192
14
frequent, generally coincident with incontinence of fæces if the bowels were at all loose. Urine was generally dark coloured and of high specific gravity, with increased secretion of urea. I noticed no casts in the urine. Sometimes the apparent in- continence in the Chinese Hospitals was due to distention of the bladder.
SKIN.
With two exceptions (urticaria and a herpetic eruption) which were ouly coincidental no rash was noticed, (but vide Case XXII.). The skin was
The skin was dry and, pungently hot, except in collapsed cases when it was cold and clammy. After the acute stage of the disease perspiration in most cases was marked. The question of the occurrences of hemorrhages should be considered in conjunction with the post mortem appearances of organs where hemorrhages have occurred. At the begin- ning of the epidemic almost all the Chinese showed small red spots about the size of a pea. When I was in Canton and enquiring about these spots a Chinese coolie volunteered the information that they were the result of insect bites, generally mosquitoes and flies. I think I am giving a guarded opinion when I say that 95% of these spots seen during the epidemic were caused by mosquitoes or flies. The condition of the blood was such that the slightest scratch or injury was generally followed by a dull pink blush appearing round it. On incision it was found to be composed of a small extravasation of thin light coloured fluid blood. All the hospitals except the Hygeia were swarming with insect life which we could not get rid of, although thousands were slaughtered daily by fly-papers and other con- trivances. In almost every case the spots appeared on the exposed parts, ankles and feet, wrists and hands and face. On the Hygeia patients received at the com- mencement of their illness scarcely ever had a single spot and there were no mos- quitoes on board and few flies. A puncture with a pin or a trivial blow or ex- coriation was often followed by the characteristic discoloration a few days later. The Chinese method of pinching (as a counter irritant) caused wonderful appear- ances on the chest and neck, the whole of this region of the body being sometimes of a colour varying from dull pink to dark violet. Mosquitoes, flies, etc., are very numerous all over Hongkong and the dead bodies which were picked up in the street showed the same spots. I never saw one of these spots above the size of a five-cent piece (the same size as a blister caused by a mosquito bite). In Kennedy- town Hospital, where patients had their pyjamas properly fastened, these spots were almost invariably confined to the exposed parts of the body. I never saw a hæmorrhage in the skin anything like those seen in purpura, which are darker in colour, at least in the centre. All these plague marks were small and dull pink in colour. One day they appeared as typical mosquito bites, the following day they looked like hæmorrhagic spots.
The word "Carbuncle" should be expunged from plague literature as I take it that "Carbuncle" when used in this connexion is meant for a haemorrhagic blister, or a bubo in the neck, several of which looked like carbuncles but were really glandular in character. These were seen in only a few cases (four I think of the early cases). A true carbuncle was never seen. Boils were several times met with during convalescence as a result of the debility caused by the disease, and differed from the ordinary tropical boils common in Hongkong in that the pus was thinner and that there was no true core or slough, whilst an inflammatory areola of redness was seldom present,-in fact they ought to be called multiple abscesses rather than boils. In one case true boils occurred early. In one bad case of multiple abscesses, necrosis of several parts of the skull took place.
Haemoptysis was very rare, only two cases (on the Hygeia and at Kennedy- town hospital) being serious. Hoematemesis and Meloena were equally rare.
Bleeding from nasal or buccal mucous membrane was noticed several times early in the epidemic. Hæmaturia was never noticed. Hemorrhage into the conjunc- tive was noticed in a few cases. Two cases of hypopyon came under observation. In speaking of hemorrhages into the conjunctivæ as being occasionally seen it must be noted that congestion of the conjunctivæ was very general at the onset of the acute cerebral symptoms.
Every pregnant woman brought to hospital aborted. All died with one exception. Contrary to what one might have expected none died from uterine hæmorrhage, but evidently from the virulence of the disease. In the cases I saw the uterus had contracted well. Haemorrhage from the genital canal was noticed in a few instances, notably in the case where hemorrhagic endemetritis was found post mortem.
The following list gives the numbers of those who had apparent hemorrhages in the Government Hospitals. It is possible that one or two more should be on