6
when it was really the usual course of the temperature unaffected by the treatment.
The occurrence of complications, e. g., the appearance of fresh buboes, secondary
pneumonia, &c, gave rise to great irregularity in the course of the temperature
(vide Charts II, XIV, XX, XXIII, XXVIII).
Nausea and vomiting were met with at the onset in almost every case, and
frequently continued for the first day or two. Splitting frontal or general
headache was present from the first and continued while the temperature
remained high, subsiding with the fall which occurred on the second or third day.
Occasionally epistaxis occurred about this time. The countenance was pale ; the
eyes red and injected with bands of deeper colour at the outer and inner canthi
owing to the eyelids remaining constantly unclosed. Sleeplessness was a distress-
ing symptom, and there was often delirium at night. The pulse frequent,
100 or more, and full at the beginning, soon became soft, compressible, and
dicrotic, and eventually running, so that it was difficult or impossible to count.
The tongue was as a rule very characteristic. At first it was tooth-indented,
somewhat swollen, and evenly covered with a thin white fur, except at the tip
and edges, where it was clean. Later, it became dry, thickly covered with a
yellowish white or brownish-white fur, the tip and edges remaining red and
irritable. The bowels were almost always constipated at first, but sometimes
diarrhoea was present.
Buboes were met with in over three-fourths of the cases, and m about halt
the number of cases in which buboes were found, the glands of the vertical set
in the groin were involved. They were as a rule noticed at the onset of the
disease, giving rise to lancinating pain, but in a number of cases were not
found until the second or third day. Generally one gland was markedly aftected,
and two or more adjacent ones less so. The affected glands varied in size from
that of a filbert to a walnut, and they were very tender from the first, although
often but little swollen. When in the groin the patient kept the thigh well
flexed on the abdomen in order to relieve tension. In about two-thirds of the
remaining cases the axillary glands were found to be affected, the patient
usually lying on his back with the arm held away from the side and kept per-
fectly still. In the remaining third the glands below the angle of the jaw or
of the superficial cervical set were enlarged.
As a rule a bubo appeared only in one region, but sometimes they were
found in more than one region, or on both sides of the body. As the disease
progressed the glands of the same chain, situated above those first affected
often became enlarged ; so that in cases of a femoral bubo the glands lying
along the course of the external iliac and common iliac vessel were also found
to be enlarged and tender on pressure. A rise in temperature occurred with
each fresh gland or group of glands involved.
In cases which proved fatal early the buboes continued hard and very
tender to the last ; while in more prolonged cases effusion, frequently large in
amount, occurred around them giving rise to a doughy or brawny swelling, and
often causing oedema of the limb below from pressure on the vessels and
nerves.
With the appearance of effusion the buboes usually became less painful,
In a few cases where the patient lived long enough, the swelling subsided by-
resolution, but in the majority of instances suppuration occurred after the seventh
or eighth day, the skin over the infiltrated area becoming inflamed. On opening
the bubo thin yellowish or sanious pus was evacuated ; the skin frequently
sloughed eventually, however, leaving an indolent unhealthy ulcer, with
ragged, overhanging edges and a greyish sloughing base, on which one or more
necrosed lymphatic glands might be seen. Such ulcers usually took weeks to
heal and gave rise to large thickened cicatrices. In cases where suppuration
did not take place the glands remained hard and indurated long after con-
valescence was established.
The nervous system was markedly affected in almost every case from the
beginning of the fever. The patient complained of extreme feebleness and
prostration ; m many cases he could only walk with the greatest difficulty and
was sometimes unable even to leave his bed. There was some loss of sensibility