clinical study of this part of the body. For this purpose the following arrangement will suffice:

1. Diseases of the anterior abdominal walls. 2. Diseases of the peritoneum and its folds.

3. Diseases of the organs contained within the abdominal cavity or pelvis, namely-(a.) Stomach and Intestines. (b.) Hepatic organs, including the liver, gall-bladder, and bile-ducts. (c.) Pancreas. (d.) Spleen. (e.) Urinary apparatus, namely, the kidneys and their pelves, the ureters, and the bladder. (f.) Supra-renal capsules. (g.) Female generative organs, including the uterus and its broad ligament, the Fallopian tubes, and the ovaries. (h.) Absorbent glands, especially the lacteal glands; with which may be also mentioned the receptaculum chyli, and the absorbent vessels.

4. Diseases of the large blood vessels within the abdomen, especially the aorta and the iliac arteries, and certain important veins.

5. Diseases of nerves within the abdomen, and particularly the sympathetic plexuses and ganglia.

6. Diseases originating in connexion with the cellular tissue in certain parts of the abdomen.

7. Diseases arising from the muscular and tendinous or bony structures forming the posterior boundary of the abdomen; from the pelvis or the structures lining it; or from the diaphragm, and invading the abdominal cavity or its anterior walls.

8. Diseases encroaching upon the abdomen from other parts, particularly from the chest.

I FIND the following passage in the interesting Lecture on the Arthritic Diathesis by Mr. Jonathan Hutchinson:-"I believe I am giving you a definition which all will accept when I say that we count as gouty all manifestations which occur in connexion with a state of health in which lithic acid is present in excess in the blood, and in which there is a tendency to the deposit of its salts in the tissues."

But what shall we say of the practical clinical value of such a definition when only a few lines previously Mr. Hutchinson has written that the detection of lithic acid in excess in the blood is "difficult of application" and "in a majority of cases not available"?

Moreover, there are many who agree with the late Dr. Murchison in recognising a state of lithaemia, which probably includes, but is not simply co-extensive with gout in the ordinary acceptance of that term, and who are not prepared to admit, in the present state of our knowledge, that the two can be regarded as co-extensive.

For my own part, I must maintain provisionally that the essential characteristic of gout or rheumatism is the acute attack.

A patient who has suffered from acute gout or acute rheumatism may be held quite properly to be gouty or rheumatic; and we must allow a certain amount of justice to the use of these adjectives to characterise certain local or general diseases from which he may suffer, and which experience has shown to be of frequent occurrence, and to present certain special peculiarities in such subjects. Moreover, when a parent, or a brother or sister, or a parent's brother or sister, has suffered from the acute form of the disease, there is also propriety in suspecting a constitutional modification; and in such cases, for therapeutic purposes especially, there is much to be said for the use of the terms gouty or rheumatic. Here, again, the results of experience in determining the frequency of such relations are of overwhelming importance in justifying the use of the terms.

But, in the absence of such histories, I think we ought to be very careful to avoid using words which imply a knowledge we do not possess, and which too often serve as a cloak for ignorance.

Mr. Hutchinson has done excellent work in the direction of pointing out the local manifestations of diathetic condi

tions, but it must not be forgotten that such signs are not altogether free from fallacy, and ought in a majority of instances to be supported by a clear history of the occurrence of the major phenomena of the disease with which they are said to be related, or they become vague and liable to introduce confusion rather than precision into our diagnosis; and it is of the utmost importance that there should be a previous clear understanding as to the kind of evidence which shall be regarded as proving satisfactorily the existence of the disease in the personal or family history.

THE PLAGUE IN RUSSIA.

By E. D. DICKSON, M.D.,

Physician to the British Embassy, Constantinople, etc.; and British Delegate to the Constantinople (Ottoman General) Board of Health.

(Continued from jaje 7.)

"WHAT connexion," asked Cabiadis, "could there have been between Mavra Pissareff and the Cossacks or persons who had returned from Kars?" To this inquiry Professor Eichwald observed-"I presume, then, that Dr. Cabiadis believes that the plague which broke out in the province of Astrakhan evolved itself spontaneously in Russia!" Cabiadis replied, that he had no preconceived notions with regard to the outbreak. What he aimed at was to inquire and search for its cause, and if the result of the inquiry showed that the malady had been imported from some other place, he would then have no hesitation in declaring it; but if these researches proved fruitless, then, rather than bewilder his mind with probabilities, he would prefer to acknowledge his ignorance, and not put forward (as had been attempted) imaginary hypotheses.

