The Plague.
Synonyms:—Bubonic plague; black death.
Definition:—This disease, which as yet has had no foothold in our country, is characterized by a violent, malignant inflammation of the glands, especially those of the groin, axilla or neck. The disease is acute in character, of specific origin, depending upon the development of the bacillus pestis; is infectious and contagious. High fever is present at first, and certain cutaneous symptoms are pathognomonic. This is a disease of Oriental countries and has as yet prevailed to no great extent elsewhere.
Etiology:—Kitasato and Yersin have demonstrated the presence of the bacillus pestis bubonicae as the especial cause of this disease. The germ causes the development of the disease in insects, vermin, and in domestic animals and fowls, as well as in man. Extreme filth and unsanitary, unhygienic conditions prevail wherever there is an outbreak. While male adults are more liable to become inoculated with the disease, it attacks all ages of both sexes.
Mode of Infection:—The original theory that the germs of this disease were inhaled and taken in with the food has not been substantiated as yet. Direct infection from the bites of insects or vermin and infection through skin abrasions and slight wounds cause this disease. Flies and fleas are thought to carry the infection from rats and other infected animals to man. Ants, mosquitos doubtless, and other insects may act as carriers also.
Symptomatology:—The Plague Commission recognized two forms of this disease, one affecting the lymphatic glands primarily and the other the lungs. Another classification recognizes four varieties. First. The usually predominating form, which presents a long train of severe acute symptoms, with local glandular involvement after the second or third day. Second. The septicemic form, in which symptoms of acute septicemia prevail, affecting the entire glandular system. Third. The pneumonic form, in which acute pulmonary inflammation occurs as the result of the infection. The glandular system does not escape in this form, but the involvement is not usually pronounced and often is not apparent except upon post mortem examinations. Fourth. The larval plague. This involves groups of glands directly, the buboes appearing without the accompanying constitutional evidences of the first variety, but little, if any, fever or other symptoms, except exhaustion.
The prodromal symptoms of a typical case of the bubonic form of the plague are few, and are seldom long continued. The direct symptoms are, first, an attack of fever, with but little, if any, chill. With the fever there is vertigo and a sudden and very severe headache, nausea, vomiting, lassitude, drowsiness, with a dull, stupid look on the face, pain in the limbs and back, and a staggering, uncertain gait, as if intoxicated.
At the end of a few hours there is an abrupt increase of the temperature from 103° to 105° or 106° F. The pulse is variable in character and force, but is apt to be small, rapid and thready.
With this, evidences of serious illness quickly appear. The patient exhibits extreme anxiety, the vomiting increases, the face becomes swollen and engorged or flushed. The tongue becomes dry and covered with a brown and later a black fur, and the teeth with sordes, and there may be sudden exhausting diarrhea. The prostration of the patient, which is at once apparent, has no relationship to the duration of the disease, and is quickly accompanied by mental dulness, stupor follows, and delirium, finally low and muttering and ultimate coma, which is usually of uremic origin. So great is the sudden debility in some cases that it amounts to a complete collapse, and death occurs without reaction. Thus far evidences of glandular involvement are not conspicuous, but if the collapse does not occur, or is survived at a period from two to five days after the onset, the lymph glands become involved, usually the inguinal glands first. The usual evidences of acute inflammation are all present in an aggravated form in the glands, pain being conspicuous. In some cases inflammation terminates by slow resolution, in others the glands become greatly enlarged and no change occurs until death. In still others there is suppuration. It is desirable after the stage of possible resolution is passed that free suppuration occur, especially if the pus be foul smelling in character. If there is but scanty escape of sanious or watery pus the virulence of the disease does not abate. In some few cases the buboes assume the appearance of carbuncles and terminate in gangrene. Skin complications are not unusual; petechiae, pustular eruptions, gangrene of small circumscribed areas, and small carbuncles occur. A hemorrhagic diathesis is a common complication, from which hemorrhages from the nose, lungs, stomach, intestines and kidneys occur.
