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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 

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. 



/ 



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MAP OF THANA COLLECTORATE IN BOMBAY PRESIDENCY. 
Plague cases from month of March to end of June, 1897. 



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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. 




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.^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. 



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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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HO Moi'"""' '"^sia an/ " 



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REFERENCES 
*"• Localities in which Plague prevailed 

X Localities in which one or more imported cases of Plague occurred 
^■i Endemic centres 



1H(I 



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140 



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DISTRIBUTK 



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ilTUaiilT8I0 



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 

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. 























































































































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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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CH. v] Experiments hy German Commissio7i 



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112 



Epidemloloijii of Plague 



[part II 



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11-4 



Ejndemiologii of Plague 



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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» 


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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. 


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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 




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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 


Fahr 


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am; pm 


am; pm 


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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 


AM ; pw 


AW . PM 


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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 


1 


2 


3 


A 


5 


6 


7 


e 


3 


10 


11 


12 


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L 


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Cent 


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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 


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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 


.'.m : PM 


ah: pv 


AM : PH 


AM : PM 


UCPH 


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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 


AM : PM 


am:pm 


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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 


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i 




700 






1 

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i 


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t . 


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if 


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ir 


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m 


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M' 


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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 


2 


3 


4 


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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« 

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Pi/he 


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106- 

105- 

104- 

103- 

102- 

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99- 

98- 
Pulse 

Resp. 



Right Femoral Bubo. 
1 2 3 





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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 




A.M. 


P.M. 


A.M. 


P.M. 


A.M. P.M. 


A.M. 


P.M. 


A.M. 


P.M. 1 


106°- 
105° 

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G.D. Septic.\emic Pl.^gue. 





MARCH 27 


MARCH 28 


MARCH 29 


MARCH 30 




A.M. P.M. 


A.M. P.M. 


A.M. P.M. 


A.M. P.M. 


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■1 



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 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 



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 




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 ^ 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 b