Part 3

3. In _the acute type_, the plague is preceded by a much shorter indisposition, sometimes by none at all, suddenly seizing persons in health. It is characterized by the following symptoms: a bitter taste in the mouth, and a viscidity of the saliva; violent head-ach[46]; redness of the eyes[47] and face; a very foul, and sometimes dry tongue; chilliness succeeded by considerable heat; a much fuller, stronger, and quicker pulse than in the slow type of the disorder, as well as more thirst, and deeper coloured urine; costiveness; buboes, and carbuncles come out soon after the attack of fever, or at the same time with it; after these, others come out; frequent vomitings supervene, and a delirium, which is generally of the low kind[48]. If, between the first and fourth day of the attack, the buboes are resolved[49], or they, as well as the carbuncles, come to suppuration, the patient recovers: on the other hand, if no suppuration takes place within that period; if the buboes and carbuncles increase to a great size, and the delirium continues, then the powers of life become exhausted, the pulse sinks, and death is ushered in by hæmorrhages, and a copious exspuition of thin phlegm[50]. Death takes place on the third, fourth, or fifth day; and it often happens, while the corpse is yet warm, that petechiæ and other spots come out. The bodies, after death, appear remarkably pale, soft, somewhat tumid, flexible, and free from fætor.

4. The plague, _in its most acute type_, attacks in various ways; but in relation to the leading symptoms, it may be reduced to two forms: in the first, a person in perfect health, without any previous marks of infection, is suddenly seized with a short but violent shivering fit, followed by a hot fit, which alternate with each other several times; but the external heat soon goes off, and the skin feels cool. The pulse is hard and very quick, with a most violent headach and intolerable anxiety about the præcordia[51]; a furious delirium generally comes on; the tongue is smooth, exceedingly dry, and after a while becomes livid; the respiration is short and laborious; the eyes, which are more prominent than in the acute plague, are very red and full of ferocity; the face and neck are turgid, at first red and afterwards livid; vomiting seldom comes on spontaneously. Such as are seized with these violent symptoms seldom live more that twenty-four hours. Most of them die apoplectic, or in a state of convulsive suffocation[52]; some, however, expire in a more placid manner. After death the bodies turn livid in those parts where nature had endeavoured to throw out buboes; and dark-coloured spots and vibices appear in different places. In the other mode of attack, the patients are affected with debility from the beginning, which, together with the anxietas præcordiorum, increases every moment; so that unless timely relief be given, death speedily comes on. In these cases, the pulse is very quick, but small, feeble, and at length imperceptible. Sometimes there is a low delirium; but in many instances the patients are sensible to the last. These are all the febrile symptoms that are observable. Rudiments or germs of buboes are seen upon the dead bodies.

Of these two varieties of the plague in its most acute form, the first was observed to take place in persons of a robust constitution and in full health, after making too hearty a meal on food not easily digested, or eating too much fruit, &c. The other variety attacked those who were under the influence of terror, or after immoderate venery, bleeding, &c.

The very acute type of the plague is less frequent than the other types, and often destroys the patient before medical assistance is called in; in so much that he who appeared well yesterday, is to day carried to his grave. In this species of the plague, I never saw perfect carbuncles and exanthemata; but buboes come out quickly after the attack, and are seen considerably elevated and livid in the dead bodies.

Such is the description of symptoms given by _Orræus_, a diligent and accurate observer. That published by _Samoïlowitz_[53], although it is not so circumstantial nor so well digested, coincides in all essential points with the above. This last author considers the plague under three different aspects or varieties, which correspond to the _three periods of its beginning, its height, and its decline_. In the first and last period, carbuncles and confluent petechiæ, or broad maculæ, are very rarely met with; whereas in the middle period, when the disorder rages with the greatest fury, they both occur in one and the same subject, and denote the utmost danger. At this period, (viz. when the plague is at its height) the pestilential particles being more virulent, more volatile, and more subtile, enter the body more readily, act upon it with greater force, and produce a disease which runs its course with greater rapidity than in either of the other two degrees or varieties of the plague.

The symptoms in _the first period of the plague_ are few and moderate; they are for the most part reducible to head-ache, vomiting, and buboes; petechiæ rarely appear[54], or if they do, they are distinct and very small; carbuncles are hardly ever seen. This degree of the plague terminates favourably by a suppuration of the buboes, often without any assistance from art. It may therefore be termed the mild or benignant form of the plague.

