A remarkable outbreak of the disease occurred among Russian troops in the
Turkestan campaign in 1877, and a similar occurrence among
recruits in Brazil is also recorded. In India in 1886 and in 1893
goitre was most unusually prevalent in the Himalayan and other
districts where it is always more or less present, and in 1894 a
1
2

1840.

Hutcheson, loc. cit.
Thomson, quoted by Hirsch.

The reference, however, is to the year

GOITRE AND CRETINISM

179

sudden outbreak of the disease occurred in the native contingent
of the DufBa Field Force. This outbreak affected the troops in
a clearance in the virgin forest in a district notorious for malaria,
and among a people where goitre was common. The soil was
described as damp and swampy, and a dense fog prevailed at the
time, allowing the sun to be seen for only four or five hours daily.
The troops were only there for ten days, yet nearly every man
developed the disease with the most alarming rapidity 1 .
Finally, while cretinism is only found in districts where goitre
prevails, there are, on the other hand, vast endemic areas of goitre
where cretinism is very rare or almost wholly unknown. In many
goitrous districts the lower animals, such as dogs, cats, sheep,
pigs, horses, and mules, have been observed to suffer from the
disease.
1

Hutcheson, loc. cit.

12

2

GOUNDOU, A N A K H R E ,
OR GROS-NEZ.
G e n e r a l Characters a n d E t i o l o g y . Goundou, Anakhre,
and Gros-nez are names given to a curious and interesting disease
which is met with on the West Coast of Africa and in some other
parts of the world. Its principal characteristic is the appearance
of symmetrical swellings on either side of the nose. It usually
begins soon after childhood, but may attack adults. The appearance of the swellings is in most cases preceded by headache
and a discharge of blood and pus from the nose. These symptoms
last some months, and then disappear, but the swellings continue
to increase, until they ultimately interfere with vision and may
destroy the eyes. The tumours appear to consist merely of a thin
hollow shell, formed of the nasal process of the superior maxilla
and adjacent bones. The swellings are oval, with their long axes
directed downwards and outwards.
The cause of the disease is unknown. Maclaud 1 has suggested
that i t is due to the larvae of some insect finding their way into
the nostrils; but, as Manson has pointed out, the symmetry of the
growths is difficult to account for on this hypothesis. Braddon
regards it as apparently due to a chronic sub-periosteal inflammation involving the nasal process and perhaps the orbital plate of
the superior maxilla and the nasal bone 2 .
H i s t o r y , Goundou seems to have been first described in a
paper read by Prof. A. MacAlister before the Royal Irish Academy
on December 10, 1882, upon what were termed the horned men
of Africa. Later descriptions of the disease were published by
Lamprey in 18873, and by Maclaud in 1895 4 . Within the past
1
3

Archives de Med. Navale, Jan. 95.
Brit. Med. Journ. Dec. 10, 1887.

2
4

Journ. Trop. Med. May 15, 1901.
Loc. cit.

GOUNDOU, A N A K H R E , OR GROS-NEZ

l8l

two years cases of apparently the same disease have been reported
from China, Sumatra, the Malay States, and Uganda, but it is not
clear that the disease is a novelty there. Indeed of the true
history of goundou practically nothing is known.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. In Europe
goundou is wholly unknown.
Asia. In Asia it has been seen in Sumatra, in the Malay
States, and in China. The number of cases recorded up to the
present is, however, exceedingly small. In Sumatra itself one
case has been seen in a Malay woman 3 . In the Malay States
three cases have been observed, two of which were in Boyanese
(natives of Sumatra), and the third in a Malay2. In China one
quite typical case has been seen in Shangpoo, in southern China,
the patient being a Chinese woman 3 .
Australasia.
The disease appears to be quite unknown in
Australasia.
Africa. In certain parts of the xAfrican continent, on the
other hand, goundou is found with considerable frequency, and
particularly on the West Coast. In some villages of the Ivory
Coast as many as one or two per cent, of the population are
affected. Maclaud believed that the disease was confined to the
riverine districts of the Lower Komoe, and that, if found elsewhere,
it was probably only in persons who had at some time or other
lived in those districts. Brault also states that the disease is
particularly common in villages in the districts' of Beltie and
Krinjabo; in Indenie, Attie, Morenou, Baoule, and Esikasso, and
in short the whole of the Lower Komoe. But though this region
is the principal centre of goundou it is certain that the disease
occurs in other parts of West Africa. Lamprey has described
three cases in Fantis, of whom one came from the Wassan
territory, one from the Gamin territory, and one was a visitor to
Cape Coast Castle. Renner has recorded a case in the village
of Kissy, on the right bank of the Rokelle or Sierra Leone river 4 .
This patient was born in the village and had never left it, and as
no other cases had been observed in the village the disease in
this instance must almost certainly have been of local origin.
Quite recently, too, evidence has been adduced that goundou is
not wholly confined even to the western half of the African
1
3

Joum. Trop. Med. Aug. 1900, p. 11.
Ibid. Dec. 1900.

2
4

Ibid. May 15, 1901.
Ibid. Jan. 15, 1900.

182

GOUNDOU, A N A K H R E , OR GROS-NEZ

continent, for two cases of it have been seen in Uganda, though
whether of local origin or imported is not stated 1 .
America. Finally the only mention of goundou on American
soil seems to be the record of a single case observed in a West
Indian negro child in 1894. Dr Strachan, who described the case,
stated that he had seen two similar examples, and had often observed a " r i d g e " in this part of the face in West Indian negroes 2 .
H e suggested that this feature in West Indian negroes might be
an example of atavism referable to some tribal peculiarity of the
original West African stock.

Factors which govern the Geographical Distribution
of G o u n d o u . This disease has up to the present been observed
solely in tropical countries, and it may therefore be presumed that
warmth is either directly or indirectly essential to its development.
Beyond this very general statement little can be said as to the
influence of other physical conditions, and no observations have
yet been published as to the relation of the disease to soil, atmospheric moisture, elevation, or the general level of sanitation and
personal hygiene. Race is probably a factor of importance, as
the overwhelming majority of cases have been seen in African
negroes and the cases in the West Indies were in negroes of
African stock. But the recent evidence, summarised above, of
the occurrence of the disease in Malays, East Indians, and
Chinese, shows that the negro family is not the only branch of
the human race liable to it. A very similar affection having
been observed in a chimpanzee 3 , it is just possible that the lower
animals may share with man the susceptibility to goundou.
1
2

Cook, Journ. Trop. Med. June r, 1901.
Brit. Med. Journ. Jan. 27, 1894.

3

Maclaud, loc. cit.

GOUT.
General C h a r a c t e r s a n d E t i o l o g y .
Gout has been
defined as " a nutritional disorder, one factor of which is an
excessive formation of uric acid, characterised clinically by attacks
of acute arthritis, by the gradual deposition of urate of soda in
and about the joints, and by the occurrence of irregular constitutional symptoms 1 ." The characters of an acute attack of " t h e
gout" are too well known to need description, as are also the
general features of chronic gout and of the so-called "gouty
diathesis." An immense variety of affections have at one time
or another been regarded as of gouty origin, but, while the term
is a convenient one, it would be difficult to define its exact
scientific meaning. The cause of gout is unknown; the disease
is essentially a disturbance of tissue metabolism, to which many
factors predispose, and in which the production of uric acid in
excess is one of the most striking features. But the excess of
this substance is in no sense the cause of the disease, for it is
found in many other conditions in no way resembling gout.
H i s t o r y . Gout or podagra is one of the oldest of known
diseases. From the time of Hippocrates to the present day it
has been mentioned by almost all the medical historians, including
the Greeks, the Romans, the Arabians, and the later medieval
writers. No doubt the term podagra in early times included
many other affections than would now be strictly classed as
gouty, and this may perhaps account for the apparently greater
frequency of the disease in many countries in former centuries
than at the present day. But there is good reason to believe
that true gout has become very much more rare in recent years
than it used to be. To what extent this diminution is to be
ascribed to changes in the habits of the civilised nations will be
referred to again later.
1
Osier.

GOUT

184

R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. Gout is
met with in almost all European countries. Apparently, however, it is particularly common in the British Isles and in
Germany, and this has been attributed to the large amount
of alcoholic drink consumed in those countries. The disease,
at least in its acute form, is incomparably less frequent at
the present day than it was a hundred years ago. It is still far
more commonly seen in England than in either Scotland or
Ireland. A very notable diminution in the prevalence of gout
in recent times has also been observed in the Low Countries and
in Switzerland. In Russia gout is seen with some frequency in
the cities, but among the vast mass of the population the disease
is certainly not a common one, in spite of the large quantities of
fermented liquor drunk by them. In Lapland, Iceland, and
the Faroes, gout is said to be unknown. The disease occurs
in European Turkey, but comparatively rarely. In Servia it is
perhaps more common; in 1894-5 gout was the cause of 0*9
per cent, of all the deaths in that kingdom. In Greece gout
was formerly rare, but I am informed by Prof. Hadji Michali of
Athens that it is daily becoming more frequent.
Asia. The distribution of gout in Asia is very imperfectly
known. There is no mention of it in recent health returns from
the Caucasus, Siberia, or Russian Central Asia. It is very doubtful
if it exists in Asia Minor, Syria, Mesopotamia, Arabia, or Persia.
In India it has been seen, both in natives and Europeans, but
as a comparatively rare disease. In Ceylon and Assam it is said
to be quite unknown. It is probably very rare, if it occurs at all,
in the East Indian Islands. No case of gout has been observed
among the hill-tribes of Java 1 . The disease is also very infrequent
in the Malay Peninsula. Gowan saw one case in a native during
four years' residence in Siam. An occasional case is seen in the
hospital at Penang 2 . There seems to be no positive evidence of
the existence of the disease in China or Japan.
Australasia.
In Australia on the other hand gout certainly
occurs and apparently with some frequency. In Queensland
occasional cases are recorded in the Annual Health Reports. In
New South Wales a certain number of cases come under hospital
treatment in some, if not in all years, and in both South Australia
1
2

Kohlbrugge.
Straits Settlements Medical Reports.

GOUT

185

and West Australia a few deaths from gout usually appear in the
annual mortality returns. There seems to be no mention of gout
in any of the Pacific Isles, but this can scarcely be taken as proof
that it does not exist there.
Africa. Gout is apparently a rare disease in the African
continent, but information upon the subject is at present very
imperfect. It is said to be unknown in Egypt, and in all the
countries along the northern shores of Africa. The West Coast
was also at one time believed to be exempt from gout; but this
is apparently not the case at the present day. In the Colonial
Hospital, Gold Coast Colony, five cases of gout were treated in
1897, and unless this was an exceptional occurrence it would
seem to show that gout is not particularly rare here. Some
decades ago it was said to be very common among the Hovas on
the central plateau of Madagascar.
America. The references to the occurrence of gout in Canada
and the United States are extremely scanty. It is seen in many
of the cities of the United States, but is probably less common
here than in England. Gout is also exceedingly rare in Mexico,
Central America, and the West Indies. In South America it is
said to be infrequent in British Guiana and almost unknown in
Brazil and Peru, but of somewhat frequent occurrence in Chile.

Factors concerned in the Geographical Distribution
of Gout. It will be seen from the above summary that the facts
concerning the distribution of gout over the earth's surface are very
imperfectly known. So far as they go they warrant the general
assertion that this disease can occur in almost all latitudes, but
that it is principally found in the temperate zones and is rare or
unknown in most tropical countries. Exposure to cold and damp
seems to favour the production of gout in the individual, and this
may be part, though it can scarcely be the whole, of the explanation of the comparative rarity of the disease in warm latitudes.
While the actual nature and cause of gout are unknown, it is
nevertheless certain that heredity has a large share in its production.
Excessive indulgence in luxurious food, especially if combined
with the consumption of much alcohol and a sedentary life,
seems undoubtedly to predispose to gout. It is believed that the
egregious excesses of this nature which were indulged in in the
early days of the Roman Empire were the main reasons of
the extreme frequency of the disease at that time. It is also

186

GOUT

believed that the greater moderation in eating and drinking which
obtains now as compared with the very different habits of our
forefathers explains the diminished frequency of gout in recent
times. The part that over-consumption of strong drink plays
in the production of the disease is uncertain. It is an undoubted
fact that heavy drinking in better-class society is not now the
rule, as it formerly was, and that the average man is not in
the habit, as his great-grandfather possibly was, of consuming
from one to three bottles of port after dinner each night, and
being carried to bed by his servants, unconscious from alcoholic
poisoning; and it is very probable that this change in social
habits has had a large share in reducing the frequency of gout.
But it is equally undeniable that alcohol is still consumed to an
enormous extent, and that though individuals in the richer strata
of society may drink less than formerly, the community as a
whole, at least in some countries, as for example, England and
Germany, drink more, and the yearly bill for alcoholic drinks in
most European countries is an increasing one.
Probably gout is influenced as much, or more, by the kind of
fermented liquor drunk as by the quantity. The heavy beers consumed in England and in Germany are said to be much more
conducive to gout than the lighter beers drunk in America.
Strong, sweet, red wines have always borne an evil reputation for
gout. The spirits distilled from some grains, as for example
whisky and vodka, are probably less nocuous in this respect;
they are at least drunk to an enormous extent in Scotland,
Ireland, and Russia, and gout is comparatively rare in these
countries.
The relation of gout to race is not wholly certain. It is far
commoner in the Aryan races of the European continent than in
any others; but it has been seen in African negroes, in the
natives of India, Siam, and the Straits Settlements, in the Hovas
of Madagascar, and in the Creoles of South America. In India
the Mohammedans suffer from it occasionally, while the Hindus
are said to escape it entirely. Probably social habits, mode" of
life and other factors are of much greater importance in predisposing to gout than any variations in racial susceptibility.

INFLUENZA.
H i s t o r y . The earliest reference to the occurrence of influenza epidemics is probably to be found in Hippocrates, and
relates to the year 412 B.C. {circa). In 591 A.D. Bishop Gregory of
Tours mentions an epidemic which was probably one of influenza.
Other epidemics are spoken of by the chroniclers as occurring
in the years 877, 889, and 927. Then after a long pause came
the great outbreak of 1173. The records of the thirteenth century
are silent as to influenza, but there were many outbreaks in the
fourteenth—notably in 1323, 1327, and 13861. From the fifteenth
century onwards the references to influenza epidemics are not only
much more numerous but are also much more definite than the
earlier ones. Hirsch, Theophilus Thompson and others have
given complete lists of the principal epidemics and pandemics
of this disease from medieval to recent times, and the story of
the latest pandemic is told in detail in a subsequent portion of
this chapter. These successive outbreaks of influenza have shown
no definite regularity either in the intervals between them, their
duration, or the area they have covered.
Innumerable names have at different times been suggested for
this disorder. The term "influenza" as applied to the disease
was first used by an Italian writer, Piero Buoninsegni, whose
Florentine history was published in 1580. It is the one now
most generally employed. The etiology of influenza is uncertain.
A minute bacillus has been observed in the secretions of influenza
patients and is thought by some to be characteristic of the disease.
It was first described simultaneously by Pfeiffer, Kitasato, and
Canon in 1892.
1
The early history of influenza is told with greater detail in a paper on
" Epidemic Influenza " read by the author before the Society of Med. Officers
of Health in 1890 and published in Public Health (April, 1890).

188

INFLUENZA

G e n e r a l E p i d e m i o l o g i c a l C h a r a c t e r s . In discussing the
geographical distribution of influenza it will be impossible to
ignore the striking epidemiological characters of the disease,
which seem to distinguish it from most other epidemic disorders.
No other disease appears to spread so rapidly, to attack almost
simultaneously so large a proportion of the people exposed to it,
or to extend in epidemic form over so wide an area of the globe.
In these respects dengue is the only other malady which at all
resembles influenza, and it will be recalled that when in 1889-90
the last epidemic of influenza swept over a great part of the globe
many people regarded it as a form of dengue. But dengue has
never prevailed as an epidemic over so wide an extent of the
earth's surface as even approximately to justify the use of the word
"universal" in regard to its prevalence, and this has certainly
on many occasions been the case in regard to influenza.
But while influenza differs from most other diseases in this
important respect, there are other characters which it shows in
common with such typical epidemic diseases, for example, as
cholera or plague. Like cholera and like plague, influenza
appears to remain for long periods together endemic in certain
countries or regions, where from time to time it becomes
epidemic; and, like them, at irregular intervals it spreads from
these centres, or from one of these centres, and becomes more
or less widely pandemic. On some of these occasions, it would
seem, the disease extends, often in a remarkably short space of
time, over very nearly the whole inhabited globe. Countries
which have been quite free from influenza for many years and
which are visited by it on these occasions may then become for
the time endemic homes of the disease; and for a considerable
period may be ravaged by recurring epidemics of this very
troublesome, and (in its total results on the community) very
fatal malady. The epidemics of influenza during the past three
winters in London, Paris, Madrid, Constantinople and many other
places were sufficient to demonstrate that after twelve years of
irregular pandemic prevalence the disease had lost none of its
vigour, or of its power to increase the general mortality to an
extent which, had the cause of the increase been plague or cholera,
would have caused very great alarm.
Whether influenza is permanently endemic in any part of the
world must for the present remain uncertain. Before 1889, when

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189

the latest pandemic extension of the disease began its course, it
was apparently endemic, and had perhaps been so for some time,
in several parts of the earth's surface. Thus influenza, or a disease
allied to it, is said to have been common in China before the year
named, and to account for its existence there a theory was
advanced that it was the result of some colossal earth-commotion
or gigantic inundation in that little-known country. It was even
suggested that some catastrophe of this sort might have raised
a cloud of dust particles which, like that following the great
Krakatau eruption of 1883, might have swept round the world
and so produced the pandemic of influenza of 1889 and following
years. The more sober observations of the medical officers in
the Chinese Customs service, however, lend no sort of support
to this view, and there is, indeed, no reason to believe that the
pandemic in question started in that country. At the same time
it appears probable that influenza was locally endemic in some
parts of China before 1889; and in 1888 a mild outbreak of the
disease occurred in Hongkong 1 .
In like manner, as will be shown later, influenza was
endemic in many parts of Russia before the pandemic " wave"
began its course. In India a few cases of "influenza" were
annually recorded for many years before 1889. So also in the
Solomon Islands, in Fiji, and in Trinidad, a disease apparently
identical with influenza had for long been endemic. Elsewhere influenza or a disease closely allied to it had from time
to time been observed. The well-known "strangers' influenza"
occurring in St Kilda, in Iceland, in other isolated islands, and
among isolated communities such as certain Indian tribes in
North America and in Brazil, which is said invariably to follow
the arrival of a stranger from the outside world—-even though the
new-comer be himself in health and come from a country free
from influenza—is a phenomenon which is established beyond
doubt, but which has not yet been explained. An outbreak of
this kind was recorded in the month of May 1889 as occurring
among the Indians, half-breeds, and whites in Athabasca and
other districts of British North America. It is noteworthy that
at the same time influenza was epidemic in Greenland and in
Bokhara, but none of these outbreaks seem to have had any
1

Cantlie. Medical Reports of the Chinese Imperial Marititne Customs.
No. 42, p. 37.

190

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connection with the great epidemic extension of the disease which
began in the following autumn.
The relation which these temporary—or possibly in some
instances permanent—endemic centres of influenza bear to the
pandemic extensions of the disease is uncertain. It appears,
however, to be exceedingly probable that the latter do have
their beginning in one of these centres. That it is always
the same one must be doubted. The history of the disease,
indeed, shows almost conclusively that this is not the case;
though probably several of the past pandemics have begun in
or near the same region of the world as that which started in
1889. It has, however, proved impossible to assert, even approximately, where most of the past pandemics began. Their early
history has been usually wrapped in obscurity, and though their
course has in some instances been traced back over considerable
distances, it has never been possible to assert definitely that
they began in one particular district or even in one particular
country. The reason of this is obvious; the disease has almost
invariably come from the East, and the further back it is traced
towards the rising sun, the greater becomes the difficulty of
obtaining accurate information.
To some extent these considerations are true in regard to the
great pandemic which began in 1889. But some few years ago, a
careful study of a large number of Russian papers and reports 1
led me to the conclusion that the area of origin of that pandemic
lay somewhere on the borders of European and Asiatic Russia,
and that the disease spread thence eastwards, westwards, and
southwards. I propose to dwell in some detail upon the ascertained facts which led me to that conclusion, as they were derived
from comparatively little-known and not easily accessible sources,
and appear to justify a more definite statement as to the place of
origin of this pandemic than has ever been possible in the case
of any of its predecessors. The following are the principal facts
1
These consisted principally of numerous articles in Russian medical
papers, various brochures and pamphlets, the annual reports of the Medical
Department of the Russian Ministry of the Interior, and a valuable report
on the influenza epidemic in the Russian army, issued at the end of 1891
by the Army Medical Department in St Petersburg. The latter report was
based upon no less than 11,000 documents, obtained in reply to a circular
sent to every army medical inspector in the empire in Nov. 1889.

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191

in connection with the early period of the outbreak of influenza
in Russia in the year 18891.
C o u r s e of t h e L a s t P a n d e m i c . Before the outbreak influenza had unquestionably been endemic in many parts of Russia.
In the official returns for 1887 and 1888 there was scarcely
a government from which some cases of, or deaths from the
disease were not reported. It appears to have been particularly
frequent in the governments lying on or near the Gulf of Finland,
and not least so in the city of St Petersburg itself. In 1889
localised epidemics of grippe occurred in the government of
Moscow in January, February, April, and June. In the Tchernigof
government, influenza broke out in the town of Borzna, and
caused a sharp epidemic, in the month of February. In Nijni
Novgorod there were three periods of prevalence of the disease
in the year 1889—the first in March and April, the second in
August, and the third {the epidemic) in October and November.
In Kazan cases of the disease occurred in the early months of the
year. It is unnecessary to multiply instances further, and it may
be* asserted with confidence that influenza was endemic in many
parts of Russia prior to the autumn of 1889.
But at that period the disease suddenly took on a new
character. Throughout the length and breadth of the country
it spread with great rapidity and with extraordinary intensity,
and crossing the frontiers of Russia gradually extended its
ravages over almost the entire inhabited globe. The relation
of this rapidly spreading form of the disease, which attacked in
many places an overwhelming proportion of the population, to
the localised, endemic form just described as existing previously in Russia is uncertain. But it appears probable that
in these phenomena we are dealing with two different forms
of one and the same disease—that in the steppes of western
Siberia in the autumn of 1889 influenza acquired extraordinary
powers of diffusion and of virulence, that it spread thence in all
directions, and that its early course was to some extent obscured
and rendered difficult to follow by the existence here and there
of the disease in its mild, endemic, non-diffusive form. That
1
For detailed references to the very large number of Russian authorities
consulted for the facts contained in the text the reader is referred to two articles
by the author, on "The Recent Pandemic of Influenza, its Place of Origin and
Mode of Spread," published in The Lancet, Jan. 20, and Feb. 10, 1894.

192

INFLUENZA

influenza did begin earlier in one part of Russia than another,
and that it did definitely spread as from a centre is demonstrated
by a study of the dates at which the earliest cases of the great
epidemic occurred in different places. I am able to reproduce
here a map which I published some years ago in The Lancet,
showing the results of a study of this nature. The dates of the
earliest cases of the disease are inserted against the names of all
the principal towns of Asiatic, and many of those of European
Russia, and in following these dates a very accurate idea is gained
not only of the course taken by the epidemic, but also of its
place of origin.
In retracing the lines of the epidemic it is found that they
converge in a region lying between 6o° and 700 east longitude,
and about the 55th or 56th degree of north latitude. Within
this region the earliest cases of influenza appear to have occurred
in Petropavlovsk (Akmolinsk province) and in Tcheliabinsk
(Orenburg government). In each of these towns the epidemic was
said to have begun in the end of September. The next earliest
cases occurred in Tiumen (Tobolsk government) on October 2nd,
and in Tomsk on October 7th 1 . Nowhere else in European
or Asiatic Russia were cases registered at so early a period (with
the exceptions already mentioned, where cases of the endemic
disease were set down as early cases of the epidemic). The
authenticity of these dates appears to be unquestionable; and
they are further supported by the fact that in each of the towns
named the epidemic attained its highest point in October, and
was declining, if not over, before the month was at an end—that
is to say before the epidemic had begun in St Petersburg and the
west of Europe.
Tcheliabinsk was at that time the terminus of a line of railway
which ran from Samara through Ufa, and which has since been
continued as the Trans-Siberian Railway; the town lies to the
east of the Ural Mountains, though just within the limits of
European Russia. Petropavlovsk lies entirely in the steppes, and
at the time of the epidemic was connected by roads with the great
postal road, which was then the main route of communication
across Siberia. This road, known as the great Moscow Tract,
is marked by the thick line across the accompanying map. There
1
All the dates given in this chapter in connection with the outbreak in
Russia are according to the Old Style.

CHART

SHOWING

THE

EARLY

COURSE

OF T H E

INFLUENZA

PANDEMIC

(The dates are those of the earliest known cases in each of the towns named)

OF

1889-90

INFLUENZA

193

was then railway communication as far as Tiumen, an important
junction where several lines of communication by rail, road, and
river diverged. This was the first town on the Moscow Tract in
which influenza appeared, the earliest cases occurring here on
October 2nd.
The region defined above as the birthplace of influenza in
1889 lies in the northern part of the Kirghiz steppes. The large
district covered by these steppes is divided into five provinces—
namely, Uralsk, Turgai, Akmolinsk, Semipalatinsk, and Semiretchinsk. The inhabitants are mostly Kirghiz, belonging to three
great divisions—the Great, Middle, and Lesser Hordes. Their
mode of life is nomadic in the summer, but as winter draws near
they select a suitable place for their zimovka, or winter quarters,
where they either pitch their felt tents (kibitki\ oi ^construct
zemlianki or earth huts for themselves and their cattle. Their
principal occupation is the rearing of cattle, and an enormous
trade in live-stock is carried on. The chief market is in the town
of Orenburg, but a considerable amount of business in cattle,
hides and leather is done at Petropavlovsk.
The suggestion that the influenza epidemic arose among these
nomad tribes was first made by the compilers of a valuable report
upon the epidemic issued by the Russian Army Medical Department, and it scarcely admits of question that a large number of
considerations go to bear out the suggestion.
Unfortunately
there is no positive evidence of the existence of influenza among
the Kirghiz before it appeared in Petropavlovsk and on the
Moscow Tract. Beyond the facts stated all is conjecture. It
is certain, however, that the places where the earliest cases of
influenza occurred were either in the steppe country or closely
bordering upon it, and there was a clear progression of the
epidemic m different directions in lines which radiated from the
steppes. Whether the cattle, possessed in large numbers by the
Kirghiz, suffered in any way from the disease, or from a disorder
at all like it, is unknown. The Kirghiz themselves call influenza
"gangei" and also "Chinese fever." The latter name might be held
to point to China as the place of origin of the disease, but, apart
from the absence of direct evidence, there are other considerations which negative the idea. The towns earliest affected by
influenza are more than a thousand miles from the Chinese frontier.
The province of Tomsk has a short strip of frontier occupied
c.

13

194

INFLUENZA

entirely by the Altai mountains, a formidable barrier to any
epidemic disease. The provinces of Semipalatinsk and Semiretchinsk, which also border u p o n ' t h e Chinese empire, were not
invaded by influenza until November and December respectively,
or much later than the appearance of the disease in Petropavlovsk.
Further, the epidemic spread from north to south in these provinces, and not from south to north as it must have done had it
been imported from China.
The radiating lines of the epidemic may be briefly traced as
follows. The disease broke out, as stated above, at Petropavlovsk
in the end of September, 1889. Thence to Tomsk is a distance
of about 1000 miles, which could be travelled by post in about six
days. Influenza broke out in Tomsk on October 7th. Nine days
later it appeared in Krasnoyarsk, some 370 miles further east along
the great Moscow Tract. It did not reach Irkutsk until November
22nd, or 46 days later than its appearance in Tomsk. Beyond
the great Baikal Lake its progress was even slower. Tchita was
invaded on December 12th, Stretinsk not until January. The road
at that time ended at Stretinsk, and passengers for Vladivostok,
Russia's naval station on the Pacific, had to descend the Amur by
steamer to Khabarovka, and thence to ascend the river Ussuri as
far as Kamne-Rybolof, whence there was a post-road to Vladivostok. Influenza broke out in the last-named town at the end
of May, 1890, and there is some interesting evidence of the
importation of infection here, not by road from the west, but
by steamer. The disease broke out immediately after the arrival
of the first steamers of the Russian volunteer fleet from Odessa,
on the opening of the navigation season of 1890. On the convict
island of Sakhalin the like fact was observed, the earliest cases
being among the keepers of a certain lighthouse immediately after
the arrival off the lighthouse of the steamer Baikal.
From Vladivostok influenza passed along the rivers Ussuri and
Amur, reaching Blagoveshtchensk in July and re-infecting Stretinsk
in August. There was thus in Eastern Siberia a double current
in the course of the epidemic, firstly from the west, and secondly
from the east.
The epidemic followed a more rapid course to the west of
its place of origin, but apparently its progress was not more
rapid than that of an ordinary traveller. The journey from
Petropavlovsk to St Petersburg, via Tiumen, by rail to Perm,

INFLUENZA

195

thence by the rivers Kama and Volga to Nijni Novgorod, and
thence by rail through Moscow, could be accomplished in eleven
or twelve days. From Tcheliabinsk, through Ufa and Samara the
journey could be completed in some six days. Between the date
of the appearance of influenza in either of these towns and the
date of the first cases in St Petersburg at least three weeks
elapsed. In the towns along the first route, influenza manifested
itself in Perm in the " middle of October," in Kazan in the
" m i d d l e " or " e n d of October," in Nijni Novgorod in the
"beginning" or "middle of October," and in Moscow about the
18th of the month. Of towns along the second route, Ufa and
Samara are the most important; in Ufa the epidemic passed
unnoticed as such, but there was a great increase in cases of
illness in the town in the early days of October and even at the
end of September; in Samara influenza appeared on October
27 th.
Influenza seems also to have followed the course of certain
rivers. Along the Ural river the disease appeared in Orenburg on
November 1st, in Uralsk on the 13th, and in Gurief at the mouth
of the river on the 22 nd. Along the Volga it appeared in Simbirsk on October 22nd, in Samara on the 27th, in Saratof on the
28th, in Tsaritsyn at the end of the month, and in Astrakhan at
the beginning of November. The influenza infection therefore
travelled down these rivers in the direction of their current, and
the same was observed in the river Lena in the Siberian government of Yakutsk; while the cholera infection, it may be recalled, was
in 1892 carried up the two first-named rivers against their current.
This difference was obviously due to accidents of geographical
position of the towns on the rivers, and not to anything inherent
in the nature of the two diseases. In the one case towns on the
upper reaches of these rivers, in the other towns at their mouths,
were nearer to the place of origin of the epidemic, and were
consequently attacked earlier in the course of the disease.
The Caucasus was not invaded until November, and some
parts of it not until towards the end of that month or the early
days of December. The Transcaucasian Railway is said to have
assisted in the spread of the disease from Tiflis. Further west,
Rostof-on-Don was invaded on November 16th; Tambof at the
end of October; Kief on November 1st; Kharkof on the 5th;
Poltava on the 23rd; Vilna on the 10th; Warsaw on October 29th.
13—2

ig6

INFLUENZA

It would serve no useful purpose to quote the dates of invasion of
other Russian towns. There is complete and more or less rapid
railway communication over all this part of the country.
More interesting evidence may be derived from the provinces
of Central Asia where there are no railways, except in Transcaspia, where the roads are few and communication slow, and
where, therefore, the epidemic could be more easily followed. In
Central Asia influenza appears to have passed from north to south
and from west to east, and to have followed the post-roads. It
seems to have been carried either from Petropavlovsk or Orenburg
to Orsk, where the epidemic began in the early days of November.
In Kazalinsk (45 7 miles to the south in the province of Turgai) the
epidemic began on November 28th; in Perovsk (233 miles further
along the same post-road) on December 4th; in Turkestan (208
miles) on the 15th; and in Tchimkent (103 miles) two days later.
At Tchimkent the road joins another great line of communication
running east and west. This is a post-road, beginning at Samarkand
on the west (then the terminus of the Transcaspian Railway) and
running through Tashkent, Tchimkent, Iliskoe, and other towns to
Kopal, thence turning northwards to Sergiopol and Semipalatinsk,
where it is joined by other roads from Omsk and Kolyvan on the
Moscow Tract. Of the actual course of influenza in Transcaspia
and along the Transcaspian Railway little is known with certainty.
In Askhabad the disease appeared about the middle of November.
Among the troops stationed there the first case was on the 15th.
How and whence the disease was introduced into Askhabad there
was no evidence to show; but from this important town the infection spread eastwards; it appeared in Kaachka on December 1st,
in Samarkand at the end of November, in Tashkent on December
1 st, in Tchimkent (as already stated) on the 17th, and in Iliskoe
on the 24th. In Viernoe, on a branch road from Iliskoe, the first
cases were observed on December 18th, and in Prjevalsk, further
along the same road, on January 12th. Another route followed by
the infection appears to have been southwards from either Omsk
or Kolyvan on the Moscow Tract to Semipalatinsk, where it
appeared in the beginning of November; thence on the one hand
to Ust-Kamenogorsk, where the first cases occurred on November
17 th, and, on the other, through Sergiopol (where there is said to
have been no epidemic at all, either among the troops or the
civil population) to Kopal, where the malady appeared on

INFLUENZA

197

December n t h , and where the road meets that already traced
from Samarkand through Iliskoe.
It has appeared to me to be useful, at the risk, of seeming
tedious, thus to describe in detail the early days of the last great
pandemic of this disease, as it establishes in a manner more exact
than was possible in the case of any previous pandemic both the
approximate place of origin, and the rapidity of spread from the
place of origin. Outside Russia it will be impossible here,
for sheer lack of space, even if it were necessary, to trace the
course of the disease in the same detail.
Westward and southward of Russia influenza spread in the winter
of 1889-90 to almost, if not quite, all the countries of Europe.
In England, it will be recalled, the epidemic appeared shortly
before Christmas, 1889. T n e Faroe Islands were visited by the
disease at a later period; Iceland was attacked in July and
August, 1890; and whalers reported that influenza appeared on
the shores of Greenland at some date not definitely stated 1 .
In Asia, the spread of the disease has been already described
in detail for the whole of Siberia and of Russian Central Asia.
In Arabia, influenza broke out at Hodeida on the Red Sea
coast early in April. In Persia, on the other hand, the disease
was prevailing early in January. In India, it appeared as an
epidemic early in 1890. In Bombay and Calcutta cases were
first noticed in the month of February, the Health Officer of the
latter city reporting that the disease was imported there from
Bombay. In the Jalaun district of the North-West Provinces
the epidemic began even earlier—in the middle of January. The
course of the disease in India seems to have been very irregular,
but in general terms the epidemic among European troops
stationed in India began in March, reached its height in April
and then began to decline, very few cases being reported in the
latter half of the year. In many places the general population
suffered earlier than the troops, while in others the reverse was the
case. Burma was affected rather later than India proper. In
Ceylon the outbreak began as early as the first week in February,
1
The Faroe Islands. By J. Russell-jeaffreson, F.R.G.S. London, 1898.
Whether Greenland shared in the great epidemic extension of influenza
subsequent to the autumn of 1889, or whether the statement of the whalers
referred to the outbreak of the disease there in May 1889 (already alluded to in
the text) is uncertain.

198

INFLUENZA

and was apparently caused by the arrival of H.M.S. Himalaya
with many cases of the disease on board. The earliest local cases
occurred among the pilot's boatmen in Colombo harbour.
Farther India seems to have been attacked not much later
than India. In the Straits. Settlements influenza appeared towards
the end of February; it was most active in Singapore, but Penang
and Malacca also suffered considerably. The East Indian Islands
seem to have escaped with a less severe epidemic than the places
just named; in Java a mild outbreak only of the disease occurred,
while in Labuan, off Borneo, there was no epidemic of any kind
in the year 1890.
In China influenza appeared in the neighbourhood of Swatow
in the latter end of February, 1890, attacking first the native
population. Hongkong is said to have been affected still earlier.
At Chinkiang the epidemic began towards the end of March, and
raged violently among the Chinese population.
Ichang was
attacked some time in April; Hoihow was affected " in the winter
and early spring"; Hankow in April (it was believed that the
infection spread to this city from Shanghai). In Wuhu influenza
appeared in March, and Foochow was visited about the same time.
Ningpo was not affected until the autumn, and in some other
places the disease did not break out until even later. Korea seems
to have escaped altogether. Formosa was less fortunate, the
disease appearing in Tamsui and Kelung in April and May, 1890.
Japan, on the other hand, is said to have been invaded by the
epidemic as early as February of that year.
The whole of Australia was visited by the epidemic. In
Victoria cases of influenza were first reported towards the end
of March, and the entire colony suffered considerably. In New
South Wales and South Australia the beginning or middle of
March was the date to which the commencement of the
epidemic was ascribed. In Queensland and Western Australia
it appears to have begun about a month later. New Zealand
and Tasmania were attacked by the disease some time during
the month of March.
Returning to the west, the course of the epidemic on the
African continent may be very briefly traced as follows. In
Egypt, influenza was observed in Cairo and other parts of
Lower Egypt as early as November, 1889 ; in December many
places elsewhere were already attacked by the disease, as, for

INFLUENZA

199

example, Alexandria, Port Said, Damietta, and Ismailia. In January and February outlying places removed from the great centres
were attacked, and the disease invaded Upper Egypt, reaching
Assouan and Wady-Halfa on the Nile only in March 1 . Along the
northern shores of Africa Algiers is said to have first felt the
effects of the epidemic in the first or second wreek of January,
1890, and in Tunis the earliest cases were reported about the same
time. On the West Coast influenza seems to have been introduced
to Sierra Leone early in March, where it broke out after the
arrival of two steamers with cases of the disease on board. In the
Gambia there was a very severe epidemic, which caused a high
mortality among the natives in the early months of 1890. Lagos
and the Gold Coast were apparently affected somewhat later, and
in Senegal the epidemic was at its height in the month of July.
In the Cameroon district, on the other hand, influenza is said not
to have become epidemic at any time.
South Africa was visited by the disease even earlier than many
places on the West Coast. Thus in Cape Town influenza
broke out in the first week in January, 1890, introduced, it
was believed, by steamers from Europe.
The date of the
commencement of the epidemic in Natal is quite uncertain, and
some medical men even denied that there had been any epidemic
there at all. Others again asserted that influenza began to be
epidemic as early as October, 1889, or before it began to prevail
in Europe outside Russia. This was the date assigned by one
observer for the outbreak in Durban, but the evidence of other
observers in that town was most conflicting. The disease seems
to have reached Basutoland about the end of March and to have
spread northwards. British Bechuanaland was attacked at the
end of April, the disease being thought to have been imported
from Cape Colony. As late as October, 1890, influenza became
epidemic in the Shire Highlands in Eastern Africa.
Of islands off the coast of Africa it is to be noted that in
May, 1890, feverish colds "apparently representative of the
influenza in a modified form " were reported from Orotava, in the
Canary Islands; while as early as January of that year an outbreak
of influenza occurred on H.M.S. Australia while at St Vincent in
the Cape Verde Islands. The Azores were also visited by the
1
VEpidemie d'Influenza en Egypte pendant VHiver
Dr Engel Bey. Le Caire, 1894.

1889-1890, par

200

INFLUENZA

disease, while St Helena seems to have escaped until the month
of August 1890. In Mauritius influenza appeared as an epidemic
in July 1890, or according to some observers not until August.
Rodriguez and Reunion, Madagascar and the Seychelles, were all
visited by influenza in that year, but with varying degrees of
severity.
The Western Hemisphere was reached by influenza almost,
if not quite as soon as the western shores of Europe. In Jamaica
the disease was recognised as epidemic on December 6th, 1889,
or some time before it had begun to be epidemic in England.
In New York the earliest case was said to have occurred on
December n t h . In Boston the disease broke out in the middle
of December, and on the 17th of that month 30 prisoners
in the Suffolk County gaol were attacked by it within a
period of twenty-four hours.
On the 19th influenza had
appeared at Buffalo, at Detroit, and at Kansas City; next day
it was reported as occurring among post-office employes at
Rochester, N.Y., and a week later it had broken out at Philadelphia, Baltimore, and many other places in the United States.
The Southern States were attacked rather later than the more
northerly ones, and it was thought that a low temperature
increased the mortality caused by the disease if it did not favour
its spread. In St Louis and New Orleans the epidemic first
appeared about January 1st, 1890. Its crisis, as shown by the
highest point reached by the mortality from all diseases and from
respiratory diseases in particular, seems to have occurred in Boston,
New York, and Brooklyn in the week ending January n t h ; in
Cleveland, Providence, and Minneapolis in the following week;
in Charleston and Washington in the week ending January 25 th,
and in St Louis, Milwaukee, and San Francisco in that ending
February 1st.
Canada also suffered severely from the first great wave of pandemic influenza in the winter of 1889-90. In Ontario the date
of the earliest case was given as December 4th, 1889. In Quebec
the disease was even said to have been observed as early as
November 20th, but it did not become epidemic until the middle
of the following month. In Manitoba the first noted occurrence
of influenza was on December 23rd; in New Brunswick it was
believed that the epidemic began "about October or November
1889." In Vancouver Island December 22nd was the date as-

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201

signed for the first cases. The North-Western Territories were
attacked apparently some time in December 1889 or January
1890, and both here and in British Columbia the "Indians,"
who live in separate bands or communities, scattered throughout
a wide extent of country, suffered greatly from the epidemic.
Newfoundland was apparently invaded in February.
In regard to the West Indies the early occurrence of influenza
in Jamaica has been already mentioned. In some other islands
of the group the date of the appearance of the epidemic is less
certain. In Trinidad it was even denied that the disease had
occurred at all, although a disorder very like influenza is said
to appear there every year in the months of January and
February. Whether an outbreak which occurred in the Trinidad
Leper Asylum early in 1890 was of the nature of this local,
annually recurring disorder, or whether it was part of the great
pandemic wave of influenza has never been determined. At Tobago the malady appeared about the end of January; at Antigua
some time in the same month; at St Kitts and Nevis early in
February; at St Vincent at the end of January; while at Barbados
it was not until the middle of April that the disease broke out.
The Bahamas, Grenada, and St Lucia were believed to have
escaped, and the Bermudas were equally fortunate, with the
exception of Ireland Island, where a very sharp epidemic occurred
among the officers and men of a number of Her Majesty's ships
lying in the harbour. The infection was imported to the island
by a Swedish corvette, the Saga, and the outbreak was almost
confined to the harbour, only eleven cases occurring on shore.
In Mexico influenza was reported to be present from
January 17th, 1890. On the last day of that month it had also
appeared in the town of Guatemala, 300 miles from the Atlantic
coast. British Honduras is said to have escaped altogether in
1890, though in subsequent years it has been less fortunate.
The course of the epidemic in South America during the first
year of its prevalence was very erratic, though as a whole this
great continent seems to have suffered from the ravages of the
malady no less than the others already briefly considered. In
British Guiana the disease first made its appearance in Georgetown
in the week ending August 2nd, 1890, yet long before this it had
invaded the greater portion of the remainder of the continent.
Thus, in Chile, on the west, influenza was prevalent from the

202

INFLUENZA

month of January, and in Buenos Aires and Monte Video on the
east from February 2nd. From the latter it was believed to have
spread northwards to Brazil. In Peru, Callao was invaded in
April; and in the same month the disease appeared in Guayaquil,
Cucuca and Quito, in Ecuador. In that country the course of
the epidemic was said to have been from south to north. Finally
in September and October 1890, a severe epidemic of what was
described as a "hybrid" of influenza and whooping-cough prevailed in the Falkland Islands, particularly in the East Island.
Such, in barest outline, was the course followed by the great
pandemic wave of influenza, which began in the autumn of 1889,
and in the course of a few months spread over almost the whole
globe—to China and Japan in the far east, to California and Chile
in the west, to Iceland and northern Canada in the north, and to
New Zealand, the Cape, and (perhaps) the Falkland Islands in
the south. That every portion of the inhabited lands within this
vast area—which practically comprises the entire earth's surface—
was visited by the disease, and that every separate community
within those lands suffered from its attacks cannot, however, be
asserted. There were many islands, and even countries of considerable size, which seem to have escaped its ravages, at any
rate during the first year or two of its prevalence. Some of
these have been already named. But it is of importance to note
that many of those geographical areas which remained untouched
for a considerable period after neighbouring areas had been invaded by the disease, were themselves invaded at a later period,
and in many instances suffered from recurring epidemics of very
great severity. Whether any geographical area of considerable
size has remained entirely free from influenza from the year 1889
up to the present date is not easy to state. For the present it
appears open to doubt, though possibly certain towns or villages,
or even communities and inhabited areas of still larger size, may
have been so fortunate as to escape its ravages altogether.
The subsequent history of the recent great pandemic of influenza, which perhaps has not yet come to an end, cannot be told in
detail here. Few of the countries invaded by the disease when it
first swept over the earth's surface in the winter of 1889-90 have
not suffered from later recurrences, as severe as, or more severe
than the first outbreak. In some countries there has been a
tendency to annual recrudescence of the disease, which has in

INFLUENZA

203

many instances made its reappearance in either the spring or the
autumn. But it is impossible to assert that influenza follows any
definite rule, either in relation to season or in regularity of
recurrence. Epidemics have occurred in the depth of winter in
many instances, and recrudescences in the summer months are
not wholly unknown. In England the winter seems to have been
more especially favourable to the renewed prevalence of the
disease. On several occasions there has been observed a tendency
towards recurrence of influenza at or about the same time at
widely separated parts of the earth's surface; but this may be
explained provisionally by supposing that the recurrence of similar
seasonal, climatic, or other conditions in these widely separated
areas favours the revival of an infection which has still remained
from the preceding outbreak of the disease.

LEPRQSY.
H i s t o r y . There can be little doubt that leprosy is one of
the oldest of diseases. The references to its existence in ancient
and medieval writers are often obscured by the uncertainty and
confusion which existed between true leprosy and a variety of
other disorders, but it is none the less certain that leprosy is of
great antiquity.
Throughout Biblical times—at least from the date of the Jewish
exodus from Egypt—it was a familiar disorder in the countries that
would now be spoken of as the Near East. An almost equal
antiquity is claimed for the disease in India and China. It is
mentioned by some of the ancient Greek writers. Through the
early medieval period it was no doubt a comparatively common
disorder; and special laws for its control, and asylums for
the reception of lepers, are known to have existed in several
European countries as early as the eighth and ninth centuries of
the Christian era. A little later the disease appears to have been
prevalent in Europe to a truly terrible extent, for between the
n t h and 13th centuries leper-houses in vast numbers were established. How far this increase in the number of leper-houses is to
be taken as implying a real increase in the prevalence of the
disease is uncertain; and equally uncertain is the influence in
spreading the disorder which has often been ascribed to the
Crusades. In recent centuries leprosy has greatly diminished
in Europe. It has, however, remained endemic in large areas of
Asia and Africa, and has been newly introduced to regions of the
.world where it was unknown before, such as many parts of
Australasia, South Africa, and North America.
The bacillus leprce, which is associated with the disease, was
first observed in the tissues of lepers by Hansen in 1873, some

LEPROSY

205

ten years before Koch published his discovery of the closely allied,
but probably distinct bacillus of tubercle.
R e c e n t Geographical D i s t r i b u t i o n . Europe. In Europe
leprosy is no longer a widely prevalent disease. The countries
containing the largest proportion of lepers are Spain, the countries
in the Balkan peninsula, and Iceland.
In the British Isles leprosy is extinct as an indigenous disease.
A small number of cases are known to exist, either in an active
or cured condition, but it is believed that in all the infection has
been contracted outside these islands. They probably do not
exceed a score.
In France a certain number of lepers are found on the south
coast, on the shores of the French Riviera 1 . They are said to be
most numerous at Contes, Eza, Peille, and La Turbie, just above
Monte Carlo. Sporadic cases are also met with in Brittany. In
Paris it is believed that there are a considerable number of persons
affected with the disease; one estimate has placed the number
at between 160 and 200. All have, so far as is known, contracted
the disease abroad. The appreciable risk which these unfortunate
people afford to their neighbours has been recently the subject of
a protest by M. Hallopeau.
In Holland 17 lepers were known to exist in 1897.
In Germany leprosy is known to exist in Memel, in the
extreme north-east corner of the country, close to the Russian
border, and on the shores of the Baltic Sea 2 . The disease was
introduced here from Russia about the year 1870. In all there
have been 2 7 cases in Memel, of which 17 have ended fatally.
In Hamburg there were ten lepers in 1898, of whom 5 were
born in Germany, 2 in Portugal, and 1 each in Sumatra, Mexico,
and Brazil. Seven were infected in Brazil, and one each in Mexico,
Penang, and the Philippines. No spread of the disease from
person to person has been seen in Hamburg. One leper was also
reported in Mecklenburg-Schwerin in January 1900, but the other
German States were quite free from the disease.
In Belgium only 4 lepers, and in Denmark not more than
three were known to exist a few years ago 3 .
1
2
3

Jeanselme. Report of the Leprosy Conference in Berlin.
R. Koch. Die Lepra-Erkrankungen im Kreise Meniel. Jena, 1897. Ehlers. y<z»2/j, 1898, p. 140. " The Geographical Distribution of Leprosy."

206

LEPROSY

In Norway, at one time the most active centre of leprosy in
Europe, the disease has steadily declined in recent years, and this
change has been attributed to the effects of the strict segregation
which has been practised in that country since the isolation law of
1885 came into force. In the year 1856 there were believed to
be 2833 lepers in Norway, but in 1896 their number had fallen
to 681, and in 1898 two leprosoria were closed and converted into
hospitals for the treatment of tuberculosis. The principal centre
of the disease is said to be still in the neighbourhood of Bergen,
just as it wras in the Middle Ages 1 .
In Sweden there are believed to be from 70 to 75 cases of
leprosy, of which some 30 are isolated. Of this number 36 live
in the province of Helsingland and 15 in Dalecarlia 2 .
Russia has always been believed to contain a large number of
lepers. Recent investigations have shown that, while the infection
is widely spread throughout the country, the actual number of
known lepers is not large in proportion to the area and population
of the country. There is reason, however, to believe that many
more cases exist than are known to the authorities. It will be
convenient to consider both Asiatic and European Russia together.
It is only since the year 1887 that accurate knowledge of the distribution of, and numbers suffering from, the disease in the
Russian Empire has been available. Between that year and the
year 1895 information of the existence of leprosy has been received
from every portion of the empire, with the exception of the following governments: Vilna, Kalisz, Lomza, Lublin, Siedleg, Radom,
Novgorod, Penza, Tambof, Tula and Elizavetpol, and the provinces of Semipalatinsk and Turgai in Central Asia. In these
governments and provinces leprosy has apparently always been
non-existent.
In a large number of other governments and provinces, such
as those of Archangel, Volhynia, Kovno, Warsaw, Kielce,
Piotrkow, Plock, Suvalki, Olonetz, Simbirsk, and Yaroslavl in
European Russia; Kutais and Daghestan in the Caucasus; Akmolinsk and Semiretchinsk in Central Asia; and Tobolsk and Tomsk
in Siberia, the number of lepers recorded is small and does not
exceed one, two, or three in a few scattered towns or villages.
From several of these areas, also, it is to be noted that the disease
is apparently disappearing, and during the last five years for which
1

Ibid.

2

Sederholm (at the Berlin Conference).

LEPROSY

207

returns are available (1891-5), the following governments have
been free from recorded cases of leprosy: Archangel, Mogilef,
Kielge, Suvalki, Olonetz, Kutais, Yeniseisk, and Akmolinsk.
There remain 14 governments and 9 provinces in which leprosy
is an endemic and more or less widely prevailing malady. These
territorial divisions, in which leprosy is most rife in Russia, are to
some extent grouped around the shores of various seas or inland
lakes, particularly the Baltic Sea, the Gulf of Finland, Lakes Peipus,
Pskof and Virtz-Jarvi (in Livonia), the Black Sea, Sea of Azof,
the Caspian and Aral Seas, the Sea of Okhotsk, and the Lakes
of Tchaldyr (in the government of Kars), of Goktcha (in that of
Erivan) and of Baikal (in that of Irkutsk, Siberia). The exceptions
to this rule are certain centres of leprosy in the Batalpashinsk
division of the Kuban province, the Piatigorsk and Naltchinsk
divisions of the Terek province, and the Stavropol government
(all in the Caucasus); and the Samarkand and Ferghana provinces
(in Central Asia).
As the result of a special inquiry made by the Medical Department of the Ministry of the Interior in 1895—1897, the most
important centres of leprosy in Russia have been grouped as
follows :—
1. The Baltic Province Group. In the provinces bordering
on the southern shores of the Baltic Sea 564 lepers were registered
in the years named. The ratio they bore to the total population
was 12*8 per hundred thousand. This part of the country would
appear, from these figures, -to be more deeply tainted with the
disease than any other, but the returns from Eastern Siberia were
extremely imperfect, and it was thought probable that leprosy was
in fact more rife in this latter region than on the Baltic. Among
the Baltic provinces Livonia occupied the first place with as many
as 26 lepers per 100,000 inhabitants; Courland had 19*9, Esthonia
10-9, and the government of St Petersburg not more than 2*2 in
the same unit of population.
2. The Black Sea and Azof Sea Group. In this group 235
lepers were registered, or i*8 per 100,000 inhabitants. The Kuban
province returned 6*2, and the Territory of the Don Cossacks 3*2
lepers per 100,000 of the population. While it is true that these
areas as a whole border on the seas named and are tainted with
leprosy to a considerable extent, it has also to be remembered
that the principal centre of the disease in the Kuban province is,

208

LEPROSY

as was pointed out above, in the interior of the country, and that
in the governments of Bessarabia, Taurida, and Kutais, all of
which border on the Black Sea, the number of lepers recorded
was exceedingly small.
3. The Caspian Sea Group. The number of lepers registered
here was 141, equivalent to 5*1 per 100,000 persons. Astrakhan
was the worst government in this group, with a ratio of 7*6 lepers
per 100,000, the Terek province coming second with a similar
ratio of 5*5. Daghestan, at one time thought to be a centre of
leprosy, appears on the contrary to be almost free from the
disease. In the recent special inquiry alluded to above no
return was received from Daghestan, but in the ordinary annual
reports of the Russian Medical Department only single cases were
returned from here in 1890, 1894, and 1895, and none in 18911893. In the government of Baku, which lies on the western
coast of the Caspian Sea, a considerable number of lepers were
registered.
4. The Aral-Caspian Group. In this group only 54 lepers
were recorded. This was equal to 2*2 per 100,000 inhabitants.
The Syr-Daria province returned figures equivalent to a ratio of
2 7 . It is, however, pointed out that in all probability a large
number of lepers exist in these regions who never come under the
observation of medical men (from whom the returns here quoted
were, in every instance, obtained), and that presumably the
number of persons suffering from the disease is very considerably
larger than the returns indicate. There is also a great paucity
of medical men in Transcaspia, Uralsk, and the other Central
Asiatic provinces, and it is impossible for them to have an accurate
knowledge of the number of lepers in the very large areas under
their care.
5. The Arctic and Pacific Ocean Group
In this enormous
territorial area, which includes the whole of northern and eastern
Siberia, only 60 lepers were recorded in 1895—1897. But so
sparse and scattered is the population of these Siberian border
provinces that this figure represented a ratio of 12 lepers in every
100,000 inhabitants. The figure, it must be added, is much below
the truth. Returns were received from but a few of the larger
towns, and from the annual reports of the Russian Medical
Department it is quite clear that a very much larger number of
lepers exist here than the (imperfect) special return appeared to

w^e

+ s

-

©©©
Leprosy moderately common.

+ +-r
Leprosy in isolated
60

communities.

80

40

40

160

DISTRIBUTION OF LEPROSY

80

120

160

LEPROSY

209

indicate. So little is truly known of the nomadic and other
indigenous tribes in these far-away regions that it is impossible
to estimate even approximately the extent to which eprosy or any
other disease prevails amongst them.
6. The Lake Baikal Group.
In the Irkutsk government
the number of lepers recorded was equivalent to 2*2 per 100,000
inhabitants. In the Transbaikal province, whence no special
returns were received, from 1 to 7 lepers have been recorded
in each annual report of the Russian Medical Department since
the year 1887.
There remain to be mentioned certain centres of leprosy in
Russia which show no grouping round the shores of seas or lakes.
Thus in the inland government of Kars, in Transcaucasia, the
number of lepers recorded in 1895—1897 was equal to 7*4 per
100,000 inhabitants; in that of Erivan the ratio was 3*0 per 100,000
inhabitants; while in that of Tiflis only a few isolated cases were
returned. In Central Asia, again, 42 cases of leprosy were registered in the provinces of Samarkand and Ferghana, both far
removed from any sea or lake. The ratio to the population was
1 "8 per 100,000. In these two provinces lepers are mostly
congregated into what are termed makhaukhans^ or leper
colonies.
Finally in the other Russian governments and provinces not
yet named only 37 lepers were found to exist in 1895-1897; and
as the population of these areas is very little short of 30,000,000,
it will be seen that the proportion of persons affected by leprosy
in them is infinitesimal. Many of these cases of the disease have
been shown to have been imported from elsewhere where leprosy
is endemic. The most frequent agents in thus transporting this,
and indeed many other diseases, are those peasants who annually
leave their homes to obtain work in other parts of the country,
and, on returning, bring the infection with them.
In the entire Russian Empire it was found by the special
return made in 1895—1897 that just 1200 lepers were known
to exist, of whom 633 were males and 567 females. But from
what has been said above as to the trustworthiness of the returns,
it cannot but be held that the actual number of lepers in Russia
largely exceeds that figure. Prof. Petersen, at the Berlin Conference on leprosy held in 1897, stated that he estimated the total
number of lepers in Russia at about 3000.
c.

14

LEPROSY

2IO

In Finland the number of lepers in 1893 was estimated at 51
(33 males and 18 females); in 1896 the number had risen to 67
(42 males and 25 females)1.
In Austria-Hungary leprosy is believed to exist only in the
form of isolated, sporadic cases.
In Spain leprosy is apparently widely spread, though accurate
knowledge of its distribution and of the numbers affected appears
to be wanting. It is said to be commonest on the south and east
coasts, and particularly in the provinces of Valencia and Alicante,
both on the east coast. There are villages in these provinces where
as many as ten or twelve families of lepers are known to exist. The
disease is apparently increasing in Spain as in Italy; for in the
province of Valencia the number of known lepers was returned in
1888 as 69, and these were distributed in 13 parishes, wrhile in
1893 the number had increased to 120, and they were distributed
in 20 parishes. Enforced segregation is not attempted in Spain,
and the overwhelming majority of lepers in that country live among
the general population without restraint. A leprosorium exists at
Granada, and another (with accommodation for 40 inmates) at
Seville, and it may consequently be assumed that the disease is
common in the southern provinces, of which these are the principal
towns. The existence of leprosy in Spain has been attributed to
importation of the infection some fifty years ago from the Philippine
Islands. In Portugal the provinces of Beira, Algarve, and Estremadura all contain lepers. One observer has reported details of
466 cases of the disease in this country 2 , but many more are
believed to exist.
In Italy there are said to be a considerable number of scattered
foci of leprosy. Lepers are not infrequently met with in the
Italian Riviera, particularly in the neighbourhood of San R e m o ;
at Turin 13 Piedmontese suffering from the disease have been
seen since 1890; in the neighbourhood of Naples 15 leprous
families were known to be living some years ago; and in 1886
eighteen lepers were counted by one observer at Albertello in
Apulia. There is reason to believe that the disease is increasing
in Italy. Up to 1891 the annual recorded deaths from leprosy
in that country had diminished, as the following figures show3.
In 1887 the recorded deaths from leprosy were 22 and the
1
3

2
Fagerlund.
Falcao.
Annuario Statistico Italiano, 1898.

LEPROSY

211

ratio per million inhabitants was 0*7; in 1888 the deaths and ratio
were respectively 15 and 0*5; in 1889, 10 and 0*3; in 1890, 7
and 0*2; while in 1891 only a single death from leprosy was
registered. But in the succeeding years the corresponding figures
have been as follows: in 1892, 4 and o*i ; in 1893, 3 and o*i;
in 1894, 5 and 0*2; in 1895, 8 and 0*3; and in 1896, as many as
17 persons died in Italy from leprosy, or o'6 per million inhabitants. There is said to be an entire absence of precautionary
measures against the spread of the disease on the part of the
people.
The countries of the Balkan peninsula are also considerably
tainted with leprosy.
Ehlers, who a few years ago made a
personal investigation into its distribution in this part of Europe,
has published the following facts1. Roumania is the only Balkan
State which issues trustworthy statistics, and in that country,
according to the most recent reports, there were 208 lepers. In
Servia, on the other hand, only three cases have been recorded 2 ,
and the same number are said to exist in Bulgaria. It is almost
certain, however, that the disease is much more widely prevalent
in these countries than these figures would imply. The same remark
also applies to the official return of 133 cases of the disease in
Bosnia and Herzegovina. In Montenegro it has been estimated
that about 100 persons, out of a population of 227,000, are afflicted
with the malady. In Turkey leprosy is common enough ; in Constantinople alone von During counted 258 lepers, and estimated
their total numbers at between 500 and 600. The disease is
particularly common among the Spanish Jews living in this city.
There is a leprosorium at Scutari, which contained some 35
patients in 1897 and 30 in October, 1902. There are a few lepers
also on Mount Athos, the mountain of the monks, in the y^gean Sea.
In Greece the number of persons affected by the disease is
known with no greater certainty than in the other countries just
mentioned, one recent estimate placing it as low as 99, and
another at between 400 and 500. It is probable that the truth
lies between the two extremes, but Prof. Hadji Michali of Athens
does not think it can exceed 200.
In some of the outlying islands in the neighbourhood of
the continent of Europe leprosy has not only been endemic
1
2

Bulletin de la Soc. Frang. de Dermal, et Syphilog.
Lazarewitch (Belgrade).

Juin, 1897.
14—2

212

LEPROSY

for a very long period, but it has shown far less tendency to
diminish here than it has on the continent itself. Thus Iceland
has been an important centre of the disease at least since the
thirteenth century, and it would appear that the number of lepers
in the island, though less than in medieval times, is increasing
rather than decreasing. Ehlers, who visited Iceland in 1889 and
again in 1895, found that the number of affected persons was at
least three times as great as the official records implied 1 . Thus
in 1889, while the official returns mentioned 47 cases only, he
himself counted without any special search as many as 144. Six
years later 15 additional cases were seen, bringing the known
number up to 159 ; and it was believed that the true number of
lepers in the island was probably about 200. Four miserable
leper asylums which existed before 1848 were abolished in that
year, as the disease was thought to be declining, but the diminution, which was apparently due to the violent epidemic of
measles which in 1846 carried off one-third of the whole population, was only temporary, and, as pointed out above, the
number of lepers in Iceland is now increasing. In the year 1895
a law enforcing segregation of lepers in their own homes was
passed. Recently (1898) a new law has been enacted providing
for the compulsory notification of every fresh case, and a new
hospital has been constructed at Reykjavik for the segregation of
at least a certain number of lepers.
In the Faroe Islands leprosy is extinct, and has been so since
the middle of the eighteenth century. The fact is a remarkable
one, for the diet of the inhabitants of these islands and of the
Icelanders is said to be precisely the same, while in regard to
climate and conditions of life the differences, if any, should be
rather more favourable to the prevalence of the disease in the
Faroes than in the more northerly island. In the Shetland and
other islands to the north of Scotland leprosy has also for long
been non-existent.
Many islands in the Mediterranean are endemic homes of the
disease. It exists in the Balearic Isles. Corsica and Sardinia are
both affected by it. In Sicily 153 cases of leprosy were reported
in the year 1888, but it was believed that this figure was far below
the truth. In Elba, Malta, and Gozo leprosy is far from un1
Prize Essays on Leprosy. New Sydenham Society, Vol. CLVii, 1895.
" On the Conditions under which Leprosy has declined in Iceland."

LEPROSY

213

common. In Malta it was the cause of six deaths in the year
1898. Crete contains a large number of lepers 1 , and it is believed that the recent disturbances in that unfortunate island led
to an increase of the disease there and a diffusion of it to
adjoining countries, particularly Greece. Thus Ehlers himself
saw, in Athens and the Piraeus, 26 cases of leprosy in fugitives
from Crete immediately before the outbreak of the Greco-Turkish
war. In Cyprus lepers are also numerous, and they are apparently
increasing, for in 1889 the number'segregated on land set apart
for the purpose near Nicosia was 63, and this had increased to 65
in 1890, and 74 in 1891.
Asia. In Asiatic Turkey leprosy is a common disease. It is
widely spread in Mesopotamia, Syria, and Asia Minor. One
estimate of the number of lepers in Asia Minor has placed them
at one per thousand of the whole population 2 . In Persia the
disease is endemic, but is—or was thirty years ago—confined to
certain districts of the hill country of Irak Ajemi, in the provinces
of Azerbijan and Khuzistan, and particularly in the localities of
Chamse, Kaswin, Sendjan, and Karadagh 3 . It is said to be
absent from the Persian shores of the Caspian, although, as
already pointed out, it is certainly met with in the Russian
provinces bordering upon that sea. Leprosy exists to some
extent in Arabia, and particularly at Muskat.
The prevalence of the disease in Asiatic Russia has been
briefly described above, and it is unnecessary to repeat what has
been said concerning its distribution in the immense areas of the
Asiatic continent which form part of the Empire of the Tsar.
It may, however, be added that the peninsula of Kamchatka
forms an important centre of leprosy, and that some of the
indigenous tribes of Eastern Siberia, such as the Yakuts, are said
to be afflicted with the disease to a very serious extent. Bokhara
also contains a large number of lepers, particularly in the neighbourhood of Sharshaouz and Kitab. Near the first-named place
are two kis/i/aks, or settlements, set aside for these unfortunate
persons. Lepers in Bokhara are avoided by other people, who
regard the disease as a scourge imposed by the Divinity as a
punishment for grievous sins. All persons suffering from it are
1
Ehlers and Cahnheim reckoned their number in 1901 at about 600 in
a population of 280,000. The Greeks rather than the Mohammedans suffer.
2
8
Von During.
Hirsch.

LEPROSY

214

sent to one of the leper kishlaks^ where apparently their sole or
main means of sustenance consists of such alms as they can
obtain on bazaar days, when they are allowed to visit the principal towns to beg from the charitable *.
In Chinese Turkestan leprosy is believed to be rare or absent,
neither the Chinese, Kirghiz, Mongols, nor Manchus suffering
from it. The Turkomans and others in the plains and desert
oases of the north seem to be free from the disease, but south
of the Celestial Mountains it is not uncommon 2 .
India has from time immemorial been one of the principal
centres of leprosy in Asia. At the present day the disease is
common throughout the greater part of the peninsula. Its distribution, however, is far from even, and while there are areas
almost free from its ravages, there are others where it is among the
most prominent of diseases. It is particularly prevalent in what
has been called the middle belt of the Himalayas, and the native
tribes in the Simla division are said to surfer from the disease to a
greater extent than the inhabitants of any other part of India 3 .
Kangra, Kulu, and the native States of Mundi, Suket, Bilaspur,
Sirmore, Chamba and others also contain a large number of lepers.
It is believed to be increasing here ; and it is noteworthy that no
caste or religion appears to be more susceptible than any other.
In Kashmir, according to the census of 1890, the number of
lepers was 202 4 . For some unexplained reason the real Kashmiris
are said to be comparatively exempt from the disease, and a
considerable portion of the lepers in Kashmir are natives of the
Punjab who flock to the cooler country in the hot season, when
the disease becomes more troublesome. The Gujurs, a tribe of
cowherds living on the Himalayan slopes, are said to surfer greatly
from leprosy. In other parts of India the malady is common,
but is apparently decreasing, the number of lepers returned in the
census of 1891 being below that of 1881. The highest ratios in
1891 were found in certain districts of Bengal (e.g. Bankura, and
Birbhum), in the Simla district, in Dehra Dun, in Kumaon and
in some others. The members of the Indian Leprosy Commission
(1890-91) found that the disease prevailed mostly inland, and
1
2
s
4

Grekof.
Raemdonck. Report of Leprosy Conference in Berlin, 1897.
Carleton. Transactions of the First Indian Medical Congi-ess.
Mitra. Ibid.

LEPROSY

215

away from the great rivers, and that the lowest ratios were those
in the Gangetic valley, in tbe Doabs, and along the west coast
from Karachi to Ahmedabad.
In Ceylon leprosy is far from uncommon. The leper asylum
at Hendala admitted 108 fresh patients in the year 1897, which
with 246 remaining over from the previous year made the total
number of leper inmates 354.
In the Malay Peninsula lepers are very frequently met with.
No trustworthy statistics as to their numbers are available, but it
has been pointed out that certain unwritten social rules and the
knowledge of the disease possessed by the natives, even by those in
the most secluded spots, indicate a wide prevalence of the disorder.
The Malays themselves suffer from it, but not to the same extent
as the Chinese immigrants who have settled in the peninsula.
Cantlie has strongly urged the view that throughout Indo-China,
the Malay Peninsula, and the East Indian islands, leprosy has
been introduced and maintained principally, if not solely, by the
immigrant Chinese.
"The Chinese," he writes, "mix very little with any but their own
people, and though leprosy is undoubtedly endemic in some parts of
the Straits its comparative rarity among the Malays is hard to account
for except on the theory that the Chinese introduced it, and by their
exclusive habits have not spread it as widely as they might otherwise
have done.
" To look at the matter from another point of view, the Malays and
the aborigines seem comparatively free from the scourge, yet the
Sandwich Islanders, their relations in blood, are the most leprous
people on earth. How can this anomaly be accounted for? It may
be, though it us only a suggestion, because the habits of the Malays
and Hawaiians are so different. The Malay is a born rover, he is
always coming into contact with other people, and his constitution is
inured to change. The Hawaiian on the other hand is an isolated
being who till less than one hundred years ago never saw a soul of his
own race. Such isolated communities are always prone to new
diseases, as we see even on the little island of St Kilda, and hence the
Hawaiian constitution was more fitted for the reception of leprosy than
that of the Malay1."
There can be little question that, whether the disease is mainly
1
Prize Essays on Leprosy. " Report on the Conditions under which
Leprosy occurs in China etc." New Sydenham Society. 1897.

2l6

LEPROSY

or solely maintained in these regions by the Chinese or not, it is
a comparatively common disease in the Straits Settlements. In
the hospitals at Singapore 65 fresh cases of leprosy were admitted
in the year 1898, and 26 lepers died. In that at Penang 81 fresh
cases were admitted, and in the leper asylum at Pulo Jerejak, in
Province Wellesley, the number of fresh cases in the same year
was 180. In Perak leprosy is widely prevalent both among
Malays and Chinese, but the aboriginal race of Sakais are not
known to suffer from it. The same immunity appears to be
shared by another aboriginal tribe, the Jakuns, in Johore, for,
though leprosy is said to occur amongst them, Wilson, who
repeatedly visited them, never succeeded in seeing a case. In
Johore the Chinese suffer more than the Malays. In Muar
leprosy is not uncommon, and here the Chinese also suffer most,
the Malays being rarely affected, while concerning the aboriginal
races no evidence is forthcoming. At Sungei-Ujong, where the
disease is rare, only the Chinese are affected and the Malays
escape it entirely.
In Siam leprosy is said to be rife in parts, and even to prevail
to an alarming extent. There are no leper establishments, at any
rate in southern Siam, and " every hamlet has its leper and every
village or town its leper quarter." In the Laos country, too,
leprosy is a very common disorder.
Among the Annamites of Cochin China the disease is widely
prevalent. Segregation is extensively practised, indicating perhaps
a prolonged acquaintance with the malady, though whether the
measure is successful in checking its spread does not appear.
Leprosy is found equally in the mountains and the plains of
Cochin China.
In the islands of the East Indies this disorder appears to behave very much as it does in the adjoining Malay peninsula. In
Sumatra it is common, particularly on the north-east coast, where
about 1000 lepers are believed to be in existence, the number
on the south-west coast being only 156. The native Malays on the
coast are said to be little affected, and the principal sufferers
here, as throughout the Far East, are the Chinese. There "is a
leprosorium at Medan, near Dili, on the north-east coast, for the
segregation of coolies from the plantations. In the interior of the
island there is said to be much leprosy among the Battaks, and
also among the Tamil immigrants from Madras, as well as among

LEPROSY

217

the Javanese and Chinese. More than one per cent, of the
Chinese are said to be lepers 1 .
In Java the disease is possibly less common; one observer 2 ,
at least, never saw a case there. On the other hand Albricht, a
Dutch physician, is quoted as saying that it is rife in the island,
and particularly in the plains 3 , and he is supported by Broes van
Dort, who states that the central part of the island contains from
30 to s& lepers, the western portion 42, and the eastern portion
the large number of 2703. The latter axids that the disease
has assumed dangerous proportions since the Dutch introduced
European civilisation, as formerly the natives killed all persons
attacked by leprosy or exposed them to die of starvation.
In the Molucca or Spice Islands, lying close to the equator,
leprosy is very prevalent, especially at Amboina and Ternate.
Borneo appears to be almost, if not quite free from the
disease 4 . In 1888 there were said to be no lepers in the island,
Hut in the next two or three years several cases developed among
Chinese immigrants, who were imported in large numbers from
the Kwangtung and Fokien provinces of China (the "cradle of
leprosy" in the East) to work on the newly-opened tobacco
estates. Later, coolies were imported from Singapore, Java, and
Sumatra. In 1890 the first case of the disease was reported, and
a palm-mat shed was built on an island to receive lepers. It
never contained more than ten inmates, all of whom, except one
Portuguese convict, were from southern China. In 1893 the
lepers were all deported and since then the north of the island
has apparently been free. Leprosy is also believed to be absent
from the south of the island.
The distribution of leprosy in the Chinese Empire is a matter
of great interest. It has been studied fully by Cantlie, from
whose essay the following facts are in the main gathered. In
Manchuria the disease is said to be unknown as an endemic, the
few cases met with occurring in Chinese from the south. It is
also said not to exist in Peking 5 although that city is full of
Manchus, Tatars and other Mongolian tribes, in addition to
Chinese proper; and on these grounds it is believed to be absent
1
2
4
5

Martin. Archives de Mdd. Navale, June, 1899.
3
Kohlbriigge.
Quoted by Cantlie.
Skertchley. (Addendum to Cantlie's Prize Essay.)
Dudgeon, quoted by Cantlie.

218

LEPROSY

from the province of Chih-li, in which Peking is situated. It can
scarcely escape notice, however, that these are very slender
grounds upon which to base a negative conclusion as to its
presence in northern China. The author quoted has adduced,
in support of this view, the case of Eastern Siberia and Sakhalin,
which, he concludes, from the absence of the malady in Vladivostok and at the mouth of the Amur, are also free from it.
It has already been pointed out above that, as regards Siberia,
leprosy is endemic throughout the whole of the eastern portion of
this great territory, and though it appears to be absent from the
island of Sakhalin—for many years past a place of exile for
Russian criminals—it is not uncommon, as will be shown later, in
Corea, which is much nearer these northern Chinese provinces
than Sakhalin. It must therefore be taken, at present, as not
quite proven that leprosy is entirely absent from these provinces.
Raemdonck, however, quotes the statement of missionaries that
neither the Chinese nor Mongolians are affected by leprosy in
Mongolia.
,
In the province of Shantung, on the Yellow Sea, one or two
lepers are said to be met with in every village, at any rate in
the neighbourhood of Wei-hsien. In the coast provinces immediately to the south, however, namely those of Kiang-su and
Chekiang, leprosy is believed to be not indigenous, and is only met
with very rarely, if at all. It is believed also to be unknown along
the course of the great Yangtze-kiang, as otherwise lepers from
there would come for treatment to Shanghai, yet, according to
Jamieson, the disease is " t h e rarest of rarities" in this city.
In the inland province of Hu-peh leprosy is known, but is no
great scourge; it is at any rate rare in Hankow, and has not of
recent years been mentioned in medical reports from Ichang. In
the adjoining province to the west, that of Sze-chuen, it is also
rare, occurring only in the Chinese and not in the aboriginal Lolos.
Returning to the coast, a change is found south of the province
of Chekiang, and in the two south-eastern coast provinces of
Fokien and Kwangtung leprosy is exceedingly common.
It
would seem that for a distance of about one thousand miles—
between Chifu and Foochow—the coast of China is free from
leprosy; that it exists to the north of this area, and to a limited
extent in the inland provinces in the same latitude, and that it
suddenly becomes widely prevalent as the coast winds round from

LEPROSY

219

east to south. The two provinces named, those of Fokien and
Kwangtung, are described as the cradle of the disease in China,
and the source whence it has spread to many other countries and
islands in the Far East. In both it is rife; in Amoy, in Canton,
Fatshan, Swatow, Pakhoi, Hongkong, and Macao—everywhere it
is described as prevalent.
The island of Hainan, off the south, coast, contains many
lepers, but only among the Chinese, who dwell on the shores.
The aborigines, of mixed Mongolian and Caucasian race,
allied to the Laos of North Siam, are believed to escape. In
Yunnan, an inland province west of Kwangtung, leprosy is also
said to be not rare 1 . Concerning its existence in the remaining
provinces of China little appears to be known.
In Corea the disease is present in the south, but is said to
diminish towards the north, and to be no great scourge in any
part of the peninsula 2 . In and around Fusan it prevails to a considerable extent, twenty cases having been seen in ten months.
At Gensan no cases were seen during fifteen months. In Se'oul
one observer saw only two cases in eighteen months, while-another
met with a considerable number of lepers there 3 .
Japan must be regarded as one of the principal homes of
leprosy in the east. The number of lepers in the Empire has been
estimated at from 75,000 to ioo,ooo 4 . The disease is said to be
twice as prevalent in the southern as in the northern provinces,
for while in the latter the number affected varies between 100
and 600 in each, in the former there are from 500 to 1200, and in
the province of Kumamoto alone as many as 2473 lepers were
recently said to be in existence. In Japan the mountainous
regions are, it is stated, more affected than the coast, and the
temples at Narita and Minobu are much visited- by lepers. The
Japanese believe leprosy to be a punishment for sins, and the unfortunate lepers flock to the holy hills and wander from one shrine
to the other as an act of expiation. In Japan generally the disease
is said to be very rare among the rich noble class of the population,
1
Michoud. Medical Reports of the. Chinese Imperial Mariti??ie Ctistoms.
No. 48.
2
Cantlie.
'6
Chinese Customs Medical Reports, No. 48 and No. 42.
4
Ashmead. Janus, 1899, p. 71. This figure is perhaps an exaggeration;
the official statistics of the Sanitary Bureau of the Japanese Home Office
returned the total number of lepers in the kingdom at only 23,647, in
September, 1897.

220

LEPROSY

who suffer from tuberculosis more than any other malady; to be
more frequent among the great middle class, whose principal
disease, however, is syphilis; and to be specially rife among the
outcast element of the population, who suffer from leprosy more
than any other disease 1 . The Ainus of northern Japan and the
Kurile Islands are said to be entirely free from the disease.
In Formosa the disease is common, particularly in the
cultivated portions of the north of the island 2 . In some villages
the number of lepers is said to be very large. Here again, just as
in the Malay Peninsula and in China, the aborigines—the
Pepohoans—are free from the disease, notwithstanding the fact
that they have been brought in contact with the Chinese, the
principal sufferers, for over two centuries. In the south of the
island leprosy is said to be comparatively rare.
The principal seat of leprosy in the Philippine Islands appears
to be in the neighbourhood of Manila, where a hospital of 180
beds, built in 1577 and rebuilt in 1774, is devoted to the treatment
of lepers.
Australasia.
In New Guinea leprosy occurs sporadically
in many parts of the island.
In the Pacific Islands, with the exception of the Hawaii group,
leprosy has gained but little hold. This exception is, however,
an extremely important one, and the Hawaii or Sandwich Isles
have of recent years become one of the principal centres of the
disorder.
Before 1848 the latter was, it is believed, unknown
in the islands, but in that year the discovery of gold in California
and consequent demand for coolie labour led to a great migration
of Chinese across the Pacific from west to east. By 1856 Hawaii
was in constant communication with California and China, and
had become a centre of trade, and it was about this time that
leprosy first appeared. The spread of the disease was extraordinarily rapid, and by 1882 some 2000 persons, or five per cent,
of the native population, were believed to be lepers. In 1865 the
leper settlement on Molokai was established, and between that
date and 1899 a total of 5125 lepers have been sent thither.
Apparently most of the Hawaiian islands are affected, but the
disease is worse in some than in others 3 .
1

Archives of Surgery, 1898, p . 380.
Rennie. Chinese Customs Med. Reports, N o . 45.
3
At the present time the disease appears to be slowly but
diminishing in Hawaii.
2

steadily

LEPROSY

221

New Caledonia is reported to be passing through an almost
equally severe experience, and leprosy is widely spread among
the natives. The numbers are variously estimated at from 1500
to 4000. A few are isolated at Belep. At Tahiti the disease has
committed great ravages.
In New Britain and in the New Hebrides, on the other hand,
leprosy is said to be unknown. The title of Leper Island attached
to one of the latter group of islands is therefore a misnomer. In
Fiji the disease is described as being very common.
In Australia 1 leprosy appeared in the latter half of the 19th
century; its introduction was probably brought about by the
immigration of Chinese in the early days of the discovery of gold.
In Victoria the disease has been practically confined to a score or
so of cases among the Chinese inhabitants. In New South Wales,
however, where some 70 cases have occurred since 1859, many
natives who have never left the country have suffered, while
rather fewer Chinese have been attacked here than in the other
Colonies2. In Queensland a considerable number of lepers both
of Chinese and other nationality have been recorded in recent
years. South Australia appears to have escaped the disease
entirely; but in the Northern Territory a small number of cases,
mostly of Chinese, have been seen and dealt with. In West
Australia only two lepers, both Chinese, had been met with up to
1897. Tasmania has remained free throughout. A table for the
whole of Australia shows a general increase of recorded cases since
1877, and an apparent increase, in New South Wales and Queensland, since special legislation for lepers was adopted.
It is
believed that more perfect registering and the greater attention
paid to the disease account for this apparent increase.
In New Zealand leprosy is said to be endemic among the
Maories, but the exact extent of it is unknown.
Africa. The malady has apparently been introduced to Algeria
from Spain. Between 1884 and 1897 nearly sixty lepers were traced
1
Prize Essays on Leprosy. " The Epidemiology of Leprosy in Australia."
By J. Ashburton Thompson, M.D., New Sydenham Society. London, 1897.
2
On January 1st, 1896, 37 lepers were under treatment in the lazaret at
Little Bay; 3 fresh cases were admitted in the year, 5 died, and 19 out of 20
Chinese patients were returned to China. On December 31st only 16 cases
remained. On December 31st, 1898, this number had fallen to 14. From
1883 to 1898, 18 whites, born in New South Wales but of European descent,
were admitted to hospital, and 33 Chinese.

222

LEPROSY

in Algiers, of whom 24 were Spaniards, 2 French, 2 Italians, and
1 Maltese; while 27 were natives, 8 being Algerian Jews and 19
Mussulmans. The Spaniards came from the provinces of Alicante
and Valentia, where, as stated above, the disease is very prevalent.
In Tunis and Morocco leprosy is said to be endemic, and in Egypt
it is common, especially in Upper Egypt and the Delta. It is also
far from rare in Abyssinia, especially in the mountains of Samen
and on the shores of Lake Tsana.
In East Africa leprosy is common, extending apparently along
the greater part of the coast from north to south. In British East
Africa, between Lake Victoria Nyanza and the sea, it is said to be
very common, particularly the nervous form of the disease 1 . In
German East Africa, somewhat further south, leprosy is more
frequently seen round the great lakes than it is on the coast, and
it is particularly common on certain islands in the Victoria Nyanza
Lake. In the Congo Free State it is apparently rare 2 .
On the West Coast of Africa it is not common. It is unknown in the Cameroons 3 and at the mouths of the Niger. It
exists, however, on the Gold Coast, in Sierra Leone, and in Senegambia. One observer (Jonkin) did not meet with it on the
coast between Sierra Leone and Old Calabar, while he found it
was fairly common about the Upper Niger and Benue rivers. It
must, however, be far from rare upon the coast, for at Lagos
numbers of lepers are seen, and as many as 99 cases of the disease
were treated in the contagious diseases hospital there in the year
1898. Jonkin 4 describes an inland endemic area of leprosy as
extending some 500 miles westward of Lake Tchad, and beyond
the waters of the Upper Niger; the town of Kano is the great
centre of the disease. North of this leprosy holds its own to the
southern fringes of the Sahara, but there is no reliable information
as to its presence in any of the desert towns or oases.
The disorder has long been endemic in South Africa5. It
1

Kobb, Beitrdge zn einer geographischen Pathologie Britisch-Ost-Afrikas.
Giessen, 1897.
2
Congres Nat. d* Hygiene... de la Belgique et dit Congo; Comptes Rendus.
Bayet says it is known, but not common, in the Congo Free State, and is
mostly seen on the Lower Congo.
3
A. Plehn. Janus, 1896-7, p. 383.
4
Report of Conference on Leprosy in Berlin, 1897.
5
Prize Essays on Leprosy. " Leprosy in South Africa," S. P. Impey, M. D.,
New Sydenham Society.

LEPROSY

223

existed in Cape Colony before the advent of the white man, and
appears to have been brought from the north. , It affected to a
considerable extent the Hottentots and to a somewhat less extent
the Bantu, or Kafir races. It is uncertain whether the Bushmen
suffered. In 1845 the well-known leper asylum on Robben Island
was established, and between that date and 1894 the number of
lepers admitted to it was 1697 \ These were not all drawn, however,
from Cape Colony, as by an arrangement with the other colonies,
and with other States, lepers from a wide area in Southern Africa
are sent to this place.
In Basutoland leprosy was probably introduced after the great
Basuto war of 1835; in 1894 some 256 lepers were believed to
exist. In the area recently known as the Orange Free State
it has increased pari passu with its increase in Cape Colony, and
in 1894 the lepers here numbered some 150. Griqualand East
and the Transkeian territory are more seriously affected by the
disease. The Griquas are half-breeds of Hottentot race; in
1863 they removed for political reasons on a long and tedious
trek from (what became) the Orange Free State and Griqualand
West. Leprosy spread in the course of their journey, and over
500 lepers were believed to be living among them in 1894.
In the area recently under the rule of the Transvaal Republic
many natives were known, to be suffering from the disease before
the late war. The exact number was uncertain. A small leper
hospital for about 20 patients existed in Pretoria. In the colony
of Natal the number of lepers increased from two in 1843 to over
100 in 1886, and to over 200 in 1894 ; the malady has spread
from kraal to kraal and from tribe to tribe until no tribe is free
from it. It is, however, confined to the blacks in Natal. In
British Bechuanaland it is very rare, and this is ascribed to the
dryness of the climate and the sparseness of the population 2 .
In Pondoland there are no lepers, the chiefs rigorously excluding,
under pain of death, all affected persons. In Zululand and Swaziland the disease is known to exist, but accurate information in
1
On January 1st, 1898, 532 lepers were under treatment at the asylum; on
January 1st, 1899, the number had increased to 560. In the leper asylum at
Emjanyama on the same dates the corresponding figures were 182 and 255
respectively.
2
The rarity of leprosy in Bechuanaland may nevertheless be doubted. In
the Vryburg district it is said to be very common in the large native locations.
(Cape of Good Hope, Reports on the Public Health for the year 1898.)

224

LEPROSY

regard to its prevalence is not available; it is probably not increasing, because the natives are believed to put to death or to
ostracise all persons suffering from it. In Mashonaland lepers
are not frequently seen.
The number of lepers in South Africa was estimated in 1894
at 1750, distributed as follows: Cape Colony, 600; Griqualand
East, 250; Transkei, 357; Basutoland, 250; Bechuanaland, 10;
Natal, 200 ; Orange Free State, 150; Transvaal, 30. It is probable
that these figures are considerably below the truth.
In many of the islands adjoining the continent of Africa
leprosy is known. In the Canary Islands there are a considerable
number of lepers, and the asylum at Las Palmas is said to draw
its inmates from each of the seven islands in the group. In
Madeira leprosy is also met with, and there is a leper hospital of
ancient date.
In Madagascar the malady is endemic and is said to be
spreading since the old laws of isolation were relaxed. In Mauritius and Rodriguez it is also endemic, attacking all the various
races living there, but especially the coloured Creoles. It is also
met with in the Seychelles.
North and Central America. Throughout the continent of
North America, from north to south, leprosy exists, mostly in the
form of scattered cases, but here and there, particularly as the
tropics are approached, it is much more common.
In Canada only some 32 lepers were believed to be living in
1894; but they may have increased since 1 . The majority of these
(21) were in Tracadie, on the southern shore of the province of
New Brunswick, where a leper asylum has been built. The
inhabitants of this shore are mostly of French origin, some
coming from Acadia and some from the province of Quebec.
Leprosy has existed here since the year 1815, and since that year
167 deaths from the disease have been recorded. The number
of cases is unknown. On Cape Breton Island it has almost
disappeared, only two cases remaining in 1894.
In British
Columbia 8 lepers, all of them Chinese, were isolated at the
Darcy Island asylum in 1897. In Manitoba 3 lepers, all from
Iceland, are, or were recently, living in the province of Winnipeg 2 .
1
Prof. J. C. Graham. Transactions of the Congress of American Physicians
and Surgeons. Washington, 1894.
2
Annual Report of the Provincial Board of Health of Ontario for 1897.

LEPROSY

225

In Canada generally the few cases of leprosy which exist can
be traced to importation by foreigners, and there seems little
tendency for the disease to become domiciled or to increase. It
has, however, lingered for a long period on the shores of New
Brunswick, and the Icelander lepers in Winnipeg may yet prove
to be a danger 1 .
In the United States leprosy is also to some extent an exotic;
it is comparatively uncommon and shows no great tendency to
increase. It is, however, widely spread throughout the various
States. The regulations as to the treatment of lepers vary in the
different States, but in none does there appear to be an accurate
record of the number of affected persons existing at the present
time. The following is an estimate made in 1894 of the number
of lepers "heretofore recognised" in the States:—Arkansas, 3 ;
California, 158; Dakota, 2 ; Florida, 6 ; Georgia, 1; Idaho, 2 ;
Illinois, 1 3 ; Indiana, 2 ; Iowa, 20; Louisiana, S^; Maryland, 4;
Massachusetts, 5; Minnesota, 120; Missouri, 2; Mississippi, 2;
New York, 100; New Jersey, 1; Oregon, 3 ; Pennsylvania, 6 ;
Utah, 3 ; Wisconsin, 20. This gives a total of 560, spread over
a considerable number of years 2 . It must be noted, however, that
this figure is probably much below the truth. Thus Osier quotes
Dyer as stating that on January 12, 1898, he knew of 124 positive
living cases in Louisiana alone, including 25 in the Leper Home
in Iberville parish. The same authority added that it was justifiable to estimate the number of lepers in the State of Louisiana as
between 300 and 500.
There appears to be nothing very characteristic in the geographical distribution of the above cases in the United States. In a
group of States, however, in the north of the Republic, the numbers
are said to illustrate the tide of settlement of Scandinavians in
transit from New York to a country and climate resembling those
of Scandinavia. In these (Minnesota, Wisconsin, and Iowa)«
170 lepers are said to have immigrated from Norway 3 , but only
30 now remain. It would seem that in the United States, as in
1
If they have not already done so. I n 1897 four cases of leprosy were
discovered in Manitoba (1 in the North-West Territories, 2 in Winnipeg,
and 1 in Selkirk). Whether these four cases included the three cases mentioned in the Ontario Report I am unable to say. Report of the Provincial
Boa? d of Health of Manitoba for 1897.
- Nevins H y d e . Transactions of the Congress of American Physicians; etc.
:j
Armauer Hansen.

C.

15

226

LEPROSY

Canada, the disease tends to diminish rather than increase after
its importation by immigrants. At present the larger number of
lepers in the country appear to be in Louisiana and California.
Leprosy also exists in Mexico, and some thirty cases are usually
under treatment at the lazaretto in the City of Mexico. The
disease has been known here since the time of Cortes, but the
authorities believe that it is not extending. It is most frequent
in the State of Sinaloa on the west coast, and in Durango to
the east of it; it is also common in Guanajuato and Jalisko and
in Guerrero on the northern frontier. In Guatemala and Salvador
scattered cases of the disease are met with. In British Llonduras
the disease is also known: 3 cases were treated at the Public
Hospital, Belize, in 1898, and 1 at the Corosal Hospital. In
Nicaragua and in the mountain regions of Costa Rica it exists in
sparsely scattered cases. Lepers are also seen in Panama, but
the numbers are unknown.
In the islands off the continent of North America leprosy is
much more common than on the mainland. In the West Indies
the number of lepers is large and is apparently increasing. It
is endemic in Cuba, and in Havana is a leper asylum for some
eighty patients.. Many hundreds of leprous persons are, however,
believed to be living in that city, or were before the war, and are
(or were) under no sanitary control whatever. Nevins Hyde
estimated the number of lepers in Cuba in 1894 at between 300
and 500, but now there are probably more. In Haiti the
disease is very widely spread, and also in Jamaica, where during
the past twenty years the average new admissions to the leper
asylum have been thirty per annum, rising in some years to
forty, and sinking in others to fifteen. In the Bahamas some
15 or 16 fresh cases come into hospital each year. The Lesser
Antilles are also more or less seriously affected by the disease. In
Guadeloupe and Martinique one person in 860 is said to be a
leper, in St Christopher the disorder is rife, while in Montserrat,
Grenada, and Dominique it is rare. In Trinidad it is increasing;
233 lepers were interned at the asylum there at the end of
1897, and 265 at the end of 1898. . In the Danish Antilles there
were in 1896 22 lepers at St Thomas, 82 (4 per 1000 of the
population) at Ste Croix, but none at St Jean. The lepers were
all of the negro or mixed races. There is a leper asylum at
Ste Croix. In St Lucia, in Antigua, and in St Vincent cases are

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227

dealt with every year; in the latter island 19 lepers were in the
asylum in 1896. In Barbados the disease must be common and
increasing, for in 1898 the daily average number of lepers resident
in the lazaretto throughout the year was 114; in 1897 it had
been i n , and in 1896 only 107. A few cases of the disease are
known to exist in Puerto Rico. In the Virgin Islands leprosy is
said to be rare.
In the Bermudas, lying alone in the Atlantic Ocean, a fewr
cases of leprosy have been under observation for a considerable
period; at the beginning of 1898 they were twelve in number, at
the end of that year they were ten.
South America. Along the north coast of South America
the malady is far from uncommon. In Venezuela many cases
are seen. In British Guiana leper asylums exist at Mahaica and
Gorchum, and in the former, in 1898, 99 fresh cases were admitted
in addition to 374 patients in the wards at the beginning of the
year. As the corresponding number at the beginning of 1895
was only 359 it seems that the disease is increasing. In French
Guiana, where it is thought to have been imported by slave boats,
one-tenth of the population are believed to be leprous; the Red
Skins here are said to escape. In Surinam (Dutch Guiana) from
500 to 2000 lepers are believed to be living. Colombia is seriously
ravaged by the disease; the number of lepers here is said to have
increased, in forty years, from 400 to over 27,000. In 1898 only
841 out of this large number of affected persons were segregated,
in three asylums, at Agua de Dios, Contratacion, and Cano de
Soro.
Along the west coast of South America leprosy is believed to
be rare. Occasional cases have been seen in Peru. Of the
prevalence of the disease in Ecuador, Bolivia, and Chile little
appears to be known.
The whole coast of the Brazils is said to be affected. The
last census of the country gave a return of some 5000 lepers,
but there are thought to be about twice this number. The disease
is specially prevalent in the states of Para, Pernambuco, Bahia,
Minas Geraes, Matto Grosso, Rio de Janeiro, and Sao Paulo.
In Uruguay, on the other hand, leprosy appears to be rare.
In the Argentine Republic lepers have been admitted to a
hospital at Buenos Aires since 1892. In that year 5 cases were
admitted, 12 in 1893, and 15 in 1894. The disease is said to
15— 2

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LEPROSY

be increasing in the interior of the country, and to prevail especially
in Corrientes, Entre-Rios, Cordoba, and Buenos Aires.

Factors determining the Geographical Distribution
of L e p r o s y . The present geographical distribution of leprosy
is to a great extent a legacy of the past, to a less extent the result
of forces and conditions now acting. In the Old World it has
remained, almost from time immemorial, in many countries, such
for example as India, Syria, the Levant, and probably in China;
while in others, as for example the greater part of Europe, it has
to a great extent disappeared, leaving behind it a few isolated
centres of the disease—such as in Iceland and in Spain, in the
Balkan countries and on the coast of Norway.
Whatever may ultimately prove to be the truth as to the contagiousness of the disease there is no question that leprosy'can be
transported from one country to another. It has been so introduced in recent times into Algeria from Spain; it was, it is
believed, imported into Spain from the Philippine Islands; it has
been on several occasions imported into the United States from
Norway; and it has been carried to Manitoba in Canada from
Iceland.
Within the past half-century it has been introduced into some
of the Pacific Islands, such as Hawaii and New Caledonia, with
the most disastrous results; and in the south-eastern portion of
Asia, in the East Indies, and in Australia, it has been mainly,
perhaps solely, distributed by the movements of Chinese from
the endemic centres of leprosy in China. In the distant past the
examples of the carriage of leprosy from one country to another
by the movements of affected persons were no less striking.
Climate, soil, elevation, and similar general conditions appear
to have but little influence on the distribution of the disease. It is
almost as common in semi-arctic Iceland as in tropical Ceylon;
and it is as rife in some of the elevated Himalayan tracts as in the
plains of India. It shows, however, a certain tendency to prevail
along the coasts of seas and lakes and rivers. The tendency is
not absolute, and there are many places in India, in Russia, in
Central Africa and elsewhere, where leprosy shows no definite
relation of this nature, and where, on the contrary, the disease is
commoner inland than on the coast. On the whole it would
seem that it is rather in local than in general conditions that the
disease finds influences favourable or unfavourable to its prevalence.

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229

Dirt, insanitation, poverty, overcrowding, and improper diet are
almost constantly found associated with the existence of leprosy,
and it is difficult not to ascribe to them a considerable share in
determining its prevalence. It is possible that these and other
factors are all essential to the multiplication and diffusion of the
bacillus leprce, which must be regarded as the essential cause of
the disease.
The view which ascribes the production of the malady to the
consumption of fish, particularly of badly salted and decomposing
fish, finds some slight support in the geographical distribution of the
disease, in that, as stated above, lepers are found in many countries
along the shores of seas, lakes, and rivers in which fish abound,
and that the disease is frequently seen in persons who eat fish of
the kind just described. A considerable number of instances
have, however, been recorded of leprosy occurring in individuals
and in races who have never tasted fish of any sort, while in India
not only does the distribution of the disease show no special
relation to seas and rivers, but leprosy is found to be common in
people whose religion and customs forbid them to touch fish.
The influence of race upon the prevalence of leprosy is not
easy to determine. Some races appear to be more liable to
become leprous than others, but such differences may as often be
ascribed to differences in mode of life and of exposure to the
cause of the disease as to true racial differences. All races can
become subjects of the malady; but at the present day Europeans
and the white races generally seem to escape it much more
readily than the natives in countries where it is endemic—as
for example, China, India, and South Africa.
Few questions in medicine have given rise to more controversy
than those connected with the mode of spread of leprosy. It was
formerly almost universally held that the disease was hereditary.
It is now much more generally held that heredity has little if any
share in its diffusion. The members of the Leprosy Congress held
in Berlin in 1897 were of this opinion, and the balance of evidence
is certainly against the view that leprosy can be transmitted from
parent to child in the same way that syphilis can be transmitted.
The question of the contagiousness of leprosy has given rise
to similar differences of opinion. But as it has been definitely
proved that the bacillus leprce is given off in the discharges from

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the sores of lepers, and in many instances in the saliva, the
nasal secretions, the urine, and even the milk of patients, it
is clear that persons living in the immediate neighbourhood of
lepers must run considerable risk of the bacillus entering their
tissues. The numerous instances in which lepers have carried
their disease from one part of the world to another have been
referred to above, and instances are not unknown of persons
coming from places entirely free from leprosy, contracting
the disease from intercourse with persons suffering from it,
and communicating it to others on their return to the leprosyfree country. The spread of the disease in Canada and the
northern United States has distinctly followed the track of the
Scandinavian and Icelandic immigrants who imported it to the
continent. All these facts point strongly to the conclusion that
leprosy, like tuberculosis, is an infective malady, and that it
spreads from person to person like any other germ-disease.
That the distribution of leprosy can to some extent be controlled by human effort should follow from this conclusion, and
the possibility of so controlling it has been shown in more than
one instance. The complete isolation, under anything like tolerable
conditions of life, of persons suffering from a disease that may last
for many years or even decades, is obviously extremely difficult.
But the success which has attended even the modified form of
isolation practised in Norway is encouraging; and at least justifies
the assertion that human effort to keep the disease within limits is
a factor, and might be a very much more important factor than it
is, in determining its geographical distribution.

L I V E R ABSCESS.
General C h a r a c t e r s and E t i o l o g y . Abscesses of the
liver may arise from a variety of causes, such as traumatism,
gall-stones, hydatids, general pyaemia, and the like. But the
solitary, so-called tropical abscess of the liver, which is met with
solely in warm climates, presents so distinct a clinical group of
symptoms that it is almost certainly due to some constant and
specific cause, and is usually regarded as a definite and separate
disease. This form of liver abscess will alone be dealt with here.
Its causation is uncertain. The pus in such an abscess is usually
sterile, or contains the ordinary pyogenic organisms or the bacillus
coli. In several instances the amceba colt, identical with that
found in some dysenteric stools, has been discovered in the pus
of liver abscesses. The close association- of this disease with
dysentery will be discussed later.
G e o g r a p h i c a l D i s t r i b u t i o n . Europe. Abscess of the
liver is said to be by no means rare in parts of Spain, Italy,
and Turkey, and it is occasionally met with in Greece. In the
south of France cases have been seen, but it is rare here, and
even in northern and central Italy and northern Spain it is much
less frequent than in the southern part of those peninsulas. In
England and other countries further north true " tropical" liver
abscess is only seen as an importation from the warmer zones of
the earth.
Asia. In some parts of the Caucasus this disease must be
extraordinarily prevalent. In the Tiflis hospital abscess of the
liver is said to be found in 4 per cent, of the autopsies 1 . It is
possible that in a certain proportion of these cases the abscess is
1

Pantiukhof, " K' Statistikii Kavkazskoi PalologiV*; Tiflis, 1898.

LIVER ABSCESS

232

not of the specific " tropical" character now under consideration,
but it seems probable that it is so in the majority of instances.
In Persia and Arabia liver abscess has been "frequently seen in
Europeans, particularly along the shores of the Red Sea and
Persian Gulf. But of all Asiatic countries India is the one where
this disease is most common. The returns for the British army
in India in the years 1886-95 showed an annual admission-rate
from abscess of the liver of 2 per 1000, with a death-rate of 1*13
per thousand strength. In the two following years the admissionrate remained the same, while the death-rate rose to 1*22 and
1*29 respectively. The admission-rate for " hepatitis " in the same
period varied between 21 and 23 per 1000 yearly. The Burma
Coast and Bengal-Orissa head the list of Indian territorial divisions
in regard to frequency of liver abscess, but it seems to occur in
all parts of the peninsula. In Rajputana it is apparently rare,
although hepatitis is a common disorder. The natives in India
suffer far less than the European residents.
Liver abscess is frequent in many of the East Indian Islands,
but here also it is mainly the European that is attacked. In 1897
among the men of the Dutch army in the East Indies there were
23 cases in Europeans and only 2 in natives. In the hospitals
and gaols of the Straits Settlements liver abscess is no rarity, and
hepatitis is exceedingly common. In Cochin China hepatitis
must be also very prevalent, as it is said to account for 3*8
per cent, of the mortality from all causes 1 , and it may therefore
be surmised that liver abscess is also a common disorder here 2 .
Both diseases are occasionally mentioned in reports from southern
China, but they do not seem to be very prevalent there, and
are rare in the northern portions of the empire. In Japan
abscess of the liver is also infrequent and only indigenous in the
southern islands.
Australasia,
There is mention of both hepatitis and liver
abscess as occurring in the Philippine Islands, Hawaii, Tahiti,
New Caledonia, and other Pacific Islands, but information as
to their existence in Australia and New Zealand seems to be
lacking.
1

Reference in Jamis, 1897-8, p. 96; I have not noted whether the figure
quoted referred to deaths among Europeans only or to total deaths.
2
Hirsch, however, quotes authorities showing that liver abscess is not
common in Cochin China.

