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published a rejoinder in which he says that the physicalwell-being of the people, their education, the increase of

public wealth, the improvement of the hygienic administra-tion of the country, the inspection and disciplining of indi-viduals dealing with obstetrics, the directing and controllingof the nursing hygiene of infants,-these are some of thethings most urgently required to be done, and as a result ofthem a numerical increase of the population of the countrymay be expected, even if the births do not increase in thesame proportion.Feb. 18th.

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SWITZERLAND.(FROM OUR OWN CORRESPONDENT.)

Successful Removal of a Subdural Tumour of the Spinal -Tract.Dr. 0. Veragut, privat-docent on neurology in Zürich, and

Dr. H. Brnn, surgeon in Lucerne, report on the followinginteresting case in the Korreqpondenzblatt fur SchweizerAerzte of Nov. 20th and Dec. lst, 1910. The patient was aman, aged 32 years, a widower, with one healthy boy,aged 3 years; his wife died from consumption and oneof his brothers from tuberculous hip disease. Four years agohe was under treatment for consumption, but was afterwardsable to continue his work. In December, 1909, he com-

plained of stiffness and pain in the nape of the neck andleft shoulder ; in January, 1910, of numbness of the leftarm which disappeared again, but afterwards the armfelt weaker. Later the right also felt numb and weak.He felt himself growing gradually weaker. At the end ofJanuary a burning sensation was felt in the nape of the neckand a burning sensation round the navel, also drawing pains inthe left leg. The apex of the left lung was retracted and dullto percussion ; catarrhal sounds were heard ; tubercle bacilliin small quantities were found in the sputum. The patientheld his head forward in a stiff manner ; on rotation he com-plained of pain. Pressure on the head and spine was pain-less. Roentgen ray pictures showed a normal condition.There was hypsesthesia over the left shoulder. Passive move-ments of the left thumb and fingers were not perceivedif the patient shut his eyes ; he could not distinguishsmall objects placed in his left hand. There was con-

traction of the pectoral and teretes muscles. Abduction ofthe left arm was deficient ; adduction with the elbow bent wasless energetic than on the right side. Spontaneous fibrillarymovement was seen in the deltoid and triceps muscles.The muscular power of the upper arm was considerablydiminished. Spontaneous flexion and extension of the armat the elbow-joint were executed very incompletely and withdifficulty. The left leg trembled in the standing positionand there was slight spasm in walking. The faradic and

galvanic reaction of deficient muscles was normal. The

triceps reflex on the left side was increased, as were also theperiosteal and tendon reflexes. Slight pressure in the lacertusfibrosus of the upper arm on the left side caused rotatoryclonus (clonic rotatory contractions) which ceased with thepressure. This clonus could only be produced in half-abductionof the upper arm and rectangular flexion of the elbow. The

patellar reflexes on both sides were increased and there wasclonic foot spasm. The Babinski sign and Oppenheim signwere present on the left side only. A diagnosis of tumour inthe spinal cord : compressing it at the level of the fourthcervical segment was made. The examination of fivecubic centimetres of cerebro-spinal fluid proved negative.(Hygiene Institute of Zurich : Professor Silberschmid.) ByFeb. 17th hypassthesia over the left shoulder was morecomplete. There was reduced sensitiveness of the wholeright side :from the fourth cervical segment downward, butno feeling of vibration (tuning fork), except in the shoulderon the right side. On the left side this was present, and wasonly absent round the patella and on the shoulder. Astereo-gnosis was total on the left side, partial on the right.The left arm could only be moved at the finger-joints.Passive movements were resisted. The right arm had lesspower. The left leg could only be slightly moved at the hip andknee. The power of the right leg was reduced. The patientwalked like a case of spastic hemiplegia. Shortness ofbreath, due to paresis of the left phrenic nerve, was present,corroborated by Roentgen ray examination ; respirations 27per minute. As regards the left arm, the triceps, periosteal,

