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the first day. In such instances the patient appears to have only taken to 

 bed after the first paroxysm of the disease had nearly or entirely gone 

 by under an insidious form. The earliest manifestation of black vomit 

 generally consists of small thin brown or black shreds, follicles, flakes, or 

 powdery particles in suspension in the liquids ejected by the stomach, or 

 else deposited upon the sides or bottom of the vessel in which it is collected. 

 The presence of red blood has the same clinical significance as that of the 

 black substance, the latter being generally considered as blood that has 

 been acted upon by the gastro-intestinal secretions. The liquid in which 

 the dark substance is contained is generally intensely acid. The proportion 

 of the black particules usually increases as the case grows worse, the 

 mixture presenting then the appearance of coffee grounds or soot in an 

 opalescent or pinkish liquid. At other times the vomit presents the 

 appearance of tar, which is the form more frequently observed in the 

 alvine discharges. The vomiting is often attended with severe retching, 

 distressing hiccough and a burning sensation in the oesophagus and throat, 

 the contents of the stomach being spurted out with violence. Towards the 

 end, in fatal cases, the pulse becomes more frequent, even though the 

 temperature may be lowering. Passive haemorrhages from the nose, gums, 

 tongue, female genitals, leech-bites, and excoriations upon the skin, and 

 sometimes even from the eyes, ears or scrotum, may be abundant ; but at 

 other times they are scarcely marked, being almost entirely limited to the 

 digestive organs. Death is often preceded by suppression of urine and 

 uraemia, but not always. Insomnia, nervous excitement, irregular breathing, 

 jaundice, subdelirium, uraemic mania, convulsive twitohings, irregular 

 pulse, coma, lividity of the extremities, often close the scene. In other cases 

 the intellect remains clear almost to the last, or the patient may suddenly 

 grow worse and within a few hours when the most imminent danger 

 seemed to have passed. 



Recoveries are not infrequent when black vomit has been only slightly 

 marked; nor are they rare even when it has been abundant, especially in 

 young subjects under the age of puberty, and in persons who have prev- 

 iously acquired some degree of immunity. In the white race, death is, how- 

 ever, the more frequent termination of the melano-albuminuric cases. In fa- 

 vourable cases the urinary secretion is maintained, epistaxis and other 

 passive haemorrhages may be abundant, but the respiration and the 

 heart action are not deeply involved (even though the pulse may be 

 remarkably slow) and the black matter or blood soon ceases to be dischar- 

 ged from the stomach or bowels. During convalescence the sequelae men- 

 tioned in connection with the plain albuminuric cases are more likely to 

 occur ; the jaundice may continue for a considerable time. 



In other cases a typhoid condition may be established and the recovery 

 considerably delayed, or the patient may never rally, the fatal termination 

 being only postponed by days or weeks. The great majority of fatal cases, 



