_WHAT IS IT?_
Any contagious and fatal epidemic disease was originally called a plague
(from _plaga_, a stroke), but this term is now applied to that
particular kind of plague which is characterised by the appearance of
high fever with inflammation of lymphatic glands or bubo, and is
therefore called the Bubonic Plague. In Sanskrit Medical Books it has
been described as _Vidradhi_ and _Visharpa_, and in Yonani as _Taoon_.
The following definition given by Cantlie is comprehensive. “Plague or
Malignant Polyadenites is an acute febrile disease of an intensely fatal
nature characterised by inflammation of the lymphatic glands, marked
cerebral and vascular disturbances, and by the presence of a specific
bacillus.”
_ITS HISTORY._
It is an ancient disease mentioned in Hindoo and Christian Scriptures.
Long before the Christian era it prevailed in Greece, attacking the town
of Piræus, where it raged for two years. Egypt, Syria, Constantinople
and Rome were visited by the plague. In Constantinople the outbreak was
once so furious that during three months from 5,000 to 10,000 deaths
occurred daily. The first historical allusion to plague was made by
Rufus, a physician who lived in the reign of Trajan (A.D. 98-117), and
who mentions of glandular swellings. In 1347, plague appeared in almost
all countries in Europe, where Hecker believes, 25 millions of persons
perished. Ireland was visited by plague three hundred years after its
invasion by Patrolan, and it is said that 9,000 people died in a week
and were buried at Tallagh near Dublin—a name which means the burial
place of the plague-stricken. Plague visited England frequently, and no
fewer than eighteen epidemics are said to have occurred before the great
plague of 1665. In 1720, 40,000 out of a population of 90,000 died at
Marseilles. In 1751, 150,000 died of plague in Constantinople. In 1799
the French Army in Syria was devastated by plague. 6,000 persons died in
Malta in 1813. In 1834-35, 14,888 persons died in Alexandria out of a
population of 42,000. In 1876 there was an outbreak of the disease at
Kumaon in Northern India, where it prevailed several times during the
present century, and where it is known as the _Maha-Mari_. It is also
said that it prevailed in 1815 on the Island of Kutch, and lasted till
1821 in Kutch and Sindh. It also occurred between the years 1828 and
1838 in Jhansi, Bareilly, Pali and Jodhpore. In China the plague has
been present for a long time in an epidemic form. In 1894 60,000 persons
died at Canton. From Canton it spread to Hongkong and to Amoy. In 1895,
it visited many places in Southern China. In 1896, it was present at
Hongkong. Some people think that the disease has come to Bombay probably
from Singapore. There was an epidemic at Merv when the Bombay outbreak
appeared, others, however, think that the epidemic at Merv was not that
of plague and that the disease has come from Hongkong.
_THE LONDON EPIDEMIC OF 1665._
The following graphic and interesting account of the great London
Epidemic of 1665 is taken from Sir William Guy’s book on “Public
Health.”
“I now turn for a more exact account of the plague of 1665 to the work
of Dr. Nathaniel Hodges, a Fellow of the College of Physicians, resident
in the City, and, as his book shows, in active practice among the
victims of the disease.
“Dr. Munk, in his roll of the Royal College of Physicians of London,
says that he ‘acquired a great name among the citizens of London; that
he remained at his post and continued in unremitting attendance on the
sick,’ and that ‘during the latter part of his life he received a
regular stipend from the City of London for the performance of his
charitable office.’
“Dr. Hodges tells us that about the close of 1664, two or three persons
died suddenly with symptoms of the plague in one family at Westminster,
that some timid neighbours of theirs took fright and removed into the
City of London carrying the taint of pestilence with them whereby the
disease, which existed only in a family or two, gained strength and
spread abroad, and ‘for want of confining the persons first seized with
it, the whole city was in a little time irrecoverably infected.’
“In December a hard frost set in, which lasted three months, and during
that time very few died of the plague. But the disease was not
extinguished; for, in the middle of the Christmas holidays, the doctor
was called to a young man in a fever, who after two days ‘had two
risings about the bigness of a nutmeg,’ ‘one on each thigh,’ with a
‘black hue’ and a ‘circle round them.’ By these and subsequent symptoms,
he judged it to be a case of plague. It did not prove fatal.
“When the frost broke, the disease gained ground and extended into
several parishes; and the authorities issued an order ‘to shut up all
the infected houses,’ so as to prevent ingress and egress. To give
effect to this order, the houses of the infected were to be marked with
a red cross, and to carry the inscription, ‘_Lord have mercy upon us_,’
and a guard was set whose duty it was to hand food and medicine to the
sick, and to prevent them from going abroad till forty days after their
recovery. In spite of these harsh measures, ‘the plague more and more
increased.’ Nor will this surprise us if we imagine the frantic and
successful efforts that must have been made by the non-infected to
escape, and the temptation to servants and nurses to appropriate and
remove the property of the dying and dead. Indeed, Dr. Hodges accuses
the nurses of strangling their patients, and secretly conveying the
pestilential taint from sores of the infected to those who were well;
and he justifies his accusation of ‘these abandoned miscreants,’ the
Gamps and Prigs of the seventeenth century, by two instances; the one of
a nurse who, ‘as she was leaving the house of a family, all dead, loaded
with her robberies, fell down dead under her burden in the streets,’ the
other of a ‘worthy citizen’ ‘who, being suspected dying by his nurse,
was beforehand stripped by her; but recovering again, he came a second
time into the world naked.’
