IX. Drinking water should be boiled before use. Raw vegetables, such as
salad, cucumber, &c., should only be used after thoroughly washing them,
and then with vinegar.
X. Personal cleanliness should be strictly observed. Daily bath,
cleaning the teeth with carbolic tooth powder, and carefully washing
hands and mouth before and after meals are essential.
XI. Those who have to attend on plague cases should be very careful.
Hands should be thoroughly washed with a disinfectant solution, and a
nail brush used soon after the patient or anything in contact with him
is touched. A bath to which some antiseptic is added should be taken
immediately after coming in contact with plague patients. Workers in
plague hospitals should be warned about scratches or wounds on their
bodies. Use of respirators with an antiseptic sprinkled over the
entrance valves is recommended. Only very healthy people should approach
plague cases. On the appearance of slightest headache, languor, or fever
an attendant should be relieved from duty.
XII. As a prophylactic 5 grains of quinine sulphate may be taken twice
daily, or a small bottle containing eucalyptus or some other volatile
disinfectant, may be carried in the pocket, and a few drops may be
occasionally poured on the handkerchief. Smoking good tobacco may have a
prophylactic value.
XIII. If plague occurs in the house, the following steps should be
taken:—
(_a_) The patient should at once be put in bed and kept in a temporary
room, which may be put up on the roof of a house. No healthy inmate of
the house should go in that room or have any connection with the sick,
except those who have to nurse the patient.
(_b_) All discharges, fæces, urine, sputum, vomited matter, &c., should
be taken in vessels with disinfectant solution in it, and some quicklime
should immediately be sprinkled over them. On no account should anything
leave the room but to be disinfected.
(_c_) Floor and bedsteads should be washed with a disinfectant solution,
clothes and other articles that touch the patient should be carefully
disinfected. Crockery and glass should be scalded. If great care and
cleanliness are not observed with regard to the bed and body linen of
the patient, the infection may be diffused through the air immediately
around the patient.
(_d_) A medical man should be at once sent for. Delay is fatal.
_INOCULATION AGAINST PLAGUE._
M. Haffkine, of cholera inoculation fame, has commenced to inoculate
against the plague under the same principles on which his inoculation
against cholera is based. By injecting into the body an attenuated virus
of plague, a very mild attack is produced, which in people inoculated
has proved harmless. This mild attack, it is thought, would protect the
system from more potent forms of the poisonous germs. The inoculation
for plague is still in its experimental stage, and cannot, for obvious
reasons, be applied to a large population. Medical attendants, nurses
and others who, by call of duty, have to constantly come in contact with
plague patients may, however, take advantage of this means of
protection, which, in the hands of M. Haffkine, may yield good results.
Yersin also claims for his serum prophylactic value. In this and all
other matters connected with bacteriology, such as germs,
sero-therapeutics, &c., the medical profession now-a-days receives a
good deal of satirical remarks from sceptical lay public. It is natural
that it should be so, for the science of bacteriology is still in its
infancy, and many of its practical applications are still in their
experimental stage. But undoubtedly the science is advancing, and by its
aid we are now better able to understand diseases and their nature. Many
facts have been demonstrated and proved with precision. What is
disbelieved to-day, may, however, be believed tomorrow, for, with all
human attempt to reveal secrets of nature, such is the case. Readers of
Smollet’s Roderick Random may remember how in the Surgeon’s Hall one of
the examiners said:—“I affirm that all wounds of the intestine whether
great or small are mortal.” Now, however, if a man dies of a wound of
the intestine, the unfortunate doctor in whose hand such a casualty
takes place runs great risk of being charged with malpraxès.
_TREATMENT._
I. _Hygienic._—The patient should take to bed immediately on the
appearance of the first symptoms. The room should have means for free
ventilation, and the temperature in it should be between 60° to 70° F.
The air of the room may be cooled by a block of ice. The room should be
kept clean, and there must not be in it any curtain, carpet or hangings.
The floor and bedsteads should be daily washed with a disinfectant
solution. A position of absolute rest in bed is to be maintained
throughout the illness.
Bedpan and urinal should be always used. Bedclothes should be light and
warm. Wearing apparel if saturated with perspiration should be changed.
