mony that they have dune their duty. Colonel5 Sinclair, of Madras, gets a C. S. I., well earned by over twenty years' excellent service in Burmah. Colonel Warburton has earned the same decoration for his work in connection with famine and plague in the N.-W. P. and his five yeans' successful administration of that province. The medical officers of the Central Provinces will find in Lt.-Col. McKay's C.I.E., a recognition of the arduous labours of all in the struggle with famine. Major Browning's able management of the Dufferin Hospital in the Madras Presidency is fitly recognized by a C. I. E. A novel feature in the Gazette is the appointment of a number of junior officers and nurses as Associates of the Order of St. John of Jerusalem, in reward for noble work during the epidemic of plague. We heartier congratulate Messrs. Jones, Jennings, King and Niblock and Sisters Robinson, Ken-
dall, Wheally, Moles, Hatchman, Hall, Home, Heriberta and Dyson on winning a decoration' so early in their service. "The path of duty is the way to glory." and although cynics may sneer, the early reward of good and approved service has an important stimulating action on
the works of others. All cannot be rewarded, but all can deserve reward and find it in the sense of duty done." "
THE PLAGUE IN CALCUTTA.
(Juflunt SJopicfj. THE NEW YEAR'S
HONOURS.
on In the comparatively short list o the morning of the 2nd January, the influence we and famine and plague is clearly manifest, testicongratulate the profession on this public
published
The following evidence regarding the outbreak of Plague in Calcutta was tendered to the Special Commission which lately visited this city. Colonel Hendlej^, I.M.S., Inspector-General of Civil Hospitals, Bengal, and officiating President of the Bengal Plague Commission, was the first witness examined. He said that his evidence exewas directed to administrative rather than cutive plague work, though in the latter connection he saw, as Residency Surgeon at Jeypur, asfar back as 189G, what he believed was a genuine case of plague. Plague was recognised in Bombay in the autumn of that j^ear. In December three religious mendicants were reported to have come from Bombaj^ to Jeypur by rail, but were refused admission into the citj'. They took refuge in some cenotaphs, and all three were said to have died of a disease having symptoms characteristic of plague. Prompt measures were then taken to prevent the entry of plague intoRajputana. For this purpose railway inspection camps were established, and a paper was drawnup for the information of officials and others, in which the nature, signs, symptoms and management of plague were described. This paper wa* seen cases of had He distributed. plague widely at Hardwar and elsewhere out of Calcutta. He described the measures adopted by Government before plague was first reported in Calcutta. These consisted mainly in the issue ttf circulars to all district officers advising greatf attention to first plague cases; provision of tern--
58
THE INDIAN MEDICAL GAZETTE.
hospitals; improvements in sanitation ; ?segregation of contacts; isolation of the sick; porary
and disinfection of buildings, clothes, &c. The .first case of plague, definitely reported as such ?in Calcutta, occurred on Sunday, 17th April. He accompanied the Health Officer and Sanitary 'Commissioner to examine the house in which ir, occurred. Since that time he had seen cases at ?the Medical College Hospital, and, as far as his knowledge and experience of tropical disease, ?which extended over 28 years, went, he had met, with no disorder resembling these cases, and ?could only come to the conclusion that the}7 were ?cases of true plague. Plague was declared in ?Calcutta on 30 April, and the province was -declared free on October 10th. Careful enquiry had been made in all cases, and every possible precaution had been taken to prevent the spread of the disease from persons infected. As regards segregation and isolation, his experience was that what might be possible in India was impossible or inexpe-one part of dient in another. The same remarks would jipply to the difference of treatment of towns In Raj putana many of the :i.nd villages. were walled, thus affording great facivillages >lities for carrying out such measures, supposing them to be thought wise or necessary. The villages in that province were well situated for ?isolation, and ordinarily they could be evacuated, and even burned without much difficulty and with comparatively little opposition or ?injury to any one when compensation was given, because the people were accustomed to fly from ?their habitations and camp in the open when, (for example, an epidemic of cholera occurs. Moreover, the inhabitants of the neighbouring villages would prevent by threats and violence persons from an infected village coming int.. ?their neighbourhood, and the latter would not attempt to do so. In Bengal, on the other hand, the villages ran into each other and the people nlid not in many cases dwell in villages at all, ?but in huts which were scattered over the field5:. -He considered that for the prevention of plague; .the immediate disinfection of houses, destruction .of clothing and the careful disposal of corpses were measures of the first importance. When he returned to Rajputana in December, 1897, plague was raging in some of the villages ,in Sirohi to the west of Mount Abu. It had ?entered the province, it was believed, from the south, having been brought by buneahs who had -come from Poona to their homes in Palanpur and in Sirohi, which is immediatly to the north of that district. The only point to which he would draw particular attention was the identity which appear to exist between the plague in Sirohi of 1897 and the mahamari or Pali plague of 183G. The medical officer in charge of the Sirohi camps had kindly made notes for him on a copy of Assistant-Surgeon Maclean's descriptive letter of Xhe Pali plague, which was written on tii'e loth
October 1836,
[Feb.
pointing
out many
points
1899.
of simi-
larity.
He knew Pali, which is about 40 miles from the Sirohi border, well in 1872-73, and it was at the time as filthy a? it is represented to have been in 1836. The first epidemic of the disease came from the Guzerat direction, and rats and domestic fowls were then observed to have died in large numbers. It was impossible to state how long the disease prevailed in Western India because the period was one of great general unhealthiness and the opportunities of investigation were
scanty.
l.M.s., Sanitary Commissioner ot detailed at length the measures that were taken, mainly under his immediate supervision, before April last to prevent plague from entering Bengal, by rail or sea. He also gave a brief history of the suspected cases which occurred in 1896, and which were held at the time not to be cases of true plague. Dr. Cook, Health Officer of Calcutta, was examined at great length in connection with the history of the plague in Calcutta. The total number of cases up to Christinas day, he said, was 230 and the total number of deaths was 192. He gave an account of inoculation in the city, and submitted a full report which he had prepared under instructions from Colonel Hendley. Had plague increased in the city, inoculation would have been more largely resorted to than Mohamedans came forward had been the case. freely to be inoculated, but the Hindus and especiall}' the Brahmins objected to it. Major Green, I.M.S., who succeeded Dr. Cook in charge of the plague operations in Calcutta, gave evidence regarding the post mortem appearances of cases which came under his observation as Superintendent of the Campbell Hospital and
Major Dyson,
Bengal,
as
Police
was now
Surgeon.
Speaking generally, Calcutta
He had no reason to believe endemic in Calcutta.
healthy.
plague was Major J. F. Evans, I.M.S., Resident Physician, Medical College Hospital, and Professor of Pathology, Medical College, in his statement that
said:?
which I am in a position to the outbreak of plague in Calregarding cutta, concerns chiefly those cases of the disease which were treated in the Medical College Hospital. These cases constitute about one-third of the total number that have occurred in Calcutta. They were admitted from that part of the town in which the first cases arose, and in which, I understand, the majority have occurred. The proportion which the Medical College cases bear to the total number recorded, the locality in which the disease was contracted, and their varied incidence as regards race entitle them, I think, to be regarded as fairly representative of the whole outbreak. With few exceptions, the cases were treated in the contagious wards of the hospital, which are under my medical charge. The
submit
information,
Feb.
