NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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Further specific proof of the non-contagiousness of plague in hospital
was furnished by one instance in which a mother ill with the disease
suckled her infant and it escaped; by one instance in which an infant with
plague was nourished on the mother's milk and she was not attacked ; and
by one instance in which a brother slept in the same bed with his
stricken brother and did not contract the disease from him.
DIAGNOSIS OE PLAGUE.
In an epidemic the diagnosis of plague is to some extent aided by
presupposition. In cases in which no buboes can be felt—comprising
13 to 14 per cent, of those observed at Parel—the diagnosis must depend
on the general symptoms and signs ; and in cases likely to prove fatal,
by confirmatory bacteriological evidences. At other times some non-
bubonic cases are likely to escape detection.
In those cases the buboes cannot be got at, if in all cases they exist,
for bacteriological examination, and mere blood cultures generally failed
to demonstrate plague bacilli, even in undoubted bubonic plague patients
who afterwards recovered. The following points guide one in arriving
at a diagnosis :—
1. Character of the tongue.
2. High temperature, with hot dry skin.
3. Injection of conjunctivae usually met with.
4. Delirium, sleeplessness, headache, vomiting.
5. Sudden onset without premonitory symptoms.
6. Dull, heavy, apathetic look.
7. Pulse full, soft, compressible and dicrotic.
8. Marked mental hebetude and lethargy.
All doubt is removed on the appearance of the bubo with some or
most of the preceding symptoms and signs; and no one sign or symptom
can be relied on as pathognomic of plague, but the general clinical
phenomena must be viewed together and the diagnosis arrived at from
the patient's condition as a whole.
The diseases most liable to be mistaken for plague, judging by those
suspected cases sent into hospital, are ague, remittent fever, syphilis,
pneumonia, epilepsy, cerebral apoplexy, uremic coma from advanced
kidney disease, ulcer with sympathetic (simple) inflammation of lymph
glands, and diarrhoea, debility, marasmus, and phthisis.
RATE OF MORTALITY.
1. Age did not seem to influence the rate of mortality.
2. Sex.—The female sex showed an excess of mortality ; 71 per cent.
of the females over 18 years of age died, whereas the men above that age
showed a death-rate of 68.6 per cent, of those attacked ; and female
children gave 64.3 per cent, of deaths to attacks as agaiust 42.5 per cent
in boys.
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No diminution in mortality or virulence was apparent during the
decline of the recent epidemic, and some of the cases admitted in the last
week were as virulent and fatal as at any period of the epidemic.
3. Situation of Buboes.—Under this head it is a remarkable fact
that cases without palpable buboes were most fatal, averaging 78.6 per
cent. Many of such cases died early of convulsions, coma, and syncope,
overwhelmed by toxic products suddenly attacking the great nerve-
centres, as it were, before there was time for an inflamed gland to arise.
The next most fatal were L axillary and R cervical in the same
proportions, then R axillary and R parotid in nearly the same ratio, next
came inguinal, and next femoral ; and multiple seemed to be least fatal.
Buboes on the R side had 66.7 per cent, mortality.
„ „ L „ 58.3 „ „
„
in the Upper part of the body 69.3 per cent, mortality.
„
„
Lower
„
„
57.2
„
The nearer the head the more fatal the case, and those with buboes-
in the neck, and especially in its anterior aspect were very fatal.
4. Race.—
(a) Native Christians had a mortality of 75 per cent, admissions
In males 63.2 per cent, died, and in females 71.4 per cent.
(b) Jews had a mortality of 75 per cent, admissions, but only
4 cases in all.
(c) Parsis had a mortality of 75 per cent, admissions ; but only
6 cases in all.
(d) Mahomedans had a mortality of 50 per cent, exactly.
(e) Hindus had a mortality of 64.5 per cent.; and males amongst
Hindus died at the rate of 65.5 per cent.; and females
of 65.1 per cent.
