London's Pulse: Medical Officer of Health reports 1848-1972

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London County Council 1900

[Report of the Medical Officer of Health for London County Council]

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The term plague, in former days employed to designate almost any and every epidemic ailment,
has in recent years come to mean a specific disease, caused by a definite bacillus, and characterised by
signs and symptoms of pronounced clinical features. Of the several adjectives associated with the
name "plague," "bubonic " is the one most frequently heard; but our increasing knowledge of plague
has justified the recognition of a " pneumonic " and a " septicaemic," as well as a bubonic type, each
possessing signs and symptoms of a sufficiently staple pathological character to justify their recognition
as true varieties. The different varieties may be classified as follows—
Varieties of type—Clinical.
Common to all varieties of plague there are certain signs, symptoms and post-mortem appearances.
When, however, one special clinical feature predominates, it is usual to group the cases in which it
occurs under one heading. This is convenient, and although the classification is for the most part
based on clinical evidence merely, it serves further to draw attention to the many covert ways in which
plague may appear, and the great difficulty in recognising its presence in every case, even when a
fairly prevalent outbreak has taken place. In enumerating the types only the distinctive feature of
each type is notified.
1. Bubonic plague is characterised by the development of a bubo or buboes during some period
of the attack. It is by far the most common variety, buboes seldom occurring in less than 70 per cent,
of the cases met with during an epidemic.
2. Septicemic plague—No bubo occurs in this variety of the disease. During life the glands
may be felt enlarged to a small extent in exposed parts, but post mortem examination shows every
gland to be swollen to some extent. Septicaemic plague is very fatal.
3. Pneumonic plague—As the name implies the lungs are primarily affected, and so far as
can be elicited by clinical examination they are the only organs which develope definite lesions. The
glands are not enlarged, nor are they found swollen after death. In some epidemics the pneumonic
type of the disease is more prevalent than in others. Patients with plague pneumonia seldom recover.
4. The nervous type—When delirium, mania, convulsive seizures, aimless wanderings, tremors,
deafness, dumbness, &c., constitute prominent features of the attack, they are sometimes referred to as
belonging to a nervous type of the disease. Convulsions in children and delirium in adults may usher
in the disease. In children this is a fact to be remembered as the convulsions may continue to occur
and the child die before other symptoms suggesting plague have developed.
5. Such terms as toxic and fulminant as applied to plague, imply a rapidly fatal issue, the patient
succumbing within 24 hours; so sudden is the onset and development that the system seems
paralysed in its effort to attain a reaction; the pallor of the face, the prostration, the low temperature,
and the feeble pulse would seem to indicate that the person attacked is struck down as if by
severe shock.
6. Cases of plague are referred to a puerperal type, when abortion or miscarriage has
occurred. Haemorrhages from the uterus and appendages occasionally occur independently of
pregnancy. Women in the later stages of pregnancy abort when attacked by plague. After
abortion due to plague few women recover.
7. Pestis ambulans indicates a mild type of the disease in which the patient may go about his
ordinary duties. The buboes may give rise to no inconvenience and no feeling of illness. It is most
commonly met in children. Several members of the household may be attacked severely by plague,
but one child may escape with a painless swelling merely. This is a very dangerous type so far as
infection is concerned, and a careful watch must be kept on the possible development of such cases.
8. Pestis minor—What is termed the larval or abortive type of plague, but which is perhaps best
designated pestis minor, is an interesting form of the disease from every point of view. During many
epidemics of true plague observers have recorded a mild form of the disease, which occurred not only
when the epidemic was at its height, but which for several months (or years) before, and for several
months (or years) after, spread amongst the community.
The importance of this ailment is that it may precede an outbreak of plague, and should be
carefully watched and recorded. The symptoms are swelling of a groin gland, inflammatory effusion in
the periglandular tissue, some initial fever and gradually increasing temperature, and a feeling of general
malaise. The skin over the bubo reddens, suppuration develops, and the pus finds its way to the
surface by two, three or more fistulous openings. The gland when excised is found surrounded by
a thin purulent fluid, and when a section is made several small necrosed or purulent foci are seen
to stud the gland tissue, which has become soft and diffluent. After removal of the gland the parts
gradually heal, and by the end of a month, with the exception of a scar, all traces of the disease