PLAGUE (λοι/χός, Pestis, Pestilentia). This name has been given to any epidemic disease causing a great mortality, and in this sense was used by Galen and the ancient medical writers, but is now confined to a special disease, otherwise called Oriental, Levantine, or Bubonic Plague, which may be shortly defined as a specific febrile disease, transmissible from the sick to healthy persons, accompanied usually by buboes and sometimes by carbuncles. This definition excludes many of the celebrated pestilences recorded in history,—such as the plague of Athens, described by Thucydides; that not less celebrated one which occurred in the reign of Marcus Aurelius and spread over nearly the whole of the Roman world (164- 180 a.d.), which is referred to, though not fully described, by the contemporary pen of Galen; and that of the 3d century (about 253), the symptoms of which are known from the allusions of St Cyprian (Sermo de Mortalitate). There is a certain resemblance between all these, but they were very different from Oriental plague.
Symptoms.— There are two chief forms :—(l)mild plague, pestis minor, larval plague (Radcliffe), peste fruste, in which the special symptoms are accompanied by little fever or general disturbance; and (2) ordinary epidemic or severe plague, pestis major, in which the general disturbance is very severe. Cases which are rapidly fatal from the general disturbance without marked local symptoms have been distinguished as fulminant plague (pestis siderans, peste foudroyante).
1. In the minor form of the disease spontaneous swellings of the glands occur, chiefly in groins and armpits, but also in neck or other parts, which either undergo resolution or suppurate. There is a certain amount of fever; the temperature is rarely high, but has been known to be 104° Fahr. The duration of the disease is ten to twenty days usually, but may be eight weeks, for most of which time the general health is little impaired and the patient able to go about as usual. It rarely, if ever, causes death, the only fatal case at Astrakhan in 1877 having been so through a complication. The disease is not obviously contagious; whether it is propagated by infection or not is unknown. It is possibly rather of a miasmatic character. This form of disease has sometimes preceded or followed severe epidemics, as in Mesopotamia (Irak) on several occasions, 1873-78, and in Astrakhan, 1877; its importance in relation to the origin of plague has only lately been appreciated.
It might be expected that gradations would be found connecting this form with the severe epidemic form; but this appears to be not usually the case, the latter form appearing somewhat suddenly and abruptly. Hence the minor form has probably often been regarded as a distinct disease, even when observed in plague countries.
2. As regards pestis major, or severe plague, the symptoms appear to have been nearly the same in all great epidemics for several centuries, if not for two thousand years, but will be best given from modern observations, such as those of Surgeon-Major Colvill, Dr Cabiadis, and others in Irak, and recent observers in India. The early symptoms are sometimes like those of ague (shivers, often long continued, and pains in the limbs), but combined with nervous symptoms. The patient becomes distracted, tosses about in constant fear of something he cannot describe, has a difficulty in understanding the questions put to him, and is slow in answering. He is often described as staggering like a drunken man. There is severe headache, intense thirst, and severe pain in the epigastrium. The eyes are red and turbid; the tongue swollen, dry, and fissured, sometimes black, sometimes remarkably white (Colvill). This condition may pass into coma even before fever sets in. In other cases bilious vomiting is the earliest symptom. The fever which sets in may last twenty-four to thirty hours, or more. The temperature maybe 100° to 107° Fahr., or even higher; but in the most rapidly fatal cases there may be little or no fever. Generally there is obstinate constipation, but sometimes diarrhoea. Besides these symptoms there are certain special ones especially characteristic of plague.
(a) Buboes or glandular swellings are observed in all except very rapidly fatal cases. They occur in 45 or 50 per cent, of the cases in the groin, in 35 per cent, in the axilla, also less frequently in the neck or other parts. These swellings may occur before the fever, simultaneously with it, or some hours after it has set in. A sudden pain like that of a stab is felt in some region of the body, which has given rise to the superstition that the unfortunate victim was wounded by the arrow of an invisible demon,—a belief recorded in Constantinople in the 6th century, and said still to survive in Mohammedan countries. The buboes may suppurate, and free discharge of matter from them has in all times been held to be a favourable sign and conducive to recovery.
(ό) Carbuncles were observed in about 2⅜ or 3 per cent, of the cases in recent epidemics in Irak. They are always an unfavourable sign.
(c) Petechiae or haemorrhagic spots on the skin have always been regarded as signs of the worst omen. Under the name of “tokens” they were considered in the English epidemics of the 16th century as the infallible signs of approaching death. “They appear generally only a few hours before death” (Colvill). Hodges (1665) noticed hardness which showed the existence of haemorrhage under the skin. The skin is sometimes so covered with petechiae as to become of a dark livid hue after death, recalling the name Black Death (Cabiadis).
The occurrence of the above symptoms, especially the first, in an idiopathic fever attacking many persons at one time is sufficient to make the diagnosis of plague.
A very notable and fatal form of the disease is that in which haemorrhages from the lungs, stomach, bowels, nose, &c., occur. These are of the worst omen, and are seen in some cases where there are no buboes, and which are rapidly fatal. This was observed in Irak in recent epidemics, in the outbreak on the Volga in 1878-79, and in the plague of India. It was a noticeable symptom in the black death, and was observed even in the plague of the 6th century. The bleeding is mostly from the lungs, and is sometimes associated with other symptoms of lung affection. This form of the disease appears, however, to have no distinct historical or geographical limit. A similar haemorrhagic form has been observed in small-pox and scarlet fever, and is always extremely fatal.
In all plague epidemics cases occur in which death takes place very rapidly, even within twenty-four hours, without the development of the special symptoms of the disease. Such cases are reported by Diemerbroek, Hodges, and others in the 17th century, and have been observed in recent epidemics in Irak, as well as in the recent plague on the Volga. Some are more like cases of poisoning than of infection, and much resemble the instances of death from the exhalations of dead bodies (cadaveric poisoning) which are met with from time to time. It is these which have given rise to the expression fulminant plague.
Duration.— The duration of an attack of plague may be from some hours to a month. Three-fifths of the cases observed by Mr Colvill were fatal on the third day, and the majority of cases in India had the same termination (Francis). Five-sixths of fatal cases end by the fifth day. Most of those who survive the fifth day get well; after the seventh day a patient in Baghdad was considered by his friends safe; and in Mr Colvill’s cases only 4 per cent, of fatal cases died after the tenth day. In non-fatal cases with suppurating buboes the disease may be protracted to two or three weeks or a month.
Mortality.— Plague is the most fatal of all known diseases which affect large numbers of people. The mortality, according to official registers in Baghdad, was 55 ’ 7 per cent, of those attacked. Dr Cabiadis thinks this too high, owing to many cases of recovery not being reported. But in some epidemics the proportion of fatal cases is much higher. In Vetlanka it was about 90 per cent., and in some other villages on the Volga every person who took the disease died. The older accounts do not give the proportion of deaths and attacks.
Morbid Anatomy.— Examinations after death have not done much to elucidate the nature of plague, except negatively. The appearances are those of death from an acute infective disease, and resemble those of typhus, except for the special affection of the lymphatic glands. The brain and the lungs are found to contain excess of blood; the right side of the heart distended, the blood darkcoloured and undergoing rapid decomposition. The spleen is found enlarged, and in a less degree the liver. The stomach and intestinal canal often show signs of inflammation and haemorrhage, sometimes ulceration. The characteristic swelling of the lymphatic glands, both external and internal, is often accompanied by inflammation of the cellular tissue around. Petechial patches are sometimes found on the internal organs. Pathology of Plague.— All that is known of plague goes to show that it is a specific febrile disease depending on the reception into the body of a specific organic contagion, which becomes multiplied in the body of the patient. Analogy makes it very probable that this contagion is a living organism of the class Bacteria, but the suspected organism has not yet been discovered. The nearest ally of plague is typhus fever, so that some authorities have spoken of it as the typhus of hot climates, modified by temperature, &c., but this opinion does not appear to have ever been held by any competent physician who has examined the disease at first hand. It appears to be as distinct from typhus as this is from enteric fever, or other so-called typhoid diseases. It has also been thought that plague is related to intermittent or remittent malarious fevers; but the most recent observations show that there is no real connexion between these diseases. In India, says Dr Francis, neither intermission nor remission has ever been observed in plague. It is quite distinct from and in no way modified by the types of fever that are caused by malaria. Dr Cabiadis speaks to the same effect of plague in Irak, and insists that the physical conditions which favour the production of marsh poison are not necessarily favourable to plague.
