APRIL 19.] THE NEW ZEALAND GAZETTE. 761

exterior lymph-gland may be the original seat of the illness. In far the majority of cases the bubo appears in the groin, or in the angle of the upper thigh, or frequently in the armpit, or, especially with children, in the neck. In some few cases the seat of the inflammation is in the glands of the back of the head, in the elbow, under the knee, in the front or rear ear-glands, the glands of the tongue, &c.

Very frequently one finds the outer lymph-glands in a slightly irritable condition, or apparently passed over by the disease-germ, whilst the deep glands of the second or third order develop into bubos; so that, for example, the groin-glands remain free, whilst an iliac or lumbar bubo emerges, which, as a perityphlitic swelling, may be felt through the walls of the abdomen. Or a neck-gland is slightly swollen, whilst a feeling of suffocation in the neighbourhood of the collar-bone and an appearance of pressure in the throat-organs betray the presence of a bubo in the upper cavity of the chest. In the bubo the individual enlarged glands may be clearly felt, or the inflammation of the intervening tissue has packed them in a thick heap, which can only be indistinctly traced in its surroundings. Frequently, also, it is surrounded by a doughy oedema spreading through the neighbouring tissues and over the skin. In the bubo the sensitiveness to pressure is usually far greater than the normal pain; so that the patient, when the section of the limb on which the bubo forms is in a restful, half-bent position, may feel no pain. A small bubo might quite easily remain unnoticed by the patient and his friends, so that the doctor must cautiously and repeatedly examine by touch all the glands within reach.

Plague-pustules and plague-carbuncles are not of frequent occurrence in comparison with plague-bubos. They begin with flea-bite-like spots, about the size of a pea, on some one part of the skin. Out of these small tender spots a smaller or larger bladder or blister, containing thick matter, quickly develops. Then it either remains during the formation of the pustule, or the surrounding tissues become thick and hard, and rapidly turn into a deep-reaching carbuncle, and then into an unhealthy abscess. From the pustule one often sees inflamed lymph-ducts leading to the nearest gland-layer, in which a bubo generally arises. Also, the complete carbuncle can be connected with the bubo set up in its neighbourhood.

The lung-plague, which predominates in some of the plague epidemics, but which as a rule yields in frequency to the glandular plague, runs almost the same course as an ordinary severe catarrhic or croupous pneumonia. Even if the bad common symptoms give it at the outset a specially virulent aspect, it cannot in an individual case be distinguished with certainty from other forms of lung inflammation without a bacteriological examination of the discharge.

Bubo, plague-pustules, inflammation of the lungs are alike the opening stage of the attack, sometimes preceding the fever, or, when it comes on, they develop their differences some hours or days after. Seldom does their appearance delay until the third day.

In all forms of plague there is early weakness of the heart. All may have at the beginning appearances of irritation in stomach and bowels, sensitiveness to pressure in the region of the epigastrium and cæcum, violent vomiting, followed by the passage of black fæces. With some regularity may be observed a slight degree of swelling of the abdomen, a soft palpable or percussible swelling of the spleen, traces of nucleo-albumen and of serum-albumen in the urine. Hæmoptysis or blood in the urine is of rarer occurrence. A diphtheritic affection of tonsils and palate is often found at an early stage; almost invariably there is more or less severe inflammation of the conjunctiva, frequently accompanied by a rapid inflammation of the cornea, which may lead to suppuration of the eyes. Red spots or stripes in the skin and in the mucous membrane are of unequal frequency in different forms of the epidemic. Sometimes one sees in the course of the disease inflammation of the lymphatic vessels develop below the bubos, blisters break out in their neighbourhood, and new bubos add themselves to the old in different parts of the body.

The course of the plague varies, always according to the organ attacked, to the extent that cases of skin and glandular plague may be mild and tolerably free from marked signs of sickness, whilst lung-plague as a rule shows severe symptoms, and quickly leads to death. Amongst the bubos those of the neck generally betoken the most severe form of disease; in their case death usually follows by suffocation. There are also cases in which, before any sign of localisation, even before the patient is aware of his illness, death supervenes with startling rapidity. The third or fourth day of illness generally brings cessation of the fever, and very frequently immediate death. If the patient survives the third or fourth day he may either continue free from fever and recover, or there is a relapse into fever, and it runs its course as before, either with or without further consequences. On the sixth or ninth day there is almost invariably a recurrence of fluctuations in the temperature and pulse lines; so that a longer illness, even in exceptional cases extending over the second week, appears conditioned by subsequent attacks, which may make themselves known even through the appearance of new secondary bubos. The fever-temperature is usually 39° to 40° C., but may be less. A rise to or continuance at 41° C. or more is often observed, especially at the beginning of the illness or of a second attack. Before death the temperature falls rapidly, or even suddenly, with the quick failure of the patient's strength; it may after that again rise, and even in the dead body show 42° C. or more.

