difficult to explain the incidence of a certain animal disease, especially the explosive septicemias, in any other way. It is difficult, for instance, to conceive the colon bacillus as acquiring pathogenic or invasive properties by a saprophytic life in the intestinal tract of man without at the same time inducing immunity in the race. It is not so difficult to conceive of colon bacilli living in such an environment in the intestinal tract of certain animals as to acquire at the same time pathogenic properties towards man. Thus micrc-organisms causing acute disease are out of place, or else endeavoring to create a new habitat. Disease itself is a temporary disturbance of relatiorship, largely accidental at first, but tending to become permanent as a form of parasitism."

Following out this idea with the chicken cholera bacillus, we have a germ known to be pathogenic to the lower animals; producing, when inoculated into such animals, an enlargement of the neighboring lymphatics, followed by death from a rapidly produced toxemia. It requires no stretch of imagination to consider this the germ causing, in these sporadic cases of supposed bubonic plague, the deaths credited to the pest bacillus.

When a bacteriologist has made a positive diagnosis, the pathologist is interested to know if the organs present the appearance usual in such disease. We have inspected the bodies in two cases reported to be plague after the autopsy had been made. These were supposed to be of the pneumonic variety. The lungs were left in situ, presenting a somewhat congested appearance, but there was no enlargement of the bronchial glands. No protocols have been dictated during the autopsies, nor have sections been prepared from the organs. This is unfortunate as it diminishes the value of the bacteriologist's report.

The clinician considers the clinical history of the living patient to be of paramount importance in making a positive diagnosis, but here again there is nothing to be obtained. In not one case can a clinical history be obtained that resembles in any way that of true bubonic plague.

All the evidence so far presented to prove a diagnosis of plague, may be summed up in the microscopical appearance of the bacillus, and the fact that the micrc-organism is pathogenic to the lower animals.

.

THE ALLEGED EXISTENCE OF PLAGUE IN SAN

FRANCISCO.

By H. D'ARCY POWER, M. D.,

Lecturer on Medicine, College of Physicians and Surgeons of San Francisco. In determining the existence or non-existence of a given disease in an individual, it may be stated, in a general way, that verification is dependent on the agreement of the clinical history with the pathological conditions as determined by autopsy; and, in case of diseases of known microbic origin, the discovery and verification of the invading organism. Furthermore, it may be stated without hesitation, that of these three factors the indications afforded by the first two greatly outweigh any deductions to be made from the third. Without wishing in any way to detract from the importance and progress of bacteriology, it is, nevertheless, clear that contention and uncertainty are found among its ablest exponents. Be it the difference between the bacillus of lepra and tuberculosis, of the B. colicommune and the B. typhosus, or of the various bacilli said to cause bubonic plague, it is evident that agreement is not yet reached, and until it is, the making of a diagnosis on purely bacteriological data is not permissible. Nor can the clinician or pathologist separately claim an absolute judgment. While it is true that the clipician often resigns his patient to the pathologist in fear and trembling, not knowing how his antemortem diagnosis may fare on the autopsy table, nevertheless, the pathologist has no exemption from error. With the exception of a few gross and necessary fatal lesions, such as a clot in the brain, or a perforation of the intestine, pathological conditions are usually mixed; and only in the light of the clinical history can we decide on the immediate cause of death.

These considerations are all important in determining whether or not bubonic plague has, or has not, existed in San Francisco. According to the local Board of Health, we are supposed to have had plague in this city since the beginning of March. My acquaintance with the sanitary conditions in the district said to be infected, and with alleged cases of plague, dates from the 30th of May, when, with Drs. Hodghead and Pillsbury, I was commissioned to make an independent investigation. I propose to state briefly the results from a clinical standpoint. Possessing the confidence of the Chinese (who were specifically instructed by their Consul-General and their leading merchants

to bring all cases of sickness to our notice), I am persuaded that all deaths and cases of serious sickness occurring between the 30th of May and this 21st day of June, have been brought to our attention. During that period I have seen thirty-one cases, of which thirteen were dead or have died.

The population of Chinatown varies at different seasons between 15,000 and 30,000; accepting for the present time the lower of these figures, we have a monthly sickness of one to two hundred and fifty people. A remarkably low record, only exceeded in this respect by the paucity of deaths. If all disease be due to pathogenic organisms, it would appear as though they also had participated in the plague scare.

