diseases, differ in their onset and progress under different
circumstances and at different periods of particular outbreaks.
Besides the ordinary form, to which as a type the greater number of
the cases more or less closely conform, there are, on the one hand,
others so severe that death takes place before the characteristic
manifestations have time to appear, and, on the other hand, cases so
light that such manifestations are but partly developed, and the
nature of the malady is only to be recognized in the light of the
prevalent epidemic influence.
Hence among the cases three forms are recognized: (_a_) The grave or
ordinary form; (_b_) the fulminant form; and (_c_) the larval or
abortive form.
(_a_) Grave or Ordinary Form.--The plague in typical cases is a
febrile malady of the most acute kind, with localizations in the form
of buboes or carbuncles.
The course of the attack may, for convenience of description, be
divided into four stages: 1, the stage of invasion; 2, the stage of
intense fever; 3, the stage of fully-developed localizations; and 4,
the stage of convalescence.[7]
[Footnote 7: This formal division of the description is suggested in
some of the older accounts. (See "_Loimologia; or, An Historical
Account of the Plague in London in 1665_, by Nathan Hodges, M.D., and
Fellow of the College of Physicians, who resided in the City all that
Time, Lond., 1721.")
The appearance of the plague in France in 1720 was the occasion of a
great number of curious and interesting publications on this subject.]
1. The stage of invasion is marked by a feeling of lassitude, by pains
in the loins and extremities. There is extreme bodily and mental
weakness, headache, fulness and throbbing of the head, dizziness. The
patient's expression is dull, stupid; he replies to questions slowly
or awkwardly, his face is pale, his eyes languid, his gait feeble and
staggering. The appearance in this stage has been compared by several
observers to that of a drunken man. Shivering occurs, but if fever be
present it is slight. Nausea, vomiting, and diarrhoea are symptoms
sometimes {778} observed. This stage begins suddenly. It is often
imperfectly developed, and it may last only a few hours or a day or
two.
2. The second stage is characterized by fever of the most intense
kind. It is ushered in by a chill, sometimes slight, commonly severe.
The lassitude continues, the headache increases, the dulness deepens
to stupor or gives way to delirium. The temperature rises to 102°-104°
F., or even to 107.6° F. The pulse quickly mounts to 120 or 130. The
skin is hot and dry; the patient complains of burning inward heat and
of great, sometimes unbearable, thirst. The eyes are sunken and
injected; the tongue moist, pale, and thickly covered with a
chalk-white or grayish pasty coating; the vomiting often continues.
The delirium is commonly active or noisy, and accompanied by great
restlessness; it may, however, be mild, tending to sopor or coma. The
progress of the disease now rapidly advances. The patient falls into
the so-called typhoid state. His tongue becomes dry, hard, and
fissured; sordes collect upon the teeth and lips, bloody crusts about
the nostrils. At this time the evidences of failure of the forces of
the circulation become conspicuous. The pulse grows feeble, small,
often irregular--sometimes it can scarcely be felt; the lips become
bluish, the extremities cold. There is tendency to collapse. During
the course of this stage buboes begin to make their appearance.
Sometimes the enlargement of the superficial lymphatics is preceded by
tenderness or pain of more or less intensity; often the glands are
found to be enlarged only upon search.
The termination of this stage is marked by a sudden fall of the
temperature to subnormal ranges (93.2° F. has been observed); at the
same time copious strong-smelling sweat not infrequently occurs. The
pulse grows feebler, and falls to 100 or below it, and the mind
becomes clearer.
3. These changes lead up to the stage of fully-developed local
manifestations. The enlarged lymphatics are most commonly situated in
the groins or on the upper part of the thighs at a point below that
commonly the seat of venereal buboes; less often they are to be found
in the armpits or the region of the angle of the jaw; as a rule, they
occupy only one or two of these positions in the same patient. They
vary in size from a little mass or kernel, only to be discovered after
careful search, to the bulk of a hen's egg or a mandarin orange. The
swelling of the gland takes place at times with great rapidity.
Suppuration is followed by the discharge of an ichorous pus, and not
rarely by ulcerative destruction of the surrounding tissues.
