Plague - Symptoms
There are two chief forms:-- (1) mild plague, pestis minor, larval plague (Radcliffe), peste fruste, in which the special symptoms are accompanied by little fever or general disturbance; and (2) ordinary epidemic or severe plague, pestis major, in which the general disturbance is very severe. Cases which are rapidly fatal from the general disturbance without marked local symptoms have been distinguished as fulminant plague (pestis siderans, peste foudroyante).
1. In the minor form of the disease spontaneous swellings of the glands occur, chiefly in groins and armpits, but also in neck or other parts, which either undergo resolution or suppurate. There is a certain amount of fever ; the temperature is rarely high, but has been known to be 104° Fahr. The duration of the disease is ten to twenty days usually, but may be eight weeks, for most of which time the general health is little impaired and the patient able to go about as usual. It rarely, if ever, causes death, the only fatal case at Astrakhan in 1877 having been so through a compilation. The disease is not obviously contagious; whether it is propagated by infection or not is unknown. It is possibly rather of a miasmatic character. This form of disease has sometimes preceded or followed epidemics, as in Mesopotamia (Irak) [Iraq] on several occasions, 1873-78, and in Astrakhan, 1877; its importance in relation to the origin of plaque has only lately been appreciated. [Footnote 159-2]
2. It might be expected that gradations would be found connecting this form with severe epidemic form ; but this appearance to be not usually the case, the latter form appearing somewhat suddenly and abruptly. Hence the minor form has probably often been regarded as a distinct disease, even when observed in plague countries.
3. As regards pestis major, or sever plague, the symptoms appear to have been nearly the same in all great epidemics for several centuries, if not for two thousand years, but will be best given from modern observations such as those of Surgeon-Major Colvill, Dr Cabiadis, and others in Irak [Iraq], and recent observers in India. The early symptoms are sometimes like those of argue( shivers, often long continued, and pains in the limbs), but combined with nervous symptoms. The patient becomes distracted, tosses about in constant fear of something he cannot describe, has a difficulty in understanding the questions put to him, and is slow in answering. He is often described as staggering like a drunken man. There is severe headache, intense thirst, and severe pain in the epigastrium. The eyes are and turbid; the tongue swollen, dry, and fissured, sometimes black, sometimes remarkably white (Colvill). This condition may pass into coma even before fever sets in. In other case bilious vomiting is the earliest symptom. The fever which sets in man last twenty-four to thirty hours, or more. The temperature may be 100° to 107° Fahr., or even higher ; but in the most rapidly fatal cases there may be little or no fever. Generally there is obstinate constipation, but sometimes diarrhaea. Besides there symptoms there are certain special ones especially characteristic of plague.
(a) Buboes or glandular swelling are observed in all except very rapidly fatal cases. They occur in 45 or 50 per cent. Of the cases in the groin, 35 per cent. in the axilla, also less frequently in the neck or other parts. These swellings may occur the fever, simultaneously with it, or some hours are it has set in. A sudden pain like that of a stab is felt in some of the body, which has given rise to the superstition that the unfortunate victim was wounded by the arrow of an invisible demon -- a belief recorded in Constantinople in the 6th century, and said still to survive in Mohammedan countries. The buboes may suppurate, and free discharge of matter from them has in all times been held to be a favourable sign and conducive to recovery.
(b) Carbuncles were observed in about 2 1/2 or 3 per cent. of the cases in recent epidemics in Irak. They are always an unfavourable sign.
(c) Petechiae or haemorrhagic spots on the skin have always been regarded as signs of the worst omen. Under the name of "tokens" they were considered in the English epidemics of the 16th century as the infallible signs of approaching death. "They appear generally only a few hours before death" (Corvill). Hodges (1665) noticed hardness which showed the existence of haemorrhage under the skin. The skin is sometimes so covered with petechiae as to become of a dark livid hue after death, recalling the name Black Death (Cabiadis).
The occurrence of the above symptoms, especially the first, in the idiopathic fever attacking many persons at one time is sufficient to make the diagnosis of plague.
A very notable and the fatal form of the disease is that in which haemorrhages from the lungs, stomach, bowels, nose, &c., occur. These are of the worst omen, and are seen in some cases where there are no buboes, and which are rapidly fatal. This was observed in Irak [Iraq] in recent epidemics, in the outbreak on the Volga in 1878-79, and in the plague of India. It was a noticeable symptom in the black death, and was observed even in the plague of the 6th century. The bleeding is mostly from the lungs, and is sometimes associated with other symptoms of lung affection. This form of the disease appears, however, to have no distinct historical or geographical limit. A similar haemorrhagic from has been observed in small-pox and scarlet fever, and is always extremely fatal.
In all plague epidemics cases occur in which death takes place very rapidly, even within twenty-four hours, without the development of the special symptoms of the disease. Such cases are reported by Diemerbroek, Hodges, and others in the 17th century century, and the have been observed in recent epidemics in Irak, as well as in the recent plague on the Volga. Some are more like cases of poisoning than of infection, and much resemble the instances of death from the exhalations of dead bodies (cadaveric poisoning which are met with from time to time. It is these which have been rise to the expression fulminant plague.
159-2 Payne, Trans Epidem. Soc. of Lond., iv. 362 ; Tholozan , La Peste en Turquie, Paris, 1880; J. N. Radcliffe, Report of Local Government Board, 1879 80 (Supplement, pp. 24, 49), and article "Plague," in Quain's Dictionary of Medicine, London, 1882.
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