Masterman,
E. "Hygiene and Disease in
Public Domain.
Digitally prepared by Ted Hildebrandt (2004)
HYGIENE AND DISEASE IN
AND IN
BIBLICAL TIMES. (Part II)
By DR. E. W. G. MASTERMAN.
(Continued from
Q.S., 1918, p. 20.)
CHAPTER
II--The Climate and Water Supply in
relation to Health
and Disease.
IT
is not always realized that
zone, and lies farther south than not only every
part of
also of most of
of the
parts of
practically that of
over, in the great central rift of the
conditions must be described as tropical.
The land as a whole is fairly well supplied with
rain, but the
rainfall is very unequally distributed throughout
the year, extending
as it does over little more than six months.
January, February,
December
and March are--in this order--the wettest months; there
may be fairly heavy showers in October, November,
April and,
exceptionally, even in May. It is
very unusual for any rain to fall
in June, July, August and--except quite at the end
of the month--
in September. The amount of the rainfall is liable
to considerable
annual fluctuations and varies with the altitude. In
regular daily observations have been taken since
1860. The
heaviest season's rainfall was 42.95 inches in
1877-78, and the lightest
12.5 inches in 1869-70. The mean annual fall is
about 26.5 inches.
There
seem to be cycles of greater and lesser falls, dry spells and
wet coming in groups, but no definite rhythm has
been observed.
In
the Maritime Plain, observations have been taken at Jaffa
(P.E.F.)
and at the German colonies of Sarona
and Wilhelma, and in the
56
HYGIENE AND DISEASE IN
Melhamiyeh. The rainfall in the
Maritime Plain is less than in
bourhood of the
regions are far less dependent upon rainfall
than the mountain
districts. We have no regular observations
recorded in the Dead
Sea
district, but the rainfall is very much less than in any other
part of
there is a rainfall comparable with that on the
highlands to the
west, but it is only a fringe of a few miles which
is so benefited.
Where
once the water-parting is passed and the gentle eastward
slope begins, the rainfall rapidly diminishes in
amount, and it is
very scanty indeed east of the Hedjaz
Railway.
In the late summer heavy clouds come up from the
west, and
during many nights the higher lands--especially in the
north--are
drenched in "dew" which does much to
fatten the grapes and olives.
In the highlands the springs, though not
infrequent, are seldom
copious, and in many parts the people of the
land have from early
historic times resorted to cisterns to store the
rain, both for their
domestic use and for their vineyards. In
of the intermittent spring 'Ain
Umm ed-Deraj, "the Virgin's Spring "
(Gihon of the Old Testament), and of the deep-lying spring
in
Bir Eyyub (En-Rogel of the Old Testament) is brackish and impreg-
nated with sewage. I have
examined samples of both these waters
and found abundant chlorides, free ammonia and
nitrites. The
main source of drinking water is consequently the
numerous rain-
filled cisterns--public and private--which have been
excavated in
the rock or, in parts of the city, in the overlying
soil. In Roman
times--perhaps even somewhat before--two systems of
aqueducts,
known respectively as the "High Level" and
"Low Level" aque-
ducts, brought water from the neighbourhood
of Wady Artas, where
to-day the three great reservoirs known as “Solomon's
Pools” now
much out of repair, bear witness to the thoroughness
of these great
“waterworks.” Wady Artas is 7 ˝ miles directly
south of
but the low level aqueduct, which alone remains
more or less com-
plete, ran 13 miles along the
hill sides to reach the city. Two
additional systems of aqueducts brought a supply
also to these pools,
a chain of wells connected up by an aqueduct,
known as a khariz,
which enters the Wady Artas by a deep rock-cut tunnel, and an
aqueduct, similar in construction to the low
level aqueduct, which
58 HYGIENE
AND DISEASE IN
runs 28 miles along the hill sides from Wady Arrub--only 5 miles
to the south in a direct line.. Both these
extensions have been long
out of repair, but from the springs in Wady Artas, by utilizing the
low level aqueduct in part and replacing it with a
4-inch iron pipe
elsewhere, a feeble stream of water still (at any
rate before the war)
reaches
able to fill their vessels with water of a fair
quality, but it is a poor
enough supply for a great city. Before this 4-inch
pipe supply was
introduced, an attempt was made to supply the needs
of the city--
then urgent through a poor season's rainfall--by
bringing water in
tanks by rail from the spring at Bittir--the
next station to Jeru-
accustomed in years gone by to have water brought
in jars or
tins from the abundant fountain at 'Ain Karim, but this has often
proved unsatisfactory as the bearers are
untrustworthy.