With these words ended the display of the incriminated articles, and the people of Vetlanka, who had come to witness them, then dispersed. But as they were returning to their homes they were heard to say, "So you see, after all, that it was these accursed fez that brought the plague into Vetlanka, and not Mavra Pissareff, as we at first believed."

The following statements, however, were obtained by Dr. Cabiadis with regard to these fez, from the Cossacks to whom they belonged:

On

1. Simeon Ivanoff Serkin, a native of Vetlanka, said that fifteen months ago he had quitted Vetlanka along with his regiment, and had gone to Kars, which was then held by the Turks. After fighting against them with no result, they fell back upon Alexandropol, then went to Kurukdara, then back to Alexandropol, then to Milekamte, then back again to Alexandropol, and finally to Kars, which they found this time occupied by the Russians. They now left it for Alexandropol, Elizabetopol, Kuba, Derbent, and returned to Astrakhan in August, 1878, and found the city in perfect health. His regiment was composed of 550 men, all in excellent health; they had lost about fifty men during the war. He did not know if any malady prevailed at Kars, and has never heard a word about plague. He and many of his comrades purchased from the shops at Kars handkerchiefs and fez, all of them quite new. At Kuba (near Derbent) they also bought some shawls. Sunday, Febuary 25, they delivered up these things to the police officer, Gavril Maxinovicz, by order of the Governor, Count Orloff Denisoff. He also added that, at the time Dr. Cabiadis was examining these things with Professor Eichwald, he was himself present there, and recognised his own fez and shawls amongst those belonging to his comrades. As far as he is aware, none of the Cossacks bought any articles of dress from the Turkish soldiers, or from the Bashi-Bozuks (volunteers), but they got all their things new from the shops. Both he and all his family enjoyed good health during the whole time of the outbreak at Vetlanka. 2. Ivan Gregori Sherbakoff, stated that about seventeen months ago he had started for Kars, following pretty nearly the same course as that already mentioned in statement No. 1. They fought the Turks twice, but without result. His regiment consisted of 600 men, all of whom enjoyed throughout good health. Very few of his comrades died during the campaign. He does not know whether any epidemic existed at Kars or at Astrakhan at the time. returned to Vetlanka four months ago. He bought from the shops at Kars some fez with tassels, and silk handker

He

chiefs. All these he delivered up on Sunday, February 25, by order of the Governor. He too was present at the examination of the things, and recognised those belonging to him. He lost his wife two months ago, during the outbreak. She caught the malady in going to see a friend of hers who was ill at the time. As far as his knowledge goes, none of the Cossacks bought articles of dress from the Turkish soldiers or from the Bashi-Bozuks.

3. Ivan Sotnikoff stated that more than a twelvemonth ago he had gone to Kars. His itinerary was similar to that mentioned in statements Nos. 1 and 2. His regiment consisted of six hundred men, all of whom enjoyed throughout good health. Some of them, however, were killed in the three engagements they had with the Turks. He does not know whether there was any outbreak at Kars or at Astrakhan at the time. He purchased a fez from the shops while at Kars, and delivered it up on Sunday, February 25, at the same time that the others were given up to Gavril Maxinovicz, by order of the Governor. None of his family fell sick during the epidemic of Vetlanka. As far as his knowledge goes, no one bought any articles from the Turkish soldiers or from the Turkish volunteers.

Dr. Cabiadis intended to interrogate all the Cossacks of Vetlanka who had gone to Kars, but as soon as it became known that he was making inquiries of them, they were ordered by the authorities not to appear before him. Dr. Cabiadis, therefore, remained ten days at Vetlanka, but failed in his efforts to obtain any further information from its inhabitants. This imposed silence he attributes to the arrival there of Eichwald-for Biesiadecky, who had gone there before Eichwald's arrival, had found the inhabitants docile and communicative; but the very moment Eichwald arrived everything changed, and it became impossible to get any details from them. This state of things lasted until the day previous to Cabiadis' departure. He then told Eichwald that, as he could not obtain any replies to the questions he had put to the inhabitants, the only thing for him to do was to return to Constantinople. On that very day, however, to his utter astonishment, Ivan Haritonoff, whom Cabiadis had been seeking for a whole week, and whom Professors Zuber and Petresco and Dr. Rozsahegyi also had wished to see, sent word to them that he would meet them in Petresco's house. There they examined him, and obtained from him the following statement:

