SYMPTOM A TOLOGY 



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is much thirst, and the tongue is coated at first with a whitish fur, 

 but later it becomes covered with sordes, as do the teeth and hps. 

 Vomiting is frequently met with, as well as diarrhoea; but the 

 abdomen is not tender, unless there are enlarged abdominal glands. 

 The spleen is always, and the liver often, enlarged. Cardiac dilata- 

 tion is an important feature of the disease, and systolic murmurs 

 may be heard. The pulse is rapid, reaching 120 to 180 early in the 

 disease, and later becoming, in bad cases, not countable. At first 

 it is full and of moderate tension, but later it becomes small, weak, 

 and intermittent. 



The coagulation of the blood is diminished. Plague bacilli can 

 be found culturally in about a third of the cases examined. The 

 number of erythrocytes and the amount of haemoglobin are distinctly 

 increased above the normal, and there is a great leucocytosis — i.e., 

 90,000 to 100,000 and more — but in the septicaemic form there may 

 be a leucopenia. The leucocytosis is almost entirely due to an 

 increase in the polymorphonuclear leucocytes. 



The breathing is rapid, and the breath sounds harsh, with moist 

 rales, but signs of lobular pneumonia and pleuritis may also occur. 

 The sputum in this type of pneumonia is very hsemorrhagic and full 

 of bacilli. 



Buboes of varying sizes may be noted in the groin, the axilla, or 

 the neck, and are very painful, respectively causing the patient to 

 lie with the leg drawn up close to the chest wall, or the head bent 

 towards the affected side. They usually appear during the first 

 twenty-four hours, and they may decline or suppurate. 



The skin is hot and dry, and may show vesicles, pustules, or areas 

 of necrosis, often called ' carbuncles ' (they are, of course, not true 

 carbuncles). Haemorrhages, in the form of petechiae or ecchymoses, 

 may be seen under the skin, and epistaxis, haematemesis, melaena, 

 and haematuria may occur. 



The quantity of urine is usually diminished, the specific gravity 

 is high, and plague bacilli may be found. If haemorrhages have 

 occurred in the urinary tract, there will be erythrocytes and 

 leucocytes, with albumen and globulin, though, apart from this, 

 there is often a trace of albumin present, while anuria is generally 

 present before death. Pregnant women always abort. 



Termination. — As the disease progresses the patient becomes 

 weaker and weaker, the mind wanders, and a wild delirium may 

 occur; but later a low muttering delirium passes into coma, and 

 death ensues from the third to the fifth day. In favourable cases the 

 tongue becomes moist and clean, the temperature declines by lysis, 

 the pulse-rate diminishes, and convalescence begins, but may be 

 much prolonged by suppuration of the buboes or by a secondary 

 septicaemia. Even now death may occur from cardiac failure, 

 suppuration, septic infection, or secondary haemorrhage. 



Varieties.— Four variations of the disease are recognized: (i) The 

 ambulatory type; (2) the bubonic type; (3) the acute septicaemic 

 type; and (4) the pneumonic type. 



