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A TREATISE ON PLAGUE
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A
TREATISE ON PLAGUE
dealing with the Historical,
Epidemiological, Clinical, Therapeutic
and Preventive aspects of the
Disease
by
W. J. SIMPSON,
M.D. Aberd., F.R.C.P. Lond., D.P.H. Camb.
Professor of Hygiene, King's College, London ; Lecturer on Tropical Hygiene,
London School of Tropical Medicine ; formerly Health Officer, Calcutta ;
Medical Adviser to the Government of Cape Colony, during the
Outbreak of Plague in 1901 ; Commissioner for the Colonial
Office to Inquire into the Causes of the Continuance of
Plague in Hongkong
Cambridge:
at the University Press
1905
Cambrttigc :
PRINTED BY JOHN CLAY, M.A.
AT THE UNIVERSITY PRESS.
Lifcfiiy
set)
TO ALL THOSE
WHO ARE ACTIVELY INTERESTED IN PLAGUE
AND ITS PREVENTION THE AUTHOR DEDICATES
THIS WORK
7S2G47
PREFACE.
THIS volume has been written at the request of the Syndics of the
Cambridge University Press with the object of bringing within
a moderate compass the principal facts concerning plague, from its
historical, epidemiological, clinical, therapeutic and preventive aspects.
Eleven years ago, plague as an epidemic disease was merely of historical
interest. Confined to some remote places in China, in India, in Persia,
in Arabia, and in Africa, its power was generally believed to be extinct.
To-day plague is a matter of concern to many countries and has been
the subject of two International Conferences. These Conferences have
met, discussed and agreed to the carrying out of measures which, while
inflicting the least injury on commerce, might reasonably be expected
to protect Europe from an invasion of the disease, and during the past
eight years Europe has, notwithstanding one or two alarms, had little
reason to doubt that the adoption of these measures has been most
serviceable in preventing the permanent lodgement of plague. Europe
is however but a small part of the world and other continents have not
been so fortunate, and although no great outburst has occurred on the
American, African, or Australian Continent, yet there remains the fact
that the disease has acquired a lodgement in these and necessitates the
greatest vigilance. Plague takes its own time and opportunities for
its development, and it is unwise to be lulled into a sense of security
by its apparent impotency to spread in a particular country. That it
is capable of spreading is seen too plainly in India. Few thought
it possible, when plague broke out in Bombay in 1896 after an ab-
sence of 200 years, that the disease would not be controlled, checked
and stamped out in a short time. It was a rude awakening when the
deaths began to mount up to a few thousands to find the old scenes
associated with plague ei)idemics reappear. The closed houses, the
viii Preface
deserted streets, and nearly half of the population of Bombay fleeing
panic-stricken from the city, testified to the fact that plague had
lost none of its old terrors, and recalled the condition of affairs described
in the old epidemics of plague. Later, when, owing to the decline of
the epidemic, confidence was restored and the people had in consequence
returned, there were congratulations as to the lightness of the attack
compared with the mortality in the great epidemics of the past, yet,
the next year and every year since 1896, the disease has recrudesced
in the city of Bombay, and the number of deaths is fast mounting up
beyond the mortality of any epidemic of plague in any single city in
the past with the exception of those of Constantinople and Grand Cairo.
And still the disease continues. Plague has moreover spread from
Bombay to the Bombay Presidency, and from the Bombay Presidency
to a large portion of India. Slow in its progress it has steadily
advanced ; and now the 30,000 deaths from plague which occurred
in India in the first year, and which created so much alarm, has reached
during the past two years over three-quarters of a million per annum.
In 1903 the number of deaths from plague in India was 853,000, and
in 1904 it was over a million, being 1,040,429. Of the million deaths
in 1904, over 350,000 occurred in one Province. The Punjaub is not a
large Province ; it has a population of under 27 millions \ or less than
that of England, and yet it lost in the course of 12 weeks in 1904 over
a quarter of a million of its inhabitants. If in the Province of Manchuria
either the Russian or Japanese army now opposed to one another were by
some misfortune completely destroyed, the catastrophe would not be
greater than what happened to the inhabitants of the Punjaub from
plague, and if both armies were destroyed it would not compare with
the destruction of human life from this disease in India in 1904. These
are the official figures, and are admitted to be below the mark on account
of concealment on the part of the inhabitants. The total number of
deaths in India officially recorded fi:-om plague since 1896 was, up to the
end of December 1904, three millions one hundred and fifty thousand.
Figures give a very inadequate representation of the amount of
misery which plague has brought and is continuing to bring to India.
Medical men and other workers engaged in plague epidemics may have
some conception of its intensity when they see whole families swept
away by the disease, but for most, and for those outside its sphere, it is
difficult to realise the full extent of suffering and desolation that has
1 Census of India l!l01 gives 26,880,217.
Preface ix
befallen hundreds of thousands of families in India and threatens the
homes of hinidreds of thousands more.
This plague is for India a grievous calamity; none the less grievous
because it is borne with that wonderful fortitude and patience so
characteristic of the people of Hindustan, nor is it limited to the
physical pain and mental grief in each home, great as they are.
Scarcity of labour and loss of trade are beginning to be felt in the
provinces worst affected, and it is not surprising that in the Indian
papers fears are expressed that if there is no abatement of the disease,
portions of the country may have to face "the possibility of large areas
of land unfilled, of trade and commerce decaying, because the popula-
tion has died or fled carrying the disease to districts hitherto un-
affected •." In fact if the plague continues its ravages, as it has every
appearance of doing, it will more slowly but as surely produce the
same conditions in India as it did in times past in Europe in the
earlier pandemics. A statement like this will come as a surprise to
most people, for in the newspapers in England there appear weekly
bulletins from Hongkong and the Mauritius giving the number of
deaths fr-om plague in the colonies in the plague season. The figures
never mount up to more than a hundred deaths a week at the most and
seldom to half that number. The impression produced by these bulletins
is that they represent the total extent of plague in the English
dominions, and the statement that in the epidemic season plague carries
off its victims in India at the rate of thirty or forty thousand a week
is received with incredulity. When it is found, however, to be true,
most of those who hear it are appalled at the condition of affairs affect-
ing our greatest dependency, for whose welfare England is responsible
and anxious to do everything in its power to maintain in a state of
happiness and prosperity.
Adverse critics are to be met with who view the ravages of plague
as a blessing rather than as an evil to be overcome by every means
possible, wh(jse contention is that plagues are necessary and are Nature's
methods of keeping down an enormous population that would otherwise
perish by hunger. It is an easy-going doctrine and saves trouble to
those unaffected. It is the reproduction in a more subtle form of an
old doctrine held many centuries ago, and which makes strange reading
for those imbued with the trend of thought of the 20th century. In the
seventh century, according to the records of the Church of Mayo-, two
' Leading article entitled " I'hi^ue administration," Pioneer Mail, .June IVtli, 1904.
- A Histori/ of Epidemic Pcstilnire^. ISy Edward Basoonibc, M.D., 1851.
S. b
M
X Preface
kings of Erin suninioncKl the ju'incipal clergy and laity to a council at
Teniora, in conseijuonce of a general dearth, the land not being sufficient
to support the increasing population. The chiefs (mdjoj^es populi)
decreed that a fast should he observed both by clergy and laity so
that they might with one accord solicit God to prai/er to remove hy
some species of pestilence the hartliensome inidtitndes of the inferior
people, " Omnes majores petebant ut niniia nuiltitudo vulgi per in-
hrniitateni alicpiani tolleretur, quia numerositas populi erat occasio
faniis." St Gei'ald and his associates suggested that it would be
more conformable to the Divine Nature and not more difficult to
multiply the fruits of the earth than to destroy its inhabitants. An
amendment was accordingly moved " to supplicate the Almighty not
to reduce the number of the men till it answered the quantity of com
usually })roduced, but to increase the produce of the land so that it
might satisfy the wants of the people." However, the nobles and clergy,
headed by St Fechin, bore down the opposition and called for a pesti-
lence on the lower orders of the people. According to the records
a pestilence was given, which included in its ravages the authors of
the petition, the two kings who had summoned the convention, with
St Fechin, the king of Ulster and Munster and a third of the nobles
concerned. Another and similar account of this incident is given in
the doings of the Saints of Ireland ^
Other critics, bearing in mind the op})osition and hostility with which
the preventive measures introduced by the Government of India in the
early days of the epidemic were met by the people, emphasise the
political dangers which are likely to arise from any action and which
justify the present policy of leaving things alone and only assisting
when aid is desired. The force of this argument must always be given
due weight when dealing with the people of India, whose mode of
thought is different from that of the West. But while admitting this,
the fact must not be lost sight of that hostility was largely engendered
by the methods adopted, owing firstly to the absence of an organised
sanitary service and the consequent employment of agencies for the
inspection of houses, repugnant to the feelings of the people, and
secondly because of a lack of knowledge of the channels by which the
disease spreads and the consequent futility of the methods adopted at
much cost and effort for the prevention of the disease. The lack
of an organised sanitary service and the lack of knowledge still
^ Acta Sanctorum Hiherniae. Tom. i. p. COl. Lovanii, 164-5.
Preface xi
remain, and if hope is to come to India it must be by their
removal. It cannot be beyond the power of statesmanship to seek
means for averting and ameliorating the sufferings of India, and yet to
do so successfully without raising dangers to the well-being of the
community or of the Government. Even those who see necessity for
caution in the methods of working to save the people from dying of
plague in the epidemic season, would probably not object to active
measures of prevention during the period of quiescence of the disease,
when there is no alarm or tendency to panic. These anticipatory
measures could easily be carried out without friction if suitable
machinery were there. Elsewhere* I have shown the nakedness of
India in sanitary organisation, and its inability under present conditions
to defend itself against epidemics of any kind. It has no thoroughly
trained and fully equipped sanitary army made up mostly of its own
people familiar with the ways of its inhabitants. It is now over ten 3'ears
since this defenceless state was shown to exist, and a scheme sketched out
for the organisation of a service for the prevention of disease. Is it too
much to suggest that some portion of the large annual surpluses of
money, which India is now obtaining by its fiscal policy, shall be devoted
to this important object ? The maintenance of a well-trained native
sanitary service to protect the people of India dying from preventable
disease is as feasible, and from a humane point of view as important,
as the maintenance of a well-organised native army to protect the
country against an external enemy. It is to be hoped that for the
sake of India an organised Public Health Service commensurate with
the requirements of the country will be created.
The formation and development of a trained sanitary service, with
which qualified women should be associated, will not be sufficient to
meet the conditions now existing. There is urgent need for systejnatic
and scientific study of the disease. More requires to be known concerning
the mode of spread of the disease in India, and of the conditions which
fovour its continuance during the non-epidemic periods. On a proper
understanding of these depend many of the preventive measures. If
rats, insects, fleas, and infected clothes are the chief factors in the dis-
semination of the disease, there is little need, unless it be for pneumonic
1 "The Need of a Sanitary Service for India." By W. J. Simpson, M.D. Tranxactions
of the First Indian Medical Congress, 1894, and Indian Medical Gazette, Dec. 18'J5.
"Plague in India." British Medical Journal, 1898.
"An Address on Preventive Work in the Tropics to the Eoyal Institute of Public
Health." By W. J. Simpson, M.D. Lancet, 1904,
62
xii Preface
plague, of resorting to isolation in liDspital and segregation camps,
which is opposed to the feelings of Hindus and Mahonniiedans
alike. If contaminated food is an important fjictor in the pro-
duction of plague, measures to secure purity should bo introduced.
But all these have to be proved for India. Seven years of golden
opportunities have passed unutilised. If the first 18 months in which
scientific study and research partly carried out by a scientific committee
in India and partly by foreign commissions be excepted, no real and
sustained efforts commensurate wdth the great issues at stake have
been made to get to understand the disease and the manner in
which it spreads, and no facts of practical value for the prevention of
plague have come from India. It seems to have been considered a
waste of money to spend 20,000 or 80,000 pounds in studying the
disease and its prevention, though twice or three times that amount
is but a small fraction of the vast sums spent for the most part
uselessly on administrative and executive methods, which, effective
enough, perhaps, in a coimtry with a fully equipped sanitary service
and when rigorously carried out at the commencement, have proved to
be in India with its conditions of no avail.
For preventive work much more light is needed on a subject
involved in obscurity, and this can only be obtained by scientific research
which shall be regular and systematic in its nature and which shall be
closely associated with a skilled and special organisation devoted to
plague administration and which shall not be confined to laboratory
experiments. Plague requires scientific investigation outside as well as
inside the laboratory. Research and administration in this matter
need to go hand in hand. Each if worked on its own lines without
reference to the other will accomplish but little, and that little is not
likely to be of much practical value. In a disease such as plague the
efforts of a sanitary service are only likely to be successful when
directed into the proper channels by its close association with scientific
research both in the laboratory and in the locality affected.
It is unnecessary to dwell on the danger of the disease spreading to
other countries or of the serious risk attendant on plague being allowed
to spread wdthout understanding the methods by w^hich this happens.
An optimistic opinion prevails that the disease will not spread and soon
die out in India. This view has been strenuously held ffom the first
and the continuance of the plague with its three milli(jn deaths has
been a .source of disappointment in this respect. Doubtless if held long
enough this view will ultimately jjrove true, but it may not be in this
Preface xiii
generation. This dying out and failure to spread are not in accordance
with the history of plague in the past when it has acquired such
dimensions as those existing in India, and there is nothing so far as may
be judged in the present condition of the world fjr it to act differently
now than formerly. On the contrary, with war in the East, with grave
economical and political disturbances existing at present and with
unusual seasons, the conditions which in earlier times favoured the
prevalence of plague do not appear to be altogether wanting for its
expansion in the present age. Whether history will repeat itself or
not or whether the risk of extension to neighbouring countries is great
or small remains for the future to decide. No one can prognosticate
one way or the other. But amidst this uncertainty there is one thing
absolutely certain, and it is that owing to this invasion of plague the
condition of the people of India in the worst affected provinces is most
deplorable. It not only claims the deepest sympathy, but also in the
interests of humanity imperatively demands the closest attention and the
adoption of suitable and adequate remedial measures for its amelioration
and for combating the spread and ravages of the disease.
In conclusion a pleasant duty devolves on me to acknowledge
with grateful thanks the kindly assistance given me in writing
this book. My acknowledgements are due to the Syndics of the
Cambridge University Press for the facilities they have afforded me in
its publication. They are also due to Dr Norman Moore and Dr Joseph
Frank Payne for assistance and advice ; also to Mr W. M. Hafifkine,
C.I.E., for his microscopical specimens of involution forms of plague
bacilli. It is impossible to over-estimate the splendid services which
have been rendered to India by Mr Hafifkine by his discoveries of a
cholera and plague prophylactic, and by his work carried out in India
amidst great ditficulties in connection therewith. Such services can
never be forgotten. My thanks are also due to Dr Choksy of Bombay
and Dr Gregory of Cape Town for the photographs representing plague
patients, also to the Colonial and India Office for access to official
records; to the Local Government Board for Dr 'Choiiison's translation
of the Paris Convention, and to the Controller of His Majesty's
Government for permission to reproduce that translation.
W. J. SIMPSON.
King's College, London,
March, 1905.
CONTENTS.
PART I.
HISTORY AND DISTRIBUTION OF PLAGUE.
CHAPTER I.
PAGE
PLAGUE FROM THE EARLY CENTURIES TO THE 19TH CENTURY , 1
Definition. — The/antiquity of iilague. — Plague in Syria, Egypt, and Lybia. —
The first recorded iJandemic- -Account of the plague at Constantinople by
Procopius. — Account of the plague at Constantinople in 558 by Agathias.
Account of the plague at Antioch by Evagrius. — Information scanty concerning
other countries attacked. — References to the pandemic by Gregory, Bishop of
Tours. — Account of Paulas Diaconus. — Plague in Ireland. — Plague from the
7th century until the Crusades. — General retrocession and quiescence of plague
in Europe, Egypt, and Syria for sevei-al centuries. — Plague at the time of the
Crusades and after. — The second recorded pandemic, later called ;the Black
Death. — Constantinople one of the gateways by which the pandemic entered
Europe. — The course of the pandemic as described by an Arabian author. —
Pandemic distinguished by its rapid .spread and destructiveness.— Guy de
Chauliac's description of the plague at Avignon.— Le Baker de Swynebroke's
account of the epidemic in England. — Plague in the 15th, 16th, and 17th
centuries. — Plague in London in the 16th and 17th centuries. — Recrudescences
and epidemic waves fi-om old endemic centres. — Remarkable cessation of plague
in Western Europe at the end of the 17th century. — Plague in the 18th
century.— Plague in West Barbary.— Plague in the 19th century.— Disappear-
ance of plague from Turkey and Egypt in the middle of the 19th century.—
Recrudescence of plague in Arabia, Mesopotamia, Persia, and 13enghazi.—
Plague in the province of Astrakhan.
CHAPTER II.
PLAGUE IN INDIA 40
Plague in India.— Plague in the early part of the 17th century.— Plague in
the Punjaub.— Plague in Ahmedabad.— Plague in Agra.— Plague at the end of
the 17th century. —Plague in the 19th century.— The districts of Garhwal and
Kumaon endemic centres of plague in India.
Contents xv
CHAPTER III.
PAGE
THE PRESRNT PANDEMIC 48
The present pandemic originated in Yunnan, une of the Western Provinces
of China. — Topographical description of Yunnan. — Trade routes from Yunnan.—
Condition of Yunnan in 1871 as observed by M, Rocher. — M. Rocher's account
of plague in Yunnan. — Ei)ideniic preceded by sickness and mortality among
rats. — Dr Lowry of Pakhoi gives first medical account of plague in Southern
China at Pakhoi. — Plague first appeared at Pakhoi in 1867. — Trade route from
Pakhoi to Yunnanfu. — Plague endemic in Pakhoi from 18G7 to 1884. — Plague
not extinct in adjoining prefecture to that of Pakhoi. — Plague at Mengtze, 1874''
to 1893. Plague at Nanningfu and Kwaium in 1893. — Plague at Canton in
1894. — Canton connected with the chief towns and districts of Kwangsi and
Kwantung.— Plague in Canton in January, 1894. — Hongkong the largest and
most important European possession near Canton. — Plague discovered in
Hongkong in May, 1894. — The plague bacillus discovered in Hongkong by
Dr S. Kitasato and later by Dr Yersin. — Plague in Macao in April, 1895. —
Canton and Hongkong become centres of distribution of plague. — Plague at
Bombay in 1896. — Commencement characterised by mildness ^nd slow exten-
sion.— Opposition to the adoption of preventive measures. — Progress of the
disease associated with the migration of rats. — Height of the first Bombay
epidemic in Feb., 1897. — Extension of the disease to the Bombay Presidency
and to other provinces in India. — Slow diffusion of the plague.— Severity of
epidemics at Dharwar and Poona. — Extension of the plague to other Presi-
dencies.— Gradually increasing mortality from the j^lague in India. — Extension
of the plague from India and China to other parts of the world. — Distribution
of plague in different parts of the world. — An endemic centre in Uganda.
PART II.
EPIDEMIOLOGY OF PLAGUE.
CHAPTER IV.
NATURE OF INFECTION
Earlier views on the nature of infection. —Discovery of the plague bacillus
and the evidence as to its causal relationship.— "^lorphological and staining
characteristics of the plague bacillus.— ^Cultural characteristics.— Involution
forms. - - Characteristic growth in bouillon.— Formation of stalactites.--Kitasato's
plague bacillus.— The vitality of the plague bacillus.— In different media.— Effect
of cold.— Effect of heat.— Effect of sun.— Effect of drying.— Variation in vii-u-
lence. — Effect of the plague bacillus in animals.
xvi Cottfntfti
CHAPTKK V.
PAOK
THE REI.ATIONSJIII' OF EPIZOOTICS TO I'LAGUE 96
Rats and mice susceptible to natural plague infection. — Relationship
between certain e[)izootics and epidemics of plague a current belief for many
centuries. — Observations of epiz(«)tics associated with plague e2)idemics. —
Plague-stricken rats, their appearance and behaviour. — Cats affected with
])lague. — Other animals affected with plague.— Result of experiments to
produce plague in animals. — Experiments by German Connnission. — Experi-
ments on animals by Austrian Commission. — Hafi'kiue's experiments. — Wilm's
experiments. — Experiments on a large scale carried out in Hongkong in 1902.
—Plague in man possibly not infrequently caused by food contaminated with
plague infection. — Plague in animals under conditions of natural infection.
CHAPTER VI.
DIFFERENT VIEWS AS REGARDS THE ETIOLOGY OF PANDEMICS AND
EPIDEMICS OF PLAGUE 130
1_ Some questions related to spontaneity. — Origin of plague long attrilnited to
putrefaction of dead bodies, or to great physical disturbances. — Pariset's theory.
— Creighton supports Pariset's \'iews. — Mortality of rats from plague not
against Pariset's theory. — Origin of plague attributed to great calamitie.s,
cosmic and telluric. — The Black Death preceded by great disturbances in
the balance of natui-e. — Creighton places the origin of the Black Death on
the borders of the Euxine or Black Sea. — Considerations showing the difficulty
and even the impossibility of now locating the origin of the 14tli century
pandemic. — Volcanic eruptions are recorded to have rendered plants and
herbage poisonous. — Great multiplication of disease germs associated with
lean or famine years. -pExceptional meteorological conditions preceded the
epidemic of jjlaguc in Hongkong. — Scarcity preceded plague in India. — Ab-
normal season preceded epidemic of plague in Hongkong. — Unusual season
l)receded epidemic of plague in Capo Town. — Conclusion.
CHAPTER VJI.
VARIATION IN POWERS OF DIFFUSION OF EPIDEMICS, AND THE
EFFECT OF SEASONAL INFLUENCES ON THEM .... 143
Variation in diffusive powers. — Self-limiting plagues. — The existing pan-
demic po.ssesses comparatively small diffusive powers. — The danger of existing
pandemic. — Plague epidemics and seasonal influences.
Plague epidemics occur at i);u-ticular .seasons of the year. — Temperature -)
affects the endemicity of plague. - Season a composite force. — Mr Baldwin ^
Latham's analysis of the infiueiu;e of climatic factors on plague.- The \ai"ying
condition of the soil .-ind its fluctuating temperature likely to have an effect on
microbic and insect life. — The temperature of the air itself not tlii'ectly in-
fluential.— At the end of the plague season infected articles lose their infectivity,
but may regain it the following season. — Instances. — The same observation has
been made in regard to small-pox and vaccine. — Seasonal periodicity of 2)lague,
and seasonal breeding period of the rat.
Conteiits xvii
CHAPTER VIII.
I'ACiK
VARIATION IN VIRULENCE OF PLAGUE EPIDEMICS .... 1.59
^Variation in virulence. — Mild epideuiiu of plague at Astrakhan and A^et- '
lianka. — The Vetlianka outbreak suddenly acquires great virulence. — Early
malignity of the Avignon epidemic of 1348, with its pneumonic symptoms
followed by a less malignant type.
Different types with varying degrees of virulence majf be seen running
concurrently or following one another in the same epidemic. — Four different
types of plague in the Pali epidemic of 1836. — Five degrees of severity noted
in the Marseilles epidemic of 1720.— Three degrees of severity observed in the
Russian epidemic of 1771. — An Aura Pestilentiae noticed in the Egyptian
epidemic of 1834-35. — Three degrees of severity in the Egyptian epidemic of
1834-35. — Sporadic cases of mild plague may precede severe epidemics of
plague, or they may bridge over the intervals of epidemics. — The import of
glandular swellings before and after plague prevalence. — Presence and absence
of certain symptoms in different epidemics. — Extraordinary and coloured sweats
in the plague of London. — Plague may increase in virulence if it appears in the
same locality in successive years.
Variation in the virulence of the disease dependent on conditions to which
the microbe snd those attacked are exposed. — Natural immunity. — Plague
commits its greatest ravages on people subjected to depressing influences.
White people have a fairly uniform mortality from plague wherever they
may be attacked. — Susceptible races may become less susceptible out of their
own country. — Susceptibility may vary in the same race in different localities.
— Variety of type is seen in all infectious diseases.
CHAPTER IX.
FOSTERING CONDITIONS OF ENDEMICITY AND EPIDEMICITY . . 176
Discrimination between recrudescence and endemicity. — Endemic centres. —
Kurdistan. — Kumaon and Garhwal. — Characteristics of the outbreaks. —
Poverty of the inhabitants, exceptionally insanitary houses and close as-
sociation of animals and men. — Dr Francis' description of the houses. — Dr
Planch's description of the houses. — Conditions in Yunnan. —Conditions in
Assyr. — Fostering conditions of plague prevalence similar in exotic localities
to those in endemic centres. — Paris in the 17th century. — Oporto in the
19th century.- Canton in the 19th and 20th centuries. — Hongkong in the
19th and 20th centuries. — Bombay in 1896. — The chawls of Bombay. — The
crowded buildings in Mandvi. — The Jains and their indifference to death. —
A scene in a Bombay building. — Mortality in the Bombay outbreak of 1896-97
small owing to preventive measures. — The three conditions in city of Bombay
observed by experts. — Notes of a morning's inspection in Bombay. — Cape
Town. — Plague chiefly a disease of the poor. — A Chinese village. — Macao. —
Conclusion.
xviii Contents
CHAPTEll X.
PAGE
DIFFUSION AND MODES OF DISSEMINATION 194
Plague is transportal ile, l)ut icciuiros i-crt.iin carriers for its disjseuiiuatioii.-
Plague travels by the most frequented ti'ade routes. — Persons sick or incubating
plague carry the infection to other localities. — Healthy persons sometimes carry
the infection. — Infection transported and disseminated by infected clothes. —
The infection conveyed to a new centre may aftect rats before human beings. —
Additional risk of extension from an infected locality during the height <jf an
epidemic. — The infection carried long distances in ships. — Transport of infec-
tion facilitated by the movements of crowds. — Transport of infection may
be by vehicles other than infected persons or infected clothes. — Instances
of infection being connected with cargoes and infected rats. — Cape Town. —
Mossel Bay. — East London. — Durban. — Osaka. — Rhajpur. — Pisco. — Callao. —
Asuncion — Unsie. — Inland towns sometimes infected by conveyance by
railway of rats infected with plague or rat-infected merchandise.
CHAPTER XI.
MODES OF DISSEMINATION IN AN INFECTED LOCALITY . . .210
Pneumonic types of plague infectious. — Septicaemic plague infectious. —
Original source of infection in the house of Kaviraj Dwarka Nath in Calcutta. — -
Bubonic plague not directly infectious. — Dissemination by infected clothes. —
Dissemination by infected rats. —Special value attaches to the observations in
South Africa and Australia. — Observations in Hongkong. — Observations in
India. — The agency by which jilague is transmitted from the rat to man. —
The flea theory.- -In the 16th and 17th centuries cats, dogs, pigeons, and fowls
were believed to spread plague.
Ancient belief in the possibility of insects conve^-ing infection. — Plague
bacilli detected in ants, bugs, and flies. — The role of animals other than rats
in the dissemination of plague not judged to be important from existing obser-
vations.— The tarbagan (Arctomys bobac) subject to an epizootic much like
plague. — The disease in man contracted from sick tarbagans.
PART III.
PLAGUE IN THE INDIVIDUAL.
CHAPTER XT J.
MORHID ANATOMY AND PATHOLOGY 226
Skin. — Lymphatic gland.s. — External primary l)uboes. — Veins in the vicinity
of the bubo affected.- Internal buboes. — Secondary buboes. —Histological
changes in primary bubo.— Histological changes in .secondary bulioes. — The
plague bacillus.— Spleen.— Circulatory system. — Respiratory system.— Liver. —
Alimentary canal. — Urinary system. — Nervous system. — Autopsies. — Bacterio-
logical condition. — Histological condition.
Contents xix
CHAPTER XIII.
I'.VGE
CHANNELS OF INFECTION 24!)
Infection through skin direct to the lymphatics. — Power of the bacilhis to
enter the system through a small lesion in the skin without producing a local
reaction at site of inoculation. — Infection through the skin direct to the
blood vessels. — Older view is that plague is a general disease, and that buboes
are its local manifestations. — Infection through the mucous membrane. —
Infection through the respiratory tract. — Mixed infection. — Mode of exit of
infection from the body. — The duration of infectivity of convalescents. — Incu-
bation period of plague.
CHAPTER XIV.
CLINICAL FEATURES 260
Different classification or types of plague. — Plague with and without buboes. —
Incubation period. — The benign bubonic or Pestis minor. — The grave bubonic
or Pestis major. — Causes of death. — Progress after the 6th or 7th day. —
Septicaemic plague. — Pneumonic plague. — Characteristic symptoms. — Symp-
toms considered in relation to systems affected. — Temperature. — Temperature
charts. — Lymphatic system buboes. — Contents and condition of buboes. —
Size. — Pain. — Tenderness. — Termination. — Situation. — Inguinal buboes. —
Axillary buboes. — Cervical buboes. —Multiple buboes. — The skin petechiae. —
Gangrenous pustules or carbuncles. — Nervous phenomena. — Vascular system. —
Blood. — Digestive system. — Urinary system. — Respiratory system. — Compli-
cations and sequelae. — Eye diseases. — Marasmus and chi-onic plague. —
Pregnancy. — Arthritis. — Concurrent diseases. — Second attacks. — Cases of
plague. — Ambulant variety.— Septic and fulminating variety. — An atypical
case. — Plague pneumonia. — Dr Manser's illness. — -Dr Midler's illness.
CHAPTER XV.
DIAGNOSIS AND PROGNOSIS 306
Diagnosis generally not difficult in a typical case of plague. — Bacteriological
test. — The serum test. — The absence of lymphangitis. — Chief difficulty arises
from the Protean character of plague. — Ambulant plague. — Septic type. —
Pneumonic plague. — Influenza and plague. — Tonsillar plague. — Prognosis. —
Caution as to prognosis. — Favourable signs. — Unfavourable signs.
CHAPTER XVI.
TREATMENT 31(}
Curative treatment powerless in the most virulent forms of plague. —
Treatment of plague in the past. — Bleeding. — The evacuant treatment. — The
stimulant and tonic treatment. — Oil friction trcatiyent. — Treatment of buboes. —
Cold water treatment. — Suggested antiseptic treatment. — Basis of the present
day treatment of plague. — Attempt at specific treatment.— Observations on the
XX CoHfeiifs
PACK
sora prepared by Yersin, Roiix, Calmettc, and Borrel. — Amoy. — Bombay. —
Karad. — Karachi. — Oporto. — Glasgow. — Cape Town. — Natal. — Hongkong. —
Bri.sbane. — Observations on Lustig's serum. — Observations on Prof. Terni's and
Bondi's serum. -Observations on Kitasato's serum. — Dosage of serinn.— Anti-
septic tre<itment. — Carbolic acid. — Cyllin. — General treatment. — Nursing. —
Hygienic conditions.— ]\Icdicines. — Local treatment of buboes. — Treatment
of carbuncles. — Treatment during convalescence. — Propiiylactic measures in
an infected bouse. — Use of disinfectants. — Protective inoculation. — Personal
hygiene. — Hygiene of the house.
PAET IV.
MEASURES FOR PREVENTION AND SUPPRESSION
OF PLAGUE.
CHAPTER XVIT.
MEASURES EMPLOYED BEFORE THE DISCOVERY OF THE BACILLUS . 333
Two periods to be considered. — Preventive measures depend on the views
which are held concerning the cause of the disease. — Trespass ofterings. —
llemoval from plague-stricken locality. — Fumigation of the dwellings and
attention to diet. — Prayers and processions. — Resignation and fatalism. —
Disposal of the dead. — Isolation of the rich. — First preventive measures of an
organised nature in Venice in 1348. — First governmental measures in 1374. —
Lazaretto established by the Venetians in 1403. — A council of health and
quarantine established in 1485 in Venice. — The Venetian system of quarantine. —
Preventive mejxsures against extension of plague to other countries. -f-Measures
in Austria and Germany in 16th century. — Educational tracts an^pamphlets
in 16th centuryv^Measures in London in 16th century. — First government
orders issued in London in Henry VI IPs reign. — Orders more severe in the
reign of Elizabeth. — Severity of measures in Aberdeen. — Enlightened policy in
Edinburgh. — First quarantine station for London established in 1664. —
Special plague officials appointed in evei-y parish in London. — Regulations in
London against the plague in the 17th century. — Hodges oi)po.sed to the shutting
up the sick and the well in the .same house. — Dr Mead's views in 1720. —
Advocacy of the establishment of ho.spitals and quarantine stations. — Evacua-
tion of infected houses. — Passport sy.stem for those wishing to leave infected
towns. — First Quarantine Act passed in reign of George IV. — International
preventive measures introduced in 1831 and 1838. --Disappearance of plague
from Turkey and Kgypt attril>uted to these international measiu-es. — Other
causes also at work. — Failure of measures to prevent spread of strong invading
epidemics, and the possible cause. — Intei-national conferences of European
Powers to consider measures of mutual i»rotection against epidemic disease
from the East. — New basis for maritime preventive measures adopted at the
Vienna Conference, 1874. — Quarantine and sanitary cordons brought into
requisition in the Russian outbreak of plague in 1879.
Contents xxi
CHAPTER XVIII.
PAGE
EXISTING MEASURES AGAINST PLAGUE AFTER DISCOVERY OF
BACILLUS 354
Measures to prevent importation of plague.
International measures. — Regulations of the Venice Convention of 1897. —
Merchandise to be prohibited or disinfected if thought necessary, but not
q\iarantined. — Quarantine on land frontiers abolished. — Quarantine not abolished
for certain classes and pilgrims. — The measures agreed upon at the Venice Con-
vention though useful did not stop altogether the importation of plague. —
Regulations of the Paris Conference of 1903. — Local measures. — Methods em-
[)loyed for the destruction of rats on board ships. — The Clayton process for
the destruction of rats and disinfection of ships. — Strength and properties of
the gas. — Precautions to be taken in carrying out the fumigation. — Uses of the
Clayton disinfectf)r on board ship. — Disinfection of baggage. — Necessity to be
in a state of preparedness. — Local measures to be adopted in anticipation of an
outbreak. — Certain principles should underlie the erection of plague hospitals. —
Health camps. — Arrangements for disposal of the dead. — Administrative
arrangements. — Bacteriological examination of rats. — Destruction of rats in a
healthy locality as a precautionary measure. — Methods available for the
destruction of rats. — Traps and poison. — Fumigation with C'layton's apparatus. —
The employment of Danysz' bacillus. — A careful watch on prevalent sickness
required, especially in the poorer quarters.
CHAPTER XIX.
MEASURES TO (;OMBAT AN OUTBREAK OF PLAGUE IN A LOCALITY . 372
Preliminary observations as to the hindrances to a locality being declared
infected with plague. — Commercial, political, and social forces nearly always
range themselves against the first announcement of plague in a town. —
Controversies in Bombay, Calcutta, Cape Town, and San Francisco. — Reported
cases of suspected plague in Johaimesburg. — Rats. — No disease which creates
so much alarm as plague. — Firmness and judgment required from the com-
mencement.— Measures necessary at the commencement not suitable when the
epidemic is beyond control. — Accurate diagnosis essential and its difficulties. —
Plague organisation previously planned to be mobilised. — Notitication to be
su2)plemeiited by visitation of houses and other measures. — Liformation to
householders. — Bacteriological examination of rats. — Outline of a plague
organisation. — Duties of the plague organisation. — The most important
measures for the suppression of 2)lague.— Segregation. — Evacuation of pre-
mises.— Circumstances modifying retention of contacts. — Existing methods
of disinfection cumbersome and unsatisfactory. — The newest and best method
of disinfecting a house infected with plague is fumigating with Clayton's
apparatus. — To prevent recrudescences. — Fumigation has its limits. — Employ-
ment of chemical disinfectants. — Burning and exposure to high temperatures.
— Boiling. —Exposure to the direct rays of sun for three or foiu- days. -Sanita-
tion.— Destruction of rats. — Destruction of rats by the employment of the vii'us
of Danysz. — Attenuation and exaltation of virulence of virus. — Manner in wliirli
cultures of Danys/.' bacillus were ust'd in Cape Town. — Use of Danysz' cultures
xxii Contents
PAGE
in the outbreak of plague at Odessa.— Other methods employed. — Symptoms in
rats suftering from the Danysz' bacillus infection. — Post-mortem appearances. —
Bacteriological examination. — General biological characters. — Staining. — Rapid
diflPerential tests. — Confirmatory dittbrential tests. — Acute toxic cases.—
Destruction of rats in warehouses, etc.
CHAPTER XX.
PREVENTIVE INOCUL.VTION 402
Haftkine's plague prophylactic based on his cholera jtrophy lactic — Prepara-
tion of Haffkine's plague prophylactic. — Method of inoculation. — Effect of the
inoculation. — Results of the inoculations. Instructions to 2)ersons inoculated. —
The prophylactic of Lustig and Galeotti.
CHAPTER XXI.
CONCLUSION 410
More precise information required regarding plague. — The facts known and
established regarding plague. — The main lines on which enquiry is needed.
APPENDIX I.
Reported deaths from plague in India in 1904, extracted from the official
weekly returns . . . . . . . . . . . . .414
APPENDIX II.
THE INTERNATIONAL SANITARY CONVENTION OF PARIS, 1903 ;
With Appendices, translated by Theodore Thomson, Esq., M.D.
PART I. GENERAL PROVISIONS.
CHAP. I. PROVISIONS TO BE OBSERVED BY THE COUNTRIES SIGNING THE CON-
VENTION ON THE APPEARANCE OF PLAGUE OR CHOLERA IN THEIR TERRITORY 416
Section T. Notification and subsequent communications to other countries . 416
Section II. The conditions under which a local area may be regarded as
infected or as having ceased to be infected 417
CHAP. II. MEASURES OF DEFENCE ON THE PART OF THE OTHER COUNTRIES
AGAINST TERRITORIES THAT HAVE BEEN DECLARED INFECTED . . .418
Section I. Publication of measures prescribed . . . . . .418
Section II. Merchandise. — Disinfection. — Importation and Transit. —
Baggage 419
Section III. Measures at Ports and Land Frontiers ..... 420
Section I V. Measures at Land Frontiers. — Travellers. — Railways. — Frontier
tracts. — River-ways 426
Contents
XXlll
PART II, SPECIAL PROVISIONS REGARDING COUNTRIES
OUTSIDE EUROPE. page
CHAP. I. ARRIVALS BY SEA 427
Section I. Measures at infected Ports on the Departure of Vessels . . 427
Section II. Measures regarding ordinary Ships from infected Northern Ports
on their arrival at the entrance to the Suez Canal or at Egyptian Ports . . 427
Section III. Pleasures in the Red Sea ....... 428
Section IV. The organisation for securing surveillance and disinfection at
Suez and at Moses' Wells 431
Section V. The passage of the Suez Canal in Quarantine .... 433
Section VI. Measures in the Persian Gulf . . . . . . . 435
Section VII. Persian ( iulf Sanitary Stations ...... 436
CHAP. II. ARRIVALS BY LAND 437
Section I. General Provisions ......... 437
Section II. Turkish Land Frontiers ........ 437
PART III. SPECIAL PROVISIONS REGARDING PILGRIMAGES.
CHAP. I. GENERAL PROVISIONS 437
CHAP. II. PILGRIM-SHIPS. — SANITARY STATIONS 438
Section I. General conditions applying to Ships 438
Section II. Measures before Departure 440
Section III. Measures during the Voyage 441
Section IV. Measures on arrival of Pilgrims in the Red Sea . . . 444
Section V. Measures for Pilgrims retm-ning home 448
451
CHAP. III. PENALTIES
PART IV.
ADMINISTRATION AND CONTROL.
L The Egyptian Sanitary, Maritime and Quarantine Board
II. The Constantinople Superior Board of Health
III. The Tangier International Board of Health .
IV. Miscellaneous Provisions ....
V^ The Persian Gulf
VI. International Health Office ....
452
453
455
455
456
456
PART V. YELLOW FEVER
457
PART VI. ADHESION AND RATIFICATION
4.-
)(
Appendix I. Regulations
Appendix II.
Appendix III. Resolutions
Index . . ...
457
459
459
461
LIST OF ILLUSTRATIONS.
Map of Yunnanfii and surrounding districts
Plague mortality in India, number of deaths
Plague specimens showing Imcilli
Involution forms of the plague bacillus
HaflPkine's stalactites ......
Chart showing the relation of epidemic and epizootic plague
Chart showing human plague and rat plague
Charts of temperatures of experimental animals.
Chart I. (Pig)
Chart II. (Pig)
Chart III. (Pig)
Chart IV. (Pig)
Chart V. (Pig)
Chart VI. (Calf)
Chart VII. (Monkey) ....
Chart VIII. (Monkey) . . ■ .
Chart IX. (Monkey) ....
Diagram A. Plague mortality in Bombay in first epidemic
Diagram B. Duration of epidemics and months of their greatest intensity in
difterent localities .....
PAGE
53
73
80
84
87
101
102
117
118
118
119
120
122
123
124
125
147
148
149
Diagram C. ]\Iortality from plague for 1903 in Calcutta, as compared with
average of previous five years .......
Diagram D. Showing seasons of the year of the greatest and least exhalation
from the ground between 150 & 151
Temperature Charts .......
Inguinal buboes ........
Axillary liubo ........
Left axillary bubo with infiltration into chest, shoulder, an
Cervical bubo ........
Cervical bubo ........
Popliteal bubo ........
Cervical bubo and necrosis on left arm ...
Supra-trochlear bubo and necrosis on arm .
Right inguinal bubo and necrosis or cai-buncle on luiii
Carbuncle or necrosis .......
Temperature chart of Dr MUller ....
Fig. (1). Disinfection l)y Clayton system of laden steamer infected with plague 364
Fig. (2). Poitable Clayton apparatus disinfecting a house .... 391
pp. 269,
270
271,
272
276
277
id arm
278
279
280
281
282
283
285
286
304
MAPS.
Map of the Bombay Presidency heticeen 70 & 71
Map of Thana Collectorate in Bombay Presidency ...... 70
Map of Surat ("ollectorate in Bombay Piesidency 70
Map of Sind in Bombay Presidency 70
Map showing course and distribution of Plague in Southern China hetveen 74 & 75
Ma]) showing distrilnition of Plague from 1894 to end of 1904 . „ 74 & 75
PABT I.
HISTORY AND DISTKIBUTION OF PLAGUE.
CHAPTER I.
PLAGUE FROM THE EARLY CENTURIES TO THE
NINETEENTH CENTURY.
Plague in the modern acceptation of the term is a specific and
Definition infectious disease affecting man and some of the lower
animals, and possessing certain definite and well-marked
symptoms which are always more or less present in every outbreak.
These symptoms in man are fever, severe headache, giddiness, congested
eyes, extreme mental depression, stammering, incoordination of the
voluntary muscles when called on to act, staggering gait and bodily
weakness, accompanied by painful swellings, with ejffusions into the
surrounding tissues, in the groin, armpit, neck, or other regions of the
lymphatic glandular system, and with an occasional eruption on the skin
of so-called carbuncles or pustules. They end in death in a large per-
centage of cases in the course of three to five days, or even in a shorter
period. The swellings or buboes which are so characteristic of the
disease, and which contain a special micro-organism recognised by its
bipolar staining, may be absent in a varying proportion of cases. In
the pneumonic variety of plague, which primarily attacks the lungs,
there are no buboes, or only a late development of them as secondary
manifestations of the disease. In the fulminating or septicaemic plague,
which is another rapidly fatal variety, there are seldom any buboes to
be detected. Plague may be therefore with buboes or without buboes.
This fact has always rendered the diagnosis of plague very difficult and
uncertain in the early stages of an epidemic, though as the epidemic
develops the types without buboes may be recognised clinically,
especially the pneumonic type with its fever, spitting of blood and great
s. 1
2 History and Distribution of Plague [part i
prostration. Even the laity who have seen much of plague are able to
distinguish this form in its most severe manifestations. Since the
discovery of the plague bacillus both the pneumonic and septicaemic types
can be as readily recognised as the bubonic by the tests which bacteriology
has recently placed in the hands of the physician. The sputum of the
one t}^je and the blood of the other contain the plague bacillus.
Accompanying or })receding plague in man there is usually an out-
break among the lower animals, particularly among rodents such as rats
and mice. In these the same micro-organism is to be found as in man
and is the causal agent of the disease. This causal agent is trans-
portable from place to place, carried by infected persons or animals or
by articles soiled by the infection, and may thus set up in a fresh centre
plague which may manifest itself in a sporadic epidemic or pandemic
form and may assume a mild or virulent type.
It is not in the above restricted sense of a specific disease that
ancient writers on epidemics and epizootics use the term plague. With
them it implies something more general and is applied to any pestilence
in man or beast with a high mortality. Dysenteries, famine fevers, the
fevers of armies, typhus fever, small-pox, and other ftital maladies in
man are included in the older designation of plague as well as the
disease which is now being dealt with. Under these circumstances it
is almost impossible to determine which of the pestilences that pre-
vailed in the Assyrian, Macedonian, Egyptian, Roman, and Grecian
empires were due to true plague and which were due to those other
diseases which went under the same general designation.
That plague in the specific sense understood in the present day did
exist, especially in Mesopotamia, there can hardly be any doubt. Occa-
sionally it is recorded that the Assyrian kings were deterred from visiting
certain places because of the prevalence of plague. The historian seldom
describes the symptoms of any pestilence which he mentions, being
content with relating that an epidemic raged at a certain time and
describing its effects on the inhabitants. To assume that most of the
epidemics thus referred to were plague is to give an exaggerated notion
of the prevalence of the disease in the different centuries, while to
recognise as plague only those epidemics in which the disease is
unmistakeable from the description of its symptoms would be to give
a very inadequate conception of its prevalence and importance.
A middle course is probably the safest, with the qualification that
plague epidemics of a severe type were not nearly so numerous as is
generally supposed. The long interval between the appearance of plague
CH. i] Antiquity of Plague 3
in Europe and its present threatening aspect, or between its occurrence
in India in the 18th century and its serious prevalence now in that
country during the past eight years is merely a repetition of its behaviour
in earlier times. The disease appears to come in cycles between which
the intervals are of considerable duration. Papon \ who has collected a
chronological list of great pestilences, gives 41 epidemics of plague as
occurring in the course of 1500 years before the Christian era, among
the empires and nations the shores of whose countries bordered on the
Mediterranean sea; 109 during the first 1500 years of the Christian
era, and 45 from the year 1500 to 1720, when plague ravaged Marseilles,
Aix, and Toulon.
Plague as stated manifests itself in the sporadic, epidemic, and
pandemic forms, and it is only severe epidemics or pandemics which
receive the attention of the historian. Even in modern times severe
epidemics in one part of the world escape attention in another part,
and it is not to be expected that under the conditions of the early
period of the world's history, mention should be made by the nations
bordering on the Mediterranean of epidemics in remote and unexplored
places. With all the advantages of modern life, with its rapid communi-
cation and telegraphic news, how little is known or heard of the plague
prevailing in China at the present day or of the plague in India which
for some months this year caused some 5000 deaths a day. If India
were not a dependency of Great Britain we should hear still less. The
details are in the archives of the Government of India.
However uncertain may be the nature of the majority of pestilences
The antiquity ^f a bygone age it is certain that plague is a disease of ^
of plague. great antiquity, for occasionally in some of the oldest
records the description is sufficiently explicit to remove all doubt as to
the disease being plague.
The Levant and the countries adjoining have been the centres of ^
plague for at least 3000 years, the first notice of the disease being in
Syria. Plague is mentioned in the Bible as occurring centuries before
the Christian era in the land of the Philistines, having broken out in
Canaan^ during military operations against the Israelites. The in-
habitants of the cities of Ashdod, Gath, and Ekron as well as those of
Beth-shemesh were attacked with " emerods " or tumours in their secret
parts, the pestilence causing a deadly destruction. It is related that in
Beth-shemesh over 50,000 persons died.
1 De la Peste, ou epoque.s viemorahles de ce Fleau. Par J. P. Papon.
2 1 Samuel, chaps, v. and vi.
1—2
4 History and Disfributio)i of Plague [part i
Even at that distant date the disease was observed to be accompanied
by an epizootic among mice, for it is recorded that in order that the
plague might be stayed the Philistines made ])ropitiatory offerings to
the Lord of Israel, of golden images of their tumours and golden images
of their mice that marred the land.
On another occasion the retreat trom Pelusium of Sennacherib's
army is attributed to a pestilence in which field mice are stated to have
played an important part, and in commemoration of the event, according
to Herodotus, a stone statue of Sethon stands in the Temple of Venus
with a mouse in his hand, with the following inscription, " Whoever looks
on me let him revere the gods."
There are earlier references in which the Israelites are threatened
with the botch of Egypt and with emerods, the disease being apparently
well known. Hippocrates gives no description of the disease. He
however states that "all fev^ers complicated with buboes are bad except
ephemerals," which may possibly be considered as evidence that he was
acquainted with plague.
With the exception of the biblical record there is no known trust-
piaeue in worthy account of the disease until we come down to the
Syria, Egypt, works of Oribasius in the 4th century A.D. in the reign
of the Emperor Julian. In this collection of ancient
authors there is a fragment on plague by Rufus of Ephesus, who lived
in the time of the Emperor Trajan and wrote at the beginning of the
2nd century B.C. He not only refers to the plague of his own time, but
also to that described by writers who lived at least a century before
him. Rufus says, "^The buboes that one calls pestilential are very
acute and often cause death. It is especially in Lybia, Egypt, and
Syria that they are seen to occur. Dionysius Curtius the Humpback
has referred to these buboes. Dioscorides and Posidonius have refen'ed
to them at length in their treatise on the plague which in their time
raged in Lybia, and they have said that it was accompanied by an acute
fever, intense pain, perturbation of the whole body, delirium, eruption
of large buboes hard and without suppuration, developing not only in
the usual places but also in the popliteal space and elbow, although in
general such inflammations do not form in these places." A treatise on
plague written in the 3rd or 4th century B.C. indicates a fairly ancient
history.
The identity of the disease thus described with plague admits of no
doubt, while to complete the picture Rufus further .states that " one can
1 (Euvres de Oribase, Bussemaker et Daremherg, livre xliv. c. xvii. p. 608.
CH. i] Plague in the Sixth Century 5
foresee a plague which approaches by paying attention to the bad condi-
tion which the seasons present ; to the manner of living less profitable
for health, and to the death of animals which precedes its invasion."
The evidence is sufficient to establish the fact that plague is of
great antiquity and that it prevailed in Lybia, Egypt, and Syria at an
early period of the world's history when these countries on the southern
and eastern shores of the Mediterranean played a leading part in the
civilisation of the day and their towns were important centres of
commerce. Plague has always been more or less connected with great
commercial centres.
At intervals down to most recent times Lybia, Egypt, and Syria
have been the scenes of plague prevalence. Situated in a unique
position, at one time centres of powerful empires and always the
gateways between the East and the West, it was there the commerce
of the world converged during the ancient and middle ages. The marts
of the ancients and of the middle ages centered here. It was immaterial
what nation wielded the sceptre of commercial supremacy, the land and
sea routes by which the produce from Asia and Africa was brought
remained the same. For thousands of years the Arabs were the
principal carriers of merchandise to and from the shores of the
Mediterranean. They brought the rich produce of the East on camels
and in caravans over the old caravan routes to Tyre and Sidon, to
Pelusium, to Alexandria, to Syria, and to Constantinople, the great
marts of which were the binding links between the East and the West.
It was there that the merchants exchanged the produce of the West
for the produce of the East, and it was there that the commerce of the
cities of Africa and Europe met that of the cities of Asia. In times of
peace the highways were thronged with caravans and merchants, but in
times of war they were the roads traversed by invading armies.
The first well-authenticated pandemic of plague is recorded to have
originated at Pelusium in Egypt in the year 542 B.C.
recorded Pelusium was in those days a large commercial entrepot
pandemic. ^^ which the merchandise from Aethiopia, Mesopotamia,
and the East was brought and there exchanged for the merchandise of
the West.
In a busy and crowded mart of this kind where merchants from
every commercial nation of the time were gathered together for barter,
conditions were favourable not only to the formation of a dangerous
focus and to the extension of the disease, but also to the disease
attracting more attention than its occurrence in some obscure village or
6 Historji aiifJ Disfrihirfion of Plague [part i
town, Pelusium was fixed upon by the historian as the starting-point
of the epidemic, but plague was more or less prevalent in Lybia, Egypt,
and Syria for centuries, and possibly in Aethiopia an endemic centre.
One author distinctly states that it arose in Aethiopia.
Plague seldom arises in the town in which it assumes such dimen-
sions as to attract more than local attention. The pandemic of the
present day is generally traced back to Hongkong and Canton, tAvo
commercial cities, one of which is generally supposed to be its source,
whereas it will be seen later on that the actual origin was from the
Chinese endemic centre of Yunnan. As a general rule the distributing
centres are mistaken for the source.
The disease was slow in travelling in those days, as it is in these. It
took two years to reach Constantinople from Pelusium. Procopius of
Caesarea in his history of the Persian war gives a vivid account of the
epidemic which attacked Constantinople. For accuracy and faithfulness
in detail it might without difficulty even after 1400 years apply to some
of those towns which have been severely affected in the present day.
Transcribed the account is as follows :
"'About the same time arose a pestilence which all but entirely
Account of destroyed the whole human race and, as it happens, men
the plague Qf over-confidence in their own abilitv referred its oris^in
at Constan- ... "
tinopie by to things which pour down secretly from the heavens, and,
Procopius. indeed, those who profess a skilfulness in these matters do
often love with marvellous vain speaking to mention causes for them
absolutely incomprehensible by the human mind, and to devise certain
strange arguments concerning nature, knowing full well that they are
saying no word of truth but quite content if they can deceive the
average man by their contentions. But, of a truth, no cause for this
pestilence can be given or imagined except God. For it did not make
its attack in one quarter of the world or against any one race of men, or
at any certain time of the year, whence any specious reasons for its
cause might be given. Spreading throughout the whole world it
attacked people of every race however far removed from one another,
sparing neither age nor sex. For whether they differed from one
another in dwelling-places or in manner of living, or in their pursuits
or any respect whatsoever, so long as the plague prevailed the difference
availed them not. Some it attacked in summer, others in winter, some at
one time, others at another. Let the sophist discuss the matter, let the
^ Procopius, De Bello Persico, lib. ii. cap. xxii. et xxiii.
CH. i] Plague In the Sixth Century 7
meteorologist take his view each in his own way, but I am going to relate
where this pestilence began and in what manner it destroyed mortals.
" It arose in Egypt, with the inhabitants of Pelusium, then dividing,
it spread one way through Alexandria and the rest of Egypt, the other
into Palestine which borders on Egypt, and then travelled over the world,
always advancing with a progress marked by certain definite spaces of
time. For it seemed to advance by a certain law and to demand
a certain space of time in every country, discharging its venom against
no one on the way casually, but spreading on this side and on that to
the uttermost ends of the world, as if it feared lest incautiously it should
pass by any corner or recess upon earth. It spared neither island nor
cave nor mountain top where men dwelt. If it passed over any place,
only slightly or mildly touching the inhabitants, it returned there after-'
wards, leaving untouched the neighbours against whom it had spent its
rage before, and it did not depart from there before it made up the full
measure of the dead in proportion to the amount of destruction which
it had brought on its neighbours. Always beginning at the sea coast
it spread into the interior. In the second year it reached Byzantium
about the middle of the spring, where, as it happened, I was staying.
Such was its origin.
"Many persons saw visions of spirits arrayed in human shapes. Who-
soever came across these visions fancied that they were struck in this
or that part of the body by some man who met them, and as soon as
they had met the spectre they were smitten with the plague. And in
the beginning those whom ghosts of this sort met, tried to avert them
by imploring the most holy names and by unceasing expiations, as long
as each of them could. But it was all in vain ; for many died even in
the temples into which they had fled for refuge. Others, shutting
themselves up within their chambers, would not listen even to friends,
and although the doors were broken in, pretended they could hear
nothing, fearing evidently that they were being called out by one of
the demons. Some did not catch the disease in that way, but when
a vision presented itself in the form of a dream, suffered the same as
those awake or seemed to hear a voice which proclaimed to them that
they were enrolled in the ranks of the dead. Many, seeing no vision,
either when awake or asleep, as a warning of the future, the disease
attacked generally in the following way. On a sudden they became
feverish, some innnediately on awakening, others while walking, others
while doing one thing, others another. There was no change in their
colour and the b(jdy did not burn as if attacked by fever ; no inflamma-
8 History ami Distribution of FlcKjue [part i
tion was apparent, but from morning until evening the fever was so
mild that neither the patient nor the physician who felt the pulse had
any suspicion of danger ; and none of those who caught the plague
thought of death. But, in some cases, on the same day, in others on
the next, in others in a few days after there arose a bubo, not merely
on what is called the groin, but under the armpit ; in some cases the
bubo appeared behind the ears and in other parts.
" What I have mentioned happened in pretty much the same way to
all ,who contracted the disease. As to the ensuing symptoms, I cannot
say whether the difference between them arose from a difference of
constitution or from the mere will of the Author of the plague. Some
were stricken with a heavy lethargy, others with raving madness, but
each and all suffered what was in keeping with these results. Those
who were weighed down with lethargy always seemed to be asleep,
forgetful of their usual avocations. If there was anyone present to
look after them they would take food at times : those who had no one
to attend to them perished for want of food. But the delirious, unable
to sleep and thinking everyone ready to murder them, were struck with
► terror and shrieking horribly tried to flee away. Those who attended
upon them, distracted by the trouble, suffered terribly, so that people
( pitied the nurse as much as the patient, not because the nurses caught
the disease by coming near the patient, for neither the physician nor
layman caught the disease by touching the sick, for many who attended
upon or buried others, contrary to general expectation, remained
unharmed at their post, and many without running any risk were seized
and died very soon, but because they were so terribly fatigued. For
they had to put back the sufferers who threw themselves out of bed and
rolled upon the floor, or had to drag them back and restrain them by
force when they wished to throw themselves out of window, when they
found water they burned to throw themselves into it, not from a desire
to drink, for men threw themselves into the sea, but moved by their
delirium. Nor was the struggle in the matter of food less, they would
not take it if they could help it.
"With some of those who were not suffering from lethargy or delirium
the bubo disappeared and agonies greater than they could bear took
away their life. Some one may conjecture that the same thing happened
to all the rest, but since they were not conscious they felt but little the
sense of pain which their delii'ium took away from them.
" The physicians being in darkness as to these attacks of plague and
thinking that the fountain-head of it was to be found in the buboes
CH. i] Plague in the Sixth Century 9
determined to examine the bodies of those who died of it ; they there-
fore opened several of them and found a growth of foul carbuncles.
" The malignant violence of the disease killed some at once, others
after many days ; with some, all over the body black pustules, as large
as a bean broke out. These could not survive even for a single day,
but in the same hour as the pustules appeared they breathed their
last. Many dropped down dead from a sudden vomiting of blood.
"This I can truly and sincerely affirm, that the most celebrated
physicians predicted the death of several who, soon after, contrary to
the general opinion, recovered, and on the other hand predicted the
recovery of many who were on the point of death.
" So in the matter of this plague, no cause was reached by man's
reason. In every case the result was something out of the usual. A
bath did one patient good; it did another just as much harm. Of
those who were left destitute of all help many died and many escaped
without it. In a word no one had discovered any way by which either
by precaution one might avoid the plague, or when the plague had
once been caught might avoid death. That one man should fall sick
was unexplainable ; that one should escape seemed a mere matter of
chance. If a pregnant woman caught the plague death was sure and
certain. Some miscarrying, others fairly delivered perished forthwith.
Yet it is said that three women in labour survived, though the children
perished ; ox\ the other hand, in one case, the mother died but the child
lived.
" Those with whom the bubo swelled and filled with pus recovered
from the plague because the violence of the carbuncle had grown less
and passed into pus, and experience teaches us that this is a sign of
recovering health. Those with whom the bubo remained unchanged
the sufferings mentioned above came upon. With some of them the
thigh became completely dried, and so however much the bubo swelled
it gathered no pus. There were some who escaped with a defect in the
tongue, so that as long as they lived they stammered or stuttered in
such a way that they could not be understood.
" The plague lasted four months in Byzantium ; it was at its height
for something like three. At the beginning only a few more persons
died than ordinarily, but afterwards as the evil increased, the number
of the dead reached 5000 a day and subsequently 10,000 and even more
than that. In the early days of the plague a man buried his own
people and cast the corpses either stealthily or perforce into graves
belonging to others ; but afterwards everything was in utter confusion.
10 History and Blsfributioii of Plague [part i
For slaves were left deprived of their masters, and citizens who had
previously been in the highest consideration found themselves destitute
of the services of their domestics, some of whom were suffering from the
plague, while others had succumbed to it. Many houses were left
absolutely empty ; and it came to pass that many people from want of
relatives or servants lay unburied for several days.
" To deal with this the Emperor as was fit and proper charged
Theodorus with the business and supplied him with soldiers and money
from the Treasury. Theodorus was in charge of the ' Emperor's
answers,' laying before him the quests of petitioners and conveying
to them the Emperor's answers. The Romans call this officer in Latin
Referendarius. Those whose houses had not been made entirely deso-
late buried their friends and relations themselves. Theodorus, paying
out the Emperor's money and adding sums of his own, saw to the burial
of the dead belonging to the needy. When all the burial-places which
were in existence were filled with dead bodies they buried the dead
bodies wherever they could round the city, and other buriers pressed
under the numbers of the dying, ascended the towers of the Sycean
walls. Removing the roofs of these towers they cast their dead into
them indiscriminately and packing them wherever they could, when
they had filled all of them almost full they placed the roofs upon them
again. The awful stench from these dead spreading over the city at
all times, but especially when the wind blew from the direction of the
towers, became daily more harmful and distressing to the citizens.
" All rites connected with the burial of the dead were neglected.
The corpses were not carried out with the usual funeral procession or
funeral hymn, it was thought enough to carry the dead to the sea shore
and cast them out there, and these they heaped up in piles upon barges
to be carried out whither hazard would take them. At that time, too,
the various factions into which the people had been divided, laying
aside their natural hatred attended to the funerals of their dead in
common and even buried those with whom they had no communion,
and moreover those who had been given over to profligacy and who
delighted in wickedness and unbridled licentiousness of life, began
strenuously to practise piety, not because they had unlearned wicked-
ness and acquired self-control and had become all of a sudden lovers of
virtue (for the evils which either by nature or long-continued habits
or tradition have become ingrained in man, cannot easily be altered
unless some spirit of holiness has breathed into them), but because in
most cases they were appalled by the calamities before their eyes and
CH. i] Plague in the Sixth Centttry 11
thinking that their own death was imminent, they were assuredly
forced by extreme necessity and had to learn self-restraint from the
awful crisis. In consequence of this, as soon as ever they recovered
from the sickness and had made up their mind that they were quite
out of danger, as though the plague had departed far from them, their
disposition fell back again into evil, and becoming much more dissolute
than of old, they surpassed themselves in wickedness and debauchery of
every kind, so that one might say with truth that the plague, whether
by accident or design, had held a searching examination and spared the
basest of the base.
"At that time it was hard to find any one at business in Byzantium :
those who were in good health remained at home and either attended
to the sick or mourned their dead. Most people who met in the
streets were bearing a corpse. All business had ceased : all the
craftsmen had deserted their crafts and the work they had in hand.
The result was a dreadful famine, which raged without limit, in a city
which was accustomed to all good things in profusion. To have even
bread or anything else enough was difficult, and was thought to be a
good thing, and so untimely death came upon certain sufferers owing to
lack of food. But to be brief: it was impossible to see any one in a
purple cloak at Byzantium, especially when the Emperor fell sick, for he
had a swollen bubo ; but, in a royal city supreme throughout the whole
Roman Empire, all dressed as private, kept at home ; such are the
particulars of the plague as it appeared in Byzantium and in other
parts of the Roman Empire. It attacked Persia too and all the
countries of the East."
There has been little or no change in the nature of the disease from
the time of its earliest description. Perhaps the mental phenomena or
the eruption of pustules or some other symptom may be more pro-
minent in one epidemic than another, but the similarity of symptoms
and general behaviour of the disease are remarkably constant. There
is the same sudden onset and the same appearance of the bubo on the
day of attack, or the next day, or a few days later ; the drowsiness in
some, the madness in others, the desire to wander and the difficulty of
keeping some patients in bed characterise the disease now as formerly :
the large size and suppuration of the bubo indicating a milder attack,
and the reverse a severe and fatal illness ; the deceptive appearance of
the patient rendering prognosis difficult, and the comparative immu-
nity of physicians and attendants are observations which apply equally
well to the disease of to-day as it did then.
12 Histori) and iJlstrihiUlon of Plague [part i
Other writers besides Procopius refer to the pandemic. From these
Account of we learn it continued for some 52 years, visiting different
the plague at places. It reappeared in Constantinople a second time in
nopiem558 558. Agathias describing its second visit says: '"In the
by Agathias. game year, i.e. 558 a.d., at the beginning of spring the
plague again ffll upon the city and destroyed innumerable multitudes;
it had never really ceased from the time when in the fifth year of the
reign of Justinian it had first visited our world. Passing frequently
between whiles from one place to another, and polluting one place after
another, and so granting, as it were, a truce to those left alone, it then
returned to Byzantium, deceived, as I think, before and having departed
from these sooner than it should. Anyhow, many persons fell down
dead as though struck by a violent apoplexy : but those who held out
the best died at last on the fifth day. The symptoms in this plague
were pretty much the same as those in the former. For they had buboes
and fevers, fevers continuous and not quotidian or daily fevers merely,
and never ceasing in the slightest degree, but stopping only on the
death of the person whom they had attacked. Some people without
any feverishness or any pain, going about their daily work, sometimes
at home and sometimes abroad fell down, and at once became lifeless,
as if they had taken death as a chance turn up. People of all ages
perished indiscriminately, but especially the young and vigorous and in
the flower of youth ; and of them the males, for the females were not
affected so much."
Evagrius, a citizen of Antioch, writing of the starting-point of this
pandemic states that it began in Aethiopia. He himself was attacked
when a child at school. His account supplements that of Procopius,
being of later date, although it is evident ft-om the context that he
was not acquainted with the writings of Procopius on the subject.
Evagrius says : " -Now I am about to declare a certain historic which
was not found until this day, it is of a certain pestilent
the plague disease which plagued mankind the space of two and fiftie
at Antioch years and prevailed so much that it destroyed in maner
by Evagnus. j i. ./ _
the whole world. For it is reported that this contagious
disease lighted upon Antioch two years after the Persians had taken the
^ Corpus Scriptoritm Hi-storiae Bijzdiitiitae Niebtihrii. Atjathiae Scholastici Ilisioriarum
lib. V. cap. X.
- The ancient ecclesiastical histories of the first six hunehed years after Christ written
in the Greek tongue by three learned historiographers, Eusebius, Socrates, and Evagrius.
The ecclesidntical Jiistorit' of Evanrhis Schaldxticu.t, lib. iv. cap. xxviii, translated out of
the Greek tongue by Meredith Harmer, D.D.
CH. i] Plague in the Sixth Centiiry 13
citie in some part much like that which Thucydides hath described, in
other respects farre unlike : it began in Aethiopia even as that which
Thucydides wrote of and spred itself afterwards throughout the whole
world, neither was there almost any one that escaped the infection
thereof. It raged so vehemently in some cities that all the inhabitants
thereof were despatched : with other towns it dealt most gently and
mildly. Neither began it at any certain time of the yeare, neither did
it cease and relent after one maner and order, for in some places it
entred with winter, in some other places about the end of spring, in
certain countries about the midst of somer, in certain others in autumne.
In some regions when it had infected some part of one city or other it
left the rest untouched. Then might a man have seen very oft where
this malady reigned certain families wholly despatched, at another time
one or two rooted out and all the city besides not once visited.
Moreover (as we have marked diligently) the families which escaped
this yeare were alone and none others despatched the next yeare, and
that which is most of all to be marvelled at, if any which inhabited the
infected cities fled into other countries where the sickness was not, they
onely Avere visited, although they removed (hoping that way to save
their lives) out of ye contagion into ye cleare. This Calamitie during the
terme and compass of these years which they call revolutions passed
through both towns and country, but the greatest mortality of all fell
upon mankind the second yeare of the revolution which comprise the
term of 15 yeares : so that I myself which write this history (for it will
not be amiss to interlace this, that the consequents may agree with the
premises) while as yet I frequented the schooles, was then troubled with
an impostume or swelling about the privy members or secret parts
of the body, and despatched diversely and sundry kinds of wayes it fell
out to my grief and sorrow that God took from me many of my children,
my wife also with divers of my kinsfolks, whereof some dwelled in the
citie and some in the country. Sych were my adventures and such
were my calamities which the course of those lamentable times
distributed unto me. When I wrote this I was 58 yeares old. Not
two yeares before, this sickness had been four times in Antioch and
when as at length the fourth revolution or compasse was paste besides my
aforesaid children God took away from me a daughter and a nephew of
mine. This disease was compound and mixt with many other maladies.
It took some men first in the head, made their eyes as red as blood and
puffed up their cheeks: afterwards it fell at their throte, and whomsoever
it took, it despatched him out of the way. It began with some with
14 History and Distribution of Plague [part i
a fire and voiding of all that was within them, in some others with
swellings about the secret parts of the body, and thereof arose burning
fires so that they died thereof within two or three days of the furthest
in such sort and of so perfect a remembrance as if they had not been
sick at all, others died mad, and carbuncles that arose out of the flesh
killed many. It fell out oftentimes that they which had this disease
and escaped the first and the second time died thereof afterwards.
The order and maner that men came by this disease was so diverse,
that it cannot with pen be expressed. Some had it by keeping company
and lying together : some others onely by touching and frequenting the
infected houses : some again took it in the market. Many of them
which fled out of the contagious cities, and were not visited themselves
infected where they came. Others which kept company with the sick
and touched not onely the sicke but the dead also were not at all.
Other some who gladly would have died for the sorrow they conceived
because their children and deare friends were departed, and therefore
thrust themselves among the sick could not have their will, the sickness
did as it were fly away from them. This pestilent disease, as I said
before, reigned throughout the whole world the space of two and fiftie
yeares and exceeded all the diseases that ever had been before
Philostratus wondered at the plague which was in his time because
it continued fifteen yeares. But the things that are to come are
uncertain and unknown unto men and they tend to the end which God
hath appointed, who knoweth both their causes and what shall become
of them." It will be noticed that Evagrius refers to a diphtheritic or
tonsillar form of plague, to a bubonic form, and to a carbuncular.
The information as far as it goes concerning this pandemic is very
definite. Procopius, Agathias, and Evagrius agree in the
scant^co^n-^ disease being not only very destructive but also very wide
cemuig- other spread. Probably the remarks as to its passing over the
attacked. whole world apply less to Europe than to Asia and Africa,
with which authors were better acquainted. But beyond
the outbreak they describe there is hardly any information as to other
localities attacked ; nor is it to be found in other authors. As regards
Europe this silence may be explained by the conditions of aftairs at this
time. Rome had fallen. The dissolution which had overtaken the
western portion of the Roman empire, overwhelming it with chaos, ruin,
and destruction, was followed by an age in whioh culture and leisure
were almost unknown. Ignorance and strife were not favourable to
literature, nor to the record of historical events. Whatever was accom-
CH. i] Plague in the Sixth Centunj 15
plished in this direction was done by some of the clergy in their
ecclesiastical chronicles. There, mixed up with accounts of religious
ceremonies and of the doings of kings, nobles, and bishops, may
occasionally be found allusions to the pandemic. They are however
mere echoes and traces of the disease infrequent in their occurrence,
which while affording evidence as to its virulence leave us none the
wiser as to its course or extent in the countries attacked.
In his ecclesiastical history of the Franks and in his other works
Gregory, Bishop of Tours, mentions several times the
Keferences to ravages of plague.
the pandemic ° i o . . „ , „
by Gregory, (a) In 546 the "Lues ingumaria devastates Germany.
xiS^s^^^ (^) In 552 it rages in different countries, and de-
populates particularly the province of Aries.
(c) In 563 it is in Auvergne, after an inundation, and attacks
Clermont, where the mortality was so great that it was impossible to count
those that died. Coffins and biers failed, and ten and even more than
ten persons were buried in the same trench. On a particular Sunday
300 corpses were counted in the basilica of St Peter. Death was
sudden. There arose in the groin and armpit a swelling resembling
a serpent, and the poison so promptly affected the sick that they died
in the course of two or three days. After Clermont, Lyons, Bourges,
Chalons, and Dijon were cruelly ravaged by the plague. Instances
of heroism and of abject fear are not wanting in the narrative. While
many fled for fear of the plague, Cato the priest remained burying the
dead, saying mass for each victim, and died of plague performing these
rites. In contrast to this Cautin the bishop removed from place to place
to avoid the plague, and returning when it was thought to be safe, was
nevertheless attacked and died.
(d) In 582 the disease is in Narbonne and evidently of a most
virulent type: "Audivimus enim eo anno in Narbonensem urbem
inguinarium morbum graviter desaevire ita ut nullum esset spatium
cum homo correptus fuisset ab eo."
(e) In 584 its ravages in the town of Albi are such that the
majority of the inhabitants died, and only a small number of citizens
were left.
(/) In 588 it attacks Marseilles and spreads from thence north-
wards. It is this year im])ortcd from Spain by a ship bringing
(a) Ex libro de Gloria Oonfessorum, cap. Ixxix.
(6) Recueil des Historiem des Gaules et de la France. Martin Bouquet. Tom ii. 1739.
Sancti Georyii Florentii Gregorii Episcopi Turonenxis HUtoriae Ecclcxiasticae Francorum,
lib. IV. cap. V. (c) Ihid. lib. iv. cap. xxxi. (d) Ibid. lib. vi. cap. xiv.
(e) Ibid. lib. vii. cap. i. (/) Ibid. lib. ix. cap. xxi. et xxii.
16 History and Distribution of Plague [part i
merchandise to Marseilles some of the purchasers of which appear to
have been attacked, one fiimily of eight being destroyed. It is noted
that the disease was not communicated at once to the different houses
but remained some time inactive and then suddenly broke out. It is
further remarked that afterwards Marseilles suffered epidemically several
times from the same plague.
{g) In 590 it is in Rome following close upon an inundation of
that city from the Tiber.
(k) In 591 it invades the province of Marseilles and while a famine
desolates the towns of Angers, of Nantes, and of Mans "Vivariensem
Avennicamque urbem graviter lues inguinaria devastavit."
There is an account by Paulus Diaconus of plague in the province
of Lififuria in 565 in the time of Narses : "^ At these times,
Account by o ,
Paulus especially in the province of Liguria. a very great plague
laconus. broke out. For on a sudden there appeared about houses
and dooi-s and furniture and clothes .certain marks, which, the more one
wished to wipe them out, the more and more appeared. But after the
end of a year there began to grow on the groin and other of the more
tender parts small glands in the shape of a walnut or a date ; these
were soon followed by the heat of a fever so intolerable that the sufferer
died within three days. If anyone got over the period of three days
there was some hope for him. There was mourning ever}'where, every-
where tears. For, as the common rumour declared that the plague
might be escaped by flight, houses were left deserted by their in-
habitants, the dogs alone guarding them : the cattle were left alone in
the fields, no shepherd watching them. You might see one day towns
or camps filled with crowds of men, and on the next day, as all took to
flight, everything in dead silence. Children fled, leaving their parents'
corpses unburied. Parents forgetting the bowels of compassion left
their children suffering from the fever. If by chance any of the old
feelings of affection moved a man to bury a relation, he himself was left
with no one to bury him and perished in doing his duty, and while he
performed the funeral rites for the corpse his own corpse was left
without any burial rites. You might see the time reduced to the
silence of old. No voice in the country, no whistling of the shepherds, .
no attacks of wild beasts upon the fiocks. The cornfields passing the
time of reaping untouched were awaiting for the reaper. The vine had
lost its leaves, its grapes were bright, but it remained unspoiled. As
(g) hoc. eit. lib. x. cap. i. (h) Ibid. lib. x. cap. xxiii.
' Rerum Italicarum Scriptores, Muratorii torn. i. 1723.
De Gesti* Langohardorum Pauli Diaconi, lib. ii. cap. iv.
CH. i] Plague in the Seventh and Eighth Centuries 17
winter drew nigh, in the hours of night as well as of the day, the
trumpet of warring hosts was heard and the roar of armies resounded
in the ears of many. There were no signs of the footsteps of passers
by, no executioner was to be seen and yet the bodies of the dead were
more than the eyes could bear. Country districts had been turned into
sepulchres and the dwelling-places of men had become a place of refuge
for wild beasts. These evils within the borders of Italy alone fell only
upon the Romans as far as the territories of the Boii and the Alamanni."
A period of 52 years brings us to the end of the 6th century. The
Plague in Buide Connaile, which proved so fatal in Ireland from 543
Ireland. ^^ g^g^ jg ascribed by some to plague. Ireland was at that
time in constant communication with Italy, and it is supposed that the
infection was imported by some of the ecclesiastics who visited Rome.
Certainly it is about the middle of the 6th century the Irish Chronicles
record that Tara, which till that time was the residence of the chief
king, was abandoned. Diarmait MacCearbhaill, the king, left it and
never returned, and it was never inhabited again. The royal burgh
appears to have been abandoned because nearly everyone had died
there, and the place came to be regarded with such dread that even its
fine position, far-extending view, and rich pastures could not induce
future kings to return to it. A hundred years later, in 663, plague
again ravaged Ireland, and in 664 was epidemic in England. Dr Norman
Moore ^ favours the view that the plague in 664 was brought to England
from Ireland and not from the Continent. It is a moot point whether
St Etheldreda died of tuberculosis or of plague. She had a swelling in
her neck, which was opened by her physician^ three days before her
death. In favour of plague there is the fact that pestilence prevailed
at the time.
No more is heard of plague in Europe till at least a century later,
but if we return to the lands in which it prevailed inter-
tiie vth cen- mittently if not continuously for centuries there are
tury until the sufficient records to show that although it appears to have
Crusades. . . . . ...,,,
died out in Europe it continued to exist m its old haunts.
The most valuable document in this connection is " Kremer's^ great
epidemics from Arabian sources," which shows Syria and the Euphrates
valley to have been during the Saracenic period the scenes of repeated
plague.
1 A Lecture on the History of Medicine as iUustrated in English Literature, by Norman
Moore, M.D. •^ Bede's Eccles. Hist. lib. iv. cap. xix.
* Ueber die yrossen Senchen des Orients, nach arabischen Quellen, A. v. Kreiner, 1880.
s. 2
18 Historji and Distrihtition of Plague [part i
Plague epidemics broke out at Ctesiphon in 628 during the reign
of Shyrujih, one of the Persian kings of the Sassanidae dynasty. It
extended to the Mahonimedan dominions, the foundations of which were
then being rapidly laid by ^lahomet. This was the first outbreak of
plague in Islamic history. The next was in 638. It broke out in
Palestine at the village of Emmaus, in Galilee, and spread over the
whole of Syria. In the same year it appeared in Bassora, carried there
by a portion of the Arabian army, which had lost from it in Syria
25,000 men. Among other historical persons who died in this epidemic
was Abu Obaidah Ibn Garrah. Two commanders-in-chief died of the
disease, the third resolved to adopt preventive measures and distributed
his troops in the highlands and desert, whereupon the plague was
extinguished.
Besides many local outbreaks there were during the 7th century
three great epidemics in Syria and four in Irak. The disorganised
condition of these countries brought about by the w^ars of conquests
and the conflicts between the Byzantians and Arabs rendered them
highly susceptible to the devastations of plague. Only twice in this
century does the plague pass beyond its endemic centres. Once in 686
it spreads into Egypt and there becomes epidemic, and again in 697 it
attacks Constantinople. In the 8th century it was epidemic in Eg3q)t
in 704, and for the first half of the century in Syria about every
ten years. So regular was its annual recurrences at Damascus during
the reign of the Caliphs of the Ommiades dynasty that it became a
custom for them to withdraw to the desert at the season when plague
began to appear. Irak also suffered from at least six severe epidemics
during the first 75 years, Bagdad being attacked with plague in 763, the
year after it was built. There was a wide-spread epidemic both in
Irak and Syria in 745, and it is likely that the destructive plague w-hich
prevailed in Sicily and Calabria in 746 — 748 and spread to Constan-
tinople in 749 was an incursion into Europe from the endemic centre.
According to Nicephorus Byzantinus this plague continued in Constan-
tinople for a year and nearly exterminated the population.
Paulus Diaconus describing this epidemic in Constantinople says :
"'In the same year the plague beginning in Sicily and Calabria, like
some devouring fire, came to Hellas and the Aegean Islands, through
the whole fourteenth indiction, scourging the impious Constantine, and
restraining him from the madness which he aroused against the holy
churches and their holy and venerable images. He, however, as
' Rerum ItaUcarum Scriptores, Muratorii torn. i. lib. xxii.
CH. i] Renewed Activity in the Eleventh Century 19
Pharaoh of old, remained uncorrected. But this plague of the bubo,
spreading in all directions, in the fifteenth indiction^ reached the royal
city. Moreover in the spring-time of the first indiction the plague
spread, and in the summer it raged so furiously that even houses that
were not attacked were closed and no one remained except such as were
bound to bury the dead.
"And so of necessity many plans were devised : boards were laid upon
animals and thus the dead placed thereon were taken to burial. Simi-
larly others were piled in waggons and carried out. But when all the
cemeteries not only in the city but in the suburbs were full, all the
reservoirs without water, and the pools and the vineyards, and the
private gardens inside the old fortifications were dug up to ensure the
burial of the dead ; and despite all this there was scarcely room to bury
the dead."
With the accession of the Abbasides and the transference of the
capital of the Caliphs to Bagdad and the prosperity which it brought
to the country under their sway, plague appears to have become
quiescent for some 50 years in Bagdad. Political capital was made of
the cessation of plague with the commencement of the Abbasidic
dynasty. An Abbasidic statesman in a public speech in Damascus said
it was to be regarded as a particular sign of the mercy of God that
plague ceased when that dynasty began. But one of those present, a
faithful adherent of the fallen dynasty, answered : " God is too merciful
to afflict a nation simultaneously with two such scourges as the plague
and the Abbasides."
This quiescence in the valley of the Euphrates for some 50 years
seems to have formed a part of a general retrocession and
General retro- . . ...
cession and decline of the disease after its intermittent activity for
Ta^uTin^ °^ '^^ years in Europe, Asia, and Africa. Subsequent to this
Europe, pandemic there were only three devastating epidemics in
Syria for ^^^JP^' ^^^ i^^ ^^2, another in (386 and a third in 719, after
several which Eyfvpt remained free of plague until 1010, nearly 300
centuries. ^-^ ^ . , , ^ ° . „ , . . . „
years. Europe also, with the exception oi the visitation oi
Constantinople in 697 and that of Sicily, Calabria, and Constantinople in
749, remained free from plague for at least 400 years, and Syria for 200
years. While appearing in epidemic form at long intervals during the
9th and 10th centuries in Irak and Persia it was not until the 11th
^ Indiction. Tlie fiscal period of 15 years instituted by Coustantine in 313 and
reckoned from the 1st of September 312, which became the usual means of dating ordinary
events and continued as such down through the Middle Ages.
2—2
\
20 HiHtorif (dhJ Distrihiition of Plague [part i
centur}- that the disease began to show a renewed activity and spread
into Syria, Egypt, and Europe. The recrudescence was coincident with
a decline in the empire of the Caliphs and a rise in the power of the
Turks. The struggle of the contending powers seems to have produced
conditions favourable to the virulence of the plague in its endemic
centres, while the movements of the different armies were favourable to
its extension in those countries brought into contact with them.
The conquests of the Sultans of Ghazna are distinguished by a great
plague in India in 1032, which spread over Persia, Mesopotamia, Asia
Minor to the neighbourhood of Constantinople, and it is probable that
it is this same epidemic which appears in Germany and Western Europe
in 1034. Germany in those days comprised the larger part of Europe,
including modern Germany, Poland, Austria, Lorraine, Burgundy, and
Upper Italy. In 1056 over a million and a half of the inhabitants in
the district of Samarcand and Bokhara died of plague.
As in the East so in Europe, the 11th century Avas characterised by
the occurrence of several devastating: eiDidemics of plague.
Plague at the „, , ■ ^ • i^n^ t -4.
time of the 1 he worst m burope was in 1094, two years previous to
Crusades and ^\^q commencement of the Crusades. There can be no
after.
doubt that plague appeared in Europe before the Crusades,
although this has been considered by some the period of its earliest
introduction. The return of the Crusaders from the Holy Land, often
bringing the disease with them, directed more attention to the mortality
which it caused in several parts of Europe. With the Crusades in the
12th and 13th centuries plague assumes a more prominent form in
Europe and becomes more frequent and violent in Egypt. In 1167 the
victorious army of Frederick the Red Beard is almost exterminated by it
in Italy, while in 1270 plague in Tunis decimates the army of Louis XI,
who, with his son, died of the disease, while the Crown Prince Philippe
was attacked and recovered. Plague was particularly severe in Europe
in 1294. Between then and 1346 it prevailed six times in different
countries in Europe. But while in Europe and Eg}^)t the plague
manifests itself with greater persistency and is characterised by in-
creasing virulence and wider diffusive powers, it exhibits in Irak and
Syria towards the close of the 13th century a decline, there being no
epidemics of any gi-eat magnitude. The depopulated condition of these
countries brought about by the loss of life caused by the wars of the
Crusaders, by the invasion of the Mongols, and by a series of destructive
earthquakes followed by famine, epidemics, epizootics and plague, afforded
small opportunity for further devastating plagues. The whole of this
CH. i] Plague in the Fourteenth Century 21
region seems to have been in the latter part of the 12th century and
the early portion of the 13th in the vortex of violent disturbances of
the ordinary course of both natural and social laws.
Quiescence of plague in its old centres did not prevent the gradually ^
The second increasing force and diffusiveness of the plague which
recorded pan- began in the 11th century, culminating in the 14th century
Cl6DllC^ l3Lu6r . .,. I'li'T !•
called tiie m an epidemic or pandemic the like of which for destruc-
Biack Death. tiveness there are no historical records. The starting-
point of this epidemic is not known. The Russian records place it in
India ; the Grecian in Scythia ; the English in the country east of the
Indians and Turks ; the Arabians in the States of the Great Khan of
Tartary and in the land of darkness ; and the Italians in Cathay.
The very unsettled condition of the whole of Asia at the time of
this epidemic and its being practically a terra incognita are probably
explanations of the vagueness of contemporary writers on this point.
Kublai Khan's empire, extending from Hungary on one side to the
coast of China on the other, had been divided auiong the Mogul Tartar
chiefs who fought among themselves for supremacy. It was under
these circumstances that the great plague of the 14th century appeared.
India, China, Tartary, Central Asia, and Russia had come into closer
contact with Persia and Mesopotamia, not by commerce, but by the
march of armies. That there was a wide diffusion in some of these
countries before it reached Europe can be gleaned froiri several authors,
but how long it lasted is unknown. Galfridi Le Baker de Swynebroke
sets it down at seven years. One of the gateways by which
nopie one of ^^ appears to have entered Europe was by Constantinople,
the gateways attacking that city in 1347, the infection having been
by which the . .
pandemic carried from the Crimea and the Volga, where the disease
entered ^^^^ then raging:. Nicephorus Greeforas thus describes it :
Europe. ft & i o
" Now about this time a deadly and pestilential disease
swooped down upon the world. It began with the Scythians and at
Lake Maeotis and the mouth of the Don, in the very beginning of the
spring and continued through all that year, passing from place to place
and devastating, in this wise, only the sea coasts, town and country
alike, as well our territories as all those which stretch without a break
as far as Cadiz and the Pillars of Hercules. But when the second year
came it passed also on to the Islands of the Aegean. Then it attacked
the Rhodians and the people of Cyprus also, and all that inhabit all the
other islands. The disease affected alike men and women, rich and ^
poor, young and old ; to put the matter in a word it spared neither
'22 Historn and Distribution of Plagne [part i
rank nor ago. Many houses were stripped entirely of their inhabitants
in one day, or sometimes in two, since no one was able to render the
sufferers help, no one either of the neighbours or of those who were
connected by blood or any relationship. Nor was it mankind alone
that the plague thus harassed as with a scourge, but all (jther animals
which dwelt with or associated with human beings who took the disease,
dogs, and horses and fowls as well, and even the mice that lived within
the walls of their houses. The symptoms of the plague which declared
themselves signs foreboding a sudden death were the following: A
swelling about the upper parts of the thighs and the arms, and accom-
panying it an effluxion of blood. This in some cases on the very same
day carried off from the present life, whether sitting or walking, those
who had been stricken by it. Andronicus, among others, the younger
of the king's sons, died of it."
There is nothing in this description to indicate that the plague was
The course of *^^*^ '^ different type from that which had previously pre-
the pandemic vailed except perhaps its virulence. The Arabian author
a,s d6scrib6(i x i j.
by an Arabian Ibn Wardy traces the course of the plague in a more
author. definite manner than Nicephorus Gregoras. He relates
that it first made its appearance in "the land of darkness'," that it then
penetrated to China and India, turned thence to the land of Usbekir
and to Transoxiania, reached Persia, depopulated (.^entral Asia, Crimea,
and Byzantium, then Cyprus and the Islands. The epidemic then
appeared in Egypt, depopulated Cairo and Alexandria, and even reached
Upper Egypt, and crept in a westerly direction along the African coast
to Barca. On the other side the epidemic from Egypt reached the
ports of Gaza and Asoalon, invaded Syria, and travelling coast wards and
inland, attacked Jerusalem, Damascus, Antioch, and Aleppo, and most
of the intervening towns, also those of Asia Minor. Ibn Batuta was in
Damascus in 1348 on his return journey from China, and he describes
the havoc which the plague caused in that city at the time of his visit.
It is possible that the great epidemic of the 14th century had its
origin in its old endemic centres in Mesopotamia and Kurdistan, and
1 The kingdom of Kiptchak, whose capital was Surai, was held by Arab writers to be
the northern limit of the habitable world, and as stated by Yule {The Book of Marco Polo
the Venetian, by Col. Henry Yule, C.B., vol. i. p. 6) in his Marco Polo, Bolghar was the
capital of the region sometimes called Great Bulgaria, by Abulfeda Immer Bulgaria, and
stood a few miles from the left bank of the Volga in latitude about 54° 54' and 90 miles
below Kazan. The old Arab writers regarded it as nearly the limit of the habitable
world and told wonders of the cold, the brief summer nights, and the fossil ivory that was
found in its vicinity.
CH. l]
Plague in the Fourteenth Century
23
that in its general extension north, east, south and west it reached
the Volga by routes similar to those which it has taken in more modern
times. There was intercourse between Persia and southern Russia, and
when it was not by commerce it was frequently by the march of armies
in the time of war. Marco Polo relates that while his father and uncle
were staying with Barca Khan at Bolghar there broke out a war
between Barca and Alan the Lord of the Tartars of the Levant, and
great hosts were mustered on either side. But in the end Barca the
Lord of the Tartars of the Ponent was defeated, though on both sides
there was great slaughter.
It would serve no useful purpose to follow up this pandemic into
the different countries, provinces and towns in Asia, Africa,
and Europe which it successively ravaged. In the course
of three years it passed over the whole of Europe and
was unique in the enormous destruction of life which it
caused, it being estimated that quite a fourth of the
population perished. This great mortality was not because the plague
caused in any one place more deaths than many of the previous or later
epidemics of the same disease, but because of its widespread nature.
Never before had it shown such diffusive qualities, or attacked so many
countries one after the other. Hecker^ gives the mortality of some
European towns which he has specially collected. It is as follows :
Pandemic
distin^ished
by its rapid
spread and
destructive-
ness.
Towns
Deaths
from Plague
Florence
60,000
Venice
100,000
Marseilles (in 1
one month) f
1G,000
Siena
70,000
Paris
50,000
St Denys
14,000
Avignon
60,000
Towns
Strasbiirg
Liibeck
Basle
Erfurt
Weimar
Limburg
London
Norwich
Deaths
from Plague
16,000
9,000
14,000
16,000
5,000
2,500
100,000
51,100
A special interest attaches to the epidemic at Avignon as an account
Guy de Chau- ^^ i^ ^^ given by a medical man, Guy de Chauliac, which is
very exceptional for these early plagues. Guy de Chauliac
says: " ^The plague commenced with us in January, it
continued seven months during which time it appeared in
liac's descrip-
tion of the
pla^e at
Avignon.
^ The Epidemics of the Middle Ai)e^, by J. F. C. Hecker, M.D., translated by B. G.
Babington, M.D., F.R.S.
'^ La Grande Chirurgie de Maistre Guy de Chauliac, par M. S. Mingelou Saule,
Traite ii. cap. v.
'24: Histonj and Distribution of Plague [part i
two forms. During the first two months, it was accompanied with a
continuous fever and with a coughing of blood. All who were attacked
died in three days. During the other months the continuous fever was
accompanied with tumours and boils, which appeared in the external
parts of the body chiefly in the armpits and in the groin. Those who
were thus attacked died in five days. The disease was so severe and so
contagious, especially that which was attended by coughing of blood,
that it was contracted not onl}- by visiting and living together with the
sick, but by being in their presence, so that people died without service
or attendants, men were buried without priests and without religious
rites, the father abandoned the son and the son approached not the
father; charity was dead and every hope lost."^
Few parts of Europe seem to have escaped. The epidemic reached
Le Baker de England in the latter part of 1348, and is thus described
swynebrokes by Le Baker de Swynebroke: " -In the year of Christ 1349^
account of . c ^ ^r- ■, ■
the epidemic m the 23rd year of the King's reign, a general plague
in England. spreading from the East of the Indians and Turks, in-
fecting a half of our habitable world, ravaged with such havoc Saracens,
Turks, Syrians, people of Palestine and then the Greeks that, compelled
by terror, they determined to accept the faith and sacraments of Christ,
hearing that the Christians on our side the sea were not afraid of the
death that came upon them more frequently than was wont. At length
the dreadful calamity passing in succession the parts beyond the Alps
and from there to the west of France and Germany in the 7th year
after its outbreak arrived in Europe. And at first it carried off almost
all the inhabitants of the seaports in Dorset, and then those living
inland, and from there it raged so dreadfully through Devon and
Somerset as far as Bristol that the men of Gloucester refused those of
Bristol entrance to their country, everyone thinking that the breath of
^ "In couuection with this epidemic it is interesting to note that the country people
in France dwelt mostly in one-storied huts having mud or clay walls and thatched roofs.
Windows were the exception. Over the door was usually an opening for air and light,
which also served as an outlet for the smoke from the brushwood fire. The sleeping-
places were dark, airless recesses, in which the people having divested themselves of all
clothing rested upon straw mattresses or sometimes on feather beds. Batliing w^as
common and much used, especially among the lower classes, and even small villages
had their public bath places." (T/it' Great Pestilence, a.d. 1348-9, by Francis Aidau
Gasquet, D.D., 1893.)
* Chronicon Gal/ridi Le Raker de Swynebroke, edited by Edward Maunde Thompson,
1889.
3 Le Baker de Swynebroke counted the year from Michaelmas, so that the early part
of 1349 with him was actually the latter part of 1348.
CH. i] Placjue in the Fourteenth Century
'10
those who lived amongst people who died of plague was infectious.
But at last it attacked Gloucester, yea and Oxford and London, and
finally the whole of England so violently that scarcely one in ten of
either sex was left alive. As the graveyards did not suffice fields were
chosen for the burial of the dead. The Bishop of London bought the
croft in London called ' No man's land,' and the Lord Walter de Magne
that which is called ' The New Church Hau,' where he founded a house
of persons in religion to bury the dead. All pleas in the King's Bench
and common pleas of necessity were stopped. Very few nobles died of
it. Among them were Lord John of Montgomerie, Captain of Calais,
and the Lord of Clistele ; they died in Calais and were buried in
London in the Church of the Carmelite Brothers of Blessed Mary. A
countless number of common people and a host of monks and nuns and
clerics as well, known to God alone, passed away. It was the young and
strong that the plague chiefly attacked. The old and feeble it commonly
spared. Scarcely anyone dared to touch the sick ; the healthy fled
from relics of the dead, precious then and now, as if they were infectious.
One day men were as happy as could be, and on the morrow they were
found dead.
"Abscesses suddenly breaking out in different parts of the body
tortured them ; they were so hard and dry that when they were cut
hardly any humour flowed from them : many persons got over them by
means of incision or by long patience. Others had small black pustules
spread all over the skin, and of these very few, nay rather scarcely one
recovered. This great pestilence, which began at Bristol on the feast of
the Assumption of the glorious Virgin and in London about the feast
of St Michael, raged for a whole year in England so terribly that it
cleared many country villages entirely of every human being.
" While this great calamity was devastating England, the Scots
rejoicing thought that they would obtain all they wished against the
English, and at the time blaspheming were wont from sheer wantonness
to perjure themselves 'by the vile death of the English.' But sorrow
following on the heels of joy, the sword of the anger of God departing
from the English drove the Scots to frenzy through leprosy no less
than it had done the English through abscesses and pustules. In the
following year it ravaged the Welsh as well as the English : and at last,
setting sail, so to speak, for Ireland it laid low the English living there
in great numbers, but scarcely touched at all the pure Irish who lived
amongst the mountains and on higher ground until the year of Christ
1357, when it unexpectedly and terribly destroyed them also every-
26 History and Distribution of Plague [part i
where." ^ The important features in this plague visitation were its
rapid and wide diffusion, its c()in])aratively short duration, the virulence
of the cases with pustules, the large proportion of cases affecting the
lungs with spitting of blood, and the great contagiousness of the
pneumonic form. Apart from its attacking the lungs the virulence and
diffusiveness of the disease in its other manifestations seem to have
been very marked. Diffusiveness may characterise one epidemic and
virulence another, but in this epidemic both qualities were united in an
exceptionally high degree.
This destructive epidemic of the 14th century formed the climax of
that expanding activity of plague which began in the
mh^ieSi**^^ 11th century and which continued at intervals to manifest
and 17th itself in a widespread manner until the end of the 17th
century. In the 15th, 16th, and 17th centuries there were
frequent outbursts and epidemics in Europe, Asia, and Africa more or
less limited in their extent.
Heberden-, who ascribes the prevalence of plague to the physical
and political miseries of the nations of Europe during these centuries,
gives a list of some of the more important places on the Continent
attacked with plague in the course of this period. Dresden was attacked
with plague in the years 1504-5, 1511-12, 1521, 1535-36, 1547,
1563-64, 1571-72, 1585-86, 1591-92, 1607, 1627-28, 1632-3-4-5-6-7.
"In 1502 the disease was at Brussels; 1517 at Verona; 1525 in
Germany; 1531 and 1534 in France; 1539 in Switzerland; 1542 at
Breslau ; 1550 at Basel: between 1550 and 1553 it spread itself
successively over almost all the habitable world; 1559 it was in
Holland; 1563 it was in Germany, and again in 1566; 1564 in Savoy;
1566 and 1568 at Milan ; 1568 at Paris ; 1572 at Basel ; 1575 at Milan ;
1576 at Venice; 1580 at Marseilles; 1593 it was in Holland and the
Low Countries; 1596 and 1597 in Germany; 1603 it was again in
Holland, also in 1609, and in the latter part of the year in Denmark;
1618 at Bergen; 1619 in Denmark; 1622 at Amsterdam, where it
continued for eight years; 1623 it was at Montpellier; 1625 at Leyden,
^ The effect in England of this severe visitation of plague was as in other countries
the disorganisation of the social system which recjuired many years for its recovery and
reconstruction. For instance it was not until 200 j'ears later that tillage was revived in
England to a similar extent. This improvement began in the time of Elizabeth (The
Growth of English Induatrn in Modern Times, lib. ii. p. 100, by W. Cunningham, D.D.,
1903).
2 Observatioiis on the increase and decrease of different diseases, and particularly of the.
plague. By Wm. Heberden, Juu., M.D., F.R.S.
CH. i] The Fifteenth, Sixteenth, Seventeenth Centuries 27
in Denmark, and in Germany; 1628 it was at Lyons; 1629 and 1630 at
Montpellier; 1631 at Dijon; in 1630 it was besides in Denmark and at
Christiania in Norway; and at Parma, Verona and other parts of Italy;
from 1633 to 1637 it was in the Netherlands, and in the latter year
at Prague; in 1649 more than 200,000 persons are said to have perished
by this disease in the southern provinces of Spain; 1649 and 1650 it
prevailed at Marseilles; 1650 it was also in Ireland; 1652 at Cracow;
1653 in Poland and Prussia; 1654 at Copenhagen; 1655 at Amsterdam;
and in the course of the same year and the three following it was in
many places in the south of Europe ; 1660 it was in Scotland ; 1663 and
1664 at Amsterdam and Hamburg; 1668 in Flanders; 1670 in Italy;
1679 at Vienna; 1680 at Leipsic ; 1684 in Norway; 1685 at Leghorn.
In 1622 the mortality by the plague at Amsterdam (at that time equal
to about one-third of London) was 4000 ; in 1623, 6000 ; in 1624, 12,000 ;
1625, 6800; in 1626, 4400; 1627, 4000; in 1628, 4500. Felix Platerus,
physician at Basel, in Switzerland, about 1580, gives an account of seven
pestilential fevers which afflicted that country in the space of 70 years.
Thomas Bartholin mentions five that raged in Denmark in his time
(1660), and Forestus relates that in his time (1570) the plague was
frequent at Cologne and Paris ; and refers the cause to the multitude of
the inhabitants and the nastiness of the streets.
" By another account Paris is said to have been infected eight times
between the years 1480 and 1590; in 1607 two hospitals of reserve,
St Louis and St Anne, were erected on purpose to receive patients
in time of plague or other great calamities. They were opened on
account of the plague in 1619, 1631, 1638, 1662 and 1668, since which
that disease has been unknown there. We are informed that about the
same time Paris was paved and the streets were widened, and the city
began to be kept cleaner."
During this period plague also prevailed frequently in Britain. The
most important outbreaks are described by Creighton in his history
of epidemics of Britain. Many of them are ascribed to importation
from the Continent. There is little doubt that the eastern coast was
more frequently affected than any other part of the country. Whether
the endemicity was kept up by communications with Holland cannot
now be determined, but it is not an unlikely explanation.
London in the London itself was never long free from plague, though
letii and i7tii severe epidemics were infrequent. Some valuable notes on
centiiries.
the occurrence of plague collected by Mr Baldwin Latham
make this clear. In the course of 136 years plague deaths were
28 Histonj and Dixfribittion of Plague [part i
recorded in London in no fewer than 84 years, but only six of these
years were characterised by severe epidemics. The six years and the
number of plague deaths recorded are : —
Year
Number of
Plague Deaths
1563
1592-93 .
23,000
22,167, according to Creighton 15,003
1603
1625
36,269
35,417
1636
10,400
1665
()8,596
Notes of the Occurrence of Plague in London and some other places in
England since the year 1543, and returns of ]ilague mortality in
London, collected hy Mr Baldivin Latham, M.I.C.E., from various sources,
and mainly from the annual Records of Weddings, Christenings, and
Burials, kept in pursuance of orders passed hy Thomas Cromwell, Lord
Privy Seal, in September, 1538'.
1543 Plague in London. Lanquette's Chronicle.
1548 Pestilence in London. Stow's Annals.
1551 Sweating sickne.s.s in London. Lanquette'.s Chronicle and Fabian's Chronicle.
1552 Plague prevalent. History of the weather.
1558 Plague in King's Lynn. Richards' King's Lynn.
1562 Plague cau.sed 20,136 deaths. Bills of Mortality, London. Brought by
.soldiers from the Continent. History of the weather.
1562-3 City and Suburbs of London : Burials 23,630 — Plague burials 20,136.
Maitland's London, page 736.
1563 23,000 persons died in London of plague between 6th April and last day
of November. Lanquette's Chronicle.
1564 Plague not fully ceased in London. Stow's Annals.
1569 Plague in London. Stow's Annals.
1574 Plague in the City. Maitland's London.
1575 Plague in King's Lynn. Mackerell's King's Lynn.
1581-2 Between 28th Dec, 1581, and 27th Dec, 1582, died of plague in London,
6,930. Maitland's London.
1587 Plague raged in King's Lynn. Richards' King's Lynn. Burials in Leeds
tripled by the plague. Annals of Yorkshire. Plague rife, — said to be
due to famine. History of the weather.
1588 Plague raged in King's Lynn. Richards' King's Lynn.
1589 Plague in Newcastle-on-Tyne. Newcastle Record.
1592* Plague in London. From March to December, 25,886 persons died, of
whom 11, .503 died of i)lague. Graunt.
1 The Recent Epidemics of Plague in Bombay. Paper read before the Geographical
Society of Manchester, the 19tb May, 1898. By H. M. Birdwood, C.S.I., LL.D.
* Excessive drought.
CH. l]
Plague in London
29
1593
1594*
1595
1603
1604
1605
1606
1607
1608
1609
1610
1611
1612t
1613
1614
1615
1616
1617
1618
1619
1620
1621
1622
1623
1624
1625
))
1626
1627
1628
1629
1630
1631
1632
1633
1634
1635
1636J
1637§
1638
1639
Plague in London. 17,844 died, of whom 10,662 died of plague, and the
christenings were 4,021.
No record for London. Very healthy at Croydon, also in County parish.
(Referred to by Graunt.)
No record for London. Great dearth in England. No record for London
until 1603.
Burials for London and Liberties, 42,042. Plague burials, 36,269.
Burials, London, 5,219 ; Plague burials, 896. Plague raged in many country
places.
Plague,
Burials, London,
Burials within walls,
Burials, London,
6,391
7,920
8,022
9,020
11,785
9,087
7,343
7,842
7,519
7,389
7,887
8,072
8,286
9,614
8,008
9,712
8,123
8,959
11,112
12,210
54,265
14,340
7,535
7,715
7,743
8,814
10,554
8,358
9,439
8,428
10,865
10,865
23,359
11,763
13,624
9,862
444
2,124
2,352
2,262
4,240
1,803
627
64
16
22
37
9
6
18
9
21
11
16
17
11
35,417
9,197
134
4
3
nil
1,317
274
8
nil
1
nil
10,400
3,082
363
314
Wet year.
Great drought.
t Tempests, Oct., Nov., and Dec.
§ Summer hot and droughty.
Drought.
30
Historji (ukI Disfrihfffioii of Plaf/ne [part i
1640 Burials, London, ... 12,771
1641 „ ... 18,291
1642 „ ... 12,167
1643 „ ... 13,202
1644 „ ... 10,933
1645 „ ... 11,479
1646 „ ... 13,532
1647 „ ... 14,059
1648 „ ... 9,996
1649* „ ... 10,532
1650 „ ... 8,581
1651 „ ... 10,773
1652 „ ... 12,539
1653 „ ... 9,083.
1654 „ ... 13,126
1655 „ ... 11,409
1656 „ ... 13,752
1657 „ ... 12,434
1658 „ ... 14,993
1659 „ ... 14,756
1660t „ ... 15,118
1661 „ ... 19,771
1662 „ ... 16,554
1663 „ ... 15,356
1664 „ ... 18,297
1665+ „ ... 97,306
1666 „ ... 12,738
1667 „ ... 1.5,842
1668 „ ... 17,278
1669 „ ... 19,432
1670 „ ... 20,198
1671 „ ... 15,729
1672 „ ... 18,230
1673 „ ... 17,504
1674 „ ... 21,201
1675 „ ... 17,214
1676 „ ... 18,732
1677 „ ... 19,067
1678 „ ... 20,678
1679 „ ... 21,730
1680 „ ... 21,053
There are no fui-tlior records of the plague.
Many of the epidemics on the Continent
former outbreak.s in the same locality or were
brought from neighbouring States. They we
* Commonwealth commenced. f Charles II.
Plague, 1,450
3,067
1,824
996
1,492
1,871
2,436
3,597
611
67
15
23
16
6
16
9
6
4
14
36
14
20
12
9
6
68,596
1,998
35
14
3
nil
5
5
5
3
1
2
2
5
2
7iil
were recrudescences of
caused by the infection
re manifestations of a
J Hot and dry.
CH. i] Plagiie and Commerce 31
disease which had become more or less endemic in some portion of the
country in which they appeared, but in addition to these
cences and there were apparently now and again great epidemic
v^Ve™from waves spreading in every direction from the old endemic
old endemic areas then in possession of the Turks and the Tartars.
Some conditions which have not yet been recognised
imparted to the disease an exceptional amount of diffusibility and
infectivity which enabled it to advance irresistibly along the ordinary
trade routes of travel and to become epidemic in most places it visited.
Plague is not the only disease which has displayed these characters.
Cholera and influenza in their visitations during the 19th century
comported themselves in a similar manner. The epidemics of plague
gradually became less frequent even in those places most exposed to its
invasion. There were eleven epidemics in Marseilles in the 16th century,
only two in the 17th century and only one in the 18th century. In
these subsequent visitations the all-pervading destruction which dis-
tinguished the 1348 pandemic was absent, though at times some
circumscribed areas would suffer from as virulent if not a more virulent
type of plague. This was the case in 1437 in Cairo, which was almost
depopulated ; in 1576 in Venice, which lost 70,000 of its inhabitants; and
in the same year in Moscow, which lost 200,000 of its inhabitants; in 1656
in Naples, which lost 300,000 of its inhabitants ; and in Rome, which lost
in the same year 145,000. Genoa also lost 60,000. There died in
London of plague in 1665 nearly 70,000 persons.
Unless maintained by fresh importations from the East the endemic
areas in Europe never seem to have long retained their endemicity.
There were many facilities for fresh importations.
From the 10th to the 16th century the Venetians possessed almost
Plague and a monopoly in the commerce between the East and the
commerce. West, their only rivals being other Italian States, such
as Genoa and Florence. Italy, more particularly Venice, was practically
the gateway through which the produce of India, China, and Persia
passed into Europe. The merchandise was brought overland in caravans
to the shores of the Mediterranean or Black Sea, and thence by ships to
the Italian State, which was the great distributing centre for Europe.
On their way through Mesopotamia and neighbouring countries the
caravans passed through endemic areas of plague. The great trade
routes from Venice to the north-west of Europe, to the Baltic and to the
North Sea, were not by sea but by land through central Germany. Tht;
Hanseatic League, that great confederacy of towns for the furtherance
32 Historii and DistrihiUion of Plaijue [part i
and protection of trade on tlic north, was the connecting link between
Venice and the north. It carried on an immense trade with Venice.
The great commercial cities of" Bremen, Dantzic, Lllbeck, Hamburg,
Cracow, Ratisbon, Augsburg, Nuremburg, Frankfort, and other towns
were connected by these land routes ; and periodical fairs were held in
them to which merchants Hocked from all parts, bringing their goods
and exchanging them for others. They afforded facilities if plague were
present for its extension. During this period plague appears to have
prevailed periodically and with great persistence in Europe, being main-
tained by fresh incursions of the disease from the East brought in the
train of armies or of commerce. Venice alone in the course of six
centuries from 900 to 1500 suffered from 63 epidemics of plague. The
Venetians were the first to learn that there was a connection between
merchants and merchandise coming from or passing through countries
affected with plague and the conveyance of that disease to healthy
localities, and for self-protection they were the first to practise against
ships from Alexandria and the Levant preventive measures in the form
of quarantine, which was based on the medical doctrines of the day.
Venice established a Lazaretto in 1403 on the island of 8te Marie of
Nazareth, and was followed in 1467 by Genoa and by Marseilles in
1526, both towns having considerable commerce with the East. The
effect of the introduction of quarantine in these three ports was how-
ever small compared to that which followed the decline of the Venetian
trade in consequence of the discovery of America and of the sea route
to the East Indies round the Cape of Good Hope.
These two great discoveries at the end of the 15th and the
beginning of the 16th century were gradually to effect a great change in
commerce, one of which was the transference of a commerce which was
exclusively overland or coasting to a sea commerce, and the other was to
change the routes of international commerce so as to deprive the
Italian States of the monopoly which they had possessed for several
centuries. Venice, the principal mart of the products of the Orient, was
not long in discovering the injurious effect likely to arise from the
discovery of the Portuguese, and in the 16th century its Government
made advances to the Portuguese with the object of buying everything
brought by the Portuguese from the East. These proposals were
rejected. Trade, however, seldom becomes suddenly diverted from its
customary routes, and though much of the commerce of the East was
shifted to Lisbon, a great deal remained in the Mediterranean, shared
by Italy and France; and it was only at the beginning of the
CH. i] Retrocession of Plague 33
17th century, when Venice lost its power in the Levant, and when the
Netherlands and England began to take the place of Portugal and
Spain, by which the commercial activities of Europe with the East were
transferred to the ports in the North Sea, that the roads northwards
from Venice and Marseilles became no longer the routes by which the
produce of the East was carried to northern towns. The Hanseatic
League came to an end about 164L The Thirty Years' War, from
1618 to 1648, which had been the means of spreading plague largely in
Europe, had practically destroyed the mercantile intercommunications
between the North and the South, and at the same time had destroyed
the League.
France, which was the only other country having direct dealings
with the Levant through Marseilles, was in a state of misery and
disorganisation during the first half of the 17th century, and was
afflicted not only with plague, but also with fiimine. Its commerce
with the Levant and North Africa was brought to its lowest point
on account of piracy in the Mediterranean and the unfriendly attitude
of the Turk. A new route to Persia through the Caspian Sea,
Astrakhan, Novgorod and Narva, was accordingly opened out in 1630,
by which for a considerable time the produce of Persia and the East was
conveyed to France.
With the altered circumstances there were fewer facilities for the
importation of plague, and after the great outbreaks
cessation of between the fifties and eighties in the 17th century, of
plague in which the plague of London in 1666 with its 70,000 deaths
Western , i -ni-
Europe at the lormed a part, plague rapidly disappeared from the whole
end of the q£ Western Europe. The last epidemic in Ireland was in
ITth century. ^ ^
1650, in Denmark 1654, in Sweden 1657, in Italy 1657, in
the Netherlands and Belgium 1664-66, in England 1666, in Switzerland
1667-68, in France 1667-68, in Western Germany 1667-68, in Spain
1677-81 and in Eastern and Southern Germany in 1679-81. The
cessation of plague in all these countries in so short a time is a
remarkable epidemiological fact. There may have been and probably
were other powerful causes at work, particularly in connection with the
natural history of the epidemic, which tended towards its exhaustion
and decline, but there is also the important fact that difficulties arose in
opportunities of renewal of the disease by fresh invasions. The abandon-
ment of the Mediterranean as the centre of commerce for Europe, the
shutting up of the Levant as the high road for the conveyance of the
produce of the East to the West, and the transfer of commercial activity
s. 3
34 History and Dhtrihution of PlaffKe [part i
to Amsterdam and London, whose connections with the Far East were
by sea and not by land, and consequently the avoidance of the former
intimate connection with endemic centres, were changes which came
into operation in the early part of the 17th century; and it appears
that it is in these great changes in the commercial relations of Western
Central Europe that the explanation of the rapid disappearance of
plague from Europe is to be sought, once the influence of war in
Central Europe and famine in France was over, rather than in any
great social change effected at that period.
Under these circumstances, quarantine, as practised in the Mediter-
ranean ports, became easier in its application and more effective in its
results. Plague continued at intervals in the neighbourhood of the new
overland route, and in those countries with which Turkey was at war,
for more than another century, but it spread very little out of the beaten
track.
During the 18th and the early part of the 19th century plague
Plague in the continued to prevail in Turkey, Asia Minor, Syria and
isth century. Egypt, and from there the disease occasionally extended
to those countries immediately bordering on their territories or to ports
in very intimate intercourse with them. In 1709 it was in Russia and
it is estimated that over 150,000 persons died in the epidemic. In
1719 it prevailed in Transylvania, Hungary and Poland, and again in
Hungary, Moravia and Austria from 1738-1744. Its extension beyond
the countries mentioned was rare. Sometimes the spreading of the
disease was connected with commerce and sometimes with war.
The plague of Marseilles in 1720 was imported from Tripoli in Syria
by a merchant vessel which had lost six of its crew on the voya.ge from
the disease. From Marseilles the plague spread to Toulon, and in the
two towns nearly 90,000 persons died.
The plague in Messina in 1743 was brought by a merchant vessel
from the Morea. The captain put in at Misselonghi in the Gulf of
Lepanto and there renewing a clean bill of health deceived the health
authorities as regards the original port which the vessel started from.
He moreover accounted for a death on board by attributing it to an
accident in which one of the sailors fell overboard. The captain died
on the 24th March, four days after the arrival of the ship, and one of
the sailors three days after the captain. The landed goods and the
vessel were burnt and the rest of the crew placed in the Lazaretto.
These measures allayed all alarm. In the meantime a fisherman had
received from the captain some infected goods and had taken them
home. The plague first appeared in this quarter of the town. But so
CH. i] Plague in Moscoiv 35
slow was its progress that on the 15th of May a thanksgiving service
was held for deliverance from this terrible malady. One physician per-
sisted in stating that a number of his patients were suffering from
plague, but his announcement was so unwelcome that he narrowly
escaped with his life. From the 15th to the 31st of May between three
and four hundred people perished, and yet on the 31st of May at
a Council held at the Governor's palace twenty three of the physicians
solemnly declared that the disease was not the plague. Notwithstanding
this the deaths rose early in June to one hundred a day, and then the
Government becoming alarmed issued orders for the necessary regula-
tions : " ^ A panic terror seized at once the people and the city was in
a manner abandoned, except by the magistrates of the health and senate,
who kept firm in the discharge of their duty, and only one of each
magistracy survived. But none of these orders were executed, the
common people could not be kept under any government, so that many
who had shut themselves up in their houses, began to think of providing
themselves by force of money not only with the common necessaries for
their sustenance as flour, rice, oil, etc., but also firearms and powder to
be able to make defence against the fury of the populace, who would
have assuredly committed violence had they not perished so very
suddenly by the distemper which swept away the greater part in a few
days. The principal mortality did not continue above 20 days, that is
from the 12th of June to the beginning of July."
Cyprus in the years 1759 and 1760 suffered from a severe epidemic
of plague, Nicosia losing 25,000 of its inhabitants. The disease was first
introduced by infected Turkish sailors shipwrecked not far from Limsol,
and later by merchant vessels from Damietta. It lasted two years,
spread over the greater part of the island and destroyed 70,000 of its
inhabitants.
The plague of Moscow in 1771, on the other hand, was the result
of war. It occurred when Catherine was at war with the Turks,
the Russian troops becoming infected as early as September 1769 by
Turkish prisoners of war. The infected troops returning to Jassy
spread plague among the inhabitants and later carried it to Moscow,
which lost over 60,000 of its population. The disease was unrecognised
at first and was called malignant epidemic fever, not an uncommon
mistake in the early days of a plague epidemic. At the commence-
ment its progress was slow. The infection was introduced in October
1770, but it was not until March 1771 that the disease assumed
1 A Treatise of the Plague, p. 516. By Patrick Russell, M.D., F.R.S., 1791.
3—2
36 Historij and .Distribution of Plague [parti
threatening proportions and the people became alarmed. According
to Dr Athanasius Shafonski, who writes an account of the epidemic and
is quoted by Dr F. C. Clemow', there were in April 778 deaths, in May
878, in June 1099, in July 1708, in August 7268, in September 21,401,
in October 17,561, in November 5235, and in December 805. The
plague continued throughout 1772, and it was not until December that
Moscow was officially declared to be free from plague. On its rapid
development in Moscow it invaded the provinces of the south and west
and destroyed 300,000 of the inhabitants.
At the close of the 18th century when plague was affecting the
French army in Egypt, West Barbary suffered severely
West from plague. It is not known how the disease originated.
ary. Some ascribed it to infected merchandise imported into
Fas from the East ; others attributed it to the locusts which had
infested West Barbary during the seven preceding years. It was
a most destructive and wide-spread epidemic and is estimated to have
destroyed two-thirds of the population of the empire. Morocco lost
50,000 of its inhabitants. Fas 65,000, Mogodor 4500, and Sa% 5000.
Many villages had nearly the whole of their inhabitants swept away.
Deabet, a village near Mogodor, lost 100 persons out of 133 in twenty
days, though it remained free for over a month from disease whilst
Mogodor was suffering, notwithstanding daily communication. The
naiTator records the following: "-Travelling through the province of
Haba shortly after the plague had exhausted itself I saw many unin-
habited ruins, which I had before witnessed as flourishing villages.
On making inquiry concerning the population of the dismal remains
I was informed that in one village which contained 600 inhabitants
four persons only had escaped the ravage. Other villages which had
contained four or five hundred had only seven or eight survivors left
to relate the calamities they had suffered. Families which had retired
to the country to avoid the infection on returning to town when all
infection had apparently ceased were generally attacked and died.
A singular instance of this kind happened at Mogodor where after the
mortality had subsided a corps of troops arrived from the city of
Zerodant in the province of Suse where the plague had been raging,
and had subsided ; these troops after remaining three days at Mogodor
1 " Plague epidemics in Russia." By Frank C. Clemow, M.D., Indian Medical Gazette,
Sept. and Oct. 1898.
^ An account of Timbuctoo and Ilauxa Territories in the interior of Africa, by El Hajee
Abd. Salam Shabeeny with notes critical and explanatory. By James Grey Jackson,
Resident for upwards of 16 years in South and West Barbary in a diplomatic and com-
mercial capacity, 1820.
CH. i] Contimied Retrocession of Plcufue 37
were attacked with the disease and it raged exclusively among them for
about a month, during which it carried off two-thirds of their original
number, one hundred men ; during this interval the other inhabitants
of the town were exempt from the disorder, though these troops were
not confined to any particular quarter, many of them having had apart-
ments in the houses of the inhabitants of the town." This epidemic of
plague in 1799 in West Barbary had only been rivalled in violence by
the pandemic in the 14th century when two-thirds of the population
perished.
As plague prevalence lessened the origin of plague epidemics in
healthy localities became easier to trace and resolved itself, in the case
of Europe, into importation of the infection from infected localities.
Recrudescences in the same locality might recur year after year for
a longer or shorter period, but with this exception plague was an exotic
which could seldom maintain itself in one place except by fresh invasions
brought about by the movement of troops or the activity of commerce.
In the early part of the 19th century plague still lingered in Turkey,
Plague in the Asia Minor, Syria and Egypt. In 1803 Constantinople
I9tii century. j^g^ 150,000 of its inhabitants from the disease. There
was a lull again until 1812-13 when the same city lost another
100,000. Only twice in the century did plague extend beyond these
limits, once in 1812-15 and again in 1828-29. On both occasions
it spread to the frontiers of Austria and of Russia, becoming epidemic
in Odessa, the Crimea, Wallachia, Moldavia and Transylvania. In the
former years it reached Malta and Noja.
