1428 



PLAGUE 



The Ambulatory Type. — This is the mildest form of the disease, 

 and is characterized by but httle fever, with sUght enlargement and 

 tenderness of a group of lymphatic glands. If the area of skin 

 drained by these glands is carefully investigated, a primary vesicle 

 will often be seen at the site of the inoculation, and considerably 

 helps in the diagnosis, for its fluid contains typical bacilli. The 

 symptoms of this type resemble those already described as 

 prodromata. 



The Bubonic Type. — ^This type agrees with the general description, 

 the bubo being usualty in the groin, less commonly in the axilla, and 

 least commonly in the neck. The fever reaches its maximum on 

 the fourth to fifth day, and lasts till the seventh to tenth day, when 

 it falls by lysis, though it may rise again if suppuration is taking 

 place in the buboes. The attitude of the patient depends upon the 

 position of the bubo, as described above. 



The Acute Septicceinic Type. — ^Here the onset is sudden, and the 

 temperature very high, with very rapid pulse, marked prostration, 

 and delirium. There may be severe vomiting, and occasionally 

 diarrhoea. No enlarged lymphatic glands are found, and the 

 diagnosis on clinical grounds may be impossible. Haemorrhages 

 may at times occur in the skin and from the regions indicated above, 

 and death rapidly takes place in from eighteen hours to three days. 

 This type of the disease is often common at the onset of an epidemic. 



The Pneumonic Type. — ^There are two distinct types of pneumonia 

 in plague — a pneumonia secondary to bubonic plague and a primary 

 pneumonia. This latter begins suddenly without prodromata, after 

 an incubation of two to five days, with chilliness, high fever, head- 

 ache, anorexia, and rapid pulse. Within twenty-four to thirty-six 

 hours the temperature is 103° to 104° F., and the pulse 110 to 130 

 beats per minute. Cough and dyspnoea appear within twenty-four 

 hours, when the expectoration is at first scanty, but soon becomes 

 abundant. At first it is only composed of mucus, but it soon 

 becomes tinged with blood and later very hsemorrhagic, and is full 

 of bacilli. The conjunctivae become injected, and the tongue 

 coated with a White or brownish fur. The breathing is very rapid, 

 and dulness may or may not be present over the bases; the breath 

 sounds are usually tubular and crepitant, and sibilant rales are 

 heard, while the vocal fremitus may be increased. Dyspnoea and 

 cyanosis are early marked features, as is the fluid bloody sputum 

 which is found by the second or third day, and is full of bacilli. 

 Pleuritis, with its usual symptoms, may also occur. Prostration is 

 extreme; the heart becomes very weak and the pulse rapid, while 

 the spleen is usually not palpable. A marked leucocytosis may 

 occur. This is a very fatal type of the disease; delirium and coma 

 appear, and cases die at the end of sixteen hours, two or three or, 

 much more rarely, four days. 



Sequelae. — Cardiac weakness, with pr oneness to syncopal attacks, 

 paralyses, septic infections of the buboes, or a general septic infec- 

 tion, or gangrene of the lung, may occur. 