As far as health is concerned there is not much
wrong with
well-stored cistern water. It is a little
"flat" but has none of the
disagreeable taste of rainwater in
European cities, which is contami-
nated by a smoky atmosphere.
Careful people ensure cleanliness
of the roofs by allowing the first day's rainfall
in each season to run
away for a few hours. Cisterns must be periodically
cleaned out,
but it is surprising how small is the sediment
deposited in even the
largest cistern, where only the roof-water is
collected. Most cisterns
are rock-cut and carefully cemented with an
impermeable cement,
in the making of which the ground-up fragments of
broken--often
ancient--pottery are used. Water so stored, if
originally pure, keeps
sweet and good for a long while and, when the
sediment is settled,
is quite bright and clear, although a Pasteur
filter shows that there
remains constantly a small quantity of undissolved earthy impurity.
In
some respects, the system of private cisterns is probably safer
than a doubtfully-managed public supply. A
water-borne disease,
such as enteric fever, cannot be carried all over
the city. On the
other hand, the small cisterns in the houses of the
poor not infre-
quently leak, and those in the
city, being often made in the soil, may
become infected with sewage. They are also mostly open
and, on this
account, liable to contamination from many sources.
Mosquitoes--
Anopheles, Culices and Stegomeyer--breed
in them in countless num-
bers, and the Anopheles are
especially dangerous as the carriers of
malaria. Cisterns should be systematically
inspected, repaired and
kept closed to the entry of mosquitoes. The only
satisfactory plan
HYGIENE AND DISEASE IN
is to provide them all with pumps instead of the
primitive hand-
buckets let down through a wide, open
well-mouth.
The Syrian native esteems "living"
(spring) water very highly,
but I have known people, accustomed to the soft
rainwater of
springs of
percentage of lime and magnesium salts.
In the villages water is, if possible, brought
from springs, even
at a considerable distance, for drinking purposes,
but in the late
summer in many places the fellahin and bedawin have to make
shift with water of a very inferior quality, obtained
from anywhere
they can get it.
With regard to the temperature, there is a great
difference be-
tween various parts of the
land. Upon the high mountain plateaux
of Judaea and Galilee,
in parts of
the higher lands east of the
though the spells of heavy rain, lasting often a week
or more at a
time, are trying in a land where the dwellings are
built rather for
heat than cold, and where fuel is scarce. To many of
the poor the
winter is a time to be endured with the reflection
that it does not
always rain. Between the bouts of rain are spells of
bright sunshine
and pleasant warmth. At times at
mountain elevations, snow falls heavily, and
occasionally lies on the
ground for some days. It is welcomed by the
agriculturalists, as
the slowly melting snow thoroughly moistens the
soil.
The mean temperature in the shade in
three colder months (January, February and March) is
48°•7 F.;
in the Maritime Plain (Wilhelma)
56°•4, and by the Jordan (Kasr
Hajla)
69°•2.
During the six months for May to October (inclusive)
the mean in
experienced. The mean of the maximum temperatures in
the shade
of the four hottest months is 84°•3 in
and 112°•5 at the
over 90° are common in the summer, temperatures over
100° are
infrequent.
The heat in the higher parts of
the cool westerly breezes which, with considerable
regularity, blow
from the middle of the forenoon until some time near
sunset, and
a north-westerly breeze is very common all the
summer night,
60 HYGIENE
AND DISEASE IN
making the hours of sleep refreshing. The most
unhealthy and
disagreeable days are those when the
dry, hot sirocco blows from
the south-east ("a dry wind of the high places
in the wilderness,"
Jer. iv, 11), sometimes
for several successive days and nights. At
such times those who have good stone houses keep the
windows
and doors closed, and to step outside from such a
house is like
stepping into the neighbourhood
of a furnace. The wind is intensely
dry and, at times, loaded with fine desert dust,
producing a haze;
vegetation languishes, the leaves droop, and most
people--especially,
perhaps, Europeans--feel varying degrees of
discomfort. During and
after a bout of such a wind, the increase in
"fever" and other illnesses
is marked. May, just after, and September and
October just before
the rains, are the worst months. In midsummer
sirocco is rare, and
in the winter the south-east wind, though dry, is
cold and bracing.
