London's Pulse: Medical Officer of Health reports 1848-1972

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London County Council 1900

[Report of the Medical Officer of Health for London County Council]

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Signs and symptoms.
Bubonic plague.
The bubonic type is taken as the standard for descriptive purposes, as the number of persons
suffering from plague, in whom this variety is met with, outnumber by a large proportion those
attacked by all the other varieties. Three-fourths of plague patients develope buboes.
Incubation—Three to five days is the usual period of incubation, but there is ample proof that
a person exposed to plague infection may develope symptoms in thirty-six hours, or the period of
incubation may extend to ten (or fourteen) days.
The prodromal symptoms are either nil, or of so indefinite a character that no specific importance
can be attached to them.
Invasion—The onset of plague is sudden:—A rigor or mere chill, a splitting headache, nausea
and vomiting, backache, a quick pulse, quickened breathing, congested conjunctive, a white coated
tongue with reddened edges and tip, a rise in temperature, sudden weakness or prostration, and a
marked mental disturbance, with or without glandular pain or swelling, constitute the initial indications
of an attack of plague. The majority of these symptoms are common to many forms of illness,
and two or three only are special. In no other disease, not even excepting cholera, does the physical
strength so suddenly decline, and in no other does mental aberration develope so quickly. The
presence of glandular swellings, or a bubo in combination with these, is well-nigh diagnostic of the
disease being plague.
As the illness proceeds the signs and symptoms present at the onset continue or increase in
severity. Vomiting may persist for a day or two or throughout the illness. The pulse at first full and
rather tense, becomes weak and compressible, and towards the end in fatal cases intermittent,
irregular or running. The breathing increases in rate with the rise in temperature and the quickness
of the pulse. The temperature may continue to rise say from 101° F. at the onset to 103°-105°-107° F.
during the first two days, or it may reach 105° F. within a few hours after invasion. After three to
five days the temperature usually falls to near the normal, but after the fifth day it may rise again
to fall on the seventh or eighth.
A clearer conception of plague will be gathered by a categorical study of the several organs and
tissues of the body.
The digestive system—The white fur on the tongue, present from the beginning of the illness,
speedily acquires a mahogany colour and finally changes to a brownish-black hue. At first the tongue
is swollen and the edges indented by the teeth, but after two or three days the dorsum is cracked and
fissured and the whole organ seems contracted in size.
The tonsils are usually reddened and may be swollen with mucous puncta on their surfaces; or
they may be actually inflamed.
Vomiting and nausea, frequently present from the onset, may continue for a day or two or
occasionally, in unfavourable cases, persist to the end. The vomited matters appear of a bilious
character at first, but later on consist merely of the food and drink that has been taken, combined with
an inordinate amount of clear fluid. Occasionally the vomit presents a coffee-ground appearance, but
this is not due to hæmatemesis.
Constipation obtains for the most part during the first day or two ; it may persist or give place
to a profuse intestinal flux. On the other hand diarrhoea may be present from the onset. Blood
occasionally appears in the stool.
The abdomen may be swollen or retracted. The liver is somewhat enlarged, and tender to
percussion; the spleen is always swollen and tender, the enlargement may be such that the spleen
occupies three or four times its normal size.
The circulatory system—The pulse, increased in frequency from the first, gains in rapidity as
the disease progresses. At first full and tense it fails after a day or two and becomes soft and compressible
and finally dicrotic or running in fatal cases.
The heart beat at the apex is more diffuse than normal; and a praecordial thrill may be
occasionally felt. The right side of the heart shows evidence of dilatation; the first sound of the
heart is short and the second feeble ; a systolic murmur is occasionally present. Pulsation of the
carotids is frequently apparent.
The respiratory system—In bubonic plague it is the exception to find any lesion of the
organs of respiration. Should bronchial or pulmonary symptoms develope, they seldom occur before the
fourth or fifth day, and usually immediately before death. The lung affections peculiar to the
pneumonic type of the disease are discussed under "pneumonic plague."
The urinary system—In some epidemics it is the rule to find a trace of albumen from almost
the onset of the disease; in other outbreaks, however, few urinary derangements occur. The urine is
always scanty, especially at the onset of plague, the specific gravity is high, and the reaction intensely
acid. Urea, uric acid and chlorides are deficient in amount; granular casts are not infrequent, and
blood in some quantity is occasionally met with. In all cases retention of urine is the rule, but
actual suppression may complicate the illness in fatal cases.