NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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In severe cases brown sordes collect upon the lips and teeth, the
patient survives some days, and fatal cases towards the end of the first
week usually show such phenomena. The gums may be soft and spongy,
rarely ulcerated, and hemorrhages were never seen.
The appetite is not impaired ; indeed the patient can take food fairly
well throughout. Of course, cases with coma, stupor, and wild delirium
refuse food, and do badly as a rule. Convalescence is not ushered in, there-
fore, with any improvement in the appetite or ravenous craving for food.
Thirst is present in nearly all cases, but is rarely excessive ; and some-
times most thirst was complained of in cases of a mild type and without
high temperature or excessive secretion of wine or sweat. It is one of
the earliest symptoms of the disease, and the patient often mentions it
as part of the initial history of the attack. Sometimes dysphagia is
present, and this was noted especially in cases where the glands in the
anterior triangle of the neck were enlarged and surrounded with a good
deal of infiltration and œdema. Such cases rapidly proved fatal, and
œdema of the glottis and marked inflammation of the pharynx and trachea
were found in post mortem.
Nausea and vomiting are common early symptoms. One or other
or both were present in 60 per cent, of the acute cases admitted. The
vomited matter was bilious in character, frequently repeated, affording no
relief, and occurring independently of the injection of food, medicines, or
stimulants. It was undoubtedly of cerebral origin, due probably to the
action of toxines on the nervous centres. Sometimes vomiting persisted,
and was a troublesome symptom even during convalescence. In its
treatment camphorodyne, bromide of ammonium, hydrocyanic acid and ice
(to suck) were found useful.
Tympanitis was not a frequent symptom. In puerperal cases,
which aborted, it was very marked. The abdomen is not distended, but
generally soft, flat, or flaccid. In the puerperal cases it was associated
with tenderness and cerebral depression and prostration, but not with
diarrhoea. Gurgling was only detected in one case, and that was of the
abdominal or typhoid type, and in a European, and was accompanied by
frequent, very offensive, acid motions, and was general over the abdomen
and not localized in the right iliac fossa. Abdominal pain was seldom
present and scarcely ever complained of, and tenderness only occasionally
noticed. The liver and spleen were in some cases found enlarged, but
more frequently those organs could not be palpated clinically. The spleen
is more generally found enlarged than the liver, and in the majority of
the post mortems this was apparent.
Constipation, in natives, was invariably found to prevail in the early
stage of the disease ; indeed diarrhoea was only present in one case of
enteric type in a European. The constipation was so obstinate as to
require a calomel and jalap purgative in most instances, and this
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otherwise, ran their course without diarrhoea supervening. During con-
valescence diarrhoea sometimes came on as a sequela, or associated and
followed by dysentery. The motions in plague are usually acid and were
not, in a single instance, found to contain bacilli although carefully looked,
for, both before and after the administration of purgatives and at different
intervals by the members of the German Plague Commission.
The Urine.—The urine diminished in quantity, and in three severe
cases it was completely suppressed. It is usually reddish-brown or darker
than normal in the early stage ; and, in convalescence, the color becomes
pale and limpid and the quantity increased. The re-action was acid, and
the specific gravity from 1,015 to 1,030 in 30 acute cases specially examined,
and the average of urea, uric acid, and chlorides diminished, and albumen
1\20 to 1\10 present in 33 per cent. of the cases. Tube casts were found in the
sediment of 15 per cent. of the cases examined in the forms of granular
epithelial and hyaline plugs. Albumen was tested for by heat and nitric
acid—the ordinary clinical tests—and during the period extending from
the third to the tenth day of the disease ; and was not found during con-
valescence. Bile pigments were generally present.
The urine, with one exception and that a fatal case, yielded negative
bacteriological results, and in no case was blood passed in or with the urine.
In only three cases was retention of urine present, necessitating the
use of the catheter ; and all of them had grave cerebral symptoms and
ended fatally.
