blood during the paroxysm, and the detection of lithic acid in excess in that fluid, is always a pathognomonic and reliable symptom. It is unfortunately, however, one difficult of application, and in a majority of cases not available. The valuable researches referred to, supported as they are by a multitude of pathological data previously and since recorded, have, however, enabled us to place this symptom in the foremost rank in reference to the diagnosis. 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. You will note that we by no means require absolute proof of the presence of lithate of soda at any given time, or in any given case. If you have succeeded in making yourself and others believe that certain symptoms are essentially connected with a state of health which usually has for its result the excessive production and depositing of this salt, then you have succeeded in convincing yourself that those symptoms are in essential nature gouty. Perhaps not in one case in twenty in which we diagnose gout do we prove lithate of soda, but we ground our opinion upon the close resemblance of the symptoms to those in other cases in which lithates were demonstrably present. And mark again, I by no means join with those who regard the presence of lithate of soda as the true beginning of gout, or even as an essential phenomenon. It is only one of many concomitant results of a special state of the system-special as regards inherited organisation, as regards digestion, assimilation, and excretion, but it is one so definite and so frequently present that it may be very suitably selected as the characteristic on which to base a conventional name. I have already implied, and shall assert more explicitly soon, that I regard the attempt to separate rheumatic gout from true gout by an abrupt line as a violence to sound pathological doctrine. It is very desirable, further, that you should not narrow your conceptions of the meaning of this important word. It is incorrect to say of any man "he has got the gout," in the same sense that we should say "he has got syphilis," "he has caught the measles." There does not exist any such abstraction as "the gout," or perhaps I ought to say there is no such entity. A man may become gouty-that is, his assimilation may have been slowly changed, and all his tissues modified in character, so that they may be liable to inflammations of the gouty type,-but he cannot receive into his system de novo the malady "gout," for the simple reason that no such entity exists. I repeat that a clear conception on this point is essential, for unless you have it you will never make due allowance for the modifications which the gouty diathesis is so prone to undergo. It is precisely because it has been built up as the slow result of numerous complicated and prolonged influences that no two cases are precisely alike, that although the well-marked examples of it are very peculiar and utterly beyond all dispute, there are others, the recognition of which will task to the utmost the skill and insight of the physician. Nothing is easier in the cases I refer to than for equally well-informed and candid observers to become involved in an interminable war of words. lect, then, that our definition of gout is a conventional one, and that it applies to the better-marked states of system which are susceptible of the most multifarious complications and of endless modifications in degree. Thus it is quite fair, quite consistent with probable truth, to say of any given case, This is not gout, but it is closely allied to it-a phrase which, in the instance of a syphilitic malady, would be simply nonsense.

Recol

Having thus attempted to define the class of maladies which we may properly call gouty, we will now turn to the subject of chronic rheumatism or rheumatic gout. This malady, like true gout, has long been recognised, and many have been the debates as to what name it ought to receive. It presents even greater varieties as to form and severity than gout itself, and hence many discrepancies in authors respecting it. We will again endeavour to take pathological results as the basis of our definition. The results of rheumatic gout to the joints affected are very peculiar. There is no deposit of lithates, but there is change in all the textures of which the joint is composed. The synovial membrane thickens, and its fringes become developed, from which pedunculated or loose cartilages at length result. The ligaments soften and stretch, and the cartilage becomes fibrous

and splits up or wears away. But whilst these changes are going on in the soft parts, yet more characteristic and permanent ones are happening in the ends of the bones themselves. These, in mild cases, have rows of little nodosities: developed on the line of junction between periosteum and cartilage, whilst in more severe ones these nodosities become confluent, and constitute projecting lips, often of very considerable size. In the worst cases all the ends of the bones. alter remarkably in form, and become expanded to twice their original size. In some cases there is great expansion, with but little evidence of wearing away; in others the bone ėburnates instead of expanding, and retains its form, but becomes polished and fluted by friction. In aggravated cases. great crippling and great deformity is the result, and hence one of the names by which this disease is known on the Continent-arthritis deformans. But here let me raise protest that it is not every case of rheumatic gout which is deforming-not the majority, rather a small minority,. and those chiefly in patients who are elderly. Rheumatic gout is a very common malady, far more common than true gout, and if, before we pronounce on its existence, we wait for the manifestation of visible deformity, we shall miss the diagnosis of all the milder cases. I have often taken occasion in this theatre to warn you against. the too common mistake of selecting for study and for record only the most exaggerated and intense forms of a malady. Endless are the misconceptions which have resulted from this error, and few subjects have suffered more from it. than the one under consideration. If every subject of the gouty diathesis would be kind enough to carry about specks. of chalk in his ears, the recognition of gout would be easy enough; and in like manner we could easily tell rheumatic gout if all its subjects had their limbs crippled and deformed. But it is not so, and in each instance we are, in a majority of cases, thrown upon our ingenuity for the discovery of other and less obvious guides to the knowledge of our patient's real state.

