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From this anacrotic stage gradual or sudden failure may set in, unless there is a general improvement in the case. The pulse generally becomes fast and run- ning and scarcely perceptible or if perceptible it is generally intermittent. On the second day if a thin patient was naked one could usually see the femoral arteries beating at a distance of several yards, and this was equally true of the other large arteries. Often this large movement was to be seen in the vessels in the neck, axilla, or groiu, and yet at the radial or posterior tibial arteries the pulse was hardly perceptible.
These four stages of the pulse (1) full and bounding (2) dicrotic (3) anacrotic (4) failure, may be looked upon as the usual sequence; though one or more of them may under some circumstances escape observation. They may all be of the shortest duration, and of course sudden heart failure may at any time prevent the later stages developing.
The area of cardiac dulness was generally enlarged early in the diseasc (apex downwards and to the left of usual position) and sometimes remained so for weeks in those who recovered, there being also an increase of dulness on the right side. There was practically no muffling of the sounds. These conditions pointed to dila- tation, yet murmurs were of rare occurrence. One would have expected to hear them more frequently even in those who were long sick and recovered. The first sound was invariably weak in the later stages. Pain in the cardiac region was gene- rally complained of. These symptoms pointed to a true myocarditis. Palpitation was frequently present and complained of. A pericardial rub I never heard, although in a few cases post mortem a small accumulation of fluid was found in the pericar- dium. I think that the tendency to hemorrhage must have been caused by some inflammatory or fatty degenerative change in the small vessels, and this may be one of the reasons why digitalis was so frequently a failure. It is to be expected that the microscopic pathology of the disease will be written by AOYAMA at some future time.
When blood was drawn from the finger tip it was found to flow more easily and to look more fluid than normal. When put under the microscope it was found that the corpuscles crenated rapidly, and did not run into rouleaux readily. The number of leucocytes increased always when the disease was at its height, and in the later stages there were occasionally to be found broken down or badly formed corpuscles. The number of red corpuscles was not materially diminished until the 7th-10th day when convalescence was setting in. The amount of homo- globin in the blood commenced to diminish from the second day of the disease, and, in some cases, became very low. In Case I. it was as low as 18 % of the normal quantity, but in this case the patient was always somewhat anemic. A diminution to 30% was frequent. The bacteriological examination of the blood will be discussed later.
Digestive System.The important symptoms in connection with this system are (i) condition of inouth and fauces; (ii) vomiting; (ii) diarrhoea or cons- tipation. The mouths of Chinese patients were invariably dry from the commence- ment, and the teeth and lips were early covered with sordes. The tongue was at the beginning of the attack almost covered with a thin white fur which became thicker, and then went through a transformation from white to black. In the early stages it was very like a typhoid fever tongue-white fur with red edges and tip, but in plague there was little or no tailing off of the fur as it approaches the edges, and the edges were not of such a bright colour as is generally the case in enteric fever. As the disease advances the fur changes from white to yellow and brown, dark-brown and black. The latter colour is confined to the middle part of the organ, toning down towards the edges which still retain their original colour, in fact like a heavy tobacco chewer's tongue dried up. The edges get somewhat redder as the disease goes on. The tongue is protruded with difficulty, the cause of this evidently being the cerebral condition, or possibly pain in the cervical glands. In Europeans, tongue conditions were never marked, owing to nourishment being taken often, and to the frequent use of the toothbrush. In the opinion of some people the dry condition of the mouth was the cause of the tongue not being easily protruded, but I consider this is a very minor cause. The fauces and pharynx were generally somewhat injected, and the tonsils somewhat swollen. When the principal bubo was situated in the cervical region, (especially if affecting the anterior cervical glands,) the tonsils and pharynx were usually intensely congested from the spread of the glandular inflammation.
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