(2). All private and public latrines and public urinals should be cleaned and disinfected daily. All receptacles used for night-soil either in the latrine or for transport should be daily disinfected.
(3). Latrine accommodation, according to the requirements of the population, should be provided.
(4). Drains should be well washed and flushed with a disinfectant solution. In towns where there is an underground sewer, it should be well flushed and ventilated, and a disinfectant solution used for cleaning it. A house-to-house examination should be made to ascertain that all house-connections are properly and efficiently trapped. Deposits in the sewer should be taken out and suitably disposed off after disinfection.
(5). Special attention for cleansing should be given to the following:—
Cesspools, privies, cow-houses, stables, slaughterhouses, markets, workshops, common lodging houses, serais, bustees, and crowded quarters of a town.
(6). All public roads should in the dry season be watered with a weak disinfectant solution.
(7). Pure drinking water should be supplied. All articles of food should be inspected. Musty and decomposing grains should not be allowed to be sold. The meat market, dairies and bakeries should be under strict sanitary supervision.
(8). Over-crowding in houses should be prevented. Steps should be taken for spreading out the population of much over-crowded and congested parts of towns.
(9). Lime in a dry state and in solution should be abundantly used in drains, &c.
(10). All railway carriages travelling through infected areas should be daily washed with a reliable disinfectant solution, such as 5 per cent. carbolic acid.
(11). Railway platforms, waiting rooms and halls, and latrines should be frequently cleaned and disinfected.
(12). There should be a system of house-to-house inspection to ascertain the sanitary condition of dwelling-houses, and also to find out, as far as possible, the condition of health of the inmates.
Common lodging houses, serais and houses of a similar nature should be most carefully examined.
(13). If plague breaks out, then isolation of cases is a great necessity. When practicable, such isolation may be done in the house of the patient. The patient should be kept in a separate room apart from those where other inmates of the house live. A temporary room could be put up on the roof of a house or in the compound, if there is any, or a tent may be pitched. Where possible, all healthy inmates of the house should at once remove themselves in camp leaving only such near relatives who must attend and nurse the patient. For patients living in lodging houses, or, where there is no means of such isolation as stated above, segregation in special isolation hospitals should at once be done. The isolation hospitals should be separate for each of the following classes—(a) for lower class people; (b) for middle class people; (c) for such people of the middle or upper class who may chose to pay for their expenses. It is needless to say that there should be special hospitals for women, where onlyfemale attendants and nurses should be employed. Hospitals should be provided with means for free ventilation, both for the sake of patients as well as attendants. No other disease requires more careful nursing than the plague, therefore ample nursing staff should be provided. The hospitals should have a separate observation ward and a separate convalescent ward, and by no means doubtful cases should be mixed up with confirmed cases. Disinfecting apparatus, sterilizers, good water supply and special laundry are other adjuncts essentially necessary for a plague hospital. Greatest care is required in the management of such a hospital, and only trained men should be employed.
Suitable means for ambulance should be provided, and should be had ready within convenient distances. They should be thoroughly disinfected after the conveyance of any case. Ambulance carts or doolies should be comfortable, for physical exertion and exhaustion, attending a long journey in the early stage, greatly compromise chance of recovery.
Burial within inhabited areas of a town or village should be stopped. Dead bodies should be removed under strict precautions for disinfection and disposed off quickly. Bodies should be buried deeply—4 to 6 feet.
I. Houses and compounds, stables, kitchen and outhouses should be thoroughly cleaned, and they should be whitewashed with lime. Air-tight dustbins should be kept in the house.
II. Rooms, specially bed-rooms, should be well ventilated, attention should be paid to the conditionof the floor, which should not be damp, and care should be taken that rats may not infest the house and spaces under the floor. If dead rats are found in the house, they should be removed and burnt, and the place thoroughly disinfected.