Of the peculiarities presented by joints which have suffered from rheumatic gout, two stand out before all others in their value as means of diagnosis-I allude to the dry grating caused by the removal of cartilage, and the development of lips. We may venture to assign the chief place to the second of these, for it is the one which is earliest to be found. Grating is never present excepting at an advanced stage, and although very characteristic then, its value becomes, of course, much limited by that fact. Nodosities and lips, on the contrary, are amongst the very earliest of the products. of this malady, and are often, indeed, present before the patient is aware that he has had any inflammation in the joint concerned. Nor have we, so far as I know, any reason to think that they occur to any characteristic extent in association with any other causes. (a) On the contrary, I believe that their diagnostic value is as great in rheumatic gout as is that of chalk concretions in true gout. Our differential definition of rheumatic gout may then, I think, be based on these peculiarities, and we may say that any form of joint disease which tends to the production of lip-like outgrowths at the margins of the cartilages has a claim to be placed in this category. I have already hinted that there are many varieties, some of them probably of considerable clinical importance, which are grouped under this head, and that in a certain large group, occurring in patients under middle age, whilst removal of cartilage is common, outgrowths of bone are rare, and if present usually small.

For the last few years I have been in the habit of using these outgrowths for the purpose of diagnosis in a somewhat novel way. I had often been struck by the remarkable pro-minence of these rheumatic lips on the condyles of the femur in museum specimens, and it occurred to me that they ought to be perceptible during life. I examined the knees of a few patients who had the disease in an advanced stage, and found that I could detect them very easily. Afterwards, with some practice, I found that I could appreciate their presence even in comparatively early stages, and also that they are frequently present when the patient has no external deformity whatever. By degrees, and after the examination and comparison of a great number of patients, I have come to rely (a) I have just seen a case somewhat exceptional to this statement. A young woman under the care of my colleague, Mr. McCarthy, had her limb amputated on account of a myeloid tumour in the tibia. She had never been rheumatic, but there were present small lips on the edges of the condyles. No doubt the joint-changes had been induced by the proximity of the tumour.

with much confidence on this symptom. If you wish to employ it successfully you must first practise carefully on healthy joints. In many, if not in most, there is a ridge at the part referred to, more or less resembling the pathological lip. The distinction between health and disease can only be acquired by practice. In examining a knee I prefer to place myself in front of my patient, and to employ both hands at once. I place the finger-tips of one hand flatly over the edges of the one condyle, and those of the other on the opposite, and then direct him to bend and extend the joint slowly several times in succession. In this way you may find the edges and appreciate their elevation without risk of error. I much prefer to use the fingers flatly at first, and not to employ their tips, as I think there is less risk of error in estimating elevation; but afterwards I use the tips in order to determine whether the lip overhangs. In wellmarked cases it curls outwards.

These condyloid crests, as I have already observed, are not to be expected in all cases. As a general rule they are present only in those who have passed middle life. You must not expect to find them in the young. In the latter absorption of cartilage without osseous outgrowth is the rule. In the aged, however, these crests are invaluable as symptoms. I have very often recognised them in cases in which the patients were not aware that the knees had ever suffered. I have often been able by their aid to say which knee had suffered most frequently, and have found the patient's statement confirm my inference. The symptom is of especial use in those cases in which we are consulted, not on account of joint affections, but for iritis, or lumbago, or a skin disease which we suspect to be of arthritic origin.

I have hitherto said little or nothing as to clinical peculiarities of rheumatic gout, beyond a hint that they are by no means the same in all cases. I intend in a subsequent lecture to consider them in detail, but for my present purpose I must here give a short sketch in order to contrast them with those of gout. In many cases rheumatic gout begins insidiously, the patient being simply liable to attacks of aching in one or more joints. It affects large and small joints almost indiscriminately. It is remarkably prone to produce synovial effusion. Almost all cases of so-called hydrops articuli belong to it. Unlike gout, and unlike acute rheumatism, it but rarely causes redness of the skin, and the shiny surface and oedematous pitting are scarcely ever present. Its paroxysms are often prolonged or of indefinite duration, but in some cases, contrary to the general belief, I must assert that they are as short and definite as those of gout itself. In other cases-and these are those more nearly allied to rheumatism than to gout-the first attack sets in severely and affects many joints. In these, instead of getting well at the end of a month or five weeks, as acute rheumatism is in duty bound to do, the disease lapses into a chronic form, and the patient may perhaps become an invalid for the remainder of his life. Still, even in these persistent cases there are generally observed remissions and paroxysmal recurrences. The pain which attends rheumatic arthritis never rises to that extreme severity which characterises gout, but it is often bad enough.