The _next degree or variety_ is that which occurs when the plague is at its height. This is the most terrible form of the disorder. All the symptoms are marked with violence. The head-ache is incessant, and the vomiting recurs frequently; the external characters are numerous; carbuncles appear in various parts of the body; the petechiæ or maculæ are very large and confluent, and often turn to carbuncles a short time before death. This happens in the following manner: two, three, or four large petechiæ run together and form a yellow pustule; sometimes a similar pustule rises upon each petechiæ; in either case, on opening the pustules, a true carbuncle appears beneath. In some instances the patient is seized from the first with a furious delirium; at other times this delirium or phrenitic state does not supervene until the second, third, or fourth day. If this disorder of the brain continues until the seventh day, there are hopes of recovery; on the other hand, if the delirium ceases on or after the first or second day, and the patient becomes tranquil and feeble, such an alteration is a certain presage of death. If this change took place in the morning, the patients died in the evening; if in the evening, they did not live over the night. At other times torpor came on, and continued through the whole of the disease, so that the patients died without pain, or at least without appearing to suffer any. In some instances, on being asked how they were, the patients replied, "very well," and called for meat and drink; but soon after they sunk into a deliquium animi, in which they remained motionless, and died.--The pulse was irregular from the beginning. When there was violent head-ache, with high delirium, &c. the pulse was full, hard, strong, and quick; on the other hand, when these symptoms ceased, whether shortly after the attack or after the second or third day, the pulse then became soft, feeble, intermitting, and not to be felt[55]. In many instances the skin was dry and hot, and the patients complained of a burning sensation, both outwardly and inwardly; in others the heat was not so great; in some the skin was yellow; in others it had a pale corpse-like appearance, joined with great flabbiness. The diarrhoea was often accompanied with an incontinence of urine, both which it was sometimes impossible to check; in such cases, these symptoms (occurring together) were the fore-runners of death. The diarrhoea was common to both sexes; but the incontinence of urine was observed in female patients only.

3. _The third degree or variety of the plague_ occurred in the decline of the epidemic. Its symptoms are the same as those which take place in the first type; and, therefore, to avoid repetition, we refer to that[56].

B.

_Questions relative to the Nature, Prevention, and curative Treatment of the Plague._

The questions proposed by Prince _Orlow_ to the physicians, and surgeons, were

1. In what manner is the contagion, which is making such great ravages in this place, propagated?

2. What are the symptoms which show that a person is infected with this disorder? In what respects does it differ from other malignant fevers, and what symptoms has it in common with them? How is the patient himself to know that he is attacked with this dreadful disorder, so as to be able to apply for help at the very beginning? How are those who are constantly with the sick, to know the disorder, so as to be put upon their guard against taking infection? And, lastly, how is the physician to be certain that it is the disease in question[57], in order that all possible means may be immediately employed to save the life of the patient?

3. Each of you is required to describe accurately the symptoms of this disorder through its whole course and under all its forms, noticing in what order the symptoms succeed each other, more especially what the symptoms are which accompany each crisis, and what those are which denote more or less danger: lastly, in what space of time, in what manner, and with what outward marks this contagious disorder terminates, whether it be in recovery or in death?

4. What are the medicines which have hitherto been administered in the different cases, in what doses, in what stage of the disorder, and with what success? The general result of these observations will determine which is the easiest and most successful method of cure.

5. What is it necessary for the patient to observe when he is taking the remedies, and when he is not; and what sort of regimen is best suited to promote the cure?

6. Lastly, each of you is required to make known, according to his own judgment and experience, what appear to be the best and surest methods by which individuals may escape this terrible scourge, and by which it may be checked, and if possible entirely eradicated; but these methods must be simple and easily put in practice.

My answers to these questions were as follow:

1. That this contagious disorder was propagated by touching the sick or dead bodies; by handling infected goods, such as clothes, furniture, and the like; by the patient's breath; or by the air of a room, confined and loaded with effluvia from the bodies of the sick; but not at all by the common atmosphere[58]. Hence those who avoid all communication with the sick, and never meddle with infected things, remain free from the plague, although they live in the same territory or in the same town where it is making its ravages; whilst the poor, not shunning communication with the sick, and putting on infected clothes, which they buy cheap or get by inheritance, are continually exposed to the contagion, and are consequently those who are chiefly attacked by the plague[59]. Now, if the cause of the plague existed in the atmosphere, or that it was carried by it in a state of activity from one place to another, it should follow, that all the inhabitants of the same territory, or at least of the same town, rich as well as poor, should be equally attacked by it; but this is not the case. All, therefore, that can be attributed to the atmosphere, with regard to the plague, is, that according to its different temperature, it disposes the human body more or less to receive the contagion; and that according as its temperature is greater or less, it renders the pestilential miasm more or less violent, or even destroys it; which, indeed, seems to have been the opinion of other writers on this subject[60]. We have seen in the preceding narrative, that the cold of winter blunted, and as it were froze the pestilential virus, whilst the heat of summer rendered it more active and volatile; nevertheless, at both these seasons, the atmosphere was as healthy as usual.