III. House drains should be cleaned and well flushed with a disinfectant solution.
IV. Nowhere in the house or compound should any kind of organic refuse be allowed to accumulate. Better not use any organic manure in the kitchen garden or house garden during an epidemic.
V. Articles of food should not be allowed to remain uncovered on the table or elsewhere, for there is chance of their infection by flies, mice, or rats.
VI. Clothes received from the dhoby’s house should be again boiled in water, dried, and then used.
VII. Bed-clothes and wearing apparel should be aired and exposed to the sun daily. As frequently as possible floors and passages should be well washed with a disinfectant solution and then well dried.
VIII. There should not be any over-crowding in bed-rooms.
IX. Drinking water should be boiled before use. Raw vegetables, such as salad, cucumber, &c., should only be used after thoroughly washing them, and then with vinegar.
X. Personal cleanliness should be strictly observed. Daily bath, cleaning the teeth with carbolic tooth powder, and carefully washing hands and mouth before and after meals are essential.
XI. Those who have to attend on plague cases should be very careful. Hands should be thoroughly washed with a disinfectant solution, and a nail brush used soon after the patient or anything in contact with him is touched. A bath to which some antiseptic is added should be taken immediately after coming in contact with plague patients. Workers in plague hospitals should be warned about scratches or wounds on their bodies. Use of respirators with an antiseptic sprinkled over the entrance valves is recommended. Only very healthy people should approach plague cases. On the appearance of slightest headache, languor, or fever an attendant should be relieved from duty.
XII. As a prophylactic 5 grains of quinine sulphate may be taken twice daily, or a small bottle containing eucalyptus or some other volatile disinfectant, may be carried in the pocket, and a few drops may be occasionally poured on the handkerchief. Smoking good tobacco may have a prophylactic value.
XIII. If plague occurs in the house, the following steps should be taken:—
(a) The patient should at once be put in bed and kept in a temporary room, which may be put up on the roof of a house. No healthy inmate of the house should go in that room or have any connection with the sick, except those who have to nurse the patient.
(b) All discharges, fæces, urine, sputum, vomited matter, &c., should be taken in vessels with disinfectant solution in it, and some quicklime should immediately be sprinkled over them. On noaccount should anything leave the room but to be disinfected.
(c) Floor and bedsteads should be washed with a disinfectant solution, clothes and other articles that touch the patient should be carefully disinfected. Crockery and glass should be scalded. If great care and cleanliness are not observed with regard to the bed and body linen of the patient, the infection may be diffused through the air immediately around the patient.
(d) A medical man should be at once sent for. Delay is fatal.
M. Haffkine, of cholera inoculation fame, has commenced to inoculate against the plague under the same principles on which his inoculation against cholera is based. By injecting into the body an attenuated virus of plague, a very mild attack is produced, which in people inoculated has proved harmless. This mild attack, it is thought, would protect the system from more potent forms of the poisonous germs. The inoculation for plague is still in its experimental stage, and cannot, for obvious reasons, be applied to a large population. Medical attendants, nurses and others who, by call of duty, have to constantly come in contact with plague patients may, however, take advantage of this means of protection, which, in the hands of M. Haffkine, may yield good results. Yersin also claims for his serum prophylactic value. In this and all other matters connected with bacteriology, such as germs, sero-therapeutics, &c., the medical profession now-a-days receives a good deal of satirical remarksfrom sceptical lay public. It is natural that it should be so, for the science of bacteriology is still in its infancy, and many of its practical applications are still in their experimental stage. But undoubtedly the science is advancing, and by its aid we are now better able to understand diseases and their nature. Many facts have been demonstrated and proved with precision. What is disbelieved to-day, may, however, be believed tomorrow, for, with all human attempt to reveal secrets of nature, such is the case. Readers of Smollet’s Roderick Random may remember how in the Surgeon’s Hall one of the examiners said:—“I affirm that all wounds of the intestine whether great or small are mortal.” Now, however, if a man dies of a wound of the intestine, the unfortunate doctor in whose hand such a casualty takes place runs great risk of being charged with malpraxès.