In 1829 it was epidemic in Greece after an absence of a century,
having been imported by Egyptian troops. Finally it was epidemic in
Constantinople in 1831 and again in 1841 and in Egypt in 1844. Then
as in the West at the end of the 17th, so in the East towards the middle
Disappear- of the 19th century a repetition of the phenomenon which
ance of has been more than once noticed in the history of plague
Turkey and occurred. In the course of five years, from 1839 to
nuddi ^°f*^^ 1844, plague disappears entirely from its old haunts in
the 19th South-Eastern Europe, the Levantine countries and Egypt,
century. j^^ ^^^^ ^j^^ Russian Government and in 1849 the Austrian
Government sent commissions to Egypt to enquire as to the disappear-
ance of plague from that'country. Both commissions failed to discover
a single case of plague.
The cessation of plague in the Levantine regions in the middle of
the 19th century was a remarkable phase in the natural history of the
disease, but it was not more remarkable than that which occurred in the
38 History and Disfrihnfion of Pfaf/ue [part i
8th century and which was followed by a prolonged period of quiescence.
Measured by the standard of great epidemics plague has been since
1844 quiescent in the Levantine regions some 60 years, but that
quiescence is short compared with the duration of the former lull.
Notwithstanding the disappearance of plague from Turkey, Eg}^t,
Syria and Asia Minor, the disease exhibited at intervals
descence of ^ leisurely activity in Arabia, Mesopotamia, Persia and the
plague in coast of Tripoli. In 1853, nine years after the disappear-
Arabia Meso- . .
potamia, ance of plague in Eg)'pt, an outbreak of the disease was
Persia and heard of in Assvr, a mountainous district of Western Arabia
Benghazi. -^ '
in Northern Yemen. This is an isolated region in which
epidemics of plague are known to have occurred in 1826, in 1832 and
in 1844, since which time there have been almost annual recurrences.
These epidemics are limited to the high Assyr plateau. Probably
endemicity of plague in this plateau is even of more ancient date.
According to Kremer a virulent outbreak of plague is mentioned in this
region as far back as 1157. Since 1853 there have been severe out-
breaks in Assyr in 1874, 1879, 1887, and 1889. In 1858 the disease
once more reappeared at Benghazi on the coast of Tripoli after an
absence of 15 years, and again in 1874. The events preceding the
plague in Benghazi were three or four years of unusual drought followed
by famine and an epizootic among cattle. It was at a time of the
utmost misery that plague broke out in an Arab camp. Plague was
also heard of as prevailing in epidemic form in 1863 in Persian Kurdistan,
and further south in the same district in 1870, 1871, the villages being
situated some 6000 to 7000 feet above the level of the sea. Later
investigations indicate that this highland region has been, like Assyr,
an endemic centre of plague for many years. Tholozan counted 15
epidemics between 1865 and 1875.
To the south of Kurdistan in Mesopotamia in the plains of the
Euphrates and Tigris plague is recorded as having been prevalent in
one district in 1867, in another in 1873-75, in a third including Bagdad
in 1873-75, and again in 1880-81, a fourth in 1884-85, and a fifth
in 1891-92. Tholozan considers Mesopotamia or Irak Arabi to be a
secondary plague centre, being of opinion that the plague is imported
from the mountainous districts of Turkish and Persian Kurdistan
along the Euphrates. This would agree with what is known of the
topographical features of the endemic centres in India and China, both
of which, Kumaon and Garhwal in India and Yunnan in China, are at a
high altitude. To the east of Kurdistan plague appeared in Astrabad
in 1876-77, in Resht in 1877, and at the mouth of the Volga in
CH. i] The last Outbreak in Europe 39
1878-79. Astrakhan at the mouth of the Volga is a great resort at
certain seasons of the year for Persian fishermen, so that diseases pre-
valent in Persia are soon apt to find their way by this route to this
part of Russia. This outbreak in the province of Astrakhan, being the
first in Europe since its disappearance from Turkey in 1841, gave rise
to much alarm and particularly so on account of its destructive character
in the village of Vetlianka, where in less than two months it caused 350
deaths in a population of 1700 inhabitants. It attacked six other small
and adjacent communities on the banks of the Volga and destroyed
Plague in the altogether about 420 persons. The disease began early in
Province of October and at the commencement manifested itself in a
mild form. The patients suffered from fever, slight but
debilitating. They had abscesses of the lymphatic glands, either in the
groin or in the armpit, which suppurated freely, and the duration of the
sickness was from 10 to 20 days. The disease gradually became more
virulent, and at the height of the epidemic from December the 9th to
the 21st the mortality reached 100 "/o of those attacked^
The early stages of this epidemic with its mild form of plague were
similar to a bubonic or glandular malady which had prevailed the year
before in the city of Astrakhan and its suburbs, where some 200 of the
inhabitants were affected and only one died. The outbreak in Vetlianka
was the last appearance of plague in Europe for 17 years-.
1 " On the progress of Levantine plague in 1878-79," by Mr Netten Kadcliffe. Medical
Supplement to the Nintli Annual Report of the Local Government Board, 1879-80.
- Though the plague had disappeared from Europe Dr Bruce Low [Twenty -eighth
Anmial Report of the Local Gorermnent Board, 1898-99. Medical Supplement. "On the
diffusion of bubonic plague from 1879 to 1898," by Dr Bruce Low) in a brief summary
shows that from 1879 to 189() not a single year passed without the development of plague
in at least one country, and in later years the disease was present in several countries at
one and the same time.
"In 1880 plague was reported to be present in Mesopotamia.
,, 1881 it was present in Mesopotamia, Persia and China.
,, 1882 in Persia and China.
„ 1883 in China.
,, 1884 in China and in India (as " Mahamari ").
,, 1885 in Persia.
,, 1886 in India (as "Mahamari") ^ Mahamari in the
,, 1887 in India (as "Mahamari") J- districts of Kumaon
,, 1888 in India (as "Mahamari") J and Garhwal.
,, 1889 in Arabia, Persia and China.
,, 1890 in Arabia, Persia and China.
,, 1891 in Arabia, China and India (as " Mahamari ").
,, 1892 in Mesopotamia, Persia, China, Russia and ? Tripoli.
,, 1893 in Arabia, China, Russia and India (as " Mahamari ").
,, 1894 in Arabia, China and India (as "Mahamari").
,, 1895 in Arabia and China.
,, 1896 in Arabia, Asia Minor, China, .Tapan, Russia and India."
CHAPTER II.
PLAGUE IN INDIA.
The English established factories at Surat, Ahmedabad, Bombay
Plague In and Agra, at the beginning of the 17th century, and until
India. ^j^g^^ time and even later the history of plague in India
is veiled in obscurity. That plague did prevail in India in or before
the 11th or 12th century is certain, for in some of the Puranas which
are at least 800 years old there are references to the disease and
instructions to the Hindus as to the precautions to be taken in the
event of its appearance. One of these is that wheneve'K a mortality
among the rats of a house is observed the inhabitant's' are to leave.
It has already been stated that according to the Arabian chronicles
India was severely visited by plague in 1031, and that this epidemic
spread to the vicinity of Constantinople. It has also" been stated that
Russian authors ascribed the origin of the great pandemic of the
14th century to the advance of an epidemic from India. There is
evidence of extensive pestilences in India in the 14th, loth and
16th centuries. References to these are to be found in the history
of the Mahommedan wars. Doctors George and John Thomson^ in
their treatise on plague mention the years 1345, 1399, 1438, 1574 and
1597 as plague years in India. Nathan^ taking his information from
the Bombay Gazetteer, in the article on Ahmedabad, mentions two re-
ferences which may point to the existence of plague in the west of India
in the 14th and 15th centuries. The first is from Ibn Batuta, who
notices that Muhammad Tughlik's army in Ma'bar (1325-51) mostly
perished of pestilence, and that at the end of the century (1399), after
Timur left, the districts through which he passed were visited by pesti-
lence. The second relates to the year 1443 when in Malwa the plague
^ A Treatise on Plague. By Major (ieorge S. Thomson, I.M.S., and Dr John
Thomson. 1901.
2 The Plague in India, 1896, 1897. R. Nathan.
CH. ii] Plague in the Seventeenth Ceiituvji 41
caused such loss of life in Sultan Ahmad I.'s army that, leaving many
of the dead unburied, he returned to Gujarat.
The connection established between Northern India and the endemic
areas of plague in Central Asia, Persia, and Irak by the Mongols would
facilitate the spread of plague into India in these early periods.
In the first decade of the I7th century plague appears to have
broken out in the Punjaub and spread over different parts
early part of <^f India, lasting about eight years. Its commencement
the 17th seems to have been connected with disease in Kandahar
century.
in which the land was overrun with mice^
The Emperor Jehangir writing of this epidemic in his memoirs says,
" -In this year (1615 A.D.), or rather in the tenth year of my reign, plague
(waba) broke out in many parts of Hindustan. It first appeared in the
Plague in the districts of the Punjaub and gradually came to Lahore.
Punjaub. j^ destroyed the lives of many Mahommedans and Hindus.
It spread through Sirhind and the Doab to Delhi and its dependent
districts, and reduced them and the villages to a miserable condition.
Now it has wholly subsided." Nawab Mu'tamad Khan referring to the
same event in the Ikbdl-ndma'-' mentions its precedence by a mouse
mortality. " When it was about to break out a mouse would rush
out of its hole as if mad, and striking itself against the door and
the walls of the house, would expire. If immediately after this signal
the occupants left the house and went away to the jungle, their lives
were saved ; if otherwise the inhabitants of the whole village would be
swept away by the hand of death." Mu'tamad Khan also adds more
information c<jncerning the epidemic than that found in the memoirs of
the Emperor Jehangir. Thus, " If any person touches the dead, or even
the clothes of the dead man, he also could not survive the fatal contact.
The effect of the epidemic was comparatively more severe upon the
Hindus. In Lahore its ravages were so great that in one house ten or
even twenty persons would die, and their surviving neighbours annoyed
by the stench would be compelled to desert their habitations. Houses
full of the dead were left locked, and no person dared to go near them
through fear of his life. It was also very severe in Kashmir where its
effects were so great that (as an instance) a darwesh who had performed
the last sad offices of washing the corpse of a friend, the very next day
1 Bornbmj Gazetteer, Vol. iv. c. xii. p. 218.
^ " The History of India as told by its own Historians." The jwsthumotis papers of the
late Sir H. M. Eliot, K.C.B. Edited and continued by Professor John Dowson, Vol. vi.
p. 316. 1875.
» Ibid. p. 406.
42 HUtoi'ji (iml DUtrlhntion of Pkufne [part i
shared the same fate. A cow which had fed upon the grass on which
the body of the man was washed also died. The dogs also which ate
the flesh of the cow fell dead upon the spot. In Hindustan no place
was free from this visitation which continued to devastate the country
for a space of eight years."
The following note kindly supplied to the author by Mr W. Foster
of the India Office refers to the plague epidemic in Ahmedabad in 1617
and 1618.
"'The city Amadawar- (at our being there with the King^) was
Plague in visited with this Pestilence in the month of May, and our
Ahmedabad. f;xmily was not exempted from that most uncomfortable
visitation ; for within the space of nine dayes seven persons that were
English of our family were taken away by it : and none of those that
dyed laid sick above twenty houres, and the major part well and sick
and dead in twelve houres, as our Surgeon (who was there all the
Physician we had) and he le(^ the way, falling sick at mid-day and the
following mid-night dead. And» there w^as three more that followed him,
one immediately after the other, who made as much hast to the grave as
he had done All those that dyed in our family of this pestilence had
their bodyes set all on fire by it, as soon as they were first visited, and
when they were dying or dead, broad spots of a black and blew colour
appeared on their brests ; and their flesh was made so extreme hot by
their most high distemper that we who survived could scarce endure to
keep our hands upon it. It was a most sad time, a fiery trial indeed
All our family (my Lord Ambassadour* only excepted) were visited with
this sickness and we all, who through God's help and goodness outlived
it, had many great blisters, fild with a thick yellow watry substance that
arose upon many Parts of our bodyes, which, when they brake, did even
burn and corrode our skins, as it ran down upon them !"
Information is also obtained from other sources of this epidemic in
Hindustan. In the account of the Embassy of Sir Thomas Roe to the
Court of the Great Mogul 1615-19 it is stated^: "I received news of
a great plauge at Agra so that I judgd it dangerous to send up
the goodes into an infected place. from whence no Comodytye could
be suffered to passe."
^ A Voijaf/e to East India. By the l\cv. Edward Teft'ry, Chai)lain to Sir Thomas Eoe,
published 1655, p. 242.
2 The old way of spelling Ahmedabad.
s Dec. 1617 to Sept. 1618. " Sir Thomas Roe.
5 Page 307.
CH. ii] Plaqve in the Seventeenth Century 43
Joseph Salbank in one of his letters^ mentions in 1(310 that plague
Plague In ^^^ existed at Agra for three months, and that there was
As^*- sometimes a daily mortality of 1000 persons. Lahore is
also mentioned as being affected, in another letter. The plague con-
tinued in Agra for at least four years. The plague- is referred to as
increasing in Agra early in 1619.
The Emperor Jehangir's autobiography'' contains the following
account of the plague at Agra: "At this time those who were loyal
represented that the disease of the plague (taun) was prevalent in the
city of Agra, so that in a day 100 people ^ more or less, were dying of it.
Under the armpits, or in the groin, or below the throat a lump comes
and they die. This is the third year that it has raged in the cold weather
and disappeared in the commencement of the hot season. It is a
strange thing that in these three years the infection has spread to all
the towns and villages in the neighbourhood of Agra, and there has
been no trace of it in Fattehpur (Sikri) and as far as for two and a half
koss from Amanabad to Fattehpur. The people of that place have
forsaken their own homes and gone to other villages."
The following extract from the Emperor's journal relates to an
occurrence which is particularly interesting as an observation on the
intimate relationship between rat plague, cat plague and human plague.
To-day similar instances might readily be quoted in which the plague
mouse or rat in a house infects the cat and afterwards plague breaks out
in the house. " The daughter of the deceased Asaf Khan who is in the
house of Khan-i-Azam, told me a strange and wonderful tale. I made
particular enquiries into its truth and write it on account of its-
strangeness. She said that one day in the court-yard of her house
she saw a mouse falling and rising in a distracted manner. It was
running about in every direction after the manner of drunkards, and
did not know where to go. She said to one of her female slaves,
' Take it by the tail and throw it before the cat.' The cat, delighted,
jumped up from its place and seized it in its mouth, but immediately
dropped it and showed aversion to it. By degrees an expression of
grief and pain showed itself in its face. The next day it was nearly
^ Letters received by the East India Company, Vol. vi. p. 198. Edited by William
Foster, B.A., 1902.
'^ Letters from Surat to East India Company, March 12, 1619.
=* "Plague an old Indian disease." By Alex. Eogers. The Indian Magazine and
Review, January, 1898.
■• There is a ^reat different-e between the estimates of the number of daily deaths {,'iven
by Salbank and the Emperor Jehangir. The latter is more likely to be correct.
44 History aiul Disfrihnfwii of Plafpie [part i
dead, when it entered into her mind to give it a little treacle. When
its mouth was open its palate and tongue appeared nearly black. It
passed three days in a state of misery, and on the fourth day came to
its senses. After this the grain of the plague (danah or bubo) appeared
in one of the female slaves and from excess of temperature and increase
of pain she had no rest. Her colour became changed ; it was yellowish
inclining to black and the fever was high. The next day she was free
of fever and died. Seven or eight people in the house died in the same
way, and some were ill. On the day I went to the garden from that
halting place, those who were ill in the garden died and in that place
the bubo did not appear again. Briefly in the space of eight or nine
days 17 people became travellers on the road to annihilation. She also
said : ' Those on whom the boil appeared, if they asked another person
for water to drink or to bathe in, these also caught the infection and at
last it came to such a pass that through extensive suspicion no one
would pass near them '."
Plague is again recorded as prevalent in India from 1684 to 1702.
It attacked Surat in 1684 and Bombay in 1689. Surat
Plague at the . " . .
end of tue was at that time a town of greater commercial importance
iTth century. ^]-^.^j^ Bombay. It possessed all the unwholesome condi-
tions which have been observed to favour the prevalence of virulence of
plague. Crowded and unclean, the streets were narrow and in places
covered with excrement of man and beast. Fryer, who visited Surat
some time before the outbreak, wonders that- a city whose people make
the streets a dung-hill should never have been visited by the plague.
The disease when it was imported in 1684 continued for six years
without interruption, varying in intensity at different seasons of the
year. Subsiding during the rainy season, viz. from June to September,
the epidemic broke out with fresh fierceness in October and, again
abating the greater part of the cold and hot seasons, raged with renewed
fury towards the end of May.
In 1684 the disease was in the army of the Emperor Aurangzebe.
The following details of the prevalence of plague about this time
collected from different records are given by Sir James Campbell in the
fourth volume of the Bombay Gazetteer.
"*This outbreak, apparently the true plague taun and waba, raged
for several years over a great part of western India. At Ahmedabad,
where it lasted for seven or eight years, its visible marks were swellings
as big as a grape or banana behind the ears, under the arms and in the
1 Gemelli Careri in ChurchilVa VoyafjeA, iv. p. 191.
CH. ii] Plague in the Nineteenth Century 45
groin, and redness round the pupils of the eyes. In 1689 it broke out
with great violence at Bijapur^ All attacked with it gave up hope !
It had been in the Deccan for several years. Near Goa in 1684 it
attacked Sultan Mosam's army and carried off 500 men a day^; raged in
Surat for six years (1684-90)^ reduced (1690) the Bombay garrison
to 35 soldiers^; was so violent that it not only took away all means of"
preparing a good end, but in a few hours in Surat, Daman and Thana
carried off whole cityfuls of people ^. and at Tatha in Sind (1696) killed
80,000 souls **. In Surat Europeans were observed to enjoy a remarkable'
immunity, but when Bombay was attacked in 1690 they suffered as-
much if not more than the natives, for it is recorded that of 800
Europeans only 50 were left, of whom six were civilians, six commissioned
officers, and not quite 40 English soldiers. Bombay, which was one
of the pleasantest places in India, was brought to be one of the most
dismal deserts."
After the epidemic in the l7th century plague seems to have
Plague in the disappeared from India as completely and as rapidly as it
19th century, ^jj^j fi-om Western Europe, for it is not until 110 years
later at the beginning of the 19th century that a small part of Cutch,
Kdthidwar, Gujarat and Sindh were again affected with the disease,
which continued from 1812 to 1821. It was at the close of a famine
that plague appeared in Cutch. "''The famine of 1811 and 1812 was,
at the close of 1812, followed in Cutch by an outbreak of pestilence so
deadly that it was said to have destroyed half the ryots in the country.
At the same time., a 'contagion raged at Ahmedabad with a fury that
can scarcely be believed.' Every house sickened, whole families were
carried off and many a funeral party coming back to the house of
mourning found that, in their absence, another member of the family
had sickened and died. So thinned were some castes that their women
had to help to carry the dead. All the fuel was burned, and though
houses were pulled down to supply logs many bodies had to be left
half consumed. Half of the people of Ahmedabad, perhaps about
50,000 souls, are said to have perished. In Ahmedabad Musalmans
and Hindus suffered alike. But in other parts it was noticed that
among Musalmans the disease was less fatal. Of the symptoms of
this sickness no details are recorded. But there seems every reason to
suppose th;'^ it was the same disease, that lulling for two years, in
1 Muntakii ^ I Luhab : Elliot, vii. p. 337. - Orme's Hixt. Frag. p. 142.
•' Ovington'P 'yyafie to Surat, p. 347. ■* Bi'uce's Annals, in. p. !f4.
' Churchill, ix> p. 191. ® Hamilton's New Account, i. p. 123.
^ Bombay Gazetteer, Vol. iv. p. 220.
46 History (ind Distribution of Plague [part i
May 1815, after one of the heaviest rainfalls on record, broke out
afresh with deadly force at Kantakot in east Cutch. In cases of this
disease slight fever was followed by great weakness and weariness,
and then swellings came in the groin and armpits, suppurating
in some cases and in others remaining hard lumps. Few stricken
with the disease recovered. Most died between the third and ninth
day It seemed to attack most fiercely the sluggish and vegetable
eaters; Rajputs escaped where Brahmans and Vainos rotted otf; oil
makers were believed to be safe. From Kantakot it spread to other
parts of Vagar, causing much loss of life in the early months (jf 1816.
In May 1816 it crossed to Morvi in Kathi;iwar." The plague in
Kathiawar was observed by Dr Gilder and Dr Whyte, both of whom
reported to the Government on the epidemic. Dr Gilder in describing
the symptoms, refers to the two forms of plague observed, the knotty
disease and the expectorating disease, obviously the bubonic and
pneumonic forms. ' He also observed that the epidemic confined itself
principally to such of the native population as subsisted entirely on
vegetable diet, namely, Brahmins, Soonars, Dhurzees and Khoomtees ;
those using animal food with but few exceptions generally escaped. It
is deserving of notice that this epidemic occurred at a time when plague
became widely diffused in the Levant, spreading to the Lower Danube,
Asia Minor, Armenia, and Northern Africa, and lasting nearly 20 years.
In the epidemic of 1812-13, 100,000 persons died of plague in
Constantinople.
Nothing more is heard of the disease on the western side of India
until 1836 when the Pali plague broke out in Marwar in Raj pu tana,
and lasted until 1838\ It is estimated that 100,000 Marwaries perished.
The Pali plague was preceded by a great mortality among cattle not
only through Marwar but in Mullani and the desert country to the
west, occasioned by a complaint said to be different from the epizootics
usually observed. In Pali itself from November 1836 to October 1837
the disease was mild and the deaths were comparatively few, but later
it acquired a more virulent form and became more prevalent and fatal.
The inhabitants fied from the town. At Taiwali rats died just before
the outbreak of plague in that place. Dr Forbes mentions that
Mr White reports that " this death of the animal attended or preceded
the disease in every town that was attacked in MarNv."^^- so that the
inhabitants of any house instantly quitted it on seeinjp'a dead rat."
^ Thesis on the Nature and History of Plague as observed i)i the Nortn-West Provinces of
India. 1840. Dr Forbes.
CH. ii] Endemic Centres in India 47
The epidemic, which was limited in its nature, also corresponded in
time with a fresh and comparatively limited activity in the Levant,
which affected the Turkish dominions in Europe and Asia as well as
in Egypt, and it is to be observed that the disappearance of plague in
Rajputana coincided with its decline and ultimate disappearance in
the Levant. Dr Forbes remarks that "for some years prior to 1832
])lague had been steadily advancing from Asia Minor through Mesopo-
tamia, Irak, round the head of the Persian Gulf and along the Persian
coast, desolating the cities Dujarbehr, Mosul, Bagdad, Busrah, and
Abusbeher, at which place it ceased or was withdrawn from European
observation." Pali' is the chief mart of Western Rajputana and placed
at the intersection of the great commercial roads from Mandavi in Cutch
to the Northern States, and from Malwa to Bahdwalpur in Sindh. It is
in a centre like this that the disease being brought by the merchants
would once more come under observation.
Apart from the foregoing epidemics which have at long intervals
prevailed in India there is a centre of plague at Garhwal
ofGarhwai ^^^^ Kumaon, two adjoining districts situated on the
and Kumaon southern slopes of the Himalayas. Here plague was
endemic ,^.. ,. ..
centres of discovered to exist m 1823. There is no information as
plague in ^^ ^^^ j^j^g ^j^|g centre of plague existed previous to its
recognition. It is possible that the plague in Kumaon in
1823 was only a part of that which prevailed in Western India from 1812
to 1821, or that it was introduced even earlier and became established
during the plagues of the 14th, 15th, or 17th centuries. Whatever
may be the date of its origin, there can be little doubt that Kumaon is
now an endemic centre, plague having occurred in limited outbreaks
even as recently as 1897. The last outbreak before plague appeared in
Bombay in 1896 was in July and September of 1893, and occurred in
a valley some 6000 feet high. Fortunately this centre is comparatively
an inactive one as regards its powers of diffusion, which is in favour
of its being a branch of the parent stock in the Levant, which has
lost not only its powers of diffusion but also the power of retaining its
hold on countries in which it had prevailed for centuries. An epidemic
in Hansi, in the province of Delhi, in 1828-29, and another in Rohilcund,
around Bareilly, in 1836-38, i)robably owed their origin to Kumaon.
' Imperial Gazetteer of India, Vol. xi. p. 1.
CHAPTER III.
THE PRESENT PANDEMIC.
The centre of interest now passes from Europe, the Levant and India
The present ^'^ *^® province of Yunnan in China from which the present
pandemic pandemic originated. The acquisition of Hongkong by
in Yunnan. the Briti.sh in 1841 and the subsequent opening of the
one of the treaty ports to commerce in 1860 were the first incidents
Western . i i • i
Provinces in the process of breaking down that exclusiveness by
of China. which China had isolated herself from the intrusion of
foreigners. Since then many missionaries, explorers and merchants
have penetrated into the interior of China which until their visit was
for Europeans a terra incognita.
They have given accounts of their experiences, with the result that,
though the interior of China as a whole and its internal affairs are still
veiled from foreigners, yet much more is known concerning important
events occurring there than ever before. A favourite field for explora-
tion was Yunnan, because of its proximity to Burma, Siam, and French
Annam, its reputed richness in minerals, and the possibility of its
becoming a highway to Western and Central China. The sixties and
seventies of the 19th century were remarkable for the number of
intrepid travellers who traversed Yunnan and other parts of China.
Lagree, Gamier, Cooper, Sprye, Sladen, Dupuis, Rocher, Richth,
Margary, Grosvenor, Baker, Gill, and later Colquhoun and Bourne, all
distinguished themselves as modem pioneers.
It was during one of these explorations that M. Rocher in 1871,
i.e. over thirty years ago, came across plague in the province
graphical ^^ Yunnan. This province is situated at the eastern con-
description fines of Burma and Thibet, has Tonking on the south, the
of Yunnan. . .
province of Sechuan on the north, and the provmces of
Kweichow and Kwangsi on the east. It is very mountainous, with high
and fertile plateaux, which ri.se towards the central portion of the province
CH. Ill] The Promnce of Yunnan 49
to between 6000 and 7000 feet. Talifu and Yunnanfn, two of the chief
cities, are situated on the shores of inland lakes and on plateaux, respec-
tively 6400 and 6900 feet in height.
The province of Yunnan, isolated by its position and its physical
features, has only a limited intercourse with its neighbours and with
the treaty ports. There are trade routes connecting Talifu and Yun-
nanfu with Burma, Thibet, and the province of Sechuan, but the
mountainous character of the country which has to be traversed, and
the cost and difficulties of transport, which has to be effected by pack
animals, cause them to be little used. Caravans from Thibet pass
Li Chiangfu on their way to Ssumao for tea.
The trend of intercourse and trade, so far as it is developed, is
Trade routes towards Tonking and the provinces of Kweichow, Kwangsi,
from Yunnan. .^j^^| Kwantung. Following the course of the Red River in
Tonking and the West River in Kwangsi and Kwantung, the journey
can be undertaken in boats for at least some part of the way. Both the
Red River and West River rise within the boundary of Yunnan, and
form more or less natural trade outlets for the province. The Red River
is navigable from Manhao in Yunnan, and passes through Tonking to
Haiphong in the gulf of Tonking. This route, notwithstanding its
advantages, has not been a favourite. The West River is navigable
from Pose, a small town situated on the borders of Yunnan and Kwangsi,
away down to Nanningfu, Wuchowfu, and Canton. Even this route has
been seldom used further east than Nanningfu. Almost invariably,
until recent years, Yunnan goods, brought down the West River as far
as Nanningfu, have, at that point, been taken from the boats and carried
across country on pack animals to Pakhoi and more recently to Muiluk.
Similarly, goods intended for Yunnan have entered Pakhoi, been con-
veyed overland to Nanningfu, been there transferred to boats, taken up
the river to Pose, and then overland again to the towns of Yunnan.
There is yet another trade route from Yunnan through the Kwangsi
province. It is more northerly than that by Pose, Nanningfu, and the
West River, which it, however, joins before this waterway enters the
province of Kwantung. The route is overland, and in an easterly
direction from Yunnan to Kingyuan in Kwangsi. It here meets the
river Lieou Kiang, and becomes a water route to Lauchaufu, which is
a great distributing centre, goods from the west being sent to Yunnan
and Kweichow provinces, and vice versa. At Lauchaufu the route
branches into two, one going overland in a north-easterly direction to
Kweilin, the capital of Kwangsi, and thence by water due south to
s. 4
50 History ((ml DisfriJmflon of Pkujue [part i
Wuchowfu. The other branch is by river, via Tsainchaufu to
Wuchowfu.
The province of Yunnan, at the time of M. E. Rocher's visit, was
Condition of '" '^ state of rebellion. The inhabitants, chiefly Mahom-
Yunnan in nie(hins, had risen against the Imperial Government, and
1871 as . .
observed by such was their power that it took some twenty years to
M. Rocher. subdue them. The traveller found large tracts of the
country devastated or deserted, and everywhere signs of depopulation
and of the ravages of warfare, great numbers of the inhabitants having
been killed in battle or afterwards massacred. To the miseries of war
and of famine Avere added those of pestilence, the infection of which was
often carried b}^ the rival armies from village to village, and from town
to town. What proportion of the depopulation of Yunnan was due to
fighting, and what proportion to famine, massacres, and pestilence, is
unknown, but their combined effect Avas to convert a populous and
thriving province into a country with few inhabitants, and one which
had to be repeopled by immigrants.
That the pestilence was plague there can be no doubt. M. Rocher's
description of the disease and its association with swellings in the
armpit, groin, and neck, allow no other conclusion. The following is
M. Rocher's account of the disease : v
" La maladie connue au Yiin-nan^ sous le nom de yang-tzii \ v^ JT } ,
M. Rocher's et qui parait n'etre autre que la peste bubonique, y fait
plague in chaque annee de nombreuses victimes ; elle sevit aussi
Yunnan. quelquefois dans le Laos et sur la frontiere du Kuei-chou.
" D'apres les renseignements que nous avons pu obtenir parmi les
notables, cette maladie semble venir de la Birmanie, d'oi^i elle est
transmise par les caravanes qui trafiquent entre les deux pays. On
n'est pas d'accord sur I'epoque de son apparition dans le Ytin-nan : les
uns disent (et la j)lus grande partie de la population est de cet avis) que
le centre et Test de la province n'ont connu le fleau qu'au debut de la
rebellion ; d'autres pretendent qu'il s'est montre dans I'extreme ouest
jusqu'a Ta-li-fu, quelques annees auparavant. En supposant que cette
derniere hypothese soit vraie, I'epidemie a du passer bien legerement dans
ces parages, puisqu'on n'en a pas eu connaissance dans les autres districts.
" Depuis le commencement de la guerre civile, cette terrible maladie
s'est dechainee avec fureur sur la province et continue, encore aujourd'hui
que la province est paisible, a y exercer ses ravages.
^ Notes sur la peste an Yiin-)i(in, La Province Chitioise du Yiiii-nan, par Emile Kocher.
Deuxifeme Partie, p. 279.
CH. Ill] Pkujue in Yunnan 51
" Ce qui ferait croire que cette epidemie n'est due qu'aux miasmes
malfaisants qui s'exhalent de la terre, c'est que les petits animaux qui
vivent dans les egouts ou sous la terre sont attaints les premiers, les
rats par exemple. Des qu'ils se sentent malades, ils sortent par bandes,
font irruption dans I'interieur "des maisons, courent afFoles, et, apres
quelques tours sur eux-memes, torabent morts ; le plus souvent ils
crevent sous les planehers, ce qui determine dans les appartements
des odeurs infectes, dont on ne decouvre que troj) tard la cause. Le
meme phenomene se produit chez tons les autres animaux, grands et
petits : les buffles, les boeufs, les moutons et les chevres sont frappes du
meme mal, et parfois aussi les oiseaux de basse-cour, mais, parmi ces
derniers, la maladie fait moins de victimes. A notre arrivee dans la
province, nous refusions d'aj outer foi aux nombreux temoignages des
indigenes, en les mettant sur le compte de leur imagination troublee ou
de leurs idees superstitieuses ; mais quand I'epidemie eclata dans le
district meme ou nous nous trouvions, il nous fut facile de nous con-
vaincre de leur veracite.
" Des que ces symptomes avant-coureurs se manifestent, la population
ne tarde pas a etre attaquee a son tour. On prend alors les precautions
estimees les plus efficaces pour se garantir dn fleau. Presque partout,
afin de purifier les maisons, on allume du feu dans toutes les chambres,
et dans certains districts on cesse de manger du pore.
" Chez I'homme, la maladie s'annonce par une fievre violente, accom-
pagnee d'une soif intense ; quelques heures apres, une tumeur d'un rouge
fonce commence a paraitre aux aisselles, a I'aine ou au cou ; la fievre
s'accentue de plus en plus, et le malade ne tarde pas a perdre connais-
sance. La tumeur grossit d'habitude jusqu'au second jour et reste
ensuite stationnaire. A partir de ce moment, le malade parait reprendre
ses sens, mais il est encore en grand danger ; car, si la tumeur, jusqu'alors
tres dure, devient molle, et si la fievre ne diminue pas, il est considere
comme perdu ; dans le cas contraire, si la tumeur perce en dehors, ce
qui amve rarement, il y a espoir de le sauver ; mais, arrive a ce point,
le malade est si affaibli que, bien que la tumeur ait abouti, il meurt
d'epuisement.
" Quelques medecins chinois ont essaye d'inciser ces tumeurs ; mais,
soit que I'operation ait ete mal faite ou trop tardivement, bien peu de
malades y survivent ; quand ils sont a bout de ressources, ils ont recours
au muse qu'ils ordonnent a la derniere extremite et a fortes doses.
" Pendant notre sejour au Ylin-nan, nous avons vu un grand nombre
de cas, et nous devons dire que la plupart ont eu un denouement funeste.
4—2
52 History (iiid Disfj-thnfion of Plague [part I
Dans les endroits on la peste ne fait que passer, on pent estimer que le
nonibre de ses victinies est environ de 4 a 6 pour 100 ; tandis que dans
d'autres districts, plus rudement eprouves, la population est complete-
ment decimee, et des families entieres disparaissent les unes apres les
autres. Dans les parages oil re])id('nnie sevit avec tant de violence, les
habitants n'hesitent pas a abandonner leurs demeures et leurs recoltes
sur pied ])oui- aller camper sur les hauteurs oil, bien souvent, le fleau
les poursuit.
"Ce qui, a notre avis, contribue beaucoup a aggraver cette deplorable
situation, c'est que les Chinois, superstitieux comme ils le sont, au lieu
d'enterrer les pestiferes, se contentent de les placer dans des bieres
qu'ils exposent au soleil, soit sur la pente des collines ou en plein champ.
II s'ensuit que les gens qui voyagent ou circulent dans les environs des
villages empestes sont a peu pres asphyxies par les odeurs nauseabondes
que repandent les cadavres en decomposition.
" Pendant les annees 1S71, 1872 et 1873, nous avons remarque que
le debut de lepidemie se manif'este toujours au commencement de la
plantation du riz, c'est-a-dire de mai a juin : apres cette epoque, elle
sevit avec vigueur dans les localites qu'elle traverse. Durant I'ete, qui
est, au Ylin-nan, la saison des pluies, elle continue de se propager avec
moins d'activite ; toutefois, c'est pour reprendre une intensite nouvelle
a I'epoque de la moisson, et c'est a partir de ce moment jusqu'a la fin de
I'annee, qu'elle fait le plus de victimes.
" Un fait etrange, que nous avons observe dans plusieurs endroits au
midi et au nord de la province, c'est que I'epidemie, au lieu d'englober
tous les lieux habites, villes et villages, qui se trouvent sur sa route,
passe a cote sans y toucher, les franchit meme, et revient quelques mois
apres, ou I'annee suivante, frapper I'endroit oublie. Voici un autre fait,
non moins curieux que le precedent : apres s'etre declaree dans presque
tous les villages disperses dans les plaines, I'epidemie eclate sur les
montagnes ou elle produit de nombreux ravages parmi les aborigenes.
D'apres ce que nous avons vu par nous-memes et la fa9on irreguliere
dent la maladie se presente, elle parait importee sur les hauteurs par les
hommes ou femmes qui vont, a certaines epoques de I'annee, travailler
dans les plaines. C'est surtout, comme nous I'avons dit plus haut, apres
la plantation du riz ou quand la recolte est terminee que le fleau quitte
le pays bas pour aller sevir sur les hauteurs.
" L'esquisse, montrant la marche suivie par la maladie pendant les
annees 1871, 1872 et 1873, a ete dressee d'apres des notes officielles
fournies ])ar les fonctionnaires des lieux pestiferes et d'apres nos propres
renseignements."
MAP OF YUNNAN FU AND SURROUNDING DISTRICTS.
Showing the Course pursued by the Plague, the Districts wherein it was most fatal
and those through which it merely passed, during 1871, 1872 and 1873.
EXPLANATION.
I Starting point of the Plague in 1871 and 1872.
_._.....- Course pursued by the Epidemic in 1871 and 1872.
Place where its advance ceased in 1872.
Starting point in 1872 and 1873.
Course pursued by the Epidemic in 1872 and 1873.
Place where its advance ceased in 1873.
Districts where the Epidemic was notably fatal.
Districts merely visited by the Epidemic.
II
III
54 Hiiitorji anrj Disfrihfffioit of Plague [part i
An earlier but similar account with chart by M. I^mile Rocher was
translated by Dr, now Sir Patrick JManson, medical adviser to the Colonial
Office, and ajjpears in the Medical Reports for the half-year ended
31st March, 1878, published by the Inspector-General of the Chinese
Customs Service. The chart reproduced here shows the course of
the epidemic from town to town in the province of Yunnan. It will
^ .^ . be noted that the first sign of the disease in an epidemic
Epidemic pre- ^ _ '■
ceded by sick- form was a sickness and mortality among rats. How and
taiity among when plague first came to Yunnan is unknown. It evidently
rats. existed there before the Mahommedan rebellion, and it was
the conditions of warfare which brought it markedly into prominence.
There are traditions of the infection having been imported from the
western frontier of Yunnan, and M. Rocher thinks that it may have
been introduced from Burma. Possibly Mahommedan pilgrims returning
from Mecca in the early part of the 19th century, when plague was
prevalent in Egypt and Arabia, may have introduced it into Yunnan.
That this journey was occasionally undertaken is evidenced by the fact
that Ma-hsing, the high priest of the Mahommedans of Yunnan, and
leader of the rebellion, visited Mecca in 1839, travelling from Yunnan
to Bhamo by the caravan route, and then by boat to Rangoon, where
he embarked in a pilgi'ims' ship. Having spent some time in the
Sacred City, Ma-hsing visited Egypt and Constantinople and returned
in 1846 to Yunnan by the river of Canton or West River. But
against this view of the importation of plague by pilgrims in the 19th
century, there is evidence of a fatal sickness having occurred among
rats and human beings in Yunnan, as far back as the last decade of the
18th century, which tends to indicate that some portion of Yunnan
had been an endemic centre for over 100 years at least.
Baker met with the disease in his travels through Yunnan in 1877.
Monsr. Fenoullett, Bishop of Yunnan, states that in 1866 a large portion
of the population of Yunnanfu succumbed to plague, and M. Rocher in
a second visit to Yunnan found that plague began to be known in 1840,
but long before that time it had existed in the western part of the
province without prevailing epidemically. The following passage found
in Hung Liang-Kih's Peh-Kiang-S/ii-Hwa^ bears witness to this, in-
asmuch as the author, who was born in 1736 and died in 1809, speaks
of his contemporary as having died of the pest in Yunnan. " Shi
Tau-Nan, the son of Shi Fan, now the Governor of Wang Kiang,
' S'litttre, Feb. 1(3, 1H99. Note by Mr Kumagusn Minakata.
CH. Ill] Plague in Pakhoi 55
was notorious for his (poetic) gift and was only 36 years old when
he died Then in Chau-Chau (in Yunnan) it happened that in
the daytime strange rats appeared in the houses, and lying down
on the ground perished with blood-spitting. There was not a man
escaped instantaneous death after being infected with the miasma.
Tau-Nan composed thereon a poem entitled ' Death of Rats,' the
masterpiece of his ; and a few daj^s after he himself died of this
queer rat epidemic."
The first medical account of plague in Southern China is given by
Dr Lowry of ^^ Lowry^ of Pakhoi in 1882, the year he was first stationed
Pakhoi gives there as Medical Officer to the Customs. His Notes on an
account of Epidemic Disease observed in Pakhoi in 1882 are extremely
plague in valuable because of the very careful and accurate manner
Southern . . . ^^ .
China at in which the disease is described, and because of the
* °'" comparisons made between it and the plague of Yunnan
and of Northern India. Dr Lowry also observed the mortality in rats
which accompanies the disease.
He remarks that " in nearly every house where the disease broke out
the rats had been coming out of their holes and dying on the floors."
The disease was not new to Pakhoi, nor to Lienchow, a city about
12 miles distant. In 1871, Mr T. E. Cocker, a Deputy Commissioner of
Customs at Hongkong, visited Pakhoi, and at the time of his visit there
was a severe outbreak of the disease, accompanied by a mortality, not
only among rats, but also among })igs and cattle. Mr Scott, Consul
General of Canton, saw cases of plague in Pakhoi in 1879. It was then
called the "Yunnan sickness" by the Chinese. Mr Netten Radcliffe, of
the medical department of the Local Government Board of England, in
his memorandum on the progress of Levantine plague in 1878 and 1879
records some important information regarding plague at Pakhoi derived
from Surgeon A. R. Lynch's journal for H.M.S. Mosquito on the Chinese
Station, 1879. It is accompanied by a map showing the presumed
route taken by the plague from Pakhoi to Yunnan ; and though the
map is doubtless correct in showing the localities affected, it is incorrect
as to the direction of the route by which the plague spread, which waf;
originally from Yunnan to Pakhoi, and not from Pakhoi to Yunnan.
Dr Lowry states in his notes that " the epidemic which I have
observed in this district does not seem to be an old disease, as it occurred
for the first time about fifteen years ago, and since that time has occurred
1 Imperial Maritime Cnstonix Medical Reportx for the half-year ended 30th September,
1882, 24th issue, 1883.
r)6 Historfi and DistributioH of Plague [part i
at certain intervals, the last severe outbreak being in 1877. I am told,
however, that a few cases occur every year, but my short
appeared at residence has not given me an opportunity of verifying
Pakboi in ^\-^\^ statement." The plague first appeared in Pakhoi in
18(J7. It is to be noted that this was at a time when the
Mahommedan rebellion in Yunnan was in full force and troops raised in
Hainan and the Pakhoi district were engaged at the seat of war.
Pakhoi is not a large town nor an old one. The population to-day is
about 20,000, and it dates back only to 1852, when some
Trade route i i i t
from Pakhoi Cantonese merchants settled there. It seems to have
0 unna u. ^h^Jven fairly well, for it Avas one of the treaty ports agreed
to be opened to foreign trade in 18(j0, though the actual opening did
not take place till some years later. Its principal and most direct
connection with Yunnan is to be seen on the map appended. The
route is long and difficult, jjartly by land and partly by water.
From Pakhoi to Nanningfu the journey had to be accomplished
overland, from Nanningfu to Pose by the West River and from Pose to
Yunnanfu again overland. Cotton goods are the principal staple article
taken from the port of Pakhoi to Yurmanfu, and there they are
exchanged for tin and opium which are brought to the coast.
During the Mahommedan rebellion trade was much disturbed, and
under the })eculiar conditions it is less likely that plague was imported
from Yunnan, by the ordinary limited intercourse of traders, into the
Pakhoi district and the island of Hainan, than by the movement of
Chinese troops, many of which, as previously stated, \vere drawn from
the island of Hainan and from the western prefectures of Kwangsi and
Kwantung close to Yunnan. No doubt there would be many traders
with the troops for the purpose of supply. This latter view of the
manner in which plague spread from Yunnan to Pakhoi appears to
be held by the Chinese, and it is more in accordance with that which is
known concerning the rapid spread of epidemics from one distant
locality to another, namely, that these epidemics of a sudden and rapid
growth are usually associated with large movements of population. An
epidemic of plague occurs in Yunnanfu in 1866, which decimates the
population while they are in the midst of war, and in 1867 Pakhoi,
one of the homes of returning troops from Yunnan, is attacked.
The distance between Yunnanfu and Pakhoi is about oOOO lis, and
it takes about 48 day stages to travel from one to another. What
intervening localities w^ere attacked is unknown, but it is unlikely
they escaped.
CH. Ill] Eastward Advance of Plague hi-
Once the disease was established in Pakhoi it seems to have become
endemic for 18 years. There was a severe epidemic in
demic in 1877. Every year it recrudesced and prevailed more or
Pakhoi from j^gg from March to June until 1884, when from the reports
1867 to 1884. ^ ^ r^ ■
of the Medical Officer of the Customs it seems to have
ceased until re-infected in 1894. This spontaneous cessation of the
plague is a phenomenon which has not infrequently manifested itself in
small towns, occasionally in large cities, and rarely in commercial towns,
such as Smyrna and other busy entrepots of trade in close communication
with infected centres.
Although Pakhoi seems to have enjoyed a freiedom from plague for
PiagTie not ^^ years, from 1 884 to 1894, the disease was far from being
extinct in ad- extinct ; it not only continued to prevail in the ])rovince of
lecture to that Yunnan and at varying intervals in the neighbouring
of Pakhoi. towns of the Kweichow, Kwangsi, and Kwantung pro-
vinces, but it was also present in the adjoining prefectures to that
in which Pakhoi is situated. They are localities away from European
contact, and it is only incidentally that plague is discovered to prevail
in them. Distant from the coast ports, from the customs stations, or
from missionary outposts, news becomes exceedingly scanty, infrequent
and unreliable, and occurrences, however important or disastrous they
may be to the localities affected, come but rarely to the ears of
Europeans. It is certain that from 1890 a gradually extending area
of the western parts of Kwangsi and Kwantung was becoming affected
with plague.
Plague pi'evailed at Lungchow, Pose, Nanningfu and Taipingfu in
1890'. It again prevailed at Lungchow in 1893. As soldiers were the
first victims of the outbreak, Dr Siminonds, who was at Lungchow at the
time, was of opinion that the disease was imported into the garrison of
Lungchow from Liencheng, a frontier town on the borders of Yunnan.
There was another epidemic in Lungchow in 1894, which was evidently
a recrudescence of the outbreak of the previous year.
Plague occurred at Kaochao in 1891, and at Ampu, which is east of
Pakhoi. in 1891-. It was also prevalent at Mouiluk in 1890 and 1893.
Mouiluk is south of Kaochao and near the French possession of
Kwan-shan-w^an. It is about 300 miles south-west of Canton.
• Imperial Maritime Ciistoni.i Mi-diral Reports for the year ended ;31st March, 1890,
38th and 39th issues, 1894.
- Imperial Maritimi- Custuius Medical Ixeporta for the year ended 30th Sejiteniber,
1893, 45th and 46th issues, 1895.
58 History and Distribution of Plague [part i
If we now go back to the Yunnan province we shall find that
as soon as the Customs opened a station at Mengtze, one of the principal
towns in the south-east of the province, plague is immediately reported
as epidemic there. It is the usual history of plague in China. Nothing
is heard of it in a particular locality until that locality
Mengtze, is visited by a European. The disease prevailed in Mengtze
1874 1893. £^^ many years prior to the advent of the Customs officers,
but it was not discovered and described by a European medical man
until 1894.
Mengtze is situated in the south-eastern part of Yunnan, in latitude
23" 34' N., and longitude 103 3(i' E. Like most of the princi})al towns
of Yunnan it is in the middle of a large plateau elevated 4500 feet
above sea-level and surrounded by mountains rising from 6000 to 9000
feet above the sea-level. The town is the centre of a large traffic
between Yunnan and the province of Kwangsi, as well as between
Yunnan and Tonking.
The Imperial Chinese Customs opened a station at Mengtze in 1899,
and the European officers on their arrival found plague prevailing. It
had recurred every year in Mengtze since 1885, and first appeared there
in 1874. There was a severe epidemic in 1892, but according to native
reports the epidemic of 1893, which continued during the months of
June, July and August, was, compared with previous epidemics, not
particularly severe. Dr Michoud^ in describing the epidemic, remarks
that " however, out of an estimated population of 10,000 or 12,000
a thousand people died. Carried outside the dwellings, the victims
of plague lay dead or dying unheeded in the streets or set in rows
leaning against the city wall." Dr Michoud continues: "In some places
whole families disappear. At the beginning of the last epidemic, we
were called to the young son of the Chengtai (Chinese General) of
Mengtze. The poor boy had just been given over by the native doctors,
who, probably from fear of displeasing the father, would not declare the
nature of the disease. As we were aware of a case of yang-tzu-ping
ha\ing already occurred in the Chengtai's yanien — considering, too, the
rapid evolution and extreme gravity of every symptom exhibited by the
little patient — disregarding, at the same time, the hypothesis of heat-
stroke or pernicious intermittent fever, we had no hesitation, in spite of
the absence of any external adenitis (and to the great displeasure of the
father), in diagnosing yang-tzu-ping. Although willing to do our best,
1 Imperial Maritime Cuistoms Medical lii'ports for the year ended 30th September, 1894,
47th and 48th issues, 1895.
Cii. Ill] Tlie Waterways of Canton 59
we insisted on the probable failure of any treatment, and urged the
necessity for immediate and energetic disinfection in order- to ward off
further diffusion of the disease. The boy died shortly afterwards.
None of the measures advised were taken because the native quacks
denied the accuracy of our diagnosis. Doubtless the failure of our
treatment had discounted the value of our advice. However that may
be, the Chengtai, an old warrior who had spent his whole life in Yunnan,
and had passed unscathed through the previous epidemics which
decimated the country, was, in a few days after the death of his son,
attacked by yang-tzu-ping and speedily perished. Some of his wives,
many of his relations and servants, were in succession attacked, all the
cases ending fatally. The people that died from yang-tzu-ping in that
yamen before the end of that epidemic numbered at least 25."
The epidemic described at Mengtze, following as it did a severe
epidemic in 1892, occurred in May, June and July of 1893.
Nanningfu Two months later the disease is stated to be epidemic
and Kwaium j^ Lungchow and in many towns of the Kwangsi province,
in 1893. ^ . -^ . ^ y .
such as Nanningfu and Kwaium, the latter of which is not
more than 200 miles from Wuchowfu.
It is clear that plague was extensively diffused at that time. It
was epidemic in Mengtze in 1893, and for several years
Canton in previously. It was also epidemic in some of the south-
western towns of Kwangsi, especially those situated on
the West or Canton River, and it was more or less prevalent in the
south-western districts of Kwantung.
The existence of plague in these places excited no interest beyond
the localities affected, and it was not until the disease reached the
delta of the West River and attacked Canton, the capital of Kwantung,
and an epidemic of exceptional proportions began to devastate the city
in the spring of 1894, that the fact that plague in a dangerous form
existed in China became generally known to the Europeans living in
that country.
Canton is the chief port, as well as the largest and most important
city in Southern China. It is the capital of the Kwantung
Canton con- • i .• -, ,■ -i j.-j.ji
nected with province and contains a population variously estimated at
thecMef 11 to 2 millions. Situated in 23' of latitude N., and
towns and " -, ,> ^ • ^ iii c ^ i\ ^ -n- • •
districts of 113 14 longitude, on the banks oi the rearl Kiver, it is
Kwangsi and gome 70 miles from the coast, and in the centre of a
Kwantung.
district traversed and intersected with waterways, formed
by the convergence of several rivers from the north, east, and west.
By this network of waterways. Canton is connected with the chief
/^
60 ffistort/ inul /)isfrif>fffl(Ht (tf Phf/ire [part I
towTis and districts in Kwangsi and Kwantung. At the mouth of the
Pearl River lies Macao on one side, and the colony of Hongkong on the
other.
The inland water communications of Canton extend westward to
the borders of Yunnan and Kweichow. The Sikiang or West River, or
Canton River as it is sometimes called, is navigable for small steamers
as far as Wuchowfu. From there to Nanningfu the passage is more
difficult on account of some dangerous rapids, but native boats make
it successfully, and ply between the two towns. From Nanningfu to
Pose the river is suitable for light draught boats, which are busily
engaged in carrying produce to and fro. Pose is on the borders of
Yunnan, and the produce reaching it by boat is taken by pack animals
overland to Mengtze.
\Vest of Nanningfu a branch of the river leads to Taipingfu and
Lungchow. It will be seen from the map that Mengtze and Lungchow,
both infected centres of plague, are on the lines of direct communication
with Canton. The West River is the natural and most convenient
trade route for produce and traffic from Yunnan, Lungchow, and the
greater portion of the Kwangsi province, but as jjreviously stated,
notwithstanding the advantages of this route, it used not to be favoured
by Chinese merchants, who preferred to take their merchandise ft-om
Nanninsrfu overland to Pakhoi, rather than direct to Canton. The
reason for this was partly because it was a shorter route to the coast,
but mainly because of the numerous likin charges between Nanningfu
and Canton, there being no fewer than sixteen likin stations. This was
altered in 1891, and the system of traffic introduced, which resulted in
a greater use of the West River for the conveyance of produce and
passengers both to and from Canton.
Whether plague reached Canton from the infected towns and
villages of the south-western part of Kwantung, or direct from Yunnan
and Kwangsi by the West River, is unknown. Probably the infection
arrived by both channels, but whichever was the first, the original
source was Y'unnan. Fatshan, a town situated on the delta of the
West River and a few miles from Canton, is said to have been infected
in 1893. It is the custom of the Chinese to send their dead to be
buried in their native village or town, and the infection at Fatshan
is attributed by them to bodies of persons who died of plague at
Mengtze having been sent to Fatshan for burial in badly fitting coffins.
The first ca.ses in Fatshan occurred in families who were connected
with Mengtze. It has already been noted that, both at Mengtze and
Lungchow, plague occurred among the militar}- stationed at each place,
CH. Ill] Plague in Canton 61
and it is a curious fact that the first case seen in Canton by a European
ph^^sician was in the family of a soldier.
The first recorded case of plague in Canton^ occurred on January
16th, 1894, when Dr Mary Niles was called in to see
ca^n in General Wong's daughter-in-law, who was reported to be
Januaxy, sufferinsf from a " boil," and who, when seen, was found to
1894.
have a very painful swelling in the inguinal region, a
temperature of 104*8° with a pulse of 160, and a petechial eruption.
The patient recovered, but the bubo, owing to sinuses forming, took a
very long time to heal. Out of seven cases seen by Dr Mary Niles up
to May 2nd, in no fewer than four purpuric spots appeared before death.
In a number of cases met with the illness was of a light character ; for
instance Dr Niles records a case in which " a lady came in a chair but
walked into the office. She looked perfectly well, temperature, pulse
and digestion normal. She said she had fever six days before, and the
following day when taking a bath discovered a swelling in the inguinal
region, of which she had not been previously aware, and which caused
her no pain. I examined the bubo and saw for myself." This case is
suggestive of other similarly mild cases, and the likelihood of these
occurring at an early stage of the outbreak without attracting any
special attention. Dr Niles further states : " It has been noticeable to
the people that rats in infected houses have died. In the house where
the child from the school was visiting when she took the disease
thirteen dead rats were swept out one morning... One of the officials,
I am told, offered 10 cash for every dead rat brought to him. He had
collected 35,000 in one month ; 2000 were brought to him in one day."
It was only towards the end of March of 1894 that the disease
began to attract attention. Dr Alexander Rennie reports^ that " a few
stray cases occurred in the beginning of March, but it was not until
the end of the month that attention was awakened on account of its
fatal prevalence in a })()()r neighbourhood near the south gate of the
city, and also in Nan-sheng-li, a quarter occupied by Mahommedans,
among whom the mortality was very high. At this time the type of
the disease was exceedingly severe — of those attacked quite 80 "/(> dying.
Towards the middle of April the cases we saw were of a milder type,
1 Plague in Canton, by Mary Niles, M.D., The China Missioiuinj Journal, June, 1894,
p. 116.
- Report on the plague prevailing in Canton during the spring and summer of 1894,
by Alexander Rennie, M.A., M.B., CM., Imperial Customs Maritime Report for tlie year
ended 30th September, 1894, 47th and 48th issues, 1895.
62 History and Disfrihuffoa of Plague [part i
but the disease subsequently became more severe, and extended its
boundaries to other parts of the city and also to Honam, the maximum
niurtality being reached about the middle of May... Rain fell copiously
during the month of May and beginning of June, so that many streets
were under water ; the temperature remained comparatively low. But
both these factors seemed to favour the propagation of the disease, as
bv the beginning of June it was rife in the western suburbs as well as
in the surrounding towns and villages. It is impossible to give any
correct estimate of the mortality, as no official records of burials are
kept. Comparing the estimates obtained from various sources, we
believe the mortality from the beginning of the epidemic to the middle
of June (the date of writing) to have been about 40,000.
"Although a goodly number of well-to-do people fell victims to the
pestilence, the chief sufferers were the poor, over-crowded and badly
housed. The people who escaped the scourge in the most marked
degree were those living in upper stories and the boating population.
With the exception of those put in boats after falling sick, scarcely a
case was noted on the river. Many well-to-do people, observing this
immunity, removed from their houses and made their homes on the
river. Judging from this circumstance, therefore, and also from the
fact that rats living in the ground and drains were the first animals to
fall victims, we infer that the specific poison emanated from the soil.
What the specific poison may be is not determined, but no doubt the
insanitary conditions referred to, exaggerated by a prolonged drought,
provided a specially suitable nidus for its growth and dissemination.
" The immunity enjoyed by residents on the foreign settlement of
Shamien is remarkable, seeing that it is separated only by a creek some
20 yards wide from houses where cases of plague occurred. Not only
did foreigners living on the settlement enjoy excellent health, but no
case of plague occurred among their servants living on the premises.
The rats also, up to the time of writing, remain healthy and lively."
I)r Rennie further states in this report that on the outbreak of the
disease occurring in Canton many persons, especially the well-to-do,
removed to the country, thus forming fresh foci for its dissemination ;
and in the same way the outbreak in Hongkong no doubt arose from
persons having migrated from Canton to Hongkong while actually
suffering from the disease, or during the short incubation period.
Dr Mary Niles also states that " patients went home to the country
in passage boats, some died in the boats, and others in their native
towns."
CH. Ill] Plague in HongTiong 63
Under such circumstances and from such a centre as Canton, which
communicates with so many places, the infection was bound to be
disseminated.
The largest and most important European possession near Canton is
Hongkong, situated at a distance of only some 80 miles,
«ie°fargeft ^^^^ daily river communication with Canton both by
and most steamers and junks. Hongkong, on account of its position
European at the mouth of the Pearl River, its population being
possession mainly Cantonese, and the great and increasing traffic
near Canton. -^ " . ^
with Canton, has been suggestively called the suburb of
Canton. The extent of intercourse between the two ports may be
gathered from the fact that nearly half-a-million of people pass each
way to and fro annually, and some 4000 river steamers and 8000 junks
annually enter the port of Hongkong from the Canton and West River
district, most of them coming from Canton and its neighbourhood.
Under such conditions it is not surprising that whatever affects
Canton is not long in making itself felt at Hongkong.
covered in In 1902 when cholera broke out in Canton there was only
Hongkong in g^j^ interval of a few weeks before the disease appeared in
May, 1894. . . .
Hongkong. And so it was with plague in 1894. As soon
as the disease was well established in epidemic form in Canton, it was
discovered to be present in Hongkong.
Although there is no positive evidence of the first cases of plague
coming from Canton, rather than from the other affected areas in its
vicinity or from Pakhoi, yet as large numbers of the inhabitants in order
to escape plague were fleeing from Canton to Hongkong, the probabilities
are greatly in its favour, particularly so when the enormous ordinary
traffic is taken into account, together with the circumstance that
detection of sick people entering the colony is impossible, because
there is no system of enquiry as to sickness, nor is there any inspection
of passengers on steamers and junks from Canton or from the West
River.
Dr Lowson, in his report on the epidemic of bubonic plague in
Hongkong in 1894^ is of opinion that the disease was imported from
Canton rather than from Pakhoi, where it did not prevail until the
latter part of the spring, and between which and Hongkong the traffic
is insignificant compared with that between Hongkong and Canton.
Once introduced into Hongkong, the disease caused the greatest alarm,
1 The Epidemic of Bubonic Plague in Hongkong, 1894, Medical Report, by James A.
Lowson, M.B., Medical Officer in charge of Epidemic Hospital, Hongkong, 1895.
64 Hisf<H'!i find Disfribufion of Plague [part I
but the epidemic, though severe, is not to be compared in intensity
with that in Canton, even if the lowest estimate of 40,000 be accepted
as the highest number of deaths. Many in Canton have estimated the
deaths from plague in that city in 1894 to have been between 80,000
and 100,000. The deaths in Hongkong did not exceed 8000.
It was in the Hongkong epidemic of 1894 that the causal agent
of plague, the plague bacillus, was discovered by Dr S.
baciUu^i^- Kitasato of Tokyo, on June 14th. Later Dr Yersin made
covered in independently a like discovery in Hongkong. The Hong-
Hongkong- by ^ . . . "^ .
Dr s. Kitasato kong epidemic began in May and ended in August, and
DrVe^sm^^ its incidence was proportionately more severe on the
female portion of the population than on the male. Macao
did not suffer epidemically from the disease until April, May and June
of 1895. During the winter of 1894 and 1895 there
Plague in ...
Macao in prevailed a fatal epidemic which attacked the respiratory
^ ■ organs, and which was believed to be influenza. It is
worth noting that this was at a time before the pneumonic type of plague
was recognised as a variety of the disease. The first case of bubonic
plague which came under the notice of the Portuguese authorities was
an imported case from Hongkong, and to this source is ascribed the
origin of the epidemic ; but as the case came under the care of the
sanitary authorities the next day after arrival, also as there was a high
mortality among the Chinese with no means of ascertaining the exact
cause of death, and as the epidemic quickly followed the introduction of
this single case, which is an unusual occurrence with plague, whose
progress at the beginning is generally slow, it is likely that Macao was
infected earlier. The epidemic reached its acme in April and May, and
disappeared in June, and returned in 1897 and 1898. From the position
of Macao and its intercourse with Canton, Pakhoi, Hongkong, and the
villages of the delta, it could only be a matter of time for it to be
infected by people coming from one or all of these places.
With Canton, Hongkong, Macao and Pakhoi infected with plague,
Canton and i^ ^^''^s not long before the disease became extensively
Hongkong be- diffused and the whole of the southern coast of China
come centres ■ i i mi • /> c< i rM. •
of distribution invaded. The accompany mg map of Southern Chma shows
of plague. ^j^g course of plague in its advance from Yunnan, and the
distribution of the disease in this region up to the year 1902.
The two most important emporia of China are Canton and Hong-
kong, and every j^ear but 1895 the disease has recurred in Hongkong
and Canton.
CH. Ill] The Marts of Canton and Hongkong 65
Admirably situated for commerce, Canton and Hongkong are the
great marts and distributing ports for the produce of Southern China ;
and Canton sends its merchandise down by the Canton River on large
and small native craft to Hongkong, where it is stored in large ware-
houses until ships arrive to take it away in exchange for the cargoes
they bring. Hongkong, though not more than sixty years old, possesses
one of the busiest harbours in the world, and has trade connections, not
only with the southern ports of China and the neighbouring islands of
the Pacific and Chinese Seas, but also with India, Australia, Japan, and
America.
It has already been stated that it was from Canton and the province
of Kwantung that Hongkong became infected with plague in 1894, and
from these sources it continues periodically to receive fresh infection.
Plague since 1896 has also become endemic in Hongkong. A great
commercial centre continually exposed to fresh infection, and in which
plague is endemic, is apt to be dangerous to places with which it is
in frequent communication, and it has thus happened that Hongkong,
besides being a great distributor of merchandise, has become also an
active centre for the distribution of plague. Sea-going ships have
conveyed the infection over the seas to India, Australia, Japan and
America, and coasting steamers have distributed it to adjacent ports.
It has not always been possible to indicate the ship that conveyed the
infection or the exact agent by which the infection was carried, whether
by man, by animals, by infected clothing, or by infected merchandise ;
but it is possible to exclude the infection being conveyed in any other
way to Japan, Australia, and America, and there is sufficient evidence
to leave no doubt as to the infection being carried by shipping having
commercial relations with infected ports in Southern China.
Hongkong is separated from most places b}'^ the sea, and the
infection has not passed overland to China, but has followed the trade
routes of the sea.
It is a very remarkable fact that plague has not spread very far
inland in China, and that hitherto its chief ravages have been limited
comparatively more or less to that portion of the country near the coast.
The infection on land has followed chiefly the routes of busiest inter-
course. There are no railways in Southern China, and the disease has
made no extensive inroads into the interior of the country, except in
those districts in which their waterways connect them with infected
localities. In the case of the infected provinces of Kwangsi and
Kwantung, and Fokien, a range of hills which forms a natural boundary
s 5
66 Ilisfori/ (1)1(1 Dififrihiition of Plague [part i
between the north and the south, and which restricts commercial
activity between them, also prevents plague from passing northwards.
But apart from this natural obstruction it seems to be a characteristic
of plague not to spread much beyond the towns and villages on the more
frequented roads of trade.
The precise date and manner of the arrival of plague infection at
Bombay are unknown. There is constant trade intercourse
Plague at ''
Bombay in between Bombay and Hongkong, the ships of Hongkong
taking the produce of Canton and the provinces of Southern
China to Bombay, and the ships of Bombay taking the produce of
Western India to Hongkong. The disease may have been introduced
by some one infected among the crew of a steamer coming from Hong-
kong, or by infected rats, or possibly infected cargo. It has happened
even as late as 1902 for plague to be imported from Bombay to Hongkong
by these ships and for the disease not to be suspected by the captain,
and it has also happened for plague-stricken rats to have been conveyed
in this way from Bombay to Hongkong. But before plague broke out
in Bombay in 1896 there was so little suspicion of the possibility of
the disease being conveyed from Hongkong to Bombay direct before
attacking intervening ports that no alarm was felt in this direction;
nor did there seem grounds for that alertness essential for the discovery
of first cases and the protection against importation. Bombay had not
been attacked by plague for nearly 200 years, though the disease had
prevailed in Gujarat, Cutch, Kathiawar, Rajputana and Sind from 1812
to 1821, in Kumaon and Garhwal on the slopes of the Himalayas
in 1823, 1834, 1847, 1876, 1884 and 1893, and in Marwar, Jodhpur,
Rajputana and Pali in 1836 and 1837.
Bombay also remained free of the disease when it was epidemic in
Mesopotamia as recently as 1891-92, which is a country much nearer to
Bombay than China. With such an experience there was an inclination
to think that Bombay was invulnerable to plague ; besides, nearly
everything concerning plague had been forgotten. By many it was
considered an extinct disease so far as modern times were concerned,
and at the most could only prevail to a limited extent among filthy
and uncivilised people. Its diagnosis, its connection with rats, and its
modes of extension needed all to be learnt afresh. Cholera was the
epidemic disease of India, and the infection of plague, an unknown
disease, was largely judged and measured by what was known of cholera.
The possibility of plague infection being spread at times by merchandise
and other agents, besides sick persons, was discarded as antiquated and
CH. Ill] Plague in Bombay 67
obsolete. It was forgotten that plague itself was antiquated, and that
our predecessors with much experience of the disease may have correctly
observed many things connected with it. Plague had been absent from
Bombay since 1702, or a period of 194 years. These long intervals
seem peculiar to the epidemiology of plague. Between the epidemic
in London in 1348 and that of 1499, a period of 150 years elapsed.
An interval of 70 years occurred between the epidemic of 1720 and the
previous great epidemic in Marseilles. Moscow was attacked in 1771,
after a period of immunity of 150 years, and Malta when attacked in
1813 had been free from an epidemic of plague for 137 years.
Though it is now evident that plague must have existed as early as
March, 1896, in Bombay, the first cases noticed appear to have occurred
near the docks on the Port Trust Estates in the Mandvi district in
August, 1896, among Moltanies who had dealings with China and
among the Lohannas and Banias of the same district. The cases were
mistaken for diphtheria and fever. At this time the mortality in the
Mandvi district was unusually high, but it was attributed to remittent
fever and lung affections. The rats were also dying in numbers, but no
particular importance was attached to this phenomenon then. It was not
until the 23rd of September, 1896, when Dr A. G. Viegas drew attention
to the disease being probably plague, that public anxiety was aroused.
The diagnosis of plague was bacteriologically confirmed by W. Haffkine,
the Government Bacteriologist, on October loth. After the first alarm
there was a reaction and opinions fluctuated from day to day as to
the nature of the disease, now being pessimistic and now optimistic,
according to the number of deaths. The majority of citizens were,
however, disinclined to believe in the possibility of plague.
Commence- . ,
ment charac- The mildness of the disease and its slow progress led to
mudness^and ^^^ being called glandular fever, or bilious fever, or indeed
slow exten- anything but plague. Haff kine's report, however, dispelled
illusions, at least on the part of the thinking public.
For the first month or so after the discovery it was more or less
limited to the Mandvi district, and then it commenced to spread. Rats
were noticed to be dying in other quarters of the town than the Mandvi
district, and wherever this happened cases of plague began to appear.
The Health Department set vigorously to work to cleanse and disinfect
the infected areas and houses, and to segregate the sick. But the
population to be dealt with was a peculiar one. Oriental in its
thoughts and habits, superstitious and fanatical, it was particularly
sensitive and antagonistic to innovation of any kind. It was used to
5—2
68 Histonj and Disfribfttiou of Plague [part i
small and short-lived epidemics of cholera, and knew the measures
taken for that disease, and it was persuaded that plague, if it existed,
would be equally short-lived. At first the preventive measures were
endured with grumblings, but as the disease continued,
the'adopwon =^"d began to look more serious, the policy adopted, western
of preventive j,^ j^g conception, suited neither Hindu nor Mahommedan.
measures. . . „ ,. r% \ j-j
Hostility and ill-feeling were soon apparent, reople did
not and would not understand that the disease was infectious. One
medical man, convinced of the non-infectious nature of the disease,
insisted on sleeping in the ward with his patients, and died of plague.
Every sanitary measure was opposed. Denunciations and protests were
soon followed by active demonstrations of ill-feeling by stoning of the
officers engaged in plague work, attacking of the ambulances, and even
storming of the plague hospital. To such a pitch of excitement were
the rougher classes of the population aroused, that there were good
grounds for fearing a riot and, worse than a riot, there were threatenings
of an exodus of the whole conservancy staff and of the dock and mill
hands, and possibly of the police themselves. To allay this state of
feeling the notification authorising compulsory removal to hospital was
withdrawn three weeks after its first appearance. This was on the
30th of October. The difficulties which beset the local authority in its
endeavour to stay the progress of the disease were not removed by this
concession. Popular feeling, mo\ed by wild rumours, the offspring of
an excited imagination, or evil design, or ignorance, was swayed first
in one direction, then in another, but never in sympathy with, or in
support of, the sanitary measures devised to check the disease. And
so the plague continued to spread. The people had lost confidence in
medical treatment. It was not a question of notification of the sick by
medical men, but of finding out the sick and dead, and cleansing and
disinfecting the house. The disease spread remarkably slowly, con-
sidering the conditions which it met with.
During October and November, the disease seemed to be stationary
^ .as regards the number of deaths recorded, but there was
Progress of "
the disease an ominous circumstance ; it was infecting new districts,
with the ^^^^ ^^ ^^^^ observed as a curious phenomenon that the
migration of progression of the disease was intimately associated with
the migration of rats. It was not the localities to which
people were fleeing from infected districts that were showing grave
infection, but those to which the rats were migrating. Suddenly, in
the beginning of December, the mortality from plague and from general
CH. Ill] Extension} to Bombay Presidencn 69
causes rose to twice the height it had attained before. Then the
epidemic began in earnest, the mortality rising week by
first Bombay week until the 2nd and 3rd week in February. By this
epidemic in time the crisis was reached, and there was a gradual but
Feb. 1897. . . . °
fluctuating fall in the weekly mortality from general
causes and from plague, until the last week in May, when it descended
to the same level as in October and November. Once the epidemic set
in, panic seized the inhabitants, and there was a general exodus from
Bombay. Homes and shops were closed, and the inhabitants sought
safety in flight. Rumour exaggerated the ravages committed by the
plague, and it was only when nearly half the population had fled from
the city, and the deaths from plague showed marked signs of declining,
that the panic began to subside. To this exodus is to be chiefly ascribed
the infection of localities outside Bombay.
In consequence of the spread of plague beyond the city the Govern-
ment of Bombay took over the control of plague operation earl}- in
March, not only for the city but for the whole Presidency.
Plague committees were formed for every large centre where plague
existed. Hospitals were erected, health camps established, and search
parties constituted. With this organisation a vigorous policy of segre-
gation of the sick, and removal of the healthy from infected houses and
areas to health camps, was carried out. It is difficult to gauge the
value of these measures, for they were introduced into Bombay after the
crisis was reached and the epidemic was already waning. But, like the
preventive measures carried out by the municipality, there can be no
doubt that they contributed in no small degree in limiting the ravages
of the epidemic. In May and June the disease was distinctly of a
milder type, and hopes were entertained that not only the worst period
had passed but also that the city of Bomba}^ would soon be free. These
hopes were not to be realised, for since its first appearance in 1896 plague
has never left Bombay. Every year there have been recrudescences,
reaching epidemic proportions in January, February, March and April.
Plague soon began to spread beyond Bombay, both by land and by
sea. Poona was affected in December, Karachee in the
the disease to same month, and as distant parts as Suhkur on the Indus
tbe Bombay ^ot long after. The infection was carried even as far as
Presidency r^ ^ ^ ■ ■ ^ ^
and to other Calcutta, where m one quarter occupied by Bombay mer-
india^'^^^ "^ chants the rats began to die, and there were a few cases
of plague, but the stringent measures there taken, espe-
cially against the rats in the infected area, were successful in preventing
the disease gaining a lodgement in ISiH), and it was not until April,
70 History and Disfribuffon of Plague [part i
1898, that plague gained a firm hold in Calcutta, apparently by fresh
introduction of infection.
Besides these important centres the malady spread to the adjacent
districts of the Bombay Presidency and its Native States, where it pre-
vailed from January to June, causing a large mortality. Each new
centre of infection in turn ofave rise to others, so that in the middle of
1897, although owing to the decline of the epidemic at that period the
deaths from plague were comparatively few, yet there were many centres
where the disease had acquired a firm hold.
The maps taken from an account of plague administration in the
Bombay Presidency from September 1896 to May 1897, by M. E.
Couchman, I.C.S., show the diffusion and spread of the disease from
Bombay along the coasts and along the lines of railway and traffic in
the interior of the Presidency. It will be observed how many places
were infected by June. These localities, in the next epidemic of
1897-98, acted as fresh centres from which more places were infected.
The diffusion of the disease was slow and b}^ no means corre-
siow diffusion sponded locally with the flight from Bombay; often long
of the plague, intervals elapsed between the first recognised imported
case and the first indigenous case, and in many localities imported cases
were not followed by indigenous cases, and when indigenous cases
occurred some considerable time usually intervened before they assumed
epidemic proportions. This slow diffusion is one of the most constant
characteristics of plague. The Great Plague of London took six months
to travel from St Giles' to Stepney. In 1830 plague existed eight
months at Alexandria before passing to Damietta and Mansurah,
though traffic was quite uninterrupted. In Bombay the plague
remained confined to the dock quarters for a considerable time before
it spread to other districts. At Poona over six months elapsed before
the disease established itself at Kirkee which was in daily communi-
cation with Poona, and only separated from it by a river spanned by
a bridge. By September and October of 1897 there was a general
rise in plague prevalence in the Bombay Presidency. The southern
portion of the Presidency, which had remained more or less free
during the first epidemic, became extensively infected, and by June,
1898, the deaths in the second epidemic were double those of the first.
61,000' deaths from plague were recorded against 29,000 in the first
period. The second epidemic was not only twice as severe as the
1 " The Bombay Plague, being a history of the progress of the Plague in the Bombay
Presidency from September 1896 to June 1899." CompileJ under the orders of Government,
by Capt. J. K. Condon, 1900, Bombay.
/
\
0
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n
(
f
m
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MAP OF THANA COLLECTORATE IN BOMBAY PRESIDENCY.
Plague cases from month of March to end of June, 1897.
T^ — ^^^
s
il( t^'JVIAHAQ.
idaniilD
.YDMaai83Hq YAaMOa mi STAHOTOaJJOD AWAHT 10 qAM
MAP OF SURAT COLLECTORATE IN BOMBAY PRESIDENCY.
Plague cases from month of March to end of June, 1897.
. /
V
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77
HO^MAHAHQ
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.Yowaaiaam YAaMoa vii axAHOToajJOD TAaua ^o qAM
.^e8i .^nu\\o hM oJ rfoisM lo riJnom moil aaero saael*?
MAP OF SIND IN BOMBAY PRESIDENCY.
Plague cases from month of March to end of June, 1897.
^rf
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y<^
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VI A T^.o"^
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CH. Ill] Extejision to otJier Presidencies 71
first, but it also established a wider area of infection. In the third
epidemic ending Jiine, 1899, the deaths reached over 115,000. In the
district of Dharwar alone there were in the course of eight
epidemics at months 80,000 deaths from plague. In the same year
Dharwar Poona suffered from its third epidemic, which was the
and Poona. ^
most severe of all. In the course of four months, during
June, July, August and September, it lost nearly 10,000 of its in-
habitants, although half its population fled panic-stricken from the city
at the commencement of the epidemic. The normal population of Poona
was 61,000. For a period of over six weeks it lost over 1000 persons
a week from plague. The greatness of the mortality may be gathered
from the fact that if a similar mortality had prevailed in London, the
metropolis would have lost over 10,000 persons a day.
Fugitives from Bombay and the Bombay Presidency were not long
in carrying infection to the other provinces of India, and
Extension of , . "^ . , . . . ^ . .
the plague this notwithstanding certain precautionary measures oi
to other inspection taken on the railways. The development of
Presidencies. ^ . _ . •'. ^
the disease in these new localities was slow, and at first
it appeared as if the disease were quite within control, but gradually,
in spite of every endeavour to stay its progress, it has spread through-
out the Indian Peninsula, affecting some places but lightly, inflicting
terrible ravages in others, and leaving many untouched.
The progress of the plague in India has been slow. During the
first three years, as pointed out by the Indian Plague Commission, the
disease was not able to extend and take a hold of the country in such
a way as seriously to affect the ordinary death rate. The Commission-
dealing with that period conclude that " ^although the figures of plague
mortality when taken by themselves are high, it is evident that plague
has not as yet been able to make itself felt as one of the most important
factors that influence the total mortality of India." It is evident that
this stage is past, and that the plague is now a very important factor in
the Indian mortality.
Each year the area of its activity widens ; each recurring epidemic
seizes on new districts besides maintaining its hold on the
Gradually i r • i i
increasing old, and now at the end of eight years the annual mortality
ftom^he^ from plague in India has risen from less than 30,000 in the
plague in first year of its prevalence to little less than a million
per annum in 1908. This represents nearly one-sixth of
the annual mortality of India.
' Report of the Iiidimi I'liujue Coiiiiiiissioit, Vol. v. chaji. ii. p. 50.
72
Historji (uhI Distribution of Plminc [part i
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CH. Ill]
Plague Mortality lit India
Number of Deaths.
1000000
900000
800000
700000
6 50000
400000
250000
200000
150000
TOTALS
SEP.
1896
TO END
or 18971
1898 1899
JAN.
1902 i 1903 TO cwo
OF APRIL
1904
->^
73
74 History and Distribution of Plague [part i
The preceding tabular statement gives the annual recorded deaths
from plague in India since 1896. The number of deaths is large, but
probably it is understated by 20 to 25 "/V But taken as it stands the
mortality is nothing less than one of the most disastrous calamities for
India. Year by year the mortality rises and there is no sign of abate-
ment. In the first four months of 1904 there were over half a million
deaths.
A very extraordinary fact brought out in this table is the immunity
of Europeans in contrast with the susceptibility of Indians, even allowing
for the comparatively small number of Europeans in India.
With plague epidemic in India and Southern China the intimate
commercial relations which exist between their infected
Extension of
the plague ports and the ports of other countries were likely to favour
and^cwna^to ^^^ spread of the disease, and as a matter of fact the
other parts history of the proo-ress of the plague is that few maritime
oftheworld. /. \ ^ . ^ . '' , „
countries participating m the rivalry oi the commerce oi
the East have not been more or less exposed to plague infection by the
arrival of ships from infected ports. As earl}- as September, 1896, two
cases of plague were discovered at the London Docks in a vessel that
left India before plague became epidemic in that country. This
experience of plague-infected vessels coming from infected ports has
happened to most maritime countries within the past eight years.
Fortunately, whether it be from precautions taken at the port, or from
conditions in the port unfavourable to the lodgement of plague, or
from the rarity with which ships carry infection on them, or from
ships being generally unfavourable to the propagation of plague,
the majority of the ports subjected to the risk have escaped. But
although there has not been a general infection of the ports, yet the
infection has been carried to many parts of the world. They include
ports in Asia, North and South America, Australia, Africa, and Europe.
It is a distribution, as far as is known, dissimilar to that of any former
epidemic of plague, its main feature being that the course followed is
a maritime one, which is most readily explained by the change in trade
routes which has taken place since the former great epidemics of plague.
The distribution is shown on the map. It is a wide diffusion so far
as distance is concerned, and is wider in this respect than
of plague in ^.hat which characterised previous pandemics, for it has
different parts reached America, Australia, and South Africa, none of
of the world. i • i , i i i i i i i
which have been ever known to have had plague imported
into them before. With the exception of Africa, the infection appears
COURSE AND DISTRIBUTION OF
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^■i Endemic centres
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CH. Ill] An African Endemic Centre 75
mainly to limit itself to the ports, or to localities near these. It is also
to be noticed that, notwithstanding the extensive sowing of the seed or
germ of plague which has taken place, there has hitherto been no
disposition for the disease to become severely epidemic except in India,
China, the Mauritius, and in the year 1900 in Cape Town. How long
this fortunate condition of affairs will continue it is impossible to say.
Plague is slow in its progress and development, and evidently has
difficulty in adapting itself to new conditions ; it remains not infrequently
for years in a more or less quiescent state, and then bursts out in a
destructive and expanding epidemic. While, therefore, the ports of a
country are infected or liable to infection from communication with
infected ports, that country is never free from the danger of suffering
from a plague epidemic which may assume large proportions.
A point of great interest in regard to the distribution of plague is
^ . the discovery in 1897 of an independent plague focus in
An endemic .... i o
centre in the district of Kissiba, to the extreme north-west of German
Uganda. ^^^^ Africa. Enquiries seem to point to the fact that
plague has been endemic in Uganda for many years, and that, for the
last 30 or 40 years, it has prevailed in sporadic or epidemic form in the
provinces of Buddu, Koki, and Nkole. It appears that about 1889, at
the time of a severe epidemic of plague in Buddu and Koki, the disease
was introduced into the district of Kissiba, where it spread rapidly, and
where in 1897 it was definitely proved by Dr Zupitza and Professor
Koch to be plague.
PAET II.
EPIDEMIOLOGY OF PLAGUE.
/
,/
CHAPTER IV.
NATURE OF INFECTION.
/
/ The nature of the infection is no longer a matter of surmise. The
discover}^ of the plague bacillus with its well-marked characteristics and
/ powers of inducing the disease in some of the lower animals, especially
' rodents, when inoculated into them, has put an end to the speculations
as to the nature of the virus.
Pestiferous emanations from the soil contaminating the atmosphere
have always been a favourite explanation of the source of
Earlier views "^ . • i i i i i
on the nature the plague virus, the nature of which has been looked upon
0 in ection. ^^ consisting of some venomous vapour or gas. Boghurst
in his Loimographica on the Plague of London of 1665 records the
general opinion, not only of his contemporaries but also of the medical
men of many previous centuries, when he says : " My opinion falls in
t wholly with those who make the earth the seminaiy and seed plotts
of these venomous vapours and pestiferous effluvia which vitiate and
corrupt the air and consequently induce the pestilence'."
This opinion was not, however, held by all. There was another
school which suspected that the infective agent of plague was a living
entity and that it was conveyed from person to person by contagion.
Athanasius Kircher is an exponent of this view. In 1658 he writes'-:
' Tnin-fuctions of the Epidemiological Society of London, Vol. xiii. 1893-94. "Loimo-
graphica. An account of the Great Plague of London in the year 1665 by William
Boghurst, Apothecary." Edited by Joseph Frank Payne, M.D.
2 Athanasii Kirclieri, E. S. J., Scrutiniitiu Physico-Medicum Contagiosae Lnin, quae
Pest in dicitur. Rome, 1658.
CH. iv] Theory of Contagion 77
" Plague is in most cases a living being ; for the sick man harassed by
pestiferous virulence soon contracts a marvellous putrefaction which we
have shown to be most apt to create worms. Now these worms, pro-
pagators of the plague, are so small, so light, so subtile, that they elude
any grasp of perception and can only be seen under the most powerful
microscope. You might call them atoms, but they spring up in such
numbers that they cannot be counted ; these worms when they have
been conceived and generated from the putrefaction are easily forced
out through all the passages and pores of the body, and since they are
moved by the slightest movement of the air, just like so many sunbeams,
are diffused here and everywhere in such a way that whatsoever they
run across, they at once adhere to most tenaciously, insinuating them-
selves deeply right down to the bottom of the pores... Now all things
are liable to catch this pestiferous brood, linen, cloths, clothes, skins,
carpets, feathers, bedsteads, ottomans, tables, articles of every sort even
to spoons, knives, table-tops, cups, belts, &c. For when this outburst
of worms or worm sprouting, even at the smallest breath of air (which
can happen either while the sick man upon his bed tossing himself now
on this side and now on that, throws the clothes and coverlets now here
now there; or while the nurses attending on the sick man make the bed
and arrange its coverings that have been cast off, or place, or raise, or
turn in any way the patient for the requirements of nature or the
working of the medicine), get blown abroad, and a virulent brood just
like atoms or particles moved by a breath of wind diffuses itself like
smoke in all directions, it needs must be that all things are infected to
which it adheres."
On this or a somewhat similar hypothesis did the contagionists
explain the infectiveness of plague until the Hongkong epidemic of
1894, when Kitasato and Yersin discovered in the buboes and in the
blood of plague patients the bacillus of plague. After reading Kircher's
description one is left in doubt as to whether he and the physicians of
his time did not actually see the plague microbe. If we except the
exaggerated facility with which the worms he speaks of as being visible
under the most powerful microscope leave the body and diffuse them-
selves in the air, the notions as to the nature of the infection and its
portability are not unlike those of the present day.
In 1894, on the outbreak of plague at Hongkong, a Japanese com-
mission of which Dr Kitasato was the Chief was despatched to Hongkong
and in a short time the discovery was made that in the blood, internal
organs, and affected glands of the body a micro-organism was to be
78 Epidemiology of Plague [part ii
found in all cases of plague. Later Dr Yersin independently made a
like discovery. The bacillus thus associated with plague
the plague ^'■^^ been proved to be the causal agent of the disease.
baciUus and Jt, is alwavs found in the buboes and affected glands of
the evidence ' • i i ■ i ,
as to its well-marked cases oi plague, in the blood and tissues of
relationship *^^ septicaemic variety of plague, and in the lungs and
sputum of pneumonic plague, and this is the case wherever
plague occurs, whether in China, India, Africa, Australia, America or
Europe. Moreover if the bacillus is isolated from a plague case and a
pure culture groAvn on ordinary nutrient media, the disease can be
produced in some of the lower animals which are susceptible, by inocula-
tion, and from the tissues of these animals the microbe can be again
recovered in pure cultures. Even more convincing than this experimental
evidence is the accidental production of the disease in man in some of the
bacteriological laboratories of Europe where no plague existed other
than that artificially produced in animals in the laboratory by inoculation
with cultures of the plague microbe. These cultures were in every case
descendants through many generations of cultures of original microbes
obtained from plague cases in India or elsewhere, and brought in culture
tubes to the locality in which the outbreak occurred. There has never
been any doubt as to the plague in the laboratories being caused from
any other source than the cultures, and the cases have occurred when
no plague existed in Europe.
There have unfortunately been three occurrences of this kind. The
first was that which happened in Vienna when in October, 1898, more
than a year after the return of the Austrian Plague Commission from
Bombay, the attendant of the Pathological Institution in Vienna, who
was acting as assistant to Albrecht and Ghon and had charge of the
animals experimented on, fell ill wath pneumonia which proved on
examination of the sputum to be plague pneumonia. He died on the
fourth day of illness from well-marked plague. Dr Mueller and two
nurses who attended the patient were also attacked with pneumonic
plague. One nurse recovered, but Dr Mueller died on the third day of
illness and the nurse a day or two later. Prompt measures were taken
to prevent the disease from spreading and no other case occurred in
Vienna then or since.
The second occurred in June, 1908, when Dr Milner Sachs, who was
studying bacteriology in Berlin, infected himself while injecting a rat
with a culture of the bacillus of plague. He contracted plague, it is
thought, by inhaling particles which were ejected from the syringe in
CH. iv] Characteristics of the Bacillus 79
a spray. He suffered from the pneumonic form. He fell ill on June
2nd and died on June 5th, although he received injections of Roux
Yersin's serum. A hospital attendant Marggraf who nursed Dr Sachs
was also attacked with pneumonic plague, but he was treated ener-
getically with Yersin's serum at an early stage of his illness and
recovered. The precautions taken to prevent spread of the disease were
successful. They consisted in isolation of the patients and of those who
had come in contact with them, and burning the personal effects and
any suspected furniture and goods.
The third accident was in January, 1904, which resulted in the death
of the Director of the Laboratory of the Imperial Institute of Experi-
mental Medicine at St Petersburg, who contracted plague whilst engaged
in experiments with plague cultures. Two others in the laboratory also
contracted plague and died from the same cause. All were treated with
plague serum, but without success.
It is curious that all the cases of plague contracted in the laboratory
and when dealing with animals have been of the pneumonic type.
The specificity of the plague bacillus is still further evidenced by the
appearance of specific protective substances in the blood of individuals
convalescent from plague and in the production of these specific pro-
tectives in the blood of experimental animals treated with plague bacilli,
also by the protection afforded by inoculation with killed plague bacilli
against a later natural infection.
Much was done in studying the morphological and cultural charac-
teristics of the plague bacillus and in investigating the
logical and behaviour of the micro-organism under known conditions,
staining before the full evidence was obtained which established
character-
istics of that the bacillus was the causal agent of the disease. It
bacUiuf"* will now be necessary to enter into the results of these
researches. The plague bacillus belongs to the same
cocco-bacillus group of Haemorrhagic Septicaemias, such as chicken
cholera and rabbit septicaemia, all of which at some period of their
existence show when stained a bipolar appearance. The typical plague
bacillus is a short thick rod rounded at its extremities and more or less
ovoid in form. It measures from '8 mm. to 2 mm. in length and is usually
from '4 mm. to "8 mm. in breadth. It is more constant in breadth than
in length, though it varies in breadth more than other bacilli. It varies
considerably in shape and size, so that in a microscopical specimen,
in addition to the typical bacilli, very diverse forms may be seen,
including long and slender bacilli together with boat-shaped, dumb-
80
Epldeniioloffn of Plague
[part II
<<#4-
4 Mt *
t
^
^▼^
'•*J?
i
Plague bacilli in contents of Bubo.
mm
Plague bacilli in Sputum.
CH. iv] Cultural Characters of Bacillus 81
bell and spherical micro-organisms resembling cocci and diplococci in
their appearance.
This pleomorphism may give rise to difficulty of recognition when
plague appears in a locality for the first time and when the decision of
the disease has to rest on a single case. Cultures however will solve
the difficulty if the stalactite test be applied. For a time the variation
in form was mistaken for contaminations and attributed to the presence
of bacilli unconnected with plague.
The bacillus is non-motile, the only motion being Brownian and not
that of translation ; one or two terminal flagella have been observed and
described, but they have been seen only by a few. No spores have
hitherto been discovered.
The bacillus is easily stained by aqueous solutions of methyl blue,
gentian violet, fuchsin, or any of the ordinary basic dyes, but is not
stained by Gram's method unless a weakened spirit solution of 50 °/o
is used instead of absolute alcohol for the decoloration process. The
bacillus is stained usually more deeply at the extremities than at the
centre and thereby acquires a very characteristic bipolar staining. This
bipolar staining is more marked in microbes taken from the tissues
direct than from cultures, also in the ovoid more than in the longer
variety of bacillus. In some cases the unstained portion is not in the
centre but at the side or end of the bacillus, and in other cases the ends
are not stained. The bipolar staining is well brought out by over-
staining in carbol fuchsin for four or five minutes and then decolorising
with absolute alcohol, or b}' treating with acetic acid and then with
carbol fuchsin. The bipolar staining is by no means constant in every
bacillus, though in a plague specimen it is generally the predominant
feature. In some smear preparations from infected tissues nearly all
the bacilli show the bipolar staining ; in others only a small proportion
exhibit this characteristic, and occasionally no bipolar staining is to be
observed. In most specimens some of the bacilli show a distinct but
unstained capsule, giving the appearance of the bacillus being" embedded
in a viscous matrix. In preparations from buboes and the haemorrhagic
effusions around them the arrangement is generally a few single micro-
organisms intermixed with a large proportion of bacilli in pairs, pre-
senting a diplococcal or diplobac-illar appearance ; and not infre(juently
several pairs are found together in shorter or longer chains and having
the appearance of streptobacilli or streptococci.
Spherical, torula-like, and disc forms may be found in old buboes
durin"' life and in affected tissues after death. These swollen and
82 Epidemiolouji of Plague [part n
irregularly shaped bacteria do not stain well, and often only a faint
outline is to be seen.
In the living plague patient the bacilli are generally very abundant
in smear specimens of the contents of the buboes and in the sangui-
nolent effusion around them, crowds being seen in the microscopic field ;
they are not infrequently to be seen in the interior of the white blood
corpuscles. But while the usual characteristic is the multitude of
bacilli in buboes, there are occasions when they are few in number, and
they are only detected by inoculating the material from the affected
gland into a culture medium. Plague bacilli are very numerous in
the sputum of pneumonic cases, which at times literally teems with
them. They are also to be seen in the blood of septicaemic cases and
in the contents of vesicles and pustules that sometimes appear on the
skin. They can be cultured from the blood and urine of living patients
suffering from the septicaemic form.
In dead bodies the bacilli are found in the affected buboes and
generally in the spleen, liver, lungs, bone marrow, bile, urine, peritoneal
fluid, and fluid of the brain. It is this universality of the plague bacillus
which is the danger attached to corpses and which renders it imperative
that special precautions shall be taken immediately death occurs to
prevent the spread of the infection. In septicaemic cases the risk is
always pronounced, but even in the bubonic form the bacilli very
frequently gain an entrance into the blood stream some time before
death and become disseminated in the tissues and in the excretions, so
that any dribbling or escape of fluid from the body which frequently
takes place will soil the bedding and the floor.
The micro-organism of plague is distinctly aerobic ; it grows easily
Cult ai ^^^ ordinary culture media such as gelatin, agar agar, broth,
character- blood serum and glycerine agar ; it grows also in milk and
scantily on potatoes. In isolating the bacillus for diagno-
stic })urposes from the living or dead body the temperature at which
the culture medium is maintained is important. Blood heat is not
favourable to the growth of the plague bacillus, and if there are other
bacilli present, such as the bacillus coli communis, streptococcus pyogenes,
or the pneumococcus, these will gi-ow while the plague bacillus will be
inhibited. Mistakes may thus easily arise, and the pneumococcus alone
or some other microbe be found in a case which is really plague. Plague
bacilli grow best at a temperature considerably below blood heat, the
most favourable being from 25' C. to 30' C. The first cultures
from the body are always slower in growth than sub-cultures. Both
CH. ivj Involution Forms of Bacillus 83
agar and gelatine plates are used in suspected cases of plague. The
growth on most of the media possesses no distinctive features peculiar
to plague other than those which are obtained on gelatine, agar agar,
and in bouillon. On blood serum it appears in 24 to 48 hours as a moist
cream-coloured or yellowish growth. On gelatine it develops in the form
of minute, translucent, and raised colonies in the course of 48 to 72
hours, and which have a dew-drop appearance ; it may even take as long
as four or five days for the colonies to become visible ; later the colonies
become denser in the centre, of a greyish-white colour and with crenate
margins. The colonies differ in their rate and extent of growth, some
remaining stationar}^ in size, others becoming considerably larger. Under
a lower power of the microscope they have at first the appearance of
ground-glass, and later a dense dark granulated centre with notched edges
more or less transparent. Deeper colonies in gelatine appear at first as
small, rounded refractive granules, white in reflected light and brown in
transmitted light. In stab cultures there is, in addition to the granular
and later continuous white growth along the tract of the needle, a film
on the surface of the gelatine. The bacilli do not liquefy gelatine, but
they liquefy blood clots.
On agar agar inoculated with plague material minute, bright, colour-
less colonies of various sizes and slightly raised develop in less than
48 hours or it may be longer. In a day or two they become small,
greyish-white hemispheres with a thin iridescent border. Some of the
colonies remain small, but others continue to grow in diameter and some
become four or five times the diameter of others. They are generally
discrete at first, but on moist agar agar the colonies coalesce and form
white and opaque patches. If touched with a platinum needle the
culture is found to be of a sticky and viscid nature, adhering in strings
to the needle, and allbwing individual colonies being moved on the
surface of the medium without disintegration.
On dry agar agar slopes when the material has been evenly spread
on the surface, minute grejdsh-white translucent colonies cover the
whole surface of the medium, which presents, as a rule, a very character-
istic ground-glass appearance by reflected light obtained when the
culture is held away from the light and looked at from the back. In
a few days there will be seen to be two types of colonies, one of which
is of small size, more or less translucent and constituting the majority,
the other larger, whiter, more opaque in ap}K'arance and gradually
changing to a slightly yellowish-brown colour as it increases in size. The
latter are the giant colonies, or cannibal colonies described by Haflfkine.
G— 2
84
Fjfuh miolofiij of Plaf/ne
[part II
» •
••••
•• • •# •
Early stages of involution forms
of plague bacillus iHaffkine).
Intermediate involution forms of
plague bacillus (Haffkine).
>9
# •
Advanced involution forms of plague bacillus (Haffkinej.
CH. iv] Involution Forms of Bacillus 85
Morphologically the two types contain the same kind of bacilli ;
possibly there are more longer bacilli in the giant colonies and more
involution forms. In sub-cultures the colonies appear earlier than in
cultures from infected tissues : they have a greater tendency to become
confluent and to form a cream-coloured growth with thin translucent
and iridescent margins possessing a pronounced crenated appearance.
Sub-cultures from the smaller colonies often show a scantier growth
than from the larger. Young colonies when examined microscopically
are found to be mainly composed of short bacilli which do not attain
the average size until the second or third day. Old colonies, especially
the giant colonies, may contain a larger proportion of longer bacilli.
The bacilli from cultures stain much more easily than those taken
Involution direct from infected tissues, and there is not the same
forms. degree of bipolar staining. Hatfkine^ found that in dry
agar agar inoculated with plague material the bacillus may undergo as
early as in 24 hours certain involution changes, so that in addition to
the short typical bacillus the culture will contain many other forms.
These bacillary forms may diverge in a small degree only from the type,
or they may become so different as to cause thera to have no resemblance
to the elements from which they are derived. Some are only enlarged
in length and breadth but do not lose their shape nor their staining
properties; others become thickened, swollen, filamented and distorted in
form, assuming bizarre figures resembling sausages, pears, spindles, clubs,
dumb-bells, biscuits, discs and other irregular globular bodies. They
stain only very slightly and irregularly and have no bipolar staining.
Vacuoles are sometimes observed. The different forms which they
assume are to be seen in the accompanying photographs and diagram.
These involution forms may develop to such dimensions as to be twenty
to thirty times the size of the ordinary young forms. In the same
microscopical specimen there will be seen every variety of shape and
size ranging fr<jm the smallest to the largest. Microbes of other diseases
vary in size, but they are usually more or less constant in their diameter.
It is not so with the plague bacillus, the diameter of which may show
very great differences in different individuals in the same specimen.
Similar differences are displayed in their capacity of staining: some stain
well and imiformly, others show the bipolar staining, others take on
only a pale colouring throughout their substance, others stain at the
circumference or only part of the circumference, and others with vacuoles
may not stain at all. According to Haffkine this power of producing
1 Brit. Medical Journal, 1897, p. 1461.
86 EpUlemiolofij/ of PlcKjue [part ii
involution forms may be lost in the laboratory after sub-culture, and
appears to be limited to recent cultures derived from plague cases. The
involution forms may not appear on dry agar agar for three or more days.
According to Hankin a 2| to '^h "/o of" salt added to the agar agar will
hasten the- ])r()ducti(jn of involution forms. Experiments with salted
agar agar on other bactei'ia do nut show the same exaggerated involu-
tion forms as are to be observed witli plague bacilli. Matzuschita^ has
shown that salted media tend to produce involution forms in bacillus
pyocyanus, the lactic acid bacillus, anthrax bacillus, and cholera bacillus.
The involution forms appear in old and dry cultures of agar and in
cultures on potatoes. They do not appear in old or fresh bouillon
cultures. Any change undergone in bouillon is that of disintegration.
The microbes under these circumstances appear to be granular, they
however retain their vitality. Involution forms are also to be found
occasionally in the tissues of human beings who have died of plague,
also in the tissues of lower animals that have been inoculated with
plague, and in animals that have died of plague contracted in the
natural way and that have been a longer time in dying than usual.
The involution forms are apt to give rise to uncertainty and disputes
at a critical stage in the development of a plague epidemic, and a
knowledge of them accordingly possesses much importance from a
diagnostic point of view. In the early period of the outbreak in Cape
Town in 1901 a number of the rats which were dying showed on
examination large numbers of bacilli which were larger than the
ordinary plague bacillus and of a biscuit shape ; mixed up as they were
in many instances with typical plague bacilli, they were obviously
involution forms of the micro-organism. The first cultures retained the
involution character and were fatal to pigeons and guinea-pigs, and
harmless to rabbits and a baboon. They however gave when cultivated
in broth the stalactite growth referred to later, and sidjsequently they
lost the involution form and approximated to the ordinary type of the
plague bacillus.
In Ixiuillon, cultures of the plague bacillus resemble those of
Characteristic "streptococcus pyogenes." The growth begins to be
growth in visible on the second day in the form of fine flocculent
bouillon. . , "
sticky masses adherent to the sides of the tube and
deposited at the bottom of the clear liquid. At times a film may also
form on the surface. Microscopically examined the cultures will be
found to contain not only bacilli single and in pairs of a coccoid
' Zeitschr. fiir Hygiene, Vol. xxxv. 1900.
CH. IY]
Stalactite Growth in Bouillon
87
character, but also short and long chains of bacilli composed of five or
more elements. These chains have often the appearance of streptococci,
but on close examination with a high power will be found to consist of
coccoid bacilli. Bacilli from young cultures stain well, and degenerative
or granular forms are not found except in old cultures. To Haffkine
is due the credit of demonstrating that the bacilli grow in a very
characteristic manner in bouillon. A few drops of oil or fat in the
form of ghee\ cocoanut oil, olive oil or linseed oil, added to the bouillon
facilitate the characteristic formation, but they are not necessary.
Bouillon so treated and sterilised, will if it is inoculated afterwards
with the plague bacillus and kept absolutely still and free from any
vibrations, show^ scarcely any signs of change during the first two
Formation of or three days. Then minute flakes appear imderneath the
stalactites. drops of oil which are floating on the surface of the
medium. These flakes, which are colonies of bacilli attached to the
drops of oil, grow, in the course of the next 12 to 24 hours, down into
the depths of the liquid in the form of stalactites which, scanty at
first, in the course of two or three days increase in number and size,
and fill up the upper half or sometimes the whole volume of the
bouillon.
' Ghee is a preparation of clarified butte
ceremonial purposes.
Haffkine's Stalactites.
r used by the Hindus as a food and for
88 Epidemioloiiy of Plague [part ii
If the Hask is shaken the stahictites fall in snow-like Hakes to the
bottom. The fluid again becomes clear, and if the culture is again
kept free of agitation small colonies will form afresh underneath the oil
globules, and once more a renewed growth of stalactites will take place
similar to the first, but slower in growth. By agitation and allowing
the flask to n-main still the process can be repeated, and a series of
fresh stalactite sfrowths can be obtained sometimes for three or four
months until the nutritive medium is exhausted. The bouillon will
then no longer be suitable for plague bacilli, which will remain alive
but will not grow in it. Sometimes when the bouillon is inoculated
direct from plague tissues, zoogieic masses of bacilli collect at the sides
of the flask and surface of the liquid, but no stalactites are formed,
lender these conditions if the flask is gently shaken the stalactites
usually appear in 24 to 36 hours.
According to Kitasato' there is a bacillus met with in plague cases
_.. . , which has not all the marked characters mentioned, but
XUb3,S3itO S
plague which when found alone resembles in many respects the
diplococcus pneumoniae. It is the one to which Kitasato
has essentially given his name. Kitasato in describing it points out
that Yersin's bacillus is larger than his, does not possess the distinctly
diplococcus appearance of the latter, is very polymorphic, does not
possess a capsule, is not motile, and is decolorised with Gram's method.
Moreover the growth of Yersin's bacillus on agar is extremely luxuriant,
and, though rather slow at first, continues for a week forming creamy
colonies projecting above the surface of the media, and only young
colonies are small and transparent. These characteristics contrast with
Kitasato's bacillus, the colonies of which are extremely delicate, trans-
parent, small discs which attain the size of a pin's head and cease
growing, and then tend to disappear on the fourth day of incubation,
presenting in all respects a close resemblance to the growth of
diplococcus pneumoniae. Kitasato's bacillus curdles milk at the end
of the second day, renders bouillon uniformly turbid at first, but
subse(piently forms fine flocculi and sedimentation at the bottom of the
test tube. This bacillus is rod-like in shape, rounded at both ends
and stains more deeply at the poles. In the glands many of them
appear like diplococci, though there is a considerable number of the
same microbes which, staining easily in the middle portion, present
distinctly bacillary forms. In the lungs, heart, brain and spinal cord
they may present an appearance like streptococci. This bacillus stains
^ "Plague," by Kitasato and Nakagawa, Twentieth Century Practice of Medicine, Vol. xv.
CH. iv] Vitality of the Bacillus 89
with Gram's method, possesses a capsule in the specimens prepared
from the blood or tissue fluids of various organs, and also in cultiva-
tions in solid serum, is slightly motile and is much more constantly
found in the blood during illness and convalescence.
It is to be noted, however, that bacteriologists to whom strains of
Kitasato's bacillus have been sent have not found all these marked
differences, and have come to the conclusion that Kitasato's and Yersin's
bacillus is the same, differing only in unimportant respects as regards
morphology and cultural characteristics as are to be observed in other
pathogenic bacilli.
Many experiments have been made to determine the power which
The vitality ^^® plague bacillus possesses of maintaining life under
of the plague unfavourable conditions. The result of these is to show
that while the bacillus is very sensitive to drying com-
bined with high temperature, yet when it is protected from these,
which must ordinarily be the case under natural conditions, it retains
its viability for long periods.
Experimenters differ in the results which they have obtained, but
the practical point is to know the longest period that the bacillus
survives under certain conditions, and accordingly most importance is
to be attached to this, which should always be taken as the safer guide.
AbeP found that plague bacilli will live in sterilised, distilled and
In different tap water for 20 days. Kasanski found it in water on the
media. 4f'^t\\ day, Wuntz and Bourge in sea water after 47 days.
Hankin ascertained that plague bacilli added to grain died out in from
6 to 13 days, Gladin- that plague bacilli will live in milk for over
8 months, and on food such as raw and coagulated albumen, turnips,
potatoes, plums, apples, cucumbers, and black bread from one to three
weeks, Stadler that the bacilli will remain alive in meat pickled for
16 days, Yokote^ that buried carcases of animals dying of plague retain
the bacillus alive for 30 days, Batzaroff^ that the organs of plague
animals, dried in vacuum for 38 days at the temperature of the room,
still contain living bacilli, and when the dried pulverised substance, so
^ Ccntralblatt fiir Bakteriolor/ic, I'drasitenkunde iind Infektionxkrankheiten, 1897.
Vol. XXI. Zur Keuntnis der Pestbacillea. Dr Eudolph Abel.
- Ihiil., 1898. Vol. XXIV. " Die Lebensfaliigkeit der Pestbacillea luiter verschiedeuen
physikalischen Bedingungeu." G. P. Gladin.
^ Ibid., 1898. Vol. xxiii. " Ueber die Lebensdauer der Pestbacillea in dor beenligten
Tierleiche." Dr L. Yokote.
■* Annales de VInstitut Pasteur, torn. xiii. p. ,38.5. "La Pneumouie pesteuse experi-
mentale." Dr Batzarotf.
90 Epidemiology of Plague [part ii
treated, was inserted into the mucous membrane of susceptible animals
it caused plague. The same observer noticed that the virulence of the
microbe in all)uniin()us tissues decreased very slowly. Faeces containing
plague bacilli and left standing at the ordinary temperature for three
days infected a guinea-pig with plague. Sputum from a pneumonic
case of plague was found to retain its virulence on the 10th day.
While the association of the streptococcus appears to exert a
stimulating effect on the virulence of the plague microbe, it has been
noticed by a number of observers that the presence of bacillus coli
communis, the bacillus subtilis, the staphylococcus and micrococcus
prodigiosus appears to exercise a retarding influence.
A gelatine plate with virulent plague bacilli upon it, which was
expo.sed in a dark and damp room, and on which saprophytic organisms
of fungi grew, was found by Simonds to have lost its infective properties
in two days. On the other hand, Gotschlich found the bacillus alive
and virulent in 8|^ months old cultures which were partially drv and
mouldy.
In broth culture Haffkine found the plague bacillus alive after
18 months. Gabritschewsky kept the bacillus in an agar culture alive
stored in a cupboard for two years, also in the pus w^hich was taken
from an infected guinea-pig and sealed in a tube. Pure cultures^ of
the plague microbe protected from drying have been known to retain
their viability for four years if protected from sunlight and kept in a
cool place. Klein- has recently reported that the bacillus obtained from
the fatal case of plague in the London Docks in 1896 still retains a
fair degree of virulence in sub-cultures ; such retention of vitality and
virulence in .sub-cultures has to be distinguished from that obtaining in
old and unrenewed cultures.
Even under intense cold the bacilli may thrive : thus Kasansky^*
showed that cultures placed outside his laboratory at
Effect of cold. . . ^ , 1 ■ , •
Kasan during the winter, and which were subjected to
temperatures ranging between 2°C. and — 31'' C. below zero for periods
of 3, 4, and 5^ months, retained their viability and were only weakened
in their virulence. Similarly at St Petersburg bacilli remained alive
at temperatures of zero and — 20" C.
' Centralbl. f. Bakt. 1901. Vol. xxix. " Ueber die Lebensdauer von Bacillus pestis
hominis in Reinkulturen." N. K. Schultz.
- Medical supplement to the 32n(l Report of the Local Government Board for 1902-1903,
p. 402.
3 Centralbl. f. Bakt. 1899. Vol. xxv. "Die Einwirkung der Winterkiilte auf die Pest-
bacillen." Dr M. W. Kasansky.
CH. IV J Vitality of the Bacillus 91
The capacity of the plague microbe to survive exposure to intense
cold is much g^reater than its power to withstand the
Effect of heat. ^- ^ • , , i • i t i
enects of mtense heat whether moist or dry. in regard
to the effect of heat on the plague microbe there is much difference
in the results obtained by different observers, the time required for
destroying the vitality of the microbe not being constant and differing
in some important particulars. The difference in time and the differing
results may be due to the different methods employed, and to the
probability that in some of the experiments the vessel containing the
plague bacilli was not wholly submerged and subjected to the tem-
perature stated. For instance in some experiments a temperature of
80° C. has killed the bacillus in five minutes, in others it has required
15 minutes. Abel observed that with 50° C. more than an hour was
required for sterilising cultures. Toptschieff\ on the other hand, found
that from two to four hours were required with a temperature of 50° C.
to destroy the vitality of the bacillus. Kitasato killed the bacillus in
half-an-hour with a temperature of 60° C. Yersin sterilised cultures of
the bacillus by maintaining them at a temperature of 58° C. for an
hour, but Albrecht and Ghon after heating cultures for an hour in a
water-bath at 55° C. to 60° C. found that all the microbes were not
destroyed and that it was possible with the microbes thus subjected to
these temperatures to produce plague in animals.
According to Haffkine after a quarter of an hour's exposure to a
temperature of 45° C. an agar or bouillon culture of plague bacilli is no
longer cultivable ; and as a matter of routine practice the plague
prophylactic is sterilised at a temperature not higher than 55° C.
continued for only 15 minutes. The microbes are killed at once when
exposed to a temperature of 100° C. moist heat, and this is the tem-
perature to which plague-infected articles should be exposed. Dry
heat requires a higher temperature and a longer exposure of the
bacillus to be destructive. Dry heat will destroy the vitality of the
plague bacillus, as shown by Gladin, in one minute at a temperature of
160° C, in five minutes at 130° to 140° C, and in 20 minutes at a
temperature from 100° to 110° C. The effect of the direct rays of the
sun is rapidly injurious to the vitality of the plague
Effect of sun. . t tt i j t j- 1 ^u '
microbe. In Hongkong and India, where the sun is
strong, experiments by Kitasato, Wilm, and the German and Indian
Plague Commissions establish the fact that plague bacilli exposed in
1 Ibid., 1898. Vol. xxiii. p. 734. "Beitrag zum Einfluss der Temperatur auf die
Mikroben der Bubonenpest." F. J. Toptschieff.
92 Epidemiolofiji of Plague [part ii
thin layers to the direct rays of the sun have their vitality destroyed in
the course of a few hours ; usually one hour suffices, but it depends on
the thickness of the layer. The devitalisation of the microbe takes
longer if the bacilli are protected by a covering or by the interstices of
woollen or other textile fabrics.
Agar or broth cultures of plague exposed for three hours to direct
sunlight in Bombay grew with difficulty when transferred to new
culture media, but were only killed after exposure for the whole day.
In temperate climates the effijct of direct sunlight is slower in its
action, and exposure of cultures for six hours by Albrecht and Ohon
had no injurious action on the microbes.
The bacilli are very sensitive to rapid desiccation ; plague bacilli on
cover- glasses placed in a desiccator containing sulphuric acid or chloride
of calcium are destroyed in a few hours. The bacilli are more sensitive
to drying at a high temperature than at a low temperature ; drying at a
Effect of temperature of S5^ C. will according to Abel's experiments
drying. j^-u ^j^^ bacilli in two to three days, while drying at 16° C.
to 20^ C. will not destroy them until the 6th and 9th day, and on one
occasion the bacilli remained alive till the 14th day.
When Kitasato dried the contents of buboes on cover-glasses and
kept them at a temperature of 28^ C. to 30° C. the vitality of the bacilli
was destroyed by the 4th day. The power of resistance to drying was
increased w'hen thread or small pieces of material were impregnated
with plague cultures or infectious matter. According to the Indian
Plague Commission, laboratory experiments under the ordinary atmo-
spheric conditions of Bombay do not demonstrate any great increase of
resistance or any long survival of the microbe when exposed to darkness
or diffuse sunlight.
Cotton, silk, wool, linen, glass, blotting-paper and gauze, impregnated
with pure cultures of the plague bacillus, with sputum from j)neumonic
plague, with emulsion of plague organs, or with peritoneal Huid from a
plague-infected guinea-pig, were found by the German Commission to
be non-infective in eight da3's, i.e. the ])lague bacilli did not survive
more than eight days in these materials under ordinary atmospheric
conditions. Moisture under certain circumstances is rapidly injurious
to the vitality of the bacillus. Ficker observed that alternate damping
of the bacillus during the process of drying hastened its death. By
such a process the bacilli were killed in from 20 to 28 hours, whereas
by drying only in the desiccator they lived for eight or nine days.
A hot and moist atmosphere will not only cause the death of the
CH. iv] Varyhig Virulence of the Bacillus 93
bacillus but will destroy its structure. The writer dried and fixed a
large number of specimens of bacilli on cover-glasses in Hongkong and
kept them in cardboard boxes. By the time they reached England
none of the bacilli would stain or could be detected. Their bodies had
evidently been macerated, disintegrated and destroyed by the moisture
of the air to which they had been subjected. Experiments on silk, wool,
cotton, cloth, etc. in Europe have shown that the bacillus may survive
45, 56, 60, and 76 days. The Indian Plague Commission also found the
plague bacillus to survive on calico for a period of 70 days.
Experiments in Sydney by Dr Tidswell' to ascertain the extra
corporeal viability of the plague bacillus on various sterilised materials
demonstrated that the plague bacilli died out in periods varying from
less than one day to three weeks, the longest being when the culture
was mixed with dust, cotton, and straw respectively and slowly dried.
A most interesting observation, and one which is of the highest
importance in its bearing on the possible long duration of the survival
of plague bacilli, is that which was carried out by Kitasato in Japan
when plague was imported into Kobe in 1899. It was suspected that
the plague had been introduced by a ship which had arrived at Kobe
with a consignment of cotton goods from Bombay : among these cotton
goods were some dead rats. It is not known how long the rats had
been dead.
Two hundred culture tubes were inoculated with portions of the
cotton and in two plague bacilli were grown and isolated.
The virulence of the plague microbes often decreases in some
Variation in cultures, while in others it apparently not only retains its
virulence. virulence but increases in intensity. The cause of the
variation is unexplained.
Batzaroff'^ succeeded in increasing the virulence of a broth culture of
the plague bacilli, which had lost its power of killing a rat and a guinea-
pig even in large doses, by depositing a portion of the culture in the
nostril of a guinea-pig. In eight days the guinea-pig died of pneumonic
i)lague. Then, by inoculating a series of guinea-pigs he was able by
the third or fourth transmission to raise the virulence of the microbe to
the degree of causing death in three days. An atmosphere containing
3 per cent, of carbonic acid gas and 97 per cent, of ordinary air at 80
1 Further observations on the mode of Infection. By Frank Tidswell, M.B. Embodied
in the Report of the Board of Health on a second outbreak of Plague at Sydney, 1902.
By J. Ashburton Thompson, M.D., President.
■■' Anilities lie I'liisiitnt I'nsteitr, 1S99. Tom. xm.
94 Epklemiolocin of Plague [part ii
to 88' F., also an admixture of 14 jjor oi-nt. of carbonic acid and 86 j)er
cent, of ordinary air at 92' F., were found by Marsh^ to enhance the
growth and the multiplication of the plague bacillus, and that under
this treatment the bacillus increases in virulence and retains its vitality
for a long time. From these experiments it is concluded that probably
the vitiation of the atmosphere, which is produced when the ventilation
of a room occupied by human beings is inadequate, is capable not only of
stimulating thi- reproduction of the jjlague bacillus but also of increasing
its virulence. Other experiments indicated that a deficiency in the
amount of oxygen is favourable to the vitality of the plague bacillus.
By passage through one species of animal the general result seems to be
an increase of virulence for that species, but a diminution of virulence
for other species.
Experiments on the duration of the vitality and virulence of the
plague microbe, though contradictory in some respects, may be taken as
indicating that, though under certain laboratory conditions the microbe
is very sensitive to atmospheric and microbic influences when the
influence of sunlight and moderately high temperature come into play,
yet under other conditions of darkness and low temperature it displays
a prolonged power of resistance and retention of virulence.
When cultures or infectious material in the dark can retain their
vitality and virulence for two and four years, it is not beyond the bounds
of credibility for certain infected articles under favourable conditions
to retain their infection for a long time, and that some of the older
observations, such as that of a rope used for letting down plague
corpses into the grave retaining infection for a long time and causing
a fresh outbreak, may not be discarded as impossible.
It has already been stated that the inoculation of susceptible animals
with the plague bacillus obtained from pure cultures causes
plague ba- certain symptoms ending in death, and that the bacillus
ciuus on jg ao^ain recovered in pure cultures from the blood and
animals. . " '■
internal organs of the affected animal. The laboratory
animals experimented on have been generally rats, mice, guinea-pigs
and rabbits. Inoculation of any of these with the plague microbe
causes a definite illness in them, followed usually by death in a few
days.
A guinea-pig inoculated with the plague microbe or with a portion
of the bubo, or the organs of a plague patient, usually becomes drowsy
and disinclined for food within 48 hours. After this period it remains
1 Report of the Ind'uui I'lniiiie (Joininission. Vol, iii. ji. 73, also Vol. v. .Vpp. iii. p. 480.
CH. rv] Vari/ing Effect of the Bacillus 95
huddled up in its cage with back arched, staring coat and half-closed
eyes, unwilling to move even when disturbed, and sometimes breathing
in a laboured manner. Towards the end it falls on its side, suffering
at intervals from tremors or convulsions, and dies in the course of the
fourth or fifth day after inocidation.
The post-mortem appearances show haemorrhagic infiltration with a
good deal of effusion at the seat of inoculation, the parts being oede-
matous for some distance from the point of inoculation. The adjacent
glands are congested and swollen, having a sanguinolent effusion around
them. The lungs are generally normal, but they may show pneumonic
patches, the heart is congested, the blood is fluid and darker in colour
than usual, the liver is mottled and congested. There are also small
petechial haemorrhages in the lungs, heart, spleen, and kidneys, as well
as in the pericardium, peritoneum and parietal pleura. The intestines
are not generally much affected. The whole appearance is one of
engorgement with dark fluid blood. Plague bacilli are to be found in
the blood, liver, and spleen, and may at times be found also in the
lungs and kidneys.
Mice and rats inoculated usually show signs of illness within 48 hours
and present much the same symptoms as those described as occurring
in the guinea-pig. The course of the disease is as a rule more rapid,
death occurring on the third day. The post-mortem appearances are
similar to those found in the guinea-pig.
The length of illness may vary in the animals inoculated, but death
generally occurs in mice in from one to three days, in rats from the
second to the fourth day, in guinea-pigs in two to five days, and in
rabbits in from four to seven days. A chronic form of plague may occur
in rats and guinea-pigs in which the animal does not die, or dies only
after several weeks or longer, and then often in an emaciated condition.
In this form the affected glands are usually found in a cheesy condition.
There are small areas of necrotic tissue in the several internal organs,
and the spleen is generally much enlarged. Only few bacilli are to be
found, but the tissues containing them, if administered to a healthy rat
or guinea-pig, will reproduce the disease.
^
CHAPTER V.
THE RELATIONSHIP OF EPIZOOTICS TO PLAGUE.
The results obtained by the experiments on laboratory animals were
Rats and mice ^^ greater import than merely affording evidence that the
susceptible to plague microbe causes a disease in them, and can be again
plague infec- recovered from their tissues. They proved that rats and
*^°°- mice were susceptible in a high degree to the plague
microbe, and suggested an explanation of the phenomenon which has
been observed from the earliest times,/and which has often accompanied
an epidemic of plague, viz. a sickness and mortality among rats and
mice. They directed attention to the rat mortality then accompanying
plague in Hongkong and to the examination of some of the rats, with
the result that the same microbe Avas discovered in the sick and dead
rats as in human beings affected with plague. Morphologically and
culturally these microbes are not to be distinguished from one another,
and their action on other animals is the same. The epizootic among
rats, which has been observed to prevail in nearly every outbreak
of plague in different countries, during the existing pandemic has been
proved by bacteriological examination to be plague.
