Sessional_Paper_1895 — Page 197

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the list, as our Wardmasters could not be expected to note it in cases where the patient came in through the night and died before the doctor's first visit in the morning. Out of about 450 cases there was Ilæmatemesis in 7; Melæna 4; Hæmoptysis 4; Epistaxis 2; Hemorrhage from Gums 1; Hemorrhage from Vagina 2; Hæmorrhagic Blebs 3; Hemorrhage into conjunctivæ 2. Of these 23 cases 18 occurred in May, so that it is evident that hemorrhages were most liable to occur when the disease was most virulent in its epidemic form.

The course of the bubocs after formation was one of four: (1) early resolution, (2) lengthened period of enlargement, (3) suppuration, (4) sloughing.

Early resolution may take place though it was only seen in some mild cases where the glandular enlargement was slight. Lengthened periods of enlargement occurred in several patients in the Slaughter House Hospital (under native doctors) where the swelling did not go down even after two months in hospital. An indu- rated mass sometimes remained on which iodine, mercury and other usual remedies had very slight effect. One of our patients (who was afterwards retained as an attendant) had a glandular mass remaining at the end of four months with practic- ally no change in size or consistence. If the patient survived, suppuration was the most frequent termination during the first two months of the epidemic, either alone or combined with sloughing. If the glandular mass was very large there was generally a slough, caused by the surrounding inflammation and suppuration, which was vividly described by a Chinese nurse as a "mixture of boiled cheese and thread." If the bubo was small it generally terminated in simple suppuration without the separation of any decided slough. Sometimes great necrosis of skin and superficial tissues occurred over the buboes, and the proximity of femoral buboes to the femoral vessels had a tendency to make one over-cautious with the knife. In the case of ALLEN the bubo took six months to heal up, the glands along the iliac vessels having evidently been enlarged, and giving the greatest trouble after suppuration.

Lymphatic abscesses may develop along the line of the lymphatic vessels. This was especially marked in the case of AOYAMA.

For a long time after the acute phase of the disease was over the tissues retain in a very low condition, incisions taking a long time to heal, there being often no appearance of the epidermis growing over an ulcer for weeks. The granulations remained flabby and unhealthy, and there was a well marked line between the granu- lations and the skin, with no attempt at growth of epidermis over the ulceration.

The presence of bacilli in the blood being a most important symptom I make no excuse for describing it fully, so far as it is necessary for diagnostic purposes. Examination is very easy when one has observed an expert at work, but it is only by attending to every little detail that easy and satisfactory examination can be carried out. Take care to have good clean cover-glasses and slides (we were bothered here very much by having on hand cover glasses which had become hazy from climatic influences). Cleanse the finger tip with alcohol; allow the alcohol to evaporate; constrict the finger with a small strip of lint; puncture the finger with a pen-nib from which half of the nib has been broken off and which has been sterilised in the flame of a spirit lamp. With a sterilised platinum point smear a very little blood in a fine layer on the clean cover-glass. Four or six cover-glasses are generally prepared as the bacillus may not be discovered in a solitary preparation. The moment the cover-glass is dry pass it three times through the flame of a spirit lamp with the blood-side away from the wick. See that the flame is a spirit flame and not merely a burning dry wick. Do not wait hours before passing the cover slip through the flame as then the specimen will generally be found useless. After passing through the flame the staining and examination can take place practically at leisure.

Dr. KITASATO found fuchsin the best stain for the bacillus while Dr. YERSIN used gentian violet. It is all a matter of taste I believe and what one is most accustomed to. Personally I find examination may be prolonged with more com- fort to the eye if gentian violet be used or even methyl blue. Fuchsin is the best stain if only a few preparations want examination. The staining fluids ought not to be too concentrated. Place a few drops of the stain on to the cover-glass pre- paration. This is better than floating it in a watch glass, being easier and wast- ing less stain (a matter of consideration in Hongkong). If of methyl blue, at once turn on to a slide, compress the preparation between a couple of layers of blotting paper without "fluff" on it, and the specimen is ready for examination. If fuchsin or gentian violet be used a period of from three to five minutes should be allowed for staining (according to the depth of the colour of the solution) and then the cover-glass should be washed with distilled water and placed on the slide and dried in the same way as above with blotting paper. If the specimen is to be kept the

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