I.Hygienic.—The patient should take to bed immediately on the appearance of the first symptoms. The room should have means for free ventilation, and the temperature in it should be between 60° to 70° F. The air of the room may be cooled by a block of ice. The room should be kept clean, and there must not be in it any curtain, carpet or hangings. The floor and bedsteads should be daily washed with a disinfectant solution. A position of absolute rest in bed is to be maintained throughout the illness.
Bedpan and urinal should be always used. Bedclothes should be light and warm. Wearing apparel if saturated with perspiration should be changed. It is best to have two beds side by side so as to beable to move the patient easily from one to another for cleansing purposes. Mattresses should be suitably protected from penetration by the discharges. The air of the sickroom can be made antiseptic by placing pieces of blotting paper saturated with eucalyptus oil or phenol on plates about the apartment or by pouring carbolic acid on hot water in a plate. The doorways should be curtained by a sheet wet with disinfectant solution. Great cleanliness of the body of the patient should be enforced by cold sponging with an antiseptic solution. Skilful nursing is essentially necessary. The motions should be disinfected by strong antiseptics such as quicklime, carbolic acid, &c., as soon as they are passed.
II.Dietetic.—From the commencement of the disease the diet should be liquid and nourishing. Milk is best. The quantity for adults should not be less than three or four pints in the twenty-four hours. It must be given in small quantities at short intervals. Soda, potash or plain carbonated water may be mixed with it. Barley water and thin sago water may also be given. If the patient’s vital powers are low, the milk may be peptonised by using Fairchild’s powders or by adding a little of Benger’s Liquor Pancreatices. In cases when milk cannot be taken in sufficient amount, animal food may be given in the form of plain meat broth. Egg-flip with or without brandy may also be given. It is useless to give strong meat essences when the digestive powers are seriously impaired, and excess of zeal in this direction does a great deal of harm. These accumulate in the intestinal canal and form a fermenting mixture in which poisonousptomaines form. Throughout the attack the patient’s strength should be husbanded as carefully as possible. When there is thirst, water, or iced water, or iced beer or stout, or ice-cream, or fruitsherbatshould be given. During convalescence great care should be taken of diet, for then the vital powers are at a very low ebb.
III.External.—In order to lower the temperature rubbing of the skin with oil from the commencement of the disease has been recommended, but this procedure is, I think, of no use. I suggest, however, that when temperature is high 15 drops of Creosote may be rubbed near the axilla. During height of fever, the body may be lightly sponged all over, twice or thrice a day, with the following solution:—
Mustard plasters to limbs and over the heart should be given when there are signs of failing heart and circulation, and over the epigastrium when there is vomiting or hiccough. Smelling salts and strong ammonia should be applied to the nostrils for their restorative action. Blister over the nape of the neck is useful when cerebral symptoms are present. Ice caps over the head is very useful and should be applied continuously. The enlarged glands may be fomented with hot water or spongio-piline wrung out of hot antiseptic solution. When they are much painful, poppy or belladonna may be added to the water. Belladonna with glycerine should be applied in the beginning and iodine afterwards. Hotcorrosive sublimate fomentations are also useful. If the glands suppurate, they should be opened aseptically and dressed with antiseptics. Proper drainage should be provided.