Suppuration occurs more frequently than resolution, but is
comparatively rare in fatal cases. Hence it has come to be popularly
regarded as a favorable prognostic sign, whilst the early subsidence
of the swelling has been looked upon as an omen of grave import.
The time of the appearance of the buboes varies greatly. In the
greater number of cases they have shown themselves on the second,
third, or fourth day of the attack, occasionally within six or eight
hours of the beginning of the attack, and occasionally they have been
observed to precede the general manifestation of the disease; rarely
they have appeared as late as the fifth day. In many cases they are
absent altogether.
Carbuncles demand attention as being among the characteristic local
manifestations of this stage. They are less common than buboes. Their
usual position is upon the lower extremities, the buttocks, or the
back of {779} the neck. In favorable cases the gangrene after a few
days becomes limited and the slough separates. Boils also occasionally
appear.
Petechiæ occur in the worst cases, and often at an early period in the
course of the disease. Their appearance usually indicates a fatal
issue. They occupy at times extensive areas of the body or the greater
part of its surface; at times they appear only in the neighborhood of
the buboes. They vary in size from a mere speck to spots several lines
in diameter. When very numerous they give a livid hue to the skin, and
that appearance to the cadaver to which, together with the high
mortality, was doubtless due the term black death by which severe
epidemics were known in the Middle Ages.
Vibices and extensive ecchymoses sometimes appear shortly before
death.
4. The stage of convalescence sets in between the sixth and tenth
days. It is often protracted by prolonged suppuration of the bubonic
enlargements. Both relapses and distinct second attacks have been
noted by recent as well as the older observers.
In addition to the foregoing sketch of the course of the disease in
its ordinary form it is necessary to describe certain other symptoms.
The attack has sometimes begun with a convulsive tremor, at other
times with a prolonged shaking, which has lasted from six hours to
three days, the patient remaining free from fever and not complaining
of cold. This condition has terminated in coma, followed speedily by
death.
Sometimes the attack has come upon the patient with great confusion of
mind, so that he appears dazed, or else a curious distraction has
befallen him in the midst of his ordinary avocations. If absent from
home, such patients commonly at once set out to return, either
trembling and staggering as though tipsy, or else rushing wildly
through the streets with frantic gestures and outcries.
The vomited matters are usually at first gastric mucus with bile,
afterward dark coffee-colored fluid; in certain cases blood is
vomited. Bleeding from the nose, lungs, bowels, vagina, and urethra
have also been observed. Cases attended by hemorrhages have in almost
all instances terminated fatally.
Constipation has been, as a rule, present during the acute stages;
later in the attack diarrhoea has occasionally occurred. It has been
looked upon as a favorable symptom.
The urine has been diminished and suppressed in grave cases.
Trustworthy observations, both as to its quantity and its chemical
composition, are wanting. It has been observed to contain blood.
As has been already pointed out, the Máhámari of North-western India
has been especially characterized by lung symptoms. Other regions also
have been visited by epidemics in which acute pulmonary lesions formed
a prominent part of the morbid complexus.
(_b_) The Fulminant Form.--Chiefly in the early days or weeks of
epidemics, but to some extent also later, cases occur in which the
intensity of the sickness is so great that the patient dies before its
usual manifestations have time to develop. The duration of the whole
attack, which ends fatally, is often not more than a few hours; its
symptoms, which differ but little if at all from those of similar
cases of other epidemic diseases--such, for example, as epidemic
cerebro-spinal fever in its fulminant {780} form--are of the most
aggravated character, and the patient perishes overwhelmed by the
infection as though struck by a thunderbolt. Profound disturbance of
the nervous centres, convulsions, coma, the rapid formation of vibices
and petechiæ, collapse, are the speedy forerunners of the fatal issue.
(_c_) The Larval or Abortive Form.--Toward the close of an epidemic
the character of the disease usually undergoes a change. It becomes
less malignant. The cases present the essential symptoms, but in
diminished intensity. Some cases terminate in an early defervescence
with rapid subsidence of beginning local manifestations; others
present merely the evidences of a slight disturbance of the general
health, without any characteristic symptoms of the prevalent disorder;
others, again, are characterized by the appearance of buboes without
pain or fever. These swellings undergo resolution in fourteen days or
thereabout. Exceptionally they suppurate.
