in spite of the Capitulations. If a cesspool bursts or over-
flows, the landlord has to remedy the defect, or he has to
stand the abuse of his tenants owing to the return of the
mosquitos. Moreover, he is promptly sued by the Government.
The consuls themselves, far from obstructing, now assist the
authorities in every way.
It is right to mention that the Suez Canal Company, through
its President, Prince d'Arenberg, have placed a large sum of
money for the maintenance of this campaign at the disposal of
the Egyptian Government.
This campaign at Port Said is perhaps the most successful
which has ever been started, and any one who is able to com-
pare Port Said in the old days with the present state of affairs
will, I am sure, eulogise the work which has been done. A
great deal remains to be done, however ; but the mosquito
campaign has paved the way for it, and has shown that with a
little perseverance sanitary reform in Egypt is not nearly so
difficult as is usually made out.
There can be no question that drainage is the next thing
required at Port Said. The present cesspool system is quite
inadequate, and it should be replaced by proper sewerage as
quickly as possible. A scheme has been drawn up and passed.
5i6 MOSQUITO REDUCTION IN EGYPT [Sect.
1 believe ; and I have heard that the Suez Canal Company have
offered to advance the necessary funds for it. It is difficult to
appreciate, therefore, why it has not been undertaken. The
Egyptian Government itself appears to be doing very little
for Port Said, but the least it might do is to accept the Canal
Company's offer and drain the town. At present negotiations
are on foot between the Government and the Company regard-
ing the latter's concession, and I suppose that the health of
Port Said has suffered for this delay. The drainage will be
expensive, for it will have to be done on the artificial pumping
system, there being no *' fall " at Port Said. Still, drainage
there is almost more necessary than at Cairo. If the place
were properly drained, the expenses attached to the mosquito
campaign would be reduced almost to a negligible quantity.
Cairo. — Cairo is a very much larger city than Port Said. It
contains an estimated population of more than half a million,
the European element being smaller than that of either Port
Said or Alexandria. The town is situated on the east bank
of the Nile, at the apex of the delta of the river. Facing
Cairo, on the other side of the river, there is the town of Ghizeh,
and between the two, on an island, there is the residential
suburb of Ghezireh. Cairo proper can almost be divided into
two portions — the native to the east and the European to the
west — by the old canal, now filled in to form a tramway,
called the Khalig. Suburbs extend to the north and south,
but the city itself is compact, and, for its population, does not
cover a very great area. Owing to the fact that the Govern-
ment owns most of the surrounding land and will not part
with it cheaply, the price of land is exorbitant, and in conse-
quence there is great overcrowding, with the erection of high
buildings containing residential flats (in this city, with its
almost tropical climate).
Cairo is infested with mosquitos. To destroy them through-
out the city would be a stupendous, but not impossible, task,
and it would involve an expenditure of about ^20,000 annually.
53] CAIRO 517
It is true that in the winter months the gnats are not so
numerous, but in the summer and autumn the pest is as bad
as in many tropical places.
Like Port Said, Cairo is built on a lake of subsoil water.
The Nile water, of course, is not confined between the banks
of the river. In fact, the underground river is much larger
than the Nile itself, and it flows directly beneath the city of
Cairo. The height of the subsoil water, therefore, varies with
the height of the Nile, and in the months of September and
October, when the Nile at Cairo is in flood, it frequently
happens that the basements of the houses are filled with water.
Every house, native or European, has its cesspool, which
leads directly into the subsoil water ; and for centuries past
all the sewage of the city has passed directly into this under-
ground lake and has saturated the soil all round. The cess-
pools of the houses built by Europeans are called " percolating
pits." They are commonly built immediately beneath the
houses, and they vary in size according to the uses put to
them. Their bases are deficient in bricks and are formed by
the porous earth only. Every cesspool dips into the subsoil
water, and bricks are removed from the walls in places to
facilitate the percolation of the sewage into the surrounding
earth. It can veritably be said that the land on which
Cairo is built is sodden with sewage. Nearly all the pits are
ventilated by short intake and long uptake shafts carried up
to the roofs of the houses, and it is by means of these pipes
that mosquitos gain access to the cesspools. A few of the
more modern houses are fitted with "fosses morass," which
are, in reality, modified liquefying tanks. Some of them are
made on a fairly satisfactory basis, but usually they are pre-
tences, and are nothing more than rather elaborate percolating
pits.
