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size—from being a thickened cord to a lump as large as a walnut. In all cases in which the femoral or inguinal regions were affected, a distinct swelling could he felt in the iliac fossa along the course of the external iliac artery. This was regarded as a valuable diagnostic sign. Erythema of the skin over the bubo, which was present in three cases, is also of some diagnostic importance.
Incubation Period.—This could not be definitely made out in any case, owing to the uncertainty as to when infection actually occurred.
Onset.—In all cases sudden and acute. In one case only, a rigor at commencement. The usual symptoms—headache, vomiting or nausea, pains in back and limbs, with sharp pain at site of future bubo. Temperature rose rapidly: in two cases it was 105.8 degrees when cases were first seen; in the ordinary severe attack it ranged from 100 to 120 degrees.
Course.—The usual symptoms of an acute febrile attack were present. Headache was severe and persistent in one case. Delirium of an acute character was present in five cases; in another case delirium tremens developed and rapidly hastened patient's death. In the seventh case delirium was very mild, whilst the eighth case was never delirious. The highest temperature recorded was 106.8°, half an hour before death. Another case rose to 106.4° before death. The temperature ran no definite course as in typhoid, but after ranging between 101° and 105° for four or five days, reached normal in from six to eight days; termination was either by crisis or by lysis. The pulse varied from 88 to 160. In one case it was never below 120, and was at times 150 to 160. In five cases a rash was present on the arms and legs; and also on the face in two of the cases. This rash consisted of small, dark-red spots, just to be felt by the finger, and not wholly disappearing on pressure. In one case a petechial rash appeared on both arms some hours before death. The spots came out in successive crops, remained for about two days, then began to fade, and left a faint brown stain on skin. Vomiting did not persist after the onset. Constipation was the general rule. Tongue was always furred, with clean, red tip and sides. Epistaxis occurred in one case, but was not severe. Speech was markedly affected in three of the cases, being of a hesitating, broken character.
Complications.—One case developed a broncho-pneumonia—two patches of consolidation in the left lung towards the base.
Diagnosis.—The clinical diagnosis of plague was confirmed by microscopic examination of material from the buboes in the living, and by the post mortem appearances and microscopic examination in the fatal cases. Cultures made from the fatal cases inoculated into guinea pigs produced death in four to five days from plague; and the cultures from the animal showed the same bacillus as at the beginning. The same bacillus was discovered in the buboes and spleens of certain rats.
