various antiseptics have been employed in this disease. Permanganate
of potassium was fortunately excluded from the list, on account of its
corrosive action, but, unfortunately, carbolic acid was conceived to
possess virtues that rendered it an eminently suitable remedy, and
creasote, which resembles it very closely, was presumed to possess
corresponding virtues. Then sulphurous acid and the sulphites, which
for a time were warranted to destroy every species of germ, were
confidently appealed to to stay the progress of cholera, and it was at
one time even a matter of dispute whether sulphite of sodium or
sulphite of potassium was the more efficacious. In truth, all of these
medicines were useless, even when they were not mischievous.
Cholera has never prevailed in any country without giving rise to
extraordinary theoretical and practical divagations. One physician in
the earliest American epidemic gravely proposed, as the best mode of
checking the diarrhoea, to plug the anus with a soft velvet cork.
Another, in England, suggested that the "blood may be kept circulating
by putting the patient on his back on a board and keeping up a
rocking, see-saw, to-and-fro movement from eighty to one hundred times
a minute." Another had the revelation that the disease is essentially
a "paralysis of the sympathetic nerve and want of performance of the
organic functions, with deficient vitality of the mucous membranes,"
and that its proper remedies are "bleeding, turpentine, and cool
drinks, without heat and stimulants;" and to this remarkable doctrine
a well-known physician gives his adhesion, thus: "The cause, I firmly
believe, is an union of the poison with the sympathetic."[74] Still
another discovered that the disease is a spinal disorder, and is to be
treated by the application of ice-bags to the spine. Were not the
evidence so palpable, it would hardly be believed that such irrational
ideas should have been published concerning a disease which had then
been under observation by the whole medical profession in Europe and
America for more than thirty years, and in Asia for a much longer
period.
[Footnote 74: _Times and Gazette_, Aug., 1866, p. 209; _ibid._, Nov.,
1866, p. 555.]
The most important lesson to be drawn from this history of the
treatment of epidemic cholera is, that the arrest of the disease in
the diarrhoeal stage is comparatively easy, and that in the stage of
collapse its cure by any means whatever is altogether an exceptional
occurrence.
{771}
THE PLAGUE.
BY JAMES C. WILSON, M.D.
DEFINITION.--An acute specific fever of short duration and very fatal,
endemic in certain Oriental countries, and frequently epidemic; it is
characterized by buboes, carbuncles, and petechiæ.
SYNONYMS.--([Greek: plêgê], _plaga_, a stroke); the Pest; Pestilence;
the Bubonic, Glandular, Inguinal Plague; the Oriental, Levantine,
Levant Plague; the Indian, Pali Plague; Máhámari; Septic or Glandular
Pestilence; Pestilential Fever, Adeno-nervous Fever; Typhus
Pestilentialis, Gravissimus, Bubonicus, Anthracicus, etc. _Gr._
[Greek: ho loimos]; _Lat._ Pestis; _Fr._ La Peste; _Ger._ die Pest,
Beulenpest.
CLASSIFICATION.--The plague, pest, pestilence, and their equivalents
in various tongues, are terms that have been used from the earliest
historical times to designate every epidemic disease attended by great
mortality. As knowledge of diseases becomes clearer the terms by which
they are designated become more definite; those which did service for
a class are restricted to particular groups, and new names are found
for other maladies only allied to such groups by superficial
resemblances. Hence by degrees the term plague has become more
restricted in its use. To-day it is understood as designating
exclusively the specific affection defined above, the bubo plague.
The student of medical history meets with insurmountable difficulties
in attempting to classify the recorded epidemics which have been
described under this term. Even when used in its more restricted
signification, difficulties as to the propriety of its application to
certain epidemics arise. Thus, nosologists are not in agreement as to
whether the great plague--the black death--which swept over Europe in
the fourteenth century and destroyed in three years twenty-five
millions of inhabitants, was a modification of the bubo plague or an
essentially different disease. A like difference of opinion exists in
regard to the relationship between the Indian or Pali plague which has
from time to time prevailed in North-western India during the present
century and the true plague.