Taking
high temperature in summer, the clear pure air and
cloudless sun-
shine are very enjoyable. Compared with
falling far short of some parts of the
experience, all the Europeans I have known have
been benefited
by occasional change to the more temperate zone,
and some ladies
find residence in high altitudes, such as
nervous system. In winter the coast and the
Tiberias and
or four months only, and even then special
precautions must be
taken against malaria.
Mention must be made here of local means
provided by nature
of treating disease. Many have found the
for rheumatism, but more definitely medicinal in
their properties
and more sanctioned by the custom of centuries, are
the hot
sulphurous springs which occur at
many places in the land. The
groups of springs at Tiberias,
the valley of the Yarmuk, and in the
Wady Zerka Ma'an, a valley opening into the
east, were all famous in Roman times as health
resorts, and are
all still used by the indigenous inhabitants. Only
at Tiberias has
any attempt been made at providing accommodation
for the bathers,
and that is ill-managed and far from clean. It is
to be hoped that
any new regime in
for the sick, and make arrangements that they may
be used to full
advantage under proper medical supervision.
HYGIENE AND DISEASE IN
The question may well be asked at the present
time how far has
nent homes there? At present
malaria and other diseases are
recurring scourges which greatly increase the
danger and discomfort
of those who would live there. But supposing these
can be in
places banished and in others mitigated, what is
likely to be the
effect on the European and his family who make the
land their
home? My impression is that in the higher mountain
regions
many Europeans may with care live comfortably, if
they learn to
restrain their energies, especially in the hot
months, and their
children can, with special precautions, be reared
in health. I have
my doubts as to whether a succession of
generations, where the
children do not have the benefit of visiting
years in their youth--as is the case with most
Europeans to-day-
would grow up such a sturdy stock as those reared in
northern
climes. In the Maritime Plain European families,
especially young
children, would probably suffer from the much
prolonged sub-tropical
heat, and visits to the highlands part of each
summer is desirable
if possible. Schools for such children might
advantageously be
situated in the mountains.
Most of the
It
is intensely malarious, and this disease is unlikely
to be eradicated
here. Though the individual--the hardy adult
workman, whose
work lies there--may, by living in a mosquito-proof
house and taking
quinine, protect himself, it is no place for a
family except for a few
months in winter. The families of those whose work
lies there
should live in the mountains, and ready means of
access, by tram
or train, should be provided for the overseers. In
the deepest parts
of the
labourers should, I suspect, be
of negro stock, as are so many of
the people there to-day.
CHAPTER III.--The Common Diseases of
The most characteristic and important of the
diseases of
is Malaria
in its various manifestations. Practically speaking, it
occurs all over the land and affects every class of
its inhabitants.