The duration of the plague is from six to ten days in typical cases
running a favorable course; those of fatal cases from one to twenty
days. Clot Bey[8] found the duration of the worst cases two or three
days, of those next in point of severity five or six days, whilst in
milder cases death did not occur until the second or third week. Of
534 fatal cases noted by W. H. Colvill, 126 occurred one day after the
attack, 80 two days after it, 105 three days, 76 four days, 60 five
days, 26 six days after the attack. After six days the number of
deaths rapidly declined; on the nineteenth day 1 death, and on the
twentieth day after the attack 11 deaths, occurred. It is said that
death after the seventh day is commonly not in consequence of the
disease itself, but of sequels. Of 16 fatal cases in the village
Prischib in Astrakhan, noted in the report of Dr. Cabiadis, and of
whom the names, as well as the day of their exposure, their falling
sick, and their death are given, 1 died in one day, 4 in two days, 6
in three days, 3 in four days, and 2 in six days.
[Footnote 8: _De la Peste observée en Égypte_, Paris, 1840.]
The mortality of the plague is greater than that of any other epidemic
disease. In all epidemics a large majority of those who contract the
disease die. This is especially true of epidemics at their beginning,
when it has often happened that for a time all the cases have
perished. Of this, as of other epidemic diseases, it is true that the
death-rate has varied in different outbreaks and at different periods
of the same outbreak. Colvill states that in the epidemic of 1874 in
Mesopotamia the mortality of stricken villages during the first half
of the time was 93 to 95 per cent. of those attacked, but that
afterward the majority of those attacked recovered. The same authority
states that in Bagdad in 1876 the mortality was 55.7 per cent. of
persons attacked. Arnauld gives the mortality at Benghazi in 1874 as
39 per cent. of attacks. The death-rate at Vetlanka was 82 per cent.
of those attacked. In Toulon in 1721, of a population of about 26,000
human beings, about 20,000 were attacked, and of these 16,000 died. It
has been by no means of rare occurrence that nearly half the
population of towns have perished in an epidemic, or that small
villages have been completely depopulated by this scourge.
COMPLICATIONS AND SEQUELS.--The appalling mortality of the plague on
its approach, the rapidity of its spread, the popular commotion upon
its appearance, its brief course, and the fact that its recent
outbreaks have {781} taken place in regions where trained European
physicians have been, with a few exceptions, beyond reach, all unite
in maintaining the gloom that has since the Middle Ages enveloped the
clinical facts of this disease.
Of its clinical course, beyond the brief outline already given, little
is accurately known, of its complications still less. In some of the
recent epidemics, and particularly in the outbreaks of plague in
India, the evidences of pulmonary lesions have been so conspicuous
that they deserve to be classed among the essential manifestations of
the disease rather than as complications; in others pulmonary
congestion, hæmoptysis, the evidences of croupous or catarrhal
pneumonia, have occurred in a small proportion of the cases. Aside
from this, there is nothing to be said as to the complications.
Among the known sequels are protracted ulceration of the enlarged
lymphatics, boils, superficial or deep abscesses, catarrhal pneumonia,
pertussis, mental troubles, and the like. Extensive and deep
cicatrices are not infrequently found in the site of the ulcerating
local manifestations.
MORBID ANATOMY.--The existing knowledge of the morbid anatomy of the
plague is but scanty. The observers of the early outbreaks contributed
nothing; the recent outbreaks have taken place under circumstances in
which anatomical investigations were impracticable. The knowledge
which we possess is almost wholly due to the investigations conducted
by the French in Egypt at the close of the last and the beginning of
the present century, and again during the years 1833 to 1838.
The descriptions of Bulant,[9] Clot Bey, and others point to gross
lesions, such as are found after death in the acute stages of the
infectious diseases in general. The viscera were engorged with dark
fluid blood; ecchymoses were often found in the mucous and the serous
membranes, in the substance of the different organs, and into the
connective tissue. The spleen was in almost all cases enlarged,
softened, and of a dark color. Not rarely the kidneys were deeply
engorged, and extravasations of blood into their substance, their
pelves, and into the surrounding connective tissues were often
encountered.