The black death of the fourteenth century and the Pali plague, though
presenting many of the characteristics of bubo plague, differ from it,
while they resemble each other, in one important particular. Among the
earlier and more common symptoms of note are those dependent upon
gangrenous inflammation of the lungs, a lesion, according to
Hirsch,[1] extremely rare in bubo plague. This author informs us that
recent observations have fully confirmed the early opinion that the
Pali plague {772} differs from that of the Levant chiefly in this
modification, and cites Pearson and Francis as saying of the former
disease that "the collective symptoms are more like those of plague
than of any other known disease.... We believe it to be in all
essential particulars identical with the plague of Egypt."
[Footnote 1: _Handbuch der historisch-geographischen Pathologie_, Dr.
August Hirsch, 1860.]
The three forms of plague--(_a_) the grave (or ordinary), (_b_) the
fulminant (pestis siderans), and (_c_) the larval or abortive,
observed in epidemics and hereafter to be described--do not represent
distinct varieties of the disease, but are merely expressions of
differences in the intensity of the action of the infecting principle
upon different groups of individuals in given communities--differences
to be explained here, as in the other infectious diseases, in part by
variations in the activity of the poison itself, in part by the
individual peculiarities and susceptibilities of those exposed to it.
HISTORICAL SKETCH.--Upon the authority of Rufus of Ephesus, quoted by
Oribasius,[2] it is stated that the bubo plague prevailed as an
endemic, and at times as an epidemic disease, in Libya, Egypt, and
Syria prior to the beginning of the Christian era.
[Footnote 2: _Medicinalia Collecta_.]
In the year 542 A.D., according to Procopius,[3] the plague appeared
in Egypt, at Pelusium; extended westward to Alexandria; eastward to
Palestine, Syria, and Persia; passed from Asia Minor to Europe, where
it first invaded Constantinople, whence it spread in all directions
with such fury that before the close of the sixth century one-half the
inhabitants of the Eastern empire had perished, either of the plague
itself or of the universal destitution that followed in its train.
[Footnote 3: See Hirsch.]
With this epidemic, known in history as the Justinian plague, this
disease established itself for the first time in Europe, where it
maintained foothold for more than a thousand years.
About the middle of the seventeenth century the wide prevalence of the
plague in Europe began to draw to an end. In Spain it was epidemic for
the last time from 1677 to 1681; in Italy the last general epidemic
came to a close in 1656, although local outbreaks continued to occur
till the beginning of the following century. In France it still
prevailed in several provinces in 1668, although it had for the most
part disappeared some years before. In Switzerland we encounter it for
the last time in 1667-68; in the Netherlands in 1677; from England the
plague disappeared with the great outbreak of 1665. In the early part
of the eighteenth century two important epidemics occurred within the
boundaries of Europe. The first spread from Turkey, through Hungary
and Poland, to Russia, thence to Norway and Sweden, and along the
shores of the Baltic Sea to the Low Countries. This epidemic came to
an end in 1714. Six years later the last great outbreak of the plague
on European soil took place. It prevailed with great fury in
Marseilles in 1720-21, and overran the whole of Provence. From this
date till the close of the century Europe remained free from the
plague, with the exception of Turkey and the contiguous countries.
During the second and third decades of the present century repeated
epidemics occurred in the Balkan Peninsula and the regions bordering
on the Lower Danube and the Black Sea. The plague appeared also in
Malta in 1813, and prevailed till 1815, and in 1816 it reached certain
of the Ionian Islands. {773} Only twice has this pest shown itself
during the present century in Western Europe--once, during the
epidemic at Malta in 1815, at Noja, a town of the Neapolitan province
of Bari; the second time, in 1820, at Majorca, whither it was carried
over from the coast of Barbary.
Between 1552 and 1784 the plague prevailed twenty-six times in Tunis
and Algiers. Some idea of the importance assumed by this scourge in
the countries of North-western Africa may be found from the fact that
many of these epidemics lasted continuously for years, that which came
in 1784 not ceasing for fifteen years. Between 1816 and 1821 the
plague again prevailed in Tunis and Algiers, and again in 1836-37.