Rheumatic gout presents great difficulties as to diagnosis in two different directions: there are cases which the physician can scarcely tell from acute rheumatism; there are others, and very different ones, which it is almost impossible to distinguish from true gout. My own belief is that in each of these instances the difficulties are insuperable, for the simple reason that the maladies in question do really merge into each other, and that the features characteristic of each exist in union.

On the third great subdivision of the arthritic family I shall not now speak. It is that of rheumatic fever or acute rheumatism.

Here then, gentlemen, to recapitulate, we have glanced at the three large subdivisions of the arthritic family; we have seen that gout is peculiar in having deposits of lithate of soda, rheumatic gout in having in the young ulceration of cartilage, and in the old absorption of cartilage with outgrowths of bone, and acute rheumatism in having synovitis without permanent articular changes, and in being very prone to damage the heart. Our next question is, Are these three maladies really related or not, and if so, to what do they owe their individual peculiarities? Let me insist that it is a question of relationship merely, not of identity. No one denies that there are most important differences between

the three-differences which it is wise and convenient to recognise by distinctive names. Still, however, the question of relationship remains a most important one. I may here conveniently admit to you, as, indeed, I have perhaps already done, that all three depend upon the same diathesis or constitutional state, and that their differences are due to the varying conditions as regards age, sex, temperament, habits of diet, exposure to climate, etc., to which the possessors of this diathesis are exposed. You will easily, I think, see that it is of great practical importance to answer this question correctly. If relationship be admitted, there is little doubt that our opinions as to the treatment of each will receive some modification. It is not, however, as regards the principles of treatment that most is to be anticipated, for the differences between the three when in actual existence are quite sufficient, however they may have been acquired, to make it probable that great differences in treatment will be necessary. As regards prevention, as regards the general management of health in those in whom the diathesis is as yet latent, or in those who are known to be descended from arthritic subjects, much more may be expected. Very probably we may find that the same general measures which prevent the one will also ward off attacks of the other. There are also other important and common maladies respecting which our notions will be much cleared if we can decide whether there does or does not really exist an arthritic diathesis which is the common parent of gout, rheumatism, and their allies. I allude to such maladies as brow-ague, lumbago, sciatica, recurrent iritis, gonorrhoeal rheumatism, and certain skin diseases. In trying to ascertain whether any one of these is really dependent upon an arthritic diathesis, we are at once met with the difficultyWhat constitutes proof of that diathesis? If one patient with recurrent iritis tells me that his mother was crippled with "rheumatic gout," but never had "gout," and another that his grandfather was a martyr to "chalk-stone gout," how am I to interpret the facts ? Am I to say that the two histories, referring to totally distinct maladies, help me not at all to an explanation of the iritis, or am I entitled to assume that in both the facts imply the existence in the family of the arthritic tendency? Such questions meet us every day in practice, and the advice which we give our patients is based upon the opinions respecting them which we chance to hold. I need say no more to enforce upon you the importance of the investigation which I propose to commence.

We must next ask, How shall such a question be set at rest? On what data can we determine the relationship or non-relationship of any given maladies? On this point I must confess I have not been able to find much information in the works which I have consulted. Although the question has been much debated and with great ability, yet I cannot help thinking that it has never been stated with sufficient precision. The proofs of relationship between any two given diseases must be of the same character as those by which we should prove alliance of any species in animals, and first among them stands, Are they the offspring of a common parentage? First cousins or even brothers may be of very different aspect; but prove their descent, and you prove their relationship. In respect to gout and rheumatic gout, it appears to me that physicians have been far too much concerned with the examination of differences, and have almost forgotten to ask, Are they not producible by the same causes and influenced by the same circumstances? I fully admit that the investigation of the cause of these maladies is surrounded with difficulty, but nevertheless much has been, and much more may yet be, effected, not only by the critical investigation of individual patients, but by ascertaining whether any given races, or any given climates or occupations, are particularly prone to produce them. If, for example, it be found that gout and rheumatic gout prevail in excess always in company,-that the same race, the same climate, the same sex, and similar ranks in society, are liable to both,-the inference as to identity of cause would become strong. Then, again, we have data of great value derivable from the history of hereditary transmission. If I succeed in making it probable that gout and rheumatic gout prevail in the same families, and that of the children of a gouty father some suffer from rheumatism and others from true gout, I feel sure that your inference from the fact will be that it is probable that the diathesis is the same, and that it derives its peculiarities in each instance from some other special conditions in each sufferer-sex, temperament, etc.