“In spite of the well intentioned measures of the authorities, the
plague continued through May and June with more or less severity,
sometimes in one place, sometimes in another, till the people becoming
thoroughly frightened, flocked out of town in crowds. But the disease
raged with redoubled fury among those that remained. Then the
authorities bestirred themselves to the utmost. They instituted a
monthly fast; and the King commanded the College of Physicians ‘to write
somewhat in English,’ that might serve as ‘a general directory.’ The
college not only obeyed the royal commands, by inventing a ‘_Plague
Water_,’ consisting of a cordial distilled off from a vinous infusion of
a score of very harmless roots, leaves, and flowers, but also appointed
two of their number to co-operate with two chosen from among the
aldermen in attending the infected; while Dr. Glisson, Regius Professor
at Cambridge, and Drs. Paget, Wharton, Berwick and Brookes volunteered
their help, with many others who survived, and eight or nine who fell
victims to their self-devotion, among whom Dr. Conyers receives
honourable mention.
“Still, in the face of every precaution, the plague continued its work
of destruction, especially among the common people, so as to be called
the ‘_Poor’s Plague_,’ and, in August and September, completely got the
mastery, ‘so that three, four or five thousand died in a week, and once
8,000.’
“And here I will follow Dr. Hodges’ example, and try to give you some
idea of the state of things then prevailing. But in doing so I must
shorten and tone down his description. ‘In some houses,’ he says
‘carcases lay waiting for burial,’ ‘in others, persons in their last
agonies.’ ‘In one room might be heard dying groans, in another the
ravings of delirium,’ and, near at hand, relations and friends bewailing
their loss and their own dismal prospects. ‘Death was the sure midwife
to all children, and infants passed immediately from the womb to the
grave.’ Some of the infected ran about staggering like drunken men, and
fell down dead in the streets, or they lay there comatose and half dead;
some lay vomiting as if they had drunk poison; others fell dead in the
market in the act of buying provisions. The plague spared ‘no order, age
or sex.’ The divine was taken in the very exercise of his priestly
office, and the physician while administering his own antidote; and
though the soldiers retreated, and encamped out of the city, the
contagion followed, and vanquished them. Many in their old age, others
in their prime, most women and still more children, perished; ‘and it
was not uncommon to see an inheritance pass successively to three or
four heirs in as many days.’ There were not sextons enough to bury the
dead, the bells ceased tolling, the burying places were full, so that
the dead were thrown into large pits, dug in waste ground, in heaps 30
or 40 together; and those who attended the funerals of their friends one
evening were often carried the next to their own long home.
“This is written of a time when the worst had not yet happened. It was
about the beginning of September that the disease was at its height.
Then fires were ordered to be burnt in the streets for three days
together; but before the time had expired, they were extinguished by
heavy rains, which ushered in the most fatal night of all with its
register of more than 4,000 deaths.
“From this, its culminating point, the plague, ‘by leisurely degrees
declined,’ ‘and before the number infected decreased, its malignity
began to relax, insomuch that few died, and those chiefly such as were
ill-managed.’ Dr. Hodges distinctly states that the pestilence did not
stop for want of subjects, but from the nature of the distemper. ‘Its
decrease was, like its beginning, moderate.’ Early in November, people
grew more healthful, and though the funerals were still frequent, ‘yet
many who had made most haste in retiring, made the most to return;’
‘insomuch that in December, they crowded back as thick as they fled.’
The houses were again inhabited; the shops re-opened; the people went
cheerfully to their work; the rooms, in which a short time before
infected persons had breathed their last, were peopled afresh, and many
went into their beds ‘before they were even cold or cleansed from the
stench of the diseased.’ ‘They had the courage now to marry again,’ ‘and
even women, before deemed barren, were said to prove prolific, so that,
although the contagion had carried off, as some computed, about 100,000,
after a few months, their loss was hardly discernable.’ But the next
spring there appeared ‘some remains of the contagion,’ which was easily
conquered by the physicians; and the whole malignity ceasing, the city
returned to perfect health, as after the great fire, ‘a new city
suddenly arose out of the ashes of the old, much better able to stand
the like flames another time.’”
_GEOGRAPHICAL DISTRIBUTION._
Plague is known in Europe, Asia and Africa, but it has not been known in
the Western Hemisphere. It is said that Mesopotamia is the home of
plague. It has been known as far North as Astrakhan in Asia and Norway
in Europe. During the last fifty years, however, it is chiefly confined
to Asia from Red Sea on one side, and the shores of the Pacific on the
other. Some are inclined to think that the plague was carried from
Himalyan India across Thibet to Yanon in Chinese territory, thence to
Pekoi whence it made its way to Canton and Hongkong. If that be so, then
the plague has accomplished a tour from Northern India _viâ_ China by
Sea route to Southern India within a period of twenty years between 1876
and 1896.