External Conditions of Plague.— The nature of the soil has little influence on plague. It may flourish in alluvial deltas, on calcareous ridges or granitic mountains. Moisture in the soil has generally been thought to be an important factor in its production, but, though often found in marsh situations, such as the banks of the Nile, the Euphrates, or even the Volga, it also occurs in India at elevations approaching 7000 feet, and in Kurdistan at 5000 to 6000 feet above the sea.
The temperature most favourable to plague is a moderately high one. The disease is unknown in the tropics. When prevalent in Egypt it was said never to penetrate farther south than Assouan. It has not crossed the plains of India within historic times. Where the disease does occur, a temperature of 80° to 85° or more, combined with absence of moisture, usually stops the epidemic. In Egypt it was observed to cease as an epidemic almost suddenly about the 2 2d to 24th of June, and not to begin again till September. In Irak it dies out suddenly during the summer. When the temperature rises above 86° it begins to diminish; and it ceases abruptly at a temperature of 113°. In India it has been observed by Dr Francis when the temperature of his tent was 83° to 95°, or in a grass hut to 105°, while the air was moist; but he thinks a lower temperature with dryness renders the poison inert.
On the other hand, in northern countries, the disease is usually checked by the cold of winter, starts up in the spring, and is most active in August and September. To this rule there have been some remarkable exceptions, such as the epidemic on the Volga in 1878-79, which raged during severe winter weather, and the great plague of Moscow in 1770.
Sanitary Conditions.— Of all the co-operating causes of the plague, uncleanliness is the most powerful,—meaning by this the accumulation of decaying animal matter around human bodies or dwellings. The saturation of the soil with filth is perhaps the most important point. A plague seat in Mesopotamia is thus described by Colvill :—“The ground is so saturated with moisture that the refuse of the village is neither absorbed nor evaporated, but . . . acquires the form of a bluish-black oily fluid, which surrounds the huts and covers the paths, and stains the walls 2 feet from the ground; and in fact the village is in such a state of filth that it requires to be seen to be believed.” Of the people among whom the Pali plague of India raged it is said “they were filthy beyond conception” (Francis). There can be little doubt that European cities in the Middle Ages, and down to the 17th century, presented very similar conditions. These conditions may be considered to act by supplying a suitable environment for the life and growth of the organized poison (or bacterium) outside the human body. Where these are wanting one of the main factors in the spread and permanence of the disease will be absent, a fact which makes it probable that increased cleanliness is the chief cause of the disappearance of plague from Europe.
Overcrowded dwellings, especially with deficient ventilation, greatly favour the spread of the disease; but this is not necessarily correlative with density of population, and plague may flourish in thinly peopled countries.
Of social conditions poverty has by far the most powerful influence on the spread and development of plague. Many plague epidemics have followed on years of famine, or been connected with destruction of crops and cattle. The races among which the disease is endemic are almost without exception under-nourished, if not destitute. In the villages on the Volga there appeared to the writer, in 1879, to be little destitution, though the diet of the people was very meagre. In all city epidemics the poor are the chief or almost the only sufferers. This is as true of Baghdad in the 19th century as it was of London in the 17 th. Those of the upper classes who have been attacked have been chiefly doctors, clergy, officials, and others whose occupations take them among the sick.
Origin and Spread of Plague.— Although the above-mentioned conditions are those in which plague originates, and may be considered in a general way essential to its continued existence, it is plain that they do not account for its origin. Poverty, overcrowding, filth, and marsh soil, with a temperature suited to plague, occur in many parts of the world where this disease has never been heard of or has ceased to exist. The geographical distribution of diseases cannot, any more than the distribution of plants or animals, be explained by climatic causes alone. With regard to plague it is quite clear that there are some parts of the world where it is at home, or, as the phrase is, “endemic.” In other parts it is probable (or, as some think, certain) that its existence, and even its periodical recurrence, depend on importation from an endemic centre. Although it is not always easy to distinguish between these cases, they must be considered separately.
In the case of an endemic disease we suppose that the poison is either kept in existence by continued transmission from one case to another, or that it can subsist outside the human body in soil, water, or otherwise. The first mode of existence is that of a pure contagious disease, such as small-pox; and it is plain that this mode of continued existence obtains in the case of plague also. It is not, however, clear that the second may not also be one of the modes of existence of plague, which would then be a so-called “miasmatic” disease like ague, as well as a contagious one. In India, for instance, the disease appears as if it depended on a poison in the soil, since it returns years after to the same spot, appearing in many villages simultaneously; and some morbid influence causes the death of animals (rats) which live under ground. Similar facts have been observed in China; and, if further inquiry should confirm the hypothesis, it would show that plague is (like anthrax or the “steppe murrain” of cattle) both miasmatic and contagious. If so, there is no difficulty in supposing the disease to be carried by contagion to a distant part, and there to be established in the soil, for a longer or shorter period, as the conditions are more or less favourable. The adoption of this hypothesis would remove many of the difficulties attending the explanation of plague epidemics, and to some extent reconcile the controversies of the last three centuries between the il contagionist” and “non-contagionist” schools. It has been maintained by the former that European epidemics have always been caused by the importation of the disease from its home in the East, by the latter that it arose on European soil in the same way as in Egypt or Syria.
In the case of an imported n on-endemic disease, the only question which arises is how the importation is effected,—whether the disease may be brought by the air alone, whether by infected persons only, or whether also by objects which have been in close relation to infected persons. Transmission of the disease by the air cannot be pronounced impossible: and there are facts to show that it is even probable with distances measured by yards, or possibly even hundreds of yards; but there is no evidence whatever that the disease has ever been carried by the air over distances measured by miles. Transmission of the disease by infected persons over longer or shorter distances, and from one country to another, is an established fact. Transmission by infected objects over great distances and from one country to another seems less clearly established. The last two cases must be separately considered.
1. It is clear that the first necessary condition to such transmission is contagion, or transference of the disease from the sick to the healthy. The existence of contagion is shown by such facts as these :—when a case of plague breaks out in a house the other inmates are extremely likely to take the disease; and even in severe forms the plague does not cease till it has affected all or nearly all the household. This is indisputably an almost universal law. In the plague of London in 1603 it was said the disease entered Jιardly any house but it seized all that lived in it. And in 1879, on the Volga, in one village, as was ascertained by Mr Colvill and the present writer, the plague attacked five houses containing thirty-three persons, all of whom except two took the disease and died. In this respect plague resembles typhus. In the next place the disease will spread from an infected house to persons who have close relations with it. Thus in the villages on the Volga it was noticed that after one family was affected cousins and relations by marriage were the next to be attacked. Doctors and those visiting the house are also exposed to the risk, though in a less degree. In Vetlanka on the Volga three physicians and six surgical assistants died. On the other hand, doctors in some instances have singularly escaped from being attacked by the disease. In Egypt, in 1835, out of ten French physicians engaged one only died, nor was this immunity secured by any precautions. These experiences do not prove that the disease is not contagious, but they modify the exaggerated notions which have been held on the subject. The facts appear to be expressed by saying that it may undoubtedly be communicated from one person to another, but chiefly by breathing the air of the sick room, and this generally from prolonged not from momentary exposure,— so that the possibility of communication by chance meetings and similar contingencies may be disregarded. This view is that of Dr Cabiadis and others who have studied plague in Irak where no doctor or assistant, with one exception, suffered from the disease. It is not inconsistent with the experience recorded in Egypt. But it is clear that the intensity of contagion varies greatly in different epidemics. Modern experience contradicts the belief formerly entertained that contact with plague patients was the only or even the chief means of acquiring the disease. Everything tends to show that the atmosphere immediately surrounding the patient is the most effectual conveyer of contagion, and more effectual in proportion as the poison is concentrated. Precisely the same relations are observed with regard to typhus.