It is best to have two beds side by side so as to be able to move the
patient easily from one to another for cleansing purposes. Mattresses
should be suitably protected from penetration by the discharges. The air
of the sickroom can be made antiseptic by placing pieces of blotting
paper saturated with eucalyptus oil or phenol on plates about the
apartment or by pouring carbolic acid on hot water in a plate. The
doorways should be curtained by a sheet wet with disinfectant solution.
Great cleanliness of the body of the patient should be enforced by cold
sponging with an antiseptic solution. Skilful nursing is essentially
necessary. The motions should be disinfected by strong antiseptics such
as quicklime, carbolic acid, &c., as soon as they are passed.
II. _Dietetic._—From the commencement of the disease the diet should be
liquid and nourishing. Milk is best. The quantity for adults should not
be less than three or four pints in the twenty-four hours. It must be
given in small quantities at short intervals. Soda, potash or plain
carbonated water may be mixed with it. Barley water and thin sago water
may also be given. If the patient’s vital powers are low, the milk may
be peptonised by using Fairchild’s powders or by adding a little of
Benger’s Liquor Pancreatices. In cases when milk cannot be taken in
sufficient amount, animal food may be given in the form of plain meat
broth. Egg-flip with or without brandy may also be given. It is useless
to give strong meat essences when the digestive powers are seriously
impaired, and excess of zeal in this direction does a great deal of
harm. These accumulate in the intestinal canal and form a fermenting
mixture in which poisonous ptomaines form. Throughout the attack the
patient’s strength should be husbanded as carefully as possible. When
there is thirst, water, or iced water, or iced beer or stout, or
ice-cream, or fruit _sherbat_ should be given. During convalescence
great care should be taken of diet, for then the vital powers are at a
very low ebb.
III. _External._—In order to lower the temperature rubbing of the skin
with oil from the commencement of the disease has been recommended, but
this procedure is, I think, of no use. I suggest, however, that when
temperature is high 15 drops of Creosote may be rubbed near the axilla.
During height of fever, the body may be lightly sponged all over, twice
or thrice a day, with the following solution:—
Thymol 40 grains.
Spirit Lavendula 2 oz.
Spirit Vin. rectif. 3 ”
Acid Acetic dil. 3 ”
Aquæ Rose add 16 ”
Mustard plasters to limbs and over the heart should be given when there
are signs of failing heart and circulation, and over the epigastrium
when there is vomiting or hiccough. Smelling salts and strong ammonia
should be applied to the nostrils for their restorative action. Blister
over the nape of the neck is useful when cerebral symptoms are present.
Ice caps over the head is very useful and should be applied
continuously. The enlarged glands may be fomented with hot water or
spongio-piline wrung out of hot antiseptic solution. When they are much
painful, poppy or belladonna may be added to the water. Belladonna with
glycerine should be applied in the beginning and iodine afterwards. Hot
corrosive sublimate fomentations are also useful. If the glands
suppurate, they should be opened aseptically and dressed with
antiseptics. Proper drainage should be provided.
IV. _Internal._—Knowing as we do that the plague is due to the toxic
products metabolized by a pathogenic bacillus, the question comes—would
an antiseptic treatment be of any use? Can we by any means induce an
antiseptic action on the blood, or have we any drug which can act as
antitoxin? It must be at once stated that no drug that has been tried
yet fulfils the above conditions. The claims of quinine, however, should
be taken into account. This drug in small repeated doses acts as a
general antiseptic. I would, therefore, advocate its use especially in
the early stages. Plague is a disease in which collapse sets in early
and cardiac asthenia is a very early complication. There is, therefore,
great urgency for early stimulation. Alcohol may be given freely, but at
the same time it must be remembered that if the organs of elimination
are not acting properly, alcohol may do harm. For their stimulant
effects whiskey or iced champagne may be given. Carbonate of ammonia or
spirit ammonia aromatic are held to be very useful stimulants in plague
cases. They may be given in combination with cinchona, digitalis and
ether. A prescription like the following may be useful:—
Ammonia Carb. 5 grains.
Chloric Ether 20 minims.