1899.]
PT AGUE FLAUvr,
in CALCUTTA.
59
earlier cases of plague were observed. As detlie by Dr. Cleinow in the Lancet of Septemmajority of the cases admitted to scribed ber 17th of this year, the first known case of Medical College Hospital came, roughly speaking, from the area tying between Harrison Roadplague on during the recent outbreak in Calcutta was J lie
the north, the New Market on the south, Wel- admitted to the contagious ward of the Medical College Hospital. The patient on adStreet on the lesley east, and Bentinck Street with Chitpur Road on the west. This mission was too ill to furnish his address, and neighbourhood is one of the oldest parts of Calcutta andhisis friends having brought him left the hospital. very populous. Natives of India constitute His the address was, however, subsequently discovermain part of the butand the man's previous history investigated, by population of the district, ed, the Health Officer. He had apparently been living besides natives, there is a very considerable community of Europeans and Eurasians, many inofCalcutta for some considerable time,and there is no them very comfortably off, a large colony inofreason to believe that he had beeninstrumental a few Chinese, Burmans, and a number of fami-introducing the disease. In fact, such information as I possess leads me to believe that the earliest lies of African descent. The buildings are one cases of and two plague observed in Calcutta were those storey brick houses, mostly old, and of individuals who had been resident in Calcutta native huts of the kind usual in Calcutta. Exfor very considerable periods, and who could isotcejtf, in the Manvari quarter, very few of the in are either large or lofty. Several wide all probability have acquired the disease elsebuildings main thoroughfares traverse the where, and then have developed it in Calcutta district, but the after intersecting streets are tortuous and so narrow, arrival. The possibility of these cases having derived infection from the persons of other inthat at their widest part a couple of vehicles fected individuals, who had acquired the disease can barely pass. The view from the roof of the elsewhere and died without 'discovery after arHospital gives an excellent idea of this rival in Calcutta, does not appear great when the pait of the town with its combination of native small number of asti and persons arriving in Calcutta pucca buildings. It would repay the from Bombay and other foci of infection is takentiouble of a visit. In the native huts and houses into account, together with the careful scrutiny oveicrowding during the night is apparently to which differcommon, and can often be easily observed, for passengers were subjected at the ent plague ie windows are on the lines of rail and chief not always furnished with shutcamps ters. channels of communication. That the disease It. is no uncommon to see the floor sight or a loom was covered with by the agency of infected articles sleeping men lying in introduced close either Over arriving 80 by rail or sea seems the only proximity. per cent, of the pafeasible solution. And yet, on the other hand,tients were natives of India. Fifteen East ndians, one Chinaman, and one Burman con-infected articles and infected human beings s ituted the remainder. No African was admit-may arrive in a populous centre without ted with this producing an epidemic of plague. Thus the disease. Io the occurrence of four fatal cases of plague in Vienna ordinary observer, the weather was un-has usual not at any rate as yet produced an during the first quarter of the jTear. I was No inteiested in the fact at the time, as it called forthoutbreak of the disease in that town. ie prediction that cholera would be later in doubt, the circumstances surrounding the Vienna appealing and might display less intensity than cases wei'e exceptional. As stated by Surgeoniad characterised it in 1896 and 1897, two rather General Bainbridge in his evidence before the bad cholera Plague Commission, as recorded in the Englishyears. man of December 3rd, 1898, it seems essential, Considerable interest attaches to the behaviour 0 after the introduction of the virus, that the cholera during the current year. In Calcutta c lolera environment should be satisfactory to its demakes its appearance yearly about the middle of its acquirement of potency. February and lasts till the establish- velopment and favour ment of the rains in the last week of June. Consequently, in the absence of the definitely uiing the rains cholera almost entirely dis- known introduction of the disease by infected inappears to return again with their cessation in dividuals, it would appear seldom possible to eptember. A few cases generally occur during indicate actually the date of introduction of the t ie latter half of tooSeptember, and in October and virus, and it would be unwise to attach ovember, but the cholera season par excellence much importance to the actual date of occuris the hot months of the year prior to the rains. rence of the first cases when they are closely year, as compared with previous years, followed by others. For the manner in which cases of cholera have been conspicuously few, the individual usually acquires infection would and its non-occurrence can lead me to believe that the earliest cases of an hardly be entirely attributed to the exodus of the outbreak of plague indicate the establishment population during the " scare," as this did not begin till of the bacillus in the soil of the locality, since piil ->0th. While the incidence of cholera has plague can hardly be regarded as infectious een unusually light, influenza was unusually in the same sense as small-pox; nor is it pospievalent during the first three months of the sible to trace a common possible source of infecyear, and about the time that the
disappeared
THE INDIAN MEDICAL GAZETTE.
160
tion, such
as
a
food-supply
or
the
frequenting
known infected locality. The first to be regarded rather as infection. a focus of as than a storm signal Of my own knowledge I know nothing of the part that rats may play in the introduction and spread of plague. The outbreak of plague in /Calcutta was remarkable by the suddenness ?of its onset without the known occurrence ot preliminary uncertain, what in tact might be termed "dropping," cases. The first cases observed were absolutely definite and were marked .down at once. The opportunities for observation have been considerable, as the Medical College Hospital is situated in the infected locality, and the people naturally sought relief in the institution to which they were accustomed The facilities available in a large to resort. the period ot time over which the and hospital .cases were spread made it possible to conduct post-mortem examinations in over half the fatal cases and thus establish the diagnosis where necessary. It has been so frequently affirmed in " certain quarters, that a type of so-called bubonic fevers" exists in Calcutta, which clinically closely resembles plague, that I feel justified in referring to the subject here. Cases of fever with enlargement of the external groups of lymphatic glands are undoubtedl}7 very common. These cases possess nothing in common with plague either clinically or pathologically. A somewhat similar fever, with glandular enlargement usually of one external Emphatic group and often erythema and oedema of the corresponding limb, is associated with filariasis. Such ?cases as I have seen do not, however, simulate plague, and since I have lived in the Medical College since 1893 and have been in charge of the medical out-patient department during the past two years and previously in 1896, it may, 1 think, be admitted that I have had a very good of meeting with the described cases opportunity ot " bubonic fever if they had any actual exisof
a
single
case
is,
therefore,
"
tence.
It appears generally accepted that in bubonic and septicemic cases the bacillus gains access to the body through the skin by some minute lesion without producing any local reaction in the majority of instances at the point of entry. In four only of the cases under my care was there a local lesion at the presumed point of entry of the organism. The bubo in each instance was located in the glands corresponding to the lesion and this was situated in two cases on the foot in *>ne case on the wrist, and in one case on the face. In the last case the local lesion developed into a carbuncle. The probable presence of the bacillus in the soil with the risk of abrasion of the skin of the hands and feet would lend support to the belief that it is through abrasion on the hands and feet that the organism generally enters. In fchisj connection I may cite the case of an East Iu lian womahand her daughter, who were ad-
[Feb.
