NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
18
Description of Plague :
[ APP. I.
conditions the microbe of bubonic plague appears to die out within
from four to six days. In a few instances, my experiments have
suggested that it may survive for periods extending up to thirteen
days. But it must be remembered that my experiments had to be
ing a sufficient supply of healthy rats in Bombay at the present tim
carried out with the aid of mice owing to the impossibility of obtaine.
It is more probable that the death of the mice in these exceptional
instances was due to the accidental presence of other microbes than
that unusually resistant forms of the bubonic microbe were present.
No. 6.
Dated Bombay, the 19th February 1897.
From—E. H. HANKIN, Esq., M.A., Chemical Examiner and Bacteriol-
ogist, North-Western Provinces and Oudh,
To—-The Secretary to the Chamber of Commerce, Bombay.
In reply to your enquiry as to whether I have ever found the
bubonic plague microbe in grain and flour, I beg to state that,
although I have examined a large number of specimens under different
conditions, Í have never succeeded in detecting it. My observations
have been carried out on both clean and dirty grain, sweepings of
granaries, under infected dwellings, grain mixed with rats' dejecta
taken from near the body of a dead rat, grain that had been carried
by rats through a hole in the wall of a granary and stored in a latrine,
but in all cases a negative result has been obtained. I have also
examined weevils and other insects parasitic on stored grain without
detecting the microbe. I have recently examined flour from a small
godown in the Fort in which rats had been dying of the plague with
a negative result.
2, It is my opinion that the only connection of grain with the
plague in Bombay is that, at the beginning of the outbreak, larger
numbers of rats were affected, and that these animals were specially
common in the neighbourhood of granaries.
No. 7.
Dated Bombay, the 31st March 1897.
From—E M. HANKIN, Esq., M. A., Chemical Examiner and Bacteriologist,
North-Western Provinces and Oudh and Central Provinces,
To—The Secretary to the Government of Bombay, Revenue Department.
I have the honour to acknowledge the receipt of your No. 2503
of 3oth March, enclosing copies of correspondence on the subject of
wool infection, and asking for my opinion,
APP. I. ]
its causes and characteristics.
19
2. In reply I beg to state that as my researches are not complet-
ed, I can only form provisional conclusions on the subject. So far
as my researches go, they tend to show that the bubonic microbe
whether derived from cultures or the organs of deceased animals, and
whether placed on cotton or sheep's wool or gunny cloth, uniformly
dies out within six days. Owing, however, to the fact that epi-
demiological evidence tends to show that clothing may in rare cases
convey the infection, I am unwilling to draw any definite conclusion
from my researches at present. It is possible that under other con-
ditions the microbe might present a greater resistance in wool than
I have hitherto found it to possess. However this may be, there is
some a priori probability that cleaned wool would be less likely to
retain the infection than dirty clothes more or less saturated with
human secretions.
3. In my experiments, in which the microbe was found to die out
in six days, the wool was tightly pressed into widemouthed bottles
immediately after infection. In Bombay, and I presume in Karachi,
after washing, the wool is exposed to sunlight, which there is every
reason for believing would tend to hasten the disappearance of the
infection.
4. The fact that the trade in wool is in the hands of native
merchants adds greatly in my opinion to the difficulty of enforcing
sanitary precautions.
The only attempt at disinfection that I
consider feasible would be that the bales should be painted with
five per cent, carbolic acid on arrival at the docks under the super-
vision of a port official.
5. In dealing with this almost, but not quite négligeable risk of
importation of the plague, I suggest that the English Government
should adopt a modification of the plan that it has already employed
in the case of cholera with conspicuous success. During the last two
cholera epidemics in Europe, nearly every country was invaded by
the disease in spite of quarantine.
England alone had no cholera
and no quarantine. The method adopted was to allow suspected
persons to go where they pleased, provided their names aad addresses
were known. They were kept under careful supervision, and in the
event of cholera developing they were immediately isolated, and the
disease thus prevented from spreading. I suggest that this system
should be applied, mutalis mutandis, to suspected goods from
Bombay. That is to say, that the importation of wool in bales should
be allowed, but that the health of factory hands employed in handling
it should be carefully supervised. I am of opinion that a case of
plague among such hands, if immediately recognised, would present
no more danger to the community than a case of cholera under similar
circumstances.
