THE FORGOTTEN OF ELLIS ISLAND
Deaths in Quarantine, 1909-1911

How We Guard Against the Introduction of Cholera

Where the Scourge Originated and How the Government Copes With It
When It Gets to These Shores
Dr. Doty Explodes Some Erroneous Beliefs on the Subject of the Dread Disease

The development of a few cases of Asiatic cholera in the Government's hospitals in Now York Harbor, as the result of infection brought here from abroad, has resulted in calling to public attention two intensely interesting discoveries made in recent years in connection with the disease.

The first is that the ailment is not nearly as likely to spread in centres where it is not actually epidemic as has generally been believed heretofore; the second is the fact that there are persons who are "cholera carriers," accounting in many instances for a longer incubation period than the formerly accepted one, which was from a few hours to five days.

These gains in knowledge should have a most reassuring effect on the public mind. It has been learned that cholera is not carried along by the wind; and persons who have been in the vicinity of cholera patients do not carry the germs of cholera away with them in their clothing unless such clothing has been contaminated by infected discharges from the sufferers.

The disease must be taken in through the mouth, so that, although extremely virulent and fatal, it is only infectious in the same manner in which typhoid and some of the other fevers are transmissible.

While there is little danger of the disease spreading here, it must be admitted that the situation in Europe is the cause of grave anxiety at present. It may be said, on the strength of information received by the Federal authorities, that there is a greater prevalence of cholera throughout the world in regions where the epidemic usually makes its appearance than has occurred for some years.

The principal menace this summer, according to Surgeon General Wyman of the United States Public Health Service, is from Italian ports, although many cases have been reported in Russian cities an well. The Surgeon General also says that this country has never been in better shape to get prompt information of new cases and to prevent cases coming into this country.

The announcement was made at a meeting of the Academy of Medicine in Paris on July 12 that two international congresses, those on tuberculosis and dermatology, scheduled for the end of September in Rome, had been postponed until next spring on account of the cholera epidemic in Italy.

Advices from Italy on the same date indicated that the epidemic had suddenly grown more serious owing to a sharp rise in temperature. Numerous cases of the disease were reported from Naples, Venice, and Genoa.

The recognition of a class of persons known as "cholera carriers" has resulted in a determination to extend the detention of all persons suspected of having been in direct contact with the disease until its presence or absence can be certified to after searching bacteriological tests. This extended detention period goes a long way toward eliminating the danger of permitting the disease to gain a foothold within our gates.

The few cases of cholera brought to this port in recent weeks and the deaths at Hoffman and Swinburne Islands, the Government's isolation stations, are not enough to justify the birth of a panic as the result of the outbreak. It is to be expected that, in spite of rigid quarantine in foreign ports, patients suffering from the disease will arrive by ones and twos occasionally, especially when there are real epidemics in some sections of Europe.

The splendid disease-fighting machine built up by Dr. Alvah H. Doty, the Health Officer of the Port, in his long years of service has kept this city, and to a large extent, the entire country, remarkably free from imported contagion, and this tends to give assurance that the city will escape with little injury as the result of the presence of cholera in the lower bay.

Dr. Doty's quarantine work has placed him in the front rank of sanitarians, and has earned for him the respect and admiration of physicians throughout the world.

The Appleton's have published recently a book by Dr. Doty on "Prevention of Infectious Diseases." This work contains a chapter on cholera embodying instructions to safeguard against the development and spread of the disease, and the methods or treatment advocated by the author and the United States Government.

"Apparently what we have recently learned in regard to cholera," Dr. Doty writes, "would show that our defense against it is much weaker than we have hitherto believed. This is not the fact. There is an extremely optimistic side to this subject, and one which has practical end scientific support."

"The belief has long existed that the ravages that cholera and other infectious diseases have caused in the East are indicative of what would occur if these diseases were to enter any community. This has been the keynote of the statements frequently made by alarmists. This belief is without any reasonable or logical foundation whatever, and it may he safely stated that where modern sanitary regulations are in force such condition's will never occur."

"On the contrary, in the absence of a general infection cholera does not extend rapidly and where proper sanitary regulations are in force should soon disappear."

