In others the disorder was more perceptible. In a few hours the eyes became muddy, the surface of the body cold, with drowsiness, lethargy, and pain at the heart. In the progress of the distemper they frequently lost the power of speech, the skin seldom recovered its warmth, or, if it did, it was only by irregular flushings. The pulse sometimes remained nearly in its natural state, but was, for the most part, low and quick. They were “by turns delirious, confused and sensible, but the comatose disposition was most prevalent. Towards the end they suffered extreme inquietude. Vomiting in some occurred the first night; in others a diarrhœa next day; both accelerating the fatal period; but these symptoms were less frequent than in some of the other classes. Buboes appeared only in a very few who survived the third day. . . . The total absence of buboes in such patients as perished suddenly I have no doubt of, nor of their being in general very rare in others of this class; though I suspect that the buboes might sometimes have been concealed, where the disease ran out to the fourth or fifth day, and for the same reason that the reports concerning the state of the corpse were sometimes not true. . . . It was very rare to find suspicious marks of infection on the bodies [of those who died within 24 hours]. . . . Carbuncles were seldom visible till the month of May, which was later than this form of the disease. It prevailed chiefly at the rise of the plague in 1760, and its revival in the two succeeding years, decreasing as the distemper spread; and though they were found dispersed in every stage of the pestilential season, yet the number of this class was proportionably small, compared with that of others. Petechiæ, vibices, or broad, livid, roundish spots, occurred sometimes, but were not common, and the two latter were seldom visible till after death.”
This account of the most malignant form of the pestilence differs considerably from that of Dr. Hodges, who seems to think that the tokens, as he calls them, very generally were to be found on the bodies of those who died suddenly. He mentions indeed a young man who was suddenly seized with a violent palpitation of the heart, and thus continued till his death, which took place in a few hours. In this case the Doctor supposed that there might be a carbuncle broke out on the heart. Dr. Russel has considered the description of the tokens given by Dr. Hodges, and compared it with that of others called by Diemerbroeck maculæ mortis, spots or tokens of death; and by this comparison it appears that the former has spoken somewhat indistinctly on the subject, confounding two different kinds of eruptions together. Dr. Hodges, however, as we have already seen (p. [10]) asserts, in his Loimologia, that the tokens rise from within, and are broadest at their bases, where he also supposes the pestilential poison chiefly to lie. To the same purpose, in his Letter to a Person of Quality he says, “The tokens have their original and rise from within, and afterwards externally show themselves; which is evident, because the basis of them is larger than their outward appearance, and the internal parts are found very often spotted, when there is no discoloration visible on the skin.” Dr. Russel, after quoting Diemerbroeck, makes the following observations: “The author (Diemerbroeck) is diffuse on this subject, and thinks it a mistaken though prevalent notion, that the maculæ are merely superficial in the skin, proceeding from putrefaction, ebullition, &c. in the blood or humours: on the contrary he affirms, they arise from the internal parts, even the periosteum, broad at the base, and tapering to their termination in the skin, being produced by the extinction and extravasation of the vital spirits. Now (says Dr. Russel) this answers exactly to one species of the tokens described by Hodges, which therefore may be reckoned the same with the maculæ mortis, and was probably the only one observed at Nimeguen,” &c. On the same subject he quotes a book entitled Medela Pestis, in which the author says that by careful dissection the tokens may be traced half-way deep in the flesh, and some, in the muscles of the breast, have been followed by the incision knife even to the bone. By the directions given by authority to the searchers in 1665, they were ordered to look narrowly for these tokens, which were described as “spots arising on the skin, chiefly about the breast and back, but sometimes also in other parts. Their colour is something various, sometimes more reddish, sometimes inclining a little towards a faint blue, and sometimes a brownish mixed with blue; the red ones have often a brownish circle about them, the brownish a reddish.”
On the subject of tokens Dr. Hodges further observes, that they differed also in their degrees of hardness, some being easily penetrated with a needle or penknife, while others, more callous or horny, were penetrated with more difficulty. They so strongly resembled warts, that they could scarce be distinguished from them; and Dr. Hodges himself was often obliged to have recourse to a needle for this purpose. They seemed hard to the touch, not unlike kernels under the skin, the superfices being smooth. “When I essayed to prove some of them (says he) I found them almost impenetrable.” Another very remarkable circumstance relative to them was, that they were often quite insensible, and this distinguished them from the carbuncle, which is always very painful. Hodges also remarks, that a quick sensibility in the skin was always a good sign, and those that went no farther than the skin would sometimes slough off.