_CAUSES_—
A disease so fatal in its nature and against which human power is so
futile was in ancient times naturally attributed to wrath of the gods.
Supernatural, astrological, and, in some instances, rationalistic causes
were assigned to it. In the fourteenth century the College of Physicians
of Paris ascribed it to the influence of constellations in India. But
more natural explanations, however, gradually followed. Putrefaction of
dead animals was assigned as a cause in Egypt. Poisoning of water-supply
was also believed to be the cause. Undue heat, rain, watery grain, and
absence of the Etesian winds were thought to generate plague. Leaving
ancient theories on the causation of the disease we find that modern
Scientists divide themselves into two classes: _first_, those who
believe in the germ theory and attribute the plague to a specific germ,
holding that germs can never arise _de novo_; _second_, those who
believe that atmospheric changes and certain telluric conditions or
insanitary surroundings engender the seeds of pestilence which are
carried through air, water or other media. The arguments in favour of
the first theory are, however, so strong and overwhelming, that it is
now almost universally accepted that plague is due to a specific poison
which grows and multiplies under favourable conditions, and that
wherever it occurs it is caused by the implantation of those germs in a
suitable soil. If the soil is not fit, the germs may be sown, but they
will not germinate and, if the soil is fit but the germs are absent, the
disease will not be seen. The soil best suited for the plague seed is
one where insanitary conditions prevail. Dirt and filth, bad
ventilation, and overcrowding are its manure. The history of plague from
ancient times fully illustrates that plague thrives in dirt, filth,
squalor and misery. Diseased grain and want of subsoil drainage are held
to be potent factors in the diffusion of plague.
_BACILLUS_—
During the Hongkong epidemic the great Japanese bacteriologist Kitasato,
who formerly worked with Koch in Germany, discovered a bacillus in
plague-stricken patients, and showed by experiments that these bacilli
if injected into lower animals produced in them symptoms of plague.
Yersin simultaneously discovered the same germs in connection with
plague. According to our modern notion of the causation of the disease,
these germs must be considered to be the specific poison which produces
the symptoms of plague. The bacilli are found in the blood, in the
buboes, and in all internal organs of the victim of the plague. They are
short rods with rounded ends, with a clear space or band in the centre,
readily stained by the aniline dyes and showing very little power of
movement. The size of the plague bacillus varies, and bacilli of same
character, but of less virulent nature, have been found in the soil of
infected places. Some bacteriologists observed some development after
death in the bacilli, this, if confirmed by observations at Bombay, will
be highly interesting from a bacteriological point of view. If mice,
rats, guinea-pigs and rabbits are inoculated with the plague bacillus,
they soon become infected and die, and in their internal organs the same
bacilli are found. They are also found in the soil and dust of houses
where plague patients were kept, but not invariably so. Kitasato found
the bacilli in the blood of patients convalescing from an attack of
plague even three or four weeks after all symptoms have disappeared. It
has been found that the bacillus dies after four days, during which it
is kept at a dry heat, or at the temperature of 80°C. or 176°F. for half
an hour, or at that of 100° C or 212°F. for a few minutes. Its resisting
power to chemical disinfectants is feeble, dying in a 1 per cent.
solution of carbolic acid or of lime water. It develops easily in many
culture media at the ordinary temperature (from 18° to 22°C). An
alkaline solution of Peptone 2 per cent., with from 1 to 2 per cent. of
gelatine, is the best nutrient medium for its cultivation.
_CONTAGIOUS AS WELL AS INFECTIOUS._
Experience has proved that plague can be transmitted from one person to
another by direct contact; when a case of plague occurs in a house,
other inmates of the house are much liable to be attacked also. Visitors
to the house, medical and other attendants are also liable to be seized
or to carry with them fresh focus of infection. It was, however, found
in the Hongkong epidemic of 1894 that none of the European medical men,
some fifteen in number, nor any of the Chinese students who were on duty
at the plague hospital died. During the Egyptian epidemic of 1835 a
French doctor, Bulard, with the courage of his conviction that plague
was not contagious wore the shirt of a patient who died from plague, and
yet did not contract the disease. Such immunity, however, was probably
due to some circumstances which might be easily explained. In the
Hongkong epidemic of 1894 three Japanese medical men contracted the
disease, and in 1896, some European nurses were attacked. In Bombay the
sad deaths of Surgeon-Major Manser and Miss Joyce prove that contagion
plays an important part in the spread of the disease.
