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You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: Plague - Its Cause and the Manner of its Extension--Its Menace--Its - Control and Suppression--Its Diagnosis and Treatment - -Author: Thomas Wright Jackson - -Contributor: Otto Schöbl - -Release Date: October 12, 2013 [EBook #43942] - -Language: English - -Character set encoding: ISO-8859-1 - -*** START OF THIS PROJECT GUTENBERG EBOOK PLAGUE *** - - - - -Produced by Chris Curnow, Sandra Eder and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - - - - - - Transcriber's note: - - Text in italics is marked with _ underscore, text in small caps - changed to ALL CAPS. Illustrations were moved to paragraph breaks. - The index is sorted by page numbers within the alphabetical groups. - This has been retained. Footnotes were moved to the end of the - corresponding paragraph. In the Latin1 file, oe/Oe was used for the - unicode oe-ligature. A list of corrections made can be found at the - end of the book. - - - - - PLAGUE - - - - - PLAGUE - - ITS CAUSE AND THE MANNER OF ITS - EXTENSION--ITS MENACE--ITS CONTROL AND - SUPPRESSION--ITS DIAGNOSIS AND TREATMENT - - BY - THOMAS WRIGHT JACKSON, M.D. - - MEMBER AMERICAN RED CROSS SANITARY COMMISSION TO SERBIA, 1915; LATELY - CAPTAIN AND ASSISTANT SURGEON, U. S. VOLUNTEERS; LATELY LECTURER ON - TROPICAL DISEASES, JEFFERSON MEDICAL COLLEGE; MEMBER OF MANILA - MEDICAL SOCIETY AND PHILIPPINE ISLANDS MEDICAL ASSOCIATION; - AUTHOR OF A TEXT BOOK ON TROPICAL MEDICINE; DIRECTOR, - DEPARTMENT OF SANITATION AND EPIDEMIOLOGY - FOR H. K. MULFORD COMPANY - - WITH BACTERIOLOGIC OBSERVATIONS - - BY - DR. OTTO SCHÖBL - - BUREAU OF SCIENCE, MANILA - - _ILLUSTRATED_ - - PRESS OF - J. B. LIPPINCOTT COMPANY - - - - - COPYRIGHT, 1916 - BY THOMAS WRIGHT JACKSON, M.D. - - - - - - THIS BOOK IS DEDICATED BY THE AUTHOR TO - - DR. ALDO CASTELLANI - - REGIUS PROFESSOR OF TROPICAL DISEASES, UNIVERSITY OF NAPLES. - EMINENT IN MEDICAL RESEARCH, MY FRIEND, COLLEAGUE AND COMRADE - DURING STRENUOUS DAYS IN SERBIA. - - - - - - CONTENTS - - - PAGE - - INTRODUCTION 11 - - CHAPTER I - - ITS HISTORY AND ITS EXTENSION 19 - - History of Plague--The Widespread Dissemination of Plague in - Recent Years--The Appearance of Plague in Porto Rico, New - Orleans and Manila. - - CHAPTER II - - THE CAUSE AND THE MENACE OF PLAGUE 28 - - Causation of the Disease and its Mode of Conveyance--Types of - Plague--Chronic Plague and Immunity in Rats--Flea Conveyance of - Plague Bacilli--The Stability of Virulence of Plague - Bacilli--Summary of Facts Concerning the Cause and Manner of - Extension of Plague. - - CHAPTER III - - ITS CONTROL AND SUPPRESSION 40 - - Plague Prevention by Extermination of Rats--General Uselessness - of the Rat and Its Enormous Destructiveness, with Details of - Trapping and Other Extermination Methods--The Manila Epidemic, - 1912-1914--The First Cases--Unusual Character of Plague Cases at - Quarantine--Clinical Description of Two Cases at - Quarantine--Inauguration of the Manila Epidemic--Directed to - Take Charge of Plague Suppression in Manila--Plague Fighting - Organization--Method of Rat Proofing and Rat - Destruction--Correspondence Between Dr. Jackson and Dr. Heiser, - Director of Public Health--Observations on Fleas and Their - Habits--Conditions of Habitations in Manila Favoring Rat - Multiplication and Spread of Plague--Comparative Statistics on - Methods of Catching Rats--The Natural Enemies of the - Flea--Zoölogic Classification of Rats--A Collection of Notes - Concerning Rat Runs, Rat Nests, Multiple House Infections and - Other Data--Sample of Detailed Orders Issued Regarding Rat - Extermination--Method of Procedure of Collecting and Forwarding - Rats Suspected of Plague Infection to Laboratory--Memoranda in - Plague Cases--Letter of Warning and Appeal for - Coöperation--Bacteriologic Observations made During the Manila - Plague Epidemic, by Dr. Otto Schöbl--Notes Concerning the - Bubonic Plague in Hong Kong, by Dr. David Roberg. - - CHAPTER IV - - ITS DIAGNOSIS AND TREATMENT 165 - - Biologic Diagnosis--Necessity for Trained - Bacteriologist--Bacteriologic Procedure--Non-Biologic - Diagnosis--Symptomatology--Pathologic Considerations--Treatment, - Conditions and Prognosis--Serum Treatment--Symptomatic - Treatment--Statistical Studies in Mortality--Dosage and - Technique of Serum Administration--Prophylactic Serum and - Anaphylaxis--Plague Vaccines. - - - - - ILLUSTRATIONS - - - PAGE - - RAT-PROOF STRUCTURE 48 - CLEANING AND RAT-PROOFING IN BASEMENT 69 - BAMBOO HOUSE SUPPORTS NOT SEALED WITH CEMENT 86 - MATERIALS MUST BE MOVED ABOUT IN THE SEARCH FOR RATS 93 - A RAT-INFESTED PLAGUE INTERIOR 95 - PROGRESSIVE POST-MORTEM CHANGES IN RAT CADAVERS 105 - PLAGUE HOUSE 116 - BAMBOO HOUSE SUPPORTS SEALED WITH CEMENT 119 - VIEW OF HOUSE WHERE INFECTED RATS WERE FOUND 120 - ANIMAL HOUSE 144 - - - - - PLAGUE - - ITS CAUSE AND THE MANNER OF ITS EXTENSION--ITS MENACE--ITS - CONTROL AND SUPPRESSION--ITS DIAGNOSIS AND TREATMENT - - - - - INTRODUCTION - - -The question of the need for new books upon medical topics must ever -remain undecided, by general agreement, in the medical profession. - -There is no such thing in medical literature as an insistent demand -from the profession for new volumes upon old topics. - -Authors need not hope, therefore, to create the impression that they -are meeting long-felt though unexpressed wants of medical readers in -launching new books. - -On the other hand, the creator of a new volume upon an old subject -should seek justification for literary paternity in the progressive -changes in the status of our knowledge of disease, its causes, -prevention, and cure. Such changes are admittedly going on with a -certain degree of constancy and at such a rate of frequency that new -presentations of old themes, are both justified and desirable from time -to time. - -With this idea in mind and with the desire to present, in useful and -practical form, a work which shall contain at least some unhackneyed -material and which shall represent modern studies and a record of -actual control work done in this justly-dreaded disease, the following -pages are submitted to the medical profession and to sanitarians -generally. - -With a profound respect for the laboratory worker and his work and with -a profound conviction that to him belongs the greater measure of credit -for real accomplishment in connection with plague up to the present -time, I desire to insist that the true utility of knowledge gained -within laboratory walls lies in its intelligent application in the -outer world and that ofttimes this application must be made by men who -are themselves without extended laboratory training. An appreciation of -principles--with an intelligent ability to accept, to appropriate, to -apply and, most of all, to refrain from entering without due -preparation the domain of the laboratory worker--is an indispensable -requisite in the equipment of the practical sanitarian, upon whom must -fall the responsibilities of success or failure in combating the -disease we are now to consider. - -During the past fourteen years it has been my privilege to observe two -epidemics of plague in the Philippine Islands. Some of these -observations were made in the capacity of a military medical officer, -but my later observations, upon which this report and study are chiefly -based, were made from the view-point of a civil health officer. At -different times I have been called upon to deal with the disease both -as sanitary officer and clinician, and from October, 1912, to July, -1914, I had charge of all plague suppressive measures in Manila. In -1914 I was also in charge, as acting chief, of the San Lazaro Hospitals -Division of the Bureau of Health, Manila, where all cases of plague are -brought, either for treatment or autopsy. - -As some of the material which I have collected for text-book articles -during the past eight years bears directly upon the present discussion -and presentation, I have ventured to quote from it, sometimes without -rephrasing, such parts as are accurate at the present time. I am also -quoting freely from the records and from the experiences of my -predecessors and colleagues in the work in Manila. - -It should be understood that the pathology of the disease has been -practically omitted from consideration as out of place in an -epidemiologic investigation and report. The pathologic side of the work -during the Manila epidemic of 1912-1914 was covered in a masterly -manner by Dr. B. C. Crowell and his associates at the Medical School of -the University of the Philippines, and I have no doubt that the record -of the work done and studies made will appear in appropriate form in -due time and will hereafter be referred to as among the most valuable -pathologic studies ever made during a plague epidemic, on account of -their accuracy and completeness. - -I have included, as of great value and directly related to the -epidemiologic phase of this study, reports of some of the bacteriologic -work done in connection with this epidemic at the Bureau of Science, -Manila, by Dr. Otto Schöbl. I am sure that the value of his studies as -reported in part here, with his permission, will be apparent to every -careful reader. I am greatly indebted to him for his permission to make -use of this portion of his studies. Having been in daily touch with Dr. -Schöbl during the year and a half of the continuance of this epidemic, -I can appreciate to the fullest extent the painstaking and accurate -character of his work and findings, of which the part here presented is -by no means the greatest. - -I am quite aware of the fact that there are those who view with some -question the practicability of controlling plague by the measures -applied in Manila, as recited here; but American plague workers are -likely to meet this unbelief by pointing to the accomplished fact, in -San Francisco, in Honolulu, in Porto Rico, as well as in Manila; and -before long, as we confidently expect, in New Orleans. - -These exponents of the school which contends that plague epidemics are -little affected by rat-excluding, rat-destroying and rat-proofing -efforts, believe that the waning and disappearance of epidemic plague -in a given place depend in chief part upon the exhaustion of -susceptible material among the rodent population. However appealing -this argument may be, it is impossible for its exponents to duplicate -American results with equal results in the cities of China, India, Java -and elsewhere, where governmental control and adequate financial -ability to carry out campaigns have been lacking, from one cause or -another. Wherever our methods have been followed, at home and in the -insular possessions of the United States, we have terminated human -epidemics of plague and have apparently put an end to rat plague in -comparatively short campaigns. So long as this discrepancy in results -continues we shall favor the American plan. When we review the work -and results of Blue and his fellows of the United States Health Service -and the officers of the Bureau of Health of the Philippine Islands, we -find little reason for us to favor a change to the expectant plan of -waiting for an epidemic to run its course. - -While speaking of the Philippine Islands, the admirable work of Strong -in Manila, covering years of study of the immunity problem, and his -dangerous and highly valuable work as a member of the Commission which -studied the Manchurian epidemic of pneumonic plague in 1911, must be -mentioned. - -Some years ago I called attention to the fact that few, if any, -American cities were prepared to meet an outbreak of plague with an -adequate supply of antipest serum and that the preparation of -antiplague serum was a neglected or overlooked branch of serum -manufacture in the United States. Since that time, in the midst of a -plague epidemic in Manila, where, for a time, the supply of locally -prepared (Bureau of Science) serum threatened to become exhausted, I -looked into the possibilities of getting a supply elsewhere and found -that, to do so, in anything like a reasonable length of time, was -impossible. Fortunately the threatened serum famine did not occur, the -local supply in Manila proving adequate, although for a few weeks we -were obliged to make use of a stock of Japanese serum which had been on -hand for several years. Since the warning of some years ago, at which -time the plague danger was an anticipated one, bubonic plague has -actually appeared in the United States (New Orleans), the cases being -sufficiently numerous to cause grave concern and to call forth the -utmost repressive efforts of the authorities. The possibility of plague -appearance in the coast cities of the United States, at any time, -cannot be disregarded and provision for the treatment of human cases, -as well as repressive (antirat) measures, is imperative. Antiplague -serum is not producible upon a few hours' notice, nor is it -manufactured in the United States. In view of present war conditions -the difficulty of securing serum from overseas sources is greatly -increased, so that we are well-nigh compelled to depend upon -home-produced serum. In view of the uselessness of drug treatment it is -plainly the duty of national, state and municipal authorities to keep -on hand a reasonable supply of antipest serum to meet any outbreak. -Manufacturers of biological products realize that the preparations for -producing, storing and marketing antiplague serum are expensive and -that the maintenance of immunized animals and the employment of expert -serologists call for expenditures which are unlikely to be recovered -from any demand for serum and that, moreover, the government is doing -and will do all that lies within its power to make the serum -unnecessary, by excluding plague. These are not encouraging conditions -to lead American serum producers to add antiplague serum to the list of -their products. If, under these adverse conditions, any producer of -biologic products shall undertake to produce and maintain an adequate -supply of antiplague serum, he will merit credit for a truly -philanthropic service and will deserve the support of governments, -national, state and municipal, as well as that of the medical -profession. - - - - - CHAPTER I - - ITS HISTORY AND ITS EXTENSION - - -In plague there exists the most intimate relationship between cause and -prevention. We will therefore set forth here, as briefly and concisely -as their importance will permit, the principal facts related to the -causation of the disease. Without an understanding of this relationship -there can be no rational preventive treatment. - -These facts constitute one of the interesting stories of modern -medicine: the story of the arrangement and interpretation of certain -apparently unrelated facts, some of them long known to men, in the -clear light of modern method; the story of the application of analysis, -synthesis, logic and experiment, all leading to the creation of an -understanding which permits us to battle successfully with _pestis -bubonica_, one of the most ancient of human plagues. - -HISTORY.--This disease has an historic interest, most engaging and -fascinating, which one finds it difficult to pass over with mere -mention. - -I venture to recall, therefore, that plague almost certainly dates -back to the pre-Christian era, the earlier record naturally being -lacking in sufficient accuracy of description to enable us to identify -the recorded epidemics, definitely and positively, with true bubonic -plague. - -An epidemic of the second century B.C., as described, seems to have -been one of true plague, while the pandemic which began in Egypt in the -sixth century A.D., thence extending to Constantinople, Europe and the -British Isles, was certainly the disease known in modern times as the -plague. This pandemic, beginning as the plague of Justinian, was -probably followed by the continuous presence of the disease in Europe, -marked by many local outbreaks and periods of quiescence and extending -down through the centuries to the period of the Crusades. In the -eleventh and twelfth centuries the returning Crusaders spread the -plague widely through Europe, which country it ravished from the -eleventh to the fourteenth centuries, reaching its climax of intensity -in the "Black Death" of Europe of the Middle Ages. The disease -thereafter continued to devastate Europe, the great population centres, -Paris and London, suffering especially from its visitations and its -more or less constant presence. The Great Plague of London, the last -important epidemic of the disease in that metropolis, began in 1664 and -lasted five years. With less than half a million of inhabitants it is -estimated that London gave one of every six or seven of her citizens to -the Black Death during the first year of the epidemic. Then followed a -remarkable disappearance of the disease from Western Europe. The -eighteenth century was marked by few epidemic appearances of plague. - -At the end of the first half of the nineteenth century it had -practically disappeared from Egypt and from European and Asiatic -Turkey, formerly its favorite haunts. In interior Asia it has probably -existed for centuries, the non-emigrating character of the people -limiting and confining its devastations. - -To these centres and to the commercial invasion of China, we must -probably trace the beginning of the present pandemic of plague, which -exists to-day, a menace to the civilized and uncivilized world. In the -days of the Crusades a religious invasion of the infected centres -caused the disease to spread throughout Christendom, while in the -present day a commercial invasion has caused it to spread completely -around the world. - -That this is a truth and not a fanciful statement is shown by the -appearance of plague in the following countries since 1894, when it -spread from interior China. In every case it has followed those -sanitary lines of least resistance, the paths of commerce. - -EXTENSION.--To the eastward, from China, it spread to Japan, the -Philippines, Australia, the Hawaiian Islands, Alaska, California, -Mexico, Peru and the western coast of South America. To the westward, -it invaded India, Mauritius, Egypt, Suez ports, Eastern, Central and -South Africa, Mediterranean ports, Great Britain (Scotland), the West -Indies and Brazil. In the last twenty years plague has caused millions -of deaths, and, during a single week in April, 1907, it destroyed more -than 75,000 lives in India, a number about equal to the deaths of a -year in London during the Great Plague of 1665. In contrast with India -the rest of the world has suffered little during the present -world-epidemic, but this loss, while relatively small, is enormous when -translated into lives and dollars. The figures for India are simply -huge. - -MORTALITY.--The official lists of _deaths_ in India for the last twenty -years include some in which the number of _reported_ deaths per year -exceeded one million, and it has been estimated that the actual number -of persons dead from the plague during this period approximates -8,000,000. - -It is gratifying to note a marked decrease in the total mortality in -the reports of the last few years, but so long as the annual death -list, year after year, was measured by hundreds of thousands, rather -than thousands, the situation could not be considered as anything but -grave. - -WIDESPREAD DISSEMINATION IN RECENT YEARS.--Without going into -statistics deeply we may consider also the list of countries, states -and islands from which plague cases have been reported officially -during the last few years. - -My purpose is to invite attention to the continued existence of various -plague foci, any one of which might serve to extend the infection -further, were governmental quarantine and public health supervision -relaxed. - -During August, September, October, November and December, 1909, plague -cases occurred in India, Mauritius, China, Japan, Egypt, Turkey, -Russia, British East Africa, the Azores, Venezuela, Ecuador, Peru, -Chili, California (two cases), and the Hawaiian Islands. - -During the first half of 1910 no very marked variation in the -distribution of plague occurred, cases being reported from practically -all of the foreign countries just named. - -A year later the situation, so far as the distribution of plague cases -is concerned, was not greatly changed, as may be seen from the -following tabulation, which I have abstracted from the _British Medical -Journal_ of September 16, 1911. - -_India._--Deaths from plague in India during the first six months, -604,634. Most prevalent (1) United Provinces, 281,317; (2) Punjab, -171,084; (3) Bengal, 58,515; (4) Bombay Presidency, 28,109. Deaths in -July, not included above, 8990. - -_Hong Kong._--April 24 to August 21, 255 cases, 194 deaths. - -_China._--Since January 1, 1911, plague was reported in varying -intensity in (provinces and towns) Manchuria, Peking, Tien-tsin, Chefo, -Shantung, Shanghai, Amoy, Foochow, Swatow, Canton, Pakhoi and Laichow. - -_Indo-China._--At Saigon, in March and April, 1911, many cases -reported. April 17 to May 7, 56 cases; 17 deaths. May 22 to May 28, 37 -cases; 12 deaths. - -_Siam._--In Bangkok plague was more severe during 1911 than in any -previous year. March 15 to April 15, 33 cases and 29 deaths. - -_Java and Sumatra._--In Java, May 25 to June 3, 105 cases and 62 deaths -(one province). In Sumatra plague was present, no statistics. - -_Straits Settlements._--A few cases, mostly imported, reported in 1911. - -_Japan._--A few cases at Kobe in 1911. In Formosa, from April 2 to -April 15, 31 cases; 24 deaths. - -_Egypt._--Plague reported from Port Said, Suakin (on board ship), Cairo -and Alexandria; also from 11 provinces. The province of Kena had a -severe outbreak, May 5 to May 31, 51 cases and 49 deaths. - -_Persia._--Several cases reported from ports on the Persian Gulf. - -_Turkey in Asia._--A few cases at Muscat, Basra and at Port of Jeddah. - -_British East Africa._--Kismayu and Port Florence reported a few cases -in April, 1911. - -_Mauritius._--January 1 to April 11, 110 cases and 70 deaths. - -_Portuguese East Africa._--Plague was reported present at Nahoria in -May, 1911. - -_Russia._--In the Kirgis Steppe in the Astrakan Government in January, -50 cases; 30 deaths. - -_South America._--Plague prevailed during 1911 in Peru, Ecuador, -Brazil, Chile and Venezuela. No severe outbreak except in Peru, where -from February to May many cases occurred and died. At Libertad, in -March, were reported 60 cases and 23 deaths. - -APPEARANCE OF PLAGUE IN PORTO RICO, NEW ORLEANS AND MANILA.--The -developments of 1912, which most concern us, were the appearance of -human plague and the discovery of plague-infected rats in Porto Rico, -Cuba, and the Philippines, and the discovery of infected rats in New -Orleans. Thus the Atlantic cities of the United States were for the -first time seriously threatened, and the menace of the pestilence at -home loomed up on our horizon with sufficient prominence to excite -public concern. Our protectors and guardians of the United States -Public Health Service, to whose watchfulness we must credit our -prolonged escape from the plague, are carrying out all the protective -measures at their command with the utmost activity. - -At the present time we find Porto Rico freed from the disease. New -Orleans has undergone and is still undergoing treatment which may be -expected, most confidently, to clear it of both human and animal -plague. - -Of Manila and the work there, much will be found in the following -pages, but as both rat plague and human plague have been absent for -more than a year we may fairly look upon the epidemic as ended. After -so long an interval as this any reappearance of plague may fairly be -viewed as a new epidemic, although it is not humanly possible to say -that rat plague has entirely and permanently disappeared from the city -of Manila, as yet. - - - - - CHAPTER II - - THE CAUSE AND THE MENACE OF PLAGUE - - -The foregoing facts are quite sufficient to make us realize both the -possibility and the danger of a world-epidemic; a danger which has -existed for some years and which recently has been especially menacing -to the United States. - -CAUSATION OF THE DISEASE.--Plague is an acute infectious epizoötic -disease, caused solely by _Bacillus pestis_, a bacterial organism. The -disease is common to man and to a number of the lower animals and -fowls. - -Prominent among the animals susceptible to the disease is the rat, and -from this animal, through the intermediation of the flea, by far the -most cases of human plague arise. In California the ground squirrel -(_Citellus beecheyi_), a rodent closely related to the marmots of Asia, -plays a similar rôle. Of the Asian marmots, the tarbagan, a large -rodent, also commonly suffers from subacute chronic plague, which is -transmissible to man as an acute disease by the fleas which the animal -harbors. - -ITS CONVEYANCE.--Although conveyance of plague through rats by contact -alone--that is to say without the medium of the flea--is denied by -modern experimenters, it is perhaps wiser and safer to consider the -disease infectious, inoculable and contagious in the common medical -meaning of these terms. While it is usually conveyed to man by the -flea, it may be acquired by the inhalation of plague bacilli and, -according to some authorities, by ingesting or swallowing the bacilli. - -When infection takes place through the digestive tract, or in other -words, by the ingestion of bacilli, either the flesh of plague-infected -animals or fowls, or food superficially contaminated with plague -bacilli by rats, cockroaches or other carriers, serves as the medium. - -Speaking practically, the possibility of infection through ingestion is -nearly negligible. Indeed, the conclusion of Simpson in regard to this -possibility has been disputed and denied. However, the recent -occurrence of plague in a cat in Manila, in my own experience, observed -with me and carefully worked out by Dr. Otto Schöbl, points strongly to -the possibility of ingestion plague, the cat in this case apparently -having acquired plague from eating rats dead from plague. - -A full account of this case appears in the bacteriologic observations -of Dr. Schöbl and in my recital of the history of the Manila epidemic. - -TYPES OF PLAGUE.--Plague in man may be of several types and these are -designated by names descriptive of the symptoms or of the regions of -the body most affected. Thus we have bubonic, septicæmic and pneumonic -types. As both mild and virulent cases occur, we also use terms -descriptive of the severity and course of the cases. Thus we describe -certain cases as ambulant, abortive, larval and fulminant. In the rat -the evidences of plague are less striking in life than they are at the -post-mortem table. Indeed plague-stricken rats, either naturally or -artificially (experimentally) infected, often show very slight -evidences of disease before death. Chronic plague in rats and a -relative immunity to inoculation in certain wild rats are fairly well -recognized phenomena. - -FLEA CONVEYANCE OF PLAGUE BACILLI.--Both male and female fleas convey -plague, but the exact method of carrying the plague bacilli from -diseased rats to man, while fairly well determined, is of such recent -decision as to leave room for further experimentation. At present it is -believed that the flea deposits plague bacilli, at the time of biting, -upon the skin, by ejecting the contents of its rectum and by -regurgitation of its stomach contents. At least the flea is known to -perform these acts at the time of biting, and the rubbing or scratching -of the flea bite with the hand may easily introduce the bacilli into -the skin at this spot.[1] - - [1] Acknowledgment is hereby made to the Contributors to "The Rat and - Its Relation to Public Health" by various authors, prepared by - direction of the Surgeon-General, P. H. and M. H. S., for numerous - facts utilized in the preparation of this article. The particular - contributors whose valuable chapters have been drawn upon for - information are D. E. Lantz, C. W. McCoy, D. H. Currie, Carrol Fox, - Rupert Blue, W. C. Rucker, R. H. Creel, M. J. Rosenau, V. C. Heiser, - W. C. Hobdy, and J. W. Kerr. - -The possibility that the flea introduces the plague bacilli upon his -mandibles, or the skin-piercing armament with which he is provided, is -also to be considered. However, the following facts support the first -proposition. It has been experimentally shown that the average capacity -of a flea's stomach is about one-half of a cubic millimetre and that -thousands of plague bacilli may be ingested by the flea during the -biting of a plague-diseased rat; that the plague bacilli multiply -enormously and for many days in the flea's stomach and that the bacilli -are found only in the insect's digestive tract; that plague bacilli are -regurgitated from the stomach and are voided from the rectum with the -digested blood. - -It has also been proved that almost all varieties of rat fleas, under -favorable circumstances, will bite man and that the most common human -flea (_Pulex irritans_) is frequently found upon rats, the flea, -generally speaking, being much less particular in his choice of hosts -and in his permanence of residence than most insects and ectoparasites -in general. - -Of the rat fleas, _Pulex pallidus_ (_Loemopsylla cheopis_) is common -under various names in India, the Philippines, Australia, Italy, Brazil -and in tropical countries generally. It bites both rat and man. -_Ceratophyllus fasciatus_, the common rat flea of Great Britain and the -United States, also bites both rat and man. In North America and -elsewhere certain other fleas of the genus _Ceratophyllus_ have been -found upon ground squirrels, cats, rats, sparrows and in chicken yards. - -Dog fleas and cat fleas (genus _Ctenocephalus_) also infest rats, and -fleas of other genera are found upon mice, rats and ground squirrels -rather indiscriminately. - -The significance of these facts in connection with prevention of -plague is apparent and it is plain that our warfare against fleas must -be made upon _all_ fleas and not upon a single variety. In this -connection the possibilities of the conveyance of plague bacilli by -other suctorial parasites and by insects which are not parasites, must -be borne in mind. - -Thus the bed-bug, the louse, the tick and the mosquito must be -suspected as possible intermediaries and the fly and the cockroach as -possible food contaminators. Indeed, laboratory experiments have -already incriminated bed-bugs, flies and lice as potential vectors of -plague bacilli. - -Experiment and observation have demonstrated, however, that above all -other parasites and insects, the flea is most likely to convey the -plague germ from rat to man, by reason of his frequent excursions from -rat-host to human-host, his taste for blood from either host, his -enormous activity and his ability to jump. After a searching inquiry -into the plague question the Indian Plague Commission came to the -conclusion that contagion plays a very minor part in the spread of the -disease, less than three per cent of human cases being so acquired. - -This commission also decided that infection is conveyed from rat to -rat and from rat to man solely through the agency of fleas. While these -conclusions are probably true--and therefore of the utmost importance -from the standpoint of practical prevention--I should question whether -the other possibilities, however remote, are entirely negligible. - -Seasonal conditions may affect the course of an epidemic in various -ways. (a) By effect upon flea prevalence, cold weather greatly -lessening the number of insects. (b) By effect upon rats, cold weather -and rains either driving them from overground to underground, or vice -versa, or from their principal avenues of travel in cities (the -sewers), into houses and buildings. (c) By effect upon the plague germ, -_Bacillus pestis_. The resistance of this organism is very variable, -sunlight and drying being its greatest enemies, while darkness and -dampness are its chief allies. So far as temperature is concerned, the -plague bacillus is not likely to be seriously affected by natural -temperatures, as it is not destroyed by heat below 150 degrees -Fahrenheit, nor by cold measured by zero Fahrenheit, which means that -it survives freezing, generally speaking. - -It is probable that the periods of greatest seasonal prevalence of -plague will be found to correspond generally with increased prevalence -of rat fleas. During the periods when rat fleas are absent or least -prevalent, the disease is perpetuated in the form of chronic (subacute) -rat plague in a small number of the rodents. The India Plague -Commission made and verified this observation. - -Cholera epidemics often abate spontaneously and this is believed to be -due in part to attenuations of virulence and changes in the cholera -organism which may be demonstrated in the laboratory. We can hardly -hope for such spontaneous abatements in plague epidemics, as it has -been found difficult to attenuate or to intensify cultures of plague -bacilli permanently in laboratory experiments with animals. If it is -true that plague epidemics are often marked by a preponderance of mild -cases in the early days and a gradual subsidence of intensity of the -cases as the epidemics wane, we probably will have to look to the -susceptibility of our patients for our explanation of this phenomenon, -rather than to variations in the virulence of the plague bacilli. If -plague bacilli continue to be distributed to susceptible people the -disease should continue with a general stability of virulence. - -STABILITY OF VIRULENCE OF _B. Pestis_.--According to Strong, stability -of virulence is a marked characteristic of _B. pestis_, it having been -shown by him that it is difficult to increase the virulence of a very -virulent strain or to intensify an attenuated one in laboratory -animals, working with monkeys, rats and guinea-pigs.[2] If his -observations are correct (and they seem to correspond with the findings -of other observers), the oft-recorded occurrence of a preponderance of -mild cases of plague in the early days of an epidemic and the gradual -subsidence in intensity of the disease as the epidemic approaches its -close will have to be explained upon other grounds than those of -variability of virulence by attenuation of virulent strains alone. -While he admits that _B. pestis_ may become attenuated under certain -conditions many times during the course of an epidemic, it may also -regain its virulence, he contends, under other conditions. - - [2] "Studies in Plague Immunity," R. P. Strong, Philippines Journal - of Science, June 1907, No. 3. Frequent reference has been made to - these studies in the preparation of this article, for which - acknowledgment is hereby made. - -With these facts concerning the cause and the manner of extension of -plague and its menace before us, we are in position to approach the -problem of prevention intelligently, and in the case of plague -prevention is preëminently preferable to cure, as well as decidedly -more practicable. - -I think we may be permitted here to sum up the problem of plague -prevention thus: Without fleas, without rats, or without human plague -cases, there can be no extension of plague, practically speaking. - -Therefore the destruction of both rats and fleas, the isolation of -human plague cases, and the exclusion from them of all suctorial -parasites and insects, will provide practical security for mankind -generally. - -A word concerning pneumonic plague may be permissible. This form of -plague occasionally occurs in epidemics of great fatality, as, for -example, the epidemic in Manchuria, North China, a few years ago. - -The mystery of this outbreak was largely dispelled by the work of the -Americans, Strong, Teague and Barber, of the Bureau of Science of -Manila. - -The occurrence of secondary pneumonia in bubonic or septicæmic plague -is rather common and it is likely that such secondary plague pneumonias -are the starting points of epidemics of pneumonic plague, _i.e._, of -cases of primary plague pneumonia, the point of infection being in the -respiratory organs and the infection being acquired through the -inspiration of plague bacilli. - -The principal prerequisites seem to be an extremely moist atmosphere -under confined conditions and a low temperature; conditions most -unfavorable to evaporation and ventilation. Under these conditions the -pneumonic patient sprays plague bacilli into the air while coughing and -droplet infection follows. - -It is therefore apparent that epidemic pneumonic plague is controllable -by sanitary and hygienic measures and, furthermore, that in the absence -of original cases of bubonic and septicæmic plague, with secondary -plague pneumonias which give rise to primary plague pneumonia in the -manner explained, respiratory plague in epidemic form will not occur. - -There is no evidence pointing to the conveyance of respiratory plague -by insects or other carriers. - - - - - CHAPTER III - - ITS CONTROL AND SUPPRESSION - - -PLAGUE PREVENTION.--At present the most promising and the most -rationally based phase of plague control is that of prevention. The -reason for this is plainly apparent. If the facts in the case are as -stated and if the conclusions of the Plague Commissioners and students -of epidemiology the world over are correct, to eradicate plague we need -only to control its carriers. - -To exterminate the rat (and perhaps the marmot and ground squirrel), to -prevent the transportation of rats or of infected rat fleas in ships, -trains, clothing, merchandise and upon the bodies of men and animals -from the numerous foci or plague centres of the world to non-infected -localities, is a beautiful plan indeed. - -Restricted to single communities, even where the intelligence, -patriotism, effort and wealth of the whole people are enlisted, the -undertaking is formidable, with obstacles to its execution, and -discouragement must often be expected. Extended in its application to -the whole plague-infected world it becomes an undertaking seemingly -impossible of accomplishment. - -Yet we are encouraged to face the situation by a glance at what has -been accomplished. The United States, perhaps, presents the highest -examples of achievement in the cases of San Francisco and Manila. The -work in San Francisco is too recent and has been too well published to -require detailed review here. A successful campaign against rats in -1907 practically terminated an epidemic of considerable proportions -well within a year. Behind this movement, however, were the powerful -machinery of the Federal Government, money in generous amount and a -considerably aroused public, resentful of the mismanagement of the 1903 -epidemic, whereby, through pure fear of financial loss to commercial -interests and by a disgraceful suppression of the truth, California was -made, permanently perhaps, one of the world's plague centres. - -It has been estimated that the rat population of the world is equal to -the human population, and this estimate does not appear to be -unreasonable when one considers as indices the destruction of the -rodents in cities by the hundreds of thousands, upon single farms by -the thousand, and the wonderful procreative powers of the rat. - -ECONOMIC IMPORTANCE OF RAT DESTRUCTION.--It is certain that the -economic importance of rat destruction upon grounds other than those -purely sanitary must be impressed upon the public wherever a rat -campaign is to be carried on. - -The absolute inutility of the rat, its enormous destructiveness to -crops, to merchandise in warehouses and in transit, to poultry, eggs, -fruits and vegetables, to buildings and furniture, and its incendiary -habits causing annual fire losses of considerable magnitude, must be -emphasized in season and out of season. Such items as the value of the -grain consumed by a single rat per year, as estimated by the experts of -the Agricultural Department, are convincing arguments in the case. At a -daily consumption of two ounces, the ration for a full-grown rat, this -grain value varies from sixty cents per year, for wheat, to two dollars -per year, for oatmeal, for each rat subsisted. Similar data in great -variety, relating to direct and indirect losses, are available for the -purpose of making impressive the economic need for rat destruction. - -Accumulated experience from various countries and cities shows plainly -that there is no single method of rat destruction to be depended upon -to the exclusion of all others and it also shows that without -governmental direction and supervision, backed by ample authority and -the ability and willingness to expend considerable money, neither -single nor combined methods will be successful. Moreover in the -countries where special effort is most needed there is often distrust -on the part of the natives, religious prejudice against the destruction -of animal life and frequently open opposition to the authorities in -their efforts to destroy rats. The same superstitions and religious -beliefs which prevent the killing of venomous snakes in India, at the -annual cost of thousands of human lives, operate against most measures -of rat destruction proposed by the Government. - -EXTERMINATION METHODS.--The plans and weapons of warfare against rats -include the use of poisons; traps; starvation; rat-proof construction -of buildings, wharves, bakeries, stables, granaries, etc.; the -introduction of diseases among the rat population by bacterial viruses -and the conservation of the natural enemies of the rat, such as the -cat, the dog, the ferret, the mongoose, and certain wild animals and -birds of the woods and fields. - -Among the most widely used and most effective poisons is arsenous acid -boiled with rice, or mixed with cheese or cornmeal in the form of a -paste, or placed upon sweets and fruits. - -Crude phosphorus is chiefly used in similar pastes. When mixed with -glucose its inflammable properties are said to be lost. Its -inflammability is, of course, a serious obstacle to its general use. - -Strychnine, owing to its bitter taste, is of little value in poisoning -rats, and when used is best combined with glucose and one per cent. of -cyanide of potassium. Soaked wheat, bread or similar food is then -treated with this mixture and placed where rats may eat it. It is said -to be eaten readily by ground squirrels with fatal effect. It is, -however, expensive and apt to be taken by domestic fowls. Most rat -poisons have the disadvantage of being dangerous to human life and must -be used with caution wherever children and ignorant native persons are -about. - -TRAPPING.--Trapping has been found to be a very effective means of rat -destruction in cities. (See later pages for relative efficiency of -traps.) Rat traps are of several varieties and are constructed upon -various principles. It is sometimes desirable to catch the rats alive -and uninjured, and for this purpose barrel traps, wire cage traps and -similar devices are placed in the rat highways. These highways are -readily discovered in the cities. Considerable care must be taken to -overcome the natural caution of the rat, and this includes judgment in -the use of attractive bait, the concealing and smoking of traps after -handling and perhaps the use of some scent, such as the oil of anise, -of which rats seem to be fond. As a general rule bait should differ -from the food naturally supplied by the locality. For example, about -granaries and stables fresh animal food should be used for bait, while -about slaughter houses, meat-markets, fish-markets and similar places, -where animal offal is abundant, the rat should be tempted with -vegetable bait. - -Where the circumstances will permit, and this is apt to be so for -ground-squirrel destruction, the burrows may be filled with some -asphyxiating or poisonous gas. In this manner whole families of -rodents, and their fleas as well, are destroyed. - -The system is not often applicable in houses, but aboard ships it is -found most effective, the holds of ships being flooded with sulphur -dioxide, developed by burning sulphur in a special furnace provided -with a pumping and piping system for delivering the gas at distant -parts of the ship. In empty ships' holds and elsewhere the simple -burning of sulphur in open vessels effects the same results, provided -sufficient sulphur and a sufficient number of vessels be used and -further provided that the generation and confining of gas be -sufficiently prolonged. In San Francisco harbor, where for more than a -year nine vessels were disinfected per day, this method was adopted as -more effective, speedy and economical than any other system. It has the -disadvantage, in the case of laden ships, of affording some danger of -fire. - -Carbon bisulphide has been extensively used in California in the -burrows of ground squirrels. Its fumes, being heavier than air, -penetrate the burrows and promptly poison or asphyxiate all living -animals and fleas. Absorbent material of some kind is saturated with -the liquid and placed in the entrance of the burrow, which is then -quickly sealed to confine the gas. - -It will be seen that, in common with other methods of rat destruction, -fumigation has a limited application and a number of serious -objections. It is particularly useful aboard ships. - -The method should never be employed by unskilled persons or those -unacquainted with the dangers to human life from noxious or -asphyxiating gases. - -STARVING RATS.--The subjects of the starvation of rats and rat-proof -construction may be considered together. - -Just as the pig in the Philippine Islands and elsewhere in the Orient -must give place as a scavenger of human excreta to modern and decent -methods of waste disposal, so must the rat, a garbage scavenger the -world over, give place to systematic garbage collection and removal, -with temporary storage of garbage in covered metal cans (rat proof). - -Incidentally it may be mentioned that the effect of such measures upon -the prevalence of flies and the transmission of disease by these -insects will be very great and very beneficial to the public health. - -Food must be kept from rats and rats must be kept from the food. -Perhaps the greatest resorts of rats are the places where cattle are -fed, where grain is stored and where animals are killed. Slaughter -houses, markets, grocery stores, restaurants, bakeries, wharves and -warehouses must be regulated by ordinances duly enforced. Much can be -done with screens of heavy iron wire with a mesh of less than one inch. - -When concrete and metal have displaced wood and plaster as construction -materials; when plank sidewalks and refuse piles are no more and when -the catch basins of sewers have been made rat-proof the subsistence -problem for the rat will be greatly increased in difficulty, and -starvation should then begin to lessen the rat population, at least in -the cities. - -RAT-PROOFING.--Municipal authorities should take up the matter of -rat-proof construction for new buildings and the rat-proofing of old -ones by approved alterations. In Manila, Hong Kong and elsewhere these -methods are receiving attention and encouraging reports are recorded, -more particularly with regard to the disappearance of plague in -districts so treated than in the disappearance of rats. This is most -important, for if the rat and his fleas are excluded from houses and -therefore from intimate association with man (an apparently feasible -matter through the rat-proof construction of buildings), protection -against human plague is in great measure accomplished. - -[Illustration: RAT PROOF STRUCTURE WITH SOLID CEMENT BASE, SOLID -CONCRETE POSTS, AND UNBOARDED CEILING] - -In Manila the disappearance and continued absence of human plague in -previously infected localities goes hand in hand with the introduction -of systematic rat-proofing in sections where cases of human plague -occur. - -These measures were first instituted in 1906 and plague disappeared -from Manila in the same year and did not reappear until 1912. - -From 1900 to 1905, $15,000 was paid in rat bounties and $325,000 was -paid for salaries, wages and expenses in rat catching, with little -appreciable effect upon the number of rats and without causing the -plague to entirely disappear. It must be admitted, however, that -practical control of the disease was attained during this period. - -Rat-proofing of dwelling houses is less expensive than perpetual -wholesale rat destruction and is a perfectly effective measure against -human plague. In the suppression of the San Francisco epidemic in 1907 -rat-proofing was also extensively resorted to. - -The expense of rat-proofing has been generally considered as -prohibitive, but if the work be confined at first to the vicinity of -infected centres and if it be carried on subsequent to rat-destruction -in corresponding areas the expense need not always be prohibitive--at -least in American governed cities. The Manila plan of plotting the city -into "plague-infected" areas corresponding with the capture of -plague-diseased rats and systematically working within geographic -boundaries in which rat plague exists or is likely to spread, as -determined by rat captures and examinations of the rats for signs of -plague, has proved to be a good plan. - -To prevent the transportation of rats in ships, trains and merchandise -is an undertaking of difficulty as well as of importance. In the case -of vessels it involves an understanding of the manner by which rats -gain ingress to the ship and the ways of preventing them from entering. -Few facts are better known, perhaps, than the fact that all ships -harbor rats, but, except to the initiated, the extent to which some -ships are infested is by no means understood. I have made voyages upon -steamships, which upon alternate trips carried forage for animals in -the holds, when the conditions were, to say the least, uncomfortable. -To have one's state-room taken possession of by rats, his clothing -carried away, or to awake with a rat in his berth are unpleasant, but -not uncommon, experiences. I personally know of a woman, prostrated -with sea-sickness, who was obliged to remain in her berth and see four -large rats disport themselves about her room, and in another case, on -the same ship, a rat jumped from the washstand into the berth of a -sleeping woman, running across her exposed face and arm. - -In travelling upon small dirty steamers in the Orient I have often -slept on deck, quite as much to avoid the rats and vermin in the -state-rooms as for better ventilation. In a certain ship in which I -travelled some of the ship's officers amused themselves by shooting -rats with an air-rifle in the lower decks, quietly hiding themselves in -dimly-lighted places and shooting the rats as they crossed the lighter -spaces. - -In many ships the rat population far exceeds the human population. In -San Francisco 310 rats were destroyed by a single fumigation on a -vessel of only 260 tons burden. In Bombay 1300 rats were destroyed at -one time upon a single ship and in London 1700 were secured at one -fumigation. - -The ease with which rats adapt themselves to new environment is shown -by the fact that they live, when permitted to do so, in cold storage -and refrigerating rooms where they grow heavy coats of fur for -protection against the cold. - -They gain ingress to ships in three principal ways: (1) By coming -overside upon gang-planks, wharf stringers, etc. (2) By passing along -the lines by which the ship is made fast to the dock, through hawse -holes, the rat being an expert rope walker. (3) By coming aboard in the -cargo. - -By the latter method rats are often brought aboard by whole families, -their fleas included. Many styles of packages such as barrels, bales, -crated goods, grain in sacks and matting in rolls present the rat with -abundant opportunity to take passage and it is probably thus, as -stowaways, that rats go to sea in the largest number. Plainly, then, -the placing of rat-funnels upon all lines from ship to wharf, the use -of special fenders, the raising of gang-planks and even anchorage in -the stream will not prevent rats from getting aboard ships unless cargo -disinfection be practised before loading the vessel. The ship itself -should be fumigated every three months if possible. - -Rats are doubtless carried in considerable numbers upon railway cars, -both freight and passenger. - -While riding in a street car in Manila in 1908 I saw a rat run along -the window ledge, to the mingled fright and amusement of the -passengers. - -The same principles which apply in the case of ships apply to cars and -trains as well. Grain cars in particular should receive especial -attention. - -RAT DESTRUCTION BY THE SPREAD OF RAT DISEASES.--The proposal to destroy -rats by wholesale, by spreading epizoötic diseases among them, through -feeding them bacterial virus, has received much attention in the last -ten years. In 1900 Danysz isolated a bacillus from field mice suffering -an epidemic disease communicable to rats, and great hopes were -entertained that by means of this method decided reductions in the rat -population would result. Indeed the results in Cape Town, South Africa, -in 1901, and in Odessa, Russia, in 1902, seemed to justify the hope to -some extent and certain observers still believe the method to be -effective. Experience with the Danysz and other organisms has shown, -however, that introduced epidemic diseases do not destroy rats in -sufficient number to do much good and that nearly all the viruses -experimented with are more or less unreliable. - -Most of the organisms are apparently related to the colon, typhoid or -hog-cholera groups. The mouse-typhoid bacillus (_B. typhi murium_) was -originally isolated by Loeffler in 1899. The paratyphoid bacillus and -Gärtner's _B. enteritidis_ correspond closely with the Danysz organism -and can scarcely be separated culturally. In rodents they produce -enteritis, sometimes hemorrhagic in character, and they are by no means -to be regarded as harmless for man, as originally supposed. In Japan, -in particular, serious and fatal cases of diarrhoeal disease have -followed the accidental eating by man of food treated by these -bacterial poisons. - -On account of the natural resistance of rats to diseases of bacterial -causation (plague being the most notable exception to this rule), and -the clinical fact that no sufficient death rate among rodents is -produced by feeding them upon bacterial viruses, as well as on account -of the dangers to man just mentioned, this method of rat destruction is -not in favor at present. - -Poisoning rats and ground squirrels by chemical poisons seems to be a -preferable method, at least equally effective and without most of the -disadvantages of uncertainty and danger which attach to the bacterial -viruses. - -RAT DESTRUCTION BY DOMESTIC ANIMALS.--Concerning the utility of such -domestic animals as are natural enemies of the rat, in the warfare -against the offending rodents, there is considerable difference of -opinion, based upon varying experiences. I leave out of consideration -all but the cat and dog. - -It will be found that wherever cats and dogs are well housed (indoors) -and well fed they are apt to be fat, lazy and inefficient. House cats -of this class will catch mice but will often leave rats alone, but -half-wild cats, obliged to forage for their own subsistence, are often -excellent rat-catchers. Small, active dogs, particularly of the terrier -breeds, will often keep houses practically free from rats and upon -farms they are especially valuable, particularly if the construction of -buildings is such as to permit them to get beneath the floors. The -employment of these animals will necessarily be confined to individuals -for the freeing of individual premises from rats. - -A fact to be borne in mind is one already cited, viz.: that cats and -dogs sometimes harbor the same fleas as the rat. Infected rat-fleas -often leave dead rats for other animals and, all things considered, -there are many other objections to the intimate house dog and house cat -which find comfortable resting places impartially upon the beds of -adults or the cribs of babies and children. - -Furthermore, my personal observations have been such as to cause -me to place small reliance in the value of the ordinary dogs and -cats found about habitations wherein the construction is favorable -to rat-harboring. - -SUMMARY OF PREVENTION FOR THE COMMUNITY.--Before passing to the -consideration of other matters I would sum up the measures of -preventive treatment for the community. There must be (1) Active -warfare against rats and other plague-affected rodents and their fleas; -(2) Modified quarantine--detention or disinfection applied to persons, -goods and animals; (3) Disinfection of cargoes shipped from infected -ports; (4) Isolation of the sick and proper disposal of the dead; (5) -International notification between governments of the occurrence of -plague within their respective territories; (6) Lastly,--but we might -say first in importance,--the early recognition of the presence of -plague and the _rapid diagnosis_ in individual cases, both of which are -dependent upon laboratory workers. - -All of these measures must be fostered, directed and aided in every -possible way by competent authority (national if possible), whose -officers must be men of great moral courage and of unselfish purpose. -Behind all of this must be generous financial support. - -I can best emphasize the importance of the observance of the principles -I have laid down by introducing personal experiences in the conduct of -the antiplague campaign in Manila during 1912, 1913 and 1914. - -I therefore present here the following account of the epidemic, the -campaign of suppression and the various lessons learned. - -It should not be difficult for the reader to make applications of the -principles already set forth and to confirm by the reported facts the -assertion that methods based upon these principles are effective. - -If repetitions of any of the foregoing principles occur it is hoped -that, when taken in connection with concrete applications cited, they -will not appear as redundant. - -THE MANILA EPIDEMIC OF 1912 TO 1914.--The chronologic facts concerning -the development and extension of plague in Manila in 1912, 1913 and -1914 are as follows: - -The disease made its reappearance in Manila, after an absence of six -years for the human disease and five years for rodent plague, two -verified human cases having been recorded in June, 1912. - -Preceding the appearance of the first Manila cases there occurred upon -incoming ships a number of cases of plague during the Spring of 1912, -detected at quarantine. Although there is no conclusive evidence which -connects these imported cases, originating in Hong Kong, China, with -the epidemic which broke out in Manila a few months later, the fact of -their occurrence and recognition is interesting enough for us to -consider before taking up the study of the Manila epidemic. Concerning -these imported cases Dr. Victor G. Heiser, then Director of Health for -the Philippines, wrote as follows in the _Philippine Journal of -Science_, in February, 1914. - - UNUSUAL CHARACTER OF PLAGUE AT QUARANTINE.--It is perhaps - worthy of note that, prior to the appearance of plague in - Manila a number of cases of the disease were found on incoming - steamers. For instance, on April 6, 1912, a death was reported - on the steamship _Zafiro_, which had arrived the day previous - from Hongkong and had been in the harbor for twenty-four hours - at the time of the death. At the medical inspection of the - vessel, which was made the day previous, no illness was - detected. An investigation showed that the victim had been on - deck on the night of April 5, 1912, in apparently good health. - The next morning, at 6 o'clock, he was found dead in his - bunk. The necropsy and subsequent biological findings - reported by Dr. R. P. Strong of the Bureau of Science showed - that death was due to pneumonic plague. - - On April 7, 1912, the steamer _Loongsang_ arrived in Manila - from Hongkong, and the captain reported that a death had - occurred the day previous in a Chinese member of the crew. - Upon investigation of this case, the captain stated that the - man was apparently in good health, but that while hauling on - a rope he fell over in an apparent faint and was placed in a - chair and in the course of a few hours expired. The necropsy - and animal inoculations showed that he had died of plague and - probably of the pneumonic variety. - - Beginning April 7, 1912, the temperature of all members of - the crew and of the passengers that arrived in vessels from - foreign ports was taken with a view to detecting any possible - cases of plague. - - On the arrival of the steamship _Taisang_ from Amoy at the - Mariveles Quarantine Station at about 6.30 A.M. on April 30, - 1912, the entire personnel was carefully examined and found - free from sickness of a suspicious nature and from elevations - of temperature. Seventy-three persons were detained to serve - a quarantine detention of seven days. On the evening of April - 30, a Chinese passenger, aged fifty-one years, was found to - have a temperature of 39° C. with a pulse of 100. He was - placed in the hospital, but protested vehemently that he was - not sick. He was carefully watched from the first; there was - a slight cough; physical examination of the chest revealed a - few râles; smears made of the sputum and stained for plague - bacilli were negative. On the fifth day, the fever still - persisted, but the patient stated that he did not feel ill - and demanded to be released from the hospital. On this day, - the expectoration was blood-stained, but no suspicious - organisms could be found in the smears nor could any physical - signs of pneumonia be detected. Furthermore, there were no - palpable glands. On the morning of the seventh day, the - temperature and pulse dropped and the general condition was - distinctly worse. The patient now admitted that he felt ill. - Several hours later, he flinched when pressure was made in - the right axilla. Lymphatic enlargement was now made out, and - by the evening of the seventh day the bubo in the axilla had - increased markedly in size, the swelling approximating 3 by 7 - centimetres. Glands now became palpable in other portions of - the body, particularly in the cervical region, and a few - hours later there were inguinal and femoral buboes. The - patient became rapidly worse, and died at 7 o'clock on the - morning of the eighth day of his illness. At the necropsy, - the glands of the right axilla and those of the right side of - the neck were found enlarged; the other lymphatic glands were - also enlarged, but to a lesser degree. There was - consolidation of the lower lobe of the right lung, and the - spleen was about twice its normal size. In brief, the - necropsy findings of a typical case of septicæmic plague were - present. Smears from the spleen and the right axillary gland - showed immense numbers of bipolar-staining organisms. - Cultures made from fresh pieces of tissues and later - inoculated into animals gave positive results for plague. - -BEGINNING OF THE MANILA EPIDEMIC.