During the first half of the present century a change took place in
the prevalence of the disease elsewhere. Shortly before its complete
disappearance from Europe it ceased to prevail in Western Africa (with
the exception of the Nile countries), in Mesopotamia, and in Persia.
It disappeared from Asia Minor, Syria, and Palestine in 1843, from
Egypt in 1844.
For a short period the plague seemed to have disappeared altogether.
Those who cherished this hope were, however, destined to
disappointment. In 1853 an outbreak occurred in the Assyr country,
Western Arabia; and from that time till the present unmistakable local
epidemics of the bubo plague have occurred in isolated regions of
Africa and Asia; thus, in 1858 at Benghazi in Tripoli; in 1857 in
Mesopotamia; in 1863 in the district of Maku, Persian Kurdistan; in
1867 in the marsh district on the right bank of the Euphrates; in 1870
in Persian Kurdistan; in 1871-73 in the Yunnan province, Western
China; in 1873 in the marsh district on the left bank of the
Euphrates. During four years following the outbreak of 1873 the
disease continued to prevail over an extensive area in the countries
bordering on the northern banks of the Persian Gulf. In 1874 it
reappeared also in the Assyr district, Western Arabia, and in
Benghazi, Northern Africa. In 1876, whilst still infesting the regions
about the Lower Euphrates, the plague appeared in South-eastern
Persia, and during this and the following years it appeared at several
isolated points on the borders of the Caspian Sea. Early in 1878 the
disease was reported as prevailing in the district of Souj-Bulak,
Persian Kurdistan, and it appeared in October of the same year at the
Cossack village Vetlanka, on the Lower Volga, district of Astrakhan,
Russia, after an absence from Europe of thirty-seven years. It has
more recently prevailed in the Assyr district, Western Arabia, and
there have been rumors of its reappearances in Persian Kurdistan.
The Indian or Pali plague (Máhámari) has prevailed in local epidemics
of great severity on several occasions during the present century in
the North-western provinces of India. This fever was first recognized
in Kutch in May, 1815, after a season of great scarcity of food. It
spread rapidly over an extensive territory, and appeared in the spring
of the following year at various points in Guzerat, next in Merawi,
later in Rhadenpur, spreading thence westward to Sindh. Not until the
following year (1817) did the pest reach the British possessions. This
epidemic continued to prevail until 1821. The disease did not reappear
until July 6, 1836, when it broke out in Pali, the principal dépôt of
traffic between the coast and North-western India. It spread with
great rapidity to the {774} adjoining provinces. Toward the close of
the year 1837 the disease broke out anew in Pali, and raged until the
spring of the following year. In 1834-35, again in 1837, there were
outbreaks of this pest in Gurwal, and in 1846 and 1847 in Karmoun,
provinces of the southern slopes of the Himalayas. This destructive
pest has raged at an altitude of 10,300 feet, and we learn from Hirsch
that it has never wholly disappeared from the mountain-districts of
the Himalayas since 1823, and that its ravages in these regions have
been so great that certain settlements have been wholly destroyed.
The fever was remittent in type, with a great tendency to become
continued; it was characterized by rapidly developing extreme
prostration, and was very fatal. In most cases there were glandular
swellings in the groins, armpits, and neck. Carbuncles and petechiæ
are not mentioned as having been observed. Dyspnoea, cough, and bloody
expectoration were frequent symptoms. Vomiting, at first of bilious
matter, later of dark, coffee-colored fluid, was likewise common.
The plague has never appeared in the western hemisphere.
ETIOLOGY.--1. Predisposing Influences.--Whilst the present views as to
the causation of the specific diseases compel us to assume a specific
infecting principle as the real cause of every outbreak of the plague,
there are certain circumstances which are recognized as so favoring
the development and action of that principle that they have come to be
looked upon as indirect or auxiliary causes of particular epidemics.
It is more in accordance with the facts to speak of them as
predisposing influences. Chief among these circumstances is that
combination of physical and social wretchedness which goes hand in
hand with poverty and overcrowding. The plague has been termed by a
recent observer (Cabiadis) miseriæ morbus, and he has thus reproduced
in 1878 a name applied to the great plague of London in 1665--the
poor's plague. All observers of recent epidemics unite in ascribing to
poverty the foremost rank among the predisposing influences of plague
epidemics. It is only necessary to enumerate the evils which form the
train of poverty, whether in cities or in villages, to complete the
list.
