Part 1

THE BUBONIC PLAGUE.

BY A. MITRA, L.R.C.P., L.R.C.S., F.C.S., _Chief Medical Officer, Kashmir._

Calcutta: THACKER, SPINK AND CO., 5 & 6, Government Place. 1897.

CONTENTS.

Page What is it? 1 Its History 1 The London Epidemic of 1865 3 Geographical Distribution 8 Causes 8 Bacillus 9 Contagious as well as Infectious 11 Nature of an Epidemic 13 Incubation 17 Symptoms 17 Varieties 21 Diagnosis 21 Prognosis 23 Microscopic and Macroscopic Appearances 24 Prevention 24 Sanitary Measures by Municipal Authorities 26 Private Hygiene 29 Inoculation against Plague 32 Treatment 33 Treatment of Symptoms 38 Disinfection 40 Purification of a Room after Plague Cases 41

THE BUBONIC PLAGUE.

_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.