The native cesspool is, if possible, more insanitary. It
consists of a long trough dug in the earth under the house.
Stone flags form its roof, and one of these flags, having a hole
5i8 MOSQUITO REDUCTION IN EGYPT [Sect.
in it, is used as the closet. No water flushing arrangement
is employed, and fluid soon soaks into the earth. For this
reason mosquitos do not breed so readily in the native as in
the European cesspools, and consequently they are not so
numerous in the native as in the European quarter of the city.
Both classes of cesspool have to be pumped out from time
to time, and conservancy carts form an important, if not an
ornamental, portion of the Cairo traffic. The pumping out
process is an expensive item for the landlord, and is a lucrative
business conducted, not by the Government, but by private
enterprise. On the plea of expense landlords frequently
neglect to cause the cesspools to be emptied until the last
moment. At present there are no drains. For the last three
years the Government has made a special drainage department
for the construction of sewerage. I have heard that the plans
of the scheme have already been passed. In the meantime,
when the soil is turned up in any part of the town for the
purpose of making the foundations of new buildings, the stench
is usually indescribable, for the subsoil water is soon reached,
and that water is practically sewage. Moreover, these excava-
tions form fruitful breeding-places for mosquitos.
The water-supply of Cairo is derived from shallow wells
placed below the town, a source which has given rise to con-
siderable controversy. In the native quarters, almost every
house has its own well, which is bored close beside the porous
cesspool. The water in the well is that which has usually
percolated in from the neighbouring cesspit. The natives
prefer this or the Nile water, which, of course, is polluted, to
that supplied from the wells at Rod el Farag. When cholera
broke out some years ago, many of the wells were filled up,
but they have nearly all been reopened. In all the cesspools,
wells and other collections of water which riddle the city,
mosquitos, cockroaches, and all sorts of vermin thrive. The
human mortality is enormous, especially the infantile mortality.
The figures supplied by the Public Health Department are
53] CAIRO 519
unreliable (as I know, for I have assisted to compile some of
them). The actual population is unknown, many deaths are
probably never reported, and sickness is not usually notified.
All deaths are supposed to be registered, the diagnosis usually
being made by a brief inspection of the dead body. Doctors
will not notify disease, because they say that it ruins their
practice. Landlords prefer to knock holes in the sides of their
cesspools and allow the sewage to flood their cellars and
basements rather than go to the expense of having them
pumped out. The water-supply is not the best obtainable,
the streets are not properly cleaned, and enormous heaps of
dung and rubbish have been allowed to accumulate for years
past on the outskirts of the city. Many of the streets are not
metalled ; which perhaps is a good thing, for the rough surface
acts as a sponge for the stale urine which would otherwise
collect in puddles. Dung and street refuse are used as fuel
generally ; and large collections of this rubbish are kept for
this purpose on the roofs of the " Turkish Baths." Nearly all
the dogs have been destroyed owing to outbreaks of rabies,
and mangy cats have taken their place as natural scavengers.
Hordes of flies, which breed in the dung and rubbish, abound
everywhere, and are nearly as great a nuisance as the mosquitos.
Without exaggeration, Cairo may be described as a city which
is hardly fit for habitation, and at present it must rank with
Moscow, Pekin and Hankow as being one of the most insanitary
spots in the world. Since the mosquito campaign. Port Said
is a health resort compared with it.
The common mosquitos found are Culexfatigafis, Stegomyia
fasdata, and a species of Anopheline called Cellia pharoensis.
They breed in the cesspools, wells and ornamental fountains.
The natives love fountains, and their houses always contain
large numbers of water vessels of all sorts and sizes.