It has been maintained that plague is a miasmatic or soil-bred disease,
and that the germs find in earth, water or in some form of fermenting or
decomposing material a suitable nidus for growth. In this sense it is
like malaria, which is endemic in a particular suitable area appearing
and disappearing according as climatic or other conditions are
favourable or unfavourable. The Chinese have a peculiar idea of the
infection of plague. They consider that the plague rises from the soil
and believe that it first attacks small animals with breathing organs
near the soil, such as rats, then animals with breathing organs a little
higher, such as poultry, pigs, dogs, goats, cows, so on till it reaches
man, whose breathing organs are higher from the soil than those of other
animals.
The rats are undoubtedly attacked with plague before and during its
prevalence among human beings, and they play an important part in the
spread of its infection. In Kumaon this rat plague was observed by the
people, and was recognized as a forerunner of the plague. The _Times of
India_, September 30th, 1896, contains the following:—“It was known more
than a month ago to all the people of Mandavi and to all the municipal
sweepers in the district that the rats were dying in thousands all over
the districts. They were found dead and dying almost everywhere, and in
places where dead rats were never found before.” In Bombay an instance
has been reported of a man trampling with bare foot on a rat which was
seen slowly passing in a room and getting attacked by the plague soon
after. Pigs, dogs, snakes, and jackals are said to be also affected by
the plague. It will be seen that flesh-eating animals are the sufferers,
due evidently to their eating plague flesh. Snakes swallow rats, and
rats become infected by consumption of poisoned material or from
infected soil or by their cannibal habit. Like other diseases due to a
specific germ, the infection of plague may be caught from various
sources such as the following—(_a_) By means of breath. Plague dust and
dirt are very potent infective agents. A man getting a whiff of dust
from the floor of a room in which there is a plague patient blown into
his face may get the infection. Sweepers and others engaged in
conservancy are, therefore, easily attacked. (_b_) By food or drink.
Grain adultered with sand or earth infected by rats may be a source of
infection. Food may also be infected by flies or diseased rats (_c_) By
direct inoculation through any abrasion in the skin or mucous membrane.
People with bare feet are, therefore, more liable to catch the
infection. The infection may be spread by infected linen, bedding,
furniture and fomites. The discharge from buboes contains the germs, and
is, therefore, highly poisonous. The fæces, the urine, the sputum, the
fur on the tongue are also infective. If the theory be true that the
poison attaches itself to the soil, then persons living on ground-floor
are more liable to the infection, and a floating population less so.
Dust laden with germs is the principal agent in the diffusion of plague
as that of any other germ disease. Professor Aoyama of Tokyo, whilst
making a _post-mortem_ examination, scratched the left third finger and
was attacked with the plague, also Dr. Ishigami, assistant to Kitasato.
_NATURE OF AN EPIDEMIC._
Plague is a very slow disease; it takes some weeks to travel from one
quarter of a city to another. It took nine months to travel from the
city of London to Soho, and ten from Hongkong to Macao—a distance of 30
miles. Thousands of persons from Canton and Hongkong sought shelter at
Macao, and there was free communication between these places, still
Macao became affected nine months after plague ceased at Hongkong. When
plague is first imported in a place, for three or four weeks isolated
cases occur in one neighbourhood. An epidemic may last only a few weeks
or months, but may extend over several years in sporadic form and a
recrudescence takes place abruptly. In Mesopotamia plague declines and
becomes dormant with the setting in of the hot weather, its activity
reawakening in winter and gathering force with the advancing spring. The
same was the case in Egypt. In Constantinople, on the contrary, as well
as in England, the disease was dormant during the cold months but became
active during the hotter. In England, September was the month of
greatest prevalence. In the epidemic at Bengazi in 1858 as well as in
Mukai in 1863 famine and plague were found together. That a water-logged
soil favours famine was illustrated during the epidemic on the Lower
Euphrates in 1867. In Persia and Arabia many epidemics were self-limited
and spontaneously came to an end after spreading on a certain area,
while, on the other hand, it has been known to obtain an endemic
foot-hold, the virus remaining from year to year, and, occasionally
under the influence of meteorological or unknown causes, becoming
epidemic among the population.
_Race._—No race seems to enjoy an immunity from the plague.
_Geology and Climate._—Except the new hemisphere the plague has found
congenial soil everywhere. It thrives as much in high and dry altitudes
as in low-lying places, as much in overcrowded towns as in sparsely
populated semi-desert regions. In temperate regions it has been known to
rage in summer, but in Astrakhan it prevailed when there were several
feet of snow on the ground. On the Volga it prevailed during the
severest cold (1878-79), as well as in the extreme heat of Smyrna
(1735). In Bombay it commenced at the end of an exceptionally dry
season, as it did in South China. During the Hongkong epidemic the rains
increased it. The increase of the epidemic at Hongkong with the rains
was probably due to the fact that the rains drove people into infected
houses, instead of sleeping outside, as they did in summer when the
weather was good. It has been said that plague flourishes in a warm
moist atmosphere and dry hot air kills it, but there are records of
plague thriving in conditions antagonistic to this theory. A temperature
between 60° and 85°F. is said to be very favourable to it.