IV.Internal.—Knowing as we do that the plague is due to the toxic products metabolized by a pathogenic bacillus, the question comes—would an antiseptic treatment be of any use? Can we by any means induce an antiseptic action on the blood, or have we any drug which can act as antitoxin? It must be at once stated that no drug that has been tried yet fulfils the above conditions. The claims of quinine, however, should be taken into account. This drug in small repeated doses acts as a general antiseptic. I would, therefore, advocate its use especially in the early stages. Plague is a disease in which collapse sets in early and cardiac asthenia is a very early complication. There is, therefore, great urgency for early stimulation. Alcohol may be given freely, but at the same time it must be remembered that if the organs of elimination are not acting properly, alcohol may do harm. For their stimulant effects whiskey or iced champagne may be given. Carbonate of ammonia or spirit ammonia aromatic are held to be very useful stimulants in plague cases. They may be given in combination with cinchona, digitalis and ether. A prescription like the following may be useful:—
For cardiac asthenia, the following may be tried:—(1) Caffeine, hypodermically, 5-grains dissolved by the aid of 5 grains of Sodium Benzoate in 20 minims of warm distilled water and injected three or four times a day if needful; (2) Ether or ethereal solution of camphor hypodermically; (3) Strychnine, hypodermically, beginning with gr. 1/60 every four or six hours till gr. 1/16 is injected, or Liquor Strychnia in 5—10-minim doses every four hours; (3) Musk may be given in 5-grain doses, or as in the following mixture:—
Digitalis does not always give good results, a fact which Lowson attributes to some inflammatory or fatty degenerative changes in the small vessels giving rise to a tendency to hæmorrhage. Stropanthus may be substituted. Transfusion of blood a hot saline solution and inhalation of oxygen have been recommended for collapse. Dr. Viegas of Bombay recommends Liquor Hydrasgyie Perchloride 10 to 15 minims every four hours if there is no albumen in the urine. Dr. Dimmock has advised subcutaneous injection of Guaicol 10 or 15 minims every two hours. Permanganate of Potash 5 to 12 grains in 24 hours has also been recommended. Dr. Blaney has recommended Medritina in two-dram doses every two hours when the kidneys are involved. Camphor has been recommended by some as a cardiac stimulant.
(1). High temperature may be reduced by antipyretics, such as antipyrin, phenacetin, antifebrine, &c. These drugs produce profuse perspiration and a certain amount of depression; it is, therefore, advisable to restrict their use during the first few hours only, and if not found responding, they should be dropped altogether. Pyrexia is but a sign of the intensity of the activities of the infective agent, and by artificially reducing the body heat we really do not lessen the virulence of the poison, as shown by the rise of the temperature again as soon as the action of the antipyretic subsides. Hyperpyrexia itself is, however, an injurious symptom, and when there is long continued high temperature it is necessary to reduce it, either by an antipyretic, quinine or cold bath, or cold sponging. Cold bath is not suitable in plague patients on account of the movement of the body which it entails, and also on account of the serious cardiac depression which accompanies the disease. Two grains of phenacetin with 1 grain of hydrobromate of quinine is a safe antipyretic. Brandy and tepid sponging are also very useful.
(2).Brain symptoms.—For headache a mustard plaster behind the upper part of the neck and over the occiput. Ice cap or Lieter’s tube or plain water should be applied over the temples and scalp. Nervine sedatives, such as Potassium Bromide, may be given for insomnia when there is not much depression. Otherwise full doses of alcohol may be tried. Opium should not be used, but in mild cases, without great depression, 10 to 20 minims of LiquorOpii sedativus with 30 minims of Sal Volatile in an ounce of camphor water may be given to soothe nervous unrest. For insomnia Lowson speaks highly of Morpinæ gr. 1/8 to gr. ½. Hyoscine gr. 1/200 to gr. 1/75 may be tried. Meningites should be treated by cold to the scalp and counter-irritation to the nape of the neck and occiput.
(3).Hæmorrhagesmay be treated by Ergot or Ergotin internally or hypodermically. When there is much hæmorrhage, use of alcohol should be partly suspended.
(4). If there is constipation, a dose of calomel may be given. In the beginning there is almost always constipation, which should be removed by a dose of calomel followed by a saline. Diarrhœa may be checked by an enema of opium. Two grains of Dover’s powder and 10 grains of tannin mixed with an ounce of gum mucilage and with two or three ounces of warm water, arrowroot or starch may be used for injection. Salol in 10-grain doses every 4 hours may be given for diarrhœa. For vomiting and hiccough sinapism over the epigastrium, sucking of ice, and for thirst acidulated water with syrup of lemon are recommended. Coma must be promptly met by cold effusion if there is pyrexia or by rectal injection of strong coffee. The bladder of the patient should be carefully watched. Pneumonia and other complications should be treated under general principles.
