1140 THE PLAGUE AND ITS DANGERS.

THE LANCET.

LONDON: SATURDAY, APRIL 21, 1900.

LAST year plague prevailed in Alexandria and Oporto andcaused a spasmodic interest in the subject which quicklysubsided as soon as the epidemic [in both centres declined.Similarly when plague first appeared in India the interestin Europe bordered on alarm until the conference of

the Powers at Venice framed regulations to preventits importation into other countries. Since then plaguehas slowly pursued its own course and has spread in

many directions in spite of the Venice Convention and

other means for its control. Plague continues its

ravages in India and destroys at present nearly 5000of its inhabitants every week. Still, so little accustomed

are the English people as a whole to take an interest

in the welfare of that great dependency, unless it is

brought home to them in some exceptional manner, that theenormous mortality does not arrest any particular attention.The distance from India, the comparative immunity of theEuropean, and the absorbing interest of the war in SouthAfrica have contributed in no small degree to intensify anindifference which everyone who has followed the effects of

the plague must deplore. The plague has now existed in

India for five years, has destroyed over 250,000 lives, andshows not the slightest tendency to abate its fury. It has

caused unrest and disturbances in important centres of Indiabecause of the preventive measures which have to be

adopted, and only last week the military had to be calledout to quell a serious riot in Cawnpore, the rioters having setfire to the segregation camp and thrown the bodies of five ofthe policemen who opposed them into the flames. The multi-

plication of centres is apt to become a political danger.Disorder is the ordinary accompaniment of great epidemicsof plague and is as likely to occur in Europe as in India. The

comparative immunity to plague of Europeans in India is

responsible for a very comforting though curious impressionthat plague is a disease of Asiatics. The occurrence of plaguein Oporto tended to shake this belief, but the decline

of the epidemic there, without attaining any great size,notwithstanding the exceptional character of the sanitarycondition of Oporto, once more strengthened this hypothesis.The outbreak of plague in Sydney is sufficient to dispelnotions of this kind. Unlike Oporto, it is not an old townand in this respect has an advantage. It possesses also a

well-organised sanitary department, and yet notwith-

standing the active and watchful care of Dr. ASH-

BURTON THOMPSON and his able staff plague has

gained an entrance and a lodgment. In Januarya lorry-driver was attacked by a mild and anomalous formof the disease and recovered. In a little over three weeks

a sailmaker was attacked and died on the eighth day, andat the same time it was reported that a greater numberthan usual of dead rats were to be seen at a certain

wharf. The sailmaker had removed five dead rats from his

water-closet shortly before his attack. As elsewhere,the mode of importation of plague into Sydney has

not been traced. Careful inquiry instituted by Dr.ASHBURTON THOMPSON takes it no further than the

landing wharves, but no light can be thrown on its

source or as to whether the infection was brought byman, by goods, or by rats. Every endeavour is being madeto stamp out the disease ; the success hitherto attained has,unfortunately, not been altogether as desired, and the

ominous fact remains that in spite of the most rigorousinspection and other port arrangements, in spite of the

recognition of early cases and their removal to hospital, andin spite of a crugade against rats, plague has attacked asmany as 90 persons, has caused 23 deaths, and after threemonths’ endeavour to stamp it out is still a source of anxiety.So far as an opinion can be formed at this stage Sydney is

not a town the conditions of which render it specially liableto be attacked with plague. Its situation, general construc-tion, and its sanitary organisation are all in its favour. The

danger lies in the disease becoming disseminated in partsof Australia less ready to defend themselves against its

invasion and in those parts which have suffered from

drought. We see that the different health authorities are

appreciating the gravity of the fact and that the health

officers have met in consultation. Special attention will nodoubt be paid to rats and we trust that it will not be

forgotten that other rodents are liable to the disease. The

rabbits which in’est Australia will, we hope, not be lostsight of as a possible source of danger.The experience of Sydney is not calculated to inspire

confidence as to the invulnerability to plague of Europeantowns or the sufficiency of the methods now in vogue tomeet an epidemic. Without being pessimistic it is well to

recognise the true nature of the situation. A good deal hasbeen learnt about plague since it started in China, thanks

mainly to savan’s who do not bear English names andwho have worked unceasingly at the problems presented,but much more apparently has still to be learnt

before the protective measures now practised are whollyeffective. While making use of what is known we should be

glad if more attention were paid to that which is not known.It would, we ft el sure, serve a most useful purpose. It

seems as remarhable as it is unintelligible that the onlyEnglish Scientific Committee to investigate plague was

appointed at the commencement of the Bombay epidemicin 1896,and that its work was completed in six months.