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233

Africa. Abscess of the liver is almost as common in Egypt,
Nubia, and Algeria as in India, In Tunisia cases are not infrequently seen. In Mauritius and Madagascar the disease is very
prevalent, and on the West Coast, particularly about Senegambia
and the shores of the Gulf of Guinea to the north of the estuary
of the Congo, it seems to be equally so. Further south on this
coast it becomes rarer. South Africa is, however, not wholly free
from it. In the Kimberley hospital it is—or was before the war—
frequently seen, but several of the cases were in persons from
" up country." Even in the Durban hospital 4 cases were treated
in 1898. I have not noted the returns for other years.
America. In Canada liver abscess is not an indigenous
disease. In the United States it is most often seen in the
southern States, but even as far north as Baltimore it is said to be
" not very infrequent" (Osier). In Mexico it is commoner in the
west than in the east. It is frequent in Guatemala, San Salvador,
Costa Rica, and Panama. On the other hand in the West Indies,
though the disease is met with, it is, at least in many of the
islands, anything but common, and the same statement holds
as to its prevalence in the Guianas. For Brazil the information
available is rather contradictory, but there seems to be no doubt
that in the north of Chile, in Peru, and in Venezuela liver abscess
is extraordinarily common—in striking contrast with its infrequency in Guiana and the West Indies.

Factors concerned in the Geographical Distribution.
The term " tropical" as applied to liver abscess, it will be seen, is
not a strictly accurate one; for though most often met with
in the tropics, the disease is quite common in many subtropical countries, and is, it seems, not wholly rare in the
more temperate States of North America and Southern Europe.
The term is, however, a useful one, and serves to show that
the affection is mainly one of hot climates. So far as the
very imperfect statistical information from most countries goes,
it may be judged that the s disease is not solely dependent upon
heat for its prevalence. It is more common, for example, in
Mauritius, Algeria, and the north of Chile than in the West Indies
or Guiana, although the latter are nearer the equator than any of
the former.
For its production in the individual the most favourable
conditions for liver abscess seem to be residence in a hot country

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and exposure to chill. Immoderate indulgence in alcoholic drink
also strongly predisposes to it, and in India and elsewhere cases
of the disorder have diminished to some extent among European
troops with a diminution of drunkenness.
Dysentery is another and probably a very important predisposing factor in the production of liver abscess. The true
relation of the two diseases is still a matter of some uncertainty.
It is however certain that an attack of dysentery often precedes
the development of an abscess of the liver. In the Caucasus—
to judge, at least, from the returns of the Tiflis hospital already
alluded to—almost all the cases of liver abscess are complicated
with dysentery. In India too there is a certain parallelism
between the statistics of the two diseases in the different geographical divisions of the country. In 1891-95, for example,
the Burma Coast and Bengal-Orissa headed the list for both
diseases; and in 8 out of the 12 geographical groups a high
dysentery rate coincided with a high hepatitis rate. But it is
said that, when more closely examined, the figures do not show
a very exact parallelism. It has also been pointed out that the
great rise in the dysentery rate after the last Afghan war was
not associated with a rise in the hepatitis rate. In summing up
the evidence on this point the late Sanitary Commissioner with
the Government of India stated that in from 21 to 59 per cent,
of fatal cases of abscess of the liver association with dysentery
had been found; while on the other hand in 20 to 25 per cent,
of fatal cases of dysentery liver abscess had been met with 1 .
This certainly shows considerable a priori grounds for believing
that there is a close relation between the two; and this view
is still further supported by the discovery (by Kartulis, Powell,
and others) of the amoeba coli, the supposed cause of tropical
dysentery, in the contents of liver abscesses.
Racial influences are probably of some importance in the distribution of liver abscess. In India, in Malaysia, on the West Coast
of Africa, in Egypt and elsewhere the European is much more
often the subject of the disease than the native. In the Caucasus
the Russians are far more frequently affected than the people of
the country. The difference between the white and the coloured
races is most marked in India; and less so in Africa and the
1
Annual Report of the Sanitary Commissioner with the Government of
India, 1894.

LIVER ABSCESS

235

West Indies, where the negroes suffer to a greater extent than
the natives in India. It is doubtful whether this difference is to
be attributed to true racial differences, or whether it is not largely
due to other causes. The European who goes for the first time
to a hot country has to pass through a process of acclimatisation
in which not a little strain is thrown on the functions of the
liver. Should he carry with him the habit of taking considerable or excessive quantities of alcohol, and should he
further not realise the great risk of chill in a hot climate,
he will be naturally far more predisposed than the native to
develop liver abscess. The fact that among European troops in
the tropics the men suffer far more than the officers, and the
women scarcely at all, shows that the liability to this disease may
be much more a^ question of individual habits and circumstances
than of racial susceptibility.

MALARIA.
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . Under the general
term malaria are included a number of intermittent and remittent,
acute and chronic, malignant and benign disorders, which modern
research tends to show may possibly be distinct and separate
diseases. For the present, however, it is convenient to deal with
them together.
Recent investigations have demonstrated that malarial diseases
are associated with the presence in the blood of certain microscopic plasmodia or hsematozoa, and that these vary in appearance
and character with the different types of the disease. For a full
description of these bodies and their relations to the varieties of
malaria the reader is referred to the writings of Laveran, Celli,
Manson, and others, and for an account of the clinical manifestations of malaria to any recently published text-book on '
Medicine. Here it must suffice to give a brief account of the
mode in which malaria is spread, and of the relation of the mosquito
to the malarial organism, as these questions have obvious and
important bearings upon the geographical distribution of the
disease.
The work of English and Italian observers has proved within
the last few years that the various forms of malaria are transmitted
mainly, and perhaps wholly, by means of the mosquito. Like the <
filaria sanguinis hominis the malarial parasite passes one portion
of its existence in the body of the mosquito. The passage of the
organism from the blood of the human being to the stomach of
the insect takes place when the latter is in the act of "biting" a
malarial patient and sucking his blood. It is believed again to
reach the tissues of the human being by like means, that is to
say by passing from an infected mosquito during the act of biting.

MALARIA

237

Whether this is the sole method by which man can be infected
is uncertain, and some still hold the view, abandoned by others,
that the malarial parasite may escape from the mosquito into
water, which on being drunk would convey it into the stomach
of a human being.
It is believed that only certain mosquitoes are capable of
transmitting the malarial parasite. These mostly, but perhaps not
exclusively, belong to the genus Anopheles. This genus contains
a very large number of species, and several of them have been
shown experimentally to be capable of harbouring the malarial
organism, but the principal carrier of malaria is believed to be
Anopheles claviger, or maculipe?inis. Of the other great genus
of mosquitoes, the Culices, the majority are regarded as incapable
of transmitting malaria; but Grassi believes that Culex penicillaris
and Culex malaria may carry the disease.
A very large number of phenomena connected with malaria
and its epidemiology are still obscure, in spite of the light thrown
upon many others by the " mosquito theory." But that the theory
is in the main correct can scarcely now be questioned, and further
observation will no doubt remove many of the obstacles which now
stand in the way of reconciling the theory with all the observed
facts of the disease.
The highly important stages in the life-history of the malarial
parasite which have been briefly summarised above, and about
which an immense literature has recently accumulated, have the
closest possible bearing upon the geographical distribution of the
disease itself. If, as there seems every reason to believe is the
case, a certain species, or certain species, of mosquito is or are
essential to the life-cycle of the parasite, it is clear that malaria will
occur only where it or they are found. A constantly increasing
body of evidence has been adduced from many countries tending
to show that the distribution of human malaria is in fact identical
with that of its mosquito host or hosts, to the extent that it is
never found in their absence, though there are certainly places in
which the malaria-mosquito is found and the disease is unknown.
More accurate knowledge is, however, yet needed as to the
exact species of mosquitoes capable of carrying malaria, and
as to their presence in all those geographical areas where malaria
is found, before precise statements as to the distribution over the
earth's surface of the malaria-bearing insects can be made, and in-

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the present chapter the distribution of the disease itself will alone
be considered.
H i s t o r y . The early history of malaria is obscure, and Hirsch
states that it is not until the sixteenth century that the records of
the disease begin to be of value. Certainly from medieval times
it has been one of the most universal of all maladies, and in many
countries it has caused an amount of suffering and death—to say
nothing of incapacitation and consequent economic loss—that can
only be characterised as appalling. Until within the last few years
the cause of malarial diseases was unknown, the method by which
they were spread was uncertain, and they themselves were regarded
as to a great extent beyond human means of prevention. They
were accepted as one of the permanent, inevitable conditions of
life in those countries wrhere they prevailed, and considerable tracts
of the earth's surface were either abandoned as uninhabitable, or
looked at askance by the colonist and the traveller as presenting
such risks to health and life that they were to be avoided at all
costs. The recent acquisition of knowledge as to the cause and
mode of spread of malaria, and the successful results already
obtained by applying this knowledge, have opened up a wholly
new prospect for these countries. They have shown that, even
if malaria cannot be wholly exterminated, it is possible to live in
a malarial country and yet' escape its attacks.
The malarial parasite was first demonstrated by Laveran in
1880. His researches were confirmed independently by Marchiafava and Celli. The mosquito had for a considerable period been
vaguely suspected of taking some part in the diffusion of malaria,
but it is only within the last five or six years that the true relation
of the one to the other has been established. The "mosquito
theory " has been gradually built up by the labours of Manson in
China and elsewhere, of Ross in India, and of the Italian observers
Bignami, Celli, and Marchiafava. The most striking incidents in
the gradual proof of the theory have perhaps been the demonstration by Ross of the life-history of proteosoma in birds (an
organism allied to that of malaria in man); the successful production of malaria by Manson in 1901 as the result of allowing
infected mosquitoes brought from Italy to bite healthy persons in
L o n d o n ; the direct cultivation of the malaria organism in the
bodies of mosquitoes by many observers; the preservation of
^healthy persons in the most malarious districts of Italy by strict

MALARIA

239

precautions against mosquito bites (certain Italian railway officials,
and Drs Sambon and Low in 1900); and similar successful
results obtained by the campaign against mosquitoes in Hongkong, Cuba, the West Coast of Africa, and elsewhere. To these
results few have contributed more than the members of successive
expeditions sent to notoriously malarial districts by the Royal
Society, by the Liverpool School of Tropical Medicine, and by
other bodies.
R e c e n t Geographical Distribution. Europe. In the
British Isles malaria, except in certain parts of the fen country, is
almost extinct as an indigenous disease, and in the cases that are
met with the patients have usually contracted the disorder abroad.
The term " malarial diseases " still forms a heading in the reports
of the Registrar-General, but the deaths in this group in England
have steadily decreased in the last two decades.
In France 1 malaria is met with on the west coast among
certain saline marshes about the mouths of the Seudre and the
Loire. It is said that when these marshes are kept in good order
for the production of salt, and only sea water admitted to them,
they cease to be malarial; but when they are abandoned or spoilt
for the production of salt (inarais gats) and fresh water mixes with
them, they become very favourable to the development of malaria.
The neighbourhoods of Rochefort and of Marennes were until
recently very unhealthy, but the latter has of late years improved.
Fever is common in Vendee and Loire Inferieure, but it is everywhere diminishing. A notable lessening of the disease has taken
place on the shores of the Lac de Grand-Lieu, near Nantes, at
St Philbert de Grand-Lieu. The type here is principally tertian,
but other types are met with. At Machecoul an endemo-epidemic
of malaria occurs from July to November, at first of tertian and
later of quartan type, with occasional pernicious forms; while
malarial cachexia is commonly seen. At Nantes and higher up
the borders of the Loire malaria is much less frequent than it was
formerly, and the same is true of Tours, where it is now unknown
in the garrison. Tertians also predominate here, but other types
occur. At Saumur severe remittents are sometimes met with.
Formerly the whole French coast from the mouth of the Gironde
to that of the Adour (Landes) was very malarial, but the fixing of
1
See a valuable article on the distribution of malaria by Laveran ; Janus,
1896-7, p. 301.

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MALARIA

dunes, the planting of sea-pines, and the cultivation of the soil have
succeeded in almost completely extinguishing the fever.
On the French Mediterranean coast there is little malaria east
of the Rhone estuary, as the shore-line here is considerably
elevated. But to the west of this river the coast becomes low
and marshy and fevers are very common. On the fie de la
Camargue, which forms practically the delta of the Rhone, and
along the Beaiicaire canal, at Aigues-mortes, are a series of
marshes which are notoriously malarial.
In the interior of France malaria is no longer very common or
severe. It still exists in the neighbourhood of La Dombes. Many
years ago a large experiment in pisciculture was made here; a
series of lakes were constructed, which were used for fish-rearing
for two years, and in the third year were drained, dried, and
re-stocked. This alternation of wetness and dryness of the soil
led to the development of a most intense endemic form of malaria
which literally decimated the population. From 1802 to 1842 the
mean life of the inhabitants of La Dombes was only 24 years. In
the last half-century great improvements have been made in the
district, and half of the land has been reclaimed for agriculture,
with the result that malaria has greatly diminished. La Sologne
(in the department of Loir-et-Cher) and La Brenne (in that of
Indre) are also feverish localities, owing to the presence of lakes
and marshes. There too the rearing of fish, which has been a
principal industry since the year 1450, has led to the development
of a severe form of malaria. As late as 1852 the inhabitants
were in a pitiable condition of misery and suffering, but since then
wide measures of drainage and cultivation have greatly improved
the health of the district, and malaria is now far less common than
formerly.
In Germany malaria is apparently diminishing rapidly. In the
three-year period 1 8 8 3 — ^ 8 5 as many as 5*2 per 1000 of the cases
of all diseases annually treated in hospital were cases of some
form of malaria, but in the next period (1886—1888) the figure had
fallen to 2*8, and in 1889 to 1891 it was only 1*9. It is severe
only on the plains, and is most prevalent among the fens of
Oldenburg, along the marshy banks of many rivers, and at certain
points on the shores of the German Ocean.
Holland, at one time the home of the most severe and fatal
forms of malaria, is nowr comparatively free from the disease, in

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241

spite of its slight elevation and low coasts. This change has been
brought about entirely by the energy of its inhabitants, who have
carried out extensive measures to prevent the inroads of the sea
and to drain the marshes which formerly existed. At the present
day malaria is met with on the coasts, in the neighbourhood of
Amsterdam and Rotterdam, and about the mouths of the Escaut
and Over-Yssel rivers, and in the island of Walcheren, of evil
memory. The continued diminution of malaria in Holland is shown
by the following figures: the deaths from continued fever have
steadily declined from 1*2 per 10,000 inhabitants in 1889 to 0*3 in
1898; in the same period the deaths from intermittent fever fell from
o*2 to o'i, and those from pernicious forms of fever from 78'to 1
—figures too small to represent in proportion to the population 1 .
A marked fall in deaths from malaria has also taken place in
recent years in Belgium 2 . The mean annual deaths from "flevres
paludeennes" in that country was 378 in the decade 1871—1880,
and only 214 in the decade 1881—1890, while in the year 1895 it
fell to 84. In 1897 the deaths were 101, which is equivalent to
about 15 per million inhabitants.
In Denmark malaria must be either almost extinct or of an
extremely mild character. In 1897 one death from intermittent
fever was recorded for the urban population of the whole country >
while in each of the five preceding years not a single death from
this cause occurred in the same group of inhabitants 3 .
In Norway malarial fever is also said to be unknown, and this
is doubtless due to the mountainous nature of the country and its
precipitous coasts, with consequent absence of fever-breeding
marshes. In Sweden, on the other hand, the disease exists. As
an endemic it is absent north of the Angerman river, in 63 0 N.
latitude. It occurs in the neighbourhood of Stockholm and in
the district of Nykoping. It has at times (e.g. in 1846) become
epidemic along the Baltic coast, and inland on the shores of the
Malar Lake, and at some points on the Wenern Lake. It is a
remarkable fact that in 1846 it also appeared in Lulea, a marshy
district at the head of the Gulf of Bothnia, close to the 66th
parallel of northern latitude. This would appear to be the most
1
2
3

C.

Annuaire
Annuaire
Statistisk

Statistique des I^ays-Bas, 1898.
Statistique de la Belgique, 1898.
Aarbog, Kjbbenhavn, 1899.
16

242

MALARIA

northerly point in Europe in which malaria has occurred, as it is
even further north than Archangel.
In Russia malaria is a very widely-spread disorder, and there
are few portions of the country entirely free from it. There is
reason to believe that it is becoming more prevalent, as the
number of registered cases of malaria treated in hospitals throughout the empire rose from an average of 1,624,098 in the years
1887—1892 to considerably over 3,000,000 in each of the years
1894 and 1895 \ Part of this rise, but not all, was probably due
to the increase of hospitals and to improved registration. The
disease is found as far north as the government of Archangel, and
is not unknown in the town of Archangel itself, on the shores of
the White Sea. It is also met with in the northerly governments
of Olonetz and Vologda. In the Baltic provinces —Courland,
Livonia, and Esthonia—which have frequently been regarded as
specially malarious, the disease is, on the contrary, far less prevalent than in many other parts of the country.
Malaria is extremely common in the Don Cossack territory
in southern Russia, perhaps more so than in any other part of the
country; thus, out of a population of about 2 \ millions, over
73,000 cases of this disease were registered in 1895. It is
exceedingly common also in the governments of Kherson and
Simpheropol (or the Crimea), on the shores of the Black Sea and
the Sea of Azov. The group of governments in south-western
Russia, known collectively as the Ukraine (Kief, Tchernigof,
Poltava, etc.), are also highly malarious. Throughout southern
Russia there are large areas of imperfectly drained, marshy country
which favour the prevalence of the disease. It is met with along
the valleys of the great rivers, such as the Don, the Bug, the
Dnieper, the Dniester, and the Volga.
The government of
Astrakhan at the mouth of the Volga is particularly malarious,
the disease occurring especially in the marshy regions in the
delta of that river, and about the shores of the Caspian Sea.
Malaria is very frequently seen also among the Bashkirs, living in
villages along the river Ural; the disease makes its appearance
here in summer as the lakes and pools round which the villages
are built begin to dry up. In the north-eastern governments
along the upper reaches of the Volga, and its great feeders, the
1
Annual Reports of the Medical Department of the Russian Ministry of
the Interior.

MALARIA

243

Kama, Viatka, and Ufa, malaria is also widely endemic and the
cause of a high annual sickness-rate.
In Austria-Hungary the malady is endemic, and causes a considerable amount of illness, but it is apparently slightly decreasing.
Thus in four successive triennial periods, beginning with 1883-85
and ending with 1892-94, the proportion of malarial cases treated
in the civil hospitals to cases of all diseases was n*6, 8*4, 9*4,
and 9*4 per 1000 respectively1. The banks of the Danube, the
Save, the Drave, and the Theiss, are notoriously malarial.
Along the coasts of Spain and Portugal there are many points
where malaria is prevalent. It is especially so in the marshy
district near the mouth of the Guadalquivir. In Spain malaria
was, some twenty years ago, more widespread than in any other
country in Europe, with the exception of Italy, but there has been
some improvement in recent years.
Italy is now the most important endemic centre of malaria in
Europe. The disease here attains the proportions of a great
national misfortune. Owing to its ravages about five million acres
of land are uncultivated, and each year it attacks some two million
of the inhabitants, and causes the death of over 15,000 persons.
The lower animals have not escaped it, and whole herds of cattle
have, it is said, within comparatively recent times fallen victims to
it2. In upper Italy the growing of rice is the principal cause
of the prevalence of the disease, and it is particularly common in
districts where stagnant water and marshes abound. In Tuscany
the chief centre is formed by the Maremma, a series of uncultivated plains separated from the sea by dunes, which prevent
the escape of water and lead to the formation of many pools and
marshes. The Pontine marshes, which adjoin the Maremma,
occupy the Mediterranean coast for a distance of some 26 miles;
they are so low and flat that as far inland as 11 miles from the
sea the land is only 4J feet above sea-level. These marshes have
a turfy, moist soil, and produce a rich vegetation. The Roman
Campagna, on the other hand, has a soil almost denuded of
vegetation, except in spring. L'Agro Romano is a marshy area
of over 1000 square miles. All these localities are notoriously
malarial. The city of Rome itself, in spite of the nearness of
these dangerous marshes, enjoys a comparative immunity from
1
2

Bulletin de VInstitut International de Statistique.
Celli.

Vol. X. Rome, 1897.
16—2

MALARIA

244

the disease. On the coasts of the Adriatic are the malarious
marshes of Apulia and at the extreme south those of Basilicata
and Calabria, the latter forming the " instep " and " toe " of the
boot-shaped peninsula.
On the eastern shore the disease begins to be severe south of
Cape Gargano, and in the south some pf the worst forms of continued and pernicious fevers, such as are rare in the north, begin to
be common. On the western coasts of Italy severe foci of malaria
exist at Grosseto in the Agro Pontino, and in the neighbourhoods
of Salerno and Paestum. Malaria is on the whole decreasing in
Italy, and there has been a steady and almost unbroken diminution
in the number of recorded deaths from the disease, from a total
of 713 per million inhabitants in 1887 to o n e °f o n r ) 7 45° m 18961.
The last-named figure is however still a very high one, and malaria
remains as in former days the most fatal disease in Italy.
In the Balkan peninsula the malady is of very frequent occurrence. In Roumania, Bulgaria, and Servia it is endemic along
the course of the Danube. In the Dobrudsha it is very prevalent.
In Montenegro it is rife in the fertile plains watered by the
Tshernitza, and other rivers flowing into the Lake of Skutari. This
lake is situated on the border between Montenegro and Albania,
and as it is now much smaller than it was in former times it has
come to be surrounded by extensive swampy tracts, in which the
conditions for the development of malaria are highly favourable2.
In many parts of Turkey in Europe malaria is extremely prevalent.
The province of Salonika has always been a foyer of paludic fevers,
and the disease is frequently reported from various parts of the
province. In Dedeagatch, in Kavala, and in other parts of
European Turkey the reports received by the Ottoman Board of
Health from its sanitary officers show clearly that malaria is the
leading disease.
In Greece malaria, fortunately of a mild type, is exceedingly
common, and is said to account for one-third of the total sickness
in the country. The great majority of the cases are intermittent
in character, the continued and pernicious types, being rare.
Many islands in the Mediterranean are malarious. The coasts
of Corsica and Sardinia are unhealthy from this cause. In Corsica
the east coast, which for a distance of some 60 miles in length
1
2

Annuario Statistico Italiano, 1898.
Levy. British Medical foumal.
April 1st, 1899, p. 801.

MALARIA

245

and two or three miles in width is low and marshy, is notoriously
fever-stricken, and in July, after the harvest is in, the inhabitants
are obliged to fly to the mountains to escape the disease. In
Sardinia malaria is very prevalent, and in the south-east of this
island, and also in parts of Sicily,' the mortality from this cause is
excessively high, rivalling that, from the same disease in the
Basilicata and Pontine marshes. In these malarious districts of
Italy and the adjoining islands the deaths from this class of fevers
alone amount to 8 per iooo inhabitants per annum.
In the island of Crete paludism also prevails to a considerable
extent, and during the recent military occupation by the Powers
many of the European troops stationed there suffered considerably
from various forms of malarial fever.
Asia. In the Caucasus paludic fevers are excessively rife in
the province of Kuban, on the eastern shores of the Black Sea,
where in 1895 v e r Y nearly 100,000 cases were registered among a
population of only 1,693,000. Malaria is not confined to the
coast, but occurs with equal intensity throughout every district
of this flat and marshy country. In the province of Terek
on the east it is only a slightly less fatal scourge.- In the
government of Stavropol, just to the north of these, malaria is
considerably less common, but is still a very serious factor in the
pathology of the country. These three provinces, which constitute
the Caucasus proper, are all flat, low-lying, and more or less
marshy. The governments of Transcaucasia, on the other hand,
are for the greater part mountainous, and here malaria is very
much less common. It is, however, present to no inconsiderable
extent in every government lying between the Black and the
Caspian Seas. It is especially prevalent along the valleys of the
Kura and Rion rivers and on the Black Sea coast.
Throughout Central Asiatic Russia malaria is rife. It is
impossible to judge of its extent here from the official figures of
registered cases of sickness or death, as the great majority of cases
in the native population do not come to the cognizance of the
Russian medical authorities. On the eastern coasts of the Caspian
Sea, around the shores of the Sea of Aral, along the banks of the
Zeriafshan, Amu Daria and Syr Daria rivers, and in the neighbourhood of the irrigation channels which intersect the country,
malaria is always present. At times it has taken on the characters of
an epidemic of intense severity. This was the case in 1897, when

246

MALARIA

in the provinces of Transcaspia and Samarkand, and especially in
the neighbourhoods of Merv and Tashkent, malaria of most
virulent character prevailed to an alarming extent. In Merv
another very severe outbreak of the disease occurred in 1900.
In Bokhara these fevers are very widely spread, and often of
very malignant character 1 . They prevail principally in the summer,
but in the valleys they occur all the year round, only lessening in
the winter. The localities particularly notorious for fevers are
Hissar, Kuliab and Patta-Hissar, and generally the towns on the
banks of the Amu Daria and its branches. So unhealthy is
Hissar in the summer that its inhabitants annually evacuate it at
the end of February for a more salubrious spot. The Russian
settlers also suffer considerably.
In Siberia malaria is also widely spread. Though there are no
doubt large areas of country more or less free from it, the disease
is nevertheless found in every province, from north to south and
from east to west. It is common along the banks of the great
rivers, as the Yenisei, the Obi, the Lena, and the Amur.
It is probable that a great part of the Arabian coast is more or
less malarious. In both Mecca and Medina all forms of malarial
fevers are seen among the Moslem pilgrims, and "pernicious
fevers " and malarial cachexia are among the commonest causes
of death among them. To wThat extent these affections are of
local origin, or how far they are contracted by the pilgrims elsewhere it is difficult to say. In the higher table-lands of Assyr
malaria is entirely unknown.
In many parts of Asia Minor malaria is common. In the
neighbourhood of Trebizond there are many marshes and all forms
of the disease are seen. At Adalia, and on the islands of Mitylene and Sarrios it is a source of much illness. It is particularly
prevalent along the shores of both the Black and Mediterranean
Seas, and at many places on the Turco-Persian frontier (Khanikin
Penjvin, etc.). Mesopotamia, the marshy district between the
Tigris and Euphrates, is exceedingly malarious. In Persia malaria
is found principally along the shores of the Caspian Sea and
the Persian Gulf, and along the Turco-Persian frontier. It is
also found at considerable elevations in the central Persian
table-lands, and is not uncommon in Teheran itself.
1
Bolnitchnaia Gazeta Botkina, 22—24, 1899, "Bokhara and its Sanitary
Condition," by Dr I. I. Grekof.

MALARIA

247

The coast of Palestine has long had an unenviable reputation
for " fevers " ; they are very prevalent at Tripoli, Jaffa, and elsewhere. Afghanistan and Baluchistan are both spoken of as
malarious countries.
In India malaria or allied fevers annually cause the death of
between four and five million persons. These deaths are classified
under the general term "fever," and while it is possible that a
certain number of them are due to other pathological conditions
it is probable that the overwhelming majority are caused by
malaria in some of its many forms1.
The disease is met with in almost all parts of the Indian
peninsula. It is commonest on the low-lying coasts of the Bay
of Bengal, and along the banks and especially at the mouths of
great rivers, such as the Indus, the Ganges, and the Brahmaputra.
A form of fever of intense severity occurs in the belt of waterlogged forest at the foot of the great Himalayan range to which
the name of the Tarai has been given. The most malarious of
the territorial divisions of India are those of the Central
Provinces, Assam, Bengal, Bombay, Coorg, and Berar.
The
provinces with the lowest mortality from malaria are those
of Lower Burma, the Madras Presidency, and Mysore 2 . The
deltas of the Indus and Ganges, already mentioned, consist of
low, marshy lands overgrown with jungle, and liable to frequent
inundations, and they are consequently notoriously .unhealthy.
Similar conditions, but less pronounced, are found throughout the
greater part of the coast line; the western shore of the peninsula
is said to be more malarious than the eastern. Bombay itself is
built on a marshy island in which malaria is rife. In Bengal, in
the neighbourhood of Calcutta, is a triangular tract of land which
is believed to be the most unhealthy area in India, with the single
exception of the Tarai. This tract is bounded by the high banks
of the Ganges and the Madhamati on the north and east, by the
districts of the Southern Parganas, Birbhum, Bankura and
Midnapur on the west, and by the tidal swamps of the Sundarbans on the south. It contains some fifteen or sixteen thousand
square miles, and includes the districts of Murshidabad, Nadia,
1
Crombie {Indian Medical Gazette, April, 1899) has made a useful provisional classification of the " Unclassified Fevers of the Tropics."
2
Annual Reports of the Sanitary Commissioner with the Government of
India.

248

MALARIA

Burdwan, Hooghly, Jessore, Khulna, Howrah and the 24 Parganas.
The population is over eleven millions. No part of this area is
more than 60 or 70 feet above sea-level, and in the 24 Parganas,
Howrah, and Khulna the average elevation is only from 10 to
20 feet. The intensity with which malaria prevails here may be
gathered from the fact that the average mortality from this disease
alone is in many parts 50 per thousand per annum, that considerably over one-half of the inhabitants have enlarged spleens, and
that in some villages this condition is found in as many as
81 *2 per cent, of the population. The disease is wor.st in low
and undrained situations, but less frequent on the elevated banks
of rivers and in well-drained sites1.
In India generally malaria has been particularly active in recent
years of famine. In the Central Provinces, after the disastrous
and sudden cessation of the monsoon rains in September 1896,
the disease became unusually virulent and widespread, and caused
a mortality for the year of no less than 29*5 per 1000 of the
inhabitants. " There was an increased production of the poison,
owing to the abrupt cessation of a heavy rainfall, and diminished
resistance due to the famine 2 ."
Many parts of Ceylon are highly malarious, and occasionally
epidemics of great malignity prevail in some districts of the island.
In the hospitals and in the gaols the enormous majority of cases
of sickness are due to malaria in one of its forms. It is a cause
of a very high annual mortality in the island generally; the deaths
from "remittent fever" and "malarial cachexia" more than doubled
between the years 1891 and 1897. In the same period those
registered as from " a g u e " diminished considerably, and those
from "simple and ill-defined fever," a term which appears to
include the greater number of malarial cases, also somewhat
declined. But in 1898 the deaths reported under all these
headings, and particularly those ascribed to " malarial cachexia,"
increased enormously 3 .
Paludism is endemic throughout Farther India and the MalayPeninsula. Many parts of Siam are highly malarious, and certain
1

Gregg. Transactions of the First Indian Medical Cong7'ess.
Annual Repoi't of the Sanitary Co?nmissioner with the Government of the
Central Provinces, for 1896.
3
Ceylon Ad??iinistration
Reports.
Report of the Principal
Civil Medical
Officer and Inspector-General
of Hospitals, for 1898.
2

MALARIA

249

forests and valleys possess a deadly reputation for the prevalence
of the most severe and fatal forms of fever. The valley of the
Mekwang, particularly in the neighbourhood of Luang Prabang,
is notoriously malarial, and " untold numbers " of natives are said
to perish of the disease each year. In the forest belt behind
Chantabun jungle fever is rife, and throughout the plains of
Cambodia malaria, mostly of the intermittent form, is commonly
met with1.
In the Malay Peninsula proper malaria is also an important
factor in the pathology of the country. At Singapore, in Penang,
and in Province Wellesley large numbers of persons annually come
under treatment for some form of remittent or intermittent fever.
In the hospitals and prisons throughout the Straits Settlements
more cases of malarial fever or malarial cachexia come under
treatment than of any other disorder, though as a cause of death
in these institutions malaria is exceeded by dysentery, beri-beri,
tubercle, and anaemia. Throughout the peninsula generally the
more severe forms of the disease are rare. It is noteworthy that
among the pilgrims annually visiting the Holy Places in the
Hedjaz the Malayans seem to be particularly liable to attacks of
intermittent fever.
In French Cochin China, Annam, and Tongking malaria is
widely prevalent. In the French settlements it is the cause of
three-fifths—and sometimes even of two-thirds—of the sicknessrate, and one-fourth of the mortality. The disease is mostly met
with on the coasts, and particularly at the delta of the great
Mekong river, which in its upper course forms the boundary
between Siam and Annam. This area of low-lying land is
mainly devoted to the growing of rice, and is subject to annual
inundations,—conditions which have universally proved favourable
to the development of malaria.
Throughout China malaria is exceedingly prevalent, though as a
rule it occurs in the more benign forms of intermittents. Severe
remittents and attacks of the most pernicious types of the disease
are, however, occasionally met with in some parts. It is said to
prevail more or less throughout the valley of the great Yangtzekiang, and is especially active after the floods to which that
river is annually liable. It is rife at many places along its banks.
At Chung-king intermittent forms of fever are very common. At
1

H. Waiington Smyth.

Five Yeais in Siam.

London, 1898.

250

MALARIA

Hankow tertians are the most frequent, then quartans and quotidians ; the most severe cases are met with in foreign residents and
are said to be imported from southern China or from Formosa.
In the natives of the surrounding districts fever prevails from the
beginning of spring to the end of autumn. At Kiu-kiang the quotidian type is the form that most often comes under observation.
Malaria is also more or less rife along the whole of the south coast
of China. All types of the disease are seen in the south-west province
of Yunnan. At Lung-chou, Pakhoi, and other places in the
Kwang-si province the disease is endemic, and it is equally so
in the adjoining province of Kwang-tung (Canton). In the Lappa
Customs district, and especially at Macao, malaria prevails in the
hot and damp summer months; at Wuchow on the Canton river
it is also common. The east coast of China is malarious in many
places. Hongkong is notorious for the prevalence of fevers.
In the neighbourhood of Swatow tertian intermittents are very
common, quotidians and quartans somewhat less so, while remittent and continued fevers are much less frequent. At Ningpo
malaria is the most prominent disease. Around Shanghai it is
also commonly met with ; it was unusually prevalent here in the
summer of 1889.
Further north, at Chifu, on the Straits of Pe-chili, malaria
became widely epidemic in the year 1895 as the result of turning
up long-undisturbed ground for road-making and building. Severe
forms of remittent fever are not rare here.
In Peking intermittent forms of fever are common enough, but
they usually assume a benign character, and pernicious attacks are
rare. At Tientsin remittent forms are not infrequently observed 1 .
In Corea malaria is the predominating disease. At Seoul,
Chemulpo, and elsewhere in the peninsula it prevails principally
in the spring and autumn.
In Japan malarial fevers are exceedingly common, particularly
on the plains where rice is extensively cultivated. An area of
malaria "of quite extraordinary intensity" is said to have developed
in recent times in the Suruga province on the Oigawa river, where
the rice fields are lower than the level of the river. This district
contained in 1882 about 51,000 inhabitants, and it was said that
1
See the successive Reports of the Medical Officers in the Chinese Customs
Service.

MALARIA

251

the annual number of cases of malaria amongst them was not less
t h a n 16,000 to 2 0 , 0 0 0 ' .

Many other islands off the Asiatic continent are homes of
malaria. In Formosa all forms of the disease are met with, but
tertians are the most frequent, while severe bilious remittent forms,
which are said to have been common in foreigners after the opening
of the port of Tamsui, are now extremely rare. About one-fourth
of the patients treated in the hospital at Tamsui are victims of
malaria. The worst regions in the island are certain valleys shut
in by hills, and flat lands lying between the mountains and the
sea, such as the Kapsulan plain and in the neighbourhood of
Tamsui. The aboriginal inhabitants of the mountainous districts
are said to enjoy relative immunity; the greatest sufferers are the
Chinese, particularly those not born in the island, and the men of
the Japanese garrisons 2 .
Throughout many of the East Indian islands malaria is widely
endemic. In Borneo it is the chief disease. Dr Nieuwenhuis, the
first European to cross the island from east to west (in 1894)
states that certain regions are free from it; thus the two capitals
on the south and west coasts, Bandjermasin and Pontianak, are
not malarious, although they lie in the midst of a marshy country
and water and mud abound in the neighbourhood. The same
was found to be the case with Palembang, in Sumatra, and at
Sambas, in western Borneo. In the more elevated regions of the
Bornean interior, malaria is rife; it is said to cause a high annual
mortality among the Dyaks, the principal inhabitants in these
regions, while the Malays in the plains suffer but little. It is not
a question of racial immunity, as the latter easily contract malaria
if they go to the hills, and, as already stated, the Malays, both in
their own country, and when on pilgrimage to Mecca and Medina,
are frequently subject to its attacks. In the north-eastern portion of
the island malaria is by far the most prevalent disease, and annually
causes a vast amount of sickness and death. In Labuan, off the
north-west coast, it figures more prominently than any other
malady in the annual hospital reports. In Java malaria is very
common among the hill tribes; it is however said not to be
endemic among dwellers in the hills, but to attack persons who
1

Sei-i-Kwai, 1898.
A. Rennie in Reports of the Medical Officers of the Chinese Customs
Service. No. 45.
2

MALARIA

252

from time to time are compelled to labour on the coffee plantations there 1 . At Batavia and other Dutch stations a heavy
mortality from malaria occurs among the Dutch residents and
soldiers stationed there. Very severe or pernicious forms of the
disease are common, and Batavia at one time had earned the
unenviable name of " t h e Dutchman's Grave." Of recent years
marked improvement has taken place in the health of the town,
mainly owing, it is believed, to improved sanitation, to a gratuitous
supply of quinine to the people, and possibly in part also to an
improved water-supply. Koch has stated that the malaria sickness-rate in the Dutch Colonial army in Batavia had diminished
by 50 per cent, in the fifteen years ending in 18992.
Throughout the Philippine Islands malaria is also extremely
prevalent. The Spanish troops in this archipelago suffered greatly
in 1895 and the following years, when the disturbances brought
about by the war led to a greatly increased prevalence of the
disease.
Australasia.
Many of the islands of Oceania are, on the other
hand, remarkably free from malaria, although the presence of
marshy^low-lying coasts seems to invite its prevalence. It would
appear to be rare in Fiji, only 2 or 3 cases coming under treatment each year in the colonial hospital at Suva.
In New
Caledonia marsh fever is said to be unknown, in spite of the
abundance of marsh-land.
In the adjoining group of the New Hebrides, on the contrary,
malaria is, it is stated, very common 3 . Severe forms of malarial
cachexia are met with here among the Papuans. The Sandwich
group and the Marquesas Islands are reported to be free from
the disorder.
In British .New Guinea, however, it is the disease most
frequently met with, attacking both natives and Europeans.
It is commonest in the low-lying districts, and appears to be
absent in the hills. Its distribution is very irregular, and some
of the most swampy spots are exempt wThile other places far
removed from swamps are notoriously malarious 4 .
1

Kohlbrugge. Janus ^ 1897-8, p. 221.
Deutsche Med. Wochenschrift.
F e b . , 1900.
3
Bernal, Archives de Medecine Navale.
Aug., 1899.
4
See Sir W . MacGregor's Annual Report for the year 1897-8. H e states
that it is very remarkable that again and again parties of twenty to thirty men,
2

MALARIA

253

Malaria is a rare disease in Australia. In West Australia
it was the cause of only 12, 6, 13, and 4 deaths respectively in the
years 1889—1892 inclusive; in 1893 and 1894 it caused not a
single death; in 1895 only 2 deaths from remittent fever were
registered, and in each of the three following years only a single
death. Intermittents were the cause of scarcely more deaths.
South Australia is equally free from malaria, and only single
deaths from remittent fever and none from intermittents were
registered here in the years 1893 to 1898. In New South Wales
less than a score of deaths per annum are attributed to malaria.
In Victoria it appears to be unknown, at least as a cause of
death, and the same is true of Tasmania. The immunity of
Australia, as contrasted with the prevalence of the disease in
New Guinea, is remarkable.
New Zealand is also free from paludism, in spite, it is said, of
the presence of marshes of considerable extent.
Africa. The north coast of Africa is not especially malarious.
In Tunisia some foci of the disease are met with in scattered parts
of the Regency, but cultivation is beginning to improve them, and
it is hoped this class of fever will disappear in time. In Tripoli
and in Morocco malaria is endemic and more or less widely
spread, but it occurs in a comparatively mild form. In Egypt
the disease is met with, especially at the mouths of the Nile,
and forms of fever are common along the whole valley of that
river, prevailing especially after the annual inundations begin to
subside.
In Abyssinia malaria is met with on the plains, but is said to
be unknown in the hills. At the northern foot of the great central
plateau of Abyssinia is a series of vast marshes, clothed with
luxurious vegetation and known as the Kollas, and here cases of
fever are exceedingly numerous. In Algeria the malady is prevalent
on the coast and along the muddy banks of rivers. The worst
regions are in the neighbourhood of Lake Alloula and on the
coasts of ChifTa, about the marshes of Ferguen, Chaiba, and
natives and Europeans, have spent several consecutive weeks in low-lying
mangrove and swampy country and have left it without a single sick man ;
while, on the other hand, of the same number of men landed in CJoudy Bay
and camped on dry ground and at a distance from swamps, all save one man
became ill of fever. Some of the worst cases have been contiacted in a dry,
limestone district.

254

MALARIA

Mazafran, all in the province of Algiers. In the province of Oran
the plains of Sig and of Habra are feverish, and in that of Constantine the plains of La Seybouse and around Lake Fezara
have the same reputation. At the time of the French conquest
of Algeria the troops suffered very severely from the ravages of
malaria, but of recent years cultivation and drainage have done
much to improve the health of the colony.
In the great Sahara desert malaria is said to be unknown,
except in the oases, but at some of these, as for example at Biskra,
it is rife.
The West Coast of Africa has, from time immemorial, been
ravaged by malaria. Few places along the entire coast are free
from it, and in many the disease occurs in its most malignant and
fatal forms. In Senegal malaria becomes violently epidemic each
year at the end of the rainy season; severe types of remittent
fever are very common, and not infrequently bilious complications
are present. In the hospital at Dakar malaria accounts for 57*5
per cent, of the total cases treated. From January to July the
disease quite disappears, but only to break out with renewed
virulence in the following months 1 . In the British colony of the
Gambia the disease is rife, and the same periodic prevalence is observed. From July to October the climate of Bathurst is extremely
b a d ; fevers abound, the natives suffering from them as well as the
European residents. The rest of the year is said to be fairly
healthy 2 . In Sierra Leone, long notorious for the deadly character
of its climate, malaria is no less prevalent.
The whole coast of Guinea is intensely malarious. The Gold
Coast, the Ivory Coast, and the Slave Coast, the mouths of the
Niger and the shores of the Cameroons, have an unenviable
reputation for their extreme unhealthiness. At Cape Coast
Castle malaria has long been the cause of a very high mortality.
At Kumasi the types of'fever met with are less severe than on
the coast. In the Cameroons the prevalence of the disease is
said to vary directly with the rainfall. The ravages it commits
here may be estimated from the fact that of thirty missionaries
sent out by the Bale mission between 1886 and 1893, ten died,
and five had to return to Europe on account of their health. In
1
Annates d* Hygiene et de Medecine Coloniafos, 1898, I.
Paludisme au Senegal."
2
Colonial Report for the Gambia for 1898.

D r Clerac, " L e

MALARIA

255

a group of ninety men stationed there 438 attacks of malaria, or
nearly five per head, occurred in the course of one and a half
years. And out of one group of 44 deaths, 34 or 77 per cent,
were caused by malaria1.
In the French Congo malaria is the most prevalent of all
diseases.
In Central Africa malaria is seen along the course of the great
rivers and around the larger lakes, but it is of less severity and
prevails to a much less extent than on the coasts. In some parts,
however, a severe type of this disease and a high degree of prevalence
are met with. In the Congo Free State malaria attacks both the
black and the white races, and in the latter pernicious forms of it
are not rare. The valleys of the Congo and the Zambesi are
notoriously feverish. In British East Africa and in German East
Africa the disease is not uncommon. The prevalence of the
fevers varies to some extent with the height above sea-level; they
are however met with at considerable heights, in Uganda prevailing
up to an elevation of 5000 feet. They are severe around Lake
Nyassa (at Bandawe, for example), and also on the shores of
Lake Tanganyika. In the Masai highlands on the other hand
there is said to be no malaria ; and about the Victoria Nyanza
and in the Shire Highlands and about Zomba (Portuguese East
Africa) the disease is not severe. In British Central Africa fevers
of tertian type are not uncommon. Along the east coast of Africa
generally malaria is far from rare, and in places, as at Zanzibar
and about the mouths of the Zambesi, it prevails to a very grave
extent. About Mombasa it is very common; but the coast of
British East Africa is said to be less feverish than that of the
German territory immediately to the south.
In many parts of South Africa malaria is observed with great
frequency; but nowhere in this part of the continent does it
attain the extent or severity which characterise it on the West
Coast and in certain regions in the interior of Central Africa.
Its prevalence varies considerably in different years. In the
region of the Transvaal" malaria is endemic in many places; in
1893 the disease was prevalent throughout the greater part of the
Republic, but in 1894 on the other hand very few cases were
recorded. In the Barberton Hospital 449 cases of the disease
1
2

F. Plehn. Ref. in Arch, de Med. Navale.
Jcmm. Trop. Med. October, 1899.

Sept. 1899.

256

MALARIA

were treated in the five years 1893—J&97- The climate of the
Transvaal is sub-tropical, and in the north and east are numerous
low-lying swampy districts with a reputation for fever. Mashonaland is a very malarial country, and many of the labourers recently
employed in railway construction there have suffered from the
fever in some form.
In Natal malaria is certainly not common. The coast of
south-eastern and southern Africa is incomparably more healthy
than either the eastern or western coasts further north. At Delagoa
Bay, however, severe malarial fever prevails at times (e.g. in 1890).
At Port Elizabeth and at East London fevers of distinctly malarial
type are recognised. At Port Elizabeth 23 cases of the disease
were treated at the Provincial Hospital in the year 1898. At
Durban doubt has been expressed whether true malaria exists'as
an endemic, but 134 cases returned as cases of malaria were
treated in the Durban Hospital in 1898 1 .
The floods to which some of the South African rivers give rise
after heavy rains lead at times to the prevalence of malarial fever.
This was the case at Gordonia in 1898, when ague became
epidemic after severe floods caused by the Orange River in the
month of January. In the same year it also prevailed at Victoria
West. At Graaff Reinet a considerable number- of cases come
under observation annually.
Further inland, on the other hand, malaria would seem to be
common in many places. In Rhodesia, within the tropics,
malaria is more frequent than in other parts of South Africa,
except in the north-eastern Transvaal and Zululand. Among the
British troops stationed in South Africa in the year 1897, malaria
attacked principally a regiment garrisoned in Rhodesia, and many
of the cases Of the disease treated in the hospitals at Capetown
are drawn from this part of the colonies. At Buluwayo malaria
is the predominating disease; the mortality from it is, however,
not high among the Europeans, though among the natives it is considerable 2 . In Zululand malaria is commonly met with, especially
in the districts of Ndwandwi, Lower Umvolosi, and Lebombo 3 .
Many of the islands off the continent of Africa are highly
malarious. In Madagascar the disease is rife along the entire
1
2
3

Report of the Durban Hospital for 1898.
Report of the Memorial Hospital at Buluwayo
Colonial Report for 1891.

for 1897-8.

MALARIA

257

coast and in the river valleys. It is found especially on the west
coast, where a series of feverish marshes extends between the
mountains and the sea. As the mountains are approached
malaria becomes rarer, but it is met with even on the high
plateaux of Antsihanaka. On the east side of the island the
malarial zone is narrower, because the hills are nearer the coast.
In the French expedition of 1895 the route chosen to gain the
interior of the island was from the western side, with the result
that the troops suffered to a disastrous extent. In ten months
6000 men died, mostly from some form of malarial fever, and
the survivors were reduced to extremities. Some points on the
coast are relatively immune, as for example Nossi Komba in the
north-west. In Antananarivo malaria is not common, but in
certain places not far from the capital it prevails to a considerable
extent. In the little island of Nossi-Be, off Madagascar, malaria
is excessively prevalent. In 1880 it was the principal factor in
a general mortality of 89 per thousand in the general population,
and of 75 per thousand in the French troops stationed there.
At Mayotta, in the Comoro Islands, "paludism absorbs the
entire pathology" of the island; no one escapes it, and the garrison
has to be changed every year.
In the Mascarene Islands malaria is now endemic. The
history of the disease here is one of great interest. Before the
year 1857 malaria was unknown in Mauritius or Reunion. During
the next few years a limited number of cases only occurred; but
in 1866-9 a violent epidemic of the disease swept through both
islands, and since that date malaria has been the most important
and prevalent of disorders met with there. Malaria is said now
to " dominate the pathology of the island [of Mauritius], not only
in the sense that it alone gives rise to more than half the total
mortality, but also in respect to its influence in modifying the
character and determining the seasonal prevalence of other
diseases 1 ." The same appears to be the case in Reunion, but
Rodriguez, which adjoins and has apparently the same climatic
and other characteristics as Mauritius or Reunion, has hitherto
escaped entirely. The fact is one of the most remarkable in
the distribution of malaria. At the present time malarial fever
and cachexia are the direct cause of one-third of the entire
mortality in Mauritius.
1

C.

Davidson.
17

258

MALARIA

In St Helena malarial fever is also met with, but to no great
extent.
North and Central America. Malaria is rare in the western
hemisphere to the north of about the 45th degree of north latitude.
Its northern limit is therefore further south here than in the eastern
hemisphere. It has not been seen in Greenland. In the marshy
tracts of the Hudson Bay territories it is also said to be unknown. In Canada it must be exceedingly rare, if it exists; it is
scarcely mentioned in recent annual health reports of any of the
provinces in the colony. The disease begins to appear about the
shores of the great lakes of Huron, Erie, and Ontario.
In the United States it is common on the coasts of North
Carolina, Pennsylvania, and New Jersey. In the prairie ravines
west of the Missouri and on the Kansas plains it is common, and
it occurs in many places in the great central plain between the
Mississippi and the Alleghany Mountains. In Massachusetts
malaria appeared, it was believed for the first time as a serious
epidemic, in 1885 ! . It broke out in a village in the eastern
portion of the State, and later spread to many other towns in the
neighbourhood. Serious outbreaks occurred at Uxbridge, N.
Saugus and Woburn. In a small district in Woburn, covering an
area of about half a square mile, it was found by a house to house
inquiry that 1900 cases of malaria had occurred in the course
of the years 1894, 1895, and 1896. In Delaware malaria is also
met with.
Along the States bordering the shores of the Gulf of Mexico
—Florida, Georgia, Alabama, Louisiana, and Texas—malaria is
a very common disorder. The delta of the Mississippi and
the neighbourhood of New Orleans are markedly feverish. On
the Pacific coast of the States, the disease is most prevalent in
California, where the Sacramento and San Joaquin valleys are
said to be specially unhealthy. In these valleys malaria is
believed to have existed only since 1846, and to have become
commoner with the introduction and development of hydraulic
mining 2 .
1
The disease was known in Massachusetts prior to 1885, but was never
severe.
2
P. King Brown, M.D. Jozir?tal of the American Medical Association.
Vol. xxxii. Jan.—June, 1899.

259

MALARIA

Both the Pacific and Atlantic shores of Mexico are malarious.
In the Bay of Vera Cruz, on the east, a series of marshes exists
behind the barrier of dunes wrhich edges the sea, and here
fevers are rife. The high plateaux more inland are free, and
in the town of Mexico itself, although surrounded by marshes,
the disease is not met writh. It is found on the coasts of Yucatan
and is endemic throughout the greater part of Guatemala,
especially in the departments of Retalhuleu, Suchitepequez,
Escuintla, and others. In British Honduras malaria " dominates
the pathology and augments the death-rate 1 "; as a rule it is
of a mild type, but at times severe outbreaks occur, as for
example in 1871-72, when it became widely epidemic. In
Stann Creek district is a flat alluvial swampy tract of black,
pultaceous offensive soil, covered with a sandy marl left by
the receding sea, and here malaria prevails, but not of a severe
type. It is endemic, but occurs in a mild form, in Nicaragua,
Costa Rica, and San Salvador, even at considerable altitudes.
In Panama malaria is excessively prevalent, and some, of
the worst forms of the disease are met with. Colon is notorious
for its feverishness, and it will be recalled that the labourers on
the ill-fated Panama Canal suffered from malaria to a disastrous
extent.
The majority of the West Indian Islands are malarious.
Cuba is excessively so, and the sufferings of the American and
Spanish troops in the recent military operations there from
both malarial and yellow fevers were very great. It was
estimated that fully 7000 Spanish troops died from' these causes
alone. In the American camps malaria was the most formidable
disease3 90 per cent, of the cases assumed the aestivo-autumnal
type; tertians were rare, and quartans almost unknown. Havana
is a well-known centre of the disease. In Jamaica 2 malaria
is an important factor in the sickness-rate, but less so than
in Cuba; a severe, remittent form of the disease was epidemic in
the island in 1897. In the Lesser Antilles the malady is very
intense in Guadeloupe and Martinique, while in Anguilla and
Barbados it is said to be v unknown. In St Lucia all types,
from the mildest to the most severe, are met with, remittents
being, however, the commonest. In St Vincent remittents and
1
2

Report of the Colonial Stirgeon for 1898.
Reports of the Island Medical
Depart?nent.
17

2

26o

MALARIA

intermittents are not uncommon, and the same is true of Grenada
and of San Domingo. In Trinidad malaria is endemic in many
places; in the Mayaro district it is always very prevalent;
in the Manzanilla and Toco districts severe forms are often
seen, and there are few parts of the island where it is not
an all-prevailing disease 1 . In the Virgin Islands a severe form
of it is endemic; in 1897 an epidemic of a pernicious malarial
fever visited the islands of Anegada, Virgin Gorda, and Tortola.
In the Bahamas malaria is not uncommon.
South America. Along the northern shores of the South
American continent the inhabitants suffer considerably from
paludic fevers. In British Guiana all forms of malaria are
exceedingly prevalent, and the disease causes a higher mortality
than any other 2 . In Dutch Guiana it is no less rife. In French
Guiana three-fourths of the total amount of sickness is due
to paludism in its many forms. Four zones have been described
here, viz. the maritime zone, consisting of the islands off the
shore (lies du Salut, etc.), which are comparatively healthy,
the littoral zone, which is less healthy, but not so feverish
as the third zone, consisting of vast marshy tracts known as
the savanes noyees or savanes tremblantes, which are so deadly
malarious that all efforts at colonising this region have failed.
The fourth zone is that of the mountains, which are sparsely
inhabited and of which little is known. In Venezuela malaria
is rife throughout the basin of the Orinoco river and along
the sea-coast.
The shores of Brazil are said to be malarious more or
less throughout their entire extent, while in the interior of the
country the disease is rarer; the valley of the Amazon is,
however, feverish. In the Argentine Republic malaria is met
with, especially in the provinces of Tucuman, Salta, Jujuy,
Corrientes, and in certain districts in the north, where marshes
are numerous, water abundant, and the temperature high. In
Paraguay, Uruguay, and La Plata there are many marshes in
the midst of the great plains, and inundations by the rivers
which flow from the slopes of the Andes are frequent, yet
in spite- of these conditions the climate is healthy and paludic
fevers are said to be rare.
1
2

Annual Report of the Sui'geon-General for 1898.
Report of the Surgeon- General Jor 1898-9.

MALARIA

26l

On the western side of the continent malaria is certainly
met with on the coasts, but becomes rare or extinct as the
great range of the Andes is approached. In Colombia the
coasts are malarious, and the same is the case in Peru and
Bolivia. Chile has on the whole a healthy climate, and south
of latitude 350 malaria is said to cease altogether in the western
hemisphere.

Factors which govern the Geographical Distribution
of Malarial D i s e a s e s . If, as was pointed out at the beginning
of this chapter, certain mosquitoes are essential to the transmission of malaria, one of the most salient factors in the
geographical distribution of the disease must necessarily be
the geographical distribution of these mosquitoes; and, further,
the well-known influence of external physical conditions upon
malaria-prevalence must now be regarded as acting not simply
upon the malarial parasite itself, nor even upon the parasite
and its human host, but also upon the insect in which it
passes part of its existence. The geographical distribution of
the specific malaria-bearing mosquitoes has not yet been fully
worked out. The influence of many external conditions on
the distribution of the disease has, on the other hand, long
been recognised, and will be briefly discussed here, without
attempting to determine in what proportions this influence acts
directly on the parasite, the human subject, or the malaria-bearing
mosquitoes.
Malarial fever may occur in almost all latitudes, including
the subarctic, temperate, and tropical zones. It is however
commoner and more severe in hot climates than in warm, and
in warm than in cold, and from the equator to the poles there is a
fairly regular decrease in both the prevalence and intensity of
the disease. In Europe the most northerly point at which
it has been seen is at the head of the Gulf of Bothnia in the
66th degree of N. latitude, and in the Russian province of
Archangel. In Asia it has been met with in Siberia, in the
northerly government of Yakutsk. In America it has occurred
as far north as Southern Labrador, but as an endemic its present
limit here is about the 45th parallel. Warmth, therefore, has
clearly a powerful influence over malarial prevalence. This
is further shown by the comparative rareness of malaria
at high altitudes. Low, marshy countries have from time

262

MALARIA

immemorial been regarded as the great homes of malaria,
and though the disease is exceptionally found in elevated and
dry regions, it is infinitely more common and severe at lower
altitudes and in moister climates. Flat, hot, marshy coasts,
as those of Western Africa; the deltas of great rivers, as of
the Mississippi, the Ganges, the Rhone, the Loire, the Volga,
the Mekong, the Indus, the Brahmaputra, and the Nile; moist
plains at the foot of great mountains, as the Himalayan Tarai
or the savanes noyees in French Guiana; low-lying lands subject
to inundations by rivers or seas; swampy rice or paddy fields;
and land that has gone out of cultivation all offer ideal conditions
for the prevalence of malaria.
Moisture is essential to the existence of malaria, mainly
no doubt because the malaria-bearing mosquito, like all other
mosquitoes, passes one portion of its life-cycle in water. The
presence of marshes, stagnant lakes, and pools is highly favourable
to malaria prevalence, and one of the most powerful measures
in ridding a country of these fevers has been the draining
of the soil and the filling in of notoriously unhealthy collections
of standing water. A measure of this kind has been long
practised empirically in Holland, in France, and elsewhere,
with most successful results in the lessening or disappearance
of malaria. It is now being extensively practised in other
countries with a more conscious and certain aim—the removal,
that is to say, of the great breeding-grounds for the malariabearing mosquito—and it is being supplemented by still more
energetic attempts to do away with even the smallest collections
of standing water—such as holes and irregularities in the surface
of land about dwellings, and all hollows or receptacles in which
water might possibly stagnate and become a breeding-place for
these insects.
It was formerly believed that in addition to warmth and
moisture a certain amount of decomposing organic matter in the
soil was necessary for the prevalence of malaria. No doubt decomposing vegetable matter is one of the commonest concomitants
of a warm and moist soil, but it does not seem to be essential to
the production of malaria, for the disease can exist in its absence.
To what extent malaria can be carried by the air is uncertain,
but it is usually believed that the infection cannot be diffused far
by air currents either in a horizontal or in a vertical direction.

MALARIA

263

The crews of ships lying some distance from a highly " feverish"
coast have often escaped attack, and there seems to be no authenticated instance of malaria being wafted by the wind to ships
passing a malarial coast. Outbreaks of malaria on shipboard
have occurred, but they have been apparently, and in some instances certainly, due to the drinking of contaminated water by the
crews. Manson speaks of at least one authenticated instance of
this kind, but he also expresses the belief that the malaria germ
soon dies in water, so that after a few days' voyage a ship's
water-supply would cease to be dangerous. The tendency of
malaria to cling, as it were, to the earth and to show but little
power of rising high above it has long been recognised, and in
Italy and many other malarious countries the peasants secure a
relative or certain immunity from attack by building their dwellings
on supports at a considerable height from the ground.
Race is perhaps a factor of some importance in the malaria
problem. All the great divisions of the human family can and
do suffer from the disease, but some appear to be much less
susceptible to it than others. The negro races are said to be to
some extent immune to it, as well as the aborigines of the
Formosan hills. It was formerly thought that the Chinese and
Malays were also relatively immune to malaria, but recent evidence
lends no support to the view. How far any apparent immunity
observed in certain native races is congenital and how far acquired
it is difficult to say. Acclimatisation seems to be possible, though
in the case of malaria, as in that of many other diseases, what is
called acclimatisation is, as Manson puts it, less " an unconscious
adaptation of the physiology of the individual" than "an intelligent
adaptation of his habits." It has now been shown that malaria is
largely a preventable disorder, and that it is possible to escape it by
a careful avoidance on the one hand of chill and other conditions
tending to increase the susceptibility of the individual, and on the
other of the introduction of the germ by the bite of the mosquito.
While malaria may be regarded as the type of a permanently
endemic disease, it has shown great fluctuations in the countries
where it is endemic, and has also the power of invading others
where it was before unknown. The latter phenomenon is of the
greatest interest and requires close study in connection with the
now generally accepted view that the disease is mosquito-borne.
Should it be proved that the appearance of malaria in any

MALARIA

264

district has coincided with the appearance there of the mosquito
which is believed to transmit the germ, no more conclusive
evidence of the specific relation of the insect to the disease could
be found. Several striking examples of recent introduction of
malaria into regions hitherto almost, if not quite, free from it
are known, and some have been already mentioned in the course
of this chapter. One of the most remarkable was the sudden
appearance of the disease in a severe form in the island of
Mauritius in 1866. Before that date the island was practically
free from malaria, but in that and the two following years a very
severe form of the disease became widely epidemic there, and ever
since, as has already been noted, the whole pathology of the island
has been dominated by the existence of this endemic malaria.
Davidson 1 , who has made a most careful study of the diseases of
Mauritius and particularly of this malarial invasion, states that he
has been informed that in or about the year 1866 a malaria-nursing
mosquito was for the first time introduced into the island. If this
should be substantiated it will furnish most important evidence of
the truth of the mosquito theory.
Another instance of the appearance of malaria in a healthy
district is that already cited of the outbreak in Massachusetts.
I am indebted to an American friend, himself one of the victims,
for some interesting information in regard to the Woburn outbreak
in 1894-5. Almost every household was attacked, and the disease
was locally attributed to the presence of certain highly insanitary
pools in the neighbourhood. Whether there was in this case an
invasion of the district by a particular kind of mosquito before the
outbreak my informant was unable to say.
In these instances the exact means by which the disease was
introduced anew can only be a matter of conjecture. In other
cases, however, a malarial outbreak has appeared to be clearly
attributable to the act of man in artificially bringing about a set
of conditions which are well known to favour the existence of
malaria. On several occasions the construction of ponds for fish
culture has been followed by the appearance of the disease, and
historical examples of this kind in the disastrous malarial endemics
of La Dombes, La Sologne, and La Brenne in France have been
mentioned above. In some ways analogous to such outbreaks,
though not quite so easily explained on the mosquito theory,
1

JamiS) 1898, p. 149.

MALARIA

265

are those epidemics of malaria which have followed on earth
disturbance on a considerable scale, such as for the construction
of railways, canals, or other public works. Of these a very
large number have now been observed in all parts of the world.
Among recent examples may be mentioned the following. During
the construction of the railway in the Transvaal in 1893 the
workmen suffered severely from malaria. At Chifu, in China,
an unusually intense malaria epidemic in 1895-6 was attributed
to the turning up of long undisturbed ground for road-making
and building1. A severe outbreak of fever in the Galle and Matara
districts in Ceylon from July 1895 to June 1896 was said to have
been "clearly traced" to soil disturbance, the result of cutting the
railway from Galle to Matara 2 . Similar observations have been
made in P'ormosa, and nearer home the fact may be recalled that
at the time of the construction of the underground railway in
London, and during the excavation of the St Martin Canal in
Paris (in 1811), and also while the fortifications were being raised
round the latter city in 1840, malarial fever became for the time
quite prevalent in the neighbourhood of the works.
Whether these outbreaks can be wholly explained by supposing
that operations of this kind lead to the formation of surface
irregularities in which water collects and stagnates, offering ready
breeding-grounds for mosquitoes, or whether the problem is not a
more complex one than this simple explanation would make it,
must be regarded at present as a matter of speculation.
On several occasions and in many countries where malaria
has for long been endemic it has at times taken on the most
severe epidemic characters without any of the obvious reasons
just discussed, such as the construction of marshes or lakes, or
disturbance of the earth by man. A very striking example of this
kind was the intense outbreak of malaria in Merv and Tashkent
and the neighbouring country in the year 1897. The disease is
always more or less present there, but in that year it caused a most
violent outbreak, resulting in very heavy mortality. Less marked
examples of epidemic fluctuations of an endemic malaria might be
cited from many other parts of the world.
Finally the diminution or disappearance of malaria in countries
or districts where it had formerly been endemic are phenomena
1
2

Chinese Customs Medical Reports.
N o . 52.
Ceylon Adminishation
Reports {Medical), 1896.

266

MALARIA

which offer many points of interest. It has long been recognised
that the draining of marshes and swamps, the cultivation of
uncultivated land, the construction of dykes and dams to prevent
the flooding of low-lying areas by rivers or by the sea, all tend to
the disappearance of malaria. Nowhere have these measures been
more successful than in Holland, where malaria was once disastrously common, and where now it is a comparative rarity. In the
near future even more striking examples of the power of man to
control, if not extinguish malaria may be available. The "malarial
campaign " has begun in earnest in many parts of the globe. The
"mosquito theory" if it has not quite succeeded in explaining all
that is obscure in regard to this disease, has already led to practical
results of such value that the world can at present afford to wait
for a complete theoretical solution of the malaria problem. In
Italy direct attacks on the malaria-bearing mosquito combined
with the most careful measures to protect the individual from its
bites have already shown that even in the most malarial regions it
is possible to escape the disease, and a wider adoption of these
and similar measures may perhaps ere long lead to the diminution,
if not to the total extinction of malaria in the peninsula. In the
British possessions on the West Coast of Africa a determined war
is being waged against malaria, and the effect has been most
encouraging. The hope indeed is already expressed of obtaining
there a result that at any early period would have seemed incredible
—the removal, that is, of the eternal reproach against those shores
of being " t h e white man's grave." It has at least been shown
that, although it may be impossible to eradicate malaria from
West Africa, the European may now take up his residence there
with enormously increased powers of protecting himself against
the attacks of the disease. In Cuba and elsewhere the energetic
application of similar measures is said to have already diminished
the deaths from malaria in a most striking way.

KALA-AZAR.

General C h a r a c t e r s and E t i o l o g y . Kala-Azar, or black
fever, is the name given to a disease met with in Assam and elsewhere, the true nature of which has given rise to some controversy.
The descriptions of the disease by different authors vary considerably, but in general terms the leading symptoms appear to

KALA-AZAR

267

be debility, wasting, recurrent attacks of high fever in the first
stage and of low fever in the second stage, rapid enlargement of
the spleen and generally also of the liver, darkening of the skin
(whence the name), cachexia, dropsy, and sometimes intercurrent
attacks of pneumonia or dysentery.
Giles, who first investigated the disease for the Indian Government, formed the opinion that it was nothing more than ankylostomiasis in anaemic subjects. Rogers, on the other hand, reported
to the Government in favour of the view that kala-azar is a form of
malaria of a peculiarly infectious character. Ross, in a third
report (1899), endorsed the latter view. Bentley has suggested
that it is identical with Malta fever1.
G e o g r a p h i c a l D i s t r i b u t i o n . Rogers states that this disease
first appeared about the year 1887 in the Rungpore district of
Bengal; and that it crossed the Brahmaputra and so entered
Assam. At first it was seen mostly in the low-lying malarious
country between the Brahmaputra and the Garo Hills, in the
Goalpara district of Assam. It seems to have steadily spread
over a considerable area of Assam and to have caused a very
serious increase in the mortality of that country. The districts
most 'severely affected have been those of Kamrup, Uarrang, and
Nowgong. The Nagar Hills have escaped completely, and some
of the other hill districts have only furnished a very few cases. The
Nowgong district has suffered most severely; in 1897 as many as
12,102 deaths from kala-azar occurred in this district alone 2 .
In the last five years there has been a tendency to decrease in
the number of deaths from this disease, and the hope is expressed
that it may be slowly disappearing from the country. The following
are the returns of deaths from kala-azar in the whole of Assam
from 1893 to 1899:—1893, 10,247; 1894, 13,164; 1895, 15,894;
1896, 15,637; 1897, 18,612; 1898, 16,472; 1899, 14,246.
1
2

Brit. Med. Journ. Sept. -20, 1902.
Report on Sanitary Measures in India in 1899-1900.

MEASLES.
General C h a r a c t e r s and E t i o l o g y . The clinical characters of measles are too well known to require description here.
The cause of the disease, however, is not known, for though it
behaves in all respects like other infective fevers of microbial
origin, no micro-organism clearly specific to it has yet been
demonstrated.
H i s t o r y . "Morbilli"or "Rosalia" was first recognised as
a separate disease distinct from smallpox in the sixteenth century.
But under these terms both measles and scarlet fever seem to have
been dealt with, and it was not until later that Sydenham and
others clearly showed the distinction between the two. Measles
has probably had a wide distribution, at least since medieval
times. It is a typical epidemic disorder, and is subject to great
fluctuations in all countries.
From time to time these epidemics have extended (or, perhaps,
synchronised) over wide areas, including even two or three adjacent
countries. Such were the epidemics of 1796—1801 in France,
Germany, and England; of 1834-6 over the greater part of
Northern and Central Europe; and of 1846-7 in Northern and
Western Europe and North America. Measles nevertheless can
scarcely be said to have ever become truly pandemic, in the sense
that influenza has from time to time.
Recent
Geographical
Distribution.
Europe.
In
England and Wales measles is among the commonest of all
diseases. It is constantly present, and shows remarkably little
fluctuation from year to year.
In the decade 1881-90 the
annual mortality from this cause was 440 per million inhabitants,
and in the decade 1861-70 it was exactly the same; in the
intermediate decade it was somewhat lower, 378 per million.

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269

In some recent years it has been unusually prevalent, in 1896
causing a mortality of no less than 572 per million, a figure which
had only once been exceeded before, when, in the year 1887,
it rose to 602.
In Scotland the measles mortality has varied, much as it has
in England, in recent times. In the decade 1881-90 the mortality
ratio from this cause was 385 per million. It is noteworthy that
a high measles death-rate (500 per million) occurred in Scotland
in 1895, in the year preceding an unusually high death-rate from
the same cause in England. In 1896 the mortality figure for
measles in Scotland was 360 and in 1897 it was 490. The
disease is essentially one of urban populations in Scotland as in
England.
In Ireland the mortality from measles has varied very widely
in recent years; in 1888 there was a severe epidemic of the disease
in the island.
In France the urban mortality from measles {i.e. in towns with
over 10,000 inhabitants) has varied much in recent years; in 1886
—90 it was equivalent to a ratio of 460 per million, and has since
varied between 170 and 380. In Paris the malady now causes
more deaths than any other infectious disease 1 .
In Belgium the deaths from measles remained remarkably constant in the years 1870 to 1895, the annual mean mortality from
this cause scarcely varying from (approximately) 500 or so per
million inhabitants. In 1897, however, it fell to about 300 per
million.
Holland, on the other hand, has shown a very fluctuating
mortality from measles, varying between n o per million in 1895
and 360 per million in 1889, the minima and maxima respectively
in the decade ending in 1898.
In the German Empire as a whole the death-rate from measles
was returned in 1894 as 332 per million, which was a slight increase on the mean of 297 per million returned for the preceding
seven years. In Prussia alone the rate was 311 in 1894 against a
mean of 319 in the preceding septennium and one of 450 in the
seven-year period before that. Saxony and Wiirtemburg have
1
The deaths from measles in Paris in the five years 1895 to 1899 weie
respectively 679, 658, 821, 876, and 904. These figures indicate a considerable
increase, in either the prevalence, or mortality, or both, of measles in the French
capital.

270

MEASLES

had comparatively lowT measles rates, the former recording means
of 294 and 271 in the two septennia named and a rate of 133 in
1894, while in the latter the three corresponding figures were 154,
221, and 272 respectively. In Bavaria and Swabia measles is, next
to croupous pneumonia, the most common of all diseases.
No less marked fluctuations in the recorded deaths from
measles are seen from year to year in Denmark. In the urban
population of that kingdom the ratio rose from a mean of 279 in
the septennium 1880—1886 to one of 403 in the next septennium,
but fell to 297 in 1894. The rates for individual years show wide
variations. The same is true for Norway, where the rates are on
the whole low; in 1893 t n e recorded deaths from measles were
scarcely more than 60 per million, but in 1894 they rose to about
230 in the same unit of population. In Sweden the ratio was 62
per million in 1894 as compared with annual means of about three
times that number in the preceding fourteen years. Judging from
these figures it would appear that measles is, on the whole, a considerably less prevalent disease in Scandinavian countries than in
the British Isles.
Measles appears to be more prevalent in Russia than in any
other European country. In the three years 1893-95 the annual
mean death-rate from this cause was 870 per million per annum
in European Russia. No part of the country is free from it. It
appears to be somewhat less prevalent in the northern government
of Archangel, but is exceedingly rife in the adjoining governments.
The Polish governments have on the whole shown lower mortality
rates than other parts of the country, and occasionally it has been
low in the Don Cossack Territory. But everywhere great fluctuations are shown from year to year.
In Austria measles caused a mean mortality of 479 per million
per annum between 1880 and 1886, and approximately the same in
the next septennium. More recently it seems to have caused fewer
deaths.
In Hungary the deaths from measles were somewhat higher,
and in Croatia and Slavonia very much higher, at any rate in
the period 1887 to 1893, w n e n they were equivalent to a mortality
of 879 per million per annum.
Switzerland shows, like so many other countries, wide variations
in the annual recorded measles mortality; for example in the
fifteen principal Swiss towns the deaths were in 1896 equal to a

MEASLES

271

ratio of about 260 per million, and in 1897 to one of about 180
only.
In Italy the mortality rate for measles has varied between
292 per million in 1894 and 806 per million in 1887, the minimum and maximum rates respectively in the ten years ending in
1896, with a tendency to diminution towards the end of that period.
In Spain the disease appears to be exceedingly common.
In the Balkan Peninsula measles is also well known. It is
practically never absent from Constantinople, and records of it
from the Salonika province and from other parts of European
Turkey are by no means rare. In Greece also measles is a
frequent disorder; it was seriously epidemic in Athens in 1898.
In Iceland measles has on four occasions caused severe
epidemics, but it is not endemic in the island.
In the Faroes the disease has also caused four epidemics in
the past, but if it exists there now, it certainly cannot be common.
It is not mentioned by a recent traveller to those islands, who
discusses at some length the principal diseases met with there 1 .
In Malta measles is frequently seen (150 cases of the disease
were treated in 1898), and in Cyprus a mild type of the disorder
occasionally becomes epidemic.
Asia. Measles is constantly present in the Caucasus and in
Transcaucasia. The number of registered cases of the disease
here fluctuates considerably, but is usually somewhat lower than
in European Russia generally, and the case-ratio per million of
the population is about equal to that of the Polish governments.
The mortality ratio in 1895 w a s about 250 per million for the
whole of the two regions, and something under 200 per million
in each of the preceding eight years. The imperfections of registration of both cases and deaths in this part of Russia has to be
borne in mind, and similar caution is required in regard to the
returns from Central Asia and Siberia. Of the numerous races
in the Caucasus the Imeritians are said to be peculiarly susceptible
to measles.
The returns from Russian Central Asia have always indicated
a remarkably low prevalence of measles, and could the figures be
regarded as trustworthy it would be permissible to state that in
the years 1887—1895 measles prevailed in these regions to only
one-twentieth, or sometimes to only one-fiftieth, of the extent to
1

The Faroe Islands, by J. Russell-Jeaffreson, F.R.G.S. 1898.

272

MEASLES

which it prevailed in European Russia in the same period.
Untrustworthy as the figures are, it is probable that the great
difference between them and the corresponding figures for European Russia is only in part accounted for by the greater imperfections in registration, and it is almost certain that the disease
is very considerably less prevalent in Central Asiatic than in
European Russia. This conclusion is the more permissible in
that in Siberia, where the imperfections of registration are probably almost as great as in Central Asia, the number of registered
cases of measles have, in the period named, borne a ratio to the
population only slightly lower than in European Russia. It is
noteworthy that among the Bashkirs, living on the EuropeanAsiatic frontiers, about the Ural and Volga rivers, measles is rare.
In the northerly government of Yakutsk it has been quite common
in recent years, and in 1900 a most violent epidemic of the
disease prevailed in the extreme north-eastern portion of Siberia,
Kamtchatka, and the Commander Islands. In this epidemic both
adults and children suffered, and in some places as many as
one-fourth of the population are said to have died from it. It
was believed that the infection was carried from Vladivostok.
In Asia Minor measles is not unknown. It was epidemic at
Trebizond in June 1898; at Bayazid in 1900; at Erzerum in the
same year, and again after the severe earthquakes there in 1901.
In the island of Samos a mild epidemic prevailed in the autumn
of 1901. In Syria, Mesopotamia, and Arabia it appears from time
to time, and cases of the disease are by no means rare among the
Mussulman pilgrims at Mecca and Medina in the Hedjaz.
In India measles is quite a frequent disease, though probably
less so than in Europe. It attacks both Europeans and natives,
and at times becomes epidemic. It would seem to be comparatively prevalent among the Gurkhas.
In Ceylon it causes more annual deaths than any other
of the zymotic diseases. Slight epidemics are frequently recorded in many parts of the island. It varies greatly in its
prevalence, and in 1891 caused a mortality of 190 per million
inhabitants; in 1894 the mortality rate was only 6 0 ; and in 1897
it was again about 190 per million.
In Burma measles is also very common, and in the Southern
Shan States it is one of the principal causes of mortality in
children.

MEASLES

273

In the Dutch East Indies it prevails to some extent. Among
the Netherlands troops stationed in this part of the world a few
mild cases occurred in the year 1897.
In China measles is an exceedingly common disease, attacking
both the native Chinese and European residents. At Hankow
many cases were recorded as occurring in native children in
1890-91, and again in 1894. At Kiukiang a wide-spread
epidemic occurred in 1895, attacking especially the children
of a Roman Catholic mission school and orphanage 3 as many
as 140 children were down with it at the same time in
this institution. At Chungking it commonly occurs in native
children in the spring and autumn. At Swatow it was epidemic
in the summer of 1891. It is seldom absent from Shanghai, and
at times becomes epidemic there. In the Pakhoi district it
prevailed widely in December 1897 and January 1898, attacking
"nearly every house in the district." In Hongkong it is a
common disease:
In Japan measles occasionally causes widespread epidemics.
A recent writer in the Sei-i-Kwai medical journal 1 states that the
great epidemics recur at intervals of about twenty years, while in
the intervals " small endemics " and isolated cases are frequent.
Australasia.
In British New Guinea measles seems to be
unknown among the native inhabitants.
In Australia, where measles is said to have been introduced in
1854, it now occurs at times in the form of epidemics, and the
annual mortality from the disease varies very greatly. In Victoria
it has not been very active in recent years; in 1897 it caused only
3 deaths in Melbourne. In South Australia it was epidemic
in 1891, causing as many as 261 deaths in a population of about
320,000 (a ratio of approximately 800 per million), but in the
following years the disease became quiescent again until 1898,
when it was somewhat prevalent, causing 54 deaths in a population
which had considerably increased in the interval. In New South
Wales measles has been the cause of little mortality in recent
years.
In West Australia measles caused no deaths in the years
1889 to 1892; 21 deaths and 6 deaths respectively in the two
following years; then again caused no deaths for two years, and
in 1897 and 1898 was responsible for 1 death and 34 deaths
1

C.

October, 1898.
18

274

MEASLES

respectively. It will be noted that a recrudescence of the disease
occurred here, as in South Australia and New Zealand, in 1898.
In Tasmania the disease at times becomes widely epidemic,
and then for several years together almost disappears. A severe
epidemic occurred in 1885, and another still more general one in
1893 and 1894. In 1893, when the disease was also epidemic in
New Zealand, as many as 2773 cases were notified and 36 deaths
were recorded, and in 1894 there were 547 notifications with
15 deaths. In 1895 the disease still prevailed to some extent
in Tasmania, but was very mild in character and no death from
it was recorded. The 36 deaths in 1893 were equivalent to a
mortality ratio of about 225 per million—not a high figure for an
"epidemic" year. The mildness in type of the disorder is clear
from the figures quoted above.
In New Zealand measles was widely epidemic in J893, causing
525 deaths. This outbreak had been preceded and was followed
by periods of quiescence; but in 1898 there was a recrudescence,
causing 57 deaths.
Measles is common in many of the Pacific Islands. In Fiji,
where it was introduced from Australia in 1875 and caused a
terribly fatal epidemic, the disease is now endemic. It attacks
both whites and natives ; in 1897 34 cases of measles (29 of which
were in Fijians) were treated in the colonial hospital at Suva.
It is known to exist also in New Caledonia, in the Society Islands
and elsewhere. In the Marquesas group, however, it is said to be
unknown.
Africa. In the countries forming the northern shores of
Africa measles is not a very common disease. In Morocco no
certain mention of it appears to be on record. In Algeria, on
the other hand, it occasionally becomes epidemic and is generally
a cause of high mortality among children. In Tunisia it is said
to be very rare; an epidemic, however, occurred in 1892 in
Tunis, causing 139 deaths. Its rarity here may be judged by the
statement that in the French army of occupation the average
annual sickness-rate from measles is only 0-89 per 1000 strength,
as contrasted with a rate of 5*59 for the rest of the French army
in other parts of the world.
In Egypt epidemics of measles occur with very considerable
frequency, and the disease is spoken of as the most fatal of all
infectious diseases among Egyptian children. Dr Engel Bey has

MEASLES

2.75

stated that more than one-third of the total deaths in children
under five years of age which occurred in the towns of Lower
Egypt in the five years 1886-1890 were due to this cause.
On the West Coast of Africa measles is undoubtedly met with;
and while it appears to be far from common in some parts, in
others it at times causes severe epidemics. Davidson states that
in Senegal it is said to be more severe than in France, but whether
this points to a wider prevalence or to a greater case-fatality in
individuals is not clear. In the colonial hospitals of Sierra
Leone and Lagos no cases of measles were treated in the year
1897, and I have found no certain mention of the disease in either
colony. On the Gold Coast, however, the disease exists, and
3 cases were admitted to the colonial hospital in 1897. In the
British possessions on the Gambia measles is at times prevalent;
in the latter half of 1891 it gave rise to an epidemic of severe
type. It is known also to exist and to attack the natives in the
Belgian Congo. In the German Cameroon territory, on the other
hand, it is said to be unknown.
Whether the disease exists to any extent among the negro
races in Central Africa appears to be doubtful. Pruen states
that he never succeeded in recognising it in the natives of
Central Africa, but he adds that he is far from sure that it
does not exist among them. Cook states with regard to Uganda
that " measles are very common, and many infants die of subsequent broncho-pneumonia, their unclothed bodies being but
poorly fitted to withstand the evil effects of chill 1 ."
On the eastern side of the African continent the degree of
prevalence of measles is a matter of some uncertainty. Epidemics
of the disease are said to be far from rare in Zanzibar. In
Abyssinia it is known. In British East Africa it is probably rare.
In Madagascar measles is said at times to become epidemic.
In the Mascarene Islands, Mauritius, Reunion, and Rodriguez,
measles at times becomes epidemic; in the intervals it remains
sporadic, and, though the individual cases are often grave, the
disease seems for a time to have lost its infectiousness. A similar
character is common to this malady in many other parts of the
world. In the Comoro Islands measles is occasionally epidemic.
In Madeira and the Canary Islands the disease is known, though
apparently not in a severe form. In St Helena it has not been
3

Journ. Trop. Afed., June 1, 1901.
18—2

276

MEASLES

mentioned as prevailing in the recent Health Reports on that
island, and the belief has been expressed that it has probably not
occurred there since an epidemic in 1807.
In South Africa measles is in many parts a very prevalent
disease and its behaviour appears to differ in no way from
that with which we are familiar at home. From the Annual
Reports on the Public Health of the various colonies in South
Africa it may be gathered that the disease at times causes more
or less severe epidemics in many places throughout the colonies.
In the year 1897, for example, it was epidemic at Albany, at
Aliwal North, in the Jamestown district and in many other
places; in 1898 outbreaks occurred in Strydenberg sub-district,
in Phillipstown town and district, and elsewhere. All the places
just mentioned are in Cape Colony. In regard to the native
territories, Tembuland, the Transkei, and Pondoland, measles has
not been mentioned in some recent reports from these regions,
but it may be doubted if this indicates that the disease is not
known there. In the Transvaal and Orange Free State measles
has from time to time caused severe epidemics. In Bechuanaland
the disease is certainly known, and is said to have usually accompanied or followed smallpox, the natives calling it sekoripanye
se senye, or the little-pox. . In Natal it is at times epidemic, and
also in Zululand.
In South Africa generally measles appears to have been
unknown before the advent of the white colonist, but it is now
a common disorder. The disastrous effects of measles in the
"concentration camps" necessitated by the recent war will be
fresh in the memory of all. In these camps children in large
numbers and at the most susceptible age were brought together,
and it is not surprising that when measles was once introduced
among them it spread rapidly. The high death-rate is easily
accounted for by the terrible ignorance displayed by the children's
mothers in the management of the disease, as revealed in recent
blue-books published on the subject.
North and Central America. In Greenland measles is said to
be unknown, but, somewhat further south, it appeared in the
Hudson Bay Territory in 1864, and ten years later was the cause
of a very deadly epidemic among the natives in Kadiak.
It is a comparatively common disease throughout the greater
portion of Canada. In the province of Quebec it is perma-

MEASLES

277

nentry present; there is no season in which it is not seen in
some town or district, and it is often prevalent in many places
at the same time. Its behaviour here is as apparently capricious
and irregular as in many other parts of the world. In the
province of Ontario the disease finds frequent mention in
successive annual Reports of the Board of Health as prevailing in many parts of the province. In Manitoba it is not
infrequently epidemic, and on several occasions outbreaks of the
disease have been clearly due to an importation by immigrants
from elsewhere. In Nova Scotia sporadic outbreaks of measles
not infrequently occur. In New Brunswick it is one of the most
conspicuous diseases; it is said to occur in " epidemic waves"
at varying intervals; in the city and county of St John 108 cases
of the disease were registered in 1897. In British Columbia
measles is at times epidemic in many parts of the colony.
In the United States measles is met writh throughout, occurring
especially in the spring months of March, April, and May. It is
said to be mainly a rural disease in the States, and it is noteworthy
that in 1897—to take the returns of a single year—no death
from it was recorded in the towns and cities of the States of
Arizona, Arkansas, Delaware, Idaho, Mississippi, Nevada, and
N. Carolina, while in many other States the numbers of deaths
from measles were small. In 'Massachusetts the disease has
been diminishing in prevalence in recent years. In Michigan
the annual mortality in the years 1881-1895 has varied, very
widely and very irregularly, between 19*3 (in 1895) and 206
(in 1888) per million living. The disorder is at times extremely
fatal among the indigenous Indians in the United States.
In Central America measles is' neither frequent nor severe.
In Mexico it is met with at times. In British Honduras it is not
common, but at times causes widespread epidemics.
In the West Indian Islands measles at times prevails to a
considerable extent. In Cuba it is said to be rare; but in
Jamaica it has recently been very frequently seen.
It was
epidemic in 1897 in the eastern district of the latter island,
and in 1898 outbreaks of the disease were recorded in many
places in the island. In Barbados a wide epidemic occurred in
1896 after the arrival of a British regiment from Halifax in
December 1895 ; no parish in the island escaped. In St Lucia
the malady was also prevalent in 1896, and in December of

278

MEASLES

that year it became widely epidemic, but in a mild form, in
St Vincent. It was also slightly epidemic in Trinidad and Tobago
in 1896. Throughout the Leeward Islands it appears to have
been somewhat rare in recent years.
South America.
In British Guiana measles occasionally
becomes epidemic; it did so in 1898, and in 1890 it was
widely prevalent at the same time as influenza. In Dutch and
French Guiana the disease is seen occasionally, but it is
usually milder than in Europe. It is met with throughout Brazil
in the form of recurring epidemics, and it is said to be more
severe in type here than in Central America and the West Indies.
One of the worst epidemics on record occurred among the natives
on the banks of the Amazon in the year 1749. Measles is also
frequently epidemic in Paraguay, Uruguay, and the Argentine
Republic, and it is no less familiar in Bolivia and Chile on the
western side of the continent. For Ecuador and Peru, and for
Venezuela, further north, there appears to be no trustworthy
evidence as to the occurrence or behaviour of the malady 1 ; but
it can certainly exist in Colombia, an epidemic having broken
out at Palmira in that country in December 19002.

Factors determining the Geographical Distribution.
Measles is one of the most widely prevalent of all diseases. It
is found in cold, temperate, sub-tropical, and tropical countries.
It is rarer in some countries than in others, but its degree of
rarity seems to show little definite relation to the distance of the
country from the equator, save that on the whole measles appears
to be commoner in temperate countries than in tropical, and that
in such northerly places as Iceland, Greenland, and the Hudson
Bay territory it is either unknown or only occurs as an imported
disease. It is probable that the last phenomenon is due rather to
the isolated position of these countries or islands than to their
northerly latitude; as when measles has been imported to Iceland
and to the Hudson Bay territory it has raged with terrible
violence. In these epidemics the disease appears to prevail until
it exhausts all the available material, and then to disappear and
remain absent until it is imported again.
Measles is far more prevalent in urban than in rural populations, and is particularly rife in densely populated large towns.
1
Neither Hirsch nor Davidson makes any mention of measles in these
2
countries.
Journ. Trop. Med., April, 1901.

MEASLES

279

London and Liverpool, for example, almost always return very
high death-rates from measles. Otherwise the general distribution
of the disease in England and Wales varies very considerably in
different years. This is to a great extent accounted for by the
varying periods which elapse between successive epidemic prevalences of the disease in different districts. Measles is essentially
a disease of childhood, and when it prevails in a district for a year
or two it seems to exhaust all the available patients of susceptible
age, and then time is needed for the appearance of a fresh supply
of subjects. An exception to this rule may perhaps be found
in very populous towns, such as London or Liverpool, where the
disease finds a constant supply of susceptible material.
The
Registrar-General has pointed out that "when there has been
a severe outbreak in any year in a given area, it will be found that
the returns of the next year show, as a rule, a subsidence in the
area itself, but an extension to the adjoining districts; another
year, and these districts are also comparatively free, while a
wider circle of surrounding districts has become infected 1 ."
Numerous examples of this behaviour of the disease have been
observed in recent years. It has further been pointed out by
the Registrar-General that high minimum rates of measles mortality are usually found in large populous areas without breaks in
the population, while the occurrence of high maximum rates in
these same areas points either to gross carelessness or to a bad
sanitary condition, or probably to both. On the other hand, low
minimum rates are apparently associated with populations broken
up into detached groups, "since the infection may under such
circumstances fail to be conveyed from one group to another, in
which case it may die out for a season."
It is very probable that the disease behaves in a similar
manner in other countries, and that this is, in part at any rate,
the explanation of its rarity in remote islands, such as Iceland and
the Faroes, and of its extreme severity when it is newly imported
to a community long free from it.
While, as already pointed out, measles is found in all latitudes,
there is reason to believe that it is often of a somewhat milder and
more benign character in tropical and sub-tropical climates than
elsewhere, but even this rule is not without marked exceptions.
In relation to season, measles varies greatly in different parts of
1

1891 Report.

28o

MEASLES

the world, and it has shown itself capable of prevailing as a severe
epidemic in all seasons. It is, however, in most countries more
frequent in the colder than in the warmer months.
Neither the character of the soil nor the degree of elevation
above sea-level appears to have any great influence upon this
disease. In its relation to race, measles appears to be as indifferent as in its relation to most other external conditions. All
races are susceptible to it, and it has been shown that it is just as
capable of attacking the Chinaman, the Hindu, and the Negro
as the European. It appears on the whole, however, to be
decidedly less common in the African negro than in most other
races.
Measles is one of the most infectious or " contagious " of all
the infective fevers. It is spread by the movements of infected
persons, and also probably by means of fomites. Its intensity in
different epidemics varies widely; some of the most severe and
fatal outbreaks, as already stated, have occurred in communities
long free from it, to which it has been newly imported. The
instance of the intense and fatal epidemic of measles in Fiji has
been mentioned above. In this outbreak the infection was believed to have been brought to the islands from Sydney in the
retinue of king Kakobau, and as many as 20,000 of the natives,
or between one-fifth and one-fourth of the population, died from it.
Other equally deadly outbreaks of measles under similar circumstances were those of 1749, among the natives on the river
Amazon; of 1829, in Astoria; of 1846, among the Indians of
Hudson Bay territory; of 1852, among the Hottentots at the
C a p e ; of 1854 and 1861, among the natives in Tasmania; and
of 1874, in Mauritius. Epidemics of such high fatality as these
are rare, and can perhaps-only occur under the special conditions
just mentioned—that is to say, the introduction of measles infection into an isolated community long free from it. The disease,
however, may be almost equally fatal under certain other conditions,
of which perhaps over-crowding and imperfect attention to nursing
and medical treatment are the most important. Measles is, indeed, a disorder the lightness or severity of which depends, to
an extent that can scarcely be exaggerated, upon the care and
attention bestowed upon the individual patient or patients. Hence
when it has broken out under circumstances where such care and
attention were well-nigh impossible, or where through ignorance

MEASLES

28l

and culpable neglect they were not applied, measles has often
become a very alarming and deadly disease. Examples of such
outbreaks during war-time are well-known, and would usually fall
into the first of the two classes of outbreaks just named—that is
to say, outbreaks under conditions where proper care and attention
were well-nigh impossible. Such were the fatal measles epidemics
among the Confederate troops in America in 1866; among the
Garde Mobile during the siege of Paris in 1871; and in the
National Army of Paraguay, in the war with Brazil. In the latter
instance, one-fifth of the army were said to have been swept away
by measles in three months, "not from the severity of the disease,"
but "from want of shelter and proper food." In the second
class of outbreaks just mentioned—that is to say, those where
proper care and attention were not applied from sheer lack
of knowledge and culpable neglect—must be placed the recent
measles epidemics in the concentration camps in South Africa. If
^t is harrowing to read of the terribly high mortality among the
children brought together largely for reasons of humanity—for
they would otherwise have been exposed to death on the veld—
it is still more harrowing to read of the astounding ignorance and
shocking treatment, or rather the lack of all proper treatment, care,
and attention, to which those attacked were exposed by their
mothers and the women of the camp generally.
Measles, as stated, is essentially a disorder of childhood. The
majority of deaths attributed to it fall in the first two years of
life. It is rather less fatal to females than to males. So far as
is known at present, measles is neither a milk- nor a water-borne
disease, and it is not known to affect any of the lower animals.

MEDITERRANEAN FEVER.
(MALTA FEVER, ROCK FEVER, NEAPOLITAN
FEVER, U N D U L A N T FEVER.)
G e n e r a l Characters a n d E t i o l o g y . It is only within
comparatively recent years that the specific character of Mediterranean or undulant fever has been recognised, and for the presenl
its geographical distribution is a matter of some uncertainty. While
the disease in its typical form presents characteristic features by
which it can without much difficulty be distinguished from other
diseases, there is a group of fevers the symptoms of which resemble those of Mediterranean fever sufficiently to have caused
no little confusion and uncertainty. The most important member
of this group is that to which the name typho-malarial fever has
been given. Considerable discussion has taken place as to the
exact nature, or even as to the existence of this fever as a specific
disease, and recently the suggestion has been made that typhomalarial fever and Mediterranean fever may be one and the same
malady. A similar suggestion has been made with regard to
kala-azar. For the present, however, it seems better to consider
separately what is known of the affections described under these
names.
Mediterranean fever has been defined as follows:—x\n endemic, pyrexial disease, occasionally prevailing as an epidemic,
having a long and indefinite duration, an irregular course, with
an almost invariable tendency to undulatory pyrexial relapses. It
is usually characterized by constipation, profuse perspirations, and
accompanied or followed by symptoms of a neuralgic character
by swelling of the joints with effusion, and other rheumatoic
symptoms. After death the spleen is found to be enlarged anc

MEDITERRANEAN

FEVER

283

often softened, many of the organs are congested, but Peyer's
glands are neither enlarged nor ulcerated, nor is ulceration present
in other parts of the small intestine. There is a constant occurrence in certain tissues of a definite species of micro-organism 1 .
This micro-organism is in the form of a coccus, and is usually
known as micrococcus melitensis; it was first described by Bruce
in 1887.
The disease thus described appears to have a somewhat wide
distribution over the earth's surface, and evidence is constantly
being brought forward of its endemicity in places where it was
not hitherto known to exist, and occasionally it would seem to
become epidemic in places where it is unknown as an endemic
disease. The specific cause of the fever, however, appears to
remain for long periods, if not permanently, in certain geographical
areas, and " endemicity " may be regarded as an important feature
of the disease.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe.
In the
British Isles this disease is never seen, excepting in patients who
have contracted it abroad. In France, according to Jaccoud,
Mediterranean fever is occasionally met with in Paris, but only
as an imported disease from Italy. Whether it exists along the
Mediterranean shores of France is uncertain, but the late
Dr Hughes, who made a close study of the disease, expressed
the belief that it is not common there. Throughout Northern
and Central Europe generally there is an absence of evidence
of its existence, either as an endemic or an imported disorder,
and it is essentially in the south of Europe and the.islands of
the Mediterranean Sea that the fever is commonly met with. It
is seen in the south of Spain, and its comparative frequency at
Gibraltar has added the name of Rock Fever to the long list of
names by which the disease has been known at different times
and places. Italy is another important endemic home of the
disease. In Naples and many places near, such as Caserta,
Benevento, Campobasso, etc., it is met with. It became epidemic in Naples in 1872. In Middle and Upper Italy it is seen
at Rome, Ariccia, Terano, Fermo, and Padua, the frequency
of the disease diminishing from south to north. It was described
in Southern Italy in 1879. It is of common occurrence in Sicily,
1
Mediterranean Fever or Undulant Fever, by M. Louis Hughes, Surg.3apt., Army Medical Staff. London, 1897.

284

MEDITERRANEAN FEVER

where it is endemic at Catania and Palermo, and is also met with
at Taormina and other villages on the southern side of Mount
Etna. Epidemics of the disease occurred at Catania in 1872^
1878, and 1884. In the Balearic Isles the fever is believed to be
endemic in Minorca. In Sardinia it is well known at Cagliari
and in the interior of the island, while there is also good reason
to believe that it exists in Corsica 1 . Malta is, perhaps, the worst
of all the endemic centres of this disease, and Malta fever is one
of the names by which it is most familiarly described. It is one
of the most serious of all maladies in the island, and is a graver
risk to the troops and others living there than is, for example,
enteric fever.
The great frequency of this fever in Malta
may be seen from the following recent figures:—in 1898, while
only 12 cases of scarlet fever, 14 of diphtheria, 150 of measles,
and 294 of enteric fever were registered, as many as 724 cases of
Mediterranean fever were reported 2 . It is possible that the disease
also exists on the shores of the Adriatic; Brunner of Trieste h r
recorded the case of a workman employed in constructing a railway in Southern Dalmatia who suffered from it3.
Further east, Mediterranean fever is met with in some parts of
the Balkan peninsula. It is said to occur in Constantinople, but
bacteriological proof of its existence there is lacking, and I have
not succeeded in hearing of a single case which could with
absolute certainty be regarded as of this nature. A form of
unclassified fever is, however, very common in this city, which
in some cases bears considerable resemblance to Malta fever
in its duration and general symptoms.
A similar disease, believed by some to be the same disease,
is also seen at Athens (Typhaldos). In Cyprus the fever is
spoken of as endemic in many of the towns (Karageorgiades) 4 ;
and in Crete it is said to have become so since the year 1890
(Capetanakis).
1
Kretz records the case of a physician who suffered, in Ajaccio, from a
fever of six months' duration, and whose blood after recovery gave positive
results with the agglutination test. {Wiener Klin. Woch., N o . 49. 1897.)
2
M a l t a : Public Health Report for 1898. T h e figures quoted appear to
include those of Gozo as well as of M a l t a ; but there are discrepancies in the
report which do not seem easy to explain.
3
Wiener Klin. Woc/i., F e b . 1900.
4
Williamson (Brit. Med. Joum., Sept. 14, 1901), on the other hand, says
the fever is not common in Cyprus.

DISTRIBUTION

OF I

2DITERRANEAN

OR MALTA F E V E R IN T H E MEDITERRANEAN

BASIN

MEDITERRANEAN

FEVER

285

Africa, The southern shores of the Mediterranean appear to
favour the prevalence of the disease to which this sea has given
its most convenient name no less than the northern shores.
Thus Mediterranean fever is met with in Tunis, in Algiers, and
perhaps in Egypt.
In Tunis, Perini stated that he saw the
disease first in the year 1879; and he added that, when the
French occupation took place, an epidemic of it broke out at
Goletta, the muddy sea-port town near Tunis, and that it had
since then been endemic there.
Regarding Algeria the evidence is less clear. Brault states that
he has seen cases there which clinically resembled Mediterranean
fever, but no bacteriological inquiry was made to confirm the
diagnosis. Recently the disease has been recognised in the
Canary Islands, but it is here apparently of a milder character
than in the Mediterranean 1 .
In regard to the existence of the fever in Egypt it appears
that cases are not infrequently seen at Alexandria, but Hughes
states that reliable information was difficult to obtain, and that
most of the cases there proved to be instances of relapse in men
transferred from Malta, where they had already suffered from the
disease. Morgan, on the other hand, is quoted as mentioning
(in 1892) the occurrence of a few cases of Mediterranean fever
in men stationed in Alexandria who had never been in other
parts of the Mediterranean. Bruce and others state that it is
unknown in Tripoli, and Hughes, who visited Benghazi and Derna
in 1893, failed to find evidence of the disease there, though at
the same time he dwells on the unreliable nature of the evidence
available. On the African shores of the Red Sea cases of this
fever have been seen. At Suakim and Massowa Milnes has
described cases indistinguishable from those seen in Malta, Naples,
and Crete, and Pasquale, Rho, and others have furnished similar
evidence of the existence of the disease there.
On the eastern shores of Africa, in Zanzibar and on the
neighbouring coasts, a fever closely allied to, if not identical
with Mediterranean fever is also said to be present 2 .
Similar
cases, about which the like doubt exists, have also been reported
from Mashonaland 3 .
1

Melland, Brit. Med. Assoc. Annual Meeting, 1902.
Joum. Trop. Med., September, 1898.
3
Ibid. Nov. 1900.
2

286

MEDITERRANEAN

FEVER

Asia. Several authorities mention the existence of Mediterranean fever at Smyrna in Asia Minor. Cases of a very similar
disease have also been described as occurring at Jerusalem, but
here, as elsewhere, the confusion existing between Mediterranean
fever and so-called typho-malarial fever renders it impossible
to make any more definite statement. The same is true in
regard to the doubtful existence of Mediterranean fever at
Aden.
The question of the presence or absence of this disease in
the Indian peninsula is one of some difficulty.
Here, as in
Asia Minor and at Aden, cases described by some" as typhomalaria, and by others as resembling true Mediterranean fever,
have been met with, and these will be referred to subsequently.
In 1879 an outbreak of a disease occurred at Chorbattia, of
which the clinical description and the temperature charts are
said to have been practically indistinguishable from those of
Mediterranean fever. Squire, again, mentions a similar occurrence at Dinapur, in Lower Bengal, in the 70th regiment, in
the year 1883. Hughes also describes the case of a man
landed at Malta from a troopship coming from India. H e was
said to be in the second week of an attack of enteric fever,
which had developed seven days after he left Bombay. The
symptoms resembled those of Mediterranean fever rather than
of enteric or malaria, quinine had no beneficial effect, and after
death (which occurred on the 14th day of the disease), while
no enteric lesions were present, the post-mortem appearances were
just those met with in acute and fatal cases of Mediterranean
fever. Unfortunately it proved impossible to confirm this opinion
by bacteriological examination. The same author quotes the
evidence of many Indian medical officers in support of the view
that this disease does exist in India; and adds that Professor
A. E. Wright and others at Netley have obtained a serum
reaction with the blood of so-called enteric fever cases invalided
from Sabathu (near Simla, in the western Himalayas) exactly
similar to that obtained in the case of Mediterranean fever.
Many of these patients had had no previous Mediterranean
service, and had suffered at Netley from symptoms indistinguishable from those of the disease in question.
More recently
observations have been published pointing to the existence of
the malady in Bombay, in several places in the Punjab, and in

MEDITERRANEAN

FEVER

287

Simla itself1. To sum up briefly it may be said that there is
constantly increasing evidence that a disease closely resembling,
if not identical with Mediterranean fever exists rather widely in
India 2 .
The evidence for the presence of Mediterranean fever in
China is of the same nature as that just quoted for its presence
in India. Thus Durand and others have described cases of an
analogous disease as occurring in Hongkong. Manson states
that he has probably seen cases in China, and Wright has
described a case of continued fever in a person from Hongkong,
in which the blood gave a serum reaction with the micrococcus
melitensis similar to that of patients who had suffered from the
fever now under consideration. Quite recently too it has been
stated that this fever exists endemically in the Philippine Islands.
It would seem to be quite common in Manila: one observer saw
three cases there in a single week, each of which gave a marked
agglutination reaction with the micrococcus even in high dilutions 3 .
America. Very great doubt existed until recently concerning
the prevalence of Mediterranean fever on the continent of North
America, but recent investigations have shown that it probably
does exist there. One case apparently of this nature was mentioned at a meeting of the Pathological Society of Philadelphia
(February 1st, 1899). The patient was an army officer, and it
was thought that he had contracted the affection in Puerto Rico,
in the West Indies; his blood gave a reaction with the micrococcus
melitensis similar to that with blood of a Mediterranean fever
patient. This was believed to have been the first case of the
disease that had ever occurred in the States, and the supposed
source of infection was, as just stated, not in the States themselves
but in a West Indian island. Eight cases have been observed
also in the Army and Navy Hospital at Hot Springs, Arkansas,
but all the patients seem to have contracted the disease elsewhere
—five apparently in the Philippines, one in Cuba, one was a
sailor from a man-of-war that had been cruising along the coasts
1

Indian Medical Gazette, Sept. and Nov. 1900, and Jan. 1901.
Three cases of the fever, in each of which the agglutination test gave
positive results, were observed in the Swat Valley in 1900. (Greig, Indian
Medical Gazette, March, 1901.) The disease is also believed to exist in Assam.
(Hislop, Indian Medical Record, May, 1902.)
3
Philadelphia Medical Record, Nov. 1900.
2

288

MEDITERRANEAN

FEVER

of South and Central America, and the eighth was a sailor from
a vessel stationed in West Indian waters.
Finally it must be added that at the General Medical Congress
held in Washington in 1893 a class of fever was described as
met with in Venezuela, and this was later compared with the fever
of Malta and Gibraltar, which it appeared to resemble closely.