The general excess of female mortality was due to the number of
pregnant females who aborted ; and to the influence of the catamenial
discharge ; and the disproportionate number of deaths from convulsions-
amongst young female children who showed an excess of mortality as-
compared with boys in the proportion of 64.3 to 42.5 per cent.
In persons who are very fat the prognosis is unfavourable.
Mental depression and fatigue, and previous privation add to the
mortality.
The following are bad omens:—Pulse over 120 ; respirations over 30;.
sleeplessness lasting several days ; early and violent delirium ; great
prostration ; carphology, subsultus; twitchings and convulsions ; hiccough,,
"typhoid state"; uralemic symptoms; presence of complications, espe-
cially broncho-pneumonia ; hypostatic congestion of the lungs; laryngitis ;.
dysentery; meningitis and pneumonia.
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The only favourable prognostic that can be relied on is the absence
•of the unfavourable symptoms noted above, and the fact that the patient
:has come early under treatment and is kept lying down, until his tem-
perature has been normal, four days. Most patients who survive eight
•days without developing complications recover.
Free excretion of urea and uric acid and the absence of albumen,
blood, and renal casts in the urine are favorable signs, and a return to
the normal quantity secreted and the presence of chlorides, one of the first
signs of amendment.
A change in the patient s manner and countenance often heralds his
recovery ; the expression is less stupid, and he becomes rational, takes
notice and the conjunctivas become less injected.
Many cases died who appeared to be recovering, and on. the other
hand some recovered whose death appeared inevitable.
Although the general mortality was 64.5 per cent., it must be pointed
out that 66 were moribund on admission, 17 died during their first day
in hospital and 38 during their second day. Excluding those 121 deaths
under 48 hours in hospital, the rate of mortality was 41 per cent, of cases
•treated.
By further excluding cases treated by M. Yersin's serum, which are
dealt with separately, the mortality of cases under hospital treatment was
only 30.8 per cent of admissions who lived over 48 hours in hospital.
Finally, there can be no doubt that the disease is a very malignant
one, many cases dying suddenly before reaching hospital even when
•compulsory segregation was enforced.
CLINICAL DESCRIPTION.
The onset of an attack of plague is usually very sudden, the patient
being struck down with the following premonitory symptoms. He is seized
with rigor or a feeling of chilliness, followed by frontal headache, nausea
and vomiting, lassitude and disinclination for exertion. The vomiting is
of cerebral origin, bilious in character, and may be frequently repeated
without bringing any relief to the patient's feeling of illness.
The tongue is large, pale (often teeth-indented) and evenly coated
first with a thin white, and later with a yellowish brown fur.
This fur is confined to the dorsum of the tongue, the tip and edges
and under-part of the tongue being bright red and clean, and the amount
of furring increases towards the back of the organ.
Thirst is generally complained of, but the appetite is good and the
taste not perverted. The bowels in natives have been invariably consti-
pated, and the urine, scanty, high-colored and febrile in character, with
some albumen and casts.
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The pulse is over 100, full, soft, and bounding, at an early stage of
the disease, becoming later, frequent, small, markedly dicrotic, and very
compressible, and finally anaerotic, running, and imperceptible and rarely
irregular or intermittent.
The respirations are accelerated, averaging over 30 per minute,
and there may be slight cough.
The face is suffused and muddy ; the conjunctivæ injected and the
eyes watery, and the general expression dull, heavy, and stupid. Usually
there is giddiness, restlessness, and loss of sleep, or snatches of sleep
broken by slight delirium and confusion of the memory and intellect.
The delirium varies in character. It may be acute, wild, raving, or wild
and busy, resembling delirium tremens. ID the former the patient shouts,
talks incoherently, is violent, and tosses about so that it id with difficulty
he can be restrained or kept in bed.
Delirium of a wild, violent nature is rapidly followed by collapse,
and if accompanied with refusal to take medicine, food, and stimulants,
usually ends in death at an early period. Sometimes the delirium is never
acute, confined to slight incoherence between sleeping and waking ; and
many fatal cases of undoubted plague never develope delirium.