1899;
to hospital on the same day, both sufferfrom bubonic plague, the bubo in the mother's ing the axilla, while the case being situated in daughter's was in the femoral region. The mother stated that two days previous to admission she had been working in the yard outside her house, while the child had in all probability been running about with bare feet. None of the nurses or hospital attendants contracted plague. The friends and relations of the plague patients were encouraged to remain in attendance on the sick, with a view to diminish their anxiety and to discredit the extraordinary rumours which were in circulation at the time. They displayed no fear of contracting infection, but for the most part proved most devoted, though not very skilled, attendants; for instance, preferring the use of their hands to that of sputum cups and such like. It is sulHcient to say that they were in intimate association with the sick, a condition, however, which requires to be seen to be thoroughly appreciated in the case of native sick and their attendants. So far as is known none of the friends contracted the disease. Two of the servants, Domes by caste, employed in the post-mortem room of the Medical College Hospital, contracted plague in the discharge of their duties. Both developed axillary buboes, and both died. Their fatal illnesses were, however, quite independent of each other and were separated by a considerable interval of time. The first Dome is understood to have scratched his finger on May 1st, while removing the skull cap at the post-mortem examination of the first case of pneumonic plague observed lie died on in the Medical College Hospital. Dome second The contracted 3rd. May plague while assisting at the post-mortem examination of the carbuncular case already referred to. An unprotected abrasion between the fingers was apparently the point of entry, and the period of incubation was about 48 hours. Though not a case of inoculation, the death of a native medical student, who assisted at the first plague post-mortem, may be considered here. The
mitfced
incubation period was, however, unusually prolonged (about 14 days), and I had no opportunity of personally examining the case; but the symptoms recorded, with the rapidly fatal result, lead
me
to
believe
septicemic plague.
that it
was
a
case
of
The cases admitted during the earlier days of the epidemic were of a much more virulent typo than those arriving later, although no abatement of mortality rate could be observed. As the epidemic advanced, the delirium became gradually less violent, and the cases, speaking generally, lived longer and became more easily managed than were those at its commencement. A somewhat similar relation between the period of an epidemic and the character assumed by the disease may be observed in cholera; but in
Feb.
PLAGUE
1899.]
IN CALCUTTA
61
cholera with abatement in severity of type a cases as they came. The diagnosis and subsediminution in mortality rate is usually to be quent report to the Health Officer was made after a consultation on each case by Major observed. In plague, however, while the characEvans and himself, and, as far as possible, every ter of the cases altered for the better, the disease care
still as fatal as ever. In conclusion, I would suggest that those eases in which the bubo becomes necrotic, instead of suppurating, are deserving of investigation. I have met four such cases?two recovered, and two died. Of the fatal cases, death was due in one to gangrene of the lungs, and in the other to plague pneumonia; but in both life was prolonged longer than would have been predicted, considering the amount and character ot the was
disease.
The President congratulated Major Evans interesting character of his evidence.
on
tiie
Lt.-Col. the
Sanders,
r.MS,
Superintendent ot that sixteen plague that hospital, and all
said admitted into of them proved fatal. He had been serving fourteen years in Calcutta and had never seen ?any similar cases before. He considered that plague was introduced into Calcutta by a lascar belonging to the steamer Dcepdale which came iroin Bombay. This lascar, after suffering for about two months in Calcutta, came to hospital and was then in a very weak state with glandular swellings. He might be mistaken, but he believed that this was a true case of plague. Natives did not fear small-pox, though they, especially the Marwaris, suffered considerably from that disease. In his opinion segregation was impossible in India. It only alarmed the people, who then ran away, carrying the disease all over the country. The plague cases he had dealt with were of a very severe type, and there was an offensiveness about the swellings he had never experienced before. All plague cases were cases
Mayo Hospital, were
carefully segregated. Lt.-Col. G. F.
A. Harris, im.s., Officiating Medical College, Calcutta, said that the total number of casesseen by him and diagnosed in consultation with Major Evans was 61 of the total 57 were males and 7 were females. Fourteen of the bubonic cases recovered (21'8 per cent.) : all the rest died (711 per cent.). I'1 43 cases distinct enlargement of the lymphatic glands (buboes) was present. In 32 of these, the buboes were either femoral or inguinal, or both combined. Only seven cases showed axillary buboes, and only four showed axillary buboes, one of the latter being complicated with a carbuncular swelling of the right cheek. On taking over the duties of his present appointment, he continued the arrangement made by his predecessor that all suspected cases of plague should be admitted into the contagious ward under the First Physician, but should be placed under the immediate medical charge of Major Evans, Resident Physician. He saw all suspected cases He visited shortly after admission. them daily. He made a careful study of all the
Principal,
taken to exclude doubtful cases being Previous to coming one case of suspected plague. This was at Nagpur in January of the present year, and his diagnosis was confirmed by Colonel Hutcheson, Administrative Medical Officer, Central Provinces, who had seen numerous cases of plague in the Bombay Presidency and elsewhere. The case referred to occurred in the person of a mill-hand from the Coorla Mills, Bombay, who subsequently died. In the light of his newly-acquired experience, he considered this to have been a combined sepHehul ticemic and pneumonic case of plague had nearly 20 years' experience in various parts of India of seeing and treating diseases of all kinds (in the North-Western Provinces and Oudh, in Bengal, in the Punjab and in the Central Provinces and in Afghanistan), and to the best of his belief and knowledge he had never, previous to the present year, seen or treated any cases iu which the clinical phenomena observed during life and pathological appearances seen after death, even remotely resembled the cases of plague which he had seen this 3'ear. In c >mmon with the majority of medical men who have had much experience of disease in India, he too had seen from time to time cases in which slight glandular enlargements had occurred in association with a moderate amount of pyrexia, but .-ill these cases recovered, and he should hesitate to classify them even among benign types or pestis. In none of these cases were there any of the severe and formidable symptoms met with, which are associated with plague, and it seemed to him that these mild cases of fever, with slight glandular enlargements, could not possibly be placed in the sama category as cases of bubonic plague. The characteristic features of plague were briefly as follow: The sudden and rapid onset, the extreme prostration, mental and ph37sical, the peculiar mental lethargy contrasting at times with the restlessness and delirium, often wild and maniacal, the excessive pyrexia with dry skin, the weak and often dicrotic pulse, the marked conjunctival injection, in many cases the hollow, sunken and staring e3res; the apparent understanding of questions, followed by incoherent and inconsequent answers, and finally the rapid development of the so-called "typhoid" condition, with early cardiac failure?all combined to make up a sufficiently characteristic picture of a severe case of septicemic plague. Turning to the local symptoms present iu bubonic cases, the extreme localised pain and the exquisite superficial tenderness of the bubonic swellings were very noticeable features. The very rapid fatal termination in the large majority of cases looked on as plague, which were treated in was
reported as cases of plague. to Calcutta, he had only seen
THE INDIAN MEDICAL GAZETTE.
62
[Fed.
