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Vomiting usually came on early and was of a bilious nature, being at first greenish, but going on to a dark-brown colour, almost grumous, Hæmatemesis was exceedingly rare during the epidemic. The question arises whether the dark grumous material vomited was not blood altered by stomachic causes.
I do not think that this is so because in these cases, (if efficient treatment was not adopted), the vomiting was sometimes constant, and pure or almost pure blood would neces- sarily have been vomited much more frequently. The vomit was generally of the same colour as the bile found in the gall-bladder post mortem. The vomiting gene- rally disappeared after counter irritation and a dose of calomel had been administered, and a free evacuation of the bowels secured. Where calomel was given early this troublesome symptom very seldom appeared. Under the care of native doctors vomiting was much more frequent than in our hospitals, and this I ascribe to want of purging, and also to the horrible concoctions of medicines and food which they forced down their patients' throats. Considering the cerebral condition of some patients it was to be expected that vomiting and retching would be frequently met with; but after the above explanation and taking into consideration the fact that the vomiting did not show the ordinary cerebral characteristics, I think that this symptom must be put down as mainly due to the condition of the liver and bowe's. The feeling of oppression, and sometimes burning, in the epigastrium was due partly to the stomach trouble, but mainly, I believe, to cardiac conditions. Hiccough was often distressing, but the first dose of morphia generally stopped it.
Constipation was the general rule, though diarrhoea was met with in a number of cases and might be classed as (a) slight looseness of the bowels; (b) severe diarrhoea. Many cases of slight diarrhoea did very well, in fact I put it down as a favourable symptom, but then it only appeared in what seemed to be milder cases. Severe diarrhoea need not necessarily be a bad symptom. As a rule when severe it was very fœtid and evidently due to an acute enteritis. There was sometimes considerable straining with it resembling dysentery, but in only one case in the epidemic in our hospitals did I see blood in the evacuations, and then it was dark in colour, no bright blood as is often found in dysentery, and had evidently come from some distance up the bowel. Pain over the liver was never complained of, pain over the spleen on a few occasions only; pain in the abdomen was due possi- bly to one or more swollen glands, or may be ascribed to colic, or frequently to distension of the bladder. Enlargement of liver and spleen was only occasionally made out by palpation and percussion.
Respiratory System.-Dyspnoea was a constant symptom and was due to a combination of causes :-(a) edema of the lungs brought on by the vasomotor paralysis and possible changes in the small vessels; (b) the febrile state, and loss of hæmoglobin; (e) cardiac. It was of an anxious and distressing character, coming on early in the disease with rapidity of respiration; the alæ nasi, however, were soon at work and the respiration became more rapid still. The dyspnoea was more of a pneumonic than of an asphyxiative type. Physical signs of hypostatic inischief were seldom well marked before the third day of illness, and even then was only so in the severe cases. Some cases got well in whose lungs no moist sound was ever heard, but I am bound to add that many a one died with precisely the same condition of affairs, post mortem examination always showing some con- gestion at the bases of the lungs. Cough was generally absent in the early stages of the disease; or if present was evidently caused by the cedema of the lungs, and was then of a short and irritating character. Many cases showed edema of the lungs without cough. These were generally rapidly fatal, the patient becoming comatose as the lungs became choked up. In a few cases the dema went on to acute pneumonia and pleurisy, but this as a rule was only seen late in the disease. Pleural effusion was seldom marked enough to diagnose before death. In some cases multiple pneumonic abscesses-undiagnosed-occurred.
Among Chinese the voice in almost every case-even where the patient was sensible-was very weak; it was not so as a rule with the Europeans whose lung power and larynges were always in a much better state than those of the natives. Laryngitis when occurring was generally the result of extension of cervical glandular inflammation, and at the end of the epidemic, when these glandular inflammations were of an extremely mild character, laryngeal mischief was not met with at all.
Affections of the urinary system were practically limited to a slight and transient albuminuria. This was always slight, a trace to 1/20th being the common report on the charts. A larger amount I never saw. Hæmaturia was not noticed amongst our cases. Retention of urine was frequent and, notwithstanding every attention to cleanliness, cystitis developed on several occasions where frequent catheterisation was necessary. Unconscious urination at the beginning of the epidemic was also
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