Chapter 4 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. Sch?bl 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 ?dematous 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 Sch?bl, already quoted.

Bacteriologic Procedure.-Dr. Sch?bl was able to secure positive blood cultures, within 24 hours, from all of a long series of cases of plague, both bubonic and septic?mic. 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 ?dematous 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 septic?mic, 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 septic?mic case, either mildly or overwhelmingly so. Accordingly the treatment should invariably be the treatment of septic?mic 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, septic?mic, pneumonic and bubonic.

The following diseases may be confounded with plague, if symptoms alone are considered: typhus (exanthematicus), influenza pneumonia, broncho-pneumonia, severe malaria, septic?mia, acute toxic typhoid, venereal bubo, mumps and tonsillitis.

I call attention again to the fact that mild cases of plague, septic?mic and bubonic, occur at times, clinical pictures in such cases being incomplete.

The statement that the prognosis in all cases of septic?mic 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 septic?mic 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 septic?mic 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 ? 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

A B C D E F G H I J K L M

N O P Q R S T U V W X Y Z

Anaphylaxis, 177

Appearance of plague in Porto Rico, 26 New Orleans, 26

Manila, 26

Appeal for public co?peration, 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, G?rtner'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 larv?, 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 Murid?, 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

G?rtner'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

L?mopsylla 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 co?peration 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 septic?mic 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, zo?logic 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

Sch?bl, 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

Zo?logic 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 Sch?bl" 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 L?mopsylla

p. 132: "While cases 5, 2, 19 and 24" 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 teni?formis was found in the liver" teni?formis changed to taeni?formis

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.