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It was found impossible to prevent them from handling the patients; yet,
notwithstanding their constant and close contact, the occurrence of only
two cases of Plague amongst the relations was brought to notice.
Amongst the Hospital Staff there were five deaths from Plague. In
the case of one ayah and one ward-boy, the form was that of Primary
Pneumonic Plague. The other three a dresser, a cook, and a 'mali' were
cases of Bubonic Plague. Little can be added to what has already been
written as regards the clinical aspect of the disease. For the purpose
of statistics, three main types have been recognised:-
I. Bubonic Plague.
II. Primary Pneumonic Plague.
III. Plague Septicęmia.
The Bubonic type was the most frequent. A comparatively rare
and very fatal form was noticed in forty cases, in which there was very
extensive brawny induration around the bubo; this occurred most fre-
quently in the case of axillary and parotid buboes, and occasionally took
the form of a diffuse cellulitis, spreading rapidly downward over the
thorax and upwards around the shoulder and to the cervical region.
In the case of parotid buboes the induration was almost always of an
extremely firm brawny character. No pus could be obtained, and inci-
sions though deep resulted in remarkably slight bleeding, the tissue
having a dense fibrous appearance.
The Pneumonic type of Plague is of great interest, and special im-
portance attaches to the differential diagnosis between the primary and
secondary forms, inasmuch as primary pneumonia is almost invariably
fatal, while recovery from the secondary form is by no means rare. Out
of eighty-eight cases of primary plague pneumonia admitted, only one
case recovered. In a typical case the usual Plague symptoms are well
marked and characteristic; from an early stage, respiration is greatly
accelerated and laboured, and in the majority of cases the sputum as-
sumes a diagnostic appearance; generally scanty but sometimes abund-
ant, it is white, frothy, and contains either minute dots or streaks of
bright red blood; occasionally the blood is more intimately mixed with
the sputum, but the usual rusty sputum is absent. Ronchi and mucous
rūles ' are general with localised patches of dullness and a few fine crepi-
tations, but more often the case proves fatal before physical signs develop.
The sputum is on examination found to be almost a pure culture of
Plague bacilli and is doubtless intensely infectious. The sputum was
in a large number of cases examined microscopically, and in one case a