--Proceeding with the Manila epidemic -inaugurated with the two cases referred to as recorded in June, 1912, -we find that the total number of cases recorded from the time of the -outbreak in 1912 until the last case in 1914 was 90. (This includes -none of the imported cases from China which developed en route to -Manila from Chinese ports.) - -Of these 90 human cases, 76 were fatal and autopsies were performed in -all instances. Fourteen persons recovered. The number of cases of -animal plague up to July, 1914, was 53. This refers only to -laboratory-proven cases of rat plague. As a matter of fact, hundreds of -dead rats, almost certainly plague rats, were found in the course of -rat-proofing operations. - -Although the period covered by this epidemic approximates two years, it -must not be supposed that the progress and extension of the epidemic -was an uninterrupted or unobstructed one. - -On the contrary, such extension as occurred was made in spite of the -most active suppressive effort, and it is believed that this effort -brought about a creditable result, as indicated by the accompanying -record. - -When one considers the favorable conditions for the natural spread of -plague, both in Manila and throughout the Philippine Islands, and -realizes the interposed difficulties and obstructions, natural and -unnatural, geographic, human and domestic, which confront us at every -turn of the path to correction, removal and reformation, our success in -checking the spread of plague appears as a real achievement, especially -when contrasted with the results of effort during the same period in a -British city of similar size but a few days' sail from Manila, where -the cases were numbered by thousands and where the infection still -persists. - -FIRST MANILA CASES.--The first case of plague (June 12, 1912) occurred -in a resident of Tondo, 920 Calle Antonio Rivera, and in the light of -subsequent developments it may perhaps be grouped with the October -cases traced to the Manila Railway Company's freight station and yard, -as 920 Calle Antonio Rivera is but a stone's throw from the Manila -Railway property. The connection, however, is not clear, and, on the -other hand, it is not wholly inconceivable that the rat epidemic and -human plague cases at the railway station in October may have been -secondary to this June case. Such speculation is fruitless, however, so -far as establishing facts is concerned. - -The second case of human plague occurred 13 days later, June 25, in a -resident of a district somewhat removed from the first case, but in -the same general section of the city. - -Then came a lull of more than a month, until August 4, during which -time no case of plague occurred; or at least none was reported. - -August brought forth five cases on the fourth, eighth, fifteenth, and -twenty-first days of the month, in residents of the Quiapo and Binondo -districts. - -These cases were unrelated to the preceding ones so far as could be -ascertained. - -Another lull of a month, until September 24, now occurred without a -reported case of human plague. During this time, however, the first -cases of rat plague were discovered, one on August 30 and two on -September 6, all of them in the Quiapo district. - -From this time (September 24) on, however, human cases occurred at -intervals of a few days until Christmas Day, 1912, the longest -plague-free period being one week; the number of cases by calendar -months being distributed as follows: September, 3 cases; October, 22 -cases; November, 12 cases; and December, 6 cases. - -GEOGRAPHIC GROUPING.--Not until October 21 was there any apparent -geographic grouping of cases indicating a well localized infected -centre. Upon this date there began the outbreak of plague among the -employees of the Manila Railway Company, laborers at the freight -station and yard of the company. This freight station and yard is -located between Calle Azcarraga, Calle Dagupan and Calle Antonio -Rivera. The outbreak totalled 17 human cases, all fatal, and extended -into November. Indeed, the last case traced to this focus occurred on -December 7, 1912. - -During the present epidemic of plague in Manila this focus was the only -one to which a larger number of cases than five could be traced, and in -all the other instances where multiple cases were traced to an infected -centre, the foci were all single buildings. - -The locations giving rise to multiple infections and the number of -cases of plague developing at each address, with months of incidence, -are as follows: Calle San Fernando (804-814), November, 1912, 4 cases; -Calle Teodoro Alonzo (518), November and December, 1912, 2 cases; Calle -Cabildo (Intramuros), November and December, 1912, 2 cases; Calle -Comercio (1028), February, 1913, 2 cases; Calle Sande (1364), April, -1913, 5 cases; Calle Juan Luna (1226), May, 1913, 2 cases. - -Returning to the Manila Railway outbreak, it is necessary to state -that a well-defined epidemic among rats preceded this outbreak, -resulting in the death of a large number of rodents (undoubtedly from -rat plague). This epidemic was not reported by the railroad company -until the outbreak of human plague had begun. It was then too late to -identify plague in the dead and mummified rats found under floors, -platforms and elsewhere, but the fact that large numbers of rats had -recently died here was established by the unanimous testimony of the -employees at the freight station and the finding of rat cadavers. - -As stated, the human outbreak here occurred upon October 21, and -fifteen cases developed within 3 days. - -This indicates an extensive desertion of fleas from plague rat cadavers -and an attack upon human beings, after a fasting period, on the part of -the fleas, of several days. The human outbreak at the station and the -death of a large number of rats at the same place, just previous, -correspond to a nicety and establish to a moral certainty the -connection necessary to explain the epidemic. - -After the railway epidemic of human plague, cases continued to occur -through November and December, without apparent relation to each other, -except in the following instances, which have already been mentioned: - -Four cases under one roof on Calle San Fernando (November 12, 13, 16 -and 22); 2 cases in one house on Calle Teodoro Alonzo (November 26 and -December 2); and 2 cases in the same house on Calle Cabildo -(Intramuros), November 23 and December 11. - -These multiple cases will be referred to elsewhere. - -The other cases during October, November and December were apparently -sporadic and unrelated, either to the other human cases or to the few -scattering cases of rat plague discovered from time to time. Without -doubt, however, all were actually related to preceding cases of rat -plague, _i.e._, to undiscovered rat cadavers, dead from plague and -deserted by infected fleas. - -In the following plague houses (see list of cases) dead rats were -actually found, although the advanced degree of desiccation and -mummification defeated the biologic determination of the cause of -death: 518 Calle Teodoro Alonzo; 973 Calle Azcarraga; 282 Estero de -Binondo. - -In other plague houses the recent finding of dead rats was alleged by -the occupants, but rather too indefinitely to record positively. - -A study of the maps and lists showing the localities in which cases of -rat plague had been found up to this time (December 26, 1912), in -connection with the location of plague houses, was much less suggestive -than a similar study of the lists and maps covering the cases of 1913. - -However, the existence of concurrent rat plague and human plague, in -corresponding sections of Manila, had been well established already by -bacteriologic studies of captured rats, made at the Bureau of Science. - -Of nearly equal weight was the observation concerning the two -epidemics, rat and human, at the Railway Station, which I have already -described. - -The year 1912 closed, then, with a recorded total of 50 human cases and -7 verified cases of rat plague. - -January, 1913, saw but a single case of human plague. This occurred on -January 24, just a month from the last previous case, that of Christmas -Day. During this month no case of rat plague was reported. - -In February, 3 human cases occurred and in March, 4 cases were -recorded. - -Early in March, 1913, cases of rat plague began to occur in the Tondo -district in a section lying between Manila Bay and the Estero de la -Reina and extending northward from Calle Moriones. This was a new -district for rat plague and as the cases increased in number we were -able to foresee and predict the appearance of human plague in the same -district, which in point of congestion of population, poverty of its -residents and in the matter of dilapidation of its light material -houses and shacks, is about the worst locality in Manila. - -From March 22 to September 20, 1913, all the cases of human plague, 11 -in number, occurred in the midst of this district. During the same -period 25 cases of rat plague were reported from the same section, and -a glance at a map of this part of Tondo instantly shows the -relationship existing here between rat plague and human plague. - -This relationship is additionally emphasized by referring to the -memoranda concerning certain overcrowded houses, in the midst of the -rat plague district, where multiple human cases occurred. (See -memoranda in re 1226 Calle Juan Luna and 1364 Calle Sande.) - -[Illustration: CLEANING AND RAT PROOFING IN BASEMENT OF 1226 CALLE JUAN -LUNA IN WHICH TWO CASES OF PLAGUE OCCURRED. RAT CADAVERS FOUND UNDER -BROKEN FLOORS (MANILA PLAGUE CAMPAIGN)] - -The human cases in April were 5 in number, all originating in the same -house, and the May cases numbered 4, two of which occurred in the same -house. - -It may be explained, in passing, that two cases of human plague, -discovered in Malolos, 25 miles from Manila, on March 23 and March 26, -respectively, were definitely traced to the same house in Manila, -number 12 Calle Aguila, Tondo, both patients having lived in the -basement of this house until within 48 hours of the development of the -disease. These persons were unrelated and were two of a large number of -people who lived in a tenement at this address. Both patients were -detected, while still alive, in Malolos, where they were living in -different and widely separated houses. One of the patients died in -Malolos but the other one was brought to Manila by train and died at -San Lazaro Hospital. Fortunately no infection was transferred to -Malolos by these two persons. In this connection it is interesting to -note that no other cases have been reported from outside of Manila, -except the small outbreak in Iloilo in the southern islands, where the -antiplague work was successfully directed by Dr. Carroll Fox. -Concerning this outbreak, Dr. Heiser, then Director of Health for the -Philippines, writes as follows (_Philippine Journal of Science_, -February, 1914): - - PLAGUE IN ILOILO.--In Iloilo, a case suspicious of plague was - reported on July 5, 1912, and this diagnosis was subsequently - confirmed by the laboratory. It occurred in the person of a - Chinaman who was reported to have come from Bais, Oriental - Negros, but later investigation showed that he had been a - resident of Iloilo at least since February, 1912. The next - case was reported August 18, and the last case, September 17, - 1912. There was a total of 9 cases. All of the cases were - confined to two houses. During July, August, September, and - October, 1146 rats were caught in the vicinity of the houses - in which the human cases had occurred, along the water front, - and in the places which were regarded as suspicious, but in - not a single instance was an infected rat found. - -DIRECTED TO TAKE CHARGE OF PLAGUE SUPPRESSIVE MEASURES.--Upon my -arrival in Manila from the United States, on October 23, 1912, I -received orders from the Director of Health to take charge of all -plague suppressive measures in Manila and I remained in charge of this -work continuously until July 11, 1914. - -PLAGUE FIGHTING ORGANIZATION.--The plague fighting organization was -composed of three American Sanitary Inspectors and from ten to fifteen -native Assistant Sanitary Inspectors of the Bureau of Health, rat -catchers and laborers of the Bureau and laborers of the City of Manila -supplied by the Department of Sanitation and Transportation. The -combined force varied in numerical strength from 100 to 150 men and was -usually divided into three parties, distributed in various parts of the -city according to the local indications and needs from time to time. - -After the invasion of Tondo by rat plague we made special effort to -rat-proof the light material houses of that section, in the course of -our cleaning operations, by the closure of the open ends of bamboo -timbers with cement and with tin cans, in the manner shown in -photographs herewith. In addition to this, special attention was given -to the repair of broken cement work, and hundreds of Bureau of Health -orders, verbal and written, were issued to owners, at my request, in -the rat plague districts. - -The number of houses in which bamboo timbers were closed by cement or -tin exceeded a thousand. - -In addition to these means, the very important matter of depopulating -the insanitary basements of the light material houses in squares where -plague has occurred was given attention, with the result that hundreds -of families were moved from these insanitary and dangerous ground-floor -rooms to quarters well above ground and measurably removed from the -rats, which roam over the ground from house to house, foraging for food -under kitchens and in ground-floor storerooms, tiendas and eating -places. The fish packing factories afford them abundant food and a -number of cases of plague have occurred adjacent to these fish-drying -establishments. - -RAT-PROOFING AND RAT DESTRUCTION.--While it is frankly admitted that -rats may not be completely exterminated by poisoning and trapping, the -statement, so frequently repeated of late, that destructive measures -really increase their number, is unwarranted and unsustained by facts, -at least in Manila. It seems to be the common practice for disbelievers -in trapping and poisoning to array the methods of rat-proofing and rat -destruction as alternative policies, whereas everyone practically -familiar with the work in such cities as Manila--or even in the United -States--knows that there is often no choice permitted. Rat-proofing is -highly desirable, permanent in its results, and in every respect the -"method of election." On the other hand, it is entirely inapplicable at -certain times and in certain localities where poverty, lack of interest -of property owners, and ofttimes lack of interest and of money on the -part of municipalities, absolutely preclude its immediate application. -It is therefore unfortunate that the statement, that rat poisoning and -trapping are ineffective, either in controlling plague or in reducing -the numbers of rats, is circulated. It may be shown easily, by the -daily records, that within a few weeks after extensive rat poisoning -and trapping (with the breaking up of nests) is pursued in a given -locality, the rat catch drops in the most decided manner. - -Individual premises may be practically cleared of rats by continued -intelligent rat catching and poisoning, and while the normal rat -birth-rate may keep pace with the normal rat death-rate it will not -keep pace with the normal death-rate plus the poisoning and trapping -death-rate in any given locality, provided that the poisoning and -trapping, with the destruction of nests, be intelligently and -continuously carried out. - -Rat-proofing and rat destruction, then, should not be contrasted as -alternative procedures or policies. Both are valuable and each has a -proper place. In communities non-infected with plague and unexposed to -infection it will probably be found that rat-proofing, carried out in -connection with the repairs of old buildings and the erection of new -ones, will meet the requirements. On the other hand, in cities exposed -to plague infection or already infected, rat destruction is bound to be -necessary for years to come. - -In emergency, the removal of people from intimate relationship with -rats (so far as is possible), as practised recently in Tondo district, -Manila, will often have to take the place of rat-proofing; and rat -destruction and expulsion will be found, in the last analysis, to be -the methods upon which success or failure in fighting plague during -epidemic time will depend. - -In this connection I quote correspondence which passed between the -Director of Health and myself in 1913. - - Upon March 22, 1913, I directed the following letter to the - Director of Health: - - SIR: I have the honor to state that Estaban Masibac, aged - twenty-two, laborer, who died at 140 Perla of bubonic plague, - slept upon the ground floor of this house upon a bamboo bed. - All these basement dwellers in this district now infected - with rat plague are in considerable danger. - - The roving rats which wander over these ground surfaces from - house to house come into pretty close contact with these - basement dwellers, and it would appear that they visit the - upper stories of the houses rather infrequently, unless food - is stored there. Upon the ground they forage upon the food - dropped there by the residents of the houses. - - I would like to have authority to order the vacation of these - basement rooms which are almost invariably unfit for human - habitations. - - I look upon this measure as an important one at this - threatening time and believe it should be enforced in every - square or block where plague rats have recently been found. - If this authority is granted it will be used judiciously. - - Very respectfully, - [Signed] T. W. JACKSON, - _Medical Inspector in Charge of Plague Suppression_. - -Upon March 24 I received the following letter of authorization: - - SIR: Confirming my verbal instructions of yesterday I have to - request that, in accordance with the recommendation contained - in your letter of March 22, that on account of the danger of - the spread of plague in the district in which plague has - appeared extensively, the basement dwellers in blocks, or - squares, in which plague has been found, should be ordered to - vacate. - - Very respectfully, - [Signed] VICTOR G. HEISER, - _Director of Health_. - -Upon November 26, 1912, five dead rats were reported from the U. S. -Army Commissary Warehouses on the Pasig River near the Malecon. They -were found dead by workmen there and were thrown into the river by the -finders and thus, unfortunately, examination for plague was prevented. - -Upon November 27, a cat, known to have caught and eaten rats recently -at the same place, was reported to be sick. I took the cat to the -Bureau of Science where she was observed until she died, three days -later. - -At autopsy, typical bubonic plague (cervical) was disclosed, and -several guinea-pigs inoculated from the spleen and bubo died from the -same disease. A guinea-pig, inoculated from a swab introduced into the -cat's rectum, also died from plague (see report of Dr. Schöbl). - -Four kittens, recently born of this plague cat, were observed for two -weeks but showed no sign of the disease. - -Subsequently about 80 rats were caught at these warehouses and in the -vicinity, but none of them showed post-mortem signs of plague. The -Medical Department, U. S. Army, then took up the matter of rat catching -on all military reservations in Manila and in all buildings thereon, -but no more cases of animal plague were discovered. - -FLEAS AND THEIR HABITS.--In "Observations Upon the Bionomics of Fleas -Bearing Upon the Epidemiology of Plague in Eastern Java," by N. H. -Swellengrebel, Ph.D., published by the government at Batavia, Dutch -India, in 1913, some interesting facts, developed by study and -experimentation, are presented. Some of these facts have a bearing on -the plague problem in the Philippines, for it should be borne in mind -that certain climatic similarities and racial similarities pertain -commonly to the Javanese and Filipinos and their respective countries. - -While we are not prepared at present to make general application of the -Javanese findings to the Philippine Islands, for lack of parallel or -confirmatory studies in the Philippines, we may state some of the -conclusions of the Java workers with propriety, and we may also point -out similarities in the construction of certain Filipino and Javanese -habitations in their relation to rat harboring. - -Swellengrebel, in Java, noted the number of fleas per rat, dealing with -_Xenopsylla cheopis_ (the commonest rat flea in Java) almost -exclusively. This flea, it will be remembered, is also the common rat -flea of India, the Philippines, Australia, Italy, Brazil and tropical -countries generally, being variously known as _Loemopsylla cheopis_, -_Pulex pallidus_, _P. brasiliensis_, _P. philippinensis_, and (in -Italy) _P. murinus_. - -It would not be unreasonable, therefore, to expect to find at least -some of his observations applicable to the Philippine Islands. - -Swellengrebel failed to find _Ctenocephalus canis_ (dog flea), _C. -felis_ (cat flea) and _Ceratophyllus fasciatas_ (the common rat flea of -the United States and Europe) upon Javanese rats. In attempting to -determine the normal flea census he found that field rats, and field -rats caught indoors, as well, generally carry fewer fleas than house -rats and that the number of fleas per house rat varies in different -districts from .02 per rat to 2.3 or 4 per rat and that this variation -is not invariably constant with the presence or absence of rat plague. -Concerning the question whether or not a high flea census may indicate -rat plague, Swellengrebel offers the reasonable opinion that there is -little doubt that plague in rats increases the number of fleas per rat -above normal and that, consequently, a sudden or marked increase in -the number of fleas per rat, without a known normal cause, indicates -increased rat mortality and probably rat plague. - -As to the influence of temperature and humidity on the hatching of -larvæ, he concludes from experimentation that the duration of -development of the egg varies under various hygrometric conditions, the -general rule being, "the lower the humidity the longer the development -period." - -As to the influences of temperature and humidity upon the transition of -larva to imago he finds that if humidity diminishes, a smaller number -of larvæ reach the adult stage; and also that a saturated humidity (in -artificial cultures), causing condensation of water in the substratum, -is very fatal to larvæ. He offers the thought that this, perhaps, -explains why only small numbers of fleas are found on field rats which -live in holes in rice fields which are necessarily damp, especially in -the rainy season. - -His experiments to determine the duration of life of fasting fleas were -made with laboratory-bred fleas which had never fed on blood and with -fleas which had already sucked blood. - -The duration of life was variable, but of those fleas already fed with -blood three-quarters (¾) perished within 10 days and the remainder -lived from ten to twenty days, only one-tenth, however, surviving for -13 days, if moist conditions were maintained. High temperature was -determined to be an unfavorable condition. - -If from these findings one should attempt to predicate or predict the -extension of plague in house rats--based on flea prevalence--and this -with relation to climatic conditions, we should be led to the -conclusion that the rainy season, with its greater humidity, would be -quite the most favorable time of year for rat plague extension in -Manila and, upon the contrary, that the hot dry season through its -unfavorable influence upon flea breeding would be the least favorable -season for rat plague in Manila. - -The hot months of 1913 did not bear out this reasoning, however, for -during these months rat plague was at its height. - -That increased prevalence of human plague has not gone hand in hand -with increased prevalence of rat plague in Manila, may be explained, I -feel sure, by the activity of our efforts to destroy rats and to remove -the people from close relationship with them. - -Another factor of possible explanation of the greatest prevalence of -human plague in Manila during the late rainy season of 1912 (October), -is the fact that rats are certainly driven above ground into houses and -therefore into closer relationship with man by heavy rainfall and the -consequent flooding of their subterranean homes. - -It appears, therefore, that the seasonal explanation of greater plague -prevalence, rat or human, is susceptible of several interpretations and -I feel sure that in countries like the Philippines seasonal variations -in heat do not suffice to rid the rats of fleas during any months of -the year. If, then, conditions of rainfall serve to drive the rats -above ground and indoors during certain months, it would be reasonable -to expect more human plague from closer relationship of rat and -man,--provided that no special measures were carried out. - -Such, however, is not invariably the rule, if statistical studies are -to be taken as evidence, and so we are reminded that generalizations -for countries of different climates and seasons are not wholly -reliable. - -Rat breeding, as well as flea breeding, is influenced by climate, but -as the reproductive activity of the rat is most retarded by cold -weather--an unknown condition in the Philippines--and as the climate -of Manila is fairly equable so far as heat and cold are concerned, the -only factor which needs to be considered is that of rainfall. As -already mentioned, rainfall doubtless serves to drive rats above ground -and so, to a certain extent, away from their nests in burrows and -underground. - -Their well-known adaptability to changing conditions, however, permits -them to house themselves comfortably above ground when driven out of -these burrows and holes. - -JAVAN OBSERVATIONS.--The following conclusions were reached by Dr. -J. J. van Loghem in a report upon "Some Epidemiological Facts -Concerning the Plague in Java" (published by Civil Medical Service in -Netherlands India-Batavia, 1912): - - 1. In plague-infected villages, as distinguished from - plague-free villages, there exists a considerable mortality - among house rats. - - 2. Rats in plague houses and plague quarters have repeatedly - died from plague. Fresh plague rats appear more often in the - houses adjoining plague houses than in the houses themselves. - - 3. The house rat exists even in the immediate vicinity of - man. - - 4. The ordinary parasite of the house rat is _Xenopsylla - cheopis_, which experimentally is known to choose man as a - host when starving. - - 5. Fresh plague rats have repeatedly been found to harbor a - great number of fleas. - - 6. Virulent plague bacilli have been demonstrated in the - stomachs of such fleas. - -Concerning the prevention of plague by improving the native dwellings, -the same observer says: "Obviously an increase in the distance between -man and rat becomes an important factor as a means of preventing the -disease." - -CONDITIONS OF MANILA HABITATIONS FAVORABLE TO RATS AND PLAGUE.--As -shown by our own experiences in Manila, this end, the separation of -rats and men, is not obtainable by destruction of rats by poison, traps -and rat catchers. Rats dying of plague in their nests furnish the -greatest danger to man. The plague problem, therefore, where rats are -already infected, from the stand-point of direct prophylaxis, is the -problem of dwellings. It was from this stand-point that we attacked the -problem in the Tondo (Manila) campaign in 1913. - -MANILA VERIFICATION OF JAVAN OBSERVATIONS.--Having in mind the -experiences of the plague investigators in Java during the recent -epidemics there (1911-1912), we sought, from the time the Manila -outbreak occurred, to verify some of the findings of the Java -investigators, at least with special reference to the nesting of rats -in close proximity to human beings and the consequent exposure of these -persons to the infected fleas which desert the rats dying from plague -in these nests. - -Not until rat plague invaded the special district of Tondo, in Manila, -in March, 1913, did the opportunity present itself. Theretofore the -Manila cases had generally appeared in houses of the so-called "hard -material districts," where house construction is entirely unlike that -with which the Java workers dealt. With the invasion of Tondo, however, -the Java and Manila conditions became similar. I quote the descriptions -of Javanese house construction from the report of Dr. J. J. Van Loghem, -"Some epidemiological facts concerning the plague in Java," Batavia, -1912. - -THE JAVAN VILLAGE HOUSE.--In substance, he says that the Java village -house, as a general type, is a one-storied structure with its roof -sloping to the front and back, _i.e._, with its ridge parallel with the -front and back aspects of the building. It is not elevated above the -ground by supports or palisades and has no separate floor, the earth -serving as the floor. - -The outer frame is of strong bamboo poles and the inner frame is also -constructed of bamboo. These bamboo timbers are perforated at various -points to permit of framing with other pieces of bamboo and for the -entrance of pegs, etc. - -The roofs of these houses are often made of tiles, but at times the -familiar thatched roof is seen. In both cases the supports or rafters -are bamboo poles. The principal piece of furniture is the "bale bale," -or bedstead, usually made of bamboo, except in the houses of the -well-to-do. Small storerooms are often located in the houses, and -stables are sometimes built against them. In many cases the family -provisions are kept in the house and the cattle are housed here as -well. - -MANILA LIGHT MATERIAL HOUSES.--If, now, we turn our attention to the -average Tondo (Manila) light material house it will be apparent that -the description given for the Java village house fairly describes the -Tondo house, except that the Philippine house is commonly elevated 2 -metres or more above the ground upon bamboo supports (see photographs). -The basement is usually enclosed in a manner similar to the principal -room of the Java house and the basement room may fairly be compared, -structurally and in the matter of its floor, with the one-story Java -house. In the Manila house, however, the floor of the upper room takes -the place of the roof of the Java house and like it is supported by -bamboo timbers. - -Here, then, in our enclosed basement story, we have a practical replica -of the one-storied Java house. - -Here, also, the principal piece of furniture is often a bamboo bed, -practically identical with the Java "bale bale," if we may judge from -photographs. - -In the Java houses the favorite nesting places for rats were found to -be the interiors of horizontal bamboo pieces of the roof, house frame -and bedstead. - -The rat usually gains entrance by gnawing through the natural -partitions between the bamboo sections near the outer end of the pole. -Our Manila photographs show both the natural open ends of such timbers -and the rat-gnawed perforations in the partitions. - -In Java, rats also nest in the thatched roofs, as they occasionally do -in the Philippines. - -NEST MATERIALS.--The materials utilized for nests by rats in Manila -and Java seem to be identical also. Straw, dry leaves and pieces of -cotton are mentioned in the Java reports. The same materials and -additional ones will be found mentioned in our reports upon nests. - -[Illustration: BAMBOO HOUSE SUPPORTS NOT SEALED WITH CEMENT. NOTE HOLES -GNAWED IN BAMBOO ENDS. RATS FREQUENTLY MAKE NESTS IN THESE HOLLOW -BAMBOO RAFTERS.] - -The presence of food was also noted in the bamboo nests in Java and we -often find articles of food in our Manila nests. - -Dr. Korn, P. H. Service, and the writer (T. W. J.) investigated a good -many of these bamboo house-timbers and we not only found such evidences -of rats as food, rat fæces and nest materials, but in one case a rat -was actually driven out of a bamboo nest by introducing a long thin -strip of wood. The evidence of similar conditions then is complete. - -We also duplicated the experiences of the Java workers in finding dead -rats inside of the bamboo house timbers in close proximity to patients -sick (or dead) with plague (see memoranda in the case of Esteban -Masabik, of 140 Calle Perla, March 22, 1913). - -Very extensive rat destruction and cleaning operations, covering a -large portion of the city of Manila and including all sections where -cases of rat plague or human plague developed, were undertaken and -this work was carried on without interruption for about two (2) years. -City laborers to the number of 60 to 150 were used and the work was -supervised by Sanitary Inspectors Brantigan and Searcy, of the Bureau -of Health. During a part of the time a flying column of 50 men, under -Sanitary Inspector Hunniecutt, was detached from the main party and -employed at placing rat poison. - -The total amount of accumulated dirt removed from houses and yards -approximated 5250 tons (for 17 months ending November 1, 1913). - -Without doubt this general cleaning campaign and the removal of this -enormous accumulation of dirt and rubbish was of great value as an -antiplague measure. - -The rat catch will always be found to depend upon several factors, -viz.: the number of persons employed; the number of traps and portions -of poison placed; the location of the operations and the length of time -a given locality is trapped, poisoned and cleaned. The variety of baits -and poisons will also affect the results. - -In addition to these factors certain others are found to operate in -reducing the rat catch, as, for example, weather conditions and the -occurrence of Sundays, holidays and the days just preceding and -following holidays. - -Upon rainy days and the days just mentioned the rat catch almost -invariably falls off. - -From statistics collected by me in connection with this work, Dr. V. G. -Heiser, then Director of Health for the Philippine Islands, published -the following memorandum in 1914. As it is a correct transcript of my -records I introduce it here in its entirety. - - COMPARATIVE STATISTICS IN RAT-CATCHING METHODS.[3]--With a - view to ascertaining which type of rat trap was most effective - and also the average number of rats that are caught by a given - number of poisoned baits that are set out, statistics were - kept during the antirat campaign in Manila. The ratio - maintained in catching rats with two types of traps is - indicated in the following table, a perusal of which will show - that for the three months ended June 30, 1913, there were - 120,565 spring or snap traps set and that for every 100 of - this type of trap set there were caught 6.9 rats. During the - same period there were 47,075 wire cage traps set; the total - number of rats caught was 339; which gives 0.72 rat caught for - each hundred traps set. For the quarter ended September 30, - 130,627 spring or snap traps were set and 9,753 rats were - caught, which gives 7.47 for each 100 traps set. During this - period 40,621 wire cage traps were set and 395 rats were - caught, which gives 0.97 rat caught for each 100 wire cage - traps set. - - [3] Reprint from the Public Health Reports, Vol. 29, No. 6, February - 6, 1914. - - ===================+==========================+========================= - | Quarter ended June 30 | Quarter ended Sept. 30 - +---------+---------+------+---------+---------+----- - Kind of trap | | Number | | | Number | - or poison | Number | of rats | Per | Number | of rats | Per - | set |caught or|cent. | set |caught or|cent. - | |poisoned | | |poisoned | - -------------------+---------+---------+------+---------+---------+----- - Spring or snare | | | | | | - traps | 120,565 | 8,377 | 6.9 | 130,627 | 7,753 | 7.47 - Wire cage traps | 47,075 | 339 | .72 | 40,621 | 395 | .97 - Poison bacon, rice,| | | | | | - or coconuts | 166,237 | 1,216 | .731| 177,309 | 216 | .12 - -------------------+---------+---------+------+-----+---+---------+----- - | Quarter ended-- - +---------+--------- - | June 30 | Sept. 30 - ----------------------------------------------------+---------+--------- - Number of rats: | | - Caught by dogs | 160 | 5 - Killed with clubs and other weapons | 2,889 | 3,818 - Found dead from other causes | 316 | 297 - ----------------------------------------------------+---------+--------- - - No accurate record was kept of the number of each kind of rat - bait set. Only the total of all was recorded. Bacon or coconut - with strychnine and rice with arsenic were used. For instance, - for the quarter ended June 30, 1913, there were 166,237 poison - baits set in new territory and the rats found poisoned average - for each 100 baits 0.72. During the next quarter there were - 177,309 baits set in territory that had been worked over, and - only 216 rats, or 0.12 rat per 100 baits, were killed. From - the foregoing it appears that the rat poison ranks lowest in - efficiency but perhaps highest in economy. In view of the - fact that the original cost of the cage trap is many times - more than that of the spring trap, and the cost of maintenance - is very high, it will be apparent that the spring trap is by - far the more economical as well as more effective of the two. - -Generally speaking, however, the number of rat catchers engaged and the -location of their operations has the largest influence upon the total -catch of rats. For the fiscal year July 1, 1912, to June 30, 1913, -inclusive, the total catch was 55,101 rats (Manila only); to December -1, 1913, 79,676. - -The most natural explanation of the general correspondence between the -highest rat catch and the highest incidence of human plague would be -upon grounds of greater activity in rat catching effort at times of -greatest plague prevalence, but from the inauguration of general -systematic rat catching there was no cessation of effort, even during -the abatement of plague, and in consequence this explanation does not -apply strictly. - -It is true, however, that whenever plague occurred in districts -theretofore free from the disease, rat catching was pushed vigorously -in the surrounding localities. - -Making due allowance for all the factors mentioned I am impressed with -the probability, amounting almost to certainty, that the catch of more -than 79,676 rats definitely affected and checked the spread of plague -in Manila in 1913; and I am of the opinion that systematic and -wholesale rat catching, carried out in the most economical manner -possible, should be persisted in indefinitely, at least until plague -disappears, wherever the disease occurs. - -Efforts to prevent the spread of plague to the provinces of Luzon, by -way of the railways, were successful and the present measures employed, -freight inspection, the fumigation of packages suspected or likely to -contain rats, and the similar treatment of freight cars showing signs -of rats, should be continued. In a few cases these measures have driven -rats out of both packages and cars and the animals have been killed by -the sanitarians on duty at the station. - -The matter of water transportation was entirely within the control of -the authorities in charge of inter-island quarantine affairs. - -Rat catching in Manila was systematically performed and all rats -captured were turned over to the Bureau of Science for examination for -plague. - -[Illustration: MATERIALS MUST BE MOVED ABOUT IN THE SEARCH FOR RATS -(MANILA PLAGUE CAMPAIGN)] - -When plague foci were discovered the localities were trapped and -poisoned both circumferentially and centrally, with a view to -preventing the diffusion of infected rats throughout the city. - -RAT-PROOFING.--The theoretic desirability and superiority of "out -building" the rat, over all other methods of rat suppression, is -admitted. The apparent impracticability of actually rat-proofing Manila -at the present time and our inability to starve the animals out, -justify the other and less permanent measure, viz.: rat catching. -However, I heartily favor and urge the most complete and thorough-going -rat-proofing of buildings actually infected with human or animal -plague, in all cases. The building ordinances of Manila already provide -for rat-proof construction in all new buildings erected. - -With a view to cutting off the food supply of the rat, more than 1100 -orders upon householders, to provide covered garbage cans, were served -in the district of Tondo alone. - -The open ends of bamboo timbers in more than 2300 houses were closed, -either by cement or tin cans, during 1913. - -THEATRE DISINFECTION.--All the cinematographs and theatres in the city -were disinfected upon repeated occasions by spraying with petroleum -and cresols, with a view to destroying fleas and preventing plague -infection. - -Attempts at deception and concealment of plague patients, upon the part -of members of their families, were numerous, but with the close -scrutiny of death certificates and dead bodies exercised at all health -stations it is believed that all cases were recognized. - -One case of extremely careless diagnosis occurred. A death certificate -was furnished by a local native doctor who certified the cause of death -to be "uterine hemorrhage." Suspicion arising, an autopsy was ordered -and a pronounced case of bubonic plague was disclosed postmortem. No -evidence of uterine hemorrhage, except slight menstrual signs, was -found. - -The destruction of infected fleas in plague houses is of course the -primary object of the disinfection by spraying, which is thoroughly -carried out in every house where a case of human plague or rat plague -appears. The method is a simple one and consists in spraying a mixture -of cresols (2 per cent.) and kerosene (98 per cent.) over all surfaces -of the house, floors, walls, underlying ground, furniture and the -spaces above ceilings, etc., using the mixture liberally and securing a -general surface distribution. There is no doubt of the toxicity of this -mixture to all fleas and bed-bugs which it reaches, and it is -undoubtedly an effective measure in rendering an infected house safe. -All of the instances of multiple house infections, where the cases -recurred after disinfection, in Manila, have been in houses where, for -one reason or another, the recommended structural rat-proofing has been -postponed or where it has not been done. Thus, on Calle San Fernando -the sequence of the four cases (their progress by days and in -consecutive houses) is explained by the travel of rats through -efficient rat runs present in the walls and ceilings, rather than by -the passage of fleas through partition walls, from uncommunicating -house to house. - -[Illustration: A RAT INFESTED PLAGUE INTERIOR] - -So also at Calle Cabildo, where the superstructure of the house was a -veritable sieve, there was a series of communicating double walls. - -At the house on Calle T. Alonso a similar condition existed, but here -the two cases which occurred may have been synchronously infected, or -nearly so, previous to disinfection of the premises. - -At Calle Comercio, where six days elapsed between two cases, the rooms -and building were piled full of merchandise, defeating immediate -disinfection, that is, efficient disinfection, until all the -merchandise was moved and the rooms were emptied. - -At 1364 Calle Sande, Tondo, where 5 cases originated, the infections -were undoubtedly almost synchronous and no infection occurred after -disinfection of the house, while at 1226 Calle Juan Luna, Tondo, the -two cases were plainly infected at about the same time and this -previous to disinfecting the premises. - -GUINEA-PIGS AS INDICATORS OF INFECTED HOUSES.--The following experiment -shows strikingly the necessity for disinfecting houses where human or -animal plague cases have occurred. - -Upon December 17, 1912, Dr. O. Schöbl, of the Bureau of Science, and -myself, placed two healthy guinea-pigs, free from fleas, in a wire trap -cage in the house at No. 4 Calle Barraca, a few hours before the house -was disinfected, a patient with plague from this house having died -within the preceding twelve hours. The cage containing the guinea-pigs -was placed exactly where the patient had slept upon the floor, as -indicated by the other tenants of the house. Disinfection was delayed -for a few hours and the guinea-pigs were left in the house for one -day. Upon December 21 one of the guinea-pigs died from typical bubonic -plague--anatomically and bacteriologically positive--other inoculated -experimental animals also developing the disease. - -Other guinea-pigs placed in plague houses on Calle Cabildo and Calle -San Fernando, after disinfection of the premises, failed to acquire -plague. - -NATURAL ENEMIES OF THE FLEA.--It was observed during the studies in -Java that certain natural enemies of fleas exist and operate against -their laboratory cultivation and their natural reproduction. - -Ants of several varieties, large and small red ants and small black -ones, were found to be very antagonistic to fleas, both in the larval -and adult states, destroying them actively. - -Fleas in the laboratory were found to be affected with mites, with a -resultant high mortality among the insects. The same parasites were not -found upon wild fleas. On account of the prevalence of mites upon the -laboratory fleas certain experiments concerning the transmission of -plague were vitiated. - -The activity of ants in attacking and disposing of rat cadavers found -in our antiplague work in Manila was frequently brought to my -attention. We invariably included an attack upon ants in treatment of -houses known to harbor, or suspected of harboring, plague rats. The -combination of kerosene and cresols, elsewhere referred to, was found -to be perfectly satisfactory in the destruction of ants; assuming, of -course, that the necessary procedure of exposing the ants, by the -moving of merchandise, boards or other protecting materials, was -performed, so that contact, by spraying the insecticide mixture, was -secured. - -ACTIVITY OF FLEAS.--It was also observed during the Java studies that -the rat flea, while rather lazy, may and does cover distances of five -metres and that he sometimes covers eighteen centimetres at a single -leap. - -In addition to this, of course, there must be considered the -possibility of his falling considerable distances. - -ZOÖLOGIC CLASSIFICATION OF RATS.--The matter of accurately, -systematically and scientifically cataloguing and classifying rats is -one of great difficulty and is not to be undertaken by anyone but a -trained naturalist. However, some of the notes we have at our disposal, -gathered from many sources, may be set before the reader. It is -extremely difficult to find exact correspondence of statement in the -various classifications offered by writers upon plague and rats. - -Dr. Lantz gives the following brief classification in his section of -the publication, "The Rat and Its Relation to Public Health." - - Order: _Rodentia._ - - Family: _Muridæ._ - - Genus: _Mus._ - - Species are many, but only three or four are cosmopolitan. - - Cosmopolitan species: _Mus rattus_--black, brown, and roof - (_Alexandrine_) rat; _Mus decumanus_--gray, barn, wharf, - sewer, and Norway rat. - -_Mus rattus_ has many varieties known throughout the world and these -are named according to color and habitat. - -In addition to the names given in Lantz's classification, we constantly -see reference to the black house rat, the brownish-gray rat (_Mus -Alexandrinus_), the ordinary ship rat, the field rat, etc.; terms -descriptive of habitat and appearance being very loosely applied. -Little account is taken, by many, of the well-known variations in the -coloration of rats due to climate and season and of the well recognized -aptitude of the rat for living in-door or out-door according to -circumstances of food supply, weather, etc. The "sawah" rat of Dutch -India, implicated in the prevalence of plague there, was formerly -considered a variety of _Mus decumanus_, but is now described as a -field variety of _Mus rattus_. So too, varieties of _Mus decumanus_ are -frequently named according to alleged geographic origin, habitat, color -and habits, viz.: sewer rat, brown rat, Norway rat and migratory rat. - -The inevitable confusion bound to arise from such loose classification -is obvious. - -Another genus, _Gunomys_ (_Nesokia_), implicated in plague, is -represented in India by two species and by at least one (an -undetermined one) in Java, some confusion existing in the matter as -yet. Members of this genus are described as large, rough-coated rats -which live both as house rats and field rats. In India the Plague -Commission reported specimens of this genus as particularly susceptible -to plague. - -In the Philippine Islands no specimens of _Gunomys_ have been observed, -but _M. rattus_ and _M. decumanus_ are both present and numerous and -both are subject to plague, as shown by the presence of the disease in -specimens examined. - -In view of the unreliability of the points of difference in rats -usually given as identifying data, such as the number and location of -the mammæ, the variations in color and the peculiarities of the -footpads, the Javan observers depend upon the conformation of the -skulls for the determination of genera, the skull of _M. rattus_ being -oval and arched, that of _M. decumanus_ more closely approaching the -square and rectangular conformation, and that of _Gunomys_ being -broader, higher and longer than either. - -In _M. rattus_ the prominent borders which separate the parietal from -the frontal surfaces of the skull are oval; in _M. decumanus_ they are -parallel or slightly divergent; in _Gunomys_ they are lyre-shaped. - -[Illustration: _M. rattus_] - -[Illustration: _M. decumanus_] - -[Illustration: _Gunomys_] - -To determine these differences the heads of the rats are cut off, the -tissues desiccated by antiformin, or by boiling and stripping. - -From experiences in Porto Rico, Creel, of the U. S. Public Health -Service, concludes that _M. norvegicus_ (_decumanus_), while -essentially a burrowing animal and not addicted to climbing or -swimming, is nevertheless quite capable of doing either. He was found -to burrow in the hardest earth to a depth of two and one-half feet and -to pass through all kinds of wood, soft brick and lime mortar, probably -by gnawing. - -The black rat and Alexandrine rat (_M. rattus_) in Porto Rico, -according to the same observer, do not burrow at all, but can climb and -jump in expert manner, and are the species found in the rural -districts, remote from houses. He found that all varieties of rats may -swim, from ships to the shore, distances of from one-fourth to one-half -mile, but that they lack the sense of direction and probably do not -land from ships naturally in this manner (_Public Health Reports_, No. -9, February 28, 1913). - -The female _decumanus_ is a prolific breeder and brings forth larger -litters than the _Mus rattus_ female. - -_Mus decumanus_ is generally conceded to be larger and more ferocious -than _Mus rattus_. For this reason he drives the smaller rats to the -upper floors, the _decumanus_ species generally living near the ground. -He is a burrower and is rarely found in the upper stories of -buildings. _Decumanus_ is known as a wharf rat, but is rarely trapped -on ships on the Pacific Coast, according to the observations of Surgeon -Simpson of the U. S. Public Health Service (_Public Health Reports_, -April 11, 1913). According to the same observer, _Mus rattus_ is the -commonest ship-borne rat. He also states that the black rat and the -roof rat (_Alexandrinus_), both varieties of _M. rattus_, differ -chiefly in color. They live in upper floors, between ceilings, in walls -and roofs and are remarkable climbers as well as being expert -rope-walkers and wire-walkers. On account of their natural wariness and -caution it is not always easy to induce them to enter or approach -traps. - -The photographs introduced were taken under my direction in Manila in -1912, 1913 and 1914. Some of them show the character of the house -construction in Tondo District, Manila, where plague flourished in -1913. Others illustrate methods of rat-proofing bamboo timbers in -houses of light material. These end openings were either closed by -introducing cement or by placing tight-fitting tin cans over the ends -of the bamboo rafters. - -There are many interesting memoranda, gathered and made in connection -with our antiplague work in Manila, especially concerning the location -and construction of rat nests found by our laborers; the materials used -and the fabrication of the nests. Memoranda giving details of rat -catching and rat-proofing are also presented and notes showing the -location of dead rats found in relation to dead human bodies of plague -victims. - -Notes concerning cases of multiple house infection are also presented -as being of possible interest. - -The Javan studies in 1911 and 1912 establish the fact that it is -possible to form a fair judgment as to the length of time a rat has -been dead, up to ten or twelve days, from the condition and appearance -of the rat cadaver, both as to decomposition and drying. A series of 50 -rats was studied. It is to be understood that the conditions under -which these observations were made were tropical conditions. They would -be fairly comparable with summer conditions in America, but should not -be followed too closely at other seasons of the year. In my own -experience I have observed that ants are likely to attack the cadaver -early and to obscure the deductions by their destruction of the body. - -[Illustration: PROGRESSIVE POST-MORTEM CHANGES IN RAT CADAVERS. THE -NUMBERS INDICATE THE NUMBER OF DAYS AFTER DEATH] - - Days after death Appearance - - First to third day Distention of the abdomen, increasing. - - Second to third day Loosening of hair by gentle pulling. - - Third to fourth day Loosening of the epidermis by gentle - pulling. - - Third to fifth day Perforation of abdominal wall with - collapse and disappearance of distention. - This perforation may result from bursting - of abdominal wall, or through anus, vulva - or thorax. - - Fourth to sixth day Moist shrinking of the body. Swarming of - maggots. Spontaneous shedding of tufts of - hair. - - Fifth to eighth day Drying of body. - - Eighth to twelfth day Complete dryness and rigidity. - -Photograph (after _Publications of the Civil Medical Service in -Netherlands, India_) shows the progressive postmortem changes in rat -cadavers, the numbers indicating the number of days after death. - -A COLLECTION OF NOTES CONCERNING RAT RUNS, RAT NESTS, THEIR LOCATION -AND OTHER DATA.--Attention is invited to the following collection of -notes concerning rat runs, rat nests and their locations and other data -collected by the various working parties under the direction of -Sanitary Inspectors Brantigan, Renner and Kennard, of Manila. - -Special attention has been given to the finding and destroying of rat -nests, and in this connection please note that during the month of May, -1913, one party of workmen (20 men) under Inspector Brantigan, killed -by hand 511 rats out of a total of 1319. This means that many nests -were broken up and that much breeding was interfered with. In June, -1913, two parties (40 men) killed 772 rats by hand out of a total of -3019. - -This work occurred in Tondo District in connection with extensive -cleaning and moving operations. - -At 1279 C. Sandejas[4] 7 rats were found in a nest at the foot of a -cluster of bamboo trees, between the trunks. Nest was made of leaves. - - [4] C. is abbreviation for Calle, the Spanish term for street. - -At 728 C. Velasquez, Tondo, 12 rats were driven from a burrow -underneath a thick cement floor by formaldehyde gas delivered in the -burrow through a rubber hose. This burrow was in sand and the rats came -out about ten minutes after the flow of gas began. All were killed or -captured and two or three died from the effects of the gas. - -On October 27, 1912, two of the rat terriers belonging to the Bureau -of Health caught 192 rats in one storeroom at the Manila Railway -Station, in 38 minutes. At various times they have killed from 10 to 25 -rats at a single location, in connection with the cleaning and moving -work done by the laborers. The dogs caught about 600 rats in all. - -On March 11, 1913, 27 rats were caught by laborers at 202 Calle Concha. -They were nesting in straw covers which had been removed from bottles. - -On March 11, 1913, 13 rats were found beneath a pile of loose tiles at -203 C. Sardinas. The nest was made of fibres from coconut shells and -straw. - -On March 13, 1913, 12 rats were found among stones scattered in a -shallow pile on the ground at C. Conservador (interior). Nest was made -of rice chaff and small pieces of cloth. - -On March 15, 1913, 9 rats were caught at 1353 C. Anloague on the ground -floor beneath a pile of boards. Nest was made of coconut fibre and -shavings. - -On March 16, 1913, 24 rats were caught at 934 (interior) Velasquez -beneath a wood pile. Nest was made of coconut-shell fibre and pieces of -cloth. - -On March 17, 1913, 14 rats were caught under a pile of hay and straw -at 173 Velasquez. Nest was made from straw, chaff and hay. - -The following articles of food were found in the above-mentioned nests: -chicken bones, rice, coconut, fish and bread. - - -MEISIC DISTRICT - -At 822 Sacristia 6 dead rats found in holes. - -At 540 T. Alonso a family of 8 rats was smoked out and all were killed. - -At 514 same street 6 rats were smoked out and killed. - -At 538, interior, same street, 4 rats were smoked out and killed. - -At 546 same street 4 rats were smoked out and killed. - -At 715 San Bernardo dead rat found in a hole. Nest made of banana -leaves and rags. - -At 627, interior, Zacateros, 9 rats were smoked out and killed. - -At 669 Benavides 6 rats were smoked out of four runs and were caught. - -At 631 Zacateros 2 rats were smoked out and killed. - -At 417, interior, Misericordia, 4 rats were secured in two holes under -a tile floor. Many rats were caught at this number (interior) in traps. - -At 221 Espelita 7 rats were found in a nest made of palm leaves and -excelsior; location of run way and nest beneath tile floor. - -At 124 Tetuan, in a nest of straw and lint, 5 rats were caught by hand, -alive. - -At 415 T. Alonso one live rat and 3 dead ones were dug out from beneath -a tile floor. - - -SAMPOLOC DISTRICT - -At 1001 Bilibid Viejo there were 5 rat runs, in a Chinese store. Eight -rats were secured in a nest under the cement floor. Nest made of straw -and paper. - -At 928 San Sebastian there were 8 rat runs. In one of them there were -caught 8 rats. The nest was made of straw. - -At the same address, later, 3 rats were caught in another run and 8 -young rats, with eyes still unopened, were found in a nest of straw. A -supply of bread was on hand in this nest. - -At 629 Tanduay 20 rats and nests of straw and paper were found. - -At the same address upon another day another rat run was found and one -large rat and 16 small ones were taken from a nest made of rags, straw, -and fibres. - - -PACO DISTRICT - -At 1115 San Andres in a Chinese tienda (food store), a long rat run and -a nest of rags, straw, and paper, and 30 small rats were found. - -One nest in a bamboo tree 30 feet above ground was found. Rats had been -observed going up the tree and one was caught at the foot of the tree -in a trap. - - -SAMPOLOC DISTRICT - -At 629 Tanduay 14 young rats and a nest of straw, paper and rags were -found in a stable. - -Same address, later, one rat run and nest of straw and rags with one -large rat and 16 small ones were found. - - -TONDO DISTRICT - -March 27, 1913, one rat was caught alive inside of a bamboo timber in -house at 51, interior, Pesqueria. - -At 631 Azcarraga 4 young rats were found in a nest of paper, leaves, -and hay. Chicken bones, crab shells, and rice were present in the nest. - -A young python was caught in a lumber yard in the Santa Cruz District -in June, 1913. In his stomach was found a half-grown rat. Another snake -was caught in a rat trap at the same address about the same time. - -PLAN FOR HOUSEHOLD RAT DESTRUCTION.