"Mavra Pissareff, aged forty-two, started from Vetlanka for Astrakhan on October 9, 1878, by that morning's steamboat, in order to meet her son, a Cossack, who had returned from Kars. On the same evening, Ivan himself started for Astrakhan, where he went to stay with a friend. Five days after this-that is, on the 14th-he was asked to go and see Mavra, as she was ill. He found her lying in bed, in a small vessel that had come from Nicolskoi with ten passengers, but without any cargo. As Mavra knew the owner of this vessel, she had taken up her residence on board, and had remained there all the time she stayed at Astrakhan. Feeling ill on the third day of her arrival, she sent for Ivan, but only succeeded in seeing him on the fifth day. Ivan, finding her very ill, took her to the church to receive the communion, and then put her on board the steamer which would take her back to her native place, Vetlanka. Ivan positively declared that Mavra had stayed and slept on board the vessel in which he found her, and had not gone on shore anywhere, but that previous to her illness she had received a visit from a Cossack, who had returned from Kars by way of Kuba, Derbent, and Petrofscoe, and who at this moment was living in his native place, Graczewka, twenty-three kilometres from Vetlanka, and who has never been ill."

This same Ivan Haritonoff, however, when examined by Professor Biesiadecky on two occasions previous to Eichwald's arrival, declared to him that Mavra had neither seen anyone nor been visited by anyone at Astrakhan.

According to Ivan, the symptoms from which Mavra had suffered were severe pain in the head and in the hypochondria; she also complained of great pain under the armpit, but he does not know if there was any swelling there, because he did not touch her. A few days later, he returned to Vetlanka, and was told that Mavra was dead. He found her niece, Praskovia Haritonoff, convalescent, and his own brother Makar, Praskovia's husband, very ill, and he died on October 27.

Praskovia Haritonoff and Pelagia Sautin, nieces of Mavra, attended Makar during his illness, and were attacked by the

malady, and gave it to their relatives and to their children; and thus these families all perished, save Makar's sister Onisia and two of his own children. Mavra's family lived in a separate house from her own, and at first escaped the infection; but afterwards two nurses were lodged in this house, and they gave the malady to its inmates, and it destroyed every one of them, including also the nurses. The symptoms of the malady, according to Ivan, were shiverings, fever, headache, pain under the ribs, and in some cases in the armpits and groins; and amongst the members of one family (Belloff's) there occurred also vomiting of blood. He does not know at what period the epidemic was at its height, because he did not go out of his house. He was told, however, that at one time, and during four days, there died more than thirty persons a day. He is certain that all those who came into contact with the sick or with the dead also perished rapidly. The panic was general, and no one went any more to the lazaret. The sisters of mercy who dwelt in that establishment all died. Those also who buried the dead all died. No one could therefore be found to do this office any longer; and such was the consternation amongst the population, that three men had to be brought from Astrakhan specially for the purpose of burying the dead. They put up in the priest's house, who died, as well as his wife and mother; his son, however, and the three grave-diggers lived. If anyone fell ill who had no relatives to look after him, he was invariably abandoned to his fate. If, on the other hand, he possessed a family, he was taken care of by them, but they all perished in consequence. There were no doctors in the place, but only medical assistants (esperti), and these all died. Towards the end of the epidemic, doctors did come at last, but they also all died.

This is the only detailed statement of the outbreak that Dr. Cabiadis was able to get at Vetlanka, notwithstanding that he remained there ten days. At every village which he visited, he was told that Mavra Pissareff came ill from Astrakhan, and that previous to her arrival no one in Vetlanka had spoken either of sickness or of death. According to the church registry, a girl named Evdokia Buharova, aged seventeen years, had died on the same day as Mavra; but she had been suffering for two years from an undetermined chronic malady. The following is Dr. Krassowsky's account of the outbreak::

Dr. Krassowsky arrived at Vetlanka on the evening of December 27 (January 8, 1879). He only saw fourteen patients, and nine of them he characterised as cases of typhus complicated with croupy pneumonia, and he believed that the epidemic had a similar type. He administered to these patients sulphate of quinine, and fancied that it did good; yet, notwithstanding, all of them died. The hygienic measures he recommended were-first, to fumigate the houses with sulphur-fumes, then air them for seven days, and finally sprinkle them with a solution of carbolic acid (10 per cent. strength); the courtyards, the latrines, and the stables to be washed with a solution composed of sulphate of iron, carbolic acid, and water; the dead to be buried in graves two metres deep, and filled up with three alternate layers of lime and earth.

The official documents seen by Dr. Cabiadis consisted of1. The necrological register of the church of Vetlanka for the months of September, October, and November, 1878, and in which the first cases of the epidemic are noted.

