[Oct.
1898.
PLAGUE EPIDEMICS IN RUSSIA: CLEMOW.
363
and despair, " so from the very beginning have little or no hope for their life." Some Historical Notes. 6. " The most important sign and symptom By FRANK G. CLEMOW, M.D., D. P. H. in the infection is a great and rapidly developLate Medical Officer in charge of the British Seamen's ing ivealcness of the whole body and all the Hospital, Cronstadt, St. Petersburg ; Secretary for Russia to the Epidemiological Society of London; members." This extreme weakness sometimes Honorary Member of the Russian National ushered in the attack. It was often accompanied Health Society ; etc. : by trembling of the hands and feet, so that Medical Officer on Special Plague Duty, Calcutta. the patient could not stand, and sometimes by {Continued from p. 336.) fainting. Suddenly, developing weakness and trembling of the limbs, without any other Of not less value than his account of the rise were deemed sufficient to arouse sussymptom, and course of the Great Plague of Moscow and On the other hand, there were a few picion. of the measures employed to deal with it, is who persons passed through an attack of the Shafonski's description of the clinical aspect of plague without any marked weakness and the disease. The description is, indeed, of unwithout even taking to their beds.* usual value, for it bears clear internal evidence the voice, ascribed by the based was that it entirely upon the author's own 7. Weakness of author to weakness of the tongue. "In some and as is the case with observation, not, personal the speech is unintelligible and disordered, as so many of the older medical writers, upon mere the tongue were frozen or bitten, or like and tradition. It will be of interestthough authority the speech of a drunken man; many are either to quote, of necessity in a condensed form, the unable to put out their tongue or and altogether of which list he gives and symptoms signs shew it with difficulty." to compare them with those of plague as recently 8. Diarrhoea, occasionally very profuse, ocmanifested in India. His definition of the disease runs as follows: curred in some cases. Sometimes it was so severe " that no remedy was able to check it, and in Plague is a disease sui generis, more dangerous such cases it was the direct cause of death. than all other diseases, highly contagious, and 9. Haemorrhage, generally from the nose or the external signs upon producing body, viz. : buboes, carbuncles and large and small blackthroat and frequently fatal. 10. Delirium, coming on with the invasion spots (petechice); for the most part endingor later. " In some there is such a frenzy that death." in rapidly to bind the person; but is needful it sometimes of the disease were the The signs and symptoms this is very rare." in the head and Pain heaviness. following:?1. 11. "In some is observed a desire for food, In some the pain is cruel, in others it is not so when they suddenly feel themselves particularly in are some the red and dim, eyes great; usually however hopeful it may this better; symptom, swollen, while some have the appearance of foretells a rapid end. It seem, generally drunken men." The pain in the head was not often happens that those who are ill of the plague and was so in a absent prominent single case, just before death have no sufferings or signs of a symptom that "many of the common people the end, but die almost without any visible movecalled it the head disease." ment of the body. This occurrence deceived 2. Chill and shivering, such as is found in at the beginning of the Moscow In some this symptom was not marked, many physicians fevers. who found the sick without notable weakPlague, in in the and severe cases, some, particularly ness and in no visible danger, but in a short time there was no rigor." these same persons were in extremis and died. 3. "After the chill quickly follows heat, the end talked considerably which in many is felt most internally, and in Many just before and even moved about, so that death seemed many both externally and internally, and lasts to be far from them, but suddenly and without as in any other cruel fever; the tongue is at the any change they died." same time dry in some, in some yellow and as 12. "In many it is noticed that they sleep though covered with glue, while in some it through almost the whole course of the illness differs little from the natural tongue." and die with scarcely any motion of the body; 4. Nausea and desire to vomit, and in many and it is generally observed that these have a actual vomiting. This was a very frequent and despairing look." symptom, which sometimes came on with the grievous Such were the general symptoms of plague as rigor and was sometimes delayed a little. seen in The local signs were the Moscow. "Vomiting is generally severe if the person who becomes infected shall eat soon after, or has following:? 1. "Black or rather livid spots, called eaten so recently before becoming infected that marushki (petechias), which are found on all the stomach has not had time to digest the food ; but even those who have eaten nothing are no * The pestis amhulans of modern writers. less prone to vomit, and many throw up a green or fluid." yellow PLAGUE EPIDEMICS IN RUSSIA
:
5. that
Anxiety, distress, fear
some
"
...
"
364
THE INDIAN MEDICAL GAZETTE.
[Oct.
1898.
parts of the body, but particularly on the breasts, the neck, the arms, and the belly; the size of a
other hand, the pest begins with buboes alone, without visible fever or other symptoms." The other symptoms usually came on sooner or later, poppy-seed or of a pea, or in some larger These spots appear in some soon after the onset though a few escaped with nothing more than of fever; and in many the body is as though the buboes. After describing the points in covered with the bites of fleas, which grow in which these buboes differed from those of venesize from hour to hour; in many they appear real disease, Shafonski adds that they sometimes " on the second day or later, and in some after In many," he continues, lasted only two days. death, and do not disappear from the dead body." it is long before they can be brought to an 2. "The very first and most decisive exterabscess, as the fever passes before the bubo is nal sign of the plague is a black boil, called a mature; and if it is already so mature that it carbuncle (carbunculus, anthrax). It may ap- is time to cut it, then, although on opening it the ripest matter flows out, yet generally the pear on any part of the body without exception, and always begins with a burning pain, as is not changed into pure matter, but comes gland though the body had been burnt, after which away like thick tallow; and if the gland do there soon appears at that spot a livid blister, not wholly come away, then the wound is long At first many from filled with a thin fluid. in healing and sometimes leaves a hole or fistula. ignorance, and others purposely, ascribe these Buboes under the arms also heal slowly' If the blisters to an actual burn, especially those who bubo was behind the ear or in the neck the The have steamed themselves in the baths. patient almost always died. bladder is at first very small, like an ordinary 4. "Wheals (vibices) and blue spots, large and pimple, but from hour to hour becoming larger small, as though the body had been beaten. and. more prominent, and around, it the body Although rarer than the former signs, yet these becomes red ; in some it rises in the course sometimes occur, from blood being poured out of a day or more, in some in a few hours, and under the skin, mostly on the back and legs; then bursts, or the patient himself, lying in generally before death, but after it in those fever, crushes it. As soon as the blister breaks who die rapidly." and the fluid escapes, then under the cuticle Neither age, sex, nor social condition was any a black spot, as though burnt, level with safeguard against the infection. Some persons, the surface of the body, is presented to the it is true, though in close and prolonged proxieye; in some the size of a polushka* and mity with the sick, escaped an attack, but such in some as big as the palm of the hand. This instances were rare. "In general it was observed sign, which is like a St. Anthony's fire turned that the young sickened more readily than the old, into a black and burnt spot, is called from its women than men, those of the moist constitution blackness a carbuncle; the burnt part is hard, than those of the dry, and the lower classes thau extends deeply and has no mature pus and no the well-to-do." Relapses were extremely rare. feeling, so that on cutting it with a knife or These were the principal clinical features of applying to it the most acrid drugs, there is no plague as recorded by a shrewd and careful pain whatever, only the living parts around observer nearly 130 years ago. Space will not feeling it. Not a single part of the body is allow of their full discussion here, but it may be exempt from these carbuncles; in many they noted that, with a few exceptions, the list of occur on the face, and, because of the gravity of symptoms closely corresponds with those of this position, there is then little hope of replague as recently observed in India. The headcovery. In many there is only one, in others ache, dimness and redness of the eyes, the rigor there are more than one or two in different and fever, the dry and loaded tongue, the tenparts of the body. At the worst period of the dency to vomit, the great depression and prostraMoscow Plague, particularly in the months of tion, the affection of the speech, the delirium, August and September, carbuncles were more the drowsiness, the buboes and carbuncles,"*? commonly noted than the other external signs, with all these signs and symptoms recent outand the sick in consequence more frequently breaks of plague have rendered modern observers died; it was very rare for one who had car- familiar. Where, however, Shafonski's descripbuncles not to take to his bed." 3. "Swellings at the site of glands, or tu* Compare Boghurst's list of diagnosticks" of the plague mours, called Buboes (bubones), which are usu- as seen in the Great Plague of London : 1. Shuddering cold at first falling sick. ally in the groins, less often under the arms, 2. Frequent vomitting, or at least retching to vomitt. and still less often behind the ears. They come 3. Headiich, dizziuess and lightness of the head. at different times; in some on the first day of Heate and thirstiness. 4. 5. Bleeding at the nose and sometymes at mouth, the fever, and in others on the second or third hemroids and menses. day; while in some nothing is^seen save fever 7. Great inward heate and outward cold. for as much as ten days; but in a few, on the 8. Carbuncles, buboes, blaines, blisters, spotts risein g on the body. * JPolvshha, a minute obsolete coin, of the value of 9. Distraction, staring, frenzy, idle talke. about one-sixieenth of a penny. 10. Drowsiness and sometymes continual watching. ....