Fevers are undoubtedly rife. Typhoid broke out in one
or more of the principal hotels each season when I was in
Cairo ; for it must be remembered that Cairo is a favourite
520 MOSQUITO REDUCTION IN EGYPT [Sect.
resort in the winter. The typhoid is probably propagated by
the vegetables, which are usually washed in old canals, or
even cesspools, by the natives when they bring them into the
town. Some years ago a scheme was made to prevent this
washing, which is done to make the vegetables glisten and
look fresh for the market ; but the Government would not
adopt it. Dengue, which is probably propagated by Culex
fatigans, occurs in epidemic form every year. Malaria exists
in Cairo, but it is only of the mild tertian and quartern types.
Following on some questions which were asked in the House
of Commons last year, a controversy arose in the Press in
Egypt regarding the incidence of the disease. One paper
said that it did not exist. But it does. Only last summer
an outbreak occurred at Ghezireh, and according to the
Statistical Report of the Public Health Department for 1908,
twenty-nine deaths occurred in Cairo alone from the disease.
The Senior Medical Officer of the Egyptian Army reported
an outbreak at Zeitoun and Abbassieh (suburbs of Cairo) on
3rd November 1907 (Letter No. 411). I have myself seen
cases of malaria, and have taken Anophelines frequently,
especially at Ghezireh. Probably the incidence of the disease
is far greater than is commonly supposed. Several other
diseases, such as Simple Continued Fever, are confounded
with it. Elephantiasis, also conveyed by Culicines, is a common
complaint, and victims are frequently seen begging in the
streets.
A real estimate of the incidence of malaria has never been
made. Last year a small spleen census was taken among
some children, but the result was vitiated by the discovery
of a disease, provisionally called " Endemic Cirrhosis of the
Liver," which occurs among them. Still, malaria exists, and
other fevers too ; which is sufficient ground for the institution
of a campaign, apart from the other great sanitary benefits
conferred by these undertakings. At one of the campaigns,
also, that at the Police School, figures have been obtained,
53] CAIRO 521
which I shall quote later, and they demonstrate amply the
beneficial results which would accrue from general mosquito
reduction. Cairo is visited annually by thousands of English
and American tourists, who live in palatial hotels, and who
cannot realise the real state of affairs. From a superficial
visit, Cairo is a most picturesque city ; but let them go off
the beaten tracks into the depths of Boulac, Saida Zenab, and
Bab el Sharia, districts which visitors do not often see, and
they will then appreciate the insanitary precipice whose brink
they visit.
The first mosquito campaign in Cairo was started by a
few English residents in the district of Kasr el Dubarra in
1904 or 1905. Only a few houses were treated (by the
residents themselves), and although a reduction in the number
of mosquitos resulted, the campaign soon lapsed owing to
the fact that many of the breeding -places were overlooked.
In the meantime. Sir Horace Pinching, K.C.M.G., Director-
General of the Egyptian Public Health Department, who
was very pleased with the work of my brother, E. H. Ross,
at Port Said, gave me an appointment as probationer in
that Service, for which I abandoned the Medical Service of
the British Navy — in the hope of having better opportunities
for scientific and sanitary work. In the autumn of 1906, His
Excellency Mansfield Pacha, then the Commandant of the
Cairo City Police, suggested to me that an experimental
campaign should be instituted privately in the Muski district
near the police headquarters. Most of the necessary funds
were provided by the police, and Mansfield Pacha used his
influence to get subscriptions from the other residents whose
property was to be treated. The campaign included the build-
ing of the Mixed Tribunals, the Opera House and the Esbekieh
Gardens. This campaign is an interesting one, for the whole
area involved was very small, about half a square mile of
densely-populated buildings situated right in the heart of the
city, where the houses were, if possible, more infested by
522 MOSQUITO REDUCTION IN EGYPT [Sect.
mosquitos than elsewhere. The result was remarkable, for
in three months the mosquitos had practically disappeared
from the area treated, whereas all round they remained as
bad as ever. Every cesspool was oiled once a week with
a mixture of refined and crude petroleum in equal parts.
All water vessels were overturned and dried out. In the
Opera House the audience could watch the performance in
comfort owing to the mosquito campaign, whereas if any one
crossed the street to one of the uncampaigned houses, he
would be pestered by hundreds of insects. This campaign
proved the point that mosquitos will not migrate far from
their original breeding - places. We received no opposition
whatever from the inhabitants, in spite of the fact that the
majority of them were Europeans, and incidentally hasheesh
and gambling dens were discovered and reported to the police.
