NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
12
Description of Plague :
[ CHAP, II.
attack. They consist of single glands, chains of glands, or two or
more separate glands agglomerated into a mass. The skin over them
is warm, tense if the bubo be large, and very tender. Sometimes
they subside and gradually disappear. Very often they suppurate and
burst, and a sudden rise of the temperature in the course of an attack
generally indicates the appearance of a fresh bubo.
Tonsilar type.
" The tonsilar type is a very peculiar one, and is characterised by
great swelling of the tonsils and the glands of the neck on one or
both sides. There is also nasal catarrh, and the appearance of the
patient is strange, with the large swollen neck, open mouth, and
inflamed sore nose, from which secretion runs. The great dangers of
these cases are asphyxia from œdema, and cellulitis extending down
into the chest.
Septiæemic type,
"The septicæmic type is characterised by an intensity of the
general symptoms due to direct entry of the virus into the blood.
Enlarged glands may appear in several regions later on.
Pneumonic type.
"The pneumonic or thoracic type is that variety in which the lungs
are primarily infected, most probably by inhalation of the virus,
and one or both of the lungs are attacked most commonly with
lobular pneumonia, although conditions indicative of lobar pneumonia
are also sometimes found. An abstract of the report of the Russian
Plague Commission read by Professor Wyssokowitz before the
Bombay Medical and Physical Society shows that after a certain
period the patches of the lobular pneumonia coalesce so as to form
circumscribed areas of exudation in healthy tissue, and that the
whole lobe is never consolidated in plague pneumonia, as it is in lobar
pneumonia. This type is very fatal, and in severe cases is occasionally
complicated with the development of external buboes, which arise
from a secondary extension of the virus.
Gastro-enteric
type.
" The gastro-enteric or abdominal type as a primary form of plague
is rare, and the earlier symptoms are difficult to distinguish from
those of the tropical enteric fever which they greatly resemble. The
diagnosis would mostly depend upon the general symptoms and the
peculiar form of the abdominal symptoms which are its leading
features.
The eruption, if there is any, is more petechial in
character ; the abdominal distension appears early and has not the
signs of that which occurs in typhoid ; also there are severe lumbar
pains, retching and vomiting, and inability to gain rest except in
certain postures. If diarrhoea occurs, the characters of the stool do
not resemble those of typhoid ; the bowels may be inactive, but this
is by no means a criterion, as many cases of tropical typhoid fever
are accompanied with constipation in the early phases. The diagno-
sis must rest on the recognition of the general symptoms, the early
CHAP. II. ]
its causes and characteristics.
13
appearance of abdominal distension, the characters of the stools
and bacteriological tests, and examinations of the blood. A variety
of this type has been seen which is choleraic in character, the
predominant symptoms being an imperceptible or only slightly
perceptible pulse, cold extremities, and excessive vomiting and
diarrhoea. The presence of a high temperature as indicated by the
thermometer would indicate the nature of the disease.
Hydrophobie
type.
"A symptomatic effect which has been seen in the glandular form
of plague is one of hydrophobie symptoms. It has been described as a
Hydrophobie type, the prominent symptoms being a terrified expres-
sion, difficulty in swallowing fluids, inability to spit or expectorate
and extreme restlessness. The fever and the bubo reveal the true
nature of the illness, and the hydrophobic symptoms may be a hysteri-
cal display of the terror with which the disease is associated."
Pulmonary type
in India and in
the Black Death.
In the account of the plague given by Hirsch stress is laid on the
fact that the pneumonic type is a characteristic form of plague in India.
He points out that although the complication of plague with bleeding
from the lungs has occurred in many other epidemics, it is only in the
case of the Black Death and Indian plagues that the cases are frequent
enough to amount to a clearly marked feature of the epidemic. The
pulmonary disorder was frequently observed both in the 1812—1821
outbreak in Gujarat and in the 1836 outbreak in Raj putaña. The
account given above shows that the pulmonary form of the disorder
has been equally marked in the present epidemic.
Mortality.
High mortality.
General
statistics.
Mortality in
hospitals.