That a relation exists between certain epizootics and epidemics of
„ , ,. ^. plague has been a current belief for many centuries. The
Relationship ^ . .
between epizootic was generally looked upon either as a sign of
zootics^and C(»ming plague or as the actual disease attacking animals
epidemics of precedent to its affecting human beings. This latter view
current belief '•'* \ii^'\d by the Chinese at the present moment and led,
for many by those who held it, to the doctrine that plagfue is a
centuries. -i • .
soil disease attacking first the animals which burrow in
the ground.
The relationship is not so clear as the many t'xamples cited in
hi-stoiy- would indicate, for plague in the early periods was confused
CH. v] Epizootics and Plague 97
with many other pestilences, and the confusion applied to animal diseases
as well. Epizootics occurring at a period when plague prevalence was
common at the same season of the year would likely be taken to be
connected in some way with plague, but that they were frequently not
related to that disease, nor even a sign of a coming plague, may be
gathered from the fact that in periods when plague was quiescent or
not existing in the country there had been similar wide-spread and
fatal epizootics of various kinds, which destroyed immense numbers of
cattle, and which were called cattle plagues because of their fatality
and the extensive range of their devastation. The designation is
retained even to-day for diseases known to have no relation to plague.
Rinderpest, for example, is a term which is applied to a number of
diseases not yet differentiated and classified, and includes small-pox,
haemorrhagic septicaemia, plague, and other infective diseases of
animals. In Rhodesia at the present day there prevails a devastating
epizootic called tick fever, or red water fever, which is destroying the
cattle of the country and which is caused by a sporozoon. Before
the microscope came into use for the diagnosis of cattle diseases
Observations this epizootic would not have been differentiated from
of epizootics other infectious diseases of cattle, and consequently the
associated ... n ■ • • i • c \ •
with plague relationship of epizootics to epidemics of plague m any
epidemics. particular case in the past must be doubtful.
With the discovery of the plague bacillus in the rat the relation-
ship of at least one epizootic to plague is established. It is the
epizootic most frequently mentioned with plague. The first reference
to it is in Syria some 3000 years ago, when the Philistines at war with
the Israelites were attacked with plague, and they made golden images
of their emerods and of the mice that marred the land^
Avicenna recognised a connection in Mesopotamia and refers to the
fact that on the approach of plague mice and other animals, which
usually live underground, leave their holes and move about in a stagger-
ing manner as if they were drunk. The inhabitants of Hindustan were
at one time familiar with the connection between rat mortality and
plague, for in the Bharjavatd Purano, written more than 800 years ago,
they are instructed to leave their dwellings immediately they notice a
mortality among rats.
In the Great Plague of 1848 other animals besides rats arc mentioned
as having been affected. Nicephorus Gregoras''^ says : " Nor was it
' 1 Samuel vi. ver. 5.
- Nicephori Gregoiae Historiae Byzuntinae lib. xvi. cap. 1.
98 Epidemiolocm of Plague [part ii
mankind alone that the plague thus harassed as with a scourge, but all
other animals that dwell with or associate with human hoings took the
disease; dogs and horses and fowls as well, and even the mice that lived
within the walls of their houses." This is corroborated by the Emperor
Cantacuzine, who stated that even the domestic animals were carried off
with plague. A Paduan chronicler' says of the epidemic of 1347 that
once the sickness entered a dwelling, all were seized by it, even the
animals. When Holstein^ was attacked in 1350 with a grievous bubo
plague it raged both in the case of man and in that of cattle.
When the plague reached Avignon* it is recorded by Baluze that
even the animals in the place, such as dogs, cats and hens, died. In
Toumay^ the mortality was especially great among the chief people and
the rich, as well as the poor. Deaths were more numerous about the
market-places and in poor narrow streets than in broader and more
spacious areas ; and whenever one or two people died in any house,
at once, or at least in a short space of time, the rest of the household
were carried off, so much so that very often in one home ten or more
ended their lives together, and in many houses the dogs and even
cats died.
At the time when the epidemic prevailed in England-' there was
according to Knighton a great mortality of sheep, so much so that in
one place there died in one pasture more than 5000 sheep, and they
were so putrid that neither beast nor bird would touch them.
Similar accounts are given by Arab authors® as to its attacking
animals and birds which ate the flesh of infected bodies that had not
been buried.
Rats, moles, serpents, conies, foxes, badgers, martens, and adders
are mentioned by later writers as having been observed to die before,
or during plague epidemics, and the appearance of these in unusual
numbers was usually considered to be the harbinger of plague.
Skeyne'', in 1568, gives as a sign of impending plague the moles and
serpents leaving their holes, "as quhan the moudeuart and serpent leauis
the Eird beand molestit be the Vapore contenit within the bowells of the
samin"; also he states, "quhan the domesticall foulis becummis pestilen-
tiale, it is ane signe of maist dangerous pest to follow."
' The Great Peatilence, 1348-9, F. A. Pasijuet, 1893.
2 Ibid. ■■' Ibid. * Ibid. 5 iiia^
* Histoire des Hiiuk, Vol. v. p. 224. J. <le (iuignes.
^ " Ane Breve Description of tbe Pest, p. 10, by Maister Gilbert Skeyne, Doctoure in
Medicine, Edin. 1568." Edited by W. F. Skene and presented to the Bannatyne Club, 1860.
CH. v] Rats and Plague 99
In treating of the plague in London, Lodge ^ mentions rats and
moles and other creatures, accustomed to living underground, forsaking
then- holes and habitations, and attributes it to corruption of the soil.
Dr Hodges^ in writing of the Great Plague of London of 1665, says
" that subterranean animals, such as moles, mice, serpents, conies, foxes,
&c. as conscious of approaching mischief, leave their burrows, and lie
open in the air which is also a certain sign of a pestilence at hand."
It must be noted, however, that no mention is made of epizootics in
accounts of many of the epidemics of plague in European cities, though
it is curious that in most, rats, dogs and cats are ordered to be
destroyed. Dr J. F. Payne informs me that in the plague on the Volga
in 1878 and 1879, which he and Dr Colville investigated, a large
mortality among rodents was observed, but its relationship to the
epidemic of plague did not impress him at the time. Now he is
inclined to think that the association was very intimate.
In the Kathiawdr epidemic in India of 1820 mortality and sickness
in cattle is referred to, but was believed to be due to other causes.
On the other hand, Dr Forbes'' mentions that in the Pali plague of
1836-38 the plague was preceded by a great mortality among the
cattle, and that the most singular phenomenon was the death of all the
rats in the village of Taiwali during the latter half of April, and
just before the plague's first appearance. Mr White reports, " they lay
dead in all places and directions in the streets, houses, and hiding places
of the walls," and " this death of the animals attended or preceded the
disease in every town that was attacked in Marwar, so that the
inhabitants of every house instantly (juitted it on seeing a dead rat."
The epidemic which prevailed in Kumaon, one of the endemic
centres in India, in 1834-5 was, according to Mr Gowan, the Com-
missioner, preceded or accompanied by a great mortality of rats in
the village. The same phenomenon was observed and commented
on by Drs Planch, Francis, Pearson, Hutcheson and Thompson in
several of the later outbreaks of plague, or Mahamari as it is called
by the natives, in Kumaon and Gharwal.
In Yunnan in Western China, another endemic centre of plague, it
is to be gathered from the reports of the French Missionaries who
have resided there, and from M. Rocher who visited the province.
^ A Treatise of the Plague, by Thomas Loilge, Doctor iu Physics, 1603, cap. iii.
2 Loimologia, or an Historical Account of the Plague in London in 16(55, p. 42. By
Nathaniel Hodges, M.D.
** The Nature and History of Plague as observed in the North-Western Provinces of India.
By Frederick Forbes, A.M., M.D.
7—2
100 Epidemiologn of Plague [part ii
that a rat mortality preceded the several outbreaks of plague', and
that other animals, great and small, such as buffaloes, oxen, sheep and
deer, and sometimes also court-yard fowls, died of the disease.
Mr Davenport'-, who was in Yunnan a few years later, mentions cats,
rats, mules, and other quadrupeds as being affected.
Mr Baber, of H.B.M.'s Consular Service, in his Notes on the route
of Mr Grosveiior's iHi.ssion in Western China, Yurnum, refers to the
mortality among rats and poultry, pigs, goats, ponies and oxen.
Dr Lowiy states* that in nearly every house in Pakhoi, where plague
broke out, rats were observed to come out of their holes and die on
the floor.
Coming to the present pandemic, a large mortality of rats was
noticed in the first affected quarters of Canton before the plague
appeared among human beings. Later on, the appearance of affected
rats in portions of the city hitherto immune was the signal of the
approaching disease, and residents who could afford to do so moved to
the suburbs, or went to live in boats moored in the river. In Canton
there is a very large boating community which remained for the most
part free of plague. This comparative immunity of boating people was
observed also in Hongkong, and has been noticed in the older epidemics
of Europe. In the great epidemics of London many of the inhabitants
took up their residence in boats, because of the freedom from plague
which the boat population enjoyed. The great mortality among rats in
Canton may be judged from the fact that 22,000 rats were taken out
of one gate of the city and buried. In Hongkong there was a great
mortality of rats during the plague epidemic of 1894, and the same
occuiTed in the subsequent annual recrudescences.
The same seasonal influences have a corresponding effect on the plague
epizootic and epidemic. From the chart for Hongkong in 1900 pre-
pared by Dr Clark, Medical Officer of Health for Hongkong, and
reproduced on the opposite page, it will be seen that the rise and fall
in the epizootic is similar to the rise and fall of the epidemic. The
very rapid rise in the rat mortality antedates the epidemic outbreak for
several weeks ; it reaches its maximum a week or so before plague and
declines with the plague mortality.
In 1902 the examination of rats for plague was carried out in
Hongkong on a most extensive scale by four bacteriologists engaged on
no other duties. It resulted in demonstrating that the great majority
' La Province CkhioiHe de Yiiniiiin. E. Rocher, Paris, 1879.
2 Commercial Reports from His Majesty^s Conxuls, Chiii/i. No. 2, 1877.
^ Notes of an epidemic disease observed at Pakhoi in 1882. Imperial Maritime
Customs Medical Reports, China, for the year ended Sept. 1882. June, 1883.
CH. V]
Rats and Plague
101
of plague cases in Hongkong in 1902 was preceded by rat plague. A
further enquiry on the same lines by Dr William Hunter^ for 1903 con-
firmed this relationship. The results for 1903 are shown in the chart
Week STH. 9th. 10TH.11th.12TH.I3th.14th.15th.16tH.I7th.18TH.19TH.20tH.21ST.22nd.23rD.24th.25th.26tH.2''TH.28TH.29TH.SQTH.31st.32nd.33ro.34th.35TH.
OF
CTED
,400
,300
,200
,000
,900
800
T\
•-
'•
•_
i
\
/
A
/^
1
r*'
A
A
,700
,600
,500
400
•
n
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on the next page, which at the same time shows that the plague in rats
continues to exist at a low level throughout the non-epidemic period of
plague. The epizootic rises at the season when young rats are most
numerous.
Governed by the same seasonal conditions, the plague epizootics
differ in time only from the plague epidemics, preceding them slightly.
' A Research into Epidemic and Epizootic Plague. By William Hunter, Government
Bacteriologist, Hongkong, 1904.
102
Ejndeniwlodjj of Plague
[part II
The precedence of the epizootic among rats which is exhibited in
the charts has been observed also in the villages and towns of China.
In an extensive enquiry made by the writer^ among European medical
men practising in Southern China and among others conversant with
plague in the villages, into the occurrence of epizootics before or during
times of plague, it was ascertained that the opinion was practically
unanimous that the rat mortality is a precursor of plague. Not only is
this opinion held by the medical men in Southern China experienced in
1 Report on the Cannes and Continuance of Plague in Hongkong. By W. J.
Simpson. M.D., 1903.
CH. v] Rats and Plague 103
plague, but it is also entertained by the Chinese whose villages or towns
have been attacked with plague.
Dr A. Lyall^ of Swatow, in referring to the order of occurrence in
plague, states, " It is generally recognised by the Chinese that rats die
first. During the year I have often been told that ' men are dying in
such and such a street ; rats have begun to die in another street, men
not yet.'" In Taiwan, Formosa, Dr J. Jj. Maxwell's experience was that,
shortly after hearing that rats were dying in such and such a house, he
would be called to a case of plague in the same house.
In Uganda, recently discovered to be a separate focus of plague,
Koch states that plague in man is preceded by plague in rats, and that
the natives of Kisiba leave their huts on this sign.
Mice as well as rats are sometimes, but not often, observed to be
affected during a plague epidemic. According to Yamagiva mice died
of plague during the epidemic of plague in Formosa. The same
phenomenon was observed at Yedda in 1898 when the plague was there.
Previous to the appearance of the epidemic of plague in Bombay, a
heavy mortality occurred among cattle, sheep, and goats. What the
exceptional mortality was due to was never ascertained. Pigeons
and cats also sickened and died during the epidemic. The most
conspicuous epizootic, however, was that which prevailed among
rats, and which bacteriological examination proved to be plague.
It broke out near the docks and gradually extended to other parts
of the city. It preceded and ran concurrently with the epidemic
of plague, and was accompanied by a great migration of rats from
locality to locality, evidently induced by alarm on the part of these
animals. In the town of Mandive^ the inspector reported that in
nearly 50 °/o of the houses he disinfected, he found dead cats and rats.
The epizootic among rats was observed in most of the towns and
villages of India in which plague became epidemic. The same phe-
nomenon presented itself in the Mauritius, Alexandria, Oporto, Naples,
Cape Town, Port Elizabeth, East London, Durban, and in Sydney and
Brisbane, precedent to and concurrently with plague prevalence.
Rats when they sicken with plague leave their holes and generally
Plague- come out into the open. They look ill and are in a dazed
stricken rats, condition ; their eyes are watery, their coats are partially
their appear- . , ^ , ■ , , i i i , • i i-/y. i i
ance and deprived 01 hair, and they hobble about with dimculty and
behaviour. stagger and fall. The nervous system is affected, showing
itself most often in lethargy, sometimes in paralytic symptoms and
sometimes in great excitement. They either make very little attempt
1 Simpson, Ihid. ^ The Plague in India, 1896-98. Nathan, Vol. n. p. 222.
104 Epidemiolofiy of Plague [part ii
to escape when approached, or they may rush about madly or caper
round the room, and their behaviour is so extraordinarily different
from what is usual that the illness from which they are suffering may
be at once suspected.
The glands of plague-infected rats, especially the submaxillary and
praesternal, are enlarged, and these, together wuth the internal organs and
blood, contain plague bacilli. The tissues are congested and of a dark
colour, and as a rule have a sodden or macerated appearance. The lungs
are congested, exude on section frothy blood, and at times contain
pneumonic patches. The spleen is generally enlarged and engorged
with blood ; the liver is also enlarged and presents in portions of it
a mottled appearance. There are petechial haemorrhages on all the
internal organs and under the pleura and peritoneum. The plague
bacilli on smear preparations often vary in appearance according to
whether the rat is examined immediately after death or later, or has
suffered from an acute or chronic illness. In the case of delay in death,
or in examination, the bacilli are often found to have undergone
involution changes.
Cats suffered from illness, accompanied with buboes and wasting, in
Cats affected Bombay, Karachi, Ahmednagar and Baroda. The Austrian
with plague. Commission caused plague in three cats by feeding them
with the bodies of animals dead of plague. One eat took the disease in
an acute form, while the other two took it in a chronic form, having
buboes on the neck and wasting.
In Cape Town there was also a great mortality among moles, but as
these animals were not examined bacteriologically it cannot be definitely
stated that the mortality was due to plague. Cats also contracted
plague as proved by post-mortem examination and bacteriological
examination, but not in great numbers. The type of plague was bubonic,
affecting the glands of the neck and the submaxillary glands. There
was sometimes extensive infiltration below the jaw, extending down to
the neck.
The post-mortem appearances met with in the cats are as follows ^
Cat I. Found dying in the street. Post-mortem showed glands in neck and
throat much swollen and filled with well marked plague bacilli. Lungs congested
and pneumonic, liver healthy, spleen healthy, mesenteric glands much enlarged but
not congested, subraaxil'ary glands much enlarged but not congested.
Cat II. Submaxillary glands enlarged, spleen enlarged, liver normal, glands
along vertebrae enlarged, axillary and groin glands enlarged, blood dark in colour,
bacilli in blood, enlarged glands and spleen.
' The post-mortems were made by Dr Robertson, Pathologist to the Cape Government,
in the presence of the author.
CH. v] Cats and Plague 105
Cat III. Submaxillary glauds enlarged and congested. The praesternal
lymphatic glands much enlarged and congested. Right lung presents patches of
acute lobular pneumonia. Heart blood fluid and dark in ap[)earance, li\er much
enlarged, clayish colour, spleen much enlarged, moderately firm in texture and
congested, kidneys normal, intestines much inflamed in condition of enteritis.
There is a general inflammatory condition of the respiratory and digestive organs.
Inguinal glands congested, plague bacilli in the glands.
Cat IV. Cat found in a house, ran a little distance and then fell down dead.
Submaxillary glands greatly swollen, great oedema of the subcutaneous cellular
tissue of neck, mesenteric glands enlarged and congested, glands in the groin and
praesternal swollen and congested, with oedema in the surrounding cellular tissues,
spleen normal, digestive system normal, lungs with patches of pneumonia, plague
bacilli in lungs and glands.
Cat V. Identical lesions to that of Cat I V. and typical plague bacilli, but not so
numerous.
Cat VI. Cat which had died after having been noticed to be sick for four or
five days. There was extensive necrosis of the tissues of the lower jaw. Post-mortem
showed submaxillary glands very much enlarged, periglandular tissue oedematous,
and veins over glands dilated. Praesternal glands on left side below pectoralis major
were enlarged and pink ; lungs were congested, heart distended, liver dark, soft, and
easily broken up, spleen not enlarged, kidneys very large and congested. Plague
bacilli were found in glands and in lungs.
Cat VII. Found dead in a house. The submaxillary glands were much
enlarged and there was an extensive infiltration of the colourless fluid into the
subcutaneous tissue below the jaw and extending down to the neck, plague bacilli
present in the glands, and infiltration.
Cat VIII. Found in a moribund condition in a house in which there was plague.
The expression in the cat's face is almost typical, head being triangular in shape,
owing to great swelling below jaw, lips thickened and eyes nearly closed.
On post-mortem the submaxillary gland on right side was yellow in colour and
foci of pus were formed. The condition of the gland on the left side was not so
advanced, but on section was soft. Surroimding the glands was much yellow fluid.
The surface of the glands was of a deep red colour, and the vessels were dilated.
There was a very large soft congested gland on either side in praesternal region.
The liver, spleen and abdominal organs were normal. The lungs were congested
but not pneumonic. The heart contained some pericardial fluid, and petechia were
on its inner surface, plague bacilli in buboes and tissues.
Cat IX. Killed because looking ill. Glands under jaw much enlarged, right
submaxillary gland on right side suppurating. Plague bacilli present.
Cat X. Found ill in empty house. Submaxillary lymphatics much enlarged,
contain plague bacilli.
Cat XI. Found ill in street. Submaxillary glands very large and haemorrhagic,
contain plagvie bacilli.
Cat XII. Found dead in .street. Submaxillary glands enlarged and haemor-
rhagic, praesternal gland enlarged, plague bacilli present.
106 Epidemiology of Plague [part ii
Dr William Hunter' records a small outbreak of ])lague among cats
in a warehouse in Kowloon, in which rats had been previously dying of
plague. In the course of his investigations he found that rats fed on
paddy soaked in the faeces or urine of plague-infected cats died of
acute rat plague. The post-mortem appearances of cat plague were,
in Hongkong, extreme congestion of all the tissues and organs, congestion
of the lymphatic glands with the presence of cortical haemorrhages, and
frequent bubonic swellings about the neck and the mesentery ; but, as
pointed out by Dr Hunter, the most interesting condition was found in
the abdomen. The peritoneum was smooth and shiny. Very little
fluid was found in the peritoneal cavity. The stomach was con-
gested, particularly on its mucous surface which showed innumerable
haemorrhages of varying size! No actual ante-mortem ulceration was
found. The small intestine was in general reddened. The ileum was
the seat of many small petechiae scattered through its entire length, the
mucous surface of which was reddened and thickened. The thickening
was chiefly due to oedema. The solitary follicles were visible, being
pin-head in size and greyish-yellow in colour. Small areas of necrosis
were present which appeared chiefly about the regions of haemorrhagic
extravasation.
In one or two cases a distinct bubonic formation was found in the
mesentery. Plague bacilli were found scattered throughout the body,
and were specially abundant in the lymphatic apparatus and in all
bubonic areas. The faeces and the urine also contained plague bacilli.
Dr Hunter also observed cases of chronic cat plague, in which the cat
became extremely emaciated, with the formation of buboes in various
situations of the body, especially about the neck. The buboes are very
chronic in growth, accompanied by extreme surrounding infiltration, and
slowly break down with the production of thick creamy pus. The animals
may live from two weeks to a month. It is a marasmus, and is well
described by the term " Pest Marasmus."
Other animals such as pigs, goats, cattle, sheep, fowls and rabbits
suffer from plague as well as man.
In Newchang"^, in the plague epidemic of 1899 two months after the
other animals first recognised cases of plague and at a time when many
piag-ue deaths were taking place, in the houses and shops in close
' A Research into Epidemic and Epizootic Plaijue. By William Hunter, (Tovernmeiit
Bacteriologist, Hongkong, 1904.
^ Imperial Maritime Customs Medical Report for half-year ended 30th Sept. 1899, 58th
issue, 1900. Dr C. C. Burgh Dal>'.s Report on the health of Newchaiig.
CH. v] Dogs and Plague 107
proximity to foreign residences it was noticed that rats, chickens,
ducks, geese, pigs, dogs, deer, and cattle were dying in unusually
large numbers.
Dr Michoud, in describing the epidemic of 1893 at Mengtze in Yunnan,
says, " We saw on some roads dogs and pigs feeding undisturbed on
corpses which no one cared to bury. These animals fell victims to their
voracity and succumbed to the scourge'."
Dr J. P. Maxwell, of Changpo in the province of Fokien, mentions
the fact of dogs occasionally dying with glandular swellings during the
plague epidemic ; he had seen four. Surgeon-Major Lyons of the
Indian Medical Service also reports that in the case of a dog which was
examined in Bombay there was post-mortem evidence of it having been
affected with plague.
In Cape Town a dog was found dying in a house. The post-mortem
examination showed the lungs to be congested and full of froth and
blood. There was lobar pneumonia. Heart was distended and full
of tarry blood. Axillary and mesenteric glands were enlarged, with
the surrounding areolar tissue congested. Liver was congested. Spleen
healthy. Kidney enlarged and congested. Plague bacilli were present
in the blood.
Additional evidence of the susceptibility of the lower animals to
Result of plague has been obtained experi men tall}'. By feeding
experiments vvith cultures of plague bacilli, by inoculation with them
to produce . .
pia^ein and by causing animals to breathe air containing plague
animals. bacilli, rodents, especially rats and guinea-pigs, have been
found to be very susceptible. The disease produced in them may be
acute or chronic. In the latter form it may exist for months. The
significance of the disease in rats will become more apparent when
treating of the continuance and spread of plague. It will at present
be sufficient to state that the role played by other rodents is small
compared with that of the rat.
As regards susceptibility of other animals to artificially induced
plague, experimenters have met with conflicting results, but in the
main the positive are more important than the negative, and as such
will be chiefly dealt with.
The following tabular statements give a summary of the experi-
ments on different animals carried out by the German and Austrian
Medical Commissions on their visit to Bombay.
1 Imperial Maritime Customs, China, Medical Reports for the year ended 30th Sep-
tember, 1894, 47th and 48tli issues, 1895
108
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Ejndemiologii of Plague
[part II
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CH. v] Experiments by Aiistrian Commission
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116 Epklemwlofiji of Playue [part ii
In view of the intimate association of the inhabitants of a great
many countries with their cattle, pigs, goats, and fowls, either in the
farm or in their houses, it is important that the question should be
decided as to whether these animals are susceptible to plague. The
Chinese belief is that cattle, pigs, fowls, as well as rats suffer from
plague, and it is in accord with the older views of Europeans when
plague was epidemic. Both the German and Austrian Commissions
failed to produce plague in oxen, pigs, and poultry. In the case of
cats the German Commission failed to produce the disease, while the
Austrian Commission succeeded by feeding. Dogs could not be success-
fully infected by feeding, but virulent plague bacilli were found in their
Haffkine's faeces. HafFkine experimented on horses, cows, sheep, and
experiments. goats by inoculation of plague cultures, but the goats alone,
without developing any acute disease, lost condition gradually, wasted
away, and after a considerable time many of them succumbed. Lowson
experimented on pigeons, ducks, crossbills, yellow-hammers, linnets
and canaries, and failed to infect them with plague. On the other hand,
Wiim's ex- Wilm ' in the Hongkong epidemic of plague in 1896 suc-
periments. ceeded in infecting a pig fed with the spleen of a man
who had died of plague ; and a number of poultry fed by him with
plague material and with pure cultures of the plague bacillus died in
3 or 4 days of plague. Piaxi and Posen'- found, when pigeons and
sparrows were starved, that they were susceptible to plague.
Further experiments on a large scale were carried out in Hongkong
Experiments ^^^ 1902 by the writer^, assisted by Dr Hunter, the Govern-
on a large ment Bacteriologist, and Dr Matsuda, a Japanese medical
scale carried ^ r^ n tt ^ ^ ^
out in Hong- nian lent to the Government of Hongkong by Japan,
kong in 1902. rpj^^ result of these experiments was to establish the
fact that calves, hens, turkeys, geese, pigeons, sheep and pigs were
susceptible to plague both by inoculation and by feeding, and that pigs
and poultry were susceptible in a high degree.
Plague material containing the plague bacillus and taken from
a plague case was employed in preference to the use of cultures of
the plague bacillus, which is more or less an artificial condition, and
it is probably to the adoption of this method that the experiments were
1 Report on the Epidemic of Bubonic Plague in Hongkong in the gear 18i)6. By Staff-
Surgeon Wilm.
■■* Revista Interna d'Igene, April, 1897.
^ Report on the Catises and Continuance of Plague in llonghung and xuggestionn as to
remedial measures. By W. ,1. Simpson, M.D., Colonial Office, 1903.
CH. V]
Experiments in Hongkong
117
attended with success. The material for experiment was always care-
fully examined before use in order to be certain of its nature. Each
experiment was checked bacteriologically and by the effect produced
by feeding rats on portions of the animal which had been experimented
on. The bacilli were isolated, and cultures of them were made, and
the effects of a few of the cultures were tested on guinea-pigs.
There were employed in the experiment 15 pigs, 7 calves, and 1 buffalo
calf, 31 hens, 7 pigeons, 6 turkeys, 6 geese, 6 ducks, 8 redbeaks,
7 monkeys, 7 guinea-pigs, and 109 rats. The result is shown in the
following statement which gives the number and percentage of the
animals that died of plague : —
Of the 15 pigs experimented on 13 equal to 86 "/o died ; of the
8 calves 7 equal to 87 "/o died; of the 31 hens 11 equal to 35 "/o died;
of the 7 pigeons all died ; of the 6 geese 3 equal to 50 "/o died ; of the
6 turkeys 4 equal to iiQ "/o died ; of the 6 ducks all died ; of the 3 red-
beaks 2 died ; of the 7 monkeys 5 equal to 70 "/o died ; of the 7 guinea-
pigs all died; of the 109 rats 727,, died.
In the case of the first 4 pigs experimented on, in which the infective
material was derived from a human being, the time was so
long before the animals showed any signs of illness that, if it
had not been that suspicion of illness arose from the daily temperatures
recorded, they probably would have been disposed of at a date anterior
to their illness and counted erroneously as failures. Of the 4 pigs first
Pigs.
Chart I.
Temperature of pig inoculated with emulsion from huho of plague case on May
31s<, and agaiii ivith emulsion of plague pneumonic lung on June 2nd.
90»
Jumt. DAus or oa5v,vArioi.i J we
Jute. D*Tt& OP oBseRvATiorts July 1
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118
Epidemiology of Plague
[part II
Chart II.
Tenvperature of fig fed with emulsion of bubo of plague case on May 3\st,
and with emulsion of plague pneumonic lung on June '2nd.
1901.
JUMt DAItS Of 0SSeM¥4Tl0mi Jwt
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Chart III.
Temperature oj a smaller pig inoculated with bouillon emulsion
of plague pneumonic lung.
1902
June dat£s of observations
2
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Cent
Fshr
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CH. y]
Experiments in Hongkong
119
experimented on 3 were fed and 1 inoculated. The 3 that were fed
died in the 5th week, while the one that was inoculated was killed in
the 5th week, the seat of inoculation having become necrosed and the
inguinal glands enlarged. The temperatures were of much the same
type, rising on the 14th or 15th day and continuing from that time at a
higher range. Of this type Charts I. and II. are examples.
The type of disease varied in intensity, however, as is seen by Chart
III., which is that of a smaller pig which was inoculated at the same
time, with the same material and with the same dose as that used for
Pig 1, the only difference being that the larger pig had had a previous
inoculation two days before with emulsion from bubo of a plague case.
Feeding with the organs of pigs which had died of plague killed in
4, 8, and 17 days. Chart IV. represents the temperature of pig that
died on the 8th day.
Chart IV.
Temperature of pig fed with the organs a,nd hlood of a pig
that had died of plague.
1902
June. dates of observations. |
II
12
13
14-
15
16
17
16
19
Cent
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120
Epidemiology of Plague
[part II
Scarification and vaccination on the abdomen of pigs with blood and
spleen pulp of other pigs which died of plague killed with plague
in 9 and 15 days; while the same process with the haemorrhagic
glands of buffalo calf dead of plague killed in 9 and 19 days. A pig,
fed with the organs of a hen which succumbed of plague, died on the
13th day.
Chart V. represents temporatui-o of pig scarified and vaccinated with
blood and spleen pulp, which died on the 9th day.
Chart V.
Temperature of pig scarified and vaccinated on abdomen ivith blood and jndp
from spleen, heart, and (/land of a pig tvJiicli had died of plague.
1302
June. dates of observations.
1 1
12
13
14-
15
16
17
18
19
20
Cent
Fahr
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The symptoms in the pig were undefined at first and nothing
indicated illness except a higher temperature than usual. The first
noticeable symptoms were slight dulness, and lethargy, though this was
often absent, congested eyes sometimes becoming very intense with
mucous discharge, great difficulty in walking, the hind legs appearing
not to be quite under control, and causing the pig to stagger and to be
very unsteady. The staggering gait is evidently due to paralysis or loss
CH. v] Experiments in Honf/konr/ 121
of co-ordinating power in the nerve centres. The appetite was good up
to the last. In some there was diarrhoea on the last day. Death as
a rule was sudden, the symptoms of serious illness being of short
duration in most of them.
The post-mortem appearances were great congestion and haemor-
rhagic condition <jf the glands ; in two cases the neck glands were the
worst affected. The large intestines were congested in those that had
been fed, in the others they were healthy. The bladder was always
congested. Plague bacilli were found in the blood, organs, and glands,
and in scrapings from the bladder. They were also in the urine, and
in the discharges from congested eyes.
In the calves experimented on the disease ran a more rapid course
than in the pig when the infection was derived from a
Calves. 1111.
human case, and was considerably accelerated when the
infection was conveyed from calf to calf The symptoms were as ill-
defined as in the pig. There was a certain amount of dulness, the
glands felt swollen and were evidently tender, and the animal lost
weight. Suddenly a comatose condition would set in. The post-mortem
appearances were those of congestion and infiltration, especially in the
region of the neck.
Chart VI. represents the temperature of a calf fed on May 29th
with emulsion of bubo from plague case and on June 2nd with emulsion
of plague pneumonic lung.
Hens fed with plague material from human plague died on the 10th,
11th and 15th day; those inoculated died on the 15th day,
Fowls.
while those inoculated or fed with material from a plague-
infected hen, or from a calf, or from a pig, or a rat, died as rapidly as the
2nd or 3rd day.
Turkeys, geese and ducks suffered from an acute or chronic form
of plague ; one type being fatal in a few days, the other in a month to
7 or 8 weeks.
An interesting experiment was the feeding of a monkey with a
banana, the inside of which was smeared with the blood of
^^^' a rat which had died of plague. The symptoms were in all
respects similar to those induced by inoculating a monkey with the same
material. Both showed a rise of temperature on the 3rd day, with
dulness, weakness and death on the sixth day. The post-mortem appear-
ances were general congestion of the organs of the body, congested glands
without any marked symptoms of enlargement and bacilli in blood and
organs.
122
Epidemiology of Plague
[part n
Chart VI.
Temperature of a calf fed rmth emulsion of bubo from plagtte case,
and 4 days later with cmidsion of plague pneumonic lung.
1902
UAf JUUE DATES OF OBSERVATIONC JUNE. |
29
30
31
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3
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6
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Another monkey fed in a similar fashion on another occasion
remained well. The positive experiment demonstrates, however, that
rat plague is communicable to the higher animals. A similar experiment
in 1896 by Wilm, in which a monkey was given a piece of sugar-cane
infected with a pure culture of the plague bacillus, and died in 5 days,
showed in the post-mortem examination a very slight swelling of the
inguinal glands, great congestion of the intestines, and sw^elling of the
mesenteric glands and of the spleen.
In another experiment a rat dead of plague, with no visible fleas
about it, but which had been opened for post-mortem examination, was
placed in a cage with a monkey. The temperature of the monkey rose
on the third day; great dulness set in at the same time, which continued
for three days, after which it lessened, and the monkey appeared to be
getting better. There was later a relapse, and death occurred on the
10th day. There were the same post-mortem appearances as in the
mt)nkey inoculated or fed with plague material, and there were plague
bacilli in the spleen and glands, but only a few^ in the blood.
CH. V]
Experiments in Homfkong
123
The exact manner in which the monkey with the plague-infected
rat in its cage became infected it is difficult to decide. It may have
been by inoculation caused by scratching, or by infection of the mouth,
the fingers of the monkey becoming infected by touching the rat ; or it
may have been possibly though unlikely due to fleas from the rat
passing to the monkey, or it may have been caused by the fleas of the
monkey passing to the rat, and then again settling on the monkey.
With the object of endeavouring to settle this point, two monkeys
were placed in specially constructed cages along with rats dead of
plague but so separated as to prevent any possibility of contact. The
cages each consisted of three compartments, the middle compartment
being separated from those at each end by rails, which, while permitting
small objects to pass between them, effectually prevented the monkey
in the compartment at one end putting his hand through to reach or
touch the rats in the compartment at the other end. The walls of the
Chart VII.
Temperature of monkey inoculated with blood from a rat dead of plague,
which had died froin feeding on the organs of a plague-infected buffalo
calf.
1902
JU M E . DATES OF OBSERVAHOHS.
13
10.
15
16
17
18
19
4
Cent.
fahr
M'.PK
»m:«i
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124
Epideunolofiy of Plague
[part II
cages were constructed of mosquito wire netting, which prevented fleas
in the cage getting outside, though they might readily pass from one
compartment of the cage to the other.
In one cage a monkey was placed in one compartment, and a rat
sick of plague in the compartment at the opposite end. This rat was
covered with fleas. Taken out three days after, there were no fleas on
it. The monkey on the 4th day had a temperature of 104-6 deg. It
became dull, did not eat, and was evidently sick, remained in a drowsy
state with its head down on its breast, and with its hand to its head ;
but after this illness had continued for nearly a week it recovered. In
the other case a monkey was placed in one compartment and four dead
rats in the compartment at the other end. The monkey on the 3rd day
had a temperature of 103-8 deg. It also became dull and drowsy and
was evidently sick, but in a few days it also recovered.
Chart VIII.
Temperature of a monkey placed in the same cage as a rat dead of plague and
which had been opened and exam,ined. Hat was quite free of fleas.
IS02
J U N B . DATES OF OBSERVATIONS
13
14-
15
16
17
18
19
70
21
Cent
Fahr
^m:pn
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CH. V]
Experiments in Hongkong
125
The temperature and course of the disease induced by the several
methods employed are seen in Charts VII., VIII., IX. and X. The type
and duration of the disease are much the same, irrespective of the
channels of infection.
Chart IX.
Temperature of monkey placed in cage, having a rat dead of plague in
adjoining cage, hut with impossibility of contact. Rat was covered with
fleas.
1902
June. July. dates of oBSEKVAnoNs.
26
27
28
29
30
1
2
3
Cent
Fahr
am;pm
am; pn
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Sheep.
A sheep fed with a bouillon emulsion of spleen from a septicaemic
case died of plague in 34 days, while another sheep fed on
blood from a calf which died of plague was affected, and died
of plague on the 10th day. The chief symptoms were difficulty of
breathing and great weakness. Post-mortem showed the spleen and
internal organs congested, glands haemorrhagic, lungs much congested,
with black patches, bladder healthy, large intestines haemorrhagic, small
intestine and stomach healthy. Plague bacilli were found in blood,
spleen, kidneys, bladder and glands.
126 Epidemiolo(jij of Plague [part ii
Three clogs fed with material from a bubo remained Avell, apart
from a rise in temperature. The German Commission and
Do&rs.
Ogata likewise failed to produce plague experimentally in
dogs. The Austrian Commission, though unable to cause illness in
dogs fed with plague-infected material, recovered highly virulent
plague bacilli from the excreta of the dogs.
Variation in susceptibility was observed in rats fed with the organs
of animals which had died of plague. Some rats took the disease
rapidly and were dead of plague by the second day ; others did not die
for a week, a fortnight, or even 3 weeks after they were fed, while
others, nearly 30 per cent., were not affected.
From the experiments it is shown : —
I. That pigs, poultry and cattle are susceptible to plague whether
derived from the infection of a human being infected with
plague, or from their own species, or from some other animal.
Sheep are also susceptible.
II. That plague among animals may be acute and rapid in its
termination, or chronic and slow in its course. In neither
case may the symptoms be very marked.
III. That the animals take the infection of plague as easily by
feeding with plague material as by inoculation.
IV. That plague material from man, pigs, poultry, cattle, and
monkeys will give plague to rats, and that plague material
from rats will give plague to monkeys by feeding, by in-
oculation, by contact and without contact ; and if to monkeys,
probably to man by the same channels.
The facility with which these animals take plague by feeding is a
very important point and it is possible that plague in man
man possibly is not infrequently contracted by the swallowing of plague-
not mfre- infected food contaminated by an infected rat, or by the
quently . ^ \ -^
caused by uncleanliness of those preparing the food ; the frequently
taminated congested condition of the stomach and intestines of plague
with plague patients, as well as the occurrence of tonsillar plague,
serve to give countenance to this view. Emphasis has
recently been given to this opinion by Dr Hunter of Hongkong, who
has observed diarrhoea, vomiting or colic to precede the fever in a
number of cases of plague. Since these experiments were made, and
more attention directed to the markets in Hongkong on account of
the knowledge as to the susceptibility of poultry, some of the poultry
CH. v] Experiments in Natal 127
exposed for sale there have been discovered to be affected with plague
during the plague season.
The chronic and ill-defined character of plague among some of
the animals perhaps also explains the endemicity of the disease in those
localities in which pigs and poultry share the living-rooms of the
inhabitants, and by their close association become, under favourable
circumstances, subjected to the risk of contracting each other's diseases.
The same character probably also explains the apparent absence of
plague in a locality during the non-epidemic season.
While these enquiries were proceeding, opportunity arose of ex-
amining into a fatal epizootic among cattle which has occurred every
year since plague began in Hongkong. Investigation showed that it
was not plague, nor was it that rinderpest which visited South Africa,
but that it was a systemic disease manifesting itself mainly in the
intestinal tract and causing at times a haemorrhagic condition of the
lymphatic glands. The causal agent was apparently a diplococcus or
diplobacillus present in the organs of the body, in the urine and in the
excreta, and probably infecting the fodder.
Further investigations of this disease by Dr W. Hunter, Government
Bacteriologist, and Mr A. Gibson, Colonial Veterinary Surgeon, confirm
the results obtained in the preliminary research and prove that the
micro-organism is constantly present. They conclude that the disease
is a form of haemorrhagic septicaemia and is allied to Pasteuralosis.
Apart fi-om the importance of the identification of this haemorrhagic
septicaemia and the differentiation from other diseases of cattle, the
prevalence of such a disease when plague is epidemic shows that
epizootics other than plague may be readily and erroneously taken for
plague ; and that nothing but a careful bacteriological examination of
the animals affected can decide the question.
Similar experiments to those carried out in Hongkong were repeated
in Natal ^ by the medical authorities, but these experiments failed to
produce the disease in pigs, fowls, or cattle. There may be several
explanations of this. In the first place the experiments were not
carried out during the epidemic season, which is always an important
factor, and secondly the plague microbe in the epidemic of Natal may
not have had that virulence which belongs to the bacillus in China.
The great difference in severity of symptoms and fatality of the plague
in China and that in South Africa has already been referred to. There
may also be a more or less comparative racial immunity among animals
1 Report on the Plague in Natal, 1902-3, by Ernest Hill, Health Officer for the Colony.
128 Epidemiol 0(1!/ of Plague [part ii
in one country as compared with another, similar to that prevailing
among human beings.
The susceptibility, which the animals referred to exhibit in regard
Plague in ani- ^^ experimental plague, is not confined to the laboratory
mais under .^Yiw more than it is to the rat, but occurs at times
conditions of '' ,. . • ,i <• p • ■ tx
natural under natural conditions in the lorm oi epizootics. How
infection. frequently and under what conditions has still to
be ascertained.
Epizootics of plague other than among rats and cats, and under
natural conditions, have been positively demonstrated in a few instances.
In China pigs and poultry have been discovered to have been attacked
by plague under natural conditions. In Hongkong^ it was demonstrated
in 1896 by bacteriological evidence that a ship-load of pigs, imported
from a locality infected with plague, died of the disease.
In 1903" poultry in the markets of Hongkong were proved to have
died of plague. In Kunkhal* near Hurdwar in the north-west provinces,
and in Jawalapur in 1897, and in Gadag near Dharwar in 1898, monkeys
were observed to fall from the trees and die in the streets, and on
examination were found to be plague-stricken. Some had buboes on
them, and the plague bacillus was isolated from their tissues. Monkeys
were also observed to be attacked by plague in other localities in India.
In Gadag a squiri'el^ was proved on bacteriological examination to
have died of plague, and squirrels died in Hubli, in Poona, in Bangalore,
in Baroda, and other places during the occurrence of plague in those
localities.
In Sydney in 1902', during the second outbreak of plague in that
city, eleven animals in the Zoological Gardens were positively ascertained
to be infected with plague. These consisted of four wallabies, one
wallaroo, one pandemelon, one tree-kangaroo, one Indian antelope, and
three guinea-pigs.
There is considerable evidence® to support the view that a fatal
' Report of the Epidemic of Jluhonic Plague in Hongkoiuj in the year 1896. By Staff-
Surgeon Wilm.
2 Report to the Sanitary Board of Hongkong, June, 1903.
3 Thirtieth Annual Report of the Sanitary Commissioner of the North-West Provinces
and Oudh for the year ending 31st December, 1897.
■* "Plague in Monkeys and Squirrels," by Alice Corthorn, M.B., Indian Medical
Gazette, 1899.
® Report of the Board of Health on a second outbreak of Plague at Sydney, 1902, by
J. A. Thompson, M.D., D.P.H. ^
•^ "Plague in Siberia and Mongolia and the Tarbagan (Arctomys bobac)," by Frank
Clemow, M.D., Journal of Tropical Medicine, Feb. 1900.
CH. v] Chronic Plague in Animals 129
sickness, which sometimes prevails in a epizootic form among a species
of marmot known as the Tarbagan (Arctomys bobac), is plague, but
hitherto there has been no direct bacteriological proof of this. This
disease has been observed to affect the tarbagans in Aksha, in the
Siberian pi'ovince of Transbaikal, and also in the valley of Solenko in
Eastern Mongolia to the north-east of Pekin.
In the different epidemic manifestations of the existing pandemic
no important epizootic other than that prevailing among rats has been
observed, such as is recorded in some of the older plague epidemics.
But the examples cited indicate that there is always a possibility of
plague becoming prevalent among many of the lower animals on
the occasion of a severe epidemic, and that the disease among these
animals may be an important agency in the maintenance and dis-
semination of plague in an infected locality. In this connection the
chronicity of plague in some of the animals experimented on in
Hongkong, the chronic form of plague as observed in guinea-pigs by
Albrecht and Ghon in their experiments, and the chronic plague
existing in rats for months as shown by Kolle and Martini are im-
portant as explaining the prolonged continuation of plague in endemic
centres.
CHAPTER VI.
DIFFERENT VIEWS AS RECxARDS THE ETIOLOGY OF
PANDEMICS AND EPIDEMICS OF PLAGUE.
The discovery of the plague bacillus has as already stated put an
end to the theory of the cause of plague being a gaseous emanation
from the soil, and to the possibility of spontaneous generation inde-
pendent of the plague bacillus. The power of growth and rapid
reproduction which the bacillus displays when sown on a favourable
medium supptn-ts the view that the infective agent of plague, notwith-
standing its feeble resistance to many hostile influences, is able to
maintain its existence, in at least some quarters of the globe, and ■
there to flourish in man, in animals, or in the soil. The continuity
of plague as thus understood, and its connection with homes of plague,
temporary or permanent, are in direct opposition to the doctrine of the
spontaneous origin of plague from particular or local conditions. This
latter hypothesis arose in great measure from failure in the past to
be able to trace a connection between great epidemics in different
places. But as plague became rarer in Western Europe during the 18th
and 19th centuries, and nearly every plague epidemic was traceable to
a fresh importation from the East, the doctrine of the spontaneity of
plague in a non-infected locality was considerably weakened, to be still
further weakened by the facts ascertained in the present pandemic,
when the facilities for tracing of cases and for chronicling them have
been better than at any previous period. The specific nature of the
infection, its differentiation from those infections causing other diseases,
such as typhus, relapsing fever, malaria, and typhoid fever, which were
formerly confused with plague, and the facilities for tracing the course
of plague from one locality to another, are factors which have assisted
in establishing the non- spontaneity of the origin of plague.
The present pandemic has exhibited an insidious, slow, steady, and
widely distributed dispersal of the infection from infected centres to
CH. vi] Parisefs Theory * 131
healthy localities, and it can be definitely stated that as far as modern
plague is concerned there is no such thing as spontaneous origin in a
non-infected locality, and that an outbreak, except in an endemic
centre, is invariably due to importation of the bacillus. On the other
hand in endemic regions the possible long vitality of the plague bacillus,
the facilities which the microbe obtains of passing through the lower
animals, without attracting any special attention either on account of
the slightness of the symptoms or the chronicity of the disease produced,
together with the variability of the bacillus in losing and acquiring
virulence in some unknown way, certainly clothe the origin of plague
in man with an apparent spontaneity.
A knowledge of the nature of the infection may be decisive enough
in negativing' the spontaneous origin of plague, but it
Some ques- * ^ ^ . , * . i" & '
tions related does not settle questions closely allied to that of spon-
to spon- taneity, viz. how does the bacillus retain or acquire its
taneity. •' \ ^
specificity and virulence, and what are the determining
factors in the diffusive qualities of plague ? Virulence of the microbe
is an inconstant factor, and may be so weakened as to lose the
power of producing a recognisable specific disease. In what way can
that virulence be retained or exalted ? It is from this aspect that the
older views of the origin of plague may be considered.
For centuries the origin of the virus or infection of plague has been
Origin of suspected to be due to putrefaction of dead bodies brought
plague long about by improper disposal, or by great physical dis-
attributed to . • , , <• mi i • i
putrefaction turbances in the phenomena oi nature. Ihe disturbances
of dead themselves, or their effects, have also been held to be not
bodies, or to
great physical only the originators of plague, but also the cause of
ances. pandemics and epidemics.
Pariset\ who was one of the Commissioners from France to study
the plague in Syria and Egypt in 1829, first gave scientific shape to
this old hypothesis that putrefaction of the bodies of the unburied
or imperfectly buried is, under certain conditions, the origin of the
plague virus.
Observing on the occasion of his investigations into plague in
Pariset's Egypt the condition of corpses buried in a soil subjected
theory. ^^ inundations, Pariset came to the conclusion that these
putrefying corpses and the })utrid emanations from them were the
source and origin of the plague virus, and the cause of the endemicity
' Memoire sur les Causes de la Peste et sitr les moyens de la detruire. Par M. Etienne
Pariset. Paris, 1837.
9—2
132 Epi(lenuoIo<i!/ of Plague [part ii
of plague in that country, which he took to be the birth-place of the
disease. In the ehiboration of his views he enters into the history of
Egypt in regard to the disposal of the dead, showing that the ancient
Egyptians down to the Christian era were most careful of their dead,
embalming them and thus preserving them from the putridity which
burial in a water-logged soil brings about. With the advance of
Christianity these precautions gradually passed into desuetude. Pariset
says: "The admirable police arrangements for sepulture were abolished.
What a false zeal accomplished at Constantinople, at Rome, at Milan,
in all the towns of the two empires, was done also in Egypt. The
bodies of the martyrs and of the faithful filled the houses, the churches
and the cemeteries as at the present day, and after a century, or a
century and a half, the new method of honouring the dead caused one
of the most terrible plagues in history to break out at Pelusium."
Following this up he shows that under the Arabian, and particularly
the Turkish rule, Egypt gradually lost its high estate, sank from a
fertile country with a healthy and highly civilised population into one
in which the inhabitants were more or less slaves, ill fed, badly housed,
and uncleanly; dwelling in huts and houses, damp and over-crowded,
and so built as to be without fresh air or sufficient light. It was under
these conditions the Copts had their family vaults in their houses, and
every time one of the family died the slab of the vault was raised and
a new corpse deposited on the older. Sometimes these vaults contained
80 to 90 bodies, and the family was only separated by a plank. There
were at the time of the enquiry 300 Coptic houses in Cairo, nearly all
occupying the centre of the city. To these insanitarj^ conditions, more
particularly the poisonous emanations from putrefying bodies in a wet
soil, and in the vicinity of dwellings, Pariset ascribes the endemicity of
plague in Egypt.
Creighton, 50 years afterwards, adopts a similar view as to the origin
of the plague virus, which he believes to be derived from
Creighton , i , ^ , • , • • ,, •
supports the crude products of cadaveric decomposition |)ollutmg
Pansefs ^^iQ soil and sub-soil. Earth-born in this wise, the plague
views. _ ' r ^)
virus could be carried by merchandise and by persons to
localities in similar conditions as regards putrefaction to those in which
the virus was generated, and finding them favourable for development
infect the soil and the emanations from it, causing thereby an outbreak.
With this special affinity for the products of cadaveric decomposition
the virus of plague in the great epidemic of 1348 found in England a
congenial soil in the monasteries and in the homes of the clergy. It
CH. VI J Creiffh ton's Views 133
may be remarked, however, that the monasteries were the centres of
record, and accordingly it would be of them that the most details of the
ravages of the epidemic would be given.
" Within the walls of the monastery, under the floor of the chapel
or cloisters, were buried not only generations of monks, but often the
bodies of princes, of notables of the surrounding country, and of great
ecclesiastics. In every parish the house of the priest would have stood
close to the church and the churchyard. One has to figure the virus of
the Black Death, not so much as carried by individuals from place to
place in their persons, or in their clothes and effects, but rather as a
leaven which has passed into the ground, spreading hither and thither
therein as if polarising the adjacent particles of the soil, and that not
instantaneously like a physical force, but so gradually as to occupy a
whole 12 months between Dorset and Yorkshire. Sooner or later it
reached to every corner of the land, manifesting its presence wherever
there were people resident. Such universality in the soil of England
we have reason to think it had. But it appears to have put forth its
greatest power in the walled town, in the monastery, and in the neigh-
bourhood of the village churchyards"
The mortality of rats and other animals in endemic centres of plague
Mortality of antecedent to, or during an outbreak of plague, has always
rats from XqwX, support to the theory that the soil is the probable
plague not ^ ^ '' , ^
against Pari- manufactory of the plague virus. It was not, however,
se s eory. m^til 1894, that the two diseases were proved to be
identical. The discovery of the plague bacillus disproves the emana-
tion h}^othesis, though it does not affect the question as to the
soil being the seminary and seed-plot of the microbe. It rather
strengthens it than otherwise. The fact that the rat suffers from a
septicaemic variety of plague, occasioned sometimes at least by canni-
balistic propensities, puts a new aspect on the subject of the relationship
of plague to the soil. It not only shows that the older observers were
partly right in their observations as to there being a connection between
plague and the soil, but it also explains what that connection is, and
how the plague can reach the dwellings of the inhabitants. Plague is
carried slowly hither and thither by rats containing the ])lague bacillus
in their bodies and in their excretions. Burial of plague corj)ses in
endemic centres is always imperfect, as is the case with the burial
of the dead generally, and it is within the range of probability that
some rats at least acquire their infection from dead bodies of men
' History of Epidemics in Great Britain, Creightou, p. 175, 1891.
134 Epidemiology of Plague [part ii
and animals. In Cairo the Coptic vaults were not likely to have
been quite safe against the attacks of these vermin.
It would appear that plague is a disease that under certain circum-
stances attacks animals other than rats as well as man. It may then
be that the bacillus regains or acquires its virulence from an animal or
series of animals through which it passes, and that some animal strains
are more capable than others of infecting the general animal kingdom.
In the pandemic of 1348, more than any other, except, perhaps, the
Justinian or Byzantine plague, animals of all kinds seem to have been
as susceptible as man. These questions are unhappily at present in
the domain of speculation and they must remain there until money
is expended in scientific research for their elucidation.
Great calamities of a cosmic or telluric nature have been assigned as
the cause, not only of the generation of the plague virus,
plague attri- but also of the virulence and diffusiveness necessary to
butedto^eat j-^nder the disease epidemic or pandemic. Plague may
cosmic and manifest itself in one city or district by a few cases ; in
another by a great epidemic ; or it may overrun a pro-
vince or country or one or two hemispheres. It is obvious that other
factors besides the mere presence of the causal agents of plague must
come into play in determining such very different results. Volcanic
eruptions, earthquakes, the unusual conjunction of certain planets,
irregular seasons, floods, droughts, famines, and the putrefaction of dead
bodies, have, one and all, been brought into requisition as special causes,
but to an age which is, more or less, unftimiliar with any continuous
succession of extraordinary physical disturbances, the causes appear
to be somewhat remote in their action and fantastical in their con-
ception. The list includes influences which are likely only to have a
subsidiary effect. The two great consequences of these catastrophes
are the ensuing putrefaction of the dead, and the miserable condition of
the living, whose homes and food have been destroyed. These de-
pressing conditions are generally favourable to the revivification and to
the rapid and wide extension of any endemic disease. India furnishes a
number of instances in which cholera has broken out in epidemic form
after a destructive inundation, as for example in the severe epidemic
which affected the survivors of the great tidal wave which swept over
the Sunderbunds in Bengal in 1879. The natural resistance of those
who escaped the flood was probably reduced by the shock which they
had suffered and by the depressing influence of inadequate shelter and
insufficient food.
CH. vi] Precedents of the Black Death 135
The antecedents in Asia of the great pandemic of 1348, given "*
in Deffuignes' Histoire Generale des Hans, and made use
The Black ....
Death pre- of by Hecker in his Epidemics of the Middle Ages, are a
distm-bances* succession of extraordinary and exceptional events denoting
in the balance s(jrae great deviation from the ordinary sequence charac-
teristic of the phenomena of nature and its seasons.
Deguignes follows the Arab historian Mahassin, who records the
commencement of the plague in Tartary and its connection with the
smell of corpses arising from the perishing of men, beasts, and even
birds in the disastrous floods. The infection thus produced obtained a
ready means of transport westwards by the northern caravan route,
whose European marts were on the Caspian and the Black Sea, and by
which gateway it entered Europe.
Hecker places the commencement of the Black Death in China, and
attributes the virulence of the disease and its pandemicity to the mighty
revolutions of the earth which are recorded to have preceded it.
"'From China to the Atlantic, the foundations of the earth wei'e ^
shaken. Throughout Asia and Europe the atmosphere was in com-
motion and endangered by its baneful influence both vegetable and
animal life." He writes of a succession of inundations, earthquakes and
famines, which, commencing in China, spread over the greater part
of the known world, and it is in China the great pandemic is held to
have originated.
Creighton, while accepting the origin of the plague virus from the
decomposition of corpses, is perplexed, like many others
places th^ ^^^^*^ \\-^i\^ given the subject their attention, to find that
origin of the though in China from 1333 to 1352 there are records of
Black Death
on the borders great physical disasters with great mortality ensuing, there
of the Euxine ^^^ j^^ entries in the chronicles of a great plague until the
or Black Sea. . & r &
latter year. For this reason, and because there were
special conditions at the European entrepots on the Black Sea favour-
able to the development of epidemic disease, he shifts the place of
commencement to the marts on the Black Sea. What were then the
conditions of the emporia or European termini of the trade from the
Far East to cause them to be suspected as the principal factors in the
generation and birth of the Black Death ?
Creighton^ describes these conditions on the authority of the
1 The Epidemics of the Middle Ages, p. 11. By J. F. C. Hecker, M.D.
- History of the Epidemics of (ircat Britain, Vol. i. p. 144. By Charles Creigliton,
M.A., M.D., 1891.
13(5 Epi(lemioli)(i[i of Plague [part ii
manuscript of Gabriel de Mussis, a jurist of Piacenza, who had been
practising as a notary or advocate among the Genoese and Venetians
trading around the shores of the Euxine and Caspian.
It was at a time when these shores and the country north of them
were harassed by the Tartar hordes. Among other incidents, the
Italian merchants were besieged, first at Tana, then at Cafifa. The
siege of the latter town was maintained for three years, and caused
those invested to be put to great straits. Plague broke out in the
Tartar array and the dead bodies were thrown by the besiegers from
their war engines into the town, so that the infection took hold of those
within the fort. The mortality, however, became so great among the
Tartars that, panic-stricken, they fled from the siege and spread the
plague wherever they went. It was then that some Italian traders, and
Gabriel de Mussis with them, escaped from Caffa in a ship and arrived
in due course at Genoa, where plague broke out in a most deadl}- form a
few days after, although none of those on hoard luere suffering from
the disease.
In making a choice between the origin of the plague virus among
the Tartar hordes besieging the merchants within the walls of Caffa and
the pre-existence of that virus for a long time latent among the goods
or effects of the besieged, Creighton gives the preference to the latter
hypothesis on the ground of advantage in probability; why the latter
should be chosen rather than the former is not very clear. Three
or more years is a long time for the virus to be latent in towns with the
conditions prevailing in Tana, Caffa, and Sarai, whereas it is not
an uncommon event for plague to be associated with armies in the field
in that part of the world. The explanation is a reasonable one if
the facts and conditions set forth by de Mussis were correct, but
unfortunately there is a doubt as to the accuracy of the account given
by him, who is looked upon rather as another Daniel de Foe than
a recorder of facts of which he himself was an eye-witness. The
lower region of the Volga was the scene of an intense exaltation
of the plague virus as recently as 1879, when a mild manifestation of
plague in Astrakhan suddenly assumed a most virulent form, but this
was in the depth of winter and without any attendant decomposition of
a special character and without the acquisition of diffusive powers. As
a matter of fact it was a self-limiting plague, though the virulence was
extremely violent.
The account given by Creighton cannot be said to literally agree
with that given by de Mussis in his manuscript, for instead of no one on
CH. vt] War and the Black Death 137
board suffering from the plague it states that on departure there were a
few sailors on board infected with the pestilential disease, and out of
a thousand passengers and crew in the several ships scarce ten survived
when the ships arrived at Genoa. Literally translated by Dr J. F. Payne
from the Latin manuscript, a copy of which is given by Haeser, the
account is as follows :
"^In the year 1346 innumerable tribes of Tartars and Saracens
perished in these regions by an inexplicable disease. Whole tracts of
country, innumerable provinces, splendid kingdoms, cities, camps, and
towns abounding in population were attacked by a horrible death, and
in a short time denuded of their inhabitants. Now a town called
Thanna, in the eastern region towards the north, a place trading with
Constantinople, was besieged and conquered by a great army of Tartars ;
and it happened that the Christian merchants, driven out by force, took
refuge within the walls of Caffa, which the Genoese had formerly built
in that region. Suddenly the infidel tribes of Tartars, collecting from
all sides, surrounded the city and besieged the Christians, who were
shut up there for nearly three years ; when lo ! a disease attacked the
Tartars, and the whole of the besieging army fell into a state of
weakness and disorder so that many thousands of them died daily. It
seemed to the besieged Christians as if arrows were shot out of the sky
to strike and humble the pride of the infidels, who rapidly died with
marks on their bodies and lumps in their joints and several parts,
followed by putrid fever ; all advice and help of the doctors being of no
avail. Whereupon the Tartars, worn out by this pestilential disease,
and falling on all sides as if thunderstruck, and seeing that they were
perishing hopelessly, ordered the corpses to be placed upon their engines
and thrown into the city of Caffa. Accordingly were the bodies of the
dead hurled over the walls, so that the Christians were not able to hide
or protect themselves from this danger, although they carried away as
many dead as possible and threw them into the sea. But soon the
whole air became infected, and the water poisoned, and such a pestilence
grew up that scarcely one out of a thousand was able to escape.
" Thus were the Orientals in all parts, both those who lived on the
southern shore and those on the north, struck down by this pestilential
disease, and almost all of them died. So great was the mortality that
Kathayans, Indians, Persians, Medes, Armenians, Georgians, Turcomans,
Arabs, Saracens, and Greeks throughout the whole of the East, gave
themselves up to clamour, weeping, and sighs, and remained in this
' Plagues Ancient and Modern. St Thomas' Hospital Keports. Vol. xvii.
138 Epidemiolociy of Plague [part ii
distress from the above-mentioned year to 1348, expecting that the Day
of Judgment was at hand.
" Now it so happened that a ship left the aforesaid land of Caffa,
having on board a few sailors (who were also infected with the pesti-
lential disease), and made for Genoa, some other ships going also to
Venice and otheis to other parts of Christendom. Marvellous to relate,
whenever the navigators arrived at any land, as if some malignant
spirits accomi)anied them, wherever they mingled with other men the
latter perished. Every city, every town, every country, and their
inhabitants of both sexes, poisoned by the pestiferous contagion of
the diseased, fell a prey to sudden death, and when one began to be
sick, soon falling and dying, he poisoned the whole of the family. Those
who came in to bury the bodies perished by the same disease. Thus
whole cities and castles were made desolate, and only the waste places
themselves were left to mourn for their dead inhabitants.
"Alas ! when our ships arrived at any city, and we entered our houses,
our relatives, our connections and neighbours flocked in to see us from
all sides, because we were still in bad health, and out of a thousand who
sailed with us scarce ten survived ; but alas ! we carried with us the
arrows of death. And while they were embracing and kissing us we
could not help pouring out poison from the lips with which we spoke.
So they, returning to their houses, soon poisoned their own families,
and within three days the whole household, struck down, succumbed
to the dart of death, and the number of the dead increased so much
that the ground was not sufficient for their graves. Priests and doctors,
whom their great care for the sick compelled to be present at the death-
bed, alas ! returned home sick themselves and quickly followed the
deceased."
The account by de Mussis as literally transcribed consorts more or
less with other contemporary authors who mention the
considera- prevalence of the pandemic in Central Asia and India
tions snowing i i
the difficulty before its entrance into Europe. The disease being ac-
and even the i • , i i • i -mi. j.
impossibiiity credited as having begun in lartary may mean any part
of now ,)f Asia, for the vast empire of Kublai Khan still remained,
locating the . ^ . 111 1
origin of the though broken up into many sections and ruled over by
14th century j^-^ descendants and lieutenants. There were Tartars
pandemic.
everywhere in power from Hungary in Europe to the
eastern coast of China. The westward wave of that great invasion
of Mongols begun by Gengiz Khan had not yet ebbed, and Tartar
and Turkish kingdoms were established on the coasts of the Persian
CH. vi] Effect of Volcaiiie Eruptions 139
Gulf and the Black Sea as they were around the Caspian. It is
difficult enough at the present day in times of peace, and with the
facilities which steam and electricity afford, to locate the origin of any
pandemic. We have examples of this in the pandemics of cholera and
influenza of the 19th century. They were never traced to any particular
source, or to any special set of conditions. The source of the recent
pandemic of influenza became a very movable affair if the localities
from which it is believed to have originated are taken into account.
It was ultimately supposed to come from Russia or some part of the
Russian dominions which extend over the greater part of Northern Asia,
and it has even been pushed back further to some remote and unknown
part of China. The tendency at all times is to locate the origin of rare
diseases in some distant and unknown country. Plague in recent years
has been given a theoretical endemic area in Thibet, a country into
which no one, until the British Expedition of 1904 forced its way in,
has been permitted to enter, and about which nothing is known. Once
creating an imaginary home in this unknown country plague is supposed
to have travelled down to Yunnan in China on one side, and Kumaon
and Garhwal in India on the other. These are all matters of assump-
tion which it is impossible to affirm or deny. Until the world is circled
with the telegraph, and that which has happened even in remote places
is immediately known, it will not be easy to locate the exact place
where a pandemic takes its origin. All that is known of the origin of
the plague of 1848 is, that having prevailed in a malignant form for
several years in the East, it entered Europe by the Black Sea, and
probably also by the caravan routes of Mesopotamia and Asia Minor,
and that it occurred at a time when the division of the Mogul or Tartar
empire on the death of Kublai Khan caused large portions of Asia to
be a constant seat of warfare.
Volcanic eruptions have on occasion apparently given rise to disease
in a limited degree. Humboldt relates that in an eruption of
eruptions are Cotopaxi SO many fish of the order Pimelodus were ejected
recorded to that they poisoned the air all round, and it is recorded by
dered plants Pouchet that near the end of the 18th century the town
and Herbage ^£ go^rra was ravaged by a malignant fever, which was
poisonous. . . r
attributable to the miasmata arising from the decompo-
sition of an enormous number of those fish vomited by a neighbouring
volcano. Humboldt again relates in his travels that at the end of
violent earthquakes the herbs that covered the Savannahs of Tucuman
acquired noxious properties, and that an epidemic disorder broke out
140 Epi(leimolo(jji of Plague [part ii
among the cattle, and a great number of them appeared stupefied or
suffocated by the deleterious vapours exhaled by the ground. If herbs
can be rendered poisonous in this way, it may be possible that low
vegetable organisms such as bacilli can acquire virulent properties under
similar conditions, or disturbances of Nature.
Atmospheric causes of a far-reaching character, which are followed
by lean and fat years of famine and plenty, are not without
pUcation of their influence on germ life in the lower plant orders.
disease germs Di'ouerhts. floods and other cosmic disturbances which are
associated o . i ■ i j
with lean or destructive to the grain and food of man and annnals, and
famine years. ^^,j-,|(.)-, .^,.^, productive of famines and general misery, do
not appear to be injuiious to the germs of disease. On the contrar}',
while the higher orders of plants wither and die, the lower orders, among
which may be included the plague bacillus, appear to find in the
exceptional circumstances conditions highly favourable to a rapid and
luxuriant growth.
Exceptional circumstances of weather and other adverse events
were not wanting in Hongkong, in India, in Bombay or
Exceptional [^ ^.he Cape to favour the development of plague, once the
meteoro- . , . . ^ ^ c^ ,■ ■ , ^i
logical infection was introduced. home time previous to the
'^ receded^ outbreak of plague in 1894 several extraordinary pheno-
tbe epidemic meiia were noticed in Hongkong. The year before extreme
Hong^g!" cold prevailed during the winter, and for three days the
Peak was covered with ice to within about 400 feet of
the sea level, and the hills on the mainland opposite Hongkong were
covered with snow. In the autumn of 1891, 1892, 1893, and 1894, an
epidemic of caterpillars^ Thialleta signifera and Pharazia bicarsisatis,
attacked the trees and grass in Hongkong in such multitudes that the
Government employed men to gather them, for which they were paid
at a certain rate. Then the flowering of the male bamboo was noticed,
and this, combined with an eclipse of the sun and the other phenomena,
presaged, according to the Chinese, an epidemic of some kind.
If the signs of the times could have been read aright, they would
have indicated that India was under conditions specially
Scarcity pre- ...
ceded plague favourable to the maintenance and spread of some epidemic
in India. disease. In 1896 there was failure of the crops over a con-
siderable part of the country, creating scarcity and a rise in the price
of food. Large numbers of famine-stricken or destitute people flocked
^ Reports of the hotuniciil ami Ajfori'stdiioii Department for Iloniikonf], 1892, 1893, and
1894.
CH. vi] Abnormal Seasons 141
from the famine districts into Bombay. In 1897 the famine area
became more extensive and there were severe earthquakes in the eastern
parts of India. The inference is not that either of these was the cause
of the plague, but that their occurrence showed an abnormal atmospheric
and terrestrial condition which was likely to favour the epidemicity of
plague once introduced into the country.
Cases of plague occurred in Bombay as early as May 1896, but it
was not until the following October that the disease attracted any
special attention and began to spread. The local phenomena which ^
preceded the epidemic are described by Dr Weir, the
Aonormal ■■ ■■•
season pre- Health Officer^ The mean temperature of the year
demic of^' "^'^^ SO'TO, which was the second highest on record during
plague in the previous 51 years. The total fall of rain amounted
°°^ ^^' to 87*6 inches, which was 15 inches above the average.
It was not only above the average, but it was abnormal also in
distribution and in duration. The heavy rainfall, owing to an ob-
struction in the sewage outfall, flooded with sewage the low-lying
portions of the city, through which the polluted streams rushed in
swirling currents, leaving banks of mud and sludge behind to ferment
or dry slowly, and although the monsoon practically ceased in August,
the shady sides of the streets in crowded portions of the city remained
damp long afterwards. In September only 1'6 inches of rain fell, being
as much below the average as the earlier months had been above.
Even in the famine years of 1876-77 the September rainfall was not
less than 4 inches. An abnormal September was followed by an
abnormal October, dry and warm. In September the godowns in
Mandvie, the district in which plague first broke out epidemically,
were still damp.
The city appears to have been in an exceptional plight due to an
abnormal season of rainfall, that lasted only about half the normal
period, and which produced an abnormally high level of sewage in the
arterial sewers, and soakage of the grain in dark and damp godowns or
granaries underneath human dwellings. All traffic to the island was
interrupted for five days. The grain lay in the wet. The low-lying
portions of Bombay were under water. At the most distant points on
the esplanade, near the head of the drainage system, water welled up
through the man-holes. The subsoil water welled up where it had
never been seen before, and wflls overflowed that had never previously
been full. Dr Weir lays stress on the fact that during this ])eriod wet
1 Report of the Health OJicer for Bombay for 18'J6, p. (JIO.
142 Epidemiology of Plague [part ii
grain was stored in wet granaries with no means of ventilation. These,
he remarks, are the conditions most favourable to the generation of
disease, and had it been necessary to cultivate the microbe, it would
not have been possible to have created artificially more fevourable con-
ditions, i.e. organic matter, moisture, warmth, and darkness. These
were the conditions which existed in the granaries, in the floors above
which the disease first became epidemic.
A similar abnormal season preceded the epidemic outbreak of plague
in Cape Town in 1901, which occurred at a time of war
Unusual ^ _
season pre- and scarcity. The season at the beginning of the year
demicof^ was altogether exceptional. It was cold when it should
plague in have been hot, wet when it should have been dry, and in
C3.136 Town
every way it was abnormal. The rainfall in January was
abnormal, and was the heaviest recorded since 1842 when observations
began to be made. In this respect the conditions of Cape Town corre-
sponded with those of Bombay in 1896, when the outbreak of plague
in September was preceded by an exceptional season and abnormal
rainfall in July and August. In Cape Town a rare comet was visible
for several nights.
It will be seen that the explanations of the causes of the origin and
development of pandemics and epidemics, as distinguished
Conclusion. ^ . / i • i i
from the conditions which have been generally observed to
favour their continuance and spread, are all within the region of specu-
lation. To-day we are no nearer their explanation than our predecessors,
who ascribed them to the anger of the gods, to astronomical conjunctions,
to putridity, to epidemic influences, and to numerous other causes. All
that is definitely known is that pandemics and epidemics are generally
associated with unusual seasons which bring distress and misery, with war
and famine and their attendant ills, with political, social or economical
conditions which are the reverse of prosperous, and which produce
general depression in the community, and also with a laxity or absence
of sanitary administration which prevents or hinders prompt dealing
with the earlier cases. They also acquire their ascendancy owing to
incomplete knowledge as to the different modes by which they spread,
and as to the laws governing these. Some of the modes are known,
but others being unknown there is always the risk, even when adminis-
trative action is prompt, of the ])reventive measures employed being
only partially successful in checking and controlling the disease.
CHAPTER VIL
VARIATION IN POWERS OF DIFFUSION OF EPIDEMICS AND
THE EFFECT OF SEASONAL INFLUENCES ON THEM.
Variation in powers of diffusion is indicated by the terms sporadic,
epidemic, and pandemic, which are applied to plague,
diffusive When the disease is imported into a country it is im-
powers. possible to foretell which quality it will assume, or how
long it will continue to retain the quality it first displays. There are
Seif-Umiting self-limiting plagues and there are plagues which possess
piagTies. great powers of diffusion, but the exact conditions under
which each obtains, or which determine the one or the other, or by
which the one is distinguished from the other before its results are
known, are, as will be surmised, still a matter for research. The factors
controlling the diffusion of plague are really unknown. The Cyrenaic,
Mesopotamian, and Persian outbreaks during the fifties, sixties, and
seventies of the 19th century were shown by Tholozan to be self-limited.
They spread to a certain extent and then stopped, not because of the
preventive measures taken, for they were usually applied either too late
or not at all, but because of some general law which is not yet under-
stood. The plague at Vetlianka was a self-limiting plague. When
alarm was aroused most energetic measures were applied, but not until
the disease had spent itself Like the local outbreak at Benghazi in
Northern Africa and in the Assyr district in Western Arabia, the outbreak
at Vetlianka began and ended within a comparatively circumscribed area.
The existing pandemic, though it may seem paradoxical to say so,
possesses comparatively small diffusive qualities, notwith-
pande^lc"^ standing its success in reaching a large number of countries.
possesses Its tendency in most places where it has acquired a footing
tiveiy small is not to spread to any great extent. This may be only
diffusive g^ temporary characteristic, for India is an exception. But
powers. .,..,, . - . . .
even in India, with the rapid means of intercommunication
which the country possesses, the extension of the disease is com-
144 Ep\(JcmU)hHiii of Plague [part ii
paratively limited, and does not compare with the progress of the
14th century or the 6th century epidemic, or with the pandemics of
influenza and cholera of the 19th centur}'. On the whole the mani-
festation of plague in ditferent places has been, with the exception of
India and China, more sporadic than epidemic. Nowhere as yet have
the great ravages common to the towns and villages of India and
Southern China been repeated elsewhere.
A great sowing of seed has been effected, but apparently for the
most part on ground which is barren or only slightly favourable to
growth. Telegraphic and postal communications have brought civilised
countries into such intimate relationship with one another that outbreaks
of plague of any considerable size are immediately heard of, and their
progress followed in a manner that was never possible before. Never
before has there been such an opportunity of watching so closely the
gradual scattering of the seed over an area of the globe which has for
centuries been free of plague. The European powers at the Venice Con-
vention of 1897 agreed to notify to each other any case of plague in their
respective dominions coming to their official notice. The result has been
the possibility for the first time of tracing the different movements and
gradual progress of the plague, and with it certain features in the epi-
demiology of plague have become conspicuous. These are the slowness
of the progressive advance, the evident difficulty with which new centres
are formed, and the absence at present of any special tendency to
severe epidemics. They are features probably not new to plague, for
they are likely to have been overlooked at earlier periods when the
facilities for obtaining information were less than they are now. If
it be true that plague has generally such a vanguard of sporadic cases
when spreading in pandemic form, these sporadic cases may be the
missing links which are so frequently wanting in tracing the connection
between concurrent epidemics in widely separated places.
There is one noticeable feature belonging to the existing pandemic
and which presages danger in the future. It is that notwithstanding
its apparent inability to cause in any one place a great epidemic, it
exhibits in some places marvellous powers of recrudescence and re-
sistance to all known measures of prevention, and this, even when the
cases are few. This tenacious capacity combined with its transporta-
bility makes it formidable because its slow progress, few cases, and
possibly slight mortality, accustom the people to its presence, and lull
the authorities into a frame of mind of looking upon it as a very
manageable disease. In the meantime it gradually dots itself over
CH. vii] Danger of existing Pandemic 145
different parts of the country, securing a firm hold in some localities
which again form fresh centres for its activity, until, in the course of
a few years, it is fairly established in the country at many centres, and
only awaits the conditions necessary for its development into an alarming
epidemic. In this respect its behaviour, when established in a country,
is likely to be similar to small-pox in an unvaccinated country in which
there are a series of years with a few cases followed by one or two
epidemic years. In Africa and South America the dotting stage appears
to be in progress.
The danger of the existing pandemic lies not so much in its present
aspects with its slight diffusive powers, but in the oppor-
the existing tunities which it may meet with of acquiring both virulence
pan emic. ^^^ diffusive qualities. Such opportunities would arise
in the case of distress on a large scale from economical or political
causes, from atmospheric conditions giving rise to scarcity, or from war.
None of these will themselves give rise to plague, but with plague
spreading as at present, any one of them would serve to render it
formidable.
It is because of these dangers that the plague in India with its
extensive area of infection may at any time become a menace to Europe,
for it possesses all the potentialities which once developed would give
it those diffusive qualities that have characterised former pandemics.
It has at present reached Cashmere and is not far from the borders of
Afghanistan. Should it attack and pass through the latter country,
it then reaches the high road through which so many epidemics have
entered Russia and Europe. There is always the possibility of the
plague in India assuming the influenza type, and should this ever occur
then there is nothing to prevent a repetition of the ravages that plague
committed in the sixth and fourteenth centuries.
From an epidemiological point of view there are two varieties of
plague. Between them are plagues which approximate more to the one
or to the other variety. The first and the most common is that which
frequents the more or less endemic areas and their neighbourhood, with
small tendency to spread. It may possess considerable powers of ex-
tension once it has passed beyond the bounds of the endemic area, but
it seldom displays any great contagious qualities, most frequently re-
taining the characters of its origin. The second is on the other hand
a plague of an expansive and diffusive character, manifestly contagious
both to man and to many kinds of the lower animals, and is capable
of causing wide-spread destruction to both.
s. 10
146 Epidemioloffy of Plague [part ii
PLAGUE EPIDEMICS AND SEASONAL INFLUENCES.
The season of the year has a very powei-ful influence on the pre-
Piague epi valence of plague and the duration of the epidemic. There
demies occur lYoxy be in any locality a few cases of plague all the year
seasons of the round, for instance in Bombay and in Hongkong there is
y®^- not a month without a case, but it is only at certain
seasons that the disease becomes epidemic. This season may vary
somewhat in different localities, but it is nearly always the same in
the same locality, and has a tendency to become earlier the further
south it occurs. Plague may occur in endemic centres such as in the
mountainous regions of Assyr or Kurdistan under conditions of intense
cold ; but intense cold or intense heat are generally inimical to the rise
of an epidemic, though they do not prevent the occurrence of sporadic
cases even outside the endemic areas, when these sporadic cases are the
remnants of a preceding epidemic or the harbingers of one that is
impending. An occasional outbreak of pneumonic plague such as the
Vetlianka outbreak may take place in the depth of a severe winter, but
it is seldom of any great dimensions. Similarly small epidemics have
occurred in Sindh with a temperature of between 110^ F. and 120" F.,
but they are exceptions.
The development and decline of the epidemic of plague m Bombay in
1806 are shown in Diagram A on the next page, taken from the report of
the Health Officer on the outbreak, and is an excellent t^-pe of the usual
characters of most great epidemics of plague. First of all there is a
period of hesitancy more or less prolonged ; then there is a sudden but
fluctuating rise which reaches its highest point in the course of three
months or in a shorter time ; and then there is a decline possessing
much the same character as the ascent but often less prolonged ; and
finally the disease lingers in a sporadic form for some months.
The duration of any of these stages may vary somewhat, being
either lengthened or shortened, so that within the plague season there
may be epidemics lasting from 4 to 8 months. If the epidemics them-
selves were anal3-sed, they would be found to be more or less a series
of epidemics invading at different times different districts of the same
city. The months of epidemic prevalence in several towns, the month
in which the epidemic reached its maximum and the duration of the
epidemic, are shown in Diagram B on page 148.
Diagram A.
Weekly Total and Average Mortality.
\?c^U
WEEK ENDING
JUN
E'JUL
I Aug.iSep
Oct
Mny Dec. Jan
°^-18961897
Feb
Mar. Apr
1
May
1 900
1,850
i,snn
•
Plague
MORTALn
Weekly
MORTALI
■Y
-•—
}
S
1,750
1,700
1,650
Total
rY .«
11 ?
Weekly ■Average
MOBTAr ITY ,
• 1 r
ii il
• •
1 600
jHT
• 1
1,550
1,500
1 450
■
1
•
1,400
•
1
1
!
1 350
i
i
1,300
1,250
1,200
1,150
1 100
!
}
1
i
•
r
-
850
800
750
700
\
1,050
11
1
A
1
i
950
\
\
•
900
850
800
650
600
'i>>n
750
500
450
•
a
W
.1
i
700
1
•
1
i
i
1
•
t .
lil
r
\
/
1
if
i
f
1
1 \
Rnn
4qo
3.4o
i/
ir
i /
m
U
•
\j
•
'a
550
•
M'
;i'
/
•
•
\
Ah
i\
500
7
V^
•
r
1/
•■•
\
/
\
Ai
M
.VI
I
100
t
\
M,
u-
v
0
J^
10—2
148
EpiclemtohKHi of Plague
Diagram B.
[part II
Duration of Epideviics and Months of their greatest Intensity in
different Localities.
Name of Locality
Moscow 1771—77
London 1665—66
Marseilles 1720
Dantzic
Oporto
Aleppo
Alexandria
Karachi 1896-97
1897—98
1898—99
1899—1900
1900—01
Hongkong 1894
1896
1898
1899
1900
1901
1902
Bombay 1896—97
1897—98
1898—99
1899—1900
1900-01
Mauritius
Cape Town
Sydney
Brisbane
Pernambuco
Oct
Nov
Dec
Jan
Feb
Mar
Apl
May
Jun
Jul.
Au(|
Sep
Oct 1 Nov
Dec
Jan
Feb
Mar
V
V
_i^_
r?c^
Y
Vf
Y
A
V
Y
V
V
A
V
A
v
A
Y
V
•J
A
V
Y
Y
A
Y
V
V
Y
A
V
A
A
'
;
^
1
V
X
\j
X
V
A
In Europe great epidemics occur in sumnier and autumn, the worst
months being usually August and September. In London the epidemics
of 1603, 1605, 1625, 1636, and 1665 resembled one another in beginning
in June and ending in J)ecember, the greatest number of deaths being
between the latter part of July and the end of September. In Marseilles
the epidemic of 1720 took a similar course, beginning in June and
declining rapidly at the end of September. In Moscow the epidemic
of 1770 raged from April to December, but by far the worst month was
September, when 21,000 deaths were recorded. In Asia Minor the
CH. VIl]
Seasonal Influences
149
epidemic season is generally sj)ring and summer. The Syrian epidemics
usually began in March or April and ended in August, the worst month
being June. The Egyptian epidemics generally commenced in December
or January and terminated in June or July, the highest mortality oc-
curring in March or April. At other periods of the year the disease
was more or less quiescent, the last half of the year having comparatively
few cases. Recent epidemics in Egypt have shown similar seasonal
characteristics. In Hongkong plague prevails epidemically in the late
spring and summer and reaches its height in May or June.
Jan.
Diagram C.
Chart showing the mortality from the Plague for the year 1903
compared with the average of the previous 5 years.
Feb. March April May .June July August Sep. Oct. Nov.
Dec.
In India there may be two epidemic seasons: one in January,
February and March, and another in August, September, October and
150 F^ndemiologt/ of Plague [part ii
November. In Bombay plague prevails from October or November to
May or June and reaches its height in February or March. In Calcutta
it prevails a little later than in Bombay and reaches its height in
March or April. The seasonal occurrence of plague in Calcutta is
shown in the Diagram C taken from the report of the Health Officer
for Calcutta for the year 1903.
On the other hand the epidemics at Poona have been later in the year.
In the Mauritius it is epidemic from July to March, arriving at its
climax usually in October or November. In the southern hemisphere
epidemics manifest themselves during the first half of the year. In
Cape Town plague was epidemic from February to June, being worst
between the end of March and the first weeks of April. It was much
the same in Brisbane and in Sydney, where the plague was first detected
towards the latter part of February ; and continued epidemically until
the end of June. Its worst period was in April.
The range of temperature favourable to plague varies considerably
in different localities, the most favourable being between
affects the ^^° ^- ^^^ ^^° ^- ' mean temperatures above 85° F.
endemicity ^nd below 50° F. are as a rule unsuitable for epidemic
of plague. . . .
prevalence. In the Hongkong epidemics any continuous
temperature above 83° F. is followed by a decline of the epidemic which
does not begin again until the following spring. In the Bombay epi-
demic there is always a fall when the mean temperature is above 82° F.
and sometimes when it reaches 80° F. In Cape Colony and Sydney
there was a decline when the temperature lowered to a mean of 50° F.
The maximum temperature in the latter places was never so high as to
check the rise of the plague once the disease had become epidemic.
Plague prevailed most at temperatures between 55° and 70° F. In the
Cape it was observed that ten days to a fortnight after a rise in the
mean temperature there was an increase in the number of plague cases.
No very marked influence seems to be exerted by rain. If any-
thing, slight rain with heat appears to favour plague, whereas heavy
and continuous rain, although often an antecedent of a plague outbreak,
seems, on the other hand, when plague has broken out, to be unfavourable
to its epidemicity especially if it is the cause of large floods. It may
be infected rats are unable to escape from the floods.
Why plague is so strongly controlled by seasonal influences is one
Season a com- of the many problems still to be solved. Season, Avith
posite force. j^g meteorological factors, is a composite force, and as such
operates in more than one way on the agents and media connected with
CH. vii] Seasonal Influences 151
plague. For instance it affects a man's constitution and powers of
resistance against infective diseases in various ways through its influence
on the air, soil and food which react on man ; it affects the plague
bacillus in regard to reproduction and virulence, and it affects animal and
insect life as well. The difficulty lies in differentiating the main factors
of which season is composed, and in determining the exact influence of
each on man, the plague germ, and on animals and insects concerned
in the spread of plague.
The older writers observing seasonal variations in plague were
content in attributing it to an " epidemic constitution," and did not
attempt to analyse what that constitution was. We are no further
advanced to-day in this respect. The only serious investigation into
the influence of different climatic factors on plague is that carried out
Mr Baldwin by Mr Baldwin Latham ^ He found no particular tem-
anaivsis^of perature of the air nor temperature of the ground to have
the influence any marked connection with the incidence of plague, but
factors on ^^^^ plague prevailed at a period of the year when exhala-
piague. tions from the ground were greatest, and ceased at a time
when the ground exhalations were slightest. Diagram D shows the
season of the year when the vaporous exhalations are highest and lowest
in Croydon. Comparing these with the weekly number of deaths from
plague in London in the years 1564, 1592, 1603, 1607, 1686, 1642, and
1665, and also with the vaporous exhalations in London during a period
of 15 years, he finds, as is shown on the diagram on page 152, that
there is a strong marked parallelism between the tensional differences
which are the cause of vapours rising from the ground and the plague
epidemics which formerly occurred in this country.
An interesting point is that a similar investigation into the tensional
differences in Bombay and the prevalence of plague there brought out
a similar result, although the period of the year in which plague
occurred in London was not the same as in Bombay. It was de-
monstrated that the forces that gave rise to earthy exhalations only
came into operation in Bombay as in London at the particular times
that the plague was rife.
Experimenting with cylinders filled with earth freely suspended
in a perforated tube within the earth, at depths of 1 foot and
2 feet below the surface, it was ascertained that the hygrometric
1 "The Climatic Conditions necessary for the Propagation of Plague." By Baldwin
Latham. Quarterly Jmtrnal of the Royal Meteorological Society, Vol. xxxvi. No. 118,
Jan. 1900.
152
Ejndemialofjij of riagne
[part II
condition of the ground varied according to the temperature of the
air and the temj)eratui-e of the ground. The earth cylinders increased
in weight when the air was warmer than the ground, and lost weight
when the temperature of the air fell below that of the ground, or in
other words when the air was warmer than the earth condensation
took place, but when the earth was warmer than the air evaporation
took place.
TENSIONAL OirrERENCE 3-2FTGRbUND AND MEAN OEW POINT CREENWICH
Q9 0? O; HIN: D? 0'.
WCtKLr TOTAL DEATHS 1665 PLAGUE DEATHS I66S LONDON
"'«o" AVERAGE TOTAL DEATHS I56*. 1592 .1603. 1608. 1636, I642.»..,«.^ AVERAGE PLAGUE DEATHS 1564, 1532,1603.1808,1638. 16*2 — ._
TOTAL r
DCATHi
8000
6000
4000
2000
The periods of the year when exhalations escape from the ground
and the quantity that then arises were then determined. Numerous
observations were made by which the temperatures of the ground
at different depths were compared with the temperatures of the dew
point, and the factors thus obtained were employed for calculating the
tensional difference between the ground air and the temperature of the
dew point. At all times the exhalations take place in proportion to
the tensional differences. The results, as stated, compared with the
period of the year of plague epidemics in Bombay and London, showed
that the rise and fall of the tensional differences between the ground
temperature and the minimum dew point agreed in a remarkable
manner with the rise and fall of plague. Mr Baldwin Latham deduces
from his observations that a high temperature of the air, by raising the
temperature of the dew point, and causing condensation to take place.
CH. vn] Seasonal Influences 153
stops plague ; while a fall in temperature means a fall in temperature
of the dew point, and the tensional difference between a low dew point
and a high ground temperature, which would at once lead to exhalations
which Mr Baldwin Latham thinks would cause liberation of plague
bacilli from the ground. There is no evidence at present as to the
possibility of plague bacilli being lifted from the soil by these forces.
The facts are against it, but the question needs to be scientifically
settled by experiment. It sounds like the old hypothetical cause of
malaria which the investigations of Laveran, Ross, Manson and others
have completely destroyed. If the vapours have any influence, it is
probably in the direction of favouring a condition productive of suscepti-
bility of the organism in man or the lower animals or in both.
The phenomena observed recently of strong electrical currents in
the earth disorganising the telegraph service indicate that the con-
ditions of the soil are influenced considerably by meteorological changes,
and that the conditions of the soil at different times may possess power-
ful properties.
The varying hygrometric condition of the soil and its fluctuating
temperature are just the conditions likely to affect the
condition of multiplication and possible virulence of the plague bacillus.
the soil and ^^ ^|^g same time they may exercise a ffreat influence on
its fluctuating _ . . .
temperature, the life of insects which may carry infection to and between
an ^effect on^^ animals susceptible to plague such as rats. An instance
microbic and of certain seasonal conditions, bringing into activity swarms
of insects, is to be seen in the annual but sudden ap-
pearance of green flies in Calcutta near the end of the rains. So great
is their number that for several nights it is impossible to read with
comfort except under a mosquito curtain. They get into the food and
drink, swarm around the lamps, and it is impossible to be comfortable
for the few nights of their ephemeral existence. The flies disappear
almost as suddenly as they come. They are the harbingers of the cold
weather. It is possible that insect life of a different order, useful in
assisting the spread of plague by acting as carriers, may be brought into
activity by certain conditions of the soil. In relation to this it is
interesting to note that Dr TidswelP, when collecting different species
of fleas infesting rats, had no difficulty during the epidemic of plague of
finding many fleas on rats, but as soon as the epidemic was over the
rats appeared to be exceptionally free of fleas. The egg, larva and
1 "Ecto-paiasites of the Eat." By Frank Tidswell, M.B. Report of the Board of
Health on a second outbreak of Placjiie at Sydney, 1902. By J. Ashburtou Thompson, M.D.,
President.
154 Epidemiology of Plague [part ii
pupa of fleas on rats are probably affected in their development by the
seasonal temperature and moisture of the soil, which vary in time in
different places but recur about the same time yearly in the same locality.
That a mean temperature of 83° F. should exert so marked a control
over an epidemic of plague, while the bacillus flourishes in man at
98 F. and in birds at 107^ F., leads one to suppose that
ture of the the influence is not a direct one on the plague bacillus
directly In- itself, which aj)pears to be able to develop at considerably
fluentiai. higher temperatures than 83° F. Especially is this view
emphasised when it is considered how much the infection is a house
infection, where direct sunshine plays a very unimportant part, the
microbe being never exposed to any very high aerial temperature, or
to any exceptionally low temperature which might destroy it.
Connected with seasonal influences is also the peculiar fact that, on
the decline of an epidemic, infected articles and houses in
^he*piague° the infected locality lose their power of infection for the
season infect- time beinsf, until the favourable season comes round again.
ed articles . . . .
lose their in- The best examples of this are from epidemics belonging to
fectivity, but ^^ earlier period than those of the existing pandemic,
may regain it i r
the foUowing because the latter are not dissociated from active measures
for the suppression of the disease. The fact is, however,
discernible in all, whether old or recent. In the plagues of London,
Marseilles, Naples and Egypt the inhabitants who fled when the epidemic
was increasing have flocked back to the infected houses towards the end
of the epidemic, have slept in infected beds, and have worn the clothes
of those who have died of plague, yet beyond a number of accidents here
and there that general infection which was to have been feared has not
taken place ; and yet when a recrudescence takes place in the season
of the following or a subsequent year, the infection is frequently, as in
Hongkong it was largely, connected with plague in the same house in
the previous year or in the year previous to that.
That healthy persons run great risk of contracting the disease during
the epidemic season by sleeping in beds previously occupied by plague
patients was shown in Cairo in 1835, when on the 15th of April two
criminals, Ibrahim Assan and Ben AH, condemned to death, were taken
from the citadel in Cairo and given beds to sleep in which had been
vacated by two patients suffering from well-marked plague. On the
19th of April, Ibrahim was attacked by plague with bubo and carbuncle.
He died on the 23rd. Ben Ali was also attacked at the end of the
3rd day with the ordinary symptoms indicating the invasion of plague,
but the illness aborted and convalescence commenced on the 4th day.
CH. vii] Rapid Loss of Infectivity 155
The rapid loss of infection at a time when the plague bacillus is
most widely distributed in a town is shown bv the following
Instances. . " . . "
passage in Hodges' Loimologia : " ' About the close of the
year, that is in the beginning of November, people grew more healthful
and such a different face was put upon the public that, although
the funerals were yet frequent, yet many who had made most haste
in retiring, made the most to return and came into the city with-
out fear; insomuch that in December they crowded back as thick as
they had fled : the houses which were before full of the dead were now
again inhabited by the living ; and the shops which had been most
part of the year shut up were again opened, and the people again cheer-
fully Avent about their wonted affairs of trade and employ, and even,
what is almost beyond belief, those citizens who were before afraid,
even of their friends and relations, would without fear venture into the
houses and rooms where infected persons had a little before breathed
their last ; nay, such comforts did inspire the languishing people and
such confidence, that many went into the beds where persons had died,
even before they were cold or cleansed from the stench of the disease."
It is not that some of the people so exposed to infection were not
attacked but the vast majority escaped, a contrast to that which
happens when the epidemic is raging. Then the infected house is
dangerous.
The arrival in Bombay of between 250,000 and 300,000 immigrants^
during the months of April, May and June, when the first epidemic was
declining exercised, as will be seen from the chart showing the fluctua-
ting rise and decline of plague and the general mortality of Bombay, no
check on the decrease of the plague, once that disease had commenced to
decline. Although the majority of these immigrants were people who
had fled from the city when plague was becoming epidemic, yet a large
proportion consisted of destitute country labourers, who had flocked into
the city from the famine districts of the Presidency in search of work.
Labour was scarce and the price of grain was high. Notwithstanding
the opening of relief works and the payment of those put on to them
of subsistence allowance, the city contained a large number of feeble,
half-starved and ill-fed persons who crowded into houses many of which
had been declared unfit for habitation. In spite of these circumstances
peculiarly favourable to plague, it was not until the next season in
' Loimoloyia, or an Historical Account of the Plariue in London in 1665. By Nath.
Hodges, M.D., p. 27.
"^ Report of the Bombay Plague Committee on the Plague in Bombay for the period
extending from the 1st July, 1897, to the 30th April, 1898.
156 Epideinloloyij of Plague [part ii
November that the plague once more began to show signs of becoming
epidemic. The disease had lost the infectivity it possessed in November,
December, January and February. This is a very striking feature of
plague, not explainable by lessened opportunity of exposure to infection
from the plague bacillus in the houses or in the sick persons. The
microbe is able, as before, to develop and multiply in the human body
if once introduced, as is to be seen by the residual number of persons
who continue to be atiected with plague, but there is some important
factor or factors wanting which it possessed just before, and endowed it
with its active qualities of infectivity and extension.
The variation in power of infectivity was well known among the
inhabitants of the Levant and Egypt, and the Franks or merchants,
taking advantage of this knowledge, shut themselves up in their houses,
whenever the disease began to show signs of progress, and continued
to do so until there was a marked decline in the disease. Little dread
was felt for the disease when it arrived at the more or less sporadic
stage.
In Cairo the plague used to rapidly decline in the month of June,
and Russell, in some criticisms which he passes on the observation of
Prosper Alpinus that the disease then suddenly ceases, remarks: "'It is
agreed by all that about the 24th of June, at Cairo, there is a remark-
able sudden alteration in the contagious property of the plague, as well
as in the malignity of the disease itself to whatever cause it is to be
ascribed " ; and " the second part of Alpinus' observation that at the same
time the pestilence ceases, the furniture in infected houses suddenly
loses all powers of communicating the disease to the inhabitants, so
that health and tranquillity are at once restored to the city, agrees in
some measure with the general experience of other places in Turkey,
where it is well known houses or goods undergo little or no purification ;
but this is to be understood with some restriction."
The restriction is that there are a fair number of exceptions. For
instance, it was ascertained that those taken ill at the close of the
epidemic of 1720 at Marseilles were mostly persons of the lower class
who had rashly exposed themselves in handling infected goods or in
communication with the sick. The fact, however, still remains that the
infective qualities of plague rapidly disappear at a time when the
bacillus is most widely distributed over the locality attacked. The loss
of infectivity is independent in a large degree of the measures taken to
destroy the bacillus. The behaviour of plague in this respect is the
1 A Treatise of the Plague. By Patrick Kussell, M.D., F.R.S., pp. 268, 269.
CH. Yii] Rapid Loss of Infectivity 157
same in Canton, where no special purification of houses and household
effects is carried out, as in Hongkong, where particular attention is
paid to the disinfection of the premises.
Referring to the practice of the Turks and Moors in Egypt, Mr Bruce
in his travels says: "^The Turks and Moors are known to be pre-
dictionists.... Secure in this principle they expose in the market-place,
immediatel}' after St John's day, the clothes of the many thousands
that had died during the late continuance of the plague, all of which
imbibe the moist air of the evening and morning, are handled, bought,
put on and worn without any apprehension of danger, and though these
consist of cotton, silk and woollen cloths which are stuffs the most re-
tentive of the infection, no accident happens to those who wear them
from their happj^ confidence,"
A very different picture from this presents itself at an earlier period
when blind faith in inevitable destiny led to practices during epi-
demics, not only in their stages of decline but also in their stage of rise
and crisis, which were most disastrous. It was not uncommon for
Turks to use immediately, while even damp with the death sweat, the
clothes and linen of persons dead of plague. "If it be God's will I should
die of plague it is unavoidable, if it be not his will it cannot hurt me,"
represented their feelings on the subject, and from such a standpoint
the practical effect was that whole families were exterminated. The
same superstition spread to Cairo, and took such firm hold there that
a traveller remarked that : " Through this Turkish belief plague occasion-
ally rages so severely at Al Cairo, and such a large number of people
fall victims to it that, on different occasions, over 500,000 persons have
died of this fatal disease within 6 months^."
A similar loss of infectivity as that observed with plague on the
decline of an epidemic was noticed in Calcutta at certain
The same ob- . . ^,
servation has seasons of the year m regard to small-pox. ihere were
^^^^^^f-*^® ^^ cycles of four or five years in which there was a rise and fall
small-pox of small-pox, and it was noticeable that if small-pox was
introduced by returning pilgrims from the Hedjaz, as it
often was, while the disease was on the descent no precautions were
necessary to prevent the spread of the disease. A case of small-pox
might be in a building with a hundred others, and yet at the "most
there might only be one or two infected, but more frequently none at
all, notwithstanding intimate exposure. While, if small-pox was on the
1 A Treatue of the PUigne. By Patrick Russell, M.D., F.Il.S.
- The Great Kpiileiuics of the East from Arabian Sources, p. 30. Kremer.
158 Epidemiology of Plague [part ii
upward grade, the danger to the inhabitants was very gi-eat if the case
was not immediately isolated. The same observations were made with
reference to the infectivity of vaccine. During the spring children and
calves showed beautiful vesicles on the vaccinated parts, while in the
rainy season there was the utmost difficulty in maintaining the vaccine
of either children or calves, the vesicles showing signs of degeneration
from the normal, and the lymph not taking when transferred.
The regularity in the seasonal periodicity of plague in an infected
locality has been attempted to be explained by the seasonal
perio^city of breeding period of the rat. Gotschlich, in discussing this
plague, and subject as regards Egypt, points out that there are two
breeding types of plague prevalence in that countiy, the winter or
period of the pneumonic type, due to infection from individual to in-
dividual, and the summer or bubonic type, due to rat
infection. The bubonic form according to this observer is always the
initial disease in man, the primary pneumonic arising in the course of
an epidemic from secondary plague pneumonia in a bubonic case. In
examining 6500 rats in the course of a year, Gotschlich found from
November to February, i.e. during the plague-free winter months, that
only 2 ^0 of the rats Avere pregnant ; in March and the first half of
April there was a gradual rise, reaching in the second part of
April 6 7„, and to 12 ^o by the middle of Ma}^ after which there
was a rapid fall, the percentage being at the end of September 5 "/o
and in October 2 "/o- It was also observed that in the plague-free
months, many of the older rats suffered from a latent or chronic form
of plague, while when the younger rats came into existence these young
rats were susceptible to the acute diseased
^ Neue epidemiologische Erfahrungen iiber die Pest in Aegypten von Prof. Dr Emil
Gotschlich. Festschrift zum sechzigsten Geburtstage von Robert Koch, 1903.
CHAPTER VIII.
VARIATION IN VIRULENCE OF PLAGUE EPIDEMICS.
A GREAT mortality in a country may not be synonymous with virulence;
for example, the epidemic of Egypt of 1834-35, though it caused some
50,000 deaths from plague in the country, had an average case mortality
of about 33 per cent., contrasting in this respect with some of the earlier
epidemics, when it was nearer 70 per cent. A comparison of epidemics
of plague with each other shows that no standard can be equally applied
Variation in to all, for they differ very considerably in their respective
virulence. severity, some epidemics being remarkably benign, others
extremely malignant, and between these extremes there is every variety
approximating more or less to one quality or the other. Nor is the
difference in type peculiar only to different epidemics, for the same
epidemic may be at one stage malignant and at another mild.
The attention which malignant plague epidemics attract almost
excludes the consideration of mild epidemics, and yet the latter are
equally important from an epidemiological point of view, for, as will
be seen later, the mild may develop gradually or suddenly into the
severe, and the severe attenuate into the mild. Great epidemics and
high mortality are so written into the history of plague, that it is
difficult to realise they are the history only of great epidemics, and that
the disease may be associated Avith neither of them. The most con-
Mild epidemic spicuous outbreak of plague of a mild nature on record is
of plague at that which occurred in the Delta of the Volga in the city
Astrakhan . . . ^ f_i_
and Vetii- of Astrakhan and its environs in the summer of 1877 ^
^"^^ Some 200 persons were attacked and only one died. The
symptoms were malaise, fever, sometimes acute, running in a few cases
to as high as 104° F., and swellings of the lymphatic glands in the neck,
^ Ninth Report of the Local Government Board, 1879-80. Supplement by the Medical
Officer, p. 49.
160 Epidtiii'ioloijii of Plcujue [part ii
groin or arm-pit. The swellings ended either in resolution or suppura-
tion. When the glands began to swell the indisposition usually dis-
appeared, the appetite and general functions of the body became normal,
and the patient, except for the swelling impeding motion, was rarely
disabled and prevented from going about. The cases ran a course of
from 10 to 20 days, sometimes longer. The disease seems to have re-
curred in the summers of 1878 and 1879, but there are no details given.
This epidemic would never have attracted special attention, had it
not been followed in the autumn of 1878 by a severe outbreak of plague
at Vetlianka, a Cossack settlement higher up the Volga in the province
of Astrakhan. The outbreak is notable for its malignity, and for
the alarm which it caused in Europe. Malignity did not, however,
characterise its commencement. From October to the middle of
November, the malady presented similar symptoms to the non-fatal
outbreak in the city of Astrakhan, viz. fever, slight but debilitating, and
glandular swellings. Dr Doppner, who saw the cases at the beginning
of November, states that they were marked by two or three paroxysms
of shivering, and succeeded by a hot stage, and by swellings of the
inguinal and axillary glands, often ending in suppuration. The sick
persons were afoot with good appetites, the organic functions un-
disturbed, and sleeping well. They had abscesses of the lymphatic
glands, either of the groin or the arm-pit, which were suppurating freely.
The duration of the sickness was from 10 to 20 days, and all the cases
recovered. In the middle of November a second phase in the disease
TheVetUanka manifested itself, and the symptoms became so violent
outbreak sud- that they proved fatal in from 12 hours to three days. From
denly ac- t w i .
quires great ^November 27th to December 9th of 100 persons attacked
virulence. 43 j-^^j .^^d 14 recoveredi. From the 9th of December
the malady became more acute. New patients, whose general state
appeared good, were seized with violent palpitation of the heart, a pulse
that could not be counted, vertigo, praecordial anxiety, haemoptysis,
and vomiting of liquid uncoagulated blood. The face was pale, expres-
sion apathetic, and eyes heavy and sunk, with dilated pupils. In the
course of a few hours extreme prostration supervened, violent feverishness
set in with somnolence, slight delirium, constipation and suppression of
urine. Fnjm the 10th of December were added to these symptoms, in
1 Keport of Dr Doppner, the Principal Medical OflScer of the Cossack troops in the
Province of Astrakhan on the outbreak of Plague in Vetlianka in November and December
1878. Ninth Ainitial Report of the Local Government Board, 1879-80. Supplement by
Medical OJicer, p. 52.
CH. viii] The Vetlianka Outbreak 161
some cases, spots upon the skin varying in size from a millet seed to
a ten copec piece ; the patients exhaled a peculiar odour like honey,
became collapsed and died during a state of lethargy. There was no
mgor mortis, and decomposition set in at the end of two or three hours.
From the 9th of December the rate of mortality increased from day
to day, and on the 14th of December every person attacked died.
In the Vetlianka outbreak it is evident that a transformation had
taken place from a mild bubonic form of plague to the septicaemic and
pneumonic varieties, the symptoms being those that are to be recognised
in patients suffering from these types of the disease in the existing
China epidemic. There was in the Vetlianka outbreak a gradual ascent
from the non-fatal cases of Astrakhan to the bubonic form of plague,
more or less malignant, which in turn reached the septicaemic and
pneumonic type. It is possible that the pneumonic cases first showed
themselves as secondary pneumonias in bubonic cases and that these
secondary pneumonias gave rise by their infective sputum to the con-
tagious primary pneumonic type. Plague of this malignant type is rarely
accompanied by buboes, and accordingly it is not surprising that some of
the medical men were inclined to think that the latter manifestations were
not plague, but typJioid pneumonia or typhus complicated with pneumonia.
It was only in 1897, during the first epidemic of plague in Bombay, that
the pneumonic form of plague, the most fatal of all forms, was clearly
ditferentiated by Dr Childe of the Indian Medical Service. In addition
to a description of its symptoms and of its pathological appearances he
showed the sputum of the patient suffering from it to be filled with
plague bacilli, and the disease to be extremely contagious. It was not
the first time the pneumonic form of plague had been recognised. Guy
de Chauliac of Avignon' in 1348 described the epidemic of plague
which ravaged Avignon as consisting of two types. The first, the most
malignant and contagious, prevailed during the first two
lignity of tbe months. The symptoms were constant fever, cough, and
dIm^°of 1348 spitting of blood, the illness ending fatally in three days,
with its pneu- The second caused no symptoms of spitting of blood, but
toms followed buboes appeared in the groin, under the arm, or in the
by a less ma- neck, and the patient gradually succumbed on the fifth
day. The second type seems only to have been observed
two months later than the pneumonic type, and appears to have lasted
five months. In this instance it was an attenuation or decrease of the
virulence and not a development or augmentation as in the preceding.
' La Grande Cliirurgie de Maixire Guy de Chauliac. Par M. S. Miugelon Saule,
Traits ii. cap. v.
S. 11
162 Epidemiolofiy of Plague [part ii
Different types with varying degrees of virulence may be seen
running concurrently or following one another in the same epidemic.
At Kathiawar in 1820 pneumonic plague and ambulant plague, which
is generally the mildest form of plague, were observed in the same
epidemic. Dr Whyte \ in writing of the varieties of plague
types with which he and Dr Gilder met with in the outbreak of plague
grees°o^ viru- '" Kathiawar in 1820, describes the pneumonic form as
lence may be follows : " The characteristic symptoms of this variety are
concurrently slight cough, pain of the chest, and haemorrhage from
or following ^j-jg ^uouth attended with fever, but with no buboes." He
one another . -i i i i •
in the same also mentions a mild bubonic variety ; he saw a great
epidemic. number who had buboes without any fever, and was told
that upwards of a hundred and twenty had suffered in this way.
" These people walked about without either alarm or inconvenience,
for none had died and not many of the buboes suppurated."
Dr Forbes- in his account of the Indian epidemic of 1836 in which
Four different plague broke out in Pali, a town in Marwar, divides the
types of types of plague seen by him into four forms : first, an
plague in the -^ V i i • ii • i i , •
Pali epidemic ordinary bubonic ; secondly, a more virulent and malignant;
of 1836. thirdly, a most fatal pneumonic in which there was scarcely
any febrile excitement, slight cough and bloody expectoration, with
oppression at the praecordia being the chief symptoms ; and fourthly,
an extremely mild form in which the glandular swellings made
their appearance with little constitutional disturbance, and were at-
tended only by languor, debility, and a great feeling of indisposition.
In the latter buboes went on slowly to suppurate and health was only
gradually restored. Dr Forbes' description of this mild form is similar
to that given by Fodere, as applying to the benign plague observed
in the Levant and in Marseilles in 1.720, and concerning which Fodere
declares that it is no less plague than the other forms, and equally
demands the attention of the physician and of the magistrates. This
plague of Marseilles was divided into five classes by the physicians
Five degrees ^'^° reported on it. The first class included the most
of severity malignant cases ending in speedy death, and was observed
Marseilles specially at the commencement of the epidemic, but
epidemic towards the end there was observed the fifth class charac-
oi 1720. • J 1 r •
tensed by few signs of illness and ending always in re-
covery. " This fifth and last class contains all such infected persons, as
1 Eeport by Dr Whyte to the Secretary to the Medical Board, Bombay, 1820.
* Nature and History oj Plague as observed in the North-lVest Provinces, by Frederick
Forbes, A.M., M.D.
CH. Aaii] The Efjyptian Aura Pestilentiae 163
without perceiving any emotion, or there appearing any trouble or lesion
of their natural functions, have buboes and carbuncles which rise by little
and little and easily turn to suppuration, becoming sometimes scirrhous,
or, which is more rare, dissipate insensibly, without leaving any bad
effect behind them ; so that without any loss of strength and without
changing their manner of living, these infected persons went about
the streets and public places, only urging themselves a simple plaster,
or asking of the physicians and surgeons such remedies as are necessary
to these sorts of suppurating or scirrhous tumours'."
Samoilowitz-, in his account of the plague in Russia in 1771, says
the disease varied according to the stage of the epidemic.
Three degrees o _ . .
of severity which he divides into three periods : that of invasion, that
thrRussian '^^ ^^^'^ middle, and that of the end or decline. The milder
epidemic of degree of the disease corresponded with the period of
invasion, in which the patients suffered from headache,
vomiting, and buboes which suppurated. Samoilowitz saw several
persons at this stage who recovered without medical assistance. Towards
the middle of the epidemic the disease assumed its most terrible and
fatal form. Then the patients had carbuncles, petechiae, headache,
delirium followed by prostration, constant vomiting, diarrhoea and in-
continence of urine. Sometimes it was impossible to stop these two last
excretions. At other times it happened to women that the menstrual
How could not be stopped, and when pregnant they miscarried, the orifice
of the womb relaxing and opening with ease. On the decline of the
epidemic milder cases again occurred, similar to those of the period of
invasion.
In the epidemic of Cairo in 1884 and 1885 investigated by Clot Bey^
. , Gaetani Bey, Lachese, and Bulard, different degrees of
An Aura . . .
Pestilentiae severity of the disease were observed at different stages of
Egyptian ^^^ epidemic, and it is stated that the great majority of
epidemic of the population felt the influence of the epidemic, though
1834-35. ^ ^ 1 o
not actually attacked with plague. Thus, among those
suffering from the Aura Pestilentiae, as it was called, painful glands
were felt in the groins, or arm-pits, the pain being usually slight, but
increased by pressure, muscular contraction or movement of the limbs,
' An Account of the Platiue at Marseilles, its symptoms, and the methods and medicines
used for curing it. By MM. Chieoyneau, Verney, and Souillier. Translated from the
French by a Physician. London, 1721.
- Memoire sur la Peste qui, en 1771, ravaga Vempire de Russie. Paris, 1783.
■* De la Peste obseriSe en Egypte. Par A. B. Clot Bey.
11—2
164 Epiflemiolog}! of Plague [part ii
and appearing or disappearing, to reappear again w ith malaise, want of
appetite, white tongue, nausea and giddiness. The expression of the
face was altered. Those who were thus affected, without ceasing from
their business, were not infrequently in danger of being attacked with
the disease.
In the first variety of the disease which was encountered in the
Three degrees middle, and especially in the decline, of the epidemic, in
of severity in addition to the phenomena belonging to the Aura Pesti-
the Eg-yptian ^ ...
epidemic of lentiae, there were observed slight fevenshness, frontal
^®^* ^^- headache, altered expression of the face, nausea, which
was sometimes followed by vomiting, and buboes and superficial car-
buncles, which appeared together or one after the other in different
glandular regions. The buboes terminated by resolution, suppuration,
or induration. The patients seldom took to bed, the perspiration was
easily established, and the termination was never fiital.
The second variety was characterised by shivering, vertigo, headache,
depression more or less profound, general lassitude, staggering gait, as if
intoxicated, lumbar pains, dazed condition, dull gaze, injected eyes, em-
barrassed speech, fi'equent respirations, nausea, vomiting of mucous and
bilious matter, which sometimes and at a more advanced stage was
blackish, with oi- without heat of skin, frequent pulse, sometimes
delirium, tranquil or agitated, restless and tiresome dreams, slight pain
in epigastrium, moist tongue with white fur and red at tip and edges,
becoming after the second or third day dry and red, or black in centre, and
cracked, fuliginous teeth, diarrhoea sometimes declaring itself after the
first vomiting, and the urine red, sometimes with blood, and diminishing
towards the end, even becoming suppressed. On the second or fourth
day this variety was distinguished by appearance of buboes in the arm-pits,
groin, or neck, very rarely in the popliteal space, and of carbuncles and of
petechiae, continuous delirium, coma and death on the fourth or fifth day.
On the other hand if the patient improved the symptoms lost their
intensity, the tongue became moist, the skin soft, the pulse stronger,
the buboes went on to resolution, suppuration, or induration, the
carbuncles, if any, stayed their necrotic action, the petechiae resolved
themselves in the manner of enchymoses, and the patient entered
into a state of convalescence on the sixth or eighth day. Sometimes
the illness was prolonged, tiie tongue remained dry, red or swollen,
its centre was covered with a blackish coating, the teeth became more
fuliginous, the abdomen swollen up, diarrhoea persisted, the motions
were foetid, sweating and diyness of the skin alteraated, the pulse was
CH. vni] Febris Interinittens Bnhonica 165
frequent and irregular, sleep was disturbed, sometimes delirious, the
buboes went on slowly towards suppuration, and when it occurred it
was serous and foetid. The patient became convalescent about the
fourteenth or twentieth day, or the symptoms became aggravated and
the issue was fatal. This variety predominated towards the middle
and decline of the epidemic.
In the third variety there was an exaggeration of all the preceding
symptoms. It was characterised by an air of hebetude, extreme mental
and physical prostration, restlessness, trembling, pains in the loins,
almost normal heat of skin, short and rapid respiration, quick, small
and full pulse, moist, large and bluish tongue, bilious vomiting, some-
times black, no pain in epigastrium, often petechiae of dark colour,
stammering speech, wandering delirium, affected intelligence, extreme
anxiety, with coma, death in 24 or 48 hours, rarely longer, with a cyanosed
aspect and without pain. If the patient lived beyond this period there
was a reaction. The pulse became stronger, the tongue red and dry, the
skin hot, the face flushed, the eyes injected, and towards the third day
there was an eruption of buboes, rarely of carbuncles. Then were estab-
lished some chances of recovery, and the patient might present similar
symptoms to those at the termination of the second variety, but this
termination was rare. Buboes, petechiae and carbuncles may be absent
in this variety. This form was found during the first months of the
epidemic almost exclusively, although it was also seen at every stage.
In the Marseilles epidemic of 1720, and the Cairo epidemic of
1834-35, the most malignant cases occurred at the commencement of
the epidemic, and the disease became milder in the later stages. This
is usually the most common behaviour of an epidemic, but is by no
means a general law, for exactly the opposite sometimes occurs, the
epidemic beginning with mild cases, as happened in the Russian
epidemic.
Mild cases are described by Dr Dutheuil as occurring sporadically
Sporadic ^^ Mesopotamia during the years 1856-1867, and were
cases of mild generally set down as typhus or malarial fever with
precede glandular swellings. One physician proposed to give
severe epi- them the name of bubonic fever, or Febris intermittens
demies of . i i •
plague, or bubonica, a term which was applied also to the earlier
bridErTover cases of plague in Bombay because of their comparative
the intervals mildness.
epi emi . That the cases in Mesopotamia were not typhus nor
malarial fever with buboes, but mild cases of plague, was shown after-
166 Epidemiology of Plague [part ii
wards by the investigations of Tholozan and Cabiadis. The mild type
of plague was carefully studied by Tholozan in regard to the Persian,
Mesopotamian, and Benghazi outbreaks, and he formed the opinion that
they, by their sporadic occurrence, bridged over the intervals between
different epidemics. In writing of the plague in Hiudieh Tholozan
remarks, "It was a question here of a severe bubonic plague which
destroyed in several months about the third of the population of the
encampment attacked. I do not speak of light sporadic cases of bubo
without fever which manifested themselves in 1856, 1858, 1859, 1860,
1861, 1864, and 1865. One of our distinguished colleagues, Dr Batailly,
saw at Bagdad, in the spring of 1867, a great number of buboes, especially
inguinal and almost always without fever, which lingered on till autumn.
Other observers, especially Dr Colville, have recognised the same fact.
At Hillah two military doctors declared that at this time the buboes
prevailed in the regiments, and that they had never given rise to any
case of death. Dr Dickson says that buboes or swellings of the glands
of the groin, axilla, or neck prevailed in the whole province of Bagdad
in the spring of 1867, and that according to native tradition this
frequency of buboes indicated the appearance of plague. At this time
also Dr Palladin observed at Divanie spontaneous buboes in the groin
of two soldiers, a gendarme and a custom-house officer. The four
patients recovered, but they all had a burning fever, a vivid thirst,
a slight delirium at night, and diarrhoea. Dr Palladin, who com-
municated these facts to me in 1870, considered them then as cases
of plague. It may be contended it is not the complete plague, but
the larval or embryonic plague, and the facts demonstrate the slow or
gradual preparation of the illness and the wide primar}^ diffusion of
the germs ^"
The Mesopotamian epidemic of plague in 1876-77^ was also pre-
ceded hy glandular stuellings free of fever. The swellings
glandular showed themselves in the groin, arm-pit, or neck, and
blforrand ^^'®^® "^* accompanied by other symptoms. They began
after plague to appear among the inhabitants at the end of autumn,
prev e e. ^^^ continued through the winter. On the cessation
of fatal plague apyretic glandular stoellings reappeared, precisely similar
to those which had preceded the outbreak, and they continued to mani-
fest themselves for about two months longer. These glandular swellings
^ La Peste en Turquie, Tholozan, p. 86.
2 " On the character of epidemic plague in Mesopotamia in 1876-77." By E. D. Dickson,
M.D. Tramactions Epidem. Society, Vol. iv., 1879.
CH. viii] The Naj^les Outbreak 167
were frequently met with, and were distinct from the chronic adenitic
swellings met with in subjects of a scrofulous tendency, and evidently
unconnected with any special diathesis.
It is curious how often these glandular swellings have been set down
as malarial fever or typhus fever with buboes. In this connection it
has been held that plague was an aggravation of either of these diseases,
and that the one could pass into the other. The pathological confusion
which gave rise to these doctrines has now passed away, and it is known
that each disease has its own specific causal agent, and that nothing
will change a malarial fever or a typhus fever into plague unless the
specific plague bacillus has been superadded. In India and in South
Africa during the epidemics of plague prevailing there the plague
bacillus has been found in the affected glands of the ambulant type,
i.e. in those cases in which the symptoms were so mild that the patient
did not require to take to bed. There are other cases in which it has
not been found, and in which it may be taken that, though the bacillus
was in sufficient numbers to irritate and enlarge the gland, it was over-
come by the vis medicatrix naturae.
Dr Tinno\ in describing the small outbreak of plague at Naples,
points out that in June and July of 1899 and 1900 a considerable mor-
tality occurred among the rats in the port together with a strange
illness among some of the workmen of the port. This illness was
characterised by the presence of buboes, which were taken as venereal
manifestations and treated as such, and it was not until October, 1901,
that the real nature of the disease was recognised in a mild case, which
had also been mistaken at first as venereal.
Dr Tinno recalls the fact that, in the plague at Noia in 1815,
Dr Morca relates that in the preceding year there were many benign
cases, whose nature escaped completely the attention of the profession
and the laity. It was only after the terrible explosion of the disease,
when the symptoms were rendered femiliar to all, that it was recognised
that in the preceding year plague was in the city and the province.