1899.
rations from them, but of this ho hud no perHe had 110 experience of sonal experience. the curative effects of plague serum, or of the effects of curative inoculation. Dr. Charles spoke of the finding of rats infected with plague. It seemed to him that these rats came from ships lying at the jetties, and especially strength was lent to this belief by the fact that Medicinal and alcoholic stimulants were freely the first case of plague occurred in Fairlie Place,, the constitutional and resorted to to combat of the cases In none seen cardiac depression. by quite close to the jetties. The domes were much alarmed ever since some of the post-mortem liiin could the method of infection be definitely the could ascertained: none of patients give domes had died of plague. Hats were dying in as to how the disease Calcutta in the middle of April, but there was any trustworthy history could have been contracted. In one case the no evidence that any rats died up to the end of March, though plague cases had occurred in bubo was axillary. In case No. 55, a Burman, He saw about the middle of March. on found the was Calcutta carbuncular a swelling right cheek, and a cervical bubo and smear prepara- the case of plague in the Manicktolla hospital, The on which plague was declared in Calcutta. tions from both these structures showed numerwas that of a woman who did not live near The infection case bacilli. ous plague general may Fairlie Place. He did not think that the authorhave started from the carbuncle becoming locally obtained information of all the cases of a No. a 1? ities 7-t, Chinaman, ble infected. In case was found on the left foot, which may have been plague that had occurred in Calcutta. He considered that Bangalore was much more favourable the focus of general infection. As far as he was for an outbreak of plague than Calcutta. He able to form an opinion on the matter, infection the take skin, (2) through could say that the sanitary arrangements in place (1) through may Calcutta had been much improved during the the lungs inhalation, and (3) through the alicases most In bubonic frequent- past four years. Even the back gullies were mentary canal. the takes skin. cleaner, and there were fewer cesspools about infection So place through ly the streets. This improvement was undoubtedly far at the Medical College Hospital they had no experience of direct contagion, i.e., from the due to the plague scare. He had seen two eases sick to the healthy, either among medical men, of plague in British Indian Street, one was a nurses, or sick attendants. European and the other a Eurasian. He had not noticed any evil effects following inoculation. He had been present at the post-mortem examination of 15?20 cases of plague of the The European houses in Calcutta were much bubonic, septicemic and pneumonic varieties. better ventilated than those used by natives. It was probable that the superior sanitary condiThe appearances presented were very striking, tions under which Europeans live as compared and in his experience quite unlike the post-mortem appearances in any other disease. In with Asiatics preserved them from plague. The bubonic cases the extensive area of infiltration personal precautions in an outbreak of plague round the affected glands, with, in some cases, were those of personal and general hygiene, necrotic patches of skin and intraglandular just as in an outbreak ot' typhus. The precausloughs, the haemorrhages round the glands, the tions of those attending cases should be based pinkish purple congestion of the glands which 011 the idea that they are in contact with a had not broken down and sloughed or suppurat- disease requiring thorough cleansing of all points ed, was quite distinctive. In the septicemic of contact with strong antiseptics in a methocases the swollen congested glands in various dical and not in a slipshod manner. As to regions, the numerous capillary hemorrhages inoculation, the position taken up by Governwere a very noticeable feature. In the pneu- ment was a fair one. There was no compulsion, monic cases the numerous areas of consolidation, but anyone wishing to be inoculated could have of characteristic shape and appearance, wed^e- his wish gratified. He had not been inoculated. Dr. F. G. Clemow was the next witness, and. shaped on the surface of the lung and roughly circular in the inner parts of the lungs, reddish his evidence was chiefly of a technical nature. grey on section and surrounded by an irregular He had, he said, been in charge of the Parel Old area of congestion, at once attracted notice. He Government House Hospital, Bombay, from 19th had seen on several occasions recent cultures of February to 3rd May 1898, and during that the plague bacillus made by Major Evans from time GG-i patients were under his care. Since cases diagnosed during life at the Medical College Gth May last he had been District Medical Officer Hospital, and, as far as he could judge, the in Calcutta. The sources of infection in the cultures corresponded to what are described as first cases of plague in Calcutta were uncertain. typical plague cultures, and he was informed It was noticed that there was a lower mortality that Majors Green and Evans had further from other infectious diseases during the outdemonstrated the fact of these cultures being break. He believed that plague was a "filth plague bacilli by making "stalactite" prepa- disease." During the outbreak dead rats were-
was also, in his in any other disease assoexperience, ciated with the combined general and local clinical phenomena of plague He had no special remarks to make on treatment. Judging by local experience, no medicines beneficial as curative agents. were
the Medical
College Hospital,
not found
?
Feb.
1899.]
PLAGUE "INOCULATION.
63
Medical Service. He said that, so far as he could found in the streets, but there had see, the case for inoculation seemed absolutely been a marked absence of these He not an absolute preventative, recently. clear; had personally investigated thirty-two casesitof was though so to a very considerable degree. The jplague in Calcutta. In seven of these he had experiments of which he had had knowledge, been able to obtain positive evidence of concurwere such as to exclude possibility of error. He rent mortality among rats. In the remaining had promised to go to Bombay to go through the cases the evidence on this records of inoculation there, and would be point was either negative or untrustworthjr. He gave particulars pleased to communicate the result to the Comof these cases. of With reference to the spread mission. He did not think the people would consent to be inoculated on a large scale before plague bj7 human communication; he drew attention to a nest of plague cases discovered in Ruj> an outbreak. They could not rely entirely on Chand Roy's Street. several inoculation for Subsequently coping with an outbreak: it was other cases were discovered in Municipal Office very valuable, but could never be anything but Street about li miles distant, and lie was able an auxiliary to sanitary measures. He had to trace the connection between these two heard of two complaints of the fluid being pugroups. With reference to the spread of plague to those trid. One of the mediums used for cultivation was mutton broth which was ?employed in carrying out plague measures, he objectionable, on instanced nine such cases that had occurred in religious grounds, to some of the natives, and he -Bombay; but added that as plague was prevalent thought a vegetable medium might be used ?throughout almost every part of Bombay at theinstead. Possibly the bottles were not putrid time, it would be impossible to assert that all ofwhen they were issued, but became so afterwards. 'these persons contracted the disease in the They had some bacteriological work going on in course of their duty, and not from some moreAgra, Calcutta, Hyderabad and Mysore, where general source. In some cases attendants badthey had laboratories, but he had for many years certainly contracted the disease from patients.urged the desirability of increasing the number. He had notes of over GO cases of plague inThey had officers who could easily take up bacpersons employed on plague work. He thenteriological work and in time develop into excelgave evidence on the occupation, age and sexlent bacteriologists. On medical officers arriving incidence of plague, general distribution of thein India they had to do two j'eai's' military duty disease, and on bacteriology. He also dealt atin order that they might learn discipline and length with the plague serums prepared by Drs. work in military hospitals ; two-thirds were Yersin and Lustig, specifying the mode of pre-then lent to the Civil Department, but were paration and storage, doses and mode of adminis- liable to be called on in time of war. There was tration, their clinical effects and the results and a clause in the regulations which would allow of officers under exceptional circumstances being percentage of mortality in cases so treated. Lt.-Col. Russell, Second Physician of the exempted by the Government of India from Medical College Hospital, said he had service, but the Principal Medical military practised ?in Assam and Lower Bengal and had never seen Officer on the military side objected to this. any cases resembling plague. After the plague Replying to different members of the Commishad occurred in Calcutta it was suggested that sion, witness stated that the second attack of the bubonic fever was endemic in Bengal. He did pi ague was probably due to the importation of not believe that such was the case. fresh germs, and not to the recrudescence of a Dr. Joubert, who had been in in previous attack. Percholoride of mercury was practice ?Calcutta for many years, said that in his own used as a disinfectant on the recommendations .practice he had seen but one case of plague, a of authorities, and its utility was confirmed by Jewess, in April last. The peculiarities of the practical experience. With regard to sanitary case were the great prostration with moderate officers, the Government had a right to make fever and great enlargement of the glands. The another nomination if the person appointed by prostration increased, there was delirium, and the Municipal author it}7 was unfitted for the the case terminated rather suddenly with violent post, but witness had no power of initiative. vomiting and blood as reported to him. There They had had no difficulty in getting good men were several cases of plague within two days in to enter the service, and those who did not like the immediate locality, and the usual story
dall, Wheally, Moles, Hatchman, Hall, Home, Heriberta and Dyson on winning a decoration' so early in their service. "The path of duty is the way to glory." and although cynics may sneer, the early reward of good and approved service has an important stimulating action on
the works of others. All cannot be rewarded, but all can deserve reward and find it in the sense of duty done." "
THE PLAGUE IN CALCUTTA.