The extremely fatal nature of plague is notorious and has charac-
terised all epidemics of the disease. A comparison of the total
number of reported seizures and deaths in the Bombay Presidency
and Sind from the beginning of the outbreak up to the 27th August
gives 80 per cent. of fatal cases. It is difficult to say how nearly
this figure approximates to the actual circumstances. On the one
hand, it is probable that cases which were not really plague were
included in the reports, and, on the other hand, the less severe cases
readily escape detection. The mortality shown by the hospital
returns is less than the above figure. The following was the per-
centage of fatal cases during the first period of the epidemic in the
hospitals at Bombay, Karachi, and Poona :—
Bombay ...
...
.,.
...
...
Karachi ...
...
...
...
Poona
...
...
...
...
53 1
59 1
64 1*
* This figure is only approximate.
14
Description of Plague :
[ CHAP. II,
A circumstance tending to increase the mortality in plague
hospitals is that the severe cases are the more likely to be brought
there. Many patients were admitted in a moribund condition.
Mortality in
Hong-kong.
The following extract from a report by Sir William Robinson, the
Governor of Hong-kong, on the Hong-kong epidemic of 1896 shows
that the rate of mortality during the. Hong-kong plague was higher
than the rate has been in India :—
"The mortality generally, as compared with 1894, shows a slight
improvement. The total number of Chinese cases up to noon on the
4th instant was 675, and the number of deaths 602, or a little more
than 89 per cent., whereas in 1894 the mortality among the Chinese
who were treated in hospitals was 93 per cent. ; and it must also
be borne in mind that in the latter calculation no account is taken of
dead bodies found in the streets and sent at once to the burial-
ground, while the returns for the current year include all deaths from
the plague. "
Mortality in
different types
of plague.
In the account given by Dr. Bitter, reproduced in the first section
of this chapter, it is said that the simple bubonic cases usually end in
recovery, and that the septicæmic cases are invariably fatal. The
reports of the Bombay hospitals show that this last statement is
somewhat too emphatic, though no doubt recovery in both septicæmic
and pneumonic cases is comparatively rare. Surgeon-Captain Thomson
gives the following account of the results observed at the Parel
Hospital, Bombay :—
" Cases without palpable buboes were most fatal, averaging 78 6
per cent. Many of such cases died early of convulsions, coma, and
syncope, overwhelmed by toxic products suddenly attacking the
great nerve centres, as it were, before there was time for an inflamed
gland to arise.
" The next most fatal were left axilliary and right cervical in the
same proportions, then right axilliary and right parotid in nearly the
same ratio; next came inguinal, and next femoral; and multiple
seemed to be least fatal.
Buboes on the right side had
...
„
„ ,, left
„ „
...
„
in the upper part of the body ...
„ ,, ,, lower „ „ „ „
66 7 per cent. mortality.
58 3
,,
,,
,,
69 3 ,, ,, ,,
57 2 „ „
„
" The nearer the head the more fatal the case, and those with
buboes in the neck, and especially in its anterior aspect were very
fatal. "
Influence of race,
sex and age.
Comparing the experience of the different hospitals, race does
not seem to have any marked effect on the rate of mortality. The
CHAP. IL ]
its causes and characteristics.
15
female sex has shown a general excess of mortality. Age does not
seem to influence the course of the disease.
Signs after Death.
Description in
General
Gatscre's Report
of the signs after
death.
The following description is from General Gatacre's report :—
" If the position of the body has not been altered after death, it will
invariably be found lying on either side with the knees flexed and the
head leaning towards the chest ; rigor mortis is delayed ; there is
softness and want of cohesion of the fibres of the muscles, the thumbs
point towards the palms of the hands ; the features have a fixed
anxious expression; the eyes are sunk in and muddy in aspect with
a peculiar lustre of the cornea, the pupils being dilated and the lids
half closed ; the tongue is swollen and coated with fur of a glisten-
ing appearance and is clean at the tip and edges ; the fur is dry,
white or yellowish-brown, cleft down the centre, and horny. The
complexion is opaque and dingy, the skin is dry, and if death has
been recent, the forehead and hands are cold and clammy ; and
enlargement of the glands in one or other locality would decide the
opinion that death had been due to plague.