and tendon reflexes were increased. The rotatory clonicspasm supervened in every position of the arm, and on slightpressure, also on tickling the left foot. The Babinski signwas present on both sides, and Oppenheim’s sign only on theleft side. The cremasteric reflex was present on the right side.The abdominal reflexes had disappeared. By Feb. 18th theleft arm was totally anaesthetic. A diagnosis of a localisedmeningitis was excluded by the normal condition of the

cerebro-spinal fluid. The slow progress of symptoms pointedto a growth of intradural but extra-medullary position,probably a sarcoma or fibro-sarcoma. On Feb. 18th, 1910,under ether narcosis, an operation was performed. Thethird and fourth spinous processes were removed and theIamina3 resected. Haemorrhage was successfully treatedby compression. The dura mater was normal, not thickened,and the subdural cavity was empty. No pulsation of the cordwas seen. No tumour. The medulla was slightly thickenedover the third segment. Slight injection of the blood-vesselsof the pia mater was present. Palpation revealed a greaterresistance, pointing to circumscribed intra-medullary tumour.The pia mater was incised and there appeared a smallspot 2 millimetres in circumference, the yellow colour ofwhich contrasted with the white nerve substance. A smalltumour of the shape of a hazel-nut was peeled outof the medulla like the yelk out of a hard-boiled egg.Scarcely any hæmorrhage occurred. The medulla began topulsate again. The pia was replaced and the dura carefullysutured with silk. Catgut sutures of soft parts were used andthe wound was drained. The tumour weighed 1¼ grammes;= 20 grains. Dimensions, 17 mm. by 11-5 mm. by 9’5 mm.Professor Schmid, of the Pathological Institute of Ziirichifound it to be a solitary tubercle with thick elastic

capsule. The patient breathed much more freely on recover-ing from narcosis. After eight hours feeling returnedslowly in the left shoulder and arm. The gradual recovery wasindicated in the original paper by tabulated reports andnumerous diagrams. The patient was discharged on the’fifty-sixth day after the operation and began work as a tele-phone operator. On June 26th he walked four miles as wellas a healthy subject, and could lift a chair with his leftarm. Slight differences of sensibility in the hand stillexisted.Feb. 18th.

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NOTES FROM CHINA.(FROM OUR OWN CORRESPONDENT.)

Pneumonic and Septicæmio Plague Epidemic.SINCE my last letter events with regard to the spread of

this epidemic have marched rapidly, and you will doubtlesshave read many telegraphic reports in the lay papers. As faras medical records go this epidemic differs in several par-ticulars from previous plague outbreaks-e.g., in its influenza-like infectiousness, its invariably fatal issue, its types, andits incidence. At the present moment it is accounting for 500deaths daily, and there is no evidence that it is in any wayabating.

History of the epidemic.-The first signs of plague occurredin the mountainous north-west region of the province ofManchuria. It is said to have originated among the trappersof the tarabagan, a small marmot-like rodent, the fur ofwhich is exported to Europe through the station ofManchuria on the Trans-Siberian line. In the summer

months the Chinese population of this district, which amountsnormally to about 3000, is augmented by some 50,000. Ina report of Nov. 24th last it was stated that up to that time300 persons had been afflicted with plague, not a single oneof whom had recovered. It is said that the precautionary andantiplague measures adopted, in the first instance, by theRussian authorities at Manchuria station were of an indifferentorder. Be that as it may, by the time the epidemic spreadto Harbin the Russians had become alive to the situationand have since done all that was possible. A perusal of thevarious reports gives ample ground for saying that if theChinese officials had fallen in with the active measures pro-posed by the Russians at Harbin the epidemic most probablywould have been limited to North Manchuria. But theChinese prefect (who has since been cashiered) showed him-self obstructive and lax to a degree, refusing assistance tothe authorities, and allowing the Chinese of the now