Cantlie has pointed out that previous to the outbreak of plague in
Hongkong and Southern China there was an unusual prevalence of
glandular enlargements which attracted some discussion at the time as
to their nature and cause. In Bombay, as has already been mentioned,
the epidemic of plague in its early stages was called bubonic fever
rather than plague, because of the glandular enlargements and com-
parative mildness of the symptoms. In Calcutta some of the first cases
' Archives de Medecine crperimentale et d' Anatomie patholoriique, Jan. 1904.
168 Fj)idemiolof/f/ of Plague [part ii
in 1896 were of so mild a nature that a controversy arose on the subject.
There can be no doubt, however, that they were cases of plague, and
that the mortality of rats in the native mercantile quarters of Calcutta,
where the produce from Bombay was stored, was due to plague.
Not only may the type and virulence of plague vary in different
epidemics, but symptoms may be present in one epidemic
Presence and . %> ± j.
absence of which are absent in another ; for example carbuncles,
certain symp- ^yhid^ appear to have been an important feature in many
toms in dif- i i _ _ ... . ,
ferent epi- of the older epidemics and an indication of severity, have
emics. ^^^^ been conspicuous for their presence in the epidemic
of to-day. When occasionally carbuncles have been present in the
existing pandemic, they have, as in the plague of Egypt in 1884-35,
rather indicated mildness than severity. The tokens, also, that
were so constant in fatal cases in the Great Plague of London in
1665 have not been observed in recent epidemics. Clot Bey, alluding
to the presence in some epidemics and absence in others of parti-
cular symptoms, points out that in the epidemic of the sixth century,
to the buboes, carbuncles and black boils or pustules there were
added affections of the throat and withering of the limbs ; that in
the fourteenth century lung affections were common, and that in
the sixteenth and seventeenth centuries sweats were a distinguish-
ing feature. In the Plague of London of 1665 there were profuse
and extraordinary sweatings in addition to the ordinary symptoms,
such as shivering, vomiting, delirium, dizziness, headache, stupefaction,
fever, sleeplessness, palpitation of the heart, bleeding of the nose,
great heat aboutv the praecordia, blains, buboes, carbuncles, which
according to Boghurst did not appear until July, spots and tokens.
Hodges, referring to this particular symptom, says : " * These sweats
also of the infected are not only profuse but also variously
dinary and coloured ; in somc of a citron hue, m others purple, in
Bweats^in the Some green or black, and in others like blood, which I
plague of take to be from the various dispositions of the mortified
venom to give different tinctures to the humours; and
by this means some experienced nurses could prognosticate the
event of the distemper from the colour of the cloaths or linen
tinged with the sweat. The sweat of some would be so foetid and
intolerable from a kind of empyreumatick disposition, possibly of the
juices, that no one could endure his nose within the stench ; some-
^ Loimologia, or an Jlifitorical Account of the Plague i)i London in 166.5. By Nath.
Hodges, M.D.
CH. viii] Increase of Virulence in Bombay 169
times it was sharp and in a manner caustick, and hence it was easy
to judge from what origin the pestilence derived its qualities, viz. from
a sharp and burning ichor that would even excoriate the parts, and some-
times vesicate them as if scalding water had been poured upon them,
sometimes cold sweats would break out while the heat raged inwardly
and excited unquenchable thirst." The variation of symptoms in indi-
viduals and seasons is remarked on by Creighton, who quotes Woodall's
experience of London plague in 1603, 1625, and 1636. A letter is
also quoted by Creighton on this variability: "'The practitioners in
physic stand amazed to meet with so many various symptoms which
they find among their patients ; one week the general distempers are
blotches and boils, the next week as clear skinned as may be, but death
spares neither; one week full of spots and tokens and perhaps the
succeeding bill none at all."
In the Moscow and Jassy epidemics it is recorded that the sweat
had a sour odour and so much viscosity as to leave on the skin a thick
and mealy coating. In the plague observed in Egypt at the end of the
18th century, during the French expedition there, the skin was observed
by the French medical men to be covered with a gummy or sticky
coating, and there were frequent haemorrhages. In the pandemic of
to-day, although occasionally gangrene, pustules, petechiae, haemorrhages,
pneumonia, and slight perspirations are seen, yet none of them are so
frequent or so predominant as to give any special character to the
different epidemics ; on the contrary their absence may be considered
to be the distinguishing feature, and their presence as exceptional. In
this respect the present pandemic may be viewed as wanting in some of
the more terrible features of plague ; whether this is a sign of at-
tenuation or degeneration, or one in which further time and opportunity
are needed for more mature development, it is impossible to say.
The epidemic at Bombay in 1896-97 is an example of plague be-
ginning in a comparatively mild form, and in the course
increase in f>f the outbreak exhibiting a progressive rise and fall in
virulence if it yinilence.
appears m the ...
same locality Thus at the municipal hospital the average percentage
^^8°°^^^'^^^ of case mortality which was 61 "5 was for the different
months :
Sept. Oct. Nov. Dec. Jan. Feb. March April May
52-23 52-23 66-67 74-12 69-00 81-64 67-35 56-66 38-46.
I History of Epidemics in Britain, p. 677. By Charles Creighton, M.A., M.U., IB'Jl
170 EpidemioUmii of Plague [part it
The type of" the disease in the recrudescence of the following year was
however of a more fatal character, and there has been a gradual increase
in virulence with successive epidemics.
In the second epidemic of 1897-98 the case mortality was from
78-55 »/n at the Arthur Road Hospital to 79-26 "/o at the Grant Road
Hospital. The third epidemic of 1898-99 was still higher, in its case
mortality being from 78-97 7o at Arthur Road to 81 -40 70 at the Mo-
dikhana Hospital. The average mortality in 5836 cases treated at the
Modikhana, Maratha, and Arthur Road Hospitals during 1898-99 was
80-39 "/o- During the fourth epidemic of 1899-1900 the non-serum
cases at Arthur Road Hospital gave a mortality of 79-54, while at the
Maratha Hospital the mortality on 2599 cases was 80-95. The normal
plague mortality at the public hospitals is, as observed by Dr Choksy\
now about 80 7o-
The virulence of plague became more severe in Bombay in the
epidemic of 1900-1901, and manifested itself in a much larger pro-
portion of cases with nudtiple buboes, and in a greater number of
septicaemic cases. In previous epidemics multiple buboes were only
to be seen in 13-95 °/o of the cases treated in hospital, whereas in 1900-
1901 they reached 63 "/o forming as the epidemic advanced the bulk of
the admissions ; 45 "/o of the cases were proved by examination of the
blood and culture of the bacillus to be already septicaemic at the time
of admission. Dr Alfons Mayr^ in Bombay examined the blood by
culture of 1014 patients on admission at the Maratha Hospital during
1902, and found that 437, equal to 43*09 7o> were septicaemic cases.
None of the septicaemic cases recovered. The pneumonic cases only
formed 2*44 "/o against 4-10 Vo in previous epidemics. In contrast to
this was the very exceptional occurrence of septicaemic cases in the
Cape Town epidemic, their existence to the extent of only 5 "/o in
Sydney, and their absence in the Brisbane epidemics. In Cape Town
the pneumonic types formed 7 Vo of the admissions and
Variation in .\ -^ f p n/^ /
the viriUence lurnished a mortality rate or 70 "/n.
of the disease Variation of virulence of the disease is probably not
dependent on . .
conditions to wholly d(>pendent on the degree of virulence of the microbe
crobe and which changes with the physical conditions it meets in
those attacked nature, and the opportunity it has of passing through
susceptible animals, but also on the differences in the
1 The Treatment of Plague with Profeitsnr Lvntig's Serum. By N. H. Cboksy, M.D.
Bombay, 1903.
'•« Ibid.
CH. viii] Varying SusceptibiUfi/ in Man and Animals 171
predisposition or susceptibility of those attacked. The facilities for
the plague microbe to become attenuated or exalted in the great
laboratory of Nature are not fewer than are to be observed under
artificial conditions in the laboratory. In the latter a race of microbes
so virulent as to cause the death of a monkey or other animal
if introduced into the body by a mere puncture under the skin, can in
a short time become so weakened as to be unable to cause death or any
marked symptom even when given in larger doses. This weakened
race of microbes can in their turn be exalted to virulence.
Different degrees of susceptibility to plague are observed when
experimenting with the same microbe on different animals at the same
time, and even when these animals are of the same species ; one will
take the disease almost at once, another will only take it after a long
period has elapsed, while others will not be affected. This varying pre-
disposition has an important influence on the type of plague and
in the extent to which it spreads in man. The variation is seen
in different races, in different communities, in different families,
and in members of the same family. It is also, as stated, seen
in animals that are the subject of experiment, some of which exhibit
a strong resisting power to the plague microbe, while others succumb
readily to its power of attack. This resisting power or natural im-
munity which belongs to the majority unless the microbe has acquired
an exceptional virulence, or has been received in overwhelming quantities,
is seen in every outbreak, but there are no infallible means of recognis-
ing it in the individual before the ordeal has been passed. Even then
the same individual, who has successfully resisted the plague at one
time, may not do so on another occasion, so that the resisting power,
natural immunity, or non-susceptibility varies in the same person at
different times.
Natural immunity has been the subject of many researches made to
Natural im- ascertain in what it consists, but these reseai-ches have
munity. j^^^ yg^ attained the object in view, except in the discovery
of the presence of protective substances in the blood which are recognis-
able mainly by their physiological effects. The production of artificial
immunity by injection of bacteria and their toxines, and the subsequent
discovery of bactericides and antitoxines thus formed in the blood, have
materially assisted these enquiries. The views generally held, founded
in large part on Ehrlich's experimental work, are that the specific
bacteria or toxines thus injected merely furnish a stimulus to the
functional activity of the cells of the body, causing them to form
172 Epidemiologii of Plague [part ii
iiniimne bodies in larger quantities than usual ; that the property of
forming specific protective bodies is not, as it seems, a newly acquired
(juality caused by the specific bacteria or their products which can
produce nothing in the body which is not already preformed in the
constitution of the specific cell protoplasm, in other words that
immunisation is only the augmentation of faculties already existing
in the cells, that these inherited faculties or specific properties of
the cells, strengthened or weakened by adaptation and selection, are
brought into every-day action by normal forces, and that the .protective
substances in the blood are formed by the assimilation of food, and will
according to Hueppe vary within certain limits with nutrition, environ-
ment and personal hygiene.
According to this view predisposition, natural iuiu^iunity, and acquired
immunity are different manifestations of the same faculties of the
specific cells of the body. This elaboration of protective substance
in the blood, which produces natural immunity, like all other in-
herited properties varies in different individuals, and is exalted or
weakened by natural forces, to which the individual is subjected. Foods,
habits, environment, climate, physical labour, and mental effort, when
suited to the organism, are evidently stimulants which increase the
natural elaboration of these protective substances, while when unsuited
to the organism and accompanied by misery, starvation, depression and
anxiety, they tend to weaken or diminish the production. It is on this
hypothesis that the varying degrees of susceptibility of communities is
explained, that the influence of race, age, sex, comes into play, and that
social and political foi'ces, so far as they affect the food,
mUsU^seTeat- welfare and condition of the people, are important factors in
estravageson the spread of plague. Plague has nearlv always committed
people sub- ^ i i " ■ t i i
jected to de- its greatest ravages on people whose vitality has been
pressing in- depressed by war, internecine conflicts, scarcity and
fluences. .
famine.
The ravages committed by the two great pandemics of plague
in 543 and 1348, and the great prevalence of plague during the
Mahommedan supremacy in the East and in Eastern Europe, have been
attributed to social, economical, and political conditions, which at the
time caused a decline in the general prosperity of the people affected,
and rendered them more susceptible to the disease.
In the present pandemic variation in virulence is observable in
different countries. Thus in Hongkong the mortality of the epidemic
ranges from 89 to 90 "/o of those attacked ; in India from 70 to 85 "/o ;
CH. VIIl]
Case Mortality in Europeans
173
Total plague
Plague mortality of
ortality anioug
Europeans treated
Europeans
in hospital
34-6 0/,
30 to 40 7o
33-3 o/„
24-3 o/„
32-4 o/„
31-6 7o
34-5 7o
440/0
28-5 o/„
in the Mauritius from 68 to 78 ■/„ ; in South America at Ascension it
was from 50 to 66 "/o ; in Kashmir it was 53 "/o ; in South Africa it was
only 48 "/q, though for the coloured population it was 56 "/o ; in Australia
it was 3470; and in Chili it was 33 "/o-
Notwithstanding this variation in virulence of the epidemics in
Wbite people different countries the case mortality among Europeans in
have a fairly different countries is extraordinarily similar, and would
uniform mor- . . ... ....
taiity from indicate that predisposition and all it implies is a very
evStheTmay P<^werful factor in combating plague,
be attacked.
Hongkong
Bombay
Cape Town
Sydney
Brisbane
Oporto
Glasgow
It is possible that this greater resistance of the white is only of
comparatively modern development, and it is a question how long
it will continue once the microbe adapts itself to European conditions.
In Bombay there was evidently, even in the case of natives, a greater
resistance to the first epidemic than to subsequent epidemics.
The clinical features of plague in China, in India, and in South
Africa, though presenting in common glandular affections and nervous
incoordination, exhibited great differences in intensity as a whole.
The difference in severity and in type was conspicuous, and it is possible
that this difference in severity accounts for the somewhat conflicting
accounts as regards mode of conveyance, channels of infection, and the
extent to which animals are affected in the different countries. The
disease in Hongkong is more virulent among the Chinese, and in
Bombay among the Indians, than it is among the coloured population
of South Africa, being about 90 "/o, 80 "/n, and 60 "/o respectively.
Locality and environment seem to have some influence, for if these
susceptible races are attacked elsewhere the mortality is
often much less. If one may judge of the account of the
plague in Iquique in Chili, given by Dr J. M. Clarke in
1903 after personal observation, the plague there is even
more modified than in South Africa or Australia. The
disease seems to have had very much its own way, little effort being
Susceptible
races may
become less
susceptible
out of their
own country
174 Epidemiologif of Plaffue [part n
made to combat it ; 500 or 600 cases out of a population of
30,000 would indicate that it was a self-limiting plague. Whether
the mildness was due to Iquique being in the rainless zone of South
America and only 20° from the equator remains to be seen. The
nationalities at Iquique are very mixed, consisting of Chilians, Peru-
vians, Bolivians, Indians and Chinese, but the disease was confined
mainly to the yellow and dark-skinned races and to the half-breeds.
Personal cleanliness is at a discount among the lower orders, many
of whom never wash the whole of their bodies. In the case of the
women and children a garment or dress is put on when new and
allowed to remain on until it falls into rags ; in some cases when a
new dress is bought it is fitted over the top of the old one. Dr Clarke
states that the single men scarcely ever own a room or portion of a
room alone. The climate being good they live in the daytime out of
doors; at night a half-dozen or even more will occupy one room in
which there is no window, and sleep on pieces of sacking spread on an
earthen floor, and this sacking is never swept, turned over, or brushed.
Closets and urinals being unknown among the lowest orders the natural
functions are performed outside and in proximity to the house. Still,
even under these conditions, the disease was of a mild character, the
young were most frequently attacked, females formed 66 "/o of the cases.
For the most part the fatal cases occurred between the ages of 16 and
22, and often death did not take place until the lapse of 20 to 25 days.
There was great confusion between plague and venereal cases, the
former being put down to the latter.
Even in India with its usual mortality ranging between 70 and 85 7o>
Susceptibility there are instances in which the mortality was exceedingly
may vary in small, not at the beginning: but throughout the epidemic,
the same race o o o i ^
in different The outbreak among the Souttars of Kosumba village
localities. jg .^ ^g^gg \^ point. Here, according to Dr Dyson ^, the
Sanitary Commissioner of Gujarat, the disease was of a mild type
characterised by slight fever of two or three days' duration, and the
formation of buboes, chiefly in the groin. " Fully three-fourths of the
thirty-one cases which occurred were of this type, and during one visit
to the village I found two boys about 12 years of age with buboes in
the groin whose fever had been so slight as to escape observation, and
they had not been recognised as ' plague.' " Race was here not a factor
in the attenuation, for in neighbouring villages the disease was virulent.
^ Account of Plague administration in the Bombay Presidency from September 1896 till
May 1897, p. 243. By M. E. Couchman, 1897.
CH. viii] Dissimilanty of Plague Ejndemic 175
Some local conditions connected either with environment or food or
both appear to have affected the constitution of the inhabitants and
rendered them more resistant or to have modified the virulence of the
attacking microbe.
Variety of type is seen in all infectious diseases. Cholera at one
^ . - time will become epidemic, causing between 70 and 80 "/o
type is seen of a mortalit}', while at another time the mortality only
fectious reaches from 18 to 20"/,,. The same is seen with small-
diseases, pox. In one epidemic it is of a malignant character and
verj' fatal, while at another it is mild and with a small death-rate.
Scarlet fever has changed within the last 20 years from a compara-
tively malignant and serious disease to one that is so mild at times
as to be scarcely recognisable. Mildness is no more permanent than
severity, and with the ever-changing conditions of nature variation
in type becomes a general law. It is impossible to say when a mild
form of plague will become virulent, or this in turn become mild. The
transformation is, nevertheless, a real one though the conditions which
bring it about are unknown. Another cause of increased virulence
may be the association of the plague microbe with other microbes.
There can be little doubt that the early decomposition to which plague
bodies are liable in some epidemics, and the offensive smell that is
stated to arise from the patients, are due, not to the disease of plague
alone, but to mixed infection. Plague may begin in a mild form in
a new locality, then pass to a virulent variety which on reaching epidemic
proportions gradually declines, and in the stage of decline loses its
malignity and returns to the mild form ; or it may commence in a
severe form and continue to be severe throughout the epidemic or
gradually become milder ; or it may begin in a mild form and remain so
to the end.
CHAPTER IX.
FOSTERING CONDITIONS OF ENDEMICITY AND EPIDEMICITY.
While the duration of individual epidemics varies, so also does the
duration of the existence of plague in a country which it has invaded.
A city may be visited by a short and sharp epidemic lasting only one
season as in Cape Town, or it may continue year after year as in
Bombay. It is often difficult to determine when the recurrences of
Discrimina- ph^gu© in a locality merge into endemicity, or in other
tion between words into the acclimatisation and the development of
recrudescence , , i • , mi n • i • •
and the disease m a new centre, ihere are tew epidemics
endemicity. ^j^g^j^ ^j-g qq^ followed by one or more recrudescences
of smaller or larger dimensions during the subsequent year, and
some of these recrudescences may occur for several successive years.
Certain localities may even suffer from periodical and frequent
epidemics, and yet the disease may not be endemic though it may
have all the appearances of such, because the locality by its situation
may be exposed to fresh importation and may have scarcely recovered
from the effects of one epidemic with its recrudescences before it is
subjected to the onset of another. These though often viewed as
endemic areas do not come under the category of those localities in
which the disease manifests itself sometimes sporadically, sometimes
epidemically, for a long series of years.
It is possible that this was the case with Egypt, which for centuries
was viewed as one of the birth-places of plague. It is remarkable,
however, that when Egypt was politically cut off from Mesopotamia
and stood in its relations to the region of the Euphrates valley in an
isolated and independent position, it remained free of plague for nearly
300 years. It is, moreover, curious that when quarantine was intro-
duced into the Ottoman Empire plague soon died out in Egypt and in
Turkey. Before quarantine the epidemics of Turkey infected Egypt
CH. ix] E)i(lemlc Centres 177
and vice versa the epidemics of Egypt infected Turkey. Quarantine
was introduced into the Turkish dominions in 1838, and in Alexandria
an International Sanitary Council for maritime and (juarantine purposes
was established in 1831. Plague disappeared from both countries by
1845, assisted no doubt by the decay into which the trade and commerce
of Bagdad with the West had fallen. A similar relationship exists
between Canton and Hongkong, by which new infections are introduced
and epidemics maintained. When plague becomes dangerous in Canton,
large numbers leave for Hongkong and bring to the colony fresh and
virulent infection, and when plague increases in Hongkong, people leave
for Cant(jn and take with them virulent plague.
There are certain localities, however, in which the disease has
Endemic prevailed for many years. Such are Kumaon and Garhwal
centres. j^-j India, and Yunnan in China, Assyr in Western Arabia,
and Irak Arabi in the valley of the Euphrates. There are other
localities where it reappears without trace of importation, such as in the
Benghazi district in Northern Africa and in the highlands of Turkish
Kurdistan. New foci have also recently been discovered in the Trans-
baikal province in the neighbourhood of Lake Baikal, and also in the
vicinity of the great lakes of Uganda.
Perhaps when more is known of these endemic centres it will be
found that endemicity even in relation to them is only a relative term
and that there are no endemic areas in the sense of plague never being
absent from them. At all events this and other kindred questions
of epidemiology and etiology will only be decided by lengthened in-
vestigation in some of these so-called endemic centres.
The old endemic areas in the region of the Tigris and Euphrates
valleys are still centres in which plague is endemic, but since the
discovery of plaarue in the higfhlands of Kurdistan, it has
Kurdistan •/ i o o
been suggested by Tholozan that Bagdad and the sur-
rounding towns and villages receive their plague from Kurdistan, which
is the actual endemic centre of this region. Babylon and Bagdad under
these circumstances from their important commercial relations are likely
to have been the distributing centres to Syria, Egypt and Persia, just as
Canton and Hongkong are to-day the distributing centres of the plague
from the endemic centre of Yunnan. The endemic areas, as now known,
are chiefly distinguished for their high altitudes, for the poverty and tilth
of the inhabitants, and for the promiscuous manner in which the cattle,
fowls, and domestic animals are permitted to live in close association
with human beings, the former often occupying the same room as
s. 12
178 Epidemiology of Plarjue [part ii
the latter. It is found also that the plague lingers longest in low-
lying countries in which the habits of the people are similar to those
of the highlands.
Apart from epidemics in India, there has existed in the North-west
Provinces since 1823, probably longer, an endemic plague centre in the
Kumaon and districts of Kumaon and Garhwal situated on the southern
Garhwai. slopes of the Himalayas. These districts, the snow-clad
peaks of which rise to an elevation of 23,000 to 26,000 feet, are bounded
on the north by the Himalayan range and by the Thibetan frontier, and
on the south by the plains of India. They lie between latitude 28° 14' 15"
and 31° 5' 30" and east longitude 76° 6' 30" and 80° 58' 15" and embrace
an area of over 11,000 square miles, in only half of which are found
localities adapted for cultivation ; of this half, three-fifths are always
covered with snow, one-fifth is cultivated, and the remainder is not\
The average altitude of the mountain ridges is about 7000 feet above
the level of the sea. The greater part of the population lives at from
3000 to 6000 feet above sea level and consists mainly of Hindus. The
villages are scattered over the mountain side, exposed to the pure air
of the hills and supplied with water from mountain streams. Villages
thus situated are about the last places which one would expect to find
to be the seat of an infectious disease such as plague, yet it is here
that the disease is known to have prevailed in 1823, 1834, 1835, 1846,
1847, 1849, 1850, 1851, 1852, 1853, 1854, 1859, 1860, 1870, 1876, 1877,
1884, 1886, 1887, 1888, 1891, 1893, 1894, 1896 and 1897^ The local
names by which it is known in the Himalaj'as are Mahamari, and Gola
or Phulkiya Rog. The .sjaiiptoms and post-mortem appearances of
Mahamari are identical with those of plague and are thus described
by Dr Pearson : " Chilliness, giddiness, unusually severe headache,
pain and throbbing of the temples, trembling of the limbs, inability to
Characteris- remain in the erect posture, great prostration of strength,
tics of the fever continued, thirst, tongue foul, chalky white, eyes
O U til) T'6 elk S
heavy, watery and injected, breathing hurried, pulse
small, frc(iuent and unequal, nausea, vomiting and purging of bilious
matters, urine high-coloured, clammy perspiration and heat and
burning of praecordia, occasionally yellowness of the skin and eyes,
wandering delirium, buboes in the groins, glandular swellings in the
axilla, or neck, carbuncles, petechiae, expectoration of blood, convulsions,
^ "Endemic Plague in India." By Surgeon-General C. R. Francis, M.B. Transactions
of the Epidemiological Society of London, Vol. iv. 1879-80.
2 The Plague in India 1896 and 1897. By R. Nathan.
CH. ix] Mahamari 179
coma terminating in death on the third or fourth day." The earlier
cases are often without buboes, being evidently of the septicaemic and
pneumonic varieties, and the later with buboes but evidently of a
virulent type. In a recent outbreak of plague in Garhwal in which
the disease was not imported from the plains, film specimens and
cultures made by Dr Chayton White were identified by Haffkine and
Hankin as plague bacilli. The view that Mahamari and the Black
Death are different diseases from bubonic plague can no longer be
entertained.
The disease varies in its diffusive power, sometimes being more or
less sporadic and confined to a few houses or to a village, at other
times extending to many villages or even down to the plains as occurred
in 1853-54. In the 1853-54 epidemic there were about 8000 deaths.
It is for the most part very virulent, ending in death in the third or
fourth da^^ In Dr Kenny's report' of 1850 it is stated that "the
mortality from Mahamari is very great, not so much in actual numbers
as relatively to the small amount of the population. The recent
mortality has been estimated by the civil authorities to be probably
25 "/u of the total population. Recent enquiries show it to have been
even greater, but the statistical details are most defective. In certain
places the destruction has been very great, of which an example has been
given of 14 deaths out of 16 people in one place. In the village of
Sarkoto in 1846-47, if the reports of the inhabitants can be trusted,
out of a population of 65 in all, 43 died, two only recovered and 20
remained without infection."
Probably during the intervals of the virulent type there are mild
cases. When Mahamari descended into the plains in 1853 so mild
were the few cases at Kasheepore that Dr Stiven was of opinion
that the swellings in the groin and arm-pit were not in the least
suggestive that the cases were analogous to Mahamari. On further
experience he formed an opposite opinion and he believed that they
were cases of Mahamari modified by the diluted nature of the infection.
Whenever the disease breaks out in a village the inhabitants leave
their houses and encamp at some distance on the hill side until they
think the infection is over. But as the first cases are frequently
without buboes the village may not be vacated until a fair number
is attacked and glandular swellings appear as one of the symptoms.
A precursory sign which almost invariably appears is the death of
1 Medical Report on the Maliamurree in Garhwal in 1849-50, aud Appendices, p. 18.
By Dr G. Kenny, Superintending Surgeon, Meerut Division, Agra, 1851.
12 2
180 Epklemiologii of Plaffue [part ii
rats in a village before plague breaks out. It is seldom that the
inhabitants avail themselves of the sign. Dr Hutcheson' mentions
the case of a village where the inhabitants vacated their houses on
account of a great mortality among rats and mice, and thus an outbreak
of Mahamari was in all probability averted.
That plague should prevail endemically in high altitudes and in
sparsely populated districts with a salubrious climate, and with the
natural surroundings of the villages exceptionally healthy, would be
per))lexine: were it not that the effects of the.se hygienic
Poverty of the ^ \. . ° , , i p i i , • i i i j
inhabitants, conditions are completely defeated by the singularly bad
exceptionauy conditions under which the people live in their houses
insanitary . .
houses and and which are highly favourable to the maintenance and
tion^of ^^°'^^^' dissemination of disease. It has already been stated that
animals the people in endemic areas are usually poor and ill-
nourished. To these may now be added exceptionally
insanitary surroundings. For Garhwal and Kumaon there is the
testimony of Drs Renny, Pearson, Francis and Planch who have at
different times investigated some of the outbreaks. Each of them
agrees in emphasising the extraordinary filthiness of the dwellings and
the uncleanliness of the inhabitants owing to the houses accommo-
dating men and animals together.
In 1850 Dr Renny- reported that "the filth is everywhere in their
villages, their houses and their persons. It destroys the otherwise pure
quality of the air and maintains ever round the inhabitants that
contaminated atmosphere so favourable to the condensation of infectious
emanations. Their dwellings are generally low and ill-ventilated except
through their bad construction ; and the advantage to the natives in
other parts of India of living in the open air is lost to the villagers of
Garhwal from the necessity of their crowding together for mutual
warmth and shelter against the inclemency of the weather. The food
of the majority is bad and insufficient." Dr C. R. Francis-', who investi-
gated the disease in 1858 along with Dr Pearson, in discussing the cause
of Mahamari and how it is propagated, says, " I am afraid that we
have no better answer to the first question than we had thirty years
ago. We now know indeed, as we presumed then, that insanitation
' " Maliamari, or the Plague in British Garhwal and Kumaon. " By J. Hutcheson, M.D.
Transactions of the First Indian Medical Goni/ress, 1894.
- Medical Report on the Mahamurree in Garhwal in 1849-5(1, and Appendices, p. 11.
By Dr C. Eenny, Superintending Surgeon, Meerut Division, Agra, 1851.
3 " Endemic Plague in India." By Surgeon-General C. R. Francis. Transactions of the
Epidemiological Society, Vol. iv. 1879-80.
CH. ix] Co7iditions in Kumaon 181
fosters the disease and doubtless invites outbreaks ; for a relaxation of
hygienic regulations (partly as a result of the mutiny of 1857 and
partly, it must be added, in consequence of the chief civil authorities in
Kumaon not believing in and therefore not rigidly enforcing them)
always has been followed by the reappearance of the disease in as violent
a form as ever. From 1854 to 1857, during which period owing to the
energy of Mr (now Sir John) Strachey in Garhwal sanitary progress was
there most vigorous and effective, the plague was comparatively
quiescent; but in 1859 and again in 1860 it visited the Northern
Pergunnahs in Kumaon with great severity ; and in these years 1000
persons died from the disease. Again in 1876-77 there occurred 291
cases of which 277 were fatal — a death-rate of about 95 per cent. !
(The official returns show that 3600 deaths from Mahamari have
occurred since its first appearance in 1823.) Until hygienic measures
were adopted, the general uncleanliness of the people in their persons and
entouracje was incredible. A small stone dwelling (built upon a surface
^ „ . , 13 feet square) consisting of two rooms each about 5 feet
Dr Francis .
description of high, one above another — the upper chimneyless and
practically windowless — tenanted by the entire family
of often more than half-a-dozen in number and by huge baskets
containing the family grain ; the lower compartment (a wooden
floor, full of cracks serving as media for the effluvium from below,
dividing the two) being occupied by the family herds consisting
of cows, goats and pigs ; a row of such dwellings (sometimes they
are single or double) spread over an irregular surface similarly
tenanted and flanked at either extremity by the ancestral heap of
manure from which streamlets of liquid filth were flowing in different
directions; the cottages covered with cucurbitaceous creepers, as
cucumbers, pumpkins, melons and the like ; a small forest of hemp,
some 8 or 10 feet high, luxuriating in the immediate neighbourhood of
the village ; a growth of underwood including nettles, &c., between the
two, and more or less surrounding the latter ; and unwashed Pater-
familias, seated in front of his fig-tree, having submitted his head to be
divested of the light infantry skirmishing in his unkempt hair !
Conceive such a village situated towards the base of a mountainous
slope, well within the range of whatever noxious influences may
emanate from the valley below ; located where there would be the
veriest minimum of ventilation ; and we cannot be surprised then when
sickness does come, it should run rampant."
In 1876 Dr Planch' says of the infected village of Kumaon: "The
' Report of the Siniitary Commissioner for the North-West Provinces for 1876.
182 Epidemiolof/t/ of Plague [part n
houses were double-storied, one room below and one above, close,
T^ T,, ^,. ill-ventilated tenements. The lower room was used as
Dr Plancn s
description of a cow-house, the upper room for family occupation,
the houses. j^^ ^j^^ lower room, about 5 feet hitrh, it had been
customary to lodge from 4 to 8 head of cattle or goats at night, and
indeed in some instances as many as the room had standing room
for; the only opening being the small doorway of entrance, tight
closed and barred at night. These rooms were seen to be littered for
about a foot in depth with decaying straw and much manure, moistened
by the fluid excrement of cattle, and the entrance way on each side and
the stone platform facing the lower story were piled with heaps of
manure which had been drawn out of the lower room as necessity
required and there left for eventual removal to the land in the ploughing
season. The upper room was noticed to be roughly divided by wooden
slabs into a front and back portion ; the former used as the family
sleeping place, the latter as a granary. The doorway, and in some
instances a round hole in the front, and a small round hole for the exit
of smoke through the roof of the house, all commonly closed at night,
were the only openings. The floor was made of thin wood, with pretty
numerous cracks so that the warmth generated by the cattle below could
reach to the sleeping people above, aftenvards locally described as
beneficial."
Dr Francis in his description adds pigs to the number of domestic
animals occupying the lower floor of the house.
The similarity of the description of one endemic centre to another is
very striking, whether it is in India, China, Persia, Mesopotamia, Ai'abia,
or North Africa.
Yunnan, the endemic centre in China, has alread}- been described.
Conditions in Like Kumat)n and Garhwal it is some 5000 to 6000 feet
Yunnan. above the level of the sea, the inhabitants live crowded
in their dvvelling-houses, and are much associated in their domestic
life with their cattle, pigs, and poultry. The same phenomenon of
mortality among rats precedes an outbreak of plague as in Kumaon
and Garhwal. The rats leave their holes, lose their timidity, stagger
about and then fall down dead. Large numbers die under the floor,
where, putrefying, they give rise to most offensive smells. The in-
habitants, knowing the signs, immediately begin to take precautions by
burning charcoal in their rooms, and in certain places they abstain
from eating pork. In connection with the abstention from eating pork
at these times attention may here be drawn to the custom of eating raw
meat. Such a custom may assist in maintaining the endemicity of plague.
CH. ix] Conditions in Assyr 183
Marco Polo says : " 'Let me tell you also that the peoj^le of that country
(Yunnan) eat their meat raw, Avhether it be of mutton, beef, buffalo,
poultry or any other kind. Thus the poor people will go to the
shambles, and take the raw liver as it comes from the carcase and
so eat it; and other meat in like manner raw, just as we eat meat that
is dressed." Besides rats, other animals such as buffaloes, oxen, sheep,
and deer, and sometimes court-yard fowls have been observed to take
the disease. The disposal of the dead, both of man and animals who
die of this disease, is defective.
The endemic centre in the plateau of Assyr, Western Arabia, is
Conditions '^Iso situated upon a range of high mountains, the
in Assyr. affected villages being some 5000 to 6000 feet above
the level of the sea. Dr Dickson, quoting the report of Dr Nouri,
who proceeded on a mission of enquiry in 1879, referring to Namasse,
the seat of government of this district, says : " The climate of this
region is cold and damp, but the soil is fertile and well watered
with pure limpid springs. It has no commercial transactions of any
consequence with other places, and the inhabitants merely cultivate
what is needed for their own immediate wants. The houses are
built of stone and adjoin one another. They consist of two stories and
contain one or two rooms with or without one or two apertures to let
in the light. The ground-floor is used as a stable, and as the winter
is very cold, the inhabitants live in it together with their animals in
a disgusting state of filth."
In the six villages of the district Dr Nouri found that, in 1874, out
of a population of 8000 persons 184 had been attacked, 155 had died,
and only 29 had recovered. All these patients were said to have
suffered from general " malaise " and fever, or from shivering followed
by fever, more or less from headache, in some cases from great thirst
and want of appetite, diarrhoea, vomiting, pain in the groins, and in
other parts of the body, with or without buboes, with (jr without red
or black specks, broken dreams, delirium, and insensibility lasting for
several days. There is no mention of a rat mortality.
It is noticeable that the inhabitants of the so-called endemic centres
live usually on the borderland of privation, any severe drought or
inundation placing them at once in a state of misery. In the Benghazi
outbreaks of 1858 and 1874 those first attacked were nomadic tribes
of Bedouin Arabs living in encampments with their cows, sheep, and
goats, but owing to preceding droughts and failure of crops brought
to the verge of famine, and later by the inclemency of the weather
1 The Book of Marco Polo. Book ii. p. oi. By Colonel Henr.v Yule, C.B., 1875.
184 Epidemiolo(f]i of Plague [part ii
reduced to a state of great miser}'. In the Assyr outbreak of 1874 the
localities had previously been visited by famine. In A[eso})()tamia in
18()7 it was after an excessive flood of the Euphrates and inundation of
the marshes that plague reappeared. Poverty and lack of nourishing
food seem to play an important role in the susceptibility of a community
to plague, and the conditions which favour the prevalence of relapsing
fever and typhus fever also favour the endemicity of plague.
The fostering conditions of plague once the disease has been intro-
Fosterinff con- fl^i<^<^d into a locality are similar to those already described
ditions of as being found in the endemic centres. The conditions
lence similar "i^'J iiot everywhere present precisely the same aspects,
in exotic custom and race modifyinff them, but they are nevertheless
localities to . . <■ o j
those in en- associated with poverty, overcrowding, bad ventilation of
emiccen res. i,,,|i>^^.s, and filth, and the concomitants of these. Though
perhaps not exactly the agents which disseminate plague they are the
auxiliaries which facilitate its progress. To-day they are found in their
greatest intensity in Eastern countries which are in the same condition
of sanitation as Europe was in the 16th and 17th centuries.
Thus London with its great plague epidemics of the years 1603,
London in the 1625, 1636, and 1665, with their respective mortalities of
17th century. 36,000. 35,000, 10,000, and 68,000, was then ill-constructed,
with narrow and crooked streets, many of them being unpaved. The
houses were built of wood and lofty ; they were dark, irregular and ill-
contrived, with each story hanging over the one below, so as almost to
meet at top, and thereby preclude as much as possible all access to
a purer air ; they were, besides, furnished with enormous signs which by
hanging in the middle of the street contributed not a little to prevent
ventilation below. The sewers at the same time were in a very
neglected state and the drains all ran above ground. The metropolis,
which now enjoys such a plentiful supply of water laid on into every
house, had till many years subsequent to the bringing in of the New
River in 1613 been but scantily furnished with this first of luxuries.
The condition of the town is stated to have been offensively dirty\
There were plague epidemics in Paris in 1619, 1631, 1638, 1662, and
Paris in the ^^^^ ' ^^^ut the latter period Paris was paved, the streets
17th century, were widened and the city began to be kept cleaner-.
igthcentur*^^ These fostering conditions are far from being absent even
now from the gi-eat centres of population in the "West.
1 Maitland's Hixtorij of London.
- Observations on the increase and decrease of different Diseases and particularly of
the PUit/ue. By Win. Heberden, Jiin., M.D. , F.R.S.
CH. ix] Conditions in Hongkong 185
When Oporto was attacked with plague in 1899 it prevailed in those
portions of the town which were densely populated, overcrowded, and
with inadequate means for the disposal of excrement and refuse. "^In
the low class quarter of the town the houses are irregularly built and
closely packed together so as to obstruct the free circulation of fresh air
and prevent the entrance of sunlight into the dwellings. Some of the
houses are built back to back, the ground-floors being damp Rotten
garbage and other offensive matter are thrown out upon the street and
are trodden into the soil and add to the unpleasant odours of the streets.
Some houses are sub-let in tenements, a family occupying each room ;
often the ground-floor is used for the stabling of animals, such as pigs
and goats."
However bad this may be from an European point of view it is not
to be compared with the narrow and crooked streets of
Canton in the -, in -i •
i9tii and 2otii Canton, the lU-ventilation and darkness oi the houses and
centuries. j-j-^^ ^Ij-j-j ^f ^^^^ streets ; nor with the overcrowding in
the^mh^and Hongkong. The conditions in Hongkong which favour
2otii cen- the prevalence of plague, apart from its proximity to
an infected part of China, consist in its being a great
emporium with immense warehouses filled with stores and infested
with rats susceptible to the disease, and its containing a very high
proportion of poor people essentially of the labouring and migratory
class, and who like all people of this class in Eastern towns live
under very insanitary conditions. Hongkong is peculiar in possessing
a greater proportion of these insanitary classes and in housing them on
a smaller space than even Bombay. Narrow streets and high houses
abound in which light and air are obstructed. So closely packed are the
buildings in the older portions of the town and so overcrowded are the
houses that in one district the density of the population reaches
840 persons per acre, which is more than three times the most crowded
area of Calcutta. Apart, however, from too many houses erected on too
small a space, the evils attendant on the overcrowding of a dirty class
of people are accentuated by the kind of buildings erected. Narrow
streets and high houses are not peculiar to Hongkong. They are the
means by which many towns manage to house a large population. But
in Hongkong in the Chinese quarters defects in the construction of the
houses intensify the obstruction of light produced by crowding together
of buildings, while subdivision of the rooms serves to increase the over-
crowding. The rooms are long and narrow with a window at each end,
the front window looking into a wide and covered verandah and the
' "Reports and Papers on Bubonic Plague." By Dr 11. Low, Local Govt. Board, 1902.
18(j Upldeviiolof/!/ of Plague [part n
back window into a small open space at the back which forms a sort of
well between two houses. Sometimes these small spaces do not exist, so
that the buildings are back to back. The lower floors of many of the
houses are remarkable for their darkness as well as being frequently
damp. Many of the lower floors of the woret kind have been changed
into store-rooms to contain the goods and merchandise for which Hong-
kong is an entrepot. These store-rooms as a rule are infested with rats,
which at times find their way up to the rooms on the higher floors. The
basements are generally rat-ridden, both floors and walls, and from the
walls being often hollow it is easy for rats to reach the upper floors.
The admission of light into the dwelling-rooms of Chinese tenement
houses is still further obstructed by the subdivisions into several cabins
or compartments, sometimes numbering up to six, which every room is
subjected to. Each cabin is let out to a separate tenant and not infre-
quently accommodates a separate family. The compartments or cubicles
are windowless rooms and are often so dark that it is impossible for any-
one coming directly from the light outside and drawing the curtain or
opening the door of the cubicle to see from the passage if the cabin is
occupied. Fresh air and sunlight never get into the cubicles except
perhaps the compartment at each end of the room opposite the window.
The cubicle system as described leads to overcrowding in its worst form
and under the worst conditions, for wherever more than two cubicles are
in a room the compartments become so dark as to render it impossible
to be kept clean.
Many of the conditions which exist in Hongkong are also to be
Bombay in found in Bombay, but on the whole the latter city contains
^®^^- i)roportionately fewer houses with windowless rooms and
with so much overcrowding. There are, however, many buildings as
bad, and many worse than in Hongkong, but they ma\' in relation to
the size of the city be considered as few in proportion.
Bombay, like Hongkong, is a port with large warehouses and stores,
and it was in that quarter where grain and rice are stored in godowns
and which are infested with rats that plague showed itself first in
epidemic form. The Hindu low castes were the greatest sufferers from
the plague in Bombay. They are so poor that they may often be seen
searching among refuse for food ; their dwellings are situated in the
most crowded localities and several families not infrequently live in one
room. They usually sleep on the floor on a thin sheet, and the ground
on which they sleep is damp and mouldy and nearly as damp as the
street outside. In one district of Bombay it is stated by the Health
Officer, Dr Weir, that 75 "/„ of the buildings were more or less unfit for
CH. ix] Conditions in Bombay 187
human habitation by reason of imperfect ventilation, darkness, and
dampness. Most of the buildings consist of double rooms separated by
a narrow and dark passage which ends in a small open space in which is
located the privy on one side and the water-tap on the other. All the
clothes of the house are washed in this yard and the dripping of the
water and the washing of the clothes render the outside walls damp.
The rooms on each side of the passage may be further subdivided, so
that the centre rooms are in darkness, while the front and back receive
but little light.
The chawls of Bombay enjoy an unenviable reputation for being
The chawls huge warrens in which human beings are packed under
of Bombay. conditions which, though not resembling the unhealthy
dwellings of the inhabitants of Kumaon and Garhwal, are in no respect
better as regards light and air and overcrowding. They frequently consist
of high buildings of five or six stories, sometimes more than 100 feet in
depth, and not more than three or four feet from adjoining buildings of
a similar type. The entrance door leads to a long passage or corridor
which runs from end to end of the building. On each side of this
passage are rooms with windows occupied by one or more families.
A staircase leads to the higher stories, which are also arranged on the
same plan of a long passage and rooms on either side. The passages
receiving light from the door and windows at the end are dark and
badly ventilated, and the rooms abutting on these passages are also
dark and badly ventilated, owing to the narrowness of the intervening
gully between the buildings adjoining. In some inspections in which
the writer joined, having for their object the discovery of plague cases,
lamps had to be used to light the way in these houses, although it was
day outside, and notwithstanding the light on one occasion he stumbled
over a sick person crouched in the darkness. Each room has one or
more occupants, and sometimes the inmates in the building amount to
some hundreds.
Some of these buildings are described by the Health Officer ^
" In the crowded buildings in Mandvi, in which the disease first
appeared, we had over 100 people in many buildings, and as many as
000 people in one building, one family living their life in one room,
opening on to a common passage in which the grain was ground, and
The crowded '"^^ ^^"® ^'^'^ ^^ which was the water-pipe under which the
buildings in clothes were washed, splashing the walls and the floor
around. We take for explanation one building in Olive
' " Report on the plague of 1H90-!J7 in Bombay." By Brigade-Surgeon Lieut. -Col.
T. S. Weir, Municipal Health Officer, p. 735.
188 Epidemiolo<i]i of Plague [part ii
Road. There are 116 rooms, and sa}' there are four persons to each
room ; it gives nearly 500 people to the house, and underneath this
mass of people densely pressed in one building, with the foulness that
must come from human beings, are three godowns and shops, and yet
this is not by any means the most crowded and densely poj)ulated
dwelling in the city. No-one can look at the size of the buildings,
and the number of rooms in each building in this locality, as shown in
this statement, without having a feeling of astonishment that the
mortality has been so low. They are most thrifty people, the Jains
and other classes who come hei'e for business from Gujarat or Kathiciwar
and live in these buildings ; they suffer as much from thrift as other
classes from want of thrift ; they seldom eat fruit, and they use very
little vegetables, unlike most Hindus. They are so thrifty that they
collect rags and rubbish in the passages of the dwellings, and so careful
of animal life that they fear to sweep near the rags they have with
much pains bound in bundles. I have never seen any
their indiflfer- people SO indifferent to the sight of the dying and the
dead. This is what the Committee appointed by Govern-
ment saw one evening during the inspection of a building. In one
A scene in room of a large building with double rooms on each floor
a building. -^y.^g .^ patient ill from bubonic plague. In the next room
was a man singing. In the room after that there was a dead body.
And in a room almost after this a group of women were laughing at us.
It was often pathetic to see the anxiety of some people to save an insect
from disinfecting fluid."
The number of cases in buildings in Mandvi Bunder is seen in the
annexed return, and the incidence of the disease by dwellings can be
studied from it. " It shows
(a) the fatality by dwellings,
(6) the effect of the measures taken in the beginning.
" The mortality has been so small in proportion to the numbers and
Mortality ^^ pressure of the population and the density of the
from bubonic houses that it has been suggested by some authorities
owing to t\\dX there may be another severe epidemic. All who
measures have seen the charts of mortality have ascribed the re-
adopted.
pressions in the mortality to the influence of the sanitary
measures adopted. There can be no doubt that the measures adopted
have reduced and lightened the mortality. There is no reason except
the influence of the measures carried out why in this city, more densely
CH. IX]
Cases in Single Buiklings
189
crowded than any city in the British Empire, the mortality has not
been much greater.
" Statement showing the number of cases of Bubonic Plague and
THE date of attack AND DEATH IN BUILDINGS ON MaNDVI BuNDER.
Street
House
No.
Key
Roman figures indicate date of attack and
italics indicate date of death
1
Broach Street
58 a
25.%— 31.8; 11.9— i6.9; 12.9; 18.9; 22.9; 28.9—
i.20; 8.10 i^.iO; 23.12 50.i^; 31.3; 25.4
28.4
2
Argyle Road
172-176
16.9— i<S.9; 20.9— ^i.9; 22.<d—26.9
3
CuUian Street
33
n. 9— 20.9; 18.\)— 24.9; 18.9; 21.9—25.9
4
Bhandup Street
9-13
18.9—24.9; 19.9; 20.9—25.9; 22.9; 28.9; 4.4
5
Akbar Street ...
Shed
18.9— .25.9
6
Musjid Siding Road ...
50-54
20.9 — ;^5.9; 25.9 — 27.9; 16.10; 16.10; 17.10;
21.10; 21.10; 22.10— 26.10; SO.IO— 2.11; 2.11
7
Do.
22
20.9—24.9; 22.9—24.9; 2S.9— 28.9; 25.9—30.9;
25.9—27.9; 26.9—30.9; 21.9—29.9; 27.9—
4.10; 28.9; 30.9— 5. JO; ^.9—3.10
Do.
22
1.10—3.10; 1.10—3.10; 2.10; 2.10—3.10; 2.10;
2.10
8
Argyle Road ...
22
20.9—^5.9; 20.9—27.9; 21.9—29.9; 28.9—30.9;
30.9—30.10
9
Musjid Station Road...
25
20.9—23.9; 21.9-30.9; 2.10; 25.10—26.10
10
Argyle Road
47
20.9—24.9
11
Musjid Station Road...
24
21.9; 28.9; 28.9— 5.i0; 1.10; 1.10; 7.10; 20.10;
27.3; 11.5
12
Olive Road
45
21.9—^9.9; 21.9-^6.9; 22.9—25.9; 23.9—25.9;
26.9—5.10; 26.9; 27.9— i.JO; 21.9—30.9; 28.9
—30.9; 28.9—4.10; 29.9; 30.9—5.10; 6.10—
15.10; 7.10; 29.9; 16.3—^^.5; 24.3— .27.5;
15.4— i7.^; 29.4; 18.5— .25.-5
13
Sholapur Street
Shed
21.9— .25.9
14
Broach Street
70
22.9; 27.9; 21.9-28.9; 28.9; 10.4— iJ.^; 11.4
15
Bhandup Street
17
22.9
16
Broach Street ...
80
25.9— .27.9; 2.4—10.4; 12.4—14.4; 24.4
17
Cullian Street
45
26.9— J27.9; 2.10—4.10; 3.4—6.4; 2.5; 25.5—
27.5; 12.6—13.6; 18.6—21.6
18
Broach Street
60
26.9—27.9; 21.9—30.9; 17.10
19
Musjid Station Road...
8-9
26.9— J. iO; 26.9
20
.\rgyle Road ...
56
26.9—^9.9; 27.9—50.9; 7.10; 8.10— iO.iO; 8.4
21
Baroda Street ...
80
26.9; 27.9; 21.9—29.9; 29.9—2.10; 30.9—1.10;
2.10; 24.10— .27.70
22
Bhandup Street
1-7
27.9— ;28.9; 27.9 — 50.9; 28.9; 16.10— .25.i0;
16.10— i9.20; 17.10; 15.3-^0.5; 22.3
23
Olive Road
39
27.9— ;29.9; 4.10—4.10; 4.10
24
Do.
33
27.9; 1.10—4.10
25
Raichore Street
Shed
28.9—30.9
26
Argyle Road
66
28.9—18.10; 16.10—18.10; 18.10; 20.10— ~^5.i0 ;
20.3—50.5; 21.5; 27.5
27
Do.
2
29.9— 4.iO; 6.10; 16.10; 17.10; 25.10— ,28.i0;
27.10; 7.11-8.ii; 19.11—21.11; 16.3—20.3;
1.4—3.4; 7.4; 13.4— i5.^; 16.4—17.4; 18.4;
24.4—25.4
190 Epidemiolofnj of Plague [part ii
" The many members of the Scientific Missions I have taken round
the citv have all been astonished at three conditions in
The three • '
conditions in **^^^" *^''ty :
city observed (^,\ Xhe size of the buildings and the number of the
by experts. , ,- • • ^,
people living in them.
(6) The density of the population.
(c) The cleanliness of the densely populated portions of the city."
To quote another paragraph in the report of the Health Officer :
" To show the pitiful condition in which the poor classes live let
us enter a building in Khara Talao inspected by His Excellency the
Governor. There is a ground-floor and a room above it. The length
of the ground-floor room is 111 feet and the width 18^ feet. There
is no means of ventilation on either side. In fact the room is a passage
with a door in front between closed walls. We counted in this room
19 men, 20 women and 17 children. What a life ! What can anything
outside this room do for the people in their misery inside ? "
The following are the notes made by the author of a morning's
inspection in October 1897 in another district, and in which the houses
were smaller and did not contain such large numbers of inmates as
the chawls. It will be seen, however, that their lack of light and air
was similar. " Met the Plague Committee at the Kama-
Notes of a .... .
morning's tipuri District, where it had been decided to form some
inspec ion. search parties to inspect the houses. Each search party was
given a street and consisted of a medical man, an inspector, a native
or European gentleman, a policeman, a man with a lamp, and another
with a bunch of keys. There was one lady doctor among the party.
The houses were taken seriatim, and each room carefully inspected
and the inmates examined. The people took to the search very
kindly, and there was no difficult}' whatever experienced. Many of
the people were out at work and their rooms locked. It was thought
necessary to examine these and the man with the bunch of keys came
into requisition. The houses in the Kamatipuri District are of a very
bad type, being rather deep and two or three stories high, having shops
in front and a long corridor passage from front to back. Into this dark
corridor open small rooms which are windowless and enjoy neither light
nor air. It is necessary to use a light before it is possible to say
whether the room is occupied or not. Behind or sometimes in the
centre of this corridor is the latrine for the house. The second story
is as dark as the ground-floor if there is a third story. As the houses
adjoin one another it is impossible to open out windows into the open
CH. ix] Conditions in Cape Town 191
air either for light or for ventilation, and the only remedy appears to
be the pulling down of every other house, which will allow windows to
be opened out into an open space and which will also secure ventilation.
Two cases of plague and one suspicious case were discovered and sent
to hospital."
In Cape Town plague broke out at a time when the town contained
many refugees on account of the Transvaal war, and when
Cape Town. jo
a large number of natives had flocked into the town.
It was among these and the poorest of the inhabitants that the plague
first began to be epidemic. Cape Town for its size has a very large
proportion of filthy slums and insanitary houses. The insanitary houses
and areas were at the time overcrowded with a heterogeneous popula-
tion, consisting of natives, coloured people, Indians, Arabs, and whites
of almost every nationality. The natives coming direct from their
kraals in the native territories to work in Cape Town, being unused
to town life, are unable to adapt themselves to their new conditions
and crowd together when permitted to an extraordinary degree. In
one house from which some plague cases were removed 65 natives
were secured as contacts, but over 30 escaped, making up a total of
nearly one hundred persons living in a house which was by no means a
large one. The poorer coloured people are as dirty in their habits as
the natives ; the Malays and Indians possess the habits of the Asiatic, and
the poorer class, Portuguese, Italian, Levantine, and Polish Jews, which
made up the bulk of the poor white, were almost as filthy as the others. It
was accordingly among a poor and crowded population living in a very
insanitary state in ill-ventilated, badly lighted and rat-infested houses
that the plague acquired a hold upon the town. The majority of the
whites attacked were foreigners. In one ward of the plague hospital
out of 16 patients eleven nationalities were represented. The distribu-
tion of plague in Cape Town followed very closely the distribution of
phthisis, the two diseases evidently finding in the insanitary houses and
insanitary habits of the inmates excellent conditions for their propaga-
tion and spread.
Far worse from a hygienic point of view were the poorer class of
houses in Port Elizabeth, where plague has continued to recrudesce
annually since its first appearance in 1901.
The plague, now as formerly, is largely a disease of the poor, and
perhaps falls proportionally more heavily than any other
a disease of infection on the lower strata of society. At one time it
e poor. acquired the name of the beggars' disease, at another the
poor plague, and at another miseriae morbus.
192 Epideniiologii of Plague [part ii
Dr Cabiadis in contrasting the immunity of Kcrbela with the
prevalence of plague in Hillah attributes the difference to the pros-
perous condition of the inhabitants of the former • place \ even the
poorest class enjoying a meat diet, and to the spacious and well-aired
houses, though the streets are narrow and crooked. He j)oints out
that Hillah is the very reverse of this ; its houses are low, confined,
and very imperfectly ventilated ; they are, moreover, generally en-
cumbered with a horse, with poultry, and with two or three buffaloes.
These animals constitute the resources whence the lower classes of
Hillah derive a livelihood by selling milk and eggs to the wealthier
inhabitants, while they themselves limit their own nourishment to
barley bread, dates, and onions, with sometimes fish in a putrescent
state.
The following is a description of a Chinese village which lost nearly
A Chinese half of its inhabitants from plague in 1902": — " Sua-bui
village. jg about an hour-and-a-half's sail from Swatow. The
houses are clustered together, with a few lanes of some 6 to 8 feet in
width and some passages not more than 4 feet intersecting the village.
Fronting the lanes are shops and houses and entrances into court-yards.
The shops are narrow, obtaining their light from the front. The houses
in many instances are entered direct from the street and consist of one
or more rooms and are usually devoid of other means of light than the
doors ; sometimes there is a small window of 1 foot in length by 9 inches
in breadth. Other entrances give access to a small court-^-ard, around
which are windowless buildings entered by separate doors. In fine
weather the inhabitants when not out in the fields spend most of their
time in the court-yard or the street. At the time of the visit the garbage
was to be seen heaped up almost everj^where, being thrown out of the
house and left to the disintegrating forces of nature and of the pigs and
fowls. Pigs roved or lay about the lanes or were in the court-yard or in
one of the rooms of the houses with the fowls. Calves and cows were
usually tied in some corner of the lane or were in the court-yard. The
drains were full of foul, putrefying black mud or stinking water which
could get no outlet, being blocked with garbage. Streets, passages and
court-yards were a mass of uncleanliness. The latrines, however, were
well-built reservoirs, the faeces and urine being valuable, but the smell
from them was extremely offensive. Several of the windowless houses
' " Supplement containing reports and papers on the progress of the Levantine
Plague," by Mr Netten Radcliffe. Khitli Annual Report, Load Govt, liuiird, 1879-80.
^ "Eeport on the causes and continuance of plague in Hongkong, and suggestions as
to remedial measures." By W. J. Simpson, M.D., F.E.C.P., 1903.
CH. IX J Conclusion 193
were closed because their inmates had fled from them either to other
villages or to the hills to escape from the plague which had been in
the house. Among the congeries of badly-lighted, badly- ventilated, and
filthy houses there were a few to be seen better built, better lighted, and
cleaner. They were the exceptions and they had escaped plague."
It is an interesting observation that Macao though so near to Hong-
kong remains comparatively free of plague after its first
outbreak there. This immunity is attributed to the de-
molition of the buildings in some of the worst areas in which plague
displayed great prevalence and malignity, and laying out in their place
model areas containing sanitary buildings with an abundance of light
and air in the rooms.
Social conditions connected with poverty, misery, deficient or ill-
nutritious food and overcrowding, combined with the
Conclusion. . • i • i i
local conditions which are generally associated with these,
such as insanitary dwellings, which are dark, damp, dirty, badly lighted,
dilapidated, and harbouring rats and insects, are the factors commonly
found to predispose to plague, and it is in a population living under
these social and local conditions that plague usually commits its
greatest ravages.
Wherever in towns there is the greatest overcrowding, the greatest
crowding together of buildings on the smallest areas, and consequently
the least amount of fresh air and sunlight in the dwelling-rooms, there
plague finds a home from which it is difficult to be dislodged. Still it
has to be recognised that insanitary conditions, although they render
a locality a suitable nursery ground for the development or spread of
the specific agent of plague, and cause the population to become
susceptible to the disease, do not appear to be the only factors
necessary to the production of an epidemic. They constitute a
favourable soil, but before the plague germ can fructify to any great
extent in that soil other factors must come into play; for instance
seasonal influences possess a very marked controlling effect on the
development and decline of plague epidemics. What these seasonal
influences embrace and the conditions they produce are still subjects of
speculation rather than of knowledge acquired by investigation, but it
is certain that even with a soil receptive of plague by reason of its
population living under insanitary conditions the plague germ once
introduced is subject to seasonal and meteorological influences for its
development and spread, and in different places it has to await these
influences before it makes any marked progress.
s. 13
CHAPTER X.
DIFFUSION AND MODES OF DISSEMINATION.
There are certain laws governing the diffusion of plague. The
infection is greatly influenced in its development by season and other
factors, but however ranch this may be it requires certain carriers for
its dissemination.
The bacillary nature of the infection of plague permits of its
transportability by means of certain vehicles. Living for
Plague is r j j ^ _ "
transportable, a time in the human being or animal it attacks, the
but requires |).^cillus is carried wherever the human being or animal
certain cam- ...
ers for its dis- goes ; moreover, capable as it is of life for a short time
semination. ^^ j^^^^ outside the animal body, it can also be transported
on articles that have been contaminated with infected secretions. The
infection is accordingly transportable by these vehicles, not only from
house to house, but also from town to town and country to country.
Plague prevalent in one locality may be carried to another locality
or another country by infected human beings, by infected household
effects, by infected merchandise, and by infected animals.
The infection is observed to travel generally by the most frequented
piagTie trade routes. The pandemic of 1348 entered Europe vid
travels by Constantinople and was brought to the coast towns of
frequented the Mediterranean by ships. It also came by Tiflis and
trade routes. Armenia into Asia Minor, and by the way of Mesopo-
tamia into Egypt. In the subsequent prevalence of plague in Europe
during the 14th, 15th, 16th, and 17th centuries the infection frequented
the great trade centres. While Venice and the Italian States were
the gateways for the commerce of the East with the West they
were subject periodically to outbreaks of plague. The great trade
routes from Venice to the north-west of Europe, to the Baltic,
and to the North Sea were not by sea but by land, through Central
CH. x] Conveyance by Sick Persons 195
Germany, and the infection was conveyed along these routes to the
great commercial cities of the Hanseatic League, and from these spread
in various directions. The Venetians were the first to recognise that
the infection of plague could be transported from place to place, and
were the first to introduce preventive measures against its introduction
by ships. They instituted quarantine in 1484 and were particularly
solicitous as to infection in merchandise.
In the existing pandemic the infection has been carried from in-
fected localities over the seas to distant ports, from Hongkong to
Bombay, Japan and San Francisco, from Bombay to Durban, from
Rosario to Cape Town, from China to Mexico, and from Mexico to Peru,
and many other distant places. As in the pandemic of 543 the corn-
ships of Egypt carried plague to Byzantium, so have the corn-ships of
modern times played an important part in the conveyance of plague
to healthy ports. The infection also has been carried overland, as in
India where most of the provinces have become infected. Sea-going
ships and railways in recent times take the place of coasting ships and
caravans of olden days. The trade routes have changed with maritime
discovery and with improved methods of navigation, and coincidently
Avith this alteration plague has been observed to be diverted from its
former channels of extension. The Mediterranean towns have not, as
formerly, been the first to be infected.
It is generally easier to observe the mode by which infection is
carried from an infected locality to some distant place than to trace
the various modes by which the disease is disseminated in an infected
town. Instances are numerous of persons incubating or sick with plague
fleeing' from a plague centre, taking the infection into
Persons sick o i o o
or incubating distant villages or ports, and there setting up new centres
the^fection ^^ ^^^ disease. The most dangerous types of plague for
to other the dissemination of the disease in this way are the
pneumonic and septicaemic; and it is not an uncommon
occurrence for the inmates of a house to be one after the other
attacked by plague after the arrival of a relative or friend who is
either suffering from or falls ill within a few days with one of these
forms of plague. Villages in China and India were frequently infected
in this way.
For inland towns and villages, separated some considerable distance
from an infected centre, human agency is the most commonly observed
mode of dissemination from one locality to another. In an enquiry
made by Captain James, I.M.S., into the source of infection of some of the
13—2
196 Epidemiolofiji of Plague [part ii
Puiijiiub villages he found that out of G3 villages no fewer than 47 or a
percentage of 73 were infected by the arrival of infected persons, and
much the same ])roportion probably holds good for other inland places.
A similar ex])erienco falls to most investigators. Captain Browning
Smith, I.M.S.\ in a recent report on plague in villages in the Amritzar
district, remarks that " in the great majority of villages infection could
be traced to human intercourse between healthy and infected villages,
and this is doubtless the manner in which the disease spreads from
village to village, the usual history being that a person went to an
infected village to visit relatives attacked with the disease or to be
present at the funeral ceremonies of dead relatives; on return to the
healthy village the person develops plague : the next step was the
infection and death of rats in the infected and adjoining houses, followed
by a rapid spread of the epidemic plague occurring in those houses and
parts of the village in which rats died." This is the usual sequence
except in pneumonic cases when infection takes place without the
customary rat infection. The following two instances recorded by
Captain Browning Smith may be mentioned.
(1) Pneumonic plague. At Munda Dina a Jullah returned from
the infected village of Bagrian on 26th January, 1903, attacked on
27th January, died the same day, and fifteen members of the family
died of pneumonic plague. The epidemic was pneumonic and only
lasted a short time and did not spread, for the last case occurred on
8th February, 1903. No rats were seen dead during the epidemic.
(2) Bubonic plague. On 7th March, 1903, Mela a Jullah returned
from Nagoke and was taken ill on the 13th, and died the same day
of bubonic plague ; rats began to die on 10th March, in the houses
adjoining, and the first case after Mela occurred in them on 14th
March. The epidemic, which lasted till 29th May and caused 174
cases with 144 deaths, was of the bubonic type.
It is not always persons ill or about to be ill with plague who
create new foci of the disease in healthy localities. Healthy
so^ns some" persons from an infected house are able at times to carry
times carry ^^g infection without being infected themselves. The
the infection. ... i • j
Hifection m these circumstances appears to be carried on
the clothes or personal effects of the traveller or refugee.
Major Anderson gives some specific instances of this kind to the
Indian Plague Commission.
I " Report on plague and inoculation operations." By S. Browning Smith, Capt. I.M.S.
Indian Medical Gazette, June, 1904.
CH. x] Conveyance hi/ Infected Clothes 197
" In Agashi the first local case occurred in the person of a Shimpi
woman at whose house some friends from Bombay had come to live.
None of these Bombay people were sick or were afterwards attacked. In
Kelwa also the first local cases occurred in the persons of two Shimpis
to whose house some Shimpis from Bombay had come five days before.
These Bombay people were in good health, and after staying three
days returned to Bombay.... At Verso va a striking instance of the
disease being carried by an apparently healthy person occurred. The
first imported case at Versova occurred on 30th January in the person
of a Brahmin who came sick from Bombay. The Brahmin school-
master of Versova visited this man while he was sick, and attended
his funeral on 31st January. The schoolmaster lived in the village
Talati's house. On the 2nd February the Talati's nephew who lived
in this house was attacked by plague, while the schoolmaster himself
was not attacked till the 5th of February.
" In Marol also the first case occurred in a house to which a number
of people had come from Bombay to attend a wedding. These people
were in good health and after staying some days they returned to
Bombay in good health....
" Again, in the village of Madhan, an isolated case occurred prior to
the outbreak there, in the person of a man at whose house a man from
Bombay had come to live^"
In these cases the agent by which the infection is transported by
the healthy person can only be a matter of conjecture. In other cases,
however, the agent is definite enough. In one of the villages of
Fukien, South China, a girl brought home a bundle of
transported clothes from a plague village. In a week or so most
and dissemi- virulent ijlague broke out in the house and nine people
nated by ^ ^ _ . • i i
infected died in that house alone ^. Plague in 1900 was nitroduced
clothes. ^^^.^ Durban from the Mauritius by infected clothing.
A boy from the Mauritius, in order to avoid detention at Durban
owing to quarantine, proceeded with his family to East London, from
which port he afterwards embarked for Durban, landing there on April
1st On the 13th of May he unpacked part of his luggage and two
days later was attacked with plague, dying on the third day of his illness.
In September, 1890, two Goanese sailors from Bombay were attacked
by plague in London a fortnight after the ship's arrival, and at least
* Report of the IndUin Phujue Comvmsion, Vol. v. chap. iii. pp. 100 and 107.
■•' Appendix to the Report on the Cmnfes and Continuance of I'lagiie in Hongkonfj, 1903.
By W. J. Simpsou, M.D.
198 Epidemiolo(i]i of Plague [part ii
37 days after leaving Bombay. It appeared to the Medical Officer of
the Local Government Board who enquired into the circumstances that
the probable cause of the infection was the wearing of clothes that
during the voyage had been stowed away in one or other of the men's
chests and only brought out after the ship's arrival in London'.
A sweeper from Chinkoa, an infected village in the Punjaub,
worked in Kulewal, in the house of a person who died of plague. The
sweeper received as a present some of the patient's clothes. He took
them home to his non-infected village and gave some of them to
a neighbour. This neighbour was attacked by plague shortly afterwards
and he appears to have been the first person who developed plague in
Chinkoa-.
Three men, some of whose friends had died from the plague in
Bombay, arrived at Ahmedabad from that city and stayed for three days
at the house of a relative outside the city wall. They then proceeded
to Kadi, their village in the Baroda State, leaving some of their clothes
behind them in the house at which they had stopped. Three days
after their departure, plague cases occurred in the room which they had
occupied. The three men were traced to Kadi, kept under observation,
but remained quite well^
At another village, Akhada, some people returned from Bombay,
bringing with them various goods and chattels. A few days later two
of the friends with whom they were staying were stricken with plague.
The visitors remained in good health*.
The infection was introduced into Rajapur in the Ahmednagur
district by a Marwari from Sirar, whose brother had died of plague and
who presented the clothing of the deceased to a family of Mahars,
of whom five caught the infection and died^
Many of the plague cases in the villages of China are attributed by
medical men there to the practice of the Chinese wearing the clothes of
persons who have died of plague. The same dangerous custom used to
exist among the Mahommedans of Turkey and Egypt when plague
1 rwenty-sixth Annual Report of the Local Govt. Board. " Report of tlie Medical Officer
for 1896-97."
2 Ileport of the Indian Plague Commission, Vol. v. chap. iii. p. 111.
* Ibid, and Report of the Epidemic of Plague in the Bombay Presidencu. By
J. A. Lowson, M.B., 1897.
* Report of the Epidemic of Plague in the Bombay Presidcncu. By J A
Lowson, M.B., 1897.
5 A History of the Progress of Plague in the Bombay Presidency. By Capt.
J. K. Condon.
CH. x] • Period of Greatest Danger 199
prevailed in these two countries and was considered to be a very potent
means for the diffusion of the disease. Another example of transport-
ability of plague infection in clothes may be cited. It is that of the
epidemic at Eyam in 1665, when plague was imported from London
during the month of September into this remote village away among
the hills of the Derbyshire Peak. The village is 150 miles from London,
not a great distance in these days of railways, but little accessible then.
Early in the month of September, when plague was at its worst in
London, there was sent to George Vicars, a tailor, a box of clothes.
He opened the box and hung the clothes to the fire and the account
states he became violently sick and ill. On the second day he was
worse, was delirious at intervals, and large swellings appeared on his
neck and groin. On the third day the plague spot was on his breast
and he died the following night. In the course of a year the plague
thus introduced into the village attacked 76 families and destroyed 267
out of 350 inhabitants, or 79 "/o of the population^
The infection imported by infected persons or by infected articles of
clothing may not be transmitted direct to man but may be
conveyed to a ^"^^ often is conveyed first of all to the rats in the house,
new centre these rodents being attacked with plague. In this way
may affect p-?- • i-,i •
rats before a new centre oi miection is set up which later is trans-
human fgJ.J.g(J ^Q J^J^JJ
beings.
A man lost his wife in Bombay from plague and
10 days later started for his native village near Hurnai, taking with him
his wife's clothes. About a week after his arrival in his village, which
until then was quite free from plague, the rats in his house and in its
vicinity began to die, and shortly afterwards five of his relatives living
in the house and who had never been out of the village were one after
the other attacked with plague and died. Lastly the man himself was
attacked with plague and later there was an outbreak of plague in the
village.
Every epidemic causes a certain amount of uneasiness and alarm at
Additional ^^^ commencement, leading to flight of the inhabitants, but
risk of ex- as the cases are not then numerous the infection has little
tension from , c ^ • ■ , i ■ , i i i , , • •
an infected chance ot being imported into many healthy localities.
locauty Then as the plague is found to only slowly progress there
height of an springs up a feeling of security, the panic abates and the
epi emic. exodus, for the time being, ceases. Later a change in the
progress of the epidemic, manifested by a sudden and rapid increase,
' Public Health, p. 95. By William A. Guy, M.B., F.R.S., 1870.
200 E2)idemi()lo(i!i of Plague [part ti
leads to renewal of the panic on a mcjre exaggerated scale and to a fresh
flight of the inhabitants compared with which the first flight was insigni-
ficant. Crowds leave the infected locality. This time the infection
among the refugees is much more disseminated. Large numbers leave
with the infection on them, either already developed, developing, or
about to develop into the most virulent types of the disease. The
chances of sowing the seeds of infection in new places by human agency
at this stage of the epidemic are therefore greater than at any other
time. The greater danger attaching to the second flight appears not to
be so much connected with the greater virulence of the disease, and
hence its greater tendency to spread, nor because of the early cases in
an epidemic being unable to create new centres of infection when
transported to healthy localities in which the conditions are favourable,
but because the later cases that flee to new districts in a rapidly rising
epidemic are much more numerous and accordingly the chances of
failure of engrafting themselves on new centres are fewer.
In the event of an outbreak of plague in a port the infection is not
only carried inland to towns and villages by road and rail, but it is also
carried by boats and ships to neighbouring and distant ports. At the
time that plague was epidemic in Bombay, refugees were occasionally
found ill on the principal roads leading fi'om the city, also in the railway
carriages and at the railway stations., where a system of inspection was
instituted. Many towns and villages close to Bombay, and a few at a
great distance, had cases of plague imported into them. Cases came by
rail even as far as Calcutta. This repeats itself in connection with
every new centre of plague: thus in 1902 no fewer than 176 cases were
withdrawn from the railway trains at Jalarpet^ the point where cases
from the Mysore territory are received. The exodus from Bombay was
by sea as well as by land, and boats and coasting steamers carried
plague patients to neighbouring ports. When plague was epidemic in
Canton the people who fled carried the infection into the villages far
and near, many of them never reaching their homes but dying on the
way ; and those who fled in boats to Hongkong brought the infection
into the Colony. The same occurrences repeated themselves in Hong-
kong, when plague became epidemic there, and were res[)()nsible for the
infection of many of the ports of Southern China, for in the flight of the
inhabitants on boats and coasting steamers the infection of plague was
carried wherever they went. In one of these flights in 1901 in the
course of five weeks no fewer than 160 persons were detected by the
' Tliirlij-niiitli Report of the Sanitdri/ Coiiunissioiier fur Madras for 1902, p. 15.
CH, x] Transporl hy Armies 201
Custom House Officers as suffering from plague on the steamers arriving
at Canton from Hongkong, and 35 passengers were during the same
time found dead of plague. These steamers were crowded with pas-
sengers and destined for short distances. In the case of long voyages
greater care is usually taken to prevent sick persons from embarking,
and there are usually not the same crowds leaving the infected port.
Fewer cases consequently occur on these ships and there is less likeli-
hood of sick persons carrying the infection to a distant port. Yet,
though the chances are greatly reduced, ships from infected ports
occasionally arrive after long voyages with persons on board suffering
from plague. The illness is not among refugees, for of the latter, as a
rule, there are none, but it is generally among the crew or sailors of the
ship or, occasionally, a passenger is attacked. A few instances will suffice
to exemplify the long distances the infection may be carried
carried long by ships. The s.s. Boi^mida arrived at Bombay in March,
distances in 1899, from Hongkong with a Chinese cook suffering fi-om
plague. The s.s. Kilharn arrived in Cape Town in 1900
from Rosario in the Argentine with the captain and several of the crew
stricken with plague. The s.s. Highland Mary arrived in Liverpool in
1900 from Buenos Ayres after a voyage of 32 days with a seaman
suffering from plague. The s.s. Ben Lomond arrived at London in
1900 from Cebu in the Philippine Islands after a voyage of 59 days with
one of the engineers affected with plague. Almost every country which
has commercial relations with infected ports can furnish instances of the
arrival of ships with plague cases on board. A full account of those
ships which arrived in England with cases of plague on board from
189G to 1901 is given by Dr R. Low in the reports and papers on
bubonic plague and issued by the Local Government Board in 1902.
Next to the migration of })anic-stricken people from infected centres
Transport of movements of crowds from infected areas, whether it be of
infection faci- armies, pilgrims, coolies, or emigrants, facilitate the trans-
litated by the . . o >
movements port of mfection. The spread of plague in Syria was
of crowds. frequently connected with the march of armies, which
had become infected. The Arabian army in 639 is stated to have
lost 25,000 men from the disease and to have been the means of
spreading the infection. Two commanders-in-chief died of the plague,
after which Abu Obeida removed his troops from the towns and
distributed them in the highlands, with the result that the plague
was successfully overcome. Similarly in Mesopotamia and Persia, the
aienas so often of conflicts and of the marching and counter-marching
202 Epidemioloff}! of Plague [part ii
of armies, the infection was carried to and fro and epidemics set up in
fresh localities. Later, infection was carried by the Crusaders who, in
turn, had received the infection from the Saracens. The Thirty Years'
War in Europe was a period of plague prevalence among the inhabitants
of the countries in which it was waged, the different armies carrying
the infection from place to place. In 1632, when the opposing armies
of Wallenstein and Gustavus Adolphus, King of Sweden, numbering
some 111,000 men, encamped close to Nuremberg, having a population
of its own of 50,000 and which was considerably increased by refugees,
plague broke out in July and in seven weeks 30,000 of the town
inhabitants perished and each of the two armies is recorded as losing
one-third of its effective strength. In the following year, 1633,
Schweidnitz in Silesia suffered from the encamping of two armies in
its neighbourhood. Of 24,000 inhabitants it is stated to have lost
16,000, i.e. two-thirds, while the Imperialist army lost 8000 out of
30,000 of its troops, or more than one-fourth, and the Swedes lost
12,000 out of 25,000, or nearly one-half^. Plague has, in more modern
times, been spread by Turkish armies in Hungary and the region of the
Balkans. The epidemic of Moscow in 1771, which cost that city 60,000
of its inhabitants, is attributed to infection being carried into the town
by Turkish prisoners of war and Russian soldiers returned from the war
then being waged between Turkey and Russia. M. Rocher in describing
the spread of plague in 1870 and 1871 in the province of Yunnan
draws attention to the infection being carried to different towns by
infected troops.
It is not always infected persons or infected clothes that spread
the infection of plague. In the South African War the
Transport . ■ ^ n n ^• ^
of infection immense transport required for feeding the army, and a
™ w les^^ portion of which was brought from infected countries, was
other than the means of introducing the infection into the South
persons or African ports. Plague broke out at Cape Town and Port
infected Elizabeth where fodder and grain, brought from Rosario
clothes. . . . Ti 1 1 , 1 • ,. , . ,
in Argentina, Bombay, and other places infected with
plague, were stored in large quantities. The infection was evidently'-
imported with the produce, either by means of infected rats or infected
material, which set up an epizootic among the local rats which in turn
infected the inhabitants.
For ships to be a danger to the port at which they arrive it is not
' La Pexte en AUemagne pendant la premiere moitie du dix-septieme sieclc. Par
E. Charv^rat. Lyons, 1892.
CH. x] Transport by Shijis 203
necessary that plague rats on board ship should infect any of the crew
or passengers on the voyage. Not infrequently, though some of the
rats on board are infected, there is no human sickness on the ship, and
vice versa, when there are a few cases of plague on board among the
passengers or crew there may be no infection of the rats. In the course
of two months in one year the rats on 7 out of 14 ships arriving in
Marseilles from an infected port were found to be infected. Kossel and
Nocht also found dead rats on board two vessels arriving in port in which
no human cases of plague had occurred, and there is one instance of
a vessel, the s.s. Rembrandt, arriving at Bristol in which plague rats
were discovered on board without any plague among passengers or crew.
The risk to the port on account of the arrival of these ships was none
the less dangerous because all the passengers were found to be in a good
state of health. No special measures of prevention were taken at the
Cape with regard to ships arriving fi-om infected ports with fodder
on board as long as there were no sick persons on board or no history of
plague during the voyage. The practices pursued in regard to such
ships were the same as elsewhere and were in conformity with the
prevalent views at the time of human agency being not only the most
important but the sole carrier of the infection, in contradistinction to
the older and no doubt also exaggerated views of a couple of centuries
ago that merchandise was the chief danger. It is becoming clearer
every day that the doctrine of human agency as the only conveyer of
infection on ships arriving from infected ports is incorrect, and that the
modern view must be modified in the light of actual experience, which
is that, notwithstanding the few cases of human plague detected among
passengers from infected ports, yet there is the fact that plague spreads
from port to port. It has to be recognised that different diseases have
often different modes of dissemination, and that which may be true and
applicable to one is not so to another. Some diseases, no doubt, are
transportable on ships from one country to another solely by human
agency, and by human agency is included not only sick persons but also
their personal effects, but so far as plague is concerned it is in a different
category and the infection can be transported bv other
IllSt3.IlC6S of cj c/ It/
infection means. It was in the great storage depots and sheds in
being con- ^^le docks at Cape Town and in the vicinity of the
nected with . .
cargoes and immense stacks of fodder in the neighbourhood of the
wharves in Port Elizabeth that the rats began to die of
Cape Town. . ° .
plague, and it was subsequent to this rat mortality that
the workmen connected with these shipments and storage depots were
204 Epidemiolofiii of Plague [part ii
first attacked with plague. In 1901 a quantity of military stores and
merchandise which had been lying at Cape Town was taken by sea to
Mossel Bay, a small town on the south coast between Cape Town and
Port Elizabeth. Soon after the landing of the shipments the rats began
to die in the neighbourhood of the landing jetty of Mossel
Bay, folhnved by a number of cases of plague among the
inhabitants, all f)f which were traced to rat infection. Apart from
military operations plague may be similarly introduced under the
conditions of ordinary maritime commerce. In East
East London. ^ k c ■ \. n ■ ^•
London, South Africa, the first indication of infection was
the death in February, 1902, of rats in a shed close to the wharves
receiving goods from Durban where plague prevailed. The rat mortality
from plague spread in the neighbourhood, after which there were cases of
human plague associated with rat infection. Plague is credited with
being re-introduced much in the same way into the port of
Durban in December, 1902, when the rats in a limited
area of the harbour frontage were attacked with plague, and a resident
was soon afterwards attacked with plague on the premises where the
rats were dying. On the 18th of November the s.s. Kassala brought
a large consignment of Lucerne hay from the Argentine, a portion
of which was delivered to the premises on which the rats first began to
die. For the first two months the majority of the cases of plague were
satisfactorily traced to infection in the shipping area and were principally
associated with rat infection.
The part which merchandise takes in the conveyance of infection
from one port to another is difficult to gauge. It is associated so
closely with the role that the rats on board may play when plague-
stricken, that the separation and consideration of the two factors apart
from one another are seldom possible.
Theoretically it is not impossible for merchandise to carry infection,
for the bacillus, once getting on to textile material, may live and retain
its virulence for a considerable period, but there is no instance in which
it has been absolutely demonstrated that merchandise unconnected
with its usual association with infected rats has been responsible for
an outbreak of plague. The detection by Kitasato of the plague
bacillus on cotton goods consigned to a mill in Osaka,
in which plague broke out after receipt of the goods,
shows that the danger may be a real one, though it is difficult to prove.
The soiling of merchandise by infected rats may account for the fact
that men employed in discharging cargo have fallen ill after sleeping
CH. x] Transport by Infected Merchandise 205
on bales or on empty sacks, and may also explain one of the means bv
which local rats become infected.
Dr J. S. Low', who was Medical Officer on plague duty in Cape
Colony, cites an instance of plague being probably caused by handling
infected goods. It was in Port Elizabeth, where a European had
occasion to unpack a bale of goods at his warehouse, after it had come
from the docks where many plague rats had been found. A rat, proved
bacteriologically to have died of plague, was found among the goods,
and four days after the man was attacked by plague. The only source
of infection at all probable is stated to have been the handling of the
infected goods, and Dr Low remarks that, had the bale gone up country,
it is possible it might have furnished the first indigenous case at its
destination.
The infection at Bhujpur, a village of Cutch, was attributed by the
authorities to infected ffunny bags, the plague breakinsf
Bhujpur. . r.T?-iii
out m the house of a Banniah who brought gunny bags
from Bombay for sale. He was attacked on the 31st July, 1898, and
two other Banniahs also who, it is said, bought gunny bags from him for
the storing and export of grain. As there was then no communication
with Bombay by sea owing to the monsoon, the Banniah had been in
Bhujpur for at least two months before being attacked with plague.
There is, however, the possibility of trade relation with Mandvi, where
plague prevailed, and that Bombay was not the actual source of in-
fection -.
Bombay, Sydney, Oporto, Naples and other places are believed to
have received their infection from infected rats on board of ships
arriving from infected ports. In the majority of ports it has been
observed that without any known entrance of sick persons, and without
any history of illness occurring among recent arrivals, the first signs of
the disease have been an outbreak of plague among the rats on the
quays, or in the immediate vicinity of the docks, and that it was among
the employees, where the rats were dying, that the first cases of plague
were discovered.
Plague appears to have been imported in 1903 into Pisco, one of the
ports of Peru, by a vessel bringing corn from Mazatlan,
where there were at the time many cases of plague. The
epidemic among men was preceded by an epizootic among rats. In the
middle of April many dead rats were found in the neighbourhood of the
^ Encyclopaedia Medica, Vol. xiii. p. 562.
■^ Indian Plague Commission, Vol. ii. p. 213.
200 Epidemiologif of Plague [part ii
Custom House, and the first individuals attacked, three in number, were
employed as sweepers in that place. In the fourth case the infection had
not this origin, but was probably acquired from one of the former, whom
he had nursed during his short illness and whose dead body he laid out
and accoinpanied from San Andres to Pisco ^
Callao is suspected to have been infected in a similar fashion, but it
was impossible when the outbreak was enquired into to
Ca.lla.0
trace the origin of infection. Attention was first attracted
to the fact that in the middle of April, 1903, numbers of rats were seen
sick and dead in various parts of Callao- ; first, in the mill of Santa Rosa ;
secondly, in the principal station of the English railway ; thirdl}', in one
of the rooms of the municipal buildings; finally in the upper stories of
the International Hotel. This phenomenon was noticed synchronously
in these different places. In the mill of Santa Rosa an unusual
mortality of rats was noticed for about 15 days, which produced an
insupportable stench in the different floors and divisions of the
establishment, including the garden, so much so, that in the room
where the sacks were stored the odour became so offensive that before
opening the door it was necessary to hold the breath and then to depart
instantly in order to let in fresh air before entering. The number of
dead rats in this mill was estimated at 300.
The first case occurred on the 28th of April in the person of Pedro
Digueroa, an employee of the mill of Santa Rosa, who died on May 1st.
In the night of the 29th of April Emilio Klapp, also a labourer at
the mill, was attacked, and died on the 6th of May. On the night of
the 30th of April Pascual Novelli, a companion of the above, and on the
1st of May Miguel Cornejo, also of the mill, fell ill, and died on the
7th inst. On the 2nd of May Pedro Castro, a painter, who had worked
at the mill from the 21st of April, fell ill with the same symptoms. On
the 3rd of May Manuel Feubi, a Chinese cook employed by the overseer
of the mill, was taken violently ill and died in 72 hours. The same day
Samuel Gonzalez, also a labourer at the mill, fell ill and died after
a prolonged struggle on the 29th of May. On the 4th, Juan Fernandez,
and on the 7th, Alfredo Valela and Juan Ramirez, all employees of the
mill, were attacked, and the first died on the 29th of May.
Thus in the course of ten days, i.e. from the 28th of April to the 7th
^ " Gaceta de los Hospitales, Civiles y Militares," 15th Feb. and 1st March, 1904.
- " La Peste Bubonica. Informe presentado a la Academia Nacional de Medicina, por
la Comision especial encai"gada de estudiar la compuesta por los mierabros titularen, Dr
Manuel K. Artoth, Dr Julian Arce, y Dr Daniel E. Lavoreria."
CH. x] Rats and Mercliandise 207
of May, ten employees of the mill of Santa Rosa fell sick, with 60 "/o of
deaths amongst the attacked. The mill was closed on the 8th of May.
Further enquiry elicited the fact that suspicious cases of plague had
occurred in Callao. In February or March of 1903 Cesar Silva, a
servant of Mr Weiss, station-master of the English railway, fell sick
with fever and double inguinal adenitis, without specific cause, and was
treated in the paying wards of the hospital of Guadeloupe, whence he
was discharged cured in about 20 days. At the end of March Jose
Aguilard, employed at the station, was attacked with high fever and
a glandular swelling in the left axilla, which suppurated and was opened,
and had besides a painful swelling of the left inguinal glands. The
Commission reporting on the outbreak regarded these two cases as
being probably either Pestis minor or Pestis ambulans.
The plague at Asuncion, the capital of Paraguay, is stated to have
Asuncion been brought on a river steamer, the s.s. Centauro, to
which at Montevideo bags of rice had been transhipped
from the sailing vessel the Zeir, which in turn had received the rice at
Rotterdam from a vessel arriving from an Indian port. On the Zeir's
arrival at Las Palmas, dead rats were found among the sacks of rice,
and afterwards on the voyage two sailors fell ill, one of them dying
suddenly. During the voyage of the Centauro from Montevideo to
Asuncion, dead rats were found on the ship, and three of the sailors
died from diseases which were considered at the time to be pneumonia,
typhoid fever, and pleurisy. A fortnight after the arrival of the
Centauro, there was a mortality among rats in the custom-house
premises at Asuncion. This mortality spread over different parts of
the town, and was later, by bacteriological examination, established
to be due to plagued
The plague at Unsie, a city in China, was traced by Dr J. P. Maxwell
to the arrival, from the plague-infucted port of Swatow, of
Ulisi6 AC? X
a boat on which there were plague-infected rats. About
the middle of April of 1902, a junk with rats dying on board arrived at
Unsie. Shortly after, rats began to die in that portion of the town
which adjoins the quay, and on May 2nd or 3rd plague broke out in
the house of a man who resided some 250 yards from the quay. Dead
rats were found in the house about a fortnight previously -.
Plague on board ship, while the vessel is in a plague-infected port,
1 Annales de Vlmtitut Pasteur, No. ii. , 1901, p. 8.57.
- Appendices to the Report on the Causes and Continuance of Playue in Hongkong. By
W. J. Simpson, M.D., 1903.
208 Epidemiolog!/ of Plague [part ii
or after its departure from such a port, ascribed to the rats on the ship
having become infected by some means, has happened sufficiently often
for such an occurrence to be reckoned as one of the risks which is run
by a ship lying in an infected port.
Inland towns sometimes OAve their infection to the importation of
rats infected with plague or rat-infected merchandise.
sometlmesTn- Especially has this been observed in Cape Colony. Graaf-
fected by con- Reinet, King William's Town, Kei Road and Burghersdor])
raUway of were infected in this manner. Dr J. A. Mitchell,
rats infected Assistant Medical Officer of Health for the Colony,
with plague . i • i p
or rat-in- reporting on these observations states that, during the first
chandi^^"^" week of February of 1903, plague-infected rats were found
in the railway station premises at Graaf-Reinet, that some
time previously a large quantity of forage and military supplies
principally from Port Elizabeth had been stored in the immediate
vicinity of these premises, and that later an epizootic of plague occurred
among the local rat population. Again, on the 7th March, four cases of
plague were almost simultaneously discovered among the employees at
the railway goods shed at King William's Town. No dead rats had
previously been observed but during the disinfection of the premises
several mummified rats and mice were discovered ; owing to their
condition it was impossible to determine the cause of death but there
appears to have been little doubt that they died of plague. Plague-
infected rats and several cases of plague were discovered later in
different parts of the town. Again, a number of dead rats in a state of
decomposition too far advanced to admit of a definite diagnosis being
made as to the cause of death, were discovered in the railway premises
at Kei Road, and four days afterwards a case of plague occurred in the
station-master's wife. During the process of disinfection of the premises
the carcases of a considerable number of rats dead of plague were
discovered. In regard to Burghersdorp an apparently healthy rat was
caught at the railway station and subsequently killed and examined.
Bacilli apparently identical with those of plague were found on micro-
scopical examination of the remains and the diagnosis of plague was
subsequently confirmed by inoculation experiments. The railway
premises were then disinfected but no dead or sick rats were discovered
during the process. Subsequently a number of dead mice were found in
forage stored near the railway station and specimens from these were
found on examination to contain plague bacilli. Dr Mitchell makes the
following pertinent remarks on this subject :
CH. x] Rats and Merchandise 200
"A number of instances has been observed where live rats have
come ashore from vessels or have been carried long distances by rail or
otherwise in bales of forage, or in 'skeleton' or partially open crates.
Sick rats are probably more likely to remain in a bale of forage or in
a crate of merchandise during transport than healthy ones. Again,
a rat suffering from plague may enter and die in a bale of forage or in
a 'skeleton' crate and thus be carried long distances by sea or rail. The
carcase remains infectious for a considerable period. On the arrival of
the bale or crate at its destination, local rats are likely to investigate its
contents, perhaps devouring the carcase of the dead rat and thus
becoming infected. Or again, bales of forage or open or ' skeleton '
crates containing fi'uit, hardware, or similar goods packed in straw or
other material of a like nature, if stored at a place where plague exists
among the rats, may be infected by their discharges, and if subsequently
removed to another locality are liable to transmit the infection to the
rat population of the latter. It is practically certain that plague
infection has been conveyed inland to Graaf-Reinet, King William's
Town, Kei Road, and Burghersdorp in one or other of these three
ways."
14
CHAPTER XL
MODES OF DISSEMINATION IN AN INFECTED LOCALITY.
It is recognised that the pneumonic type of plague is distinctly and
directly infectious. Medical men and nurses have fre-
type of quently been attacked while attending on patients suffering
plague in- from this variety of the disease, whereas it is rare for them
ffiptiioiis
to contract plague from patients suffering from the septi-
caemic or bubonic form. The sputum of a pneumonic plague patient
teems with virulent bacilli which, in the act of coughing, may be trans-
mitted a short distance through the air. Nurse Macdougall in Bombay
attending to a patient suffering from pneumonic plague received, during
a fit of coughing on the part of the patient, a particle of plague sputum
in the eye, which next day set up conjunctivitis followed by swelling of
the parotid and cervical glands and an attack of plague to which she
succumbed. Surgeon-Major Manser of Bombay contracted pneumonic
plague of which he died by attending a patient suffering from this form
of the disease, and Nurse Joyce who nursed him was attacked on the
evening of the third day by pneumonic plague and died in two days.
Dr Mueller of Vienna and Nurse Pecha contracted pneumonic plague
while attending on Barisch, the laboratory attendant who received his
infection while working among the infected laboratory animals. In Cape
Town, Miss Kayser, the lady superintendent of the Plague Hospital,
contracted pneumonic plague from a patient, and after a few days'
illness died : the day after her death her sister, who had nursed her, was
taken ill and died of pneiimonic ])lague.
The occurrence t)f ])neumonic cases in a town is, as a rule, traceable
to personal contact with jjatients affected with this form of the disease
and the history is generally one of the disease spreading in the track of
relations and fi'iends who have visited, and who have come into close
relationship with the patient. The source of pneumonic plague, although
frequently, is, by no means, always derived from an antecedent case.
CH. xi] Pnemnonic Plague directly infectious 211
This is exemplified by the occasional cases of pneumonic plague which
arise among persons in the laboratory. The history of most of these
cases is that the persons attacked have been dealing with infected
animals and the disease has most probably been contracted from these
animals. The mode of conveyance of the infection might easily be
the hand which has become infected by handling a plague-stricken
rat and which has been accidentally raised to the nose, thereby infecting
the nasal mucous membrane. It may be in such instances that the
type of the disease in the infecting animals is pneumonic, but this has
yet to be established.
To a similar source, viz. infected animals, may occasionally be traced
the first in a series of pneumonic cases occurring in an infected locality,
the first case generally arising in a house in which a large number of
rats have died. The author has observed this in a number of cases.
Once established as pneumonic plague the infection breeds true, for
some time giving rise to pneumonic cases, but later it fails to
reproduce itself in this form and is propagated as a septicaemic
or bubonic type. The Indian Plague Commission^ give in their report
a genealogical table, constructed from material furnished them by
Surgeon-Major Green of the Indian Medical Service, which exhibits the
very remarkable power of pneumonic plague giving rise to pneumonic
plague fi-om patient to patient through no fewer than five consecutive
series. The table is reproduced on page 212.
On the other hand experience shows that pneumonic cases give rise
to bubonic cases both when contracted under the ordinary condition of
natural infection and also under accidental circumstances such as a
post-mortem. There are several cases on record in which, owing to an
accidental wound in the hand when performing a post-mortem on
a pneumonic case of plague, plague of a bubonic type has been con-
tracted. There is a case also reported in which a patient delirious
with pneumonic plague bit a compounder at Hubli on the thumb, who
afterwards suffered from a mild attack of plague with an axillary bubo.
The infectivity of septicaemic and of bubonic cases which become
„ ^. septicaemic before death is not to be iudged by the rarity
Septicaemic ... j n j j
piagne in- with which medical men and nurses contract plague when
attending such cases in hospital. If that were the
standard the conclusion arrived at would be that the powers of in-
fection were feeble instead of being as they are extremely potent. The
' Report of the Indian Flngue Commission, Vol. v. p. 91.
14—2
•212
Epidi'iuloloffn of Plaf/ue
[part II
ORIGINAL SOURCE OF INFECTION IN THE HOUSE OF KAVIRAJ
DWARKA NATH IN CALCUTTA.
r
1
I
1
1
2
3
4
1 ■
1
5
Kedar Nath
Basanta Kumar Madhu Sudan
Sita Nath
Bishnadi
Bhattacharji
Das
Bliattacharji
died Calcutta
Brahmacl
died Calcutta
died Calcutta died
Calcutta
31/8/98
died Cha
16/8/98
23/8/98 29/8/98
' 1
31/8/91
1
1
6
1
1
7
i
1
8
1
1
9
1
1
10
1
II
Dr Amulaya
Shashi Bhusan
Upendra Nath
Girija Prosanna
Puddomoni,
Compoundei
Chann Bose,
Sen
Eai,
Raj,
servant in house
attendee
who attended
attended on
nephew of Girija,
in whuse house
where Sita Nath
Bishnadu
Sita Nath,
Sita Nath,
died
Sita Nath lived,
lived,
died
died Calcutta
died Calcutta
Backergunge
died Backergunge died Calcutta
Chausa
4/9/98
•4/9/98
4/9/98
5/9/98
i
1
6/9/98
6/9/98
r
12
1
13
Tarak
,
Binodini,
servant of (
Sirija, wi
fe of Girija,
died Backer
gunge
died
5/9/98
Backergunge
1
12/9/98
14
Lakhi Some,
brother-in
-law
of Tarak, visited
Tarak and died
Backergunge
9/9/98
1
1
1
15
16
17
18
Mukta,
Ramnidhi,
Ramani,
Baikuntha
visited
assisted at w
ife of Lakhi Some,
lived in Tarak's
Lakhi Some,
Lakhi Some's
nursed him, died
house, nursed
died cremation, died
Backergunge
Lakhi Some and
Backergimge
Backergunge
17/9/98
cremated him, died
16/9/98
16/9/98
1
Harsundari,
Backergunge
17/9/98
1
20
w
ife of Ramnidhi
Kamini,
nursed him, died
wife of Baikuntha,
Backergunge
nursed him, died
22/9/98
Backergunge
23/9/98
CH. xi] Si tuple Bubonic Plague not directly infectious 213
conditions of home life under which plague generally occurs and the
conditions of nursing in a small, ill-lighted, and badly- ventilated room
by relatives and friends are in quite a different category from those
existing in hospitals. Under the conditions of the home the general
distribution of the plague bacillus in the blood, internal organs, and
excretions in septicaemic cases renders them dangerously infective,
especially when discharges are wiped away by the hands or with the
clothes of the attendants. Plague bacilli escape from the body in
septicaemic cases in the secretions and discharges of the mucous
membranes, gaining an exit by the mouth and nostrils, bowels and
kidneys. If the plague patient is not removed to hospital, secondary
cases usually follow independently of other indirect means by which
the disease may spread in a house.
Undertakers and those who lay out the dead are apt to contract
the disease. In Hongkong many of the undertakers perished, and there
is a general impression among the Chinese that the corpse is more
dangerous than the patient. Attendance at funerals, especially when
connected with feasting or ceremonial rites, is often dangerous, plague
afterwards affecting those who have been present. Two of the earlier
cases in the Glasgow outbreak of 1900 were traced to attendances
on a " wake " on the occasion of a child and its grandmother having
died of plague but whose deaths were certified to be "zymotic enteritis"
and " acute gastro-enteritis'."
On the other hand bubonic plague which remains simple bubonic
Simple l)lague is not directly infectious even under conditions of
bubonic home life and it seldom affects the relatives and friends
plague not . . .....
directly in immediate and intimate association with the patient.
infectious. j^ -g |^^ ^^ means certain that bubonic cases, even of the
Pestis ambulans type, are not indirectly infectious though the manner
in which the infection leaves the body and the agency by which it
spreads are still only matters of speculation. Captain James of the
Indian Medical Service instances the village of Gobindpur in the Punjaub
which he sets down as having become infected by the arrival of a boy
suffering from Pestis ambulans. The person living next door to this
boy in the same enclosure was attacked with a severe form of plague.
Among indirect means of dissemination of plague, infected clothes
have a share. How lar^e that share is it is difficult to
Dissemma- ...
tion by in- estimate; it probably varies in different epidemics and
fected clothes. i ^■n> , • ^ mi ^ r
under dmerent circumstances. I he custom oi removing
^ "Eepoit on certain Cases of Plague occurriug iu Glasgow in 1900." By tlie Medical
Officer of Health.
214 Epidemiolociji of Plar/ue [part ii
as many articles as possible fi-om an infected house is probal)ly more
common and more skilfully carried out amcmg Asiatic people wherever
they may be than among Europeans. It often happens that by the
time the health officials hear of the death and arrive at the infected
house, most or a great many of the portable household articles have
disappeared. In Cape Town there was much secret disposal of effects
when Malays wei'e attacked, but the practice was not limited to them.
It is remarkable how adherent the infection may remain among the
different members of a family and its branches, the infection being
discovered in many instances to be associated with the surreptitious
disposal and removal, from house to house, of effects which have not
been subjected to disinfection. It was noticed in India that the
incidence on the Dhobies or washermen was exceptionally heavy.
Plague-stricken rats must also be included as one of the indirect
modes of dissemination of the disease in a locality. The
Dissemma- -^ _
tion by association of epizootics of plague among rats with epi-
ec e ra s. fi^iyjicg of plague has already been referred to as having
been observed in many important epidemics of plague. In fact as
regards modern plague since 1894 there has been no great prevalence
in any part of the world without also an epizootic among rats.
As opportunity for observation has arisen in the different epidemics
in different places the part which this epizootic takes in the dissemina-
tion of plague has been discovered to be exceptionally powerful.
Certain observers have gone so far as to declare that with the
exception of pneumonic plague propagated by direct contagion all
other forms of plague are disseminated by the rat. This is an extreme
view which like many extreme views though containing much, perhaps
the greater portion, that is correct, does not represent the whole truth.
It is interesting to note that, though dogs and cats were considered
to be dangerous both on account of their suffering from plague and
their carrying infectious material on their coats, nowhere does the part
which the rat has been observed to play in the dissemination of plague
appear to have been recognised in the same light as during this
pandemic. The phenomenon of rat mortality was taken as a sign of
a coming plague or that plague was a soil disease and that these ground
animals became first affected with plague, rather than that the rats
themselves were dangerous.
Hankin and Simonds in 1898 summarised in the Annaiesde I'histitut
Pasteur the facts which had then been observed, and came to the
conclusion that rats played an important part in the dissemination of
the disease. This conclusion was the same as tliut which had been
CH. xi] Disseminafi'on hi/ Rat^ 215
arrived at by many with practical experience of plague. Since that
time there has been ample opportunity of verifying its correctness.
The great influence which plague-stricken rats exercise in the
dissemination of the disease comes prominently into notice in those
towns and places where plague cases are removed to hospital with
promptitude, and where the infected clothes are disinfected, and yet the
epidemic continues to develop. Such has been the case in Cape Town,
Port Elizabeth, East London, Durban and other towns in South Africa,
and also in Brisbane and Sydney in Australia.
Special value attaches to the observations in South Africa and
Australia, because the history of each case was more
Special value . "^
attaches to readily traceable than m Eastern countries. The spread
tfons^irsoutii ^^ plague in the towns of South Africa and Australia was
Africa and associated principally with the course of the plague epi-
zootic among rats, the direct infection from human being
to human being and the indirect infection communicated by infected
clothes having been eliminated by the action of the sanitary adminis-
tration.
In Cape Town not only were the first cases in the docks associated
with the rat mortality and traceable to it, but the progress of the
disease in its later phases was notably connected either with the move-
ment of rats from infected centres, which resulted in the setting up
of new foci of disease, or with the infection of rats in new centres by
other modes than the migration of rats. As regards the latter mode,
a block of houses was infected by bringing to one of its houses bales
of goods from the docks. Whether these bales of goods contained
infected rats at the time of their removal from the docks, or were
infected in the docks themselves by the discharges from plague rats,
it is impossible to say, but the conveyance of these goods to a healthy
part of the town infected the local rats. On the discovery of infection
of the rats all the houses but one were evacuated. The single exception
was left because there was no available accommodation in the health
camp. In a short time plague attacked the inmates of the house, Avhile
the others who had been removed to camp remained unaffected. In
Cape Town it was possible, by bacteriological examination of the rats
brought in from different parts of the town, to trace in a general way
the course of the plague epidemic, for it corresponded with that of the
epizootic.
The majority of cases of plague were traceable to infection from rats,
dead or infected rodents being found at the residences and workshops
216 Epidemioloffii of Plague [part ii
of those attacked with the disease. The number occasionall}' found
under the floors of infected premises was extraordinary, notwithstanding
the absence of the signs of sick or dead rats on the surface of the
premises. In one house there were as many as 105 rats discovered by
the cleansing department, in another 52, and in the majority one to
half-a-dozen. There were houses in which no rats were found and
in many of these cases the source of infection was traced to other
causes.
The same intimate association of plague-stricken rats with plague
in man and the relationship of cause which the fonner bore to the
latter were traced in Port Elizabeth, East London, Durban and other
towns invaded with plague.
Two interesting features about the epizootic among rats in Port
Elizabeth are worthy of mention. The first is that the epizootic has
never been so severe as that which prevailed in Cape Town, and the
second is that it has continued in a more or less sporadic form since
its commencement. Similarly, the epidemic of plague has not been
of a very severe character and has continued in a more or less sporadic
form. There are evidently different degrees of severity and rapidity
of diffusion of plague among rats as there are differences in this respect
in epidemics of plague in different localities. Apparently when the rats
are much infected and over a wide area in a locality, the epidemic in
man is correspondingly wide and severe, but when the rats are only
sporadically attacked the disease in man is also sporadic.
The history of the epidemics in S^Tlney in 1900 and 1901, and in
Brisbane in 1901 and 1902, which agrees in many respects with that
of South Africa, and w hich establishes both in time and place the close
relationship existing between the incidence of rat plague and the
subsequent occurrences of human plague, demonstrates the very im-
portant share Avhich rat plague takes in the dissemination of human
plague, and the very small part that human intercourse sometimes
plays in the local diffusion of the disease.
In the Hongkong epidemic of 1902 hundreds of rats were daily
examined bacteriologically, and it was found that the
Si*Hongkong- P''*2^6"ce of plague-infected rats in a house or locality
meant, sooner or later, if immediate measures of precaution
were not taken, cases of plague in that locality or house, and that
the dissemination of the plague by rats was even a more influential
factor in the spread of the disease than its dissemination by man. By
an examination of the rats it was possible to plot out the localities
CH. xi] Dissemwation by Rats 217
which were likely to remain healthy and those in which plague cases
might be expected. It was observed in Hongkong that the rat plague
would occasionally pass along a number of houses on one side of the
street and then suddenly pass over to the other side. A similar
phenomenon has been observed in different epidemics of plague in
human beings, and there is reason now to suppose that the explanation
of this peculiar course of plague is to be found in the movements of
infected rats. To turn now to a few specific instances. In 1901 30
men were employed in Hongkong to collect rats, and no fewer than
nine or 80 "/„ died of plague, three others leaving the Colony sick.
In a piivate firm of 30 coolies employed in sorting, and one of whose
duties was to collect dead rats from the godown when required, five or
16'6"/o contracted plague and died. In another firm rats were dying
in the store-room and two men engaged in removing them were
attacked with and died of plague. There are similar examples to these
mentioned by Hankin and Simonds in the Bombay epi-
m india*^°'^^ demic. Hankin records a case of this kind in a mill in
which there were several thousands of workmen. Rats were
noticed to die in large numbers ; 20 coolies were employed to remove the
dead rats; out of the 20 no fewer than 12 were attacked by the plague,
while the rest of the workmen and others in the building remained
healthy. Simonds also records an example of rat infection in two
women caused by handling dead rats. The inhabitants of a village
in the Punjaub w^ere turned out of their village and placed in camp
because of a commencing mortality among rats. While in camp two
women were permitted to visit their home and found on the floor of
their house some dead rats ; these they picked up and threw into the
street ; they returned to camp and a few days later they were attacked
with plague. Two instances placed before the Indian Plague Com-
mission may be mentioned. Both were villages in the Punjaub and
under the supervision of Captain James of the Indian Medical Service.
" The inhabitants of Mahlgahla, some 2500 in number, were placed
in camp by Captain James, I. M.S., on account of an outbreak of plague
which was confined to one special quarter of the village. This quarter
having been disinfected without incident the disinfection of the rest
of the evacuated village w-as taken in hand. In the absence of other
available labour the house owners were here employed upon the
disinfection of their own houses. As soon as they were set to work
they came upon dead rats all over the village, in one case no fewer
than 15 of these being found in a single room. F'ive days after the
218 EpidemioliHui of Plague [part ii
coinmencenient of the work of disinfecting the houses, which had been
free of plague at the time the vilhige was evacuated, numerous cases
of plague began to occur among the disinfectors. So severe was the
outbreak of the disease among these (the resulting epidemic did not
subside till 75 persons in all had been attacked) that the disinfec-
tion operations had to be suspended. The quarter of the village
in which most of the disinfectors were attacked was the quarter
most remote fi'om that in which the original group of plague cases
had occurred'."
The second case is the village of Chak ]\alal, which was evacuated
as a precautionary measure. " A few days afterwards owing to the
downpour of rain a considerable number of the inhabitants returned
to their houses. A number of rats (and these were shown by bacterio-
logical examination to have died of plague) were found lying dead all
over the village. Within a few days afterwards quite a considerable
number of people contracted plague. It seems clear that the infection
was here disseminated over the w hole village as a result of the outbreak
of plague in an epidemic form among rats"^."
The agency by w^hich plague is transmitted from the rat to man is
unfortunately still a matter of conjecture. Three modes
The agency . "^ .
by which have been suggested ; one is by the parasites on the rat,
plague IS .^ second is by food which has been contaminated by the
transmitted ■^ _ J
from the rat saliva, excreta, and urine of plague-stricken rats, and a
third is by inoculation of the foot or hand owing to an
abrasion coming into contact with bacilli on the rat itself or on some-
thing soiled by the plague rat. It will only be necessary to deal at this
stage with the first, as the others wall be considered when treating of
the channels by which the infection enters the human system. Of the
The flea parasites of the rat the flea is the most important, firet
theory. because it is a blood -sucking insect, and secondly because
it possesses the power of transferring itself from animal to animal. Many
observers, the first being Ogata^, have found plague bacilli in fleas taken
from plague-infected rats, the bacilli remaining in the bodies of the fleas
for some time after feeding on infected blood. The fleas themselves are
apparently not injuriously affected by the bacilli. On this observation,
coupled with the fact that fleas are frequently numerous on such rats,
Simonds conceived the theory that the flea is the connecting agent
' Report Indian Plague Conunitmion, Vol. v. chap. iii. p. 124.
2 Ibid. p. 1-25.
^ "Ueber die Pestepidemie ill Formosa." Centralhlatt fi'ir Bakteriologic, Vol. .\xi. 1897.
CH. XI] The Role of Titfected Flem 219
between plague in man and the rat. When the rat becomes ill it is
sometimes covered with fleas, which leave the body on its death and
transfer themselves to other animals. It is in this transference of fleas
from an infected rat to a healthy one or to man that Simonds explains
the mode of dissemination between rat and rat and between rat and
man. Nuttall' in subjecting these views to the experimental test,
including both bugs and fleas, which he allowed to bite animals dying
from plague and then inniiediately afterwards transferred them to
healthy animals, was unable to produce a single case of infection.
The theory of Simonds rests on the view that plague is usually
caused both in man and in the rat by inoculation of the infection
through the skin, and on the aptitude of rat fleas for biting man. Both
of these have been controverted. It is a fascinating theory, but it still
requires much more evidence in its support than exists at present to
place it on an absolutely flirm foundation, and even then it by no
means excludes other agencies.
Four species of fleas, Typhlopsylla rausculi, Pulex fasciatus, Pulex
serraticeps, and Pulex pallidus, have been found on rats, while two,
Pulex irritans and Pulex serraticeps, have been found on man. The
Pulex serraticeps is also commonly found on dogs and cats. There can
be little doubt that the Pvdices will bite man if they have the
opportunity though it may be only on occasion that they do so. The
fact that they do bite man has been observed by Tidswell" and by
Gauthier^ and Raybaud.
The only experiments hitherto made which appear to support the
view that fleas from a plague rat may possibly cause plague in higher
animals are those mentioned as having been made at Hongkong. They
are, however, not conclusive in that the results obtained were solely
clinical, the illness from which the monkeys suffered not proving fatal,
and no examinations having been made to ascertain the presence or
absence of plague bacilli in the organs of the monkeys.
On the other hand, the transmission of plague from rat to rat by
the agency of fleas has been successfully accomplished by MM. J. C.
Gauthier and A. Raybaud, who in five experiments were able to convey
' Nuttall, "On the role of insects, arachnids, and myriapods as carriers in the spread
of bacterial and parasitic diseases of men and animals." Johns Hopkins Hospital Ri ports,
Vol. VIII. 1900.
- Report of the Board of Health on a Second Outbreak of Planue at Si/dney, 1902, by
J. A. Thompson, M.D., D.P.H.
* Revue d^Hjifiiene, xxv. p. 4'2t), May, 1903.
220 Epidemioloify of Plague [part ii
the disease to healthy rats by the bites of fieas which had fed on a
plague-infected rat.
Experiments also carried out in Bombay by Dr Elkington and
Captain Liston of the Indian Medical Service were successful in con-
veying the disease by Heas from infected to healthy rats and from a
septicaemic case of ])lague in man to healthy rats^
An interesting obseivation was made by Dr J. M. Clarke in regard
to the immunity of a locality near which })lague was prevalent. While
plague continued at Lpiique not a single case of plague originated in the
interior- innuediately adjoining, which was on the Pampas and some three
thousand feet above the sea, where the deposits of nitrate of soda are
found together with immense salt beds, although there was a continual
interchange of population whose habits were filthy, and sanitary measures
unknown. It is suggested by Dr Clarke that the immunity might have
been due to fleas not being able to live in the locality. By way of
experiment a number of fleas were taken up and in less than one hour
they all died.
Rats do not exhaust the list of rodents or other animals which may
disseminate plague. It was a commonly accepted opinion
lu the 16th , 1 . , 1 -, K 1 • 1 , • ,
and 17th m the loth and uth centuries that cats, dogs, pigeons and
centuries fowls spread the disease. Athanasius Kircher, after de-
cats, dogs, J^ '
pigeons and scribing the manner in which the contagious virus adheres
believed to ^'* bedding, linen, clothes, skins, carpets, leather, even to
spread spoons, knives, tabletops, cups, shoes, belts, &c., adds that
animals such as " cats, dogs, pigeons, fowls and the like,
dwelling within the precincts of an infected house at the very first
contact with the things infected take the contagiousness which breeds
contagion ; and even if, by a kind of contrariety of nature, they are not
affected internally by it they nevertheless do carry it into the neigh-
bouring houses and spread the plague they have caught throughout the
city. Therefore, in time of plague, the slaying and extermination of
dogs and cats and suchlike domestic animals is ])rescribed. Examples
beyond all count show how great is the danger from such animals when
a house is stricken by plague^" He quotes the case of a nun in Milan
who, w^hen the plague was lieginning in that city, isolated herself from
her companions and endeavouivd to protect herself by fumigating and
burning of .scents in hor chamber. On one occasion, however, having
1 Aiistnilasiau Medical Gazette, xxii. p. .348, August, 11)03.
2 Athanasii Kircheri, E. S. J., Scnttiniuni I'lnjuico-Mi'dicinii C<)nta<jiosae I-tiis, quae
Pestis dicitur. Home, 1G58.
cii. xi] Older Views regarding Dissemination 221
to leave her cell, the door was left open and on her return she found a
cat on the bed that had caught the plague elsewhere, which is believed
to have infected the bed, which again infected the nun, who was attacked
and died on the third day of her illness. It is remarked by Orengius, on
whose authority the story is given, that the cats on the premises were
killed and the nunnery after that was free from the contagion.
There are few old " plague orders " that do not attach importance to
the destruction of dogs and cats. Dr Maunagetta in his "plague order"
mentions that Dr Marsilius Ficinus, who reports on the plague of 1479
in Florence, states that plague was conveyed from infected houses to
healthy ones by cats and dogs. Roderick von Casto made a similar
observation during one of the plagues of Hamburg.
At Padua during an epidemic all the dogs and cats within a radius
of 4 miles were destroyed in order to prevent the extension of the
plague. In the London epidemic of 1543' the plague order enjoins
among other things " that all persons having any dogs in their house,
other than hounds, spaniels, or mastiffs, necessary for the custody or safe
keeping of their houses, should forthwith convey them out of the citv or
cause them to be killed and carried out of the city and burned at the
common lay-stall, and that such as kept hounds, spaniels, or mastiffs
should not suffer them to go abroad but closely confine them."
In subsequent orders similar injunctions in regard to dogs, cats, and
swine appear. At the height of the Marseilles epidemic it is recorded
that no fewer than 10,000 dogs had been killed. Skeyne in 1568 remarks
that if the domestic fowls become pestilential it is the sign of a most
dangerous pest to follow. The Franks in Egypt and Syria, when
shutting themselves up in their houses during the plague season, which
used to be their custom, also shut up in cages their dogs and cats, and
were careful to shut up all openings or holes to prevent any animal
gaining access to the house from the outside. Any animal entering the
house was immediately killed.
It was, moreover, held that insects were the means of conveying
Ancient beUef contagion. Dr Girolamo Mercurialis in the 16th century
in the possi- states that flies filled with the iuice from patients as well
bility of in- . . i • , , • ,
sects convey- i'ls corpses passmg into the neighbourmg houses and
ing infection, tainting with their dirt, eatables, have brought the con-
tagion upon such people as partook of them. Athanasius Kircher
instances a case of infection caused by a hornet : " In the late plague of
^ History of Epidemiol in Britain, Vol. i. p. 314. By Cbailes Creigbton, M.A., M.U.,
1891.
222 Epldemiolocfy of Plague [part ii
Naples a nobleman was looking at something at the window when
suddenly a hornet tlew in and settled upon his nose and stinging him
produced a swelling : gradually this grew and the poison creeping
through his flesh within two days of catching the plague he died, most
certainly from the contagious humour which the insect had sucked from
a corpse."
From observations then made, when plague used to be prevalent in
Europe and Egypt, it is evident the opinion was formed that animals
and insects were able to spread the infection. That opinion has been
confirmed in many respects by the experiments and observations of
recent years. It has already been shown that fleas may be transmitters
of plague infection from rat to rat. Ants, bugs, flies and mosquitoes
have also at various times come under suspicion of being either active
or passive agents in the dissemination of plaefue. Plague
Plague bacilli . i o o
detected in bacilli have been detected in ants, bugs and flies which
and^kf^^^ have fed on or come into contact with plague material in
an infected house, or in a mortuary, or in the laboratory.
An interesting case is reported by Calmette and Salimbeni in the
Oporto epidemic of 1899 in which the lesion produced by the bite of a
bug was the starting-point of an infection of plague'. The person
attacked was bitten on the night of Sept. 21st by a bug on the left
hand ; the next day the hand and forearm were in a state of intense
inflammatory oedema and at the site of the bite a large black areola
formed, the centre quickly necrosing and the necrosis extending soon
over the whole of the doi^sum of the hand. On the same day the
symptoms of plague declared themselves. On the 23rd September the
temperature was 40° C. ; there was delirium ; the cervical glands were
much engorged and painful, especially the right ; the inguinal glands on
both sides were slightly swollen and sensitive to pressure; a track of
lymphangitis on right thigh and ecchymosis on the back of the right
hand. On the 24th September the temperature was 38-5^ C, pulse 120,
tongue and lips fuliginous, respiration frequent and the patient sank into
a state of coma which continued for three days, death occurring on the
27th September. The post-mortem of this case showed large necrotic
ulceration on the dorsum of the left hand, a right femoro-inguinal bubo,
which when incised exuded a dense and viscous chocolate-coloured
fluid; general glandular enlargement and the usual appearances of
a septicaemia.
' "La Peate Bubonique, etude ile repiiiemie d'Oporto en 1899." I'ar A. Calmette et
A. T. Salimbeui, Aimules de I'lnslilut Fasteur, December, 1899.
CH. xi] The Tarbafian and Plague 223
It is established experimentally that animals of different species are
The r6ie of more or less susceptible to plague ; among these are cats,
animals other dogs, pigs, calves, sheep, poultry, monkeys, and squirrels
than rats in , , y^, ^ i ^ ^• i
the dissemi- '^^ncl snakes, rlague has also been discovered as occurring
nation of ^y natural infection among cats in the Mauritius, Cape
plague not "^ ° . , ' r
judged to be Town and elsewhere, among dogs in China, among poultry
from^existing ^^^ Hongkong, among monkeys, squirrels and porcupines in
observa- India, and in a wallaroo, pademelon, tree-kangaroo, Indian
antelope and wallabies in Sydney. There is reason, also, to
suspect the susceptibility of moles and bats. The role of all these
animals in the direct dissemination of plague in the existing pandemic
has not yet been proved to be of much importance. Possibly, as plague
becomes more diffused and endemic in the areas that it has invaded, the
natural infection to which these animals are subject may have a greater
opportunity of becoming more general, and the older observations as to
their power of disseminating the infection will be found to be correct.
In regard to direct infection communicated by the cat an interesting
case occurred in the Cape Town outbreak of 1901. The Rev. Mr Gress-
ley, who took up his residence in the Health Camp and voluntarily
performed the duties of chaplain, was attacked with plague under the
following circumstances : a cat of his became sick and after a few days
died ; examination proved its illness and death to be due to plague.
One peculiarity of the bacillus, however, was its staining with Gram's
method. A few days afterwards Mr Gressley was attacked with plague,
his infection being attributed to the cat. Curiously enough the bacillus
in Mr Gressley 's bubo also possessed the character of staining with
Gram's method.
The epizootic disease which affects the tarbagan marmot, a rodent
„^ , .^ which is very common in the Transbaikal province of
The tarbagan . '^ '■
(Arctomys bo- Siberia, has already been stated to be communicable to
toanepi-°* '"'"^- Although the bacteriological test has not been
zootic much applied yet the descriptions given by Dr Bieliavski and
l)r Rieshetnikof respectively leave little doubt that the
disease affecting these rodents, and which is liable to be communicated
to man, is ])lague.