"
"
"
?
?
Oct.
1898.]
PLAGUE
EPIDEMICS
IN RUSSIA: CLEMOW.
perhaps unique
in
365
of plague. It is in wliat respect the blue from the petechias already dewill not permit of a further discussion of the Russian author's description of plague,* and with the brief statement that he makes no mention of the occurrence in Moscow of a pneumonic form of plague nor of any coincident affection of rats or other lower animals, the Great Plague of Moscow (already perhaps discussed at rather more than due length) must be dismissed, to make way for a brief account of some more recent epidemics. During the present century plague has visited Russia on more than one occasion, though never with any great severity or over a wide area.*f* In 1807 it spread from Persia to the Caucasus, and thence to Astrakhan and Saratof on the Yolga. This was an exceedingly mild outbreak, and was the cause of only 101 cases and 91 deaths in all. In 1828 the Russian Troops in Wallachia were attacked with plague, and in July of the same severe epidemic occurred at a rather year the taking of Kars by the Russians. According!to one authority more than one-tenth of the inhabitants of that town fell victims to the plague ; according to another there were in the town 2,24G cases with 2,197 deaths (a mortality one large slough, leaving a deep, lagged, pus- of about 9S per cent.), while among the Russian secreting cavity, often very slow in healing. garrison there were 381 cases with only 142 Shafonski's description of "carbuncles" does deaths (a mortality of less than 40 per cent.). not, it will be observed, correspond in its entireIn 1838 a limited outbreak occurred in Odessa, t\r with any of these lesions, though it has and between 1839 and 1843 a few isolated points in common with each of them. The de- epidemics occurred in different parts of Transscription of the buboes scarcely needs comment; caucasia. For the past 55 years Russian soil but the mention of vibices\ is remarkable, and has been quite free from plague, with the singel 12. Dissolution of strength. but important exception of the circumscribed 17. The tongue presently furred aU over with white outbreak on the lower reaches of the Volga, fur. known as the Vetlianka epidemic, ?" Loimograpliia, or an Experimental Relation of the generally from the the village which suffered last name of in the Remarkable what hatli Plague, of happened Plague in the City of London." by William Boghurst, London, most severely. Though small in itself and quite 1566. For the first time printed in full in the Transactions localised this epidemic derives an importance of the Epidemiological Society, Vol. XIII, 181)3-4. from the fact that it was the last occurrence of *In the definition of the disease already quoted it will be observed that the Russian author the buboes first plague in Europe.^
tion of the disease differs from that of the plague as seen in Bombay is principally i" the following points. The black spots or petechias, so common in the Moscow Plague as to be given first place in the list of external signs,* were of the rarest occurrence, if indeed they occurred at ajl in Bombay."f* The description of the socalled carbuncles" does not, it will be noted, at all correspond to the definition of carbuncle as that word is specifically applied in modern medicine. It may, indeed, be questioned whether true carbuncle ever occurs as a symptom of plague. In the present writer's experience the principal local lesions in plague, apart from the buboes, would appear to be the following:? (1) Collections of purulent or sero-purulent or sanguineo-purulent fluid, on an inflamed base, which on bursting or being opened, leave a slowly healing ulcer; (2) patches, varying much in size, of necrosis of the skin, sometimes but not always occurring where irritants (such as the native marking-nut) have been applied, sometimes as the result of pressure (as over the sacrum or occipital protuberance), sometimes idiopathieally, with 110 obvious local cause ; and (3) a necrosis of the skin over a bubo and of the bubo itself, both skin and bubo separating as
not
easy to
quite spots differed scribed. Space "
descriptions
"
see
"
places
among the external signs of plague, a course which modern observers would certainly be inclined to follow. The black " tokens" spots or petechias are obviously the same as the so prominent in accounts of the Great Plague of London. is a iu recent Their marked absence striking epidemics bat undoubted fact, in in was which I charge of the f During ten weeks Parel Plague Hospital, Bombay. 502 cases of plague were admitted to the wards, in addition to 162 patients already in hospital at the time of my taking it over. Among these 664 patients, in only two did there occur a dusky rash which raised a suspicion of its being possibly petechial in character. A much longer acquaintance with the appearances of rashes in a dark skin than I possessed would have been necessary to determine accurately the nature of the rash, and I have since kept an open mind on the question, with a tendency, however, to regard the spots seen in these two cases as other than petechial in character. The deeper haamorrliages so often found around buboes, and on mucous and serous membranes iu plague cadavers form, on the other hand, a strong a priori argument in favour of the probability of petechial rashes occurring. | TIbices were not observed as a symptom of plague in a single case in Parel. An urticarial rash did, however, occur in one out of fifty patients subjected (unsuccessfully; to
the serum treatment. I regarded it as an effect of the rather than as a manifestation of plague. The comparative prominence given by Sliafonski (and by others of the older writers upon plague) to vomiting, diarrhoea and hemorrhages as symptoms of plague would have afforded interesting points for discussion did space allow. All. in my experience, occur in plague, but, with the exception of the first, neither frequently nor with great se verity, and I have never seen either diarrhoea or hajinorrhage the direct cause of death. Diarrhoea has been more frequent in the early stages of the cases I have seen in Calcutta than in the cases observed in Bombay. f In an article upon the Plague in India receutly published in the Nineteenth Century, it is regrettable that the otherwise well informed writer has been led to make the sweeping assertion that plague is endemic in Russia, "sometimes of a mild type, but more often virulent.' The facts stated in the text will suffice to refute this statement ; and I have failed to find any authority upon which it could have been based. " 4< should perhaps be auded. J In an epidemic form Three suspicious cases occurred, it will be remembered, upon ships coming from India to the Thames in the autumn of 189G.
serum *
b.
