Plague and pestilence in literature and art

by Sir Raymond Henry Payne Crawfurd

The acute, often abrupt, onset of the Athenian pestilence, with profound depression, severe headache, and suffused conjunctivae, though met with in a moiety of cases of plague, is eminently characteristic of typhus. The striking appearance of the bloodshot eyeballs has led to much confusion between the two diseases.

The aspect of the tongue and fauces inclines rather to the side of typhus. In each disease the tongue is at first heavily coated with a thick white fur, and tends later to become dry and parched. But in typhus there is a special tendency, as the disease advances, for the tongue to bleed from fissures at the edges. So frequently is this the case, that this feature has been regarded as of diagnostic value in the presence of an outbreak of typhus. A boggy reddened appearance of the fauces is usual in typhus, and is seen also in a proportion of plague patients.

Unnatural and even foetid breath may be met with in any acute infectious fever, but foetor is in no way characteristic of any. Doubtless it was far more common in times when the alphabet of oral hygiene had not yet found acceptance as a necessary detail of medical regimen. Murchison describes the breath of typhus patients as foetid, and in addition it is well known that a repulsive odour may be given off from their bodies. Salius Diversus mentioned it three centuries ago, and it has been a commonplace of many subsequent writers. Curschmann failed to detect it, and attributed its absence to the free ventilation of the sick wards. A layman, as Thucydides was, might well ascribe to the breath a foetor permeating the whole atmosphere around the patient.

Sneezing has long been associated in popular tradition with plague, and an old legend refers the association to the plague of Rome at the commencement of the pontificate of Gregory the Great, when it is said that those who sneezed died. The most careful and observant of modern physicians do not, however confirm the connexion. Russell states that he was on the look out for it during the plague of Aleppo and did not observe it: Simpson does not even mention it. Nor does it appear to be noteworthy as a symptom either of typhus or of any other acute infectious fever, though it would be in accord with the swollen and congested state of the nasal mucosa in typhus, to which Curschmann has drawn special attention. Perhaps the tradition is a mere old wives’ tale, for sneezing has been regarded as an ominous sign from great antiquity, and as far back at least as the composition of the Odyssey. Aristotle frankly confessed himself unable to explain the connexion.

Curschmann met with hoarseness and laryngeal catarrh commonly in typhus, but though catarrh of the whole respiratory tract may occur in plague, it is not an outstanding feature. Cough is frequent in either disease; so also is vomiting, often of great severity: and if protracted will exhibit a succession of changes of colour, such as Thucydides has described, first the food contents of the stomach, then green bilious vomit, and finally blood, either red or altered to brown or black. Hiccough and empty retching are liable to ensue on severe vomiting from any enduring cause.

It is not clear to what Thucydides appropriates the term σπασμός: the context would suggest that spasm of the diaphragm, such as accompanies protracted vomiting, is indicated. But it may also signify true convulsions, which are an occasional complication of both diseases. Convulsive tremor of the limbs, and indeed of the whole body, is habitual at the height of typhus, and is not infrequent in plague.

We should naturally look to the appearance of the skin and of the eruption to afford criteria for a sure diagnosis, but such is not the case. True, there is a remarkable resemblance to Murchison’s description of the skin of typhus patients, in an English hospital. ‘The face’, he says, ‘is often flushed. The flushing is general over the entire face. It is never pink: sometimes it is reddish or reddish brown, but more commonly it is of a dusky, earthy, or leaden hue: in grave cases it may be livid.’ No corresponding appearance of the skin is to be seen in plague.

Thucydides has described the eruption as consisting of φλύκταιναι μικραὶ καὶ ἕλκη, words that have generally been rendered as ‘small blisters and ulcers’, and for this reason have been held to exclude positively a diagnosis of typhus fever. So certain a conclusion is hardly justified by the facts. Outbreaks of gangrenous dermatitis, in which multiple bullae or blisters, leaving an ulcerated base, have broken out over the body surface, have been not uncommon features of a typhus epidemic, and from their virulently contagious character such outbreaks would have been more prone to occur amid all the neglect and destitution of a beleaguered garrison. Murchison has described the resulting appearances in the following words: ‘I have seen bullae filled with light or dark fluid, or large pustules appear on various parts of the body during the progress of the fever. Stokes has observed bullae of this description followed after bursting by deep ulcers with sharp margins.’ But extensive ulceration such as this must inevitably have left permanent scarring, at least as marked as the ‘pitting’ produced by small-pox, and we can hardly presume that this could have escaped the critical Greek eye of so keen an observer as Thucydides. The whole question arises of the exact significance of the words ἕλκος and φλύκταινα.

In his treatise Περὶ Ἑλκῶν Hippocrates uses the term ἕλκος not only for open wounds and ulcers, but also for burns, wheals, and wounds in general.

Homer uses it for wounds of every kind. It so happens that the wounds of the Iliad are almost all the open wounds produced by spear and arrow, but Homer also uses it for the bite of a snake[201] and for the wound inflicted by lightning.[202]