_Sex and Age._—Both sexes are equally liable. It is said that people
between the ages of 10 to 30 are frequently attacked. But experience
shows that children and old people are alike liable to attack. In Bombay
the disease has occurred most frequently between the ages of 20 and 30,
and the male sex has suffered more than the female.
_Occupation._—During one epidemic, water-carriers, or those who used
much water, or who dealt in oil and fats were found comparatively free;
but this observation cannot be relied upon. Those whose business
requires them to come much in contact with the sick, and also those who
are engaged in cleaning are naturally more exposed to infection. It has
been said that one attack generally protects from a second, which, if it
occurs, usually runs a mild course.
_Sanitation and Personal Hygiene._—Plague, germs thrive in filth. Bad
hygienic conditions, over-crowding, insufficient ventilation, and
absence of sunlight in dwelling houses, accumulation of decomposing
organic matter, effluvia from bad drains, sewer and cesspools are causes
that favour the growth and dissemination of an epidemic of plague. When
it attacks a town, it, therefore, naturally selects first the poorer
classes who live in ill-ventilated and over-crowded houses.
Over-crowding within dwelling houses is a fertile source of producing a
constitution fitted for the reception of plague-germs. Such portions of
towns where there is much congestion and over-crowding suffer most.
Scarcity of food favours plague. It has been called _Miseriæ Morbus_, or
the disease of misery, and the plague of London was called the “poor’s
plague.” In Kumaon there is the usual custom of keeping cattle in the
lower room of a hut, where a crowd of cattle stand udder deep in fœtid
straw. In one of the rooms of the upper storey grain is kept, and in
another the whole family sleeps with doors and windows shut. Such
conditions are undoubtedly very favourable to plague.
_Predisposition._—Chill and exposure to cold, indigestion and any other
disease producing a debilitated condition of body, fatigue, overwork,
error of diet, mental emotion, and a terror of attack are predisposing
causes. Catarrhs often predispose an attack.
_INCUBATION._
Or how long does it take for the poison to develop symptoms after
infection: generally three to six days, but the period may be up to ten
days. The period varies with the virulence of the poison. The germs,
however, remain active outside a host for a long time. An instance has
been reported, in which a man, after handling some ropes which 20 years
previously had been used in the burial of plague corpses, took the
disease and died of it.
_SYMPTOMS._
The usual premonitory symptoms are headache, loss of appetite, a feeling
of general depression and aching of limbs. These symptoms may either be
mild or may appear at once in very aggravated form; violent headache
being usually of an acute dull character, accompanied by throbbing in
the temples, giddiness, sleeplessness, palpitation, a feeling of
oppression of the chest, even mental delusion may appear on the first
day. The look of the patient is anxious, pale and cyanosed. The
expression of the face resembles that of a man who has had no sleep for
two or three nights but is being overpowered with the fatigue consequent
to it. These symptoms are usually ushered in with a rise in the
temperature. Well-marked rigor is usually not seen, but a slight shiver
or chillness is complained of. Pulse is full, bounding and rapid—130 or
more per minute. Respiration is difficult and accelerated even to 40 or
50 per minute. Skin is dry and hot, face puffed, conjunctivæ congested.
Sense of hearing is dull. Speech is thick and faltering. Tongue is dry
and coated with greyish white or dark brown heavy fur. Violent thirst is
present. Sometimes Patchiæ appear on the skin. In a few hours, or a few
days after the appearance of the first symptoms, a swollen gland appears
either in the neck or axilla or groin. The gland most commonly affected
is one or some of the femoral chain. An inguinal, axillary or a cervical
gland may also be affected. A number of glands may swell at one time or
glands in all the above situations may be felt painful and swollen. The
glands of the neck are most frequently attacked in children. Pains in
the lower part of the abdomen and along the spine indicate affection of
internal lymphatic glands. In some cases the first symptom noticed is a
swollen and painful gland, but fever soon manifests itself. The
glandular enlargement may antedate, coincide with, or follow the rise in
temperature. Sometimes only pain in the gland is complained of, but no
swelling is observed. The temperature rises gradually and goes up to
104°, 105° or 106° F. In some cases a temperature of 108° was observed.
There may be a marked morning fall and an evening exacerbation, which is
a favourable sign, or the temperature may remain high persistently. All
the above symptoms become soon aggravated when the second stage or stage
of acute development of the disease appears. Brain symptoms show
themselves. Lowson noticed four distinct type of brain symptoms—(1)
comatose, when the patient lies paralysed, mind and body; (2) wildly
delirious, when the patient struggles and fights and still retains a
fair command of rational speech; (3) apathetic, when he lies perfectly
quiet but is drowsy; (4) convulsive, which condition occurs when there
is inflammation of the meninges or hæmorrhage in the brain.
In this stage all symptoms of a pronounced typhoid condition supervene.
Tongue becomes parched and black. Sordes cover the teeth. Gradually a
somnolent condition and low muttering delirium supervene. In some cases
the delirium is violent and furious, while in others it culminates in
complete stupor and coma. Picking of the bed-clothes, and subsultus
tendinum are common, and the urine and fæces are passed involuntarily.