2. The register kept by the Municipality (Commune) of Vetlanka of the attacks and deaths that occurred while the epidemic lasted-that is, from October 17 (29), 1878, up to January 13 (25), 1879.

3. The notes left by the late Drs. Morosoff and Gregorieff. 4. The report drawn up by Dr. Döpner, Medical Inspector of the Cossacks, who went on two occasions to visit Vetlanka, viz., on November 18 (30) and December 5 (17), 1878.

5. The official telegrams relating to the epidemic. 1. The necrological registry for September, October, and November, kept at the church of Vetlanka, gives 5 deaths during the month of September, 6 during October, and 19 during November. Thirteen of these last deaths are put down to pernicious fever; all the rest to attacks of diarrhoea, catarrh, and to old age.

2. The Municipality register shows 371 deaths, 357 of which were caused by the epidemic (318 upon natives of the place, and 39 upon strangers). Amongst the strangers who died of the epidemic are noted-a priest, his wife and mother,

three doctors, six assistant medical officers, and two sisters of mercy. The outbreak lasted thirteen weeks. It reached its acme during the ninth week; and the greatest daily number of deaths (viz., 36) occurred on December 16. Only 61 of the persons attacked got well.

3. The notes kept by Drs. Morosoff and Gregorieff (who both died during the outbreak) record 70 cases attended by them in December: 17 of these are put down as typhoid fever, of which 15 died; and 43 are put down as croupy pneumonia, of which 41 died. The other 10 cases (of which 5 were fatal) were put down as-diarrhoea, 2; pleuritic effusion, 1; ulcer, 1; ague, 2; menorrhagia, 3; unspecified, 1. 4. Dr. Döpner telegraphed from Novi-Vremie, on January 21, 1878 (February 2), that at the commencement of the outbreak of Vetlanka, and up to the beginning of November, intermittent fever had prevailed amongst the inhabitants; but afterwards glandular swellings appeared in the armpits and groins. He therefore went to Vetlanka on November 18 (30), and saw there eight patients suffering from mild intermittent and remittent fevers, with suppurating axillary and inguinal glandular swellings. The patients were cheerful, walked about, had a good appetite, and slept well. They had been ill ten to twenty days. All such cases, according to the declarations of the felcer (medical assistant), recovered.

Dr. Döpner had seen, in 1877, at Vorpost, near Astrakhan, forty cases of a similar affection, and fifteen cases at Kazaci-Bogor. Later on, he learned that a malady of a very fatal nature was prevailing at Vetlanka; he therefore again went there in December, and saw twenty-three patients suffering from the following symptoms: headache, aching in the limbs, shiverings and flushes of heat, meteorismus, tumefaction of the liver and spleen, pulse 100 to 120. These symptoms lasted two or three days. In favourable cases, perspiration came on; in unfavourable, the fever recurred, accompanied with delirium, insomnia, and restlessness; the temperature of the body rose to 42° Centigrade; the tongue became dry; the discharges from the bowels became black, and the urine high-coloured and scanty. Death generally supervened during the first or second paroxysm (seldom during a third), and was preceded by a convulsive fit or by great prostration. Out of 100 patients that were taken ill from November 27 to December 9, 43 (sic) died, and only 14 recovered. On December 9 the malady assumed a more severe type: violent palpitations of the heart came on, rendering the pulse imperceptible; vertigo, restlessness, spitting of blood, vomiting of blood, prostration, somnolency, wandering of the mind, suppression of urine, constipation of the bowels, showed themselves. On December 10, petechia began to appear, and the patients exhaled an odour of honey, owing (says Dr. Krassowsky) to their being drenched with honey. Death followed the stage of prostration and that of somnolency (? coma). From December 9 to 14 all who fell ill died.

At the first inspection made by Dr. Döpner, he styled the malady a remittent fever complicated with buboes, such as described by Griesinger. After his second inspection, however, and after keeping a record of ten cases under his own observation, he declared the malady to be a severe malignant fever of the recurrent type; but, from the statement made by the felcer, this recurrent type existed also in the affection which Dr. Döpner had seen on November 18, and which he had named a remittent fever with buboes. Yet Dr. Döpner believed that the one was a consequence of the other, and that the symptoms noted by him authorised him to consider the malady as a malignant typhus, or as Hirsch's Indian plague, or as a new disease, partaking of the characters of both plague and typhus.

5. The official telegrams seen by Dr. Cabiadis were

(a.) A telegram of December 6 (18) from Dr. Döpner, announcing that there were twenty-three persons ill at Vetlanka, and asking that they might be isolated from the rest of the population, and that temporary hospitals might be established in that place.