Factors concerned in the Geographical Distribution.
Until fuller and more certain data are available to show the
exact distribution of this disease over the earth's surface, it is
difficult to draw conclusions as to the influence of various conditions in determining it. Year by year, almost month by
month, fresh observations are published from many parts of the
world tending to show that this fever is diffused much more
widely than had been hitherto believed to be the case. So that
any conclusions that may be drawn as to its relation to external
circumstances can only be put forward tentatively, and as liable to
be upset by later knowledge.
But so far as present knowledge goes, it allows us to say that
the great home of this fever is the basin of the Mediterranean
Sea; that it is not equally common on all the shores of that sea,
but that where it is common here it is very much more so than
in any other part of the earth's surface. In the Mediterranean
basin it is most common and most severe at Malta, at Gibraltar,
in the Balearic Islands, in Cyprus, in Crete, and on the south
Italian coast. But it is seen more or less in many other parts
of both the European and African shores of the sea, and in the
Levant. Elsewhere the disease has occurred with more or less
certainty in scattered parts of the continents of Asia, Africa, and
America, but not hitherto in Australia or the Pacific Islands.
In many of the places it has been reported from, there is not
only great uncertainty as to the diagnosis, but there is also
evidence that, even if existent, it is a very rare disorder.
Should so-called typho-malarial fever prove to be identical
with Mediterranean fever, then very important modifications would
have to be made in the above statements, and the Mediterranean
basin could no longer be regarded as the great centre of this disease.
A certain degree of warmth would seem to be favourable to
the prevalence of Malta fever. It is not, however, a tropical
disease, and seems to prefer a warm, temperate climate to extremes either of heat or cold. It has never been seen in really cool

MEDITERRANEAN

289

FEVER

climates; in Italy it becomes less frequent from south to north,
and in Europe generally the most northerly records of its (even
doubtful) appearance have been the occurrence of imported cases
in France and the British Isles. In America, too, the suspected
cases already referred to seem all to have been contracted in the
warmer zones of that continent.
The relation of the disease to temperature is further shown in
its seasonal variations. It is most common in the summer, the
largest number of cases occurring in July; it begins to diminish
in the autumn, and is rare in winter and spring. Though commonest at low altitudes, Mediterranean fever has been seen, at
least in India, in hill stations at a height of 7000 ft. above
sea-level.
It is not an infectious disease. In those countries where it
is known to exist it is essentially an endemic disorder, but it has
at times taken on epidemic characters. Hughes believed that it
was largely associated with insanitary conditions and particularly
with a sewage-soaked soil. As with so many other diseases,
however, the true relations of insanitary conditions to this fever
are very difficult to establish. It certainly attacks persons of the
well-to-do classes living in large and well-ventilated dwellings to
almost, if not quite as great an extent as the poorer classes of the
population living in conditions of overcrowding and dirt.
Malta fever may perhaps be an air-borne disease. There
seems to be no positive proof that it is water-borne. It is mainly
a disease of young adult life, being commonest in the age-groups
between ten and thirty, and very rare after fifty. Men seem to
suffer more than women.

c.

19

MUMPS.
H i s t o r y . The disease known as mumps is very clearly
described in the writings of Hippocrates, and is mentioned by all
the ancient Greek and Roman medical authors. It is not, however, until the beginning of the 18th century that the records are
concise enough to enable the distribution of the disease to be
traced.
Since then it has been a widely diffused disorder, occurring as an endemic or as successive epidemics in almost all parts
of the world.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe.
Mumps
is a common disorder in all European countries. Statistics are
to a great extent wanting to indicate the relative frequency with
which it occurs in different parts of the continent. But no
country is free from it. It is frequently seen in the British Isles
and in all countries of Western Europe. Throughout European
Russia it is no rarity, and is found as far north as the shores of
the White Sea, and in the south on those of the Black Sea. It is
a very common disorder in many of the Balkan States, and constantly comes under observation in Constantinople. In Bavaria
and Swabia mumps appears to occur with remarkable frequency.
In the far north epidemics of the disease have been observed in
the past in Iceland, Lapland and the Faroes.
Asia. The distribution of mumps throughout Asia is not
easy to follow. The disease, from its comparative harmlessness, is
frequently omitted by writers from the list of maladies prevailing
in a given country; while, owing to the rarity with which it causes
death, it is often excluded from tables of the principal causes of
mortality in official statistics, when such exist.
In the Russian possessions in Asia—Siberia, the Caucasus,
and Russian Central Asia—mumps is no rarity. In the three

MUMPS

291

years 1893-1895 cases of the disease were reported from every
one of the provinces of the Caucasus proper and of Transcaucasia;
in the last-named year the total number of cases recorded in both
territories was 3238, with 142 deaths. Similarly throughout all
parts of Siberia mumps is met with, including the Amur province,
the territory of Chita on the Russo-Mongolian frontier, the far
northerly province of Yakutsk, and the island of Sakhalin. In
Central Asiatic Russia it seems to be just as common as in Europe,
and cases of the disease are yearly recorded from Transcaspia, from
the Turkestan provinces, and from the Semipalatinsk and Semiretchinsk territories between the latter and Siberia proper.
Little is known of the prevalence of mumps in Mesopotamia,
Arabia, and Asia Minor. It occurs from time to time in Persia,
and was epidemic on the Turco-Persian frontier in the winter of
1901-T902. It is also seen on some of the islands off the coast
of Asia Minor, and was epidemic in Mitylene at the latter end of
1901.

In India mumps is very frequently seen. The natives of
India are perhaps rather specially susceptible to the infection.
Native children are constantly brought under observation suffering
from it, and adults do not escape it, Buchanan speaks of it as
"exceedingly common" among the Indian natives 1 .
In the
native army in India considerable numbers of the men are yearly
treated for it. Thus in 1896 as many as 1081 cases of mumps
were recorded in this section of the Indian army, and in 1897 the
cases numbered 742. Many cases are also observed in the Indian
gaols; the figures fluctuate considerably, but in 1896 as many as
945 prisoners were attacked by the disease, while in 1897 this
figure rose to 2264. In the latter year the largest proportion of
cases were reported from the North-West Provinces and Oudh.
European residents and troops stationed in India are also affected
by the disease. Mumps is met with not only in the plains of
India, but also at considerable heights. An epidemic of the
disease was reported from the Hindu Khush in 1892, affecting
principally the Sepoys of two regiments of the Kashmir Imperial
Reserve. The infection was, however, believed to have been
brought up from the plains. In the following year (1893) the
men of another newly-arrived regiment were attacked by the
disease.^ In neither instance, apparently, did it spread to the
1

Jonrn. Trop. Med.

Sept. 1899.
19

2

292

MUMPS

inhabitants of the villages in or near which the troops were
quartered.
In Ceylon mumps prevails to some extent from time to time.
The Chinese are not immune to mumps, though whether the
disease is common in China it is difficult to say. In Chung-king
an epidemic of mumps prevailed among the native inhabitants in
the winter of 1897-8 \ and it has occurred elsewhere in China, as
for example in the Chung-poo valley, in the province of Fokien.
Recent medical writers upon the pathology of that country are,
however, for the most part silent in regard to this disease.
In the East Indian Islands mumps is probably rare. The disease
is said to be unknown among the hill tribes of Java. Kohlbriigge
has mentioned an epidemic of mumps affecting foreigners in the
island, but adds that the infection did not spread to the natives 2 .
Australasia.
Mumps is not unknown in Australia, but appears
to be a comparatively rare disorder there. In West Australia
only one death from the disease was reported in the mortality
statistics for the ten years 1889-1898; that death occurred in
1895. In South Australia in the same ten years a single death
from mumps was reported in 1891, and another in 1895. In
Queensland similarly this disease makes a very rare appearance in
the annual health reports as a cause of death. In New Guinea
it appears to be unknown.
Mumps occasionally appears in some of the Pacific Islands.
In the Solomon group epidemics of the disease are not unknown,
and sometimes it is severe enough to be a cause of death. In Fiji
an occasional case is admitted to hospital.
Africa. In many parts of the African continent mumps is met
with, and is indeed by no means a rare disorder.
Along the west coast it is frequently seen. In most recent years
the Colonial Report for the Gambia has recorded the occurrence
of several cases of mumps in the colony and of deaths from the
disease. It is mentioned among the maladies to which the native
inhabitants of the Belgian Congo are liable3. In the Cameroons
there was a small epidemic of mumps in 1895 I a n d in Uganda
it is said to be very common.
1

Med. Reports of Imperial Chinese Maritime Customs. No. 55.
James, 1897-8, p. 221.
'
3
Cong. Nat. dy Hygiene et de Climatologie Med. de la Belgique et dti Congo>
1897.
2

MUMPS

293

Throughout South Africa mumps is not a rare disease. It
occurs in the form of epidemics, and these occasionally assume an
intense character, affecting a large proportion of the population.
An outbreak of this kind occurred in Namaqualand in 1898, after
many years' complete freedom from the disease, and in the large
centres of population as many as three-fourths of the inhabitants
were attacked. The malady is not absent from the pathology of
Cape Colony, and it has been the cause of epidemics in several
parts of it in the last few years.
The disease is also known in Madagascar and in Mauritius.
North America. Recent reports from the Canadian provinces
show that mumps is a well-known disease in most, if not all of
them. In the Ontario reports it finds frequent mention as
occurring in many parts of the province. In Manitoba a considerable number of cases are yearly seen. In New Brunswick
the disease is also not unknown, and even as far north as Alaska
it has occurred epidemically.
Throughout the United States mumps is an exceedingly
common disorder; it was the cause of a most violent epidemic
among the Confederate troops during the War of Secession. It is
also met with in Mexico.
In the West Indies epidemics of it are far from rare. Recent
reports from Jamaica make mention of outbreaks in several parts
of the island.
South America. With the exception of mention of an epidemic
of mumps in Peru, medical literature appears to be silent as to the
existence of this disease on the South American continent.

Factors governing the Geographical Distribution of
M u m p s . This disease has a practically universal distribution over
the earth's surface. It can apparently exist independently of latitude,
climate, altitude above sea-level, and conditions of soil. It is a
highly "contagious" disorder, and frequently occurs in the form of
epidemics, sometimes of great severity, though not of long duration.
Institutions, such as schools, orphanages, or prisons, are the more
usual scenes of such epidemics, but larger communities may be
affected. Mumps may even be epidemic over whole countries,
but has never become truly pandemic. . It prefers cold and wet
weather to warm and dry, and the majority of epidemics occur in
the winter and spring.
The disorder is most often seen in children and adolescents,

294

MUMPS

but adults are by no means exempt from it, and it has often attacked
soldiers in barracks or in the field, witness the very severe outbreak during the American War of Secession already mentioned.
Many other epidemics affecting troops in India, France, Germany
and elsewhere might be quoted.
Sanitary conditions, or the reverse, seem to be wholly without
influence upon the prevalence of this disease.
Its relation to race is somewhat uncertain. All the great
divisions of the human family have at some time suffered from i t ;
but in some epidemics among mixed communities the disease has
shown a certain selective power, attacking only persons of one
race and sparing others. This was the case in the outbreak in
New Archangel, Alaska, in 1843-4, when only the' natives were
attacked while the Europeans escaped. In a recent epidemic in
Java the natives escaped while the foreign residents were attacked.

MYCETOMA (MADURA FOOT).
General C h a r a c t e r s a n d E t i o l o g y .
Mycetoma is a
peculiar affection of the foot, sometimes of the hand, and very
rarely of the knee, thigh, jaw, or neck, which is met with most
often in India. The foot is the part of the body usually affected,
and hence the name Madura foot so commonly applied to the
disease.
In its most characteristic form it begins with the
appearance of nodules in the subcutaneous tissues. The nodules
enlarge and coalesce; they may soften and discharge an offensive,
oily fluid, containing small granular bodies, of a yellow, pink, or
black colour. The foot becomes swollen to twice or thrice its
original size; all traces of the constituent tissues of bone, muscle,
and tendon disappear and become replaced by a more or less
uniform gelatinous mass, in which are a number of cysts' and
sinuses containing either a black, truffle-like substance (the black
variety) or a yellowish fish-roe-like substance (the white variety).
The disease never ends in a spontaneous cure. The limb
becomes useless and the muscles wasted, and unless the affected
member be amputated the general health may suffer considerably,
and death may ultimately occur from exhaustion or some intercurrent disease.
In the white variety of mycetoma a ray-shaped fungus resembling that of actinomycosis is found in the tissues of the
affected limb, to which Vincent has given the name of Nocardia
or Streptothrix madurce. The fish-roe-like bodies are made up of
aggregations of the fungus. In the black variety a somewhat
similar, but less distinctly ray-formed mycelial growth is present.
The ray-fungus of the white variety has been successfully grown in
artificial cultures, but does not appear to be inoculable in the
lower animals. While most observers regard the fungus as the

296

MYCETOMA (MADURA FOOT)

cause of the disease, Berkeley, Cunningham, and others have
expressed the belief that it is merely an accidental infection of a
part already the subject of mycetoma, the true cause of which
must, according to this view, be looked for elsewhere.
H i s t o r y . The earliest reference to this disease is apparently
to be found in the writings of Kampfer, published early in the
18th century. Probably the malady is of considerable antiquity
in India. In recent times special attention has been directed to
it by Vandyke Carter (1859 and subsequent years), who described
its clinical and anatomical characters, while the parasitology of
the disease has been the subject of careful studies by Vincent,
Boyce and Surveyor, and Kanthack.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Madura foot was
believed at one time to be met with only in India. Later
observations have shown that it does occur elsewhere, but India
is still the principal home of the disease. Hirsch states that it is
found in many parts of the Karnatic (Malabar Coast and inland
places near); at Pondicherry and Karikal; at Bellary^ Tanjore,
Guntur, Madura, Cuddapah, Trichinopoli and Combaconam;
on the slope of the western Ghats; in Ratnagiri, Poona and
many other districts of the Bombay Presidency; in Kattiwar,
Gujerat and Kutch ; at Karachi and other places in Sindh; in
Bhawalpur, Bikanir, and other parts of Rajputana; in Jhelum
in the Punjab and in Sirsa and Hissar in the North-West Provinces.
It appears to be absent from the eastern half of the peninsula, or
if it occurs there it is only in the form of imported cases. In many
parts of the areas in which it exists it is a disease of very considerable frequency.
The first notice of the occurrence of mycetoma outside India
seems to have been in 1883, when Collas recorded its existence in
the island of Reunion. Cases have also been seen in French
Guiana, and at Saigon in Cochin-China. Libouroux has stated
that one instance has been observed in Constantinople, and Bassini
has operated on a single case at Padua in Italy. Gemy and
Vincent have described a case in a native of Morocco, and
Berenger-Ferand, who saw the disease among the negroes of
Senegal, ventured to express the opinion that mycetoma exists in
all parts of Africa, in the latitude of Senegal, from the Atlantic
to the Red Sea. Positive evidence, however, in confirmation of
this view seems to be lacking. Rho has stated that it is urt-

MYCETOMA (MADURA FOOT)

297

known at Massowa on the Red Sea coast 1 . A few cases have
been seen in Algeria.
Quite recently evidence has been published of the existence
of mycetoma in Central America and the West Indies 2 . Two
unmistakable cases have been seen in Cuba, in which Streptothrix madurce was present. In Costa Rica Madura foot is said
to be quite common, though it has often been confused with
elephantiasis. In Nicaragua also it seems to be by no means rare.
There appears, then, to be good reason to believe that there is a
mycetoma area in the tropical portions of the New World
comparable to the Indian and African areas of this disease.
F a c t o r s D e t e r m i n i n g t h e D i s t r i b u t i o n . The exact
distribution of this disease over the earth's surface is so imperfectly known that it is difficult to discuss to any useful purpose
the various conditions and causes which have led to its presence
in one country and its absence in another. Of recent years it
has been shown to exist in places where it had never before been
heard of, and fresh observations may at any time show that it has
a wider distribution than is even now believed.
But, so far as may be gathered from the records hitherto
published, mycetoma is found only in hot countries. It appears
to be confined to the tropical or subtropical regions of Africa,
Asia, and Central America; and has only been seen in quite
limited parts of those regions. It occurs on all varieties of soil.
The influence of race upon its distribution is uncertain. The
fact that it is much commoner in India than elsewhere can scarcely
be attributed solely to a special susceptibility of the Indian native
to the disease. In those parts of India where it occurs the Hindu
population suffers more than the Mohammedan, while the Europeans and Eurasians entirely escape it. The European and Eurasian
may perhaps be immune to the disease, or the fact that they do
not suffer from it may be merely due to their custom of wearing
boots, while the native goes bare-footed. The African negro and
the natives of Morocco can become subjects of the affection.
Nothing is known as to the manner in which the disease is
contracted, or spread from person to person. The known facts
concerning mycetoma favour the view that it is a " place disease ";
that is to say that the specific cause of it remains for long periods
x
2

Janus, 1896-7, p. 598.
Pan-America7i Congress, Med. Record, Feb. 25, 1901.

298

MYCETOMA (MADURA P\)OT)

together in certain defined areas. It seems probable that the
specific cause of it, whether this be the ray-fungus or something else, exists in the soil or water of these infected areas, and
gains access to the tissues by penetrating the whole or abraded
skin of the foot. No other explanation so readily accounts for
the ease with which the barefooted native contracts mycetoma,
while others living in the same regions and covering the feet
escape. But up to the present neither the ray-fungus nor any
other suggested cause of the disease has been detected in the soil
or water of the affected areas. Nor is there any evidence to show
that mycetoma can be spread by direct infection from person to
person.

OPHTHALMIA, TRACHOMA,
AND OTHER EYE DISEASES.
Exception may well be taken, on scientific grounds, to a discussion of the geographical distribution of eye diseases as a whole,
and not of each particular affection separately. Iritis, glaucoma,
cataract, corneal ulcers, purulent ophthalmia, granular lids and
the like are each due to more or less different causes, and are
pathologically so distinct that it may seem to serve but little
purpose to deal with them together. But, on the other hand, it
has to be pointed out that, at present, materials do not exist for a
comparative study of the distribution of each eye affection separately ; while at the same time there are a number of known facts
of much interest, relating to the distribution of some of these
affections, which it may be useful to group together. In the
present chapter, while a large number of eye affections will be
incidentally mentioned, the greatest prominence will be given to
ophthalmia and trachoma.
Geographical Distribution.
Europe.
In the British
Isles all forms of eye affection are met with from time to time.
Purulent ophthalmia and trachoma are practically confined to the
poorer classes, living in conditions of dirt and overcrowding.
They are probably rarer in England than in any other country
in the world. In Ireland the chronic form of trachoma is said to
be relatively common.
In the continental states of Europe these diseases are found
in greatest intensity among peasant populations, in barracks, in
schools, and particularly among that class of the general population
whose personal habits, and neglect of treatment and of precautionary measures to prevent their spread, greatly favour the preva-

300

OPHTHALMIA AND OTHER EYE DISEASES

lence of these affections. The late Dr Van Millingen published
the following table, showing the percentage of trachomatous cases
to all other cases of eye disease in different countries \
England 0*07
Scotland 0 7
Ireland 3
America 3
France 4
Belgium 4

Holland 7*05
Spain 11*09
Hungary 14
Turkey 18
Bulgaria 20
Russia 25

Greece 25
Italy 25
Portugal 25
Central Asia 45
Africa 50
Roumania 52

Germany does not appear in this table. But in Eastern and
Western Prussia granular ophthalmia seems to be exceedingly
common. In 1897 Hirschberg examined some 7000 schoolchildren in these provinces, with the result that in no school were
less than 5 per cent, found to be trachomatous, and in one school
the proportion rose to as high as 47 per cent 2 . In 1898, again,
Rimpler found in a gymnasium at Gottingen that 26*4 per cent,
of the students were trachomatous 3 . In Russia purulent and
granular ophthalmia are remarkably common among the peasants,
as well as many other forms of eye disease. As the result of
neglect of these conditions blindness is sadly frequent. In 1893 a
well-known benevolent institution in St Petersburg inaugurated a
system of "flying squads" of surgeons and nurses to visit all parts
of the empire and try to relieve some of the^vast mass of suffering
from eye disease. Seven such " s q u a d s " were sent in the first
year. In 1898 the number had risen to 3 6 ; they visited many
parts of European Russia, the Caucasus, Central Asia, and Siberia,
and treated 50,222 patients, of whom 3432 were found to be
irreparably blind. In many parts of Russia, as also in Central
Asia, Montenegro and elsewhere, the frequency of eye diseases is
attributed to the absence of chimneys to the peasants' huts, and
the irritating effect of the smoke which consequently fills the
rooms. In the Faroe Islands on the other hand, where eye
diseases are common, they are ascribed to exposure to the weather
in that cold and damp climate; and the same cause may perhaps
explain the cases of ophthalmia that are occasionally seen in
French fishermen off the Newfoundland coasts.
Asia. The frequency of these diseases in the Caucasus, Russian
Central Asia, and Siberia has been pointed out above. The
1
2
3

Annates d'' Oculistique. Sept. 1895.
Klinisches Jahrbuch, Bd 6.
Deutsche Med. Woch.

OPHTHALMIA AND OTHER EYE DISEASES

3OI

Bashkirs suffer greatly from them 1 , and in Bokhara they are
extremely prevalent 2 . In Arabia, Syria, Asia Minor, and Mesopotamia few diseases are commoner than conjunctivitis. In Persia
ophthalmia is disastrously prevalent, not only in the cities, but
also in the mountain chains between Shiraz and Ispahan. At
Khanikin and Suleimaniye, on the Turko-Persian frontier, trachoma
and ophthalmia abound, and at Kermanshah the majority of the
inhabitants suffer from these diseases.
In many parts of India conjunctivitis occurs with great frequency. In Ceylon it is common in some parts, but the inhabitants of the high central area are said to be relatively immune
(Hirschberg). In the Straits Settlements ophthalmia must be
prevalent, to judge from the returns of the Singapore prisons and
the Penang hospital. In the Dutch East Indies both natives and
Europeans suffer to a considerable extent from simple and granular
ophthalmia. In Java, among the hill tribes, conjunctivitis is
common,- while trachoma on the other hand is little seen3.
In China all forms of eye disease are extraordinarily prevalent;
with the exception of alimentary troubles no group of diseases is
more so. Conjunctivitis, entropion, cataract, keratitis, pannus,
granular lids, and trichiasis abound. Ulcers of the cornea, with
perforation and staphyloma are also very common; pterygium is
said to be frequent, but glaucoma infrequent 4 . Granular eye
disease seems to be particularly rife in China. In Yiinnan it
abounds, and in Southern China generally it is said to constitute
78 per cent, of all forms of eye disease. It is scarcely less common
in Japan, where the proportion of such cases is said to be 75 per
cent.5 In Corea ophthalmia is the second most frequent of all
diseases, and blindness is very common.
Australasia.
In Australia ophthalmia is said to be of very
frequent occurrence among the aborigines. It also occurs among
the white population; in 1895, f° r example, it was almost epidemic
at Hampden, and in 1897 at Lowan, Victoria; in the former it was
so prevalent that a school had to be closed in consequence. In
British New Guinea, on the other hand, there is apparently no
contagious ophthalmia 6 . In some of the Pacific Islands, as for
1
3
5
6

Meditzina. 1896, No. 2
Kohlbrugge.
Mujashita of Tokio.
Brit. New Guinea. Annual Report, 1898.

2
4

Grekof.
Coltman.

302

OPHTHALMIA AND O T H E R EYE DISEASES

example Fiji, conjunctivitis and other eye diseases come under
treatment, but with what degree of frequency I have no means of
saying.
Africa.
All forms of eye-disease seem to be particularly
frequent in, Egypt. As the name Egyptian ophthalmia, often
applied to acute granular ophthalmia, implies, this disease is rife
in that country. Trachoma is probably more prevalent here than
in any other country in the world. Van Millingen estimated
the proportion of trachomatous cases to all other cases of eye
disease in Egypt at 80 per cent. In this as in many other hot
countries the frequency of ophthalmia is largely favoured by the
glare of the sun, by dust, and by swarms of flies.
In Algeria trachoma is exceedingly common, and often attacks
whole families1. An intermittent form of ophthalmia has also
been described as occurring here which is thought to accompany
or replace paroxysms of acute intermittent fevers. It is said to be
always unilateral and nearly always to affect the left eye. This
form of eye disease has also been seen in the United States, but
never in China 2 .
On the West Coast of Africa many forms of eye affection are
seen, some of them in large numbers, but trachoma seems to be
remarkably rare. The negro races of Senegambia and the Guinea
Coast are said to be immune to it. Plehn never saw a single
case in the German Cameroon Territory. In Central Africa and
on the East Coast other forms of eye disease abound; they are
spoken of as the curse of the country, and nowhere in the world,
it is said, is blindness so common as in this continent. In
Bechuanaland and generally throughout South Africa ophthalmia
is also exceedingly prevalent.
America. To what extent the majority of eye diseases occur
in Canada and the United States I am unable to say. From the
table already quoted from Van Millingen, it would seem that
trachoma is a comparatively rare disease in America. It is said
that none of the indigenous tribes of Canada suffer from it. Some
of the Indian tribes of the United States, however, are subject
to it, and the Chinese found in the big American cities are said
to be particularly liable to it. In Kentucky a peculiar form of the
affection is said to be met with, to which the name "Kentucky
1
2

Gros. Jantis, 1898, p. 181.
Yarr. Journ. Trap. Med. Nov. 1899.

OPHTHALMIA AND O T H E R EYE DISEASES

303

trachoma" is locally given. The negroes in the United States are
said to escape the disease.
For South America, ophthalmia is spoken of as an " endemoepidemic" disease in British Guiana; and in Peru, Chile, and
Bolivia cases of ophthalmia are not only very frequent, but are
often of a very obstinate character. In Brazil it is no less frequent
and severe, and usually takes the form of so-called " Egyptian
ophthalmia " (Lombard).

Factors concerned in the Distribution of Ophthalmia
and T r a c h o m a . All forms of conjunctival inflammation, whether
simple, catarrhal, purulent, follicular, granular, acute or chronic,
appear to be more or less contagious. Some, particularly those of
gonorrhceal origin, and the acute and chronic granular forms, are
highly contagious. They are consequently found to be most
common among overcrowded communities, where the chance of
the infective discharge being carried to the eyes of others is
greatest. They are rare among the well-to-do classes in all
countries, and most frequent among those classes who use towels
or handkerchiefs in common, and who are ignorant or careless as
to the necessity of treatment and of taking precautions to prevent
their spread. Dirt and mal-hygiene greatly favour their prevalence. In many hot and sunny countries the glare of the sun,
clouds of hot, irritating and foul dust, and the carriage of
infection by means of flies, all contribute to diffuse the disease
widely.
High, pure mountain air seems to be really inimical to the
spread of these troubles, and they are certainly found at their
worst in low-lying regions.
" True epidemics of ophthalmia are by no means rare, particularly occurring in institutions, such as schools and barracks.
In regard to trachoma, or the granular form of ophthalmia,
it seems probable that racial susceptibility has a good deal to do
with its distribution. The Mongolian races appear to be particularly
liable to it. The high proportion of trachomatous to other cases
of eye disease in China and Japan has already been pointed out,
and the same tendency is observed among the Chinese inhabitants
of American cities, the East Indies, and the Malay Peninsula.
Manson has suggested that this marked liability to trachoma in
these races may be due to the peculiar elongated almond-shape
of the Mongolian eye.

304

O P H T H A L M I A AND O T H E R EYE DISEASES

.At the other extreme there are certain races that possess a
relative or almost positive immunity from this form of eye disease.
Thus it is said that the African negro rarely or never suffers
from it. The almost or quite complete absence of trachoma from
the West Coast of Africa, already pointed out, supports this statement; and it is further said that in the United States negroes
have remained free from trachoma even when the disease was
epidemic among whites in their immediate neighbourhood. Thus
the " Kentucky trachoma," already alluded to as common among
the white population of Kentucky, never attacks the blacks. Some
years ago, it is said, in Tennessee, a number of white labourers,
mostly Irish, and a number of negroes were employed together in
railway construction, and trachoma broke out with great severity
among the former, yet there was not a single case among the
latter. It is probable however that the immunity of the negro race
to trachoma is not absolute. The late Prof. Van Millingen of
Constantinople pointed out that, while the negro eunuchs in the
harems of that city, who live a lazy, comfortable life, escape the
disease, other negroes living in a state of overcrowding and dirt
suffer considerably from it, trachoma accounting for 24 per cent,
of all their ocular affections1.
The indigenous tribes of Canada are also said to be immune
to trachoma. The Crees and Santeux tribes of Manitoba, living
side by side with the Russian Mennonites, appear to escape its
attacks, although the latter suffer from it severely. The Indian
tribes of the United States, on the other hand, are liable to
become subjects of trachoma 2 .
1

Annales d^Oculistique. Sept. 1895.
For a discussion of this question see papers by M. T. Yarr, F.R.C.S.I.,
in the Journal of Tropical Med., May, 1899, and in the Brit. Med. Journal\
May, 1899, from which the facts in the text are quoted.
2

PELLAGRA.
General C h a r a c t e r s a n d E t i o l o g y . Pellagra is a nutritional disease, occurring most often in the spring, either as
an epidemic or endemic disorder. The clinical features are more
or less fully described in all text-books of medicine, to which
the reader is referred for details. Here it will suffice to state that
the disease is characterised at first by general weakness, headache,
giddiness, spinal pain, gastric disturbance, not infrequently
diarrhoea, and a peculiar skin eruption. This eruption appears
on the back of the hands, on the face, on the feet (of bare-footed
people), and more rarely on the back and chest. There is a general
erythematous condition, with drying and exfoliation of the
epidermis ; the skin becomes very rough and dry, and sometimes
suppuration and crust formation are observed. In severe cases
the cerebro-spinal and sympathetic nervous systems appear to be
deeply involved; there may be delirium and various spasmodic
and paralytic phenomena, and a condition allied to scurvy on the
one hand and to typhoid on the other may supervene. Severe
mental trouble, particularly melancholia, imbecility, and suicidal
mania, may follow prolonged or repeated attacks. The disease
has been known to last from ten to fifteen years, and even longer.
Pellagra is generally believed to be caused by the consumption
of damaged grain, and there is very strong evidence that the
disease is an intoxication produced by eating badly kept and
decomposing maize or maize-flour. This question will be discussed
more fully in a later part of the chapter.
H i s t o r y . This malady was first recognised and described in
Spain, where it is said to have been endemic, at least in the
Asturian district of Oviedo, since 1735. Since that date it has
become very widely prevalent in other parts of the peninsula.
c.

20

306

PELLAGRA

A little later it began to extend in Italy, where isolated cases are
known to have occurred even before the date just mentioned.
The earliest record of pellagra in France is nearly a century
later, and it was not until 1829 that the first accounts of it in that
country appeared, though the disease itself was observed there as
early as 1818. In 1833 the malady was recognised in Roumania,
in 1839 it appeared in Corfu, and in quite recent years it has been
frequently seen in some parts of southern Russia.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . The distribution of
pellagra over the earth's surface is a peculiarly limited one. Up
to the present it has only been met with in Europe and in Africa,
and in both continents it has only been seen in certain countries.
These countries are Spain, Italy, France, Roumania, Bosnia, Croatia,
Russia, and the island of Corfu in Europe, and Egypt in Africa.
In Spain the disease is known as the mal de la rosa. It is
•—or was up to 1879—particularly prevalent in Asturias, and
especially in the communes of Regueras, Llanera, Corbera, and
Carefio. In addition to the above places, Hirsch states that
pellagra affects many of the inhabitants of Lower Arragon and
Burgos, of the provinces of Guadalajara and Cuenca, of the
district on the frontiers of Navarra and Arragon, of the Ebro valley
in the province of Zaragoza, of the level banks of the Douro and
Tormes in the province of Zamora, and of Galicia. In some
villages as many as 2 per cent, of the population were found to
suffer from it.
At the present day Italy is one of the principal centres of
pellagra. The history of the disease in that country since its
appearance there early in the 18th century has been one of
constant extension, both in the number of persons attacked and
in the area of country affected. But it has never extended to the
southern provinces—the Abruzzi, Campania, Apulia, Basilicata, and
Calabria—and has remained confined to the northern and central
provinces. Lombardy, Venetia, and Emilia are - the areas in
which it is most prevalent. In Lombardy it is most common
in the provinces of Brescia, Bergamo, Cremona, and Milan; in
Venetia, in the provinces of Padua and Rovigo; in Emilia in
those of Ferrara, Piacenza, and Parma. „In Piedmont, Liguria,
Tuscany, Rome, Umbria, and the Marches the disease is met with
to a less extent. Pellagra is a cause of no inconsiderable mortality
in Italy, as shewn by the following figures. In 1887 the deaths

PELLAGRA

307

from this disease for the whole country were equal to 125 per
"million of the population; in 1888 the ratio was 117; in 1889,
104; in 1890, 123; in 1891, 142; in 1892, 1 4 1 ; in 1893, 106;
in 1894, 9 8 ; in 1895, 105; and in 1896, 99 per million. The
deaths from pellagra in these years were very much more
numerous in Italy than the deaths from acute and chronic
rheumatism together; they were about the same as the deaths
from croup, and were not very much less numerous than those
from scarlet fever. Lombroso has stated that as many as five
per cent, of the village populations in northern Italy have been
known to suffer from the disease.
In France pellagra is more or less endemic in the coast-region
of the Gironde, in the Landes, in the Hautes-Pyrenees and BassesPyrenees, in the Haute-Garonne and Aude. Sporadic cases of the
disease have also been reported from a number of other parts of
France, including Paris.
The disease is believed to have existed in Roumania since the
year 1833 at least, although cases were not treated in hospital
until 1846. Since then there has been a considerable increase in
its degree of frequency. Of the two divisions of the country,
Moldavia and Wallachia, the former is more affected than the latter.
This area of pellagra prevalence is contiguous with the Russian
centre of the malady. Up to the present the disease has only been
reported in Russia from the governments of Bessarabia and
Kherson. In Bessarabia it has been for some years endemic, and
it has recently become so in the Tiraspol uyezd^ or district, of
Kherson 1 . In both governments many Moldavian inhabitants are
found, and these appear to be especially liable to the disorder.
The volost (or collection of villages) most affected is that of
Lungovo, but it must also be very prevalent in Dubosary, for
one medical man, in the month of April, 1901, alone, registered as
many as 30 cases of the disease there.
In Bosnia and Croatia pellagra is certainly met with and is
perhaps common 2 . In Turkey, on the other hand, it is unknown.
In Corfu pellagra first appeared in 1839, and after 1856 it
became truly endemic.
Until recently it was believed that the disease was confined to
countries between the 42nd and 46th degree of north latitude.
1
2

Bolnitchnaia
Gazeta Botkina, May 23, 1901.
Wien. Med. Woch. 1901. N o . 10.
20—2

3o8

PELLAGRA

But it is now known that it prevails in Egypt, and even as far
south as Assouan, which is almost within the tropics (latitude
240 N.). It is much more frequent in Lower than in Upper
Egypt, where it is in fact a rarity. The disease is said to be
unknown in the Fayoum, and to be rare in the neighbourhood of
Luxor. It is rare also in Alexandria, Port Said, and Suez, but is
common in the provinces nearest to Cairo. Some cases have been
seen at Tokar by the Red Sea, among starving Arabs, after a
famine in 1891 1 .

Factors concerned in the Geographical Distribution
of P e l l a g r a . From the date of the earliest observations on
pellagra in Spain down to the present day the disease has been
ascribed to the use of maize as food, and this view of its mode of
production is now almost universally held. It is based on the
facts that the disease did not appear in Europe until after the
introduction of maize as an article of food, that it disappears when
maize is excluded from the dietary, and that it is endemic only in
those areas where maize is the chief article of diet. Its relative
frequency, moreover, in the different parts of those countries where
it is met with seems to depend on the extent to which maize or
maize products are eaten by the people. In Italy this is especially
the case, and pellagra is there most common where polenta, or
maize porridge is the staple food of the peasants, and least so
where this is largely combined with, or replaced by other articles
of food, such as wheaten bread, potatoes, and chestnuts. In
Egypt, again, pellagra is most common in Lower Egypt, where
maize is much grown and eaten, and rare in Upper Egypt, where
maize is little eaten or not at all, and where millet is the chief
grain food of the peasants. In the Fayoum, too, and near Luxor,
where as we have seen the disease is very rare, the natives scarcely
eat any maize.
The large majority of writers upon pellagra agree that good
sound maize, well cultivated and well harvested and properly
stored, will not give the disease, but that when the reverse of these
conditions obtains pellagra is likely to follow. Thus the affection
is unknown in those tropical or sub-tropical countries where maize
is indigenous, and where it can be grown and harvested under the
most favourable conditions, and it is only found in countries
where this cereal is an exotic, and where care is not exercised in
1

Sandwith, Brit. Med. Assoc. 1898.

Paper on " Pellagra in Egypt."

PELLAGRA

309

supervising all the steps between the sowing of the grain and its
ultimate consumption in the food of the peasantry. The grain
may be cut before it is ripe, or it may be cut and stored in a
damp state, or it may be stored in pits in the ground where it
becomes damp and rotten, and all these conditions favour the
development of pellagra. In Roumania and in Italy the disease
is commonest where the climate or soil are such as to render the
production of a good crop of maize most difficult. Hence, also,
the disease is most often seen, and indeed may become epidemic,
in years when there has been a bad maize harvest, and "when
the maize corn has been malformed, gathered half ripe owing to
the peasantry being short of food, and stored or used in the wet
state." In Bessarabia and the Kherson government in Southern
Russia it is the Moldavian inhabitants who suffer most, and it is
precisely they who live on maize {kukuruz) for the most part
badly kept. At all times the Moldavians are said to prefer maize
to other flours, but in famine years they are compelled to subsist
mainly upon it. This flour is badly preserved, and becomes sour
and more or less offensive to most tastes. But the Moldavians
make a variety of yastva or food-stuffs out of it, and hence the
great extent to which they have suffered from pellagra in the
recent years of bad harvest and famine.
The exact nature of the pellagra poison is not known. It
has been surmised that the disease may be due to some chemical
substance produced in decomposing or fermenting maize, or to
some micro-organism growing in the grain, or to a parasitic mould
growing on or in the grain.
Lombroso, after careful observations and experiments, was
of opinion that the disease was not brought about by any
parasitic mould, but that it was probably due to a toxic chemical
substance developed in the decomposing grain. This view is now
most generally held, and it does not exclude the possibility that
the toxic substance, whatever it may be, is developed in the maize
by the action of certain micro-organisms which are constantly
found in such grain.
Such factors as the climate, soil, and geological and physical
characters of the country affect the distribution of pellagra only
in so far as they make the growth and harvesting of maize a
difficult or an easy proceeding. In like manner race, in itself,
is probably of no importance in determining the prevalence of the

3io

PELLAGRA

disease. In some instances, it is true, one people—as, for example,
the Moldavians in southern Russia—has appeared to suffer more
than another in the same district. But this has been due to no
racial susceptibility, and simply to the fact that the affected persons
have eaten maize in the condition already described, while the
non-affected have not done so.

PLAGUE.
General C h a r a c t e r s a n d E t i o l o g y . Clinically plague
occurs under three principal forms :—the bubonic, the pneumonic,
and the septicaemia Some observers have spoken of a fourth
form,—the abdominal or enteric, but it is doubtful whether this
form exists. The clinical varieties of the disease have been
thought to depend upon the different modes of penetration of
the bacillus into the tissues—the bubonic by its passage through
the skin and its multiplication in a lymphatic gland; the pneumonic by its being inhaled and multiplying in the lungs; the
abdominal (if such variety exist) by its entering the alimentary
passages. There is, however, evidence which seems to point to
the possibility that each variety of the disease may have a distinct
and specific character, bubonic cases giving rise to fresh bubonic
cases, and pneumonic cases to fresh pneumonic cases. The
Indian Plague Commission is of opinion that this, rather than
the accident of the mode of penetration of the bacilli into the
tissues, determines the character of the attack. But the evidence
on the point is conflicting.
Each variety of the disease may become septicemic before
death by the passage of the bacilli into the blood-stream. In
some instances the attack seems to be septicsemic from the
beginning.
A mild form of plague or bubonic fever, or even a condition
of enlarged glands without fever, is often seen before and during
a plague epidemic, and is known as pestis ambulans or pestis
minor.
H i s t o r y . The oldest known historical references to the
occurrence of plague are probably contained in the early books
of the Old Testament. The Biblical use of the word plague is,

312

PLAGUE

like its medieval use, more often than not, in the general sense of
a pestilence or epidemic disease, rather than in the specific sense
of the disease now known as bubonic plague. The expression
" a plague of leprosy " is a common one, and there is no reason
•to suppose that any of the ten " plagues " of Egypt were of the
character of the malady now under discussion. But in a few
instances there are some grounds for believing that the disease
mentioned was in truth bubonic plague and no other. The most
remarkable reference of this nature is found in the First Book
of Samuel 1 . The whole history of the outbreak there described

1

i Samuel iv, v, vi. The Philistines defeated the Israelites at the
battle of Eben-ezer, and took the Ark. After arriving at Ashdod the pestilence
appeared. In the ordinary version the reading is " and (He) smote them with
emerods." In fear that the presence of the Ark in their midst was the cause
of their misfortunes they sent it first to Gath and then to Ekron. But in both
places the disease appeared. In the former " H e smote the men of the city,
both small and great, and they had emerods in their secret parts"; in the
latter " there was a deadly destruction throughout all the city," and " the men
that died not were smitten with the emerods." This is not the place to
discuss the meaning of the word " emerods," which occurs rather frequently
in the Old Testament, and which some have explained as meaning haemorrhoids.
But it may be noted that in the Revised Version the word " tumour " is substituted in the text for the word " emerod," and in the marginal notes an alternative
reading is in each case given, " or plague boils." It may therefore be accepted,
at least, that this pestilence was one in which *' tumours " were a prominent
symptom; and " tumours in their secret parts" might well be taken as a
description of inguinal buboes. In the meantime there seems to have been
a veritable plague of mice. In the ordinary version there is only incidental
reference to " t h e mice that mar the land" (i Samuel vi, 5); but in the
Septuagint version the references are more distinct. Thus in the latter version
it is stated (chap, v, 6) that " i n the midst of the land thereof mice were
brought forth, and there was a great and deadly destruction in the city " ;
and further (chap, vi, 1) that " their land swarmed with mice." So that at
the time of this pestilence there was clearly an unusual number of mice, and
perhaps some unusual migrations of these animals, bringing them more to the
notice of the people.
After retaining the Ark for seven months, during which period the plague
apparently did not abate, the Philistines, in alarm, determined to return the
Ark to the Israelites. After consulting their priests and diviners, they placed
on the Ark images in gold of their " tumours " and of the " mice that marred
the land" besides a coffer of jewels as a guilt-offering, and sent back the Ark,
drawn by two milch-kine and followed by some of the lords of the Philistines.
The milch-kine brought the holy vessel to Beth-shemesh, and the lords of the
Philistines, having seen the Berh-shemites obtain possession of it, returned the

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313

is so full of interest that I have discussed it at some length in
the footnote below, and it need only be briefly summarised here.
The Philistines had conquered the Israelites and captured the
Ark, and retired with it to Ashdod. There a whole series of
misfortunes befell them: the idol Dagon fell and was broken
in pieces, a plague of mice ravaged the land, and at the same
time the people were smitten with "tumours." This pestilence
followed the Philistines in their subsequent movements, and seems
to-have been carried by them to the Israelites, who suffered from
a most deadly epidemic. The exact nature of the disease here
referred to is, of course, uncertain, but it is not perhaps stretching
the limits of possibility too wide to suppose that a plague epidemic
smote the Philistines, that it spread with them in their movements
from city to city, and was finally carried by them when they
returned the Ark to the Israelites. Geographically the whole
epidemic was confined to the country lying in the extreme southeast corner of the Mediterranean Sea; commencing in " Ashdod
and the coast thereof" (that is to say the region south of Jaffa)
and spreading inland. The mention of " the mice that marred the
land " has a more than passing interest, in view of the well-known
susceptibility of these animals to plague.
The many other epidemics mentioned in the Old Testament
may or may not have been examples of plague, and it would serve
but little purpose to dwell upon them in detail. As an example
of a somewhat remarkable one may be mentioned the " p l a g u e "
which visited the Israelites after the punishment of Korah,
Dathan, and Abiram and caused the death of 14,700 people 1 .
Another pestilence mentioned in Biblical writings is that which
was sent as a punishment for David's disobedience in numbering
the people, in direct contravention of the divine injunctions'2.
same day. But another fearful epidemic smote the Beth-shemil.es, as a punishment for having looked into the Ark, and no less than 50,070 persons perished.
For the curious it may be mentioned that in Deuteronomy xx\ in, 27, the
disobedient are threatened with " the botch of Egypt and with the emerods,"
to which, as before, the Revised Veision adds a marginal note "or tumours, or
plague boils." In support of the view that the plague was in fact referred to,
it may further be pointed out that throughout medieval times and down to the
reign of Elizabeth the plague was constantly spoken of as the " b o t c h , " the
word signifying the bubo, or the most prominent and characteristic feature of
the disease.
1
2
Numbers xvi.
2 Samuel xxiv.

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PLAGUE

David was given the choice of a famine, a war, or " a pestilence
and a distemper upon the Hebrews for three days." H e chose
the last, and seventy thousand persons perished of the pestilence.
The story of it is told in some detail by Josephus, but there is no
clear evidence as to what was the nature of the disease.
Vague and uncertain as are the references to plague in the
Bible, they are equally so in the secular literature of the preChristian era. The historians of the time make not infrequent
mention of pestilences, particularly as attacking armies and besieged cities, but, with scarcely an exception, there is nothing
to show positively that these were outbreaks of bubonic plague.
The famous Plague of Athens (430-428 B.C.) was almost certainly
not of this character.
Thucydides, who himself suffered from it,
has left a sufficiently detailed description of the symptoms to
justify this conclusion, and to indicate that the mortality, which
was excessively high, was probably due to many diseases (of which
small-pox and typhoid fever would seem to have been the most
important), aggravated by the horrors of overcrowding in a besieged city.
The sole certain mention of a plague epidemic in the preChristian period is contained in the writings of Rufus of Ephesus,
a physician of the time of Trajan, who refers to the records of
certain Greek physicians concerning an epidemic in the third
century before Christ. This epidemic ravaged Syria, Egypt, and
Libya, and of its nature there can be little doubt, for the contemporary physicians quoted by the author just named described
the disease as " accompanied by an acute fever, by terrible pain,
by a trouble of the whole body, by delirium, and by the appearance of large buboes, hard and without suppuration, not only in
the usual positions, but also behind the knee and at the elbow."
In the second century of our era (164-180), during the reign
of Marcus Aurelius, a widespread epidemic seems to have ravaged
the greater part of Europe. But of far greater intensity was the
historical outbreak in the reign of Justinian. It began in Egypt
in 542, and spread thence to Syria, Byzantium, and Europe. This
great pestilence lasted, with intermissions, for at least 52 years.
The evidence is perhaps not quite conclusive whether the various
epidemics occurring in different parts of the Roman world during
this long period are rightly grouped as constituting one great
pandemic outbreak of plague, or whether a number of other

PLAGUE

315

diseases, such as small-pox, have not been included with them.
But in any case it appears safe to say that from the year 542, for
the next half century and possibly longer, plague was generally
very prevalent 1 .
Between the plague of Justinian's time and the Black Death
of the fourteenth century many outbreaks of pestilence occurred
in different parts of Europe, some of which there is good reason
to believe were of the nature of bubonic plague.
Of all great historical outbreaks the Black Death is the most
important, as it was the most deadly and appalling in its consequences of any either before or since. Its origin is obscure.
Plague had been present in certain parts of Europe during the early
half of the fourteenth century, but in these places the disease
had apparently shown little tendency to become widely spread, and
nearly all writers agree that the intensely fatal form of plague to
which the name of Black Death has been given was a fresh importation from the East. It was in Genoa in the spring of 1347; and
in the same year it was in Constantinople, Cyprus, Greece, and
(later) in Marseilles.
The manner in which it was imported to these places has been
the subject of much controversy, but certain facts may be regarded
as now fairly well-established and as tending to show the source
of this great pandemic. The contemporary imperial historian,
John Kantakuzin, who himself saw the disease in Constantinople,
stated that it had come from the country of the Hyperborean
Scythians, that is to say, from the steppes of southern Russia and
the Crimea. Another Byzantine writer, Nicephorus Gregoras,
ascribed it to the same source. There is evidence in the Russian
1
T h e principal authorities for this great historical event are the writings of
two illustrious lawyers, Procopius of Constantinople and Evagrius of Antioch,
each of whom became prefect of his own city, and both of whom weie eyewitnesses of the principal events of the plague ; while one (Evagrius) not only
himself suffered from it, but lost his wife, many children, and a large number
of relations and servants. T o these witnesses may be added Bishop Gregory of
Tours, who makes brief reference to the plague in France. This pestilence
began at Pelusium in Egypt and spread thence to Alexandria and to Syria.
It took two years to reach Constantinople (April 544), and was gradually
carried to nearly all parts of the then civilized world. It was in Gaul in 546.
I n most countries it began at the sea-coast and spread inland. Procopius has
left a description of the disease seen by him in Constantinople which is so full of
detail as to leave no doubt that it was the plague. Evagrius describes at least
four recurrences of the disease at Antioch, the last in the year 592.

3i6

PLAGUE

chronicles to show that plague was prevalent in 1346 in the
country round the river Don, at Surai and Bezdej on the Volga,
as well as in the Caucasus, Armenia, and Khiva, and it may be
regarded as almost certain that southern Russia was the part of
Europe first invaded by the Black Death 1 .
How the Tatar inhabitants of those broad steppes first
contracted the disease is far less certain. They had constant
relations with China, and hence it is thought the infection may
have been derived from that country. The supposition is
a priori a plausible one. The Tatar khans, at least until
the time of their first serious defeat by the Russians under
Dmitri of the Don at the battle of Kulikovo in 1380, kept
open the route from China by the northern roads through what
are now called Semipalatinsk, Semiretchinsk, and the Kirghiz
steppes of Turgai and Uralsk, to the north of the Aral and
Caspian Seas. An infectious disease existing in China might
possibly have been carried by the Tatars to Europe. Unfortunately,
however, there is no positive proof of the existence of plague in
China at that time. On the contrary, the Chinese annalists make
no mention of the disease for the half century before this period,
and the contemporary Arabian traveller Ibn-Batuta, who spent the
four years 1342-46 in China, does not seem to have seen or heard
of the disease there.
An alternative suggestion has been made that the Black Death
came from India, and there are many considerations in favour of
this view. Plague is known to have been prevalent in India in
the early part of the fourteenth century. Between the years 1325
and 1351 Muhammad Tighlak's army in Malabar mostly perished
of the disease. The Arabian traveller just quoted, Ibn-Batuta,
himself saw and was attacked by the disease at Muttra, Muhammad
Tighlak's capital—apparently in the year 13322. Further it may
1
T h e Troitzki Chronicle states that there was pestilence then " in the East,
in the H o r d e and in Ornatch " (at the mouth of the Don), and " i n Sarai and
in Bezdej " both on the Volga ; and " in other countries," and a great plague
" a m o n g the Bessermans" (or Khivans), " a n d among the Tatars, and the
A i m e n i a n s , " and " a m o n g the A b a z i a n s " and among the Genoese and
Venetians in Taurida and in Azof, and among the Tcherkessi. T h e Pskof
Chronicle states boldly that the plague came from India.
(See also
Karamzin's lst07'ia Gosudarstva Rossiiskavo, Vol. IV and Notes.)
2
Travels of Ibn-Batuta,
translated from the abridged Arabic M S . copies by
the Rev. Samuel Lee, B . D . , London, printed for the Oriental T r a n s . Com., 1829.

PLAGUE

317

be noted that the Russian contemporary chroniclers and other
later writers (e.g. Fracastori in the 16th century) ascribed the
origin of the Black Death to India. The fact that plague was
epidemic in Khiva, Armenia, and the Caucasus, about the period
of its appearance on the Volga and the Don, seems to show that
the Black Death was imported to Europe by way of southern
Central Asia, and this lends still greater probability to the view
that it may have come from India 1 .
Whatever may have been the source of this outbreak, it spread
slowiy over the whole of Europe, including Scandinavia and
Iceland, and was even carried to Greenland. The northern part
of Russia was not invaded until the year 1851, and then the
disease came from the west, and not from the south-eastern
steppes, where it had prevailed five years previously. It has been
computed that from first to last the Black Death caused the death
of some twenty-five million people.
Throughout the remainder of the fourteenth, and in the two
succeeding centuries, plague was practically endemic throughout
the greater part of Europe, and from time to time caused severe
epidemics affecting larger or smaller areas. It was not until the
seventeenth century that it began to recede, as it were, eastwards;
that is to say, the western portions of Europe gradually became
free from the plague, and wrhile the disease remained in the East
and still from time to time spread westwards, each succeeding
epidemic was more limited than the one before it. Denmark
seems to have been the first European country to be freed from
the disease; the last epidemic occurred there in 1654. The dates
of the last epidemics in other countries appear to have been as
follows: Sweden, 1657; England, 1666 or 1667; Switzerland,
1667-8; France (with the exception of the great outbreak in
Marseilles and its neighbourhood in 1720) also in 1667-8;
western Germany in the same years; and Spain, 1677-81.
1
T h e additional argument in favour of I n d i a as the source of the Black
Death, advanced by Hirsch and others, that the pulmonary form of the disease
was specially prominent in the Black Death and has always been a distinguishing feature of plague in India, can scarcely now be held as valid.
Pneumonic plague has been shown to be no rarity in modern epidemics
outside I n d i a ; and it is open to question whether lung symptoms were not
just as prominent in other great epidemics of plague as in the Black Death of
the 14th century.

3i8

PLAGUE

At this time and in the succeeding century plague seems to
have been confined as an endemic disease in Europe to the
Balkan peninsula, whence from time to time it was still able to
spread to the north and west and cause epidemics of no little
severity.
Russia, then very frequently at war with Turkey,
suffered more from these outbreaks than any other country.
A serious epidemic occurred there in 1709; and in 1710, when
Peter the Great was attacking the fortress of Riga, 60,000 persons
perished from plague. In 1718 there was another epidemic, and
in 1770-2 there occurred in Moscow one of the most fatal pestilences ever seen in Russia 1 . Throughout that century a number
of outbreaks occurred in Austria, in Hungary, and on the shores
of the Black Sea and the Adriatic.
In the first half of the nineteenth century plague showed but
little activity in Europe. In 1807 it spread from the Caucasus
to Astrakhan and Saratof on the Volga. In 1813 it caused an
epidemic in Malta, and in 1815 another at Noja in Italy. In
1820 it appeared in the Balearic Isles. In 1828-9 the Russian
troops in Wallachia were attacked by it, and in the same year a
rather severe epidemic occurred at the taking of Kars by the
Russians.
In 1837 plague broke out in the Greek island of Poros, in
1838 there was a small outbreak in Odessa, and between 1839
and 1843 a few isolated epidemics occurred in Transcaucasia. In
Constantinople plague seems to have prevailed rather frequently
up to the year 1839, but after a small outbreak there in 1841 the
disease completely died out, and with its disappearance from the
Turkish capital the whole continent of Europe became exempt
from plague and remained so, with one slight exception, until the
last few years of the century.
In the latter half of the nineteenth century the centre of
interest in the story of plague shifts from Europe to certain remote
portions of Asia and Africa. As this period is of special importance, as preceding the present wide extension of the disease, it
deserves to be dealt with in some detail. But before doing so it
is necessary to recount, very briefly, the early history of plague
outside Europe.
1
See papers by the author upon Plague Epidemics in Russia, in the
Practitioner, November, 1894; and the Indian Med. Gazette, September and
October, 1898.

PLAGUE

319

In Asia, plague is no doubt a disease of some antiquity, but
its early history here is even more obscure than in Europe. For
China there is no certain reference to any great epidemic before
the 18th century, in the latter half of which there is reason to
believe that plague prevailed in Yunnan, the province where it is
still endemic 1 . A contemporary author wrote of this as follows :—
"Then in Chau-Chau [in Yunnan] it happened that in the daytime
strange rats appeared in the houses, and lying down on the ground
perished with blood-spitting. There was not a man escaped the
instantaneous death after being infected with the miasma. Tau-Nan
composed thereon a poem entitled 'Death of Rats'—the masterpiece of his ; and a few days after he himself died of this queer rat
epidemic2."
There can be little doubt that this was the plague as we now
know it.
In India plague was certainly epidemic in the early fourteenth
century, in the time of Muhammad Tighlak. At the end of that
century (1399), after Timur's ravaging hordes had left the country,
there was another severe pestilence, perhaps of plague, in the
districts he had traversed. In 1443, again, Sultan Ahmed I. lost so
many of his men from plague that he was compelled to return to
Gujerat; this disease is spoken of by historians as "ta'un," the
name still used in the East.
The famine in India of 1590-4 was followed by a pestilence
which depopulated whole cities, villages, and hamlets, and which
may have been the plague. In 1611 plague appeared in the
Punjab; it was called " w a b a " or "waba-o-ta'un." " W a b a " or
" veba " and " ta'un " are still the names for plague in Turkey and
Arabia, in Persia and Hindustan. This epidemic spread through
Lahore and the Doab to Delhi and northwards to Kashmir. No
place in the peninsula, it is said, escaped it. It lasted eight years.
In Kandahar it was accompanied by a swarming and unusual
1
Lowson {hid. Med. Gazette, January, 1897) states that he caused a search
to be made into Chinese literature, but no record was found of any historical
epidemic which made a mark in the annals of the country. On the other hand
the Chinese annals contain innumerable records of pestilences—as well as of
other great national disasters, such as earthquakes, floods, and supernatural
visitations—and it may well be that some of these pestilences were epidemics
of plague.
2
See note in JVature, F e b . 16, 1899, hy Mr Kumagusu Minakata.

320

PLAGUE

behaviour of mice. Later, in 1684, the army of Aurungzebe
suffered from it, and from that year to 1691 plague raged severely
over the greater part of western India, particularly in Bombay,
Surat, Goa, Ahmedabad, Bulsar, Daman, Thana, and Sindh.
During the 18th century the Indian annals are silent as to the
behaviour of plague, but early in the 19th the disease again
became active. In 1812 it broke out in Cutch, and spread
thence to Kathiawar, Ahmedabad, Radhanpar, the southern part
of Sindh and other places. This outbreak died out about 1821.
In 1823 occurs the first account of plague in the hills of Garhwal
and Kumaon, where it has ever since been endemic. In 1828-9
a plague-like disease was present at Hansi, and in 1836-8
occurred the well-known outbreak at Pali in Jodhpur State,
Rajputana.
In Persia the earliest epidemic of the plague is believed to
have been that of 1571-75, and between that date and 1835 that
country was visited several times by the disease. In Mesopotamia
there was an outbreak of plague in 1596 in Baghdad, and then
follows a period of two centuries without any record of its existence there. But in 1773 it reappeared in Mesopotamia, and
again in 1800-1, 1830-34, and 1867. Syria, Armenia, and Asia
Minor have been the scenes of frequent outbreaks from the
earliest historical times, and together with Egypt and Turkey were
regarded as the permanent homes of plague at the end of the 18th
and beginning of the 19th centuries. The Red Sea coast of
Arabia has more than once been visited by plague, and even in
Mecca isolated cases have been seen. No serious epidemic has
however occurred at any time in the Moslem Holy Places, and
this comparative immunity is ascribed by the faithful to the
special protection of the Prophet 1 .
In Africa, the earliest known scene of a plague outbreak was
in Egypt and the adjoining country of Libya on the west The
epidemic of the third century B.C. already referred to mostly
prevailed here; the Great Plague of Justinian's reign also began
here. For a time, perhaps, plague was endemic in Egypt, and for
1
As is pointed out later in the text, Medina has always escaped, but Mecca
has been less fortunate. Thus in 1815, when plague was raging in Jedda and
Yanbo, great numbers of the inhabitants of the former place fled to Mecca,
" thinking to be safe in that sacred asylum, but they carried the disease with
them, and a number of Mekkans died, although much less in proportion than
at Djidda [Jedda]." Burckhardt, Travels in Arabia, London, 1829.

REGIONS IN W H I C H PLAGUE WAS ENDEMIC OR
B E T W E E N 1850 AND 1894

EPIDEMIC

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321

long it was customary to regard that country as the permanent
home and source of the disease. How far this was actually the
case it is difficult to say. It is more than possible that some
confusion has long existed in the popular mind between the
Biblical Plagues of Egypt and the specific disease to which we
give the name of plague. Throughout medieval times almost
nothing seems to be positively known of what the disease was
doing in that country, but from the 16th century onwards there
are more certain records, and Egypt then seems to have justly
shared with Eastern Europe and the Levant the reputation of
being the source of most of the European epidemics.
Towards the close of the 18th century there were frequent
outbreaks in Egypt, but even then there appear to have been
intervals of from two to five years' duration when the country was
more or less free from it. Lastly in 1844, three years after its
disappearance from Constantinople—its last foothold in Europe
—plague died out in Egypt, and did not appear there again until
the year 1899.
Algeria was the scene of several epidemics of plague between
the years 1552 and 1837 ; Tripoli and Tunis probably suffered in
each of these outbreaks, as the infection travelled from Egypt
westward.
Morocco was visited by the disease on six occasions between
the years 1678 and 1819. So far as is known plague had occurred
in no other part of the African continent before the middle of the
century just closed.
E n d e m i c C e n t r e s a n d E p i d e m i c Outbreaks of P l a g u e
in t h e l a s t h a l f of t h e 19th C e n t u r y . For many years
succeeding the year 1850 plague was confined to a limited number
of comparatively small and somewhat remote areas, in which the
disease was either truly endemic or in which it recurred at somewhat long and irregular intervals. Europe had been free of it
for a considerable period. America and Australasia had never,
so far as is known, been visited by plague in historical times.
The southern hemisphere was also believed to have entirely
escaped its ravages, and all the known centres of plague were
confined to the continent of Asia and the northern part of
Africa1.
1
See " T h e Endemic Centres of Plague," a series of papers by the author
in the Journal ofTropical Medicine, March—May, 1900.

C.

21

322

PLAGUE

In Asia the most important, if not the only regions in which
plague had existed as an endemic disease since 1850 and before
1894, were certain areas in China, India, Mesopotamia, Arabia,
Persia, Siberia, Mongolia, and possibly Russian Central Asia.
In Africa similar foci of plague have existed or developed in the
same period in Uganda and in Tripoli.
(a) In China^ plague has been endemic in the south-western
province of Yunnan, bordering on Tibet and Burma, possibly for
a century or more, and certainly since the great Mohammedan
rebellion in i860. Within an area bounded approximately by
the 1 ooth and 104th degrees of east longitude, and the 23rd and
28th degrees of north latitude, the disease has prevailed more or
less severely every year. Outside this area and outside this
province other centres also appear to have existed for some time,
as for example at or near iVn-pu in the Kwangtung province,
while in many other places plague has broken out frequently
though at somewhat irregular intervals, and it is uncertain
whether the disease is truly endemic or is on each occasion
imported from the centre in Yiinnan. Among these places may
be mentioned Pakhoi, and Lungchou in the province of Kwang-si.
It has at times spread to many other places in this province and
in that of Kwangtung, and less often to the province of Kwei-chou,
to the north-east of Yunnan, and to Laos, between Yunnan and
Siam. It never spread to Tongking or Annam, or to northern
China. The outbreaks in the later years of the period under
consideration were much less severe than those in the earlier
years. But in 1893 and 1894 a marked accession of activity was
observed in the endemic area of Yiinnan, and in many of the
other places mentioned, and in 1894 the disease appeared for the
first time in history in Canton, whence it spread to Hongkong.
If, as there is good reason to believe, the later appearance of
plague in India and elsewhere was due to an extension of the
infection from one of these places, then the Yunnan centre of
endemic plague must be regarded as the cradle of origin of the
recent wide extension of the disease to so many parts of the earth's
surface.
(b) In India plague has been endemic in the districts of
Kumaon and Garhwal, on the southern slopes of the Himalayas,
1
For detailed references concerning plague in China see the author's paper
in the Journal of Tropical Medicine, March, 1900, p . 200.

PLAGUE

323

since the year 1823. The disease, known locally as maha?nari1^
has appeared in one or both provinces at very irregular intervals
since that date. Outbreaks occurred in 1834-5, in 1837, and in
1846-7. Between 1847 a n d 1854 the disease became epidemic
in each successive year. In 1853-4 it spread far beyond its
usual limits and caused a serious degree of mortality in the
adjoining plains. It was epidemic again in 1859-60, in 1869-70,
and in each of the years from 1875 to 1878. In 1884 and each of
the following four years it was present in some part of the districts,
and again in 1891, 1892, and 1893, a few cases of mahamari were
observed. In 1894 it is doubtful if any cases occurred, in 1895
there is no mention of it, but in 1896 and 1897 limited outbreaks
were dealt with by the authorities.
The Himalayan centres of plague have been much less active
of recent years than formerly, in the sense that the later outbreaks, though possibly more frequent, are the cause of a much
smaller mortality than the earlier ones. The quiescence of the
disease here in the years 1892 to 1896 was in marked contrast
with the unusual activity of the Chinese centres at the same
period, and it is almost certain that the recent epidemic prevalence
in India is due to an extension of plague from China, and not to
an extension of mahamari from the Himalayas.
(c) In Mesopotamia plague appeared, after an absence of
2,^ years, in 18672. The scene of that year's outbreak was the
Hindieh marshes on the Lower Euphrates. In 1873 ^ w a s e pidemic in the same region, but on both sides of the river, and in
1875 it broke out in a district rather more to the south. In 1876
Baghdad and other places suffered severely, and 20,000 persons
were believed to have died of it in that year. In 1877 it was
epidemic again in Baghdad and elsewhere, but not to so fatal an
extent as in the previous year. In 1880 plague broke out in the
El-Zayad tribe about the end of September; thence it spread to
1
It appears possible that some of the epidemics of mahamari here
enumerated weie epidemics, not of plague, but of some other disorder, as the
term is said to be used by the natives for an outbreak of any very severe disease.
It is probable, however, that the large majority were epidemics of plague.
2
The history of plague in Mesopotamia, Persia, and Arabia is based upon
reports contained in Parliamentary Paper C. 2262, " Papers relating to the
Modern History and Recent Progress of Levantine Plague " (1879), a n ( l l l P o n
numerous unpublished reports and papers contained in the Archives of the
International Board of Health at Constantinople.

21 — 2

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Chenafie in November, and reached Djaara in January 1881.
From Djaara it spread to Nedjef, where in the course of some four
months it caused 3000 deaths. In 1884 it was again epidemic,
attacking especially the populations of Bedra, Zorbatia, Djizan,
and Mendelli. In 1892 plague was prevalent among the Arab
tribes on either side of the Shott-el-Ghraf, in the Muntefik district.
Since that date the only known occurrence of plague in Mesopotamia has been a small outbreak of the disease in Baghdad in 1901,
followed by a number of mild cases of a bubonic disorder during
several months, and by a second small outbreak officially recognised
as plague in January 1902.
(d) In Persia, where plague had appeared for the last time in
1835, a small epidemic of the disease occurred in 1863 in the
extreme north-wrest corner of the country, in and around Maku.
In 1870 it again broke out on an elevated tableland to the southeast of Lake Urumia and in 1876 it was epidemic in the
province of Khusistan in the extreme south-west of the country.
In December 1876 it was present in two villages 25 leagues
distant from the shores of the Caspian Sea, and in March 1877
it appeared in Resht, quite close to the coasts of that sea.
In Resht and its neighbourhood 4000 persons were believed to
have died from the disease. In September it was reported from
the Khalkal district of Azerbijan, and in the same month it was
(possibly) present in Astrabad and (doubtfully) in Herat. In
January 1878 plague was again epidemic in villages in Persian
Kurdistan and remained there until April.
In 1881 it reappeared in the northern part of Kurdistan, and in two villages
in Khorassan, near the Afghan frontier. In 1882 it was epidemic
at Sooutch-Boulak and Uzundere; in 1883 a t Djivanrao and in
its neighbourhood; in 1885 in and near Hamadan, the place of
assembly for Persian pilgrims en route to the Shiah buryinggrounds of Nedjef and Kerbela; in 1889 in villages in the
neighbourhood of Merivan; and in 1890 in the district of
Mahideste, near the Turco-Persian frontier. In 1896 a small
outbreak of plague is said to have occurred among a Turkish
regiment of Hamidie cavalry stationed in the nahy'e of Aughnot,
in the sandjak of Guendj, close to the Persian frontier. The
appearance of the disease at Bushire and at Bender-Dilem, both
on the shores of the Persian Gulf, in 1899, will be briefly mentioned later. It is unknown whether it was due to an imported

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infection from India, or to a manifestation of the disease already
endemic in the country. Finally in 1900 a severe outbreak of
plague again occurred in the Djivanrao district, and was the cause
of considerable mortality.
(e) A centre of plague, or of a disease very closely allied to it,
has existed for some years past in the Transbaikal province of
Siberia1. The exact nature of the disease here is uncertain, but
as its principal features are fever and the appearance of glandular
swellings or buboes it is probable that it is in truth the plague
itself. It is associated with, and apparently dependent upon, an
epizootic disease which attacks a species of marmot known
locally as the tarbagan {Arctomys bobac). These animals abound
in the plains of Transbaikalia, and they are also found over a wide
area in Europe and Asia. In Europe they extend as far west as
Russia and eastern Germany, and in Asia they are found in
Siberia, Mongolia, and Tibet. So far as is known they suffer from
the disease in question only in the plains beyond Lake Baikal,
and possibly in a certain part of eastern Mongolia, where, as will
be shown later, human plague is also endemic. The outbreaks of
tarbagan plague occur at short but irregular intervals, in the
autumn of certain years. The disease is intensely infectious; it
attacks persons who touch the bodies of animals that have died
from it, and from them spreads to others in their immediate
neighbourhood.
( / ) In the valley of So-len-ko in eastern Mongolia, at a
distance of twelve days' ride from Peking, plague has been endemic
at least since the year 1888. It breaks out each year in the late
summer and sometimes causes a very high mortality in a number
of villages, the inhabitants of which live in a state of filth excessive
even for Chinese villages. The marmot referred to in the last
paragraph, Arctomys bobac, is found in the neighbourhood, and
it is said to suffer from an analogous disease, but in this
region the dependence of the disease in man upon that in the
animals is much less direct and obvious than in the Siberian
centre just described.
(g) The possibility of the existence of plague as an endemic
disease in Russian Central Asia has recently been pointed out.
The evidence for its existence is of the following character. In
1

See paper by the author, " Plague in Siberia and Mongolia and the
Tarbagan" in thtjotirn. Trop. Med., February, 1900.

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October 1898 a severe epidemic of plague broke out in the village
of Anzob ? in a remote mountainous region near the borders of
the Samarkand province and Bokhara. Upon inquiry it was
found that many of the inhabitants of this and an adjoining village
had suffered during the past twenty years from attacks of a disease
the principal symptoms of which were fever and glandular
swellings. For the present it remains uncertain whether this
endemic disease is in truth plague. Dr Levin, who conducted
the inquiry on behalf of the Russian Government, thought
that this disease and the outbreaks of plague on the Lower
Volga and on the Caspian (which will be mentioned again later)
might be due to carriage of infection from Mongolia by means of
Kalmuck and Kirghiz pilgrims, who might have visited certain
sacred Moslem shrines in Mongolia and brought the disease back
with them. Against this view, however, must be set the enormous
distances between the areas just named and the Mongolian centres
of plague. Moreover the Mussulman inhabitants of the Kirghiz
steppes east of the Volga are said to have no "holy places" of any
kind in Mongolia; while the Kalmucks, who live to the west of
the Volga, are despised and looked upon as heathens by both
Mongolians and Kirghiz and are not allowed to pass through the
Kirghiz steppes \
(h) Plague has for the greater part of a century been endemic
in the hilly country of Assyr, in south-western Arabia. The
disease is believed to have been imported here from Egypt, as
the result of the invasion of the country by Egyptian troops in
the second decade of last century. The first known outbreak of
plague_ here was in 1816. A second serious epidemic was that
of 1853. Since 1874 the disease has been more active, and the
cause of several epidemic outbreaks. From 1874-79 it was very
prevalent among the Beni-Sheir tribe of Arabs; in 1889, in 1893,
in 1894, in 1895, in 1896, in 1900, in 1901, and in 1902 more or less
serious extensions of the disease took place; but it is remarkable
that in no instance has the infection left the hills and spread to
the plains. The Assyr foyer of plague is practically confined to
a strip of mountainous country, mainly occupied by the Beni-Sheir
and Beni-Amr tribes of Arabs. The climate is temperate; in
winter it is cool but not excessively cold. The inhabitants are
extremely poor, and live in a state of much filth and misery.
1

Goldberg, Bolnitchnaia Gazeta Botkina, 1900, No. 1^.

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327

Although the centre is not infrequently visited by Bedouins from
other parts of Arabia, it is only on very rare occasions that any
of them contract the disease, and even when this occurs they
never carry it to other places 1 .
(/) In Africa one of the most important centres of plague is
situated in Uganda on the north-western shores of the Victoria
Nyanza. How long the disease has existed in this locality is unknown, but it has certainly been there for the last twelve or fifteen
years, and probably considerably longer. Kaumpali^ as it, is
called locally, has been described by many writers upon Central
Africa, and its true nature has been known for a considerable
period.
Complete scientific proof that it is indeed the plague
was obtained by Koch and Zupitza in 1898. It is most severe
in Buddu, the most southerly province of Uganda, and around
Bukoba and Kitangule on adjoining German territory.
It at
times causes an excessively high mortality, as for example in
1898-9, when the Sultan of that region reported that no less
than 467 deaths from plague had occurred in the course of a
year in Bukoba out of a population of only 715. It was also very
active in and around the capital after the wars of 1889 and 1890.
Another sharp epidemic occurred in Buddu about 1896, and it
has recently been carried by native traders to some of the islands
on the Victoria Nyanza 2 .
(J) In the province of Benghazi in the regency of Tripoli,
North Africa, plague has become epidemic on two occasions
in the period under review. In 1858 it prevailed rather widely
in four out of the five divisions of the province, and in 1874 an
epidemic of great intensity (attacking 533 persons in a population
of 734) almost decimated a few tribes inhabiting the Cyrenaic
plateau. Since that date there has been no word of plague in
Tripoli, and it appears probable that the disease is no longer
endemic in the country.
1
Doughty {Travels in Arabia, Vol. 1. p . 618) has described a number of
ruined villages in the north-east of Arabia, in a diiect line between the plaguecentres in Mesopotamia and Assyr, the inhabitants of which had been carried
off by a disease described as plague, or waba, apparently about the year 1870.
H a d this malady truly been the plague, the occurrence might have established
an important link between the two plague-centres desciibed in the text. But
from the brief account given of the symptoms it seems most probable that they
were due to some other affection rather than plague.
2
Cook, Journ. Trofi. Med., J u n e 1, 1901.

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(k) Once and once only during the period now under review
has plague appeared in Europe. It will be recalled that in
March, 1877, the disease was severely epidemic in Resht near
the Persian shores of the Caspian Sea. There is reason to
believe that it may have been carried some months previously
to the Russian shores of that sea.
In Baku three deaths
occurred in November 1896, all in the same house and all after
a short attack of fever accompanied by buboes. In the autumn
of 1877 a v e r y similar disease appeared among the Russian troops
in the Caucasus, engaged in operations connected with the RussoTurkish war1. At the same time some cases of a like character
were seen among the Russian troops in European Turkey. In
the summer of 1877 a disease, of which fever and buboes were
the principal features, was prevalent in the town of Astrakhan and
in a number of villages around. These cases have been regarded
as of the nature of a mild form of plague and they form an
important link connecting the outbreaks in Persia, and particularly
that in Resht, with the epidemic on the Volga. The outbreak
on the Volga was confined to six villages, of which Vetlianka was
the most important. It lasted from October 1878 to the early
months of 1879, and was self-limited, coming to an end before
any organised measures for its extinction were put into force2.
E p i d e m i c E x t e n s i o n of P l a g u e s i n c e 1894. The above
are the principal, and so far as is known the only places on the
earth's surface in which plague prevailed in the latter half of the
nineteenth century before the year 1894. That year was an
epoch in the history of the disease, as it marked the commencement of the widest, though far from the most severe, pandemic
1
T h e late Count Loris Melikof was in command of these troops, and a
year and a half later he was appointed to take entire charge of the plague
measures in the government of Astrakhan after the outbreak of plague at
Vetlianka. It was when holding the latter appointment that he recalled that
a disease which was described at the time as " typhus fever with buboes," had
in 1877 caused a high mortality among his men in the Caucasus. T h e medical
authorities in St Petersburg came to the conclusion that in all probability this
disease had been plague, and apparently plague of a far from mild form, since
the case mortality was from 75 to 80 per cent. (Protocols of the Society of
Russian Physicians in St Petersburg, 1879.) Galanin (Bubonnaia
Tchuma,
St Petersburg, 1897), who served as surgeon in the Russo-Turkish war, states
that analogous cases occurred among the troops in European Turkey.
2
F o r the details of this epidemic see the author's papers upon plague in
Russia already referred to.

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329

extension of plague in historical times. The course of the disease
in the last eight years has been as follows.
Early in 1894 plague broke out in Canton, where it had
never before been seen. In the preceding year the disease had
been unusually active in the endemic centres already described
in southern China, and it had extended to places on the direct
route between those centres and Canton. The epidemic in
Canton, a city of a million and a half inhabitants, living in the
midst of filth and insanitary surroundings, lasted several months
and was a severe one. In May 1894, if not earlier^ plague
appeared in Hongkong, and there is little doubt that the infection
was brought there from Canton, which is only 90 miles distant,
and is in constant communication with the former. On May 10th
Hongkong was officially declared to be an infected port. Throughout the hot and rainy season the disease was widely prevalent.
In July it began to decline, and by August the epidemic was
practically over. In the following year no epidemic recurred;
but in 1896 there was a severe recrudescence of the disease,
lasting from January to June. In 1897, plague, though still
present in Hongkong, caused no widespread epidemic, but
in 1898 a third outbreak of great severity took place.
The
alternation of epidemic and non-epidemic years which characterised
the period 1894 to 1898 was broken in 1899, when plague was
prevalent to as serious an extent as it had been in the preceding
year. Through the winter of 1899-1900 the disease was quiescent,
but in 1900, in 1901, and in 1902 it was again epidemic.
During subsequent years plague has continued with varying
degrees of activity in Canton. For 1895 there is an absence of
positive information, but in 1896 and in each succeeding year
there have been recrudescences of the disease in the city.
Many other places in and near China were invaded by plague
in 1894 or subsequent years. In 1894 a few cases were imported
to Swatow, and in the following year a small epidemic occurred
there.
In 1897, 1899, and 1900 this port was the scene
of renewed outbreaks. From Swatow the disease spread to
Chao-Yang. In 1895 & appeared at Pochin and Hoihow in the
island of Hainan (opposite Pakhoi). Amoy also suffered considerably in 1895, 1896, 1897, and 1899, the recrudescences
occurring each year in the months from May to October. The
two Portuguese customs ports of Macao and Lappa, both near

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Hongkong, were scenes of severe epidemics of plague in 1895
and 1896, and of less severe ones in 1897, 1898, and 1900. In
1898 a small, localised outbreak occurred at Nha-Trang on the
shores of Annam. The outbreak here, at first attributed to the
presence in the port of a scientific laboratory in which important
experiments with plague material had been carried out, was later
shown to be probably due to an importation from some Chinese
port, such as Pakhoi.
Finally plague appeared in 1899 in the town of Newchwang
on the shores of the Gulf of Liao-tong in northern China. The
town is now largely under Russian influence, and the infection
was thought to have been imported by coolies who wTere
brought in large numbers from southern China to assist in the
construction of the Manchurian branch of the great Siberian
railway. The outbreak was never severe here, and with the
exception of a few cases in Hai-chou, Hai-chen, and Port Arthur
the disease was confined to the town of Newchwang. In 1900
plague was again epidemic here.
From China plague spread to Formosa and Japan. In Japan,
Kobe, Nagasaki, and Osaka have been the scenes of recurrent
outbreaks of considerable severity.
The unfortunate experience which the Indian peninsula is now
passing through from the ravages of plague began in the year
1896. In September of that year the disease was recognised in
Bombay, but as it had by that time taken a serious hold of the
city it is certain that it had already been there for some considerable time, and possibly since the early part of the year. The
origin of the first outbreak in the city has never been determined,
but the balance of probability is in favour of the view that the
infection was imported from China. The evidence in favour of
the alternative view that it was due to an extension of mahamari
from the Himalayan centres already described is so slight as to be
practically negligible. Since 1896 the disease has been truly
epidemic in Bombay. Each year, approximately at the same
period (December to March or April), plague has raged with, if
anything, increasing intensity, and the mortality caused by it in
the past winter (1901-2) was as high as that in the first year of its
prevalence.
In October 1896 plague had already passed beyond the limits
of Bombay and the island upon which that city is built. In that

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331

and the following three or four months imported cases of plague
were detected in various places in the Bombay Presidency, and at
longer or shorter intervals these cases were followed by others
among the resident population of those places. This process was
continued throughout the winter, until there were few portions of
the Presidency, from Shikarpur in the north to Kolhapur and Goa
in the south, that had not been invaded by the disease. In some
places the epidemic was more severe than in Bombay itself.
Thus in Mandvi, on the island of Kutch, n per cent, of the
population were attacked in the first year's epidemic, while in Goa
the proportion was no less than 33 per cent. Karachi also
suffered to some extent, having an attack rate of about 4 per cent.
In Poona the first year's outbreak was also of considerable
severity.
During the summer of 1897 there was a marked decline in
the intensity of the epidemic throughout the Bombay Presidency.
But in the late summer months a recrudescence of the disease
began, and in the following winter plague was as widely prevalent
as in the preceding year.
Bombay and Karachi suffered a
second severe visitation. In Hubli, in the extreme south of the
Presidency, a violent outbreak occurred in July, August, and
September, that is to say at the height of the monsoon, when in
the previous year plague had been everywhere relatively quiescent.
An autumn epidemic occurred this year (1898) throughout the
southern Mahratta country, Dharwar, Satara, Belgaum, and
Kolhapur suffering especially. From November to the following
March (1899) there was a general decrease in the prevalence of
plague throughout the Presidency, excepting in Bombay and
Karachi, in each of which a third epidemic outburst prevailed in
the early months of the year. In the summer of 1899 the disease
again died down, but it never wholly disappeared, and in July a
serious increase took place in the Poona district and in the
Belgaum state. In Poona the most violent and deadly outbreak yet recorded raged throughout the late summer months,
the mortality for three weeks together remaining at the terrible
figure of over 500 per 1000 per annum.
(The highest in
Bombay in any week has been 142 per 1000.) In the states of
Kolhapur, Nasik, and Belgaum the disease was active at this time,
and also at Hyderabad in Sindh. In the winters of 1899-1900, °f
1900-1, and of 1901-2 Bombay suffered from its fourth, fifth, and

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sixth serious epidemics, and in many other parts of the Presidency plague was prevalent.
Outside this Presidency the spread of plague was at first
remarkably slow. In the North-West Provinces small outbreaks
have occurred at Hardwar, Kankhal, Jawalapur, and Khandraoni.
In the Punjab plague appeared in October 1897, and in the
following winter a large total number of deaths occurred in nearly
100 villages scattered throughout the Hoshiarpur and Jullundur
districts. In the winter and spring of 1901-2 the Punjab suffered
from a violent outbreak of plague, which was for several weeks
the cause of an enormously high mortality. Hyderabad in the
Nizam's territory has also been visited by plague on several
occasions since the autumn of 1897, and the mortality throughout
a great portion of the territory has been at times considerable. The Central Provinces have on the whole suffered but
little from plague, a few cases only having been reported from
Hinghenghat, Nagpur, and Bhundara in 1898 and early 1899. ^ n
the summer of 1899, however, a more severe outbreak occurred in
Hinghenghat, and in October the disease was spreading in
Nagpur. Rajputana has at no time suffered severely. In Bengal
the infection of plague was extremely slow in gaining a footing.
Calcutta itself was not invaded, with the exception of some controversial cases in the autumn of 1896, until the month of March
or April 1898. A very mild outbreak prevailed there for the
following three or four months ; a second and more severe epidemic
ensued in the early months of 1899, and in February to April 1900
and again in the early months of 1901 and 1902 still more serious
epidemics, causing a mortality comparable to that in Bombay,
prevailed in Calcutta. In other parts of Bengal the course of the
disease has been similar to that in Calcutta, and after the occurrence of scattered cases in a very large number of towns and
villages an epidemic of great gravity occurred in many places in
the first quarter of 1899. The towns and districts most seriously
affected then and since have been those of Patna, Saran, Gaya, and
Monghir.
Southern India has also not escaped the ravages of plague.
Already before the end of the year 1897 the infection had spread
as far south as Travancore. But it was not until the following
year that the disease gave rise to a serious epidemic south of the
Bombay Presidency. In August of that year a violent outbreak

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333

occurred in the province of Mysore, the city and cantonment of
Bangalore suffering severely. In the Madras Presidency the malady
has, since the year 1898, given rise to epidemics in several places,
but it has nowhere raged with great intensity in this part of
India.
Throughout the Indian peninsula plague has caused an amount
of sickness and death in the course of the past six years which
it is difficult to estimate. The returns from many places are
incomplete, and it is probable that a considerable number of
cases and deaths have escaped registration, but a moderate
computation must place the mortality from the disease at little
less than 600,000, a figure which, though high in itself, is incomparably lower than the total mortality from cholera in India in the
same period. Farther India has hitherto suffered much less than
India proper from the plague. A few imported cases have been
dealt with in Rangoon, and an outbreak of some intensity occurred
at Akyab in 1901. In Penang a small outbreak occurred in July
1899. ^ n Singapore several imported cases have from time to
time been dealt with, but the disease has never become epidemic
here or elsewhere in the Malay Peninsula.
Plague, it has been pointed out, remained epidemic in China
outside its endemic foci for two or more years before it appeared
in India. Not long after its appearance in India it began to be
heard of in other parts of the world. Jedda, the great pilgrim
port of Arabia, was one of the earliest places to be invaded by the
disease; at the end of May or early in June, 1897, cases of plague
began to occur there, and an epidemic fortunately of small
proportions, prevailed during the next four or five weeks. In 1898
a second outbreak occurred between the months of March (or,
possibly, January) and April, scattered cases continuing to occur
until July. A third limited outbreak developed in February 1899.
It is a matter for congratulation that in spite of the large number
of pilgrims to Mecca and Medina who passed through Jedda in
each of these years no widespread epidemic of plague occurred
among them. Only two known cases of plague occurred in
Mecca in 1899, and Medina is still able to boast, as it did in the
time of Burton's memorable pilgrimage, that the Ta'un or plague
has never entered its gates.
The origin of the first outbreak in Jedda has never been
explained. It was believed not to have been caused by an

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imported infection from the Assyr centre already described.
More probably it came from India, but it is noteworthy that the
departure of Indian pilgrims to the Hedjaz had been prohibited
by the Indian Government as early as February 20th, 1897, or
three months before the disease appeared in Jedda. Possibly it
was brought to Jedda indirectly from Bombay by traders from
the coasts of Hadramut and Muskat, who have frequent relations
both with Bombay and with the Red Sea coast of Arabia. In
1900 a few cases of plague occurred in Yanbo, to the north of
Jedda.
At the end of August, 1898, a very fatal epidemic of plague
occurred in the village of Anzob, and a few deaths from the
disease in an adjoining village, in the remote mountainous district
of southern Turkestan, close to the borders, of Bokhara. This
has been already referred to, and the possibility has been
pointed out of the endemic existence of plague in this region.
The source of the outbreak remains unknown; it was a very
severe one locally, causing the death of 237 persons out of a
population of 387, or 61 per cent, of the total inhabitants.
In the month of November of the same year plague appeared
in Madagascar and in Mauritius. The former was probably
invaded first. The occurrence was of historical importance as the
first known appearance of plague in the southern hemisphere 1 .
Its subsequent spread to South America, the Pacific Islands, and
Australia has further shown that the view previously held that
plague could not exist south of a certain latitude is untenable.
In Madagascar the disease prevailed with some severity from
November 1898 to February 1899, in which period it caused some
200 deaths. After an interval of quiescence it became active
again in July, and lingered on in Tamatave—the locality most, if
not solely affected—until towards the end of the year, when the
island was officially declared plague-free. A third small outbreak
occurred in October 1900, and a fourth in 1902. The original source
of infection in Madagascar is uncertain; it has been suggested
that it was imported by Arab sailing-boats, or boutres, which make
frequent calls at ports on the Indian coasts of Madagascar and
the Mascarene Islands. It has also been ascribed to a direct
importation by a boat from Bombay: the first victims are said to
1

Strictly speaking the centre in Uganda is mainly in the southern hemisphere, but it is practically an equatorial region.

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have been natives employed in unloading the cargo of rice
brought by this boat.
In Mauritius plague was recognised in January 1899, but the
infection had probably gained the shores of the island some two
months earlier. The epidemic here soon became one of considerable severity, from 50 to 100 cases of the disease occurring
weekly through the months of August, September, October, and
November, 1899. In the following winter months the mortality
decreased, but the disease never completely disappeared. It again
became epidemic in the autumn of 1900, and has ever since been
more or less active in the island.
In February 1899 ^Y0 deaths from plague occurred in the
Transvaal; one at Middelburg, on the line between Lorenzo
Marquez and Pretoria, and the other at Kaapmuiden, near Barberton, some hundred miles distant from Middelburg. Both victims
were natives of India, and in both the infection had probably been
imported from that country. Whether the two patients had had any
relations with each other is not clear; if not, the occurrence of the
two cases at about the same period is at least remarkable. There
was no spread of the disease in their neighbourhood. But in, or
before August, 1899, several deaths from a disease believed to be
plague were reported from Magude, two days' journey from
Lorenzo Marquez. On September 14th it was officially announced
in the House of Assembly at Cape Town that the disease at
Magude was plague, and that 42 cases, all fatal, had occurred
up to that date. Later information in regard to this outbreak has
been scanty and uncertain. In October or early November cases
of plague occurred in Lorenzo Marquez itself, and it was feared
that a grave extension of the disease might ensue on the outbreak
of the war in South Africa. Fortunately this fear, which was fully
justified by numerous precedents in past history, has not been
substantiated by events. But late in 1900 the disease was
epidemic at King William's Town, and during 1901 outbreaks
of some little severity occurred in Cape Town and Port Elizabeth,
while isolated cases were reported from Mossel Bay, Ladysmith,
Mafeking, Hermon, Imvani, Somerset West, and Stellenbosch.
In May, 1899, the presence of plague in Alexandria was
officially announced. Egypt had not been the scene of a plague
epidemic for some fifty-five years, and the announcement gave rise
to no little alarm. The exact date of the outbreak here is un-

336

PLAGUE

certain, but there is reason to believe that the infection was already
in the city in the early months of the year. The earliest recognised
cases occurred among the Greek community. The mode of
introduction of the infection into Alexandria could not be explained with certainty. The city is in frequent communication
with Bombay, and it is possible, though not proven, that the
disease was imported by infected goods, or by rats, from the Indian
port. The outbreak was never severe in Alexandria, but it
lingered throughout the summer and autumn, reappearing on
three separate occasions after the disease was believed to have
been stamped out and the measures for its control had been
relaxed. Throughout the winter Alexandria remained free from
plague, but in the spring and summer of 1900 the disease again
appeared and caused a certain amount of sporadic sickness and
death. A small number of cases also occurred in that year at
Port Said, Damietta, and Cairo. In 1901 limited outbreaks of
plague were recorded in Zagazig, Minieh, Mansoura, Alexandria,
Mit-Gamr, Tanta, Zifteh and a few other places, but in 1902 the
disease was confined to Alexandria.
In the month of July, 1899, P^gue was reported from Oporto
on the shores of Portugal, and from Kolobovka, a village at
the mouth, of the Volga. These outbreaks derived importance
from the fact that they were the first reappearance of plague in
Europe since the epidemic on the Volga in 1878-1879. The
epidemic in Oporto was slightly the eailier of the two. It
probably began in June, but the first recognised case occurred
early in July. The epidemic reached its highest point in October,
in which month 95 persons were attacked by the disease. It
then declined, and by the end of the year was almost, if
not quite extinct. The origin of the Oporto outbreak could
not be ascertained. It could scarcely have been due to a revival of infection remaining from a previous epidemic, as
Oporto and the whole of Portugal had been free from plague for
some two centuries. The earliest cases were among dock-labourer^
or persons living near the docks, and it is probable that the
infection was in some way imported by sea. No recognised importation could, however, be traced. It is interesting to note, as
probably not without bearing on this question, that, during the
last six years' prevalence of plague, Portuguese possessions have
suffered considerably throughout the world. In India Goa was

2 0 ••*• i

40

The Endemic
Centre in
Yunnan
(China) whence there is reason to
believe Plague has spread to the rest
of the world since 1894.
Those towns in which Plague has
j~~ome epidemic since 1894 are
underlined with a red line
Places
in which Plague has appeared but
no epidemic has followed are not so
underlined
The red shading iti India
indicates
_ that the greater part of the Peninsula has been more or less affected
with Plague; the individual places
being too numerous to mention.
Only those places and countries are
marked in the map in which Plague
has appeared since 1894.

60

160

120

8(5

DISTRIBUTION

40

40

OF P L A G U E

BETWEEN

T H E , YEARS

120

1894 A N D

1902

160

PLAGUE

337

the scene of a very severe epidemic, and Daman lost one-third of
its inhabitants in 1897 ; in China, the Portuguese ports of Macao
and Lappa have had the infection of plague in their midst—at
intervals if not constantly—since 1895 ; in South Africa it was
present in Portuguese territory (Magude and Lorenzo Marquez)
in 1899; and in the autumn of that year epidemics of some
severity prevailed in Brazil and Paraguay, countries having constant relations with Portugal. To this may be added the fact that
numbers of Portuguese are found in or near many other places
and countries where plague has recently prevailed.
Oporto was almost the only place in Portugal in which plague
appeared. In Baguin, a village some twelve miles from Oporto,
nine cases with five deaths occurred in October. At Braga, a
manufacturing town forty miles to the rtorth of Oporto, two imported cases occurred. In Lisbon plague caused the death of
Dr Pestana, a distinguished physician and bacteriologist, but no
other cases, imported or indigenous, occurred in the capital. A
slight recrudescence of plague occurred in Oporto in 1900, since
which date Portugal seems to have been free from the disease.
The outbreak at Kolobovka, at the mouth of the Volga, on
the shores of the Caspian Sea, began, it is believed, on July 16th
(28th), 1899. Between that date and August 9th (21st) twentyfour persons were attacked by the disease, and in all but one the
attack proved fatal. Special interest attaches to this epidemic, as
in no less than 20 out of the total 24 cases the disease developed
in its pneumonic form. There was no spread of the infection
outside the village named. Exactly the same difficulty was met
with here as elsewhere in attempting to account for the origin of
the epidemic. It is difficult to believe, as suggested by one
Russian authority, that the infection was imported here from the
centre in Mongolia, some 4000 miles away. It is just conceivable
that it may have come from the neighbourhood of Anzob, in the
Samarkand province, but of this no proof was forthcoming.
A second outbreak of plague occurred in this neighbourhood
at the end of November, or early in December, 1899. In this
instance the disease appeared in two Kirghiz aouls, or settlements,
in the maritime division of the Krasnoyarsk uyezdy or district, of
the government of Astrakhan. The names of these two settlements were Kishkine-Aral, and Kine-Aral; they are situated on
islands, at some distance from the mainland. Some 59 cases,
c.

22

338

PLAGUE

every one of which proved fatal, occurred here, and all are said
to have been of the pneumonic form of the disease. Other
doubtful outbreaks occurred in 1900 at Vladimirovka in the
government of Astrakhan, and at Tolovka, in that of Samara.
In 1899 an outbreak of plague of some severity occurred on
the Ivory Coast of the Gulf of Guinea. It lasted from March to
May and is said to have decimated the black population.
In the latter part of September, 1899, telegraphic news was
received that plague had appeared in Asuncion, the capital of
Paraguay. Paraguay is an inland country in the heart of South
America; plague had never before in history appeared in the
western hemisphere, and it seemed almost incredible that, having
travelled so far, it should appear not, as in so many other places,
on the coast, but some 600 miles up country. Later all doubt
was removed as to the specific nature of the outbreak, and it
subsequently appeared in Buenos Aires, Rosario, Rio de Janeiro,
Santos, Sao Paulo, and elsewhere, indicating that a considerable
area of this part of the South American continent was affected by
the disease.
In the same year plague broke out for the first time in history
in Australasia. In Australia itself outbreaks of varying intensity,
but none of very great severity, have been reported from Sydney
(New South Wales), from Melbourne (Victoria), from Brisbane and
Rockhampton (Queensland), from Perth and Fremantle (West
Australia), arid from Adelaide (South Australia). A few isolated
cases have also occurred in the interior, but practically plague in
Australia has been limited to the seaports. In the Pacific Islands
some cases occurred in Honolulu at the end of the year 1900, and
in New Caledonia about the same period.
In 1900 and 1901 several small outbreaks of plague occurred
in different parts of the Turkish Empire. In Smyrna the disease
was present from May to July 1900; in December a small but
very fatal epidemic of the pneumonic form of the disorder was
reported from Tomasso, a neighbouring village, and a case of
bubonic plague in the town itself followed in January 1901. In
May and September single cases occurred here, and again one
case in December, one in January, and one in October, 1902.
A small group of cases were discovered at Beirut on the Syrian
coast in July, 1900, and more than once plague has occurred in
that port upon ships coming from elsewhere. In January, 1902,

PLAGUE

339

a single case occurred there in a patient who had left Baghdad
some time before, and may have imported the disease from that
city. In June, 1900, there was a single case at Trebizond, and
in 1901 a small explosion of the disease occurred at Samsoun.
In Constantinople plague first appeared indigenously in January,
1901, and again in May, and it was fitfully present in the city
and its neighbourhood throughout the greater part of the rest of
the year. In 1902 it again gave rise to a few sporadic cases.
Batum and Odessa were the scenes of limited outbreaks in
the latter half of 1901, and in Odessa a considerable number of
cases of the disease were dealt with in the summer and autumn
of 1902. In the autumn of 1900 a limited epidemic appeared in
Glasgow, and in the following year the late summer was marked
by another small explosion there. About the same time as this
second outbreak Liverpool was visited by the disease, but it
attacked only a very few people.
In Cardiff and Hull single cases of plague have also occurred,
but, with the exception of imported cases of the disease on board
ships, no other parts of the British Isles have as yet been visited
by the malady.
Finally mention must be made of the occurrence of three
cases of plague in Vienna in 1898, traced to infection from a
laboratory in which observations on the plague bacillus were being
conducted; of an (uncertain) outbreak of the disease in Algeria
in 1899; of the appearance of plague in Aden in the spring and
summer of 1900 ; of small epidemics of the disease at Bushire and
Kishm on the Persian Gulf; of its reported outbreak on more
than one occasion a t ' Muskat; of a certain number of cases of
the disease in the Chinese part of San Francisco in 1900 and
1901, and of a few cases in the Philippine Islands in the same
years; of a single case on the island of Chios, and of a concentrated but brief outbreak at Naples in 1901 ; of a single death at
Salt Lake City, Utah, in the same year; of small epidemics in
Baghdad in May 1901, and January 1902, with possibly continued
presence of the disease there in the mild form of bubonic fever
between the two recognised outbreaks; and of a large number
of cases of the disease at Nairobi in British East Africa early
in 1902.
Plague on Board Ship. During the past eight years of plague
prevalence a very large number of instances of the appearance of
22—2

340

PLAGUE

the disease on ship-board have been recorded. These have
occurred in a great many parts of the world. In this manner
plague has actually been imported to innumerable ports, but it
has been exceptional to find such imported cases followed by a
local epidemic; and even when this course of events has been
observed, there has usually been no apparent connection between
the imported case and the subsequent indigenous cases. On the
contrary it would seem that imported cases on ship-board, probably
from the fact that they are recognised and dealt with, do not offer
great risk, and that when plague has become epidemic in a port
or country hitherto exempt, it has gained access there in some
much more insidious way—either by the importation of infected
rats or infected merchandise.
Cases of plague on ship-board have usually occurred upon
ships that have left an infected port, and most commonly within
a comparatively short period after sailing. It must be confessed,
however, that there have been some notable exceptions. For
example, in the autumn of 1896 some cases occurred on ships
in the Thames that had left India nearly six weeks previously. A
case of plague developed on the s.s. "Golconda" at Marseilles
on December 17, 1898, though the ship had left Calcutta—then,
technically, a plague-free port—some three weeks earlier. An
exactly parallel incident occurred on the s.s. "Peninsular" in
September, 1899, and many other instances of the kind might
be mentioned.
It is noteworthy that in the majority of instances of plague on
ships the patient has been one of the crew, and more often than
not a fireman, or one of the ship's servants whose occupation
would bring him into relation with that part of the ship where the
stores are kept and where rats would most likely abound. In very
many, but in far from all of the published instances, dead or sick
rats have been seen upon ships where plague has occurred on
board. As a rule a ship outbreak of plague is limited to a very
few cases, the disease being much more easily controllable than
yellow fever, beri-beri, or influenza under the like conditions.
Sometimes, however, the plague infection seems to cling to the
fabric of the ship itself. Perhaps the most striking example of
this was the s.s. " Mahallah," a Red Sea mail boat, on which
(in 1898) cases of plague persistently recurred after each of three
successive and very thorough disinfections.