The pupils are dilated. The skin is bathed with profuse perspiration.
The pulse is dichrotic and compressible, and gradually becomes
anachrotic and intermittent till it finally fails. The area of cardiac
dullness is increased and pain in the cardiac region is complained of.
Heart begins to fail rapidly. The usual complications of this stage
are—(1) meningites; (2) hæmorrhages; (3) severe gastric disturbance,
such as vomiting, diarrhœa, hiccough. As a rule, constipation is found
during the course of an attack, but diarrhœa, even severe, may appear.
There may be pain in the abdomen. Bladder may be distended and a
catheter may be necessary to evacuate it. Cystitics often develop. Œdema
of the lungs, pleurisy and pneumonia may also complicate a case.
Hæmaturia, hæmoptysis and hæmatemesis may be seen. Bronchitis and
hypostatic inflammation may occur. The urine always shows presence of
albumen. Death may take place from cardiac failure or from any of the
above complications. Death may take place within three or four days,
though in some virulent cases the patient dies within twenty-four hours.
If the primary collapse is tided over, there is great chance of
recovery, still deaths often occur of complications several days after
the attack.
In mild cases the second stage is not so severe, and temperature may
fall by lysis or crisis—the latter being rare.
The glands in the meantime become swollen and are surrounded by a
sero-sanguinous exudation. The surrounding parts are œdematous. The
glands usually do not suppurate, but they may do so and slough. The
usual course after their enlargement is one of four: (1) resolution; (2)
lengthened period of enlargement; (3) suppuration; (4) sloughing. In
cases that recover the symptoms gradually take a favourable turn and
recovery is as rapid as the attack. The fever slackens, the pulse
becomes stronger, the tongue moist and the typhoid symptoms gradually
pass away. The buboes either suppurate or subside; symptoms of secondary
pyaemic conditions, however, may sometimes develop. Deviations from the
typical course are, however, often observed. Some cases take an
extremely rapid course, the patient succumbing within from 12 hours to
two days. The duration of the disease varies between a few hours and a
few weeks, but on an average up to the commencement of the convalescence
it seems to last from 6 to 10 days. During convalescence the vitality of
the issues are very low. Head symptoms sometimes persist for some time.
Temper is irritable. The sloughing glands often take a long time to
heal. Convalescence is soon established.
_VARIETIES._
Just as before an epidemic of cholera visits a place, it is usual to
observe cases of mild diarrhœa, and indigestion prevailing amongst its
population; so, before plague actually breaks out, it has been found
that cases of buboes and parotites with fever are commonly observed.
Such cases were called _Pestis Minor_ at Astrakhan. “No one died from
the disease _per se_, but few people were confined to bed.” It is not
known whether in _pestis minor_ the plague germs could be found; but
presumably not.
Drs. Simpson and Cobb of Calcutta have described what is called _Pestis
Ambulans_, or an ambulatory form of plague, in which plague germs have
been found. The commonly accepted types of plague are (1) Fulminant; (2)
Typical; (3) _Pestis Minor_ (including _ambulans_). The cause of the
first two is the bacillus discovered by Kitasato, and they are very
fatal, of the third, the cause may be an allied bacterium less potent to
produce toxic effects on man, and it may come and go but plague may not
break out. In ambulatory form the patient has slight fever and glandular
enlargement, but he can move about.
_DIAGNOSIS_—
It is difficult to differentiate a case of true plague in its early
stages from a case of fever with benign glandular swellings or mumps.
The premonitory symptoms of plague, and even the early symptoms of the
first stage, may be due to many different diseases and therefore great
caution is needed. It is needless to say how important it is that such
diagnosis should be done with great care, specially when plague cases
have to be isolated, for if a case of simple fever with benign
lymphadenitis be brought in close contact with patients suffering from
true plague, it is a serious matter with the former. A venereal bubo, or
scrofulous enlargement of glands, or enlargement of femoral or inguinal
gland due to traumatic or other causes which may be attended with fever
should not be mistaken for a plague symptom. A medical man who has,
however, carefully observed the facies of a few cases of true plague,
and who carefully takes into consideration all other probable conditions
which may be mistaken for plague, may not commit a mistake, but its
probabilities are to be borne in mind. The practical lesson is, that all
doubtful cases should be isolated and kept separate from cases of
pronounced type. The plague bears some resemblance to typhus. Murchison
says: “Plague is perhaps the typhus of warm climates, the two diseases
being generated from similar causes and differing only in intensity from
the effects of climate and other collateral circumstances.” In typhus
there is a characteristic rush, and in plague there is bubo, but this
order of things have been found in some instances to have changed, there
being eruption in plague and bubo in typhus. The two diseases are,
however, different and bacteriological and clinical evidence corroborate
this view. Cantlie adds another disease, which he says he mistook for
plague:—“On June 26th, 1894, when the plague was at its height, I saw a
Parsee patient dwelling in a house in which plague existed, suffering
from fever 104°(F.), dry tongue, headache, backache and large swollen
glands in the left groin, which had suddenly appeared. Plague seemed the
only diagnosis, and the man, much against his will, was sent to the
plague hospital. In two days he came back again quite well, and on
examining him I found his urine thick and milky. That night I found
filaria in the man’s blood, and knew I had made a mistake in the first
instance. Of course, the mistake is most likely to happen, but
nevertheless it is not pleasant to think that we had subjected the man
to the terrible danger of plague infection.”
