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vomiting which may be severe and constant, intense headache, injection of the ocular
conjunction, and a feeling of great prostration, aggravated by the vomiting and,
further, by inability to sleep, which is a marked symptom. The character of the
tongue is a definite one, and the patient is irritable in showing it and does so in a
jerky way, or moves it rapidly from side to side when protruding it. It is moist and
thickened, the edges and tip are clean and coloured from light to deepish red, and it
is coated on the rest of its surface with a thin fur, often of a peculiar white glistening
appearance, or of a light reddish brown colour. There is also a perceptible impediment
in the speech.
The pulse varies in rate from 100 to 140, and also in volume ; usually it is full,
soft and dicrotic, the latter sign being recognizable even in the early stages of the
disease, and it becomes thready as the heart's action gets dangerously weak.
The
bowels are generally constipated, often to an obstinate degree, but in some cases they
are relaxed, and the motions then have a peculiarly offensive smell.
There may be also a short dry cough, and a darting pain in some lymphatic gland
regions. The urine is highly acid and rapidly decomposes on standing, triple phos-
phates being deposited, and the specific gravity varies from 1010 to 1035. The urea
and uric acid are diminished, and albumen is present in a number of cases.
With the progress of the case the temperature rises quickly, usually reaching a
maximum of 103, 104, or higher about the third or fourth day, though in severe cases
earlier ; the pulse becomes weaker, and in the worst cases the temperature rises very
high and the patient succumbs to the peculiarly exhausting effects of the disease in a
very short time : 24 or 48 hours, or even less.
If the patient survives the
acute early stage, the febrile symptoms are more aggravated with the rise of tempera-
ture, the pulse becomes thready, the tongue is less moist and more irritable at the tip
and edges, while the prostration and insomnia increase and cause a look of deep
anxiety and distress.
In those cases where cerebral symptoms supervene, certain features manifest
themselves about the third day, which are due either to congestion of the nervous
centres or to involvement of them in the septicsemic process. The look of anxiety
now gives way to heavy expressionless countenance, which is liable to be mistaken
for an improvement, but is really due to want of control over the muscles and loss of
tone in them. The patient is sensible of all that goes on near him, but appears to be
only partially conscious, listless, and drowsy, and it is with difficulty ho can be made
to hear distinctly. His speech is thick and indistinct from loss of power of co-ordi-
nation of muscular movements, which is noticed also in most of his other muscular
efforts ; and these effects are due, not only to an implication of the cerebral and spinal
centres in the toxœmic results, but also to some general peripheral neuritis, the results
of which continue as sequelse in some of the cases. There may be also cramps in
the muscles. In other cases there is great irritability of the cerebral centres, which
is shown by violent delirium. The further progress of the case depends upon its
circumstances according to type, and in those cases where the symptoms peculiar to
the type improve and the temperature goes down, the cerebral symptoms remain for
some time and then gradually subside. When the primary symptoms increase or the
type is complicated, the symptoms attributable to the nervous system may assume
the form of violent delirium or coma vigil, the latter being most grave.
The general symptoms above detailed characterise all the types of plague, and
the adjunctive features peculiar to each type may receive brief mention.
The glandular or bubonic is the common form of plague, and comprises about
80 to 90 per cent. of all cases. Coincident with all or some of the general
symptoms, one or more swellings appear at some one of the positions in which