Thirdly, we have the test of hybridism. Is it possible to mix up gout and rheumatic gout together, or rheumatic gout and true rheumatism, so that the characteristic features of the two shall be blended? Of course it is very possible for two quite distinct maladies to prevail by mere chance in the same person at the same time; but if we find that this admixture is common-that it is, in fact, the rule rather than the exception-then, I think, most will agree that such easy blending is strongly in favour of prior relationship.

ORIGINAL COMMUNICATIONS.

THE PLAGUE IN RUSSIA.

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

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

THE following paper is a summary of a report addressed by Dr. Giovanni Cabiadis to the Constantinople Board of Health on the outbreak which occurred in the province of Astrakhan, in Russia, between the middle of October, 1878, and the end of January, 1879. It was read before the Epidemiological Society, November 3, 1880.

Dr. Cabiadis begins his report with a topographical description of the localities where the epidemic occurred. All the places seen by him along the banks of the Volga, from Tzaritzyn to Astrakhan, were very much alike; and what struck him most (at first) was the width and straightness of the thoroughfares. The dwellings in which the natives live are mere wooden huts, and hardly any of them are supplied with latrines; rich and poor, all inhabit buildings of the same size and style, and the largest hut does not contain more than three rooms, and the loftiest room does not exceed 268 centimetres in height. Adjoining the hut there is a spacious yard to hold cows, sheep, goats, pigs, dogs, horses, and poultry, and which serves at the same time as a latrine. Three or four of these huts are usually built round the same courtyard, but each hut is inhabited by a separate family. The huts occupied by the needy classes are very small and low-roofed. Little holes pierced through their sides serve for windows, and admit a faint light, but they are hermetically closed up in winter in order to keep out the cold. The people live in a filthy state, and the air they breathe in their close habitations is stifling and sickening. The soil is alluvial and damp, and the climate marked by extreme ranges of temperature. In winter the thermometer falls to at least 15° below Réaumur's zero; whilst in summer it rises to 37° above it. The natives are of middle stature, and not particularly robust; their skin is of a tawny hue, and their mental faculties are devoid of intelligence. They occupy themselves partly with agriculture and the rearing of cattle, but chiefly with fishing. Attached to nearly every village will be found the "wattaga," or shed containing pits for curing and storing away salt-fish. The stench that arises from these pits is such that, excepting to those accustomed to their noxious odour, it is beyond the power of human endurance to remain within the sheds for more than a few minutes. The above details give an idea of the dirty and insalutary conditions in which the inhabitants of those regions exist. The indigent classes subsist on vegetable food consisting principally of a soup called "borsci," composed of rice cooked with salted cabbage, and to which fish is sometimes added. The wealthier classes occasionally feed on meat and articles prepared from milk (such as butter, cheese, curds, etc.), but in general they prefer sending these articles to other places for sale, and limiting their own diet to fresh or salted fish.

ACCOUNT OF THE OUTBREAK.

When Dr. Cabiadis visited the localities smitten by the outbreak, the malady had already ceased; he had no opportunity, therefore, of examining patients affected with it, and was obliged to gather his information from statements given him by the inhabitants, by the Russian authorities, and by the medical practitioners. Dr. Cabiadis left Constantinople on February 5, and arrived at Tzaritzyn on the 14th. There he found General Count Loris Melikoff, to whom he gave the

letter of introduction he had brought with him from the Russian Ambassador at Constantinople. After reading it, Count Loris Melikoff informed him that the outbreak had already ceased, and that for the last nineteen days no fresh case of it had appeared anywhere. He then inquired what Dr. Cabiadis' opinion might be with regard to the malady which had prevailed at Kars during the war. Cabiadis replied that as he was at that time at Bagdad he could not know what was occurring at Kars. Loris Melikoff then rejoined that he was not alluding to the maladies which might have existed amongst the inhabitants and Turkish garrison at Kars, but to the epidemic which prevailed in the Russian army. To this remark Cabiadis replied that in fact he had heard of an outbreak of typhus having prevailed amongst the Russian soldiers, and he had no doubt but that his Excellency had received an account of it from the Russian medical officers. Loris Melikoff added that in fact the Russian doctors had given a description of this malady, and had characterised it as typhus, but that he was convinced it was the plague.