It has been disputed whether dead bodies convey infection of plague. Formerly the contagion from this source was greatly dreaded, and the task of burying thought to be specially dangerous. But the French in Egypt made more than a hundred post-mortem examinations without precautions and without harm. In Mesopotamia and in Russia no autopsies were made, but in the latter country some striking instances were noted of those engaged in burying the dead themselves dying of the plague. On the whole both facts and analogy lead to the belief that the disease may be derived from touching or being near a dead body, but not that there is any special danger of infection from this source.
2. It is a very momentous question whether the contagion is capable of being conveyed by clothes and other objects which have been in contact with the sick. The very general belief that this is so has been controverted only by the French physicians in Egypt, one of whom, Bulard, himself wore a shirt, taken direct from the body of a plague patient, for two days. They also state that in Egypt it was customary, when a plague epidemic was over, to sell the clothes and effects of those who had died of plague, without, as is affirmed, communicating the disease. In Constantinople they were customarily sold at once; and it is alleged that the dealers in old clothes did not specially suffer. In 1835 the hospital at Cairo, where 3000 plague patients had been treated, was used, without even changing the bed coverings, immediately after the epidemic for other patients, without harm. Negative instances of this kind might be multiplied, but their importance is diminished by the consideration that the communicability of plague, by whatever means, is always found to become spontaneously weak at the decline of the epidemic, till it is extinct altogether. While the epidemic influence lasts there is abundant evidence that infected clothes, <kc., are among the means by which the disease spreads. In Egypt, in 1835, two criminals condemned to death were for the sake of experiment placed in the clothes and beds of those who had died of plague, and both took the disease, one dying. Instances are given by White (Treatise on the Plague, p. 161, London, 1847) of the disease spreading “like wildfire” through the distribution of infected garments, and of those engaged in disinfecting clothes and other objects being suddenly seized with the complaint, e.g., on opening a box containing infected garments. While the reality of this mode of communication cannot reasonably be doubted, it admits of some question whether the plague has ever been thus conveyed over great distances, or from one country to another. The best known instance in England is the alleged transmission of plague from London to the village of Eyam in Derbyshire in 1665 by an infected parcel of clothes,—a story which cannot be criticized at this distance of time, but which presents some weak points. Dr Cabiadis states that he has seen plague thus conveyed in Irak to places outside the existing focus of infection, but gives no details. On the whole we must consider the exportation of plague by clothes over great distances, and into countries not subject to the same epidemic conditions as the infected country, “not proven.”
The communication of plague by merchandise or objects not personal, coming from an infected country, rests upon still more defective evidence, though at one time generally believed. In virtue of this belief all goods, especially those regarded as susceptible (as wool, furs, raw cotton, <fcc.), were, when coming from an infected or suspected country, subjected to disinfection under special regulations. But there is really no evidence that plague was ever thus transmitted or that these regulations kept it out. On the contrary there are numberless instances of this supposed cause having failed to operate when it might have been most expected to do so.
During the plague at Alexandria in 1835, which destroyed 9000 persons in that city, the exportation of cotton from the Government warehouses was never interrupted, though the plague was most destructive in those very buildings. It was loaded on English and other ships without any precautions whatever. Twenty-five ships, eight of which were infected with plague, conveyed cotton amounting to 31,000 bales to England. Nevertheless no case of plague is known to have occurred among the quarantine officers or others engaged in unloading these ships or disinfecting their cargoes in quarantine. Equally large quantities were exported to Marseilles and Trieste, and smaller quantities to other ports, with the same result. Further, no case of infection has occurred among quarantine officers or persons employed to disinfect goods, from this cause alone, either at Marseilles since 1720, or at any European lazaretto. The conclusion is that the fear of importation of plague by merchandise coming from an infected country rests on no solid foundation.
By whatever-means, there is no doubt that plague is diffused or “spreads” from one place to another, and that its spread is connected mediately or immediately, in most cases at least, with human intercourse. But this diffusion appears to take place as a rule slowly, and to be effected by the formation of new foci of contaminated atmosphere. Such foci on land will be inhabited houses, and the disease will creep in a gradual though irregular manner from house to house and street to street. It was so in London in 1665; and in Russia in 1878, as has been said, the disease was confined to one village for two months, though for great part of the time communication was perfectly open. In 1834 plague existed eight months at Alexandria before passing to Damietta and Mansoorah, though traffic was quite uninterrupted. These new foci of disease are doubtless mostly produced by persons infected with the disease, actually or in incubation, who form a contaminated atmosphere around them in a place previously healthy.
Transmission of the disease by sea may take place in the same manner,—a ship forming a focus of disease as easily as a house, and being obviously specially liable to concentrate the poison. It is by a floating atmosphere of plague, and not by casual contaminated objects, that the disease has been conveyed, when it has been, from one port to another of the Mediterranean. The reality of the mode of transmission is shown by the fact that between 1720 and 1846 twenty-five ships arrived at French and Italian ports with the plague among their crews; and in the case of those arriving at Marseilles (ten in number), which were carefully observed, there were several instances of plague being communicated in the lazaretto to surgeons and others, or to those placed in charge of the ships. Of these persons several died,—without, however, any exten sion of the disease to the town. From this it is clear that plague may be transmitted by ships, and may spread at the point to which it is conveyed, if the surrounding circumstances are favourable. In all these cases the ships had left the infected ports at a time when an epidemic of plague, and not merely sporadic cases, prevailed there. No similar facts are on record as to the importation of plague by ships to England,—the probable cause of this difference being the greater length of the voyage from the Levantine ports, and the precautions taken at those ports to prevent the shipment of infected persons or goods. Plague has never been brought to an English quarantine station.
In such cases it must remain undetermined whether the disease would have spread, had it not been interrupted by the quarantine. As we have seen, plague will often die out in the cases which convey it without spreading; and hence some have supposed (with Sydenham) that an “epidemic constitution” is necessary at any particular time and place in order that the disease should become general, but the practical value of this law is diminished by the fact that there is no means of recognizing the epidemic constitution except by the actual production of an epidemic.
Plague, like all similar diseases, and in a specially high degree, is subject to the law of periodicity. Even when it is most strictly endemic it seldoms prevails continuously, but appears in definite outbreaks, or epidemics, with intervals in which there are either no cases of plague or only so-called sporadic cases. This may be partly due to the general law that the susceptibility of the population to a special disease is exhausted by an epidemic, partly to the immensely increased transmissibility of the disease caused by the increased number of cases, so that when once a certain stage of severity has been reached the disease progresses in a far more rapid ratio. In most epidemics of plague there is at one time a sudden and alarming increase in mortality; but, by a law not yet understood, each epidemic is liable to a spontaneous decline, which is sometimes sudden. This may be connected with rise or fall in the temperature of the air, but is not always so. The disease may be dormant during the cold or hot weather (as the case may be) and reappear when the temperature is favourable again, but not necessarily. It is generally agreed that plague is transmissible to another country only when it is epidemic, and not from sporadic cases.
Incubation.— It is a very important question what time may elapse between a person receiving the poison and showing symptoms of the disease. The usual time of incubation appears to be from three to five days. In certain very malignant epidemics this period may be shortened, and, it is thought, reduced to even less than a day. In rare cases incubation may be prolonged to eight days. There are doubtful accounts of ten days’ incubation. Generally a week’s observation would show whether a suspected person was really affected or no. It has been thought that articles contaminated by contact with plague patients may retain the power of communicating the disease for weeks, months, or even years; but of this there is no adequate proof.
Treatment.— No special line of treatment has proved efficacious in checking the disease once established. Special symptoms are treated in accordance with the ordinary rules of practice, and need not here be considered. Free ventilation appears to be of the greatest service in preventing the spread of the disease, and probably in promoting recovery.