--The following plan for household -rat destruction was proposed by me to the Director of Health. It is -considered worthy of trial if rat plague appears in new districts. - - Proposal for periodic household rat poisoning in Manila. - - Proposed that, upon a certain day of each week, rat poison be - issued free to all applicants (householders) in Manila who - agree to place same about their premises, permitting the - poison to remain in place for 48 hours. - - Instructions and poison placards to be issued with the - poison. Issues to be made from Station Health Offices and - records of issue to be kept. - - Collections of dead rats to be made at the end of 24 hours - and 48 hours by Bureau of Health employees. Poison portions - to be collected and turned in at the Station Health Offices - at the end of 48 hours, that is, at the time of the last rat - collection. Rats to be tagged and examined for plague in the - usual manner. - - Due newspaper notice of the plan and of the gratuitous issue - of poison to be given to the people and their coöperation - requested. - - Plan to be tested for at least two months. - - -MULTIPLE HOUSE INFECTION - -Memorandum concerning 1364 Calle Sande: - -Within 72 hours (April 25-27) five fatal cases of plague, all in -Filipinos, occurred in Manila. The five deceased persons lived at 334 -C. P. Rada (Meisic), 1419, interior, C. Dagupan, 1364 C. Sande (Tondo), -642 C. Ylala (Meisic), and 1492, interior, C. Dagupan (Tondo). - -The following relationships were established by inquiry and -investigation and the circumstances point strongly to a common source -of infection and to a single geographic focus of plague infection in -connection with all of the cases, viz.: at 1364 C. Sande (Tondo). - - José Raymundo, boy, aged fifteen, lived at 334 C. P. Rada and - worked daily until taken sick on Tuesday, April 22, at 1364 - Sande, in the shop of Simplicio Enriques, a silversmith, who - lived part of the time at the same address. - - José Raymundo died of bubonic plague at San Lazaro Hospital - on Friday, April 25, 1913. - - Norberta Mendoza, woman, aged fifty-six, lived at 1418, - interior, C. Dagupan. She was the mother-in-law of Simplicio - Enriques, the silversmith at 1364 Sande, and visited her - son-in-law there frequently and within a few days of her last - illness. She was taken sick April 22 and died at 1419, - interior, C. Dagupan, on the morning of April 26. At autopsy - at San Lazaro morgue, the same day, bubonic plague was found - to be present and the cause of her death. - - Trinidad Galves, a young woman, aged sixteen, lived at 1364 - Sande and was taken sick there on April 25. She was removed - to San Lazaro Hospital and died there April 26, extensive - plague lesions being found at autopsy. - - Pablo Banzon, man, aged twenty-six, living at 646 C. Ylaya, - was taken sick on Friday, April 25. He was removed to San - Lazaro Hospital Saturday afternoon and died there Sunday - evening, April 27. He was shown to have plague by - bacteriologic examination made at the Bureau of Science. He - worked at 1364 Sande as a silversmith, with José Raymundo and - was employed by Simplicio Enriques. - - Simplicio Enriques, aged twenty-seven, a silversmith, - conducting his business at 1364 C. Sande and employing José - Raymundo and Pablo Banzon, was taken sick about April 23. He - moved to two different houses in the interval between the - onset of his sickness and his transfer to San Lazaro Hospital - on April 27, first to 1419 C. Dagupan, interior, where he - remained until the death of his mother at this house; then to - 1492 Dagupan, interior, from which place he was transferred - to San Lazaro Hospital, where he died with bubonic plague a - few days later. Diagnosis was confirmed at autopsy. - -The two women were patients of Dr. Hernando of Calle Ylaya. He -recognized the case of the elder woman as a probable case of plague, -after death, and reported the matter to the Bureau of Health. - -The house at 1364 C. Sande is of the type in which cases of rat plague -and human plague have recently been found. In our operations to put the -house in a safe condition we found one dead rat, mummified, in the -basement. Unfortunately, the workmen who swept it out did not note the -exact location at which it was found. The house is in the midst of the -district where rat plague has raged since early in March, 1913. The -basement contained unauthorized and illegal sleeping rooms until a few -days before this outbreak when they were removed in the course of our -antiplague operations. The building is constructed of bamboo with a -nipa thatch roof. - -The front part of the basement was paved, but the pavement was -undermined and broken. Being convinced that dead plague rats were -present in the vicinity of this house and probably within it, I -directed that the cement floor under the silversmith shop and the -barber shop, located upon the ground floor at this address, be torn up. -Accordingly, this was done (April 28) and three dead rats and one live -one were found beneath the cement. As the bodies were mummified and -unfit for bacteriologic examination they were burned. The living rat -was examined at the Bureau of Science but was found to be healthy. The -cement floor was broken and permitted fleas from the dead rats to enter -the basement room of the house which was occupied by the silversmith -shop. The rats doubtless died from plague and the hungry fleas in due -time attacked the nearest persons at hand, the unfortunate occupants of -the silversmith shop and the two women who frequented the room also. - -These facts account for the epidemic at 1364 Sande very completely. - -The premises at 1364 Calle Sande were quarantined by the following -order: - - MANILA, April 27, 1913. - - The premises 1364 Sande are hereby declared in Quarantine for - Bubonic Plague by order of the Director of Health. - - The inmates will be permitted to leave the building and find - quarters elsewhere, provided they leave their addresses with - the policeman in charge, so that they may be readily found. - They must remain in the District of Tondo. If they remain in - the house they will be obliged to stay in the upper story of - the house and will have to arrange for meals to be sent in. - - The barber shop and "platero" shop are hereby ordered closed - until further orders. - - By order of the Director of Health. - - [Signed] T. W. JACKSON, - _Medical Inspector, in Charge of Plague Suppression_. - -Memorandum reporting circumstance surrounding 2 cases of plague at -1226 C. Juan Luna (May 17, 1913): - - Valeriano Lausin, aged fourteen, Filipino male, Carmelo maker - by trade but out of work at time he was taken sick, recently - removed to this house from 917 C. Jaboneros where he had been - employed. The patient fixes the date at about a week previous - to his sickness, but the proprietors of 917 Jaboneros are - positive in their statement that he left the place where he - lived and worked, at least two weeks before. This boy - recovered. - -The circumstances and especially the occurrence of a second case at -1226 C. Juan Luna, indicate that infection was incurred here. - -Moreover, this house is in the midst of a rat-plague infected district. - -[Illustration: PLAGUE HOUSE, 1226 CALLE JUAN LUNA] - -The house is of bamboo and nipa construction and contained illegal -basement rooms until a week ago. About 60 persons lived in this house -which was once licensed as a tenement but which is unsanitary in a -multitude of ways. Bamboo construction, overcrowding, dirty condition -and absence of proper drainage, water-closet, proper kitchens and paved -ground floors, together with bad ventilation, made it a dangerous -habitation and the added condition of plague infection made it -necessary to vacate and quarantine the building. - -On May 15, at the daily inspection of contacts in the house 1226 C. -Juan Luna, Filomena Suñga, aged nineteen, and a relative of the owner -of the building, was found to be sick. Her only symptom was fever, but -she was transferred to San Lazaro upon suspicion and promptly developed -symptoms of plague. She died in a few days and the diagnosis of plague -was verified at autopsy. The following order was issued: - - STATION "C," TONDO, BUREAU OF HEALTH, - MANILA, P. I., May 15, 1913. - - By order of the Director of Health, the house No. 1226 C. - Juan Luna is declared infected and is quarantined this date, - for Bubonic Plague. The house will be vacated and a policeman - will register the names of all residents and the addresses to - which they remove. - - The residents may remove their personal effects but will not - be permitted to return while the quarantine is in effect. - - [Signed] T. W. JACKSON, - _Medical Inspector, Station "C," Tondo_. - -Memorandum: Human body (dead from plague) and dead rats found in the -same basement room. Upon March 21, 1913, a Filipino laborer living at -140 Calle Perla, Tondo, was found dead from bubonic plague. - -Upon careful investigation and search of the premises the following -findings were disclosed: - -One rat, large, mummified and dry and therefore dead for at least one -week, was found clinging to a bamboo wall just back of the cot upon -which the dead human body was found. - -In a section of bamboo, in a timber constituting the ceiling of the -basement and also the upper part of the door frame, a rat, dead and -dried up, was found. This section was the end section of the timber -which was partly covered with nipa thatch, with which the sides of the -house were covered. The ends of a number of the outside rafters -(bamboo) were found to be gnawed through. - -[Illustration: BAMBOO HOUSE SUPPORTS SEALED WITH CEMENT TO PREVENT -ENTRANCE OF RATS (MANILA PLAGUE CAMPAIGN)] - -Similar conditions were found in adjoining houses and in one case a -live rat was driven out of a nest in the bamboo. - -SAMPLE OF DETAILED ORDERS ISSUED.--Sample of detailed orders issued by -Medical Inspector in Charge of Plague Suppression. Similar orders were -issued whenever new districts were entered or new work undertaken. - - Memorandum Order. Effective March 25, 1913: - - Beginning to-day, 13 men under Assistant Inspector Parás, - will commence cleaning operations at C. Ostra, extending - from the Bay to C. Sande and will clean towards C. Moriones. - They will be provided with a disinfecting pump and will - disinfect the ground surfaces wherever disturbed, outdoors - and indoors. Cleaning is to be done in the most thorough - manner possible, searching meanwhile for rat nests and rat - harbors; re-piling wood, tiles, stones and merchandise; - moving all movable goods out of doors in their search for - rats and rat-holes or nests. All goods are to be piled above - ground at an elevation of at least one foot. All bamboo beds - and bamboo rafters and parts of the house (in the basements) - made of bamboo or of double walls are to be thoroughly - investigated for rats. All foodstuff attractive for rats is - to be placed in covered boxes or galvanized iron cans, tin - cans or barrels, with tight-fitting covers. Special attention - is to be paid to straw, hay, shavings, grain, rat-holes, and - food. - - Two men will be detailed to cement up ends of bamboo and - rat-holes, but will not do general repairing. They will carry - materials for mixing cement as needed and will not be - wasteful of materials. - - If this force proves to be insufficient in numbers, - additional men may be detailed from the other working - parties. - - [Signed] T. W. JACKSON, - _Medical Inspector in Charge of Plague Suppression_. - -Specimen order issued to Sanitary Inspector assisting in Plague -Suppression by Medical Inspector in charge. - - Sanitary Inspector, Bureau of Health: - - Please place the gang of workmen under your charge in the - square bounded by Calles Velasquez, Moriones, Concha and - Manila Bay which is infected with rat plague. Treat the - houses and properties there in the same manner in which other - plague-infected districts have been treated, viz.: by - policing the houses and yards, vacating all basements of - light-material houses in which human habitations are - illegally present; removing (with the consent of the - occupants) all unauthorized basement sleeping places, beds, - platforms, etc., and other illegal structures, closing up the - open ends of bamboo rafters or timbers of the house with tin - or cement. - - Where the occupants resist this action sanitary orders should - be issued in the usual manner and interference should be - stopped until the order is served and complied with. There - are a number of most insanitary and unsuitable shelters of - bamboo, tin, etc., used for houses by a number of families in - this square and it is desirable to tear down these huts if - permission can be secured. If permission is refused orders - should be issued on the usual form. - - [Signed] T. W. JACKSON, - _In Charge of Plague Suppression_. - -[Illustration: VIEW OF HOUSE AT 447 CALLE CONSERVADOR, TONDO, WHERE -INFECTED RATS WERE FOUND (MANILA PLAGUE CAMPAIGN)] - -Specimen order issued by the Medical Inspector in charge of Plague -Suppression. - - STATION "C," TONDO, May 21, 1913. - - Redistribution of rat catchers and laborers engaged in - antiplague work. Effective May 2, 1913. - - Sanitary Inspector Kennard and 20 rat catchers will move into - Tondo District and trap and poison rats in the district - bounded on the west by Manila Bay and on the east by Estero - Reina. The work will be begun at the extreme north water - boundary of this district and will proceed toward the south. - - Sanitary Inspector Brantigan with a similar number of rat - catchers (20) will work within the same east and west - boundaries and will begin trapping and poisoning at Calle - Moriones, proceeding north. The poisoning and trapping is to - be done in the most thorough manner possible, as this is a - dangerously infected district and rat-plague must be - controlled and terminated here. - - The laborers, 60 men, divided into 4 parties of 15 men each - under Assistant Sanitary Inspectors Jesús, De la Rosa, - Laxamana and Parás, will continue the cleaning operations now - under way on both sides of C. Juan Luna south of C. Moriones - (plague localities in the same neighborhood), and thoroughly - disinfect. - - One party of 15 men will work in the vicinity of C. Perla, - vacate basements as habitations, search for dead rats in - yards, houses, bamboos, under broken concrete, etc., and will - close up openings in structural bamboo by means of tin and - cement. Emphasis is placed upon the necessity for permanently - vacating basements and men will be sent back over the ground - daily to see that the persons moved out do not return. - Reports are desired so that prosecutions for violations of - the law may be instituted if necessary. - - [Signed] T. W. JACKSON, - _Medical Inspector in Charge of Plague Suppression_. - -Specimen order issued to Assistants. - - May 4, 1913. STATION "C," BUREAU OF HEALTH: - - Please place work parties in (interior) 1627-1629 Sande and - 525 C. Azcarraga, to clean, disinfect and thoroughly - investigate these premises and the houses, stables and other - buildings in the vicinity. Search for rats, living and dead, - rat nests and rats in bamboos and wood piles, stone piles, - stables, under planks and elsewhere. Cement the openings in - bamboos in houses or close with tin. Make notes on needed - structural work. Do the work as thoroughly as possible. - - [Signed] T. W. JACKSON, - _Medical Inspector in Charge of Plague Suppression_. - -METHOD OF PROCEDURE IN COLLECTING AND FORWARDING RATS SUSPECTED OF -PLAGUE INFECTION TO THE LABORATORY IN MANILA, P. I.--Rat -catching,--trapping and poisoning,--is conducted in accordance with -instructions contained in the Sanitary Inspector's Handbook (pp. 36, -37, 38) issued by the Bureau of Health. - -Rats are collected in Manila and forwarded to the Bureau of Science for -autopsy and for biologic examination for the presence of plague bacilli -in the following manner: - -The various groups of rat catchers are provided with receptacles (iron -pails) and a supply of a mixture of kerosene, cresol and water -(kerosene 10 parts, cresol 2 parts; water 88 parts). - -In these vessels, filled with the pulicidal mixture, the rats are -immersed, with a minimum amount of handling, as soon as they are found -(whether in traps or dead from poison). - -If captured alive they are killed and then promptly immersed. The -mixture must be well shaken or stirred when used, as it separates upon -standing. The immersion is, of course, for the purpose of destroying -any fleas which may be present upon the captured rat. - -A paper tag showing the date and the exact location of the place of -capture, with the name or group number of the rat catcher, is next -affixed to a foot or to the tail of the rat and firmly tied upon the -same, where it remains until the rat cadaver is finally disposed of. -This tag is a card of strong Manila paper and the record upon it is -made with an ordinary lead-pencil, as both ink and indelible pencil -marks are apt to become illegible from wetting, whereas lead-pencil -marks are little affected thereby. - -If desired, the disinfected tag in any given case of rat plague may be -returned to the Bureau of Health, for identification, where an accurate -record of every rat captured is kept. - -After dipping and tagging, the rats are taken to a central point, again -dipped, and placed in large, tightly-covered, galvanized iron cans, in -which containers they are delivered to the laboratory by cart, once or -twice daily. - -THE CASE OF MR. C.--The following are the facts concerning the case of -Mr. W. C., a prominent American resident of Manila who suffered and -died from plague in 1914. - -Mr. C., an editor, was taken ill with plague on the night of September -18, sought medical advice and entered St. Paul's Hospital September 19, -and was transferred to San Lazaro Hospital, September 20, with an -established clinical and bacteriologic diagnosis of bubonic plague. He -survived till September 22. - -Upon September 21, in the course of disinfecting the business office of -Mr. C., located in a district which had furnished a number of cases of -both rat and human plague, a dead rat, mummified, was found in the -right hand drawer of his desk and fleas were seen to hop from the -drawer upon opening it. - -A flea killed by the disinfecting mixture at this desk was identified -at the Bureau of Science as a rat flea (_Xenopsylla cheopis_). - -The rat cadaver was sent to the Bureau of Science and the following -facts were reported from there some days later: - -The mummified rat and skeleton were pulverized in a sterile mortar and -an emulsion was made and injected into guinea-pigs. The animals died -from plague in a few days and plague bacilli were recovered from the -tissues, as well as from the rat cadaver, by culture. - -A second rat cadaver, found at the same time in the same building, -during cleaning operations, was similarly treated with identical -results. - -There could scarcely be a stronger chain of convincing evidence against -the rat and the flea, nor a more complete and convincing explanation of -Mr. C.'s death than that afforded by these established facts and -official documents. So far as I know there is no more striking case on -record in the modern history of plague. - -LETTER OF WARNING AND APPEAL.--The following letter of warning and -appeal for coöperation was suggested and framed by me February 10, -1914, at the time that extensive rat plague was discovered in the heart -of the business district of Manila. I presented it to the Director of -Health with a strong recommendation for approval and publication and -after consideration he approved and authorized publication upon -February 10. No change was made in the wording of the proclamation, -but it was issued over the signature of the Director of Health to give -added force and authority to the appeal. The results were, as I had -hoped they might be, highly beneficial. The taking of the public into -the confidence of the health authorities brought about a coöperation, -without which our efforts in this difficult situation would have been -sadly handicapped. It is my belief that this method should often be -used by health authorities, particularly where an intelligent community -is threatened. - - TO WHOM IT MAY CONCERN: - - You are hereby informed that the district bounded by Calles - Rosario, Juan Luna, Dasmariñas and Plaza Calderon (and - possibly the neighborhood bordering upon this congested - district) is a dangerous one for all persons living or - conducting business therein, on account of the presence there - of extensive rat plague. Six human cases (with five deaths) - have recently developed there and many dead rats have been - found. All human cases have been directly traced to rats dead - from plague. - - The Bureau of Health is now doing everything within its power - to make this district safe, but the attention of all - citizens, property owners and tenants is called to the fact - that they are required by law to keep their premises free - from rats and to abolish all structural conditions of the - buildings which favor the harboring of rats. This means - rat-proofing, and owners are earnestly urged to perform this - necessary work now, under the direction of the Bureau of - Health. - - As a temporary expedient and safeguard all interiors, walls, - floors and ceilings should be sprayed with kerosene daily, or - at intervals of two days, to kill the fleas which carry - plague from rats to human beings. All dark insanitary places - used for living rooms should be vacated at once; all - merchandise should be piled upon trusses at least a foot - above the floor; all straw, shavings and other material - attractive to rats for nesting, should be removed and burned - and all food materials upon which rats may feed and live - should be placed in covered boxes, bins or cans. - - All rat-holes should be permanently closed and all broken - cement or masonry should be repaired. - - Observance of these instructions may save the lives of - yourselves, your families and your tenants. It is your duty - to do your part in this matter, a part which neither the - Bureau of Health nor the Government can do for you. - - Through very great effort the Bureau of Health has controlled - plague in Manila and the Philippine Islands during the last - two years. - - Residents must now do their part, and owners of property must - permanently make their buildings safe for tenants, both for - business and residential purposes. - -BACTERIOLOGIC OBSERVATIONS MADE BY DR. OTTO SCHÖBL.--The following -observations upon the bacteriologic aspect of the Manila epidemic which -we are considering were made by Dr. Otto Schöbl of the Biological -Laboratory of the Bureau of Science, Manila, and pertain to the cases -of the first year of the epidemic. They were printed in the December -number of the _Philippine Journal of Science_ in 1913, but as they -belong so definitely to the epidemic I am describing and as Dr. Schöbl -has expressed his willingness for me to quote them in full, I gladly -accept his permission. Dr. Schöbl advanced the possibilities of -blood-culture diagnosis to such a point of reliability that it became -practically possible for us to expect positive culture in nearly every -case of true plague and the whole matter of bacteriologic diagnosis was -perfected to a high degree of efficiency under his administration of -the laboratory work. - -He relates his observations as follows: - - During the recent outbreak of plague in Manila, I had the - opportunity to make certain observations which are of - interest. These observations were made in the examination of: - (1) Specimens taken from patients and from dead bodies at - autopsies, (2) samples of blood-sucking insects collected in - houses where plague patients had lived, (3) rodents caught by - trap or poisoned in the parts of the city where plague cases - occurred from time to time, and (4) domestic animals suspected - of plague infection. - - I. BACTERIOLOGICAL EXAMINATION OF PLAGUE PATIENTS - - In order to secure as early diagnosis as possible, the - following procedure of investigation was adopted: - - 1. The bubo was aspirated by means of a sterile hypodermic - syringe. The material thus obtained was placed in the water - of condensation of an agar-slant culture tube. - - 2. At least 7 centimetres of blood were withdrawn from the - _cubital_ vein by means of another sterile syringe, and 5 - centimetres of it were placed in an Erlenmeyer's flask, - containing 200 centimetres of neutral meat broth. The rest of - the blood was emptied into a sterile tube, and used for - agglutination tests. - - Cultures obtained by this method were examined - microscopically, and the growths on various culture media - were studied. Gram stain, Löffler's methylene blue, and - hanging-drop method were used. Polar-staining and chain - formation in liquid media and the characteristic type of - colony on the surface of agar were looked for. Animal - inoculation was performed in every case, and the culture - isolated from each case was identified by agglutination test, - rabbit's immune serum being used. - - The results of the bacteriological examination of a series of - 24 patients are tabulated in the two following tables. Table - I includes the fatal cases and Table II those cases which - recovered. - - The diagnosis of plague could be safely made from the - microscopical examination of the liquid aspirated from the - bubo in the majority of the cases. However, in certain - instances the amount of the aspirated fluid being small and - the bacilli very few, it was impossible to diagnose the case, - especially when the cultures from the bubo were negative. - Repeated examination of the patient was necessary under those - conditions, but it happened in cases 22 and 23 that the - patients died of plague before a second examination could be - made. The smears and cultures from case 22 remained sterile, - while the smears and cultures made from the swelling on the - neck of patient 23 revealed the presence of pneumococci. Both - patients died of plague, as was ascertained by examination of - the organs after death. - - TABLE I.--EXAMINATION OF FATAL CASES OF PLAGUE - - ======================================================================== - |Date of Examination 1912 - | +-------------------------- - | |Duration of illness _Days_ - | | +---------------------- - | | |Hours before death - | | | +---------------- - | | | | Bubo - | | | |Smear - | | | | Culture - | | | | Animal - | | | | inoculation - | | | | +---------- - | | | | | Blood - | | | | |Culture - | | | Age | | | | | Aggluti- - Patient | Race |Sex |_Years_| | | | | nation - --------------+--------+----+-------+--------+---+-----+-----+---------- - 1. Sing Nu |Chinese |Male| (?) |July 11| 5 | 48 |+ + +|0 0 - | | | | | | | | - 3. Aluncion | | | | | | | | - Raymundo |Filipino|Male| 15 |Sept. 29| 3 | ... |+ + +|0 0 - | | | | | | | | - 4. Filo | | | | | | | | - Almalas |Filipino|Male| 39 |Oct. 10| 4 | 22 |+ + +|+ - - | | | | | | | | - 6. Polycarpio| | | | | | | | - Guzman |Filipino|Male| 34 |Oct. 22| 2 | ... |+ + +|0 0 - | | | | | | | | - 7. José | | | | | | | | - Sarmiento |Filipino|Male| 37 |Oct. 22| 3 | ... |+ + +|0 0 - | | | | | | | | - 8. Julian | | | | | | | | - Gonzales |Filipino|Male| 41 |Oct. 22| 3 | 23½ |0 0 0|+ - - | | | | | | | | - 9. Valeriano | | | | | | | | - Buencamino|Filipino|Male| 31 |Oct. 22| 3 | 10 |+ + +|+ - - | | | | | | | | - 10. Pedro | | | | | | | | - Nicomedes |Filipino|Male| 30 |Oct. 22| 2 | 5¾ |+ + +|+ - - | | | | | | | | - 12. Regino | | | | | | | | - Gulano |Filipino|Male| 34 |{Oct. 22| 2 |106 |0 0 0|+ - - | | | |{Oct. 24| 4 | 82 |0 0 0|0 0 - | | | | | | | | - 13. Martin | | | | | | | | - Dimalanta |Filipino|Male| 35 |Oct. 23| 3 | 25½ |+ + +|+ - - | | | | | | | | - 14. Roberto | | | | | | | | - Obiso |Filipino|Male| 5 |Oct. 23| 1 | 53 |+ + +|+ - - | | | | | | | | - 15. Juan | | | | | | | | - Barceta |Filipino|Male| 23 |Oct. 24| 3 | 37 |+ + +|+ - - | | | | | | | | - 16. Yu Tum |Chinese |Male| 14 |Oct. 24| 2 | ... |+ + +|0 0 - | | | | | | | | - 17. Augustin | | | | | | | | - Monterey |Filipino|Male| 29 |Nov. 1| 1 | 27 |+ + +|+ - - | | | | | | | | - 18. Demetrio | | | | | | | | - Pabraw |Filipino|Male| 27 |Nov. 23| 4 | 15 |0 0 0|+ - - | | | | | | | | - 21. Ambrosio | | | | | | | | - Sobremonte|Filipino|Male| 20 |Dec. 7| 6 | 1 |+ + +|+ - - | | | | | | | | - 22. Mateo | | | | | | | | - Marcelo |Filipino|Male| 8 |Aug. 20 |(?)| ... |- - -|0 0 - | | | | | | | | - 23. Alejandro | | | | | | | | - Gita |Filipino|Male| [A]17 |Nov. 24 | 3 | ... |- - -|0 0 - --------------+--------+----+-------+--------+---+-----+-----+---------- - - ======================================================================== - |Date of Examination 1912 - | +-------------------------- - | |Duration of illness _Days_ - | | +---------------------- - | | |Hours before death - | | | +---------------- - | | | | Skin - | | | |Smear - | | | | Culture - | | | | Animal - | | | | inoculation - | | | | +---------- - | | | | | Sputum - | | | | |Smear - | | | | | Culture - | | | | | Animal - | | | Age | | | | | inocu- - Patient | Race |Sex |_Years_| | | | | lation - --------------+--------+----+-------+--------+---+-----+-----+---------- - 1. Sing Nu |Chinese |Male| (?) |July 11| 5 | 48 |+ + +|- - - - | | | | | | | | - 3. Aluncion | | | | | | | | - Raymundo |Filipino|Male| 15 |Sept. 29| 3 | ... |0 0 0|0 0 0 - | | | | | | | | - 4. Filo | | | | | | | | - Almalas |Filipino|Male| 39 |Oct. 10| 4 | 22 |+ + +|0 0 0 - | | | | | | | | - 6. Polycarpio| | | | | | | | - Guzman |Filipino|Male| 34 |Oct. 22| 2 | ... |0 0 0|0 0 0 - | | | | | | | | - 7. José | | | | | | | | - Sarmiento |Filipino|Male| 37 |Oct. 22| 3 | ... |0 0 0|0 0 0 - | | | | | | | | - 8. Julian | | | | | | | | - Gonzales |Filipino|Male| 41 |Oct. 22| 3 | 23½ |0 0 0|+ + + - | | | | | | | | - 9. Valeriano | | | | | | | | - Buencamino|Filipino|Male| 31 |Oct. 22| 3 | 10 |0 0 0|0 0 0 - | | | | | | | | - 10. Pedro | | | | | | | | - Nicomedes |Filipino|Male| 30 |Oct. 22| 2 | 5¾ |0 0 0|0 0 0 - | | | | | | | | - 12. Regino | | | | | | | | - Gulano |Filipino|Male| 34 |{Oct. 22| 2 |106 |0 0 0|0 0 0 - | | | |{Oct. 24| 4 | 82 |0 0 0|+ + + - | | | | | | | | - 13. Martin | | | | | | | | - Dimalanta |Filipino|Male| 35 |Oct. 23| 3 | 25½ |0 0 0|0 0 0 - | | | | | | | | - 14. Roberto | | | | | | | | - Obiso |Filipino|Male| 25 |Oct. 23| 1 | 53 |0 0 0|0 0 0 - | | | | | | | | - 15. Juan | | | | | | | | - Barceta |Filipino|Male| 23 |Oct. 24| 3 | 37 |0 0 0|0 0 0 - | | | | | | | | - 16. Yu Tum |Chinese |Male| 14 |Oct. 24| 2 | ... |0 0 0|0 0 0 - | | | | | | | | - 17. Augustin | | | | | | | | - Monterey |Filipino|Male| 29 |Nov. 1| 1 | 27 |0 0 0|0 0 0 - | | | | | | | | - 18. Demetrio | | | | | | | | - Pabraw |Filipino|Male| 27 |Nov. 23| 4 | 15 |+ + +|0 0 0 - | | | | | | | | - 21. Ambrosio | | | | | | | | - Sobremonte|Filipino|Male| 20 |Dec. 7| 6 | 1 |0 0 0|0 0 0 - | | | | | | | | - 22. Mateo | | | | | | | | - Marcelo |Filipino|Male| 8 |Aug. 20 |(?)| ... |0 0 0|0 0 0 - | | | | | | | | - 23. Alejandro | | | | | | | | - Gita |Filipino|Male| [A]17 |Nov. 24 | 3 | ... |0 0 0|0 0 0 - --------------+--------+----+-------+--------+---+-----+-----+---------- - - [A] Months. - - TABLE II.--EXAMINATION OF PLAGUE PATIENTS WHO RECOVERED - - ========================================================================= - |Date of examination 1912 - | +----------------------- - | |Duration of disease - | | +---------------- - | | | Bubo - | | |Smear - | | | Culture - | | | Animal - | | | inoculation - | | | +---------- - | | | | Blood - | | | |Culture - | | | Age | | | | Aggluti- - Patient | Race | Sex |_Years_| | | | nation - ----------------+--------+------+-------+--------+------+-----+---------- - | | | | 1912 |_Days_| | - | | | |{Sept.29| 2 |- - -|0 0 - | | | |{Oct. 2| 5 |+ + +|0 0 - 2. Dionisio |Filipino|Male | 18 |{Oct. 3| 6 |0 0 0|- +1:16 - Capate | | | |{Oct. 7| 10 |- - -|0 0 - | | | |{Oct. 15| 18 |- - -|- +1:64 - | | | | | | | - 5. Alejandra |European|Female| 6 |Oct. 20| 7 |+ + +|0 0 - Fisher | | | | | | | - | | | |{Oct. 22| 2 |+ + +|+ - - | | | |{Oct. 24| 4 |+ + +|0 0 - 11. Gabriel |Filipino|Male | 21 |{Oct. 26| 6 |0 0 0|- +1:16 - Sevilla | | | |{Nov. 8| 18 |- - -|0 0 - | | | |{Nov. 15| 25 |- - -|- +1:64 - | | | | | | | - | | | |{Nov. 26| 3 |+ + +|+ - - | | | |{Dec. 6| 13 |0 0 0|- +1:32 - 19. Esteban |Filipino|Male | 15 |{Dec. 16| 23 |- - -|- +1:60 - Roa | | | |{ 1913 | | | - | | | |{Jan. 11| 48 |- - -|- +1:120 - | | | | | | | - | | | |{Dec. 2| (?) |+ + +|0 0 - 20. Sia Su |Chinese |Male | 35 |{Dec. 5| -- |0 0 0|+ - - | | | |{Dec. 16| -- |- - -|- +1:80 - | | | | | | | - 24. Purificacion|Filipino|Female| 19 |{Dec. 11| 3 |+ + +|0 0 - del Val | | | |{Feb. 11| 33 |- - -|0 0 - ----------------+--------+------+-------+-------------------------------- - NOTE.--The bubo in Nos. 2, 5, and 24 never opened - spontaneously. The pus was aspirated at the time of the - second, eventually third, examination. Nos. 11 and 19 opened - spontaneously. A fistula formed along the canal which was - caused by the puncture, and healed up in several weeks. Hard - inguinal buboes of secondary order persisted in patient 19 at - the time of second examination. No plague bacilli were found - either in the bubo of the first or second order. Patient 20 - had a considerable amount of pus in the inguinal primary bubo, - but it was not opened until after the last examination. - - Two of the patients, cases 8 and 12, had numerous plague - bacilli in the sputum at the time when the expectoration - showed the presence of blood (twenty-three and one-half and - eighty-two hours, respectively, before death). In 3 cases I - was able to prove the presence of _Bacillus pestis_ in the - skin lesions, _intra vitam_, fifteen, twenty-two, and - forty-eight hours, respectively, before death. In case 18 - there was no doubt that the skin lesions, which covered the - whole body and the face, were of secondary nature, as the - patient died shortly afterward. It was undoubtedly a case - similar to those reported by Gotschlich and Zabolotny.[5] In - the other two patients there was only 1 maculopapulous - efflorescence on the foot in case 1 (with a corresponding - femoral bubo) and 2 lesions of the same type on the arm and - forearm in case 4 (with a corresponding axillary bubo). It is - possible that these lesions were the original port of entry of - infection. Numerous plague bacilli were found in the skin - lesions of these cases, both microscopically and in culture. - - [5] Kolle und Wassermann: Handbuch der pathogenen - Mikroorganismen. Gustav Fischer, Jena (1903), =2=, 521. - - The plague patients tabulated in Table II recovered. They - were all treated with antiplague serum. While cases 5, 11, 19, - and 24 appeared clinically to be rather severe, cases 2 and - 20 were mild. - - It can be seen from the table that the plague bacilli may not - be detected in the enlarged gland at first (case 2) and that - their presence may be revealed only after repeated - examination of the bubo. It is also evident from the results - of repeated examinations that the plague bacilli disappear - from the infected gland in a comparatively short time, as a - rule at the time when pus starts to form. Contrary to the - findings in patients who died, distinct phagocytosis was - noticed in the smears made from the aspirated liquid in those - patients who recovered and who had been treated with serum - soon after the onset of the disease. It is undoubtedly this - process that clears the gland of the infectious agents. - - The general opinion in regard to the presence of _Bacillus - pestis_ in the circulating blood seems to have been, as - Thompson remarks, that "the bacillus is rarely to be found in - the peripheral blood stream before the agonal stage."[6] - - [6] Journ. Hyg., Cambridge (1906), =6=, 558. - - The Austrian Commission, using few drops of blood, found - positive blood culture in 40 per cent; Calvert in Manila in - 100 per cent when examined twenty-four hours before death; - Choksy, Berestneff, and Mayr in 45 per cent; and Greig in 60 - per cent. The Indian Commission examined 28 patients, and - obtained positive blood cultures in 16 out of 23 fatal cases. - Not a single positive blood culture was obtained from the - patients who survived. The time of blood examination in - positive cases was three and one-half to seventy-five and - one-half hours before death. The amount of blood used was 1 - cubic centimetre. Only 6 out of the 30 samples, which gave - positive blood culture, were found positive by microscopical - examination of blood smears. The following conclusions are - based on these observations in regard to the septicæmic stage - of bubonic plague: (1) "A severe septicæmia may be present - at a comparatively early stage of the disease and for a - considerable number of hours before death, and (2) the - septicæmia may be of an irregular and fluctuating type."[7] - - [7] _Ibid._ (1907), =7=, 395. - - From the tables it will be seen that out of 15 patients - examined by me, 14 gave positive blood culture; and of these - 3 recovered. One blood culture revealed the presence of - streptococcus in addition to _Bacillus pestis_. The results - of the examinations tabulated in Tables I and II show, in - agreement with the findings of the Indian Commission, the - occasional early occurrence of plague bacilli in the blood - stream, as the time of examination in the positive cases - varied from one hour to one hundred six hours before death. - In consideration of the ephemeral character of the septicæmic - stage of plague, as evidenced by repeated blood cultures in - the three patients who recovered, one can hardly avoid the - impression that there is a certain degree of septicæmia in - every case of plague. The possibility of detecting the - bacillus in the circulating blood increases in proportion - with the quantity of blood used for culture. The best chance - to recover plague bacilli from the circulating blood seems to - be in the stage of high fever and general prostration. - - The phenomenon of agglutination of plague bacilli by the - serum of patients was first observed by Wissokowitsch and - Zabolotny in 1897[8] and later confirmed by the German Plague - Commission. Vagedes, Klein, and others[8] pointed out the - defects of the reaction as a diagnostic means. Aside from - the technical difficulties, the reaction was found - inconstant, and its occurrence was not noticed until the - second week of the disease and even then only in low - dilutions of the serum. - - [8] Referred to in Kolle und Wassermann: Handbuch der - pathogenen Mikroorganismen (1903), =2=, 524. - - Although the recent work of Strong[9] and of Strong and - Teague[10] has reduced the technical difficulties, the fact - remains that positive agglutination of plague bacilli by the - patient's serum cannot be obtained in the first week of the - disease, and, therefore, the isolation of plague bacilli from - the body of the patient is still the only quick and safe - method of plague diagnosis. - - [9] The Philippine Journal of Science, Sec. B. (1907), =2=, - 155. - - [10] _Ibid._ (1912), =7=, 194-201. - - Having utilized the technic devised by Teague, I have had no - difficulty in performing the agglutination test in plague. - The emulsion of plague bacilli, to be used for the test, was - prepared by suspending young cultures of virulent plague - bacilli, grown at 30° C., in salt solution and filtering the - suspension through filter paper. No antiseptic was added nor - heat applied. Serial dilutions of unheated patient's serum - were mixed with equal amounts of bacterial suspension in - small test tubes. Incubation at 35° C. followed. Controls, - consisting of serial dilutions of normal human serum as well - as bacterial suspensions without serum, excluded any possible - error which might have been caused by spontaneous - sedimentation of the bacterial suspension; while a parallel - test with highly agglutinant serum facilitated the reading of - positive results. - - Altogether, 22 tests were performed on 15 patients, 11 of - whom were fatal cases and 4 of whom recovered. In the - negative reactions, the duration of the disease at the time - of examination ranges from two to six days. The non-fatal - cases showed slight agglutination from the sixth day on. From - that day, the agglutination titer of the serum was found to - rise, and the agglutinins persisted in the blood of - convalescents up to the seventh week of the disease.[11] - - [11] It is hoped that it will be possible to examine some of - the survivors for agglutination from time to time. - - It must be borne in mind that the patients, who showed - positive agglutination, had been vigorously treated with - antiplague serum. Nevertheless, in consideration of the low - titer of the curative serum (dilution 1:32, agglutination - positive; dilution 1:64, agglutination negative), the rise of - the agglutinant power of the patient's serum in dilutions - higher than 1:16 cannot be explained as wholly due to passive - immunity, but rather to active immunity arrived at on the - principle of simultaneous immunization. - - From the preceding observations the following conclusions are - drawn: - - 1. The importance of blood cultures as a diagnostic means is - evident from the fact that positive blood culture was - obtained in practically every case that was examined in the - febrile stage of the disease, even when buboes or signs of - pulmonary involvement had not been detected clinically. - - 2. It is also evident that _Bacillus pestis_ may be found in - the circulating blood of the patients even in cases which - subsequently recover. - - 3. The period of time during which _Bacillus pestis_ - circulates in the blood is evidently short and irregular. - - 4. Mixed infection may be encountered in plague septicæmia - (_Streptococcus_, _Pneumococcus_). - - 5. The agglutination test is of no value for the diagnosis of - plague, as it was found positive only in convalescents. - - 6. Phagocytosis of plague bacilli in the bubo was noticed - only in patients who recovered after being vigorously treated - with curative serum. - - 7. The presence of numerous plague bacilli in comparatively - insignificant skin lesions during the life of the patient - points to the possibility of direct transmission, while the - fact that a patient without any apparent bubo, who is not so - sick as to be detained from his daily occupation, may - expectorate large numbers of plague bacilli, are facts of - great importance with regard to the communication of the - disease. It is obvious that the last-mentioned condition - might, and very likely does, give rise to an epidemic of - pneumonic plague if the atmospheric and sanitary conditions - are favorable. - - TABLE III.--INSECTS FOUND TO CONTAIN BACILLUS PESTIS - - ====================================================================== - | | |Experi- - | | |mental - Author | Insect | Source of infection |trans- - | | |mission - ---------------+---------------+---------------------------+---------- - Yersin |Flies |Laboratory infection | - Nuttal |Flies |Experimental infection | - Nuttal |Bedbugs |Experimental infection |Negative - | | | by bite. - Nuttal |Flea |Experimental infection |Negative. - Hankin |Ant's fæces |Fed on plague material | - Hankin |Bedbugs |Plague hospital | - Ogata |Flea |Plague rats | - Simond |Flea |Plague rats, experimental |Positive. - Tindswell, 1900|Flea |Plague rats |Negative. - Tindswell, 1903|Flea |Plague rats |Negative. - Kolle |Flea |Experimental infection |Negative. - Gauthier and |Flea |Experimental infection |Positive. - Raybaud | | | - Liston |Flea |Epidemic among pigs; | - | | harbored fleas; | - | | dead rats found |Positive. - Zirolia |Flea |Retained _Bacillus pestis_,| - | | 7-8 days | - British |Flea |Repeated experiments |Positive. - Commission | | | - Verbijtski |Flea and bedbug|Experimental infection |Positive. - La Bonadière |Fly | | - and | | | - Xanthopulides| | | - Herzog |_Pediculus |Dead body of plague case | - | capitis_ | | - ---------------+---------------+---------------------------+---------- - - - II. OBSERVATIONS ON THE TRANSMISSION OF PLAGUE BY - BLOOD-SUCKING INSECTS - - Judging from the data which have been collected from the - literature[12] on the transmission of plague (Table III), - Simond seems to have been the first to call attention to - the important part which blood-sucking insects, particularly - fleas, play in the transmission of plague. Although many - investigators have been successful in demonstrating the - presence of _Bacillus pestis_ in the digestive system of - blood-sucking insects, it was not until the experiments of - Gauthier and Raybaud that the actual transmission of plague - infection by fleas was convincingly proved. Ever since the - exhaustive and conclusive experiments, which were carried out - both under natural and artificial conditions by the British - Plague Commission, and the work of Verbijtski, which antedates - the British Commission, were presented, there has been no - doubt that the transmission of plague by blood-sucking - insects, particularly by the fleas, is one, although not the - only, mode of spreading this disease. It is obvious, as Herzog - correctly remarks, that the factors which are responsible for - the spreading of plague must be considered individually in - each epidemic and in various parts of the world as well. There - is no doubt that the importance of any insect in the - transmission of plague depends on its habits as well as on - those of the host, be it either animal or man. - - [12] Centralbl. f. Backt., 1 Abt. (1897), =22=, 87, 437. - Report of Indian Plague Commission (1898-99). Zeitschr. f. - Hyg. u. Infectionskrankh. (1901), =36=, 89. Kolle und - Wassermann: Handbuch der pathogenen Mikroorganismen (1903), - =2=, 538. Zeitschr. f. Hyg. u. Infectionskrankh. (1905), =51=, - 268. Journ. Hyg., Cambridge (1907-10), plague numbers. _Ibid._ - (1908), =8=, 162, 260. - - During the recent outbreak of plague in Manila, several - samples of bed-bugs from the beds of the plague patients and - dog fleas from a plague-infected house were collected and - examined, but with negative result. - - In spite of the fact that it adds nothing new to the question - of whether or not plague can be transmitted by fleas, since - the question has been conclusively answered by the work of - the Indian Commission, nevertheless the following - observations of a small outbreak of plague among animals, the - spreading of which was due solely to fleas, are of interest. - - One wild rat was inoculated with strain Iloilo 3 of - _Bacillus pestis_. The skin adjoining the root of the right - ear was scarified, and a loopful of the culture was smeared - on the scarified skin. The rat was found dead three days - after the inoculation. - - The cage containing the dead rat was immersed in kreolin - solution. At autopsy the cervical glands were found slightly - swollen, somewhat reddened, but no hæmorrhagic oedema of the - surrounding tissue was noticeable. There was slight necrosis - at the place of inoculation, showing superficial, purulent - discharge. Clear effusion in both pleural cavities and one - hemorrhage in the pleura were found. The lungs were - hyperæmic, but otherwise normal. The spleen was of somewhat - darker color, but otherwise normal in size and appearance. - The liver showed a slight degree of parenchymatous - degeneration, the congestion making prominent the structure - of the organ. The typical, although not constant, changes of - the organ, which are characteristic of natural plague - infection in rats, were absent. The kidneys were without - macroscopic change. The lymph glands, with exception of the - cervical nodes, were normal. - - Examination of the rat's fur revealed ectoparasites on the - neck, under the chin, and back of the ears; these at the time - of the examination apparently were dead. About 6 common rat - fleas were found and identified as _Loemopsylla cheopis_ - Rothsch. The parasites were immersed in sterile salt solution - for three hours. When removed in a dry test tube, they began - to move about sluggishly. The intestinal tract of these fleas - contained blood. - - Five of the fleas were crushed by means of sterile forceps, - and inserted in a pocket under the shaved skin of a - guinea-pig. The animal died of plague within three days, - showing considerable hemorrhagic oedema around the place of - inoculation, typical bilateral inguinal buboes, and - characteristic changes in the spleen. Smears and cultures - made from the bubo and spleen were positive for _Bacillus - pestis_. - - Another wild rat, which was in a separate cage in the same - room where rat 1 had been kept, died twenty-four hours after - rat 1. The two cages were at least 10 centimetres apart. Rat - 2 harbored fleas of the same species as were found on rat 1. - - Numerous severe bites were detected back of the ears and on - the neck of the dead animal. The post-mortem findings were - identical with those described in rat 1; that is, cervical - buboes, pleural effusion, and slightly enlarged spleen. - - It is well to remark that both rats had been kept in the same - room for about six months. Fleas had never been noticed on - our guinea-pigs. During the time the rats had been kept in - the plague house no irregular results were noticed in - plague-inoculated animals. At the time the first rat was - inoculated no other plague-infected animals were in the - plague house, and since that time another building has been - used for plague-infected animals. - - Two days after the death of rat 2 three guinea-pigs, which - were kept in separate cages in the same room, were found dead - of plague (smears and cultures were both positive). Several - fleas (_Loemopsylla cheopis_) were found on the necks of these - animals. They were collected and inoculated in the same way - as the fleas from the first rat. The experimental animal, - which was inoculated with the fleas, was killed and found to - be infected with plague. The findings were local reaction, - inguinal buboes, and typical spleen. Smears and cultures were - positive for _Bacillus pestis_. - - Although numerous healthy guinea-pigs were examined in the - same plague house, no fleas could be found at that time, only - the 2 rats and the first 3 guinea-pigs are positively known - to have harbored fleas, the latter after the death of the - rats and not before. - - The gross lesions in these naturally infected guinea-pigs - were somewhat unlike those found in guinea-pigs infected - either by vaccination or by intraperitoneal or subcutaneous - inoculation. All except one showed primary buboes on the neck - with more or less extensive hemorrhagic oedema extending in - some cases over the thorax. There was little pleural effusion - present; the spleen always showed typical changes of necrotic - foci varying in size and number. In one instance similar foci - were found also in the liver, large enough to be visible - macroscopically. This was in a case where like changes were - found in the lungs. - - Only one of the guinea-pigs showed an exception, in that the - primary buboes were located in the inguinal region, with - pelvic and axillary glands secondarily involved. These are - the findings usually met within guinea-pigs artificially - infected with plague by the vaccination method, if the lower - part of the abdomen be chosen for inoculation. The reason for - such a deviation from the findings in the rest of the - guinea-pigs may lie in the fact that this animal was almost - completely deprived of hair by a skin disease. - - It is of importance to mention the skin lesions which were - found on the necks of the guinea-pigs, particularly under the - chin. Besides small red spots which appeared to be fresh flea - bites, small, elevated, and fairly deep infiltrations partly - covered with moist scab were found in the skin under the - chin. Other animals showed changes usually found in the - scarified skin of guinea-pigs after artificial inoculation - with plague material. The base of each cutaneous - efflorescence was hemorrhagic and oedematous. - - A histological study of the tissues of these guinea-pigs - known to be naturally infected by plague fleas showed the - following changes: - - THE CERVICAL BUBO.--The enlarged lymphatic gland was - surrounded with a thickened capsule. Necrosis existed in the - subcapsular part of the gland, where it formed an almost - continuous circular zone, leaving the central part less - changed. Smaller irregular necrotic foci were scattered - throughout the section. Polymorphonuclears in various stages - of disintegration were found throughout the section. - - _The Lungs._--Very few blood extravasations were present in - the alveoli; otherwise normal. - - _The Spleen._--The capsule was thin. There were subcapsular - hemorrhages. The Malpighian bodies were somewhat enlarged, - but of normal structure. Throughout the parenchyma irregular - multiple necrotic foci were found, leaving but little of - spleen tissue intact. Numerous polymorphonuclears which were - present showed varying degrees of karyorrhexis. - - _The Kidneys._--The outline of the cells was indefinite; a - few miliary hemorrhages existed in the cortical part of the - organ. - - _The Liver._--There was excessive congestion, fatty - degeneration, and pigmentation of the cells. The capsule was - slightly thickened. - - _The Skin._--The epithelium was missing in one place in the - section, and cellular infiltration extended from that place - into the subepithelial layer of the surrounding skin. The - same kind of infiltration reached deep into the skin, stripes - of cellular infiltration penetrating into the tissue along - the muscle fibres. There was no direct connection between the - cellular infiltration and the follicles of the hair. - - It may be well to describe in detail the time of death from - plague among these and the other animals in this outbreak, as - well as the time when the plague house was disinfected. - - The first animal (rat 1) having been inoculated on August 27, - in the afternoon, died of plague within three days (August - 30). The second animal (rat 2) died twenty-four hours later. - Guinea-pigs 3, 4, and 5 (see plan) were found dead on the - morning of September 2; that is, two days after the death of - rat 2 and three days after the death of rat 1. - - The same day that the three guinea-pigs were found dead of - plague, rooms I, III, IV, and VI were thoroughly disinfected. - The floor, the ceiling, and the walls were sprayed with - kerosene and lysol solution. The remaining animals in room VI - were destroyed, and the cages disinfected. No animals were - kept in rooms I, III, and IV at that time. - - Three days after the death of animal 5, guinea-pigs 6 and 7 - were found dead of plague, while the next day guinea-pigs 8 - and 9 died. No death occurred on September 7, but the next - two days each recorded two plague guinea-pigs (10, 11, 12, - and 13). On September 11, the last guinea-pig died of plague - in this outbreak. The whole building was then thoroughly - disinfected. No plague-inoculated animals were kept in the - rooms after the first sign of the epidemic. After September - 11, no more cases of spontaneous plague infection were - observed. - -[Illustration: ANIMAL HOUSE] - - It will be noticed that the epidemic lasted eleven days - after the first animal died and fourteen days after animal 1 - was inoculated. Altogether, 14 animals out of at least 200 - animals exposed died of plague. - - No death occurred among rabbits, although these animals were - distributed among the guinea-pigs. In fact, 2 rabbits were - surrounded by plague guinea-pigs 8, 9, and 10, but did not - contract plague. - - From the epidemiological standpoint it is interesting to know - the dimensions and location of the cages in which the animals - were kept. - - Aside from the 2 rats which were confined in ordinary traps - that stood on a table 80 centimetres high, the rest of the - animals were kept in regular metal animal cages. The - dimensions of the cages are: Fifty centimetres long, 36 - centimetres broad, and 30 centimetres high. The cage stands - on four legs each 10 centimetres long; the centre of the - bottom of the cage holds a drain opening 8 centimetres above - the floor. - - The majority of the cages in room II were located on the - floor; some on the second shelf of a wooden rack. This - last-mentioned arrangement, judging from the construction of - the wooden frame, allowed a continuous passageway for the - fleas to the second shelf of the racks. On the other hand, - the deaths among the guinea-pigs in room V were restricted to - the cages standing on the floor, the majority of cages in - that room being placed on tables 80 centimetres high. - - Only a theoretical explanation can be given of the short - duration and sudden cessation of the outbreak. One can assume - with great probability that the first partial disinfection - drove the fleas away from the primary source of infection, - and that they traveled as far as possible. They finally - settled in those guinea-pig cages which had not been molested - by the first disinfection. Having no new supply of plague - blood (all of the plague-infected guinea-pigs having been - removed, most of them before death), the fleas soon cleared - themselves of plague bacilli. The peculiar feature of the - outbreak, namely, the failure to find fleas on the animals in - rooms II and V, finds its explanation in the observation of - the Indian Commission who found that the fleas "died or - disappeared very rapidly." - - The following conclusions can be drawn from these - observations: - - 1. The common rat flea (_Loemopsylla cheopis_) prefers the rat - to the guinea-pig. - - 2. In the absence of rats it will attack guinea-pigs rather - than rabbits. - - 3. The fleas which have sucked blood from rats or guinea-pigs - afflicted with plague septicæmia were found to harbor - virulent plague bacilli inside of their bodies. - - 4. The transmission of plague infection by direct or indirect - contact being excluded in our case, the fact that fleas of - the same species and harboring plague bacilli were found on - the rat and on the guinea-pigs, the presence of flea bites on - the rats and on the guinea-pigs with positive findings of - skin lesions on that part of the body where the fleas and - flea bites were located, together with the anatomical picture - of the findings in the guinea-pigs, lead to but one - explanation; namely, that the plague infection was - transmitted by fleas. - - - III. OBSERVATIONS ON ANIMALS SUSPECTED OF PLAGUE - - Out of the several tens of thousands of rodents examined - during the antirat campaign, we have found only two plague - rats which showed the typical picture of natural plague - infection in rat; that is, cervical buboes with surrounding - oedema, subcutaneous injection, pleural effusion, enlarged - spleen, and such changes of the liver as are characteristic - of natural plague infection in rats. Microscopically, large - numbers of plague bacilli were found in these cases, and pure - cultures of _Bacillus pestis_ were recovered from the spleen. - Histological examination of internal organs, particularly - that of the liver, confirmed the bacteriological findings. - The remainder of the plague rats exhibited only two of the - signs of plague infection, namely, bubo and oedema of the - surrounding tissue, and eventually hemorrhages. - - Besides plague infection, a great number of rats showed - purulent conditions from causes other than plague. Abscesses - of the lungs were frequently met with, and cervical or - axillary buboes are not uncommon in Manila rats. Various - pyogenic bacteria were found in the pus of such abscesses. Of - the less common was _Bacillus pyocyaneus_ and the - pneumobacillus of Friedländer. Chronic plague was excluded in - these cases since the animal inoculation failed to produce - plague infection. - - More than half of the rats examined harbored parasites in - their organs. _Echinococcus taeniæformis_ was found in the - liver of practically every gray rat, while a small _Ascaris_ - and _Tænia diminuta_ were not uncommon in the intestines. Two - rats were found to have sarcosporidiosis, 2.6 per cent. - showed rat leprosy, and 7.4 per cent. trypanosomiasis. One - tumor of the mammary gland and one tumor in the axillary - region were encountered, while one tumor of the large - curvature of the stomach proved to be a chronic inflammatory - tumor due to parasites. One peritoneal tumor in a rat (_Mus - decumanus_) gave the impression of a malignant tumor on - account of the miliary dissemination of the peritoneum. It - was found to consist of muscle and spindle-cell sarcomatous - tissue. Ectoparasites were very seldom noticed, on account of - the method of collecting the rats. When present, they were - mites and fleas. - - In the naturally infected plague rats the rigidity of the - fresh cadaver was pronounced. The primary bubo was in every - case cervical. Cervical glands were enlarged and hemorrhagic - with slight oedema of the surrounding tissue. The subcutaneous - injection extended over the neck and chest. The inguinal - glands were small and pigmented. The lungs were collapsed, - and showed hemorrhagic foci. The spleen was slightly - enlarged, firm, and dark red. The liver was rather large, - firm, pale red, with shade of yellow, which was caused by - minute yellowish foci thickly scattered throughout the tissue - and visible through the capsule. The kidneys were hyperæmic. - The intestines were without change. The serous membranes were - pale with no hemorrhages. - - Histological examination of the tissue of naturally infected - plague rats showed the following changes: - - _Liver._--The structure of the organ was well marked; the - veins dilated, trabeculæ slightly compressed, nuclei well - stained, and few of the liver cells showed vacuoles. Small - foci, most numerous under Glisson's capsule, were scattered - throughout the organ; they varied in size, but were not - larger than a miliary tubercle. The small necrotic foci were - found to consist of few necrotic liver cells. The centre of - the larger foci was formed by degenerated and necrotic liver - tissue, surrounded by round-cell infiltration. - Polymorphonuclears were also found in the zone of cellular - infiltration. There was a slight degree of hemorrhage in - each focus. Epithelioid cells and large vesicular cells with - several nuclei were to be found. The foci, mentioned above, - were sharply demarcated from the surrounding liver tissue, - which appeared to be intact. - - _Spleen._--The structure was well preserved, the capsule - thin. The Malpighian bodies were normal as to the elements of - which they consist. Cells with pycnotic nuclei were scattered - throughout the organ, and vesicular cells with small, deeply - stained, excentrically located nuclei were present. - Polymorphonuclears were found in the tissue in considerable - numbers. No localized necrotic foci could be found in - sections through the spleen. - - _Cervical Glands._--The blood-vessels were considerably - distended. A few hemorrhages and polymorphonuclears were - present. Oedema of the capsules and surrounding tissue - existed. Part of the gland was necrotic. - - _Lungs._--The blood-vessels were distended. The alveoli - contained homogeneous masses and blood. There were numerous - subpleural hemorrhages. The bronchi were collapsed, and - contained mucus. - - _Kidneys._--The cortical part showed subdued structure; the - epithelial cells had an indefinite outline and occasionally - showed vacuolization. The medullar part was better preserved. - There were miliary subcapsular hemorrhages. A few small foci - were scattered throughout both medullar and cortical parts. - They consisted of round-cell infiltration. - - - NATURAL PLAGUE INFECTION IN A CAT - - The experiments of the German Plague Commission proved that - cats showed considerable resistance to plague infection as - cutaneous and subcutaneous inoculations failed to infect - them. According to the Austrian Commission, cats develop - submaxillary buboes if fed on plague material. They are said - by Albrecht and Gohn[13] sometimes to recover. Out of four - cats fed on plague material two died of plague, one showing - submaxillary, the other mesenterial buboes. Virulent plague - bacilli were found in the discharge from the nose and also in - the fæces of cats which apparently did not become infected - after having been fed on plague material. - - [13] Über die Beulenpest in Bombay im Jahre 1897 (1897), II - B, II C. - - One case of spontaneous plague infection of a cat was - recorded by Thompson[14] in Sydney. - - [14] Report of an outbreak in Sydney, 1900. Referred to in - Kolle and Wassermann (1903), =2=, 510. - - W. Hunter,[15] in Hongkong made observations on cats - suffering from plague infection. The author also undertook a - few experiments, and arrived at the following conclusions: - - 1. Cats suffer from plague. - - 2. The disease may be acute or chronic. - - 3. The type of the disease is septicæmic. - - 4. The animals may occasionally play a part in the - dissemination of plague. - - 5. In plague-infected areas cats probably become infected - through rats, which they devour as food. - - 6. In plague-infected districts possible plague infection in - cats is of great importance from a domestic point of view. - - [15] Lancet (1905), =I=, 1064. - - On November 27, 1912, a sick cat was brought to the - laboratory for examination. It was reported that the animal - was found in a warehouse in which dead rats had been found - some time previously. The rats were not examined. In the - morning of the 30th, the cat was found dead in the cage where - it had been kept under observation. The following are the - post-mortem findings: - - The animal was a fairly well-nourished female.