easily found.
Most cases aided diagnosis, in the first month of the visitation, by having well marked buboes upon admission to hospital. Sometimes the conjunctivæ show marked bile staining. It will not do to accept a bubo as indisputable evidence of plague-bear in mind that lymphadenitis is not eliminated from human ills at a time when the bubonic plague is in evidence and that in lymphadenitis (associated say with a wound of the foot) you may get your fever, pulse, general malaise and bubo in the most common site of bubonic plague selection. One or two such cases were sent to us during the recent epidemic. Sometimes an individual may not know he is suffering at all. In one case I took the temperature of an Indian who looked ill but who had come to see about the burial of a compatriot, and who com- plained of no unpleasant symptom, but was rather amused at my using the thermo- meter in his case. He had a temperature of 103° F. and a small cervical bubo, In the wards he had a very grave attack and only just missed joining his friend whom he had come to bury.
The facies of a plague patient has been variously described by classical writers. Shortly it may be put down as a mixture of anxiety, cyanosis an1 dyspnoe until the first mentioned is overcome by the nervous symptoms; whilst the character of the gait depends solely on the state of the cerebral system.
Generally speaking there is something indescribable in the face of the plague stricken which seems to help your diagnosis, an expression as if the sufferer himself knew all about it, and his inner consciousness had left its mark on his features.
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Temperature attracts notice early. It rises, as a rule, gradually and not suddenly as it does in malaria. In most of the European cases and in the Japanese doctors, who were watched from the beginning, it took from twelve to thirty-six hours to reach the primary maximum. This primary maximum in the early part of the epidemic was generally from 104° to 106 F., a temperature of 106° F. being frequent. As time went on this seemed to fall to 105° and later still a temperature of 104° was seldom reached in the first stage. At the beginning of May the period of pyrexia due to the disease itself was somewhat longer than it was about the end of June, whilst in August it was shorter than it was in the middle of the epidemic. Secondary complications often keep up the temperature for a fortnight or even longer after the acute stage of the disease has passe 1. now speaking of cases that recovered. In most severe cases the tendency is for the temperature to keep about the same level for some time. In milder cases a gradual (sometimes only slight) fall takes place; most recovering cases show a well marked morning fall and evening rise. The temperature may fall by lysis or crisis-the latter being very rare. Antipyretics generally affect the temperature very slightly, and in looking at some of the charts, although falls of 2° or 3o are sometimes noticed, still the majority of cases show very little fall. In some cases where a large fall (say of four degrees) was brought about the fall was coincident with approaching death. During the first month the highest temperature on admission was 106.° 6 F. The highest temperature noted in this period was in a child æt. 5 years on the third day when it reached 107.° 4 F. During the second month our highest temperature on admission was 106 and highest reached 106.94. F., but only five or six others were noted above 105°. The highest temperature recorded in the epidemic was 108.o8 in a child.
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Well marked rigor at the commencement of the disease was conspicuous by its absence, in many cases the first thing that attracted notice being the headache due to fever. Many cases complained of a slight shiver or chillness. In connection with the absence of marked rigor it is interesting to note that in Hongkong malarial attacks have frequently no cold stage at all. Previous records of the disease make the rigor generally well markel.
The swollen glands that were apparent most generally affected the femoral chain in Chinese as well as in Europeans. In Chinese, infection by inoculation was frequent owing to coolies going barefooted. All the Shropshire Regiment men infected bad femoral or inguinal buboes, and they were well booted; so that there must be some reason for the femoral glands being especially liable to enlargement. However, seeing that the disease often causes a general enlargement of glands, I think that the mere point as to which set of glands is usually enlarged has been made too much of; more especially considering that sometimes the biggest gland is situated in the abdomen out of sight until the post mortem examination is made. The pain in the bubo was very great at first; later on it became less; and finally towards the end when no apparent swelling was noticed it was only occasionally, on considerable pressure over some of the most generally affected regions, that what might be termed a "differential pain" was discovered. Sometimes pain was notice- able a considerable time before the enlarged gland was noticed. At the commence- ment of the epidemic the noticeable bubocs were very large and as the epidemic
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