It
is very prevalent in
Recent
investigations have shown that during these months (August
to October) 27.30 per cent. of
all the children actually attending
school have malarial parasites in their blood; and on
examination,
62 HYGIENE
AND DISEASE IN
the blood of 7,771 persons of all classes and
conditions revealed
parasites in 26.7 percent. The percentages were
remarkably divided,
being 40.5 per cent. among
the poor Jews, 31.1 per cent. among
the Moslems, 16.4 per cent. among
the native Christians, and 7.2
per cent. among the
Europeans. Practically, the percentage is an
index of social environment and hygienic
surroundings, the Euro-
peans in particular having
learned the lesson of prevention and early
cure. Malaria occurs, though as a rule to a lesser
extent, in all the
towns and villages in the mountain region, especially
those bordering
on the
The incidence of malaria is now known to depend
very largely
on the water supply of a district and the nearness
to areas where
the fever lingers longest throughout the year,
because the healthy
are infected from the sick through certain kinds of
mosquitoes,
which pass the larva and pupa state of their lives in
water. Five
species of the sub-family Anophelinae have been identified
in
Anopheles Maculipennis (the common Anopheles of Jerusalem), Pyreto-
phorus Palestinensis, Pyretophoris Sergentii (only as yet identified
in
and Cella Pseudopictus. Of these the first two are the most
widely
distributed and important. The usual situations of
breeding of the
larvae of these mosquitoes are the marshy pools and
sluggish streams
of the low lands; in the neighbourhood
of
on the coast, especially around
district, such semi-stagnant pools occur in
numbers. In
the larvae of the two first-mentioned varieties
breed in countless
numbers in the semi-closed rainwater cisterns
attached to almost
all the houses, and it is therefore little wonder
that malarial fevers
are there continuously propagated. There are many
villages and
small towns where there are no suitable breeding
grounds, and in
such places malarial fevers are rare. The forms of
malaria are the
Tertian
(occurring every third day, that is, with one day's interval),
the Quartian (with two
days' interval), and the Tropical, or double
Tertian, where the fever is remittent but not
intermittent.
The
only satisfactory means of distinguishing the three
forms lies in
microscopical examination of the
blood in all cases. This we did for
one whole year in all cases coming to my hospital,
as far as possible
on the first occasion of any given attack of
fever. Out of 2,166
such cases, we found parasites in 46.5 per cent.,
and of these cases
HYGIENE AND DISEASE IN
25.5
per cent. had Tertian parasites, 27.4 per cent. Quartian para-
sites, and 47.1 per cent. Tropical or malignant
malarial parasites
many cases were doubly infected, and some had all
varieties at one
time. Almost all the Tropical cases occurred in the
hot months, July
to November, and no fresh infections occurred in
the cool weather,
because this particular parasite cannot develop
in the body of the
mosquito in so cool a temperature. Were it not
for the continual
re-infection of the inhabitants by
people returning fever-stricken
from the tropical Ghor,
this, by far the most dangerous form of
malaria, would die out in the mountains. The
closing of cisterns,
the destruction of the larvae by putting a small
quantity of petro-
leum on the surface of the
water (which in no way spoils the water
for drinking purposes if the water is taken from
some depth by
means of a pump, and in any case evaporates in a few
hours), and
the isolation of the sick within mosquito-proof
curtains or buildings,
are some of the means which have already been
introduced to
diminish infection. The prophylactic use of
quinine has also been
tried with considerable success. In the case of many
European
houses, the use of wire netting for windows and doors
has greatly
reduced the number of these pests and almost
entirely prevented
malaria. The systematic carrying out of
well-recognized measures
might reduce malaria, in
The
loss of life, particularly infant life, through malaria is terrible;
in many districts every infant in arms will be
found to have an
enormous "ague cake " (enlarged
spleen), to be anaemic and often
dropsical. The anaemia caused by malaria lays the victims open to
infection by various other diseases on account of
their reduced
constitutional resistance, and makes
them anxious cases for surgical
operations as they are specially liable to haemorrhage. Malaria
is thus directly and indirectly responsible for
more deaths among
children and young adults in many parts of these
lands than
any other disease. During recent years a number of
cases of
Blackwater fever have occurred: they have been almost exclu-
sively among Europeans-Germans
and immigrant Jews--and chiefly
in the "colonies" around
Valley. In some years the disease has assumed a
great virulence and
the mortality has been very high. Even in
from time to time among the residents.
Enteric
fever,
always endemic, at times occurs in epidemics.
It
is particularly fatal to Europeans; doubtless many of the native
64 HYGIENE
AND DISEASE IN
children suffer from mild attacks in infancy and
are, later in life,
more or less immune. Of other fevers, typhus,
influenza, and (on
the coast) Dengue fever all occur in epidemics.
Sporadic cases of
Malta
fever are seen at times, and also Spirillum (relapsing) fever.
Measles,
rubeola, mumps, whooping-cough, and chicken-pox are
almost always to be found among the children; the
first-mentioned
at times bursts forth with startling severity.