Early in 1907 a new campaign was started in Kasr el
Dubarra by myself under the orders of Sir H. Pinching. This
district is bordered by the Nile and contains the best residential
houses in Cairo, including the British Agency. It is right to
mention that this campaign was restarted largely at the
instigation of Lady Cromer, who suggested that it might be
instituted on scientific lines by a responsible official ; not by
private enterprise, like the first attempt in 1904. Sir Horace
Pinching ordered the funds to be provided after a rough
estimate of the cost had been prepared. The next step was
to obtain permission from the residents themselves to allow
us to enter their houses. It was considered preferable to
obtain permission from individuals rather than from their
consuls, because at that time some of the consuls in Cairo
were not on very friendly terms with the Government. Letters
printed in several languages were sent to the residents, and
a large number were soon answered giving permission. The
European residents never appeared to object when they
appreciated that they would have nothing to pay — a point
which was clearly stated in the printed letters. Curiously
53] KASR EL DUBARRA 523
enough, the only persons who objected were the natives who
had no right to refuse. We could, of course, have entered
the houses of the local subjects without their permission, but
E^ypt is governed by a diplomatic administration rather
than by a scientific one, and it seemed more diplomatic to
treat both native and European alike. The objectors were
called upon and the campaign explained to them. Lady
Cromer came to the rescue, and was indefatigable in calling
and seeing personally many of those who refused to allow us
to enter their houses, and allaying their suspicions. By the
end of January the campaign was in full swing, the brigade
consisting of a European foreman and two native labourers.
In about three months, when the mosquitos ought to have
been reappearing owing to the return of the hot weather, the
residents noticed that their houses remained practically free,
in spite of the fact that the pest was assuming its usual pro-
portions in the other uncampaigned parts of the city. One
by one the objectors asked that the campaign might be
instituted in their houses, for they began to realise the benefit
of it. For instance, one of the gentlemen who objected to
the campaign at the outset was a native prince. His palace,
therefore, was not entered. After a few months his neighbours
began to complain that the mosquitos from his house annoyed
them ; and he, on entering their houses, remarked on the
reduction of the number of gnats. Suddenly a polite letter
was received asking for a visit from the brigade, and the
letter was followed by a visit from the objector himself, who
implored us to destroy his mosquitos. From instances such
as this we learnt that it is better to ignore objections to the
visits of a brigade rather than to endeavour to persuade people.
Let the campaign be continued in the houses of others ; after
a short time I think that it will be found that all objections
will disappear.
The following October, when the mosquitos ought to have
been at their worst, Kasr el Dubarra enjoyed comparative
524 MOSQUITO REDUCTION IN EGYPT [Sect.
immunity from them, and at the Semiramis Hotel, which is
in the district, visitors and tourists could sleep without mosquito
curtains, the only place of this nature in Cairo where this has
ever been done.
At the beginning of 1907, on the initiative of Sir H.
Pinching and Major Elgood, a small campaign was also started
by me in the Police School at Cairo. This school contained
about five hundred students, recruits for the Police Force in
Egypt, and it was established in an old palace in the Abdin
quarter of the city. The palace is a very large building sur-
rounded by a garden. It is built on the native plan in the
shape of a quadrangle with a large courtyard in the centre.
It was infested with mosquitos, from which the students suffered
greatly. The ceiling of the school hospital, which formed
part of the building, used to be black with the gnats, a sight
I have never seen before. Like many of these native palaces,
there were more than seventy latrines, all of the native pattern,
which communicated with large cesspools under the building.
These cesspools were not ventilated, and the only access to
them was through the closets themselves which led directly
into them. In the garden there were the inevitable fountains,
and a sort of pond which was used for irrigation purposes.
Oil used to be poured down most of the latrines ; others were
sealed up. The pond and fountains were emptied. The
number of mosquitos was greatly reduced in a very short
time, and before I left Cairo a year later, they had practically
disappeared. Major Elgood, the Commandant of the school,
then kindly undertook to supervise this campaign, and when,
at a later date, the school was moved to new buildings at
Abbassieh, a fresh campaign has been started there by him
with most successful results. The year before this campaign
was started, 26 to 27^ of ^he. personnel were admitted to hospital
suffering from various forms of fever, including dengue and
simple continued fever (probably some were cases of malaria).
