1. THE COURSE OF THE DISEASE.
183
The symptoms of plague in the year 1896 were very various, according to the severity and the type of the cases.
It is therefore impossible to present a simple clinical picture of the disease. I shall first describe in general terms the symptoms proper to plague, and shall then more particularly describe the various forms that are met with in practice.
The disease began in most cases without prodromata, with rigor and sensation of heat. These were quickly followed by the other symptoms, of which the principal were great prostration, fever, and glandular swelling. If prodromal symptoms occurred, these as a rule lasted only a few hours or one or two days; they were lassitude, headache, dizziness, loss of appetite, and lumbar pain.
After the onset of the disease, signs of a constitutional disorder followed, severe dull headache, great weakness, and overpowering sensation of fatigue. The patient showed a quite characteristic pain-drawn expression of countenance. Around the eyes, on the forehead, and on the cheeks, the skin usually assumed a blue-black colour; the skin of the eyelids became bright red; the eyes were sunken; and expression was fixed and vacant. Frequently, in addition, the difficult hesitating speech and the staggering tremulous gait, with the dulling of the senses and of the intellectual powers, early combined to give the patient an utterly stupefied appearance. Often from the beginning the patients were quite quiet and indifferent to their surroundings; frequently, however, when the sensations of internal heat and distress gained the upper hand, they threw themselves restlessly to and fro on their beds, became delirious and soon quite speechless. The delirium was usually of a muttering kind, and exhibited these characteristics, that the patient moved his hands restlessly to and fro, picking at the bed-clothes, as if he were picking wool (floccilation), muttering to himself unceasingly. Sometimes, however, the delirium was of a violent character. The patients sprang from their beds, struck wildly about, and swore at those around them.
Fever was present in all cases, but varied greatly in height and duration. A regular, typical fever-curve, such as is seen in most other specific febrile diseases, was never observed. Sometimes the temperature oscillated at a high level, between 39.5° and 41° C. (103° F. and 106° F.), sometimes it ranged only between 38 and 39° C. (100.6° and 102° F.). Generally speaking, the height of the temperature afforded no criterion of the severity of the case; patients with high temperatures and patients with low temperatures alike quickly succumbed. In many cases the fever lasted a few hours only, the temperature then falling to normal or to subnormal (to 35° C.-96° F.); in many cases, on the other hand, the fever was of several weeks' duration. In 30% of the cases—70% died already within the first six days of the illness—the fever lasted from six to ten days, usually reaching its height (39.5° to 41° C.=103° to 106° F.), from the third to the fifth day, and then gradually falling to the normal. This course of the fever may be regarded as typical of the disease, and as having a not unfavourable prognostic signification. After this first stage of fever, in the latter course of the disease, fever of a remittent type frequently appeared. This was due to the formation of lymphatic glandular or other abscesses, a fever of suppuration or of septic absorption, and varied in duration according to the originating cause. 10% of those patients that survived the first virulence of the disease were carried off by this secondary fever.
The skin was in all cases hot and dry. Shortly before death, cold sweats frequently occurred. No critical or lytical sweats were observed in connexion with the decline of the fever.
Petechiae were seen in 3% only of the cases; they appeared in very severe cases, and shortly before death. Herpetic or varioloid eruptions occurred in 2% of the cases; icteric tint of skin also in 2%. In 3% of the patients carbuncular affections of the skin were observed; these were situated on the abdomen near the navel, on the back over the shoulder-blades, on the neck, and on the legs. They began usually as small ecchymotic spots on the skin, looking like flea-bites; these soon increased in size and became covered with small vesicles, while the surrounding skin became hard and swollen. The swellings
1. THE COURSE OF THE DISEASE.
183
The symptoms of plagne in the year 1896 were very various, according to the severity and the type of the cases.
It is therefore impossible to present a simple clinical picture of the disease. I shall first describe in general terms the symptoms proper to plague, and shall then more particularly describe the various forms that are met with in practice.
The disease began in most cases without prodromata, with rigor and sensation of heat. These were quickly followed by the other symptoms, of which the principal were great prostration, fever, and glandular swelling. If prodromal symptoms occurred, these as a rule lasted only a few hours or one or two days; they were lassitude, headache, dizziness, loss of appetite, and lumbar pain.
After the onset of the disease, signs of a constitutional disorder followed, severe dall headache, great weakness, and overpowering sensation of fatigue. The patient showed a quite characteristic pain-drawn expression of countenance. Around the eyes, on the forehead, and on the cheeks, the skin usually assumed a blue-black colour; the skin of the eyelids became bright red; the eyes were sanken; and expression was fixed and vacant. Frequently, in addition, the difficult hesitating speech and the staggering tremulous gait, with the dulling of the senses and of the intellectual powers, early combined to give the patient an utterly stupefied appearance. Often from the beginning the patients were quite quiet and indifferent to their surroundings; frequently, however, when the sensations of internal heat and distress gained the upper hand, they threw themselves restlessly to and fo on their beds, became delirious and soon quite speechless. The delirium was usually of a muttering kind, and exhibited these characteristics, that the patient moved his hands restlessly to and fro, picking at the bed-clothes, as if he were picking wool (floccilation), muttering to himself unceasingly. Sometimes, however, the delirium was of a violent character. The patients sprang from their beds, struck wildly about, and swore at those around them.
Fever was present in all cases, but varied greatly in height and duration. A regular, typical fever-curve, such as is seen in most other specific febrile diseases, was never observed. Sometimes the temperature oscillated at a high level, between 39.5° and 41° C. (103° F. and 106" F.), sometimes it ranged only between 38 and 39° C. (100,6° and 102° F.). Generally speaking, the height of the temperature afforded no criterion of the severity of the case; patients with high temperatures and patients with low temperatures alike quickly succumbed. In many cases the fever lasted a few hours only, the temperature then falling to normal or to subnormal (to 35° C.-96° F.); in many cases, on the other hand, the fever was of several weeks' duration. In 30% of the cases-70% died already within the first six days of the illness-the fever lasted from six to ten days, usually reaching its Jame (39.5° to 41° C.=103° to 106° F.), from the third to the fifth day, and then gradually falling to the normal. This course of the fever may be regarded as typical of the disease, and as having a not unfavourable prognostic signification. After this first stage of fever, in the latter course of the disease, fever of a remittent type frequently appeared. This was due to the formation of lymphatic glandular or other abscesses, a fever of suppuration or of septic absorption, and varied in duration according to the originating cause. 10% of those patients that survived the first virulence of the disease were carried off by this secondary fever.
The skin was in all cases hot and dry. Shortly before death, cold sweats frequently occurred. No critical or lytical sweats were observed in connexion with the decline of the fever.
Petechin were
seen in 3% only of the cases; they appeared in very severe cases, and shortly before death. Herpetic for varioloid eruptions occurred in 2% of the cases; icteric tint of skin also in 2%. fu 3% of the patients carbuncular affections of the skin were observed; these were situated on the abdomen near the navel, on the back over the shoulder-blades, on the neck, and on the legs. They began usually as small ecchymotic spots on the skin, looking like flea-bites; these soon increased in size and became covered with small vesicles, while the surrounding skin became hard and swollen. The swellings
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