If the case is fatal and the patient survives the original collapse, the end occurs on the third, fourth or fifth day. If the disease is prolonged beyond this time the chances for recovery are good, but the convalescence will be greatly protracted.
If the infection expends itself upon the respiratory passages, as in the pneumonic form, the symptoms are those of acute, sudden and extremely severe inflammation of the lungs, with a copious watery sputum, rusty colored or distinctly streaked with blood. Children are more susceptible to this form, to which they usually quickly succumb.
In the septicemic form there is an absence of the evidences of local glandular involvement (buboes), but there is general glandular inflammation. There is a more general septicemic condition with the usual evidences of persistent fever and rapidly increasing debility. These cases are usually hemorrhagic in character.
The larval form prevails usually when an epidemic is abating. The general constitutional symptoms are not conspicuous, but the local bubonic invasion is severe, but is quite amenable to local treatment. The mortality of this form is not high.
Prognosis:—The death rate has been universally high in the Orient, ranging from fifty to eighty or ninety per cent in prevailing epidemics. The severity depends upon the social and sanitary or hygienic conditions of those attacked. With the best possible conditions among civilized peoples the mortality may not be above fifteen per cent.
The mortality of the pneumonic cases is higher than that of the other types, that of the septicemic next in severity, the bubonic next, and the larval form the lowest.
Treatment:—No specific course has yet been adopted for the cure of this disease. The treatment has been symptomatic and general. The removal of the patients to sanitary environments is imperative. The indicated remedies are as follows: For the acute fever, aconite in small frequent doses for a few hours, then followed by bryonia, with frequent cool sponging for the high temperature is essential. The above remedies must be given in conjunction with phytolacca and echinacea, and the two latter remedies should be continued throughout the entire course of the disease, the former in five-minim doses and the latter in from fifteen to thirty-minim doses every two hours. Belladonna should be given in frequently repeated drop doses of the tincture during the congestive period. Echinacea three parts, Phytolacca one part, should also be applied freely from the first over the glands, which become involved, by saturating gauze, and covering with rubber protective. As soon as there is marked inflammation in a single gland or group of glands ten minims of echinacea should be injected hypodermically into the surrounding tissues or directly into the gland substance, and the external application continued. The echinacea may be injected in three or four localities at the same time. Future injections may or may not be of service. If needed, there will be an abatement of the symptoms from the injection, with an exacerbation later, when the injection may be repeated.
If resolution of the local inflamed glands does not quickly occur, suppuration must be encouraged by dressing them with a gauze mass kept saturated in a full strength boric acid solution or a ten per cent carbolic acid solution, and best applied hot and covered with rubber protective or oiled silk and kept hot. They must be freely opened upon the least presentment of the presence of pus.
Other of our remedies that should be of service in this disease are veratrum in five minim doses four times daily when sthenia prevails and no heart weakness threatens or berberis, which will be indicated if the skin symptoms predominate. If petechia prevails it should be given with small dose of belladonna, and capsicum may be applied externally. Baptisia if extreme sepsis, and blood depravations are plainly apparent, and podophyllum, may be given, with acetate of potassium, for their influence on glands, if no diarrhea or renal complications exist. Pipsissewa should be of much service. Dr. Fox of Connecticut has much confidence in it as a superior alterative in glandular disease. Iron is important, not only in convalescence, but during the course of the attack. Another remedy that has been used to much advantage is carbolic acid. This has been given by the mouth until some mild physiological symptoms were induced, with good results. Thompson gave as high as twelve grains every two hours. In collapse, three grains in hot physiological salt solution should be given by hypodermoclysis, or in smaller quantity of the solution, five grains could be given twice daily, or one grain in proper solution could be injected into the tissues immediate to inflamed glands in several localities three or four times within twenty-four hours, or into the gland itself, with no harm. Hypodermic injections would be more directly fatal to the bacillus in much less dosage than would be the case if the agent were given by the mouth.
The results of the antitoxin treatment of the plague have not as yet been satisfactory. There is enough to encourage a strong endeavor to perfect the treatment with the belief that it will ultimately be of universal application.