Prevention.— There can be no doubt whatever of the efficacy of hygienic measures in rendering a locality unsuitable for the spread of plague. Such measures include, not only personal cleanliness, but especially the removal of all foul organic matters, good drainage, and prevention of overcrowding; all such measures might be looked upon by our readers generally as matters of course, but are quite unknown in most of the homes of plague. Since there is no doubt that plague may be carried from places where it prevails epidemically, measures to prevent such importation cannot be neglected. The best known of such measures is the system of quarantine first produced about 1480. See Quarantine. The efficiency of quarantine has been much discussed, and very strong opinions have been expressed for and against it. The subject is too large for discussion here; but it would appear that, while the system as originally applied in the Mediterranean, when traffic was comparatively slow and infrequent, and when European cities presented an extremely favourable soil for plague if introduced, was a real protection, the regulations have long ceased to correspond to the actual state of medical knowledge; and, in addition, it would be impossible to apply them to our crowded traffic. The alternative is a system of medical inspection of all arrivals in our ports, and strict isolation of ships in which plague has occurred or is suspected. Such a ship should then be treated as an infected house.
Prevention of the Spread of Plague.— When cases of plague have once occurred in a town or on board a ship in port, the house or ship should be emptied of its inhabitants, the sick removed to a hospital, the sound placed in an isolated building and subjected to observation for at least a week, or, better, ten days. The clothes of sick persons had better be burnt, their bedding and furniture completely disinfected. The house should in the meantime be rigidly closed until it has been disinfected. If these measures are taken in time, there can be no objection to Allowing free emigration of the population. Isolation of the place bv a “sanitary cordon” would only be possible in very exceptional positions, and as a rule would aggravate, by overcrowding, the intensity of the disease within.
History of the Plague.— The first historical notice of the plague is contained in a fragment of the physician Rufus of Ephesus, who lived in the time of Trajan, preserved in the Collections of Oribasius. Rufus speaks of the buboes called pestilential as being specially fatal, and as being found chiefly in Libya, Egypt, and Syria. He refers to the testimony of a physician Dionysius, who lived probably in the 3d century b.c. or earlier, and to Dioscorides and Posidonius, who fully described these buboes in a work on the plague which prevailed in Libya in their time. Whatever the precise date of these physicians may have been, this passage shows the antiquity of the plague in northern Africa, which for centuries was considered as its home. The great plague referred to by Livy (lx., Epitome) an dιnore fully by Orosius (Histor., iv. 11) was probably the same, though the symptoms are not recorded. It is reported to have destroyed a million of persons in Africa, but is not stated to have passée! into Europe.
It is not till the 6th century of our era, in the reign of Justinian, that we find bubonic plague in Europe, as a part of the great cycle of pestilence, accompanied by extraordinary natural phenomena, which lasted fifty years, and is described with a singular misunderstanding of medical terms by Gibbon in his forty-third chapter. The descriptions of the contemporary writers Procopius, Evagrius, and Gregory of Tours are quite unmistakable. The plague of Justinian began at Pelusium in Egypt in 542 a.d. ; it spread over Egypt, and in the same or the next year passed to Constantinople, where it carried off 10,000 persons in one day, with all the symptoms of bubonic plague. It appeared in Gaul in 546, where it is described by Gregory of Tours with the same symptoms as lues inguinaria (from the frequent seat of buboes in the groin). In Italy there was a great mortality in 543, but the most notable epidemic was in 565, which so depopulated the country as to leave it an easy prey to the Lombards. In 571 it is again recorded in Liguria, and in 590 a great epidemic at Rome is connected with the pontificate of Gregory the Great. But it spread in fact over the whole Roman world, beginning in maritime towns and radiating inland. In another direction it extended from Egypt along the north coast of Africa. Whether the numerous pestilences recorded in the 7th century were the plague cannot now be said; but it is possible the pestilences in England chronicled by Bede in the years 664, 672, 679, and 683 may have been of this disease, especially as in 690 pestis inguinaria is again recorded in Rome. For the epidemics of the succeeding centuries we must refer to more detailed works.
It is impossible, however, to pass over the great cycle of epidemics in the 14th century known as the Black Death. Whether in all the pestilences known by this name the disease was really the same may admit of doubt, but it is clear that in some at least it was the bubonic plague. Contemporary observers agree that the disease was introduced from the East; and one eye-witness, Gabriel de Mussis, an Italian lawyer, traced, or indeed accompanied, the march of the plague from the Crimea (whither it was said to have been introduced from Tartary) to Genoa, where with a handful of survivors of a Genoese expedition he landed probably at the end of the year 1347. He narrates how the few that had themselves escaped the pest transmitted the contagion to all they met. Other accounts, especially old Russian chronicles, place the origin of the disease still further to the east in Cathay (or China), where, as is confirmed to some extent by Chinese records, pestilence and destructive inundations are said to have destroyed the enormous number of thirteen millions. It appears to have passed by way of Armenia into Asia Minor and thence to Egypt and northern Africa. Nearly the whole of Europe was gradually overrun by the pestilence. It reached Sicily in 1346, Constantinople, Greece, and parts of Italy early in 1347, and towards the end of that year Marseilles. In 1348 it attacked Spain, northern Italy and Rome, eastern Germany, many parts of France including Paris, and England; from England it is said to have been conveyed to the Scandinavian countries. In England the western counties were first invaded early in the year, and London in November. In 1349 we hear of it in the midlands; and in subsequent years, at least till 1357, it prevailed in parts of the country, or generally, especially in the towns. In 1352 Oxford lost two-thirds of her academical population. The outbreaks of 1361 and 1368, known as the second and third plagues of the reign of Edward III., were doubtless of the same disease, though by some historians not called the black death. Scotland and Ireland, though later affected, did not escape.
The nature of this pestilence has been a matter of much controversy, and some have doubted its being truly the plague. But when the symptoms are fully described they seem to justify this conclusion, one character only being thought to make a distinction between this and Oriental plague, viz., the special implication of the lungs as shown by spitting of blood and other symptoms. Guy de Chauliac notes this feature in the earlier epidemic at Avignon, not in the later. Moreover, as this complication was a marked feature in certain epidemics of plague in India, the hypothesis has been framed by Hirsch that a special variety of plague, pestis Indica, still found in India, is that which overran the world in the 14th century. But the same symptoms (haemoptysis) have been seen, though less notably, in many plague epidemics, even in the latest, that in Russia in 1878-79, and, moreover, according to the latest accounts, are not a special feature of Indian plague. According to Surgeon-General Francis (Trans. Epidem. Soc,, vol. v. p. 398) “haemorrhage is not an ordinary accompaniment” of Indian plague, though when seen it is in the form of haemoptysis. It seems, therefore, impossible to make a special variety of Indian plague, or to refer the black death to any such special form. Gabriel de Mussis describes it even in the East, before its arrival in Europe, as a bubonic disease.
The mortality of the black death was, as is well known, enormous. It is estimated in various parts of Europe at two-thirds or three-fourths of the population in the first pestilence, in England even higher, but some countries were much less severely affected. Hecker calculates that one-fourth of the population of Europe, or 25 millions of persons, died in the whole of the epidemics. It is hardly necessary to dwell upon the social results of this terrible mortality. In England great part of the country remained untilled, and the deficiency of labourers was such as to cause a sudden rise of wages, which, in spite of attempts to check it by legislation, is thought to have effected the final emancipation of the labouring class. On the other hand a great transfer of property to the church took place, with what results is well known.
In the 15th century the plague recurred frequently in nearly all parts of Europe. In the first quarter it was very destructive in Italy, in Spain (especially Barcelona and Seville), in Germany, and in England, where London was severely visited in 1400 and 1406, and again in 1428. In 1427 80,000 persons died in Dantzic and the neighbourhood. In 1438-39 the plague was in Germany, and its occurrence at Basel was described by Aeneas Sylvius, afterwards Pope Pius II. In 1448-50 Italy (Kircher), Germany (Lersch, from old chronicles), France, and Spain were ravaged by a plague supposed to have arisen in Asia, scarcely less destructive than the black death. England was probably seldom quite free from plague, but the next great outbreak is recorded in 1472 and following years. In 1466 40,000 persons died of plague in Paris; in 1477-85 the cities of northern Italy were devastated, and in 1485 Brussels. In the fifteenth year of Henry VII. (1499-1500) a severe plague in London caused the king to retire to Calais.