The course of the plague-fever here sketched is in many cases disturbed by accessory infections of a different kind; but more generally other infections become merged in the special plague-disease, along with the fever which is conditioned by them, especially infection by streptococcus, staphylococcus, pneumococcus, or influenza bacilli.

Death may interrupt the course of the illness at any period. In cases of recovery all symptoms of illness may suddenly or gradually disappear. The cause of death is, when not suffocation by reason of a neck-bubo or inflammation of the lungs, the gradual or sudden paralysis of the circulation of the blood.

Recoveries range from 10 per cent. to, at the highest, 40 per cent. of those attacked. Recovery follows after the subsidence of the fever attack, in the case of the glandular plague by gradual dispersion, or almost as frequently by suppuration, of the bubo; in carbuncle-plague by the slow or speedy peeling-off of the injured tissue.

Recovery is tedious in the more serious cases. The patient who appears to have got well may sooner or later succumb to a sudden syncope of the heart. Many die of septic fever, some of supervening plague-meningitis. Secondary infections, especially of a pulmonic character, aggravated by bad nursing and insanitary surroundings, kill numerous convalescents. Even after weeks and months many succumb to a lingering weakness caused by protracted suppuration, by a slow degeneration of the internal organs, or by an increasing impoverishment of the blood. Amongst the sequelæ paralysis in the region of the most diverse nerve-tracts plays a leading part.

The ordinary prognosis of the plague-disease is, in the case of extensive mortality, bad. In an individual case it is impossible to say the result with any certainty. One can only say that any patient free from fever after the third or sixth day will probably recover, unless some serious complication should arise.

An early appearance of the bubo is proportionately favourable. Specially unfavourable are vomiting of blood, bloody stools, petechiæ, the delayed outbreak of boils and carbuncles, diphtheria of the tonsils. Hiccough announces the approach of death. From lung-plague few recover. Previous long-standing and chronic diseases of the lung are almost certainly against recovery. Plague mortality mounts high among consumptives, the syphilitic, and the drinkers.

A second attack of the plague is exceptional, and, generally speaking, fatal.

During the epidemic the speedy maturing of the severe fever symptoms in most cases renders diagnosis easy, if there is also a fully developed local region of disease in the lymph-glands, on the skin, or in the lungs, more especially if beyond this may be observed delirium, tottering gait, exceptionally weak pulse, injection of the eyes, and a white-coated tongue. But apart from the epidemic, even in fully developed cases of the sickness, the diagnosis is limited to probability, because it has to extend its view to disease of the spleen, malignant intermittent fever or typhus, and the ordinary pneumonia. The milder cases, with their ordinary and unimportant local disease-symptoms, and the severe cases, in which death anticipates the formation of a local disease-product, alike evade diagnosis, unless it is supported by bacteriological examination before or after death.

The main safeguard against a mistaken diagnosis is a reference to the plague-generator. We must give here a short account of its distinctive characteristics.

The plague-generator is a bacillus without movement of its own, which in form and size exhibits considerable diversity according to external conditions of development, the nature of its nutrient, and the like. As a rule it appears as a short bar rounded at the ends, its length being twice to three times its breadth. Not infrequently, however, the difference between length and breadth is so slight that the bar-like form is not conspicuous.

The plague-bacillus is easily coloured for mounting with the usual aniline colouring matter. The outer portion of the bacillus, and especially the ends, colour more strongly than the middle (polar colouring), and this appearance specially shows after careful colouring with methylene blue. Plague-bacilli will not colour by the Gram method.

The artificial cultivation of the plague-bacillus succeeds when the air gains access to it, and is easy in the usual solid and fluid nutritive media, such as agar-agar, solidified blood-serum, gelatine, soup, &c.; on the other hand, when the air is excluded growth is checked. In a sugary medium plague-