160 has a difficulty in understanding the questions put to him, and is slow in answering. He is often described as staggering like a drunken man. There is severe head ache, intense thirst, and severe pain in the epigastrium. The eyes are red and turbid ; the tongue swollen, dry, and fissured, sometimes black, sometimes remarkably white (Colvill). This condition may pass into coma even before fever sets in. In other cases bilious vomiting is the earliest symptom. The fever which sets in may last twenty-four to thirty hours, or more. The temperature maybe 100 to 107 Fahr., or even higher; but in the most rapidly fatal cases there may be little or no fever. Generally there is obstinate constipation, but sometimes diarrhoea. Besides these symptoms there are certain special ones especially characteristic of plague. () Buboes or glandular swellings are observed in all except very rapidly fatal cases. They occur in 45 or 50 per cent, of the cases in the groin, in 35 per cent, in the axilla, also less frequently in the neck or other parts. These swellings may occur before the fever, simultaneously with it, or some hours after it has set in. A sudden pain like that of a stab is felt in some region of the body, which has given rise to the superstition that the unfor tunate victim was wounded by the arrow of an invisible demon, a belief recorded in Constantinople in the 6th century, and said still to survive in Mohammedan coun tries. The buboes may suppurate, and free discharge of matter from them has in all times been held to be a favourable sign and conducive to recovery. (6) Carbuncles were observed in about 2^ or 3 per cent, of the cases in recent epidemics in Irak. They are always an unfavourable sign. (c) Petechiae or haamorrhagie spots on the skin have always been regarded as signs of the worst omen. Under the name of " tokens " they were considered in the English epidemics of the 16th century as the infallible signs of approaching death. " They appear generally only a few hours before death " (Colvill). Hodges (1665) noticed hard ness which showed the existence of haemorrhage under the skin. The skin is sometimes so covered with petechise as to become of a dark livid hue after death, recalling the name Black Death (Cabiadis). The occurrence of the above symptoms, especially the first, in an idiopathic fever attacking many persons at one time is sufficient to make the diagnosis of plague. A very notable and fatal form of the disease is that in which haemorrhages from the lungs, stomach, bowels, nose, &c., occur. These are of the worst omen, and are seen in some cases where there are no buboes, and which are rapidly fatal. This was observed in Irak in recent epidemics, in the outbreak on the Volga in 1878-79, and in the plague of India. It was a noticeable symptom in the black death, and was observed even in the plague of the 6th century. The bleeding is mostly from the lungs, and is sometimes associated with other symptoms of lung affection. This form of the disease appears, however, to have no distinct historical or geographical limit. A similar haemorrhagic form has been observed in small-pox and scarlet fever, and is always extremely fatal. In all plague epidemics cases occur in which death takes place very rapidly, even within twenty-four hours, without the development of the special symptoms of the disease. Such cases are reported by Diemerbroek, Hodges, and others in the 17th century, and have been observed in recent epidemics in Irak, as well as in the recent plague on the Volga. Some are more like cases of poisoning than of infection, and much resemble the instances of death from the exhalations of dead bodies (cadaveric poisoning) which are met with from time to time. It is these which have given rise to the expression fulminant plague. Duration. The duration of an attack of plague may be from some hours to a month. Three-fifths of the cases observed by Mr Colvill were fatal on the third day, and the majority of cases in India had the same termination (Francis). Five-sixths of fatal cases end by the fifth day. Most of those who survive the fifth day get well ; after the seventh day a patient in Baghdad was considered by his friends safe ; and in Mr ColvilFs cases only 4 per cent, of fatal cases died after the tenth day. In non-fatal cases with suppurating buboes the disease may be protracted to two or three weeks or a month. Mortality. Plague is the most fatal of all known diseases which affect large numbers of people. The mortality, according to official registers in Baghdad, was 55 7 per cent, of those attacked. I)r Cabiadis thinks this too high, owing to many cases of recovery not being re ported. But in some epidemics the proportion of fatal cases is much higher. In Vetlanka it was about 90 per cent., and in some other villages on the Volga every person who took the disease died. The older accounts do not give the proportion of deaths and attacks. Morbid Anatomy. Examinations after death have not done much to elucidate the nature of plague, except nega tively. The appearances are those of death from an acute infective disease, and resemble those of typhus, except for the special affection of the lymphatic glands. The brain and the lungs are found to contain excess of blood ; the right side of the heart distended, the blood dark- coloured and undergoing rapid decomposition. 1 The spleen is found enlarged, and in a less degree the liver. The stomach and intestinal canal often show signs of inflam mation and haemorrhage, sometimes ulceration. The characteristic swelling of the lymphatic glands, both ex ternal and internal, is often accompanied by inflammation of the cellular tissue around. Petechial patches are some times found on the internal organs. 2 Pathology of Plague. All that is known of plague goes to show that it is a specific febrile disease depending on the reception into the body of a specific organic contagion, which becomes multiplied in the body of the patient. Analogy makes it very probable that this contagion is a living organism of the class Bacteria, but the suspected organism has not yet been discovered. The nearest ally of plague is typhus fever, so that some authorities have spoken of it as the typhus of hot climates, modified by temperature, &c., but this opinion does not appear to have ever been held by any competent physician who has examined the disease at first hand. It appears to be as distinct from typhus as this is from enteric fever, or other so-called typhoid diseases. It has also been thought that plague is related to intermittent or remittent malarious fevers ; but the most recent observations show that there is no real connexion between these diseases. In India, says Dr Francis, neither intermission nor remission has ever been observed in plague. It is quite distinct from and in no way modified by the types of fever that are caused by malaria. I)r Cabiadis speaks to the same effect of plague in Irak, and insists that the physical conditions which favour the production of marsh poison are not necessarily favourable to plague. External Conditions of Playue. The nature of the soil 1 This post-mortem decomposition of the l>lood is doubtless the cause of some appearances described with great particularity in the older accounts. a Our knowledge of the morbid anatomy of plague is derived almost entirely from the observation of the French physicians in Egypt during the epidemic in 1835-36. Earlier observations are of no value, and in later epidemics of Irak and Russia none have been made. In India Drs Pearson and Francis made a few autopsies. Clot-Bey, De Id Peste en tigypte, Paris, 1840 ; Bulard, De la Peste Orientate, Paris,
1839; Francis, Indian Annals of Medical Science, vol. i., 1854.