36G
THE INDIAN MEDICAL GAZETTE.
The origin of the Vetlianka epidemic has never been quite cleared up. It is worthy of note that it coincided, like so mail)' of its predecessors, with a war between Russia and Turkey. The late Professor Botkin, of St. Petersburg, was of opinion that plague was present in the army of the Caucasus in the autumn of 1877, for Count Loris-Melikof, who was in command, wrote at that time that a great mortality was prevailing among the troops from a disease described as typhus fever with buboes," and that 75 or 80 per cent, of the cases proved fatal. The fact that this disease was not spread widely throughout Russia when the troops were dispersed was attributed by Botkin to a supposed immunity of the country to the infection of plague. An indication of the presence of the infection in a mild form might, he thought, be found in a tendency, noted at the time, to a prevalence of glandular swellings among patients seen in St. Petersburg and other places. However this may be the fact remains that, with the exception of some suspicious cases near Astrakhan in 1877, and one or two doubtful cases in the governments of Nijni Novgorod, Riazan and Taurida, and in the towns of Odessa and St. Petersburg,* the actual outbreak of plague was confined to some half dozen Cossack stanitzas, or villages, in the government of Astrakhan and lying on either bank of the River Volga. Much doubt and obscurity hangs over the early period of the outbreak,! for, with one exception, the entire medical and sanitary staff, from whom alone a trustworthy history of the outbreak could have been obtained, all caught the ^ disease and died from it. Three medical men (Drs. Koch, Morozof and Grigorief), sixfeldschers, or trained hospitals attendants, and a brother and sister of charity were among the early victims of the epidemic. Dr. Doppner was the sole survivor of this devoted band, and it is on his evidence that later writers upon the epidemic have based their account of its origin.
...
*
in St.
Petersburg-,
which Botkin regarded as one of true plague, and some other equally suspicious cases which followed it, may be found fully recorded and discussed in the Protocols of the Society of Russian Physicians in St. Petersburg. Some reflection may also there be found of the intense excitement which in the capital. The this case appears to have aroused popular dissatisfaction at Botkiu's expression of opinion nature of the the case was answered as to by a special meeting- of the Society and the presentation to him of addresses of both from the Society enthusiastic confidence, and from the profession generally. most accurate accounts of this epidemic are those The | of the Foreign Commissioners who visited the scene of the epidemic, too late to see any typical cases, but not too late to collect valuable cotes and recent impressions from observers The Russian Government, it should be exon the spot. other European Governments to plained, invited each of the send Commissions to investigate the epidemic on the spot, and the invitations were largely responded to. The British Commissioners were Drs. Colvil 1 and Payne. A summary of their report and of those of the other Commissions will be found in the supplement to the Ninth Annual of the Medical Officer to the Local Government The
Report Board.
suspicious
case
The first
[Oct.
1898.
appears to have occurred in October 3rd (15th) 1878, when an old man, named Agap Kharitonof, is said to have fallen sick shortly after opening a packet which he had received from his son in Asiatic Turkey.* According to another account this patient died, not from plague, but from pneumonia, the result of chill and exposure while fishing on the Volga, and the first case was therefore that of a young girl, a member of the same household.*}" All authorities are agreed that the plague spread first in this household and thence to other households, and finally to other villages along the banks of the river. The first case outside Vetlianka was in the .village of Prishib, some seven miles distant, where a woman named Arina Ephraimof, who had stayed in Vetlianka from November 30th to December 3rd, returned to Prishib on the latter date, and sickened two days later, dying on the 11th. Of eight other members of her household seven caught the disease and died. This sequence of events was repeated on many occasions in this
Vetlianka,
case
on
epidemic. The Yolga plague seems to have been essentially a house or family disease, carrying off entire households when it had once gained a footing in them, but shewing little tendency to spread widely or (with the exception of Vetlianka) to attack many households. In Yetlianka almost
one-fourth of the population and rather more than one-fifth succumbed to the epidemic. Elsewhere, as the following table will show, the proportion of cases and deaths to the population was infinitely smaller were
exactly
attacked,
Statistical Table of the Vetlianka Epidemic, 1878-79. Duration of epidemic.
Name of
Village. Vetlianka Prishib Stavitzkoe
...
Selitrianoe
...
Udatclinoe
...
Michael ovskoe
17th Oct. 1878 to 27th May 1879. 5th to 24th Dec. 1878. 15th Dec. 1878 to 5tli Jan. 1879. 19th Dec. 1878 to 19th Jan. 1879. 13th Dec. 1878 to 18th Jan. 1879. 15th Dec. 1878 to 7th Jan.1879.
Totals of
cases
Popula- Cases. Deaths. tion. 1,837
453
372
3,523
16
16
2,155
8
8
2,499
32
30
8G0
2
2
668
4
3
515
431
and deaths.
Compare the well-known story of the introduction of plague into the village of Eyam in Derbyshire in 1665 by a parcel of infected clothes sent from London ; and many other similar instances throughout plague literature. Con*
siderable
doubt
plausible
as
of
necessity attaches to these stories, appear. More recent experience would fomites that show seem to play little, if any, part in spreading plague over long distances, or from country to country. f The English Commissioners give the 17ch (29th) of October as the date of the first case of plague in Yetlianka.
they
Ocr.
1898.J
PLAGUE EPIDEMICS IN RUSSIA: CLEMOW.