2. That it was sometimes difficult to ascertain the existence of the plague on its first appearance; but that afterwards it was attended by certain marks, which distinguish it from every other disease. These characteristic marks are petechiæ, buboes, and carbuncles. When these occur in a disorder which is very rapid in its progress, is accompanied with fever (unless when it destroys suddenly) and is highly contagious, there can be no doubt that such a disorder is the plague[61].

To determine with certainty whether a disorder which prevails in any place is the plague, it must have all the symptoms which I have just described in one or more patients. These symptoms taken singly, do not constitute the plague; for many other disorders are equally rapid in their course; petechiæ appear in common putrid fevers; in some malignant fevers carbuncles are met with; buboes are produced by the venereal disease and scurvy; and some times, though very rarely, a crisis happens in putrid fevers by abscesses forming under the arm-pits; but these abscesses arise later in these cases than they do in the plague, and moreover they are not accompanied with buboes and the other symptoms which characterize the plague. The high degree of contagion by which the disorder is propagated from one person to another, enters necessarily into the definition of the plague; without it there is no plague. In a word, if there is a frequent communication, either by commerce or in consequence of war, with Turkey or Egypt, and some persons, or a great number of persons, are attacked with a disorder which corresponds exactly to the definition above given, it is certain that it is the plague.

3. For the answer to this third question, the reader has only to revert to the description of symptoms in note A of the Addenda. As for the prognosis, it is attended with great uncertainty in cases of the plague. In some instances, an indisposition apparently slight, is quickly followed by death; whilst others who seem to be on the point of death, recover[62]. In general, when the buboes suppurate well, and there is a separation of the eschars from the carbuncles, accompanied with an abatement of the other symptoms, a favourable prognostic may be given.

4. That hitherto medicine had done very little good, the disorder being so rapid in its course as not to allow time for the remedies to act; but that the Peruvian bark and mineral acids, in large doses, ought, in my opinion, to form the basis of the curative treatment.

From the preceding history of the plague it appears, that those who are attacked with this disorder are affected with nervous symptoms before the fever comes on, and that the fever itself is of a highly putrid nature, accompanied with marks peculiar to itself, and which distinguish it from all other fevers. The proportion of those in whom the plague appears under the form of an inflammatory fever, is very small: and this happens only in the beginning of the disorder, in plethoric subjects; and that in these instances, from being inflammatory it quickly becomes putrid. Thus there are two sets of symptoms in the plague, viz. those which depend on nervous irritation, and those which depend on the putrid condition of the blood. The first I call the _nervous_, and the second the _putrid state_.

In the first, or nervous state, the indication is to promote perspiration by warm acidulated drinks, such as infusions of tea and other herbs mixed with lemon juice or vinegar, camphorated emulsions, camphor julep with vinegar and musk, &c. If ever bleeding is proper, it is at this period, and in plethoric subjects.

In the second, or putrid state, vomits, the Peruvian-bark, and mineral acids are the most promising remedies. The violence and rapidity with which the disease runs its course, require that these medicines should be administered in powerful doses. In the month of September, a woman, aged twenty-four, was seized with head-ache, fever, and vomiting; shortly after, a bubo came out on the right groin, and another under the arm-pit on the same side, of the size of a hazel nut; the next day small petechiæ appeared over the whole body; she was weak and drowsy; the tongue was white and moist; the urine pale; and she complained of head-ache and oppression about the præcordia. After I had made her vomit by giving her twenty grains of ipecacuanha, I ordered her a very strong decoction of Peruvian bark, to a quart of which were added a drachm and a half of the extract of the same bark, a drachm of the acid elixir of vitriol of the London Pharmacopoeia, and an ounce of syrup of marshmallow; she took three ounces of this mixture every other hour, and besides this, she also took four times in the day, half a drachm of Peruvian bark in powder. For her common drink, she had a decoction of barley, acidulated with spirit of vitriol. The buboes increased gradually, insomuch that in the space of a few days they were as large as walnuts; they continued in this state, without any signs of suppuration. The patient began to mend regularly, and at the end of a week, she was almost entirely recovered; she was then removed, in spite of all my remonstrances to the contrary, to the hospital, from which she was dismissed a short time afterwards, and came to see me, in perfect health.

