NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
68
last cases were of a malarial remittent type, and were kept in a separate
ward. Bacteriological evidence confirmed the diagnosis, and both ended
fatally.
A reference to the table will show the fallacy of depending on the
appearance of so-called characteristic buboes in this disease and the use of
the term " Bubonic Fever" to be a misnomer. All cases without buboes
—other than primary pneumonias—were shown by examination post
mortem, or by bacteriological test to be Plague, wherever an opportunity to
do so could be got. The majority of buboes left to take a natural course
subsided without suppurating. In only 7 per cent. of acute bubonic
cases, in which no irritant application had been used, and to which
sedative liniments or ointments had been applied, did suppuration
ensue, whilst, as was generally the case when such irritants had been
used, suppuration was the rule. Patients liked to busy themselves with
treatment of the local expression of the disease, and poultices, marking
nut, iodine, or nitrate of silver were very constantly used.
Many observers think that the vis medicatrix naturæ in plague is by
suppuration of the inflamed gland ; but nature's trend in this disease is
to place the patient on the burning ghat. It is overlooked that at
least 60 per cent. of plague patients died before there has been time for
suppuration, and how many died before reaching hospital, struck down
suddenly, no one can estimate. No doubt, if the patient survives long
enough, suppuration may occur, especially when poultices or irritants
have been used. It would appear that such conclusions as that sup-
puration is beneficial, result from a study of virtually selected cases ;
and the safer and juster conclusion is that, because the patient has
survived long enough, his bubo has suppurated, and not that because
of the suppuration he has recovered.
In some instances patients with buboes were sent into hospital who were
proved by bacteriological methods not to have Plague; Two instances
of sympathetic buboes due to ulcer of the leg were of such a nature, and
one case of syphilis ; none of which on puncture and cultivation of the
contents of the inflamed glands gave any characteristic growth.
As regards treatment of buboes, an emollient sedative application,
such as glycerine and belladona, is generally useful. Poulticing and
incisions were not practised, but in patients received from other hospitals
ample opportunity was afforded for studying the results of such modes
of treatment as seemed to delay convalescence considerably and lead
to anæmia and debility. Excision of the bubo was entertained, but not
considered prudent. To promote absorption equal parts of creosote and
glycerine seemed the best application.
This was rubbed in on alternate days, in one drachm at a time in
some cases, and generally with good effect. Iodine was of no use in
procuring absorption. An ointment of oléate of mercury (10 per cent.)
gave satisfactory results in hastening the absorption of the buboes.
69
Opening the buboes, except when this is absolutely necessary, is to
be deprecated, as wounds in plague patients heal very tardily, and if
opened at all, this should be done freely and the wound immediately
deluged with antiseptics, and treated antiseptically to avoid the absorption
of noxious products.
Treatment.—Prophylactic and Rational.
The removal of the defective sanitary condition which gives rise to
the disease, the segregation of the sick in hospitals, and of their friends
in observation camps until the period of incubation is over, and the dis-
infection of habitations, fomites of all kinds, and personal hygiene.
The value of segregation can be appreciated by a consideration of
the facts of the contagiousness of plague in habitations and its almost
non-contagiousness in hospitals.
In the treatment of plague, symptoms can be relieved and the chances
of a favourable termination promoted ; but little can be done to shorten
its course or ensure recovery.
If the patient can be kept alive till the eighth day without complica-
tions supervening, the disease will have exhausted itself and the patient
recover.
The success of any treatment depends on early and good nursing,
and keeping the patient lying down until the temperature has been
normal for at least four days. The injudicious breach of this rule, viz.,
that the patient should not even sit up for any purpose, led to the death of
twenty convalescents by syncope in spite of urgent and repeated warnings.
Abundance of fresh air is of next importance, and in Parel each
patient had nearly 2,000 cubic feet of air space and free perflation of air.
On admission, the patient was undressed, well washed (including
the head) with hot water and carbolic soap, and a change of clothing
provided. Those who seemed too weak for general bathing were care-
fully sponged all over. Personal clothing too filthy or worthless was
burned at once. Valuable clothing was disinfected by steeping in 1 in
2,000 perchloride of mercury solution before being sent to be washed.
Every patient on admission got rum mixture as a stimulant and
some sago congee, if required in the opinion of the medical attendant.