Smallpox when it sweeps through
the land, has a very high
mortality; vaccination is but half-heartedly
carried out even in the
large towns, and scarcely at all in the villages. I
have known cases
of unvaccinated Europeans-travellers
and residents--being fatally
attacked. Inoculation is still resorted to at
times, with terrible
results.
Scarlet
fever appears
to have been recently introduced, and
its toll of victims in the towns has been enormous.
Diphtheria occurs from time to time,
but probably less so--
paradoxically enough--than in the
more sanitary cities of
Dysentery is most commonly a
complication of malarial attacks,
but acute (amoebic) dysentery also occurs not
infrequently, a large
proportion of the cases being fatal. Tropical
abscess of the liver is
by no means uncommon, as a sequela
of dysentery.
Cholera, known to the natives
as howa el-asfar ("the yellow
wind"), appears in severe epidemics at
intervals, with an enormous
mortality. In nothing does the fatalism of the
ignorant natives
appear more prominently than in their attitude towards
this
disease. In spite of all warnings, they will
wash the clothes of
cholera patients in the village water-supply; at
Tiberias, during the
terrible epidemic of 1902, many of the people
could not be induced
to drink the boiled water freely and liberally
supplied to them by
the resident Scotch doctor, but used this for
washing their clothes
and drank of the sewage-infected lake-water at
their doors. It is
not wonderful that the epidemic decimated the town.
Fortunately,
epidemics of this disease have been rare during
the last half-century.
Plague. has not occurred in epidemic form
in
the first third of the nineteenth century, though
sporadic cases
have been detected and isolated at the ports; in
earlier ages it
swept over the land with terrible effect.
Erysipelas is by no means uncommon
among the town-dwellers,
many cases contracting infection at the site of the
"issues" the
people make and keep permanently open on their arms
and elsewhere
HYGIENE AND DISEASE IN
with the idea of benefiting their chronic
eye-diseases. Tetanus
occurs occasionally, and cases of hydrophobia from the
bites of
camels, jackals and cats, as well as pariah dogs,
occur annually. The
Turkish
Government, through the local authorities, assist all
such
cases, when needing financial help, to go to
for treatment by the Pasteur method, and just
before the war the
“International
Health Bureau” established a small "Pasteur Insti-
tute" in
European assistance in this disease.
Acute
rheumatism
is fairly common, and is responsible for
a large proportion of the cases of valvular disease of the heart.
Such
cases do badly on account of the poor food, the anaemia
pro-
duced by malaria, and, in the
cases of women, the very youthful
age of marriage, frequent child-bearing, and hard
life generally.
The
closely allied disease, chorea (St. Vitus's dance),
is not uncommon.
Chronic
rheumatoid arthritis
is commoner among the Jews
and other European residents than among the
fellahin. Next to
malaria the disease germ most responsible for
death in
land during the last few years has been appalling.
Tubercular
disease of the lungs (phthisis), of the bowels (tabes rnesenterica), of
the bones and joints (producing caries of the
spine, hip disease,
etc.),
and of the lymphatic glands, occur everywhere. Cases of
Phthisis (consumption) are often
exceedingly acute, even when
pure air and a semi-outdoor life are secured. This
is due, doubtless,
in many instances, to the mistaken kindness of
friends, who quietly
allow patients to refuse nourishment when there is a
disinclination
for food. There is a growing dread of infection in
this disease,
and many poor sufferers are shockingly neglected by
their relatives,
who are afraid to associate with them. There might
be a fine field
for philanthropic effort in the establishment of
efficient sanatoria
for such cases. There is already one such in
north of
to the great number of cases of this disease which
have been sent
to the land from other countries. Jews from
used constantly to arrive, advised by their doctors
to try the pure
air of
tubercle bacilli from cases of advanced disease,
who pass months
crouched up in dark corners, spitting infective
sputum all over the
floor, and in a state of filth and neglect. A great
deal of tuberculous
66 HYGIENE
AND DISEASE IN
meat, which is rejected as tarif (ritually
"unclean") by the Jews,
is freely sold among other classes. Oxen and cows
are not readily
killed while useful, and their failure of strength in ploughing or in
milk-production is often due to tuberculous disease; they are thus
peculiarly liable to come into the hands of the
butcher in that
condition. With respect to tubercle of glands,
bones and joints,