He now proposed to Cabiadis that he should take a few days' rest before proceeding to the smitten districts, and sent him with an orderly to Professor Eichwald, the Russian medical delegate and superintendent of the medical staff. After several fruitless attempts made to obtain an interview with this officer, both on that and on the following day, Cabiadis finally succeeded in finding him in the afternoon of the third day, and met, at the same time, Professor Hirsch, of Berlin, the German delegate. These two gentlemen put many questions to him concerning the plague that had appeared in Mesopotamia, and more especially made inquiries as to the type the outbreak had assumed, and as to the precautions taken by Dr. Cabiadis in order to protect himself against its infection. Eichwald then told Cabiadis that, as all the delegates were anxious to proceed as soon as possible to the scene of the late outbreak, and as there was not a sufficient number of horses for them all, he would have to wait a few days; but Cabiadis having expressed his earnest desire to start as soon as possible, Eichwald consented to take him along with him and Hirsch next day, February 16. Lack of horses, however, compelled Eichwald and Hirsch, at last, to proceed without him, and Cabiadis was therefore obliged to wait until the 17th, and left Tzaritzyn in company with Dr. Scinighiroff and Dr. Sophia Bestoujewa, Eichwald's assistants, and arrived on the same day at Sarepta (a German colony, thirty kilometres distant from Tzaritzyn), where they spent the night. Next morning, after a ride of two kilometres, they reached one of the lazaret stations of the sanitary cordon enclosing the whole province of Astrakhan. This lazaret consisted of three small huts intended for the performance of quarantine of those persons that came from places within the cordon, but who had not undergone the quarantine at Vyassowka. Vyassowka is ninety kilometres distant from this Lazaret, and is the quarantine station for the inner cordon, which embraced the infected localities, and was intended to protect the districts on the northern line of the outbreak. This station consisted of two huts, each containing two rooms for the reception of persons put into quarantine. Besides these, there was a hut of one room for the disinfection of clothing, and another hut for the medical examination of the persons arriving there.

On February 19, after a journey of twenty-six kilometres from Vyassowka, Dr. Cabiadis reached Staritzkoi, a village lying on the right bank of the Volga, four kilometres distant from the river, and one hundred kilometres from Vetlanka, the principal seat of the outbreak. Staritzkoi contains

a population of 2000 souls, and at the time of the outbreak of Vetlanka nine attacks of plague occurred in this village, all of them fatal. The following is the account given of these attacks to Cabiadis by the " Kehya" or prefect, and by the sergeant of the police force :-" Ulvana. Aksenova Tazkova, a woman sixty years of age, went to Vetlanka on December 9, during the prevalence of the epidemic, in order to read prayers over the dead previous to their burial. She returned to Staritzkoi on December 15, fell sick, and died within twenty-four hours. The symptoms presented by her malady were-intense headache, pain in the hypochondria, and thirst. There were seven persons living in the house at the time Ulvana fell ill and died; but after her death, two of her relatives came to stay with them, in order to wash her corpse previous to its burial. A female

friend, who had been suffering a long time from cancer of the lip, also came to the house to take a farewell view of her. All these people died, one after the other, within ten days, except two children who escaped unaffected. All manifested during their illness the same symptoms as those shown by Ulvana; but one of them also vomited blood. It is uncertain whether glandular swellings presented themselves upon any of these cases. The shortest period within which death supervened, from the commencement of the attack, was twenty-four hours; and the longest, four days. On the occurrence of the first two deaths in this house, the inhabitants of the village became alarmed at the circumstance, and removed the rest of the family, and the two women who had come to wash Ulvana's body, into two houses 'away from the village; but soon after, the family came back to its own house, and more deaths having occurred in it, all the surviving members were carried back to the isolated houses where they had previously been put, and there died, except the two children who escaped the malady, and are still living. The woman, however, who was affected with cancer of the lip, returned to her own home, went to bed, and died within two days." Dr. Cabiadis and Professor Eichwald visited the localities where these houses had stood; for the houses themselves had been burnt down in consequence of the occurrence of plague in them: they also visited the cemetery where these people had been buried. Dr. Rutkofski, who was sent to Staritzkoi by the Russian Government on the occasion of the outbreak, arrived there on January 1, after the first four deaths had already occurred. He stopped there until February 9, and was succeeded by Dr. Krüdner. According to Dr. Rutkofski's statement, Ulvana Aksenova did not go to Vetlanka for the mere purpose of reading prayers over the dead, but also upon commercial business, and brought back with her two parcels containing stuffs from Turkey, which she intended to sell in her native place. Professor Eichwald, therefore, basing his belief on this statement, attributes the outbreak of plague in the village of Staritzkoi to the stuffs said to have been brought from Turkey, setting aside, apparently, the fact that Ulvana was taken ill immediately after her return from Vetlanka, where plague was raging at the time.