Generally along with the delirium there is sleeplessness, and the
patient's attention can be momentarily arrested by speaking loudly to
him, but he soon lapses into incoherent muttering.
His cerebration seems to be at a low level, and there is a want of
power to concentrate the thoughts for any length of time on any one
subject, so that he soon becomes wearied, fails to keep up a connected
conversation, and only partially utters replies to questions ; in fact, there
is a general subjection of the mental faculties : hebetude and lethargy.
The symptoms of nervous excitement may last for days—indeed
in one case they lasted nearly continuously for days and became more
marked towards evening and in the night-time,—or may pass into
nervous depression and stupor. The prostration is now marked, the
patient lying in the dorsal decubitus, sighing, muttering slightly, or still
and motionless, as if overwhelmed with some toxic cerebral poison, and
utterly indifferent to all surroundings.
Tremors, subsultus, tossing of the arms aimlessly before the face and
picking at the bed clothes supervene. The eyes are firmly closed, the
pupils contracted, the conjunctivæ markedly injected, and the countenance
stupid and vacant; deafness is also generally present. The tongue becomes
dry, brownish, and rough in two lines on each side of the centrai râphè,
with thick whitey-brown fur, chipping in flakes, which leave raw red
patches often showing fissures ; it is protruded slowly and with difficulty,
und the patient often forgets to withdraw it for a time until loudly
spoken to. It is rarely tremulous. Sordes collect on the teeth and
H
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lips, and constipation continues. In this state the patient may continue
for some hours or several days, and even recover. But usually the stupor
passes into fatal coma, or the pulse becomes frequent (140—160), small,
weak, or scarcely perceptible, the surface cold, especially the extremities,
and the case ends fatally in coma and syncope. On the other hand there
may be an amendment, and the patient returns to consciousness and life.
He is extremely debilitated and at first bewildered, but soon gets in touch
with his surroundings. The pulse may become normal and the tempera-
ture fall, generally by lysis, which is by far the more favourable terminar
tion in this disease, or rarely by exisis ; the tongue becomes clean and moist;
and without any critical accompaniment, such as diarrhœa, perspiration,
or increased flow of urine, the patient may rapidly regain his senses and
no permanent blot remain.
It must be remembered that the disease presents great varieties, from
the most wild and hardly recognizable forms to the most severe, and one
can seldom tell from the symptoms alone whether a given case is going to
turn out favourably or fatally. In mild cases the pulse may never go
above 100, or the temperature above 101, and slight (or no) confusion
of the intellect, headache, and sleeplessness be the only symptoms of
cerebral derangement. The diagnosis can only be made by the discovery
of an inflamed and perhaps only slightly enlarged lymphatic gland,
and by a bacteriological examination microscopically, and by cultivation
of the extracted matter from this gland.
PRINCIPAL SYMPTOMS OP PLAGUE.
Physiognomy.—The physiognomy of a plague patient, when this
phenomenon is present, as was found in about half the cases at Parel, is
peculiar and striking and will often direct attention to the nature of the
disease from which he is suffering. The countenance is dull, vacant,
and anxious, and the eyelids and mouth are kept half open. The patient
has a furtive look, rarely meets his eyelids in winking, and seldom
performs that act ; gazes about him vacantly and does not seem to care
to talk or to notice persons or things about him. In addition, the con-
junctivæ are injected, often markedly so : the eyes suffused and the pupils
usually normal.
The Temperature.—The temperature in plague is elevated from a
very early period of the disease. Some cases seen within ten hours of
the initial rigor showed a rise up to 103.4° F., and no case has been met
with in which symptoms of plague were present without an accompany-
ing rise of temperature, so that it may be defined as a febrile disease.
The temperature is of a remitttent type, with slight ranges of 1 or 2
degrees, but sometimes sudden rises up to 107.4° F. even, and there is
usually an evening exacerbation noticeable.