(Juflunt SJopicfj. THE NEW YEAR'S
HONOURS.
on In the comparatively short list o the morning of the 2nd January, the influence we and famine and plague is clearly manifest, testicongratulate the profession on this public
published
The following evidence regarding the outbreak of Plague in Calcutta was tendered to the Special Commission which lately visited this city. Colonel Hendlej^, I.M.S., Inspector-General of Civil Hospitals, Bengal, and officiating President of the Bengal Plague Commission, was the first witness examined. He said that his evidence exewas directed to administrative rather than cutive plague work, though in the latter connection he saw, as Residency Surgeon at Jeypur, asfar back as 189G, what he believed was a genuine case of plague. Plague was recognised in Bombay in the autumn of that j^ear. In December three religious mendicants were reported to have come from Bombaj^ to Jeypur by rail, but were refused admission into the citj'. They took refuge in some cenotaphs, and all three were said to have died of a disease having symptoms characteristic of plague. Prompt measures were then taken to prevent the entry of plague intoRajputana. For this purpose railway inspection camps were established, and a paper was drawnup for the information of officials and others, in which the nature, signs, symptoms and management of plague were described. This paper wa* seen cases of had He distributed. plague widely at Hardwar and elsewhere out of Calcutta. He described the measures adopted by Government before plague was first reported in Calcutta. These consisted mainly in the issue ttf circulars to all district officers advising greatf attention to first plague cases; provision of tern--
58
THE INDIAN MEDICAL GAZETTE.
hospitals; improvements in sanitation ; ?segregation of contacts; isolation of the sick; porary
and disinfection of buildings, clothes, &c. The .first case of plague, definitely reported as such ?in Calcutta, occurred on Sunday, 17th April. He accompanied the Health Officer and Sanitary 'Commissioner to examine the house in which ir, occurred. Since that time he had seen cases at ?the Medical College Hospital, and, as far as his knowledge and experience of tropical disease, ?which extended over 28 years, went, he had met, with no disorder resembling these cases, and ?could only come to the conclusion that the}7 were ?cases of true plague. Plague was declared in ?Calcutta on 30 April, and the province was -declared free on October 10th. Careful enquiry had been made in all cases, and every possible precaution had been taken to prevent the spread of the disease from persons infected. As regards segregation and isolation, his experience was that what might be possible in India was impossible or inexpe-one part of dient in another. The same remarks would jipply to the difference of treatment of towns In Raj putana many of the :i.nd villages. were walled, thus affording great facivillages >lities for carrying out such measures, supposing them to be thought wise or necessary. The villages in that province were well situated for ?isolation, and ordinarily they could be evacuated, and even burned without much difficulty and with comparatively little opposition or ?injury to any one when compensation was given, because the people were accustomed to fly from ?their habitations and camp in the open when, (for example, an epidemic of cholera occurs. Moreover, the inhabitants of the neighbouring villages would prevent by threats and violence persons from an infected village coming int.. ?their neighbourhood, and the latter would not attempt to do so. In Bengal, on the other hand, the villages ran into each other and the people nlid not in many cases dwell in villages at all, ?but in huts which were scattered over the field5:. -He considered that for the prevention of plague; .the immediate disinfection of houses, destruction .of clothing and the careful disposal of corpses were measures of the first importance. When he returned to Rajputana in December, 1897, plague was raging in some of the villages ,in Sirohi to the west of Mount Abu. It had ?entered the province, it was believed, from the south, having been brought by buneahs who had -come from Poona to their homes in Palanpur and in Sirohi, which is immediatly to the north of that district. The only point to which he would draw particular attention was the identity which appear to exist between the plague in Sirohi of 1897 and the mahamari or Pali plague of 183G. The medical officer in charge of the Sirohi camps had kindly made notes for him on a copy of Assistant-Surgeon Maclean's descriptive letter of Xhe Pali plague, which was written on tii'e loth
October 1836,
[Feb.
pointing
out many
points
1899.
of simi-
larity.
He knew Pali, which is about 40 miles from the Sirohi border, well in 1872-73, and it was at the time as filthy a? it is represented to have been in 1836. The first epidemic of the disease came from the Guzerat direction, and rats and domestic fowls were then observed to have died in large numbers. It was impossible to state how long the disease prevailed in Western India because the period was one of great general unhealthiness and the opportunities of investigation were
scanty.
l.M.s., Sanitary Commissioner ot detailed at length the measures that were taken, mainly under his immediate supervision, before April last to prevent plague from entering Bengal, by rail or sea. He also gave a brief history of the suspected cases which occurred in 1896, and which were held at the time not to be cases of true plague. Dr. Cook, Health Officer of Calcutta, was examined at great length in connection with the history of the plague in Calcutta. The total number of cases up to Christinas day, he said, was 230 and the total number of deaths was 192. He gave an account of inoculation in the city, and submitted a full report which he had prepared under instructions from Colonel Hendley. Had plague increased in the city, inoculation would have been more largely resorted to than Mohamedans came forward had been the case. freely to be inoculated, but the Hindus and especiall}' the Brahmins objected to it. Major Green, I.M.S., who succeeded Dr. Cook in charge of the plague operations in Calcutta, gave evidence regarding the post mortem appearances of cases which came under his observation as Superintendent of the Campbell Hospital and
Major Dyson,
Bengal,
as
Police
was now
Surgeon.
Speaking generally, Calcutta
He had no reason to believe endemic in Calcutta.
healthy.
plague was Major J. F. Evans, I.M.S., Resident Physician, Medical College Hospital, and Professor of Pathology, Medical College, in his statement that
said:?
which I am in a position to the outbreak of plague in Calregarding cutta, concerns chiefly those cases of the disease which were treated in the Medical College Hospital. These cases constitute about one-third of the total number that have occurred in Calcutta. They were admitted from that part of the town in which the first cases arose, and in which, I understand, the majority have occurred. The proportion which the Medical College cases bear to the total number recorded, the locality in which the disease was contracted, and their varied incidence as regards race entitle them, I think, to be regarded as fairly representative of the whole outbreak. With few exceptions, the cases were treated in the contagious wards of the hospital, which are under my medical charge. The
submit
information,
Feb.
1899.]
PT AGUE FLAUvr,
in CALCUTTA.
