49
the afternoon he felt some pain at the lower part of the left axilla just under
the anterior fold, but there was no glandular enlargement or pain in the glands
any where. On January 4th, had passed a bad night and felt very ill, temperature
104.6, pulse 113, respiration 25, tongue still moist, with a little fur behind, and
no sordes about the lips or teeth ; the other symptoms as before. During the
night he began to cough and brought up some watery sero-mucous fluid, slightly
blood-tinged, and the pain remained in the same place, only more diffused now,
being felt over an area of a square inch.- At this part some moist sounds could
be heard like those of early pneumonia, and they could also be heard just below
the left clavicle ; the rest of the lungs and other organs appeared to be normal,
as did the lymphatic glands. Patient considered that he had pneumonia, but
the symptoms were not like ordinary pneumonia.
For the onset was different, the condition of the tongue and mouth different,
there was no dyspnoea or pneumonic disproportion of pulse and respiration, and
the sputum was not at all like rusty sputum ; for it was loose and free, coming up
with the slightest cough, it was watery, looking more like serum than mucus,
and it was slightly pink, not rusty yellow at all. Also there was the striking
fact that the patient's general condition was far worse than could be explained
by the small amount of lung-disease present. So I examined the sputum under
the miscroscope, and found it full of bacilli looking like those of plague, and
cultures were made from which a pure growth of the plague-bacillus was obtain-
ed. During 4th and 5th, patient became steadily worse, his temperature re-
mained about 104, and his expectoration became most profuse ; the moist sounds
were heard over a larger area, as well as slightly at the bases ; the respirations
increased to 35, and then to 45, and the pulse to 120 and 135 ; and he ultimately
died early on January 6th.
There is also the case of the nurse who attended him, who unfortunately
died of a similar form of plague. In brief she became ill on the evening of
January 7th, and showed symptoms of pneumonia on January 8th. She rapidly
became worse and died on the 10th, but her sputum was not nearly so profuse
as in the former case, and symptoms of exhaustion came on much earlier. She
also had no glandular pain or enlargement whatever, and bacteriologically her
sputum was exactly as described above. Other cases were met with in which,
besides plague-pneumonia, there was also general enlargement of the glands,—
plague-septicaemia ; and clinically it was found that either the pneumonia was
primary, and the glandular enlargement secondary, or that the disease first
shewed itself in the glands and later on in the lungs ; and whilst some of the
latter recovered, the former were usually rapidly fatal. Also the sputum was
not always as has been described above, for in some cases the presence of blood
in it was a marked feature, and it was either moderate or abundant in quantity.
These pneumonic forms of plague are highly infectious and probably take a
large share in the spread of the disease ; for in these cases the patient's sputum
is practically a virulent pure culture of the plague-bacillus, and as there is
reason to believe that many of the cases are not recognised as plague at all,
precautions are not taken by the patients' friends, and the dangerous nature of
the disease is not appreciated. I have no means of knowing how frequent this
variety of plague has been in the present epidemic, but there is some evidence
to show that a considerable number of cases have occurred. Moreover, it seems
likely that a ship's passenger suffering from this form of plague might escape
detection by sanitary officers, and might be permitted to land at his destination
as though he were the subject of simple pneumonia ; and so a centre of infection
for the spread of plague would be established, With regard to the literature
on this subject, I have not been able to find a published description of this
variety of plague ; but an allusion to it is made in the accounts of the Pali
epidemic of 1836, and it is stated that the Astrakhan outbreak of 1877 was
first regarded as croupous pneumonia or as typhus complicated by pneumonia ;
from the reports on the Hongkong epidemic it appears that plague-pneumonia
did not occur there. There is just this to add : the usual definition of plague
in works on medicine is—" A specific fever attended by bubo of the inguinal or
other glands," but it is clear that such, a form of words does not include all
varieties of the disease. (This paper was read before a meeting of the Bombay
Medical and Physical Society on April 2nd, 1897.)
B 1751—13