367
It will be observed that the epidemic fell the epidemic was marked by a gradually diminprincipally in the late months of 1878 and Janu- ishing mortality. According to the English ary 1879, that is to say in almost, but not quite, Commissioners "in the third period of the outthe coldest period of the year.* In this fact?? break?the period of decline?the disease retained the character which it had presented in the a fact curiously little dwelt upon in the literature of the epidemic?may in all probability be found second period of its progress (the period of the explanation of the peculiar character and culmination), the acuteness of the symptoms and behaviour of this epidemic, in displaying the the rapidity of course sensibly abating; while utmost intensity and virulence in individual the indications of pathological changes in the households, while not spreading over any very glandular system, which had been rarely oblarge area. At that time of year the degree of served and no doubt in great part overlooked cold, though not so extreme as in January or during the acme of the outbreak, again began Februaiy, would be very great. Fishing, the to appeal-." But little space is left to discuss the measures staple industry in those regions, and other out-door labour, would be at an end, and the taken to meetand control the Vetlianka epidemic. villagers would spend most of their time inside They appear to be divisible into two groups? their huts, around or even upon the stove. In measures adopted by the villagers themselves and other words, the conditions would be such that measures put in force at a later period by the local contact and communication between individual and imperial authorities. The measures adopted members of a household were at their maximum, by the villagers themselves appear to have conwhile communication between neighbouring sisted mainly in an attempt to isolate every house households or neighbouring villages was at its in which a case of plague occurred, and completely cut off all communication between the inmates minimum. With regard to the symptomatology of this of this and of adjoining houses. The effort, epidemic it has to be noted, for reasons already though crude, seems to have been fairly stated, that but little is known of its clinical thorough. In Vetlianka it was put into execuaspect while the epidemic was at its height. tion too late to be of any use; but in the other There would appear, however, to have been villages there seems reason to believe that this three distinct periods, in each of which the measure, aided by the climatic and social condisease presented different characters.! In the ditions already referred to, was of some service in earliest period the cases presented a mild remit- checking the spread of infection. The crudity and cruelty, however, of a measure which tent or intermittent fever, the lymphatic glands of groin or axilla became enlarged and suppurat- consists in shutting up sick and well together in ed, the patients did not take to their beds, and an infected house and leaving them to their the mortality was less than one per cent. Later fate, are obvious, and there can be little doubt that it was largely responsible for the fearful the disease manifested- itself with violent palpitation of the heart, irregular pulse, vertigo, mortality in individual households to which revomiting of liquid uncoagulated blood, apathy ference has already been made.* The measures adopted by the local and impeand dilated pupils, followed by extreme prostration, violent fever and somnolence, delirium, rial authorities were not put into force until From the 10th of much later, until, in fact, the epidemic had begun constipation and anuria. to decline. Count Loris-Melikof, whose name December were added to these symptoms, in has been already mentioned, had in the meantime some cases, spots upon the skin, varying in size been appointed Governor-General of Astrakhan, from a millet-seed to a ten-copeck piece, or even and it fell to him to execute, if not to devise, The patients had a peculiar odour larger. the measures about to be described. which recalled that of honey, and death followed These with absolute exhaustion of the vital forces. measures, so far as they were directed towards the The corpses did not stiffen, and decomposition safe-guarding of the rest of the empire from the began in from two to three hours. From the spread of infection, were based solely on an 9th of December the rate of mortality increased implicit acceptance of the efficacy of quarantine. from day to da}^ and reached on the 14th of Certain measures of general hygiene and disDecember cent per cent."} The third period of infection, extremely thorough in themselves, were carried out after the 20th of February * In Vetlianka the total mortality from all causes rose to 1879, but it will be obvious from a glance at the its highest point, 169, in the week, December 10th to 16th ; above table that they cannot be credited with in the preceding week it had been ouly 56, and iu the following week it fell to 54. In normal times the mortality in any share in the extinction of the epidemic. The "
the village was less than 1 per week. f These notes are based on the account of the disease written by Dr. Doppner, the sole survivor, as already stated, of those who saw the disease at its worst. He based his account upon his own experience and upon the notes left by his colleagues who died from the disease. J Many of the cases in the first and second period of the epidemic would appear, from the evidence of other authorities. to have been pneumonic in character.
* The sole provision made for nursing the sick was the selection by the villagers of certain old women " well known for their drunken habits," who were alone found williug to undertake the dangerous duty. There appears to have been much panic in the villages and not a little cruelty and inhumanity were displayed as the inevitable result.
THE INDIAN MEDICAL GAZETTE.
368
late in applifor the same reason it is impossible to suppose that they had anything to do with the disappearance of the disease. But they are of sufficient interest in themselves to merit brief description. When Count Loris-Melikof visited Tsaritsyn the Volga on January 20th (February 1st) on he issued orders that a cordon of troops should be placed round every village or locality in which a case ot plague had occurred, and that all communication between such places and the outside world should be cut off, until a period of 42 daj7s had elapsed from the occurrence of the last case. A second cordon of Cossacks was drawn round an area some hundred miles in length and fifteen miles in breadth, including the bed of the Hiver Volga and all the villages in which plague had appeared. In this cordon the were posted at stations three versts (two
quarantine cation, and
measures were
equally
troops miles) apart, a constant patrol being kept up between adjacent stations. A ten days' qua-
rantine was enforced by this cordon. Finally a similar cordon was drawn round the entire governments of Astrakhan and Saratof. In the infected villages themselves, it should be added, all houses in which a case of plague had occurred, and all articles of furniture or clothing which had been in any waj^ exposed to infection, were destroyed by fire. According to the English report upon the epidemic : "The hygienic measures carried out were of the most uncompromising character, and were executed with a vigour which must have left its mark on the villages subjected to them for many years to The quarantine arrangements would, no come. doubt, have been executed with equal vigour, but the outbreak was practically at an end before they were fully established, and the vigour of execution relaxed with the decline and cessation of the urgency." The last case in the Vetlianka epidemic occurred on May 27th, 1879. From that date to the present time Russia and Europe have been free from plague. Literature. 1.
M.
J.
1897.
Galanin,
"
Bubonic
Plague,"
St. Petersburg
2. Vysotski, Lubimof and Kotovshtchikof, " Lectures upon Plasrue, delivered in the Imperial University of Kazan." Kazan, 1897. " Plague and Cholera Epidemics 3. N. K. Shtchepotief, 1884. in the Government of Astrakhan." Kazan, " Bubonic Plague," 4. S. Botkin and G. Skoritchenko. the in Medical Army St. Lectures delivered 1897. Petersburg'. St. Petersburg, '' its Plague, Symptomatology, etc." 5. Y. E. Ignatief, Moscow, 1897. of Russian the of Society Physicians in St. Protocols 6 11 and 12. St. Petersburg, 1879. Petersburg. Nos. 8, 9, 10, Annual Report of the Local 7. Supplement to the Ninth Rppoit and Papers on the Government Board, 1879-80. Recent Progress of Levantine Plague. " The Successes of Science in the 8. J. J. Metohnikof. read Study of Plague and its control.' a paper1S97. at the InSt. Petersin Moscow, ternational Medical
Academy"
.
.
.
_
Congress
?burg,
1897.
.
[Oct.
1898.
F. G. Clemow, "Notes 011 some past Epidemics of in Russia," The Practitioner, October, 1894. " " 10. J. F. Payne, article upon Plague in the British
9.
Plague
Encyclopcedia.
Hirsch and M. Sommerbrodt, " Mittbeilungen im Winter, 1878-9, im russischen Gouvernement, Astrachan." Berliu, 1880. " La Peste du 12. 0. Zuber (French Commissioner), Gouvernement d'Astrakhan en 1878-1879." Paris, 1880. 13. "The Epidemics of the Middle Ages" from the German of J. F. C. Ilecker, M.D., translated by B. G. Babington, M.D., F.R.S., Sydenham Society Publication. London, 1859. 11. A. iieber die
Pest-Epidemie
1898.