PLAGUE

Factors concerned in the Geographical

341

Distri-

b u t i o n of P l a g u e . The geographical distribution of the
malady is frequently varying. In the past it has tended to
remain for long intervals in certain countries or districts, which
have at one time been of the nature of low-lying alluvial plains,
or deltas at the mouths of rivers, at another (as in the latter half
of the nineteenth century) of remote mountainous regions, away
from the main routes of trade or travel, and sparsely inhabited
by highlanders of various races, who appear to have nothing in
common save that they live in the midst of filth and insanitary
surroundings.
On at least four known occasions in the world's history
plague has become more or less truly pandemic. The first
occasion was in the reign of Marcus Aurelius in the second
century. The second was in the sixth century, in the time of
Justinian, when plague ravaged the Roman world for some fifty
or more years. The third occasion was the terrible outbreak of
the Black Death in 1347 and the following years, in which some
25,000,000 persons in Europe alone are believed to have lost
their lives. That pandemic spread to the furthest known limits
of the eastern hemisphere north of the equator. The fourth wide
extension of plague is now running its course and has been briefly
described above.
The present pandemic has shown that plague can exist and
become epidemic both to the south of the equator and in the
western hemisphere. It has shown that its limits are not of
necessity determined by lines of latitude or longitude nor by
isotherms, and that when once the infection is imported to any
portion of the earth's surface it will tend to become epidemic
there, provided the local conditions are favourable. At present
the most southerly place in which plague has appeared, though
not in' epidemic form, has been Melbourne, in (about) 38° south
latitude. In the north, the disease became epidemic in 1349 as
far north as Iceland and Greenland, and it is not beyond the
bounds of possibility that the present pandemic may extend considerably further towards the pole than it has hitherto.
In general terms, however, plague is mainly a disease of
temperate and subtropical countries, prevailing most frequently,
and as a rule most intensely, when the temperature is neither
excessively hot nor remarkably cold. Its seasonal variations in

342

PLAGUE

countries where it has been endemic or epidemic have been more
constant than in the case of some other diseases. In the endemic
centres in Mongolia and in Yunnan ; in the recent epidemic recurrences in Alexandria, Oporto, Hongkong, Constantinople, Madagascar and Mauritius; in the historical plague prevalences in
Europe and in Northern Africa, plague has usually been most
active in the warmer part of the year. In some Indian cities, on
the other hand, where the cool season more closely resembles the
warm season of more temperate climates, plague has in each of
the last six years declined in the summer and increased in the
winter months. For India taken as a whole the curve of plague
in recent years has shown two maxima and two minima. The
first maximum has fallen in the warm and dry month of March;
the second in the warm and moist months of October and
November. The first minimum has coincided with the commencement of the rains in the hot and moist month of J u n e ;
the second, with the cool and dry months of December and
January. Upon these data and a large number of others examined
by the Indian Plague Commission the conclusion has been arrived
at that neither the temperature nor the humidity of the air has
any influence in India upon the amount of plague prevalence. In
individual places in India the epidemic outbursts of plague have
occurred at very different seasons of the year. Some, as was
pointed out above, have been observed in the coldest months.
Others, as for example those in Hubli and Bangalore in 1898 and
in Poona in 1899, have occurred in the hot season.
Neither extremes of heat nor extremes of cold suffice to prevent
the appearance of plague. To the examples of outbreaks in hot
weather just named may be added the small epidemic at Jedda
in 1897, when the thermometer stood for a whole week at a time
(at the very middle of the epidemic period) at about i n ° F a h r .
in the shade, and was as high as 174*2° in the sun. At the other
extreme may be mentioned the outbreak on the Lower Volga
during intensely cold weather between October 1878 and January
1879, and that on the Persian mountains near Lake Urumia
in 1870, when plague broke out while the villagers were snowed
up in their dwellings, 4000-6000 feet above sea-level.
It must be doubted whether elevation above sea-level is of
any great importance in plague distribution. It was for long
believed that the disease lingered in low-lying alluvial plains

PLAGUE

343

and river deltas. But in recent decades it has been in high
table-lands or hilly districts that plague has been for the most
part endemic. Of this character are the endemic centres in the
Himalayas, in Arabia, and in Mongolia, and among examples
of plague epidemics at great heights may be mentioned several
in Persia at 4000-6000 feet above sea-level and the outbreak at
Anzob in Russian Central Asia (1898), at an altitude of from
6000 to 7000 feet.

There is little to show that racial susceptibilities greatly
influence the distribution of plague. No race is certainly immune to it. In China and India, and elsewhere, Europeans
have to a certain extent escaped it, but not a few have been
attacked, and all have probably been not only much less exposed
to infection than the natives, but also better able to guard against
it by taking judicious precautions. In India the Eurasians suffered
much more than the Europeans but much less than the natives.
At Cape Town the proportion of Europeans to natives attacked
has been remarkably high. It is noteworthy that in spite of its
geographical position between China and India, in both of which
plague has recently been so widely active, the Malay Peninsula
has practically escaped the disease; and to this may be added
the statement that in Cape Town the Malay inhabitants, who are
rather numerous, have not suffered. Possibly this race has a
certain immunity to plague, but more extended observations on
the point are needed.
Plague is one of the infective fevers and may therefore be
spread by the movements of infected persons. There is, however,
good reason for believing that its distribution over the earth's
surface is brought about less by the movements of infected
individuals than by other means. The plague virus can exist
for long periods outside the human body, not only in inanimate
objects {fomites) but also in the lower animals, many of which
are capable of suffering from plague, while others may harbour
the bacillus and carry it from one place to another without
actually suffering from the disease. Among, the lower animals
that are capable of actually contracting plague under natural
conditions the most important are rats, mice, monkeys, bandicoots, squirrels, cats, and marmots 1 . Of these, rats suffer far
1
See the author's papers upon "Plague in the Lower Animals," Brit.
Med. Journal^ May 12th and 19th, 1900.

PLAGUE

344

the most frequently, and are of all animals—not, perhaps,
excluding man—the most important agents in the spread of the
disease. Mice are less susceptible, but appear in some instances
to have suffered considerably, and may have been agents in
spreading the infection.
Monkeys, bandicoots, squirrels, and
cats have on rare occasions been attacked by plague, but there
is nothing to show that they have aided to any considerable
extent in diffusing the disease in man. Marmots undoubtedly
spread a disease allied to plague in Transbaikalia and possibly
in Mongolia. The evidence in regard to dogs, pigs, sheep,
goats, and jackals is less conclusive, but there is no reason
to believe that these animals play any great part in spreading
plague. Horses and cows do not appear to have ever contracted
the disease under natural conditions, and may be disregarded as
active agents in spreading it. Birds are equally immune, and
there is no evidence to show that either they or reptiles or fishes
have ever aided in multiplying and diffusing the infection. Insects,
on the other hand, are probably agents of considerable importance
in its spread.
The close association of rat epizootics with human plague
is perhaps one of the most important phenomena in the epidemiology of plague. The appearance of the disease in rats is sometimes accompanied by migrations and other unusual behaviour
among these animals. When plague is present rats probably
become infected with ease, either by living in infected soil, by
eating contaminated grain or other food-stuffs, by feeding off the
flesh of other animals (including human beings) dead of plague,
by sniffing at infected rags, articles of clothing, or dressings from
plague patients, and perhaps by means of the bite of an infected
insect. It would be out of place here to describe the symptoms
produced in these animals, or to discuss the bacteriological and
other evidence to prove that the disease in them is in truth the
same disease as in man 1 . Their identity has now been placed
beyond the possibility of doubt. In modern times few outbreaks
of plague have occurred without fresh evidence being adduced
of the presence of the disease in rats. In earlier times, it is
true, authors rarely made mention of any unusual phenomena
among rats during a plague epidemic. For the two great pan1

I have discussed the evidence at some length in the Brit. Med. Journal\

May 19, 1900.

PLAGUE

345

demies of the disease, those of the 6th and 14th centuries, no
record can apparently be found in the writings of any of the
principal historical authorities that would show that there was
then any unusual disease or mortality among rats l ; and not less
remarkable is ^ the absence of reference to rat-mortality in connection with a large number of other epidemics, as, for example
the great pestilence in Marseilles in 1720, that in Moscow in
1770-71, and apparently the greater number of outbreaks in the
nineteenth century in Europe, Egypt, Arabia,' Mesopotamia,
Tripoli, and elsewhere. In some of these instances there was,
perhaps, no rat sickness, but it is more likely that in many of them
it was present but overlooked. For unless special attention were
directed to it, or unless it were present to a striking extent, a
phenomenon of this kind would easily escape notice, or if observed
might easily escape record by an observer or historian.
On the other hand sickness and mortality among rats or other
rodents have been recorded in connection with not a few of the
historical epidemics. The Biblical mention of the "mice that
marred the land " at the time of a plague (?) epidemic among the
Philistines and Israelites has already been alluded to. Probably
one of the oldest references to plague in rats is that contained
in the Bhagavata Purana, one of the most important and perhaps
one of the most ancient of the sacred Hindu writings. The
people are there instructed to quit their houses and go to the
plains as soon as they observe that "rats fall from the roof above,
jump about and die." Clearly there was risk of disease appearing
in man if he remained in his house, and it is a fact of the highest
interest that the instructions contained in this ancient writing are
followed to this day in many parts of India when an unusual
sickness or mortality is observed among rats. Avicena (A.D. IOOO)
states that, when plague is approaching, mice and other animals
that usually live underground leave their holes and stagger as
* though drunk 2 . Lodge, one of the best known of English writers
1
Probably all kinds of rats were less common in the civilised world at those
periods of history than they are now. The brown rat, for "example, is thought
to have reached England only as late as the beginning of the 18th century.
A complete knowledge of the distribution and comparative frequency of the
different varieties of rats in all countries and at all periods might throw much
light upon this interesting question.
2
Reference in Indian Plague Commission Report, p. 132, footnote; where
the statement of Avicena is quoted from an article by Dr Rudolf Abel in the

346

PLAGUE

on plague, makes mention of unusual phenomena among rats in
connection with the disease 1 . When plague was prevalent in
India in 1611-18 rats and mice seem to have been affected by
the disease. The Emperor Jehangir has left a detailed account of
the epidemic as he observed it in Agra, and in one passage he
succinctly states that a sick rat was seen in a certain house, and
that the rat was killed by a cat, which belonged to the daughter
of the owner of the house. A slave, who was ordered to remove
the body of the rat, was subsequently attacked with plague; and
later the girl who owned the cat, her mother, and finally all the
members of the family were seized with the disease. This record,
so far as the sequence of facts is concerned, might have been
taken from a Plague Report of yesterday, instead of from an
Indian author who lived nearly three centuries ago.
During the Great Plague of London in 1665 it was apparently
feared that rats and mice might be the means of spreading the
infection, and there was a general crusade against these animals.
"All possible endeavours," writes Defoe, "were used also to
destroy the mice and rats, especially the latter, by laying ratsbane and other poisons for them, and a prodigious multitude
of them were also destroyed 2 /' Almost equally remarkable is the
reference to rat disease in Yunnan in the 16th century, to which
detailed allusion has already been made. In the last half-century
the endemic prevalence of plague in this Chinese province has,
Zeitschrift fiir Hygiene, 1901. I have not had access to this article, and can
therefore only observe with surprise that the Commissioners r e m a r k : — " i t is
noteworthy in this connection that the minute bibliographical researches of
D r Rudolf Abel, extending over the whole field of classical, mediaeval and
modern literature, bring out clearly that there are no records of epidemics
among rats occurring concurrently with plague among m e n . "
1
T h e passage r u n s : " A n d when as rats, moules, and other creatures
(accustomed to live underground) forsake their holes and habitations it is a
token of conception in the same, by reason that such sorts of creatures forsake
their wonted place of a b o d e . " N o mention is made here of actual disease in
the rats, only of unusual migrations.
N o t e also the death of " dogs, cats, mice, and rats " in Leeds in 1645 during
a plague epidemic.
2
In Hongkong, in innumerable places in India, in Alexandria, Odessa,
Oporto, and elsewhere " a prodigious m u l t i t u d e " of rats have been destroyed
in the last few years, under precisely the same conditions and with precisely the
same object. T h e trite saying that " H i s t o r y repeats itself" has perhaps
seldom been more strikingly exemplified.

PLAGUE

347

in like manner, been constantly associated with sickness in rats;
and the same remark applies to the endemic centres of plague
in the Himalayas. Finally, during the recent wide extension of
the disease, from almost all quarters of the world where plague
has broken out there has been a steady stream of evidence,
establishing beyond question a close correlation between plague
epizootics in rats and plague epidemics in man.
To what extent rats are the means of carrying plague over
the earth's surface is still a matter of doubt. It is, however,
certain that in recent years the epidemic appearance of plague
in a country far removed from any other country where the
disease was known to exist, has very rarely been traceable to the
passage of an infected person from one to the other. In this
respect plague differs essentially from a disease such as small-pox,
the spread of which can almost invariably be traced to the movements of human beings. It is therefore almost certain that the
infection of plague is carried from country to country by other
than human agency, and the most probable explanation is that
it is carried either by rats or by infected merchandise. As to
the carriage of plague over shorter distances—as from town to
town in an infected country—it may be said that the appearance
of plague as an epidemic has often followed the arrival of a sick
person from an infected area, but even then a considerable
interval has elapsed between the arrival of the latter and the
occurrence of subsequent cases. This interval has very often
been characterised by the development of a plague epizootic
among rats. While this has, in India at least, been the most
common course of events, it must be added that in many outbreaks no trace of rat-infection has been discovered, and that in
others a plague epizootic among rats has not been followed by a
plague epidemic in man.
The part played by insects in the spread of plague is not yet
fully determined, but the experiments of Simond, Yersin, and
Hankin have shown that the disease may be transmitted, either
actively or passively, from rat to rat and from rat to man by
means of certain insects, of which probably the flea is the most
important. Considerable doubt, however, has been thrown by
Nuttall, Galli-Valerio, and others, upon the suggestion that insects
are the principal, or even an important means of spreading
plague.

348

PLAGUE

While rats and some other lower animals form important
media for the persistence of plague infection outside the human
body, it is probable also that the infection can remain for considerable periods in inanimate objects without losing its activity.
There are many historical instances of plague appearing in a
hitherto plague-free district after the arrival of infected goods
from a district where plague was present; and though it is easy
to find flaws in the records of many of these instances, it nevertheless remains almost certain that the disease can be spread over
the earth's surface by means of infected goods or fomites. What
particular class of goods is most likely to carry the infection
it is difficult to say. The European nations have agreed at
successive international conferences to regard the following as
" susceptible " articles, the importation of which may be prohibited
in time of plague:—body-linen, personal clothing that has been
worn, bedding that has been used, rags (including those compressed by hydraulic pressure), used sacks, carpets, and embroideries, raw hides, untanned and fresh skins, fresh animal
refuse, claws, hoofs, horse-hair, hair of other animals, silk and
raw wool, and human hair.
Possibly the infection may cling to other objects than these.
Grain and food-stuffs generally have been regarded with much
suspicion, and it is certainly noteworthy that in an immense
number of recent outbreaks of plague (e.g. to name a few only,
those in Bombay, Calcutta, and many other Indian cities, in
Mauritius, in Oporto, in Alexandria, and in Constantinople) the
disease has first appeared or has been most active among persons
whose employment or place of residence brought them in relation
to grain stores, or to bakeries, bread-shops, or groceries, where
grain or other food articles were handled. The close association,
however, of such places with rats, which are naturally most found
where grain and other food are most abundant, must not be
forgotten; and it is probable that the phenomenon just noted is
often to be explained in this way rather than by supposing that
in each instance the grain or other food-stuff was the primary
agent in carrying the infection.
The relation of plague to insanitary surroundings has been
much debated. The facts appear to be briefly as follows. In
all those geographical areas where plague has been endemic
during the last half-century the inhabitants have been persons

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349

living in much filth, poverty, and unhygienic surroundings. It is
impossible to read the accounts of plague prevalence in Yunnan,
in Mongolia, in the Himalayas, in Persia, in Mesopotamia, and in
Arabia, and not be struck by the extraordinary resemblance
between the conditions of life in all these regions. They may
be briefly summarised by the words filth and misery. During
the recent years of plague activity the disease has caused very
serious epidemics only in certain Chinese and Indian towns.
The published descriptions of Canton and Hongkong leave no
room for doubt as to the filth and insanitation under which the
Chinese live; and no one who has explored a Bombay chawl
or a Calcutta bustee, would hesitate to declare that the native
part of a great Indian city abounds in filth and in sanitary
deficiencies. Outside India and China, in those places where
plague has succeeded in establishing itself to any extent—as in
Alexandria, Mauritius, and certain South American towns—dirt,
and a low level of general hygiene are very prominent features
in all the published accounts of the way in which the inhabitants
of those places live.
On the other hand, plague has appeared and even caused
small, temporary epidemics, in houses or institutions that were
irreproachable as regards cleanliness and general sanitary arrangements. Such outbreaks, however, have been exceptional; they have
usually occurred where plague was already seriously epidemic
among dirty and insanitary conditions in the near neighbourhood,
and they have been as a rule controlled with considerable ease.
Of the many conditions implied under the general term
insanitation, it seems probable that the aggregation of numbers
of susceptible persons together in dark, dirty, ill-ventilated rooms
is the most favourable to the epidemic extension of plague. To
this may be added as contributory conditions, at least in India,
the absence of flooring to huts, enabling rats to gain free access
to them, the practice of sleeping on the bare ground, and of going
about bare-footed, and a lack of knowledge or willingness to
recognise the first cases of the disease, or premonitory rat-sickness,
and to take early measures in consequence. Defects in watersupplies cannot in any way be charged with favouring plague
extension. Defects in the removal of excreta and of refuse are
more liable to suspicion. That dirt and a sewage-soaked soil
tend to encourage plague prevalence, if not—as was at one time

3SO

PLAGUE

thought—to generate the disease de novo, is an opinion now less
generally held than formerly. Faecal pollution of soil, imperfect
removal of refuse, and filth-accumulation have, however, been
such frequent accompaniments of severe plague prevalences that
it is difficult to deny them all share in the sum of conditions
* favouring the spread of the disease.
It is not easy to assert exactly how various sanitary defects act
in favouring the spread of plague. The plague bacillus under
artificial conditions soon dies out, or at least soon ceases to be
recognisable, if grown among other saprophytic organisms such as
are found in filth, refuse, and sewage-polluted soil. Yet under
natural conditions the infection lingers for months together in a
saprophytic state between successive outbreaks in human beings
(as, e.g. in the endemic centres above described); and it is clearly
capable of thriving under those very conditions of soil-pollution
and filth-accumulation which a priori seem to be unfavourable to
the life of the bacillus. On the other hand, even in artificial
growths, the bacillus likes best the very conditions of moisture,
darkness, lack of oxygen, and excess of carbonic acid which are
found in close, overcrowded, and ill-ventilated dwellings1.
While it is probable that insanitation is a very powerful factor
in plague distribution, it does not explain all the phenomena of
the disease. It fails to explain why plague remains many decades
or even centuries together confined to quite limited areas, and
then, without apparent reason, spreads widely over the earth's
surface. It fails to explain the gradual eastward recession of
plague in Europe at the end of the seventeenth century, or its
complete disappearance from that continent and from Egypt in
the fifth decade of the nineteenth century.
No doubt the
sanitary condition of most European countries is very much better
now than it was in the middle ages ; and this may possibly be in
part the reason why the infection of plague has not in the past
few years, in spite of repeated importation, been able to sweep
over the continent as it did in the fourteenth century, or indeed
to obtain a serious foothold anywhere. But it would be rash to
assert that it is the whole explanation. No great or startling
improvement took place in the sanitation of Europe at the end of
1
See the President's Minority Report, App. iv., Report of the Indian
Plague Commission, 1901 ; where these and other considerations are developed
at great length.

PLAGUE

351

the 17th century, to account for the disappearance there of plague;
nor was anything of the kind observed in Egypt or Constantinople
to explain why plague died out in those localities in the middle of
the nineteenth century.
In the wide epidemic extensions of plague over the earth's
surface, just as in the case of influenza and cholera, there seems
to be a more or less sudden increase in the activity of the disease
in one of its endemic centres, and a carriage of infection thence
in all directions along the lines of trade and travel. On no
occasion has there been anything to show that a simultaneous
increase in activity took place in all or even in many of the
endemic centres. The Black Death shewed a clear progression
from some eastern country, probably India, to Central Asia and
Southern and Eastern Europe, and so to the west. The present
extension of plague has also come from the East. A most careful study of the records of all the known epidemic centres of the
disease in the last half of the nineteenth century shows that in one
alone was there any unusual activity just before plague began its
wrorld travels in 1894. That centre, or group of centres, was the
one already described in Southern China, and there can be little
doubt that the subsequent extension of the disease over the
earth's surface is to be traced from it.

PNEUMONIA.
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . In the present
chapter it is intended to discuss the geographical distribution
of croupous or lobar pneumonia only, so far as this is possible.
The data for a study of this kind are, however, imperfect, in that
under the heading " pneumonia " cases of broncho-pneumonia are
very often included, while in not a few reports and statistical
returns " pneumonia" is not treated at all as a separate disease
but is grouped together with pleurisy, or even absorbed in the
more general group of " diseases of the respiratory system." In
recent years, however, the specific character of croupous pneumonia has been more and more recognised, and the practice of
grouping the disease among the acute infective disorders instead
of with respiratory diseases is now very generally followed. This
practice appears to be fully justified by the many characters which
pneumonia has in common with these disorders, by its tendency
in some instances at least to become highly infectious from
person to person, and by its occurrence at times in marked
epidemic form.
There are indeed, some indications that under the general
term " pneumonia" more than one form of specific infective
disease may be included. It is certain that some bacilli, as for
example the plague bacillus, can primarily infect the lung and
cause a definite (lobular) pneumonic condition. It is no less
certain that an attack of influenza is constantly associated with
the development of pneumonia, though in this case it is still
uncertain whether the condition is brought about by a primary
invasion of the lung by the micro-organism of influenza or whether
it is not a double infection. The frequent co-existence of pneumonia with enteric fever has also given rise to the suggestion that

PNEUMONIA

353

the typhoid bacillus may in these instances have selected the lung
instead of the intestines for its primary attack. But for the
present the exact explanation of these cases is uncertain, although
some authors speak of a "typhoid pneumonia" as a recognised
pathological entity.
The mode of production of an acute attack of typical croupous
pneumonia is also as yet not wholly explained. A large number
of micro-organisms are found in the sputa in such cases, the most
constant being the diplococcus of Frankel and Weichselbaum and
the micrococcus of Friedlander, and in some epidemics the
bacillus pneumonia of Klein.
It is possible that the epidemic and highly contagious forms
of pneumonia are manifestations of a different disease from the
ordinary idiopathic case's of pneumonia, which usually show a low
degree or apparent absence of infectivity. A few widespread
epidemics, and many localised outbreaks of this nature have been
recorded in the past.
H i s t o r y . The antiquity of ordinary croupous pneumonia is
unknown. It is probable that the pneumonia of influenza and
the pneumonia of plague are as old as the history of those
diseases themselves, for there are few ancient or modern writers
on either the one or the other who in their descriptions of the
disease do not refer to lung symptoms in terms which more or less
closely indicate the occurrence of pneumonia.
True epidemics of inflammation of the lungs or pneumonia
have occurred in many parts of the world at least since the
sixteenth century. Hirsch has summarised most fully the facts,
so far as they are known, of these successive outbreaks 1 . In the
sixteenth century the records are most numerous for epidemics
in Germany, Switzerland, Italy, the Netherlands, and France;
in the seventeenth for Germany, Switzerland, and Italy; and in
the eighteenth for Italy, Switzerland, France, Spain, England,
Denmark, and North America. In the century that has just come
to a close a very large number of epidemics occurred in the
countries already named. While the overwhelming majority of
these in the past have been reported from either Europe or
America, it is certain that they can and do occur in Asia,
Australasia, and Africa, and mention will be made later of such
1

c.

Vol. in. p. 125.
23

354

PNEUMONIA

epidemic prevalences of the disease in India, New Guinea, and
South Africa.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. In the
British Isles pneumonia is a very common disorder and a cause
of considerable mortality, especially in the winter and spring
months. It sometimes takes the form of an epidemic; a very
severe one of the kind broke out at Middlesborough in 1888, and
caused as many as 369 deaths.
In France pneumonia and broncho-pneumonia are responsible
for a heavy annual mortality. Thus in the years 1887-1898 in
French towns with over 10,000 inhabitants, the deaths from these
causes varied between 1650 and 2320 per million of the population. The pneumonia death-rate in French towns is considerably
higher than that in many English, towns, 'though lower than that
in Christiania or Copenhagen.
In the urban population of Denmark "pneumonia crouposa"
is a very frequent cause of death, though of quite recent years
the mortality from this cause has tended to diminish. The
deaths in Danish towns from this cause in the six years 1892 to
1897 were respectively 611, 588, 431, 405, 425, 444 1 . With the
exceptions of "cholerine and acute intestinal catarrh," "phthisis
pulmonalis " and " cancer," no other disease or group of diseases
causes so many deaths in the inhabitants of Danish towns as the
one now under consideration. So also in Norway croupous
pneumonia is a cause of more deaths than any other disease save
"tubercle of the lung"—the groups of intestinal disorders and
cancers proving much less fatal here than the lung affection in
question 2 .
Throughout the whole of European Russia pneumonia is one
of the commonest of affections. It is seen in the government of
Archangel on the shores of the White Sea, in the Baltic Provinces,
in Poland, in the Ukraine, on the Volga, and on the shores of the
Caspian and Black Seas. It seems to be rather more frequent
on the whole in the southerly than in the northerly governments.
In Bavaria and Swabia pneumonia appears to be more frequently seen than any of the acute infectious disorders.
Of the prevalence of pneumonia in Spain it is difficult to give
1

Statistik Aarbog, Kjobenhavn, 1899. The estimated population of these
Danish towns was 784,000 in 1895.
2
Statistik Aarbogfor Kongeriget Norge, 1897.

PNEUMONIA

355

an accurate account, but it cannot be rare, for in the Spanish
army it is a common cause of invaliding. In the report for that
army for the year 1895 ^ *s stated that this disease is frequently
observed among the troops in the peninsula or stationed on the
Spanish possessions off the African coast. In that year few other
diseases accounted for more cases of sickness or of death than
pneumonia.
It is a no less common disorder in Italy. The health statistics
of that country for the ten years from 1887 to 1896 show that pneumonia caused a higher mortality-rate than any other disease—
enteric disorders (including diarrhoea, dysentery etc.) alone excepted. It is in most years more than twice as fatal as pulmonary
tubercle, the latter causing an annual mortality of about 1000
per million, while the deaths from pneumonia average from 2000
to over 2500 per million1.
In European Turkey pneumonia is very frequently seen at the
present day. At Preveza, for example, in the first half of 1901
more than one-third of the total deaths were attributed to pneumonia ; at Kavala it is far from rare as a cause of mortality,
and from many parts of the Salonika province k is frequently
reported.
°
In the Faroe Islands pneumonia is classed together with
pleurisy and bronchitis as among the most frequent causes of
death.
The evidence for the existence of croupous pneumonia as an
indigenous disease in the island of Malta is conflicting. In the
Colonial Reports for the possession numerous deaths from this
cause are yearly returned. But the late Capt. Louis Hughes has
left it on record that during six years' residence in the island he
never saw a case of "acute croupous lobar pneumonia." Many
cases of catarrhal (lobular) pneumonia had come under treatment
in that period, in persons suffering from Malta fever or from enteric,
but a case of true lobar pneumonia of indigenous origin had not
been observed. Many cases of the latter form of affection had
however been seen in men removed from troopships, eight to
twelve days out from England 2 .
Asia. Pneumonia is not rare in Asia Minor. In reports
from Trebizond, Samsun, and other towns it often occupies a
1
2

Annuario Statistico Italiano, 1898.
Journ. Trop. Med.> Sept. 1899.
23—2

35^

PNEUMONIA

conspicuous position among the diseases named, and cases are
frequently reported from Rhodes and other islands off the
coast.
Pneumonia is a very frequent cause of death among the
Moslem pilgrims to Mecca, and apparently also among the permanent inhabitants of that city. Generally speaking the disease
is said to be rare on the coasts of Arabia and common in the
interior.
In the Caucasus the disease is no rarity, particularly towards
the end of autumn and in the spring. It is the most frequent
cause of death among malarial subjects in this part of the world,
and at times it becomes truly epidemic 1 .
The returns from the Central Asiatic provinces of Russia and
of Siberia are very imperfect for this as for most other diseases.
As they stand they seem to indicate that pneumonia, while known
throughout Asiatic Russia, is of much less frequent occurrence there
than in European Russia, but this must be regarded as doubtful.
None of the Siberian provinces are free from it, but the largest
number of cases are reported from those of Irkutsk, Tobolsk,
Tomsk, the Amur, and Tchita, while the returns from the convict
island of Sakhalin also indicate a considerable degree of frequency
of this disease among its inhabitants.
In Mesopotamia pneumonia is seen, and in the Persian capital
many cases occur every winter. At Basra, at the head of the
Persian Gulf, the disease is also by no means rare.
In the Indian peninsula pneumonia is a serious affection and
a cause of a high degree of mortality. Its distribution here
presents many points of the greatest interest. Certain parts of
the country appear to be peculiarly favourable to the prevalence
of the disease, and from year to year larger proportions of invalidings and of deaths from this cause are recorded from these
districts than from any others. The highest degree of prevalence
is almost, if not quite invariably, found to occur in the Indus
valley, whether the returns of the Indian army or of the Indian
gaols be taken as the index. In Peshawar the disease is particularly common. As a cause of death, however, pneumonia would
appear to be more frequent in the Punjab than even in the Indus
valley. From the returns of the gaols in India it may be gathered
Pantiukhof.

PNEUMONIA

357

that the Upper sub-Himalayan districts are, next to the Indus
valley, the most affected by this disease, and then follow, in order
of frequency, Central India and the Hills.
On the North-West Frontier epidemics of pneumonia are far
from rare. Outbreaks of the kind occurred in the Tirah field
force and the Malakand force, and occasionally epidemics of an
infectious form of the disease are observed in Umballa in troops
returning from field service. In the Hindu-Khush, on the other
hand, pneumonia is rare, and in the Hunza expedition there was
not a single case, although the men bivouacked without tents at a
height of 7000 ft. In Kashmir also the disease is not common.
Whether true croupous pneumonia is a frequent disorder among
the general population in India it is difficult to say. Buchanan
states that, whereas formerly many cases of "text-book pneumonia " were seen there, such cases are now rare, and that, when
met with, pneumonia is usually of the catarrhal or lobular form.
Possibly this observation may be explained by the frequency with
which the latter form of the disease follows on, or is associated
with, influenza—a disorder which has been present in India, with
varying degrees of severity, since 1890.
Pneumonia is very prevalent in Ceylon, where it is the third
most fatal of all diseases.
In some of the East Indian Islands, as for example Borneo,
pneumonia is fairly common, but in others it appears to be seen
only exceptionally. In the Malay Peninsula and in Indo-China
the disease is perhaps rare; in Singapore it is said to be exceedingly rare. The evidence in regard to China is imperfect
and conflicting, but it is probable that it is at the present day by
no means rare in many parts of that country. In Shanghai it is
said to have been almost unknown before 1890, but to have been
of not infrequent occurrence since; and if this is so, it may most
plausibly be explained by the fact that the influenza pandemic
dates from the year named. The disease certainly exists among
the native Chinese, and cases are not uncommonly seen at
Kiukiang, Swatow, Lung-chow and other places. At Chungking
it is said to be rather rare.
Throughout Japan pneumonia is met with frequently, from
north to south.
Australasia.
In certain parts of British New Guinea an
epidemic form of pneumonia is common among the natives at

358

PNEUMONIA

the beginning of the cold season, and apparently the disease is
here of a contagious character (MacGregor).
In Australia pneumonia is very widely prevalent and a frequent
cause of death, and there is reason to believe that of recent years
it has shown a tendency to increase as a cause of mortality.
Thus in Queensland the deaths from it increased considerably
between the years 1893 and 1897, and it stands second only
to pulmonary tubercle as the most fatal of all diseases. It is
particularly severe here in winter. A still more striking increase
in the pneumonia mortality is shown in the returns from West
Australia for the years 1889-98, the figures having risen steadily
in that time from 12 deaths in 1889 to 169 deaths in 1898.
It is probable that the advent of the influenza pandemic to
Australia in the early part of the period in question has been
largely responsible for this striking rise in pneumonia mortality.
Pneumonia occurs with varying frequency in the Pacific
Islands; in some, as for example New Caledonia, it is said to
be particularly fatal to the native inhabitants.
Africa. The malady appears to be decidedly rare in Egypt,
in Tunis, and perhaps in Morocco, while in Algeria, on the
other hand, it is said to be of very common occurrence and
to cause a higher mortality than in either England or France.
Certainly in the years 1896, 1897, and 1898, the disease caused
a larger number of deaths in Algerian towns with over 30,000
inhabitants than any other group of diseases, with the exception
of phthisis and diarrhceal disorders. On the West Coast of
Africa pneumonia is said frequently to attack the natives in
Senegambia, the Congo Free State, and the Cameroons. Europeans in these portions of the African continent appear to be
less liable to its attacks. In Lagos the disease is very common
and is particularly fatal to Kroomen.
Throughout South Africa pneumonia seems to be a very
common disorder. At the Kimberley hospital many natives are
annually treated for it; at Grey's hospital, King William's Town,
and in the Durban hospital, it is one of the most prominent of
diseases; and from Grahamstown and other places in Cape
Colony similar reports are published. Epidemics of pneumonia
are said to prevail from time to time in some of the coast towns
of South Africa, and the occurrence of dust-storms may, it is

PNEUMONIA

359
1

thought, stand in some causal relation to these epidemics . The
natives in Mount Frere district (Native Territories) are very
frequently attacked by it.
It is found that pneumonia is exceedingly common in Uganda
and that it is met with throughout the greater part of Central and
East Africa. Accurate statistics as to its prevalence are wanting,
and such information as is available is largely vitiated by confusion
between pneumonia and other respiratory disorders. But it may
fairly be stated that all the evidence points to the conclusion that
the black races of the African continent are peculiarly liable to be
attacked by pneumonia, and that it is often very fatal amongst
them.
In Madagascar and Mauritius pneumonia is by no means rare.
North and Central America. In the far north of the American
continent pneumonia is widely prevalent. In the Hudson Bay
territories and in Greenland it attacks both Europeans and
natives. In all parts of Canada the disease is exceedingly common;
and throughout the United States it is said to be the most fatal
of all maladies, next to pulmonary tubercle 2 . It is certain that
pneumonia is either commoner or more fatal, or both, on the
continent of North America than in many European countries.
Davidson has made a careful study of the distribution of the
disease in the United States, and finds that, while of more or
less frequent occurrence almost throughout, it is less common
on the coasts than in the interior, that it is rare on the South
Atlantic coasts, in the Appalachian highlands, in the southern
part of the Pacific coast and a part of the Gulf coast, but that
generally speaking the principal areas in which it is found to
be in excess lie south of lat. 41 0 . Contrary to what might
have been anticipated pneumonia is somewhat less fatal to the
Indian races in North America than to the white and black
races. The black races succumb most easily to it. There has
been a very great increase in the pneumonia mortality in the last
half-century in the State of Massachusetts.
In Mexico pneumonia is both frequent and fatal on the
central plateau; it is a frequent cause of death in Guatemala;
and the natives of British Honduras are said to be particularly
1
2

Hillier. Lecture at the London Polyclinic, Feb. 1900.
Census Report, 1890.

360

PNEUMONIA

liable to fall victims to its attacks. In Nicaragua and Costa Rica,
on the other hand, it seems to be rare.
The disease is frequently seen in many of the West Indian
islands. In reports from Cuba, Barbados, St Lucia, and many
others it finds frequent mention. In Jamaica it is particularly
prevalent in the months of December, January, and February,
although there is not more rain in these months than in the
summer, nor is it especially cold at that season.
South America. Among the inhabitants of British Guiana'
pneumonia is a very fatal disease. The Indian races are particularly liable to it, and in some recent years it has been
the cause of not less than two-thirds of the total mortality
from all causes. Here, as in so many other countries, the
occurrence of the influenza pandemic has caused a great rise
in the pneumonia mortality. The disease is by no means rare
in French Guiana, it is met with in all parts of Brazil, and
appears to be particularly common in Uruguay and Paraguay.
I n the Brazilian army pneumonia and pleurisy together are said
to cause nearly one-third of the total mortality. Martin de
Moussey 1 speaks of an adynamic form of pneumonia met with
in the Andes, which, he states, is common and fatal in all the
Andean provinces proper, and in Santiago del Estero, Cordoba,
and San Luis in the winter season.
On the western side of the continent it is found that pneumonia
is very common both on the coasts of Peru and in the Sierra.
The same statement is true in regard to Chile, or, at least, for its
capital, Valparaiso. In the Falkland Islands, on the other hand,
the disease is almost unknown, in spite of a climate which would,
a priori, appear to be most favourable to its prevalence.

Factors concerned in the Geographical Distribution
of P n e u m o n i a . From the above rapid sketch of the present day
prevalence of pneumonia it will be seen that the affection exists
to a greater or less degree in almost all parts of the earth's surface.
Not only does it occur in all the four continents and in Australasia,
but it is met with more or less in every great geographical division
of them. It is doubtful whether there is any area of considerable
size from which pneumonia is entirely absent, while in a very large
number of countries it is extremely common and a cause of an
annual mortality which is exceeded by that of few other diseases.
1

Cited by Davidson.

PNEUMONIA

361

As already pointed out, however, there are marked differences in
the frequency of pneumonia in different countries, and an endeavour
has been made—which up to the present has not been wholly
successful—to discover what are the influences at work that
produce these differences.
" C h i l l " has from time immemorial been regarded as one of
the most important and immediate factors in the production of
an attack of pneumonia in the individual, and at no very distant
period the disease was regarded as an ordinary inflammation of
the lung, the result of exposure to cold. This view, now largely
modified, also gave rise to the expectation that pneumonia would
be found to be most common in cold climates, and to be least
common or absent in the warm zones on either side of the
equator. A study of its distribution over the earth's surface,
however, soon dispelled this anticipation, and showed that pneumonia can and does exist in all latitudes, and that it is probably
quite as common in the tropical belts of Asia, Africa, and South
America as in the temperate climes of central Europe or the cold
regions of Canada and Greenland. Some observers have even
gone further and tried to show that the warmer the country the
commoner will pneumonia be. Sanders endeavoured to prove,
by means of tables, that the ' incidence of the disease increases as the equator is approached and the mean temperature
increases 1 . But this view appears to err in the opposite direction,
and our present knowledge of the disease rather warrants the
statement that mean temperature has no effect on its prevalence,
but that it can and does prevail in all latitudes, quite independently
of their nearness to or remoteness from the equator.
The same is to a great extent true of the relation of pneumonia
to altitude. Thus the disease is just as common in the Himalayan
districts of India as in the plains ; and it is found at considerable
elevations in the Mexican plateaux and in the highlands of South
America, Arabia, Persia, and the Caucasus. There is, in fact,
nothing to show that elevation has by itself any influence on the
distribution of pneumonia.
Changes of temperature, on the other hand, are probably
important factors in determining its distribution, at least in regard
to time. In its seasonal relations pneumonia, in most countries,
no matter what their geographical position, shows a tendency to
1

American Journal of Medical Science, 1882.

362

PNEUMONIA

prevail in the winter and spring, when changes of temperature are
most marked and the individual is most exposed to the risk of
chill. It has been extremely rarely that a pneumonia epidemic
or a maximum prevalence of pneumonia has fallen in the summer
months.
It is probable that insanitary conditions aid to a considerable
extent in the production of the malady, and that overcrowding
and insufficient ventilation are particularly active in this respect.
Dirt and escape of sewer-gas into houses may also be not without
influence. These factors have usually been more or less at work
in the well-known epidemics or prevalences of pneumonia in such
institutions as gaols, barracks, or schools. In some epidemics,
too, over larger areas the most insanitary dwellings in the area
seem to have suffered the most.
In all considerations of this kind, however, in regard to this
malady it is important to remember that, as already pointed out,
the term "pneumonia" probably includes more than one form of
disease, and that as our knowledge of the various kinds of
pneumonia becomes greater it will probably be found that they
are differently influenced by the different factors just discussed.
It is almost certain, for example, that simple idiopathic croupous
pneumonia is much more closely associated in its causation with
changes of temperature and "chill" than is the epidemic infectious
form -of the disease, while the latter is almost certainly more
intimately connected with the existence of insanitary conditions
than the former.
It is certain, too, that in the individual any influences which
depress the general vitality predispose to pneumonia, and among
these may be mentioned exposure to cold and wet, fatigue,
poverty, mental trouble, and exhaustion from other diseases.
The influence of race upon the predisposition to pneumonia is
probably not very great. All races appear to be capable of
suffering from it, but it is probable that the negro is the most
susceptible. The tendency of negroes to develope the disease
when transported from their native country to other and
particularly colder climes has long been recognised ; but here the
racial question is obscured by the possible presence of some of the
other depressing factors already alluded to.
Varieties of soil appear to have no direct and universal
influence upon pneumonia prevalence, nor has the configuration

PNEUMONIA

3^3

or general geological character of the land. No doubt in individual outbreaks or prevalences these factors are not wholly without
their influence, but no general law can as yet be deduced in
regard to them. Some have believed that a l6w level of subsoil
water was favourable to the development of pneumonia, but this
view has been combated by others. The effect of rainfall is also
uncertain, but in some occurrences of the epidemic form of the
disease a heavy rainfall has seemed to aid in extinguishing the
outbreak. This was notably the case in the well-known epidemic
of pneumonia at Middlesborough in 1888.
In regard to the influence of sex it is generally admitted that
males are more liable to pneumonia than females, though the
disease is usually more severe and fatal in the latter. Persons
of all ages are liable to it, but particularly those in the more
advanced age-groups. It is peculiarly fatal to old persons and
very young children.

RELAPSING FEVER.
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . Relapsing or famine
fever is, as its name implies, a fever characterised by the
occurrence of relapses; usually at intervals of about a week.
There is no eruption. The disease is most frequently seen as
an epidemic, is often associated with conditions of ill-nutrition
and overcrowding, and is always accompanied by the presence
in the blood of a specific organism, the spirillum or spirochete
obermeieri.
This disease presents many points in common with typhus
fever, and in France, Germany, and Russia is usually known as
" typhus recurrens." It is, however, a distinct and separate disease,
and its geographical distribution differs from that of typhus in this
respect, that though often found in countries and places where
typhus is endemic, and often occurring in epidemics simultaneously with epidemics of typhus, its distribution over the
earth's surface is much more limited than is that of the latter
disease.
H i s t o r y . The antiquity of relapsing fever is very uncertain.
The oldest known references to it appear to be those relating to
certain epidemics in Scotland and Ireland in the first half of the
eighteenth century. A large number of outbreaks were recorded
there, and later in England, in the eighteenth and earlier portions
of the nineteenth centuries. On the continent of Europe it is
known to have occurred in parts of Russia since the year 1857;
and in other countries its history only dates from about the
same period, or even later. Relapsing fever was for a long time
imperfectly recognised as a separate disease, and it was often
confused with other diseases, particularly typhoid fever, and the
so-called bilious typhoid, under which name Griesinger first

RELAPSING FEVER

3^5

described an analogous fever met with in Egypt. It was not until
the discovery in 1873, by Obermeier, of the spirillum which bears
his name, that the pathology of the disease was placed on a
satisfactory basis.
R e c e n t Geographical D i s t r i b u t i o n .
Eurdpe,
The
British Isles were formerly regarded as essentially the home of
relapsing fever. Now, however, the disease is but rarely seen
here. In England and Wales a few deaths from this cause are
annually recorded by the Registrar-General, but the fever is even
rarer than its congener, typhus. The same is true of Scotland;
and in Ireland, once the scene of most extensive epidemics,
relapsing fever is now seen only exceptionally.
On the continent of Europe the disease has been met with
principally in the north, the south remaining almost, if not quite
free from its ravages. France is said to have escaped altogether,
in spite of its nearness to the British Isles, where the fever was
formerly at times epidemic. A few cases only have been recorded
in Belgium. In Germany, on the other hand, many epidemics
have been observed, in some of which, if not in all, the infection
appears to have been imported from Poland or Russia, where the
disease is truly endemic. In Denmark relapsing fever is said to
be unknown, and in Norway and Sweden it has only been seen
on rare occasions. In Russia, however, it is far from uncommon.
It has been well recognised there at least since the year 1857, after
which date the disease spread widely through the country, but
there is good reason to believe that it was prevalent at an earlier
period. Reitlinger, whose profound study of this disease as
it appears in Russia remains the most authoritative work on
the subject, states that relapsing fever has prevailed as an
epidemic as far north as the government of Archangel, though
apparently as an importation from St Petersburg, the infection
being carried by labourers returning to their homes from the
capital \ In the same way the northerly government of Olonetz has
been invaded by the fever, though that of Vologda, which adjoins
and is even more closely populated than that of Olonetz, had
up to 1874 escaped2. In Finland relapsing fever has appeared
independently, generally as the result of famines. St Petersburg
1

Investigations into the History, Geography, and Statistics of Relapsing
Fever in Russia (in Russian). By L. Reitlinger, St Petersburg. 1874.
a
This government now yearly returns some cases of relapsing fever.

366

RELAPSING FEVER

and its neighbourhood, however, at the time Reitlinger wrote,
constituted the great centre for relapsing fever, whence the
infection was frequently carried in all directions to other parts of
the country. The northerly governments always suffered the
most severely, and without exception the disease always appeared
in the winter—facts which are doubtless to be explained by the
greater overcrowding and confinement to close ill-ventilated rooms
which especially prevail in the winter in Russia. Moscow has at
times suffered severely. Many of the Polish governments, and
also those of the Ukraine in the south-west of the country, have
been the scene of epidemics. Relapsing fever has been severely
epidemic in the easterly governments of Perm and Viatka, and less
so in those of Orenburg and Ufa. Odessa has in like manner
been visited by frequently recurring outbreaks \
At the present day this disease appears to be very widely endemic throughout European Russia. In the three years 1893-5
cases were reported from every government throughout the country:
the largest numbers being returned from the governments on the
Volga, and the smallest from the Baltic provinces. After the great
famine of 1891 the disease was very widely epidemic through a
great part of Russia. In St Petersburg an enormous number of
cases were treated, occurring especially among the shifting inmates
of the "night-refuges," representing the poorest and most wretched
portion of the population. The disease is occasionally seen among
the Bashkirs inhabiting the steppes in the neighbourhood of the
Ural River, but is not very common among them 2 .
Throughout southern Europe generally, Austria would seem to
be the only country which has at all extensively suffered from
relapsing fever. Spain, Switzerland, and Italy have all remained
free from it. In the Balkan peninsula the disorder does not appear
to be endemic, though in the Russo-Turkish war of 1877-8 several
epidemic outbreaks of the fever occurred here among the Russian
troops. A few cases were seen at that time in Constantinople,
but in each instance they could be traced to importation from
Odessa. In recent years the disease seems to have been absent
from the Turkish capital. In some of the Mediterranean islands
relapsing fever is said to have occurred somewhat frequently in
the past.
1
In the Crimean war both French and English troops suffered severely
2
from relapsing fever.
Nikolski.

RELAPSING FEVER

367

Asia. The malady has never been very prevalent in the
Caucasus. In former years it affected to some extent the men
employed in the fishing industry of Saliany on the river Kura, and
in the city of Tiflis. In the ten years 1888-98 only a few
isolated cases of the disease have been seen in the latter town 1 .
In Batum and other places on the Transcaucasian Railway
sporadic cases of the fever have occurred from time to time
since 18942. In Turkestan it formerly had a somewhat wide
prevalence, the infection being carried from fortress to fortress by
the movements of the Russian troops. Of recent years, however,
it would seem to have become exceedingly rare throughout
Russian Central Asia, the cases returned from these provinces in
the years 1893-5 being reckoned by units, while from many parts
not a single case was recorded. In Siberia the disease appears to
be much commoner. It was originally introduced from Europe
by means of exiles and emigrants, and spread over the whole of
both western and eastern Siberia, as far as the Primorskaia, or
Maritime Province, and the region of the Ussuri river, in Manchuria. In recent years cases have been annually reported from
most parts of the country; the government of Tobolsk usually
returning the largest figures, and that of Yakutsk, in the far
north, the smallest.
Of the existence of relapsing feverv in the near East, in
Asia Minor, Syria, Mesopotamia, and Persia, comparatively little
is known.
The fevers formerly known as "Levant fever,"
"Bukowina fever," and "Smyrna fever," seem to have been
very probably of the nature of relapsing fever.
In India the disease has been known to exist since the
middle of last century. Epidemics have since appeared in all
parts of the peninsula. During the past three years it has
been severely .epidemic in Bombay concurrently with plague,
and it is interesting to note that the two diseases have been
observed to occur simultaneously in the same individual. To
what extent relapsing fever has prevailed in India in connection with the recent unprecedented famine, later publications
than those I have as yet had access to will probably show. But it
is noteworthy that in the Central Provinces the fever which accompanied the famine of 1896 was described as being not of " a
1
2

Statistics of Caucasian Pathology. By Dr I. I* Pantiukhof. Tiflis, 1898.
Bolnitchnaia Gazeta Botkina, 1900, No. 22.

368

RELAPSING FEVER

contagious, relapsing, or typhus type 1 ." Among the hill tribes of
the Himalayas relapsing fever is at times epidemic. There is an
absence of records of this disease in Farther India, in the Malay
Peninsula, and in the East Indian Islands, but quite recently a
single case was observed in Sumatra, the patient being a Chinese
coolie immigrant from Swatow, who evidently brought the infection
with him 2 .
In China relapsing fever is found constantly associated with
typhus 3 . It is mentioned as the most common form of fever
at Teng-chow-fu, and, this being so, it is permissible to suppose
that it is not a rare disease in other parts of the country. In
1877 it was epidemic at Tientsin, and in former years has raged
in Hongkong, Peking, and other places in Northern China.
Much uncertainty exists as to whether relapsing fever has ever
appeared in Japan.
Baelz suggests that an epidemic which
ravaged the town of Kochi in the island of Shikoku in 1881 may
have been of this nature, but is unable to prove or disprove the
truth of his conjecture 4 .
Australasia.
The Polynesian islands seem hitherto to have
escaped the ravages of this fever, and the same statement may
apparently be made in regard to Australia and New Zealand.
The sole mention of the disease which I find in recent health
reports from these countries is the occurrence of one death from
it in West Australia in the year 1895, the only death of the kind
in the ten years 1889-98.
Africa.
Information upon the existence of relapsing fever on
the African continent is extremely scanty. If absence of mention
of the disease is to be accepted as proving the absence of the
disease itself in any given country, then it would appear
that this fever is unknown in most parts of Africa.
It
seems to have been formerly endemic in Egypt, and perhaps is
still so, but in the statistics of that country the returns for relapsing fever are included under the general heading of " fievres
typhi ques," together with enteric and typhus. In Nubia and
Abyssinia it was also believed to have been endemic in former
years, and in Algeria several cases were seen during the typhus
1
2
3
4

Annual Sanitary Report of the Central Provinces for 1896.
Graham, Journ. Trop. Med. June, 1901.
Coltman.
Sei-i-Kwai. Oct. 1898.

RELAPSING FEVER

369

fever epidemic of 1867. The fever has also been observed in
Morocco in connection with famines following on the ravages
committed by locusts.
From India the disease appears to have been carried as
" coolie fever " to Mauritius and Reunion, but for a long period
the former island at least has been free from it.
America. Relapsing fever has on several occasions in the
past been introduced into various parts of the United States,
principally by means of emigrants from Ireland, where the disease,
as was shown above, was constantly epidemic in former years.
At the present day I am aware of no evidence to show that this
fever exists at all, either as an endemic or epidemic disease, in any
part either of the North or of the South American continent.
Osier, indeed, states definitely in regard to the United States
that, since the epidemic of 1869 in New York and Philadelphia,
relapsing fever has not again appeared.
There seems to be a complete absence of mention of the
disease in Mexico, the Central American States, and the West
Indies.
In South America relapsing fever has never been seen in the
Guianas, nor in Uruguay, Patagonia, nor apparently on the
Pacific Coasts. But in the Andes it was severely epidemic some
thirty or forty years ago. It was described as occurring nowhere
at a lower level than 1500 metres, and as attacking communities
living as high as 4000 metres above sea-level1. This seems to be
the only certain mention of the disease in the whole South
American continent.

Factors determining the Geographical Distribution.
The principal factors in the geographical distribution of relapsing
fever appear to be of a rather less complex character than in the
case of some other diseases. The fever is invariably associated
with the presence in the blood of an organism called, after its
discoverer, the spirillum obermeieri. For the development and
transmission of this organism certain conditions require to be
present, the most important of which are overcrowding and want
of sufficient food. Its constant association with dearth and famine
and the name popularly applied to it of " famine fever " (a name
which it shares with typhus), show how close is the relation between
1

C.

Baldow, Gaz. Med. de Paris, 1865. Quoted by Lombard.
24

370

RELAPSING FEVER

the two phenomena. The disease is practically confined to the
poorest classes of the community, who are the first to suffer when
a bad harvest or a succession of bad harvests sends up the price
of food. Overcrowding seems to favour the epidemic spread of
the fever, for there is no question that the infection can be
communicated from person to person \ and in some epidemics it
has seemed that overcrowding might be a more important element
in the production of the disease than scarcity of food.
Relapsing fever is also spread from place to place by the
movements of infected persons, and perhaps of infected articles
such as clothing. Its spread through Siberia was shown to be
clearly due to the movements of emigrants and exiles; and in
European Russia it was in the past, and perhaps is still, spread by
the migratory habits of the peasants, who seek work in the capital
or elsewhere, and returning to their homes carry the seeds of the
disease with them. In America immigrants from the British Isles
were the agents bringing the disease into the country, and it
should be added that it has never spread far from the immediate
surroundings of these immigrants, or tended to become endemic in
the States into which it was introduced.,
Whether the infection can also be spread by the medium
of contaminated articles such as clothes may perhaps be
regarded as somewhat less certain than its dissemination by
human beings; but important evidence of its diffusion in this
manner is forthcoming from Edinburgh, St Petersburg, Breslau,
Philadelphia, and New York, and such a mode of spread must
be regarded as at least possible.
Neither race, climate, season, elevation above sea-level, the
geological nature of the soil, nor the conformation of the country
seems to have any influence on the distribution of relapsing fever.
Finally it is of interest to note that while dearth and famine
are the most important elements in its prevalence, there is a
considerable amount of evidence showing that these conditions
may be present without the development of relapsing fever.
This fact may be reasonably explained by supposing that the
spirillar organism which appears to be essential to the production of the disease is not universally present, and that in its
absence no amount of malnutrition or innutrition will suffice to
bring about the particular group of symptoms so well recognised
under the name of relapsing fever.

RHEUMATISM.
General C h a r a c t e r s a n d E t i o l o g y . The term rheumatism includes a considerable variety of conditions—such as
acute articular rheumatism or rheumatic fever, chronic articular
rheumatism, acute and chronic muscular rheumatism, rheumatic
affections of the heart, and a variety of neuralgic and other
painful phenomena attributed to the so-called rheumatic diathesis.
While some uncertainty exists as to the etiology of these various
clinical conditions, and while it is possible - that in time some of
them will be shown to be specifically distinct and due to separate
and different causes, they are for the present conveniently regarded
as forming a fairly clear and recognisable disease-group, and they
will therefore be dealt with here together,
The geographical distribution of this group of diseases is an
exceedingly wide one; and there are few inhabited countries on
the earth's surface, from which medical observations are forthcoming, in which some mention is not made of the occasional or
frequent occurrence of rheumatic affections.
Their frequency, however, varies considerably in different
countries, and it will be the object of the present chapter to
show approximately the relative degree of frequency or rarity
with which these affections are found in various portions of the
globe. Unfortunately, published records are of comparatively little
service in this respect; statistics of the prevalence of the disease
being for the most part wanting, while mortality statistics are
misleading, inasmuch as the number of deaths directly attributed
to rheumatism bears but a small proportion to the number of
people who have at some time or other suffered from rheumatic
affections, or even to the number of those who are distinctly of the
so-called rheumatic diathesis.
24—2

372

RHEUMATISM

The pathology of rheumatic affections is uncertain. It is
probable that rheumatic fever is not one and the same disease
with chronic articular or muscular rheumatism, and modern observations have shown that in its epidemiological and clinical
characters it has much in common with the acute infective fevers.
Rheumatic fever, in fact, now stands with pneumonia on the
border line between the group of inflammatory affections of
special tissues due to "chill" and the group of infective fevers.
Newsholme has shown that it often occurs in epidemics of some
regularity, at intervals of from three to six years.
The bacteriology of the malady has been largely worked at,
but with no positive results as yet, although some have suggested
that the disease may be due to a primary growth of specific microorganisms in the tonsils. It was at one time generally held to be
a disease of chemical origin, due to an excess of lactic acid in the
tissues.
H i s t o r y . It is certain that rheumatic affections are of very
great antiquity. Tombs have been quite recently opened in Egypt,
and skeletons found inside, the bones of which showed distinctly
recognisable rheumatic changes. The recognition and description
of these affections, however, is of much later date. Throughout
the medieval period great, confusion arose between the terms
" r h e u m a " and "catarrh" which were used indifferently in the
humoral pathology of the time, and were constantly called upon
to explain a variety of diseases. It was only in the 17 th century
that the word rheumatism came to be restricted more or less to
the group of diseases to which it at present applies. Joint
affections were long recognised and described under the general
term "arthritis," which included not only rheumatism but also
gout and other forms of disease. An English physician, Pitcairn,
first showed the intimate relation of "heart disease and rheumatism
in 1778.
Recent Geographical Distribution.
Europe.
Both
rheumatic fever and the more chronic forms of the disease are
exceedingly common in the British Isles. In the year 1888
a Collective Investigation Committee of the British Medical
Association made an inquiry into their prevalence, and found
that there was no part of Great Britain or Ireland where both
acute and sub-acute rheumatism did not prevail extensively.
In France the official mortality-returns contain no column

RHEUMATISM

373

for these diseases; but Lombard states that they are frequent
throughout the whole of France, and principally so in the centre
and north.
Chronic rheumatic affections are said to be very common in the
country districts of Belgium. In Germany acute rheumatism and
heart disease appear to be particularly frequent in Bavaria and in
Alsace-Lorraine, a fact which has been attributed (with what
justice I do not know) to the excessive amount of beer-drinking
in those countries. All forms of rheumatism are very prevalent
in Bavaria and Swabia. In Denmark rheumatic fever is fairly
common; it varies slightly in amount from year to year, and in
recent times years of maximum prevalence have been 1871, 1873,
and 1883-1888 (Newsholme). The deaths attributed to this
cause in Danish towns between 1892 and 1897 varied from 37
in the first to 55 in the last year named. The periods of greater
prevalence of rheumatic fever in Denmark corresponded to a
certain extent with similar periods in Norway, where the years
of maximum prevalence were respectively 1871, 1876, and 1888—
1889. The returns from Sweden are less complete, but rheumatic
fever is common throughout the country, and particularly so in the
northern districts.
It is difficult to judge of the frequency of these affections in
Russia, but I can assert, from personal observation, that in the
capital and along the shores of the Gulf of Finland rheumatic
fever, the more chronic forms of articular rheumatism, and muscular rheumatism all occur with considerable frequency. The
returns from all the administrative divisions of Russia show also
that rheumatism is widely prevalent throughout the country, but
as rheumatic fever is not treated separately from the other fevers
in the returns it is impossible to judge of its relative frequency in
this as compared with other countries.
On the behaviour of these diseases in Austria-Hungary I have
no information. But in Italy the acute form of rheumatism caused
an annual mortality in the years 1887 to 1896 which varied between
25 and 36 per million inhabitants; while the deaths attributed to
the chronic varieties varied between 30 and 39 per million in the
same period. These figures probably indicate a considerable
degree of prevalence of the disease or diseases. In Spain and
in Portugal rheumatic fever is said to be very common.
Lombard states that rheumatism is endemic on the plateau of

374

RHEUMATISM

Castile and in the Asturias, and that it is frequently seen in
Seville, Granada, Valencia, and Malaga.
Rheumatism is of frequent occurrence in many parts of the
Balkan peninsula. From the Salonika province of Turkey and
elsewhere reports of it are frequent. It is probably commoner
in the mountains than in the plains. In the hilly country of
Montenegro all forms of rheumatism, both articular and muscular,
are said to be very prevalent, and this is attributed to the rigour
and humidity of the climate. In Constantinople and on the
shores of the Bosporus and Sea of Marmora no class of illness
is more frequently seen than the various forms of rheumatism,
more particularly the sub-acute and chronic forms, both muscular
and articular. Generally throughout European Turkey rheumatism
and malaria are the two most prevalent of all diseases.
In Iceland and in the Faroes not only the»less acute forms of
rheumatism but also true rheumatic fever are of very common
occurrence.
Asia. In some parts of Asia Minor rheumatism is frequently
seen. In Trebizond rheumatic affections are very common, on
account, it is said, of the excessive moisture in the air in and
around this Black Sea port.
Acute rheumatism is a very frequent disorder in Mitylene
and some other islands off the coast, and at Tripoli, on the Syrian
littoral, this group of diseases is no rarity.
In the Caucasus rheumatism, both muscular and articular, is
one of the commonest of disorders. In central Asiatic Russia
(Turkestan, Transcaspia, etc.) it is perhaps much less prevalent than in European Russia, but statistics from these regions
are too imperfect to allow of any definite conclusions on this
point. Through all parts of Siberia, from east to west and from
north to south, rheumatic affections are very common, though to
what extent rheumatic fever shares in this frequency I am unable
to say. It is said to be of frequent occurrence, however, at
Tomsk and in Kamchatka.
Among the pilgrims to the holy cities of the Hedjaz rheumatic
affections of all kinds are commonly seen, including sciatica,
neuralgia, and other conditions which may plausibly be attributed
to rheumatism. In Afghanistan it is very prevalent, and in Persia
probably by no means rare. At Khanikin on the Turco-Persian
frontier, after the heavy rains of early winter, forms of this malady

RHEUMATISM

375

are extremely common, particularly among the poorer classes of
the population exposed to the weather.
Rheumatism is apparently far from rare in the Indian peninsula.
Some writers have stated the contrary, and dwelt on the extreme
infrequency of all forms of rheumatic affection, including organic
heart lesions, in that country 1 . But the official returns show that
both Anglo-Indian residents and natives suffer not a little from
these diseases. In the English army in India the admission and
death-rates from these causes are actually higher than in England.
Bengal is said to be the Presidency in which rheumatic diseases
are most prevalent, Bombay that in which they are most fatal,
while Madras has the lowest admission and death-rates 2 . Chronic
forms of the disease are common in the cold season and rains in
Rajputana, but the acute forms are rare. They are equally rare
in Assam, and in the Malay Peninsula. At Penang and Singapore
indeed they are almost unknown. McClosky, during a residence
of eight years in the Straits Settlements and the Malay Peninsula,
never saw a single case of rheumatic fever in a native, and only
one in a European, who had suffered previously at home.
Valvular cardiac lesions were equally rare, and a history of
rheumatic fever could never be elicited. Only in the postmortem room had this observer seen chronic valvular lesions
in the bodies of natives which were undoubtedly of rheumatic
origin3. At Perak, similarly, Clarke never saw a single case of
true acute rheumatism during a residence of five years 4 .
That rheumatic affections occur in many of the East Indian
Islands is certain, though their comparative frequency in the
different islands is less so. They are far from rare in Java and in
British North Borneo; in Sumatra and the Lampongs they are
rife, particularly in the latter, arid in the Rhio archipelago they
are very prevalent. In the Dutch East Indian possessions generally,
however, they appear to occur with no great frequency, as in the
Indo-Dutch army rheumatism, at least in its acute articular form,
is not a common disease, and when it occurs it is usually in a
mild form.
1
Buchanan (Journ. Irop. Med. Nov. 1899) says that not only acute rheumatism but also chronic rheumatic arthritis and organic heart-murmurs are
exceedingly rare in India. Cantlie (ibid. Oct. 1899) when visiting several
cities in India did not see a single case of rheumatic fever in hospital.
2
3
4
Davidson.
Journ. Trop. Med. Jan. 1900.
Ibid. Nov. 1899.

376

RHEUMATISM

The evidence as to the frequency of these diseases in China is
rather conflicting. Cantlie has stated, after many years' residence
in China, that he never saw a case of rheumatic fever in hospital
there 1 . But mention of both acute and chronic rheumatism is
by no means rare in the reports of the medical officers in the
Chinese Customs service.
Thus, for example, 15 cases of
articular rheumatism, acute or chronic, were recorded at Lungchow in 1895-6 2 . Rheumatic arthritis is spoken of as a common
disease in the natives of Wuchow 3 , where gonorrheal rheumatism is also of frequent occurrence. At Ichang rheumatic
pains and swellings of extremities are very common complaints 4 .
Finally Coltman roundly states that rheumatic fever is prevalent
in Foochow, Shanghai, Soochow, Chifu, Lao Ling and Hangchow; while chronic musqular rheumatism is common all over
China 5 . To this may be added the statement that the Chinese
in Formosa suffer much from rheumatism 6 . In Mongolia rheumatism is said to be the most prevalent disorder. In Japan the
more chronic forms of the disease appear to be common, while
acute articular rheumatism is very rare, at least in Yokohama and
Tokio.
Australasia.
The sub-acute forms of rheumatism are occasionally seen in both natives and Europeans in British New Guinea.
Throughout Australia rheumatic affections appear for the most
part to be rare, and are probably a good deal rarer than in
England, for example. Only occasional mention of them is found
in the health reports from the different colonies, although in
South Australia and New South Wales the number of deaths
from this cause is by no means inconsiderable, while heart disease
does not seem to be particularly infrequent in any of them.
Rheumatic disorders are probably equally rare in New Zealand,
but in many of the islands of the Pacific—as, for example, New
Caledonia, the Society Islands, and the Marquesas group—they
are of very frequent occurrence, and in the Sandwich Islands they
are, or were some years ago, said to be amongst the most common
of disorders. In Samoa, too, many cases of rheumatism are seen.
1
2
3
5
6

Journ. Trop. Med. Oct. 1899.
Chinese Customs Med. Reports, No. 52.
4
Ibid. No. 56.
Ibid.
The Chinese, their present etc. 1891.
Chinese Custo?ns Med. Reports, No. 45.

RHEUMATISM

377

Africa. In Egypt rheumatic affections seem to be remarkably
prevalent.
In Tunis both acute and chronic rheumatism are exceedingly
frequent among Europeans and natives alike, forming about a
third of the diseases treated (Davidson). In Algeria, on the
other hand, acute articular rheumatism is said to be of infrequent
occurrence, while in Morocco the acute forms of the disease are
rare and the chronic forms are common.
Turning to the western regions of the African continent it is
found that acute articular rheumatism is very prevalent in Senegal;
that in the Gambia a few cases of rheumatism are annually treated
in the colonial hospital; that in Sierra Leone and Lagos such
disorders form a remarkably high proportion of the total cases
admitted to hospital; and that on the Gold Coast rheumatism is
among the commonest of diseases to which the natives are liable.
Sporadic cases are seen in the Cameroons. In the Congo Free
State rheumatism is seen with some frequency, and generally
throughout Central Africa rheumatism is prevalent, though most
often seen in its more chronic forms, the acute forms being rare
(Pruen). Heart disease is also no rarity in Central Africa.
In East Africa rheumatic affections are certainly known. In
Uganda they occur with some frequency; in Manyuema they
are both common and fatal among the natives, and in Nubia and
Abyssinia they are frequently met with.
Finally in South Africa this group of diseases is found to
prevail in many parts to a considerable extent. In the native
territories of the Transkei, Tembuland, and Pondoland, rheumatism
is among the commonest of disorders. In Bechuanaland it is
also of frequent occurrence. In Mashonaland, on the other hand,
it is perhaps rare; one observer never saw a single case of acute
rheumatism during two years' residence there 1 . At most of the
large hospitals in Cape Colony and Natal rheumatic diseases contribute a considerable proportion of the cases annually treated.
In Mauritius, Rodriguez, and the Seychelles, this group of
diseases appears to be rather prevalent 2 . In Madagascar acute
rheumatism is apparently not common among the natives, but
the muscular and syphilitic forms are very frequently met with.
1

Todd, Journ. Trop. Med. Nov. 1900.
Colonial Reports. Davidson on the other hand says that rheumatism is
comparatively rare in the Seychelles.
2

373

RHEUMATISM

North America. In Greenland rheumatism is said to be one
of the commonest of maladies, but " it is not so certain if acute
articular rheumatism prevails there to a corresponding extent."
Generally throughout Canada rheumatic affections are met with,
but whether with great or little frequency I am unable to say.
The same statement has to be made in regard to their prevalence
in the United States, where, however, these diseases are said
to be commoner in the south than in the north (Lombard).
In Massachusetts the mortality ascribed to rheumatism has
rather increased in recent decades. Osier is of opinion, from
personal observation, that rheumatism is more prevalent in the
Canadian city of Montreal than in the United States cities of
Philadelphia and Baltimore. In Mexico it is found that rheumatism is of frequent occurrence on the Anahuac plateau,
while it is extremely rare in the low-lying coast town of Vera
Cruz.
In the West Indies the disease is common enough. Both the
acute and chronic forms are often seen in Jamaica, St Vincent,
Grenada, Antigua, and St Lucia. In the Virgin Islands rheumatism and malarial fever are the twro most prominent of all
diseases, and both in the Leeward Islands and the Bahamas
rheumatic affections must be particularly prevalent. In the latter
"rheumatism" accounted for more admissions to hospital than
any other disease in the years 1897 and 1898.
Central and South America.
Little appears to be known
of the comparative prevalence of these affections in Central
America, save that rheumatic fever is rare in Guatemala, while
in British Honduras acute rheumatic fever, as well as chorea and
valvular heart lesions, which are so constantly associated with it,
are said to be entirely unknowrn.
In British Guiana true rheumatic fever appears to be a rarity,
while other forms of rheumatic disease are very widely prevalent.
This would seem to be no less the case in French Guiana. In
Brazil these affections are moderately prevalent. They are probably more so in the Argentine Republic, where all forms of the
disease including rheumatic fever are very common, both in the
capital and in the interior, along the Parana, Uruguay, and
Paraguay rivers.
In Ecuador, Chile, and Peru rheumatic disorders are frequently
seen, and there is perhaps no part of the world where they are

RHEUMATISM

379

more common than along the western shores of the South
American continent.
It is not surprising to find that in the Falkland Islands, with
their damp, cold climate, chronic and muscular rheumatism are
both common and intractable.
F a c t o r s affecting t h e G e o g r a p h i c a l D i s t r i b u t i o n of
R h e u m a t i c D i s e a s e s . For the present our knowledge on
this matter is very incomplete. It is certain, as already pointed
out, that under the general term rheumatism a considerable
number of pathological entities are included. It is only for the
sake of convenience and on account of a certain similarity of
clinical features that they are grouped together, but there is no
true evidence that, for example, muscular and articular rheumatism
are the manifestations of one and the same disease, while, as
previously stated, there is considerable evidence that the chronic
forms of both are pathologically distinct from true rheumatic fever.
It is therefore not surprising that the geographical distribution of
these various forms of the disease is by no means uniform. Materials
for a complete study of their distribution are, for reasons pointed out
at the beginning of this chapter, not available, and all that can be
stated at present is that in very many countries rheumatic fever is
rare or quite unknown, while the chronic articular form and the
muscular form of the disease are very common. Among countries
where this is the case may be mentioned Morocco, Central Africa,
British Guiana, Japan, and some parts of India. On the other
hand there are many countries where a frequency of acute rheumatic arthritis is found to co-exist with a frequency of the other
forms of rheumatism; and others where all alike are equally rare. It
is easier to name the countries where rheumatic affections of all
kinds are rare than where they are common, and among such
countries may be mentioned the Malay Peninsula and Straits
Settlements, some parts of Australia and New Zealand, Guatemala,
and British Honduras.
No one will question that, in the individual, "chill" is the
most frequent and immediate antecedent of an attack of
rheumatism, whether of the acute or of the other varieties; and
in general terms the disorders included in the list of rheumatic
affections are more common in cold countries than in warm,
and particularly common in some regions with a bleak, damp
climate, such as that of the Faroes or the Falkland Islands.

38o

RHEUMATISM

But there are very striking exceptions to this statement, and
rheumatic affections seem to be nowhere commoner than along
the dry and by no means cold coasts of Chile. Their comparative
frequency also in the warm regions of New Caledonia, the Sandwich,
Society, and Marquesas Islands, many of the West Indian Islands,
Central Africa, and India, show conclusively that a low degree of
temperature is not necessary for their prevalence. Some, indeed,
have believed that rheumatic affections are more prevalent in warm
than in cold latitudes, but this is hardly borne out by the facts. In
regard to rheumatic fever it is certain that the reverse is the case.
It is probable that sudden changes of temperature, particularly
in a moist climate, afford very favourable conditions for the prevalence of all forms of rheumatism, but particularly for the more
chronic articular and muscular forms. Neither the geological nor
physical characters of a district seem to have any direct influence,
except in so far as they affect the climate. These diseases are
certainly very prevalent in many countries at high altitudes such
as the plateaux of Mexico, the highlands of Norway, Montenegro,
and Arabia, and the Swiss Alps, but they are also extremely prevalent at such low altitudes as the coast of Chile, the West Coast
of Africa, and generally throughout the British Isles.

RICKETS.
General C h a r a c t e r s a n d E t i o l o g y . Rickets is a nutritional disorder common among children. Its main features are
slight fever, general sensitiveness of the whole body, delayed
ossification of the bones, retarded dentition, and imperfect nutrition of all the tissues. Wasting is marked, and very often
the soft bones yield to pressure with consequent deformity. The
liver, spleen, and lymphatic glands are frequently enlarged, and
there is great diminution in the calcareous salts in the bones.
Rickets is usually associated with, and probably caused by, deficient
or improper dietary, together with want of sunlight and bad
ventilation. Prolonged lactation also favours its development.
H i s t o r y . The disease was first described accurately by
Glisson in the 17th century. It is probably of as great antiquity
as any of the other diseases to which ill-nourished children ,are
liable, but the materials are wanting for an accurate knowledge of
its history.
G e o g r a p h i c a l D i s t r i b u t i o n . Europe.
Rickets is very
common among the poorer classes in the British Isles. It is
probably equally so in France, Germany, Holland, and Belgium.
In many European countries the returns for scrofula and rickets
are taken together, and it is impossible to say what proportion of
the mortality is due to each of the two diseases. Thus in Holland
the mortality from the two disorders together has diminished from
330 per million inhabitants in 1889 to 130 in 1898. In the
urban population of Denmark the mortality from rickets alone
remained stationary at about 140 per million in the years 1892-97.
In Norway svek, or rickets, is by no means rare 1 . In Sweden it
is called Engelska sjukan or " the English disease." In Lapland
1

Axel Johannessen, Janus, 1897-8, p. 46.

382

RICKETS

the disease is said to be almost unknown. Throughout the greater
part of European Russia it is common. It is also frequent in
Northern Italy, while in Southern Italy and Spain it is rare. In
Turkey it is comparatively commonly seen.
In Iceland and the Faroe Islands rickets is said to be a very
infrequent disorder.
Asia. The returns from the Caucasus, from Siberia, and from
Russian Central Asia, show that the disease occurs in all these
regions, but with considerably less frequency than in European
Russia. Among the Bashkirs it is said to be quite exceptional
to see a rickety child 1 . It is also rarer in Syria, Persia, and
Arabia, than it is in most European countries. In India it is so
exceedingly rare that a case in a native is considered worthy of
record in a medical journal 2 . In Ceylon, on the other hand, it
seems to be very much commoner, and it has recently been the
cause of from one to three hundred deaths annually in that island
(say, from 30 to 100 per million inhabitants). So also in Burma
rickets is no rarity3, at least in the Southern Shan States. In Siam,
however, it is said to be unknown (Rasch), and from its very rare
mention in reports from the Straits Settlements it must be supposed
to be very infrequent there. In many of the East Indian Islands
rickets is also very rare or unknown. Nieuwenhuis examined over
5000 children in Borneo without meeting a single case, and in
Java it is said to be unknown.
In China and Cochin China rickets is rarer than in Europe,
and in Japan it is very little seen.
Australasia.
Rickets is probably one of the rarest of disorders in Australia. The only recent mention of it that I have
come across is the record of occasional deaths from the disease
in West Australia in the last decade. In some of the Pacific
Islands, however, it seems to be common, and in the New Hebrides
the greater part of the children are said to be either rickety or
scrofulous4. In Fiji only an occasional case seems to be met with.
Africa. This disease is by no means common in Egypt, in
Algeria, in Senegal, and generally in the tropical zones of the
African continent. I have no information as to its prevalence in
1
2
3
4

Nikolski.
Maynard, Indian Med. Gazette, 1899, p. 167.
Henderson, Indian Med. Gazette, July, 1899.
Beinal, Archives de Med. Navale> August, 1899.

RICKETS

383

South Africa, save that an occasional case is admitted to the
Durban hospital. . In Madagascar and ' the Comoro Islands
it is almost unknown.
America. In North Greenland rickets rarely occurs.
It is comparatively uncommon also in Canada; and in the
United States it is certainly less frequent than in Europe. In
the cities, however, it is very prevalent, " particularly among the
children of the negro and of the Italian races." In Mexico, on
the other hand, the disease is said to be almost unknown. In
Guatemala it exists, but causes a low mortality only1. In Honduras it is said to be practically unknown.
The disease is also, perhaps, very rare in the West Indies and
generally throughout South America, but exact information of
recent date seems to be lacking.
F a c t o r s c o n c e r n e d in t h e D i s t r i b u t i o n . It must be
admitted that materials do not exist for an exact comparative study
of the distribution of rickets. It is one of the diseases that is
often omitted from reports on the pathology of any given country;
and in statistical tables it is very often grouped with other diseases.
But it may be gathered from the material available that rickets is
mainly a disorder of countries with temperate or cool climates.
It is rare, or absent in countries with tropical or sub-tropical
climates. It is most frequent in the central and northern parts of
Europe. In the far north of both the eastern and western hemispheres it again becomes rare.
Wet plains and valleys are thought to be favourable to the
prevalence of rickets, while on dry soils and at high altitudes the
disease is less common and less severe.
The influence of race is not very clear. It occurs in children
of very diverse nationality, but it is noteworthy that in some
tropical countries, as for example Java and India, where rickets
is almost unknown in natives, it is occasionally seen in Europeans.
Negroes are certainly not immune to it.
Improper dietary and impure air are, as already stated, the
principal predisposing causes of rickets. Hence its frequency in
the poor inhabitants of European and American cities, who live
under conditions of overcrowding and general bad hygiene.
Hence also, in all probability, its rarity among the Bashkirs and
1
In 1894 rickets was the cause of 33 deaths in Guatemala ; equivalent to
about 23 per million inhabitants.

384

RICKETS

Kirghiz on the Russian steppes, and among the Kabyles of
Algeria. It is more than probable also that the infrequency of
the disease in warm countries is largely due to the open air life
led there, and the beneficent influence on young children of
sunlight and fresh air.
It would almost seem that a plentiful supply of pure air is of
even greater importance in preventing (and in curing) this malady
than the nature of the diet. But the exact share taken by each of
these factors in the production of the disease is not always easy to
determine. It has been shown experimentally that the condition
of rickets in the lower animals can be brought about and controlled
by variations in their dietary. Bland Sutton's experiments with
lion cubs at the Zoological Gardens have proved this conclusively.

SCARLET FEVER.
H i s t o r y . It was pointed out in the chapter on measles that
the early history of that disease was obscured by the confusion
that long prevailed between it and scarlet fever. A second source
of confusion in the history of the latter is found in its resemblance
to diphtheria, miliary fever, and other diseases. So that it is not
until the sixteenth or seventeenth century that anything definite
is known as to the prevalence of scarlet fever. Probably it existed
long before that date, at least on the continent of Europe. Sydenham first clearly differentiated the disease. Nothing is known as
to its first appearance in Asia or Africa. It is thought to have
been introduced into North America in 1735, into South America
in 1829-31, and into Australia and Polynesia in 1847-8.
Recent Geographical Distribution.
Europe.
The
mortality from scarlet fever in England and Wales has greatly
decreased in recent times. In the three decades commencing in
1861 and ending in 1890, the death-rates from this disease were
respectively 972, 716, and 334 per million; and since the year
1890 the fall has been almost unbroken, until in 1900 the ratio
was only 119 per million.
This reduction in recorded scarlet fever deaths has been in
part ascribed to a lowered birth-rate, with a consequent smaller
proportion of children at susceptible ages, in part to improved
sanitary conditions and the great increase of isolation hospitals,
and in part to the type of disease having become milder in recent
years. How far the decline is due to these causes and how far
it is due to a really diminished prevalence of the malady is
uncertain.
A considerable fall in scarlet fever mortality has also been
observed in Scotland; the mean death-rate per million living in
c.

25

386

SCARLET FEVER

the decade 1881-90 was 286, and in 1896 it had fallen to 160,
slightly rising again in 1897 to 170 per million, and in 1900 to
190 per million. An even more striking fall has been observed in
Ireland, where the average annual mortality in the years 1881-90
was 210 per million, and in 1900 only 55.
In France, in towns with over 10,000 inhabitants, the scarlet
fever mortality has fallen from 80 per million per annum in the
years 1886-90 to 30 and 40 respectively in the years 1897 and
1898. As these figures refer to an urban population only, they
must be held to indicate a very low degree of prevalence of scarlet
fever in France.
In Belgium also a parallel fall has been observed; the mean
annual recorded deaths in the years 1871-80 were 1963, in
1881-90 they fell to 1303, and in 1897 were only 1019, in spite
of an increasing population. The last figure was equal to about
160 per million living. Scarlet fever mortality in Holland is
remarkably low, the ratios in the ten years ending 1898 varying
between 20 and 50 per million inhabitants per annum; the lowest
ratios occurred at the beginning of this period, and the highest
about its middle, a tendency to fall again being noticed in the
later years.
Throughout the German Empire the scarlet fever mortality,
as in England and Belgium, has very markedly declined in recent
years. The mean annual death-rate per million living, for the
whole empire, fell from 253 in the septennium 1887-93 to 184 in
1894. The decline was no less marked in each part of the empire
taken separately; and the returns from Prussia, Saxony, Bavaria,
and Wurtemburg all indicate a great reduction between the years
1880 and 1894, the figures for the latest year being in some
instances only one-third or one-fourth of those for the earlier years
of the period.
In Denmark the disease wTas somewhat unusually prevalent
in the years 1893-95, but was very much less so in 1896 and
1897. In the principal Danish towns the deaths in 1897 were
equal to a ratio of about 40 per million inhabitants. In Norway
a reduction in the deaths from the disease comparable with that
already pointed out for other countries was very noticeable in the
years 1881-1893. In the five-year period 1881-86 the annual
recorded deaths were over 800 ; in the next quinquennium they
fell to about 500, and in 1893 they had steadily fallen to only

SCARLET FEVER

387

195. In the following year, however, they rose again to 275^ or
approximately 135 per million living. In Sweden the recorded
deaths from this disease steadily fell from 1658 in 1891 to 654 in
1896; the last figure was equal to a ratio of about 130 per
million.
Scarlet fever, like most other infectious diseases, is much more
prevalent in European Russia than in any other continental
country. The mean death-rate from this cause in 1893-95 was
no less than n 40 per million living. No part of the country is
free from the disease; it is quite common in the northerly
government of Archangel and in the southerly governments of
Astrakhan and the Crimea. The lowest ratios of registered cases
in recent years have usually been met with in the Polish governments.
In Austria the deaths from this zymotic in 1896 were equal to
a ratio of about 360 per million; in the years 1880-86 the mean
annual ratio had been 592, and in 1887-1893 it had been 561.
These figures indicate a distinct reduction in recent years, though
a much less striking one than in some other countries. In
Hungary in the year 1897 the deaths from the disease were about
550 per million; the mortality had considerably declined between
1887 and 1894 in both Hungary with Fiume, and in Croatia with
Slavonia, which together make up the Hungarian kingdom, and
particularly in the latter, but the returns for 1897 showed a
marked rise over those of 1894.
In Switzerland a steady fall in scarlet fever mortality has also
been observed; in the 15 principal towns the deaths from this
cause fell from 88 in 1889 to 14 in 1897; the last figure was equal
to about 23 per million. In Italy the fall has been no less
striking; the death-ratio per million having steadily declined
from 496 in 1887 to 104 in 1896. For Spain and Portugal
recent figures are lacking, but Davidson, in 1892, gave the ratio
in towns in the peninsula at only 146 per million. For the
Balkan countries trustworthy figures are also for the most part
absent; but in Servia the recorded deaths from scarlet fever in
1894 were 1304, which was approximately at the rate of 565 per
million. In some other countries in the Balkan peninsula the
disease is also of frequent occurrence. In Constantinople it is
more or less constantly present, but usually of a mild type. In
Montenegro and Albania it is said to be seldom seen, and in

. 25~2

3 88

SCARLET FEVER

Greece, though often epidemic, it is reported to be perhaps less
fatal than in the rest of Europe.
In Iceland the malady is not endemic but is occasionally
introduced from without. In the Faroe Islands, though not
unknown, it is very rare and usually of a mild type 1 .
In the islands of the Mediterranean scarlet fever is met with,
though apparently somewhat less commonly than on the
continent In Malta in 1898 only 12 cases of the disease were
recorded, a figure much lower than that of most of the other
zymotics.
Asia. The recorded cases of scarlet fever in'the Caucasus
and Transcaucasia have, of recent years, been very much lower in
proportion to the population than in European Russia. In 1894
and 1895 the recorded deaths (probably below the truth) were
at the rate of about 300 per million living.
In Tiflis the
disease is said to be almost confined to the Russian inhabitants.
In Central Asiatic Russia the recorded cases are still lower, and
have usually been scarcely one-tenth of even those in the
Caucasus. This may be partly owing to imperfect registration, but
the very great difference both in recorded cases and deaths in
these regions must be in great part due to a really diminished
prevalence of the disease in the Central Asiatic provinces. In
1895 the recorded deaths here were at the rate of only 10 per
million inhabitants. In Siberia, on the other hand, the returns of
cases have indicated a prevalence of scarlet fever about equal to
that in the Caucasus, and therefore much lower than that in
European Russia but higher than that in Central Asia. The
figures for the remote province of Yakutsk are, perhaps, even
more untrustworthy than others, but it may be noted that in
recent years either no cases at all or only 2 or 3 per annum have
been returned from that part of the country. The disease appears
to be far from rare in the Amur province, in that of Tchita on the
Mongolian frontier, and in most other Siberian provinces. Among
the Bashkirs on the Kirghiz steppes it is said to be of infrequent
occurrence.
In Arabia scarlatina is met with; among the pilgrims at
Medina several cases are observed in every pilgrim season.
In Syria scarlet fever is said to be seldom seen: in Mesopotamia it is at times epidemic. In Persia it is probably common,
1

Russell-Jeafifreson, op. cit.

SCARLET FEVER

389

in Teheran, at least, several cases occur from time to time. In
Asia Minor it is perhaps not uncommon, for I have notes of its
epidemic occurrence in Samsun in 1900; in Mitylene in 1901 ;
and in Erzerum with some severity in December 1901, when
owing to a series of earthquakes the people were living in a sad
condition of overcrowding and mal-hygiene.
In India scarlet fever is an extremely rare disease. It occurs
occasionally in the form of a few isolated cases; sometimes in
persons newly arrived from England, who may be supposed to
have brought the infection with them, but sometimes also in
residents to whom no such explanation would apply. The few
recorded cases have been mostly, but not entirely, in Europeans.
They have been observed in Calcutta, Simla, Saharanpur, Bangalore, Rawal-Pindi, Darjiling, Assam, Cachar, Sitapur, Ranikhet,
Hyderabad, Ceylon, and elsewhere1. In 1893 no cases were
recorded in the British or native army in India; in 1894 there
were 8 in the British, and 11 in the native army; in 1895 a single
case; in 1896, eight cases in the British troops; and in 1897 as
many as 27 in the British troops, but none in the native troops.
In a large proportion of the isolated cases recorded in the
various parts of India named the disorder could not be traced
to any imported infection, either from other parts of India or
from abroad. But in 1899, when as many as 83 cases of the
disease occurred in the British army in India, it was believed that
most of them could be traced to importation by the s.s. "Simla" 2 .
In Kashmir the disease is quite unknown.
In Farther India the disease appears to be equally rare.
Recent writers on the pathology of Siam make no mention of it.
It was not seen by one observer 3 during an eight years' residence
in the Straits Settlements (Penang and Singapore). Again, no
accounts of it in Annam, Tongking, and Cochin China are forthcoming, and it is indeed said to be unknown there.
In China and Corea scarlatina, to judge by the rare mention
of the disease in the reports of the Customs Medical Officers,
is not a common disorder, though it is certainly not unknown.
At Shanghai 9 or 10 known cases occurred among the foreign
residents in 1890-91, and the remark is made that this disease
1
2
3

Caddy and Cook, Indian Medical Gazette, August, 1899.
Report on Sanitary Measures in India, 1899-1900.
yicdosky, Journ. Trop. Med. 1900, p. 156.

390

SCARLET FEVER

as well as diphtheria is now losing its former character of an
interesting rarity 1 . In 1893 it was widely prevalent in Shanghai,
though not regarded as epidemic 2 . Further south on the other
hand it appears to be more rare. Cantlie, in a long period of
residence, saw only one case in Hongkong, and that was in a
patient who had landed from England two days before3. In 1898
four cases of the disease were seen by the Medical Officer of
Health for Hongkong, two on H.M.S. "Barfleur" and two on
H.M.S. "Powerful"; in all it was thought that the infection
was imported from England. The disease can certainly exist
in the tropics, and several cases have been recorded as occurring
on ships in the Pacific and Indian Oceans.
In Japan scarlet fever is "excessively rare" (Davidson) 4 . On
the more northerly island of Sakhalin, however, it is far from
uncommon, and in 1895 a s many as 86 cases with 17 deaths
were recorded in the 26,421 inhabitants of this Russian convictisland.
In the Malay Islands the disease appears to be very rare or
almost unknown. This is so in Sumatra; while in Java, Borneo,
Celebes, and the Philippine Islands it is said to be quite unknown.
In New Guinea it is not seen, at all events in the aborigines.
Australasia.
In Australia this disorder is at times epidemic.
It was so in a mild form in Melbourne in 1896 and 1897. In
New South Wales it appears to have been very prevalent in 1897.
In South Australia from 1 to 35 deaths were annually reported
between 1889 and 1898, the highest figure occurring in the year
1894. In Western Australia it is either very rare or very mild, as
with the exceptions of 1 fatal case in 1895 and 2 in 1897 no
deaths from this cause were registered in the colony in the ten
years 1889-98. The epidemic of 1897 noted in Victoria and
New South Wales seems to have spread to Tasmania, where it
caused 203 cases and 5 deaths in the year; in the preceding year
it was very prevalent at Zeehan and Hobart. Six years before the
disease had also been widely prevalent in the island.
1

Imperial Chinese Customs Medical Reports', No. 41.
Ibid. No. 46.
3
Journal of Tropical Medicine, July 1899, P* 332*
4
A writer in the Sei-i-kwai (October 1898) states that he saw 9 cases
of the disease in Yokohama in 1877, and a few more cases at the end of
1880 and beginning of 188r, when "there were pretty numerous cases in the
city.' ,
2

SCARLET FEVER

391

In New Zealand the recorded deaths from scarlet fever were
respectively 19, 31, and 24 in the three years 1889-91, but they
have since not exceeded 6 in any year, at least up to 1898. On
the whole the recent history of the disease in Australia and New
Zealand has shown that it is a far less significant cause of death
here than in most European countries. This is in part explained
by the disease occurring in a milder form, but is also due to a
much lower degree of prevalence.
In the Polynesian Islands scarlet fever is very rare or altogether
absent. It is unknown in Fiji, and in the Marquesas Islands,
and is only occasionally seen, mostly in the white population, and
in mild form, in New Caledonia and the Society Islands.
Africa. The disease is not common in northern Africa. In
Egypt it is said to be almost unknown. The infection is not
infrequently imported into the country, but it has never spread to
any extent, and the disease, when it does attack Egyptian children,
is of a mild character. In Algeria it is almost equally rare.
In Tunis also it is only exceptionally seen, and the average
sickness-rate from this cause in the French army of occupation
is only 0*57 per 1000 strength, as contrasted with a rate of
3*98 for the rest of the French army. Throughout the greater
part of tropical Africa the malady appears to be unknown or very
rare. Pruen, during a long residence in Eastern Central Africa,
never succeeded in recognising it, though he was not prepared to
say it did not exist there. Cook, during four years' residence in
Uganda, never saw a case. It is not met with in Senegal, and
no mention of it is to be found in (recent) health reports from
Gambia, Lagos, or the Gold Coast. It is absent from the
Cameroon district, and is not named by writers on the diseases
of the Congo Free State, of Central Africa, or of British East
Africa.
In Abyssinia the disease occurs at long intervals; but further
south on the east coast it is said to be unknown. It is not seen
at Zanzibar.
In South Africa scarlet fever is somewhat more common,
though still a rare disease. It is but little mentioned in recent
colonial reports, but occasional cases occurred in scattered parts of
Cape Colony in 1898, and in 1891 it was epidemic at Hope Town.
It is also rare in Natal and in Bechuanaland, and it is doubtful
whether it exists in Mashonaland.

392

SCARLET FEVER

In Madagascar and the Seychelles it is unknown. In Mauritius it is seen occasionally, but never spreads.
North and Central America,
Scarlet fever is said to be
unknown in Greenland or in the northern portions of the Hudson
Bay territory, but in Alaska it has appeared on at least one
occasion 1 . In the more temperate portions of Canada it is not
uncommon. In Quebec it was epidemic in 1889 and more
severely so in 1893. ^ n e latter epidemic spread all over the
province from the west, where it was introduced from the United
States. In Ontario it is occasionally epidemic; it was unusually
prevalent in Toronto early in 1897, and in that year there was a
serious outbreak of the disease in a new settlement of Galician
immigrants in Manitoba, where the malady often prevails. In
New Brunswick it was epidemic in several places in 1895, and
in Nova Scotia and British Columbia it occurs in epidemic
form from time to time. The disease is also not unknown in
Newfoundland.
In the United States scarlatina is not infrequently observed
in the north, but is much less common in the south. It appeared
among the causes of death in every State in 1897 with few exceptions ; but in Arizona, Arkansas, Florida, Idaho, Mississippi,
Montana, Tennessee and North Carolina no deaths from it were
recorded in the urban population in that year, while in each of
the States of Louisiana, New Mexico, and Virginia only a single
death was recorded.
The decrease in the mortality in this disorder which has been
so very striking in many European countries in recent years appears
to have been also observed in the United States, at least in some
of them. In Massachusetts the deaths per million living in the
four quinquennial periods contained between the years 1871 and
1890 were respectively 860, 410, 270 and 170 per annum. There
was a slight rise in the years 1891-94, when the mean ratio was
250 per million. In Michigan the decrease has only been observed
1
It was severely epidemic in the Yukon district of Alaska in 1862. Dall,
who travelled there in 1867, wrote that he " passed by several deserted houses
formerly inhabited by some Indians of the Kutchin tribes, who all died five
years ago of scarlet fever. This fever was introduced by a trading vessel at the
mouth of the Chilkaht River. From the Chilkaht Indians it spread to those
of the Upper Yukon and down the river to this point, where all died and the
disease spent itself." The Yukon Territory, London, 1898.

SCARLET FEVER

393

within more recent years, the most marked decline occurring
between the years 1891 and 1894, when.the mortality fell from
202 to 51 per million living. Whether a similar fall has been
observed in other States I am not in a position to say.
In Mexico scarlet fever is said to be very rare in the warm
plains on the coasts, but perhaps more frequent on the cooler
central plateau. In Central America generally the disease is
probably exceedingly rare. In British Honduras 3 cases resembling scarlatina were observed at Belize in 1898, but they
were regarded as very exceptional and no clue could be found to
their origin.
The West Indian Islands appear to enjoy a considerable degree
of immunity from scarlet fever. Information on this point is
imperfect but the disease is said to be unknown in many of the
islands and very rare in others. There is some doubt about its
existence in Cuba; in Jamaica a single case occurred at NPort
Royal in January 1898, and the disease was reported from the
Western St Andrew district in April of the same year, but in neither
instance was there any spread 1 . It is said to be known in Trinidad,
but during 1897-1899 it has not been mentioned in the Annual
Reports on the health of that island, nor in those of St Vincent,
St Lucia, Barbados, the Bahamas, or the Leeward Islands. In
the Bermudas 3 cases were notified in 1898. In Puerto Rico the
malady is unknown.
South America.
The existence of scarlet fever along the
northern shores of this continent is doubtful. I can find no
mention of the disease in several recent reports of the SurgeonGeneral for British Guiana. Concerning Dutch and French Guiana,
Venezuela, and Colombia information appears to be lacking. It
is known in Brazil, and Davidson wrote in 1892 that " scarlet fever,
which was rare during the first three decades of this ceiitury, has
of late years been frequently epidemic, and has made many
victims." Whether these later epidemics reached the northern,
equatorial regions of this vast country, or were confined to parts
further from the equator is not stated, but the earlier outbreaks
were apparently limited to the southern and central provinces
—Rio Grande, Santa Catarina, Sao Paulo, Minas Geraes, and
to Rio de Janeiro 2 .
1

A severe epidemic of scarlet fever spread over the whole island of
2
Jamaica in 1841.
Brunei, quoted by Hirsch.

394

SCARLET FEVER

In Uruguay and Paraguay the disease is said to become
frequently epidemic, and often to assume a very severe type;
in the former Republic it was the cause of only two recorded
deaths in 1897. In the Argentine Republic the disease became
epidemic in 1895 and 1896, and caused in the province of Buenos
Aires 368 and 375 deaths respectively in the two years. In 1897
the deaths from this cause were only 123, and of these 46 occurred
in the northern region, 70 in the central, 7 in the southern and
none in the Patagonian region of the province.
For the western side of the South American continent information is scanty. In Chile the disease is said to have been
frequently epidemic since 1829, the year of its first appearance.
Outbreaks have also been observed in Peru.
F a c t o r s c o n c e r n e d in t h e G e o g r a p h i c a l D i s t r i b u t i o n .
Scarlet fever is essentially a disease of temperate climates. In
the tropics it is almost unknown—perhaps quite unknown as an
indigenous disease. In India it is seen very rarely, and of the
small number of cases there recorded a considerable proportion
have been clearly due to importation. In Farther India it is at
least equally rare, or—so far as the absence of positive evidence
would indicate— perhaps unknown, and the same is true of the
Malay Islands, New Guinea, Southern China, and Japan. In
tropical Africa, the tropical portions of North America, Central
America, the West Indies, and the tropical areas of South America,
scarlet fever is either never met with or is excessively rare.
In sub-tropical countries the disease begins to be rather more
common, and there appears to be an almost regular gradation in
its degree of prevalence as the distance from the equator increases,
until in countries with a temperate or even moderately cool climate
it becomes quite common. This gradation can be easily followed
in many parts of the world, both in the northern and southern
hemispheres. For example along the northern shores of Africa
the disease is but little seen; in the southern European countries
it is probably somewhat commoner, but still less common than in
the countries of Central and Northern Europe. In like manner,
while it is probably unknown in tropical Africa, it is met with, but
still comparatively rarely, in South Africa, which is, of course, a
sub-tropical region, bearing about the same relation to the equator
as Algeria or Tunis in the north. In China it would seem to be
more common in the north than in the south; it is very rare in

SCARLET FEVER

395

Japan, and comparatively common in Sakhalin, further north. We
have seen how in Central Asiatic Russia it causes a very low mortality, a much higher one in the Caucasus, and an extremely high
one in European Russia. Similarly, in the western hemisphere,
in sub-tropical Mexico it is rare, while in the southern United
States it is more prevalent, and in the northern States and
Canada it is quite a common disease.
Extreme cold, on the other hand, seems to be almost as
inimical to scarlet fever prevalence as extreme heat. In Iceland
the disease, as already stated, is an exotic and in the Faroes it is
very rare. In Greenland and northern Canada it is said to be
unknown, though it has been epidemic at least once in Alaska.
In the north of Siberia it is also perhaps non-existent. It must,
however, be borne in mind that these remote northerly regions are
perhaps too sparsely inhabited to keep the disease going continuously on their own account. Scarlet fever is mainly a disease
of childhood and seems to require a large susceptible population
to remain permanently endemic in any area. Like measles, as
already pointed out, it can occur and cause very severe epidemics
in such northerly and inhospitable climes as that of the Yukon
territory. But, like measles also, it appears to die out in these
regions after exhausting all the available material, and a reimportation of infection and a fresh generation of susceptible
persons are then needed before the disease can recur.
While distance from the equator on the one hand and the
poles on the other is undoubtedly one of the most important
influences in determining the prevalence of scarlet fever, other
influences are also at work. Too little is as yet known with
certainty as to the seasonal and meteorological relations of the
disease to state that these conditions are of any importance,
or if so, of how much importance. The seasonal variations of
scarlet fever vary widely in different parts of the world. In such
places as New York, Michigan State, and England, in which the
seasons of the year do not differ very vastly, the period of
maximum prevalence of scarlet fever falls in a totally different
month in each, being in April in the first, in January in the
second, and October in the third.
The influence of race is also uncertain. People so ethnologically distinct as the Chinese, the natives of South Africa, and the
inhabitants of the principal European countries all suffer con-

39^

SCARLET FEVER

siderably from the disease; and it has been observed both in the
aborigines of Australia and in the North American Indians. But
it is certain that some races are more susceptible to the infection than others. The statistics of recent censuses in the
United States of America tend to show that the disease is less
prevalent and less fatal among the negroes and Red Indians
than among the whites. It has already been pointed out that
of the few cases of scarlet fever observed in India, almost all
have occurred among Europeans, and a very small number indeed
in natives of the country. The difficulty, however, of recognising
the disease in persons with a dark-coloured skin must be taken
into account, and it is certain that the natives of India are not
entirely immune to the infection.
The effect of improved sanitary conditions and especially of
increased care in isolating patients in hospitals has been already
alluded to. These measures have certainly seemed to be of value
in England in lessening the mortality of this disease and perhaps
its prevalence also, and it is probable that they have had the same
effect in other countries. But scarlet fever appears to have varying
periods of increased or diminished prevalence independently of
these conditions, and the recent reduction of mortality from the
disease in England and elsewhere cannot wholly be ascribed to
improved sanitation or to the increased use of isolation-hospitals,
or to the other conditions named earlier in this chapter as possible
explanations.
This great reduction in mortality from scarlet fever within
recent years in a very large number of countries is one of the
most-remarkable phenomena in connection with the disease. It
has been observed to a striking extent in the British Isles, in
Belgium, Germany, Denmark, Norway, Sweden, Switzerland, Italy,
and the States of Michigan and Massachusetts; and to a less
extent in Austria and Hungary. In Russia, on the other hand,
there has been no decrease of the malady, at least between 1887
and 1895. I n the countries named the decrease, it must be
pointed out, has extended over a very varying number of years.
In many the material at my disposal only covers a comparatively
short series of years, while in others it goes back for half a
century or more. The two sets of figures are not strictly comparable, and a reduction observed in the course of five or ten
years may be a merely temporary phenomenon of no great

SCARLET FEVER

397

significance, as the disease has admittedly a tendency to wax and
wane for periods of years. In England and Wales the fall was
steady from i860 to 1900 (the date of the most recent report);
in Belgium from 1870-1897; in Norway from 1881-93; in
Massachusetts from 1871 to 1890 (with a slight rise in 1891-4).
Elsewhere the periods of observation were much shorter.
Scarlet fever is a disease with a high degree of infectivity, and
is hence the cause of somewhat frequent epidemics in schools and
similar institutions. Epidemics of a wider character, over whole
communities and even over many countries, have also been recorded. In all countries, as just stated, there are periodic rises
and falls in scarlet fever prevalence, but they show no tendency to
regularity.
There is little doubt that the infection of this fever can be
retained for long periods and carried considerable distances in
fomites. It is doubtful if it can be carried to any extent by the
air, nor is it believed to be transmissible by water. Milk on the
other hand is perhaps capable of containing the infective material
and giving the disease to susceptible persons. Power and Klein
investigated an outbreak of scarlet fever at Hendon in 1885 and
formed the opinion that the infection in that case was to be traced
to a certain milk supply. The cows from which the milk was
taken suffered from a vesicular affection of the udder, and a
streptococcus apparently identical with that of scarlet fever was
obtained, both from the cows, from the milk, and from the scarlet
fever patients. The exact nature of the " Hendon disease " in the
cows still remains somewhat doubtful, but the possibility of the
infection of scarlet fever being carried by milk is quite strong
enough to justify all reasonable precautions to prevent its occurrence.

