184 STRONG AND TEAGUE. 



advanced cases, the pulse becoming gradually more rapid, feeble, 

 and running; finally it can not be felt. 



Gallop rhythm of the heart sounds are frequently observed. 

 Death takes place from cardiac paralysis and exhaustion. The 

 patients frequently succumb after slight physical exertion, such 

 as sitting up in bed to take nourishment or on being moved. A 

 few hours before death the temperature often declines to below 

 normal. Delirium and coma are frequently present before death. 



The urine in the later stages may show the presence of al- 

 bumin. The diazo and indican reactions have not been observed 

 in the few cases in which the urine was tested. Extravasations 

 of blood have been found in the pelves of the kidneys at post- 

 mortem examination. 



The spleen is usually not palpable, and the lymphatic glands 

 not enlarged. Petechise or larger haemorrhages of the skin are 

 usually not present. Bloodly diarrhoea is occasionally observed. 

 Plague bacilli frequently may be present in the blood in such num- 

 bers that a simple, microscopical examination suffices for their de- 

 tection ; in other cases, cultures are necessary for their discovery. 

 A marked leucocytosis may occur, though in some cases the leu- 

 cocytes are not increased. In the primary septicemic cases the 

 course of the disease is very rapid. There may be no manifesta- 

 tions of disturbances of the lung. The cardiac symptoms are very 

 prominent. The patients soon pass into a comatose condition and 

 die. 



PHYSICAL SIGNS. 



The physical signs in the lungs are often slight, even in cases 

 well advanced in the disease. On percussion, dulness is often 

 absent, and the vocal fremitus and resonance unchanged. In a 

 small proportion of cases, however, smaller or larger areas of 

 dulness may be discovered. On auscultation rales are frequently 

 not present, except shortly before death. When present early 

 in the disease, they are usually of the fine variety. Numerous 

 moist rales are heard late in the disease, and are due to the oedem- 

 atous condition of the lungs. The character of the rales is in 

 accordance with what one would expect from the condition of the 

 lungs and bronchi and the character of the exudate observed at 

 necropsy. Coarse rales such as occur in cases of catarrhal bron- 

 chitis usually are not present. Feeble, respiratory sounds, tubu- 

 lar modification, or pure tubular respiration over small areas are 

 the conditions found most commonly on auscultation. Not in- 

 frequently a dry, pleuritic rub is heard. 



The limits of dulness of the heart are sometimes increased 