On February 20, Dr. Cabiadis left Staritzkoi for Tchernyjar, a village of 6000 inhabitants, twenty-five kilometres distant from Staritzkoi. Tchernyjar was not affected by the malady. Next day (the 21st) he went on to Nicolskoi, a village on the right bank of the Volga, containing 1500 inhabitants, and twenty-five kilometres distant from Vetlanka. Two attacks, supposed to have been plague, occurred in this village. The following is the account given of them by a police-sergeant to Cabiadis:-" Pavloa, a woman seventy-two years old, who had arrived from Vetlanka on December 22, fell ill, and died within twenty-four hours. After her death her relatives abandoned the house for thirty days, then fumigated it, and afterwards returned to it. Maskina, a woman thirty-nine years old, without ever having quitted Nicolskoi, fell ill on December 26, and died on the following day. She had no direct intercourse with Pavloa, but her two children assisted at Pavloa's funeral. After Maskina's death, her husband and the two children were put into quarantine in the lazaret for thirty days." According to the account given to Professor Biesiadecky (the Austro-Hungarian delegate), Pavloa had started for Vet lanka ten days before her death, but was unable to get to that place in consequence of being stopped by the cordon sanitaire; she therefore returned to Nicolskoi, but was refused admittance under the impression that she had gone to Vetlanka. She was accordingly stripped of her clothes, and washed with cold water while the temperature of the air stood at 12° under Réaumur's zero (5° Fahrenheit), and then sent to Prischib, fifteen kilometres distant, and put into a solitary hut outside the village. From this place she fled, and returned to her own home, suffering from cough and difficult breathing. Notwithstanding her illness, her daughter, through fear of the police and of the inhabitants, hid her amongst the pigs. On the third day she became much worse, and died on December 23 -that is, on the seventh day of her illness.

From this place Cabiadis went on to Prischib, a village of 1500 inhabitants, ten kilometres distant from Nicolskoi, and fifteen from the Volga. Here he again met Professor Eichwald and the Russian Commissioners sent there to estimate the value of the houses which had been visited by the plague, in order that they might be destroyed by fire

and the owners indemnified for their loss. Dr. Cabiadis here remarks that before leaving Constantinople he had read in the public newspapers that whole villages had been burnt down by the Government in order to get rid of the pestilential germs; but on arriving at those very places he found that this had not been done, and that the only houses which had really been destroyed were the three houses at Staritzkoi already mentioned by him, and that these had only been burned down two days previous to his arrival there. In Prischib there occurred sixteen cases of plague, all of them fatal. Dr. Cabiadis classes these cases into three groups:

First Group.-Arina Effrimoff, a woman twenty years of age, native of Vetlanka, but living with her husband in Prischib, went to see her relatives in Vetlanka on the occasion of the death of her aunt, named Matrona. She stayed at Vetlanka from November 30 until December 3. On returning to Prischib she fell ill on the 5th, and died on the 11th of that month. Through fear of catching the disease, no one could be found to bury the body; her husband was therefore obliged to perform this painful duty himself, assisted by his younger brother, named Nicola. This family consisted of nine persons, eight of whom died. Four fell ill on the 14th, one of them dying on the 16th, and the other three on the 17th; on the 19th another fell ill, and died on the 21st; on the 20th two more of the family fell ill-one died on the 23rd, and the other on the 24th. Thus within thirteen days all the members of this family perished except an old woman named Russanova, who ran away.

Second Group.-This group consists of four women, three of them sisters of mercy, and the other their servant. All of them died of the plague. The sisters of mercy went to Vetlanka during the epidemic for the purpose of reading prayers over the dead. They remained there six days, and returned to Prischib on December 8. On the 12th all of them fell ill at the same time; one died on the 15th, two died on the 16th, and the fourth died on the 18th of that month.

Third Group.-This consisted of four strong, healthy men, chosen by lot to perform the duty of burying the dead. They lived close to the abode of the aforenamed sisters of mercy. One of them, named Ivan Petroff, seeing that one of the sisters (Poliakova) was ill, and had nobody to attend on her, went to her on the 15th, fell ill on the 18th, died on the 19th, and was buried by his companions. One of these was taken ill on the 20th, and died on the 23rd; the two others fell ill on the 22nd, and died on the 24th of December. The plague, therefore, lasted in Prischib from December 5 to 24, and destroyed sixteen persons. The symptoms manifested by them were tremor, constipation of the bowels, bilious vomiting, coma, heat of the head; in some cases high fever, cough, and headache, and in one case vomiting of blood. The bodies of the sisters of mercy and of their servant turned black.