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thoroughly infected district to use the south bound railway.Fu-Chia-Tien, the Chinatown of Harbin, speedily became ahotbed of plague, and the absence of all restrictions in theway of segregation and quarantine has been followed by thesteady spread of the epidemic southwards along the railway.From Changchun it spread to Mukden, and from theresouth-east to Dalny and south-west to Shan-hai-Kuan, whereit passed through the Great Wall into China. Yung-ping-fu,a country town a short distance south of Shan-hai-Kuan (theportal of the Great Wall), became infected, and cases haveoccurred at Tientsin and Peking. From Tientsin it spreaddown another railway into the heart of the province ofShantung; and from Peking the infection spread by thePeking-Hankow railway S.S.W. to Paoting-fu and Lung-hua-Tien, on the way to Mid-China. By steamers and nativetraffic infection was carried across the Gulf of Chihli toChefoo. And now it remains to be seen if it will maintainits virulence till it reaches the humid zone of Mid-China,with all its teeming millions of people. Up to the time ofwriting the spread in Tientsin and Peking, two large cities,has been very slow, being limited in each to a mere handfulof cases, the contacts from one infection.

Character of the epidemic. -Although Chinese figures indi-cate a certain number of recoveries, all the information givenby foreign medical men on the spot points to a mortality of 100per cent. Rats and fleas do not come into the question aspropagators; there has been no noticeable mortality amongthe former. The transmission has been, like influenza, fromman to man, and by direct contact with excretions, or indi-rectly through the air by the breath and moist particles afew yards round the patient. The majority (about 90 percent.) of the cases have been of the pneumonic variety, therest septicasmic plague. The following extract from a letterto me from Dr. W. H. Graham Aspland, now on plague duty atHarbin, gives an idea of the conditions there: " Daily mor-tality during past week 160 ; about 40 to 60 die in ourhospitals, the remainder picked up by our sanitary men inthe streets. In the Russian quarter 40 to 50 deaths daily.Duration of disease after becoming suspects is 2 hours to2 days. All pneumonic and septicsemic cases with tempera-ture 104° are found going about the streets and declare theyhave no sickness. Three hours after they are dead. It is

simply incredible. Such a condition of life and death isunparalleled in its severity." Except for the deaths of twoEuropean medical men and 25 Russians at Harbin (out of apopulation of 30,000 Russians) the epidemic has been confinedto the Chinese coolie classes. So far not a single death hasbeen noted among the Japanese, of whom there are thousandsin Manchuria, many living among the Chinese under verysimilar conditions-the only difference being that they are a cleaner race. In Fu-Chia-Tien-Chinese Harbin-the reduc- tion in population, according to Chinese official estimates, from plague and departures in consequence of it, is from 40,000 to 15,000. It is impossible for anyone to give figures or say Iwhat dimensions the epidemic has assumed, owing to the native habit of concealment, against which the plague Iofficials are unable to fight and before which all attempts at obtaining reliable statistics fail lamentably. The mortalityrate may be taken at 99-100 per cent.

Local conditions.-Owing to severe cold in Manchuria thepopulace remain indoors as much as possible, and in smallunventilated rooms which are usually overcrowded. At

night they sleep in rows on k’angs "-raised mud platformsoccupying from three- to four-fifths of the sleeping-room.Wrapping themselves in dirty furs and wadded coverlets,four to six people lie together in a confined, close atmospherethat most Europeans would find insupportable. The sanitaryconditions of towns in Manchuria are notoriously bad,and the soil is impregnated with filth and unremoved

garbage.Manner of spread.-This is mainly due to the railway

(the Imperial Railway of North China). Though the neces-sary quarantine and inspection measures were not put intoforce till many people had come through from the infectedarea, the railway traffic may now be said to be under propersupervision. Foreign medical men are in charge of all the mainstations, and by order of the Prince Regent all traffic hasbeen entirely suspended from Mukden in Central Manchuriato the Great Wall. But this has been only a part of thebattle. Finding the trains stopped, the Chinese took to theroad. Manchuria is invaded every year by thousands ofcoolies and agricultural labourers from the large provinces of

