to 19° S. latitude. Plague has never been known in the Western Hemisphere or anywhere south of 19° N. of the Equator.2 The Basin of the Mediterranean and the strip of country which runs parallel to that sea across the Asian continent from Turkey to China may be roughly taken as its present belt during the nineteenth century, but the Mediterranean part of the belt has disappeared almost wholly within the present generation. A map of the plague-stricken districts within the last fifty years shows plague astride the Himalayas with a giant limb reaching on one side the Red Sea and on the other the shores of the Pacific. What determines the distribution it is impossible to say. Racial distinctions do not account for it, as the Mongoloid and Indo-European races are equally attacked. Neither ocean nor air currents have aught to do with its transit. It seems to thrive in the densely packed population of Canton and in the sparsely populated semi desert regions of Rajputana and Arabia; the elevated plateau of Thibet and the low-lying valleys of the Euphrates are equally affected. It occurs during the summer's heat and the winter's snows. In fact, no known meteorological condition has any effect upon either the genesis or the exodus of plague. Pigeons are said to be severely stricken in Bombay at the present moment, but what kind of pigeon is attacked I have not yet been able to ascertain. When we have the information it will be interesting to note its geographical distribution. We have no notice from China, however, of the pigeons being attacked by plague. The part the rat plays as a distributor of plague will be dealt with later when we come to consider the relationship of animals to plague generally. and it is the life-history of this bacillus which must in As animals are affected, it is interesting to inquire what I was of the belief until within the last few days that animals are affected, what is their geographical distribution, this disease-this pestis minor-was of a nature wholly and what share, if any, they take in its spread. The animal apart from true plague. From Calcutta, however, the news which above all others is known to be affected by plague is of the discovery of a bacillus allied in every respect to the the rat; but the wide geographical area throughout which Kitasato bacillus of true plague and associated with the this animal is met with would seem to frustrate any attempt variety of plague known as pestis minor has altered my to determine a collateral distribution. On looking a little views, although the bacillus is stated not to possess the more closely, however, we find rats (the Murina) divided toxic or virulent properties of the true plague bacillus, but into two great sections-the mures, inhabiting the Old to be similar in all other respects. The real question at World (except Madagascar), and the sigmodontes, inhabiting issue at present is: Is there a disease of an epidemic the New World and Madagascar. Of the mures, one sub- character, attended by a low death rate, characterised by family, that of the Nesokia, is met with, reaching from polyadenitis and showing in the blood and tissues a bacillus Palestine to Formosa across the northern part of India. The resembling the bacillus met with in typical plague (malignant southern limit in India seems to be where the great bandi- polyadenitis), and yet so apart clinically that it is either a coot, or pig rat, exists, and here plague is unknown. This is separate disease or caused by the same bacillus in a lesser the only animal which presents a habitation well-nigh coror non-toxic form? In the discussion of this subject it is responding to the present distribution of plague, and it is necessary to ask the following questions:-1. Does pestis the animal above all others which is looked upon as being minor occur as a precursor, as a collateral ailment, or a liable to be attacked by plague. The geographical distribu-sequela of true plague? 2. Is it confined to the plague belt tion of this family of rats well-nigh coincides with the plague delineated in the map? 3. Has it anything to do with belt as delineated. plague? 4. Is it a disease per sc? Dr. Payne in the Encyclopædia Britannica," writes as follows: "In the minor form of the disease spontaneous swellings of the glands occur chiefly in the armpits, but also in the neck or other parts, which either undergo resolution or suppurate. There is a certain amount of fever; the temperature is rarely high, but has. been known to be 104° F. The duration of the disease is from ten to twenty days usually, but may be eight weeks, for most of which time the general health is but little With regard to the continuity of plague outbreaks it impaired and the patient able to go about as usual. It would appear that in the plague belt the disease is ever rarely, if ever, causes death, the only fatal case at Astrakan active, now in one place and now in another. At times we in 1877 having been so through a complication. The disease find it in Arabia, then in Persia and the Himalayas, and the is not obviously contagious; whether it is propagated by wave travels eastwards over Yunnan and Southern China to infection or not is unknown. It is possibly rather of a the sea. The