On inquiry being made by Dr. Cabiadis, whether buboes had been noticed upon any of these cases, he was told that the patients were too ill to call attention to this indication, had it existed, and no one dared handle their persons from fear of catching the malady. These details were furnished to Dr. Cabiadis by the sergeant of police, in the presence of Mr. Constantine Lebedoff, Councillor of State, and President of the Commission appointed to estimate the cost of destroying the houses infected by the plague. They tally exactly with the information obtained by Professor Biesiadecky from the old woman Russanova in so far as relates to her own family, and with that obtained from the local authorities and from a Cossack with reference to the rest. Professor Eichwald, however, holds to the following story related to him by the curate of Prischib, who, it is said, found upon the altar of his church an old crumpled dress made of the Persian stuff called " cannauss." The curate did not know at the time to whom the dress belonged, but was afterwards told by the mother of Poliakova (one of the sisters of mercy) that her daughter had brought it from Vetlanka, and had put it herself upon the altar. On hearing this, he removed the dress with great precaution from the altar, and burnt it. Professor Eichwald imagines, therefore, that this dress, although manufactured in Persia, must have come from Turkey, and must have brought with it the germs of the plague. But, granting that it had really come from Vetlanka, and been brought

by one of the sisters of mercy, what need is there of, attributing their illness to the dress, seeing that they themselves had been in Vetlanka at the very moment when plague was raging in that place?

On February 21, Dr. Cabiadis left Prischib, and arrived at Vetlanka. Vetlanka is a stanitza or Cossack settlement, situated upon one of the most elevated spots on the right bank of the Volga. It is therefore less damp than many other places in that district, and yet, notwithstanding, it has been decimated by the epidemic. Previous to the outbreak its population amounted to 1700 souls, but when Cabiadis visited it there were only 1300. These were all Cossacks, and administered their own affairs themselves, the Russian Government interfering only when called upon to do so. Fish is the sole produce of the place, and as the river is frozen during six months of the year, the poverty of these people may easily be imagined, from the fact that they have to sustain themselves during twelve months with the gains they obtain during the six months they are able to work. Hence they frequently find themselves deprived of all means of existence, and the Russian Government is then obliged to make an allowance to each family of from three to five roubles, according to the number of persons composing it. This pittance affords about eleven centimes per diem, at the utmost, to each individual. Fish is not taxed at all, and the village possesses a large "wattaga" or shed for preparing and salting it. The climate, dwellings, and streets of Vetlanka are such as have already been described with regard to the other villages in the district of the Volga; vegetation, however, is here very scanty. Dr. Cabiadis thinks that it must have been from Vetlanka that the plague was transmitted to Prischib and to Staritzkoi, as well as to the villages of Michaelowka and Selitrenoi on the left bank of the Volga.

On arriving at Vetlanka, Dr. Cabiadis met there Professors Eichwald, Hirsch, Petresco (the Roumanian delegate), and Biesiadecky (the Austrian delegate). On the 22nd, Count Orloff Denisoff, the acting Governor of Vetlanka, called a meeting of all the delegates at his residence, in order to comply with Count Loris Melikoff's wishes that they should forward him a collective telegram expressing their opinion as to the nature of the outbreak which had manifested itself in that country. There were present at this meeting-Count Orloff Denisoff, the acting Governor of Vetlanka; M. Pissaref, the Red Cross delegate; Professor Eichwald, the Russian delegate; Professor Hirsch, the German delegate; Professor Biesiadecky, the Austrian delegate; Professor Petresco, the Roumanian delegate, and his assistant, Dr. Protopapesco; Dr. Krassowsky, the Russian medical officer stationed at Vetlanka after the first week in January, 1879; and Dr. Cabiadis, the Ottoman delegate. During the discussion which ensued, Professor Biesiadecky remarked that the result of the inquiries made by him at Vetlanka showed that buboes had also been noticed amongst the manifestations of the epidemic. To this remark Professor Eichwald observed that what Count Loris Melikoff wanted to know was the name to be given to the outbreak. To this Dr. Cabiadis replied, that from the information obtained by him while at Staritzkoi and at Prischib, the contagious and fatal character of the outbreak was manifest, and its propensity of attacking and destroying successively, within a few days, all the members of a family, while sparing at the same time their neighbours and the inhabitants of the place in general, shows it to have been one of true bubonic plague-a malady which he had carefully studied, on two occasions, during two epidemics at Bagdad. His convictions were, moreover, strengthened by Professor Biesiadecky's declaration that buboes had actually been noticed on the patients attacked by the epidemic. All the other delegates seconded this opinion, and it was therefore officially announced that the outbreak which had shown itself in the province of Astrakhan, from the middle of October, 1878, to the end of January, 1879, was one of bubonic plague.