59
earlier cases of plague were observed. As detlie by Dr. Cleinow in the Lancet of Septemmajority of the cases admitted to scribed ber 17th of this year, the first known case of Medical College Hospital came, roughly speaking, from the area tying between Harrison Roadplague on during the recent outbreak in Calcutta was J lie
the north, the New Market on the south, Wel- admitted to the contagious ward of the Medical College Hospital. The patient on adStreet on the lesley east, and Bentinck Street with Chitpur Road on the west. This mission was too ill to furnish his address, and neighbourhood is one of the oldest parts of Calcutta andhisis friends having brought him left the hospital. very populous. Natives of India constitute His the address was, however, subsequently discovermain part of the butand the man's previous history investigated, by population of the district, ed, the Health Officer. He had apparently been living besides natives, there is a very considerable community of Europeans and Eurasians, many inofCalcutta for some considerable time,and there is no them very comfortably off, a large colony inofreason to believe that he had beeninstrumental a few Chinese, Burmans, and a number of fami-introducing the disease. In fact, such information as I possess leads me to believe that the earliest lies of African descent. The buildings are one cases of and two plague observed in Calcutta were those storey brick houses, mostly old, and of individuals who had been resident in Calcutta native huts of the kind usual in Calcutta. Exfor very considerable periods, and who could isotcejtf, in the Manvari quarter, very few of the in are either large or lofty. Several wide all probability have acquired the disease elsebuildings main thoroughfares traverse the where, and then have developed it in Calcutta district, but the after intersecting streets are tortuous and so narrow, arrival. The possibility of these cases having derived infection from the persons of other inthat at their widest part a couple of vehicles fected individuals, who had acquired the disease can barely pass. The view from the roof of the elsewhere and died without 'discovery after arHospital gives an excellent idea of this rival in Calcutta, does not appear great when the pait of the town with its combination of native small number of asti and persons arriving in Calcutta pucca buildings. It would repay the from Bombay and other foci of infection is takentiouble of a visit. In the native huts and houses into account, together with the careful scrutiny oveicrowding during the night is apparently to which differcommon, and can often be easily observed, for passengers were subjected at the ent plague ie windows are on the lines of rail and chief not always furnished with shutcamps ters. channels of communication. That the disease It. is no uncommon to see the floor sight or a loom was covered with by the agency of infected articles sleeping men lying in introduced close either Over arriving 80 by rail or sea seems the only proximity. per cent, of the pafeasible solution. And yet, on the other hand,tients were natives of India. Fifteen East ndians, one Chinaman, and one Burman con-infected articles and infected human beings s ituted the remainder. No African was admit-may arrive in a populous centre without ted with this producing an epidemic of plague. Thus the disease. Io the occurrence of four fatal cases of plague in Vienna ordinary observer, the weather was un-has usual not at any rate as yet produced an during the first quarter of the jTear. I was No inteiested in the fact at the time, as it called forthoutbreak of the disease in that town. ie prediction that cholera would be later in doubt, the circumstances surrounding the Vienna appealing and might display less intensity than cases wei'e exceptional. As stated by Surgeoniad characterised it in 1896 and 1897, two rather General Bainbridge in his evidence before the bad cholera Plague Commission, as recorded in the Englishyears. man of December 3rd, 1898, it seems essential, Considerable interest attaches to the behaviour 0 after the introduction of the virus, that the cholera during the current year. In Calcutta c lolera environment should be satisfactory to its demakes its appearance yearly about the middle of its acquirement of potency. February and lasts till the establish- velopment and favour ment of the rains in the last week of June. Consequently, in the absence of the definitely uiing the rains cholera almost entirely dis- known introduction of the disease by infected inappears to return again with their cessation in dividuals, it would appear seldom possible to eptember. A few cases generally occur during indicate actually the date of introduction of the t ie latter half of tooSeptember, and in October and virus, and it would be unwise to attach ovember, but the cholera season par excellence much importance to the actual date of occuris the hot months of the year prior to the rains. rence of the first cases when they are closely year, as compared with previous years, followed by others. For the manner in which cases of cholera have been conspicuously few, the individual usually acquires infection would and its non-occurrence can lead me to believe that the earliest cases of an hardly be entirely attributed to the exodus of the outbreak of plague indicate the establishment population during the " scare," as this did not begin till of the bacillus in the soil of the locality, since piil ->0th. While the incidence of cholera has plague can hardly be regarded as infectious een unusually light, influenza was unusually in the same sense as small-pox; nor is it pospievalent during the first three months of the sible to trace a common possible source of infecyear, and about the time that the
disappeared
THE INDIAN MEDICAL GAZETTE.
160
tion, such
as
a
food-supply
or
the
frequenting
known infected locality. The first to be regarded rather as infection. a focus of as than a storm signal Of my own knowledge I know nothing of the part that rats may play in the introduction and spread of plague. The outbreak of plague in /Calcutta was remarkable by the suddenness ?of its onset without the known occurrence ot preliminary uncertain, what in tact might be termed "dropping," cases. The first cases observed were absolutely definite and were marked .down at once. The opportunities for observation have been considerable, as the Medical College Hospital is situated in the infected locality, and the people naturally sought relief in the institution to which they were accustomed The facilities available in a large to resort. the period ot time over which the and hospital .cases were spread made it possible to conduct post-mortem examinations in over half the fatal cases and thus establish the diagnosis where necessary. It has been so frequently affirmed in " certain quarters, that a type of so-called bubonic fevers" exists in Calcutta, which clinically closely resembles plague, that I feel justified in referring to the subject here. Cases of fever with enlargement of the external groups of lymphatic glands are undoubtedl}7 very common. These cases possess nothing in common with plague either clinically or pathologically. A somewhat similar fever, with glandular enlargement usually of one external Emphatic group and often erythema and oedema of the corresponding limb, is associated with filariasis. Such ?cases as I have seen do not, however, simulate plague, and since I have lived in the Medical College since 1893 and have been in charge of the medical out-patient department during the past two years and previously in 1896, it may, 1 think, be admitted that I have had a very good of meeting with the described cases opportunity ot " bubonic fever if they had any actual exisof
a
single
case
is,
therefore,
"
tence.
It appears generally accepted that in bubonic and septicemic cases the bacillus gains access to the body through the skin by some minute lesion without producing any local reaction in the majority of instances at the point of entry. In four only of the cases under my care was there a local lesion at the presumed point of entry of the organism. The bubo in each instance was located in the glands corresponding to the lesion and this was situated in two cases on the foot in *>ne case on the wrist, and in one case on the face. In the last case the local lesion developed into a carbuncle. The probable presence of the bacillus in the soil with the risk of abrasion of the skin of the hands and feet would lend support to the belief that it is through abrasion on the hands and feet that the organism generally enters. In fchisj connection I may cite the case of an East Iu lian womahand her daughter, who were ad-
[Feb.
