224
Pulmonary.
Conjunctivitis.
expresses apathy, the patient looks stupefied as if intoxicated and does not readily
answer questions, but one is not struck with the gravity of the condition or the danger
to life. Even the worst cases are apt to deceive the inexperienced, and make him
believe the case to be free from danger, when, in reality, it has only a few hours to live.
How many cases can one call to mind of fine robust patients in this condition in the
morning found dead at the evening visit. There is still another class of patient met
with chiefly at the beginning of the epidemic, but also in the middle and at the end,
who are suddenly stricken down with illness and die in a few hours, without any of the
external characteristic manifestations of the disease, the amount of the toxin produced
by the bacilli being so great that the central nervous system is completely over-
whelmed and its function arrested. It is in cases intermediate between the latter and
an attack of ordinary intensity, that the symptom of aphasia is so commonly observed.
Curiously, the histories of these cases have been precisely the same : high temperature ;
the attack chiefly localised in the nervous system ; delirium lasting a variable time
usually short, followed by sometimes complete loss of power to produce any sound
(aphonia), or more often, whilst consciousness remains intact, there is complete loss of
power to convert thoughts into words. Fortunately the majority of these cases recover
the lost power rapidly, the thickened disjointed guttural attempt at speech indicating
the first favourable sign. In association with this condition in several cases there has
been marked ataxia shown by the feeble grip, the inability to perform purposive co-
ordinate movements either with the hands or arms or legs ; this also clears up rapidly
as recovery advances. During the later stages of the disease there has been one well-
marked case of right hemiplegia. In these latter cases, buboes have not been a con-
spicuous symptom. Lastly, after the epidemic had reached its height, pulmonary
disturbance has been the most predominating and fatal feature. It takes the form of
catarrhal pneumonia, and may be either primary or secondary ; the primary form and
the attack localised in the central nervous system have been by far the most fatal
symptoms developed. Not a single case of primary pneumonia has recovered, and so
far the same may be said of the secondary form. Conjunctivitis has also been a
frequent symptom, starting as a simple suffusion of the conjunctiv* followed by corneal
ulcers, panophthalmitis, and often leading to destruction of one or both eyes.
Complications.
Plague is a disease marked by a very protracted convalescence ; during this period
complications of the most varied description are likely to develope.
The most frequent are—
(a) Sloughing of glands entire, with the skin over them.
(b) Multiple synovitis, sometimes leading to suppuration. This condition in
the early stages has many symptoms in common with acute rheuma-
tism, later it becomes localised in the joints, chiefly wrists, ankles,
knees, and elbows, and may be followed by suppuration. In one case
the left knee-joint alone was affected.
(c) Secondary pneumonia.
(d) Conjunctivitis, corneal ulcers, panophthalmitis.
(e) Pareses and paralysis, aphonia, aphasia, hemiplegia, imbecility.
(f) Thrombosis.
(g) Retention of urine.
(h) Suppression.
(i) Pyœmia.
Diagnosis,
There is apparently no other idiopathic fever attacking a large number of
people at the same time, which is characterised by glandular swellings and by those
grave symptoms of the nervous blood and biliary systems which show themselves in an