(b.) A telegram of December 7 (19), from Dr. Kok, announcing that the bubonic fever had ceased, but that since November 23 (December 5) a recurrent fever had begun to prevail at Vetlanka. The malady ran a rapid course, caused great debility, and reached its acme on the third day. In favourable cases, perspiration came on; while in those terminating in death, the paroxysms became more violent, and were accompanied with delirium, high fever, and convulsions. In some cases there was a continual vomiting, and in some

hæmorrhage from the bowels. Death generally supervened after a convulsive fit. This telegram further states that the Cossacks of Vetlanka belonged to the regiment which had returned from the seat of the war; that they had been inspected on their return, as well as all the other soldiers who had come back from Asia, and that they had all been found healthy and free from maladies.

(c.) A telegram from the Ispravnik (local Civil Authority) of Notajefsk, dated on December 12 (24), stating that Dr. Döpner had declared the malady of Vetlanka to be highly contagious.

(d.) A telegram from General Foss to the Government, saying that the recurrent fever had changed into typhus. (e.) A telegram from Dr. Zvigmann (Civil Medical Inspector), declaring that the plague existed at Vetlanka, and asking for the establishment of a cordon, and the isolation of the sick; that in Prischib four women had died who had come from Vetlanka, where they had gone to read prayers to the dead, and that the symptoms shown by them werevertigo, unsteadiness of gait like that of a tipsy person, anxiety and restlessness, fever, thirst, vomiting of blood, rapid loss of strength, apathy; and that these women had apparently arrived from Vetlanka on the 12th (N.S.); two of them had died on the morning, and two on the evening of the 15th, but that no buboes or spots had been observed upon any of them. That, with the exception of these sisters of mercy, and the persons who assisted in burying the dead, all the patients had belonged to one and the same family. And that on the 19th two children of this same family and a nurse had fallen ill with headache, distress in the præcordial region, thirst, and fever.

(f.) A telegram from the Pristoff (Attorney-General) of the first district, dated on the 20th, announcing that the eldest daughter and a nurse (also of the above-named family) had fallen ill.

(g.) A telegram from Döpner and Zvigmann, dated from Einotajefsk on December 15 (27), stating as follows:-In the beginning of November, cases of ague were observed (at Vetlanka), marked by two or three paroxysms of shivering, and succeeded by a hot stage, and by swellings of the inguinal and axillary glands, often ending in suppuration. On November 27 (December 9) this outbreak assumed a new form: the glandular swellings did not appear, but the patients became affected with shiverings, pain in the forehead and temples, vomiting, intense heat, aching in the limbs, giddiness, headache, altered features, injected eyes, nausea, anorexia, furred and dry tongue; in some cases præcordial distress, discharges of blood, insomnia, delirium, and great weakness. These symptoms reached their acme on the third day. In the few cases which terminated favourably, profuse perspiration came on, with an abatement in the frequency of the pulse, and a subsidence of the restlessness; while in those cases which terminated fatally, no perspiration showed itself, but instead, great weakness came on, with dulness, delirium, deafness, burning heat, dryness and whiteness of the tongue, and involuntary movements; and in some instances continual vomiting and purging of blood, and convulsions, or coma, closed the scene. Relapses occurred occasionally in convalescence, and always ended in death. On December 9 (21) the character of the outbreak assumed another type. The general appearance of the patient remained good, but a feeling of distress would suddenly come on, with nausea, vomiting, sanguineous discharges from the bowels, frequency of pulse, palpitation of the heart, and after a few hours intense heat, prostration, and coma. On the 10th, added to the above symptoms, spots of various sizes appeared upon the body, followed by death.

These rapid pathological changes, the failure of every treatment tried, and the infectious and contagious character shown by the malady, led Döpner and Pleanoff to call for quarantine restrictions. In their opinion the outbreak of Vetlanka resembled plague.

(h.) A telegram, dated December 19, from Drs. Morosoff and Gregorieff, addressed to General Foss, saying: -" In the course of our inspection of the stanitza (of Vetlanka) we found fourteen patients; two suffering from diarrhoea, two from pleurisy, two from typhoid, and eight from ague. No plague, however, exists in the place. After the 15th, the severity of the cold increased, and the epidemic diminished considerably.