Now as to the diseases with which these people suffered. Of the thirty-one cases, no less than thirteen were well marked tuberculosis, ten of the usual pulmonary type, one of the intestines, one peritoneal, and one miliary. Add four cases of pneumonia and bronchitis, and we have fourteen cases of pulmonary disease, exclusive of two others claimed by the Board of Health as pneumonic plague. Of the thirteen dead seven, or 61 per cent, were tubercular without dispute. My reason for advancing these figures is this: in the Journal of the American Medical Association, May 19th, Dr. Kellogg, the City Bacteriologist, contended that as in January and February the Chinese mortality from pulmonary disease greatly exceeded the Caucasian, therefore, "we are justified in the suspicion that some of these cases were plague." To-day, with an abnormally low death rate, and with every care in diagnosis and post-mortem investigation, the death rate from pulmonary and tubercular disease is higher than when Dr. Kellogg felt justified in having suspicions. The fact is, that anyone with the smallest experience of Chinese health and sanitation, is well aware of their addiction to these diseases. Some of these deaths were announced as suspect, though neither I nor my colleagues were able to find the slightest ground for suspicion.

During this period three of the cases were claimed as undoubted plague. Of these, the first was enclosed in lime before we had an opportunity to examine it, and our request to do so was refused by the Board of Health. Concerning the cause of death in this case I have no means of forming an opinion.

The second case was that of Chew Yeu Gam, a Chinese "doctor," whose body I was called to examine some three hours

1

after death. It was stated that he had been ailing for two years, confined to his room for five days, and had died without wit nesses. The latter circumstance appears to be common with the Chinese, who keep no strict watch over their sick. As this case had rectal temperature above normal and showed slight enlargement of left inguinal and right cervical glands, I reported it to the Board of Health, and arranged with their agents to be present at the autopsy on the morrow. In the mean time the Board of Health passed an order excluding myself and colleagues from the quarantined district. This order was set aside by the court on the Monday, but in the intervening day an autopsy was made and we were deprived of the opportunity of forming an opinion concerning the cause of death as revealed by the morbid anatomy. Dr. Pillsbury, however, obtained portions of the inguinal and cervical glands, and from his report and that of Dr. Mouser, I am assured that the diagnosis of plague could not be deduced from the bacteriological evidence.

The third case of alleged plague was that of a Chinaman who died outside the quarantine district, and at whose autopsy I was present. As in all these so-called plague cases, the subject had not been observed alive, and the scant clinical history obtainable from the Chinese was not that of plague; nor was there anything in the post-mortem appearances to suggest this disease. The abdominal organs were anæmic rather than hypersemic, the glands normal, and little to account for death beyond a hypostatic congestion of the lungs.

Kitasato, describing pneumonic plague, says that the lungs are studded" with foci of broncho-pneumonia surrounded by a zone of congested tissue," and Balzaroff, writing last year in the Annals of the Pasteur Institute, points out that the surface of such lungs are studded with what he calls pseudo-tubercles. No such conditions were present in this case, nor were the bronchial glands enlarged. While the glandular system is not necessarily involved in pneumonic plague, it is scarcely possible that the bronchial glands could escape. I understand that this case was claimed as plague on bacteriological evidence. On the other hand, Dr. Pillsbury, who took specimens, declares that the bacillus present was the pneumococcus, and not the B. pestis. Be this as it may, I hold that the lack of clinical history and of recognized post-mortem conditions are sufficient grounds to reject the diagnosis of plague. I have, therefore, not found a

case in the past twenty-three days that can with any probability be claimed as undoubted plague.

The experience gained by these investigations naturally provokes the question as to whether there has ever been a case of plague in San Francisco. If, in the cases of which we have knowledge, conclusions were reached on such a small basis of evidence, what assurance have we that the earlier cases were more wisely tested? If the City Bacteriologist felt justified in suspecting plague because more Chinese than whites died of pulmonary lesions, may not his other suspicions rest on as fallacious a foundation? Again, it is not a little curious that none of these eleven cases were seen alive. Is the desire to die unattended one of the new symptoms of plague? Furthermore, how many of the bubonic type had well developed buboes? How many of the so-called pneumonic cases had discrete lobular inflammation and enlarged bronchial glands? Dr. Hoffmann, of Honolulu, who, I believe, in that town, performed autopsies on two hundred bodies, including seventy cases of plague, assured me that in the bubonic form the periglandular tissues are always deeply infiltrated before death, and that in pneumonic cases the bronchial glands are invariably enlarged, though not necessarily to a great extent. Are they atypical? Two-three might be—but ELEVEN? It answers itself.

Now note the next wonder: Eleven cases in more than three months, all in old inhabitants, and many separated in time by more than the average incubation period. Was the incubation period also atypical? It is strange! Then where did they come from? It has never been suggested that any two stood in an etiological relationship; they neither lived together nor met, so far as we know. Whence came their infection? From eleven other plague cases? Then what became of these? From merchandise? Is there any history of these eleven having used any article from a common source, and that a plague spot? If so, it is not in evidence. Nor do our difficulties end here; the eleven discrete cases have in no instance infected a relative, friend or attendant, and that under conditions that favor contagion. We are lost in wonders. Eleven cases; none seen alive; all atypical; all independent and without a suggested origin; all caught from somewhere, but not themselves contagious. If under these circumstances an ordinary physician dependent on nothing better than common sense and