[16] The - subcutaneous tissue, pericardium, mediastinum, and - mesenterium contained considerable amounts of fat. - - [16] The cat was the mother of 4 kittens which were about 3 - weeks old at the time the cat was delivered for examination. - They were kept under observation for several weeks, but - showed no signs of plague infection. - - The subcutaneous tissue of the neck showed oedema and small - hemorrhages. The submaxillary tissues were swollen on both - sides. When the fasciæ and superficial muscles of the neck - were removed, enlarged glands were found on both sides. These - were closely attached to the submaxillary salivary glands. - The surrounding tissue was oedematous, but no hemorrhages were - noticed in the vicinity of the enlarged glands. Upon section - the glands were found to be necrotic, and upon pressure a - thin purulent liquid escaped. There were no hemorrhages - within the glands. Several enlarged lymph-nodes, smaller in - size, could be followed down the neck on the left side. The - lymph-nodes in the axillæ as well as in the groins and - peribronchial nodes were normal. The mesenteric glands were - slightly enlarged and reddened. - - The lungs were slightly collapsed. A clear, sanguineous, - slightly coagulated effusion was observed in both pleural - cavities. The tissue of the lungs showed considerable oedema - and hypostasis. The bronchi and pharynx showed no changes, - the mucous membrane being pale and thin. - - The heart was normal. - - The spleen was enlarged, of light red color, with follicles - slightly prominent. - - The stomach contents was blackish in color; there were no - hemorrhages or ulcers in the mucosa. - - The liver was somewhat enlarged. The organ showed prominent - structure, the centres of the acini being red, the periphery - lighter in color. - - The kidneys were slightly enlarged and pale. The capsule - peeled off easily, the venæ stellatæ were prominent, the - surface smooth; there were no hemorrhages. The cortex was - increased in breadth and was of the same color as the - surface; the pyramids were darker in color. The organ was of - fragile consistence. - - Suprarenals were normal, as were also intestine and bladder. - - The histological findings were as follows: - - _Bubo._--The capsule of the gland was oedematous. The whole - gland as seen in cross section had undergone necrosis, except - a few foci which still showed cellular structure. - - _Lungs._--The alveoli were filled with homogeneous masses, - containing but few degenerated epithelial cells and - leucocytes. The blood-vessels were dilated, particularly in - the subpleural part of the organ. In some places capillary - mycotic emboli with subsequent hemorrhage were encountered. - The large blood-vessels and bronchi were normal. - - _Salivary Glands._--Those glands attached to the primary bubo - showed the normal structure of a combined mucous and serous - gland. - - _Liver._--There was considerable congestion. The centres of - the acini showed parenchymatous and fatty degeneration. The - cells on the periphery of the acini exhibited typical fatty - infiltration. The large blood-vessels and small ducts were - without change. - - _Kidney._--The cells of the kidney showed various degrees of - degeneration, ranging from parenchymatous to fatty - infiltration. There were a few capillary hemorrhages and - hyaline casts present. - - _Suprarenals._--These showed slight degeneration. - - _Spleen._--This organ showed congestion, a few hemorrhages, - and bacterial emboli; otherwise normal. - - The bacteriological examination of the material from this cat - gave the following results: - - 1. _Smears:_ - - _a._ From the buboes showed degenerated leucocytes, many - lymphocytes, and numerous bacteria, some of which resembled - _Bacillus pestis_ in their polar staining. - - _b._ From the spleen showed numerous plague-like, - polar-stained bacilli. Round involution forms were present. - - 2. _Cultures:_ - - _a._ From the buboes were badly contaminated with _Bacillus - coli_ and _Bacillus pyocyaneus_ colonies. - - _b._ From the spleen: A few scattered colonies of _Bacillus - pyocyaneus_ developed on the surface of the agar. Between the - large colonies a scanty growth of dewy appearance was - noticed. Smears made from this growth revealed plague-like - bacilli of the cultural type, showing a few club-shaped - involution forms. Subcultures were made in order to secure - pure culture. They showed a pure growth of _Bacillus pestis_ - as indicated by the morphology of bacilli and shape of the - colonies. Agglutination with plague-immune serum was - positive. - - 3. _Inoculation experiments (vaccination method):_ - - _a._ One guinea-pig was inoculated with the material from the - left bubo, another one with material from the right bubo. - They died of plague on the third and fifth days, - respectively. - - _b._ One guinea-pig was inoculated with the material from the - spleen. It died of plague on the third day. - - _c._ One guinea-pig was inoculated with material from the - nostrils obtained by swab. The animal survived, showing no - indication of plague. - - _d._ One guinea-pig was inoculated with material from the - rectum obtained by swab. It died of plague on the fifth day. - - Although plague infection among cats is apparently a rare - occurrence, the fact that cats may contract the disease in - spite of the high degree of resistance to plague infection - has to be considered from the hygienic standpoint. - - To appreciate the important rôle which cats may play in the - spreading of the disease one need only consider the close - contact of these animals with rats on one side and human - beings on the other. It is also a well-established fact that - not only plague-infected cats, but also those which have - devoured plague-infected material and remained apparently - normal, may excrete plague bacilli which have retained their - full virulence. - -NOTES ON PLAGUE IN HONG KONG BY DR. ROBERG.--During the Hong Kong -epidemic of plague which preceded and was coincident with that of -Manila, I visited that city twice (December, 1913, and July, 1914), but -I did not closely investigate the methods adopted and carried out by -the authorities there, for the reason that the Manila plan was so much -more productive of results, as shown by the apparent inability of the -Hong Kong officials to gain control of the disease. However, I received -from Dr. David Roberg, of the Oregon State Board of Health, a copy of a -report made by him to the Secretary of his State Board of Health, -following an investigation of the Hong Kong epidemic and the methods -there followed. I have Dr. Roberg's permission to use his report and it -is herewith presented. It is dated Manila, April 16, 1914, and is as -follows: - - I have the following notes to present on the epidemic of - bubonic plague in Hongkong. - - On April 5th when I arrived in Hongkong the epidemic was - rapidly approaching its height. With its onset in January - there were 47 cases, in February 42, and in March 223. During - the week previous to April 5th, there were 91 cases; during - the six days I was in Hongkong they averaged 15 a day. - - Judging from previous epidemics the present one will be - exceptionally severe. The season for the occurrence of human - plague is from the months of February to July. The onset is - gradual; in May it reaches its maximum and then declines. In - the epidemic of 1912, for the city of Victoria the monthly - rate showed the following, January 9, February 22, March 61, - April 265, May 513, June 346, July 105, August 11, and - September 1. Comparing these rates with those of the present - year it will be seen that the number for March far exceeds - that of two years previous. - - Illustrating the season for human plague, with its onset, - maximum and decline, are the monthly rates for the city of - Kowloon during 1912, when the following cases occurred: - February 2, March 12, April 52, May 246, June 152, July 39, - August 8, and September 3. - - The season for human cases is determined by the condition of - the rats. At the close of the season in July the rats die off - from plague in great numbers as it is then the hottest time - of the year. During the months from September to February the - rats increase in number and in susceptibility to the extent - of being sufficient to again infect human beings. Moreover - every other year shows a marked severity in the epidemics of - human bubonic plague. This is explained by the fact that it - requires two years' time for the rat population to become of - sufficient greatness and susceptibility to cause a severe - human outbreak. This is shown by the yearly number of cases - since the year 1911. During the years 1911, 1912 and 1913 - respectively, there were 253, 1847, and 408 cases. During the - present year the monthly rate is exceeding that of the heavy - year of 1912. - - The severe epidemic in 1912 was a result of the influx of - 50,000 Chinese refugees into Hongkong during the revolution - in 1911. The number of rats in the native district depends - upon the available food supply, and as a result of this human - overcrowding the amount of waste food so increased in the - houses, yards and streets, that the over accumulation of - garbage could not be kept pace with. This influx also brought - in great numbers of susceptible rats. - - The number of rats killed off during the epidemic in 1912 - were so great that in 1913 they had not recovered - sufficiently to cause a severe outbreak during that year, and - as a result of the lightness of epidemic in 1913, they are so - increased in number and susceptibility now that they are - causing a very severe epidemic in human beings. - - Of rats in Hongkong they have the _Mus decumanus_ or drain - rat and the _Mus rattus_ or house rat. It is noteworthy that - the drain rat is found plague-infected throughout the year, - while the house rat is found infected only during the period - in which the human epidemics occur, namely from February to - July. The number of infected rats a year run parallel to the - number of monthly cases. - - The bulk of human infection is due to the spread of house - rats. Man also becomes infected by the drain rat when the - drains are flooded by rain storms and the rats are driven - into the houses. - - What has made plague permanent in Hongkong is the - overcrowding of the native districts. Besides there is a - floating population entering and leaving the native quarters, - numbering about 4000 a day. The native houses have been built - with double floors and walls which harbor the rats. Where the - construction is of wood it is possible to remove the rat - spaces. It has been found since the introduction of plague - into Hongkong in 1894, that those districts containing the - greatest number of soft brick houses with hollow walls, have - shown the greatest incidence of plague. This can not be - remedied as it would involve the destruction of buildings on - too large a scale. - - - THE WORK OF THE SANITARY BOARD - - The area under the control of the Board comprises the Island - of Hongkong containing 32 square miles, with a sea frontage - of 13 miles in length. Included also is the old city of - Kowloon which is situated one mile and a third across the - harbor and contains two and three-fourths square miles. The - city of Victoria on the northern shore of the Island of - Hongkong has a sea frontage of 5 miles, contains about ten - thousand domestic buildings, of which about one thousand are - non-Chinese. - - The population of Hongkong is difficult to estimate, as the - floating population is so great. In the 1912 census there - were 446,614 Chinese and 21,163 non-Chinese. - - The city of Victoria is divided into 10 Urban Health - Districts and old Kowloon into 2. There is an inspector in - charge of each. These districts are built over an area - averaging from 31 to 140 acres. The houses in these districts - average one thousand and the population from 8000 to 33,000. - There are four inspectors in charge of the scavenging work, - one for the disinfection stations in Victoria and old - Kowloon, one for the cemeteries and two for general duty. - - The measures employed by the Sanitary Board are summarized as - follows: - - 1. The exclusion of rats from all dwellings by means of - concreted ground surfaces, the protection of all drain - openings and ventilating openings by iron gratings, and the - prohibition of ceilings and of hollow walls in new buildings - and in those existing buildings from which they have been - removed by order. - - 2. The collection and bacteriological examination of all dead - rats. Facilities for the collection of rats in the quarters - are provided in the shape of small covered bins attached to - lamp posts, telephone posts, electric light poles, etc. These - bins contain a carbolic acid disinfectant, and the - inhabitants are invited to at once put into them all rats - found or killed by them. There are 650 of these bins - distributed throughout the city and its suburbs, and each of - them is visited twice daily by rat collectors who take all - rats found by them to the City Bacteriologist. Each rat is at - once labelled with the number of the bin from which it is - taken, and if subsequently found to be plague infected, a - special survey is immediately made of the block of houses in - that vicinity. All rat-holes and rat runs are filled up with - broken glass and cement, defective gratings and drains dealt - with, and rat poison distributed free to the occupants. If - several plague-infected rats are found in one locality, a - special house-to-house survey and cleansing of that district - is made. - - 3. The destruction of rats by poison, traps and birdlime - boards; special efforts in this direction being made just - before the onset of the regular plague season which is in the - months of from March to July. - - 4. The encouraging of the community to keep cats. - - 5. The systematic cleaning and washing out of all native - dwellings at least once in three months with a flea killing - mixture made by emulsifying kerosene in water. - - 6. An efficient daily scavenging of all streets and lanes - and the daily removal of refuse from the houses, coupled - with the provision of covered metal dust-bins, to reduce as - far as possible the amount of food available for rats. - - 7. The disinfection of plague-infected premises by stripping - them and washing them out thoroughly with a kerosene - emulsion. The bedding, clothing, carpets, rugs, etc., are - conveyed in a huge covered basket to the disinfecting plant - and sterilized with superheated steam. No objection is made - to the treatment of plague cases in native hospitals, and no - restrictions are imposed in regard to the burial of those - dead with plague except the provision of a substantial - coffin. - - 8. Every effort is made by means of lectures, addresses and - explanations to induce the native population to participate - in the above preventive measures. - -Upon my last visit to Hong Kong, in July last, plague was abating. _The -South China Morning Post_ of July 15, 1914, contained the following -statement: - - Plague is gradually disappearing from Hongkong. Last week's - return shows that there were 26 cases, of which 19 were fatal. - All were Chinese. The total number of cases for the current - year to date is 2093, with 1939 deaths resulting. - -I regret that circumstances do not permit me to relate in detail the -work done and the observations made during the closing six months of -the Manila epidemic. - -Up to the day of my departure from the Philippines, in July, 1914, I -remained in charge of plague suppression, but the added duties of -administration at San Lazaro Hospital and the coincident occurrence of -a cholera epidemic prevented me from keeping a detailed record in such -form as to permit reproduction here. It will therefore suffice to say -that the first six months of 1914 witnessed the passing of the most -threatening situation that has confronted the city of Manila in years. -The record of plague rats found does not convey an accurate idea of the -prevalence of rat plague by any means, for the simple reason that, when -found, the rat cadavers were in such condition as to forbid -bacteriologic examination; and inasmuch as the bacteriologic test of -plague had been used exclusively in determining rat plague up to this -time, it seemed desirable to adhere to the original method. - -In February we found in one of the districts, in which we undertook -systematic work in consequence of a few cases of human plague, a very -large number of dead rats, in and adjacent to houses which furnished -human plague cases. In one building alone more than 150 rat cadavers -were found during our cleaning and rat-proofing operations. It is this -district concerning which the letter to the public (already quoted) was -written. - -The methods followed in treating this new and dangerous focus of -infection did not differ from those practised during the previous year, -except in the matter of intensity. Forces of the cleaning and -rat-catching gangs were increased and the utmost thoroughness of -treatment was insisted upon. The results fully justified our policy and -demonstrated again how feasible it is to fight plague successfully if -adequate authority be given. - -During the last year of the epidemic in Manila it became the rule for -us to expect our plague workers to locate and find the identical rat -cadaver from which the infected fleas bore the disease to the human -victim, provided the spot upon the floor where the patient's sleeping -mat had been placed was known. In the better class of houses the rat -(sometimes more than one) was found dead beneath the floor, behind some -post casing, or in other space caused by double construction. Time and -again I have directed the removal of some panel of woodwork, some post -casing, or a board of the floor with the full expectation (seldom -unrealized) of finding a dead rat or a rat nest. These experiences were -positively uncanny at times. In the houses of the poorer class, usually -of bamboo and thatch construction, the finding of the rat was less easy -and more uncertain, although the nest was repeatedly found, and as -related elsewhere the dead rat itself might be found in a hollow bamboo -timber, or in the thatch construction of the wall. In a house on Calle -Echague, from which a Filipino and his wife were removed, dead, within -a few hours of each other, several dead rats were found in the floor -(the only piece of double construction in the whole house) within four -feet from the spot where the sleeping mats were placed. A rat hole led -to the nest and through this hole the fleas from the dead rats found -their way to the human victims sleeping on the floor above the encased -nest. - -These instances could be multiplied many times, but there is no longer -any special reason to do so, as the rat and the rat-flea are so -completely incriminated as to render these repetitions quite -unnecessary, however interesting they may be to the plague worker. The -danger of pursuing these investigations, to the persons so engaged, -must not be lost sight of, and exposure of such nests and rat cadavers -should invariably be preceded by thorough spraying of the place, and -particularly of the spot where tearing out of double construction is to -be done. I know of no more dangerous employment than this, both for -laborer and bystander. - - - - - CHAPTER IV - - ITS DIAGNOSIS AND TREATMENT - - -It was not my original intention to include the subjects of diagnosis -and treatment in this presentation, except in so far as I have already -referred to them in the relation of my Manila experiences in the -preceding pages. I have decided, however, to add a chapter upon -Diagnosis and Treatment, for the sake of completeness. No attempt will -be made to present these subjects in the orthodox way. - -Rather, my remarks will be confined to such matter as I believe to be -thoroughly practical and relevant. - -In my opinion, the day has arrived when we may properly exclude from -such handbooks as this one (intended for practical guidance), all such -methods of diagnosis and treatment as have failed to meet the test of -actual experience through a reasonable length of time. Twice in recent -years,[17] I have described the diagnosis and treatment of plague, -attempting in each case to present a reasonably full account of the -methods employed and advocated by authorities, for theoretic reasons -and from the recorded personal experiences of medical men throughout -the world. There comes a time, however, when wheat and chaff must be -separated and when methods which have failed, in application, to -justify preformed expectations must be relegated to the department of -historical medicine. - - [17] Tropical Medicine (1907) and Hare's Modern Treatment (1911), - vol. 1. - -Judging from recent medical text books it is evident that medical -writers are generally accepting this view as the proper one. At any -rate, my experiences and those of my medical friends during the Manila -epidemic of 1912-1914, have led me to discard as impracticable, -unproven, disproven or unpromising, certain plans of treatment formerly -deemed worthy of trial. I do not refer to these methods individually -but will content myself, instead, with reciting briefly the methods -which I believe, from personal experience and the collected experience -of others, to be worthy of continuance and of further trial. - -DIAGNOSIS.--The rapid diagnosis of plague is always of the utmost -importance, both from the view-point of prognosis and treatment, in the -individual case, and from the community view-point of the recognition -of the presence of a dangerous communicable disease, with the resultant -obligation falling upon the health authorities. - -THE BIOLOGIC DIAGNOSIS.--Let us understand, first and finally, that but -one diagnosis is absolutely and irrefutably dependable, viz.: the -biologic diagnosis. Herein I would include not only the recovery of the -pest bacillus from the patient, but the recovery and identification of -the organism from inoculated animals, infected from blood, tissues, -secretions or cultivated plague bacilli derived from the human patient -or cadaver. - -This entire process involves a lapse of time of several days, and, -while it is indispensable in the earliest cases of an epidemic, and -highly desirable for the proper study of all cases of plague, it is -impracticable and unnecessary, in communities where plague is known to -exist, to carry out more than the first steps of the biologic -diagnosis, viz.: the recovery of _B. pestis_ (morphologic -identification) from the patient. - -NECESSITY FOR TRAINED BACTERIOLOGIST.--It is evident that the services -of a trained bacteriologist are indispensable in the accurate diagnosis -of plague, unless (as rarely is the case) the observer himself is both -clinician and bacteriologist. Even in this case it is far better for -two persons, clinician and bacteriologist, to work together. I will not -discuss the technic of the procedures of biologic diagnosis, which is -described by Dr. Schöbl in the preceding pages. Except under -circumstances of necessity, the clinician should always turn this work -over to the bacteriologist. - -Serum reactions, when present, occur too late to be of service in -practical diagnosis. - -The necessary procedures of the biologic diagnosis include -blood-culture, smear examination (microscopic) of aspirated material -from the oedematous tissues surrounding gland masses and from glands -themselves; examination of sputum smears and of thick-blood smears. - -All should be practised but, according to our Manila experiences, smear -examinations of aspirated material and blood cultures are the most -reliable methods, in the hands of a competent bacteriologist. Attention -is invited to the reports of Dr. Otto Schöbl, already quoted. - -BACTERIOLOGIC PROCEDURE.--Dr. Schöbl was able to secure positive blood -cultures, within 24 hours, from all of a long series of cases of -plague, both bubonic and septicæmic. As much blood as it was possible -to secure was aspirated from superficial veins and introduced into the -culture media at the bedside, ten c.c. being secured whenever it was -possible. - -The smear preparations for staining and culture inoculations upon -slants were also made at the bedside from aspirated matter obtained -from oedematous periglandular tissues or from gland puncture, an -aspirating syringe being used. The drop or two of fluid which can be -expelled from the hollow needle is usually sufficient for smears and -tube inoculations. - -NON-BIOLOGIC DIAGNOSIS.--I do not contend that other diagnostic means -than biologic ones should not be used in plague. - -On the contrary, it will inevitably happen at times that resort must be -had to methods of diagnosis which are purely clinical. When this is the -case, treatment, along lines to be detailed presently, should be -instituted upon the establishment of a presumptive diagnosis. This -presumptive diagnosis may be reached after due consideration of -physical signs and symptoms. A carefully taken history of the onset -and course of the disease will be valuable but unfortunately such -histories can rarely be secured. It is far safer to mistakenly -pronounce a case "plague" and to institute appropriate treatment, than -it is to hesitate in the absence of a perfect clinical picture and to -permit the golden moment for treatment to pass. - -It must be remembered that septicæmic, bubonic and pneumonic plague are -all manifestations of systemic infection with _B. pestis_; that they -are all expressions of the same disease; that they call for the same -treatment and that when the distinctive signs of bubo or pneumonia -appear the disease is dangerously advanced. - -It should also be realized that every case is, almost from its onset, a -septicæmic case, either mildly or overwhelmingly so. Accordingly the -treatment should invariably be the treatment of septicæmic plague. - -The attitude of the diagnostician should be one of suspicion and he -should have the courage to carry out antiplague treatment, practically -upon suspicion. In this way only can the mortality of plague be greatly -reduced. It is true of plague, just as it is true of cholera, that many -of the fatal cases develop and become hopeless before the disease is -suspected or diagnosticated. It is also true that many fatal cases of -plague, in times of epidemic, completely escape recognition during -life, the diagnosis being made in the autopsy room. - -Therefore, I lay great stress upon the necessity for an attitude of -suspicion on the part of practitioners, wherever even a single case of -plague (human or rodent) is known to have occurred. - -When it becomes necessary to establish a presumptive diagnosis, _i.e._, -without resort to the microscope, the following symptoms and physical -signs will be found to be most significant. - -SYMPTOMATOLOGY.--Acuteness of onset; rapidity of fever development; -rapidity of the development of mental dulness or cloudiness, impairment -of speech, delirium, stupor or restlessness; early and extreme -prostration (perhaps more pronounced than in any other acute disease); -extreme tenderness over involved gland masses, in the bubonic type of -plague; cough, with considerable frothy sputum, soon becoming -blood-discolored, in the pneumonic type of plague; and early cardiac -asthenia in all clinical types of plague, septicæmic, pneumonic and -bubonic. - -The following diseases may be confounded with plague, if symptoms -alone are considered: typhus (_exanthematicus_), influenza pneumonia, -broncho-pneumonia, severe malaria, septicæmia, acute toxic typhoid, -venereal bubo, mumps and tonsillitis. - -I call attention again to the fact that mild cases of plague, -septicæmic and bubonic, occur at times, clinical pictures in such cases -being incomplete. - -The statement that the prognosis in all cases of septicæmic plague is -hopeless is not confirmed by my experience. - -It should also be remembered that primary pneumonic plague and -secondary pneumonia developing in the course of systemic plague are -quite different in their significance and mortality, primary pneumonic -plague being well nigh invariably fatal. - -PATHOLOGIC CONSIDERATIONS.--Only the student of plague pathology, who -has seen a large number of complete autopsies, can understand how -universal is the involvement of organs, glands and tissues in systemic -plague and how widespread is the distribution of _B. pestis_ throughout -the body, and he will best understand how treatment, to be in the -least effective, must be given in the very earliest hours of the -disease. - -Plague is an exquisitely septicæmic disease and this fact must never be -lost sight of by the therapeutist, who must realize that from the -earliest moment of infection all plague is septicæmic plague. - -TREATMENT, CONDITIONS AND PROGNOSIS.--Passing to the subject of -treatment let us, first of all, admit that even under the most -favorable and approved conditions of treatment the mortality is -extremely high. On account of the delay which usually occurs in the -recognition of plague,--a delay which in the natural order of things is -and must be the rule rather than the exception, because of the rapidity -of onset of the disease and the fact that it occurs much more -frequently in the lower social classes than elsewhere,--no brilliant -results are to be expected from any plan of treatment. - -The matter of plague treatment is far from being in the same -satisfactory state as the matter of preventive control. I do feel, -however, that biologic treatment from the earliest possible moment, -with serum, is of the greatest promise, however discouraging the -general prognosis may be in plague. - -SERUM TREATMENT.--Recent writers agree that there is no treatment with -curative value except that with antipest serum. To this belief I -subscribe assent, as I find it entirely in accord with my experience -and that of my colleagues in Manila during 1912-1914. - -Holding this view, I can see no reason for repeating here the details -of purely symptomatic treatment. Symptomatic treatment has for its -object the securing of comfort and of relief from suffering for the -patient and is highly proper in its place, remembering always that it -is not curative and that if employed alone it is worse than inadequate. - -SYMPTOMATIC TREATMENT.--Opiates (morphine by needle) for pain, delirium -and excitement; application of ice bags and cold or tepid sponge -bathing for high temperature; stimulants for heart weakness, are all -indicated and are required in nearly every case of plague. - -As a rule surgery is not called for nor appropriate, except in cases -which develop secondary surgical conditions, which conditions we need -not consider at this time. - -STATISTICAL STUDIES IN MORTALITY.--The statistical study of plague -mortality from the point of view of treatment is misleading and -unsatisfactory for reasons already given in our discussion of -treatment, viz.: failure to secure early recognition and early serum -treatment, and the greater incidence of plague in the lower social -classes. - -Few statistical compilations divide the cases studied into moribund and -non-moribund, and indeed such division, being a matter of judgment, -largely involves the personal equation of the observer. - -The ease with which statistics may be moulded to support theories, or -to break them down, all with perfect honesty of purpose, is proverbial. - -To me, the spectacle of a single case of plague, apparently ill unto -death, recovering under the administration of antiplague serum, is more -impressive than the contemplation of statistics; and I have seen more -than one such case respond to serum treatment and recover. - -So far as it goes, however, the study of statistics supports the view -that treatment with antiplague serum is effective. - -I have not at hand the records of the last 20 or more cases, but of -the first 68 cases of plague in the recent Manila epidemic, 32 were -either found dead or died upon the same day that they were found. - -If we exclude these cases from consideration there remain 36 cases. All -of these patients received serum treatment and ten of them recovered. - -It is at once apparent that this percentage of recoveries (27 per cent. -plus) is far more favorable than the actual percentage of recovery in -the series in which cases found dead and moribund are considered, the -recovery percentage here being a little more than 14 per cent. It is -also quite fair, it seems to me, to make this separation of cases, or -even a more liberal one, if we are to consider the effects of serum -treatment statistically. - -DOSAGE AND TECHNIQUE OF SERUM ADMINISTRATION.--The amount of antiplague -serum to be given will vary somewhat with the age and weight of the -patient and with the apparent severity of the case. - -In general terms it may be said that adults should be given from 300 -c.c. to 500 c.c. of serum by injection, 100 c.c. being given every four -hours. The injection may be either intramuscular or intravenous. - -In view of the improvements in technic of intravenous administrations -and its comparative simplicity, and especially in view of the -uncertainties and delays of absorption from the tissues, the -intravenous route should be given the preference. The serum may be -delivered intravenously from a large glass syringe, the introduction -being very slowly made, or through a gravity apparatus, as in the -administration of salvarsan. The serum should not be diluted. - -The use of antiplague serum for protective (immunizing) purposes is -also recommended--especially when exposure to infection has -occurred--in the same way in which diphtheria antitoxin is used. Its -protective properties are conceded to be somewhat superior to those of -plague vaccines as the protection conferred is immediate, whereas -plague vaccines do not protect until sometime after their -administration. The dose is from 30 c.c. to 50 c.c. - -PROPHYLACTIC SERUM AND ANAPHYLAXIS.--On one occasion in Manila in 1913, -when some 30 persons were given prophylactic doses of serum, -intramuscularly, following a particularly dangerous exposure to fleas -from rats dead from plague, there occurred a number of cases of "serum -sickness" (anaphylaxis). These persons suffered from severe urticarial, -arthralgic and nervous symptoms, lasting for several days and a few -were obliged to enter a hospital. In one case the symptoms did not -entirely abate for a week. It has been stated that newly-prepared serum -is particularly apt to produce serum sickness when used for immunizing -purposes. This form of protection is brief (1 to 2 weeks) and is best -suited for use where there has been special exposure. - -PLAGUE VACCINES.--Haffkine originally proposed prophylactic -immunization, using killed broth cultures of _B. pestis_ (carbolized to -½ per cent.), giving two injections at intervals of 10 days. -Statistically it seems to be shown that this prophylactic immunization -with dead bacteria reduces the incidence and mortality one-fourth or -one-half (approximately). Experimentally, also, it appears that -antibodies (agglutinins) are produced by the vaccine (and modifications -thereof). Instead of broth cultures, normal salt solution suspensions -of killed pest bacilli are usually used in vaccines at present. - -Castellani[18] has prepared a combined cholera and plague vaccine for -use in countries where both diseases coincidentally prevail. It is a -mixed vaccine, so prepared that 1 c.c. of the emulsion contains 1000 -millions of plague bacilli and 2000 millions of cholera vibrios. The -cultures are grown on agar, killed by phenol and suspended in normal -salt solution. - - [18] A. Castellani: Journal of Ceylon Branch of British Medical - Association, June, 1914. - -He finds (1) that inoculation of the vaccine in the lower animals -induces a production of protective substances for the plague bacillus -and the cholera vibrio; (2) that the inoculation of human beings is -harmless (producing less reaction than the Haffkine inoculation); (3) -that a small amount of agglutinins, both for plague and cholera, appear -in the blood of most inoculated persons (similar to amounts produced by -Haffkine's vaccine), a rough index only of the amount of immunity -produced. - - - - - INDEX - - - Anaphylaxis, 177 - Appearance of plague in Porto Rico, 26 - New Orleans, 26 - Manila, 26 - Appeal for public coöperation, 126, 127 - Australia, plague in, 22 - Alaska, plague in, 22 - Africa, South, plague in, 22 - Africa, Central, plague in, 22 - Africa, East, plague in, 22 - Africa, British East, plague in, 25 - Africa, Portuguese East, plague in, 26 - Asian marmot, 28 - Australia, rat fleas of, 32 - Activity of fleas, 33 - Attenuation of virulence of cholera organism, 35 - Bacillus pestis, 35 - Adaptability of rat to temperature and environment, 51 - Anti-plague campaign in Manila, 1912-1914, 57 - Amoy, importation of plague from, 59 - Anti-rat measures in R. R. cars, 92 - Activity of fleas, 98 - Austrian Plague Commission, 133 - Agglutination of plague bacilli, 134-135 - Animals suspected of plague, observations on, 146-149 - Abatement of plague in Hong Kong in 1914, 160 - Anti-plague work, dangers of, 163, 164 - - Bacteriologic observations, 127 - Bacillus pestis, in air, 38 - in ants, 138 - in bedbugs, 33, 138 - conveyance by fleas, 28, 30, 31 - cultivation of, 133, 138 - cultural characteristics of, 133, 138 - in circulating blood, 133, 136 - in cats, 150 - effect of temperature upon, 34 - in flies, 33, 138 - in fleas, 138 - in lice, 33, 138 - effect of seasonal conditions on, 34 - in cockroaches, 33 - in sputum, 132 - stability of virulence of, 35, 36 - in skin, 132 - Blue, Dr. Rupert, 31 - Brazil, plague in, 22 - Black Death of Europe, 20 - British East Africa, plague in, 25 - Bite of flea, 31 - Brazil, rat fleas of, 32 - Bedbug, conveyance of B. pestis by, 33 - Barber, Dr. M., 38 - Bacterial viruses for rat destruction, 43 - Bacterial virus, Danysz, 53 - Bacillus, Danysz, 53 - use of, in Odessa, 53 - use of, in Cape Town, 53 - B. typhi murium, 53 - Bacillus, mouse-typhoid, of Loeffler, 53 - B. enteritidis, Gärtner's, 54 - Bacterial rat poisons, use of, in Japan, 54 - Beginning of Manila epidemic, 60 - Binondo, Manila, plague in, 63 - Bamboo timbers, closing ends of, 71 - Basements, insanitary, 72 - Birth-rate of rats, 73 - Bionomics of fleas, 77 - Batavia, Dutch India (Java), 77 - Bureau of Science, Manila, 92 - Barn rat, 99 - Burrowing ability of rats, 102 - Breaking up rat nests, Manila, 106 - Bacteriologic examination of plague patients, 128 - Blood-sucking insects, transmission of plague by, 137 - Bacillus pestis, insects found to contain (Table III), 138, 139 - Biologic diagnosis of plague, 167 - procedure, diagnosis, 168 - - Cause of plague, 28 - Conveyance of plague, 28 - Control of plague, 40 - Crowell, Dr. B. C., 14 - China, plague in, 21, 22, 24 - California, plague in, 22 - Central Africa, plague in, 22 - California ground squirrel, 28 - Contact, plague through, 29 - Contagious plague, 29 - Contagion, India Plague Commission on, 33 - Cockroaches in plague conveyance, 29, 33 - Cats, plague in, 29, 76, 149 - Chronic plague in rats, 35 - Chronic rat plague, India Plague Commission on, 35 - Currie, Dr. D. H., 31 - Creel, Dr. R. H., U. S. P. H. Service, 31, 101 - Castellani, Dr. Aldo (dedication), 179 - Ceratophyllus fasciatus, 32 - Cat fleas, 32 - Ctenocephalus, 32 - Citellus beecheyi, 28 - Cholera epidemics, spontaneous abatement of, 35 - organism, attenuation of virulence of, 35 - California, a plague centre, 41 - Cost of rat proofing, 49 - Chemical poisoning of rats and ground squirrels, 54 - Community, summary of prevention for, 56 - Close of year 1912 in Manila, 67 - Closing ends of bamboo timbers, 71 - Cat plague case in Manila, 76, 149 fleas, 78 - Correspondence of Philippine and Japan conditions, 83 - Comparative statistics in rat catching methods, 89 - Cresols, 94 - Coloration of rats, 99 - Conformation of skulls in rats, 101 - Climbing ability of rats, 102 - Collection and forwarding of rats (Manila), 122, 123 - Case of Mr. C. (Manila), 124, 125 - Concealing plague cases, 94 - Conclusions concerning blood culture in plague diagnosis, 136 - from observations of plague outbreak among experimental animals - (Manila), 146 - Cat, natural plague infection in, 149-154 - Conditions, treatment and prognosis, 173 - Combined vaccines, 179 - - Diagnosis of plague, 165 - Definition of plague, 28 - Digestive tract, infection through, 29 - Dog fleas, 32 - Droplet infection, 38 - Destruction of rats by diseases, 53 - Danysz bacterial virus, 53 - bacillus, 53 - use of, in Odessa, 53 - use of, in Cape Town, 53 - Destruction of rats by domestic animals, 54 - Disinfection of ship cargoes, 56 - Dead, proper disposal of, 56 - Dispersion of fleas from rat cadavers, Manila, 65 - Death-rate of rats, 73 - Dutch India, Batavia (Java), 77 - Duration of life of fasting fleas, 79 - Dead rats in bamboo house timbers, 87 - Disinfection, theatre, Manila, 93 - Deception and concealment of plague cases, 94 - Differential points in rats, unreliability of, 101 - Driving out rats with formaldehyde gas (Manila), 106 - Dangers of anti-plague work, 163, 164 - Diagnosis, rapid, of plague, importance of, 166 - biologic, of plague, 167 - non-biologic, 169, 170 - Dosage and technique of serum administration, 176, 177 - - Extension of plague, 19, 22 - Egypt, plague in, 20, 23, 25 - East Africa, plague in, 22 - Epidemics, effect of seasonal conditions on, 34 - wane of, 35 - Epidemic pneumonic plague, 38 - Economic importance of rat destruction, 42 - Estimations of loss by U. S. Agricultural Department, 42 - Effect of superstitions and religious beliefs in India, 43 - of rat poisoning and trapping, 73 - Epidemiologic facts concerning plague in Java, 82 - Examination of fatal cases of plague (Table I), 130 - of cases of plague who recovered (Table II), 131 - Experimental animals, plague in, 139-145 - - Flea conveyance of B. pestis, 30 - Flies, conveyance of B. pestis by, 33 - Fowls, plague conveyance by, 29 - Flea's stomach, capacity of, 31 - bite and plague conveyance, 31 - Flea prevalence, effect of seasonal conditions on, 34 - Fox, Dr. Carrol, 31, 70 - Fleas, dog, 32 - cat, 32 - mice, 32 - ground squirrel, 32 - activity of, 33, 98 - Fumigation of ships, 46 - Flea carriers, objection to domestic cats and dogs as, 55 - Favorable conditions for spread of plague in Manila, 61 - First Manila cases in 1912, 62 - Fleas and their habits, 77 - bionomics of, 77 - rat, of Philippines, 78 - of Australia, 78 - of Italy, 78 - cat, 78 - per rat, variations in number of (Java), 78 - Flea larvæ, effect of temperature and humidity on, 79 - imago, effect of temperature and humidity on, 79 - Fasting fleas, duration of life of, 79 - Flea prevalence, prediction of plague extension from, 80 - natural enemies of, 97 - activity of, 33, 98 - Field rat, 99 - Family Muridæ, 99 - Ferocity of Mus decumanus, 102 - Feasibility of fighting plague successfully, 162 - of Manila policy of plague control, 162 - - Great plague of London, 21 - Great Britain, plague in, 22 - Ground squirrel, California, 28 - Great Britain, rat fleas of, 32 - Ground squirrel, fleas of, 32 - Gärtner's B. enteritidis, 54 - Geographic grouping of plague cases in Manila, 63 - Ground-floor sleeping quarters, 72 - General cleaning campaign, Manila, 88 - Garbage cans, sanitary orders, Manila, 93 - Guinea-pigs as indicators of infected houses, 96 - Genus Mus, 99 - Gray rat, 99 - Gunomys (Nesokia), 100 - Gnawing ability of rats, 102 - German Plague Commission, 149 - - History of plague, 19 - Hawaii, plague in, 22 - Hong Kong, plague in, 24, 58, 154 - Heiser, Dr. V. C., 31, 58, 70, 75, 89 - Hobdy, Dr. W. C., 31 - House cats as rat catchers, 55 - Half wild cats as rat catchers, 55 - Human plague in Tondo district, Manila, 68 - Houses in Tondo, light material, 71 - House disinfection by spraying, 94 - Household rat destruction, plan for, 111 - Hong Kong, notes on plague in, by Dr. Roberg, 153, 154, 155, 156, 157, - 158, 159, 160 - the work of the Sanitary Board, 158 - abatement of plague in 1914, 160 - Haffkine vaccine, 178, 179 - - Introduction, 11 - India, plague in, 24 - Indo-China, plague in, 24 - Infection through digestive tract, 29 - Ingestion, plague, 29 - India, rat fleas of, 32 - Italy, rat fleas of, 32 - India Plague Commission on contagion, 33 - on chronic rat plague, 35 - Immunity, plague, 36 - India, effect of superstitions and religious belief in, 43 - Isolation of sick, 56 - Importation of plague from Amoy, 59 - Iloilo, P. I., plague in, 70 - Insanitary basements, 72 - Interpretation of the rat catch and plague incidence, 91 - Infected houses, guinea-pigs as indicators of, 96 - India Plague Commission, 100 - Insects found to contain Bacillus pestis (Table III), 138, 139 - Importance of rapid diagnosis of plague, 166 - - Japanese anti-plague serum, 18 - Japan, plague in, 22, 25 - Java, plague in, 25 - Japan, bacterial rat poisons, use of, in, 54 - Jackson, Dr. T. W., correspondence, 75 - Java, Batavia, Dutch India, 77 - Xenopsylla cheopis in, 77 - variations in number of fleas per rat, 78 - epidemiologic facts concerning plague in, 82 - Javan village house, 84 - "bale bale," rats in, 86 - Java, sawah rat of, 100 - Jumping ability of rats, 102 - Java, studies of rat cadavers in, 104 - - Kerr, Dr. J. W., 31 - Korn, Dr. W., U. S. P. H. Service, 87 - Kerosene as an insecticide, 94 - - London, great plague of, 21 - Lantz, Dr. D. E., 31 - classification of rats, 99 - Loemopsylla cheopis, 32 - Louse, conveyance of B. pestis by, 33 - Loeffler, mouse-typhoid bacillus of, 53 - Laboratory-proven plague rats and others in Manila, 61 - Light material houses in Tondo, 71 - Manila, 85 - Letter of warning and appeal, 125, 126 - Location of rat cadavers in relation to human plague cases, Manila, - 162, 163 - - Mortality, 22, 23, 174, 175 - Menace of plague, 28 - Manila, plague in, 26 - Manufacture of anti-plague serum, 18 - Middle Ages, plague in, 20 - Mexico, plague in, 22 - Mauritius, plague in, 22, 25 - Mediterranean ports, plague in, 22 - Marmot, Asian, 28 - Mice, fleas of, 32 - Manchuria, pneumonic plague in, 37 - Methods of entry of rats into ships and cars, 52 - Mouse-typhoid bacillus of Loeffler, 53 - Murium, B. typhi, 53 - Manila, Anti-plague Campaign in 1912-1914 in, 57 - epidemic, 1912-1914, 57 - plague at quarantine in, 58 - importation of plague from Hong Kong in 1912, 58 - Mariveles Quarantine Station, 59 - Manila epidemic, beginning of, 60 - Mortality and numbers of Manila plague cases, 61 - Manila cases in 1912, first, 62 - geographic grouping of plague cases in, 63 - R. R. station focus, 64 - dispersion of fleas from rat cadavers, 65 - close of year 1912 in, 67 - Malolos, P. I., plague in, 69 - Manila, taking charge of plague suppression measures in, 70 - plague fighting organization in, 71 - rat plague in U. S. Army Commissary warehouse, 76 - habitations and plague, 83 - light material house, 85 - general cleaning campaign, 88 - theatre, disinfection in, 93 - Mus rattus, 99 - alexandrinus, 99 - Mus decumanus, 99 - ferocity of, 102 - Manila, breaking up of rat nests, 106 - driving out rats by formaldehyde gas, 106 - rat killing with dogs, 107 - rat nests in trees, 110 - snakes in rat traps, 111 - rat swallowed by snake, 111 - Multiple house infection (Manila), 112-117 - Manila, collection and forwarding of rats, 122, 123 - Mr. C., case of Manila, 124, 125 - Manila, bacteriologic observation, 127 - outbreak of plague among experimental animals, 139-145 - conclusions from observation of plague outbreak among experimental - animals, 146 - San Lazaro Hospital, 13, 69, 161 - location of rat cadavers in relation to human plague cases, 162, 163 - Mortality, statistical studies in, 22, 174, 175, 176 - McCoy, Dr. C. W., 31 - - New Orleans, plague in, 26 - Natural enemies of the rat, 43 - National aid, necessity of, 56 - Numbers and mortality of Manila plague cases, 61 - Nest materials, 86 - Natural enemies of the flea, 97 - Norway rat, 99 - Notes on rat runs, 105 - nests, 105 - food, 105 - Natural plague infection in a cat, 149-154 - Notes on plague in Hong Kong by Dr. Roberg, 153-160 - Non-biologic diagnosis, 169, 170 - - Objection to domestic cats and dogs as flea carriers, 55 - Order Rodentia, 99 - Outbreak of plague among experimental animals (Manila), 139-145 - Observations of animals suspected of plague, 146-149 - - Plague conveyance, 28 - in 1910, 24 - conveyance by suction of insects, 33 - Porto Rico, plague appears in, 26 - Public coöperation in plague control, 126, 127 - Practicability of plague control, 15 - Philippines, plague in, 22 - Peru, plague in, 22 - Persia, plague in, 25 - Portuguese East Africa, plague in, 26 - Public Health Service, U. S., 26, 37 - Pulex irritans, 32 - pallidus, 32 - Plague pneumonia, secondary, 39 - Pneumonic plague epidemic, 38 - Prevention problem, summary of, 37 - Pneumonic plague, 37 - in Manchuria, 37 - Plague immunity, 36 - treatment and diagnosis of, 165 - control, 40 - prevention, 40 - suppression, 40 - campaign in San Francisco, 41 - Poisons used for rat destruction, 43, 44 - Poisonous gases, rat destruction by, 45 - Prevention for community, summary of, 56 - Proper disposal of dead, 56 - _Philippine Journal of Science_, 58, 70, 128 - Plague at quarantine in Manila, 58 - from Hong Kong, Manila, importation of, in 1912, 58 - from Amoy, importation of, 59 - cases, numbers and mortality of Manila, 61 - rats, laboratory-proven, and others in Manila, 61 - in Quiapo, Manila, 63 - in Binondo, Manila, 63 - cases in Manila, geographic grouping of, 63 - in Malolos, P. I., 69 - in Iloilo, P. I., 70 - Plague suppressive measures, Manila, taking charge of, 70 - fighting organization in Manila, 71 - Population, removal of, in emergency, 74 - Plague, cat, case of, Manila, 29, 76, 150 - rat, in U. S. Army Commissary warehouse, Manila, 76 - Prediction of plague extension from flea prevalence, 80 - Plague prevalence, seasonal explanation of, 81 - in Java, epidemiologic facts concerning, 82 - Manila habitations and, 83 - Tondo (Manila) habitations and, 83 - cases, deception and concealment of, 94 - commission, India, 100 - Postmortem changes, in rats (Table), 105 - in rats (illustration), 105 - time of death of rats as indicated by, 104 - Plan for household rat destruction, 111 - Plague patients, bacteriologic examination of, 128 - examination of fatal cases of (Table I), 130 - of cases who recovered from (Table II), 131 - commission, Austrian, 133 - bacilli from circulating blood, recovering, 134 - Plague bacilli, agglutination of, 134, 135 - diagnosis, conclusions concerning blood culture in, 136 - by blood sucking insects, transmission of, 137 - among experimental animals, outbreak of (Manila), 139-145 - outbreak among experimental animals, conclusions from observations - of (Manila), 146 - observations on animals suspected of, 146-149 - commission, German, 149 - in Hong Kong, notes on, by Dr. Roberg, 153-160 - in Hong Kong in 1914, abatement of, 160 - feasibility of fighting successfully, 162 - control, feasibility of Manila policy of, 162 - cases (human), location of rat cadavers in relation to - (Manila), 162, 163 - importance of rapid diagnosis of, 166 - biologic diagnosis of, 167 - a septicæmic disease in all cases, 170 - symptomatology of, 171 - Pathologic considerations, 172 - Prognosis, treatment, conditions and, 173 - Plague, serum treatment of, 174 - symptomatic treatment, 174 - Prophylactic serum and anaphylaxis, 177 - Plague vaccines, 178, 179 - - Quarantine, modified, 56 - station, Mariveles, 59 - Quiapo, Manila, plague in, 63 - - Rat fleas of Italy, 32 - of Brazil, 32 - of Great Britain, 32 - of United States, 32 - Rats, chronic plague in, 35 - subacute plague in, 35 - Requisites of the practical sanitarian, 12 - Russia, plague in, 26 - Rats, wild, plague in, 29 - effect of seasonal conditions on, 34 - Rucker, Dr. W. C., 31 - Rosenau, Dr. M, J., 31 - Rat fleas, varieties of, 32 - of India, 32 - of Australia, 32 - Rat population of the world, 41 - destruction, economic importance of, 42 - extermination methods, 43 - natural enemies of, 43 - destruction, bacterial viruses for, 43 - poisons used for, 43, 44 - trapping, 44 - traps, varieties, 45 - destruction by poisonous gases, 45 - Rats, starving, 47 - Rat proofing, 48 - cost of, 49, 93 - infestation of ships, 50 - adaptability of, 51 - Rat's, methods of entry of, 52 - Rat destruction by rat diseases, 53 - Resistance of rat to diseases of bacterial causation, 54 - Rats and ground squirrels, chemical poisoning of, 54 - Rat destruction by domestic animals, 54 - catchers, house cats as, 55 - half wild cats as, 55 - terrier dogs as, 55 - on farms, terrier dogs as, 55 - Rapid diagnosis, importance of, 56 - Rat cadavers, dispersion of fleas in Manila from, 65 - plague in Tondo district, Manila, 68 - proofing and rat destruction, 72 - inapplicable at times, 73 - poisoning, trapping, effects of, 73 - Rats, birth-rate of, 73 - death-rate of, 73 - Removal of population in emergency, 74 - Rat plague in U. S. Army Commissary warehouse, Manila, 76 - fleas of Philippines, 78 - of Australia, 78 - Rat fleas of Italy, 78 - breeding as influenced by climate, 81 - in Javan "bale bale," 86 - in thatched roofs, 86 - dead, in bamboo house timbers, 87 - Rat catch, variations in, 88 - Rat catching methods, comparative statistics in, 89 - Rat catch and plague incidence, interpretation of, 91 - Rats, zoölogic classification of, 98 - Rat, ship, 99 - field, 99 - Rats, coloration of, 99 - Rat, Norway, 99 - gray, 99 - barn, 99 - sewer, 99 - Rats, unreliability of differential points in, 101 - conformation of skulls in, 101 - gnawing ability of, 102 - burrowing ability of, 102 - climbing ability of, 102 - jumping ability of, 102 - swimming ability of, 102 - Rat litters, size of, 102 - Rats as wire walkers, 103 - as rope walkers, 103 - Rat cadavers in Java, studies of, 104 - time of death as indicated by postmortem changes of, 104 - Rats, postmortem changes in (Table), 105 - (illustration), 105 - Rat runs, notes on, 105 - nests, notes on, 105 - food, notes on, 105 - nests (Manila), breaking up, 106 - Rats driven out with formaldehyde gas (Manila), 106 - Rat killing with dogs (Manila), 107 - Rat's nests in trees (Manila), 110 - Rat traps, snakes in (Manila), 111 - swallowed by snake (Manila), 111 - Rats, collection and forwarding of (Manila), 122, 123 - Recovering plague bacilli from circulating blood, 134 - Roberg, Dr. David, 154 - - Stability of virulence of B. pestis, 36 - Spread of plague in recent years, 23 - Suppression of plague, 40 - San Lazaro Hospital, Manila, 13, 69, 161 - Schöbl, Dr. Otto, 14, 29, 30, 76, 96, 127 - Strong, Dr. R. P., 16, 36, 38, 59, 135 - Sixth century, plague in, 20 - South America, plague in, 22, 26 - Siam, plague in, 25 - Suez, plague in, 22 - South Africa, plague in, 22 - Scotland, plague in, 22 - Sumatra, plague in, 25 - Straits Settlements, plague in, 25 - Simpson, Dr. W. J. - Suctorial parasites in plague conveyance, 33 - Seasonal conditions, effect on epidemics of, 34 - on rats of, 34 - on Bacillus pestis of, 34 - on flea prevalence of, 34 - Subacute plague in rats, 35 - Spontaneous abatement of cholera, 35 - Secondary plague pneumonia, 39 - Summary of prevention problem, 37 - San Francisco, plague campaign in, 41 - Ships, fumigation of, 46 - Starving rats, 47 - Ships, rat infestation of, 50 - Summary of prevention for community, 56 - Ship cargoes, disinfection of, 56 - Sick, isolation of, 56 - Steamer, Loongsang, 59 - Taisang, 59 - Spread of plague in Manila, favorable conditions for, 61 - Sleeping quarters, ground floor, 72 - Swellengrebel, Ph.D., N. H., 77 - Seasonal explanations of plague prevalence, 81 - Sanitary orders, Manila (garbage cans), 93 - Ship rat, 99 - Sewer rat, 99 - Sawah rat of Java, 100 - Swimming ability of rats, 102 - Size of rat litters, 102 - Simpson, surgeon, U. S. P. H. Service, 103 - Studies of rat cadavers in Java, 104 - Snakes in rat traps (Manila), 111 - Snake, rat swallowed by (Manila), 111 - Specimen, sanitary orders, 116-121 - Sanitary Board (Hong Kong), the work of, 158 - Symptomatology of plague, 171 - Serum treatment of plague, 174 - Symptomatic treatment of plague, 174 - Statistical studies in mortality, 174-176 - Serum administration, dosage and technique of, 176, 177 - - Types of plague, 30 - Treatment of plague, 165 - Turkey in Asia, plague in, 25 - Tarbagan, 28 - Teague, Dr. O., 38 - Terrier dogs as rat catchers, 55 - Terrier dogs as rat catchers on farms, 55 - Tondo district, Manila, rat plague in, 68 - human plague in, 68 - Taking charge of plague suppressive measures, Manila, 70 - Tondo, light material houses in, 71 - Tondo, Manila, habitations and plague, 83 - Theatre disinfection, Manila, 93 - Time of death of rat as indicated by postmortem changes, 104 - Transmission of plague by blood-sucking insects, 137 - Trained bacteriologist, necessity for, 167 - Treatment, conditions, and prognosis, 173 - serum, of plague, 174 - symptomatic, of plague, 174 - Technique and dosage of serum administration, 176, 177 - - United States Public Health Service, 26 - rat fleas of, 32 - - Varieties of rat fleas, 32 - of rat traps, 45 - Variations in number of fleas per rat (Java), 78 - Van Loghem, Dr. J. J., 82, 84 - Variations in the rat catch, 88 - Vaccines, plague, 178, 179 - Vaccine, Haffkine, 178, 179 - Vaccines, combined, 179 - - Widespread dissemination in recent years, 23 - West Indies, plague in, 29 - Wane of epidemics, 15, 35 - Work of Sanitary Board (Hong Kong), 158 - - Xenopsylla cheopis in Java, 77 - - Zoölogic classification of rats, 98 - - - - - Transcriber's note: - - The following corrections have been made: - - Title page: Period added after J in "J B. Lippincott Company" - - Dedication: Period added after "DAYS IN SERBIA" - - Table of Contents: "Epidemic, By Dr. Otto Schöbl" By changed to by - - p. 21: "christendom" changed to Christendom - - p. 32: Removed italic type from the word genus in "genus - Ctenocephalus" - - p. 62: "secondary to this July case" July changed to June - - p. 78: "known as Loemopsylla cheopsis" Loemopsylla changed to - Loemopsylla - - p. 132: "While cases 5, 2, 19, and 24 appeared" 2 changed to 11 - - p. 139: "fleas from a plagueinfected house" plagueinfected changed to - plague-infected - - p. 142: "usually met with in" with in changed to within - - p. 147: "Echinococcus teniæformis was found in the liver" teniæformis - changed to taeniæformis - - Index: "Swellengreble" changed to Swellengrebel - - Footnote 5: "Jena (1903) 2" added comma after closing bracket - - Everything else retained as printed, including inconsistencies in - hyphenation. The index entry for Simpson, Dr. W. 