Dr Clemow gives in the Journal of Tropical Medicine^ a full and
interesting account of the disease, derived from the contents of two
articles published in the Joumal of General Hygiene and Legal ami
' "Plague ill Siberia and Mongolia and the Tarbagan (Arctomys bobac)." By Frank
Clemow, M.D., D.P.H., Journal of Tropical Medicine, February, 1900.
224 Epklenuolofiji of Plague [paut ii
Practical Medicine for A])ril, 1895 {Viestnik obshtchestvennoi Gigienui
Sudehwi i Praktitcheskoi Meditzinui), the official journal of the medical
department of the Russian Ministry of the Interior.
The tarbagan is a rodent of about 26 inches in length, with a thick
fur of a dull yellow colour, which is of a darker shading on the back and
snout and round the lips and eyes. The animal builds large under-
ground dwellings in which it hybernates from Sepfcember to ]\Iarch. It
is hunted b}- the nomad Buriats and by the Cossacks, its flesh being
considered a delicacy for the table, but it is principally sought for
on account of its fat, which is used for greasing straps, harness and other
leather objects. In some years, and usuall}^ in the autumn, the tarbagan
is attacked by an epizootic disease, the symptoms of which are as
follows.
The animal becomes languid and ceases to bark ; its gait is unsteady
and sometimes under one shoulder a reddish tense swelling appears ; if
far from its home the animal may be unable from its dazed condition to
find it, and readily falls a prey to its foes. Sometimes the swelling is
absent or very small, and the Buriats, to determine whether the animal
is diseased or not cut into the sole of one pad and if the blood is
coagidated they consider the animal is diseased and give it to the dogs.
Dr Clemow remark.^- that it is an interesting fact that neither dogs nor
wolves contract the disease.
The disease in man which is believed to be contracted from this
The disease epizootic disease of the tarbagan has the clinical symptoms
in man con- ,)f i)lague with its gi'eat fatality. The symptoms are severe
tracted from i o o ., ^ jr
sick tarba- headache, fever, vomiting, sometimes diarrhoea, but more
^^°^ commonly constipation, and pain in the arm-pit or groin
with glandular swelling, which, however, is not always present, ending
fatally as a rule in a few days. In the village of Soktui in August,
1889, in a Cossack family of ten persons a girl aged 16 years died of
this disease after three days' illness, and her death was followed by that
of three other members of the fiimily. Then a relative took home some
of the clothes and washed thi'ui, and in a few days was attacked with the
disease and died. Five other members of this second family were
attacked and died and only a child of five years remained unaffected; a
young Buriat aged 10 years, who played with the children, also sickened
and died.
It appears that the membei-s of the family first attacked were
occupied in catching and skinning tarbagans, and two years later one of
the remaining .six sons contracted the disease and died after skinning
CH. xi] The Tarhagan Disease 225
and removing the fat from a sickly looking animal. His death was
followed by that of his brother, aged 5. At the same time in the town
of Aksha a small outbreak took place, the first case being that of a man
who, while away from home, had eaten some tarbagan flesh with some
Mongolians. He sickened the day after his return and died three days
afterwards. Five other members of the family were attacked and died.
One of these was removed while ill to a neighbour's house, where two of
the household afterwards sickened and died. The symptoms were high
fever, giddiness, severe headache, red and flushed face with anxious
expression, rapid and progressively weaker pulse. Some patients com-
plained of oppression and pain in the chest with occasional dry cough,
and the expectoration of a small amount of occasionally blood-stained
sputum. The weakness and depression were extreme, but there was
usually consciousness to the end. In some there was pain and swelling
of the glands in the axilla or groin, while in others there were no
glandular swellings.
In 1894 there was a severe visitation in Soktui in another Cossack
family, which was caused by the head of the family, on his way to attend
the court at Tzagan-Olui, carrying six tarbagans which his dog had
caught and killed. The rapidity with which the animals were caught
seemed to show that they must have been suffering from disease. He
was taken ill two days after his return home and died three days later.
His symptoms were headache, drowsiness, vomiting and diarrhoea. On
September 14th the youngest son fell ill with the same symptoms, and
had pain and swelling " in the arm-pits and groins." On September
15th a son, on the 17th the mother, on the 19th the grandfather,
on the 29th the grandmother, on the 23rd the eldest daughter fell ill
and died.
None of the villagers would go near the sick but they brought food
and drink for them, which they placed at some distance from the infected
house. The dead were buried by the survivors, who threw into the
grave the clothes and linen of the deceased. Sixteen days after the last
death the survivors went to the house of a relative after changing all
their clothes in an out-house, burning their old clothes and putting
on new ones provided by the relative.
The tarbagan is to be found in Eastern Europe, Siberia, Mongolia,
and Tibet, but, as pointed out by Dr Clemow, there is no evidence to
show that it suffers from the fatal epizootic described except in the
Transbaikal province, and possibly in the neighbourhood of the Solenko
valley in Mongolia,
s. 15
PART III.
PLAGUE IN THE INDIVIDUAL.
CHAPTER XII.
MORBID ANATOMY AND PATHOLOGY.
It is usually on the post-mortem table that the first case of plague is
discovered. The characteristic appearance in a necropsy of plague is
that of engorgement and haemorrhage associated witli enlargement
of the lymphatic glands and extravasations into the periglandular
tissues of one or more groups of these glands. Nearly every organ
participates more or less in the extravasation of blood from the veins.
Professor Frazer' (now Sir Thomas) points out that the vascular
changes, and especially the pervading and characteristic tendency to
extravasation of blood in almost every part of the body, are closely
reproduced in the toxaemia caused by the organic poison secreted by the
venom glands of several species of serpents, such as the black snake
(Pseudechis porphyriacus) of Australia.
Pathological changes special to plague occur in the skin, lymphatic
glands and the adjoining blood vessels, in the spleen, lungs,
heart, liver, and kidneys. Decomposition of the dead
body is ncjt accelerated in plague unless in thi; mixed form when strepto-
cocci are present, then putrefaction may set in very early. On the skin
there are often small haemorrhages chiefly on and in the vicinity of the
bubo and on the head, arms, neck and shoulders ; these haemorrhages
contain plague bacilli. Haemorrhages are also found in the muscles,
chiefly in those of the abdomen and of the temporal bones, as well as in
' Report of the Indian Plague Commission, Vol. v. Appendix ii. p. 436.
CH. xii] Morbid Anatomy and Pathology 227
the muscles near the primary bubo ; they contain polynuclear leucocytes
and plague bacilli. Carbuncles, boils, vesicles, or pustules may be
present on any part of the body. Epidemics differ much in this respect,
some being distinguished for the comparative rarity of these skin
manifestations, others for their frequency. They appear over intensely
inflamed glands or in other regions of the body, and are local infiltrations
of the skin and areolar tissue and contain plague bacilli and leucocytes.
They vary in size, present at first a vesicular or blister-like appearance
on the surface of the skin, but when the blister is broken there is under-
neath an ulcer with uneven surface of a reddish-yellow colour. Cut
into, they are thick, hard and dense and haemorrhagic.
The condition of the lymph glands is peculiar to plague. There is
Lymphatic ^^ other infectious disease which shows a similar multiple
glands. inflammation of the lymphatic glands, together with
haemorrhages, exudative infiltrations into the periglandular tissue, and
presence of characteristic bacilli.
In the bubonic form the gland or group of glands affected are
manifested externally as buboes in the region of the groin,
primary arm-pit, and neck. The groin is by far the most fi-equent
'^ °^^' site, one or both sides exhibiting buboes. Occasionally
there are buboes at the elbow and in the space behind the knee. The
buboes vary in size and shape according to their situation, the number
of glands affected, and the amount of haemorrhagic serous or sero-
sanguinolent effusion from the glands into the periglandular tissue. At
times the amount of effusion is small or absent, and only one or a few
glands slightly swollen, then the bubo is small and easily felt. Most
frequently the opposite conditions prevail. The effusion is extensive,
the bubo is large and readily recognised. Then the connective tissue is
infiltrated with blood or with a yellow gelatinous oedema, or with both,
which mats together the haemorrhagic and much swollen glands and
forms a swelling which may be the size of a man's fist. The exact
limits of this tumour are often ill-defined owing to a surrounding
oedematous condition. Between the above-mentioned extremes there is
every gradation. Anatomically then the bubo consists of connective
tissue more or less engorged or infiltrated with blood, or serum, or both,
which forms a dense sanguineous gelatinous or oedematous mass in
a state of inflammation in which is embedded one or more enlarged
glands inflamed or haemorrhagically infarcted. On the boundaries of
this hard and tense tumour there is often an extensive oedema. The
colour of the bubo and the adjacent tissues will accord with the relative
15—2
228 Plague in the Indiviiliial [part m
amount of blood or exudative infiltration et!"used from the glands, the
one being black and the other yellow. Much variety in coloration will
occur according to whichever predominates. The mass will also exhibit
different stages of inflammation, exudation, haemorrhagic infarction,
suppuration and necrosis according to the intensity of the disease and
the (hiratinn of the illness. The size of the separate swollen glands
varies, being from that of a pea to that of a walnut. The enlargement
is due to hyperaemia, inflammation, exudation and haemorrhage, and
these processes obliterate more or less the distinction between cortical
and medullary substance. The condition of the lymphatic glands
depends largely on the time of death. In severe cases in which death
takes place rapidly the glands may be of a purple or dark plum colour,
and partially or completely infarcted haemorrhagically and exhibit on
section a deep red-brown or blackish-red appearance. The haemorrhages
with an exudative oedema may have broken through the capsules and
infiltrated the surrounding periglandular tissue, matting together the
separate glands which are in various stages of inflammation, and
involving the neighbouring fascia, adipose tissue, muscles, vessels and
nerve sheaths to a greater or less extent. In other cases the glands are
red or violet or brownish-red in colour, moderately hard and with their
capsules distended. On section the parenchyma may be of soft or firm
consistence and of a granular mottled or marbled appearance, the me-
dullary substance being profusely sprinkled or streaked with bright red
extravasations of varying sizes. At the periphery of the gland there is
frequently a fine granulation formed of yelloAv nodules, on which there is
a ropy or viscid material. The exudation is not so haemorrhagic but of
a sero-sanguinolent nature forming a yellow, gelatinous oedema mixed
with blood extravasations. Commencing necrosis is evidenced by a
greyish-yellow or mottled brownish-red and grey appearance. In later
cases in which the disease is protracted to the 8th or 9th day, the
parenchyma of the gland usually contains a yellow or yellowish-red pus,
while the periglandular tissue may have improved in condition or is in
a state of suppuration. In other cases there may be a general sloughing
of glands and tissues.
The veins in the vicinity of the bubo, such as the femoral, axillary
and jugular, participate more or less in the disease, beinsf
Veins in the i ,7 , • „ , • • •
vicinity of emDeauea in a yellow gelatinous mass containing extra va-
^ff^ Td° sated blood. They are affected by the haemorrhagic in-
filtration and inflammatory exudations proceeding from
the glands, and are thus often incorporated in the bubo mass forming
CH. XTi] Morbid AncUomy and Pathology 229
a part of the tumour. The haemorrhages and inflammatory exudations
do not confine themselves to an infiltration of the tissues around the
veins, but they penetrate into and between their walls so that when the
veins are opened their inner surface shows large and suffused hae-
moiThagic patches which become smaller, more isolated and punctated
the further away they are from the bubo. By the haemorrhages into
the walls of the veins there is established a direct communication
between the glands and the veins.
Major Childe, I. M.S., was the first to point out this haemorrhage into
the walls of the veins included in the bubo and the continuity of the
extravasated blood in the gland, in the areolar tissue outside the gland
and in the walls of the veins incorporated in the bubo'.
This destruction of the walls of blood vessels, inside and outside the
glands leading to haemorrhages, appears chiefly to be brought about by
the plague bacillus and its toxines in the glands and in the exudative
infiltration acting chemically on the minute vessels of the walls.
There may be other buboes in connection with the buboes in the
Internal groin, arm-pit, and neck. A bubo in the groin not infi-e-
buboes. quently extends through the crural ring into the pelvis and
abdominal cavity, involving successively the glands, tissues, and vessels
in the iliac and lumbar regions and forming one or more large tumours.
The bubo possesses similar characters to the ordinary bubo, both as
regards the degree of intensity and number of glands affected and as
regards the amount of sero-sanguinolent infiltration and oedema into
the tissues around them ; occasionally the iliac glands show much more
change and swelling than the inguinal. In some cases the chain of
glands along the spinal c(jlumn as far as the thoracic cavity and even up
to the hinder mediastinal glands are extensively affected, or this
condition may extend over to the glands of the other side of the body
and thei'e may be large buboes on both sides of the spine to the
diaphragm. Similarly in an axillary bubo the chain of glands to the
subclavian vein and to the neck may participate, while a bubo in the
cervical region may extend down into the thoracic wall and affect the
glands there and frequently to the axilla. These internal buboes like
the external are characterised by altered and swollen glands, haemon-hages
and oedema, and may be in a worse condition than the external ones,
but the area involved and the acute inflammatory changes in the
surrounding tissues are usually less, there being more of the yellowish
gelatinous oedema than there is of the copious haemorrhagic infiltration
characteristic of those buboes first affected. The glands may vary from
1 Report of Major Lyons, I.M.S., President, Bombay Plague Research Committee.
230 Plarjnc in the Individual [part iii
the size of a pea to an olive, and on section display a considerable range
in the degi-ee to which they are affected, some being completely
haemorrhagically infarcted, while others are of a reddish-brown, reddish-
yellow, or straw-yellow colour. Of internal glands the mesenteric and
retroperitoneal are frequently affected. This was very noticeable in the
autopsies at Hongkong. They were generally dark red or purple in
colour, of the size of a bean, and embedded in an extravasated mass of
blood. The adjoining veins and lymph vessels were in these cases
dilated and their walls suffused with blood.
There are other buboes which in contradistinction to those already
Secondary referred to may be termed secondary^ although they may
buboes. not be preceded by primary buboes. They originate when
the circulation is invaded in force by the plague bacilli, which are then
carried by the blood to different glands in the body. This occurs either
in consequence of the walls of the veins incorporated in the bubo be-
coming so damaged by the infiltration as to permit of a direct entrance
for the microbes from the glands into the circulation, or it occurs in
cases when the blood stream is directly infected and the bacilli mul-
tiply in the blood instead of in the lymphatic glands. In each
instance the disease becomes septicaemic, that is, the blood stream
becomes the agent for the distribution of the plague bacilli to the
different organs and glands in the body. These secondary buboes
may therefore develop in all regions of the body quite independently of
the seat of a primary bubo, from which they differ in some very important
respects. The glands are enlarged, but seldom larger than a bean or
hazel-nut ; they are hard and solid and of a pink colour ; on section they
are found to be engorged with blood ; and the parenchyma is hyperaemic,
soft, of splenic consistence and easily scraped off with a knife. In a
later stage the soft, swollen, parenchymatous tissue is oedematous, with
distinct greyish-red haemorrhages and softened areas : in still later cases
the haemorrhagic infarcts occupy a considerable area within the gland,
but do not go beyond the capsule, so that further than occasional
oedematous condition of the surrounding tissues there is rarely any
haemorrhagic or gelatinous infiltration to be seen connected with these
glands.
The best description of the histological changes is given by
Albrecht and Ghon^ whose work in Bombay in this respect on behalf of
the Austrian Government is of the most careful and minute character.
' "Ueber die Beulenpest in Bombay im .Jahre 1897." Gesammtbericht der von der
Kaiserlichen Akndnuie der Wisseugchaft in Wien znm Studium der Beulenpest nach Indien
entsendeter Connni.ision. Vienna, 18'.)8.
CH. xii] Morbid Anatomy and Patlwlogy 231
Thi' histological changes in the bubo are essentially those which
are produced by the irritating and destructive action of
changes in the plague bacillus and its toxines. They appear to be
primary gj,g^ qx\ inflammatory action on the cellular elements of the
bubo. . ....
tissues, followed by necrotic and disintegrating processes
which affect the capillaries and blood vessels, leading to haeinorrhages
and exudative infiltrations which favour a further destructive effect and
a further spread of the bacillus. Wherever bacilli are to be found in
large numbers, which is the case in a primary bubo, there, sooner or
later, the tissues gradually break up, disintegrate, and finally form into
masses of detritus. With the gland as the starting-point of the tissue
changes in the bubo, the glandular tissue shows a more advanced degree
of haemorrhages, infiltration of leucocytes and bacilli and necrotic de-
generations than the periglandular tissue.
With the invasion of the bacilli, which may be aggregated in masses
in the gland or extend throughout the whole gland, the parenchyma is
either partially or completely disintegrated. Haemorrhagic extravasations
take the place of the disintegrated portion of the gland, or it is crowded
with polynuclear leucocytes showing a tendency to necrosis. There is
also a very abundant infiltration of plague bacilli. The appearance is
variable, depending on the amount of the haemorrhages, the infiltration
of leucocytes and bacilli and the necrosis. With the complete or almost
complete disintegration of the adenoid tissue, the normal structure of
the gland disappears and the separate parts are indistinguishable. The
leucocytes are in such masses that they give the appearance of a
purulent infiltration. In the infiltration itself there is a granular
disintegration of the nuclei as well as of the leucocytes, the detritus
extending over large areas, or the outline of the cells may be more or
less retained, but the nuclei have disappeared or are indistinct. The
necrosis is generally most marked in the central portions of the gland,
while the haemorrhages and infiltrations of leucocytes and bacilli are to
be best seen at the periphery. The bacilli in the region of the necrotic
portions assume more or less the degenerative forms to be found in other
parts. In fresh pus there is to be found in addition to polynuclear
leucocytes numerous fully degenerated cells and debris of cells and
nuclei. The walls of the vessels and capillaries that have resisted
the disintegrating process are thickened and dilated, while the others
which have given way and from which the blood has poured out are in
all stages of necrosis, some consisting of mere shreds and detritus. The
blood is coagulated and forms a network both within and without the
232 Pkiffue in the Individual [part hi
vessels, or is broken up into debris. In this network or debris are nuclei
of cells, disintegrated leucocytes, and plague bacilli. The capsule of the
gland is broken in places by the extravasation of blood and infiltration
of the periglandular tissue with bacilli and leucocytes, and its fibres are
torn, swollen or destroyed so as to be indistinguishable from the
affected glandular and periglandular tissues. The infiltration of the
surrounding connective and adipose tissue, when not haemon-hagic,
is essentially cellulai- and contains jxilynucleai- leucocytes in different
stages of disintegration, and large numbers of plague bacilli. The
oedema, on the other hand, is either homogeneous or finely granular
in character. In some cases there is not much haemorrhage or cellular
infiltration into the connective and adipose tissue, but merely
oedematous fluid swarming with plague bacilli. The lymphatic vessels
in the vicinity of the disintegrated glands are usually much dilated,
being filled with lymph cells and masses of plague bacilli mixed with
a few white and red blood corpuscles. The walls of the vessel are
thirmer, but there is rarely any great change in them, though occasionally
the}' are filled with bacilli and leucocytes or are necrotic and so
disintegrated as to form detritus-like masses.
In the secondary buboes or those infected by plague bacilli conveyed
to them by the circulation the chansres in the glands are
Histological . ° . . ,
changes in not nearly so pronounced. The parenchyma is uniformly
secondary hyperaemic, the capillaries and vessels being distended with
blood in which will be found plague bacilli in varying
numbers ; the fibrous capsule of the gland remains intact, the lymphatic
vessels and lymph channels are distended with lymph cells, and the
sinus is much distended, its cells being swollen, pale, granular, or fatty.
Within the sinus are often polynuclear leucocytes and red blood
corpuscles, frequently arranged around vessels or smaller haemorrhages.
Sometimes the sinus is gorged with blood or there are necrotic centres
with granular disintegration of the cell nuclei.
In buboes which have healed before the process of necrosis or deep-
seated suppuration has begun, complete resolution takes place, leaving
only a slight but general thickening of the capsule of the parenchyma
of the gland, of the blood vessels, and of the connective tissue.
The most characteristic feature of cover-glass and sectional prepara-
The plague tions fi'om primary buboes is the enormous number of
bacillus. plague bacilli which are to be seen. Even when necrosis
of the gland has set in, and there are few bacilli in the cover-glass pre-
parations, the cultun's funiisli many colonies of plague bacilli.
cii. xn] Morbid Anatomy and Pathology 23o
The more typical-shaped bacilli are usually to be found in the
peripheral portions of the periglandular tissues, whereas the degenera-
tive or involution forms are generally in those parts of the bubo most
affected, where the plague bacilli have destroyed the tissues, and which
correspond with the gland. The plague bacilli are generally extra-
cellular, and it is only in the most recent infiltration that they may be
seen within the leucocytes. In secondary buboes, however, the plague
bacilli may be seen within the swollen oi' desquamated endothelium of
the capillaries and lymphatic vessels. In a cover-glass preparation the
size and form of the bacilli correspond with the histological changes in
the bubo. At an early stage the typical short, thick rod forms with
rounded ends, often exhibiting a capsule, are the most numerous. They
may be single, in pairs, and in short chains, and stain deeply at the
poles with carbol-fuchsin, borax methyl-blue, Loeffler's methylene blue,
or other aniline dyes. The number of bacilli taking on the bi-polar
staining is very noticeable. In later stages the bacillus tends to lose
its plump appearance and assumes much variety in shape and irregu-
larity of size. There is to be seen coccoid, globular, spherical, bladder-
like, tadpole, and sickle-shaped forms, which differ much in their staining
properties, some of them staining but faintly, others only at the margin
of the circumference or on a portion of the rim, and others remaining
colourless.
It is not infrequent to meet with a mixed infection in plague,
and in these cases the pneumococcus may be found with the plague
bacillus ; or the streptococcus or staphylococcus may be associated with it.
It frequently happens that when a cover-glass preparation shows
numerous plague bacilli mixed with only small numbers of streptococci,
diplococci, and staphylococci, the cultures do not show plague bacilli.
This occurs not only with cultures from glands and buboes, but also
with cultures from the spleen and liver in which plague bacilli are
distinct and numerous in smear specimens. Sometimes when only
a few bacilli, or perhaps none, are seen on the cover-glass preparation,
cultures may show colonies of plague bacilli. It is important, therefore,
as pointed out by Albrecht and Ghon^ when it is a question of doubtful
diagnosis, that both cultures and cover-glass preparations should be
made, and they should be supplemented by inoculation of animals.
Another important point is that though the bacillus is often not to
1 " Ueber die Beulenpest in Bombay im Jahre 1897." Gesatiniitbericht der von der
Kaiserlichen Akadeinie der Wisse use haft in U'ien zuiii Stitditiin der lieulenpeat iiach
Indien eiitsendeter Commission. Vienna, 1898, p. 508.
234 Plague in the Individual [part m
be found in a suppurating bubo, yet sujjpuration does not necessarily
destroy its vitality. It has been found in cases of this description in
man and also in animals. The Austrian Commission first drew atten-
tion to this^ In this connection two cases are mentioned by Dr Choksy^
of Bombay, in which iliac buboes were opened through the abdominal
wall on the 48th day of illness, and the pus was found to contain plague
bacilli in an active state and capable of growth when cultured.
Plague bacilli are not only present in the buboes and adjacent
tissues, but in septic cases they are also present in the blood, in the
glands, in the lungs, liver, kidney, in the bone marrow, in the bile, in
the urine and faeces, in the peritoneal fluid, and in fact in every organ
and secretion of the body.
The spleen is enlarged and congested, having the capsule distended,
of a light grey opacity and sometimes marbled with hae-
mon-hages. On section it is seen to be much engorged,
is a deep red, chocolate-brown or purple colour, and has a granular
appearance. The Malpighian bodies are swollen and engorged, the
substance may be fairly firm or friable and soft, or it may be almost
diffluent.
Histologically the changes in the spleen are similar to those in the
lymphatic glands, and consist of haemorrhages, inflammations, infiltra-
tion of leucocytes and bacilli, and necrosis. The infiltration of the pulp
and blood spaces with blood, polynuclear leucocytes and epithelial cells,
renders the spongy structure of the spleen indistinct. The Malpighian
corpuscles remain intact. The trabiculae are mostly swollen.
Small necrotic centres are frequently to be seen surrounded by
numerous plague bacilli. They are formed by the coagulating and
disintegrating action of the bacilli, and are composed of the debris of
the disintegrated walls of the blood vessels and the detritus of coagu-
lated blood. Plague bacilli have been found in the spleen of a patient
who died on the 52nd day of illness I
The pericardial cavity usually contains a large quantity of blood-
circuiatory stained or straw-coloured f^uid. Ecchymoses occur on the
system. pericardium and endocardium. The heart muscle is pale,
soft, and friable, and is in a condition of cloudy swelling or fatty de-
generation. The right side is usually distended with dark red blood
and coagulated to form soft clots, or is in a semi-fluid condition. On
^ " Ueber die Beulenpest in Bombay im Jahre 1897," p. 510.
- The Treatment of Plague with Professor Lustig's Serum. By N. H. Choksy, M.D., 1903.
3 H, Albrecht u. A. Ghon. " Ueber die Beulenpest in Bombay iiu Jahre 1897," p. 532.
CH. XII J Morbid Anatomi/ and Pathologif 235
the valves may occasionally be observed haemonhagic growths. The
blood itself is in a state of leucocytosis of the polynuclear variety, and
generally contains plague bacilli. It has very little tendency to coagu-
late and remains fluid. It is usually of a very dark colour. The great
veins of the thorax and abdomen are distended with dark blood, and
there is a general distension of the veins and smaller blood vessels,
accompanied by large and small haemorrhages. Haemorrhages are, in
fact, one of the characteristics of the disease. There are haemorrhages
in nearly every organ of the body, on the serous and mucous coats of
the cavities, and in and around the specially affected lymphatic glands.
The plague bacilli and their toxines appear to have a peculiar coagu-
lative and necrotic effect on the walls of the smaller veins and minute
capillaries, leading to exudations.
The veins of the trunk when cut open display numerous small
punctated haemorrhages which, the nearer the veins approach the
vicinity of a bubo, become haemorrhagic patches of considerable size.
It has already been stated, that the walls of large veins in the region
of primary buboes are much affected. In those veins which are em-
bedded in the sero-sanguinolent, gelatinous, or haemorrhagic infiltration,
and which are thus subjected to the solvent action of the plague
bacillus and its glutinous toxines, the outer walls become destroyed,
and the tunica intima exhibits large haemorrhagic and suffused patches
with erosions. In the event of perforation taking place through the
intima, the copious haemorrhagic and oedematous effusions crowded
with bacilli find their way into the blood stream : microscopical examina-
tion shows that the coats of the venous walls are separated by masses of
blood, that the endothelium is taken off or has disappeared, and that
plague bacilli are present in great numbers. Venous haemorrhage of
this kind only occurs as a rule when the lymphatic glands are in an
advanced state of change.
The mucous membrane of the larynx, trachea and the large bronchi
The respira- exhibit a more or less catarrhal condition. In some cases
tory system. of cervical bubo or in tonsillar plague the exudation may
extend to the glottis, causing oedema of one or both folds of this organ.
The effusion presents the same yellowish jelly-like appearance character-
istic of oedema in the vicinity of the bubo. Microscopically it consists
of homogeneous, finely granular fluid containing leucocytes, red corpuscles
and plague bacilli.
In all forms of plague the lungs are congested and oedematous, and
on section a sero-frothy mucus exudes from them. There are small
236 Plague in ihc TitdivUlual [part m
haemorrhages into the lungs and more or less extensive pleural hae-
morrhages in the region of the diaphragm, on the chest walls, and on
the surface of the lung. Microscopically the vessels of bronchi, lung
tissue and pleura are distended with blood, plague bacilli are to be seen
in the lung oedema, and especially wherever there are haemorrhages.
In the pneumonic form of plague first described by Childe', which
is of a primary character and usually unaccompanied by buboes, and in
the pneumonic form of a secondary nature with buboes, the lungs are the
seat of a well-marked disseminated broncho-pneumonia. In pneumonic
plague, in addition to the great engorgement and oedema of the lungs
which exist in other forms of plague, the bronchi are inflamed and
haemoiThagic, and filled with a blood-stained frothy mucus, and the lung
tissue contains numerous pneumonic patches scattered throughout its
substance. These patches vary in size fi'om a pea to that of an egg, and,
when superficial, are raised above the siirface, forming small tumours ; the
pleura over them generally shows signs of inflammation and is covered with
a fibrinous exudation. They are of a deep red, pink or reddish-grey colour,
solid, airless, and sink in water, and they are separated fi"om the surround-
ing crepitant lung tissue by a distinct ring of engorgement. The patches
are lobular in type, and as a rule are distinct, but they may be con-
fluent so as to form large areas or even afl:ect the whole of one lobe
and exhibit the appearance of that of a croupous pneumonia. In these
cases the consistence of the part is friable, the colour is of a chocolate
hue, and on pressure there exudes from the lung a prune-coloured
liquid rich in plague bacilli. The bronchial glands are engorged,
swollen, and are often haemorrhagic. Microscopical examination of the
pneumonic patches shows the alveoli to contain catarrhal epithelium,
leucocytes, blood cells, granular debris, and fibrils of destroyed septa,
together with a homogeneous coagulated mass of oedematous fluid and a
large number of plague bacilli occasionally mixed with pneumococci and
streptococci. The bronchioles and bronchi are also full of plague
bacilli, which during life appear in the sputum ; portions of the patches
may have iindergone necrosis. The fibrinous exudation in the pleura
contains plague bacilli. The patches in secondary pneumonia are fre-
quently of the nature of small metastatic infarcts.
There is an interesting record of a post-mortem made b)' Dr
Thomson on plague in the Great Plague of London. It was evidently
of the pneumonic type ; it is that of a dissection of a young man who
^ Report by Surgeon-Major Lyons, I. M.S., of Bombay, President of the Plague Research
Committee.
CH. xii] Morbid Anatomy and PatJiolofjy :>37
died of plague. It is recorded that " the superficies of the lungs were
stigmatized with several large ill-favoured marks, much tumefied and
distended, the inward part being pertunded with my knife a sanious
dreggy corruption issued forth and a pale ichor destitute of any bloods"
T>T Thomson was himself attacked with plague the next day after
the dissection, but recovered and got up on the 8th day ; he, however,
had a relapse. Three other persons were attacked in his house but all
recovered.
The liver may be enlarged or normal in size and engorged with
blood, but the parenchyma is generally pale, soft, and
tiiable and in a state of cloudy swelling or fatty degenera-
tion. Yellow necrotic patches are often seen in its substance, and
especially on its upper surface. On microscopical examination the
capillaries are seen to be distended and may show colonies of plague
bacilli with leucocytes, both of which are particularly numerous in and
near the yellow necrotic patches, as well as in numerous ecchymoses,
which may be often seen on the surface of the liver and on the glissonic
capsule.
The gall-bladder has its mucous membrane not infrequently studded
with small multiple haemorrhages, which sometimes joining give it
a dark, marbled appearance. These minute haemorrhages may extend
into the mucous membrane of the bile-ducts. Plague bacilli are in
these haemorrhages as well as in the bile.
The pancreas may be congested but is otherwise normal in ap-
pearance.
The mucous membrane of the pharynx and oesophagus are generally
Alimentary congested and inflamed and the seat of petechiae. The
canal. tonsils may be normal but sometimes they are swollen and
haemorrhagic, presenting on section the mottled appearance seen in
buboes. In some cases the tonsil may be surrounded by an oedematous
infiltration, extending into the palatine arch or to the glottis. In other
cases both pharynx and tonsil may be covered by a pseudo-diphtheritic
dirty-yellowish membrane which undergoes necrosis. This destructive
process is due to infiltration of plague bacilli, often mixed with other
pyogenic microbes. In connection with this condition of the tonsils the
lymph glands of the neck are generally affected and plague bacilli are
to be found in the sputum.
It may be here pointed out that in a number of experiments on
^ "Loimotomia on the Test," by George Thomson, M.D., 166G.
238 Plague in the Individual [part hi
animals already mentioned, in which plague was produced by feeding
with plague bacilli, the pharynx and cervical glands were much
affected.
■ Small punctate haemorrhages occur in the stomach and intestines in
the mucous coat, and extra vasated blood is occasionally to be found in the
stomach. At times the haemorrhages in stomach and intestines may be
extensive and the mucous membrane intensely inflamed and covered
with mucus. In these cases there is an infiltration into or oedema of
the sub-mucous coat. The solitary glands and Peyer's patches are often
congested and swollen, the patches being denuded of their epithelium
and sometimes ulcerated. Ulcerations may occur on the ileo-caecal
valve. In the haemorrhages are plague bacilli. There are extrava-
sations into the mesentery. The mesenteric and retro-peritoneal glands
sometimes show much swelling, inflammation, and haemorrhagic in-
filtration. This was more frequent in Hongkong than elsewhere.
There, not infrequently, were observed extensive extravasations of blood
in the mesentery, and in the majority of cases more or less enlargement
and inflammation of the mesenteric glands, which varied from a white to
a purple colour, and were sometimes surrounded by a sero-sanguineous
infiltration similar to that of an external bubo.
The connective tissue around the kidneys is frequently infiltrated
The urinary with a large mass of extra vasated blood of a tarry colour,
system. The kidneys are swollen, purplish in colour, and with the
surface dotted with petechiae. The stellate veins are visible, the capsule
nsually adherent, and the kidney substance pale and soft from parenchy-
matous and fatty degeneration. The cortical portion is the most affected,
being studded more or less by yellow necrotic foci, attaining at times
the size of a pea. These foci contain a very large number of plague
bacilli and polynuclear leucocytes.
Sometimes the glomeruli are swollen and the capillaries may have
undergone necrotic changes. There are haemorrhages into the mucous
membrane of the pelvis, and occasionally these are so extensive as to
break through the mucons membrane and pass into the ureter, coagula
of blood being then found in the pelvis of the kidney, the ureter and
bladder. Plague bacilli are to be found in these haemorrhages ; the
ureter besides containing coagulated blood has on its mucous membrane
petechiae. The bladder is generally contracted, and its mucous mem-
brane the seat of numerous small haemorrhages which contain plague
bacilli. Owing to the haemorrhage in the kidneys and along the urinary
tract the urine as a rule contains plague bacilli.
CH. xii] Aiito2)sies 239
The suprarenal capsule may be normal although engorged, or it may
be the seat of necrotic centres.
The cerebral membranes are congested and the venous sinuses
Nervous engorged with blood. Petechiae or ecchymoses may be seen
system. jj-j ^j^g dura mater. There may be extravasation of blood
or effusion of serous fluid into the cavity of the arachnoid or under that
membrane. The cortex of the brain may be in a state of congestion,
while the substance of the brain shows an unusual number of red points
in it indicating increased vascularity. It may also be oedematous, but
beyond slight softening of the tissue there appears to be no marked
lesion in the brain substance. The spinal cord when examined is found
to be congested.
Bubonic plague, judged by the pathological changes observed in the
dead body, is a disease both of the lymphatic and vascular
system, on which the plague bacilli and its toxines when
brought in contact with them in large numbers and quantity exercise
an inflammatory, coagulative and necrotic effect. The microbic agent
and its toxines thus acting lead to enlargement of the external and
internal lymph glands, necrosis of their substance and often haemorrhage
or infiltration into the surrounding tissues, to dilatation of the veins
and capillaries, to destruction of their walls, to haemorrhagic extravasa-
tions into nearly every part of the body, to enlargement and en-
gorgement of various organs, and to metastatic parenchymatous de-
generation in the liver, spleen, and kidneys. Pneumonic plague differs
from bubonic in having these changes more concentrated on the lung
tissues and its lymphatic system than on the other lymph glands of the
body.
Autopsies.
Malay girl, aged 7 years. Nothing on skin. On making an incision
into skin over inguinal region, left inguinal <jland found to be the size of
a large Brazil nut ; surface haemorrhagic on one portion. On section
upper half dark maroon or coffee colour, lower half dark grey with streaks
of haemorrhage passing from the surface to the interior. Around the
gland a large amount of haemorrhagic infiltration extending well above
Poupart's ligament and also down to nearly one- third of the upper part
of the thigh, matting together in its fibrinated tissue a number of
maroon-coloured glands. The oedema extends beyond this infiltration.
The infiltration and oedema of the left inguinal glands extend to the
240 Plague in the Individual [part hi
iliac glands inside the abdoinon which are also haemorrhagic and coffee-
coloured, but there is no extensive oedema around these iliac glands ; the
right iliac glands healthy.
The right inguinal region enlarged but not so much as the left ;
periphery of gland haemorrhagic, the central portion being greyish in
colour. Left and right lungs not pneumonic but coffee-coloured. The
spleen enlarged, elastic and much engorged. Plague bacilli in glands,
lungs, and spleen.
Malay girl, aged 12 years. Taken ill with fever and difficulty of
breathing, and j^ain in the abdomen, was ill for 3 days, no buboes.
Died suddenly ; diagnosis, inflammation of the bowels.
Post-mortem. Glands in both groins slightly enlarged and haemor-
rhagic. Fat of right groin blood-stained. Femoral vein deeply congested.
Glands in iliac region congested. Glands of mesentery enlarged and of
a maroon appearance. Small intestine inflamed and congested. Langs
not patchy, but with one lobe on either side deeply congested and full of
a prune-coloured juice. Plague bacilli found in the lungs, glands, and
other organs of body.
Hindu, male, aged 28 years. Fell ill on 17th July. Admitted to
hospital on the evening of the 21st.
History. On 17th July, evening, was suddenly attacked with
vomiting accompanied with fever and very bad headache. About the
same time he felt a stabbing pain in the left groin and noticed that a
swelling was there. The next day he was very prostrated and almost
uncon.scious.
Present state. Is in great agony. Pulse cannot be counted. Tem-
perature 101 'IF.; typical plague tongue, surface covered with yelhjwish-
brown coating with small red points in it. In left femoral region a bubo,
size of a large hen's ag^. Skin over bubo red and much infiltrated.
Patient died one hour after admission.
Post-mortem. Skin in femoral region haemorrhagically discoloured.
Bubo size of a hen's egg ; on section there oozes out a bloody oedematous
gelatinous fluid ; the periglandular tissue of a gelatinous nature with a
great infiltration of blood. All the lymphatic glands of this region matted
together forming one large bubo, which on section is of a dark violet
colour; lymijhatic glands in right region are swollen and form small
separate buboes. All the lymphatic glands in the body are swollen and
congested. On ojjoning chest lungs contract normally, lungs oedematous:
interlobular ecchymoses. In left lung on section a few .small rose-coloured
patches; on pressure a red-yellow fluid devoid of air oozes out. Over
CH. XII ] Autopsies -241
the heart iiuuicruu.s ecchyinoses. Heart small, valves and openings
normal. Spleen very much enlarged. Capsule of spleen very distended.
On section the pulp is swollen and friable. Kidneys slightly enlarged.
On section surface shows swollen cortex, discoloured and with in-
distinct picture. Liver enlarged, structure indistinct. Stomach normal.
Mucous membrane of ileum very much injected, but no ulcerations.
In fossa iliacum a recto-peritoneal bubo of walnut size on right side ;
mesenteric glands swollen and congested.
Bacteriological examination. Numerous plague bacilli in direct
preparations from bubo and glands on right side, blood, and spleen.
All give ])ure cultures.
Hindu, male, aged 25 \ Admitted on March 6th and died the same
day. History unknown.
Post-mortem next morning.
Well-developed, well-nourished body. Rigor mortis almost dis-
appeared, no petechiae visible. Conjunctivae injected, mucous mem-
brane of the mouth pale. Under Poupart's ligament, near the median
line, a lymphatic gland larger than a hazel-nut can be felt.
No oedema of the lower extremities. The skin of the soles much
fissured; no exterior injuries perceptible. The Igrnphatic glands in
both submaxillary regions the size of beans, and on section dark red and
juicy. Both tonsils enlarged, on section exhibit many yellow spots; the
left side is infiltrated with a soft medullary substance, and is very juicy,
dark red, and sprinkled with yellow. The mucous membrane of the
pharynx is reddish-violet and swollen, the mucous membrane of the epi-
glottis is much reddened and swollen. The follicles at the base of
the tongue reddened and enlarged ; numerous punctiform ecchymoses
in the larynx and at the root of the tongue. Lungs congested, and on
section frothy and slightly oedematous. Pericay'diuni contains a small
amount of clear serous fluid, epicardium dotted with ecchymoses size of
millet seeds ; heart normal in size, fibrinous coagula, left side paren-
chymatous, pale and soft. The mucous membrane of the trachea and
the large bronchia somewhat reddened. The lymphatic glands at the
bifurcation as large as beans and infarcted. Alimentary canal not patho-
logically changed. Liver soft, but normal in size ; on section moderately
haemorrhagic, flecked with yellow ; generally brownish-grey, the outlines
of the lobes obliterated. The gall-bladder filled with dark bile, mucous
membrane thin and yellowish-brown. Spleen very soft, and dark red
on section ; pulp oozy, stroma not increased, follicles recognisable, in
1 Case extracted from the Report of the Austrian Plague ComuiisgiQu.
s. 16
242 Flar/ur in IIk Individual [part hi
parts. Right kidney somewhat eiilarcred and congested on section ;
cortex swollen, sprinkled, and striped with greyish-yellow and red, well
bordered otf from the pyramids, the periphery of the latter being in-
jected with vivid red. Condition of left kidney similar. Both renal
pelves normal. The bladder filled with yellowish urine, its raucous
membrane whitish. The deep wfniinal lyiiiplmtic r/lands at the interior
femoral ring on the left side the size of hazel-nuts: three lymphatic
glands about the size of beans in their vicinity. The connective tissue
round the latter, and round the iliac vessels, is wet with gelatinous
material, and sanguineously infiltrated, as is also the vicinity of both
ureters. There are numerous confluent dark bluish-red haemorrhages
in the wall of the left femoral vein, composed of smaller haemorrhages
about the size of millet seeds, and which infiltrate almost the entire
intima of the region. The superficial inguinal lymphatic glands of the
left side considerably swollen, moderately hard, protruding on incision,
haemorrhagic and congested, and infiltrated with yellow spots.
1. Three forms of bacteria are found in cover-glass preparations
of the left tonsil, but not in very great numbers. A long,
Bacterio- . " " . . ,
logical con slender species of bacillus is most prominent, and ovoid or
*^*^°°' longish forms of typical plague bacilli are present in some-
what less numbers ; they take bipolar staining well, and most lie singly,
more rarely as diplobacilli. The third species, present in least numbers,
is formed as a minute rod, likewise with bipolar stain, and which re-
sembles the smallest diplococcus. No plague colonies are visible in the
cultures, but there are numerous colonies of the coli group and the
spore-bearing rodlets.
2. A haemorrhagically infiltrated cervical lymphatic gland from
the left submaxillary region exhibits, microscopically, typical plague
bacilli in fairly large numbers, lying singly or as diplococci, and of
roundish or <jval form ; in addition to bacilli exhibiting good bipolar
staining there arc paler, ovoid, and large, roundish, inflated forms.
The cultures are contaminated and are therefore not used.
3. Numerous plague bacilli are exhibited microscopically in the
juice of the spleen ; they mostly lie alone, being of round, oval, or longish
form, with bipolar stain, or are only stained faintly, and of various forms.
The cultures exhibit numerous plague colonies exclusively.
4. Cover-glass preparations of a haemorrhagically infiltrated super-
ficial inguinal lymphatic gland of the right side exhibit copious masses
of plague bacilli in the same form and order as 3, but the degenerative
forms are more numerous ; every form is present, even the large inflated
CH. xii] Autopsies 243
forms, of which frecjuently only the outlines are sbained (annular
forms).
On using Pittfield's mixture no distinct capsular appearances are
seen, but one may observe a faintly tinted violet area in a number of
bacilli ; this area is more or less distinctly bordered, or there may be
an unstained area which is bordered off by a stained contour.
The cultures exhibit very numerous colonies of the plague bacillus,
and 6 colonies of the unknown species of bacillus (contamination).
1. Enlarged superficial l>/niphatic gland fro'ni the left inguinal
Histological region. Only isolated follicles in the cortical layer are left
condition. Qf \\-^q. parenchyma, also a few septa of the. connective
tissue closely infiltrated by poly nuclear leucocytes, and ninnerous small
and large vessels full of blood, the walls of which in places are closely
infiltrated by leucocytes.
The enlargement of the gland seems mostly to have been caused by
enormous masses of plague bacilli, which infiltrate it entirely in
connected masses, cutting into the vessels in all directions and including
relatively few leucocytes. In between there are small haemorrhages in
all directions, often round vessels with entirely homogeneous walls.
These (veins, arteries, and lymph vessels) often contain numerous
polynuclear leucocytes and numbers of bacilli.
The fibrous capsule of the lymphatic gland infiltrated by copious
round-cell and bacillar infiltration, so that there is no sharp border
between the gland and its vicinity. In the latter also enormous
numbers of bacilli and copious confluent haemorrhages are found. The
adipose tissue, especially, appears to be so closely infiltrated with
bacilli in parts that its meshes seem to be surrounded by broad lines of
bacilli. Only slight nuclear atrophy or cellular disintegration. The
plague bacilli only stain slightly with methylene blue, and particularly
where they lie close together in large masses exhibit pronounced coccus
forms (separate ones being remarkably large). They are situated
extra- and intracellularly. There are no other bacteria, and only very
little fibrine is perceptible.
2. Lymphatic gland from the left side of neck (fossa submaxillaris)
about the size of a bean. The gland exhibits extensive hyperaemia,
the numerous capillaries and small vessels being quite full of blood.
There are only a few isolated extravasations of blood. The sinuses
somewhat dilated, and in them, here and there, single red blood cells
and polynuclear leucocytes in moderate numbers are seen. Attention is
immediately arrested by the size of the endothelial cells and their nuclei
16—2
244 Phajui' in tltr liHUvidual [part iii
which belong to the fine lynij)h channels of the sinus and cover the
follicles and rays of medullary substance, and which almost entirely fill
the sinus. Thev are frequently of epithelial-like form, having either
one or several faintly stained nuclei with several nucleoli which appear
to be round or lobulate.
The end(jthelium of the blood vessels is also large, with large pale
nuclei. In sections stained with alkaline methylene blue, plague bacilli
are seen, more or less abundant in number, in each of the numerous
blood vessels; they are in diplococcus form, and are always adjacent to
or within the endothelial cells. Only a few isolated groups are found in
the sinus.
3. Sections through the left tonsil exhibit the same condition
generally as that of the gland described above : extensive hyperaemia
with increase of the polynuclear leucocytes; in addition, Avell-defined
bordering off of the adenoid tissue from the surrounding connective
tissue, and healthy epithelial covering. No haemorrhages.
Here, also in almost every dilated blood vessel, there are large or
small agglomerations of plague bacilli : adjacent to the endothelium, or,
doubtless, also within it. There are small groups consisting of only a
few bacilli in the adenoid tissue and always in an intracellular position.
The cells surrounding them are large endothelial cells that are unfilled
collapsed blood or lymph capillaries.
4. The histological examination of somewhat enlarged follicles at
the base of the tongue shows the same results. The so-called germinal
centre is copiously infiltrated with polynuclear leucocytes. The con-
dition as regards the plague bacillus is also analogous.
5. Spleen exhibits histologically a very copious infiltration of
polynuclear leucocytes in the region of the pulp, as well as severe
hyperaemia. Many pulp cavities remain intact and filled with blood,
the endothelium cells very large; in those parts where there exist
sanguineous infiltrations of the pulp, they are mixed irregularly with
the extravasated blood. Follicles frequently remarkably small, and free
from bacilli. The spleen substance is infiltrated with enormous masses
of plague bacilli, which are sometimes intracellular. At some places
there are isolated, long, thick rods (saprophytes) which stain well with
methylene blue. Trabeculae somewhat spread, faintly coloured, and
having irregular granulations in parts ; their nuclei likewise very pale.
6. Kidney. The epithelial cells of the renal cortex, particularly
the tubuli contorti, either large and unshapely as if swollen, with faintly
coloured nuclei, or without nucleus, in which case the borders can hardly
CH. xii] Autojjsies 245
be distinguished or are entirely obliterated and contain drops of fat of
various size. In the interior of the tubules numerous indistinctly
granulated masses stained with eosin. The capillaries in part greatly
dilated and there are small extravasations of blood between the tubuli
in the interstitial connective tissue. The glomeruli large ; sometimes
filled with blood ; the separate capillary loops dilated. The nuclei of
the epithelia of Bowman's capsule very numerous and large. No
particular changes in the renal pyramids. Small groups of plague
bacilli to be seen in the dilated capillaries of the glomeruli and of
the connective tissue interstices of the cortex.
In this case the infection, doubtless, originates from that region of
the skin appertaining to the left inguinal group of
lymphatic glands. At this side the deep-seated inguinal
lymphatic glands in the region of the interior crural ring are con-
siderably altered, there are copious haemorrhages, especially in the wall
of the large veins, and there is also the typical gelatinous yellowish
oedema.
Microscopically the liver and kidneys exhibit distinct signs of
degeneration ; the spleen is acutely swollen. Excepting those haemor-
rhages in the region of the primary bubo no others are discoverable.
The microscopical examination exhibits the enlargement of a
superficial inguinal lymphatic gland principally induced by enormous
bacillary infiltration and, in a far less degree, by the increase of the
polynuclear leucocytes and by haemorrhages.
The swelling of the lymphatic apparatus at the neck is caused by
being swamped by plague bacilli. They are present in the lumens of
the vessels and are frequently demonstrable in their endothelial cells.
Whereas, therefore, we first of all observe intensely active hyperaemia
in the fresh metastatic glands infected through the circulation, we also
find increase of the polynuclear leucocytes in the dilated sinus, and
germinal centres, and a remarkable swelling of the lymphatic endothelia
and the cells of the sinus, with swelling and lobulation of their nuclei.
The acute splenic tumour is caused by hyperaemia, enormous infil-
tration of bacilli and leucocytes permeating the organ evenly, and
proliferation of the endothelium of the pulp cavity.
Extensive fatty degeneration is found in the kidney, especially in
the epithelia of the tubuli contorti ; this is sometimes increased to
complete nuclear atrophy. The glomeruli are large, often quite full of
blood ; there are isolated haemorrhages in the interstitial tissue.
Plague bacilli are discernible everywhere in the capillaries.
246 Phif/Hc in the Individual [part hi
Bacteriologically, the case is proved to be one of pure plague
infection.
Cliinese. " An adult male, aet. 25, brought to the public mortuary for
examination'. The body was found in a deserted house. The corpse
was that of a well-nourished man. The skin had the cyanosed appear-
ance met with in plague. On superficial examination the case looked
like one of small-pox, vesicles and pustules being scattered over the face,
shoulders, arras, body, and legs. The caretaker of the mortuary, who
has had a large experience, pointed out the case as one of small-pox.
An eruption covered the skin. Papules, vesicles, and pustules were
present side by side. They were numerous over the neck, back,
shoulders, back of arms, ventral surface of the abdomen, the extensor
surfiices of the thigh and the buttocks.
"The papules were fewest in number. They were small, never larger
than a pea, raised above the general surface of the skin, and surrounded
by extravasated blood.
" The vesicles varied in size, they were occasionally umbilicated,
apparently ran together, contained turbid serum containing a few plague
bacilli and were also surrounded by a discoloured area of skin due to
blood extravasation. The pustules were the most numerous. They also
varied much in size. One was present on the shoulder which resembled
an ordinary boil. Their bacteriological contents were subject to
considerable variation. Plague bacilli were found in what appeared to
be the most recently formed pustules. In others, which were evidently
more advanced, no plague bacilli were found, ordinary pyogenic micro-
organisms being present. There was no question of small-pox.
" A bubo was present in the right groin, which contained plague
bacilli.
" Plague bacilli were also found in the heart blood and spleen.
" This case was interesting from several points of view, namely : —
1. The bubonic nature of the case.
2 The presence of a generalised skin eruption.
3. The nature of the eruption being papular, vesicular, and
pustular.
4. The presence of the B. pestis in the erupted foci.
5. The absence of an}' apparent lymphatic connection between
the eruption and the bubo.
6. The likeness presented by the case to small-pox."
^ A Risearch into Epidemic and Epizootic Pldiinc. By William Hunter, Government
Bacteriologist, Hongkong, 1'.I04.
CH. xii] Aiito^mes 247
The following are brief notes of some post-mortems, made for
diagnostic purposes, on persons who died during prevalence of plague.
Indian, male. Large bubo in right groin, skin over bubo plum
colour; on section gland shows dirty yellowish colour with fleshy
patches and haemorrhagic streaks. Glands embedded in haemorrhagic
clots and oedema. Plague bacilli y)resent.
Malay, male. Right inguinal bubo (leg flexed and abducted on
post-mortem table). Much oedema of subcutaneous tissue in region of
groin. This extends up on the anterior abdominal wall for about
3 inches. The subcutaneous fat is marked with petechiae. Glands
large, dark brown in colour, and surrounded with blood-stained oedema.
Smears swarming with typical bacilli.
European, male. Glands in groin not enlarged. No bacilli. Right
lung adherent slightly ; lower part of upper and all lower lobe in a state
of grey hepatisation, very friable. On section dirty brown fluid poured
out ; air had been entering to some extent the affected portion ;
there was some gelatinous exudation between the lower part of lung
and diaphragm. Smears contain B. j)estis. The immediate cause of
death was a large ante-mortem clot in left side of heart.
Malay, female. Glands in right femoral and inguinal region
enlarged, very dark in colour. Smears from same contain many
typical bacilli. Lungs large, pneumonic (early stage) portions in
both bases, B. pestis in smears. Spleen large, very soft. Kidneys
soft and congested. Suprarenal glands dark in colour and congested
around.
Coloured, female. Femoral and inguinal glands on right side
are much enlarged, the inguinal being congested and haemorrhagic.
No organisms found in the glands on microscopic examination. There
had been great haemorrhage from the nose and mouth just previous to
death. Lungs pneumonic, several patches and full of blood. B. pestis
present in the pneumonic patches. Liver cirrhotic, spleen large, but
no bacilli present.
European, female. There is a mark purple in colour, like a bruise,
over left femoral region, a distinct swelling being noticed, soft and
boggy to the touch, no enlarged gland can be exactly made out.
On section it is seen that much haemorrhage has taken place into
the subcutaneous and intermuscular tissue, the glands are much
enlarged and soft, almost black in colour and completely surrounded by
extravasated blood. Smears made from glands and blood sui'i-ounding
them swarm with B. pentis.
248 Plagiic In the Tndlvifhial [part hi
Greek, male. Glands in groins small, pink, not haeniorrhagic.
Pericardium filled with clear yellow fluid, a few petechiae on outer
surface. Base and lower lobe of left lung quite solid, pleura tense, on
section a dark, thick, blood-stained and prune-juice fluid, sticky in
character, exudes. The suifac-e of the section mottled and streaked
with haemorrhages much like gland. No pleurisy. Right lung also
pneumonic and solid. Tyjiical B. pestis present in great numbers.
Malay, feinale. Glands in left groin enlarged ; upper half of
largest gland deep red-brown in colour, the lower part only pink.
Much oedema around the glands, the oedema extending for about
3 inches on to the abdominal wall on the left side. B. pedis present
in great nundiers in smears from glands and spleen.
CHAPTER XIII.
CHANNELS OF INFECTION.
It is a well-known flict that the glands draining a pigmented or
tattooed cutaneous area are blackish in colour. It is in view of this
Infection fad, and of the further fixct that microbes which gain access
through the ^q ^}^q lymph channels throusrh the skin are obstructed
skin direct to."^^ n i i -i no ^
the lymph- m the nearest groups of glands and affect them by their
**^°^' pathogenic action, that the occurrence of primary buboes in
the inguinal and axillary regions in most cases of plague has given rise
to the conception that the most frequent mode of entrance of the in-
fection is through the skin direct to the lymphatics. According to
this view the plague microbe, having reached the lymphatic vessels
distributed in the skin, is conveyed by them to the lymph glands,
which, becoming affected, form the buboes in question. At this stage
no bacilli are to be detected in the blood in the majority of cases, and
it is m^t until a direct communicaticm is opened between the infected
glands of the bubo and the walls of the adjoining veins, by the coagu-
lative and necrotic action on the tissues by the plague microbe and its
toxines contained in the bubo, that there is an entrance of bacilli in
great numbers into the general circulation. The entrance of the bacilli
into the blood in septicaemic cases is explained by the weak screen
which the lymphatic glands are able to furnish against the penetrative
energy of a virulent microbe. The explanation is not a very satisfactory
one. The limitation which narrows down the entrance of the microbes
to the vascular system by the path of the lymphatic vessels is of too
restrictive a nature, even when the infection has taken place through
the skin.
The anatomical distribution of the superficial lymphatics with their
collecting trunks converging to the inguinal and axillary regions cer-
tainly affords ffxcilities for the absorption of the infection, in the case
250 Plmjue in the Jndividual [part iii
of an accidental wound of the skin, if the infection docs not ])ass direct
into the blood stream.
Instances occur in nearly every epidemic in which medical men
Post-mortem contract plague through a wound or abrasion in their hand
wounds. which has been infected while performing a post-mortem
on a plague case. Aoyama in Hongkong in 1894, Sticker in Bombay
in 1898, Evans in Calcutta in 1899, and Pestana in Oporto in 1900,
mav be mentioned among the man}- that have become infected in
this way. In such cases the first visible sign of disease is usually
an axillary bubo, the plague bacillus having found its way to the group
of glands draining the area sul)jected to the inoculation. Sometimes
there are clear signs of lymphangitis proceeding from the seat of
inoculation to the affected glands, sometimes there is a vesicle at the
site of infection without any further local reaction, as in Sticker's
case, while at times there is no positive evidence to be gathered by any
visible local reaction as to the exact site of the entrance of the plague
bacilli, although that site is known from the circumstance of the
wound. Aoyama, who scratched his left hand at one post-mortem, and
his right hand at another post-mortem four days after, suffered from
a bubo in the left axilla without lymphangitis, and with a well-marked
lymphangitis on the right arm. This power of the bacillus to enter the
..^ system throug-h a small lesion in the skin without pro-
Power of the -^ * . . ^ .
baciUus to ducing a local reaction at the seat of the inocvdation is
tein thro^uth^ noteworthy, for, apart from accidental woundings of the
a small lesion skin at post-mortems, the seat of inoculation in natural
in the skin . „ . • i i i i , _ , , .
without pro- miections is seldom traceable, not more than 5 /„ showing
ducing a local .^■^,, visible siffns of the infection having entered through
reaction at •' o . . ° °
site of inocu- a wound. So remarkable is this fact that there are some
physicians who hold the opinion that the skin is not the
most frequent channel of infection, but that the bacillus is taken into the
lungs, or alimentary canal, enters the general circulation and multiplies
in the blood, or selects the glands in the groin, arm-pit, or neck for its
multijjlication. Small-pox can, like plague, be produced by inoculation,
but it is contended, and reasonably so, that inoculation of the small-pox
virus is not the most frequent mode by which the natural small-pox
gains an entrance into the human system. In plague there may be an
eruption of vesicles which contain plague bacilli over different parts of
the body, which can only be considered as a manifestation of a general
disease and not as a local infection. Phlyctenules of a vesicular,
pustular, carbuncular, or furuncular nature are occasionally to be
CH. xiii] Channels of Infection 251
observed on the hand or arm when there are axillary buboes, and on
the foot or leg in inguinal buboes ; but on the whole the appearance of
such or of other signs is rare. The phlyctenules contain plague bacilli,
and are usually ascribed to the bite or sting of an infected insect.
There are now a number of cases recorded of direct infection caused
by the bite of a plague-stricken rat. A case of infection by the bite of
a sick rat is reported by Dr Francis Clark, the Medical Officer of Health
foi- Hongkong. A man employed as a turncock was bitten on the left
thumb and some two or three days later the arm became swollen and
painful. The man died in some 9 or 10 days, his illness not being
reported. On post-mortem examination two small wounds were found
on the ball of the left thumb, the left hand and fore-arm were much
swollen, and in the left axilla there was a brawny, oedematous swelling,
in the midst of which was an enlarged haemorrhagic gland ; a smear
preparation from this gland showed numerous typical plague bacilli ^
It has been observed that disinfectors and others exposed to the
infection appear to be less liable to be attacked when wearing boots.
The explanation of this may be that the boots protect the feet which have
lesions on them from coming in contact with infectious material, or that
they protect them from the bites of infected insects. The experiments
already referred to in another part of this work show that infected fleas
are capable of infecting healthy rats and possibly monkeys with plague,
that these same fleas will attack man when they are hungry, and it is
reasonable to suppose that their capacity to cause plague in animals
extends to man. It has also been observed that oilmen appear to enjoy
exceptional immunity from plague, which has been attributed to the
protection afforded by the oil to the skin. It used to be a common
practice for oil to be employed as a protective against plague.
Sometimes a prick or scratch with an infected instrument may
Infection introduce the infection direct into the blood vessels of the
through the part and thence into the circulation, and then the bacilli
to the blood ^i^a-Y lodge in a group of glands more remote than that
vessels. receiving the lymph from the wounded part. For instance
at Oporto in 1900 Professor Levi of Stockholm had the front part of his
left fore-arm accidentally scratched by an infected knife while he was
performing a post-mortem. The wound was immediately washed and
bathed with a solution of sublimate and lysol. In 40 hours a sudden
pain was felt in the left groin together with general malaise, and in
' "A Report of the Epidemic of Bubonic Plague in Hongkong for the year 1900." By the
Medical Officer of Health for the Colony.
252 Plague in the Individual [part hi
8 hours a femoral bubo developed at the seat of pain. In this case
there was no screening or arrest of the bacilli until they reached the
inguinal region, and the route by which they arrived at this group of
glands could not have been through the lymphatic system. The selection
of the inguinal region for the bubo when the infection entered the system
through the skin of the fore-arm is noteworthy. A similar direct blood
infection may take place when the inoculation of the bacillus is effected
by the bite of an infected insect. It is possible also for a blood infection
to occur by the direct connection which sometimes exists anatomically
between the lymphatic vessels and veins, and occasionally arteries in the
thoracic, axillary and inguinal region. These direct connections between
the lymphatic and circulatory systems have been shown by Dr Leaf
to exist'. He points out that some of the smaller arteries in the thoracic
region open directly into lymphatic trunks ; that direct communications
are found to exist between arteries, lymphatic vessels and veins in many
regions of the body ; and that the portal, axillary, internal iliac, and the
azygos veins all directly communicate with the lymphatic system. It
is evident that if, under these conditions, one of the systems becomes
infected, there is an opportunity of the infection spreading to the other
system, and it is by no means a sine quel non that the blood stream is
only infected after the lymph glands in the bubo have broken down,
even in those cases when the infection travels along the lymph
channels.
The frequency of septicaemic cases, amounting in some epidemics to
at least 50 and 60^0 c>f the cases, indicates that the plague bacillus can
obtain ready access to the blood, and this without any greater injury to
the glands in the inguinal or axillary regions than that to other lymph
glands in the body. The similar condition of all the lymph glands of the
body points to some other entrance of the bacillus into the system than
through the inguinal or axillary glands.
That infection can and often does take place through the skin there
is no manner of doubt, but when this mode of infection occurs it is not
established that the i)lague bacillus reaches the inguinal or axillary
regions only by the lymph channels. It is not even established that the
skin is the most frequent channel of infection.
The preponderance of inguinal buboes among people with bare feet
was held at one time to be proof of infection through the skin of the
feet. Among people that go about barefooted cracks and abrasions on
1 " On the Relation of Blood to Lymphatic Vessels." By C. H. Leaf, M.B. Lancet,
March 3rd, 1900.
CH. xiii] Channels of Infection 253
the feet are common, and this fact was used as an argument in support
of this mode of infection. But the same preponderance of inguinal
buboes occurs among Europeans when booted, and in most epidemics, in
whatever part of the world they may occur, inguinal buboes are the
most frequent. Further, in cases of primary bubo of the inguinal or
axillary region, the bubo is not always the first symptom of illness.
There may be shivering, fever, prostration, and general illness for a day
or several days before there is any appearance of a bubo. The order of
symptoms is such as to be suggestive that during the period of incuba-
tion and earlier stage of the disease the bacillus is already in some part
of the vascular system, and only later selects the group of glands for its
bubonic manifestations. It is possible that in some cases in which the
buboes appear to be the first manifestation, infection of the inguinal
or axillary glands also takes place from the blood, these groups of
glands possessing a selective power for the plague bacilli in the blood.
This view has certain facts in its support. Plague microbes have been
found in the blood in mild types of the disease when large quantities of
blood have been employed for the examination. They have also been
found in the blood, so far as Hongkong is concerned, in every variety of
the disease there. The detection of the bacilli was made by taking
thick films of blood, washing out their haemoglobin, and then staining.
The method is the same as that adopted by Ross for detecting the
malarial organism. By this method plague bacilli have been discovered
in the blood before the onset of the fever or the appearance of buboes,
during the progress of the disease and during convalescence.
The fact of the bubo frequently making its appearance several
Older view is days after the onset of the illness favours the view just
that plague enunciated, and which was held by older writers, viz. that
disease, and plague is primarily a general disease, and that the affection
that the bu- ^f ^|^^, glands, internal or external, with the eruption of
boes are its . . . .
local mani- the bubo or buboes, is a local manifestation of the disease
similar to that which appears in the skin eruption in
small-pox, scarlet fever, and measles. It is based on the general ex-
perience that the glands in all cases of plague are more or less affected.
This view is contrary to that commonly accepted to-day, which considers
the bubo to be the primary local lesion, the toxines from which become
absorbed and give rise to the general symptoms. The whole question
still appears to be a moot point and is by no means yet settled.
Neither view adopted exclusively explains the different types of ])lague.
In the early days of the Bombay epidemic when the latter theory
2o4 Plague in the Individtial [part hi
was formulated, it was a rare occurrence to detect plague bacilli in
bubonic cases except a short time before death, but now at least
45 7o of the cases received into hospital contain plague bacilli in their
blood. The latter percentage more nearly approaches the results
obtained by Kitasato, Wilm, and others in Hongkong, where in the
epidemic of 1894 and the recurring outbreaks since then plague bacilli
have been found in the blood in more than 80 Vo of the cases. It is
evident that plague may differ in its character at different times in one
locality as well as in different localities, and that the absence or presence
of certain characteristics in an epidemic does not justify denial or
positive assurance of their existence in another. At the same time
that which appears obvious in one epidemic may receive considerable
modification when viewed from the experience derived in another
epidemic.
Inoculation through the mucous membrane is another mode of
infection. The mucous membrane is more liable than the
through the skin to slight abrasions, and the passage of infected food
mucous over its surface probably subjects it to a more fi'equent
membrane. . . .
exposure to the risk of infection than even any part of the
skin. Not infrequent channels of infection are the mouth and the
tonsils, giving ri.se respectively to submaxillary and cervical buboes;
this has often been proved experimentally. Monkeys, pigs, calves, sheep,
rats, hens, ducks, geese and pigeons contract plague by feeding on food
which has previously been infected. The monkey is the nearest approach
to man of the animals experimented on, and plague-infected food
certainly gives plague to the monkey. The plague is often of a septi-
caemic type with no particular enlargement of the glands of the neck,
while sometimes there is a very distinct affection of the tonsils and
glands of the neck. The facility with which the lower animals contract
plague by feeding is in fiivour of man contracting it often in the same
way. In Hongkong the mesenteric glands were often swollen and
extravasated and the condition of the stomach was very haemorrhagic ;
the morbid appearances seemed to point to a primary infection of the
glands, but in those cases in which the glands were not specially affected
the fact does not exclude infection from the alimentary canal, in that if
it is admitted that a septicaemic case of plague may be caused by an
infection through the skin without any primary buboes or any visible
sign of solution of continuity the same conditions may apply to the
infection passing through an intact mucous membrane. Plague bacilli
placed on the mucous membrane of the nostrils and tonsils will pass
CH. xiii] Channels of Infection 255
through these membranes although there may be no lesion. The
situation of the blood vessels above the lymphatic network in the
alimentary canal may allow of the direct entrance of the bacillus into
the circulation. On deducting these cases in which the cervical glands
appeared to be primarily infected the usual type of })lague caused by
feeding animals with plague material was the septicaemic. On the
other hand it is necessary to point out that in Natal, where plague has
never reached epidemic proportions, experiments by feeding carried out
after the plague season failed to produce plague in animals'.
The presence of plague bacilli in the intestinal contents, mucus of
the mouth and urine, of about one-third of the rats infected with plague
subjects the food which may be exposed over-night in an infected house
to considerable risk of contamination. With food that has still to be
cooked the danger is small, but with food that has already been cooked
and which will be eaten cold the danger of infection is great. It is
of small importance what part of the alimentary canal takes up the
infection.
In Hongkong plague-infected fowls were discovered in the markets,
and it was pointed out by Dr Atkinson, the Principal Medical
Officer of Health of Hongkong, that it is the custom of many of the
Chinese to use the uncooked entrails of fowls as a sort of relish, and to
eat fowls only half-cooked, preferring them in this condition. Under
these circumstances the danger attendant on eating plague-infected
poultry is a real one. In 1903 Dr Hunter discovered plague bacilli
in two samples of rice taken from a house in Hongkong.
Cervical buboes may be caused by infection derived from the skin, or
from the mouth, or tonsils, or nostrils. Buboes in the cervical region in
Chinese patients have been traced to mothers sucking the open buboes
of their children. Unless there is a clear history it may be difficult to
say from the appearance of the tonsils and pharynx which is the source
of infection, because these often become affected by extension of the
yjathological changes from the cervical glands. Similar inflammatory
and diphtheritic appearances may sometimes be seen in the tonsils in
cases in which the infection has obtained access to the blood and when
the buboes are inguinal or axillary. Plague bacilli may be found in the
sputum whenever the tonsils and pharynx are much affected, whether
due to a local infection, or to an extension from the cervical glands, or
to a general infection.
1 Report oil the Phujue in Natal, 1902-3. By Ernest Hill, Health Officer for the
Colony.
•2.')0 Plague in the fndundaal [part hi
In 1 897 a Bombay nurse at the Parel Hospital received in the eye a
particle of sputum coughed up by a patient suffering from pneumonic
plague. Although the parts were carefully washed conjunctivitis set in
the next day, which was followed by a swelling of the parotid, a bubo
below the ear on the affected side, and death. A similar case occurred
in Hongkong.
Another mode of infection is by the respiratory tract. The local
infection of nostrils, pharynx, or mouth may extend into
througiTthe ^^e lungs and set up the pneumonic form of plague, or the
respiratory bacillus may gain an entrance direct into the lungs by the
inspiration of infected material producing bronchitis and
pneumonia. In the latter mode of infection there is no primary bubo
of the neck. There is no cervical bubo when the broncho-pneumonia
of plague is experimentally caused by the intratracheal injection of
cultures of the plague bacillus. Pneumonic plague has also followed
subcutaneous injection of animals with plague material from pneumonic
plague, so that it is apparent that primary plague pneumonia may be
produced in some cases by the plague bacillus entering the lungs from
the general circulation. It appears to be a case of selection of the
lungs instead of the glands of the groin, arm-pit, or neck. In this
connection some of the cases of plague caused by post-mortem wounds
have resulted in plague pneumonia, and it is a curious fact that those
cases which have arisen from laboratory infections, and which are
generally attributed to direct infection from animals handled, were of
a pneumonic type.
The secondary pneumonia of plague is caused by an infection from
Mixed the general circulation sequent either to a septicaemic
infection. ^,.^^^^ ,)j. ^q ^]^g haemorrhagic extravasation of a bubo into
a vein. In pneumonic plague the specific bacillus is often associated
with the diplococcus pneumoniae, which may in some pneumonic
patches be exceedingly numerous and in greater numbers than the
plague bacillus.
Mixed infections, except in the lung when the diplococcus pneumoniae
is associated with the plague microbe, appear to be generally due to the
entrance into the blood of other micro-organisms through the ulcerated
nmcous membrane of the mouth and tonsils.
During life the mode of exit of infection will depend on the type of
the disease and the condition of the patient. In the
Mode of exit ,. • i • i ^i
of infection bubonic type m its earlier stages, m which the primary
from the ^^^t^^ appears to be the result of the plague bacillus
cii. xiii] Duration of Infectivity 257
reaching the affected glands by the lymphatic channels, the infective
agent is limited to the glandular or periglandular tissue and only
finds an exit externally when the bubo suppurates. At the stage
of suppuration bacilli are often not to be found in the pus, and
it is only towards the periphery of the necrosed tissue that bacilli, not
infrequently of an involuted form, may be discovered. The rounded
forms which are very common may be mistaken for micrococci, and the
bladder-like forms are apt to be overlooked because of their not staining
well. There is, however, much variation in both the number of bacilli
and the duration of their vitality in suppurating buboes. Generally
the bacilli are rapidly destroyed, and few or even none may be left to
escape to contaminate dressings and bed-clothes, but occasionally they
retain their vitality for a long period and remain alive so long as any
pus or necrosed tissue remains.
In cervical buboes in consequence of the involvement of the mucous
membrane of the mouth and pharynx and of the tonsils, plague bacilli
may escape by the mouth in the sputum and saliva. Similarly bacilli
may appear in the sputum when the tonsils or glands of the mouth are
primarily infected. As boils, vesicles, pustules, haemorrhages, and other
eruptions on the skin which occur in plague usually contain plague
bacilli, any detachment, rupture or breach of the epidermis over these
will allow of the escape of plague bacilli. Should the bacilli find their
way in considerable numbers from the primary bubo into the general
circulation, which is a common occurrence a short time before death,
then the avenues of exit become similar to those of a plague case which
is septicaemic from the commencement.
In a septicaemic case all the secretions and excretions except the
perspiration may contain the plague microbe, and the infectious agent
may consequently appear in the sputum, saliva, urine, and faeces, and in
haemorrhagic discharges. In the pneumonic cases there are usually
enormous numbers of bacilli in the sputum. In the dead body the
bacillus is usually in all the fluids of the system and will escape with
any sanguineous discharges that may dribble from the cavities.
Closely connected with the mode of exit of the infective agent from
the body is the duration of vitality of the bacillus in
The diiration , . , , . . , . ,
of the infect- convalescent patients. In sniiple bubonic cases in which
ivityofcoii- there is no secondary pneumonia or other complication,
valescents. . -^ ^ ^
and in which the buboes resolve themselves and there are
no bacilli in the blood, the infectivity is practically nil and need not be
considered, but where the buboes suppurate the duration of the presence
s. 17
258 Plague in tlie Individual [part hi
of the bacillus varies so much that no set time can be placed upon it,
and the only method of ascertaining freedom of infection is to examine
microscopically and make cultures of the pus. In cases of doubt it may
be advisable to inoculate an animal. There are occasionally cases of
indolent buboes with late suppuration, and in these the vitality of the
bacillus may be prolonged for a very lengthened period. Thus two
cases are mentioned by Dr Choksy of Bombay, in which iliac^ buboes
were opened through the abdominal wall on the 48th day of illness and
the pus was found to contain plague bacilli in an active state and
capable of growth when cultured.
Kitasato isolated plague bacilli from the blood of convalescents, and
this observation has been repeated and confirmed in Hongkong, but
it is not determined how long they may remain in the system. The
Austrian Connnission- found plague bacilli in the spleen of a patient
who died on tlie 52nd day, which points to the possibility of a patient
retaining the infection for a long time.
Dr Gotschlich^ records three instances of convalescents from pneu-
monic plague, which were treated in the hospital at Alexandria, showing
bacilli of a virulent type in their sputum for considerable periods after
they were apparently well. In the first case the bacilli retained their
virulency to the 76th day of the patient's illness and the 42nd day after
rising from his bed. In the second case the bacilli in the sputum were
virulent on the 35th day after the onset of the disease, and 6 days after
the patient had so far recovered as to leave his bed. In the third case
the bacilli were isolated from the sputum up to the 41st day from the
commencement of the illness and 19 days after the patient had left his bed.
The importance of a bacteriological examination of the sputum is
obvious in order that patients shall not be allowed to mix with healthy
persons while they are still in an infective state, and that due pre-
cautions shall be taken to disinfect the sputum as long as it contains
plague bacilli. This question of the duration of the infectivity of
patients who have been ill with plague requires much more investiga-
tion than it has yet received.
The best mass of evidence collected on the length of the incubation
Incubation period of plague is that recorded by the Indian Plague
period of Commission^ Information regarding 71 cases is given,
p ague. together with the references derived from the records of
' The Treatment of Plague with Profexsor Litstig's Scrum. By N. H. Choksy, M.D.
1'.I0.S.
- H. Albrecht u. A. Ghon. Ueher die Beulcnpest in Bombay im Jahrc 1897, p. 532.
=' Zeitschrijt fiir Hygiene and Infectionskrankheiteii, 1899, xxxii. p. 402.
•* Report of the Indian Plague Commission, Vol. v. cap. iii. p. 78.
CH. xni] Inciibatlon Period 259
segregation and evacuation camps. The cases are divided into three
classes.
Class I. Group A, cases in which there is a history of a direct
inoculation of infective material, and Group B, cases where there is
a history of the patient having come specially into contact with
infection on a particular occasion. In both groups there were cases in
which the incubation period could not have been longer than 24 hours
and other cases in which it extended to 5 days. The average length of
the incubation period was about 3 days.
Class II consists of cases in which there is a history of the patient
having been in contact with infection on and after a particular day.
The data gathered for this class confirm those of Class I in placing the
period of incubation between one and five days.
Class III represents cases in which plague developed after removal
from infected surroundings. Out of 753 cases noted, 15 or 1"9 7o>
developed plague after the 10th day. It is stated, however, that these
later cases may have contracted the infection after removal to camp.
It is not the shortest period of incubation that is the most important
for preventive measures, except it be a question as to whether a person
exposed to the infection should be inoculated and the possibility or
probability of the disease coming on before the prophylactic has had
time to act. The extreme limit of the incubation period is however of
the greatest consequence as forming a basis for practice in regard to the
length of time required to segregate persons who have been exposed to
infection, or to isolate crowds of emigrants or coolies from an infected
country before their admission to one which is not infected, or to
declare when a person who has been exposed to infection is safe from
attack. In the vast majority of cases 6 days may be considered to be
the extreme limit of the incubation period, but there is a residuum in
which 10 days, fixed by the Venice Convention, are needed to cover the
incubation period. There are very exceptional cases in which the
period of incubation appears to have extended to 12 and even 14 days.
But these are rareties and, except when dealing with emigrants and
coolies in large numbers, they may be disregarded. The Paris Con-
vention of 1903 has fixed a period of 5 days for isolation of persons from
plague-infected ships, and which may or may not be followed by
surveillance of not more than 5 days.
17—2
CHAPTER XIV.
CLINICAL FEATURES.
Plague was formerly classified according to the mildness or severity
of the disease as Pestis Minor and Pestis Major, and
classification Pestis Siderans or Pestis Fulminans. Pestis Minor in-
or types of eluded cases which were of a mild character and ended in
plague.
recovery. Pestis Major comprised the more severe cases.
Pestis Siderans or Pestis Fulminans embraced those cases that were
rapidly or suddenly fatal. Other terms, such as bubonic, haemorrhagic,
and nervous, were employed to designate the more prominent features
that presented themselves in particular cases.
The classification now adopted is one which is based more or less on
the particular system of the body invaded in force by the plague
bacillus, and plague is divided into bubonic, septicaemic, and pneu-
monic, according to whether the glandular, circulatory, or respiratory
systems are mostly involved. Other types, such as cellulo-cutaneous
or carbuncular, intestinal and cerebral, have been described. They are
applied to cases in which some symptom or symptoms are more pro-
nounced than usual. A separate classification of these atypical cases
only unnecessarily complicates matters and will not be followed here,
though it should be mentioned that such modification of symptoms
has to be borne in mind from a diagnostic point of view. Even the
three accepted types are artificial distinctions useful to draw attention
to the different garbs in which the disease may present itself, and in
the case of the pneumonic variety, which is highly infective, valuable
from an administrative point of view in that it is desirable the cases
should be immediately isolated ; but they are, after all, only different
manifestations or degrees of the same disease which in its main features
has a common likeness. The type with buboes is the most common,
CH. xiv] Clinical Features 261
ranging from 70 to SO per cent, of the cases. Typical cases of each
variety may be met with in every epidemic but they very fre(|uently run
into one another. Thus the bubonic form may become septicaemic, the
septicaemic may develop buboes or pneumonia, and the pneumonic may
become septicaemic or bubonic or both.
The disease also in its varying types may range from a mild to a
severe attack, from a prolonged illness to death within a few hours, and
it may have many of its symptoms absent or run an irregular course.
The cases met with in China and India presented very considerable
differences from those in South Africa, and it was difficult to realise at
first that the patients were suffering from the same disease. The
frequent presence of great mental aberration and of typhoid symptoms
in the former contrasted with their comparative absence in the
latter. It is probably variations of this kind which lead to such
different observations in different places, as regards the mode of in-
fection, the variation in types, the liability of animals to disease, and the
degree of infectivity. There are few diseases which present a greater
variety of manifestations.
Plague may, for descriptive purposes, be broadly classified into
plague with buboes and plague without buboes. This
and without distinction is only a clinical one, for in all forms of plague
the lymphatic glandular system, although it may not be
detected during life, is found in post-mortems to be more or less
affected. This is even the case in the pneumonic form. Superadded
to the symptoms peculiar to the several varieties of plague, such as the
appearance of buboes in bubonic plague and the affection of the lungs
in pneumonic plague, and the sudden and intense prostration in septi-
caemic plague, there are certain symptoms in plague which are common
to every variety. They are, the peculiar expression of the face, the
characteristic appearance of the tongue, the intoxication or perturbation
of the nervous system, the halting speech, the staggering gait, and the
great prostration. These will be referred to later on.
The incubation period of whatever type the disease may be varies
generally between a few hours and five days, it being
p°riod*^°° rarely longer. Cases have been recorded with longer
periods, but it is often difficult to dissociate froin them
the possible exposure to infected clothes or infected animals at a date
later than that which is believed to be the time of infection. Still the
evidence at present existing does not exclude the possibility of the
period of incubation being prolonged occasionally to 12 or 14 days.
262 Plague in the Imliridnrd [part tit
Promunitory syiiiptoviis are seldom observed. They, however,
Premonitory occur in some cases and more in some epidemics than in
symptoms. others. They usually consist in loss of appetite, languor,
low spirits, frontal headache, furred tongue with red tip and edges,
nausea, vomiting, diarrhoea, giddiness, weakness in the limbs, and pains
in the loins. These may continue for one or two days when the period
of invasion sets in, the symptoms of which vary according to the severit}'
of the attack. Perhaps the most remarkable characteristic in con-
nection with plague is the difference in the onset and progress of the
disease in different cases. On the one hand no disease except cholera
manifests in its severer forms so rapid a development of its symptoms
and overwhelms or prostrates the patient to the verge of death in so
short a time. On the other hand it may take a most leisurely course.
In the mild variety of the bubonic form, which corresponds to the
^ ^ . Pestis minor of the older classification, there is, in addition
Tne benign •
bubonic or to the phenomena already mentioned as occasionally met
Pestis minor. ^^^^^^ _^^ prodromata, ill-defined or well-defined fever, pain
and tenderness in the groin, arm-pit, or neck, with the appearance at
the seat of pain of a glandular swelling or bubo, tender to pressure
or on movement of the parts, general debility, slight congestion of the
eyes, and slightly thickened speech. This is the acute form, which may
only last a week, the symptoms disappearing after the patient perspires.
The bubo terminates in resolution, suppuration, or induration. The
patient may not take to bed or at most is confined to it for only a few
days. In the more chronic form, which may last two or more months,
the bubo or buboes are indolent and they may undergo a slow process of
suppuration and sloughing, constituting a serious drain on the general
health of the patient, producing anaemia and extreme debility.
In the so\ere variety of the bubonic form, which often includes
septicaemic and pneumonic cases, and which is usually
The grave i t" J
bubonic or described under Pestis major, the invasion of the disease
major. ^^ ^^ ^ ^^^j^ sudden and pronounced, the onset being abrupt,
apparently without warning and frequently coming on when the person
attacked is at work. The disease is often fully established in a few
hours or at most in one day. The symptoms consist of shiverings or
tremblings, with fever of a remittent type, hot and dry skin, flushed
face, injected eyes, nausea and vomiting of mucous and bilious matter,
diarrhoea, severe and splitting frontal headache, depression, great giddi-
ness,'staggering gait when walking, as if intoxicated, quickened pulse
and respiration, stabbing pains in epigastrium, back and loins, white-
CH. xiv] Clinical Features 263
coated tongue, which is red at the tip and edges, mouth and fences
dry, and intense thirst. These symptoms differ little from those which
characterise the onset of any specific disease, and have nothing to
distinguish them at this early stage unless they are associated with
glandular enlargements in some region of the body. If a bubo appears
it is usually ushered in by intense pain in the groin, arm-pit, or neck,
which is increased by movement or pressure. The pain at first is so
severe that the attention of the patient is mainly directed to it,
all other symptoms being considered insignificant compared to the
suffering experienced in the gland affected. The pain is followed by
a swelling which constitutes the bubo, and which, small and tender at
first, consists of a single gland or a group of inflamed glands, the outlines
of which are easy to define, but later cannot be differentiated. The
bubo may remain small, hard and tense, or it may increase in dimensions
and form a brawny, boggy oedematous swelling the size of a man's fist
or that of an orange. It may reach a large size in a few hours or it
may take several days for its full development. Gangrenous pustules
may also accompany the bubo or appear later on different parts of the
skin, and petechiae may be seen in some cases before death. If there
is no bubo, the .symptoms may be those of pneumonia or of extreme
nervous prostration and muscular weakness, and instead of the face
being flushed it may be pale and the temperature not much over
100° F. As the disease progresses the headache and vertigo increase
in severity, the fever rises or continues at its maximum, the eyes
assume a more suffused, congested, and sunken appearance, the face is
drawn, and the expression is either anxious and denotes suffering or
it is fixed and vacant. There is much restlessness, with an uncontrollable
desire lo wander about aimlessly to some other locality. Profound de-
pression, great prostration, and an overpowering sense of fatigue set
in. Ordinary consciousness is retained, but even with apparently perfect
consciousness the mental condition is one of hebetude or drowsiness.
The intellect loses its keenness and responds slowly to outward stimuli.
Questions are answered slowly, the words or sentences being articulated
in an embarrassed and hesitating manner, each syllable being pro-
nounced slowly, indistinctly, and with difficulty, or the speech is staccato
in character and uttered in a hurried and irritable tone. Cerebral
derangement may occasionally be absent even at a later stage, but
usually increasing disturbance of the nervous system quickly follows,
evidenced by protracted sleeplessness or greater drowsiness, which may
alternate with delirium, or by a drowsy and lethargic condition which
264 Plague in flu //uJirUhiaJ [part m
merges inti) jiiot'ound t-oiiia. The deliiiiun may be of a quiet, noisy,
furious, or terrifying kind ; it is often of a muttering kind with rest-
lessness and picking of the hed-clothes ; but it may be violent and
there may be much difficulty in keeping the patient in bed. The
whitish coating of the tongue turns after the second or third day
to a brown or reddish-brown colour, while the tips and edges remain
red. The tongue, which was moist, now becomes dry, and sordes appear
on the lips and teeth, the urine contains albumen, and the abdomen
swells. The respiration becomes more frequent, accompanied by dyspnoea
and cough. The pulse, which is soft and easily compressible at the
onset, becomes intermittent, dicrotic and thready and difficult to count,
and there is a tendency to collapse, the patient's extremities becoming
cold and clammy. Concun'ently pneumonic complications are apt to
arise.
The patient may die from the disease in 48 or 24 hours or even less,
Causes of ^^'i^h all the symptoms fully developed, or death may be
'^®^*^- delaj-ed to any time between the third and seventh day
or later, but it usually occurs between the second and sixth day, and
generally takes place from heart feilure ; it may, however, be brought
about by exha\istion or collapse caused by haemorrhage, or by asphyxia
by pressure of the buboes and surrounding oedema on the respiratory
organs, or by involvement of the lungs, or by coma from the poisonous
effect of the toxines on the nervous centres.
After the sixth or seventh day the patient's chances of recovery are
Progress after ^^^^ch increased, and in favourable cases the fever decreases,
the sixth or the skin perspires, the tongue becomes moist, the pulse
seventh day. , , . i mi
stronger, and the expression natural, ihe temperature
is usually normal about the tenth day. Once convalescence begins, which
may be on the sixth or eighth day, the progress may be rapid or it may
become tedious and protracted, and the patient may not be well for
six to ten weeks or longer. Sometimes the symptoms do not improve
on the sixth or eighth day. The tongue remains dry, reddish, cracked,
and with a dark coating, the teeth and lips retain their sordes and a
typhoid condition develops. The abdomen becomes more swollen,
the diarrhoea, if any, is more obstinate, and the motions ai'e foetid ;
the pulse continues frequent and irregular, the respiration laborious,
the skin alternates between dryness and a state of perspiration, the
sleep is disturbed and unrefreshing, and the patient lies in a condition
of apathy and stupor. The buboes suppurate and discharge an offensive
serous fluid, and it is not until the fifteenth or twentieth day that there
CH. xiv] Clinical Features 265
are any signs of convalescence, or it may happen about, this time that
the patient's strength gives way and death ensues.
The severest forms of plague are those that are classified as the
septicaemic and pneumonic varieties ; they correspond to the Pestis
siderans or malignant form of the older writers, and generall}' prove
fatal before the eruption of buboes.
The septic variety of plague is a virulent type, in which the
Septicaemic lymphatic glands usually show no special enlargement
plague. during life and consequently the bubo is absent, but
after death the glands are found to be generally affected, being some-
what enlarged and much congested. In this form of plague the bacilli
invade the blood in large numbers and are easily detected. The
chief characteristics are the rapidity with which nervous and cerebral
symptoms supervene and their intensity. The patient is profoundly
affected by the amount and strength of the poison received, which
appears to concentrate itself on the central nervous system. The attack
begins with trembling and rigors, intense headache, vomiting, and high
fever. At times the depression of the vital powers is so great that
there is no power in the patient for reaction, and the temperature does
not reach 100° F. ; the countenance is pale and the expression apathetic
or depicts intense anxiety. Extreme nervous prostration, weakness,
drowsiness, restlessness, hurried and panting respiration, small and full
pulse, tympanitis, delirium, picking of the bed-clothes, stupor and coma
quickly follow on. The evacuations are involuntary, the patient becomes
cold, and dies on the first, second, or third day. In these cases there
may be bleeding from the nose, kidneys, and bowels. If there is any
reaction, as is sometimes the case, the pulse becomes stronger, the face
flushed, the eyes congested, and on the third, fourth, or fifth day
buboes may appear simultaneously in the groin, arm-pit, or neck.
In pneumonic plague unaccompanied by buboes, and in which the
Pneumonic primary localisation of the disease is in the lungs, the
plague. illness commences with a rigor, general malaise, severe
headache, nausea, vomiting, and pain in the limbs, followed by fever
varying in range from 102'' F. to 105° F., a sense of constriction across
the chest, difficult and hurried breathing, cough and expectoration.
In other cases a few days may elapse before the lung symptoms develop.
Consciousness is generally not disturbed. The sputum, at first watery
and frothy and tinged with blood, generally becomes more profuse as the
disease advances, but less aerated. Sometimes it is scanty and consists
of small })ellets of congealed blood. The sputum has not the glairy
266 Plagye in the Tncliri final [part tit
viscid, rusty character of that of acute pneumonia, though on the clothes
it may be mistaken for this. Physical examination does not reveal signs
of sufficient gravity to account for the severity of the symptoms. On
auscultation the stethoscopic signs may be those of lobular pneumonia ;
moist sounds and crepitation may be heard over the pneumonic patches,
but there is seldom marked dullness at the base or at the spots where
crepitation is detected, and however hurried the breathing and quick the
pulse may be there is not that disproportion between the pulse and
respiration ratio which obtains in acute pneumonia. The lung symptoms
and cardiac distress rapidly grow worse, delirium supervenes, there is
gradual failure of the heart's action with or without coma, and death
with a cyanosed aspect occurs on the fourth or fifth day or earlier. This
form of plague, besides being the most infectious, is the most fatal.
In cases which recover or linger for some time buboes are likely to
appear, and in some cases the pneumonia and buboes may occur
simultaneously at the commencement of the illness.
[ In each of these forms the symptoms more or less common are
Characteristic subject to many modifications. The Pestica facies changes
symptoms. during the illness, being dependent on the state of
consciousness of the patient, on the kind of delirium, on the severity
of the headache, and on the degree of giddiness which forms part of the
symptoms. Many have injected eyes, a distressed aspect of countenance,
the eyelids slightly closed and the mouth slightly open ; some
wear an expression of pain. As a rule the countenance in the early
stages depicts anxiety and distress, and in the later stages resignation
and apathy. The resigned, listless, and apathetic countenance is apt
to deceive the physician, causing him, unless experienced in the disease,
to entertain the opinion that the patient is better, Avhereas it is due
to relaxation of the facial muscles from partial loss of nervous power
and is not an improvement, but a sign of gravity and danger. With
delirium the face is flushed and the expression may be one of dis-
traction, anxiety, terror, or menace, the patient being wild with ex-
citement ; the eyes are red, congested and sunken, and the conjunctivae
ai-e injected. In a state of stupor the expression is gloomy, depressed,
apathetic or vacant, the mouth is half open and the patient has the
appearance of being under an hypnotic and yet unable to sleep, the
eyes remaining wide open or half closed, glassy, vacant, and lustreless.
The tongue is generally swollen, indented, and is protruded with
difficulty in a tremulous or jerky manner; it is coated on the surface
with a creamy- white fur with angry looking papillae showing through,
CH. xiv] Clinical Features 267
and the tips and edges are clean and I'od. Later the coating on the
surface of the tongue is dry and has a mother-o'-pearl or glistening
appearance ; and later still it forms into a yellowish or reddish-brown or
black crust and resembles that seen in typhus and typhoid fever. The
lips, teeth, and gums become covered with sordes. The plague virus
evidently produces a progressively intoxicating effect on the nervous
system, which dis})lays itself with varying degrees of intensity in
different ways on different constitutions. In some there is insomnia,
in others wild delirium, in others stupor, in all more or less loss of
coordinating power over the voluntary muscles and dulling of the
senses. The staggering gait and the inability to coordinate the move-
ment of the hands are very characteristic symptoms. There is no
paralysis of the limbs, but from the physical weakness, vertigo, and toxic
impression on the nervous system the voluntary muscles are not
completely under the command of the patient. The speech is also
peculiarly hesitating, stuttering, thick, lisping, indistinct, and mono-
syllabic, often like that of a drunken man. The memory is confused.
and in answering questions the patient forgets half the sentence or
syllable of the word which he began to utter. It has happened that
a plague patient with these symptoms has been taken to the police
station under the supposition that the speech, staggering gait, and
confusion of mind were due to drunkenness.
The general clinical features of plague in its different forms
Symptoms having been described, some of the important symptoms
inTeiation ^^'^^^^ ^^® system affected may now be more fully dealt
to systems with.
Tlie temperature is not characteristic; it rises in the
Temperature. ^^^^^^^[^ fo^m to 103°, 104" F. or may be to 105° F. or to
106° F., and may reach its highest on the evening of the first day and
continue at its maximum, but more usually it gradually rises, reaching
its maximum on the evening of the second or third and sometimes, but
seldom, on the fourth day, an intermission of a degree or more frequently
taking place during a part of the day. On the third, fourth, or fifth day
the temperature usually falls 2 or 3 degrees or more, continues at this
low temperature for a few hours or a day and then rises again, reaching
nearly the same or a greater height than that of the previous evening.
This primary fall in temperature is sometimes ascribed to the effect of
medicines, but it is a feature which is common to many cases of plague
when left to their natural course. With this secondary rise, especially
if higher than the first, the symptoms increase in gravity and the patient
268 Plague in the Ju(lh'khi(d [part in
is in a perilous condition. It' this stage is successfully passed through,
the temperature again falls the next day, and then by successive evening
exacerbations and morning remissions steadily comes down by degrees to
normal or sub-normal, which may be reached on any morning between
the sixth and eleventh day. In simple bubonic cases of a mild character
the temperature may fell to normal as early as the second or third day ;
on the other hand the occurrence of complications or the eruption of
buboes may cause great irregularity in the temperature and completely
obliterate the more or less typical primary and secondary rise with the
apyrexial interval.
Little is to be gathered as regards prognosis from the temperature ;
generally the higher the temperature the graver are the symptoms ; and
the later the first curve terminates the more likely is the secondary
reaction to be moderate. Fluctuating temperatures may mean nothing*
but if simultaneously with the fall of temperature there is a considerable
rise in the frequency of the pulse, the conjunction is, as a rule, un-
favourable. A sudden fall of temperature with a collapsed condition of
the patient usually indicates a fatal issue ; on the other hand, a fall
of temperature by degrees between the fifth and seventh day may be
looked upon as favourable. Sometimes the temperature is low and
becomes subnormal.
Occasionall}^ there may be no fever during the illness, which may
merely consist of indisposition, coated tongue, headache, slight giddiness,
and a bubo in groin, arm-pit, or neck. The illness is such as not to con-
fine the patient to bed, but is often protracted and sometimes terminates
suddenly in death.
In septicaemic plague the temperature is usually high at the com-
raencemcnt, remains high, and runs an irregular course. In the most
severe cases of the septicaemic type the temperature may not rise
above 100° F. or less in the early stage, and it is only if the patient
lives long enough for reaction to set in that there is any considerable
rise in temperature.
In pneumonic plague the temperature is high and usnall}' runs an
irregular course. It may continue high to the end or f;ill suddenly
before the patient's death.
CH. XIV]
Teinperattire Charts
269
The Charts taken from Surg eon- Major Lyon's Report on the Plague in
Bombay, and from DrJ. A. Lowsorts Report on Plaque in Hongkong, and from
some Cape Town cases will shoiv the general character of the temperature in
plague.
J.G.G.(E) L. Fkm. Bubo Suppurated Rec.
Day
F
106
105
104
105
102
101
WO
99
38
97
Pulse
1
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P^v
P.S.(H) L. Fem. Bubo Suppurated Eec.
270
Plague in the Iiullvklual
[part III
A.K.H.(M) Left Axillary Bubo.
W.(E) L. Fem. BuiJo Resolution Rec.
Day
F
lib
104
lOi
102
101
100
?9
9«
97
Pi/he
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106-
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104-
103-
102-
101-
100-
99-
98-
Pulse
Resp.
Right Femoral Bubo.
1 2 3
^ J
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CII. xiv]
Temper atu) 'e Ch at -ts
Left Axillary Bubo.
271
29 30 1 2 3 4 6 6 7 8 9 10 1 1 12 13 H 16
Lei't Cehvical Bubo.
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272
Plague in the Individual [part ttt
M.K. Pneumonic Plague.
APRIL 19
APRIL 20
APRIL 21
APRIL 22
APRIL 23
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MARCH 27
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CH. xiv] Clinical Fecit tires 273
Contemporaneously with the fever, or before, or soon after its
Lvmoiiatic appearance, in some cases several days, and in rare cases a
system week or more later, intense pain is felt in one or more of
the glandular regions of the body, generally in the femoro-
inguinal, axillary or cervical region, or occasionally in thv epitrochlear
or popliteal space. At the seat of pain one or more of the glands is
noticed to be swollen and to be specially tender on pressure. In the
next 12 hours or in a shorter time the swelling rapidly increases in size
and a bubo is formed. Sometimes more than one region is affected,
and often groups of glands on the same course of lymphatics become
successively infected. As a rule only one region of the body is affected,
though in a small percentage of cases buboes may appear of a bilateral
or multiple character in any part of the lymphatic glandular system.
The bubo may be completely formed in a few hours, but more fre-
quently its full development takes from one to five days.
The bubo or swelling consists of one or more inflamed and swollen
lymphatic glands with a sero-sanguinolent or hacmorrhagic
condition of effusion into the periglandular tissue, which, while matting
°^^' together the neighbouring glands into a hard mass, also
infiltrates the tissues around and renders them firm and oedematous.
The periglandular tissue like the glands becomes inflamed. The effusion
may be profuse or scanty. In cases which prove rapidly fatal the
glands may remain hard and painful without any palpable periglandular
infiltration, but the usvial course, if the patient lives long enough, is
extreme pain, swelling of the gland or glands, effusion, and the forma-
tion of a distinct bubo.
The discovery of the plague bacillus in the blood in nearly 45 "/o of
the cases of plague admitted into hospital in Bombay in recent years,
and the still greater percentage in Hongkong, would seem, as already
stated, to indicate that the older views were more correct than the
modern, and that the bubo in most cases is only a local manifestation
of the disease already in the blood. Every extravasation whether on
the skin or elsewhere contains plague bacilli.
The fact of the bubo frequently making its appearance several
days after the onset of the illness is also in favour of plague being
primarily a general disease, the affection of the glands with the
eruption of the bubo or buboes being a local manifestation of the
disease as much as the skin eruption in small-pox, scarlet fever, or
measles. This view is contrary to that commonly accepted to-day,
which considers the bubo to be the primary local lesion, the toxines
s. 18
274 Placjue in the TndivUlual [part hi
from which become absorbed and give rise to the general symp-
toms.
The smaller the bubo usually the more fatal is the attack. The
size of the bubo depends on the number of glands
affected and the amount of effusion matting the inflamed
glands together and infiltrating into the surrounding tissues. When
the effusion is small the bubo may be no larger than an almond
and the affected glands may be distinctly felt, but when the quantity
of periglandular fluid is large it may be the size of a man's fist
or larger; then the outline of the glands is not to be discovered by
palpation. The bubo is usually of an oval or round shape and of uneven
surface owing to the conglomeration of affected glands. At first
moveable from surrounding structures it becomes adherent and im-
moveable, it is somewhat doughy or boggy to the touch on the surface
and of a hard consistence in the deeper tissue. The skin over the bubo
loses its soft and loose texture, becomes thickened, appears smooth and
tense, and is sometimes reddened or of a dusky hue from inflammatory
action. On the surface of the bubo may be haemorrhages, carbuncles or
blisters, and the skin covering the bubo may become gangrenous.
Pain, tenderness, and swelling are the general character-
istics of the bubo. The pain may be dull and aching
or sharp and stabbing, and is independent of the size of the bubo. The
smaller the size of the bubo the more painful is it likely to be. Much
of the pain disappears as the swelling increases in size. Sometimes
there is no pain, and the bubo when lying deep is only detected by the
tenderness caused by pressing over the part. Sometimes there is neither
pain nor tenderness and the bubo can be handled without causing any
Tenderness inconvenience to the patient. Tenderness on pressure
over the region of the glands is useful in a confirmatory
sense when the glands are small or lie so deep as not to be felt, but
absence of tenderness does not always mean no affected glands. Some-
times the tenderness is so acute that pressure over the bubo will cause
wincing and moaning from pain even when the patient is in a comatose
condition. In the acute stage of development if the bubo is cut into
it will bleed freely and the swollen glands will present a brick-red or
purple colour. At a later stage a similar incision will usually show
yellow or blood-stained pus.
The bubo in its natural course terminates by suppuration or by
Termination •'^l"»ghing, or it subsides by resolution, becoming dispersed
and absorbed, or it indurates and remains as a hard lump
CH. xiv] Clinical Features '21q
for an indefinite period. In the event of suppuration, if the case is an
uncomplicated one, the process begins after the seventh or eighth day
without any rise of temperature, the skin over the infiltrated area
becoming inflamed, and is completed in the course of ten or twelve days.
The suppurating bubo heals in the course of a week to a month, leaving
a large scar, more or less varying in size according to the amount of
sloughing which has taken place. The healing process may, however,
not be completed for six weeks or two months or longer. Indolent
buboes, especially those in the iliac regions, may not suppurate for long
periods. Choksy records a case of a bubo of this kind being opened
on the 48th day of the patient's illness ^
When the suppuration is accompanied as it may be by much
sloughing, either of the bubo or of the bubo and the infiltrated tissue
around it, large cavernous ulcers with rugged and indurated margins
may result, laying bare the muscles, nerves, and blood vessels of the part
and forming deep and unhealthy looking wounds which take a long time
to heal and which are a heavy drain on the patient's strength. These
large sloughing excavations, which are at all times dangerous, are
specially so when they occur in the pelvis in connection with iliac
buboes.
The pus in mild cases is healthy and presents no unusual characters,
but in the more severe cases it varies much, sometimes being offensive
and serous, at other times being chocolate colour and like wine lees and
mixed with coagulated blood.
If the bubo ends in resolution the periglandular infiltration de-
creases, the outlines of the glands get more distinct, the glands lose
their tenderness on pressure, the skin becomes softer, and beyond
a slight induration and possibly a pigmenting of the skin there is little
trace of the inflammation to which the glands and their surroundings
have been subjected.
The situation of the buboes in order of frequency in the external
glandular region is the same in every country where plague
Situation j ./ i o
occurs, whether the inhabitants wear boots or not. The
most frequent seat for them is the inguino-femoral region, the next is
the axillary, and the next the cervical.
A patient suffering from an inguinal bubo usually lies in bed with
Inguinal the thigh flexed to relieve any pressure on the painful
buboes. swelling. In the inguinal region the bubo may occupy
a horizontal or vertical position, according to the group of glands
' The Treatment of Phu/iw with Prof. Lustirj's Serum. By N. H. Choksy, M.D.
18—2
•276
Plaffue in flic TntJividual [part ill
Inguinal Bubo.
Inguinal Bubo.
CH. XIV]
Clinical Feahu^es
277
that may be specially affected in Scai'pa'.s triangle. The vertical
set of glands below Poupart's ligament are the most frequently affected.
The swelling may be small or it may be as large as an orange, and the
oedema of the surrounding tissues may extend as far as the knee or well
on to the abdominal wall. The figures on p. 276 show the kind of buboes
most commonly met with in the inguinal region. Only one groin may
be the seat of a bubo or bc^th groins may be affected. The bubo in the
inguinal region not infrequently extends into the iliac region, affecting
the chain of glands and lymphatics in the abdominal cavity and forming
a hard tumour to be felt through the abdominal wall. This iliac bubo
is painful on pressure and may attain large dimensions. Sometimes
these iliac buboes occur without any very noticeable enlargement of
the inguinal glands, and may if situated on the right side be mistaken
for the results of typhlitis or appendicitis.
Axillary Bubo.
278
Plagtie in the Individual
[part III
Patients with axillary buboes usually lie on the back with the
AxiUary affected arm held away from the side. In the axilla the
buboes. bubo often occludes the axillary space and obliterates the
outline of the margin of the pectoralis major. The exudation may
become much greater than that accompanying inguinal buboes, and may
extend over the side of the chest down to the loins and upwards to the
shoulders, and even to the side of the neck. The result of this extensive
sero-sanguiuolent effusion is the formation on the side of the patient of
- '■ '^Ht^
Left Axillary Bubo with Infiltration into Chest,
Shoulder and Arm.
a hard mass which is apt to interfere very materially with the respiratory
movements or become a dangerous slough. Incision does not lessen the
swelling, there being little exudation from the wound, which soon
becomes dry and heals readily. The fluid that does exude does not
coagulate spontaneously but coagulates on heating and on the addition
of nitric acid. Axillaiy buboes with extensive exudation usually end
CH. XIV]
Clinical Features
279
fatally. Sometimes an axillary bubo will cause swelling of some of the
cervical glands. It has been observed that axillary buboes are fre-
quently associated with septicaemic and secondary pneumonia.
Buboes of the cervical region may be under the jaw or at its angle,
Cervical ^^ the neck and in the tonsils. The swelling in these
buboes. situations may be small, and the disease run an ordinary
course, or it may be so great as to place the patient in imminent danger
of suffocation. The oedema may extend down below the clavicles or to
the chest and into the axilla, or upwards to the face and head, or inwards
into the soft tissues with consequent pressure on neighbouring organs.
Cervical Bubo.
•280
Plague In the Individual
[part III
The trachea is subjected t<> more or less pressure and the glottis is apt
to become oedematous. In these cases the patient lies down with head
thrown back or sits up in bed, breathes hurriedly and with difficulty, the
respirations being wheezy and stridulent, and the pharynx more or less
fixed and immobile during inspiration, the voice is nasal, there is much
difficulty in opening the jaw and the sputum contains blood and plague
bacilli. The lips and cheeks may become cyanosed or the face may be
pallid. Patients suffering from this form of the disease, which is
generally tonsillar in its character, with the mucous membrane of the
tonsils, pharynx, and larynx highly inflamed, infiltrated, with serous
effusion, and sometimes covered with a pseudo-diphtheric membrane,
present very similar symptoms to those attacked with diphtheria. In
many epidemics the early cases of this type have been mistaken for
Cervical Bubo.
CH. XIV]
Clinical Features
281
diphtheria. This was the case in Bombay, where some of the earlier
cases of plague with swollen cervical glands were diagnosed as diphtheria.
The sloughing of the skin over cervical buboes reminds one of what was
seen in cases of scarlet fever when the cases were more malignant than
they are at the present day.
Popliteal Bubo.
282
Plaffue in the Tndwidiial
[part III
Cervical Bubo and Necrosis on Left Ai
CH. XIV]
Clinical Features
283
Buboes occasionally occur on other sites than those mentioned ; in
fact they may be found wherever glands exist. The most common of
these unusual sites are the epitrochlear region and popliteal space, but
the glands of the breast, testicle, or other parts may be exceptionally
affected with buboes.
^ifiT'^'Cv
,^
Supra-trochlear Bubo and Necrosis on Arm.
]\Iultiple buboes may also occur either in regions in close proximity
Multiple to the primary bubo or in distant regions, or contiguous
buboes. buboes may appear almost simultaneously. In the first
case it is generally held that the pathological evidence indicates the
passage of the bacillus to the dther glandular group by the chain of
glands and lymphatic vessels connecting them, or by the oedema formed
from the first affected gland. Contiguous buboes most frequently occur
in the femoral inguinal and iliac regions and often within a few hours
of the onset of the disease. Although clinically these are all that
are discernible the post-mortem examination usually shows buboes,
haemorrhages and swollen glands in the deeper tissues of the thoracic,
abdominal and pelvic cavities. In the case of buboes occurring simul-
taneously in such distant parts as the groin and axilla it is accepted
-^4 Plag}(e w the Individual [part m
that they can only be caused by bacilli being carried by the blood stream
to the affected glands. In severe septicaemic cases however the glands
of the whole glandular system of the body are affected, but they do not
pass the stage of engorgement and slight swelling and clinically are not
readily recognisable in the groin, arm-pit, or other region. In these
cases extensive multiplication of the bacilli takes place in the blood
rather than in the glands.
Petechiae of variable size and pustules forming necrotic patches, or
The skin. what were formerly called carbuncles, may appear on the
Petechiae. buboes or independently of them. The petechiae are
generally over buboes or on the abdomen, but they may be found in
other parts of the body, such as the face, neck, breast, and extremities.
Larger ecchymotic patches are occasionally seen. The petechiae and
ecchymotic patches probably correspond to the tokens in the Great
Plague of London Avhich appear to have been a common feature in
fatal cases. Neither petechiae nor ecchymoses have formed important
sjinptoms in the different epidemics of the present pandemic, but they
are occasionally seen well-marked in severe cases before death. In
addition to patches of dark-coloured petechiae or ecchymoses there has
been occasionally an eruption of pustules. The pustules on the skin
may be of a variable nature, and in some cases of plague they have
been so numerous as to raise a doubt as to whether it was not a
case of small-pox that was being dealt with. This, however, is excep-
tional, but it is possible that this pustular form of plague was more
common in some of the older epidemics.
More commonly, but still rarely as compared with the epidemics
Gangrenous **^ former days, there is a slight eruption of a few pustules
pustules or or carbuncles in the course of the disease and after the
appearance of the bubo. They may appear in any part
of the body and at any period of the acute stage of the illness. The
pustules usually commence as ecchymotic or petechial spots, having the
appearance of a flea-bite and with the same burning sensation in them ;
these ecchymotic patches rapidly increase in size and then rise in the
form of blisters with or without umbilication, while the circumference
becomes hard, swollen and inflamed. The blisters contain at first a
clear, serous fluid, which is later dark, sero-sanguinolent or haemorrhagic ;
and in the contents are plague bacilli. The blisters soon break and
show at their base a moist, bluish-red, inflamed and angr^^-looking
circular or irregular patch, which at this stage may dry up and go
no further, or the inflamniation iii;iv extend to the subcutaneous tissue,
CII. xiv]
Clinical Features
285
causing a circumscribed ur diffuse swelling, the centre of which begins
in a few hours to necrose, forming a leathery-looking scab. From this
centre the necrosis spreads rapidly to the periphery. The result is the
formation of indolent ulcers more or less deep or superficial with hard
and red overhanging margins. The necrosis may stop when the patch
has reached a circumference of one or two inches, which is the usual
limit, but in some cases it may continue to spread to the diameter
of even eight or twelve inches, laying bare the muscles, the nerves
and blood vessels, and even the bones, and sometimes causing severe
haemorrhage. The slough is thrown off by suppuration and the drain
on the strength of the patient is proportional to the size and number
of ulcers formed by these gangrenous pustules. They may occur in all
parts of the body, the largest having been noticed in the gluteal and
Right Inguinal Bubo and Necrosis or Carbuncle on Loin.
scapular region. Choksy has obsei'ved' that the mortality of plague
cases in which these cellulo-cutaneous necroses occur is less than the
> The Treatment of Plague icith Prof. Liistiy's Serum. By N. H. Choksy, M.D.
286
Plague in the Individual
[part III
bubonic type without them. A similar observation was made in Egypt
in the epidemic of 1834-35, in which their occurrence was considered
favourable. In the latter epidemic the so-called carbuncular variety
appeared only at the middle and decline of the epidemic when the
Carbuncle or Necrosis.
type of the disease was less fatal. In a small percentage of cases a
single pustule on the wrist or ankle or other part of the body appears
at the commencement of the disease. If on the wrist or ankle, a bubo
usually occurs in the axilla or inguinal region of the same side. In
such cases the mortality is less than in those in which an eruption of
pustules manifests itself during the course of the disease. Plague
bacilli with pyogenic organism are to be detected in the early stage in
the pustules single or multiple.
CH. xiv] Clinical Features 287
Next to the eruption of buboes the most characteristic symptoms
Nervous ^"^^ those connected with the nervous system. Most of
phenomena. these have already been mentioned, such as at the
conmaencement of the illness the great depression, severe headache,
giddiness, staggering gait, and stammering speech. The headache is
usually frontal, though it may not be confined to any special part, and
is not infrequently general. It is sometimes dull but more commonly
acute in character. Restlessness and a desire to wander from one
place to another are often exhibited in the early stage. Sleep is only
obtained in snatches and is unrefreshing. As the disease progresses the
disturbing effect of the toxines manifests itself on the intelligence in a
marked degree, though this is not always the case. There are cases in
which the patient remains conscious, rational, and with speech unaffected
to the last, not an uncommon occurrence in primary pneumonic plague.
Mental clearness is, however, the exception, but it sometimes occurs.
It is of no special prognostic value. Heaviness, drowsiness, confusion
of ideas and a state of hebetude, alternating with delirium of a low
muttering or excited nature, are the most characteristic mental con-
ditions. They come on early in the disease. The delirium may be
continuous or only present at night, or it may be absent, and the
patient remain in a semi-conscious condition. There are all transition
stages of mental condition, from that in which the patient is easily
aroused and answers questions slowly but with difficulty in a somewhat
hesitating and stammering manner, to that in which he is in a state
of stupor, with all the senses dulled, difficult to arouse, and if he
answers it is in a muttering, indistinct and almost unintelligible manner,
like that of a drunken man. There may be complete aphasia, the
patient being unable to speak from paralysis of the laryngeal muscles.
The dumbness may continue during convalescence and sometimes after
recovery. The sense of taste may be perverted or lost during the
illness. The delirium has already been described as being noisy or
of a quiet character. It may be so violent as to necessitate the patient
being put under restraint in bed to prevent self-injury or escape from
the sick-room ; sometimes it is accompanied by suicidal or homicidal
tendencies and by hallucinations of a terrifying nature. The acute
forms of delirium are more frequent than the low muttering variety.
At the later stages hyjjeraesthesia of the skin, ti-emors, twitchings
and spasms of the muscles of the face, neck, limbs, abdominal wall
or chest, with convulsive seizures of the body, occasionally mark the
strong irritating and toxic effect of the virus on the nervous system.
On the other hand the action of the virus may be that of an hypnotic ;
288 Pla<in( In tin IndirUUial [part hi
then, instead of gesticulations and incessant talking, the patient lies
with lixed gaze, indifferent to surroundings, with facial muscles relaxed,
powers of articulation lost, and in a state of nuiita] and physical inertia.
If the patient recovers the improvement is at most very gradual, and
at times there may remain as sequelae a state of dementia, aphasia,
or ataxia, which may be temporary or, rarely, permanent. One of the
features of plague in those that recover is that the cerebral and
nervous disturbances from which they have suffered are mostly functional
in their nature, and do not commonly cause any permanent injury.
A feeling of oppression is frequently experienced over the praecardial
Vascular regions. In mild cases of plague there may be no devia-
system. ^Jq,^ ^f |^|^^ pulse from normal, but in the more or less
severe cases weakness soon displays itself, and in proportion to the
severity of the nervous phenomena, the pulse shows signs of a tendency
to heart failure produced by the paralysing effect of the plague toxines.
In connection with this are the frequency of the pulse and the rapid
fall in arterial tension. Even on the second day the pulse rate will rise
to 120, 130, or 140. At first full and somewhat frequent the pulse soon
becomes feeble, rapid, intermittent and dicrotic, and, at last, in cases
likely to be fatal, so thready that it is impossible to count. Sometimes
heart failure may suddenly occur -without any sign of collapse. Sudden
exertion, such as sitting up in bed or getting out of bed, may be the
immediate cause of heart failure, but this may happen also without
any such strain on the heart's action.
Lowson gives three sph3'gmographic tracings of the pulse in plague
which are here reproduced. Two are of the radial pulse and one of the
femoral, the first radial tracing showing the dicrotic pulse, the second
radial and femoral illustrating the anacrotic pulse preceding failure.
His description of the tracings is as follows :
" The pulse which at first is full and bounding becomes (usually
in from six to thirty-six hours) dicrotic and fairly easily compressible
at the wrist. The accompanying tracing shows such a pulse where the
dicrotism, although not extreme, is w^ell marked.
" Intermittency is often noticeable in this second stage of the pulse
and becomes more marked as the third stage develops, when it becomes
anacrotic and almost like the pulse of aortic insufficiency, there being
CH. XIV]
Clinical Features
289
no rebound wave at all, nor the slightest trace of it by sphygmograph
in a well-marked case. In addition it is at this period very easily
compressible, and the actual range of movement of the vessel is very
limited at the wrist, whereas in the larger vessels the upheaval is
usually well marked, slight pressure at the femoral being sufficient to
arrest the pulse. The following tracing of the radial pulse is taken
from a patient at this stage, there being no pressure on the sphygmo-
graph button exce])t its own weight.
" This patient was a very lean man, and consequently a tracing of
his femoral pulse could be easily obtained as the vessel passed over the
brim of the pelvis. With slightly over an ounce of pressure (enough
to visibly diminish the range of movement) the accompanying tracing
was got.
" From this anacrotic stage gi-adual or sudden failure may set in,
unless there is a general improvement in the case. The pulse generally
becomes fast and running and scarcely perceptible or if perceptible it
is generally intermittent. On the second day if a thin patient was
naked one could usually see the femoral arteries beating at a distance
of several yards, and this was equally true of the other large arteries.
Often this large movement was to be seen in the vessels in the neck,
axilla, or groin, and yet at the radial or posterior tibial arteries the pulse
was hardly perceptible."
The sounds of the heart are usually clear but feeble. The blood
contains, as the disease advances, an increasing number of
leucocytes of the polynuclear kind, and at the later stages
a short time before death large numbers of plague bacilli may be de-
tected in the blood in bubonic cases, while in septicaemic cases plague
bacilli are in the blood at an early stage. According to observations
recently made in Hongkong, plague bacilli may be present in cases of
plague during the initial stage, even before there is any marked rise in
temperature or before the disease manifests itself in the septicaemic or
bubonic form. The histories of four cases are given in which plague bacilli
are shown to be present in the blood at a very early stage. A fact like
s. 19
The blood.
290 Plaxfue in the Individual [part m
this may account for the severity of the disease among the Chinese,
whereas in European races and others the bacilhis cannot at present
readily nuilti])ly in the blood and selects in preference the lymphatic
system. In the Bombay epidemic of 1896 there were few septicaemic
cases compared with the number in later epidemics, while in the South
African and Australian epidemics septicaemic cases were conspicuous
by their absence.
Case No. IK F. A., admitted to the Government Civil Hospital on the 17th
March, 1903, comi)laining of severe diarrhoea. Temperature on admission, normal.
The blood was examined with negative results. The character of the stool was loose,
bile-stained and foul-smelling. Nothing characteristic was found in the stool when
examined microscopically. The number of .stools on the day of admission was 6.
On the 18th 4 .stools, on the 19th 4 stools, and on the 20th he had 2 stools. All the
stools were of the same character as described. The temperature was still noi-mal
on the 20th. On the evening of the 20th it suddenly rose to 102° F. The diarrhoea
was still present. On the 21st the evening temperature was 103° F., diarrhoea still
present. On the 22ud the temjierature was 103° F., diarrhoea small in amount.
The l)lood was examined by the method recommended by Ross for malaria, and a
number of oval, bipolar-shaped micro-organisms were found. These were regarded as
plague bacilli, and the patient was removed to Kennedy Town Hospital. Here he
complained of severe headache and sleepiness. The tongue was thickly furred, and
in general the patient presented all the signs of severe plague infection. No bubo
developed. He went through an extremely severe attack of plague of the septicaemic
type.
Case No. II. S. S., a police constable, was admitted to the Government Civil
Hospital on 3rd Jmie, 1903, complaining of vomiting and diarrhoea of a day's
duration. On admi.ssion the dejecta were found to be watery, bile-stained, and foul-
smelling. The tongue was fin-red. The temperatm-e was 100° F. The blood was
examined by Ross's method, and large numbers of bacilli identical with the B. pestis
were found. On the strength of this, the patient was removed to the Infectious
Diseases Hospital, where a severe and typical bubonic plague developed.
Case No. III. T. K., a Chinese police constable, was admitted to the Govern-
ment Civil Hospital on the 4th March, 1903, complaining of severe "colic," vomiting
and constant watery diarrhoea. The bowels opened twice soon after admission, and
the dejecta were watery and brownish-yellow in colour. Nothing abnormal was found
in the stools. The patient looked very pinched, ill, and .somnolent. The tempera-
ture was 99° F.
On the 5th the temperature was .still 99° F. The patient was very sleepy and
dixll. He complained of severe headache. The tongue had become thickly coated.