The 16th century was not more free from plague than the 15th. Simultaneously with a terrible pestilence which is reported to have nearly depopulated China, plague prevailed over Germany, Holland, Italy, and Spain in the first decade of the century, and revivedat various times in the first half. In 1529 there was plague in Edinburgh; in London in 1537-39, and again 1547-48; and also in the north of England, though probably not absent before. Some of the epidemics of this period in Italy and Germany are known by the accounts of eminent physicians, as Vochs, Fracastor, Mercurialis, Borgarucci, Ingrassia, Massaria, Amici, &c., whose writings are important because the question of contagion first began to be raised, and also plague had to be distinguished from typhus fever, which began in this"century to appear in Europe.
The epidemic of 1563-64 in London and England was very severe, a thousand dying weekly in London. In Paris about this time plague was an everyday occurrence, of which some were less afraid than of a headache (Borgarucci). In 1570 200,000 persons died in Moscow and the neighbourhood, in 1572 50,000 at Lyons; in 1568 and 1574 plague was at Edinburgh, and in 1570 at Newcastle. When, however, in 1575 a new wave of plague passed over Europe, its origin was referred to Constantinople, whence it was said to have spread by sea to Malta, Sicily, and Italy, and by land through the Austrian territories to Germany. Others contended that the disease originated locally; and, indeed, considering previous history, no importation of plague would seem necessary to explain its presence in Europe. Italysufferedseverely(Venice,inl576,lost 70,000); the north of Europe not less, though later; London in 1580-82. In 1585 Breslau witnessed the most destructive plague known in its history. The great plague of 1592 in London seems to have been a part of the same epidemic, which was hardly extinguished by the end of the century, and is noted in London again in 1599. On the whole, this century shows a decrease of plague in Europe.
In the first half of the 17th century plague was still prevalent in Europe, though considerably less so than in the Middle Ages. In the second half a still greater decline is observable, and by the third quarter the disease had disappeared or was disappearing from a great part of western Europe. The epidemics in England will be most conveniently considered in one series. From this time onwards we have the guidance of the “Bills of Mortality” issued in London, which, though drawn up on the evidence of ignorant persons, are doubtless roughly true. The accession of James I. in 1603 was marked by a very destructive plague which killed 38,000 in London. In this and subsequent years the disease was widely diffused in England—for instance, Oxford, Derbyshire, Newcastle. It prevailed at the same time in Holland, and had done so some years previously in northern Germany. In the same year (1603) one million persons are said to have died of plague in Egypt. This plague is said to have lasted eight years in London. At all events in 1609 we have the second great plague year, with a mortality of 11,785. After this there is a remission till about 1620, when plague again began to spread in northern Europe, especially Germany and Holland, which was at that time ravaged by war. In 1625 (the year of the siege of Breda in Holland) is the third great London plague with 35,417 deaths,—though the year 1624 was remarkably exempt, and 1626 nearly so. In 1630 was the great plague of Milan, described by Ripamouti. In 1632 a severe epidemic, apparently plague, was in Derbyshire. 1636 is the fourth great plague year in London with a mortality of 10,400, and even in the next year 3082 persons died of the same disease. The same year 7000 out of 20,000 inhabitants of Newcastle died of plague; in 1635 it was at Hull. About the same time, 1635-37, plague was prevalent in Holland, and the epidemic of Nimeguen is celebrated as having been described by Diemerbroeck, whose work (Tractatus de Peste, 4to, 1641-65) is one of the most important on the subject. The English epidemic was widely spread and lasted till 1647, in which year, the mortality amounting to 3597, we have the fifth epidemic in London. The army diseases of the Civil Wars were chiefly typhus and malarial fevers, but plague was not unknown among them, as at Wallingford Castle (Willis, “Of Fea vers,” Works, ed. 1681, p. 131) and Dunstar Castle. From this time till 1664 little was heard of plague in England, though it did not cease on the Continent. In Ireland it is said to have been seen for the last time in 1650.
In 1656 one of the most destructive of all recorded epidemics in Europe raged in Naples; it is said to have carried off 300,000 persons in the space of five months. It passed to Rome, but there was much less fatal, making 14,000 victims only—a result attributed by some to the precautions and sanitary measures introduced by Cardinal Gastaldi, whose work, a splendid folio, written on this occasion (Tractatus de avertenda et profliganda peste politico- legalis, Bologna, 1684) is historically one of the most important on the subject of quarantine, &c. Genoa lost 60,000 inhabitants from the same disease, but Tuscany remained untouched. The comparatively limited spread of this frightful epidemic in Italy at this time is a most noteworthy fact. Minorca is said to have been depopulated. Nevertheless the epidemic spread in the next few yeàrs over Spain and Germany, and a little later to Holland, where Amsterdam in 1663-64 was again ravaged with a mortality given as 50,000, also Rotterdam and Haarlem. Hamburg suffered in 1664.
The Great Plague of London.— The preceding enumeration will have prepared the reader to view the great plague of 1664-65 in its true relation to others, and not as an isolated phenomenon. The preceding years had been unusually free from plague, and it was not mentioned in the bills of mortality till in the autumn of 1664 (November 2d) a few isolated cases were observed in the parishes of St Giles and St Martin’s, Westminster, and a few occurred in the following winter, which was very severe. About May 1665 the disease again became noticeable, and spread, but somewhat slowly. Boghurst, a contemporary doctor, notices that it crept down Hol-bqrn and took six months to travel from the western suburbs (St Giles) to the eastern (Stepney) through the city. The mortality rapidly rose from 43 in May to 590 in June, 6137 in July, 17,036 in August, 31,159 in September, after which it began to decline. The total number of deaths from plague in that year, according to the bills of mortality was 68,596, in a population estimated at 460,000, out of whom two-thirds are supposed to have fled to escape the contagion. This number is likely to be rather too low than too high, since of the 6432 deaths from spotted fever many were probably really from plague, though not declared so to avoid painful restrictions. In December there was a sudden fall in the mortality which continued through the winter; but in 1666 nearly 2000 deaths from plague are recorded.
According to some authorities, especially Hodges, the plague was imported into London by bales of merchandise from Holland, which came originally from the Levant; according to others it was introduced by Dutch prisoners of war; but Boghurst regarded it as of local origin. It is in favour of the theory that it spread by some means from Holland that plague had been all but extinct in London for some seventeen years, and prevailed in Holland in 1663-64. But from its past history and local conditions, London might well be deemed capable of producing such an epidemic. In the bills of mortality since 1603 there are only three years when no deaths from plague are recorded. The uncleanliness of the city was comparable to that of Oriental cities at the present day, and, according to contemporary testimony (Garencières, Angliae Flagellum, London 1647, p. 85), little improved since Erasmus wrote his well-known description. The spread of the disease only partially supported the doctrine of contagion, as Boghurst says:—“The disease spread not altogether by contagion at first, nor began only at one place and spread further and further as an eating sore doth all over the body, but fell upon several places of city and suburbs like rain.” In fact dissemination seems to have taken place, as usual, by the conversion of one house after another into a focus of disease, a process favoured by the fatal custom of shutting up infected houses with all their inmates, which was not only almost equivalent to a sentence of death on all therein, but caused a dangerous concentration of the poison. The well-known custom of marking such houses with a red cross and the legend ‘ 1 God have mercy upon us !” was no new thing: it is found in a proclamation in the possession of the present writer dated 1641; and it was probably older still. Hodges testifies to the futility and injurious effects of these regulations. The lord mayor and magistrates not only carried out the appointed administrative measures, but looked to the cleanliness of the city and the relief of the poor, so that there was little or no actual want; and the burial arrangements appear to have been well attended to. The college of physicians, by royal command, put forth such advice and prescriptions as were thought best for the emergency. But it is clear that neither these measures nor medical treatment had any effect in checking the disease. Early in November with colder weather it began to decline; and in December there was so little fear of contagion that those who had left the city “crowded back as thick as they fled.” As has often been observed in other plague epidemics, sound people could enter infected houses and even sleep in the beds of those who had died of the plague “before they were even cold or cleansed from the stench of the diseased” (Hodges). The symptoms of the disease being such as have been generally observed need not be here considered. The disease was, as always, most destructive in squalid, dirty neighbourhoods and among the poor, so as to be called the “poor’s plague.” Those who lived in the town in barges or ships did not take the disease; and the houses on London Bridge were but little affected. Of those doctors who remained in the city some eight or nine died, not a large proportion. Some had the rare courage to investigate the mysterious disease by dissecting the bodies of the dead. Hodges implies that he did so, though he left no full account of his observations. Dr George Thomson, a chemist and a disciple of Van Helmont, followed the example, and nearly lost his life by an attack which immediately followed.
