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 œdematous 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 œdematous 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
Lœmopsylla 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
Lœmopsylla
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. J. is missing its
page reference.