1899;
to hospital on the same day, both sufferfrom bubonic plague, the bubo in the mother's ing the axilla, while the case being situated in daughter's was in the femoral region. The mother stated that two days previous to admission she had been working in the yard outside her house, while the child had in all probability been running about with bare feet. None of the nurses or hospital attendants contracted plague. The friends and relations of the plague patients were encouraged to remain in attendance on the sick, with a view to diminish their anxiety and to discredit the extraordinary rumours which were in circulation at the time. They displayed no fear of contracting infection, but for the most part proved most devoted, though not very skilled, attendants; for instance, preferring the use of their hands to that of sputum cups and such like. It is sulHcient to say that they were in intimate association with the sick, a condition, however, which requires to be seen to be thoroughly appreciated in the case of native sick and their attendants. So far as is known none of the friends contracted the disease. Two of the servants, Domes by caste, employed in the post-mortem room of the Medical College Hospital, contracted plague in the discharge of their duties. Both developed axillary buboes, and both died. Their fatal illnesses were, however, quite independent of each other and were separated by a considerable interval of time. The first Dome is understood to have scratched his finger on May 1st, while removing the skull cap at the post-mortem examination of the first case of pneumonic plague observed lie died on in the Medical College Hospital. Dome second The contracted 3rd. May plague while assisting at the post-mortem examination of the carbuncular case already referred to. An unprotected abrasion between the fingers was apparently the point of entry, and the period of incubation was about 48 hours. Though not a case of inoculation, the death of a native medical student, who assisted at the first plague post-mortem, may be considered here. The
mitfced
incubation period was, however, unusually prolonged (about 14 days), and I had no opportunity of personally examining the case; but the symptoms recorded, with the rapidly fatal result, lead
me
to
believe
septicemic plague.
that it
was
a
case
of
The cases admitted during the earlier days of the epidemic were of a much more virulent typo than those arriving later, although no abatement of mortality rate could be observed. As the epidemic advanced, the delirium became gradually less violent, and the cases, speaking generally, lived longer and became more easily managed than were those at its commencement. A somewhat similar relation between the period of an epidemic and the character assumed by the disease may be observed in cholera; but in
Feb.
PLAGUE
1899.]
IN CALCUTTA
61
cholera with abatement in severity of type a cases as they came. The diagnosis and subsediminution in mortality rate is usually to be quent report to the Health Officer was made after a consultation on each case by Major observed. In plague, however, while the characEvans and himself, and, as far as possible, every ter of the cases altered for the better, the disease care
still as fatal as ever. In conclusion, I would suggest that those eases in which the bubo becomes necrotic, instead of suppurating, are deserving of investigation. I have met four such cases?two recovered, and two died. Of the fatal cases, death was due in one to gangrene of the lungs, and in the other to plague pneumonia; but in both life was prolonged longer than would have been predicted, considering the amount and character ot the was
disease.
The President congratulated Major Evans interesting character of his evidence.
on
tiie
Lt.-Col. the
Sanders,
r.MS,
Superintendent ot that sixteen plague that hospital, and all
said admitted into of them proved fatal. He had been serving fourteen years in Calcutta and had never seen ?any similar cases before. He considered that plague was introduced into Calcutta by a lascar belonging to the steamer Dcepdale which came iroin Bombay. This lascar, after suffering for about two months in Calcutta, came to hospital and was then in a very weak state with glandular swellings. He might be mistaken, but he believed that this was a true case of plague. Natives did not fear small-pox, though they, especially the Marwaris, suffered considerably from that disease. In his opinion segregation was impossible in India. It only alarmed the people, who then ran away, carrying the disease all over the country. The plague cases he had dealt with were of a very severe type, and there was an offensiveness about the swellings he had never experienced before. All plague cases were cases
Mayo Hospital, were
carefully segregated. Lt.-Col. G. F.
A. Harris, im.s., Officiating Medical College, Calcutta, said that the total number of casesseen by him and diagnosed in consultation with Major Evans was 61 of the total 57 were males and 7 were females. Fourteen of the bubonic cases recovered (21'8 per cent.) : all the rest died (711 per cent.). I'1 43 cases distinct enlargement of the lymphatic glands (buboes) was present. In 32 of these, the buboes were either femoral or inguinal, or both combined. Only seven cases showed axillary buboes, and only four showed axillary buboes, one of the latter being complicated with a carbuncular swelling of the right cheek. On taking over the duties of his present appointment, he continued the arrangement made by his predecessor that all suspected cases of plague should be admitted into the contagious ward under the First Physician, but should be placed under the immediate medical charge of Major Evans, Resident Physician. He saw all suspected cases He visited shortly after admission. them daily. He made a careful study of all the
Principal,
taken to exclude doubtful cases being Previous to coming one case of suspected plague. This was at Nagpur in January of the present year, and his diagnosis was confirmed by Colonel Hutcheson, Administrative Medical Officer, Central Provinces, who had seen numerous cases of plague in the Bombay Presidency and elsewhere. The case referred to occurred in the person of a mill-hand from the Coorla Mills, Bombay, who subsequently died. In the light of his newly-acquired experience, he considered this to have been a combined sepHehul ticemic and pneumonic case of plague had nearly 20 years' experience in various parts of India of seeing and treating diseases of all kinds (in the North-Western Provinces and Oudh, in Bengal, in the Punjab and in the Central Provinces and in Afghanistan), and to the best of his belief and knowledge he had never, previous to the present year, seen or treated any cases iu which the clinical phenomena observed during life and pathological appearances seen after death, even remotely resembled the cases of plague which he had seen this 3'ear. In c >mmon with the majority of medical men who have had much experience of disease in India, he too had seen from time to time cases in which slight glandular enlargements had occurred in association with a moderate amount of pyrexia, but .-ill these cases recovered, and he should hesitate to classify them even among benign types or pestis. In none of these cases were there any of the severe and formidable symptoms met with, which are associated with plague, and it seemed to him that these mild cases of fever, with slight glandular enlargements, could not possibly be placed in the sama category as cases of bubonic plague. The characteristic features of plague were briefly as follow: The sudden and rapid onset, the extreme prostration, mental and ph37sical, the peculiar mental lethargy contrasting at times with the restlessness and delirium, often wild and maniacal, the excessive pyrexia with dry skin, the weak and often dicrotic pulse, the marked conjunctival injection, in many cases the hollow, sunken and staring e3res; the apparent understanding of questions, followed by incoherent and inconsequent answers, and finally the rapid development of the so-called "typhoid" condition, with early cardiac failure?all combined to make up a sufficiently characteristic picture of a severe case of septicemic plague. Turning to the local symptoms present iu bubonic cases, the extreme localised pain and the exquisite superficial tenderness of the bubonic swellings were very noticeable features. The very rapid fatal termination in the large majority of cases looked on as plague, which were treated in was
reported as cases of plague. to Calcutta, he had only seen
THE INDIAN MEDICAL GAZETTE.
62
[Fed.