Nervous Symptoms.—One of the earliest and most constant symp-
toms of plague is headache. It was found at some stage, in 94 per cent.
of acute cases, was severe ; and the patient complained of it during the first
few days in the majority of such cases. Headache is most often frontal
or temporal in seat, rarely vertical or occipital, and is of a dull heavy
character ; sometimes intense, or ill-defined and throbbing, and in still
fewer cases it may be absent.
Giddiness in most cases is complained of as a very early symptom
along with headache, and prevents the patient from sitting up, walking
about, or attending to his duties. It is very rarely, indeed, that pains in
the loins, back, or limbs are met with, so that the disease can hardly be
simulated by small-pox back-ache.
Delirium and obscuration of the mental faculties are almost invari-
ably met with at some period in this disease, although mild cases are
met with which never become delirious or show mental confusion. The
character and amount of delirium vary greatly, and present no relation
to the severity of the attack. Of 100 consecutive cases mental aberration
or delirium was present in 74 at some period. The patient is apathetic,
hesitating, stupid, and his mental faculties blunted and confused, whilst he
appears irritable and does not like to be disturbed. The delirium appears
early, often at the very beginning of the disease, and is most marked at
night throughout. Sometimes patients appear wakeful and delirious by
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night, and stupid, drowsy, and comatose by day. If the patient is about
to recover, delirium ceases. Some cases develope late maniacal delirium
during convalescence, refuse food, and die of marasmus in spite of forced
feeding, When delirium is present, headache is not a prominent symptom,
or else the patient is too mentally confused to complain of it.
Most commonly the delirium is of a low muttering type ; when left
to himself the patient is restless, and irritable, and, when roused, answers
in a slow, hesitating, rambling, and incoherent manner, and with great
effort apparently.
Some patients are fidgety, tossing their limbs about, drawing up their
leg and shooting it out fully extended again, move about in bed, try
to get up without definite object, laugh, sigh, moan, and have busy
delirium like the delirium tremens of the drunkard.
Occasionally there is wild, fierce, maniacal delirium. The patient is
sleepless, rolls his head about, shouts, refuses all nourishment, and is re-
strained with great difficulty. The muscular power of such a patient may
be surprising, and one young girl required considerable strength to keep
her in bed. This form of delirium soon ends in collapse, profound mus-
cular and nervous prostration and death. This wild form of delirium was
mostly seen in young and strongly-built muscular patients, and the few
who recovered from such a state remembered nothing of it, the mind ap-
pearing to remain a perfect blank.
Sleeplessness was noted in 90 per cent. of acute cases, and is one of
the earliest symptoms, and may be present for several days and nights in
succession. It is a favorable sign when a patient sleeps well and
naturally. Somnolence, apart from stupor and coma, was not met with;
and coma-vigil not observed.
Prostration and loss of muscular tone are early developed, but these
would appear to depend on implication of the nerve centres ; and in some
cases the patient has voluntarily walked some distance to the hospital, to
die in a day or two of extreme nervous prostration.
As a rule, prostration increases with the advance of the disease, and
is marked in those who have had delirium and great excitement and strug-
gling when unconscious. Prostration may develope quite suddenly and
prove rapidly fatal in persons who, but an hour before, were apparently
quite on the way to ultimate recovery. Should a patient recover from
such a prostrate condition, there are great lassitude, weakness, and want
of energy for a long time, following it. Along with the prostration there
is usually dorsal decubitus.
The general absence of involuntary discharge of fæces and urine
and the only occasional retention of urine show that muscular paralysis
does not often exist ; whilst conjunctivitis and ulcération of the corneæ
from inability to close the eyelids point to nervous centres poisoned by
the products of the specific bacillus.
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Sub-sultus tendinum and spasmodic contractions of the hands, arms,
and face are seen in severe cases, and in one case the spasms succeeded
each other at the rate of 18 to 20 per minute and affected the flexors and
adductors of both upper extremities. In this case double axillary buboes
appeared within the first 24 hours simultaneously.