The maximum is attained on the second or third day, and in the natural
uncomplicated course of the disease there is usually a slight remission from
the fifth to the seventh day. This remission was noted in some of the
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earliest cases uninfluenced by antipyretic treatment, and seems peculiar
to plague. The temperature can be only very temporarily influenced by
drugs, and antifebrin and phenacetin were employed in a few cases on
trial, but not with encouraging results, so that their use was abandoned.
Tepid sponging repeated every time the temperature touched 103.5° F.,
und the application of the ice-bag and administration of diaphoretic
mixture with stimulants came to be looked upon with most favor in
combating this symptom.
A fall of temperature by lysis from the fifth to seventh day is a favor-
able symptom ; and very often the use of some medicament, or resort to
one of the methods of surgical interference with the local expression of
the disease, by excising or injecting the inflamed gland, has been credited
with an unwarrantable influence on the temperature curve. A decided
rise of the temperature during the course of the disease after the seventh
clay is mostly due to the advent of some complication, such as secondary
broncho-pneumonia, boils, lymphangitis, or septicaemia, and indicates
prolonged convalescence or an unfavorable issue.
Marked elevation of temperature does not of itself mean an abnormally
severe or necessarily fatal case, and in some cases the temperature has
reached 106.4° F., and yet the patient has recovered. On the other hand
cásea may be severe and even fatal, mostly from toxic nervous symptoms,
when the temperature has never reached 103° F. In fatal cases the
temperature has ranged as high as 107° F. at, and even after, death. The
average of cases ranged between 102° F. to 105° F., and the lowest had
100° F. only. As a rule, the T is 102—105 ; P 110—120 ; R 20—30.
The Skin.—The skin is almost invariably dry and hot ; yet very rarely
perspiration was noted on the forehead or chest, and in this respect
the disease presents a marked contrast to the freely perspiring and moist
skin of ague and remittent fever, which have frequently been sent in
to hospital under suspicion of being plague.
An eruption on the skin of any distinctive character, although
frequently looked for, was not found. In a few cases, at most, fugitive
erythematous, or urticarial rashes, or mosquito, or lichen tropicus were
discovered. Sudamina were rarely seen, and purpura spots, vibices, and
desquamation conspicuous by their absence.
In a small number of instances abrasions, and in five cases a distinet
vesicle, were found on the extremity or part of the body in which the
primary bubo was situated. The lymphatics, however, leading from
those vesicles never were found inflamed. In all five cases the contents
of the vesicles, when examined microscopically and by bacteriological
cultivation, yielded positive evidence of the presence of the bacillus of
plague. From such absolutely positive results one may state that the
source of infection has been by inoculation through the skin, perhaps by
an abrasion or small cut, but that this is the invariable and only mode
by which the bacillus gains an entrance is open to grave doubt. The
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lymphatic gland in anatomical connection with the vesicle was inflamed
and tender in each of those cases, and was the only one affected as far as
could be made ont.
The occurrence of boils was frequently noted as a sequela, and true
carbuncles were never met with in any of the Parel patients. An acute
necrosis of the skin, sub-cutaneous tissue, and gland occurred in three
instances, but was not of such clinical features as to arouse the idea of
carbuncle in the mind of the observers. It is to be further noted that in
every such instance the patient or his friends had applied some irritant over
the gland, usually a mixture of marking-nut, chunam and ghoor (molasses).
That carbuncles are met with in plague, one can hardly doubt ; but
the experience of the Parel cases would lead one to conclude that their
appearance is not characteristic or, by any means, a diagnostic of plague.
That they were carefully looked out for at Parel with the assistance of
other investigators precludes the idea that their presence could have been
overlooked.
In some cases a peculiar earthy, cellar-like odour was detectable from
the patients' skin and breath. It is a remarkable fact that this odour
was quite familiar to the nurses, and noted independently by one of the
very intelligent nursing sisters, who thought it was confined to fatal cases.