Since then there is ample evidence to prove that we

are supremely ignorant of the means of the diffusion

of plague, and yet all these years have been lost in treadingthe old paths without attempting to search for others thatmay be new. Even when the plague broke out in Oportoit was not thought to be serious enough to demand an

investigation into its methods of spread. This state of

lethargy which appears to be constitutional in England will,we fear, have a rude awakening. It will not be because

of the absence of warnings. The insidious character

of the plague, the pandemic powers which evidentlybelong to it, and its progressive extension have been

persistently pointed out by Professor W. J. SiMPSOK’

on many occasions. Last year we gave prominence to

1141THE BRITISH CENSUS, 1901.

his address before the Sanitary Institute on the recrudes-cence of plague in the East and its relation to Europe,and in THE LANCET of April 14th we published an im-

portant address by him on the subject to the South-West

London Medical Society. In these and other papers he

has always urged that side by side with the ordinary I

measures there is an absolute necessity for scientific

research, declaring that it is only by continued investiga-tion on systematic lines that we are likely to discover

further means of securing protection. Plague is the same

as it always has been, and the only safe course is not

to shut our eyes to its power and to our provedinefficiency of defence but to prepare beforehand for

eventualities by sparing no pains or expense in ascertainingthe tactics of the enemy. This is necessary in the interests

of England and her colonies, but there are special reasonsthat it should be done for the sake of South Africa. For

should plague gain a foothold in any of its towns, as it

has done in Sydney, the drought of the summer and autumn,the large armies in the field, the misery caused by the warand the pestilential condition of the battlefields are factorswell known to influence the rapid spread of the disease.

THE Act making provision for next year’s census in

England and Wales and Scotland having received royalassent, it is now possible to discuss the points in whichthe Act differs from the Acts that provided for precedingcensuses in England and Wales and Scotland. In the first

place, however, it is necessary to notice, with serious

regret, that the Act for the usual decennial census does

not make provision for that simple intermediate census

which year by year becomes increasingly necessary in orderto assure approximate accuracy and trustworthiness to theperiodical returns of vital statistics issued by the Registrars-General for England and Wales and Scotland and bymedical officers of health for counties, county boroughs, andother Local Government areas. Notwithstanding the urgentappeal of the Royal Statistical Society, supported by collec-tive representation from associations of medical officers ofhealth, actuaries, and county councils, all interested in, and

qualified to approach the Government on, this subject, thePresident of the Local Government Board, while expressingsympathy with the desire for a quinquennial census, intro-duced the Bill without any attempt to meet the generalappeal for a simple enumeration of the population (withdistinction of sex and age) in 1906, mid-way between theusual decennial census in 1901 and 1911. Sir FRANCIS PowELL

gave notice of amendments to the Bill on the second readingin the Commons, with a view to provide for this inter-

mediate census, but they were ruled out of order, and oncemore through the apathy of the Local Government Board,on a matter of real, though indirect, importance for thepromotion of public health, the realisation of a quin-quennial census is relegated to the off-chance of convincingthe President of the Local Government Board in 1905 that

the very moderate expenditure involved in a simple enumera-tion in 1906 would, from a public health point of view, bedistinctly remunerative by strengthening the efforts of localauthorities in the acceleration of sanitary progress.The Census (Great Britain) Act, 1900, apart from the fact

that it provides for the census in England and Wales and

Scotland, whereas in 1890 two separate Census Acts were

passed, is identical in all essential provisions with

previous Acts, although in drafting it has been con-

siderably simplified with advantage. The new Census

Act leaves the Registrars-General of England and Walesand Scotland with a freer discretiop as to the method

of dealing with the householders’ schedules and the

subsequent tabulation of the results. It will thus

be possible to adopt the card system of tabulation

in place of the previous system of making ticks

on elaborate abstract, sheets. Judging by the experi-ence of foreign countries and of some of our colonies,the card system not only tends to expeditious, accurate,and economical tabulation, but it opens up possibilitiesof additional combinations of statistical facts which the