20
Description of Plague:
[ APP. I.
No. 8.
Plague and animals.
Despatch from the Government of Bombay, to the Secretary of State, No. 28,
dated the 25th September 1897-
" We have the honour to acknowledge the receipt of your telegram,
dated 18th March 1897, inquiring whether our advisers apprehend
any risk of infection with plague poison of animal lymph prepared
within plague areas, and if so, what precautions are being taken in
the matter.
" 2. In reply we have to state that we have consulted the Surgeon-
General and the Sanitary Commissioner. We have also availed
ourselves of the expert opinions of Dr. J. A. Lowson, Plague Com-
missioner, and Mons. W. M. Haffkine, C.I.E., on the question whether
cattle are liable to plague infection, and append copies of their reports
for Your Lordship's information. The result of these inquiries goes,
in our opinion, to establish that there is no appreciable risk of any
plague infection from animal vaccine prepared with the precautions
that have been observed. The grounds for this view may be stated
as follows.
" 3. In the first place, the Sanitary and Medical Advisers of this
Government consider that, even if theoretically there might be a risk
of plague poison affecting animal lymph prepared within plague areas,
yet in practice, owing to the strict antiseptic precautions observed in
the preparations of the calf before inoculation and the care with which
the lymph is collected and stored, the risk is reduced to a minimum.
The calves are most carefully examined by skilled Veterinary Officers
and none but the most healthy are used as ' Vaccinifers.' Great care
is taken of them during the time they are developing vaccinia, and
any sign of disease during this period is most carefully looked for. In
fact the precautions taken render it almost impossible for anything,
but the best lymph from absolutely healthy calves being taken.
" 4. This supposition is very strongly supported by the test of
actual experience during the past year. In this Presidency vaccine
lymph is prepared and sent out from only two centres, viz., Bombay
and Karachi, in both of which plague till lately existed in a highly
epidemic form ; and the Sanitary Commissioner reports that, though
numerous consignments of the lymph have been sent to various places
since January last, there has been no report or even suspicion of any
case of plague having resulted from its use. Nor has there been any
case in which a calf, either in Bombay or Karachi, has, after supply-
ing lymph, developed plague. They have, on the contrary, all
remained healthy.
" 5. It is in fact very doubtful whether cattle are susceptible to
plague, at all events, to anything like the same degree as human
APP. I. ]
its
causes and characteristics.
21
beings. There has been no record of any disease or deaths among
cattle in the many places where the epidemic has raged in the Bombay
Presidency which could be attributed to plague ; and, as will be seen
from Dr. Lowson's report, in Cutch-Mandvi inquiry has shown that
cattle remained perfectly healthy, while the plague was at its worst
in that town. The so-called cases of plague in cattle have, at least
in one instance, been pronounced by competent veterinary opinion as
renderpest. Dr. Lowson reports that he carried out experiments in
Hong-kong in conjunction with the Colonial Veterinary Surgeon, in
which it was proved that cattle, after direct inoculation with pure
culture of plague bacilli, did not develop plague, and, with the excep-
tion of temporary fever and refusal of food, remained healthy.
Moreover, plague bacilli could not be found microscopically or bacterio-
logically in their blood, nor were there any signs of plague, such as
enlarged glands, along the chain of lymphatics from the spot where
the inoculation was made. Mons. Haffkine's experiments in Bombay,
like Dr. Lowson's in Hong-kong, tend to prove the immunity of cattle
generally from plague. Mons. Haffkine injected hypodermically
horses, goats, cows, and sheep with considerable doses of virulent
plague cultures. The operation caused an attack of fever from which
they all, except the goats, recovered in a short time with perhaps
local swelling and suppurations at the seat of inoculation. The goats
alone, without developing any acute disease, lost condition, gradu-
ally wasted away, and after a considerable time many of them suc-
cumbed. He further states that one of the cows gave birth to a calf
during the period she was operated on, and both cow and calf re-
mained healthy. Finally, Mons. Haffkine considers that his experi-
ments show that no spontaneous plague infection, which in nature can
take place with much smaller doses of virus than those used by him
on horses, cows, goats, and sheep, is likely to affect these animals ;
and the Surgeon-General concurs in this opinion.