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You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: Plague - Its Cause and the Manner of its Extension--Its Menace--Its - Control and Suppression--Its Diagnosis and Treatment - -Author: Thomas Wright Jackson - -Contributor: Otto Schoebl - -Release Date: October 12, 2013 [EBook #43942] - -Language: English - -Character set encoding: ASCII - -*** START OF THIS PROJECT GUTENBERG EBOOK PLAGUE *** - - - - -Produced by Chris Curnow, Sandra Eder and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - - - - - - Transcriber's note: - - Text in italics is marked with _ underscore, text in small caps - changed to ALL CAPS. Illustrations were moved to paragraph breaks. - The index is sorted by page numbers within the alphabetical groups. - This has been retained. Footnotes were moved to the end of the - corresponding paragraph. In the Latin1 file, oe/Oe was used for the - unicode oe-ligature. A list of corrections made can be found at the - end of the book. - - - - - PLAGUE - - - - - PLAGUE - - ITS CAUSE AND THE MANNER OF ITS - EXTENSION--ITS MENACE--ITS CONTROL AND - SUPPRESSION--ITS DIAGNOSIS AND TREATMENT - - BY - THOMAS WRIGHT JACKSON, M.D. - - MEMBER AMERICAN RED CROSS SANITARY COMMISSION TO SERBIA, 1915; LATELY - CAPTAIN AND ASSISTANT SURGEON, U. S. VOLUNTEERS; LATELY LECTURER ON - TROPICAL DISEASES, JEFFERSON MEDICAL COLLEGE; MEMBER OF MANILA - MEDICAL SOCIETY AND PHILIPPINE ISLANDS MEDICAL ASSOCIATION; - AUTHOR OF A TEXT BOOK ON TROPICAL MEDICINE; DIRECTOR, - DEPARTMENT OF SANITATION AND EPIDEMIOLOGY - FOR H. K. MULFORD COMPANY - - WITH BACTERIOLOGIC OBSERVATIONS - - BY - DR. OTTO SCHOeBL - - BUREAU OF SCIENCE, MANILA - - _ILLUSTRATED_ - - PRESS OF - J. B. LIPPINCOTT COMPANY - - - - - COPYRIGHT, 1916 - BY THOMAS WRIGHT JACKSON, M.D. - - - - - - THIS BOOK IS DEDICATED BY THE AUTHOR TO - - DR. ALDO CASTELLANI - - REGIUS PROFESSOR OF TROPICAL DISEASES, UNIVERSITY OF NAPLES. - EMINENT IN MEDICAL RESEARCH, MY FRIEND, COLLEAGUE AND COMRADE - DURING STRENUOUS DAYS IN SERBIA. - - - - - - CONTENTS - - - PAGE - - INTRODUCTION 11 - - CHAPTER I - - ITS HISTORY AND ITS EXTENSION 19 - - History of Plague--The Widespread Dissemination of Plague in - Recent Years--The Appearance of Plague in Porto Rico, New - Orleans and Manila. - - CHAPTER II - - THE CAUSE AND THE MENACE OF PLAGUE 28 - - Causation of the Disease and its Mode of Conveyance--Types of - Plague--Chronic Plague and Immunity in Rats--Flea Conveyance of - Plague Bacilli--The Stability of Virulence of Plague - Bacilli--Summary of Facts Concerning the Cause and Manner of - Extension of Plague. - - CHAPTER III - - ITS CONTROL AND SUPPRESSION 40 - - Plague Prevention by Extermination of Rats--General Uselessness - of the Rat and Its Enormous Destructiveness, with Details of - Trapping and Other Extermination Methods--The Manila Epidemic, - 1912-1914--The First Cases--Unusual Character of Plague Cases at - Quarantine--Clinical Description of Two Cases at - Quarantine--Inauguration of the Manila Epidemic--Directed to - Take Charge of Plague Suppression in Manila--Plague Fighting - Organization--Method of Rat Proofing and Rat - Destruction--Correspondence Between Dr. Jackson and Dr. Heiser, - Director of Public Health--Observations on Fleas and Their - Habits--Conditions of Habitations in Manila Favoring Rat - Multiplication and Spread of Plague--Comparative Statistics on - Methods of Catching Rats--The Natural Enemies of the - Flea--Zoologic Classification of Rats--A Collection of Notes - Concerning Rat Runs, Rat Nests, Multiple House Infections and - Other Data--Sample of Detailed Orders Issued Regarding Rat - Extermination--Method of Procedure of Collecting and Forwarding - Rats Suspected of Plague Infection to Laboratory--Memoranda in - Plague Cases--Letter of Warning and Appeal for - Cooperation--Bacteriologic Observations made During the Manila - Plague Epidemic, by Dr. Otto Schoebl--Notes Concerning the - Bubonic Plague in Hong Kong, by Dr. David Roberg. - - CHAPTER IV - - ITS DIAGNOSIS AND TREATMENT 165 - - Biologic Diagnosis--Necessity for Trained - Bacteriologist--Bacteriologic Procedure--Non-Biologic - Diagnosis--Symptomatology--Pathologic Considerations--Treatment, - Conditions and Prognosis--Serum Treatment--Symptomatic - Treatment--Statistical Studies in Mortality--Dosage and - Technique of Serum Administration--Prophylactic Serum and - Anaphylaxis--Plague Vaccines. - - - - - ILLUSTRATIONS - - - PAGE - - RAT-PROOF STRUCTURE 48 - CLEANING AND RAT-PROOFING IN BASEMENT 69 - BAMBOO HOUSE SUPPORTS NOT SEALED WITH CEMENT 86 - MATERIALS MUST BE MOVED ABOUT IN THE SEARCH FOR RATS 93 - A RAT-INFESTED PLAGUE INTERIOR 95 - PROGRESSIVE POST-MORTEM CHANGES IN RAT CADAVERS 105 - PLAGUE HOUSE 116 - BAMBOO HOUSE SUPPORTS SEALED WITH CEMENT 119 - VIEW OF HOUSE WHERE INFECTED RATS WERE FOUND 120 - ANIMAL HOUSE 144 - - - - - PLAGUE - - ITS CAUSE AND THE MANNER OF ITS EXTENSION--ITS MENACE--ITS - CONTROL AND SUPPRESSION--ITS DIAGNOSIS AND TREATMENT - - - - - INTRODUCTION - - -The question of the need for new books upon medical topics must ever -remain undecided, by general agreement, in the medical profession. - -There is no such thing in medical literature as an insistent demand -from the profession for new volumes upon old topics. - -Authors need not hope, therefore, to create the impression that they -are meeting long-felt though unexpressed wants of medical readers in -launching new books. - -On the other hand, the creator of a new volume upon an old subject -should seek justification for literary paternity in the progressive -changes in the status of our knowledge of disease, its causes, -prevention, and cure. Such changes are admittedly going on with a -certain degree of constancy and at such a rate of frequency that new -presentations of old themes, are both justified and desirable from time -to time. - -With this idea in mind and with the desire to present, in useful and -practical form, a work which shall contain at least some unhackneyed -material and which shall represent modern studies and a record of -actual control work done in this justly-dreaded disease, the following -pages are submitted to the medical profession and to sanitarians -generally. - -With a profound respect for the laboratory worker and his work and with -a profound conviction that to him belongs the greater measure of credit -for real accomplishment in connection with plague up to the present -time, I desire to insist that the true utility of knowledge gained -within laboratory walls lies in its intelligent application in the -outer world and that ofttimes this application must be made by men who -are themselves without extended laboratory training. An appreciation of -principles--with an intelligent ability to accept, to appropriate, to -apply and, most of all, to refrain from entering without due -preparation the domain of the laboratory worker--is an indispensable -requisite in the equipment of the practical sanitarian, upon whom must -fall the responsibilities of success or failure in combating the -disease we are now to consider. - -During the past fourteen years it has been my privilege to observe two -epidemics of plague in the Philippine Islands. Some of these -observations were made in the capacity of a military medical officer, -but my later observations, upon which this report and study are chiefly -based, were made from the view-point of a civil health officer. At -different times I have been called upon to deal with the disease both -as sanitary officer and clinician, and from October, 1912, to July, -1914, I had charge of all plague suppressive measures in Manila. In -1914 I was also in charge, as acting chief, of the San Lazaro Hospitals -Division of the Bureau of Health, Manila, where all cases of plague are -brought, either for treatment or autopsy. - -As some of the material which I have collected for text-book articles -during the past eight years bears directly upon the present discussion -and presentation, I have ventured to quote from it, sometimes without -rephrasing, such parts as are accurate at the present time. I am also -quoting freely from the records and from the experiences of my -predecessors and colleagues in the work in Manila. - -It should be understood that the pathology of the disease has been -practically omitted from consideration as out of place in an -epidemiologic investigation and report. The pathologic side of the work -during the Manila epidemic of 1912-1914 was covered in a masterly -manner by Dr. B. C. Crowell and his associates at the Medical School of -the University of the Philippines, and I have no doubt that the record -of the work done and studies made will appear in appropriate form in -due time and will hereafter be referred to as among the most valuable -pathologic studies ever made during a plague epidemic, on account of -their accuracy and completeness. - -I have included, as of great value and directly related to the -epidemiologic phase of this study, reports of some of the bacteriologic -work done in connection with this epidemic at the Bureau of Science, -Manila, by Dr. Otto Schoebl. I am sure that the value of his studies as -reported in part here, with his permission, will be apparent to every -careful reader. I am greatly indebted to him for his permission to make -use of this portion of his studies. Having been in daily touch with Dr. -Schoebl during the year and a half of the continuance of this epidemic, -I can appreciate to the fullest extent the painstaking and accurate -character of his work and findings, of which the part here presented is -by no means the greatest. - -I am quite aware of the fact that there are those who view with some -question the practicability of controlling plague by the measures -applied in Manila, as recited here; but American plague workers are -likely to meet this unbelief by pointing to the accomplished fact, in -San Francisco, in Honolulu, in Porto Rico, as well as in Manila; and -before long, as we confidently expect, in New Orleans. - -These exponents of the school which contends that plague epidemics are -little affected by rat-excluding, rat-destroying and rat-proofing -efforts, believe that the waning and disappearance of epidemic plague -in a given place depend in chief part upon the exhaustion of -susceptible material among the rodent population. However appealing -this argument may be, it is impossible for its exponents to duplicate -American results with equal results in the cities of China, India, Java -and elsewhere, where governmental control and adequate financial -ability to carry out campaigns have been lacking, from one cause or -another. Wherever our methods have been followed, at home and in the -insular possessions of the United States, we have terminated human -epidemics of plague and have apparently put an end to rat plague in -comparatively short campaigns. So long as this discrepancy in results -continues we shall favor the American plan. When we review the work -and results of Blue and his fellows of the United States Health Service -and the officers of the Bureau of Health of the Philippine Islands, we -find little reason for us to favor a change to the expectant plan of -waiting for an epidemic to run its course. - -While speaking of the Philippine Islands, the admirable work of Strong -in Manila, covering years of study of the immunity problem, and his -dangerous and highly valuable work as a member of the Commission which -studied the Manchurian epidemic of pneumonic plague in 1911, must be -mentioned. - -Some years ago I called attention to the fact that few, if any, -American cities were prepared to meet an outbreak of plague with an -adequate supply of antipest serum and that the preparation of -antiplague serum was a neglected or overlooked branch of serum -manufacture in the United States. Since that time, in the midst of a -plague epidemic in Manila, where, for a time, the supply of locally -prepared (Bureau of Science) serum threatened to become exhausted, I -looked into the possibilities of getting a supply elsewhere and found -that, to do so, in anything like a reasonable length of time, was -impossible. Fortunately the threatened serum famine did not occur, the -local supply in Manila proving adequate, although for a few weeks we -were obliged to make use of a stock of Japanese serum which had been on -hand for several years. Since the warning of some years ago, at which -time the plague danger was an anticipated one, bubonic plague has -actually appeared in the United States (New Orleans), the cases being -sufficiently numerous to cause grave concern and to call forth the -utmost repressive efforts of the authorities. The possibility of plague -appearance in the coast cities of the United States, at any time, -cannot be disregarded and provision for the treatment of human cases, -as well as repressive (antirat) measures, is imperative. Antiplague -serum is not producible upon a few hours' notice, nor is it -manufactured in the United States. In view of present war conditions -the difficulty of securing serum from overseas sources is greatly -increased, so that we are well-nigh compelled to depend upon -home-produced serum. In view of the uselessness of drug treatment it is -plainly the duty of national, state and municipal authorities to keep -on hand a reasonable supply of antipest serum to meet any outbreak. -Manufacturers of biological products realize that the preparations for -producing, storing and marketing antiplague serum are expensive and -that the maintenance of immunized animals and the employment of expert -serologists call for expenditures which are unlikely to be recovered -from any demand for serum and that, moreover, the government is doing -and will do all that lies within its power to make the serum -unnecessary, by excluding plague. These are not encouraging conditions -to lead American serum producers to add antiplague serum to the list of -their products. If, under these adverse conditions, any producer of -biologic products shall undertake to produce and maintain an adequate -supply of antiplague serum, he will merit credit for a truly -philanthropic service and will deserve the support of governments, -national, state and municipal, as well as that of the medical -profession. - - - - - CHAPTER I - - ITS HISTORY AND ITS EXTENSION - - -In plague there exists the most intimate relationship between cause and -prevention. We will therefore set forth here, as briefly and concisely -as their importance will permit, the principal facts related to the -causation of the disease. Without an understanding of this relationship -there can be no rational preventive treatment. - -These facts constitute one of the interesting stories of modern -medicine: the story of the arrangement and interpretation of certain -apparently unrelated facts, some of them long known to men, in the -clear light of modern method; the story of the application of analysis, -synthesis, logic and experiment, all leading to the creation of an -understanding which permits us to battle successfully with _pestis -bubonica_, one of the most ancient of human plagues. - -HISTORY.--This disease has an historic interest, most engaging and -fascinating, which one finds it difficult to pass over with mere -mention. - -I venture to recall, therefore, that plague almost certainly dates -back to the pre-Christian era, the earlier record naturally being -lacking in sufficient accuracy of description to enable us to identify -the recorded epidemics, definitely and positively, with true bubonic -plague. - -An epidemic of the second century B.C., as described, seems to have -been one of true plague, while the pandemic which began in Egypt in the -sixth century A.D., thence extending to Constantinople, Europe and the -British Isles, was certainly the disease known in modern times as the -plague. This pandemic, beginning as the plague of Justinian, was -probably followed by the continuous presence of the disease in Europe, -marked by many local outbreaks and periods of quiescence and extending -down through the centuries to the period of the Crusades. In the -eleventh and twelfth centuries the returning Crusaders spread the -plague widely through Europe, which country it ravished from the -eleventh to the fourteenth centuries, reaching its climax of intensity -in the "Black Death" of Europe of the Middle Ages. The disease -thereafter continued to devastate Europe, the great population centres, -Paris and London, suffering especially from its visitations and its -more or less constant presence. The Great Plague of London, the last -important epidemic of the disease in that metropolis, began in 1664 and -lasted five years. With less than half a million of inhabitants it is -estimated that London gave one of every six or seven of her citizens to -the Black Death during the first year of the epidemic. Then followed a -remarkable disappearance of the disease from Western Europe. The -eighteenth century was marked by few epidemic appearances of plague. - -At the end of the first half of the nineteenth century it had -practically disappeared from Egypt and from European and Asiatic -Turkey, formerly its favorite haunts. In interior Asia it has probably -existed for centuries, the non-emigrating character of the people -limiting and confining its devastations. - -To these centres and to the commercial invasion of China, we must -probably trace the beginning of the present pandemic of plague, which -exists to-day, a menace to the civilized and uncivilized world. In the -days of the Crusades a religious invasion of the infected centres -caused the disease to spread throughout Christendom, while in the -present day a commercial invasion has caused it to spread completely -around the world. - -That this is a truth and not a fanciful statement is shown by the -appearance of plague in the following countries since 1894, when it -spread from interior China. In every case it has followed those -sanitary lines of least resistance, the paths of commerce. - -EXTENSION.--To the eastward, from China, it spread to Japan, the -Philippines, Australia, the Hawaiian Islands, Alaska, California, -Mexico, Peru and the western coast of South America. To the westward, -it invaded India, Mauritius, Egypt, Suez ports, Eastern, Central and -South Africa, Mediterranean ports, Great Britain (Scotland), the West -Indies and Brazil. In the last twenty years plague has caused millions -of deaths, and, during a single week in April, 1907, it destroyed more -than 75,000 lives in India, a number about equal to the deaths of a -year in London during the Great Plague of 1665. In contrast with India -the rest of the world has suffered little during the present -world-epidemic, but this loss, while relatively small, is enormous when -translated into lives and dollars. The figures for India are simply -huge. - -MORTALITY.--The official lists of _deaths_ in India for the last twenty -years include some in which the number of _reported_ deaths per year -exceeded one million, and it has been estimated that the actual number -of persons dead from the plague during this period approximates -8,000,000. - -It is gratifying to note a marked decrease in the total mortality in -the reports of the last few years, but so long as the annual death -list, year after year, was measured by hundreds of thousands, rather -than thousands, the situation could not be considered as anything but -grave. - -WIDESPREAD DISSEMINATION IN RECENT YEARS.--Without going into -statistics deeply we may consider also the list of countries, states -and islands from which plague cases have been reported officially -during the last few years. - -My purpose is to invite attention to the continued existence of various -plague foci, any one of which might serve to extend the infection -further, were governmental quarantine and public health supervision -relaxed. - -During August, September, October, November and December, 1909, plague -cases occurred in India, Mauritius, China, Japan, Egypt, Turkey, -Russia, British East Africa, the Azores, Venezuela, Ecuador, Peru, -Chili, California (two cases), and the Hawaiian Islands. - -During the first half of 1910 no very marked variation in the -distribution of plague occurred, cases being reported from practically -all of the foreign countries just named. - -A year later the situation, so far as the distribution of plague cases -is concerned, was not greatly changed, as may be seen from the -following tabulation, which I have abstracted from the _British Medical -Journal_ of September 16, 1911. - -_India._--Deaths from plague in India during the first six months, -604,634. Most prevalent (1) United Provinces, 281,317; (2) Punjab, -171,084; (3) Bengal, 58,515; (4) Bombay Presidency, 28,109. Deaths in -July, not included above, 8990. - -_Hong Kong._--April 24 to August 21, 255 cases, 194 deaths. - -_China._--Since January 1, 1911, plague was reported in varying -intensity in (provinces and towns) Manchuria, Peking, Tien-tsin, Chefo, -Shantung, Shanghai, Amoy, Foochow, Swatow, Canton, Pakhoi and Laichow. - -_Indo-China._--At Saigon, in March and April, 1911, many cases -reported. April 17 to May 7, 56 cases; 17 deaths. May 22 to May 28, 37 -cases; 12 deaths. - -_Siam._--In Bangkok plague was more severe during 1911 than in any -previous year. March 15 to April 15, 33 cases and 29 deaths. - -_Java and Sumatra._--In Java, May 25 to June 3, 105 cases and 62 deaths -(one province). In Sumatra plague was present, no statistics. - -_Straits Settlements._--A few cases, mostly imported, reported in 1911. - -_Japan._--A few cases at Kobe in 1911. In Formosa, from April 2 to -April 15, 31 cases; 24 deaths. - -_Egypt._--Plague reported from Port Said, Suakin (on board ship), Cairo -and Alexandria; also from 11 provinces. The province of Kena had a -severe outbreak, May 5 to May 31, 51 cases and 49 deaths. - -_Persia._--Several cases reported from ports on the Persian Gulf. - -_Turkey in Asia._--A few cases at Muscat, Basra and at Port of Jeddah. - -_British East Africa._--Kismayu and Port Florence reported a few cases -in April, 1911. - -_Mauritius._--January 1 to April 11, 110 cases and 70 deaths. - -_Portuguese East Africa._--Plague was reported present at Nahoria in -May, 1911. - -_Russia._--In the Kirgis Steppe in the Astrakan Government in January, -50 cases; 30 deaths. - -_South America._--Plague prevailed during 1911 in Peru, Ecuador, -Brazil, Chile and Venezuela. No severe outbreak except in Peru, where -from February to May many cases occurred and died. At Libertad, in -March, were reported 60 cases and 23 deaths. - -APPEARANCE OF PLAGUE IN PORTO RICO, NEW ORLEANS AND MANILA.--The -developments of 1912, which most concern us, were the appearance of -human plague and the discovery of plague-infected rats in Porto Rico, -Cuba, and the Philippines, and the discovery of infected rats in New -Orleans. Thus the Atlantic cities of the United States were for the -first time seriously threatened, and the menace of the pestilence at -home loomed up on our horizon with sufficient prominence to excite -public concern. Our protectors and guardians of the United States -Public Health Service, to whose watchfulness we must credit our -prolonged escape from the plague, are carrying out all the protective -measures at their command with the utmost activity. - -At the present time we find Porto Rico freed from the disease. New -Orleans has undergone and is still undergoing treatment which may be -expected, most confidently, to clear it of both human and animal -plague. - -Of Manila and the work there, much will be found in the following -pages, but as both rat plague and human plague have been absent for -more than a year we may fairly look upon the epidemic as ended. After -so long an interval as this any reappearance of plague may fairly be -viewed as a new epidemic, although it is not humanly possible to say -that rat plague has entirely and permanently disappeared from the city -of Manila, as yet. - - - - - CHAPTER II - - THE CAUSE AND THE MENACE OF PLAGUE - - -The foregoing facts are quite sufficient to make us realize both the -possibility and the danger of a world-epidemic; a danger which has -existed for some years and which recently has been especially menacing -to the United States. - -CAUSATION OF THE DISEASE.--Plague is an acute infectious epizootic -disease, caused solely by _Bacillus pestis_, a bacterial organism. The -disease is common to man and to a number of the lower animals and -fowls. - -Prominent among the animals susceptible to the disease is the rat, and -from this animal, through the intermediation of the flea, by far the -most cases of human plague arise. In California the ground squirrel -(_Citellus beecheyi_), a rodent closely related to the marmots of Asia, -plays a similar role. Of the Asian marmots, the tarbagan, a large -rodent, also commonly suffers from subacute chronic plague, which is -transmissible to man as an acute disease by the fleas which the animal -harbors. - -ITS CONVEYANCE.--Although conveyance of plague through rats by contact -alone--that is to say without the medium of the flea--is denied by -modern experimenters, it is perhaps wiser and safer to consider the -disease infectious, inoculable and contagious in the common medical -meaning of these terms. While it is usually conveyed to man by the -flea, it may be acquired by the inhalation of plague bacilli and, -according to some authorities, by ingesting or swallowing the bacilli. - -When infection takes place through the digestive tract, or in other -words, by the ingestion of bacilli, either the flesh of plague-infected -animals or fowls, or food superficially contaminated with plague -bacilli by rats, cockroaches or other carriers, serves as the medium. - -Speaking practically, the possibility of infection through ingestion is -nearly negligible. Indeed, the conclusion of Simpson in regard to this -possibility has been disputed and denied. However, the recent -occurrence of plague in a cat in Manila, in my own experience, observed -with me and carefully worked out by Dr. Otto Schoebl, points strongly to -the possibility of ingestion plague, the cat in this case apparently -having acquired plague from eating rats dead from plague. - -A full account of this case appears in the bacteriologic observations -of Dr. Schoebl and in my recital of the history of the Manila epidemic. - -TYPES OF PLAGUE.--Plague in man may be of several types and these are -designated by names descriptive of the symptoms or of the regions of -the body most affected. Thus we have bubonic, septicaemic and pneumonic -types. As both mild and virulent cases occur, we also use terms -descriptive of the severity and course of the cases. Thus we describe -certain cases as ambulant, abortive, larval and fulminant. In the rat -the evidences of plague are less striking in life than they are at the -post-mortem table. Indeed plague-stricken rats, either naturally or -artificially (experimentally) infected, often show very slight -evidences of disease before death. Chronic plague in rats and a -relative immunity to inoculation in certain wild rats are fairly well -recognized phenomena. - -FLEA CONVEYANCE OF PLAGUE BACILLI.--Both male and female fleas convey -plague, but the exact method of carrying the plague bacilli from -diseased rats to man, while fairly well determined, is of such recent -decision as to leave room for further experimentation. At present it is -believed that the flea deposits plague bacilli, at the time of biting, -upon the skin, by ejecting the contents of its rectum and by -regurgitation of its stomach contents. At least the flea is known to -perform these acts at the time of biting, and the rubbing or scratching -of the flea bite with the hand may easily introduce the bacilli into -the skin at this spot.[1] - - [1] Acknowledgment is hereby made to the Contributors to "The Rat and - Its Relation to Public Health" by various authors, prepared by - direction of the Surgeon-General, P. H. and M. H. S., for numerous - facts utilized in the preparation of this article. The particular - contributors whose valuable chapters have been drawn upon for - information are D. E. Lantz, C. W. McCoy, D. H. Currie, Carrol Fox, - Rupert Blue, W. C. Rucker, R. H. Creel, M. J. Rosenau, V. C. Heiser, - W. C. Hobdy, and J. W. Kerr. - -The possibility that the flea introduces the plague bacilli upon his -mandibles, or the skin-piercing armament with which he is provided, is -also to be considered. However, the following facts support the first -proposition. It has been experimentally shown that the average capacity -of a flea's stomach is about one-half of a cubic millimetre and that -thousands of plague bacilli may be ingested by the flea during the -biting of a plague-diseased rat; that the plague bacilli multiply -enormously and for many days in the flea's stomach and that the bacilli -are found only in the insect's digestive tract; that plague bacilli are -regurgitated from the stomach and are voided from the rectum with the -digested blood. - -It has also been proved that almost all varieties of rat fleas, under -favorable circumstances, will bite man and that the most common human -flea (_Pulex irritans_) is frequently found upon rats, the flea, -generally speaking, being much less particular in his choice of hosts -and in his permanence of residence than most insects and ectoparasites -in general. - -Of the rat fleas, _Pulex pallidus_ (_Loemopsylla cheopis_) is common -under various names in India, the Philippines, Australia, Italy, Brazil -and in tropical countries generally. It bites both rat and man. -_Ceratophyllus fasciatus_, the common rat flea of Great Britain and the -United States, also bites both rat and man. In North America and -elsewhere certain other fleas of the genus _Ceratophyllus_ have been -found upon ground squirrels, cats, rats, sparrows and in chicken yards. - -Dog fleas and cat fleas (genus _Ctenocephalus_) also infest rats, and -fleas of other genera are found upon mice, rats and ground squirrels -rather indiscriminately. - -The significance of these facts in connection with prevention of -plague is apparent and it is plain that our warfare against fleas must -be made upon _all_ fleas and not upon a single variety. In this -connection the possibilities of the conveyance of plague bacilli by -other suctorial parasites and by insects which are not parasites, must -be borne in mind. - -Thus the bed-bug, the louse, the tick and the mosquito must be -suspected as possible intermediaries and the fly and the cockroach as -possible food contaminators. Indeed, laboratory experiments have -already incriminated bed-bugs, flies and lice as potential vectors of -plague bacilli. - -Experiment and observation have demonstrated, however, that above all -other parasites and insects, the flea is most likely to convey the -plague germ from rat to man, by reason of his frequent excursions from -rat-host to human-host, his taste for blood from either host, his -enormous activity and his ability to jump. After a searching inquiry -into the plague question the Indian Plague Commission came to the -conclusion that contagion plays a very minor part in the spread of the -disease, less than three per cent of human cases being so acquired. - -This commission also decided that infection is conveyed from rat to -rat and from rat to man solely through the agency of fleas. While these -conclusions are probably true--and therefore of the utmost importance -from the standpoint of practical prevention--I should question whether -the other possibilities, however remote, are entirely negligible. - -Seasonal conditions may affect the course of an epidemic in various -ways. (a) By effect upon flea prevalence, cold weather greatly -lessening the number of insects. (b) By effect upon rats, cold weather -and rains either driving them from overground to underground, or vice -versa, or from their principal avenues of travel in cities (the -sewers), into houses and buildings. (c) By effect upon the plague germ, -_Bacillus pestis_. The resistance of this organism is very variable, -sunlight and drying being its greatest enemies, while darkness and -dampness are its chief allies. So far as temperature is concerned, the -plague bacillus is not likely to be seriously affected by natural -temperatures, as it is not destroyed by heat below 150 degrees -Fahrenheit, nor by cold measured by zero Fahrenheit, which means that -it survives freezing, generally speaking. - -It is probable that the periods of greatest seasonal prevalence of -plague will be found to correspond generally with increased prevalence -of rat fleas. During the periods when rat fleas are absent or least -prevalent, the disease is perpetuated in the form of chronic (subacute) -rat plague in a small number of the rodents. The India Plague -Commission made and verified this observation. - -Cholera epidemics often abate spontaneously and this is believed to be -due in part to attenuations of virulence and changes in the cholera -organism which may be demonstrated in the laboratory. We can hardly -hope for such spontaneous abatements in plague epidemics, as it has -been found difficult to attenuate or to intensify cultures of plague -bacilli permanently in laboratory experiments with animals. If it is -true that plague epidemics are often marked by a preponderance of mild -cases in the early days and a gradual subsidence of intensity of the -cases as the epidemics wane, we probably will have to look to the -susceptibility of our patients for our explanation of this phenomenon, -rather than to variations in the virulence of the plague bacilli. If -plague bacilli continue to be distributed to susceptible people the -disease should continue with a general stability of virulence. - -STABILITY OF VIRULENCE OF _B. Pestis_.--According to Strong, stability -of virulence is a marked characteristic of _B. pestis_, it having been -shown by him that it is difficult to increase the virulence of a very -virulent strain or to intensify an attenuated one in laboratory -animals, working with monkeys, rats and guinea-pigs.[2] If his -observations are correct (and they seem to correspond with the findings -of other observers), the oft-recorded occurrence of a preponderance of -mild cases of plague in the early days of an epidemic and the gradual -subsidence in intensity of the disease as the epidemic approaches its -close will have to be explained upon other grounds than those of -variability of virulence by attenuation of virulent strains alone. -While he admits that _B. pestis_ may become attenuated under certain -conditions many times during the course of an epidemic, it may also -regain its virulence, he contends, under other conditions. - - [2] "Studies in Plague Immunity," R. P. Strong, Philippines Journal - of Science, June 1907, No. 3. Frequent reference has been made to - these studies in the preparation of this article, for which - acknowledgment is hereby made. - -With these facts concerning the cause and the manner of extension of -plague and its menace before us, we are in position to approach the -problem of prevention intelligently, and in the case of plague -prevention is preeminently preferable to cure, as well as decidedly -more practicable. - -I think we may be permitted here to sum up the problem of plague -prevention thus: Without fleas, without rats, or without human plague -cases, there can be no extension of plague, practically speaking. - -Therefore the destruction of both rats and fleas, the isolation of -human plague cases, and the exclusion from them of all suctorial -parasites and insects, will provide practical security for mankind -generally. - -A word concerning pneumonic plague may be permissible. This form of -plague occasionally occurs in epidemics of great fatality, as, for -example, the epidemic in Manchuria, North China, a few years ago. - -The mystery of this outbreak was largely dispelled by the work of the -Americans, Strong, Teague and Barber, of the Bureau of Science of -Manila. - -The occurrence of secondary pneumonia in bubonic or septicaemic plague -is rather common and it is likely that such secondary plague pneumonias -are the starting points of epidemics of pneumonic plague, _i.e._, of -cases of primary plague pneumonia, the point of infection being in the -respiratory organs and the infection being acquired through the -inspiration of plague bacilli. - -The principal prerequisites seem to be an extremely moist atmosphere -under confined conditions and a low temperature; conditions most -unfavorable to evaporation and ventilation. Under these conditions the -pneumonic patient sprays plague bacilli into the air while coughing and -droplet infection follows. - -It is therefore apparent that epidemic pneumonic plague is controllable -by sanitary and hygienic measures and, furthermore, that in the absence -of original cases of bubonic and septicaemic plague, with secondary -plague pneumonias which give rise to primary plague pneumonia in the -manner explained, respiratory plague in epidemic form will not occur. - -There is no evidence pointing to the conveyance of respiratory plague -by insects or other carriers. - - - - - CHAPTER III - - ITS CONTROL AND SUPPRESSION - - -PLAGUE PREVENTION.--At present the most promising and the most -rationally based phase of plague control is that of prevention. The -reason for this is plainly apparent. If the facts in the case are as -stated and if the conclusions of the Plague Commissioners and students -of epidemiology the world over are correct, to eradicate plague we need -only to control its carriers. - -To exterminate the rat (and perhaps the marmot and ground squirrel), to -prevent the transportation of rats or of infected rat fleas in ships, -trains, clothing, merchandise and upon the bodies of men and animals -from the numerous foci or plague centres of the world to non-infected -localities, is a beautiful plan indeed. - -Restricted to single communities, even where the intelligence, -patriotism, effort and wealth of the whole people are enlisted, the -undertaking is formidable, with obstacles to its execution, and -discouragement must often be expected. Extended in its application to -the whole plague-infected world it becomes an undertaking seemingly -impossible of accomplishment. - -Yet we are encouraged to face the situation by a glance at what has -been accomplished. The United States, perhaps, presents the highest -examples of achievement in the cases of San Francisco and Manila. The -work in San Francisco is too recent and has been too well published to -require detailed review here. A successful campaign against rats in -1907 practically terminated an epidemic of considerable proportions -well within a year. Behind this movement, however, were the powerful -machinery of the Federal Government, money in generous amount and a -considerably aroused public, resentful of the mismanagement of the 1903 -epidemic, whereby, through pure fear of financial loss to commercial -interests and by a disgraceful suppression of the truth, California was -made, permanently perhaps, one of the world's plague centres. - -It has been estimated that the rat population of the world is equal to -the human population, and this estimate does not appear to be -unreasonable when one considers as indices the destruction of the -rodents in cities by the hundreds of thousands, upon single farms by -the thousand, and the wonderful procreative powers of the rat. - -ECONOMIC IMPORTANCE OF RAT DESTRUCTION.--It is certain that the -economic importance of rat destruction upon grounds other than those -purely sanitary must be impressed upon the public wherever a rat -campaign is to be carried on. - -The absolute inutility of the rat, its enormous destructiveness to -crops, to merchandise in warehouses and in transit, to poultry, eggs, -fruits and vegetables, to buildings and furniture, and its incendiary -habits causing annual fire losses of considerable magnitude, must be -emphasized in season and out of season. Such items as the value of the -grain consumed by a single rat per year, as estimated by the experts of -the Agricultural Department, are convincing arguments in the case. At a -daily consumption of two ounces, the ration for a full-grown rat, this -grain value varies from sixty cents per year, for wheat, to two dollars -per year, for oatmeal, for each rat subsisted. Similar data in great -variety, relating to direct and indirect losses, are available for the -purpose of making impressive the economic need for rat destruction. - -Accumulated experience from various countries and cities shows plainly -that there is no single method of rat destruction to be depended upon -to the exclusion of all others and it also shows that without -governmental direction and supervision, backed by ample authority and -the ability and willingness to expend considerable money, neither -single nor combined methods will be successful. Moreover in the -countries where special effort is most needed there is often distrust -on the part of the natives, religious prejudice against the destruction -of animal life and frequently open opposition to the authorities in -their efforts to destroy rats. The same superstitions and religious -beliefs which prevent the killing of venomous snakes in India, at the -annual cost of thousands of human lives, operate against most measures -of rat destruction proposed by the Government. - -EXTERMINATION METHODS.--The plans and weapons of warfare against rats -include the use of poisons; traps; starvation; rat-proof construction -of buildings, wharves, bakeries, stables, granaries, etc.; the -introduction of diseases among the rat population by bacterial viruses -and the conservation of the natural enemies of the rat, such as the -cat, the dog, the ferret, the mongoose, and certain wild animals and -birds of the woods and fields. - -Among the most widely used and most effective poisons is arsenous acid -boiled with rice, or mixed with cheese or cornmeal in the form of a -paste, or placed upon sweets and fruits. - -Crude phosphorus is chiefly used in similar pastes. When mixed with -glucose its inflammable properties are said to be lost. Its -inflammability is, of course, a serious obstacle to its general use. - -Strychnine, owing to its bitter taste, is of little value in poisoning -rats, and when used is best combined with glucose and one per cent. of -cyanide of potassium. Soaked wheat, bread or similar food is then -treated with this mixture and placed where rats may eat it. It is said -to be eaten readily by ground squirrels with fatal effect. It is, -however, expensive and apt to be taken by domestic fowls. Most rat -poisons have the disadvantage of being dangerous to human life and must -be used with caution wherever children and ignorant native persons are -about. - -TRAPPING.--Trapping has been found to be a very effective means of rat -destruction in cities. (See later pages for relative efficiency of -traps.) Rat traps are of several varieties and are constructed upon -various principles. It is sometimes desirable to catch the rats alive -and uninjured, and for this purpose barrel traps, wire cage traps and -similar devices are placed in the rat highways. These highways are -readily discovered in the cities. Considerable care must be taken to -overcome the natural caution of the rat, and this includes judgment in -the use of attractive bait, the concealing and smoking of traps after -handling and perhaps the use of some scent, such as the oil of anise, -of which rats seem to be fond. As a general rule bait should differ -from the food naturally supplied by the locality. For example, about -granaries and stables fresh animal food should be used for bait, while -about slaughter houses, meat-markets, fish-markets and similar places, -where animal offal is abundant, the rat should be tempted with -vegetable bait. - -Where the circumstances will permit, and this is apt to be so for -ground-squirrel destruction, the burrows may be filled with some -asphyxiating or poisonous gas. In this manner whole families of -rodents, and their fleas as well, are destroyed. - -The system is not often applicable in houses, but aboard ships it is -found most effective, the holds of ships being flooded with sulphur -dioxide, developed by burning sulphur in a special furnace provided -with a pumping and piping system for delivering the gas at distant -parts of the ship. In empty ships' holds and elsewhere the simple -burning of sulphur in open vessels effects the same results, provided -sufficient sulphur and a sufficient number of vessels be used and -further provided that the generation and confining of gas be -sufficiently prolonged. In San Francisco harbor, where for more than a -year nine vessels were disinfected per day, this method was adopted as -more effective, speedy and economical than any other system. It has the -disadvantage, in the case of laden ships, of affording some danger of -fire. - -Carbon bisulphide has been extensively used in California in the -burrows of ground squirrels. Its fumes, being heavier than air, -penetrate the burrows and promptly poison or asphyxiate all living -animals and fleas. Absorbent material of some kind is saturated with -the liquid and placed in the entrance of the burrow, which is then -quickly sealed to confine the gas. - -It will be seen that, in common with other methods of rat destruction, -fumigation has a limited application and a number of serious -objections. It is particularly useful aboard ships. - -The method should never be employed by unskilled persons or those -unacquainted with the dangers to human life from noxious or -asphyxiating gases. - -STARVING RATS.--The subjects of the starvation of rats and rat-proof -construction may be considered together. - -Just as the pig in the Philippine Islands and elsewhere in the Orient -must give place as a scavenger of human excreta to modern and decent -methods of waste disposal, so must the rat, a garbage scavenger the -world over, give place to systematic garbage collection and removal, -with temporary storage of garbage in covered metal cans (rat proof). - -Incidentally it may be mentioned that the effect of such measures upon -the prevalence of flies and the transmission of disease by these -insects will be very great and very beneficial to the public health. - -Food must be kept from rats and rats must be kept from the food. -Perhaps the greatest resorts of rats are the places where cattle are -fed, where grain is stored and where animals are killed. Slaughter -houses, markets, grocery stores, restaurants, bakeries, wharves and -warehouses must be regulated by ordinances duly enforced. Much can be -done with screens of heavy iron wire with a mesh of less than one inch. - -When concrete and metal have displaced wood and plaster as construction -materials; when plank sidewalks and refuse piles are no more and when -the catch basins of sewers have been made rat-proof the subsistence -problem for the rat will be greatly increased in difficulty, and -starvation should then begin to lessen the rat population, at least in -the cities. - -RAT-PROOFING.--Municipal authorities should take up the matter of -rat-proof construction for new buildings and the rat-proofing of old -ones by approved alterations. In Manila, Hong Kong and elsewhere these -methods are receiving attention and encouraging reports are recorded, -more particularly with regard to the disappearance of plague in -districts so treated than in the disappearance of rats. This is most -important, for if the rat and his fleas are excluded from houses and -therefore from intimate association with man (an apparently feasible -matter through the rat-proof construction of buildings), protection -against human plague is in great measure accomplished. - -[Illustration: RAT PROOF STRUCTURE WITH SOLID CEMENT BASE, SOLID -CONCRETE POSTS, AND UNBOARDED CEILING] - -In Manila the disappearance and continued absence of human plague in -previously infected localities goes hand in hand with the introduction -of systematic rat-proofing in sections where cases of human plague -occur. - -These measures were first instituted in 1906 and plague disappeared -from Manila in the same year and did not reappear until 1912. - -From 1900 to 1905, $15,000 was paid in rat bounties and $325,000 was -paid for salaries, wages and expenses in rat catching, with little -appreciable effect upon the number of rats and without causing the -plague to entirely disappear. It must be admitted, however, that -practical control of the disease was attained during this period. - -Rat-proofing of dwelling houses is less expensive than perpetual -wholesale rat destruction and is a perfectly effective measure against -human plague. In the suppression of the San Francisco epidemic in 1907 -rat-proofing was also extensively resorted to. - -The expense of rat-proofing has been generally considered as -prohibitive, but if the work be confined at first to the vicinity of -infected centres and if it be carried on subsequent to rat-destruction -in corresponding areas the expense need not always be prohibitive--at -least in American governed cities. The Manila plan of plotting the city -into "plague-infected" areas corresponding with the capture of -plague-diseased rats and systematically working within geographic -boundaries in which rat plague exists or is likely to spread, as -determined by rat captures and examinations of the rats for signs of -plague, has proved to be a good plan. - -To prevent the transportation of rats in ships, trains and merchandise -is an undertaking of difficulty as well as of importance. In the case -of vessels it involves an understanding of the manner by which rats -gain ingress to the ship and the ways of preventing them from entering. -Few facts are better known, perhaps, than the fact that all ships -harbor rats, but, except to the initiated, the extent to which some -ships are infested is by no means understood. I have made voyages upon -steamships, which upon alternate trips carried forage for animals in -the holds, when the conditions were, to say the least, uncomfortable. -To have one's state-room taken possession of by rats, his clothing -carried away, or to awake with a rat in his berth are unpleasant, but -not uncommon, experiences. I personally know of a woman, prostrated -with sea-sickness, who was obliged to remain in her berth and see four -large rats disport themselves about her room, and in another case, on -the same ship, a rat jumped from the washstand into the berth of a -sleeping woman, running across her exposed face and arm. - -In travelling upon small dirty steamers in the Orient I have often -slept on deck, quite as much to avoid the rats and vermin in the -state-rooms as for better ventilation. In a certain ship in which I -travelled some of the ship's officers amused themselves by shooting -rats with an air-rifle in the lower decks, quietly hiding themselves in -dimly-lighted places and shooting the rats as they crossed the lighter -spaces. - -In many ships the rat population far exceeds the human population. In -San Francisco 310 rats were destroyed by a single fumigation on a -vessel of only 260 tons burden. In Bombay 1300 rats were destroyed at -one time upon a single ship and in London 1700 were secured at one -fumigation. - -The ease with which rats adapt themselves to new environment is shown -by the fact that they live, when permitted to do so, in cold storage -and refrigerating rooms where they grow heavy coats of fur for -protection against the cold. - -They gain ingress to ships in three principal ways: (1) By coming -overside upon gang-planks, wharf stringers, etc. (2) By passing along -the lines by which the ship is made fast to the dock, through hawse -holes, the rat being an expert rope walker. (3) By coming aboard in the -cargo. - -By the latter method rats are often brought aboard by whole families, -their fleas included. Many styles of packages such as barrels, bales, -crated goods, grain in sacks and matting in rolls present the rat with -abundant opportunity to take passage and it is probably thus, as -stowaways, that rats go to sea in the largest number. Plainly, then, -the placing of rat-funnels upon all lines from ship to wharf, the use -of special fenders, the raising of gang-planks and even anchorage in -the stream will not prevent rats from getting aboard ships unless cargo -disinfection be practised before loading the vessel. The ship itself -should be fumigated every three months if possible. - -Rats are doubtless carried in considerable numbers upon railway cars, -both freight and passenger. - -While riding in a street car in Manila in 1908 I saw a rat run along -the window ledge, to the mingled fright and amusement of the -passengers. - -The same principles which apply in the case of ships apply to cars and -trains as well. Grain cars in particular should receive especial -attention. - -RAT DESTRUCTION BY THE SPREAD OF RAT DISEASES.--The proposal to destroy -rats by wholesale, by spreading epizootic diseases among them, through -feeding them bacterial virus, has received much attention in the last -ten years. In 1900 Danysz isolated a bacillus from field mice suffering -an epidemic disease communicable to rats, and great hopes were -entertained that by means of this method decided reductions in the rat -population would result. Indeed the results in Cape Town, South Africa, -in 1901, and in Odessa, Russia, in 1902, seemed to justify the hope to -some extent and certain observers still believe the method to be -effective. Experience with the Danysz and other organisms has shown, -however, that introduced epidemic diseases do not destroy rats in -sufficient number to do much good and that nearly all the viruses -experimented with are more or less unreliable. - -Most of the organisms are apparently related to the colon, typhoid or -hog-cholera groups. The mouse-typhoid bacillus (_B. typhi murium_) was -originally isolated by Loeffler in 1899. The paratyphoid bacillus and -Gaertner's _B. enteritidis_ correspond closely with the Danysz organism -and can scarcely be separated culturally. In rodents they produce -enteritis, sometimes hemorrhagic in character, and they are by no means -to be regarded as harmless for man, as originally supposed. In Japan, -in particular, serious and fatal cases of diarrhoeal disease have -followed the accidental eating by man of food treated by these -bacterial poisons. - -On account of the natural resistance of rats to diseases of bacterial -causation (plague being the most notable exception to this rule), and -the clinical fact that no sufficient death rate among rodents is -produced by feeding them upon bacterial viruses, as well as on account -of the dangers to man just mentioned, this method of rat destruction is -not in favor at present. - -Poisoning rats and ground squirrels by chemical poisons seems to be a -preferable method, at least equally effective and without most of the -disadvantages of uncertainty and danger which attach to the bacterial -viruses. - -RAT DESTRUCTION BY DOMESTIC ANIMALS.--Concerning the utility of such -domestic animals as are natural enemies of the rat, in the warfare -against the offending rodents, there is considerable difference of -opinion, based upon varying experiences. I leave out of consideration -all but the cat and dog. - -It will be found that wherever cats and dogs are well housed (indoors) -and well fed they are apt to be fat, lazy and inefficient. House cats -of this class will catch mice but will often leave rats alone, but -half-wild cats, obliged to forage for their own subsistence, are often -excellent rat-catchers. Small, active dogs, particularly of the terrier -breeds, will often keep houses practically free from rats and upon -farms they are especially valuable, particularly if the construction of -buildings is such as to permit them to get beneath the floors. The -employment of these animals will necessarily be confined to individuals -for the freeing of individual premises from rats. - -A fact to be borne in mind is one already cited, viz.: that cats and -dogs sometimes harbor the same fleas as the rat. Infected rat-fleas -often leave dead rats for other animals and, all things considered, -there are many other objections to the intimate house dog and house cat -which find comfortable resting places impartially upon the beds of -adults or the cribs of babies and children. - -Furthermore, my personal observations have been such as to cause -me to place small reliance in the value of the ordinary dogs and -cats found about habitations wherein the construction is favorable -to rat-harboring. - -SUMMARY OF PREVENTION FOR THE COMMUNITY.--Before passing to the -consideration of other matters I would sum up the measures of -preventive treatment for the community. There must be (1) Active -warfare against rats and other plague-affected rodents and their fleas; -(2) Modified quarantine--detention or disinfection applied to persons, -goods and animals; (3) Disinfection of cargoes shipped from infected -ports; (4) Isolation of the sick and proper disposal of the dead; (5) -International notification between governments of the occurrence of -plague within their respective territories; (6) Lastly,--but we might -say first in importance,--the early recognition of the presence of -plague and the _rapid diagnosis_ in individual cases, both of which are -dependent upon laboratory workers. - -All of these measures must be fostered, directed and aided in every -possible way by competent authority (national if possible), whose -officers must be men of great moral courage and of unselfish purpose. -Behind all of this must be generous financial support. - -I can best emphasize the importance of the observance of the principles -I have laid down by introducing personal experiences in the conduct of -the antiplague campaign in Manila during 1912, 1913 and 1914. - -I therefore present here the following account of the epidemic, the -campaign of suppression and the various lessons learned. - -It should not be difficult for the reader to make applications of the -principles already set forth and to confirm by the reported facts the -assertion that methods based upon these principles are effective. - -If repetitions of any of the foregoing principles occur it is hoped -that, when taken in connection with concrete applications cited, they -will not appear as redundant. - -THE MANILA EPIDEMIC OF 1912 TO 1914.--The chronologic facts concerning -the development and extension of plague in Manila in 1912, 1913 and -1914 are as follows: - -The disease made its reappearance in Manila, after an absence of six -years for the human disease and five years for rodent plague, two -verified human cases having been recorded in June, 1912. - -Preceding the appearance of the first Manila cases there occurred upon -incoming ships a number of cases of plague during the Spring of 1912, -detected at quarantine. Although there is no conclusive evidence which -connects these imported cases, originating in Hong Kong, China, with -the epidemic which broke out in Manila a few months later, the fact of -their occurrence and recognition is interesting enough for us to -consider before taking up the study of the Manila epidemic. Concerning -these imported cases Dr. Victor G. Heiser, then Director of Health for -the Philippines, wrote as follows in the _Philippine Journal of -Science_, in February, 1914. - - UNUSUAL CHARACTER OF PLAGUE AT QUARANTINE.--It is perhaps - worthy of note that, prior to the appearance of plague in - Manila a number of cases of the disease were found on incoming - steamers. For instance, on April 6, 1912, a death was reported - on the steamship _Zafiro_, which had arrived the day previous - from Hongkong and had been in the harbor for twenty-four hours - at the time of the death. At the medical inspection of the - vessel, which was made the day previous, no illness was - detected. An investigation showed that the victim had been on - deck on the night of April 5, 1912, in apparently good health. - The next morning, at 6 o'clock, he was found dead in his - bunk. The necropsy and subsequent biological findings - reported by Dr. R. P. Strong of the Bureau of Science showed - that death was due to pneumonic plague. - - On April 7, 1912, the steamer _Loongsang_ arrived in Manila - from Hongkong, and the captain reported that a death had - occurred the day previous in a Chinese member of the crew. - Upon investigation of this case, the captain stated that the - man was apparently in good health, but that while hauling on - a rope he fell over in an apparent faint and was placed in a - chair and in the course of a few hours expired. The necropsy - and animal inoculations showed that he had died of plague and - probably of the pneumonic variety. - - Beginning April 7, 1912, the temperature of all members of - the crew and of the passengers that arrived in vessels from - foreign ports was taken with a view to detecting any possible - cases of plague. - - On the arrival of the steamship _Taisang_ from Amoy at the - Mariveles Quarantine Station at about 6.30 A.M. on April 30, - 1912, the entire personnel was carefully examined and found - free from sickness of a suspicious nature and from elevations - of temperature. Seventy-three persons were detained to serve - a quarantine detention of seven days. On the evening of April - 30, a Chinese passenger, aged fifty-one years, was found to - have a temperature of 39 deg. C. with a pulse of 100. He was - placed in the hospital, but protested vehemently that he was - not sick. He was carefully watched from the first; there was - a slight cough; physical examination of the chest revealed a - few rales; smears made of the sputum and stained for plague - bacilli were negative. On the fifth day, the fever still - persisted, but the patient stated that he did not feel ill - and demanded to be released from the hospital. On this day, - the expectoration was blood-stained, but no suspicious - organisms could be found in the smears nor could any physical - signs of pneumonia be detected. Furthermore, there were no - palpable glands. On the morning of the seventh day, the - temperature and pulse dropped and the general condition was - distinctly worse. The patient now admitted that he felt ill. - Several hours later, he flinched when pressure was made in - the right axilla. Lymphatic enlargement was now made out, and - by the evening of the seventh day the bubo in the axilla had - increased markedly in size, the swelling approximating 3 by 7 - centimetres. Glands now became palpable in other portions of - the body, particularly in the cervical region, and a few - hours later there were inguinal and femoral buboes. The - patient became rapidly worse, and died at 7 o'clock on the - morning of the eighth day of his illness. At the necropsy, - the glands of the right axilla and those of the right side of - the neck were found enlarged; the other lymphatic glands were - also enlarged, but to a lesser degree. There was - consolidation of the lower lobe of the right lung, and the - spleen was about twice its normal size. In brief, the - necropsy findings of a typical case of septicaemic plague were - present. Smears from the spleen and the right axillary gland - showed immense numbers of bipolar-staining organisms. - Cultures made from fresh pieces of tissues and later - inoculated into animals gave positive results for plague. - -BEGINNING OF THE MANILA EPIDEMIC.