SCURVY.
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . Scurvy is mainly
characterized by great general debility, spongy swelling and
bleeding of the gums, subcutaneous and deeper haemorrhages in
other parts of the body, and occasionally severe joint and other
affections.
Many views have been held as to the causation of scurvy, but
most are agreed in regarding it as a disease of mal-nutrition.
Prolonged deprivation of fresh vegetable and animal food, particularly if combined with exposure to cold, fatigue, want, and
other depressing conditions, has been the most usual precursor of
an outbreak of scurvy. Hence it has been most commonly seen
among the crews of imperfectly-equipped Arctic or Antarctic
expeditions; among shipwrecked sailors; in times of famine and
of war; and among semi-civilised races whose dietary has been
at fault in quantity or in quality. It is not infrequently seen in
children whose regimen is faulty. An excess of salted or preserved
articles of food, or the consumption of flour, meat, or other food
in a state of commencing decomposition through .being improperly
kept, have been thought by many to be contributory, if not the
main causes of the development of the scorbutic condition. It
must be added, however, that the scorbutic condition, or one
closely resembling it, has at times developed under circumstances
where none of the causes just named were present, and hence
some observers are of opinion that the real cause of scurvy yet
remains to be discovered. Some have suggested that the disease
is of microbial origin, but no specific micro-organism has been
found with certainty in association with the set of symptoms
grouped under the name of scurvy. Frerichs, Frein, and others
claim to have found such organisms, but their exact relation to
the disease is doubtful.

SCURVY

399

H i s t o r y . It is probable that scurvy has existed from time
immemorial, but the references to it by early writers are scanty
and vague. Hippocrates, Celsus, Avicena, and other GraecoRoman and Arabian physicians perhaps mention it. It seems
probable that the Crusaders, just as certain European armies in
recent wars, suffered from it. Vasco da Gama and other early
explorers, particularly those who attempted to discover the NorthWest passage, had to contend with its ravages. For centuries no
long voyage, whether to the Arctic regions or to any other part of
the world, was undertaken without the certainty that a large proportion of the crew would fall victims to scurvy. It is difficult at
the present day to realise the terrible tribute in lives that naval
ships and merchantmen had to pay to the disease. It is only by
studying the actual records of the time, such as the narratives
of Drake's, Hawkins', or Anson's voyages, that any idea of its
ravages can be gained. It was no unusual thing for one-half,
two-thirds, four-fifths, or even a still higher proportion of the crew
to die of scurvy in the course of a single voyage.
The classical works of Dr James Lind, physician to Haslar
Hospital, first drew attention to this appalling and preventable loss
of life on board ship, and from his time the disease has largely
lost its terrors. Throughout the last century scurvy at sea made
its worst ravages in the Arctic expeditions; and even so recently
as 1875-6, and in so expensively-equipped an expedition as that
of the " Alert" and the " Discovery," it was one of the worst ills
with which the crews had to contend. Nansen's great expedition,
on the other hand, has shown that the malady is not a necessary
accompaniment of even a long stay in Arctic regions.
On land a large number of epidemics of scurvy or of an allied
disease have been recorded as occurring in many countries in all
parts of the world. A complete chronological record of 143
epidemics is given by Hirsch, and of these no less than 35
occurred in Russia alone.
G e o g r a p h i c a l D i s t r i b u t i o n in t h e P r e s e n t D a y .
Europe. Scurvy, at one time a formidable disease in our prisons,
is now rarely seen in the British Isles. Occasional cases are
admitted to the Seamen's Hospital at Greenwich, but these are
imported, and an indigenous case is probably unknown. In
Ireland scurvy was severely prevalent at the time of the great
potato famine of 1846-7. In France and Germany the condition is

SCURVY

AOO

now very rarely met with; and the reasons for its disappearance
from these countries are the same as for its disappearance from
the British Isles-—namely, a vast improvement in the dietary and
general hygiene on board ships, in the army, and in prisons. In
Denmark cases of the disease are occasionally seen, and each year
from one to six deaths are returned as attributable" to this cause
among the Danish urban population. In the northern portions
of Sweden and Norway scurvy is said to still exist as an endemic
disorder, attacking not only the Lapps but also the other inhabitants.
It is also found to a considerable extent in Iceland.
But of all European countries Russia is the most deeply
affected by this disease. In the past a larger number of epidemics have occurred here than in any other country, and at
the present day Russia is still one of the most important homes
of the malady. It is always present to a greater or less extent in
all parts of European Russia, and every year a considerable
number of deaths ascribed to it are returned from each of the
" governments" into which the country is divided.
Those
returning the smallest proportion of cases and deaths are the
Polish governments and the Baltic provinces, while that returning
the highest is the government of Archangel. The city of
Archangel and the northern portion generally of European Russia
have always had an unenviable reputation for the prevalence of
scurvy, and they still maintain it. The disease is endemic on the
shores of the Kola Peninsula, north of the White Sea, including
parts of Lapland and the Murman coast, and at times becomes
epidemic there 1 . But while it is most prevalent in the northern
portions of Russia, it may be questioned whether it is not almost
equally so in several other parts of the country. In St Petersburg
and its neighbourhood the scorbutic condition is certainly far from
rare. The returns from the government of Voronezh, on the
Volga, also indicate an exceptional frequency of the disease, and
many other governments—on the Volga, in the Ukraine, in the far
north-east—return high figures of scurvy mortality.
In the Crimea scurvy is not unknown at the present day, and
its ravages at the time of the Crimean War, both among the
Russian and the allied troops, have become historical. In the
early months of the war the French were believed to have lost
more men from this disease than from the guns of the enemy.
1

Sivre, Kazan University Med. Society, Oct. 1901.

SCURVY

40I

In some parts of Austria-Hungary scurvy is known, and has
at times become epidemic. In Italy it is less rare than in some
other countries, and is the cause of an annual death-rate which
varied in the years 1887 to 1896 (inclusive) between 9 and 18
per million inhabitants living. Scurvy in Italy is still a disease of
fortresses and prisons, and is especially met with in Venetia and
along the valley of the Po. It is said to be endemic also in
Roumania. In European Turkey it is now very rarely seen, only
an occasional case being met with from time to time. In Greece,
too, it is an exceptional malady.
Asia, The official returns of scurvy from the Caucasus
proper and from mountainous Transcaucasia indicate that the
disease is far from rare in all parts of both regions. It is met
with also in most parts of Russian Central Asia and Siberia, and it
is interesting to note that in many parts of the latter, notably in the
Amur province, it is the well-fed upper classes and the Russian
soldiers and peasant-immigrants who suffer most, while the native
tribes, such as the Samoyeds, the Giliaks, the Golds, Ainus, and
nomadic Tunguses suffer little 1 . The fact is a remarkable one,
as these tribes are mainly flesh-eaters, though also eating bilberries
and other wild berries, while those who suffer from scurvy are
well fed and eat a large variety of vegetables of all kinds.
Among the Bashkirs, about the Ural River, scurvy is very
rarely seen in ordinary years, but after the famine of 1891-92
they suffered greatly from it. In Asia Minor and Syria the
disease is rarely met with, and there is little evidence to show that
it is at all common in Arabia. On the Yemen coast, however,
it is said to be endemic, and at Aden a scorbutic taint is believed
to account for a large number of the cases of bowel complaint
which come under treatment 2 .
In India the malady has become comparatively rare among the
European troops stationed there. At one time it was a scourge
in Indian prisons and caused a vast amount of mortality, but
improved dieting and hygiene have largely reduced its ravages.
1
Zeland, The Russian
Army-Medical
Journal
(Voenno-meditzinskit
Journal),
1882, pp. 217-18. T h e explanation advanced by this author is
that the Russian soldiers and immigrants live in houses with d a m p and rotting
wooden floors, while the floors of the native huts are of damp-proof clay, and
are constantly dried and "disinfected " by the smoke from their fires.
2
Report of Sanitary Commr. with the Govt, of India, 1897.

C.

26

402

SCURVY

It still, however, occurs in gaols in India, where it is especially
found associated with a malarial taint, but it is always an
imported disease and never developes among the prisoners in
consequence of the prison regime 1 . In the native population it
is said to prevail extensively at certain times, and in the northwestern portion of the Indo-Gangetic valley—in Sindh and Marwar—it is said to be endemic. At times it has become so widely
prevalent as to deserve to be called epidemic. In Rajputana it is
rarely seen in years of plenty 2 . In Ceylon the disorder seems to
be rare; an occasional death from it is, however, from time to time
reported. In Siam it was formerly said to be entirely unknown,
but Rasch reports having seen two characteristic cases—not in
inhabitants of Bangkok itself but in persons from the island of
Kosichang in the Gulf of Siam3.
In Cochin China scurvy is, or was, not uncommon ; and in
China itself it was reported some decades ago (in 1870) to have
been rather frequently seen among the poor in the northern portion of that country, and particularly in Peking 4 . Recent writers
in the Medical Reports of the Chinese Maritime Customs make
no mention of the presence or absence of scurvy in China. The
evidence for its existence in Japan is rather conflicting. Sollaud5,
writing in 1882, spoke of the disease as common among the
poorer classes in that country, but Iskerski, a Russian writer,
stated in a paper published in 1899 that scurvy was unknown in
Japan, either in the fleet, the army, or the general population 6 .
Australasia.
It must be doubted whether scurvy exists to any
extent in Australia or the Pacific Islands generally. It is true
that in Australia itself severe epidemics of the disease formerly
attacked exploring parties who penetrated into the interior of the
island-continent, and at one time it was spoken of as endemic
among the shepherds on the Darling Downs, in the north of New
South Wales. But at the present day the disease is probably a
rarity in Australia. In recent Health Reports from Queensland
and New South Wales I find no mention of it. In South Australia
not a single death attributable to it occurred between the years
1889-1898 (both inclusive), and it is only in the Health Reports
1
2
4
6

Col. K. McLeod, M.D., LL.D., Journ. Trop. Med. Sept. 1898.
3
Adams, op. cit.
Janus, 1896-7, p. 445.
5
Morache, quoted by Hirsch,
Quoted by Hirsch.
Botkin's Hospital Gazette {Bolnitchnaia Gazeta Botkina), August, 1899.

SCURVY

403

of West Australia that a small number of deaths from scurvy are
annually reported.
In Tasmania and New Zealand the disease is probably equally
rare, if not unknown : and I find no mention of its occurrence in
any of the Pacific Islands.
Africa. The negro races of the African continent appear to
possess a high degree of susceptibility to scurvy. In many parts
of the continent the disease is common. Filippo Rho, in describing the pathology of Massowa and its neighbourhood, states
that scurvy rages everywhere among the natives, though few of
the Italian troops stationed there were attacked 1 . In Central
Africa also the scorbutic condition is very frequently met with
among the native inhabitants 2 . In the neighbourhood of the
great African lakes the disease is perhaps less common. Pruen,
at least, who spent several years in that part of the continent,
never saw a case of it; but adds at the same time that he is
not sure that it does not exist there. Scurvy has at times been
epidemic in Egypt, and was, and perhaps is still, commonly seen
in Abyssinia among foreigners or among slaves, but not in the
native population.
On the northern shores of Africa the only reference to the
existence of scurvy is the record of some epidemics of the
disease in Algeria in the past. In recent reports from Algiers
I have come across no mention of the disease. On the West
Coast of Africa it was at one time very frequently seen among the
natives, but is probably less common at the present day.
In South Africa scurvy is a rather prominent disease. The
workers in the gold-fields are said to suffer particularly, and shortly
before the outbreak of the war attention was called to the need of
altering and improving the dietary of the miners on this account.
At the Frontier Hospital, Queenstown (Cape Colony), several
cases are treated every year. At the Butterworth Hospital also
scurvy accounts for a large percentage of the cases annually
admitted for treatment. At Barkly West the disease was spoken
of as "prevalent" in 1897, and it seems to have given rise to
a small epidemic there. A few isolated cases were also reported
from Engcobo in the Native Territories; the patients were natives
who had returned from working at Capetown and Johannesburg,
1

Janus', 1896-7, p. 598.

2

Ibid. 1896-7, p. 389.
26—2

4°4

SCURVY

and the disease did not spread to others. During the war the
amount of scurvy among the South African miners is said to have
increased considerably, owing to the supply of fresh vegetables
and of lime-juice running short. The disease prevailed to some
extent in the garrison of Kimberley during the siege of that town
in the winter of 1899-1900.
Occasional cases of scurvy—sometimes, possibly always, imported—are recorded from Mauritius and from St Helena.
America. The extreme north of the North American continent
and particularly the shores of Hudson Bay have always had an
evil reputation for the prevalence of the malady. It must be
remembered, however, that scurvy has always been associated in
the past with the peculiar conditions found in connection with
Arctic expeditions, and that by far the larger number of the latter
have been those in search of the North-West passage, and therefore
in this very part of the North American continent. The natives of
these regions are said to enjoy an almost complete immunity
from scurvy, and it is only under the conditions of absence of
fresh vegetable food, together with fatigue and privation, such as
explorers, and formerly the lumbermen of northern Canada were
exposed to, that scurvy has been found to prevail in these
countries.
In the United States scurvy is now a rare disorder, but cases
are sometimes seen among sailors in the seaport towns, and in the
mining districts of Pennsylvania the Hungarian, Bohemian, and
Italian settlers are not infrequently attacked (Osier). Scurvy in
infants, caused by improper dietary, is said to be increasing in the
States. In the past it caused a considerable amount of sickness
among the troops taking part in the American Civil War, and also
in the Mexican War; and at the time of the famous " gold rush "
in California not a few of the immigrants suffered from it. It is
probably rare at the present day in the West Indies; cases of it
are however occasionally mentioned in recent reports from some
of the Leeward group.
The evidence for or against the existence of scurvy in South
America is excessively scanty. Four cases of the disease were
mentioned in the Health Reports for British Guiana for the year
1898; but with one other exception this is the only mention I have
come across of this disease in the South American continent.
The other exception is a reference by Hirsch to a report—as far

SCURVY

405

back as the year 1844—of imported cases of scurvy in certain
negroes brought from Africa to the Brazils.
Outbreaks at Sea. While outbreaks of scurvy at sea were at
one time the rule in all long voyages they are now quite exceptional. There can be no question that this is due to the compulsory
provision of lime-juice or other anti-scorbutics on board all ships,
to. the shorter duration of voyages, and to the greater ease with
which fresh vegetable and animal food can be obtained and
preserved—even throughout the longest voyage. In the absence
of fresh food and of anti-scorbutics, however, an outbreak of
scurvy occasionally takes place at sea even in the present day.
Thus in 1891 a Dutch ship arrived at Mauritius from Akyab with
a number of cases of scurvy on board; many of the patients were
in the last stages of the disease when the ship arrived, and many
died 1 .

Factors determining the Geographical Distribution.
Scurvy is a disease which, for obvious reasons, has no permanent
geographical distribution. Dependent as it probably is upon a
faulty dietary, - it is found only under the special and usually
temporary conditions where the particular error in diet prevails,
and disappears when the error is corrected. But these conditions
appear to be more or less permanently existent among certain
communities, as for example among the Russian peasantry and
Laplanders, in certain gaols and barracks in India and elsewhere,
and among the natives of many parts of Africa.
It will be observed that scurvy is not dependent upon temperature for its development. It has been found in the tropics,
in temperate zones, and near the poles. Some writers have
believed that cold and exposure to wet are strong predisposing
factors in the production of scurvy, but it would seem that they
are so only in the sense that they weaken the resisting powers of
a person exposed to them, and make him more liable to develope
scurvy when the other special conditions needed to produce the
disease are present; and the same statement appears to apply
equally well to prolonged exposure to a warm, relaxing climate,
such as is met with in the tropics.
The soil seems to have little, if any, influence on the prevalence
of scurvy on land. Overcrowding, insanitation, and all that they
1

year

Mauritius. Report of the Chief Med. Officer on the Med. Depart, for the
1891.

406

SCURVY

imply, are probably favouring conditions. But there is a very
general consensus of opinion that scurvy is essentially due to a
defective dietary. It would be out of place here to enter into a
discussion of the medical and physiological problems involved in
the question of the true etiology of scurvy, and particularly as to
the exact chemical constituent of diet the lack of which produces
the scorbutic state. It will suffice to say that the evidence is
practically conclusive that in most, if not all " outbreaks" of
scurvy, an absence of fresh vegetable food or some substitute for
it, as lime-juice or fresh meat, has been the main cause of the
disease. Other conditions, such as those of climate, soil, or
hygiene, of general inanition, of the consumption of decomposed
food or of salted meat or fish—all of which have been urged at
different times as the real cause of scurvy—are probably to be
regarded as only contributing to the production of the disease 1 .
It will be seen, therefore, that the scorbutic state is one which
can be prevented from developing by proper attention to diet
The disease, if it may be truly called a "disease," is, in fact, a
preventable one. Its complete disappearance from the earth's
surface is only a question of the right regulation, at all times and
in all places, of the dietary. In getting rid of it permanently
there would be no question here, as in the case of " infectious "
diseases, of getting rid of a specific virus—of destroying a prevalent
and dangerous micro-organism. Some authors, as we have seen,
have hazarded the opinion that scurvy is due to a micro-organism
and that it does belong to the group of infectious diseases, but
there is little to give colour to the suggestion. It is not likely,
then, that it will ever permanently disappear. Errors of diet, and
particularly lack of fresh vegetables and meat, and the consumption
of badly kept and tainted food, are conditions which must from
time to time recur here and there, and whenever they do recur,
it is more than probable that they will be accompanied or followed
by the development of the scorbutic state in the individual, and,
if many are so affected at one time, by the occurrence of a so-called
" outbreak" of the malady.
1
Jackson and Harley, however,
believe that the main factor in the
fresh vegetables or lime-juice from
d u e to improperly preserved food,
Royal Soc, March, 1900.)

as the result of experiments on monkeys,
production of scurvy is not the absence of
the dietary, but that the malady is mainly
and particularly to tainted meat.
{Proc.

S L E E P I N G SICKNESS, or
NEGRO L E T H A R G Y .
General C h a r a c t e r s a n d E t i o l o g y . Sleeping sickness
or negro lethargy is a remarkable and extremely fatal disease,
which occurs as an endemic, and sometimes as an epidemic, in
certain limited geographical areas. Its principal feature is an
increasing tendency to sleepiness, until at last the patient becomes
completely comatose, and after a longer or shorter period dies.
The premonitory symptoms—such as a peculiar expression, a
puffiness of the face, occasional attacks of headache, vertigo, fever,
or diarrhoea—are usually well-marked, and during the later stages
a number of severe nervous symptoms, such as spasms, paralysis,
maniacal outbursts, etc., may develope. The disease may last
for a few months or even for as long as two or three years, and
it appears to be invariably fatal.
Innumerable theories have been advanced to account for the
causation of sleeping sickness. Many of these have been abandoned, and now possess a historical interest only. Thus the
suggestions that the disease is caused by sthe smoking of Indian
hemp, by the excessive drinking of palm wine, or by criminal
poisoning; that it is the result of " depressing emotions, particularly those associated with the slave-trade"; that it is due to the
presence of enlarged scrofulous glands in the neck pressing upon
the cervical vessels and so lessening the blood supply to the brain;
or that it is the outcome of a cerebral sclerosis of scrofulous
origin—have all been shown to be untenable. Recently Scheube
has suggested that negro lethargy may be an intoxication analogous to ergotism, and caused by the parasites of maize, rice
and other cereals. Still more recently Manson has pointed out
the possibility that the disease may be in some way due to the

408

SLEEPING SICKNESS, OR NEGRO LETHARGY

filaria perstans. It is certain that the geographical distribution
of this filaria and of sleeping sickness very closely correspond,
and as the filaria has been found in several cases of this disease
the theory that they are causally related to each other finds much
to support it1. In 1901 a scientific committee, sent by the
Portuguese Ministry of Marine to study this disease, came to the
conclusion that it is due to a micro-organism to which they gave
the name of diplo-streptococcus. In 1902 a Commission was sent
to Uganda for the same purpose under the auspices of the Royal
Society, the Foreign Office, and the London School of Tropical
Medicine, and it has lately been stated that the members of it
have been successful in discovering the cause of the disease.
H i s t o r y . The earliest description of negro lethargy dates
from the year 1800, when Winterbottom, a surgeon in the British
service, called attention to its occurrence in natives on the shores
of the Bight of Benin. Later, in 1840, Clarke published a more
detailed account of it as observed in Sierra Leone. Since then a
very large number of observations on the disease and its causation
have been published. Nothing, however, is known as to the
history of the disease itself before the nineteenth century. During
that century and until quite recently it has shown a very constant
distribution, being strictly confined, as an indigenous disorder, to
the tropical portions of Western Africa, and when appearing
elsewhere—as in the West Indies, Brazil, and possibly British
Guiana—doing so only as an importation from Africa, and mainly,
if not solely, in negroes from the African coast. With the
disappearance of the traffic in slaves between the eastern and
the western hemispheres sleeping sickness has almost, if not quite,
disappeared from the latter. But in Africa it has recently become
much more prevalent than formerly and has spread widely to the
east and south, though still remaining a tropical disorder.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Sleeping sickness,
so far as is known at present, is met with as an indigenous disease
principally along the West Coast of Africa. Its northern boundary
appears to be the Senegal river, while to the south it is limited by
the southern border of the Portuguese colonies. It is particularly
common in the French colony of Senegambia, and 4 in some of
the ports here it has at times been so severe that the extraordinary
See page 611.

SLEEPING SICKNESS, OR NEGRO LETHARGY

409

phenomenon has been seen of a negro garrison being replaced by
white troops (French marine infantry) on account of the losses
caused among the former by its ravages. This has happened at
Portudal and Joal, ports facing the island of Goree 1 .
The disease is also common along the shores of the Gulf of
Guinea. In Liberia, at Grand Bassam on the Ivory Coast, on the
Pepper Coast, along the Gold Coast, and at Old Calabar in the
Bight of Biafra it is frequently seen 2 . On Fernando Po and other
islands in the Bight itself cases are met with. In Principe Island
it was "raging" in 1901, and had been very active for the previous
fourteen years3. Along the valley of the Congo it has long
been known as an endemic disorder. Centres of the disease are
irregularly scattered through the Congo Free State 4 , and Sims has
recorded cases of it at Stanley Falls, in the very heart of equatorial
Africa. Further east, in Uganda, sleeping sickness has now established itself as a very serious endemic disease. During the past
year or two it has become extraordinarily prevalent there. Thus
writing early in 1901 on the diseases of Uganda, Dr A. R. Cook
merely stated that "sleeping sickness is said to be common in
Busoga to the east of Uganda," but that he had only had two
cases in the hospital at Mengo 5 . A little later Dr J. H. Cook
reported an extension of the disease in Uganda 6 , and in December,
1901, the latter observer wrote that " i n the districts of Kyagwe,
in Busoga, and latterly round Mengo, it is literally slaying
hundreds 7 ." In the Mengo dispensary he was seeing from four
to six new cases every week. It had spread to the islands on
Lake Victoria Nyanza, and on the island of Burruna alone had
caused the death of over 200 natives.
To the south sleeping sickness is found with considerable
frequency in the Portuguese colony of Angola, in certain parts
of which it is so prevalent as to be spoken of as a serious bar
to negro colonisation. It has been particularly active recently in
the northern districts, where whole villages are said to have been
depopulated by it.
1
3

Corre, and Brault.
Report of the Portuguese Scientific Committee.

2

Brault.
Ref. in Journ.

Trop.

Med., May 15, 1902.
4
5
7

Congress cFHygiene et de Climat. Med. de la Belgique et du Congo, 1897.
6
Journ. Trop. Med., June r, 19CM.
Ibid. July 15, 1901.
Ibid. F e b . 15, 1902.

4IO

SLEEPING SICKNESS, OR NEGRO LETHARGY

While sleeping sickness is only found as an indigenous disorder
in the tropical portions of Africa, secondary centres of the disease
have from time to time developed in other regions of the world,
though it is almost certain that these secondary centres have
always owed their origin to importation from Africa. The
malady was formerly far from rare among negroes transported
from Africa to the West Indies, the Bahamas, and Brazil. Guerin
about the middle of last century saw as many as 148 cases of this
kind during twelve years' practice in Martinique; and Nicolas
believed that one per cent, of the deaths among negro immigrants
on the voyage from Africa to the West Indies were due to sleeping
sickness. But at the present day the disease is said to be unknown
among the black population of the West Indies or of Brazil. In
the Guianas, however, there is some evidence pointing to the
possibility that it is now endemic. Ferguson reports that he
has seen well-marked examples of the disease in British Guiana 1 .
His patients were not all negroes, and from the fact that the
ankylostomum duodenale was present in them, he came to the conclusion that negro lethargy was nothing else than ankylostomiasis,
the symptoms being modified by individual or racial peculiarities.
This opinion is, however, combated by Ozzard, who states that
he never saw a case of the sickness in British Guiana, and
believes that Ferguson must have mistaken advanced cases of
ankylostomiasis for the sleeping sickness2.

Factors concerned in the Geographical Distribution.
Negro lethargy is entirely a tropical disorder. As an endemic it
is strictly limited to the continent of Africa, between the 16th
degree of north latitude and the 18th degree of south latitude.
It is not confined to the coast nor to the western half of the
continent, but is seen in the very heart of the Congo Free State
and in Uganda—countries which have no coast line.
In its area of endemic prevalence the disease is very irregularly
spread both in regard to space and time. It occurs in the form
mostly of scattered centres, consisting of single villages or groups
of villages. These centres are not, however, permanent, and the
disease would seem to migrate from one area to another. Having
destroyed half the population, perhaps, of one village, it passes
on to another village or group of villages that had been hitherto
1
2

Brit. Med. Journ., 1899, Vol. I. p. 315.
Ibid. p. 964.

SLEEPING SICKNESS, OR NEGRO LETHARGY

411

free from it. It is sometimes the cause of the most deadly
epidemics, and whole villages have been known to be swept away
by it. It is rightly dreaded by the negro inhabitants of those
regions where it may occur, for no certain case of recovery from
an attack of the sickness has apparently been recorded.
The relations of the disease to race are unusually well-marked.
It is almost wholly confined to the African negro. In its endemic
home in tropical Africa it is practically the native black alone that
suffers from sleeping sickness. When the disease was formerly
seen in the West Indies it was almost solely among negroes
imported from Africa, and it never attacked those born on the
plantations, or who had become domiciled on American soil.
Rare cases have been seen in half-castes and in Moors, and Corre
has mentioned a doubtful case in a white man. In British
Guiana Ferguson believed he had seen the malady in persons
other than negroes, but for the present considerable doubt must
attach to his cases. It is noteworthy that, in those areas of
Western Africa where negro lethargy is endemic, negroes coming
from other districts are particularly liable to it, the local inhabitants appearing to become in a sense acclimatised 1 .
1

Corre, Arch, de Mid. Navale, 1877.

SMALL-POX.
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . The characters of
an attack of small-pox do not require description here. The
cause of the disease is unknown. It presents all the features of
an infective fever of microbial origin, but no micro-organism has
yet been found that can with certainty be regarded as specific
to it. Klein and Copeman have, however, described a minute
bacillus, occurring in small-pox pustules, which may perhaps
prove to be the organism sought for.
H i s t o r y . Small-pox seems to have been known in India and
China from time immemorial. In both countries the disease has
been placed under the special protection or patronage of a goddess,
to whom temples were dedicated and in whose honour sacrifices
were performed. Ebers believes that he has found a reference to
the existence of small-pox in ancient Egypt (about 3730 B.C.) in
the papyrus that bears his name.
Throughout classical and
medieval times references to the occurrence of small-pox are
comparatively numerous.
The oldest known purely medical
account of the disease seems to be that of the Arabian writer
Rhazes, of the tenth century. In more modern times there are
records of small-pox epidemics in almost all parts of the inhabited
world. After the introduction of vaccination by Jenner at the
end of the eighteenth century the prevalence of the disease
diminished to a remarkable extent in all countries where the
practice was adopted. Small-pox, however, still causes local or
general epidemics from time to time. The former seem to be
largely due to the neglect of vaccination, the latter to some
unknown factor in the natural history of the disease which leads
it at intervals—like plague, cholera, or influenza—to spread widely
over the earth's surface. The last great epidemic, or pandemic,

SMALL-POX

413

of this kind occurred between the years 1868 and 1873, when
the disease overran the greater part of Europe and North America
and caused a large number of deaths.
The practice of "inoculating" for small-pox, that is to say of
introducing the matter from a small-pox pustule into the tissues
of a healthy person, in order to bring about a mild attack of
the disease, and so render him immune from a severe attack, is
said to have been first practised in China about the year 1000 B.C.
In India the custom is perhaps older. It is still resorted to in
both countries, as also in Tunisia, Persia and elsewhere. At what
period the practice was introduced into Europe it is difficult to
say, but it appears to have come there from the East. It was
made known in England early in the 18th century by the
writings of Lady Mary Wortley Montagu, the wife of the British
Ambassador at Constantinople, where it was at that time largely
performed. Unfortunately, inoculating the small-pox not only
often led to fatal results, but it multiplied the number of persons
suffering from the disease—and consequently the sources of infection to others—to an enormous extent. Hence it was generally
abandoned on the introduction of vaccination.
Jenner's admirable essay on the protection from small-pox
afforded to human beings by the inoculation of the cow-pox
was published in 1796. Few great discoveries have found such
immediate or such general acceptation, and in the course of a
few years vaccination had been introduced into most civilised
countries. It was not until some time later that it began to be
enforced by law. In England gratuitous vaccination was provided
in 1840, but it was still optional; in 1854 vaccination was made
obligatory, but it was not until 1871 that public vaccination
officers were appointed and the practice more or less rigidly
enforced. In 1899, owing largely to the clamour of a section of
the population opposed to the practice, the law was again relaxed,
and parents who have registered a " conscientious objection " to
vaccination are now allowed to leave their children unprotected
against the attacks of this still deadly disease.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. In England
and Wales small-pox gave rise to an annual mean mortality of
45 per million living in the decade 1881-1890. It had been
very much higher in the preceding ten years, when the British Isles
did not escape from the pandemic extension of the disease which

414

SMALL-POX

marked the earlier years of that decennium. The mortality
figure from this cause was exceedingly low in the years 1889-91,
but there then followed a considerable rise in the death-rate.
The deaths in 1892 were equal to 15 per million, in 1893 to
49 per million, and in 1894 to 27 per million inhabitants. A
marked fall then ensued, and in the years 1895-1900 the mortality
ratios were respectively 7, 18, less than 1, 8, 5, and 3 per million.
Severe epidemics within recent years in Middlesborough, Gloucester, London, and elsewhere, have aroused public attention to the
immense power for evil which this disease still possesses when
not kept in check by systematic vaccination.
In Scotland small-pox caused an average of 4 deaths per
million inhabitants each year in the decade 1881-1890. In
subsequent years the deaths from this disease have for the most
part been few in number. Ten were registered in 1897 and only
1 in 1898.
In Ireland small-pox was epidemic in 1894-5, but between
1895 and 1900 it almost disappeared.
In France the disease has become much rarer within the last
ten years; in towns of over 10,000 inhabitants the deaths from it
steadily fell from a total of 1897 in 1891 to only 105 in 1898.
The death-rate has also decreased considerably in recent times in
Belgium. The mean for the years 1871-1880 was, as in most
other countries, very high, as many as 5,080 deaths per annum
being recorded from this disease; but in 1881-1890 this figure
fell to 1361 ; in 1895 only 298 deaths were registered, and in
1897 only 140. The last figure shows a ratio of about 22 per
million inhabitants.
In Holland the prevalence of small-pox has varied greatly in
recent years. A marked rise in the deaths from this cause
occurred, just as in England and Wales, in the period 1892-94.
In each of these years the mortality rates were 10, 40, and 130
per million respectively; a rapid fall then set in and in 1897 and
1898 only 1 and 7 deaths from small-pox respectively were
registered.
In the German Empire generally the malady is now almost
extinct. This happy result has been brought about, almost if
not quite entirely, by the enforcement of universal vaccination
and re-vaccination. The deaths from the disease in 1894 were
returned as 2 per million inhabitants; the mean ratio for each

SMALL-POX

415

of the preceding 7 years having been 3 per million. This insignificant degree of mortality is seen in all parts of the country.
In Prussia the figures are the same as for the whole empire; in
Saxony the deaths in 1894 were only 1 per million inhabitants;
in Wiirtemburg the mean for 1887-1893 was as low as 0*2 per
million. In Bavaria the ratio fell from 2 per million in the septennium named, to 1 per million in 1894. The disease is not,
however, quite extinct in Bavaria or Swabia, for 249 cases of it
have been reported in the ten years 1889-98 in Bavaria, and
35 in the same period in Swabia.
In Denmark the disease has been almost unknown in recent
years, only two deaths from it having been reported in the
urban population since 1892 (1 in 1894 and 1 in 1896). In
Norway it has not been mentioned in the list of fatal diseases
during recent years, and has therefore presumably disappeared
from the country.
In Sweden small-pox caused an annual
mortality of 25 per million in the years 1880-1886, of 1 per
million in the next septennium, and of 4 per million in 1894.
Small-pox is more prevalent in Russia than in almost any other
European country. In the years 1893-95 the mortality ratio
from this cause was 530 per million in European Russia, the
next highest ratio occurring in Hungary (350 per million in the
same period). No part of the country is free from it, the degree
of prevalence in different governments or provinces varying widely
in different years. The number of registered cases of the disease
has in some recent years (1893-4) been considerably lower in
the Don Cossack Territory than elsewhere, but this has not always
been the case, and in 1895 it was actually higher here than in
almost any other division of the country. Small-pox is met with
in the far northerly governments of Archangel and Olonetz, in
the Baltic Provinces, in the Ukraine—in brief, in every division
of European Russia, and it is almost everywhere a cause of
considerable mortality. It was particularly rife in Polish Russia
in 1893. Vaccination, it may be added, is not compulsory in
Russia, though it is encouraged by various government and local
authorities, by the parish priests, and by certain voluntary societies
and agencies. Among the Bashkirs on the European-Asiatic
borders of Russia, north of the Caspian, small-pox is said to be
not common; these people have no prejudices against vaccination
and it is to some extent practised amongst them.

416

SMALL-POX

In Austria small-pox was some years ago a very frequent
and fatal disease. In the Austrian empire the recorded deaths
from this cause in the seven years 1880-86 were 638 per million
per annum; in the next septennium they fell to 366 per
million.
In Hungary small-pox has of recent years been more active
than in Austria. Thus, in the two successive septennia named
above, the mean small-pox mortality rates in Hungary with Fiume
were 653 and 439 respectively, and in Croatia with Slavonia as
many as $&& and 812.
In Switzerland the disorder is apparently a rare one. In the
15 principal towns 1 death only was recorded in 1895, against
18 in 1894, 11 in 1893, 8 in 1892, and 3 in 1891.
A very marked decline has recently taken place in the
recorded small-pox mortality in Italy. In the four years 18871890 the deaths from this cause in any single year varied between
233 and 610 per million, but between 1891 and 1896 the ratio
never exceeded 97 in a single year, and in 1896 was only 65
per million inhabitants.
Small-pox is very widely spread in Spain and Portugal.
Davidson, writing in 1892, stated that it caused an annual
mortality in the principal towns of 1307 per million.
The
lower classes are said to be much opposed to vaccination. It
sometimes appears in Gibraltar, where it caused serious epidemics
in 1883-84, and again in 1889-90, owing, it is said, to neglect of
re-vaccination in the civil population.
In the countries of the Balkan Peninsula small-pox is rife.
In Servia it caused 4233 deaths in 1894-5, or 1830 per
million living. In the other Balkan States the disease is also
far more prevalent than in the west. In Turkey in Europe
it was at one time a conspicuous cause of sickness and
death. In Constantinople, however, it has become very much
less common in the last few years than it was formerly, and is
now indeed a rare disorder. A few years ago a house-to-house
visitation was made, and every inmate compelled to undergo
vaccination nolens volens, and the diminution in the disease is
directly attributable to this. In Salonika and some other provinces
of European Turkey small-pox is said to have become comparatively rare since vaccination and re-vaccination have been
more widely practised. A severe epidemic of the disease occurred

SMALL-POX

417

in the autumn of 1901 at Kavala on the iEgean shores 1 . In
Greece the malady occurs, but with no great frequency.
Small-pox is occasionally introduced into Iceland, but in
recent times little of it has been seen, thanks in part to the
efficient vaccination of the people and in part to prompt isolation
of cases. In the Faroe Islands no case of small-pox has been
recorded since 1856, a result also ascribed to careful vaccination.
As to the prevalence of small-pox in some of the islands of the
Mediterranean accurate information appears to be wanting. In
Malta it is at times epidemic; it was widely so in 1898, owing to
importations of infection from Tunis and Benghazi, 109 cases in
all occurring.
Asia. Small-pox was more prevalent in the Caucasus and
Transcaucasia in the years 1887-1895 than in any other part of
the Russian empire, so far as may be judged from,the returns of
registered cases of the disease. It appears to be rife throughout
this portion of the empire.
In Russian Central Asia, on the other hand, the recorded
cases and deaths were remarkably low in the same p e r i o d averaging one-seventh, or even less, of the cases and deaths in
the same unit of population recorded in the Caucasus, and about
one-fourth of those in the Russian empire as a whole. How far
this is due to imperfections of registration in this part of the
country cannot be said.
In Siberia the registered cases of the disease in the same series
of years bore almost the same ratio to the population as those
in the Russian empire as a whole. Small-pox at times causes
severe epidemics in some parts of Siberia. The indigenous races
of that country are particularly liable to it, and even as far north
as the shores of the Arctic Ocean serious epidemics sometimes
occur among the natives.
Throughout the greater part of Arabia small-pox is the cause
of a high mortality. In the Yemen district it is rife and almost
uncontrolled by vaccination, and I am informed by eye-witnesses
who have travelled in that country that the remains of villages
may be seen, every inhabitant of which has been carried off by
this scourge. Among the Mussulman pilgrims at Mecca a very
large number are yearly attacked by the disease, which accounts
for more deaths among them than any other affection.
1

c.

Reports of Sanitary Officers to the Ottoman Board of Health.
27

4i8

SMALL-POX

In Syria, in Mesopotamia, and in Persia small-pox is endemic.
It was epidemic in Baghdad in November 1898, and in the
Lebanon provinces in the same year. At Basra at the head of
the Persian Gulf it is far from rare. In Persia it is said to be of
milder form than in Europe; it is truly endemic in Teheran,
where the old custom of variolisation is still practised. Epidemics
from time to time occur in the provinces, and recently (November
1901) outbreaks of the kind occurred at Tabriz and at Enzeli,
attacking both natives and Europeans.
The disease is no less endemic throughout the Indian
peninsula. Its degree of prevalence varies widely, but in the past
few years it has been unusually active. In 1894 and 1895 t n e
recorded mortality was lower than in the preceding years, some
44,000 or 45,000 deaths occurring in each year; but in 1896 the
recorded deaths suddenly rose to 141,443 and in 1897 to 167,318.
In 1896 the increase had been general throughout all parts of the
country, but was greatest in Ajmir-Merwara, and in the Punjab,
which also showed the highest mortality ratio. In 1897 the
increase was most marked in the North-West Provinces and Oudh.
In Assam and Mysore in 1896 the disease caused mortalities
exceeding 1000 per million, while in Ajmir-Merwara the mortality
was no less than 7050 per million inhabitants. In 1897 Assam,
the North-West Provinces and Oudh, and Mysore all returned
mortality ratios of over 1000 per million. It is of interest to
note that small-pox has appeared to have " little or no connection
with famine; certainly it did not particularly affect the distressed
districts 1 ."
In the Rajputana States, where small-pox was once very
frequent, it is said to have much diminished since the introduction
of vaccination.
The disease is common in India in the north and in the south,
in the hills and in the plains. In the Hindu-Khush it has from
time immemorial raged as an epidemic at intervals of from five to
twenty years. In 1891 it spread gradually up the Indus valley to
Chilas, and in the autumn kept the Chilasis quiet during the HunzaNagar expedition. It reached Gilgit by Christmas, and thence
was apparently distributed widely by a body of released prisoners.
It caused in the end a very severe and fatal epidemic in Nagar
1

1896.

Report of the Sanitary Commissioner of the N. W. Provinces and Oudh for

SMALL-POX

419

(where no vaccinations had been performed), and a mild one in
Hunza (where several vaccinations had been performed in the
previous year). It is of interest to note that, in the absence of
vaccine lymph, the old practice of small-pox inoculation was
revived on a large scale, and—it is claimed—with remarkable
success, the epidemic subsiding in a fortnight1.
In Ceylon small-pox is at times epidemic ; it was so in 1891,
when it caused 452 deaths; in other years it is quiescent, as in
1894, when only 3 deaths from it were recorded; in 1897 the
number was 25.
In Farther India the affection is very common. In the southern
Shan States in Burma it is one of the principal causes of death in
childhood. Of Siam almost the same may be said; it was very
prevalent here in 1898. The Siamese make no attempt to isolate
the sick, and it is said that persons ill with the disease may be
seen in the streets picking off the scabs, or bathing in the streams
while still in the suppurative stage. It is endemic in the Malay
Peninsula, and is frequently seen in the British Straits Settlements.
In 1898, 84 cases with 46 deaths occurred in Singapore town alone,
2 deaths were recorded in Penang and 1 in Province Wellesley in
the same year, and as many as 93 cases with 23 deaths in Malacca.
In Annam and Tongking it is at times epidemic and fatal in an
unvaccinated population.
In China small-pox is one of the commonest diseases It is
met with almost everywhere, particularly in the winter months.
It is believed to be largely spread by the practice of variolisation,
which is still performed by inserting a pledget of small-pox
crusts into the nostrils.
In recent years it has been very
frequently epidemic in many places, and is constantly mentioned
in the reports of the Customs Medical Officers. At Wuhu it
is said to have caused the deaths of 2000 children under twelve
in the winter of 1890-1891 2 . In Shanghai it was unusually prevalent in 1893) a t Ningpo it was severely epidemic in 1893—4; it
raged in and near Hoihow (Hainan Island) in 1894-5, m Hankow
in 1896, in Canton in 1896-7, and in Chung-king in 1897-8. In
Hongkong it was epidemic through a great part of 1898. In the
Yunnan province it appears intermittently, and in Manchuria it
is often very prevalent.
1
2

Capt. H. B. Luard, I. M. S., Trans. 1st Indian Medical Congress•, 1894.
Med. Reports of the Imp. Chin. Mar. Customs, No. 42.
27—2

420

SMALL-POX

In Corea it usually rages in the winter months.
In Japan small-pox is constantly present in some part of the
archipelago, with varying degrees of severity. In 1893 as many as
41,898 cases of the disease with 11,852 deaths were recorded, but
in 1894 these figures fell to 12,418 and 3,342 respectively. The
last figure was equivalent to a ratio of about 80 per million
inhabitants.
The increased frequency of vaccination in many of the islands
of the Malay Archipelago is said to have diminished the prevalence
of small-pox considerably in recent years. This has been the case
in Sumatra, Java, and Celebes. In Java the disease is now almost
unknown. In Borneo it from time to time becomes epidemic. In
Labuan, off the coast of British North Borneo, it is occasionally
seen, but no cases have been recorded in recent hospital reports
from that colony. Among the Dutch troops in Netherlands-India
only a few cases of the disease, all of a mild type, were recorded
in 1897.
Australasia.
In British New Guinea small-pox appears to be
unknown, though it is spoken of as endemic in German New
Guinea and the Bismarck Archipelago 1 . In Australia it has been
extremely rare in recent years; it has been several times imported
into Victoria in the last decade, but has never spread or become
epidemic. In South Australia a single death in 1898 was the first
recorded in the colony for at least ten years. In Queensland no
death from the disease was registered in any of the years 1893-1897
inclusive. In Western Australia 7 deaths from small-pox occurred
in 1893 and 2 in 1894, none occurring in any other year of the
decade 1889 to 1898. No mention is made of the disease in
recent reports of the Board of Health of Tasmania 2 , nor in recent
reports from New Zealand, and it may therefore be assumed that
both these colonies can still claim—as they could when Hirsch
wrote twenty years ago—that they have always remained free from
small-pox. In former years the disease was terribly prevalent
among the Australian aborigines, and is said to have carried off
from one-third to one-half of some of the tribes. Its absence from
New Zealand is, therefore, all the more a matter for congratulation,
1

Colonial Report of the British Solomon Islands, 1897.
It has been conjectured that in the past, before the colonisation of
Tasmania by the white man, the aborigines may have suffered severely from
small-pox, but I do not know whether the conjecture is well founded.
2

SMALL-POX

421

as the Maori race, which has shown itself to be so susceptible to
some other diseases, as for example tubercle, could not fail to suffer
severely from it.
Some of the Polynesian islands have equally escaped smallpox. It has never been known, for example, to occur in Fiji or
in the Samoan Islands. In some other groups however, as the
Society Islands and New Caledonia, it has been frequently epidemic.
Africa. Small-pox is endemic in the countries on the
northern shores of Africa. It is very common in Morocco, and
Dr Guillemard informs me that a severe and very fatal epidemic
occurred in Mogador in 1892.
In Tunisia it is the commonest
of all diseases, and variolisation is practised here, as in China,
with disastrous results. The disease caused 1645 deaths in Tunis
alone in 1888, and 870 in 1894—both epidemic years ! . In Algeria
also small-pox is extremely prevalent, the mortality from the disease
some ten years ago averaging 1685 per million inhabitants per
annum. Oran has suffered greatly from its ravages. It was
severely epidemic in 1896, when it caused 343 deaths in the six
principal Algerian towns, but in the following year this figure sank
to 35, and in 1898 to 29.
Egypt has been comparatively free from small-pox since the
introduction of vaccination in 1827, before which date the
mortality from the disease was excessively high. Now the larger
number of cases which occur are said to be due to importations
from the surrounding countries, wThere vaccination is almost or
quite unknown.
On the western side of the African continent small-pox is
rife. In Senegal it is frequently epidemic. In Sierra Leone 165
cases with n deaths occurred in the colonial hospitals in 1897,
and in Lagos 189 cases with 6 deaths were recorded in the same
year; these were among the highest figures for any single disease
in the former, and quite the highest in the latter. In the Gold
Coast colony it is endemic in the natives; 261 cases of the disease
with 48 deaths were recorded in 1897, and many others wrere
known to have occurred. In the Cameroon district, on the other
hand, it is said to be unknown 2 .
1
In the intervals between these two years the deaths from small-pox in
Tunis were numbered by units.
2
A. Plehn.

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422

Throughout the greater part of Central Africa small-pox is
extremely common. In Belgian Congo and in French Congo
and elsewhere it is often very widely prevalent and fatal.
The disease is largely spread in Central, Eastern, and Western
Africa by the movements of traders. There are said to be few
caravans in which a case or cases of small-pox do not occur;
variolisation, which is occasionally practised, may also aid in
spreading the infection. Pruen states that the natives often suffer
from very mild attacks, and many recover from the worst confluent
forms of the disease.
On the eastern side of Africa the disease is widely endemic.
In Abyssinia it is very common, and it is reported to have ravaged
the Abyssinian army under Ras Makonnen in 1898. At Massowa,
on the Red Sea, it is rife, yet the well-vaccinated Italian army
escaped without a single case during the campaign in 1895. In
British East Africa it is believed to have been rare in the last
twrenty or thirty years, as pock-marks are only met with in persons
no longer young 1 . On the Upper Zambesi also the disease only
occurs at long intervals in epidemic form. In Unyoro it is said
not to be endemic, though it is sometimes imported from the
coast, but in Uganda, on the other hand, it is very deadly, slaying
its hundreds 2 . In Zanzibar and along the Mozambique coast the
disease is thought to be endemic.
Throughout South Africa small-pox is met with; usually in the
form of scattered cases, but occasionally as severe epidemics. It
is particularly common in the native territories and often spreads
from them to other parts of the country. In' 1898 it was epidemic
among the natives in several places in Tembuland, the Transkei,
and Pondoland, and it appeared also in the Transvaal, the
Orange Free State, Natal, and Cape Colony. Three outbreaks
occurred in Griqualand West in this year. In many large tracts
of South Africa no vaccination whatever is performed. In Cape
Colony vaccination is done by the Cape Police, who travel from
place to place and are said to do a vast amount of good and useful work in this way; elsewhere vaccination is resorted to solely or
mainly when small-pox threatens.
In Madagascar and Mauritius small-pox is probably not
endemic, but at times has been imported from the African
1

Kolb.

2

A. R. Cook, Journ. Trop. Med. June 1, 1901.

SMALL-POX

423

continent and become seriously epidemic. In Madagascar it has
often in the past caused terrible epidemics, the outbreaks being
usually traceable to the importation of slaves from Africa. In
Mauritius it was epidemic in 1891, and on two previous occasions
in the 19th century.
North and Central America, The malady has been epidemic
in Greenland on at least four occasions in history. In Alaska it
carried off almost one-half of the population in 1838-39. As to
its behaviour in these northern regions in recent years I have no
information.
In Canada small-pox is met with, but has not been very active
in the last decade. In the province of Quebec the last severe
epidemic was in 1885-6, when almost the whole province, and
especially the city of Montreal, was ravaged by it. Since that date
occasional small outbreaks of the disease have occurred here and
there 1 . In Ontario the mean annual number of recorded cases
in the period 1882-86 was 128, in the next quinquennium it fell
to 16, and in that ending in 1891 to only 7. Ontario is by its
inland position largely sheltered from the importation by immigrants of small-pox and other diseases. In Manitoba imported
cases occasionally occur; and also in British Columbia, where in
1892 the disease caused a severe epidemic in the city of Victoria.
In the United States small-pox is now, thanks to vaccination
and other measures, a disease of much rarer occurrence than
formerly. In the year 1897 not a single death from it was
recorded in the cities and towns of the large majority of the
States, and from 1 to 5 cteaths only in each of the following:—
Alabama, Georgia, Massachusetts, Missouri, New Mexico, Ohio,
Pennsylvania, and Texas. In New York State the deaths numbered 28. In Massachusetts a limited outbreak occurred in
1893-4, but since then very few cases have been seen. In
Michigan the small-pox mortality has been extremely low since
1
An outbreak of this kind occurred in Quebec in 1895, and was entirely
traceable to the movements of one person—a young girl, with small-pox on her,
who fled across country, by train and boat, from Quebec to Carleton (county of
Bonaventure). A large number of persons with whom she came in contact either
caught the disease or carried it to others, with consequent local outbreaks in
many places. Her track was indeed marked by small-pox cases to the number
of 151, and deaths to the number of 32, occurring in 44 different houses.
Report of the Board of Health of the Prov. of Quebec, 1895-6.

424

SMALL-POX

the great epidemic year, 1872. At that time the United States
were suffering very severely from the pandemic of the disease
to which reference has already been made. In former years the
malady literally decimated many of the Indian tribes on the
North-American continent. At the present time it seems principally to attack the negro population. It 1898 it was very
prevalent among the negroes of Kentucky, and early in 1899
was widely epidemic in many of the southern States. In some
places what were called " shot-gun quarantines " were established
by the excited populace.
In Georgia and Ohio it was very
rife, Alabama is said to have been for long severely * affected,
while in other States the prevalence of the disease was traced
to importation from Cuba, where during the war it was terribly
active.
In Mexico the disease is common, particularly among the
Indians; it was very rife throughout the country in 1898. In
British Honduras it was epidemic on the last occasion in 1891.
In other Central American countries it has at times become
epidemic, especially attacking the Indian tribes.
In many of the West Indian Islands small-pox is far from
rare. In Cuba it is endemic, and during the recent troubles
prevailed in a malignant form and to a wide extent. In January,
1899, it was said that over 5000 cases of the disease were then
under treatment at Holguin, and many hundreds elsewhere. In
Jamaica it is at times epidemic; in Haiti it is spoken of as
endemic; in Trinidad outbreaks occur at intervals. In the Leeward Islands on the other hand, and in many other British West
Indian Islands, small-pox appears to have been quiescent or absent
in recent years. In Puerto Rico it was seriously epidemic in the
winter of 1898-9, but after the vigorous enforcement of vaccination
—over 800,000 persons being vaccinated in three months—the
disease completely disappeared.
South America. Along the northern coasts of South America
small-pox appears to be comparatively rare, and of milder type
than in some other countries. In the Guianas little mention of
the disease has been made in recent years. It has been absent
from British Guiana for many years, thanks to strict precautions
for preventing its importation. In Venezuela it was severely
epidemic in 1898 ; in Valencia alone, high up in the Cordilleras,
2000 cases occurred, with 600 deaths. In Brazil it has in times

SMALL-POX

425

past been very fatal, particularly to the coloured population. It
is still very rife among the negro inhabitants of the dirty, overcrowded portions of some Brazilian cities, such for example as
Bahia. In Uruguay it caused 96 deaths in 1897, which was
equivalent to about 120 per million inhabitants. In the Argentine
Republic it was epidemic in 1888, 1890, and 1891, and the mean
mortality from the disease in the Buenos Aires province in those
years was 470 per million inhabitants. In 1897 the recorded
deaths in the same province were 94 in number, of which 44
occurred in the northern region, 19 in the central, 30 in the
southern, a'nd 1 in the Patagonian region of the province. In
Chile small-pox has in the past caused very violent epidemics
among the Indian and coloured populations.
In Peru the disease is far from uncommon; in Callao a severe
epidemic occurred in 1891, causing 238 deaths, and in 1896
another caused a still higher mortality in that city, the deaths
numbering as many as 309.
F a c t o r s c o n c e r n e d in t h e G e o g r a p h i c a l D i s t r i b u t i o n .
Small-pox has occurred in almost all portions of the inhabited
globe. It has shown no regard for lines of latitude or isotherms,
and has been just as severe and widespread in the tropics and in
sub-arctic regions as in the temperate zones. It is true that in
recent times the disease has been little seen in some remote
northerly regions, as Iceland, the Faroe Islands, and apparently
Greenland and the far north of North America; but this can in
no way be attributed to climatic conditions, for in the past it
has caused serious epidemics in each of the regions named.
Their recent immunity from the disease would appear to be
largely due to their remote position and rare intercourse with the
rest of the world—conditions which greatly lessen the risk of
chance importation of infection—while in Iceland and the Faroe
Islands, if not elsewhere, the practice of vaccination and precautions to prevent carriage of the infection to their shores have
had a large share in keeping the islands free from the disease.
The entire immunity from small-pox hitherto enjoyed by Tasmania, New Zealand, Fiji, Samoa, and some other islands in
the Pacific Ocean must be attributed in great part to the same
causes.
There is, however, no doubt that small-pox is to some extent
influenced by changes of temperatHre. This is shown by its

426

SMALL-POX

seasonal variations in countries where it is endemic or epidemic.
In almost all parts of the world the disease has shown greatest
activity in the cooler portion of the year. This has been observed
with remarkable uniformity not only in both the northern and
southern hemispheres, where, of course, the seasons are reversed,
but in tropical, subtropical, and temperate climates. In England,
for example, the small-pox curve is high from January to May,
and low in the summer. In India the disease is most prevalent
in the cool season, between January and April, but its prevalence
and its virulence are said to increase as the temperature rises,
and in some parts of the country the maximum occurs in the hot
month of May, or even in June. In Brazil the small-pox season
is in October, November, and December, or the spring months in
those latitudes, and in Chile it lasts during the winter and spring
(July to November). The same seasonal relation of small-pox is
observed in most European countries, in North America, in China,
in Tunisia,^ in Egypt and elsewhere. The recent serious outbreak
of the disease in London also fell in the winter months. On exceptional occasions, however, small-pox has been severely epidemic
in the summer.
Small-pox possesses a high degree of infectivity. When introduced into a community that has not been protected from its
attacks, either artificially by vaccination, or naturally by recent
prevalence of the malady, it is one of the most deadly of diseases,
and may give rise to the most fatal epidemics. Many historical
examples of this kind are on record. In the sixteenth century,
when the infection was carried to the New World, it attacked the
indigenous races with extraordinary violence and swept away
whole tribes in the West Indies, Mexico, Brazil, and Chile. In
more recent times it has been scarcely less disastrous to many of
the native tribes in Australia, Canada, and the United States, as
well as in Siberia.
Like measles, scarlet-fever, and other diseases, small-pox dies
out from small, isolated communities, where the supply of susceptible persons is not sufficient to keep the disease going, and
it may remain absent from such communities for a long period
until a fresh importation of infection occurs. This has been
the case in Iceland and the Faroes, in Mauritius, and elsewhere. In continental countries, on the other hand, it seems to
remain endemic, so long as there is a sufficiently numerous sus-

SMALL-POX

427

ceptible and unprotected population to keep up a succession of
cases. In such countries it is not equally prevalent in all years;
the disease is more active in some years, less in others. In most
civilised countries this behaviour of small-pox is now largely
obscured by the practice of vaccination; but it was clearly seen
in the centuries before vaccination was introduced. The records
of the disease in many countries in the 17th and 18th centuries
seem to show that it had a certain tendency to periodicity, its
activity waxing and waning every three or four years in some
countries, in others at longer intervals. This periodicity in
small-pox prevalence—as also in the case of scarlet-fever, diphtheria, and other diseases—has never been quite regular, the
intervals varying not a little in length. It is a phenomenon
worthy of attention, and one that has not yet been quite satisfactorily explained.
The virus of small-pox is mainly spread by the movements of
human beings. It can, however, exist for some time outside the
human body, whether attached to articles that have been near the
sick—as bedding, body-linen, or even the furniture of the sickroom—or in the air. It seems capable even o f being carried
considerable distances through the air without losing its virulence.
Attention was drawn to this mode of spread of small-pox—the
possibility of which many had vaguely surmised before—by the
investigations of Mr Power, of the Medical Department of the
Local Government Board, in 1882 and subsequent years. Certain
small-pox hospitals were taken as centres, and careful plans of the
neighbourhood being prepared, concentric circles were drawn on
the plans at distances representing one-quarter, one-half, threequarters, and one mile from the hospital respectively. The number
of small-pox cases occurring during fixed periods in each of these
concentric areas was then determined, and it was found that they
diminished regularly from within outwards. The conclusion drawn
was that the hospital must have acted as a centre, from which the
infection had been carried by the air and had been the cause of
the large number of cases in its vicinity. Accepting this view it
would seem that the virus of small-pox can be wafted through the
air over a distance of some half-a-mile or more and still retain its
vitality. The conclusion was further supported by an inquiry into
the frequency of small-pox in certain parts of London, respectively before and after the opening of small-pox hospitals in their

428

SMALL-POX

neighbourhood. It was found that the disease had become considerably more prevalent in these localities after the hospitals had
been opened than it had been before. The recent epidemic
of small-pox in London seems to have furnished still further
confirmatory evidence on this point, and to have shown that the
virus of the disease was carried from the small-pox ships on the
Thames over nearly half a mile of water to the Essex shores,
where it accounted for a large number of cases. This aerial
diffusion of the infection is believed, however, to take place only
or mainly when a number of acute cases are aggregated together,
and perhaps only under certain—as yet undefined—atmospheric
conditions. While the theory of the aerial convection of smallpox has been contested by some observers, it is now generally
accepted, and has led to the practice of removing small-pox
patients either to land-hospitals in sparsely inhabited districts,
outside the limits of large towns, or, as in London, to floating
hospitals. It has further shown that even this measure is not
without its dangers, and that it will not adequately control the
disease unless supplemented by general vaccination and revaccination of the surrounding population.
Small-pox is the most striking example of a disease which can
to a very great extent be kept in check by prophylactic measures.
The adoption of universal compulsory vaccination and re-vaccination—an ideal not yet even approximately attained in any country
with the exception of Germany—would, there is good reason to
believe, exterminate the disease altogether. The partial measure
of more or less general, and more or less compulsory vaccination
with occasional resort to re-vaccination, which is in vogue in most
civilised countries, has already succeeded in diminishing the
prevalence of the disorder to an extent that can with difficulty
be realised by those who have not studied its history. It
would be out of place here to enter fully into the whole
question of vaccination—recently the subject of so much controversy—or to add unnecessarily to the already enormous bulk
of literature upon this subject. It must suffice to state that at
the present day no single group of factors is of such importance
in determining the distribution of small-pox over the earth's
surface as the presence or absence, the efficiency or inefficiency,
of general vaccination and re-vaccination. For it is now clearly
established that inefficient vaccination, and vaccination in infancy

SMALL-POX

429

only, do not render the vaccinated person immune to the disease
for life.
Innumerable illustrations of this statement have been already
brought forward in this chapter. In few European countries, for
example, are vaccination and re-vaccination so thoroughly carried
out as in Germany, and in few countries is small-pox so rare. In
Russia, in Austria, in Spain and Portugal, where both are largely
neglected, small-pox is constantly present. In Arabia, in China,
in Central and parts of Southern Africa, where vaccination is
practically unknown, the disease is extremely rife. Nor is the
difference less striking when lesser units are taken; and the
incidence of small-pox on different communities in a given country
is found to vary inversely with the extent to which vaccination is
practised amongst them. Two recent examples will suffice to
illustrate this fact. In Tunis serious epidemics of small-pox
occurred in 1888 and in 1894. The population consisted of some
100,000 Arabs, entirely unvaccinated, 30,000 Europeans, among
whom vaccination was practised but neglected, and 30,000 Jews,
spoken of as " well-vaccinated " as a community. In the first of
the two epidemics mentioned, out of 1645 deaths from small-pox,
1384 occurred in Arabs, 160 in Europeans, and 101 in Jews;
and in the second, of 870 deaths, 712 occurred in Arabs, 128 in
Europeans, and only 30 in Jews 1 . The second example is even
more conclusive ; while small-pox raged among the unvaccinated
native population of Massowa, the well-vaccinated Italian troops
stationed there during the recent war in Erythraea escaped without a single case.
While vaccination is thus one of the leading factors in the
present day distribution of small-pox, it is not the only one.
When once a community or a country has succeeded in ridding
itself of the disease it can continue for long periods together more
or less free from it by strict precautions at its ports and frontiers
to prevent the importation of infection, and immediately to detect
and isolate any infected person arriving from outside. This has
been the case in recent years in some of the Canadian provinces,
where small-pox has occurred mainly in the form of imported
cases in Chinese or other immigrants; in Madagascar and
Mauritius, where the infection is always imported from the
La Tunisie, Histoire et Description.

Paris, 1896.

43o

SMALL-POX

African mainland; in Iceland, which has usually received the
infection from Denmark; in British Guiana, which has been
kept free from the disease for many years; and in the Faroes,
where no small-pox has now been seen for* nearly half a
century.
Whether the remarkable immunity from small-pox
which Fiji and the Samoan Islands are said to have enjoyed
up to the present is due to measures to prevent its importation
or to some other cause I am unable to say; but there seems
to be practically no doubt that the fact that New Zealand and
Tasmania have never had an indigenous case of the disease is
entirely the result of such measures. Cases of small-pox have,
it is said, been brought to their shores, but they have been
promptly dealt with, and the disease has not spread to others.
Small-pox has shown no definite relations to soil or to altitude
above sea-level. Few diseases are indeed more indifferent to all
external physical conditions than this. Race has possibly some
slight influence on its distribution. A high level of susceptibility
to the infection of small-pox seems to exist in most, if not all
races, but all observers agree that it is particularly high in the
African negro. This race, when negro slavery was practised, was
frequently the means of carrying small-pox from the Old to the
New World. They still suffer greatly from it and succumb to it
more easily than white men. The fact, already mentioned more
than once, that Fiji and the Samoan group have never been
invaded by small-pox, raises the question whether the inhabitants
of these islands possess any immunity from the disease. This
question does not yet appear to have received an answer.
The relation of small-pox prevalence to general insanitary
conditions has been the subject of much controversy. A low level
of general hygiene and public health administration undoubtedly
favours small-pox prevalence in many ways. Insanitary surroundings usually imply a diminished power of resistance in individuals
to the attacks of any infective disorder. Overcrowding greatly
favours the chances of the infection being transmitted from person
to person. These conditions, moreover, are constantly found
associated with a lack of the knowledge needed not only to
recognise the early cases, but to grasp the necessity of. at once
reporting and dealing with them when discovered. They are
often too, but by no means always, met with among classes of
the population who have failed to understand the value of vacci-

SMALL-POX

431

nation, or, through carelessness, inertia, or a fatal readiness to
accept the misguided teaching of those opposed to the measure,
have not had recourse to it.
Among general measures of public health administration, the
provision of good water-supplies and of drainage-systems, the
inspection of food-supplies and the like, have never been shown
to have any direct influence over small-pox diffusion. On the
other hand there are few diseases so directly amenable to certain
public health measures of another character. It has already been
shown that an administrative area can be kept free from small-pox
for long periods together by measures directed to prevent the
introduction of the infection from outside, and to isolate immediately any imported case. No small-pox-free community can
safely ignore a measure of this kind. But it requires to be
supplemented by others. Of these the most important is the
provision of means for general vaccination and re-vaccination, so
that even should the infection be imported—a contingency certain
to happen sooner or later—it will find a sterile soil and must
die out. Other measures are the construction in suitable places
of hospitals for the immediate isolation of an imported case;
arrangements for the prompt detection and removal of any person
suffering from the disease; and provision of means for the disinfection and destruction without delay of the infective material
in the patient and his surroundings. If these measures are of the
greatest importance in maintaining a freedom from small-pox in
communities already free from it, they are a fortiori of the first
necessity in endeavouring to get rid of the disease in a community
or a country where it is already established.

S Y P H I L I S AND O T H E R
DISEASES.

VENEREAL

General Characters and Etiology.
The group of
venereal diseases—syphilis in its various manifestations, gonorrhoea
and chancroids—may be most conveniently dealt with as a whole.
Though each is due to a distinct and separate cause—either
certainly or presumably a micro-organism—the means by which
they are spread and the social and other conditions which tend
to make them common or rare are practically the same for all,
and it would serve but little purpose from the view-point of
medical geography to deal with them separately.
It must at once be confessed that no materials exist for an
exact comparative study of the frequency of these diseases in different countries. With the exception of syphilis they are almost
never immediate causes of death, and consequently mortality
statistics are lacking for comparison; while even as regards
syphilis it is often rather a remote than an immediate cause of
death, so that the statistics of deaths registered as due to this
cause are of only approximate value. Moreover in many countries
where syphilis is extremely rife death registration is unknown.
It becomes necessary, therefore, for the most part to fall back
upon general statements, upon impressions derived from hospital
returns, or upon the observations of travellers in remote countries.
In general terms these diseases may be said to have an almost
world-wide distribution. But, as they are essentially of a preventable character, it is found that they are most common among
those nations and among those classes of society whose moral
views do not prevent promiscuous and uncontrolled sexual intercourse, and who are ignorant of the great infectivity of these
diseases and of the need of preventing their spread either by

SYPHILIS AND OTHER V E N E R E A L DISEASES

433

venereal or non-venereal means. Of these two means of spread
the former is of course the most usual and is perhaps the only
one among educated communities, but the latter is very frequently seen both among uncivilised and uneducated races, such
as the Chinese or the Russian peasantry, and among the lower
classes of most civilised nations.
H i s t o r y . Descriptions of diseases of the generative organs
associated with impure sexual intercourse are found in all times
of the world's history. - The Mosaic Law contained a large number
of provisions that seem almost certainly to have been directed to
the prevention of this class of diseases. In India and in China
they seem to have been known at very remote periods. But
while this group of maladies as a whole dates back to the earliest
times, much controversy has arisen over the question whether
syphilis as now seen is of equal antiquity. Its origin, like that
of all other diseases, is quite unknown, and it is not until the
Middle Ages that the descriptions left us of diseases of the
generative organs can be positively affirmed to refer to this and
not to some other form of venereal affections. There can be no
doubt that at the end of the fifteenth century syphilis became
enormously more prevalent in Europe than it had been before,
and indeed it spread very much like an epidemic of some zymotic.
Hirsch, in summing up this branch of the subject, came to the
conclusion "that the venereal diseases had occurred in Europe,
and, so far as we know, also in various parts of Asia, from the
earliest times; that syphilis overran a large part of Europe towards the end of the fifteenth century in epidemic-like diffusion,
when it attracted the general attention of the profession for the
first time and was first recognised by its peculiar features; that
after the extinction of that epidemic, which lasted about thirty
years, the disease fell again to its former level; that it was imported from Europe to other parts of the globe as a consequence
of commerce between countries; but that even at the present day
there are some places, remote from the general stream of traffic,
which it has not reached." The truth of these statements will be
illustrated in the following pages, wrhere mention will also be made
of some epidemics of syphilis later than that of the fifteenth century.
R e c e n t Geographical D i s t r i b u t i o n . Europe. Throughout Europe these diseases are found with very varying degrees of
frequency and severity. In the British Isles they are common
c.
28

434

SYPHILIS AND OTHER VENEREAL DISEASES

enough, but the deaths attributed to syphilis have slightly declined
within the last decade.
In France venereal diseases are found principally in the larger
towns, where, however, a system of control of prostitutes and
houses for immoral purposes tends to restrict their spread.
Germany is believed to be rather more free from venereal
diseases than any other European country, but the statement
must be accepted with caution. In Denmark, Norway, and
Sweden they are very widely spread, and in Norway at least
the deaths from syphilis have slightly increased in recent years.
In Lapland this disease is rare. In Russia, on the other hand,
syphilis and venereal diseases are extremely prevalent, and
constitute in many parts of the country a veritable scourge.
From returns recently published 1 it appears that in the years
1889-94 the proportion of population in the different "governments" of European Russia treated for syphilis varied between
700 and 10,300 per million inhabitants, while the proportion
treated for other venereal disorders varied between 420 and
4270 per million. The figures are only approximate, and are
probably much below the truth, and it is certain that in some
districts a very large percentage of the peasantry are syphilitic.
There is no portion of European Russia free from this disease.
It is met with in the extreme north in the government of
Archangel, and in the extreme south along the shores of the
Black Sea. It is common in Poland, on the banks of the Volga
and among the Cossacks of the Don Territory. It is somewhat
less common in Finland. In recent years there has been a steady
increase in the number of reported cases of syphilis in Russia.
In Southern Europe these diseases are widely prevalent. In
Spain they are said to be exceedingly common, but somewhat less
so in Portugal. In Italy they appear to be about as frequent as
in the British Isles; the mortality from syphilis in the peninsula
has varied from 64 to 78 per million living in the years 1887-96,
while in England and Wales it has ranged over very much the
same limits. In the Balkan countries venereal diseases are very
common. Lombard states that in Roumania almost the entire
population is infected with syphilis, but the statement is probably
1
Report of the Conference on Syphilis•, held in St Petersburg by Imperial
command in 1897. St Petersburg, 1897. (In Russian.)

SYPHILIS AND O T H E R VENEREAL DISEASES

435

exaggerated. In Turkey in Europe these diseases are very prevalent. They are largely distributed by soldiers and others returning
from the capital to their homes, and in this and other ways syphilis
has been carried from Constantinople to all parts both of Turkey
in Europe and Asia Minor. In Montenegro syphilis is not rare;
it is said to have been imported by Montenegrin emigrants returning from Constantinople or from more western capitals, where they
have contracted the disease.
In many parts of Greece all disorders of this class are very
prevalent, and in the northern part of the country a form of
syphilis of the most inveterate kind is met with, which is locally
known as spirokolon.
In Iceland and the Faroes syphilis and other venereal diseases
are exceedingly rare, owing, it is said, to the moral habits of the
islanders rather than to the rigours of the climate.
Asia, Throughout the Caucasus and Transcaucasia venereal
diseases are widely prevalent, but if we may judge from the
returns of a single hospital (that at Tiflis) it would seem that
the Russian inhabitants are more affected than the native races.
In the country to the north of the Caspian Sea, in the valley
of the Ural river, and among the Bashkir and other Tatar tribes
on the borders of European and Asiatic Russia, syphilis appears
to be comparatively rare. It was at one time more prevalent
than now among these races, but at present it seems to be mainly
introduced to the steppes by the younger members of the community returning from Russian towns visited by them. The
Bashkirs have a high reputation for sexual morality, and prostitution is said to be unknown amongst them 1 .
Among the
Kirghiz hordes syphilis is almost unknown and for similar
reasons 2 .
From Central Asiatic Russia and Siberia the information as
to the prevalence of these diseases is far from full or trustworthy,
but it indicates that they are more or less common throughout.
They are not, however, universal, and the returns from a considerable number of gold-mines and other mines in the Yakutsk
government, in the Amur and Transbaikal provinces, and elsewhere, show a comparatively small proportion of syphilitics among
1

Nikolski.
Matzkevitch, The Kirghiz Steppes of the Turgai Province in the Cholera
Epidemic-of"1892. St Petersburg, 1893. (In Russian.)
2

28—2

436

SYPHILIS AND OTHER VENEREAL DISEASES

the persons employed in them. From two mines in the Kirghiz
steppes of Semipalatinsk and Semiretchinsk information is forthcoming that not a case of venereal disease of any kind had been
met with there during the course of five years (i 889-1893). Some
of the aboriginal Siberian inhabitants, such as the Samoyeds,
Yakuts, Tunguses, and Buriats, are on the other hand said to be
seriously infected with syphilis. In Central Asia this disease is
also extremely rife in parts. It ^is found everywhere in Bokhara,
and in consequence of the entire absence of treatment the most
horribly severe forms of the malady are met with—forms that are
said to be unknown in more civilised countries \
Throughout Asia Minor and Syria syphilis is met with, and in
many parts of Armenia it is exceedingly common. The great
extent and severity of the disease in Asia Minor have attracted
much attention, and a systematic attempt to bring it under control
has recently been made by Prof, von During under the auspices of
the Sultan. In Arabia it is spoken of as " frightfully common,"
and it is probably by no means rare in Persia. At Basra, at
the head of the Persian Gulf, it is a frequent disorder.
Venereal diseases are met with with great frequency almost
throughout the Indian peninsula, and certain parts of the country
are notorious for the amount of syphilis and other diseases of the
class among the inhabitants. In Kashmir, for example, syphilis is
the greatest scourge of the country. The majority of the tribes
living on the southern slopes of the Himalayas are more or
less deeply infected with it. Carleton 2 states that, as the result
of "careful and extensive inquiries," he believes that not five
per cent, of the population in the Simla Division have escaped
infection; and this extremely serious spread of the disease has all
occurred within the last thirty years. Many of the villages in the
Hindu-Khush are also largely infected by syphilis, although other
forms of venereal disease are said to be comparatively rare both
among the natives and among the troops stationed in that region.
In Rajputana all forms of venereal disease are very commonly met
with.
The frequency of this class of disorder among British troops
in India has long been notorious, and the enormous increase of
cases of the kind within recent years has justifiably given rise to
1
2

Grekof.
Transactions of the First Indian Medical Congress, 1894.

SYPHILIS AND OTHER VENEREAL DISEASES

437

no little alarm, and to a demand for more stringent preventive
measures than have hitherto been adopted. The increase in these
diseases, and especially in primary syphilis, which has been observed
in the British troops in India in the last thirty years is seen clearly
from the following table. The figures indicate cases per thousand
strength.
Year
1872

73
74
75
76
77
78
79

Primary
Syphilis
6l*2

Total Venereal
Disease

52*4

1667

68*3
67*1
59'8

192*7
205*1
189*9
208*5

65*2

95'3
79-2

80

87*9

81

92

82

87*6

83
84
85

87-2
90*2
122*1

179

27i*3
234*8
249*7
260*5
265*2
270*3

*9.V9
342 7 1

Year
1886

87
88
89
90
9i
92

93
94
95
96
97
98
99

Primary
Syphilis

'57'9
142*1
142*1
225*1
2207
159*2
161*1
213*6
248*1
239

226*4
201 *7

—
—

Total Venereal
Disease

389V
3 6l*2

370*6
481*5

533*5
400*7
409*9

466

s 11 ^
5^2*3
511*6

4857 2
362*9
3!3*4

From these figures it will be seen that while the invalidings
for venereal diseases of all kinds had nearly trebled in number
in this period, those for primary syphilis alone were nearly four
times as numerous in the later years of the period as they were in
the earlier. Since 1895 a marked fall has set in. This fall is
thought to be "partly unreal 7 ' and due to treating more of the
men as out-patients, and " partly real" and the result of certain
judicious measures of prevention.
The native troops in India are much less severely affected by
these diseases, and the annual number of cases among them
since the year 1877 has varied between the extremes of 26 and
41 per thousand. The ratio has been remarkably steady, and the
increase just referred to as observed among the British troops was
not accompanied by a similar increase in the native army.
1

Including troops on active service in Burma.
This reduction was then considered more apparent than real, as among
troops in cantonments the ratio was 507 *8, and the lower figure was obtained
by including troops on active service. The figures of the next two years,
however, show that there has been a very real diminution.
2

43^

SYPHILIS AND OTHER VENEREAL DISEASES

In Ceylon syphilis appears to be much less common than on
the Indian mainland. Many of the East Indian Islands are, on
the other hand, very seriously affected by this and other forms of
venereal disease. Thus in Borneo, according to Nieuwenhuis,
syphilis prevails to a terrible extent and "causes ravages in
individuals and in tribes in a way that Europe has no idea of."
Gonorrhoea, too, is excessively frequent in the island, and often
assumes alarmingly severe forms. In Java, on the contrary,
syphilis is said to be rare. The Indo-Dutch army, both native
and European, suffers considerably from venereal diseases, and
it is noteworthy that here, as in British India, these maladies
have become much more common in recent years among European
troops than formerly, while in the natives they have remained
stationary.
Throughout the countries of the south-eastern corner of the
Asiatic continent venereal diseases are excessively rife. In Singapore and the Straits Settlements syphilis is one of the commonest
of maladies, and the venereal group as a whole accounts for more
admissions to hospital than any other group of diseases. They
appear to be on the increase 1 . At Saigon, in French Cochin
China, syphilis gives rise to more than one-fifth of the total
admissions to hospital (Davidson). In Siam and among the Laos
it is extremely prevalent, and in Tongking it is not only prevalent
but is said to be increasingly so.
From all parts of China come reports of the extreme frequency
of both syphilis and gonorrhoea. Soft chancres are, perhaps, not
very frequent here, one observer at least regarding them as of less
common occurrence than in his own country, the United States 2 .
But of the terrible prevalence of the other forms of venereal
disease in China there can be no question. No attempt is made
to control them, and many writers speak of the disgusting carelessness with which they are allowed to spread by venereal and
non-venereal channels, while no effort is made to conceal their
existence from the eye of the passer-by or to treat them in the
individual. In many places a high proportion of the total population is syphilitic; and in Pakhoi, according to one writer, who
is perhaps not to be taken quite literally, the entire population is
1

Medical Report for the Straits Settlements for 1898.
The Chinese, their Present and Future, Medical, Political, and Social.
By R. Coltman, Junior, M.D., 1891.
2

SYPHILIS AND O T H E R V E N E R E A L DISEASES

439

syphilised1. Corea seems to be no less deeply ravaged by syphilis
than China, and soft sores are spoken of as common. In Japan
the disease is also very widely prevalent, and it is said to be the
principal scourge of the great middle class of the population 2 .
Australasia.
Syphilis is common enough in the Philippine
Islands, both among natives and Europeans. In New Guinea
venereal diseases have been introduced on several occasions, but
usually in the less severe forms. Quite recently there was a fresh
introduction of syphilis in Murua, and the infection has spread
rapidly. Sir William MacGregor states that the effect of these
diseases on the inhabitants of New Guinea from the Solomon
and New Hebrides Islands is often disastrous, while among the
autochthones, on the other hand, the disease does not seem so
far to have assumed the same malignant type. From other sources
it may be gathered that syphilis is a very frequent disease in some
of the Solomon Islands, especially in those, such as Ugi, which
have much intercourse with the. outside world 3 ; but in the New
Hebrides it seems that venereal disease is not common, and
one observer saw cases there in the white inhabitants only4. •
Australia appears to be comparatively free from the class of
disorders now under consideration; as a cause of death, at least,
syphilis may be regarded as an insignificant disease, so far as
the white population is concerned. Among the aboriginal inhabitants, however, the story is a very different one, and the malady,
once unknown in the island before the advent of the European, has
played no small part in the extermination of the native population,
and is still frequent among them. In New Zealand venereal
diseases are as rare as in Australia.
. Africa. Syphilis is widely distributed in Egypt and the Sudan.
It is found in all parts of the Nile Valley, and British troops
stationed in the country are more tainted by it than at home.
Among the Baggaras, now a scattered and shattered race, but a
few years ago the ruling people in the Sudan, venereal diseases
were rife to a terrible degree. Father Ohrwalder, who passed ten
1

Chinese Customs Medical Reports. No. 45.
Archives of Surgery, 1898, p. 380.
3
The Solomon Islands and their Natives. By H. B. Guppy, M.B., F.R.G.S.
London, 1887.
4
"Notes sur les Nouvelles Hebrides," par le Dr Bernal. Arch, de Med.
Navalef Aug. 1899.
2

440

SYPHILIS AND OTHER VENEREAL DISEASES

years of captivity in the Mahdi's camp, has given a graphic picture
of the ravages of these maladies in the Baggaras and their slaves.
" T h e immorality of the slaves," he writes, "is quite beyond
description, but it cannot be the fault of the unfortunate creatures
themselves, for in their own savage homes it is not so. They
learn all the vices of their masters, and indeed are forced to
participate in them or submit to a flogging; consequently disease
of the most loathsome kind is everywhere prevalent, and to be free
from it is thought to be the mark of a poor creature....At first the
Baggara were not affected to any large extent; but contact with
the inhabitants of the Nile valley has communicated the pest,
which is now eating into the constitution of this, the most
powerful and warlike tribe in the Sudan." Things have changed
greatly since those words were written, and " the most powerful
and warlike tribe in the Sudan" is such no longer.
In Tunis and Algeria syphilis and other venereal diseases are
far from rare. In Algeria soft chancres are remarkably common,
and the French troops stationed there suffer more from this
affection than French troops in any other part of the world1.
Syphilis has also been exceedingly widely prevalent since the
French occupation. Throughout Morocco syphilis of a malignant
type is widely met with, and there can be little doubt that the
population of the greater part of the West Coast of Africa is
seriously infected by this and other venereal diseases. In Senegal
very virulent types of these disorders are common. In Sierra
Leone and Lagos many cases of the kind are annually treated in
the hospitals. Among the natives of the Gold Coast Colony
" one of the gravest features " it is said, in regard to the principal
diseases from which they suffer, " is the prevalence of untreated
syphilis." These people refuse to submit to the lengthened course
of treatment required for its control, and consequently the disease
is practically left untreated, with the result that a large proportion
of the population are seriously crippled and the economic loss to
the colony is considerable. Here, as elsewhere among ignorant
races, the malady is spread largely by non-venereal means. In the
Cameroon district, on the other hand, syphilis is said to be very
rare, and was at one time quite unknown.
In the Belgian Congo this disease has apparently been imported
by European and Arab intruders, the aboriginal inhabitants having
1
Brault.

SYPHILIS AND OTHER VENEREAL DISEASES

441-

formerly been quite free from it1. Syphilis is spoken of as rare in
German Central Africa, while gonorrhoea, on the other hand, is
extraordinarily prevalent there.
On the eastern side of the African continent venereal diseases
are widely met with. One of the principal centres of syphilis here
is found in Nubia, whence it has been spread by soldiers to the
country bordering the northern lakes 2 . In Abyssinia the disease
is universally existent. The natives of Uganda and of Manyuema
also surfer greatly. In the southern lake region syphilis appears
to have been formerly little known, but it has increased of late
years owing to more frequent communication with the coast 3 .
On the upper and middle Zambesi, on the other hand, syphilis
is said to be rare, and in British East Africa it is exceedingly rare in the interior, though not uncommonly seen on the
coast. Gonorrhoea is, on the other hand, frequently seen in this
possession4. In Zanzibar syphilis is or was excessively common;
and one author, writing some years ago, even went so far as
to assert that five-sixths of the population were probably syphilitic5.
Venereal diseases of all kinds are excessively widely spread
throughout South Africa. In Cape Colony syphilis is a common
disorder; the natives surfer greatly from its ravages, and in some
districts, as for example that of Molteno, it is said to be distinctly
increasing. Similarly reports from Prieska, from the Durban
Hospital, from Mafeking, and from Mount Frere for the year
1898 spoke of a serious degree of prevalence of syphilis among
both the native and the white populations there, and in most of
these places it was becoming more, rather than less prevalent. In
the large native locations in the Vryburg district the disease was
also described in the year preceding the outbreak of the war as
excessively common. So also in the native territories of Tembuland, the Transkei, and Pondoland syphilis was then very widely
met with, and no measures could be enforced to check its spread.
In Namaqualand the natives suffered considerably from the same
disorder, but gonorrhoea seems to have been rare. In Bechuanaland syphilis is, or was, no less frequent, and in Basutoland—
1
Congres Nat. d'Hygiene et de Climatologie Medicale de la Belgique et du
Congo, 1897. Comptes Rendus.
2
4
Davidson.
* Ibid.
Kolb.
5
Lostalot-Bachoue (1876), quoted by Hirsch.

442

SYPHILIS AND OTHER V E N E R E A L DISEASES

where, as generally in South Africa, the disease is known by the
name of mocaula—it was said to be "extremely prevalent."
Among the native populations of South Africa this group of
diseases appears to be spread to a very great extent by nonvenereal methods.
In Mauritius syphilis is far from rare, and the Indian population in particular is said to suffer considerably from its ravages.
America. Little is known with accuracy in regard to the
degree to which these diseases prevail in the far north of the
American continent. In Greenland syphilis is said to be unknown, in spite of the visits of whaling- vessels and the existence
of prostitution. In Sitka, Alaska, and in the Aleutian Islands, on
the other hand, the disease is by no means rare. Whether in the
more temperate provinces of Canada it is common or rare I have
no data for determining. This and other venereal diseases find
occasional mention in the Health Reports from most of the
Canadian provinces, and neither the colonists nor the native
population are quite free from them. Syphilis was at one time,
and is perhaps still, very common and malignant among the
natives in British Columbia and Vancouver Island, and to a less
extent in Ontario. The " Ottawa disease " described by Stratton
in 1849 a s affecting the Indians on the banks of the Grand River,
Lake Erie, is believed to have been syphilis.
In regard to the degree of frequency or infrequency of these
diseases in the United States of America I have also no accurate
data at hand All writers are, however, agreed that venereal
diseases, and especially syphilis, have in the recent past ravaged
to a terrible extent the native Indian population of the States.
As among the aboriginal tribes of Africa, so among those of North
America, syphilis was unknown before the coming of the white
man, but once introduced amongst them it spread like an
epidemic, and has no doubt been an important factor in the
gradual disappearance of these peoples before the advance of
so-called civilisation.
In the Southern States the infection
appears to have been introduced among the native tribes from
Mexico, and the various tribes suffered in proportion as they
held intercourse with the Mexicans. In California the opening
of the gold-fields led to a serious diffusion of the disease.
Mexico itself is, or was some decades ago, one of the most
intense centres of syphilis in the Western hemisphere. In the

SYPHILIS AND O T H E R VENEREAL DISEASES

443

Central American States also the disease was widely spread; but
in British Honduras at least syphilis is at the present day not at
all common.
In the various islands of the West Indies, to judge from recent
Health Reports, syphilis is common in some, less so in others,
but is probably not entirely absent from any. In Jamaica it is
very prevalent and appears to be increasingly s o ; the same
statement holds good for St Vincent, and apparently for most of
the Leeward Islands. In the Virgin Islands, however, syphilis is
said to be rare.
The northern regions of the South American continent are
not a little affected by syphilis. In British Guiana 1 primary
venereal sores are said to be greatly on the increase; and all
races are reported to suffer alike. In Dutch Guiana, however,
syphilis is not frequent and is generally benign, " except among
the negroes in the forests, amongst whom it is more common
and severe." But it is in Brazil that the most serious prevalence
of this disease is met with, and it seems doubtful whether any
other country in the world, with the possible exception of Mexico,
is so deeply infected by it. The low state of morals, the indulgence in vices of an indescribable character, and the general
ignorance and carelessness of the people are mainly responsible
for this extraordinary prevalence of syphilis. The disease is met
with in some of its worst forms, and the mortality it causes is
excessively high.
The remaining South American States are apparently little less
ravaged than Brazil by this and other venereal diseases. In Chile,
Bolivia, and Peru, in Paraguay and the Argentine Republic,
syphilis is, or was within quite recent times, prevalent to a truly
terrible extent; and, if reports from these countries are not
exaggerated, it must be accepted that South America as a whole
is incomparably more deeply ravaged by this disease than any
other continent.

Factors concerned in the Geographical Distribut i o n . It will be seen from this rapid review of the distribution
of venereal disorders that they are found in almost all parts of
the world. While this statement is true of the group of diseases
as a whole, it seems to be no less true of the most important
Report of the Surgeon-General for 1898-99.

444

SYPHILIS AND OTHER VENEREAL DISEASES

member of the group. Almost the only regions on the earth's
surface where syphilis has not been seen are Greenland, and
certain remote parts of North and South America and South
Africa, inhabited by tribes who have had little or no intercourse
with the rest of the world.
Syphilis has shown itself to be quite regardless of lines of
latitude or isotherms. Its absence or rarity in such northerly
latitudes as those of Greenland and Iceland cannot be attributed
to distance from the equator, for it has been exceedingly rife in
Alaska, British Columbia, and Vancouver Island. It has been
very generally thought that the type of the disease was more
severe in cold countries than in warm, but even this must be
doubted. Some of the worst forms of syphilis appear to be met
with in such countries as Bokhara, China, Brazil, Morocco, Senegal,
and Western Africa generally—all countries with warm or temperate
climates. The severity of the disease, indeed, seems to be less a
question of climate than of treatment. In all the countries just
named the cases among the native populations are left to a large
extent without any treatment at all, and hence they assume a
most malignant and virulent type, such as is rarely seen in more
civilised communities.
Altitude above sea-level has also apparently little or no
influence upon the distribution of these diseases. Racial conditions may possibly have something to do with the frequency
or infrequency of syphilis in a community, and the belief has
been expressed that the inhabitants of certain countries,—such
as those of Iceland, Newfoundland, Greenland, and Madagascar—
were relatively insusceptible to the malady. But it is questionable
whether its rarity in those countries is to be ascribed altogether
to racial causes, or whether it is not rather due to other factors,
among which—at least in some instances—a higher level of morals
and an absence of irregular and uncontrolled intercourse must be
granted some share. A study of the history of the disease also
shows that certain races have for a time remained remarkably free
from it, giving rise to the belief that they possessed a racial immunity, while subsequent events have shown that no such immunity
has existed. This, for example, has been the case in regard to the
natives of Bechuanaland, who thirty years ago were thought to
be relatively insusceptible to syphilis, but who are now seriously
ravaged by the disease.

SYPHILIS AND O T H E R VENEREAL DISEASES

445

It was pointed out in the beginning of this chapter that of the
origin and antiquity of syphilis nothing is known with certainty
save that it has probably existed from very remote times. At the
present day the disorder is generally associated with a certain
degree of civilisation. The history of recent centuries has shown
that it is not found among the aboriginal inhabitants of newly
explored countries, and that it has been invariably introduced by
the soldier, the trader, and the settler, who, while being the direct
means of importing the actual virus of the disease, have been too
often the indirect means of introducing those particular vices
which encourage its spread. In North America, in Brazil and
the other South American States, in Siberia, Australia, and
Africa, syphilis has been communicated to the native populations
by the white man, and in many instances has committed terrible
havoc amongst them. Of the many factors which taken together
lead to the gradual extermination of the more primitive races
when brought into contact with the more advanced, this disease
is probably one of the most important.
Venereal diseases are, as already stated, in their essence
controllable, and it has been proved over and over again that
their degree of prevalence can be lessened greatly by police
regulations and other measures. The outcry raised by a section
of the public at home over the enforcement of the Contagious
Diseases Act may have been based on a perfectly genuine and
legitimate sentiment, but it should not be allowed to blind the
eyes of even the most sensitive of purists to certain obvious facts.
It is an undeniable scientific fact that these diseases have always
been least prevalent where measures such as those prescribed by
the Acts in question have been stringently enforced, and most so
where such measures have been in abeyance.
If left uncontrolled by any kind of adequate precautions to
prevent its spreading, both by venereal and non-venereal channels,
syphilis may become so common a disease as to justify the use
of the term epidemic in regard to it. War with its unrestrained
license—when war was conducted on less humane and civilised
principles than it is at the present day—has been in the past the
most frequent and powerful cause of these so-called syphilis
"epidemics/' or "epidemo-endemics." A considerable number
of well-known historical examples of this occurrence have been
recorded. The Sibbens or Sivvens, SL form of syphilis which

446

SYPHILIS AND OTHER VENEREAL DISEASES

appeared in the south-western parts of Scotland in the middle
of the seventeenth century and later spread to the Highlands,
was apparently introduced to the country as the result of the
invasion by Cromwell's troops. The Radesyge^ an endemic
manifestation of syphilis which occurred in Norway early in
the eighteenth century, was carried to Sweden in 1762 by the
Swedish troops returning from the Seven Years' War; and later,
in 1790, syphilis was again imported to Sweden in like manner
at the end of the war in Finland. The syphiloids of Jutland,
Lithuania and Courland—endemic or epidemic outbreaks which
occurred in the latter half of the eighteenth century—were
attributed to the landing of Russian troops in those countries.
Similarly syphilis became endemic in Servia in 1810 and subsequent years, after the occupation of the country by RussoServian and Turkish troops; and the Russo-Turkish war of
1828-9 led to a wide spread of the disorder. But perhaps the
most striking example of this nature was the disastrous epidemic
of the disease through a great part of Europe in the fifteenth century, to which reference has already been made. " It was especially
Charles VIII's army of mercenaries," writes Hirsch in relation
to this event, "returning from Italy, relaxed by licentiousness,
broken up into lawless bands and overrunning France, Switzerland,
the Netherlands and Germany, which carried with them, as we
are expressly told by many medical writers and chroniclers of the
time, the germs of syphilis over the whole country, wherever an
adventurous life led them."
But syphilis is also at times spread on a large scale by the
movements of bodies of men other than troops, and in times of
peace. The well-known Dithmarschen or Holstein disease, which
was a very severe endemo-epidemic of syphilis lasting from the
latter half of the eighteenth century well on to the middle of
the nineteenth, was certainly spread and was perhaps originated
in this manner. It was at any rate associated at its origin with
the arrival of a large number of foreign navvies, especially from
East Friesland, who flocked into the Suder-Dithmarschen for the
work of embanking the Crown Prince Dyke. In exactly the same
manner in Russia at the present day, fewr things aid more in the
spread of syphilis than the movements of bodies of labourers who
annually leave their homes to find work in other parts of the
country, and on returning bring the infection of syphilis with them.

T E T A N U S AND T R I S M U S
NEONATORUM.
General C h a r a c t e r s a n d E t i o l o g y . The clinical features
of an attack of tetanus are too familiar to need description here.
The disease may be "idiopathic" or it may follow on injury. In
all cases it must be supposed that some solution of continuity of
the skin exists, and that the tetanus bacillus gains access to the
tissues by this means. The specific causal relation of this bacillus
to the disease has been finally proved. The bacillus exists
principally in the soil and in manure heaps, and hence tetanus is
particularly liable to occur in association with wounds that have
been contaminated with one or other of these materials. Puerperal
tetanus is occasionally seen after childbirth, and in newly-born
children tetanus or trismus neonatorum is by no means rare in
some countries. All forms of tetanus have become much rarer
since the introduction of antisepsis and asepsis in the treatment of
wounds and in midwifery.
The lower animals are liable to suffer from tetanus; the horse
is the most susceptible, but oxen and sheep have also been
attacked by it.
H i s t o r y . Tetanus was known to the earliest medical writers
from Hippocrates downwards. There is nothing to show that the
disease has varied in frequency or in its general geographical
distribution at different periods of the world's history.
The infective nature of the disease was first shown in 1884
by Carle and Rattone, who reproduced the symptoms in animals
by inoculation with the secretions of a wound in a tetanic patient.
Nicolaier, a year later, produced the disease in mice by inoculating
them with garden earth, and he observed the tetanus bacillus in
their tissues. Kitasato, in 1889, first succeeded in obtaining the
bacillus in pure culture.

448

TETANUS AND TRISMUS NEONATORUM

G e o g r a p h i c a l D i s t r i b u t i o n . Europe, In the temperate
countries of Europe tetanus is not a particularly common disorder.
In the British Isles it is only occasionally seen. Trismus neonatorum was at one time extraordinarily frequent in St Kilda, in the
western Hebrides, but is said to have been brought to an end
since a trained nurse was sent to the island to teach the midwives
to apply antiseptics to the navels of young infants. It is noteworthy
that this form of tetanus is said to be quite unknown in the
Faroes, while in Iceland, on the other hand, it is, or was some ;
decades ago, most disastrously prevalent and fatal. Traumatic
and idiopathic tetanus would, on the whole, appear to be somewhat
more frequent in southern Europe than in the north. In Russia
the public health returns seem to indicate that the disease is
remarkably infrequent in all the European provinces. In Italy it
is commoner, and causes an annual mortality of from 20 to 35
per million. The tetanus of infants is comparatively frequent in
Italy, and in former times it was very common in some parts of
Spain and in the Balearic Isles. Tetanus occurs in Turkey, but
with no very striking frequency.
Asia. The returns from the Caucasus, Central Asia, and
Siberia, if trustworthy, would show that tetanus was a very rare
disorder in all these regions. But, as has been repeatedly pointed
out before, the statistics from these parts of the Russian Empire
are too imperfect to be taken as the basis of any final conclusion.
In Arabia and Syria tetanus is said to be common. It is much
more frequent also in India and in Ceylon than in most European
countries, though its degree of prevalence varies considerably in
different parts of the Indian peninsula. Cases of the disease are
not infrequent in the Singapore prisons. In the East Indies and
in Cochin China, on the other hand, it does not seem to be a
particularly common disorder.
Australasia.
Regarding Australia information seems to be
lacking, but in some of the Pacific Islands, as for example New
Caledonia, tetanus is said to be remarkably frequent. Trismus
neonatorum is a common cause of death in many of the islands.
Africa. In Egypt tetanus is a common disease. In Algeria
it is particularly frequent in the provinces of Oran and Constantine.
Senegambia is spoken of as one of its principal seats, and certainly
in the colonial hospitals both of the Gambia and of Lagos a considerable number of cases of the disease are yearly seen. In the

T E T A N U S AND TRISMUS NEONATORUM

449

Cameroon territory, however, Plehn states that he never saw a
case. At the Cape tetanus is said to be decidedly common, and
in Madagascar and Mauritius it seems to be particularly frequent.
In the latter island about two-thirds of the deaths ascribed to
tetanus are due to trismus neonatorum.
America. Tetanus does not seem to be a very common
disorder in Canada nor in the northern United States. But in
some of the Southern States, and also in Mexico, Central America,
and some of the West Indies it is peculiarly rife. Thus in British
Honduras it is said to be exceedingly frequent, and here, as
elsewhere, its frequency is ascribed to the great amount of soil
pollution by stable manure 1 . In Guatemala also it is the cause
of a considerable mortality.
But it is in some of the West Indies that this disease attains
its highest degree of prevalence. In Cuba it is extraordinarily
common, and the utmost care is needed in treating wounds to
prevent tetanus supervening. The same appears to be true for
San Domingo, Jamaica, and many of the other islands. In Barbados a remarkable epidemic of tetanus occurred in the General
Hospital, between March and June, 1897. In some of the islands,
however—St Lucia and Trinidad—the disease is rarer.
In British Guiana and generally in the tropical portions of
Brazil, the Argentine Republic, Peru and Ecuador, tetanus is
exceedingly prevalent; while trismus neonatorum accounts for an
enormously high mortality.
F a c t o r s c o n c e r n e d in t h e D i s t r i b u t i o n . Tetanus, it
will be seen, is very much more often met with in tropical and
subtropical countries than in the more temperate zones. This
may perhaps be explained by the conditions being more favourable
in a hot than in a cold climate for the growth and multiplication
of the tetanus bacillus in the soil, this bacillus being essentially
a saprophytic organism. The absence or scantiness of the clothing
worn by the natives of tropical countries, their habit of going about
bare-footed, and their frequent neglect to cover up or treat skin
abrasions, ulcers, or injuries, may also be held to account for their
greater liability to the disorder.
Any skin discontinuity, however small, may suffice for the
entrance of the bacillus to the tissues. Some have believed that
1

c.

Report of the Colonial Surgeon for 1898.
29

4SO

T E T A N U S AND TRISMUS

NEONATORUM

chill alone, without any skin abrasion, suffices to bring on an
attack, but this view can scarcely be held now. The abrasion may
be merely the prick of a thorn, or the bite of a mosquito. In
newly-born infants the site of entry of the bacillus is probably
usually at the navel, during the separation of the stump of the
umbilical cord. Whatever may be the nature of the abrasion, the
more it is exposed to the chance of dust, soil, or manure gaining
access to it, the greater is the chance of an attack of tetanus.
Hence, as already stated, ordinary tetanus, trismus neonatorum,
and puerperal tetanus have diminished greatly wherever the
principles of asepsis, whether in surgery or midwifery, have been
understood and applied. Hence, also, in all probability the
frequency of infantile trismus in some cold countries, such as
Iceland, in reversal of the general rule in regard to the tetanus
of adults, which, as just stated, is most common in hot latitudes.
It is probable that wherever the tetanus bacillus exists, if infants
are not kept scrupulously clean, or are allowed to roll about on
the dirty floors of crowded and insanitary huts, trismus neonatorum will be a common disease. Its absence from the Faroes is
remarkable, and it would be interesting to know whether the
tetanus bacillus exists in the soil of those islands.
Of all races the negro is said to be most susceptible to tetanus.
In the tropics the natives suffer much more than the European
residents; and this is particularly true in regard to infantile
trismus. But whether this is due to a real racial difference in
susceptibility, or whether it is caused by the greater exposure of
natives to the risk of soil-contamination of wounds, is open to
question.

