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chances of recovery are hopeful. In septicaemic plague the patient has much less chance of recovery.
Death may occur in thirty-six hours or may be delayed until the fourth or fifth day. Few recover from
this variety of plague. From the pneumonic variety of plague few recover; death usually occurs from
the third to the fifth day. Convalescence in every instance is very slow; the patient is unfit for
sustained physical or mental work for several months after an attack of plague.
Diagnosis.
Conclusive proof that a person is suffering from plague can be arrived at only by proving
the plague bacillus to be present in the excretions, in the glands or periglandular effusion, or in
the blood. But clinical evidences are usually sufficiently pronounced to suggest that the illness is
due to plague. The sudden onset, the marked prostration, the mental aberration, the splitting headache,
vomiting and nausea, backache, the rise in temperature, the furred tongue, when taken in conjunction
with tenderness and pain in some one of the groups of glands are sufficient to indicate the
necessity for a speedy microscopic search for the plague bacillus.
Pneumonic plague is apt to be regarded as simple pneumonia. The rapidity of the development
of all the signs and symptoms are, however, peculiar to plague infection. The early delirium, the
early signs of patchy pneumonia, the presence of blood in the expectoration from almost the onset,
combined with extreme prostration would seem to indicate a specific form of illness. " Glandular "
fever in children is apt to be mistaken for plague during an epidemic. Convulsions in children may
usher in an attack of plague. Typhus fever, although an uncommon disease, presents several
of the signs and symptoms characteristic of the plague, but typhus fever developes more slowly;
the rash is unlike the plague petechias which are occasionally met with ; the prostration and the
delirium come on at a later stage of the disease. Typhoid fever even may be confounded with
what is called the " typhoid " variety of plague, but a 48 hours' study of the temperature will generally
suffice to differentiate the diseases.
Prognosis.
The chances of recovery in individual cases are well nigh incalculable, as the most favourable
appearances are sometimes delusive, and the most hopeless-looking cases may recover. In China,
among patients under treatment by Chinese " doctors," over 95 per cent, of those attacked
died. In India, 70 per cent, of natives who were attacked by plague and were, more or less, under
European treatment died. Amongst white people the death rate is much less ; about 35 per cent,
only died in India. In Sydney, 103 persons died out of 303 attacked.
Pathological anatomy.
Bubonic, plague.
An examination of the surface of the body of a person dead of bubonic plague may
reveal petechiae, bites and scratchings, and less frequently boils and 'carbuncles'. The situation
of the bubo is generally readily apparent. On examining a bubo that has not formed an abscess
and broken, there will be found around the bubo a large accumulation of perivascular inflammatory
effusion extending some way, it may be great way, in the surrounding tissues, or an extensive
haemorrhage may be found. The glands involved will be found matted together by tissue infiltrated
with serum, coagulated blood or inflammatory fluids. One gland of the group may be found as large
as a walnut, the others varying in size from a bean to a hazel nut. All the glands are intensely
engorged, the smaller on section appear dark in colour, the larger of a bright red or even pink
tinge. In consistence, the less swollen glands may be almost normal, but the more enlarged are soft
and diffluent to the touch. As a rule every gland in the body is swollen to some degree, and not only
is this true of the limb glands but the lumbar, the mesenteric and the mediastinal glands may be all
involved.
The respiratory organs in bubonic plague are not deeply affected, but subpleural petechiae and
haemorrhage both parietal and visceral are frequently seen. The cavity of the pleura always shows a
fair amount of pleural fluid which may be occasionally blood-stained. The lungs are oedematous,
intensely congested and minute haemorrhages may be seen in their tissues. A frothy mucus, occasionally
blood-tinged, occupies the bronchi.
The heart and pericardium—Petechiae on the parietal and visceral layers of the pericardium are
commonly met with, and some two or three ounces of fluid, occasionally blood-stained, occupies the
cavity of the pericardium. The heart muscle appears flabby, and the tissue cloudy as if from fatty
degeneration ; the right side of the heart is usually dilated, and the walls of the great veins approaching
the heart show small subendothelial haemorrhages in their coats.
The abdominal viscera—Beneath both the parietal and visceral layers of the peritoneum
haemorrhages are to be seen. Retro-peritoneal haemorrhage, haemorrhages into the mesentery and
omentum at times attain wide dimensions, and around the kidneys the largest of all extravasations of
blood occur. The mucous membrane of the stomach and intestines are deeply congested, petechiae
are common, and occasionally considerable haemorrhages. The solitary glands and Peyer's patches are