Convulsions, in very young children, seemed to take the place of
delirium, and the little patients in four instances expired apparently from
the very severity of the convulsions, overwhelmed with acute toxæmia
before an inflamed gland had developed.
Other forms of spasmodic movements were seen in some fatal cases
in the fumbling at the bed-clothes and aimless tossing of the arms ;
and, in a few patients, hiccough, from which few patients recovered. Con-
vulsions usually ended in coma and death, and in three cases the
convulsions were noted during the death agony.
The marked prominence of nervous symptoms shows that the brunt
of the disease falls on the nerve centres, and that the toxines absorbed
from, the primarily inflamed gland into the blood, or, in pneumonic
cases, formed directly in the blood, act injuriously by a sort of selective
affinity on the nervous system. The great frequency of nervous sequelæ
confirms this to demonstration.
SPECIAL SENSES.
Eyes. —The conjunctivæ are generally injected, and in more than
half the acute cases were markedly so, at the beginning of the disease,
and the eyes suffused. There may be leashes of inflamed and engorged
vessels often noticed at the two canthi, especially where the pressure
of the lids is wanting. This injection of the ocular conjunctivæ is a
valuable diagnostic sign as it is met with early, and generally in cases in
which a characteristic bubo has not appeared.
Acute conjunctivitis was seen in five cases, hypopyonin one case, and
ecchymosis in two cases, whilst ulcération, panophthalmitis, and chemosis
were among the sequelæ which developed in seven convalescents.
Photophobia did not appear to be present, and patients never com-
plained of it.
The pupils were most frequently normal, next most frequently con-
tracted, and very seldom dilated or unequal.
Ears.—Deafness is generally present; as the patient, when addressed in
the ordinary tone of voice, will often ask to have the question repeated, and
even then only understands when he is spoken to loudly and distinctly.
Patients who had not been getting quinine appeared to suffer, and
syringing of the ears did not lessen the deafness : of which the explana-
tion is difficult. The dulness of the mental faculties may be the cause of
this apparent deafness.
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Otorrhcea did not occur in a single case, nor was inflamation of the
meatus or membrane tympani seen.
Smell.—Parosmia and Epistaxis were never seen at any time.
Taste.—The sense of taste is not affected, and patients usually partake
of whatever is given them with apparent relish. Very occasionally a
patient complained of an acid bitter taste in the mouth ; but none ever
mentioned a bad taste.
Sensibility and Touch.—Perversions of the sense of touch, were
never noted.
COMPLICATIONS AND SEQUELAE OF PLAGUE.
Many cases develope complications and sequelæ which prolong the
course of the primary fever and delay convalescence, and ultimately turn
the chances of recovery against the patient and cause his death.
The most frequent complication was broncho-pneumonia which de-
veloped in a course of the disease in 19 cases ; 17 ending fatally. The
disease began insidiously, and between the 4th and 8th day ; cough and
slight expectoration being present. Pain in the chest is seldom com-
plained of. Very often a rise in the temperature and quickened breath-
ing were the first indications of its onset.
Of the 19 cases, 12 were men, 5 women and 2 children. The physi-
cal signs were confined to a small area, and slight. Bronchitis was only
noticed in 2 cases.
Pneumonia as a primary affection was seen in 9 cases. In none of
the primary Pneumonia cases were tangible buboes found. The disease
began as pneumonia, but the temperature was not very high, and only a few
scattered patches in one lobe generally were detectable on auscultation.
Expectoration was sero-mucoid, scanty, and occasionally tinged with blood.
The sputum was rich in bacilli and yielded pure cultures by growth \ill\.
agar-agar. All primary pneumonia cases at Parel hospital ended fatally.
One case developed left Pneumo-thorax which proved fatal 37 days after
admission, and this was the latest day on which an acute case died in Parel
hospital. Pleurisy is not a common complication and is latent, no sharp
pain being complained of, and the effused fluid quickly absorbed, never
becoming purulent in the 2 cases noted ; these both ended in recovery.
