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slough which had completely separated, but which still caused a good deal of suppuration (one more reason why one should open the primary bubo freely). The use of iodine, iodide of potash ointment, mercury, &c. locally, all seemed useless even in the later stages of the bubo which had not suppurated. Treat the debility, and the bubo will disappear of its own accord was what our experience taught us. Not only this but the irritation caused by these applications sometimes led to unpleasant results, which it was well to avoid. As a rule an open bubo took from one to three months to close, very few healed under a month. Keloid formation on the site of bubo was frequent in the Mongolian subject. Several cases have come to Hospital lately to be seen.
The vitality of the tissues after plague reached a lower point, I think, than it does after any other debilitating acute disease. In most cases there was not the slightest reaction of the tissues, if cut they remained almost in statu quo for days, and granulating wounds were generally called "granulating" by courtesy.
It was only to be expected that head symptoms would occasionally persist for some time. Irritability, perversity of temper, and headache occurred frequently, and even a temporary aberration of mind in some cases.
The condition of the vascular system generally improved rapidly-after the fever disappeared-under iron, strychnia and arsenic, but even here palpitation, breathlessness, and other signs of cardiac weakness persisted for a time.
No case
of permanent cardiac valvular mischief have I yet noticed however in any of the European patients. In convalescence digitalis has not been prescribed. In the few cases where symptoms of odema of lung, or pneumonia, persisted after the fall of temperature the condition improved by good food, tonics, and the occasional application of iodine externally to the chest.
In some cases the sloughing was extensive, and extended by the lymphatic vessels. In these cases no attempt to heal up took place until the general tone of the system improved.
I have seen some cases lie absolutely comatose for several days in the Chinese Hospital and recover in a most marvellous manner, but these were the exceptions. The mere fact that a man was comatose for so long a time as four days would point to a bad prognosis; yet in the Slaughter House several cases lay in that condition almost uncared for and recovered without a bad symptom afterwards.
Death occurs by—
(a) Sudden heart failure.
In some cases the slightest exertion caused death, even in those who seemed to be convalescent; and it was of the utmost importance that all movement out of bed be disallowed. Some cases had this failure brought on while on the bed pan.
pan. Others jumped out of bed in delirium only to be put back, practically pulseless, to die.
(b) Gradual heart failure depending on brain conditions and cardiac
weakness.
In these cases the lungs were usually edematous, and the combination of brain and dyspnoea generally brought about a rapidly fatal result.
(c) Extension of the inflammatory mischief in the neck by causing
obstruction.
In these cases nothing could really be done as the state of the patient when it occurred would have made tracheotomy a difficult if not a totally ineffective operation, and would in all human probability have proved fatal. In these cases the amount of oedema and sero-sanguineous exudation all round the anterior part of the neck would have made the operation so tedious that the patient would probably have died before its completion. (d) Hæmoptysis.
The cause of a couple of deaths. (e) Hæmorrhage after sloughing buboes.
Two cases of sloughing into the iliac arteries occurred and death took place almost instantaneously.
(f) Hæmorrhage into the Pous Varolii.
This undoubtedly helped to bring about a dissolution in
some cases.
(g) Pyæmia and exhaustion.
These were occasionally the cause of death, but infrequently. (h) Meningitis and cerebritis,
These really come under (b).
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