(10)
Frequent at the outset, and again in the later stages of the disease; while during the period of acute fever, constipation predominated. It was rare for diarrhoea to continue throughout the whole time of acute fever. Blood, mucus, and epithelium frequently appeared in the stools. In 20% of the cases, in which definite buboes were not formed, the intestinal symptoms were so predominant that the illness had to be regarded as essentially an intestinal affection—a view, indeed, as will be later shown, confirmed by the results of post-mortem examination. The parotid glands were frequently swollen and painful at some time in the course of the disease. The liver and the spleen also were often found to be painful and enlarged.
The respiratory tract showed the fewest symptoms of disease. The breathing was frequent in proportion to the height of the fever. When buboes formed in the neck in the neighbourhood of the larynx or trachea, and shortly before death when the lungs became oedematous, the breathing was labouring and dyspnoeal. In 10% of the cases, bronchial catarrh came on in the course of the disease, most commonly appearing from the fourth to the tenth day. In 6% of the cases, the expectoration was bloody. In one case, hæmoptysis was observed; and in one case, pneumonia, with consecutive pulmonary abscess and purulent pleurisy. Pulmonary symptoms never influenced the general character of the disease in the early stages, but appeared only when the illness was well-established; they seemed always to be secondary phenomena. Patients suffering from plague without buboes but with prominent symptoms of disease of the respiratory organs were never observed.
(11)
185
Sometimes death took place from a quite unexpected sudden collapse, sometimes from rapidly developed convulsions with coma, sometimes with signs of exhaustion from the intensity of the intoxication; these were usually cases in which death occurred during the first ten days of the disease. Sometimes the cause of death was an earlier or later developed septic or pyæmic condition; this occurred in the later stages of the disease.
The order of appearance of the symptoms as well as the intensity and duration of the disease were, as already frequently mentioned, extremely various in different cases.
At first, during the height of the epidemic, the cases were for the most part very speedily fatal. Signs of the most intense depression of the nervous functions rapidly came on. The patients became drowsy and silent, and passed into a restless, comatose condition, vomited occasionally, passed their motions under them, became cold, with a hideous, livid, corpse-like tint of face, and died usually within from twelve hours to two days from the onset of the illness, with high fever, or sometimes abnormal temperature or moderate fever only, and frequently without any outwardly recognizable buboes.
Very near in degree of danger to these extremely fatal cases were cases in which an unusually high grade of fever soon came on, showing occasionally remissions and irregular exacerbations, with severe epigastric pain and tendency to vomit, and with the secretion of urine almost entirely suppressed. In these cases buboes usually developed, and the patient died of exhaustion on the third, fourth, or fifth day of the illness. If, however, he survived, he suffered usually for a long time from suppuration of the glands, or from the formation of abscesses, or from other complications such as nephritis, pneumonia, or parotiditis.
Dilatation of the right side of the heart was shown to exist in many cases. Systolic murmurs were often heard at the apex of the heart. At the beginning of the disease, the pulse was as a rule full and tense, and rarely irregular. The frequency was on the average 90 to 120 per minute. Before death the pulse usually became feeble, frequent, and irregular, and rose to 140 to 160 per minute.
At the beginning of the disease, the secretion of urine was frequently diminished or entirely suppressed. The colour of the urine was dark red, often turbid. In 95% of the cases, the urine at the outset of the disease contained albumen (usually 0.1 to 0.5%). It often contained indican. Only rarely was the urine ruddy from free admixture of blood. On microscopic examination, granular casts and white and red blood-corpuscles were frequently detected. After the decline of the fever the albumen most commonly quickly disappeared from the urine; in many cases, however, traces were still present one or two months later. In three cases only was slight oedema of the legs and feet noticed in connexion with the albuminuria. In women during the stage of fever the catamenial flow was usually very free. In one Chinese woman abortion took place.
Besides these severe cases of plague, slighter cases were also met with, which were especially frequent towards the end of the epidemic. In these cases the above-described symptoms were developed only in a minor degree. The urinary secretion was normal. Buboes sometimes appeared and quickly suppurated or underwent resolution; ordinarily, however, slight glandular swellings only were to be detected. The course was generally quick and favourable. Even in some of these cases, however, death occurred suddenly and unexpectedly. Quite exceptionally, ambulatory cases were seen, almost afebrile, with a somewhat tedious course, characterised by the development of small buboes, or even merely by pain without discoverable swelling in the inguinal or axillary region or in various parts of the body.
According to the symptoms bubonic plague may be defined in general terms as an extremely malignant acute disease, with pronounced typhoid state, in the course of which buboes and abscesses usually, and carbuncles very rarely, appear.
The nervous symptoms frequently noticed were muscular twitchings, deafness, loss of consciousness, and delirium of all kinds. In one case, in a boy, immediately before death, rigidity of the neck, trismus, and tonic and clonic spasms were observed.
The eyes were in some cases affected with purulent conjunctivitis, keratitis, and hypopyon. In five cases panophthalmitis occurred, and in the only one of these patients that survived complete blindness was the result.
Convalescence began at very various times. In many cases it set in at the end of the first or the beginning of the second week, after the cessation of the fever and with the subsidence of the glandular swellings; frequently, however, it did not begin to be established for four weeks or longer, the illness being kept up by suppuration of the glands and by other complications (such as new glandular swellings, abscesses of all kinds, nephritis, etc.). Recovery was not as a rule complete until from one to four months had elapsed.
The mortality of the disease among the patients in hospital was 73%. In 70% death took place in the first six days of the illness; in 3%, from the 7th to the 42nd day. Among Europeans, the mortality was 50%, both in the Kennedy Town Hospital and in the Government Civil Hospital. In the latter, of nine Europeans treated, four died. In considering the mortality among Asiatics, if we take into account those brought dead to the hospital, the mortality is greatly increased, viz., to 90%. If, however, we further take into consideration the fact that a large number of those attacked fled to Canton or were transported thither with the permission of the Government, and that a certain proportion of these recovered, we arrive at an average mortality for the whole epidemic of about 85%.