Phthisis came on in 2 cases during convalescence and carried off
the patients. Rapid emaciation and debility, profuse sweating, purulent
expectoration and hectic fever, but no hæmoptysis, were the prominent
symptoms.
Laryngitis occurred in 5 cases and proved to be a serious compli-
cation. In all instances a bubo in the. anterior part of the neck, or be-
neath the sterno-neastoid or in the parotid region, accompanied or preceded
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the laryngitis and all ended fatally by ædema of the glottis and enormous
oedema of the subcutaneous cellular tissue of the neck below the jaw and
in front of the throat. In most cases this swelling came on rapidly and
changed—by partially obscuring—the features of the sufferer.
DISEASES OF THE NERVOUS SYSTEM.
Meningitis.—True meningitis came under notice in 2 cases and both
ended fatally. Inflammation of the membranes of the brain was dis-
covered at the post-mortems.
The frequent presence of symptoms of cerebral disturbance and the
rarity of true meningeal inflammation would seem to prove that the symp-
toms depend on toxæmia.
Imbecility and mania are rarely developed after plague. Only two
convalescents showed signs of imbecility in the form of delirium, refusal
to take food, marasmus, dementia and death; and one patient transferred
from another hospital had mania as a late sequela.
As a rule the mental faculties are completely restored after the first
few days of convalescence ; so that organic brain lesion must be rare.
There was no fever or headache accompanying the imbecility ; but
anæmia and mental depression.
Tonics, stimulants, and sedatives to induce sleep—preferably opium—
benefited such cases.
Paralysis.—Paralysis is frequently seen as a sequela of plague. In
Parel 7 patients developed Aphasia in from 10 days to 30 days after the
beginning of convalescence. All recovered speech before being discharged ;
and the longest period during which a patient remained aphasie was one
month. Recovery was gradual but complete in every instance.
Hemiplegia occurred in 5 patients and they all recovered muscular
power except one who was transferred after 93 days in hospital to a house
for the indigent poor. Paraplegia was seen in 3 patients during convales-
cence ; facial paralysis twice, and local paralysis, affecting the upper arm
on one side, in two cases. All recovered.
Spastic paraplegia developed in one man 2 months after convales-
cence and he ultimately was discharged cured.
In all 20 patients had paralysis of different sorts, and all recovered ;
so that gross lesions of the nerve centres could hardly have been the
exciting cause. One is rather inclined to attribute such sequelæ to
toxines acting on the nerve centres or nuclei of origin of the affected
nerves.
DISEASES OF THE DIGESTIVE SYSTEM.
Pharyngitis.—Inflammation of the pharynx causing difficulty in
swallowing, interfering with nutrition, and leading to ædema glottidis
was a marked complication twice.
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Ulceration of the mucous lining of the palate was seen once.
Hæmatemesis was never observed nor was malæna met with, and
considering the engorged state of the gastro-epiploic vessels met with
after death, and the numerous gastric and intestinal petœchiæ, this seems
an unexpected clinical record.
Diarrhæa was only met with in one case of the abdominal enteric
type, in a European, accompanied wich tympanitis, frequent fœtid watery
motions, and ending fatally on the 6th day of the disease.
Dysentery, as a sequela, was marked in 12 cases leading to great
anæmia, profound debility, and tardy convalescence, and death in 3 in-
stances.
Jaundice was never met with in Parel hospital.
Diseases of the urinary organs.—Albuminuria was noted in 50 per
cent. of the cases examined, and tube casts in 25 per cent. of those. Hæma-
turia occurred only once, associated with suppression of urine, uræmia,
and death. Cystitis was never met with.
Complications of menstruation and the puerperal state.—Menstrua-
tion is often induced by an attack of plague and is occasionally profuse.
in seven females this state was set up by their developing plague. Five
of them died and two recovered. In one case menstruation had been
absent some 6 months, and was brought on twice during the life of the
patient in hospital, and ultimately this patient succumbed. The
impression remains on one's mind that the presence of the catamenia
during the acute stage of plague is a complication of grave omen.