The diarrhoea was still profuse and of the same character. The blood was examined
as in other cases. Bacteria moqihologically identical with the B. pestis were found.
He was removed at once to Kennedy Town Hospital where he passed through a
typical attack of plague of the bubonic type.
^ A Research into Epidemic and Epizootic Plague. By Wm. Hunter, Government
Bacteriologist, Hongkong, 1904.
CH. xiv] Clinical Features 291
Case No. IV. H. T., a Chinese coolie, was admitted to tlie Government Civil
Hospital on the 16th March, 1903, complaining of cramps in the abdomen, headache,
vomiting and diarrhoea. On admission the temperature was 100"8° F., the tongue
was fo»il, headache was constantly complained of, and vomiting and diarrhoea con-
tinued severe. Xothing abnormal was found microscopically in the stools. They
had the usual naked-eye appearance. During the first 24 hours after admission the
patient had 2-2 stools. The blood was examined as in other cases and organisms
identical with plague bacilli found. He was transferred to Kennedy Town Hospital
and deoeloped into a typical case of septicaemic plague loitli no bubonic formation.
The appetite varies, being sometimes lost and at other times almost
The digestive I'^venous. Intense thirst is, however, a more constant
system. symptom. The characteristic condition of the tongue at
the different stages of illness has already been referred to. The soft
palate, fauces, and pharynx are inflamed, the tonsils swollen and may be
covered with a diphtheritic coating. Patients may complain of burning,
dryness and rawness in the throat. Vomiting preceded by nausea is
one of the initial and most frequent symptoms : occasionally it may
continue during the whole acute period of the illness. The material
vomited after the digesta is a watery fluid, bilious or dark like coffee-
grounds, and sometimes containing blood.
Constipation is the usual condition at the onset but dian-hoea may
supervene later or even begin with the illness. The evacuations are
usually very foetid and of a yellow or bilious colour. Sometimes they
are dysenteric in character, blood, mucus, and epithelium appearing in
the stools. Occasionally the diarrhoea is of such violence as to suggest
cholera. These intestinal symptoms have been observed in India and
China. In Hongkong Wilm' noted that in 20 Y„ of the cases in which
no external buboes were formed the intestinal symptoms were so predo-
minant that the illness had to be regarded as an intestinal affection.
Post-mortem examination of these cases revealed enlargement and
inflammatory changes in the mesenteric and retro-peritoneal glands,
and congestion and dilatation of the blood and lymph vessels between
the affected glands and the intestine. A similar but milder form of
visceral plague has been observed in Egypt by Valassopoulo-.
Captain Hojel-', I.M.S., first drew attention to the occurrence in the
Bombay epidemic of a type of the disease in which abdominal symptoms
* Report on the Epidemic of Bubonic Plague at Ilongkon;) in the year 1896. By Staff-
Surgeon Wilm.
2 La Peste d'AIexandric en 1899. Par le Dr A. Valassopoulo, 1901.
•' Report of tlie Bombay Bubonic Plague Research Committee by Surgeon-Major Ijyons,
I. M.S., Pre.sident of the Bombay Research Committee.
19—2
292 Plague in the IncUvulual [part in
predominated. In this form there were pain and tenderness in the
epigastric region, pain in the back, abdominal tension, enlargement of
the liver and spleen, and low nervous symptoms similar to those met
with in enteric fever, accompanied in some cases by the appearance of
petechiae on the abdomen and lower part of the thorax resembling the
rash of enteric fever. Peyer's patches were found after death to be
slightly raised, oedematous and congested, the solitary follicles as large
as a hemp seed, but there was no enlargement of the mesenteric glands.
The urine is scanty, high-coloured, sometimes smoky, acid, and of
•me urinaxy varying degrees of specific gi-avity : it contains albumen
system. in the majority of cases, but is deficient in chlorides, urea
and uric acid. In grave cases there may be haematuria, or there may
be suppression or retention in the one case owing to cessation of secre-
tion, in the other to loss of power of the functions of the bladder,
necessitating the employment of the catheter to draw off the urine.
Plague bacilli are present in some cases ^
The respiration in the milder cases or at the commencement of
Respiratory those which become more serious may remain unaltered
system. or only slightly accelerated, but with the severer forms
and as the disease advances the condition of the respiration becomes
an important feature in the disease. Oppression and tightness across
the chest are experienced, the breathing is laborious, the respiration
increased in frequency, rising to 30, 40, 50, and even 60 per minute ;
the breathing is hurried and difficult, the dyspnoea being due to a
gradually increasing oedema of the lungs, which causes much distress to
the patient. Cough is generally present. The sputum is scanty and
viscid at first and later purulent, and in simple cases without blood.
Auscultation and percussion may reveal signs of congestion of the base
of the lung and a more general catarrh, or of nothing specially abnormal.
In some cases there is bronchitis and secondary plague pneumonia as
complications. Clinically there is nothing to facilitate the recognition
of secondary pneumonia save a decrease in the respiratory murmur,
some slight crepitant rales, and the rapid deterioration in the condition
of the patient.
Comj)lications and Sequelae.
The complications of plague are mainly those coniu'ctcd with the
Compiica- respiratory system, such as bronchitis, oedema of the lungs,
tions. and secondary pneumonia ; occasionally pleurisy and pneu-
' A iistrian Report.
CH. xiv] Com2)lications and Sequelae 293
mothorax may be met with. The first three may be viewed rather as
an extension of the infective process to (ither parts of the system at a
later stage of the disease, and from this aspect they form but a part of
the disease. On the other hand there are plague cases with severe
constitutional disturbances without these respiratory troubles. In-
flammatory affections of the eve are not infrequent com-
Eye diseases. ... -^ .
plications of plague ; these may range from a simple
inflammatory state to one which is accompanied by ulceration of the
cornea, by copious haemorrhages, and in some cases total destruction of
the eyesight.
Marasmus is another complication which occasionally sets in during
Marasmus ^^^ period of convalescence. It usually ends in death,
and chronic The patient becomes emaciated, feeble in mind and body,
unable to take food, gets into a typhoid condition, and
gradually sinks. This state may be caused by secondary infections
of a pyaemic nature, in which streptococci and staphylococci play
their part, or by the intense toxic effect of the plague virus.
Closely connected with this marasmus condition is another in which
the disease runs a chronic course from the commencement. The patient
may walk about notwithstanding a certain amount of indisposition and
catarrh and yet succumb later to the disease, and be found the subject
of abscesses containing plague bacilli in the lungs, liver, and spleen.
This chronic tj^pe closely resembles that found in the lower animals.
Indolence of buboes, sinuses connected with buboes maintaining
chronic discharges, and sloughing of buboes or of gangrenous pustules
can hardly be classed as complications though they materially protract
the duration of the illness and sap the strength of the patient. Abscesses
and boils may also appear in different parts of the body and contribute
to a retardation of recovery.
In pregnant women the most important complication is that of
abortion, which in the majority of cases is fatal to mother
Pregnancy. . .
and child. The danger of plague under this condition both
to mother and child has been observed in every epidemic, ancient and
modern. Exceptions may occur in which one or other or both may live,
but they are rare.
Choksy mentions arthritis as being a common complication of cases
of plague coming under his observation in Bombay ^ He
xxTtf JlTltiiS. 1*1' •
describes it as appearing generally during convalescence
^ Report ov Plague at Arthur Road Hotipitdl, Bomhai/. By Khan Bahadour N. H.
Choksy, M.D.
294 PJcufuc in the ImlivkJnal [part m
and being ushered in with feverish reaction, the temperature rising
slowly after having been low for a considerable time, accompanied by
swelling and effusion into the joints. It ran a more or less acute
course, and the joints princi])ally involved were the shoulder, elbow,
wrist, knee and ankle. Malaria, bei-iberi, cholera, relapsing fever,
pulmonary phthisis and syphilis are diseases which have at times
conciurent been observed to coexist with plague. There is probably
diseases. ^o disease that may not accidentally coexist with it, but
these being the most common in India and China, where plague has
been epidemic, the conjunction has been met with most frequently.
None of them give any immunity against an attack of plague. In
the Hongkong plague epidemic of 1902, when cholera also prevailed as
an epidemic, the two diseases were occasionally observed in the same
person. The same has been noted in India. In Bombay during the
prevalence of relapsing fever, cases of plague were seen in which, in
addition to the plague bacillus isolated from the patient, the spirillum
was observed in the blood.
Plague may occur in a patient suffering fi-om malaria, or malaria
ma}' supervene in the course of an attack of plague. In these cases the
malarial parasite may be found in the blood, and the plague bacillus in
the bubo, in the sputum, or in the blood.
Of sequelae the most important are affections of the nervous system.
Aphasia, ataxia, and dementia are the most common :
Sequelae. i i i ^^ o i .
happily they are generally oi a temporary character
though they may be permanent. Parotitis may also occur. Blindness
also follows some of the destructive injuries to the eye, while the
sloughing associated with buboes or pustules may injure important
blood vessels and cause dangerous haemorrhage. Gangrene of the limb
has also been observed in some rare cases.
Second attacks, though rare, do occur sometimes. It is now and
Second again difficult to distinguish them from relapses which
attacks. ^Ij^q occur occasionally. But this only happens when the
second attack closely follows the first. Three cases of second attack
are recorded as having occurred in the first epidemic at Bombay ^
One was a European lady who was attacked at Hongkong in June,
1894, with a cervical bubo from which she recovered at the beginning
of August. She was again attacked with plague at Bombay in December,
1896, with a femoral bubo which resolved without suppuration. The
second attack was milder than the first.
1 Report of the Health OlHcur for Bombay for 1896.
CH. xiv] Second Attacks of Plague 295
The second case was that of a native in Bombay, the details of which
are as follows : —
First attack. Octuber 30, 1896. Mahomed AUybux Kadirally
(age 5S), Samuel Street, No. 197, second-floor.
3rd day. Left parotid bubo, size of a pigeon's egg, tender. Pulse
150; respiration 44; temperature 105. Shivering, delirious (bubo
second day). 40 minims of medretine given and 10 minims of liq.
hydrarg. perchl. every 2 hours. Calomel gr. 2 stat. Ice to the head ;
2 powders given.
October 31. Restless, 3 motions. Temperature 103 ; pulse un-
countable ; respiration 56 ; bubo more painful and tender. Delirious.
Medretine given. Phenacetin and soda salicylate every 2 hours, as
necessary.
November 1. Pulse 180; respiration 44; temperature 103'5. De-
lirious ; sleep disturbed ; right lung congested. Had one motion. Had
3 powders and medretine given, 2 oz. in 24 hours. Mixtures, stimulants
and expectorants.
November 2. Bubo enlarging and painful ; pulse 130 ; respiration
40 ; temperature 102^2. No headache ; lung clear ; had one motion.
Treatment same.
November 3. Temperature 101; pulse 132; respiration 33. A
little better. Medretine given every 2 hours, and ext. carnis and rum
every 4 hours.
November 4. Temperature 102'2 ; pulse 144 ; respiration 40 ; bubo
subsiding; right parotid gland appears tender; medretine every 4 hours;
ext. carnis and rum every 4 hours.
November 6. Temperature 100; pulse 140; respiration 40; lungs
a little congested.
November 8. Temperature 99; pulse 128; respiration 36.
November 15. No fever; bubo suppurated; pulse 112.
Second attack or recurrence. December 2. Temperature 105 ; re-
spiration 40 ; pulse 144. Very delirious, and starting in bed. Over
left parotid gland much swollen and very tender. Liq. hyd. per
m. 15 every 2 hours.
December 3. Temperature 104 ; respiration GO ; pulse 100.
December 4^. Temperature 104; respiration 40 ; pulse 102 ; delirium
less.
December 5. Temperature 100 ; respiration 40; pulse 100; delirium
less.
December 6. Doing well.
296 Pliujue ill tJtc Jndiridual [part hi
The third case was Mr C. T., " an Inspector in the Bombay Customs
House, a Bania by caste, age 27, who was attacked first in February,
1897 ; temperature rising to 105 and a gland in the left femoral region
becoming enlarged and painful. Under treatment the gland subsided
and the fever disappeared in a week ; after that he enjoyed perfect
health for nearly two months, when he had a second attack and the same
gland again became enlarged and painful. This second attack can be
traced to his nui'sing and almost living in the same house with a plague
patient at Matoonga. On this occasion the gland suppurated and was
removed by an operation. The patient made a very slow recovery and
was finally discharged cured, after living for more than two months in
the hospital."
These are all cases of recovery, but Matignon in his account of the
bubonic plague in Mongolia records the case of a man who, the previous
year, had been attacked with very characteristic plague with buboes
and died of plague the following year.
Clot Bey points out that Evagrius, Yallere, Diemerbroech, Chenot,
Orreus and Schrauel cite cases of relapses of plague observed by them
and refers to Bertrand, who in the Marseilles epidemic mentions some
persons who were attacked three times daring the same epidemic.
Clot Bey and his colleagues saw in Eg}^t several patients who died
of plague who, on a previous occasion, had recovered from the disease.
Russell out of 4400 plague cases met with 28 cases of reinfection ^
Cases of Plague.
A. B., a Kaffir boy, admitted to hospital, having a swelling in the
Ambulant left groiii. His history was that of feeling indisposed
variety. three or four days before, having experienced slight
shivering, nausea, and loss of appetite, after which a swelling appeared
in the groin ; next day the malaise disappeared. Examination in
hospital showed that the patient had no fever, the temperature being
subnormal and registering 97° F. There was a bubo about the size
of a pigeon's egg immediately above Poupart's ligament in the left
groin ; the skin over the bubo was red but mobile. The tongue was
coated with a white fur and was red at the tip and edges. The eyes
were not congested. There was no lisping nor slumng of the speech,
and his intellect was as quick as ordinarily. On examination of the
contents of the enlarged glands no bacilli were discoverable, but on
1 A Treatise of the Plamie, p. 190. By Patrick Eussell, M.D., F.R.S., 1701.
CH. xiv] Cases of Plague 297
culture of the contents, characteristic growths of the plague bacillus
were found. A guinea-pig and rabbit inoculated with the culture died
in 40 hours from typical plague. The glands had been noticed three
days before the patient's visit to hospital. On the third day of his
admission the temperature reached normal, he appeared in every way
well, and the bubo, instead of suppurating, ultimately disappeared by
resolution.
A. B., Malay, 50 years, fell ill on July 9th at 4 a.m. in the Cape
Septic and Town contact camp, was sent to hospital at 8 a.m., but
fulminating died on the way. Thirteen days previously his son died
at home after 4 days' illness of plague. A. B. was sent
with his family to the contact camp for 12 days' observation and was to
have been sent home on the day of the morning on which he fell ill.
On the night of the 8th he ate his supper, was apparently well and
was seen by the Medical Officer on the latter's evening inspection.
Some time after 3 a.m. on the 9th he woke up and remarked to his
wife that he did not feel well. At 4 a.m. he suddenly had an attack
of shivering and difficulty of breathing and fell almost immediately
into a state of collapse, dying at 8 a.m. The patient being a Malay
no post-mortem could be obtained at the time, but punctures were
made into the spleen, liver and lungs, and the contents drawn off
not only gave smear preparations which swarmed with plague bacilli,
but also pure cultures of the microbe. No buboes could be detected
by careful palpation and examination of the external parts.
C. 1)., Malay, wife of A. B., fell ill on the 10th July at 9 p.m.
and died at 2 a.m. on the 11th. Patient came to the contact camp
with her husband. When her husband died on the morning of the
9th July she felt quite well, but on the 10th was depressed, which
was attributed to her having lost her son and husband by plague. On
the 10th at 9 p.m. Dr McCulloch, the medical officer of the contact
camp, made his usual visit and C. D. was found in bed. The daughter
states that her mother felt shivery, which she attributed to grief.
Professor Levin and Dr McCulloch made a careful examination of
her condition. There was no congestion of the face, tongue was
normal, temperature 98'3, pulse small, soft and 98 per minute, respira-
tion slightly hurried, rate 28 per minute, lungs and heart sounds
normal. Cervical, axillary and inguinal regions carefully examined
and no indication of swollen glands or buboes observed. The nurse
was instructed to immediately call the medical men if she noticed
any change for the worse in the condition of the patient. At 2 a.m. of
298 Plague in the Individ ual [part hi
the 11th the patient suddenly became comatose and died before the
arrival of the doctors.
Post-mortem on the 11th. In left axillary region a bubo the size
of a pigeon's egg was found. The situation of the bubo was immediately
behind the border of the pectoralis muscle and on the dead body was
easily discernible, both to sight and touch. Section of the bubo showed
a red-violet, granular surface. With pressure there oozed out a red-
yellow thick fluid. Nearly all the lymphatic glands in the body were
enlarged, congested, and on section showed a red-violet surface. Pleural
cavities contained about a pint of clear yellow fluid. Ltings free, but
oedematous. On section a great quantity of reddish-yellow aerated
fluid oozed out. Heart normal in size, valves and openings free, but
the margins of the valves rose-coloured and thickened. Spleen much
enlarged, pulp dark red colour and friable. Kidneys with sub-capsular
ecchymoses ; section showed cortical substance swollen, picture indis-
tinct, numerous ecchymoses in pelvis, also haemorrhage. Liver enlarged,
necrotic patches and fatty infiltration on surface. Stoinach contained
coffee-coloured fluid and numerous ecchymoses and haemorrhages on
mucous membrane. Blood showed leucocytosis.
Bacteriolofjical examination. Smear preparations from bubo, glands,
spleen, liver and blood swarming with plague bacilli. Cultures from
these organs give pure cultures.
The rapidity of such cases and the absence of buboes or their
appearance immediately before death may easily lead to the true nature
of the disease being overlooked. In some cases even the most ex-
perienced may be left in doubt and it is only by an examination of the
blood during life or by a post-mortem examination that an absolute
diagnosis can be made.
James Lombard, coloured, 39 years, admitted to hospital on 13th
An atypical June. History. On morning of 10th became suddenly
^^^^' ill with severe shivering and vomiting and severe pain
in the joints, especially in the loins. In the afternoon he observed on
his face, arms, and chest, patches, which on the following day, the
11th, developed into small bladders which covered the whole body.
On the 12th felt pains in axilla and groin. Seen on this day by the
Inspecting Medical Officer, who found painful buboes in axillae and
groins and a pustular and papular rash on forehead and cheeks. Smears
from glands and pustules contained plague bacilli. The pustules were
small, irregular in shape, with no umbilication and no surrounding
infiltration nor induration of skin.
CH. xiv] Cases of Plague 299
Present state\ General state grave. Patient is very weak, speech
indistinct and stuttering, conjunctivae congested and injected, lips
very dry, tongue covered with thick dirty brown and crusty coating.
Temperature 1008° F. ; pulse small and soft, 120 ; respiration
hurried, 32 per minute. On the face, arras, legs, on the front side
of the body and parts of the back, are numerous pustules from the size
of a pin's head to a halfpenny, mostly single but often confluent ; some
limpid and when pricked a clear fluid oozes out ; others opaque and on
puncture a dirty yellow thickish fluid oozes out. A number of the
pustules dried up, leaving crusts. In the lumbar region on the
right side a carbuncle of the size of a halfpenny with dark,
raised, undermined, rugged borders ; the bottom of the ulcer covered
with a thick purulent dirty yellow matter; another carbuncle on
the right side on the margin of the lowest rib. In the cervical
region buboes of the size of a hazel-nut, two on each side ; the skin
not red over them but readily mobile ; the buboes not painful to
pressure but painful when head moved. In each of the axillae a bubo
of the size of a pigeon's egg, and of the same character as the cervical
buboes. Also on both sides epitrochlear buboes ; on the right arm the
epitrochlear very swollen and very painful on pressure and movement ;
the skin very red and not mobile. The whole part very hard and
much infiltrated. Femoral buboes on both sides of the size of hazel-
nuts, slightly painful on pressure ; skin not changed. The first sound
of heart indistinct, other sounds normal ; lungs normal.
Intravenous injection of 20 c.c. Yersin given. A second dose was
given, but when he received 7 c.c. patient began to be restless and the
injection was stopped. He became cyanotic and breathed more hurriedly.
Ether injection was given subcutaneously and in a few minutes he
recovered ; 40 c.c. Yersin given subcutaneously.
14fth. Patient slept a little during the night/ and took some
nourishment ; very weak, pulse small, bad, almost impossible to count.
Temperature 100°. 40 cc. Yersin subcutaneously.
15th. General state very bad, patient very restless, incontinence
of rectum and bladder, pulse not countable. Temperature lOl'S"" in
morning and 104° in evening.
16th. Coma.
11th. Died.
Post-mortem. On face, arms, legs, and most parts of body encrusted
1 " Bubonpesten i Kap," 1901. Reseherattelse af Med. Dr Ernest Levin. Stockholm,
1902.
300 Plcujuc ut the Individual [part hi
pustules. Buboes already described. Section of buboes showed a
thick, putty-like pus. Both lungs fixed to pleura with easily detached
connective tissue. Sub-pleural haemorrhage. Lower part of left lung
covered with a thin fibrinous e.xudation. On section of lower part of
left lung, small granular elevated patches of a rosy colour with a
distinct slightly depressed centre. In other part of left lung a few
similar patches noticed.
Lower lobe of right lung had also a fibrinous covering. Section of
right lung showed a grey-red, elevated, granular surface of an hepatic
appearance, and on pressure there oozed out a dirty red-yellow fluid
devoid of air.
In other parts of lung similar patches as in left. At the base of
the heart several sub-pericardial ecchymoses. Heart slightly enlarged ;
valve openings normal. In the muscular tissue of heart greyish-yellow
patches. Sj)leen not enlarged, dark red ; consistence soft and friable.
Kidneys with sub-capsular ecchymosis.
Section of kidney. The cortical substance swollen and thickened
and not distinct. Liver enlarged with fatty infiltration. Stomach and
intestines normal.
Bacteriological examination. Pus from pustules on 14th June
exhibited in direct preparation a few typical bacilli. In culture only
staphylococci. Axillary bubo, femoral bubo, heart blood and lungs
showed no bacilli in either smear preparations or in cultures.
There are two varieties of pneumonic plague. One is primary in its
Plague character, and the other is secondary or symptomatic,
pneumonia. Primary plague pneumonia is a type of the disease
in which the primary localisation of the plague bacillus takes place in
some of the lobules of the lungs instead of in the glands of the groin,
arm-pit, or neck or other glands of the lymphatic system.
Secondary pneumonia, on the other hand, develops in the course of
other ty]Des of plague and is due to a secondary infection which has
reached the lungs metastatically through the circulation or lymphatic
vessels from some other already infected centre of the body, or has,
as in the case of tonsillar plague, been inhaled into the lungs.
The clinical aspects of primary pneumonic plague are not very
distinctive, and were it not for the discovery of plague bacilli in the
sputum this type of plague may easily be mistaken for broncho-
pneumonia. Surgeon-Major Childe's description^ of the symptoms of
' Report by Surgeon-Major Lj-ons, I.;SI.S., President of the Plague Research Com-
mittee.
CH. xiv] Cases of Plague 301
the illness of Dr Manser of Bombay and of the nurse who attended
him, both of whom were attacked with plague, will, with Dr Poch's
description of Dr Mueller's illness, illustrate this type of the disease.
" With regard to the clinical symptoms of these cases, it fell to me to
Dr Manser's attend on the late Dr Manser, and as he died of this form
illness. ^f plague I will mention a few facts about his case. He
was in his usual health on January 2nd, and had a sudden rigor in the
morning and felt fever coming on. During the day a bad headache
developed, he felt nausea and vomited several times, and he had pains
and a tired feeling in his limbs ; his tongue remained clean and moist,
and his skin was slightly moist. At 2 p.m., temperature 108'4, pulse 116,
respiration 25, and there were but slight variations during the day. On
January 3rd, had passed a bad night and felt worse, and all the
symptoms persisted, except the aching in the limbs, and he felt very ill.
The temperature remained between 103'5 and 104"5, pulse about 110,
and the respirations about 23 throughout the day. During the after-
noon he felt some pain at the lower part of the left axilla just
underneath the anterior fold, but there was no glandular enlargement or
pain in the glands anywhere. On January 4th, had passed a bad night
and felt very ill, temperature 104*6, pulse 113, respiration 25, tongue
still moist, with a little fur behind, and no sordes about the lips and
teeth, other symptoms as before. During the night he began to cough
and brought up some watery sero-mucous fluid, slightly blood-tinged,
and the pain remained in the same place, only more diffused now, being
felt over an area of a square inch. At this part some moist sounds
could be heard like early pneumonia, and they could also be heard just
below the left clavicle ; the rest of the lungs and other organs appeared
to be normal, as did the lymphatic glands. Patient considered that he
had pneumonia, but the symptoms were not like ordinary pneumonia.
For the onset was different, the condition of the mouth and tongue
different, there was no dyspnoea or pneumonic disproportion of pulse and
respiration, and the sputum was not at all like rusty sputum ; for it was
loose and free, coming up with the slightest cough, it was watery, looking
more like serum than mucus, and it was slightly pink, not rusty yellow
at all. Also there was the striking fact that the patient's general
condition was far worse than could be explained by the small amount of
lung-disease present. So I examined the sputum under the microscope,
and found it full of bacilli looking like those of plague, and cultures
were made from which a pure growth of the plague bacillus was
obtained. During 4th and 5th, patient became steadily worse, his
'302 Plafjvf in titr Individual [part hi
temperature remained about 104, and his expectoration became more
profuse ; the moist sounds were heard over a larger area, as well as
slightly at the bases ; the respirations increased to 35, and then to 45,
and the pulse to 120 and 135; and he ultimately died early on
January 6th.
" There is also the case of the nurse who attended him, who un-
fortunately died of a similar form of plague. In brief she became ill on
the evening of January 7th, and showed symptoms of pneumonia on
January 8th. She rapidly became worse and died on the 10th, but her
sputum was not nearly so profuse as in the former case, and symptoms
of exhaustion came on much earlier. She also had no glandular pain or
enlargement whatever and bacteriologically her sputum was exactly as
described above. Other cases were met with in which besides plague-
pneumonia, there was also general enlargement of the glands, — plague-
septicaemia ; and clinically it was found that either the pneumonia was
primary, and the glandular enlargement secondary, or that the disease
first showed itself in the glands and later on in the lungs ; and whilst
some of the latter recovered, the former were usually rapidly fatal.
Also the sputum was not always as has been described above, for in some
cases the presence of blood in it was a marked feature, and it was either
moderate or abundant in quantit^^ These pneumonic forms of plague
are highly infectious and probably take a large share in the spread of
the disease ; for in these cases the patient's sputum is practically
a virulent pure culture of the plague bacillus, and as there is reason to
believe that many of the cases are not recognised as plague at all, pre-
cautions are not taken by the patients' friends, and the dangerous nature
of the disease is not appreciated."
Dr Poch' begins by referring to the circumstances by which
Dr MueUer's l^^ Mueller contracted the infection. On the 15th Oct.
illness. \^m, Franz Barisch, the servant of the pathological
institution in Vienna, who had been assigned to the assistance of
Albrecht and Ghon to render them service in their investigations on
plague, fell ill with the symptoms of a commencing pneumonia. His
sputum was examined by Drs Ghon and Albrecht on account of their
suspicions being aroused by his previous work, and this examination
awakened a suspicion of infection by plague bacilli.
Dr ]\Iucller who was called to examine him clinically had him
immediately removed with all precautions to an isolation ward of the
1 Ueber die BeulenpesI in litmihai/ im Jahre 1897. Vol. i. Anhang. .
CH. xiv] Cases of Plague 303
Vienna General Hospital. At the same time Dr Ghon })ersonally
superintended the disinfection of Barisch's home.
Though Dr Mueller during the first days of the illness could not
with certainty confirm a diagnosis of infection with plague bacilli he
adopted all precautionary sanitary measures and impressed on the two
nurses the greatest caution. He bestowed much attention and care on
the patient and did not hesitate to examine him repeatedly and
minutely. It was in this service that he contracted plague.
On the 18th of October, on the 4th day of the disease, the servant
died of pneumonic plague. This diagnosis was fully confirmed bacterio-
logically and clinically.
On the 20th of October one of Barisch's nurses, who in the meantime
had been strictly isolated, became feverish. On this account both of
them were taken to the isolation ward of the Emperor Franz Joseph
Hospital, whither Dr Mueller also betook himself, having of his own free
will offered himself for the treatment of the sick nurse.
On his arrival in the hospital Dr Mueller was seemingly quite well,
but on the same evening he felt continually cold, and walked up and down
the room shivering and rubbing his hands, although the room was well
heated. He complained of feeling low-spirited and had crural pains.
He also coughed, but without expectoration. He attributed this indis-
position to fatigue and a chill. The nurse attending on him formed
the impression that he was feverish and begged him to take his
temperature. This, however, he did not do. He left his supper almost
untouched and went to bed at 8 o'clock. He slept quietly and
soundly.
On the 21st of October Dr Mueller paid his morning visit to Barisch's
two nurses. He looked very pale, felt languid and lay down again
at 9 a.m. in order to rest. At this time his pulse was 110, he coughed
a great deal but brought nothing up. About midday he got up again,
but had to go back to bed shortly after. His temperature was now
taken for the first time. It was 38'2 C.
He now began to expectorate ; it was a reddish and thin fluid.
Dr Kretz who undertook the examination of the sputum confirmed the
existence of plague bacilli. Although it was sought to deceive
Dr Mueller as to the results of this examination, he himself confirmed
the diagnosis of pneumonic plague from his symptoms and held fast to
his opinion. The pulse was small, tense, the highest frequency 120.
At 2 p.m. his respiration was accelerated to 40 and regular. The fits of
coughing became more frequent and copious reddish sputum was
304
Playne In the I nd'n'idual
[part III
expectorated. The i)atient did not complain of pain. The fever at
6 p.m. reached its highest point, 408° C. Consciousness was maintained.
Digitalis and alcohol were given. He was very thirsty. He decidedly
refused an injection of plague serum.
In the course of the afternoon he had two Huid, not bloody stools.
He had a fairly good night, woke a few times, was delirious a short time ;
soon, however, fell asleep again.
On the morning of October 22nd the conjunctivae of the patient were
much reddened. He was unconscious and noisy delirium set in. Speech
Dr MUELLKK
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was woolly and in<listinct. Large cpuxntities of ri'ddish Huid s})utum
were brought u\) in frequent short fits of coughing. On this day
Dr Mueller took no solid nourishment. He had a second dose of
digitalis and a good quantity of alcohol. In the afternoon he com-
CH. xi\ ] Cams of Plague 305
plained of pain in his chest and asked for morphia. He, however,
hardly took a third of what was ordered him, the pains having in the
meantime diminished. At (J p.m. the respiration was quickened and
very difficult, frequency 59. Cyanosis set in. The fits of coughing
became more frequent still and rattling with a quantity of bloody
expectoration. There were no skin haemorrhages or glandular
swellings. In the afternoon he had 4 thin, not bloody stools, with
accompanying pains. Consciousness was dulled. When the thermo-
meter was applied Dr Mueller awoke out of his somnolent condition
and began to count pulse and respiration. He made frequent mistakes,
and began to count anew until he came to a result. At 10 p.m. the
temperature sank to 37 '8 and fin- a short time consciousness was again
clearer. Then again great restlessness and delirium set in.
Oil the 23?yZ of October at 1 a.m. Dr Mueller stood up and walked
up and down the room with help, then he lay down again and went to
sleep. Later he woke again and passed urine. There were never
involuntary motions or urinating.
At 4< a.m. the temperature was 38° C, breathing was difficult, cyanosis
had increased.
At 4.15 a.m. rattling in the throat began, bloody mucus poured in
quantities from the mouth and at 4.30 a.m. death set in.
20
/
CHAPTER XV.
DIAGNOSIS AND PROGNOSIS.
In the majority of cases there is no difficulty in the diagnosis of
plague. The sudden onset, the severe headache, the
Diagnosis piddiness, the high fever of a remittent type, with hot
generally not . . ^ jt '
difficult in a dry skin, the drawn and anxious face, the red and con-
of pTague^^^ gested eyes without photophobia, the flushed countenance,
the stuttering, thick and indistinct speech like that of a
drunken man, the coated tongue red at the ti}) and edges, the staggering
gait, the incoordination of the voluntary muscles, the desire to wander
about, the quick feeble pulse, the hurried respiration, the rapid develop-
ment of cerebral sym])t(>ms, the heavy drowsy and stupid mental condition,
and the formation of a bubo or buboes in the region of the lymphatic
glands present such a clear picture of plague that the disease may be
readily recognised by a careful observer who is on the alert as to the
possible occurrence of plague.
The bubo which is the most characteristic symptom may at the time
of examination not be in evidence. The bubo generally appears within
24 h(jurs but may be delayed till the third, fourth, or fifth day and in
some exceptional cases even longer, the other sjanptoms being well
defined. In some cases the affected glands do not form buboes, but
are usually recognisable from their exquisite tenderness when touched ;
in other cases they are deeply situated and it is only by strong pressure
over the parts that they are detected. When the clinical symptoms
indicate plague, and yet there is no bubo in the groin, arm-pit or neck,
a careful examination of the abdomen often reveals a bubo in the iliac
or lumbar region.
In milder cases when some of the symptoms are absent, and es-
])ecially when consciousness and a clear intellect obscure the character
of the disease, the ])ulse is of valuable assistance as a guide to diagnosis.
CH. xv] Diagnosis and Prognosis 307
It is rapid and feeble, and out of all })roportion to the condition of the
patient.
Before this pandemic the diagnosis of plague had to rest on the
clinical symptoms, but now to these is added the bacteriological test.
Bacterio- ^J puncturing the bubo even at its earliest stage a small
logical test. quantity of the gelatinous contents can be sucked out with
a sterilised glass pipette guarded at the mouth end by sterilised cotton
wool. If the contents so obtained are then spread out on a glass slide
or cover-glass, gently heated as in the ordinary preparation of a micro-
scopical specimen, coloured with carbol fuchsin or gentian violet, and
then examined by a -^^ oil immersion lens, the field will be seen to be
covered with cocco-bacilli or diplo-bacteria, large numbers of them being
more deeply stained at the ends than in the centre. No other disease
with swollen lymphatic glands presents microbes such as these. Their
presence is sufficient to arouse the greatest suspicion at any time, and
the material ought to be taken at once to a laboratory where the bacilli
can be cultivated and the confirmatory tests applied. When plague is
known to prevail in a country the discovery of bacilli by microscopical
examination, combined with the clinical features, is sufficient to make
the diagnosis of plague a certainty.
In cases in which the bubo has suppurated the pus only exceptionally
contains plague bacilli and the diagnosis must then rest on the clinical
features considered as a whole, together with the specific agglutination
test of the blood.
The serum test, however, is one not of much practical utility owing
The serum ^o the fact that frequently no reaction is given with the
test. blood of patients convalescing from plague, and to the
further fact that in an ordinary culture of plague bacilli the microbes
are often so massed together that an extra clumping by the aggluti-
nating process of the serum is difficult to recognise. The Indian Plague
Commission' in summing up their experience on this subject came to
the conclusion that " no practical value attaches to the method of serum
diagnosis in the case of plague."
On the other hand^ Cairns in the Glasgow epidemic found by a
series of careful experiments that if agar cultures are emulsified with
sterile 0'75"/o salt solution a homogeneous emulsion of the plague
bacillus is obtainable and that the sedimentation test under these
1 Report of the Indian Phujue Commisaion, Vol. v. chap. iii. p. 68.
- Report on certain Cases of Plague in Glasgow in 1900. By the Medical Ollicer uf
Health.
20—2
308 Flafjm in the IndlvUhial [part hi
conditions gave good results and that the diagnostic vahie of the
reaction became more apparent during and subsequently to the stage
(tf convalescence when the possibility of a bacteriological diagnosis is
more or less remote.
The absence of lymphangitis connected with the bubo serves as
„^ ^ a diagnostic point in favour of its being a plague bubo
The absence » ^ . i i
of lymphan- owing to the fact that the microbe of plague very seldom
^^ ^^' leaves any trace of local reaction at its point of entry. In
cases in which a pustule does appear at what may be considered the
point of entry, bacteriological examination shows in the case of the
plague pustule plague bacilli which at once differentiate it from a
malignant pustule or from a septicaemic pustule with lymphangitis,
the cultures of which will show^ streptococci.
The difficulty of clinical diagnosis arises chiefly in recognising the
Chief diffl- several forms and types which the disease assumes, and
cuity arises more particularly is this the case with the ambulant,
from the Pro- . . :; . ■ ^ ^ ^
tean charac- se})ticaemic, and pneumonic types without buboes, as
ter of plague. ^^,g}j .^^g ysnth the tonsillar form associated with cervical
buboes.
If there is no suspicion of plague and no bacteriological examination
made, the clinical features and even the post-mortem appearances may
be attributed to some other disease. The events wdiich occurred at
Paraguay in connection with plague illustrate that which may occur
under any circumstances in which plague has never been seen before.
The first case at Asuncion showed a glandular enlargement and some
obscure lung affection, death being attributed to disease of the lungs.
The second case showed symptoms believed by one medical man to be
those of acute gastritis and by another to be those of a general affection,
possibly yellow fever. It was because of this latter opinion that several
distinguished physicians were sent to attend the post-mortem examina-
tion in order to decide the question, as it was of importance that if the
disease were yellow fever, precautionary measures to prevent its spread
should be immediately adopted. The necrops}- revealed general con-
gestion of the internal organs, haemorrhagic swellings in the spleen, an
enlarged liver, and an acute gastro-enteritis. The conclusion arrived at
was that it was not a case of yellow fever. No one, however, suspected
plague, which was unknown in America and which w-as not known to be
nearer than Egy])t. The third case, which came off the same ship, was
that of a sailor who went to a small village at some distance from
Asuncion. He was taken ill there and five months afterwards, on his
CH. xv] Diagnosis and Prognosis 309
return to Asuncion he was found on examination to have the signs still
on him of buboes characteristic of plague. The three cases are
excellent examples of the uncertainty of the diagnosis of plague when
no suspicion of plague is in the mind of the medical man. The true
significance of these cases in Asuncion was not realised until five months
afterwards and then only when a new disease, distinguished by symptoms
resembling typhus fever, meningitis, and pneumonia, and frequently
accompanied by glandular enlargements in the groin, axilla, or neck, had
appeared and prevailed, first of all in a sporadic form in the town for
about two months, and later in an epidemic fijrm in the barracks. Only
gradually was the suspicion aroused that the disease might be plague,
and once that suspicion became general, the discovery, isolation, and
culture of the plague bacillus, the classical symptoms of plague which
many of the cases presented, and the no less characteristic anatomical
features which were observed at the post-mortem examination cleared
away every possible doubt. In an investigation which followed this
discovery no difficulty was experienced in tracing the new disease back
to its commencement ; nor was there any difficulty in recognising the
symptoms and post-mortem appearances, which had perplexed the
medical men six months previously, as belonging to true cases of
plague.
The ambulant form is apt to be overlooked from the mildness of the
Ambulant symptoms. Slight fever, malaise, headache and congested
plague. gygy have nothing characteristic about them to indicate
such a grave disease as plague, and a glandular swelling may occur
under other circumstances, such as syphilis, mumps, and abrasions,
wounds, or ulcers with sympathetic glands. It is only possible by
a process of careful exclusion combined with a history of the case and
a knowledge of plague being in the neighbourhood, that suspicion may
be aroused, and it is only by bacteriological methods that a reliable con-
firmation of the suspicion can be obtained. Microscopical examination
is not sufficient, but must be supplemented by cultures of the contents
of the bubo and by inoculation of animals. The inoculations are
performed in one set of animals with the pure cultures obtained and in
another set by the crude contents of the bubo. The latter method,
however, is not a reliable one for isolating the plague microbe if mixed
with other bacteria. In attempting cultures from the blood the best
results are obtained when comparatively large quantities such as 1 c.c.
or 2 c.c. are employed. The medical practitioner has seldom the time or
the apparatus for a complete bacteriological examination, which in cases
310 Plague in the fnflividnal [part m
of this kind should be delegated to the bacteriologist of the local
authority.
The illness is sometimes of a short duration and sometimes of
a chronic nature, and some of the symptoms may be absent. Fre-
quently towards the termination of an epidemic diffuse swellings over
the cervical and parotid glands with or without fever, together with
quick pulse, drawn face and hesitating speech, occur in persons who have
been associated with plague persons or plague houses. These cases
occurring at the end of an epidemic do not present the same difficulties
as ambulant cases at the commencement of an epidemic. Such cases
were observed in Bombay and in Cape Town.
In the fulminating, septic and pneumonic types of the disease, in
which no buboes may be found, an examination of the blood and sputum
for the characteristic bacilli is the chief diagnostic test. In fact in all
cases that are clinically obscure bacteriological examination is needed
to elucidate them.
In the septic type the bacilli early invade the blood and the patient
is prostrated with the intensity and amount of the poison
Septic type. . i • i • i
which has penetrated into the system. Besides the common
symptoms belonging to all forms of plague this type is characterised by
a pallid and a])athetic expression and a rapid setting in of extreme
nervous jirostration, delirium, coma and death, the patient often suffering
from haemorrhages from the nose, kidneys, or bowels. In the less rapid
septicaemic cases, besides the detection of plague bacilli in the blood,
plague bacilli Avill be found occasionally in the urine, and in the
expectoration of those with hyjjostasis of the lungs and of those with
secondary pneumonia. It is a type of disease which is very apt to be
overlooked. The absence of buboes, the normal or subnormal tempera-
ture in the morning in some cases and the rise of temperature to not
more than 100'' or 101^ are not symptoms which readily raise suspicion
as to plague. There are other cases in which a sharp attack of diarrhoea
is the most evident symptom. There are other cases again in which the
patient is attacked with fever of a remittent type without showing the
pulse, tongue, or characteristic appearance of a plague patient, and the
bubo if any appears is delayed to the 7th or 8th day. Yet any of these
may die suddenly and it is only the sudden death which attracts
attention.
Pneumonic ])lague is specially apt to be overlooked, its ])hysical signs
Pneumonic being often ill-defined. During an epidemic of plague
plague. cases of pneumonia should be viewed with suspicion
cii. xv] Diagnosis and Prognosis 311
especially if associated with enlargement of the spleen. In the
pneumonic type the bacilli are to be detected in the sputum, the disease
localising itself first in the lungs. The symptoms are those of a
broncho-pneumonia with much greater prostration. Dyspnoea, cough
and expectoration of a watery fluid tinged with blood are the chief
clinical features. The absence of any well-marked and special physical
signs of serious lung mischief which would account for the gravity
and rapidity of development of the general symptoms is a feature that
should raise suspicions as to the possibility of primary plague pneumonia.
The sputum of all respiratory affections during an epidemic of plague
should be examined bacteriologically and tested by inoculation on
animals for plague bacilli.
The difficulty connected with the diagnosis of pneumonic plague
will be seen from the following case recorded by Dr A. C. F. Halford' of
Brisbane which was provisionally diagnosed as measles.
" Aged 30, living at South Brisbane, was admitted to the Brisbane
General Hospital on the 4th June, 1901. The patient was quite well
until the 28th May, 1901, Avhen he complained of headache and feverish-
ness. Next day he complained also of chilliness, headache, feverishness
and weakness. He continued in the same condition until the 1st June,
when he got up and went for a walk, feeling better. He had on some
previous occasions suffered from fever contracted in New Guinea, and
put his present illness down to the same cause. He got worse again
that night, and remained in bed all the next day. On the 3rd he com-
plained of pains all over his body. On the 4th the pains were more
severe and the breathing became rapid and his voice husky. He Avas
seen by a medical man who noticed a rash like that of measles about
the body, but more especially marked on the arms. The eyes were
injected and the patient had a slight cough. A provisional diagnosis of
measles was made, and the patient removed to the General Hospital.
On admission his temperature was 103, pulse 140, and respirations 60.
No bronchial breathing could be detected, but there were moist sounds
from base to apex on both sides. He only lived a few hours in the
hospital but he had no serum, and at the post-mortem examination the
whole of both lungs were found extensively consolidated. The bronchial
glands were enlarged and blackened with haemorrhagic inflammation.
No enlarged glands were found anywhere else, nor was there any other
macroscopic changes noted in the other organs. Smear preparations
' Report on 117 Cases of Plague occarriinj in Brisbane. By the Medical Officer to the
Metropolitan Joint Board for the Prevention of Epidemic Disease, Brisbane, 1902.
312 Plarfue in fltr hnlirhhial [part hi
from the affected lungs .showed presence of innumerable plague bacilli
apparently in pure culture. An infected rat was found at the place of
his employment."
In those cases of pneumonic plague in which there is only slight
cough and no sputum, it is impossible at an early stage of an epidemic
to form more than a suspicion until either the further development of
lung symptoms with expectoration gives an opportunity of detecting and
isolating the plague bacillus, or the death of the patient allows of
a post-mortem examination. During an epidemic it is safer to class
all doubtful cases as plague provisionally. If during the epidemic of
plague there is also a prevalence of influenza, some of the latter cases
Influenza and '^^^J resemble so closely plague cases without buboes, that
plague. even the most experienced physician may be unable to
differentiate the one from the other, and the diagnosis has to depend
on the bacteriological examination of the sputum and the blood. The
possibility of the two diseases occurring together in the same patient is
not to be overlooked.
The tonsillar variet}' of plague which is generally associated with
Tonsiiius buboes in the neck may be mistaken for diphtheria, as
plague. ^y;^g ^\^Q pr^gy jjj Bombay. The bacteriological examination
of the sputum and of the exudative coating on the tonsils will readily
differentiate the diseases. If plague bacilli are not found in these
materials, puncture of the enlarged gland or bubo, and examination of
its contents will be necessary.
In the pustular variety of the disease plague bacilli are generally
found in the pustules, but care has to be taken that the plague
microbes are not overlooked as they are sometimes present in these skin
eruptions in the atypical or degenerative forms.
Plague has been mistaken for malaria, typhoid, and typhus fever,
typhlitis, meningitis, pneumonia, diphtheria, influenza, relapsing fever,
syphilis and filariasis with enlarged glands. It has occurred in con-
junction with most of these, so that the discovery of the special
micro-organism, if any, of these diseases, does not exclude plague unless
the microbe of plague has also been searched for and not found.
The prognosis of plague in a particular individual depends on
a number of circumstances, such as the race and age of
Prognosis. . , , °
the person attacked, the period of the epidemic when
attacked, the variety of plague, and the degree of reaction which the
patient manifests against the disease. In the existing epidemic a
white person always has a better chance of recovery than a coloured
CH. XV]
Diagnosis and Proffuosis
313
person. Taking general averages it may be stated that of white people
attacked two-thirds recover, while of coloured people attacked two-
thirds die. Children between 5 and 10 years of age usually have
the lowest mortality, and persons attacked during the decline of an
epidemic have a greater chance of recovery than those attacked when
the epidemic is on the increase. The variety of plague also makes a
difference. Pneumonic plague is very serious and generally ends fatally.
Septicaemic plague is also of a very grave character and the prognosis
is most unfavourable. In the bubonic type the situation of the buboes
exercises an influence on the gravity of the illness. Axillary buboes
have the highest mortality, femoral and iliac the next, and cervical the
next. The order of the three latter may be reversed. Dr Choksy^
analysing 9500 cases treated in Bombay gives the subjoined relative
mortality according to (a) the type of the disease, and (6) the situation
of the bubo in lyicomplicated bubonic cases.
(a)
Simple Bubonic Plague
Septicaemic Plague ...
Pneumonic Plague
Cellulo-cutaneous Plague
Axillary
Cervical
Inguinal
Multiple
Femoral
Other situations
Parotid ...
(6)
Mortality
77-25%
89-62
96-69
62-00
Mortality
81-29 "/o
78-87
77-62
75-87
72-56
71-42
70-34
Major W. E. Jennings- gives a detailed analysis of 16,132 bubonic
cases and the regional case mortality. They are as follows : —
Cases Mortality
1712 78-0 7o
1866 ' 77-1
2429
2539
1922
1988
1006
2207
463
Left axillary...
Eight axillary
Left femoral
Right femoral
Left inguinal
Eight inguinal
Cervical
Multiple
Parotid
The Treatment of Plaijue bij Pro/
75-4
72-3
71-7
70-1
70-5
70-0
68-6
fesnor l^ustig'x Serum. By N. H. Choksy, M.D.
2 A Manual of Plaijuc. By W. E. Jennings, M.B., CM., Major Indian Medical
Service, 1903.
314 Plague in the Indk'idual [part hi
Of cases admitted into the Paivl Hospital, during the Bombay
epidemic of 1890-97, Major G. S. Thomson, I.M.S., gives the following
details^ : —
Mortality Men Women fliildren Boys Girls
64-5 »/„ C8-6% 71 7o ^S-S'/o ^2-5 »/o Gl-SO/o
Situation MorUlity
of bubo Total Percentage Males Females Died Recovered percentage
Eight axilla 47 loo 30 17 34 13 72-4
Left axilla 32 10 o IG 16 24 8 75
Right femoral ol) 19-6 45 14 33 26 56
Left femoral 31 10-2 18 13 14 17 45-2
Eight inguinal 17 5 6 11 6 10 7 59
Left inguinal 32 10 -5 25 7 21 11 65-6
Eight cervical 8 2-6 7 1 6 2 75
Left cervical 4 13 2 2 2 2 50
Eight parotid 7 2-3 3 4 5 2 71-4
Left parotid 1 0 3 1 — — 1 —
Multiple 24 7-9 15 9 14 10 58-3
No buboes 42 13-8 29 13 33 9 78-6
The utmost circumspection has to be exercised in giving an opinion
Caution as ^^ ^^^ future course of the illness as there is no disease so
to prognosis. deceptive and so likely to mislead the physician. Patients,
who to all appearances are in a state of convalescence or whose symptoms
are mild and augur a speedy recovery, may suddenly die of heart failure
with or Avithout some slight exertion in getting out of bed, or they may
suddenly develop secondary infection of other glands or organs, or fall
into an apathetic or marasmic condition ; or patients with the gravest
of symptoms whose condition seems hopeless may suddenly and un-
expectedly improve and rapidly convalesce. A good pulse not more
than 120 or 130 per minute in the acute stage, absence of acute cerebral
disturbance, or of dyspnoea, and a rapid development of the bubo with-
out extensive infiltration are collectively favourable signs ; so is absence
Favourable ^^ albumen from the urine and presence of chlorides ; also
sigiis. constipation or a few loose motions a day Avithout diarrhoea.
Suppuration of the bubo is also favourable, as it indicates that the
patient has successfully passed through the first (j or 7 days, which is
the most dangerous period. In Hongkong Wilm showed that 75 "/o of
the deaths occurred within the first 6 days, and this may be taken as the
general rule.
1 A Treatise on Plague. By Major George S. Thomson and Dr John Thomson, 1901.
CH. xv] Diagnosis and Prognosis 315
Among unfavourable signs are great frequency of the pulse and
Unfavourable respiration from the commencement of the illness ; high
si&iis. temperature which continues or a sudden fall of tempera-
ture with collapse ; or a secondary rise which is much higher than
the primary ; continued insomnia ; early and violent delirium ; sub-
sidence of the bubo within the first 4 or 5 days, or sudden and ex-
tensive infiltration around the bubo ; severe vomiting or continuous
diarrhoea, tympanitic flatulence, convulsions, haemorrhages from various
channels ; cyanosis, suppression of urine, the setting in of secondary
infections ; dicrotic and almost uncountable pulse.
The discovery of plague bacilli in the blood in large numbers is
always a sign of great gravity.
CHAPTER XVL
TREATMENT.
Cl^RATiVE medicine is powerless to combat the powerful and rapidly
disintegrating forces at work in the system in a virulent
treatment ^^^® ^^ plague. The post-mortem appearances render it
powerless in too plain that no mode of treatment as yet known to the
the most , • • t i rv
virulent physician can prevent or neutralise the etiects oi the
forms of plague poison. In the mildest forms at the other end of
the scale treatment is seldom required and the patients
recover with or without medicine.
It is between these two extremes that medical treatment may be
beneficial, but how much of the cure in successful cases is due to the
treatment and how much to nature it is often impossible to estimate.
Many modes of treatment have found favour in plague, and often
the most opposite in kind. Thcii- multiplicity throws a certain doubt
on their value, especially as the mortality of plague varies much in
accordance with the virulence of the virus, the period of the epidemic,
and the race and age of the person attacked.
Before considering the modern mode of treatment and its results, it
Treatment of ^'^ desirable to glance over the several methods in vogue in
plague in the earlier epidemics. It will serve, at least, to pr-event
them from being resorted to again with exaggerated hopes
of success, and it may at the same time prevent an undue estimate of
the value of those in use at the present time; for all of them, not-
withstanding the energy with which they have been applied and the
apparent benefit derived from them at times in some epidemics, have
more or less signally failed at other times in the same epidemic, or in
others. The general average mortality belonging to the epidemic never
seems to have been reduced to any great extent.
CH. xvi] Treatment 317
Bleeding has been practised since the time of Galen, who appears
to have recovered from the disease after scarifying his
Bleeding. ^ • ^ ^ • ■ J <=>
thighs and drawing off a large quantity of blood. Syden-
ham attributes his own success to bleeding, though, as a matter of fact,
he was in London only when the disease was declining and assuming a
milder form. Both Hodges and Boghurst, who practised throughout
the whole epidemic, agree in stating that treatment by bleeding was
most destructive and pernicious, to which Boghurst adds the employ-
ment of emetics and purgatives.
Bleeding was employed largely in the epidemic of Egypt of 1834-35
without any satisfactory results, Aubert, alone, reporting favourably
upon it, when combined with other treatment. Leeches have also
been used either alone or with bleeding, to relieve congestions, but
in many cases it was found difficult or impossible to arrest the bleeding
from the wound inflicted by the bite of the leech. Bleeding was also
in some cases combined with emetics, diaphoretics and blisters. Emetics
and quinine were tried in the Moscow epidemic. Evacuants, purgatives,
The evacuant calomel, inunction of mercurial preparations have been
treatment. tried, only in turn to give way to other drugs. Stimulants,
sudorifics, and an occasional bleeding were resorted to in the Marseilles
epidemic.
Stimulants, such as ether, ammonia, camphor, musk, brandy, wine.
The stimulant sarsaparilla, coffee, etc. have been largely used alone or
and tonic combined with tonics. Strychnine has been pushed to
a dangerous extent with the object of counteracting the
paralysing effect of the plague poison on the nervous system. Often
antiphlogistic, tonic, and stimulant treatment was employed according
to the stage of illness or degree of severity of the case.
Oil frictions enjoyed a great reputation at the end of the 18th and
Oil friction beginning of the 19th century. Assalini referring to this
treatment. mode of treatment says ^ :
" It has been observed that those people who manufacture or carry
oil are never attacked with plague. Hence it has been maintained that
frictions of tepid oil prevent or cure this disease. The result of the
observations made by father Louis of Padua, director of the hospital
for the plague at Smyrna, is the most favourable. He asserts that
^ Observations on the Disease called the Plague. By P. Assalini, M.D., one of the Chief
Sm-fjeons of the Consular Guards. Translated from the French by Adam Neale, of the
University of Edinburgh. London, 180-i.
318 Plague in the Individual [part iii
during the 27 years he has been in this situation he has seen no means
employed against the disease more useful than the friction of oil, and
to this day in Smyrna and several lazarettos in the Levant frictions of
tepid oil are generally adopted as the best remedy. As soon as a
patient attacked with the plague is received into the hospital in
Smyrna he is taken into a close chamber, where they light a large
pan of coals in which they throw sugar and juniper berries or other
perfumes, they then strip off all his clothes and rub his whole body
witli warm oil until profuse sweats break out. The patient is then put
into bed; and whenever the sweating ceases they repeat the friction in
the same manner, and so on successively during several days until the
disease has spent its violence in consequence of the sweating. One pint
of oil is sufficient for each friction, taking care not to commence the
second before the sweating occasioned by the first has ceased.
" In the space of 5 years 250 persons infected with plague have been
received in the hospital of Smyrna, and I am assured that all those who
were thus treated have recovered, and that the number of persons
preserved from the plague by frictions of oil is immense."
The buboes and carbuncles have been subjected to many different
Treatment kinds of treatment. They have been incised, blistered,
of buboes. .^jd cauterised with the object of hastening their develop-
ment on the })rinciple that the sooner they reached maturity the
earlier would the virulence of the disease diminish, for it was noticed
that with the suppuration of the buboes and the maturation of the
carbuncles the patients began to convalesce. A sign of the acute stage
of the illness being nearly at an end was evidently mistaken for the
cause producing that happy termination. The only occasions on which
the knife is found to be useful are when pus has formed in the bubo and
when masses of necrosed glands are lying in suppurating buboes.
In contrast to the different kinds of active treatment was that which
Cold water confined itself to the giving of the patient cold water,
treatment. lemonade, acidulated drinks, or rice water. It possessed,
at all events, the merits of simplicity and its advocates claimed their
successes.
In 1762, on the theory that the pestilential virus was an alkaline
Su z ted ferment exalting and decomposing the humours, it was
antiseptic suggested that after a purge ^ one or tw^o drops of an
antiseptic capable of neutralising this alkali and rc-
1 Papon. J)e la Peste, 1801, p. 141.
CH. xvi] Treatment 319
establishing equilibrium should be cautiously injected into the veins
of the patient. This suggestion apjjears never to have been carried
out in practice, but it is interesting to recall it, when the hopes of the
physician now mainly rest on intravenous injections of serums having
for their object the neutralisation of toxines in the blood.
To-day plague, as a disease, is viewed as the manifestation of
a struggle between the natural powers of the person
Basis of the . . i i i ^ i • i r i i . , ^
present day attacked and the virulence of the plague microbe. On
treatment of this basis medicines are administered to maintain the
plague.
strength ot the patient, who is also carefully nursed with
the same object in view. Then serotherapy is employed, having for its
object the neutralisation of the toxines and the destruction of the plague
bacillus ; or drugs with disinfecting properties are given to destroy the
microbe and prevent its multiplication.
The serum treatment of plague dates only from the discovery of the
Attempt at plague bacillus, and it appears a rational one if the theories
specific treat- on which it is based are correct, the chief of which is that
a specific antidote is obtainable from the serum of animals
inoculated with the bacillus of the disease.
Serum was prepared by Yersin, Roux, Calmette, and Borrel by the
same methods as were employed by Behring- in his pre-
Observations . .,.,,.. •'^ '' . , . .
on the sera parations of antidiphtheritic serum, horses being mtra-
preparedby venouslv injected in order to obtain the antidotal serum.
Yersin. Roux, - •'
Calmette, and Serum thus prepared was first employed in China by
Yersin, in whose hands it gave some marvellous results ;
Amoy. . .
the mortality in 26 cases treated, 3 in Canton and 23 at
Amoy, being only 7 "/o- Of the 23 Amoy cases 12 were treated in the
first and second day of their illness and all rapidly recovered without
their buboes suppurating ; 7 were treated on the third and fourth day
and they recovered slowly wdth suppurating buboes ; 4 were treated on
the fifth day of illness and 2 recovered. There was accordingly no
mortality among those treated during the first 4 days, and a mortality
of 50 "/o when the patients did not receive treatment until the fifth day.
The dose of serum injected subcutaneously in the last cases was from
60 to 90 c.c.
Yersin was invited to Bombay. Fifty cases were treated by him,
but the results were not nearly the same as those obtained
Bombay. ^• n ^
at Amoy. Ihe mortality of the cases treated was now
34 "/„. Analysed, the details are as follows :
320 Pkifjae in the Ijidiridual [part hi
17 treated on first ( 15 recovered ] , ^„ , ,.,
1 f u 111) I 1-0 uiortality.
daj' of illness [ 2 died j
17 treated on second f 11 recovered 1 .,^n , i-.
, „.„ I <-. r 1 r ^^ '0 mortality,
day of illness [ G died j
12 treated on tliird f C recovered 1 .„„, ^ ,.,
1 f -11 \ f r J i ''0 '<• "loi'tiility.
day of illness [ G died J
lay
■eati
day of illness
treated on fiftl
day of illness j
3 treated on fourth | 1 recoveredl ,
, ,. , ^ GU7o niortahtv.
2 died J
1 treated on fifth i , ,. ,
1 died.
Karad
In the same epidemic at Bombay the German Commission treated
26 cases of plague with Yersin's serum with the result that 13 died and
13 recovered, which gave a mortality of 50 "/o-
11 treated on first ( 5 recovered 1 ^ , . „, ,.
day of illness j 6 died | ''^^'o "A, mortality.
9 treated on second ( 4 recovered "1 „ „ . . , , . ,
1 r J- J r '^'^ A) mortality.
day of illness [ 5 died J
6 treated on third f 4 recovered ! „^„„, , ,.,
„ .„ - ,. , i 33-3 ",, mortality.
day of illness ( 2 died j ' " ^
In Karad Dr Simonds treated 32 cases with serum, of which 21 died,
giving a mortality of 65"5 "/o- Of the 32 cases 27 were
bubonic, the details of which are subjoined ^
2 treated on first ( 1 recovered ] ^^„, ....
„ .,, i . ■,■ ■, y ^0% mortality,
day of illness ] 1 died j " ^
17 treated on second f 5 recovered ) ^^„, , ,.,
,.••., i -.r. T 1 r "0% mortality,
day of illness | 12 died J '" "^
5 treated on third f 1 recovered 1 ,-^n, ^ ,.^
-^ , r ^ r 8^ 7o mortality,
day of illness I 4 died J
3 treated on fourth f 1 recovered 1 ^„„,w ,.^
- . ... i ^ ,. , \ 66-6 "/n mortality,
day of illness ( 2 died J '^ "^
In Karachi Dr Simonds treated 51 cases with serum, of which 37
Karachi. died, giving a mortality of 53 "/u-
9 treated on first f 5 recovered ) , , , „, , ,..
„ .„ { ,. , y 44-4 "A, inortahty.
day of illness ) 4 died J '" ^
28 treated on second f 14 recovered 1 .„„, , ,.^
. .,, - , . T 1 f *^0 7o mortality,
day of illness t 14 died J
' Report of the Indian Phujue CommUsion, chap. v. p. 303.
CH. xvi] Treatment 321
42-1 o/o mortality.
19 treated on third J 11 recovered )
day of illness ( 8 died /
10 treated on fourth J 2 recovered
day of illness \ 8 died
3 treated on fifth { 1 recovered
day of illness | 2 died
1 treated on sixth
day of illness
80«/o mortality.
66% mortality.
I
1 died.
In Cutch, Mandvi, Capt. Mason, R.A.M.C, treated 100 cases with
sennn with a case mortality of 59 7o' ^^^^ i^ appears that the treatment
was applied during the 4 months of a declining epidemic.
The results obtained in the observations made by the Indian Plague
Commission showed but a very small balance in favour of the Yersin
treatment, and they conclude that on the whole a certain amount of
advantage in all prcjbability accrued to the patients injected with
Yersin's serum.
In Oporto Drs Calmette and Salimbeni^ treated with serum in 1899,
from the 3rd of September to the 18th of November, 142
cases of plague, 140 in hospital and 2 in the town. Of
these 21 died, which is equal to a mortality of 1478 7o- During the
same time there occurred in the town 72 cases of plague which were
not removed to hospital and not treated with serum. Of these 46 died,
which is equal to a mortality of 63'7 7o- The details are as follows :
Cases
Deaths
Mortality
3rd Sept.
—30th Sept.
Hospital
28
2
7-14%
Town
26
16
61-57
1st Oct.-
-•28th Oct.
Hospital
90
14
15-5
Town
28
15
53-57
29th Oct.
— 18tli Nov.
Hospital
24
5
20-83
Town
18
12
66-65
These results more nearly approach those first obtained by Yersin.
It is possible that the efficacy of the serum depends largely on its mode
of preparation. The serum used at Oporto was obtained by injecting
horses first of all with dead cultures and then with living cultures which
had been raised in virulence. Greater success was obtained in Oporto
when the serum was used in large doses and when employed intra-
venously. At the beginning of the illness or as soon as the patient
1 AnnaUi de I'Institut Pasteur, tome xiii. Dec. 1899.
« 21
322 Plague lit tlic ln(lirklual [part hi
came under observation an intravenous injection of 20 cubic centimetres
of the serum was given, followed by two subcutaneous injections of 40
cubic centimetres each in the first 24 hours, and subcutaneously of from
10 to 20 cubic centimetres or 40 cubic centimetres on the next and
subsequent days until the temperature fell to normal, and even for two
days afterwards. Dr Calmette and Dr Salimbeni report that no ill
results ensued from these injections further than an occasional erythema
and articular pains, which were no more intense after the intravenous
than after the subcutaneous injections.
In the few Glasgow cases in which Yersin's serum was tried intra-
venous injections seemed, in most cases, to produce a
marked therapeutic effect, except in those cases in which
double infection existed from the beginning of the illness^.
In Cape Town no precise data were kept regarding this mode of
treatment but the results were not so marked as to
Cape Town. , • i • • • -^ /«
produce any special impression in its tavour.
In Natal 61 cases out of 124 admitted to hospital are recorded as
havinof been treated with serum, of whom 33 died, making
Natal . .
a mortalit}' of 54 "/o ; while of 63 cases not treated with
serum 39 died, giving a mortality of 62 7„'. It is remarked, however, by
the Medical Officer of Health that the administration of the serum was
withheld in 10 cases owing to the patients being moribund on admission.
Perhaps a more potent factor of the apparent better results of the serum
was that this division included all the white patients admitted, number-
ing 14, of whom 3 died. When these were excluded and the results
from its use among natives were compared they are no longer favourable
to the serum.
Thus, 47 cases were treated with serum, of whom 30 died, which is
equal to a mortality of 63"82 "/o ; while 63 cases were not treated with
serum, of whom 39 died, which is equal to a mortality of 62 "/q.
In Hongkong no favourable results have been observed at any time
from the -use of Yersin's treatment. In 1902, 94 cases
were treated in the Kennedy Town Hospital with Cal-
mette's serum, with a mortality of 85"1 Vo- The details are as follows' :
^ Report on certain Cases of Plague occurring in Glasgoic in 1900. By the Medical
Officer of Health.
- Report on the Plague in Natal, 1902-3. By Ernest Hill, M.E.C.S., D.P.H.
' Report on Plague Cases treated in the Kennedy Town Hospital, Hongkong. By
J. C. Thomson, M.D., 1903.
cii. xvi] Treatment 323
Treatment
Cases
Deaths
Mortality
Europeans
3
1
33-3 o/o
Portuguese
1
1
100
Chinese
80
73
91-3
Other Races
10
5
50 0
94 80 85-1
In the same hospital the mortality of cases treated in the ordinary
way was :
1894
1896
1898
1899
1900
1901
76»/o
74"/,,
81-80%,
81-8%
770/0
76-5 »/o
When again the results of the serum treatment are compared with
those obtained in the hospital in Hongkong during the first epidemic
of 1894 before the plague serum was devised, it will be seen from the
subjoined statement that there is not much to choose between the two.
Affected
Died
Mortal
Europeans
11
2
18-2
Jajmnese
10
6
60
Manila men
1
1
100
Eurasians
3
3
100
Indians
13
10
77
Portuguese
18
12
66
Mahiys
3
3
100
West Indians
1
1
100
Chinese
2619
2447
93-4
It is thought possible, however, that if the serum were made locally
and used fresh better results might be obtained.
On the other hand in Brisbane" its efficacy was considered undoubted
when given intravenously and in large doses. There were
no fulminant or septicaemic cases in Brisbane. Its ad-
ministration in the ordinary bubonic cases was followed by a sudden fall
of temperature, a moist skin and profuse perspiration, also by improve-
ment of the mental condition, and of the pulse and respirations.
In 1900 of 56 persons suffering from plague 25 died, yielding
a mortality of 44'6"/o; no scrum was then available. In 1901 of 29
cases treated with serum
20 recovered] ^^.^^, . y.
^ ,. , \ 1 7 2 7o mortality.
5 died j
1 The Epidemic of Bubonic Plarjiie, 1894. By James A. Lowson, M.D.
'- Report of 117 Cases of rUKjue in sporadic form in Brisbane. By A. C. F. Halford, M.D.,
Medical Officer of Health.
21-^2
824 Plague In the Tiulividual [part hi
In 1902 of 65 cases treated with serum
•^VT'''''H 13-8 Vo mortality.
9 died I
It would appear that the benefits derived from the use of Yersin's
serum are somewhat uncertain. Sometimes excellent results appear
to follow its administration, sometimes only moderately good results
are observed, and at other times absolutely no effect seems to be pro-
duced. On the whole, for white races in which the disease is com-
paratively mild the serum treatment is likely to be more efficacious
than for coloured people, especially when administered intravenously in
large doses. As regards the people of India and of China, in whose
countries the disease is now epidemic in a virulent form, serum treat-
ment has not given the brilliant results which were expected.
Lustig's serum, like Yersin's, gave most promising results on its
first trial. In June and Julv, 1897, it was administered
Observations
on Lustig's to six serious cases, all of whom recovered. This was at
^ ^^^' a time when the epidemic had declined.
Since then it has been tried in some 1500 cases in Bombay, and
all that can be claimed for it is that when septicaemic cases, which
form over 40 "/o of the total, are excluded, then it reduces the mortality
of the remainder, i.e. bubonic cases, to a greater degree than in similar
cases under ordinary treatment. The same observation appears to
apply equally to the effect of Yersin's serum in Bombay. The
virulence of the plague in Bombay, judged of by the case mortality,
has increased from 60^0 in 1897 to nearly 80°/o during the past 4 or 5
years. No evidence is forthcoming as yet that the serum can destroy
the plague bacilli in the blood.
The statistical table on page 325 is given by Dr N. H. Choksy,
showing the results of the treatment of plague patients with Lustig's
serum in some of the municipal hospitals of Bombay from 1898 to 1902.
Dr Choksy, who has had an exceptionall}^ large experience in the
treatment of plague in Bombay, is strongly impressed with the value of
serotherapy in plague, and expresses his conviction in its efficacy in the
following terms : " Should those who are conversant with the application
of the serum in plague be entrusted with 100 persons provided the
cases are not septicaemic, they would be able to bring round at least
60, if not more, by the use either of Lustig's or Roux's serum of the
strength that has bt'en used in Bombay during the last two epidemics."
The proviso, it will be noted, is a large one, and accentuates the small
assistance to be derived from the most advanced treatment.
CH. XVl]
Treatment
Arthur Road Hosjiital.
325
System of
Treatment
Serum-Treated
Patients
Patients under Ordi-
nary Treatment
Difference
in favour
Period
1
3
;g
Case
Mortality
per cent.
u
Si
i
0
Case
Mortality
per cent.
Serum
Patients
per cent.
March to Oct. 1898
Jan. to April and June
1899
May 1899 and July 1899
to Aug. 1900
August 1900 to Feb. 1901
(3 extra cases)
March, April and May
1901
Selection
Do.
Alternate
Selection
Alternate
257
189
484
55
104
145
124
329
m
81
56-4
65-60
68-00
65-45
77-82
752
884
484
184
102
595
734
385
144
81
79-1
83-03
79-5
78-26
79-42
22-7
17-4
11-5
12-81
1-53
Maratha Hospital.
1898
Selection
28
17
60-71
80-7
20-0
Nov. 1900 to Jan. 1901
Do.
38
32
84-21
...
88-8
4-59
August to Dec. 1901 ...
Do.
44
31
70-45
203
161
79-31
(11-5)8-86
April and May 1902 ...
Alternate
31
31
100-00
31
29
93-54
Nil.
folk
Between November, 1902, and July, 1903, a trial was made in
Bombay, under the supervision of the Bombay Laboratory,
of serum prepared by Professor Terni and Bondi in
Messina^ The cases for treatment were taken alternately
as they were admitted to hospital. The results were as
111 cases treated f 21 recovered 1 „., ^„n/ . ,-,
•.Lu -^ r./^ J- J ^ 81-08% mortality.
with serum ( 90 died J '" -^
Observations
on Professor
Terni's and
Bondi's
serum.
112 cases treated [21 recovered
without serum I 91 died
81-25% mortality.
Subsequently, another batch of 16 patients were treated with the
same serum in another Bombay hospital, 16 alternate patients being
left for comparison. Of the first category 12 died, and of the second, 11.
In 1904, a serum prepared by Dr Brazil in San Pavlo, which was
reported to give good results in Brazil, was tried by the laboratory.
In one hospital the proportion of deaths, among the injected, was 41
out of .50, and among the control cases, 45 out of 50 ; in another, the
' British Medical Journal, Sept. 24, 1904.
326 Pkujae in the halh'Ulaal [part hi
injected gave a ])ro])ortion of 17 deaths out of 20, and the control cases
of 15 out of 20. The treatment in all cases consisted in hypodermic
injections, the doses in tht' latter experiments amounting sometimes to
several hundred cubic centimetres.
Kitasato's serum has been used in Tainan with controls. The odd
numbers were injected with serum. The even numbers
Observations ^
on Kitasato's were not injected, but early extirpation of the glands and
general systemic treatment was adopted. The results
recorded are as follows.
56 cases treated f 37 recovered
with serum
56 cases treated ("21 recovered
without serum
f 37 recovered ').-,.,,.„/ 4. 1-4.
i 19 died I '»-9n/o mortahty.
f 21 recovered 1 ..^ , „, . y.
I .35 died ) <>2-.>"/o mortahty.
These results are excellent, no doubt, but it is clear from that which
has been observed with the sera prepared by Yersin and Lustig that
the value of a serum for the specific or curative treatment of plague
cannot be determined by one or two series of test experiments, but that
it needs many series of trials under varying circumstances before
anything like an accurate estimate of its efficacy or antidotal powers
can be made.
The serum which shall possess evident and indisputable specific or
antidotal powers against plague during an epidemic has still to be
discovered. To deserve the name of a specific it must do something
more than show good results during the decline of an epidemic or
during the quiescent stage, when only sporadic cases occur. At the
same time the administration of the different sera as empl()3'ed at the
present time, and more especially if injected intravenously and early,
appears to give the patient a better chance of recovery than any
pharmacopeal drug, which is not appraising their value very highly ;
and in some instances the state of the patient after the injection
is so much improved that it can only be attributed to the action of
the serum.
The amount of serum injected intravenously usually varies from
Dosage of 20 to 40 c.c. according to the severity of the case. The
serum. intravenous injection is generally supplemented by a
subcutaneous injection of 20 to 40 c.c. The usual practice is to repeat
the dose every 12 or 24 hours, and continue it for 3 or 5 days after the
general improvement of the patient. A fall in the temperature, less pain
in the bubo, a clearer intellect, and an iiupi'owiiient in the ])uls(' indicate
CH. xvi] Treatment ?j^1
signs of amelioration. If the effect of the serum is only slight and the
symptoms urgent, intravenous injections may be repeated as frequently
and at as short intervals as in the discretion of the medical attendant
is advisable. Larger doses than 40c.c. have been given intravenously
at one time, in some cases amounting to 80, 100, and in one case to
400 c.c, apparently without harmful results. When subcutaneous
injections alone are used it is believed that better results have been
noticed in those instances in which the injections have been made in
the region which is drained by the affected bubo. Beyond, possibly,
a temporary rise in temperature accompanied by transient rigors,
rashes of various kinds, but of an evanescent character, and painful
swellings of the joints amenable to doses of salicylate of soda, no other
ill-effects have been observed from the administration of plague sera.
None of the results fi-om serum treatment have surpassed or even come
up to the results obtained at the hosjjital in Smyrna from the oil
friction, and which was used much in the plague at Tangiers in 1809,
in the epidemic of Malta in 1813, and again when plague was prevalent
in Tunis in 1818-1819. With a more extended experience, however,
it has, like other curative methods, fallen into desuetude.
The internal administration of disinfectants has been tried in
Hongkong. The first experiment was in 1901, when
treatment. 80 grains a day of carbolic acid were given to each
patient : 204 cases were thus treated with a mortality
of 76-57o.
Cases
Deaths
Mortality
Europeans
24
8
33-37o
Portuguese
16
12
75-0
Chinese
136
121
89-0
Other Races
28
1-5
53-6
204 156 76-6
On the suggestion of Dr Atkinson ^ principal Civil Officer of Hongkong,
a fi-esh trial was made in 1903 with carbolic acid even in larger doses.
Accordingly 144 grains of carbolic acid were administered daily, divided
into two-hourly doses of 12 grains each in a mixture flavoured with
syrup of orange and chloroform water, in some cases over long periods.
One patient consumed over 2500 grains of pure carbolic acid before his
blood was free from plague bacilli. Carbolic acid poisoning appears to
have been practically unknown. In a few cases carboluria developed,
but the omission of one or two doses was usually sufficient to clear the
^ liejyort on Plague Cases treated in the Kennedy Town Hospital, Hongkong. By
.J. C. Thomson, M.D., 1903.
328
Plague in tJic J n dividual
[part III
urine and permit resumption of the remedy in full doses. In certain
cases dyspeptic symptoms occurred, but in these greater dilution of the
mixture with water was all that was required to overcome this obstacle
to its consumption. Dr J. C. Thomson, who made the trial in 143 cases,
formed the opinion that it was the most hopeful means of treating
plague thus far at the disposal of the medical authorities in Hongkong.
Dr Thomson gives the two following tables showing the racial and
general mortality before and during the use of carbolic acid.
Before Carbolic Acid tvas used,
i.e. in the firat half of the epidemic.
Cases
Cured
Convalescent
Deaths
Mortality
Europeans
2
1
1
50-0 »/o
Portuguese
Chinese
123
15
2
106
86-2
Other Races
14
2
12
85-7
139
18
119
20
Under the use of Carbolic Acid,
i.e. in the second half of the epidemic.
143
69
22
85-7
Cases
Cured
Convalescent
Deaths
Mortality
Europeans
22
17
4
1
4-5 %
Portuguese
1
1
Chinese
80
31
3
46
57-5
Other Races
40
20
15
5
12-0
36-4
91
It is admitted that tAvo circumstances need to be taken into
consideration when comparing these figures ; the first is that the
treatment with carbolic acid was commenced late in the epidemic, at
a stage when, as Dr Thomson remarks, there is a greater natural
tendency to recovery, the disease being invariably more virulent early in
the season ; the second is that, owing to the adoption of an improved
method of examination of plague blood, a much larger number of very
mild cases, many of which would not have been diagnosed as plague in
former years, were proved to be plague and sent to Kennedy Town
Hospital. These cases swelled the proportion of recoveries.
The internal administration of carbolic acid suggests the possibility
of cyllin being useful under similar circumstances. Cyllin
has the advantages of being safer, and a more powerful
CyUin.
CH. xvi] Treatment 329
bactericide, but whether it will exercise any curative effect on plague
patients is not known.
Notwithstanding the disappointing results of the serum treatment,
General i^' ^'^^ ^^ ^^ confessed that there is no better in the hands
treatment. of the physician. In falling back on general treatment
there is no attempt to deal with the manufactory of poison elaborated
in the system. The struggle must be between the attacking force of
the microbe and the resisting power of the patient, assisted by the skill
of the medical man whose aims are to conserve the strength of the
patient, check as much as possible the severity of the symptoms and
tide over periods of danger due to exhaustion. Good nursing is a very
important factor in preserving the strength of the patient. The nursing
is difficult and at times dangerous on account of the
IftiTsinsr
delusions of the patient, who may, accordingly, resist
being fed and resent being attended, or who may be constantly
attempting to get out of bed and escape. Under certain conditions
it is absolutely necessary to employ mechanical restraint to keep
the patient from inflicting self-injuries or being dangerous. Good
nursing combined with early confinement to bed, the maintenance
of the recumbent position to prevent syncope, careful feeding and
general treatment to maintain the patient's strength and prevent
complications if possible, are calculated to give the best results, both
with or without serotherapy.
The patient should be placed under the best hygienic conditions.
Hygienic The more abundant the fresh air to which he is exposed,
conditions. ^\yQ better are the chances of recovery. In Cape Town at
the commencement of the epidemic, when in one ward the accommoda-
tion was cramped, the ventilation defective, and the patients over-
crowded, it was observed that the cases did badly, and at the same
time became dangerously infective. Removal to a large tent, in which
the patients were practically treated in the open air, produced a
marvellous change in the character of the disease, the symptoms at
once ameliorating and becoming milder.
The treatment is usually commenced by clearing the bowels, calomel
followed by a saline or other purgative being admini-
Medicines. i t^ c ^^ ^ .^ , •
stered. Heart failure is perhaps the most important
symptom to be contended against. Early signs of it in the course
of the disease usually portend a fatal result, and drugs do not
appear to be of much value. For sustaining the action of the heart
and counteracting the want of tone of the blood vessels the most
330 Phiffue in the Individual [part hi
successful results have been obtained by the employment of strych-
nine 4'jy gr., hypodermically ever}'^ 4 to 5 hours, or of 5 to 10 minims
of the liquor, or a combination of strychnine and strophanthus
hypodermically injected. Benefit sometimes follows the administration
of digitalis, especially when combined with diffusible stimulants. Digi-
talis by the mouth and strophanthus by subcutaneous injection have
also been found to exercise a ])articularly good effect. General stimu-
lants, such as carbonate of ammonia and camphor, are indicated at an
early stage.
To control the febrile symptoms and check delirium, ice bags to the
head, sponging of the body, and the use of hy})notics which are not
depressants, are beneficial. Morphine carefully administered, either
alone or combined with bromide of potassium or atropine, is generally
employed to induce sleep, but many hypnotics may have to be tried
before that which suits the patient is found. Antipyrine is not suitable
for the reduction of the pyrexia.
Complications are treated on general principles.
The pain and tenderness of buboes are much relieved by ice bags,
which have also a good effect in circumscribing the in-
ment of filtrations. Other applications, such as belladonna and
poultices, at times prove useful. The bubo is opened when
pus forms, but nothing is gained by too early incision. The opened
bubo is dressed with antiseptics and drained if required. Gangrenous
debris in the suppurating bubo is removed by the knife. Extirpation
of the infected gland or glands is sometimes practised, but this mode of
treatment is limited in its application, nor can it be applied to buboes
within the abdominal wall. It appears not always to have been
unaccompanied with risk to the patients. In Bombay injections into
the buboes of iodised oil, liquor iodi, carbolic acid, liquor iodi with
carbolic acid, creolin, quinine, mercuric chloride, and red iodide of
mercuiy were tried, but without any better results than when the
buboes were left alone.
For carbuncles Choksy found that a subcutaneous injection of
Treatment of corrosive sublimate, varying in dose from J^ to y\y or 1
carbuncles. ^f .^ grain, had an excellent effect and prevented them
fi'om increasing in size.
The treatment of convalescence is mainly directed to restoring the
Treatment general tone and vitality of the system, which, as a rule,
during con- have been enfeebled to a remarkable degree by the illness,
and treating the anaemia which is associated with the
CH. xvij Permnal Prophnlaxis 331
debility. Iron, quinine and tonics are indicated combined with nourish-
ing and easily digested food. During the first week great care requires
to be taken to prevent the patient from getting out of or even sitting
up in bed owing to the danger of heart failure. In uncomplicated cases
the patient is usually well in 5 or 6 weeks. In other cases recovery
may be delayed for months, caused by the infection of fresh glands, the
formation of abscesses and large sloughing ulcers, and other complica-
tions.
The precautions to be taken by the physician to prevent the spread
of the disease in the family consists in notifying the case
Prophylactic , i i , • • i i i •,•
measures in to the local authorities, on whom rests the responsibility
an infected f^^. carrying out the necessary measures, and to prevent ex-
tension from the house until the local authorities can take
action. If the circumstances of the case do not permit of removal to
the hospital, the patient should be strictly isolated in the most secluded
and best ventilated room in the house. An acid solution of perchloride
of mercury of the strength of 1 in 500 or an alkaline solution of cyllin of
the strength of 1 in 200 is recommended as a disinfectant. Sputum,
urine and excreta should be received in vessels containing either of these
disinfectants. A solution of 1 in 1000 of perchloride of mercury, or 1 in 500
Use of dis- of cyllin may be used in vessels for soaking soiled clothes,
infectants. disinfecting cups, spoons, etc., or washing the hands of
the medical attendant and nurse after handling the patient. Nothing
from a patient should be discharged down a water-closet or drain
without being thoroughly mixed with an abundant quantity of dis-
infectant, otherwise rats in the sewer may become infected and carry
the disease elsewhere. In the event of death a sheet soaked in the
strong perchloride solution should be wrapped around the body and
carbolised or cyllinised sawdust put into the coffin.
Of prophylactic measures to protect the medical attendant, the
Protective nurse and the relatives who come into close association
inoculation. with the infected, the most important is immediate
inoculation with Haffkine's prophylactic or Yersin's plague serum.
The dose of Haffkine's prophylactic is usually 2 to 5 c.c. for an
adult, and "5 to 1 c.c. for children, injected subcutaneously into the
arm or flank. It causes in a few hours a rise of temperature to
102° F., sometimes to 105' F., headache, nausea, malaise and dis-
comfort, which usually continues for about 48 hours. At the site of
the inoculation a painful swelling appears which necessitates rest for
a day or two and remains evident for at least a week. Immunity
332 Plafjue in the Individual [part hi
is established in a week's time, but })artial immunity much earlier. At
no time does it render the inoculated more susceptible to the disease.
The protection lasts, it is believed, tor at least 6 or 7 months, which is
the usual duration of an epidemic.
The dose of Yersin's serum is 10 to 20 c.c, and it is administered
h^^odemiically in the same way as Haffkine's prophylactic. The serum
does not cause nearly the same degree of discomfort or local inflamma-
toiy action and produces a more immediate immunising effect, but in
some persons it may be followed in a week or fortnight's time by
symptoms simulating rheumatism, accompanied by swelling of some of
the joints, which is successfully treated by the administration of sali-
cylate of soda. The protective effect is also of a very limited duration
and is lost in about a fortnight's time. Owing, however, to the small
discomfort -which it generally produces it can be repeated before the
expiration of this period.
Neither Haffkine's prophylactic nor Yersin's serum thus ad-
ministered afford an absolute protection against a plague attack,
but they do protect in a very high degree, and if the person inoculated
is afterwards attacked with plague, the chances of recovery are greater
than when not inoculated.
Individual prophylaxis will also include scrupulous cleanliness, care-
Personai ful attention to the condition of the skin, especially the
hygiene. hands, regular manner of living, and avoidance of fatigue
and of unnecessarily prolonged exposure in a dark, ill- ventilated and
infected room, especially at night.
Plague will not spread in a sanitary house if the precautions
Hygiene of mentioned are taken. But by a sanitary house is meant,
the house. Qjje that is clean, well lighted, well ventilated, and free
from rats. If there are any rats measures should be taken at once
to destroy them and remove any conditions which are liable to harbour
them.
PAET IV.
MEASURES FOR PREVENTION AND SUPPRESSION
OF PLAGUE.
CHAPTER XVII.
MEASURES EMPLOYED BEFORE THE DISCOVERY
OF THE BACILLUS.
There are two periods during which preventive measures against
Two Deriods plague may be considered. The first period embraces the
to be con- past before the plague bacillus was discovered, and is of
historical interest rather than of practical guidance for the
measures of to-day. The preventive measures of this period are de-
scribed because an account of them shows their very slow, chequered,
and halting development and the source of many existing practices.
The second period deals with the present-day methods employed in
combating plague.
Methods of prevention necessarily depend on the views which are
held concerning the cause of the disease, and as these
measures de- views change from time to time the measures accordingly
views'wiiich vary. When plague was considered to be the scourge of
are held con- an angered deity or the work of evil spirits, men resorted
cause of the to penances, sacrifices, and prayers. Thus when the
disease. Philistines defeated the Israelites in battle, captured the
ark and brought it into their own country, and plague broke out among
them causing a deadly destruction in the towns and villages of the
victors, the only method of protection adopted appears to have been the
Trespass niaking of golden images of their tumours and of the 9
offerings. mice that marred the land, and sending them with the ark •
on a new cart drawn by two milch kine to the Israelites as a trespass
offering to the " God of Israel " that He might lighten His hand and take
the plague away from them.
Seventeen centuries later another people in possession of Syria
entertained the view that plague was caused by the sting of hostile
334 TJic Pnrrntion <tu<l Siij)])ref<^ion of Plague [part iv
spirits, was a purification from the soil of sin, and that death from it
was a martyrdom. These were the Mahommedan Arabs. Holding this
doctrine they discountenanced flight from a plague-stricken village,
though, at the same time, it was held to be foolish to go to a locality
where plague prevailed. Ideas of this kind usually exercised a salutary
influence in checking the spread of plague from village to village and in
restricting the general dissemination of the disease. But in time of war
the protection afforded was lost, for armies moving from place to place
carried the disease with them. Omar, in conquering Syria, lost an
enormous number of his soldiers from plague. It is estimated that one
of the Arabian armies lost 25,000 men. It was only after two com-
manders-in-chief had succumbed to the disease, that the
Removal from ,i • i j j i. • j j. i.-
plague- third commander determined to use preventive measures.
stricken }^e distributed his troops in the mountains and desert,
locality. .
with the result that plague ceased. It is the first record
of a successful protective policy being followed with the distinct object
of saving a large community from the ravages of plague. From this
time, though to remove from a plague-stricken village was still held by
many to be a sin, the Caliphs made it a custom to spend a part of the
year in the desert to avoid the plague which prevailed at a certain
season of the year at their capital, and the measures introduced by Abu
Obaidah, the commander, fcMind favour with the majority.
In the more brilliant and cultured period of Arabian history
Fvimig-ation medical science was largely guided by the teachings of
of the dweu- Hippocrates and Galen with reference to epidemics and
attention to their causes. The Arabian physicians regarded plague as
*^®*" a disease caused by toxic properties in the air, aggravated
by disturbances in the body caused by diet or bad water. Fumigation
of the dwellings with musk, camphor, sedge, and sandal wood was
advised, with a strict regulation of the diet, certain articles such as
onions, vinegar, and pickled fish being recommended, while soup and
fruits were forbidden.
With the decline of Arabian culture, the fall of the rule of the
first Caliphs, and the rise of the military and uncultured rule of
the Ottoman, preventive measures gradually fell into desuetude. The
terrible experiences of the epidemics of the 13th and 14th centuries,
together with the deep-rooted spirit of fatalism in the Mahommedan
faith, appear to have produced in a rude, superstitious, and religious
people a blind faith in destiny •. But before this was reached, prayers
1 Veher die grossen Seuchen dex Orients nach unthischen Qiiellen. A. v. Kramer, 1880.
I
CH. xvii] Prayers and Processions 335
and processions unfamiliar to the earlier Mahommedans as a means of pro-
Prayers and tection against plague, were resorted to. Ibn Batuta\ the
processions. celebrated Moorish traveller, witnessed a strange procession
in Damascus in 1348, on the occasion of the Black Death. He arrived
at Damascus on a Thursday in the month of July. Argunshah, the
Governor, had proclaimed a public fast of three days. On its completion
the Emirs, Sheikhs, Cadis, Priests, and all classes of the population
assembled by invitation in the principal mosques of the town and passed
the night in prayers and praising God, and in registering vows. On the
Friday morning, having offered up the morning prayer, they left the
mosque and marched barefooted through the town carrying the Koran.
They were joined by the Jews carrying the Bible, and by the Christians
carrying the New Testament. Women and children formed part of the
procession, and all engaged in weeping, supplicating and seeking
protection by means of their books and their prophets. Ibn Batuta
remarks that there was an undoubted alleviation, for the number that
died in Damascus was not greater than 2000 a day, whereas in Cairo and
Old Cairo the mortality reached the appalling number of 24,000 a
day.
To the majority of people, however, as epidemic followed epidemic.
Resignation causing an extraordinary destruction, prayers seemed to be
and fatalism, of no avail, and resignation and fatalism took their place.
To seek safety in flight, or to take any measure against plague, was
held to be useless. The bolt could not miss its aim if God had destined
it to strike. In the 15th and 16th centuries the Turks who held these •
views put on the clothes and linen of plague patients even while they
were damp with the death-sweat. They even rubbed their faces with
these clothes, and in doing so would justify the action by saying that if
it be God's will I should die of plague it is unavoidable, and if it be not
His will it cannot hurt me. In Cairo, where the same beliefs prevailed, »
the people visited the infected houses and took no precautions, and the
mortality was enormous.
Fortunately for Europe, the fatp.lism of the East never acquired
Disposal of 'T- strong hold in the West ; pilgrimages, processions,
the dead. prayers, and flight continued for a long time to be resorted
to at the time of plague. But the only sanitary measure which pressed
itself as a necessity on all was the disposal of the dead, and, as the
ordinary modes of burial failed to meet the requirement, arrangements
were made by which large numbers of bodies could be buried in trenches
and pits. Later, other measures of protection were tried by individuals
1 Voyages cVIhn Batoutah. Par C. Defremery et le Dr B. E. Sanguinetti, 1853.
336 The Prevention and Supjn-ession of Plague [part iv
under the advice and influence of the more learned physicians. House-
isolation of holds shut themselves up and attempted to avoid contagion
the rich. ^^, cutting off all communication and intercourse with
others. Special attention was paid to diet and cleanliness, and fumiga-
tions were practised. It was not, however, until the experiences of the
pandemic of 1848 or the Black Death that views regarding the
contagious nature of plague, and the infectious condition of the air,
became sufficiently general to give rise to any organised attempt to meet
First pre- epidemics of plague by preventive measures other than
ventive those open to the individual. At the commencement of
measures of ^
an organised this pandemic in Italy efforts were made by some of the
Venice in towns to save themselves, by refusing admission to the
1348. plague-stricken, and by the adoption of other protective
measures. The Venetians forbade vessels with plague on board
(J approaching the port, and when plague broke out in Venice the sick
were carried into the suburbs to die or recover. The authorities at
Milan kept the town free of the epidemic for a long time by shutting up
and barricading three houses infected with plague. Boccaccio relates
that the plague reached Florence " in spite of all the means that human
foresight could suggest, as keeping the city free from filth and excluding
all suspected persons, notwithstanding frequent consultations what
else was to be done, not omitting prayers to God in frequent pro-
cession."
The first Governmental measures against infection were organised by
First Govern- ^^unt Bernabo in Reggio in January, 1374 ^ The regula-
mentaimea- tions i)rovided that every plague patient was to be taken
sures in 1374. 7 . . ./ i o i
out of the city into the fields, there to die or recover, that
persons wh(^ nursed or attended upon a plague patient were to be
* isolated for 10 days before being free to associate with others, that the
priests were to examine the diseased and give notice to the officials,
under punishment of confiscation of their goods and of being burnt
alive, that persons importing the plague were to forfeit their goods, and
that none except those appointed were to attend plague patients under
penalty of death and forfeiture of their fortune. In 1383 on plague
returning to Lombardy, Count Bernabo rendered his measures still more
stringent by forbidding, on pain of death, people from plague-stricken
places being admitted to his territories.
Other Governments followed Count Bernabo's example, though
perhaps with not the same stringency. On plague visiting Italy again
1 The Epidemics of the Middle Ages. By J. F. C. Hecker, M.D. Translated by
B. G. Babington, M.D., F.R.S., 18.59.
CH. xvii] Vencfidn Lazaretto est ((J)l inked 337
in 1399 measures were introduced to destroy the infection. Infected
houses were thoroughly fumigated and ventilated for 8 or 10 days, they
were further purified from noxious vapours by fires, and were fumigated
by balsams and resins. Straw and rags in infected houses were burnt,
and the bedsteads which had been used were set out for 4 days in the
rain or sunshine. It was forbidden to use the beds and clothes from an
infected house without permission, and without first subjecting them to
a thorough cleansing and washing, and then drying them at the fire or
in the sun. Thus it is evident that serious efforts were made in some
of the Italian states to grapple with the plague, and it is remarkable
how closely they resemble those of to-day. Examination of the sick,
notification to the authorities, isolation of the patient and of the
attendants, and disinfection of the house and household furniture by
fumigation and ventilation, burning or washing of certain articles, and
exposure to the sun of others were all employed.
In the 15th century a still further advance was made. In 1403^
Lazaretto ^^'^'^ Venetians established a lazaretto for the treatment
established and isolation of plague patients at a distance of about
by the . r & i
Venetians 2 miles from the town. It was situated on an island, and
in 1403. p^^|. Q^ from all communication with the town. In 1467
the Genoese imitated the Venetians and also established a lazaretto. In
1475 there was a plague hospital at Inch Keith in the Firth of Forth.
Later, in 1485, the lazaretto system was extended in Venice, to provide not
only for the treatment and segregation of plague patients for 40 days,
and for the purification of their clothes and effects, but also for an
elaborate system of isolation and purification of all persons and
passengers coming from countries infected. with plague. The merchants
of Venice had experienced the injurious effect which the importation
and prevalence of plague had exercised on their commerce and
prosperity.
In the course of six centuries, from 901 to 1500, the Venetian state had
suffered from 63 epidemics of plague, and they determined
A council of .p i i
health and to make a strenuous effort to protect themselves as much
estawLhed ''''^ possible. With this object in view they established in
in 1485 in 1485 a Council of Health, whose duty it was to do
everything to meet the invasion of plague. For this
purpose they framed certain regulations for the management of the
lazarettos, the duration of detention, and the method of purification to
be adopted. The places of detention and purification were called the
' Knsai smr I'Hygiene Internatioimlc. Par Adrian Proust. Paris, 1873.
s. 22
338 The Prevention (unl Snj>i>re'ssi(nt of Plaffue [part IV
lazarettos, and the period during which the detention and ])uritication
were undergone was called the quarantine, the minimum being 40 days.
Gradually the term quarantine was used to embrace the whole system,
and will in future be employed in this sense. The quarantine
regulations of 14S5 are interesting from an historical point of view
because they formed the pattern for most quarantine regulations against
plague for the past 500 years, and were only materially altered in 1897
at the conference of the European Powers held in Venice, when plague
became epidemic in Bombay, and because they indicate the notions of
infection that were held in the 15th century, the belief as to the
infectious principles being dissipated by exposure to air and sunshine,
and the opinion as to the period necessary to cover the development of
any latent principle of contagion. It was even then recognised that
the infection manifested itself earlier than 40 days in persons, but as it
was difficult to separate persons from their belongings, it was determined
to require the same length of pui'ification for both. Briefly, the
„ .. Venetian system^ was as follows : Every vessel coming from
The Venetian ■^ . . ' • n n
system of the Levant was to hoist on the mizen-mast a yellow flag
quarantine. before approaching the port. The vessel was then met by
an official who took charge of and anchored it at a particular place.
The captain, after all papers and letters were fumigated, accompanied a
second official to the Health Office under certain precautions, where he
was questioned as to the voyage, the ports he had touched at, and the
state of health of those on board. A careful examination was made of
his papers with special reference to the number of passengers and crew,
the clearness of his bills of health, the kind of merchandise on board, and
the ports from which it came. If the ship was from a country that was
free of plague, and the Health Office was satisfied, pratique was allowed.
If, on the other hand, it came from a suspected place the captain was
conducted back to the ship, a list was made of the names of every one
on board, and another list of the belongings of each person. Orders
were then given for unlading the ship. Goods were distinguished
as susceptible and unsusceptible, or receptive and unreceptive, which
referred to their powers of retaining infection. The latter did not
undergo any purification or retention, and, under certain regulations,
were handed at once from the vessel by officials under the control of the
Health Office. The former were taken in boats under precautions of the
lazaretto for purification. The passengers with their baggage were also
taken to the lazaretto, none being allowed to perform quarantine on
' AtCDUiit of the (Jffici' i)f Health, Venice. LonJon, 1752.
CH. xvTi] Venetia'n Qxiarantme 339
board for fear that the things worn or wearable should not be sufficiently
purified. The lazarettos consisted of a number of buildings in which
quarters were arranged for the accommodation of healthy passengers in
small groups. Shut off from these by high walls were other buildings con-
sisting of large open and covered sheds designed for the exposure to the air
in all weathers of the different kinds of merchandise. Persons falling sick
of plague were removed to the old lazaretto, while healthy passengers were
housed in the new ; and goods and merchandise were taken to the sheds
and there opened up. The boxes and trunks of the passengers were also
opened and everything in them, whether wearing apparel or merchandise,
was hung up and exposed to the air. When these preliminaries were
completed the quarantine of 40 days commenced and not before.
The procedure adopted for the goods was to take them out of their
bags and cases, or to undo the bales and deposit them in separate heaps
about 4 feet high in the sheds. These heaps were then thoroughly
aired by being turned over and handled, and then removed from one
place to another, the object being that every part in turn should get
exposed to the sun and air. There were rules of purification to be
adopted for every kind of merchandise. The greatest attention was
paid to woollen goods, as these were considered to retain the infection
much more tenaciously than other kinds. They were turned over,
handled, and removed from place to place daily. Silks, linens, furs,
and ribbons were thoroughly aired twice a day, and removed to another
place twice a week. Cottons, thread, camel hair, and similar articles
which came in bags, were differently dealt with. The bags were
unsewn on one side and left for 20 days, the contents each day being
stirred up by the naked arms of the workmen appointed to do it. The
bags were then turned and unsewn on the other side and the contents
similarly treated for 20 days. Wax, sponges, and animals with short
hair were purified by being passed through running water. Feathered
animals were sprinkled with vinegar. Corn, salt, seeds, minerals, wood,
gold-dust, sugars, cheeses, fruits, smoked fish and meat, drugs, liquors,
brandies, oils, wines and similar articles were considered non-susceptible,
and could be taken away at once. If the period of 40 days were passed
in quarantine without sickness of a suspicious nature among the
passengers or the workmen who were employed airing the merchandise,
the passengers and goods were allowed admission into the town. Should,
however, in the course of the 40 days illness of a suspicious character
occur, 40 more days wc^re to be passed in ([uarantine in the
lazaretto.
22—2
340 The Prevention nnd Snj>jnrssi()n of Plw/ne [part iv
The whole system, it will be seen, was based on the establishment
of the lazaretto at a convenient place near the port, and so situated as
to be completely isolated from the town, where passengers and mer-
chandise from an infected country could be subjected to a thorough
])urification which was supposed to take 40 days for its completion.
Quarantine in a lazaretto under the Italian system was not simply
the retention of passengers and goods in a quarantine station or ship
for 40 days, under the impression that the poison of plague would in
that time be destroyed, but it was the purification or disinfection of
passengers, etfects, and merchandise by means of washing and exposure
to the air and sun for a certain period, and no goods were considered to
be purified unless they were opened up and so arranged that every
portion received a thorough airing ; the duration of the quarantine
depended on the medical opinion of the time, and, though the arbitrary
fixing of 40 days seems now with the advance of medical science to be
an extraordinary time compared with that which is needed, yet it is
impossible not to recognise that with the means of disinfection at their
disposal the procedure was admirably adapted for the purposes in view,
and the conditions of maritime commerce at that time; and it is equally
impossible to withhold our admiration of the completeness of the sj^stem
adopted by the Venetians, who, from their intimate intercourse with the
Levant, necessarily ran the greatest risk fi'om the importation of
plague.
The advance made in the mode of disinfection in modern times can
effect in less than 40 hours the purification of goods and passengers,
effects which were then believed to need 40 days.
The system was adopted slowly by other nations, but with a less
appreciation of the underlying principles, so that little
Extension of . , . • T i tt ■ i
preventive remamed m comm(jn with the Venetian system than
measures ^l-^g circumstance that both ijassengers and goods were
against i • i ° ' . ,
plague to detained for 40 days. The system of quarantine de-
countries generated often into the mere crowding of people into
insanitary buildings in which there was every chance of
their becoming ill, and allowing pratique after they had been detained
for 40 days, or the keeping of every one on board for that period, not
infrequently in an unhealthy anchorage.
Austria and Germany, exposed to plague from Italy and Turkey,
early adopted preventive measures in times of plague similar to those
employed in the inland states of Italy. These consisted in making
large fires in the s(juare and crossways of the towns and villages.
CH. xvii] Pamphlet i^ oi) Plac/ue 341
fumigation of the council chambers and private dwellings, prohibition
of the yearly markets, isolation and shutting up of in-
1Vl6£LSU.I'6S ill */ «/ ox
Austria and fected houses, building of hospitals outside the town, or
ifith^^'^^t"^ using of old leper hospitals, and the closing of the public
bath-houses. The town magistrates were empowered to
enforce these measures in their own districts. But, as this power did
not always prove to be sufficient, the Government of the country, in
order to secure uniformity and a more rigorous administration, issued
general orders. Thus in Austria^ the Emperor Maximilian, in 1512, issued
a mandate that the gipsies, who were disliked, and looked upon not only
as Turkish spies and thieves, but also as carriers of plague, were not
allowed to stay in Austria, nor to form an encampment, nor even to pass
through the country. As the condition of the air was considered to
materially assist in producing and spreading plague, regulations were
made to keep the streets and lanes clean and to remove heaps of
manure and other refuse from houses under the penalty of a fine :
whoever threw manure or other rubbish into the streams was taken
before the magistrate and fined.
In Vienna the Government printed short and simple directions
written by physicians instructing the inhabitants what
tracts and ^^ ^^'^ ^^ protect themselves against plague and what
pamphlets in medicines they should take in case of illness \ A general
16th century. , . . , ^^_, , „ , • , ,
order was given in 1521 that all people, particularly
heads of households, should be provided with these small publications,
so that, in case of danger, they might exactly know what to do.
In 1522 Dr Johann Saltzman published a pamphlet on the rules by
which protection may be obtained against the pestilence. This was
printed and put up on walls, and on the doors of the churches and the
gates of the city.
In England, the introduction of measures against plague probably
owe their origin to Venetian influence. The first preventive action
recorded is in 151 3-, when two servants of the Venetian envoy died of
plaffue in London, and their beds, sheets, and other
Measures in ^ '^
London in effects were thrown into the river. It is in this year
16th cen ury. ^j^^^^ ^l^^ inhabitants of houses infected with plague
were ordered to keep in their houses and put out wisps to warn
others that the houses were infected. It was in 1516-', when the
Venetian ambassador removed from London to Putney because of a
1 Peinlich's Gei<cJiichte der Pest ; also Geschichte der Pest in Steurmiirk.
2 History of Epidemics in Britain, Vol. i. p. 288, Creigliton.
■> Ibid. p. 290.
342 The Prcnnfiitn (uhI Si(p])resdon of Plague [part iv
death t'loiu ])lagm' in his house, that the first reference is made to
quarantine in England. The ambassador was not allowed to see
Wolsey until 40 days elajised from the ease of plague in his house.
Again, in 151<S. the same Venetian ambassador had plague in his
house, and writes to \'enice from Lambeth that on the expiration of
40 days, which had nearly come to an end, he would not foil to do his
duty as heretofore. It was not, however, until 1543 that any general
order on the subject was issued. It is as follows :
"35 Hen. VIII'. A precept issued to the aldermen: — That they
should cause their beadles to set the sign of the cross
% First Govern- i • i i ^ ^ ^ nn- 1-11 1
ment orders flt on every house which should be afflicted with the plague,
issued in .^^^^ there continue for forty days:
London in . .
Henry viii's " That no person who was able to live by himself, and
^^ ^" should be afflicted with the plague, should go abroad or
into any company for one month after his sickness, and that all others
who could not live without their daily labour should as much as in
them lay refrain from going abroad, and should for forty days after
(illegible) and continually carry a white rod in their hand, two foot
long :
" That every perstin whose house had been infected should, after
a visitation, carry all the straw and (illegible) in the night privately
into the fields and burn ; they should also carry clothes of the infected
in the fields to be cured :
"That no housekeeper should put any person diseased out of his
house into the street or other place unless they provided housing for
them in some other house :
" That all persons having any dogs in their houses other than
hounds, spaniels or mastiffs, necessary for the custody or safe keeping
of their houses, should forthwith convey them out of the city, or cause
them to be killed and carried out of the city and buried at the common
laystall :
" That such as kept hounds, spaniels or mastiffs should not suffer
them to go abroad, but closely confine them :
" That the churchwardens of every parish should employ somebody
to keep out all common beggars out of churches on holy days, and to
cause them to remain without doors :
" That all the streets, lanes, etc. within the wards should be cleansed :
" That the aldermen should cause this precept to be read in the
churches."
^ History of Kpitlemics in liritaiii, pp. 312, ;-513, Creighton.
CH. xvii] Measures in Emjland and Scotland 343
The order about dogs and cats apyjears to have been a very general
one.
Later, in Queen Elizabeth's time, the orders became more stringent,
approaching in severity the regulations issued in the 15th century by
Count Bernabo. To protect the Court at Windsor a
severe in the giiHows was set up in the market-place of Windsor, to
reign of hang' all such as should come there from London. It
Elizabeth. ° . .
was forbidden to bring wares to, through, or by Windsor,
or to carry wood or other stuff to or from London on the river by
Windsor . upon pain of hanging without any judgment, and any
people who received wares out of London into Windsor were to be
turned out of their houses, and their houses shut up. In London
quarantine and sanitation were rigorously insisted on by the Privy
Council in orders to the Mayor, while in 1580S when the disease was
raging in Lisbon, the Lord Mayor was authorised by Lord Treasurer
Burghley to take measures in concurrence with the officers of the port,
to prevent in regard of arrivals from Lisbon the lodging of merchants
or mariners in the city or suburbs, or the discharge of goods from ships
until they have had some time for airing and in the meantime to
provide proper necessaries on board ships detained.
It was not only in Windsor that severe measures against plague
were carried out. In Aberdeen the orders became
Severity of
measures in gradually more rigorous. As early as 1498 guards were
Aberdeen. ^^^ ^^ ^^^ ^^^^ gates to prevent suspected persons •
entering during the day, and the gates were locked at night. In
1514 lodges were erected on the links and gallowhill, where the
infected or suspected were to remain for 40 days. In 1546 it is
recorded that a citizen was burnt on the left hand with a hot iron
for not notifying to the authorities that his child was sick of
plague. In 1585 three gibbets were erected in different parts of the
town, " in case any infected person arrive or repair by sea or land to this
burgh, or in case any indweller of this burgh receive, house, or harbour, ♦
or give meat or drink to the infectit person or persons, the man be
hangit, and the woman drownitl"
In Edinburgh the infected families were removed with all their «
Eniie-ht d goods and furniture to the moor and there lodged in
policy in huts hastily erected for their accommodation. They were
in urg . allowed to be visited by their friends in C(jnipany with
1 English Sanitary Inatitutions, p. 94. By Sir John Simon, K.C.B.
- History of Epidemics in Britain, Vol. i. p. 371. By Charles Creighton, M.A., M.D.,
1894.
344 TJir Prevention and Snjfpression of Plague [part iv
an officer. Those who concealed the pest in their liouses were liable
to be punished with death. The clothes were meanwhile purified by
boiling in a cauldron erected in the o])en air, and their houses were
cleansed by proper officers. These regulations were under the care of
two citizens selected foi- the purpose; for each of whom, as for the
cleansers and bearers of the dead, a gown of grey was made, with a
white St Andrew's cross before and behind.
It will be noted that the measures adopted here differed from those
practised in London, in which the pest-houses were very few in number,
and the plague-stricken were usually shut up in their houses. In fact
in every epidemic of plague from the time of Henry VIII to that of
1665, which was the last epidemic in England, the practice of shutting
up the sick and suspected in the same house became increasingly
more rigorous. In the reign of James I an Act was passed for the
charitable relief and ordering of persons infected with
First .... . " . .
quarantine plague, authority bemg given to justices oi the peace,
station for mayors, baillies, and other head officers to appoint, within
established their several districts, examiners, searchers, watchmen,
keepers, and buriers for the persons and places infected, to
give directions for the prevention and avoidance of infection. In 1664*
the Lord Mayor and Court of Aldermen of London proposed to the Lords
of the Council " that after the custom of other countries, vessels coming
from infected parts should not be permitted to come nearer than
Gravesend or such like distance, where repositories after the manner of
lazarettos should be appointed, into which the ships might discharge
their cargoes to be aired for 40 days." The proposal was accepted, and
the first ([uarantine station for L(^ndoii Avas established, the crew and
passengers being kept on board while the apparel, goods, household
stuff and bedding were aired on shore. Notwithstanding these orders,
plague, which had been endemic in London for many years, broke out in
the winter of 1664.
In the London plague of 1665 the Lord Mayor, Sir John Lawrence,
Special and Aldermen of the City of London issued orders ap-
^ffl^i pointing in every parish special officials. The examiners
appointed were to make a house-to-house inspection, and were to
TKLrisiTof en<piire and learn what houses were infected and the
London. number of the sick, and to give orders and see that the
infected houses were shut u]). The watchmen were to have a special
care that no y)erson went in or out of such houses. The searchers,
who wx're women, were to assist the surgeons in examining corpses and
1 English ScDiitcirij Institutions, p. 99. By Sir John Simon, K.C.B., 1890.
CH. xvii] Bef/fflattons in London in the 17 fJi Centnn/ 345
to report whether the death was due to plague or not. Nurses were
shut up for 28 days after the decease of any person dying of the
infection.
Under orders concerning infected houses and persons sick of the
plague, certain regulations were framed, and as they define clearly what
was the practice in the 17th century I shall transcribe them \
Notice to be given of the sickness. The master of every house as
soon as anyone in his house complaineth, either of
Regulations '' ^ i • i
in London botch or puq^Ie or swelling m any part of his body, or
nfaeue in ^ ffiHeth otherwise sick without apparent cause of some
the 17th other disease, shall give knowledge thereof to the
examiner of health within two hours after the said sign
shall appear.
Sequest7'ation of tlie sick. As soon as any man shall be found by
this examiner, chirurgeon, or searcher, to be sick of the plague, he shall^
the same night be sequestered in the same house, and in case he be so
sequestered then, though he afterwards die not, the house wherein he
sickened shall be shut up for a month, after the use of the due preser-
vatives taken by the rest.
Airing the stuff. For sequestration of the goods and stuff of the
infected, their bedding, and apparel, and hangings of chambers must be
well aired with fire, and such perfumes as are requisite within the in-
fected house, before they be taken again to use ; this to be done by the
appointment of the examiner.
Shutting up of the house. If any person shall have visited any man
known to be infected of the plague, or entered willingly into any known «
infected house being not allowed, the house wherein he inhabiteth shall
be shut up for certain days by the examiner's direction.
None to be removed out of infected houses but etc. Item. That none
be removed out of the house where he falleth sick of the infection into
any other house of the city (except it be to the 2)est-house or a tent, or
unto some such house which the owner of the said visited house holdeth
in his own hands and occupieth by his own servants) and so as security
be given to the parish whither such remove be made, that the attendance
and charge about the said visited persons shall be observed and charged
in all the particularities before expressed, without any cost of that parish
to which any such remove shall happen to be made and this remove to
be done by night : and it shall be lawful to any person that hath two
houses to remove either his sound or his infected people to his spare
^ The author is indebted to Professor Kenwood of University College for a copy of these
orders and regulations.
346 T/te Frerention and Sfq/pressioif of Plan ue [i*art iv
house at his choice, so as, if he send away first his sound he may not
after send thither the sick, nor again unto the sick the sound, and
that the same which he sendeth be for one week at the least shut
up and sechided from company, for fear of some infection at the first
not appearing.
Burial of the dead. That the burial of the dead by this visitation
be, at most convenient hours, always before sun rising or after sun
setting with the privity of the churchwardens or constable, and not
otherwise : and that no neighbours or friends be suffered to accompany
the corpse to church, or to enter the house visited, upon pain of having
his house shut up, or be imprisoned, and that no coqise dying of infection
shall be buried or remain in any church in time of common prayer,
sermon, or lecture. And that no children be suffered at time of
burial of any corpse in any church, churchyard, or burying place to
come near the corpse, coffin, or grave, and that all the graves shall be at
least six foot deep, and further all public assemblies at other burials are
to be forborne during the continuance of this visitation.
No infected stuff to be altered. That no clothes, stuff, bedding, or
garment be suffered to be carried or conveyed out of any infected
houses, and that the criers and carriers abroad of bedding or old apparel
to be sold or pawned be utterly prohibited and restrained, and no
brokers of bedding or old apparel be permitted to make any outward
show or spread forth on their stalls, shopboards or windows towards any
street, lane, common-way, or passage, any old bedding, apparel, or other
stuff out of any infected house, within two months after the infection
hath been there or his house shall be shut up as infected and so shall
continue shut up twenty days at least.
No person to he conveyed out of any infected house. If any person
visited do fortune by negligent looking unto, or by any other means, to
come, or be conveyed from a place infected, to any other place, the parish
from whence such party hath come or been conveyed upon notice thereof
given shall at their charge cause the said party so visited and escaped
to be can-ied and brought back again by night, and the parties in this
case offending to be punished at the direction of the alderman of the
ward ; and the hou.se of the receiver of such visited person to be shut up
for twenty days.
Every visited house to be marked. That every house visited be
marked with a red cross of a foot long, in the middle of the door, evident
to be seen and with these usual printed words, that is to say, "Lord,
have mercy upon us," to be set close over the same cross, there to continue
until lawful opening of the same house.
CH. xvii] Refiidatioiis in London in the 17th Century 347
Every visited house to be watched. That the constables see every
house shut up and to be attended Avith watchmen which may keep them
in and minister necessaries unto them at their own charges (if they be
able) or at the common charge if they be unable. The shutting up to
be for the space of four weeks after all be whole. That precise orders
be taken that the searchers, chirurgeons, keepers, and buriers are not to
pass the street without holding a red rod or wand of three foot in length
in their hands, open and evident to be seen, and are not to go into any
other house than into their own or into that whereunto they are directed
or sent for ; but to forbear and abstain from company, especially when
they have been lately used in any such business or attendance.
Inmates. That where several inmates are in one and the same
house, and any person in that house happen to be infected, no other
person or family of such house shall be suffered to remove him or
themselves without a certificate from the examiners of health of that
parish, or in default thereof, the house whither they so remove shall
be shut up as in case of visitation.
Hackney coaches. That care be taken of hackney coachmen that
they may not (as some have been observed to do) after carrying of
infected persons to the pest-house and other places be admitted to
common use till their coaches be well aired and have stood unemployed
by the space of five or six days after such service.
There were also orders issued for the cleansing and keeping of the
houses and streets sweet, and the prohibition of the sale of stinking fish,
or unwholesome flesh, or musty corn, or other corrupt fruits, or the use
of musty and unwholesome casks in breweries and tippling houses. It
was further ordered that no hogs, dogs, or cats, or tame pigeons
or conies be suffered to be kept within any part of the city.
Plays, public feastings and large assemblies were prohibited,
and regulations were made regarding beggars and tippling houses.
Yet as Hodges remarks in his Loimologia, or an historical account of
Hode-es ^^^ plague in London in 1665, " although both the makers
opposed and executors of the laws were very diligent in their duty
shutting up during the late sickness the contagion notwithstanding
the sick spread." He is doubtful whether the shutting up of
and the well / . .
in the same infected houses proved a serviceable measure, and he is of
house. opinion that many lost their lives by it, the tragical mark
on the door driving proper assistance from them. In his chapter on
preservation from a })estilence he remarks that " the timely separation
also of the infected from the well is absolutely necessary to be done,
because the most sure way of sjjreading it is letting the sick and well
348 The Preventunt ami Siqfpression of Plafjue [part iv
converse together. Public funerals ought to be forbid, as also all kinds
of meetings and frequent intercourse of several persons together; an
injunction also of quaiantine from infected places according to the
custom of trading nations is by any means nitt to lie omitted and
carelessly to be executed'."
In 1720 these views, which a})})arciill3' prevailed in Scotland as early
as the 16th century, and led to the Scotch system of
Dr Mead's . .
views in evacuating infected houses, are more fully developed by
•^^^°' Dr Mead on the occasion of the epidemic of plague in
Marseilles which gave rise to much alarm in England. In his short
discourse concerning pestilential contagion, and the methods to be used
to prevent it, Dr Mead advocates the establishment of
Ad.V0C3-CV of
the establish- lazarettos and quarantine on the Venetian system to pre-
ment of want the importation of plague by sea, and in the event of
hospitals and ^ r .
quarantine the disease breaking out in a locality the abandonment
s a ions. ^^ ^j^^ shutting up of infected houses, and the substitution
of a system by which the houses were evacuated, the sick being removed
to special airy buildings and the sound to others, both being three or
four miles outside the town. The sound people were to be stripped of
their clothes, and washed and shaved before they went into their new
lodsfings. After the infected houses were evacuated it was
Evacuation o o
of infected advised that the goods should be buried and if possible
houses. ^j^g houses demolished or cleansed. In addition to these
measures great attention was to be paid to sanitation. If the plague
increased to such an extent that the sick were too many to be
removed, then he advised the fumigation of the houses with vinegar
or smoke of sulphur, and attention to health of the individual, the
personal use of issues, smoking, flight, care in burial of the dead,
the prohibition of assemblies, and the forbidding of convalescents
leaving their houses until a certain time had elapsed. To prevent the
plague spreading fi-om town to town he advised a modification of the
cordons sanitaires that were customary on the Continent. " -The best
Passport method for which, where it can be done, is to cast up a
system for Une about the town infected at a convenient distance and
to°ieave % phicing a guard to hinder the people passing from
infected j^ without due regulation to other towns: but not
absolutely to foi'bid any to withdraw themselves, as
town
^ Loiviologia, or an Historical Accnnnt of the Plafiiic in London in 10(>5, p. 106.
By Nath. Hodges, M.D. London, 1720.
- A Dincoxirse on the Plague, p. 142. By Richard Mead, Fellow of the College of
Physicians and of the Eoyal yociety. Ninth Edition, 1744.
CH. xvii] Dr Mead's Views hi 1720 349
they have now done in France according to the usual practice abroad,
which is an unnecessary severity, not to call it a cruelty. I think
it will be enough if all who desire to pass the line be permitted
to do it, upon condition they first perform quarantine for about 20 days
in tents or other more convenient habitation. But the greatest care
must be taken that none pass without conforming themselves to this
order, both by diligent watch and by punishing with the utmost severity
any that shall either have done so or attempt it ; and the better to
discover such it will be requisite to oblige all, who travel in any part of
the country, under the same penalties to carry with them certificates
either of their coming from places not infected, or of their passing the
line by permission. This I take to be a more effectual method to keep
the infection from spreading than the absolute refusing a passage to
people upon any terms. For when men are in such imminent danger
of their lives where they are, many no doubt if not otherwise allowed to
escape will use endeavours to do it secretly let the hazard be ever so
great, and it can hardly be but some will succeed in their attempts ; as
we see fell out in France notwithstanding all their care. But one that
gets off thus clandestinely will be more likely to carry the distemper
with him than twenty, nay a hundred, that go away under the preceding
regulations : especially because the infection of the place he flies from
will be by this management rendered much more intense ; for confining
people and shutting them up in great numbers will make the distemper
rage with augmented force, even to the increasing it beyond what can
be easily imagined, as appears from the account that the learned
Gasendus has given us of a memorable plague which happened at Digno
in Provence, where he lived in the year 1619. This was so terrible that
in one summer out of 10,000 inhabitants it left but 1500, and of these all
but five or six had gone through the disease, and he assigns this as
the principal cause of the great destruction, that the citizens were too
closely confined and not suffered so much as to go into their comitry
houses."