TUBERCLE.
General C h a r a c t e r s a n d E t i o l o g y . The large group of
diseases to which the term tubercular is applied has a distribution
little short of world-wide. In this respect it is equalled or perhaps
even surpassed by some other diseases, but in the enormous sum
of human mortality to which it gives rise this class of disorder
stands without a rival. In many countries it is quite common to
find that one-twelfth or one-tenth of the deaths from all causes
are due to it, and in some smaller areas and communities the
proportion may rise to one-eighth, one-sixth, or even one-fifth.
While the manifestations of tubercular disease are very varied,
depending principally upon the organ or tissue primarily affected,
they are rightly treated as a single, etiologically distinct group,
for all are associated with the presence and action of a specific
bacillus, the bacillus tuberculosis of Koch. The principal forms
of disease usually included in statistical returns under the heading
of "tubercular" are pulmonary consumption or phthisis, tubercular meningitis, tabes mesenterica or abdominal tuberculosis,
and general disseminated tuberculosis. In a few countries the
figures for each form of the disease are available separately, in
others they are returned together in one total, while in others
again only the figures for pulmonary tuberculosis or phthisis are
to be obtained. In the following discussion of the geographical
distribution of these diseases all forms of tubercular affection are,
whenever possible, dealt with together, as neither facts nor figures
are available for a comparison of the distribution of each form
separately. It is scarcely necessary to add that in every case the
form of tubercular disease which contributes most largely to the
total sum of tubercular mortality at all ages is the pulmonary
form. Tubercular meningitis and tabes mesenterica, on the other
hand, are the most fatal forms of the disease in infancy.
29—2

452

TUBERCLE

H i s t o r y . It is believed that pulmonary consumption is one
of the oldest of known diseases. Mention of it is found in some
of the earliest of medical writings. It would seem to have become
commoner in most civilised countries in modern than in earlier
times, but the evidence on this point is very uncertain. Within
quite recent decades there is reason to believe that it has become
rather less frequent than it was half a century ago in some
European countries, while in others its prevalence has increased.
A diminution in phthisis has been observed in England and
Scotland, and in Prussia, Denmark, and Italy. In Russia, Ireland,
Wiirtemburg, and Norway the frequency of "consumption" appears
on the other hand to be on the increase. Outside Europe there
has been a slight decrease in the prevalence of the disease in
Queensland, and in some at least of the United States, as for
example, Massachusetts and Pennsylvania; while there has been
an increase in the colony of Victoria, in the Caucasus, among the
Bashkirs, in Greenland, and in some parts of Canada.
The history of other tubercular affections is practically unknown. The tubercle bacillus was first identified by Koch, who
published his discovery in 1882.
R e c e n t Geographical D i s t r i b u t i o n . Europe.
While
tubercular diseases are the cause of a very high degree of
mortality in the British Isles, it is some satisfaction to note
that the deaths due to them have of recent years become
distinctly fewer than formerly. During the twenty years ending
in 1890 the deaths under this heading in England and Wales
diminished by as many as 25 per cent., and the fall has been
steadily maintained since. But " consumption" and the other
forms of the disease produced by the action of the tubercle bacillus
are still excessively prevalent, and cause a total mortality which
in 1900 was no less than 1899 per million living. London
maintains an unenviable reputation for a high death-rate from
these causes, but they are found not less active in such rural
counties as Hampshire and Devonshire than in districts mainly
devoted to manufactures, such as Lancashire, Northumberland,
and South Wales. In Scotland the diminution in mortality from
these diseases has been less marked than south of the Border, and
the deaths they cause are still considerably over 2000 per million
inhabitants each year; while in Ireland, far from decreasing, tubercular affections are yearly causing a greater mortality^ Thus the

TUBERCLE

453

ratio in the sister isle rose from an average of 2600 per million in
the decade 1871-80, to one of 2700 in the next decade, and in
the years 1897-1900 it was not less than 2900.
Tubercular diseases are also excessively rife in France.
Statistics for the entire population a r c not available, but in the
towns they gave rise to a mortality which in the years 1887-90
was as high as 3480 per million living, and in 1898, though
somewhat lower, was still over 3400 per million. Of this total
pulmonary phthisis was responsible for over three-fourths. In
Belgium this group of affections causes a mortality exceeding that
produced by any other disease or group of diseases, and the same
would appear to be true of Holland 1 . In Germany tubercular
diseases are equally, or possibly more prevalent. In Prussia they
are perhaps more so than elsewhere, but in the last twenty years
the mortality from this cause has diminished considerably, while
in Wiirtemburg the figures, though showing a somewhat lower
degree of prevalence than in Prussia, have indicated an increase
rather than decrease of these diseases.
In Denmark tubercle seems to be less active as a cause of
death than in France or Germany; the deaths in the Danish
towns in the years 1892-97 have been less than 1800 per million
each year, and show a tendency to decrease. The great prevalence
of tubercle in Norway and Sweden is shown by the fact that in
the former the deaths from tubercular diseases of the lungs alone
account for 15 or 16 per cent, of the deaths from all causes, while
in the latter these diseases are particularly fatal. In Norway the
mortality from all forms of tubercular affections averages about
2300-2500 per annum, and appears to be increasing. Lapland,
on the other hand, is comparatively free from tubercular
disease.
Throughout European Russia tubercle is found with great
frequency. It is, perhaps, on the whole more prevalent in the
north than in the centre, and in the centre than in the south, but
it is most prevalent of all in the Baltic provinces. Recently
1
No useful statistics of the tubercular death-rate in Holland are available ;
the returns published in the Annuaire Statistique des Pays-Bas contain the
following three headings, each of which probably includes part of the mortality
from this group of diseases, viz:—"debility and phthisis," "laryngeal and
pulmonary phthisis, haemoptysis and diabetes," and finally "chronic diseases
of the respiratory organs."

TUBERCLE

454

published statistics indicate that it is increasing in most parts of
the country.
In Austria-Hungary this group of diseases appears to be more
fatal than in any other European country, pulmonary tubercle
alone causing a mortality rate of 3682 per million per annum in
the years 1887-93 in Austria proper, and one of 3008 in Hungary
(with Fiume) in the same period. In Switzerland these diseases
are less frequent, but the death-rate from phthisis in the Swiss
towns is by no means inconsiderable. The pure mountain air of
the Swiss Alps has long been known as peculiarly inimical to the
causes of " consumption " and peculiarly favourable to its treatment. Tubercle is said to be exceedingly common and fatal in
Spain and Portugal, while in Italy, though still very frequent, it
appears to be decreasing, the mortality from this cause having
recently fallen to less than 2000 per million. In the countries
of the Balkan peninsula pulmonary phthisis is one of the most
fatal of diseases. In Servia this variety of tubercular affection
alone caused a mortality of some 2400 per million in the years
1894-5. In European Turkey the mortality from this cause
among the poorer classes of the population is also very high; in
Constantinople itself, in Prevesa, and in other places tubercular
disorders are a greater cause of death than any other variety of
disease. In Montenegro, in spite of the mountainous nature of
the country, " consumption " is exceedingly common. So also in
Greece tuberculosis causes a high annual mortality, particularly
in the towns, but it becomes rather less prevalent and fatal as
the mountainous part of the country is approached 1 . I n . t h e
Greek prisons tubercle is extremely rife.
In the Faroe Islands it is a remarkable fact that pulmonary
phthisis appears to be almost unknown. Other forms of tubercular disease have been met with there in recent years, but it is
believed that these cases can be traced to the importation of the
germ in the meat of diseased Scotch or English cattle. Not less
remarkable is the comparative rarity of consumption in Iceland.
Asia. In Arabia tubercular diseases are common enough on
the coasts, though less so on the rocky table-lands in the interior.
At Medina " consumption" is said to be a prolific source of
death among the female population, and this is attributed to the
1

Reports of the 1st Pan- Hellenic Medical Congress, 1901.

TUBERCLE

455

custom of early marriage, and consequent early child-bearing,
which prevails there as in most Moslem countries. In many
parts of Syria and Asia Minor this class of disease is also very
prevalent and fatal, particularly on the plains, while in the higherlying districts it is less common. In Mitylene and in Rhodes
tubercular affections cause more deaths than any other form of
disease. Erzerum and the mountainous country in its neighbourhood are spoken of as remarkably free from them, though
when they do occur there they run a rapid course. The
same is to a great extent true of the mountainous parts of the
Caucasus, the flat plains of the Caucasus proper (the provinces of
Stavropol, of the Kuban and of the Terek) returning comparatively
high mortality-rates from tubercle, while in many parts of the
mountainous region of Transcaucasia the tubercular mortality is
exceedingly low. At one time (in the sixties) it was even believed
that the natives of these regions were quite free from these diseases;
and that they were very rare seems to be proved by the fact
that among the autopsies performed in a large hospital—that
at Kutais—in the years 1863-5 tubercle was found to be the
cause of death in but one instance. In quite recent years,
however, these diseases have, it is said, become very much
more prevalent, and in the last ten years have taken a serious
hold of many of the Transcaucasian towns, such as Tiflis and
Kutais. The villagers and hill-dwellers are still comparatively
free from their ravages 1 .
The official returns from Russian Central Asia (Transcaspia,
Turkestan, Turgai, Uralsk, etc.) also indicate a remarkably low
degree of prevalence of tubercular diseases in these regions, but
the figures must be accepted with much reserve. Further north
the immense stretches of steppe country which extend eastwards
from the Ural river have acquired a reputation for a high degree
of immunity from tubercular affections, and large numbers of
tubercular patients from European Russia annually migrate thither
to undergo the so-called " Koumiss treatment/' which, together
with the extreme purity of the steppe-air, and the open airjife
enjoined, has produced very favourable results in many instances.
The Bashkir inhabitants of these regions were at one time believed
to be quite free from consumption, but a Russian physician,
1

Pantiukhof.

456

TUBERCLE

Nikolski, observed or collected records of 92 cases of tubercular
disease among them between the years 1880 and 1895, a n d he
asserts that its prevalence here is increasing, in spite of the fresh
pure air and the koumiss diet to which they are accustomed.
In Siberia, if the official statistics may be accepted as even approximately accurate, tubercular affections are considerably more
active than in the Caucasus and Central Asia, though much less
so than in European Russia. The disappearance of the native
Siberian tribes, the Buriats, the Yakuts, the Tunguses and others,
which is rapidly being brought about by many social, political, and
other causes, is, it is said, not a little hastened by the prevalence
of tubercular disease amongst them.
In Persia, Afghanistan, and Baluchistan, this form of disease
is said to be comparatively rare, but the information hitherto
available in regard to these countries is scanty, and fuller knowledge may reveal that it is commoner here than is supposed.
At Suleimaniye and other places on the Turkish side of the TurcoPersian frontier it is certainly far from rare.
Throughout the Indian peninsula tubercular diseases are met
with, with varying frequency, both among the natives and in
Europeans. In general terms it would seem that Assam and
Lower Bengal suffer the least from the ravages of the tubercle
bacillus, while in Southern India, on the west coast and in
Rajputana, the group of affections which it gives rise to are
exceedingly common. In Indian gaols these diseases are the
cause of a considerable annual mortality; and among the troops
in India, both native and British, they are not rare. Of the native
troops the Gurkhas are said to be particularly liable to consumption,
and it is the principal cause of death amongst them. It is to be
noted, however, that in Nepal, the home of the Gurkha race,
phthisis is said to be "far from prevalent 1 ,'' and the high mortality
from this cause to which Gurkha troops appear 'to be liable
elsewhere, must therefore be ascribed to other than racial reasons.
On the southern slopes of the Himalayas consumption is met
with, even at considerable heights, but it is less common here
than on the plains. In Kashmir it is said to be rare, and to
occur only among the shawl-weavers and others who lead an indoor
life. Returns from Ceylon show that tubercular diseases, though
1

Report of the Sanitary Commis. with the Government of India, 1897.

TUBERCLE

457

the cause of nearly 3000 deaths annually, are much less prevalent
in the island than in any European country.
In many of the East Indian Islands phthisis appears to be
rare, though certainly not unknown. In Borneo, however, it is
said to be almost unknown among the natives, Malays or Dyaks,
and Nieuwenhuis, who travelled across the island in 1894,
only saw one case of incontestable tubercle in a native. In
Java phthisis is said to occur to a considerable extent both in
Europeans and natives.
In the Malay Peninsula, however,
phthisis and tubercular disease generally are comparatively uncommon. The number of patients treated for these maladies in
the hospitals of the Straits Settlements is remarkably small in
comparison with the numbers admitted for other disorders. Lupus
also appears to be a particularly rare affection in the Straits Settlements. In French Indo-China tubercle is perhaps commoner,
and in Siam tubercular diseases are said to cause a considerable
mortality (Rasch).
Through the whole of China these diseases are frequently met
with. The Chinese appear to be very susceptible to the action
of the tubercle bacillus, and cases of consumption with them
often run a very rapid course. Corea shows no freedom from
the disease; the Japanese inhabitants of Chemulpo and other
centres being particularly liable to its attacks. In both Coreans
and Japanese, just as in the case of the Chinese, the course of the
malady is often extremely acute. In Japan itself tuberculosis is
widely met with; it is regarded as the principal scourge of the
rich class of nobles, while syphilis is the commonest disease
among the middle classes, and leprosy among the outcasts 1 .
Australasia. In New Guinea phthisis is rare, and was probably
unknown to the original Papuan inhabitants. Many parts of
Australia, on the other hand, present a moderately high degree of
tuberculosis prevalence. In Queensland phthisis is the most
fatal of all diseases; the death-rate from this cause is however
decreasing, and has fallen from n 15 per million in 1893 to
874 per million in 1897. The Pacific Islanders resident in the
colony seem to be particularly liable to tubercular diseases, and
nearly one-half of the deaths amongst them are due to some
affection of this nature; moreover, while they form less than
Archives of Surgery', 1898. p. 380.

458

TUBERCLE

2 per cent, of the total population, they contribute nearly 22
per cent, of the total deaths recorded from phthisis. In South
Australia the degree of prevalence of phthisis appears to be about
the same as in Queensland. ' In Victoria this form of tubercular
affection is, however, much more active than in any other of the
Australian colonies, and its frequency is said to be increasing 1 .
Tasmania, on the other hand, seems to present conditions much
less favourable to the ravages of the tubercle bacillus, and the
phthisis mortality in 1896 varied between 450 per million in the
midland districts and 800 per million in the north-eastern. In New
Zealand, as in Australia generally, pulmonary phthisis is the cause
of more deaths each year than any other disease. The mortality
from this and all other forms of tubercular affection was remarkably constant during the 1889-98 decade, always slightly exceeding the thousand per million. It will be observed from these
figures that both in Australia and New Zealand tubercular diseases,
although in many parts of these colonies the most fatal of all
maladies, are nevertheless much less potent as a cause of death
than they are in Great Britain or in many other European
countries. Some parts of Australia are regarded as presenting
remarkably favourable conditions for the relief of consumptive
patients, and in several places sanatoria have been opened for
their reception and treatment.
In many islands of the Pacific, phthisis and other tubercular
disorders are met with with considerable frequency. In the Fiji
group, in the Society Islands, in the New Hebrides, and in the
Hawaiian or Sandwich Islands phthisis causes a deplorable
mortality among the natives, and in other groups it is very
prevalent.
Africa.
Egypt appears to possess a remarkable degree of
freedom from the ravages of tubercular diseases. Phthisis is met
with to some extent in Lower Egypt, about the mouth of the Nile
and at Cairo, but in Middle and Upper Egypt it is very rare. The
air of the desert, or such part of it as is not annually inundated by
the Nile, being quite clear and free from a trace of humidity, offers
conditions exactly the reverse of those needed for the existence of
the tubercle bacillus as a cause of endemic disease; and in certain
forms of pulmonary tubercle the climate here seems capable of
McAdam, Intercolonial MedicalJournal, Jan. 20, 1899.

TUBERCLE

459

arresting the process in the lungs, at least for a time. Upper
Egypt has for some time taken its place among health-resorts for
consumptives. Abyssinia is also reported to enjoy considerable
immunity from tubercular affections.
In Tunisia there is reason to believe that tubercular diseases
are also rare. Exact information on this point is difficult to obtain,
but in spite of the occurrence of cases of phthisis among the
natives, the French authorities believe the disease to be far from
common. The Tunisian " Corps & occupation" presents fewer
cases of tubercular affection than any other corps of the French
army; and the fact is also noteworthy that in the cattle killed at
the Tunis abattoir cases of tubercle are quite exceptional \
In Algeria, on the contrary, tubercular diseases are far from
rare. Gros believes that they have become much more frequent
since the war which ended in the French occupation, though not
unknown before2. The number of cases of consumption is said
to be largely augmented by the arrival of phthisical subjects from
France, and also of immigrants from Spain, many of whom are
tubercular. Among the Arab population of Algeria the women
suffer to some extent, but among the Jews phthisis is very rare.
The nomad Arabs of Morocco are seldom the subjects of tubercle,
but cases of phthisis are seen in the towns of that country.
Turning to the West Coast of Africa it is found that there
is a considerable amount of " consumption " among the natives
of the Gambia, where in the months of December and January the
winds are often very cold, and the ill-clad natives easily succumb
to the attacks of the tubercular micro-organism.
European
settlers on this coast do not suffer greatly from phthisis. In
Sierra Leone tubercular affections are apparently not common,
though not altogether absent. The same statement is true of
Lagos and generally of the coasts of Guinea. In the Cameroons
phthisis is said to be unknown among the natives 3 .
The great susceptibility of the black races to consumption
is notorious, and when negroes are removed from their African
homes to the cooler climates @ Europe or America this is the
f
1

La Tunisie. Histoire et Description. Paris and Nancy. 1896.
Janus, 1899.
3
While pulmonary tubercle appears to be not a common affection in West
Africa generally, very marked cases of destructive lupus are at times met with.
(MacGregor.)
2

460

TUBERCLE

most prolific cause of death amongst them. It seems certain that
they also suffer from it in their own country. It has just been
shown that in some parts of the West Coast this disease is far
from rare, and in the interior of the African continent it is also
met with, though with what degree of frequency it is difficult to
say. In the Congo Free State consumption is not uncommonly
seen. In German Central Africa cases of the disease are met
with, though not wTith great frequency. On the east side of the
continent it is found to be rare, or at least comparatively rare, on
the coast region. More inland, in the neighbourhood of the great
lakes, it is perhaps commoner. Pruen, though not specifically
mentioning consumption, states that lung affections are very
common among the natives of this part of Africa. He points
out that the sudden changes of temperature in the rainy season,
with no corresponding change in the garments worn, notoriously
induce these conditions, and lung affections secondary to malarial
fever are a fruitful source of death. It may be reasonably
supposed that part of this mortality from lung disease is due
to pulmonary phthisis
In Uganda all forms of tubercular
affections seem to be common.
In the cooler climate, or climates, of South Africa the natives
are found to suffer from the diseases now under consideration to
a still greater extent than in the tropical regions of the continent.
In the native territories of Tembuland, Pondoland and the
Transkei phthisis is spoken of as " alarmingly prevalent" in spite
of the open-air life led by the people 1 . Among natives living in
towns, such as Kimberley, East London, and Grahamstown, the
disease is said to be making rapid strides, no doubt on account
of the conditions under which the people live, but from wholly
rural districts reports of the great ravages caused by this form of
disease are also forthcoming.
On the other hand the white population of South Africa
appear to show a lesser tendency to suffer from tubercular
disease than the natives. Phthisis is said to be commoner along
the coast than inland, and in some towns it is a cause of high
mortality. At Port Elizabeth, Grahamstown, King William's
Town, Cape Town, and Durban, a considerable number of
phthisical subjects come under treatment every year, and in
1
Cape of Good Hope Reports upon the Government and State-aided Hospitals
and Asylums for 1898.

TUBERCLE

461

some of these towns phthisis causes more deaths than any other
disease. It is to be noted that a certain proportion of these cases
dealt with in South African hospitals are imported from England
or elsewhere; and in recent reports upon the health of the South
African colonies may be found repeated protests against the sending of consumptive persons, often in a most advanced and hopeless
state, to a country where many of them have no friends or means
of support, and eventually become a charge on the community.
While tubercular diseases, at least of the lung, are common
enough in the towns in southern Africa, there are large stretches
of country where they are comparatively rare. Thus in Bechuanaland and Mashonaland, in many parts of Natal, in the Transvaal,
and in Basutoland, phthisis is rarely met with. In Matabeleland
it is also apparently not a common disorder, and only five cases
were admitted to the Memorial Hospital at Buluwayo in the
year 1897-8. In Mafeking phthisis was not very frequently seen
before the war. The Boers in the Transvaal were rarely affected
by tuberculosis 1 .
The islands off the coast of Africa are not free from tubercular
affections. In Mauritius phthisis is common, and very rapid in
its course; it causes a mortality of about 1300 per million per
annum. In Rodriguez it is less common, and causes a mortality
of only 750 per million. In Madagascar it is far from rare
in the interior province of Imerina, but is less prevalent on the
coasts. Among the western African islands it is found that
phthisis is not at all exceptional among the poor in Madeira,
though rare among the upper classes of the natives. In the
Canary Islands it is prevalent to some extent, but in the Cape
Verde Islands it is rare. Both Madeira and the Canary Islands
have been found suitable for the treatment of certain forms of
consumption, though their reputation in this respect is not so
high as in 'former years.
America. In the northern part of the continent of North
America tubercular diseases are very prevalent. In far away
Greenland we have it on the authority of Nansen, the Arctic
traveller, that tuberculosis is the great scourge of the inhabitants.
" Of late," he writes (in 1890), " t h e disease has manifested itself
to an alarming extent, especially in the form of pulmonary
1

Dr Alfred Hillier, Lecture at the London Polyclinic, Feb. 7, 1900.

462

TUBERCLE

tuberculosis, which is the great scourge of Greenlanders, It
would be difficult to find a community with a proportionally
larger number of inhabitants suffering from this plague. While
we were in Godthaab, two died, and ten or twelve more were
merely struggling for life; and this out of a total of something
like one hundred. The disease was so common that it was
almost easier to reckon up those who were free from it than
those who had it 1 ."
In like manner consumption is the principal cause of death
among the Eskimos and Indian tribes throughout Alaska, Hudson
Bay Territory, and Labrador.
The more temperate climates of the other Canadian provinces afford no immunity to the ravages of tubercle.
In
Quebec pulmonary phthisis is very widely spread, and, after
"diarrhceal disorders," is the greatest factor in the general
mortality, one-twelfth of which is caused by this disease. From
almost all parts of Ontario come reports showing that more
deaths are caused by phthisis and other tubercular diseases than
by any other single disorder, and the same statement holds
good for the province of New Brunswick. The prevalence of
these affections is said to be increasing in Nova Scotia, and they
are of frequent occurrence in Newfoundland to the east, and
to the west in British Columbia. In Manitoba the mortality from
tuberculosis exceeds that caused by all other infectious diseases.
A recent writer on the public health conditions of Canada
remarks that this class of diseases is more rife both in Canada
itself and in the United States than in Great Britain, and
the facts just cited above, taken as they are from the official
reports of each province, go far to bear out this statement so
far as it concerns Canada, while in regard to the United States
it can be fully confirmed from other sources. The excessive
frequency of these diseases throughout the Republic formed the
substance of a number of resolutions passed by the Thirteenth
annual meeting of the Conference of State and Provincial Boards
of Health of North America, held at Detroit in 1898; and one
of these resolutions was to the effect that tuberculosis causes
more mortality in the States than all other contagious diseases
put together. It is some satisfaction, however, to note that, rife
1

The First Crossing of Greenland.

By Fridtjof Nansen, 1890.

TUBERCLE

463

as tuberculosis is, it was once much more so. In the urban
population of Massachusetts, for example, the "phthisis" mortality
has fallen from 4080 per million inhabitants in the year 1856 to
2190 per million in the year 1895. Similarly the "phthisis"
mortality in Philadelphia has fallen in the last fifteen years from
about 14 per cent, of the deaths from all causes to about 10 per
cent. The distribution of consumption through the States is, of
course, not uniform. Davidson gives the following as the areas
of greatest and least prevalence. The areas of greatest phthisis
mortality are, he says, the Pacific Ocean region, the North Atlantic
coast, the Ohio river belt, the North-Eastern plateau, the central
plains of Kentucky and Tennessee (Indiana being little affected),
the middle Atlantic coast, and the interior plateau; while the
regions where consumption is least fatal are the western plains,
comprising West Texas, Kansas, Nebraska, and Western Dakota,
the Cordillera region, the South Atlantic coast, and the South
Mississippi river belt.
In Mexico phthisis prevails to some extent on both coasts,
but on the high table-lands of the interior it is rare. In Guatemala
it is known, but is apparently much less fatal than in European
countries; in 1894 it caused a mortality of less than 250 per
million inhabitants. In British Honduras on the other hand
"phthisis of a peculiarly rapid and fatal character" is "fairly
common." In Nicaragua, San Salvador, and Costa Rica phthisis
is found along the coast to a greater or lesser extent, while it is
rare in the high-lying lands of the interior.
The population of many, indeed of most, of the West Indian
Islands are widely affected by tubercular disease. From Barbados,
from St Lucia, Grenada, and Trinidad, all in the Windward
group, reports are forthcoming showing that pulmonary phthisis
is there, as in so many other parts of the world, the most deadly
of scourges. In the Leeward group it is scarcely less prevalent,
and in most of the larger islands of the West Indies it causes a
very high annual mortality. Thus in Jamaica in 1897 the phthisis
mortality was equal to 2760 per million living, the prevalence of
the disease being closely associated with the unhealthy habits
and overcrowding of the population. In Cuba consumption
is equally rife, and in some years has caused nearly twenty per
cent, of the deaths from all causes. Similarly, from the Bahama
hospital reports it appears that more phthisical patients are

4^4

TUBERCLE

admitted to hospital than any other kind, while in Bermuda
no other disease causes so high a mortality.
In British Guiana while the pulmonary form of tubercle is,
according to a statement of the Surgeon-General of the colony,
not a very prevalent disease, affections included under the general
heading of " tubercle " cause no little sickness and mortality each
year, the figures under this heading being only second to those
under "malaria" as regards cases, and far ahead of all other
figures as regards deaths. In Georgetown itself phthisis has
in recent years become far more prevalent and fatal than it was
formerly. In Dutch and French Guiana there is reason to believe
that this disease is common in low-lying districts, but less so in
the more elevated interior.
Along the coasts of Brazil tubercular diseases are met with
with great frequency. They are excessively rife in Rio de Janeiro,
where in the years 1886-1897 the deaths from this cause varied
between 9*5 and 19*4 per cent, of the deaths from all causes.
The people of northern and central Brazil are said to be peculiarly
disposed to phthisis, and this tendency is probably favoured by the
warm, moist climate and the conditions of life which prevail there.
Some localities in Brazil, however, appear to be free from it, as, for
example, Campos do Jardao, Barbacena, etc. It is noteworthy,
also, that tubercle is said to be found with great frequency in
cattle in Brazil. The coasts of the Argentine Republic and of
Uruguay appear to be as favourable to the prevalence of tubercular
diseases as those of Brazil, while the high-lying regions towards
the Andes range are much less affected. In the province of
Buenos Aires no other disease is so fruitful a source of death, and
the same appears to be the case in Monte Video, where the
Spanish population are said to be especially affected. In the
Falkland Islands, on the other hand, phthisis is extremely rare,
and those who have contracted the disease elsewhere improve
by a residence in the islands.
Turning to the west coast of South America it is found that
along the shores of Chile phthisis is far from rare, and that in
Valparaiso it is exceedingly common, while in the Bolivian sierras,
on the contrary, it is said to be entirely unknown, both among
the Indian and the white population. A similar distribution of
the disease appears to hold for the countries of Ecuador
and Peru, where on the low-lying coasts consumption is very

465

TUBERCLE

commonly seen, while the mountainous interior is relatively or
absolutely free from it.

Factors which determine the Geographical Distrib u t i o n . It will be observed that tubercular diseases have, as
was stated at the beginning of this chapter, an almost world-wide
distribution. Their degree of prevalence varies, it is true, within
somewhat wide limits, but there appears to be no geographical
unit of any considerable size in which they are quite unknown.
They are consequently found under an extreme variety of conditions as regards temperature. Phthisis is as great a scourge
among the inhabitants of semi-arctic Greenland as among those of
the temperate shores of Great Britain, or of the tropical coasts
of Brazil and Ecuador. Nearness to or distance from the equator,
indeed, seems to be without influence upon this form of tubercular
disease; for though it is mild or comparatively rare in some warm
countries, such as Egypt, Tunisia, Guatemala, the Malay Peninsula,
the Straits Settlements, the East Indies, New Guinea, and some
parts of Brazil, it is exceedingly common in many other countries
in the same latitudes as those just named. In like manner,
although the Falkland Islands, Iceland, the Faroes, and Lapland,
are examples of cold countries comparatively free from tubercular
diseases, there are other regions equally cold, as, for example,
Greenland, the Hudson Bay territories, and Labrador, where
they are rife.
It was at one time believed, and there is indeed still a large
body of evidence to show, that cold is the principal predisposing
or determining cause of the onset of " consumption." But whatever the influence of cold may be, it is less a question of an
absolutely than of a relatively low temperature. Thus it is found
that on the coasts of Africa the natives, accustomed for most
of the year to a warm climate, fall victims to tubercular disease
when the cooler weather of winter sets i n ; and the same class
of people, when removed from the tropics to a cooler country,
easily succumb to the malady. Humidity probably plays a still
more important role than temperature in the distribution of
tubercle. A moist atmosphere seems the most favourable to the
activity and spread of the bacillus. The well-recognised fact
that consumption is rare or unknown in the Swiss Alps, in the
South American sierras, and in other high-lying districts is no
doubt partly to be explained by the relative dryness of the
c.

30

466

TUBERCLE

atmosphere in these regions, and this is borne out by the equal
rarity of the disease in the plains of Upper Egypt, where the air is
almost entirely devoid of humidity.
But more important than temperature or humidity, whether
absolute or relative, is the purity of the air. It appears almost
certain that the freedom from consumption of communities
dwelling at great heights is to a very great extent due to the
absence of organic impurities in the air constantly breathed by
them. In addition to the instances just named of high altitudes
where tubercle is little known, many other equally striking examples
are forthcoming from all parts of the world. In Greece, in Arabia,
in Asia Minor, in the Caucasus, in Mexico, in the Central
American Republics, in the Guianas, in the Argentine Republic
and Uruguay, in Ecuador, and in Peru, tubercular diseases are
found to be rife in the low-lying coast districts or plains, and rare
or unknown in the adjoining mountains or table-lands. But even
this very general rule is not without exceptions. In Madagascar,
for example, phthisis is spoken of as " far from rare" in the
Imerina province on the central plateau, and as " b y no means
prevalent" on the coasts 1 . In the mountainous countries of
Norway and Montenegro, and on the slopes of the Himalayas,
even at considerable heights, pulmonary phthisis occurs with great
frequency; while, on the other hand, the Russian steppes on the
borders of Asia and Europe, the desert plains of Egypt, and the
western plains of the United States of America, are all examples
of low-level areas where this disease is comparatively rare. In
spite of these exceptions, however, the general rule holds good
that a high altitude is less favourable, at least to pulmonary
tubercle, than a low one. No doubt many factors are at work in
producing this result. Among these must be mentioned the
lowered barometrical pressure, the consequent rarity of the air and
more active respiratory movements needed, and the healthier life led
by some of these communities, all of which would tend to increase
their resistance to the attacks of the tubercle bacillus. But, over
and above this, the greater purity of the mountain air over that of
the plains below has an importance that can scarcely be exaggerated.
At the other end of the scale phthisis is found prevailing to its
greatest extent among overcrowded communities, dwellers in
Davidson.

467

TUBERCLE

insanitary cities or villages, the air of which is constantly contaminated by organic exhalations. The infective nature of tubercular disease has long been fully recognised, and the condition
of overcrowding directly favours the passage of the infecting
organism from one individual to another, while at the same time
it is associated with a lowered condition of vitality and a greater
amount of organic impurity in the air.
Among general sanitary defects, overcrowding and deficient
ventilation are apparently the most powerful aids to the diffusion
of tubercular disease. A recognition of this fact, and the introduction of improvements in the' construction, ventilation, and
management of barracks, gaols, and schools, has led to an immense reduction in phthisis prevalence in institutions of this kind,
where at one time it was excessively high. Some other sanitary
and public health measures, as, for example, improved watersupply and drainage systems, cannot be regarded as having any
direct influence upon tubercular diseases. The supervision of
food supplies, on the other hand, was, until recently, believed to
be of the first importance in their control. That some of the
lower animals, particularly horned cattle, can and do largely suffer
from a disease closely allied to tubercular disease in man, and
associated with a bacillus closely resembling, if not identical with,
the human tubercle bacillus, has long been recognised. So like
does the one disease appear to be to the other, that from a public
health point of view it seemed necessary to treat them as identical;
and every precaution to prevent the consumption of meat or milk
from tubercular cattle was, and, until the question is finally settled,
still is, amply justified. Doubt, however, had from time to time
been thrown upon their identity, and the question was brought to
a head by Prof. Koch in a communication made to the British
Medical Association in 1901. In this paper the author stated his
conviction that tuberculosis in man and tuberculosis in cattle are
two distinct and separate diseases, and that the disease in the
latter cannot be communicated to the former. The announcement gave rise to considerable controversy at the time, and led in
England to the appointment of a Government Commission to
inquire into this very important question. Until the results of
this inquiry shall be made known the matter may be regarded
as sub judice.
The 'distribution of tubercular diseases is influenced to some

3°—2

468

TUBERCLE

extent by racial differences. All races suffer, but the negro
appears to be particularly liable to them.
The ease with
which negroes fall a prey to consumption when removed to a
cooler clime and to other social conditions than they have been
accustomed to is notorious. The Chinese and Japanese are also
highly susceptible to tubercle
The Jewish race, on the contrary, is said to be comparatively immune to it. The contact of
the civilised with the uncivilised races has nearly always led to
the introduction among the latter of certain diseases, of which
tubercle has often been one of the most deadly. Its spread among
native races under these conditions is no doubt largely due to
changes in their habits, and to the substitution of town-life
in overcrowded ill-ventilated houses for the more healthy, openair life formerly led by them. Drink and other demoralising
vices of so-called civilisation no doubt aid in the process. This
disastrous effect of tubercular diseases among native races after
the advent of the white man has been seen in modern times
among the Kanakas of New Caledonia, the natives of Hawaii and
other Pacific Islands, the Maoris of New Zealand, the aborigines
of Australia, and the indigenous tribes of Siberia.
The nature of the soil has probably considerable influence on
phthisis prevalence. It was shown by Bowditch in America in
1862, and by Buchanan in England in 1867, that the disease is
greatly favoured by a damp, impervious soil. Buchanan, indeed,
gave to the condition of soil the first position among all factors
concerned in the distribution of phthisis. His conclusions were
that (at least in the three English counties where his observations
were made) phthisis is less common on pervious than impervious
soil; that it is less common on high-lying pervious soils than on
low-lying pervious soils; that it is less common on sloping impervious soils than on level impervious soils; that wetness of soil
conduces to phthisis in people living on it; and that no other
circumstance can be detected that coincides on a large scale with
the greater or less prevalence of phthisis than the one condition
of soil.

T Y P H O I D or E N T E R I C

FEVER

(and TYPHO-MALARIA).
H i s t o r y . The early history of typhoid fever is practically
unknown. In the seventeenth and eighteenth centuries there is
frequent mention of a class of fever which may fairly be regarded
as enteric; but it was not until the beginning of the nineteenth
century that a true conception of the specific character of the
disease was formed. It was for long confused with various other
fevers, of which typhus was the most important. The distinction
between typhus and typhoid fevers, though suspected previously
by various observers, was finally and fully established by Sir William
Jenner in 1849-51. The typhoid bacillus, which is believed to be
specific to the disease, was first described in the years 1880-81, by
Eberth, Koch, and Klebs j and was first cultivated successfully on
artificial media by Gaffky in 1884.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. In England and Wales the mortality from enteric fever has shown"
a most gratifying diminution within the past thirty years. In
the years 1871 to 1875 the deaths annually recorded from this
cause were equal to a rate of 374 per million living, but this figure
has steadily fallen, until in 1892 a minimum rate of only 137 per
million was reached. There has been a slight rise again in the
years since 1892, the highest mortality being in 1893, when it was
equal to 229 per million. There are certain more or less welldefined areas in England and Wales where the disease shows
a special tendency to prevail year after year. One such area
consists of eighteen registration districts occupying the eastern
portion of the counties of Northumberland and Durham; the
deaths from enteric have been constantly higher in this area than
in the country as a whole for a long period of years. The county

470

TYPHOID OR ENTERIC FEVER

of Lancashire forms another area in which the disease is persistently prevalent. In Nottinghamshire also enteric fever seems to
be endemic in certain contiguous districts (Nottingham, Basford,
and Mansfield), which together contain about three-fourths of the
population of the county. Other areas of unusual prevalence are
found in the West and East Ridings of Yorkshire and elsewhere.
It will be observed that all these are in the main essentially
manufacturing areas. While the general distribution of enteric
fever in England and Wales shows on the whole a considerable
degree of constancy from year to year, temporary variations in its
distribution, owing to the occurrence of severe local epidemics,
are not infrequent. Among the most notable examples of such
epidemics may be mentioned those in the Tees Valley in 1890
and 1891, at King's Lynn in 1891 and 1892, and the extremely
severe outbreak at Worthing in 1893. Epidemics of this kind
are almost invariably traced to a definite pollution of the drinkingwater supply with faecal matter, and, in most instances, with the
excreta from persons suffering from typhoid fever.
In Scotland the mortality from enteric fever, which had been
231 per million per annum in the decade 1881-1890, fell to 180
in 1895, a n d in each of the two following years was 160 per
million. The degree of prevalence of the disease, as judged by
the mortality, is about the same in Scotland as in England. In
both countries typhoid fever is far more prevalent in towns than
in country districts. In Ireland the disease caused an annual
mortality of 161 per million in the years 1881-90 and of 192
in 1890-99; but here, as elsewhere, it seems probable that some
of the deaths returned under the headings of " simple continued "
and "ill-defined" fevers should in truth be ascribed to enteric
fever.
In the larger French towns of over 10,000 inhabitants typhoid
fever has caused a diminishing mortality in recent years. The
ratio of deaths from this cause in 1886-90 was 530 per million
per annum; this figure fell to 370 in 1891, and has further
diminished to 260 and 270 in the years 1897 and 1898
respectively.
The returns of* typhoid fever in Holland are still grouped
with those of typhus. The deaths from the two diseases
together fell from 140 per million inhabitants in 1889 to a
minimum of 90 per million in 1897. What proportion of this

TYPHOID OR ENTERIC FEVER

471

mortality was due to enteric alone cannot be stated, but it is
clear that the disease is very much less common in Holland than
in the British Islands 1 . Recently attention has been called to
the remarkable fact that this relative freedom from typhoid fever
is maintained in Holland in spite of the method in vogue there
of removing excreta—or, perhaps, it should be said because of
the care with which the method is carried out. The excreta are
removed dry, and after being mixed with peat-ashes and streetsweepings are converted into manure which is spread over the
fields. "When we consider," says Dr Poore, "that dairy farming is the staple industry of these provinces [Groningen and
Friesland], that milk, which is most sensitive to typhoid fever
infection, is everywhere abundant, and that human excreta containing a certain proportion of typhoid fever excreta are used, and
have been used for ages, to manure this fertile district which almost
lies in the water, the comparative freedom from enteric fever seems
very full of instruction 2 ." In two large towns, Groningen and
Leeuwarden, with populations respectively of 63,863 and 31,598,
not a single death from typhoid occurred in the year 1897.
A very marked reduction in enteric prevalence has come about
in recent years in Belgium. In the decade 1871-80 the mean
deaths from this cause each year numbered 4 1 6 1 ; in the next
decade they fell to 2807; in 1895 the deaths from typhoid were
only 1843, a n d m I ^97 o n t y I 59^- The last figure was equivalent to
a mortality of 246 per million inhabitants. The disease, though
decreasing, is therefore very much more frequent in Belgium than
in Holland.
In Denmark the deaths from typhoid fever have shown somewhat less tendency to decline in recent years than in the other
countries already named, at any rate in the urban population. In
1892 the deaths from this cause among the dwellers in Danish
towns were 109; in 1895 t n e Y r o s e t o I 2 2 > an< ^ m ^ e following
two years they fell to 94 and 87 respectively. If, as is happening
in other countries, the urban population in Denmark is annually
increasing at the expense of the rural, the diminution of mortality
1

Prof. Saltet, of Amsterdam, has shown that the mortality from typhoid
fever in Holland was reduced by as much as 72 per cent, in towns in the
years 1875-95, and by 60 per cent, in rural populations in the same period.
(Epidemiological Society, May 19th, 1899.)
2
The Milroy Lectures, 1899. By G. V. Poore, M.D., F.R.C.P.

472

TYPHOID OR ENTERIC FEVER

in the last three years named may be more striking than it seems.
The deaths in 1895 w e r e equivalent to a ratio of 155 per million
living. In Copenhagen itself there has been a very marked and
steady decrease in the deaths from enteric during the last sixty or
seventy years1.
The mortality from enteric fever in the German Empire is
relatively low, and the same diminution in the prevalence of the
disease which has been observed in other countries has also been
seen here. The deaths in 1894 were equivalent to 131 per million
inhabitants; in the preceding seven years (1887-1893) the annual
mortality was 165 per million. The prevalence of typhoid fever
has varied considerably in various portions of the empire, but all
have shown a very marked decline in its prevalence within recent
times. Thus in Prussia the deaths from this cause fell from 445
per million per annum in the years 1880-1886 to 215 per million
per annum in the next septennium, and to 151 in 1894. Saxony
has recently had a remarkably low death-rate from typhoid; in
1894 it was only 60 per million, as compared with rates of 260
and 132 per million respectively in the two septennial periods just
referred to. In Wiirtemburg the fall has been somewhat less
striking, the mortality rates for the two septennia and for the year
1894 being 199, 107, and 104 respectively. In Bavaria the
corresponding rates in the same time-periods were 206, 119, and
83 per million.
In Norway the enteric fever death-rate is low. It steadily
decreased until the year 1892, when the mortality from this cause
also reached its minimum in England. Since that date there
has been a slight rise in the number of deaths. The enteric
fever mortality in Norway in 1891 was approximately 105 and
in 1894 about 70 per million. The disease is perhaps even
less prevalent in Norway than in Holland, and considerably less
so than in England.
In Sweden typhoid fever appears, on the other hand, to be
very much more prevalent. In the seven-year period 1887-1893
the mortality in that country was equal to 278 per million; it fell
in the next septennium to 218, and in 1894 was 186 per million
living.
In European Russia there is no doubt that enteric fever
is the cause of a very much higher mortality than in most
1

Schierbeck, 7rans. Epidemiol. Soc. 1900-1.

TYPHOID OR ENTERIC FEVER

473

other European countries. In the three years 1893-1895
the deaths from it were equal to an annual mortality of 880
per million living. It is to be noted, however, that in the
Russian returns "undetermined" forms of fever are included
under the heading of "abdominal typhus" {briushnoi tyf>h\
and that the true enteric mortality is therefore perhaps lower
than this figure would indicate. Unlike the other countries
already named, Russia has shown comparatively little diminution
in typhoid fever mortality in recent years. The returns from
various parts of the country for this disease, as for all others,
are approximate only, but they indicate a very wide-spread
prevalence of typhoid fever throughout all parts of European
Russia.
The frequency of this and other acute abdominal
diseases in Russia is closely associated with the imperfect
character of the public water-supplies, of the drainage-systems,
and generally of the public health administration in the smaller
towns and villages. Typhoid fever is much less prevalent-in the
northerly government of Archangel than in Russia generally; the
other parts of the country in which it has been least prevalent
in recent years (1887 to 1895) n a v e been the Baltic Provinces,
the governments on the Vistula—that is to say, Russian Poland
—and the Don Cossack territory. In these the number of
registered cases of the disease (not deaths, as have been hitherto
dealt with for other countries) varied between 700 and 1100 per
million, whereas in the rest of European Russia the registered
cases varied between 1900 and 2800 per million. Much caution
is needed in accepting these figures as representing the total
prevalence of the disease, but they have a certain value for
purposes of comparison inter se\
The Austro-Hungarian empire has a very high annual mortality
from enteric fever. In Austria the deaths from this cause were
724 per million per annum in the septennium 1880 to 1886,
and 522 in that ending in 1893. This reduction in mortality
has apparently been maintained. In Hungary the typhoid fever
deaths in the two successive septennial periods just mentioned
1
The figures are taken from the Annual Reports of the Medical Department
of the Russian Ministry of the Interior. There is an obvious • discrepancy
between a general " enteric " death-rate of 880 per million and the recorded
case-rates quoted in the text, and it can only be explained by supposing that a
large number of cases which recover escape record.

474

TYPHOID OR ENTERIC FEVER

were at the rate of 698 and 504 per million inhabitants respectively; in 1897 they had sunk to 480 per million. Considerable
caution is probably necessary in accepting these figures as more
than an approximate indication of the true mortality from this
malady, but it is extremely unlikely that they are above the truth,
and they fully justify the assertion that in the Austro-Hungarian
empire typhoid fever is excessively prevalent. The same appears
to be the case in Croatia and Slavonia (annexes of the Crown
of Hungary, but under separate administration and laws), where
the mortality from this disorder has in many years been not less
than 600 per million per annum.
The deaths from enteric fever in Switzerland have recently
diminished very considerably, and are now fewer in proportion
to the population than in the British Isles. This is, at least, the
case in the fifteen Swiss towns with a population exceeding ten
thousand inhabitants. In these towns the mortality from this
cause fell from 243 per million in 1889 (which was a considerably
higher figure than that for the preceding year) to a minimum
of 75 per million in 1896, In the following year it rose again
slightly, to 100 per million, but this was still a low figure, and
Switzerland is comparable with Holland in its relative freedom
from the disease.
In Italy the deaths from enteric fever have considerably
diminished in recent years, but are still high; the mortality
ratio fell steadily from 925 per million in 1887 to 439 in 1894.
In Spain and Portugal the disease is said to be particularly
frequent.
For the countries of the Balkan peninsula accurate figures
of the prevalence of, or mortality from, enteric fever are not
available.
In Servia all forms of "typhus," including the
abdominal form or enteric fever, are dealt with under a single
heading. In Turkey typhoid fever is a very common disorder, and
is constantly present in Constantinople and its neighbourhood.
In 1898 it caused a severe epidemic in Macedonia, where it was
said to have been imported from Thessaly. During the Turkish
occupation of Thessaly after the war enteric was excessively prevalent. From many parts of the province of Salonika cases are from
time to time reported.
In the Faroe Islands typhoid fever is said to have been
unknown for a considerable number of years. On the other

TYPHOID OR ENTERIC FEVER

475

hand the disease is met with as far north as Iceland, and has
repeatedly caused epidemics in that island.
Enteric fever is the cause of a considerable mortality in Malta.
In Crete the disease appears to be endemic, and the English
troops, both officers and men, suffered considerably from it during
the troubles in that island a few years ago. In Cyprus enteric
fever at times becomes epidemic and causes much mortality, as,
for example, in 1889.
Asia. In the Caucasus and Transcaucasia it would appear
from the official returns that typhoid fever is a very much less
frequent disease than in any other part of the empire, with the
exception of Central Asiatic Russia. The registered cases during
the years 1887-1895 varied between 220 and 270 per million per
annum, in contrast to the much higher ratios for European Russia
quoted above. It is noteworthy that the disease appears to be, if
anything, less prevalent in the three flat, marshy provinces of the
Caucasus proper than in the mountainous regions of Transcaucasia.
The figures are however too untrustworthy to bear much weight,
and it is to be noted that a recent writer states that typhoid
has, within the last ten years, taken considerable hold in the
Caucasus, particularly in the towns; though nowhere causing a
severe epidemic 1 .
In Russian Central Asia the reported cases of typhoid fever
in the same period were lower still, and were equivalent to a
ratio varying between 50 and 120 per million per annum. To
what extent these very low ratios in Transcaspia, Turkestan,
and the other provinces of Russian Central Asia are to be
ascribed to defects in diagnosis and registration, or to a real
infrequency of the malady in those regions, can. only be a
matter of surmise. The difference is, however, so very great
between the ratios for these provinces ancf for European Russia,
and also fo'r Siberia, that it cannot all be due to defective
registration and diagnosis (which are known to obtain in the
other parts of Russia, though perhaps to a less extent), and it
may be asserted with considerable confidence that enteric fever
is a comparatively infrequent disease in the regions lying beyond
the Caspian Sea. Among the Bashkirs, on the other hand, who
live mainly in the regions lying north of that sea, in the basins
1

Pantiukhof, op. cit.

476

TYPHOID OR ENTERIC FEVER

of the Volga and the Ural rivers, it is not uncommon, and
it occasionally becomes epidemic throughout an entire village.
Siberia occupies an intermediate position between Central Asia
and European Russia, the case-ratio varying in the years 18871895 between 990 and 1330 per million of the population. The
disease appears to be esjpecially prevalent in the governments of
Irkutsk and the Amur. It is found in the northerly province of
Yakutsk, and rare cases are returned from the most northerly
district of that province, that of Verkhoyansk, the greatest portion
of which lies within the Arctic circle. At Blagoveshtchensk and
at Vladivostok it has prevailed to a considerable extent.
Typhoid fever is certainly known in Arabia, and in the early
months of 1898 it was epidemic at Hodeida on the Red Sea
coast. It is said to be common along the coasts, but absent
from the Arabian plateau. The latter statement is certainly far
too sweeping, for of recent years it has caused an excessive
degree of mortality among the highlanders of Assyr. In 1900 a
severe epidemic of the disease was reported as prevailing among
them. At Mecca, too, it is a frequent cause of death among the
pilgrims.
At Aden 3*5 per thousand of the British troops stationed there
were annually attacked by typhoid in the ten years ending 1895 ;
in the year 1897 the proportion fell to r 8 i per thousand.
In Asia Minor the disease is common ; it is very prevalent in
Smyrna in the winter of most years; at Trebizond it is often
seen; at Erzerum it becomes epidemic every spring 1 ; and in
Chios, Samos, Mitylene, Rhodes, and other islands off the coast
it is of common occurrence.
The disease is frequently seen at Aleppo, Damascus, Jaffa,
Tripoli, and other places in Syria. It undoubtedly exists in Persia,
usually as a sporadic disorder, but occasionally in the form of
intense epidemics, as, for example, at Bidjar, a village six days
north of Kermanshah, in the autumn of 1900. It is common
enough in Teheran itself, where both natives and Europeans
suffer.
At no distant period the existence of enteric fever in India
1

It was seriously epidemic in Erzerum after the earthquakes there in
1901, and this was attributed to an enormous mass of mud which spread over
the streets and led to serious pollution of the water-supply.

TYPHOID OR ENTERIC FEVER

477

was denied, but later knowledge has shown > the extraordinarily
inaccurate nature of this view, and it is now recognised as one of
the most fatal of all diseases among European residents in that
country. The European races suffer to a far greater extent than the
natives, and for a considerable time it was even doubted whether
the natives of India were not immune to the disease; but it has
now been proved beyond question that they can and do suffer
from it, though to an incomparably less extent than Europeans 1 .
In 1897 only 51 cases with 15 deaths were recorded in the whole
native army; in the previous year the figures were 19 cases with
5 deaths. It would seem that the disease is becoming somewhat
more common in the native troops, or else improved diagnosis is
causing an apparent increase in the cases and deaths. The admission-rate rose from an annual average of 0*2 per thousand
strength in the decade 1886-95 to 0*4 in 1897, and the deathrate from '09 to *i2. In Indian gaols, on the other hand, the
admission-rate remained the same in the two periods (0*3 per
thousand strength). In the Central gaol at Nagpur 25 cases of
enteric in natives were treated between the years 1894 and 1899.
It is noteworthy that the Gurkhas seem considerably more
prone to typhoid fever than other native races, and hence the
disease is commoner where Gurkha regiments are stationed
than elsewhere2. Its prevalence in the native troops in Assam
is directly ascribed to the number of men of this race stationed
there.
The blood of natives over the age of childhood has been
repeatedly found to react to Widal's test, which would indicate
that the persons whose blood was examined had suffered from a
previous attack of the disease. Evidence of a similar character,
which has, however, been questioned, has been adduced in
regard to the negroes in Africa, and the apparent immunity of
1
The Sanitary Officer of South Canara stated, in 1897, that enteric fever is
endemic in the town of Bangalore. This was characterised by the Sanitary
Commissioner with the Government of India as an " unusual acknowledgement of the constant presence, as a matter of observed fact, of enteric fever
in an Indian city."
2
Dr Andrew Duncan (Major I.M.S. retired), on the other hand, stated in
a discussion before the Brit. Med. Assoc, Ipswich, 1900, that, contrary to
popular belief, enteric fever is not a common disease among Gurkhas. He
had only seen one case among them.

478

TYPHOID OR ENTERIC FEVER

other native races—in Algeria and elsewhere—has been quoted,
and the view tentatively put forward that these races may owe
their apparent immunity to their suffering from unrecognised
attacks of the disease in childhood 1 . "There is no question
that the virus of typhoid fever is very widely spread throughout
India; it attacks Europeans in all parts of the peninsula, and
the typhoid bacillus has been found by Hankin and others in
the drinking-water supplies of such towns as Lucknow, Fatehgarh,
Meerut, Muttra, Agra, Sabathu, Mean Mir, Amritsar, Cherat,
Mhow, and Deesa, and in milk from Fatehgarh and Dagshai.
The native population must be constantly and specially exposed
to its attacks from their habit of frequently bathing in and
drinking the water of foul tanks, streams, and rivers, and it is
probable that large numbers acquire an immunity to the disease
by constant exposure to its cause. It has also to be remembered
that an enormous proportion of natives are not attended by
skilled observers, and that it is therefore possible that large
numbers of cases of and deaths from enteric fever occur in
native children which are regarded as due to some other cause.
Support is lent to this view by the readiness with which English
soldiers newly arrived in India contract the disease. Fuller
information is, however, required before the degree of liability
of the natives of India to enteric fever can be determined with
accuracy.
Among European troops in India enteric fever is the most
prolific source of sickness and death. The degree of its prevalence
in any given station varies very greatly in different years, but no
portion of the peninsula seems to be free from the disease. The
following table shows the admission-rates under this heading in
European troops stationed at the places named, firstly in the
decennium 1886-95, and secondly in the year 1897, when the
disease was excessively prevalent throughout India.
1
Lt.-Col. A. Adams, I.M.S., who has seen undoubted cases of enteric fever
in natives in Rajputana, where the disease even at times becomes epidemic,
also expresses the belief that most of the children of the country suffer at some
time from enteric fever. The Western Rajputana States, London, 1899.

TYPHOID OR E N T E R I C FEVER

479

ENTERIC FEVER IN EUROPEAN TROOPS IN INDIA.
Station

Annual mean, 1886—1895
Admission-rate
per thousand
strength

1897

Death-rate

Admission-rate

Agra

24

7-66

166*4

Umballa

21*7

5'4i
678

64T

7*o7

48-5

Death-ra
45*04
I5'32
16-95

Mhow

27*5

Lucknow
Meerut

37'3
26-8

Allahabad

24*2

7-83
4'84

Peshawar

187

7*88

47*4
44*8
44'2

3*47
6*04

40*2

7-2

36*2

877
779
6-6

49

11'93
18*58
i4'34
26-93

Bangalore

E6

Secunderabad

23*7

Rawalpindi

24'5

6'85

32-2

5"4

22*6
I8-I

477
2-52

i4'7
117

5*5
2-94

3*o7
1-83

8-2

3*64
0-89

2-47
4-18

2"0

1-99

i-9

0*96

Rangoon
Quetta

*5

Poona

i5'4

*'55
3*15
5-06

Bareilly

39*8

9-41

Wellington

7*5
13-8

2*46

Karachi
Colaba
Fort

4'9
6-8

DufFerin

Moultan
Fort

16-8

William

22*5

3*5

4*3

2-13

3*5

i-8r

—

19*6

Aden

5-28

32*4

—
„

9-01

In Ceylon enteric fever is certainly met with. Cases are
annually recorded in most parts of the island, and in the Report
upon hospitals in the Northern Province for 1897 attention was
called to " the constant and increasing occurrence of typhoid cases
in town and district." In Colombo the disease is not infrequently
seen, but it has been on the decline since the introduction of a
pure water-supply1.
In Farther India and the Malay Peninsula enteric fever is also
seen to some extent, but far more among Europeans than among
natives. In Siam it is known, though evidently far from common.
In the Malay Peninsula it is, perhaps, more frequent. In the
town of Singapore 186 cases of the disease were recorded in 1896,
55 in 1897, and 82 in 1898 ; and deaths annually occur from it
1

Medical Report for Ceylon for 1898.

480

TYPHOID OR ENTERIC FEVER

among the prisoners in the Singapore gaol. But the disease is
not mentioned in the list of the principal causes of death in the
Straits Settlements generally.
In French Cochin China enteric occupies the fifth position in
the list of principal causes of mortality among European residents.
In the Dutch East Indies enteric fever is essentially a disease
of Europeans and not of natives. In the year 1897 among 17,000
European (Dutch) troops stationed in this part of the world 29
were attacked with the disease, while in nearly 25,000 Asiatic
troops only 8 cases were recorded.
That enteric fever exists in China there can now be little
doubt. Europeans frequently suffer from it, and probably the
native Chinese are also attacked.
Some doubt as to the
possibility of the natives contracting it seems to have existed
until recently, because it is practically never possible to obtain
a post-mortem examination of a Chinese patient, and observers
have hesitated to diagnose the disease upon the clinical appearances only. On at least one occasion, however, its nature
has been proved by an autopsy on a Chinaman in Canton.
At Shanghai enteric fever occurs, according to some authorities
rarely, according to others with great frequency. At Hankow, on
the Yangtze-Kiang, the disease every year attacks the foreign
residents, the steamer population and visitors, and at times the
sailors on the naval boats stationed there contract it. A " severe
epidemic" of enteric prevailed there in 1894. The natives of
this place are believed also to suffer from the disease. At Swatow
4 cases of typhoid were treated in the Seamen's Hospital in 1896,
presumably in Europeans. Three cases were seen at Canton in
the same year; the disease was said in 1894 to have become less
frequent there than formerly, but many cases were believed to
have occurred in the south-eastern corner of the city in that year.
Several cases were recorded at Foochow in the same year. At
Hongkong 33 cases of enteric were treated in the Government
Civil Hospital in 1898. On the other hand some observers elsewhere in China furnish negative evidence. Thus MacCartney
doubts if true typhoid is ever seen at Chungking, and the same
doubt is expressed by others at Ningpo and many other places.
In the northerly province of Manchuria the disease certainly
exists; and the Russian troops stationed there have suffered from
it considerably.

TYPHOID OR ENTERIC FEVER

481

In Corea enteric would seem to be a rare disease, though not
unknown. In the island of Formosa no genuine case has, it is
said, been seen; but here, also, improved methods of diagnosis
may, as in China, show that the disease does exist.
In Japan 34,069 cases of typhoid fever with 8183 deaths were
registered in 1893, and 36,667 cases with 8054 deaths in 1894.
The mortality from this cause therefore oscillated about 200 per
million in the years in question.
Australasia.
In British New Guinea enteric fever is said to
be quite unknown.
In Australia, on the other hand, not only is the disease very
widely prevalent, but it has, at least in many parts, become
much more so in recent years than it was formerly. In Queensland it is the most frequent and fatal of all the so-called
"miasmatic" diseases. It caused a mortality here of 255 per
million in 1893, which fell in each of the following two years to
a minimum of 159 in 1895 ; but then a marked rise set in, the
ratios in 1896 and 1897 being 279 and 382 per million respectively.
In New South Wales the disease is also very prevalent.
In
Victoria the cases of enteric annually reported usually exceed
those of any other zymotic disease. In South Australia the
recorded deaths from typhoid fever fell from 128 in 1889 to
62 in 1893, but since that date the figures have risen, and
in 1897 the deaths numbered 106, and in 1898, 145. The last
figure was equivalent to a mortality of about 400 per million
of the population. In Western Australia a most marked and
excessive rise in enteric mortality was observed in the years
1895-1897. In the years 1889-1891 the recorded deaths from
this cause had been 13, 3, and 19 respectively; in the next
three years they rose to 55, 28, and 7 3 ; but in the following
three years the very large' numbers of 325, 400, and 407 respectively were recorded, followed by a fall to 296 in the year
1898. This excessive rise in typhoid fever mortality is, of course,
out of all proportion to the increase in the population at the
same time, and seems to indicate an enormously increased
prevalence of the disease. The figure for 1897 was equivalent
to a mortality of not less than 2420 per million inhabitants.
In Tasmania typhoid fever is a conspicuous disease, causing
yearly between 40 and 50 deaths (between 200 and 300 per
million inhabitants). It is essentially a malady of towns, and
c.

31

482

TYPHOID OR ENTERIC FEVER

frequently becomes epidemic in Hobart, Launceston, and other
places. It is said to be particularly rife among the mining
population.
In the Pacific Islands enteric fever is now met with, though
before the year 1875 it is believed to have been unknown there.
In that year a case was observed in one of the islands in a
gentleman newly arrived from Australia, and in this way the
infection is thought to have been introduced to Polynesia 1 . It
is now no great rarity in some of the islands. It prevailed
extensively among the United States troops stationed in Honolulu
in 1898. In Fiji two cases of the disease in Europeans were
treated in the Colonial Hospital at Suva in 1898 and six in 1897 ;
but in neither year were cases recorded in the natives. The
disease exists among the natives of New Caledonia, observers
differing, however, as to the extent of its prevalence. In the
Sandwich Islands the natives are said to suffer considerably, and
it is stated to be endemic in the Society and the Marquesas Islands.
In New Zealand the recorded deaths from enteric fever have
not varied greatly in recent years. In the decennium 1889-1898
they showed no definite tendency to increase or decrease; in the
first year of the period 118 deaths were recorded, and in the
last 120; in the year of greatest prevalence in the interval 145
deaths from this cause occurred, and in that of the least 94.
The mortality in 1898 was equivalent to about 160 per million,
indicating a degree of prevalence of typhoid fever in New Zealand
about equal to that of the disease in England in recent years.
Africa.
In Egypt enteric fever is particularly prevalent. It
is believed to be rife throughout the Nile valley and especially
in Lower Egypt. There is, it is said on good authority, no
station abroad in which British troops serve where the sickness
and mortality rates for typhoid fever are as high as in Egypt.
Among our soldiers returning from Khartum to Cairo, after the
defeat of the Mahdi, the disease was very active, although on
the advance up the Nile the health of the army had been
exceptionally good. It was suggested that the relaxation of the
strict discipline enacted during the advance may have favoured
the development of the disease on the return.
1

Sir William MacGregor, K.CM.G. etc., Address delivered to the London
School of Trop. Med. Oct. 3, 1900.

TYPHOID OR E N T E R I C FEVER

483

In Tunisia the disorder is now much less frequent and severe
than it was formerly. At the time of the French occupation in
1882 it was particularly prevalent. In Algeria it is of common
occurrence among Europeans, but until recently it was believed
to be rare among natives. Of the total number of typhoid patients
treated in the French hospitals at Mascara and Mostaganem the
natives formed only from 6 to 8 per cent. But here, as was shown
to be the case in regard to the natives of India, the belief has
been expressed that the immunity of the natives may be only~
apparent and not real. The Arabs in Algeria apply for medical
treatment with great unwillingness, and there is reason to believe
that many of them may have suffered from typhoid fever in
childhood or youth, and thus acquired immunity to the disease.
Some uncertainty existed until recently in regard to the
frequency or even the existence of typhoid fever among the
native negro races of the central zone of the African continent.
It is now, however, generally admitted that the disease certainly
exists here, though with what degree of frequency is still undetermined.
Pruen states, for Central Africa generally, that
typhoid fever, as well as dysentery and diarrhoea, prevail most
at the beginning of the rainy season. H e speaks of the disease
as occurring on the shores of the Victoria Nyanza. Undoubted
cases of enteric have also been seen in Uganda by others 1 . In
the Cameroon district a small epidemic of typhoid fever was
observed among the natives in 1894, and in two cases the
presence of intestinal ulceration and gastro-intestinal catarrh was
demonstrated by post-mortem examinations; in 1895 several
sporadic cases occurred in the natives, and two Europeans were
attacked. It is probably, however, a comparatively rare disease
on the West Coast of Africa generally. It' is not mentioned in
some recent Annual Reports on the health of the Gold Coast
Colony, of Lagos, of the Gambia, and of Sierra Leone, and several
writers upon the principal diseases of the Belgian Congo make no
reference to typhoid fever, though acknowledging the existence
of typho-malarial fever in that country. In Senegal it is said
to be met with occasionally both among Europeans and natives.
In Eastern Africa it is probably also rare. At Zanzibar it does
not appear to have been recognised, and in British and German
East Africa it is not included among the diseases met with.
1

A. R. Cook, Journ. Trop. Med. March 1, 1902.
31—2

484

TYPHOID OR ENTERIC FEVER

In Madagascar typhoid fever is stated to be a very common
disease in the central plateau and rather less so on the coast;
the Hovas are said to suffer from it severely.
In Mauritius it is also frequent, especially in the Riviere du
Rempart district in the north of the island. It is very prevalent
on the great sugar estates, owing to the insanitary habits of the
natives and their entire indifference to the pollution of soil and
of drinking-water. It has been endemic here since 1838.
It certainly exists in St Helena, one case being recorded in
the Colonial Hospital Report for the island in 1898, and seven
in 1897.
The wide prevalence of typhoid fever throughout South Africa
is in marked contrast with its comparative rarity in the central
portions of that continent. In both colonial and other territories
in the south it is everywhere, almost without exception, the
predominating disease. In Cape Colony it is widely endemic,
and not infrequently becomes epidemic. Its frequency is clearly
shown by the hospital returns and by the reports of the health
officers in the various districts of the colony. In the Somerset
Hospital at Cape Town, the Frontier Hospital at Queenstown,
the Albany Hospital at Grahamstown, the Provincial Hospital
at Port Elizabeth, and in many others, typhoid fever occupies
the first or nearly the first position among the diseases dealt
with. The medical officer of the Grey Hospital at King William's
Town wrote in 1898 that enteric fever was not only the most
prevalent disease, but that it was increasing and that "from a
public health point of view such a state of matters is scandalous."
In Kimberley the disease was very rife in the hot weather of
1897, but considerably less so in 1898. In Gordonia it was
epidemic in 1897-98, in the Strydenburg sub-district it caused
a severe and alarming epidemic in 1898, and the mortality
among the natives was very high. From Fraserburg, Cradock,
Queenstown, Richmond, Victoria West, Vryburg, and from most
other places whence reports are received, there is the same evidence
of the frequency of enteric fever. In Namaqualand it is constantly
present. In the native territories of Tembuland, the Transkei and
Pondoland it is a less conspicuous disease, but is at times epidemic
in several places. In Griqualand West it was epidemic in 1898.
In Mashonaland it appears to occur only sporadically.
In Natal also typhoid fever is widely prevalent. In the Durban

TYPHOID OR ENTERIC FEVER

485

Hospital it is one of the most frequent diseases dealt with, and
at Pietermaritzburg it is constantly present.
In Basutoland the malady is frequently epidemic in the native
villages, and in Rhodesia it is known, a few cases of it coming
under treatment in the Memorial Hospital in Buluwayo both in
1897 and 1898.
North and Central America. Enteric has been observed in
epidemic form as far north as Greenland, Labrador, and Sitka.
In Quebec typhoid fever is of much less frequent occurrence
than it was some years ago. Outbreaks occur here and there in
the province from time to time, but they have become rarer as
greater attention has been paid to the protection of water-supplies.
In the province of Ontario it prevails more or less in the autumn
months, but here also it is diminishing. In 1897 the disease was
prevalent in a few districts, particularly in the mining centres in
the west of the province. The town of Kingston, where typhoid
in former years was common, is now almost free from the disease,
thanks to improved sewering and water-supply. In New Brunswick
the disorder is frequently seen; 49 cases occurred in the city and
county of St John in 1897, and 19 cases at Fredericton in the
same year, and it is mentioned in the reports from most other
places in the province.
In Nova Scotia sporadic outbreaks
occur at times in different parts of the province. In Manitoba
the disease is met with and appears to be far from infrequent,
though somewhat less so in recent years than formerly. The
cases recorded in the province in the four years 1894 to 1897
were respectively 568, 187, 147, and 274. In British Columbia
enteric is frequent; in 1896 epidemics of the disease were
reported from Kamloops, Rossland, Nelson and other places, in
the last-named in the depth of winter when snow lay deep on
the ground. In Vancouver Island it is also met with.
Typhoid fever appears to be prevalent in greater or less degree
throughout the United States. In 1897 there was not a single
State in which deaths from the disease were not included among
the mortality statistics of the principal towns and cities, with the
doubtful exception of Idaho. In the urban population of the other
States the mortality varied between 100 and 500 per million inhabitants. In some States this has considerably diminished in
recent times. Thus in Massachusetts the mean annual death-rate
from typhoid fever fell from 820 per million inhabitants in the

486

TYPHOID OR ENTERIC FEVER

quinquennium 1871-75 to 450 in the next quinquennium. In the
next five years it rose again to 500, but fell to 410 and 320 respectively in the two succeeding quinquennia. The mortality rates in
the chief cities of this State showed an exactly parallel course in the
same period, the figures for the cities being almost identical with
those for the State as a whole, but certain places, as for example
North Adams, have,a constant bad reputation for the prevalence of
typhoid. It is interesting to note that in Massachusetts the decline
in mortality from this disease has coincided with the introduction
of public water-supplies, and an instructive diagram was recently
published by the State Board of Health showing an exact parallelism between the line of typhoid fever mortality and the line
indicating the percentage of population not furnished with public
water-supplies. As the latter has diminished, so with unfailing
regularity has the former.
In the State of Michigan enteric fever is believed to prevail in
successive waves, the principal of these being some twelve years
apart and one or two minor waves occurring in the intervals.
The mortality from the disease fell in this State from 526 per
million in 1881 to 214 in the following year, and from 1882 to
1895 it n a s fluctuated irregularly between 200 and 400 per million
per annum.
Mexico is said to enjoy a remarkable immunity from typhoid
fever, and in British Honduras the disease is said to be unknown.
In Guatemala, on the other hand, it is probably not rare, for in
1894 the recorded deaths—229 in number—were equivalent to a
mortality of 160 per-million.
In many of the West Indian Islands enteric fever is frequently seen. In Jamaica it is particularly prevalent. In the
year ending March 31, 1898, the recorded deaths in Kingston
were equal to 719 per million of the population, and the disease
is spoken of as a serious menace to the health of the island, " the
conditions for its dissemination and consequent permanent continuance and increase" existing everywhere. In Trinidad a few
cases were recorded in many districts, e.g. those of Port of Spain,
Chaquana and Guaracara, and in many hospitals, e.g. that of
San Fernando, in 1898. In Cuba enteric was terribly prevalent
during the wrar of 1897. In Barbados cases were reported from
many places in these two years, and in 1898 53 cases of the
disease were treated at various hospitals and institutions through-

TYPHOID OR ENTERIC FEVER

487

out the island. In Golden Ridge it is spoken of as endemic. In
the Leeward Islands generally, though the disease is apparently
not a very conspicuous one, some cases are always mentioned
in the annual reports of the Colonial Hospitals. In the Bahamas
an occasional case is mentioned in the like reports for these islands.
In the Bermudas typhoid fever seems to be much commoner than
in the more southerly islands; 60 cases of the disease were
registered in 1898, and many others were thought to have escaped
diagnosis and. record, particularly in the coloured population, who
are said to suffer frequently from it in a mild form.
South America.
In British Guiana the recorded cases of
typhoid fever are low in comparison with those of many other
acute diseases; it is said, however, to prevail considerably among
the coloured races (mostly negroes). In French Guiana it is
observed at all seasons and among all races. In Brazil it is
common; it is very prevalent in Rio de Janeiro, and in many
towns and villages of the interior a severe type of the disorder
is said to be met with.
In the Argentine Republic typhoid fever is exceedingly
prevalent. In the Statistical Annual for the province of Buenos
Aires for 1897 it is stated that the disease there has a grave and
permanent character. In the ten years 1888 to 1897 the mortality
from this cause was equal to 650 per million inhabitants per annum,
or about four times as great as the corresponding mortality in England within recent years. In 1897 the recorded deaths from this
cause in the province were 534 in number (about 533 per million),
of which 270 occurred in the northern region, 182 in the central,
77 in the southern, and 5 in the Patagonian region of the province.
In the Uruguay Republic the disease is also widely spread.
In 1897 it was the cause of 302 registered deaths—a figure far
higher than the returns of any other of the zymotic diseases,
and equivalent to a mortality of little short of 400 per million
inhabitants. The disease is knowTn in Peru and is said to be
common in Callao; the statistics, however, for that city return
• enteric and malaria under one and the same heading.
F a c t o r s w h i c h d e t e r m i n e t h e D i s t r i b u t i o n , Few diseases are more widely spread over the earth's surface than enteric
fever. It is almost ubiquitous. It is met with in the tropics,
in the temperate zones, and in sub-arctic regions. No latitude is
altogether free from it, for though it is rare or even unknown in

488

TYPHOID OR ENTERIC FEVER

a few tropical and subtropical countries, such as British Honduras,
Mexico, New Guinea, Central and Western Africa, it is endemic
in many other countries in the same latitudes and with similar
climates. That it can occur and even remain endemic in the
presence of extremes both of heat and cold is shown on the one
hand by its persistence in India, in Ceylon, and many of the West
Indian Islands, and on the other by its appearance as an epidemic
in Greenland and Labrador, and its constant presence in Northern
Siberia. It is, however, mainly in the temperate zones that typhoid
fever is most widely and permanently prevalent.
In its seasonal relations typhoid fever, in many parts of the
world, prevails most in the autumn and least in the spring and
early summer. In tropical and subtropical countries, however, it
is said to be most common in the hot season. In Central Africa
it is most prevalent at the beginning of the rainy season, " when
the showers first moisten the refuse lying about and thus cause its
decomposition, and then wash the decomposing materials into the
nearest stream." Elevation above sea-level appears to have little
determining influence in the distribution of the disease, and it
flourishes* just as well in the Transcaucasian mountains as in the
plains to the north of them, in the Arabian Highlands as in the
flat coast-line of the Hedjaz, and on the central plateau of
Madagascar as on the shores of that island. Its relation to
different kinds of soil is uncertain, but it is held by many that
fluctuations in the height of the sub-soil water may be a powerful
factor in typhoid prevalence. This view, first advanced by
Pettenkoffer and Buhl, is briefly as follows :—typhoid fever cases
increase in number as the sub-soil water falls, and decrease as it
rises, and the wider the fluctuations in the sub-soil water the
greater will be the frequency of typhoid. The rule has been
followed in a considerable number of epidemics in various
countries, but there have been, on the other hand, many epidemics
in which it did not hold good.
It is now almost universally admitted that enteric fever is a
water-borne disease; and though it may possibly be spread in
other ways, it is certain that its most frequent method of diffusion
is by means of sewage-contaminated water. As in the case of cholera,
so in that of typhoid fever, the specific virus appears to be contained in the dejecta of persons suffering from the disease, and
when drinking-water is directly or indirectly contaminated with

TYPHOID OR ENTERIC FEVER

489

such dejecta it becomes the most potent, though probably not
the sole means of diffusing infection. Innumerable epidemics
have been traced with certainty to a water-supply thus specifically contaminated. This does not exclude the recognition of
other modes of diffusion of the virus. Direct infection from person
to person appears to be possible; infected dust may almost
certainly spread the disease; and there is not a little evidence
to show that the typhoid fever poison may be conveyed by—some
even believe it may be generated in—the air of sewers and drains.
The escape of sewer-gas into dwellings has certainly in many
instances been associated with the occurrence of typhoid fever,
and the possibility of the specific virus thus gaining access to the
dwelling can scarcely be denied. Other hygienic defects are very
commonly found in association with a high degree of typhoid
prevalence, and the disease may be justly regarded as one to a
great extent dependent upon insanitation. In other words it is
largely, though perhaps for the present not wholly, a preventable
disease, and has been found to diminish in a striking manner as
the general level of sanitation has risen in a city or country. Of
all great public measures for improving the health of the community the most powerful in combating typhoid prevalence have
been the provision of pure water-supplies and the construction of
good systems of drainage. In England the late Sir George
Buchanan showed clearly how the deaths from typhoid fever had
steadily declined with the increase and improvement of sewerage
systems. In innumerable places at home and abroad care to prevent contamination of water-supplies has led to equally satisfactory
results. Some striking examples have been already quoted in the
course of this chapter. Milk and other articles of food may also,
it is believed, become contaminated by the typhoid fever virus and
be the means of its diffusion, and no doubt a better supervision
over the purity of food-supplies has had its share, among other
public health measures, in diminishing the prevalence of the malady.
The very noteworthy diminution in typhoid fever mortality
in many European countries in recent years may justly be
attributed to a general improvement in the level of sanitation
and public health administration. Diminution of this kind has
been observed in the last few decades in the British Isles, in
France, Holland, Belgium, Denmark, Germany, Norway, Austria,
Hungary, Switzerland, and Italy.

490

TYPHOID OR E N T E R I C

FEVER

Race is probably a factor of considerable importance in the
distribution of typhoid fever. All races are perhaps capable of
suffering from it, but all are not equally liable to its attacks. It
has already been seen how much more susceptible the European
in India is to the disease than the native. Among the natives
themselves also there are different degrees of susceptibility, and
the Gurkha is believed to be particularly liable to it. A similar
excessive susceptibility of the European over the native is seen
in the Malay Peninsula, in the Dutch East Indies, in China,
Algeria, and elsewhere. No doubt in many of these instances the
racial element is not the whole explanation of the difference; the
Europeans attacked by the disease are often new-comers, exposed
for the first time to a particular form of typhoid infection to which
the native has long been "acclimatised," if he has not been actually
" immunised " by a recognised or unrecognised attack of the disease. In the United States the white races are said to suffer most
from the disease, the coloured races slightly less, and the Indians
least of all; the difference between the three races is not, however, very striking. In French Guiana all races, Europeans,
negroes, and Indians, are liable to it.
Of the many diseases which war brings in its train none is
perhaps so frequent and fatal as typhoid fever. There is scarcely
a war of recent times in which thousands of lives have not been
sacrificed to it. The South African war has been no exception,
and, indeed, in the great outbreak which attacked our men in and
around Bloemfontein in 1900, this war has furnished one of the
most striking examples of modern times of the deadly effects of
this disease upon troops. The frequency of enteric fever during
military operations is to be attributed, perhaps wholly, but certainly
mainly, to the ease with which streams and other water-supplies
become contaminated with sewage-matter, and to the absence or
inadequacy of the measures taken to prevent the men drinking
such polluted water. A movement has been recently set on foot
to induce military authorities to pay more attention to this
question, and to evolve some scheme of providing troops with
pure water under all conditions of military life. Any experiment
of this kind will be watched with great interest, and should it
succeed in abolishing, or even in greatly diminishing the typhoid
scourge in future wars, the recent terrible experiences of our men
in South Africa will not have been in vain.

TYPHOMALARIA

491

TYPHO-MALARIA.

Typho-malaria and malarial typhoid are names that have been
employed by many writers to indicate a form of disease presenting
the symptoms of both malaria and typhoid fever. That the two
diseases can exist in the same subject at the same time there can
be no doubt. Lyon \ in New York, has demonstrated the malarial
organism in the blood and the Eberth bacillus in the spleen and
intestine of five patients presenting symptoms of both diseases.
Washbourn in South Africa, during the war2, A. R. Cook in
Uganda 3 , Alvaro in Naples, and others have made precisely
similar observations. In the same way small-pox and malaria,
plague and malaria, plague and leprosy, typhus fever and scurvy,
scarlet fever and diphtheria, measles and chicken-pox, have been
observed on several occasions to attack a person at the same time,
and the list of diseases which may occur in pairs in the same
individual could no doubt be lengthened considerably 4 .
The name typho-malaria has, however, come to be used by
many writers to describe a disease which they believe is not due
to a combination of the two infections, but distinct from either—
a third disease, in fact. If this view should prove correct, and if
from the many " unclassified" fevers which certainly exist, one
should come to be clearly differentiated, both clinically and
etiologically, and take its place in the list of named fevers, it may
be hoped that some other name will be found for it than this At
present no other name has been suggested, and the term typhomalaria or malarial typhoid will therefore be used here to indicate
a group of cases, some of which may ultimately prove to be of the
nature of a distinct and separate disease. The confusion existing
between Mediterranean fever and typho-malaria has been pointed
out in an earlier chapter 5 . Whether the many obscure fevers
met with in the near east—such as "Cyprus fever," "Bukowina
1

American Journal of Med. Sciences, Jan. 1899.
Brit. Med. Journal, April 20, 1901.
Journ. Trop. Med. March 1, 1902.
4
See a paper on this subject by F, Foord Caiger, M.D., B.S.
of the Epidemiological Society. 1893-4.
5
See p. 282.
2

3

Transact,

TYPHO-MALARIA

492

fever," the "bilious typhoid" described by Griesinger in Egypt,
the " bilious typhus " seen every summer in Alexandria, " Smyrna
fever," " Levant fever," and many others—are or are not of the
nature of so-called typho-malaria there is no scientific evidence
to show.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . The evidence of
the existence of this disease in Europe is not very conclusive.
In Greece, where both malarial and typhoid fevers are extremely
prevalent, cases presenting difficulty of diagnosis, and apparently
on the border line of the two diseases, are often seen. Dr Cardamatis of Athens, who has discussed at length the fevers of that
country, does not, however, include typho-malaria amongst them 1 .
H e concludes that the large majority met with there belong
to one or other of three distinct groups—paludic fevers, fevers
due to auto-intoxication (from gastro-intestinal disturbance),
and typhoid fevers. In Constantinople and the neighbourhood
a class of obscure fevers is very commonly seen in which some
of the features of both malaria and typhoid are present, but it
would be difficult to assert that these are identical with the cases
described by American writers as typho-malaria.
It is principally in America and in Africa that the disease
known under this name has been seen. In America it was first
described by Woodward as observed by him in the Federal army
on the Potomac in the year 1861. According to that author over
57,000 cases of this disease, with over 5000 deaths, occurred in
the American army; but it seems probable that these figures
included a large number of cases of, and deaths from, other
disorders. At the present day the term typho-malaria is frequently
used by American medical writers, and cases of the disease
known by this name appear to be not infrequent in many
parts of the United States. In New York, Pennsylvania, parts of
New England, and Ohio the term is most commonly met with.
In Michigan it is accepted by the State Board of Health, and in
some parts of the State the malady thus indicated appears to be
one of the fifteen diseases most prevalent in certain years2.
In British North America this form of disease is also not
unknown. Thus at Greenwood city, in British Columbia, a mild
1
2

La Grece Medicate, 1900.
Prof. G. Dock, M.D., New York Medical Journal, Feb. 25, 1899.

TYPHO-MALARIA

493

outbreak of "typho-malarial fever" occurred in 1897, and, in the
opinion of the Medical Officer of Health, was caused by soil disturbance. The course of a stream called the Boundary Creek
had been changed within the limits of the city, and the attacks
of this disease were distributed among those who used the water
drawn from the channel just below the point where its course had
been changed. In the preceding year a "fever of typho-malarial
type which ran a typhoid course" was met with at Richmond,
also in British Columbia; in this outbreak 26 Japanese,
12 Indians and 18 white persons were attacked.
A disease of like character appears to be endemic in some
of the West Indian Islands. In the hospital reports of the
Leeward Islands occasional mention is found of cases of typhomalarial fever; and in Cuba during the recent disturbances many
cases of the kind were observed among the American troops
employed in the war.
In many parts of the African continent fever described as of
typho-malarial character has been met with. Vincent saw 17 cases
in Algeria. On the West Coast it has been seen in the Gambia, in
Senegal, and in the Belgian Congo. On the Red Sea coast the Italian
troops suffered from it in Erythrea in 1897. In South Africa this
type of fever appears to be common. It is occasionally epidemic
in some parts of Cape Colony, where it is locally known as
" River Fever " or " South African Fever." Epidemics of it were
reported from Gordonia in 1897-8, and from the Xalanga district
in 1898, and here as elsewhere the suspicion arose that the fever
in question might possibly be true Mediterranean fever. In the
Galeka-Gaika campaign of 1877-8 and in the Zulu war of 1879
it is also to be noted that the British troops suffered heavily from
a mixed infection of enteric fever and malaria (Sambon). In the
recent war Washbourn saw a case in which " a well-marked attack
of remittent malaria with parasites in the blood recurred during
the incubation period of enteric fever1."
Finally from some parts of the continent of Asia reports of
the existence of this form of fever have been published. The
occurrence in Jerusalem of a typho-malarial disease bearing some
resemblances to Mediterranean fever has been already mentioned 2 .
In China typho-malarial fever is apparently far from rare, and
1

Brit. Med. Journal, April 20, 1901.

2

See p. 286.

494

TYPHO-MALARIA

mention of its occurrence in the reports of the medical officers
in the Chinese Customs Service is comparatively frequent. In
quite recent years it has been reported from Hankow, from
Canton, from Chungking, and from Mengtsze in Yunnan. In
India it seems probable that this form of disease is met with, but
here again doubt has arisen as to whether it is riot of the nature
of Mediterranean or undulant fever.

TYPHUS FEVER.
H i s t o r y . Uncertain references to this disease are found in
the records of some of the oldest writers and historians, and there
is good reason to believe that in the earliest ages of the world's
history typhus fever accompanied famines, sieges, and wars, just
as it has in modern times. The first definite mention of the disease
has been assigned to the eleventh century. Throughout the Middle
Ages and down to the last century typhus fever was exceedingly
prevalent in most European countries, and was the cause of
frequent epidemics. In the nineteenth century there was a very
general lessening in the activity of the disease. The Napoleonic
wars had led to a most serious and deadly extension of typhus
fever over a great part of the continent. But when these came
to an end in 1815, and an era of peace began, there was a marked
subsidence in typhus prevalence. Since that date the disease has
remained endemic in certain countries only, but has elsewhere
either disappeared altogether or become very rare. In 1846-7,
however, there was again a wide diffusion of typhus fever over
Europe, and serious epidemics of it are constantly recorded from
different parts of the world where famine and want and other
conditions exist to bring them about.
R e c e n t Geographical D i s t r i b u t i o n . Europe. In England
of recent years typhus fever has been gradually becoming extinct.
It still lingers, however, in certain areas in the north-west and
northern registration divisions of the country, where the overcrowding and other conditions which favour its development are
most markedly present. This was very clearly seen in the records
for the decade 1881-90, when considerably over half the deaths
from typhus recorded for the whole country occurred in districts
containing not more than one-eighteenth of the entire population.

496

TYPHUS FEVER

These districts were situated in Cheshire, Lancashire, Durham,
and Northumberland; the mortality here from this disease in
the decennium in question was as high as 139 per million, while
in the rest of England it was only 7 per million. In the last
decennium a still further decrease in the mortality from typhus
has been observed, and in 1899 and 1900 it was less than 1 per
million.
In Scotland occasional localised outbreaks of the disease
occur from time to time. In the decade 1881-90 the average
annual mortality from this cause was 33 per million, or some
126 deaths per annum; in 1895 on ^y 34 deaths were recorded;
in 1896 the deaths from typhus numbered 38, and in 1897 they
fell again to 29.
In Ireland the disease is very much more common, though
in recent years there has been a tendency to a steady decline
in its prevalence. Thus in the three decades 1871-80, 1881-90,
and 1891-1900, the mean mortality rates from this malady were
141,' n o , and 47 per million respectively. Ireland was formerly
regarded as one of the most important European centres of
typhus fever infection, and was the principal source of epidemics
in England and Scotland in the past.
The degree of prevalence of typhus fever in France has varied
widely in recent years. Thus in 1893 as many as 200 deaths from
the disease were recorded in the group of towns with over 10,000
inhabitants. The deaths from this cause then fell to 63 in 1894,
to 11 in T895, to 7 in 1896, and to 4 in 1897; and in 1898 the
towns were apparently free from the disease, no deaths from typhus
fever being recorded in them in that year. The malady appears
to be endemic to some extent in Brittany, and the epidemic of
1893 just mentioned, which prevailed principally in Paris, and
between that city and Havre, was thought to have originated
in the Breton centres of the disease 1 .
In Germany typhus is said to be commoner in the east
than in the west, in consequence, it is thought, of the greater
proximity to Russia and Austria, where the disease is endemic.
In Silesia and parts of Prussia it is also perhaps endemic. In
Saxony, Bavaria, and Wurtemburg, on the other hand, it is
said to be almost unknown.
In Holland it appears to be
1
Contribution a VEtude de FEpidemie de Typhus Exanthematique du Nord
de la France en 1892-3, par le Dr Netter, Paris, 1893.

TYPHUS FEVER

497

exceedingly rare, and in Denmark it must be equally so, for only
four deaths from the disease have been recorded as occurring in
the Danish urban population in the six years 1892-1897, and
all four occurred in the same year (1893).
In Norway and Sweden a few cases of the disease occur every
year, but it is apparently not a common malady in either country.
In Russia, on the other hand, there can be no doubt that
it is exceedingly frequently met with. There is no portion of
the Russian Empire, whether in Europe or Asia, from which cases
of and deaths from this disease are not yearly reported. Its
distribution varies from time to time, but so far as may be judged
from the published statistics of cases and deaths it is only in the
Central Asiatic provinces of Russia, in the Baltic provinces, and in
the Caucasus that the disease is rare. The following table shows
the recent returns of typhus fever in the various territorial divisions
of the Russian Empire, the figures representing the numbers of
registered cases per million inhabitants.

\

30

200

120

680
730
570
280

Central
Asiatic
Provinces

540

160

/

,
|
The
Caucasus
IOO

50

360
600
230

Siberia

/

40
60

IOO

39°
280
170

Baltic
Governments 1

/

ASIATIC RUSSIA

The Don
Cossacks

1020

V

i860
1290
830

Polish

Governments 1
with
I
Zemstvos^-

1887-92 (mean) 410
660
1893
1894
550
440
1895

Year

Governments

Governments
without
\
Zemstvos1 1

EUROPEAN RUSSIA

50
70
IO
IO

Total

740
1230

860
570

It will be observed from this table that typhus fever is most
common in European Russia, and particularly in those parts of the
country in which government by Zemstvos has been introduced.
These, it is to be added, constitute by far the greater part of European
Russia proper. It will further be noted that the disease is somewhat less common in Siberia, still less so in Polish Russia and in
the country of the Don Cossacks, and markedly less so in the
Baltic provinces; while, as stated already, in the Caucasus and
Central Asia it is, so far as these figures may be accepted as an
1
That is to say in which the system of local government by bodies known
as Zemstvos has, or has not, been introduced.

C.

32

498

TYPHUS FEVER

index, comparatively rare. This fever was exceedingly prevalent
in Russia during and after the great famine of 1891, particularly
in Saratof, Kazan, Tambof, and other districts where the suffering
from the famine was greatest. Many cases were seen in which a
severe form of typhus was combined with scurvy; and it is noteworthy that the great Russian surgeon Pirogof states in one of his
essays that the same combination of diseases was very common
among both the besiegers and besieged during the siege of Sevastopol in the Crimean war.
The frequency or infrequency of typhus fever in AustriaHungary is a matter of some uncertainty. In the year 1896 some
1009 deaths from this cause were recorded in the country, but the
large majority of them occurred in Galicia. In the other provinces
no deaths from this disease were registered, with the exception of
a few in Carinthia, Silesia, Bukowina, and Dalmatia. Epidemics
have not been infrequent in the past in the Austrian Empire,
particularly in Galicia.
In Italy typhus has of recent years been exceedingly rare. In
1887 and 1888 the recorded deaths from the disease in that country
were equal to a mortality-rate of 65 and 71 per million respectively; but after 1888 the mortality-rate fell, and from 1890 to
1896 it never exceeded three per million, and in some years was
less than one per million. Formerly typhus fever was excessively
common in Italy, which was ranked next to Ireland and the
Slavonic countries among the leading endemic centres of the
disease in Europe. In Spain and Portugal there is little certain
information as to the frequency of this disease, but it is said to be
rare in the Peninsula. In Turkey in Europe it is rare at the present
day. After the Russo-Turkish war of 1877 and the Turco-Greek
war of ^1896 there was a considerable amount of the disease in
some parts of the country, but it has since almost disappeared.
In Constantinople it may be doubted whether it is ever seen now
as an indigenous disorder.
The malady has been epidemic on more than one occasion in
the past in Iceland, but it does not seem to be endemic there, and
in the Faroes it has never been met with.
Asia. The prevalence of this disease in the Russian portions
of Asia, i.e. the Caucasus, Central Asia, and Siberia, has been
already discussed.
In Asia Minor, Armenia, and Syria, typhus fever is said to

T Y P H U S FEVER

499

occur, not as an endemic disease, but in the form of occasional
epidemics. In Mesopotamia, on the other hand, it is said to be
endemic.
There can be little doubt that it is also an endemic
disease in Persia. In Teheran it occurs in the form of occasional
epidemics; and, elsewhere, recurring outbreaks of the disease
appear to be not uncommon. In 1880 and 1881 it raged with
great severity in some localities that had been devastated by a
Kurdish invasion.
As regards the prevalence of typhus fever in India and
Baluchistan it appears that there is a somewhat extensive area
in which the disease is truly endemic. This area includes the
Trans-Indus districts from Baluchistan to Yusufzai, extending
through the Hazara and Rawal-pindi districts, and including the
Himalayan hill-tracts1. The Yusufzai valley, near Peshawur, is a
well-known home of the disease, in which epidemics are far from
uncommon. In Kumaon and Garhwal, on the southern slopes
of the Himalayas, it seems that it is also more or less endemic.
But a certain amount of confusion has arisen between typhus and
plague in these provinces. It appears that both these diseases
occur here at times in epidemic form. The terms sunjar and
ma/iamari, in general use among the Himalayan hill tribes, have
been usually held to mean typhus fever and plague respectively.
But an epidemic of sunjar was investigated in 1899 by Dr Leonard
Rogers, and proved to be one of relapsing fever 2 ; and it appeared
from inquiries made on the spot that mild outbreaks of any epidemic disease in these hill-tracts are termed sunjar, and severe
ones mahamari.
In some parts of India, as for example in
Rajputana, typhus fever is said to be unknown. It is interesting
to note in this connection that the fever which has prevailed in
the Central Provinces in consequence of the recent famine, has
not been of the nature of typhus fever. Typhus is also unknown
in Ceylon.
Concerning the East Indian islands and the Malay Peninsula
the information is more scanty. In Borneo there appears to be no
certain record of the occurrence of this disease, while in Java it is
1
Transactions of the Indian Medical Congress^ 1894. In 1892-3 the disease
became epidemic among the Ghilzai labourers (from Jellalabad) employed in
building the Mushkaf-Bolan Railway.
2
Annual Report of the Sanitary Commissioner of the North-Western
Provinces and Oudh.

32—2

Soo

TYPHUS FEVER

definitely said to be unknown, at least among the hill tribes,
and as it is among hill tribes that typhus fever generally finds
favourable conditions for its prevalence, it may be assumed that
the disease is absent from the whole island. On the other hand
typhus is said to have been observed in Celebes. I find no
mention of the disease in recent reports from British North
Borneo, nor in any recent reports or writings that I have
consulted upon the pathology of the Straits Settlements, Siam,
Cochin China, or Tongking.
In China typhus fever would seem to be rare in the south,
while in the north it is commonly met with. At Peking and
throughout the north generally the disease is endemic, and tends
to become epidemic each recurring spring. It is known to the
natives as Yen-ping. The fever known as "Peking fever" is said
to be no other than typhus. In China and elsewhere the disease
is closely associated with conditions of overcrowding and misery,
and it is consequently mostly among the natives that it is found to
prevail. The European residents usually escape its attacks, unless
they, too, are living under conditions resembling those under
which the natives live. This has sometimes happened in the case
of foreign missionaries, who then appear to have suffered no less
than the natives themselves. In some years the disease has been
so severe among the Chinese that the hospital attendants have fled
panic-stricken to escape the infection1. Reports of the occurrence of typhus are also forthcoming from Chingkiang, Hankow,
and Taiping-fu. At Shanghai, on the other hand, the disease
seems to be rare, and at Amoy it is said to be unknown in
spite of the presence of a large number of typical fever dens.
In general terms it seems to become comparatively rare to the
south of Shanghai, and in Canton its existence has been denied
altogether, though an outbreak of fever called chut-pan, or spotted
fever, which occurred in Canton in 1879, may have been one of
typhus.
The existence of typhus fever in Japan has also been denied,
but it appears that the disease was epidemic in Tokio in the spring
of 1881. A large number of convicts in the prisons were attacked
and the disease spread more or less over the whole city, more than
one hundred cases being reported to the police 2 . Since that date
1
2

Matignon. Chinese Imperial Maritime Customs Medical Reports, 1895-6.
Sei-i-kwai. October n , 1898.

TYPHUS FEVER

SOI

a few cases of typhus have been recorded every year in some part
of Japan, and particularly in the Hiogo province.
Australasia.
In the Philippine Islands and New Guinea I
find no mention of typhus fever, and in Australia the disease
appears to be rare, if indeed it is known there. In New Zealand,
and throughout the islands of the Pacific it seems to be unknown.
Africa,
Whether typhus fever be endemic in Egypt, or
whether it is always imported from Nubia, where according to
Hirsch it is endemic, there can be no doubt that the disease is
met with in Egypt, and is no great rarity there. It has been
known to break out with considerable severity in Egyptian prisons,
as, for example, in that of Tourah in 1886 and again in 1890. In
the latter year typhus was unusually prevalent in many parts of
Egypt; it was particularly severe at Tantah, Zagazig, and some
other places.
It has often been said that typhus is endemic in Tripoli. This
does not appear to be true of the Cyrenaic plateau, where the
disease is not permanently endemic, but has on certain occasions
broken out and caused epidemics of extreme intensity. An
outbreak of this kind occurred in 1892-3. Dr Biednavski, who
investigated it on behalf of the Turkish sanitary administration,
informs me that it succeeded several years of serious famine, and
that the inhabitants, mostly nomad Bedawin, had collected in
the three principal towns, Benghazi, Merdj, and Derna, under
conditions of overcrowding, filth, and mal-hygiene which need
not be dwelt upon. Typhus broke out, and in the course of
some three or four months caused the death of about 15,000
persons in a population which perhaps did not exceed some
40,000 souls. Since that date, so far as is known, there has been
no epidemic recurrence of the disease.
In Algeria it is seen, though rarely. Hirsch, however, says
that it is—or was—endemic and occasionally epidemic in Kabylia.
In Morocco it is said sometimes to occur in the train of famines
caused by the ravages of locusts.
On the West Coast of Africa the disease appears to be
almost unknown. It is not mentioned in most recent reports
or publications on the prevailing diseases of the Gambia, Lagos,,
the Gold Coast, Sierra Leone, or the Cameroons. It appears
to be in like manner absent from the list of diseases met with
in the Congo Free State. Equally remarkable is the absence

S02

TYPHUS F E V E R

or extreme rarity of typhus fever in South Africa. Doubt has
been expressed whether the disease does exist at all in this part
of the world, and, if it does, it is certainly among the rarest of
all disorders. In recent official reports from the Cape Colony,
from Natal, and from the other British possessions in that region
there appears to be no mention whatever of typhus fever, at least
up to the time of the outbreak of the late war. In 1898
three isolated cases of the disease were reported from the ^ubdistrict of Petrusville, in Cape Colony, and this would seem to be
almost, if not quite, the only instance in which typhus fever has
appeared in this part of the world in recent times.
The disease appears to be equally rare or unknown on the
east coast of Africa, and in the islands of Madagascar, the
Seychelles, and Mauritius.
North and Central America. At the present day typhus fever
must be regarded as a rarity throughout the greater part of
British North America and the United States. In both it has in
times past prevailed to a greater or less extent, usually in the form
of localised outbreaks, which, in the majority of instances, were
traceable to importation by immigrants from Ireland. " In many
cases," writes Hirsch, " t h e disease was confined exclusively to
immigrants; in others it spread among the population of the
seaports, particularly in the filthy and crowded quarters, but
without ever attaining the dimensions of a great epidemic." In
neither Canada nor the United States has typhus ever become
truly endemic, and in recent reports from the Canadian provinces,
and in such reports from the States as I have had access to, the
name of this disease is conspicuous by its absence. Osier states
that it is occasionally seen in New York and Philadelphia, and
mentions an epidemic of it in 1877 in the House of Refuge
in Montreal.
In Mexico, on the other hand, it is truly endemic,
and has apparently been so for more than three centuries.
Prof. Monjuras of San Luis Potosi states that the disease is
exceedingly common in that town; no season of the year is free
from it, and he even adds that there is no day in the year on
which cases are not recorded. As many as 851 deaths from this
cause have been reported in the city in five years. The disease
here, as elsewhere, is closely associated with poverty and overcrowding. Typhus appears to be common enough throughout

TYPHUS FEVER

S03

the whole Mexican Republic, but especially so in the high
plateaux of the interior. In British Honduras and Guatemala,
however, it appears to be as little seen as it is further north
in the United States; but in Nicaragua at least one epidemic of
it has been recorded in the past (in 1851). The West Indies
and Bermuda have enjoyed an immunity from its ravages for
some decades.
South America. Typhus fever has not, in the last few years,
been seen in British Guiana, nor is it apparently known in the
other Guianas, Colombia, or Venezuela. In Brazil, however, it
certainly occurs at times, as, for example, at Rio de Janeiro.
In Peru it is still more common, and in the sierras especially
has at no remote period caused great ravages among the Indian
inhabitants. It is believed that typhus was originally introduced
to Peru from Spain, and probably at a very early period. The
disease is apparently endemic, and at times epidemic in Chile and
Bolivia1. Further south, in the Argentine Republic, Paraguay,
Uruguay, and the Falkland Islands it is said to be unknown.

Factors determining the Geographical Distribution.
Typhus fever is an excellent example of that group of diseases which
have become rarer as civilisation has advanced. It is essentially
associated with ill-nutrition, overcrowding, misery, and insanitation.
But while all these conditions are of common occurrence all the
world over, the same is not true of typhus fever, and it seems that
another factor, in all probability a specific germ, is necessary to its
development in addition to the conditions already named. The
micro-organism, if there be one associated with the disease, has
not, however, yet been discovered with certainty.
The recent distribution of the disease has been a rather
remarkable one. In Europe, where it was at one time almost
universal, it has remained endemic to any notable extent only
in the British Isles, Brittany, Russia, and parts of Austria and
Germany. In Asia it appears, to be endemic in Mesopotamia,
Persia, the Himalayan belt of India, and Siberia. In Africa it
is probably endemic only in Nubia, and perhaps in Egypt; in
the New World only in Mexico, Peru, Chile and Bolivia. But
while the truly endemic range of the disorder is thus restricted
at the present day, in the past, and indeed in quite recent times,
it has prevailed as an epidemic in many other parts of the world.
1

Braull.

504

TYPHUS FEVER

The countries in which, so far as is known, it has never been seen
either in endemic or epidemic form are Australia, New Zealand, the
Pacific Islands, the greater part of Central and Southern Africa,
a considerable portion of the United States, the Argentine
Republic, Paraguay, Uruguay, and the Falkland Islands.
Typhus fever shows unusually definite relations to atmospheric
temperature, and this accounts in part, though by no means wholly,
for its geographical distribution. In all countries where it is
endemic it is most active in the cooler months of the year. It is,
indeed, essentially a disease of temperate and cold climates. In
the tropical and sub-tropical countries named above in the list
of its endemic areas, the disease is found to occur principally
at considerable heights above sea-level, where the temperature
conditions are practically those of the temperate or cool zones.
In like manner the larger number of epidemic outbreaks in all
countries have occurred in the cooler portion of the year. No
doubt this is mainly due to the increased chances of infection in
the winter, when people are apt to be more crowded together in
insanitary dwellings than in the summer.
The relation of typhus fever to altitude above sea-level, of
which mention has just been made, is apparently in the main a
question of temperature. In the temperate zones the disease is
found prevailing principally in low-lying areas, or indifferently in
flat and in mountainous regions. In the flat plains of European
Russia, for example, it is met with more or less throughout, and
in the Caucasus there does not appear to be any striking difference
in its prevalence between the low-lying Caucasus proper and the,
highly-mountainous Transcaucasia. But as the tropics are approached, if typhus fever occurs at all as an endemic disease, it
is mainly at considerable heights, as, for example, in the Himalayan belt of India, in the high plateaux of Mexico, and in the
sierras of Chile and Peru.
But of all the external conditions favouring the prevalence of
this zymotic none are so important as those of insufficient food,
overcrowding, and insanitation. The names " famine fever " and
" hunger typhus " often given to the disease are a recognition of
its close dependence upon insufficiency of food. The historical
examples of typhus fever epidemics following on great famines are
numerous. In Russia during recent years of bad harvest the
disease has been widely prevalent, and in 1892 it was one of

TYPHUS FEVER

505

the worst and most fatal results of the great famine of that year.
Quite recently, in November, 1902, a serious outbreak occurred
in Podolia as the result of dearth. In Algeria and Tunisia in
1868, in Tripoli in 1893, in Ireland in 1846-7, typhus fever
epidemics of extreme severity were associated with failure of the
harvest and consequent famine and misery. But it is important
to note that by no means all famines have been accompanied by
such outbreaks. The recent famine years in the Central Provinces
of India, for example, have been marked by unusual prevalence of
" fevers " and perhaps other diseases, yet among the sicknesses
vaguely classed as "fevers" typhus does not seem to have been
one. Nor, on the other hand, does famine appear to be essential
to the prevalence of this disease. Virchow drew attention to this
fact in connection with the typhus outbreak in Upper Silesia in
1847-8, and a quarter of a century earlier Graves had clearly
shown in Ireland that typhus could prevail in years of plenty.
The occurrence of serious famine without the appearance of
typhus is no doubt to be explained by the statement made
above, that the disease is most probably due to some microparasite. It was formerly very generally believed that it could
be generated de novo under conditions of want and misery, but
this must now be considered extremely doubtful; and in all probability in the absence of the specific micro-organism no degree
of dearth or famine can give rise to the disease.
If starvation is one of the most favourable conditions for the
prevalence of this malady, overcrowding and misery are scarcely
less so. The frequent occurrence of typhus fever epidemics in the
past in besieged cities, and in connection with military operations
generally, has apparently been largely favoured by these latter conditions, although in many instances no doubt the former—starvation
or at least an insufficiency of proper food—has also been present.
The wide extension of typhus fever in Europe during the Napoleonic wars has already been noted, and the marked reduction in
its prevalence over the whole continent after Napoleon's fall shows
clearly how important a factor war may be in determining the
geographical distribution of this disease. In the Franco-Prussian
and Russo-Turkish wars there were serious outbreaks of typhus.
Both sides suffered from it severely in the Crimean war.
Among the Russian troops its prevalence and severity have been
attributed by Russian writers as much to insufficiency of the food

So6

TYPHUS FEVER

supplies as to overcrowding1. The English troops also suffered
greatly from the disease in the winter of 1854-5 ; it was less
active in the following summer, and in the winter of 1855-6
the troops were much less affected by it, as they had now been
provided with better quarters and were less overcrowded. In this
second winter of the war, however, the French troops who were
encamped in close tents on wet ground suffered from typhus.
In the Franco-German war the disease broke out among the
population of Metz during the siege, yet the troops encamped in
the outworks, who were better fed and less crowded, almost
escaped it. The Germans do not appear to have had any typhus
in their army during the war, and this has been ascribed to the
strict military hygiene enforced by them in the field. In the
Russo-Turkish war of 1877-8 there was a good deal of the
disease among the Russian troops both in the Caucasus and in
European Turkey. Innumerable other instances of typhus in
war time might be quoted, and they all show the close correlation
of the disease with want and overcrowding.
These conditions are unfortunately found in many countries at
other times than those of war. Few of the infective fevers have
shown so direct and positive a relation to sanitary deficiencies as
this, and particularly to such deficiencies as overcrowding and bad
ventilation. Dirt, squalor, and misery generally, accumulations of
filth and refuse, and imperfect removal of sewage are sanitary
defects so commonly found together with the others just named
that they may also have something to do with typhus fever prevalence. But it is probable that overcrowding and ill-ventilation
are the most important. They have been universally found in the
great epidemics and endemics of typhus. In former days, when the
gaols and workhouses in all European countries were shockingly
overcrowded, and ventilation almost unknown, the disease was
rife in these institutions; and it was more or less rife just in
proportion as the buildings were more or less overcrowded and
more or less badly ventilated. When Howard made his memorable
visitation of British and Continental gaols in the eighteenth century,
" the prisons were the central seminaries and forcing-houses from
which the typhus-contagion of those days was ever overflowing
1
Golod i Vuizuwaemiria im holiczni. (Famine and the Diseases caused
by it.) By A. A. Lipski, St Petersburg, 1892.