Pregnancy.—Four pregnant women were admitted for plague.
Every one of them aborted and died. Three were at the 6th month and
one at the 4th month of pregnancy. All the foetus were dead and in two
instances their skin was desquamating. Three of the foetus were
examined post-mortem, and hæmorrhagic petechiæ were found in the cere-
bral membranes, stomach intestines, and elsewhere, but no plague
bacilli could be demonstrated anywhere in their bodies by microscopic
examination or bacteriological culture methods. It would appear that the
toxic products in the blood of the mother can give an entrance into the
tissues of the foetus and cause its death and, discharge from the uterus
prematurely. Abortion took place in one case on the first clay of attack ;
mother 4 months pregnant. In two others abortion came on during the 2nd
day, and in the remaining case on the 3rd day of the attack, the mothers
being 6 months pregnant. In one 6 months case the mother's temperature
and general condition were favourable for recovery, but, in spite of opium
in large doses, miscarriage came on and precipitated a fatal issue. The
mothers died at the following dates : One on the 5th day, one on the
3rd day, one on the 4th day, and one on the 22nd day of the disease ;
the latter from septicæmia. Unless this experience be exceptional,
pregnancy must be looked upon as a very alarming and generally fatal
complication of plague.
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Diseases of the skin and cellular tissue.—Bed-sores only developed in
one case at the end of 20 days, and this patient was particularly helpless
and unable to move in bed, or help herself in any way owing to paralysis;
The seat of the bed-sores was over the sacrum. No case developed gan-
grene as a sequela. Lymphangitis occurred in 7 cases, led to abscess which
had to be opened, and protracted convalescence.
In one case a month
elapsed before the lymphangitis developed itself ; most of the others
came on between the 10th and 20th day of convalescence. It was a re-
markable phenomenon that the temperature was seldom elevated. In two
patients only did it touch 99.8°F., and pain in the affected part was often
the only symptom complained of. The lower extremities in the calf
of one leg was the seat in 5 instances, once in the neck, and once in the
parotid region. In no instance did the pus of the abscesses yield
plague bacilli, although every such case was carefully examined for this
object.
Boils are a frequent sequela ; 15 patients having one or more boils at
same period of their convalescence. Boils usually appeared about the
10th day. The most frequent scat was the scalp; next the legs ; and
next the upper extremities. One patient had 15 boils at one time, 13
on the scalp, 1 on the face over the parotid gland, and 1 on the side of
the neck, and they all appeared between the 15th and 20th day. This
patient died ; the other 14 recovered.
The boils could not be attributed to any want of fresh vegetables in
the dietary, as 4 oz. of vegetables weŕe given 2 days in the week und 1 oz.
of lime-juice twice weekly to each of the patients.
One patient had 21 consecutive boils and ultimately recovered,
although convalescence was complicated by double broncho-pneumonia as
well.
Syphilis was present in 4 patients admitted, of whom 1 died and 3
recovered.
Buboes in Plague.—A tabular statement of the sites of buboes has
been already given. They are usually accompanied by some pain. Indeed,
very often, the onset of pain is the first thing to direct the patient's
attention to the inflamed gland. Tenderness is an almost invariable sign,
and ædema surrounding the bubo. A large amount of surrounding
ædema is an unfavourable symptom. The skin over the bubo is general-
ly freely moveable, seldom inflamed, and still less frequently overpainful.
The bubo is generally found to be tender, rather than painful, and even
exquisitely tender patients seldom cried out with pain but winced when
the bubo was touched. Buboes never preceded the onset of general symp-
toms in any of the cases met with. They usually came on rapidly in the
majority of cases (70 per cent. of those with buboes) on the 2nd day ;
next most frequently on the 3rd day (15 per cent); next on the 4th
day, 12 per cent.; and on the 5th day 2 per cent ; and in 2 cases did not
appear till the 6th day from the onset of the initial symptoms. Both these
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