The patient was put into a fresh bed in the appropriate acute ward, and
the presence of at least one attendant constantly enforced. As a
routine to adults, five grains of calomel and thirty grains of compound
jalap powder were administered.
The patients were fed four times in the day, and acute cases had
always a supply of sago congee, Brand's Essence of Mutton, or Virol, or
Liebeg's Extract of Meat, and rum up to eight ounces in the day, and
especially at night.
70
Symptoms were treated by appropriate remedies as they arose. The
fever was best combated by sponging and the ice-cap. Antipyretics,
such as antifebrin and phenacetin, were not found suitable and had only
a transient effect in reducing high temperature.
Stimulants were well borne, and it seemed almost impossible to in
toxicate plague patients with large doses of alcohol—up to eight ounces in
the day in several instances. Even in boys and patients unaccustomed to
alcohol, this quantum failed to induce drunkenness.
Medicinal stimulants and tonics, especially nervine stimulants, were
most useful. In acute cases a routine dose was—
Rx. Acidi Nitro-hydrochlorici dil...
Quininæ sulphatis ...
Liquor strychninæ
Spirit chloroformi ...
Aquæ camphoræ ad
...
...
...
...
m. 20.
gr. 5.
m. 5.
m 20.
\ill\ 1
Three times
daily.
Among other useful drugs employed were ammonia carbonate, citrate
of caffeine, tincture of strophanthus, tincture of digitalis and nitrate of
pilocarpine (for uræmic symptoms).
For theRelief of Distressing Symptoms.—Headache was treated by the
ice-cap, blisters occasionally (but not found remedial), evaporating lotions,
and especially camphorodyne, bromide of ammonium, and opiates.
Sleeplessness was combated by liq. opii (sedative) or liq. morphine,
bromides and camphorodyne.
Vomiting was usually checked by bismuth, mucilage, and hydro-
cyanic acid, in effervescing draughts. Pulmonary congestion by diffusible
stimulants, turpentine stupes, blisters, and alcoholic stimulants ; with
digitalis.
As a special mode of treatment, liq. hydrargyri perchloride was
resorted to from a conviction of the value of such a powerful disinfectant
in specific disease, and the likelihood of its being useful as an intestinal
disinfectant and bactericide.
At first it was given in drachm doses, well diluted, three times daily ;
later in half ounce doses every two hours for four doses; and then in the
same quantities every eight hours. In no case of plague did these
enormous doses induce salivation, although this phenomenon was carefully
sought for.
One doubtful case became salivated slightly after the third dose, and
the bubo in this case was proved to be sympathetic from an ulcer on the
foot. The bubo in the groin cf the corresponding leg was punctured
antiseptically and the contents examined microscopically and by bacterio-
looical cultures, and found not to contain the specific micro-organism
of plague. This mode of treatment is therefore both diagnostic and
rational.
71
The drug was also given by hypodermic injection below the situation
of the inflamed gland in five cases, and four of these recovered, and one
died. The general result of the hospital treatment may be attributed to
this mode of medication (with remedies for prominent symptoms and
complications), and gave 69.2 per cent. of recoveries, excluding cases
moribund on admission, and those treated by MM. Yersin and Haffkine.
The Hospital staff and skilled and intelligent nurses had great con-
fidence in the perchloride of mercury treatment ; but it is only right to
state that many cases treated early and vigorously with this drug died ;
after perhaps temporary benefit and prolonged life.
In one remarkable case which died six days after admission from
double broncho-pneumonia, and under full doses of mercury, the German
Scientific Plague Mission Experts found plague bacilli on three different
days in the blood cultures, and the day before death, and at the post-
mortem not a single plague bacillus could be demonstrated in the blood
or any of the organs. Their conviction was that the patient died from
the severe complication, and had his vitality been greater and no compli-
cation supervened, he would certainly not have died of plague ; all the
bacilli being destroyed.
No after untoward symptoms developed in convalescents after
mercurial treatment in such heroic doses.
The discovery of a curative remedy for plague remains yet to be
demonstrated.
