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. 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.