After the campaign had been in progress for some time, the
53] HELUAN 525
fever showed a decline, thus — June 1908 to June 1909, the
incidence of fever fell to 7"2%. The average number of the
personnel is about five hundred. In a paper describing this
campaign/ Major Elgood gives the following figures : — Year
1907-1908, eighty-eight cases of dengue occurred. During the
year 1908- 1909, when the campaign was in progress, the number
of cases fell to six.
In March 1907 a campaign was started at Heluan by myself
under the orders of Sir H. Pinching. The initial procedure
was similar to that adopted at Kasr el Dubarra. Heluan is
a town built in the desert about 15 miles to the south of
Cairo. It is famed as a health resort owing to its hot sulphur
springs and dry, invigorating climate. There are many hotels
and sanatoria, and the town itself is a growing one considerably
larger than Ismailia. The reason why Sir H. Pinching ordered
the campaign to be started at Heluan was because malaria
existed there. Anophelines had been taken, and examination
of blood-films taken at random from native children demon-
strated benign parasites ; an examination which had been
made sometime previously by Dr Dreyer of the Public Health
Department.
A new brigade was formed, and all the water collections
and cesspools were treated with petroleum. Mosquitos were
found to be breeding in some pools of sulphur water, which
had collected in some places owing to overflow from the sulphur
wells. It seems that after this water has been allowed to stand
for some time, the sulphur precipitates, and the larvae of
mosquitos (including these of Cellia pJiaroensis) will then thrive
in it. An attempt was made to drain this surplus water, which
will be an expensive undertaking. In the meantime, as much
of it as possible was oiled.
Heluan was famed almost as much for its mosquitos as it
^ "Some Account of the Preventive Measures taken "against Mosquitos at the
Police School, Cairo," by Major 1*. G. Elgood. Cairo Scientific Journal^ No. 34,
vol. iii., and Brit. Med. Journ., i6th Oct. 1909.
526 MOSQUITO REDUCTION IN EGYPT [Sect.
was for its sulphur baths ; even in the winter months one was
being bitten night and day. Nearly all the gardens have
fountains, but unlike the houses in Cairo, the cesspools are
usually to be found in the garden or courtyard. Stegomyia
breed freely in the fountains, which were therefore stocked with
fish. Some householders objected to oil being poured into the
fountains because it is unsightly, and it was found that a
common variety of Nile fish ( Tilapia nilotica) is very hardy and
will keep small collections of water free from larvae. The
cesspools are constructed very deeply in Heluan, as the subsoil
water, especially in the east and north of the town, can only be
found at a considerable depth. There are not many water-
closets, and the result is that some of the cesspools are dry
except in " pockets " which have formed in the earth. To reach
these " pockets " with oil, it was frequently necessary to send a
man down into the cesspool itself. In this case a rule was
made that a lighted candle was previously lowered to test for
the presence of poisonous gases — an important precaution
against accident.
The results of the campaigns in Cairo and Heluan may be
summed up together, for in every case it was practically the
same. The number of mosquitos began to diminish perceptibly
in about three months ; and in Heluan, in six months, people
were sleeping without mosquito curtains. Even those people
who were inclined to doubt the possibility of ridding districts
of Cairo of mosquitos, had to admit that the destruction of the
pest is not only a possible, but really an easy problem.
In September 1907 Dr Dreyer again examined blood-films
from some children in Heluan, and found that very few parasites
could now be demonstrated. No cases of dengue occurred there
during the autumn of the same year, although an epidemic of
the disease was in progress in other parts of Egypt,
Apart from the prevention of disease, however, mosquito
campaigns are valuable measures to be adopted in a country
like Egypt, for they bring the officials who organise them more
53] RESULT 527
in touch with the inhabitants, who, consisting largely of natives,
are inclined to mistrust those set above them. Mosquito brigades
are constantly visiting the houses, and when the inhabitants
appreciate that something is really being done for them, they
take an interest in the work, and ultimately further this and
other sanitary reforms. When I left Egypt in January 1908