also used instead of “septi-caemic,” and though etymologically
objectionable, it is otherwise better, as “septicaemic” already
has a specific and quite different meaning.) It should be understood
that this classification is a clinical one, and that the
second and third varieties are just as much plague as the first.
It is necessary to say this, because a misleading use of the word
“bubonic” has given rise to the erroneous idea that true plague
is necessarily bubonic, and that non-bubonic types are a different
disease altogether. The word “plague”—or “pest,” which is
the name used in other languages—had originally a general
meaning, and may have required qualifications when applied to
this particular fever; but it has now become a specific label,
and the prefix “bubonic” should be dropped.
The illness varies within the widest limits, and exhibits all gradations of severity, from a mere indisposition, which may pass almost unnoticed, to an extreme violence, only equalled by the most violent forms of cholera. The mild cases are always bubonic; the other varieties are invariably severe, and almost always fatal. Incubation is generally from four to six days, but it has been observed as short as thirty-six hours and as long as ten days (Bombay Research Committee). Incubation, however, is so difficult a thing to determine that it is unwise to lay down any positive limit. As a rule the onset is sudden and well marked. The symptoms may be described under the headings given above. (1) Bubonic cases usually constitute three-fourths of the whole, and the symptoms may therefore be called typical. In a well-marked case there is usually an initial rigor—in children convulsions—followed by a rise of temperature, with vomiting, headache, giddiness, intolerance to light; pain in epigastrium, back and limbs; sleeplessness, apathy or delirium. The headache is described as splitting; delirium is of the busy type, like delirium tremens. The temperature varies greatly; it is not usually high on the first day—from 101° to 103°—and may even be normal, but sometimes it rises rapidly to 104° or 105° or even 107° F.; a fall of two or three degrees on the second or third day has frequently been observed. The eyes are red and injected, the tongue is somewhat swollen, and at first covered with a thin white fur, except at the tip and edges, but later it is dry, and the fur yellow or brownish. Prostration is marked. Constipation is the rule at first, but diarrhoea may be present, and is a bad sign. A characteristic symptom in severe cases is that the patient appears dazed and stupid, is thick in speech, and staggers. The condition has often been mistaken for intoxication. There is nothing, however, in all these symptoms positively distinctive of plague, unless it is already prevalent. The really pathognomonic sign is the appearance of buboes or inflamed glands, which happens early in the illness, usually on the second day; sometimes they are present from the outset, sometimes they cannot be detected before the third day, or even later. The commonest seat is the groin, and next to that the axilla; the cervical, submaxillary and femoral glands are less frequently affected. Sometimes the buboes are multiple and on both sides, but more commonly they are unilateral. The pain is described as lancinating. If left, they usually suppurate and open outwards by sloughing of the skin, but they may subside spontaneously, or remain hard and indurated. Petechiae occur over buboes or on the abdomen, but they are not very common, except in fatal cases, when they appear shortly before death. Boils and carbuncles are rare. (2) Pneumonic plague was observed and described in many of the old epidemics, and particularly by two medical men, Dr Gilder and Dr Whyte, in the outbreak in Kathiawar in r8r6; but its precise significance was first recognized by Childe in Bombay. He demonstrated the presence of the bacilli in the sputa, and showed that the inflammation in the lungs was set up by primary plague infection. The pneumonia is usually lobular, the onset marked by rigors, with difficult and hurried breathing, cough and expectoration. The prostration is great and the course of the illness rapid The breathing becomes very hurried—forty to sixty respirations in the minute—and the face dusky. The expectoration soon becomes watery and profuse, with little whitish specks, which contain great quantities of bacilli. The temperature is high and irregular. The physical signs are those of broncho-pneumonia; oedema of the lungs soon supervenes, and death occurs in three or four days. (3) In septicaemic cases the symptoms are those of the bubonic type, but more severe and without buboes. Prostration and cerebral symptoms are particularly marked; the temperature rises rapidly and very high. The patient may die comatose within twenty-four hours, but more commonly death occurs on the second or third day. Recovery is very rare.
There is no reason for doubting that the disease described above is identical with the European plagues of the 14th and subsequent centuries. It does not differ from them in its clinical features more than epidemics of other diseases are apt to vary at different times, or more than can be accounted for by difference of handling. The swellings and discolorations of the skin which play so large a part in old descriptions would probably be equally striking now but for the surgical treatment of buboes. Similarly, the comparatively small destructiveness of modern plague, even in India, may be explained by the improved sanitary conditions and energetic measures dictated by modern knowledge. The case mortality still remains exceedingly high. The lowest recorded is 34% in Sydney, and the highest 95% at Hong Kong in 1899. During the first few weeks in Bombay it was calculated by Dr Viegas to be as high as 99%. It is very much higher among Orientals than among Europeans. In the Bombay hospitals it was about 70% among the former, and between 30 and 40% among the latter, which was much the same as in Oporto, Sydney and Cape Town. It appears, therefore, that plague is less fatal to Europeans than cholera. The average duration of fatal cases is five or six days, in the House of Correction at Byculla, where the exact period could be well observed, it was five and a half days. Patients who survive the tenth or twelfth day have a good chance of recovery. Convalescence is usually prolonged. Second attacks are rare, but have been known to occur.
Diagnosis.—When plague is prevalent in a locality, the diagnosis is easy in fairly well-marked cases of the bubonic type, but less so in the other varieties. When it is not prevalent the diagnosis is never easy, and in pneumonia and septicaemic cases it is impossible without bacteriological assistance. The earliest cases have hardly ever been even suspected at the time in any outbreak in a fresh locality. It may be taken at first for almost any fever, particularly typhoid, or for venereal disease or lymphangitis. In plague countries the diseases with which it is most liable to be confounded are malaria, relapsing fever and typhus, or broncho-pneumonia in pneumonia cases.
Treatment.—The treatment of plague is still symptomatic. The points requiring most attention are the cerebral symptoms—headache, sleeplessness, delirium, &c.—and the state of the heart. Alcohol and cardiac stimulants may be required to prevent heart failure. Speaking generally, it is important to preserve strength and guard against collapse. Extracts of supra-renal gland have been found useful. Buboes should be treated on ordinary surgical principles. An antitoxic serum has been prepared from horses by the Institut Pasteur in France, but has not met with success. The results in India obtained by British and various foreign observers were uniformly unfavourable, and the verdict of the Research Committee (1900) was that the serum had “failed to influence favourably the mortality among those attacked.” Success was somewhat noisily claimed for an improved method tried in Oporto, but the evidence is of little or no value. Of 142 cases treated, 21 died; while of 72 cases not treated, 46 died; but the former were all hospital patients, and included several convalescents and many cases of extreme mildness, whereas the non-serum cases were treated at home or not at all, some being only discovered when death had made further concealment impossible. Later observations have, however, established that the Yersin-Roux serum is of undoubted benefit when used early in the case, in fact during the first twenty-four hours. Very large doses, so much as 150 cc. may be injected subcutaneously or preferably intravenously, and it is stated to modify the whole course of