" If death occur during delirium or convulsions, there may be
distortion of the features, in which, if the patient dies while on his
back, the head is thrown to either side and the legs are separated.
Petechial spots may also be noted, although in the epidemic in Bombay
they have been comparatively few. In death from pneumonic plague
the body and face have a dusky bluish livid hue, sputum hangs about
the lips, and the body seems shrunken and collapsed. "
Bacteriological examination of different forms of
Plague.
Dr. Bitter's
bacteriogical
examination of
different types of
plague.
The following is a summary of Dr. Bitter's bacteriological exam-
ination of different forms of plague. The subject is of particular
importance inasmuch as it affords a clue to the manner in which
plague is spread from sick persons.
Simple Bubonic Plague—The bacilli die quickly in a suppurating
gland. No bacilli were found in the blood of any patient who
recovered from plague. Nor were bacilli found in the sputum, urine
or fecal matter of any patient suffering from simple bubonic plague.
Septicæmic Type.—An examination of living patients showed the
existence of bacilli in the primary bubo and the surrounding tissue.
16
Description of Plague :
[ CHAP. II.
Shortly before death bacilli were found in numbers in the blood and
bacilli were in two cases detected in blood-stained sputum.
An examination of dead bodies disclosed the presence of enormous
quantities of bacilli in the glands primarily affected. In the neighbour-
ing glands they were found in smaller number. Bacilli were found
in all cases in the blood ; in most cases abundant and in some cases
rare. In the liver, kidneys and lungs they were found to about the
same extent as in the blood ; in the spleen they were more abundant.
Bacilli were discovered in the urine, in the large intestine and in the
sputum,
Pneumonic Type.—Enormous quantities of bacilli were found in
the pneumonic foci and in the congested parts surrounding them. In
the healthy tissue of the lung they were not frequent. Large numbers
were found in the fluid in the bronchi. In the bronchial glands there
were no bacilli at all, or only a few. In the blood and in the
spleen and other abdominal organs few bacilli were detected. In the
lymphatic glands there were either none or they were not more
numerous than in the blood.
Difficulties of Diagnosis.
Scheube's
remarks on
diagnosis.
Scheube makes the following remarks :—
" The diagnosis of the plague is frequently difficult particularly at
the commencement of epidemics. In severe cases, malignant malaria
and typhus may be mistaken for it ; and in milder ones venereal buboes
and other lymphatic inflammations may lead to errors in diagnosis
What is decisive for the diagnosis is epidemic occurrence, i.e.,
coincidence with the presence of an epidemic,the extraordinarily severe
general suffering accompanied by high fever, and the buboes. Even
although there may be exceptionally rapid cases in which the buboes
are absent, these will in any epidemic be cases of a typical nature,
leaving no possible doubt of the nature of the diagnosis."
Difficulty of
diagnosing
isolated cases or
cases during the
beginning of an
epidemic.
Failure to detect
the first cases in
Bombay.
It is, however, at the beginning of an epidemic or on the occurrence
of isolated cases that the diagnosis is of special importance and that
the failure to detect the disease may lead to the most serious conse-
quences. In the autumn of 1896 the existence of bubonic plague in
Bombay for some time escaped detection.
There is reason to believe that cases of plague occurred for some
months before the existence of the disease was discoverd, and that
from the latter part of August onwards these cases were sufficiently
numerous to affect materially the general mortality of the City. The
grounds on which this opinion was formed are explained in Chapter V.
CHAP. IL]
its causes and characteristics.
17
Difficulties in
diagnosing the
disease
experienced in
Bombay.
In the report prepared by Mr. Snow, the Municipal Commissioner
of the City of Bombay, the following remarks are made with regard
to the difficulty experienced in diagnosing plague :
" The difficulty of accurately diagnosing this multiform disease is
admittedly very great ; many suspicious cases were put down as
diphtheria; the resemblance to enteric often made the differential
diagnosis exceedingly difficult in the absence of bacteriological
examination ; and even bacteriological examination not infrequently
proved abortive in clear cases of the plague. The disease in its
more infectious type was generally pneumonic and devoid of
glandular enlargements, or was wont to take the form of high fever
with slight cough. Doctors often differed in their opinions about
cases, and no clearer illustration of the difficulties of diagnosis can
be given than the fact that at the latest stages of the epidemic
numbers of cases had to be segregated—and that by medical officers—-
not because the patients had plague, but because they had suspicious
symptoms.''