Sulphuric Ether 15 ”
Tint. Digitalis 5 ”
Tint. Cinchona 1 dram.
Aquæ Camphor 1 ounce.
Every three hours.
For cardiac asthenia, the following may be tried:—(1) Caffeine,
hypodermically, 5-grains dissolved by the aid of 5 grains of Sodium
Benzoate in 20 minims of warm distilled water and injected three or four
times a day if needful; (2) Ether or ethereal solution of camphor
hypodermically; (3) Strychnine, hypodermically, beginning with gr. 1/60
every four or six hours till gr. 1/16 is injected, or Liquor Strychnia
in 5—10-minim doses every four hours; (3) Musk may be given in 5-grain
doses, or as in the following mixture:—
Pulv. Moschi 10 grains.
Mucilage Acacia 2 drams.
Syr. Aurantii 2 ”
Aquæ Camphor ½ ounce.
To be given every 6 hours.
Digitalis does not always give good results, a fact which Lowson
attributes to some inflammatory or fatty degenerative changes in the
small vessels giving rise to a tendency to hæmorrhage. Stropanthus may
be substituted. Transfusion of blood a hot saline solution and
inhalation of oxygen have been recommended for collapse. Dr. Viegas of
Bombay recommends Liquor Hydrasgyie Perchloride 10 to 15 minims every
four hours if there is no albumen in the urine. Dr. Dimmock has advised
subcutaneous injection of Guaicol 10 or 15 minims every two hours.
Permanganate of Potash 5 to 12 grains in 24 hours has also been
recommended. Dr. Blaney has recommended Medritina in two-dram doses
every two hours when the kidneys are involved. Camphor has been
recommended by some as a cardiac stimulant.
_TREATMENT OF SYMPTOMS._
(1). High temperature may be reduced by antipyretics, such as antipyrin,
phenacetin, antifebrine, &c. These drugs produce profuse perspiration
and a certain amount of depression; it is, therefore, advisable to
restrict their use during the first few hours only, and if not found
responding, they should be dropped altogether. Pyrexia is but a sign of
the intensity of the activities of the infective agent, and by
artificially reducing the body heat we really do not lessen the
virulence of the poison, as shown by the rise of the temperature again
as soon as the action of the antipyretic subsides. Hyperpyrexia itself
is, however, an injurious symptom, and when there is long continued high
temperature it is necessary to reduce it, either by an antipyretic,
quinine or cold bath, or cold sponging. Cold bath is not suitable in
plague patients on account of the movement of the body which it entails,
and also on account of the serious cardiac depression which accompanies
the disease. Two grains of phenacetin with 1 grain of hydrobromate of
quinine is a safe antipyretic. Brandy and tepid sponging are also very
useful.
(2). _Brain symptoms._—For headache a mustard plaster behind the upper
part of the neck and over the occiput. Ice cap or Lieter’s tube or plain
water should be applied over the temples and scalp. Nervine sedatives,
such as Potassium Bromide, may be given for insomnia when there is not
much depression. Otherwise full doses of alcohol may be tried. Opium
should not be used, but in mild cases, without great depression, 10 to
20 minims of Liquor Opii sedativus with 30 minims of Sal Volatile in an
ounce of camphor water may be given to soothe nervous unrest. For
insomnia Lowson speaks highly of Morpinæ gr. 1/8 to gr. ½. Hyoscine gr.
1/200 to gr. 1/75 may be tried. Meningites should be treated by cold to
the scalp and counter-irritation to the nape of the neck and occiput.
(3). _Hæmorrhages_ may be treated by Ergot or Ergotin internally or
hypodermically. When there is much hæmorrhage, use of alcohol should be
partly suspended.
(4). If there is constipation, a dose of calomel may be given. In the
beginning there is almost always constipation, which should be removed
by a dose of calomel followed by a saline. Diarrhœa may be checked by an
enema of opium. Two grains of Dover’s powder and 10 grains of tannin
mixed with an ounce of gum mucilage and with two or three ounces of warm
water, arrowroot or starch may be used for injection. Salol in 10-grain
doses every 4 hours may be given for diarrhœa. For vomiting and hiccough
sinapism over the epigastrium, sucking of ice, and for thirst acidulated
water with syrup of lemon are recommended. Coma must be promptly met by
cold effusion if there is pyrexia or by rectal injection of strong
coffee. The bladder of the patient should be carefully watched.