disease oscillates, now east and now west, miasmatic character. This form of disease has sometimes but with a fatal precision, making the slow swing of the preceded or followed severe epidemics, as in Mesopotamia. pendulum of plague within a fairly definite area. A glance (Irak) on several occasions (1873-78) and in Astrakan (1877). at the table giving the dates at which plague appeared in Its importance in relation to the origin of plague has only epidemic form since 1850 will confirm this. Taking the lately been appreciated. It might be expected that gradachief seats passed en route between the Red Sea and the tions would be found connecting this form with the severe Pacific we find that plague appeared as follows:-In 1850, epidemic form; but this appears to be not usually the case, India; 1850, China; 1853, Arabia; 1853, India; 1856, the latter form appearing somewhat suddenly and abruptly Tripoli; 1858, Mesopotamia; 1859, Tripoli; 1863, Persia; hence the minor form has probably often been regarded 1867, Mesopotamia; 1869, India; 1871, Yunnan; 1872, as a 'distinct' disease, even when observed in plague. Persia; 1873, Mesopotamia; 1874, Arabia; 1876, India; countries." From all hands we have evidence of such a 1876, Mesopotamia; 1877, Tripoli; 1877, Russia (Caspian disease-namely a pestis disease— namely a pestis minor benign polyadenitis. Sea); 1879, Arabia; 1880, Mesopotamia; 1881, Persia; 1881, 1. The Russian outbreak at Astrakan in 1877 was probably ;. China (Pakhoi); 1883, Afghanistan; 1884. Mesopotamia; nay, certainly, of this nature, the low rate of mortality being 1886, Persia; 1887-89, Arabia; 1890, China (Yunnan); 1893, sufficient to stamp it other than true plague. It is to be Tripoli; 1894, China (Canton, Hong-Kong); 1895, China noted also that the typical plague which ranged in (Macao); 1896, China (Hong - Kong) ; 1896, India the same province appeared, not amongst the community (Bombay); and 1896, Merv (?). A study of this table shows afflicted with pestis minor, but in a district 150 miles the continuity of the course of plague and how the eruption away, where pestis minor was unknown. 2. In Calcutta in one district is followed by its appearance in another. A A six six years ago a form of fever existed among the slow traveller, it, however, stays when it comes, and unless British troops there which in all points resembled the the scenes of its visitation are well garnished it becomes present form of bubonic fever which exists there nowendemic. namely, fever with specific glandular swellings. 3. We have it also from Calcutta that the natives are frequently 4. In the far east, from Singapore, the Straits, and along allicted with glandular enlargements during malarial fever. the coast of China as far as Shanghai, between the years. The cause of plague is the advent of a definite bacillus, 2 This remark requires to be accepted with reservation, as it is reported that several cases of plague came to Hong-Kong from Singapore (2° north latitude). ;: 1892 and 1896, we have accounts of a singular affection of the inguinal glands which occupied the attention of the Singapore and Hong-Kong branches of the British Medical Association. The correspondence was carried on between the societies, and there is no doubt the affection at both places was identical in its nature. I am compelled to draw attention to this subject in consequence of a paper which appeared in the British Medical Journal of Sept. 26th, 1896, by Surgeon C. C. Godding, R.N. Surgeon Godding refers to many cases of chronic glandular swelling attended by fever and anæmia, and he gives a careful clinical account of several such cases as having occurred in Hong-Kong. This is the first notice to the profession generally of a type of ailment with which all practitioners in the far east are but too familiar. When the literature of the present outbreaks of plague comes to be written, the recorder will no doubt light upon these cases of glandular swellings given by Surgeon Godding, and take them as evidence of the association of pestis minor with the malignant type. We must, therefore, deal with them, come to what conclusions we may. When I brought the matter before the Hong-Kong Medical Society in 1893, I mentioned that I employed the term "bubon d'emblée" to designate the condition and that I had treated thirty-eight cases in thirty-two months. My account of the ailment was as follows: "A slowly developing nonvenereal bubo occurring in one or other groin, attended by general weakness, anæmia, and fever. The groin glands affected are discrete at first, but gradually the swellings amalgamate and a large mass as big as half an orange or larger presents. At the end of about twenty days points of boggy softness occur, and if the bubo be left to itself the skin becomes undermined and the pus finds its way to the surface through two or three or more fistulous openings. The swelling, when cut into early, shows a peri glandular serous infiltration, and when pus occurs the gland will be found lying detached except by shreds of tissue at one or two points. The gland when cut into shows many focal points of suppuration and breaks down quite easily beneath the fingers.' Surgeon Godding advocates arsenic as almost a specific, but my own treatment latterly was early incision. It is necessary to make a clean sweep of every gland that can be felt or seen, as there is a great tendency to recurrence in any gland or piece of a gland that is left. Seeing that glands, except strumous glands, are seldom excised for other diseases, I examined the records of the Government Civil Hospital in Hong-Kong in connexion with the excision of glands, and I found the following:-In 1891, 19 buboes were scraped or excised; cervical glands, 1. In 1892, I have not the record. In 1893, 27 buboes were scraped or excised. In 1894, 12 buboes were scraped or excised. 