Sessional_Paper_1904 — Page 643

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The speech is also regarded as characteristic. The conjunctivæ are usually intensely injected and often there is marked photophobia. Jerking movements of the muscles accompanied by a sort of intention tremor are usually present in typical cases.

These are among the most important symptoms usually described in character- istic cases of plague. They are followed by the development of the so-called types of the disease, namely, the bubonic, pneumonic and septicæamic plagues. These clinical symptoms. aided by the demonstration of the specific cause in an individual complete the diagnosis. As already noted, such diagnoses have to be made as rapidly as possible during an epidemic. There is a constant influx of patients and with the preparation of the various necessaries requisite for their treatment, the time of plague officers is fully occupied. Consequently I venture to state that in the majority of cases a careful note of all the initial manifestations of the disease has not been made. Again trustworthy accounts of the earliest symptoms of the disease are difficult to obtain. The majority of patients are not brought to Hospital until a day or two after the onset of the disease, and even on reaching the Hospital the sensorium of these patients is so altered that a reliable account of the onset of the disease is either unattainable on uptrustworthy.

In

The initial manifestations of the disease, which I regard as having been to a great extent lost sight of, are those arising from the gastro-intestinal tract. the varions Reports on Plague, including those of the Commissions, mere mention is made of the occurrence of diarrhoea and vomiting. Their appearance is apparently regarded as ordinary symptoms occurring during the advent of an fectious disease.

WILM, however, in his Report on Plague in Hongkong in 1896, describes shortly the occurrence of such manifestations and lays some stress upon them. On page 9 of this report we find the following:-"The symptoms of disorder of the digestive tract were very numerous. At the outset of the disease the tongue usually became swollen, bright red at the tip and edges, and was covered with a greyish white fur. Usually on the second or third day of the disease, the fur became brownish or black, and dried in a crust. The tongue becomes cracked and fissured so that it soon resembles that seen in typhus or in enteric fever about the third week of the disease. The lips soon become dry and often fissured, the mucous membrane of the mouth and pharynx was usually bright red. The appetite disappeared. There was frequently uncontrollable vomiting and great thirst, with a painful sensation of heat in the stomach and the lower part of the abdomen. The vomit was sometimes watery, sometimes bilious, sometimes like coffee grounds. Diarrhoea was frequent at the outset and again in the later stages of the disease

Blood, mucus, and epithelium frequently appeared in the stools.

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WILM concluded, as the result of his observations, that an intestinal type of plague existed. He says that in 20 % of the cases, the intestinal symptoms were so predominant, that the illness had to be regarded as essentially an intestinal affection.'

WILM's results do not appear to have attracted a great deal of attention. The members of the various Indian Plague Commissions do not deny the existence of such a type of the disease, yet were unable to support it. Such a type of plague is put down by them as a form specially met with in Hongkong, and of no great importance so far as the pathogenesis of the disease is concerned.

On my arrival in Hongkong, I was prepared to meet with the classical types of plague, as laid down in the various Reports. My experience of plague at the Mortuary confirmed the presence of these types. At the same time I was struck by the appearances presented post-mortem. According to the type of case ex- ainined, buboes, pneumonias, etc., were found and the general morbid alterations in the tissues and organs more or less harmonised with my expectations. What seemed to me to be wanting in the reports on the pathological aspects of these cases, was a description of the appearances presented by the gastro-intestinal canal.

In the vast majority of cases examined post-mortem, a careful examination of the

gut showed the presence of pathological change. Previous to the disturbance of the contents of the abdomen, one could observe on opening the peritoneal cavity, patchy congestion of the stomach and intestines. The vessels leading to