Generalities.—The excreta were received into bed-pans already
sprinkled with 15 per cent. carbolic powder, and before removal from
the ward a solution of 1 in 2,000 perchloride of mercury was poured
over the mass. This solution was colored blue by aniline and kept in a
separate place to distinguish it and prevent accidental poisoning. The
fluid and solid portions were separated and stored in suitable receptacles
mixed with phenyle 1 in 30, and the fluid portion removed in the con-
servancy cart. The solid excreta, already disinfected again by phenyle,
were mixed with dry sawdust, thrown on stable litter, dried in the sun,
deposited on layers of charcoal, and destroyed in the incinerator.
All bandages and dressings were destroyed by fire after being soiled
once.
Dead bodies were wrapped in a sheet soaked in perchloride of
mercury and immediately removed to the mortuary.
The bedding was disinfected before being washed and again taken
into use, the straw stuffing of pillows and mattresses burnt, and the cots
re-whitewashed.
Discharges from patients, soiling the floor, were at once disinfected
with carbolic powder, and swept up and removed ; and the place further
disinfected with perchoride solution and whitewashed or scrubbed.
18
72
Patients in hospital were allowed to sit up when the temperature
had been normal four days, and then moved into the convalescent wards.
They were not discharged as a rule till ten days afterwards at the earliest.
The majority of patients were discharged 23 days after admission. The
shortest stay in hospital was 9 days, the longest 100, before conva-
lescence was established. One convalescent deserted on the 23rd day.
Before discharge each patient received a warm bath with carbolic
soap, a perfectly new suit of clothing, a small gratuity, and a certifi-
cate of recovery from infectious diseases, stating the number of days in
hospital.
As measures of personal hygienic precautions, the hands of attendants
were dipped in mercurial solution, a special complete suit of hospital cloth-
ing put on before going on duty, and on coming off duty disinfected and
dried in the sun ; and a bath twice daily, containing a little phenyle,
enjoined.
The Rontgen Rays were tried on five patients, and two of them died and
three recovered. They were used for periods of half an hour over the
bubo. Patients seemed slightly benefited. The apparatus was presented
by the Maharaj Tagore, but unfortunately opportunities to test its efficacy
did not occur, and when the installation was ready further plague cases
ceased to be received into hospital.
BACTERIOLOGY OF PLAGUE.
The following points were personally verified in the bacteriological
investigation of plague at Parel, or communicated by the German
Experts :—
Professor Dieudonnè states : " In cover-glass preparations, in fatal
cases, the specific micro-organism was discovered. In only one case that
recovered was the bacillus demonstrated, and this was in a child 4 years
old with right parotid bubo, in whose blood bacilli were found four times
out of five examinations. In no case was the bacillus found in the fæces
or urine. In every case it was discoverable in the contents of the inflamed
lymphatic gland and in pneumonic cases in the expectoration. It was not
found in the pus from buboes, or abscesses following lymphangitis ; and
repeated examinations failed to discover it in the blood or buboes of
convalescents when the temperature reached normal."
VERIFIED PERSONALLY.
The micro-organism is 1 mm. by 2 or 3 mms. Both ends stain deeply
with aniline dyes. It is a short, thick rod with rounded ends as seen
by 1/12 oil immersion lens. It is non-motile in hanging drop preparations.
It is decolorised by Gram's method.
It grows on agar-agar and gelatine. It takes 24 to 48 hours for
characteristic whitish grey, (pin-head size,) colours to form, and they have
irridescent borders.
73
Spores are not formed, and it does not liquefy the media. Viewed by
transmitted light, the growth has a stippled, granular appearance like the
back of the looking glass. The growth on agar is alkaline.
Involuted forms, in the shape of small cocci, large cocci, pyriform
bodies, dumbbell-like forms, but without a handle, and swollen bodies
were produced on salt solution 4 per cent. in agar, also by 1/200,000 of
perchloride of mercury in agar ; and by dipping into 25 per cent. sterile
salt solution momentarily and touching the agar surface at one spot
(blob culture on pure agar) in 24 hours.
When involution-form cultures were re-inoculated on to pure agar,
they reverted to the ordinary type met with.
The virulence of involuted forms was not investigated owing to
want of opportunity. The optimum temperature is 37° C.
Heat up to 120° F. killed the cultures on agar, and an old agar
tube re-sterilised failed to produce a growth on three occasions when re-
inoculated.