The spread of cholera abroad is earlier this year than in previous cholera years. The immigration from Italy is so much greater than from any other country where the disease is likely to become epidemic that the Public Health Service has concentrated its inspection there.

The effort to guard against this source of infection began last July, when the five days' detention of steerage passengers for this country was resumed at European ports.

In September last, on account of the prevalence of the disease in Russia, and the report of its appearance in Italy and Germany, the Consular officers at Marseilles, Havre, and Cherbourg. France, and Genoa, Palermo, and Messina, Italy, were instructed to detain passengers from all parts of Russia and disinfect their baggage. From that time until now some of the best Surgeons of the Public Health service have been on duty in Italy watching the disease.

Surgeon H. D. Gettings and Passed (sic) Assistant Surgeon W. W. King are stationed at Naples, and have several Acting Assistant Surgeons under them who watch Messina and other places where eases have occurred. Surgeon J. M. Eager is stationed at Palermo, and has assistants under him watching various points.

The reports from these officers indicate that the disease has not been materially checked, and that there is still danger of cases developing among passengers from some of these ports.

The latest information shows that cholera has appeared in Greece and the Consul General at Athens telegraphs that a case has been reported at Laurium in Attica, ten miles south of Athens. The health authorities think it came from Italy.

In response to orders cabled to Passed (sic) Assistant Surgeon King at Naples, directing him to report the total number of cholera cases and deaths at Naples from the beginning of the present outbreak, June 8, to date, and to give the same information for the rest of Continental Italy, Palermo, Messina, and for Sicily, exclusive of Palermo and Messina, and hereafter to report new cases and deaths every five days, and to also report the sailing of vessels, the following was received:

"Have just received official bulletin of July 6. Totals-Naples, 216 cases and 68 deaths; rest of Continental Italy, 374 cases and 116 deaths: Palermo, 282 cases and 75 deaths; Messina, none; rest of Sicily, 27 cases and 11 deaths; Principe Piemonte sailed July 6 for New Yolk."

It would be difficult to gain a comprehensive knowledge of cholera and its prevention more readily than by referring to Dr. Doty's article on the subject. The following extracts are taken from it:

"The appearance of cholera either on shipboard or on land calls for greater care in the isolation of those sick with the disease, the detection of the medium of infection, the disinfection of the excreta and the effects of the patient and the treatment of those under observation than in the case of any other infectious disease.

"The source of infection where serious outbreaks occur is usually a common one and under these circumstances the disease is apt to spread with great rapidity. Fortunately, however, in communities where proper sanitary conditions exist and on modern passenger steamships there is practically but little danger of a general cholera infection due to an infected water supply.

"Those living in a community where cholera exists may escape infection by observing certain simple precautions relating to food and drink, cleanliness, etc.

"Cholera is not contracted in the same manner as smallpox, measles, etc., but through the mouth, by infected food or drink containing the specific organisms of the disease, or by the hands or articles contaminated by discharges from the intestinal tract of those who are carriers of this organism.

"Upon the appearances of cholera the most extended and exhaustive investigation should be made to discover the medium of infection; this course is imperative and unless it is carefully followed out the outbreak will not be successfully controlled. The influence or the fomites theory regarding the means of infection is still apparent in connection with this disease, and clothing, baggage, letters, etc., are frequently referred to as media of infection.

"There is no practical or scientific support for this belief if clothing directly contaminated with intestinal discharges is excluded. The acceptance of this theory may very seriously interfere with an early detection of the real cause of the out break.

"The danger of the introduction of cholera from one port to another is not so much by typical cases (which are usually easily detected) as the mild or irregular ones, which often pass unrecognized. Cholera may appear in the form of a simple diarrhœa which excites little or no suspicion, or it may appear in a more obscure manner, and simulate some other affection.

"Furthermore, cholera is not infrequently transmitted from one place to another by well persons known as carriers, who may act as a medium of infection without presenting any symptoms of the disease. This has an exceedingly important bearing in the consideration of the means by which this disease is transmitted.

"While certain articles of food or drink brought from an infected district may contain the specific organism of cholera and may subsequently act as media of infection, there is reason to believe that this is not of very frequent occurrence.