T Y P H U S FEVER

507

into fleets and barracks and hospitals, and was a constant terror
to courts of justice and to the common population \"
In more modern times the disease has lingered among peasant
populations in Ireland, Brittany, Russia and elsewhere, among
whom conditions of overcrowding, ill-ventilation, and squalor are
only too commonly found. In its recent epidemic outbreaks
also (other than those in connection with wars, already discussed)
overcrowding and ill-ventilation have been the constant accompaniments of the disease. In Algiers, for example, in the great
epidemic of 1867-8, the people had flocked to the towns for
food, and-were crowded together in temporary buildings run up
to receive them, when the disease appeared amongst them.
Exactly the same conditions preceded the outbreak in Tunis in
1868; and the terrible epidemic in the Cyrenaic plateau in 1893
was mainly fostered by the densely overcrowded state of the few
towns there, the result of a preceding famine.
The reduction in typhus fever prevalence in many European
countries in recent times may, with a probability amounting almost
to certainty, be attributed to improvements in sanitation. Of
these improvements, by far the most important have been the
reduction of overcrowding; the opening up of the over-built,
over-populated, filthy slums a n d . rookeries of large cities; the
provision of better house accommodation for the lower classes;
the introduction of proper systems of ventilation, and the provision
of more space per head in gaols, reformatories, workhouses,
barracks, and ships. To these may perhaps be added a general
rise in wages, and an improvement in the social and domestic
conditions under which most classes of the population live.
Where typhus fever now lingers in the capitals and large cities
of civilised countries, as for example in Berlin and in Dublin,
it is solely among the poorest classes of the population, who live
under those conditions of overcrowding and squalor, and perhaps
of want, already described.
Other public health measures, as the provision of water-supplies,
the construction of drains and sewers, and the inspection of foodsupplies, can scarcely affect the prevalence of this disease directly.
For the infection of typhus is not spread by water; it is almost
certainly not spread by sewer-gas; and it does not, so far as is
1

English Sanitary Institutions.

p. 140.

By Sir John Simon, London, 1890,

508

TYPHUS FEVER

known, attack any of the lower animals. The infection is indeed
probably spread solely by the air or by infected fomites. Typhus
fever is one of the most directly infectious of all diseases. The
atmosphere around a typhus fever patient appears to contain the
infecting agent, whatever this may be, in large quantities and in
a high degree of virulence. Those in immediate attendance upon
persons suffering from the disease often become infected. To
what distance the virus can be spread by the air is quite unknown ;
but there seem to be no observations showing that it can be
carried over long distances like that of small-pox. Most probably
the infecting agent is highly virulent in the air immediately around
the patient, and rapidly becomes innocuous after travelling only a
short distance through the atmosphere. It can, however, attach
itself to linen and clothes, the walls of rooms, and furniture: and
in this way the infecting material of typhus is believed, on some
occasions, to have remained active for some time after leaving the
patient's body, and even to have been carried long distances over
the earth's surface.
Typhus fever has shown no very definite relations to race,
and it is probable that racial differences have had little or no
share in determining its geographical distribution. The European
races, the Himalayan hill tribes, the Indians of the plains, the
Chinese, the Kabyles and Arabs of Algiers and Tripoli, the
African negroes, the Indians of Chile and Peru, and the mulattos
of North America have all suffered from it; and though there does
not seem to be any mention of typhus occurring among the native
tribes of Australia and New Zealand, the Pacific Islands, the
United States, or the southern portion of South America, this
is more likely to be due to the fact that the infection has never
reached them than to any racial immunity.

WHOOPING-COUGH.
History.
The first certain mention of whooping-cough
relates to an epidemic in Paris in the year 1578. In the next
two centuries it was rarely referred to by medical or other writers.
From the 18th century onwards there are numerous records of
epidemics in many parts of the world. Hirsch, however, believes
that this disease is really of comparatively modern origin, and
that it has spread over the globe within recent times.
R e c e n t Geographical Distribution. Europe, In England
and Wales whooping-cough is very frequently seen. As a cause
of death it has diminished to some extent in recent years. The
mean annual death-rate per million from the disease was 527 in
the years 1861-70, 512 in the next decade, and 450 ih the years
1881-90. It has since been still lower, but has fluctuated considerably ; the lowest ratio since registration began was observed
in 1895, when it was only 316 per million. Whooping-cough has
a distribution not unlike measles; it is most fatal in large centres
of population and in mining districts. In the decennium 1881-90
the lowest ratios were met with in Westmoreland (193 per million),
Dorset (230), and Hereford (231); and the highest in Lancashire
(520), Essex (537), and London (690 per million).
The disease has recently caused a higher mortality-rate in
Scotland than south of the Tweed. The ratio of deaths from
whooping-cough in Scotland in 1881-90 was 605 per million per
annum; in each of the years 1895 and 1896 it was 470, and in
1897 it rose again to 690 per million.
In Ireland the mean annual mortality from this disease in the
decade 1881-90 wras only 290, and in 1890-99 only 280, per million.
In French towns of over 10,000 inhabitants the deaths from
whooping-cough varied between 90 and 170 per million in the
years 1886-1898;

5io

WHOOPING-COUGH

In Belgium the deaths from this cause remained at about the
same figure from 1870 to 1895; t n e annual mean of recorded
deaths fluctuating but slightly above and below 3800 (something
over 600 per million inhabitants); in 1897 they fell to 2809, or
approximately 430 per million. In Holland the disease is a less
conspicuous cause of mortality, the ratios of deaths per million
inhabitants varying between 220 and 360 in the years 1889-98
inclusive. The figures for Holland show no tendency to diminution in recent years.
In the German Empire there was a slight increase in the
recorded deaths from this cause in the years 1892-4, but the
records for a number of years show considerable fluctations in
the mortality-rates. This is true of all the principal divisions
of the empire.
In Denmark whooping-cough has caused a mortality among
urban residents varying between 184 (in 1894) and 490 (in 1895),
respectively the lowest and highest rates between the years 1892
and 1897. In 1897 the ratio was about 190 per million. Equally
wide fluctuations have been observed in Norway, with a tendency
in the four years 1891-1894 to an alternation of years with high
and years with low mortality. The mortality-rate in 1893 was
about 85, and in 1894 about 220 per million inhabitants. In
Sweden the deaths from this cause fell considerably between 1891
and 1895, the mortality figure for the latter year being approximately 115 per million; but in 1896 it rose to 222.
Whooping-cough is the cause of a higher mortality in Russia
than in most other European countries excepting Hungary. The
deaths from this disease in European Russia in the years 1893-95
were equivalent to an annual ratio of 660 per million. Very wide
fluctuations are noted from year to year in the prevalence of the
malady in various parts of the country. It is commonly met with
throughout, from north to south and from east to west. The Polish
governments have of recent years returned a somewhat lower
proportion of cases than have others, but returns of cases are
notoriously unreliable in any country.
In Austria the deaths from the disease in 1896 were equal to
a mortality-rate of about 410 per million; in the years 1892-94
they are said to have been at the still higher annual rate of 650
per million. In Hungary whooping-cough appears to be a most
prolific cause of mortality; in 1897 the death-rate from it was as

WHOOPING-COUGH

5 11

high as 1060 (approximately) per million. In the years 1892-94
the mean annual mortality from the disease was 660 per million.
In Switzerland the mortality varies widely; in the fifteen large
Swiss towns the lowest rate in recent years occurred in 1893
(150 per million); it rose in the next year to nearly double, but
subsequently fell to 157 in 1897.
The returns of whooping-cough deaths in Italy have shown a
steady fall in recent years. The mortality-rate rose from 257
per million in 1868 to 435 in 1890, but has since declined to a
minimum of 213 in 1896. In Spain and Portugal whooping-cough
is said to be only moderately prevalent; and Davidson states that
the death-rates from this cause, both in town and country, were
(the years are not named) only about half those which obtained
in England. It is probable, however, that the disease fluctuates
widely here, as elsewhere.
For the Balkan countries full information is lacking. In
Servia the disease must have been either extremely malignant or
extraordinarily prevalent in 1894 (the only year for which I have
had access to statistics); for in that year the deaths from it were
4227 in number, or approximately 1800 per million inhabitants;
and it accounted for 6*63 per cent, of the deaths from all causes.
In Constantinople the disease is always present, and reports
of it are by no means rare from provincial Turkish towns and
villages.
Whooping-cough "is not endemic in Iceland, and, what is
still more remarkable, it has never been observed to spread even
when introduced into the country"—an observation which becomes
still more striking when the very different behaviour of measles
and other infectious disorders after importation to the island
is recalled.
In the Faroes it has been epidemic on three
occasions only.
It is certainly known in some of the islands of the Mediterranean. Eight cases of the disease were registered in Malta
in 1898.
Asia. So far as may be gathered from the admittedly imperfect returns of cases of disease from the Caucasus, whoopingcough appears to be much less common there than in European
Russia. In the years 1887—95 the returns were constantly
from one-third to one-fifth of those in the same unit of population in the European governments. The recorded deaths from

512

WHOOPING-COUGH

this cause in the Caucasian provinces in 1895 were at the rate
of about 71 per million. In Russian Central Asia the returns
of cases are still lower, averaging only from one-third to onefourth of those received from the Caucasus. The recorded deaths
in the provinces beyond the Caspian in 1895 w e r e o n t y 19 in
all, or about 3 per million inhabitants. To what extent this figure
really implied that the disease was very rare here in that year there
are no data to show. In 1894 the corresponding figure had been
about 5 7 per million.
In Siberia the registered cases of whooping-cough have varied
widely in recent years; in some years they have been much lower
in proportion to the population than in European Russia, while in
others they have been higher than in the majority of the governments on this side of the Urals. In 1895 the recorded cases in
vSiberia were only one-third as many as in 1894. The disease
is certainly met with in the remote northerly government of
Yakutsk; it appears to be quite common in the province of the
Amur, and it is included in the returns from the government of
Tchita, on the Mongolian borders, as well as from all other
Siberian " governments."
The disease is occasionally epidemic in Mesopotamia and
Kurdistan ; of its prevalence in Syria, Asia Minor, and Persia
little seems to be known. In India it becomes epidemic from
time to time, but rarely with great severity. It is seen not only in
the plains but also in the hills; in 1893 it was epidemic, at the
same time as measles, in the Hindu-Khush, especially among the
country people in the hilly parts of Gor and Gilgit.
In Ceylon it is occasionally epidemic; it was so in many
villages in the summer months of 1897.
Of its prevalence in Farther India little seems to be known.
It is not mentioned by recent writers on the pathology of Siam.
Davidson makes no reference to it among the diseases of the
Malay Peninsula, Annam, or Tongking. I find no mention of it in
recent reports from the Straits Settlements. In Burma, however,
it has been seen recently; a severe epidemic of the disease
occurred in Rangoon in 1901, and necessitated the closing of the
schools. This was the first known epidemic of the kind in
Rangoon during the last quarter of a century.
In China, on the other hand, whooping-cough is apparently
not a rare disease. In Shanghai it is said to be endemic, attacking

WHOOPING-COUGH

513

both natives and Europeans 1 , it was epidemic among the Chinese
inhabitants of the town in May—July, 1891 2 . It was very
prevalent also at Wenchow in 1892 3 . In the Tientsin district it
"went the round of the children," both foreign and Chinese, in the
summer of 18974.
The disease is probably rare in the Malay Archipelago. It is
mentioned among the epidemic diseases seen in Borneo. It has
not been seen among the hill tribes in Java, and it is not named
among the prevalent diseases of Sumatra, Celebes, or the Philippine
Islands. The absence of mention of the disease is, of course, not
proof that it does not occur in these islands.
Australasia.
In British New Guinea whooping-cough appears
to be unknown among the aborigines. In Australia the disease is
commonly prevalent, but varies widely in its activity from year to
year. In Queensland the deaths from this cause in 1893 were
equal to 299 per million inhabitants, in the following year they
were scarcely more than one-fourth as many, and have fluctuated
widely since, another epidemic occurring in 1895. ^n New South
Wales it is occasionally epidemic. In Victoria it has apparently
not been very prevalent in some recent years; in 1896 it was the
cause of only 4 deaths in Melbourne, and, in 1895, of 7 deaths.
In South Australia it seems to have been more active than
usual in 1890, 1893, and 1898; in the last-named year causing
112 deaths, as contrasted with no deaths whatever in the preceding
year. In West Australia the deaths in the years 1893-98 were
respectively o, 4, 21, 9, 3, and 8.
In Tasmania the disorder was epidemic along the northwest coast in 1895-96, but it disappeared completely in 1897.
In New Zealand it was epidemic in 1891, wThen it caused as many
as 242 deaths; but in the three years 1896-98 the recorded
fatal cases were only 24, 2, and 6, respectively.
In the Polynesian Islands whooping-cough occurs, rarely in
some, in others in epidemics. It is not unknown in Fiji, where
occasional cases of the disease are met with in the natives ; it has
also been seen among the Kanakas in New Caledonia, and is
occasionally epidemic in the Sandwich Islands.
Africa. Whooping-cough was some years ago of very considerable frequency in Egypt, attacking especially the children of
1

Chinese Customs Med. Rep. No. 41.
* Ibid. No. 44.

c

2
4

Ibid. No. 42.
Ibid. No. 54.

33

514

WHOOPING-COUGH

the natives, and less often those of foreigners living in the country.
More recently the mortality from the disease is said to have
diminished very considerably, at least in the towns of Lower Egypt,
and this is attributed to increase of knowledge on the part of
the people, to the greater care they have learnt to take of their
children, and to their greater readiness to seek earlier treatment.
In the Western Sudan and Algeria the disorder is said to be by
no means rare.
On the West Coast whooping-cough not infrequently prevails.
In Senegal it is said often to become epidemic. In the Cameroon
district it was epidemic in the autumn of 1895.
For the East Coast of Africa information is incomplete. On
the Middle Zambesi the disease becomes epidemic from time
to time) and may possibly exist throughout Central Africa; I find
no positive mention of it, however, by some recent writers on the
pathology of British East Africa and of Abyssinia, although in
Uganda it is spoken of as common.
Whooping-cough is not unknown in Mauritius, and a few cases
of it are occasionally mentioned in the annual medical reports
of the colony. In the Seychelles Islands it is said to be of rather
frequent occurrence and to cause a high mortality.
In South Africa the disease is common enough and finds
frequent mention in the colonial reports. It was epidemic in many
parts of the Cape Colony in 1896, 1897, and 1898; at Aberdeen
it was very severely prevalent in 1896, and less so in 1897. It
was widely spread all over Namaqualand in 1898, and early in the
same year it was reported as causing serious epidemics at Elliot,
at Elliotdale, and at Willowdale, all in the native territories. At
Elliotdale it led to a large mortality among native children.
In Griqualand West many cases occurred about the same time.
In British Bechuanaland the disease becomes from time to time
epidemic, but it is said to be milder than in England. Many
cases have been seen in both children and adults among the
Kafir inhabitants of Mashonaland.
North and Central America. Of the existence or prevalence
of whooping-cough in the far north of the American continent
little can be said with certainty. Lombard states that it appeared
in Labrador for the first time in 1875-76, and was probably
imported from the south, where it was then epidemic. It has
apparently not been seen in Greenland since 1849, before which

WHOOPING-COUGH

5I5

date it had been several times epidemic. In Canada it is far
from rare. In the provinces of Quebec and Ontario it occurs in
occasional epidemics. In New Brunswick it is described as coming
in " epidemic waves." In Manitoba a considerable number of cases
of the disease were registered in 1896, and it finds frequent mention
ip the annual health reports from Nova Scotia on the east and
British Columbia on the west.
Throughout the United States of America whooping-cough is
more or less frequently met with. In the returns of deaths in
the principal cities and towns of the Republic for the year 1897
this affection appears as a cause of death in every State, with
the exceptions of Arizona, Arkansas, Idaho, Nevada, New Mexico,
and North Carolina. It was nowhere, however, a cause of high
mortality. In Massachusetts the mean mortality from whoopingcough fell from 220 per million per annum in the years 1856—75
to 140 per million in the years 1876-95.
Information is largely lacking in regard to the behaviour of
the disease in Mexico and the Central American Republics. In
Costa Rica it is said to have been epidemic in 1866, but to be of
less frequent occurrence than in the West Indies. In British
Honduras and Guatemala the disease is occasionally epidemic.
It was so in the former, in the Toledo district, in October 1898,
apparently as the result of an invasion of the infection from Guatemala. It prevailed in Belize in November, and in 1899 spread to
Honduras.
In some of the West Indian Islands whooping-cough has of
recent years' been very prevalent. In Jamaica it was epidemic in
May and June, 1897, throughout the eastern district of the island;
at Port Antonio it prevailed during 1896 and 1897; in West
St Andrew large numbers of children were attacked between
August, 1897, a n d February, 1898. In Grenada the disease was
epidemic at the end of 1898. In St Lucia, in Trinidad, .and in
Barbados it prevailed at the beginning of that year.
South America. I have failed to find any recent information
as to the occurrence of whooping-cough in many of the countries
of the South American continent. In Uruguay it was the cause
of 53 deaths in 1897, or 4*34 per thousand of the deaths from all
causes. This figure is equal to a ratio of about 66 per million
inhabitants. In the Buenos Aires province of the Argentine
Republic 126 deaths from whooping-cough were recorded in the
33~2

S 16

WHOOPING-COUGH

same year; of these 54 occurred in the northern regions, 52 in
the central, 20 in the southern, and none in Patagonia. The
disease is certainly met with as far south as the Falkland Islands,
where it "prevailed to a sad extent for so small a community" on
East Island at the end of 1890 ! . Influenza was epidemic at the
time, and the mortality among children was very high.

Factors concerned in the Geographical Distribut i o n . It will be seen that whooping-cough has an extremely
wide distribution. No latitude has entirely escaped it. But
while the disease has shown that it can exist and even cause
epidemics in tropical, sub-tropical, temperate, and sub-arctic
regions, it is not equally common nor equally severe in all. It
is mainly a disease of temperate and cool climates, and is both
rarer and less malignant and fatal in warm or hot countries.
This relation of the disease to latitude is to some extent shown
by the mortality rates quoted above for the different European
countries. The more northerly countries—Norway and Sweden,
Denmark, Russia, Germany, the Low Countries, and the British
Isles—have all returned in recent years higher mortality rates from
this disease than the more southerly countries of France, Spain
and Portugal.
The only exceptions to this rule have been
Austria-Hungary, Italy, and perhaps Servia. Similarly in Africa,
although statistics are wanting, whooping-cough seems to be
decidedly more common and severe in the cooler south than in
the tropical zone. In Asia, in like manner, the disease is both
less frequent and less severe as a rule in India, Farther India,
and the Malay islands than in Siberia and northern China. Similar
evidence is forthcoming from America, where it is more prevalent
and of a worse type in Canada and the Northern States than in
the tropical and sub-tropical portions of the continent.
But while this rule generally holds good it has not been
without marked exceptions. Some have been already mentioned,
as for example the recent occurrence of a severe epidemic of the
disease in Burma (Rangoon); and to this may be added the
mention of "pernicious epidemics of whooping-cough" in the
past in many islands of the West Indies. Moreover the remarkable
rareness and mildness of the disease in Iceland and the Faroes
show that distance from the equator does not of necessity imply
increased prevalence or severity of whooping-cough.
1

Falkland Islands Consular Reports', 1890.

WHOOPING-COUGH

517

In its seasonal variations the disease has shown much the
same relation to temperature as in its geographical distribution.
That is to say, it has as a rule been most common and most
severe in the cool seasons of the year. The difference between the
seasons, however,—at least as regards prevalence of the disease—
has not been very marked, and a large number of summer
epidemics have been recorded. As regards the character of the
malady, on the other hand, it seems to have been usually distinctly more severe and fatal in winter epidemics than in those
occurring in the summer, at least in England. This rule, however,
has not been observed in all countries.
Neither altitude above sea-level nor the character of the soil
has had any influence upon the distribution of whooping-cough.
Racial susceptibility also appears to be a factor of little importance, for all races are affected, though some, perhaps, have
suffered from it more than others. Thus in the United States,
for example, the negro inhabitants fall victims to it much more
readily than those of other races.
Whooping-cough is a highly infectious disorder. It is mainly,
but not wholly, a disease of childhood, and frequently gives rise
to epidemics in schools or other collections of susceptible individuals. Epidemics of a wider character, affecting whole towns,
whole countries, or even several contiguous countries, have occurred,
and, in every country where it is endemic, its degree of prevalence
varies greatly from year to year. Like all other infective diseases,
however, the " cycles " of greater and lesser prevalence are very
irregular and appear to conform to no law.
The infection can apparently cling to inanimate objects, such
as clothes, fomites generally, and the furniture of rooms, but
the principal means by which it is spread appear to be the
movements of infected individuals. Whooping-cough is not
known to attack any of the lower animals, nor is it thought to
be spread by the agency of water or milk. It does not seem
to be in any way dependent upon sanitary or insanitary conditions, and when epidemic it attacks all classes alike.
*

YELLOW

FEVER.

G e n e r a l C h a r a c t e r s a n d E t i o l o g y . Yellow Fever may
be defined as an endemo-epidemic disease, infectious in character,
the most prominent symptoms of which are extreme depression,
jaundice (whence its name), suppression of urine, and haemorrhages
from mucous surfaces. The frequency with which the haemorrhage
occurs into the stomach, causing the vomiting of partly digested
blood, is indicated by the name of "vomito negro" or "black
vomit," commonly applied to it in its western endemic home.
The disease is believed by some observers to be constantly
associated with the presence in the tissues, and later in the blood
of the patient, of a micro-organism to which its discoverer, Prof.
Sanarelli of Bologna, gave the name of bacillus icteroides. The
evidence as to the relation of this bacillus to the disease is
contradictory. A Commission appointed by the Marine Hospital
Service of the United States in 1898 believed that it was the
specific cause of yellow fever. Sternberg, on the other hand,
and other more recent observers have made experiments and
observations which seem to show that this bacillus has no
causative relation to the disease.
A series of important investigations have recently been made
in America, by Surgeons Walter Reed and James Carroll, and
other members of the United States Army Commission, upon the
part played by mosquitoes in the spread of yellow fever. Space
will not permit here of a full account of their carefully planned
experiments, for the details of which the reader is referred to the
papers enumerated in the footnote below1. It will suffice to say
here that several non-immune individuals were exposed for long
periods together to the most intimate contact with clothes or
1
"The Etiology of Yellow Fever. A Preliminary Note." Philadelphia
MedicalJournal^ Oct. 27, 1900.

YELLOW FEVER

519

fomites worn a n d soiled by yellow fever patients, without developing
t h e d i s e a s e ; while, if bitten by m o s q u i t o e s that h a d twelve or
m o r e days before bitten yellow fever patients, these s a m e a n d
o t h e r n o n - i m m u n e individuals developed t h e disease, almost
without exception. T h e particular m o s q u i t o believed to b e t h e
carrier of t h e yellow fever virus is Culex fasciatus
or Stegomyia
fasciata.
T h e following were t h e conclusions arrived at by t h e
a u t h o r s of t h e above e x p e r i m e n t s : —
1. T h e mosquito, C.fasciatus^
the parasite of yellow fever.

serves as the intermediate host for

2. Yellow fever is transmitted to the non-immune individual by
means of the bite of the mosquito that has previously fed on the blood
of those sick with this disease.
3. An interval of about twelve days or more after contamination
appears to be necessary before the mosquito is capable of conveying
the infection.
4. T h e bite of the mosquito at an earlier period after contamination
does not appear to confer any immunity against a subsequent attack.
5. Yellow fever can also be experimentally produced by the
subcutaneous injection of blood taken from the general circulation
during the first or second days of this disease.
6. An attack of yellow fever, produced by the bite of the mosquito,
confers immunity against the subsequent injection of the blood of an
individual suffering from the non-experimental form of this disease.
7. T h e period of incubation in 13 cases of experimental yellow
fever has varied from 41 hours to 5 days and 17 hours.
8. Yellow fever is not conveyed by fomites, and hence disinfection
of articles of clothing, bedding, or merchandise supposedly contaminated
by contact with those sick with this disease, is unnecessary.
9. A house may be said to be infected with yellow fever only when
there are present within its walls contaminated mosquitoes capable of
conveying the parasite of this disease.

"The Etiology of Yellow Fever. A Supplemental Note." American
Medicine, Feb. 22, 1902.
"The Etiology of Yellow Fever. An Additional Note." Journal of the
American Medical Association, Feb. 16, 1901.
' ' Experimental Yellow Fever.'' Trans. Association of American Physicians,
vol. xvi. 1901.
" Recent Researches on Yellow Fever." By Wm. Reid, M.D. The Journal
of Hygiene', vol. ii. No. 2, April 1, 1902.

520

YELLOW FEVER

10. The spread of yellow fever can be most effectually controlled
by measures directed to the destruction of mosquitoes and the protection
of the sick against the bites of these insects.
n . While the mode of propagation of yellow fever has now been
definitely determined, the specific cause of this disease remains to be
discovered. *
H i s t o r y . The first certain records of yellow fever relate
to the early part of the seventeenth century. The natives and
settlers in the West Indies suffered from severe pestilences at an
earlier date, but it is doubtful if these were of the nature of yellow
fever. From 1635 to the present day epidemics of it have been
very frequent in ^tnd near the West Indies. The disease is said
to have reached South America only on two occasions (1740 and
1842) before the year 1849. ^ w a s t n e n introduced to Brazil,
and from that date to the present day has been endemic there,
and has occasionally spread thence to other parts of the continent.
The antiquity of the African centres of yellow fever is uncertain.
There is mention of an epidemic of the disease in St Louis,
Senegal, due to importation from Sierra Leone, in 1778. From
1810 to the present day it has been repeatedly epidemic in a
portion of the West-Coast region which will be more accurately
defined later. Its extensions to Europe will also be discussed in
a subsequent part of the chapter.
Geographical Distribution.
The area of endemic
prevalence of yellow fever is on the whole a remarkably constant
one. It is practically confined to tropical or sub-tropical regions,
and to but a limited portion of these. The shores of the tropical
and sub-tropical sections of the Atlantic Ocean can alone be
regarded as permanent seats of the disease. It may, indeed, be
questioned whether the truly endemic area of infection is not still
more limited, for, as will be shown later, it cannot be regarded as
certain that outbreaks of the disease on the eastern or African
coasts of the ocean are not the result of carriage of the infection
from the western or American coasts. So far as a somewhat
imperfect knowledge of the history of the disease enables us to
judge, it seems certain that originally yellow fever was essentially
an American disorder, and that though the infection has to some
extent become domiciled on the African shores, it is more than
probable it was originally brought there from South America or
the West Indies. It is to be noted that some writers have

YELLOW FEVER

521

held exactly the contrary view, and believed that yellow fever was
originally imported to the West Indies by means of infected
negroes from Africa. The facts of history are, however, against
this view, and there is much evidence to show that this fever was
known in those parts of America where it still prevails even before
the discovery of the continent by Europeans, and long before the
transport of negroes from Africa to the West Indies began to be
practised.
In recent times yellow fever has rarely spread beyond an area
which may be roughly defined as follows. In America its northerly
limit of epidemic occurrence has been 46 0 50' (Quebec in 1805),
and its southerly limit about the 35 th degree of south latitude
(Buenos Aires and Monte Video). In Africa the limits are much
more restricted, the disease never spreading inland and being
confined to certain points of the coast between the Equator and
the Tropic of Cancer. It will be shown later that the disease has
on several occasions passed beyond these limits, but always as a
temporary epidemic outbreak, and it has never become truly
endemic outside this area. Within the area it is found to be
constantly present, and is perhaps only truly endemic, within still
more restricted limits.
Endemic Centres and Epidemic Extensions in the New World.
The Greater Antilles group of the West Indian Islands may
be regarded as essentially the home of yellow fever, and it is
almost certain that the prevalence of the disease on the shores
of the Gulf of Mexico and of Brazil is to be traced originally to
a spread of infection from the West Indies. In certain of the
Antilles yellow fever is constantly present. Cuba is, or was, one
of the most severely affected islands of the group. Before 1901
the fever used to become epidemic here every summer, but no
period of the year was free from it, and in many years it was a
veritable scourge. Here, as elsewhere, the behaviour of the disease
was irregular and almost capricious in character; in some years it
was mild and the cause of but few deaths, in others it was extraordinarily active. In 1893 it caused 26*8 per cent, of the total
deaths in Cuba during the six summer months. More recently it
has been widely prevalent again; the disturbances in connection
with the rebellion and the Spanish-American war gave it an
immense impetus, and in 1897 as many as 2583 deaths from this
disease occurred in the military hospitals of Havana and Regla

522

YELLOW FEVER

alone, while in the whole island no less than 6034 deaths from
it were recorded—a mortality which may be held to imply the
occurrence of about 30,000 cases. The recent history of the
disease in Cuba is discussed at greater length below.
Haiti must be regarded as a centre of yellow fever. In
Guadeloupe epidemics have frequently occurred, and it is possible,
though perhaps not quite proved, that these are due to the revival
of an endemic infection and not to, repeated importations. In
Jamaica it is believed by some that the epidemics which break
out at intervals are always the result of an importation of infection.
Morse, however, in a recent report on the health of this island 1
takes the opposite view, and believes that the severe outbreak
in 1897 was not due to an infection brought from elsewhere
but to the renewed activity of an infection remaining dormant in
the island itself. The latter explanation seems to apply also to
the marked recrudescence of yellow fever in Martinique in the
years 1895-98.
In most of the other islands of the Lesser Antilles yellow
fever is apparently not truly endemic, and when outbreaks of the
disease occur here they can usually be traced to an introduction of
the virus from elsewhere. The same statement holds good for the
Bermudas and Bahamas, and for Trinidad and Barbados.
It was formerly believed that the shores of the Gulf of Mexico
were deeply and permanently affected by this disease, and it is
certain that for long periods together several places, such as Vera
Cruz and New Orleans, were ravaged by it. But the disappearance
of the fever from these coasts for intervals of some length, and the
apparent feasibility of keeping it away from ports where strict
measures against its introduction were enforced—as at New
Orleans, Mobile, and Charleston—seem to show that it is not
truly endemic on these shores, but that its occurrence there is
due to introduction from without. A fortiori is this the case in
regard to the occurrence of the disease in the interior of Mexico
and even on its western shores, and its extension northwards up
the Mississippi valley and along the Atlantic coasts of the States,
which will be discussed later.
The epidemic extensions of yellow fever in the immediate
neighbourhood of its endemic home in the Greater Antilles, some
1

Report of Island Medical Department, for year ending March 31, 1898.

YELLOW FEVER

523

of which have just been referred to, are irregular both in time and
in extent. As an example of a moderately extensive epidemic of the
disease the last severe outbreak in these regions may be very briefly
described. As already stated, Cuba, the real home of yellow fever,
was under special conditions in the year 1897—conditions of war
and general disturbance such as favour the spread of any infectious
disorder. The result was not only a severe recrudescence of
yellow fever in the island itself but a wide extension of it elsewhere, which, if not wholly, may at least in part be ascribed to
this exceptional cause. In Jamaica it began to be epidemic in
October and November of that year, and caused no little mortality
in the island. As early as August the disease was already present
at Ocean Springs on the Louisiana coast, and in September
at Mazatlan in Mexico, and in that and the following year it
prevailed in many parts of that country and of the States bordering the Gulf of Mexico. Vera Cruz, Tampico, San Fernando,
New Orleans, Mobile, Edwards, Biloxi,. Galveston, Houston and
Montgomery in Alabama were visited by it. The Mississippi
valley was infected as far north as the town of Cairo in Illinois
(about 37 0 north). Isolated outbreaks or cases were also reported
from places on the Atlantic coast of the southern States, and single
cases occurred in the Colombia district of Washington and in
New York. About the same period yellow fever was epidemic at
Panama in Central America and spread thence to Colon, but in
this case the infection seems to have been brought from the south
and not from Cuba. This outbreak will be referred to later.
The epidemic extension of yellow fever just described was a
fairly characteristic example, but others in the past have been even
more extensive. Hirsch mentions the following States as having
at some time or other been the scene of an epidemic:—Texas,
Louisiana, Arkansas, Mississippi, Tennessee, Alabama, Florida,
Georgia, South and North Carolina, Virginia, Maryland and Dela-^
ware, Pennsylvania, New Jersey, New York, Connecticut, Rhode I.,
Massachusetts and New Hampshire. Canada has been visited by
yellow fever only on two occasions, in 1805 (Quebec) and in 1861
(Halifax, Nova Scotia).
It is noteworthy that many of the Central American States
have suffered remarkably little from yellow fever, in spite of their
nearness to the West Indies. In Nicaragua, San Salvador, and
British Honduras but one epidemic of the disease has been

YELLOW FEVER

524

observed. None of these seem to have taken any share in the
epidemic of 1897-8. The comparative rarity of yellow fever in
Central America is the more noteworthy in that the adjoining
countries of the northern part of South America have not at all
infrequently suffered from outbreaks of the disease. The Atlantic
coast of Colombia has been frequently visited, and so also have
Venezuela and the Guianas. The fever is possibly even endemic
in British Guiana.
The coasts of Brazil are now seriously infected with this disease.
It is believed that the infection was brought thither so recently as
the year 1849. The North-American brig Brazil arrived at Bahia
in that year from New Orleans, where yellow fever was prevalent.
She lost two of her crew on the voyage, and after her arrival the
disease appeared among those who had communicated with the
ship, and later upon other vessels in the harbour. From Bahia it
spread to Rio de Janeiro, and from 1851 to 1861 it was more or
less severely .active each year on the Brazilian coasts. In 1862
its activity diminished remarkably, only twelve deaths from the
disease being recorded that year in the town of Rio de Janeiro;
in the following year 15 deaths occurred there, and then for four
years not a single death was recorded. But in 1868 it reappeared,
and from that day to this Rio de Janeiro has been annually ravaged
by an outbreak of greater or less severity. The following are the
returns of yellow fever deaths in Brazil since the year 1868 j the
larger number of these deaths occurred in the city of Rio de Janeiro
itself.
Year

Deaths

1868
1869
1870
1871
1872

18
274
IIl8

1873
1874
1875
1876
1877

9
295
3^59
841
1308
3476
283

Year
1878

Deaths
1177

1879
1880
1881
1882
1883
1884
1885
1886
1887

974
1623
257
502
1606
64O
445
1446
135

Year
1888
1889
1890
1891
1892
1893
1894
1895
1896
1897

Deaths
754
2155
719
4456
43i3
742
4715
818
2909
159

Peru seems to have escaped in the recent period of yellow
fever activity in South America 1 , but it has been visited by the
1
Three deaths from the disease occurred at Callao, in Peru, in 1889, but
none have been recorded since, at least up to the year 1896.

^C

40

The areas in red indicate
regions
where
Yelloiv
Fpver is now endemic
The areas hatched in red
are those where Yellow
Fever has been at some
time epidemic.
The red arrows show the
routes {probably)
followed by Yellow Fever in
its epidemic
extensions.

60

160

120

80

40

40

DISTRIBUTION

OF Y E L L O W

FEVER

80

120

160

YELLOW FEVER

525.

disease on several occasions, and Hirsch states that it was constantly present from 1854-1869. Ecuador has been less frequently
visited, but it appears that the disease was epidemic at Guayaquil as recently as the year 1897, and the outbreak of yellow
fever in Panama alluded to above is said to have been due to infection brought from Guayaquil. These extensions of the disease
to the western coasts of South America must, however, be
regarded as exceptional, and as an endemic disorder yellow fever
is found in South America only on the eastern shores.
Further south Asuncion, Monte Video, and Buenos Aires
have all been visited by yellow fever at different times, but only
exceptionally, and Buenos Aires must be regarded as forming the
southern limit of its epidemic spread.
Endemic Centres and Epidemic Extensions in Africa. While
the regions just described form the western and more important
area of yellow fever prevalence, a second area of great epidemiological interest is found on the eastern side of the Atlantic, on
the shores of Western Africa. This area is of much smaller
size than the American one; it is confined to the Gold Coast,
Sierra Leone, and portions of the Gambia and Senegal coasts.
Of the original source of the disease here but little is known
with certainty, but it seems probable that the infection was
brought to Africa from the coasts of America or the West Indies.
Whether each succeeding outbreak has been due to a fresh
importation of infection must be doubted, and at the present day
yellow fever appears to be truly endemic on the Gold Coast and at
Sierra Leone, whence it has at times spread to Senegal and some
of the West African Islands. The outbreaks have been most
numerous in Sierra Leone, but Senegambia has also been frequently
visited. Hirsch mentions only three outbreaks on the Gold
Coast (in 1852, 1857, and 1862); but quite recently the disease
has again appeared, and it seems possible that it is really endemic
there. The Colonial Report for this colony for the year 1895
states that " the endemic fever assumed a pseudo-epidemic form
of malignant type" which closely resembled yellow fever. The
outbreak, which was limited to Axim, Chama, Elmina, Cape Coast,
Salt Pond, and Accra, caused a very high mortality, and almost led
to a panic among the European inhabitants. Dr Easmon, in his
sanitary and medical report on the colony for the year 1897,
describes this fever as " a pseudo-epidemic fever of a malignant

526

YELLOW FEVER

type, closely approaching in its clinical manifestations the vomito
negro or yellow fever of the West Indies," and he states that it
was again epidemic at the Gold Coast Stations in the second
quarter of 1897. At Salt Pond, of six Europeans who died, three
presented the classical symptoms of yellow fever.
The dividing line between yellow fever and the severer
" bilious " forms of malaria is clinically a very thin one, but the
author of the report just quoted is inclined to regard this Gold
Coast fever as, if not identical with, at least indistinguishable from
yellow fever. In 1899 Grand Bassam, on the Ivory Coast, was
visited by a severe epidemic of this disease, and in 1900 the
same affection broke out in many places in Senegal, which had
been "almost" free from the disease, it is said, during the
preceding nineteen years. The towns of St Louis, Dakar, Goree
and Rufisque suffered very severely, and there was almost a panic
in the colony.
From these (endemic ?) centres of yellow fever in Africa the
disease has spread in the past to the Benin coast (in 1862); to
the Congo Coast (in 1816, i860, 1862, and 1865); to Ascension
Island (in 1823 and 1837); to Fernando Po (in 1839 a n d 1862);
to the Cape Verde Islands on three occasions, and to the Canary
Islands on five occasions. The Cameroon district is said to have
escaped it. The most southerly limit of extension of the disease
in Africa has been St Paul de Loanda, in Angola. It seems
probable that it has never spread very far inland, but has been
confined mainly, if not entirely, to the coast-line.
Yellow Fever outside its Endemic Zimits.
It remains to refer
to the occasional spread of yellow fever beyond its usual limits.
In the form of single or multiple cases on board a vessel, the
carriage of yellow fever to places outside the areas above described,
to the coasts of North America and even to Europe, has been by
no means rare. But the tendency in such cases is for the disease
to disappear when the ship reaches cooler climes, and the
development of an epidemic outside the tropical or sub-tropical
regions above defined has been excessively rare. The recorded
instances of such an occurrence date back to somewhat distant
periods, and no European epidemic of yellow fever has been
seen since the small outbreak in Madrid in 1878. In the
eighteenth century several epidemics of the disease occurred
at Cadiz, and one each at Malaga and Lisbon.
In the

YELLOW FEVER

527

nineteenth century a more extensive epidemic began in 1800
in Cadiz, and in four years spread over a great part of Granada
and Andalusia, and northwards along the banks of the Guadalquivir
to Cordova, and from Andalusia to the seaboard of Murcia,
Valencia, and Catalonia. A second and more limited outbreak in
1810-12 was confined to Cadiz, Cartagena, and Gibraltar, and to
several coast towns of Granada, Murcia, and Valencia. The third
and last great epidemic in Spain, that of 1819-21, affected much the
same areas, and since that date small outbreaks of yellow fever have
occurred in Spain on four occasions only. The last was in 1878
when troops returning from Cuba brought the disease to Madrid.
Lisbon and Oporto have also occasionally been visited by the
fever.
The European outbreaks of yellow fever have been almost
confined to the Iberian peninsula, the only exceptions being
three small epidemics in Majorca, in 1804, 1821, and 1870; and
an outbreak at Leghorn in 1804, which was due to an importation
from Cadiz.
The shores of England and of France have, on rare occasions,
been visited by ships having cases of yellow fever on board, but
no epidemic of the disease has resulted, although on some of
these occasions (as at Brest in 1856, at St Nazaire in 1861, and
at Swansea in 1864) a certain number of persons who have had
communication with the infected ships have caught the disease;
and on one occasion, at St Nazaire, the crews of ships lying near
another with cases on board became infected.

Factors concerned in the Geographical Distribut i o n . The geographical distribution of yellow fever is remarkable
both for its peculiarly limited character and for the great constancy
with which the disease remains within its prescribed limits. The
explanation of these facts is not wholly easy, but on the other
hand the manner in which this fever is influenced by surrounding
conditions is better understood and more easily demonstrated
than is the case with many other infectious diseases. Thus in
regard to temperature yellow fever shows very definite relations.
It does not occur as an endemic disease in places where the mean
winter temperature is much below 65 ° F. In its endemic areas
it is always worst in the hot season and dies away as the cold
weather advances; and, as already stated, it almost invariably
disappears from an infected ship as soon as she arrives in

528

YELLOW FEVER

cooler latitudes.
It is to be noted, however, that, though
epidemics of yellow fever seem to require a certain amount of
warmth for their development, they can, when once developed,
continue for a considerable time with a low thermometer. When
the temperature sinks to freezing point, however, they invariably
disappear.
Sea-coasts, and particularly low-lying and insanitary porttowns, are specially liable to the attacks of yellow fever within
the zone. The courses of river valleys, such as the Mississippi
and the Amazon, have also on some occasions been followed in
the spread of the disease. It is comparatively rare to find the
fever at any great height above sea-level. On some exceptional
occasions yellow fever has been epidemic at a height of 2000 to
3000 feet, as on the east coast of Mexico, and even at a height of
4000 feet, as at Newcastle in Jamaica. But it has never appeared
at a greater height than this, and in Mexico it has not occurred
in places more than 3300 feet above sea-level. Further observations on the distribution of the mosquito which is believed to
carry the infection will, no doubt, satisfactorily explain this relation
of the disease to altitude.
Similar observations are needed to explain the relation of
yellow fever to race. This factor has hitherto seemed to be one
of no little importance in the distribution of the disease. The
white races, the American Indian, and the Hindu coolie have
all suffered from it, but the negro race appears to possess a
remarkable immunity. Nor does this immunity seem to be an
acquired characteristic from long exposure to the infection through
one or more generations, for in many instances negroes newly
introduced into an infected city have escaped the disease. There
would seem to be something in negro blood which either tends
to protect the individual from the disease, or (what is perhaps
more probable) renders him less liable to the bites of infected
mosquitoes. It is noteworthy that half-breeds, quadroons, and
others of mixed black and white descent are no longer immune,
but show a degree of susceptibility to the disease which varies
inversely with the amount of negro blood in their veins.
While the negro race is relatively immune to yellow fever,
almost all other races, with the exception perhaps of the Chinese,
seem liable to contract the malady if exposed to it. Persons,
however, who live in the yellow fever zone and have been exposed

YELLOW FEVER

529

to one or more epidemics of the disease, seem to lose their
susceptibility to some extent, and it is the new-comer and the
stranger that are more particularly liable to attack. No doubt
this is in«great part the explanation of the violent outbreaks of
yellow fever which have attended military operations or the movements of immigrants within the yellow fever zone. An example
of this has been seen in the excessively high mortality from the
disease in Cuba during the recent years of rebellion and war.
Large bodies of unacclimatised troops were successively landed
on the island, both from Spain and from America, and a considerable proportion of them of necessity fell victims to this most
fatal disorder.
The character of the soil has, it seems, little if any influence
on the distribution of yellow fever. The disease has prevailed on the
most varied geological formations. A certain amount of moisture
and an excess of decomposing organic matter in the soil seem to
favour its existence. Dirt and filth and insanitary conditions
generally are perhaps needed for the genesis of the disease, or at
any rate for its development as an epidemic. As Hirsch pointed
out, epidemics have always started " i n seaports, in the immediate
neighbourhood of the harbour and the wharves, and generally
speaking in the filthy quarters of the town, the centres of poverty,
misery, and vice, with their narrow and foul-smelling streets, their
tenements densely crowded from cellar to garret, their taverns,
dancing-saloons, and lodging-houses. It is after the epidemic has
come to a head in these purlieus that it begins to spread, always
in the first instance into the' immediate neighbourhood; but not
infrequently it remains confined to them, and the other parts of
the town some distance off and better situated hygienically may
be little troubled by the sickness or not at all."
The work of the American surgeons referred to above has
established a strong h priori argument in favour of the view that
this disease is spread mainly, if not solely, by mosquitoes. 'Still
stronger support to it is found in the remarkable results that
have followed a practical application of the mosquito theory
in the attempt to deal with yellow fever in its worst endemic
home, and it may be interesting to quote these results before
briefly discussing the theory in some of its other bearings. In
February, 1901, a systematic effort was inaugurated in Havana
to get rid of yellow fever, by quarantining every patient, by
c.

34

530

YELLOW FEVER

protecting his r o o m with wire screens so as to prevent m o s q u i t o e s
b e c o m i n g infected b y sucking his blood, a n d by destroying as far
as possible all m o s q u i t o e s within a given radius of e a c h case of
t h e disease. T h e a c c o m p a n y i n g charts, borrowed from t h e late
Surgeon R e e d ' s a c c o u n t of t h e experiment, indicate very clearly
t h e a d m i r a b l e result of t h e s e efforts. T h e y are best explained in
that author's own words :—
" As an illustration of what has been accomplished by these newer
sanitary regulations, I may state that counting from the date when
they were put into force, viz. February 15th, 1901—Havana was
freed from yellow fever within ninety days ; so that from May 7th to
July 1st—a period of fifty-four days—no cases occurred. Notwithstanding the fact that on the latter date and during the months of
July, August, and September, the disease was repeatedly introduced
into Havana from an inland town, no difficulty was encountered in
promptly stamping it out by the same measures of sanitation intelligently applied both in the city of Havana as well as in the town
of Santiago de las Vegas, whence the disease was being brought into
Havana.
" A s a further illustration of the remarkable sanitary victory accomplished over a disease whose progress we had heretofore been
powerless to arrest, I will close this paper by inviting the reader's
attention, first to the accompanying Chart I, which shows the average
monthly mortality from yellow fever in Havana for the twenty years
1880-1899 inclusive, and also the mortality by month for the years
1900 and 1901. I will then ask him to examine Chart II, which shows
the progress of yellow fever in Havana during the epidemic year
ending March 1st, 1901, when the sanitary authorities were putting
forth every effort known at that time to sanitary science in order to
control the march of the disease ; and when he has satisfied himself
that no effect whatever was produced upon the epidemic of that year,
I will invite his attention to Chart I I I , which shows the occurrences
of this disease in H a v a n a for the epidemic year March 1st, 1901, to
March 1st, 1902, during which year yellow fever was fought on the
theory that the specific agent of this disease is transmitted solely by
means of the bites of infected mosquitoes. By carefully comparing
the figures both as to deaths and cases in these two Charts, and
recalling that between the years 1853 and 1900 there have been
recorded in the city of H a v a n a 35,952 deaths from yellow fever, he
will then be able to more clearly appreciate the value of the work
accomplished by the American Army Commission."
T h e i m p o r t a n t bearing of these observations on t h e geography
of yellow fever is obvious. I t remains to discover t h e actual

I.

Chart showing the monthly mortality from Yellow Fever in H a v a n a
for the 20 years 1880—1899, and for the year igoo—igoi.

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infective material of the disease itself, whether a bacillus or other
organism, to determine what particular species of mosquito are
capable of acting as its intermediate host, and to ascertain the
exact distribution of the latter over the earth's surface. In this,
as in so many other parasitic diseases, three elements appear to
be necessary for its production—the infecting organism, the intermediate host, and a susceptible human population. It must be
supposed that all three elements exist at their fullest in the
endemic centres of the disease in the West Indies and Brazil.
In the secondary centres on the West Coast of Africa they must
also exist, though probably to a lesser extent. One factor, at
least—the susceptibility of the population—is probably less favourable here than in America. The negro race, as pointed out above,
is remarkably immune to yellow fever, and the tropical and subtropical zones of Africa are peopled by negroes. Possibly in
this fact, possibly in the absence of the yellow-fever-bearing mosquito from the interior of Africa, or possibly again in both these
facts, is to be found the reason why the African continent has
seemed to act as a barrier to the easterly extension of the disease.
Whether the inhabitants of Morocco, Algiers, and the rest of the
northern shores of Africa—with sea-coasts well within the limits of
latitude of the American yellow fever zone—are or are not immune
to the disease; or whether the specific mosquito is absent from
those regions—has not yet been determined. From the point of
view of latitude and climate there seems no reason why the
infection should not have invaded these countries and spread by
them to the east and even invaded Asia, and it is a remarkable
fact that it never has done so. Possibly the infection has never
been introduced to their shores; although' during the epidemics
in Spain in former years they must have been frequently exposed
to the chance of invasion, and on one occasion at least (in 1804)
the disease did break out as close to the shores of Morocco as the
small island containing the Spanish fortress of Alhucemas.
Finally, it is well known that the virus of yellow fever can be
carried over long distances by sea, and ship-epidemics of the
disease are by no means rare. It has hitherto been believed that
the infection could be thus carried not only in the bodies of
persons suifering from the disease but also in infected articles.
Many instances have been recorded in which linen and other
personal effects have apparently retained the poison for a con34—2

532

YELLOW FEVER

siderable time and been the means of spreading the disease.
The American experiments referred to above seemed to prove
that such infected articles cannot of themselves give the disease
to susceptible persons, even after very prolonged and close contact with them. But further observations may yet perhaps prove
that if, in addition to articles soiled with the blood or excreta of
yellow fever patients, the right kind of mosquito is also present,
it may be capable of taking up the infecting material from the
articles and later introducing it into susceptible human beings.

BOOK II.
DISEASES OF T H E SKIN.

SKIN DISEASES IN GENERAL.
It must at once be confessed that materials do not exist for
an individual study—to any useful end—of the distribution of
the majority of skin diseases. Or it should perhaps be said that
the materials exist, but not in an available form. Diseases of this
class are rarely fatal, and are consequently scarcely mentioned in
the statistical Health Reports of most countries; and there are in
fact no general and accurate statistics by which their frequency
in different parts of the earth can be judged of. Even when
mentioned in the returns from any country they are more often
than not spoken of as a whole, with nothing to indicate what
particular skin diseases are meant.
Affections of the skin are, of course, exceedingly numerous
and varied, and differ widely in their causation. A considerable
number of them, however, are directly transmissible from person
to person, and are largely favoured by dirt, by a low level of
personal hygiene, and by ignorance or apathy leading to neglect
of treatment. The result is that these particular diseases, and
consequently the group of skin diseases as a whole, are found
to be peculiarly common where conditions of this kind prevail.
In European countries they are most prevalent among the poorer
and less educated classes, and where overcrowding and sanitary
defects are greatest. In tropical and sub-tropical countries they
are often found to run rife amongst native races, who think little
of personal hygiene or of taking steps to cure the disease or
prevent its spread to others.
Many of these disorders seem to flourish best in warm countries,
and hence the whole group is probably more prevalent in and
near the tropics than in more temperate zones. But the difference
does not appear to be very great, and "skin diseases" are not

536

SKIN DISEASES IN GENERAL

only extremely common among the peasant classes of many
European countries, but are strikingly so as far north as Greenland, Iceland, and the Faroes. Some have an almost world-wide
distribution. Eczema, for example, is found in all latitudes, if not
in all countries. Psoriasis is almost universal, though it is thought
to be most common in tropical and sub-tropical countries and
among the coloured races. Itch is, perhaps, quite universal.
Acne, seborrhcea, urticaria, the various forms of herpes including
herpes zoster, and many other skin affections have a very wide
diffusion, if not quite so universal as those just named.
The class of ringworm diseases—i.e. those due to some variety
of trichophyton or tinea—are common in many countries, but
especially so in and near the tropics. Ordinary ringworm (Trichophyton tonsurans), favus, and tinea versicolor have a very wide
distribution in all latitudes. " Dhobi itch," a troublesome skin
eruption in the axilla and about the genitals, is another example
of this class. It is very frequent in many hot countries and few
European residents in the tropics escape an attack of it at some
time or other. Tinea imbricata and pinta are of the same character,
and as they have a very distinct and interesting geographical distribution they will be separately discussed later.
Perhaps the commonest of all the skin diseases to which
unacclimatised persons are liable in the tropics is " prickly heat,"
or lichen tropicus. This is a simple papular eruption as a rule,
of no serious import except for the irritation and often intolerable
itching it may give rise to. Most Europeans suffer from it more
or less after arriving in a hot climate, but while in some it causes
practically no trouble at all, in others it may be of a most violent
character, causing really intense suffering and some constitutional
disturbance. It is not confined to the tropics and may occur in
any hot climate. It has been seen as far north as Sicily and
Minorca in the Old World, and in the Mississippi Valley in the
New.
Boils and carbuncles are forms of skin affection that occur
more or less in all latitudes, but are most frequent in hot countries.
They attack all races to some extent, but boils affect particularly
the European resident in the tropics. Like prickly heat and
dhobi itch, one or two boils or a crop of boils are almost certain
to develope sooner or later during a prolonged stay in hot
countries. When very numerous they may cause a long and

SKIN DISEASES IN GENERAL

537

painful illness and leave a good deal of debility behind. In some
years they appear in so many individuals as to justify the use of
the term epidemic. Such epidemics of furunculosis have been
seen not only in India and other tropical countries, but in the
United States, in England, Scotland, Ireland, France, the Cape,
Hungary, and Italy.
Pemphigus contagiosus is the name given by Manson to a
form of skin disease in the tropics which appears to correspond
to the impetigo contagiosa of more temperate climates. It has
been seen mostly in Southern China, where it is very common in
the hot weather, and in some years almost epidemic. It is also a
frequent disorder in the Straits Settlements and in Madras, and
perhaps in some other tropical countries.
The following skin affections, some of which have been
named already, have a distinct and peculiar geographical distribution and are deserving of brief sections to themselves:—craw-craw,
oriental sore, pinta, tropical phagedena, tinea imbricata, verruga
peruviana and yaws. Mycetoma is sometimes classified among
skin diseases, but as it affects the entire tissues of a limb it has
been dealt with elsewhere.

CRAW-CRAW.
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . Craw-craw, or krakra, is the name given to a peculiar affection met with among
natives of the West Coast of Africa and the French Congo. The
exact nature of the malady is for the present uncertain. Probably
the name is frequently applied by the natives indiscriminately to
a variety of skin diseases. But the affection usually described
as craw-craw appears to be distinct and characteristic enough.
Attention was first drawn to it by O'Neil in the year 1875. The
disease is characterised by the appearance of papules which pass
on to pustular formation and ulceration. The parts most often
affected are the hands, feet, and lower extremities; but the
eruption may cover the whole body. A filaria which presents
some resemblances to the filaria perstans has been found in the
pustules, but its exact relation to the disease has not been
determined. Filaria perstans being exceedingly common in those
countries where craw-craw prevails, it is possible that their presence
in these cases is a mere coincidence, and that they do not stand
in any causal relation to it. Manson has suggested that the filaria
found in cases of craw-craw, which shows some slight differences
from the ordinary form of filaria perstans, may be an advanced
form of that parasite; and he suggests that the skin may be the
normal channel by which it escapes from the human body, after
undergoing there a certain measure of development.
Recently Bennett, after experience of the disease in Southern
Nigeria, has expressed the opinion that craw-craw is merely a
pustular eczema; that it is not a specific disease; that the filaria
is found in cases of so-called craw-craw in just the same proportion
that it is found in the general population of the districts; and that
the name craw-craw, which is given by the natives to almost all

CRAW-CRAW

539

skin diseases excepting yaws, should be abandoned as indicating
any distinct and separable malady 1 .
G e o g r a p h i c a l D i s t r i b u t i o n . The disease usually known
under this name is apparently confined to the African continent.
On the West Coast it is very common, particularly in the district
of Old Calabar and in the Cameroons 2 . It is also found widely
in the French Congo and along the valley of the Ubangi river.
Dr J. Emily, who accompanied the Marchand mission to Fashoda
in the Sudan in 1898, states that he saw cases in the districts of
Libreville, Loango, and Brazzaville, and at nearly all the stations
along the Ubangi. The disease attacked many of the members
of Major Marchand's expedition, and caused much suffering and
subsequent anaemia. Two officers of the expedition who contracted
it at Loango and Brazzaville respectively were still suffering from
it a year and a half later 8 .
1
2
3

Journ. of Trop. Med. Feb. 15, 1901.
Plehn, Janus> 1896-7, p. 383.
Arch, de Med. Novate, Jan. 1899.

ORIENTAL SORE.
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . A great variety of
names have been applied to a skin affection which, though found
in many widely distant countries, probably owns an identical cause
in all. The "Aleppo button," t h e " Delhi sore," the " Penjdeh
ulcer," the " clou de Biskra," the " bouton d'orient," are a few of
the names under which the affection is known. It usually begins
with a certain amount of itching, followed by the appearance of a
small papule, which enlarges and becomes indurated.
This
period of induration, which may last from one to four months, is
followed by a period of ulceration, during which an indolent,
slowly-spreading ulcer forms. This ulcer, which is covered by
crusts and with some discharge, itches, but is not as a rule painful.
After another interval, of usually some months' duration, healing sets
in. A depressed, pinkish or brownish cicatrix is left behind, which
may cause no little deformity from contraction. Several such
sores may be present at the same time, and may seriously affect
the health of the patient, more especially if, as occasionally
happens, they should be complicated with lymphangitis, adenitis,
phlebitis, erysipelas, or sloughing phagedaena. Second attacks are
rare.
The late Dr Tilbury Fox proposed the name Oriental sore for
this disease, and, until a better can be found, this title seems more
convenient than any other.
If, however, a disease recently
described by Juliano 1 as being common in Bahia in Brazil should
prove to be identical with the one under discussion, it may be
hoped some other name will be found for it.
H i s t o r y . The earliest known accounts of this affection
came from Aleppo, where, at the end of the 18th century,
Ref. in Manson's Tropical Diseases.

O R I E N T A L SORE

541

Russell first observed it, and described it under the name of
Aleppo boil. Later it was seen in other parts of the Levant, but
it was not until the latter half of the nineteenth century that it
came to be recognised as having a much wider distribution than
was at first supposed.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. This sore
is practically unknown at the present day in any part of the
continent of Europe. Half a century ago Libert observed some
cases presumed to be of this nature among Tatars in the Crimea,
but there seems to be no recent evidence of its existence there or
in any other part of European Russia.
Asia. Syria and Asia Minor have long been recognised as
countries in which oriental sore is common. In Syria it is said
to occur chiefly in the northern districts of the Orontes, between
Killis and Aleppo; while it is rare in the towns and villages to the
west of Aleppo, and unknown among the Bedawin and in the
Kurdish highlands. In Asia Minor it is met with at Brusa.
In the Caucasus it has been seen in the government of Elizavetpol.
It is probably common in the Russian Central Asiatic provinces
of Transcaspia and Turkestan. What is known in Tashkent as
"Sart disease" by the Russians, or as "Afghan sore" by the
natives, is most likely of this character. It is described as " a very
disagreeable ulcer, which breaks out on the face or hands, spreading constantly, and eating deeper and deeper 1 ."
In Bokhara it is particularly frequent at Patta-Hissar, Shirabad
and elsewhere. All the inhabitants of these regions suffer from
it, without distinction of sex, social condition, or nationality, and
it is said that the Russian soldiers on the frontier guard rarely
escape it 2 . In Mesopotamia oriental sore is particularly common ;
at Baghdad almost every inhabitant seems to have suffered from it
at some time, and visitors are often attacked. It is not confined
to Baghdad, and Hirsch states that it is found throughout the whole
plain between the Tigris and Euphrates, from Diarbekr through
Baghdad to Basra. It also occurs in Crete and Cyprus.
In Persia it is commonest in the central regions of Teheran,
Kashan and Ispahan, less frequent in Hamadan, and unknown in
the northern mountainous districts and on the shores of the
Caspian. The name of Penjdeh ulcer indicates that it is common
1
2

Turkestan.
Grekof.

By Eugene Schuyler, London, 1876, vol. I., p. 148.

542

O R I E N T A L SORE

at Penjdeh on the borders of Russian and Afghan territory. It
probably occurs also in Afghanistan and Baluchistan. In India it
is found over a large area which extends along the Indus from the
Punjab (Lahore, Multan) southwards through Sindh, and eastwards
through Rajputana and the North-West Provinces as far as Delhi,
Meerut, Lucknow, and Gwalior. Bengal proper, Madras, Central
India, and most of the Bombay presidency appear to be free from
the malady (Hirsch). In recent years its frequency in Delhi is
said to have much decreased. The so-called " Nepal button " is
probably not of the character of the sore now under consideration.
There is no positive evidence that this affection exists in
Asia to the east of the Indian peninsula, or in any portion of
Australasia.
Africa.
Cases of oriental sore have been seen in Egypt, at
Suez and Cairo. In Algeria it has been observed at many places,
notably at Tlemcen, near the Morocco frontier, at Ouaregla in the
Oran province, at Algiers itself and Laghouat in the Algiers
province, and at Biskra, Tugurt, and Liban in the Constantine
province. In the Tunisian Sahara it is said to be very common.
In Morocco it is seen principally on the banks of the Muluya
river.

Factors which govern the Geographical Distribut i o n . This disease is essentially one of warm countries. So far
as is known at present it is confined to the sub-tropical regions
and northern coasts of Africa, to the south-western portion of
Asia, and to tropical and sub-tropical India. Moderate warmth
rather than excessive heat must therefore be regarded as favouring
its occurrence, and this conclusion is supported to some extent
by the relations of the disease to seasonal changes. In India it
most usually appears, not during the hot season, but at the
beginning of the cold weather, after the rains have ceased. In
Aleppo and Algeria the affection is commonest in the autumn.
Neither the nature of the soil nor the height above sea-level seems
to have any influence over the distribution of the malady, which
is equally indifferent to the sex, race, and social condition of the
people among whom it prevails.
Oriental sore is probably a contagious disorder. The discharges can cause fresh sores by inoculation both in the
same individual and in others, and also in the lower animals.
It is probable therefore that the affection is due to a micro-

O R I E N T A L SORE

543

organism contained in the discharges, but the specific microorganism, if it exists, has not yet been detected. It has been
suggested that the infection may be carried from person to person
by means of flies or other insects, but there seems to be no
positive proof that this takes place. From the date of the earliest
records of the disease down to the present day there has been a
very general belief that oriental sore may be spread by means of
drinking-water. In Algeria, in Aleppo, in India and elsewhere
the behaviour of the disease has on some occasions seemed to
show that the infection might perhaps be spread in this way.
But on the whole the balance of evidence seems to be against
this view. In Algiers and elsewhere an excessive consumption of
dates has sometimes been held responsible for the appearance of
the sore, but here again there seems to be no certain proof that
they stand in the relation of cause and effect.
Oriental sore is essentially an endemic disease. There is
little to show that its geographical distribution undergoes any
considerable variation from year to year, or perhaps even from
century to century. But its degree of frequency varies to some
extent from time to time in those areas where it is endemic, and it
has occasionally become so general as almost to deserve the title
of epidemic.
It has already been pointed out that the sore can be artificially
produced in the lower animals by inoculation. To this it must
be added that certain animals seem to be capable of suffering
from it under natural conditions. Thus in Syria and India dogs
are said to have been subjects of the disease on several occasions;
and in Syria oriental sore has been seen in the horse.

TROPICAL P H A G E D E N A .
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . Phagedenic tropical
ulcers are found in almost all tropical countries. While simple
clean wounds heal with almost exceptional rapidity in the healthy
natives of these countries, it is at the same time true that any
small, jagged, contused wound, ulcer, or other solution of skin
continuity in these countries may take on a malignant, phagedenic
character and cause wide and destructive ulceration, seriously
endangering the patient's life. Any small abrasion, even a mere
insect bite, may suffice to start the process. A chigo ulcer or the
site of a yaws papule may become phagedenic. Persons in a low
state of health, depressed by attacks of malaria or other disease,
are particularly liable to become subjects of these ulcers, which
are commonest on the feet, but are also met with in other
parts of the body. The symptoms of tropical phagedena
closely resemble those of hospital gangrene, at one time so
common in all hospitals, and it is still uncertain whether the two
processes are not identical.
Tropical phagedena is almost
certainly due to some micro-parasitic infection, but the specific
organism has not yet been certainly detected. Le Dantec, in 1884,
described a bacillus found in these ulcers in Arab convicts in
French Guiana, and a similar bacillus is said to have been observed
by Clarac at Martinique, and by Peht in the Comoro Islands.
Its specific relation to the disease has not yet, however, been
finally proved.
G e o g r a p h i c a l D i s t r i b u t i o n . Europe. Europe being outside the tropical and sub-tropical zones, true tropical phagedena
is unknown on this continent. If hospital gangrene is pathologically identical with it, it also is now never seen in well-managed
European hospitals.

TROPICAL

PHAGEDENA

545

Asia. On the Arabian shores of the Red Sea phagedaenic
ulcers are very common from Yanbo to Aden. In the province
of Yemen the so-called Yemen ulcer appears to belong to this
group. In India such ulcers occur with great frequency, particularly in Lower Bengal, Orissa, Arakan, the Malabar Coast, and
Sindh. Possibly the so-called Jalkat sore is of this nature. This
is a peculiar affection, met with at Jalkat and Chilas on the
upper Indus, near the Afghan-Kashmir frontier, and also at
Punial and Skardoo. It is said to be caused originally by the
bite of the so-called Chilas fly1.
In Farther India and the Malay Islands these ulcers are probably common. In Siam they are very frequently seen 2 . In British
North Borneo large numbers of them are yearly treated, and in
the Dutch possessions in the East Indies no complaint seems to
be more common than ulcers among the natives. In the Straits
Settlements they are very rife; in each of the years 1897 and
1898, for example, over 600 cases of this nature were treated
in the hospitals, and in the Singapore prisons such ulcers very
frequently come under treatment.
In Annam and French Cochin-China also the disease must
be extremely prevalent. The French expeditionary corps suffered
very severely from it. In Southern China ulcers of one kind
or another are very common in the natives, but it is not clear
whether these are of the tropical phagedaenic variety.
Australasia.
In many of the Polynesian islands the natives
suffer greatly from phagedaenic ulcers. In New Caledonia, for
example, they are, or were at one time, a serious source of
disablement not only to the natives but also to the crews of the
French men-of-war stationed there. In Fiji at the present day
between one-fourth and one-third of the cases treated in the
Colonial hospital are usually cases of ulcer, and in the Solomon
Islands large ulcerous sores, particularly on the feet, occur with
great frequency3.
Africa. This form of ulcer is also widely spread in tropical
and sub-tropical Africa. Whether it exists endemically in Algeria
is uncertain. Many cases of it were treated in the hospitals after
the return of the Algerian (Arab and Kabyle) porters from the
French expedition to Madagascar; but the men seem to have
1
2

c

Trans. 1st Indian Medical Congress; 1894.
3
Rasch, Janus, 1896-7.
Guppy, op. cit.

35

546

TROPICAL

PHAGEDENA

contracted the sores in that island, and evidence is apparently
lacking of the presence of phagedsena in Algeria as an indigenous
disease. In Abyssinia, the Sudan, and Egypt, however, it is far from
rare. At Massowa severe forms of phagedsenic ulceration are seen \
These ulcers are also frequent in Somaliland and Zanzibar, and the
well-known '"Mozambique ulcer" is probably of this character.
On the West Coast phagedaenic ulcer is extremely common on the
Gold Coast, in Senegambia, and elsewhere. In Madagascar it is
also constantly met with, and, as already stated, was a serious
source of trouble among the porters employed in the French
expedition in 1895.
America. Tropical phagedsena is very commonly seen in
Mexico, in Guatemala, Nicaragua, Honduras, and other Central
American States. In the West Indian Islands the natives suffer
greatly from it. In Trinidad, for example, and generally throughout
the Leeward Islands, few diseases more commonly come under
treatment. At St Lucia in 1898 ulcers were so widespread as to be
spoken of as an " epidemic," and they caused much maiming and
disablement among the people. In Jamaica a certain number of
cases are admitted to hospital each year.
In South America these ulcers probably occur throughout the
tropical zone, but the fullest accounts of them have come from the
Guianas. In French Guiana they seem to be particularly frequent
and severe.

Factors governing the Geographical Distribution.
As the name usually given to these ulcers implies, they are mostly
found within the tropics. In Asia and in America they appear
to be wholly or almost wholly tropical; in Africa they are found
mainly in the tropical zones, but also in the sub-tropical regions
of Egypt and—doubtfully—of Algeria. A high temperature may
therefore be regarded as necessary to their endemic prevalence.
They also prefer low-lying damp places, such as swamps, the
alluvial beds of rivers, and sea-coasts, though they may develope
at considerable altitudes, as in the Abyssinian highlands and the
Himalayas.
The state of health of the individual is of importance as a
predisposing factor in the development of the ulcers, and, as has
been stated above, persons already weakened by other illnesses are
very liable to become subjects of them. Whether there is any
1
Rho.

TROPICAL PHAGEDENA

547

true racial susceptibility or immunity to them is uncertain. All
native races living in tropical countries, and Europeans migrating
there, may become the subjects of phagedaenic ulcers. Some,
however, do seem to suffer more than others. Brault, for example,
has shown that in the French expedition to Madagascar, while the
Kabyle and Arab porters already alluded to suffered very seriously
from sloughing ulcers, the negroes from the Sudan and the Somalis
remained almost entirely free from them. H e states that all went
barefooted and passed through the expedition equally badly
equipped and under exactly the same circumstances, yet the one
race suffered severely while the others appeared to be more or less
immune. This, however, can scarcely be accepted as an instance
of true racial difference in susceptibility to the affection, for the
Somalis and the Sudanese negroes are certainly not immune to
these ulcers in their own countries. It is therefore possible that
the porters of these races employed by the French in Madagascar
had already suffered from them, or were more or less immune from
constant exposure to the conditions which bring them about, while
the Kabyles and Arabs from Algeria were readily attacked by a
form of disease which does not appear to be endemic in their own
country.

35—2

PINTA.
General C h a r a c t e r s a n d E t i o l o g y . Pinta or Mai de las
rintas is a remarkable epiphytic disease, which until recently was
believed to be confined to Central America and the contiguous
areas of Mexico and South America, but is now known to have
a much wider distribution. It is essentially a dermatomycosis,
commencing in the form of isolated spots of discoloured skin.
There is more or less severe itching in the spots, which become
rough and scurfy from desquamation of the epidermis. The
spots enlarge and multiply, and when the disease is fully developed
the whole surface of the body (including, rarely, the palms of the
hands) may be mottled with patches of red, blue, black, or white
discoloration, giving a markedly grotesque appearance to the
patient. It causes little constitutional disturbance and is never
fatal.
Pinta is caused by a microscopic parasite, with mycelium and
pigmented spores. The mycelium measures from 18 to 20/x in
length by 2 /x in breadth; and the spores are from 8 to 12 //> in
diameter. The difference in colour in the patches may depend
on differences in the pigmentation of the spores or upon the
mode of distribution of the parasite in the layers of the skin.
T h e disease is almost certainly contagious. Montoza of Medellin
(Colombia) claims to have found the pinta fungus in the waters of
the Colombian gold-mines, and also in the bodies of mosquitoes
which he believes to be carriers of the disease. It is noteworthy
also that in Mexico the natives attribute the spread of pinta to
the agency of mosquitoes.
H i s t o r y . Very little is known as to the history of pinta.
It is said to have been prevalent in the southern parts of North
America before the Spanish conquest of Mexico, and to have been
imported to Mexico only as late as about the year 1775.

PINTA

549

The disease has only recently been recognised in other parts
of the world than Central and South America.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . Europe. No case
of pinta has, up to the present, been observed in any European
country or in any of the islands adjacent to Europe.
Asia. In Asia it is still perhaps open to question whether the
disease exists. Recently, it is true, cases have been described as
occurring in Perak in the Malay States which bear great resemblance to the accepted descriptions of pinta. In the Journal of
Tropical Medicine for February 15 th, 1901, Dr P. G. Edgar has
described in detail a case of this kind. Doubt, however, has been
thrown upon the nature of the case on account of the absence of
coloured, red or blue, patches and the incomplete description of
the fungus found 1 . Leucoderma, or white patching of the skin, is
by no means rare in natives of India, and it has been suggested
that this case, where the patient was from southern India, was
not one of true pinta, but an example of leucoderma. For the
present the question is undecided, but if this and similar cases
seen in that part of the world are indeed instances of pinta, then
the disease must have a much wider distribution than was formerly
believed, for the author just quoted writes :—" Less typical cases of
pinta than the one described here are not uncommon among the
Malays, Chinese, and Tamils in Perak and the Straits Settlements.
Among the Malays the disease is known under the name of sopah;
it is fairly common in the Kuala Kangsar district in Perak, occurring
among several members of the same family."
There is no mention of pinta or a disease resembling it in any
other country of Asia, nor in any part of Australia, New Zealand,
or the Pacific Islands.
Africa.
In Africa pinta or a similar disease is said to have
been met with in the north (Manson), in Egypt (Sandwith), and
on the West Coast. Some uncertainty still exists as to the
identity of the African malady with that observed in America, but
Dr Osborne Browne, who had seen pinta in British Honduras and
was subsequently transferred to the Gold Coast, is satisfied that the
disease met with in the latter country is true pinta. H e states
that it is very common on the Gold Coast, where the natives
erroneously attribute it to yaws, although the latter disease may
have occurred years before the pinta. H e adds also that the
1

Journ. Trop. Med. April 15, 1901.

PINTA

5SO

natives aver that pinta extends into Hausaland about Kano, where
it is called tungere. " T h e fungus," he states, "is in all cases
identical 1 ."
North and Central America. But if of very limited distribution
in the Old World, pinta is much more widely met with in the New.
In Mexico it is endemic along the west coast, particularly in
the provinces of Guerrero, Valladolid, and Michoacan; it is more
rare in the interior, and has not been seen further to the east
than the western districts of the Tabasco province. The east
coast of Mexico appears to be entirely free from it. In some
villages in Mexico as many as 9 per cent, of the population are
affected by it, and in 1826 there was in the Mexican capital a
whole regiment composed exclusively of "pintados." The Mexican
name for the disease is salt sayanolitzth'2'.
In Central America it is found, though rarely, in Panama.
In British Honduras it is exceedingly common, and as many as
60 per cent, of the adult Caribs in that colony are said to be
affected by it; while in some places the proportion is even higher,
and nearly every adult Carib is said to suffer3. The Carib name
for it is wall-wall, meaning a surface not uniform in colour.
South America. There is no mention of pinta in any of the
West Indian Islands, but in several parts of South America the
disease is seen. In Venezuela it is endemic in the provinces of
Barquisimeto and Merida. In most parts of Colombia it is very
prevalent, and particularly so in the province of Santander. It has
been seen at one or two places in Peru and Chile, and finally
it has been reported from Brazil, in the district between the
Juciparana and the Sant' Antonio rivers.

Factors which govern the Geographical Distribution.
In addition to the presence of the specific parasitic fungus, certain
other conditions seem to be necessary for the prevalence of pinta.
These are a warm climate, want of cleanliness and general hygiene,
and an absence of precautions to prevent its spread from person
to person.
That warmth is one essential for its existence is clear from the
fact that pinta is only met with in tropical and sub-tropical latitudes;
that in Mexico it is no longer found as an endemic above an
1

Journ. Trop. Med. June 15, 1901.
Mexico as I saw it. By Mrs Alec. Tweedie, 1901.
3
Osborne Browne, Journ. Trop. Med. January, 1900.
2

PINTA

SSI

elevation of 1500 feet; while in Colombia it is seen only in places
with a mean temperature of from 68° to 85° F. A damp soil is
said also to favour its development, and it is particularly frequent
along the banks of damp or swampy rivers.
Want of personal hygiene and particularly want of cleanliness
are also favouring factors. The poor and the dirty are the classes
of population most liable to it. Race has also probably some
influence. In British Honduras, for example, it is observed that
Europeans and white Spaniards escape almost altogether, and that
Creoles are only occasionally attacked, while, as already stated, an
immense proportion of the Carib population are subjects of the
disease. To what extent this immunity or relative immunity of
certain races is truly a racial characteristic, or to what extent it is
due to a higher level of cleanliness, care, and personal hygiene is
not, however, clear. In the Malay Peninsula not only Malays,
but also Chinese and Tamils are attacked (if, indeed, the disease
observed there is in truth pinta); and (with the same proviso) the
true negroes of western Africa can also suffer from it.
There is considerable evidence that pinta is contagious, and
that it is spread from place to place and from person to person by
the movements of infected individuals.

TINEA IMBRICATA (TOKELAU
RINGWORM).
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . Tinea imbricata is
a skin affection characterised by a concentric arrangement of
closely set rings of scaling epidermis. It may gradually spread
over the whole surface of the body, with the exception, usually, of
the palms of the hands and the soles of the feet. It is an
objectionable, but apparently in no sense serious, skin disease, of
wide distribution in the Far East.
It is caused by a trichophyton.
H i s t o r y . Nothing is known as to the origin and early
history of this skin affection. If, as there seems reason to believe,
the disease called "gune" is the same as the Tokelau ringworm, then its existence has been known since the year 1844.
Under that name the medical officers of the United States Exploring Expedition under Commodore Wilkes described an endemic
skin disease as seen by them in the Gilbert Islands, and the
description tallies closely with that of tinea imbricata 1 . In 1870
Turner gave an account of the affection2, and stated that it had
been imported from the Gilbert Islands to the Tokelau group, and
later to the Samoa Islands. In the latter it is thought the disease
did not exist before i860. In 1870 it was introduced to Fiji, and
two years later had become pretty general there 3 . In 1874 Tilbury
Fox described the fungus associated with the disease, as observed
by him in some scrapings sent from Samoa 4 . More recently many
observers have given accounts of it. All are agreed that its dis1
2
3

Narrative of the U. S. Exploring Expedition, 1844.
Glasgow Med. Jotirtial, Aug. 1870.
4
Daniels.
Lancet, Aug. 29, 1874.

TINEA IMBRICATA (TOKELAU RINGWORM)

553

tribution is a constantly expanding one. Within the latter half of
the nineteenth century it has been carried to large numbers of the
Pacific Islands where it was unknown before, and in many has
taken a firm hold, which it seems little likely to relinquish for the
present.
R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . This form of skin
disease is met with most commonly in the Pacific Islands. The
inhabitants of the Tokelau and Solomon Islands are particularly
affected by it. These two groups are some fifteen hundred
miles apart, arid, as might be anticipated, the disease is not
confined to them, but is also seen in many of the intervening
islands.
In the Solomon Islands it is thought that not less than twofifths of the entire population are subjects of this skin affection1.
Its degree of frequency varies in the different islands of this group.
In Treasury Island, for example, as many as four-fifths of the
people are affected by it. Half of the thirty wives who share the
joys and sorrows of the chief of this island are said to be almost
covered with the eruption. In one of the Florida Islands " quite
half" of the population have the disease.
In the Tokelau or Union group the disease is particularly
common in Bowditch Island.
Northwards it has been seen in the Sandwich Islands, and
westwards and northwards in the Ladrones 2 , in Mindanao, the
most southerly of the Philippine Islands, and in the Pelew and
Caroline groups.
The disease is found in New Britain, New Guinea, and some
of the adjoining islands. In British New Guinea it is very prevalent both at the western and eastern extremities, and " is
gradually closing in on the central district, which it will before
long completely invade 3 ." In the neighbouring groups of Ke
and Aru, in Teste Island, and Woodlark Island, the disease is
common. In New Ireland and the Duke of York Island it is no
less so.
1
See an interesting account of the disorder in* The Solomon Islands and their
Natives, by H. B. Guppy, M.B., F.G.S., late Surgeon R.N. London, 1887.
2
Dampier, Voyage round the World.
3
British New Guinea, Annual Report, 1897-8. By Sir William MacGregor, K.C.M.G. Later evidence seems to show that this prophecy is being
fulfilled. Cases have been reported at Port Moresby on the south coast of the
island {Journ. Trop. Med. Oct. 1900).

554

T I N E A IMBRICATA (TOKELAU

RINGWORM)

Tokelau ringworm is found in many of the South Pacific
Islands. In the New Hebrides it is widely diffused. Bernal
states that in some of the islands of this group, and particularly
where the population is dense, as on the east coast of Mallicolo,
at Atchin, Vao, and Whala, almost every inhabitant is affected by
it. In the Fiji group it has become very general since its introduction in the year 1870, and the Gilbert, Ellice, Tonga, and
Samoa Islands have all been invaded by the disease. It has also
been met with in the Loyalty Islands and in New Caledonia.
The ringworm has also spread to Formosa. While comparatively rare among the Chinese inhabitants, it is fairly common
among the Pepohoans of the Kapsulan plains, and among the
Hakkas, who are brought most into contact with the aboriginal
inhabitants of the island. The aborigines of the mountains suffer
less from the disease than the more civilised aborigines of the
plains. In the Kilai plain Rennie found quite six per cent, of
the semi-civilised native inhabitants affected by it. While no
rarity, then, in Formosa, it will be seen that tinea imbricata
attacks a far smaller proportion of the population here than, for
example, in the Solomon Islands.
A few cases have been recorded at Foochow and other places
on the southern shores of China by Manson, but these occurred
only in persons who had come from Malacca or elsewhere in
Malaysia, where it appears to be a very frequent disorder 1 . Nieuwenhuis found that many of the natives of Borneo suffer from
the affection2. Tamson also refers to its frequency among the
Dyaks of that island, who have given it the names of kurab or
babouron*. It has also been seen in Sumatra 4 , and in Gisser,
Ceram, Ceram Laut, and Goram. In Burma the disease has been
known to exist in Rangoon, Maubin, Tomeghu and Akyab. The
only place in India where it has been observed is Chittagong, near
the Ganges delta. It has been recorded from the island of NossiBe, off Madagascar.

Factors governing the Geographical Distribution.
Tinea imbricata is practically confined to the tropics. A damp,
warm climate, with a minimum temperature of 700 Fahr., and
1
2
3
4

Wallace, The Malay Archipelago.
Janus, 1897-8, p. 205.
Archives de Med. Navale, Sept. 1899.
Illustrated Supplement to the Journal of Trop. Med. Feb. 1899.

TINEA IMBRICATA (TOKELAU RINGWORM)

555

an average of from 80 to 90 0 Fahr. is the most favourable for the
existence of the disease. In addition to heat and moisture, dirt
and a general condition of bad hygiene seem to be, if not
essential, at least conducive to its spread. It is usually seen in
native populations who pay little attention to personal hygiene,
and, as it causes but slight inconvenience in the way of irritation,
and is not viewed with disgust by the majority of subjects, it is
very often left untreated. As it is also extremely contagious,
it rapidly spreads in a community of this kind, when once introduced among them.
In regard to race, the disease has hitherto been mainly
confined to the Papuans, Malays, and the mixed races which
people Oceania, but especially to the first named. These people
have been the main carriers of the dermic fungus which causes
the disease, from island to island, through a great part of Polynesia and the Far East. But how far this is to be ascribed to a
true racial predisposition is uncertain. In Formosa the Chinese
have suffered much less than the aboriginal inhabitants. The
origin of the latter race in this island is somewhat obscure, and
Rennie has suggested that the very fact that Tokelau ringworm is
common among them and rare among the Chinese may help to
solve this ethnological problem, by indicating that the disease was
brought to Formosa by a representative of one or more of the
present tribes whose original home was one of the Pacific Islands 1 .
Tinea imbricata has shown no special relation to age or sex.
It is very easily got rid of by appropriate treatment, but the inhabitants of the affected countries rarely submit to the necessary
measures.
Chinese Customs Med. Reports, No. 45.

V E R R U G A P E R U V I A N A or
T H E PERUVIAN WART.
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . Verruga or the
Peruvian Wart is a disease resembling, but probably distinct
from yaws. The whole course of an attack of verruga usually
lasts for several months. The first few weeks, which may be
called the period of invasion, are characterised by a condition of
fever, acute rheumatic pains in the muscles, bones, and joints,
and a general sense of ill-health, together with headache, giddiness, and a feeling of contraction in the gullet. The most
characteristic feature of the disease is an eruption, consisting of
raised, elastic, reddish-blue tumours, sessile or pedunculated,
varying in size from that of a filbert to that of a pigeon's egg.
These wart-like tumours appear to be of the nature of highly
vascular granulomata. Warts may appear not only on the skin
but also on the mucous linings of the mouth, the nose, pharynx,
alimentary tract, bladder, uterus, and vagina. They bleed with
considerable ease, and hence anaemia is often brought about by
haemorrhages from the external warts, or by loss of blood from
the internal passages. It is possible that these haemorrhages are
favoured by the reduced atmospheric pressure found at the high
altitudes where verruga prevails, as they are said to cease when
patients descend to lower levels. The disease may end in recovery,
by the drying and shrivelling of the tumours until they fall off,
leaving a small ulcer which slowly heals; or (in from 6 to 10 per
cent, of the cases) in death, either from profuse haemorrhages or
from some complication.
Its cause is unknown.
H i s t o r y . The earliest mention of verruga relates to the
16th century. Zarate, the Chancellor of Lima whose History of

VERRUGA

PERUVIANA

557

Peru was published in 1543, speaks of the existence there of a
disease which certainly resembles the modern descriptions of
verruga. " T h e men here," he wrote, "suffer from a wart or
small tumour like a boil, very malignant and dangerous, which
appears on the face or other parts of the body, and is more
destructive than the small-pox and almost as disastrous as the
plague itself." When Pizarro, with his small army of 700 men,
was conquering Peru, it is said that more than one-fourth of his
men died from haemorrhages following gangrenous ulcers of the
skin. For the next three hundred years history seems to be
silent as to the existence of this disease. But in 1842 Archibald
Smith described it anew in the Edinburgh Medical and Surgical
Journal, and since then there have been numerous references to
it in medical literature.
R e c e n t Geographical D i s t r i b u t i o n . Verruga, so far as
is known, is now confined to certain Peruvian valleys on the
western slopes of the Andes. Hirsch quotes authorities to the
effect that its headquarters are at Santa Ulaya in the Huarichi
district, Matucana and a few other villages in Cocachacra, the
valleys at the foot of the Cerro de Pasco, inhabited for the
most part by miners, and several valleys in Chiquiang and
the mountainous districts to the south of Lima. Imported
cases have occasionally been seen outside these limits, as on the
littoral of Peru. No cases have been seen on the eastern slopes
of the Andes, and the disease is apparently unknown in Chile,
Bolivia, or Colombia.
The disease is endemic in these regions, but on at least one
occasion it seems to have become epidemic. This was in 1874,
when large numbers of labourers employed in making the railway
between Lima and Oroya were attacked. This outbreak caused
a considerable mortality. The disease is sometimes called Oroya
fever, but this would appear to be a misnomer, as it is unknown
as an endemic disorder in Oroya itself1.
Whether this disease exists in any other part of the world it is
difficult to say. Beaumannoir has described a case of illness in
the island of Reunion which he believed to have been verruga;
and de Havilland Hall mentions a similar disease which he was
informed exists in Zaruma, Ecuador. Mr Hutchinson treated a
1
La Maladie de Carrion ou la Verruga Peruvienne, by E. Odriozola.
Paris, 1898.

558

VERRUGA PERUVIANA

case in London, but the patient had worked in a Peruvian silvermine five years before, and the attack was presumably a recurrence
of the disease contracted then.

Factors governing the Geographical Distribution.
Unless verruga is, as some observers think, only a severe form of
yaws, it has perhaps the most limited distribution of any known
disease. It is found, with the uncertain exceptions just named,
solely in certain quebradas or narrow deep valleys or ravines on
the western slope of the Andes, between the limits of the 9th
and 16th degrees of south latitude. The verruga valleys vary in
height from 2500 to 8000 feet. The temperature in the daytime
is often very high (95 0 to 1030 F.) but the daily variations are
great, and the nights are often cold. The inhabitants live under
conditions of much poverty and misery.
The valleys in which verruga prevails are said to be formed
of bare rock (granite or diorite) and are usually traversed by a
stream. In some valleys it is to the water of these streams
that the disease is attributed. In the valley of Huarochiri, for
example, there is a stream which for this reason is called the
Agua de verrugas. Whether this theory of the origin of the
disease has any real basis in truth it is difficult to say. Some have
thought that verruga is spread mostly by contagion. Its general
characters lend great probability to the view that it is caused by
some micro-organism, but none has ever been discovered that
could be called specific to the disease. On the other hand it is
known to be inoculable. In 1875, at t n e t i m e OI" the outbreak
on the Lima-Oroya railway already mentioned, doubt seems to
have arisen as to the true nature of that disease, and a medical
student named Carrion had the courage to inoculate himself from
one of the cases. H e developed verruga and thus showed the
identity of the two diseases, but unfortunately he succumbed to
the attack. His memory is kept alive by the name of Maladie de
Carrion which is often applied to this disease, particularly by
French authors.
While verruga is thus clearly inoculable, there is no certain
evidence that it is usually spread from person to person by means
of the discharges from the warts. The opinion of the inhabitants,
of the verruga valleys seems to be generally against the view that
it is spread in this way. Its degree of " contagiousness," in the
popular sense of that word, is in any case probably not very high,

VERRUGA

PERUVIANA

559

and cases of verruga are treated in the general wards of the Lima
hospitals without any spread of the disease to others.
In its relation to race verruga has shown a much greater
tendency to attack white persons than either the Indians or
negroes living in or visiting the verruga valleys. Bourse has even
stated that no white foreigner who has lived any length of time in
one of these valleys escapes the disease. H e adds that during
the outbreak on the Lima-Oroya Railway all the foreign engineers
(mostly English) employed in superintending the work were
attacked and several died; while of forty sailors who had deserted
from a British ship and taken work on the railway, thirty died of the
disease in the course of seven or eight months. It appears to be
much more severe and fatal in foreigners coming to the verruga
valleys than in the natives, who seem to acquire a sort of immunity
to its attacks.
Verruga is said to attack some of the lower animals, particularly
horses and mules, while even dogs, pigs, cows, lambs, turkeys and
chickens are all stated to suffer from the disease.

Y A W S or FRAMBCESIA.
G e n e r a l C h a r a c t e r s a n d E t i o l o g y . The terms Yaws
and Frambcesia are the most usual and therefore the most convenient titles for a malady which is met with in many tropical and
subtropical countries, and to which a different name has been given
in almost every country where it has been observed. It seems,
at least, that the diseases known as piati in the French colonies,
in the Antilles, and in Guiana* as aboukoue on the Gaboon
river \ as buba in Brazil and Venezuela; as keisse or changon
in Madagascar; as pateh in Malaysia ; as bouton cPAmboine in the
Moluccas; as pooro'e in Borneo ; asparanghi in Ceylon; as tonga,
coko, or patita in Polynesia; and by other native names on the
African coasts and elsewhere, are in reality identical with the
disease known in many English colonies as yaws.
The essential character of this disorder is the appearance of a
papular eruption, turning to tubercles, which are prominent,
covered with a crust, and present when the crust is removed a
reddish " raspberry-like " surface,—an appearance which has given
the disease the scientific name of frambcesia. The general health
is often seriously affected, and occasionally deep lesions of the
joints and the bones are present in addition to the characteristic
skin eruption.
Much discussion has arisen over the exact nature of yaws.
One school of 'observers holds that the disease is in truth a
manifestation of the virus of syphilis. Others believe that several
pathological conditions are included under the general name, the
rash in some individuals being syphilitic, in others tubercular in
origin, and in others again possibly due to some other not
clearly known cause. A third view is that yaws is a specific
disease, sui generis, without relation to syphilis, tubercle, or any

YAWS OR FRAMBGESIA

561

other malady. The micro-organism, if any exists, associated with
the disease has not been demonstrated.
H i s t o r y . The early history of yaws is obscure, and has
been rendered the more so on account of its frequent confusion
with other disorders—particularly syphilis. The earliest reference
to it is by the traveller Oviedo, who records its existence in
Hispaniola (San Domingo), in the seventeenth century. In the
same century medical accounts of the disease were forthcoming
from Brazil, from the East Indies, and from the West Indies ; and
later it was recognised in Africa and some of the Pacific Islands.
In most of the countries where it is now endemic it appears to
have existed for a very long period, and in some "from time
immemorial."
Much discussion has taken place as to the original habitat
of the disease; some observers contending that yaws was at one
time an affection confined entirely to the negroes of West Africa,
and that it has been carried by them to other parts of the world.
But the fact that yaws was described in the West Indies and
Brazil long before the transport of negro slaves to those shores
from the coasts of Africa began to be practised, and that it is
known to have existed for a very long time in the Pacific Islands
—the inhabitants of which have had no dealings with West African
negroes—suffice entirely to disprove this view.
Geographical D i s t r i b u t i o n . Europe. Yaws is at the
present day apparently quite unknown in Europe. Whether it has
ever occurred on the Continent in the past is uncertain ; but several
writers are prepared to regard the historical epidemics of sibbens or
sivvens, a disease which was introduced by Cromwell's army into
Scotland in the seventeenth century, the radesyge of Norway and
Sweden which prevailed especially after the Seven Years' War, and
some others, as of the nature of frambcesia. These historical outbreaks of a disease which certainly in some wTays resembled that
now under consideration have been dealt with in the chapter on
syphilis and need not therefore be more fully discussed here. A
disease analogous to yaws is said to be endemic in Greece, and in
the published accounts of it, its resemblance to the " radesyge " of
Norway is dwelt upon 1 ; and the so-called "button-scurvy" which
prevailed last century in Ireland had not a little in common with
yaws.
1

c.

Conference of Greek Physicians, 1882.

36

$62

YAWS OR FRAMBCESIA

Asia. Central and Western Asia—including Persia, Arabia,
Syria, Mesopotamia, and Afghanistan—appear to be free from
this disease. There is at any rate no positive record of its
existence in any of these countries, nor in the whole of Siberia,
Mongolia, China, and Japan. In India it is probably exceedingly
rare ; only occasional cases have been seen, though in Pondicherry
it was at one time rather common among the Hindu population.
In very striking contrast to its rarity on the mainland of the Indian
peninsula is its great frequency in Ceylon. It seems to prevail in
all parts of the island and to be one of the most common of all
diseases there. It is seen in every village, attacking not only the
poor but also the well-to-do classes. There is not a health report
from any portion of the island in which fiaranghi, the name given
to it by the Sinhalese, does not occupy a most prominent
position. It is perhaps now diminishing either in prevalence or in
severity, as the number of deaths attributed to it in recent years in
Ceylon has steadily fallen l.
In Farther India yaws is occasionally seen. It was epidemic
in the Surma valley in Assam in 1894, and a disease called by
the natives kroc-na, seen in Upper Burma, seems to be no other
than yaws2.
In the East Indian Islands yaws is frequently seen, but there
is reason to believe that it is less prevalent here than in Ceylon.
Nieuwenhuis, the first European to cross Borneo (1894), says that
it is "common enough" in that island. Mention of it is found
in the annual reports of the Dutch troops in the Netherlands,
Indies. It is endemic in Java, attacking the natives, Chinese,
and Creoles, in Batavia and Pasuruan, but not affecting
Europeans. It is common in Celebes and the Moluccas, where
it is known as bouton d'Amboine; less so, perhaps, in the Rhio
group, and apparently rare in Sumatra and Bangka.
Australasia.
Throughout Australia, Tasmania, and New
Zealand yaws is, it seems, entirely unknown. But in many
of the adjoining islands in the Pacific Ocean it is a common
disorder. I find no mention of it in the Philippines, but in
1
The deaths from "paranghi " in Ceylon in each of the seven years 18911897 were respectively 314, 266, 275, 282, 199, 193, and 138; the last figure
in the series is considerably'less than half the first.
2
Trans. Indian Med. Congress, 1894.

YAWS OR FRAMBCESIA

563

British New Guinea 1 it is said to be " universally endemic/'
though of a milder character than in other parts of the Pacific,
and not causing much trouble. The natives of New Guinea
have not invented a name for it, for which we may at least be
grateful. In the Fiji Islands yaws, here known as coko, is endemic,
and apparently a cause of much sickness among children; the
Indian population of this group seem to suffer especially. The
Friendly or Tonga islanders are also affected by it, and it is met
with in the Loyalty Islands, Samoa, New Caledonia, and the New
Hebrides.
Africa. I am aware of no proof of the existence of yaws
or framboesia in Egypt; and the only references to its occurrence
in any of the countries along the northern and eastern coasts
of the African continent are brief statements that it is met with in
Algiers, in the Nile basin, and at Mozambique. But on the west
coast, and to some extent in the interior, yaws, or a disease closely
allied to it, is met with, and with considerable frequency. Thus
in Wadai, in the region of the Upper Ubangi, and just to the north
of the Congo Free State, plan or yaws is said to be the chief
cause of infantile mortality. On the Gaboon river it is equally
common, and is known by the natives under the name of aboukoue2.
In Bornu and at Timbuctoo it is believed to exist.
In the Gold Coast yaws is endemic " i n all its forms,"
and it is noteworthy that the medical officers in this colony
believe that a late affection of the bones and joints frequently
met with among the natives there is a result of untreated yaws 3 .
In Lagos the disease is not unknown; 7 cases of it were treated
in the Colonial Hospital there in 1897 and 14 in 1898. It is
said to be almost peculiar to the Ijebus and Aworis, tribes
inhabiting the lagoon littoral near Lagos. It is probably seen
in several other regions of the West Coast, but information upon
its exact distribution is incomplete and occasionally contradictory. Hirsch states that it is endemic "from Senegambia to
Angola"; Plehn, on the other hand, says it is unknown in the
Cameroon district. It is possibly endemic in the Congo Free
State, and it is exceedingly common in Uganda.
There is little evidence of the existence of yaws in South
1
2
3

Annual Report on British New Guinea for 1897-8.
Bestion, Arch, de Med. Nav. 1881.
Sanitary and Medical Report of the Gold Coast Colony for 1897.
36—2

564

YAWS OR FRAMBCESIA

Africa, but I find mention of a single case of the disease
admitted to the Durban Hospital in 1898 \ and in the same
year four patients—a mother and 3 children—were admitted
to the Kimberley Hospital, suffering from a rash which closely
resembled that of yaws2. Finally in Madagascar and the Comoro
Islands yaws is met with rather frequently, and though not known
with certainty to exist in Mauritius an affection of the feet is seen
there, called locally crab-yaws, which may perhaps be of this
nature 3 .
America. In Canada and the Northern States of America
yaws is entirely unknown. In the Southern States ft is said
to be common, but of its exact distribution or intensity in
this region I have not come across any detailed evidence. In
regard to the West Indies, however, all uncertainty disappears,
and there can be no question that these islands form one of the
most important centres in the world of this disease. The majority
of the islands seem to be affected by it to a greater or less extent.
In Jamaica it is excessively common, and causes "terrible havoc"
among the children of the island—a havoc largely contributed
to by the ignorance of the native parents and their reluctance
to allow the disease to be treated. In Cuba it is well known.
In the French Antilles, Guadeloupe and Martinique, le pian was
so widely prevalent in the 18th century that " a chaque habitation
etait annexee une case a pian pour loger les malades" (Le
Dantec). It is scarcely less common in the same islands at the
present day. In Trinidad, St Lucia, and Grenada yaws has
become such a serious endemic disorder that special hospitals
for its treatment have been instituted, and yearly deal with a large
number of patients. Antigua and Dominica are both deeply
affected by it, no other disease accounting for so many cases
treated in hospital. In the Virgin Islands, on the other hand,
yaws is a rare disorder.
In Central America yaws is probably not
the only mention of it being that of its rather
in Punta Arenas, in Costa Rica.
In South America, yaws has a fairly wide
cases of the disease are yearly mentioned in
1
2
3

a common disease,
frequent occurrence
distribution. A few
the Health Reports

Durban Hospital Reports, 1898.
youm. Trop. Med. Feb. 1900.
Davidson.

DISTRIBUTION

OF YAWS OR

FRAMBCESIA

YAWS OR FRAMBCESIA

565

of British Guiana. In French Guiana Le Dantec saw several
cases called pian by the negroes, but some were cases of leprosy,
others yielded to syphilitic treatment, and others were a mixture
of ecthyma and ulceration. In Venezuela yaws also probably
exists, and is known by the name of buba. The same name is
applied to the disease as met with in Brazil. It is said to
occur in all the provinces of the Brazilian Republic, but the
Indians living in the virgin forests far from the coasts are free
from it1. In the other South American territories yaws appears
to be entirely unknown.

Factors concerned in the Geographical Distribution.
Comparatively few disorders are so strictly confined within limits
of latitude as the malady under consideration. It is at the present
day essentially a tropical disease. Even in the past—unless, indeed, we are to regard as yaws those epidemics of an apparently
similar but more probably syphilitic disorder which occurred in
Scotland, in Norway, and elsewhere, and have been already referred to—yaws has rarely been seen outside the tropical zone.
The only other exceptions seem to have been the appearances
of the disease in Assam (for Asia); in Algiers, possibly the Nile
valley, and Durban (for Africa); and" perhaps in some of the
southern United States (for the Western Hemisphere). But,
even if all these be genuine instances of yaws and not of some
other disease, it will be observed that they have all occurred in
districts closely bordering on the tropics.
Within the tropics yaws is found principally in certain great
island groups,—notably in Ceylon, the Malay Archipelago, New
Guinea, and the Pacific Islands in the Old World, and in the West
Indies in the New World. It is also found on certain coasts of the
corresponding continents—notably on the West Coast of Africa,
on the coasts of Guiana and Brazil, and to some extent on that of
the Indian peninsula.
In many of the islands just named yaws is a serious cause
of disablement to the general population, and is among the most
prominent of all diseases.
The occurrence of yaws almost solely within the tropics must
be taken to indicate that it needs a high degree of temperature
for its prevalence. All races have at times suffered from its attacks,
1

Breda, of Padua, quoted by Le Dantec.