" 6. Under these circumstances, we have come to the conclusion
that there is no apparent reason to apprehend any risk of plague
poison affecting animal lymph prepared with the special precautions
taken in Bombay and Karachi."
No. 9.
Remarks on the Treatment of Bubonic Plague by
James Cantlie, M.B.
At first sight it would seem as though the treatment of plague
was a subject which it is useless to discuss, as it is repeatedly stated
22
Description of Plague :
[ APP. I.
that we have no cure for plague. We have no "cure" for many,
nay, most, of our diseases, yet experience has shown that, although
no specific treatment is known, still with care, judicious nursing and
medical supervision, ailments, such as typhoid cholera, and zymotic
diseases generally, can be, and are, conducted to a successful termi-
nation. Much therefore as it is desirable to know what will " cure "
the disease, it is not consistent with our behaviour in other illnesses
to stand by and wait until it is discovered what form of attenuated
virus may be tried as a specific remedy.
Once for all let it be understood that in no disease does one get
such immediate results from careful and prompt medical treatment,
and as a direct outcome of watchful nursing, as in plague ; and per-
haps one ought to add to that " in the case of Europeans".
Natives, whether of China or India, succumb more readily to
plague than Europeans. There are one or two reasons for this: 1. A
native seldom comes to a doctor (a European doctor most of all) until
the disease is well advanced. 2. In point of stamina the poorer
natives are a long way below northern Europeans. 3. The inherited
dislike of the native for all forms of stimulants, be they medicinal or
alcoholic, during illness. 4. The belief of the natives in the old adage
that "to starve a fever" is correct.
The difference between
Europeans and natives was well illustrated, during the 1894 epidemic
in Hong-kong, by the fact that out of II British patients, 9
recovered, a mortality of only 18.2 per cent. ; whilst the Chinese died
at the rate of something like 95 per cent. This favourable result
cannot, however, be ascribed altogether to racial influence ; it was
rather due to the effect that medical treatment and good nursing had
upon the. course of the disease. The British patients were seen early
in the disease. They could take, and stand, stimulants, medicinal
and alcoholic well, and the result was the satisfactory number of re-
coveries which took place. Even with such Asiatics as would submit
to similar treatment, most markedly in the case of the Japanese
doctors, were the satisfactory results of treatment during plague
manifest.
The attendance of the doctor must be prompt, and his treatment
must be decisive. In fact, during the first five days of illness in
plague, the doctor must be within a few minutes' call. To each ward
of a hospital a doctor should be assigned, or, if a valuable life is at
stake in a private house, medical aid must be obtainable in a few
seconds. The changes are so rapid in plague, the feature of the
disease so fulminant, that without immediate treatment being possible
success is hopeless.
APP. I. ]
its causes and characteristics.
23
NURSING.
In a hospital ward, during the first five days of illness, practically
two patients require an attendant to themselves if the utmost good
possible is to be done. A nurse must never let her patient out of
sight for a moment, be the patient asleep or awake. She cannot
leave the ward or room, without posting a deputy, for any purpose
whatever. No nurse should be on duty for more than eight hours at
a time ; still better is it to follow the four hours " watches " kept at
sea.
The number of nurses required may seem outrageous, but we have
in many illnesses a day and night nurse for private patients, and no
more is demanded in this the most fatal illness known. Of course
plague comes in epidemics, and the number of nurses is limited, no
doubt ; but we must not lose sight of what is necessary in considering
what is expedient. Shortly, it may be put that a liberal supply of
doctors and nurses is essential if the lives of the plague-stricken, be
they native or European, are to be saved.