older system does not afford. Among the minor improve-ments in the Act, compared with preceding Census Acts,may be noted the following, mainly due to the suggestionsof the Royal Statistical Society. An attempt will for thefirst time be made to ascertain the nationality of personsborn abroad. There is also an instruction to record, withreference to houses uninhabited on the census night, whether

they are occupied or unoccupied, that is, whether they are orare not on the rate-books. An additional clause in the Act

under notice has especial interest for medical officers of

health. This clause provides that the Registrar-Generalmay, at the request and cost of the council of any county,borough, or urban district, cause special abstracts to be

prepared, containing statistical information derivable fromthe census returns and not included in the published CensusReport, which in the Registrar-General’s opinion the

council may reasonably require. The card method of

tabulation would materially facilitate the preparation of

these supplementary local returns which would in manycases be invaluable to medical officers of health in the

prosecution of special investigations.In response to an urgent appeal of the Registrar-

General, supported by memorials from the Royal StatisticalSociety and other scientific associations interested in censusmatters, the Act just passed will allow of more time forpreparatory measures than has on previous occasions been

afforded, as the Census Acts have not usually received royaassent until the close of the session in the year precedingthe census year. The four additional months available

for preparation on the present occasion will afford

invaluable opportunity for well-considered revision of

the sub-division of the country into enumeration dis-

tricts, with due regard to the boundaries of the various

local areas, which revision will much facilitate the

final tabulation of the results of the census. It is there-

fore reasonable to hope that the report upon the census of1901, dealing with its results, may be available at an earlierdate than was found possible on previous occasions, as it isobvious that the value of a census depends to a large extent

upon the promptness with which its results can be made

available for national and local statistical purposes.

THE rejection of the Bill introduced by the London

County Council for the purchase of the metropolitanwater companies’ undertakings leaves with the Govern-

ment the responsibility of daaling with the uestion. But

1142 THE CONTROL OF THE LONDON WATER-SUPPLY.

in a Parliamentary session like the present one, in whichso much time must necessarily be occupied by questionsreferring to the war, it would probably be impracticable forthe Government to devise a scheme embodying everythingrecommended by Lord LLANDAFF’S Commission’s Report andto bring in a Bill which would have any chance of passing.The Government cannot be advised at the present junctureto deal with the question of the formation of a new

Water Board or the purchase of the metropolitan water

companies’ undertakings. To any such proposed legislationwhenever brought forward a great many objections will

be forthcoming from the authorities of the districts

affected, whose interests are not only not identical but

are often opposed to one another. We do not hesitate

to say that a Bill intended to give effect to all the recom-mendations of Lord LLANDAFF’S Commission with regardto the formation and composition of a Water Board wouldmeet with the strongest resistance, and whatever may

be the justice of that resistance it is clear that at the

present time the Government could not deal with it. There

are, however, recommendations in Lord LLANDAFF’S Com-mission’s Report which deserve, and would meet with,general approval on the part of all the water consumers

of the metropolitan district. These recommendations refer

to the question of "control "-that is, to the placing ofthe present metropolitan water companies under a more

efficient and thorough condition of supervision bythe Local Government Board. Whether the companies areallowed to continue to supply water in the future as theyhave in the past, or whether their businesses are bought upby a Water Board, the measures of control recommended byLord LLANDAFF’S Commission’s Report should, in the opinionof the Commission, be carried out. And to our mind there

is no reason whatever why there should be any delay in

passing an Act which will be of use in either case. Mr.

CHAPLIN has recently pointed out that although Lord

LLANDAFF’S Commission’s Report has been issued the

evidence has not been published. This should not be made

a pretext for delay.We may mention some of the directions in which control

is urgently called for. The Act of 1871 which providedfor the appointment of a Water Examiner to the Local

Government Board made no provision that he should havethe right of entry to the works of the companies. Anyinspection, therefore, which he makes is done by the11 courtesy " of the companies. The Water Examiner oughtto be able to enter any works of the companies at any timeas a matter not of courtesy but of right. He will then

be able to ascertain the cause of any defect with regardto the filtration of the water. And he should have powerto make regulations as to the construction of filter-

beds and their effluents; for example, each filter-bed

should have a separate filter-well so that a samplecan be taken at will and the results of filtration in each

bed determined, while the rate of filtration oughtalso to be automatically recorded. The examinations

of the filtered water should be more frequently made, andthe work should be done by men appointed by the WaterExaminer. The companies which obtain their supplies from