--Proceeding with the Manila epidemic -inaugurated with the two cases referred to as recorded in June, 1912, -we find that the total number of cases recorded from the time of the -outbreak in 1912 until the last case in 1914 was 90. (This includes -none of the imported cases from China which developed en route to -Manila from Chinese ports.) - -Of these 90 human cases, 76 were fatal and autopsies were performed in -all instances. Fourteen persons recovered. The number of cases of -animal plague up to July, 1914, was 53. This refers only to -laboratory-proven cases of rat plague. As a matter of fact, hundreds of -dead rats, almost certainly plague rats, were found in the course of -rat-proofing operations. - -Although the period covered by this epidemic approximates two years, it -must not be supposed that the progress and extension of the epidemic -was an uninterrupted or unobstructed one. - -On the contrary, such extension as occurred was made in spite of the -most active suppressive effort, and it is believed that this effort -brought about a creditable result, as indicated by the accompanying -record. - -When one considers the favorable conditions for the natural spread of -plague, both in Manila and throughout the Philippine Islands, and -realizes the interposed difficulties and obstructions, natural and -unnatural, geographic, human and domestic, which confront us at every -turn of the path to correction, removal and reformation, our success in -checking the spread of plague appears as a real achievement, especially -when contrasted with the results of effort during the same period in a -British city of similar size but a few days' sail from Manila, where -the cases were numbered by thousands and where the infection still -persists. - -FIRST MANILA CASES.--The first case of plague (June 12, 1912) occurred -in a resident of Tondo, 920 Calle Antonio Rivera, and in the light of -subsequent developments it may perhaps be grouped with the October -cases traced to the Manila Railway Company's freight station and yard, -as 920 Calle Antonio Rivera is but a stone's throw from the Manila -Railway property. The connection, however, is not clear, and, on the -other hand, it is not wholly inconceivable that the rat epidemic and -human plague cases at the railway station in October may have been -secondary to this June case. Such speculation is fruitless, however, so -far as establishing facts is concerned. - -The second case of human plague occurred 13 days later, June 25, in a -resident of a district somewhat removed from the first case, but in -the same general section of the city. - -Then came a lull of more than a month, until August 4, during which -time no case of plague occurred; or at least none was reported. - -August brought forth five cases on the fourth, eighth, fifteenth, and -twenty-first days of the month, in residents of the Quiapo and Binondo -districts. - -These cases were unrelated to the preceding ones so far as could be -ascertained. - -Another lull of a month, until September 24, now occurred without a -reported case of human plague. During this time, however, the first -cases of rat plague were discovered, one on August 30 and two on -September 6, all of them in the Quiapo district. - -From this time (September 24) on, however, human cases occurred at -intervals of a few days until Christmas Day, 1912, the longest -plague-free period being one week; the number of cases by calendar -months being distributed as follows: September, 3 cases; October, 22 -cases; November, 12 cases; and December, 6 cases. - -GEOGRAPHIC GROUPING.--Not until October 21 was there any apparent -geographic grouping of cases indicating a well localized infected -centre. Upon this date there began the outbreak of plague among the -employees of the Manila Railway Company, laborers at the freight -station and yard of the company. This freight station and yard is -located between Calle Azcarraga, Calle Dagupan and Calle Antonio -Rivera. The outbreak totalled 17 human cases, all fatal, and extended -into November. Indeed, the last case traced to this focus occurred on -December 7, 1912. - -During the present epidemic of plague in Manila this focus was the only -one to which a larger number of cases than five could be traced, and in -all the other instances where multiple cases were traced to an infected -centre, the foci were all single buildings. - -The locations giving rise to multiple infections and the number of -cases of plague developing at each address, with months of incidence, -are as follows: Calle San Fernando (804-814), November, 1912, 4 cases; -Calle Teodoro Alonzo (518), November and December, 1912, 2 cases; Calle -Cabildo (Intramuros), November and December, 1912, 2 cases; Calle -Comercio (1028), February, 1913, 2 cases; Calle Sande (1364), April, -1913, 5 cases; Calle Juan Luna (1226), May, 1913, 2 cases. - -Returning to the Manila Railway outbreak, it is necessary to state -that a well-defined epidemic among rats preceded this outbreak, -resulting in the death of a large number of rodents (undoubtedly from -rat plague). This epidemic was not reported by the railroad company -until the outbreak of human plague had begun. It was then too late to -identify plague in the dead and mummified rats found under floors, -platforms and elsewhere, but the fact that large numbers of rats had -recently died here was established by the unanimous testimony of the -employees at the freight station and the finding of rat cadavers. - -As stated, the human outbreak here occurred upon October 21, and -fifteen cases developed within 3 days. - -This indicates an extensive desertion of fleas from plague rat cadavers -and an attack upon human beings, after a fasting period, on the part of -the fleas, of several days. The human outbreak at the station and the -death of a large number of rats at the same place, just previous, -correspond to a nicety and establish to a moral certainty the -connection necessary to explain the epidemic. - -After the railway epidemic of human plague, cases continued to occur -through November and December, without apparent relation to each other, -except in the following instances, which have already been mentioned: - -Four cases under one roof on Calle San Fernando (November 12, 13, 16 -and 22); 2 cases in one house on Calle Teodoro Alonzo (November 26 and -December 2); and 2 cases in the same house on Calle Cabildo -(Intramuros), November 23 and December 11. - -These multiple cases will be referred to elsewhere. - -The other cases during October, November and December were apparently -sporadic and unrelated, either to the other human cases or to the few -scattering cases of rat plague discovered from time to time. Without -doubt, however, all were actually related to preceding cases of rat -plague, _i.e._, to undiscovered rat cadavers, dead from plague and -deserted by infected fleas. - -In the following plague houses (see list of cases) dead rats were -actually found, although the advanced degree of desiccation and -mummification defeated the biologic determination of the cause of -death: 518 Calle Teodoro Alonzo; 973 Calle Azcarraga; 282 Estero de -Binondo. - -In other plague houses the recent finding of dead rats was alleged by -the occupants, but rather too indefinitely to record positively. - -A study of the maps and lists showing the localities in which cases of -rat plague had been found up to this time (December 26, 1912), in -connection with the location of plague houses, was much less suggestive -than a similar study of the lists and maps covering the cases of 1913. - -However, the existence of concurrent rat plague and human plague, in -corresponding sections of Manila, had been well established already by -bacteriologic studies of captured rats, made at the Bureau of Science. - -Of nearly equal weight was the observation concerning the two -epidemics, rat and human, at the Railway Station, which I have already -described. - -The year 1912 closed, then, with a recorded total of 50 human cases and -7 verified cases of rat plague. - -January, 1913, saw but a single case of human plague. This occurred on -January 24, just a month from the last previous case, that of Christmas -Day. During this month no case of rat plague was reported. - -In February, 3 human cases occurred and in March, 4 cases were -recorded. - -Early in March, 1913, cases of rat plague began to occur in the Tondo -district in a section lying between Manila Bay and the Estero de la -Reina and extending northward from Calle Moriones. This was a new -district for rat plague and as the cases increased in number we were -able to foresee and predict the appearance of human plague in the same -district, which in point of congestion of population, poverty of its -residents and in the matter of dilapidation of its light material -houses and shacks, is about the worst locality in Manila. - -From March 22 to September 20, 1913, all the cases of human plague, 11 -in number, occurred in the midst of this district. During the same -period 25 cases of rat plague were reported from the same section, and -a glance at a map of this part of Tondo instantly shows the -relationship existing here between rat plague and human plague. - -This relationship is additionally emphasized by referring to the -memoranda concerning certain overcrowded houses, in the midst of the -rat plague district, where multiple human cases occurred. (See -memoranda in re 1226 Calle Juan Luna and 1364 Calle Sande.) - -[Illustration: CLEANING AND RAT PROOFING IN BASEMENT OF 1226 CALLE JUAN -LUNA IN WHICH TWO CASES OF PLAGUE OCCURRED. RAT CADAVERS FOUND UNDER -BROKEN FLOORS (MANILA PLAGUE CAMPAIGN)] - -The human cases in April were 5 in number, all originating in the same -house, and the May cases numbered 4, two of which occurred in the same -house. - -It may be explained, in passing, that two cases of human plague, -discovered in Malolos, 25 miles from Manila, on March 23 and March 26, -respectively, were definitely traced to the same house in Manila, -number 12 Calle Aguila, Tondo, both patients having lived in the -basement of this house until within 48 hours of the development of the -disease. These persons were unrelated and were two of a large number of -people who lived in a tenement at this address. Both patients were -detected, while still alive, in Malolos, where they were living in -different and widely separated houses. One of the patients died in -Malolos but the other one was brought to Manila by train and died at -San Lazaro Hospital. Fortunately no infection was transferred to -Malolos by these two persons. In this connection it is interesting to -note that no other cases have been reported from outside of Manila, -except the small outbreak in Iloilo in the southern islands, where the -antiplague work was successfully directed by Dr. Carroll Fox. -Concerning this outbreak, Dr. Heiser, then Director of Health for the -Philippines, writes as follows (_Philippine Journal of Science_, -February, 1914): - - PLAGUE IN ILOILO.--In Iloilo, a case suspicious of plague was - reported on July 5, 1912, and this diagnosis was subsequently - confirmed by the laboratory. It occurred in the person of a - Chinaman who was reported to have come from Bais, Oriental - Negros, but later investigation showed that he had been a - resident of Iloilo at least since February, 1912. The next - case was reported August 18, and the last case, September 17, - 1912. There was a total of 9 cases. All of the cases were - confined to two houses. During July, August, September, and - October, 1146 rats were caught in the vicinity of the houses - in which the human cases had occurred, along the water front, - and in the places which were regarded as suspicious, but in - not a single instance was an infected rat found. - -DIRECTED TO TAKE CHARGE OF PLAGUE SUPPRESSIVE MEASURES.--Upon my -arrival in Manila from the United States, on October 23, 1912, I -received orders from the Director of Health to take charge of all -plague suppressive measures in Manila and I remained in charge of this -work continuously until July 11, 1914. - -PLAGUE FIGHTING ORGANIZATION.--The plague fighting organization was -composed of three American Sanitary Inspectors and from ten to fifteen -native Assistant Sanitary Inspectors of the Bureau of Health, rat -catchers and laborers of the Bureau and laborers of the City of Manila -supplied by the Department of Sanitation and Transportation. The -combined force varied in numerical strength from 100 to 150 men and was -usually divided into three parties, distributed in various parts of the -city according to the local indications and needs from time to time. - -After the invasion of Tondo by rat plague we made special effort to -rat-proof the light material houses of that section, in the course of -our cleaning operations, by the closure of the open ends of bamboo -timbers with cement and with tin cans, in the manner shown in -photographs herewith. In addition to this, special attention was given -to the repair of broken cement work, and hundreds of Bureau of Health -orders, verbal and written, were issued to owners, at my request, in -the rat plague districts. - -The number of houses in which bamboo timbers were closed by cement or -tin exceeded a thousand. - -In addition to these means, the very important matter of depopulating -the insanitary basements of the light material houses in squares where -plague has occurred was given attention, with the result that hundreds -of families were moved from these insanitary and dangerous ground-floor -rooms to quarters well above ground and measurably removed from the -rats, which roam over the ground from house to house, foraging for food -under kitchens and in ground-floor storerooms, tiendas and eating -places. The fish packing factories afford them abundant food and a -number of cases of plague have occurred adjacent to these fish-drying -establishments. - -RAT-PROOFING AND RAT DESTRUCTION.--While it is frankly admitted that -rats may not be completely exterminated by poisoning and trapping, the -statement, so frequently repeated of late, that destructive measures -really increase their number, is unwarranted and unsustained by facts, -at least in Manila. It seems to be the common practice for disbelievers -in trapping and poisoning to array the methods of rat-proofing and rat -destruction as alternative policies, whereas everyone practically -familiar with the work in such cities as Manila--or even in the United -States--knows that there is often no choice permitted. Rat-proofing is -highly desirable, permanent in its results, and in every respect the -"method of election." On the other hand, it is entirely inapplicable at -certain times and in certain localities where poverty, lack of interest -of property owners, and ofttimes lack of interest and of money on the -part of municipalities, absolutely preclude its immediate application. -It is therefore unfortunate that the statement, that rat poisoning and -trapping are ineffective, either in controlling plague or in reducing -the numbers of rats, is circulated. It may be shown easily, by the -daily records, that within a few weeks after extensive rat poisoning -and trapping (with the breaking up of nests) is pursued in a given -locality, the rat catch drops in the most decided manner. - -Individual premises may be practically cleared of rats by continued -intelligent rat catching and poisoning, and while the normal rat -birth-rate may keep pace with the normal rat death-rate it will not -keep pace with the normal death-rate plus the poisoning and trapping -death-rate in any given locality, provided that the poisoning and -trapping, with the destruction of nests, be intelligently and -continuously carried out. - -Rat-proofing and rat destruction, then, should not be contrasted as -alternative procedures or policies. Both are valuable and each has a -proper place. In communities non-infected with plague and unexposed to -infection it will probably be found that rat-proofing, carried out in -connection with the repairs of old buildings and the erection of new -ones, will meet the requirements. On the other hand, in cities exposed -to plague infection or already infected, rat destruction is bound to be -necessary for years to come. - -In emergency, the removal of people from intimate relationship with -rats (so far as is possible), as practised recently in Tondo district, -Manila, will often have to take the place of rat-proofing; and rat -destruction and expulsion will be found, in the last analysis, to be -the methods upon which success or failure in fighting plague during -epidemic time will depend. - -In this connection I quote correspondence which passed between the -Director of Health and myself in 1913. - - Upon March 22, 1913, I directed the following letter to the - Director of Health: - - SIR: I have the honor to state that Estaban Masibac, aged - twenty-two, laborer, who died at 140 Perla of bubonic plague, - slept upon the ground floor of this house upon a bamboo bed. - All these basement dwellers in this district now infected - with rat plague are in considerable danger. - - The roving rats which wander over these ground surfaces from - house to house come into pretty close contact with these - basement dwellers, and it would appear that they visit the - upper stories of the houses rather infrequently, unless food - is stored there. Upon the ground they forage upon the food - dropped there by the residents of the houses. - - I would like to have authority to order the vacation of these - basement rooms which are almost invariably unfit for human - habitations. - - I look upon this measure as an important one at this - threatening time and believe it should be enforced in every - square or block where plague rats have recently been found. - If this authority is granted it will be used judiciously. - - Very respectfully, - [Signed] T. W. JACKSON, - _Medical Inspector in Charge of Plague Suppression_. - -Upon March 24 I received the following letter of authorization: - - SIR: Confirming my verbal instructions of yesterday I have to - request that, in accordance with the recommendation contained - in your letter of March 22, that on account of the danger of - the spread of plague in the district in which plague has - appeared extensively, the basement dwellers in blocks, or - squares, in which plague has been found, should be ordered to - vacate. - - Very respectfully, - [Signed] VICTOR G. HEISER, - _Director of Health_. - -Upon November 26, 1912, five dead rats were reported from the U. S. -Army Commissary Warehouses on the Pasig River near the Malecon. They -were found dead by workmen there and were thrown into the river by the -finders and thus, unfortunately, examination for plague was prevented. - -Upon November 27, a cat, known to have caught and eaten rats recently -at the same place, was reported to be sick. I took the cat to the -Bureau of Science where she was observed until she died, three days -later. - -At autopsy, typical bubonic plague (cervical) was disclosed, and -several guinea-pigs inoculated from the spleen and bubo died from the -same disease. A guinea-pig, inoculated from a swab introduced into the -cat's rectum, also died from plague (see report of Dr. Schoebl). - -Four kittens, recently born of this plague cat, were observed for two -weeks but showed no sign of the disease. - -Subsequently about 80 rats were caught at these warehouses and in the -vicinity, but none of them showed post-mortem signs of plague. The -Medical Department, U. S. Army, then took up the matter of rat catching -on all military reservations in Manila and in all buildings thereon, -but no more cases of animal plague were discovered. - -FLEAS AND THEIR HABITS.--In "Observations Upon the Bionomics of Fleas -Bearing Upon the Epidemiology of Plague in Eastern Java," by N. H. -Swellengrebel, Ph.D., published by the government at Batavia, Dutch -India, in 1913, some interesting facts, developed by study and -experimentation, are presented. Some of these facts have a bearing on -the plague problem in the Philippines, for it should be borne in mind -that certain climatic similarities and racial similarities pertain -commonly to the Javanese and Filipinos and their respective countries. - -While we are not prepared at present to make general application of the -Javanese findings to the Philippine Islands, for lack of parallel or -confirmatory studies in the Philippines, we may state some of the -conclusions of the Java workers with propriety, and we may also point -out similarities in the construction of certain Filipino and Javanese -habitations in their relation to rat harboring. - -Swellengrebel, in Java, noted the number of fleas per rat, dealing with -_Xenopsylla cheopis_ (the commonest rat flea in Java) almost -exclusively. This flea, it will be remembered, is also the common rat -flea of India, the Philippines, Australia, Italy, Brazil and tropical -countries generally, being variously known as _Loemopsylla cheopis_, -_Pulex pallidus_, _P. brasiliensis_, _P. philippinensis_, and (in -Italy) _P. murinus_. - -It would not be unreasonable, therefore, to expect to find at least -some of his observations applicable to the Philippine Islands. - -Swellengrebel failed to find _Ctenocephalus canis_ (dog flea), _C. -felis_ (cat flea) and _Ceratophyllus fasciatas_ (the common rat flea of -the United States and Europe) upon Javanese rats. In attempting to -determine the normal flea census he found that field rats, and field -rats caught indoors, as well, generally carry fewer fleas than house -rats and that the number of fleas per house rat varies in different -districts from .02 per rat to 2.3 or 4 per rat and that this variation -is not invariably constant with the presence or absence of rat plague. -Concerning the question whether or not a high flea census may indicate -rat plague, Swellengrebel offers the reasonable opinion that there is -little doubt that plague in rats increases the number of fleas per rat -above normal and that, consequently, a sudden or marked increase in -the number of fleas per rat, without a known normal cause, indicates -increased rat mortality and probably rat plague. - -As to the influence of temperature and humidity on the hatching of -larvae, he concludes from experimentation that the duration of -development of the egg varies under various hygrometric conditions, the -general rule being, "the lower the humidity the longer the development -period." - -As to the influences of temperature and humidity upon the transition of -larva to imago he finds that if humidity diminishes, a smaller number -of larvae reach the adult stage; and also that a saturated humidity (in -artificial cultures), causing condensation of water in the substratum, -is very fatal to larvae. He offers the thought that this, perhaps, -explains why only small numbers of fleas are found on field rats which -live in holes in rice fields which are necessarily damp, especially in -the rainy season. - -His experiments to determine the duration of life of fasting fleas were -made with laboratory-bred fleas which had never fed on blood and with -fleas which had already sucked blood. - -The duration of life was variable, but of those fleas already fed with -blood three-quarters (3/4) perished within 10 days and the remainder -lived from ten to twenty days, only one-tenth, however, surviving for -13 days, if moist conditions were maintained. High temperature was -determined to be an unfavorable condition. - -If from these findings one should attempt to predicate or predict the -extension of plague in house rats--based on flea prevalence--and this -with relation to climatic conditions, we should be led to the -conclusion that the rainy season, with its greater humidity, would be -quite the most favorable time of year for rat plague extension in -Manila and, upon the contrary, that the hot dry season through its -unfavorable influence upon flea breeding would be the least favorable -season for rat plague in Manila. - -The hot months of 1913 did not bear out this reasoning, however, for -during these months rat plague was at its height. - -That increased prevalence of human plague has not gone hand in hand -with increased prevalence of rat plague in Manila, may be explained, I -feel sure, by the activity of our efforts to destroy rats and to remove -the people from close relationship with them. - -Another factor of possible explanation of the greatest prevalence of -human plague in Manila during the late rainy season of 1912 (October), -is the fact that rats are certainly driven above ground into houses and -therefore into closer relationship with man by heavy rainfall and the -consequent flooding of their subterranean homes. - -It appears, therefore, that the seasonal explanation of greater plague -prevalence, rat or human, is susceptible of several interpretations and -I feel sure that in countries like the Philippines seasonal variations -in heat do not suffice to rid the rats of fleas during any months of -the year. If, then, conditions of rainfall serve to drive the rats -above ground and indoors during certain months, it would be reasonable -to expect more human plague from closer relationship of rat and -man,--provided that no special measures were carried out. - -Such, however, is not invariably the rule, if statistical studies are -to be taken as evidence, and so we are reminded that generalizations -for countries of different climates and seasons are not wholly -reliable. - -Rat breeding, as well as flea breeding, is influenced by climate, but -as the reproductive activity of the rat is most retarded by cold -weather--an unknown condition in the Philippines--and as the climate -of Manila is fairly equable so far as heat and cold are concerned, the -only factor which needs to be considered is that of rainfall. As -already mentioned, rainfall doubtless serves to drive rats above ground -and so, to a certain extent, away from their nests in burrows and -underground. - -Their well-known adaptability to changing conditions, however, permits -them to house themselves comfortably above ground when driven out of -these burrows and holes. - -JAVAN OBSERVATIONS.--The following conclusions were reached by Dr. -J. J. van Loghem in a report upon "Some Epidemiological Facts -Concerning the Plague in Java" (published by Civil Medical Service in -Netherlands India-Batavia, 1912): - - 1. In plague-infected villages, as distinguished from - plague-free villages, there exists a considerable mortality - among house rats. - - 2. Rats in plague houses and plague quarters have repeatedly - died from plague. Fresh plague rats appear more often in the - houses adjoining plague houses than in the houses themselves. - - 3. The house rat exists even in the immediate vicinity of - man. - - 4. The ordinary parasite of the house rat is _Xenopsylla - cheopis_, which experimentally is known to choose man as a - host when starving. - - 5. Fresh plague rats have repeatedly been found to harbor a - great number of fleas. - - 6. Virulent plague bacilli have been demonstrated in the - stomachs of such fleas. - -Concerning the prevention of plague by improving the native dwellings, -the same observer says: "Obviously an increase in the distance between -man and rat becomes an important factor as a means of preventing the -disease." - -CONDITIONS OF MANILA HABITATIONS FAVORABLE TO RATS AND PLAGUE.--As -shown by our own experiences in Manila, this end, the separation of -rats and men, is not obtainable by destruction of rats by poison, traps -and rat catchers. Rats dying of plague in their nests furnish the -greatest danger to man. The plague problem, therefore, where rats are -already infected, from the stand-point of direct prophylaxis, is the -problem of dwellings. It was from this stand-point that we attacked the -problem in the Tondo (Manila) campaign in 1913. - -MANILA VERIFICATION OF JAVAN OBSERVATIONS.--Having in mind the -experiences of the plague investigators in Java during the recent -epidemics there (1911-1912), we sought, from the time the Manila -outbreak occurred, to verify some of the findings of the Java -investigators, at least with special reference to the nesting of rats -in close proximity to human beings and the consequent exposure of these -persons to the infected fleas which desert the rats dying from plague -in these nests. - -Not until rat plague invaded the special district of Tondo, in Manila, -in March, 1913, did the opportunity present itself. Theretofore the -Manila cases had generally appeared in houses of the so-called "hard -material districts," where house construction is entirely unlike that -with which the Java workers dealt. With the invasion of Tondo, however, -the Java and Manila conditions became similar. I quote the descriptions -of Javanese house construction from the report of Dr. J. J. Van Loghem, -"Some epidemiological facts concerning the plague in Java," Batavia, -1912. - -THE JAVAN VILLAGE HOUSE.--In substance, he says that the Java village -house, as a general type, is a one-storied structure with its roof -sloping to the front and back, _i.e._, with its ridge parallel with the -front and back aspects of the building. It is not elevated above the -ground by supports or palisades and has no separate floor, the earth -serving as the floor. - -The outer frame is of strong bamboo poles and the inner frame is also -constructed of bamboo. These bamboo timbers are perforated at various -points to permit of framing with other pieces of bamboo and for the -entrance of pegs, etc. - -The roofs of these houses are often made of tiles, but at times the -familiar thatched roof is seen. In both cases the supports or rafters -are bamboo poles. The principal piece of furniture is the "bale bale," -or bedstead, usually made of bamboo, except in the houses of the -well-to-do. Small storerooms are often located in the houses, and -stables are sometimes built against them. In many cases the family -provisions are kept in the house and the cattle are housed here as -well. - -MANILA LIGHT MATERIAL HOUSES.--If, now, we turn our attention to the -average Tondo (Manila) light material house it will be apparent that -the description given for the Java village house fairly describes the -Tondo house, except that the Philippine house is commonly elevated 2 -metres or more above the ground upon bamboo supports (see photographs). -The basement is usually enclosed in a manner similar to the principal -room of the Java house and the basement room may fairly be compared, -structurally and in the matter of its floor, with the one-story Java -house. In the Manila house, however, the floor of the upper room takes -the place of the roof of the Java house and like it is supported by -bamboo timbers. - -Here, then, in our enclosed basement story, we have a practical replica -of the one-storied Java house. - -Here, also, the principal piece of furniture is often a bamboo bed, -practically identical with the Java "bale bale," if we may judge from -photographs. - -In the Java houses the favorite nesting places for rats were found to -be the interiors of horizontal bamboo pieces of the roof, house frame -and bedstead. - -The rat usually gains entrance by gnawing through the natural -partitions between the bamboo sections near the outer end of the pole. -Our Manila photographs show both the natural open ends of such timbers -and the rat-gnawed perforations in the partitions. - -In Java, rats also nest in the thatched roofs, as they occasionally do -in the Philippines. - -NEST MATERIALS.--The materials utilized for nests by rats in Manila -and Java seem to be identical also. Straw, dry leaves and pieces of -cotton are mentioned in the Java reports. The same materials and -additional ones will be found mentioned in our reports upon nests. - -[Illustration: BAMBOO HOUSE SUPPORTS NOT SEALED WITH CEMENT. NOTE HOLES -GNAWED IN BAMBOO ENDS. RATS FREQUENTLY MAKE NESTS IN THESE HOLLOW -BAMBOO RAFTERS.] - -The presence of food was also noted in the bamboo nests in Java and we -often find articles of food in our Manila nests. - -Dr. Korn, P. H. Service, and the writer (T. W. J.) investigated a good -many of these bamboo house-timbers and we not only found such evidences -of rats as food, rat faeces and nest materials, but in one case a rat -was actually driven out of a bamboo nest by introducing a long thin -strip of wood. The evidence of similar conditions then is complete. - -We also duplicated the experiences of the Java workers in finding dead -rats inside of the bamboo house timbers in close proximity to patients -sick (or dead) with plague (see memoranda in the case of Esteban -Masabik, of 140 Calle Perla, March 22, 1913). - -Very extensive rat destruction and cleaning operations, covering a -large portion of the city of Manila and including all sections where -cases of rat plague or human plague developed, were undertaken and -this work was carried on without interruption for about two (2) years. -City laborers to the number of 60 to 150 were used and the work was -supervised by Sanitary Inspectors Brantigan and Searcy, of the Bureau -of Health. During a part of the time a flying column of 50 men, under -Sanitary Inspector Hunniecutt, was detached from the main party and -employed at placing rat poison. - -The total amount of accumulated dirt removed from houses and yards -approximated 5250 tons (for 17 months ending November 1, 1913). - -Without doubt this general cleaning campaign and the removal of this -enormous accumulation of dirt and rubbish was of great value as an -antiplague measure. - -The rat catch will always be found to depend upon several factors, -viz.: the number of persons employed; the number of traps and portions -of poison placed; the location of the operations and the length of time -a given locality is trapped, poisoned and cleaned. The variety of baits -and poisons will also affect the results. - -In addition to these factors certain others are found to operate in -reducing the rat catch, as, for example, weather conditions and the -occurrence of Sundays, holidays and the days just preceding and -following holidays. - -Upon rainy days and the days just mentioned the rat catch almost -invariably falls off. - -From statistics collected by me in connection with this work, Dr. V. G. -Heiser, then Director of Health for the Philippine Islands, published -the following memorandum in 1914. As it is a correct transcript of my -records I introduce it here in its entirety. - - COMPARATIVE STATISTICS IN RAT-CATCHING METHODS.[3]--With a - view to ascertaining which type of rat trap was most effective - and also the average number of rats that are caught by a given - number of poisoned baits that are set out, statistics were - kept during the antirat campaign in Manila. The ratio - maintained in catching rats with two types of traps is - indicated in the following table, a perusal of which will show - that for the three months ended June 30, 1913, there were - 120,565 spring or snap traps set and that for every 100 of - this type of trap set there were caught 6.9 rats. During the - same period there were 47,075 wire cage traps set; the total - number of rats caught was 339; which gives 0.72 rat caught for - each hundred traps set. For the quarter ended September 30, - 130,627 spring or snap traps were set and 9,753 rats were - caught, which gives 7.47 for each 100 traps set. During this - period 40,621 wire cage traps were set and 395 rats were - caught, which gives 0.97 rat caught for each 100 wire cage - traps set. - - [3] Reprint from the Public Health Reports, Vol. 29, No. 6, February - 6, 1914. - - ===================+==========================+========================= - | Quarter ended June 30 | Quarter ended Sept. 30 - +---------+---------+------+---------+---------+----- - Kind of trap | | Number | | | Number | - or poison | Number | of rats | Per | Number | of rats | Per - | set |caught or|cent. | set |caught or|cent. - | |poisoned | | |poisoned | - -------------------+---------+---------+------+---------+---------+----- - Spring or snare | | | | | | - traps | 120,565 | 8,377 | 6.9 | 130,627 | 7,753 | 7.47 - Wire cage traps | 47,075 | 339 | .72 | 40,621 | 395 | .97 - Poison bacon, rice,| | | | | | - or coconuts | 166,237 | 1,216 | .731| 177,309 | 216 | .12 - -------------------+---------+---------+------+-----+---+---------+----- - | Quarter ended-- - +---------+--------- - | June 30 | Sept. 30 - ----------------------------------------------------+---------+--------- - Number of rats: | | - Caught by dogs | 160 | 5 - Killed with clubs and other weapons | 2,889 | 3,818 - Found dead from other causes | 316 | 297 - ----------------------------------------------------+---------+--------- - - No accurate record was kept of the number of each kind of rat - bait set. Only the total of all was recorded. Bacon or coconut - with strychnine and rice with arsenic were used. For instance, - for the quarter ended June 30, 1913, there were 166,237 poison - baits set in new territory and the rats found poisoned average - for each 100 baits 0.72. During the next quarter there were - 177,309 baits set in territory that had been worked over, and - only 216 rats, or 0.12 rat per 100 baits, were killed. From - the foregoing it appears that the rat poison ranks lowest in - efficiency but perhaps highest in economy. In view of the - fact that the original cost of the cage trap is many times - more than that of the spring trap, and the cost of maintenance - is very high, it will be apparent that the spring trap is by - far the more economical as well as more effective of the two. - -Generally speaking, however, the number of rat catchers engaged and the -location of their operations has the largest influence upon the total -catch of rats. For the fiscal year July 1, 1912, to June 30, 1913, -inclusive, the total catch was 55,101 rats (Manila only); to December -1, 1913, 79,676. - -The most natural explanation of the general correspondence between the -highest rat catch and the highest incidence of human plague would be -upon grounds of greater activity in rat catching effort at times of -greatest plague prevalence, but from the inauguration of general -systematic rat catching there was no cessation of effort, even during -the abatement of plague, and in consequence this explanation does not -apply strictly. - -It is true, however, that whenever plague occurred in districts -theretofore free from the disease, rat catching was pushed vigorously -in the surrounding localities. - -Making due allowance for all the factors mentioned I am impressed with -the probability, amounting almost to certainty, that the catch of more -than 79,676 rats definitely affected and checked the spread of plague -in Manila in 1913; and I am of the opinion that systematic and -wholesale rat catching, carried out in the most economical manner -possible, should be persisted in indefinitely, at least until plague -disappears, wherever the disease occurs. - -Efforts to prevent the spread of plague to the provinces of Luzon, by -way of the railways, were successful and the present measures employed, -freight inspection, the fumigation of packages suspected or likely to -contain rats, and the similar treatment of freight cars showing signs -of rats, should be continued. In a few cases these measures have driven -rats out of both packages and cars and the animals have been killed by -the sanitarians on duty at the station. - -The matter of water transportation was entirely within the control of -the authorities in charge of inter-island quarantine affairs. - -Rat catching in Manila was systematically performed and all rats -captured were turned over to the Bureau of Science for examination for -plague. - -[Illustration: MATERIALS MUST BE MOVED ABOUT IN THE SEARCH FOR RATS -(MANILA PLAGUE CAMPAIGN)] - -When plague foci were discovered the localities were trapped and -poisoned both circumferentially and centrally, with a view to -preventing the diffusion of infected rats throughout the city. - -RAT-PROOFING.--The theoretic desirability and superiority of "out -building" the rat, over all other methods of rat suppression, is -admitted. The apparent impracticability of actually rat-proofing Manila -at the present time and our inability to starve the animals out, -justify the other and less permanent measure, viz.: rat catching. -However, I heartily favor and urge the most complete and thorough-going -rat-proofing of buildings actually infected with human or animal -plague, in all cases. The building ordinances of Manila already provide -for rat-proof construction in all new buildings erected. - -With a view to cutting off the food supply of the rat, more than 1100 -orders upon householders, to provide covered garbage cans, were served -in the district of Tondo alone. - -The open ends of bamboo timbers in more than 2300 houses were closed, -either by cement or tin cans, during 1913. - -THEATRE DISINFECTION.--All the cinematographs and theatres in the city -were disinfected upon repeated occasions by spraying with petroleum -and cresols, with a view to destroying fleas and preventing plague -infection. - -Attempts at deception and concealment of plague patients, upon the part -of members of their families, were numerous, but with the close -scrutiny of death certificates and dead bodies exercised at all health -stations it is believed that all cases were recognized. - -One case of extremely careless diagnosis occurred. A death certificate -was furnished by a local native doctor who certified the cause of death -to be "uterine hemorrhage." Suspicion arising, an autopsy was ordered -and a pronounced case of bubonic plague was disclosed postmortem. No -evidence of uterine hemorrhage, except slight menstrual signs, was -found. - -The destruction of infected fleas in plague houses is of course the -primary object of the disinfection by spraying, which is thoroughly -carried out in every house where a case of human plague or rat plague -appears. The method is a simple one and consists in spraying a mixture -of cresols (2 per cent.) and kerosene (98 per cent.) over all surfaces -of the house, floors, walls, underlying ground, furniture and the -spaces above ceilings, etc., using the mixture liberally and securing a -general surface distribution. There is no doubt of the toxicity of this -mixture to all fleas and bed-bugs which it reaches, and it is -undoubtedly an effective measure in rendering an infected house safe. -All of the instances of multiple house infections, where the cases -recurred after disinfection, in Manila, have been in houses where, for -one reason or another, the recommended structural rat-proofing has been -postponed or where it has not been done. Thus, on Calle San Fernando -the sequence of the four cases (their progress by days and in -consecutive houses) is explained by the travel of rats through -efficient rat runs present in the walls and ceilings, rather than by -the passage of fleas through partition walls, from uncommunicating -house to house. - -[Illustration: A RAT INFESTED PLAGUE INTERIOR] - -So also at Calle Cabildo, where the superstructure of the house was a -veritable sieve, there was a series of communicating double walls. - -At the house on Calle T. Alonso a similar condition existed, but here -the two cases which occurred may have been synchronously infected, or -nearly so, previous to disinfection of the premises. - -At Calle Comercio, where six days elapsed between two cases, the rooms -and building were piled full of merchandise, defeating immediate -disinfection, that is, efficient disinfection, until all the -merchandise was moved and the rooms were emptied. - -At 1364 Calle Sande, Tondo, where 5 cases originated, the infections -were undoubtedly almost synchronous and no infection occurred after -disinfection of the house, while at 1226 Calle Juan Luna, Tondo, the -two cases were plainly infected at about the same time and this -previous to disinfecting the premises. - -GUINEA-PIGS AS INDICATORS OF INFECTED HOUSES.--The following experiment -shows strikingly the necessity for disinfecting houses where human or -animal plague cases have occurred. - -Upon December 17, 1912, Dr. O. Schoebl, of the Bureau of Science, and -myself, placed two healthy guinea-pigs, free from fleas, in a wire trap -cage in the house at No. 4 Calle Barraca, a few hours before the house -was disinfected, a patient with plague from this house having died -within the preceding twelve hours. The cage containing the guinea-pigs -was placed exactly where the patient had slept upon the floor, as -indicated by the other tenants of the house. Disinfection was delayed -for a few hours and the guinea-pigs were left in the house for one -day. Upon December 21 one of the guinea-pigs died from typical bubonic -plague--anatomically and bacteriologically positive--other inoculated -experimental animals also developing the disease. - -Other guinea-pigs placed in plague houses on Calle Cabildo and Calle -San Fernando, after disinfection of the premises, failed to acquire -plague. - -NATURAL ENEMIES OF THE FLEA.--It was observed during the studies in -Java that certain natural enemies of fleas exist and operate against -their laboratory cultivation and their natural reproduction. - -Ants of several varieties, large and small red ants and small black -ones, were found to be very antagonistic to fleas, both in the larval -and adult states, destroying them actively. - -Fleas in the laboratory were found to be affected with mites, with a -resultant high mortality among the insects. The same parasites were not -found upon wild fleas. On account of the prevalence of mites upon the -laboratory fleas certain experiments concerning the transmission of -plague were vitiated. - -The activity of ants in attacking and disposing of rat cadavers found -in our antiplague work in Manila was frequently brought to my -attention. We invariably included an attack upon ants in treatment of -houses known to harbor, or suspected of harboring, plague rats. The -combination of kerosene and cresols, elsewhere referred to, was found -to be perfectly satisfactory in the destruction of ants; assuming, of -course, that the necessary procedure of exposing the ants, by the -moving of merchandise, boards or other protecting materials, was -performed, so that contact, by spraying the insecticide mixture, was -secured. - -ACTIVITY OF FLEAS.--It was also observed during the Java studies that -the rat flea, while rather lazy, may and does cover distances of five -metres and that he sometimes covers eighteen centimetres at a single -leap. - -In addition to this, of course, there must be considered the -possibility of his falling considerable distances. - -ZOOLOGIC CLASSIFICATION OF RATS.--The matter of accurately, -systematically and scientifically cataloguing and classifying rats is -one of great difficulty and is not to be undertaken by anyone but a -trained naturalist. However, some of the notes we have at our disposal, -gathered from many sources, may be set before the reader. It is -extremely difficult to find exact correspondence of statement in the -various classifications offered by writers upon plague and rats. - -Dr. Lantz gives the following brief classification in his section of -the publication, "The Rat and Its Relation to Public Health." - - Order: _Rodentia._ - - Family: _Muridae._ - - Genus: _Mus._ - - Species are many, but only three or four are cosmopolitan. - - Cosmopolitan species: _Mus rattus_--black, brown, and roof - (_Alexandrine_) rat; _Mus decumanus_--gray, barn, wharf, - sewer, and Norway rat. - -_Mus rattus_ has many varieties known throughout the world and these -are named according to color and habitat. - -In addition to the names given in Lantz's classification, we constantly -see reference to the black house rat, the brownish-gray rat (_Mus -Alexandrinus_), the ordinary ship rat, the field rat, etc.; terms -descriptive of habitat and appearance being very loosely applied. -Little account is taken, by many, of the well-known variations in the -coloration of rats due to climate and season and of the well recognized -aptitude of the rat for living in-door or out-door according to -circumstances of food supply, weather, etc. The "sawah" rat of Dutch -India, implicated in the prevalence of plague there, was formerly -considered a variety of _Mus decumanus_, but is now described as a -field variety of _Mus rattus_. So too, varieties of _Mus decumanus_ are -frequently named according to alleged geographic origin, habitat, color -and habits, viz.: sewer rat, brown rat, Norway rat and migratory rat. - -The inevitable confusion bound to arise from such loose classification -is obvious. - -Another genus, _Gunomys_ (_Nesokia_), implicated in plague, is -represented in India by two species and by at least one (an -undetermined one) in Java, some confusion existing in the matter as -yet. Members of this genus are described as large, rough-coated rats -which live both as house rats and field rats. In India the Plague -Commission reported specimens of this genus as particularly susceptible -to plague. - -In the Philippine Islands no specimens of _Gunomys_ have been observed, -but _M. rattus_ and _M. decumanus_ are both present and numerous and -both are subject to plague, as shown by the presence of the disease in -specimens examined. - -In view of the unreliability of the points of difference in rats -usually given as identifying data, such as the number and location of -the mammae, the variations in color and the peculiarities of the -footpads, the Javan observers depend upon the conformation of the -skulls for the determination of genera, the skull of _M. rattus_ being -oval and arched, that of _M. decumanus_ more closely approaching the -square and rectangular conformation, and that of _Gunomys_ being -broader, higher and longer than either. - -In _M. rattus_ the prominent borders which separate the parietal from -the frontal surfaces of the skull are oval; in _M. decumanus_ they are -parallel or slightly divergent; in _Gunomys_ they are lyre-shaped. - -[Illustration: _M. rattus_] - -[Illustration: _M. decumanus_] - -[Illustration: _Gunomys_] - -To determine these differences the heads of the rats are cut off, the -tissues desiccated by antiformin, or by boiling and stripping. - -From experiences in Porto Rico, Creel, of the U. S. Public Health -Service, concludes that _M. norvegicus_ (_decumanus_), while -essentially a burrowing animal and not addicted to climbing or -swimming, is nevertheless quite capable of doing either. He was found -to burrow in the hardest earth to a depth of two and one-half feet and -to pass through all kinds of wood, soft brick and lime mortar, probably -by gnawing. - -The black rat and Alexandrine rat (_M. rattus_) in Porto Rico, -according to the same observer, do not burrow at all, but can climb and -jump in expert manner, and are the species found in the rural -districts, remote from houses. He found that all varieties of rats may -swim, from ships to the shore, distances of from one-fourth to one-half -mile, but that they lack the sense of direction and probably do not -land from ships naturally in this manner (_Public Health Reports_, No. -9, February 28, 1913). - -The female _decumanus_ is a prolific breeder and brings forth larger -litters than the _Mus rattus_ female. - -_Mus decumanus_ is generally conceded to be larger and more ferocious -than _Mus rattus_. For this reason he drives the smaller rats to the -upper floors, the _decumanus_ species generally living near the ground. -He is a burrower and is rarely found in the upper stories of -buildings. _Decumanus_ is known as a wharf rat, but is rarely trapped -on ships on the Pacific Coast, according to the observations of Surgeon -Simpson of the U. S. Public Health Service (_Public Health Reports_, -April 11, 1913). According to the same observer, _Mus rattus_ is the -commonest ship-borne rat. He also states that the black rat and the -roof rat (_Alexandrinus_), both varieties of _M. rattus_, differ -chiefly in color. They live in upper floors, between ceilings, in walls -and roofs and are remarkable climbers as well as being expert -rope-walkers and wire-walkers. On account of their natural wariness and -caution it is not always easy to induce them to enter or approach -traps. - -The photographs introduced were taken under my direction in Manila in -1912, 1913 and 1914. Some of them show the character of the house -construction in Tondo District, Manila, where plague flourished in -1913. Others illustrate methods of rat-proofing bamboo timbers in -houses of light material. These end openings were either closed by -introducing cement or by placing tight-fitting tin cans over the ends -of the bamboo rafters. - -There are many interesting memoranda, gathered and made in connection -with our antiplague work in Manila, especially concerning the location -and construction of rat nests found by our laborers; the materials used -and the fabrication of the nests. Memoranda giving details of rat -catching and rat-proofing are also presented and notes showing the -location of dead rats found in relation to dead human bodies of plague -victims. - -Notes concerning cases of multiple house infection are also presented -as being of possible interest. - -The Javan studies in 1911 and 1912 establish the fact that it is -possible to form a fair judgment as to the length of time a rat has -been dead, up to ten or twelve days, from the condition and appearance -of the rat cadaver, both as to decomposition and drying. A series of 50 -rats was studied. It is to be understood that the conditions under -which these observations were made were tropical conditions. They would -be fairly comparable with summer conditions in America, but should not -be followed too closely at other seasons of the year. In my own -experience I have observed that ants are likely to attack the cadaver -early and to obscure the deductions by their destruction of the body. - -[Illustration: PROGRESSIVE POST-MORTEM CHANGES IN RAT CADAVERS. THE -NUMBERS INDICATE THE NUMBER OF DAYS AFTER DEATH] - - Days after death Appearance - - First to third day Distention of the abdomen, increasing. - - Second to third day Loosening of hair by gentle pulling. - - Third to fourth day Loosening of the epidermis by gentle - pulling. - - Third to fifth day Perforation of abdominal wall with - collapse and disappearance of distention. - This perforation may result from bursting - of abdominal wall, or through anus, vulva - or thorax. - - Fourth to sixth day Moist shrinking of the body. Swarming of - maggots. Spontaneous shedding of tufts of - hair. - - Fifth to eighth day Drying of body. - - Eighth to twelfth day Complete dryness and rigidity. - -Photograph (after _Publications of the Civil Medical Service in -Netherlands, India_) shows the progressive postmortem changes in rat -cadavers, the numbers indicating the number of days after death. - -A COLLECTION OF NOTES CONCERNING RAT RUNS, RAT NESTS, THEIR LOCATION -AND OTHER DATA.--Attention is invited to the following collection of -notes concerning rat runs, rat nests and their locations and other data -collected by the various working parties under the direction of -Sanitary Inspectors Brantigan, Renner and Kennard, of Manila. - -Special attention has been given to the finding and destroying of rat -nests, and in this connection please note that during the month of May, -1913, one party of workmen (20 men) under Inspector Brantigan, killed -by hand 511 rats out of a total of 1319. This means that many nests -were broken up and that much breeding was interfered with. In June, -1913, two parties (40 men) killed 772 rats by hand out of a total of -3019. - -This work occurred in Tondo District in connection with extensive -cleaning and moving operations. - -At 1279 C. Sandejas[4] 7 rats were found in a nest at the foot of a -cluster of bamboo trees, between the trunks. Nest was made of leaves. - - [4] C. is abbreviation for Calle, the Spanish term for street. - -At 728 C. Velasquez, Tondo, 12 rats were driven from a burrow -underneath a thick cement floor by formaldehyde gas delivered in the -burrow through a rubber hose. This burrow was in sand and the rats came -out about ten minutes after the flow of gas began. All were killed or -captured and two or three died from the effects of the gas. - -On October 27, 1912, two of the rat terriers belonging to the Bureau -of Health caught 192 rats in one storeroom at the Manila Railway -Station, in 38 minutes. At various times they have killed from 10 to 25 -rats at a single location, in connection with the cleaning and moving -work done by the laborers. The dogs caught about 600 rats in all. - -On March 11, 1913, 27 rats were caught by laborers at 202 Calle Concha. -They were nesting in straw covers which had been removed from bottles. - -On March 11, 1913, 13 rats were found beneath a pile of loose tiles at -203 C. Sardinas. The nest was made of fibres from coconut shells and -straw. - -On March 13, 1913, 12 rats were found among stones scattered in a -shallow pile on the ground at C. Conservador (interior). Nest was made -of rice chaff and small pieces of cloth. - -On March 15, 1913, 9 rats were caught at 1353 C. Anloague on the ground -floor beneath a pile of boards. Nest was made of coconut fibre and -shavings. - -On March 16, 1913, 24 rats were caught at 934 (interior) Velasquez -beneath a wood pile. Nest was made of coconut-shell fibre and pieces of -cloth. - -On March 17, 1913, 14 rats were caught under a pile of hay and straw -at 173 Velasquez. Nest was made from straw, chaff and hay. - -The following articles of food were found in the above-mentioned nests: -chicken bones, rice, coconut, fish and bread. - - -MEISIC DISTRICT - -At 822 Sacristia 6 dead rats found in holes. - -At 540 T. Alonso a family of 8 rats was smoked out and all were killed. - -At 514 same street 6 rats were smoked out and killed. - -At 538, interior, same street, 4 rats were smoked out and killed. - -At 546 same street 4 rats were smoked out and killed. - -At 715 San Bernardo dead rat found in a hole. Nest made of banana -leaves and rags. - -At 627, interior, Zacateros, 9 rats were smoked out and killed. - -At 669 Benavides 6 rats were smoked out of four runs and were caught. - -At 631 Zacateros 2 rats were smoked out and killed. - -At 417, interior, Misericordia, 4 rats were secured in two holes under -a tile floor. Many rats were caught at this number (interior) in traps. - -At 221 Espelita 7 rats were found in a nest made of palm leaves and -excelsior; location of run way and nest beneath tile floor. - -At 124 Tetuan, in a nest of straw and lint, 5 rats were caught by hand, -alive. - -At 415 T. Alonso one live rat and 3 dead ones were dug out from beneath -a tile floor. - - -SAMPOLOC DISTRICT - -At 1001 Bilibid Viejo there were 5 rat runs, in a Chinese store. Eight -rats were secured in a nest under the cement floor. Nest made of straw -and paper. - -At 928 San Sebastian there were 8 rat runs. In one of them there were -caught 8 rats. The nest was made of straw. - -At the same address, later, 3 rats were caught in another run and 8 -young rats, with eyes still unopened, were found in a nest of straw. A -supply of bread was on hand in this nest. - -At 629 Tanduay 20 rats and nests of straw and paper were found. - -At the same address upon another day another rat run was found and one -large rat and 16 small ones were taken from a nest made of rags, straw, -and fibres. - - -PACO DISTRICT - -At 1115 San Andres in a Chinese tienda (food store), a long rat run and -a nest of rags, straw, and paper, and 30 small rats were found. - -One nest in a bamboo tree 30 feet above ground was found. Rats had been -observed going up the tree and one was caught at the foot of the tree -in a trap. - - -SAMPOLOC DISTRICT - -At 629 Tanduay 14 young rats and a nest of straw, paper and rags were -found in a stable. - -Same address, later, one rat run and nest of straw and rags with one -large rat and 16 small ones were found. - - -TONDO DISTRICT - -March 27, 1913, one rat was caught alive inside of a bamboo timber in -house at 51, interior, Pesqueria. - -At 631 Azcarraga 4 young rats were found in a nest of paper, leaves, -and hay. Chicken bones, crab shells, and rice were present in the nest. - -A young python was caught in a lumber yard in the Santa Cruz District -in June, 1913. In his stomach was found a half-grown rat. Another snake -was caught in a rat trap at the same address about the same time. - -PLAN FOR HOUSEHOLD RAT DESTRUCTION.