The plague of 1665 was widely spread over England, and was generally regarded as having been transmitted from London, as it appeared mostly later than in the metropolis, and in many cases the importation by a particular person could be traced. Places near London were earliest affected, as Brentford, Greenwich, Deptford; but in July or August 1665 it was already in Southampton, Sunderland, Newcastle, &c. A wider distribution occurred in the next year. Oxford entirely escaped, though the residence of the court and in constant communication with London. The exemption was attributed to cleanliness and good drainage.
After 1666 there was no epidemic of plague in London or any part of England, though sporadic cases appear in bills of mortality up to 1679; and a column filled up with “0” was left till 1703, when it finally disappeared. The disappearance of plague in London was attributed to the Great Fire, but no such cause existed in other cities. It has also been ascribed to quarantine, but no effective quarantine was established till 1720, so that the cessation of plague in England must be regarded as spontaneous.
But this was no isolated fact. A similar cessation of plague was noted soon after in the greater part of western Europe. In 1666 a severe plague raged in Cologne and on the Rhine, which was prolonged till 1670 in the district. In the Netherlands there was plague in 1667-69, but there are no definite notices of it after 1672. France saw the last plague epidemic in 1668, till it reappeared in 1720. In the years 1675-84 a new plague epidemic appeared in North Africa, Turkey, Poland, Hungary, Austria, and Germany, progressing generally northward. Malta lost 11,000 persons in 1675. The plague of Vienna in 1679 was very severe, causing 76,000 or probably more deaths. Prague in 1681 lost 83,000 by plague. Dresden was affected in 1680, Magdeburg and Halle in 1682,—in the latter town with a mortality of 4397 out of a population of about 10,000. Many North German cities suffered about the same time; but in 1683 the plague disappeared from Germany till the epidemic of 1707. In Spain it ceased about 1681; in Italy certain cities were attacked till the end of the century, but not later (Hirsch).
Plague in the 18iΛ Century.— At the beginning of this period plague was very prevalent in Constantinople and along the Danube. In 1703 it caused great destruction in the Ukraine. In 1704 it began to spread through Poland, and later to Silesia, Lithuania, Prussia, and a great part of Germany and Scandinavia. In Prussia and Lithuania 283,000 persons perished; Dantzic, Hamburg, and other northern cities suffered severely. Copenhagen was attacked in 1710. In Stockholm there was a mortality of 40,000. Certain places near Brunswick (10° E. long.) marked the western limit of the epidemic; and cholera was arrested at the same spot in later years (Haeser).
At the same time the plague spread westward from the Danube to Transylvania and Styria, and (1713) appeared in Austria and Bohemia, causing great mortality in Vienna. Thence it passed to Prague and Ratisbon—to the former, possibly to the latter, almost certainly conveyed by human intercourse. This city (12° E. long.) was the western limit reached in this year. Haeser states that the plague disappeared everywhere in Europe after the great hurricane of February 27, 1714.
In 1717 plague raged severely in Constantinople; and in 1719 it made a fresh progress westwards into Transylvania, Hungary, Galicia, and Poland, but not farther (about 20° E. long.). It thus appears that each successive invasion had a more easterly western limit, and that the gradual narrowing of the range of plague, which began in the 17th century, was still going on.
This process suffered a temporary interruption by the outbreak of plague of southern France in 1720-22. In 1720 Marseilles became affected with an epidemic plague, the origin of which was attributed by some to contagion through the ship of a Captain Chataud which arrived, May 20, 1720, from Syria, where plague at that time prevailed, though not epidemically when he sailed. Six of the crew had died on the voyage to Leghorn, but the disease was declared not to be plague. Cases of plague occurred, however, on the ship, and on June 22 among porters unloading the cargo. Hence, according to believers in contagion, the disease passed to families in the “old town,” the poorest and unhealthiest quarter. In the meantime other ships had arrived from Syria, which were put in quarantine. According to others the plague arose in Marseilles from local causes; and recently discovered data show that suspicious cases of contagious disease occurred in the town before the arrival of Chataud’s ship. Opinions were divided, and the evidence appears even now nearly balanced, though the believers in contagion and importation gained the victory in public opinion. The pestilence was fearfully severe. Thousands of unburied corpses filled the streets, and in all 40,000 to 60,000 persons were carried off. In December 1721 the plague passed away, though isolated cases occurred in 1722. It passed to, or at least broke out in, Arles and Aix in 1720, causing great mortality, but in Toulon not till 1721, when it destroyed two-thirds of the population. The epidemic spread generally over Provence, but not to other parts of France, notwithstanding that, as confessed by D’Antrechaus, consul of Toulon, a believer in the exclusive power of contagion, there were abundant opportunities. The disease was in fact, as in other cases, self-limited. In all 87,659 persons are said to have died out of a population of nearly 250,000.
This great epidemic caused a panic in England, which led to the introduction (under Mead’s advice) of quarantine regulations, never previously enforced, and also led to the publication of many pamphlets, &c., beside Mead’s well-known Discourse on Pestilential Contagion (London, 1720).
^Plague in Sicily in 1743.—An outbreak of plague at Messina in 1743 is important, not only for its fatality, but as one of the strongest cases in favour of the theory of imported contagion. Messina had been free from plague since 1624, and the Sicilians prided themselves on the rigour of the quarantine laws which were thought to have preserved them. In May 1743 a vessel arrived from Corfu, on board of which had occurred some suspicious deaths. The ship and cargo were burnt, but soon after cases of a suspicious form of disease were observed in the hospital and in the poorest [»arts of the town; and in the summer a fearful epidemic of plague developed itself which destroyed 40,000 or 50,000 persons, and then became extinct without spreading to other parts of Sicily.
Spread of Plague from the East.— Independent of the episodes of Marseilles and Messina, the spread of plague from the East continued to exhibit the above-mentioned law of limitation. In 1738-44 the disease was in the Ukraine, Hungary, the borders of Carniola, Moravia, and Austria, extending along the Carpathians as far as Poland (20° E. long.), and also in Bukowina (25° E. long.). It lasted till 1745, and then disappeared from those parts for fifteen years. In 1755-57 plague prevailed in parts of European Turkey, whence it on one occasion extended into Transylvania, in the neighbourhood of Cron⅛tadt, where it was checked (25° '5 E. long.).
In 1770 a destructive plague arose in Moldavia during the Russo-Turkish War, and shortly afterwards in Wallachia, apparently endemic in the former country at least. It affected also Transylvania and part of Hungary, and still more severely Poland, but was confined to Podolia, Volhynia, the Ukraine, and the eastern part of Galicia (25° E. long.), not even penetrating as far as Warsaw. After destroying, it is said, 300,000 persons, and without being checked by any quarantine regulations, the plague died out finally in March 1771, being remarkable for its short duration and spontaneous limitation (Haeser).
In another direction the plague spread over Little Russia in 1770, and desolated Kieff, while in the next year it broke out in Moscow and produced one of the most destructive epidemics of modern times. More than 50,000 persons, nearly one-fourth of the population, were carried off.