1894 was the plague year, and the list of operations is stated to be incomplete. Taking this evidence in conjunction with Surgeon Godding's and the private practitioners' in Hong-Kong and Singapore we have weighty evidence of a widespread affection, be the cause what it may.3 Another form of glandular idiopathic enlargement is seen in what may be styled an epidemic form in children. In the year 1891, I reported twenty-three cases at the Medical Society in Hong-Kong, and since that date cases have frequently occurred. The affection consists of an enlargement of one gland, seldom more, in the necks of children over the sterno-mastoid about the middle of its length The swelling is seen upon the sterno-mastoid, but it might be found to commence, were it met with early enough, in a gland on its anterior border. The disease appears infectious and is attended by feverishness. There is no throat affection, nor is the seat of the disease in the parotid. We, the medical practitioners, styled the condition for convenience sake mumps, but we all admitted that neither the parotid nor the submaxillary glands were the seat of trouble. It will be remembered that the term "peculiar form of mumps" was employed by some to designate the Astrakan disease in 1877. 6. In the years 1893-4, and since, in Hong-Kong, cases of fever of a typho-malarial type occasionally presented in the third or fourth week a general enlargement of lymphatic glands, which lasted for a week or ten days and then subsiled. They were deemed interesting cases at the time, but with the fresh light thrown upon them by recent investigation, more especially the researches in Calcutta, they assume a new aspect. Europeans were mostly attacked by these buboes, being 88 per cent. of the cases operated upon. To sum up the evidence before us it would seem--(1) that a fever with glandular enlargement, pestis minor, a benign polyadenitis," is an established disease; (2) that it may be independent of plague or malignant polyadenitis; (3) that the two may coexist; and (4) that the one may exist independently of the other. As to infection and contagion, direct contagion, that is, transference of the disease from the sick to the healthy by bodily contact would appear at the first glance to be an element in the transmission of plague. How otherwise can we explain the circumstance that, when a case of plague occurs in a house, those dwelling in the house and brought in contact with the sufferer are almost certain to be seized, and not only so, but few, if any, of the other inmates escape. The next in order to be seized by plague are the relatives of the sick and the visitors to the house, who, going to their own homes, set up a fresh focus of infection. Of the community, medical men, clergymen, and attendants, who are brought in contact with the sufferers, more readily acquire the disease than others who are alien to the family and house. These facts would appear to prove conclusively the contagious nature of plague. But there is another side to the argument. As long ago as 1835, when plague was epidemic in Egypt, out of ten French medical men who attended the sick only one contracted the disease. Further, we have the well-known case of Bulard during the same outbreak, who, anxious to prove his contention that the contagious nature of plague was much exaggerated, for two days wore the shirt of a patient who had died from plague. Yet Bulard did not contract the disease. More recently we have the evidence of the Hong-Kong epidemic in 1894. None of the European medical men in attendance on the plague patients, in all, some fifteen in number, were attacked by plague. Those men were freely exposed in the wards and at post-mortem examinations, yet none were infected. Further, none of the British or Italian born nurses-these were the only two European nationalities represented—were attacked by plague during 1894. But a more interesting fact still is that none of the Chinese students of the College of Medicine were attacked. For six weeks these men were on duty in turns night and day in the Plague Hospital. Eight of them acted as ward attendants and clerks throughout the period and were consequently in constant contact with the sick. A racial immunity might be claimed for Europeans, but in face of this fact it cannot hold good. If there be any truth in the acquisition of disease during an epidemic by fear or nervousness ness the case of these students refutes the legend. They saw that the Europeans escaped and how terribly their countrymen suffered; they had to contend with the superstitious beliefs of their