Professor Eichwald then said that their mission ought not to be limited to this simple announcement, but that it ought also to endeavour to trace the source of the outbreak. Historical facts, he added, showed that all the previous outbreaks of plague in Russia had their origin in the two neighbouring states-Turkey and Persia. There could not be a doubt, therefore, that the late

outbreak came also from Bagdad, and was brought by the troops sent up to Kars from that province at a time when the plague was raging there. The Russian Government had in consequence protested against such a step, foreseeing the danger which would menace all Europe if this dreadful scourge were imported into Russia. In support of his argument, he read a long report drawn up by Professor Pelikan, President of the Medical Council of St. Petersburg, and proposed that the delegates should affix their signatures to this paper, so that the European Governments, basing their opinion upon this document, might compel Turkey and Persia to adopt efficacious hygienic measures to extinguish the sources of that scourge in their countries. He added that such efforts ought to be made in the name of humanity, in order to give them greater weight and render them more useful to all. But if, on the other hand, the Commission were to decline sanctioning Pelikan's report, its assembling there for the mere purpose of declaring that the outbreak had been one of plague would lead to no practical results.

Professor Hirsch praised Pelikan's report, and seconded Professor Eichwald's proposal, saying that he was convinced of the truth of his arguments, and that in his writings he had himself attributed a similar origin to the. plague. He even took up the pen and was on the point of putting his name to the paper, when Dr. Cabiadis expressed his astonishment that, without having sifted the matter properly, and without even having given time to the Commission to inquire into the details of the malady of Vetlanka (Biesiadecky excepted, who had been there three days), they wished to attribute its outbreak to an importation from Turkey. He further added, that in the month of May, 1878-that is, at a time when plague had ceased entirely in Mesopotamia-he had been ordered by the Constantinople Board of Health to proceed from Musseyeb (a station on the Euphrates, near Bagdad) to Salahié (another station on the Euphrates, on the road into Kurdistan), and there put into quarantine the regiment of cavalry which was to go from Bagdad to Kars to take part in the hostilities against Russia. He therefore protested against the idea of this Astrakhan plague having been imported from Turkey.

Professor Biesiadecky took the same view as Cabiadis, and declared that they could not sign Pelikan's report, seeing that the facts elicited up to that moment did not in any way confirm the supposition that this outbreak had come from Turkey; that they ought therefore to follow up the inquiry, and visit Astrakhan, from whence it is said that Mavra Pissareff had gone to Vetlanka ill with the disease, and had given it to Vetlanka. On the results of such inquiry only could the Commission give an opinion as to the origin of the outbreak, provided even then that the facts acquired by them justified their doing so. Professor Petresco seconded Dr. Cabiadis' and Biesiadecky's views, and Professor Eichwald therefore withdrew Pelikan's paper. This discussion having come to a close, M. Orloff Denisoff drew up the following telegram, which was signed by all the members of the Commission, and sent to General Count Loris Melikoff :

"Sur l'invitation du Gouvernement Russe d'exprimer leur avis, les soussignés déclarent que la maladie observée dans le Gouvernement d'Astrakhan depuis la mois Octobre, 1878 (vieux style), jusqu'à la fin de Janvier, 1879, était une épidémie de peste revêtant la forme qu'on désigne vulgairement du nom de peste levantine bubonique. Les soussignés croient devoir se réserver d'exprimer leur opinion sur l'importation de la maladie jusqu'à ce que des recherches ultérieures aient fourni des données précises. L'épidémie doit être considérée comme éteinte, vu que depuis le 28 Janvier il n'a été noté aucun cas de maladie, ou de mort. On ne peut, pourtant, donner une garantie sûre que la maladie ne puisse reparaître dans une ou plusieurs des localités qui ont été atteintes, et spécialement à Vetlanka, qui a été cruellement ravagée. Dans les circonstances actuelles, les soussignés croient pourvir recommander les mésures suivantes, proposées par le Professeur Eichwald:

"1. Surveillance médicale prolongée des lieux suspects. "2. Maintien des cordons sanitaires, qui entourent chacun des lieux envahis jusqu'à l'écoulement du terme légale de six semaines.

"3. Prolongation du cordon général entourant toutes les