(i.) A report drawn up by Dr. Gregorieff, declaring that neither he nor Dr. Morosoff had seen any instance of plague,

but only cases of croupy pneumonia. Its symptoms were: headache; shiverings; increased temperature of the body, rising up to 40° Centigrade; acute pains; cough; expectoration of viscous rusty or red sputa; dyspnoea; lividity of the skin; dulness on percussion over the chest; bronchial respiration; bronchophony; rattles in the throat; death, generally within six days of the illness.

(j.) A telegram from General Foss, dated on the 28th, stating that a careful inspection of the sick had given no indication of plague, but had shown the existence of an epidemic outbreak of croupy pneumonia; and adding that the great mortality of these cases arose from the detestable hygienic and dietetic conditions of the people, and that this explained also the infectious character of the outbreak. Quarantine measures were not deemed necessary; but if doubts were entertained as to the nature of the malady, specialists ought to be sent to the seat of the outbreak. This telegram is signed by Nicolski, Gregorieff, Golubeff, and Colonel Pleanoff.

(k.) A telegram from Pleanoff, saying that many persons are ill, and that Krassowsky considers the outbreak as one of croupy pneumonia.

(1.) A telegram from Krassowsky, dated on the 29th, calling the malady typhoid pneumonia, and stating that he had noted also a case with a sore in the groin of long standing.

(m.) Another telegram from Krassowsky, dated on the 31st, announcing a fresh case of pneumonia, one apparently of typhus, one of ague, and two deaths from typhoid pneumonia. He declares, moreover, that up to that moment no case whatever of plague had shown itself.

(n.) A telegram from Krassowsky of January 1 (13) announcing another case of typhus, and three cases of a doubtful character. The Vetlanka malady is declared to be a typhus, frequently complicated with pneumonia. The great mortality is attributed to the bad hygienic and dietetic conditions of the people. More than 300 persons were then ill, and 273 deaths had already occurred.

(o.) A telegram from Krassowsky of January 2 (14) declares that the recent cases of typhus were all derived from infected houses.

(p.) A telegram from Krassowsky of January 4 (16) announces that at Staritzkoi a similar typhus prevailed.

(2.) A telegram from Krassowsky of January 7 (19) announces that Dr. Gregorieff had fallen ill on the 6th; his malady not clearly made out.

(r.) A telegram from Krassowsky of January 10 (22), stating that Gregorieff had died on the 8th, but that no fresh case had occurred.

(s.) A telegram from Krassowsky, also of the 10th (22nd), stating that Dr. Gregorieff's brother, Petroff, had caught cold, had fallen ill on the 9th, and had died on the same night.

(t.) A telegram from Krassowsky of January 14 (26) announces a great many deaths from cold; and that the sister of mercy, Dobbriggina, had died on the previous day of a violent cold.

(u.) A telegram dated January 11 (23), from Dr. Polivanoff to the Minister of the Interior, declares that the epidemic of Vetlanka was undoubtedly one of plague; that from the month of October up to December it was associated with buboes, but that after that period it assumed a pulmonary form.

[Note.-From the tenor of a telegram sent by Colonel Xorstow, it would appear that Dr. Polivanoff had not seen any of the Vetlanka doctors.]

(v.) A summary report, drawn up by Dr. Zvigmann, stating that, notwithstanding the persistence of the epidemic and the uninterrupted presence of medical men at Vetlanka, no detailed and reliable information on the outbreak had yet been given, as fully shown by the tenor of the above telegrams. The statements regarding its contagious nature were vague; the number of deaths which had occurred in each family, and at what period, and under what circumstances, were not mentioned; clinical observations were altogether wanting, as also the precise date of the commencement of the outbreak.

(w.) An announcement from Dr. Kok, stating that only two suspicious cases had occurred at the village of Udatchnoi, one upon a lad thirteen years of age, who fell ill on December 13 (25), with headache and bleeding from the nose, and who died on the 18th (30th), and who had been staying at Vetlanka until the 8th (20th); the other case was that of

[Communicated by Mr. P. T. THANE, House-Physician.] JAMES B., aged fifty-one, a looking-glass silverer, married, was admitted on September 9, 1880, with the following history-In 1848 he became a looking-glass silverer; this occupation he followed for thirteen years, when he became affected with tremors and was in a similar condition to the present. From this attack he perfectly recovered. He then became an engine-driver, and continued as such for three years; and for the following six years he drove a large van. In 1870 he again took to his old work, silvering lookingglasses, and this he has done up to the present attack. He noticed, some six months before admission, that the tremors were again commencing in his hands, and since then they have increased in intensity, so that one week before admission he had to give up his work. He had only noticed that his speech was affected for some two weeks. He stated that his saliva dribbled at times from his mouth, but not so at present.