Exposure to strong sunlight for a few minutes killed the bacilli, but
mere staining them without beating did not seem to do so.
Alkaline bouillon containing fat produced flake-like islands under-
neath the surface, which fall to the bottom like vermicelli choppings on
shaking the containing flask. This growth appeared in 24 to 48 hours,
and continued to grow and develop fresh festooned flakes for upwards of
a month.
The growth on agar is sticky and viscid, and non-adherent to the
medium.
Bacilli were not found in the lochial discharges of aborted females,
nor in the catamenial discharge, nor in the bodies of the products of con-
ception in three out of four foetus examined.
Numerous bacilli were found in the inflamed gland by rubbing a
cover slip on a freshly-cut (sterile) surface, drying the slip, and staining
in the ordinary basic aniline dyes.
A beautiful double stain for tissues with specific plague bacilli con-
sists of alcoholic solution of eosin followed by methyl blue, the tissue
being fixed by alcohol without heat, and the slide gently washed in
water, between the two additions of dyes.
POST-MORTEM APPEARANCES.
In all 36 autopsies were preformed at Parel, the smallness of the
number being explained by the difficulty of obtaining leave to make post-
mortems on natives of India, owing to the objections of their relatives.
No case was examined without full consent of the deceased's friends,
and most of the bodies were unclaimed.
74
Summarising, the appearances noted were—
Rigor mortis of short duration and not well marked.
Emaciation, not pronounced, owing to rapidity of death.
No particular tendency to rapid putrefaction.
Discolorations of the skin and cuticular eruptions or
abrasions absent. Boils and wounds, the result of sequelæ or
opened abscesses, and inflamed glands occasionally found. Blood
darker and more fluid than natural. Cerebral membranes
congested and the sinuses full of dark, thin, blood. Pia mater
and brain substance ædematous, with numerous punctiform
hæmorrhages. Petæchiæ on the membranes often noted,
especially on the pia and dura mater of the vault. Ventricular
serum above normal amount. Actual cerebral apoplexy never
seen.
Pharynx and æsophagus generally normal ; at most slight
redness and congestion of the mucous membrane of the former.
Stomach hypergæmic, and vessels much congested, especially at
the greater cardiac end ; numerous hæmorrhagic petœchiæ in the
mucous coat along the lines of congested blood-vessels. Erosions
of the surface at the pyloric end in some cases, and mammilation
and soft oedema of the mucous membrane in others.
The duodenum had generally a normal appearance, a few
punctiform hæmorrhages and small petœchiæ excepted.
The ileum and large intestine presented numerous petœchiæ
and patches of congestion, and the solitary and agminated glands
usually swollen, especially in the lower part of the ileum. No
ulcération of Peyer's patches found.
The mesenteric and retro-peritoneal glands were more or
less affected in nearly all cases, being enlarged, dark grayish or
red in color, but seldom showing hæmorrhagic infiltration or
suppurating foci.
The spleen was enlarged, dark brown, blue, grey, or red
on surface, acutely congested and with petœchiæ on the capsule,
and hemorrhages in the stroma.
Liver enlarged with pale yellow necrotic patches super-
ficially, with small hæmorrhages under the capsule. Petœchiæ
were commonly found on the upper surface on each side of the
suspensory ligament. On section its substance was bloody,
soft, and friable.
The gall bladder contained bile and showed many minute
petœchiæ on its serous and mucous coats and in the bile-ducts.
The pericardium often showed petœchiæ, and occasionally
some were found on the endocardium. The heart substance was
invariably healthy and no valvular lesions discoverable.
75
The larynx was of a dark purplish red hue on the surface,
and the mucous membrane ædematous and congested with sero-
mucoid exudation and ædema glottidis in some instances.
The lungs were usually congested and œdematous, espe-
cially the lower lobes ; and frothy, bloody exudation oozed
out on section. Pneumonic cases had inflamed patches at the
margins and on the front of the lobe affected. The patches were
airless, friable, and surrounded by rings of engorged and con-
gested lung. Pleurisy was seldom found. Petæchiæ and ecchy-
moses were frequent on the visceral pleura, and rare on the
parietal.
Pleural effusion and adherent pleuræ met with in one case.