Dr. McCabe Dallas, who was in charge of the Grant Road Plague
Hospital in Bombay, stated that during the early months of the
epidemic the pulmonary form of the disease escaped detection and
thus spread the infection unchecked. Dr. Bitter also noticed the
difficulty of diagnosing pneumonic cases by clinical symptoms.
Cases diagnosed
as plague which
are really
unconnected
with that
disease.
The experience of the City of Bombay illustrates how plague may
escape detection at the beginning of an epidemic. On the other hand,
when the alarm of plague has been raised, cases are often diagnosed as
plague which are really unconnected with that disease. On a number
of occasions reports were made to the Government of India of the
occurrence of plague cases in different parts of India which subse-
quently were found not to be true cases of plague.
Instance from
Calcutta.
The most important instance occurred in the city of Calcutta.
Early in October 1896, that is to say, shortly after the existence of
plague in Bombay had been ascertained, the occurrence of ten cases
in Calcutta and one in Howrāh affirmed to be plague was reported
by medical officers to the Special Medical Board appointed by the
Government of Bengal. Considerable alarm was experienced, but
after sifting the evidence the Medical Board were able to report*
that these eleven cases were not true cases of plague, but simple cases
of enlarged glands, fever, bronchitis, and venereal disease. They
stated that looking only to the clinical symptoms they had no hesita-
tion in expressing their emphatic opinion that none of the cases could
properly be described as cases of bubonic plague.
* Appendix I.
3
18
Description of Plague :
[ CHAP. II,
Simple
instructions
circulated by
Local
Governments.
Some of the Local Governments and Administrations published a
simple statement of the symptoms of the disease with a view to assist
their officers and other persons in determining whether grounds
existed for suspecting a case of plague and for adopting the prescribed
precautions. The following extract from the orders circulated by
the Government of the North-Western Provinces and Oudh will
suffice as an example :—
"The symptoms of plague are fever of recent commencement,
violent headache, severe pain in the back and limbs, and lassitude.
The glands in the groin, or in the armpit or neck, are generally
swollen and tender, but this is not invariably the case. Cough and
pain in the lungs are frequently observed, and delirium often comes
on early in the disease. Death occurs often in two or three days."
In Bombay the Plague Committee issued simple instructions to the
Justices of the Peace and the non-medical officers who were on the
Committee's staff.
Bacteriological
tests.
Microscopical
examination and
cultivation.
Failure of the
bacteriological
investigation in
the Calcutta
cases.
Bacteriological research affords tests of importance in diagnosing
plague. A microscopical preparation made with the contents of the
affected gland shows numerous diplobacteria of characteristic shape
and size. A miscroscopical preparation made with the blood of the
patient is also sometimes employed, but the bacteria occur in lesser
number, or, in cases of simple bubonic plague, not all, and the test
is more difficult and less reliable. In pneumonic cases the vast number
of bacilli in the sputum facilitate bacteriological examination. Experi-
ence has shown that although the miscroscopic test is of great utility,
it cannot altogether be relied on, and certainly not unless performed
by a person with special knowledge and training. The cultivation
of the bacteria by placing the infected matter in nutritive media
gives a characteristic and more certain result. Dr. Bitter states
that it is impossible to obtain conclusive results by merely preparing
a coloured microscopical preparation from the blood ; to obtain reliable
evidence it is essential that a cultivation should be made. But even
in this case the experiment to be entirely trustworthy must be made
by a bacteriologist (of experience. In Appendix No. I is an in-
structive note by Brigade-Surgeon-Lieutenant-Colonel D. D. Cun-
ningham on the misleading character of the results obtained by the
bacteriological investigation in connection with the alleged Calcutta
plague cases alluded to above. The medical officers who first inves-
tigated the cases alleged that they had found bacilli of plague in the
blood of six of the patients. Dr. Cunningham demonstrated that all
these so-called plague bacilli might be readily obtained from specimens
of the blood of perfectly healthy animals under the influence of brief
exposure to air, in even scrupulously clean localities,
CHAP. IL]
its causes and characteristics,
19
M. Haffkine's
instructions for
diagnosis.