Dr Mead's recommendations fortunately were never required to be
put in practice in England. Some of them were adopted in India during
the present epidemic of plague. In England quarantine regulations
First auaran- were never favourably received, and it was not until the
tine Act reit^n of George IV that a quarantine Act was passed by
passed in . . . r ./
reign of Parliament for Great Britain and Ireland. It was repealed
George IV. jj^ 1897, and all quarantine was abolished. The countries
bordering on the Mediterranean, especially Italy, France, and Spain,
always attached mucli importance to quarantine and the lazaretto
350 TIte Freiwntion ajul Sf(/)pirfisfO)f of Plague [part TV
system as a protection against plague. Their intimate intercourse
with, and comparative proximity to the Levant largely influenced
their views, which appear to have been formed not without founda-
tion, for since the epidemic in Marseilles and Provence in 1720,
which caused nearly 90,000 deaths, plague has been introduced into
International ^^^^ quarantine station at Marseilles before the Chinese
preventive epidemic came into being no fewer than nine times,
Soducerir *1^® 1'^^^ b^ing in 1837. In 1838 quarantine stations were
1831 and formed in the Turkish dominions in order that plague
should be dealt with by European measures nearer its
centre. The direction of these sanitary precautions was entrusted "to a
Superior Council of Health in Constantinople to which the European
Powers delegated medical men. Previous to this, at the time of the
cholera of 1831, an International Sanitary Council was established at
Alexandria for the protection of Europe against moving epidemics from
Disappear- ^^® 'E'S.st. It is to the establishment of sanitary stations
S)m°Turkf''^ and an active supervision on the highways of plague, and
and Egypt at- <»n the frontiers and gateways of Europe, that the dis-
Se*inter- appearance of plague from Turkey and Egypt is generally
national attributed, the disease not being truly endemic in these
measures. ,■ ■, , ■ j t ■ , ^ ^
countries, but imported into them from centres m Mesopo-
tamia and Arabia. The retrocession of the plague from Egypt and
Turkey was so remarkable an event, and followed so closely on the
organisation of protective measures, being not more than 7 years in the
one case and 14 years in the other, that it is difficult to dissociate from
them the relationship of cause and effect. There is no reason to
challenge the beneficial effect which is likely to have been exercised by
these sanitary measures, but on the other hand it is possible to
other causes exaggerate their influence. In a previous chapter the
also at work, g^at change which took place in the trade routes from the
East is pointed out, and the very great influence which such a change
IS likely to have exerted in preventing the transportation of the infection
of plague from endemic centres is discussed. Plague had been per-
ceptibly receding eastwards for the past 150 years, and not in any
known relationship with the introduction of protective measures. Its
pandemic area appears to have been contracting considerably both in
Europe and the East. In the 17th century plague disappeared from
the greater part of Western Europe in ten years, and in every succeeding
epidemic the tendency was to recede further eastwards, which is notice-
able until the middle of the 19th century, when in the course of five
years, from 1839 to 1844, it disappeared entirely- fi-om its eld haunts in
CH. xvii] International Cotiferences in the l^th Century 351
South-eastern Europe, the Levant, and Egypt. The epidemiological
factor is, therefore, not to be forgotten in judging of the value of the
restrictive measures, and of the two it would appear that the first was
the more influential. Why at one time a disease takes on the character
of an invading force with the power of transmissibility, and at other
times is possessed of a tendency to remain stationary, or even to
contract its area over which it has prevailed, it is impossible with our
present knowledge to explain. It is nevertheless a fact, and it is
remarkable that whenever a strong invading epidemic
measures to has to be dealt with, the organisation of quarantines,
prevent cordons sanitaires, and other restrictive measures mostly
spread of . . . , .
strong invad- fail. The failure may be due to the invading epidemic
^°^^th^'^^°^^''^ possessing other means of extension than the ordinary,
possible or to the fact that the usual modes of extension of ordinary
epidemics are not known, and that the protective measures
employed cover only a few of the means of attack, and possibly not the
most important. We are still too much in the dark regarding plague,
but an illustration of the latter point may be taken from cholera. The
discovery that cholera spreads by water and could be introduced into
a town by the river from which the inhabitants obtained their drinking
water was not antagonistic to the view that cholera was transportable
from place to place but it completely demonstrated that, while the
cordon sanitaire and quarantine were doing their part in the defence, the
disease was capable of entering the town by ways over which these had
not the slightest control, and hence they were bound to fail.
In the same way quarantine might be effective in preventing patients
suffering from yellow fever being landed fi^om a vessel, and yet yellow
fever might not be prevented fi:om gaining access to the port because of
infected mosquitoes which would not be dealt with by quarantine.
With the disappearance of plague from Egypt and Turkey in the
middle of the 19th century, the same urgency for pre-
International , • • j. i.i ^ v ^ i j.- j
conferences caution against the spread ot plague no longer continued.
of European q^'h^ lazarettos, quarantines, and cordons sanitaires,
Pow6rs to
consider which were the weapons employed by each country to
nieasures safeguard itself against the importation of plague, were
protection now used to meet the invasion of cholera. Failure to
epmemic prevent importation was attributed to a want of uniformity
disease from [^^ ^he measures adopted, and as the checking of these
tbe East. . ^ t-i • •
epidemics was a matter of European interest it was
considered advisable that in times of danger representatives of the
:3.")2 The Prerention <(n(I Suitjn'cssioii of rUujiu' [i'AKT iv
European Powers should meet and discuss the means of defence which
might be adopted in common for frontier and for seaport. The first
of these conferences was held in Paris in 1852, and the second in
Constantinople in 1806, but no radical change was effected in the older
regulations at either of these meetings. At the third conference,
New basis for li^^wever, held in Vienna in 1874, an important agreement
maritime was come to which placed the maritime preventive
IjrGVGIltiVG
measures measures on a different basis than had been the case
adopted at hitherto. It was decided that the guiding principle for
the Vienna . -ipi-p
Conference, action was not to be the arrival of a ship from an
^*^*" infected country, but the state of health of those on board.
Quarantine in its former sense was abolished, and the period of in-
cubation of the sickness on board became the standard or limit of
duration of detention. In the conference at Rome in 1885 land
quarantines and cordons sanitaires for cholera were declared to be
useless. Other conferences, at Venice in 1892, at Dresden in 1893,
and at Paris in 1894, were held on the subject of cholera. Plague
was not considered. For many years it had appeared to be almost
extinct.
There were local outbreaks in Benghazi in 1856, 1858, 1859, and
1874, and in Mesopotamia in 1867, but it was not until
Quarantine ^ ^ . . - _
and sanitary the very fatal outbreak at Vetlianka on the Volga in 18/9
brouffht into ^^^^ any alarm was caused by the disease. In each of
requisition in these outbreaks the sanitary cordons and quarantine
outbreak regulations were brought into requisition. Before these
of plague local outbreaks it had been shown bv the investigations
in 1879. -^ . . °
by Aubert Roche, and the French Commission who en-
quired into the question in 1843, that notwithstanding some exceptions
ordinarily the maximum period of incubation did not exceed eight days.
In the Vetlianka outbreak there were special cordons around infected
villages, and a general cordon around the district containing the infected
villages. Persons who had been in an infected village had to undergo
42 days of quarantine, and persons outside the infected villages, but
within the general cordon, wishing to leave had to undergo 10 days'
quarantine'. Tholozan clearly establishes that neither for the Benghazi
noi- the Mesopotamian outbreaks did the quarantine or the sanitary
cordons exercise the slightest influence in controlling the disease. They
were not put into force until the epidemics were nearly at an end. The
evidence is not so positive as regards the Vetlianka outbreak on the
' Ninth Aniiuiil Hipmt of the JmcuI Goverjiiuent Board. Levantine Plague, 187i'-80.
CH. xvii] Diial Charader of Plague Epidemics 353
Volga, though even here the cordons were placed round the village and
district only at a late period of the outbreak. Notwithstanding the
fatality of the disease in the outbreaks which were investigated in
Benghazi, Mesopotamia, Vetlianka and Persia, one fact becomes evident
in all, and it is that the disease at that time possessed very slight
disposition to spread. On the contrary, each outbreak presented a
well-marked tendency to self-limitation and was apparently quite
unafifected by the measures tardily introduced for its suppression.
It is the dual character of plague which causes difficulty in estimating
the value of the older or even of the newer methods of dealing with an
epidemic. At one time the disease possesses most active properties of
extension, while at other times it is almost devoid of them. Accordingly
in an epidemic wanting in diffusive attributes and strictly self-limited in
its character, the measures adopted for its control very readily acquire a
reputation for efficacy which they do not deserve, while in an epidemic
with strong diffusive powers they may readily be under-estimated from
their apparent powerlessness in either altering the course of the epidemic
or preventing its spread to other localities. It will only be when more
is known of the general laws governing epidemics of plague that a true
estimate of such measures can be made.
23
CHAPTER XVIII.
EXISTING MEASURES AGAINST PLAGUE,
AFTER DISCOVERY OF BACILLUS.
Measures to prevent importation of plague.
Existing measures against plague may be divided into those taken
to prevent the importation of the disease and its spread into other
countries and locahties, and those for the suppression of the disease in
the locaHty infected. These may be further subdivided into Interna-
tional and Local.
Two motives have inspired international action against plague ; one
is a common interest of self-preservation from a disease
measures. which is extremely destructive and the germs of which
are transportable from place to place ; the other is that
there should be some uniformity of action so as not to interfere with
commerce more than is absolutely necessary. International measures of
prevention as regards Europe are, as has been shown, a product of the
early part of the 19th century.
In 1897 an international conference of the European Powers was
held at Venice and a convention was signed, in which it was agreed
that certain protective measures, having for their object efficiency but
at the same time the avoidance of unnecessary restrictions on commerce,
should be put into force against the threatened invasion of plague from
the East. It was further agreed that any infringement of the conven-
tion on the part of any one of the signatories absolved the other
Powers from adherence to the agreement with reference to that par-
ticular Power and allowed them to adopt towards it, if necessary, more
stringent measures.
The regulations framed at the conference were based on the
, . views entertained at the time that the chief danger of
Regrulations ...
of the Venice the spread of plague was associated with sick persons
of 1897.^'°° and their personal effects, and that the period of incu-
bation was the determining factor in the limitation of
detention for observation purposes. The regulations included :
CH. xviii] Venice Convention of 1897 355
(1) International notification of places infected with plague, so
that all being apprised of the fact, each Government has the opportunity
of taking in time the necessary precautions for self-protection.
(2) Medical inspection of crew and passengers leaving infected
ports, the prevention of the embarkation of any person showing
symptoms of plague and the disinfection of infected and suspected
articles.
(3) Special precautions with regard to ships coming from infected
ports and passing through the Red Sea or Persian Gulf, the gateways of
the maritime traffic of the East with Europe.
(4) Special precautions with regard to pilgrims from an infected
country.
(5) Measures to be taken at the port of arrival with regard to
vessels from an infected port. Such vessels are classified as healthy,
suspected, and infected. Healthy vessels are those which have left an
infected port for 10 days and more and have had no cases of plague on
board. Suspected vessels are those in which cases of plague have
occurred but not within 12 days, and infected vessels are those in which
plague cases have occurred within 12 days of arrival.
All ships coming from infected ports are subjected to medical
inspection and the measures taken depend on the events that have
occurred during the voyage. Certain terms are used in this connection.
The term " observation " means isolation of the passengers on board
a ship or in a lazaretto till they have obtained free pratique, and
" surveillance " means that the passengers will not be isolated but
on arriving at their destination they will be kept under medical
surveillance.
Healthy ships are at once given free pratique and the passengers
and crew are subjected to "surveillance" for 10 days from the date on
which the ship left an infected port. The authorities may also insist on
the pumping out of the bilge water and the substitution of good drinking
water for the water stored on board.
Suspected ships are treated with more care. The crew and passengers
are subjected to " surveillance " for 10 days from the date of arrival of
the ship. The soiled linen and personal effects of the crew and passengers
are disinfected. The bilge water is pumped out after disinfection and
a supply of good drinking water is substituted for that stored on board.
All parts of the ship which have been inhabited by plague patients are
disinfected and the local authorities have power to order a more thorough
disinfection.
23—2
356 The Prevention and Suppression of Plague [part iv
Infected ships have their sick landed at once and isolated, and the
crew and passengers are, at the discretion (jf the local authority, subjected
to " observation " or " surveillance " for a period varying according to the
sanitary condition of the ship and the date of the last case of plague,
but which must not exceed 10 days. The other precautions are similar
to those laid down for suspected vessels. The soiled linen and personal
effects of the crew and passengers suspected of being infected, and all
parts of the ship which have been inhabited by plague patients, are
disinfected. It is within the power of the local authority to cause
a more thorough disinfection. The bilge water after disinfection is
pumped out and good drinking water substituted for the water stored
on board.
As regards merchandise, cargo, and baggage, the old system of
Merchandise (|narantine has completely given way to either absolute
to be pro- prohibition of the importation of susceptible goods, or to
hibited or , . . „ . , . . n ^ r^
disinfected dismiection according to the option oi the (jrovernments
If thought concerned. The only articles which must be compulsorily
necessary . . . , -^ _ _ _ ^ ■'
but not disinfected, if admitted, are soiled linen, wearing apparel,
quaran me . clothes, and articles carried as personal baggage, or house-
hold goods coming fi'om a local area declared to be infected, and
which the local sanitary authority deems contaminated. Disinfection
of merchandise is only enforced in the case of merchandise and articles
which the local sanitary authority considers contaminated, or whose
importation may be prohibited.
The susceptible articles or goods which may be prohibited are :
1. Used linen, clothing, personal effects, and bedding.
2. Rags, including rags compressed by hydraulic force, which are
carried as merchandise in bales.
3. Old sacking, carpets, and old embroidery.
4. "Raw hides, untanned and fresh skins.
5. Animal refuse, claws, hoofs, horse-hair, hair of animals generally,
raw silk, and wool.
6. Human hair.
Quarantine on land frontiers for merchandise is abolished, and letters
and correspondence, yjrinted matter, books and business
Quarantine , i • i i
on land documents, except parcels received through post, are sub-
aboiish?d jected to no restriction or disinfection. Quarantine on
land frontiers is also abolished for travellers. Medical
inspection on the railways, at the custom houses, and at special stations,
with the detention of the sick and the surveillance of travellers from an
CH. xviii] Paris Convention of 1903 357
infected area, are the measures on which reliance is placed to screen
out the sick fi'om the healthy, and to keep a control over the spread
of the disease.
As certain classes of people, such as gipsies and vagabonds,
Quarantine emigrants, and persons travelling or crossing the frontiers
not aboUshed in large bodies, are a special danger in conveying disease,
classes and the same liberty is not accorded to them, and each
pUgrims. Government reserves the right to take special measures
against them.
It is this particular danger attached to crowds moving from one
place to another that has necessitated the framing of special and more
stringent regulations for the control of the pilgrim traffic to and from
the Hedjaz. The Kaabah in Mecca is to the Mahommedan the holiest
place on earth, and Medina contains the shrine of their prophet. It is
the ardent desire of every Moslem to carry out the injunction of
Mahomet to make a pilgrimage to the Holy Land and worship at the
Kaabah. They come from India, Persia and the adjoining countries,
Java and the Malayan Archipelago, from the Mauritius, Zanzibar and
Madagascar, from Africa, from Asia Minor, and from the Turkish and
Russian Dominions. All who are able converge to this one centre to
be present and to engage in the rites and ceremonies of the Kurban
Bairam festival. The fatigues, privations, and insanitary conditions to
which the poorer pilgrims are subjected during the voyage to the
Hedjaz, the crowding that takes place during the festival, and the
misery and filth that follow from the overcrowding, are all conducive to
the prevalence of infectious diseases, the seeds of which are apt to be
scattered on the track of the pilgrims on their return journey and to be
carried back even to their distant homes.
The convention was not signed by Portugal, Turkey, Greece, and
Servia.
In 1903 another conference of the Powers was held in Paris for the
The measures Purpose of codifying the terms agreed to in previous
agreed upon conferences and modifying or adding: to them. Bv this
at the Venice ^ 0 a j
Convention time more was known of plague and it was evident that
h^d"^\"^*^^^ although the international measures agreed to in 1897 had
stopped proved useful and that Europe remained free of epidemic
thlTmporta- P^^g^^^' Y^^ ^^"^^^ then there had been a small outbreak in
tion of Oporto in 1899, in Glasgow in 1900, in Naples in 1901, and
p ague. ^^ Marseilles in 1 903, and in none of these places was the
infection traceable to imported cases of plague in human beings. More-
358 The Prevention and Suppression of Plague [part tv
over, notwithstanding similar regulations having been put into operation
in many of the ports whose Governments were not signatories to the
Venice Convention, plague had spread to them and was gradually
distributing itself from port to port in different parts of the world. It
was obvious that the axiom which applied to cholera and which was
adopted in 1874 at the Vienna Conference for that disease and on which
protective measures against plague Avere based, viz. that it is not the
arrival of the ship which renders it necessary to treat the same, but the
state of health of those on it, had to be modified in the light of experience
of plague and shape itself somewhat more in accordance with the older
views. Much had been learnt during the six years about the plague
bacillus and the disease itself It was now known that there is a bubonic,
septicaemic, pneumonic and pustular form of plague ; that only the
septicaemic and pneumonic forms are specially infective ; that the period
of incubation is usually less and rarely more than 10 days ; that rats are
very susceptible to plague ; that there is a connection between rat plague
and human plague ; that certain animals besides rats may take plague ;
that plague is transportable by infected human beings, infected animals,
especially rats, and by infected clothing and by articles contaminated with
infective material, and that Haffkine's prophylactic and Yersin's serum
exert a sensible protective effect.
The regulations of the Paris Convention of 1903 confirm those of
the Venice Convention except in two important respects.
of the Paris Oi^e is that the period of detention of infected ships is
Conference reduced from 10 to 5 days, and the second is that in
of 1903. . . . . . •' .
addition to disinfection of an infected vessel all the rats on
board must be destroyed. The creation at Paris of an international
sanitary office to receive and transmit sanitary information to the
countries which adhere to the convention was also agreed to as
desirable. The full text of the Paris Convention of 1903 is given in
Appendix II of this work.
Local measures to prevent the importation of plague devolves
Local usually on the municipal authorities under the supervision
measures. ,jf Government. They mostly consist in providing the
machinery to carry out the regulations framed at the Venice and Paris
Conventions. Additional protective measures may be taken by the
signatories of the convention so long as they do not run counter to the
principles and regulations of the convention itself. Arrangements
are accordingly made to provide for :
(a) Medical inspection of all ships coming from infected ports.
CH. xviii] Local Measure.^ of Prevention 359
(6) Hospitals for the isolation of plague cases arriving from an
infected country.
(c) Observation buildings for persons whom it is thought advisable
to place under observation.
{d) Medical surveillance.
(e) Disinfection of suspected and infected ships, of soiled linen and
of luggage.
(y) Destruction of rats on board suspected and infected ships, and
also on ships from infected ports.
(^) Prevention of ships from infected or suspected ports being
moored alongside the wharves or quays unless rats have been
destroyed.
ill) The inspection of forage, fruit crates, grain bags, and other
cargo from infected centres to prevent the conveyance of rats in them
and the possible importation by rail of some which may be plague-
infected.
Next to the prevention of admission of cases of plague and the early
isolation of any which may have escaped medical inspection but which
were discovered after arrival at their destination during the period of
surveillance, the most important measures are the destruction of rats on
board ships from infected ports and disinfection of suspected and
infected ships. Until recently the destruction of rats on board ship was -
peculiarly difficult, no method being found to be entirely
employed satisfactory. The generation of carbonic acid gas was
destruction tried but it was found to be very expensive, and not
of rats on very effective ; carbonic oxide was also employed but
the colourless, odourless and poisonous nature of the gas
renders it unsafe and dangerous to use. Only since the introduction
of the Clayton process of fumigating with sulphur-polyoxide has a
thoroughly satisfactory, efficient and controllable method of destropng
rats on board ship with certainty come into use, and it moreover has
the advantage of germicidal and insecticidal properties.
These triple powers, together with the fact that it has no injurious
effect on textile fabrics or on gfrain, render it of the highest
The Clayton , i ^ i • \ ^ c y- ■ c ^■
process for value, not only for destroying rats, but also tor dismiectmg
the destruc- ships, whether empty or full of grain or other cargo except
and disinfec- fruit and vegetables. The gas, which analyses show to be
tion of ships. ^ mixture of SO2 and SO3 together with some unknown
gaseous toxic combination of sulphur and oxygen, is generated by
burning rolls of sulphur at an intense heat in a very simply constructed
360 The Prevention anrl Suppression of Plague [part iv
apparatus, which is usually fixed on a small launch so that the machine
may be brought to the side of any ship that requires fumigation. Air
is supplied to the burning sulphur by an induced draught, which at the
same time draws the heated gases so formed through a cooler attached
to the apparatus. This cooler is kept at a low temperature by a con-
tinuous passage of water through it. The water can be taken from
the dock. From the cooler the gas, reduced in temperature and volume,
passes to a blower, which propels it through a hose-pipe to the part of
the ship that is to be fumigated. There is a return hose-pipe which
draws the air fi-om the chamber that is being fumigated to the furnace.
It is this air which first supplies the sulphur in the furnace with oxygen
for combustion, but as the percentage of gas in the compartment that
is being fumigated rises, the withdrawal of such air to feed the furnace
cannot be continued, as 5 "/o of the gas in air possesses fire-extinguishing
properties. Even a smaller percentage would cause the sulphur to burn
badly, and tend to put out the fire. Accordingly, whenever the return-
ing air from the compartment registers 3 "/o) the cormection between the
return-pipe and the furnace is closed, and a valve is opened near to
where the pipe enters, which permits an incurrent of fi:-esh air to the
furnace from the outside. When the percentage of gas in the furnace
rises to about 18, and there is a tendency to exceed this, in order to
prevent any volatilisation and deposit of sulphur along the pipes a
second valve is opened, which keeps the percentage of gas formed in
the furnace at a regular standard.
The system is first one of propulsion and exhaustion, but when the
air exhausted contains 3 "/o of gas, the exhaust pipe is
properties of shut off, and a high percentage of gas is then continued
^ ^^^' to be propelled into the chamber until the air in it reaches
a saturation of 12 to 15 "/o- A very simple contrivance indicates the
percentage of gas that is being propelled or exhausted through the
tubes, and by a similar test the percentage of gas in the compartment
that is being fumigated can be ascertained. A percentage of between
10 and 12 is sufficient for all purposes; a large machine is capable of
generating 800 cubic feet per minute of 18 " o gas. The gas driven
into the supply pipe emerges from it into the chamber to be fumigated
in the form of a white fuming gas, which is exceedingly irritating to the
mucous membrane of the respiratory passages when breathed in small
quantities and in a confined space. The presence of the gas is thus
readily detected and recognised by the irritating effect it produces on
the respiratory passages and by the fact that it is visible. These two
CH. xviii] Fiunigathn by the Clayton System 361
qualities are particularly advantageous, because those employed in carry-
ing out the fumigations are able to see the gas when it escapes from the
pipes, and they are rendered so uncomfortable by the irritation of the
eyes, nostrils, throat and chest as the percentage of gas increases in the
room, that it necessitates a speedy retreat from the room to the fresh air
outside, and thus there is no chance of the operators being injuriously
affected by the gas. This irritating effect on the mucous membrane of
the respiratory passages drives rats, insects and other vermin from their
holes and hiding-places in search of relief, and they die in the open
where their dead bodies can be collected, thus avoiding the great
inconvenience of rats dying in their holes from poison or from- the use
of non-odorous gases such as carbonic oxide and carbonic acid. The
gas itself has no effect on the clothes or the person of those exposed
to it, provided fresh air is supplied for breathing purposes. In a
number of experiments carried out by the writer the engineer who was
conducting the operations put on a specially designed diving helmet
and several times entered a passage and cabin saturated with 10 to 12 "/o
of the gas, and removed articles which had been exposed.
The readiness with which the gas is detected compares very
favourably with carbonic acid and carbonic oxide gases, which are not
only odourless but invisible, and if breathed even in small quantities
are liable to produce poisonous effects without any warning.
The gases formed by the combustion of sulphur at a high tempera-
ture such as is attained in the Clayton furnace, which not infrequently
reaches 1800° F., are of a complex and unstable character, consisting of
S0.2 and SO- and other higher sulphur oxides. When sulphur is burned
in the open air the product is almost entirely sulphurous acid (SO.2) with
a very minute quantity of sulphuric anhydride (SO3), but in the Clayton
furnace, where the products do not readily escape, besides the production
of SO.2 a second reaction takes place and a greater quantity of the
sulphurous acid (SO.) is converted into sulphuric anhydride (SO3).
There are limits to the production of the sulphuric anhydride (SO3) in
the furnace as heat decomposes it into sulphurous acid and oxygen,
but analyses show that the amount of sulphuric anhydride sent
through the blower is more than 60 times greater than that pro-
duced by burning sulphur in the open air under ordinary conditions.
Sulphurous acid does not show any signs of cloudiness in the air while
sulphuric anhydride is intensely cloudy. It is this smoky character of
the gas pumped from the Clayton furnace which distinguishes it from
sulphurous acid alone which is colourless, and it is the presence of the
362 The Prevention and Suppression of Plague [part iv
sulphuric anhydride and possibly other unstable oxides which endows the
gas with its highly toxic properties.
From a series of experiments carried out in the early part of 1903
by Professor R. Tanner Hewlett, Dr H. S. Willson and the writer on
board the s.s. Manora in the port of London it was ascertained that :
1. The gas generated from the Clayton furnace and saturating
the holds of the ship to the extent of 10 and 12 "/y is a toxic gas.
2. That a six hours' and even a four hours' exposure to a 10 "/o or
12 "/o gas is fatal to rats and insects such as cockroaches, bugs, fleas, and
grubs, and to mosquitoes and mosquito larvae and pupae. As a matter
of fact all of these are destroyed by a much shorter exposure to a gas
of 3Vo.
3. That a similar exposure to a 10 or 12 70 gas is destructive to
the vitality of the bacillus of plague, cholera and typhoid fever, but has
no action on the spores of anthrax.
4. That the gas is a preservative of meat when moderably exposed,
and is not injurious to food-stuflfs except fruit and some kinds of
vegetables.
5. That merchandise, such as dyed silks, print stuffs, books,
photographs, tea, coffee, etc., if dry, are unaffected by the gas.
6. That upholstering stuffs and machinery sustain no damage
from the gas, but that metals are tarnished and afterwards require to be
cleaned, when they regain their former appearance.
These observations are in consonance with those observed elsewhere.
Dr Calmette, Director of the Pasteur Institute at Lille, found that dry
cultures of streptococcus and of typhoid bacillus mixed with or without
blood were destroyed by exposure for six hours to an 8 "/o concentration of
the gas generated by a Clayton machine, and that cultures of plague
and of cholera were destroyed even by a two hours' exposure to an
8Vo gas.
Steamers with and without cargo, hospitals and other buildings have
been fumigated with the gas with destructive effect to every form of
vermin, and to cultures of bacilli placed under condititms calculated to
test to the utmost the penetrative power of the gas. Large numbers of
vessels with cargo of every kind have been fumigated at Dunkerque and
elsewhere with success and without any damage to the cargo.
Textile fabrics of the most delicate colours, so long as they are pro-
tected by wrappings from the direct action of the gas, are not affected
either in texture or colour. In an experiment made with 150 samples
of coloured silks, three were slightly changed in tint but not bleached.
CH. xviii] DeMnictioit of Ratx hi/ Claiftou System 363
In merchantable bales they would not be exposed to the direct action of
the gas.
Experiments have also been made by Dr Clemow at Liverpool, Drs
Savage and Walford at Cardiff, Dr Robertson at Cape Town, in which
plague bacilli and rats have been killed in a few hours' exposure to a 10
and 12 7o strength. Other experiments made by Dr W. A. Evans of
Bradford, by Dr Dzeryhopky of St Petersburg, by Dr Tamayo, who
carried on similar experiments in New York on behalf of the Peruvian
Government, confirm these observations.
In 1904 the Local Government Board issued a report on the destruc-
tion of rats and disinfection on shipboard by J. S. Haldane, M.D., F.R.S.,
and John Wade, D.Sc, in which from observations on the Clayton
process they conclude that :
" For the treatment of a vessel's hold the Clayton method possesses
very distinct advantages. In the first place, the process of filling the
hold with the gas can be carried out simply by gravitation. The gas
must in time find its way to the bottom because it is heavier than air.
Any hold can thus be treated, whatever the construction or system of
ventilation may be. In the second place the process is perfectly safe.
There is not the slightest risk of fire or explosion, and the possibility of
asphyxiating any one on board is, with ordinary care, very remote, as the
gas is so unpleasant that any one exposed to it would at once become
alarmed, and escape long before any dangerous effect was produced; and
moreover the gas is visible. A third advantage is that the gas, unlike
carbonic oxide, kills insects. A fourth is that, as shown in Dr Wade's
report, which on this point confirms and amplifies the results of other
observers, the gas produced by the Clayton apparatus is a very efficient
disinfectant, provided it penetrates.
"The disadvantages of the process are: (1) That it causes serious
damage to various articles of food, such as fruit, flour or meat, and slight
damage to metal work, etc. (2) That it is absorbed to a considerable
extent by articles of cargo, and therefore penetrates a mass of cargo very
slowly. It is thus not nearly so rapid in its action in holds filled with
cargo as in empty holds, cabins, etc. Whether it will with certainty
kill all rats in a hold after a few hours of continuous treatment is still
uncertain."
The damage to metal consists, as stated before, only of slight tarnish-
ing, which cleaning will remove, and as regards the efficiency of the gas
in killing rats in a cargo-laden ship there is ample evidence of certainty
in the large number of ships that have been successfully treated,
provided the gas is retained in the cargo-holds for 12 hours. Cargoes
Precautions
to be taken
in carrying
out the
fumigation.
364 The Prevention} and Supjwemioi) of Plague [part iv
of sugar from the Mauritius are now treated on their arrival at Durban
by fumigation with a Cla3-ton uiachine with excellent results, and with
no damage to the cargo.
The objections to fumigation by the ordinary process of burning
sulphur are the risk of fire and the bleaching effect which
it frecjuently causes to the goods subjected to the process.
Neither of these risks are encountered in fumigating with
the Clayton apparatus.
The secret of the success of the method and of no injurious effects
being produced either on the texture or colour of the fabrics exposed to
the action of the gas, appears to lie in the cooling of the gas before it is
forced into the compartment to be fumigated ; were it pumped in in
a heated condition there would be condensation of moisture and
permanent absorption of the gas when it cooled, which would be then
liable to damage some of the merchandise. In fumigating, it is im-
portant that the compartments already fumigated should not be opened
until those adjoining have been filled with gas. This jjrecaution is
necessary to prevent the rats escaping into compartments already
fumigated. For the same reason it is also necessnry to leave no part of
Fig. I. Disinfection by Clayton System of laden Steamer infected with Plague.
CH. xviii] Dislufectioii by Clayton System 365
the ship unfuinigated ; even the boats should be exposed to the fumes.
The duration of the fumigation should be adapted to the size of the
ship. For small ships the gas, at a concentrated strength of 10 to 12 Y,,,
should be shut into the holds for fully 6 hours, while for the largest
vessels and liners it should be for much longer, which need cause no
great inconvenience, for if the fumigation is begun in the early
morning the cabins which have been disinfected will be fit for occupa-
tion at night, while the holds will retain the gas for the whole night.
This or similar arrangement will permit of the exposure of the cargo to
the action of the gas for 24 hours or longer without inconvenience or
much delay. The gas can be used for disinfecting every part of the
ship except the decks, which can be washed down with a solution of
corrosive sublimate or cyllin. Such a fumigation destroys rats, vermin
and plague infection. Fig. 1 shows the Clayton apparatus at work
disinfecting a plague-infected ship.
A process which will destroy the rats and insects on ships having
commercial relations with plague-infected ports, and will
Uses of the , , , • <• • / , , • ,
Clayton dis- '■^^ the same time destroy the miection oi plague which
infector on ^-^^ l^g ^^ ^j^^ ships, and accomplish these without
board ship. -^ ^ . ^ .
damage to the merchandise and cargo, is a weapon of the
utmost value, when properly used in combating the spread of plague.
There can be no doubt that the toxic gas generated by the Clayton
apparatus is such a weapon, and it is obvious that the general adoption
of the Clayton apparatus and its proper use in infected ports, and also
in those ports which have commercial relations with infected ports, will
secure a greater degree of safety with less inconvenience, delay and
expense than has been attained by the existing precautions or by
quarantine. Ships, especially mail steamers, carrying a disinfector on
board can under the supervision of their medical officer readily be
fumigated and have their rats destroyed on the voyage and before
arriving in port. Ships carrying emigrants, coolies and soldiers, also
cargoes of fodder, forage and grain, would be less liable to transport
disease if periodically subjected to the action of the gas.
In the case of transit ports, where only a small amount of cargo is
taken on, and it is impossible to clear the hold of the ship of all the rats
which have been killed by the fumigation, it is sufficient to fill up the
hold with gas and keep it there until the port of arrival is reached, to
prevent the rats which have been killed from decomposing.
Baggage on suspected and infected ships is far more expeditiously
Disinfection ''^^^^^ c(Kiveniently disinfected by the Clayton process than
of baggage. by any other. This can be done before the passengers
36<5 The Prevention and Suppression of Plaffue [part iv
arrive at port, if a disinfector is carried by the ship, or it can be done
by the local authority on ' arrival of the ship. If there is no Clayton
apparatus, the older processes will have to be adopted, which may be
exposure of the baggage and personal effects to the fumes of sulphur,
which is useless, or to the fumes of formalin, or boiling of the effects
in water, or soaking them in water to which a disinfectant has been
added, or subjecting them to steam sterilisation. The employment of
boiling water, disinTectants or steam is inapplicable to feathers, leather,
furs, skins, and other goods, as they would be spoiled.
The use of the apparatus is not limited to maritime commerce ; it is
useful on shore as well. One of the features of plague in South Africa
and elsewhere has been the number of railway stations and stores
in which plague rats have been discovered, the infection most probably
having been conveyed in the cargo by the trains. Disinfection of ware-
houses by the gas, fumigation of cargo at the place of departure and,
if need be, at the place of arrival, and disinfection of railway carriages
in like manner, are practical measures likely to be most useful in
preventing the spread of the disease from infected localities. Its utility
in disinfection of plague-infected houses will be referred to later on.
One of the most conspicuous features in the history of plague
epidemics and of the measures taken for their prevention
be in a state i^ ^^^ constant unpreparedness to combat the disease.
of prepared- jj^ Marseilles in 1720, though there was a quarantine
ness. . ■* . .
station, there were no arrangements for dealing Avith
plague should it arise. It was on the 25th of May that the plague
ship which is believed to have brought the infection arrived; it was
the 9th of July before the first case of plague was recognised among
the residents of Marseilles, and it was not until the 3rd of August
that it was decided that 150 citizens should be appointed to look after
the wants of the poor, and not until the 8th before it was resolved to
establish a pest-house. To combat plague, promptitude, foresight and
action on scientific lines are recpiired at every stage.
The precautionary measures to prevent the importation of plague
^ , should be supplemented bv others which are of an an-
Local mea- _ ^ *■ -^
sures to be ticipatory character and which have for their object not
anticipation '"^l^ the dealing promptly with a possible outbreak of
of an out- itlaq-ue, but also the early discovery of rat ])lague and the
break. ' . "^ " . .
destruction of rats. The actual organisation for this
purpose does not require to be on more than a very moderate scale,
but it is necessary that it shall be conceived on a liberal basis, so as
to allow of ready adaptation to the circumstances which may arise.
CH. xvni] Plague ffosjntals 367
Preparation should be made beforehand by the health authorities for
the rapid and ample provision of temporary hospitals for the sick, and
observation wards for doubtful cases ; for the selection of reception
houses, lazarettos or health camps for contacts, until the infected
houses are disinfected ; for the burial of the dead ; and for a special
plague organisation. It is unnecessary to enter minutely into the
kind of hospital required for plague cases, which will depend very
much on the locality, the resources available, and the people to be
treated.
Certain principles should be adopted, whatever the structure of the
. building. First of all, it is not advisable for the hospital
cipies should or hospitals to be erected too far from the infected town,
erection of otherwise conveyance from the home to the hospital may
pia^e \)Q too fatiguing for the patient. There is no danger in
hospitals. & & r &
a properly constructed plague hospital being erected
inside the town so long as it is kept free fi'om rats and is sufficiently
isolated from other buildings ; secondly, it is of the greatest importance
that every ward should have plenty of sunlight and very free ventila-
tion— the more the patients are subjected to the open-air treatment
the better is their chance of recovery ; thirdly, overcrowding must be
avoided at all costs, because crowding together of patients appears to
intensify the virulence of infection ; fourthly, the cases should as
far as possible be classified, mild cases being placed together and not
mixed up with the more serious — pneumonic cases appear to do best in
tents; and fifthly, accommodation should be provided for different
classes. The structure of the hospital should be as simple as possible.
The accommodation in hospital, health camp, observation wards, and
their number of staff, medical, nursing, and employees will, in the event
of a serious outbreak, require to be increased many times without
delay, and arrangements should accordingly be made to meet this
contingency.
Attached to the hospital but separate from it within the enclosure
of the hospital premises should be receiving rooms, observation wards,
administrative block, bacteriological laboratory, mortuary, laundry and
disinfecting apparatus, ambulance sheds, destructor for burning excreta,
etc., medical officers' quarters, nurses' quarters, and attendants' quarters.
The health camp or observation buildings, in which contacts are
lodged until their houses are disinfected, should not be
Health camps. . .
within the hospital premises, but it is advantageous for
them to be near one another. In addition to the necessary accom-
368 The Prevention and Suppression of Plague [part iv
modation, adequate provision should be made for disinfection and
washing the personal effects of those who may be removed. As in
the hospitals, so in the health camps or lazarettos, special accommo-
dation is necessary for different classes.
Arrangements require to be made for the proper disposal of the
dead. This has always been a source of difficulty. Burial
Arrangements • i • • i i
for disposal of should not be left to mdividual and private undertakers
the dead. without careful supervision, and there should always be
in readiness a special organisation to deal with the work, for im-
mediately the mortality rises to any great extent such an organisation
only can cope with the pressure of work. Cremation is the most
sanitary method of disposal when not objected to.
Nothing ought to be left to the last. A medical service should be
in readiness for the hospital and health camps and for
Administra- . . ... ,.
tive arrange- medical inspection, inoculations, and other medical
^^^ ^' measures necessary for the town or locality threatened.
Similarly, a nursing service has to be provided, and a special plague
service under the control of the medical service to carry out the removal
of the sick, the transportation of the healthy from infected houses to
the reception houses, the cleansing and disinfection of infected houses,
the removal of infected articles for destruction or disinfection, the
destruction of rats, the inspection of bake-houses, lodging-houses, rag
stores, pawnbrokers' shops, warehouses, grain depots, corn and oil
chandlers, etc., in the infected locality. Both the special plague service
and ordinary sanitary semdce should be under the direction of the
permanent health officer of the town, assisted by a special and adequate
medical staff. If there is no medical officer of health then a special
officer will be appointed. A dual control is to be avoided if possible.
To divorce the ordinary sanitary department from that which is newly
constituted for the emergency is to lose the experience of the older
department and not to obtain the best work out of the organisation ;
but to endeavour to deal with plague by the ordinary sanitar}^ depart-
ment is to court failure, for the routine sanitary work will be neglected
and there are measures to be adopted in plague which are not pro\dded
for under ordinary circumstances.
The nucleus of a plague department should accordinglj' be formed
capable of rapid extension; provision should also be made for the
bacteriological examination of rats, for their regular destruction, and
for the general sanitary improvement of the most crowded and in-
sanitary places.
CH. xviii] Systematic Examination of Rats 369
Bacteriological examination of rats should be carried out regularly
_ ^ . in all ports that are in communication with infected
Bacteno- ^
logical exami- ports, and when the ports of a country are infected, then
in the inland towns which have commercial relations with
these ports. As the docks and the neighbourhood of the docks are
the localities in a port in which the rat is likely to become first infected
with plague, the health conditions of the rat in these localities should
be carefully watched, which can only be efficiently done by systematic
and regular bacteriological examination. A bacteriologist should be
employed whose duty is to record daily the result of the bacteriological
examination of rats brought to him from different parts of the docks.
In inland towns the same watch is to be kept over the rats in the
markets and their neighbourhood, the railway stations, sheds and store-
houses belonging to them, the granaries, warehouses, rag stores,
slaughter-houses, workshops, and restaurants.
The susceptibility of rats and mice to plague, and their powers of
_ ^ . disseminating: the disease, render it imperative as a
Destruction . ° • i i i
of rats in precautionary measure that these animals should be de-
iocaUt*^a a stroyed in a healthy locality carrying on an extensive
precaution- traffic with an infected centre. The destruction of the
ary measure. ^ i ■ j u j • i r
rats and mice removes a dangerous breeding ground tor
plague. By clearing the healthy port beforehand of its indigenous rats
and mice, the locality is, to a certain extent, immunised. The measure
is, for plague, as necessary a sanitary precaution as the provision before-
hand of an unpolluted supply of water on the occasion of a threatened
invasion of cholera. In cholera the water contaminated with the
microbe disseminates the disease. In plague rats and mice infected
with the plague bacillus disseminate plague. The two agencies may
not be of the same importance and rank in their respective spheres.
In the case of cholera contaminated water is the chief di.sseminator and
with a protected supply a large epidemic is impossible. It would be
rash to assert an equivalent relationship between infected rats and
plague epidemics, but there can be little doubt that if there are no rats
and mice to infect, plague has a greater difficulty in effecting a lodge-
ment and spreading widely in a localit3^ The contagion having been
transported to a healthy place by sick mice or sick rats or by infected
baggage and merchandise, the indigenous rats appear to be, in a number
of cases, the link in the chain connecting the new epidemic with the
old, and if that link is wanting there is in those cases no serious
epidemic.
s. 24
370 TJte Prevention and Suppression of Plague [part iy
A systematic destruction of rats should also be carried out both
Methods i" ports and in inland towns in those localities which
available for are apt to be infected. To acconii)lish this the co-
tionofrats. Operation of the inhabitants should, if possible, be
Traps and obtained, wh(j bv means of traps and rat poison, such as
poison. arsenic, phosphorus and str3^chnine mixed with flour, can
destroy large numbers, especially if a small reward is offered for
each rat broucrht in to the depot. For the destruction of rats by the
local authorities two processes are useful and can be both used with
Fumigation advantage. The first is the fumigation with sulphurous
with Clay- pras of the sewers, warehouses, depots, stores, markets,
ton s appara- °
tus. stables, and sheds by Clayton's apparatus ; and the second
The employ- is by the employment of cultures of Danysz' bacillus for
Danysz' poisoning rats. The bacillus of Danysz isolated by him
bacuius. from field mice suffering from an epizootic which spon-
taneously broke out in the laboratory is harmless to man and to all
domestic animals, but is pathogenic to mice and rats. Its power of
causing an epizootic among rats is, however, limited, and it is far from
being able to produce an epizootic either so diffuse or destructive as
plague in these animals. Even plague which is so destructive to them
does not totally destroy the rat colonies in a town. The bacilli of
Loeftier and Loser are pathogenic to mice and not to rats. The Loeffler
bacillus or bacillus typhi nuirium is pathogenic to ordinary mice (mus
masculus) and field mice (mus agricola) ; the bacillus of Loser is fixtal to
mus agrarius, that of Mereshkowsky to ground squirrels.
A careful watch at the same time has to be kept on the nature of
A carefiu sickness prevalent and on the causes of death. The
watch on sputum of lung cases not clearl}^ due to other causes
sickness re- should be systematically examined and if thought necessary
quired, .^ thorough bacteriolos^ical examination should be made
especiaUy m " o
the poorer and the cultures tested on animals. This w^atch has to
^" ^^^' be specially kept on the sickness prevalent in the poorer
quarters, for plague is essentially a disease of the poor, attaching
itself to the poorest, most crowded, and filthiest localities of a town.
General sanitary measures for the whole of a town or a district
necessarily form a part of the ordinary routine against disease, epidemic
or otherwise, but zeal and expenditure in this direction must not be
allowed to overshadow the special measures that are required against
plague. The display of exceptional effort and the adoption of extra-
ordinary' measures in the general cleaning and disinfecting of the streets
CH. xviii] Caution as to General Measures 371
outside the most susceptible areas may assist in allaying public alarm,
but they will not exercise the slightest influence on the progress of an
epidemic of plague any more than they will arrest an epidemic of small-
pox. It is not general measures that are required but special measures
against special localities. Plague, in addition to being disseminated
by rats, has been observed to be favoured in its prevalence by darkness
and dampness, and is believed to be assisted in its spread by vermin in
general. No time should be lost in the application of measures having
for their object the removal of these causes, especially in common
lodging and tenement houses.
24—2
CHAPTER XIX.
MEASURES TO COMBAT AN OUTBREAK OF PLAGUE
IN A LOCALITY.
In the past all great outbursts of plague have been remarkable for
the similarity of their history. The obscurity of the
Preliminary -^ -^ . . ■;
observations earlier cases, the contradictory opinions of medical men,
Mn*^ances to ^^^ apprehension of the merchants as to the injury which
a locality |)lague would inflict on their commerce, and the alarm of
Glared in- t'^*^ populace at the very name of plague, have always been
fected with against the early recognition of the disease and have led to
plague. ...
denial of its existence or to great delay in admitting that
the disease was plague. Controversy was substituted for immediate
action, with the consequence that the necessary precautions which are
invaluable at the commencement were not taken until too late.
Muriatori, referring to such occurrences in connection with plague,
instances the plague at Venice in 1576, at Florence in 1630, at Malta in
1675, and at Venice in 1718. Russell in dealing with the same subject
refers to the Marseilles and Messina epidemics of 1720 and 1743. In
1720 Chicoyneau and Verny, sent by the King to study the disease
which had prevailed for some time at Marseilles, recognised its true
nature three months after the disease first began. Messina is worthy
of quotation >: "In that plague it appears that after the death of
the master and one of the mariners of the ship, which brought the
infection from the Morea in the latter end of March, the ship and cargo
were destroyed and the remaining crew were put under a rigorous
quarantine. That, no other accidents intervening, the first alarm
subsiding, the people resumed confidence as if all had been over, and the
15th of May was appointed for a Te Deum in the cathedral. That the
ceremony was interrupted after the people were assembled by a
physician who declared that he had reason for thinking that the plague
' Itussoll oil the Plague, 1791, pp. 513 and 511.
CH. xix] Rehictance to rccogtdse Plague 373
was actually in the place. A declaration which endangered his own life,
it being with difficulty he made his escape from the fury of the populace,
and though from that period to the end of the month between three and
four hundred perished of a distemper which he continued to affirm was
the genuine plague, no precautions were taken. He persisted singly in
his opinion against the rest of the faculty, who, in spite of unequivocal
symptoms, contended it was only an ordinary epidemic distemper. On
the 31st of May an assembly of thirty physicians there concurred
in a formal attestation of its not being the plague. Lastly, that the
funerals soon increased to one hundred daily. Government at length, but
too late, took the alarm, and dreadful scenes of unparalleled anarchy
followed." The diseases that have been most commonly confounded
with plague are typhoid and typhus fever, gastro-enteritis, diphtheria,
influenza, pneumonia, different forms of pernicious intermittent fever,
parotiditis, scrofula, and syphilis, apoplexy and meningitis.
With the discovery of the plague bacillus one great obstacle in the
way of the early adoption of preventive measures against plague has
been removed. Still, even with the assistance which is given in the
detection of plague cases by bacteriological methods, many difficulties
are met with in dealing promptly with plague immediately it appears in
a locality. Human nature is still the same and is liable to be swayed
in the same way and by the same influences as formerly, and although
the diagnosis of plague can with certainty be established with the
adoption of accurate methods, yet the different forms that plague
assumes, its insidious character, and its likeness often to diseases already
prevalent in the locality, are circumstances which surround its early
recognition with difficulties, especially when medical men are in-
experienced with its symptoms, diagnosis, and Protean forms. Two
features are specially characteristic of plague. They are, first, the slow,
irregular and gradual manner in which the disease acquires a hold over
a locality into which it is imported and which may later on become the
scene of an epidemic; and secondly, the obscurity which often surrounds
the earlier cases. The first is apt to raise false hopes of the disease
dying out, to cause the procrastination of effective measures, and to
favour the postponement of careful enquiries into the disease at a stage
when its movements and mode of spread are more easily followed than
later on. The other gives rise to disputes as to the nature of the
disease and consequently to the loss of valuable time.
It is not surprising under these circumstances that the early cases
most probably escape detection, and that even when suspicion arises the
responsibility which is incurred by the medical man who announces the
374 The Prevention and Suppression of Plague [part iv
appearance of plague in a community is shirked while there is the
slightest doubt on the subject. That doubt can only be removed by a
thorough knowledge of the disease, both from a clinical and bacterio-
logical point of view.
Even when the diagnosis is inade, other considerations come into
play, tending, if possible, to conceal or minimise the extent
po^ri^and ^*^ ^^^ outbreak. Commercial, political, and social forces
social forces nearly always range themselves against the first announce-
range them- ment of plague in a town. Every endeavour is made
selves against ^q show that the medical man is mistaken and that there
the first an-
nouncement is some sinister motive underlying his statement. Plague
a town^^ "^ ^^^ ^^^^ none of its terrors to the general population, to
whom it means some ill-defined fear, restriction, or loss,
and it is met often by a blind denial of its existence. The same
mistake is repeated over and over again. It is forgotten or unrecognised
that plague is not influenced by policies however subtle, and that no
denial of its presence when in the midst of a community will in the
slightest degree affect the course it may take.
No disease has raised so much controversy as to its existence when
_ ^ .it first ai)pears in a locality. In Bombay, when Dr Viegas
Controversies . ^^ •' -^ "_
in Bombay, in September, 1896, announced that plague prevailed in
Cape Town, ^^^ ^^^J^ ways and means were discovered to throw dis-
and San credit on his iudginent, and valuable time was wasted in
Francisco. Ji, , .
controversy. The same controversy happened in 1896 and
1898 in Calcutta, it threatened to recur in Cape Town in 1901, it made
itself manifest in San Francisco, and was apparently not absent in 1903
in Johannesburg when the presence of plague might be expected to be
particularly dreaded \
In connection with Johannesburg, where plague broke out in March,
1904, the following antecedent circumstances in 1903 are instructive
because of the difificulties, even with the employment of the bacterio-
logical test, of recognising beyond doubt early cases of plague.
Case No. 1. February 9th, 1903. A Jew (M. L.) living in a crowded
Reported tenement house in Becker Street, book-keeper in forage
cases of store. Sickened 9th February ; high tem))erature : con-
plague in siderable prostration; when seen on 12th February had
Johannes- large bubo in right groin ; no venereal history, but slight
abrasion on meatus urinarius afterwards noted. Patient
1 Keport of the Medical Officer of Health for period from 1st July, 1902, to 30th June,
1903. By Charles Porter, M.D., D.P.H.
CH. xix] Difficulties in recoguisiiKj Plague 375
removed to venereal ward of lazaretto, where glands were removed.
He eventually recovered. Bacillus pestis could not be found in the
blood and no bacteria of any kind in stained sections of groin
glands.
Cases Nos. 2 and 8. March 21st, 1903. Dutch mason and wife in
Vrededorp. Man had been suffering from asthma (5 years) and
pneumonia (14 days) with some swelling of neck glands, and died
suddenly at 8 a.m. from heart failure. Woman who was pregnant
miscarried from shock, bled profusely, and died at 9 a.m. Neither in
the post-mortem nor bacteriological examination was there the slightest
indication of plague, but the organism of pneumonia (pneumococcus)
was found in both cases. Before the Medical Officer of Health could
get to the house, however, white-helmeted policemen had been posted
there and alarm created locally that was most unnecessary.
Case No. 4. March 28th, 1903. Native "John," who died suddenly
at 71, Korte Street. Had come from Krugersdorp some three weeks
before ; large bubo in right arm-pit ; right arm and right side of chest
swollen and oedematous. Congestion of bases of both lungs. No
plague bacillus found, but pneumococcus present.
Case No. 5. April 11th, 1903. Male adult, native, employed at the
hospital. Had an ordinary, but very large abscess in right arm-pit.
Removed to lazaretto, abscess opened, and boy soon recovered. Neither
the organism of plague nor that of pneumonia was found.
Case No. 6. April 19th, 1903. Boy died suddenly in Pritchard
Street, and police were informed by medical man who was called in,
that death was due to plague. Post-mortem made same day by
district surgeon, who returned death due to " scurvy and heart disease,"
adding that "' there was absolutely no sign of plague " and that he
thought the practitioner in question should be asked on what he had
based his diagnosis and created quite an unjustifiable panic. Nothing
suggestive of plague was found bacteriologically.
Case No. 7. April 28th, 1903. Zulu " Pesuana." This boy was
removed to hospital from a store in Eloff Street on April 27th ;
developed a large abscess and brawny swelling in right axilla on
April 28th ; was removed to the plague camp on the 29th and on
admission there* presented bloodshot eyes, brown tongue, sordes on
lips, and was semi-comatose, dying on April 30th. The medical man
who was attending him had no doubt that he was suffering from plague.
This belief received confirmation from the naked-eye post-mortem
appearances which were typical of that disease, as well as from the
376 The Prevention and Suppression of Plague [part iv
boy's statement that he had only arrived in Johannesburg from Xatal
16 days before.
This case occasioned grave anxiety and as the boy's pass could not
be found some days elapsed before he could be traced at the Pass Office,
when, however, it was found that he had been at least four months at
Johannesburg. Portions of the affected glands and of the spleen were
examined bacteriologically and were both found to contain very virulent
pneumococci, but there was no indication of the plague bacillus, and the
case was therefore one of severe pneumonia.
Case No. 8. April 28th, 1908. Native boy from Saver Street.
Sickened on April 28th. Seen by medical attendant and Medical
Officer of Health on April 30th ; large bubo and brawny swelling in
right groin ; bloodshot eyes, extremely prostrate and ill. Removed at
once to plague camp and died on May 1st. Had not been out of
Johannesburg for ten months. Results of post-mortem and bacterio-
logical examination were almost identical with the preceding case
(No. 7) and death was eventually ascribed to pneumonia.
In each of the foregoing cases stringent measures of disinfection
were adopted, the names and addresses of contacts were taken, their
clothing and persons were purified and they were kept under obser-
vation for fourteen days. The only case which caused real anxiety was
No. 7, owing largely to the sufferer's statement that he had only just
come up from Natal. On May 20th it was reported that four coolies
had died very suddenly in the location. They had, however, been
attended by a medical man, and he was able to state there was no
suspicion of plague.
On December 22nd, 1908, a notice was placarded offering Sd. per
head for every rat brought in to the Corj)oration depots,
and in every suspicious case the rats were forwarded to
the Government bacteriologist for examination but in no instance Avas
the plague bacillus found.
In January, 1908, a notable mortality amongst rats was noticed at
Henwood's Arcade and the bodies of several were examined with
negative results. In April, 1908, complaint was received of rats
dying in large numbers in the Market Buildings, and the bodies of
38 (taken from beneath flooring, etc.) were sent to the Government
bacteriologist but were too decomposed for examinati(jn by him. Other
15, also decomposed, were afterwards found, and on the strength of this,
a local reporter, to whom the true facts of the matter had been carefully
explained by the Medical Officer of Health, deliberately published a
CH. xix] The Pnenmococcus and Plagae BaciUns 377
false and very alarming statement to the effect that the rats in the
market were infected, and that 400 rats had been found there.
This statement together with rumours which obtained credence in
regard to the Zulu Pesuana {vide supra) gave rise to the belief, which
was cabled to Europe, that there was plague in Johannesburg, and in
consequence the following telegram was sent on May 2nd to the Medical
Officer by H.E. the Lieutenant-Governor : — " Suspected cases from
Johannesburg not bubonic plague. Five cases have been recently
referred to Government Laboratory but none have been plague. All
cases have been deaths of natives who died suddenly and three cases
presented enlarged glands. Enlargement in all cases was due to
bacteria other than plague, namely, bacteria of pneumonia, bacteria
to which natives in this country appear to be unusually susceptible.
Please publish this information."
In many cases of plague Kitasato's bacillus is the only microbe to
be found in the blood and tissues and it has such a resemblance to the
diplococcus pneumoniae that it creates hesitation in early cases unless
the clinical features of plague are also present. The next that is heard
of plague in Johannesburg is on the 21st of March, 1904, when 30 deaths
were reported from plague.
For the successful isolation of the plague bacillus when mixed with
the pneumococcus care requires to be taken to cultivate the plague
bacillus at a low temperature by which the pneumococcus and other
bacilli may be eliminated. Dr W. C. Pakes^ and Dr F. H. Joseph have
recently recommended the employment of broth with an acidity of + 25
or + 30, and incubated at 37° C. The acidity inhibits the growth of the
pneumococcus but does not affect that of the plague bacillus. The
resulting cultivation is then injected into guinea-pigs or rabbits.
There is no disease which creates so much alarm and excitement as
plague. When an epidemic has once developed and unless
No disease . ...
which creates care is taken to allay the state of panic that is likely to
so much alarm arise, the feeline; of the populace among excitable nations
as plague. . " . • i •
may readily culminate in disturbances or hostile demon-
strations. Of course this will largely depend on the nationality affected
with plague. In Iquique in Chili the medical authorities were
obstructed in their duties ; in Calcutta some of the medical men were
attacked ; in Poona the Commissioner directing plague operations was
shot ; in Cawnpore the native apothecary engaged on plague duties was
' " The use of acid media in the isolation of the plague bacillus," British Medical
Journal, January 21, 1905.
378 The Prevention and Siqtpression of Plague [part iv
burnt ; in Bombay there were riots ; in Cape Town the Malays had to be
firmly dealt with, as they were inclined to assume a hostile attitude.
The great moi'tality of plague is apt to produce the impression
among the ignorant and turbulent that those taken to hospital are
j)oisoned by the doctors. In past times, when plague patients were
not removed to hospital, the great mortality was frequently ascribed
to poisoning of the wells by Jews and others, with the result that
popular resentment spent its fury on these innocent people.
There are generally two periods of alarm. One is when plague is
first announced, the second is when, after a considerable period of slight
fluctuations in regard to the daily numbers, there is suddenly a great
increase of cases and deaths and the epidemic has fairly set in, rapidly
rising to a crisis.
At both periods there is flight of the inhabitants. The first flight is
comparatively harmless from the point of view of spreading the disease,
because very few of the inhabitants are infected. From this aspect, the
flight is likely to be beneficial than otherwise, because it tends to reduce
overcrowding, which is an important factor in the spread of plague.
The second flight, on the other hand, is dangerous on account of the
large numbers of infected persons taking their infected personal effects
with them and thus spreading the disease in the healthy localities to
which they go.
Panic will not be prevented by the authorities concealing the
number of cases of plague, for rumour will soon magnify the number of
those not reported. A daily report with the actual number of new cases
with the locality in which they occur, and the publication in the
newspapers and by hand-bills of a few simple rules which may be carried
Firmness and t'^^t by each householder to protect the inmates against
judg-ment plague, will materially assist in restoring confidence, which
reqmred from . . . .
the com- will be strengthened if the authorities act irom the com-
mencement, uiencement with firnmess and judgment. Vacillation will
almost inevitably lead to disturbances, and certainly, later on, to an
epidemic.
If there is to be a panic it is better to take place early than late, as
flight at the conmiencement does but comparatively little harm and will
at most be short in duration. The risk lies in the possibilities of the
authorities relaxing at this stage the active and stringent measures
which they have decided on and thus allow the disease to gain ground.
When plague has once assumed epidemic proportions no measures that
are known will arrest the natural course of the epidemic in the particular
cii. xix] Accurate Diagnosis essential 379
locality in which it is raging. They can only act as checks and
Measures palliatives and as such require to be used with discretion,
necessary at Measures which are imperatively necessary at the com-
mencement mencement, having for their object the arrest or control of
not suitable the disease, and which entail the removal of every sick
when the i i • i i i • i •
epidemic person to the hos])ital, and the isolation of contacts,
controi^*^ cannot be fully carried out, unless under exceptional cir-
cumstances, at the height of an extensive epidemic. To do
so is only to add to the alarm and to increase the desire on the part of the
inhabitants to leave the locality, both of which it is most important to
allay, first because of the danger of hostile demonstrations, and secondly
because of the risk of infection to which the surrounding healthy
districts will be exposed. Great activity in the removal of the sick
when an extensive epidemic is approaching its height is a waste of
energy which might with more profit be expended in other directions.
For instance it is better to be directed to the protection of the healthy
in the infected districts and to the safeguarding of the surrounding
localities in which plague has not yet gained a foothold.
In combating plague an accurate diagnosis is all-important, and
Accurate unless the most careful examination is made in every
diagnosis instance the difficulties of diagnosis in early cases are
and its ' manifold, owing often to the masked character of the
difficulties. disease. Plague has been mistaken for influenza, lymphan-
gitis, pneumonia, bronchitis, pleurisy, typhoid fever, typhus fever,
malarial fever, relapsing fever, yellow fever, rheumatic fever, septicaemia,
pericarditis, endocarditis, peritonitis, appendicitis, dysentery, gastric
enteritis, beri-beri, syphilis, venereal bubo, non-venereal bubo, mumps,
adenitis, and parotitis. In Bombay some of the earlier cases with
swollen cervical glands and throat symptoms were mistaken for diph-
theria. In Jedda, where lung symptoms predominated, the earlier cases
were taken for influenza. In Calcutta some of the cases were attributed
to syphilis, others to non-venereal buboes. Dr Kinyoun^ relates some
instructive cases in this connection.
" In San Francisco a case of illness occurred which, clinically, was
that of typhoid fever, passed muster as such until three weeks later
the autopsy and bacteriological examination demonstrated plague.
Another case was clinically that of diplitheria, but no cultures were
made from the throat; antitoxin was administered when the case was
^ "The prophylaxis of Plague," by J. J. Kinyoun, M.D., The Journal <i/ the American
Medical Association, Vol. xlii. No. 3.
380 Tltc Prevention and Sii]>pression of Plague [part iv
moribund. During his last houis, while in (k'liriuni, he coughed and
spat in the nurse's fece, some of the sputum entering the eye. The
nurse was immediately immunised with large doses of diphtheria anti-
toxin. I)espite this precaution she became ill within less than 30 hours
and died of an acute fever four days later. Autopsy revealed an acute
septicaemia due to plague. Another gave a tjjoical history of lobar
pneumonia and the death certificate was made out accordingly.
" The room in which the patient died was closed for two weeks, when
it was occupied by a woman and child. Fotir or five days after occupancy
both became ill, one with bubonic, the other with pneumonic plague.
A case was diagnosed as phlegmonous erysipelas and was treated as such
for 10 days, but on post-mortem examination plague bacilli were isolated
from the phlegmonous tissues, the heart's blood and spleen. Another
case occurring s«Jon afterwards certainly did present the evidences of
acute myocarditis. The blood, however, showed leucocytes and pest-like
bacilli. The autopsy was confirmatory of plague septicaemia. In
Hongkong I saw in consultation a case which all of us agreed was one
of acute appendicitis requiring immediate surgical interference. The
blood showed considerable increase in the number of the white cells and
many malarial parasites. The surgeon concluded to wait until quinine
had been administered. On the next day the patient was worse,
temperature higher, slight effusion into the peritoneum. The operation
was deferred and death occurred on the next day. Autopsy revealed
a plague infection of the retro-peritoneal glands near the appendix. In
a case of a child in Manila presenting all the symptoms of a catarrhal
pneumonia, autopsy confirmatory, the bacteriological examination showed
the cause to be plague bacillus."
In a country in which beri-beri prevails sudden death from heart
failure due to plague would not unlikely at first be assigned to beri-
beri. In Japan plague in some instances was mistaken for beri-beri and
a similar mistake was made in Manila. It is not improbable that some
of the cases were really beri-beri attacked with plague.
The early diagnosis of plague is the first essential to success in
dealing with the prevention of the disease in a locality in which it
a})pears. Failure to recognise the nature of the disease allows a start
which is not readily overtaken. It requires to be borne in mind that
plague may occur without external signs of buboes, and that cases may
arise without appearing to have the slightest connection with each other.
The diagnosis must rest on the clinical features, on bacteriological
examination, and on the history of the case. There are three varieties
CH. xix] I)}tt'oduction of Plafjue Measures 381
of the disease which require special attention from the obscurity of their
symptoms. These are the siderans, fulminating or septicaemic cases,
the pneumonic, and the ambulatory cases. The symptoms of pneumonic
plague may be so obscure as to even perplex experts thoroughly
acquainted with the disease. This is illustrated by the Vienna out-
break in which Drs Miiller and Ghon, members of the Austrian Plague
Commission to Bombay, were for several days in doubt as to the true
character of the disease from which Barisch, the assistant in the patho-
logical laboratory, was suffering. It is important, therefore, that all
lung affections should be bacteriologically examined when plague is
threatened. Similarly with ambulant plague or pestis minor, it is not
unusual for these cases when occurring at the commencement of an
epidemic, to be attributed to some other cause such as malaria, venereal
disease, strain, mumps, scrofulous glandular enlargement, and the
glandular fever of children. Again, persons with plague may appear to
be only slightly indisposed, and yet die suddenly. Accordingly when a
district is liable to be threatened with plague, a most careful watch
requires to be kept over the character of the prevalent sickness an<l of
the causes of death, and if there occur cases of disease about which
uncertainty arises as to whether they are plague or not, or there are
cases with anomalous symptoms with sudden or unexpected death, no
pains should be spared to arrive at a definite diagnosis by a most careful
and thorough examination, and in the event of the slightest doubt the
case or cases should be treated as plague and the necessary precautions
taken. Over-caution is easily rectified and can do no harm, whereas
neglect to deal with a true case of plague because of the doubts which
exist as to its exact nature, may be followed by the most unfortunate
results : once plague has been recognised in a locality inactivity and
procrastination are unpardonable, for it is only at the beginning that
preventive measures have a chance of success. It is then that measures
which ensure early diagnosis and notification of the disease are of
supreme importance.
The diagnosis of plague having been made in an infected locality the
machinery previously designed and organised to deal with
ganisation the plague, and if possible, to stamp it out should be set
planned^ to be ^"^ motion. The forces to combat plague should, as it were,
mobilised. j^^ mobilised, and operations shoidd be begun at once.
The invasion of a locality by the plague bacillus differs from that of a
hostile army in that the movements of the former are less discoverable,
its resources are greater in that it possesses the power of self-
382 The Prevention and Siq)2)ression of Plague [part iv
multiplication, and it is only recognised by its effects. For these
reasons its attack is likely to be more serious and destructive than
that of any army if not resolutely met at the beginning. No ex-
penditure is considered too great to defeat and get rid of an invading
army, but, as a rule, in the case of })lague, there is not the same
solicitude at the early stage when it is possible, and when the organi-
sation and expenditure are most likely to be effective.
Pr()in])t notification of cases of plague or suspected plague by the
medical attendant and householder is one of the means of
be supple- securing early intelligence of human cases, but it must be
mented by supplemented by the search for cases among the very poor
visitation of , ^ . . . n , , , ^■ ^ ro 11
houses, and by visitation 01 the houses, by medical omcers, and by
°^^^^ followins: up the results obtained by a systematic bac-
measures. . . . . .
teriological examination of the rats in the different
districts into which the infected locality should be divided for the
purposes of administration. Special search for cases should always be
made in localities in which the rats are found to be infected.
Too great reliance is not to be placed on notification by medical
men, even in those towns in which notification of infectious disease is a
matter of ordinary routine in other epidemic diseases, for the poorer
people will very often not call in medical aid in plague cases. The
notification is therefore supplemented by house-to-house visitation.
The searching out of plague cases is no new system. It was provided
for in England in the ordinances of James I. At that time women were
employed none of whom had any special knowledge of the disease ; most
of them were derived from a class that was not very trustworthy.
They were assisted, when required, by surgeons. Now the visitors are,
or should be, medical men and medical women assisted by sanitary
inspectors. In the absence of a trained sanitary service in India,
laymen had to direct the operations against plague, and, in a number of
instances, soldiers had to be employed for house-to-house inspection.
Neither soldiers nor policemen are fitted for this work, and they are
more likely than other agencies to cause resentment, panic, and con-
cealment of cases, which are serious obstacles to the proper working
of an organisation intended to check the plague. The disease whether
in force in a locality or not should be sought out by medical inspectors,
and their attention directed not only to sickness among people, but also
to sickness and mortality among animals, particularly among rats, mice
and cats. Encouragement should be given to all householders, especially
in the affected area, to notify to the central or local health officer the
CH. xix] Hi(in((n Pk((/ne to he fore.sf ailed 383
occurrence of sudden or suspicious illness in their households. For
this purpose advice to that effect, together with a descrip-
to house- tion of the common symptoms of plague, should be printed
on leaflets, distributed in the affected area, and published in
the newspapers. Similarly the illness and mortality of rats and mice
should be described and the inhabitants urged to report any unusual
sickness or mortality they may note among these animals. There is no
difficulty in recognising the disease in rats. The rat affected with
plague usually leaves its usual hiding-place and comes out into the
open. It is seen at once to be very ill, and is generally in a dazed
condition ; its eyes are watery and bleary, its coat is probably sometimes
partially deprived of hair, it hobbles about with difficulty, and it
staggers and falls. It has lost its timidity of man in its evident desire
for fresh air, and it has no energy to attempt to escape. On account of
the disposition of the sick rats to leave their runs when ill of plague,
the epizootic among them whether in a house, warehouse, market or
street, can hardly fail to attract notice if the attention of the inhabitants
is directed to the subject, though in some instances, such as in Cape
Town, the mortality of rats was not particularly noticeable until the floors
of infected houses were taken up and examined. A daily and systematic
inspection by the sanitary staff of houses, especially those that are
old and dilapidated, cellars, warehouses, chandlers, corn-chandlers, oil-
shops, bakeries, groceries, stables, hay-lofts, and other buildings which
are likely to be infested with rats and mice, is necessary to ascertain
the presence of sick rats.
The examination of rats which is another means of notification is not
a quick process, and the bacteriologist will seldom be able
Bacterio- . ,
logical ex- to examine more than 100 or at most 150 a day, so that to
animation overtake the many that are likely to be brought for ex-
amination by the rat-catchers, inspectors, and others, it is
essential that a large staff of bacteriologists shall be employed for this
work alone. The more rats examined in the infected and other parts of
the town, the more exactly can the course of infection be traced, so
far as it is disseminated by the rat, the more accurately the non-infected
localities be ascertained, and the more precisely preventive measures can
be applied. The address or locality at which the rat is found is written
on a label and fixed to the animal. If it proves to be an infected
animal the information thus recorded permits of preventive measures
being taken in the infected house or locality before man maybe attacked.
All rats after examination should be cremated. At the time of collection
384 TJie Prevention and Suppression of Flof/ne [part iv
from the houses they are taken up with short tongs and dipped in a
bucket containing a disinfectant.
It will be unnecessary in a work of this kind to give more than an
outline of the organisation required to combat plague.
Outline of ...,,.-. i i j
a piagne or- Such an organisation will consist of several sub-depart-
gamsation ^^ents to carry out specific duties, and the whole will
be presided over by a Medical Director wath the requisite professional
assistance and clerical staft' to administer, direct and co-ordinate the
necessary operations in the campaign against plague.
The subjoined plan gives an outline of such an organisation.
Outline of Plague Organisation.
Medical Director with Assistants
and clerical Staff.
1 .
Bacterio-
1
District
I
Medical
1
Hospital and health
1
Superintendent
1
Medical
Committee
logists.
Medical
Inocu-
camp staff, medical
and trained
Inspectors
for scientifi
Officers.
lators.
and nursing and
Inspectors with
for port
investigatioi
administrative
establishment.
and rail-
of the
establishments.
ways.
disease.
The Plague Department as thus constituted would for executive
purposes be associated wath the sanitary inspectors. The Chief Sanitary'
Inspector would probably be appointed as Superintendent of the Plague
Department, and under him some of the smartest sanitary inspectors,
their places being temporarily filled up for routine sanitary work by
new men.
To the bacteriologists would be assigned the duties of (a) performing
autopsies, (6) examining rats and other animals, (c) exam-
the plague ining suspected cases, {d) preparing the virus of Danysz,
organisation. ^^^ preparing Hatfkine's prophylactic.
The same laboratory which would be near the mortuary will suffice
for the bacteriological examination of specimens and preparations from
suspected cases of plague alive or dead, and of specimens and preparations
from the rats brought for examination, but it is advisable to have
another laboratory elsew^here for the preparation of Danysz' cultures
and Haffkine's prophylactic.
To the district medical officers who should place themselves in close
a.ssociation with the medical practitioners of the district would be allotted
the duties of visiting their district to discover, locate, and examine all
cases of suspected sickness ; of tracing out the history of cases of plague
or suspected plague that have been reported ; of supervising removal of
CH. xix] P1ag)i€ Organisation 385
patients from infected houses, the disinfection of houses, reporting
insanitary conditions in houses or buildings visited requiring rectifica-
tion ; and of inspecting the markets in the district.
To the medical inoculators would fall the duties of inoculating as
many persons as possible with Haffkine's prophylactic or Yersin's
serum.
To the superintendent, trained inspectors, and establishment, which
would be divided into convenient corps, would be given the duties to
remove plague cases to hospital, and contacts to health camp or
reception house, to arrange and carry out the burial of plague cases,
to disinfect houses or blocks of houses infected with plague, to disinfect
clothes and articles likely to be affected, to distribute Danysz' virus or
other rat poison, to destroy rats in sewers, warehouses, etc., by fumigation,
to take up floors if necessary and remove dead rats after disinfection, to
collect dead rats for bacteriological examination and to cremate them
afterwards. As in the course of their duties the inspectors will be sure
to come across a number of houses in which there will be a great
accumulation of filth there should be an establishment for its removal.
To the medical inspectors and staff for port and railways would be
given the duties to examine passengers and crews of vessels leaving
port, to fumigate ships before their departure in order to destroy rats on
board, to fumigate railway goods vans, or store sheds likely to contain
rats, to examine passengers leaving or arriving from an infected place,
and to furnish names and addresses to local authorities.
The sanitary inspectors who carry out the ordinary routine duties of
their office will redouble their efforts to keep their respective districts in
a clean and sanitary condition, and by associating themselves with the
district medical officer will be able to serve notices for cleansing or other
sanitary requirements which may be thought necessary in houses that
have been disinfected. They will also be able to secure the adoption of
alterations that may be required to make houses rat-proof
To the hospital staff would be entrusted the duties of scrutinising
the diagnosis of patients brought to hospital and placing them in the
observation wards or in the ordinary wards of the hospital ; of treating
and nursing the patients ; and of carrying out the duties appertaining to
an infectious isolation hospital.
To the staff of the health camp or reception house would be
assigned the duties of receiving, providing for, and discharging contacts
in a condition to be free of the danger of infection.
To the Committee for scientific investigation of the disease would
s. 25
:386 TJk' Prevention and Stippression of Plague [part iv
be assigned the testing by experiment, observation and enquiry with
the object of their solution all those difficult problems, with reference
to plague and its methods of extension, which continually arise during
a plague epidemic.
The most important suppressive measures employed in a plague-
The most infected locality are isolation of the sick, evacuation of
important infected houses until they are thoroughly disinfected,
measures for ,. . „ . ,. ■ p i / i ^ ^- " c , •
the suppres- dismiection 01 iniected houses, destruction oi rats in
sionofpiague. infected districts, preventive inoculation, and super\dsion
over departures by ship and rail. These are carried out by the special
plague organisation with its intelligence department for the early dis-
covery of plague in human beings and in animals, more especially rats.
Isolation of the sick from the healthy is essential in all cases.
Plague occurs for the most part in insanitary and over-
Segregation. IIIT- 1 11 • 1
crowded localities, and under these circumstances the
isolation can only be properly effected by removal to hospital. In
the early stages of an epidemic, it is safer to remove eveiy case because
some even of the bubonic cases may develop secondary pneumonia, and
thus becoming highly infectious may give rise to cases of primary
pneumonic plague. There are instances, however, in which by reason of
the condition of the patient, or the excellence of the surroundings, the
disease having been contracted elsewhere, removal to hospital need not
be insisted upon, but in these cases special care has to be taken that
the nursing be of a skilled kind, which at the same time will ensure
isolation and proper disinfection of discharges. For this purpose, then,
an organisation against plague is incomplete unless it has skilled nurses,
not (jnly for the patients in the plague hospitals, but also for those
patients who are permitted to remain at home.
Isolation of the sick in hospital does not remove the infection of the
rats and other vermin which probably gave rise to the disease ; it only
removes one source of danger, which, in the bubonic form, is not an
important one but which is more important in the case of the
pneumonic and septicaemic types, the sputum and discharges of which
are likely to infect whatever articles they come in contact with. An
exaggerated opinion of the benefits to be derived from segregation in
dealing with plague was entertained at first because of the view that
plague spread by human agency only. But now that the main factors
in its dissemination appear to be infected clothing, infected animals,
and possibly, infected insects, isolation and the results to be obtained
by it are likely to be duly estimated at their projjer vaha'. At the
CH. xix] Evacuation of Infected House.^ 387
same time^ the value of isolation must not be under-estimated because,
although the patient is only one source of danger, the infection is of
such a character as to produce the others, rats and insects in their turn
being liable to be infected by man.
Evacuation of the house until it is free of infection is based on the well-
Evacuation of known fact that plague, once introduced, has a tendency to
premises. attack first one and another of the inmates until all or the
majority have suffered from plague. To this fact is ascribed in a measure
the severity of the epidemics of the 16th and 17th centuries, when the
recognised mode of isolating plague patients was to shut them up with
the healthy in the infected house and to prevent any egress or ingress
by placing a guard or watchman outside the barricaded house. The
healthy were thus subjected to the risk of infection from the plague
patient as well as from house infection. In every epidemic, even in
modem times, there are instances of whole households being destroyed.
The infection is remarkably adherent to the house. Not infrequently
it has happened that the inhabitants of a house, in which plague has
occurred, have been attacked with plague on their return to the house
even after a month's absence, and one of the most notable features in
cases of annual recrudescences is the persistency with which plague cases
occur in the same houses or blocks of houses that were previously in-
fected. The vacating of the infected house until it has been thoroughly
disinfected has two objects in view, one of which is to remove healthy
persons from a centre of infection ; the other is to allow of thorough
Circum- disinfection of the house. When the vacating is promptly
stances effected experience has proved that for ordinary bubonic
modifying- , . . , .
retention of plague the number of contacts fallmg ill afterwards is
contacts. comparatively smalls If therefore pneumonic cases, and
those of the septicaemic variety in which the patient has not been
early discovered be excepted, contacts may after two days, which will
be generally needed for thorough disinfection of the infected house and
household effects, be almost regarded as a negligible factor, and may
return to their disinfected houses. They can be kept as well under
Inedical surveillance at their homes as in the health camp or reception
house, and can be allowed to go to their work. Inoculation, however,
with Haffkine's prophylactic or Yersin's serum should be pressed upon
them. This arrangement considerably lessens the number who have to
be provided for in the health camp or reception house and at the same
1 Ferrari in 1630, and Cardinal Castaldy in 1657, observed that by evacuation of the
infected house less than 5 "/ii of the inmates contracted plague.
25—2
388 Tlte Prevention utid Stijtpresdon of Flag ve [part iv
time lessens the cost of administration. Before leaving the health camp
contacts would require to bathe and put on clean and disinfected
clothing. In pneumonic and septicaemic cases it is safer in the early
stages of an epidemic to retain the contacts for a period of 8 to 10
days before permitting them to return home. In septicaemic cases
much will however depend on the time that has elapsed between
the illness of the patient and the notification. If the notification is
made soon after illness commences, there is seldom need for a longer
period of detention than that necessaiy to disinfect the house thoroughly.
Contacts at home should be visited daily by the medical officer.
When dealing with waifs, strays, migratory people, persons living in
lodging-houses, and low-class natives, over whom very little control can
be exercised as to their whereabouts at an}^ time, the fiill period of
10 days in the health camp or reception house sh(!uld be insisted on.
Matters like these would be decided on at the discretion of the medical
officer of health or medical director of the plague operations. Evacua-
tion of a whole block of buildings on an infected area, and the
transference of the inhabitants to healthy surroundings, is one of the
most powerful means of dealing eSectually with an epidemic at its
commencement. Plague administrators in India are unanimously of
opinion that for villages this measure is most effective if it is carried
out completely and the villagers are not permitted to visit their infected
houses or to reoccupy their houses prematurely. Evacuation on a very
large scale is not practicable in towns, but it is found very useful when
applied to blocks of buildings or to particular classes of people that may
be infected. In Hongkong it was repeatedly found that evacuation of
a block of buildings, and housing the people for a time in another block
specially provided for them, exercised a veiy marked influence in con-
trolling the disease in contrast to the result attained when the blocks
were not evacuated. The sequence of cases in a block in Hongkong
before closing is interesting as it tends to show how plague travels from
one house to another in a block or streets
No. of House
Date of Case
3 on April 14th
5
„ 16th
4
„ 18th
7
„ 21st
8
„ 2l8t
3
„ 23rd
4
„ 24th
1 Report of the Acting Medical Officer of Health, 1903. Hongkong.
CH. xix] Existing Methods of Disinfecting Houses 389
The combined effect of evacuation and inoculation against plague is
well illustrated in the occurrences at Cape Town. When plague was
found to be spreading rapidly among the natives of Cape ToAvn it was
decided to evacuate the plague-infected areas and remove the natives
to a location on the outskirts of the town. The accommodation was
provided most expeditiously and under great pressure by the Public
Works Department. In the course of one afternoon one thousand were
removed, and in a short time all the natives in Cape Town, except some
that were accommodated by the Harbour Board inside the docks, were
removed from the town and placed under sanitary supervision in
comfortable huts made of corrugated iron. All except about 12 were
inoculated, and with the exception of the first few days of their
residence in the location when cases of plague developed among those
who already had the disease in their system, there were only four cases
afterwards in a community of 7000 persons, and this notwithstanding
the fact that the natives went into the town to work at the docks and
went into some of the most infected centres of the town. The plague
was practically stamped out among the natives but continued among
the white and coloured population. *
The house having been vacated the next important step is its
Disinfection of disinfection. For this purpose the practice in vogue in
the house. towns consists in :
(1) Fumigation of the house by formalin, or by chlorine, or by
burning sulphur.
(2) Removal in a closed conveyance of clothes, bedding, and
textile articles to a central disinfecting depot to be disinfected by
steam.
(3) Stripping of the walls of paper, washing or spraying the walls
with a disinfectant, and then scraping them.
(4) Removal of the scrapings and of rags and articles of small value
to the yard and burning them.
(5) Washing and scrubbing with disinfectants of the solid furniture,
walls, floors, stairs, and other parts of the house,
(6) Disinfection of the drains, yards and premises generally.
(7) The removal of dead rats, if any, from under the floors, and the
blocking up of rat runs.
The procedure requires a large staff, first, for the taking of inventories
of everything in the house in order that compensation, if claimed, shall
be properly adjudged, secondly, for the removal and return of the effects
390 TJic Prevention and Sup2)ression of Plafjue [part iv
in special conveyances, thirdly, for the disinfection and cleansing of the
articles at the central disinfection station, and fourthly for the cleansing
and disinfection of the infected house. It, moreover, involves the
employment of several methods of disinfection, gaseous, mechanical,
chemical, by steam, and by burning, and it is not infrequent after the
whole process is completed to find that insects are still alive in the
disinfected house, and there is no certainty of having destroyed the rats.
With plague increasing rapidly there is difficulty in completing the
process in 10 days, and, when completed there are usually many
complaints on behalf of the occupiers of infected houses that some of
their effects have been spoiled or destroyed by the disinfection, or some
are missing and cannot be found. There is nothing which adds so much
to the difficulties of dealing with plague as the hostile attitude of the
lower classes, who are mainly affected, and much of this hostility is due
to the necessity there is under the present methods to remove the
healthy from infected houses for periods of 10 days or a fortnight until
their houses are disinfected and cleansed, and to the loss or destruction
of some of their effects in the procedure. To these may be added the
displacement and disturbance of everything in the house.
For these reasons existing methods are cumbersome and far from
being satisfactor}^ The formalin is destructive to the
methods of microbe in about 3 or 4 hours, but has no penetrative
disinfection i- j-i • /v--, a j- ^
cumbersome powers and IS accordingly insufficient. According to
and unsatis- Catterina fumigation with pine wood is more effective, the
factory.
bacilli being killed in 40 minutes. The sulphur fumiga-
tion, although held in high repute in the 16th and 17th centuries, is
very uncertain in its action and mostly useless. The burning of sulphur
in the open air only gives off a 4^0 of sulphurous acid and ^^ of a
milligramme of sulphuric anhydride in a litre of the gas.
Hanking examining a room after the ordinary sulphur disinfection
process carried out by natives in India, found that no disinfection took
place. Under better conditions in an experiment carried out by himself,
and in which the walls and ceilings were first sprayed with water before
the sulphur was burnt in the room, the plague microbe was not killed,
and the only effect on agar tubes containing the microbe was that, when
transferred to fresh agar, the colonies were not very numerous, suggesting
a slightly retarding action.
1 The Plague in India, 1896, 1897. K. Nathan.
CH. xix] Neii^ Method of Dmnfecting Houses
391
The best fumigation with the best results is with the Clayton gas or
sulphnr-polyoxide. It is a process of disinfection which
will take the place of the older methods. In addition to
sulphurous acid every litre of the gas contains 6y%
milligrammes or over of sulphuric anhydride against J^ of
a milligramme contained in a litre of gas by burning
sulphur in the open air under ordinary conditions ; it
contains other unstable compounds of sulphur and oxygen,
the exact nature of which has not been determined. The fumigation
attains the object in view, viz. the disinfection of the house and the
household effects, without having to supplement it with other modes of
disinfection, and Avithout having to remove anything from the house.
It destroys the infection of plague on clothes, bedding, floor or any
The newest
and best
method of
disinfecting
a house
infected
with plague
is fumigating
with Clayton's
apparatus.
Fig. 2. Portable Clayton Apparatus disinfecting a House.
392 The Prevention and Suppressio7i of PUufne [part iv
part of the house that has been contaminated ; it destroys the rats,
fleas, bugs, or other insects that may be in the house, and if the
fumigation is extended to the rat runs and the covered drains, it will
destroy any infection that may be in these. Fumigation by a Clayton
apparatus brought to the house simplifies the work of disinfection, while
at the same time the operation is rendered more certain, more efficient,
and safer to the disinfecting establishment. One pound of sulphur is
used for every 400 cubic feet of space to be disinfected.
The apparatus having been brought to the front or back of the house
and the few preliminaries carried out, such as the sealing of the
chimneys and outlets of the house, the opening of the drawers and
boxes and cupboards, which can be done by one of the household, the
covering over with cloths or paper any stuffs or material of delicate
colours, and the opening up of floors in the neighbourhood of rat runs,
everything is ready for disinfection. As exposure to the gas of wine,
fruit, and flour in open bottles, tins or vessels will injure these articles,
they should either be removed or sealed up in close vessels. The pipes
and branch pipes are then fixed and put into the house wherever required,
and the gas is pumped into the house and maintained at a saturation of
12 "/o for 8 to 12 hours, or all night, with the result that everything
living, whether rats, insects, or the plague bacillus will be destroyed.
The windows are then opened in order to thoroughly ventilate the
rooms, and after a few hours the house can be entered and dead rats and
insects removed, after which the rooms are ready for occupation with
safety. Disinfection by this method of fumigation saves the necessity
of having a central station for steam disinfection and of removing clothes,
bedding, etc. to this central station, everything being disinfected in situ,
in the house. It dispenses with the complicated procedure now connected
with the removal of household goods and with the displacement of every-
thing in the house in order to cleanse with disinfectants the furniture and
walls, floors, and other parts of the house, and by this secures as far as
possible freedom from disturbance, loss, or damage of household effects.
It reduces to two days at the most the stay in the reception houses
or health camp of contacts except those who have been associated with
pneumonic cases.
A method such as this will tend to diminish the surreptitious disposal
of infected clothes, which is one of the greatest difficulties encountered
by the older system. No assurance will convince the more ignorant
people that the clothes will be brought back imdamaged after disinfection.
In a few instances they have had reason to view the assurance with
CH. xix] Measures to Prevent Recrudescences 393
suspicion. Exceptions are always at these times exaggerated into
common occurrences.
To prevent the escape of plague-infected rats it is advisable to fill
the houses abutting on the infected house with the polyoxide before
commencing with the infected house. Once the infected house is filled
with the gas, there is no further need of the gas in the adjoining houses,
which can be emptied of it at once so that they may be reoccupied. A
few hours will suffice for this, which at the same time is a protective
measure for the inmates of these houses. The same apparatus by a
system of pipes will disinfect several adjacent houses at the same time,
a precautionary measure which it is advisable to employ when plague
rats are found in more than one house of the block. The underground
drains of the house can be disinfected with the gas at the same time and
also the sewers of the locality.
In localities in which plague annually recrudesces the systematic
To prevent re- disinfection of houses and destruction of rats in them
crudescences. during the period of quiescence are very important measures
in combating these recrudescences. Occasionally it may not be convenient
to disinfect the whole house at one time with the Clayton system.
Under these circumstances, with proper arrangements and care, a part
of the house can be completed before the other part is commenced.
Such an arrangement would prove invaluable for the disinfection of
Zenanas, where the women would remove to another portion of the
house until their quarters were disinfected. Indian houses with their
courtyards are well adapted to such an arrangement, which however
would not be suitable for chawls and most tenement houses, which
should be disinfected at one operation.
Fumigation has its limits and can only be applied to houses,
buildings, sewers, drains, and other structures that are
has its limits, closed or capable of being enclosed. For surface drains
Employment outside the house, and on the premises, for the yard or
of chemical j^g contents, which it may be considered advisable to
disinfectants. . . ...
disinfect, and for privies and latrines, corrosive sublimate,
cyllin, carbolic acid, sulphuric acid, or milk of lime are the most useful
disinfectants. Corrosive sublimate 1 in 1000 and 1 in 500 in an acid
solution, cyllin 1 in 200 in an alkaline solution, carbolic acid 1 in 20,
sulphuric acid 1 in 250 mixed with half the quantity of permanganate
of potash, milk of lime 1 in 100, permanganate of potash 1 in 100, are the
usual strengths.
In localities where no fumigating apparatus is available recourse
394 Tlie Prevention atKl Snpjn'cssioH of Plmjne [part iv
must be had to s],)raying with corrosive sublimate, cyllin, carbolic acid
or other efficient disinfectant.
Corrosive sublimate, which has a very powerful destructive action on
plague bacilli even in such dilutions as 1 in 5000 and 1 in 10,000 when
brought directly in contact with them, in a medium which does not
decompose it, possesses certain disadvantages which have to be guarded
against ; it acts on metals, it is thrown out of solution by alkalis and
organic matter, it is precipitated by hard waters, it is decomposed
by oxides forming insoluble oxide of mercury, a property which inter-
dicts its use for walls newly lime- washed; it is acted on ])y the sulphur
and sulphuretted hydrogen of decomposing organic matter, and is apt to
lose its germicidal effect on discharges, sputum and the like by forming
a coating of albuminate of mercury which protects the micro-organism
to be destroyed. To prevent liability to decomposition and the formation
of inert compounds, there is usually added to the solution of corrosive
sublimate, when employed for other purposes than steeping clothes and
utensils in the solution or disinfecting the hands, a quantity of hydro-
chloric acid, which in slight excess adds to the disinfecting power, and
some chloride of ammonia or soda, which is conducive to its keeping
powers and assists in disintegrating organic matters. The solution
commonly employed consists of:
Perchloride of mercury
21 ozs.
Chloride of sodium
15 „
Hydrochloric acid
100 „
Water
340 „
476 „
Five ounces of this solution mixed in a gallon of water gives a
strength of 1 in 725, which is a convenient strength for ordinary
pui-poses. By using less water for the standard solution a strength
of 1 in 500 may be obtained, which is useful for the interior of houses
contaminated with much organic matter. It is useful to add to the
solution some aniline dye to give it colour in order to avoid accidents
by its being mistaken for water. For steeping clothes and utensils in
or for disinfecting the hands a solution of the strength of 1 in 1000 is
sufficient. The same strength can be used for washing furniture, which
should be first washed down with soft-soap to remove grease ; a 3 p.c.
solution of soft-soap alone is injurious to the plague bacillus. Under
certain circumstances a solution of corrosive sublimate of the strength
CH. xix] Other Methods of Disinfection 395
of 1 in 1000 is not satisfactory for disinfecting purposes. Dr Marshy
experimenting in the Plague Research Laboratory of Bombay, found the
action of the sohition of corrosive sublimate considerably neutralised on
floors and walls saturated with organic matter, and especially when
dealing with the mud floors of native huts and houses smeared with
cow-dung, the properties of the disinfectant being interfered with by
the alkalinity of the cow-dung and the compound ammonia bases which
it contains. He calculates that 100 square feet of a cow-dung floor
require about 8 gallons of the 1 in 725 acid solution to vitally damage
any contaminating plague micro-organisms, and that, as the perchloride
of mercury solution has only a surface action, its destructive powers
would be small if the contaminating material were below the immediate
surface, or were the surface protected by leaves, bits of rag, etc.
The Indian Plague Commission as a result of a series of experiments
on the material obtained from a |)aved or cemented floor came to the
conclusion that a perchloride solution of the strength of 1 in 500 was
efficacious for the interior of houses contaminated with organic matter.
The difficulties in connection with cow-dung floors in native huts
would be overcome by the Clayton system of disinfection.
Permanganate of potash possesses an equally powerful destructive
effect on plague bacilli as corrosive sublimate, a solution of 1 in 10,000
of the permanganate having been shown by Hankin to destroy the
bacillus in 5 minutes. But like the corrosive sublimate it is decomposed
when brought into contact with organic matter, which considerably
interferes with its action as a disinfectant. A solution of the strength
of 1 or 2 p.c. is, however, able to act even in the presence of an excess of
organic matter.
In dealing with huts in villages where no means of disinfection exists
it is often cheaper and more effective to burn the huts
exposure to together with the infected articles in the hut. If this is
Mgh tern- inadvisable, the hut may be subiected to the desiccating
peratures. . '' . , .
mfluence of a high temperature by burning cow-dung m a
smouldering fashion inside it, and afterwards by unroofing a part and
exposing the interior to the direct rays of the sun. The clothes should
either be soaked in a disinfectant solution or boiled in a cauldron.
Boiling effectually and rapidly destroys the bacillus of
plague, and any clothes in the cauldron in water subjected
to a temperature of between 60" C. and 100° C. for half-an-hour will
^ Minutes of Evidence taken by the Indian Plague Commission, Vol. iii. pp. 68 — 74 ;
also Note on Disinfection with Perchloride of Mercury, by E. L. Marsh.
396 Tlie Prevent ion and Siq^pression of Placfne [part iv
have been completely sterilised. Where objects such as wool, silk,
leather, or furs would be injured or destroyed by immer-
direct rays of sion in boiling water and where no fumigation by formalin
Sim for 3 or jg available, they should be spread out in as thin layers
as possible and exposed to the direct rays of the sun for
3 or 4 days. Textile fabrics impregnated with plague bacilli have
been disinfected experimentally by a 4 hours' exposure to the direct
rays of the sun in India and Hongkong. Bedding and clothes that are
contaminated should be burnt.
Sunlight, fresh air, good ventilation and dryness are very important
fectors in the sterilisation of the plague microbe and
Sanitation. , ....
should always be brought into requisition as sanitary
measures both in the prevention and checking of plague. It will be
found as a rule that the houses and localities which retain plague the
longest are those which are dark, badly ventilated, and damp, and by
reason of these conditions are attractive to rats and vermin and are
favourable to the prolonged survival and vitality of the plague bacillus,
while it is noticeable that even in a badly infected locality houses which
possess plenty of light, good ventilation and dryness enjoy a large
measure of immunity. The sanitary condition of houses and quarters
frequented b}- tramps, beggars, coolies, emigrants, and pilgrims requires
special attention, for they are very liable to become infected and remain
centres of infection, being occupied by a migratory class of people who,
as a rule, are dirty in their habits and persons and not infrequently
covered with vermin.
The systematic destruction of rats is a very important measure for
Destruction combating plague, and with this object in view large
of rats. quantities of Danysz' virus should be distributed and
spread as a poison.
Preparation of the virus of Danysz on a scale which is to be useful
requires an adequate staff. Danysz' bacillus is a micro-
of^ra^*bv*the *->i"g^i^ism of the coli group isolated from field mice suffer-
empioyment ing from a fatal epizootic, and morphologically identical
of Danysz. with the bacillus typhi murium of Loeffler. Danysz was
able to set up an illness among grey rats (mus decumanus)
by feeding them with cultures of this bacillus. Out of 10 rats there
died as a rule two or three, while others fell sick but recovered and others
remained quite well. Outside the laboratory the effect of the cultures
was tested experimentally in Paris and Hamburg on a small scale with
success, but adverse criticism based on unsuccessful results following
CH. xix] Destrnction of Eats hi/ Datu/sz' BaciJhis 397
experiments elsewhere led to its not being applied to any practical use,
and it was not until the Cape Town epidemic of plague in 1901 that
the destruction of rats by this method was tried on a large scale.
The results obtained at first were far from being satisfactory, but
those obtained later when new methods were employed were more
successful.
It was found after exhaustive tests made by Dr R. W. Dodgson, the
Director of the Cape Government Research Laboratory, that
Attenuation , ^ it-, x • i i i i •
and exaita- the cultures sent from the rasteur institute had lost their
ien^e*of vS^s virulence and were either non-pathogenic to the white and
grey rat (mus decumanus) and the black rat (mus ratus) or
only produced a transient indisposition in the rats after they were fed.
Two methods were accordingly adopted to raise the virulence of the
microbe. The first was enclosure of the attenuated cultures in collodion
capsules and enclosing them in the peritoneal cavity of a rat for varying
periods. The other was the injection of the attenuated cultures into
the peritoneal cavity of a rat and allowing the microbe to develop there
for a period of 12 to 24 hours. The peritoneal effusion at the expiration
of 24 hours was removed and placed in a sterile tube for from 12 to
24 hours for the purpose of aeration. Cultures from this were then made
and fresh passages made through rats. After a series of 6 to 8 passages
the microbe recovered its virulence, which was easily maintained by an
occasional passage in a similar way through rats. The peritoneal fluid
was transferred after 12 to 24 hours' aeration to the surface of agar and
allowed to grow as a wash culture. This growth was then mixed with
bouillon and the resulting emulsion spread evenly over the surface of
agar in large flasks or bottles. After 24 hours' incubation the virus
w^as ready for use. The latter method, being much more convenient
than the former, was adopted as a matter of routine.
Instead of attempting to set up an epizootic by inoculation of a
number of rats and allowing them to escape when ill in
in which ^^^ hope that their carcases would be eaten by other rats,
cultures of it was decided to soak pieces of bread in cultures of the
Danysz' . . . i • i ■ i
bacillus were Virus, and distribute them m the same manner as is done
used in ^^^^h ordinary rat poison, so that the rats might eat of
this infected bread. The virus was made ready for use
in the following manner: bouillon was poured into the bottles or flat
flasks containing the growth of the bacillus on agar and shaken up
until the culture was thoroughly emulsified. It was then poured into
dishes, and pieces of stale bread previously dried and of about the size
398 TJte Prevention and Suppression of Plar/ffe [part iv
of one cubic inch were dipped into the mixture, care being taken not to
soak the bread too long, otherwise it wcnild become pulpy. The agar was
also broken up and mixed with the pieces of bread, it being tasty and
readily eaten by the rats. When the bread with tlie virus on it was dry
it was packed up in tins and was then ready to be distributed by the
rat-catchers or inspectors in the evening. By this method thousands of
doses of the virus can be distributed nightly in whatever locality it may
be considered to be most required. As the virus does not act on the
rats which have eaten the bread for from 8 to 10 days it should be laid
nightly for that period in the same places, for experience shows that the
rats will continue to eat the bread thus soaked until they fall ill. When,
however, illness sets in, the others will disappear from the house, and
there is more likelihood of their having eaten some of the bread if the
virus is spread nightly. Rats suffering from the disease were found at
houses some distance from those in which the virus was laid. The result
of the experiment was, on the whole, very satisfactory in Cape Town.
Freshly prepared bread will have to be used every night and the media
used must always be alkaline. The best alkalinity has been found by
experiment to be N/SSNaoCo^. All media must be kept alkaline, as
the bacillus very rapidly develops acidity, thus inducing an auto-
attenuation. The advantage of the virus is that it can be prepared
in immense quantities in the laboratory if there is a sufficient staff for
that purpose, and that it is harmless to human beings, dogs, cats, fowls,
pigs, pigeons, monkeys, and other animals, so that there may be no
anxiety in laying down large quantities.
Dr Danysz has recently drawn attention to the tendency of this
microbe diminishing in virulence progressively in the course of its
passage through the rat and the difficulty of increasing that virulence.
There can be no doubt, however, that the virulence was both increased
and maintained in Cape Town by the method referred to. Dr Danysz
points out that when making experiments on 20 or 30 rats at a time
there is certain to be obtained from one or two of these animals a
microbe of more virulence than the others, and that in this way the
virulence of the culture may be maintained for two or three months. It
IS in this way that Dr Danysz has been able to maintain a supply of
virulent cultures for eight years, and has been able to use them for
practical experiments on farms, warehouses, hospitals, workhouses, etc.
In 60% of these operations the rats entirely disappeared, in 15 «/
the results were entirely negative, and in 25 "/„ complete destruction was"
not obtained.
CH. xix] Destruction of Rats hy Dauysz' Bacillus 399
In 1902^ Dr Danysz' bacillus was used to destroy the rats during
UseofDanysz' ^^^® outbreak of plague in Odessa, with the result that
cultures in the the rats completely disappeared. The operation was
outbreak of ,..,,. ^ '' p i • i • i
plague at divided into two parts, one oi which was carried out m
Odessa. September, the other in October. In September the
proprietors of all houses were ordered to conduct matters themselves,
but in October the sanitary authorities enlisted the services of the
medical men and medical students of the town. All rats found dead
or alive 8 days after the distribution of the virus were examined to
ascertain whether they were or were not infected with the microbe.
It was found that in those quarters where the instructions were
carefull}^ carried out the results of the necropsy of the rats were without
exception positive, while in other quarters they only reached 42 to
45 7o- Several weeks after the operations it was with the utmost
difficulty, even with the offer of a reward, to procure any rats. The
Director of the Pasteur Institute of Odessa, who superintended the
operations, states that the employment of the virus was far superior
to that of other measures used, and that no illness among human beings
or domestic animals could be traced to its use.
Other methods may be used for the destruction of rats where the
Danysz' virus is not obtainable, and may consist in the
methods employment of professional rat-catchers and the distribution
employed. ^^ ^^^ poison in the form of arsenic, phosphorus, and
strychnine mixed with other substances ; in the event of such poisons
being used they should not be distributed without warning in the
newspaper, should be laid late at night, and the portions not eaten
during the night should be removed early in the morning by the
official. These precautions are to avoid accidents to children and
the poisoning of other animals.
The following description of the symptoms, post-mortem appearances,
and diagnosis of the disease in rats caused by the bacillus of Danysz
will be found useful, and is supplied by Dr Dodgson :
The symptoms of the disease usually manifest themselves about
3(j hours before death. The rat becomes lethargfic, "mopes"
Symptoms in • , -, ^ ^■ ^ ■ T •
rats suflFering with fur erected, and displays an intense thirst. Inco-
Da^s*z^^ ordinate movements are occasionally seen ; when they
baciuus occur the animal will usually be found to be suffering
from an acute adhesive (non-suppurative) peritonitis.
1 "A Microbe Pathogenic to Rats," by Dr J. Danysz, Britixh Medical Journal,
April 23, 1904.
400 The Prevention and Snppression of Plague [part iv
The tail and fur near the anus are usually stained with muco-
sanious discharge.
The intestines contain undigested food mixed with glairy mucus or
Post-mortem muco-sanious material, and there are usually no formed
appearances. masses of faeces in the colon or rectum, such as are always
found in healthy rats. The intestinal walls are oedematous and trans-
lucent, but there is little or no congestion of the blood vessels of either
the intestines or the mesentery. Peyer's patches may show infiltration,
never ulceration. The spleen is enlarged to from 2 to 10 times its
normal size. It is congested, and may show white metastatic growths
of the bacillus as large as a pin's head. Lymphatic glands are never
enlarged or engorged, except when peritonitis is present, in which case
the mesenteric glands may be engorged.
The bacillus can readily be isolated from the spleen, blood, peritoneal
Bacterio- Aind, etc., by the usual methods. Smears rarely show
logical anything like the number of bacilli as are usually found
in those made from the spleen, etc., of rats which have died
of plague. The bacilli are actively motile. They are about 2 microm.
General long by 'lb broad. Nothing characteristic about the
cha^act^rs growths on ordinary media. In bouillon thread forms
soon occur. On acid media coccoid involution forms
staining. appear after about 24 hours. Stain readily with aniline
dyes. Ai-e decolorised by " gram." In old cultures, and rarely in fresh
smears from organs, faint bi-polar staining is met with.
The bacillus can readily be distinguished from :
jj^^^jj (1) Bacillus pest is :
differential (a) Motility.
(b) The copious evolution of gas in 2 7o glucose agar
shake cultures, after about from 6 to 12 hours' incubation at 37° C.
(2) Bacillus coli communis :
(a) Non-production of gas in 2 "/o lactose agar shake cultures
after 48 hours.
(b) Non-coagulation of milk.
Confirmatory tests :
confirmatory C^) From B. 2Jestis :
differential (a) GroAvs readily in 5 "L NaCl bouillon,
tests >/ I "
(b) Causes uniform turbidity in " ghee " bouillon.
Never any signs of stalactites.
(2) From B. coli :
(a) Non-production of gas in gelatine shakes.
CH. xix] Campaign in the Quiescent Period 401
(6) Non-production of indol. (No smell.)
(c) Non-production of HCN in amygdaline bouillon.
Rats eating the carcases of others dead of the disease may die after
Acute toxic 36 hours of acute poisoning (ptomaine ?). In these the post-
cases, mortem appearances are negative, except the condition of
the intestines. This closely resembles that described above as occurring
in the septicaemic cases. The oedema of the walls of the gut is even
more pronounced than in the septicaemic cases, but there may be a few
semi-formed faecal masses in the rectum. The bacillus cannot be
isolated from the blood or organs in these acute toxic cases, but it is
fairly easily isolated from the contents of the intestines by the usual
methods. In performing the lactose test, it is necessary to ascertain
that the lactose is pure. In ordinary impure lactose, or in lactose that
has been kept for some time, especially if damp, a small amount of gas
may be evolved in the course of 24 hours.
Large numbers of rats may also be destroyed by fumigating
buildings with sulphur-polyoxide by Clayton's apparatus,
of rats in Such fumigation may be applied to warehouses, grain,
Icehouses, ^^^\ j-j^g depots, slaughter-houses and other buildings
which harbour rats, also to sewers and drains. For the
destruction of rats a 3 or 4 "/o saturation of the gas in the building for
two hours will suffice, and no damage to grain or textile fabrics need
be feared.
• Plague measures should not cease as soon as the epidemic declines ;
Campaigns ''^"^^y should continue throughout the period of quiescence
against with the object of preventing a recrudescence. These
plague during . .
the quiescent measures should consist more particularly in destroying
period. j.j^^g generally, in fumigating the houses and blocks of
houses that have been infected, along with the neighbouring houses
that have remained healthy, together with the drains and rats' runs
connected with them, and in bacteriologically examining systematically
rats, mice, and sick cats, with the view of ascertaining where active
plague is still lurking, and taking measures to eradicate this special
source of huma,n plague. Preventive measures should precede and
forestall human plague in an infected locality and not wait until a case
occurs.
26
CHAPTER XX.
PREVENTIVE INOCULATION.
There is another preventive measure which is of great vahie. It
is preventive inoculation. But unless the danger is urgent few of the
poorer classes are likely to resort to it until plague has broken out
in a house or in its immediate vicinity. It is advisable to be in
possession of an abundant supply of Haffkine's prophylactic in order
that those who may be persuaded to be inoculated can be treated.
A preventive prophylactic against plague was discovered in 1896 by
„ , Haffkine, his previous experience derived from the results
plague obtained from his cholera prophylactic serving as a guide
based ^n° ^° ^^^ leading him to make some material alterations in
his cholera the mode of preparation of the plaffue prophylactic. The
prophylactic. , • . , x , • • - f u r
anti-cholera protective consists oi a culture on agar oi
living comma bacilli fixed at a uniform strength of virulence by passing
through an animal. The bacilli when the culture is ready are detached
from the agar by suspending them in sterile water, and drawing up the
emulsion in a sterile syringe. A small dose of this emulsion injected
under the skin produces a certain amount of local inflammatory action
accompanied by a temporary rise in temperature and a feeling of malaise
lasting from one to two days. The swelling at the seat of the inocula-
tion may last a week and then disappear. The bacteria die in the
tissues at the seat of the inoculation ; in the process the intracellular
toxines become absorbed and immunity is generally established in the
course of four days. Sometimes dead cultures preserved in a slightly
carbolised solution are used instead of the living cultures. They act in
a similar way, the bodies of the bacilli disintegrating with the liberation
of the intracellular toxines ; but pi'eference is given to the use of living
cultures in cholera because the results obtained fi'om them are believed
to be better and of longer duration. The innnunity varies according to
CH. xx] Anti-cJwlera Pro2)hylactic 403
the strength of the prophylactic, the dose, and the length of time that
elapses between the inoculations and the infection. With weak vaccines
and small doses the immunising effect is more or less transient and
rapidly disappears, and even with strong vaccines and ordinary doses
the protection does not last longer than two years. In Calcutta a
comparison of the inoculated and not inoculated showed an incidence
of cholera 22 times greater on the not inoculated than on the inoculated;
but this difference only lasted two years, after which the two classes
rapidly approached one another in their liability to attack. A remarkable
observation was made during the investigation into the effects of the
anti-cholera inoculations in India. It was that, though there is always
a marked difference between the incidence of the disease on the
inoculated and not inoculated, yet the preservative effect of the
prophylactic appears to be principally limited to preventing attacks
and does not extend to lessening the deaths among those attacked ;
for when persons are attacked with cholera the inoculation has no effect
in reducing the mortality or giving a better chance of recovery. Theo-
retically this is explained by the serum of the blood of the inoculated
containing no antitoxic properties, and consequently being unable to
resist or neutralise the effects caused by the pouring in of toxines by
microbes which have established themselves in the intestines. Kolle
and Pfeiffer, by inoculating a number of students with the anti-
choleraic fluid, ascertained by experiment that the serum of those
inoculated contains bactericidal products which possess a rapid and
destructive effect on comma bacilli to an extent 200 times greater
than the serum of those not inoculated. It would appear, therefore,
that while the blood of the inoculated against cholera is rich in bacteri-
cidal products, it is poor in antitoxins, and that, though it is able by
means of its bactericidal products to protect the system against the
lodgement and multiplication of the bacillus and so prevent an attack,
yet by the absence of antitoxic properties it is unable to prevent the
poisonous effects of the toxines should the microbe effecting a lodgement
in the intestines overcome the destructive effect of the bactericides and
go on multiplying. This is obviously an important defect in the anti-
. cholera inoculations and one likely to narrow its sphere of usefulness.
The experience thus gained proved to be valuable at a time when the
question arose as to the possibility of preparing a prophylactic for
plague. The defect attaching to th6 cholera prophylactic had to be
remedied if possible, inasmuch as it was not only desirable to provide
against the microbe, but also against its toxines. Instead, therefore, of
2G— 2
404 The Prevention and Suppression of Plaffue [part iv
preparing the plague prophylactic on similar lines, Haffkine decided to
adopt a method which should provide a mixture containing a large
quantity of extracellular toxines secreted by the microbes, as well as
an abundance of the bodies of the plague bacilli containing in them-
selves the intracellular toxines. By inoculation with a mixture of this
kind it was assumed that both a bactericidal and antitoxic power of
resistance would be obtained.
It was impossible to use living plague bacilli for protective purposes,
as these grow in the tissues and invade the system ; accordingly dead
vaccines had to be resorted to, the bacilli, after secreting a sufficiency
of toxines, being destroyed before the prophylactic is administered. In
the case of employing dead vaccines there is not the same necessity for
fixing at a uniform standard the strength of the virulence of the plague
microbe as in the case of the cholera microbe, because the plague
prophylactic consists of the dead bodies of the bacilli and of their
products, and, like the antitoxins of diphtheria, can be measured. A
larger measured dose of a mixture prepared from a less virulent microbe
will produce the same effect as a smaller dose the product of a more
virulent race.
The mode of preparing the prophylactic is simple. To a flask
containing nutrient bouillon a very small quantity of
Preparation i i i -i • ^ n ^ ■ \
of Haffkine's melted butter or oil is added ; the flask is closed by a
plague cotton plug, placed in the autoclave, sterilised, and then
prophylactic. jr c r > >
allowed to cool. The fluid is then carefully inoculated
through the cotton-wool plug by means of a pipette filled with a culture
of the plague bacillus which is obtained first from a plague case or
which is maintained in virulence by passing through animals. In India
there is no need to place the flask in an incubator ; it may be set aside
in a shaded place, the growth proceeding at the ordinar}^ temperature of
the air. When that temperature falls below 25° C. the air of the room is
warmed by lighting some gas-burners. Elsewhere, and out of the tropics,
the flask is placed in an incubator with a temperature ranging between
30° C. and 32" C. An alteration in the contents of the flask is soon
perceptible ; the fluid remains quite clear, but from the particles of fat
floating on the surface of the liquid there is seen to be suspended in the-
depth a series of fine thread-like growths which on the slightest
disturbance or oscillation become detached and broken up, falling
gradually like fine flakes of snow to the bottom of the flask and which
are replaced by a fresh crop in a few days. These gi'owths are the
colonies of plague bacilli which have attached themselves to the fat and
CH. xx] Haffklne's Plague ProphylaviiG 405
have grown downwards into the depths of the liquid, giving a peculiar
stalactite appearance to the growth. The stalactites in the course of 2
or 3 days fill up the upper half or sometimes even the whole volume of
the liquid. The flasks are shaken periodically, when the stalactites
have been fully grown, to allow the colonies to become detached, and to
fall to the bottom in order to permit of fresh growths of a similar kind
and so to accumulate at the bottom of the flask a large quantity of the
bodies of the bacilli. This is continued for the period of 6 weeks, when
by that time the culture contains the bodies of a large mass of plague
bacilli and a large quantity of extracellular toxines formed by the
microbes in their process of growth. The culture being ripe for use its
purity is tested by drawing off a small quantity by a sterilised pipette
and transferring it to the surface of an agar tube and noting the physical
and microscopical appearances of the growth produced. If the agar is
dry and the culture spread evenly over the surface the thin, translucent,
colourless growth characteristic of plague will form in 2 or 3 days and
any colonies of foreign microbes intermixed with it will be distinctly
seen. The test proving to be satisfactory the bacilli are now to be
killed. To kill the bacilli the flask containing the prophylactic is placed
in a water-bath with another flask containing water and having in it a
thermometer which indicates the heat to which both fluids are subjected
in the bath. The temperature is raised to 50 — 55° C. and is then kept
at this level for a quarter of an hour. In other laboratories the cultures
are usually exposed to a temperature of 60° C. for an hour. This is
sufficient to kill the bacilli, after which a small quantity of carbolic acid
in the proportion of ^^^ part of the bulk of the prophylactic is added
for preventive purposes. It is not wise to subject the prophylactic to a
higher temperature than necessary, though its immunising properties
are not wholly destroyed until it has been exposed to a temperature of
100° C; as a precautionary measure, however, to ensure that all bacilli in
the flask are destroyed that portion of the flask which is not submerged
in the heated water of the bath should be always heated in the flame of
a bunsen burner. The prophylactic consisting of sediment and fluid is
now ready for use, and is shaken up so as to make a uniform mixture,
which is then decanted into small bottles, and corked with india-rubber
stoppers. The standardisation of the prophylactic or the determination
of the dose is ascertained by testing the toxic effect of a given quantity on
a few individuals, the standard being the smallest quantity which produces
an average temperature of 102° F. in a series of cases. For an adult
this is as a rule 2i to 5 cubic centimetres. The test in this instance is
406 The PrcrcufioH ((rul Suppression of Plague [part iv
the febrile action produced on man instead of the killing power on
animals. The storage of the projjhylactic is important. Bottles with
ordinary corks have frequently failed to keep the vaccine free of
contamination ; hermetically sealed tubes or bulbs are undoubtedly the
best and safest method of storage.
A modification of the above method in the preparation of Half kine's
prophylactic has been employed in the Government laboratory in
Bombay. The flasks of broth are not filled to such a high level as before,
the shallower contents being used in order to secure a more abundant
aeration of the fluid. The cultivation flasks are only slightly vibrated
to dislodge the stalactites and are not shaken up as formerly. When
ivady ii four days' growth on 300 square centimetres of agar surface is
emulsified in 400 c.cs. of a two-months-old broth cultivation. This
mixture is then sterilised for 15 minutes at 50 to 55° C. and ^"/o of
carbolic acid added to it. The prophylactic is then tested to ascertain
whether it has been completely sterilised, after which it is decanted into
special laboratory phials which are then stoppered with india-rubber
corks. In Japan and the Pasteur Institute a similar process for preparing
the prophylactic is employed, but more dependence is placed on the
cultures on agar rather than in broth. Kitasato's prophylactic prepared
from agar cultures was used with good results in Formosa.
The method of decanting and storage is open to improvement, and
Dr E. Maynard has devised a storage flask which alloAvs of the cultures
in the flask being decanted without exposure to the air and which admits
of being hermetically sealed instead of being corked. This arrangement
which was much needed reduces the possibility of contamination of the
prophylactic with other microbes.
At the time of inoculation great care has to be taken in securing
Method of complete sterilisation of the syringe and needle. To attain
inoculation. ^^js object the following procedure is recommended if no
portable steriliser is at hand. A Colins syringe, previously boiled to
sterilise it, is filled with a solution of carbolic acid and its needle is
dipped into hot carbolic oil; it is then washed out several times
thoroughly with sterile water, after which it is ready to be filled with
the prophylactic. This is efl"ected by breaking the sealed bulb containing
the prophylactic and drawing it directly up into the syringe. The arm
or loin is generally chosen as the seat of inoculation. This part is first
washed with a swab of cotton-wool soaked in a solution of carbolic acid
of the strength of 1 in 20, the skin is raised by the forefinger and thumb,
the needle of the syringe is plunged into the raised part, 2^ to 5 cubic centi-
CH. xx] Effect of Haffkine's Plague-inoculations 407
metres of the fluid are rapidly injected, the needle is removed and the raised
skin allowed to fall back to its old position. The part is once more
swabbed with carbolic acid and the operation is over. Before proceeding
to inoculate the next person the needle of the syringe is either dipped
in hot oil or is rubbed over with cotton-wool soaked in a solution
of carbolic acid. This process between every operation secures anti-
septicism and avoids any inflammation due to extraneous contamination
Effect of the o^ ^^e wound. The effect of the inoculation is not noticed
inoculation. f^j. i^q f^j.g|^ 3 or 4 hours, then a slight feverishness sets
in, and in the course of 12 hours may in some cases reach 102 to 103° F.
Occasionally it rises higher, even to 104 and 105^ F. At the same time
there is a feeling of tenderness at the seat of inoculation, which becomes
reddened, swollen and painful, and there may be tenderness and swelling
of the nearest glands. Headache, malaise, and general discomfort
accompany the local and feverish disturbance, which varies much in
different persons, some being but only slightly affected and able to go
on with their usual occupation, while others are indisposed for a day or
two. The fever disappears in one or two days, and the patient feels
well except for the pain at the seat of inoculation, which may last from
several days to a week, the swelling not disappearing for a week or two
longer.
In the many hundreds of thousands of inoculations that have been
performed no injurious result has been known to follow, except in
1902 when a bottle got contaminated with tetanus bacilli, with the
result that those who were inoculated died of tetanus. The inoculations,
with a prophylactic which has been carefully prepared and stored, are
harmless, though the effects for the first few days are far from being
pleasant.
The results of the inoculation in plague-stricken districts in India
Results of the 3,re summed up by the Indian Plague Commission,
inoculations. \ Inoculation sensibly diminishes the incidence of
plague attacks on the inoculated population, but the protection which is
afforded against attacks is not absolute.
2. Inoculation greatly diminishes the plague death-rate among the
inoculated population. This is due not only to the fact that the rate of
attack is diminished, but also to the fact that the fatality of attacks is
diminished.
3. Inoculation does not appear to confer any great degree of
protection within the first few days after the operation has been
performed.
408 The Prevention and Sffppressioii of Play ue [part iv
The Commission were unable to assign a numerical expression to the
measure of protection from attack or death which inoculation confers, for
it appeared to be subject to considerable variation, dependent on the
strength of the virulence of the microbe employed, in the preparation of
the prophylactic, the varying length of time to which many of the
cultures were subjected, many being much less than 6 weeks, and the
difference in the amount of the dose administered. More uniformity in
these respects, and improvements in decanting and storage are
admittedly required. At the same time there can be little doubt that
in a number of the observations recorded after careful investigation,
the diminution of mortality among the inoculated as compared with the
not inoculated was not less than from 70 to 80 "/o- The most recent
information from India would indicate that the proportion of deaths
to attacks in the inoculated was under 25 7,,, or less than one-half
observed in the not inoculated.
It is not to be forgotten that the prophylactic takes 48 hours to act,
and in the meantime does not confer protection any more than is
afforded by vaccination against small-pox during the first week. In
the case, therefore, of nurses or others who have to come into contact
at once with plague patients a preliminary inoculation with Yersin's
serum, which effects a rapid protection, should be performed.
It is generally advisable to furnish the person inoculated with a
short account of the symptoms likely to follow and of the precautions
which should be taken to avoid indiscretions. The following hand-bill
is useful for this purpose :
INSTRUCTIONS TO PERSONS INOCULATED.
1. Three or four hours after inoculation the patient will experience headache,
general malaise, fever, and slight jiain at the seat of inoculation. These symptoms
will continue for about 48 hours.
2. Patient should rest for 24 hours at least and abstain from all work. The
arm should be kept in a sling reaching from the wrist to the elbow in order to
ensure perfect rest to the arm.
3. The arm may be bathed with a little hot water or a lotion containing lead
and opium, which may be obtained from any druggist.
4. The diet should be light. A purgative on the tii'st day lessens the local
reaction.
Another prophylactic has been prepared by Professors A. Lustig and
G. Galeotti of Florence. It is a nucleo-proteid pre-
The prophy- ^ ^
lactic of pared from the plague bacdlus.
