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in about 33 per cent. they were absent or appreciably diminished in numbers in the heart blood and spleen. On a consideration of these facts the question suggests itself does the serum act as a bactericide or as a bacterioloytic agent? Is the absence, or the diminution in number, of the bacilli to be attributed to the action of the serum? I am aware that in estimating numbers in this manner objection may be taken on the ground that the method is not rigidly scientific. I grant that. It is however difficult, if not impossible, to reckon in any other way, and at all events whatever the error may be it is uniform. On the whole I strongly incline to the opinion that the serum is effective in the direction of destroying the Plague bacilli within the body, as their absence from the heart blood in about 50 per cent. of the cases shews. Why then does it not meet with more success when applied as a means of treatment? The reason probably is that cases of Plague do not come under treatment early enough, are not in point of fact diagnosed early enough. In consequence the poison is poured out rapidly from the bacteria and penetrating into the system closely and widely gets out of range of the serum, which is only a bactericide and not an antitoxin, and hence has very little effect, if any, upon the course of the disease. I think however that if the treatment of a case were to be undertaken sufficiently early, or on the other hand if the constitu- tion of the serum could be suitably modified the effect of its action would be probably more successful Acting upon these ideas it is my intention to again. use the serum when opportunity occurs. (It is right I should add that the serum which I used had been kept in the Colony for some time, and that some of it came via Suez-two circumstances which may have combined to impair its efficiency to some extent).
Reviewing the treatment of Plague, and considering as well other methods which have been applied from time to time I fear it is impossible to avoid the con- clusion that up to the present we have discovered nothing that is really effective, nothing that can rank as a specific in the same way as the Diphtheria Antitoxin. The use of Carbolic acid in heroic doses was not conspicuously successful, and I consider we have sufficient grounds to revise the favourable impression which was formed of it the previous year. The only effective means of treatment we can adopt is to keep up the strength of the patient and at the same time watch the action of the heart and guard against its weakness and failure. Should we be able, by so doing, to tide over a sufficient period of time, the effect produced by the in- intensity of the poison will be reacted against and ultimately overcome by the for- mations of antitoxin in the blood, and then the system will be enabled to resist the infection and go on to recovery. Four cases of Plague were admitted which had passed the critical stage of the disease without having been treated. They did not require much treatment in hospital beyond that which I have sketched above, and they ultimately recovered. Until we can discover an anti body, our treatment cannot be anything but expectant and symptomatic, and above all we should refrain from interfering with or thwarting the processes of nature."
Thus, being impotent as regards treatment, it behoves us to be most careful. in preventing the development and spread of Plague. The consideration of the means is out of place in this Report but I might summarise concisely what is re- quired to this end-Elbow Room, Fresh Air, and Sunlight.
CLINICAL NOTES.
The maturation of the Bubo.-I have found in some cases that when the bubo, if it was a solitary one, matured and opened spontaneously and discharged freely, the prognosis was much more favourable and the patient generally recover- ed. In three such cases 1 found no Plague bacilli in the discharges (although they had been present in the blood), but there were crowds of Staphylococci: in another case the pus was sterile. The Plague bacilli in such cases seem to dis- appear, but whether this disappearance is caused by the local leucocytosis I am unable to say.
At any rate the discharging bubo seems to act as a sort of destruc- tive agency for them, and as consequence the active secretion of the poison must be proportionately modified. Acting upon this idea I endeavoured to imitate the process of Nature, and when suitable cases occurred the bubo was assiduously fomented with hot sublimate solution, and if it matured was opened. Two cases treated like this recovered, many did not. It may be urged that it is only in mild cases that solitary buboes are present for I found it convenient to treat in this manner only those cases in which solitary buboes were present. But the number of buboes is not always in proportion to the degree of infection, and as Nature has given the hint, it is worth working on those lines.