PLAGUE EPIDEMICS IN RUSSIA: CLEMOW.
363
and despair, " so from the very beginning have little or no hope for their life." Some Historical Notes. 6. " The most important sign and symptom By FRANK G. CLEMOW, M.D., D. P. H. in the infection is a great and rapidly developLate Medical Officer in charge of the British Seamen's ing ivealcness of the whole body and all the Hospital, Cronstadt, St. Petersburg ; Secretary for Russia to the Epidemiological Society of London; members." This extreme weakness sometimes Honorary Member of the Russian National ushered in the attack. It was often accompanied Health Society ; etc. : by trembling of the hands and feet, so that Medical Officer on Special Plague Duty, Calcutta. the patient could not stand, and sometimes by {Continued from p. 336.) fainting. Suddenly, developing weakness and trembling of the limbs, without any other Of not less value than his account of the rise were deemed sufficient to arouse sussymptom, and course of the Great Plague of Moscow and On the other hand, there were a few picion. of the measures employed to deal with it, is who persons passed through an attack of the Shafonski's description of the clinical aspect of plague without any marked weakness and the disease. The description is, indeed, of unwithout even taking to their beds.* usual value, for it bears clear internal evidence the voice, ascribed by the based was that it entirely upon the author's own 7. Weakness of author to weakness of the tongue. "In some and as is the case with observation, not, personal the speech is unintelligible and disordered, as so many of the older medical writers, upon mere the tongue were frozen or bitten, or like and tradition. It will be of interestthough authority the speech of a drunken man; many are either to quote, of necessity in a condensed form, the unable to put out their tongue or and altogether of which list he gives and symptoms signs shew it with difficulty." to compare them with those of plague as recently 8. Diarrhoea, occasionally very profuse, ocmanifested in India. His definition of the disease runs as follows: curred in some cases. Sometimes it was so severe " that no remedy was able to check it, and in Plague is a disease sui generis, more dangerous such cases it was the direct cause of death. than all other diseases, highly contagious, and 9. Haemorrhage, generally from the nose or the external signs upon producing body, viz. : buboes, carbuncles and large and small blackthroat and frequently fatal. 10. Delirium, coming on with the invasion spots (petechice); for the most part endingor later. " In some there is such a frenzy that death." in rapidly to bind the person; but is needful it sometimes of the disease were the The signs and symptoms this is very rare." in the head and Pain heaviness. following:?1. 11. "In some is observed a desire for food, In some the pain is cruel, in others it is not so when they suddenly feel themselves particularly in are some the red and dim, eyes great; usually however hopeful it may this better; symptom, swollen, while some have the appearance of foretells a rapid end. It seem, generally drunken men." The pain in the head was not often happens that those who are ill of the plague and was so in a absent prominent single case, just before death have no sufferings or signs of a symptom that "many of the common people the end, but die almost without any visible movecalled it the head disease." ment of the body. This occurrence deceived 2. Chill and shivering, such as is found in at the beginning of the Moscow In some this symptom was not marked, many physicians fevers. who found the sick without notable weakPlague, in in the and severe cases, some, particularly ness and in no visible danger, but in a short time there was no rigor." these same persons were in extremis and died. 3. "After the chill quickly follows heat, the end talked considerably which in many is felt most internally, and in Many just before and even moved about, so that death seemed many both externally and internally, and lasts to be far from them, but suddenly and without as in any other cruel fever; the tongue is at the any change they died." same time dry in some, in some yellow and as 12. "In many it is noticed that they sleep though covered with glue, while in some it through almost the whole course of the illness differs little from the natural tongue." and die with scarcely any motion of the body; 4. Nausea and desire to vomit, and in many and it is generally observed that these have a actual vomiting. This was a very frequent and despairing look." symptom, which sometimes came on with the grievous Such were the general symptoms of plague as rigor and was sometimes delayed a little. seen in The local signs were the Moscow. "Vomiting is generally severe if the person who becomes infected shall eat soon after, or has following:? 1. "Black or rather livid spots, called eaten so recently before becoming infected that marushki (petechias), which are found on all the stomach has not had time to digest the food ; but even those who have eaten nothing are no * The pestis amhulans of modern writers. less prone to vomit, and many throw up a green or fluid." yellow PLAGUE EPIDEMICS IN RUSSIA
:
5. that
Anxiety, distress, fear
some
"
...
"
364
THE INDIAN MEDICAL GAZETTE.
[Oct.
1898.
parts of the body, but particularly on the breasts, the neck, the arms, and the belly; the size of a
other hand, the pest begins with buboes alone, without visible fever or other symptoms." The other symptoms usually came on sooner or later, poppy-seed or of a pea, or in some larger These spots appear in some soon after the onset though a few escaped with nothing more than of fever; and in many the body is as though the buboes. After describing the points in covered with the bites of fleas, which grow in which these buboes differed from those of venesize from hour to hour; in many they appear real disease, Shafonski adds that they sometimes " on the second day or later, and in some after In many," he continues, lasted only two days. death, and do not disappear from the dead body." it is long before they can be brought to an 2. "The very first and most decisive exterabscess, as the fever passes before the bubo is nal sign of the plague is a black boil, called a mature; and if it is already so mature that it carbuncle (carbunculus, anthrax). It may ap- is time to cut it, then, although on opening it the ripest matter flows out, yet generally the pear on any part of the body without exception, and always begins with a burning pain, as is not changed into pure matter, but comes gland though the body had been burnt, after which away like thick tallow; and if the gland do there soon appears at that spot a livid blister, not wholly come away, then the wound is long At first many from filled with a thin fluid. in healing and sometimes leaves a hole or fistula. ignorance, and others purposely, ascribe these Buboes under the arms also heal slowly' If the blisters to an actual burn, especially those who bubo was behind the ear or in the neck the The have steamed themselves in the baths. patient almost always died. bladder is at first very small, like an ordinary 4. "Wheals (vibices) and blue spots, large and pimple, but from hour to hour becoming larger small, as though the body had been beaten. and. more prominent, and around, it the body Although rarer than the former signs, yet these becomes red ; in some it rises in the course sometimes occur, from blood being poured out of a day or more, in some in a few hours, and under the skin, mostly on the back and legs; then bursts, or the patient himself, lying in generally before death, but after it in those fever, crushes it. As soon as the blister breaks who die rapidly." and the fluid escapes, then under the cuticle Neither age, sex, nor social condition was any a black spot, as though burnt, level with safeguard against the infection. Some persons, the surface of the body, is presented to the it is true, though in close and prolonged proxieye; in some the size of a polushka* and mity with the sick, escaped an attack, but such in some as big as the palm of the hand. This instances were rare. "In general it was observed sign, which is like a St. Anthony's fire turned that the young sickened more readily than the old, into a black and burnt spot, is called from its women than men, those of the moist constitution blackness a carbuncle; the burnt part is hard, than those of the dry, and the lower classes thau extends deeply and has no mature pus and no the well-to-do." Relapses were extremely rare. feeling, so that on cutting it with a knife or These were the principal clinical features of applying to it the most acrid drugs, there is no plague as recorded by a shrewd and careful pain whatever, only the living parts around observer nearly 130 years ago. Space will not feeling it. Not a single part of the body is allow of their full discussion here, but it may be exempt from these carbuncles; in many they noted that, with a few exceptions, the list of occur on the face, and, because of the gravity of symptoms closely corresponds with those of this position, there is then little hope of replague as recently observed in India. The headcovery. In many there is only one, in others ache, dimness and redness of the eyes, the rigor there are more than one or two in different and fever, the dry and loaded tongue, the tenparts of the body. At the worst period of the dency to vomit, the great depression and prostraMoscow Plague, particularly in the months of tion, the affection of the speech, the delirium, August and September, carbuncles were more the drowsiness, the buboes and carbuncles,"*? commonly noted than the other external signs, with all these signs and symptoms recent outand the sick in consequence more frequently breaks of plague have rendered modern observers died; it was very rare for one who had car- familiar. Where, however, Shafonski's descripbuncles not to take to his bed." 3. "Swellings at the site of glands, or tu* Compare Boghurst's list of diagnosticks" of the plague mours, called Buboes (bubones), which are usu- as seen in the Great Plague of London : 1. Shuddering cold at first falling sick. ally in the groins, less often under the arms, 2. Frequent vomitting, or at least retching to vomitt. and still less often behind the ears. They come 3. Headiich, dizziuess and lightness of the head. at different times; in some on the first day of Heate and thirstiness. 4. 5. Bleeding at the nose and sometymes at mouth, the fever, and in others on the second or third hemroids and menses. day; while in some nothing is^seen save fever 7. Great inward heate and outward cold. for as much as ten days; but in a few, on the 8. Carbuncles, buboes, blaines, blisters, spotts risein g on the body. * JPolvshha, a minute obsolete coin, of the value of 9. Distraction, staring, frenzy, idle talke. about one-sixieenth of a penny. 10. Drowsiness and sometymes continual watching. ....