September 9.-When admitted his temperature was 99°, pulse 66. He was a somewhat emaciated man, complaining of tremors of the hands, of general weakness, and of an affection of his speech. He was quite unable to keep his hands quiet, they being in a continual state of trembling. All voluntary motions, such as putting a spoon to the mouth, were effected by several violent jerks. It was noticed that his right leg and arm were evidently weaker than the left, though he could not grasp well with either. He could not thoroughly articulate his words, bringing out each word very deliberately, and pausing between each. His mouth was in a very dirty condition-teeth brown, gums retracted and slightly blue. Most of his teeth were present and firm in their sockets. Heart and breath sounds normal; urine normal, no trace of mercury to be found in it. Patient was put upon three-grain doses of iodide of potassium, and a fish diet.

The difficulty of speech and the tremors increased until the 15th, when he was observed to be very strange in his manner, and was made to answer questions with great difficulty, and he passed his water under him. Six ounces of port wine were daily given.

On the 16th he became quite unconscious, not knowing his friends, but he rallied towards evening, and in this state he continued for two days, during which time he passed everything under him.

Later

18th.-On the morning of the 18th he became very restless and troublesome, trying to get out of bed, and to catch imaginary objects, and did not recognise anyone around him. Bromide of potassium was given, and repeated with chloral hydrate, but the delirium increased notwithstanding, and a strait waistcoat had to be used to keep him in bed. on one-sixth of a grain of morphia was given hypodermically, after which he quieted down. Fifteen grains of bromide of potassium were now added to the iodide of potassium mixture. He continued in this semi-delirious condition during the next ten days, sometimes being rational and fairly quiet, and at others quite delirious. His speech varied at times, but the tremors gradually increased, so that his pulse frequently could not be counted at the

wrist on account of their intensity. His urine had often to be withdrawn by a catheter, and about this time some cystitis was set up. He was getting very prostrate and depressed.

On October 4 the mixture of iodide and bromide of potassium was discontinued, and one grain of sulphate of quinine and eight minims of dilute hydrochloric acid were given three times a day, and patient was placed upon a full diet, with two eggs, jelly, and beef-tea. He continued the port wine. About this time a small bed-sore formed over sacrum, but this soon healed up. His appetite now improved, and also his general condition, his tremors gradually diminishing and speech returning.

On October 15 he, at his own request, was given double the ordinary amount of meat and eight ounces of port wine daily, and extra bread. He quickly gained strength, his appetite being enormous, and on October 31 was able to sit up in a chair; and by this time he could feed himself, the tremors having diminished. His cystitis gradually passed away, and on November 23 he was able to walk without assistance.

On December 11 he went to Eastbourne, by which time he felt quite well. The tremors were then scarcely perceptible, but slight affection of speech remained.

CASE OF INFANTILE PARALYSIS.

(Under the care of Dr. FINLAY.)

E. B., aged five, was admitted into the Middlesex Hospital on September 9, 1879. Her mother was stated to have died of consumption, and two sisters of croup; the father and three other children being reported healthy. Measles and whooping-cough were the only previous illnesses from which she herself had suffered. Six days before admission, on her endeavouring to get out of bed in the morning, it was found that she could not stand, having lost the use of her legs: she had gone to bed perfectly well on the previous evening. She complained of pain in the arms and legs, the latter especially, and she had some degree of sickness and thirst with impaired appetite and delirium. This was the stepmother's

account.

On admission she was observed to be a fairly well nourished child, with somewhat rickety chest. She lay in bed on her left side with the head thrown back and knees drawn up, crying out if placed on her back, and on any attempt being made to straighten her legs. On being lifted up and placed on her feet her legs seemed perfectly powerless. She complained of pain and tenderness in both legs, which she said she was unable to move; also of pain in the lumbar region, which, however, appeared to be due to a blister the size of a five-shilling piece applied before admission. Control of the sphincters was unimpaired, the urine normal, and the tongue clean and moist. Cutaneous sensibility was unimpaired, if not exaggerated, the muscles flaccid, and their reflex excitability and electrical contractility abolished. Physical examination of the chest and abdomen revealed nothing abnormal. The temperature was 98° and the pulse 100. At first she was put upon a tonic treatment with cod-liver oil, and it was observed that she sweated much during sleep, especially about the head and face.

Four days after admission (September 13) treatment by galvanism was commenced, ten cells of a Leclanché battery being used for the first few days.