Enough has been said as to the rapidity of the onset, the develop-
ment, and the fatality of plague to make the importance of early
treatment in the disease and of the requisite promptness in its
administration understood. The symptoms and signs change so
rapidly, and in such varying successions, that no stereotyped line of
treatment can be followed. Now it is delirium which calls for relief,
now cardiac distress, or vomiting may supervene ; or an unexpected
loss of pulse, or a collapse totally without warning, may carry off the
patient before any help is obtainable. The much despised legend
"Treat symptoms as they arise" is the maxim in plague, and if the
word "promptly" were added, the summary of plague treatment is
before us. The disease caused by a bacillus, the toxic effects of which
upon the blood give rise to functional derangements of possibly all
organs, but most markedly of the nervous system, central and periphe-
ral. The poison is so acute that, with the exception of the glandular
inflammation, but little structural change is met with in the more
vital organs. The cardiac trouble which is so marked an accom-
paniment of the disease is evidently a functional one, and the result
of derangement of the nervous supply of the heart. This has
constantly to be borne in mind when the subject of drugs is dealt
with.
The subject of segregation, temporary hospitals, quarantine, and
disinfection generally, are not dealt with here. I propose merely to
deal with general and medicinal treatment.
24
Description of Plague :
[ APP. I.
GENERAL TREATMENT.
The essentials are of free ventilation, a cool room (6° to 7° F.
where such is possible), a plentiful supply of hot and cold water, ice,
a sufficiency of servants, and, of course, all the appliances of a modern
hospital. Deaths are so frequent and so sudden that when the
hospital is large it is necessary to have men employed whose duty it
is to remove, to disinfect, and to dispose of the dead.
Nothing should be allowed to leave the ward but to be disinfected.
Crockery and glass should be scalded, Faeces should be sprinkled
with quick-lime; bed and bedding if not burnt are to be disinfected
by heat ; the steam disinfector is well-nigh essential. Scrupulous
cleanliness of the floor and bedsteads obtained by washing with a dis-
infectant solution are of primary importance, and all doorways should
be curtained by a sheet wet with carbolic acid, Jeyes' or other reliable
antiseptic.
The patient should not be allowed to get out of bed for any
purpose, but the use of the bed pan and urine bottle should be
insisted on. So many times has it occurred that the patient has
tumbled over dead whilst getting up to stool, etc., that this is an
imperative measure to insist upon.
MEDICAL TREATMENT.
Purgation.—When the patient is first seen, the foul state of the
tongue, the foul breath, the jaundiced tinge of the conjunctivas, and a
generally bilious aspect, suggests a purge. For this purpose, calomel
in 5-grain to io-grain doses recommends itself. This is to be followed
by a saline in some five hours' time. Against this treatment it may
be argued that the drain upon the system and the lowering action of
calomel are deleterious, but, if given quite early in the disease and
not when the pulse is flagging-, it undoubtedly seems to do good. It
frequently stops vomiting, which is often present, it clears away the
jaundiced aspect, it restores the power of taking nourishment, and it
seems to diminish mental aberration and cardiac distress. If a full
gall bladder justifies the exhibition of calomel, post mortem evidence
of that condition is not wanting. So far as is known, bacilli of plague
escape from the body in greatest numbers by the bowel. In the
breath, sweat or urine bacilli are but sparsely met with, but in the
faeces a rich supply is found. This points to the necessity of ample
disinfection as being requisite for all latrines, bedpans, closets, etc.,
but it also proclaims as justifiable and rational the attempt to assist
Nature in expelling the poison of plague by a free action of the
bowels.
APP. I. ]
its causes and characteristics.
25
Stimulation.—-From the very first onset, or certainly after
twenty-four or forty-eight hours, it will be found necessary to stimu-
late the plague patient by food, by alcohol, or by medicine.
Food,—Unless the patient is actually delirious there is not-
usually much difficulty in feeding plague patients. In fact,, in com-
parison with allied ailments, appetite is wonderfully good. One
encourages this in a general way,, but the occurrence of sudden death
supervening after the ingestion of a full bowel of rice, for example, and
its accompaniments, in the case of Chinese patients on several occa-
sions, leads one to the belief that a full meal is not without its,
danger. The heart is in such a condition that it takes but little to
disconcert its rhythm, and the pressure consequent upon a full
stomach is calculated to do this. Food should be in small quantities,
frequently repeated, and of a kind which is easily digested. Brand's
essence of beef, in fluid or jelly form, is excellent,, but any beef jelly
will do. Ox-tail soup, mutton broth, beef and chicken tea, should be
constantly on hand to suit the varying palate of the patient. Conjee
water—that is the water in which rice is boiled—is useful as a drink
and serves as nourishment. Milk with ice (sipped slowly), and ice
cream (Lowson) are particularly grateful 1 .