"All vessels arriving from cholera-infected or suspected districts having on board even mild cases of diarrhœa, or those who are ill with an affection the diagnosis of which cannot be clearly defined or in which cholera cannot be excluded, should be held until a specimen is obtained and subjected to a bacteriological examination.

"Neither the vessel, passengers, nor crew should be released, nor should any one be allowed to board the vessel except the Quarantine staff, until the bacteriological examination is completed and a favorable report presented. The statement or explanation of the patient, the ship's surgeon, or any one else on board regarding the cause of the sickness should never be accepted in lieu of this precaution, no matter how plausible it may be.

"This course should also be followed on any incoming vessel where a passenger or member of the crew presents symptoms suspicious of cholera, even though the vessel may come from a presumably non-Infected area, for certain places may become infected and persons depart from them before the disease is officially recognized.

"It is as a rule difficult to properly isolate cholera patients on shipboard and to keep under observation those who have presumably been exposed to infection. Moreover, thorough disinfection cannot be thoroughly carried out while passengers and crew remain on the vessel, as the appearance of secondary cases always calls for a repetition of the latter treatment.

"Therefore, when a vessel on which cholera has occurred arrives at Quarantine, the patient and those held for observation should be promptly removed, except in some special instance where their detention on the vessel is justifiable, otherwise an indefinite, expensive, and avoidable delay to commerce may result.

"No condition ever occurs on sea or on land where more thorough disinfection is called for than in the presence of cholera. The exact details of this work cannot be specified, as the requirements differ in each instance. On shipboard the extent and the character of disinfection required depend chiefly upon the source of infection, whether this occurred before departure or afterward.

"If infection occurred before embarkation and the case was promptly recognized and isolated, the disinfection required is far loss important than in instances where there is reasonable evidence that an infected centre exists on the ship in the form of a contaminated water or food supply.

"The disinfection is very mulch simplified if it is understood that cholera is contracted only through the mouth by contaminated water or food, or by the hands or articles which have been in contact with the intestinal discharges of cholera patients, and not by the general supply of clothing, bedding, etc.

"The only clothing which needs attention is that belonging to the sick and possibly to those in close and prolonged contact with the patient. The clothing, baggage, and effects of others on board and also the vessel's cargo need not be disinfected or disturbed.

"Water tanks should receive the most careful consideration and should be disinfected and emptied if there is the slightest evidence of their being the source of infection. However, there is but little danger of this on modern passenger vessels.

"Great care should be taken by quarantine officers and their employees in the removal of a case of cholera from an incoming vessel, and in disinfection, etc., to avoid contracting the disease themselves and transmitting it to others. They should neither eat, drink, nor smoke on board, in order to avoid mouth infection. Subordinates are apt to become careless about these details and should therefore always work under the careful observation of a medical officer.

"Rubber gloves, and also stiff-back rubber overshoes which can be removed without using the hands and which are to be disinfected with boiling water each time after use, should be worn by quarantine employees while disinfection is being performed. The importance of protecting the hands while dealing with cases of cholera cannot be overestimated.

"In treating certain diseases of the first class at Quarantine, it is frequently deemed proper to allow some of the passengers or crew who are well, and who can be depended upon to obey instructions, to proceed with the ship to its destination. However, in the presence of cholera, this should be confined to the cabin passengers, and they should he released only in instances where there is no evidence of ship or general infection and when there have been no cases or suspicious cases in their part of the vessel.

"For disinfection in the apartment of cholera cases nothing equals boiling water; it is clearly the most valuable agent that can be used. The special advantages of this agent is its absolute certainty and rapidity of action-its availability and absence of danger and expense. A receptacle for boiling water can almost always be improvised with little or no expense.

"Although it is believed that the ordinary period of incubation of cholera is from one to five days, recent investigation has conclusively shown that an indefinite and prolonged period may intervene between the time when the specific organism is taken into the system of a person and the appearance of the symptoms of the disease. Furthermore, persons known as carriers, in whose intestinal tract the organism is present, may act as media of infection and transmit the disease to others and still remain well.