The strength of the current was increased to twenty-five cells on September 17, but apparently without effect. On the following day, however, there was certainly some reaction, and the child seemed to feel the current in the left leg; and on the 19th it was felt still more distinctly in the left leg, and slightly also in the right.

On the 20th, rubbing the legs for ten minutes at a time was commenced, being alternated with the galvanism, and it was noticed that she was able to move both legs slightly. For the next three days the strength of the current was reduced to from fifteen to ten cells, more seeming to cause pain. During a month following, the same treatment was pursued steadily, galvanism being applied almost daily and the legs regularly rubbed, and on October 19 it was noted that the child could straighten the left leg perfectly and the right pretty well. She could lie comfortably in any position, and sit up in bed, with her feet resting on a chair by its side, without pain. She was still, however, unable to stand.

For another month there was little change in her con

dition, a somewhat severe intercurrent attack of tonsillitis having taken place; but on November 26 a further improvement was noted in her being able to move the legs more freely.

On December 7 she was able to stand, and even to walk, though with a rather unsteady gait. From this time she continued steadily to improve, being able, during the last three weeks of her stay in hospital, to move about the ward without assistance. She was discharged on January 6, 1880On December 2, 1880, she was brought to the out-patient room for inspection. Her stepmother's report was that for a couple of months after her discharge from the hospital she used to "fall about a great deal," but that she then recovered the use of her legs completely. She can now walk and run perfectly well, the legs being equal in every respect; she has no pain or tenderness, the legs are well nourished, and her general health is good.

Remarks. According to general experience, one of the characteristic features of infantile paralysis is the comparative rarity of absolute recovery: one limb where several have been affected, or one or more groups of muscles in a limb, commonly remaining permanently disabled and undergoing atrophy. The result in the present case was completely satisfactory, and this constitutes probably its chief point of interest. It was a specially favourable case for treatment, in that it came under observation so shortly after the onset of the disease; and it seems not unreasonable to credit the early and persistent treatment by galvanism with a large measure of the success which was obtained.

CHARITABLE BEQUESTS.-The following medical charities benefit under the will of the late Sir Francis Lycett, sworn under £200,000, viz. :-The Hospital for Consumption and Diseases of the Chest, Brompton, £500; the Royal Hospital for Incurables, Putney, £500; the Asylum for Idiots, Earlswood, £500; King's Cross Hospital (?), £500; and the Victoria-park Hospital for Diseases of the Chest, £500; the Royal Free Hospital, Gray's-inn-road, £200; the Cancer Hospital, Brompton, £200; St. Mary's Hospital, Paddington, £100; and the Truss Society, Queen-street, Cheapside, £100.

AFFECTIONS OF THE EYE IN SCORBUTUS.-Dr. Fialkowski, writing from his experience in the ophthalmic department of the Dünsburg Military Hospital, observes. that scorbutic affections of the eye were not of common occurrence, being little more than 3 per cent. The conjunctiva bulbi is the part most frequently attacked, and then the episcleral tissue, the external skin of the eyelids being less often affected, and the cornea still less so. Only one example of choroidal and retinal hyperæmia occurred; while in no instance were the lens and vitreous body affected. The disease of the bulbus conjunctivæ consisted of more or less considerable effusion of blood into its texture, absorption occurring very slowly, and relapse being very frequent, prior to complete absorption being effected. The temporal side was the especial seat of the effusion. Effusion into the episcleral tissue, in which the conjunctiva remained intact, usually took place at the upper part of the bulb, being accompanied by a very tedious episcleritis. The patients complain of severe pains in the ciliary region, which is also excessively sensitive to pressure. In these cases the iris is very hyperemic, but there is no effusion into the anterior chamber. When the eyelids are affected, there is great effusion under the skin, the upper lid being usually only affected. Absorption here, too, is very tedious. The cornea may become implicated during the course of any of the above effusions, always assuming the characters of parenchymatous keratitis, and pursuing a favourable course, in that the ulcerative process is never set up. In scorbutic patients suffering from trachoma, effusion into the conjunctiva palpebrarum frequently occurs, as well as into the trachoma. In these cases the application of sulphate of copper in substance gives rise to excessive irritation of the whole eye, and tannin is a preferable application. Sometimes in these scorbutic patients hemeralopia is present without any pathological condition of the fundus being observable, a slight dilatation of the pupil being, however, remarkable. The prognosis in these affections is favourable. The treatment is expectant and dietetic. In obstinate episcleritis iodine is useful, as is cod-liver oil in hemeralopia.Petersburg Med. Woch, 1880, No. 45.