The remaining European plague-epidemics of the 18th century were inconsiderable, but on that very account noteworthy. Transylvania was again affected in 1785, Slavonia and Livonia (a district of eastern Galicia) in 1795-96 (25°E. long.), Volhynia in 1798. The disease, while reappearing in the seats of the terrible earlier epidemics, was more limited in its range and of shorter duration. An epidemic in Dalmatia in 1783-84 is noteworthy in connexion with later outbreaks in the same region. In the last years of the century (1799-1800) there was a new epidemic in Syria and Egypt, where it affected the French and afterwards the English army.
Plague in the Pèth Century.— This history divides itself naturally into two periods—1800-1845, and 1853 to the present time.
1800-1845.—Plague appeared at Constantinople in 1802-3, about the same time in Armenia (Kars), and in 1801 in Baghdad. It had prevailed since 1798 in Georgia and the Caucasus, and in 1803-6 began to spread from the north of the Caucasus into Russia, till in 1806 it was established at or near Astrakhan, and in 1807 reached Zareff, 200 miles higher up the Volga. These localities are interesting as being near those where plague appeared in 1877-78. It is also said to have entered the government of Saratoff, but probably no great distance. The plague remained in the Caucasus and Georgia till 1819 at least. In 1828-31 it was in Armenia, and again in 1840-43, since which time it has not been heard of in that country.
In 1808 plague was at Constantinople, in 1809 at Smyrna. In 1812 was a more general epidemic affecting these places and also Egypt. An outbreak at Odessa is supposed to have been brought from Constantinople and thence to have passed to Transylvania. In 1813 a severe plague at Bucharest is supposed to have been brought from Constantinople. About the same time plague prevailed in Bosnia, and is supposed to have passed thence to Dalmatia in 1815. In 1814-15 it again appeared in Egypt, and once more invaded the continent of Europe in Albania and Bosnia. Two insular outbreaks, Malta in 1813 and Corfu in 1815, attracted much attention as being both thought to be cases of importation by sea-traffic, and there seems good reason for this opinion.
A panic spread through Europe in 1815 in consequence of an outbreak in Noja on the eastern coast of Italy, its last appearance in that country. According to one view it was imported from the opposite coast of Dalmatia, though no definite history of contagion ιvas established; according to others, it originated endemically in that place. It remained, however, strictly confined to a small district, perhaps in consequence of the extraordinarily rigorous measures of isolation adopted by the Italian Government. In 1828 an isolated epidemic appeared in Greece in the Morea, supposed to have been brought by troops from Egypt. In 1824-25 an outbreak took place at Tutchkoff in Bessarabia; the town was strictly isolated by a military cordon and the disease did not spread. Cronstadt in Transylvania was the scene of a small outbreak in 1828, which was said to be isolated by similar measures (Lorinser). A far more serious epidemic was connected with the campaign of the Russian army against Turkey in 1828-29. Moldavia, Wallachia, and Bessarabia were widely affected; the disease broke out also in Odessa and the Crimea, and isolated cases occurred in Transylvania. The most northerly points reached by the plague were near Czernowitz on the frontier of Bessarabia, and Bukowina, and its limitation was as before attributed to the Russian and Austrian military cordons.
In 1831 another epidemic occurred in Constantinople and Roumelia; in 1837 again in Roumelia, and in Odessa,—its last appearance in those regions, and the last on the European continent except an isolated outbreak in Dalmatia in 1840, and one in Constantinople in 1841.
The plague-epidemics in Egypt between 1833 and 1845, when it was last observed in that country, are very important in the history of plague, since the disease was almost for the first time scientifically studied in its home by skilled European physicians, chiefly French. The disease was found to be less contagious than reported to be by popular tradition, and most of the French school went so far as to deny the contagiousness of the disease altogether. The epidemic of 1834-35 was not less destructive than many of those notorious in history; but in 1844-45 the disease disappeared, and it has never been seen since in the country which was for centuries regarded as its native home. This result can hardly be attributed to quarantine, though it is probable that increased attention to sanitary measures under the influence of educated medical officials may have had much to do with it. But on the large scale it is a part of the great eastward recession of the plague, which is an undoubted fact, however it is to be explained. In 1840 Dalmatia (17° E. long.), in 1841 Constantinople (29° E. long.), in 1843-44 the eastern parts of Egypt (31° E. long.), were the western boundaries of plague. The same law has, with one notable exception, been observed since.
1853-84.—Since the apparent extinction of plague in Egypt in 1845, it has appeared in several points of Asia and Africa, and once in Europe.
In 1853 plague appeared in a district of western Arabia, the Asir country in North Yemen, and it is known to have occurred in the same district in 1815, as it did afterwards in 1874 and 1879. In 1874 the disease extended within four days’ march of Mecca. From the scantiness of population the mortality has not been great, but it is clear that this is one of the endemic seats of plague.
In June 1858 intelligence was received in Constantinople of an outbreak of disease at the small town Benghazi, in the district of Barca, province of Tripoli, North Africa, which though at first misunderstood was clearly bubonic plague. From later researches there is reason to believe that it commenced in 1856 or in 1855. The disease did not spread, and ceased in the autumn, to return with less violence in 1859, when it died out. In the autumn of 1873 it returned, but apparently came again to a spontaneous termination. At all events it has not been heard of since.
After the epidemic of Benghazi in 1856-59, plague was next heard of in the district of Maku, in the extreme north-west of Persia in November 1863. It occurred in a scattered population, and the mortality was not absolutely large.
In 1867 an outbreak of plague was reported in Mesopotamia (Irak), among the marshes of Hindieh bordering on the lower Euphrates; and, as it has prevailed at intervals up to the present time in the same country, great importance attaches to its history. The epidemic began in December 1866 (or probably earlier) and ceased in June 1867. But numerous cases of non-fatal mild bubonic disease (mild plague or pestis minor') occurred both before and after the epidemic, and according to Tholozan similar cases had been observed nearly every year from 1856 to 1865.
The next severe epidemic of plague in Irak began in December 1873. But facts collected by Tholozan show that pestis minor, or sporadic cases of true plague, had appeared in 1868 and subsequent years. The outbreak of 1873-74 began about 60 miles from the origin of that of 1867. It caused a much greater mortality and extended over a much wider area than that of 1867, including the towns of Kerbela and Hilleh. After a short interval it reappeared at Diyanieh in December 1874, and spread over a much wider area than in the previous epidemics. This epidemic was carefully studied by Surgeon-Major Colvill. He estimated the mortality at 4000. The epidemic ceased in July, but broke out again early in 1876, and in this year extended northwards to Baghdad and beyond. The whole area now affected extended 250 miles from north-west to south-east, and the total number of deaths was believed to be 20,000. In 1877 plague also occurred at Shuster in south-west Persia, probably conveyed by pilgrims returning from Irak, and caused great mortality.
After its customary cessation in the autumn (a pause attributed as before to the efficiency of quarantine regulations), the epidemic began again in October 1876, though sporadic cases occurred all the summer. The disease appeared in 1877 in other parts of Mesopotamia also with less severity than in 1876, but over a wider area, being now announced at Samara, a town 70 miles above Baghdad on the Tigris. Since then the existence of plague in Baghdad or Mesopotamia has not been announced till the year 1884, when accounts again appeared in the newspapers, and in July the usual official statement occurs that the plague has been stamped out. The above account of plague in Irak is the most complete history of a succession of epidemics in one country which we have had of late years.
To complete the history of plague in Persia it should be stated that in 1870—71 it appeared in a district of Mukri in Persian Kurdistan to the south of Lake Urumiah (far removed from the outbreak of 1863). The epidemic appears, however, to have died out in 1871, and no further accounts of plague there have been received. The district had suffered in the great epidemic of plague in Persia in 1829-35. In the winter 1876-77 a disease which appears to have been plague appeared in two villages in the extreme north of the province of Khorasan, about 25 leagues from the south-east angle of the Caspian Sea. In March 1877 plague broke out in Resht, a town of 20,000 inhabitants, in the province of Ghilan, near the Caspian Sea at its south-west angle, from which there is a certain amount of trade with Astrakhan. In 1832 a very destructive plague had carried off half the inhabitants. In 1877 the plague was very fatal. From March to September 4000 persons were calculated to have died. The disease continued till the spring of 1878. In 1877 there was a doubtful report of the same disease at Astrabad, and also in some parts near the Perso-Afghan frontier. In 1878 plague again occurred in Kurdistan in the district of So-uj-Bulak, said by Dr Tholozan to be the same as in the district of Mukri where it occurred in 1870-71. These scattered outbreaks of plague in Persian territory are the more remarkable because that country has been generally noted for its freedom from plague (as compared with Asiatic Turkey and the Levant).