"
"
"
?
?
Oct.
1898.]
PLAGUE
EPIDEMICS
IN RUSSIA: CLEMOW.
perhaps unique
in
365
of plague. It is in wliat respect the blue from the petechias already dewill not permit of a further discussion of the Russian author's description of plague,* and with the brief statement that he makes no mention of the occurrence in Moscow of a pneumonic form of plague nor of any coincident affection of rats or other lower animals, the Great Plague of Moscow (already perhaps discussed at rather more than due length) must be dismissed, to make way for a brief account of some more recent epidemics. During the present century plague has visited Russia on more than one occasion, though never with any great severity or over a wide area.*f* In 1807 it spread from Persia to the Caucasus, and thence to Astrakhan and Saratof on the Yolga. This was an exceedingly mild outbreak, and was the cause of only 101 cases and 91 deaths in all. In 1828 the Russian Troops in Wallachia were attacked with plague, and in July of the same severe epidemic occurred at a rather year the taking of Kars by the Russians. According!to one authority more than one-tenth of the inhabitants of that town fell victims to the plague ; according to another there were in the town 2,24G cases with 2,197 deaths (a mortality one large slough, leaving a deep, lagged, pus- of about 9S per cent.), while among the Russian secreting cavity, often very slow in healing. garrison there were 381 cases with only 142 Shafonski's description of "carbuncles" does deaths (a mortality of less than 40 per cent.). not, it will be observed, correspond in its entireIn 1838 a limited outbreak occurred in Odessa, t\r with any of these lesions, though it has and between 1839 and 1843 a few isolated points in common with each of them. The de- epidemics occurred in different parts of Transscription of the buboes scarcely needs comment; caucasia. For the past 55 years Russian soil but the mention of vibices\ is remarkable, and has been quite free from plague, with the singel 12. Dissolution of strength. but important exception of the circumscribed 17. The tongue presently furred aU over with white outbreak on the lower reaches of the Volga, fur. known as the Vetlianka epidemic, ?" Loimograpliia, or an Experimental Relation of the generally from the the village which suffered last name of in the Remarkable what hatli Plague, of happened Plague in the City of London." by William Boghurst, London, most severely. Though small in itself and quite 1566. For the first time printed in full in the Transactions localised this epidemic derives an importance of the Epidemiological Society, Vol. XIII, 181)3-4. from the fact that it was the last occurrence of *In the definition of the disease already quoted it will be observed that the Russian author the buboes first plague in Europe.^
tion of the disease differs from that of the plague as seen in Bombay is principally i" the following points. The black spots or petechias, so common in the Moscow Plague as to be given first place in the list of external signs,* were of the rarest occurrence, if indeed they occurred at ajl in Bombay."f* The description of the socalled carbuncles" does not, it will be noted, at all correspond to the definition of carbuncle as that word is specifically applied in modern medicine. It may, indeed, be questioned whether true carbuncle ever occurs as a symptom of plague. In the present writer's experience the principal local lesions in plague, apart from the buboes, would appear to be the following:? (1) Collections of purulent or sero-purulent or sanguineo-purulent fluid, on an inflamed base, which on bursting or being opened, leave a slowly healing ulcer; (2) patches, varying much in size, of necrosis of the skin, sometimes but not always occurring where irritants (such as the native marking-nut) have been applied, sometimes as the result of pressure (as over the sacrum or occipital protuberance), sometimes idiopathieally, with 110 obvious local cause ; and (3) a necrosis of the skin over a bubo and of the bubo itself, both skin and bubo separating as
not
easy to
quite spots differed scribed. Space "
descriptions
"
see
"
places
among the external signs of plague, a course which modern observers would certainly be inclined to follow. The black " tokens" spots or petechias are obviously the same as the so prominent in accounts of the Great Plague of London. is a iu recent Their marked absence striking epidemics bat undoubted fact, in in was which I charge of the f During ten weeks Parel Plague Hospital, Bombay. 502 cases of plague were admitted to the wards, in addition to 162 patients already in hospital at the time of my taking it over. Among these 664 patients, in only two did there occur a dusky rash which raised a suspicion of its being possibly petechial in character. A much longer acquaintance with the appearances of rashes in a dark skin than I possessed would have been necessary to determine accurately the nature of the rash, and I have since kept an open mind on the question, with a tendency, however, to regard the spots seen in these two cases as other than petechial in character. The deeper haamorrliages so often found around buboes, and on mucous and serous membranes iu plague cadavers form, on the other hand, a strong a priori argument in favour of the probability of petechial rashes occurring. | TIbices were not observed as a symptom of plague in a single case in Parel. An urticarial rash did, however, occur in one out of fifty patients subjected (unsuccessfully; to
the serum treatment. I regarded it as an effect of the rather than as a manifestation of plague. The comparative prominence given by Sliafonski (and by others of the older writers upon plague) to vomiting, diarrhoea and hemorrhages as symptoms of plague would have afforded interesting points for discussion did space allow. All. in my experience, occur in plague, but, with the exception of the first, neither frequently nor with great se verity, and I have never seen either diarrhoea or hajinorrhage the direct cause of death. Diarrhoea has been more frequent in the early stages of the cases I have seen in Calcutta than in the cases observed in Bombay. f In an article upon the Plague in India receutly published in the Nineteenth Century, it is regrettable that the otherwise well informed writer has been led to make the sweeping assertion that plague is endemic in Russia, "sometimes of a mild type, but more often virulent.' The facts stated in the text will suffice to refute this statement ; and I have failed to find any authority upon which it could have been based. " 4< should perhaps be auded. J In an epidemic form Three suspicious cases occurred, it will be remembered, upon ships coming from India to the Thames in the autumn of 189G.
serum *
b.