[Footnote 9: _De la peste oriental d'apres les matérnaux recuillés à
Alexandrie, à Smyrne, etc., pendant les Années 1833 à 1838_, Paris,
1839.]
The only constant and characteristic changes relate to the lymphatic
system. The lymphatic glands were, as a rule, enlarged and deeply
injected with blood. Where no buboes existed the glands of the various
cavities of the body showed evidences of acute inflammatory processes.
In some instances the affection of the glands appeared to be general;
less frequently it was most conspicuous in, or apparently limited to,
one or more great groups. Thus, the bronchial, the mediastinal, the
mesenteric, the lumbar, etc. were severally the seat of marked changes
with or without enlargement of superficial groups, or several of these
groups were at the same time implicated.
In no instance were symmetrical enlargements of the inguinal regions,
the axillæ, or the throat met with.
According to Runnel,[10] in 2700 cases there were inguinal buboes in
1841, axillary in 569, maxillary in 231; inguinal buboes occurred 175
times on both sides, 729 times on the right only, 589 times on the
left only; the axillary buboes were double 9 times, right only 185,
left only {782} 163. Buboes of the neck only occurred 130 times, and
of them 67 cases were children.
[Footnote 10: _A Treatise on the Plague_, London, 1791.]
The connective tissue surrounding the affected glands was the seat of
an infiltration sometimes serous, sometimes cellular; it also very
commonly contained more or less extensive extravasations of blood.
Even where no buboes appeared on the surface of the body the glands
were enlarged to twice their usual size or more. The substance of the
glands in the larger swellings was at times uniformly red or violet,
again whitish or marbled or pulpy or denser, or of the consistence of
fat. It was also sometimes soft like jelly, and rarely it contained
minute collections of pus. Some observers speak of dilatation of the
lymph-vessels in the neighborhood of the enlarged glands.
DIAGNOSIS.--The difficulties attending the recognition of the plague
at the beginning of an outbreak speedily subside. The rapid spread of
the disease, its frightful mortality, the overwhelming intensity of
the symptoms, the prompt occurrence of cases characterized by buboes,
carbuncles, or petechiæ, are collectively considered diagnostic of
this, and of no other disease whatever. In regions subject to the
repeated visitations of this pest there exists a universal
unwillingness to mention even the name of a disease whose suspected
presence alone is followed by consequences of the most serious nature
to the freedom of personal and commercial intercourse. To this
unwillingness, rather than to any real likeness between the plague and
other diseases with which it has been compared, are to be traced most
of the difficulties as to the differential diagnosis that have been
raised, especially in the regions bordering on the Mediterranean Sea.
It is not, therefore, necessary in this place to discuss the diagnosis
between the plague and malarial and other pernicious fevers, malignant
typhus, epidemic dysentery, lymphadenitis, syphilitic buboes,
parotitis, and so forth.
TREATMENT.--Preventive.--The efficient treatment consists in
prophylaxis. The history of this disease indicates with singular
clearness the measures which, properly carried out, are capable of
controlling the spread of the epidemic diseases. These measures
arrange themselves into two groups, of which the first has to do with
the removal of the conditions familiar to the development of the
disease, the predisposing influences; and the second with the
restriction of the disease to the locality in which it shows
itself--isolation, quarantine.
The conditions favorable to the development of the plague have already
been set forth under the heading Etiology. They relate to poverty and
ignorance, and their attendant evils, in communities. They are those
conditions which tend to disappear under the influences of
civilization, and in truth it may be said that at the present time the
plague occurs only in half-civilized countries.
Preventive medicine has achieved no other work comparing in magnitude
and importance with the extinction of the plague in Europe. This was,
to use the words of Hirsch, "a gradual process, and kept pace in great
measure with the development and perfection of the quarantine system
with reference to the Orient and the different countries of Europe."