Drink»—Thirst is at times a marked symptom, and its relief
should be attended to by allowing the patient anything in reason.
Ice to suck, if not kept up too long ; water or lemon and water (not
lemonade) to drink, if not in such quantity as to distend the stomach j.
peer and stout iced, especially for Europeans, is " at once stimulant,
soporific,, nutritious, and thirst-quenching." (Lowson.) Brandy or
whisky diluted with not more than three or four times its quantity of
water (not aërated waters) should be freely supplied. When the
pulse shows signs of falling, or collapse or faintness supervene, then
of course alcohol is doubly beneficial, and brandy is preferable to
whisky as a cardiac stimulant.
Delirium.—When active, the delirium of plague is best combated
by cold to the head. Letter's coil would be perhaps the readiest
method, provided the patient could be kept still, but an ice-bag or a
constantly wetted cloth is efficient. These applications combined
with tepid sponging of the body at frequent intervals seem grateful
to the patient, are useful means of reducing temperature, and seem
the safest and readiest method of quietening active delirium.
Hyoscine.—In most cases, but not in all, hyoscine administered
hypodermically in doses of gr. 1/001 is perhaps the most efficient and
safe of the hypnotics. It calms the nervous system and induces sleep,
when everything else fails. Hyoscine should be one of the first drugs,
in the armamentarium of a plague hospital.
b 4-
26
Description of Plague :
[ APP. I.
Morphine.—At times nothing but morphine administered hypo-
dermically in doses of gr. 1/8 to 1/4 is of any avail. A priori one would
not select it as a hypnotic or anodyne, but experience has proved it
to be reliable, and not so unsafe as to exclude its use. It is almost
certain that when painful adenitis complicates the cerebral intoxica-
tion, morphine effects its purpose. The safest method of adminis-
tration is in combination with atropine.
Bromide of Potassium.—An occasional dose of bromide of potas-
sium during delirium is useful and without danger, but its prolonged
use is not permissible,
Diarrhoea.— An occasional looseness should not be stopped unless
it continues over twelve hours, and the patient seems exhausted there-
by. It is but seldom obstinate, and yields to salol in gr. x doses, or to
an enema of starch and opium ; or, still better, a suppository of
morphine and cocaine, gr. 1/4 and gr. 1/2 respectively, more especially
when continued straining persists. (Lowson.)
Vomiting frequently ushers in an attack of plague, and may per-
list throughout the illness. When the latter condition obtains, it is an
unfavourable sign, as loss of strength ensues owing to the rejection of
food and medicines. A mustard plaster to the epigastrium, ice to
suck, and an effervescent draught of a few drops of hydrocyanic acid
and liquor morphiae are generally sufficient to check this untoward
symptom. (Lowson.)
Pyrexia no doubt accounts for some of the delirium, the restless-
ness, the headache, and subsequent collapse. Hyperpyrexia is ex-
ceptional, The usual chemical antipyretics, antipyrin, and phenacetin
are such severe depressants that they are at a discount and should not
be used. Should hyperpyrexia necessitate its use, one hypodermic of
antipyrin is no doubt justifiable, but only as a last resource. Frequent
sponging with tepid water, ice to the head and nape of the neck, iced
drinks, and a short application of the wet pack, with the administra-
tion of brandy by the mouth or by the rectum, are useful when
promptly and rationally used.
Stimulants externally.—Flying blisters of mustard to the limbs,
abdomen, and over the heart are useful. Smellinsc-salts and strong
'
O
O
ammonia applied to the nostrils often succeed in restoring the pulse,
rousing the patient in collapse, and not infrequently cause him to
rally from what seems a moribund state. (Lowson.) Nor is this kind
of stimulation of mere passing effect, for in several instances, when
death seemed inevitable and at hand, patients have revived and actual-
ly recovered permanently.