deep wells should be compelled to keep an accurate recordof the height of the water in the wells and of the amount

which is pumped daily. It is very important that this byno means new suggestion should be acted upon. As longago as the year 1893 Lord BALFOUR’S Commission reportedin favour of this measure of control and Lord LLANDAFF’SCommission concurs in the recommendation. There is no

excuse for further delay in giving statutory power to carryit out. It may be worth while to quote the exact words givenin Lord BALFOUR’s Commission’s Report. " We think it of

very great importance," says the Report, "that distinct obli-gations should be laid upon any company or local authoritywhich is allowed to pump water from the chalk for purposesof public supply to keep accurate observations of the

effect of their operations on the level of the water in thewells from which they pump and to return the results to thewater examiner under such regulations as may be framed.The great difficulty which we have had to encounter

has been in getting accurate and reliable information asto the actual effect of the operations now carried on. The

importance of procuring this will increase each year as thelimit of what can be taken from any district with safetyis gradually being reached." Had this recommendation been

carried out when it was made nearly seven years ago we

should now be in possession of facts which would be of the

greatest use in helping to estimate the quantity of waterwhich the chalk formations near London are, and are likelyto be, able to supply.

There is another point which deserves the early attentionof the Government. Although this was not brought beforeLord LLANDAFF’S Commission we think well to notice

it in this place, especially in view of the increased

duties which will be thrown on the Water Examiner

when he is properly provided with facilities to do his

work. Under the Act of 1871 provision for the paymentof the salary of the Water Examiner was imposed onthe metropolitan water companies. It is obviously unfair tothe companies that they should have to pay, or even con-tribute towards the payment of, an ojBEher who is speciallyappointed to keep them up to their duties. The sum con-

tributed by each company is doubtless small, but that doesnot attect the principle of the question. Again, it is

derogatory to the position of so important an official as theWater Examiner to the Local Government Board that his

salary should be paid by a number of trading companies.At the present time the Water Examiner is obliged to relyfor his statistics upon the figures supplied to him by the

engineers and other officials of the metropolitan water

companies. The reports of some of the experts which he

publishes in his official record are made not by his own

employes but by gentlemen chosen by, and paid by, the

companies. The Water Examiner should have the power of

obtaining directly all the information which he requires forhis reports and the work should be done either by him-self or by subordinates appointed by, and responsible to,him and these subordinates should be paid not by the

metropolitan water companies but by the Local GovernmentBoard. There may be, and perhaps naturally, an objectionon the part of the Treasury to increase expenses in this way,but in a matter of such very great importance parsimonyis entirely misplaced.The Act of 1871 brought into force another unsatisfactory

arrangement which needs immediate amendment. Under

1143THE ROYAL ARMY MEDICAL CORPS SOUTH AFRICA FUND.

this Act an auditor was appointed by the Local GovernmentBoard to examine the accounts of the water companies.But under this Act it was provided that should one of

the companies feel aggrieved by a decision of the Auditor

the matter in dispute is to be referred to arbitration,when the Auditor himself out of his own pocket has

to fee counsel and pay his own costs. This is really amonstrous iniquity. In the Report on this matter

Lord LLANDAFF’S Commission says: "We think that

provision should be made for paying the expenses of the

Auditor out of public moneys, as he is a public officer ; andthat he should not be discouraged from asserting his views,in opposition to the companies, by the prospect of being outof pocket if he does so." The Auditor is paid from the samesources as is the Water Examiner-that is to say, his salary isobtained from the water companies, and although the moneyis paid to him through the Local Government Board thefact remains that he is actually paid by money derived fromthe profits of the water companies which are privatebusiness speculations. We are strongly of opinion that allthe officials appointed to supervise the London water-supplyshould be paid entirely out of Government funds. It is a

most undignified arrangement that persons holding positionsof such power and responsibility should be paid in the wayat present arranged.We have no doubt that a Bill containing provisions

necessary to increase the power of control of the Water

Examiner to the Local Government Board in the respectswhich we have mentioned and at the same time to

arrange for the payment of the officials from publicfunds would be supported from both sides of the

House. The question of the London water-supply is one

of really national importance and party politics cannot

properly be intruded into a matter which is intrinsicallyabove the considerations of class and of party interests.