The smell was quite distinct from that due to involuntary passing of the
motions or urine in the bed, and was observed in some cases in which the
patient had perfect control over his evacuations. Generally, cases ending
in fatal septicæmia evolved this odour from the skin and breath, but a few
patients in which its presence was unmistakeable, recovered.
The Pulse.—As a rule, the pulse is over 100 per minute, and a slow
pulse was not met with in a single case of plague. It may reach 120 to
140, or even 170, per minute during the course of the disease. Seen early
in the disease, the patient will be found to have a frequent (110 to 120),
full, bounding, soft, and compressible pulse which is markedly dicrotic
and presents a want of vehemence in the stroke. A gradual fall in the
frequency of the pulse-rate is a favorable sign, and a great rise after a
fall means some complication supervening. There does not appear to be
any definite pulse-respiration ratio, although at first both are elevated, and
finally it becomes very rapid and often imperceptible before death.
A marked character of the pulse, on which some interesting observa-
tion were made both during the fever and in convalescence, was the in-
fluence of posture on its frequency and force. The frequency became
increased by as many as 20 to 32 beats per minute, and it became
small, weak, almost thready and irregular (and all this seemed to be due
to the great prostration of the nervous system) when the patient was
helped gently and carefully to sit up. The heart's sounds were con
stantly found to be normal, although the impulse was diffused and strong.
No murmurs were detected in any patient at Parel at any stage of the
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malady, and the heart at the post mortem showed no valvular lesions or
visible alteration of its musculature. Softening of the structures was
conspicuous by its absence, and yet the alarming suddenness of death
in patients convalescing from an attack of plague seemed to foreshadow
such pathological change. In all probability the syncope met with in
such cases is secondary to toxic degeneration of the central nervous
mechanism, and is due to sudden vaso-motor paralysis. No fact in the
clinical phenomena of plague remains more indelibly impressed on the
mind than the extremely frequent and alarmingly sudden and unexpected
death of patients who are apparently well on the road to recovery. The
pulse may be normal in frequency and force, the temperature normal for
some clays, and yet some slight exertion, such as sitting up prematurely in
bed, may lead to fatal syncope, and nothing was found in two such cases
in the heart itself to account for the result.
Respiratory System.—The respiration usually exceeds 25 in the be-
ginning of an ordinary case, and that without any lung complication, and
often rises to 30 or even 48 up till 60 per minute. In grave cases it is
hurried, sighing, and often irregular, and sometimes the alæ nasi can be
seen to take part in the respiratory act. When there is coma the breath-
ing may be blowing, with the mouth closed, and the cheeks puffing, and
the respirations irregular.
Hypostatic congestion of the lungs is met with as a complication of
plague and is usual in fatal cases ; congestion taking place in the most
dependent parts of the lungs as the power of the circulation wanes. When
this supervenes, the respirations mount up to 30 or 40 and up to 60 or
upwards per minute, and are hurried and laboured, whilst at the same
time the temperature may be nearly normal, and cold extremities and
stupor, deepening into coma, close the scene. In this condition there may
be only slight, if any, cough or expectoration, and physical examination
alone reveals to the physician the dangerous condition of the patient.
This condition demands the free exhibition of diffusible stimulants and
strychnine with tincture of strophanthus and carbonate of ammonia, on
which most reliance can be placed.
Digestive System.—The tongue from the very first is coated with a
whitish, thin, silvery fur, confined to the clorsum and increasing in depth
towards the root of the organ and most marked on each side of the râphè,
while the underneath part and tip and edges of the tongue are red and
clean, with prominent fungiform papillæ and the whole tongue moist
The fur becomes yellow, then brown and cracked, and falling off in flakes
which expose a clean, raw, red, irritable-looking surface. In no case
did the tongue appear black, or contracted into a ball, or bleeding and
ulcerated, or fissured. The amount of furring showed no relation
to the severity of the case. During convalescence the tongue becomes
clean at the sides, and the fur slowly and gradually disappears. In
fatal cases the tongue is tremulous, protruded with difficulty, and dry
and flaky.
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