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(c) Apathetic. where he lay perfectly quiet, and took nourishment when it was offered to him; in fact lay in a drowsy, but always more or less conscious, condition until improvement or death took place. (d) A convulsive type brought on either by the inflammation of the
meninges and brain matter or by a hemorrhage. These convul sions were often severe. (In Case I, they were only stopped by chloroform. P.M. no hemorrhage was found.)
In Case XV. they always began in the left arm (hand) and were truly Jack- sonian in nature pointing to some cortical lesion round the right fissure of Rolando. (See remarks on case.) Occasionally they resembled tetanus, the opisthotonos being very great. Subsultus tendinum did not occur early as a rule, but generally late in the disease. Picking at the bed clothes, trying to catch imaginary objects, in fact all the symptoms of meningitis were almost always present; in a few cases however they were absent, and such cases were usually of a very mild nature. Patients often had hallucinations beginning generally on the second day of the illness. All these cerebral symptoms followed the primary lymphatic affection and their rapid appearance was not to be wondered at when one considers the close connection between the arachnoid and the lymphatic system.
The vascular is the other system which was especially affected. The principal items to note were-
(1) The vasomotor paralysis which rapidly appeared involving the heart
itself as well as the vessels.
(2) The liability to sudden heart failure.
(3) The symptoms probably due to organic changes in the heart in those
who recovered.
There are four stages of the pulse in plague. During the first stage it is in the majority of cases full and bounding. In some it is feeble and collapsed. When in the latter state cyanosis is usually well marked and the patient is evidently moribund. The pulse which at first is full and bounding becomes (usually in from six to thirty-six hours) dicrotic and fairly easily compressible at the wrist. The accompanying tracing shows such a pulse where the dicrotism, although not extreme, is well marked.
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Intermittency is often noticeable in this second stage of the pulse and becomes more marked as the third stage develops, when it becomes anacrotic and almost like the pulse of aortic insufficiency, there being no rebound wave at all, nor the slightest trace of it by sphygmograph in a well marked case. In addition it is at this period very easily compressible, and the actual range of movement of the vessel is very limited at the wrist, whereas in the larger vessels the upheaval is usually well marked, slight pressure at the femoral being sufficient to arrest the pulse. The following tracing of the radial pulse is taken from a patient at this stage, there being no pressure on the sphygmograph button, except its own weight.
This patient was a very lean man, and consequently a tracing of his femoral pulse could be easily obtained as the vessel passed over the brim of the pelvis. With slightly over an ounce of pressure, (enough to visibly diminish the range of movement), the accompanying tracing was got.