Sessional_Paper_1904 — Page 642

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The Symptom Complex of Plague.

It is not my intention to enter into any detailed description of the symptoms and physical signs of Plague. Many excellent accounts of these have been given. by those interested in the disease. The phases of the disease in Hongkong are in accordance with those found in other parts of the world.

My reason for discussing the clinical aspect of plague is, that certain symp- toms complained of by individuals during the earliest stages of the disease, appear to have attracted but scant attention. It is unfortunate that these have not been fully investigated, because from my researches, some of these symptoms are indi- cative of the starting point of the disease, and the deductions drawn from their appearance are verified by the results obtained after death.

It would appear that the majority of medical men, actively engaged in dia- gnosing the presence or absence of plague infection in man, have restricted their enquiries to the prominent symptoms and signs of the disease, paying but little attention to the exact mode of onset of the affection, and such symptoms which may have been present previous to the occurrence of fever-a bubo, etc.-or even before they come under the eye of the plague expert.

The diagnosis of cases of plague has to be made as soon as possible. During plague epidemics, the time at the disposal of those in charge of plague patients is fully occupied. Little or no attention can be paid to the detailed clinical aspect of the cases.

Consequently in plague infected localities, the clinical observations have rarely gone beyond the classical symptoms of the disease-namely, those upon which the physician depends in order to arrive at a correct diagnosis. Again the clinical features presented by cases of plague are not so carefully enquire into now-a-days, owing to the introduction of more rapid and accurate ineans of arriving at a diagnosis, namely, the demonstration in the tissues of the canŝul agent itself- the Bacillus pestis.

In connection with my researches into the clinics of plague, I have asked myself, whether those well known symptoms of the disease are the only impor- tant evidences of plague, or whether there exist others, and if so, do these add any- thing to our knowledge of the pathology of the disease? The B. pestis does not produce a soluble toxin, The poison which it produces is intimately bound up with the bacterial protoplasm. It is of the nature of a protein. It is very lethal. Widespread evidence is present, in every case of plague, of its powerful action. All organs and tissues of the body are profuudly altered. The circulatory appa- ratus of the body is one of the systems most affected by the plague poison. cases of plague show an early and extreme cardiac weakness. The heart beat is quickened, the pulse dierotic, and becoming towards the close of life thread like.

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The exact pathology of this action of the plague poison on the cardiac apparatus is as yet undetermined. It would appear to act centrally. In all cases there occur marked chromatolytic changes in the nerve cells of the brain. appearance presented by the central nervous tissue in a case of plague, is similar to that found after death from acute intoxication due to some poison. The fever curve is far from typical. It usually rises suddenly to an appreciable height, and subsequently maintains an elevated position with morning remissions. Such remissions may be extreme. As WILM says, no criterion of the severity of a case is afforded by the temperature chart. Patients may be supposed to be progressing favourably towards recovery and the physician in charge may have pronounced the prognosis as good, yet on his arrival the following day, he is told that the patient died suddenly during the night. Such is the history of many cases. It shows the dangers of giving an early prognosis in cases of plague. Experienced plague physicians avoid as much as possible the question of prognosis until the patient is well into a state of convalescence. It is the cardiac apparatus which one has to deal with, and it is to this system that the physician must exert his best skill,

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Again intense headache with a feeling of giddiness is one of the earliest complaints. This is usually accompanied by persistent vomiting. The patients when brought to Hospital often appear as if intoxicated with alcohol. sensorium is profundly affected, often accompanied by somnolence and great prostration.