Pneumonia and other complications should be treated under general
principles.
When temperature falls and convalescence begins, the stimulants should
be lessened, and afterwards a tonic with quinine, acid nitromuriatic
dil., tincture calumba or quassia may be given with infusion aurantii.
_Serum treatment._—The whole system of serum therapeutics is due to the
genius of Pasteur. Diphtheria and tetanus are diseases that are caused
by specific germs and are now successfully treated by immunised serum.
Tetanus can be prevented and even cured by the injection of serum of
other animals vaccinated against this disease: this process has been
applied by Yersin for producing a plague serum, for which a prophylactic
and curative power is claimed, and this serum may be called plague
antitoxin. Yersin treated his first case in Canton. At Amoy, the people
were less averse to treatment, and in 10 days he was able to treat 23
with two deaths only. As yet Yersin’s serum has been tried in the
declared diseases, but Yersin also proposes to use it as a preventive.
Haffkine also proposes to make use of his serum for curative purpose.
Yersin’s serum is older than Haffkine’s, otherwise bacteriologically
they are identical. The subject is in far too unsettled a condition at
present, but it has no doubt a hopeful future before it.
_DISINFECTION._
Substances which can prevent infectious diseases from spreading by
destroying their specific germs are called disinfectants. These
disinfectants can kill pathogenic germs. Heat is a most powerful agent
in killing-germs, therefore anything which is subjected to prolonged
boiling becomes sterile or germ-free. For purification of clothes and
bedding, heat is the best agent, either by boiling them in water or by
placing them in a hot-air chamber. The usual arrangement is a furnace
with the smoke shaft passing under or on one side of a brick chamber and
with a hot-air blast from a shaft running through or under the fire into
the chamber itself, or into a passage below it, whence it passes into
the chamber through a valve; an exit for the hot-air is provided at the
top of the chamber, the clothes are suspended in the chamber, at a
little distance from the walls. Various kinds of ingenious apparatus
have been recently contrived and are used. Steam disinfecting chambers
are necessary for the disinfection of clothes, &c., of a large
population, and all large towns and railway stations should have them.
High pressure steam in an apparatus contrived for the intermission of
its pressure is found to give the best heat penetration to large
non-conducting articles such as bedding. Fumigation by burning sulphur
or chlorine is a very useful method for disinfection of rooms. Large
bonfires of sulphur may also have a beneficial effect on the air.
_PURIFICATION OF A ROOM AFTER PLAGUE CASES_—
All woodwork should be thoroughly cleansed with soft soap and water, to
which a little carbolic acid has been added. The walls should be scraped
and then washed with hot lime to which carbolic acid should be added in
the proportion of one pint to four gallons of water. Then the room
should be fumigated for 3 hours, with all doors and windows and the
chimney being closed, sulphur about 1 seer for every 100 cubic feet of
space should be put in a metallic dish, a little alcohol is poured on
it, and it is lighted. After 3 hours the doors and windows should be
opened and kept open for 24 or 36 hours. Rooms may be disinfected by
chlorine. Carbolic acid in 5 per cent. solution is useful for all
ordinary purposes, such as washing hands, utensils, &c.
Quicklime is the cheapest and the most easily procurable disinfectant
for drains and for disinfection of discharges. Carbolic powder made by
adding carbolic acid to lime is very useful for the disinfection of
public latrines, drains and sewers. Corrosive sublimate, in the
proportion of 1 part in 4,000, is the most efficient germicide known and
should be used diluted with water for sprinkling on public roads and for
flushing drains and washing latrines, &c. It is, however, poisonous and
corrodes metal drain pipes. In quarantine or isolation camp the latrines
should be of the dry earth system. Carbolic acid powder should be
largely used in them. The question of suitable disposal of sewage
depends on the circumstances of each town or village, but incineration
is the most sanitary method during an epidemic. Other disinfectants too,
such as Jey’s Fluid, Creoline, Phenyle, Izal, Sanitas, may also be used.