"The existence of cholera carriers has recently been very effectively confirmed in the service of the author at the New York Quarantine Station."

Dr. Doty goes on to explain that the organism may not be stirred into activity so as to produce cholera in some of these carriers unless excited thereto by a debauch or some other irregularity of conduct.

"The more extended knowledge." the author continues, "which has recently come to us regarding cholera clearly indicates that five days do not cover the maximum period of incubation, which it has been shown may involve an indefinite period, and that while the detention of a group of suspects for five days would probably cover the period of incubation of typical cases it does not offer full protection to the public."

"The fact that there are various periods of incubation in cholera, particularly among the milder types, and that the latter may be transmitted by carriers who show no evidence of the disease, calls for more extended means of protection against cholera than have heretofore been in operation."

"In the consideration of this subject it must be fully appreciated that quarantine or the coast defense against the invasion of infectious diseases cannot offer full protection against the introduction of cholera into seaports or the interior."

"An attempt to carry out such a measure, while it would not secure the desired result, would go far toward destroying commerce, would be impracticable and not in accord with modern sanitation, chiefly for the reason that the period of incubation is uncertain and the existence of cholera carriers has been practically proved."

"This brings us to a realization of the fact that hereafter each community must be prepared to accept the responsibility which belongs to it in the protection of its people against this as well as other infectious diseases, and very forcibly suggests what practical sanitarians have long hoped, i.e., the presence in each town and city of a health officer or health officials who are practically as well as theoretically familiar with infectious diseases, who understand the importance of their early detection, either in the typical mild, or irregular form-an exceedingly important factor in the control of outbreaks."

"It would seem reasonable that in the future we must recognize that isolated cases of cholera may appear in any place which has known or unknown intercourse with cholera-infected places, and the possibility of this must to recognized, but it must also be understood that, while this is so, if general infection is guarded against and proper precautions are taken in individual cases, even the same that are properly carried out in the presence of typhoid fever, we may, as a rule, dismiss the idea of serious results to a community."

It is to be remembered that many of the discoveries referred to by Dr. Doty have been made during the period of his long service as guardian of the Port of New York, and some of them have resulted from the knowledge gained by his experience and untiring efforts to keep the country as free as possible from infectious diseases.

Some idea of the prevalence of cholera this year may be gained from the Public Health and Marine Hospital Services health reports. The following cases and of deaths from cholera, plague, yellow fever and smallpox were reported to the Surgeon General of the United States Public Health and Marine Hospital Service during the week ended July 7, 1911:

There was some agitation here last year as the result of the presence of a few cholera cases at the Quarantine Station, but the last real cholera scare at this port was late in the Summer of 1892.

On Sept. 1 of that year the Hamburg-American liner Moravia arrived at Quarantine flying the yellow flag. She reported that on her voyage twenty-two of her 230 passengers had died of cholera. During the month that followed ninety-six passengers died either on the way to New York or in Quarantine. Five deaths occurred in the city but so strict were the precautions taken that no secondary cases developed.

An incident always remembered in Quarantine circles occurred on Sept. 12 of that year, when the steamboat Cepheus attempted to land the Normania's passengers on Fire Island, a section of which had been claimed for quarantine purposes. When the boat was about to make a landing the two or three hundred residents of the island made a demonstration and would allow no one to disembark.

Two or three attempts to land proved futile, and Senator McPherson made an appeal to the crowd, but they brandished sticks and he gave it up. Two lawyers obtained an injunction to prevent the landing, but Gov. Flower vacated it and the passengers landed the next day.

There was another cholera scare in 1893. On Aug. 4, the Karamania arrived and reported three deaths from cholera on the voyage. The passengers were quarantined on Hoffman Island. The survivors were released on Aug. 24. There were 450 alive of the original list of 471.

In the sixty years preceding 1892 there were five epidemics of cholera in this city, resulting in l5,000 deaths. The first outbreak was in 1832, the second in 1834, the third in 1848, the fourth in 1854, and the fifth in 1865.

(sic) = Stands for "Spelling is correct" and identifies that the spelling of the word found before this acronym in the above text is correctly spelled as shown in the original published article.

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