Along with these tokens we can scarce doubt that petechiæ and vibices made their appearance. The former, even in the inferior degrees of the distemper, were dangerous, the latter always fatal, never appearing till the patient is within a few hours of death, sometimes indeed not till death has taken place. Of the petechiæ Dr. Russel says, that for the most part they predicted death, but not without exception. Such as he observed were round, somewhat smaller than a recent flea-bite. They were distinct, few in number, and scattered irregularly about the breast and mastoid muscles. When they did not appear till the approach of death, they were from the first livid, or very dusky; but if they appeared early, they were of a less deep colour, changing afterwards to livid. Hodges speaks of them as deeper coloured than the spots of malignant fever, not fixed in any particular spot, sometimes few, but commonly very numerous; the colour sometimes red or purple, sometimes yellow, and sometimes livid or black. From Gotwald, Russel quotes a description of these spots, which he divides into four species. 1. Reddish, like flea-bites, soon growing brown or black; appearing on all parts of the body except the face. 2. In the form of lentils, spreading like the former all over the body; ruddy at first, but in 24 hours growing dark or ash-coloured. 3. Large brown spots, scattered here and there, sometimes intermixed with the lentil kind. 4. Not unlike the measles, spreading all over the body, rising afterwards in small blisters without any matter, vanishing about the fifth day. Russel also takes notice of a species of petechiæ which were very numerous, confluent, and of a dark red or dusky colour and irregular figure. These were sometimes remarked in the interstices of the former. Such instances occurred but rarely.
The vibices were much larger than the petechiæ. Gotwald says that they covered the face as high as the nose, and from thence spread to the forehead, disfiguring the patient in a frightful manner. They did not appear till a short time before death. Often they appeared unexpectedly, shooting up like lightning from the breast to the face, in spots of various colours, blue, green, brown and yellow. Diemerbroeck describes them as oblong spots of a livid or black colour, like strokes drawn with a pen; sometimes they were larger, the biggest resembling the strokes of a whip. Russel takes notice of a kind of marbled appearance which took place at the height of the disease, or a few hours before death; the colours being a faint blue, and darkish red, both more or less obscure at times, but never bright. It was not permanent, vanishing in one place, without leaving any trace, and returning at short intervals. “The skin in various places was sometimes deformed by narrow streaks of reddish purple, or livid colour. When such took possession of the face they gave a frightful appearance to the countenance, and frequently made such an alteration in the features, and so completely disguised the patient, as to render him hardly knowable by his acquaintance. A streak nearly of the same kind was sometimes observed darting from the edges of the buboes and carbuncles. The vibices or weals were much longer and broader, and more exactly resembled the marks left in the fleshy parts by blows or stripes; they were found chiefly on the thighs, buttock, and back, and made their appearance several hours before death, in some cases, but in others not till after. Large blue or purple spots, the maculæ magnæ of authors, were sometimes observed with or without the vibices, a little while before the patient expired, but most commonly were discovered only on the corpse. Their figure in general was round, sometimes irregular.”
Whether all these mortal signs appeared on such as died very suddenly of plagues, and were by the English writers confounded under the general name of tokens, cannot certainly be determined. Dr. Russel saw none who died within the twenty-four hours, and few who died within thirty hours, so that we cannot from him expect any particular account of the situation of those who died suddenly. In general, however, he says, that “in the most destructive forms of the plague, the vital principle seems to be suddenly, as it were, extinguished, or else enfeebled to a degree capable only for a short while to resist the violence of the disease; in the subordinate forms, the vital and animal functions, variously affected, are carried on in a defective, disorderly manner, and denote more or less danger accordingly.” It seems probable therefore that in those who are suddenly killed, the same effects take place in a short time which are observed to take place after a longer space in those who die gradually, buboes only excepted, which require for their formation a longer time than is allowed to the patient to live. Internal mortifications, or rather eschars, are therefore to be suspected, and dissections have evinced that this was really the case; but besides these there was an appearance observed in the plague at Marseilles which is not taken notice of by former physicians; viz. a preternatural enlargement of the heart. M. Deidier on that occasion communicated an account of nine dissections, but of these only one had died without eruptions. This was a woman of 40 years of age, who lived till the third day. In her “the mediastinum[101] was torn towards the upper part; the pericardium of a livid colour; the heart larger than in its natural state, by the swelling of its ventricles; full of thick, black blood. The liver was also very large, and of a livid colour, with a carbuncular pustule on the side of the gall-bladder, which was filled with very black bile.” In others who had eruptions, and who of consequence we must suppose to have lived longer, the enlargement of the heart was still more remarkable. In one who lived eleven days, the heart was of double the bigness, having scarce any blood in the ventricles, whose cavities were filled each with a large polypus, that on the right side having dilated the auricle to the breadth of four inches. The liver also was larger than ordinary, and the gall-bladder full of a black and green bile. The appearances were much the same in all the rest, but, as the time they sustained the disease is not mentioned, we cannot determine whether the enlargement of the heart took place at the very first, or was only an adventitious symptom after the fever had come on. Dr. Russel takes notice that such patients as he attended complained greatly of their heart. “A sense of oppression about the præcordia (says he) which the sick were at a loss to describe, was, in one degree or other, a constant attendant on the plague, except in very slight cases of infection; and where it came on early, or persisted in a high degree, was always a dangerous symptom. The sick showed how severely they suffered by their perpetually changing their posture, in hopes of relief; but, when asked where their pain lay, they either answered hastily they could not tell, or, with a fixed, wild look, exclaimed kulbi! kulbi! (my heart! my heart!) This anxiety increasing as the disease advanced, terminated at length in mortal inquietude, the patient, for many hours, in the last stages, incessantly writhing his body and limbs as if in agony. Though pain at the heart was often conjoined with the symptom just mentioned, and by the sick seemingly blended together, it appeared to be different, and to exist separately. They often exclaimed as in the other, my heart! my heart! pointing also towards the scrobiculum cordis, but then would add eujani kulbi, my heart pains me; or naar fi kulbi, my heart is on fire.” This last pain the Doctor supposes might have its seat in the upper orifice of the stomach; the extreme anxiety may be accounted for from the enlargement of the heart; but as neither of these symptoms took place in such as died in a very short time, we must be apt to consider this enlargement not as any primary and essential symptom of the disease, but as one which takes place when the vital powers are able to oppose for some considerable time the cause of the disease.