country, inherited and acquired; they were breathing the same air, eating similar food, hearing daily, hourly even, of the deaths of their friends, relatives and acquaintances, yet none of them succumbed to plague. We have, therefore, two opposite conditions before usnamely, plague entering a house and seizing practically all the inmates; and, on the other hand, medical men, nurses, and native students acting as clerks and dressers escaping completely. Where, then, lies the truth of the contagious nature of plague? As usual, there is a channel of escape from either of these two extremes of argument. The immunity above related does not extend indefinitely. The Europeans attacked during the 1894 epidemic were chiefly soldiers of the Shropshire regiment, then stationed in Hong-Kong. When plague required sanitary interference beyond the power of the local board these soldiers came forward and volunteered to help in the work of cleansing and purifying the city. The work assigned to them was of the most laborious order and they were exposed to a concentration of the contagion, for the field of their duty lay amongst the dwellings of the poorest class of Chinese who were suffering from plague. Those houses were of the vilest kind of habitation mankind is acquainted with; small, windowless, low-ceilinged, reeking with filth and excretions, they presented infection in its most concentrated form. Further, the soldiers had to use spade and shovel to dig down into the accumulated layers of dirt on the floors of the houses and throw it into the street. It was this occupation more than any other to which is attributed the infection of the soldiers. During the 1894 epidemic two of the sisters of the Italian Convent contracted the disease and died, but they were neither of them Italian born; they were both Eurasians and in very humble circumstances. In 1894, also, three Japanese medical men contracted plague, of whom one died. The two who recovered were both considered to have inoculated themselves at a post-mortem examination on a case of plague. The facts recorded would seem to show that, during the 1894 epidemic in Hong-Kong, English practitioners and nurses enjoyed an immunity which did not extend to the Japanese medical men or to the nurses of Eurasian blood. The evidence of the subsequent outbreak in Hong Kong in 1896 goes to show that Europeans were much more frequently attacked than in 1894, and two of the nurses in attendance on the sick contracted plague. One of the nurses was a British-born nursing sister at the Plague Hospital, where she had been for many months. She never was ill until the very end of the epidemic, when she got a sharp attack of plague, from which, however, she fortunately recovered. The sister (Katherine M'Intosh) believes she was infected by a little child she nursed, and whom she frequently carried about in her arms. The other European nurse was an Italian-born sister in the convent, who believed she was infected in the same way-viz., by nursing and carrying about a child sick from plague. The Italian sister died from her disease. It is interesting to note that the patient from whom the English sister contracted her disease recovered, whereas the patient of the Italian sister died. Was the recovery of the English sister due to a lessened degree of infection, seeing that her patient recovered, and the death of the latter due to the extreme malignancy of the emanations from the body of the dying child? is a pertinent question. Nor is this all, for yet another sister in the convent died, presumably infected whilst nursing her companion. These three deaths seem to point markedly to contagion rather than infection as the means of spread, for although there were some 600 persons in the convent none of the other inmates were afflicted thereby. Gathering this evidence together and trying to focus it we find that the soldiers who were affected were exposed-if there is any truth in intensity of contagium at all—to the most concentrated form of the poison. They worked not in the streets in the open air, but in reeking hovels for several hours together Intimate and prolonged contact with the contagium in an active condition seems to be the explanation of their infection. The same is to be said of the two European nurses who were seized. Both attributed their ailment to intimate and prolonged contact with a generating source-viz., a child carried in the arms not for a few minutes, but for several hours daily extending over several days. That there are, moreover, degrees of power in the contagium, even when emanating from the human body, seems to be supported by the nurse and infecting child both recovering in the one instance, and the nurse and infecting child both dying in another. Bulard sleeping in the dead man's shirt proves nothing further than that the plague-infected garment did not generate poison of an intensity sufficient to infect. The poison grew every moment more dilute, but a nurse carrying a child, throwing off contagium continuously, is an exposure of a different stamp. The immunity of the medical men and Chinese students does not annul the effect of prolonged and intimate contact as being a means of spread; for it must be remembered that the medical