The attempts which have been made in the past to

make party capital out of the London water question will

’be rendered entirely futile in the future if the President of

the Local Government Board will consider the question onits merits and will introduce a Bill which is obviously forthe public good.

Annotations.

THE ROYAL ARMY MEDICAL CORPS SOUTHAFRICA FUND.

II Ne quid nimis." "

THE third circular just issued in connexion with this fundcontains some information which will be found both usefuland interesting to those who are taking any part in pro-moting its excellent design and objects. In the two

previous circulars an account of the formation and objectsof the fund was given. The present circular is in-tended partly as a report from the Executive Committeeto the subscribers, while at the same time advocatingstill further the claims of the non-commissioned officersand men of the Royal Army Medical Corps. The fund

supplies comforts to those attending on the sick andwounded only and has obtained, we are glad to say, themost generous support from all classes, obieny from themedical profession. The subscriptions received by thetreasurer amount to Z1795 6s. 6d., to say nothing of the

consignments of clothing and gifts in kind frorfi all

quarters. The office in Victoria-street having proved incon-venient in many ways has been removed to 77, George-street, Portman-square, W., where all communications areto be addressed in future. Gifts in kind and all inquiriesare to be directed to the honorary secretary at this address.The first list of subscribers to the fund appeared in the

Times of Feb. 27th and a second will be published shortly.The method of procedure in the distribution of thefunds and gifts and the nature of the further require-ments are clearly set forth in the circular togetherwith a list of those articles mentioned in a despatch fromLord Roberts as being most needed for the approaching coldweather. Mrs. Skey Muir, the wife of the Deputy Director-General of the Army Medical Service, is kindly acting ashonorary secretary. Cheques should be made payable to theRoyal Army Medical Corps South Africa Fund and crossedHolt and Co. Subscriptions are to be sent to the honorarytreasurer, Mrs. Charters Symonds, 58, Portland-place, W., orto Messrs. Holt and Co., 3, Whitehall-place, S.W. It isneedless to add that the object of the fund has our entiresympathy and support and that we wish its promoters everysuccess in their excellent and humane undertaking.

HEMIPLEGIA IN SCARLET FEVER.

AT the meeting of the Société Medicale des Hopitaux ofParis on March 16th M. Ferrier related two cases of

scarlet fever complicated by hemiplegia. This compli-cation is exceedingly rare. Dr. Foord Caiger does not

mention it in his article in "Allbutt’s System ofMedicine" which contains an analysis of the complica-tions met with in 4015 cases of scarlet fever in the

South-Western Fever Hospital. In the first case a soldierhad a very severe attack of scarlet fever which beganon Dec. 15th, 1898. It was attended with great pyrexia,extreme rapidity of pulse, prsecordial distress, and dyspnoeawithout pulmonary lesions. On the fifth day, however, hewas better and the disease seemed to be running a normalcourse; but suddenly on the seventh day an apoplecticseizure took place. It was attended by unconsciousness andcomplete left hemiplegia with early and transient rigidity.The coma passed off on the third day, but the hemiplegiapersisted. After a tim the hemiplegic symptoms slightlyimproved and hemianagsthesia, which was at first com-

plete, partly disappeared. In April, 1899, he was dis-

charged from hospital convalescent. When seen againin August the left arm was contracted in semiflexion,the forearm was flexed at right angles to the arm,and the fingers were bent on the palm. The patient couldnot perform any movement of the fingers, wrist, or elbow,and could only slightly raise the arm from the side. Thelower limb was in the position of extension ; movements ofthe toes and ankle were impossible ; the knee could be

slightly flexed and the thigh considerably. Walking wasperformed with difficulty. The left side of the face was alittle smoother than the right and the asymmetry was

exaggerated on laughing. The paralysed limbs were slightlyatrophied, showed some cyanosis, and were of lower tempera-ture than on the other side. The tendon reflexes were in-creased on the left side and the plantar reflex was extensor "

(Babinski’s sign). Sensibility was present, but there wasdifficulty in localising sensations and in recognising the

position of the limbs. In the second case a soldier had a

sore throat on Dec. 21st, 1898, and entered hospital withscarlet fever on the following day. The disease ran an ordi-

nary course until Dec. 27th, when an attack of apoplexy verysimilar to that in the first case occurred. There was

complete left hemiplegia, but the coma was not so pro-longed. After some weeks movement and sensibility re-

appeared in the left leg and the patient could walk withoutQ 4