Death commonly occurred on the seventh or the ninth day. One recognizes here submission to the authoritative doctrine of critical days. Hippocrates[211] defined them on the basis of equal and unequal numbers:
Equal—4, 6, 8, 10, 14, 28, 30, 48, 60, 80, 100.
Unequal—5, 7, 9, 11, 17, 21, 27, 31.
Taking the mean of the numbers, the plague of Athens claimed its victims for the most part about the eighth day of the disease. A layman would hardly have had the opportunity, or indeed the inclination, to make an exact statistical computation, and in this fact perhaps lies this unexpected lapse of Thucydides into subservience to medical orthodoxy.
With regard to the day of death in typhus fever, Curschmann says: ‘When death is caused simply by the severity of the disease, it occurs usually in the middle or second half of the second week. A fatal termination before the ninth day, or as early as the fifth or sixth day, occurs only in the most severe forms of the disease, or in individuals with little resisting power.’ Now, not only was the Athenian pestilence severe in type, but there was also an almost complete absence of the nursing and medical regimen that will have served to prolong the duration of cases, that have ultimately proved fatal, in recent epidemics. In plague death usually occurs between the second and sixth days, seldom later, and few patients survive to the seventh or ninth day without the appearance of buboes.
If the victims survived this period, the disease fastened on the bowels and produced violent ulceration (ἕλκωσις). Initial constipation, followed, as the disease develops, by diarrhoea, which is sometimes profuse and intractable, is met with both in typhus and plague.
The disease began in the head and gradually passed through the whole body. If the sufferer survived so long, it would often seize the extremities and make its mark, attacking the privy parts and fingers and toes. Some escaped with the loss of these and with the loss of their eyes. This terminal gangrene of the extremities is of frequent occurrence in typhus, but is rare in plague, and very rare in other acute infectious fevers. Curschmann says: ‘Many patients continue to suffer for some time after defervescence (of typhus fever) from gangrene of the ears, fingers, toes, tip of the nose, and skin of the penis and scrotum, arising during the febrile period.’ Gangrenous changes around a carbuncle are occasional in plague, but not as an independent affection of the extremities. Neglected plague buboes, even nowadays in Indian epidemics, do exceptionally become gangrenous, as the result of an intercurrent erysipelas. Necrotic ulceration of the eyeballs is well authenticated as a complication of typhus as well as of plague.
Some recovered from the disease, but with complete loss of memory. This again is a frequent consequence, usually temporary, but sometimes permanent, of typhus. According to Curschmann, ‘the patient’s recollection of his illness is almost always very limited in severe or moderately severe cases. True psychoses appear to be rare during convalescence. Mild melancholia and hallucinations are sometimes seen, and even mania has been observed.’
The combination of gangrene with mental symptoms inevitably suggests the thought of ergotism (poisoning by a fungus of rye-grain), and Read and Kobert have expended much ingenuity in support of this hypothesis. One of the Athenian corn routes did actually tap the northern shores of the Euxine, and southern Russia has been one of the chief centres of epidemics of ergotism. But there is no need to invoke this condition, to explain symptoms which are commonly encountered in typhus, and no warrant either for so doing, seeing that the clinical features of the visitation had little in common with ergotism. Kobert’s ingenious arguments in favour of ergotism, superimposed on some other unidentified disease, merely substitute one impasse for another.
Thucydides observes that one feature distinguished the Athenian pestilence from ordinary diseases. Birds and beasts of prey, which feed on human flesh, would not as a rule touch the bodies, but, if they did, they died. In fact, the birds of prey disappeared altogether, and were not to be seen either about the bodies or anywhere else. In the case of the dogs this was particularly noticeable, because they live with man. The paragraph is curiously involved, but contains three statements of fact:
1. That vultures were nowhere to be seen.