man "visits" only, he does not stay for a day beside one case as a relative does, nor does he sleep or eat under the same roof as does a nurse. In this way also the immunity of the Chinese students is to be accounted for. They performed their task in a newlybuilt, commodious, and roomy mat-shed. Freely ventilated by being raised three feet from the ground, and its lofty roof constructed so that air swept across between the side walls and the roof with large apertures in the roof itself, the chance of contracting the disease from so diluted a form was reduced to a minimum. The practical lesson to be learned from these statements is that free ventilation, and attention to ordinary hygienic rules, lessen the chance of contracting the disease to a very great extent, not only for Europeans, but also for natives; but that all are liable to contract the disease when either from the calls of duty or wilful neglect exposure is extreme. (To be continued.) AWARDS FOR MEDICAL SERVICES.-Dr. J. S. Mackay and Dr. Alex. L. Curror of Kirkcaldy have been awarded by the town council £100 each for services rendered by them during the late epidemic of typhoid fever. A Clinical Lecture ON PELVIC INFLAMMATION IN WOMEN. Delivered at the Middlesex Hospital on Dec. 3rd, 1896, OBSTETRIC PHYSICIAN TO THE HOSPITAL; EXAMINER IN OBSTETRIC GENTLEMEN, -Pelvic inflammation in women is probably the most frequent disease which in one form or another is met with in general practice; it is often dangerous to life and always causes a great amount of chronic suffering if allowed to progress unchecked. On the other hand, if diagnosed and treated in its early stages it can often be cured. Far better still, if proper preventive measures (which we will consider presently) be adopted many women can be saved from the onset of the disease. In the first place let me say that the manner in which pelvic inflammation has been hitherto dealt with in most textbooks on the diseases of women requires complete revision. Formerly it was the custom to divide pelvic inflammation into (a) perimetritis or pelvic peritonitis, and (b) parametritis or pelvic cellulitis, to give a long string of causes for each disease, and to describe separately the symptoms, physical signs, and treatment of each. But nowadays with the help of the light which has been thrown on the subject by performing abdominal section for diseases of the ovaries and tubes the situation is completely changed. And what do we learn? Why, that parametritis (pelvic cellulitis) is rarely met with except after parturition, and that pelvic peritonitis (perimetritis) is in the vast majority of cases associated with, and caused by, pre-existing disease in the Fallopian tubes or ovaries, or both. This being so, when discussing pelvic inflammation in women we must consider not only perimetritis and parametritis, but also disease of the tubes (salpingitis, hydrosalpinx, pyosalpinx, and hæmatosalpinx) and of the ovaries (ovaritis and ovarian abscess). I particularly want you to remember that, except after parturition, pelvic inflammation in its widest sense is due to infection extending along the Fallopian tubes from the uterus. A precisely analogous state of things is met with in disease of the appendix vermiformis. The peritonitis, cellulitis, and abscesses which complicate an appendicitis are due to an infection inside the appendix which passes through its walls to the surrounding peritoneum and cellular tissue. In exactly the same manner does an infection of the Fallopian tube cause similar results: with this difference, that the infection, instead of having to extend through the walls of the tube (as in the case of the appendix), finds an easy exit in the first instance through the abdominal ostium. The cause, then, of pelvic inflammation is almost always either septic or specific infection. Septic infection is in the great majority of cases the result of parturition, though a few cases may be due to the use of sponge or laminaria tents or to operations performed on the uterus with dirty instruments; this latter is not very likely to occur in these days of aseptic surgery. Bernutz analyses 99 cases of peritonitis as follows: 43 occurred in puerpera; 28 occurred after gonorrhea; 20 occurred during menstruation; and 8 were traumatic-viz., 3 owing to excessive coitus, 2 from syphilis, 2 from the use of the sound, and 1 from the use of the vaginal douche. Specific infection from gonorrhoea is accountable for 28 of the 99 cases; but in my opinion the 20 cases in which menstruation is given as a cause of peritonitis had in addition disease of the tubes, probably of gonorrhoeal origin. So that almost all the cases of peritonitis occurring in women, apart from labour, are most likely secondary to specific infection from gonorrhoea. I do not go so far as to say that any man who contracts gonorrhoea and gets completely cured of it before he marries is in the least likely to infect his wife; but, from personal knowledge, I can assure you that men who consider themselves well and who are passed sound" by their medical men, but who probably have a slight and occasional gleet which the excitement of marriage renders virulent, do sometimes infect their wives with gonorrhoea, |