Gaieo«t^^ The method of preparation consists in cultivating
plague bacilli on agar plates, scraping off the growth and
CH. xx] Lustig and Galeott'Cs Plague ProphgJactic 409
dissolving it in a 1 "/o sterilised solution of caustic potash \ To the
mixture is added a very dilute solution of hydrochloric or acetic acid
until there is a slight acid reaction and the resulting precipitate is
collected on filter-paper, washed, and dried. The precipitate is com-
posed of a nucleo-proteid and is readily soluble in a weak solution of
carbonate of soda. The dose for a man is 3 milligranmies, which
injected produces in a feAV hours shivering and general malaise, followed
by a rise of temperature to 101° or 102° F. and painful swelling at the
seat of inoculation. The general reaction subsides within 36 hours and
the local action within 3 or 4 days.
The claims made on behalf of the nucleo-proteid is that its efficacy
has been proved on rats, rabbits, guinea-pigs, and monkeys, that it is
harmless to man and is devoid of many of the toxic and depressant
substances which are contained in liquid cultures of the bacillus. The
advantages over Haffkine's prophylactic are set forth as being, first that
the substance required for the production of immunity is isolated and
used alone and not mixed with extraneous and possibly harmful
products ; that it is not heated and therefore does not lose any of its
immunising properties ; that there is no danger of its becoming
contaminated, as is the possibility with each separate bottle of Haff-
kine's prophylactic ; that being dry it can be easily preserved ; that it
can be administered in well-defined doses, which is not the case with
Haffkine's ; and that it cannot offend the religious susceptibilities of
the population of India. There are no data as to the value of this
prophylactic in protecting man against plague.
1 "Preventive Inoculation against Bubonic Plague" by Professors A. Lustig and
G, Galeotti. British Medical Journal, Feb. 10, 1900.
CHAPTER XXL
CONCLUSION.
From the foregoing it may be gathered that the existing knowledge
More precise '^^ plague is not as precise and exact as it should be to
information secure unvarying successful control. The little that is
r6QuiP6d
regarding known is nevertheless very useful in the prevention of
plague. j^jj outbreak in its early stages, especially if it is of the
pneumonic type and is limited to human infection. But once an
outbreak reaches certain dimensions the lack of exact knowledge
regarding many of the modes of dissemination and channels of infection
and the conditions which affect the spread of the disease renders the
methods of prevention uncertain and ineffective. The extent of an
epidemic then depends on those unknown conditions which produce
an actively diffusive plague or a self-limited plague.
The discovery of the plague bacillus has given precision to the
diagnosis of plague, enabling the disease in man or rats to be recognised
at a very early stage of its existence, and this, combined with the
notification system and a sanitary organisation which can act at once,
robs plague of many of the advantages it possessed in earlier times
when attacking a town or district. Preventive measures were seldom
introduced in the older epidemics until the outbreak was well-developed,
and then, whatever measures wez'e introduced, and however strict they
were, they appear to have been of small value in influencing the course
of the epidemic. In this respect, therefore, those countries free of
plague, and which i)ossess a properly organised sanitary system prepared
to act in accordance with the principles which our present knowledge
lays down, are in a much better position to prevent the importation and
withstand the attacks of the advance-guard of a threatening epidemic
of plague than was the case when no such organisation existed.
Still, owing to an imperfect knowledge of the different modes and
CH. xxi] Problems awaiting Solation 411
avenues by which plague attacks, it by no means folhjws that these
measures will always be successful, nor, if the epidemic is small in
extent, whether mild or virulent, that the limitation has been due
solely to the measures taken. It is impossible to be absolutely certain
of either while so much is unknown regarding plague, though at the
same time it would be reprehensible not to act vigorously on the
guidance given by existing information. The facts known and
The facts established can be easily summarised. They have already
known and been mentioned, but they wilt bear repetition. They are,
regarding that plague is due to a bacillus ; that there is a bubonic,
plague. septicaeraic, pneumonic, and pustular form; that the
pneumonic form is very infective ; that there is a connection between
rat plague and human plague ; that rats may disseminate plague as
well as man ; that the disease both in human beings and in rats is
seasonal ; that certain animals besides rats take plague ; that the
disease in man and animals may be of a chronic nature; that Haflfkine's
prophylactic subcutaneously injected with a syringe has considerable
protective effect, but that its mode of administration and the local
discomfort produced by it militate against its general use on a large
scale ; and, lastly, that there is no curative treatment that is effective
against virulent plague. It is evident that much more requires to
be known if epidemic as distinguished from sporadic plague is to be
brought under control, either from a preventive or cui'ative point of
view. The suggestion is not that there exists no information on the
subjects about to be mentioned as requiring close investigation, but,
as will be gathered from a perusal of this volume, the information is
not sufficiently exact to ensure absolute safety even in Europe.
The following may be given as examples of questions on which
systematic research is needed :
The main
lines on whicli [a) The length of time an infected patient or infected animal
enquiry is retains infection. Bacteriolosrical examinations are made for
needed. ....
diagnostic purposes but seldom to ascertain period of infection.
{b) What proportion of plague cases are traceable to house infection either in
dwelling-houses or workshops and what proportion to other causes ?
(c) In the case of house infection what does it consist of, contaminated foo<i,
contaminated floors, or dust, or plague rats, or plague insects, or other agents ?
{d) The history of plague cases as regards the source of their infection and the
conditions under which it took effect.
(e) Whether rats or man are the chief di.sseminatoi's of plague, and in what
proportion ?
(/) Whether other animals arc disseminators of plague without being affected
412 The Prevention and SKpjjression of Plague [part iv
themselves, and in what way? It was a common belief when plague used to prevail
in Europe that cats and dogs thus conveyed infection. If this is so is it due to
insects on these animals ?
(g) Whether insects such as fleas, bugs, flies, etc., disseminate plague, and if so,
the length of time they will retain the infection ?
(A) What are the species of fleas on the rats, fowls, cats, and dogs in the locality
investigated, and which of them attack men ?
(i) What is the life-history of fleas and other insects in the affected locality in
relation to the epidemic and non-epidemic season of plague, and in their relationship
to man and the domesticated animals ?
(k) Whether there are other modes of dissemination besides animals and
insects ? Are rice stores and granaries, apart from their infected rats, disseminators
of plague by the infection of their goods ? How long does the bacillus live on fruits
and cooked food ?
(l) How is the infection conveyed from man to man and from animal to animal ?
except in pneumonic cases the infection does not appear to be direct. What are
the indirect agencies and in what way do they act ?
(m) How is the infection conveyed from man to the rat and in what way from
rat to man ? Is it by infected food, or by insect carriers ? A similar question
arises in regard to infection conveyed to and from poultry and other animals. Are
vegetable eaters more susceptible to plague than eaters of a mixed diet ?
(n) Does season affect the bacillus or its carriers and in what way ? To what
is due the rapid loss of infection of plague after an epidemic has reached its height ?
Is it climatic and due to the growth of saprophytic organisms destroying the
bacillus or rendering it attenuated in virulence, or is it due to some change in
the life-history of the carriers such as fleas, etc. ?
(o) What is the reason of dormancy in non-epidemic .seasons, and what are the
agents at work producing recrudescence ?
(p) What are the best agents for destroying the bacillus or its carriers ?
(q) What modification could be eflfected in the administration of HaffTiine's
prophylactic to make its use more general ? If it were protected in capsules so
as to pass through the stomach into the intestines and escape the digestive and
peptonising action of the stomach and u})per portion of the small intestine, would
it be absorbed in sulficient quantities for proi)hylactic purposes ? What is the
action of gastric juice and pancreatic juice on the prophylactic? Do they render
it inert ? If rendered inert would the intracellular toxines prepared by the liquid
air system be also rendered inert or would they more readily pass through the
living mucous membrane? If administration by the digestive system should fail in
both it might still be well to consider, in any further experituental work upon
the i)reparation of a plague prophylactic, the method em[)loyed by Dr Allan
Macfodyen for obtaining the fresh cell plasma of pathogenic bacteria for the
purpose of vaccination or immunisation and illustrated in his work on typhoid
and other organisms.
(r) By what mei\ns can the antidotal effect of Yersin's serum or of that of
others be rendered more powerful and curative against virulent plague ? The serum
CH. xxi] No Nation safe against Plague 413
requires to possess properties which shall be not only bactericidal but also powerfully
antitoxic in order that it may neutralise the toxines set free by the death of the
plague bacillus. Such a combination of properties in the serum is difficult to
obtain from the plague bacillus. A serum with bactericidal properties alone is
likely to aggravate the disease once the bacteria appear in large quantities in the
blood, while if the serum possesses antitoxic properties only it is no protection
against the multiplication of the bacteria and the final production of an over-
whelming quantity of toxines too great to be neutralised.
The subjects about which more information is needed are by no
means exhausted in the list given ; much more is required to be known
concerning the plague bacillus in nature. But the questions are
sufficiently numerous to indicate the amount of uncertainty and
ignorance which still exists concerning essentials connected with the
epidemiology, prevention, and treatment of plague, and they serve to
accentuate the fact that while this state of doubt and ignorance
continues no nation is safe against the ravages of plague should the
disease, as it threatens to do, present itself in the virulent and diffusive
pandemic form.
414
Ai^pendix I
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APPENDIX II.
THE INTERNATIONAL SANITARY CONVENTION
OF PARIS, 1903;
WITH APPENDICES,
TRANSLATED BY
THEODORE THOMSON, ESQ., M.D.
PART I.
{Reprodiiced hy kind permission of the Controller of
His Majesty's Stationery Office.)
GENERAL PROVISIONS.
CHAPTER I.
PROVISIONS TO BE OBSERVED BY THE COUNTRIES SIGNING THE CONVENTION
ON THE APPEARANCE OF PLAGUE OR CHOLERA IN THEIR TERRITORY.
. Section 1.— Notification and subsequent communications to
the other countries.
Art. I. — Every Government must inmiediately notify to the other
Governments the first appearance of recognised cases of plague or cholera
in its territory.
Art. 2. — Such notification shall l)e accompanied or very promptly followed
by detailed information as to : —
(1) where the disease has appeared ;
(2) the date of its appearance, its source, and its type ;
(3) the number of known cases and deaths ;
Paris Convention, 1903 417
(4) in the case of plague, the presence of that disease or of unusual
mortality among rats or mice ;
(5) the measures taken immediately on the first appearance of the
disease.
Art. 3. — The notification and the information prescribed in Articles 1
and 2 shnll be supplied to the diplomatic or consular agencies in the capital
of the infected country. In the case of countries not represented there, the
notification and the information shall be telegraphed direct to the Govern-
ments of these countries.
Art. 4. — The notification and the information prescribed in Articles 1
and 2 shall be followed by subsequent communications furnished regularly
and in such fashion as to keep the Governments informed of the course of
the epidemic. These communications shall be made at least once a week,
shall be as complete as possible, and shall, in particular, indicate the pre-
cautions adopted with a view to prevent spread of the disease. They must
set out with precision : —
(1) the preventive measures taken in the way of sanitary inspection or
of medical investigation, of isolation, and of disinfection ;
(2) the measures adopted in the case of outgoing vessels to prevent
exportation of the disease, and, particularly, in the case contemplated in
Art. 2 (4), the measures taken against rats.
Art. 5. — It is of primary importance that the foregoing provisions be
promptly and scrupulously complied with. i!^otitication is of no real ^alue
unless every Government be itself informed, in time, of cases of plague and
cholera and also of doubtful cases occurring in its territory. It cannot
therefore be too strongly impressed on the several Governments that they
should make notification of plague and cholera compulsory, and that they
should keep themselves informed as to any unusual mortality among rats
or mice, particularly in ports.
Art. 6. — It is to be understood that neighbouring countries reserve to
themselves the right to make special arrangements with the object of
organising direct exchange of information between the principal adminis-
trative officers on their frontiers.
Section II. — The conditions under ivhich a local area may he
regarded as infected or as having ceased, to he infected.
Art. 7. — -The notification of a first case of plague or cholera shall not lead
to the adoption of the measures prescribed in the following Chapter II.
against the local area in which the case has occurred. But when several
s. 27
418 Aj)2)endix II
non-imported cases of plague have occurred, or when the ca,ses of cholera
constituted a /oyer\ the local area shall be declared infected.
Art. 8. — In order that the measures be limited to places which are
infected, Governments must apply them to arrivals from infected local areas
oidy. " Local area " means a portion of territory clearly defined in the
information that accompanies or follows notification — as, for instance,
a province, a "government," a district, a department, a canton, an island,
a commune, a town, a quarter in a town, a village, a port, a polder, an
agglomeration, etc., whatever may be the extent and population of these
portions of territor}'. But this limitation to the infected local area must be
accepted only on the definite condition that the Government of the infected
country take the measures necessary («) for preventing the export of the
things specified in Art. 12 (1) and (2) derived from the infected local area,
unless previously disinfected, and (b) for checking the spread of the epidemic.
When a local area is infected no restrictive measure shall be taken
against arrivals from that local area, if they have left it not less than five
days before the beginning of the epidemic.
Art. 9. — In order that a local area cease to l)e regarded as infected it
must be oflScially established : — (1) that no death from nor fresh case of
plague or cholera has occurred within the five daj's following either the
isolation'" or the death or recovery of the last case of plague or cholera;
(2) that all measures of disinfection have been carried out and that, in the
case of plague, measures have been taken against rats.
CHAPTER II.
MEASURES OF DEFENCE, ON THE PART OP THE OTHER COUNTRIES,
AGAINST TERRITORIES THAT HAVE BEEN DECLARED INFECTED.
Section I. — Publication of measiires prescribed.
Art. 10.— The Government of each country shall immediately make
public the measures which it considers necessary to prescribe with regard
' Tntnuldior^s )iotc. The expression "centre of dissemination" may he taken as a fair
equivalent for the word "foyer." It seems desiraitle, however, to retain the oriijinal term
in the text, in vieio of the difficulty of decidimi xchat is to be regarded as constituting
a "foyer" of cholera. This question was debated at some length at the Dresden Conference
in 1893, and was again raised at the Paris Conference in 1903 by the translator and others.
At the Dresden Conference, Professor Brouardel, one of the French delegates, stated that an
exact definition of the word "foyer" %vas a difficult matter. At the Paris Conference in
1903, the word, after some discussion, teas retained without definition of its precise signi-
ficance in relation icith cholera.
" "Isolation" means the isolation of the sick person, of those in permanent attendance
on him, and the prohibition of visits by any other person.
Paris Convention, 1903 419
to arrivals from an infected country or local area. It shall forthwith
communicate these measures to the diplomatic or consular agent of the
infected country resident in the capital, and also to the Internatif)nal
Sanitary Boards. It shall also communicate, through the same channels,
the withdrawal of these measures or any modifications of them. In the
absence of a diplomatic or consular agency in the capital, the communica-
tions shall be made direct to the Government of the country concerned.
Section II. — Merchandise. — Disinfection. — Importation and
Transit. — Baggage.
Art. 11. — No article of merchandise is in itself capable of conveying
plague or cholera. Merchandise becomes dangerous only when contaminated
by plague or cholera products.
Art. 12. — Only such merchandise and things as the local sanitary
authority considers infected may be subjected to disinfection. Provided
always that the merchandise or things hereinafter specified may be subjected
to disinfection or their importation may even be prohibited, irrespective of
any evidence as to whether or not they are infected : — (1) Body-linen,
wearing apparel, bedding that has been in use. But when these things are
carried as baggage or in consequence of a change of abode (household goods),
their importation may not be prohibited but they shall be dealt with as
prescribed in Article 19. Soldiers' and sailors' kits, returned to their country
after their death, are to be regarded as of the nature of the things specified
in the first sentence of (1) of this article. (2) Rags, save, in the case of
cholera, rags compressed and carried in Ijound bales as merchandise in bulk.
The importation of the following articles may not be prohibited : — Fresli
waste derived directly fi-om spinning, weaving, making up, or bleaching
establishments ; artificial wools (KunstwoUe, shoddy) and new paper
clippings.
Art. 13. — The transit of the merchandise and things specified in (1) aiid
(2) of the foregoing article may not be prohibited if they are packed so that
they cannot be manipulated on the way. Similarly, when such merchandise
and things have been so conveyed that they cannot have come into contact
with contaminated articles on the way, their transit through an infected local
area must not hinder their importation into the country to which they are
consigned.
Art. 14. — Importation of the merchandise and things spi^cified in (1) and
(2) of Article 12 shall not be prohibited if it l)e proved to the authority of
the country to which they are consigned that they were despatched not less
than five days before the commencement of the epidemic.
27—2
420 Ap2)en(Jix II
Art. lo.^It rests with the .-uitlioi'ity of the country to which the
merchandise and things are consigned to decide in what manner and at what
place disinfection shall be carried out, and what shall be the methods adopted
to secure destruction of rats. These operations must be performed in such
fasliion as to injure articles as little as jjossible. It rests with each State to
settle questions of consequent compensation for damage caused by measures
of disinfection or of i-at-destruction. If, on account of measures taken to
secure destruction of rats on Ijoard ship, chai-ges are levied by tlie sanitary
authorit}' either directly or indirectly through a company or a private person,
the rates of these charges must Ije in accordance with a tariff made public
beforehand, and so drawn up that the State or the sanitary authority shall,
on the whole, derive no profit from its application.
Art. 16. — Letters and correspondence, printed matter, books, newspapers,
business documents, etc. (not including parcels conveyed by post), shall not be
subject to disinfection or to any restriction whatsoever.
Art. 17. — Merchandise, whether it has come by land or by sea, may not
be detained at frontiers or at ports ; the only measures that may be taken are
those specified in the foregoing Article 12. Provided always that if merchan-
dise, which has come by sea and is either not packed oi- imperfectly packed,
has become infected during the voyage by i-ats ascertained to have plague,
and if such merchandise cannot be disinfected, the destruction of the germs
may be secured by storing the merchandise during a period not to exceed two
weeks. It is to be understood that the application of this measure shall not
in any way delay the ship nor give rise to extra expenses by reason of
deficient storage-accommodation in any port.
Art. 18. — When merchandise has undergone disinfection in accordance
with the provisions of Art. 12, or has been temporarily stored in virtue of
the proviso contained in Art. 17, the proprietor of such merchandise or his
representative has the right to exact from the sanitary authority that has
ordered the disinfection or the storage a certificate showing the measures
that have been taken.
Art. 19. — ■Baf/<j(u/e. — Soiled linen, clothing and articles carried as baggage
or as household goods, fiom a local area declared to be infected, shall undergo
disinfection only in those instances where the sanitary authority considers
them infected.
Skction III. — Measures at ports aad land frontiers.
Art. 20. — Classification of ships. — A ship shall be regarded as infected if
there is plague or cholera on board or if there ha\e been one or more cases of
plague or cholera on board within seven days.
Paris Convention, 1903 4*21
A ship sluill be regarded as suspected if there ha\e been cases of phigue or
cholera on board at the time of (h'parture or during the voyage but no fresli
case within seven days.
A ship shall be regarded an hea/thi/, notwithstanding its having come from
an infected port, if there has been no death from nor case of plague or
cholera on board either before departure or during the voyage or on
arrival.
Art. 21. — In the case of playne, infected ships shall undergo the following
measures ; —
(1) medical inspection ;
(2) the sick shall immediately be disembarked and isolated ;
(3) the other persons must also be disembarked if possible, and either
be kept under observation' during a period which shall not exceed five dn,ys
and which may or may not be followed by surveillance'- of not more than
five days' duration, or merely be subjected to surveillance during a period
which shall not exceed ten days. The period shall date from the arrival of
the ship. It rests with the sanitary authority of the port, after taking into
consideration the date of the last case, the condition of the ship, and the
local possibilities, to take that one of these measures which seems to them
preferable ;
(4) such soiled linen, wearing-apparel, and articles belonging to the
crew •■' and passengers as are, in the opinion of the sanitary authority, infected
shall be disinfected ;
(5) the parts of the ship that have been occupied by persons ill with
plague, or that, in the opinion of the sanitary authority, are infected, must
be disinfected ;
(6) the rats on board must be destroyed, either before or after discharge
of cargo, as quickly as possible and, in any case, within a maximum time of
forty-eight hours, and so as to avoid damage to merchandise and to the ship's
plating and engines. In the case of ships in ballast, this pi'ocess must be
carried out as soon as possible before taking cargo.
Art. 22. — In the case of plague, suspected ships shall undergo the
measures specified in (1), (4), and (5) of Article 21.
^ "Observation" means isolation of travellers either on board a shij) or in a sanitary
station before they obtain free j^ratique.
"Surveillance" means that travellers are not isolated; they receive free pratique
immediately, bat the authorities of the several places whither they are bound are informed
of their coming and they are subjected to medical examination with a view to ascertaining
their state of health.
* " Crew " means persons forming (n- having formed part of the crew or staff of the
ship and includes stewards, waiters, cafedji, etc. The word nmst be interpreted in this
sense in all instances in which it occurs in this Convention.
422 A2}]tri>(Ji.T I J
In addition, the crew and passengers may be subjected to surveillance, the
duration of which, dating from the arrival of the ship, shall not exceed five
days. The crew may, during the same period, be prevented from leaving the
ship except on duty.
Destruction of rats on boai-d is recommended. This process shall be
carried out, either before or after discharge of cargo, as quickly as possible
and, in any case, witliin a maximum time of forty-eight hours, and so as to
avoid damage to merchandise and to the ship's plating and engines. In the
case of ships in ballast, this process, if there be occasion for it, shall be
carried out as soon as possible and, in any case, before taking cargo.
Art. 23. — ^In the case oi jilagiw, healthy ships shall be given free pratique
immediately, whatever their bill of liealtli may be. The only measures which
the authority of the port of arrival may take as regards these ships are the
following : —
(1) medical inspection;
(l') disinfection of soiled linen, wearing apparel and other ai'ticles
belonging to the crew and passengers, but only in exceptional instances, when
the sanitary authority has special reasons for regarding them as infected ;
(3) the sanitary authority may subject ships from an infected port to
a pi'ocess intended to secure destruction of rats on board, either before or
after discharge of cargo, although this measure must not be resorted to as a
general rule. This process must bo carried out as soon as possible and, in any
case, must not take longer than twenty-four hours, and so as to avoid damage
to merchandise and to the ship's plating and engines, and also so as not to
interfere with the coming and going of passengers and crew between ship
and shore. In the case of ships in ballast, the process, if there be occasion
for it, shall be carried out as soon as possible and, in an}' case, before taking
cargo.
If a ship from an infected port has been subjected to measures of rat-
destruction, these cannot be repeated unless the ship has called at an infected
port and has there l)rc)ught up to the quay, or unless sick or dead rats are
found on board.
The ci-ew and passengers may be subjected to surveillance during a period
which shall not exceed five days reckoned from the date on which the ship
left the infected port. The crew may, during the same period, be prevented
from leaving the ship except on duty.
The competent authority at the port of arrival may, in all cases, exact a
certificate, given on oath, from the doctor of the ship, or, in his default, from
the captain, testifying that there has not been a case of plague on board .since
departure and that unusual mortality among rats lias not been observed.
Art. 24. — When rats on a Jieallln/ ship have been shown by bacteriological
Paris Convention, 1903 423
examination to have plague, or wlien unusual mortality among these rodents
has been observ'ed, the measures to adopt are as follows : —
I. Ships with rats having plague : —
(«) medical inspection ;
{h) the rats must be destroyed, either before or after discharge of cargo,
as quickly as possible and, in any case, within a maximum time of forty-eight
hours, and so as to avoid damage to merchandise and to the ship's plating and
engines. Ships in ballast shall undergo this process as soon as possible and,
in any case, before taking cargo ;
(c) such parts of the ship and such articles as the local sanitary
authority regards as infected shall be disinfected ;
(d) the passengers and crew may be subjected to surveillance during
a period which must not exceed five days reckoned from the date of arrival,
save in exceptional instances in which the sanitary authority may prolong the
surveillance up to not more than ten days.
II. Ships on which unusual mortality among rats has been observed : — -
[a) medical inspection ;
{h) the rats shall be examined for plague as far and as quickly as
possible ;
(c) if it be considered necessary to destroy the rats, such destruction
shall take place subject to the conditions specified above as i-egards ships with
rats having plague ;
{d) until all suspicion shall have been removed, the passengers and
crew may be subjected to surveillance for a period which shall not exceed five
days reckoned from the date of arrival, save in exceptional instances in
which the sanitary authority may prolong the surveillance up to not more
than ten days.
Art. 25. — The sanitary authority of the port shall, whenever requested,
furnish the captain, the ship-owner, or the ship-owner's agent, with a certifi-
cate stating that measures of rat-destruction have been carried out, and
giving the reasons why they were resorted to.
Art. 26. — In the case of cholera, infected ships shall undergo the following
measures : —
(1) medical inspection ;
(2) the sick shall be immediately disembarked and isolated ;
(3) the other persons must also be disembarked, if possible, and either
be kept under observation or subjected to surveillance during a jjeriod which
shall vary with the health conditions of the ship and the date of the last case,
but which shall not exceed five days reckoned from the arrival of the ship ;
(4) such .soiled linen, wearing apparel, and articles belonging to the
424 Appendix II
crew and passengers as are, in tlie opinion of the sanitary authority of the
port, infected shall be disinfected ;
(5) the parts of the ship that have been occupied b}^ persons ill with
cholera, or that the sanitary authority regard as infected, shall be dis-
infected ;
(6) the bilge-water shall be disinfected and pumped out.
The sanitary autliority may or<ler that a supply of wholesome drinking-
water be substituted for that stored on board.
Casting human excreta, or allowing them to pass, without preliminary
disinfection, into the waters of the port may be prohibited.
Art. 27. — In the case of cholera, suspected ships shall undergo the
measures prescribed in (I), (4), (5), and (6) of Article 26.
The crew and passengers maybe subjected to surveillance during a period
wliich must not exceed five days reckoned from the arrival of the ship. It is
recommended that the crew be prevented, during the same period, from
leaving the ship except on duty.
Art. 28. — In the case of cholera, healthy ships shall be given free pratique
immediately, whatever their bill of health may be.
The only measures that the authority of the port of arrival may prescribe
as regards these ships are those specified in (1), (4), and (6) of Article 26.
The crew and passengers may be subjected to surveillance, in respect of
their state of health, during a period which must not exceed five days
reckoned from the date on which the ship left the infected port. It is
recommended that the crew be prevented, during the same period, from
leaving the ship except on duty.
The competent authority at the port of arrival may, in all cases, exact
a certificate, gi\-en on oath, from the doctor of the ship or, in his default,
from the captaiii, testifying that there has not been a case of cholera on
board since departure.
Art. 29. — In applying the measures specified in Articles 21-28, the fact
of a ship of any of the three classes before-mentioned carrying a doctor and
disinfecting apparatus (disinfecting chambers) shall receive due consideration
on the pai-t of the competent authority. In tlie case of plague, like con-
sideration shall be given when the ship is provided with apparatus for the
destruction of i-ats.
The sanitary autliorities of States that find it convenient to come to an
agreement on the matter, may dispense with medical inspection and other
measures in the case of healthy ships carrying a doctor specially commis-
sioned by their country.
.\rt. 30. — Special measures may Ije prescribed as regards ships that are
Paris Convention, 1903 425
overcrowded, and more especially as regards emigrant ships, or any other
ship in an unsanitary condition.
Art. 31. — Ships refusing to submit to measui'es prescribed l)y a port
authority, in virtue of the provisions of this Convention, shall be at liberty
to put out to sea. Such ships may be permitted to land goods after the
following necessary precautions have been taken, viz. : —
(1) isolation of the ship, ci"ew, and passengers;
(2) in the case of plague, request for information as to whether there
has been any unusual mortality among rats on board ;
(3) in the case of cholera, disinfection and evacuation of the bilge-
water and the substitution of wholesome drinking-water for that stored on
board.
Such ships may also be authorised to disembark passengers at their
request, on the condition that such passengers submit to the measui'es
prescriljed by the local authority.
Art. 32. — Ships from an infected place, that have been disinfected and
have undergone adequate sanitary measures, shall not, on their arrival in
another port, be subjected to these measures a second time, if no case has
occurred since the disinfection was performed and if they have not called
at an infected port. A ship which has merely disembarked passengers and
their baggage, or mails, without having been in communication with the
shore, shall not be regarded as having called at the port.
Art. 33. — Passengers arriving by an infected ship are entitled to exact
from the sanitary authority of the port a certificate showing the date of their
arrival and the measures taken as regards themselves and their baggage.
Art. 34. — Coasting traffic shall be dealt with by special I'egulations to be
agreed upon by the countries concerned.
Art. 35. — Without prejudice to the right of (jtovernments to agree to
establish sanitary stations in common, every country must provide at least
one port on each of its seaboards with an organisation and an equipment
sufficient for the reception of a ship, whatever its health conditions may be.
It is recommended that, when a healthy ship from an infected port
arrives in a large sea-port, such ship should not be sent away to another port
with a view to the carrying out of the sanitary measures prescribed.
In every country, the ports open to arrivals from ports infected with
plague or cholera must be so equipped that healthy ships can there undei-go
the prescribed measures upon their arrival and be not sent to another port
for the purpose. Governments shall make known what ports in their
country are open to arrivals from ports infected with plague or cholera.
Art. 36. — ^It is recommended that there be provided in large sea-ports: —
(a) a properly-organised port medical service and permanent medical
supervision of the health-conditions of crews and of the population of the
port;
426 Appniflix II
(b) suitable accommodation for the isolation of the sick and for
keeping suspected persons under observation.
(c) bacteriological laboratories and the buildings and jdant necessary
for efficient disinfection ;
{(I) a supply of drinking-water of quality above suspicion at the
disposal of the port, and a system of scavenging that offers every possible
guarantee for the removal of excrement and refuse.
Section IV. — -Measures at land frontiers. — Travellers. — Railways.
- — Frontier tracts. — River-ways.
Art. 37. — Land quarantine must no longer be resorted to. Only such
persons as show sj-mptoms of plague or of cholera may be detained at frontiers.
This principle does not deprive a State of the right to close a portion of
its frontiers in case of need.
Art. 38. — It is important that the railway staff keep watch over the state
of health of travellers.
Art. 39. — Medical intervention shall be limited to inspection of ti'avellers
and care of the sick. When this inspection is resorted to, it shall, as far as
possible, be combined with the Customs' examination in order that travellers
may suffer as little delay as possible. Only those persons who are visibly
ailing shall be subjected to a thorough medical examination.
Art. 40. — It is a measure of the greatest value to subject travellers that
have come from an infected place, on their arrival at their destination, to
surveillance for a j^eriod which should not exceed ten or live days, reckoned
from the date of their departure, in the case of plague or cholera respectively.
Art. 41. — Governments have the right reserved to them of taking special
measures in regard of certain classes of persons, notably gipsies, vagrants,
emigrants, and persons travelling or crossing the frontier in bands.
Art. 42. — Railway-carriages for passengers, mails, or luggage may not be
detained at a frontier. If one of these carriages be infected or shall have
been occupied by a person suffering from plague or from cholera, it shall be
detached from the train for disinfection at the earliest possible moment. The
same procedure shall apply in the case of goods trucks.
Art. 43. — Measures in relation with the crossing of frontiers by railway
and postal staff come within the scope of the administrations concerned. They
sliall lit> arranged so as not to hamper the service.
Art. 44.— -The regulation of frontier traffic and questions connected there-
with, as also the adoption of exceptioiial measures of surveilliUice, must be
left as matters for special ai-rangement between adjoining States.
Art. 45. — The sanitary control of ri\er-ways is a matter for special
arrangement by the Governments of States abutting thereon.
Paris Convention, 1903 427
PART II.
SPECIAL PROVISIONS REGARDING COUNTRIES
OUTSIDE EUROPE.
CHAPTER I.
ARRIVALS BY SEA.
Section I. — Measures at infected ports on the departure of vessels.
Art. 46. — The competent author! t}'' shall take effectual measures to
prevent the embarkation of persons showing symptoms of plague or of
cholera.
Every person taking passage by a ship must be individually examined at
the time of embarkation, by day and on shore, during such time as may be
necessary, by a doctor appointed by the public authority. The consular
authority of the countiy to which the ship belongs may be represented at
this examination.
In exception of this provision, the medical examination may, at
Alexandria and Port Said, take place on board whenever the local sanitary
authority consider this course to be of service ; subject, however, to the
reservation that third-class passengers shall not afterwards be authorised to
leave the ship. The medical examination m.iy be conducted by night in the
case of first-class and second-class passengers, but not in the case of third-
class passengers.
Art. 47. — The competent authority shall take effectual measures :
(1) to prevent the exportation of such merchandise or articles of any
sort as it may regard as infected and which have not previously' been
disinfected on shore under the supervision of a doctor appointed by the
public authority ;
(2) in the case of plague, to prevent rats gaining access to ships ;
(3) in the case of cholera, to see that drinking-water taken on board is
wholesome.
Section II. — Measures regarding ordinary ships from infected northern
jiorts, on their arrival at the entrance to the Suez Canal or at Egyptian
ports.
Art. 48. — Ordinary healthy ships from a port, infected with plague or
with cholera, in Europe or in the Mediterranean basin, proposing to pass
through the Suez Canal, shall be granted passage in quarantine; and shall
continue their voyage under five days' observation.
428 Appendix 11
Art. 49. — Ordinary healtlnj sliips, wishing to touch at Egypt, may put in
at Alexandria or Port Said, where tlieir passengers shall complete the period
of five days' observation, either on board, or in a sanitary station, as the local
sanitary authority may decide.
Art. 50. — -The measures to be taken as regards infected and suspected
ships from an European or ^Mediterranean port infected with plague or with
cholera, wishing to touch at an Egyptian port or to pass through the Suez
Canal, shall be settled by the Egyptian Sanitary Board in conformity with
the provisions of this Convention. The regulations embodying these
measures nmst, to become effective, be accepted by the several Powers repre-
sented on the Board : they shall establish the measures to which ships,
pas.sengers, and merchandise are to be subjected, and must be submitted
with the least possible delay.
Section III. — Measures hi the Red Sea.
A. — Meastires reyardiny ordinary ships from the South, touching at
Rid Sea ports or hound for the Mediterranean.
Art. 51. — In addition to the general provisions comprised in Part I,
Chapter II, Section III, concerning the classification of ships as infected,
suspected, or healthy, and the measures regarding them, the special pro-
visions, embodied in the following articles, shall apply to ordinary ships
entering tlie Red Sea from the south.
Art. 52. — Healthy ships must have completed or must complete five full
days' observation reckoned from the time of their departure from the last
infected port touched at.
They shall be entitled to pass through the Suez Canal in quarantine and
shall enter the Mediterranean continuing the above-mentioned five days'
observation. Ships witli a doctor and a disinfecting chamber shall not
undergo disinfection pi'ior to tlie passage in (][uarantine.
Art. 53. — Suspected ships shall be treated in a manner which shall differ
according as to whether they have or have not a doctor and a disinfecting
apparatus (disinfecting chamber).
(a) Those that have a doctor and a disinfecting apparatus (disinfecting
chamber) that fulfils the requisite conditions shall be allowed to pass through
the Suez Canal in quarantine subject to the regulations prescribed for the
passage.
(b) Those that have n(;ithcr doctor nor disinfecting apparatus (dis-
infecting chamber) shall, before being allowed to pass through the Canal in
quai-antine, be detained at Suez or at Moses' Wells for such time as may be
necessary for the performance of the disinfection presciibed and for assurance
that the health conditions on board are satisfactory.
Paris Convention, 1903 429
Passage in quarantine shall be granted to inail-l)oats or packets specially
devoted to passenger traffic that have a doctor 1)ut no disinfecting apparatus
(disinfecting chamber), if it be officially established to the satisfaction of the
local authority that cleansing and disinfection have been properly carried
out at the place of departure or during the voyage.
Free pratique may be granted at Suez, on the termination of the
procedure prescribed by the regulations, to mail-boats or packets specially
devoted to passenger traffic that have a doctor but no disinfecting apparatus
(disinfecting chamber) if tlie last case of plague or cliolera occurred more than
seven days before and if the health conditions of the ship are satisfactory.
In the case of a vessel that has had a healthy voyage of less than seven
days' duration, passengers for Egypt shall be landed at an establishment
appointed by the Alexandria Board and isolated for such time as may be
necessary for the completion of five days' observation. Their soiled linen
and their wearing apparel shall be disinfected. They shall then be granted
free pratique.
Ships that have had a health}' voyage of less than seven days' duration
and that wish to have free pratique for Egypt shall be detained at an
establishment, appointed by the Alexandria Board, during such time as
may be necessary for the completion of five days' ob3er^'ation ; they shall
undergo the measures prescribed by the regulations for suspected vessels.
When plague or cholera has occurred among the crew only, no soiled
linen shall be disinfected save that of the crew, the whole of which, however,
shall undergo disinfection ; the crew's quarters shall also be disinfected.
Art. 54. — Infected ships shall be divided into two classes, ships with
a doctor and a disinfecting apparatus (disinfecting chamber), and ships
without a doctor and without a disinfecting apparatus (disinfecting chamber),
(a) Ships without a doctor and without a disinfecting apparatus
(disinfecting chamVjer) shall he detained at Moses' Wells^; persons that
show symptoms of plague or cholera shall be disembarked and isolated in
a hospital. Disinfection shall be thoroughly carried out. The other persons
shall be disembarked and isolated in as small groups as possible so that, if
plague or cholera break out in one group, the whole party will not be
affected. The soiled linen and the clothing of passengers and crew, and
other articles used by them, siiall be disinfected, as also shall the ship.
It is to be understood that there is no question of discharging mer-
chandise, but only of disinfecting the infected part of the ship.
The passengers shall remain five days at an establishment appointed by
the Egyptian Sanitary Maritime and Quarantine Board. When cases of
' The sick shall, as far as possible, be landed at Moses' Wells ; the other persous may
be kept uuder obseivation at a sanitary station appointed by the Egyptian Hanitary
Maritime and Quarantine Board (pilots' lazaret).
430 Appendix II
plagne and cholera have not occurred for several days the term o isolation
shall be shortened. Its duration shall vary according to the date of recovery,
death, or isolation of the last case. Thus, if six days have elapsed since the
recovery, death, or isolation of the last case, the period of observation shall
be one day ; if only five days have elapsed, the period shall be two days ; if
only four days have elapsed, the period shall be three days ; if only three
days have elapsed, the period shall be four days ; if only two days or one day
have elapsed, the period shall be five days.
(6) Ships with a doctor and a disinfecting apparatus (disinfecting
chamber) shall be detained at Moses' Wells. The ship's doctor must state,
on oath, which persons on board have symptoms of plague or of cholera.
These persons shall be disembarked and isolated.
After these persons have been disembarked, such of the soiled linen of
the other passengei's as the sanitary authority regards as dangerous and that
of the ci'ew shall be disinfected on board. When plague or cholera has
occurred only among the crew, the disinfection of linen shall be carried
out only as regards tlie soiled linen of the crew and the linen of the crew's
quarters.
The ship's doctor must also declare, on oath, which part or compartment
of the ship was occupied by the sick and to wliich section of the hospital
they were removed. He must also declare, on oath, which persons have been
in relation with the plague or cholera patient since the first appearance of
the disease, either by direct contact or by contact with objects that may
have been infected. Only these persons shall be regarded as suspected.
The part or compartment of the ship, and the section of the hospital, that
have been occupied by the sick, shall be thoroughly disinfected. " Part of
the ship " shall mean the cabin of the sick person, the adjoining cabins, the
passage to these cabins, the deck, the parts of the deck where the sick person
or persons have remained for some time. If it be impossible to disinfect the
part or compartment of the ship that has been occupied by plague or cholera
sick without disembarking the persons declared to be suspected, these persons
shall either be transferred to another ship .specially reserved for the pui'pose,
or be landed and accommodated in the sanitary station without being brought
into contact with the sick, who must be kept in the hospital. This stay on
board ship or on shore, for purposes of disinfection, shall be as short as
possible and shall not exceed twenty-four hours.
The suspected persons shall be kept under observation, either on their
own ship or on the ship reserved for that purpose, for a period which shall
vary according to the circumstances and in the manner set out in the third
paragraph of sub-section (a) of this article.
Tlie time occupied in carrying out the measures prescribed by the regula-
tions shall be included in the observation period.
Paris Convention, 1903 431
Passage in quarantine may, if deemed possible by the sanitary authority,
be allowed before expiry of the periods of detention indicated above. It
shall in any case be granted on the completion of disinfection if the ship
leaves behind, in addition to its sick, the persons classed above as "suspected."
A barge fitted with a disinfecting chandler may be brouglit alongside the
ship with a view to hastening the process of disinfection.
Infected vessels seeking free pratique in Egypt shall be detained five days
at Moses' "Wells ; they shall, in addition, undergo the same measures as are
taken in the case of infected ships arriving in Europe.
B. — Measures regardhiy ordinary ships from infected ports in
the Hedjaz during the inlijrinuuje season.
Art. 55. — If, during the Mecca pilgrimage, plague or cholera is prevalent
in the Hedjaz, ships from the Hedjaz or from any other part of the Arabian
coast of the Red Sea, that have not tliere taken on board any pilgrims or
like collections of persons and on which there has been no suspicious incident
during the voyage, shall be classed as ordinaiy suspected ships and shall be
subjected to the preventive measures and the treatment prescribed for such
ships.
If they are bound for Egypt they shall undergo, at a sanitaiy station
appointed by the Sanitary Marilime and Quarantine Board, five days'
observation, reckoned from the date of their departure, whether it be
cholera or plague that is in question. They shall, moreover, be subjected
to all the measures prescribed for suspected ships (disinfection, etc.), and
shall not be granted free pratique until after favourable medical inspection.
It is to be understood that, if there have been suspicious incidents on
board during the voyage, the period of observation shall be undergone at
Moses' Wells and shall be five days whether it be cholera or plague that is
in question.
Section IV. — The organisation for securing surveillance and
disinfection at Suez and at Moses" Wells.
Art. 56. — Every ship arriving at Suez shall undergo the medical in-
spection prescribed by the regulations. This inspection shall be conducted by
one or more of the doctors attached to the station, and sliall, in the case of
ships from a port infected with plague or with cholera, ))e made by day. It
may, however, in the case of ships wishing to pass through the Canal, take
place by night when the ship is lighted by electricity, and in all cases in
which the local sanitary authority is satisfied that the ship is sufiiciently well
lighted.
432 Aj)pi'ndix II
Art. 57. — There shall be at least seven doctors at the Suez station, — a
principal medical officer and six medical officers. They must hold a re-
cognised diploma and, in their .selection, preference is to be given to medical
men who have made a special study of practical epidemiology and practical
bacteriology. They shall be appointed by the Minister of the Interior on the
recommendation of the Sanitary Maritime and Quarantine Board of Egypt.
The salary of the medical officers shall commence at 8000 francs and rise by
progressive increments to 12,000 francs; that of the principal medical officer
shall commence at 12,000 francs and rise to 15,000 francs.
Should this medical staff prove insufficient, naval doctors of the several
States may be employed, under the orders of the Principal Medical Officer of
the sanitary station.
Art. 58. — The supervision and performance of the Suez Canal prophylactic
measures at the Moses' Wells and Tor stations, shall be entrusted to a staff
of sanitary guards.
Art. 59. — This staff shall consist of ten guards. They shall be selected
from retired non-commissioned officers, of higher than corporal's rank, of the
armies and navies of Europe and Egypt. These guards are elected, after the
Board is satisfied as to their htness, according to the procedure laid down in
Article 14 of the Khedivial Decree of 19th June, 1893.
Art. 60. — There shall be two classes of guards; four of the first class, six
of the second class.
Art. 61. — The yearly pay of these guards shall be £160 Egyptian, rising
by progressive increments to a maximum of £200 Egyptian, for the first
class ; and £120 Egyptian, rising by progressive increments to a maximum of
£168 Egyptian, for the second class.
Art. 62. — These guards shall have the status of police officers, with the
right to invoke aid in cases where the sanitary regulations are infringed.
They shall be under the immediate control of the adniinistrator-in-chief of
the establishment at Suez or Tor. They must have practical knowledge of
all the methods of disinfection in use, and must know how to manipulate
disinfecting materials and apparatus.
Art. 63. — The disinfecting and isolation station at Moses' Wells shall be
under the control of the principal medical t)fficer at Suez. If sick persons are
landed at the Moses' Wells Station, two of the Suez medical officers shall be
kept in residence there, one to attend to cases of plague or cholera, the other
to attend to persons not suffering from these diseases. If there should be
cases of plague, of cholera, and of other diseases at the same time, three
medical officers shall Ije kept in residence ; one for plague cases, one for
cholera cases, and the third for persons suffering from other diseases.
Paris Convention, 1903 433
Art. 64. — -The disinfecting and isolation station at Moses' Wells must be
provided with : —
(1) at least three disinfecting chambers, of which one shall be on
a barge, and the plant retjuired for rat-destruction ;
(2) two isolation hospitals, each with twelve beds, one for cases of
plague and persons suspected of having plague, the other for cases of cholera
and persons suspected of having cholera. These hospitals must be so
arranged that, in each of them, the sick, the suspected, and men and women
can be segregated from one another ;
(3) buildings, hospital-tents, and ordinary tents, for the accommodation
of persons landed ;
(4) a sufficient number of baths and shower-baths ;
(5) the necessary buildings for general staff, doctors, guards, etc. ;
a store, and a laundry ;
(6) a reservoir for the water-supply ;
(7) the several buildings must be so arranged that the sick, or infected
or suspected articles, cannot be brought into contact with other persons.
Art. 65. — The disinfecting chambers at Moses' Wells shall be entrusted
to the special care of a skilled mechanic.
Section V. — The 'passage of the Suez Canal in quarantine.
Art. 66. — Permission to pass the Suez Canal in quarantine shall be
granted by the Suez sanitary authority ; the Board shall be immediately
informed when such permission is given. In doubtful cases, the decision
shall rest with the Board.
Art. 67. — When the permission provided for in the preceding article has
been given, a telegram shall at once be sent to the authority appointed by
each Power. The telegram shall be sent at the expense of the ship.
Art. 68. — Each Power shall issue an edict subjecting to penalties those
vessels which depart from the course declared by the captain and enter with-
out license one of the ports of that Power. Exception shall be made in the
case of circumstances beyond control and when a break in the voyage cannot
be avoided.
Art. 69. — When the health-visit takes place, the captain must declare if
he has on board gangs of native stokers, or hired servants, of any description,
not included in the roll of the crew, or the register kept for the purpose.
The following questions, in particular, shall be put to the captains of all ships
arriving at Suez from the south and shall be answered by them on oath : —
Have you any supernumeraries : stokers, or other hands not included
in the ship's roll or in the special register ?
s. 28
434 Ai^peiidir IT
What is their nationality ?
Wliere did you eml)ark tliem ?
The medical officers must satisfy themselves as to the presence of these
supernumeraries, and if they find that any of their number are missing, they
must enquire carefully into the cause of their absence.
Art. 70. — A sanitary officer and two sanitary guards shall go on board.
They must accompany the ship as far as Port Said ; their duty is to prevent
communication, and to see to the execution of the measures prescribed for the
passage of the Canal.
Art. 71. — All embarkation and disembarkation, and all transhipment of
passengers or goods, are forbidden during the passage of the Canal from Suez
to Port Said.
Provided always that travellers may embark at Port Said in quarantine.
Art. 72. — Ships passing through the Canal in quarantine must make the
journey from Suez to Port Said without lying up.
In case of the vessel running aground, or being compelled to lie up, the
necessary operations shall be carried out by the staff of the ship, all communi-
cation with the staff of the Suez Canal Company being avoided.
Art. 73. — Infected or suspected transports passing through the Canal in
quarantine with troops must do so only by day. If they are compelled to
pass the night in the Canal, they shall anchor in Lake Timsah or in the
Great Lake.
Ai't. 74. — Ships that pass through the Canal in quarantine are forbidden to
stop at Port Said except as provided for by the second paragraph of Article 71
and by Article 75. Revictualling must be effected by the means at the dis-
posal of the ship. All stevedores and others who have gone on board shall
be isolated on the quarantine barge, where their clothing shall be disinfected
as prescribed l>y the regulations.
Art, 75. — When it is absolutely necessary for ships passing in quarantine
to coal at Port Said, they must do so at a place to be fixed by the Sanitary
Board, where the necessary isolation and sanitary supervision can be secured.
The coaling may be done by the labourers of the port in cases where
effective supervision of this operation is possible, and when all contact with
the crew can be avoided. At night, the coaling-place must be lighted by
electricity.
Art. 76. — Pilots, electricians, agents of the Company, and sanitary guards
shall be disembarked at Port Said outside the port, between the jetties, and
shall be taken thence direct to the quarantine barge, where their clothing
shall be disinfected if necessary.
Paris Convention, 1903 435
Art. 77. — As regards the passage of the Suez Canal, the following advan-
tages shall be accorded to ships of war as hereinafter specified.
The quarantine authority shall accept them as healthy on their presenting
a certificate signed by the ship-surgeons, countersigned by tlie captain, and
stating on oath : —
(rt) that there has not been, either at the time of departure or during
the voyage, a case of plague or of cholera on board ;
(h) that a careful examination of evei'yone on board, without excep-
tion, has been made within 12 hours of arinval at the Egyptian port, and that
no case of either of these diseases has been detected.
These ships shall not undergo medical inspection, and shall be given free
pratique at once subject to their having completed five clear days since leaving
the last infected port at which they called. Such of these ships as have not
completed the requisite period may pass through the Canal in quarantine
without medical inspection provided they produce the certificate above
mentioned to the quarantine authority.
Notwithstanding the foregoing pi'ovisions, the quarantine authority shall
have the right of medically inspecting, by its officers, ships of wai- in all
instances in which it considers this procedure necessary.
Infected or suspected ships of war shall be subject to the regulations
in force.
Only fighting-units shall be regarded as ships of war. Transports and
hospital-ships shall be classed as ordinary ships.
Art. 78. — The Egyptian Mai'itime and Quarantine Board may arrange
the conveyance, by rail, over Egyptian territory, of mails and ordinary
passengers from infected countries in quarantine trains, under the conditions
specified in Appendix No. 1.
Section VI. — Measures in the Persian Gulf.
Art. 79. — Ships shall undergo the health-visit at the Island of Ormuz
sanitary station before they enter the Persian Gulf. They shall undergo the
measures specified in Section III, Chapter II, Part I, tliat their health
conditions and the place whence they have come render applicable. Ships,
liowev'er, that have to proceed up the Shatt-el-Arab shall be permitted, if the
period of observation has not been completed, to continue their voyage, on
condition that they traverse the Persian Gulf and the Shatt-el-Arab in
quarantine. A chief guard and two sanitary guards, taken on board at
Ormuz, shall keep the ship under supervision as far as Bassorah, where a
second medical inspection shall be made and the necessary measures of
disinfection carried out. Pending the organisation of the Ormuz sanitary
station, the sanitary guards shall be taken on at the temporary station
28-^2
436 Appe))(lhT II
provided in accordance with pai-a<:fra])h 2 of Article 82 hereinafter, and
these guards shall accompany ships proceeding in quarantine up the Sliatt-el-
Arab to the station pro^'ided in the neighbourhood of Bassorah.
Ships that have to call at Persian ports to disembark passengers or goods
may do so at Bender-Bushire.
It is to be clearly understood that a sliip which continues healthy after
five days, reckoned from her date of departure from the last port infected by
plague or cholera at which she has touched, shall be granted free pratique at
Persian Gulf ports, provided she is ascertained to be healthy on arrival.
Art. 80. — In so far as the classification of ships and the measures they
are to undergo are concerned. Articles 20 to 28 of this Convention apply in
the Persian Gulf, subject to the three following modifications : —
(1) observation, for the same period, shall always be substituted for
surveillance of passengers and crew ;
(2) healthy ships cannot be granted free pratique unless they have
completed five full days since leaving the last infected port at which they
have touched ;
(3) in the case of suspected ships the j^eriod of five days' observation
of passengers and crew shall be reckoned from the time at which there ceased
to be a case of plague or of cholera on board.
Sectiox VII. — Persian Gulf Sanitary Stations.
Art. 81. — Sanitary stations must he provided, under the direction and at
the expense of the Constantinople Board of Health, one at the Island of
Ormuz, the other at a spot to be selected in the neighbourhood of Bassorah.
At the Ormuz sanitary station there shall be at least two doctors,
sanitary otficers, sanitary guards, and a complete plant for disinfection
and for destruction of rats. A small hospital shall be erected.
At the station near Bassorah there shall be pro\'ided a large lazaret
with a stafF of several doctors, and ])uil(]iiigs and plant for the disinfection
of goods.
Art. 82.— The Ccjiistaiitinople Superior Board of Health, which has the
control of the Bassorali sanitary station, shall have the same power as
regards the Ormuz station.
Pending the construction of the Ornmz sanitaiy station, a sanitary post
shall be provided there by the Constantinople Superior Board of Health.
Paris Convention, 1903 437
CHAPTER II.
ARKIVALS BY LAND.
Section I. — General 2ii'ovisions.
Art. 8.3. — The measures taken in respect of arrivals by land from districts
infected with ]>lague or with cholera must be in conformity witli the sanitary
principles laid down in this Convention.
Modern methods of disinfection must be substituted for land quarantine.
With this object, disinfecting chambers and other disinfecting plant shall be
established at properly selected points on the roads frequented by travellers.
The same methods shall be adopted on railways, whether now in existence or
constructed hereafter. Merchandise shall be disinfected in accordance with
the principles of this Convention.
Art. 84. — Every Government is at liberty, in case of need, to close a
portion of its frontiers to passengers and merchandise in localities wdiere
there is difficulty in organising sanitary supervision.
Section 1I.~ Turkish land frontiers.
Art. 85. — The Constantinople Superior Board of Health must organise
without delay the sanitary stations of Hanikin and Kizil-Dizie, near Bayazid,
on the Turko-Persian and Turko-Russian frontiers.
PART III.
SPECIAL PROVISIONS REGARDING PILGRIMAGES.
CHAPTER L
GENERAL PROVISIONS.
Art. SG. — The provisions of Articles 46 and 47, Part IT, are applicable
to persons and things that have to be taken on board a pilgrim ship leaving
a port in the Indian Ocean or Oceania, even when the port is not infected
with plague or with cholera.
Art. 87. — When there are cases of plague or of cholera in the port,
embarkation on pilgrim-ships shall not take place until the persons, collected
in groups, shall have been subjected to observation sufficient to ensure that
none of them are suffering from plague or cholera. It is to be understood
that, as regards the adoption of this measure, every Goveinnient may take
local circumstances and possibilities into account.
438 Ajypendix II
Art. 88. — If local circumstances permit, pilgrims must prove that they
possess the means absolutely necessary for the accomplishment of the
pilgrimage, and, in particular, that they have a return-ticket.
Art. 89. — Only steamships shiill be permitted to carry pilgrims on long
voj'ages. The carriage of pilgrims by other ships on such voyages shall be
prohibited.
Art. 90. — Pilgrim ships that are coasters intended for short passages
known as " coasting voyages " siiall be subject to the provisions of the
special regulations for the Hedjaz pilgrimage, which shall be published by
the Constantinople Board of Health, in conformity with the principles laid
down in this Convention.
Art. 91. — A ship which, in addition to ordinary passengers, among whom
pilgrims of the upper classes may be included, carries pilgrims of the lowest
class in less proportion than one pilgrim per 100 tons gross, shall not be
considered a pilgrim ship.
Art. 92. — Ever}' pilgrim-ship, on entering the Red Sea or the Persian
Gulf, must observe the provisions of the special regulations for the Hedjaz
pilgrimage, which shall be published by the Constantinople Board of Health,
in conformity with the principles laid down in this Convention.
Art. 93. — The captain must pay all sanitaiy imposts leviable on pilgrims.
These imposts must be covered by the price of the ticket.
Art. 94. — As far as practicable, jjilgrims who embark or disembark at
sanitary stations must have no contact with one another at the landing-
places.
Ships that have disembarked their pilgrims must change their anchorage
before commencing re-embarkation.
Pilgrims who have been disembarked must be distributed in camp in as
small groups as possible. It is necessary that they be supplied with whole-
some drinking-water, obtained either from local sources or by distillation.
Art. 95. — When there is plague or cholera in the Hedjaz, provivsions
brought b}' pilgrims shall be destroyed if the sanitary authority consider it
necessary.
CHAPTER II.
PILGIUM-SIIIPS. — SANITAKV STATIONS.
Skction I. — GeveraJ condilioiDi aj^ph/ing to sliips.
Art. 9G. — The ship must be capable of accommodating the pilgrims in the
between decks.
Over and above the space letiuired for the crew, the ship must provide
Paris Conveiition, 1903 439
for each person, irrespective of age, an area of 1'50 square metres, equivalent
to 16 English square feet, and a height between decks of aliout 1-80 metres.
In coasting vessels, each pilgrim must he allowed a s^sace at least 2 metres
wide along the gunwales.
Art. 97. — On each side of the ship, on deck, a place must be set apart,
screened from view and furnished with a hand-pump, for the supply of sea-
water for the needs of the pilgrims. One such place must be reserved
exclusively for women.
Art. 98.- — ^The ship must be provided, in addition to closets for the crew,
with latrines, fitted with a flushing apparatus or with a water tap, in a
minimum proportion of one latrine per hundred passengei's. Some of these
latrines shall be reserved exclusively for women.
There must be no closets between decks or in the hold.
Art. 99. — The ship must have two places for cooking set apart fur the
use of tlie pilgrims. Pilgrims shall l)e forbidden to light fires elsewhere,
especially on deck.
Art. 100. — A properly fitted hospital, constructed with due attention to
safety and health, must be reserved for the accommodation of the sick. It
must be capable of accommodating, at the rate of three square metres per
patient, not less than five per cent, of the pilgrims taken on board.
Art. 101. — The ship must be provided with the means of segregating
persons showing symptoms of plague or of cholera.
Art. 102.^ — ^Every ship must carry such medical remedies, disinfectants,
and things as are necessary for the treatment of the sick. The regulations
framed for this class of ship by each Government must specify the nature
and the quantity of these remedies'. Medicine and attendance shall be
provided for the pilgrims free of charge.
Art. 103. — Every .ship taking pilgrims must carry a duly qualified
doctor, commissioned by the Government of the country to which the
ship belongs or by the Government of the port where the pilgrims are
embarked. A second doctor must be carried when the number of pilgrims
on board exceeds 1000.
Art. 104. — The captain must cause notices, in the languages chiefly
spoken in the countries inhabited by the pilgrims he is taking, to be posted
up on the ship in a conspicuous place, accessible to all conceined, showing : —
(1) the destination of the ship ;
(2) the price of tickets ;
(3) the daily ration of food and water allowed to each pilgiiiii ;
' It is to be desire;! tliat every shii^ be provided with the chief iinmuuising agents
(anti-plague serum, Haffkine's propliylactic, etc.).
440 Appendix II
(4) the price of articles, not included in the daily ration, which may
be procured on extra payment.
Art. 105.— The heavy baggage of pilgrims shall be registered, numbered,
and put in the hold. Pilgrims may keep with them only such things as are
absolutely necessary. The n.ature, amount, and dimensions of these things
shall be decided by regulations framed \)y each Government for its own ships.
Art. lOG. — The provisions of Chapter I, of Sections I, II, and III of
Chapter II, and of Chapter III, of Part III of this Convention shall be
posted up, in the form of regulations, in the language of the country to
which the ship belongs, and also in the languages chiefly spoken in the
countries inhabited by the pilgrims to be embarked, in a conspicuous and
accessil^le place on every deck and between-decks of every ship carrying
pilgriins.
Section II. — Measures before departiire.
Art. 107. — The captain or, in his default, the owner or agent of every
pilgrim-ship must, not less than three days before departure, declare to the
conipetent authority of the port of departure his intention to embark pilgrims.
At ports of call, the captain or, in his default, the owner or agent of every
pilgrim-ship must make the same declaration twelve hours before the de-
parture of the ship. This declaration must .specify the proposed date of
departure and the destination of the ship.
Art. 108. — On receipt of the declaration provided for by the preceding
article the competent authority shall proceed, at the expense of the captain,
to inspect and measure the ship. The consular authority of the country to
which the ship belongs may be present at this inspection. Inspection
alone shall take place if the captain already has a certificate of measure-
ment furnished by the competent authority of his country, unless it be
suspected that the certificate no longer represents correctly the real con-
dition of the ship'.
Art. 109. — The competent authority shall not permit the departure of
a pilgrim-ship until satisfied : —
(a) that the ship has been thoroughly cleaned and, if necessary,
disinfected ;
(b) that the ship is in a condition to undertake the voyage without
danger, that she is properl}' manned, etjuipped and ventilated, and provided
1 At present tbe competent authority is : in British India, an officer appointed for the
purpose by the Local Government (Native Passengers' Ships Act, 1877, Article 7) ; in the
Dutch Indies, tbe master of the port ; in Turkey, the sanitary authority ; in Austro-
Hungary, the port authority ; in Italy, the captain of the port ; in France, Tunis, and
Spain, the sanitary authority; in Egypt, the sanitary quarantine authority.
Paris Convention, 1903 441
with a sufficient number of boats ; that there is on board nothing that is, or
may become, injurious to the health or safety of the passengers, and that the
deck is of wood or of iron sheathed in wood ;
(c) that there is on board, properly stowed away, over and above the
rations for the crew, sufficient food and fuel of good quality for all the
pilgrims, during the declared duration of the voyage ;
{d) that the drinking-water is of good quality and from a source free
from risk of contamination ; that it is in sufficient quantity ; that the tanks
for drinking-water are safe fi'om all contamination and so closed that the
water can be supplied only by means of taps or pumps. The water-supply
fittings known as " sucoirs " shall be absolutely prohildted ;
(e) that the vessel carries a condenser, capable of distilling a minimum
quantity of five litres of water per diem for every person on board, including
crew ;
(y) that the ship possesses a disinfecting chamber, ascertained by the
sanitary authority of the port where the pilgrims embarked to be safe and
efficacious ;
{y) that, in accordance with Articles 102 and 103, the vessel carries a
duly qualified doctor commissioned^ either by the Government of tlie country
to which she belongs or by the Government of the port where the pilgrims
embark, and that she carries medical stores ;
(A) that the deck is free from merchandise and all encumbrances ;
(i) that the arrangements on board are such as to allow of the
measures prescribed in the following Section III being carried out.
Art. 110. — The captain may not start without having in his possession : —
(1) a list, countersigned by the competent authority, showing the
name, sex, and total number of pilgrims he is authorised to carry ;
(2) a bill-of-health, giving the name, nationality, and tonnage of the
ship, the name of the captain and of the doctor, the exact number of persons
embarked — crew, pilgrims and other passengers — the nature of the cargo and
the place of departure.
The competent authority shall note on the bill-of-health whether the
number of pilgrims permissible under the regulations has been embarked
or not, and, in the latter case, the additional number of passengers the
vessel is authorised to embark at subsequent ports of call.
Sectiox III. — Measures during the' voyaye.
Art. 111. — During the voyage the deck must be kept free from encum-
brances ; it must be reserved, night and day, for the passengers, and placed
at their disposal without charge.
1 Exception is made in the case of Governments without commissioned doctors.
442 Aj^pendix II
Art. 112. — The between-decks must be carefully cleansed and rubbed
witli dry sand, mixed with disinfectants, every day while the pilgrims are
on deck.
Art. 113. — The latrines allotted to the passengers, as well as those for the
crew, must be kept clean, aiad must be cleansed and disinfected three times
a day.
Art. 114. — The excretions and dejecta of persons showing symptoms of
plague or of cholera must be received in vessels containing a disinfecting
solution. These vessels shall be emptied into the latrines, which must be
thoroughly disinfected every time this is done.
Art. 115. — All bedding, carpets, and clothing that have been in contact
with the sick persons referred to in the preceding article must be immediately
disinfected. The observance of this rule is specially enjoined in respect of
the clothes of persons who have been near the sick, and which may have
been contaminated. Such of the above-mentioned articles as are of no value
must be either thrown overboard, if the ship is not in harbour or in a canal,
or else burnt. Other articles must be carried to the disinfecting chamber in
impermeable bags washed in a disinfecting solution.
Art. 116. — The quarters occupied by the sick, refei'red to in Article 100,
must be thoroughly disinfected.
Art. 117. — It is compulsory on pilgrim-ships to undergo such measures of
disinfection as are in accordance with the regulations on this subject that
are, for the time being, in force in the country under whose flag they sail.
Art. 118. — Not less than five litres of drinking-water must each day be
put at the disposal of ever}' pilgrim, irrespective of age, free of charge.
Art. 119. — If there be any doubt as to the quality of the drinking-water
or any reason to suspect that it may possibly have become contaminated,
either at its source or during the voyage, it must be boiled or otherwise
sterilised, and the captain shall be responsible for seeing that it is thrown
overboard at the first port of call at which he can procure a purer supply.
Art. 120. — The doctor shall visit the pilgrims, tend the sick, and see that
the principles of hygiene are observed on board.
He must in particular : —
( 1 ) satisfy himself that the rations issued to the pilgrims are of good
quality, that their quantity is in accordance with contract, and that they are
properly prepared;
(2) satisfy him.self that the provisions of Article 118, regarding the
distribution of water, are obser^ ed ;
(3) if there be any doubt as to the quality of the drinking-water, call
the attention of the captain, in writing, to the provisions of Article 119;
Paris Convention, 1903 443
(4) satisfy himself that the ship is always kept clean, and particularly
that the latrines are cleansed in accordance with the provisions of Article
113;
(5) satisfy himself that the pilgrims' quarters are kept wholesome, and,
in case of the occurrence of infectious disease, that disinfection is carried out
in accordance with A rticles 116 and 117;
(6) keep a diary of all occurrences related to health during the voyage,
and submit this diary to the competent authority at the port of arrival.
Art. 121. — Only the persons charged with the care of plague or cholera
patients shall have access to them, and these persons must not come in
contact with the other persons that have been embarked.
Art. 122. — In the event of a death occurring during the voyage, the
ca[)tain must enter the fact opposite the name of the deceased, on the list
countersigned by the authority of the port of departure, and must also enter
in the log the name of the deceased, his age, the place from which he came,
the supposed cause of death according to the medical certificate, and the date
of death.
In the event of a death from infectious disease, the corpse, wraj)ped in
a shroud impregnated with a disinfecting solution, must be committed to the
deep.
Art. 123. — The captain must see that all preventive measures taken
during the voyage are entered in the log. The log shall be submitted by
him to the competent authority at the port of arrival.
At each port of call the captain must cause the list drawn up in accord-
ance with Article 110 to be countersigned by the competent authority.
In the event of a pilgrim disembarking during the voyage, the captain
must note the fact on the list, opposite the pilgrim's name.
In the event of persons embarking, their names must be entered on the
list in accordance with the foregoing Article 110. This must be done befoi'e
the competent authority, as in duty bound, again countersigns the list.
Art. 124. — The bill-of-health given at the port of departure must not be
changed during the voyage.
It shall be countersigned at eacJi port of call by the sanitary authority,
who shall enter : —
(1) the number of passengers disembarked or embarked at the port ;
(2) anything that has happened at sea affecting the life or health of the
persons embarked ;
(3) the health conditions of the port of call.
444 Appendix II
Section IV. — Measures on arrival of jjilgrims in the Red Sea.
A. Sanitary control of ships from an infected jwrt, going from the
south to the Hedjaz with Mohammedan jntgrims.
Art. 125. — Pilgrim-ships from the south, bound for the Hedjaz, must, in
the first instance, put in at the Kamaran sanitary station, and shall be dealt
with as provided by Articles 126-128.
Art. 126. — Ships found, on medical inspection, to be healtliy shall be
given free pratique on completion of the following procedure : —
The pilgrims shall be disembarked ; they shall take a shower-bath or
bathe in the sea ; their soiled linen and any portion of their personal eflfects
or their baggage, open, in the opinion of the sanitary authority, to suspicion,
shall be disinfected. The duration of these operations, including dis-
embarkation and embarkation, must not exceed forty-eight hours.
If no recognised or suspected case of plague or of cholera be discovered
during these operations, the pilgrims shall immediately be re-embarked and
the ship shall proceed to the Hedjaz.
In the case of plague, the provisions of Articles 23 and 24 regarding rats
shall apply in the event of there being any of these vermin on board.
Art. 127. — Suspected ships, which have had cases of plague or of cholera
on board at the time of departure, but no fresh case of plague or of cholera
within seven days, shall be dealt with as follows : —
The pilgrims shall be disembarked ; they shall take a shower-bath or
bathe in the sea ; their soiled linen and any portion of their personal effects
or their baggage, open, in the opinion of the sanitary authority, to suspicion,
shall be disinfected. In time of cholera, the bilge-water shall be pumped
out. The parts of the ship occupied by the sick shall be disinfected. The
duration of these operations, including disembarkation and embarkation,
must not exceed forty-eight hours.
If no case or suspected case of plague or of cholera be discovered during
these operations, the pilgrims shall immediately be re-embarked and the ship
shall proceed to Jeddah, where a second medical inspection shall take place
on board. If the result be favourable and if the ship's doctor certifies in
writing and on oath that there has been no case of plague or of cholera
during the passage, the pilgrims shall be landed forthwith. If, however, one
or more recognised or suspected cases of plague or of cholera prove to have
occurred during the voyage or on arrival, the ship sliall be sent back to
Kamaran where she shall again be dealt with as infected.
Inthe case of plague, the provisions of the third paragraph of Article 22
shall apply in the event of there being rats on board.
Pan's Convention}, 1903 445
Art. 128. — Injected ships, that is to say, ships witli cases of plague or of
cholera on board, or that have had cases of plague or of cholei'a on board
within seven days, shall be dealt with as follows : —
Persons su Bering from plague or from cholex'a shall be disembarked and
isolated in hospital. The other passengers shall be disembarked and isolated
in as small groups as possible, in order that, if plague or cholei'a break out in
one group, the whole party may not be affected.
The soiled linen, clothing and personal effects of the crew and the
passengers shall be disinfected, as also shall the ship. The disinfection shall
be carried out thoroughly. Provided always that the local sanitary authority
may decide that heavy baggage and merchandise need not be unloaded, and
that only part of the ship need be disinfected.
The passengers shall remain at the Kamaran station seven or five days,
according as to whether plague or cholera is in question. When no cases of
plague or of cholera have occurred for several days the period of isolation
may be shortened, and may vary according to the date of occurrence of the
last case and the decision of the sanitary authority.
The ship shall then proceed to Jeddah, where everyone on board shall
undergo a thorough medical examination. If the result be favourable the
ship shall be given free pratique. If, however, recognised cases of plague or
of cholera have occurred on board during the voyage or on arrival, the ship
shall be sent back to Kamaran, where she shall again be dealt with as infected.
In the case of plague, the measures specified in Article 21 regarding rats
shall be adopted in the event of there being any of these vermin on board.
1. The Kamaran Station.
Art. 129. — At the Kamaran station the following conditions must be
fulfilled :—
Complete evacuation of the island by its inhabitants.
For the safety and convenience of shipping in the bay of Kamaran
Island, provision of : —
(1) a sufiicient number of buoys and beacons;
(2) a main pier or quay for the landing of passengers and baggage;
(3) a separate stage for the emljarkation of the pilgrims in each
encampment ;
(4) a steam-tug and sufficient barges for the disembarkation and
embarkation of pilgrims.
Art. 130. — The disembarkation of pilgrims from infected ships shall be
effected by the ship's own resources. If these be inadequate, the persons and
the barges that assist in the disembarkation shall undergo the same measures
as the pilgrims and the infected ship.
446 A2)pendLr IT
Art. 131. — The equipment of the sanitary station shall compi-ise the
following : —
(1) A railway-system connecting the landing places with the adminis-
trative ))uildings, the disinfecting stations, the various staff pi'emises, and
the encampments ;
(2) administrative buildings and premises for the sanitary and other
staff;
(3) buildings for the disinfection and washing of wearing apparel and
other articles ;
(4) buildings where the pilgrims are to have shower-baths or sea baths
while their clothes are being disinfected ;
(5) separate and completely isolated hospitals for both sexes : —
(rr) for the observation of suspected persons,
(b) for plague patients,
(c) for cholera patients,
{d) for patients suffering from other contagious diseases,
(e) for ordinary patients ;
(6) encampments completely separated from each other, the distance
between them to be as great as possible ; pilgi-ims' quarters constructed on
the most approved sanitary principles, and not to contain more than 25
persons each ;
(7) a well-situated cemetery, distant from all dwellings, free from
sub-soil water, and drained to the depth of half a-metre below the level of the
graves ;
(8) steam disinfectors in sufficient number, and fulfilling all the
conditions of safety, efficacy and rapidity ; apparatus for destroying rats ;
(9) spray-producers, disinfecting chambers and the necessary appli-
ances for chemical disinfection ;
(10) water-distilling machines ; apparatus for the sterilisation of
water by heat ; ice machines. A system of pipes and covered reservoirs,
impervious, and from which water can be taken only by means of taps or
pumps, for the distribution of drinking-water.
(11) a bacteriological laboratory with the necessary staff;
(12) provision of portable receptacles f(jr the reception of faecal matters
after disinfection, and a system of disposal of these matters on one of the
parts of the island farthest from the encampments, due regard being had to
the conditions necessary for the proper working, from a sanitary point of
view, of the land used for this purpose ;
(13) a system of removal of slop and waste waters from the encamp-
ments, which shall prevent their stagnation or use for drinking purposes.
The slop and waste waters of the hospitals must be disinfected.
Paris Convention, 1903 447
Art. 132. — The sanitaiy authority shall provide, in each encampment,
a store for food and a store for fuel.
The tariff of prices fixed by the competent authority shall be posted up
in several places in the encampment, in the languages commonly spoken in
the countries inhabited by the pilgrims.
The doctor of the encampment shall be responsible for the daily control
of the quality and quantity of the provisions.
Water shall be provided free of charge.
2. The stations at Abu-All, Abu-Said, Jeddah, Vasta, and Yambo.
Art. 133. — At the sanitary stations of Abu-Ali, Abu-Said, Vasta, as
well as those of Jeddah and Yarabo, the following conditions must be
fulfilled :—
(1) the construction of four hospitals at Abu-Ali, two for cases of
plague, male and female, two for cases of cholera, male and female ;
(2) the construction of a hospital for ordinaiy cases, at Vasta ;
(3) the provision, at Abu-Said and at Vasta, of stone buildings
capable of accommodating fifty persons each ;
(4) the provision of three disinfecting chambers at Abu-Ali, Abu-
Said, and Vasta, with laundries, accessories, and apparatus for destroying
rats ;
(5) the provision of shower-baths at Abu-Said and Vasta ;
(6) on each of the islands of Abu-Said and Vasta, provision of
distilling machines capable together of yielding 15 tons of water per day ;
(7) the disposal of faecal matters and slop and waste waters on the
lines accepted in the case of Kamaran ;
(8) the provision of a cemetery on one of the islands ;
(9) the provision, at Jeddah and Yambo, of the buildings and plant
for sanitary purposes referred to in Article 150, particularly disinfecting
chambers, and other means of securing disinfection for the pilgrims returning
from the Hedjaz.
Art. 134. — The rules laid down regarding food and water at Kamaran shall
apply to the encampments of Abu-Ali, Abu-Said, and Vasta.
B. Sanitary control of ships from, the north going to the Hedjaz
ivith Mohamviedan inlgrims.
Art. 135. — If it be not established that there is plague or cholera at the
port of departure or in its neighbourhood, and if no case of plague or of
cholera has occurred during the voyage, the ship shall be granted free pratique
forthwith.
448 Appendix II
Art. 136. — If it be established tliat there is plague or cholera at the port
of departure or in its neiglibourliood, or if a case of plague or of cholera has
occurred during the voyage, the ship shall be dealt with, at El-Tor, in the
manner prescribed for ships coming from the south and stopping at Kamaran.
The ships shall tliereafter be granted free pratique.
Section V. — Measures for pilgrims returnimj home.
A. Homeward-bound pilgrim-ships, going north.
Art. 137. — Every ship from a port in the Hedjaz or from any other port
on the Arabian coast of the Red Sea, carrying pilgrims or any like collection
of persons, and bound for Suez or a Mediterranean port, must proceed to
El- Tor, there to undergo the observation and the sanitary measures specified
in Articles 141-143.
Art. 138. — Ships bringing back Mohammedan pilgrims to the Mediter-
ranean shall not pass through the Canal save in quarantine.
Art. 139. — Agents of shipping lines and captains of ships are warned
that, on completion of their period of observation at El-Tor sanitary station,
only Egyptian pilgrims will be permitted to leave the ship definitively, in
order to return to their homes. Only pilgrims with a certificate of residence,
issued b}' an Egyptian authority and made out in the form presci'ibed, shall
be recognised as Egyptians or inhabitants of Egypt. Specimens of this
certificate shall be deposited with the consular and sanitary authorities
at Jeddah and Yambo, where they may be seen by shipping agents and ship
captains.
Non-Egyptian pilgrims, such as Turks, Russians, Persians, Tunisians,
Algerians, inhabitants of Morocco, etc., may not, after leaving El-Tor, be
disembarked at an Egj'ptian port. Agents of shipping lines and shij) captains
are therefore warned that the transhipment of non Egyptian pilgrims at Tor,
Suez, Port Said, or Alexandria, is prohibited.
Vessels carrying pilgrims belonging to the nationalities mentioned in the
preceding paragraph shall be treated according to the rules for such pilgrims,
and shall not be permitted to enter any Egyptian port in the Mediterranean.
Art. 140. — Egyptian pilgrims shall undergo at El-Tor, Suakim, or any
other station appointed by the Egyptian Sanitary Board, observation
for a period of three days and medical inspection, before being given
free pratiipie.
Art. 141.- — If it be established that there is plague or cholera in the
Hedjaz or at the port whence the ship has come, or that either of these
diseases has occurred in the Hedjaz during the pilgrimage, the ship
Paris Convention, 1903 449
shall be dealt with, at El-Tor, in the manner prescribed fur infected ships
at Kamaran.
Persons suffering from plague or cholera shall be landed and isolated in
hospital. The other passengers shall be landed and isolated in as small
groups as possible in order that, if plague or cholera break out in one group,
the whole party may not be affected.
The soiled linen, clothing and personal effects of the crew and the
passengers, and such baggage and merchandise as are suspected of being
infected, shall be landed for purposes of disinfection. These articles, and
also the ship, shall be thoroughly disinfected. Provided always that the local
sanitary authority may decide that heavy baggage and merchandise need not
be unloaded and that only part of the ship need be disinfected.
The provisions of Articles 21 and 24 regarding rats shall apply in the
event of there being any of these vermin on board.
Whether it be plague or cholera that is in question, all the pilgrims shall
be kept under observation for seven clear days, reckoned from the day on
which the measures of disinfection were completed. If a case of plague or
of cholera occur in a section, the period of seven days for that section shall
be reckoned from the day on which the last case occurred.
Art. 142. — In the circumstances provided for by the foregoing article,
Egyptian pilgrims shall, in addition, be kept under observation for a further
period of three days.
Art. 143. — If it be not established that there is plague or cholera in
the Hedjaz or at the port whence the ship has come, or that either of
these diseases has occurred in the Hedjaz during the pilgrimage, the ship
shall be dealt with, at El-Tor, in the manner prescribed for healthy ships at
Kamaran.
The pilgrims shall be landed ; they shall take a shower-bath or bathe in
the sea ; their soiled linen and any portion of their personal effects or their
baggage, open, in the opinion of the sanitary authority, to suspicion, shall be
disinfected. The duration of these operations, including disembarkation and
embarkation, must not exceed 72 hours.
Provided always that a pilgrim-ship, belonging to a country that has
given its adhesion to the provisions of this Convention and of previous
Conventions, if she has had no case of plague or of cholera during the voyage
from Jeddah to Yambo and El-Tor, and if it be established by medical examina-
tion, conducted at El-Tor after disembarkation, of every one on board, that she
has no such case, may be permitted by the Egyptian Sanitary Board to pass
through the Suez Canal in quarantine, even by night, subject to the fulfilment
of the four following conditions : —
(1) that, in order to secure medical attendance of persons on board,
s. 29
450 Appendix II
the ship carries one or more doctors, commissioned by the Government of tlie
country to which she belongs ;
(2) that the ship is provided with disinfecting chambers, and it is
established that the soiled linen has been disinfected during the voyage ;
(3) that it is proved that the number of pilgrims is not in excess of
that permitted by the pilgrimage regulations ;
(4) that the captain undertakes to sail direct to a port in the country
to which the ship belongs.
The medical examination, after disembarkation at El-Tor, must be made
with as little delay as possible.
The sanitary tax, payable to the Quarantine Administration, shall be the
same as the pilgrims would have had to pay if they had remained in quarantine
for three days.
Art. 144. — In the event of a suspicious case occui'ring on board during
the voyage from El-Tor to Suez, the ship shall be sent back to El-Tor.
Art. 145. — Transhipment of pilgrims at Egyptian ports is strictly pro-
hibited.
Art. 146. — Ships from the Hedjaz, carrying pilgrims bound for the
African coast of the Red Sea, shall be permitted to proceed direct to Suakim
or such other place as the Alexandria Sanitary Board shall appoint, there to
undergo the same quarantine measures as those at El-Tor.
Art. 147. — Ships from the Hedjaz, or fi'om a port on the Arabian coast
of the Red Sea, with a clean bill-of-health, not carrying pilgrims or
like collections of persons, and without suspicious incident during the
voyage, shall, on favourable medical inspection, be given free pratique
at Suez.
Art. 148. — When it is established that there is plague or cholera in the
Hedjaz : —
(1) caravans of Egyptian pilgrims must, before proceeding to Egypt,
undergo strict quarantine at El-Tor for seven days, whether it be plague
or cholera that is in question ; they must thereafter be kept under observation
at El-Tor for three days, after which they shall not be granted free pratique
until after favourable medical inspection and disinfection of effects ;
(2) caravans of pilgrims from other countries, returning home by land,
shall undergo the same measures as Egyptian caravans, and must be
accompanied by sanitary guards to the borders of the desert.
Art. 149. — When plague or cholera has not been reported to have
occurred in the Hedjaz, caravans of pilgrims coming from the Hedjaz by
way of Akaba or Moila shall, on their arrival at the canal or at ISTakhel,
undergo medical inspection and disinfection of soiled linen and personal
effects.
Paris Conventloti, 1903 451
B. — Homeward-hovnd pilyrims, going south.
Art. 150. — The ports of embarkation in the Hedjaz shall be provided
with buildings and plant for sanitary purposes sufficient to permit, in
the case of pilgrims homeward-bound to the south, the taking of the
measures rendered compulsory by the provisions of Articles 46 and 47, on
the departure of these pilgrims from ports beyond the Strait of Bab-el-
Mandeb. These measures shall be optional ; that is to say, they shall not be
carried out unless the consular authority of the country to which the pilgrims
belong, or the doctor of the ship by which they propose to go, considers them
necessar)'.
CHAPTER III.
PENALTIES.
Art. 151. — Any captain convicted of a breach of his contract for
the supply of water, food, or fuel, shall be liable to a fine of 2 pounds
Turkish ^ This fine shall be paid to tlie pilgrim who has sufiered from
the breach of contract on proof that he demanded its fulfilment without
efi^ect.
Art. 152. — Any infringement of Article 104 shall be punished by a fine of
30 pounds Turkish,
Art. 153.— Any captain, who commits, or knowingly allows to be
committed, any fraud with res[)ect to the list of pilgrims, or of the
bill-of-health provided for bj' Article 110, shall be liable to a fine of 50
pounds Turkish.
Art. 154. — Any ship-captain arriving without a bill-of-health from the
port of departure, or without its having been countersigned at the ports
of call, or unprovided with the prescribed list, duly kept in accordance with
Articles 110, 123, and 124, shall be liable, in each instance, to a fine of
12 pounds Turkish.
Art. 155. — Any captain convicted of having or of having had on board
more than 100 pilgrims, without a commissioned doctor, in accordance with
the provisions of Article 103, shall be liable to a fine of 300 pounds Turkish.
Art. 156. — Any captain convicted of having or of having had on board
more pilgrims than he is permitted, by the provisions of Article 110, to
carry, shall be liable to a fine of five pounds Turkish for each pilgrim in
excess of the proper number.
The pilgrims in excess of the proper number shall be disembarked at the
first station where there is a competent authority, and the captain is bound
1 A Turkish pound is of the value of 22^ francs.
29—2
452 Ap2)en(lix II
to provide the pilgrims so diseinbarkcd with sufficient inoney to onaWe them
to reach their destination.
Art. 157. — Any captain convicted of having disembarked pilgrims at
a place other than their destination, unless with their consent, or from
una^'oidable cause, shall be liable to a fine of 20 pounds Turkish for each
pilgrim wrongfull}' disembarked.
Art. 158. — Any other infringement of the provisions relating to pilgrim-
ships shall be punished by a fine of from 10 to 100 pounds Turkish.
Art. 159. — Any known infringement during the voyage shall be entered
in the bill-of-health, and in the list of pilgrims. The competent authority
shall pi-epare a statement of the case and submit it in the proper quarter.
Art. 160. — In Turkish ports, infringements of the provisions relating to
pilgrim-ships shall be tried before, and the fine imposed by, the competent
authority, in accordance with the provisions of Articles 173 and 174.
Art. 161. — All agents required to assist in carrying out the provisions of
this Convention regarding pilgrim-ships shall be liable to punishment,
agreeably to the laws of their respective countries, for any failure on
their part in carrying out the aforesaid provisions.
PART IV.
ADMINISTRATION AND CONTROL.
I- — Tlie Egyptian Sanitary, Maritime, and Quarantine Board.
Art. 162. — The provisions of Appendix III of the Venice Sanitary
Convention of January 30th, 1892, regarding the composition, the functions,
and the manner of discharge of the functions of the Egyptian Sanitary,
Maritime and Quarantine Board, as provided by the Decrees of His
Highness the Khedive under the dates of June 19th, 1893, and December
25th, 1894, and also by the Ministerial Order of June 19th, 1894, are
confirmed.
The said Decrees and Order are appended to this Convention,
Art. 163. — The ordinary expenses arising out of the provisions of this
Convention, and in particular those due to increase of the staff employed by
the Egyptian Sanitary, :\Iaiitime and Quarantine Board, shall be defrayed
by an additional yearly contribution by the Egyptian Government of a sum
of four thousand pounds Egyptian, which may be paid out of the surplus of
the lighthouse dues remaining at the disposal of that Government. Provided
always that from this sum shall be deducted the amount produced by an
Paris Convention, 1903 458
additional quarantine charge of 10 P. T. (piastre taritF) on each pilgrim, to
be levied at El- Tor.
In the event of the Egyptian Government finding difficulty in bearing
this proportion of the expenses, it would be for the Powers represented on
the Sanitary Board to approach the Khedivial Government with a view to
securing part of these expenses being borne by the latter.
Art. 164. — It devolves upon the Egyptian Sanitarj', Maritime and
Quarantine Board to bring into harmony with the provisions of this
Convention the regulations it now applies to plague, cholera, and yellow
fever, and also the regulations regarding arrivals from Arabian ports in the
Red Sea during the pilgrimage season. If necessary, it shall revise, to the
same end, the general sanitary, maritime, and quarantine police regulations
now in force.
To become effective, these regulations must be approved by the several
Powers represented on the Board.
II. — The Constantinople Superior Board of Health.
Art. 165. — The framing of the measures to be taken with a view to
preventing the introduction into the Turkish Empire and the transmission
to other countries of epidemic disease, devolves upon the Constantinople
Superior Board of Health.
Art. 106. — The number of Tux'kish delegates on the Superior Board of
Health, having the right to vote, shall be four, namely : —
the President of the Board, or, in his absence, the Acting President
of the meeting. They shall have a casting vote only ;
the Inspector-General of the sanitary service ;
the Assistant-Inspector ;
the Delegate acting as intermediary between the Board and the
Sublime Porte, known as Mouhassebedgi.
Art. 167. — The appointment of the Inspector-General, the Assistant-
Inspector, and the Delegate before-mentioned, nominated by the Board,
shall be ratified by the Turkish Government.
Art. 168. — The High Contracting Parties recognise the right of
Roumania, as a maritime Power, to representation by a delegate on the
Board.
Art. 169. — The delegates of the several States must be duly qualified
doctors, holding the diploma of a European faculty of medicine, and
belonging to the nation they represent, or consular officials of rank not
lower than Vice-Consul or of equivalent rank. The delegates must be in
no way connected with the local authority or with a shipping company.
These provisions shall not apply to the delegates now in office.
454 Appendix II
Art. 170. — The decisions of the Superior Board of Health, carried by
a majority of its meml)ers, shall come into force, without appeal.
The Governments signing this Convention agree that their representatives
at Constantinople shall be instructed to inform the Turkish Government of
this Convention and to approach that Government with a view to securing
its accession thereto.
Art. 171. — The enforcement and the control of the provisions of this
Convention regarding the pilgrimages and of measures against the intro-
duction and the spread of plague and of cholera, shall be entrusted, within
the scope of the Constantinople Superior Board of Health's jurisdiction, to a
Committee selected from among members of that Board exclusively, and
composed of representatives of the several Powers adhering to this Convention.
The representatives of Turkey on this Committee shall be thi-ee in number ;
one of them shall be the President of the Committee. When the votes are
equally divided, the President shall have a casting vote.
Art. 172. — There shall be a staff of qualified doctors, w^ell-trained dis-
infecters and mechanics, and also sanitary guards selected from persons who
have been officers or non-commis.sioned officers of higher than corporal's rank
in the military service, whose duty it shall be to secure, within the jurisdiction
of the Constantinople Superior Board of Health, the proper working of the
several sanitary estaWishments enumerated in and prescribed by this Con-
vention.
Art. 173. — The sanitary authority of a Turkish port of call or of arrival,
which has convicted anyone of an infringement of the regulations, shall
prepare a statement of the case, to which the captain is entitled to add
comments in writing. A certified cop}' of this statement shall be sent, at
the port of call or of arrival, to the consular authority of the country under
whose flag the ship sails. The amount of the fine imposed shall be deposited
with the consular authority or, if there be no consul, with the sanitary
authority. The fine shall not be definitely handed over to the Constantinople
Superior Board of Health until the consular Commission, described in the
article next following, shall have gi\en judgment as to whether such fine be
valid.
Another certified copy of the statement must be forwaided by the con-
victing sanitary authority to the President of the Constantinople Board of
Health, who shall bring the document to the notice of the consular Commission.
The nature of the infringement and the deposit of the fine shall l:»e noted
upon the bill-of -health by the sanitary or the consular authority.
Art. 174. — A consular Commission shall be established at Constantinople
to decide between contradictory statements made by sanitary agents and
incriminated captains. It shall be appointed yearly by the consular
Paris Convention, 1903 455
authority. The Sanitary Adaiinistration may be represented by a person dis-
chai'ging tlie duties of public prosecutor. The consul of the country
concerned shall always be invited to attend ; he shall be entitled to vote.
Art. 175.^ — The cost of providing, within the jurisdiction of the Con-
stantinople Superior Board of Health, the sanitary posts, both permanent
and temporary, prescribed by this Convention, shall be, in so far as
construction of buildings is concerned, debited to the Turkish Government.
The Constantinople Superior Board of Health is authorised, if necessary and
in case of emergency, to advance from the reserve fund the necessary money,
which shall, upon demand, be furnished by the "Mixed Commission entrusted
with the revision of sanitary charges." In this event, the Board must see to
the construction of these establishments.
The Constantinople Superior Board of Health must organise, without
delay, the sanitary stations of Hanikin and Kizil-Dizie, near Bayazid, on the
Turko-Persian and Turko-Russian frontiers, out of the moneys now placed at
its disposal.
The other expenses arising, within the jurisdiction of the said Board,
from the measures prescribed by this Convention, shall be mutually borne by
the Turkish Government and the Constantinople Superior Board of Health,
as agreed upon by the Government and the Powers represented on the Board.
III. — The Tangier International Board of Health.
Art. 176. — In the interests of the public health, the High Contracting
Parties agree that their representatives in Morocco shall again direct the
attention of the Tangier International Board of Health to the necessity of
carrying out the provisions of the sanitary Conventions.
IV. — Miscellaneous provisions.
Art. 177. — Each Government shall decide as to the means it shall employ
to secure disinfection and the destruction of rats'.
1 The following methods of disinfection are given by way of guide : —
Wearing apparel, old rags, infected dressings, papers and other articles of no value
should be burnt.
Personal effects, bedding, mattresses infected with plague can be efficiently disinfected
either by means of a high-pressure steam disinfecting chamber or a current-steam dis-
infecting chamber at a temperature of 100° Centigrade, or by exposure to formol vapours.
Articles, such as coverlets and bed-linen, that can be steeped in antiseptic solutions
without damage, can be disinfected by 1 per 1000 solutions of perchloride of mercury, 3
per 100 solutions of carbolic acid, 3 per 100 solutions of lysol or commercial cresyl, 1 per
100 solutions of formol (one part of the commercial solution of formaldehyde at 40 per
100), or 1 per 100 solutions of the alkaline hypoclilorides (sodium or potassium), that is to
say, 1 part of the ordmary solution of commercial hypochlorite. The period of contact
456 A2)pendix II
Art. 178. — The sums realised by sanitary charges and fines may not,
in any instance whatever, be used for any purposes other than those under
the control of the Boards of Health.
Art. 179. — The High Contracting Parties undertake that their Public
Health Departments shall frame a set of instructions intended to enable ship-
captains, particularly when there is no doctor on board, to carry out the
provisions of this Convention regarding plague and cholera, and also to carry
out the regulations regarding yellow fever.
Y.—The Persian Gulf.
Art. 180. — The cost of construction and upkeep of the sanitary station to
be provided, in accordance with Article 81 of this Convention, on the Lsland
of Ormuz, shall be debited to the Constantinople Superior Board of Health.
The said Board's Mixed Commission of revision shall meet at the earliest
date possible in order to furnish, on the Board's request, the necessary
moneys to be derived from the available reserve funds.
VI. — Internatimud Health Office.
Art. 181. — The Conference having taken note of the resolutions, hereto
appended, passed by its Commission of Ways and Means regarding the
creation of an International Health Office in Paris, the French Government
shall, at such time as it may think fit, submit, by diplomatic channels,
proposals on this subject to the States represented at the Conference.
must obviou.sly be long enough to allow dried germs to be well penetrated by the antiseptic
solution : four to six hours will suffice.
To secure destruction of rats, three processes are now made use of : —
(1) Sulphurous acid mixed with a small quantity of sulphuric anhydride, driven
under pressure into holds and mixed with the air. This destroys rats and insects and will,
it is stated, destroy the plague bacillus also if the proportion of sulphuro-sulphuric anhy-
dride be sufficiently great.
(2) An incombustible mixture of carbon monoxide and carbon dioxide, passed into
holds.
(3) Carbonic acid so employed as to constitute 80 per cent, of the air in tbe ship.
The last two methods kill rodents but it is not chiimed that they destroy insects or the
plague bacillus.
The Technical Commission of the Paris (1903) Sanitary Conference specified the three
following processes— a mixture of sulphuro-sulphuric anhydrides, a mixture of carbonic
oxide and carbonic acid, and carbonic acid— as being among those to which Governments
might resort, and expressed the opinion that the sanitary authority should, in every
mstance wbere it did not itself do the work, superintend its performance and make sure
that tbe rats had been killed.
Paris Convention, 1903 457
PART V.
YELLOW FEVER.
Art. 182. — The countries concerned are recommended to modify their
sanitary regulations in such fashion as to bring them into harmony with the
present scientific data as to the manner in which yellow fever is transmitted,
and, in particular, as to the part played by mosquitoes in carrying the germs
of the disease.
PART VI.
ADHESION AND RATIFICATION.
Art. 183. — The Governments that have not signed this Convention are
allowed to become parties thereto at their request. Such adhesion shall be
notified, by diplomatic channels, to the Government of the French Republic,
and by that Government to the other Governments that have signed the
Convention.
Art. 184. — This Convention shall be ratified, and the ratifications thereof
shall be deposited at Paris as soon as may be practicable.
It shall be put in force as soon as it shall have been made public in such
manner as is in accordance with the laws of the States that sign it. As
regards the relations between the Powers that ratify or become parties to it,
it shall replace the International Sanitary Conventions signed on January
30th, 1892, April 15th, 1893, April 3rd, 1894, and March 19th, 1897.
The previous Conventions, above cited, shall continue in force in the case
of Powers which, having signed or become parties to them, do not ratify or
become parties to this Convention.
APPENDIX I. {See Art. 78.)
REGULATIONS
REGARDING THE CONVEYANCE OF PASSENGERS AND MAILS FROM INFECTED
COUNTRIES THROUGH EGYPT BY QUARANTINE TRAIN.
Art. 1. — The Egyptian Railway Executive that wishes to run a quarantine train
in connection with ships arriving from infected ports, must give notice thereof to
the local quarantine authority not less than two hours before the time of departure
of such train.
Art. 2. — The passengers shall land at a place appointed by the quarantine
authority with the consent of the Railway Executive and the Egyptian Government,
29—5
458 AjyjjemUx II
and shall proceed, without auy communication, direct from the ship to the train,
under the supervision of a transit-othcer and of two or more sanitary guards.
Art. 3. — The passengers' personal belongings, baggage, etc., shall be conveyed in
quarantine, by the means at the disposal of the ship.
Art. 4. — In so far as quarantine measures are concerned, the railway staff shall
obey the orders of the transit-officer.
Art. 5. — The carriages employed in this service shall be corridor-carriages. In
each carriage there shall be a sanitary guard, whose duty it shall be to keej) watch
over the passengers. The railway staff shall not hold any communication with the
passengers.
A doctor on the quarantine staff shall go with the train.
Art. 6. — The passengers' heavy baggage shall be put in a special van which the
transit-officer shall seal before the train starts. Upon arrival the seals shall be
removed by the tran.sit-officer.
Transference of passengers to another train or taking passengers during the
jom'uey is prohibited.
Art. 7. — The closets shall be furnished with pails, containing a certain amount of
antiseptic, for the reception of the passengers' dejecta.
Art. 8. — No one, except the staff absolutely necessary, shall be allowed on
railway platforms at which the train may have to stop.
Art. 9. — Every train may have a restaurant-car. The remnants of meals shall
be destroyed. The staff of the restaurant-car and such other railway servants as
have come in contact, from any cause, with passengers, shall undergo the same
measures as the pilots and electricians at Port Said or Suez, or such measures as the
Board may consider necessary.
Art. 10. — Passengers are absolutely prohibited from throwing anything whatever
out of the windows, doors, etc.
Art. 11. — In every train a hospital compartment shall be kept empty so as to
secure isolation of the sick therein, should such contingency arise. This compart-
ment shall be fitted up in accordance with the direction of the Quarantine Board.
If plague or cholera appear among the passengers, the sick person shall
immediately be isolated in the special compartment, and shall, on the arrival of the
train, be removed forthwith to the quarantine lazaret. The other passengers shall
proceed on their joui-ney in quarantine.
Art. 12. — If a case of plague or of cholera occur during the journey, the train
will be disinfected by the quarantine authority.
In all instances the vans carrying baggage and mails shall be disinfected
immediately after the arrival of the train.
Art. 13. — The transference of passengers, baggage, etc., from train to ship shall
be effected in the same way as on arrival. The ship that takes the passengers shall
immediately be put in quarantine, and any incident that may have occurred during
the journey shall be noted on the bill-of-health, with specific mention of any persons
that may have been in contact with the sick.
Fatns Conve7itio7i, 1903 459
Art. 14. — The expenses incurred by the quarantine administrative body shall be
debited to whoever requisitioned the quarantine train.
Art. 15. — The President of the Board, or his substitute, shall have the right to
exercise supervision over the train during the whole of its journey. The President
may, moreover, entrust the duty of such supervision to a high official (above and
beyond the transit-officer and the sanitary guards). This official shall have access
to the train on his showing an order signed by the President.
APPENDIX 11. (See Art. 162.)
[This Appendix, consisting of the Khedivial Decrees of \^th Jione, 1893, and 2bth
December, 1894, and of the Ministerial Order of 19th June, 1893, is not here reproduced.']
APPENDIX III. {See Art. 181.)
RESOLUTIONS
PASSED BY THE COMMISSION OF WAYS AND MEANS OF THE SANITARY CONFERENCE
OF PARIS REGARDING AN INTERNATIONAL HEALTH OFFICE.
I. — An International Health Office shall be established on the lines followed in
the institution and conduct of the International Office of Weights and Measures.
It shall have its seat in Paris.
II. — The International Office shall fulfil the function of collecting information as
to the progress of infectious diseases. To this end it shall receive information given
to it by the chief Health Authorities of the States that are parties to it.
III. — The Office shall periodically set out the results of these labours in official
reports which shall be communicated to the contracting Governments. These
reports must be made public.
IV. — The Office shall be supported by contributions from the contracting
Governments.
V. — The Government, in whose country the International Office is to be
established, shall be charged with the submission, within three months of the
signing of the proceedings of the Conference, for the approvtil of the contracting
States, of Regulations for the institution and conduct of that Office.
INDEX.
Aberdeen, severity of measures iu 343
Abnormal season in Bombay 141
Absence of lymphangitis BOH
Account of phume at Antioch 12, 16 ; at
Constantinople 6, 12 ; first medical, at
Pakhoi 55 ; in England 24
Accurate diarjuosis essential 379 ; and its
difficulties 379
Acute toxic cases in rats 401
Additional risk of extension 199
Administrative arrangements 368
Agathias' account of plague 12
Agi-a, plague in 43
Ahmadabad, plague in 42
Alarm created by plague 377
Alimentary canal 237
Ambulant plague 296, 309
Amoy 319
Ancient belief as to infection 221
Animals affected with jDlague 106; effect of
bacillus on 94; experiments on 113;
result of experiments 107 ; under natural
infection 128
Antiquity of plague 3
Antiseptic treatment 318, 327
Ants, plague bacilli in 222
Appearance of plague rats 103
Appendix I 414
Appendix II 416
Appendix III of Paris Convention 459
Arabia, recrudescence in 38
Arctoniys bobac 223
Arthritis 293
Assyr, conditions in 183
Astrakhan, plague in 39, 159
Asuncion 2U7
Attempt at specific treatment 319
Attention to diet 334
Atypical case 298
Aura pestilentiae in Egypt 163
Australia and S. Africa 215
Austria and Germany, measures in 341
Austrian Commission (expts.) 113
Autopsies 239
Avignon epidemic 23, 161
Axillary buboes 27H
Bacilli in ants, bugs, and flies 222
Bacillus, Danysz' 3'J6, 397 ; discovered 64 ;
Kitasato's 88
Bacteriological condition in post-mortem
242 ; examination of rats 369, 383 ; test 307
Barbaiy, West, plague in 36
Basis of present treatment 319
Benghazi, recrudescence in 38
Benign bubonic 262
Black Death 21, 135
Bleeding 317
Blood 289
Blood vessels, infection to 251
Boiling 395
Bombay 66, 69, 186, 187, 319 ; Presidency,
extension to 69, 141
Bouillon, characteristic growth in 86
Brisbane 323
Bubo, changes in primary 231 ; changes in
secondary 231 ; local treatment of 330 ;
treatment of 318 ; veins in vicinity of
228
Buboes, axillary 278 ; cervical 279 ; con-
tents and condition of 273 ; external
primary 227 ; inguinal 275 ; internal 229
lymphatic system 273 ; multiple 283
pain 274 ; secondary 230 ; situation 275
size 274 ; tenderness 274 ; termination
274 ; with and without 261
Bubonic, benign 262 ; grave 262 ; not directly
infectious 213
Bugs, ants, and flies, bacilli in 222
Callao 206
Calves, experiments on 121, 122
Canton and Hongkong centres of distri-
bution 64 ; connected with Kwangsi and
Kwantung 59 ; Hongkong largest Euro-
pean possession near 63 ; in the I9th and
20th century 185 ; plague at, in 1894 59 ;
plague in, in Jan. 1894 61
Cajje 'Town 191, 203, 322 ; unusual season
preceded epidemic in 142
Carbolic acid treatment 327, 328
Carbuncles 284 ; treatment of 330
Cargoes, infection connected with 203
Case, an atypical 298
Cases 296 '
Cats affected with plague 104
Cats, dogs, etc. in 16th and 17th centuries
220
Causes of death 264
Caution as to prognosis 314
4(32
Index
Certain carriers required 194
Certain symptoms in epidemics 1G8
Cervical buboes 27i)
Channels of infection 249
Characteristic growth in bouillon 86 ;
symptoms 260
Characteristics, cultural H2; of outbreaks
in Kumaon 178
Chawls of Bombay 187
Chemical disinfectants 393
China and India 74
Chinese village 192
Chronic plague and marasmus 293
Circulatory system 234
Clai/toii api)aratus the best disinfector for
houses 391; for ships 359, 365; process
for destroying rats 359
Climatic factors, influence of 151
Clinical features 260
Cold water treatment 318
Coloured sweats in plague of London 168
Commerce, plague and 31
Commission, Austrian, experiments 113 ;
German, experiments 108
Complications 292
Conclusion 410
Concurrent diseases 294
Condition, bacteriological 242 ; histological
243
Conditions affecting insect life 153 ; hygienic
329; in animals 128; in Assyr 183; in
Yunnan 182
Constantinople, account of plague at 6, 12 ;
gateway for entrance of pandemic 21
Contents and condition of buboes 273
Controvex'sies in Bombay ; Calcutta ; Cape
Town ; San Francisco 374
Convalescence, treatment during 330
Convalescents, infectivity of 257
Council of health in Venice 337
Course of pandemic 22
Creiqhton on Pariset's views 132 ; on the
Black Death 135
Crowded buildings in Mandvi 187
Crusades, plague and the 17; plague at
time of 20
Cultural characteristics 82
Curative treatment powerless 316
Cyllin 328
Danger of existing pandemic 145
Danysz'' bacillus 370; attenuation of viru-
lence of 397 ; destruction of rats with
39() ; differential tests of 400 ; exaltation
of virulence of 397 ; general biology of
400; staining of 400; used in Cape Town
397 ; used in Odessa 399
Dead, disposal of the 331, 335, 368
Death, causes of 2t)4
Definition of plague 1
Depressing influences and plague 172
Description, Dr Dowry's, of Pakhoi 55;
Francis', of houses in Garhwal and Ku-
maon 181; Planch's, of houses in Garh-
wal and Kumaon 181 ; of Yunnan 48
Destruction of rats 396 ; in healthy locality
369 ; in warehouses 401
Diagnosis and prognosis 306 ; in typical
case 306
Different epidemics 168 ; media 89 ; types
concurrent 162 ; views as to etiology 130
DiJ'nsion and modes of dissemination 194 ;
slow, of the plague 70
Diffusive powers, variation in 143
Digestive system 291
Disappearance of plague from Egypt 37, 350;
from Turkey 37, 350
Discover!/ of bacillus 78 ; existing methods
after 354
Diseases running concurrently 294
Disinfectants, chemical 393 ; use of 331
Disinfection, existing methods unsatis-
factory 390; of baggage 364; of the
house 389, 391
Disposal of the dead 331, 335
Dissonination by infected clothes 213 ; by
infected rats 214
Distribution of plague, and history 1 ;
Canton a centre of 64 ; Hongkong a
centre of 64; in different parts of world 74
Districts of Garhwal and Kumaon 47
Dogs, cats, pigeons and fowls 220
Dosage of serum 326
Dr Manser's illness 300
Dr Miiller's illness 302
Drying effect 92
Durban 204
Duties of plague organisation 384
Earlier views as to infection 76
Early malignity of Avignon epidemic 161
East London 204
Edinburgh, enlightened policy of 343
Educational tracts 341
Effect of drying 92 ; of inoculation 407 ;
of the bacillus on animals 94; of the
plague on animals 94
Egypt and Turkey 4, 350 ; disappearance
of plague from 37 ; retrocession in Syria
and 19
Egyptian epidemic, aura pestilentiae in 163 ;
three degrees of severity of 164
Eighteenth century, plague in the 34
Endemic centre in Uganda 75 ; centres 177 ;
plague in Pakhoi 57
Endemicity and epidemicity 176 ; affected
by temperature 150
England, account of epidemic in 24
Enlightened policy in Edinburgh 343
Epidemic, account of, in England 24 ; at
Astrakhan and Vetlianka 159 ; height of
first Bombay 69 ; preceded by mortality
among rats 53, 101, 102. 103
Epidemics and pandemics 130; at different
seasons 146 ; severity of, at Dharwar and
Poena 71
Index
463
Epidemiology 71)
Epizootic, tarbagan subject to 223
Epizootics, associated with plague epidemics
97 ; relationship of, to plague 96
Erection of plague hospitals 367
Establishment of hospitals 348; of quaran-
tine stations 348
Etiology of pandemics and epidemics 130
European Powers, International confer-
ences of 351
Evacuant treatment 317
Evacuation of infected houses 348 ; of
premises 387
Evagrius' account of the plague 12
Exceptional conditions in Hongkong 140
Existing measures 354 ; pandemic 143
Experiments by Austrian Commission 113;
by German Commission 108; in Hong-
kong 116 ; of Haffkine 116 ; on animals
107; on calves 121, 122; on fowls 121;
on monkeys 121, 123, 124; on pigs 117,
118, 119, 120
Exposure to direct rays of sun 396 ; high
temperatui'es 395
Extension, additional risk of 199 ; from
India and China 74 ; to the Bombay
Presidency 69
External primary buboes 227
Eye diseases 293
Facts known and established 411
Failure of measures to prevent spread 351
Favourable signs 314
Features, clinical 260
Firmness and judgment required 378
First governmental measures 336 ; govern-
mental orders in London 342 ; preventive
measures in Venice 336 ; Quarantine Act
349 ; recorded pandemic 5
Five degrees of severity in Marseilles epi-
demic 162
Flea theory 218
Flies, ants, and bugs, bacilli in 222
Food, infected, possibly causes plague 126
Formation of stalactites 87
Fostering conditions of plague 184; of en-
demicity 176; of epidemicity 176
Fowls, experiments on 121 ; pigeons, cats,
and dogs 220
Francis' description of houses in Garhwal
and Kumaon 181
Fulminating and septic variety 297
Fumigation has its limits 393 ; of dwellings
334; with Clayton's apparatus 370
Gangrenous pustules 284
Garhwal and Kumaon 47, 178
General retrocession in Europe 19 ; treat-
ment 329
German Commission, experiments by 108
Germany and Austria, measui'es in 341
Glandular swellings before and after plague
166
Glasgow 322
Gradually increasing mortality in India 71
Grave bubonic or Pestis major 262
Gregory, Bishop of Tours 15
Guy de Chauliac's description of plague
23
Haffkine's experiments 116 ; plague pro-
phylactic 402 ; prophylactic, preparation
of 404 ; stalactites 87
Health camps 367
Healthy persons can carry infection 196
Height of first Bombay epidemic 69
Hindrances to declare a place infected 372
Histological changes in primary bubo 231 ;
changes in secondary bubo 232; condition
243
History and distribution of plague 1
Hodges' views 347
Hongkong 322; and Canton centres of dis-
tribution 64; experiments in 116; in the
19th and 20th century 185; meteorological
conditions in 140; observations in 216
House, hygiene of the 332
Householders, information to 383
Hygiene of the house 332 ; jiersonal 332
Hygienic conditions 329
Immunity, natural 171
Increased virulence in successive years 169
Incubation period 258, 261, 352
India and China, observations in 217; ex-
tension from to other parts 74; extension
to Bombay Presidency in 69 ; Garhwal
and Kumaon endemic centres in 47
gradually increasing mortality in 71
observations in 217 ; plague in 40
scarcity preceded plague in 140
Infected articles lose infectivity 154 ;
articles may retain infectivity 154 ;
clothes, dissemination by 213 ; house,
prophylaxis in 331 ; houses, evacuation
of 348 ; locality, modes of infection in
210
Infection carried by healthy persons 196 ;
carried by sick persons 195 ; carried long
distances in ships 201 ; channels of 249 ;
connected with cargoes and rats 203 ;
mixed 256 ; mode of exit of, from body
256 ; nature of 76 ; of inland towns 208 ;
through mucous membrane 254 ; through
respiratory tract 256 ; through skin to
blood vessels 251 ; through skin to lym-
phatics 249 ; transported by infected
clothes 197 ; transported by movements
of crowds 201
Infectious diseases, variety of type in 175
Infectivity of convalescents 257
Influence of climatic factors 151
Influenza and plague 312
Information to householders 383
Inguinal buboes 275
Inoculation, effects of 407 ; method of 406 ;
preventive 402; protective 331; results of
407
464
Index
luternal buboes 229
International conference of Powers 351 ■,
measures 354 ; preventive measures 350
Involution forms 85
Ireland, plague in 17
Isolation of the rich 336
Jains indifferent to death 188
Johannesburg, reported cases in 374
Karachi 69, 320
Karad 320
Kitasato discovers bacillus 63
Kitasato's bacillus 88 ; serum 326
Kumaon and Garhwal endemic centres 47
Kurdistan 177
Kwaium and Nanuingfu, plague at 59
Kwangsi and Kwautuug connected with
chief towns 59
Lazaretto established by Venetians 337
Le Baker de Swynebroke on plague 24
Liver 237
Local measures 358 ; in anticipation of
outbreak 366
Local treatment of buboes 330
Loudon, first governmental orders in 342 ;
plague in 27, 184 ; quarantine station for
344
Lowry's account of plague at Pakhoi 55
Lustig and Galeotti's prophylactic 408
Lustig's serum 324
Lybia, Syria and Egypt, plague in 4
Lj'mphangitis, absence of 308
Lymphatic buboes 273 ; glands 227
Lymphatics, infection through skin to 349
Macao 193 ; plague in 1895 64
Mahamari 179
Main lines of enquiry 411
Man contracts disease from tarbagan 224
Mandvi, crowded buildings in 187
Manser's illness 300
Marasmus and chronic plague 293
Maritime preventive measures 352
Marseilles epidemic 162
Mead's views 348
Measures 379 ; after discovery of bacillus
354 ; for prevention and suppression 333 ;
for prevention of extension 340 ; for
suppressing plague 386 ; in Austria and
Germany 341 ; in London 341 ; inter-
national 354 ; local 358 ; to combat
plague 372 ; t(j prevent importation 354
Media, bacillus in different 89
Medicines 329
Mengtze, plague at 58
Merchandise 356
Mesopotamia, recrudescence in 38
Metliod of inoculation 406
Methods against rats on sliips 359 ; for
destru^-ing rats 370
Mice and rats susceptible 96
Migration of rats 68
Mixed infection 256
Mode of exit of infection 256
Modes of dissemination and diffusion 194 ;
in infected locality 210
Monkeys, experiments on 121, 123-5
Morbid anatomy and pathology 226
More precise information required 410
Morphology of bacillus 79
Mortality and measures 188; in India 71;
of rats and Pariset's theory 133
Mossel Bay 204
Mucous membrane, infection through 254
Miiller's illness 302
Multiple buboes 283
Nanningfu and Kwaium, plague at 59
Natal 322
Natural immunity 171
Nature of infection 76 ; earlier views on
the 76
Nervous phenomena 285; system 239
Nineteenth century-, Canton in the 185;
Hongkong in the 185 ; Oporto iu the 184 ;
plague in the 37, 45
Notes of a morning's inspection 190
Notification and visitation 382
Nursing 329
Observations of epizootics 97 ; in Hongkong
216; in India 217 ; valuable in Australia
215; valuable in S. Africa 215
Odessa, Danysz' bacillus used in 399
Oil friction treatment 317
Old view regarding plague 253
Oporto 321; in the 19th century 184
Opposition to preventive measures 68
Orders severe in Elizabeth's reign 343
Orijjiii attributed to cosmic and telluric
calamities 134; physical disturbances
131 ; putrefaction of dead bodies 131
Osaka 204
Other animals affected with plague 106
Outlines of plague organisation 384
Pain of buboes 274
Pakhoi, Lowry's account of plague in 55 ;
plague appeared in, iu 1867 56 ; plague
endemic iu 57 ; plague not extinct in
vicinity of 57
Pali epidemic, four types in 162 ; trade
routes from 56
Pandemic, course of the 22; distinguished
by rapid spread 23; references to the 15;
tlie first recorded 5 ; the present 48 ;
the second recorded (Black Death) 21
Pandemics and epidemics, different views 130
Paris Convkxtion, regulations of 358 ;
general jjrovisions 416 ; provisions out-
side Europe 427; special provisions 437;
administration and control 452: Appen-
dix I 457 ; III 459
Paris in the 17th century 185
Passport system 348
Past treatment 316
Index
465
Pathology and morbid anatomy 226
Paulus Diaconus' account 16
Period of incubation 258, 261, 352
Persia, recrudescence in 88
Personal hygiene 332
Pestis major or grave bubonic 262 ; minor
or benign bubonic 262
Petechiae of skin 284
Phenomena, nervous 287
Physical disturbances 131
Pigeons, fowls, cats, and dogs 220
Pigs, experiments on 117, 118, 119, 120
Pisco 205
Plar/ue bacillus discovered 64 ; hospitals
367; in animals 128; in man 126; organi-
sation 381, 384 ; post-mortem wounds
250 ; to the 19th century 1
Plagues, self-limiting 143, 353
Planch's description 181
Pneumonic type 210, 265, 306, 310
Poona and Dharwar 71
Poor, plague and the 191
Power of bacillus 250
Prayers and processions 335
Pregnancy 293, 300
Premonitory symptoms 262
Present pandemic 48
Prevention and suppression 333 ; of recru-
descences 393
Preventive inoculation 402; measures against
extension 340; measures opposed 68
Primary buboes, external 227 ; histological
changes in 231
Procopius' account 6
Proynosi.s 312 ; and diagnosis 306 ; caution
as to 314
Progress after sixth day 264 ; of disease,
and rats 68
Prophylactic of Lustig and Galeotti 408
Prophylaxis in infected house 331
Protean character of plague 308
Protective inoculation 381
Proiunioiis, general 416 ; outside Europe 427 ;
special 437
Putrefaction of dead bodies 131
Quarantine and sanitary cordons 352 ;
council of, in Venice 337 ; not abolished
for certain classes 357 ; on land frontiers
abolished 356 ; station for London 344 ;
stations, establishment of 848 ; Venetian
system of 388
Questions relating to spontaneity 131
Rat.s 376; acute toxic cases in 401 ; affected
before man 199 ; agency of transmission
from 218 ; and mice susceptible 96 ;
bacteriological examination of 369, 383,
400 ; destruction of 359, 896 ; destruction
of, in liealthy localities 869 ; destruction
of, in warehouses 401 ; destruction of,
with Danysz' bacillus 89(); dissemination
by infected 214 ; epidemics and mortality
of 54 ; infection connected with 208 ;
plague-stricken 103; post-mortem appear-
ances in 400; seasonal breeding period of
158
Kecrudescence of plague 31
llecrudescences, prevention of 393, 401
Recurrence 295
Keferences to the pandemic 15
Regulations of Paris Conference 358
Relationship of epizootics and epidemics
96 ; to plague 96
Remarkable cessation of plague 33
Removal from infected locality 334
Resignation to fate 835
Respiratory system 235, 292 ; tract, infec-
tion through 256
Result of experiments on animals 107
Results of inoculations 407
Rhujpur 205
Rocher's account 50
Role of other animals 50
Russian epidemic 163
Sanitation 396
Scarcity preceded plague in India 140
Scene in a Bombay building 188
Season a composite force 150
Second attacks 294, 295 ; recorded pan-
demic 21
Secondary buboes 230 ; histological changes
in 232
Segregation 386
Self-limiting plagues 143, 353
Septic and fulminating type 297, 310
Septicaemic plague 265 ; infectious 211
Sequelae 294
Sera 'prepared by Borrel, Calmette, Roux,
Yersin 319
Senim, Bondi's and Terni's 325 ; dosage of
326 ; Kitasato's 326 ; Lustig's 324 ; test
307
Seventeenth century, London in 184 ; Paris
in 184 ; plague in 14, 44
Severity of epidemics 71 ; of measures in
Aberdeen 343
Ships, infection and 201
Sick persons carry infection 195
Signs favourable 314 ; unfavourable 315
Situation of buboes 275
Size of buboes 274
Skin, infection through 249, 250 ; petechiae
of 284
Slow diffusion 70
South Africa and Australia 215
Sjjecial provisions 437
Specific treatment 819
Spleen 234
Spontaneity 131
Sporadic cases precede epidemics 165
Staining of bacillus 79
Stalactites, formation of 87
Stimulant and tonic treatment 317
Suggested antiseptic treatment 818
466
Index
Suppression and pieveution 333
Susceptibility may vary 174
Susceptible races 173
Symptomx characteristic '2(j{\ ; in relation to
systems 267
Syria, Egypt and Lybia 4; Europe and
Egypt 19
Tarbagan subject to epizootic 2'2'S ; man
contracts disease from 224
Temperature of patients 267 ; affects ende-
micity 150 ; of air not influential ir)4
Tenderness of buboes 274
Termination of buboes 274
Terni's and Bondi's serum 325
Text, bacteriological 307 ; serum 307
Three conditions observed in Bombay 190
Tonsillar plague 312
Topographical description of Yunnan 48
Trade routes from Yunnan 49 ; from
Pakhoi to Yunnanfu 56 ; plague travels
by 194
Transport of infection by crowds 201 ; by
various vehicles 202
Traps and poison 370
Treatment 316 ; attempts at specific 319
basis of present day 319 ; cold water 318
curative, powerless in virulent forms 316
during convalescence 330; evacuant 317
general 329 ; in the past 316 ; of buboes
318, 330 ; of carbuncles 330 ; oil friction
317; stimulant and tonic 317; sera 319
Trespass offerings 333
Turkey and Egypt 37
Uganda, an endemic centre in 75
Unfavourable signs 315
Uniform mortality and white people 173
Unsie 207
Unusual season and plague in Cape Town
142
Urinary system 239, 292
Use of disinfectants 331
Valuable observations in Australia 215 ; n
S. Africa 215
Variation in effect of seasonal influences
143 ; in powers of diffusion 143 ; in viru-
lence 93, 159; in virulence dependent on
conditions 170
Variety, ambulant 296 ; septicaemic and
fulminating 297; pneumonic, 300; of type
in infectious diseases 175
Vascular system 288
Veins near bubo affected 228
Venetian system of quarantine 338
Venetians, lazaretto established by 337
Venice Convention 354, 357 ; council of
health established in 337 ; first preventive
measures in 336
Vetlianka, epidemic at 159; acquires viru-
lence 160
Vienna Conference 352
Village, a Chinese 192
Virulence, variation in 93, 159
Vitality of the bacillus 89
Volcanic eruptions, efl'ect on plants 139
Watching prevalent sickness 370
West Barbary, plague in 36
Western Europe, cessation of plague in 33
White people and uniform mortality 173
Wilm's experiments 116
Wounds, post-mortem 250
Y'ersin and Kitasato discover bacillus 64
Yunnan, conditions in 182; condition of, in
1871 50; present pandemic, origin in 48;
Rocher's account of plague in 50; topo-
graphical description of 48; trade routes
from 49
Yunnanfu, trade route from Pakhoi to 56
CAMBRIDGE: PRINTED BY JOHN CLAY, M.A. AT THE UNIVERSITY PRESS.
(X
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