36G
THE INDIAN MEDICAL GAZETTE.
The origin of the Vetlianka epidemic has never been quite cleared up. It is worthy of note that it coincided, like so mail)' of its predecessors, with a war between Russia and Turkey. The late Professor Botkin, of St. Petersburg, was of opinion that plague was present in the army of the Caucasus in the autumn of 1877, for Count Loris-Melikof, who was in command, wrote at that time that a great mortality was prevailing among the troops from a disease described as typhus fever with buboes," and that 75 or 80 per cent, of the cases proved fatal. The fact that this disease was not spread widely throughout Russia when the troops were dispersed was attributed by Botkin to a supposed immunity of the country to the infection of plague. An indication of the presence of the infection in a mild form might, he thought, be found in a tendency, noted at the time, to a prevalence of glandular swellings among patients seen in St. Petersburg and other places. However this may be the fact remains that, with the exception of some suspicious cases near Astrakhan in 1877, and one or two doubtful cases in the governments of Nijni Novgorod, Riazan and Taurida, and in the towns of Odessa and St. Petersburg,* the actual outbreak of plague was confined to some half dozen Cossack stanitzas, or villages, in the government of Astrakhan and lying on either bank of the River Volga. Much doubt and obscurity hangs over the early period of the outbreak,! for, with one exception, the entire medical and sanitary staff, from whom alone a trustworthy history of the outbreak could have been obtained, all caught the ^ disease and died from it. Three medical men (Drs. Koch, Morozof and Grigorief), sixfeldschers, or trained hospitals attendants, and a brother and sister of charity were among the early victims of the epidemic. Dr. Doppner was the sole survivor of this devoted band, and it is on his evidence that later writers upon the epidemic have based their account of its origin.
...
*
in St.
Petersburg-,
which Botkin regarded as one of true plague, and some other equally suspicious cases which followed it, may be found fully recorded and discussed in the Protocols of the Society of Russian Physicians in St. Petersburg. Some reflection may also there be found of the intense excitement which in the capital. The this case appears to have aroused popular dissatisfaction at Botkiu's expression of opinion nature of the the case was answered as to by a special meeting- of the Society and the presentation to him of addresses of both from the Society enthusiastic confidence, and from the profession generally. most accurate accounts of this epidemic are those The | of the Foreign Commissioners who visited the scene of the epidemic, too late to see any typical cases, but not too late to collect valuable cotes and recent impressions from observers The Russian Government, it should be exon the spot. other European Governments to plained, invited each of the send Commissions to investigate the epidemic on the spot, and the invitations were largely responded to. The British Commissioners were Drs. Colvil 1 and Payne. A summary of their report and of those of the other Commissions will be found in the supplement to the Ninth Annual of the Medical Officer to the Local Government The
Report Board.
suspicious
case
The first
[Oct.
1898.
appears to have occurred in October 3rd (15th) 1878, when an old man, named Agap Kharitonof, is said to have fallen sick shortly after opening a packet which he had received from his son in Asiatic Turkey.* According to another account this patient died, not from plague, but from pneumonia, the result of chill and exposure while fishing on the Volga, and the first case was therefore that of a young girl, a member of the same household.*}" All authorities are agreed that the plague spread first in this household and thence to other households, and finally to other villages along the banks of the river. The first case outside Vetlianka was in the .village of Prishib, some seven miles distant, where a woman named Arina Ephraimof, who had stayed in Vetlianka from November 30th to December 3rd, returned to Prishib on the latter date, and sickened two days later, dying on the 11th. Of eight other members of her household seven caught the disease and died. This sequence of events was repeated on many occasions in this
Vetlianka,
case
on
epidemic. The Yolga plague seems to have been essentially a house or family disease, carrying off entire households when it had once gained a footing in them, but shewing little tendency to spread widely or (with the exception of Vetlianka) to attack many households. In Yetlianka almost
one-fourth of the population and rather more than one-fifth succumbed to the epidemic. Elsewhere, as the following table will show, the proportion of cases and deaths to the population was infinitely smaller were
exactly
attacked,
Statistical Table of the Vetlianka Epidemic, 1878-79. Duration of epidemic.
Name of
Village. Vetlianka Prishib Stavitzkoe
...
Selitrianoe
...
Udatclinoe
...
Michael ovskoe
17th Oct. 1878 to 27th May 1879. 5th to 24th Dec. 1878. 15th Dec. 1878 to 5tli Jan. 1879. 19th Dec. 1878 to 19th Jan. 1879. 13th Dec. 1878 to 18th Jan. 1879. 15th Dec. 1878 to 7th Jan.1879.
Totals of
cases
Popula- Cases. Deaths. tion. 1,837
453
372
3,523
16
16
2,155
8
8
2,499
32
30
8G0
2
2
668
4
3
515
431
and deaths.
Compare the well-known story of the introduction of plague into the village of Eyam in Derbyshire in 1665 by a parcel of infected clothes sent from London ; and many other similar instances throughout plague literature. Con*
siderable
doubt
plausible
as
of
necessity attaches to these stories, appear. More recent experience would fomites that show seem to play little, if any, part in spreading plague over long distances, or from country to country. f The English Commissioners give the 17ch (29th) of October as the date of the first case of plague in Yetlianka.
they
Ocr.
1898.J
PLAGUE EPIDEMICS IN RUSSIA: CLEMOW.