With poverty come ignorance and neglect of all sanitary laws;
overcrowding and ill ventilation; personal filthiness; improper as
well as insufficient diet; indifference as to the location of
dwellings and their surroundings. The condition of the villages which
have been the scene of some of the recent epidemics beggars
description. All observers unite in testifying to such accumulations
of filth in and around the houses as requires to be seen to be
believed. In these communities latrines are unknown, and no such thing
as organized scavenging has ever existed.
The accumulation of unburied or imperfectly buried corpses has been
looked upon as the real cause of the plague, and some of the recent
epidemics have followed the prevalence of distinctive epizoötics.
Whilst it is not difficult to disprove that under ordinary
circumstances the effluvia from exposed and rotting carcasses can give
rise to outbreaks of the plague, it is more than probable that an
atmosphere charged with such emanations (together with other causes)
can so unfavorably influence a community as to increase its
susceptibility to the specific cause of this or any other infective
disease. There can be but little doubt that the {775} dead bodies of
the victims of the plague are capable of disseminating the disease,
and that the reopening of graves containing such bodies, even after a
long period of time, has given rise to fresh outbreaks of the disease.
The season of the year does not appear to exert any very marked
influence upon the development of epidemics, if we base our deductions
upon observations made in different countries. In northern countries
the disease has prevailed as severely in mid-winter as in summer. The
epidemics of London showed a rise during July and August, their
furious prevalence in September, and a gradual decline during October
and November. In Constantinople the disease has commonly remained
dormant during the winter months, and become active as the weather
grew hotter. In Egypt, on the contrary, the activity of the outbreaks
has developed in winter, increased with the advance of spring, and
suddenly abated upon the advent of the summer. Such also has been the
case with the three general epidemics in Mesopotamia studied by
Tholozan.[4] "Their beginning took place in winter, their development
during the spring, their decline and their extinction in summer. Their
recrudescences obeyed the same laws: after an incubation during the
summer season ... revivification took place in winter and in spring."
It is added in this writer's account that the exceptional hot weather
of summer in that country, and especially that of the shores of the
Persian Gulf, has always moderated or directed the course of epidemics
of this pest. In Cairo the epidemics have usually ceased upon the
recurrence of intense summer heat in June. Dampness, and particularly
a thoroughly wet soil, are favorable to the development and spread of
the disease. The marshy regions of the Lower Euphrates, the shores of
the Caspian and the Black Seas, the valley of the Nile, have been the
scenes of repeated visitations. On the other hand, the plague has
maintained its foothold in the mountainous districts of Western
Arabia, in Yunnan, on the slopes of the Himalayas at a great
elevation, and upon a dry, non-alluvial soil even more firmly than in
the low and humid plains of Mesopotamia.[5]
[Footnote 4: _Histoire de la Peste Bubonique en Mesopotamie_, 2d
Mémoire, Paris, 1874.]
[Footnote 5: Tholozan, _Histoire de la Peste Bubonique en Perse_, 1st
Mémoire, Paris, 1874.]
Individual predisposition to contract the disease seems to be
increased by all depressing influences, among which may be mentioned
excessive bodily or mental exertion, intense and prolonged anxiety,
fear, and the like. Previous debilitating disease also increases the
liability to the attack. Neither sex nor age exerts an influence in
this respect, save that after the age of fifty few contract the
disease. Occupation confers no immunity. Physicians, nurses, and
others occupied in the care of the sick, and those who bury the dead,
have especially suffered in recent[6] as well as in the older
outbreaks. Oil-carriers and dealers in oils and fats, and to a less
degree water-carriers and the attendants at baths, are said to enjoy a
comparative immunity from attack. Those who have suffered from the
disease and recovered also enjoy a relative immunity. Second attacks
are usually of less intensity than the first.