In his account of the origin of the plague, Dr. Russel takes notice of the opinion that, at the communication of the infection, the sick were sometimes sensible of having received it. This has been observed by Dr. Lind in malignant fevers; it has also been observed in plagues, as we have seen from Dr. Hodges, Verdoni, and others; but Russel says he never saw any instance of this. He owns, however, that he has seen instances of the disease quickly succeeding a panic fear of being infested. “In cases (says he) where the disease was not discovered to be the plague, till upon the eruption of buboes after two or three days, I have known several persons who had, till then, without the least suspicion, frequented the sick, struck suddenly with a panic, and imagine themselves ill. They felt shooting pains in their groins, confusion in the head, and a loathing. Though in some these complaints were merely imaginary, and soon vanished, in others they proved real; the symptoms increasing, and being followed by eruptions. In such cases I suspected the latent infection to have been excited by terror.”
In the instance formerly quoted from Dr. Guthrie at Petersburg, we have a notable example of this sudden seizure by a stroke. His information was derived from the physician-general of the Russian army. This gentleman assured him, that “he had seen men, in apparent good health, instantaneously drop down, as if shot by a musket ball, by the sudden action of the pestiferous miasma, and upon duty again in 24 hours, perfectly recovered by the operation of a strong vomit.” Whether or not these men felt any stroke at the instant of their falling we are not told: possibly it might be only a syncope very common in the plague, which took place at the very first invasion. Russel informs us, that “the sudden loss of strength, and disturbance of the functions attributed to the brain and heart, are reckoned, in a particular manner, symptoms of the plague. In their highest degree they distinguish the most fatal forms of the disease; and, under different modifications, adhere to all its varieties. . . . The early appearance of faintness was very remarkable in the plague,” &c.
Thus we see that the plague attacks without fever in two different modes; one, by attacking and destroying the solid parts of the body, the other, without any disorganization of the body, attacking the vital principle itself, or rather the blood, from which this principle is derived, so that a temporary suspension of all the functions ensues. The analogy between the cause of pestilence and those visible substances called poisons, is very remarkable in some things, though in others it totally fails. In the Medical Repository[102] we have a dissertation upon this analogy by Dr. Edward Miller. He observes, that this analogy has been generally overlooked, chiefly on account of the invisible nature of the aerial poison, and the suddenness of death from poisons, more frequently than from pestilential diseases. This he accounts for from the largeness of the dose of poisons compared with that of contagion; “but (says he) by diminishing the quantity to an appropriate amount, these noxious substances (the poisons) may be made to exhibit the course, duration, and nearly all the phenomena, of what is called a malignant fever. But, above all, the attention of physicians has been diverted from this analogy between miasmata and poisons, by the febrile part of the character which generally belongs to pestilential diseases, and which, in common apprehension, is constantly connected with them. Yet these diseases are by no means universally accompanied with what is strictly called fever. There is often a degree of virulence in the Asiatic plague, in the yellow fever, and in all the other forms of pestilential and malignant diseases, which altogether transcends the process of fever, and extinguishes life in a more summary manner. In the worst cases both of poison and pestilence, the febrile part of the symptoms excites little attention.”
Our author does not say in what this virulence consists. In the cases of those who die with the tokens upon them, the cause is plainly within the body; the destroying power acting with greatest efficacy below the skin in the soft substance of the flesh. Where the patient is suddenly seized in the manner described by Dr. Guthrie, the cause seems to be something foreign to the body suddenly inhaled, the effects being similar to those of fixed air when drawn in by the breath, and of consequence easily expelled by a vigorous action of the powers of the system. Guthrie observes, that, in such cases, it seems “as if the contagious matter existed in a very loose state in the first passages at the beginning of the disease.”