641647-1895-Medical-Report-on-the-Epidemic-of-Bubonic-Hague-in-1894 — Page 13

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THE HONGKONG GOVERNMENT GAZETTE, 13TH APRIL, 1895.

a patient complained of occipital headache and, on one or two occasions, of pain in the back of the neck-evidently of spinal origin. The headache gradually merged into delirium as the meningitis developed. Convergent strabismus or divergent strabismus was occasionally present-generally the former. "Both eyes turned to right or left" was also noticed in some cases. Occasionally where hemorrhage was diagnosed the pupils were unequal but in one conspicuous case where a haemorrhage on one side of the brain was supposed to exist (diagnosis concurred in by Professor AOYAMA), no haemorrhage was found and I think that in many cases the mere meningeal inflammation caused symptoms which would lead one to suppose

that a one-sided lesion was present. Cases generally developed brain symptoms which could be differentiated into four distinct types :-

(a) Comatose, where the patient lay practically paralysed, mind and body. (b) Wildly delirious, where he struggled and fought and still retained a

fair command of rational speech.

(c) Apathetic, where he lay perfectly quiet, and took nourishment when it was offered to him; in fact lay in a drowsy, but always more or less conscious, condition until improvement or death took place. (d) A convulsive type brought on either by the inflammation of the meninges and brain matter or by a hemorrhage. These convul- sions were often severe. (In Case I. they were only stopped by chloroform. P.M. no hemorrhage was found.)

In Case XV, they always began in the left arm (hand) and were truly Jack- sonian in nature pointing to some cortical lesion round the right fissure of Rolando. (See remarks on case.) Occasionally they resembled tetanus, the opisthotonos being very great. Subsultus tendinum did not occur early as a rule, but generally late in the disease. Picking at the bed clothes, trying to catch imaginary objects, in fact all the symptoms of meningitis were almost always present; in a few cases however they were absent, and such cases were usually of a very mild nature. Patients often had hallucinations beginning generally on the second day of the illness. All these cerebral symptoms followed the primary lymphatic affection and their rapid appearance was not to be wondered at when one considers the close connection between the arachnoid and the lymphatic system.

The vascular is the other system which was especially affected. The principal items to note were-

(1) The vasomotor paralysis which rapidly appeared involving the heart

itself as well as the vessels.

(2) The liability to sudden heart failure.

(3) The symptoms probably due to organic changes in the heart in those

who recovered.

There are four stages of the pulse in plague. During the first stage it is in the majority of cases full and bounding. In some it is feeble and collapsed. When in the latter state cyanosis is usually well marked and the patient is evidently moribund. The pulse which at first is full and bounding becomes (usually in from six to thirty-six hours) dicrotic and fairly easily compressible at the wrist. The accompanying tracing* shows such a pulse where the dicrotism, although not extreme, is well marked.

Intermittency is often noticeable in this second stage of the pulse and becomes inore marked as the third stage develops, when it becomes anacrotic and almost like the pulse of aortic insufficiency, there being no rebound wave at all, nor the slightest trace of it by sphygmograph in a well marked case. In addition it is at this period very easily compressible, and the actual range of movement of the vessel is very limited at the wrist, whereas in the larger vessels the upheaval is usually well marked, slight pressure at the femoral being sufficient to arrest the pulse. The following tracing* of the radial pulse is taken from a patient at this stage, there being no pressure on the sphygmograph button, except its own weight.

This patient was a very lean man, and consequently a tracing of his femoral pulse could be easily obtained as the vessel passed over the brim of the pelvis. With slightly over an ounce of pressure, (enough to visibly diminish the range of movement), the accompanying tracing* was got.

* Pulse tracing not printed here.

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