566

YAWS OR FRAMBCESIA

but the negro and other coloured races are particularly susceptible
to it. Indeed, while the white man almost escapes in countries
where yaws exists, it is found that the half-breeds, mulattoes and
others, are attacked by it to a certain extent, and the coloured
population most of all. Of coloured races the negro appears to
be more susceptible than any. It would seem, then, that there is
a direct relation between the prevalence of yaws and the depth
of colour of the population. As the depth of colour of the skin is
only a question of the quantity and nature of the pigment in the
cells of the dermis, this fact raises the question whether yaws,
in its causation, is not in some way dependent upon this element
of the skin. The question appears to open up lines upon which
further research might be carried out in those countries where
the disease exists.
Both sexes and all ages suffer from yaws. Dirt and insanitation
perhaps favour its development, but they do not seem to be
essential to it. The disease is highly "contagious," and it is
probable that direct infection from person to person is the
principal way in which it is spread. It may also be spread,
however, by means of infected articles, and the virus can
apparently cling to clothes or sleeping mats that have been used
by an infected person, and thus be transmitted to others.
Sexual intercourse has been known to cause its spread; and it is
believed to have been diffused at times, though fuller evidence on
these points is wanted, by means of the common house-fly, and
by vaccination. In its endemic homes yaws has frequently also
been spread by the natives voluntarily inoculating their children
with the crusts from another patient—a practice which is wisely
discouraged. Heredity seems to play little part in its prevalence.

BOOK III.
ANIMAL PARASITES AND T H E
DISEASES ASSOCIATED W I T H
THEM.

CESTODES.
i. TiENIA SOLIUM.
G e o g r a p h i c a l D i s t r i b u t i o n . Europe. This worm is found
especially in Russia, East Prussia, some parts of Thuringia, of
Belgium and of Switzerland; in Roumania; and among the nonMussulman population of Turkey; and it is probably not entirely
unknown in each or any of the remaining European countries. In
Iceland, however, it is very rare, if it occurs at all.
Asia. Intestinal worms of all kinds are very common in the
Caucasus and Russian Central Asia, but the statistics deal with
the group as a whole, and not with each particular worm. Whether,
therefore, Tcenia solium is common here or not I am unable to
say. The same remarks apply to the occurrence of such worms
in Siberia and among the Bashkirs. In some Bashkir villages
every inhabitant is said to harbour an intestinal worm of some
kind. In India Tcenia solium is never seen among the purely
vegetable-eating Hindus, and is apparently not very common
among the other races. The parasite is perhaps commoner in
China than in any other Asiatic country. It abounds in and
around Peking, in Wuchow, and in other towns 1 .
Australasia.
Tcenia solium is said to be unknown in New
Guinea. It occurs in the Fiji Islands.
Africa. It appears to be common in British East Africa.
In Massowa it is frequent among the natives. On the other
hand it is rare in Egypt. On the West Coast taenia is common
enough, though in the Cameroons it is said to be less often met
with than the Guinea-worm.
1
Coltman, on the other hand, never saw a single case of the worm during
six years' residence in Shantung.

CESTODES

S7o

America. This taenia is said to be unknown in Greenland.
It is seen in Newfoundland. It is rare in the United States, and
also in Guatemala and some of the West India Islands, but
apparently less so in Mexico. It is uncertain whether this is the
particular form of tape-worm met with in Brazil.
F a c t o r s c o n c e r n e d in t h e D i s t r i b u t i o n .
The distribution of this worm depends almost wholly on the fact that
part of its life-history (the cysticercus stage) is passed in the pig.
Hence it is found in man only among those races and in those
countries where pork is a common article of food. Hence also its
extreme rarity or entire absence among orthodox Mussulman communities, who never touch the flesh of the pig, and among such
purely vegetable feeders as the Hindus, Egyptians and others.
Since the alarm created a few years ago by the increase of
trichiniasis led to a lessened consumption of pork in Europe
this worm is said to have become considerably- rarer.
2.

TAENIA

MEDIOCANELLATA.

G e o g r a p h i c a l D i s t r i b u t i o n . Europe. This worm is comparatively common in most European countries, and in many it is
far more frequent than T. solium. Its prevalence is believed
to have increased in recent years.
Asia. The parasite is seen in Syria and Arabia, and occurs
with some frequency in India, but solely, or almost solely, among
European residents or flesh-eating Mohammedans. It is said to
be common among the Buriats in southern Siberia, and also in
China and Japan. In China and Cochin-China it is more prevalent than T. solium.
Africa. In Abyssinia this tape-worm abounds; and in Egypt,
Nubia, Algeria, and the western Sudan it is exceedingly common.
It is found also with great frequency on the West Coast, and seems
to be by no means rare in South Africa.
America. In the United States Tcenia mediocanellata is the
form of tape-worm most usually met with. In South America the
only mention of it relates to its occurrence in the Argentine
Republic, where it is extremely prevalent.
F a c t o r s c o n c e r n e d in t h e D i s t r i b u t i o n . The cysticercus stage of this parasite is passed in horned cattle; hence the
worm is found in man only where imperfectly cooked beef is eaten.

CESTODES

571

Like T. solium it is never seen among strict vegetable eaters,
as the Hindus. It is said to have become more common
in France, Denmark, and Switzerland in recent years, owing to
increased importation of beef from Algeria, and the consumption
of it in a raw state as a strengthening article of food for invalids.
3. T ^ N I A

NANA.

T h e P a r a s i t e is the smallest of human tape-worms, varying
from 10 to 15 mm. (about half an inch). It is identical with
T. murina which affects rats, and is of little clinical importance
unless present in large numbers, when it occasions gastro-intestinal
disorder.
G e o g r a p h i c a l D i s t r i b u t i o n . It has been found in Egypt
(where it was first detected by Bilharz in 1852), in Italy, Buenos
Aires, and Bangkok, Siam.
4. TAENIA MADAGASCARIENSIS.
T h e P a r a s i t e may be as long as 24 cm. (about nine or ten
inches), and about \ of an inch broad. The intermediate host is
unknown, but Blanchard suggests it may possibly be the cockroach.
G e o g r a p h i c a l D i s t r i b u t i o n . This worm has been seen
in Mayotta in the Comoro Islands, in Mauritius, in Bangkok,
in Georgetown, British Guiana, and in Nossi Be off the Madagascar coast.
5. T ^ N I A FLAVO-PUNCTATA.
T h e P a r a s i t e , which was first described by Weinland, is
about 8 to 12 inches in length, and is characterised by the joints
in the fore part being marked by a large yellow spot—the
distended receptaculum seminis.
G e o g r a p h i c a l D i s t r i b u t i o n . This taenia would appear to
be very uncommon, and two or three cases, from the United
States and from Italy, have alone been recorded.
Nothing is known of the intermediate host.
6. TAENIA CANINA.
T h e P a r a s i t e , identical with T. cucumerina and T. elliptica^
is recognisable by its delicate form and small size (12 to 35 mm.),

CESTODES

572

and also by the fact of its having two sets of reproductive organs
in each mature segment. It occurs principally in the dog and cat.
Its geographical distribution is imperfectly known, but it has been
stated occasionally to affect man in the West Indies, and not infrequently in Scandinavia.
7.

TAENIA ECHINOCOCCUS : H Y D A T I D S .

T h e P a r a s i t e . The adult taenia occurs in the dog, wolf,
and jackal. The embryo form of the parasite gives rise in man
to the well-known hydatid or echinococcus cysts, which may
occur in any part of the body, but are most common in the liver,
and (in order of frequency) in the intestinal canal, the lungs, the
kidneys, and the central nervous system.
G e o g r a p h i c a l D i s t r i b u t i o n . Europe. Hydatids probably
occur in all European countries with more or less frequency,
but statistics are incomplete as to their relative degree of prevalence in different countries. They are said to be remarkably
common in Iceland. Different observers have estimated that from
one-fortieth to one-seventh of the whole population of Iceland are
the subjects of hydatids. It is remarkable, on the other hand,
that in the Faroe Islands the disease is quite unknown 1 , in spite
of the large numbers of dogs and sheep and cattle, and the similar
general conditions here to those obtaining in Iceland. In Turkey
hydatids are rather exceptionally frequent, and there can be little
doubt that this is due to the large number of dogs in that country
and their close relations with the people.
Asia. In the Caucasus the disease is frequently seen; the
post-mortem records of the Tiflis Hospital show that 2 per cent, of
all bodies examined have hydatid cysts in the liver.
Hydatids are of by no means rare occurrence in many parts of
India. In China the disease must be rare, for Dr Cantlie only
saw it once in 40,000 cases.
Australasia.
Hydatids are peculiarly common in many parts
of Australia, where, no doubt, they are to be associated with the
large numbers of dogs employed in sheep-farming. Victoria was
formerly spoken of as one of the principal centres of hydatid
disease. In South Australia it was the cause of from 7 to
15 deaths in each of the ten years 1889-98 (say from 20 to 45
1

The Faroe Islands, by J. Russell-Jeaffreson, F.R.G.S., London, 1898.

CESTODES

573

per million inhabitants). In Queensland it caused three deaths in
1898 ; I have not seen the records of previous years. In Tasmania it is also rather common, but in New Zealand it was at one
time considerably less s o ; the average death-rate in the latter
between 1882-88 was only 6*6 per million. In recent years it
has, apparently, become much more common here, as in 1898 it
was the cause of 20 deaths, or about 27 per million living. There
seems to be no mention of the occurrence of hydatids in the
Pacific Islands.
Africa. In Egypt and in Algeria hydatids are not infrequent.
For the rest of the continent information on this point seems to be
lacking.
America. In Canada and the United States hydatids are
extremely rare and the great majority of cases occur in foreigners.
Osier states that up to 1891 he had found records of only 85 cases
in all in both countries. H e adds that many instances have
occurred in the Icelandic settlements of Manitoba, particularly
since the year 1874, the date of the Icelandic immigration.
There seems to be no mention of hydatids in Central or South
America, or the West Indies.
F a c t o r s c o n c e r n e d in t h e D i s t r i b u t i o n . As stated
above, the adult worm occurs in the dog and some other
animals. The ova escape in the intestinal excreta, and either pass
directly to the human host, or enter the bodies of sheep and
cattle, both of which are liable to the disease. Hydatids are
therefore found most commonly among persons who have much to
do with the rearing of these animals, and particularly among such
classes' as the Icelanders, and the shepherds and cowherds of
Australia, who spend their lives in close contact both with their
flocks and herds and with the dogs that help them in their work.
In Iceland the dogs live in the same dwellings, eat off the same
platter, and even share the same bed as their owners, and this
would seem to explain the frequency of hydatids in that island.
But it is less easy to account for their absence from the Faroe
Islands, where the conditions are probably not- very different,
unless, indeed, the parasite has never been imported there.
8.

BOTHRIOCEPHALUS

LATUS.

Geographical Distribution.
Europe.
This worm is
almost confined to the continent of Europe. It is most common

CESTODES

574

on the coasts of Sweden; on the Russian and Finnish shores of
the Gulf of Finland; in the neighbourhood of some of the Swiss
lakes, and in the adjoining departments of France. It is less
frequent, but still common, in Poland, East Prussia, Denmark,
Holland, Belgium, and about the Italian lakes. Occasional
examples of it are seen in parts of Germany, in Brittany, and in
Ireland.
Asia. This worm was formerly said to occur not infrequently
in children sent home from Ceylon to England; and it has been
found in the crews of ships of war on the Dutch East India station.
It is stated also to have been met with in Japan.
Africa. The parasite is said to occur in British East Africa1,
and (doubtfully) in South Africa.
America. At least one case has been recorded in Canada.
The worm exists also in Mexico.
F a c t o r s c o n c e r n e d in t h e D i s t r i b u t i o n . The ova of
Bothriocephalus latus develope in the peritoneum and muscles of
the pike and other fish. Hence they only pass into the human
body through the consumption of infected and imperfectly cooked
fish. The parasite is consequently found in greatest frequency
on the shores of seas, lakes, or other inland waters. The brief
summary given above of its distribution shows clearly this relation
of the worm to sea or inland coasts; and a closer study of its
frequency in Sweden and Switzerland has elicited the fact that the
number of cases varies inversely with the distance from the water.
9.

BOTHRIOCEPHALUS

MANSONI.

T h e P a r a s i t e . The larval form only has been seen. It
measures from 30 to 35 cm. in length (12 to 14 inches). It has
been found in the sub-peritoneal fascia, and on one occasion
in the pleural cavity.
G e o g r a p h i c a l D i s t r i b u t i o n . Manson first discovered the
worm in a Chinese cadaver at Amoy. Scheube extracted a
similar parasite from the urethra of a Japanese; and it has also
been seen at Bathurst in Australia. Daniels has observed a
similar worm in British Guiana.
1

Kolb.

TREMATODES.
i.

D I S T O M U M P U L M O N A L E vel D. R I N G E R I
(Endemic Haemoptysis).

T h e P a r a s i t e . This is a fluke-shaped worm, about onequarter or three-eighths of an inch in length. Its life-history is
unknown. One or more worms may be found in the lungs at
a time. They burrow into the organ and give rise to serious
symptoms, of which chronic cough, rusty sputum, and more or less
extensive haemoptysis are the most important. The fluke has also
been found in the liver, peritoneum, testes, and brain.
G e o g r a p h i c a l D i s t r i b u t i o n . It is mainly if not wholly
confined to Japan, Corea, and Formosa. In northern Formosa
it is probably very common, but it is said to be unknown in the
south of the island. Rennie states that he found it in 0*9 per cent,
of patients seen at the Tamsui Hospital, but that it is probably
more frequent than this figure would represent, and Manson
records that in some parts of the island and in some Japanese
villages as many as from 10 to 30 per cent, of the population are
affected.
This, or an allied fluke, has been seen in the United States in
the dog and the cat, but does not yet seem to have been observed
there in man.
2. DISTOMUM CRASSUM vel D. BUSKI.
T h e P a r a s i t e is the largest fluke seen in man. It may be
2 or 2\ inches in length. Its life-history is unknown. It inhabits
the upper part of the small intestine in man, and may cause
diarrhoea and other intestinal trouble.

576

TREMATODES

G e o g r a p h i c a l D i s t r i b u t i o n . This worm was discovered
in 1843 by Busk in a Lascar who had died in the Greenwich
Hospital. It has been seen several times in China (Canton,
Ningpo, etc.) and also in Borneo, Sumatra, the Straits Settlements,
Assam, India, and on one occasion in an East Indian immigrant
in British Guiana.
3.

DISTOMUM SINENSE.

T h e P a r a s i t e . This fluke, first discovered in 1874, is about
three-quarters of an inch in length. It inhabits the bile-ducts and
gall-bladder, and sets up a serious disease which may prove fatal.
The cachexia is said to resemble that of sheep-rot.
G e o g r a p h i c a l D i s t r i b u t i o n . This distomum has been
observed in India, Mauritius, Japan, Corea, Formosa, China, and
Tongking. It is said to be very common in the last named
country, and in some parts of Japan 20 per cent, of the population
have been found to be subjects of it.
4.

DISTOMUM HETEROPHYES.

T h e P a r a s i t e is the smallest of the human flukes, measuring
only 1J mm. in length; it is of a bright red colour. It occurs in
the small intestine and is probably harmless.
G e o g r a p h i c a l D i s t r i b u t i o n . It was observed by Bilharz
in Cairo in 1851, and has apparently only been found in Egyptian
subjects.
5.

B I L H A R Z I A HiSEMATOBIA (Endemic Hematuria).

T h e P a r a s i t e . Bilharzia hcematobia or Distomum hcematobium is a trematode worm, differing from most other of its
allies in being bisexual, that is to say, the two sexes occur in
different individuals. The male is about 15 mm. in length, and
1 mm. in breadth; the female is about one-third longer than the
male. The adult parasites exist in the veins of various parts of
the body, but in post-mortem examination are seen especially in
those of the portal system.
The life-history of the parasite is not fully known, but it is
believed, from analogy with other nearly allied worms, that it passes
part of its existence in some extra-human host. It is conjectured
that this is some form of living organism found in fresh water,

BILHARZIA HyEMATOBIA

577

possibly, Guillemard suggests, Melania tuberculata. The method
of infection still remains unknown, but it seems probable that it
is not by ingestion of the animal, but by the armed embryos
directly penetrating the body during bathing. The pathological
effects associated with the presence of this worm are brought about
by the extrusion of the ova in the veins of the various tissues.
Of these by far the most important are the mucous and submucous tissues of the bladder and ureters, but eggs have also
been found in the walls of the intestine, in the kidneys, generative
organs, liver, heart, and even the lungs. The animal or its ova
may give rise to the formation of urinary calculi in any part of the
urinary tract.
The leading symptoms of bilharzia disease are most often
referable to the urinary system. The urine is thick and contains
blood, and microscopic examination reveals the presence of the
ova. The presence of the parasite in other parts may lead to
the appearance of other symptoms referable to those parts. But
the bladder symptoms are almost always the most prominent,
and hence "bilharzia disease," and "endemic haematuria" have
come to be regarded as almost convertible terms. The parasites
may be present in the tissues without causing any symptoms, but
sooner or later, and particularly if the haematuria is persistent and
.prolonged, the health suffers more or less severely. The disease
may last for months or years; complete recovery is by no means
rare, but death as a direct result of the infection is not unknown.
For a fuller account of the pathology and clinical characters of this
affection the reader is referred to the writings of Sonsino and others.
H i s t o r y . The parasite was first identified in Cairo in the
year 1851 by Bilharz, whose name it bears. Of the history, of
the worm itself almost nothing is known. The occurrence of
haematuria, and the frequency of urinary calculi in Egypt had
long been recognised, and it is therefore probable that the1
parasite has long been domiciled in the blood of the Egyptian
population. In 1864 Harley first observed the disease in persons
coming from the Cape. It has since been recognised in many
other parts of Africa, and in scattered portions of some other
continents.
R e c e n t Geographical D i s t r i b u t i o n . Europe. It must
be regarded as doubtful whether bilharzia disease exists as an
endemic in any part of the European continent.
c

37

578

TREMATODES

Asia. Observations on the presence of the parasite in Asiatic
countries are not numerous.
The bilharzia has been observed in Mecca, and on the
Arabian coasts of the Red Sea. Hatch, of Bombay, .who saw
several cases there, found that Mussulmans returning from pilgrimage in the Hedjaz were particularly liable to be affected by the
disease, and there is some reason to believe that it is common
in Arabia. At least one case has been seen in Cyprus 1 .
In Mesopotamia, in the valleys of the Tigris and Euphrates,
the parasite has been observed by Sturrock.
In India bilharzia has been met with, especially on the west
coast.
It is doubtful whether the parasite exists in China. Brault,
of Algiers, examined the blood of a large number of French
troops returning from Tongking, and sent to hospital at Dey, but
never succeeded in finding either the parasite or its eggs.
Africa.
In contrast with its comparative rarity in Asia this
trematode has a wide distribution through the greater part of the
African continent. Egypt has long been known as a country
where endemic haematuria was common, and it was at Cairo,
as already stated, that the parasitic cause of the disease was
first detected. It is still extremely common in the country.
Sonsino, as the result of 91 necropsies performed in Lower Egypt
between 1875 and T883, found bilharzia infection in 42 (or 46
per cent.). This was even a larger proportion than that recorded
by Bilharz and Griesinger in the early 'fifties.' The latter made
their observations in the Kasr-el-ain Hospital at Cairo, and found
bilharzia in 117 out of 363 necropsies (or 32 per cent.).
In Tripoli there is no positive evidence of its presence, but in
southern Tunisia its endemicity has been proved by the French
observers Villeneuve and Brault. The parasite seems to be most
common here, and its effects most severe, in Gafsa, " where it is
quite as bad as in Egypt." It is also seen at Gabes. In Algeria
it is described as not uncommon.
On the west coast of Africa the parasite is found on the Gold
Coast in Nigeria and in the German Cameroon territory. At
Chisamka, Angola, a spot 300 miles from the west coast and 400
south of the Congo, bilharzia has also been detected 2 .
1
2

Brit. Med. Jour. 1902, Vol. II. p. 956.
Massey, Journ. Trop. Med. Feb. 15, 1901.

BILHARZIA

H/EMATOBIA

579

On the east coast the parasite has been met with throughout
—from Egypt to the Cape. It is, however, apparently absent
from Massowa on the Red Sea shores (Rho). In Abyssinia, on
the other- hand, it is probably common, as the Italian troops in
the last Abyssinian campaign suffered considerably from it. In
Zanzibar, on the Mozambique coast, and on the lower reaches of
the Zambesi it is very often seen. Further south the parasite
is found on the shores of Delagoa Bay, and St Lucia Bay. At
Port Elizabeth and Uitenhage in Cape Colony it seems to be
particularly frequent 1 , and it is also very common in Natal. In
Pietermaritzburg, according to Batho, " i t seems as if the majority
of the male youth were affected."
Generally through Central and South Africa bilharzia disease
seems to be prevalent. In the north endemic hsematuria, conjecturally due to this parasite, is said to be very common in
the countries of the Tibbos, Lake Tchad, Darfur and Kordofan.
Cases have been seen in Uganda, and in British Central Africa
bilharzia is one of the most frequent causes of anaemia. In the
Congo Free State it is common 2 . In the south it is met with in
the Transvaal and in KafTraria and elsewhere. Occasional cases
have been seen in Mashonaland, apparently imported from elsewhere. The parasite has been identified in at least two cases at
Bloemfontein, in the Orange River Colony 3 , and it is thought
that a large proportion of the cases of hematuria which occurred
among the troops during the Boer War were of bilharzic origin.
In Madagascar, Mauritius, Reunion, and Nossi Be there is
more or less definite proof of the presence of this parasite. In
Mauritius, Chevreau, Chazal, and Davidson have demonstrated its
existence. In the case of the other islands named the statements
as to its presence are less positive. Brault, after the return of the
French troops from Madagascar, examined a considerable number
for bilharzia, but neither in Europeans nor in natives did he find
it present in a single case.
America. Until quite recently it was believed that bilharzia
did not occur on the American continent. But early in 1900
Dr E. Walker reported a case of the disease as observed in
Sparta in the State of Illinois. Great care is said to have been
1
2
3

Sambon, Joiirn. Trofi. Med. Nov. 1899.
Brault, loc. cit.
Journ. Trop. Med. Oct. 1, 1901.
37—2

58o

TREMATODES

taken to avoid error in the diagnosis, and this case must therefore
be regarded as the first recorded example of the bilharzia disease
in the New World. Recently Manson has reported a case in an
English resident in the West Indies who had never been in any
country where bilharzia was known to exist, so that, if not
B. hczmatobia itself, it is probable that some closely allied species
exists in the archipelago.

Factors governing the Geographical Distribution.
This parasite is largely but not wholly confined to tropical and
subtropical countries. To the north of the equator it seems, until
quite recently, to have been observed nowhere to the north of
the African shores of the Mediterranean (latitude 35° N.). The
only recent exception has been the recognition of the parasite in
the State of Illinois in North America. Southward, the limit of
extension of the worm has similarly been the southern extremity
of the African continent (about 35° S.). It is remarkable that
the bilharzia disease is so frequent in Africa as to be spoken of by
one authority as "the most prominent, prevalent, and important
disease" in that continent; while in the other continents it is
either unknown, or at most occurs as a more or less exceptional
disorder in very limited areas. Further observations may show
that this distome exists much more widely than is supposed, and
that its distribution is much more continuous and less "patchy"
than the observations hitherto published would seem to indicate.
It is more than probable that the great determining factor in
the distribution of bilharzia will prove to be the distribution of
the living organism, whatever this may be, which forms its
intermediate host. Up to the present this organism has not been
identified; but whether it prove to be some mollusc, crustacean,
or arthropod, or something wholly different from any of these, it is
clear that if it be an essential factor in the life-cycle of the
bilharzia, neither this parasite nor the disease it produces will be
found in those countries where the particular organism is absent.
The true relation of such physical conditions as latitude, temperature, elevation, soil, etc., to the distribution of bilharzia will then
become apparent; and it will probably be found that those
factors have only an indirect influence on the parasite, though
they may have an all-powerful influence in determining the
presence or absence, the frequency or infrequency, of the intermediate host.

TREMATODES

6.

OTHER

581

TREMATODES.

Distomum lanceolatum, found once or twice in patients in
Germany and France; Distomum conjunctum, recorded by
Professor McConnell in Calcutta; and the liver-fluke, Fasciola
hepatica, which has occasionally occurred in man, are too rare to
demand extended reference here. Amphistomum hominis also is
a parasite of almost no clinical importance. It has been found
solely in India (Lewis and McConnell); in Assam (Giles); and in
an East Indian immigrant in British Guiana (Law).

NEMATODES.
ASCA

RIDES.
i.

ASCARIS LUMBRICOIDES.

T h e P a r a s i t e . The male of the round-worm, one of the
commonest of the parasites of man, measures from 15 to 25 cm.
in length by 4 mm. in breadth; the female 16 to 45 cm. by 6 mm.
Both are cylindrical. The ova may be spherical, ovoid, or
sometimes barrel-shaped, and it would seem that they are capable
of hatching direct in man, no intermediate host being necessary.
The life-history is, however, still uncertain.
Geographical Distribution.
The round-worm has
practically a world-wide distribution. It is, however, particularly
common in tropical and subtropical countries. Recent writers
have , dwelt on its frequency in China, in India, in Java, in
Mauritius, on the Gold Coast, in the West Indies, and in the
Pacific Islands; and there are abundant references in the past to
its prevalence in nearly all other warm countries. It is common
enough, also, in the temperate zones, and even in Newfoundland
and Greenland it occurs indigenously. It is only in Iceland that
it would seem to be rare.
2.

OXYURIS V E R M I C U L A R I S .

T h e P a r a s i t e . The male of the thread-worm is very much
smaller than the female, measuring only from 3 to 5 mm. in length,
while the female is from 9 to 12 mm. The eggs are oval and
flatter on one side than on the other. No intermediate host is
necessary, and auto-infection keeps up the disorder.
G e o g r a p h i c a l D i s t r i b u t i o n . The thread-worm has, apparently, quite as wide a distribution as Ascaris lumbricoides.
Like it, it is most common in tropical and subtropical countries.
It differs from it, however, in being extremely frequent in Iceland.

ANKYLOSTOMIASIS

533

STRONGYLES.
3. STRONGYLUS GIGAS.
T h e P a r a s i t e . This very large nematode has been well
described as resembling an overgrown Ascaris lumbricoides. The
male measures from 14 to 35 cm. in length, and the female may
be from 25 cm. to a metre in length, the breadth varying from
4 to 12 mm. The larval stage is possibly passed in some fish.
The parasite has only been very rarely met with in man, but is
not uncommon, according to Leuckart, in the dog, wolf, fox, and
seal.
G e o g r a p h i c a l D i s t r i b u t i o n . The parasite has been recorded as occurring, in the lower animals, in most countries of
Europe and the New World.
4. ANKYLOSTOMUM DUODENALE
(Ankylostomiasis and Pani-Ghao).
T h e P a r a s i t e . The male varies in length from 6 to 12 mm.,
the female from 7 to 18 mm. : the diameter of the former is about
half a millimetre, and of the female about 1 millimetre. Both
are cylindrical, tapering towards the anterior, or buccal end, where
there is a curious mouth-capsule, provided with four claw-shaped
hooks or teeth, two on the dorsal and two on the ventral aspect.
The worm is greyish-white when empty, and reddish or reddishbrown when full of blood.
It is found usually in the jejunum, where it attaches itself by
its toothed mouth-capsule to the mucous lining of the bowel, and
sucks the blood of the host, it is believed, in considerable
quantities. The eggs, escaping from the female ankylostomum,
pass out in the faeces of the host. Some of the quite early
stages of development of the embryo are passed in the body of
the host, but for the most part development occurs after the
faeces have escaped, and the circumstances favouring it seem
to be a plentiful air supply, a warm but not too hot temperature,
and deposition of the faeces containing the eggs on the soil.
Sooner or later the ovum, or larva, is swallowed by a human
being, in whose intestinal canal it again becomes the sexually
mature parasite.

584

NEMATODES

This worm and the disease associated with it assume a grave
importance in the pathology of many countries, in consequence of
the vast numbers of the labouring classes affected by them, and
the resulting loss of labour.
Ankylostomiasis is the name applied to the group of symptoms
associated with the presence of considerable numbers of this
worm in the intestine. It is characterised by a severe and progressive anaemia, accompanied by dyspepsia and other symptoms
of alimentary disturbance, and, when prolonged, with symptoms
of serious affection of the circulatory system. Serous effusions
may occur in different parts, and fatty degeneration of the heart
may follow. It is not rarely a direct or indirect cause of death.
The mere presence of a few ankylostomes in the intestine can
scarcely be said to constitute a condition of ankylostomiasis, and
the parasite may, indeed, exist in considerable numbers without
giving rise to any symptoms of its presence. In such cases it
is only on the post-mortem table that it is found in the bowelcontents. The number of parasites required to produce definite
symptoms in life varies very widely in different individuals, and
perhaps in different races. Rogers has proposed to limit the term
ankylostomiasis to that condition in which "some 500 of the
worms have been present for upwards of six months, and have
by themselves produced distinct anaemia and other well-known
symptoms." As, however, it must be very difficult, if not impossible, in most cases to determine that 500 worms have been
present for six months, or indeed that any definite number have
been present for any definite period, it would seem better to
employ the term in a more general manner, as indicating a
condition in which the symptoms of ankylostomiasis are associated with the proved presence of a considerable number of
worms, and are believed to be caused by them.
In Assam, Bengal and elsewhere persons have been known to
harbour as many as a hundred or more of the worms without
showing any marked symptoms of illness. Much appears to
depend upon the general condition of health of the subject of
these parasites. Any pre-existing disease of a debilitating kind,
and particularly if associated with anaemia, appears to favour the
development of the condition of ankylostomiasis. A person in
good general health may be able to tolerate the presence of a
large number of the worms without his health suffering, while in

1

ANKYLOSTOMIASIS

585

another person of indifferent general health, a smaller number of
worms may give rise to the characteristic symptoms of the disease.
The one is able to make good the loss of blood caused by the
presence of the worms, while the other is not.
Pani-Ghao, or Ground-itch, is the name given to a skin
affection which has been met with in Assam, Trinidad, and many
other tropical countries. Its causation was for long unknown but
evidence has recently been published tending to show that, at least
in many cases, it is due to the penetration of ankylostomum larvae
into the skin of the patient. Looss and Sandwith, of Cairo, have
both shown experimentally that such penetration is possible.
Bentley, of Assam, has repeated these experiments, and has further
discovered the larvae in the skin of patients suffering from panighao 1 . The disease affects only the lower extremities, and hence
is often called the " sore-feet of coolies." It takes the form of an
erythema, followed by vesicle and pustule formation, and may go
on to ulceration and even gangrene. Dalgetty, of South Sylhet2,
has described an acarus found in the skin in some of these cases,
and it may therefore be assumed that more diseases than one are
included under the colloquial term of ground-itch or pani-ghao.
This affection is by no means an essential accompaniment of
ankylostomiasis. So far as is known at present its geographical
distribution is much more limited than that of the latter, and it
may therefore be supposed that the parasite most usually gains
access to the human body by means of the alimentary canal, and
only in some instances by penetrating the skin.
H i s t o r y . The parasite was first described by Dubini, of
Milan, in 1843. It w a s later observed by Pruner and Bilharz in
Egypt. Griesinger in 1854 first showed the true relation of the
parasite to the disease then known as "cachexie aqueuse," or
"Egyptian chlorosis," and now generally spoken of as "ankylostomiasis." In 1878 Grassi and Parona first showed that the
presence of the worm could be detected in the living body by
searching for the eggs in the dejecta. The St Gothard Tunnel
epidemic of this disease in 1880 again drew general attention to
the parasite and its effects, and within the last decade its wide
diffusion and importance in certain countries have become more
fully recognised.
1
2

C. A. Bentley, M.D., Brit. Med. Journ. Jan. 25, 1902.
Journ. Trop. Med. March 1, 1901.

586

NEMATODES

R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . The known distribution of Ankylostomum duodenale is a wide one, but it is
probable that its actual distribution is still wider. It is only
within quite recent years that its presence has been proved in
many countries where it was not known before to exist. More
detailed observations directed to this point, and particularly the
systematic examination of the intestinal contents of living persons
and of cadavera, will in the future probably show that this parasite
is more widely spread throughout the world than is known to be
the case at present.
Europe. The parasite was until recently unknown in the
British Isles. But, in the latter part of 1902, Dr Haldane, in
the course of an enquiry into the ventilation of Cornish mines,
carried out on behalf of the Home Office, found that there was a
serious outbreak of ankylostomiasis at the Dolcoath mine, Camborne. This appears to be the first mention of the disease in the
British Isles 1 .
In France it has been seen among miners at St Etienne in the
Department of the Loire.
It has been observed also in Belgium and Germany. In 1899
ankylostomiasis was reported to be prevailing severely in the
neighbourhood of Liege among the working population, and
particularly among miners 2 . The source of the disease here was
a matter of controversy. The most northerly places in Europe
where the worm had been observed before were Cologne, and
Dortrnund in Westphalia; and some Belgian writers have believed
that their country was infected by the parasite by means of workmen coming from the Cologne brickfields. German writers, on
the other hand, assert that both Belgium and Cologne were
invaded by means of infected labourers coming from the
St Gothard tunnel. A third view is that advocated by Sonsino,
who is of opinion that even before the famous St Gothard epidemic
the ankylostomum was already " diffused among certain classes of
workmen in the northern countries of Europe, such as France,
Belgium, Germany, Holland, and Austria, as well as in Italy and
in more southern countries 3 ." I have not been able to confirm
this mention of the existence of the parasite in Holland.
1
2
3

Brit. Med.Journ. Dec. 13, 1902.
Revue Scientifique, 1899, No. 22.
Janus, March—April, 1900.

ANKYLOSTOMIASIS

5

87

In miners working in the coal-mines of Hungary the affection
is perhaps common. One Hungarian observer is quoted as having
treated 470 patients of this class for ankylostomiasis, in a period
the length of which is not stated 1 .
The disease caused by this parasite has been observed on an
extended scale in Italy. Hirsch has given references to its
occurrence in many places in the northern part of the peninsula—
as in the district of Treviso (Venetia), at Florence, Turin, and
Cesena, and particularly in the provinces of Milan and Pavia in
Lombardy. It was to this last centre of the disease that was
ascribed the historical outbreak of ankylostomiasis among the
labourers employed in making the St Gothard tunnel. On this
occasion men working both on the Italian and on the Swiss sides
of the mountain range were affected.
Asia. Information is entirely lacking as to the presence or
absence of this worm in all the countries of Nearer Asia, as also
in Siberia.
The parasite, on the other hand, is exceedingly common
throughout the Indian peninsula and Ceylon. In recent years
systematic inquiries have been made by many medical officers in
India as to' the presence of the worm in the patients under
their charge, both in life and after death, and it has been
found in a very large proportion of subjects so examined.
Dobson, Rogers, and others have shown that in Assam, Bengal,
and some other parts of India from 60 to 80 per cent, of the
population harbour the parasite, in numbers varying from a very
few up to one hundred or more, with apparently no symptoms of
a serious nature. As the Sanitary Commissioner with the Government of India pointed out in a recent report, the apparent
frequency of the ankylostomum in a given district depends largely
on the keenness with which the medical officer in charge of the
district prosecutes a search for its presence. Some observers
have even succeeded in finding them in every patient examined
for them. Thus Griin and Jacoby discovered them in the intestinal contents of every one of 78 Sinhalese whose excreta were
searched; and in the case of six Madrasis the same results
wTere obtained 2 . Close, on the other hand, as the result of
81 autopsies made at Budaon in the North-West Provinces, only
1
2

Janus, 1899, p. 151.
Berliner Klin. Woehemekrift, No. 36, 1896.

588

NEMATODES

found the worm in 68 per cent, of males examined (28 cases), and
40 per cent, of females (16 cases); or 54 per cent, of both sexes 1 .
In some of the hospitals in Ceylon it is believed that the majority
of cases of dysentery, diarrhoea, and debility that come under
treatment are due to the action of this parasite.
In convicts in the Andaman Islands the ankylostomum was
found by one observer in the excreta of 75 out of 100 subjects
examined for its presence 2 . In Burma the worm is widely prevalent. In Assam and the Malay Peninsula it has been detected,
and, as it certainly exists in Java and Borneo, it is probable that
it has a wide distribution in the East Indian Islands. It has also
been found in Cochin China, in French Indo-China, and in Japan.
In some parts of China it is probably very common.
Pani-ghao has been seen at Cachar, and Sylhet in Assam.
The coolies employed in the tea plantations suffer from it to a
very considerable extent.
Australasia.
The parasite also exists in Australia, and ankylostomiasis is occasionally sufficiently severe to be a cause of
death. Nine deaths from this cause occurred in Queensland in
1896. It has also been observed in some of the Pacific Islands;
thus as long ago as 1876 it was found in some of the Fijian mountaineers and in recruits from the Solomon Islands (MacGregor).
Africa.
Egypt has long been recognised as a country in
which ankylostomum is a common parasite and ankylostomiasis
a common disorder. It was as the result of work in a Cairo
hospital that Griesinger first proved the relation of the worm to
the anaemic and cachectic symptoms of the disease.
The disease is, on the other hand, said to be absent from the
pathology of Massowa, on the western shores of the Red Sea.
It is uncertain if it exists in Algeria, and there is apparently no
mention of its occurrence in Tripoli or Morocco. The absence
of any mention of this parasite, however, cannot be regarded as
proof that it does not exist in those countries. Sonsino found
that it was common in Gabes, in Southern Tunisia.
In Lagos, on the West Coast of Africa, ankylostomiasis is said
to be common, and to be a cause of much of the mortality
attributed to " d r o p s y " and "ansemia 3 ." In Senegambia the
1
2
3

Indian Medical Gazette, May, 1899.
Report of San. Commiss. ivith Gov. of India, 1897.
H. Strachan, L.R.C.P., M.R.C.S., Journ. Trop. Med. March, 1899.

ANKYLOSTOMIASIS

589

disease is not rarely met with, and it is probable that later observations will show that it is widely diffused along the West Coast
of Africa. The parasite is widely spread in the Belgian Congo,
where it is a common cause of anaemia in both the white and
black-skinned inhabitants. Guillemard also found it in Madeira.
The ankylostomum is known to occur in Mauritius, where it
was first demonstrated by Lesur. It has also been observed at
Mayotta, in the Comoro Islands, and on the Zanzibar coast.
The disease is not unknown in South Africa. The parasite
was found to be present in the intestinal contents of some 45
European miners, working in the Kimberley and de Beers mines,
during a period of ten months (1897-98). The previous record
of the disease in this region is uncertain; but it is said to have
been prevalent in Kimberley as early as 1890, beyond which date
the statistics do not go. The disease here was much commoner
among the men working underground than in those employed on
the surface. Matthias, who described this outbreak, while regarding it as the first known instance of a serious epidemic of the
affection in South Africa, was of opinion that it is probably endemic
in many parts of that region l .
North and Central America. It is apparently only in the southern
portions of the United States that the ankylostomum has been
observed in the continent of North America. Cases of the
disease it produces have been reported from Louisiana, Alabama,
and Georgia.
It has only recently been demonstrated that this nematode
occurs in Central America. It had for some time been suspected
by the medical officers in British Honduras that the parasite
existed there, but it was only in August 1898 that at a post-mortem
examination it was discovered in the intestinal contents. Later
it was detected in living subjects. It is probably common in this
colony. As the result of sixteen autopsies, it was found in abundance in eleven, in small numbers in two, and was entirely absent
only in three. In the district known as Orange Walk it was
almost as common as the ordinary round or thread-worm. Panighao or ground-itch is also very frequent in this colony.
- The inhabitants of many of the West Indian Islands are
affected by the worm. In Grenada it must be a very common
1
South African Medical Journal.
October, 1898.

Quoted in the Journ.

Trop. Med.

590

NEMATODES

parasite, and a considerable number of cases of ankylostomiasis
are yearly treated at the Colony Hospital. In St Lucia the
disease caused by it is a very prominent one, and the Colonial
Surgeon in a recent report (for 1898) expresses his belief that
" every labourer in the island has either ankylostoma, ascaris
lumbricoides, or oxyuris vermicularis." It is noteworthy, however,
that a large proportion of the cases of ankylostomiasis treated in
St Lucia occur in coolies imported from India. Thus in 1897,
out of 252 cases of the disease no less than 208 were in Indian
coolies1. In Puerto Rico anaemia is said to be the great scourge
of the island, and it is believed to be due to the ankylostomum.
In Antigua it is extremely common. In Trinidad both ankylostomiasis and pani-ghao are exceedingly prevalent and the cause
of much sickness; and in Barbados and St Kitts the parasite is
met with.
In Bermuda no cases of ankylostomiasis have apparently
been seen, though owing to immigration from the adjoining West
Indian Islands it is constantly threatened by an importation of
the disease 2 .
South America. Throughout British Guiana both the parasite
and the disorder it gives rise to are widely spread. The affection
takes a prominent position in the list of diseases observed in the
colony, and is a not inconspicuous cause of death. The residents
on the sugar estates are said to be principally affected by it. In
French and Dutch Guiana the worm is also not uncommon.
Hirsch has quoted a number of authorities for t h e existence of
"malignant anaemia," apparently due to this parasite, in the'past
throughout Brazil, "where," he wrote, "it is prevalent over the
whole of the country excepting the most southern or sub-tropical
provinces—equally on the coast and in the valleys and elevated
regions of the interior." It has also been seen in the valleys of
the upper basin of the Marafion in northern Peru as well as
among the natives of Sarayacu on the pampas of the Sacramento 3 , and it is not unknown in Colombia and Venezuela.
F a c t o r s c o n c e r n e d in t h e G e o g r a p h i c a l D i s t r i b u t i o n . The ankylostomum is found mainly in hot or warm
1

Annual Report on the Hospitals and Charitable Institutions of St Lucia,

1898.
2
3

See the Report of the Medical Officer of Health for Bermuda for 1898.
Hirsch, Vol. II. p. 314.

ANKYLOSTOMIASIS

591

countries. It does not appear to have been observed as yet,
even as an imported parasite, to the north of the latitude of
Dortmund in Europe, or the Southern States in America; while as
a cause of permanent, endemic disease it is almost confined to
tropical or subtropical countries. The only country which forms
an exception to this statement is Italy, where it is common.
Within the tropical and subtropical zones the parasite has now
been observed in a very large number of countries.
Later
observation may show that it is absent from none, as it requires
looking for, and, as already stated, has recently been detected in
countries where it was not previously suspected to exist.
The parasite has been met with at very varying heights above
sea-level. It is said to be most common in marshy soil.
There appears to be little room for doubt that the soil plays
an important part in the life-history of the animal and in its
transmission to man. It was pointed out above that the ova of
the worm leave the body in the intestinal excreta. Their further
development takes place in muddy water, mud, or damp earth,
while, for the final stage, and in order that they may again become
sexually mature worms, they must enter the tissues of a human
being. This probably takes place by means of foul drinking-water;
or perhaps more commonly by being transferred in the act of
eating from earth-soiled hands to the mouth; or, thirdly, by a
direct penetration of the skin. Hence it is most common to
find the affection in persons who work in the earth. In India
and the colonies it is the labourers on tea, coffee, or sugar plantations who suffer most. In Belgium, Germany, Hungary, South
Africa and elsewhere it has been the miners who have mostly
harboured the worm. The outbreak in connection with the
St Gothard tunnel was a marked example of the occurrence of
ankylostomiasis in persons digging in the soil. Evidence of a
similar character is forthcoming from nearly all countries where
the parasite exists. In many instances, moreover, the entrance of
the worm into the human stomach has been traced to the
dangerous and disgusting habit of earth-eating or geophagy.
The spread of the worm and the disease caused by it over the
earth's surface is brought about mainly, if not solely, by the movements of infected human beings. The St Gothard tunnel outbreak
seems to have been due to the employment of Italian workmen
from parts of Italy where the parasite is known to be common,

592

NEMATODES

and it has already been pointed out that the spread of the disease
in Europe may plausibly be attributed to the movements of
infected labourers coming from the St Gothard tunnel, or from
the Cologne brickfields. It seems to have been frequently carried
to the West Indies in the bodies of Indian coolies.
The distribution of the parasite is apparently little influenced
by varying susceptibility in different races. So far as can be
gathered it is probable that all races can become hosts of the
worm in those countries where it occurs, and that any difference
in the frequency of its occurrence between European and native,
or between white and coloured races, is accounted for by difference
in exposure to the risk of infection.

TRIG HO TRA

CHELIDES.
5.

TRICHOCEPHALUS

DISPAR.

T h e Parasite.
Trichocephalus dzsflar, or T. hominis^ the
whip-worm^ is common in the human intestine, especially in the
caecum. The male and female are nearly the same size—from
35 to 50 mm.—but the latter are slightly the longer. Both have
the long, filiform neck, expanding into the thickish body, but
while in the male the latter is spirally coiled, in the female it is
nearly straight. The oval, brownish eggs are easily recognisable
by the clear blunt spines at each extremity. There is no intermediate host, the animal reaching the stomach of its human host
while still in the egg.
G e o g r a p h i c a l D i s t r i b u t i o n . The whip-worm is of almost
universal distribution, and is in some places very common. Merat
records that in ten years of post-mortem examinations in Paris he
was always able to demonstrate the existence of this species to his
pupils whenever he so desired, even in the case of subjects who
had met with a violent death when in perfect health. It is known
in the Malay islands equally with America; in Africa not less than
in Europe. Accurate statistics, as in the case of many of the
entozoa, are wanting as to the comparative frequency and distribution of this parasite, but it is perhaps more common in warm
than cold climates.

TRICHINIASIS

6.

593

TRICHINA SPIRALIS.

T h e P a r a s i t e . The adult worm lives in the small intestine.
The embryos pass into the tissues and bore their way to the
voluntary muscles, where they become encapsuled. They may be
present in large numbers and give rise to serious and even fatal
symptoms.
G e o g r a p h i c a l D i s t r i b u t i o n . Europe. Trichiniasis, the
disease resulting from the presence of this worm in the tissues,
has always been much more common in Germany than in any
other part of the world, and particularly in North Germany. It
has frequently been " epidemic " there. In South Germany it is
less common but still by no means rare. In Great Britain it is
not often seen now, but two small epidemics of it have been
recorded in the .past, one at Workington in Cumberland in 1871,
and one on board a training ship in the Thames in 1879. It n a s
been seen in France, as also in Denmark, Sweden, and Russia.
I n Russia it was prevalent to a considerable extent in St Petersburg, Moscow, Riga, and Lodz between the years 1873 a n d 1879.
Small epidemics of trichiniasis have also occurred in Austria,
Switzerland, and Spain; and isolated cases in Italy, Portugal,
and Roumania. The worm is unknown in the Netherlands, and
has apparently never been seen in Turkey.
Asia. From the very scanty records of trichiniasis in Asia, no
more definite statement is possible than that it has been seen in
Syria, in India, and in China.
Africa. The only mention of the parasite in Africa relates to
its discovery at an autopsy made in Algiers in 1867.
America. A considerable number of epidemics of trichiniasis
have been observed in the past in many parts of the United
States, but mostly in New York and in other north-eastern States.
Osier has stated that " t h e dissecting-room and post-mortem
statistics show that from one-half to two per cent, of all bodies
contain trichinae," so that the parasite is apparently a far from
rare one in America. There seems to be no mention of this
entozoon or the disease caused by it in Central America, the
West Indies, or South America.
F a c t o r s c o n c e r n e d in t h e D i s t r i b u t i o n . The trichina
•enters the human body solely from the consumption of raw or
c.

38

NEMATODES

594

insufficiently cooked flesh of the pig. The encapsuled worm
occurs in the muscles of the latter animal, as in those of man.
When trichinous pork is eaten by man, the eggs escape in the
alimentary canal, the embryos are set free, and if a sufficient
number of them bore their way into the tissues they set up
the disease known as trichiniasis.
Hence the disease is only found among pork-eating people,
and principally among persons who eat the flesh—whether in the
form of ham, of pork, or of sausages—in a raw state or imperfectly
cooked. The frequent consumption of raw ham and of wurst in
North Germany accounts for the frequency of the disease there.
Thorough cooking is necessary to destroy the worm, and merely
salting or smoking the flesh that contains it is not sufficient.
Trichiniasis has become a good deal rarer in the last twenty
years, owing to increased precautions being taken to prevent the
consumption of trichinous flesh. These were largely the result of
the " s c a r e " caused about the years 1875-1880 by the growing
frequency of the disease in many parts of Europe and America.
Systematic inspection of meat is now carried out in Germany,
England, and elsewhere, and this has led to a marked diminution
in its prevalence. In Holland, where very strict precautionary
measures are carried out, the parasite is apparently non-existent.

FILARIJE.
7.

FILARIA

MEDINENSIS

(Guinea-worm).

T h e P a r a s i t e . The Filaria or Dracunculus medinensis, or
Guinea-worm, varies in length from about one to three feet, or
even longer. Only the female is known. She is found, in man,
buried in the connective tissue of some part of the body—usually,
but not always, the lower extremity. Each adult female worm
contains an enormous number of embryos. These are ejected
from her body at the sore where the creature "points," and
probably live for a considerable time in water. Fedchenko
has shown that the embryos enter the bodies of a certain freshwater Cyclops, where they undergo part of their development.
The channel by which the larva enters the human system has
been a-subject of much discussion, and for the present it must be
regarded as not finally determined whether it is swallowed in

GUINEA-WORM

595

drinking-water, or penetrates the skin of the trunk or limbs, or (as
seems probable) whether it may not follow both these paths. The
presence of a living Guinea-worm in the tissues may not give rise
to much trouble or discomfort for a considerable time. But
sooner or later the worm pierces the skin, apparently in order to
eject the young embryos. In most countries the natives who
suffer from the filaria seize this opportunity to extract one end of
the worm, and then proceed to wind it little by little, and day
by day, round a stick or piece of wood until it comes away
entire. Care is taken to prevent its rupture, for, should this
occur, the myriads of embryos escape into the tissues and set up
violent local and general reaction, often with disastrous results.
Premature death of the worm, before she has " presented" at
some surface point, may lead to abscess formation, or she may
remain imbedded for years as an apparently harmless, often
cretified, body.
H i s t o r y . The earliest positive reference to the existence of
the Guinea-worm is apparently that of Plutarch, who quotes a
description of it as occurring on the shores of the Red Sea by a
writer who lived in the second century before Christ. A later
account of it is that of Leonides, in the second century of the
Christian era, who mentions it as met with in Ethiopia and India.
Both these writers speak of the disease as caused by a living worm,
but Galen, Soranus, and many of the Arabian physicians threw
doubt upon this explanation of its causation, and suggested that
the object extracted from the bodies of those affected was no worm
at all, but a diseased vein, or nerve, or other tissue of the patient.
But the right view as to its nature gradually prevailed, and, as a
knowledge of zoology and the use of the microscope advanced,
the exact characters of the worm and its position in the group of
human parasites were finally established.
G e o g r a p h i c a l D i s t r i b u t i o n . Europe. The worm is unknown in Europe.
Asia. It has been seen in Syria, but there appears to be
no record of it in Asia Minor. In Arabia it occurs with some
frequency, particularly in Arabia Petrsea, and on the coasts of the
Hedjaz and the Yemen. In spite of the name Filaria medinensis,
it is probably rare at Medina as an indigenous parasite, though
common enough among the Mussulman pilgrims of all nationalities
who yearly visit the Hedjaz.
38-2

596

NEMATODES

It was formerly seen in the Kirghiz steppes and even to the
north of the Caspian Sea, in so high a latitude as 47° N. 1 But
recent writers on the pathology of the inhabitants of the Kirghiz
steppes and of the Bashkirs make no mention of it In Bokhara
it wTas at one time very prevalent, and a not uncommon name for
it was the Bokhara worm. At the present day, however, it is
much rarer than formerly. Grekof, a Russian observer who has
studied the prevailing diseases of the state of Bokhara, never saw
a single person affected by the worm. In many parts of Russian
Turkestan it is frequently seen. At Tashkent it is said to be rare,
but in Jisakh and Karshi it is very common, or was a few decades
ago, at which period it was apparently not very frequent in Samarkand 2 . It is endemic on the southern shores of Persia.
The Guinea-worm is very widely spread throughout the Indian
peninsula, but it is almost entirely confined to the native inhabitants, and rarely attacks the European residents. From the
returns of the Indian native army and of Indian gaols some idea
may be gathered of the frequency with which the parasite is met
with. In 1896 there were 534 cases of Guinea-worm affection in
the native army, this being equivalent to 4*2 per thousand strength.
In 1897 the corresponding figures were 632 cases, or 4*9 per
thousand strength. The largest proportion of the cases were
reported from the south-eastern districts, from Rajputana, Central
India, and Gujerat. The parasite was also common in the Deccan,
and it was not entirely absent from any of the geographical
divisions of the peninsula. The gaol returns indicated that the
highest degree of prevalence was in the Deccan and Southern
India. In the years in question there were no cases in the
European army. The Rajputana States of Mewar and Marwar
have always been known as regions where the worm is particularly
common, and this appears to be the case at the present day3.
But it is frequently seen in many other parts of India, and would
appear to be rare only in the North-West Provinces, in Lower
Bengal, and in the coast belts of the Madras Presidency (Northern
Circars, Carnatic, and Cochin).
1
Kampfer, quoted by Hirsch; apparently the observation was made in
the early years of the 18th century.
2
Turkestan, by Eugene Schuyler, London, 1876. Vol. I. p. 147.
3
The Western Rajputana States (Adams). Also Thornhill; First Indian
Medical Congress, 1894. The Mewar Bhil contingent of the Indian army have
always suffered considerably from the worm.

GUINEA-WORM

597

In Ceylon the dracunculus is frequently seen, especially among
the labourers employed on the coffee estates 1 .
In Farther India, the Malay Peninsula and Archipelago, China
and Japan, the worm is apparently quite unknown as an indigenous
parasite. It is said to have been seen in Java in former years but
only among troops imported from Africa, and as soon as the
transfer of such troops ceased the worm disappeared from the
island.
The parasite is apparently unknown in British New Guinea
(MacGregor), and probably also in other parts of the island, and
there is no mention of its occurrence in Australia, New Zealand,
or any of the Pacific Islands.
Africa. As the name most usually given to this parasite
implies, one of its principal centres of diffusion is on the shores
of the Gulf of Guinea. It is found, indeed, throughout the
greater part of the west coast of the African continent, but
appears to be most common along the northern shores of the
Gulf. In Senegambia, particularly in the basin of the Senegal
river, it is not rarely seen. But it is still more generally diffused
on the Ivory and Gold Coasts, in Dahomey, and in the basins
of the Niger and Gaboon. In the Cameroon territory, on the
shores of the Bight of Biafra, it occurs somewhat less frequently ;
and further south, towards the mouth of the Congo, is rare and
perhaps unknown as a true indigenous parasite. In the Congo
State the Congolese natives are said not to be affected by it,
though it is well known among labourers imported to the Congo
from Accra, Elmina, and Lagos.
In British East Africa the Guinea-worm is not infrequently met
with. It abounds in the Nile Valley below the Albert Nyanza, but
does not exist in Unyoro or Uganda, except in people who have
lately come from the infected district. In Abyssinia it is said to
occur only on the coast. In Nubia, Kordofan, and Darfur it is
endemic; but it is not so in either Tunis, Egypt, or the Greater
Sudan, and if it occurs in any of these it is only as an imported
parasite. There is no mention of the worm among the parasites of
South Africa.
America. Cases of Guinea-worm were at one time far more
numerous in North and South America and the West Indies than
they are at the present day. As the negro slave was the principal
1
Thornhill.

598

NEMATODES

carrier of the parasite from Africa to the west, so with the
cessation of the slave-trade the worm has become exceedingly
rare in America. Examples are, however, seen from time to time
in the United States. Osier mentions two instances, apparently
of indigenous origin, occurring respectively in Fortress Monroe,
Virginia, and in Philadelphia; but he adds that a majority of the
cases mentioned in American journals have been imported. Occasional cases, apparently also due to importation, are seen in Trinidad
and other West Indian Islands.
The vOnly mention of the disease in recent times in South
America relates to the existence of a small endemic centre in
the village of Feira de Santa Anna in the Bahia province of
Brazil.

Factors concerned in the Geographical Distribut i o n . From the above summary of the recent distribution of
Guinea-worm it will be seen that the parasite is almost confined
to tropical or subtropical countries. The only exception to this
rule has been the mention, by a writer at the beginning of the
18th century, of the existence of the worm to the north of the
Caspian Sea, in latitude 47° N. It is very doubtful if it still
exists there at the present day, and its most northerly limit now
seems to be between 40 0 and 45° N. in Russian Turkestan.
While mainly a parasite of hot or warm countries, it is not
found in all such climates. It is most abundant in the great
tropical belt of Africa, which is believed by many to be the
original habitat of the worm. It is also fairly common in parts of
Western and Central Asia, and in India, but further east than
India it is unknown, at least as an indigenous parasite. In the
New World, though it has been seen as far north as Philadelphia
(40 0 N.), it is only in the tropical zone that it is anything but extremely rare, and in this zone it is found in a few places only, and
more often than not as an imported parasite.
Warmth may be regarded therefore as necessary for the
prevalence of Guinea-worm. A certain degree of moisture is
equally needed.
The parasite, as already pointed out, is
believed to pass one portion of its existence in certain lowly
fresh-water organisms, and its distribution over the world's surface
is no doubt largely, though probably not wholly, determined by the
distribution of these particular crustaceans. That is to say, that,
although this particular fresh-water cyclops may have a much

GUINEA-WORM ,

599

wider distribution than the Guinea-worm, the latter, on the other
hand, cannot multiply and flourish as an indigenous parasite
in the absence of' the cyclops. As water, then, is a primary
necessity for the cyclops, it is equally a primary necessity for the
multiplication of the worm. It is also, there is good reason to
believe, the principal means by which the parasite gains access to
the tissues of man.
The relation between the frequency of the parasite in any
district and the amount of rainfall is probably not, as some have
thought, a direct one. It has varied greatly in different countries
and at different times. In both Africa and India it has sometimes been unusually frequent after heavy rains, and at other
times in hot, dry weather. The former condition would no doubt
favour the multiplication of the cyclops, and indirectly that
of the worm itself. The latter condition would lead to a lessening
of the amount of water in pools," water-courses, or other sources of
water-supply; and as the water became more concentrated the
chances of any given quantity of it containing embryos of the
worm would increase, and in like manner the chances of human
infection would also become greater.
Dracunculus shows no definite relations to the geological
character of the soil. It is probably little influenced by race.
The white man always suffers, it is true, to a far less extent than,
the native in those countries where the worm is common, but this
is apparently solely due to the fact that he is far less exposed to
chance infection, in that his limbs are protected by clothes and
boots, and that he is more careful in attending to the source of his
drinking-water.
Guinea-worm has been spread over the earth's surface mainly
by the movements of infected human beings, and these have most
frequently been persons of the negro race. It is very probable, as
pointed out above, that the worm is originally of African origin,
and that if it is now endemic elsewhere, it is so only as the result
of importation from Africa. Within quite recent times carriage
of the worm from this continent has been frequently observed.
Its appearance in Java as the result of the transfer of troops from
Africa, and its disappearance from the island as soon as this
military movement ceased, was mentioned above. In like manner
the appearance of the worm in Egypt, Tunisia, the West Indies,
Guiana, and Brazil, has been repeatedly traced to importation by

6oo

NEMATODES

infected negroes from those parts of Africa where it is common.
At the time when negro slaves were being carried to America in
large numbers such instances of importation of the Guinea-worm
were far more frequent than now.

8.

F I L A R I A B A N C R O F T I {Filaria Nocturna, and
Filaria Sanguinis Hominis).

T h e P a r a s i t e . The Filaria bancrofti is believed to be the
adult form of the Filaria nocturna. The latter name is now
most commonly employed to designate a parasite which was
formerly known as the Filaria sanguinis hominis—the parasite
associated with a very large number of pathological conditions,
all of which are characterised by more or less severe affection
of the lymphatic system. Of these various diseases, due more
or less directly to the Filaria nocturna, Manson has enumerated the following :—ulcers ; lymphangitis ; varicose groin glands ;
varicose axillary glands; lymph scrotum; cutaneous and deep
lymphatic varix; orchitis; chyluria; elephantiasis of the leg,,
scrotum, vulva, arm, mamma and elsewhere; chylous dropsy of
the tunica vaginalis; chylous ascites; chylous diarrhoea, and
probably other forms of disease depending on obstruction or
varicosity of the lymphatics, or on death of the parent filarial
Of all these varied affections elephantiasis is by far the most
widely spread, and will consequently be most frequently referred
to here. It would be interesting to make a comparative study
of the frequency and geographical distribution of each of the
diseases caused by this filaria; but, even if space permitted, it is
doubtful if the necessary material exists for such a study; and it
must suffice here to point out briefly what is known as to the
distribution either of the filaria itself, or of the group of diseases
as a whole with which it is associated.
The embryonic form, or Filaria noclurna, is a microscopic
worm, about -^ of an inch in length and -g^Vo" or •$-—-$ of an inch
in breadth. Its diameter is thus about that of a red blood corpuscle.
For the structural characters of this worm the reader is referred to
any recent text-book upon tropical diseases or helminthology.
The parasite is found in the blood, as a rule, only during the
night hours, say from 5 or 6 o'clock in the evening, to 8 or 9
o'clock the next morning. During the day it is absent from the

FILARIASIS

601

general circulation, and Manson has recently made an observation
which seems to show that during these hours the parasite retires
to the larger arteries near the heart, and to. the lungs.
Like most of the human blood-worms this filaria requires an
intermediate host to complete its life cycle. The intermediate
host in this instance is a certain species (or perhaps several
species) of mosquito. The mosquito bites a filarial patient,
and in the act of sucking his blood the filariae pass into the
stomach of the insect. Thence they migrate to the thoracic
muscles. A mosquito's life is a short one; after depositing
her eggs (it is only the female mosquito that bites and that
can therefore carry this or other filariae) on the surface of
stagnant water, she dies. The filaria, now about y1^ inch in
length, escapes from her dead body and sooner or later may be
taken into the body of a human being again, by means of
drinking-water. It is believed to pass by boring from the human
stomach into the lymphatics, where it becomes sexually mature,
and where new generations of embryo filariae are produced.
While this has hitherto been most generally believed to be the
method by which the parasite gains access to the human frame,
it has to be added that a second method is also possible. This
is by the passage of the filaria from the mosquito to the human
tissues while the mosquito is " biting," and support is lent to this
view by the recent demonstration by Low and James of the
presence of filariae in the proboscis of the insect. Grassi and
Noe and trie Liverpool Expedition to Nigeria have also confirmed
this observation. The mature parasite (called the Filaria bancrofti
after Dr Bancroft, of Brisbane, who first observed them) is a long
worm, from three to four inches in length, and about the thickness
of a hair. It has been found in cyst-like dilatations of the distal
lymphatics; in lymphatic varices; in the larger lymphatic trunks
between the glands; in the glands themselves, and in the thoracic
duct
H i s t o r y . The early history of the many affections that are
now known to be caused by the Filaria sanguinis homims is
obscure. Of the many filarial disorders elephantiasis is the only
one for the history of which materials exist to any considerable
extent, and even their value is largely diminished by the confusion
which existed in the earlier records between leprosy (elephantiasis
GrcEcorum) and the disease now under consideration (elephan-

602

NEMATODES

tiasis Arabuni).
There is every reason to believe that the filarial
elephantiasis is of considerable antiquity, and there seems no
good reason to doubt that the other filarial disorders enumerated above are of the same age. So far as the scanty
historical records go, they are said to show that the distribution
of the disease in medieval times was very much what it is at the
present day. The Filaria noctuma, which is now regarded as
almost certainly the cause of elephantiasis and the other affections
named, was first discovered by Demarquay in 1863 in a case of
chylous dropsy of the tunica vaginalis. In 1866 Wiicherer found
the same parasite in the urine in several cases of chyluria. In the
same year Lewis found it in India, and a little later proved that the
normal habitat of the embryo parasite (which he called the Filaria
sanguinis hominis) was the blood of man. Recently Manson
and others have devoted much work to this and other filarial, and
it is now generally accepted that the Filaria noctur?ia, the Filaria
bancrofti, and elephantiasis and the other affections named, bear
to each other the definite relations which have been described
above.
R e c e n t Geographical D i s t r i b u t i o n .
Europe.
True
elephantiasis and the other forms of filarial disease are not known
with certainty to be indigenous in any parts of Europe. Examples of elephantiasis are occasionally seen in several European
countries in persons who have contracted the disease elsewhere,
and from time to time cases are recorded, even in subjects who
have never left their own country, in which the clinical symptoms
are indistinguishable from those of elephantiasis. But in these
instances there is a lack of evidence of the filarial origin of
the disease, and for the present there is no reason to believe that
Filaria nocturna exists in any part of Europe. The countries in
which cases of the kind just mentioned have been seen are
England \ Scotland, Ireland, the south of France, Greece, Turkey,
Portugal, and Spain.
Asia. Filarial disease exists in Syria and in Arabia, where
examples of elephantiasis are seen, though probably with no great
1
Sir Dyce Duckworth, at a meeting of the Clinical Society on Jan. 13, 1899,
showed a case of leg elephantiasis in a girl aged 20, who had never left
Yorkshire. The blood in this case was practically normal, and no filariae were
ever found. Dr Toogood at the same meeting mentioned two similar cases
occurring in anaemic girls.

FILARIASIS

603

frequency. I am aware of no positive evidence of the presence
of the filaria in either the Caucasus, Central Asiatic Russia, or
Siberia, but should not be surprised to learn that it exists in
Transcaspia, Turkestan, and the other Russian possessions in
Central Asia.
In India elephantiasis is a comparatively frequent disorder.
It is said to be most prevalent along the shores of Lower Bengal
and of Orissa, in Pondicherry, at a few places on the Coromandel
Coast (particularly Tanjore at the extreme south), and most of all
on the Malabar Coast. In Travancore and Cochin it seems to
be extremely common, and different observers state that from 10
to 50 per cent, of the population are affected by it in the latter
town. It is rarer in the Deccan and Upper India.
In many parts of Ceylon elephantiasis is a common disorder.
Here, as in India, many of the village inhabitants live near tanks,
drink tank water, and eat fish taken from tanks, and in this way
nb doubt the embryo filarise gain access to their bodies. Elephantiasis, or Barawa, as it is called by the Sinhalese, has been
shown to be most prevalent in villages near the swTampy ground of
old, abandoned tanks. The scrotal, labial, and pectoral forms of
the affection are said to be rare here, and so also is chyluria1.
These diseases are also met with in many of the East Indian
islands. Elephantiasis is said to prevail most in the Lampong
country of Sumatra, in Banka, the Nicobars and the Philippines,
while in Java, Amboina and other islands it is less often seen.
Filarial disease is far from rare in the Malay Peninsula, and
every year a certain number of cases are treated in the hospitals
of Penang and Singapore. Among the Annamese it is common.
In China the Filaria sanguinis has a wide distribution, and in
some parts affects a considerable proportion of the inhabitants 2 .
Its degree of frequency appears to vary rather widely. It is
common in the Shan-tung province; is "extremely prevalent"
in Huang Yen, a division of the prefecture of T'ai-chou; and is
rather frequently seen at Ningpo. In the Fo-kien province the
disease is perhaps more general than in any other. At Amoy it
accounts for 2 per cent, of the patients treated in hospital.
1

Thornhill, Journ. Trop. Med. Dec. 1898.
See Chinese Customs Medical Reports, Nos. 45 and 55. Also Coltman,
op. cit.
2

NEMATODES

604

In Japan elephantiasis is seen, but apparently is rather less
common than on the southern and south-eastern coasts of China.
The observation, originally made by Myers in 1881'1, that the
natives of Formosa, in spite of the proximity of the island to
China, are to a great extent free from this parasite, has been
recently confirmed. In the course of a seven years' residence in
Formosa (1886 to 1892) Rennie only saw six cases of elephantiasis
in the Tamsui native hospital. H e adds that the disease appears
to be exceedingly rare in persons born in, and never resident out
of the island, and that this is probably to be explained by the
curious fact that the filaria-nurturing mosquito is not native to
Formosa.
Australasia. In British New Guinea elephantiasis is endemic,
but is not apparently a very common disorder (MacGregor).
Filariasis is certainly no rarity in Fiji. Many cases of
elephantiasis and of " lymphangitis" of filarial origin are yearly
treated in the colonial hospital at Suva, the patients being mostly
native Fijians, but occasionally Europeans are afflicted by the
disease. In Samoa it is said that about every second individual
is the subject of elephantiasis; in Huahine Island of the Society
group the proportion rises to seven-tenths of the adult male
inhabitants, and it is also of frequent occurrence in Tahiti and
Raiatea.
In the Solomon Islands elephantiasis is not uncommon. It
here usually assumes the form of lymph-scrotum, but cases in
which the limbs are affected are sometimes seen. It is noteworthy that the natives of these islands attribute the disease to the
water of certain streams 2 . In New Caledonia, Wallis Island, and
the Gambier group, the disease is very prevalent; and it exists,
but to a less extent, in the Marquesas and Hawaii groups. In
the Tonga or Friendly Islands nearly one-third of the population
are said to harbour the filaria.
It has been sometimes stated that elephantiasis does not exist
in Australia or New Zealand as an endemic disease, but recent
mention has been made of the occurrence of a case of filariasis
in Queensland 3 , and one death from it was recorded in the
Report of the Registrar-General for this colony for 1896.
1
2
3

Chinese Customs Medical Reports, No. 21 and No. 23.
Guppy, op. cit.
Bancroft, Journ. Trop. Med. Jan. 1900, p. 149.

FILARIASIS

60S

Africa,
Filarial disease is not infrequently seen in Egypt, and
is most common in Lower Egypt, particularly at Rosetta, Damietta,
and some other places. It is found also in swampy valleys in
Abyssinia, and in parts of Tunis and Algeria. It is however
apparently not met with at Massowa on the Red Sea. It is also
said to be absent from the upper valleys of the Nile; but on the
other hand it occurs as an endemic in some regions to the south
of the Sahara, such as Bornu, Segu Sicorro, and Ogowe.
Turning to the western part of the continent a wide degree of
prevalence of elephantiasis is found in many districts. It appears
to be a common disorder in Senegambia. On the Gold Coast
cases are not infrequently seen; and at Lagos the disease undoubtedly exists, though it is not common. It is found also on
the Benin coast, the Spice coast, and at Sierra Leone, while in
the Cameroons the filaria is by no means a rare parasite. In the
Belgian Congo it is said that " t h e majority" of the negro inhabitants harbour these haematozoa. Elephantiasis and the other
forms of filarial disease are at any rate very commonly seen in the
possession. Elephantiasis is very common in Uganda 1 , and filarial
diseases certainly exist in Zanzibar and Mombasa. In British
Central Africa, Daniels found that the Filaria nocturna and
elephantiasis occurred with considerable frequency on the Lower
Shire River, on the Zambesi, and at the north end of Lake Nyassa,
while in the Shire and Angoni highlands, on the Upper Shire, at
the south end of Lake Nyassa, and in Likoma neither the parasite
nor the disease appeared to exist2.
Throughout South Africa elephantiasis is apparently very rare,
though not wholly unknown. One observer met with only two
cases of the disease in a total of 40,000 patients in the course
of seven years. Of the two patients, one came from the Kentani
district, in the native territory of the Transkei, and the other from
a locality not named 3 .
The parasite is comparatively frequently seen in Madagascar,
and at Mayotta in the Comoro Islands. In Mauritius elephantiasis,
chyluria, and varicose groin glands are also common affections.
America.
Filarial diseases appear to be absent from the
1

Cook, ibid. June 1, 1901.
Ibid. June 15, 1901.
3
.South African Medical fournal.
1899.
2

Quoted in fount.

Trop. Med. March,

6o6

NEMATODES

pathology of Canada and of the Northern States of the American
Union; but in some of the Southern States they seem to exist
rather extensively. They are also found with some frequency
in Mexico, and in the Central American States of Nicaragua,
Costa Rica, and Panama.
Filarial disorders are of frequent occurrence in many of the
West Indian islands. In Cuba they are very common 3 , and they
are found with considerable frequency in Barbados, Martinique,
Guadeloupe, Trinidad, St Vincent, St Bartholomew, St Kitts, and
Montserrat. In St Lucia, on the other hand, the Filaria nocturna is
exceedingly rare, and elephantiasis is consequently not a common
disorder. A few cases are however treated yearly at the hospital
and poor asylum.
In South America elephantiasis is said to be endemic on the
coast and marshy plains of Guiana, in some parts of Brazil, and
on the shores of Colombia, Venezuela, and Peru. In British
Guiana filarial affections appear to be particularly common.
Daniels found the Filaria nocturna in 52 out of 348 persons
examined for it at Georgetown, and Ozzard found it in 28 out of
100 persons in whom it was looked for at New Amsterdam. It is
also of comparatively frequent occurrence in some parts of Brazil;
one observer has found it at Bahia in about one-twelfth of the
persons examined for it.

Factors determining the Geographical Distribution.
From the brief account already given of the group of diseases
associated with the Filaria nocturna, it will be seen that a number
of factors are primarily necessary to their production. There is firstly
the specific filaria itself; there is secondly the specific mosquito
(or perhaps several species of mosquito) in which it undergoes its
extra-human phase; and there must obviously be a susceptible
population, and a set of physical conditions favourable both to
the life of the parasite, to the life of its insect host, and to its
easy passage from the latter to the human subject, and again from
the human subject to the mosquito.
As to the filaria itself it is very generally admitted that the
parasite above described, and it alone, is the specific cause of the
group of diseases here dealt with. Less is known as to the specific
character of any particular mosquito or mosquitoes as the filarial
1

Commercial Cuba, by W. J. Clark, London, 1899.

FILARIASIS

607

host. Bancroft, in Australia, has found Culex ciliaris (Linn.)
an efficient host for the filaria, and has shown that two other
mosquitoes, Culex notoscriptus (Skuse) and Culex annulirostris
(Skuse) are not hospitable. The Anopheles musivus behaved
in a manner which showed that it might harbour the filaria, and
James has shown that Anopheles rossi and perhaps other species
of Anopheles may act in a similar manner.
In regard to the presence of a susceptible population, it is for
the present uncertain whether individuals or races do or do not
differ in their susceptibility to filariasis, provided they are under
exactly the same conditions of exposure to the risk of contracting
it. It is true that the dark-skinned races in India, the islands off
the East Coast of Africa, and the West Indies seem to be most liable
to it, while white men living in countries where the filaria exists
appear to largely escape it. But this may to a great extent, if not
wholly, be explained by the different conditions under which the'
two classes live. In India, for example, the native constantly
bathes in and drinks the water of tanks and streams which may
well contain the eggs and embryo forms of the Filaria nocturna.
H e rarely, if ever, employs a mosquito net or a punkah at night,
and is thus far more exposed than the average European to the
bites of mosquitoes, so that whether the filaria finds its way to the
human tissues by drinking-water, by penetrating the skin during
bathing, or by means of a mosquito bite, it is certain that the
native in India (and to a great extent the argument applies elsewhere) is much more exposed to its attacks than the European.
Moreover when Europeans are attacked in India they are usually
of the poorer classes and " country-born," and consequently their
mode of life, in regard to their degree of exposure to the risk of
filariasis, may be presumed more closely to resemble that of the
native Indian than that of the average European. Maitland 1 ,
indeed, after 24 years' residence in India, has stated that he never
met with nor heard of a case in a well-to-do European in that country.
It is certain that filariasis may occur under suitable conditions in
a great variety of races, including the various Hindu, Mohammedan,
and other races of the Indian peninsula, the East Indians, Malays,
Annamese, Chinese, Pacific I slanders, African and American negroes,
as also in persons of mixed races, as the half-castes or half-breeds in
India and in South America.
1

Brit. Med. Assoc. Annual Meeting, 1900.

6o8

NEMATODES

It is probable therefore that race is in itself a less important
factor in the geographical distribution of filariasis than certain
physical conditions which affect, favourably or otherwise, the lifehistory of the parasite to which it is due. For a general prevalence
of filariasis it is clear that the physical conditions, such as
temperature, moisture etc., must be favourable not only to the life
of the filaria itself, but also to that of the mosquito in which one
portion of its existence is spent. A considerable degree of warmth
appears to be essential to either the one or the other, or perhaps
to both. It is at least certain that the principal endemic areas of
filariasis both in the Old and New World are in or near the tropics.
True filarial elephantiasis appears to be unknown as an indigenous
disorder in regions more than 35 0 to the north or 300 to the south
of the equator. A moist atmosphere seems also to favour its
prevalence, as it is commoner on the coasts than in the interior of
countries, and is most frequent in low-lying damp localities on the
shores of rivers and streams, while it is absent or rare in higher
and drier places. This is, no doubt, largely to be explained by
the important part which water plays in the life-histories both of
the filaria itself and of its mosquito-host. Both may be said to
pass one stage of their existence in water, and, as already stated, it
is highly probable that it is by means of filaria-containing water
that the parasite usually gains access to the human being.
Finally, conditions which enable the filaria to pass with ease
from the human to the insect host, and vice versa, must be
present if filariasis is to be a common disorder. Some of these
conditions have been already named. They are, on the one
hand, the exposure of filarial subjects to the bites of mosquitoes,
with the risk or certainty of contaminating the mosquito; and on
the other the exposure of healthy subjects either to the bites of
filaria-containing mosquitoes, or to the risk of filarial infection by
drinking or bathing in contaminated water. Such risks are
clearly to a great extent avoidable; and if, in countries where
filariasis exists, every individual, whether the subject of it or not,
took every possible precaution to avoid being bitten by mosquitoes,
and to drink and bathe in no water the purity of which was not
above suspicion, it is more than probable that filariasis would
cease to exist. A useful auxiliary measure would be the destruction
of the mosquito, and the success recently met with in the war
against the malaria-bearing Anopheles may warrant the hope that

609

FILARIA LOA

a similar campaign against the insect which carries Filaria nocturna
would lead to equally satisfactory results.
9.

FILARIA

DIURNA.

T h e P a r a s i t e . Filaria diurna is the name applied by
Manson to a parasite which resembles Filaria nocturna in all
its physical characters, but differs from it in that it is found
in the blood, not during the night, but during the day. His
observations were made on two negro patients, one of whom came
from Old Calabar and the other from the Congo; and as one of
them had some years previously had a Filaria loa in one of his
eyes it seemed possible that the Filaria diurna might be the
embryo form of the sexually mature Filaria loa.
T h e G e o g r a p h i c a l D i s t r i b u t i o n of this parasite appears
to be limited to certain regions of Africa. Manson believes
it to be extremely common among the natives of the Lower Niger,
where one-fourth of the population may be affected by it. Brault
states that it is found especially at Old Calabar, along the Guinea
Coast, and on the Congo River. Cook has seen two cases of it
in Uganda 1 . It is not known to occasion any pathological condition.
10.

F I L A R I A LOA.

T h e P a r a s i t e . Filaria loa is a small thread-like worm,
the two sexes of which occur in different individuals. The male
is about an inch in length, the female rather longer. The worm
is found in the connective tissues, and seems to wander about
from one part of the body to another. It is most usual to find
it under the conjunctiva, or in the connective tissue in the
neighbourhood of the eye, or just under the skin on the bridge of
the nose. It is believed to pass by wriggling movements under
the skin from one eye to the other, or to other parts of the
body.
The life-history of this filaria is unknown. Manson suggests
that Filaria diurna^ above described, may be the embryonic form
of Filaria loa. No embryos have been found in the peripheral
blood of persons the subjects of the loa worm, and nothing is
1

c

Journ. Trop. Med. June 1, 1901.

39

6io

NEMATODES

known as to the way in which it leaves the human host, or
whether (as is probable) it passes part of its life-cycle in some
insect host, as is the case with Filai'ia nocturna.
G e o g r a p h i c a l D i s t r i b u t i o n . This parasite is only found
in the West Coast region of Africa. It is probably rather common
here and particularly in the neighbourhood of Old Calabar. It
is also found on the Congo; and a case has been seen as far
inland as Talagouga on the Ogowe, 120 miles from the coast 1 .
The late Miss Mary Kingsley, the well-known African traveller,
stated that on the Ogowe river nearly every inhabitant suffers
from the worm. It is said to be endemic from a few degrees
north of the equator to about ten degrees south. It seems to
be absent from the Cameroon territory. Formerly it is said to
have been seen from time to time among negroes in America,
but since the slave-trade from Africa to the New World has ceased,
this parasite is no longer found on the other side of the Atlantic.
11.

FILARIA

DEMARQUAII.

Filaria demarquaii resembles Filaria nocturna and Filaria
diurna in shape, but, at least in dried specimens, appears to be
only about one-half their size. It was first described by Manson,
who found it in 10 specimens of blood (out of 152 examined)
taken from natives of St Vincent in the West Indies. It shows no
periodicity, and is present in the peripheral circulation day and
night. Parasites apparently identical with this were also found
in blood taken from natives of St Lucia in the West Indies, and
from Papuans. Brault states that this filaria occurs throughout
the Lower Niger district in West Africa. Manson is inclined to
think that F demarquaii and F ozzardi of British Guiana are the
same species.
12.

FILARIA

OZZARDI.

Filaria ozzardi is the name provisionally applied by Manson
to a nematode embryo observed by Ozzard, Daniels, and himself
in the blood of certain aboriginal Carib Indians in British
Guiana. These people are said never to suffer from elephantiasis, and Filaria nocturna has never been seen in their blood,
* Yarr, Journ. Trop. Med. Feb. 1899.

FILARIA

PERSTANS

6ll

so that the filaria now under consideration is probably of a
separate species. It closely resembles Filaria demarquaii, but
about every sixth parasite in a microscopical specimen is seen to
have a pointed instead of a blunt tail. The exact relation of
this filaria to both Filaria demarquaii and Filaria perstans is uncertain. Daniels found the mature form of the worm in the
bodies of two Demerara Indians, whose blood during life had
contained both blunt- and sharp-tailed embryos. The mature
worm was about 3 inches long and very slender—about one-third
the diameter of Filaria bancrofti.
13.

FILARIA

PERSTANS.

T h e P a r a s i t e . Filaria perstans is much smaller than either
F diurna or nocturna, and presents some other physical characteristics—such as the absence of a sheath, an abruptly rounded
caudal end, and the power of locomotion—which markedly distinguish it from the other filarise1. The mature form of the worm
is unknown, and its pathological effects are uncertain. Manson
has however suggested that it may possibly be the cause of negro
lethargy and of some of the forms of African craw-craw. Both these
diseases are treated separately elsewhere in this volume, and here
it will suffice to state what is known of the geographical distribution of the filaria itself.
G e o g r a p h i c a l D i s t r i b u t i o n . This parasite appears to be
confined wholly to the negro races of Africa. Manson found
it in natives from Old Calabar and the Congo, both from the
coast and from the interior. Firket, of Liege, also observed it in
Congo natives. Brault states that it is confined to the west coast
between the mouths of the Senegal and the south of Benguela;
but, as just stated, it is found not only on the coast, but also in
the interior. Nor is it confined wholly to the western part of the
continent, for Cook records that he has found it in three instances
in the Uganda Protectorate 2 . The only mention of the parasite
outside Africa is a reference by Manson to its doubtful occurrence
in Demerara Caribs. The latter observer failed to find it in West
Indian negroes, and in natives of the Malay Peninsula, China, and
India.
1

For a full description of this and the other filariae the reader is referred to
Dr Patrick Manson's Tropical Diseases.
2
Journ. Trop. Med. June 1, 1901.

39— 2

6l2

NEMATODES

14.

FILARIA

MAGALHAESI.

Filaria magalhaesi is the name given to a fllaria, of which the
adult form only has been observed in a single case by Prof.
Magalhaes of Rio de Janeiro. It differs essentially from F. batterof ti (the adult form of F nocturna), but it has been conjectured
that it may be the mature form of F. detnarquaii or F. ozzardu
Its life-history and pathological effects are quite unknown. The
single case in which it was observed was that of a child who died
in Rio de Janeiro.

PARASITIC A R A C H N I D S
INSECTS.
A.
i.

AND

ARACHNIDS.

PENTASTOMUM

CONSTRICTUM.

T h e P a r a s i t e . This is an elongated larval form, varying in
length from half an inch to an inch and a half, and with 23 rings
on the abdomen. It occurs in cysts in the liver and occasionally
in the lungs. It may be the cause of serious and even fatal
illness.
G e o g r a p h i c a l D i s t r i b u t i o n . The parasite was first observed
in Cairo, where it has only been seen in the bodies of negroes.
It is uncertain therefore whether it is truly indigenous to Egypt, or
imported from the Sudan. It has also been found in a soldier
who died at Bathurst, Gambia; in an African slave coming from
St Helena; and in some natives of the Belgian Congo 1 . Flint
mentions a case in Missouri, in which from 75 to 100 of the parasites were expectorated. Osier refers to this case and adds that in
1869 he saw a specimen which had been passed in the urine by a
patient of a Toronto practitioner. This would seem to indicate
that the parasite may exist in the urinary passages as well as in
the liver or lungs, and that it may occur in northern latitudes.
The parasite seems to be mainly one of the negro race.
Pruner, of Egypt, found it in a giraffe.
2.

S A R C O P T E S SCABIEI.

G e o g r a p h i c a l D i s t r i b u t i o n . Itch is common among the
very dirty classes of almost all countries. In Europe it is said to
1

Congrfc Nat, d"* Hygiene

de la Belgiqtie et du Congo, 1897.

614

PARASITIC A R A C H N I D S AND INSECTS

be particularly frequent in Iceland and the Faroe Islands, Norway,
Poland, Russia, some parts of Eastern Germany, France, and the
Ionian Islands.
In Asia it is widely seen throughout Siberia and Kamchatka;
in the Caucasus, and in Russian Central Asia; in India and
China; in Persia and Arabia. In fact it is practically universal
throughout the continent. In some of the Australasian islands,
on the other hand, the disease is rare, and it is said to be unknown
in New Guinea.
In Africa itch is apparently met with in many parts of the
continent, but some confusion exists here between scabies and
craw-craw, a disease which is dealt with elsewhere. ,
In America scabies is less common in Canada and the United
States than in Europe. It is extremely frequent in Brazil and
Peru, and is probably endemic in Central America and the West
Indies.
F a c t o r s c o n c e r n e d in t h e D i s t r i b u t i o n . Scabies is
found in all races and in all climates. The parasite, dirt, and
neglect are apparently the only essential factors for the prevalence
of the disease.

B.

INSECTS.

The Flea, Pulex irritans, has a world-wide distribution. In
itself it is harmless to man, but as a possible carrier of the infection
of plague and other diseases it has a certain pathological importance. The Bed-bug, Cimex lectularius, has also an extremely
wide distribution and is of exactly the same pathological significance as the flea.
The larvae of various flies have occasionally been found in
the human alimentary canal and given rise to some trouble and
more alarm. In other instances they have penetrated the nasal
passages, and even passed into the frontal sinuses and antrum.
In such cases ulcerative processes and caries may be set up,
leading to perforation into the cranial cavity, with resulting
meningitis and death. Such troublesome larvae have been observed
mostly in hot countries, such as India, Senegambia, Mexico,
Central America, Cayenne, Colombia, Brazil, and the Argentine
Republic.

PULEX PENETRANS

615

PULEX PENETRANS.
T h e Parasite.
The jigger, chigo, or sand-flea (Pulex
penetrans) is an insect closely resembling, but rather smaller
than, the common domestic flea. It usually penetrates the
skin of the feet and causes no little trouble from the inflammation subsequently set up. The female alone enters the
human tissues in this way. Immediately after impregnation she
burrows through the skin of the first warm-blooded animal that
comes in her way. As ovulation progresses she becomes enormously distended, and, in consequence, much inflammation with
pus formation is set up in the tissues of the host. The skin usually
ulcerates, and the insect is in this way expelled. While the foot
is the usual site for the chigo, it has been known to penetrate
the skin of the scrotum, penis, perineum, thighs, hands, and face.
The affection is not in itself a grave one, but the subject of it
suffers greatly and is for the time seriously disabled; and as the
resulting ulcer lends itself readily to septic absorption, or to the
development of tropical phagadsena or other serious complications,
the chigo disease is not one that can be lightly regarded.
Usually only one or two chigos are present in a patient, but
occasionally they are very numerous; probably the largest number
ever seen in a single individual was 280, removed from a boy at
one time 1 .
*
H i s t o r y . The chigo is said to have been known for over
a century in South America and the West Indies. About the
middle of the nineteenth century it seems to have been introduced
to the West Coast of Africa in the sand ballast of a ship coming
from Brazil. In Africa the pest at first spread slowly. Stanley's
last expedition and the increase of movement brought about by
advancing civilisation are said to have been the means of spreading
it more rapidly over the continent. It became widely diffused
over the Congo Free State; by 1891 it had crossed as far as Lake
Nyassa and appeared in Uganda; in 1894 it had reached the
Shire Highlands, and some time later it was carried to the East
Coast of Africa. In 1899 it appeared for the first time in Madagascar, and in the same year it was imported to India.
1

Janus, T899, p. 439.

6\6

PARASITIC A R A C H N I D S AND INSECTS

R e c e n t G e o g r a p h i c a l D i s t r i b u t i o n . America. At the
present day the chigo is found with great frequency in some of the
West Indian Islands and in the neighbouring portion of South
America. In Cuba it is particularly troublesome. " The worst of
all the pests on the island," writes a recent author, "is the nigua
or jigger, so-called, sometimes described as a cross between Satan
and the wood-tick, and the torment from their attacks is said to be
worse than would be possible from either of their reputed progenitors 1 ." In Jamaica many cases of chigo come under treatment
at the hospitals each year. It occurs in Mexico, both in the
eastern and western provinces, and even at considerable heights.
It has also been seen in Honduras, Guatemala, Costa Rica,
San Salvador, and Panama, and has been met with further
north in Florida. In French Guiana and in Brazil it is very widely
prevalent, and it is known to occur in the tropical parts of Paraguay, Chile, Colombia, and Peru.
Africa. In Africa the chigo is found through the entire
tropical zone from west to east. The easterly spread of the pest
across this continent has been briefly described above, and is a
phenomenon of very great interest. Whether it was truly imported
here from America by means of infected sand from Brazil or not,
it is certain that it has appeared in Africa only in quite recent
times. It is now firmly established in the Cameroon district2,
and in the whole of the Congo valley. It has travelled as far
south as Mashonaland, where it is widely disseminated and a
cause of much trouble to the natives 3 . In Uganda it was first
seen in 1891. Its appearance here was attributed indirectly to
Stanley's expedition in relief of Emin Pasha. " This expedition,"
writes Dr Cook, on medical mission work in Uganda, " d i d not
actually enter Uganda, but many Baganda who had been driven
out of their country by a revolution met with Stanley's expedition
and brought back the jiggers to Uganda. Coming up country in
1896," the same author continues, " w e met the jiggers just before
we got to Machakos. Following the caravan route they slowly
made their way down to the coast, which they reached about
1899. Till the natives realised their nature they did great damage
and caused the loss of many toes, etc. 4 " This course of the
1
2
4

Com7?iercial Cuba, by W. J. Clark, London, 1899.
3
Plehn.
Todd, Journ. Trop. Med. Nov. 1900.
Ibid. June 1st, 1901.

PULEX

PENETRANS

617

parasite is more or less confirmed by other writers. It appears,
however, that it must have reached the coast earlier than 1899.
Sir Harry Johnston states that it reached the shores of Lake
Tanganyika first; and then those of Lake Nyassa, where it was
first heard of at Karonga about 1891. It was in Southern Nyassa
in 1892, and in 1894 was already a serious pest at Zomba and
throughout the Shire highlands. It appeared at Chinde on the
sea-coast in 1895. Lionel Decle states that he found it all over
the shores of Lake Tanganyika, in Uha, Unyamwezi, Usukuma;
on the shores of the Victoria Nyanza; and throughout Uganda
and Usoga 1 . The southern part of the Masai country was alone
free.
There is other proof that the pest must have been well established
on the east coast before 1899. Already at the beginning of January of
that year the medical officer in charge of the 4th Bombay Infantry,
then stationed in East Africa, reported to Bombay that the chigo
was firmly established at Mombasa 2 . It probably reached Zanzibar
about the same time, and a little later it appeared in Madagascar.
In a communication made to the French Academie de Medicine,
on Jan. 30th, 1900, M. Blanchard stated that the chigo had
reached that island some nine or ten months previously. It
was first seen on the west coast (nearest the continent) and its
appearance coincided with the arrival there of native troops,
Senegalese and Haussas, from the mainland. Owing to the
sandy nature of the coast it spread very rapidly through the
island and appears now to be definitely established there.
Asia.
The first known introduction of the jigger pest into
India in 1899 w a s traced to the return from Africa to Bombay
of the Indian regiment named above. That regiment left Mombasa on December 3rd, 1898, and in the course of the voyage
between Aden and Bombay 26 fully developed cases of chigo
were discovered among the men and followers. Many native
coolies returning in the ship were also affected by it, and subsequently some indigenous cases were reported from Bombay.
It is probable, however, that the insect had been imported to India
before this incident without being recognised. The alarm created
by its discovery led to a careful system of inspection of arrivals from
Africa, and in 1899 as many as 168 cases of chigo were found on
1
2

Three Years in Savage Africa, London, 1898.
Kilkelly, Indian Medical Gazette, April, 1899.

6l8

PARASITIC ARACHNIDS AND INSECTS

vessels arriving in Bombay. In 1900 this figure fell to 125 and
in 1901 to 46. Sir B. Franklin, to whom I am indebted for these
figures, writes to me that "before 1899 cases must have occurred
among the coolies returning from Africa, but so far as is known
without the pest establishing a foot-hold in this country ; and it is
doubtful if the damp coast districts to which the parasite would
first be brought are suited to the development of the larval stage.5>
The parasite does not seem to have spread beyond Bombay, and
this is attributed to the great range of temperature and the
monsoon-conditions to which the greater part of India is liable
and which are probably inimical to its naturalisation.
The marked diminution in the number of imported cases is
attributed to stringent measures to prevent the departure from
Africa of persons the subject of chigo, and to ensure'the prompt
recognition and treatment of cases developing during the voyage
or after arrival in India.
Factors determining the Geographical Distribution.
The chigo appears to thrive best in a warm, dry, sandy soil, and has
up to the present only been seen in countries with a high average
temperature. In America it is found exclusively between the
limits of 300 N. and 30 0 S. In Africa it is essentially a tropical—
almost an equatorial pest. In Asia it has at present only been
reported from tropical India. The future history of the insect
may show that it can exist elsewhere. Its diffusion over the
earth's surface seems to be principally, if not entirely, dependent
upon human movements. It has been transported by infected individuals over a whole continent in a few decades, in the wake of
explorers and traders; and within the last few years it has been
carried by sea across the Indian Ocean. On two occasions it
has been brought to Europe, though without in any way becoming
endemic here. The first occasion was in 1866 at Toulon, when a
sailor was found to be the subject of chigo, on board a ship which
had left Cayenne six months before.
The second instance
occurred in Paris, in a man who had arrived from Pernambuco.
Possibly the movements of animals may aid in its diffusion, for it
is said that not only human beings, but dogs, cats, and pigs, and
even birds and mice may harbour the insect.
It is almost certain that the habit of going about bare-footed
enormously increases the chances of becoming infected in a region
where the chigo exists. But the wearing of boots does not

PULEX

PENETRANS

619

ensure absolute protection. It is possible that, like the ordinary
domestic flea, the chigo may be carried about in clothing as well
as buried in the tissues. In Cuba there is a general belief that it
thrives and breeds in woollen garments, while a person dressed
entirely in cotton or linen is rarely troubled with it.
The chigo is usually most troublesome during the period
immediately after its fresh introduction into a country. It may
then attack so many persons as really to deserve the name of a pest,
and one of no little gravity. In Uganda, for example, for the
first two years after its introduction, "its ravages were so terrible
that it assumed the dimensions of a veritable plague. Many
hundreds of people lost one or more toes, and I should think"
(wrote the Principal Medical Officer to the Protectorate) "half
the population were temporarily incapacitated for longer or shorter
periods." Decle has described a village in Africa in which not a
single man, woman, or child was free from chigo ulcers. As time
goes on the chigo perhaps diminishes in numbers, or the people
learn to protect themselves from it, and the pest becomes much
less frequent and serious.

LIST OF PRINCIPAL AUTHORITIES.
GENERAL.
1.

Handbook of Geographical and Historical Pathology.
By D r
August Hirsch. (New Sydenham Society.)
2. Geographical Pathology.
By Andrew Davidson, M.D., F.R.C.P.
Ed. Edin. and Lond., 1892.
3. Hygiene and Diseases of Warm Climates.
Edited by Andrew
Davidson, M.D., F.R.C.P. Ed. Edin. and Lond., 1893.
4. Tropical Diseases. By Patrick Manson, M.D., LL.D. London,
1899.
5. Traite de Climatologie Medicate.
Par le D r H. C. Lombard.
Paris, 1877-80.
6. Traite Pratique des Maladies des Pays-Chauds. Par le D r Fernand
Roux. Paris, 1888-89.
7. Precis de Pathologie Exotique (Maladies des Pays-Chauds et des
Pays-Froids). P a r A. le Dantec. Paris, 1900.
8. Traite des Maladies des Pays-Chauds.
Par F. Brault. Paris,
1900.
9. Bulletin
de Vlnstitut
International
de Statistique.
Vol. X.
Rome, 1897.

EUROPE.
10.
11.
12.
13.

Annual Reports (and Supplements to Annual Reports) of the
Registrar-General for England and Wales.
Annual Reports (and Supplements to Annual Reports) of the
Registrar-General
for Scotland.
|
Annual Reports (and Supplements to Annual Reports) of the
Registrar- General for Ireland.
Annual Reports of the Medical Officer to the Local
Government
Boards and Supplements to the same.

LIST OF PRINCIPAL A U T H O R I T I E S
14.

15.
16.
17.
18.
19.
20.

21.

22.
23.
24.
25.
26.
27.
28.
29.

621

Statistique Sanitaire des Villes de France et dAlgerie,
pendant
Vannee 1898, et Tableaux Recapitulaiifs
des amines 1886-98.
Melun, 1899.
Annuaire Statistique de la Belgique.
Annuaire Statistique des Pays-Bas.
Stalistik Aarbog.
Copenhagen, 1899.
Statistik Aarbog for Kongeriget Norge.
1897.
Bidrag Till Sveriges Officiela Statistik (for ar 1896).
Annual Reports (in Russian) of the Medical Departinent of the
Russian Ministry of the Interior (from 1887, the year of their
commencement, to 1895). St Petersburg.
The Bashkirs: A n Ethnographical and Sanitary-A
nthropological
Investigation (in Russian). By D r P. Nikolski. St Petersburg,
1899.
Osterreichisches Statistisches Handbuch.
Wien, 1899.
Ungarisches Statistisches fahrbuch.
1897.
Statistisches Jahrbuch der Schweiz.
1899.
Annuario S talis tico Italiano.
1898.
Annuaire Statistique du Royaume de Serbie. Belgrade, 1898.
The Faroe Islands. By J. Russell Jeaffreson, F.R.G.S. London,
1898.
Colonial Hospital Reports for
Gibraltar.
Public Health Reports (Annual). Malta.

ASIA.
30.

31.
32.
33.
34.
35.
36.

37.
38.

Reports (mostly unprinted) to the Ottoman Board of Healthy
Constantinople, from Sanitary Officers in all parts of the
Turkish Empire (including European Turkey, Asia Minor,
Syria, Arabia, the Turco-Persian Frontier and Tripoli (Africa)).
Stalis tiki Kavkazskoi Patologii.
I. I. Pantiukhof. Tiflis, 1898.
Annual Reports of the Sanitary Commissioner with the Government of India.
Annual Reports of the Sanitary Commissioners with the separate
Governments of India.
Annual Reports on Sanitary Measures in India.
Transactions
of the 1st Indian Medical Congress.
Calcutta,
December, 1894.
The Western Rajputana States.
A Medico-Topographical
and
General Account of Marwar,
Sirohi, and Jaisalmir.
By
Lt.-Col. A. Adams, I.M.S. London, 1899.
Ceylon Administration
Reports.
Reports of the Principal Civil
Medical Officer and Inspector-General of Civil Hospitals.
T h e Straits Settlements. Medical Reports (Annual).

622
39.
40.
41.
42.
43.
44.

LIST OF PRINCIPAL

AUTHORITIES

Labuan. Colonial Hospital Report (unprinted).
Five Years in Siam.
By H. Waringtoh Smyth, M.A., LL.B.
London, 1898.
Medical Reports of the Imperial Ma7'itime Customs of China.
Hongkong. Principal Civil Medical Officers Reports (Annual).
The Chinese; their Present and Future, Medical, Political, and
Social. By Robert Goltman, Junr., M.D. 1891.
A nnual Report of the Central Sanitary Bureau attached to the
Home Departme?it of the Imperial Japanese
Government.
Tokio, 1897.

AUSTRALASIA.
46.
47.
48.
49.
50.
52.
53-

Annual Reports of British New Guinea.
''
Queensland. Reports of the
Registrar-General.
New South Wales. Annual
Reports.
Victoria. Reports of the Board of Public Health.
South Australia. Statistical
Registers.
Western Australia. Statistical
Registers.
Tasmania. Central Board of Health Reports.
Statistics of New Zealand.
1898.
Blue Book of Fiji.
The Solomon Islands and their Natives.
By H. B. Guppy, M.B.,
F.G.S., late Surgeon R.N. London, 1887.

AFRICA.
55.

Egypt. Reports, Statistical and Medical, of the Ministry oj the
Interior.
Cairo.
56. La Tunisie.
Histoire et Desc?'iption.
L'Association Franchise
pour Pavancement des Sciences. Paris et Nancy, 1896.
57. The Arab and the African.
S. Tristram Pruen, M.D. London,
1891.
58.' Sierra Leone. Colonial Hospital
Reports.
59. Lagos. Colonial Hospital
Reports.
60. Gold Coast Colony. Sanitary and Medical Reports.
61. Gambia. Colonial Hospital
Reports.
62. Congres National d'Hygiene et de Climatologie Me'dicale de la
Belgique et du Congo, 1897. Comptes Rendus.
63. Cape of Good Hope. Reports on the Government and Stateaided Hospitals and Asyhims.
(Including Reports on the
Public Health, etc.)
64. Reports of the Durban
Hospital.

LIST OF PRINCIPAL A U T H O R I T I E S
65.
66.

Mauritius. Reports of the Medical
Inspector.
St Helena. Colonial Hospital Reports (unprinted).

NORTH
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
yy.
78.
79.

AMERICA.

Reports of the Board of Health of the Province of Quebec.
„
„
„
„
„
„
Nova Scotia.
„
„
„
„
„
„
New
Brunswick.
„
„
„
„
„
„
Manitoba.
„
„
„
„
„
„
British
Columbia.
„
„
„
„
„
„
Ontario.
Public Health Reports.
Issued by the Supervising SurgeonGeneral, Marine Hospital Service. Washington.
Mortality Statistics in the United States for the year 1897.
Transactions
of the Congress of American
Physicians
and
Surgeons.
Washington, 1894.
2 5 th A nnual Report of the Health Department of the City of Boston,
28th Annual Report of the State Board of Health of Massachusetts. 1897.
Annual Report of the State Board of Health of the State of
Michigan.
1897.
The Principles and Practice of Medicine.
By W. Osier, M.D.,
LL.D., F.R.S. Edinburgh and London, 1901.

CENTRAL AMERICA A N D
WEST INDIES.
80.
81
82,
83
.84.
85
86,
87
88,
89,
90.
91
92,

623

THE

British Honduras. Report of the Colonial Surgeon.
1899.
Guatemala. Annuario Estadistico.
1898.
Jamaica. Reports of the Island Medical
Department.
Grenada. Reports of Medical Officers.
Bermuda. Reports of the Medical Officer of Health, and of the
Registrar- General.
Virgin Islands. Annual Reports of the Commissioner.
Antigua. Reports of the Registrar-General. *
St Lucia. Annical Reports on the Hospitals and
Sanitary
Institutio?is.
Bahamas Blue Book.
St Vincent. Medical Reports.
Barbados. Reports of the Poor Law Inspector.
Leeward Islands. Colonial Hospital
Reports.
Trinidad. Annual Reports of the
Surgeon-General.

624

LIST OF PRINCIPAL

SOUTH
93.
94.
95.
96.
97.

AUTHORITIES

AMERICA.

British Guiana. Colonial Reports.
British Guiana. Annual Reports of the
Surgeon-General.
Anuario Estadistico de la Provincia de Buenos Aires, ano 1897.
La Plata, 1899.
Anuario
Estadistico
de la Republica Oriental de
Uruguay.
Montevideo, 1898.
T h e Falkland Islands. Colonial Reports.

CAMBRIDGE : PRINTED BY J AND C. F. CLAY AT THE UNIVERSITY PRESS.