--The following plan for household -rat destruction was proposed by me to the Director of Health. It is -considered worthy of trial if rat plague appears in new districts. - - Proposal for periodic household rat poisoning in Manila. - - Proposed that, upon a certain day of each week, rat poison be - issued free to all applicants (householders) in Manila who - agree to place same about their premises, permitting the - poison to remain in place for 48 hours. - - Instructions and poison placards to be issued with the - poison. Issues to be made from Station Health Offices and - records of issue to be kept. - - Collections of dead rats to be made at the end of 24 hours - and 48 hours by Bureau of Health employees. Poison portions - to be collected and turned in at the Station Health Offices - at the end of 48 hours, that is, at the time of the last rat - collection. Rats to be tagged and examined for plague in the - usual manner. - - Due newspaper notice of the plan and of the gratuitous issue - of poison to be given to the people and their cooperation - requested. - - Plan to be tested for at least two months. - - -MULTIPLE HOUSE INFECTION - -Memorandum concerning 1364 Calle Sande: - -Within 72 hours (April 25-27) five fatal cases of plague, all in -Filipinos, occurred in Manila. The five deceased persons lived at 334 -C. P. Rada (Meisic), 1419, interior, C. Dagupan, 1364 C. Sande (Tondo), -642 C. Ylala (Meisic), and 1492, interior, C. Dagupan (Tondo). - -The following relationships were established by inquiry and -investigation and the circumstances point strongly to a common source -of infection and to a single geographic focus of plague infection in -connection with all of the cases, viz.: at 1364 C. Sande (Tondo). - - Jose Raymundo, boy, aged fifteen, lived at 334 C. P. Rada and - worked daily until taken sick on Tuesday, April 22, at 1364 - Sande, in the shop of Simplicio Enriques, a silversmith, who - lived part of the time at the same address. - - Jose Raymundo died of bubonic plague at San Lazaro Hospital - on Friday, April 25, 1913. - - Norberta Mendoza, woman, aged fifty-six, lived at 1418, - interior, C. Dagupan. She was the mother-in-law of Simplicio - Enriques, the silversmith at 1364 Sande, and visited her - son-in-law there frequently and within a few days of her last - illness. She was taken sick April 22 and died at 1419, - interior, C. Dagupan, on the morning of April 26. At autopsy - at San Lazaro morgue, the same day, bubonic plague was found - to be present and the cause of her death. - - Trinidad Galves, a young woman, aged sixteen, lived at 1364 - Sande and was taken sick there on April 25. She was removed - to San Lazaro Hospital and died there April 26, extensive - plague lesions being found at autopsy. - - Pablo Banzon, man, aged twenty-six, living at 646 C. Ylaya, - was taken sick on Friday, April 25. He was removed to San - Lazaro Hospital Saturday afternoon and died there Sunday - evening, April 27. He was shown to have plague by - bacteriologic examination made at the Bureau of Science. He - worked at 1364 Sande as a silversmith, with Jose Raymundo and - was employed by Simplicio Enriques. - - Simplicio Enriques, aged twenty-seven, a silversmith, - conducting his business at 1364 C. Sande and employing Jose - Raymundo and Pablo Banzon, was taken sick about April 23. He - moved to two different houses in the interval between the - onset of his sickness and his transfer to San Lazaro Hospital - on April 27, first to 1419 C. Dagupan, interior, where he - remained until the death of his mother at this house; then to - 1492 Dagupan, interior, from which place he was transferred - to San Lazaro Hospital, where he died with bubonic plague a - few days later. Diagnosis was confirmed at autopsy. - -The two women were patients of Dr. Hernando of Calle Ylaya. He -recognized the case of the elder woman as a probable case of plague, -after death, and reported the matter to the Bureau of Health. - -The house at 1364 C. Sande is of the type in which cases of rat plague -and human plague have recently been found. In our operations to put the -house in a safe condition we found one dead rat, mummified, in the -basement. Unfortunately, the workmen who swept it out did not note the -exact location at which it was found. The house is in the midst of the -district where rat plague has raged since early in March, 1913. The -basement contained unauthorized and illegal sleeping rooms until a few -days before this outbreak when they were removed in the course of our -antiplague operations. The building is constructed of bamboo with a -nipa thatch roof. - -The front part of the basement was paved, but the pavement was -undermined and broken. Being convinced that dead plague rats were -present in the vicinity of this house and probably within it, I -directed that the cement floor under the silversmith shop and the -barber shop, located upon the ground floor at this address, be torn up. -Accordingly, this was done (April 28) and three dead rats and one live -one were found beneath the cement. As the bodies were mummified and -unfit for bacteriologic examination they were burned. The living rat -was examined at the Bureau of Science but was found to be healthy. The -cement floor was broken and permitted fleas from the dead rats to enter -the basement room of the house which was occupied by the silversmith -shop. The rats doubtless died from plague and the hungry fleas in due -time attacked the nearest persons at hand, the unfortunate occupants of -the silversmith shop and the two women who frequented the room also. - -These facts account for the epidemic at 1364 Sande very completely. - -The premises at 1364 Calle Sande were quarantined by the following -order: - - MANILA, April 27, 1913. - - The premises 1364 Sande are hereby declared in Quarantine for - Bubonic Plague by order of the Director of Health. - - The inmates will be permitted to leave the building and find - quarters elsewhere, provided they leave their addresses with - the policeman in charge, so that they may be readily found. - They must remain in the District of Tondo. If they remain in - the house they will be obliged to stay in the upper story of - the house and will have to arrange for meals to be sent in. - - The barber shop and "platero" shop are hereby ordered closed - until further orders. - - By order of the Director of Health. - - [Signed] T. W. JACKSON, - _Medical Inspector, in Charge of Plague Suppression_. - -Memorandum reporting circumstance surrounding 2 cases of plague at -1226 C. Juan Luna (May 17, 1913): - - Valeriano Lausin, aged fourteen, Filipino male, Carmelo maker - by trade but out of work at time he was taken sick, recently - removed to this house from 917 C. Jaboneros where he had been - employed. The patient fixes the date at about a week previous - to his sickness, but the proprietors of 917 Jaboneros are - positive in their statement that he left the place where he - lived and worked, at least two weeks before. This boy - recovered. - -The circumstances and especially the occurrence of a second case at -1226 C. Juan Luna, indicate that infection was incurred here. - -Moreover, this house is in the midst of a rat-plague infected district. - -[Illustration: PLAGUE HOUSE, 1226 CALLE JUAN LUNA] - -The house is of bamboo and nipa construction and contained illegal -basement rooms until a week ago. About 60 persons lived in this house -which was once licensed as a tenement but which is unsanitary in a -multitude of ways. Bamboo construction, overcrowding, dirty condition -and absence of proper drainage, water-closet, proper kitchens and paved -ground floors, together with bad ventilation, made it a dangerous -habitation and the added condition of plague infection made it -necessary to vacate and quarantine the building. - -On May 15, at the daily inspection of contacts in the house 1226 C. -Juan Luna, Filomena Sunga, aged nineteen, and a relative of the owner -of the building, was found to be sick. Her only symptom was fever, but -she was transferred to San Lazaro upon suspicion and promptly developed -symptoms of plague. She died in a few days and the diagnosis of plague -was verified at autopsy. The following order was issued: - - STATION "C," TONDO, BUREAU OF HEALTH, - MANILA, P. I., May 15, 1913. - - By order of the Director of Health, the house No. 1226 C. - Juan Luna is declared infected and is quarantined this date, - for Bubonic Plague. The house will be vacated and a policeman - will register the names of all residents and the addresses to - which they remove. - - The residents may remove their personal effects but will not - be permitted to return while the quarantine is in effect. - - [Signed] T. W. JACKSON, - _Medical Inspector, Station "C," Tondo_. - -Memorandum: Human body (dead from plague) and dead rats found in the -same basement room. Upon March 21, 1913, a Filipino laborer living at -140 Calle Perla, Tondo, was found dead from bubonic plague. - -Upon careful investigation and search of the premises the following -findings were disclosed: - -One rat, large, mummified and dry and therefore dead for at least one -week, was found clinging to a bamboo wall just back of the cot upon -which the dead human body was found. - -In a section of bamboo, in a timber constituting the ceiling of the -basement and also the upper part of the door frame, a rat, dead and -dried up, was found. This section was the end section of the timber -which was partly covered with nipa thatch, with which the sides of the -house were covered. The ends of a number of the outside rafters -(bamboo) were found to be gnawed through. - -[Illustration: BAMBOO HOUSE SUPPORTS SEALED WITH CEMENT TO PREVENT -ENTRANCE OF RATS (MANILA PLAGUE CAMPAIGN)] - -Similar conditions were found in adjoining houses and in one case a -live rat was driven out of a nest in the bamboo. - -SAMPLE OF DETAILED ORDERS ISSUED.--Sample of detailed orders issued by -Medical Inspector in Charge of Plague Suppression. Similar orders were -issued whenever new districts were entered or new work undertaken. - - Memorandum Order. Effective March 25, 1913: - - Beginning to-day, 13 men under Assistant Inspector Paras, - will commence cleaning operations at C. Ostra, extending - from the Bay to C. Sande and will clean towards C. Moriones. - They will be provided with a disinfecting pump and will - disinfect the ground surfaces wherever disturbed, outdoors - and indoors. Cleaning is to be done in the most thorough - manner possible, searching meanwhile for rat nests and rat - harbors; re-piling wood, tiles, stones and merchandise; - moving all movable goods out of doors in their search for - rats and rat-holes or nests. All goods are to be piled above - ground at an elevation of at least one foot. All bamboo beds - and bamboo rafters and parts of the house (in the basements) - made of bamboo or of double walls are to be thoroughly - investigated for rats. All foodstuff attractive for rats is - to be placed in covered boxes or galvanized iron cans, tin - cans or barrels, with tight-fitting covers. Special attention - is to be paid to straw, hay, shavings, grain, rat-holes, and - food. - - Two men will be detailed to cement up ends of bamboo and - rat-holes, but will not do general repairing. They will carry - materials for mixing cement as needed and will not be - wasteful of materials. - - If this force proves to be insufficient in numbers, - additional men may be detailed from the other working - parties. - - [Signed] T. W. JACKSON, - _Medical Inspector in Charge of Plague Suppression_. - -Specimen order issued to Sanitary Inspector assisting in Plague -Suppression by Medical Inspector in charge. - - Sanitary Inspector, Bureau of Health: - - Please place the gang of workmen under your charge in the - square bounded by Calles Velasquez, Moriones, Concha and - Manila Bay which is infected with rat plague. Treat the - houses and properties there in the same manner in which other - plague-infected districts have been treated, viz.: by - policing the houses and yards, vacating all basements of - light-material houses in which human habitations are - illegally present; removing (with the consent of the - occupants) all unauthorized basement sleeping places, beds, - platforms, etc., and other illegal structures, closing up the - open ends of bamboo rafters or timbers of the house with tin - or cement. - - Where the occupants resist this action sanitary orders should - be issued in the usual manner and interference should be - stopped until the order is served and complied with. There - are a number of most insanitary and unsuitable shelters of - bamboo, tin, etc., used for houses by a number of families in - this square and it is desirable to tear down these huts if - permission can be secured. If permission is refused orders - should be issued on the usual form. - - [Signed] T. W. JACKSON, - _In Charge of Plague Suppression_. - -[Illustration: VIEW OF HOUSE AT 447 CALLE CONSERVADOR, TONDO, WHERE -INFECTED RATS WERE FOUND (MANILA PLAGUE CAMPAIGN)] - -Specimen order issued by the Medical Inspector in charge of Plague -Suppression. - - STATION "C," TONDO, May 21, 1913. - - Redistribution of rat catchers and laborers engaged in - antiplague work. Effective May 2, 1913. - - Sanitary Inspector Kennard and 20 rat catchers will move into - Tondo District and trap and poison rats in the district - bounded on the west by Manila Bay and on the east by Estero - Reina. The work will be begun at the extreme north water - boundary of this district and will proceed toward the south. - - Sanitary Inspector Brantigan with a similar number of rat - catchers (20) will work within the same east and west - boundaries and will begin trapping and poisoning at Calle - Moriones, proceeding north. The poisoning and trapping is to - be done in the most thorough manner possible, as this is a - dangerously infected district and rat-plague must be - controlled and terminated here. - - The laborers, 60 men, divided into 4 parties of 15 men each - under Assistant Sanitary Inspectors Jesus, De la Rosa, - Laxamana and Paras, will continue the cleaning operations now - under way on both sides of C. Juan Luna south of C. Moriones - (plague localities in the same neighborhood), and thoroughly - disinfect. - - One party of 15 men will work in the vicinity of C. Perla, - vacate basements as habitations, search for dead rats in - yards, houses, bamboos, under broken concrete, etc., and will - close up openings in structural bamboo by means of tin and - cement. Emphasis is placed upon the necessity for permanently - vacating basements and men will be sent back over the ground - daily to see that the persons moved out do not return. - Reports are desired so that prosecutions for violations of - the law may be instituted if necessary. - - [Signed] T. W. JACKSON, - _Medical Inspector in Charge of Plague Suppression_. - -Specimen order issued to Assistants. - - May 4, 1913. STATION "C," BUREAU OF HEALTH: - - Please place work parties in (interior) 1627-1629 Sande and - 525 C. Azcarraga, to clean, disinfect and thoroughly - investigate these premises and the houses, stables and other - buildings in the vicinity. Search for rats, living and dead, - rat nests and rats in bamboos and wood piles, stone piles, - stables, under planks and elsewhere. Cement the openings in - bamboos in houses or close with tin. Make notes on needed - structural work. Do the work as thoroughly as possible. - - [Signed] T. W. JACKSON, - _Medical Inspector in Charge of Plague Suppression_. - -METHOD OF PROCEDURE IN COLLECTING AND FORWARDING RATS SUSPECTED OF -PLAGUE INFECTION TO THE LABORATORY IN MANILA, P. I.--Rat -catching,--trapping and poisoning,--is conducted in accordance with -instructions contained in the Sanitary Inspector's Handbook (pp. 36, -37, 38) issued by the Bureau of Health. - -Rats are collected in Manila and forwarded to the Bureau of Science for -autopsy and for biologic examination for the presence of plague bacilli -in the following manner: - -The various groups of rat catchers are provided with receptacles (iron -pails) and a supply of a mixture of kerosene, cresol and water -(kerosene 10 parts, cresol 2 parts; water 88 parts). - -In these vessels, filled with the pulicidal mixture, the rats are -immersed, with a minimum amount of handling, as soon as they are found -(whether in traps or dead from poison). - -If captured alive they are killed and then promptly immersed. The -mixture must be well shaken or stirred when used, as it separates upon -standing. The immersion is, of course, for the purpose of destroying -any fleas which may be present upon the captured rat. - -A paper tag showing the date and the exact location of the place of -capture, with the name or group number of the rat catcher, is next -affixed to a foot or to the tail of the rat and firmly tied upon the -same, where it remains until the rat cadaver is finally disposed of. -This tag is a card of strong Manila paper and the record upon it is -made with an ordinary lead-pencil, as both ink and indelible pencil -marks are apt to become illegible from wetting, whereas lead-pencil -marks are little affected thereby. - -If desired, the disinfected tag in any given case of rat plague may be -returned to the Bureau of Health, for identification, where an accurate -record of every rat captured is kept. - -After dipping and tagging, the rats are taken to a central point, again -dipped, and placed in large, tightly-covered, galvanized iron cans, in -which containers they are delivered to the laboratory by cart, once or -twice daily. - -THE CASE OF MR. C.--The following are the facts concerning the case of -Mr. W. C., a prominent American resident of Manila who suffered and -died from plague in 1914. - -Mr. C., an editor, was taken ill with plague on the night of September -18, sought medical advice and entered St. Paul's Hospital September 19, -and was transferred to San Lazaro Hospital, September 20, with an -established clinical and bacteriologic diagnosis of bubonic plague. He -survived till September 22. - -Upon September 21, in the course of disinfecting the business office of -Mr. C., located in a district which had furnished a number of cases of -both rat and human plague, a dead rat, mummified, was found in the -right hand drawer of his desk and fleas were seen to hop from the -drawer upon opening it. - -A flea killed by the disinfecting mixture at this desk was identified -at the Bureau of Science as a rat flea (_Xenopsylla cheopis_). - -The rat cadaver was sent to the Bureau of Science and the following -facts were reported from there some days later: - -The mummified rat and skeleton were pulverized in a sterile mortar and -an emulsion was made and injected into guinea-pigs. The animals died -from plague in a few days and plague bacilli were recovered from the -tissues, as well as from the rat cadaver, by culture. - -A second rat cadaver, found at the same time in the same building, -during cleaning operations, was similarly treated with identical -results. - -There could scarcely be a stronger chain of convincing evidence against -the rat and the flea, nor a more complete and convincing explanation of -Mr. C.'s death than that afforded by these established facts and -official documents. So far as I know there is no more striking case on -record in the modern history of plague. - -LETTER OF WARNING AND APPEAL.--The following letter of warning and -appeal for cooperation was suggested and framed by me February 10, -1914, at the time that extensive rat plague was discovered in the heart -of the business district of Manila. I presented it to the Director of -Health with a strong recommendation for approval and publication and -after consideration he approved and authorized publication upon -February 10. No change was made in the wording of the proclamation, -but it was issued over the signature of the Director of Health to give -added force and authority to the appeal. The results were, as I had -hoped they might be, highly beneficial. The taking of the public into -the confidence of the health authorities brought about a cooperation, -without which our efforts in this difficult situation would have been -sadly handicapped. It is my belief that this method should often be -used by health authorities, particularly where an intelligent community -is threatened. - - TO WHOM IT MAY CONCERN: - - You are hereby informed that the district bounded by Calles - Rosario, Juan Luna, Dasmarinas and Plaza Calderon (and - possibly the neighborhood bordering upon this congested - district) is a dangerous one for all persons living or - conducting business therein, on account of the presence there - of extensive rat plague. Six human cases (with five deaths) - have recently developed there and many dead rats have been - found. All human cases have been directly traced to rats dead - from plague. - - The Bureau of Health is now doing everything within its power - to make this district safe, but the attention of all - citizens, property owners and tenants is called to the fact - that they are required by law to keep their premises free - from rats and to abolish all structural conditions of the - buildings which favor the harboring of rats. This means - rat-proofing, and owners are earnestly urged to perform this - necessary work now, under the direction of the Bureau of - Health. - - As a temporary expedient and safeguard all interiors, walls, - floors and ceilings should be sprayed with kerosene daily, or - at intervals of two days, to kill the fleas which carry - plague from rats to human beings. All dark insanitary places - used for living rooms should be vacated at once; all - merchandise should be piled upon trusses at least a foot - above the floor; all straw, shavings and other material - attractive to rats for nesting, should be removed and burned - and all food materials upon which rats may feed and live - should be placed in covered boxes, bins or cans. - - All rat-holes should be permanently closed and all broken - cement or masonry should be repaired. - - Observance of these instructions may save the lives of - yourselves, your families and your tenants. It is your duty - to do your part in this matter, a part which neither the - Bureau of Health nor the Government can do for you. - - Through very great effort the Bureau of Health has controlled - plague in Manila and the Philippine Islands during the last - two years. - - Residents must now do their part, and owners of property must - permanently make their buildings safe for tenants, both for - business and residential purposes. - -BACTERIOLOGIC OBSERVATIONS MADE BY DR. OTTO SCHOeBL.--The following -observations upon the bacteriologic aspect of the Manila epidemic which -we are considering were made by Dr. Otto Schoebl of the Biological -Laboratory of the Bureau of Science, Manila, and pertain to the cases -of the first year of the epidemic. They were printed in the December -number of the _Philippine Journal of Science_ in 1913, but as they -belong so definitely to the epidemic I am describing and as Dr. Schoebl -has expressed his willingness for me to quote them in full, I gladly -accept his permission. Dr. Schoebl advanced the possibilities of -blood-culture diagnosis to such a point of reliability that it became -practically possible for us to expect positive culture in nearly every -case of true plague and the whole matter of bacteriologic diagnosis was -perfected to a high degree of efficiency under his administration of -the laboratory work. - -He relates his observations as follows: - - During the recent outbreak of plague in Manila, I had the - opportunity to make certain observations which are of - interest. These observations were made in the examination of: - (1) Specimens taken from patients and from dead bodies at - autopsies, (2) samples of blood-sucking insects collected in - houses where plague patients had lived, (3) rodents caught by - trap or poisoned in the parts of the city where plague cases - occurred from time to time, and (4) domestic animals suspected - of plague infection. - - I. BACTERIOLOGICAL EXAMINATION OF PLAGUE PATIENTS - - In order to secure as early diagnosis as possible, the - following procedure of investigation was adopted: - - 1. The bubo was aspirated by means of a sterile hypodermic - syringe. The material thus obtained was placed in the water - of condensation of an agar-slant culture tube. - - 2. At least 7 centimetres of blood were withdrawn from the - _cubital_ vein by means of another sterile syringe, and 5 - centimetres of it were placed in an Erlenmeyer's flask, - containing 200 centimetres of neutral meat broth. The rest of - the blood was emptied into a sterile tube, and used for - agglutination tests. - - Cultures obtained by this method were examined - microscopically, and the growths on various culture media - were studied. Gram stain, Loeffler's methylene blue, and - hanging-drop method were used. Polar-staining and chain - formation in liquid media and the characteristic type of - colony on the surface of agar were looked for. Animal - inoculation was performed in every case, and the culture - isolated from each case was identified by agglutination test, - rabbit's immune serum being used. - - The results of the bacteriological examination of a series of - 24 patients are tabulated in the two following tables. Table - I includes the fatal cases and Table II those cases which - recovered. - - The diagnosis of plague could be safely made from the - microscopical examination of the liquid aspirated from the - bubo in the majority of the cases. However, in certain - instances the amount of the aspirated fluid being small and - the bacilli very few, it was impossible to diagnose the case, - especially when the cultures from the bubo were negative. - Repeated examination of the patient was necessary under those - conditions, but it happened in cases 22 and 23 that the - patients died of plague before a second examination could be - made. The smears and cultures from case 22 remained sterile, - while the smears and cultures made from the swelling on the - neck of patient 23 revealed the presence of pneumococci. Both - patients died of plague, as was ascertained by examination of - the organs after death. - - TABLE I.--EXAMINATION OF FATAL CASES OF PLAGUE - - ======================================================================== - |Date of Examination 1912 - | +-------------------------- - | |Duration of illness _Days_ - | | +---------------------- - | | |Hours before death - | | | +---------------- - | | | | Bubo - | | | |Smear - | | | | Culture - | | | | Animal - | | | | inoculation - | | | | +---------- - | | | | | Blood - | | | | |Culture - | | | Age | | | | | Aggluti- - Patient | Race |Sex |_Years_| | | | | nation - --------------+--------+----+-------+--------+---+-----+-----+---------- - 1. Sing Nu |Chinese |Male| (?) |July 11| 5 | 48 |+ + +|0 0 - | | | | | | | | - 3. Aluncion | | | | | | | | - Raymundo |Filipino|Male| 15 |Sept. 29| 3 | ... |+ + +|0 0 - | | | | | | | | - 4. Filo | | | | | | | | - Almalas |Filipino|Male| 39 |Oct. 10| 4 | 22 |+ + +|+ - - | | | | | | | | - 6. Polycarpio| | | | | | | | - Guzman |Filipino|Male| 34 |Oct. 22| 2 | ... |+ + +|0 0 - | | | | | | | | - 7. Jose | | | | | | | | - Sarmiento |Filipino|Male| 37 |Oct. 22| 3 | ... |+ + +|0 0 - | | | | | | | | - 8. Julian | | | | | | | | - Gonzales |Filipino|Male| 41 |Oct. 22| 3 | 231/2 |0 0 0|+ - - | | | | | | | | - 9. Valeriano | | | | | | | | - Buencamino|Filipino|Male| 31 |Oct. 22| 3 | 10 |+ + +|+ - - | | | | | | | | - 10. Pedro | | | | | | | | - Nicomedes |Filipino|Male| 30 |Oct. 22| 2 | 53/4 |+ + +|+ - - | | | | | | | | - 12. Regino | | | | | | | | - Gulano |Filipino|Male| 34 |{Oct. 22| 2 |106 |0 0 0|+ - - | | | |{Oct. 24| 4 | 82 |0 0 0|0 0 - | | | | | | | | - 13. Martin | | | | | | | | - Dimalanta |Filipino|Male| 35 |Oct. 23| 3 | 251/2 |+ + +|+ - - | | | | | | | | - 14. Roberto | | | | | | | | - Obiso |Filipino|Male| 5 |Oct. 23| 1 | 53 |+ + +|+ - - | | | | | | | | - 15. Juan | | | | | | | | - Barceta |Filipino|Male| 23 |Oct. 24| 3 | 37 |+ + +|+ - - | | | | | | | | - 16. Yu Tum |Chinese |Male| 14 |Oct. 24| 2 | ... |+ + +|0 0 - | | | | | | | | - 17. Augustin | | | | | | | | - Monterey |Filipino|Male| 29 |Nov. 1| 1 | 27 |+ + +|+ - - | | | | | | | | - 18. Demetrio | | | | | | | | - Pabraw |Filipino|Male| 27 |Nov. 23| 4 | 15 |0 0 0|+ - - | | | | | | | | - 21. Ambrosio | | | | | | | | - Sobremonte|Filipino|Male| 20 |Dec. 7| 6 | 1 |+ + +|+ - - | | | | | | | | - 22. Mateo | | | | | | | | - Marcelo |Filipino|Male| 8 |Aug. 20 |(?)| ... |- - -|0 0 - | | | | | | | | - 23. Alejandro | | | | | | | | - Gita |Filipino|Male| [A]17 |Nov. 24 | 3 | ... |- - -|0 0 - --------------+--------+----+-------+--------+---+-----+-----+---------- - - ======================================================================== - |Date of Examination 1912 - | +-------------------------- - | |Duration of illness _Days_ - | | +---------------------- - | | |Hours before death - | | | +---------------- - | | | | Skin - | | | |Smear - | | | | Culture - | | | | Animal - | | | | inoculation - | | | | +---------- - | | | | | Sputum - | | | | |Smear - | | | | | Culture - | | | | | Animal - | | | Age | | | | | inocu- - Patient | Race |Sex |_Years_| | | | | lation - --------------+--------+----+-------+--------+---+-----+-----+---------- - 1. Sing Nu |Chinese |Male| (?) |July 11| 5 | 48 |+ + +|- - - - | | | | | | | | - 3. Aluncion | | | | | | | | - Raymundo |Filipino|Male| 15 |Sept. 29| 3 | ... |0 0 0|0 0 0 - | | | | | | | | - 4. Filo | | | | | | | | - Almalas |Filipino|Male| 39 |Oct. 10| 4 | 22 |+ + +|0 0 0 - | | | | | | | | - 6. Polycarpio| | | | | | | | - Guzman |Filipino|Male| 34 |Oct. 22| 2 | ... |0 0 0|0 0 0 - | | | | | | | | - 7. Jose | | | | | | | | - Sarmiento |Filipino|Male| 37 |Oct. 22| 3 | ... |0 0 0|0 0 0 - | | | | | | | | - 8. Julian | | | | | | | | - Gonzales |Filipino|Male| 41 |Oct. 22| 3 | 231/2 |0 0 0|+ + + - | | | | | | | | - 9. Valeriano | | | | | | | | - Buencamino|Filipino|Male| 31 |Oct. 22| 3 | 10 |0 0 0|0 0 0 - | | | | | | | | - 10. Pedro | | | | | | | | - Nicomedes |Filipino|Male| 30 |Oct. 22| 2 | 53/4 |0 0 0|0 0 0 - | | | | | | | | - 12. Regino | | | | | | | | - Gulano |Filipino|Male| 34 |{Oct. 22| 2 |106 |0 0 0|0 0 0 - | | | |{Oct. 24| 4 | 82 |0 0 0|+ + + - | | | | | | | | - 13. Martin | | | | | | | | - Dimalanta |Filipino|Male| 35 |Oct. 23| 3 | 251/2 |0 0 0|0 0 0 - | | | | | | | | - 14. Roberto | | | | | | | | - Obiso |Filipino|Male| 25 |Oct. 23| 1 | 53 |0 0 0|0 0 0 - | | | | | | | | - 15. Juan | | | | | | | | - Barceta |Filipino|Male| 23 |Oct. 24| 3 | 37 |0 0 0|0 0 0 - | | | | | | | | - 16. Yu Tum |Chinese |Male| 14 |Oct. 24| 2 | ... |0 0 0|0 0 0 - | | | | | | | | - 17. Augustin | | | | | | | | - Monterey |Filipino|Male| 29 |Nov. 1| 1 | 27 |0 0 0|0 0 0 - | | | | | | | | - 18. Demetrio | | | | | | | | - Pabraw |Filipino|Male| 27 |Nov. 23| 4 | 15 |+ + +|0 0 0 - | | | | | | | | - 21. Ambrosio | | | | | | | | - Sobremonte|Filipino|Male| 20 |Dec. 7| 6 | 1 |0 0 0|0 0 0 - | | | | | | | | - 22. Mateo | | | | | | | | - Marcelo |Filipino|Male| 8 |Aug. 20 |(?)| ... |0 0 0|0 0 0 - | | | | | | | | - 23. Alejandro | | | | | | | | - Gita |Filipino|Male| [A]17 |Nov. 24 | 3 | ... |0 0 0|0 0 0 - --------------+--------+----+-------+--------+---+-----+-----+---------- - - [A] Months. - - TABLE II.--EXAMINATION OF PLAGUE PATIENTS WHO RECOVERED - - ========================================================================= - |Date of examination 1912 - | +----------------------- - | |Duration of disease - | | +---------------- - | | | Bubo - | | |Smear - | | | Culture - | | | Animal - | | | inoculation - | | | +---------- - | | | | Blood - | | | |Culture - | | | Age | | | | Aggluti- - Patient | Race | Sex |_Years_| | | | nation - ----------------+--------+------+-------+--------+------+-----+---------- - | | | | 1912 |_Days_| | - | | | |{Sept.29| 2 |- - -|0 0 - | | | |{Oct. 2| 5 |+ + +|0 0 - 2. Dionisio |Filipino|Male | 18 |{Oct. 3| 6 |0 0 0|- +1:16 - Capate | | | |{Oct. 7| 10 |- - -|0 0 - | | | |{Oct. 15| 18 |- - -|- +1:64 - | | | | | | | - 5. Alejandra |European|Female| 6 |Oct. 20| 7 |+ + +|0 0 - Fisher | | | | | | | - | | | |{Oct. 22| 2 |+ + +|+ - - | | | |{Oct. 24| 4 |+ + +|0 0 - 11. Gabriel |Filipino|Male | 21 |{Oct. 26| 6 |0 0 0|- +1:16 - Sevilla | | | |{Nov. 8| 18 |- - -|0 0 - | | | |{Nov. 15| 25 |- - -|- +1:64 - | | | | | | | - | | | |{Nov. 26| 3 |+ + +|+ - - | | | |{Dec. 6| 13 |0 0 0|- +1:32 - 19. Esteban |Filipino|Male | 15 |{Dec. 16| 23 |- - -|- +1:60 - Roa | | | |{ 1913 | | | - | | | |{Jan. 11| 48 |- - -|- +1:120 - | | | | | | | - | | | |{Dec. 2| (?) |+ + +|0 0 - 20. Sia Su |Chinese |Male | 35 |{Dec. 5| -- |0 0 0|+ - - | | | |{Dec. 16| -- |- - -|- +1:80 - | | | | | | | - 24. Purificacion|Filipino|Female| 19 |{Dec. 11| 3 |+ + +|0 0 - del Val | | | |{Feb. 11| 33 |- - -|0 0 - ----------------+--------+------+-------+-------------------------------- - NOTE.--The bubo in Nos. 2, 5, and 24 never opened - spontaneously. The pus was aspirated at the time of the - second, eventually third, examination. Nos. 11 and 19 opened - spontaneously. A fistula formed along the canal which was - caused by the puncture, and healed up in several weeks. Hard - inguinal buboes of secondary order persisted in patient 19 at - the time of second examination. No plague bacilli were found - either in the bubo of the first or second order. Patient 20 - had a considerable amount of pus in the inguinal primary bubo, - but it was not opened until after the last examination. - - Two of the patients, cases 8 and 12, had numerous plague - bacilli in the sputum at the time when the expectoration - showed the presence of blood (twenty-three and one-half and - eighty-two hours, respectively, before death). In 3 cases I - was able to prove the presence of _Bacillus pestis_ in the - skin lesions, _intra vitam_, fifteen, twenty-two, and - forty-eight hours, respectively, before death. In case 18 - there was no doubt that the skin lesions, which covered the - whole body and the face, were of secondary nature, as the - patient died shortly afterward. It was undoubtedly a case - similar to those reported by Gotschlich and Zabolotny.[5] In - the other two patients there was only 1 maculopapulous - efflorescence on the foot in case 1 (with a corresponding - femoral bubo) and 2 lesions of the same type on the arm and - forearm in case 4 (with a corresponding axillary bubo). It is - possible that these lesions were the original port of entry of - infection. Numerous plague bacilli were found in the skin - lesions of these cases, both microscopically and in culture. - - [5] Kolle und Wassermann: Handbuch der pathogenen - Mikroorganismen. Gustav Fischer, Jena (1903), =2=, 521. - - The plague patients tabulated in Table II recovered. They - were all treated with antiplague serum. While cases 5, 11, 19, - and 24 appeared clinically to be rather severe, cases 2 and - 20 were mild. - - It can be seen from the table that the plague bacilli may not - be detected in the enlarged gland at first (case 2) and that - their presence may be revealed only after repeated - examination of the bubo. It is also evident from the results - of repeated examinations that the plague bacilli disappear - from the infected gland in a comparatively short time, as a - rule at the time when pus starts to form. Contrary to the - findings in patients who died, distinct phagocytosis was - noticed in the smears made from the aspirated liquid in those - patients who recovered and who had been treated with serum - soon after the onset of the disease. It is undoubtedly this - process that clears the gland of the infectious agents. - - The general opinion in regard to the presence of _Bacillus - pestis_ in the circulating blood seems to have been, as - Thompson remarks, that "the bacillus is rarely to be found in - the peripheral blood stream before the agonal stage."[6] - - [6] Journ. Hyg., Cambridge (1906), =6=, 558. - - The Austrian Commission, using few drops of blood, found - positive blood culture in 40 per cent; Calvert in Manila in - 100 per cent when examined twenty-four hours before death; - Choksy, Berestneff, and Mayr in 45 per cent; and Greig in 60 - per cent. The Indian Commission examined 28 patients, and - obtained positive blood cultures in 16 out of 23 fatal cases. - Not a single positive blood culture was obtained from the - patients who survived. The time of blood examination in - positive cases was three and one-half to seventy-five and - one-half hours before death. The amount of blood used was 1 - cubic centimetre. Only 6 out of the 30 samples, which gave - positive blood culture, were found positive by microscopical - examination of blood smears. The following conclusions are - based on these observations in regard to the septicaemic stage - of bubonic plague: (1) "A severe septicaemia may be present - at a comparatively early stage of the disease and for a - considerable number of hours before death, and (2) the - septicaemia may be of an irregular and fluctuating type."[7] - - [7] _Ibid._ (1907), =7=, 395. - - From the tables it will be seen that out of 15 patients - examined by me, 14 gave positive blood culture; and of these - 3 recovered. One blood culture revealed the presence of - streptococcus in addition to _Bacillus pestis_. The results - of the examinations tabulated in Tables I and II show, in - agreement with the findings of the Indian Commission, the - occasional early occurrence of plague bacilli in the blood - stream, as the time of examination in the positive cases - varied from one hour to one hundred six hours before death. - In consideration of the ephemeral character of the septicaemic - stage of plague, as evidenced by repeated blood cultures in - the three patients who recovered, one can hardly avoid the - impression that there is a certain degree of septicaemia in - every case of plague. The possibility of detecting the - bacillus in the circulating blood increases in proportion - with the quantity of blood used for culture. The best chance - to recover plague bacilli from the circulating blood seems to - be in the stage of high fever and general prostration. - - The phenomenon of agglutination of plague bacilli by the - serum of patients was first observed by Wissokowitsch and - Zabolotny in 1897[8] and later confirmed by the German Plague - Commission. Vagedes, Klein, and others[8] pointed out the - defects of the reaction as a diagnostic means. Aside from - the technical difficulties, the reaction was found - inconstant, and its occurrence was not noticed until the - second week of the disease and even then only in low - dilutions of the serum. - - [8] Referred to in Kolle und Wassermann: Handbuch der - pathogenen Mikroorganismen (1903), =2=, 524. - - Although the recent work of Strong[9] and of Strong and - Teague[10] has reduced the technical difficulties, the fact - remains that positive agglutination of plague bacilli by the - patient's serum cannot be obtained in the first week of the - disease, and, therefore, the isolation of plague bacilli from - the body of the patient is still the only quick and safe - method of plague diagnosis. - - [9] The Philippine Journal of Science, Sec. B. (1907), =2=, - 155. - - [10] _Ibid._ (1912), =7=, 194-201. - - Having utilized the technic devised by Teague, I have had no - difficulty in performing the agglutination test in plague. - The emulsion of plague bacilli, to be used for the test, was - prepared by suspending young cultures of virulent plague - bacilli, grown at 30 deg. C., in salt solution and filtering the - suspension through filter paper. No antiseptic was added nor - heat applied. Serial dilutions of unheated patient's serum - were mixed with equal amounts of bacterial suspension in - small test tubes. Incubation at 35 deg. C. followed. Controls, - consisting of serial dilutions of normal human serum as well - as bacterial suspensions without serum, excluded any possible - error which might have been caused by spontaneous - sedimentation of the bacterial suspension; while a parallel - test with highly agglutinant serum facilitated the reading of - positive results. - - Altogether, 22 tests were performed on 15 patients, 11 of - whom were fatal cases and 4 of whom recovered. In the - negative reactions, the duration of the disease at the time - of examination ranges from two to six days. The non-fatal - cases showed slight agglutination from the sixth day on. From - that day, the agglutination titer of the serum was found to - rise, and the agglutinins persisted in the blood of - convalescents up to the seventh week of the disease.[11] - - [11] It is hoped that it will be possible to examine some of - the survivors for agglutination from time to time. - - It must be borne in mind that the patients, who showed - positive agglutination, had been vigorously treated with - antiplague serum. Nevertheless, in consideration of the low - titer of the curative serum (dilution 1:32, agglutination - positive; dilution 1:64, agglutination negative), the rise of - the agglutinant power of the patient's serum in dilutions - higher than 1:16 cannot be explained as wholly due to passive - immunity, but rather to active immunity arrived at on the - principle of simultaneous immunization. - - From the preceding observations the following conclusions are - drawn: - - 1. The importance of blood cultures as a diagnostic means is - evident from the fact that positive blood culture was - obtained in practically every case that was examined in the - febrile stage of the disease, even when buboes or signs of - pulmonary involvement had not been detected clinically. - - 2. It is also evident that _Bacillus pestis_ may be found in - the circulating blood of the patients even in cases which - subsequently recover. - - 3. The period of time during which _Bacillus pestis_ - circulates in the blood is evidently short and irregular. - - 4. Mixed infection may be encountered in plague septicaemia - (_Streptococcus_, _Pneumococcus_). - - 5. The agglutination test is of no value for the diagnosis of - plague, as it was found positive only in convalescents. - - 6. Phagocytosis of plague bacilli in the bubo was noticed - only in patients who recovered after being vigorously treated - with curative serum. - - 7. The presence of numerous plague bacilli in comparatively - insignificant skin lesions during the life of the patient - points to the possibility of direct transmission, while the - fact that a patient without any apparent bubo, who is not so - sick as to be detained from his daily occupation, may - expectorate large numbers of plague bacilli, are facts of - great importance with regard to the communication of the - disease. It is obvious that the last-mentioned condition - might, and very likely does, give rise to an epidemic of - pneumonic plague if the atmospheric and sanitary conditions - are favorable. - - TABLE III.--INSECTS FOUND TO CONTAIN BACILLUS PESTIS - - ====================================================================== - | | |Experi- - | | |mental - Author | Insect | Source of infection |trans- - | | |mission - ---------------+---------------+---------------------------+---------- - Yersin |Flies |Laboratory infection | - Nuttal |Flies |Experimental infection | - Nuttal |Bedbugs |Experimental infection |Negative - | | | by bite. - Nuttal |Flea |Experimental infection |Negative. - Hankin |Ant's faeces |Fed on plague material | - Hankin |Bedbugs |Plague hospital | - Ogata |Flea |Plague rats | - Simond |Flea |Plague rats, experimental |Positive. - Tindswell, 1900|Flea |Plague rats |Negative. - Tindswell, 1903|Flea |Plague rats |Negative. - Kolle |Flea |Experimental infection |Negative. - Gauthier and |Flea |Experimental infection |Positive. - Raybaud | | | - Liston |Flea |Epidemic among pigs; | - | | harbored fleas; | - | | dead rats found |Positive. - Zirolia |Flea |Retained _Bacillus pestis_,| - | | 7-8 days | - British |Flea |Repeated experiments |Positive. - Commission | | | - Verbijtski |Flea and bedbug|Experimental infection |Positive. - La Bonadiere |Fly | | - and | | | - Xanthopulides| | | - Herzog |_Pediculus |Dead body of plague case | - | capitis_ | | - ---------------+---------------+---------------------------+---------- - - - II. OBSERVATIONS ON THE TRANSMISSION OF PLAGUE BY - BLOOD-SUCKING INSECTS - - Judging from the data which have been collected from the - literature[12] on the transmission of plague (Table III), - Simond seems to have been the first to call attention to - the important part which blood-sucking insects, particularly - fleas, play in the transmission of plague. Although many - investigators have been successful in demonstrating the - presence of _Bacillus pestis_ in the digestive system of - blood-sucking insects, it was not until the experiments of - Gauthier and Raybaud that the actual transmission of plague - infection by fleas was convincingly proved. Ever since the - exhaustive and conclusive experiments, which were carried out - both under natural and artificial conditions by the British - Plague Commission, and the work of Verbijtski, which antedates - the British Commission, were presented, there has been no - doubt that the transmission of plague by blood-sucking - insects, particularly by the fleas, is one, although not the - only, mode of spreading this disease. It is obvious, as Herzog - correctly remarks, that the factors which are responsible for - the spreading of plague must be considered individually in - each epidemic and in various parts of the world as well. There - is no doubt that the importance of any insect in the - transmission of plague depends on its habits as well as on - those of the host, be it either animal or man. - - [12] Centralbl. f. Backt., 1 Abt. (1897), =22=, 87, 437. - Report of Indian Plague Commission (1898-99). Zeitschr. f. - Hyg. u. Infectionskrankh. (1901), =36=, 89. Kolle und - Wassermann: Handbuch der pathogenen Mikroorganismen (1903), - =2=, 538. Zeitschr. f. Hyg. u. Infectionskrankh. (1905), =51=, - 268. Journ. Hyg., Cambridge (1907-10), plague numbers. _Ibid._ - (1908), =8=, 162, 260. - - During the recent outbreak of plague in Manila, several - samples of bed-bugs from the beds of the plague patients and - dog fleas from a plague-infected house were collected and - examined, but with negative result. - - In spite of the fact that it adds nothing new to the question - of whether or not plague can be transmitted by fleas, since - the question has been conclusively answered by the work of - the Indian Commission, nevertheless the following - observations of a small outbreak of plague among animals, the - spreading of which was due solely to fleas, are of interest. - - One wild rat was inoculated with strain Iloilo 3 of - _Bacillus pestis_. The skin adjoining the root of the right - ear was scarified, and a loopful of the culture was smeared - on the scarified skin. The rat was found dead three days - after the inoculation. - - The cage containing the dead rat was immersed in kreolin - solution. At autopsy the cervical glands were found slightly - swollen, somewhat reddened, but no haemorrhagic oedema of the - surrounding tissue was noticeable. There was slight necrosis - at the place of inoculation, showing superficial, purulent - discharge. Clear effusion in both pleural cavities and one - hemorrhage in the pleura were found. The lungs were - hyperaemic, but otherwise normal. The spleen was of somewhat - darker color, but otherwise normal in size and appearance. - The liver showed a slight degree of parenchymatous - degeneration, the congestion making prominent the structure - of the organ. The typical, although not constant, changes of - the organ, which are characteristic of natural plague - infection in rats, were absent. The kidneys were without - macroscopic change. The lymph glands, with exception of the - cervical nodes, were normal. - - Examination of the rat's fur revealed ectoparasites on the - neck, under the chin, and back of the ears; these at the time - of the examination apparently were dead. About 6 common rat - fleas were found and identified as _Loemopsylla cheopis_ - Rothsch. The parasites were immersed in sterile salt solution - for three hours. When removed in a dry test tube, they began - to move about sluggishly. The intestinal tract of these fleas - contained blood. - - Five of the fleas were crushed by means of sterile forceps, - and inserted in a pocket under the shaved skin of a - guinea-pig. The animal died of plague within three days, - showing considerable hemorrhagic oedema around the place of - inoculation, typical bilateral inguinal buboes, and - characteristic changes in the spleen. Smears and cultures - made from the bubo and spleen were positive for _Bacillus - pestis_. - - Another wild rat, which was in a separate cage in the same - room where rat 1 had been kept, died twenty-four hours after - rat 1. The two cages were at least 10 centimetres apart. Rat - 2 harbored fleas of the same species as were found on rat 1. - - Numerous severe bites were detected back of the ears and on - the neck of the dead animal. The post-mortem findings were - identical with those described in rat 1; that is, cervical - buboes, pleural effusion, and slightly enlarged spleen. - - It is well to remark that both rats had been kept in the same - room for about six months. Fleas had never been noticed on - our guinea-pigs. During the time the rats had been kept in - the plague house no irregular results were noticed in - plague-inoculated animals. At the time the first rat was - inoculated no other plague-infected animals were in the - plague house, and since that time another building has been - used for plague-infected animals. - - Two days after the death of rat 2 three guinea-pigs, which - were kept in separate cages in the same room, were found dead - of plague (smears and cultures were both positive). Several - fleas (_Loemopsylla cheopis_) were found on the necks of these - animals. They were collected and inoculated in the same way - as the fleas from the first rat. The experimental animal, - which was inoculated with the fleas, was killed and found to - be infected with plague. The findings were local reaction, - inguinal buboes, and typical spleen. Smears and cultures were - positive for _Bacillus pestis_. - - Although numerous healthy guinea-pigs were examined in the - same plague house, no fleas could be found at that time, only - the 2 rats and the first 3 guinea-pigs are positively known - to have harbored fleas, the latter after the death of the - rats and not before. - - The gross lesions in these naturally infected guinea-pigs - were somewhat unlike those found in guinea-pigs infected - either by vaccination or by intraperitoneal or subcutaneous - inoculation. All except one showed primary buboes on the neck - with more or less extensive hemorrhagic oedema extending in - some cases over the thorax. There was little pleural effusion - present; the spleen always showed typical changes of necrotic - foci varying in size and number. In one instance similar foci - were found also in the liver, large enough to be visible - macroscopically. This was in a case where like changes were - found in the lungs. - - Only one of the guinea-pigs showed an exception, in that the - primary buboes were located in the inguinal region, with - pelvic and axillary glands secondarily involved. These are - the findings usually met within guinea-pigs artificially - infected with plague by the vaccination method, if the lower - part of the abdomen be chosen for inoculation. The reason for - such a deviation from the findings in the rest of the - guinea-pigs may lie in the fact that this animal was almost - completely deprived of hair by a skin disease. - - It is of importance to mention the skin lesions which were - found on the necks of the guinea-pigs, particularly under the - chin. Besides small red spots which appeared to be fresh flea - bites, small, elevated, and fairly deep infiltrations partly - covered with moist scab were found in the skin under the - chin. Other animals showed changes usually found in the - scarified skin of guinea-pigs after artificial inoculation - with plague material. The base of each cutaneous - efflorescence was hemorrhagic and oedematous. - - A histological study of the tissues of these guinea-pigs - known to be naturally infected by plague fleas showed the - following changes: - - THE CERVICAL BUBO.--The enlarged lymphatic gland was - surrounded with a thickened capsule. Necrosis existed in the - subcapsular part of the gland, where it formed an almost - continuous circular zone, leaving the central part less - changed. Smaller irregular necrotic foci were scattered - throughout the section. Polymorphonuclears in various stages - of disintegration were found throughout the section. - - _The Lungs._--Very few blood extravasations were present in - the alveoli; otherwise normal. - - _The Spleen._--The capsule was thin. There were subcapsular - hemorrhages. The Malpighian bodies were somewhat enlarged, - but of normal structure. Throughout the parenchyma irregular - multiple necrotic foci were found, leaving but little of - spleen tissue intact. Numerous polymorphonuclears which were - present showed varying degrees of karyorrhexis. - - _The Kidneys._--The outline of the cells was indefinite; a - few miliary hemorrhages existed in the cortical part of the - organ. - - _The Liver._--There was excessive congestion, fatty - degeneration, and pigmentation of the cells. The capsule was - slightly thickened. - - _The Skin._--The epithelium was missing in one place in the - section, and cellular infiltration extended from that place - into the subepithelial layer of the surrounding skin. The - same kind of infiltration reached deep into the skin, stripes - of cellular infiltration penetrating into the tissue along - the muscle fibres. There was no direct connection between the - cellular infiltration and the follicles of the hair. - - It may be well to describe in detail the time of death from - plague among these and the other animals in this outbreak, as - well as the time when the plague house was disinfected. - - The first animal (rat 1) having been inoculated on August 27, - in the afternoon, died of plague within three days (August - 30). The second animal (rat 2) died twenty-four hours later. - Guinea-pigs 3, 4, and 5 (see plan) were found dead on the - morning of September 2; that is, two days after the death of - rat 2 and three days after the death of rat 1. - - The same day that the three guinea-pigs were found dead of - plague, rooms I, III, IV, and VI were thoroughly disinfected. - The floor, the ceiling, and the walls were sprayed with - kerosene and lysol solution. The remaining animals in room VI - were destroyed, and the cages disinfected. No animals were - kept in rooms I, III, and IV at that time. - - Three days after the death of animal 5, guinea-pigs 6 and 7 - were found dead of plague, while the next day guinea-pigs 8 - and 9 died. No death occurred on September 7, but the next - two days each recorded two plague guinea-pigs (10, 11, 12, - and 13). On September 11, the last guinea-pig died of plague - in this outbreak. The whole building was then thoroughly - disinfected. No plague-inoculated animals were kept in the - rooms after the first sign of the epidemic. After September - 11, no more cases of spontaneous plague infection were - observed. - -[Illustration: ANIMAL HOUSE] - - It will be noticed that the epidemic lasted eleven days - after the first animal died and fourteen days after animal 1 - was inoculated. Altogether, 14 animals out of at least 200 - animals exposed died of plague. - - No death occurred among rabbits, although these animals were - distributed among the guinea-pigs. In fact, 2 rabbits were - surrounded by plague guinea-pigs 8, 9, and 10, but did not - contract plague. - - From the epidemiological standpoint it is interesting to know - the dimensions and location of the cages in which the animals - were kept. - - Aside from the 2 rats which were confined in ordinary traps - that stood on a table 80 centimetres high, the rest of the - animals were kept in regular metal animal cages. The - dimensions of the cages are: Fifty centimetres long, 36 - centimetres broad, and 30 centimetres high. The cage stands - on four legs each 10 centimetres long; the centre of the - bottom of the cage holds a drain opening 8 centimetres above - the floor. - - The majority of the cages in room II were located on the - floor; some on the second shelf of a wooden rack. This - last-mentioned arrangement, judging from the construction of - the wooden frame, allowed a continuous passageway for the - fleas to the second shelf of the racks. On the other hand, - the deaths among the guinea-pigs in room V were restricted to - the cages standing on the floor, the majority of cages in - that room being placed on tables 80 centimetres high. - - Only a theoretical explanation can be given of the short - duration and sudden cessation of the outbreak. One can assume - with great probability that the first partial disinfection - drove the fleas away from the primary source of infection, - and that they traveled as far as possible. They finally - settled in those guinea-pig cages which had not been molested - by the first disinfection. Having no new supply of plague - blood (all of the plague-infected guinea-pigs having been - removed, most of them before death), the fleas soon cleared - themselves of plague bacilli. The peculiar feature of the - outbreak, namely, the failure to find fleas on the animals in - rooms II and V, finds its explanation in the observation of - the Indian Commission who found that the fleas "died or - disappeared very rapidly." - - The following conclusions can be drawn from these - observations: - - 1. The common rat flea (_Loemopsylla cheopis_) prefers the rat - to the guinea-pig. - - 2. In the absence of rats it will attack guinea-pigs rather - than rabbits. - - 3. The fleas which have sucked blood from rats or guinea-pigs - afflicted with plague septicaemia were found to harbor - virulent plague bacilli inside of their bodies. - - 4. The transmission of plague infection by direct or indirect - contact being excluded in our case, the fact that fleas of - the same species and harboring plague bacilli were found on - the rat and on the guinea-pigs, the presence of flea bites on - the rats and on the guinea-pigs with positive findings of - skin lesions on that part of the body where the fleas and - flea bites were located, together with the anatomical picture - of the findings in the guinea-pigs, lead to but one - explanation; namely, that the plague infection was - transmitted by fleas. - - - III. OBSERVATIONS ON ANIMALS SUSPECTED OF PLAGUE - - Out of the several tens of thousands of rodents examined - during the antirat campaign, we have found only two plague - rats which showed the typical picture of natural plague - infection in rat; that is, cervical buboes with surrounding - oedema, subcutaneous injection, pleural effusion, enlarged - spleen, and such changes of the liver as are characteristic - of natural plague infection in rats. Microscopically, large - numbers of plague bacilli were found in these cases, and pure - cultures of _Bacillus pestis_ were recovered from the spleen. - Histological examination of internal organs, particularly - that of the liver, confirmed the bacteriological findings. - The remainder of the plague rats exhibited only two of the - signs of plague infection, namely, bubo and oedema of the - surrounding tissue, and eventually hemorrhages. - - Besides plague infection, a great number of rats showed - purulent conditions from causes other than plague. Abscesses - of the lungs were frequently met with, and cervical or - axillary buboes are not uncommon in Manila rats. Various - pyogenic bacteria were found in the pus of such abscesses. Of - the less common was _Bacillus pyocyaneus_ and the - pneumobacillus of Friedlaender. Chronic plague was excluded in - these cases since the animal inoculation failed to produce - plague infection. - - More than half of the rats examined harbored parasites in - their organs. _Echinococcus taeniaeformis_ was found in the - liver of practically every gray rat, while a small _Ascaris_ - and _Taenia diminuta_ were not uncommon in the intestines. Two - rats were found to have sarcosporidiosis, 2.6 per cent. - showed rat leprosy, and 7.4 per cent. trypanosomiasis. One - tumor of the mammary gland and one tumor in the axillary - region were encountered, while one tumor of the large - curvature of the stomach proved to be a chronic inflammatory - tumor due to parasites. One peritoneal tumor in a rat (_Mus - decumanus_) gave the impression of a malignant tumor on - account of the miliary dissemination of the peritoneum. It - was found to consist of muscle and spindle-cell sarcomatous - tissue. Ectoparasites were very seldom noticed, on account of - the method of collecting the rats. When present, they were - mites and fleas. - - In the naturally infected plague rats the rigidity of the - fresh cadaver was pronounced. The primary bubo was in every - case cervical. Cervical glands were enlarged and hemorrhagic - with slight oedema of the surrounding tissue. The subcutaneous - injection extended over the neck and chest. The inguinal - glands were small and pigmented. The lungs were collapsed, - and showed hemorrhagic foci. The spleen was slightly - enlarged, firm, and dark red. The liver was rather large, - firm, pale red, with shade of yellow, which was caused by - minute yellowish foci thickly scattered throughout the tissue - and visible through the capsule. The kidneys were hyperaemic. - The intestines were without change. The serous membranes were - pale with no hemorrhages. - - Histological examination of the tissue of naturally infected - plague rats showed the following changes: - - _Liver._--The structure of the organ was well marked; the - veins dilated, trabeculae slightly compressed, nuclei well - stained, and few of the liver cells showed vacuoles. Small - foci, most numerous under Glisson's capsule, were scattered - throughout the organ; they varied in size, but were not - larger than a miliary tubercle. The small necrotic foci were - found to consist of few necrotic liver cells. The centre of - the larger foci was formed by degenerated and necrotic liver - tissue, surrounded by round-cell infiltration. - Polymorphonuclears were also found in the zone of cellular - infiltration. There was a slight degree of hemorrhage in - each focus. Epithelioid cells and large vesicular cells with - several nuclei were to be found. The foci, mentioned above, - were sharply demarcated from the surrounding liver tissue, - which appeared to be intact. - - _Spleen._--The structure was well preserved, the capsule - thin. The Malpighian bodies were normal as to the elements of - which they consist. Cells with pycnotic nuclei were scattered - throughout the organ, and vesicular cells with small, deeply - stained, excentrically located nuclei were present. - Polymorphonuclears were found in the tissue in considerable - numbers. No localized necrotic foci could be found in - sections through the spleen. - - _Cervical Glands._--The blood-vessels were considerably - distended. A few hemorrhages and polymorphonuclears were - present. Oedema of the capsules and surrounding tissue - existed. Part of the gland was necrotic. - - _Lungs._--The blood-vessels were distended. The alveoli - contained homogeneous masses and blood. There were numerous - subpleural hemorrhages. The bronchi were collapsed, and - contained mucus. - - _Kidneys._--The cortical part showed subdued structure; the - epithelial cells had an indefinite outline and occasionally - showed vacuolization. The medullar part was better preserved. - There were miliary subcapsular hemorrhages. A few small foci - were scattered throughout both medullar and cortical parts. - They consisted of round-cell infiltration. - - - NATURAL PLAGUE INFECTION IN A CAT - - The experiments of the German Plague Commission proved that - cats showed considerable resistance to plague infection as - cutaneous and subcutaneous inoculations failed to infect - them. According to the Austrian Commission, cats develop - submaxillary buboes if fed on plague material. They are said - by Albrecht and Gohn[13] sometimes to recover. Out of four - cats fed on plague material two died of plague, one showing - submaxillary, the other mesenterial buboes. Virulent plague - bacilli were found in the discharge from the nose and also in - the faeces of cats which apparently did not become infected - after having been fed on plague material. - - [13] Ueber die Beulenpest in Bombay im Jahre 1897 (1897), II - B, II C. - - One case of spontaneous plague infection of a cat was - recorded by Thompson[14] in Sydney. - - [14] Report of an outbreak in Sydney, 1900. Referred to in - Kolle and Wassermann (1903), =2=, 510. - - W. Hunter,[15] in Hongkong made observations on cats - suffering from plague infection. The author also undertook a - few experiments, and arrived at the following conclusions: - - 1. Cats suffer from plague. - - 2. The disease may be acute or chronic. - - 3. The type of the disease is septicaemic. - - 4. The animals may occasionally play a part in the - dissemination of plague. - - 5. In plague-infected areas cats probably become infected - through rats, which they devour as food. - - 6. In plague-infected districts possible plague infection in - cats is of great importance from a domestic point of view. - - [15] Lancet (1905), =I=, 1064. - - On November 27, 1912, a sick cat was brought to the - laboratory for examination. It was reported that the animal - was found in a warehouse in which dead rats had been found - some time previously. The rats were not examined. In the - morning of the 30th, the cat was found dead in the cage where - it had been kept under observation. The following are the - post-mortem findings: - - The animal was a fairly well-nourished female.