367
It will be observed that the epidemic fell the epidemic was marked by a gradually diminprincipally in the late months of 1878 and Janu- ishing mortality. According to the English ary 1879, that is to say in almost, but not quite, Commissioners "in the third period of the outthe coldest period of the year.* In this fact?? break?the period of decline?the disease retained the character which it had presented in the a fact curiously little dwelt upon in the literature of the epidemic?may in all probability be found second period of its progress (the period of the explanation of the peculiar character and culmination), the acuteness of the symptoms and behaviour of this epidemic, in displaying the the rapidity of course sensibly abating; while utmost intensity and virulence in individual the indications of pathological changes in the households, while not spreading over any very glandular system, which had been rarely oblarge area. At that time of year the degree of served and no doubt in great part overlooked cold, though not so extreme as in January or during the acme of the outbreak, again began Februaiy, would be very great. Fishing, the to appeal-." But little space is left to discuss the measures staple industry in those regions, and other out-door labour, would be at an end, and the taken to meetand control the Vetlianka epidemic. villagers would spend most of their time inside They appear to be divisible into two groups? their huts, around or even upon the stove. In measures adopted by the villagers themselves and other words, the conditions would be such that measures put in force at a later period by the local contact and communication between individual and imperial authorities. The measures adopted members of a household were at their maximum, by the villagers themselves appear to have conwhile communication between neighbouring sisted mainly in an attempt to isolate every house households or neighbouring villages was at its in which a case of plague occurred, and completely cut off all communication between the inmates minimum. With regard to the symptomatology of this of this and of adjoining houses. The effort, epidemic it has to be noted, for reasons already though crude, seems to have been fairly stated, that but little is known of its clinical thorough. In Vetlianka it was put into execuaspect while the epidemic was at its height. tion too late to be of any use; but in the other There would appear, however, to have been villages there seems reason to believe that this three distinct periods, in each of which the measure, aided by the climatic and social condisease presented different characters.! In the ditions already referred to, was of some service in earliest period the cases presented a mild remit- checking the spread of infection. The crudity and cruelty, however, of a measure which tent or intermittent fever, the lymphatic glands of groin or axilla became enlarged and suppurat- consists in shutting up sick and well together in ed, the patients did not take to their beds, and an infected house and leaving them to their the mortality was less than one per cent. Later fate, are obvious, and there can be little doubt that it was largely responsible for the fearful the disease manifested- itself with violent palpitation of the heart, irregular pulse, vertigo, mortality in individual households to which revomiting of liquid uncoagulated blood, apathy ference has already been made.* The measures adopted by the local and impeand dilated pupils, followed by extreme prostration, violent fever and somnolence, delirium, rial authorities were not put into force until From the 10th of much later, until, in fact, the epidemic had begun constipation and anuria. to decline. Count Loris-Melikof, whose name December were added to these symptoms, in has been already mentioned, had in the meantime some cases, spots upon the skin, varying in size been appointed Governor-General of Astrakhan, from a millet-seed to a ten-copeck piece, or even and it fell to him to execute, if not to devise, The patients had a peculiar odour larger. the measures about to be described. which recalled that of honey, and death followed These with absolute exhaustion of the vital forces. measures, so far as they were directed towards the The corpses did not stiffen, and decomposition safe-guarding of the rest of the empire from the began in from two to three hours. From the spread of infection, were based solely on an 9th of December the rate of mortality increased implicit acceptance of the efficacy of quarantine. from day to da}^ and reached on the 14th of Certain measures of general hygiene and disDecember cent per cent."} The third period of infection, extremely thorough in themselves, were carried out after the 20th of February * In Vetlianka the total mortality from all causes rose to 1879, but it will be obvious from a glance at the its highest point, 169, in the week, December 10th to 16th ; above table that they cannot be credited with in the preceding week it had been ouly 56, and iu the following week it fell to 54. In normal times the mortality in any share in the extinction of the epidemic. The "
the village was less than 1 per week. f These notes are based on the account of the disease written by Dr. Doppner, the sole survivor, as already stated, of those who saw the disease at its worst. He based his account upon his own experience and upon the notes left by his colleagues who died from the disease. J Many of the cases in the first and second period of the epidemic would appear, from the evidence of other authorities. to have been pneumonic in character.
* The sole provision made for nursing the sick was the selection by the villagers of certain old women " well known for their drunken habits," who were alone found williug to undertake the dangerous duty. There appears to have been much panic in the villages and not a little cruelty and inhumanity were displayed as the inevitable result.
THE INDIAN MEDICAL GAZETTE.
368
late in applifor the same reason it is impossible to suppose that they had anything to do with the disappearance of the disease. But they are of sufficient interest in themselves to merit brief description. When Count Loris-Melikof visited Tsaritsyn the Volga on January 20th (February 1st) on he issued orders that a cordon of troops should be placed round every village or locality in which a case ot plague had occurred, and that all communication between such places and the outside world should be cut off, until a period of 42 daj7s had elapsed from the occurrence of the last case. A second cordon of Cossacks was drawn round an area some hundred miles in length and fifteen miles in breadth, including the bed of the Hiver Volga and all the villages in which plague had appeared. In this cordon the were posted at stations three versts (two
quarantine cation, and
measures were
equally
troops miles) apart, a constant patrol being kept up between adjacent stations. A ten days' qua-
rantine was enforced by this cordon. Finally a similar cordon was drawn round the entire governments of Astrakhan and Saratof. In the infected villages themselves, it should be added, all houses in which a case of plague had occurred, and all articles of furniture or clothing which had been in any waj^ exposed to infection, were destroyed by fire. According to the English report upon the epidemic : "The hygienic measures carried out were of the most uncompromising character, and were executed with a vigour which must have left its mark on the villages subjected to them for many years to The quarantine arrangements would, no come. doubt, have been executed with equal vigour, but the outbreak was practically at an end before they were fully established, and the vigour of execution relaxed with the decline and cessation of the urgency." The last case in the Vetlianka epidemic occurred on May 27th, 1879. From that date to the present time Russia and Europe have been free from plague. Literature. 1.
M.
J.
1897.
Galanin,
"
Bubonic
Plague,"
St. Petersburg
2. Vysotski, Lubimof and Kotovshtchikof, " Lectures upon Plasrue, delivered in the Imperial University of Kazan." Kazan, 1897. " Plague and Cholera Epidemics 3. N. K. Shtchepotief, 1884. in the Government of Astrakhan." Kazan, " Bubonic Plague," 4. S. Botkin and G. Skoritchenko. the in Medical Army St. Lectures delivered 1897. Petersburg'. St. Petersburg, '' its Plague, Symptomatology, etc." 5. Y. E. Ignatief, Moscow, 1897. of Russian the of Society Physicians in St. Protocols 6 11 and 12. St. Petersburg, 1879. Petersburg. Nos. 8, 9, 10, Annual Report of the Local 7. Supplement to the Ninth Rppoit and Papers on the Government Board, 1879-80. Recent Progress of Levantine Plague. " The Successes of Science in the 8. J. J. Metohnikof. read Study of Plague and its control.' a paper1S97. at the InSt. Petersin Moscow, ternational Medical
Academy"
.
.
.
_
Congress
?burg,
1897.
.
[Oct.
1898.
F. G. Clemow, "Notes 011 some past Epidemics of in Russia," The Practitioner, October, 1894. " " 10. J. F. Payne, article upon Plague in the British
9.
Plague
Encyclopcedia.
Hirsch and M. Sommerbrodt, " Mittbeilungen im Winter, 1878-9, im russischen Gouvernement, Astrachan." Berliu, 1880. " La Peste du 12. 0. Zuber (French Commissioner), Gouvernement d'Astrakhan en 1878-1879." Paris, 1880. 13. "The Epidemics of the Middle Ages" from the German of J. F. C. Ilecker, M.D., translated by B. G. Babington, M.D., F.R.S., Sydenham Society Publication. London, 1859. 11. A. iieber die
Pest-Epidemie