When temperature falls and convalescence begins, the stimulants should be lessened, and afterwards a tonic with quinine, acid nitromuriatic dil.,tincture calumba or quassia may be given with infusion aurantii.
Serum treatment.—The whole system of serum therapeutics is due to the genius of Pasteur. Diphtheria and tetanus are diseases that are caused by specific germs and are now successfully treated by immunised serum. Tetanus can be prevented and even cured by the injection of serum of other animals vaccinated against this disease: this process has been applied by Yersin for producing a plague serum, for which a prophylactic and curative power is claimed, and this serum may be called plague antitoxin. Yersin treated his first case in Canton. At Amoy, the people were less averse to treatment, and in 10 days he was able to treat 23 with two deaths only. As yet Yersin’s serum has been tried in the declared diseases, but Yersin also proposes to use it as a preventive. Haffkine also proposes to make use of his serum for curative purpose. Yersin’s serum is older than Haffkine’s, otherwise bacteriologically they are identical. The subject is in far too unsettled a condition at present, but it has no doubt a hopeful future before it.
Substances which can prevent infectious diseases from spreading by destroying their specific germs are called disinfectants. These disinfectants can kill pathogenic germs. Heat is a most powerful agent in killing-germs, therefore anything which is subjected to prolonged boiling becomes sterile or germ-free. For purification of clothes and bedding, heat is the best agent, either by boiling them in water or by placing them in a hot-air chamber. Theusual arrangement is a furnace with the smoke shaft passing under or on one side of a brick chamber and with a hot-air blast from a shaft running through or under the fire into the chamber itself, or into a passage below it, whence it passes into the chamber through a valve; an exit for the hot-air is provided at the top of the chamber, the clothes are suspended in the chamber, at a little distance from the walls. Various kinds of ingenious apparatus have been recently contrived and are used. Steam disinfecting chambers are necessary for the disinfection of clothes, &c., of a large population, and all large towns and railway stations should have them. High pressure steam in an apparatus contrived for the intermission of its pressure is found to give the best heat penetration to large non-conducting articles such as bedding. Fumigation by burning sulphur or chlorine is a very useful method for disinfection of rooms. Large bonfires of sulphur may also have a beneficial effect on the air.
All woodwork should be thoroughly cleansed with soft soap and water, to which a little carbolic acid has been added. The walls should be scraped and then washed with hot lime to which carbolic acid should be added in the proportion of one pint to four gallons of water. Then the room should be fumigated for 3 hours, with all doors and windows and the chimney being closed, sulphur about 1 seer for every 100 cubic feet of space should be put in a metallic dish, a little alcohol is poured on it, and it is lighted. After 3 hours the doors andwindows should be opened and kept open for 24 or 36 hours. Rooms may be disinfected by chlorine. Carbolic acid in 5 per cent. solution is useful for all ordinary purposes, such as washing hands, utensils, &c.
Quicklime is the cheapest and the most easily procurable disinfectant for drains and for disinfection of discharges. Carbolic powder made by adding carbolic acid to lime is very useful for the disinfection of public latrines, drains and sewers. Corrosive sublimate, in the proportion of 1 part in 4,000, is the most efficient germicide known and should be used diluted with water for sprinkling on public roads and for flushing drains and washing latrines, &c. It is, however, poisonous and corrodes metal drain pipes. In quarantine or isolation camp the latrines should be of the dry earth system. Carbolic acid powder should be largely used in them. The question of suitable disposal of sewage depends on the circumstances of each town or village, but incineration is the most sanitary method during an epidemic. Other disinfectants too, such as Jey’s Fluid, Creoline, Phenyle, Izal, Sanitas, may also be used.