[16] The - subcutaneous tissue, pericardium, mediastinum, and - mesenterium contained considerable amounts of fat. - - [16] The cat was the mother of 4 kittens which were about 3 - weeks old at the time the cat was delivered for examination. - They were kept under observation for several weeks, but - showed no signs of plague infection. - - The subcutaneous tissue of the neck showed oedema and small - hemorrhages. The submaxillary tissues were swollen on both - sides. When the fasciae and superficial muscles of the neck - were removed, enlarged glands were found on both sides. These - were closely attached to the submaxillary salivary glands. - The surrounding tissue was oedematous, but no hemorrhages were - noticed in the vicinity of the enlarged glands. Upon section - the glands were found to be necrotic, and upon pressure a - thin purulent liquid escaped. There were no hemorrhages - within the glands. Several enlarged lymph-nodes, smaller in - size, could be followed down the neck on the left side. The - lymph-nodes in the axillae as well as in the groins and - peribronchial nodes were normal. The mesenteric glands were - slightly enlarged and reddened. - - The lungs were slightly collapsed. A clear, sanguineous, - slightly coagulated effusion was observed in both pleural - cavities. The tissue of the lungs showed considerable oedema - and hypostasis. The bronchi and pharynx showed no changes, - the mucous membrane being pale and thin. - - The heart was normal. - - The spleen was enlarged, of light red color, with follicles - slightly prominent. - - The stomach contents was blackish in color; there were no - hemorrhages or ulcers in the mucosa. - - The liver was somewhat enlarged. The organ showed prominent - structure, the centres of the acini being red, the periphery - lighter in color. - - The kidneys were slightly enlarged and pale. The capsule - peeled off easily, the venae stellatae were prominent, the - surface smooth; there were no hemorrhages. The cortex was - increased in breadth and was of the same color as the - surface; the pyramids were darker in color. The organ was of - fragile consistence. - - Suprarenals were normal, as were also intestine and bladder. - - The histological findings were as follows: - - _Bubo._--The capsule of the gland was oedematous. The whole - gland as seen in cross section had undergone necrosis, except - a few foci which still showed cellular structure. - - _Lungs._--The alveoli were filled with homogeneous masses, - containing but few degenerated epithelial cells and - leucocytes. The blood-vessels were dilated, particularly in - the subpleural part of the organ. In some places capillary - mycotic emboli with subsequent hemorrhage were encountered. - The large blood-vessels and bronchi were normal. - - _Salivary Glands._--Those glands attached to the primary bubo - showed the normal structure of a combined mucous and serous - gland. - - _Liver._--There was considerable congestion. The centres of - the acini showed parenchymatous and fatty degeneration. The - cells on the periphery of the acini exhibited typical fatty - infiltration. The large blood-vessels and small ducts were - without change. - - _Kidney._--The cells of the kidney showed various degrees of - degeneration, ranging from parenchymatous to fatty - infiltration. There were a few capillary hemorrhages and - hyaline casts present. - - _Suprarenals._--These showed slight degeneration. - - _Spleen._--This organ showed congestion, a few hemorrhages, - and bacterial emboli; otherwise normal. - - The bacteriological examination of the material from this cat - gave the following results: - - 1. _Smears:_ - - _a._ From the buboes showed degenerated leucocytes, many - lymphocytes, and numerous bacteria, some of which resembled - _Bacillus pestis_ in their polar staining. - - _b._ From the spleen showed numerous plague-like, - polar-stained bacilli. Round involution forms were present. - - 2. _Cultures:_ - - _a._ From the buboes were badly contaminated with _Bacillus - coli_ and _Bacillus pyocyaneus_ colonies. - - _b._ From the spleen: A few scattered colonies of _Bacillus - pyocyaneus_ developed on the surface of the agar. Between the - large colonies a scanty growth of dewy appearance was - noticed. Smears made from this growth revealed plague-like - bacilli of the cultural type, showing a few club-shaped - involution forms. Subcultures were made in order to secure - pure culture. They showed a pure growth of _Bacillus pestis_ - as indicated by the morphology of bacilli and shape of the - colonies. Agglutination with plague-immune serum was - positive. - - 3. _Inoculation experiments (vaccination method):_ - - _a._ One guinea-pig was inoculated with the material from the - left bubo, another one with material from the right bubo. - They died of plague on the third and fifth days, - respectively. - - _b._ One guinea-pig was inoculated with the material from the - spleen. It died of plague on the third day. - - _c._ One guinea-pig was inoculated with material from the - nostrils obtained by swab. The animal survived, showing no - indication of plague. - - _d._ One guinea-pig was inoculated with material from the - rectum obtained by swab. It died of plague on the fifth day. - - Although plague infection among cats is apparently a rare - occurrence, the fact that cats may contract the disease in - spite of the high degree of resistance to plague infection - has to be considered from the hygienic standpoint. - - To appreciate the important role which cats may play in the - spreading of the disease one need only consider the close - contact of these animals with rats on one side and human - beings on the other. It is also a well-established fact that - not only plague-infected cats, but also those which have - devoured plague-infected material and remained apparently - normal, may excrete plague bacilli which have retained their - full virulence. - -NOTES ON PLAGUE IN HONG KONG BY DR. ROBERG.--During the Hong Kong -epidemic of plague which preceded and was coincident with that of -Manila, I visited that city twice (December, 1913, and July, 1914), but -I did not closely investigate the methods adopted and carried out by -the authorities there, for the reason that the Manila plan was so much -more productive of results, as shown by the apparent inability of the -Hong Kong officials to gain control of the disease. However, I received -from Dr. David Roberg, of the Oregon State Board of Health, a copy of a -report made by him to the Secretary of his State Board of Health, -following an investigation of the Hong Kong epidemic and the methods -there followed. I have Dr. Roberg's permission to use his report and it -is herewith presented. It is dated Manila, April 16, 1914, and is as -follows: - - I have the following notes to present on the epidemic of - bubonic plague in Hongkong. - - On April 5th when I arrived in Hongkong the epidemic was - rapidly approaching its height. With its onset in January - there were 47 cases, in February 42, and in March 223. During - the week previous to April 5th, there were 91 cases; during - the six days I was in Hongkong they averaged 15 a day. - - Judging from previous epidemics the present one will be - exceptionally severe. The season for the occurrence of human - plague is from the months of February to July. The onset is - gradual; in May it reaches its maximum and then declines. In - the epidemic of 1912, for the city of Victoria the monthly - rate showed the following, January 9, February 22, March 61, - April 265, May 513, June 346, July 105, August 11, and - September 1. Comparing these rates with those of the present - year it will be seen that the number for March far exceeds - that of two years previous. - - Illustrating the season for human plague, with its onset, - maximum and decline, are the monthly rates for the city of - Kowloon during 1912, when the following cases occurred: - February 2, March 12, April 52, May 246, June 152, July 39, - August 8, and September 3. - - The season for human cases is determined by the condition of - the rats. At the close of the season in July the rats die off - from plague in great numbers as it is then the hottest time - of the year. During the months from September to February the - rats increase in number and in susceptibility to the extent - of being sufficient to again infect human beings. Moreover - every other year shows a marked severity in the epidemics of - human bubonic plague. This is explained by the fact that it - requires two years' time for the rat population to become of - sufficient greatness and susceptibility to cause a severe - human outbreak. This is shown by the yearly number of cases - since the year 1911. During the years 1911, 1912 and 1913 - respectively, there were 253, 1847, and 408 cases. During the - present year the monthly rate is exceeding that of the heavy - year of 1912. - - The severe epidemic in 1912 was a result of the influx of - 50,000 Chinese refugees into Hongkong during the revolution - in 1911. The number of rats in the native district depends - upon the available food supply, and as a result of this human - overcrowding the amount of waste food so increased in the - houses, yards and streets, that the over accumulation of - garbage could not be kept pace with. This influx also brought - in great numbers of susceptible rats. - - The number of rats killed off during the epidemic in 1912 - were so great that in 1913 they had not recovered - sufficiently to cause a severe outbreak during that year, and - as a result of the lightness of epidemic in 1913, they are so - increased in number and susceptibility now that they are - causing a very severe epidemic in human beings. - - Of rats in Hongkong they have the _Mus decumanus_ or drain - rat and the _Mus rattus_ or house rat. It is noteworthy that - the drain rat is found plague-infected throughout the year, - while the house rat is found infected only during the period - in which the human epidemics occur, namely from February to - July. The number of infected rats a year run parallel to the - number of monthly cases. - - The bulk of human infection is due to the spread of house - rats. Man also becomes infected by the drain rat when the - drains are flooded by rain storms and the rats are driven - into the houses. - - What has made plague permanent in Hongkong is the - overcrowding of the native districts. Besides there is a - floating population entering and leaving the native quarters, - numbering about 4000 a day. The native houses have been built - with double floors and walls which harbor the rats. Where the - construction is of wood it is possible to remove the rat - spaces. It has been found since the introduction of plague - into Hongkong in 1894, that those districts containing the - greatest number of soft brick houses with hollow walls, have - shown the greatest incidence of plague. This can not be - remedied as it would involve the destruction of buildings on - too large a scale. - - - THE WORK OF THE SANITARY BOARD - - The area under the control of the Board comprises the Island - of Hongkong containing 32 square miles, with a sea frontage - of 13 miles in length. Included also is the old city of - Kowloon which is situated one mile and a third across the - harbor and contains two and three-fourths square miles. The - city of Victoria on the northern shore of the Island of - Hongkong has a sea frontage of 5 miles, contains about ten - thousand domestic buildings, of which about one thousand are - non-Chinese. - - The population of Hongkong is difficult to estimate, as the - floating population is so great. In the 1912 census there - were 446,614 Chinese and 21,163 non-Chinese. - - The city of Victoria is divided into 10 Urban Health - Districts and old Kowloon into 2. There is an inspector in - charge of each. These districts are built over an area - averaging from 31 to 140 acres. The houses in these districts - average one thousand and the population from 8000 to 33,000. - There are four inspectors in charge of the scavenging work, - one for the disinfection stations in Victoria and old - Kowloon, one for the cemeteries and two for general duty. - - The measures employed by the Sanitary Board are summarized as - follows: - - 1. The exclusion of rats from all dwellings by means of - concreted ground surfaces, the protection of all drain - openings and ventilating openings by iron gratings, and the - prohibition of ceilings and of hollow walls in new buildings - and in those existing buildings from which they have been - removed by order. - - 2. The collection and bacteriological examination of all dead - rats. Facilities for the collection of rats in the quarters - are provided in the shape of small covered bins attached to - lamp posts, telephone posts, electric light poles, etc. These - bins contain a carbolic acid disinfectant, and the - inhabitants are invited to at once put into them all rats - found or killed by them. There are 650 of these bins - distributed throughout the city and its suburbs, and each of - them is visited twice daily by rat collectors who take all - rats found by them to the City Bacteriologist. Each rat is at - once labelled with the number of the bin from which it is - taken, and if subsequently found to be plague infected, a - special survey is immediately made of the block of houses in - that vicinity. All rat-holes and rat runs are filled up with - broken glass and cement, defective gratings and drains dealt - with, and rat poison distributed free to the occupants. If - several plague-infected rats are found in one locality, a - special house-to-house survey and cleansing of that district - is made. - - 3. The destruction of rats by poison, traps and birdlime - boards; special efforts in this direction being made just - before the onset of the regular plague season which is in the - months of from March to July. - - 4. The encouraging of the community to keep cats. - - 5. The systematic cleaning and washing out of all native - dwellings at least once in three months with a flea killing - mixture made by emulsifying kerosene in water. - - 6. An efficient daily scavenging of all streets and lanes - and the daily removal of refuse from the houses, coupled - with the provision of covered metal dust-bins, to reduce as - far as possible the amount of food available for rats. - - 7. The disinfection of plague-infected premises by stripping - them and washing them out thoroughly with a kerosene - emulsion. The bedding, clothing, carpets, rugs, etc., are - conveyed in a huge covered basket to the disinfecting plant - and sterilized with superheated steam. No objection is made - to the treatment of plague cases in native hospitals, and no - restrictions are imposed in regard to the burial of those - dead with plague except the provision of a substantial - coffin. - - 8. Every effort is made by means of lectures, addresses and - explanations to induce the native population to participate - in the above preventive measures. - -Upon my last visit to Hong Kong, in July last, plague was abating. _The -South China Morning Post_ of July 15, 1914, contained the following -statement: - - Plague is gradually disappearing from Hongkong. Last week's - return shows that there were 26 cases, of which 19 were fatal. - All were Chinese. The total number of cases for the current - year to date is 2093, with 1939 deaths resulting. - -I regret that circumstances do not permit me to relate in detail the -work done and the observations made during the closing six months of -the Manila epidemic. - -Up to the day of my departure from the Philippines, in July, 1914, I -remained in charge of plague suppression, but the added duties of -administration at San Lazaro Hospital and the coincident occurrence of -a cholera epidemic prevented me from keeping a detailed record in such -form as to permit reproduction here. It will therefore suffice to say -that the first six months of 1914 witnessed the passing of the most -threatening situation that has confronted the city of Manila in years. -The record of plague rats found does not convey an accurate idea of the -prevalence of rat plague by any means, for the simple reason that, when -found, the rat cadavers were in such condition as to forbid -bacteriologic examination; and inasmuch as the bacteriologic test of -plague had been used exclusively in determining rat plague up to this -time, it seemed desirable to adhere to the original method. - -In February we found in one of the districts, in which we undertook -systematic work in consequence of a few cases of human plague, a very -large number of dead rats, in and adjacent to houses which furnished -human plague cases. In one building alone more than 150 rat cadavers -were found during our cleaning and rat-proofing operations. It is this -district concerning which the letter to the public (already quoted) was -written. - -The methods followed in treating this new and dangerous focus of -infection did not differ from those practised during the previous year, -except in the matter of intensity. Forces of the cleaning and -rat-catching gangs were increased and the utmost thoroughness of -treatment was insisted upon. The results fully justified our policy and -demonstrated again how feasible it is to fight plague successfully if -adequate authority be given. - -During the last year of the epidemic in Manila it became the rule for -us to expect our plague workers to locate and find the identical rat -cadaver from which the infected fleas bore the disease to the human -victim, provided the spot upon the floor where the patient's sleeping -mat had been placed was known. In the better class of houses the rat -(sometimes more than one) was found dead beneath the floor, behind some -post casing, or in other space caused by double construction. Time and -again I have directed the removal of some panel of woodwork, some post -casing, or a board of the floor with the full expectation (seldom -unrealized) of finding a dead rat or a rat nest. These experiences were -positively uncanny at times. In the houses of the poorer class, usually -of bamboo and thatch construction, the finding of the rat was less easy -and more uncertain, although the nest was repeatedly found, and as -related elsewhere the dead rat itself might be found in a hollow bamboo -timber, or in the thatch construction of the wall. In a house on Calle -Echague, from which a Filipino and his wife were removed, dead, within -a few hours of each other, several dead rats were found in the floor -(the only piece of double construction in the whole house) within four -feet from the spot where the sleeping mats were placed. A rat hole led -to the nest and through this hole the fleas from the dead rats found -their way to the human victims sleeping on the floor above the encased -nest. - -These instances could be multiplied many times, but there is no longer -any special reason to do so, as the rat and the rat-flea are so -completely incriminated as to render these repetitions quite -unnecessary, however interesting they may be to the plague worker. The -danger of pursuing these investigations, to the persons so engaged, -must not be lost sight of, and exposure of such nests and rat cadavers -should invariably be preceded by thorough spraying of the place, and -particularly of the spot where tearing out of double construction is to -be done. I know of no more dangerous employment than this, both for -laborer and bystander. - - - - - CHAPTER IV - - ITS DIAGNOSIS AND TREATMENT - - -It was not my original intention to include the subjects of diagnosis -and treatment in this presentation, except in so far as I have already -referred to them in the relation of my Manila experiences in the -preceding pages. I have decided, however, to add a chapter upon -Diagnosis and Treatment, for the sake of completeness. No attempt will -be made to present these subjects in the orthodox way. - -Rather, my remarks will be confined to such matter as I believe to be -thoroughly practical and relevant. - -In my opinion, the day has arrived when we may properly exclude from -such handbooks as this one (intended for practical guidance), all such -methods of diagnosis and treatment as have failed to meet the test of -actual experience through a reasonable length of time. Twice in recent -years,[17] I have described the diagnosis and treatment of plague, -attempting in each case to present a reasonably full account of the -methods employed and advocated by authorities, for theoretic reasons -and from the recorded personal experiences of medical men throughout -the world. There comes a time, however, when wheat and chaff must be -separated and when methods which have failed, in application, to -justify preformed expectations must be relegated to the department of -historical medicine. - - [17] Tropical Medicine (1907) and Hare's Modern Treatment (1911), - vol. 1. - -Judging from recent medical text books it is evident that medical -writers are generally accepting this view as the proper one. At any -rate, my experiences and those of my medical friends during the Manila -epidemic of 1912-1914, have led me to discard as impracticable, -unproven, disproven or unpromising, certain plans of treatment formerly -deemed worthy of trial. I do not refer to these methods individually -but will content myself, instead, with reciting briefly the methods -which I believe, from personal experience and the collected experience -of others, to be worthy of continuance and of further trial. - -DIAGNOSIS.--The rapid diagnosis of plague is always of the utmost -importance, both from the view-point of prognosis and treatment, in the -individual case, and from the community view-point of the recognition -of the presence of a dangerous communicable disease, with the resultant -obligation falling upon the health authorities. - -THE BIOLOGIC DIAGNOSIS.--Let us understand, first and finally, that but -one diagnosis is absolutely and irrefutably dependable, viz.: the -biologic diagnosis. Herein I would include not only the recovery of the -pest bacillus from the patient, but the recovery and identification of -the organism from inoculated animals, infected from blood, tissues, -secretions or cultivated plague bacilli derived from the human patient -or cadaver. - -This entire process involves a lapse of time of several days, and, -while it is indispensable in the earliest cases of an epidemic, and -highly desirable for the proper study of all cases of plague, it is -impracticable and unnecessary, in communities where plague is known to -exist, to carry out more than the first steps of the biologic -diagnosis, viz.: the recovery of _B. pestis_ (morphologic -identification) from the patient. - -NECESSITY FOR TRAINED BACTERIOLOGIST.--It is evident that the services -of a trained bacteriologist are indispensable in the accurate diagnosis -of plague, unless (as rarely is the case) the observer himself is both -clinician and bacteriologist. Even in this case it is far better for -two persons, clinician and bacteriologist, to work together. I will not -discuss the technic of the procedures of biologic diagnosis, which is -described by Dr. Schoebl in the preceding pages. Except under -circumstances of necessity, the clinician should always turn this work -over to the bacteriologist. - -Serum reactions, when present, occur too late to be of service in -practical diagnosis. - -The necessary procedures of the biologic diagnosis include -blood-culture, smear examination (microscopic) of aspirated material -from the oedematous tissues surrounding gland masses and from glands -themselves; examination of sputum smears and of thick-blood smears. - -All should be practised but, according to our Manila experiences, smear -examinations of aspirated material and blood cultures are the most -reliable methods, in the hands of a competent bacteriologist. Attention -is invited to the reports of Dr. Otto Schoebl, already quoted. - -BACTERIOLOGIC PROCEDURE.--Dr. Schoebl was able to secure positive blood -cultures, within 24 hours, from all of a long series of cases of -plague, both bubonic and septicaemic. As much blood as it was possible -to secure was aspirated from superficial veins and introduced into the -culture media at the bedside, ten c.c. being secured whenever it was -possible. - -The smear preparations for staining and culture inoculations upon -slants were also made at the bedside from aspirated matter obtained -from oedematous periglandular tissues or from gland puncture, an -aspirating syringe being used. The drop or two of fluid which can be -expelled from the hollow needle is usually sufficient for smears and -tube inoculations. - -NON-BIOLOGIC DIAGNOSIS.--I do not contend that other diagnostic means -than biologic ones should not be used in plague. - -On the contrary, it will inevitably happen at times that resort must be -had to methods of diagnosis which are purely clinical. When this is the -case, treatment, along lines to be detailed presently, should be -instituted upon the establishment of a presumptive diagnosis. This -presumptive diagnosis may be reached after due consideration of -physical signs and symptoms. A carefully taken history of the onset -and course of the disease will be valuable but unfortunately such -histories can rarely be secured. It is far safer to mistakenly -pronounce a case "plague" and to institute appropriate treatment, than -it is to hesitate in the absence of a perfect clinical picture and to -permit the golden moment for treatment to pass. - -It must be remembered that septicaemic, bubonic and pneumonic plague are -all manifestations of systemic infection with _B. pestis_; that they -are all expressions of the same disease; that they call for the same -treatment and that when the distinctive signs of bubo or pneumonia -appear the disease is dangerously advanced. - -It should also be realized that every case is, almost from its onset, a -septicaemic case, either mildly or overwhelmingly so. Accordingly the -treatment should invariably be the treatment of septicaemic plague. - -The attitude of the diagnostician should be one of suspicion and he -should have the courage to carry out antiplague treatment, practically -upon suspicion. In this way only can the mortality of plague be greatly -reduced. It is true of plague, just as it is true of cholera, that many -of the fatal cases develop and become hopeless before the disease is -suspected or diagnosticated. It is also true that many fatal cases of -plague, in times of epidemic, completely escape recognition during -life, the diagnosis being made in the autopsy room. - -Therefore, I lay great stress upon the necessity for an attitude of -suspicion on the part of practitioners, wherever even a single case of -plague (human or rodent) is known to have occurred. - -When it becomes necessary to establish a presumptive diagnosis, _i.e._, -without resort to the microscope, the following symptoms and physical -signs will be found to be most significant. - -SYMPTOMATOLOGY.--Acuteness of onset; rapidity of fever development; -rapidity of the development of mental dulness or cloudiness, impairment -of speech, delirium, stupor or restlessness; early and extreme -prostration (perhaps more pronounced than in any other acute disease); -extreme tenderness over involved gland masses, in the bubonic type of -plague; cough, with considerable frothy sputum, soon becoming -blood-discolored, in the pneumonic type of plague; and early cardiac -asthenia in all clinical types of plague, septicaemic, pneumonic and -bubonic. - -The following diseases may be confounded with plague, if symptoms -alone are considered: typhus (_exanthematicus_), influenza pneumonia, -broncho-pneumonia, severe malaria, septicaemia, acute toxic typhoid, -venereal bubo, mumps and tonsillitis. - -I call attention again to the fact that mild cases of plague, -septicaemic and bubonic, occur at times, clinical pictures in such cases -being incomplete. - -The statement that the prognosis in all cases of septicaemic plague is -hopeless is not confirmed by my experience. - -It should also be remembered that primary pneumonic plague and -secondary pneumonia developing in the course of systemic plague are -quite different in their significance and mortality, primary pneumonic -plague being well nigh invariably fatal. - -PATHOLOGIC CONSIDERATIONS.--Only the student of plague pathology, who -has seen a large number of complete autopsies, can understand how -universal is the involvement of organs, glands and tissues in systemic -plague and how widespread is the distribution of _B. pestis_ throughout -the body, and he will best understand how treatment, to be in the -least effective, must be given in the very earliest hours of the -disease. - -Plague is an exquisitely septicaemic disease and this fact must never be -lost sight of by the therapeutist, who must realize that from the -earliest moment of infection all plague is septicaemic plague. - -TREATMENT, CONDITIONS AND PROGNOSIS.--Passing to the subject of -treatment let us, first of all, admit that even under the most -favorable and approved conditions of treatment the mortality is -extremely high. On account of the delay which usually occurs in the -recognition of plague,--a delay which in the natural order of things is -and must be the rule rather than the exception, because of the rapidity -of onset of the disease and the fact that it occurs much more -frequently in the lower social classes than elsewhere,--no brilliant -results are to be expected from any plan of treatment. - -The matter of plague treatment is far from being in the same -satisfactory state as the matter of preventive control. I do feel, -however, that biologic treatment from the earliest possible moment, -with serum, is of the greatest promise, however discouraging the -general prognosis may be in plague. - -SERUM TREATMENT.--Recent writers agree that there is no treatment with -curative value except that with antipest serum. To this belief I -subscribe assent, as I find it entirely in accord with my experience -and that of my colleagues in Manila during 1912-1914. - -Holding this view, I can see no reason for repeating here the details -of purely symptomatic treatment. Symptomatic treatment has for its -object the securing of comfort and of relief from suffering for the -patient and is highly proper in its place, remembering always that it -is not curative and that if employed alone it is worse than inadequate. - -SYMPTOMATIC TREATMENT.--Opiates (morphine by needle) for pain, delirium -and excitement; application of ice bags and cold or tepid sponge -bathing for high temperature; stimulants for heart weakness, are all -indicated and are required in nearly every case of plague. - -As a rule surgery is not called for nor appropriate, except in cases -which develop secondary surgical conditions, which conditions we need -not consider at this time. - -STATISTICAL STUDIES IN MORTALITY.--The statistical study of plague -mortality from the point of view of treatment is misleading and -unsatisfactory for reasons already given in our discussion of -treatment, viz.: failure to secure early recognition and early serum -treatment, and the greater incidence of plague in the lower social -classes. - -Few statistical compilations divide the cases studied into moribund and -non-moribund, and indeed such division, being a matter of judgment, -largely involves the personal equation of the observer. - -The ease with which statistics may be moulded to support theories, or -to break them down, all with perfect honesty of purpose, is proverbial. - -To me, the spectacle of a single case of plague, apparently ill unto -death, recovering under the administration of antiplague serum, is more -impressive than the contemplation of statistics; and I have seen more -than one such case respond to serum treatment and recover. - -So far as it goes, however, the study of statistics supports the view -that treatment with antiplague serum is effective. - -I have not at hand the records of the last 20 or more cases, but of -the first 68 cases of plague in the recent Manila epidemic, 32 were -either found dead or died upon the same day that they were found. - -If we exclude these cases from consideration there remain 36 cases. All -of these patients received serum treatment and ten of them recovered. - -It is at once apparent that this percentage of recoveries (27 per cent. -plus) is far more favorable than the actual percentage of recovery in -the series in which cases found dead and moribund are considered, the -recovery percentage here being a little more than 14 per cent. It is -also quite fair, it seems to me, to make this separation of cases, or -even a more liberal one, if we are to consider the effects of serum -treatment statistically. - -DOSAGE AND TECHNIQUE OF SERUM ADMINISTRATION.--The amount of antiplague -serum to be given will vary somewhat with the age and weight of the -patient and with the apparent severity of the case. - -In general terms it may be said that adults should be given from 300 -c.c. to 500 c.c. of serum by injection, 100 c.c. being given every four -hours. The injection may be either intramuscular or intravenous. - -In view of the improvements in technic of intravenous administrations -and its comparative simplicity, and especially in view of the -uncertainties and delays of absorption from the tissues, the -intravenous route should be given the preference. The serum may be -delivered intravenously from a large glass syringe, the introduction -being very slowly made, or through a gravity apparatus, as in the -administration of salvarsan. The serum should not be diluted. - -The use of antiplague serum for protective (immunizing) purposes is -also recommended--especially when exposure to infection has -occurred--in the same way in which diphtheria antitoxin is used. Its -protective properties are conceded to be somewhat superior to those of -plague vaccines as the protection conferred is immediate, whereas -plague vaccines do not protect until sometime after their -administration. The dose is from 30 c.c. to 50 c.c. - -PROPHYLACTIC SERUM AND ANAPHYLAXIS.--On one occasion in Manila in 1913, -when some 30 persons were given prophylactic doses of serum, -intramuscularly, following a particularly dangerous exposure to fleas -from rats dead from plague, there occurred a number of cases of "serum -sickness" (anaphylaxis). These persons suffered from severe urticarial, -arthralgic and nervous symptoms, lasting for several days and a few -were obliged to enter a hospital. In one case the symptoms did not -entirely abate for a week. It has been stated that newly-prepared serum -is particularly apt to produce serum sickness when used for immunizing -purposes. This form of protection is brief (1 to 2 weeks) and is best -suited for use where there has been special exposure. - -PLAGUE VACCINES.--Haffkine originally proposed prophylactic -immunization, using killed broth cultures of _B. pestis_ (carbolized to -1/2 per cent.), giving two injections at intervals of 10 days. -Statistically it seems to be shown that this prophylactic immunization -with dead bacteria reduces the incidence and mortality one-fourth or -one-half (approximately). Experimentally, also, it appears that -antibodies (agglutinins) are produced by the vaccine (and modifications -thereof). Instead of broth cultures, normal salt solution suspensions -of killed pest bacilli are usually used in vaccines at present. - -Castellani[18] has prepared a combined cholera and plague vaccine for -use in countries where both diseases coincidentally prevail. It is a -mixed vaccine, so prepared that 1 c.c. of the emulsion contains 1000 -millions of plague bacilli and 2000 millions of cholera vibrios. The -cultures are grown on agar, killed by phenol and suspended in normal -salt solution. - - [18] A. Castellani: Journal of Ceylon Branch of British Medical - Association, June, 1914. - -He finds (1) that inoculation of the vaccine in the lower animals -induces a production of protective substances for the plague bacillus -and the cholera vibrio; (2) that the inoculation of human beings is -harmless (producing less reaction than the Haffkine inoculation); (3) -that a small amount of agglutinins, both for plague and cholera, appear -in the blood of most inoculated persons (similar to amounts produced by -Haffkine's vaccine), a rough index only of the amount of immunity -produced. - - - - - INDEX - - - Anaphylaxis, 177 - Appearance of plague in Porto Rico, 26 - New Orleans, 26 - Manila, 26 - Appeal for public cooperation, 126, 127 - Australia, plague in, 22 - Alaska, plague in, 22 - Africa, South, plague in, 22 - Africa, Central, plague in, 22 - Africa, East, plague in, 22 - Africa, British East, plague in, 25 - Africa, Portuguese East, plague in, 26 - Asian marmot, 28 - Australia, rat fleas of, 32 - Activity of fleas, 33 - Attenuation of virulence of cholera organism, 35 - Bacillus pestis, 35 - Adaptability of rat to temperature and environment, 51 - Anti-plague campaign in Manila, 1912-1914, 57 - Amoy, importation of plague from, 59 - Anti-rat measures in R. R. cars, 92 - Activity of fleas, 98 - Austrian Plague Commission, 133 - Agglutination of plague bacilli, 134-135 - Animals suspected of plague, observations on, 146-149 - Abatement of plague in Hong Kong in 1914, 160 - Anti-plague work, dangers of, 163, 164 - - Bacteriologic observations, 127 - Bacillus pestis, in air, 38 - in ants, 138 - in bedbugs, 33, 138 - conveyance by fleas, 28, 30, 31 - cultivation of, 133, 138 - cultural characteristics of, 133, 138 - in circulating blood, 133, 136 - in cats, 150 - effect of temperature upon, 34 - in flies, 33, 138 - in fleas, 138 - in lice, 33, 138 - effect of seasonal conditions on, 34 - in cockroaches, 33 - in sputum, 132 - stability of virulence of, 35, 36 - in skin, 132 - Blue, Dr. Rupert, 31 - Brazil, plague in, 22 - Black Death of Europe, 20 - British East Africa, plague in, 25 - Bite of flea, 31 - Brazil, rat fleas of, 32 - Bedbug, conveyance of B. pestis by, 33 - Barber, Dr. M., 38 - Bacterial viruses for rat destruction, 43 - Bacterial virus, Danysz, 53 - Bacillus, Danysz, 53 - use of, in Odessa, 53 - use of, in Cape Town, 53 - B. typhi murium, 53 - Bacillus, mouse-typhoid, of Loeffler, 53 - B. enteritidis, Gaertner's, 54 - Bacterial rat poisons, use of, in Japan, 54 - Beginning of Manila epidemic, 60 - Binondo, Manila, plague in, 63 - Bamboo timbers, closing ends of, 71 - Basements, insanitary, 72 - Birth-rate of rats, 73 - Bionomics of fleas, 77 - Batavia, Dutch India (Java), 77 - Bureau of Science, Manila, 92 - Barn rat, 99 - Burrowing ability of rats, 102 - Breaking up rat nests, Manila, 106 - Bacteriologic examination of plague patients, 128 - Blood-sucking insects, transmission of plague by, 137 - Bacillus pestis, insects found to contain (Table III), 138, 139 - Biologic diagnosis of plague, 167 - procedure, diagnosis, 168 - - Cause of plague, 28 - Conveyance of plague, 28 - Control of plague, 40 - Crowell, Dr. B. C., 14 - China, plague in, 21, 22, 24 - California, plague in, 22 - Central Africa, plague in, 22 - California ground squirrel, 28 - Contact, plague through, 29 - Contagious plague, 29 - Contagion, India Plague Commission on, 33 - Cockroaches in plague conveyance, 29, 33 - Cats, plague in, 29, 76, 149 - Chronic plague in rats, 35 - Chronic rat plague, India Plague Commission on, 35 - Currie, Dr. D. H., 31 - Creel, Dr. R. H., U. S. P. H. Service, 31, 101 - Castellani, Dr. Aldo (dedication), 179 - Ceratophyllus fasciatus, 32 - Cat fleas, 32 - Ctenocephalus, 32 - Citellus beecheyi, 28 - Cholera epidemics, spontaneous abatement of, 35 - organism, attenuation of virulence of, 35 - California, a plague centre, 41 - Cost of rat proofing, 49 - Chemical poisoning of rats and ground squirrels, 54 - Community, summary of prevention for, 56 - Close of year 1912 in Manila, 67 - Closing ends of bamboo timbers, 71 - Cat plague case in Manila, 76, 149 fleas, 78 - Correspondence of Philippine and Japan conditions, 83 - Comparative statistics in rat catching methods, 89 - Cresols, 94 - Coloration of rats, 99 - Conformation of skulls in rats, 101 - Climbing ability of rats, 102 - Collection and forwarding of rats (Manila), 122, 123 - Case of Mr. C. (Manila), 124, 125 - Concealing plague cases, 94 - Conclusions concerning blood culture in plague diagnosis, 136 - from observations of plague outbreak among experimental animals - (Manila), 146 - Cat, natural plague infection in, 149-154 - Conditions, treatment and prognosis, 173 - Combined vaccines, 179 - - Diagnosis of plague, 165 - Definition of plague, 28 - Digestive tract, infection through, 29 - Dog fleas, 32 - Droplet infection, 38 - Destruction of rats by diseases, 53 - Danysz bacterial virus, 53 - bacillus, 53 - use of, in Odessa, 53 - use of, in Cape Town, 53 - Destruction of rats by domestic animals, 54 - Disinfection of ship cargoes, 56 - Dead, proper disposal of, 56 - Dispersion of fleas from rat cadavers, Manila, 65 - Death-rate of rats, 73 - Dutch India, Batavia (Java), 77 - Duration of life of fasting fleas, 79 - Dead rats in bamboo house timbers, 87 - Disinfection, theatre, Manila, 93 - Deception and concealment of plague cases, 94 - Differential points in rats, unreliability of, 101 - Driving out rats with formaldehyde gas (Manila), 106 - Dangers of anti-plague work, 163, 164 - Diagnosis, rapid, of plague, importance of, 166 - biologic, of plague, 167 - non-biologic, 169, 170 - Dosage and technique of serum administration, 176, 177 - - Extension of plague, 19, 22 - Egypt, plague in, 20, 23, 25 - East Africa, plague in, 22 - Epidemics, effect of seasonal conditions on, 34 - wane of, 35 - Epidemic pneumonic plague, 38 - Economic importance of rat destruction, 42 - Estimations of loss by U. S. Agricultural Department, 42 - Effect of superstitions and religious beliefs in India, 43 - of rat poisoning and trapping, 73 - Epidemiologic facts concerning plague in Java, 82 - Examination of fatal cases of plague (Table I), 130 - of cases of plague who recovered (Table II), 131 - Experimental animals, plague in, 139-145 - - Flea conveyance of B. pestis, 30 - Flies, conveyance of B. pestis by, 33 - Fowls, plague conveyance by, 29 - Flea's stomach, capacity of, 31 - bite and plague conveyance, 31 - Flea prevalence, effect of seasonal conditions on, 34 - Fox, Dr. Carrol, 31, 70 - Fleas, dog, 32 - cat, 32 - mice, 32 - ground squirrel, 32 - activity of, 33, 98 - Fumigation of ships, 46 - Flea carriers, objection to domestic cats and dogs as, 55 - Favorable conditions for spread of plague in Manila, 61 - First Manila cases in 1912, 62 - Fleas and their habits, 77 - bionomics of, 77 - rat, of Philippines, 78 - of Australia, 78 - of Italy, 78 - cat, 78 - per rat, variations in number of (Java), 78 - Flea larvae, effect of temperature and humidity on, 79 - imago, effect of temperature and humidity on, 79 - Fasting fleas, duration of life of, 79 - Flea prevalence, prediction of plague extension from, 80 - natural enemies of, 97 - activity of, 33, 98 - Field rat, 99 - Family Muridae, 99 - Ferocity of Mus decumanus, 102 - Feasibility of fighting plague successfully, 162 - of Manila policy of plague control, 162 - - Great plague of London, 21 - Great Britain, plague in, 22 - Ground squirrel, California, 28 - Great Britain, rat fleas of, 32 - Ground squirrel, fleas of, 32 - Gaertner's B. enteritidis, 54 - Geographic grouping of plague cases in Manila, 63 - Ground-floor sleeping quarters, 72 - General cleaning campaign, Manila, 88 - Garbage cans, sanitary orders, Manila, 93 - Guinea-pigs as indicators of infected houses, 96 - Genus Mus, 99 - Gray rat, 99 - Gunomys (Nesokia), 100 - Gnawing ability of rats, 102 - German Plague Commission, 149 - - History of plague, 19 - Hawaii, plague in, 22 - Hong Kong, plague in, 24, 58, 154 - Heiser, Dr. V. C., 31, 58, 70, 75, 89 - Hobdy, Dr. W. C., 31 - House cats as rat catchers, 55 - Half wild cats as rat catchers, 55 - Human plague in Tondo district, Manila, 68 - Houses in Tondo, light material, 71 - House disinfection by spraying, 94 - Household rat destruction, plan for, 111 - Hong Kong, notes on plague in, by Dr. Roberg, 153, 154, 155, 156, 157, - 158, 159, 160 - the work of the Sanitary Board, 158 - abatement of plague in 1914, 160 - Haffkine vaccine, 178, 179 - - Introduction, 11 - India, plague in, 24 - Indo-China, plague in, 24 - Infection through digestive tract, 29 - Ingestion, plague, 29 - India, rat fleas of, 32 - Italy, rat fleas of, 32 - India Plague Commission on contagion, 33 - on chronic rat plague, 35 - Immunity, plague, 36 - India, effect of superstitions and religious belief in, 43 - Isolation of sick, 56 - Importation of plague from Amoy, 59 - Iloilo, P. I., plague in, 70 - Insanitary basements, 72 - Interpretation of the rat catch and plague incidence, 91 - Infected houses, guinea-pigs as indicators of, 96 - India Plague Commission, 100 - Insects found to contain Bacillus pestis (Table III), 138, 139 - Importance of rapid diagnosis of plague, 166 - - Japanese anti-plague serum, 18 - Japan, plague in, 22, 25 - Java, plague in, 25 - Japan, bacterial rat poisons, use of, in, 54 - Jackson, Dr. T. W., correspondence, 75 - Java, Batavia, Dutch India, 77 - Xenopsylla cheopis in, 77 - variations in number of fleas per rat, 78 - epidemiologic facts concerning plague in, 82 - Javan village house, 84 - "bale bale," rats in, 86 - Java, sawah rat of, 100 - Jumping ability of rats, 102 - Java, studies of rat cadavers in, 104 - - Kerr, Dr. J. W., 31 - Korn, Dr. W., U. S. P. H. Service, 87 - Kerosene as an insecticide, 94 - - London, great plague of, 21 - Lantz, Dr. D. E., 31 - classification of rats, 99 - Loemopsylla cheopis, 32 - Louse, conveyance of B. pestis by, 33 - Loeffler, mouse-typhoid bacillus of, 53 - Laboratory-proven plague rats and others in Manila, 61 - Light material houses in Tondo, 71 - Manila, 85 - Letter of warning and appeal, 125, 126 - Location of rat cadavers in relation to human plague cases, Manila, - 162, 163 - - Mortality, 22, 23, 174, 175 - Menace of plague, 28 - Manila, plague in, 26 - Manufacture of anti-plague serum, 18 - Middle Ages, plague in, 20 - Mexico, plague in, 22 - Mauritius, plague in, 22, 25 - Mediterranean ports, plague in, 22 - Marmot, Asian, 28 - Mice, fleas of, 32 - Manchuria, pneumonic plague in, 37 - Methods of entry of rats into ships and cars, 52 - Mouse-typhoid bacillus of Loeffler, 53 - Murium, B. typhi, 53 - Manila, Anti-plague Campaign in 1912-1914 in, 57 - epidemic, 1912-1914, 57 - plague at quarantine in, 58 - importation of plague from Hong Kong in 1912, 58 - Mariveles Quarantine Station, 59 - Manila epidemic, beginning of, 60 - Mortality and numbers of Manila plague cases, 61 - Manila cases in 1912, first, 62 - geographic grouping of plague cases in, 63 - R. R. station focus, 64 - dispersion of fleas from rat cadavers, 65 - close of year 1912 in, 67 - Malolos, P. I., plague in, 69 - Manila, taking charge of plague suppression measures in, 70 - plague fighting organization in, 71 - rat plague in U. S. Army Commissary warehouse, 76 - habitations and plague, 83 - light material house, 85 - general cleaning campaign, 88 - theatre, disinfection in, 93 - Mus rattus, 99 - alexandrinus, 99 - Mus decumanus, 99 - ferocity of, 102 - Manila, breaking up of rat nests, 106 - driving out rats by formaldehyde gas, 106 - rat killing with dogs, 107 - rat nests in trees, 110 - snakes in rat traps, 111 - rat swallowed by snake, 111 - Multiple house infection (Manila), 112-117 - Manila, collection and forwarding of rats, 122, 123 - Mr. C., case of Manila, 124, 125 - Manila, bacteriologic observation, 127 - outbreak of plague among experimental animals, 139-145 - conclusions from observation of plague outbreak among experimental - animals, 146 - San Lazaro Hospital, 13, 69, 161 - location of rat cadavers in relation to human plague cases, 162, 163 - Mortality, statistical studies in, 22, 174, 175, 176 - McCoy, Dr. C. W., 31 - - New Orleans, plague in, 26 - Natural enemies of the rat, 43 - National aid, necessity of, 56 - Numbers and mortality of Manila plague cases, 61 - Nest materials, 86 - Natural enemies of the flea, 97 - Norway rat, 99 - Notes on rat runs, 105 - nests, 105 - food, 105 - Natural plague infection in a cat, 149-154 - Notes on plague in Hong Kong by Dr. Roberg, 153-160 - Non-biologic diagnosis, 169, 170 - - Objection to domestic cats and dogs as flea carriers, 55 - Order Rodentia, 99 - Outbreak of plague among experimental animals (Manila), 139-145 - Observations of animals suspected of plague, 146-149 - - Plague conveyance, 28 - in 1910, 24 - conveyance by suction of insects, 33 - Porto Rico, plague appears in, 26 - Public cooperation in plague control, 126, 127 - Practicability of plague control, 15 - Philippines, plague in, 22 - Peru, plague in, 22 - Persia, plague in, 25 - Portuguese East Africa, plague in, 26 - Public Health Service, U. S., 26, 37 - Pulex irritans, 32 - pallidus, 32 - Plague pneumonia, secondary, 39 - Pneumonic plague epidemic, 38 - Prevention problem, summary of, 37 - Pneumonic plague, 37 - in Manchuria, 37 - Plague immunity, 36 - treatment and diagnosis of, 165 - control, 40 - prevention, 40 - suppression, 40 - campaign in San Francisco, 41 - Poisons used for rat destruction, 43, 44 - Poisonous gases, rat destruction by, 45 - Prevention for community, summary of, 56 - Proper disposal of dead, 56 - _Philippine Journal of Science_, 58, 70, 128 - Plague at quarantine in Manila, 58 - from Hong Kong, Manila, importation of, in 1912, 58 - from Amoy, importation of, 59 - cases, numbers and mortality of Manila, 61 - rats, laboratory-proven, and others in Manila, 61 - in Quiapo, Manila, 63 - in Binondo, Manila, 63 - cases in Manila, geographic grouping of, 63 - in Malolos, P. I., 69 - in Iloilo, P. I., 70 - Plague suppressive measures, Manila, taking charge of, 70 - fighting organization in Manila, 71 - Population, removal of, in emergency, 74 - Plague, cat, case of, Manila, 29, 76, 150 - rat, in U. S. Army Commissary warehouse, Manila, 76 - Prediction of plague extension from flea prevalence, 80 - Plague prevalence, seasonal explanation of, 81 - in Java, epidemiologic facts concerning, 82 - Manila habitations and, 83 - Tondo (Manila) habitations and, 83 - cases, deception and concealment of, 94 - commission, India, 100 - Postmortem changes, in rats (Table), 105 - in rats (illustration), 105 - time of death of rats as indicated by, 104 - Plan for household rat destruction, 111 - Plague patients, bacteriologic examination of, 128 - examination of fatal cases of (Table I), 130 - of cases who recovered from (Table II), 131 - commission, Austrian, 133 - bacilli from circulating blood, recovering, 134 - Plague bacilli, agglutination of, 134, 135 - diagnosis, conclusions concerning blood culture in, 136 - by blood sucking insects, transmission of, 137 - among experimental animals, outbreak of (Manila), 139-145 - outbreak among experimental animals, conclusions from observations - of (Manila), 146 - observations on animals suspected of, 146-149 - commission, German, 149 - in Hong Kong, notes on, by Dr. Roberg, 153-160 - in Hong Kong in 1914, abatement of, 160 - feasibility of fighting successfully, 162 - control, feasibility of Manila policy of, 162 - cases (human), location of rat cadavers in relation to - (Manila), 162, 163 - importance of rapid diagnosis of, 166 - biologic diagnosis of, 167 - a septicaemic disease in all cases, 170 - symptomatology of, 171 - Pathologic considerations, 172 - Prognosis, treatment, conditions and, 173 - Plague, serum treatment of, 174 - symptomatic treatment, 174 - Prophylactic serum and anaphylaxis, 177 - Plague vaccines, 178, 179 - - Quarantine, modified, 56 - station, Mariveles, 59 - Quiapo, Manila, plague in, 63 - - Rat fleas of Italy, 32 - of Brazil, 32 - of Great Britain, 32 - of United States, 32 - Rats, chronic plague in, 35 - subacute plague in, 35 - Requisites of the practical sanitarian, 12 - Russia, plague in, 26 - Rats, wild, plague in, 29 - effect of seasonal conditions on, 34 - Rucker, Dr. W. C., 31 - Rosenau, Dr. M, J., 31 - Rat fleas, varieties of, 32 - of India, 32 - of Australia, 32 - Rat population of the world, 41 - destruction, economic importance of, 42 - extermination methods, 43 - natural enemies of, 43 - destruction, bacterial viruses for, 43 - poisons used for, 43, 44 - trapping, 44 - traps, varieties, 45 - destruction by poisonous gases, 45 - Rats, starving, 47 - Rat proofing, 48 - cost of, 49, 93 - infestation of ships, 50 - adaptability of, 51 - Rat's, methods of entry of, 52 - Rat destruction by rat diseases, 53 - Resistance of rat to diseases of bacterial causation, 54 - Rats and ground squirrels, chemical poisoning of, 54 - Rat destruction by domestic animals, 54 - catchers, house cats as, 55 - half wild cats as, 55 - terrier dogs as, 55 - on farms, terrier dogs as, 55 - Rapid diagnosis, importance of, 56 - Rat cadavers, dispersion of fleas in Manila from, 65 - plague in Tondo district, Manila, 68 - proofing and rat destruction, 72 - inapplicable at times, 73 - poisoning, trapping, effects of, 73 - Rats, birth-rate of, 73 - death-rate of, 73 - Removal of population in emergency, 74 - Rat plague in U. S. Army Commissary warehouse, Manila, 76 - fleas of Philippines, 78 - of Australia, 78 - Rat fleas of Italy, 78 - breeding as influenced by climate, 81 - in Javan "bale bale," 86 - in thatched roofs, 86 - dead, in bamboo house timbers, 87 - Rat catch, variations in, 88 - Rat catching methods, comparative statistics in, 89 - Rat catch and plague incidence, interpretation of, 91 - Rats, zoologic classification of, 98 - Rat, ship, 99 - field, 99 - Rats, coloration of, 99 - Rat, Norway, 99 - gray, 99 - barn, 99 - sewer, 99 - Rats, unreliability of differential points in, 101 - conformation of skulls in, 101 - gnawing ability of, 102 - burrowing ability of, 102 - climbing ability of, 102 - jumping ability of, 102 - swimming ability of, 102 - Rat litters, size of, 102 - Rats as wire walkers, 103 - as rope walkers, 103 - Rat cadavers in Java, studies of, 104 - time of death as indicated by postmortem changes of, 104 - Rats, postmortem changes in (Table), 105 - (illustration), 105 - Rat runs, notes on, 105 - nests, notes on, 105 - food, notes on, 105 - nests (Manila), breaking up, 106 - Rats driven out with formaldehyde gas (Manila), 106 - Rat killing with dogs (Manila), 107 - Rat's nests in trees (Manila), 110 - Rat traps, snakes in (Manila), 111 - swallowed by snake (Manila), 111 - Rats, collection and forwarding of (Manila), 122, 123 - Recovering plague bacilli from circulating blood, 134 - Roberg, Dr. David, 154 - - Stability of virulence of B. pestis, 36 - Spread of plague in recent years, 23 - Suppression of plague, 40 - San Lazaro Hospital, Manila, 13, 69, 161 - Schoebl, Dr. Otto, 14, 29, 30, 76, 96, 127 - Strong, Dr. R. P., 16, 36, 38, 59, 135 - Sixth century, plague in, 20 - South America, plague in, 22, 26 - Siam, plague in, 25 - Suez, plague in, 22 - South Africa, plague in, 22 - Scotland, plague in, 22 - Sumatra, plague in, 25 - Straits Settlements, plague in, 25 - Simpson, Dr. W. J. - Suctorial parasites in plague conveyance, 33 - Seasonal conditions, effect on epidemics of, 34 - on rats of, 34 - on Bacillus pestis of, 34 - on flea prevalence of, 34 - Subacute plague in rats, 35 - Spontaneous abatement of cholera, 35 - Secondary plague pneumonia, 39 - Summary of prevention problem, 37 - San Francisco, plague campaign in, 41 - Ships, fumigation of, 46 - Starving rats, 47 - Ships, rat infestation of, 50 - Summary of prevention for community, 56 - Ship cargoes, disinfection of, 56 - Sick, isolation of, 56 - Steamer, Loongsang, 59 - Taisang, 59 - Spread of plague in Manila, favorable conditions for, 61 - Sleeping quarters, ground floor, 72 - Swellengrebel, Ph.D., N. H., 77 - Seasonal explanations of plague prevalence, 81 - Sanitary orders, Manila (garbage cans), 93 - Ship rat, 99 - Sewer rat, 99 - Sawah rat of Java, 100 - Swimming ability of rats, 102 - Size of rat litters, 102 - Simpson, surgeon, U. S. P. H. Service, 103 - Studies of rat cadavers in Java, 104 - Snakes in rat traps (Manila), 111 - Snake, rat swallowed by (Manila), 111 - Specimen, sanitary orders, 116-121 - Sanitary Board (Hong Kong), the work of, 158 - Symptomatology of plague, 171 - Serum treatment of plague, 174 - Symptomatic treatment of plague, 174 - Statistical studies in mortality, 174-176 - Serum administration, dosage and technique of, 176, 177 - - Types of plague, 30 - Treatment of plague, 165 - Turkey in Asia, plague in, 25 - Tarbagan, 28 - Teague, Dr. O., 38 - Terrier dogs as rat catchers, 55 - Terrier dogs as rat catchers on farms, 55 - Tondo district, Manila, rat plague in, 68 - human plague in, 68 - Taking charge of plague suppressive measures, Manila, 70 - Tondo, light material houses in, 71 - Tondo, Manila, habitations and plague, 83 - Theatre disinfection, Manila, 93 - Time of death of rat as indicated by postmortem changes, 104 - Transmission of plague by blood-sucking insects, 137 - Trained bacteriologist, necessity for, 167 - Treatment, conditions, and prognosis, 173 - serum, of plague, 174 - symptomatic, of plague, 174 - Technique and dosage of serum administration, 176, 177 - - United States Public Health Service, 26 - rat fleas of, 32 - - Varieties of rat fleas, 32 - of rat traps, 45 - Variations in number of fleas per rat (Java), 78 - Van Loghem, Dr. J. J., 82, 84 - Variations in the rat catch, 88 - Vaccines, plague, 178, 179 - Vaccine, Haffkine, 178, 179 - Vaccines, combined, 179 - - Widespread dissemination in recent years, 23 - West Indies, plague in, 29 - Wane of epidemics, 15, 35 - Work of Sanitary Board (Hong Kong), 158 - - Xenopsylla cheopis in Java, 77 - - Zoologic classification of rats, 98 - - - - - Transcriber's note: - - The following corrections have been made: - - Title page: Period added after J in "J B. Lippincott Company" - - Dedication: Period added after "DAYS IN SERBIA" - - Table of Contents: "Epidemic, By Dr. Otto Schoebl" By changed to by - - p. 21: "christendom" changed to Christendom - - p. 32: Removed italic type from the word genus in "genus - Ctenocephalus" - - p. 62: "secondary to this July case" July changed to June - - p. 78: "known as Loemopsylla cheopsis" Loemopsylla changed to - Loemopsylla - - p. 132: "While cases 5, 2, 19, and 24 appeared" 2 changed to 11 - - p. 139: "fleas from a plagueinfected house" plagueinfected changed to - plague-infected - - p. 142: "usually met with in" with in changed to within - - p. 147: "Echinococcus teniaeformis was found in the liver" teniaeformis - changed to taeniaeformis - - Index: "Swellengreble" changed to Swellengrebel - - Footnote 5: "Jena (1903) 2" added comma after closing bracket - - Everything else retained as printed, including inconsistencies in - hyphenation. The index entry for Simpson, Dr. W. 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