Part 2

_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.