By this mode of treatment I am persuaded that those who have the plague in its moderate and slow form, may be rescued from death. This is further confirmed by the cases of three children, one of whom was only a year old, and the two others still younger; each of them had a pestilential bubo in the groin, accompanied with fever and great debility. After they had taken the decoction of Peruvian bark, mixed with the extract, they got better; the buboes ripened and yielded a good pus. Two of these children got quite well; the third was carried off during his convalescence, by convulsions occasioned by the teeth. Although this happened in the month of December, when the disorder, being more mild, allowed many to recover; nevertheless these facts serve to establish the efficacy of the remedy, since the symptoms of the plague are always worse in children than adults, and its good effects were seen in all the three patients at the same time.

But the cure of the plague by the mineral acids and Peruvian bark, is only to be expected when the disease appears under its less violent forms. In a great number of instances (where the disease has been more violent) these remedies have been prescribed, not only without effecting a cure, but even without retarding death for a moment. Various other medicines, such as theriaca (which has been so improperly cried up in the plague) camphor, dulcified spirit of nitre, &c. have in like manner failed; so that we are compelled to acknowledge, that the plague (under its more violent forms) is of such a malignant nature as not to yield to any medicines with which we are yet acquainted, howsoever well adapted they may, _à priori_, seem to be for getting the better of this disorder. From analogy and the preceding facts, I am inclined to place more reliance upon the Peruvian bark and acids, given in large doses, than upon any other remedy; joining with them, to obviate debility, camphor, elixir of vitriol, wine, and blisters. Some were relieved by gentle emetics, such as ipecacuanha. A surgeon who had brought with him from England a great quantity of _James_'s Powder, prescribed it to several patients; but I never heard that it answered better than ipecacuanha or other emetics[63]. Purgatives, even of the most gentle sort, were hurtful; they brought on a diarrhoea which it was scarcely possible to check, and which weakened the patients exceedingly. I consider bleeding to be very improper in the plague; nevertheless I would not forbid it entirely, where the disease, in plethoric subjects, assumes an inflammatory form, and is accompanied with phrenitis; which, however, was seldom the case in the plague at Moscow[64].

5. That during the convalescence, wine, malt-liquor, kuas (the small beer of Russia) light vegetable food[65], and above all fresh air, were proper and necessary. The same diet which is suited to putrid fevers is equally suited to the plague. Nothing answers better for raising the drooping spirits and recruiting the strength of the weak and convalescent, than well fermented malt liquor, or wine and water.

6. That as to checking its progress and entirely eradicating the pestilence, that, in the present extended state of the disorder, would be attended with much difficulty; but that whatever tended to lessen the communication between the sick and healthy, and to prevent the latter from coming in contact with infected clothes, furniture, &c. would contribute to this end; and that I hoped the frost would not only weaken the contagion, but in a great measure destroy it.

When physicians of science and probity declare that they are convinced of the existence of the plague in any place, it is incumbent on the magistrates, without paying any regard to the contrary opinions of other practitioners, to take the necessary precautions for preserving the health of the public, by removing, as soon as possible, all infected persons, as well as those who are under suspicion of being infected, out of the town, to a house standing by itself, and to surround the building with guards, in order to cut off all communication. As it is of great importance in the beginning of the plague to suppress it in secret, an infected family may be removed in the night-time, without giving rise to any suspicions concerning the disorder; which if it has, as yet, appeared only in this family, may be thus extinguished, without exciting a general alarm[66]. But when several families have become infected, it is then no longer possible to keep it a secret from the public, since the precautions which it is necessary to employ must make it known. In such a case, the impested, as well as all those who have dwelt under the same roofs with them, must be cut off from all further communication with the rest of the inhabitants. The clothes and furniture belonging to the sick (excepting such things as are of a hard and solid texture, which it will be sufficient to wash with vinegar) must be burnt. The goods that are thrown into the fire must not be touched with the hands, but be taken hold of by tongs and poles furnished with hooks at the end[67]; in the same way, the dead bodies are to be put into the carts, that carry them to the burying-grounds. Persons who may be relied on, should be appointed to see that all these directions are strictly complied with. The relations and friends of the sick should be persuaded to burn the clothes and other effects which they may at different times have received; and the health of such friends and relatives should be well watched by the physicians.

A Board of Health, composed of some persons of rank, two or three physicians, and as many of the principal citizens, should regulate, under the authority of the magistrates, all matters relative to the health and safety of the inhabitants. This Board or Committee should divide the town into quarters or districts, in each of which they should appoint a physician to visit the sick; they should enjoin the inhabitants to apprize them whenever any individual in a family is taken ill; and they should order that no person be buried until the corpse shall have been examined by one of the faculty, and a note be given certifying the disorder of which the person died. If there should not be a sufficient number of physicians, the surgeons may be employed in this business.