The most constant pathological appearance was the presence
of hæmorrhages in great numbers in the capsule and pelves of
the kidneys ; and engorgement of the renal organs with blood ;
and infiltration of the peri-renal tissues and absence of the
normal fatty surroundings.
The capsule was loose ; cortex increased, and dark red ; and
pyramids prominent and congested.
The buboes consisted of inflamed lymphatic glands with
hæmorrhagic foci, and surrounding connective tissue œdematous
and infiltrated with blood and serum. The morbid alterations
were more noted in external than internal buboes, even when the
latter were the only ones present.
The blood-vessels and lymphatics in the neighbourhood
of the buboes were infiltrated and sometimes adhered to the
inflamed superjacent mass of altered gland tissue.
Very often a matted mass of inflamed glands were found
leading up along the blood-vessels from the primary external
bubo ; and in one instanee this condition was found extending
from the femoral glands along the iliac vessels and aorta to
the diaphragm. The mesenteric glands in vascular relation
with the affected intestines were invariably enlarged.
In puerperal cases the aborted hæmorrhagic infiltration
between the -layers of the broad ligament, inflammatory œdema
of the round ligaments and ovaries, and petœchiæ, and softening
of the mucous and serous membranes of the sub-involuted
uterus were noticeable.
In one such case a piece of adherent placenta was found
at the uterine ostium of the right Fallopian tube. Hæmorrhages
in the sheaths of the blood-vessels were frequent, and infective
infiltration extending from the femoral bubo in nearest relation
along the veins.
19
81
Of the remaining 23 cases of undoubted plague, 13 died and 10 recovered ;
mortality per cent., 56.5.
Known day of disease.
1st day
2nd ,
3rd & 4th day
4th & 5th „
Definitely known in hours 3 — 42
...
...
Died.
2
8
4
1
7
Recovered.
6
1
1
1
Percentage of
mortality.
50.0
57.2
80.0
60.0
87.5
The temperature charts, with the actual times of taking observations, show in
red when the patients were injected, the amount of serum, and the exact tempera-
ture at the time of injection. The temperature, pulse, and respirations were
recorded and taken personally immediately before injection in each case.
The most obvious effect was a marked fall in the temperature. In a few cases
the fever increased, and in a few no effect was produced.
Patients seemed less liable to complications, but No. 9 in the series developed
double broncho-pneumonia on the fourth day in hospital ; and, after, 80 ccms, of
serum had been injected. The pneumonia came on two days after the last injection,
and he died eight days later.
Delirium seemed to be lessened by the serum. No improvement in the
general condition of the patients could be seen, and the inflamed glands were
certainly not favourably affected.
In one case, given in detail, in which the latest Pasteur Institute serum was
used, the patient was not benefited in any way. (This serum had the guarantee
of M. Roux and M. Yersin.) On the contrary, fresh buboes appeared, and the
primary bubo became larger, more inflamed with increased surrounding œdema,
and the little patient died. This patient was injected exactly 42 hours from the
initial rigor, had a full dose of 40cc—a large quantity for a child 4 years old—
It was not a severe type of the disease, but in every way a most suitable case
for curative serum treatment according to the dicta of M. Yerain.
The serum was perfectly innocuous and unirritating. Two patienta developed
temporary urticaria, and one slight synoritis of one knee joint, after injection.
In cases that recovered, convalescence was no quicker than under ordinary
methods of treatment, and suppuration of the inflamed glands, if they had been
previously irritated, was not prevented.
Patients once put on serum treatment got no other drugs except sleeping
draughts or purgatives as occasion demanded.
The general mortality was slightly better than under hospital routine treatment,
in the proportion of 56.5 to 64.5, but in the latter were 66 moribund on admission ;
and if these 66 are excluded (and 28 cases treated otherwise), the proportion of
deaths amongst M. Yersin's cases to hospital cases stands at 56.5 to 33.5 per cent. of
cases treated.
Case No. 1 in the series had hypostatic pneumonia and had been ill four or five
days when injected. None of the others had complications at the time the serum treat-
ment was begun. The cases generally were of the ordinary mild type, and the last of
the series specially selected for early treatment show no favourable results over those
treated at a later stage of the disease. If anything, serum cases received more
nursing and general attention than other cases.
No. 13 in the series had recurrence of the urticaria on and off up till two months
after recovery.