[Footnote 6: See summary of a report addressed by Dr. G. Cabiadis to
the Constantinople Board of Health on the outbreak in Astrakhan in
Russia, 1878-79, by E. D. Dickson, M.D., _Medical Times and Gazette_,
1881, vol. i. pp. 4, 32, 119.]
2. The Exciting Cause.--The exciting cause of the plague must, in
{776} the present state of our knowledge, be assumed to be a specific
infecting principle. Upon no other hypothesis can the continued
existence of a disease so specific in its characters, unchanged
through the course of centuries, disappearing when the influences
favorable to its presence cease, reappearing in certain regions when
they again arise, be explained. Capable of being transmitted by the
vehicles of commercial intercourse, of control by quarantine and
cordons sanitaires, of spreading from limited foci of contagion into
overwhelming epidemics, the plague is the very type of the infective
diseases. The nature of this infecting principle is wholly unknown. It
is probably a microphyte capable of development within the human
organism--capable also of a prolonged independent existence under
favorable circumstances outside of the body, and of again giving rise
to the disease. The plague is properly to be classed as a
contagious-miasmatic disease (Liebermeister) with cholera, dysentery,
and enteric fever. It continues to exist by the continuous propagation
of its cause, and it spreads by the transportation of that cause.
It is conceded on all hands that the plague has never arisen
autochthonously in Europe, but has in every instance been conveyed
thither. Those who regard its reappearance after long intervals of
time in those countries where it still occasionally prevails as
spontaneous are compelled to ignore difficulties in reasoning far
greater than the supposition of an equally prolonged condition of
quiescence or an inexplicable or unsuspected reintroduction of the
cause.
As to the disputed question of the contagiousness of the plague, to
set forth the arguments and examples adduced in favor of either view
would far exceed the limits of the present article. All the facts are
to be explained upon the theory that the exciting cause of the plague,
like that of cholera and enteric fever, consists of a miasm that must
undergo certain changes outside the body before acquiring its virulent
properties, and that the time required for these changes is
exceedingly brief. But what the physical properties of this miasm are,
or how it finds access to the body, or how it is eliminated, are alike
utterly unknown to us.
It is certain, however, that it is incapable of being freely
transmitted to great distances in the air. Whether or not it is
conveyed or retained by the discharges from the bowel is not known.
The history of recently observed outbreaks, from which alone definite
and trustworthy facts are to be obtained, goes to show that the
exciting cause of the plague clings closely to the patients and their
immediate belongings. The closer the relation between those sick and
the healthy, the greater the risk that the latter will contract the
disease. Those in the house with the patients are more liable to fall
sick than those in the adjoining houses--those who are constantly in
their presence than those who occasionally see them. Thus, nurses much
more frequently contract the plague than doctors, though the latter
have in all epidemics been largely numbered among the victims. Among
357 deaths in the outbreak in Vetlanka, already referred to, were a
priest, his wife and mother, three doctors, six assistant medical
officers, and two Sisters of Mercy. Dr. Cabiadis remarks that the
information obtained "shows that the malady propagated itself, in the
first instance, from the sick to their relatives and to those who
lived with them or who assisted them during their illness. If, on the
one hand, these facts showed its contagious character, on the other
hand evidence is {777} still wanting to prove whether this
transmission of the malady was caused by contact with the sick and
their clothing, or by breathing an atmosphere impregnated with the
deleterious particles emanating from their morbid bodies."
The period of incubation is from two to seven days. In the report of
the commission of the French Academy of Medicine, drawn up by Prus in
1844, the statement appears that the plague has never shown itself
among compromised persons after an isolation of eight days. The recent
outbreaks tend to confirm this conclusion. L. Arnaud concluded from
observations made at Benghazi in 1874 that the mean duration of this
period was five or six days, and that the maximum did not exceed eight
days. Cabiadis sets this stage down as three days as the rule, but as
occasionally not exceeding twenty-four hours. He found no data,
however, to show the longest period to which it could extend. Hirsch,
from information collected in his investigation of the same epidemic
(that of Astrakhan), concluded that the minimum period of incubation
observed was from two to three days, the maximum more than eight, and
that the average was five days. He states that very short or very long
periods were seldom observed.