It has since been known that a few cases of plague occurred in January 1877 at Baku on the west shore of the Caspian, in Russian territory.
The last outbreak of plague on European soil was that of 1878-79 on the banks of the Volga, which caused a panic throughout Europe. It is now known that in the summer of 1877 a disease prevailed in several villages in the neighbourhood of Astrakhan and in the city itself, which was clearly a mild form of plague (pestis minor). It caused no deaths (or only one due to a complication) and died out apparently spontaneously. An official physician, Dr Kastorsky, who investigated the matter for the Government, declared the disease to be identical with that prevailing in the same year at Resht in Persia; another physician, Dr Janizky, even gave it the name of pestis nostras. In October 1878 some cases appeared in the stanitza or Cossack military settlement of Vetlanka, 130 miles from Astrakhan on the right bank of the Volga, which seem to have puzzled the physicians who first observed them, but on November 30th were recognized as being but the same mild plague as had been observed the year before near Astrakhan by Dr Döppner, chief medical officer of the Cossacks of Astrakhan. His report on the epidemic is the only original one we have. At the end of November the disease became suddenly more severe, and most of those attacked died; and from the 21st December it became still more malignant, death occurring in some cases in a few hours, and without any buboes being formed. No case of recovery was known in this period. At the end of the year it rapidly declined, and in the first weeks of January still more so. The last death was on January 24. In the second half of December, when the disease had already lasted two months, cases of plague occurred in several neighbouring villages, all of an extremely malignant type, so that in some places all who were attacked died. In most of these cases the disease began with persons who had been at Vetlanka, though this was not universally established. The inhabitants of these villages, terrified at the accounts from Vetlanka, strictly isolated the sick, and thus probably checked the spread of the disease. But it evidently suffered a spontaneous decline. By the end of January there were no cases left in the district except at one village (Selitren-noye), where the last occurred on the 9th February. The total number of cases in Vetlanka, out of a population of about 1700, was 417, of whom 362 died. In the other villages there were about 62 deaths from plague, and not more than two or three cases of recovery. In consequence of the alarm excited by this last appearance of plague upon European soil, most European Governments sent special commissions to the spot. The British commissioners were Surgeon-Major Colvill and the present writer, who, like all the foreign commissioners, reached the spot when the epidemic was over. With respect to the origin of this epidemic, the possibility of its having originated on the spot, as in Resht and on the Euphrates in very similar situations, is not to be denied. An attempt was made to show that the contagion was brought home by Cossacks returning from the Turkish War, but on absolutely no evidence. In the opinion of the writer the real beginning of the disease was in the year 1877, in the vicinity of Astrakhan, and the sudden development of the malignant out of a mild form of the disease is no more than has been observed in other places. The Astrakhan disease may have been imported from Resht or Baku, or may have been caused concurrently with the epidemics of these places by some cause affecting the basin of the Caspian generally. But the conditions under which these mild or miasmatic forms of plague are spread are as yet unknown.
Plagia: in India,.— It used to be held as a maxim that plague never appeared east of the Indus; nevertheless it has been observed during this century in more than one distinct centre in India. So long ago as 1815 the disease appeared in Guzerat, Kattywar, and Cutch, “after three years of severe famine.” It reappeared early next year, in the same locality, when it extended to Sind as far as Hyderabad, and in another direction south-east as far as Ahmedabad and Dhollerah. But it disappeared from these parts in 1820 or early in 1821, and was not heard of again till July 1836, when a disease broke out into violence at the town of Pali in Mar war in Raj pu tana. It spread from Pali to the province of Meywar, but died out spontaneously in the hot season of 1837, and has never been heard of again in that part of India. The origin of these two epidemics was obscure. No importation from other countries could be traced.
In 1823 (though not officially known till later) an epidemic broke out at Kedarnath in Gurwhal, a sub-district of Kumaon on the south-west of the Himalayas, on a high situation. In 1834 and 1836 other epidemics occurred, which at last attracted the attention of Government. In 1849-50, and again in 1852, the disease raged very severely and spread southward. In 1853 Dr Francis and Dr Pearson were appointed a commission to inquire into the malady. In 1876-77 another outbreak occurred, since which time no accounts of the epidemic have been received. The symptoms of this disease, called maha murree by the natives, are precisely those of Oriental plague. The feature of blood-spitting, to which much importance has been attached, appears to be not a common one. A very remarkable circumstance is the death of animals (rats, and more rarely snakes), which occurs at the outbreak of an epidemic. The rats bring up blood, and the body of one examined after death by Dr Francis showed an affection of the lungs. Maha murree is intensely communicable, but does not show much tendency to spread, since pilgrims who visit the mountain shrines are not affected and do not convey the disease. It is doubtless connected with uncleanliness and poverty, but Dr Francis believes that the poison exists in the soil, which becomes more and more contaminated with it. The disease is pretty clearly endemic, not imported.
It is remarkable that of late years reports have come of the occurrence of Oriental plague in China. It has been observed in the province of Yunnan since 1871, and also at Pakhoi, a port in the Tong-king Gulf, as lately as 1882,—but said to have prevailed there at least fifteen years. In Yunnan it appears to be endemic, though there are rumours of its having been brought from Burmah, and become more noticeable after the suppression of a rebellion in that province. The climate is temperate and the country partly mountainous. Some regard the disease as being conveyed from Pakhoi to Yunnan. In both places the symptoms were the same, of undoubted bubonic plague. It has always been noticed, as in India, that rats leave their holes and die at the beginning of an epidemic; and the same mortality has been observed among cats, dogs, cattle, ponies, deer, &c. At Pakhoi it recurs nearly every year. Uncleanly habits have much to do with fostering the disease.
It thus appears that at the present time plague exists, or has existed within ten years, in the following parts of the world :—(1) Benghazi, Africa; (2) Persian Kurdistan; (3) Irak, on the Tigris and Euphrates; (4) the Asir country, western Arabia; (5) on the lower Volga, Russia; (6) northern Persia and the shores of the Caspian; (7) Kumaon and Gurhwal, India; (8) Yunnan and Pakhoi, China. Except Benghazi all these places show an eastward recession as compared with the old seats of plague known to us.
Literature.— See the following works, besides those already quoted Kanιin-tus, Regim en contra epidinιiam sice pestem, 4to, circa 1494 (many editions); Jacobus Soldus, Opus insigne de Peste, 4to, Bologna, 1478; Alex. Benedictus, De Observatione in Pestilentia, 4to, Ven., 1493; Nicolaus Massa, De Febre Pestilenti ι, 4to, Ven., 1556, &c.; [Fioravanti, Regimento della Peste, 8vo, Ven., 1565]; John Woodall, The Surgeon's Mate, folio, London, 1639; Van Helmont, Tumulus Pestis, 8vo, Cologne, 1644, &c.; [Muratori, Trattato del Ooιerno della Peste, Modena, 1714]; John Howard, An Account of Lazarettoes in Europe, <fcc., 4to, London, 1789; Patrick Russell, A Treatise of the Plague, 4to, London, 1791; Thomas Hancock, Researches into the Laics of Pestilence, 8vo, London, 1821; [Foderé, Leçons sur les Epidémies, <tc., 4 vols. 8vo, Paris, 1822-24]; [Ségur Dupeyron, Recherches Historiques, <kc., sur la Peste, 1837]; Bulard, La Peste Orientale, 8vo, Paris, 1839; Griesinger, Die Infectionskrankheiten, 2d e<l., 8vo, Erlangen, 1864.