This author continues: "I cannot, in fact, understand how any one
criticising the facts without prejudice, and having regard to the
{783} state of the plague in the East, can for a moment hesitate to
attribute the chief cause of the disappearance of the plague from
European soil to a well-regulated quarantine system." The European has
by no means lost his susceptibility to the disease. He is liable to
attack in the East. His protection at home lies in the restriction of
the exciting cause of the disease to its present haunts.
Any extended notice of quarantine and quarantine laws is beyond the
scope of this article. It may be said, however, that with reference to
the plague measures quite unnecessary under ordinary circumstances
assume the greatest importance when this disease makes its appearance
in countries bordering upon Europe, and that no amount of hardship to
individuals necessary to avert so great a calamity as a plague
epidemic could be looked upon as excessive. Indeed, we can with
difficulty realize the severity with which measures of isolation have
been carried into effect at times when the devastation produced by the
plague was still vividly remembered. Violation of the orders issued
during an epidemic has been punished with no less a penalty than
death. It is related that upon the appearance of the plague in the
little town of Noja in Lower Italy in 1815, troops were despatched
immediately to surround the place with a cordon. The town was
encircled by two deep ditches, and opposite the gates three ditches
were spanned by drawbridges, which served as a means for the
introduction of provisions, but no other communication was allowed.
Only letters were allowed to leave the city, and these were first
dipped in vinegar. Cannons were posted at the city gates. The ditches
were occupied by sentinels, who were ordered to shoot down any one who
approached and failed to stand still the moment he was hailed. A
plague patient who escaped while delirious and attempted to pass the
lines was, in fact, shot dead. Outside this cordon two others were
established. Those who disobeyed the orders were treated with the
greatest severity. An inhabitant of Noja, who had thrown a pack of
cards to the soldiers, together with the soldier who picked it up, was
tried by court-martial and shot.[11]
[Footnote 11: _Ueber die Pest zu Noja_, Nürnberg, 1818, quoted by
Liebermeister in _Ziemssen's Encyclopedia_, article "Plague."]
Lower Italy, possibly Europe also, owed its escape to the rigorous
measures carried out in this instance; nor can it be doubted that the
measures of isolation practised during the outbreak on the Volga
1878-79 restricted the disease to the district in which it appeared
and brought it to a speedy end. On this occasion three efficient
cordons were established to isolate the infected places. The first
cordon was put around every place where plague prevailed, to prevent
persons from entering or quitting that locality until forty-two days
had elapsed after the last attack of the malady there. The second
cordon was formed around the infected area, encircling all the
infected localities. Its circumference extended 800 kilometres, and
was guarded by pickets of soldiers stationed at intervals of five
kilometres. This cordon had four quarantine stations. The third and
outermost cordon was established round the whole province of
Astrakhan. It served to control the functions of the inner cordons,
inasmuch as all persons coming from within its area, who could not
prove that they had undergone quarantine at the stations of the middle
cordon, were stopped.
{784} The complete disinfection of all clothing and other articles
used in the service of the sick is to be included among measures of
prophylaxis. It is no uncommon thing to destroy by fire the houses in
which cases have occurred, along with their contents.
No efficient means of protection are known for those who during an
outbreak cannot escape from the infected neighborhood. It would be
without purpose other than to amuse the reader to reproduce the quaint
fancies of the older physicians in this matter, or to dwell upon the
amulets and incantations, the absurd costumes, the protective power of
tobacco, according to Diemerhoeck, or the disbelief in its virtues on
the part of Hodges, who preferred "canary, of the best sort, of which
he frequently drank while he attended the sick."
Clinical.--"The treatment of individual cases must in the present
state of knowledge be expectant and symptomatic. Notwithstanding our
acquaintance with the symptoms that characterize plague, we are
utterly ignorant of the treatment best suited to its cases"
(Cabiadis).
Physicians who have written from personal observation unite in
advising a treatment of the simplest kind. Ventilation, cleanliness, a
liquid diet, abundant cool drinks, are to be ordered. The initial
collapse and the evidences of failure of the circulation call for the
use of stimulants, and especially of alcohol. Cold or tepid sponging,
in accordance with the sensations of the patient, may be resorted to.
If there be high fever an energetic antipyretic treatment might be
carried out. Cold effusion is said to have been of use in many
instances.