_PROGNOSIS._
The mortality from plague may be about 90 per cent. or more when the
epidemic is at its height. In the beginning, or towards the end of the
epidemic, the mortality is less, as it is the case with all other
epidemic diseases. The average mortality at Bombay has been 84 per cent.
and in Karachi 89 per cent. It is, therefore, more fatal than all other
epidemic diseases, the mortality from cholera during the height of an
epidemic being about 60 per cent.
In children and in the aged the disease is more fatal than in healthy
adults. Cases in which the bubo appears early and is single, or in which
there is a distinct morning remission, or less general prostration or
free perspiration, or in which there is no diarrhœa, have greater chance
of recovery. Rapid suppuration of the buboes indicates a favourable
termination. Buboes do not suppurate as a rule until the primary fever
has fallen. On the other hand, carbuncles, multiple buboes (specially on
the neck), meningitis, hæmorrhages, pleurisy, pneumonia, diarrhœa,
gastric irritation, cyanosis, jaundice and continued pyrexia are
unfavourable signs.
_MICROSCOPIC AND MACROSCOPIC APPEARANCES._
Bacilli are found in all the internal organs, notably in the spleen, in
blood and in the enlarged glands.
Body does not show much emaciation; decomposition commences early. Black
hæmorrhagic patches are often found on the skin. The brain and membranes
are congested. Sanguinous or serous effusions are found in serous
cavities. Right side of the heart is dilated and is usually found full
of coagulated or liquid blood. Cardiac muscles pale. The liver is
enlarged and congested. The spleen is much enlarged, soft and congested.
Hæmorrhagic patches have been found in the stomach. The mesenteric
glands are enlarged. Kidneys congested. Bladder is sometimes found
filled with bloody urine. The buboes are sometimes found to be soft and
caseous. The tissues surrounding them are infiltrated with a reddish
gelatinous exudation. The whole lymphatic chain from groin to the glands
of the sacral or lumbar plexus, or from the axilla and neck to the
glands of the mediastinum are affected. The internal glands are found
more or less enlarged, injected and infiltrated with sanguineous fluid.
The lymphatic follicles and Peyer’s patches in the intestines are found
swollen. Hæmorrhages are found in the mesentery.
_PREVENTION._—
It is evident from what has been said that to prevent plague our efforts
should be directed in two ways:—(1) To prevent the importation of germs;
(2) to make the environment of a place such that the germs, even if
imported, may not find suitable condition for their growth. To
accomplish the first we need (_a_) inspection of people coming from
infected places; (_b_) stopping importation of such articles as may
carry infection with them; (_c_) quarantine, a word which owes its
origin to the fact that, daring the epidemic of plague at Milan in 1527,
patients when cured were despatched to lazarettos and detained there 40
days.
For the second, we require (_a_) sanitary precautions by guardians of
public health; (_b_) observance of rules of personal hygiene by which
good health can be maintained.
(1). Wherever possible a medical inspection should be made to prevent
importation of the disease. This is, however, a very difficult matter,
and one unforeseen difficulty was experienced at Sukkur, where it was
found that people booked to stations short of Sukkur, and rebooked at
stations on the other side. Still this measure is highly important, and
should be carried out most rigorously as long as there is any chance of
importation of plague into an unaffected country. It is needless to feel
the pulse of the patient; his gait, temperature, and look would afford a
great deal of information. Information should be obtained from where the
patient is travelling. An examination should also be made of clothes.
Dirty clothes, soiled linen and rags should not be allowed to pass
through an inspection post.
(2). There should be a disinfecting or sterilizing room fitted with a
steam sterilizer in all large railway stations, where all goods should
be disinfected. Mail bags should also be subjected to this disinfection.
Transmission of such goods as corpses, used clothes, rags, waste paper,
fur, hide, feather, and fish should be entirely suspended.
(3). If quarantine is imposed, it should be for a period not less than
ten days. Every arrangement, however, should be made for suitable
accommodation and sanitation in quarantine camps. In a quarantine camp
new arrivals should not be mixed up with those who are already in
quarantine.
(4). Ships from infected ports should be carefully watched. If any
infection is discovered, then isolation of the sick, disinfection of the
ship and quarantine are required, but ships with clean bills of health,
and if ten days have passed since its departure from the infected port,
may be admitted after medical inspection. It must, however, be borne in
mind that rats could easily carry infection from one port to another
without any fear of detection. These facts show that medical inspection
and quarantine may be useful, but they can never be perfect, and
therefore the principal safeguard of a place lies in the improvement of
its sanitation, and therefore greater attention and energy should be
directed towards it.