A set of instructions for the symptomatic and bacteriological diag-
nosis of plague prepared by M. Haffkine is contained in Appendix I.
Period of Incubation.
Previous
experience.
The time over which the period of incubation may extend is a
most important matter from the point of view of preventive measures. '
Yersin gives the period at four to six days. Scheube states that the
period ranges from two to seven days, that in particularly virulent
epidemics it may only take a few hours, and that quite exceptionally
it may last as long as fifteen days. Wilm states that the observations
made in the Hong-kong epidemics of 1894 and 1896 showed that the
period of incubation might extend to nine days, but was usually three
to six days only. He cites one case in the jail in which the period
apparently extended to fifteen days. In the Venice Sanitary Con-
vention of March 1897 a ten-days period is taken as the practical
basis for preventive measures. The same period has been adopted
for the precautionary measures taken in India.
Experience of
the present
epidemic. Ten
days the
maximum period.
It is believed that there has not been a single authenticated case
in the present epidemic of a period of incubation of more than ten
days. The ordinary period is undoubtedly less than this and as a
rule the period does not exceed five days, though in some cases
it appears to extend to between five and ten days. Special opportun-
ity was givenfor investigating the period of incubation in the camps
that were established in many places for the shelter of persons made
to evacuate infected localities, and for the segregation of persons who
had been specially exposed to the risk of infection.
In the large segregation camps which were established at Poona
the cases of plague which occurred were discovered after the follow-
ing intervals :—
On the 1st day of segregation
...
...
„
2nd „
„
„
3rd „
„
„
4th
,,
„
...
...
„
5th
„
„
...
...
„ 6th
„
,,
...
...
„
7th „
„
,,
10th
„
„
„
...
3 cases.
3 »
3 »
2
„
2
„
1 case.
1 „
2 cases.
It must be remembered in considering these figures that even in
segregation camps there is a possibility of fresh infection,
20
Description of Plague:
[ CHAP. II.
Predisposing and protective circumstances in the
Individual.
Occupation,
race, age and
sex.
The following information is derived from the reports of the Parel
and Grant Road Plague Hospitals in Bombay.
No occupations in themselves predispose to plague. There is also
no race predisposition, but the classes who attend to personal cleanli-
ness and live in healthy surroundings secured a marked immunity :—
" The ages most exposed to risk range between 20 and 40 years in
both sexes. Thirty years seems the maximum danger point. From
youth up to this figure the disease gradually increases, and having
reached its height then, manifests a corresponding decline as the age
advances. Plague then may be characterised as more virulent in adult
life than at any other period.
" Approximately in relation to the sexes, males have been attacked
in rather more than twice the number of females, this being prob-
ably due to their greater exposure and partly to the fact that a
large number of women and children left the city during the course"
of the epidemic."
Second
attacks.
Second attacks of plague are certainly rare, but one attack does not
seem to confer complete immunity. The following examples are given
in the report of the Parel Hospital :—
" One attack does not confer immunity from another, as one patient
had a second and fatal attack, and one had a relapse. The second
attack was in a woman aged 40; convalescent 18 days; attacked
27 days after the initial symptoms of the primary attack ; and died
five days afterwards. The primary attack lasted nine days and the
fatal one five days, and in the latter she developed a fresh bubo in a
different site from the original one, had fever, delirium, stupor, coma,
and unconsciousness. The general characters of an acute attack were
present in the tongue ; pulse, respiration, skin, eyes, intestinal canal,
typhoid state and mental condition. Her temperature had been
normal 18 days when the fatal attack came on."
Dissemination of the Bacillus from the Sick.
Danger of
infection varies
in different
types.
Simple
bubonic type.
The bacillus multiplies in the organism of those attacked by the
disease, and the first stage in the study of its dissemination is to ascer-
tain the mode in which it emerges from them. This differs considerably
in the different forms of the disease. According to Dr. Bitter the
danger of infection from the simple type of bubonic plague is com-
paratively trifling. There is no danger from the excretions since