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and from the gut were engorged and in their neighbourhood small hæmorrhagic extravasations were frequently found. On examination more closely, the gut was found to be thickened, dematous with occasional hemorrhages between its different tunics. The mucous membrane was usually much congested, thickened and pulpy. Numerous extravasations of blood of varying size were found, and in some places actual erosion and ulceration had taken place. In a few cases the humen of the gut was found to contain brownish black tarry material, evidently blood changed in colour owing to the action of HS. The changes were most marked in the lower small intestine, and gradually diminished in severity towards the stomach. In the stomach and duodenum the changes were sometimes extremely pronounced, but such usually occurred in patches of limited extent. Again enormous hæmorrbages are frequently found into the mucous membrane of the stomach. On examining the mesentery and contained lymphatic glands, changes were also found. The mesentery itself was often considerably thickened and sodden from cedema, with marked capillary injection. Large haemorrhages were also found.
The lymphatic glands were also affected. They were enlarged and congested, and on section were found to be cedematous and often hæmorrhagic. All these changes will be discussed at greater length under the results of post-mortem examinations.
Having satisfied myself as to the more or less constancy of well marked intestinal changes in all varieties of the disease, I looked for assistance or con- firmation of the presence of these lesions. The literature on plague was of little value. Beyond the mere mention of certain pathological changes in the intestine, no further comments are made. I consulted Professor SIMPSON, pointing out to him these changes. He agreed with these statements which I have just made, and told me that, to the naked eye, the appearances of plague corpses were similar to what he had seen in South Africa and India, and from the presence of these changes in the gastro-intestinal tract, he was more inclined than ever to support the gastro-intestinal origin of the disease.
Again WILM's reports were of use. My own post-mortem results agreed in the main with those of this observer.
In order to obtain more definite information in regard to these intestinal changes, I appealed to the clinical side of plague, hoping thereby to obtain evidence by the presence of symptoms of au affection of the gut. My help therefore, had to come from the various reports furnished by the Medical Officer in charge of the Infectious Diseases Hospital and the Superintendent of the Government Civil Hospital, both of whom had most experience with cases of plague during the last epidemic.
The presence of symptoms indicative of marked affection of the gastro-intestinal tract in plagne do not appear to have called for comment by the Medical Officer in charge of Kennedy Town Hospital. Mention is made of the presence of vomit- ing and diarrhea, but no details are given in the notes on the cases as to the date of onset of these symptoms, their duration, character and severity, etc.
It is interesting, however, to find that symptoms were found present in the majority of the cases, pointing to some affection of the alimentary canal.
During plague epidemics, a considerable number of individuals, complaining of indefinite symptoms, apply to the Government Civil Hospital for treatment. Many of these, after clinical examination turn out to be early cases of plague, and are forthwith despatched to the Infectious Diseases Hospital. Dr. BELL, the Superintendent of the Government Civil Hospital, tells me that many individuals. have applied for treatment during the earliest stages of the disease, at a time when the history of the illness could be obtained with a certain amount of accuracy, Being specially interested in the question of the early diagnosis of the disease, Dr. BELL noted carefully the various symptoms complained of by each individual patient. On making enquiry as to the primary symptoms complained of by plague patients, Dr. BELL furnished me with the notes of the cases which came under observation and, as will be seen, he has been able to assist me greatly in regard to the question of the occurrence of marked evidence of an affection of the gastro-intestinal tract in plaque,