Shantung and Chihli, who go north to earn the high wagesprevalent there. With the approach of the Chinese New Yearthey return in legions, keen to be home for their great annualfestival. They will go through fire and water to get back,and it is to such that practically all the cases south of theGreat Wall are due. If stopped travelling by train, theytramp the distance by roads-on which no adequate pre.cautions against infection have been taken-and nothingshort of the most drastic measures will keep them back. To

prevent this flood of coolies pouring into Dairen, the portfrom which they cross into Shantung, the Japanese havestretched a military cordon across the neck of the peninsulaby Kiuchow, and are threatening to strengthen this cordonwith a live (electric) wire fence.

In the beginning of January the Imperial Government sentDr. J. G. Gibb of the Union Medical College to help Dr. GnohLean Tuck at Harbin (to whom I referred in my last letter).Shortly after this Dr. Mesny, the French medical man, becameinfected while visiting the Russian Hospital and died two dayslater from pneumonic plague. Since then Dr. Aspland and Dr.J. M. Stenhouse, also of the Union Medical College, have goneup on behalf of the Imperial Government and have been doingall they can to fight the epidemic. At every station downthe line medical missionaries have come forward in the mostgallant way and borne the brunt in combating the mostappalling conditions. At Mukden Dr. A. F. Jackson, of theScotch Presbyterian Mission, has succumbed to plague, as wellas three trained Chinese medical men. The medical professionat the present moment, by these sacrifices and by the number ofwilling volunteer practitioners, stands higher in the estimationof the Chinese Government than it ever did before. Thestruggle has been almost entirely in the hands of medical mis.sionaries. If it were not for them China would have to meetthis epidemic with a few foreign-trained Chinese medical menof little experience, and lacking in the necessary foresight forpreventive measures. The Central Government has beenfortunate in having an able and enlightened official at thehead of plague affairs. The Honourable Saoke A. Sze (anAmerican M.A.) has from the beginning taken a wide viewof the whole question, and if only his orders had been carriedout by local officials it is probable that many lives would havebeen spared. Mr. Sze has concerted with foreign medical men,followed their advice, and by dint of hard work has gotquarantine stations established and much preventive workput in hand. The local officials in Manchuria have not onlyremained apathetic and indifferent but have consistentlymaintained their dislike and disregard of anything savouringof foreign intervention, even though obviously in their owninterests. The Chinese Government has acceded to the

request of the Russian Government to appoint an internationalcommission of plague experts from certain Powers. It isdoubtful if there are any experts available who can comewith an experience gained from similar epidemics, for thelocal conditions differ very much from those of bubonic

plague. No doubt such a commission will be of value later,but for the present there is dire need of foreign medical menat the various stricken towns. The Government offers alllocal travelling expenses, 300 taels a month (a tael isworth 2s. 9d.), and an indemnity in case of death of10,000 taels, to any medical man who may volunteer to

help.lnoculation.-It is too early yet to give figures of the value

of Haffkine’s prophylactic vaccine. I am at present endeavour-ing to gather information on this point. Medical advices fromHarbin have not spoken favourably of Yersin’s serum, thoughthey incline to think favourably of Haffkine’s vaccine. Thereis ample scope for bacteriological work, as it is increasinglyfelt that the difference in type of the epidemic from thoserecorded elsewhere calls for the manufacture of vaccine onthe spot from the local bacillus.Peking, Jan. 30th.

ROYAL SOCIETY OF MEDICINE: BALNEOLOGICALAND CLIMATOLOGICAL SECTION.-After the meeting of theection on Wednesday next, as announced in the weeklyliary of events, the members will dine together at 7 P.M. at’agani’s Restaurant, Great Portland-street, W. The chargeor the dinner is 3s. 6d., and members may bring theirriends. Dr. A. Manuel, 14, Clarges-street, Mayfair, Jondon, W., would be glad to receive names of those

ntending to dine.