1899.
rations from them, but of this ho hud no perHe had 110 experience of sonal experience. the curative effects of plague serum, or of the effects of curative inoculation. Dr. Charles spoke of the finding of rats infected with plague. It seemed to him that these rats came from ships lying at the jetties, and especially strength was lent to this belief by the fact that Medicinal and alcoholic stimulants were freely the first case of plague occurred in Fairlie Place,, the constitutional and resorted to to combat of the cases In none seen cardiac depression. by quite close to the jetties. The domes were much alarmed ever since some of the post-mortem liiin could the method of infection be definitely the could ascertained: none of patients give domes had died of plague. Hats were dying in as to how the disease Calcutta in the middle of April, but there was any trustworthy history could have been contracted. In one case the no evidence that any rats died up to the end of March, though plague cases had occurred in bubo was axillary. In case No. 55, a Burman, He saw about the middle of March. on found the was Calcutta carbuncular a swelling right cheek, and a cervical bubo and smear prepara- the case of plague in the Manicktolla hospital, The on which plague was declared in Calcutta. tions from both these structures showed numerwas that of a woman who did not live near The infection case bacilli. ous plague general may Fairlie Place. He did not think that the authorhave started from the carbuncle becoming locally obtained information of all the cases of a No. a 1? ities 7-t, Chinaman, ble infected. In case was found on the left foot, which may have been plague that had occurred in Calcutta. He considered that Bangalore was much more favourable the focus of general infection. As far as he was for an outbreak of plague than Calcutta. He able to form an opinion on the matter, infection the take skin, (2) through could say that the sanitary arrangements in place (1) through may Calcutta had been much improved during the the lungs inhalation, and (3) through the alicases most In bubonic frequent- past four years. Even the back gullies were mentary canal. the takes skin. cleaner, and there were fewer cesspools about infection So place through ly the streets. This improvement was undoubtedly far at the Medical College Hospital they had no experience of direct contagion, i.e., from the due to the plague scare. He had seen two eases sick to the healthy, either among medical men, of plague in British Indian Street, one was a nurses, or sick attendants. European and the other a Eurasian. He had not noticed any evil effects following inoculation. He had been present at the post-mortem examination of 15?20 cases of plague of the The European houses in Calcutta were much bubonic, septicemic and pneumonic varieties. better ventilated than those used by natives. It was probable that the superior sanitary condiThe appearances presented were very striking, tions under which Europeans live as compared and in his experience quite unlike the post-mortem appearances in any other disease. In with Asiatics preserved them from plague. The bubonic cases the extensive area of infiltration personal precautions in an outbreak of plague round the affected glands, with, in some cases, were those of personal and general hygiene, necrotic patches of skin and intraglandular just as in an outbreak ot' typhus. The precausloughs, the haemorrhages round the glands, the tions of those attending cases should be based pinkish purple congestion of the glands which 011 the idea that they are in contact with a had not broken down and sloughed or suppurat- disease requiring thorough cleansing of all points ed, was quite distinctive. In the septicemic of contact with strong antiseptics in a methocases the swollen congested glands in various dical and not in a slipshod manner. As to regions, the numerous capillary hemorrhages inoculation, the position taken up by Governwere a very noticeable feature. In the pneu- ment was a fair one. There was no compulsion, monic cases the numerous areas of consolidation, but anyone wishing to be inoculated could have of characteristic shape and appearance, wed^e- his wish gratified. He had not been inoculated. Dr. F. G. Clemow was the next witness, and. shaped on the surface of the lung and roughly circular in the inner parts of the lungs, reddish his evidence was chiefly of a technical nature. grey on section and surrounded by an irregular He had, he said, been in charge of the Parel Old area of congestion, at once attracted notice. He Government House Hospital, Bombay, from 19th had seen on several occasions recent cultures of February to 3rd May 1898, and during that the plague bacillus made by Major Evans from time GG-i patients were under his care. Since cases diagnosed during life at the Medical College Gth May last he had been District Medical Officer Hospital, and, as far as he could judge, the in Calcutta. The sources of infection in the cultures corresponded to what are described as first cases of plague in Calcutta were uncertain. typical plague cultures, and he was informed It was noticed that there was a lower mortality that Majors Green and Evans had further from other infectious diseases during the outdemonstrated the fact of these cultures being break. He believed that plague was a "filth plague bacilli by making "stalactite" prepa- disease." During the outbreak dead rats were-
was also, in his in any other disease assoexperience, ciated with the combined general and local clinical phenomena of plague He had no special remarks to make on treatment. Judging by local experience, no medicines beneficial as curative agents. were
the Medical
College Hospital,
not found
?
Feb.
1899.]
PLAGUE "INOCULATION.
63
Medical Service. He said that, so far as he could found in the streets, but there had see, the case for inoculation seemed absolutely been a marked absence of these He not an absolute preventative, recently. clear; had personally investigated thirty-two casesitof was though so to a very considerable degree. The jplague in Calcutta. In seven of these he had experiments of which he had had knowledge, been able to obtain positive evidence of concurwere such as to exclude possibility of error. He rent mortality among rats. In the remaining had promised to go to Bombay to go through the cases the evidence on this records of inoculation there, and would be point was either negative or untrustworthjr. He gave particulars pleased to communicate the result to the Comof these cases. of With reference to the spread mission. He did not think the people would consent to be inoculated on a large scale before plague bj7 human communication; he drew attention to a nest of plague cases discovered in Ruj> an outbreak. They could not rely entirely on Chand Roy's Street. several inoculation for Subsequently coping with an outbreak: it was other cases were discovered in Municipal Office very valuable, but could never be anything but Street about li miles distant, and lie was able an auxiliary to sanitary measures. He had to trace the connection between these two heard of two complaints of the fluid being pugroups. With reference to the spread of plague to those trid. One of the mediums used for cultivation was mutton broth which was ?employed in carrying out plague measures, he objectionable, on instanced nine such cases that had occurred in religious grounds, to some of the natives, and he -Bombay; but added that as plague was prevalent thought a vegetable medium might be used ?throughout almost every part of Bombay at theinstead. Possibly the bottles were not putrid time, it would be impossible to assert that all ofwhen they were issued, but became so afterwards. 'these persons contracted the disease in the They had some bacteriological work going on in course of their duty, and not from some moreAgra, Calcutta, Hyderabad and Mysore, where general source. In some cases attendants badthey had laboratories, but he had for many years certainly contracted the disease from patients.urged the desirability of increasing the number. He had notes of over GO cases of plague inThey had officers who could easily take up bacpersons employed on plague work. He thenteriological work and in time develop into excelgave evidence on the occupation, age and sexlent bacteriologists. On medical officers arriving incidence of plague, general distribution of thein India they had to do two j'eai's' military duty disease, and on bacteriology. He also dealt atin order that they might learn discipline and length with the plague serums prepared by Drs. work in military hospitals ; two-thirds were Yersin and Lustig, specifying the mode of pre-then lent to the Civil Department, but were paration and storage, doses and mode of adminis- liable to be called on in time of war. There was tration, their clinical effects and the results and a clause in the regulations which would allow of officers under exceptional circumstances being percentage of mortality in cases so treated. Lt.-Col. Russell, Second Physician of the exempted by the Government of India from Medical College Hospital, said he had service, but the Principal Medical military practised ?in Assam and Lower Bengal and had never seen Officer on the military side objected to this. any cases resembling plague. After the plague Replying to different members of the Commishad occurred in Calcutta it was suggested that sion, witness stated that the second attack of the bubonic fever was endemic in Bengal. He did pi ague was probably due to the importation of not believe that such was the case. fresh germs, and not to the recrudescence of a Dr. Joubert, who had been in in previous attack. Percholoride of mercury was practice ?Calcutta for many years, said that in his own used as a disinfectant on the recommendations .practice he had seen but one case of plague, a of authorities, and its utility was confirmed by Jewess, in April last. The peculiarities of the practical experience. With regard to sanitary case were the great prostration with moderate officers, the Government had a right to make fever and great enlargement of the glands. The another nomination if the person appointed by prostration increased, there was delirium, and the Municipal author it}7 was unfitted for the the case terminated rather suddenly with violent post, but witness had no power of initiative. vomiting and blood as reported to him. There They had had no difficulty in getting good men were several cases of plague within two days in to enter the service, and those who did not like the immediate locality, and the usual story
