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went on their size gradually diminished. Although pain and size generally went together, frequently a small gland was to be met with which would be as painful as a very large one. At the commencement of the epidemic the babo was always sur- rounded by a considerable amount of sero-sanguineous exudation, and as time went on it was found that this diminished also, the end of the epidemic showing very few cases which had any exudation at all. Sometimes there was a very large amount of œdema around the bubo quite distinct from the sero-sanguineous exudation around, and a "doughy" feeling could be detected in the bubo during the course of the first twenty-four hours, probably due to the rapid pouring out of exudation. Femoral buboes as a rule were most painful, parotid swellings standing at the same level. Those situated in the axillary and cervical regions did not cause so much discomfort, unless in the latter region the swelling reached close to the trachea or the mastoid cells. The abdominal pain was I consider in some cases due to inflammation of some of the mesenteric glands. In the case of the Italian Convent sister who died this was undoubtedly the case, as the slightest pressure over a spot on the left side of the umbilicus caused great pain, and immediately under this spot the only well marked enlarged gland in the abdomen was found at the post mortem examination. This is interesting when one considers the question of sensibility of the peritoneum. The bubo when present generally appeared within 24 hours of the onset of the fever. In two or three cases we got a history of the bubo appearing before the fever, but as a thermometer had not been used I place some doubt on the accuracy of the statements made. In numbers of cases the swelling did not appear till later, in one case not till about the ninth day of the disease when the temperature suddenly dropped, and the case became rapidly convalescent. In another case it appeared on the sixth day and the disease still continued to run an acute course. In a few cases where a small bubo was present for four or five days a sudden enlargement was noticed and the patients rapidly sank. This was especially marked in three cases with cervical buboes. I ascribed this mostly to the sudden extension of the swelling to the larynx. From the rapid way in which the pulse and respiration became worse in these cases, however, it is quite possible that interference with the pneumo-gastric and phrenic nerves may have been the immediate causes of bringing about a suddenly fatal issue. I formed the opinion that a sudden enlargement of a bubo, after having been practically stationary for some time, is of grave portent.
aorta.
Sometimes a whole chain of glands was enlarged; when this was so, if the patient survived, widespread sloughing was to be anticipated later. On two or three occasions on the post mortem table a large hemorrhagic mass of glands was found running from the apex of Scarpa's triangle to the bifurcation of the abdominal The question as to whether the bubo was a true suppurating one was raised, one medical man being of opinion that an opening, (although made on account of supposed suppuration), was made too soon, and that suppuration was the result of incision. This had to be disproved more or less to his satisfaction. The Chinese Hospital (Slaughter House) contained patients on whom a knife was never used, -one morning we counted 43 patients there. Of these, 34 had buboes that had suppurated and burst of their own accord, some of them having caused serious sloughing. An immediate small rise in temperature often followed the incision of a gland, even when pus was evacuated.
Cerebral symptoms appeared early in the disease. They were due to two causes principally (a) meningitis, (b) hemorrhages. Headache began with the fever. It was generally fronto-temporal and most severe in the early cases.
I may say here that all symptoms of the disease seemed to be more acute at the beginning of the epidemic than they were later. The headache was generally a combination of an acute dull pain accompanied by throbbing in the temples. Sometimes (rarely) a patient complained of occipital headache and, on one or two occasions, of pain in the back of the neck-evidently of spinal origin. The headache gradually merged into delirium as the meningitis developed. Convergent strabismus or divergent strabismus was occasionally present-generally the former. "Both eyes turned to right or left" was also noticed in some cases. Occasionally where hemorrhage was diagnosed the pupils were unequal but in one conspicuous case where a hemorrhage on one side of the brain was supposed to exist (diagnosis concurred in by Professor AOYAMA), no hemorrhage was found and I think that in many cases the merc meningeal inflammation caused symptoms which would lead one to suppose that a one-sided lesion was present. Cases generally developed brain symptoms which could be differentiated into four distinct types :-
(a) Comatose, where the patient lay practically paralysed, mind and body. (6) Wildly delirious, where he struggled and fought and still retained a
fair command of rational speech.