11
normal or subnormal between the fifth and seventh days) and the rapidly fatal
course of the disease in the majority of cases, render the diagnosis unmistakeable.
When however the disease takes the form of •primary plague pneumonia, it
becomes exceedingly difficult to diagnose, whilst at the same time, owing to the
danger of infection from the sputa which contain plague bacilli in great num-
bers, it is most important to recognise it early. In primary plague pueumonia
the absence of acute or subacute bronchitis before the attack ; the rapidity with
which high fever, severe headache and marked prostration occur after the onset ;
the character of the expectoration, less viscid from the first and early becoming
profuse and watery, and generally tinged with blood or reddish from admixture
of blood ; the rapidity with which signs of oedema of the lungs appear ; the
quality of the pulse, which is never full and bounding, and soon becomes very
soft and frequent, serve to distinguish it from ordinary broncho-pneumonia or
lobar pneumonia in the majority of cases; and the presence in all cases of im-
mense numbers of plague bacilli in the sputa, from which cultures can be
obtained, renders the diagnosis certain.
Severe cases of malarial fever may be distinguished from plague by
the nature of the onset, the cold stage being more prolonged, the features
pale and shrunken, and the nails blue. In the hot stage the face becomes
flushed and the pulse full and bounding, but is not so frequent as in plague.
In malarial cases, too, the temperature generally shews marked periodicity;
there is no prostration, patients possessing as a rule their muscular strength and
mental energy; and buboes are very rarely met with.
Relapsing fever, like plague, occurs in times of scarcity. In both the onset
is sudden, and rapidly followed by high fever, accompanied by severe headache,
frequent pulse, and a hot and burning skin ; the tongue is furred white, the
temperature reaches its maximum on the first or second day, and a remission ac-
companied by sweating often occurs on the second or third day, the temperature
falling to normal between the fifth and seventh days (vide Chart XXI).
But in relapsing fever there is giddiness ; prostration is slight; jaundice not in-
frequently occurs on the third or fourth day ; the face is flushed, and the expres-
sion is not stupid nor confused ; buboes are not met with ; and spirilla are found
in the blood during the height of the fever.
Plague in its onset and early symptoms somewhat resembles Typhus fever.
But the duskiness and flushing of the face present at the beginning of typhus
fever, and the occurrence of an eruption on the body and limbs between the fifth
and seventh days, as well as the different course of the temperature {vide Chart
IX.) and the absence of buboes would serve to distinguish between them.
Owing to the feebleness, .thick utterance and staggering gait, frequently
seen in plague cases, the disease is sometimes mistaken for alcoholic poisoning.
The following is a typical case. Govind Jeeva was taken by his friends for
treatment to a qualified medical practitioner. They stated that he had had a
fall, and the following note of his case was made: " Pupils slightly dilated,
breath smells very faintly of alcohol, has a slight contused wound over but not
exposing malar bone," and an emetic was prescribed. Fortunately this was not
given. Next day a note was made as follows : " Bowels not opened for two days,
is not quite recovered from the effects of drink,'' and on the following clay :
" Speech indistinct, temperature 102° F., bowels not opened." On the fourth
day he died. In this case enquiry showed that the patient had been two days
ill with fever, and was given a little alcohol after having fallen down in a faint.
He was seen by another medical man shortly after the emetic was prescribed, and
found to have a very frequent and feeble pulse, fever, and a typically coated
tongue. The diagnosis of plague was made and afterwards verified by post
mortem examination. Had the ease been one of alcoholic poisoning, there would
have been a full and bounding pulse, a normal or subnormal temperature,
and considerable mental excitement ; or in a later stage drowsiness, or coma
with stertorous breathing, a slow and compressible pulse, and a subnormal
temperature.
In plague cases where abdominal symptoms are marked and a typhoid con-
dition has supervened, the diagnostic features given by Surgeon-Captain Hojel