_Sanitary Measures that should be taken by Municipal and Railway
authorities._
(1). All filth should be removed from the vicinity of towns and villages
and _burnt_, and no filth of any kind should be allowed to remain within
an inhabited area for any length of time.
(2). All private and public latrines and public urinals should be
cleaned and disinfected daily. All receptacles used for night-soil
either in the latrine or for transport should be daily disinfected.
(3). Latrine accommodation, according to the requirements of the
population, should be provided.
(4). Drains should be well washed and flushed with a disinfectant
solution. In towns where there is an underground sewer, it should be
well flushed and ventilated, and a disinfectant solution used for
cleaning it. A house-to-house examination should be made to ascertain
that all house-connections are properly and efficiently trapped.
Deposits in the sewer should be taken out and suitably disposed off
after disinfection.
(5). Special attention for cleansing should be given to the following:—
Cesspools, privies, cow-houses, stables, slaughterhouses, markets,
workshops, common lodging houses, serais, bustees, and crowded quarters
of a town.
(6). All public roads should in the dry season be watered with a weak
disinfectant solution.
(7). Pure drinking water should be supplied. All articles of food should
be inspected. Musty and decomposing grains should not be allowed to be
sold. The meat market, dairies and bakeries should be under strict
sanitary supervision.
(8). Over-crowding in houses should be prevented. Steps should be taken
for spreading out the population of much over-crowded and congested
parts of towns.
(9). Lime in a dry state and in solution should be abundantly used in
drains, &c.
(10). All railway carriages travelling through infected areas should be
daily washed with a reliable disinfectant solution, such as 5 per cent.
carbolic acid.
(11). Railway platforms, waiting rooms and halls, and latrines should be
frequently cleaned and disinfected.
(12). There should be a system of house-to-house inspection to ascertain
the sanitary condition of dwelling-houses, and also to find out, as far
as possible, the condition of health of the inmates.
Common lodging houses, serais and houses of a similar nature should be
most carefully examined.
(13). If plague breaks out, then isolation of cases is a great
necessity. When practicable, such isolation may be done in the house of
the patient. The patient should be kept in a separate room apart from
those where other inmates of the house live. A temporary room could be
put up on the roof of a house or in the compound, if there is any, or a
tent may be pitched. Where possible, all healthy inmates of the house
should at once remove themselves in camp leaving only such near
relatives who must attend and nurse the patient. For patients living in
lodging houses, or, where there is no means of such isolation as stated
above, segregation in special isolation hospitals should at once be
done. The isolation hospitals should be separate for each of the
following classes—(_a_) for lower class people; (_b_) for middle class
people; (_c_) for such people of the middle or upper class who may chose
to pay for their expenses. It is needless to say that there should be
special hospitals for women, where only female attendants and nurses
should be employed. Hospitals should be provided with means for free
ventilation, both for the sake of patients as well as attendants. No
other disease requires more careful nursing than the plague, therefore
ample nursing staff should be provided. The hospitals should have a
separate observation ward and a separate convalescent ward, and by no
means doubtful cases should be mixed up with confirmed cases.
Disinfecting apparatus, sterilizers, good water supply and special
laundry are other adjuncts essentially necessary for a plague hospital.
Greatest care is required in the management of such a hospital, and only
trained men should be employed.
Suitable means for ambulance should be provided, and should be had ready
within convenient distances. They should be thoroughly disinfected after
the conveyance of any case. Ambulance carts or doolies should be
comfortable, for physical exertion and exhaustion, attending a long
journey in the early stage, greatly compromise chance of recovery.
Burial within inhabited areas of a town or village should be stopped.
Dead bodies should be removed under strict precautions for disinfection
and disposed off quickly. Bodies should be buried deeply—4 to 6 feet.
_PRIVATE HYGIENE._
I. Houses and compounds, stables, kitchen and outhouses should be
thoroughly cleaned, and they should be whitewashed with lime. Air-tight
dustbins should be kept in the house.
II. Rooms, specially bed-rooms, should be well ventilated, attention
should be paid to the condition of the floor, which should not be damp,
and care should be taken that rats may not infest the house and spaces
under the floor. If dead rats are found in the house, they should be
removed and burnt, and the place thoroughly disinfected.
III. House drains should be cleaned and well flushed with a disinfectant
solution.
IV. Nowhere in the house or compound should any kind of organic refuse
be allowed to accumulate. Better not use any organic manure in the
kitchen garden or house garden during an epidemic.
V. Articles of food should not be allowed to remain uncovered on the
table or elsewhere, for there is chance of their infection by flies,
mice, or rats.
VI. Clothes received from the dhoby’s house should be again boiled in
water, dried, and then used.
VII. Bed-clothes and wearing apparel should be aired and exposed to the
sun daily. As frequently as possible floors and passages should be well
washed with a disinfectant solution and then well dried.